The burden of dissatisfaction among medical professionals concerns both physicians and policy makers, especially given the potential ramifications on the work force.1, 2 Abundant research documents a strong relationship between low levels of physician satisfaction and burnout,37 intention to leave,6, 815 and job turnover.13, 1618 Moreover, low physician satisfaction is associated with self‐reported psychiatric symptoms1921 and poorer perceived mental health.22 Not surprisingly, dissatisfied physicians are less likely to recommend to medical students that they pursue their specialty.23

Importantly, physician satisfaction appears to benefit patients. Several studies show a positive relationship between higher physician satisfaction and patient satisfaction and outcomes.2426 Patients cared for by satisfied physicians declare more trust and confidence in their physicians, have better continuity, higher ratings of their care,26, 27 lower no‐show rates,25 and enhanced adherence to their medical care.28 There is also some evidence that higher job satisfaction is associated with lower likelihood of patient errors and suboptimal patient care.29

Physician satisfaction can be influenced by factors intrinsic to the individual physician (age, gender, race, and specialty) and extrinsic to the physician (work environment, practice setting, patient characteristics, and income).22, 30 In this way, satisfaction is not a static property in any physician or physician group, but reflects a dynamic interplay among the expectations and environments within which they work. Although each physician, physician group, and specialty has distinct factors that affect satisfaction, none are immune to potential dissatisfaction.

Given the documented impact of physician satisfaction on multiple aspects of healthcare delivery, we undertook a systematic review of the existing literature to achieve a greater understanding of the current state of U.S. physician satisfaction. In addition, we sought to identify the major survey tools used to measure satisfaction and the characteristics intrinsic and extrinsic to the physician that are associated with satisfaction. We conclude by suggesting needed additional research.

Materials and Methods

We performed a literature search of MEDLINE (http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed) for articles from 1970 through 2007 to identify studies that provide a quantitative assessment of U.S. physician satisfaction and/or the factors associated with satisfaction. With assistance from a medical librarian with expertise in search coordination, we chose the following Medical Subject Heading (MeSH) phrases: (physicians OR physician's role OR physician's, women) AND (job satisfaction OR career satisfaction OR burnout). The search was further limited to humans and abstracts with no language restriction. The reviewers also searched reference lists to identify other relevant studies not in the search, as well as available online abstracts from the national meetings of the Society of Hospital Medicine (20022005) and the Society of General Internal Medicine (20052007). All of the abstracts were reviewed by 2 independent reviewers (D.S. and S.M.) for inclusion into the study. Study inclusion was limited to articles that reported physician satisfaction (career, professional, work, practice, job satisfaction, or overall satisfaction) or factors associated with physician satisfaction. Disagreements were resolved by consensus. After exclusions, 97 articles were included for review (Figure 1). Each study was listed by physician type sampled, whether the information was derived from a previously conducted (larger) sample, the sample size and response rate, the satisfaction measurement/subale, and satisfaction results (Appendix 1). Thirty‐seven studies that utilized multivariate analyses to report factors independently associated with satisfaction are listed in Appendix 2, along with the direction and strength of association. Confounders controlled for in these studies are listed in Appendix 3. Studies that extracted data from 1 of the 4 nationally representative studies (Community Tracking Studies [CTS], Physician Worklife Study [PWS], Women Physician Health Study [WPHS], and Robert Wood Johnson Studies [RWJS]) were considered of higher quality and generalizability than the small cross‐sectional studies. Due to the heterogeneity in physician type sampled and multiple satisfaction measurements used, a meta‐analysis of the literature was not performed, and a qualitative analysis is reported.

Figure 1

Results

Of the 97 studies, 69 were cross‐sectional (distributed to purposive and often convenience samples of physicians) with sampling sizes ranging from 39 to 6441 and response rates ranging from 31% to 97% (Appendix 1). The other 28 were from larger nationally representative studies (Table 1), including the CTS (n = 92, 45, 71, 74, 91, 102, 104106), RWJS (n = 81, 18, 3334, 39, 40, 60, 61), PWS (n = 711, 22, 23, 55, 83, 92, 99), and WPHS (n = 444, 4951). Fourteen articles reported information from longitudinal (n = 2)18, 86 or repeated cross‐sectional studies (n = 12)1, 2, 39, 73, 76, 79, 85, 91, 96, 97, 102, 110 to help determine satisfaction trends. The survey instruments from the 4 national physician surveys are outlined in Table 1. The types of satisfaction reported are outlined in Figure 2.

