A supplement to Internal Medicine News supported by Supported by Santarus, Inc. The supplement is based on a faculty interview.

To view the supplement, click the image above.

FACULTY
Sheila E. Crowe, MD
Associate Professor of Internal Medicine
Division of Gastroenterology and Hepatology
Digestive Health Center of Excellence
University of Virginia

A supplement to Internal Medicine News supported by Supported by Santarus, Inc. The supplement is based on a faculty interview.

To view the supplement, click the image above.

FACULTY
Sheila E. Crowe, MD
Associate Professor of Internal Medicine
Division of Gastroenterology and Hepatology
Digestive Health Center of Excellence
University of Virginia

A supplement to Internal Medicine News supported by Supported by Santarus, Inc. The supplement is based on a faculty interview.

To view the supplement, click the image above.

FACULTY
Sheila E. Crowe, MD
Associate Professor of Internal Medicine
Division of Gastroenterology and Hepatology
Digestive Health Center of Excellence
University of Virginia

A supplement to Internal Medicine News supported by Takeda Pharmaceuticals North America, Inc. The supplement is based on a faculty interview.

To view the supplement, click the image above.

FACULTY
Anthony J. Lembo, MD
Assistant Professor of Medicine
Beth Israel Deaconess
Medical Center
Harvard Medical School

A supplement to Internal Medicine News supported by Takeda Pharmaceuticals North America, Inc. The supplement is based on a faculty interview.

To view the supplement, click the image above.

FACULTY
Anthony J. Lembo, MD
Assistant Professor of Medicine
Beth Israel Deaconess
Medical Center
Harvard Medical School

A supplement to Internal Medicine News supported by Takeda Pharmaceuticals North America, Inc. The supplement is based on a faculty interview.

To view the supplement, click the image above.

FACULTY
Anthony J. Lembo, MD
Assistant Professor of Medicine
Beth Israel Deaconess
Medical Center
Harvard Medical School

A concerted effort to reduce patient falls in Minnesota hospitals culminated last year as the Gopher State reported zero fatal falls—a result heavily attributed to hospitalist efforts.

A report last month from Minnesota health officials shows that no patients died from falls in 2009. It was the first fatality-free reporting period since the state began publicly disclosing adverse events six years ago. In 2008, 10 fall-related fatalities were reported in Minnesota hospitals.

"We went through our order sets and eliminated potentially unnecessary medications across the board," says Scott Tongen, MD, a hospitalist and medical director for quality at United Hospital in St. Paul. "And we challenged hospitalists to stop prescribing those … and at the same time we had to work with the nursing staff."

Dr. Tongen says his hospital, which is part of the Allina Hospitals and Clinics system, attacked the issue of falls by emphasizing hourly rounding by the nursing staff and collaborating with HM leaders. The state also developed Minnesota Falls Prevention, an award-winning Web site that shines light on the issue of preventable falls.

"I think one of the keys to success is empowering the nursing staff to work with the hospitalist service in partnership to accomplish this goal," says hospitalist James Young, MD, who works at United and is president of SHM's Minnesota chapter. "I know that at United, our nurses are far from mute and are not bashful about telling us when a patient is at risk. We are not bashful in educating them about why sleepers aren't a great idea for elderly patients. … It’s a team effort."

A concerted effort to reduce patient falls in Minnesota hospitals culminated last year as the Gopher State reported zero fatal falls—a result heavily attributed to hospitalist efforts.

A report last month from Minnesota health officials shows that no patients died from falls in 2009. It was the first fatality-free reporting period since the state began publicly disclosing adverse events six years ago. In 2008, 10 fall-related fatalities were reported in Minnesota hospitals.

"We went through our order sets and eliminated potentially unnecessary medications across the board," says Scott Tongen, MD, a hospitalist and medical director for quality at United Hospital in St. Paul. "And we challenged hospitalists to stop prescribing those … and at the same time we had to work with the nursing staff."

Dr. Tongen says his hospital, which is part of the Allina Hospitals and Clinics system, attacked the issue of falls by emphasizing hourly rounding by the nursing staff and collaborating with HM leaders. The state also developed Minnesota Falls Prevention, an award-winning Web site that shines light on the issue of preventable falls.

"I think one of the keys to success is empowering the nursing staff to work with the hospitalist service in partnership to accomplish this goal," says hospitalist James Young, MD, who works at United and is president of SHM's Minnesota chapter. "I know that at United, our nurses are far from mute and are not bashful about telling us when a patient is at risk. We are not bashful in educating them about why sleepers aren't a great idea for elderly patients. … It’s a team effort."

A concerted effort to reduce patient falls in Minnesota hospitals culminated last year as the Gopher State reported zero fatal falls—a result heavily attributed to hospitalist efforts.

A report last month from Minnesota health officials shows that no patients died from falls in 2009. It was the first fatality-free reporting period since the state began publicly disclosing adverse events six years ago. In 2008, 10 fall-related fatalities were reported in Minnesota hospitals.

"We went through our order sets and eliminated potentially unnecessary medications across the board," says Scott Tongen, MD, a hospitalist and medical director for quality at United Hospital in St. Paul. "And we challenged hospitalists to stop prescribing those … and at the same time we had to work with the nursing staff."

Dr. Tongen says his hospital, which is part of the Allina Hospitals and Clinics system, attacked the issue of falls by emphasizing hourly rounding by the nursing staff and collaborating with HM leaders. The state also developed Minnesota Falls Prevention, an award-winning Web site that shines light on the issue of preventable falls.

"I think one of the keys to success is empowering the nursing staff to work with the hospitalist service in partnership to accomplish this goal," says hospitalist James Young, MD, who works at United and is president of SHM's Minnesota chapter. "I know that at United, our nurses are far from mute and are not bashful about telling us when a patient is at risk. We are not bashful in educating them about why sleepers aren't a great idea for elderly patients. … It’s a team effort."

Clinical question: Does B-type natriuretic peptide (BNP) have prognostic value for cardiovascular events independent of left ventricular end-diastolic pressure in patients suspected of having coronary artery disease?

Background: BNP has prognostic value in predicting death in multiple populations, including patients with stable coronary artery disease, independent of left ventricular ejection fracture (LVEF). However, BNP and invasively measured LV filling pressure correlate weakly, and there is little data on BNP’s ability to predict cardiovascular events independently of LV filling pressure.

Study design: Retrospective cohort study.

Setting: Private, nonprofit hospital.

Synopsis: The study examined 1,059 eligible patients who were referred for coronary angiography from March 2002 to April 2008. The patients were followed for a mean of almost two years.

BNP, LV end-diastolic pressure (LVEDP), and EF were measured within 24 hours of angiography. Outcomes included myocardial infarction (MI), heart failure (HF) admissions, and death.

In univariate analysis, BNP and EF were predictive of death and HF admissions as dichotomous and continuous variables; LVEDP was predictive only as a continuous variable. BNP as a continuous variable also was predictive of future MI.

In multivariate analysis, BNP predicted the composite outcome of HF admission and death, with a hazard ratio (HR) of 1.37. BNP also predicted death alone and HF admissions alone independent of EF and LVEDP.

Overall, BNP was a much better predictor of death and HF admissions than LVEDP. Because BNP is not closely linked to LVEDP, strategies to reduce BNP levels independent of LV filling pressure are warranted.

The study was limited by its retrospective nature and the fact that it included a heterogeneous population.

Bottom line: In patients with coronary disease, BNP is a stronger predictor of death and HF admission than LVEDP.

Citation: Rodgers RK, May HT, Anderson JL, Muhlestein JB. Prognostic value of B-type natriuretic peptide for cardiovascular events independent of left ventricular end-diastolic pressure. Am Heart J. 2009;158:777-783.

Reviewed for TH eWire by Jill Goldenberg, MD, Alan Briones, MD, Dennis Chang, MD, Brian Markoff, MD, FHM, Erin Rule, MD, Andrew Dunn, MD, FACP, FHM, Division of General Internal Medicine, Mount Sinai School of Medicine, New York City

For more HM-related literature reviews, visit our Web site.

Clinical question: Does B-type natriuretic peptide (BNP) have prognostic value for cardiovascular events independent of left ventricular end-diastolic pressure in patients suspected of having coronary artery disease?

