Kenneth G. Simone, DO, FHM, grew up as the son of a revered pediatrician. As a child, he often accompanied his father on hospital rounds and house calls, developing an appreciation for the “old-fashioned” medicine his father practiced.

Already inspired to follow in his father’s footsteps, Dr. Simone became even more convinced of his calling when the physician-patient roles were reversed: His dad developed a kidney disorder that cut his career—and ultimately his life—short. “His illness and my exposure to hospitals added to my desire to pursue medicine,” Dr. Simone says. “It instilled the drive to help others, to make a difference in someone’s or some family’s life.”

He has done that by developing multiple private medical practices, building the hospitalist program at St. Joseph Hospital in Bangor, Maine, and offering consulting services to more than 100 practices.

“It has always been my nature to challenge myself and put myself in situations that take me out of my comfort zone,” says Dr. Simone, president of Hospitalist and Practice Solutions, a practice-management consultancy in Veazie, Maine. “I enjoy building things from scratch, creating, rebuilding, thinking outside the box, and networking with other healthcare professionals.”

Question: What made you decide to start Hospitalist and Practice Solutions (HPS)?

Answer: HPS was established because of the demand for my services. Initially, word spread locally and then regionally about the work I did at St. Joseph Hospital. As a natural offshoot of my growing interest in helping other programs, HPS became a national consulting firm.

Q: Why did you think this venture could provide a valuable service?

A: I believed there were more effective healthcare delivery systems with which to provide both quality and cost-effective medical care. As time went on, I gained a very unique perspective working as both a hospitalist and referring PCP in private practice. This experience, coupled with my work as an administrative director for a hospitalist program, allowed me to develop applications to help hospitalist programs on a broader basis. I realized the advice I offered to other programs consistently rendered a positive effect.

Q: Which do you find more enjoyable: building a hospitalist program from the ground up or rebuilding a struggling program?

A: I truly enjoy the challenges of both equally. Projects that involve building a program de novo appeal to my creative side. These projects enable me to work with professionals to build a customized program that meets the needs of the community.

Q: What challenges are unique to each?

A: Rebuilding an established program involves critical analysis of the current program to identify what has gone wrong, what has been successful, and what will work in the future. It calls upon one’s skills to build consensus and instill trust in the process because the stakeholders may be apprehensive to have a consultant critically review their program and hospital. In many instances, conflict management is necessary.

In both the creation and rebuilding of an HM program, it is imperative to implement strategies that guide the program to future success. Both projects also require strategic planning and the development of tools and tactics that emphasize collaboration and collegiality.

Q: Do the failing programs you help to rebuild have characteristics in common?

A: Common themes include lack of planning and consensus-building before program start-up, inadequate tools and strategies to support effective practice management, and failure to align the hospitalist practice and sponsoring hospital’s goals and vision. Another common problem is the absence of a hospitalist recruitment and retention plan, which may lead to provider turnover and program instability.

Many programs experience problems due to ineffective leadership, poor implementation and follow-through, and lack of both a short- and long-term strategic plan. Some programs are victims of their own success. The program is not properly prepared to handle the demand for its services and grow accordingly.

Q: You help programs create effective recruitment and retention plans. You also wrote a book on the subject. Why are recruitment and retention challenging for so many programs?

A: The primary contributor is that [hospitalist] supply falls significantly short of physician demand. A secondary contributor is the generational expectations of the younger physician workforce. … In addition, leaders may not prioritize recruitment and retention because they lack an appreciation for the consequences of failed efforts.

Q: What advice would you offer hospitalist program leaders about how they can improve those aspects of their programs?

A: No. 1, create an effective recruitment and retention plan and execute the plan with precision. No. 2, approach recruitment and retention with the same attention to detail as you approach patient care.

Q: You’re offering best-practice advice to help your clients develop and sustain effective programs. What advice do you find yourself giving to your clients that you wish someone gave to you early in your career?

A: From my perspective as a hospitalist administrative director, the advice I would offer is for individuals to believe in themselves and stay engaged. If you feel you have something to offer to the practice or healthcare system as a whole, share it with the appropriate parties. If you experience problems within the workplace, seek resolution in a timely manner. Stay positive and be part of the solution, not part of the problem.

Q: You have written two hospitalist books and coauthored two others. Do you have plans to write another?

A: I wouldn’t say I have immediate plans, but I am always thinking about topics and other projects that would provide value to readers. I’ve got some exciting ideas for future projects, but they are in a very early stage of development.

Q: How would you compare the feeling you get from finishing a book with the satisfaction you derive from other aspects of your career?

A: Writing a book is a highly personal accomplishment for me, while caring for patients is more of a team accomplishment that involves the patient, family, and other healthcare professionals. Typically, the completion of a book is a finite event, while caring for a patient is a long-term commitment.

Q: What is your biggest professional reward?

A: Helping people, whether they are patients in my role as physician, or other professionals—physicians, practice administrators, and hospital administrators—in my role as a practice management consultant. Whenever I reflect on my career, I tell myself how lucky I am. There are not many professions or individuals who have an opportunity to close the door behind them and have other human beings entrust them with their most intimate information. Also, there are very few individuals who are able to impact the delivery of medical care from a systems perspective. I get to do both, and for that I am most grateful.

Q: What is your biggest professional challenge?

A: Saying “no” when someone asks for help. There is nothing more rewarding for me than to help others. With that said, I try not to overextend myself, because that wouldn’t be fair to my family, colleagues, friends, or clients.

Q: What’s next for you professionally?

A: I will continue to concentrate my effort on building my hospitalist consultative practice and expanding the services I offer. In addition, I’m always tempted to explore the valley of the unknown. What excites me is venturing into new areas and to challenge myself to grow as both an individual and professional. TH

Mark Leiser is a freelance writer based in New Jersey.

Kenneth G. Simone, DO, FHM, grew up as the son of a revered pediatrician. As a child, he often accompanied his father on hospital rounds and house calls, developing an appreciation for the “old-fashioned” medicine his father practiced.

Already inspired to follow in his father’s footsteps, Dr. Simone became even more convinced of his calling when the physician-patient roles were reversed: His dad developed a kidney disorder that cut his career—and ultimately his life—short. “His illness and my exposure to hospitals added to my desire to pursue medicine,” Dr. Simone says. “It instilled the drive to help others, to make a difference in someone’s or some family’s life.”

He has done that by developing multiple private medical practices, building the hospitalist program at St. Joseph Hospital in Bangor, Maine, and offering consulting services to more than 100 practices.

“It has always been my nature to challenge myself and put myself in situations that take me out of my comfort zone,” says Dr. Simone, president of Hospitalist and Practice Solutions, a practice-management consultancy in Veazie, Maine. “I enjoy building things from scratch, creating, rebuilding, thinking outside the box, and networking with other healthcare professionals.”

Question: What made you decide to start Hospitalist and Practice Solutions (HPS)?

Answer: HPS was established because of the demand for my services. Initially, word spread locally and then regionally about the work I did at St. Joseph Hospital. As a natural offshoot of my growing interest in helping other programs, HPS became a national consulting firm.

Q: Why did you think this venture could provide a valuable service?

A: I believed there were more effective healthcare delivery systems with which to provide both quality and cost-effective medical care. As time went on, I gained a very unique perspective working as both a hospitalist and referring PCP in private practice. This experience, coupled with my work as an administrative director for a hospitalist program, allowed me to develop applications to help hospitalist programs on a broader basis. I realized the advice I offered to other programs consistently rendered a positive effect.

Q: Which do you find more enjoyable: building a hospitalist program from the ground up or rebuilding a struggling program?

A: I truly enjoy the challenges of both equally. Projects that involve building a program de novo appeal to my creative side. These projects enable me to work with professionals to build a customized program that meets the needs of the community.

Q: What challenges are unique to each?

A: Rebuilding an established program involves critical analysis of the current program to identify what has gone wrong, what has been successful, and what will work in the future. It calls upon one’s skills to build consensus and instill trust in the process because the stakeholders may be apprehensive to have a consultant critically review their program and hospital. In many instances, conflict management is necessary.

In both the creation and rebuilding of an HM program, it is imperative to implement strategies that guide the program to future success. Both projects also require strategic planning and the development of tools and tactics that emphasize collaboration and collegiality.

Q: Do the failing programs you help to rebuild have characteristics in common?

A: Common themes include lack of planning and consensus-building before program start-up, inadequate tools and strategies to support effective practice management, and failure to align the hospitalist practice and sponsoring hospital’s goals and vision. Another common problem is the absence of a hospitalist recruitment and retention plan, which may lead to provider turnover and program instability.

Many programs experience problems due to ineffective leadership, poor implementation and follow-through, and lack of both a short- and long-term strategic plan. Some programs are victims of their own success. The program is not properly prepared to handle the demand for its services and grow accordingly.

Q: You help programs create effective recruitment and retention plans. You also wrote a book on the subject. Why are recruitment and retention challenging for so many programs?

A: The primary contributor is that [hospitalist] supply falls significantly short of physician demand. A secondary contributor is the generational expectations of the younger physician workforce. … In addition, leaders may not prioritize recruitment and retention because they lack an appreciation for the consequences of failed efforts.

Q: What advice would you offer hospitalist program leaders about how they can improve those aspects of their programs?

A: No. 1, create an effective recruitment and retention plan and execute the plan with precision. No. 2, approach recruitment and retention with the same attention to detail as you approach patient care.

Q: You’re offering best-practice advice to help your clients develop and sustain effective programs. What advice do you find yourself giving to your clients that you wish someone gave to you early in your career?

A: From my perspective as a hospitalist administrative director, the advice I would offer is for individuals to believe in themselves and stay engaged. If you feel you have something to offer to the practice or healthcare system as a whole, share it with the appropriate parties. If you experience problems within the workplace, seek resolution in a timely manner. Stay positive and be part of the solution, not part of the problem.

Q: You have written two hospitalist books and coauthored two others. Do you have plans to write another?

A: I wouldn’t say I have immediate plans, but I am always thinking about topics and other projects that would provide value to readers. I’ve got some exciting ideas for future projects, but they are in a very early stage of development.

Q: How would you compare the feeling you get from finishing a book with the satisfaction you derive from other aspects of your career?

A: Writing a book is a highly personal accomplishment for me, while caring for patients is more of a team accomplishment that involves the patient, family, and other healthcare professionals. Typically, the completion of a book is a finite event, while caring for a patient is a long-term commitment.

Q: What is your biggest professional reward?

A: Helping people, whether they are patients in my role as physician, or other professionals—physicians, practice administrators, and hospital administrators—in my role as a practice management consultant. Whenever I reflect on my career, I tell myself how lucky I am. There are not many professions or individuals who have an opportunity to close the door behind them and have other human beings entrust them with their most intimate information. Also, there are very few individuals who are able to impact the delivery of medical care from a systems perspective. I get to do both, and for that I am most grateful.

Q: What is your biggest professional challenge?

A: Saying “no” when someone asks for help. There is nothing more rewarding for me than to help others. With that said, I try not to overextend myself, because that wouldn’t be fair to my family, colleagues, friends, or clients.

Q: What’s next for you professionally?

A: I will continue to concentrate my effort on building my hospitalist consultative practice and expanding the services I offer. In addition, I’m always tempted to explore the valley of the unknown. What excites me is venturing into new areas and to challenge myself to grow as both an individual and professional. TH

Mark Leiser is a freelance writer based in New Jersey.

Kenneth G. Simone, DO, FHM, grew up as the son of a revered pediatrician. As a child, he often accompanied his father on hospital rounds and house calls, developing an appreciation for the “old-fashioned” medicine his father practiced.

Already inspired to follow in his father’s footsteps, Dr. Simone became even more convinced of his calling when the physician-patient roles were reversed: His dad developed a kidney disorder that cut his career—and ultimately his life—short. “His illness and my exposure to hospitals added to my desire to pursue medicine,” Dr. Simone says. “It instilled the drive to help others, to make a difference in someone’s or some family’s life.”

He has done that by developing multiple private medical practices, building the hospitalist program at St. Joseph Hospital in Bangor, Maine, and offering consulting services to more than 100 practices.

“It has always been my nature to challenge myself and put myself in situations that take me out of my comfort zone,” says Dr. Simone, president of Hospitalist and Practice Solutions, a practice-management consultancy in Veazie, Maine. “I enjoy building things from scratch, creating, rebuilding, thinking outside the box, and networking with other healthcare professionals.”

Question: What made you decide to start Hospitalist and Practice Solutions (HPS)?

Answer: HPS was established because of the demand for my services. Initially, word spread locally and then regionally about the work I did at St. Joseph Hospital. As a natural offshoot of my growing interest in helping other programs, HPS became a national consulting firm.

Q: Why did you think this venture could provide a valuable service?

A: I believed there were more effective healthcare delivery systems with which to provide both quality and cost-effective medical care. As time went on, I gained a very unique perspective working as both a hospitalist and referring PCP in private practice. This experience, coupled with my work as an administrative director for a hospitalist program, allowed me to develop applications to help hospitalist programs on a broader basis. I realized the advice I offered to other programs consistently rendered a positive effect.

Q: Which do you find more enjoyable: building a hospitalist program from the ground up or rebuilding a struggling program?

A: I truly enjoy the challenges of both equally. Projects that involve building a program de novo appeal to my creative side. These projects enable me to work with professionals to build a customized program that meets the needs of the community.

Q: What challenges are unique to each?

A: Rebuilding an established program involves critical analysis of the current program to identify what has gone wrong, what has been successful, and what will work in the future. It calls upon one’s skills to build consensus and instill trust in the process because the stakeholders may be apprehensive to have a consultant critically review their program and hospital. In many instances, conflict management is necessary.

In both the creation and rebuilding of an HM program, it is imperative to implement strategies that guide the program to future success. Both projects also require strategic planning and the development of tools and tactics that emphasize collaboration and collegiality.

Q: Do the failing programs you help to rebuild have characteristics in common?

A: Common themes include lack of planning and consensus-building before program start-up, inadequate tools and strategies to support effective practice management, and failure to align the hospitalist practice and sponsoring hospital’s goals and vision. Another common problem is the absence of a hospitalist recruitment and retention plan, which may lead to provider turnover and program instability.

Many programs experience problems due to ineffective leadership, poor implementation and follow-through, and lack of both a short- and long-term strategic plan. Some programs are victims of their own success. The program is not properly prepared to handle the demand for its services and grow accordingly.

Q: You help programs create effective recruitment and retention plans. You also wrote a book on the subject. Why are recruitment and retention challenging for so many programs?

A: The primary contributor is that [hospitalist] supply falls significantly short of physician demand. A secondary contributor is the generational expectations of the younger physician workforce. … In addition, leaders may not prioritize recruitment and retention because they lack an appreciation for the consequences of failed efforts.

Q: What advice would you offer hospitalist program leaders about how they can improve those aspects of their programs?

A: No. 1, create an effective recruitment and retention plan and execute the plan with precision. No. 2, approach recruitment and retention with the same attention to detail as you approach patient care.

Q: You’re offering best-practice advice to help your clients develop and sustain effective programs. What advice do you find yourself giving to your clients that you wish someone gave to you early in your career?

A: From my perspective as a hospitalist administrative director, the advice I would offer is for individuals to believe in themselves and stay engaged. If you feel you have something to offer to the practice or healthcare system as a whole, share it with the appropriate parties. If you experience problems within the workplace, seek resolution in a timely manner. Stay positive and be part of the solution, not part of the problem.

Q: You have written two hospitalist books and coauthored two others. Do you have plans to write another?

A: I wouldn’t say I have immediate plans, but I am always thinking about topics and other projects that would provide value to readers. I’ve got some exciting ideas for future projects, but they are in a very early stage of development.

Q: How would you compare the feeling you get from finishing a book with the satisfaction you derive from other aspects of your career?

A: Writing a book is a highly personal accomplishment for me, while caring for patients is more of a team accomplishment that involves the patient, family, and other healthcare professionals. Typically, the completion of a book is a finite event, while caring for a patient is a long-term commitment.

Q: What is your biggest professional reward?

A: Helping people, whether they are patients in my role as physician, or other professionals—physicians, practice administrators, and hospital administrators—in my role as a practice management consultant. Whenever I reflect on my career, I tell myself how lucky I am. There are not many professions or individuals who have an opportunity to close the door behind them and have other human beings entrust them with their most intimate information. Also, there are very few individuals who are able to impact the delivery of medical care from a systems perspective. I get to do both, and for that I am most grateful.

Q: What is your biggest professional challenge?

A: Saying “no” when someone asks for help. There is nothing more rewarding for me than to help others. With that said, I try not to overextend myself, because that wouldn’t be fair to my family, colleagues, friends, or clients.

Q: What’s next for you professionally?

A: I will continue to concentrate my effort on building my hospitalist consultative practice and expanding the services I offer. In addition, I’m always tempted to explore the valley of the unknown. What excites me is venturing into new areas and to challenge myself to grow as both an individual and professional. TH

Mark Leiser is a freelance writer based in New Jersey.

Case

A 46-year-old woman with Addison’s disease and type II diabetes presents with one day of right leg pain, swelling, and redness. She has had mild nausea and vomiting over the past week, with an episode of diarrhea three days prior. She takes hydrocortisone 30mg in the morning and 10mg at bedtime, as well as fludrocortisone 0.2mg in the morning. She is afebrile with a pulse of 108 beats per minute. Her initial blood pressure was 74/49 mmHg, which improved to 84/45 mmHg following one liter of normal saline. She is mentating appropriately. The physical exam is significant for a large, tender area of erythema and warmth from the right ankle to mid-calf. She is admitted for cellulitis and intravenous antibiotics are initiated.

Does she require an increase in her glucocorticoid dose during her acute illness?

Overview

Adrenal insufficiency occurs in approximately 5 out of every 10,000 people and results from primary failure of the adrenal gland, or secondary impairment of the hypothalamic-pituitary-adrenal (HPA) axis, which regulates cortisol secretion.1 In developed countries, 90% of primary adrenal insufficiency (Addison’s disease) cases are due to autoimmune adrenalitis, which might occur in isolation or as part of an autoimmune polyglandular syndrome.^1,2 Secondary adrenal insufficiency is most commonly the result of chronic glucocorticoid therapy, though lesions involving the hypothalamus or pituitary gland might be implicated.^2,3

In a healthy individual, cortisol is secreted in a diurnal pattern from the adrenal glands under the control of corticotropin (ACTH) produced by the pituitary gland and corticotropin-releasing hormone (CRH) produced by the hypothalamus (see Figure 1, p. 19). In the normal state, during periods of such systemic stress as illness, trauma, burns, or surgery, cortisol production increases to a degree roughly proportional to the degree of illness (as much as sixfold).^4,5 Patients with adrenal insufficiency are unable to mount an appropriate cortisol response and, therefore, are at risk for adrenal crisis—a life-threatening condition characterized by hypotension and hypovolemic shock.

Although recommendations for high-dose intravenous steroids in adrenally insufficient patients who are critically ill or undergoing surgery have been extensively discussed in the literature, there are relatively few data regarding the appropriate management of adrenal insufficiency in patients hospitalized for noncritical illness.

Several recent studies have investigated the patient characteristics, situations, and conditions most likely to provoke adrenal crisis in order to establish guidelines dictating the use of supra-physiologic steroid dosing.

Review of the Data

Studies have estimated the prevalence of adrenal crisis in patients with underlying insufficiency at 3.3 to 6.3 events per 100 patient years, with 42% of patients reporting at least one crisis.^2,5,6 A recent survey of 982 patients with Addison’s disease in the United Kingdom reported an 8% annual frequency.⁷

A retrospective Japanese study reviewed the medical charts of 137 adult patients receiving steroid replacement for established primary or secondary adrenal insufficiency. The authors noted a significant positive association between adrenal crisis and long-term steroid replacement (>4 years), concomitant mental disorder, and sex hormone deficiency. A combination of any of these factors further increased the risk.⁸

A more recent survey of 444 patients ages 17-81 assessed independent risk factors for adrenal crisis in the setting of primary (N=254) or secondary (N=190) adrenal insufficiency. The incidence of crisis was higher in primary versus secondary insufficiency. In patients with primary insufficiency, concomitant, non-endocrine disorders increased the risk of adrenal crisis, whereas diabetes insipidus and female gender increased risk in patients with secondary insufficiency. This same study also investigated events leading to a crisis and found gastrointestinal infection to be the most frequent factor, followed by other infectious or febrile illnesses. Overall, infection comprised 45% of all identified triggers.⁶

A similar study conducted by White and Arlt evaluated 841 Addison’s patients in the United Kingdom, Canada, Australia, and New Zealand.⁷ Again, gastrointestinal illness was the most common provoking factor, responsible for 56% of all reported crises. Flulike illness followed at 11%, followed by infections and surgical procedures at 6% each. This study found a higher risk of crisis in patients with diabetes (type I or II), premature ovarian failure, and asthma; the presence of multiple comorbidities further increased risk.