Figure 2

Major Characteristics Associated with Physician Satisfaction

Both factors intrinsic to the physician and characteristics of the job influence physician satisfaction (Figure 3). Intrinsic physician factors are typically not changeable when developing strategies to improve satisfaction. However, they do significantly affect what physicians consider important when choosing a job, and influence how physicians respond to changes in the job. Job characteristics, or extrinsic factors, are generally considered more modifiable when developing institutional strategies to improve satisfaction. Although the intrinsic factors are seemingly unmodifiable, one must take them into account when assessing satisfaction in order to determine the independent effects that the more modifiable extrinsic factors have on satisfaction. The next section describes the variables associated with satisfaction, from the 37 studies that utilized multivariate analyses (Appendix 2) to control for other factors (Appendix 3).

Figure 3

Physician Factors

Job Factors

Other Physician Factors

Board certification may be modestly positively associated with satisfaction, and being a foreign medical graduate may be modestly negatively associated with satisfaction, although this is limited to few studies.9, 45, 74, 98, 104, 106 Other physician characteristics, such as personal matters (marital status, home stress, mental health, personal satisfaction), work matters (amount of charity care they provide and history of work harassment), and personality (reform mindedness and tolerance for uncertainty) require further research.50, 56, 88, 98, 104

Discussion

Our review of satisfaction trends for U.S. physicians revealed relative stability except for a slight decline among PCPs. We found factors significantly associated with satisfaction to include both physician (age and specialty) and job factors (work demand, work control, colleague support, ability to maintain patient relationships, practice setting, income satisfaction, and incentive types). Based on limited data, the association with race/ethnicity and part‐time work requires more research, and factors that do not appear to have an independent effect on satisfaction include physician gender, patient‐payer mix, and patient characteristics.

As the fastest growing specialty in the history of American medicine, hospital medicine should focus on career satisfaction as a top priority in shaping the future of the more than 20,000 hospitalists now practicing. Although the term hospitalist was coined less than 15 years ago114 the demand for hospitalists is expected to grow to as many as 50,000 by 2020.115 In this time of rapid growth, in order to mold a sustainable specialty, we must all recognize the factors that contribute to satisfaction and strive to maintain good job‐person fit. For individual hospitalists, all of these mediators of satisfaction should be considered when contemplating employment. To ensure a mutual fit, each physician must reflect on how their goals and values coincide with those of the program they are considering. For hospital medicine program leaders, areas of program‐specific dissatisfaction must be continually sought and addressed.

In this review, the variables with the strongest associations with satisfaction that are most pertinent to hospitalists are work demand, control, income/emncentives, and collegial relationships. These variables coincide with the 4 pillars of career satisfaction identified in the Society of Hospital Medicine Career Satisfaction Task Force.116 Perceived work stress/pressure and objective workload can easily (and serially) be measured, and the latter can be compared to national benchmarks to ensure appropriate workload expectations.116 Reducing work pressure/stress may involve assessing and matching variations in workload with manpower, reducing nonclinical tasks by utilizing administrative assistants or physician extenders, or having an emergency plan for unexpected absences. Autonomy and control can be assessed by the job‐fit questionnaire to identify programwide and physician‐specific areas of potential discontent.116 Increasing autonomy/control may involve pursuing leadership within hospital projects or committees, creatively scheduling flexibility, and seeking support from hospital administration. Income expectations should also be couched within national benchmarks, and incentive programs should reflect work quality rather than quantity. Collegial support can be enhanced by instituting a mentoring program, journal club, regular social function, or configuration of offices spaces to allow proximity. Although the conclusions of this review are limited by the lack of hospitalists included in the studies and our inability to perform a meta‐analysis, we believe extrapolation of this information to hospitalist physicians is valid and appropriate. That said, future studies specifically addressing hospitalist satisfaction are needed to ensure this.

Conclusions

In summary, physician satisfaction is not a static parameter, but a dynamic entity mediated by both physician‐related and job‐related factors, the majority of which are modifiable. Thus hospitalists and hospital medicine program leaders can be optimistic that uncovering the presence of dissatisfaction through surveys, and addressing the issues triggering it, should enhance physician satisfaction. With improved awareness of mitigating factors of dissatisfaction and commitments to improvement, there is reason for hope. It is unreasonable to believe that dissatisfaction is intrinsic to any medical profession. It is reasonable to believe that physician satisfaction, with all of its desirable implications, can be attained through continual research and prioritization.