Background: BNP has prognostic value in predicting death in multiple populations, including patients with stable coronary artery disease, independent of left ventricular ejection fracture (LVEF). However, BNP and invasively measured LV filling pressure correlate weakly, and there is little data on BNP’s ability to predict cardiovascular events independently of LV filling pressure.

Study design: Retrospective cohort study.

Setting: Private, nonprofit hospital.

Synopsis: The study examined 1,059 eligible patients who were referred for coronary angiography from March 2002 to April 2008. The patients were followed for a mean of almost two years.

BNP, LV end-diastolic pressure (LVEDP), and EF were measured within 24 hours of angiography. Outcomes included myocardial infarction (MI), heart failure (HF) admissions, and death.

In univariate analysis, BNP and EF were predictive of death and HF admissions as dichotomous and continuous variables; LVEDP was predictive only as a continuous variable. BNP as a continuous variable also was predictive of future MI.

In multivariate analysis, BNP predicted the composite outcome of HF admission and death, with a hazard ratio (HR) of 1.37. BNP also predicted death alone and HF admissions alone independent of EF and LVEDP.

Overall, BNP was a much better predictor of death and HF admissions than LVEDP. Because BNP is not closely linked to LVEDP, strategies to reduce BNP levels independent of LV filling pressure are warranted.

The study was limited by its retrospective nature and the fact that it included a heterogeneous population.

Bottom line: In patients with coronary disease, BNP is a stronger predictor of death and HF admission than LVEDP.

Citation: Rodgers RK, May HT, Anderson JL, Muhlestein JB. Prognostic value of B-type natriuretic peptide for cardiovascular events independent of left ventricular end-diastolic pressure. Am Heart J. 2009;158:777-783.

Reviewed for TH eWire by Jill Goldenberg, MD, Alan Briones, MD, Dennis Chang, MD, Brian Markoff, MD, FHM, Erin Rule, MD, Andrew Dunn, MD, FACP, FHM, Division of General Internal Medicine, Mount Sinai School of Medicine, New York City

For more HM-related literature reviews, visit our Web site.

Clinical question: Does B-type natriuretic peptide (BNP) have prognostic value for cardiovascular events independent of left ventricular end-diastolic pressure in patients suspected of having coronary artery disease?

Background: BNP has prognostic value in predicting death in multiple populations, including patients with stable coronary artery disease, independent of left ventricular ejection fracture (LVEF). However, BNP and invasively measured LV filling pressure correlate weakly, and there is little data on BNP’s ability to predict cardiovascular events independently of LV filling pressure.

Study design: Retrospective cohort study.

Setting: Private, nonprofit hospital.

Synopsis: The study examined 1,059 eligible patients who were referred for coronary angiography from March 2002 to April 2008. The patients were followed for a mean of almost two years.

BNP, LV end-diastolic pressure (LVEDP), and EF were measured within 24 hours of angiography. Outcomes included myocardial infarction (MI), heart failure (HF) admissions, and death.

In univariate analysis, BNP and EF were predictive of death and HF admissions as dichotomous and continuous variables; LVEDP was predictive only as a continuous variable. BNP as a continuous variable also was predictive of future MI.

In multivariate analysis, BNP predicted the composite outcome of HF admission and death, with a hazard ratio (HR) of 1.37. BNP also predicted death alone and HF admissions alone independent of EF and LVEDP.

Overall, BNP was a much better predictor of death and HF admissions than LVEDP. Because BNP is not closely linked to LVEDP, strategies to reduce BNP levels independent of LV filling pressure are warranted.

The study was limited by its retrospective nature and the fact that it included a heterogeneous population.

Bottom line: In patients with coronary disease, BNP is a stronger predictor of death and HF admission than LVEDP.

Citation: Rodgers RK, May HT, Anderson JL, Muhlestein JB. Prognostic value of B-type natriuretic peptide for cardiovascular events independent of left ventricular end-diastolic pressure. Am Heart J. 2009;158:777-783.

Reviewed for TH eWire by Jill Goldenberg, MD, Alan Briones, MD, Dennis Chang, MD, Brian Markoff, MD, FHM, Erin Rule, MD, Andrew Dunn, MD, FACP, FHM, Division of General Internal Medicine, Mount Sinai School of Medicine, New York City

For more HM-related literature reviews, visit our Web site.

Kelly Wachsberg, MD, a third-year resident at Northwestern University's Feinberg School of Medicine in Chicago talks about what she learned at HM09.

Click here to listen to the audio interview.

Bipin Mistry, MD, talks about what he liked about HM09 in Chicago.

Click here to listen to the audio interview.

Kelly Wachsberg, MD, a third-year resident at Northwestern University's Feinberg School of Medicine in Chicago talks about what she learned at HM09.

Click here to listen to the audio interview.

Bipin Mistry, MD, talks about what he liked about HM09 in Chicago.

Click here to listen to the audio interview.

Kelly Wachsberg, MD, a third-year resident at Northwestern University's Feinberg School of Medicine in Chicago talks about what she learned at HM09.

Click here to listen to the audio interview.

Bipin Mistry, MD, talks about what he liked about HM09 in Chicago.

Click here to listen to the audio interview.

Hours after the devastating earthquake that shook the Haitian capital of Port-au-Prince, University of Miami Miller School of Medicine physicians, nurses, and administrators were drawing up plans to aid in the relief effort. One day after the quake, a tent hospital was erected at the airport, and dozens of providers were on the ground caring for the wounded, orphaned, and visibly shaken.

Hospitalists Amir Jaffer, MD, FHM, and Lisa Luly-Rivera, MD (photo, at right), recently returned from a five-day medical relief mission. They worked with surgeons and coordinated with nursing staff to ensure patients were properly hydrated and had the right pain medications. The staff also managed patients’ medical conditions and nutrition. Dr. Jaffer, an associate professor and the division chief of hospital medicine at the Miller School of Medicine, oversaw the transfer of 138 patients from a makeshift hospital to the new tent hospital, which opened Jan. 20 and offers spacious wards, a pathology lab, and two operating rooms.

“Most of the patients had a fracture, amputation, infected wound, or a spinal cord injury,” Dr. Jaffer says. “The conditions were dire when we landed. The role of the hospitalists was managing care. We also were involved in triaging patients who were being transferred.”

On Jan. 22, nearly 10 days after the quake, the university opened an imaging center radiology lab. “Some of the patients were splinted and needed X-ray,” Dr. Jaffer says, adding that more than 100 films were completed the first day. “Some patients were being brought in to us a week later who had fractures that had not been cared for.”

One of the poorest countries in the world, Haiti’s lack of infrastructure is wreaking havoc on rescue and relief efforts. The people are afraid to return to their homes, “and they have no place to go,” Dr. Jaffer says.

The 25 hospitalists in the HM group at the University of Miami Miller School of Medicine are planning five-day rotations to Haiti. The hospital needs translators, nurses, and internal-medicine specialists to cover the shifts of providers traveling to Haiti. If you’re interested in helping out, send an e-mail to the university. If you’d like to assist relief efforts in Haiti, make a donation to the American Red Cross.

Hours after the devastating earthquake that shook the Haitian capital of Port-au-Prince, University of Miami Miller School of Medicine physicians, nurses, and administrators were drawing up plans to aid in the relief effort. One day after the quake, a tent hospital was erected at the airport, and dozens of providers were on the ground caring for the wounded, orphaned, and visibly shaken.

Hospitalists Amir Jaffer, MD, FHM, and Lisa Luly-Rivera, MD (photo, at right), recently returned from a five-day medical relief mission. They worked with surgeons and coordinated with nursing staff to ensure patients were properly hydrated and had the right pain medications. The staff also managed patients’ medical conditions and nutrition. Dr. Jaffer, an associate professor and the division chief of hospital medicine at the Miller School of Medicine, oversaw the transfer of 138 patients from a makeshift hospital to the new tent hospital, which opened Jan. 20 and offers spacious wards, a pathology lab, and two operating rooms.

“Most of the patients had a fracture, amputation, infected wound, or a spinal cord injury,” Dr. Jaffer says. “The conditions were dire when we landed. The role of the hospitalists was managing care. We also were involved in triaging patients who were being transferred.”

