[email protected]

Divorce is so common in the United States – ending about half of all marriages – that it will affect many patients and families in your practice. If your practice has about 2,000 children and adolescents from about 1,500 families, for example, hundreds of families will be dealing with predivorce marital tension, the divorce itself, or postdivorce concerns.

Start by screening for family functioning at every annual visit. Specifically, try to identify strife and stress early on, at a time when your inventions have the greatest preventive impact. Ask open-ended questions such as, “How are things going in the family?” or “Is there any tension or discord in the family or in the marriage?”

I recommend using the broader term “discord” because it will pick up a pending divorce and also identify other family stressors for the child. For example, research indicates that the years of arguing and fighting that often precede divorce may be more damaging to the child in the long term than the divorce itself.

Once you identify marital or family stress, strive for the following three long-term goals to optimize a healthy outcome for the child.

▸ First, make sure the child continues to function well in school, with peers, in activities, and in areas of self-esteem. The firr certain key signs that a child is not functioning well. Persistently lower school performance is one sign. Most children are't concentrate or perform as well at school in the year of the divorce, but it is a warning sign if the problems persist. Determine whether the child is still having difficulty adjusting to the divorce, and assess if there is ongoing discord or fighting about visitation, custody, child rearing, or finances after the divorce. Another warning sign is the child who drops an after-school activity during a divorce crisis, and fails to retume itin the next school year.

How a child relates to friends after the divorce can be important. In particular, ascertain how young or midadolescents treat members of the opposite sex. Look for patterns in their relationships that repeat some of the dysfunctional behaviors of their parents' marriage. Keep in mind that children are often unaware that they are repeating these family patterns.

For example, are girls who are adversely affected by divorce especially vulnerable to getting involved with older teenagers who might take advantage of them? Do you see any evidence of longing in the girls, or signs that they are seeking to replace something missing in their paternal relationship? This type of behavior is much less likely if the girl has had a good relationship with her father before, during, and after the divorce.

With teenage boys, consider how they treat their girlfriends. Is the boy supportive in his relationships, or does he have girlfriend after girlfriend because of a callous or insensitive attitude?

Referral for a mental health evaluation might be appropriate if you see a pattern of continuing dysfunction in a major area of the child's life or of unsatisfactory relationships as these younger teenagers enter high school, particularly if they are alienated from a parent.

▸ Second, ensure that parents are open and willing to answer the child's questions as the child tries to make sense of the divorce at each developmental stage. Help postdivorce families encourage the child to ask questions on an ongoing basis. If divorce happened when the child was a toddler, for example, they are going to have questions 5, 10, and 15 years later that they could not conceptualize until they reached the appropriate developmental point.

Parents may need your advice on how best to talk to their 5- or 8-year-old, a time when information should be concrete and straightforward. In contrast, a 14-year-old may be able to understand more conceptual and nuanced answers to their questions. For example, a younger child is unlikely to think about the divorce in terms of an extramarital affair or the impact on their college finances, but that may not be the case when the child is 14 or 15 years old. Keep in mind that many adolescents do not ask parents such difficult questions unless they are given permission in advance, and it's at a time when they feel safe and at ease.

▸ Third, counsel the family to facilitate a good relationship between the child and each parent over the long term. When families come to me and there is a lot of tension about visitation, custody, and money, I often focus them on the long-term goals. I ask, “What kind of relationship do you want with your child 10 and 15 years from now?”; “What is likely to result in a good long-term relationship with them?”; “Do you want to be able to be at their wedding?”; “Do you want to be close to your grandchildren?” Going all out for an extra few hours of visitation or not paying a bill is not likely to help achieve these long-term goals.

Again, early screening and intervention make your job easier. If a patient or family comes to you after years of negativity and a court fight over a bitter divorce, your ability to intervene effectively is already very limited.

Divorce is often an angry and divisive time. You can advise parents not to act out of anger by offering examples of divorcing parents who invested a lot of time and energy into winning short-term victories, only to see their efforts backfire later. Some parents believe that the child will be closer to them if they can make the child angry at the spouse. But children who feel they have to betray one parent to please the other often become resentful of this role over time.

In contrast, children who observe their parents working together with a sense of harmony and cooperation to make the custody, visitation, financial, and other arrangements successful are much less likely to blame themselves for the divorce. They also are much less likely to feel guilty when they connect more to one parent or the other at different points in their development.

It is important to monitor your patients for long-term effects of divorce up to and including the time you transition them to an adult care provider. Ask the older adolescent questions such as, “How do you feel about the divorce now, looking back on it [5, 10, or 15] years later?”; “How do you think it's affected you?”; and “Are there any things you'd like to change?”

If you do a review of how they integrated the divorce when they are in 10th or 11th grade, you will still have time to address any unresolved issues. If the child is distant with one parent, you can at least wonder if this is a point in time to reconnect and repair that relationship before the teenager goes to work or college and moves to being fully independent.

Pediatricians often have limited time to intervene. Some find this work very gratifying and feel comfortable with divorce-related issues. Others may choose to refer the patient to a social worker, psychologist, or child and adolescent psychiatrist, according to the severity of the situation. Some pediatric practices are fortunate to have a full- or part-time social worker.

If you want to counsel but your time is limited, consider offering a divorced-parent discussion and education group in your practice. You and/or a social worker could facilitate this forum. This resource can help parents share their experiences and strategies to ensure that children emerge as happy and healthy as possible after a divorce. In addition, this intervention can be cost-neutral if you charge parents a nominal fee.

[email protected]

Divorce is so common in the United States – ending about half of all marriages – that it will affect many patients and families in your practice. If your practice has about 2,000 children and adolescents from about 1,500 families, for example, hundreds of families will be dealing with predivorce marital tension, the divorce itself, or postdivorce concerns.

Start by screening for family functioning at every annual visit. Specifically, try to identify strife and stress early on, at a time when your inventions have the greatest preventive impact. Ask open-ended questions such as, “How are things going in the family?” or “Is there any tension or discord in the family or in the marriage?”

I recommend using the broader term “discord” because it will pick up a pending divorce and also identify other family stressors for the child. For example, research indicates that the years of arguing and fighting that often precede divorce may be more damaging to the child in the long term than the divorce itself.

Once you identify marital or family stress, strive for the following three long-term goals to optimize a healthy outcome for the child.