The burden of dissatisfaction among medical professionals concerns both physicians and policy makers, especially given the potential ramifications on the work force.1, 2 Abundant research documents a strong relationship between low levels of physician satisfaction and burnout,37 intention to leave,6, 815 and job turnover.13, 1618 Moreover, low physician satisfaction is associated with self‐reported psychiatric symptoms1921 and poorer perceived mental health.22 Not surprisingly, dissatisfied physicians are less likely to recommend to medical students that they pursue their specialty.23

Importantly, physician satisfaction appears to benefit patients. Several studies show a positive relationship between higher physician satisfaction and patient satisfaction and outcomes.2426 Patients cared for by satisfied physicians declare more trust and confidence in their physicians, have better continuity, higher ratings of their care,26, 27 lower no‐show rates,25 and enhanced adherence to their medical care.28 There is also some evidence that higher job satisfaction is associated with lower likelihood of patient errors and suboptimal patient care.29

Physician satisfaction can be influenced by factors intrinsic to the individual physician (age, gender, race, and specialty) and extrinsic to the physician (work environment, practice setting, patient characteristics, and income).22, 30 In this way, satisfaction is not a static property in any physician or physician group, but reflects a dynamic interplay among the expectations and environments within which they work. Although each physician, physician group, and specialty has distinct factors that affect satisfaction, none are immune to potential dissatisfaction.

Given the documented impact of physician satisfaction on multiple aspects of healthcare delivery, we undertook a systematic review of the existing literature to achieve a greater understanding of the current state of U.S. physician satisfaction. In addition, we sought to identify the major survey tools used to measure satisfaction and the characteristics intrinsic and extrinsic to the physician that are associated with satisfaction. We conclude by suggesting needed additional research.

Materials and Methods

We performed a literature search of MEDLINE (http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed) for articles from 1970 through 2007 to identify studies that provide a quantitative assessment of U.S. physician satisfaction and/or the factors associated with satisfaction. With assistance from a medical librarian with expertise in search coordination, we chose the following Medical Subject Heading (MeSH) phrases: (physicians OR physician's role OR physician's, women) AND (job satisfaction OR career satisfaction OR burnout). The search was further limited to humans and abstracts with no language restriction. The reviewers also searched reference lists to identify other relevant studies not in the search, as well as available online abstracts from the national meetings of the Society of Hospital Medicine (20022005) and the Society of General Internal Medicine (20052007). All of the abstracts were reviewed by 2 independent reviewers (D.S. and S.M.) for inclusion into the study. Study inclusion was limited to articles that reported physician satisfaction (career, professional, work, practice, job satisfaction, or overall satisfaction) or factors associated with physician satisfaction. Disagreements were resolved by consensus. After exclusions, 97 articles were included for review (Figure 1). Each study was listed by physician type sampled, whether the information was derived from a previously conducted (larger) sample, the sample size and response rate, the satisfaction measurement/subale, and satisfaction results (Appendix 1). Thirty‐seven studies that utilized multivariate analyses to report factors independently associated with satisfaction are listed in Appendix 2, along with the direction and strength of association. Confounders controlled for in these studies are listed in Appendix 3. Studies that extracted data from 1 of the 4 nationally representative studies (Community Tracking Studies [CTS], Physician Worklife Study [PWS], Women Physician Health Study [WPHS], and Robert Wood Johnson Studies [RWJS]) were considered of higher quality and generalizability than the small cross‐sectional studies. Due to the heterogeneity in physician type sampled and multiple satisfaction measurements used, a meta‐analysis of the literature was not performed, and a qualitative analysis is reported.

Figure 1

Results

Of the 97 studies, 69 were cross‐sectional (distributed to purposive and often convenience samples of physicians) with sampling sizes ranging from 39 to 6441 and response rates ranging from 31% to 97% (Appendix 1). The other 28 were from larger nationally representative studies (Table 1), including the CTS (n = 92, 45, 71, 74, 91, 102, 104106), RWJS (n = 81, 18, 3334, 39, 40, 60, 61), PWS (n = 711, 22, 23, 55, 83, 92, 99), and WPHS (n = 444, 4951). Fourteen articles reported information from longitudinal (n = 2)18, 86 or repeated cross‐sectional studies (n = 12)1, 2, 39, 73, 76, 79, 85, 91, 96, 97, 102, 110 to help determine satisfaction trends. The survey instruments from the 4 national physician surveys are outlined in Table 1. The types of satisfaction reported are outlined in Figure 2.