On Jan. 22, nearly 10 days after the quake, the university opened an imaging center radiology lab. “Some of the patients were splinted and needed X-ray,” Dr. Jaffer says, adding that more than 100 films were completed the first day. “Some patients were being brought in to us a week later who had fractures that had not been cared for.”

One of the poorest countries in the world, Haiti’s lack of infrastructure is wreaking havoc on rescue and relief efforts. The people are afraid to return to their homes, “and they have no place to go,” Dr. Jaffer says.

The 25 hospitalists in the HM group at the University of Miami Miller School of Medicine are planning five-day rotations to Haiti. The hospital needs translators, nurses, and internal-medicine specialists to cover the shifts of providers traveling to Haiti. If you’re interested in helping out, send an e-mail to the university. If you’d like to assist relief efforts in Haiti, make a donation to the American Red Cross.

Hours after the devastating earthquake that shook the Haitian capital of Port-au-Prince, University of Miami Miller School of Medicine physicians, nurses, and administrators were drawing up plans to aid in the relief effort. One day after the quake, a tent hospital was erected at the airport, and dozens of providers were on the ground caring for the wounded, orphaned, and visibly shaken.

Hospitalists Amir Jaffer, MD, FHM, and Lisa Luly-Rivera, MD (photo, at right), recently returned from a five-day medical relief mission. They worked with surgeons and coordinated with nursing staff to ensure patients were properly hydrated and had the right pain medications. The staff also managed patients’ medical conditions and nutrition. Dr. Jaffer, an associate professor and the division chief of hospital medicine at the Miller School of Medicine, oversaw the transfer of 138 patients from a makeshift hospital to the new tent hospital, which opened Jan. 20 and offers spacious wards, a pathology lab, and two operating rooms.

“Most of the patients had a fracture, amputation, infected wound, or a spinal cord injury,” Dr. Jaffer says. “The conditions were dire when we landed. The role of the hospitalists was managing care. We also were involved in triaging patients who were being transferred.”

On Jan. 22, nearly 10 days after the quake, the university opened an imaging center radiology lab. “Some of the patients were splinted and needed X-ray,” Dr. Jaffer says, adding that more than 100 films were completed the first day. “Some patients were being brought in to us a week later who had fractures that had not been cared for.”

One of the poorest countries in the world, Haiti’s lack of infrastructure is wreaking havoc on rescue and relief efforts. The people are afraid to return to their homes, “and they have no place to go,” Dr. Jaffer says.

The 25 hospitalists in the HM group at the University of Miami Miller School of Medicine are planning five-day rotations to Haiti. The hospital needs translators, nurses, and internal-medicine specialists to cover the shifts of providers traveling to Haiti. If you’re interested in helping out, send an e-mail to the university. If you’d like to assist relief efforts in Haiti, make a donation to the American Red Cross.

A recent article in the New England Journal of Medicine (2009;361:2637-2645) questions whether improved planning for hospital discharges decreases readmission rates.

Ashish Jha, MD, MPH, of the Harvard School of Public Health and colleagues examined two publicly reported discharge-planning quality measures from the Centers for Medicare and Medicaid Services’ (CMS) Hospital Quality Alliance. The measures focus on documentation that discharge instructions were provided to patients with congestive heart failure and patients’ self-reported experience with discharge planning.

The researchers found no correlation with rates of readmission for congestive heart failure and pneumonia, and only weak correlation between the two quality measures. Based on their findings, the team concluded that public reporting of quality-related discharge-planning measures is unlikely to yield significant reductions in rehospitalization rates.

A number of national initiatives, including SHM’s Project BOOST (Better Outcomes for Older Adults through Safe Transitions), are focused on improving hospital discharge planning processes and care transitions, which are significant themes in the national health reform debate.

But the NEJM results should not be surprising, says Arpana Vidyarthi, MD, hospitalist and director of quality at the University of California at San Francisco. “Discharge planning is not a five-minute thing you do on the day of discharge. Improving the discharge process actually starts on the day of hospital admission. It is a complex problem and it needs multifaceted, evidence-based solutions,” including process evaluations by hospital teams and the application of supporting communications technology.

A recent article in the New England Journal of Medicine (2009;361:2637-2645) questions whether improved planning for hospital discharges decreases readmission rates.

Ashish Jha, MD, MPH, of the Harvard School of Public Health and colleagues examined two publicly reported discharge-planning quality measures from the Centers for Medicare and Medicaid Services’ (CMS) Hospital Quality Alliance. The measures focus on documentation that discharge instructions were provided to patients with congestive heart failure and patients’ self-reported experience with discharge planning.

The researchers found no correlation with rates of readmission for congestive heart failure and pneumonia, and only weak correlation between the two quality measures. Based on their findings, the team concluded that public reporting of quality-related discharge-planning measures is unlikely to yield significant reductions in rehospitalization rates.

A number of national initiatives, including SHM’s Project BOOST (Better Outcomes for Older Adults through Safe Transitions), are focused on improving hospital discharge planning processes and care transitions, which are significant themes in the national health reform debate.

But the NEJM results should not be surprising, says Arpana Vidyarthi, MD, hospitalist and director of quality at the University of California at San Francisco. “Discharge planning is not a five-minute thing you do on the day of discharge. Improving the discharge process actually starts on the day of hospital admission. It is a complex problem and it needs multifaceted, evidence-based solutions,” including process evaluations by hospital teams and the application of supporting communications technology.

A recent article in the New England Journal of Medicine (2009;361:2637-2645) questions whether improved planning for hospital discharges decreases readmission rates.

Ashish Jha, MD, MPH, of the Harvard School of Public Health and colleagues examined two publicly reported discharge-planning quality measures from the Centers for Medicare and Medicaid Services’ (CMS) Hospital Quality Alliance. The measures focus on documentation that discharge instructions were provided to patients with congestive heart failure and patients’ self-reported experience with discharge planning.

The researchers found no correlation with rates of readmission for congestive heart failure and pneumonia, and only weak correlation between the two quality measures. Based on their findings, the team concluded that public reporting of quality-related discharge-planning measures is unlikely to yield significant reductions in rehospitalization rates.

A number of national initiatives, including SHM’s Project BOOST (Better Outcomes for Older Adults through Safe Transitions), are focused on improving hospital discharge planning processes and care transitions, which are significant themes in the national health reform debate.

But the NEJM results should not be surprising, says Arpana Vidyarthi, MD, hospitalist and director of quality at the University of California at San Francisco. “Discharge planning is not a five-minute thing you do on the day of discharge. Improving the discharge process actually starts on the day of hospital admission. It is a complex problem and it needs multifaceted, evidence-based solutions,” including process evaluations by hospital teams and the application of supporting communications technology.

DR. HOSPITALIST

Transitions of Care Integral to HM Patient Care

I just finished my internal-medicine training and started a job as a hospitalist. We are a new hospitalist group, and I have been told that “transitions of care” is important to HM groups. I understand that getting information back to the patients’ primary-care physicians (PCPs) is important, but I am worried that I don’t have the whole picture. Is there something I am missing?

E. Parkhurst, MD

Tampa, Fla.

Dr. Hospitalist responds: Congrats on your new job. I am pleased to hear that you are motivated to learn more about transitions of care. It is important to hospitalist groups, but even more important to patients. I suspect your instincts are correct. You have an idea of what is meant by “transitions of care,” but probably do not appreciate all the nuances of the term. I certainly did not when I came out of training many years ago.

Transitions of care is a critical aspect of every patient’s care, and thus should be important to every healthcare provider. Our job is to care for the hospitalized patient and help them navigate through the complex systems of the hospital. How well we guide the patients through these transitions is reflected in their outcomes.

What is the definition of “transitions of care”? I find it useful to think about the patient’s journey when the decision is made to hospitalize the patient. When the patient is hospitalized, it is easy to recognize that the patient’s physical location is different; some, if not all, of the patient’s providers are different, too. The patient might have the same PCP caring for them in the hospital, but the nurses are different. The contrast is more evident if all of the patient’s providers are different. The ED is the point of entry for most patients. This is another location with another group of providers who do not have knowledge of all of the patient’s medical issues.

The hospital discharge is another inevitable transition. Most patients go home, but some will go to another healthcare facility (e.g., rehabilitation hospital) with another group of providers.