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Medications. Glucocorticoid therapy is known to suppress the HPA axis. Although it was once believed that the duration and dose of therapy correlated directly with the degree of HPA suppression, more recent studies have failed to find any definite relationship.⁹ Patients taking the equivalent of 5mg of prednisone per day should continue to have an intact HPA axis, as this dose mimics physiologic secretion of cortisol in a healthy individual.³

However, the dose and duration of therapy at which suppression occurs is highly variable between patients. In general, patients on 7.5mg of prednisone or more per day for at least three weeks should be considered to be suppressed.^3,9 Additionally, progesterone derivatives (i.e., megestrol) have glucocorticoid activity and might suppress HPA function. Other medications that might have related effects are those that inhibit enzymes involved in cortisol synthesis; ketoconazole and etomidate are common examples. Rifampin and several classes of anti-epileptic drugs induce enzymes, which increase hepatic metabolism of cortisol (see Table 1, p. 18).

Hyperthyroidism. Thyroid hormone is involved in the metabolism of cortisol, thus an increase in T4 correlates with lower levels. Adrenal insufficiency and thyroid disease might coexist within the autoimmune polyglandular syndrome. Initiation or uptitration of thyroid replacement should be avoided if acute adrenal insufficiency is suspected, as this might provoke an adrenal crisis. Conversely, any patient with adrenal insufficiency who has uncontrolled hyperthyroidism should receive two to three times their usual glucocorticoid replacement.^1,2

Pregnancy. Levels of cortisol-binding globulin increase throughout pregnancy. In women with intact adrenal function, free cortisol levels also rise during the third trimester. Therefore, glucocorticoid replacement should be increased by 50% during the last three months of pregnancy.²

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Acute illness. The cortisol response to stress is highly variable and dependent on a number of factors, including age, underlying health, and genetics. In general, most experts recommend doubling or tripling the daily replacement dose during mild to moderate illness until recovery (often referred to as the “sick-day rules”). What constitutes “recovery” is not clearly defined. When oral intake is compromised, as with vomiting or diarrhea, parenteral administration of steroids is recommended.^1-5,9,10 Patients with adrenal insufficiency should be provided an emergency injection kit to use and further counseled to seek medical attention. Injection kits typically consist of 100mg of hydrocortisone or 4mg of dexamethasone, although other glucocorticoids may be used (see Table 2, above left, for conversions).

Limited data are available to support guidelines for glucocorticoid adjustment during acute, non-critical illness. Published guidelines vary both in illness categorization and category-specific recommendations (see Table 3, below).

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Coursin and Wood devised a set of guidelines based on a literature review and consultation with experts, categorizing medical illness as minor, moderate, severe, and critical (see Table 3).³ For noncritical illness, they recommended continuation of standard replacement therapy with an additional, once-daily dose, which varied according to illness severity.

Cooper and Stewart conducted a similar review, basing their guidelines on a categorization of mild, moderate, severe/critical, or septic shock. These guidelines recommended a total daily dose of glucocorticoid supplementation, rather than an addition of a single dose to current therapy. They also stated that the least severe category of illness (defined as mild) did not require any change to a patient’s regular therapy.⁴

Jung et al classified illness as minimal, minor, moderate, severe, and critical.⁹ Under these guidelines, supplemental therapy was not advised for minimal (nonfebrile) illness. Moderate illness, including cellulitis, warranted a doubling or tripling of the outpatient dose until recovery, which was consistent with prior expert recommendation. More severe illness warranted intravenous administration of steroids.

Back to the Case

The patient had a mild case of cellulitis, classified by most experts as moderate illness, which responded well to vancomycin. Her outpatient glucocorticoid dose was doubled on admission and administered orally for the duration of her hospitalization, as she had no further episodes of vomiting or diarrhea.

Review of the patient’s records from prior hospitalizations and ambulatory visits revealed that her systolic blood pressure typically ran in the 80 mmHg to 100 mmHg range. Following initial volume resuscitation, her systolic blood pressure remained in the 90-100 mmHg range.

She was discharged home in stable condition, with instructions to complete a course of oral trimethoprim/sulfamethoxazole, resume her baseline dose of hydrocortisone the day after discharge, and follow up with her PCP for further monitoring and adjustment of her adrenal replacement therapy.

Bottom Line

For adults with adrenal insufficiency hospitalized with noncritical, nonsurgical illness, the expert recommendation is to double or triple the usual outpatient dose of glucocorticoid; however, data to support this is limited, and each patient should be assessed carefully and monitored to determine the optimal dose adjustment. TH

Dr. Shaw is a resident in the Department of Medicine at the University of Washington School of Medicine in Seattle. Dr. Best is an assistant professor of medicine in the division of general internal medicine, University of Washington School of Medicine.

References

1. Arlt W. The approach to the adult with newly diagnosed adrenal insufficiency. J Clin Endocrinol Metab. 2009;94(4):1059-1067.
2. Arlt W, Allolio B. Adrenal insufficiency. Lancet. 2003; 361:1881-1893.
3. Coursin DB, Wood KE. Corticosteroid supplementation for adrenal insufficiency. JAMA. 2002;287:236-240.
4. Cooper MS, Stewart PM. Corticosteroid insufficiency in acutely ill patients. N Engl J Med. 2003;348:727-734.
5. Hahner S, Allolio B. Therapeutic management of adrenal insufficiency. Best Pract Res Clin Endocrinol Metab. 2009;23:167-179.
6. Hahner S, Loeffler M, Bleicken B, et al. Epidemiology of adrenal crisis in chronic adrenal insufficiency: the need for new prevention strategies. Eur J Endocrinol. 2010;162:597:602.
7. White K, Arlt W. Adrenal crisis in treated Addison’s disease: a predictable but under-managed event. Eur J Endocrinol. 2010;162:115-120.
8. Omori K, Nomura K, Shimizu S, Omori N, Takano K. Risk factors for adrenal crises in patients with adrenal insufficiency. Endocr J. 2003;50:745-752.
9. Jung C, Inder WJ. Management of adrenal insufficiency during the stress of medical illness and surgery. Med J Aust. 2008;188:409-413.
10. Crown A, Lightman S. Why is the management of glucocorticoid deficiency still controversial: a review of the literature. Clin Endocrinol. 2005;63:483-492.

Case

A 46-year-old woman with Addison’s disease and type II diabetes presents with one day of right leg pain, swelling, and redness. She has had mild nausea and vomiting over the past week, with an episode of diarrhea three days prior. She takes hydrocortisone 30mg in the morning and 10mg at bedtime, as well as fludrocortisone 0.2mg in the morning. She is afebrile with a pulse of 108 beats per minute. Her initial blood pressure was 74/49 mmHg, which improved to 84/45 mmHg following one liter of normal saline. She is mentating appropriately. The physical exam is significant for a large, tender area of erythema and warmth from the right ankle to mid-calf. She is admitted for cellulitis and intravenous antibiotics are initiated.

Does she require an increase in her glucocorticoid dose during her acute illness?

Overview

Adrenal insufficiency occurs in approximately 5 out of every 10,000 people and results from primary failure of the adrenal gland, or secondary impairment of the hypothalamic-pituitary-adrenal (HPA) axis, which regulates cortisol secretion.1 In developed countries, 90% of primary adrenal insufficiency (Addison’s disease) cases are due to autoimmune adrenalitis, which might occur in isolation or as part of an autoimmune polyglandular syndrome.^1,2 Secondary adrenal insufficiency is most commonly the result of chronic glucocorticoid therapy, though lesions involving the hypothalamus or pituitary gland might be implicated.^2,3

In a healthy individual, cortisol is secreted in a diurnal pattern from the adrenal glands under the control of corticotropin (ACTH) produced by the pituitary gland and corticotropin-releasing hormone (CRH) produced by the hypothalamus (see Figure 1, p. 19). In the normal state, during periods of such systemic stress as illness, trauma, burns, or surgery, cortisol production increases to a degree roughly proportional to the degree of illness (as much as sixfold).^4,5 Patients with adrenal insufficiency are unable to mount an appropriate cortisol response and, therefore, are at risk for adrenal crisis—a life-threatening condition characterized by hypotension and hypovolemic shock.

Although recommendations for high-dose intravenous steroids in adrenally insufficient patients who are critically ill or undergoing surgery have been extensively discussed in the literature, there are relatively few data regarding the appropriate management of adrenal insufficiency in patients hospitalized for noncritical illness.

Several recent studies have investigated the patient characteristics, situations, and conditions most likely to provoke adrenal crisis in order to establish guidelines dictating the use of supra-physiologic steroid dosing.

Review of the Data

Studies have estimated the prevalence of adrenal crisis in patients with underlying insufficiency at 3.3 to 6.3 events per 100 patient years, with 42% of patients reporting at least one crisis.^2,5,6 A recent survey of 982 patients with Addison’s disease in the United Kingdom reported an 8% annual frequency.⁷

A retrospective Japanese study reviewed the medical charts of 137 adult patients receiving steroid replacement for established primary or secondary adrenal insufficiency. The authors noted a significant positive association between adrenal crisis and long-term steroid replacement (>4 years), concomitant mental disorder, and sex hormone deficiency. A combination of any of these factors further increased the risk.⁸

A more recent survey of 444 patients ages 17-81 assessed independent risk factors for adrenal crisis in the setting of primary (N=254) or secondary (N=190) adrenal insufficiency. The incidence of crisis was higher in primary versus secondary insufficiency. In patients with primary insufficiency, concomitant, non-endocrine disorders increased the risk of adrenal crisis, whereas diabetes insipidus and female gender increased risk in patients with secondary insufficiency. This same study also investigated events leading to a crisis and found gastrointestinal infection to be the most frequent factor, followed by other infectious or febrile illnesses. Overall, infection comprised 45% of all identified triggers.⁶

A similar study conducted by White and Arlt evaluated 841 Addison’s patients in the United Kingdom, Canada, Australia, and New Zealand.⁷ Again, gastrointestinal illness was the most common provoking factor, responsible for 56% of all reported crises. Flulike illness followed at 11%, followed by infections and surgical procedures at 6% each. This study found a higher risk of crisis in patients with diabetes (type I or II), premature ovarian failure, and asthma; the presence of multiple comorbidities further increased risk.

click for large version

Medications. Glucocorticoid therapy is known to suppress the HPA axis. Although it was once believed that the duration and dose of therapy correlated directly with the degree of HPA suppression, more recent studies have failed to find any definite relationship.⁹ Patients taking the equivalent of 5mg of prednisone per day should continue to have an intact HPA axis, as this dose mimics physiologic secretion of cortisol in a healthy individual.³

However, the dose and duration of therapy at which suppression occurs is highly variable between patients. In general, patients on 7.5mg of prednisone or more per day for at least three weeks should be considered to be suppressed.^3,9 Additionally, progesterone derivatives (i.e., megestrol) have glucocorticoid activity and might suppress HPA function. Other medications that might have related effects are those that inhibit enzymes involved in cortisol synthesis; ketoconazole and etomidate are common examples. Rifampin and several classes of anti-epileptic drugs induce enzymes, which increase hepatic metabolism of cortisol (see Table 1, p. 18).

Hyperthyroidism. Thyroid hormone is involved in the metabolism of cortisol, thus an increase in T4 correlates with lower levels. Adrenal insufficiency and thyroid disease might coexist within the autoimmune polyglandular syndrome. Initiation or uptitration of thyroid replacement should be avoided if acute adrenal insufficiency is suspected, as this might provoke an adrenal crisis. Conversely, any patient with adrenal insufficiency who has uncontrolled hyperthyroidism should receive two to three times their usual glucocorticoid replacement.^1,2

Pregnancy. Levels of cortisol-binding globulin increase throughout pregnancy. In women with intact adrenal function, free cortisol levels also rise during the third trimester. Therefore, glucocorticoid replacement should be increased by 50% during the last three months of pregnancy.²

click for large version

Acute illness. The cortisol response to stress is highly variable and dependent on a number of factors, including age, underlying health, and genetics. In general, most experts recommend doubling or tripling the daily replacement dose during mild to moderate illness until recovery (often referred to as the “sick-day rules”). What constitutes “recovery” is not clearly defined. When oral intake is compromised, as with vomiting or diarrhea, parenteral administration of steroids is recommended.^1-5,9,10 Patients with adrenal insufficiency should be provided an emergency injection kit to use and further counseled to seek medical attention. Injection kits typically consist of 100mg of hydrocortisone or 4mg of dexamethasone, although other glucocorticoids may be used (see Table 2, above left, for conversions).

Limited data are available to support guidelines for glucocorticoid adjustment during acute, non-critical illness. Published guidelines vary both in illness categorization and category-specific recommendations (see Table 3, below).

click for large version

Coursin and Wood devised a set of guidelines based on a literature review and consultation with experts, categorizing medical illness as minor, moderate, severe, and critical (see Table 3).³ For noncritical illness, they recommended continuation of standard replacement therapy with an additional, once-daily dose, which varied according to illness severity.

Cooper and Stewart conducted a similar review, basing their guidelines on a categorization of mild, moderate, severe/critical, or septic shock. These guidelines recommended a total daily dose of glucocorticoid supplementation, rather than an addition of a single dose to current therapy. They also stated that the least severe category of illness (defined as mild) did not require any change to a patient’s regular therapy.⁴

Jung et al classified illness as minimal, minor, moderate, severe, and critical.⁹ Under these guidelines, supplemental therapy was not advised for minimal (nonfebrile) illness. Moderate illness, including cellulitis, warranted a doubling or tripling of the outpatient dose until recovery, which was consistent with prior expert recommendation. More severe illness warranted intravenous administration of steroids.

Back to the Case

The patient had a mild case of cellulitis, classified by most experts as moderate illness, which responded well to vancomycin. Her outpatient glucocorticoid dose was doubled on admission and administered orally for the duration of her hospitalization, as she had no further episodes of vomiting or diarrhea.

Review of the patient’s records from prior hospitalizations and ambulatory visits revealed that her systolic blood pressure typically ran in the 80 mmHg to 100 mmHg range. Following initial volume resuscitation, her systolic blood pressure remained in the 90-100 mmHg range.

She was discharged home in stable condition, with instructions to complete a course of oral trimethoprim/sulfamethoxazole, resume her baseline dose of hydrocortisone the day after discharge, and follow up with her PCP for further monitoring and adjustment of her adrenal replacement therapy.

Bottom Line

For adults with adrenal insufficiency hospitalized with noncritical, nonsurgical illness, the expert recommendation is to double or triple the usual outpatient dose of glucocorticoid; however, data to support this is limited, and each patient should be assessed carefully and monitored to determine the optimal dose adjustment. TH

Dr. Shaw is a resident in the Department of Medicine at the University of Washington School of Medicine in Seattle. Dr. Best is an assistant professor of medicine in the division of general internal medicine, University of Washington School of Medicine.

References

1. Arlt W. The approach to the adult with newly diagnosed adrenal insufficiency. J Clin Endocrinol Metab. 2009;94(4):1059-1067.
2. Arlt W, Allolio B. Adrenal insufficiency. Lancet. 2003; 361:1881-1893.
3. Coursin DB, Wood KE. Corticosteroid supplementation for adrenal insufficiency. JAMA. 2002;287:236-240.
4. Cooper MS, Stewart PM. Corticosteroid insufficiency in acutely ill patients. N Engl J Med. 2003;348:727-734.
5. Hahner S, Allolio B. Therapeutic management of adrenal insufficiency. Best Pract Res Clin Endocrinol Metab. 2009;23:167-179.
6. Hahner S, Loeffler M, Bleicken B, et al. Epidemiology of adrenal crisis in chronic adrenal insufficiency: the need for new prevention strategies. Eur J Endocrinol. 2010;162:597:602.
7. White K, Arlt W. Adrenal crisis in treated Addison’s disease: a predictable but under-managed event. Eur J Endocrinol. 2010;162:115-120.
8. Omori K, Nomura K, Shimizu S, Omori N, Takano K. Risk factors for adrenal crises in patients with adrenal insufficiency. Endocr J. 2003;50:745-752.
9. Jung C, Inder WJ. Management of adrenal insufficiency during the stress of medical illness and surgery. Med J Aust. 2008;188:409-413.
10. Crown A, Lightman S. Why is the management of glucocorticoid deficiency still controversial: a review of the literature. Clin Endocrinol. 2005;63:483-492.

Case

A 46-year-old woman with Addison’s disease and type II diabetes presents with one day of right leg pain, swelling, and redness. She has had mild nausea and vomiting over the past week, with an episode of diarrhea three days prior. She takes hydrocortisone 30mg in the morning and 10mg at bedtime, as well as fludrocortisone 0.2mg in the morning. She is afebrile with a pulse of 108 beats per minute. Her initial blood pressure was 74/49 mmHg, which improved to 84/45 mmHg following one liter of normal saline. She is mentating appropriately. The physical exam is significant for a large, tender area of erythema and warmth from the right ankle to mid-calf. She is admitted for cellulitis and intravenous antibiotics are initiated.

Does she require an increase in her glucocorticoid dose during her acute illness?

Overview

Adrenal insufficiency occurs in approximately 5 out of every 10,000 people and results from primary failure of the adrenal gland, or secondary impairment of the hypothalamic-pituitary-adrenal (HPA) axis, which regulates cortisol secretion.1 In developed countries, 90% of primary adrenal insufficiency (Addison’s disease) cases are due to autoimmune adrenalitis, which might occur in isolation or as part of an autoimmune polyglandular syndrome.^1,2 Secondary adrenal insufficiency is most commonly the result of chronic glucocorticoid therapy, though lesions involving the hypothalamus or pituitary gland might be implicated.^2,3

In a healthy individual, cortisol is secreted in a diurnal pattern from the adrenal glands under the control of corticotropin (ACTH) produced by the pituitary gland and corticotropin-releasing hormone (CRH) produced by the hypothalamus (see Figure 1, p. 19). In the normal state, during periods of such systemic stress as illness, trauma, burns, or surgery, cortisol production increases to a degree roughly proportional to the degree of illness (as much as sixfold).^4,5 Patients with adrenal insufficiency are unable to mount an appropriate cortisol response and, therefore, are at risk for adrenal crisis—a life-threatening condition characterized by hypotension and hypovolemic shock.

Although recommendations for high-dose intravenous steroids in adrenally insufficient patients who are critically ill or undergoing surgery have been extensively discussed in the literature, there are relatively few data regarding the appropriate management of adrenal insufficiency in patients hospitalized for noncritical illness.

Several recent studies have investigated the patient characteristics, situations, and conditions most likely to provoke adrenal crisis in order to establish guidelines dictating the use of supra-physiologic steroid dosing.

Review of the Data

Studies have estimated the prevalence of adrenal crisis in patients with underlying insufficiency at 3.3 to 6.3 events per 100 patient years, with 42% of patients reporting at least one crisis.^2,5,6 A recent survey of 982 patients with Addison’s disease in the United Kingdom reported an 8% annual frequency.⁷

A retrospective Japanese study reviewed the medical charts of 137 adult patients receiving steroid replacement for established primary or secondary adrenal insufficiency. The authors noted a significant positive association between adrenal crisis and long-term steroid replacement (>4 years), concomitant mental disorder, and sex hormone deficiency. A combination of any of these factors further increased the risk.⁸

A more recent survey of 444 patients ages 17-81 assessed independent risk factors for adrenal crisis in the setting of primary (N=254) or secondary (N=190) adrenal insufficiency. The incidence of crisis was higher in primary versus secondary insufficiency. In patients with primary insufficiency, concomitant, non-endocrine disorders increased the risk of adrenal crisis, whereas diabetes insipidus and female gender increased risk in patients with secondary insufficiency. This same study also investigated events leading to a crisis and found gastrointestinal infection to be the most frequent factor, followed by other infectious or febrile illnesses. Overall, infection comprised 45% of all identified triggers.⁶

A similar study conducted by White and Arlt evaluated 841 Addison’s patients in the United Kingdom, Canada, Australia, and New Zealand.⁷ Again, gastrointestinal illness was the most common provoking factor, responsible for 56% of all reported crises. Flulike illness followed at 11%, followed by infections and surgical procedures at 6% each. This study found a higher risk of crisis in patients with diabetes (type I or II), premature ovarian failure, and asthma; the presence of multiple comorbidities further increased risk.

click for large version

Medications. Glucocorticoid therapy is known to suppress the HPA axis. Although it was once believed that the duration and dose of therapy correlated directly with the degree of HPA suppression, more recent studies have failed to find any definite relationship.⁹ Patients taking the equivalent of 5mg of prednisone per day should continue to have an intact HPA axis, as this dose mimics physiologic secretion of cortisol in a healthy individual.³

However, the dose and duration of therapy at which suppression occurs is highly variable between patients. In general, patients on 7.5mg of prednisone or more per day for at least three weeks should be considered to be suppressed.^3,9 Additionally, progesterone derivatives (i.e., megestrol) have glucocorticoid activity and might suppress HPA function. Other medications that might have related effects are those that inhibit enzymes involved in cortisol synthesis; ketoconazole and etomidate are common examples. Rifampin and several classes of anti-epileptic drugs induce enzymes, which increase hepatic metabolism of cortisol (see Table 1, p. 18).