Figure 2

Major Characteristics Associated with Physician Satisfaction

Both factors intrinsic to the physician and characteristics of the job influence physician satisfaction (Figure 3). Intrinsic physician factors are typically not changeable when developing strategies to improve satisfaction. However, they do significantly affect what physicians consider important when choosing a job, and influence how physicians respond to changes in the job. Job characteristics, or extrinsic factors, are generally considered more modifiable when developing institutional strategies to improve satisfaction. Although the intrinsic factors are seemingly unmodifiable, one must take them into account when assessing satisfaction in order to determine the independent effects that the more modifiable extrinsic factors have on satisfaction. The next section describes the variables associated with satisfaction, from the 37 studies that utilized multivariate analyses (Appendix 2) to control for other factors (Appendix 3).

Figure 3

Physician Factors

Job Factors

Other Physician Factors

Board certification may be modestly positively associated with satisfaction, and being a foreign medical graduate may be modestly negatively associated with satisfaction, although this is limited to few studies.9, 45, 74, 98, 104, 106 Other physician characteristics, such as personal matters (marital status, home stress, mental health, personal satisfaction), work matters (amount of charity care they provide and history of work harassment), and personality (reform mindedness and tolerance for uncertainty) require further research.50, 56, 88, 98, 104

Discussion

Our review of satisfaction trends for U.S. physicians revealed relative stability except for a slight decline among PCPs. We found factors significantly associated with satisfaction to include both physician (age and specialty) and job factors (work demand, work control, colleague support, ability to maintain patient relationships, practice setting, income satisfaction, and incentive types). Based on limited data, the association with race/ethnicity and part‐time work requires more research, and factors that do not appear to have an independent effect on satisfaction include physician gender, patient‐payer mix, and patient characteristics.

As the fastest growing specialty in the history of American medicine, hospital medicine should focus on career satisfaction as a top priority in shaping the future of the more than 20,000 hospitalists now practicing. Although the term hospitalist was coined less than 15 years ago114 the demand for hospitalists is expected to grow to as many as 50,000 by 2020.115 In this time of rapid growth, in order to mold a sustainable specialty, we must all recognize the factors that contribute to satisfaction and strive to maintain good job‐person fit. For individual hospitalists, all of these mediators of satisfaction should be considered when contemplating employment. To ensure a mutual fit, each physician must reflect on how their goals and values coincide with those of the program they are considering. For hospital medicine program leaders, areas of program‐specific dissatisfaction must be continually sought and addressed.

In this review, the variables with the strongest associations with satisfaction that are most pertinent to hospitalists are work demand, control, income/emncentives, and collegial relationships. These variables coincide with the 4 pillars of career satisfaction identified in the Society of Hospital Medicine Career Satisfaction Task Force.116 Perceived work stress/pressure and objective workload can easily (and serially) be measured, and the latter can be compared to national benchmarks to ensure appropriate workload expectations.116 Reducing work pressure/stress may involve assessing and matching variations in workload with manpower, reducing nonclinical tasks by utilizing administrative assistants or physician extenders, or having an emergency plan for unexpected absences. Autonomy and control can be assessed by the job‐fit questionnaire to identify programwide and physician‐specific areas of potential discontent.116 Increasing autonomy/control may involve pursuing leadership within hospital projects or committees, creatively scheduling flexibility, and seeking support from hospital administration. Income expectations should also be couched within national benchmarks, and incentive programs should reflect work quality rather than quantity. Collegial support can be enhanced by instituting a mentoring program, journal club, regular social function, or configuration of offices spaces to allow proximity. Although the conclusions of this review are limited by the lack of hospitalists included in the studies and our inability to perform a meta‐analysis, we believe extrapolation of this information to hospitalist physicians is valid and appropriate. That said, future studies specifically addressing hospitalist satisfaction are needed to ensure this.

Conclusions

In summary, physician satisfaction is not a static parameter, but a dynamic entity mediated by both physician‐related and job‐related factors, the majority of which are modifiable. Thus hospitalists and hospital medicine program leaders can be optimistic that uncovering the presence of dissatisfaction through surveys, and addressing the issues triggering it, should enhance physician satisfaction. With improved awareness of mitigating factors of dissatisfaction and commitments to improvement, there is reason for hope. It is unreasonable to believe that dissatisfaction is intrinsic to any medical profession. It is reasonable to believe that physician satisfaction, with all of its desirable implications, can be attained through continual research and prioritization.