▸ First, make sure the child continues to function well in school, with peers, in activities, and in areas of self-esteem. The firr certain key signs that a child is not functioning well. Persistently lower school performance is one sign. Most children are't concentrate or perform as well at school in the year of the divorce, but it is a warning sign if the problems persist. Determine whether the child is still having difficulty adjusting to the divorce, and assess if there is ongoing discord or fighting about visitation, custody, child rearing, or finances after the divorce. Another warning sign is the child who drops an after-school activity during a divorce crisis, and fails to retume itin the next school year.

How a child relates to friends after the divorce can be important. In particular, ascertain how young or midadolescents treat members of the opposite sex. Look for patterns in their relationships that repeat some of the dysfunctional behaviors of their parents' marriage. Keep in mind that children are often unaware that they are repeating these family patterns.

For example, are girls who are adversely affected by divorce especially vulnerable to getting involved with older teenagers who might take advantage of them? Do you see any evidence of longing in the girls, or signs that they are seeking to replace something missing in their paternal relationship? This type of behavior is much less likely if the girl has had a good relationship with her father before, during, and after the divorce.

With teenage boys, consider how they treat their girlfriends. Is the boy supportive in his relationships, or does he have girlfriend after girlfriend because of a callous or insensitive attitude?

Referral for a mental health evaluation might be appropriate if you see a pattern of continuing dysfunction in a major area of the child's life or of unsatisfactory relationships as these younger teenagers enter high school, particularly if they are alienated from a parent.

▸ Second, ensure that parents are open and willing to answer the child's questions as the child tries to make sense of the divorce at each developmental stage. Help postdivorce families encourage the child to ask questions on an ongoing basis. If divorce happened when the child was a toddler, for example, they are going to have questions 5, 10, and 15 years later that they could not conceptualize until they reached the appropriate developmental point.

Parents may need your advice on how best to talk to their 5- or 8-year-old, a time when information should be concrete and straightforward. In contrast, a 14-year-old may be able to understand more conceptual and nuanced answers to their questions. For example, a younger child is unlikely to think about the divorce in terms of an extramarital affair or the impact on their college finances, but that may not be the case when the child is 14 or 15 years old. Keep in mind that many adolescents do not ask parents such difficult questions unless they are given permission in advance, and it's at a time when they feel safe and at ease.

▸ Third, counsel the family to facilitate a good relationship between the child and each parent over the long term. When families come to me and there is a lot of tension about visitation, custody, and money, I often focus them on the long-term goals. I ask, “What kind of relationship do you want with your child 10 and 15 years from now?”; “What is likely to result in a good long-term relationship with them?”; “Do you want to be able to be at their wedding?”; “Do you want to be close to your grandchildren?” Going all out for an extra few hours of visitation or not paying a bill is not likely to help achieve these long-term goals.

Again, early screening and intervention make your job easier. If a patient or family comes to you after years of negativity and a court fight over a bitter divorce, your ability to intervene effectively is already very limited.

Divorce is often an angry and divisive time. You can advise parents not to act out of anger by offering examples of divorcing parents who invested a lot of time and energy into winning short-term victories, only to see their efforts backfire later. Some parents believe that the child will be closer to them if they can make the child angry at the spouse. But children who feel they have to betray one parent to please the other often become resentful of this role over time.

In contrast, children who observe their parents working together with a sense of harmony and cooperation to make the custody, visitation, financial, and other arrangements successful are much less likely to blame themselves for the divorce. They also are much less likely to feel guilty when they connect more to one parent or the other at different points in their development.

It is important to monitor your patients for long-term effects of divorce up to and including the time you transition them to an adult care provider. Ask the older adolescent questions such as, “How do you feel about the divorce now, looking back on it [5, 10, or 15] years later?”; “How do you think it's affected you?”; and “Are there any things you'd like to change?”

If you do a review of how they integrated the divorce when they are in 10th or 11th grade, you will still have time to address any unresolved issues. If the child is distant with one parent, you can at least wonder if this is a point in time to reconnect and repair that relationship before the teenager goes to work or college and moves to being fully independent.

Pediatricians often have limited time to intervene. Some find this work very gratifying and feel comfortable with divorce-related issues. Others may choose to refer the patient to a social worker, psychologist, or child and adolescent psychiatrist, according to the severity of the situation. Some pediatric practices are fortunate to have a full- or part-time social worker.

If you want to counsel but your time is limited, consider offering a divorced-parent discussion and education group in your practice. You and/or a social worker could facilitate this forum. This resource can help parents share their experiences and strategies to ensure that children emerge as happy and healthy as possible after a divorce. In addition, this intervention can be cost-neutral if you charge parents a nominal fee.

[email protected]

Divorce is so common in the United States – ending about half of all marriages – that it will affect many patients and families in your practice. If your practice has about 2,000 children and adolescents from about 1,500 families, for example, hundreds of families will be dealing with predivorce marital tension, the divorce itself, or postdivorce concerns.

Start by screening for family functioning at every annual visit. Specifically, try to identify strife and stress early on, at a time when your inventions have the greatest preventive impact. Ask open-ended questions such as, “How are things going in the family?” or “Is there any tension or discord in the family or in the marriage?”

I recommend using the broader term “discord” because it will pick up a pending divorce and also identify other family stressors for the child. For example, research indicates that the years of arguing and fighting that often precede divorce may be more damaging to the child in the long term than the divorce itself.

Once you identify marital or family stress, strive for the following three long-term goals to optimize a healthy outcome for the child.

▸ First, make sure the child continues to function well in school, with peers, in activities, and in areas of self-esteem. The firr certain key signs that a child is not functioning well. Persistently lower school performance is one sign. Most children are't concentrate or perform as well at school in the year of the divorce, but it is a warning sign if the problems persist. Determine whether the child is still having difficulty adjusting to the divorce, and assess if there is ongoing discord or fighting about visitation, custody, child rearing, or finances after the divorce. Another warning sign is the child who drops an after-school activity during a divorce crisis, and fails to retume itin the next school year.

How a child relates to friends after the divorce can be important. In particular, ascertain how young or midadolescents treat members of the opposite sex. Look for patterns in their relationships that repeat some of the dysfunctional behaviors of their parents' marriage. Keep in mind that children are often unaware that they are repeating these family patterns.

For example, are girls who are adversely affected by divorce especially vulnerable to getting involved with older teenagers who might take advantage of them? Do you see any evidence of longing in the girls, or signs that they are seeking to replace something missing in their paternal relationship? This type of behavior is much less likely if the girl has had a good relationship with her father before, during, and after the divorce.