Hyperthyroidism. Thyroid hormone is involved in the metabolism of cortisol, thus an increase in T4 correlates with lower levels. Adrenal insufficiency and thyroid disease might coexist within the autoimmune polyglandular syndrome. Initiation or uptitration of thyroid replacement should be avoided if acute adrenal insufficiency is suspected, as this might provoke an adrenal crisis. Conversely, any patient with adrenal insufficiency who has uncontrolled hyperthyroidism should receive two to three times their usual glucocorticoid replacement.^1,2

Pregnancy. Levels of cortisol-binding globulin increase throughout pregnancy. In women with intact adrenal function, free cortisol levels also rise during the third trimester. Therefore, glucocorticoid replacement should be increased by 50% during the last three months of pregnancy.²

click for large version

Acute illness. The cortisol response to stress is highly variable and dependent on a number of factors, including age, underlying health, and genetics. In general, most experts recommend doubling or tripling the daily replacement dose during mild to moderate illness until recovery (often referred to as the “sick-day rules”). What constitutes “recovery” is not clearly defined. When oral intake is compromised, as with vomiting or diarrhea, parenteral administration of steroids is recommended.^1-5,9,10 Patients with adrenal insufficiency should be provided an emergency injection kit to use and further counseled to seek medical attention. Injection kits typically consist of 100mg of hydrocortisone or 4mg of dexamethasone, although other glucocorticoids may be used (see Table 2, above left, for conversions).

Limited data are available to support guidelines for glucocorticoid adjustment during acute, non-critical illness. Published guidelines vary both in illness categorization and category-specific recommendations (see Table 3, below).

click for large version

Coursin and Wood devised a set of guidelines based on a literature review and consultation with experts, categorizing medical illness as minor, moderate, severe, and critical (see Table 3).³ For noncritical illness, they recommended continuation of standard replacement therapy with an additional, once-daily dose, which varied according to illness severity.

Cooper and Stewart conducted a similar review, basing their guidelines on a categorization of mild, moderate, severe/critical, or septic shock. These guidelines recommended a total daily dose of glucocorticoid supplementation, rather than an addition of a single dose to current therapy. They also stated that the least severe category of illness (defined as mild) did not require any change to a patient’s regular therapy.⁴

Jung et al classified illness as minimal, minor, moderate, severe, and critical.⁹ Under these guidelines, supplemental therapy was not advised for minimal (nonfebrile) illness. Moderate illness, including cellulitis, warranted a doubling or tripling of the outpatient dose until recovery, which was consistent with prior expert recommendation. More severe illness warranted intravenous administration of steroids.

Back to the Case

The patient had a mild case of cellulitis, classified by most experts as moderate illness, which responded well to vancomycin. Her outpatient glucocorticoid dose was doubled on admission and administered orally for the duration of her hospitalization, as she had no further episodes of vomiting or diarrhea.

Review of the patient’s records from prior hospitalizations and ambulatory visits revealed that her systolic blood pressure typically ran in the 80 mmHg to 100 mmHg range. Following initial volume resuscitation, her systolic blood pressure remained in the 90-100 mmHg range.

She was discharged home in stable condition, with instructions to complete a course of oral trimethoprim/sulfamethoxazole, resume her baseline dose of hydrocortisone the day after discharge, and follow up with her PCP for further monitoring and adjustment of her adrenal replacement therapy.

Bottom Line

For adults with adrenal insufficiency hospitalized with noncritical, nonsurgical illness, the expert recommendation is to double or triple the usual outpatient dose of glucocorticoid; however, data to support this is limited, and each patient should be assessed carefully and monitored to determine the optimal dose adjustment. TH

Dr. Shaw is a resident in the Department of Medicine at the University of Washington School of Medicine in Seattle. Dr. Best is an assistant professor of medicine in the division of general internal medicine, University of Washington School of Medicine.

References

1. Arlt W. The approach to the adult with newly diagnosed adrenal insufficiency. J Clin Endocrinol Metab. 2009;94(4):1059-1067.
2. Arlt W, Allolio B. Adrenal insufficiency. Lancet. 2003; 361:1881-1893.
3. Coursin DB, Wood KE. Corticosteroid supplementation for adrenal insufficiency. JAMA. 2002;287:236-240.
4. Cooper MS, Stewart PM. Corticosteroid insufficiency in acutely ill patients. N Engl J Med. 2003;348:727-734.
5. Hahner S, Allolio B. Therapeutic management of adrenal insufficiency. Best Pract Res Clin Endocrinol Metab. 2009;23:167-179.
6. Hahner S, Loeffler M, Bleicken B, et al. Epidemiology of adrenal crisis in chronic adrenal insufficiency: the need for new prevention strategies. Eur J Endocrinol. 2010;162:597:602.
7. White K, Arlt W. Adrenal crisis in treated Addison’s disease: a predictable but under-managed event. Eur J Endocrinol. 2010;162:115-120.
8. Omori K, Nomura K, Shimizu S, Omori N, Takano K. Risk factors for adrenal crises in patients with adrenal insufficiency. Endocr J. 2003;50:745-752.
9. Jung C, Inder WJ. Management of adrenal insufficiency during the stress of medical illness and surgery. Med J Aust. 2008;188:409-413.
10. Crown A, Lightman S. Why is the management of glucocorticoid deficiency still controversial: a review of the literature. Clin Endocrinol. 2005;63:483-492.

Although the term “hospitalist” was coined in 1996 in a New England Journal of Medicine article, the field of HM grew organically from pressure to optimize hospital economics and improve efficiency in economically pressed healthcare markets.¹

Scholarship in HM has also grown and now includes regular publications of investigations exploring optimization of efficiency and quality, many with an emphasis on patient safety. In this way, HM is a unique field, with tools for approaching problems that aren’t commonly used in other branches of medicine.

In parallel to the emergence of HM as a field distinct from general internal medicine (IM), the HM fellowship is similar but distinct. Such fellowships serve multiple purposes.

HM fellowships can add clinical expertise and scholarship skills for a career in HM. While early HM research focused on proving the value of the hospitalist model, the field has expanded greatly for those interested in an academic career. The molding of a safer, more efficient hospital of the future depends on the creativity and scholarship of HM leaders. Further, experts suggest that with its unique emphasis on quality, safety, and efficiency, the field will be a key player in healthcare reform.² Its strength lies in traditional clinical research, as well as further adoption of lessons from other fields including industry, ethnography, and public health.³ As such, fellowships to train future leaders and researchers is essential.

SHM’s website (www.hospitalmedicine.org/fellowships) lists dozens of IM hospitalist fellowships, as well as programs in family practice, pediatrics, and psychiatry. These programs last from one to three years, accept from one to six fellows per year, and exist in locations throughout the U.S. and Canada.

An excellent description of the nature and scope of pediatric HM fellowships was published last year in the Journal of Hospital Medicine.⁴ Descriptions of IM and HM fellowships also have been published.^3,5

Hospitalist fellowships, like IM fellowships, aren’t credentialed by a governing body. In contrast to subspecialty fellowships, no separate specialty board exam is required for admittance to the field after completion of fellowship. HM positions do not require training after residency, and HM job opportunities continue to outpace the available workforce. This is the basis for the most important question confronting anyone considering such a fellowship: How is a fellowship of benefit to a career as a hospitalist?

Program Types

Ranji and colleagues wrote that the “goal of hospital medicine fellowship training is to produce clinicians who are trained explicitly in studying and optimizing medical care of the hospitalized patient and in disseminating that knowledge for the advancement of patient care.”³ A review of information available for the different programs reveals two distinct approaches to this goal, with much overlap but distinct emphases:

Clinical programs usually last one year with a majority of time spent filling clinical responsibilities. In addition to providing focused exposure to HM with an emphasis on the Core Competencies in Hospital Medicine as outlined by SHM, such a program generally expands a trainee’s clinical scope. Additional training in palliative care, the management of neurologic emergencies, and comanagement of surgical patients are likely to be a part of clinical practice but often are underemphasized during residency. Research expectations vary, but most clinical programs allot some time for quality-improvement (QI) projects.

Clinical fellowships also afford more leadership training than most jobs would offer in the period immediately following residency. It also offers the possibility of refining clinical skills and developing a clinical niche.

Academic programs last two years and are characterized by two to four months of clinical responsibility per year. They offer a formal teaching curriculum and provide dedicated training in research, health policy, or health economics.³ Research training varies from program to program. Most include basic biostatistics and research-method coursework at a minimum; others offer the option to pursue a graduate degree in clinical research or public health.

Academic programs also offer dedicated research mentorship.

Other Considerations

The value of an HM fellowship lies in career development. The decision to commit to a relatively low-paying fellowship can be a difficult one, especially given the debt burden most graduating residents bear and the abundance of high-paying HM jobs. It also is important for those interested in a career as an academic hospitalist to consider not only HM fellowships, but other programs as well, such as the Robert Wood Johnson Clinical Scholars Program (rwjcsp.unc.edu/about/index.html).

While all of the fellowship programs aren’t geared specifically toward the hospitalist, they often incorporate faculty with expertise that would benefit a future academic hospitalist. Of course, the best fit for an individual depends on their particular interests and needs.

Fellowship in HM can offer training in clinical skills, clinical research, teaching, and quality and patient safety. Anyone interested in an HM career should consider a fellowship an opportunity for career development in a young specialty entrenched in revolutionizing the care of hospitalized patients. Academic HM fellowships hold the promise of empowering tomorrow’s academic leaders with the tools to continue to move the field forward. TH

Dr. Mann is a fellow in the division of hospital medicine, Department of Medicine, at Mount Sinai School of Medicine in New York City. Dr. Markoff is associate division chief and fellowship director in the division of hospital medicine, Department of Medicine, at Mount Sinai School of Medicine in New York City.

References

1. Wachter RM. Reflections: the hospitalist movement a decade later. J Hosp Med. 2006;1(4):248-252.
2. Wachter RM. Keynote presentation. SHM national meeting. National Harbor, Md.: May 2010.
3. Ranji SR, Rosenman DJ, Amin AN, Kripalani S. Hospital medicine fellowships: works in progress. Am J Med. 2006;119(1):72.e1-e7.
4. Freed GL, Dunham KM, Research advisory committee of the American Board of Pediatrics. Characteristics of pediatric hospital medicine fellowships and training programs. J Hosp Med. 2009;4:157-163.
5. Arora V, Fang MC, Kripalani S, Amin AN. Preparing for “diastole”: advanced training opportunities for academic hospitalists. J Hosp Med. 2006;1(6):368-377.

Although the term “hospitalist” was coined in 1996 in a New England Journal of Medicine article, the field of HM grew organically from pressure to optimize hospital economics and improve efficiency in economically pressed healthcare markets.¹

Scholarship in HM has also grown and now includes regular publications of investigations exploring optimization of efficiency and quality, many with an emphasis on patient safety. In this way, HM is a unique field, with tools for approaching problems that aren’t commonly used in other branches of medicine.

In parallel to the emergence of HM as a field distinct from general internal medicine (IM), the HM fellowship is similar but distinct. Such fellowships serve multiple purposes.

HM fellowships can add clinical expertise and scholarship skills for a career in HM. While early HM research focused on proving the value of the hospitalist model, the field has expanded greatly for those interested in an academic career. The molding of a safer, more efficient hospital of the future depends on the creativity and scholarship of HM leaders. Further, experts suggest that with its unique emphasis on quality, safety, and efficiency, the field will be a key player in healthcare reform.² Its strength lies in traditional clinical research, as well as further adoption of lessons from other fields including industry, ethnography, and public health.³ As such, fellowships to train future leaders and researchers is essential.

SHM’s website (www.hospitalmedicine.org/fellowships) lists dozens of IM hospitalist fellowships, as well as programs in family practice, pediatrics, and psychiatry. These programs last from one to three years, accept from one to six fellows per year, and exist in locations throughout the U.S. and Canada.

An excellent description of the nature and scope of pediatric HM fellowships was published last year in the Journal of Hospital Medicine.⁴ Descriptions of IM and HM fellowships also have been published.^3,5

Hospitalist fellowships, like IM fellowships, aren’t credentialed by a governing body. In contrast to subspecialty fellowships, no separate specialty board exam is required for admittance to the field after completion of fellowship. HM positions do not require training after residency, and HM job opportunities continue to outpace the available workforce. This is the basis for the most important question confronting anyone considering such a fellowship: How is a fellowship of benefit to a career as a hospitalist?

Program Types

Ranji and colleagues wrote that the “goal of hospital medicine fellowship training is to produce clinicians who are trained explicitly in studying and optimizing medical care of the hospitalized patient and in disseminating that knowledge for the advancement of patient care.”³ A review of information available for the different programs reveals two distinct approaches to this goal, with much overlap but distinct emphases:

Clinical programs usually last one year with a majority of time spent filling clinical responsibilities. In addition to providing focused exposure to HM with an emphasis on the Core Competencies in Hospital Medicine as outlined by SHM, such a program generally expands a trainee’s clinical scope. Additional training in palliative care, the management of neurologic emergencies, and comanagement of surgical patients are likely to be a part of clinical practice but often are underemphasized during residency. Research expectations vary, but most clinical programs allot some time for quality-improvement (QI) projects.

Clinical fellowships also afford more leadership training than most jobs would offer in the period immediately following residency. It also offers the possibility of refining clinical skills and developing a clinical niche.

Academic programs last two years and are characterized by two to four months of clinical responsibility per year. They offer a formal teaching curriculum and provide dedicated training in research, health policy, or health economics.³ Research training varies from program to program. Most include basic biostatistics and research-method coursework at a minimum; others offer the option to pursue a graduate degree in clinical research or public health.

Academic programs also offer dedicated research mentorship.

Other Considerations

The value of an HM fellowship lies in career development. The decision to commit to a relatively low-paying fellowship can be a difficult one, especially given the debt burden most graduating residents bear and the abundance of high-paying HM jobs. It also is important for those interested in a career as an academic hospitalist to consider not only HM fellowships, but other programs as well, such as the Robert Wood Johnson Clinical Scholars Program (rwjcsp.unc.edu/about/index.html).

While all of the fellowship programs aren’t geared specifically toward the hospitalist, they often incorporate faculty with expertise that would benefit a future academic hospitalist. Of course, the best fit for an individual depends on their particular interests and needs.

Fellowship in HM can offer training in clinical skills, clinical research, teaching, and quality and patient safety. Anyone interested in an HM career should consider a fellowship an opportunity for career development in a young specialty entrenched in revolutionizing the care of hospitalized patients. Academic HM fellowships hold the promise of empowering tomorrow’s academic leaders with the tools to continue to move the field forward. TH

Dr. Mann is a fellow in the division of hospital medicine, Department of Medicine, at Mount Sinai School of Medicine in New York City. Dr. Markoff is associate division chief and fellowship director in the division of hospital medicine, Department of Medicine, at Mount Sinai School of Medicine in New York City.

References

1. Wachter RM. Reflections: the hospitalist movement a decade later. J Hosp Med. 2006;1(4):248-252.
2. Wachter RM. Keynote presentation. SHM national meeting. National Harbor, Md.: May 2010.
3. Ranji SR, Rosenman DJ, Amin AN, Kripalani S. Hospital medicine fellowships: works in progress. Am J Med. 2006;119(1):72.e1-e7.
4. Freed GL, Dunham KM, Research advisory committee of the American Board of Pediatrics. Characteristics of pediatric hospital medicine fellowships and training programs. J Hosp Med. 2009;4:157-163.
5. Arora V, Fang MC, Kripalani S, Amin AN. Preparing for “diastole”: advanced training opportunities for academic hospitalists. J Hosp Med. 2006;1(6):368-377.

Although the term “hospitalist” was coined in 1996 in a New England Journal of Medicine article, the field of HM grew organically from pressure to optimize hospital economics and improve efficiency in economically pressed healthcare markets.¹

Scholarship in HM has also grown and now includes regular publications of investigations exploring optimization of efficiency and quality, many with an emphasis on patient safety. In this way, HM is a unique field, with tools for approaching problems that aren’t commonly used in other branches of medicine.

In parallel to the emergence of HM as a field distinct from general internal medicine (IM), the HM fellowship is similar but distinct. Such fellowships serve multiple purposes.

HM fellowships can add clinical expertise and scholarship skills for a career in HM. While early HM research focused on proving the value of the hospitalist model, the field has expanded greatly for those interested in an academic career. The molding of a safer, more efficient hospital of the future depends on the creativity and scholarship of HM leaders. Further, experts suggest that with its unique emphasis on quality, safety, and efficiency, the field will be a key player in healthcare reform.² Its strength lies in traditional clinical research, as well as further adoption of lessons from other fields including industry, ethnography, and public health.³ As such, fellowships to train future leaders and researchers is essential.

SHM’s website (www.hospitalmedicine.org/fellowships) lists dozens of IM hospitalist fellowships, as well as programs in family practice, pediatrics, and psychiatry. These programs last from one to three years, accept from one to six fellows per year, and exist in locations throughout the U.S. and Canada.

An excellent description of the nature and scope of pediatric HM fellowships was published last year in the Journal of Hospital Medicine.⁴ Descriptions of IM and HM fellowships also have been published.^3,5

Hospitalist fellowships, like IM fellowships, aren’t credentialed by a governing body. In contrast to subspecialty fellowships, no separate specialty board exam is required for admittance to the field after completion of fellowship. HM positions do not require training after residency, and HM job opportunities continue to outpace the available workforce. This is the basis for the most important question confronting anyone considering such a fellowship: How is a fellowship of benefit to a career as a hospitalist?

Program Types

Ranji and colleagues wrote that the “goal of hospital medicine fellowship training is to produce clinicians who are trained explicitly in studying and optimizing medical care of the hospitalized patient and in disseminating that knowledge for the advancement of patient care.”³ A review of information available for the different programs reveals two distinct approaches to this goal, with much overlap but distinct emphases:

Clinical programs usually last one year with a majority of time spent filling clinical responsibilities. In addition to providing focused exposure to HM with an emphasis on the Core Competencies in Hospital Medicine as outlined by SHM, such a program generally expands a trainee’s clinical scope. Additional training in palliative care, the management of neurologic emergencies, and comanagement of surgical patients are likely to be a part of clinical practice but often are underemphasized during residency. Research expectations vary, but most clinical programs allot some time for quality-improvement (QI) projects.

Clinical fellowships also afford more leadership training than most jobs would offer in the period immediately following residency. It also offers the possibility of refining clinical skills and developing a clinical niche.

Academic programs last two years and are characterized by two to four months of clinical responsibility per year. They offer a formal teaching curriculum and provide dedicated training in research, health policy, or health economics.³ Research training varies from program to program. Most include basic biostatistics and research-method coursework at a minimum; others offer the option to pursue a graduate degree in clinical research or public health.

Academic programs also offer dedicated research mentorship.

Other Considerations

The value of an HM fellowship lies in career development. The decision to commit to a relatively low-paying fellowship can be a difficult one, especially given the debt burden most graduating residents bear and the abundance of high-paying HM jobs. It also is important for those interested in a career as an academic hospitalist to consider not only HM fellowships, but other programs as well, such as the Robert Wood Johnson Clinical Scholars Program (rwjcsp.unc.edu/about/index.html).

While all of the fellowship programs aren’t geared specifically toward the hospitalist, they often incorporate faculty with expertise that would benefit a future academic hospitalist. Of course, the best fit for an individual depends on their particular interests and needs.

Fellowship in HM can offer training in clinical skills, clinical research, teaching, and quality and patient safety. Anyone interested in an HM career should consider a fellowship an opportunity for career development in a young specialty entrenched in revolutionizing the care of hospitalized patients. Academic HM fellowships hold the promise of empowering tomorrow’s academic leaders with the tools to continue to move the field forward. TH

Dr. Mann is a fellow in the division of hospital medicine, Department of Medicine, at Mount Sinai School of Medicine in New York City. Dr. Markoff is associate division chief and fellowship director in the division of hospital medicine, Department of Medicine, at Mount Sinai School of Medicine in New York City.

References

1. Wachter RM. Reflections: the hospitalist movement a decade later. J Hosp Med. 2006;1(4):248-252.
2. Wachter RM. Keynote presentation. SHM national meeting. National Harbor, Md.: May 2010.
3. Ranji SR, Rosenman DJ, Amin AN, Kripalani S. Hospital medicine fellowships: works in progress. Am J Med. 2006;119(1):72.e1-e7.
4. Freed GL, Dunham KM, Research advisory committee of the American Board of Pediatrics. Characteristics of pediatric hospital medicine fellowships and training programs. J Hosp Med. 2009;4:157-163.
5. Arora V, Fang MC, Kripalani S, Amin AN. Preparing for “diastole”: advanced training opportunities for academic hospitalists. J Hosp Med. 2006;1(6):368-377.

Recent media reports about the dangers surrounding unused prescription medications, including abuse by teens and medications finding their way into the water supply, have prompted an increase in inquiries to healthcare providers about disposing of unused medication. These issues are complicated when controlled substances are involved.

Often, providers are unsure how to respond to patient questions about medication disposal. For example, what would you do if a patient requests an alternative medication because of an unwanted side effect and brings the originally prescribed medication back to you? What if the family of a recently expired patient brings unused medication to you and asks you to donate it to other patients? What if you have a colleague who performs mission work; could you accept and donate unused medication for use in another country?

Unfortunately, the Controlled Substances Act (CSA) does not provide a readily available mechanism to accomplish efficient, secure, and environmentally sound methods to collect and use or dispose of unwanted controlled substances. This article explains the rules physicians must adhere to and guidelines for “taking back” controlled substances.

The Legislation

Enacted in 1970, the CSA combined all existing federal drug laws into a single statute. It created five “schedules” in which certain drugs are classified. These “scheduled” drugs are commonly referred to as controlled substances. A drug’s classification depends on its potential for abuse and its currently accepted medical use in the U.S. Additionally, provisions of international treaties impact classification.