The burden of dissatisfaction among medical professionals concerns both physicians and policy makers, especially given the potential ramifications on the work force.1, 2 Abundant research documents a strong relationship between low levels of physician satisfaction and burnout,37 intention to leave,6, 815 and job turnover.13, 1618 Moreover, low physician satisfaction is associated with self‐reported psychiatric symptoms1921 and poorer perceived mental health.22 Not surprisingly, dissatisfied physicians are less likely to recommend to medical students that they pursue their specialty.23

Importantly, physician satisfaction appears to benefit patients. Several studies show a positive relationship between higher physician satisfaction and patient satisfaction and outcomes.2426 Patients cared for by satisfied physicians declare more trust and confidence in their physicians, have better continuity, higher ratings of their care,26, 27 lower no‐show rates,25 and enhanced adherence to their medical care.28 There is also some evidence that higher job satisfaction is associated with lower likelihood of patient errors and suboptimal patient care.29

Physician satisfaction can be influenced by factors intrinsic to the individual physician (age, gender, race, and specialty) and extrinsic to the physician (work environment, practice setting, patient characteristics, and income).22, 30 In this way, satisfaction is not a static property in any physician or physician group, but reflects a dynamic interplay among the expectations and environments within which they work. Although each physician, physician group, and specialty has distinct factors that affect satisfaction, none are immune to potential dissatisfaction.

Given the documented impact of physician satisfaction on multiple aspects of healthcare delivery, we undertook a systematic review of the existing literature to achieve a greater understanding of the current state of U.S. physician satisfaction. In addition, we sought to identify the major survey tools used to measure satisfaction and the characteristics intrinsic and extrinsic to the physician that are associated with satisfaction. We conclude by suggesting needed additional research.

Materials and Methods

We performed a literature search of MEDLINE (http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed) for articles from 1970 through 2007 to identify studies that provide a quantitative assessment of U.S. physician satisfaction and/or the factors associated with satisfaction. With assistance from a medical librarian with expertise in search coordination, we chose the following Medical Subject Heading (MeSH) phrases: (physicians OR physician's role OR physician's, women) AND (job satisfaction OR career satisfaction OR burnout). The search was further limited to humans and abstracts with no language restriction. The reviewers also searched reference lists to identify other relevant studies not in the search, as well as available online abstracts from the national meetings of the Society of Hospital Medicine (20022005) and the Society of General Internal Medicine (20052007). All of the abstracts were reviewed by 2 independent reviewers (D.S. and S.M.) for inclusion into the study. Study inclusion was limited to articles that reported physician satisfaction (career, professional, work, practice, job satisfaction, or overall satisfaction) or factors associated with physician satisfaction. Disagreements were resolved by consensus. After exclusions, 97 articles were included for review (Figure 1). Each study was listed by physician type sampled, whether the information was derived from a previously conducted (larger) sample, the sample size and response rate, the satisfaction measurement/subale, and satisfaction results (Appendix 1). Thirty‐seven studies that utilized multivariate analyses to report factors independently associated with satisfaction are listed in Appendix 2, along with the direction and strength of association. Confounders controlled for in these studies are listed in Appendix 3. Studies that extracted data from 1 of the 4 nationally representative studies (Community Tracking Studies [CTS], Physician Worklife Study [PWS], Women Physician Health Study [WPHS], and Robert Wood Johnson Studies [RWJS]) were considered of higher quality and generalizability than the small cross‐sectional studies. Due to the heterogeneity in physician type sampled and multiple satisfaction measurements used, a meta‐analysis of the literature was not performed, and a qualitative analysis is reported.

Figure 1

Results

Of the 97 studies, 69 were cross‐sectional (distributed to purposive and often convenience samples of physicians) with sampling sizes ranging from 39 to 6441 and response rates ranging from 31% to 97% (Appendix 1). The other 28 were from larger nationally representative studies (Table 1), including the CTS (n = 92, 45, 71, 74, 91, 102, 104106), RWJS (n = 81, 18, 3334, 39, 40, 60, 61), PWS (n = 711, 22, 23, 55, 83, 92, 99), and WPHS (n = 444, 4951). Fourteen articles reported information from longitudinal (n = 2)18, 86 or repeated cross‐sectional studies (n = 12)1, 2, 39, 73, 76, 79, 85, 91, 96, 97, 102, 110 to help determine satisfaction trends. The survey instruments from the 4 national physician surveys are outlined in Table 1. The types of satisfaction reported are outlined in Figure 2.