With teenage boys, consider how they treat their girlfriends. Is the boy supportive in his relationships, or does he have girlfriend after girlfriend because of a callous or insensitive attitude?

Referral for a mental health evaluation might be appropriate if you see a pattern of continuing dysfunction in a major area of the child's life or of unsatisfactory relationships as these younger teenagers enter high school, particularly if they are alienated from a parent.

▸ Second, ensure that parents are open and willing to answer the child's questions as the child tries to make sense of the divorce at each developmental stage. Help postdivorce families encourage the child to ask questions on an ongoing basis. If divorce happened when the child was a toddler, for example, they are going to have questions 5, 10, and 15 years later that they could not conceptualize until they reached the appropriate developmental point.

Parents may need your advice on how best to talk to their 5- or 8-year-old, a time when information should be concrete and straightforward. In contrast, a 14-year-old may be able to understand more conceptual and nuanced answers to their questions. For example, a younger child is unlikely to think about the divorce in terms of an extramarital affair or the impact on their college finances, but that may not be the case when the child is 14 or 15 years old. Keep in mind that many adolescents do not ask parents such difficult questions unless they are given permission in advance, and it's at a time when they feel safe and at ease.

▸ Third, counsel the family to facilitate a good relationship between the child and each parent over the long term. When families come to me and there is a lot of tension about visitation, custody, and money, I often focus them on the long-term goals. I ask, “What kind of relationship do you want with your child 10 and 15 years from now?”; “What is likely to result in a good long-term relationship with them?”; “Do you want to be able to be at their wedding?”; “Do you want to be close to your grandchildren?” Going all out for an extra few hours of visitation or not paying a bill is not likely to help achieve these long-term goals.

Again, early screening and intervention make your job easier. If a patient or family comes to you after years of negativity and a court fight over a bitter divorce, your ability to intervene effectively is already very limited.

Divorce is often an angry and divisive time. You can advise parents not to act out of anger by offering examples of divorcing parents who invested a lot of time and energy into winning short-term victories, only to see their efforts backfire later. Some parents believe that the child will be closer to them if they can make the child angry at the spouse. But children who feel they have to betray one parent to please the other often become resentful of this role over time.

In contrast, children who observe their parents working together with a sense of harmony and cooperation to make the custody, visitation, financial, and other arrangements successful are much less likely to blame themselves for the divorce. They also are much less likely to feel guilty when they connect more to one parent or the other at different points in their development.

It is important to monitor your patients for long-term effects of divorce up to and including the time you transition them to an adult care provider. Ask the older adolescent questions such as, “How do you feel about the divorce now, looking back on it [5, 10, or 15] years later?”; “How do you think it's affected you?”; and “Are there any things you'd like to change?”

If you do a review of how they integrated the divorce when they are in 10th or 11th grade, you will still have time to address any unresolved issues. If the child is distant with one parent, you can at least wonder if this is a point in time to reconnect and repair that relationship before the teenager goes to work or college and moves to being fully independent.

Pediatricians often have limited time to intervene. Some find this work very gratifying and feel comfortable with divorce-related issues. Others may choose to refer the patient to a social worker, psychologist, or child and adolescent psychiatrist, according to the severity of the situation. Some pediatric practices are fortunate to have a full- or part-time social worker.

If you want to counsel but your time is limited, consider offering a divorced-parent discussion and education group in your practice. You and/or a social worker could facilitate this forum. This resource can help parents share their experiences and strategies to ensure that children emerge as happy and healthy as possible after a divorce. In addition, this intervention can be cost-neutral if you charge parents a nominal fee.

Hospitalists should take care to remember the potentially violent offenders and situations that surround them daily at work, says a member of SHM's Practice Management Committee.

Michael Radzienda, MD, SFHM, vice president of hospital medicine and clinical effectiveness at Vanguard Health System in Southborough, Mass., says the recent shooting of a doctor at Johns Hopkins Hospital in Baltimore serves as a stark reminder that violence in the hospital is a concern for providers more than ever. To Dr. Radzienda's mind, that includes patients attacking doctors or patients attacking other patients.

"It's a newer issue for hospitalists, but one that they need to pay attention to," Dr. Radzienda says. "The volume of high-risk interactions that a hospitalist might have is significant compared to what that volume might have looked like 10 years ago before the hospitalist (model) took off."

And while one might think the incident at Johns Hopkins is enough to shine a lasting spotlight on the issue, a report from The Joint Commission this summer on hospital violence faded relatively quickly after its issuance. The commission's Sentinel Event Database, in fact, includes a category of assault, rape, and homicide (combined) with 256 reports since 1995, a number the organization suggests is under-reported. The commission's latest report, published in June, found that since 2004, hospitals have reported "significant increases in reports of assault, rape, and homicide, with the greater number of reports in the last three years."

The report recommends physicians learn techniques to identify potentially violent patients, implement violence de-escalation approaches, and even conduct violence audits to help determine an institution’s safety protocols.

Dr. Radzienda understands that training time and resources are stretched thin, but he says more focus on violence would be helpful to institutions and individual physicians. "The problem is someone needs to recognize this type of thing," he says. "But how do you prioritize that?"

Hospitalists should take care to remember the potentially violent offenders and situations that surround them daily at work, says a member of SHM's Practice Management Committee.

Michael Radzienda, MD, SFHM, vice president of hospital medicine and clinical effectiveness at Vanguard Health System in Southborough, Mass., says the recent shooting of a doctor at Johns Hopkins Hospital in Baltimore serves as a stark reminder that violence in the hospital is a concern for providers more than ever. To Dr. Radzienda's mind, that includes patients attacking doctors or patients attacking other patients.

"It's a newer issue for hospitalists, but one that they need to pay attention to," Dr. Radzienda says. "The volume of high-risk interactions that a hospitalist might have is significant compared to what that volume might have looked like 10 years ago before the hospitalist (model) took off."

And while one might think the incident at Johns Hopkins is enough to shine a lasting spotlight on the issue, a report from The Joint Commission this summer on hospital violence faded relatively quickly after its issuance. The commission's Sentinel Event Database, in fact, includes a category of assault, rape, and homicide (combined) with 256 reports since 1995, a number the organization suggests is under-reported. The commission's latest report, published in June, found that since 2004, hospitals have reported "significant increases in reports of assault, rape, and homicide, with the greater number of reports in the last three years."