Under the classification system, Schedule I drugs have a high potential for abuse and have no currently accepted medical use in treatment in the U.S. In contrast, Schedule V drugs have a low potential for abuse and do have a currently accepted medical use in treatment in the U.S.

The CSA governs the manufacture, import, export, possession, use, and distribution of controlled substances. In doing so, the CSA established a system to register those authorized to handle controlled substances. Manufacturers, dispensers, distributors, and individual practitioners who prescribe controlled substances must be registered with the Drug Enforcement Administration (DEA).

The CSA requires registrants to keep certain records for at least two years related to their handling of controlled substances. For example, physician registrants must keep records of controlled substances in Schedules II, III, IV, and V that are dispensed via methods other than prescribing or administering (e.g., industry samples). Inventories of controlled substances are required. Most notably, physicians generally are not required to keep records of prescribed medications; however, records must be kept if drugs are dispensed or administered. Moreover, there are heightened recordkeeping responsibilities for providers who prescribe, dispense, or administer for maintenance or detoxification.

Controlled Substance “Takeback”

The system of registration established by the CSA prohibits a DEA registrant from acquiring controlled substances from nonregistered entities and, in turn, bars an end-user from distributing pharmaceutical controlled substances to a DEA registrant. In other words, physicians cannot receive controlled substances from anyone who does not also have a registration. Thus, physicians may not “take back” prescribed medications from patients or their family members. Similarly, except in cases of a drug being recalled or a dispensing error, patients are not allowed to return controlled medications to a pharmacy.

Information on how a patient or family member should properly dispose of medication is commonly misunderstood. DEA regulations provide a process for nonregistrants to dispose of unused medication; however, it is cumbersome and meant to be used only when dealing with large quantities of controlled substances (e.g., large quantities of abandoned drugs). In such cases, the DEA special agent in charge (SAC) may instruct on disposal, which may include transfer of the substance to a DEA registrant, delivery to a DEA agent or office, destruction in the presence of an agent of the administration or other authorized person, or by other means. The person must submit a letter to the local SAC, which includes:

• Name and address of the person;
• Name and quantity of each controlled substance to be disposed of;
• Explanation of how the applicant obtained the controlled substance, if known; and
• Name, address, and registration number, if known, of the person who possessed the controlled substances prior to the applicant.

Federal legislation also provides a way for the DEA to grant approval to law-enforcement agencies to operate “takeback” programs. The regulation states that “any person in possession of a controlled substance and desiring to dispose of such substance may request assistance from the SAC in the area in which the person is located.” The regulation allows the SAC to authorize and specify the means of disposal to assure that the controlled substances do not become available to unauthorized persons.

State and local government agencies and community associations might hold takeback programs only if law enforcement makes the request, takes custody of the controlled substances, and is responsible for the disposal.

The U.S. Office of National Drug Control Policy has published guidelines for medication disposal. These guidelines advise flushing medications only if the prescription label or accompanying patient information specifically states to do so. Instead of flushing, the guidelines recommend that medications be disposed of through a takeback program or by:

• Taking the prescription drugs out of their original containers;
• Mixing the drugs with an undesirable substance, such as cat litter or used coffee grounds;
• Placing the mixture into a disposable container with a lid, such as an empty margarine tub, or into a sealable bag;
• Concealing or removing personal information, including Rx number, on the empty containers by covering it with black permanent marker or duct tape, or by scratching it off; and
• Placing the sealed container with the mixture, and the empty drug containers, in the trash.

Unused Medication Donation

The rising cost of prescription medication leaves many questioning whether there is a need for a safe method to allow unused medication to be donated to others. At least 10 states have passed laws allowing or encouraging the donation of unused pharmaceutical drugs. Many of these programs involve healthcare facilities, nursing homes, or pharmacies. The CSA and current DEA regulations, however, prohibit patients from delivering or distributing controlled substances to a DEA registrant, even if it is for the purpose of a donation. Moreover, the Food and Drug Administration (FDA) does not permit redistribution of medications, except under limited circumstances.

Consequently, state law may be inconsistent with federal law for donation and reuse of controlled substances.

Conclusion

Physicians who fail to comply with CSA handling requirements are subject to criminal charges, discipline against their DEA registration, and discipline against their license to practice medicine. Consequently, physicians should use caution whenever handling unused medication.

The application of various aspects of the CSA and implementing rules is situation-specific. Moreover, the DEA may issue additional regulations. Accordingly, if you have a question about a specific situation, consult an attorney, or contact your local DEA field division office and ask for the diversion duty agent. TH

Patrick O’Rourke works in the Office of University Counsel, Department of Litigation, University of Colorado Denver.

Recent media reports about the dangers surrounding unused prescription medications, including abuse by teens and medications finding their way into the water supply, have prompted an increase in inquiries to healthcare providers about disposing of unused medication. These issues are complicated when controlled substances are involved.

Often, providers are unsure how to respond to patient questions about medication disposal. For example, what would you do if a patient requests an alternative medication because of an unwanted side effect and brings the originally prescribed medication back to you? What if the family of a recently expired patient brings unused medication to you and asks you to donate it to other patients? What if you have a colleague who performs mission work; could you accept and donate unused medication for use in another country?

Unfortunately, the Controlled Substances Act (CSA) does not provide a readily available mechanism to accomplish efficient, secure, and environmentally sound methods to collect and use or dispose of unwanted controlled substances. This article explains the rules physicians must adhere to and guidelines for “taking back” controlled substances.

The Legislation

Enacted in 1970, the CSA combined all existing federal drug laws into a single statute. It created five “schedules” in which certain drugs are classified. These “scheduled” drugs are commonly referred to as controlled substances. A drug’s classification depends on its potential for abuse and its currently accepted medical use in the U.S. Additionally, provisions of international treaties impact classification.

Under the classification system, Schedule I drugs have a high potential for abuse and have no currently accepted medical use in treatment in the U.S. In contrast, Schedule V drugs have a low potential for abuse and do have a currently accepted medical use in treatment in the U.S.

The CSA governs the manufacture, import, export, possession, use, and distribution of controlled substances. In doing so, the CSA established a system to register those authorized to handle controlled substances. Manufacturers, dispensers, distributors, and individual practitioners who prescribe controlled substances must be registered with the Drug Enforcement Administration (DEA).

The CSA requires registrants to keep certain records for at least two years related to their handling of controlled substances. For example, physician registrants must keep records of controlled substances in Schedules II, III, IV, and V that are dispensed via methods other than prescribing or administering (e.g., industry samples). Inventories of controlled substances are required. Most notably, physicians generally are not required to keep records of prescribed medications; however, records must be kept if drugs are dispensed or administered. Moreover, there are heightened recordkeeping responsibilities for providers who prescribe, dispense, or administer for maintenance or detoxification.

Controlled Substance “Takeback”

The system of registration established by the CSA prohibits a DEA registrant from acquiring controlled substances from nonregistered entities and, in turn, bars an end-user from distributing pharmaceutical controlled substances to a DEA registrant. In other words, physicians cannot receive controlled substances from anyone who does not also have a registration. Thus, physicians may not “take back” prescribed medications from patients or their family members. Similarly, except in cases of a drug being recalled or a dispensing error, patients are not allowed to return controlled medications to a pharmacy.

Information on how a patient or family member should properly dispose of medication is commonly misunderstood. DEA regulations provide a process for nonregistrants to dispose of unused medication; however, it is cumbersome and meant to be used only when dealing with large quantities of controlled substances (e.g., large quantities of abandoned drugs). In such cases, the DEA special agent in charge (SAC) may instruct on disposal, which may include transfer of the substance to a DEA registrant, delivery to a DEA agent or office, destruction in the presence of an agent of the administration or other authorized person, or by other means. The person must submit a letter to the local SAC, which includes:

• Name and address of the person;
• Name and quantity of each controlled substance to be disposed of;
• Explanation of how the applicant obtained the controlled substance, if known; and
• Name, address, and registration number, if known, of the person who possessed the controlled substances prior to the applicant.

Federal legislation also provides a way for the DEA to grant approval to law-enforcement agencies to operate “takeback” programs. The regulation states that “any person in possession of a controlled substance and desiring to dispose of such substance may request assistance from the SAC in the area in which the person is located.” The regulation allows the SAC to authorize and specify the means of disposal to assure that the controlled substances do not become available to unauthorized persons.

State and local government agencies and community associations might hold takeback programs only if law enforcement makes the request, takes custody of the controlled substances, and is responsible for the disposal.

The U.S. Office of National Drug Control Policy has published guidelines for medication disposal. These guidelines advise flushing medications only if the prescription label or accompanying patient information specifically states to do so. Instead of flushing, the guidelines recommend that medications be disposed of through a takeback program or by:

• Taking the prescription drugs out of their original containers;
• Mixing the drugs with an undesirable substance, such as cat litter or used coffee grounds;
• Placing the mixture into a disposable container with a lid, such as an empty margarine tub, or into a sealable bag;
• Concealing or removing personal information, including Rx number, on the empty containers by covering it with black permanent marker or duct tape, or by scratching it off; and
• Placing the sealed container with the mixture, and the empty drug containers, in the trash.

Unused Medication Donation

The rising cost of prescription medication leaves many questioning whether there is a need for a safe method to allow unused medication to be donated to others. At least 10 states have passed laws allowing or encouraging the donation of unused pharmaceutical drugs. Many of these programs involve healthcare facilities, nursing homes, or pharmacies. The CSA and current DEA regulations, however, prohibit patients from delivering or distributing controlled substances to a DEA registrant, even if it is for the purpose of a donation. Moreover, the Food and Drug Administration (FDA) does not permit redistribution of medications, except under limited circumstances.

Consequently, state law may be inconsistent with federal law for donation and reuse of controlled substances.

Conclusion

Physicians who fail to comply with CSA handling requirements are subject to criminal charges, discipline against their DEA registration, and discipline against their license to practice medicine. Consequently, physicians should use caution whenever handling unused medication.

The application of various aspects of the CSA and implementing rules is situation-specific. Moreover, the DEA may issue additional regulations. Accordingly, if you have a question about a specific situation, consult an attorney, or contact your local DEA field division office and ask for the diversion duty agent. TH

Patrick O’Rourke works in the Office of University Counsel, Department of Litigation, University of Colorado Denver.

Recent media reports about the dangers surrounding unused prescription medications, including abuse by teens and medications finding their way into the water supply, have prompted an increase in inquiries to healthcare providers about disposing of unused medication. These issues are complicated when controlled substances are involved.

Often, providers are unsure how to respond to patient questions about medication disposal. For example, what would you do if a patient requests an alternative medication because of an unwanted side effect and brings the originally prescribed medication back to you? What if the family of a recently expired patient brings unused medication to you and asks you to donate it to other patients? What if you have a colleague who performs mission work; could you accept and donate unused medication for use in another country?

Unfortunately, the Controlled Substances Act (CSA) does not provide a readily available mechanism to accomplish efficient, secure, and environmentally sound methods to collect and use or dispose of unwanted controlled substances. This article explains the rules physicians must adhere to and guidelines for “taking back” controlled substances.

The Legislation

Enacted in 1970, the CSA combined all existing federal drug laws into a single statute. It created five “schedules” in which certain drugs are classified. These “scheduled” drugs are commonly referred to as controlled substances. A drug’s classification depends on its potential for abuse and its currently accepted medical use in the U.S. Additionally, provisions of international treaties impact classification.

Under the classification system, Schedule I drugs have a high potential for abuse and have no currently accepted medical use in treatment in the U.S. In contrast, Schedule V drugs have a low potential for abuse and do have a currently accepted medical use in treatment in the U.S.

The CSA governs the manufacture, import, export, possession, use, and distribution of controlled substances. In doing so, the CSA established a system to register those authorized to handle controlled substances. Manufacturers, dispensers, distributors, and individual practitioners who prescribe controlled substances must be registered with the Drug Enforcement Administration (DEA).

The CSA requires registrants to keep certain records for at least two years related to their handling of controlled substances. For example, physician registrants must keep records of controlled substances in Schedules II, III, IV, and V that are dispensed via methods other than prescribing or administering (e.g., industry samples). Inventories of controlled substances are required. Most notably, physicians generally are not required to keep records of prescribed medications; however, records must be kept if drugs are dispensed or administered. Moreover, there are heightened recordkeeping responsibilities for providers who prescribe, dispense, or administer for maintenance or detoxification.

Controlled Substance “Takeback”

The system of registration established by the CSA prohibits a DEA registrant from acquiring controlled substances from nonregistered entities and, in turn, bars an end-user from distributing pharmaceutical controlled substances to a DEA registrant. In other words, physicians cannot receive controlled substances from anyone who does not also have a registration. Thus, physicians may not “take back” prescribed medications from patients or their family members. Similarly, except in cases of a drug being recalled or a dispensing error, patients are not allowed to return controlled medications to a pharmacy.

Information on how a patient or family member should properly dispose of medication is commonly misunderstood. DEA regulations provide a process for nonregistrants to dispose of unused medication; however, it is cumbersome and meant to be used only when dealing with large quantities of controlled substances (e.g., large quantities of abandoned drugs). In such cases, the DEA special agent in charge (SAC) may instruct on disposal, which may include transfer of the substance to a DEA registrant, delivery to a DEA agent or office, destruction in the presence of an agent of the administration or other authorized person, or by other means. The person must submit a letter to the local SAC, which includes:

• Name and address of the person;
• Name and quantity of each controlled substance to be disposed of;
• Explanation of how the applicant obtained the controlled substance, if known; and
• Name, address, and registration number, if known, of the person who possessed the controlled substances prior to the applicant.

Federal legislation also provides a way for the DEA to grant approval to law-enforcement agencies to operate “takeback” programs. The regulation states that “any person in possession of a controlled substance and desiring to dispose of such substance may request assistance from the SAC in the area in which the person is located.” The regulation allows the SAC to authorize and specify the means of disposal to assure that the controlled substances do not become available to unauthorized persons.

State and local government agencies and community associations might hold takeback programs only if law enforcement makes the request, takes custody of the controlled substances, and is responsible for the disposal.

The U.S. Office of National Drug Control Policy has published guidelines for medication disposal. These guidelines advise flushing medications only if the prescription label or accompanying patient information specifically states to do so. Instead of flushing, the guidelines recommend that medications be disposed of through a takeback program or by:

• Taking the prescription drugs out of their original containers;
• Mixing the drugs with an undesirable substance, such as cat litter or used coffee grounds;
• Placing the mixture into a disposable container with a lid, such as an empty margarine tub, or into a sealable bag;
• Concealing or removing personal information, including Rx number, on the empty containers by covering it with black permanent marker or duct tape, or by scratching it off; and
• Placing the sealed container with the mixture, and the empty drug containers, in the trash.

Unused Medication Donation

The rising cost of prescription medication leaves many questioning whether there is a need for a safe method to allow unused medication to be donated to others. At least 10 states have passed laws allowing or encouraging the donation of unused pharmaceutical drugs. Many of these programs involve healthcare facilities, nursing homes, or pharmacies. The CSA and current DEA regulations, however, prohibit patients from delivering or distributing controlled substances to a DEA registrant, even if it is for the purpose of a donation. Moreover, the Food and Drug Administration (FDA) does not permit redistribution of medications, except under limited circumstances.

Consequently, state law may be inconsistent with federal law for donation and reuse of controlled substances.

Conclusion

Physicians who fail to comply with CSA handling requirements are subject to criminal charges, discipline against their DEA registration, and discipline against their license to practice medicine. Consequently, physicians should use caution whenever handling unused medication.

The application of various aspects of the CSA and implementing rules is situation-specific. Moreover, the DEA may issue additional regulations. Accordingly, if you have a question about a specific situation, consult an attorney, or contact your local DEA field division office and ask for the diversion duty agent. TH

Patrick O’Rourke works in the Office of University Counsel, Department of Litigation, University of Colorado Denver.

From the outset, HM has been about efficiency. And there was nothing wrong with that, for value is quality divided by cost. But in our story, we found that mere efficiency was not enough: The lowering of the denominator (cost) had to be met with an escalation of the numerator (quality) to ensure value.

And see us as being born in the right place at the right time. For with the national focus turning to the need for quality and patient safety, hospital medicine was in the right place and the right time to heed the call to action: appropriately stepping up to enact efforts to make the slope of the line (on a chart of quality vs. cost) “STEEEPER” … finding systems innovations to make care Safe, Timely, Efficient, Effective, Equitable, and Patient-centered.

Of course, the story continued with the Affordable Care Act and healthcare reform, greatly accelerating our evolution as change agents. And now we find ourselves fully invested in a “change the system” mentality, perfectly positioned to meaningfully change healthcare for millions of people. But threats loom—specifically, the “R” in the STEEEPER mnemonic: the risks to quality in the face of healthcare reform.

So in the next chapter of our story, I present to you our challenge: how to overcome the threats to quality in the context of healthcare reform. The first three are presented here; in subsequent articles, I will address the remainder. Overcoming all threats will hinge on mastering the four truisms of cultural change:

1. Systems drive function;
2. Every system is perfectly designed to produce the outcomes that it does;
3. This is not an issue of people needing to try harder; and
4. The “no blame” culture begins with a paradigm shift from the “person at fault” to the “system at fault.”

Threat 1: Failure to Fund Quality

SHM elected to merge its annual State of Hospital Medicine survey with the MGMA. Though not without risk, this has resulted in the anticipated benefits. The MGMA collaboration brings greater leverage in working with the C-suite, which is pre-programmed to react to MGMA surveys. From the most recent MGMA survey comes good news: The financial compensation for hospitalists has increased. A sobering insight, however, is that this increase in compensation has been met with a corresponding increase in work intensity—RVUs. Further, the link between RVUs and compensation appears to be tightening, quantifying what has long been of concern: The time devoted to the nonclinical “value added” duties of the hospitalist is shrinking.

The threat to the culture of quality is captured in the single question: How many RVUs is a quality-improvement (QI) project worth? I’m not sure we have that answer. But without an answer, it is difficult to believe that meaningful QI can be expected without time to do so. And again, as the gap between compensation and RVUs narrows, one is left wondering if there will soon be a day where there is no value-added time remaining to perform QI at all.

Fortunately, the Affordable Care Act might provide some movement in the right direction via value-based purchasing. Linking quality outcomes to financial reimbursement is a big step forward in the hospitalist’s quest to leverage the C-suite in trading RVUs for devoted QI time. Although we still are left asking the question of how many RVUs a QI project is worth, value-based purchasing at least sets the stage for the conversation. But in the interim, it is still upon hospitalists to design these QI projects, and to learn the skills necessary to see the design to its fruition.

Threat 2: Quality Stops at Core Measures

It is hard to argue that fulfilling “core measures” is a bad thing. Nonetheless, the core measures were not meant to be quality; instead, they were meant as surrogate measures of quality. The presumption of the core-measures initiative is that the system would exist without direct attention to the core measures, operating as it ordinarily would with generic attention to meeting all standards of quality for all diseases. And at some point in time, the core measures would be assessed to give an overall assessment of the system’s quality.

What has evolved, however, is a concerted attention to meeting the core measures, with little regard to the overall culture of quality.

Let’s say you were tasked with improving the public school system in your state. As a measure of the improvement, you choose five of the 1,000 schools as “core measure” schools. The state board of education is told that the performance of these five sample schools will be assessed at the end of the year, and financial support for the system as a whole will hinge on their performance. The intended result is that attention would be paid to improving the performance of every school in the system, and this improvement would be reflected in the performance of the five sample schools. The board of education could take the route of improving all schools, but the more pragmatic route would be to funnel all resources into these five schools, to the detriment of resources for the other 995 schools. The performance of the core measure schools would dramatically improve, and funding would be secured. But ask yourself: Did the performance of the school system as a whole actually improve?

Such is the risk of the core measures in healthcare. The original intent of the core measures was to instill a culture of QI for all points of care. And this has been a valuable contribution to changing the consciousness of the healthcare system. The presumption was that the core measures would be “seeds,” and that by emphasizing these select measures, the QI culture eventually would spread to all aspects of patient care. But this plan hinged on the presumption that that there is an unlimited amount of mental energy and resources to be devoted to all tasks within healthcare. The reality is that there is a fixed amount of intellectual energy and resources to be devoted to the various aspects of healthcare. One wonders if the overemphasis on meeting the core measures might actually have taken the wind out of the sails for QI in other non-core-measure patient care.

The implications are twofold. By definition, a core measure has to be applicable to all healthcare systems, and with a fixed amount of mental energy and resources, there is a real risk that what portion is reserved for QI finds its way only to the core indicators, especially if they are overemphasized in the system. The second implication is captured in our experience with time to antibiotics. With meeting the core indicator as the priority, many systems instituted the “work-around”: Give antibiotics to every patient presenting to the ED, and you will be sure to have met the four-hour window in the core indicator. The result was an exponential increase in inappropriate antibiotic administration and radiographic tests, all because meeting the indicator became more important than the overall goal.

As stewards of the hospital system, it is upon us to ensure that the original intent of core measures remains secure: The core measures seed a culture of quality, but do not become ends in and of themselves. QI apart from the core measures must remain an equal priority, and it is the hospitalist who will be central in ensuring this comes to fruition.