As you can see, the admission and discharge from the hospital involves multiple transitions. But multiple transitions also occur within the hospital. The patient could move from the general medical ward to the ICU and back; the patient might spend time in the surgical suite or operating room. Many patients go to radiology or other parts of the hospital for testing or procedures. At each location, the patient has a new group of providers.

But even if a physical location does not change, there could be a transition in care. During the day, one hospitalist or nurse might care for the patient. At night, another group of doctors and nurses are responsible for the patient’s care. Information must be transmitted and received between all of the parties at each transition in order for the appropriate care to proceed.

Effective transitions can improve provider efficiency. Think about how much easier it is to care for a patient whose care you assume when you have a clear understanding of the patient’s issues. Minimizing medical errors and increasing effective communication can reduce medical and legal risks. Effective transitions also minimize the length of hospital stay for the patient and minimize the risk of unnecessary readmission to the hospital. These can result in enhanced financial outcomes.

I think the key to effective and safe transitions of care is to create a mutually-agreed-upon process of communication and a level of expectation from all providers to carry out their role in the process. This is always easier said than done. In fact, the lack of an agreed-upon process often is a common barrier to effective transitions of care. Each participant’s role in the patient’s transitions might compete with another set of agendas.

As you can see, transitions of care is a complex topic, and I have only briefly reviewed it here. For more information, visit www.hospitalmedicine.org/boost. TH

Image Source: AMANE KANEKO

DR. HOSPITALIST

Transitions of Care Integral to HM Patient Care

I just finished my internal-medicine training and started a job as a hospitalist. We are a new hospitalist group, and I have been told that “transitions of care” is important to HM groups. I understand that getting information back to the patients’ primary-care physicians (PCPs) is important, but I am worried that I don’t have the whole picture. Is there something I am missing?

E. Parkhurst, MD

Tampa, Fla.

Dr. Hospitalist responds: Congrats on your new job. I am pleased to hear that you are motivated to learn more about transitions of care. It is important to hospitalist groups, but even more important to patients. I suspect your instincts are correct. You have an idea of what is meant by “transitions of care,” but probably do not appreciate all the nuances of the term. I certainly did not when I came out of training many years ago.

Transitions of care is a critical aspect of every patient’s care, and thus should be important to every healthcare provider. Our job is to care for the hospitalized patient and help them navigate through the complex systems of the hospital. How well we guide the patients through these transitions is reflected in their outcomes.

What is the definition of “transitions of care”? I find it useful to think about the patient’s journey when the decision is made to hospitalize the patient. When the patient is hospitalized, it is easy to recognize that the patient’s physical location is different; some, if not all, of the patient’s providers are different, too. The patient might have the same PCP caring for them in the hospital, but the nurses are different. The contrast is more evident if all of the patient’s providers are different. The ED is the point of entry for most patients. This is another location with another group of providers who do not have knowledge of all of the patient’s medical issues.

The hospital discharge is another inevitable transition. Most patients go home, but some will go to another healthcare facility (e.g., rehabilitation hospital) with another group of providers.

As you can see, the admission and discharge from the hospital involves multiple transitions. But multiple transitions also occur within the hospital. The patient could move from the general medical ward to the ICU and back; the patient might spend time in the surgical suite or operating room. Many patients go to radiology or other parts of the hospital for testing or procedures. At each location, the patient has a new group of providers.

But even if a physical location does not change, there could be a transition in care. During the day, one hospitalist or nurse might care for the patient. At night, another group of doctors and nurses are responsible for the patient’s care. Information must be transmitted and received between all of the parties at each transition in order for the appropriate care to proceed.

Effective transitions can improve provider efficiency. Think about how much easier it is to care for a patient whose care you assume when you have a clear understanding of the patient’s issues. Minimizing medical errors and increasing effective communication can reduce medical and legal risks. Effective transitions also minimize the length of hospital stay for the patient and minimize the risk of unnecessary readmission to the hospital. These can result in enhanced financial outcomes.

I think the key to effective and safe transitions of care is to create a mutually-agreed-upon process of communication and a level of expectation from all providers to carry out their role in the process. This is always easier said than done. In fact, the lack of an agreed-upon process often is a common barrier to effective transitions of care. Each participant’s role in the patient’s transitions might compete with another set of agendas.

As you can see, transitions of care is a complex topic, and I have only briefly reviewed it here. For more information, visit www.hospitalmedicine.org/boost. TH

Image Source: AMANE KANEKO

DR. HOSPITALIST

Transitions of Care Integral to HM Patient Care

I just finished my internal-medicine training and started a job as a hospitalist. We are a new hospitalist group, and I have been told that “transitions of care” is important to HM groups. I understand that getting information back to the patients’ primary-care physicians (PCPs) is important, but I am worried that I don’t have the whole picture. Is there something I am missing?

E. Parkhurst, MD

Tampa, Fla.

Dr. Hospitalist responds: Congrats on your new job. I am pleased to hear that you are motivated to learn more about transitions of care. It is important to hospitalist groups, but even more important to patients. I suspect your instincts are correct. You have an idea of what is meant by “transitions of care,” but probably do not appreciate all the nuances of the term. I certainly did not when I came out of training many years ago.

Transitions of care is a critical aspect of every patient’s care, and thus should be important to every healthcare provider. Our job is to care for the hospitalized patient and help them navigate through the complex systems of the hospital. How well we guide the patients through these transitions is reflected in their outcomes.

What is the definition of “transitions of care”? I find it useful to think about the patient’s journey when the decision is made to hospitalize the patient. When the patient is hospitalized, it is easy to recognize that the patient’s physical location is different; some, if not all, of the patient’s providers are different, too. The patient might have the same PCP caring for them in the hospital, but the nurses are different. The contrast is more evident if all of the patient’s providers are different. The ED is the point of entry for most patients. This is another location with another group of providers who do not have knowledge of all of the patient’s medical issues.

The hospital discharge is another inevitable transition. Most patients go home, but some will go to another healthcare facility (e.g., rehabilitation hospital) with another group of providers.

As you can see, the admission and discharge from the hospital involves multiple transitions. But multiple transitions also occur within the hospital. The patient could move from the general medical ward to the ICU and back; the patient might spend time in the surgical suite or operating room. Many patients go to radiology or other parts of the hospital for testing or procedures. At each location, the patient has a new group of providers.

But even if a physical location does not change, there could be a transition in care. During the day, one hospitalist or nurse might care for the patient. At night, another group of doctors and nurses are responsible for the patient’s care. Information must be transmitted and received between all of the parties at each transition in order for the appropriate care to proceed.

Effective transitions can improve provider efficiency. Think about how much easier it is to care for a patient whose care you assume when you have a clear understanding of the patient’s issues. Minimizing medical errors and increasing effective communication can reduce medical and legal risks. Effective transitions also minimize the length of hospital stay for the patient and minimize the risk of unnecessary readmission to the hospital. These can result in enhanced financial outcomes.

I think the key to effective and safe transitions of care is to create a mutually-agreed-upon process of communication and a level of expectation from all providers to carry out their role in the process. This is always easier said than done. In fact, the lack of an agreed-upon process often is a common barrier to effective transitions of care. Each participant’s role in the patient’s transitions might compete with another set of agendas.

As you can see, transitions of care is a complex topic, and I have only briefly reviewed it here. For more information, visit www.hospitalmedicine.org/boost. TH

Image Source: AMANE KANEKO

John Nelson, MD, FHM, FACP

Editor’s note: This is the first of a three-part series.

My experience is that some, maybe even most, hospitalists tend to assume there is a standard or “right” way to organize things like work schedules, compensation, or even the assignment of patients among the group’s providers. Some will say things like “SHM says the best hospitalist schedule is …” or “The best way to compensate hospitalists is …”

But there really isn’t a “best” way to manage any particular attribute of a practice. Don’t make the mistake of assuming your method is best, or that it’s the way “everybody else does it.” Although scheduling and compensation are marquee issues for hospitalists, approaches to distributing new patients is much less visible. Many groups tend to assume their method is the only reasonable approach. The best approach, however, varies from one practice to the next. You should be open to hearing approaches to scheduling that are different from your own.

Assign Patients by “Load Leveling”

I’ve come across a lot—and I mean a lot—of different approaches to distributing new patients in HM groups around the country, but it seems pretty clear that the most common method is to undertake “load leveling” on a daily or ongoing basis.