The report recommends physicians learn techniques to identify potentially violent patients, implement violence de-escalation approaches, and even conduct violence audits to help determine an institution’s safety protocols.

Dr. Radzienda understands that training time and resources are stretched thin, but he says more focus on violence would be helpful to institutions and individual physicians. "The problem is someone needs to recognize this type of thing," he says. "But how do you prioritize that?"

Hospitalists should take care to remember the potentially violent offenders and situations that surround them daily at work, says a member of SHM's Practice Management Committee.

Michael Radzienda, MD, SFHM, vice president of hospital medicine and clinical effectiveness at Vanguard Health System in Southborough, Mass., says the recent shooting of a doctor at Johns Hopkins Hospital in Baltimore serves as a stark reminder that violence in the hospital is a concern for providers more than ever. To Dr. Radzienda's mind, that includes patients attacking doctors or patients attacking other patients.

"It's a newer issue for hospitalists, but one that they need to pay attention to," Dr. Radzienda says. "The volume of high-risk interactions that a hospitalist might have is significant compared to what that volume might have looked like 10 years ago before the hospitalist (model) took off."

And while one might think the incident at Johns Hopkins is enough to shine a lasting spotlight on the issue, a report from The Joint Commission this summer on hospital violence faded relatively quickly after its issuance. The commission's Sentinel Event Database, in fact, includes a category of assault, rape, and homicide (combined) with 256 reports since 1995, a number the organization suggests is under-reported. The commission's latest report, published in June, found that since 2004, hospitals have reported "significant increases in reports of assault, rape, and homicide, with the greater number of reports in the last three years."

The report recommends physicians learn techniques to identify potentially violent patients, implement violence de-escalation approaches, and even conduct violence audits to help determine an institution’s safety protocols.

Dr. Radzienda understands that training time and resources are stretched thin, but he says more focus on violence would be helpful to institutions and individual physicians. "The problem is someone needs to recognize this type of thing," he says. "But how do you prioritize that?"

There is going to be a healthcare crisis in Haiti in the next few years if things don’t markedly improve, says Jocelyn David, MD, chief hospitalist at the Miami VA Healthcare System in Miami, who has traveled to the island nation four times since the Jan. 12 earthquake.

Dr. David returned on Aug. 15 from a four-day trip she took with the Haitian Resource Development Foundation to assess the needs of smaller hospitals outside the capital of Port-au-Prince.

"People are traveling from the capital to these hospitals because the hospitals in the city are overwhelmed and struggling due to a lack of funds," Dr. David says.

Some city hospitals, such as CDTI du Sacre Coeur Hospital, one of the country’s more modern medical facilities, have outright closed, she says.

“I was surprised that I didn’t see any improvement,” says Mario A. Reyes, MD, FAAP, FHM, director of Pediatric Hospital Medicine at Miami Children’s Hospital, who volunteered in Haiti in January and went back in August to visit the Children’s Hospital of the Hopital de l’Universite d’Etat d’Haiti (HUEH), the largest academic public pediatric hospital in the capital.

The Children's Hospital is uninhabitable; medical staff are treating patients in makeshift wood houses provided by the United Nations, he says. Children sleep in hospital beds without mattresses, and oxygen tanks are shared by four or five children. There are no ultrasounds, and ventilators, IV lines, and antibiotics are in short supply, he says.

"There is a frustration among Haitian physicians that things aren't being done as quickly as they should," Dr. Reyes says. "The needs are immense."

Dr. David plans another trip to Haiti in October to train healthcare providers in BLS, ALS, and intubations in order to expand the limited emergency care. Meanwhile, Dr. Reyes and a group of physicians who work at Miami Children's Hospital are organizing professional and academic trips to HUEH so physicians can lend their expertise.

"That's what the Haitian providers want," he says. "They want us to teach and work with them."

The first trip is planned for December, and the group hopes the American Academy of Pediatrics will endorse their effort, which likely will include donating medical equipment and developing a telemedicine program.

Pediatric hospitalists who are interested in joining one of the trips to the Children’s Hospital of the Hopital de l’Universite d’Etat d’Haiti can contact Dr. Reyes at 305-668-5500 or at [email protected].

There is going to be a healthcare crisis in Haiti in the next few years if things don’t markedly improve, says Jocelyn David, MD, chief hospitalist at the Miami VA Healthcare System in Miami, who has traveled to the island nation four times since the Jan. 12 earthquake.

Dr. David returned on Aug. 15 from a four-day trip she took with the Haitian Resource Development Foundation to assess the needs of smaller hospitals outside the capital of Port-au-Prince.

"People are traveling from the capital to these hospitals because the hospitals in the city are overwhelmed and struggling due to a lack of funds," Dr. David says.

Some city hospitals, such as CDTI du Sacre Coeur Hospital, one of the country’s more modern medical facilities, have outright closed, she says.

“I was surprised that I didn’t see any improvement,” says Mario A. Reyes, MD, FAAP, FHM, director of Pediatric Hospital Medicine at Miami Children’s Hospital, who volunteered in Haiti in January and went back in August to visit the Children’s Hospital of the Hopital de l’Universite d’Etat d’Haiti (HUEH), the largest academic public pediatric hospital in the capital.

The Children's Hospital is uninhabitable; medical staff are treating patients in makeshift wood houses provided by the United Nations, he says. Children sleep in hospital beds without mattresses, and oxygen tanks are shared by four or five children. There are no ultrasounds, and ventilators, IV lines, and antibiotics are in short supply, he says.

"There is a frustration among Haitian physicians that things aren't being done as quickly as they should," Dr. Reyes says. "The needs are immense."

Dr. David plans another trip to Haiti in October to train healthcare providers in BLS, ALS, and intubations in order to expand the limited emergency care. Meanwhile, Dr. Reyes and a group of physicians who work at Miami Children's Hospital are organizing professional and academic trips to HUEH so physicians can lend their expertise.

"That's what the Haitian providers want," he says. "They want us to teach and work with them."

The first trip is planned for December, and the group hopes the American Academy of Pediatrics will endorse their effort, which likely will include donating medical equipment and developing a telemedicine program.

Pediatric hospitalists who are interested in joining one of the trips to the Children’s Hospital of the Hopital de l’Universite d’Etat d’Haiti can contact Dr. Reyes at 305-668-5500 or at [email protected].