Figure 2

Major Characteristics Associated with Physician Satisfaction

Both factors intrinsic to the physician and characteristics of the job influence physician satisfaction (Figure 3). Intrinsic physician factors are typically not changeable when developing strategies to improve satisfaction. However, they do significantly affect what physicians consider important when choosing a job, and influence how physicians respond to changes in the job. Job characteristics, or extrinsic factors, are generally considered more modifiable when developing institutional strategies to improve satisfaction. Although the intrinsic factors are seemingly unmodifiable, one must take them into account when assessing satisfaction in order to determine the independent effects that the more modifiable extrinsic factors have on satisfaction. The next section describes the variables associated with satisfaction, from the 37 studies that utilized multivariate analyses (Appendix 2) to control for other factors (Appendix 3).

Figure 3

Physician Factors

Job Factors

Other Physician Factors

Board certification may be modestly positively associated with satisfaction, and being a foreign medical graduate may be modestly negatively associated with satisfaction, although this is limited to few studies.9, 45, 74, 98, 104, 106 Other physician characteristics, such as personal matters (marital status, home stress, mental health, personal satisfaction), work matters (amount of charity care they provide and history of work harassment), and personality (reform mindedness and tolerance for uncertainty) require further research.50, 56, 88, 98, 104

Discussion

Our review of satisfaction trends for U.S. physicians revealed relative stability except for a slight decline among PCPs. We found factors significantly associated with satisfaction to include both physician (age and specialty) and job factors (work demand, work control, colleague support, ability to maintain patient relationships, practice setting, income satisfaction, and incentive types). Based on limited data, the association with race/ethnicity and part‐time work requires more research, and factors that do not appear to have an independent effect on satisfaction include physician gender, patient‐payer mix, and patient characteristics.

As the fastest growing specialty in the history of American medicine, hospital medicine should focus on career satisfaction as a top priority in shaping the future of the more than 20,000 hospitalists now practicing. Although the term hospitalist was coined less than 15 years ago114 the demand for hospitalists is expected to grow to as many as 50,000 by 2020.115 In this time of rapid growth, in order to mold a sustainable specialty, we must all recognize the factors that contribute to satisfaction and strive to maintain good job‐person fit. For individual hospitalists, all of these mediators of satisfaction should be considered when contemplating employment. To ensure a mutual fit, each physician must reflect on how their goals and values coincide with those of the program they are considering. For hospital medicine program leaders, areas of program‐specific dissatisfaction must be continually sought and addressed.

In this review, the variables with the strongest associations with satisfaction that are most pertinent to hospitalists are work demand, control, income/emncentives, and collegial relationships. These variables coincide with the 4 pillars of career satisfaction identified in the Society of Hospital Medicine Career Satisfaction Task Force.116 Perceived work stress/pressure and objective workload can easily (and serially) be measured, and the latter can be compared to national benchmarks to ensure appropriate workload expectations.116 Reducing work pressure/stress may involve assessing and matching variations in workload with manpower, reducing nonclinical tasks by utilizing administrative assistants or physician extenders, or having an emergency plan for unexpected absences. Autonomy and control can be assessed by the job‐fit questionnaire to identify programwide and physician‐specific areas of potential discontent.116 Increasing autonomy/control may involve pursuing leadership within hospital projects or committees, creatively scheduling flexibility, and seeking support from hospital administration. Income expectations should also be couched within national benchmarks, and incentive programs should reflect work quality rather than quantity. Collegial support can be enhanced by instituting a mentoring program, journal club, regular social function, or configuration of offices spaces to allow proximity. Although the conclusions of this review are limited by the lack of hospitalists included in the studies and our inability to perform a meta‐analysis, we believe extrapolation of this information to hospitalist physicians is valid and appropriate. That said, future studies specifically addressing hospitalist satisfaction are needed to ensure this.

Conclusions

In summary, physician satisfaction is not a static parameter, but a dynamic entity mediated by both physician‐related and job‐related factors, the majority of which are modifiable. Thus hospitalists and hospital medicine program leaders can be optimistic that uncovering the presence of dissatisfaction through surveys, and addressing the issues triggering it, should enhance physician satisfaction. With improved awareness of mitigating factors of dissatisfaction and commitments to improvement, there is reason for hope. It is unreasonable to believe that dissatisfaction is intrinsic to any medical profession. It is reasonable to believe that physician satisfaction, with all of its desirable implications, can be attained through continual research and prioritization.