For example, groups that have a separate night shift (the night doctor performs no daytime work the day before or the day after a night shift) typically distribute the night’s new patients with the intent of having each daytime doctor start with the same number of patients. The group might more heavily weight some patients, such as those in the ICU (e.g., each ICU patient counts as 1.5 or two non-ICU patients), but most groups don’t. Over the course of the day shift, new referrals will be distributed evenly among the doctors one at a time, sort of like dealing a deck of cards.

This approach aims to avoid significant imbalances in patient loads and has the potential cultural benefit of everyone sharing equally in busy and slow days. Groups that use it tend to see it as the best option because it is the fairest way to divide up the workload.

Practices that use load-leveling almost always use a schedule built on shifts of a predetermined and fixed duration. For example, say the day shift always works from 7 a.m. to 7 p.m. This schedule usually has the majority of compensation paid via a fixed annual salary or fixed shift rate. One potential problem with this approach is that the doctor who is efficient and discharges a lot of patients today is “rewarded” with more new patients tomorrow. Hospitalists who are allergic to work might have an incentive to have a patient wait until tomorrow to discharge to avoid having to assume the care of yet another patient tomorrow morning. Hospital executives who are focused on length-of-stay management might be concerned if they knew this was a potential issue. Of course, the reverse is true as well. In a practice that doesn’t aggressively undertake load-leveling, a less-than-admirable hospitalist could push patients to discharge earlier than optimal just to have one less patient the next day.

Another cost of this approach is that the distribution of patients can be time-consuming each morning. It also offers the opportunity for some in the group to decide they’re treated unfairly. For instance, you might hear the occasional “just last Tuesday, I started with 16 patients, compared with 15 for everyone else. Now you want me to do it again? You’re being unfair to me; it’s someone else’s turn to take the extra patient.”

Assignment by Location

Groups that use “unit-based” hospitalists distribute patients according to the unit the patient is admitted to—and the hospitalist covering that unit. The pros and cons of unit-based hospitalists are many (see “A Unit-Based Approach,” September 2007), but there is an obvious tension between keeping patient loads even among hospitalists and ensuring that all of a hospitalist’s patients are on “their” unit. Practicality usually requires a compromise between pure unit-based assignment and load-leveling.

Uneven Assignments

Some groups assign patients according to a predetermined algorithm and employ load-leveling only when patient loads become extremely unbalanced. For example, Dr. Jones gets all the new referrals today, and Dr. James gets them tomorrow. The idea is that patient loads end up close to even over time, even if they’re unbalanced on any given day.

A system like this allows everyone, including the hospitalists themselves, ED staff, etc., to know who will take the next patient. It decreases the need to communicate the “who’s next” information time after time during the course of the day. In small- to medium-sized practices, it could mean no one needs to function as the triage doctor (i.e., the person who inefficiently answers the service calls, scribbles down clinical information, then calls the hospitalist who is due to take the next patient and relays all the pertinent patient info). This system allows the

hospitalists to know which days will be harder (e.g., taking on the care of new patients) and which days will be easier (e.g., rounding but not assuming care of new patients). Allowing uneven loads also eliminates the need to spend energy working to even the loads and risking that some in the group feel as if they aren’t being treated fairly.

Uncommon yet Intriguing Approaches

Pair referring primary-care physicians (PCPs) with specific hospitalists. I’ve encountered two groups that had hospitalists always admit patients from the same PCPs. In other words, hospitalist Dr. Hancock always serves as attending for patients referred by the same nine PCPs, and hospitalist Dr. Franklin always attends to patients from a different set of PCPs. It seems to me that there could be tremendous benefit in working closely with the same PCPs, most notably getting to know the PCPs’ office staff. But this system raises the risk of creating out-of-balance patient loads, among other problems. It is really attractive to me, but most groups will decide its costs outweigh its benefits.

Hospitalist and patient stay connected during admission. I’m not aware of any group that uses this method (let me know if you do!), but there could be benefits to having each patient see the same hospitalist during each hospital stay. Of course, that is assuming the hospitalist is on duty. Hospitalist and patient could be paired upon the patient’s first admission. The hospitalist could form an excellent relationship with the patient and family; the time spent by the hospitalist getting to know patients on admission would be reduced, and I suspect there might be some benefit in the quality of care.

This method, however, likely results in the most uneven patient loads, and load-leveling would be difficult, if not impossible. Even if hospitalist and patient did form a tight bond, there is a high probability that the hospitalist would be off for the duration of the patient’s next admission. So despite what I suspect are tremendous benefits, this approach may not be feasible for any group.

In next month’s column, I will discuss issues related to the way patients are distributed. 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 co-director and faculty for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. This column represents his views and is not intended to reflect an official position of SHM.

John Nelson, MD, FHM, FACP

Editor’s note: This is the first of a three-part series.

My experience is that some, maybe even most, hospitalists tend to assume there is a standard or “right” way to organize things like work schedules, compensation, or even the assignment of patients among the group’s providers. Some will say things like “SHM says the best hospitalist schedule is …” or “The best way to compensate hospitalists is …”

But there really isn’t a “best” way to manage any particular attribute of a practice. Don’t make the mistake of assuming your method is best, or that it’s the way “everybody else does it.” Although scheduling and compensation are marquee issues for hospitalists, approaches to distributing new patients is much less visible. Many groups tend to assume their method is the only reasonable approach. The best approach, however, varies from one practice to the next. You should be open to hearing approaches to scheduling that are different from your own.

Assign Patients by “Load Leveling”

I’ve come across a lot—and I mean a lot—of different approaches to distributing new patients in HM groups around the country, but it seems pretty clear that the most common method is to undertake “load leveling” on a daily or ongoing basis.

For example, groups that have a separate night shift (the night doctor performs no daytime work the day before or the day after a night shift) typically distribute the night’s new patients with the intent of having each daytime doctor start with the same number of patients. The group might more heavily weight some patients, such as those in the ICU (e.g., each ICU patient counts as 1.5 or two non-ICU patients), but most groups don’t. Over the course of the day shift, new referrals will be distributed evenly among the doctors one at a time, sort of like dealing a deck of cards.

This approach aims to avoid significant imbalances in patient loads and has the potential cultural benefit of everyone sharing equally in busy and slow days. Groups that use it tend to see it as the best option because it is the fairest way to divide up the workload.

Practices that use load-leveling almost always use a schedule built on shifts of a predetermined and fixed duration. For example, say the day shift always works from 7 a.m. to 7 p.m. This schedule usually has the majority of compensation paid via a fixed annual salary or fixed shift rate. One potential problem with this approach is that the doctor who is efficient and discharges a lot of patients today is “rewarded” with more new patients tomorrow. Hospitalists who are allergic to work might have an incentive to have a patient wait until tomorrow to discharge to avoid having to assume the care of yet another patient tomorrow morning. Hospital executives who are focused on length-of-stay management might be concerned if they knew this was a potential issue. Of course, the reverse is true as well. In a practice that doesn’t aggressively undertake load-leveling, a less-than-admirable hospitalist could push patients to discharge earlier than optimal just to have one less patient the next day.

Another cost of this approach is that the distribution of patients can be time-consuming each morning. It also offers the opportunity for some in the group to decide they’re treated unfairly. For instance, you might hear the occasional “just last Tuesday, I started with 16 patients, compared with 15 for everyone else. Now you want me to do it again? You’re being unfair to me; it’s someone else’s turn to take the extra patient.”

Assignment by Location

Groups that use “unit-based” hospitalists distribute patients according to the unit the patient is admitted to—and the hospitalist covering that unit. The pros and cons of unit-based hospitalists are many (see “A Unit-Based Approach,” September 2007), but there is an obvious tension between keeping patient loads even among hospitalists and ensuring that all of a hospitalist’s patients are on “their” unit. Practicality usually requires a compromise between pure unit-based assignment and load-leveling.

Uneven Assignments

Some groups assign patients according to a predetermined algorithm and employ load-leveling only when patient loads become extremely unbalanced. For example, Dr. Jones gets all the new referrals today, and Dr. James gets them tomorrow. The idea is that patient loads end up close to even over time, even if they’re unbalanced on any given day.