Threat 3: Misplaced Incentives

There is an interesting anecdote in Steven Levitt and Stephen Dubner’s book Freakonomics.¹ The story begins with a daycare center struggling with a problem: Some parents are showing up late to pick up their children at the end of the day, and this is costing the center in the way of overtime charges for the staff. To solve the problem, the center elects to institute a financial disincentive: Those showing up late to pick up their children will pay a modest financial penalty.

Fast-forward to months after the policy was put in place. The result? An exponential increase in the number of parents showing up late to pick up their children.

How do you explain worsening performance in spite of a financial disincentive? The answer resides in understanding human behavior. According to the authors, there are three primary motivations in life: financial, social, and moral. As ugly as it sounds, the decisions people make in life are driven by one of these three motivations. There is nothing wrong with providing incentives for behavior; incentives work.

But the danger arises when incentives are mismatched to behaviors. For example, if a financial outcome is the goal, then financial incentives make sense. If a social outcome (people should play better as a team) is the goal, the social incentives make sense (public recognition). But when the incentives get misaligned with their respective goals, trouble results.

What went wrong with the daycare’s plan is simple—most of the parents were motivated to pick up their children on time out of moral (“I gave my word”) or social (“I don’t want to be talked about by other parents”) incentives. But once a financial incentive was offered, the daycare center had essentially given the parents a way out in absolving their social and moral obligations. The parents had essentially cost-adjusted their behavior.

If you think this couldn’t happen to the healthcare system, let me ask you this. As a hospitalist, I see all of my patients early in the morning, because I see it as part of my obligation to the hospital team to discharge patients by 11 a.m. (social motivation).

But what if the CEO released this directive: “You will see all of your patients early in the morning, or you will take a $1,000 a year pay cut.” Is it possible that I might cost-adjust the $1,000 in exchange for sleeping in a little later and not having to deal with the morning traffic? I don’t know.

When it comes to financial incentives, there is a valley in the U-shaped curve. When the financial incentive is trivial, it is disregarded and the social/moral motivations of behavior persist (the kids are picked up on time; I persist in seeing patients early in the morning). When the financial incentive is huge, the financial incentive trumps all social/moral motivations, ensuring compliance with the goal behavior (every kid is picked up on time to avoid a penalty; I see all patients early in the day to avoid a larger penalty).

But in between is the risk zone: When the person feels they are paying an appropriate penance for not complying with the goal behavior, the financial disincentive absolves any social/moral guilt.

Healthcare reform is about incentives—and there is nothing wrong with that. But as the stewards of the inpatient healthcare system, it is upon us as hospitalists to ensure that the incentives remain matched to their intended goals, and that the untoward consequences of the incentives do not adversely affect the quality and safety of a patient’s care.

It is safe to say that the Affordable Care Act of 2010 moves us closer to a true environment of quality and patient safety. But it is equally safe to say that meaningful change will require more than what the law can provide. As stewards of the inpatient system, we have a responsibility to ensure that the healthcare system, particularly in how it responds to incentives, evolves to remain patient-centered, effective, and safe.

The next chapter in our story—the hospitalists’ story—will be one of accountability and responsibility. While there are things the government can do, the majority of what needs to be done will come directly from us. TH

Dr. Wiese is president of SHM.

Reference

1. Levitt SD, Dubner SJ. Freakonomics: A Rogue Economist Explores the Hidden Side of Everything. New York City: William Morrow; 2005.

From the outset, HM has been about efficiency. And there was nothing wrong with that, for value is quality divided by cost. But in our story, we found that mere efficiency was not enough: The lowering of the denominator (cost) had to be met with an escalation of the numerator (quality) to ensure value.

And see us as being born in the right place at the right time. For with the national focus turning to the need for quality and patient safety, hospital medicine was in the right place and the right time to heed the call to action: appropriately stepping up to enact efforts to make the slope of the line (on a chart of quality vs. cost) “STEEEPER” … finding systems innovations to make care Safe, Timely, Efficient, Effective, Equitable, and Patient-centered.

Of course, the story continued with the Affordable Care Act and healthcare reform, greatly accelerating our evolution as change agents. And now we find ourselves fully invested in a “change the system” mentality, perfectly positioned to meaningfully change healthcare for millions of people. But threats loom—specifically, the “R” in the STEEEPER mnemonic: the risks to quality in the face of healthcare reform.

So in the next chapter of our story, I present to you our challenge: how to overcome the threats to quality in the context of healthcare reform. The first three are presented here; in subsequent articles, I will address the remainder. Overcoming all threats will hinge on mastering the four truisms of cultural change:

1. Systems drive function;
2. Every system is perfectly designed to produce the outcomes that it does;
3. This is not an issue of people needing to try harder; and
4. The “no blame” culture begins with a paradigm shift from the “person at fault” to the “system at fault.”

Threat 1: Failure to Fund Quality

SHM elected to merge its annual State of Hospital Medicine survey with the MGMA. Though not without risk, this has resulted in the anticipated benefits. The MGMA collaboration brings greater leverage in working with the C-suite, which is pre-programmed to react to MGMA surveys. From the most recent MGMA survey comes good news: The financial compensation for hospitalists has increased. A sobering insight, however, is that this increase in compensation has been met with a corresponding increase in work intensity—RVUs. Further, the link between RVUs and compensation appears to be tightening, quantifying what has long been of concern: The time devoted to the nonclinical “value added” duties of the hospitalist is shrinking.

The threat to the culture of quality is captured in the single question: How many RVUs is a quality-improvement (QI) project worth? I’m not sure we have that answer. But without an answer, it is difficult to believe that meaningful QI can be expected without time to do so. And again, as the gap between compensation and RVUs narrows, one is left wondering if there will soon be a day where there is no value-added time remaining to perform QI at all.

Fortunately, the Affordable Care Act might provide some movement in the right direction via value-based purchasing. Linking quality outcomes to financial reimbursement is a big step forward in the hospitalist’s quest to leverage the C-suite in trading RVUs for devoted QI time. Although we still are left asking the question of how many RVUs a QI project is worth, value-based purchasing at least sets the stage for the conversation. But in the interim, it is still upon hospitalists to design these QI projects, and to learn the skills necessary to see the design to its fruition.

Threat 2: Quality Stops at Core Measures

It is hard to argue that fulfilling “core measures” is a bad thing. Nonetheless, the core measures were not meant to be quality; instead, they were meant as surrogate measures of quality. The presumption of the core-measures initiative is that the system would exist without direct attention to the core measures, operating as it ordinarily would with generic attention to meeting all standards of quality for all diseases. And at some point in time, the core measures would be assessed to give an overall assessment of the system’s quality.

What has evolved, however, is a concerted attention to meeting the core measures, with little regard to the overall culture of quality.

Let’s say you were tasked with improving the public school system in your state. As a measure of the improvement, you choose five of the 1,000 schools as “core measure” schools. The state board of education is told that the performance of these five sample schools will be assessed at the end of the year, and financial support for the system as a whole will hinge on their performance. The intended result is that attention would be paid to improving the performance of every school in the system, and this improvement would be reflected in the performance of the five sample schools. The board of education could take the route of improving all schools, but the more pragmatic route would be to funnel all resources into these five schools, to the detriment of resources for the other 995 schools. The performance of the core measure schools would dramatically improve, and funding would be secured. But ask yourself: Did the performance of the school system as a whole actually improve?

Such is the risk of the core measures in healthcare. The original intent of the core measures was to instill a culture of QI for all points of care. And this has been a valuable contribution to changing the consciousness of the healthcare system. The presumption was that the core measures would be “seeds,” and that by emphasizing these select measures, the QI culture eventually would spread to all aspects of patient care. But this plan hinged on the presumption that that there is an unlimited amount of mental energy and resources to be devoted to all tasks within healthcare. The reality is that there is a fixed amount of intellectual energy and resources to be devoted to the various aspects of healthcare. One wonders if the overemphasis on meeting the core measures might actually have taken the wind out of the sails for QI in other non-core-measure patient care.

The implications are twofold. By definition, a core measure has to be applicable to all healthcare systems, and with a fixed amount of mental energy and resources, there is a real risk that what portion is reserved for QI finds its way only to the core indicators, especially if they are overemphasized in the system. The second implication is captured in our experience with time to antibiotics. With meeting the core indicator as the priority, many systems instituted the “work-around”: Give antibiotics to every patient presenting to the ED, and you will be sure to have met the four-hour window in the core indicator. The result was an exponential increase in inappropriate antibiotic administration and radiographic tests, all because meeting the indicator became more important than the overall goal.

As stewards of the hospital system, it is upon us to ensure that the original intent of core measures remains secure: The core measures seed a culture of quality, but do not become ends in and of themselves. QI apart from the core measures must remain an equal priority, and it is the hospitalist who will be central in ensuring this comes to fruition.

Threat 3: Misplaced Incentives

There is an interesting anecdote in Steven Levitt and Stephen Dubner’s book Freakonomics.¹ The story begins with a daycare center struggling with a problem: Some parents are showing up late to pick up their children at the end of the day, and this is costing the center in the way of overtime charges for the staff. To solve the problem, the center elects to institute a financial disincentive: Those showing up late to pick up their children will pay a modest financial penalty.

Fast-forward to months after the policy was put in place. The result? An exponential increase in the number of parents showing up late to pick up their children.

How do you explain worsening performance in spite of a financial disincentive? The answer resides in understanding human behavior. According to the authors, there are three primary motivations in life: financial, social, and moral. As ugly as it sounds, the decisions people make in life are driven by one of these three motivations. There is nothing wrong with providing incentives for behavior; incentives work.

But the danger arises when incentives are mismatched to behaviors. For example, if a financial outcome is the goal, then financial incentives make sense. If a social outcome (people should play better as a team) is the goal, the social incentives make sense (public recognition). But when the incentives get misaligned with their respective goals, trouble results.

What went wrong with the daycare’s plan is simple—most of the parents were motivated to pick up their children on time out of moral (“I gave my word”) or social (“I don’t want to be talked about by other parents”) incentives. But once a financial incentive was offered, the daycare center had essentially given the parents a way out in absolving their social and moral obligations. The parents had essentially cost-adjusted their behavior.

If you think this couldn’t happen to the healthcare system, let me ask you this. As a hospitalist, I see all of my patients early in the morning, because I see it as part of my obligation to the hospital team to discharge patients by 11 a.m. (social motivation).

But what if the CEO released this directive: “You will see all of your patients early in the morning, or you will take a $1,000 a year pay cut.” Is it possible that I might cost-adjust the $1,000 in exchange for sleeping in a little later and not having to deal with the morning traffic? I don’t know.

When it comes to financial incentives, there is a valley in the U-shaped curve. When the financial incentive is trivial, it is disregarded and the social/moral motivations of behavior persist (the kids are picked up on time; I persist in seeing patients early in the morning). When the financial incentive is huge, the financial incentive trumps all social/moral motivations, ensuring compliance with the goal behavior (every kid is picked up on time to avoid a penalty; I see all patients early in the day to avoid a larger penalty).

But in between is the risk zone: When the person feels they are paying an appropriate penance for not complying with the goal behavior, the financial disincentive absolves any social/moral guilt.

Healthcare reform is about incentives—and there is nothing wrong with that. But as the stewards of the inpatient healthcare system, it is upon us as hospitalists to ensure that the incentives remain matched to their intended goals, and that the untoward consequences of the incentives do not adversely affect the quality and safety of a patient’s care.

It is safe to say that the Affordable Care Act of 2010 moves us closer to a true environment of quality and patient safety. But it is equally safe to say that meaningful change will require more than what the law can provide. As stewards of the inpatient system, we have a responsibility to ensure that the healthcare system, particularly in how it responds to incentives, evolves to remain patient-centered, effective, and safe.

The next chapter in our story—the hospitalists’ story—will be one of accountability and responsibility. While there are things the government can do, the majority of what needs to be done will come directly from us. TH

Dr. Wiese is president of SHM.

Reference

1. Levitt SD, Dubner SJ. Freakonomics: A Rogue Economist Explores the Hidden Side of Everything. New York City: William Morrow; 2005.

From the outset, HM has been about efficiency. And there was nothing wrong with that, for value is quality divided by cost. But in our story, we found that mere efficiency was not enough: The lowering of the denominator (cost) had to be met with an escalation of the numerator (quality) to ensure value.

And see us as being born in the right place at the right time. For with the national focus turning to the need for quality and patient safety, hospital medicine was in the right place and the right time to heed the call to action: appropriately stepping up to enact efforts to make the slope of the line (on a chart of quality vs. cost) “STEEEPER” … finding systems innovations to make care Safe, Timely, Efficient, Effective, Equitable, and Patient-centered.

Of course, the story continued with the Affordable Care Act and healthcare reform, greatly accelerating our evolution as change agents. And now we find ourselves fully invested in a “change the system” mentality, perfectly positioned to meaningfully change healthcare for millions of people. But threats loom—specifically, the “R” in the STEEEPER mnemonic: the risks to quality in the face of healthcare reform.

So in the next chapter of our story, I present to you our challenge: how to overcome the threats to quality in the context of healthcare reform. The first three are presented here; in subsequent articles, I will address the remainder. Overcoming all threats will hinge on mastering the four truisms of cultural change:

1. Systems drive function;
2. Every system is perfectly designed to produce the outcomes that it does;
3. This is not an issue of people needing to try harder; and
4. The “no blame” culture begins with a paradigm shift from the “person at fault” to the “system at fault.”

Threat 1: Failure to Fund Quality

SHM elected to merge its annual State of Hospital Medicine survey with the MGMA. Though not without risk, this has resulted in the anticipated benefits. The MGMA collaboration brings greater leverage in working with the C-suite, which is pre-programmed to react to MGMA surveys. From the most recent MGMA survey comes good news: The financial compensation for hospitalists has increased. A sobering insight, however, is that this increase in compensation has been met with a corresponding increase in work intensity—RVUs. Further, the link between RVUs and compensation appears to be tightening, quantifying what has long been of concern: The time devoted to the nonclinical “value added” duties of the hospitalist is shrinking.

The threat to the culture of quality is captured in the single question: How many RVUs is a quality-improvement (QI) project worth? I’m not sure we have that answer. But without an answer, it is difficult to believe that meaningful QI can be expected without time to do so. And again, as the gap between compensation and RVUs narrows, one is left wondering if there will soon be a day where there is no value-added time remaining to perform QI at all.

Fortunately, the Affordable Care Act might provide some movement in the right direction via value-based purchasing. Linking quality outcomes to financial reimbursement is a big step forward in the hospitalist’s quest to leverage the C-suite in trading RVUs for devoted QI time. Although we still are left asking the question of how many RVUs a QI project is worth, value-based purchasing at least sets the stage for the conversation. But in the interim, it is still upon hospitalists to design these QI projects, and to learn the skills necessary to see the design to its fruition.

Threat 2: Quality Stops at Core Measures

It is hard to argue that fulfilling “core measures” is a bad thing. Nonetheless, the core measures were not meant to be quality; instead, they were meant as surrogate measures of quality. The presumption of the core-measures initiative is that the system would exist without direct attention to the core measures, operating as it ordinarily would with generic attention to meeting all standards of quality for all diseases. And at some point in time, the core measures would be assessed to give an overall assessment of the system’s quality.

What has evolved, however, is a concerted attention to meeting the core measures, with little regard to the overall culture of quality.

Let’s say you were tasked with improving the public school system in your state. As a measure of the improvement, you choose five of the 1,000 schools as “core measure” schools. The state board of education is told that the performance of these five sample schools will be assessed at the end of the year, and financial support for the system as a whole will hinge on their performance. The intended result is that attention would be paid to improving the performance of every school in the system, and this improvement would be reflected in the performance of the five sample schools. The board of education could take the route of improving all schools, but the more pragmatic route would be to funnel all resources into these five schools, to the detriment of resources for the other 995 schools. The performance of the core measure schools would dramatically improve, and funding would be secured. But ask yourself: Did the performance of the school system as a whole actually improve?

Such is the risk of the core measures in healthcare. The original intent of the core measures was to instill a culture of QI for all points of care. And this has been a valuable contribution to changing the consciousness of the healthcare system. The presumption was that the core measures would be “seeds,” and that by emphasizing these select measures, the QI culture eventually would spread to all aspects of patient care. But this plan hinged on the presumption that that there is an unlimited amount of mental energy and resources to be devoted to all tasks within healthcare. The reality is that there is a fixed amount of intellectual energy and resources to be devoted to the various aspects of healthcare. One wonders if the overemphasis on meeting the core measures might actually have taken the wind out of the sails for QI in other non-core-measure patient care.

The implications are twofold. By definition, a core measure has to be applicable to all healthcare systems, and with a fixed amount of mental energy and resources, there is a real risk that what portion is reserved for QI finds its way only to the core indicators, especially if they are overemphasized in the system. The second implication is captured in our experience with time to antibiotics. With meeting the core indicator as the priority, many systems instituted the “work-around”: Give antibiotics to every patient presenting to the ED, and you will be sure to have met the four-hour window in the core indicator. The result was an exponential increase in inappropriate antibiotic administration and radiographic tests, all because meeting the indicator became more important than the overall goal.

As stewards of the hospital system, it is upon us to ensure that the original intent of core measures remains secure: The core measures seed a culture of quality, but do not become ends in and of themselves. QI apart from the core measures must remain an equal priority, and it is the hospitalist who will be central in ensuring this comes to fruition.

Threat 3: Misplaced Incentives

There is an interesting anecdote in Steven Levitt and Stephen Dubner’s book Freakonomics.¹ The story begins with a daycare center struggling with a problem: Some parents are showing up late to pick up their children at the end of the day, and this is costing the center in the way of overtime charges for the staff. To solve the problem, the center elects to institute a financial disincentive: Those showing up late to pick up their children will pay a modest financial penalty.

Fast-forward to months after the policy was put in place. The result? An exponential increase in the number of parents showing up late to pick up their children.

How do you explain worsening performance in spite of a financial disincentive? The answer resides in understanding human behavior. According to the authors, there are three primary motivations in life: financial, social, and moral. As ugly as it sounds, the decisions people make in life are driven by one of these three motivations. There is nothing wrong with providing incentives for behavior; incentives work.

But the danger arises when incentives are mismatched to behaviors. For example, if a financial outcome is the goal, then financial incentives make sense. If a social outcome (people should play better as a team) is the goal, the social incentives make sense (public recognition). But when the incentives get misaligned with their respective goals, trouble results.

What went wrong with the daycare’s plan is simple—most of the parents were motivated to pick up their children on time out of moral (“I gave my word”) or social (“I don’t want to be talked about by other parents”) incentives. But once a financial incentive was offered, the daycare center had essentially given the parents a way out in absolving their social and moral obligations. The parents had essentially cost-adjusted their behavior.

If you think this couldn’t happen to the healthcare system, let me ask you this. As a hospitalist, I see all of my patients early in the morning, because I see it as part of my obligation to the hospital team to discharge patients by 11 a.m. (social motivation).

But what if the CEO released this directive: “You will see all of your patients early in the morning, or you will take a $1,000 a year pay cut.” Is it possible that I might cost-adjust the $1,000 in exchange for sleeping in a little later and not having to deal with the morning traffic? I don’t know.

When it comes to financial incentives, there is a valley in the U-shaped curve. When the financial incentive is trivial, it is disregarded and the social/moral motivations of behavior persist (the kids are picked up on time; I persist in seeing patients early in the morning). When the financial incentive is huge, the financial incentive trumps all social/moral motivations, ensuring compliance with the goal behavior (every kid is picked up on time to avoid a penalty; I see all patients early in the day to avoid a larger penalty).

But in between is the risk zone: When the person feels they are paying an appropriate penance for not complying with the goal behavior, the financial disincentive absolves any social/moral guilt.

Healthcare reform is about incentives—and there is nothing wrong with that. But as the stewards of the inpatient healthcare system, it is upon us as hospitalists to ensure that the incentives remain matched to their intended goals, and that the untoward consequences of the incentives do not adversely affect the quality and safety of a patient’s care.

It is safe to say that the Affordable Care Act of 2010 moves us closer to a true environment of quality and patient safety. But it is equally safe to say that meaningful change will require more than what the law can provide. As stewards of the inpatient system, we have a responsibility to ensure that the healthcare system, particularly in how it responds to incentives, evolves to remain patient-centered, effective, and safe.

The next chapter in our story—the hospitalists’ story—will be one of accountability and responsibility. While there are things the government can do, the majority of what needs to be done will come directly from us. TH

Dr. Wiese is president of SHM.

Reference

1. Levitt SD, Dubner SJ. Freakonomics: A Rogue Economist Explores the Hidden Side of Everything. New York City: William Morrow; 2005.

Several months ago, my toilet broke. You should also know that I’m not particularly handy. So when I first realized that the toilet bowl seemed to fill constantly, I got a little stressed out.

How much was it going cost to call in a plumber on the weekend?

What kind of a water bill was I going to have?

Was this a serious problem?

I took a quick peek in the tank, but that just made me more confused. I was paralyzed by a lack of know-how.

Normally, I would have just Googled a local plumber. But that day, I decided to do something different. Maybe it was because it was the fantasy football offseason. Maybe it was because my wife had started to ask my father-in-law to change light bulbs around the house. Or, maybe, I wanted to learn to actually fix the problem. A few hours later, after an Internet lesson in toilet physiology, a $4.12 trip to Home Depot, and a wet pair of hands, I had replaced my first toilet flapper.