There is going to be a healthcare crisis in Haiti in the next few years if things don’t markedly improve, says Jocelyn David, MD, chief hospitalist at the Miami VA Healthcare System in Miami, who has traveled to the island nation four times since the Jan. 12 earthquake.

Dr. David returned on Aug. 15 from a four-day trip she took with the Haitian Resource Development Foundation to assess the needs of smaller hospitals outside the capital of Port-au-Prince.

"People are traveling from the capital to these hospitals because the hospitals in the city are overwhelmed and struggling due to a lack of funds," Dr. David says.

Some city hospitals, such as CDTI du Sacre Coeur Hospital, one of the country’s more modern medical facilities, have outright closed, she says.

“I was surprised that I didn’t see any improvement,” says Mario A. Reyes, MD, FAAP, FHM, director of Pediatric Hospital Medicine at Miami Children’s Hospital, who volunteered in Haiti in January and went back in August to visit the Children’s Hospital of the Hopital de l’Universite d’Etat d’Haiti (HUEH), the largest academic public pediatric hospital in the capital.

The Children's Hospital is uninhabitable; medical staff are treating patients in makeshift wood houses provided by the United Nations, he says. Children sleep in hospital beds without mattresses, and oxygen tanks are shared by four or five children. There are no ultrasounds, and ventilators, IV lines, and antibiotics are in short supply, he says.

"There is a frustration among Haitian physicians that things aren't being done as quickly as they should," Dr. Reyes says. "The needs are immense."

Dr. David plans another trip to Haiti in October to train healthcare providers in BLS, ALS, and intubations in order to expand the limited emergency care. Meanwhile, Dr. Reyes and a group of physicians who work at Miami Children's Hospital are organizing professional and academic trips to HUEH so physicians can lend their expertise.

"That's what the Haitian providers want," he says. "They want us to teach and work with them."

The first trip is planned for December, and the group hopes the American Academy of Pediatrics will endorse their effort, which likely will include donating medical equipment and developing a telemedicine program.

Pediatric hospitalists who are interested in joining one of the trips to the Children’s Hospital of the Hopital de l’Universite d’Etat d’Haiti can contact Dr. Reyes at 305-668-5500 or at [email protected].

Enter text here

Enter text here

Enter text here

The advisory panel for the US Food and Drug Administration (FDA) voted unanimously on September 20 to recommend approval of dabigatran, an anticoagulant under investigation for the reduction of stroke risk and non-CNS systemic embolism in patients with atrial fibrillation.

The advisory board only voted that dabigatran works at least as well as warfarin. But unlike warfarin, dabigatran does not require laboratory monitoring. Therefore, dabigatran is less difficult to use than the current standard of care.

The decision was based on the randomized, noninferiority RE-LY (Randomized Evaluation of Long-Term Anticoagulation Therapy) trial of 18,000 patients. The trial compared unblinded warfarin administration with blinded doses of dabigatran at 110 mg and 150 mg.

The hazard ratio of dabigatran compared with warfarin was 0.66 (P<0.003) in the 150 mg dabigatran arm and 0.91 (P<0.0001) in the 110 mg dabigatran arm.

Bleeding risk remains the top safety concern. Receiving 150 mg of dabigatran seems to run the same risk as warfarin for bleeding complications, but in 110 mg doses of dabigatran, the risk was less than warfarin.

Conflict arose among committee members regarding whether or not to approve both doses. Some members disagreed, seeing that the 110 mg dose was only noninferior to warfarin, not superior. Other members believed that approving both doses would ensure wider use of the drug leading to the prevention of a greater number of strokes in atrial fibrillation patients.

There is one unexplained finding of the RE-LY study. Myocardial infarction rates were higher on dabigatran compared with warfarin. For every 1000 patients treated with dabigatran, there may be 2 more myocardial infarctions than in patients treated with warfarin.

The FDA often follows the advice of the panel of experts, although it is not required to.

The advisory panel for the US Food and Drug Administration (FDA) voted unanimously on September 20 to recommend approval of dabigatran, an anticoagulant under investigation for the reduction of stroke risk and non-CNS systemic embolism in patients with atrial fibrillation.

The advisory board only voted that dabigatran works at least as well as warfarin. But unlike warfarin, dabigatran does not require laboratory monitoring. Therefore, dabigatran is less difficult to use than the current standard of care.

The decision was based on the randomized, noninferiority RE-LY (Randomized Evaluation of Long-Term Anticoagulation Therapy) trial of 18,000 patients. The trial compared unblinded warfarin administration with blinded doses of dabigatran at 110 mg and 150 mg.

The hazard ratio of dabigatran compared with warfarin was 0.66 (P<0.003) in the 150 mg dabigatran arm and 0.91 (P<0.0001) in the 110 mg dabigatran arm.

Bleeding risk remains the top safety concern. Receiving 150 mg of dabigatran seems to run the same risk as warfarin for bleeding complications, but in 110 mg doses of dabigatran, the risk was less than warfarin.

Conflict arose among committee members regarding whether or not to approve both doses. Some members disagreed, seeing that the 110 mg dose was only noninferior to warfarin, not superior. Other members believed that approving both doses would ensure wider use of the drug leading to the prevention of a greater number of strokes in atrial fibrillation patients.

There is one unexplained finding of the RE-LY study. Myocardial infarction rates were higher on dabigatran compared with warfarin. For every 1000 patients treated with dabigatran, there may be 2 more myocardial infarctions than in patients treated with warfarin.

The FDA often follows the advice of the panel of experts, although it is not required to.

The advisory panel for the US Food and Drug Administration (FDA) voted unanimously on September 20 to recommend approval of dabigatran, an anticoagulant under investigation for the reduction of stroke risk and non-CNS systemic embolism in patients with atrial fibrillation.

The advisory board only voted that dabigatran works at least as well as warfarin. But unlike warfarin, dabigatran does not require laboratory monitoring. Therefore, dabigatran is less difficult to use than the current standard of care.

The decision was based on the randomized, noninferiority RE-LY (Randomized Evaluation of Long-Term Anticoagulation Therapy) trial of 18,000 patients. The trial compared unblinded warfarin administration with blinded doses of dabigatran at 110 mg and 150 mg.

The hazard ratio of dabigatran compared with warfarin was 0.66 (P<0.003) in the 150 mg dabigatran arm and 0.91 (P<0.0001) in the 110 mg dabigatran arm.