A system like this allows everyone, including the hospitalists themselves, ED staff, etc., to know who will take the next patient. It decreases the need to communicate the “who’s next” information time after time during the course of the day. In small- to medium-sized practices, it could mean no one needs to function as the triage doctor (i.e., the person who inefficiently answers the service calls, scribbles down clinical information, then calls the hospitalist who is due to take the next patient and relays all the pertinent patient info). This system allows the

hospitalists to know which days will be harder (e.g., taking on the care of new patients) and which days will be easier (e.g., rounding but not assuming care of new patients). Allowing uneven loads also eliminates the need to spend energy working to even the loads and risking that some in the group feel as if they aren’t being treated fairly.

Uncommon yet Intriguing Approaches

Pair referring primary-care physicians (PCPs) with specific hospitalists. I’ve encountered two groups that had hospitalists always admit patients from the same PCPs. In other words, hospitalist Dr. Hancock always serves as attending for patients referred by the same nine PCPs, and hospitalist Dr. Franklin always attends to patients from a different set of PCPs. It seems to me that there could be tremendous benefit in working closely with the same PCPs, most notably getting to know the PCPs’ office staff. But this system raises the risk of creating out-of-balance patient loads, among other problems. It is really attractive to me, but most groups will decide its costs outweigh its benefits.

Hospitalist and patient stay connected during admission. I’m not aware of any group that uses this method (let me know if you do!), but there could be benefits to having each patient see the same hospitalist during each hospital stay. Of course, that is assuming the hospitalist is on duty. Hospitalist and patient could be paired upon the patient’s first admission. The hospitalist could form an excellent relationship with the patient and family; the time spent by the hospitalist getting to know patients on admission would be reduced, and I suspect there might be some benefit in the quality of care.

This method, however, likely results in the most uneven patient loads, and load-leveling would be difficult, if not impossible. Even if hospitalist and patient did form a tight bond, there is a high probability that the hospitalist would be off for the duration of the patient’s next admission. So despite what I suspect are tremendous benefits, this approach may not be feasible for any group.

In next month’s column, I will discuss issues related to the way patients are distributed. 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 co-director and faculty for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. This column represents his views and is not intended to reflect an official position of SHM.

John Nelson, MD, FHM, FACP

Editor’s note: This is the first of a three-part series.

My experience is that some, maybe even most, hospitalists tend to assume there is a standard or “right” way to organize things like work schedules, compensation, or even the assignment of patients among the group’s providers. Some will say things like “SHM says the best hospitalist schedule is …” or “The best way to compensate hospitalists is …”

But there really isn’t a “best” way to manage any particular attribute of a practice. Don’t make the mistake of assuming your method is best, or that it’s the way “everybody else does it.” Although scheduling and compensation are marquee issues for hospitalists, approaches to distributing new patients is much less visible. Many groups tend to assume their method is the only reasonable approach. The best approach, however, varies from one practice to the next. You should be open to hearing approaches to scheduling that are different from your own.

Assign Patients by “Load Leveling”

I’ve come across a lot—and I mean a lot—of different approaches to distributing new patients in HM groups around the country, but it seems pretty clear that the most common method is to undertake “load leveling” on a daily or ongoing basis.

For example, groups that have a separate night shift (the night doctor performs no daytime work the day before or the day after a night shift) typically distribute the night’s new patients with the intent of having each daytime doctor start with the same number of patients. The group might more heavily weight some patients, such as those in the ICU (e.g., each ICU patient counts as 1.5 or two non-ICU patients), but most groups don’t. Over the course of the day shift, new referrals will be distributed evenly among the doctors one at a time, sort of like dealing a deck of cards.

This approach aims to avoid significant imbalances in patient loads and has the potential cultural benefit of everyone sharing equally in busy and slow days. Groups that use it tend to see it as the best option because it is the fairest way to divide up the workload.

Practices that use load-leveling almost always use a schedule built on shifts of a predetermined and fixed duration. For example, say the day shift always works from 7 a.m. to 7 p.m. This schedule usually has the majority of compensation paid via a fixed annual salary or fixed shift rate. One potential problem with this approach is that the doctor who is efficient and discharges a lot of patients today is “rewarded” with more new patients tomorrow. Hospitalists who are allergic to work might have an incentive to have a patient wait until tomorrow to discharge to avoid having to assume the care of yet another patient tomorrow morning. Hospital executives who are focused on length-of-stay management might be concerned if they knew this was a potential issue. Of course, the reverse is true as well. In a practice that doesn’t aggressively undertake load-leveling, a less-than-admirable hospitalist could push patients to discharge earlier than optimal just to have one less patient the next day.

Another cost of this approach is that the distribution of patients can be time-consuming each morning. It also offers the opportunity for some in the group to decide they’re treated unfairly. For instance, you might hear the occasional “just last Tuesday, I started with 16 patients, compared with 15 for everyone else. Now you want me to do it again? You’re being unfair to me; it’s someone else’s turn to take the extra patient.”

Assignment by Location

Groups that use “unit-based” hospitalists distribute patients according to the unit the patient is admitted to—and the hospitalist covering that unit. The pros and cons of unit-based hospitalists are many (see “A Unit-Based Approach,” September 2007), but there is an obvious tension between keeping patient loads even among hospitalists and ensuring that all of a hospitalist’s patients are on “their” unit. Practicality usually requires a compromise between pure unit-based assignment and load-leveling.

Uneven Assignments

Some groups assign patients according to a predetermined algorithm and employ load-leveling only when patient loads become extremely unbalanced. For example, Dr. Jones gets all the new referrals today, and Dr. James gets them tomorrow. The idea is that patient loads end up close to even over time, even if they’re unbalanced on any given day.

A system like this allows everyone, including the hospitalists themselves, ED staff, etc., to know who will take the next patient. It decreases the need to communicate the “who’s next” information time after time during the course of the day. In small- to medium-sized practices, it could mean no one needs to function as the triage doctor (i.e., the person who inefficiently answers the service calls, scribbles down clinical information, then calls the hospitalist who is due to take the next patient and relays all the pertinent patient info). This system allows the

hospitalists to know which days will be harder (e.g., taking on the care of new patients) and which days will be easier (e.g., rounding but not assuming care of new patients). Allowing uneven loads also eliminates the need to spend energy working to even the loads and risking that some in the group feel as if they aren’t being treated fairly.

Uncommon yet Intriguing Approaches

Pair referring primary-care physicians (PCPs) with specific hospitalists. I’ve encountered two groups that had hospitalists always admit patients from the same PCPs. In other words, hospitalist Dr. Hancock always serves as attending for patients referred by the same nine PCPs, and hospitalist Dr. Franklin always attends to patients from a different set of PCPs. It seems to me that there could be tremendous benefit in working closely with the same PCPs, most notably getting to know the PCPs’ office staff. But this system raises the risk of creating out-of-balance patient loads, among other problems. It is really attractive to me, but most groups will decide its costs outweigh its benefits.

Hospitalist and patient stay connected during admission. I’m not aware of any group that uses this method (let me know if you do!), but there could be benefits to having each patient see the same hospitalist during each hospital stay. Of course, that is assuming the hospitalist is on duty. Hospitalist and patient could be paired upon the patient’s first admission. The hospitalist could form an excellent relationship with the patient and family; the time spent by the hospitalist getting to know patients on admission would be reduced, and I suspect there might be some benefit in the quality of care.

This method, however, likely results in the most uneven patient loads, and load-leveling would be difficult, if not impossible. Even if hospitalist and patient did form a tight bond, there is a high probability that the hospitalist would be off for the duration of the patient’s next admission. So despite what I suspect are tremendous benefits, this approach may not be feasible for any group.

In next month’s column, I will discuss issues related to the way patients are distributed. 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 co-director and faculty for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. This column represents his views and is not intended to reflect an official position of SHM.

Jeff Glasheen, MD, FHM

Four eyes staring, boring through me, unblinking. Locked in a pose holding a hand-scrawled sign commanding their father to ♥♥GET WELL NOW♥♥, the photo of the 14-month-old twin girls was reproduced off a cheap color printer and taped to the window, backlit by the Christmas Eve morning sun. Both the sun and the daughters demanded my attention—the former a brilliant reminder of the glories of the day, the latter the sobering reality of a family rocked by illness.