This wasn’t the rebuilding of a car engine, but it was a clear DIY step toward self-improvement. Easily the most memorable moment here was my sense of accomplishment.

I felt empowered.

One Part Science, One Part Art

It’s taken me a while to realize this, but I’ve begun to take advantage of improvement opportunities at work as well. No, I haven’t been moonlighting as a plumber for my hospital. I’ve just been fortunate to be part of a trifecta of rewarding quality-improvement (QI) projects over the past year. Before I’d gotten my hands dirty with these, my understanding of QI was fairly naive. I’d heard about Plan-Do-Study-Act many times. I had listened to a talk at a national conference. And I had kept up with the general medical literature on the subject.

But none of those activities had truly prepared me for experience of actually doing the work on my own.

By taking on a project, an ambitious attempt to reduce continuous pulse oximetry use, I experienced a crash course in both the science and the art of process improvement. I was forced to overcome my “I don’t know how” inertia. And with expert guidance in the form of a clinical safety and effectiveness class, I learned the importance of run charts (science) and a well-crafted multidisciplinary team (art) in changing established but inefficient behavior.

Our rates of continuous pulse oximetry usage dropped by 50%, and cost savings were $12,000 per year on one unit. These results made my prior attempts at change—years of complaining about ingrained nursing culture—look infantile. (OK, maybe it was ineffective, but who hasn’t complained about the overuse of continuous monitoring?)

I haven’t met a pediatric hospitalist who wouldn’t understand the symbolic importance of this success. But I know of many hospitalists who have not yet participated in meaningful QI project. Imagine calling a plumber who grasped the flush and fill mechanism of a toilet but had never touched real porcelain. Here’s an even better analogy: What if doctors could get licensed without having touched real patients?

If pediatric hospitalists are to transform the care delivery of hospitalized children, and quality learning only comes through hands-on training, then we need some more hands in the pot.

Discharge Improvement

On the heels of my first project, I was fortunate enough to augment my education through another effort—this time with a cohort of fellow pediatric hospitalists. This was a national collaborative to improve discharge handoffs, and I will admit that, at the outset, I was as puzzled as the first time I pulled the lid off the tank of the toilet. There were just too many permutations on PCP communication at the participating institutions, and some felt our aim of timely discharge handoffs was unattainable.

What carried me through, however, was the collective and infectious DIY—no, QIY (Quality Improve-it-Yourself) attitude of the group. We were all learning, and regular participation in the collaborative essentially guaranteed improvement. We achieved our aim of 90% communication with PCPs within two days of discharge. The secret was simple: The more you do, the more you learn.

Pediatric hospitalists can transform care delivery through a focus on safe and quality care, but the tools to accomplish this must come through post-residency, on-the-job learning. This QI know-how must efficiently spread among our ranks through practical and project-based educational efforts. It’s “see one, do one, teach one,” but we’re not talking about lumbar punctures anymore.

This is a journey in which we all take on the responsibility of rolling up our sleeves and simply learn by doing. And here is where the third leg of my as-yet-unfinished QI course unfolds.

Through my involvement with the Value in Inpatient Pediatrics (VIP) Network, I’ve gained a newfound vision for what the future might hold. VIP has evolved from a benchmarking project focused on bronchiolitis to an improvement network that will incorporate projects similar to the discharge handoff collaborative above.

In the process, a model for how to rapidly spread QI learning has emerged. The capacity lies in the network’s rapidly growing connectivity. The power comes from the individuals: motivated, card-carrying pediatric hospitalists from a wide array of sites. Collaborative learning harbors the potential to exponentially increase the pace at which we improve.

The future of our quality care is bright. I see an open network of improvement doers and learners. I see collaboration on quality and safety initiatives in all manner of hospitals and communities. I see that this will all be built upon a foundation of hard work and a QIY attitude.

You, too, will play a role.

Just don’t be afraid to get your hands a little dirty. TH

Dr. Shen is medical director of hospital medicine at Dell Children’s Medical Center in Austin, Texas. He is pediatric editor of The Hospitalist.

Several months ago, my toilet broke. You should also know that I’m not particularly handy. So when I first realized that the toilet bowl seemed to fill constantly, I got a little stressed out.

How much was it going cost to call in a plumber on the weekend?

What kind of a water bill was I going to have?

Was this a serious problem?

I took a quick peek in the tank, but that just made me more confused. I was paralyzed by a lack of know-how.

Normally, I would have just Googled a local plumber. But that day, I decided to do something different. Maybe it was because it was the fantasy football offseason. Maybe it was because my wife had started to ask my father-in-law to change light bulbs around the house. Or, maybe, I wanted to learn to actually fix the problem. A few hours later, after an Internet lesson in toilet physiology, a $4.12 trip to Home Depot, and a wet pair of hands, I had replaced my first toilet flapper.

This wasn’t the rebuilding of a car engine, but it was a clear DIY step toward self-improvement. Easily the most memorable moment here was my sense of accomplishment.

I felt empowered.

One Part Science, One Part Art

It’s taken me a while to realize this, but I’ve begun to take advantage of improvement opportunities at work as well. No, I haven’t been moonlighting as a plumber for my hospital. I’ve just been fortunate to be part of a trifecta of rewarding quality-improvement (QI) projects over the past year. Before I’d gotten my hands dirty with these, my understanding of QI was fairly naive. I’d heard about Plan-Do-Study-Act many times. I had listened to a talk at a national conference. And I had kept up with the general medical literature on the subject.

But none of those activities had truly prepared me for experience of actually doing the work on my own.

By taking on a project, an ambitious attempt to reduce continuous pulse oximetry use, I experienced a crash course in both the science and the art of process improvement. I was forced to overcome my “I don’t know how” inertia. And with expert guidance in the form of a clinical safety and effectiveness class, I learned the importance of run charts (science) and a well-crafted multidisciplinary team (art) in changing established but inefficient behavior.

Our rates of continuous pulse oximetry usage dropped by 50%, and cost savings were $12,000 per year on one unit. These results made my prior attempts at change—years of complaining about ingrained nursing culture—look infantile. (OK, maybe it was ineffective, but who hasn’t complained about the overuse of continuous monitoring?)

I haven’t met a pediatric hospitalist who wouldn’t understand the symbolic importance of this success. But I know of many hospitalists who have not yet participated in meaningful QI project. Imagine calling a plumber who grasped the flush and fill mechanism of a toilet but had never touched real porcelain. Here’s an even better analogy: What if doctors could get licensed without having touched real patients?

If pediatric hospitalists are to transform the care delivery of hospitalized children, and quality learning only comes through hands-on training, then we need some more hands in the pot.

Discharge Improvement

On the heels of my first project, I was fortunate enough to augment my education through another effort—this time with a cohort of fellow pediatric hospitalists. This was a national collaborative to improve discharge handoffs, and I will admit that, at the outset, I was as puzzled as the first time I pulled the lid off the tank of the toilet. There were just too many permutations on PCP communication at the participating institutions, and some felt our aim of timely discharge handoffs was unattainable.

What carried me through, however, was the collective and infectious DIY—no, QIY (Quality Improve-it-Yourself) attitude of the group. We were all learning, and regular participation in the collaborative essentially guaranteed improvement. We achieved our aim of 90% communication with PCPs within two days of discharge. The secret was simple: The more you do, the more you learn.

Pediatric hospitalists can transform care delivery through a focus on safe and quality care, but the tools to accomplish this must come through post-residency, on-the-job learning. This QI know-how must efficiently spread among our ranks through practical and project-based educational efforts. It’s “see one, do one, teach one,” but we’re not talking about lumbar punctures anymore.

This is a journey in which we all take on the responsibility of rolling up our sleeves and simply learn by doing. And here is where the third leg of my as-yet-unfinished QI course unfolds.

Through my involvement with the Value in Inpatient Pediatrics (VIP) Network, I’ve gained a newfound vision for what the future might hold. VIP has evolved from a benchmarking project focused on bronchiolitis to an improvement network that will incorporate projects similar to the discharge handoff collaborative above.

In the process, a model for how to rapidly spread QI learning has emerged. The capacity lies in the network’s rapidly growing connectivity. The power comes from the individuals: motivated, card-carrying pediatric hospitalists from a wide array of sites. Collaborative learning harbors the potential to exponentially increase the pace at which we improve.

The future of our quality care is bright. I see an open network of improvement doers and learners. I see collaboration on quality and safety initiatives in all manner of hospitals and communities. I see that this will all be built upon a foundation of hard work and a QIY attitude.

You, too, will play a role.

Just don’t be afraid to get your hands a little dirty. TH

Dr. Shen is medical director of hospital medicine at Dell Children’s Medical Center in Austin, Texas. He is pediatric editor of The Hospitalist.

Several months ago, my toilet broke. You should also know that I’m not particularly handy. So when I first realized that the toilet bowl seemed to fill constantly, I got a little stressed out.

How much was it going cost to call in a plumber on the weekend?

What kind of a water bill was I going to have?

Was this a serious problem?

I took a quick peek in the tank, but that just made me more confused. I was paralyzed by a lack of know-how.

Normally, I would have just Googled a local plumber. But that day, I decided to do something different. Maybe it was because it was the fantasy football offseason. Maybe it was because my wife had started to ask my father-in-law to change light bulbs around the house. Or, maybe, I wanted to learn to actually fix the problem. A few hours later, after an Internet lesson in toilet physiology, a $4.12 trip to Home Depot, and a wet pair of hands, I had replaced my first toilet flapper.

This wasn’t the rebuilding of a car engine, but it was a clear DIY step toward self-improvement. Easily the most memorable moment here was my sense of accomplishment.

I felt empowered.

One Part Science, One Part Art

It’s taken me a while to realize this, but I’ve begun to take advantage of improvement opportunities at work as well. No, I haven’t been moonlighting as a plumber for my hospital. I’ve just been fortunate to be part of a trifecta of rewarding quality-improvement (QI) projects over the past year. Before I’d gotten my hands dirty with these, my understanding of QI was fairly naive. I’d heard about Plan-Do-Study-Act many times. I had listened to a talk at a national conference. And I had kept up with the general medical literature on the subject.

But none of those activities had truly prepared me for experience of actually doing the work on my own.

By taking on a project, an ambitious attempt to reduce continuous pulse oximetry use, I experienced a crash course in both the science and the art of process improvement. I was forced to overcome my “I don’t know how” inertia. And with expert guidance in the form of a clinical safety and effectiveness class, I learned the importance of run charts (science) and a well-crafted multidisciplinary team (art) in changing established but inefficient behavior.

Our rates of continuous pulse oximetry usage dropped by 50%, and cost savings were $12,000 per year on one unit. These results made my prior attempts at change—years of complaining about ingrained nursing culture—look infantile. (OK, maybe it was ineffective, but who hasn’t complained about the overuse of continuous monitoring?)

I haven’t met a pediatric hospitalist who wouldn’t understand the symbolic importance of this success. But I know of many hospitalists who have not yet participated in meaningful QI project. Imagine calling a plumber who grasped the flush and fill mechanism of a toilet but had never touched real porcelain. Here’s an even better analogy: What if doctors could get licensed without having touched real patients?

If pediatric hospitalists are to transform the care delivery of hospitalized children, and quality learning only comes through hands-on training, then we need some more hands in the pot.

Discharge Improvement

On the heels of my first project, I was fortunate enough to augment my education through another effort—this time with a cohort of fellow pediatric hospitalists. This was a national collaborative to improve discharge handoffs, and I will admit that, at the outset, I was as puzzled as the first time I pulled the lid off the tank of the toilet. There were just too many permutations on PCP communication at the participating institutions, and some felt our aim of timely discharge handoffs was unattainable.

What carried me through, however, was the collective and infectious DIY—no, QIY (Quality Improve-it-Yourself) attitude of the group. We were all learning, and regular participation in the collaborative essentially guaranteed improvement. We achieved our aim of 90% communication with PCPs within two days of discharge. The secret was simple: The more you do, the more you learn.

Pediatric hospitalists can transform care delivery through a focus on safe and quality care, but the tools to accomplish this must come through post-residency, on-the-job learning. This QI know-how must efficiently spread among our ranks through practical and project-based educational efforts. It’s “see one, do one, teach one,” but we’re not talking about lumbar punctures anymore.

This is a journey in which we all take on the responsibility of rolling up our sleeves and simply learn by doing. And here is where the third leg of my as-yet-unfinished QI course unfolds.

Through my involvement with the Value in Inpatient Pediatrics (VIP) Network, I’ve gained a newfound vision for what the future might hold. VIP has evolved from a benchmarking project focused on bronchiolitis to an improvement network that will incorporate projects similar to the discharge handoff collaborative above.

In the process, a model for how to rapidly spread QI learning has emerged. The capacity lies in the network’s rapidly growing connectivity. The power comes from the individuals: motivated, card-carrying pediatric hospitalists from a wide array of sites. Collaborative learning harbors the potential to exponentially increase the pace at which we improve.

The future of our quality care is bright. I see an open network of improvement doers and learners. I see collaboration on quality and safety initiatives in all manner of hospitals and communities. I see that this will all be built upon a foundation of hard work and a QIY attitude.

You, too, will play a role.

Just don’t be afraid to get your hands a little dirty. TH

Dr. Shen is medical director of hospital medicine at Dell Children’s Medical Center in Austin, Texas. He is pediatric editor of The Hospitalist.

Despite never advancing his musical tastes beyond the arena bands of the 1970s and ’80s (think Def Leppard), Mark Williams, MD, FACP, FHM, editor-in-chief of the Journal of Hospital Medicine, has done a great job in securing informative and meaningful research and opinion for the journal. Did you see read the July/August 2010 issue of JHM? It is a great example of content uniquely relevant to hospitalists: several original research articles documenting how hospitalists spend their time. Anyone thinking about the best way to organize and operate a hospitalist practice should read through these studies, along with one published by Kevin O’Leary, MD, and colleagues in the March/April 2006 issue.¹ But as a service, I’ll provide a CliffsNotes version of them, along with some comments here.

Time-Motion Studies

What all the studies demonstrate is that academic hospitalists spend only about 15% to 20% of their time in direct patient care, generally defined as time spent taking a patient’s history and examination, meeting with families, etc. Indirect patient care, such as time spent reviewing records, documenting, and communicating with consultants and other patient care staff, consumes about 60% to 70% of their time. The remainder of time is spent in transit (around 7% of each day) and in personal activities.

Remember, all these studies reported on academic hospitalists in large academic medical centers. As noted in the discussion sections, the results in nonteaching community hospitals might be different. My guess is that community hospitalists spend about the same portion of time in the broad categories above, but the individual activities within each category might differ. So I’m willing to believe that these studies tell us something about the majority of hospitalists who practice outside of academia.

90 Minutes of Doctoring?

While the JHM studies assess hospitalist time in a number of different categories, I think it makes the most sense to divide our time into just two categories: “real doctoring” and other. We’ll probably never see a study that divides hospitalists’ time that way, as there would be endless debate about what is and isn’t real doctoring. But it is worth thinking about your work this way.

A lot of what the studies generally defined as indirect patient care is still “real doctoring.” Things like reviewing old records are critically important and typically can’t be done adequately by a nonclinician. But the 10 minutes you spent to get the CD of outside X-rays to show up on your computer, and rearranging the faxed pages so they’re all oriented the same way and in order, are not a good use of your time; a clerical person could do it.

I periodically have an experience that makes me think I spend too much time on patients’ social issues (e.g. long conversations about why Medicare won’t pay for a patient’s skilled nursing facility stay) and too little on “real doctoring.” One such experience is when I have a patient with an unusual pulmonary infiltrate and the radiologist is able to generate a much more comprehensive differential diagnosis than I can. This is embarrassing. Maybe the radiologist is just smarter than I am, but I think it could be because, compared to me, he spends more of his time every day thinking about “real medicine,” such as pulmonary diseases, and less time dealing with nonclinical issues.

Even though we’re paid for a full day’s work, I suspect many hospitalists might spend only about 90 minutes a day immersed in thought about “real medicine,” while doctors in most other specialties probably spend a lot more. If I’m right, then it shouldn’t be a surprise that after practicing for many years, the radiologist who spends several hours a day exercising his fund of medical knowledge probably has more command of some clinical things than a hospitalist who does so only 90 minutes a day. Actively practicing as a hospitalist might not be as effective a method of maintaining proficiency as it is in other specialties. More than many other specialties, we need to rely on self-study and continuing education courses to prevent erosion of our knowledge base.

I’ve just made up this 90-minute figure. I have no idea how accurate it might be, and, the JHM studies don’t offer a lot of insight either. Clearly, it varies a lot by individual doctor and practice setting. How much of your day do you think you spend on “real doctoring” vs. other activities?

What really matters is whether we’ve ended up with too much work that isn’t “real doctoring.” Sure, all of the work needs to be done, but the system isn’t served best when paying a doctor to do work a less expensive person could do.

Max “Doctoring” Time

I think most hospitalists, including me, are stuck spending too much time on activities that don’t add value. For example, while complete and informative documentation is essential, most of us probably spend too much time on it, in part because we’re trying to immunize against lawsuits and ensure our documentation matches the relevant coding regulations.

I think hospitalists have a communication burden that is higher than that of most other specialties. The JHM article by Tipping and colleagues notes that a time-motion study of ED doctors (Ann Emerg Med. 1998:31(1):87-91) found that they spent 13% of their time communicating with other providers and staff, compared with their finding that hospitalists spent 26% of their time communicating.² Only a portion of this communication is real doctoring. Discussing patient management with a surgeon is, but spending 20 minutes figuring out which surgeon is on call and how to reach her isn’t.

Tipping’s study also found that when patient census was above average, hospitalists spent less time communicating and documenting in the electronic record, even though the total time spent working on those days increased. Of course, it is possible that when the patient census is below average, we just work more slowly and let work fill the time available, and the reduced time spent documenting and communicating when busy simply reflects working more efficiently. But I suspect that when our patient census climbs above a certain point, or we’re made less efficient by things like implementing a new technology, we compensate in part by relying on consultants more to do the real doctoring we would otherwise be doing and communicating with them less.

All of us should be thinking about ways to make communication as efficient as possible so that we can spend less time doing it. I’m hopeful that we will figure out new ways to communicate (e-mail, text, IM, etc.) that are quicker and just as effective in certain situations.

Coda

I try to write most of my columns in a way that minimizes the editorializing and maximizes the practical advice. This month is an exception; it’s all editorializing. But I do have some advice for Dr. Williams: Investigate music options other than the arena bands of the 1980s. Try something like Alison Krauss’ live album or Puccini’s opera Gianni Schicchi, which has the beautiful aria O mio babbino caro.

Or do what I do: Ask former SHM board member Brad Flansbaum, MD, SFHM, for advice. TH

Dr. Nelson has been a practicing hospitalist since 1988 and is co-founder and past president of SHM. He is a principal in Nelson Flores Hospital Medicine Consultants, a national hospitalist practice management consulting firm (www.nelsonflores.com). He is course co-director and faculty for SHM’s “Best Practices in Managing a Hospital Medicine Program.” This column represents his views and is not intended to reflect an official position of SHM.

References

1. O’Leary KJ, Liebovitz DM, Baker DW. How hospitalists spend their time: insights on efficiency and safety. J Hosp Med. 2006;1(2):88-93.
2. Tipping MD, Forth VE, O’Leary KJ, et al. Where did the day go? A time-motion study of hospitalists. J Hosp Med. 2010;5(6):323-328.

Despite never advancing his musical tastes beyond the arena bands of the 1970s and ’80s (think Def Leppard), Mark Williams, MD, FACP, FHM, editor-in-chief of the Journal of Hospital Medicine, has done a great job in securing informative and meaningful research and opinion for the journal. Did you see read the July/August 2010 issue of JHM? It is a great example of content uniquely relevant to hospitalists: several original research articles documenting how hospitalists spend their time. Anyone thinking about the best way to organize and operate a hospitalist practice should read through these studies, along with one published by Kevin O’Leary, MD, and colleagues in the March/April 2006 issue.¹ But as a service, I’ll provide a CliffsNotes version of them, along with some comments here.

Time-Motion Studies

What all the studies demonstrate is that academic hospitalists spend only about 15% to 20% of their time in direct patient care, generally defined as time spent taking a patient’s history and examination, meeting with families, etc. Indirect patient care, such as time spent reviewing records, documenting, and communicating with consultants and other patient care staff, consumes about 60% to 70% of their time. The remainder of time is spent in transit (around 7% of each day) and in personal activities.

Remember, all these studies reported on academic hospitalists in large academic medical centers. As noted in the discussion sections, the results in nonteaching community hospitals might be different. My guess is that community hospitalists spend about the same portion of time in the broad categories above, but the individual activities within each category might differ. So I’m willing to believe that these studies tell us something about the majority of hospitalists who practice outside of academia.

90 Minutes of Doctoring?

While the JHM studies assess hospitalist time in a number of different categories, I think it makes the most sense to divide our time into just two categories: “real doctoring” and other. We’ll probably never see a study that divides hospitalists’ time that way, as there would be endless debate about what is and isn’t real doctoring. But it is worth thinking about your work this way.