Bleeding risk remains the top safety concern. Receiving 150 mg of dabigatran seems to run the same risk as warfarin for bleeding complications, but in 110 mg doses of dabigatran, the risk was less than warfarin.

Conflict arose among committee members regarding whether or not to approve both doses. Some members disagreed, seeing that the 110 mg dose was only noninferior to warfarin, not superior. Other members believed that approving both doses would ensure wider use of the drug leading to the prevention of a greater number of strokes in atrial fibrillation patients.

There is one unexplained finding of the RE-LY study. Myocardial infarction rates were higher on dabigatran compared with warfarin. For every 1000 patients treated with dabigatran, there may be 2 more myocardial infarctions than in patients treated with warfarin.

The FDA often follows the advice of the panel of experts, although it is not required to.

Hospitalists might be able to help reduce their institutions' readmission rate by adding in targeted screenings for depressive symptoms, according to the author of a study in this month’s Journal of Hospital Medicine.

The report found that patients surveyed with said symptoms had a higher rate of readmission at 30 days after discharge (0.563 vs. 0.296) (DOI: 10.1002/jhm.673). Similar data were found at both 60 and 90 days after discharge.

Suzanne Mitchell, MD, MS, an instructor at Boston University School of Medicine/Boston Medical Center and one of the authors of the study, thinks the work should be a first step toward creating transitional-care programs that target depressive symptoms. “If we just screen and have nothing to offer, we’re not really helping patients out,” Dr. Mitchell says. “It’s an important piece to have some kind of program available to help bridge the transition process.”

Dr. Mitchell says that as more research associates depression with readmission rates, HM leaders will begin to see the value in creating programs to better communicate with patients about it. Ideas include follow-up phone calls with a PCP to discuss mental-health support options.

She adds that while hospitalists taking patient histories might glean information about depressive symptoms, HM groups can consider more targeted questions to determine a patient’s risk.

“Being able to open that conversation and having it on your radar is very important,” Dr. Mitchell says. “I find that if I don’t open the conversation, it doesn’t happen. But once I do, the patient is open to disclosing.”

Hospitalists might be able to help reduce their institutions' readmission rate by adding in targeted screenings for depressive symptoms, according to the author of a study in this month’s Journal of Hospital Medicine.

The report found that patients surveyed with said symptoms had a higher rate of readmission at 30 days after discharge (0.563 vs. 0.296) (DOI: 10.1002/jhm.673). Similar data were found at both 60 and 90 days after discharge.

Suzanne Mitchell, MD, MS, an instructor at Boston University School of Medicine/Boston Medical Center and one of the authors of the study, thinks the work should be a first step toward creating transitional-care programs that target depressive symptoms. “If we just screen and have nothing to offer, we’re not really helping patients out,” Dr. Mitchell says. “It’s an important piece to have some kind of program available to help bridge the transition process.”

Dr. Mitchell says that as more research associates depression with readmission rates, HM leaders will begin to see the value in creating programs to better communicate with patients about it. Ideas include follow-up phone calls with a PCP to discuss mental-health support options.

She adds that while hospitalists taking patient histories might glean information about depressive symptoms, HM groups can consider more targeted questions to determine a patient’s risk.

“Being able to open that conversation and having it on your radar is very important,” Dr. Mitchell says. “I find that if I don’t open the conversation, it doesn’t happen. But once I do, the patient is open to disclosing.”

Hospitalists might be able to help reduce their institutions' readmission rate by adding in targeted screenings for depressive symptoms, according to the author of a study in this month’s Journal of Hospital Medicine.

The report found that patients surveyed with said symptoms had a higher rate of readmission at 30 days after discharge (0.563 vs. 0.296) (DOI: 10.1002/jhm.673). Similar data were found at both 60 and 90 days after discharge.

Suzanne Mitchell, MD, MS, an instructor at Boston University School of Medicine/Boston Medical Center and one of the authors of the study, thinks the work should be a first step toward creating transitional-care programs that target depressive symptoms. “If we just screen and have nothing to offer, we’re not really helping patients out,” Dr. Mitchell says. “It’s an important piece to have some kind of program available to help bridge the transition process.”

Dr. Mitchell says that as more research associates depression with readmission rates, HM leaders will begin to see the value in creating programs to better communicate with patients about it. Ideas include follow-up phone calls with a PCP to discuss mental-health support options.

She adds that while hospitalists taking patient histories might glean information about depressive symptoms, HM groups can consider more targeted questions to determine a patient’s risk.

“Being able to open that conversation and having it on your radar is very important,” Dr. Mitchell says. “I find that if I don’t open the conversation, it doesn’t happen. But once I do, the patient is open to disclosing.”

Clinical question: Does the incorporation of bar-code verification technology within an electronic medication-administration system (eMAR) reduce the rate of medication errors?

Background: More than a fourth of medication-related inpatient adverse events are due to errors. Bar-code verification technology reduces the incidence of such errors; however, the quantitative effect of implementing such technology is unknown.

Study design: Before-and-after quasi-experimental study.

Setting: Single academic tertiary-care medical center in Boston.

Synopsis: Investigators directly observed 14,041 medication administrations in patient units that did and did not have bar-code eMAR. They reported a 41.4% relative reduction (RR) in medication administration errors (11.5% error rate before versus 6.8% after adoption of this technology) and 50.8% RR in the rate of potential adverse drug events (3.1% versus 1.6%). Significant reductions in wrong medication, dose, and administration documentation errors were noted. Order transcription errors were completely eliminated (6% versus 0%). Although errors in medication administration timing fell by 27.3%, no significant difference in the number of potential adverse events related to timing errors was found.

The investigators estimated that approximately 145,000 potential adverse drug events would be prevented from amongst an annual 1.69 million medication orders.

Pre-existent computerized physician order entry and bar-code verification technology in the pharmacy at the study hospital might limit the generalization of these results. Additionally, potential, not actual, adverse drug events were reported. Lastly, the study compared early implementers with late implementers.

Bottom line: Bar-code verification technology substantially reduced the number of medication administration errors and associated adverse drug events and completely eliminated the occurrence of transcription errors.

Citation: Poon EG, Keohane CA, Yoon CS, et al. Effect of bar-code technology on the safety of medication administration. N Engl J Med. 2010;362(18):1698-1707.