A growing number of reports indicate that communication failures among physicians at transitions of care are critical to patient safety.16 The practice of physician handoffs at shift and service changes are variable, with no standardized protocol shown to be effective at ensuring complete transmission of information.7 In 2006, the Joint Commission set a National Patient Safety Goal to implement a standardized approach to hand off communications.8 Hospitalists stand to be impacted by this decision due to the frequency of care transitions that are inherent in hospital practice. The Society of Hospital Medicine (SHM) recognizes safe transitions of care as a core competency of hospitalists and is actively exploring standardization of the process.9 While recent attention has focused on improved communication during shift changes, little data exists to guide handoffs among hospitalists at service changes.

Good service change communication is an essential skill of hospital medicine because frequent service handoffs are often unavoidable in hospitalist practices that seek to balance the demand for around‐the‐clock coverage for inpatients and the need to create sustainable schedules to avoid physician burnout.10 But the tradeoff between fewer hours worked and discontinuity of care is well recognized.7 Increasingly fragmented care without corresponding improvements in handoff communication may exacerbate the problem. This study aims to characterize communication practices among hospitalists during service changes and to describe adverse and near miss events that may occur as a result of poor handoffs during these vulnerable care transitions.

Methods

Results

Service Change Communication

Fifty‐six of 60 (93%) surveys evaluating service changes were completed and returned. All (17) eligible hospitalists participated. All but 1 completed survey indicated that some form of handoff communication took place between the incoming and the outgoing hospitalists. The median time category spent on service change communications was 6 to 15 minutes. Forty‐eight of 55 (87%) respondents who participated in handoff communication reported communicating on the day prior to the transition day, while the remainder communicated 2 or 3 days prior to, or on the transition day. Most communicated verbally, either by telephone (75%) or face to face (16%); 10% of respondents who did not speak with the outgoing physician received e‐mail as the main method of communication. The distribution of time spent on the service change communication is summarized in Figure 1A.

Figure 1

Discussion

To our knowledge, this is the first study of service changes among hospitalists. The results suggest that hospitalists in an academic medical center face obstacles to effective communication during service changes. A significant number of handoffs were described by hospitalists as incomplete and that missing information were associated with negative outcomes at the patient level. Reports of incomplete handoffs were associated with uncertainty by incoming physicians about the plan of care for patients and with the need to spend more time dealing with issues arising from this uncertainty. Although most of the effects on patients were near‐misses and not adverse events, the details elicited in this study reveal the threats to patient safety that arise from ineffective communication.

Interestingly, verbal communication was not associated with better transmission of information in this study. One reason for this may be the almost universal use of verbal communication in the service change handoffs among hospitalists at the UCMC. The value of verbal communication is supported by other studies that suggest the benefits of verbal exchanges combined with typed information sheets.15

In our study, hospitalists spent a significant amount of time resolving issues that arose from incomplete communication at service change. The need to retrieve missing information from charts and electronic medical records is to be expected, even if the handoffs were complete, but the use of patients and their family as redundant sources of information may lead to delay and stakeholder dissatisfaction. Likewise, consulting physicians were sometimes frustrated by not having their recommendations passed on during hospitalist service changes and of being asked to repeat their recommendations to each new incoming hospitalist. Moreover, many patients and consulting physicians were not informed about upcoming service changes by hospitalists. Informing stakeholders of staffing changes may be an important component of handoffs that requires attention.4, 16

The frequent communication between the outgoing and incoming hospitalists, even after their original handoff communication, points to the possible benefit of an overlap period during which outgoing physicians remain available to fill gaps in information. The willingness of outgoing hospitalists in this study to initiate this interaction reveals an opportunity for an intervention and is contrary to existing concerns that hospitalists, as opposed to primary care physicians, absolve themselves of patient responsibilities when their shift is completed.17, 18

Ensuring that handoff communication is concise and systematic is essential to improving the quality of care provided by hospitalists. An all‐inclusive transmission of unprocessed information, no matter how detailed, does not improve completeness of communication. Instead, we find that the complete transmission of patient information consists of both the discussion of the salient factual information about the case and the outgoing physician's assessment and future plan. A new strategy to improve completeness of service change communication may involve the use of a checklist to ensure a comprehensive review of critical details, as well as the use of narratives to tie together a coherent plan.