A lot of what the studies generally defined as indirect patient care is still “real doctoring.” Things like reviewing old records are critically important and typically can’t be done adequately by a nonclinician. But the 10 minutes you spent to get the CD of outside X-rays to show up on your computer, and rearranging the faxed pages so they’re all oriented the same way and in order, are not a good use of your time; a clerical person could do it.

I periodically have an experience that makes me think I spend too much time on patients’ social issues (e.g. long conversations about why Medicare won’t pay for a patient’s skilled nursing facility stay) and too little on “real doctoring.” One such experience is when I have a patient with an unusual pulmonary infiltrate and the radiologist is able to generate a much more comprehensive differential diagnosis than I can. This is embarrassing. Maybe the radiologist is just smarter than I am, but I think it could be because, compared to me, he spends more of his time every day thinking about “real medicine,” such as pulmonary diseases, and less time dealing with nonclinical issues.

Even though we’re paid for a full day’s work, I suspect many hospitalists might spend only about 90 minutes a day immersed in thought about “real medicine,” while doctors in most other specialties probably spend a lot more. If I’m right, then it shouldn’t be a surprise that after practicing for many years, the radiologist who spends several hours a day exercising his fund of medical knowledge probably has more command of some clinical things than a hospitalist who does so only 90 minutes a day. Actively practicing as a hospitalist might not be as effective a method of maintaining proficiency as it is in other specialties. More than many other specialties, we need to rely on self-study and continuing education courses to prevent erosion of our knowledge base.

I’ve just made up this 90-minute figure. I have no idea how accurate it might be, and, the JHM studies don’t offer a lot of insight either. Clearly, it varies a lot by individual doctor and practice setting. How much of your day do you think you spend on “real doctoring” vs. other activities?

What really matters is whether we’ve ended up with too much work that isn’t “real doctoring.” Sure, all of the work needs to be done, but the system isn’t served best when paying a doctor to do work a less expensive person could do.

Max “Doctoring” Time

I think most hospitalists, including me, are stuck spending too much time on activities that don’t add value. For example, while complete and informative documentation is essential, most of us probably spend too much time on it, in part because we’re trying to immunize against lawsuits and ensure our documentation matches the relevant coding regulations.

I think hospitalists have a communication burden that is higher than that of most other specialties. The JHM article by Tipping and colleagues notes that a time-motion study of ED doctors (Ann Emerg Med. 1998:31(1):87-91) found that they spent 13% of their time communicating with other providers and staff, compared with their finding that hospitalists spent 26% of their time communicating.² Only a portion of this communication is real doctoring. Discussing patient management with a surgeon is, but spending 20 minutes figuring out which surgeon is on call and how to reach her isn’t.

Tipping’s study also found that when patient census was above average, hospitalists spent less time communicating and documenting in the electronic record, even though the total time spent working on those days increased. Of course, it is possible that when the patient census is below average, we just work more slowly and let work fill the time available, and the reduced time spent documenting and communicating when busy simply reflects working more efficiently. But I suspect that when our patient census climbs above a certain point, or we’re made less efficient by things like implementing a new technology, we compensate in part by relying on consultants more to do the real doctoring we would otherwise be doing and communicating with them less.

All of us should be thinking about ways to make communication as efficient as possible so that we can spend less time doing it. I’m hopeful that we will figure out new ways to communicate (e-mail, text, IM, etc.) that are quicker and just as effective in certain situations.

Coda

I try to write most of my columns in a way that minimizes the editorializing and maximizes the practical advice. This month is an exception; it’s all editorializing. But I do have some advice for Dr. Williams: Investigate music options other than the arena bands of the 1980s. Try something like Alison Krauss’ live album or Puccini’s opera Gianni Schicchi, which has the beautiful aria O mio babbino caro.

Or do what I do: Ask former SHM board member Brad Flansbaum, MD, SFHM, for advice. TH

Dr. Nelson has been a practicing hospitalist since 1988 and is co-founder and past president of SHM. He is a principal in Nelson Flores Hospital Medicine Consultants, a national hospitalist practice management consulting firm (www.nelsonflores.com). He is course co-director and faculty for SHM’s “Best Practices in Managing a Hospital Medicine Program.” This column represents his views and is not intended to reflect an official position of SHM.

References

1. O’Leary KJ, Liebovitz DM, Baker DW. How hospitalists spend their time: insights on efficiency and safety. J Hosp Med. 2006;1(2):88-93.
2. Tipping MD, Forth VE, O’Leary KJ, et al. Where did the day go? A time-motion study of hospitalists. J Hosp Med. 2010;5(6):323-328.

Despite never advancing his musical tastes beyond the arena bands of the 1970s and ’80s (think Def Leppard), Mark Williams, MD, FACP, FHM, editor-in-chief of the Journal of Hospital Medicine, has done a great job in securing informative and meaningful research and opinion for the journal. Did you see read the July/August 2010 issue of JHM? It is a great example of content uniquely relevant to hospitalists: several original research articles documenting how hospitalists spend their time. Anyone thinking about the best way to organize and operate a hospitalist practice should read through these studies, along with one published by Kevin O’Leary, MD, and colleagues in the March/April 2006 issue.¹ But as a service, I’ll provide a CliffsNotes version of them, along with some comments here.

Time-Motion Studies

What all the studies demonstrate is that academic hospitalists spend only about 15% to 20% of their time in direct patient care, generally defined as time spent taking a patient’s history and examination, meeting with families, etc. Indirect patient care, such as time spent reviewing records, documenting, and communicating with consultants and other patient care staff, consumes about 60% to 70% of their time. The remainder of time is spent in transit (around 7% of each day) and in personal activities.

Remember, all these studies reported on academic hospitalists in large academic medical centers. As noted in the discussion sections, the results in nonteaching community hospitals might be different. My guess is that community hospitalists spend about the same portion of time in the broad categories above, but the individual activities within each category might differ. So I’m willing to believe that these studies tell us something about the majority of hospitalists who practice outside of academia.

90 Minutes of Doctoring?

While the JHM studies assess hospitalist time in a number of different categories, I think it makes the most sense to divide our time into just two categories: “real doctoring” and other. We’ll probably never see a study that divides hospitalists’ time that way, as there would be endless debate about what is and isn’t real doctoring. But it is worth thinking about your work this way.

A lot of what the studies generally defined as indirect patient care is still “real doctoring.” Things like reviewing old records are critically important and typically can’t be done adequately by a nonclinician. But the 10 minutes you spent to get the CD of outside X-rays to show up on your computer, and rearranging the faxed pages so they’re all oriented the same way and in order, are not a good use of your time; a clerical person could do it.

I periodically have an experience that makes me think I spend too much time on patients’ social issues (e.g. long conversations about why Medicare won’t pay for a patient’s skilled nursing facility stay) and too little on “real doctoring.” One such experience is when I have a patient with an unusual pulmonary infiltrate and the radiologist is able to generate a much more comprehensive differential diagnosis than I can. This is embarrassing. Maybe the radiologist is just smarter than I am, but I think it could be because, compared to me, he spends more of his time every day thinking about “real medicine,” such as pulmonary diseases, and less time dealing with nonclinical issues.

Even though we’re paid for a full day’s work, I suspect many hospitalists might spend only about 90 minutes a day immersed in thought about “real medicine,” while doctors in most other specialties probably spend a lot more. If I’m right, then it shouldn’t be a surprise that after practicing for many years, the radiologist who spends several hours a day exercising his fund of medical knowledge probably has more command of some clinical things than a hospitalist who does so only 90 minutes a day. Actively practicing as a hospitalist might not be as effective a method of maintaining proficiency as it is in other specialties. More than many other specialties, we need to rely on self-study and continuing education courses to prevent erosion of our knowledge base.

I’ve just made up this 90-minute figure. I have no idea how accurate it might be, and, the JHM studies don’t offer a lot of insight either. Clearly, it varies a lot by individual doctor and practice setting. How much of your day do you think you spend on “real doctoring” vs. other activities?

What really matters is whether we’ve ended up with too much work that isn’t “real doctoring.” Sure, all of the work needs to be done, but the system isn’t served best when paying a doctor to do work a less expensive person could do.

Max “Doctoring” Time

I think most hospitalists, including me, are stuck spending too much time on activities that don’t add value. For example, while complete and informative documentation is essential, most of us probably spend too much time on it, in part because we’re trying to immunize against lawsuits and ensure our documentation matches the relevant coding regulations.

I think hospitalists have a communication burden that is higher than that of most other specialties. The JHM article by Tipping and colleagues notes that a time-motion study of ED doctors (Ann Emerg Med. 1998:31(1):87-91) found that they spent 13% of their time communicating with other providers and staff, compared with their finding that hospitalists spent 26% of their time communicating.² Only a portion of this communication is real doctoring. Discussing patient management with a surgeon is, but spending 20 minutes figuring out which surgeon is on call and how to reach her isn’t.

Tipping’s study also found that when patient census was above average, hospitalists spent less time communicating and documenting in the electronic record, even though the total time spent working on those days increased. Of course, it is possible that when the patient census is below average, we just work more slowly and let work fill the time available, and the reduced time spent documenting and communicating when busy simply reflects working more efficiently. But I suspect that when our patient census climbs above a certain point, or we’re made less efficient by things like implementing a new technology, we compensate in part by relying on consultants more to do the real doctoring we would otherwise be doing and communicating with them less.

All of us should be thinking about ways to make communication as efficient as possible so that we can spend less time doing it. I’m hopeful that we will figure out new ways to communicate (e-mail, text, IM, etc.) that are quicker and just as effective in certain situations.

Coda

I try to write most of my columns in a way that minimizes the editorializing and maximizes the practical advice. This month is an exception; it’s all editorializing. But I do have some advice for Dr. Williams: Investigate music options other than the arena bands of the 1980s. Try something like Alison Krauss’ live album or Puccini’s opera Gianni Schicchi, which has the beautiful aria O mio babbino caro.

Or do what I do: Ask former SHM board member Brad Flansbaum, MD, SFHM, for advice. TH

Dr. Nelson has been a practicing hospitalist since 1988 and is co-founder and past president of SHM. He is a principal in Nelson Flores Hospital Medicine Consultants, a national hospitalist practice management consulting firm (www.nelsonflores.com). He is course co-director and faculty for SHM’s “Best Practices in Managing a Hospital Medicine Program.” This column represents his views and is not intended to reflect an official position of SHM.

References

1. O’Leary KJ, Liebovitz DM, Baker DW. How hospitalists spend their time: insights on efficiency and safety. J Hosp Med. 2006;1(2):88-93.
2. Tipping MD, Forth VE, O’Leary KJ, et al. Where did the day go? A time-motion study of hospitalists. J Hosp Med. 2010;5(6):323-328.

If every system is perfectly designed to get the results it gets …

And if 15 million patients are harmed every year from medical care …

And if as many as 98,000 people die every year due to medical errors in hospitals …

Then what does that say about the system we have designed?

A System Designed to Competently Hurt Many

By now you’ve no doubt heard, read, and possibly even uttered the above facts and figures yourself. I think we all have our opinions about the veracity of these numbers, but I don’t think any of us would argue with the sentiment. The U.S. healthcare system comprises the most competent, compassionate, well-meaning, and caring professionals on this planet—who harm, maim, and kill countless people every year.

What a discomforting paradox.

Equity: The Overlooked Quality Domain

Many years back, the Institute of Medicine (IOM) published a list of six “domains” of healthcare quality. You’ve no doubt stumbled across the IOM’s Safe … Timely … Effective … Efficient … Equitable … Patient-Centered mnemonic recipe—STEEEP—for high-quality care.¹ In fact, it’s hard to read a journal, attend a medical presentation, or open a local newspaper without finding reference to these domains. It’s all the rage to talk about wrong-site surgery (safe), access to care (timely), comparative-effectiveness research (effective), lean concepts (efficient), and individualized medicine (patient-centered). However, the sixth domain often seems to get the Jan Brady treatment—minimized, marginalized, and oft-forgotten.

The IOM defines equitable care as that which “does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location, and socioeconomic status.”1 To be sure, there is some hum at the national level about issues of equity, especially around healthcare coverage for all. And this is important. However, what appears lost in the rant surrounding the inherent inequities in our tiered health insurance system is that we have blantant inequalities baked into the everyday machinery of our hospitals. And they affect all, regardless of skin color, gender, or insurance status.

Think for a moment about your hospital. Are the type, level, and access to care equal at all times? Does the level of care change when the streetlights come on? How about on weekends and holidays? Do your operating rooms run on Saturdays and Sundays? Can patients get chemotherapy on the weekends? Does your hospital alter its nursing staff ratios after hours? Can you get an ultrasound at midnight? How about a urology or neurosurgery consult at 2 a.m.? How about getting interventional radiology to place an IVC filter on a holiday?

Now scratch a bit closer to home. Does your hospitalist group downstaff on weekends and holidays, even though the volumes probably warrant more coverage? Are your night providers part of your group, or are they moonlighters? Do your after-hours providers cross-cover and admit a reasonable number of patients, or are they frequently overwhelmed? Do they cover patients or admit for services that they don’t typically care for during the day (e.g. ICU, neurosurgical, subspecialty cardiology or oncology patients)? For the intensely ill patients admitted to U.S. hospitals today, should the type and availability of care differ when it’s delivered at 3 p.m. or 3 a.m., Sunday or Monday?

Disregarding the macro-inequities in our societal approach to healthcare, can we even ensure equitable care within our own hospital walls 24 hours a day, seven days a week?

The Answer: An Unfortunate “No”

For the record, I hate working nights, abhor working weekends, and resent working holidays. But the thing I’d hate even more than working nights, weekends, and holidays would be being a patient admitted during a night, weekend, or holiday. To understand why, I have to look no further than my hospital parking lot. During bankers’ hours, I can barely find a parking spot on the top floor of our multilevel parking structure.

Fast-forward to Saturday, and I have my pick of empty football fields’ worth of spots on all floors. Ditto Sundays, nights, and holidays.

Why is it that nationally, a collectively near-trillion-dollar hospital enterprise finds it acceptable to effectively shutter itself for a quarter to a third of the week? Especially when doing so seems to counter their primary mission of providing safe, timely, effective, efficient, equitable, and patient-centered care.

The Weekend Effect

There are, of course, economic and operational reasons to downshift during off hours—some hospitals don’t have the elective procedures to run operating rooms seven days a week, and very few patients want to have their elective colonoscopy at 11 p.m. or their chemotherapy during Thanksgiving dinner. However, in most cases, the reasons for doing so center on hospital staff and physician satisfaction. Most us of just don’t like working off hours. As a result, studies have shown significantly less access to such high-level care as coronary angiography and percutaneous coronary intervention on weekends.^2,3

And the effects of this “weekend effect” can be devastating.

A recent paper in the New England Journal of Medicine reported that for every 1,000 patients admitted with a myocardial infarction on a weekend, nine more would die than a comparable group admitted during the week.⁴ Their offense? Having the misfortune to get ill on a Saturday morning. The authors concluded that this higher mortality was secondary to a lower rate of invasive cardiac procedures, presumably because they were less available. And the weekend effect isn’t just limited to coronary care. Poorer outcomes, including higher mortality rates, have been reported for weekend admissions to the neonatal ICU and adult ICU, as well as admission for epiglottitis, ruptured abdominal aortic aneurysms, and pulmonary embolism.^5,6,7

So let’s connect the dots: A system designed with inequal access to lifesaving therapies and appropriate staffing results in worse outcomes, more harm, more deaths.

To be clear, 98,000 people don’t die every year because of my disdain for working nights and weekends. This is a much deeper problem that hinges on many unsatisfactory systems working unsatisfactorily in tandem (e.g. see the other five IOM domains of quality care). Furthermore, I don’t mean to suggest that hospitalists necessarily have a lot of say in cardiac catheterization schedules. Yet we do control our own systems of care—how many patients we admit and cover during a shift, how strongly we advocate for timely testing and consultation, how we staff weekends and cover patients at night.

And, more and more, we are in a position to enhance the care delivery systems of the hospital and its providers that surround us. With that comes a responsibility to ensure that these systems are highly functioning and equitable, regardless of the time of day, day of the week.

If we are going to fundamentally enhance the quality of care, then we have to design safer systems of care. It will take time and resources to alter many of our bruised systems of care, but we can begin by at least ensuring equity in how we deliver care at our own institutions. That is, unless we are comfortable with a system perfectly designed to harm. TH

Dr. Glasheen is associate professor of medicine at the University of Colorado Denver, where he serves as director of the Hospital Medicine Program and the Hospitalist Training Program, and as associate program director of the Internal Medicine Residency Program.

References

1. Institute of Medicine (IOM). Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, D.C.: National Academy Press; 2001.
2. Bell CM, Redelmeier DA. Waiting for urgent procedures on the weekend among emergently hospitalized patients. Am J Med. 2004:117(3):175-181.
3. Magid DJ, Wang Y, Herrin J, et al. Relationship between time of day, day of week, timeliness of reperfusion, and in-hospital mortality for patients with acute ST-segment elevation myocardial infarction. JAMA. 2005;294(7):803-812.
4. Kostis WJ, Demissie K, Marcella SW, Shao YH, Wilson AC, Moreyra AE. Weekend versus weekday admission and mortality from myocardial infarction. N Eng J Med. 2007;356 (11):1099-1109.
5. Hendry RA. The weekend—a dangerous time to be born? Br J Obstet Gynaecol. 1981;88(12):1200-1203.
6. Barnett MJ, Kaboli PJ, Sirio CA, Rosenthal GE. Day of the week of intensive care admission and patient outcomes: a multisite regional evaluation. Med Care. 2002;40(6):530-539.
7. Bell CM, Redelmeier DA. Mortality among patients admitted to hospitals on weekends as compared with weekdays. N Eng J Med. 2001;345(9):663-668.

If every system is perfectly designed to get the results it gets …

And if 15 million patients are harmed every year from medical care …

And if as many as 98,000 people die every year due to medical errors in hospitals …

Then what does that say about the system we have designed?

A System Designed to Competently Hurt Many

By now you’ve no doubt heard, read, and possibly even uttered the above facts and figures yourself. I think we all have our opinions about the veracity of these numbers, but I don’t think any of us would argue with the sentiment. The U.S. healthcare system comprises the most competent, compassionate, well-meaning, and caring professionals on this planet—who harm, maim, and kill countless people every year.

What a discomforting paradox.

Equity: The Overlooked Quality Domain

Many years back, the Institute of Medicine (IOM) published a list of six “domains” of healthcare quality. You’ve no doubt stumbled across the IOM’s Safe … Timely … Effective … Efficient … Equitable … Patient-Centered mnemonic recipe—STEEEP—for high-quality care.¹ In fact, it’s hard to read a journal, attend a medical presentation, or open a local newspaper without finding reference to these domains. It’s all the rage to talk about wrong-site surgery (safe), access to care (timely), comparative-effectiveness research (effective), lean concepts (efficient), and individualized medicine (patient-centered). However, the sixth domain often seems to get the Jan Brady treatment—minimized, marginalized, and oft-forgotten.

The IOM defines equitable care as that which “does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location, and socioeconomic status.”1 To be sure, there is some hum at the national level about issues of equity, especially around healthcare coverage for all. And this is important. However, what appears lost in the rant surrounding the inherent inequities in our tiered health insurance system is that we have blantant inequalities baked into the everyday machinery of our hospitals. And they affect all, regardless of skin color, gender, or insurance status.

Think for a moment about your hospital. Are the type, level, and access to care equal at all times? Does the level of care change when the streetlights come on? How about on weekends and holidays? Do your operating rooms run on Saturdays and Sundays? Can patients get chemotherapy on the weekends? Does your hospital alter its nursing staff ratios after hours? Can you get an ultrasound at midnight? How about a urology or neurosurgery consult at 2 a.m.? How about getting interventional radiology to place an IVC filter on a holiday?

Now scratch a bit closer to home. Does your hospitalist group downstaff on weekends and holidays, even though the volumes probably warrant more coverage? Are your night providers part of your group, or are they moonlighters? Do your after-hours providers cross-cover and admit a reasonable number of patients, or are they frequently overwhelmed? Do they cover patients or admit for services that they don’t typically care for during the day (e.g. ICU, neurosurgical, subspecialty cardiology or oncology patients)? For the intensely ill patients admitted to U.S. hospitals today, should the type and availability of care differ when it’s delivered at 3 p.m. or 3 a.m., Sunday or Monday?

Disregarding the macro-inequities in our societal approach to healthcare, can we even ensure equitable care within our own hospital walls 24 hours a day, seven days a week?

The Answer: An Unfortunate “No”

For the record, I hate working nights, abhor working weekends, and resent working holidays. But the thing I’d hate even more than working nights, weekends, and holidays would be being a patient admitted during a night, weekend, or holiday. To understand why, I have to look no further than my hospital parking lot. During bankers’ hours, I can barely find a parking spot on the top floor of our multilevel parking structure.

Fast-forward to Saturday, and I have my pick of empty football fields’ worth of spots on all floors. Ditto Sundays, nights, and holidays.

Why is it that nationally, a collectively near-trillion-dollar hospital enterprise finds it acceptable to effectively shutter itself for a quarter to a third of the week? Especially when doing so seems to counter their primary mission of providing safe, timely, effective, efficient, equitable, and patient-centered care.