Reviewed for TH eWire by Robert Chang, MD, Anita Hart, MD, Hae-won Kim, MD, Robert Paretti, MD, Helena Pasieka, MD, and Matt Smitherman, MD, University of Michigan, Ann Arbor.

For more physician reviews of HM-related research, visit our website.

Clinical question: Does the incorporation of bar-code verification technology within an electronic medication-administration system (eMAR) reduce the rate of medication errors?

Background: More than a fourth of medication-related inpatient adverse events are due to errors. Bar-code verification technology reduces the incidence of such errors; however, the quantitative effect of implementing such technology is unknown.

Study design: Before-and-after quasi-experimental study.

Setting: Single academic tertiary-care medical center in Boston.

Synopsis: Investigators directly observed 14,041 medication administrations in patient units that did and did not have bar-code eMAR. They reported a 41.4% relative reduction (RR) in medication administration errors (11.5% error rate before versus 6.8% after adoption of this technology) and 50.8% RR in the rate of potential adverse drug events (3.1% versus 1.6%). Significant reductions in wrong medication, dose, and administration documentation errors were noted. Order transcription errors were completely eliminated (6% versus 0%). Although errors in medication administration timing fell by 27.3%, no significant difference in the number of potential adverse events related to timing errors was found.

The investigators estimated that approximately 145,000 potential adverse drug events would be prevented from amongst an annual 1.69 million medication orders.

Pre-existent computerized physician order entry and bar-code verification technology in the pharmacy at the study hospital might limit the generalization of these results. Additionally, potential, not actual, adverse drug events were reported. Lastly, the study compared early implementers with late implementers.

Bottom line: Bar-code verification technology substantially reduced the number of medication administration errors and associated adverse drug events and completely eliminated the occurrence of transcription errors.

Citation: Poon EG, Keohane CA, Yoon CS, et al. Effect of bar-code technology on the safety of medication administration. N Engl J Med. 2010;362(18):1698-1707.

Reviewed for TH eWire by Robert Chang, MD, Anita Hart, MD, Hae-won Kim, MD, Robert Paretti, MD, Helena Pasieka, MD, and Matt Smitherman, MD, University of Michigan, Ann Arbor.

For more physician reviews of HM-related research, visit our website.

Clinical question: Does the incorporation of bar-code verification technology within an electronic medication-administration system (eMAR) reduce the rate of medication errors?

Background: More than a fourth of medication-related inpatient adverse events are due to errors. Bar-code verification technology reduces the incidence of such errors; however, the quantitative effect of implementing such technology is unknown.

Study design: Before-and-after quasi-experimental study.

Setting: Single academic tertiary-care medical center in Boston.

Synopsis: Investigators directly observed 14,041 medication administrations in patient units that did and did not have bar-code eMAR. They reported a 41.4% relative reduction (RR) in medication administration errors (11.5% error rate before versus 6.8% after adoption of this technology) and 50.8% RR in the rate of potential adverse drug events (3.1% versus 1.6%). Significant reductions in wrong medication, dose, and administration documentation errors were noted. Order transcription errors were completely eliminated (6% versus 0%). Although errors in medication administration timing fell by 27.3%, no significant difference in the number of potential adverse events related to timing errors was found.

The investigators estimated that approximately 145,000 potential adverse drug events would be prevented from amongst an annual 1.69 million medication orders.

Pre-existent computerized physician order entry and bar-code verification technology in the pharmacy at the study hospital might limit the generalization of these results. Additionally, potential, not actual, adverse drug events were reported. Lastly, the study compared early implementers with late implementers.

Bottom line: Bar-code verification technology substantially reduced the number of medication administration errors and associated adverse drug events and completely eliminated the occurrence of transcription errors.

Citation: Poon EG, Keohane CA, Yoon CS, et al. Effect of bar-code technology on the safety of medication administration. N Engl J Med. 2010;362(18):1698-1707.

Reviewed for TH eWire by Robert Chang, MD, Anita Hart, MD, Hae-won Kim, MD, Robert Paretti, MD, Helena Pasieka, MD, and Matt Smitherman, MD, University of Michigan, Ann Arbor.

For more physician reviews of HM-related research, visit our website.

An Archives of Internal Medicine report and a U.S. Food and Drug Administration (FDA) advisory that question the long-term safety of inferior vena cava (IVC) filters should give hospitalists pause, one HM leader says.

The Aug. 9 report (PDF) found that the Bard Recovery and Bard G2 filters “had high prevalences of fracture and embolization, with potentially life-threatening sequelae." An FDA advisory issued the same day as the study cautioned that retrievable filters are not always removed from patients once the risk of pulmonary embolism (PE) has subsided, further increasing the risks.

“We’re going to be thinking more than twice before we recommend when these filters are placed in and then thinking twice about when we get them out,” says Shaker Eid, MD, an instructor of medicine at Johns Hopkins University School of Medicine in Baltimore.

Dr. Eid, however, cautions HM leaders about being too fearful of the data. The Archives report, he notes, was a single-center study. And while the FDA reports that the use of filters grew exponentially from 1979 to 2007, new American College of Chest Physicians guidelines from 2008 have limited their use mostly to patients who cannot receive anticoagulation treatments, Dr. Eid notes.

In cases in which they are necessary to implant, or in instances in which a patient already has a permanent IVC filter implanted, Dr. Eid recommends hospitalists be diligent in working with the filter.

An Archives of Internal Medicine report and a U.S. Food and Drug Administration (FDA) advisory that question the long-term safety of inferior vena cava (IVC) filters should give hospitalists pause, one HM leader says.

The Aug. 9 report (PDF) found that the Bard Recovery and Bard G2 filters “had high prevalences of fracture and embolization, with potentially life-threatening sequelae." An FDA advisory issued the same day as the study cautioned that retrievable filters are not always removed from patients once the risk of pulmonary embolism (PE) has subsided, further increasing the risks.

“We’re going to be thinking more than twice before we recommend when these filters are placed in and then thinking twice about when we get them out,” says Shaker Eid, MD, an instructor of medicine at Johns Hopkins University School of Medicine in Baltimore.

Dr. Eid, however, cautions HM leaders about being too fearful of the data. The Archives report, he notes, was a single-center study. And while the FDA reports that the use of filters grew exponentially from 1979 to 2007, new American College of Chest Physicians guidelines from 2008 have limited their use mostly to patients who cannot receive anticoagulation treatments, Dr. Eid notes.