Mr. Jasper, an otherwise healthy 36-year-old male who recently was diagnosed with a rare, life-threatening disease, would not be spending this holiday with his daughters. In fact, because of our hospital’s flu precautions, he hadn’t seen them in the six weeks he’d been an inpatient. In that time, one of his girls had learned to talk; the other had learned to walk. Mr. Jasper was a distant bystander. He was upset but understanding of his situation—even optimistic, remarkably. However, those girls’ eyes told a different story. What weeks ago shone as the cute countenances of toddlers—silly, carefree, cheerful—now articulated a different tone. “Let my father come home!” they beseeched.

Staring into those eyes on rounds that morning, I was haunted by a thought that had gnawed at my subconscious for weeks. It was likely, albeit not guaranteed, that we’d get Mr. Jasper home to his wife and daughters. However, it would be at a cost. Of course, there would be psychological costs, but I was more acutely concerned with the financial costs. Mr. Jasper, you see, is uninsured.

Healthcare Reform: Too Late for Many

Thousands of miles away, the U.S. Senate was, at that exact time, voting for legislation to greatly reform and expand the U.S. healthcare system. Passed along partisan lines, the bill now awaits reconciliation with the House of Representatives’ bill. From there, it will go before President Obama for signature into law. If passed, this legislation promises to give healthcare coverage to another 30 million Americans.

For Mr. Jasper, this new law will come too late.

It’ll also be too late for Mrs. Anderson, a middle-aged asthmatic now intubated in our ICU, wheezing against constricted bronchioles. Three days earlier, she was seen in the ED for worsening dyspnea, cough, and sputum production. Her symptoms resolved after a few courses of nebulized albuterol and IV steroids, and she was sent home with a prescription for prednisone and inhalers. Unable to afford to fill those prescriptions, her disease progressed, eventually strangling her breathing and tangling her in a healthcare system more willing to pay for the care of disease complications than disease prevention.

Face-to-Face with Catastrophe

Later that morning, I was asked by one of our ED physicians to see Mr. Reynolds and “persuade” him to be admitted to the hospital. Mr. Reynolds has insurance. In fact, of the 11 patients I saw that day, he was one of only three who did. One had Medicaid, the other Medicare.

Mr. Reynolds had a high-deductible, catastrophic-insurance policy. As such, he was wrestling with the decision of whether to come into the hospital to treat his severe cellulitis with IV antibiotics (our formal recommendation), or treat this at home with oral antibiotics. His face wore the torment of the trade-offs. The former surely would cost him his entire $5,000 deductible; the latter, perhaps his life, or at least a limb. As the erythema glared at me, I struggled to recollect a medical school lecture applicable to this situation.

My last patient of the day was Mr. Ramon. He, too, was uninsured. Felled by diabetic ketoacidosis, he was admitted and, as 19-year-olds are wont to do, rebounded quickly. New-onset diabetes, however, was the least of his concerns. With a girlfriend and young child at home, he had to get out of the hospital and return to his job as soon as possible: mouths to feed. Having seen his father lose limbs, kidneys, eyes, and ultimately his life to diabetes, he was motivated to do the right thing.

Unfortunately, motivation doesn’t pay for insulin. I wondered what would come of him in the next 30 years. Would he be able to care for his disease and live a long and prosperous life, or would this admission be just one in a long series of hospital stays?

Broken System

Every hospitalist is aware of these issues and could no doubt fill pages with similarly horrific stories of a healthcare system long broken. It’s remarkable how much of my time I spend trying to figure out a way to cobble together a passable (the notion of “gold standard” therapy long gone) therapeutic plan for my patients—the Walmart list of $4 drugs has taken white-coat prominence over my “Pocket Pharmacopoeia.”

This isn’t to say the U.S. healthcare system doesn’t do a lot of great things. It does, and that cannot be discounted. It’s also not to say that the bill before Congress is the answer. Still, the fact that medical costs limit many Americans from accessing needed care and have become the leading cause of bankruptcy in the U.S. should arouse concern in even the most ardent opponents of healthcare reform. Regardless of one’s political leanings and feelings about the current attempts at healthcare reform, it’s difficult to stand by and helplessly watch our patients struggle to maneuver within a system that so often seems to work against so many of them.

What’s easy to lose in the D.C. rhetoric and town-hall warfare is that every day, we delay healthcare reform results in undue patient suffering, both physical and financial. It is a system that is broken and needs, in the words of Mr. Jasper’s daughters, to “get well now.”

Before leaving to celebrate the holiday with my family, I was compelled to return to Mr. Jasper’s room. Unfortunately, the patient was off getting a treatment. But his daughters were still there, faces unchanged. Again, drawn to those eyes, I wondered what would become of this situation.

Would he make it home?

How would his family pay the bills?

What would this mean for his daughters’ future?

Would he and his family be forced to declare bankruptcy?

Would the family ever truly recover?

Staring at the picture in the window, I couldn’t help but think of my own children, also waiting for their father to come home from the hospital to celebrate the holidays.

As I turned to leave, my mind lost in thoughts of untimely illness, ill-fated outcomes, and financial devastation, I realized that in America today, nothing more than circumstances kept me from seeing my own children’s eyes staring back at me from that window. 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.

Jeff Glasheen, MD, FHM

Four eyes staring, boring through me, unblinking. Locked in a pose holding a hand-scrawled sign commanding their father to ♥♥GET WELL NOW♥♥, the photo of the 14-month-old twin girls was reproduced off a cheap color printer and taped to the window, backlit by the Christmas Eve morning sun. Both the sun and the daughters demanded my attention—the former a brilliant reminder of the glories of the day, the latter the sobering reality of a family rocked by illness.

Mr. Jasper, an otherwise healthy 36-year-old male who recently was diagnosed with a rare, life-threatening disease, would not be spending this holiday with his daughters. In fact, because of our hospital’s flu precautions, he hadn’t seen them in the six weeks he’d been an inpatient. In that time, one of his girls had learned to talk; the other had learned to walk. Mr. Jasper was a distant bystander. He was upset but understanding of his situation—even optimistic, remarkably. However, those girls’ eyes told a different story. What weeks ago shone as the cute countenances of toddlers—silly, carefree, cheerful—now articulated a different tone. “Let my father come home!” they beseeched.

Staring into those eyes on rounds that morning, I was haunted by a thought that had gnawed at my subconscious for weeks. It was likely, albeit not guaranteed, that we’d get Mr. Jasper home to his wife and daughters. However, it would be at a cost. Of course, there would be psychological costs, but I was more acutely concerned with the financial costs. Mr. Jasper, you see, is uninsured.

Healthcare Reform: Too Late for Many

Thousands of miles away, the U.S. Senate was, at that exact time, voting for legislation to greatly reform and expand the U.S. healthcare system. Passed along partisan lines, the bill now awaits reconciliation with the House of Representatives’ bill. From there, it will go before President Obama for signature into law. If passed, this legislation promises to give healthcare coverage to another 30 million Americans.

For Mr. Jasper, this new law will come too late.

It’ll also be too late for Mrs. Anderson, a middle-aged asthmatic now intubated in our ICU, wheezing against constricted bronchioles. Three days earlier, she was seen in the ED for worsening dyspnea, cough, and sputum production. Her symptoms resolved after a few courses of nebulized albuterol and IV steroids, and she was sent home with a prescription for prednisone and inhalers. Unable to afford to fill those prescriptions, her disease progressed, eventually strangling her breathing and tangling her in a healthcare system more willing to pay for the care of disease complications than disease prevention.

Face-to-Face with Catastrophe

Later that morning, I was asked by one of our ED physicians to see Mr. Reynolds and “persuade” him to be admitted to the hospital. Mr. Reynolds has insurance. In fact, of the 11 patients I saw that day, he was one of only three who did. One had Medicaid, the other Medicare.

Mr. Reynolds had a high-deductible, catastrophic-insurance policy. As such, he was wrestling with the decision of whether to come into the hospital to treat his severe cellulitis with IV antibiotics (our formal recommendation), or treat this at home with oral antibiotics. His face wore the torment of the trade-offs. The former surely would cost him his entire $5,000 deductible; the latter, perhaps his life, or at least a limb. As the erythema glared at me, I struggled to recollect a medical school lecture applicable to this situation.