The Weekend Effect

There are, of course, economic and operational reasons to downshift during off hours—some hospitals don’t have the elective procedures to run operating rooms seven days a week, and very few patients want to have their elective colonoscopy at 11 p.m. or their chemotherapy during Thanksgiving dinner. However, in most cases, the reasons for doing so center on hospital staff and physician satisfaction. Most us of just don’t like working off hours. As a result, studies have shown significantly less access to such high-level care as coronary angiography and percutaneous coronary intervention on weekends.^2,3

And the effects of this “weekend effect” can be devastating.

A recent paper in the New England Journal of Medicine reported that for every 1,000 patients admitted with a myocardial infarction on a weekend, nine more would die than a comparable group admitted during the week.⁴ Their offense? Having the misfortune to get ill on a Saturday morning. The authors concluded that this higher mortality was secondary to a lower rate of invasive cardiac procedures, presumably because they were less available. And the weekend effect isn’t just limited to coronary care. Poorer outcomes, including higher mortality rates, have been reported for weekend admissions to the neonatal ICU and adult ICU, as well as admission for epiglottitis, ruptured abdominal aortic aneurysms, and pulmonary embolism.^5,6,7

So let’s connect the dots: A system designed with inequal access to lifesaving therapies and appropriate staffing results in worse outcomes, more harm, more deaths.

To be clear, 98,000 people don’t die every year because of my disdain for working nights and weekends. This is a much deeper problem that hinges on many unsatisfactory systems working unsatisfactorily in tandem (e.g. see the other five IOM domains of quality care). Furthermore, I don’t mean to suggest that hospitalists necessarily have a lot of say in cardiac catheterization schedules. Yet we do control our own systems of care—how many patients we admit and cover during a shift, how strongly we advocate for timely testing and consultation, how we staff weekends and cover patients at night.

And, more and more, we are in a position to enhance the care delivery systems of the hospital and its providers that surround us. With that comes a responsibility to ensure that these systems are highly functioning and equitable, regardless of the time of day, day of the week.

If we are going to fundamentally enhance the quality of care, then we have to design safer systems of care. It will take time and resources to alter many of our bruised systems of care, but we can begin by at least ensuring equity in how we deliver care at our own institutions. That is, unless we are comfortable with a system perfectly designed to harm. TH

Dr. Glasheen is associate professor of medicine at the University of Colorado Denver, where he serves as director of the Hospital Medicine Program and the Hospitalist Training Program, and as associate program director of the Internal Medicine Residency Program.

References

1. Institute of Medicine (IOM). Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, D.C.: National Academy Press; 2001.
2. Bell CM, Redelmeier DA. Waiting for urgent procedures on the weekend among emergently hospitalized patients. Am J Med. 2004:117(3):175-181.
3. Magid DJ, Wang Y, Herrin J, et al. Relationship between time of day, day of week, timeliness of reperfusion, and in-hospital mortality for patients with acute ST-segment elevation myocardial infarction. JAMA. 2005;294(7):803-812.
4. Kostis WJ, Demissie K, Marcella SW, Shao YH, Wilson AC, Moreyra AE. Weekend versus weekday admission and mortality from myocardial infarction. N Eng J Med. 2007;356 (11):1099-1109.
5. Hendry RA. The weekend—a dangerous time to be born? Br J Obstet Gynaecol. 1981;88(12):1200-1203.
6. Barnett MJ, Kaboli PJ, Sirio CA, Rosenthal GE. Day of the week of intensive care admission and patient outcomes: a multisite regional evaluation. Med Care. 2002;40(6):530-539.
7. Bell CM, Redelmeier DA. Mortality among patients admitted to hospitals on weekends as compared with weekdays. N Eng J Med. 2001;345(9):663-668.

If every system is perfectly designed to get the results it gets …

And if 15 million patients are harmed every year from medical care …

And if as many as 98,000 people die every year due to medical errors in hospitals …

Then what does that say about the system we have designed?

A System Designed to Competently Hurt Many

By now you’ve no doubt heard, read, and possibly even uttered the above facts and figures yourself. I think we all have our opinions about the veracity of these numbers, but I don’t think any of us would argue with the sentiment. The U.S. healthcare system comprises the most competent, compassionate, well-meaning, and caring professionals on this planet—who harm, maim, and kill countless people every year.

What a discomforting paradox.

Equity: The Overlooked Quality Domain

Many years back, the Institute of Medicine (IOM) published a list of six “domains” of healthcare quality. You’ve no doubt stumbled across the IOM’s Safe … Timely … Effective … Efficient … Equitable … Patient-Centered mnemonic recipe—STEEEP—for high-quality care.¹ In fact, it’s hard to read a journal, attend a medical presentation, or open a local newspaper without finding reference to these domains. It’s all the rage to talk about wrong-site surgery (safe), access to care (timely), comparative-effectiveness research (effective), lean concepts (efficient), and individualized medicine (patient-centered). However, the sixth domain often seems to get the Jan Brady treatment—minimized, marginalized, and oft-forgotten.

The IOM defines equitable care as that which “does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location, and socioeconomic status.”1 To be sure, there is some hum at the national level about issues of equity, especially around healthcare coverage for all. And this is important. However, what appears lost in the rant surrounding the inherent inequities in our tiered health insurance system is that we have blantant inequalities baked into the everyday machinery of our hospitals. And they affect all, regardless of skin color, gender, or insurance status.

Think for a moment about your hospital. Are the type, level, and access to care equal at all times? Does the level of care change when the streetlights come on? How about on weekends and holidays? Do your operating rooms run on Saturdays and Sundays? Can patients get chemotherapy on the weekends? Does your hospital alter its nursing staff ratios after hours? Can you get an ultrasound at midnight? How about a urology or neurosurgery consult at 2 a.m.? How about getting interventional radiology to place an IVC filter on a holiday?

Now scratch a bit closer to home. Does your hospitalist group downstaff on weekends and holidays, even though the volumes probably warrant more coverage? Are your night providers part of your group, or are they moonlighters? Do your after-hours providers cross-cover and admit a reasonable number of patients, or are they frequently overwhelmed? Do they cover patients or admit for services that they don’t typically care for during the day (e.g. ICU, neurosurgical, subspecialty cardiology or oncology patients)? For the intensely ill patients admitted to U.S. hospitals today, should the type and availability of care differ when it’s delivered at 3 p.m. or 3 a.m., Sunday or Monday?

Disregarding the macro-inequities in our societal approach to healthcare, can we even ensure equitable care within our own hospital walls 24 hours a day, seven days a week?

The Answer: An Unfortunate “No”

For the record, I hate working nights, abhor working weekends, and resent working holidays. But the thing I’d hate even more than working nights, weekends, and holidays would be being a patient admitted during a night, weekend, or holiday. To understand why, I have to look no further than my hospital parking lot. During bankers’ hours, I can barely find a parking spot on the top floor of our multilevel parking structure.

Fast-forward to Saturday, and I have my pick of empty football fields’ worth of spots on all floors. Ditto Sundays, nights, and holidays.

Why is it that nationally, a collectively near-trillion-dollar hospital enterprise finds it acceptable to effectively shutter itself for a quarter to a third of the week? Especially when doing so seems to counter their primary mission of providing safe, timely, effective, efficient, equitable, and patient-centered care.

The Weekend Effect

There are, of course, economic and operational reasons to downshift during off hours—some hospitals don’t have the elective procedures to run operating rooms seven days a week, and very few patients want to have their elective colonoscopy at 11 p.m. or their chemotherapy during Thanksgiving dinner. However, in most cases, the reasons for doing so center on hospital staff and physician satisfaction. Most us of just don’t like working off hours. As a result, studies have shown significantly less access to such high-level care as coronary angiography and percutaneous coronary intervention on weekends.^2,3

And the effects of this “weekend effect” can be devastating.

A recent paper in the New England Journal of Medicine reported that for every 1,000 patients admitted with a myocardial infarction on a weekend, nine more would die than a comparable group admitted during the week.⁴ Their offense? Having the misfortune to get ill on a Saturday morning. The authors concluded that this higher mortality was secondary to a lower rate of invasive cardiac procedures, presumably because they were less available. And the weekend effect isn’t just limited to coronary care. Poorer outcomes, including higher mortality rates, have been reported for weekend admissions to the neonatal ICU and adult ICU, as well as admission for epiglottitis, ruptured abdominal aortic aneurysms, and pulmonary embolism.^5,6,7

So let’s connect the dots: A system designed with inequal access to lifesaving therapies and appropriate staffing results in worse outcomes, more harm, more deaths.

To be clear, 98,000 people don’t die every year because of my disdain for working nights and weekends. This is a much deeper problem that hinges on many unsatisfactory systems working unsatisfactorily in tandem (e.g. see the other five IOM domains of quality care). Furthermore, I don’t mean to suggest that hospitalists necessarily have a lot of say in cardiac catheterization schedules. Yet we do control our own systems of care—how many patients we admit and cover during a shift, how strongly we advocate for timely testing and consultation, how we staff weekends and cover patients at night.

And, more and more, we are in a position to enhance the care delivery systems of the hospital and its providers that surround us. With that comes a responsibility to ensure that these systems are highly functioning and equitable, regardless of the time of day, day of the week.

If we are going to fundamentally enhance the quality of care, then we have to design safer systems of care. It will take time and resources to alter many of our bruised systems of care, but we can begin by at least ensuring equity in how we deliver care at our own institutions. That is, unless we are comfortable with a system perfectly designed to harm. TH

Dr. Glasheen is associate professor of medicine at the University of Colorado Denver, where he serves as director of the Hospital Medicine Program and the Hospitalist Training Program, and as associate program director of the Internal Medicine Residency Program.

References

1. Institute of Medicine (IOM). Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, D.C.: National Academy Press; 2001.
2. Bell CM, Redelmeier DA. Waiting for urgent procedures on the weekend among emergently hospitalized patients. Am J Med. 2004:117(3):175-181.
3. Magid DJ, Wang Y, Herrin J, et al. Relationship between time of day, day of week, timeliness of reperfusion, and in-hospital mortality for patients with acute ST-segment elevation myocardial infarction. JAMA. 2005;294(7):803-812.
4. Kostis WJ, Demissie K, Marcella SW, Shao YH, Wilson AC, Moreyra AE. Weekend versus weekday admission and mortality from myocardial infarction. N Eng J Med. 2007;356 (11):1099-1109.
5. Hendry RA. The weekend—a dangerous time to be born? Br J Obstet Gynaecol. 1981;88(12):1200-1203.
6. Barnett MJ, Kaboli PJ, Sirio CA, Rosenthal GE. Day of the week of intensive care admission and patient outcomes: a multisite regional evaluation. Med Care. 2002;40(6):530-539.
7. Bell CM, Redelmeier DA. Mortality among patients admitted to hospitals on weekends as compared with weekdays. N Eng J Med. 2001;345(9):663-668.

While most physicians say patients who discharge from the hospital against medical advice (AMA) put themselves at great risk, little research has been conducted to prove that theory. So two hospitalists at the Montefiore Medical Center in Bronx, N.Y., put it to the test, and they found that discharge AMA could literally be a matter of life or death.

In their award-winning HM10 research poster (PDF), Will Southern, MD, MS, and Julia Arnsten, MD, MPH, discovered that discharge AMA significantly increases the risk for both mortality and readmission in a general medical inpatient population. Their research equally divided more than 7,100 inpatients into two groups that were identical in every measurable domain, including admission laboratory values, acuity of illness, and medical history; one of the two groups chose discharge AMA.

Results showed that the AMA group was at a 45% increased risk of mortality and readmission within 30 days, whereas the non-AMA group was at approximately half the risk, with only a 27% chance of mortality and readmission.

Acknowledging the possibility that patients intuitively know when they are ready to leave and the fundamental medical, behavioral, and psychiatric differences in patients who discharge AMA, Dr. Southern says, "the real question is, 'If I [the hospitalist] intervene and, by whatever means necessary, try to convince the patients not to leave AMA, are their outcomes improved?' "

According to Dr. Southern, outcomes can be improved through patient communication, engagement, and intervention. "If you're interested in leaving AMA, it's OK, it's your choice," he says, "but your chances of being dead within the next 30 days are about double and your chances of being readmitted are about double."

Dr. Southern says that, although their findings are a useful starting point for further disease-centric study, for the practicing hospitalist with a patient considering discharge AMA, "it's about finding out why someone needs to leave: They need to feed their cat, cash their Social Security check, whatever the reason is."

While most physicians say patients who discharge from the hospital against medical advice (AMA) put themselves at great risk, little research has been conducted to prove that theory. So two hospitalists at the Montefiore Medical Center in Bronx, N.Y., put it to the test, and they found that discharge AMA could literally be a matter of life or death.

In their award-winning HM10 research poster (PDF), Will Southern, MD, MS, and Julia Arnsten, MD, MPH, discovered that discharge AMA significantly increases the risk for both mortality and readmission in a general medical inpatient population. Their research equally divided more than 7,100 inpatients into two groups that were identical in every measurable domain, including admission laboratory values, acuity of illness, and medical history; one of the two groups chose discharge AMA.

Results showed that the AMA group was at a 45% increased risk of mortality and readmission within 30 days, whereas the non-AMA group was at approximately half the risk, with only a 27% chance of mortality and readmission.

Acknowledging the possibility that patients intuitively know when they are ready to leave and the fundamental medical, behavioral, and psychiatric differences in patients who discharge AMA, Dr. Southern says, "the real question is, 'If I [the hospitalist] intervene and, by whatever means necessary, try to convince the patients not to leave AMA, are their outcomes improved?' "

According to Dr. Southern, outcomes can be improved through patient communication, engagement, and intervention. "If you're interested in leaving AMA, it's OK, it's your choice," he says, "but your chances of being dead within the next 30 days are about double and your chances of being readmitted are about double."

Dr. Southern says that, although their findings are a useful starting point for further disease-centric study, for the practicing hospitalist with a patient considering discharge AMA, "it's about finding out why someone needs to leave: They need to feed their cat, cash their Social Security check, whatever the reason is."

While most physicians say patients who discharge from the hospital against medical advice (AMA) put themselves at great risk, little research has been conducted to prove that theory. So two hospitalists at the Montefiore Medical Center in Bronx, N.Y., put it to the test, and they found that discharge AMA could literally be a matter of life or death.

In their award-winning HM10 research poster (PDF), Will Southern, MD, MS, and Julia Arnsten, MD, MPH, discovered that discharge AMA significantly increases the risk for both mortality and readmission in a general medical inpatient population. Their research equally divided more than 7,100 inpatients into two groups that were identical in every measurable domain, including admission laboratory values, acuity of illness, and medical history; one of the two groups chose discharge AMA.

Results showed that the AMA group was at a 45% increased risk of mortality and readmission within 30 days, whereas the non-AMA group was at approximately half the risk, with only a 27% chance of mortality and readmission.

Acknowledging the possibility that patients intuitively know when they are ready to leave and the fundamental medical, behavioral, and psychiatric differences in patients who discharge AMA, Dr. Southern says, "the real question is, 'If I [the hospitalist] intervene and, by whatever means necessary, try to convince the patients not to leave AMA, are their outcomes improved?' "

According to Dr. Southern, outcomes can be improved through patient communication, engagement, and intervention. "If you're interested in leaving AMA, it's OK, it's your choice," he says, "but your chances of being dead within the next 30 days are about double and your chances of being readmitted are about double."

Dr. Southern says that, although their findings are a useful starting point for further disease-centric study, for the practicing hospitalist with a patient considering discharge AMA, "it's about finding out why someone needs to leave: They need to feed their cat, cash their Social Security check, whatever the reason is."

Martin Johns, MD, joined Gifford Medical Center, a 25-bed full access hospital in rural Randolph, Vt., five years ago to launch its HM program. The landmark push toward implementing electronic health records (EHR) now has Dr. Johns and his colleagues scrambling.

Dr. Johns, whose program now has four hospitalists and four physician assistants, recently spoke with The Hospitalist eWire to talk about the technology challenges specifically faced by rural hospitalist programs.

Question: What role did EHR play in your HM group when you began the service?

Answer: Five years ago, I was definitely concerned about that. I came from Geisinger Medical Center (in Danville, Pa.). They had Epic embedded into every aspect of documentation. I was very used to the seamless integration of information in transitions of care. I was somewhat spoiled in that regard, but I also realized a small hospital was going to have different types of systems.

Q: How far has your digital record-keeping in the hospital come to date?

A: We currently have a data repository more than EHR. CPSI is the system we use. One of the difficulties in us making the decision to move to an EHR is a very interesting problem for all small hospitals. Because they require so much augmentation after installation, small hospitals can't afford to have your large Epic system, for example, to put in place. They can't have 10 IT people in house running the service. What ends up happening is that the hospital purchases an EHR based on outpatient clinic interest and said EHR usually doesn't really speak to your inpatient system.

Q: How can a smaller institution transition into a comprehensive system?

A: The biggest barrier is there's just not a really great all-level-of-care product that would take you through that in a small hospital. It's just too difficult and too expensive for someone to create that product, or at least it appears that way. An all-encompassing solution for a small hospital—the market is not just there.

Q: So where does that leave the rural hospitalist?

A: At a smaller place, it sets up all the variables for a communication breakdown. Mrs. Jones comes in for cataract surgery and she gets morphine and she has a reaction. That's on her hospital chart, but doesn't make its way onto her clinic chart. Those are the breakdowns that can happen and that's really challenging. … With this EHR push, if it's not done correctly, the patient can suffer more than they would with paper records.

Martin Johns, MD, joined Gifford Medical Center, a 25-bed full access hospital in rural Randolph, Vt., five years ago to launch its HM program. The landmark push toward implementing electronic health records (EHR) now has Dr. Johns and his colleagues scrambling.

Dr. Johns, whose program now has four hospitalists and four physician assistants, recently spoke with The Hospitalist eWire to talk about the technology challenges specifically faced by rural hospitalist programs.

Question: What role did EHR play in your HM group when you began the service?

Answer: Five years ago, I was definitely concerned about that. I came from Geisinger Medical Center (in Danville, Pa.). They had Epic embedded into every aspect of documentation. I was very used to the seamless integration of information in transitions of care. I was somewhat spoiled in that regard, but I also realized a small hospital was going to have different types of systems.

Q: How far has your digital record-keeping in the hospital come to date?

A: We currently have a data repository more than EHR. CPSI is the system we use. One of the difficulties in us making the decision to move to an EHR is a very interesting problem for all small hospitals. Because they require so much augmentation after installation, small hospitals can't afford to have your large Epic system, for example, to put in place. They can't have 10 IT people in house running the service. What ends up happening is that the hospital purchases an EHR based on outpatient clinic interest and said EHR usually doesn't really speak to your inpatient system.

Q: How can a smaller institution transition into a comprehensive system?

A: The biggest barrier is there's just not a really great all-level-of-care product that would take you through that in a small hospital. It's just too difficult and too expensive for someone to create that product, or at least it appears that way. An all-encompassing solution for a small hospital—the market is not just there.

Q: So where does that leave the rural hospitalist?

A: At a smaller place, it sets up all the variables for a communication breakdown. Mrs. Jones comes in for cataract surgery and she gets morphine and she has a reaction. That's on her hospital chart, but doesn't make its way onto her clinic chart. Those are the breakdowns that can happen and that's really challenging. … With this EHR push, if it's not done correctly, the patient can suffer more than they would with paper records.

Martin Johns, MD, joined Gifford Medical Center, a 25-bed full access hospital in rural Randolph, Vt., five years ago to launch its HM program. The landmark push toward implementing electronic health records (EHR) now has Dr. Johns and his colleagues scrambling.

Dr. Johns, whose program now has four hospitalists and four physician assistants, recently spoke with The Hospitalist eWire to talk about the technology challenges specifically faced by rural hospitalist programs.

Question: What role did EHR play in your HM group when you began the service?

Answer: Five years ago, I was definitely concerned about that. I came from Geisinger Medical Center (in Danville, Pa.). They had Epic embedded into every aspect of documentation. I was very used to the seamless integration of information in transitions of care. I was somewhat spoiled in that regard, but I also realized a small hospital was going to have different types of systems.

Q: How far has your digital record-keeping in the hospital come to date?

A: We currently have a data repository more than EHR. CPSI is the system we use. One of the difficulties in us making the decision to move to an EHR is a very interesting problem for all small hospitals. Because they require so much augmentation after installation, small hospitals can't afford to have your large Epic system, for example, to put in place. They can't have 10 IT people in house running the service. What ends up happening is that the hospital purchases an EHR based on outpatient clinic interest and said EHR usually doesn't really speak to your inpatient system.

Q: How can a smaller institution transition into a comprehensive system?

A: The biggest barrier is there's just not a really great all-level-of-care product that would take you through that in a small hospital. It's just too difficult and too expensive for someone to create that product, or at least it appears that way. An all-encompassing solution for a small hospital—the market is not just there.

Q: So where does that leave the rural hospitalist?

A: At a smaller place, it sets up all the variables for a communication breakdown. Mrs. Jones comes in for cataract surgery and she gets morphine and she has a reaction. That's on her hospital chart, but doesn't make its way onto her clinic chart. Those are the breakdowns that can happen and that's really challenging. … With this EHR push, if it's not done correctly, the patient can suffer more than they would with paper records.