In cases in which they are necessary to implant, or in instances in which a patient already has a permanent IVC filter implanted, Dr. Eid recommends hospitalists be diligent in working with the filter.

An Archives of Internal Medicine report and a U.S. Food and Drug Administration (FDA) advisory that question the long-term safety of inferior vena cava (IVC) filters should give hospitalists pause, one HM leader says.

The Aug. 9 report (PDF) found that the Bard Recovery and Bard G2 filters “had high prevalences of fracture and embolization, with potentially life-threatening sequelae." An FDA advisory issued the same day as the study cautioned that retrievable filters are not always removed from patients once the risk of pulmonary embolism (PE) has subsided, further increasing the risks.

“We’re going to be thinking more than twice before we recommend when these filters are placed in and then thinking twice about when we get them out,” says Shaker Eid, MD, an instructor of medicine at Johns Hopkins University School of Medicine in Baltimore.

Dr. Eid, however, cautions HM leaders about being too fearful of the data. The Archives report, he notes, was a single-center study. And while the FDA reports that the use of filters grew exponentially from 1979 to 2007, new American College of Chest Physicians guidelines from 2008 have limited their use mostly to patients who cannot receive anticoagulation treatments, Dr. Eid notes.

In cases in which they are necessary to implant, or in instances in which a patient already has a permanent IVC filter implanted, Dr. Eid recommends hospitalists be diligent in working with the filter.

Could U.S. hospitals learn from how HM is practiced in developing nations such as Ecuador? David Gaus, MD, MS, founder and director of Andean Health and Development (AHD), thinks so.

Dr. Gaus, who spends half the year as assistant clinical professor of medicine and teaching hospitalist at the University of Wisconsin and the other half with AHD in Ecuador, was inspired to pursue a medical degree by doing development work in Ecuador. When he returned to Ecuador in 1995 to be a doctor to the poor, he discovered a major gap in the healthcare system, between undertrained rural PCPs and the specialist-heavy medical practice in the country’s capital of Quito.

Under his leadership, AHD established a hospital in the rural community of Pedro Vicente Maldonado; it opened in 2000 and now is financially self-sufficient. “The focus was on the need for cost-effective, high-quality hospital services in a country with a dearth of hospitals,” he says.

At the hospital, family-practice physicians serve as hospitalists and deal with a wide spectrum of clinical needs ranging from car accidents and complicated pregnancies to snake bites and toxic organic phosphate herbicide exposure.

“Rural hospitals can’t afford five or six types of attendings, but if you have well-trained family practitioners backed by a general surgeon, they can handle most of the spectrum of clinical needs and the chaos management,” he says. Increasingly, those clinical needs include such chronic degenerative diseases as diabetes, hypertension, and arthritis, for which Ecuador’s cadre of rural PCPs are not trained.

Dr. Gaus is planning a second hospital in the larger Ecuadorean city of Santo Domingo (population 400,000), with the support of the Ministry of Public Health and the Social Security system. The new facility, using the same model and hospitalist roles, will open in 12 to 18 months and will increase the number of three-year family-practice residency slots from six to 20.

Could U.S. hospitals learn from how HM is practiced in developing nations such as Ecuador? David Gaus, MD, MS, founder and director of Andean Health and Development (AHD), thinks so.

Dr. Gaus, who spends half the year as assistant clinical professor of medicine and teaching hospitalist at the University of Wisconsin and the other half with AHD in Ecuador, was inspired to pursue a medical degree by doing development work in Ecuador. When he returned to Ecuador in 1995 to be a doctor to the poor, he discovered a major gap in the healthcare system, between undertrained rural PCPs and the specialist-heavy medical practice in the country’s capital of Quito.

Under his leadership, AHD established a hospital in the rural community of Pedro Vicente Maldonado; it opened in 2000 and now is financially self-sufficient. “The focus was on the need for cost-effective, high-quality hospital services in a country with a dearth of hospitals,” he says.

At the hospital, family-practice physicians serve as hospitalists and deal with a wide spectrum of clinical needs ranging from car accidents and complicated pregnancies to snake bites and toxic organic phosphate herbicide exposure.

“Rural hospitals can’t afford five or six types of attendings, but if you have well-trained family practitioners backed by a general surgeon, they can handle most of the spectrum of clinical needs and the chaos management,” he says. Increasingly, those clinical needs include such chronic degenerative diseases as diabetes, hypertension, and arthritis, for which Ecuador’s cadre of rural PCPs are not trained.

Dr. Gaus is planning a second hospital in the larger Ecuadorean city of Santo Domingo (population 400,000), with the support of the Ministry of Public Health and the Social Security system. The new facility, using the same model and hospitalist roles, will open in 12 to 18 months and will increase the number of three-year family-practice residency slots from six to 20.

Could U.S. hospitals learn from how HM is practiced in developing nations such as Ecuador? David Gaus, MD, MS, founder and director of Andean Health and Development (AHD), thinks so.

Dr. Gaus, who spends half the year as assistant clinical professor of medicine and teaching hospitalist at the University of Wisconsin and the other half with AHD in Ecuador, was inspired to pursue a medical degree by doing development work in Ecuador. When he returned to Ecuador in 1995 to be a doctor to the poor, he discovered a major gap in the healthcare system, between undertrained rural PCPs and the specialist-heavy medical practice in the country’s capital of Quito.

Under his leadership, AHD established a hospital in the rural community of Pedro Vicente Maldonado; it opened in 2000 and now is financially self-sufficient. “The focus was on the need for cost-effective, high-quality hospital services in a country with a dearth of hospitals,” he says.

At the hospital, family-practice physicians serve as hospitalists and deal with a wide spectrum of clinical needs ranging from car accidents and complicated pregnancies to snake bites and toxic organic phosphate herbicide exposure.

“Rural hospitals can’t afford five or six types of attendings, but if you have well-trained family practitioners backed by a general surgeon, they can handle most of the spectrum of clinical needs and the chaos management,” he says. Increasingly, those clinical needs include such chronic degenerative diseases as diabetes, hypertension, and arthritis, for which Ecuador’s cadre of rural PCPs are not trained.

Dr. Gaus is planning a second hospital in the larger Ecuadorean city of Santo Domingo (population 400,000), with the support of the Ministry of Public Health and the Social Security system. The new facility, using the same model and hospitalist roles, will open in 12 to 18 months and will increase the number of three-year family-practice residency slots from six to 20.