My last patient of the day was Mr. Ramon. He, too, was uninsured. Felled by diabetic ketoacidosis, he was admitted and, as 19-year-olds are wont to do, rebounded quickly. New-onset diabetes, however, was the least of his concerns. With a girlfriend and young child at home, he had to get out of the hospital and return to his job as soon as possible: mouths to feed. Having seen his father lose limbs, kidneys, eyes, and ultimately his life to diabetes, he was motivated to do the right thing.

Unfortunately, motivation doesn’t pay for insulin. I wondered what would come of him in the next 30 years. Would he be able to care for his disease and live a long and prosperous life, or would this admission be just one in a long series of hospital stays?

Broken System

Every hospitalist is aware of these issues and could no doubt fill pages with similarly horrific stories of a healthcare system long broken. It’s remarkable how much of my time I spend trying to figure out a way to cobble together a passable (the notion of “gold standard” therapy long gone) therapeutic plan for my patients—the Walmart list of $4 drugs has taken white-coat prominence over my “Pocket Pharmacopoeia.”

This isn’t to say the U.S. healthcare system doesn’t do a lot of great things. It does, and that cannot be discounted. It’s also not to say that the bill before Congress is the answer. Still, the fact that medical costs limit many Americans from accessing needed care and have become the leading cause of bankruptcy in the U.S. should arouse concern in even the most ardent opponents of healthcare reform. Regardless of one’s political leanings and feelings about the current attempts at healthcare reform, it’s difficult to stand by and helplessly watch our patients struggle to maneuver within a system that so often seems to work against so many of them.

What’s easy to lose in the D.C. rhetoric and town-hall warfare is that every day, we delay healthcare reform results in undue patient suffering, both physical and financial. It is a system that is broken and needs, in the words of Mr. Jasper’s daughters, to “get well now.”

Before leaving to celebrate the holiday with my family, I was compelled to return to Mr. Jasper’s room. Unfortunately, the patient was off getting a treatment. But his daughters were still there, faces unchanged. Again, drawn to those eyes, I wondered what would become of this situation.

Would he make it home?

How would his family pay the bills?

What would this mean for his daughters’ future?

Would he and his family be forced to declare bankruptcy?

Would the family ever truly recover?

Staring at the picture in the window, I couldn’t help but think of my own children, also waiting for their father to come home from the hospital to celebrate the holidays.

As I turned to leave, my mind lost in thoughts of untimely illness, ill-fated outcomes, and financial devastation, I realized that in America today, nothing more than circumstances kept me from seeing my own children’s eyes staring back at me from that window. 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.

Jeff Glasheen, MD, FHM

Four eyes staring, boring through me, unblinking. Locked in a pose holding a hand-scrawled sign commanding their father to ♥♥GET WELL NOW♥♥, the photo of the 14-month-old twin girls was reproduced off a cheap color printer and taped to the window, backlit by the Christmas Eve morning sun. Both the sun and the daughters demanded my attention—the former a brilliant reminder of the glories of the day, the latter the sobering reality of a family rocked by illness.

Mr. Jasper, an otherwise healthy 36-year-old male who recently was diagnosed with a rare, life-threatening disease, would not be spending this holiday with his daughters. In fact, because of our hospital’s flu precautions, he hadn’t seen them in the six weeks he’d been an inpatient. In that time, one of his girls had learned to talk; the other had learned to walk. Mr. Jasper was a distant bystander. He was upset but understanding of his situation—even optimistic, remarkably. However, those girls’ eyes told a different story. What weeks ago shone as the cute countenances of toddlers—silly, carefree, cheerful—now articulated a different tone. “Let my father come home!” they beseeched.

Staring into those eyes on rounds that morning, I was haunted by a thought that had gnawed at my subconscious for weeks. It was likely, albeit not guaranteed, that we’d get Mr. Jasper home to his wife and daughters. However, it would be at a cost. Of course, there would be psychological costs, but I was more acutely concerned with the financial costs. Mr. Jasper, you see, is uninsured.

Healthcare Reform: Too Late for Many

Thousands of miles away, the U.S. Senate was, at that exact time, voting for legislation to greatly reform and expand the U.S. healthcare system. Passed along partisan lines, the bill now awaits reconciliation with the House of Representatives’ bill. From there, it will go before President Obama for signature into law. If passed, this legislation promises to give healthcare coverage to another 30 million Americans.

For Mr. Jasper, this new law will come too late.

It’ll also be too late for Mrs. Anderson, a middle-aged asthmatic now intubated in our ICU, wheezing against constricted bronchioles. Three days earlier, she was seen in the ED for worsening dyspnea, cough, and sputum production. Her symptoms resolved after a few courses of nebulized albuterol and IV steroids, and she was sent home with a prescription for prednisone and inhalers. Unable to afford to fill those prescriptions, her disease progressed, eventually strangling her breathing and tangling her in a healthcare system more willing to pay for the care of disease complications than disease prevention.

Face-to-Face with Catastrophe

Later that morning, I was asked by one of our ED physicians to see Mr. Reynolds and “persuade” him to be admitted to the hospital. Mr. Reynolds has insurance. In fact, of the 11 patients I saw that day, he was one of only three who did. One had Medicaid, the other Medicare.

Mr. Reynolds had a high-deductible, catastrophic-insurance policy. As such, he was wrestling with the decision of whether to come into the hospital to treat his severe cellulitis with IV antibiotics (our formal recommendation), or treat this at home with oral antibiotics. His face wore the torment of the trade-offs. The former surely would cost him his entire $5,000 deductible; the latter, perhaps his life, or at least a limb. As the erythema glared at me, I struggled to recollect a medical school lecture applicable to this situation.

My last patient of the day was Mr. Ramon. He, too, was uninsured. Felled by diabetic ketoacidosis, he was admitted and, as 19-year-olds are wont to do, rebounded quickly. New-onset diabetes, however, was the least of his concerns. With a girlfriend and young child at home, he had to get out of the hospital and return to his job as soon as possible: mouths to feed. Having seen his father lose limbs, kidneys, eyes, and ultimately his life to diabetes, he was motivated to do the right thing.

Unfortunately, motivation doesn’t pay for insulin. I wondered what would come of him in the next 30 years. Would he be able to care for his disease and live a long and prosperous life, or would this admission be just one in a long series of hospital stays?

Broken System

Every hospitalist is aware of these issues and could no doubt fill pages with similarly horrific stories of a healthcare system long broken. It’s remarkable how much of my time I spend trying to figure out a way to cobble together a passable (the notion of “gold standard” therapy long gone) therapeutic plan for my patients—the Walmart list of $4 drugs has taken white-coat prominence over my “Pocket Pharmacopoeia.”

This isn’t to say the U.S. healthcare system doesn’t do a lot of great things. It does, and that cannot be discounted. It’s also not to say that the bill before Congress is the answer. Still, the fact that medical costs limit many Americans from accessing needed care and have become the leading cause of bankruptcy in the U.S. should arouse concern in even the most ardent opponents of healthcare reform. Regardless of one’s political leanings and feelings about the current attempts at healthcare reform, it’s difficult to stand by and helplessly watch our patients struggle to maneuver within a system that so often seems to work against so many of them.

What’s easy to lose in the D.C. rhetoric and town-hall warfare is that every day, we delay healthcare reform results in undue patient suffering, both physical and financial. It is a system that is broken and needs, in the words of Mr. Jasper’s daughters, to “get well now.”

Before leaving to celebrate the holiday with my family, I was compelled to return to Mr. Jasper’s room. Unfortunately, the patient was off getting a treatment. But his daughters were still there, faces unchanged. Again, drawn to those eyes, I wondered what would become of this situation.

Would he make it home?

How would his family pay the bills?

What would this mean for his daughters’ future?

Would he and his family be forced to declare bankruptcy?

Would the family ever truly recover?

Staring at the picture in the window, I couldn’t help but think of my own children, also waiting for their father to come home from the hospital to celebrate the holidays.

As I turned to leave, my mind lost in thoughts of untimely illness, ill-fated outcomes, and financial devastation, I realized that in America today, nothing more than circumstances kept me from seeing my own children’s eyes staring back at me from that window. 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.