Alternative cutpoints for the dichotomized Likert categories for uncertainty about the plan and completeness of the handoff were explored. For example, it is also reasonable to interpret the response somewhat certain, referring to the plan of care on the transition day, as belonging to the dichotomized category uncertain as opposed to certain. A broader definition of uncertain increased the number of responses in that category but the variable's associations with other item responses were not significantly different from the results presented. We chose the symmetrical dichotomization cutpoint to ensure similar number of answers in each category.

There are several limitations with this study. First, the study was limited to self‐reported data without confirmation by direct observation. Additionally, responses to survey questions that ask participants to recollect details of a past handoff communication are subject to recall bias. We tried to minimize this bias effect by adhering to a schedule that surveyed hospitalists almost exactly at 48 hours into their rotation. However, there may still be hindsight bias about the respondents' perceived completeness of the handoffs based on the events of those 48 hours.19 In addition, a service of difficult patients requiring more of the hospitalist's time could influence his or her perception of a poor handoff through reverse causation. The study is not immune to a Hawthorne effect during the 8 months study period.20 This was a single‐center study examining 1 clinical service. The small sample size limits the depth of our analysis, but this is the first work to describe this phenomenon and although the data is not definitive, it may stimulate further work in the area. Although our study focused on completeness as the sole measure of handoff adequacy, additional measures may be explored in future studies. Finally, our findings may not be generalizable because of the unique features of the UCMC's hospitalist program, such as the specialized patient population. An examination of other practice settings is indicated for future studies.

Significant variability exists in the methods used to conduct service changes. Although a previous qualitative study of handoffs at our institution yielded a theme of poor communication around specific individuals,21 consistently poor communicators did not emerge as a theme in this qualitative analysis. We believe that episodes of incomplete communication are not always attributable to individual deficits and suggest that solutions to the communication problem exist at the systems level. The development and implementation of future interventions to improve hospitalist service changes may incorporate some of the elements suggested here.

A growing number of reports indicate that communication failures among physicians at transitions of care are critical to patient safety.16 The practice of physician handoffs at shift and service changes are variable, with no standardized protocol shown to be effective at ensuring complete transmission of information.7 In 2006, the Joint Commission set a National Patient Safety Goal to implement a standardized approach to hand off communications.8 Hospitalists stand to be impacted by this decision due to the frequency of care transitions that are inherent in hospital practice. The Society of Hospital Medicine (SHM) recognizes safe transitions of care as a core competency of hospitalists and is actively exploring standardization of the process.9 While recent attention has focused on improved communication during shift changes, little data exists to guide handoffs among hospitalists at service changes.

Good service change communication is an essential skill of hospital medicine because frequent service handoffs are often unavoidable in hospitalist practices that seek to balance the demand for around‐the‐clock coverage for inpatients and the need to create sustainable schedules to avoid physician burnout.10 But the tradeoff between fewer hours worked and discontinuity of care is well recognized.7 Increasingly fragmented care without corresponding improvements in handoff communication may exacerbate the problem. This study aims to characterize communication practices among hospitalists during service changes and to describe adverse and near miss events that may occur as a result of poor handoffs during these vulnerable care transitions.

Methods

Results

Service Change Communication

Fifty‐six of 60 (93%) surveys evaluating service changes were completed and returned. All (17) eligible hospitalists participated. All but 1 completed survey indicated that some form of handoff communication took place between the incoming and the outgoing hospitalists. The median time category spent on service change communications was 6 to 15 minutes. Forty‐eight of 55 (87%) respondents who participated in handoff communication reported communicating on the day prior to the transition day, while the remainder communicated 2 or 3 days prior to, or on the transition day. Most communicated verbally, either by telephone (75%) or face to face (16%); 10% of respondents who did not speak with the outgoing physician received e‐mail as the main method of communication. The distribution of time spent on the service change communication is summarized in Figure 1A.

Figure 1

Discussion

To our knowledge, this is the first study of service changes among hospitalists. The results suggest that hospitalists in an academic medical center face obstacles to effective communication during service changes. A significant number of handoffs were described by hospitalists as incomplete and that missing information were associated with negative outcomes at the patient level. Reports of incomplete handoffs were associated with uncertainty by incoming physicians about the plan of care for patients and with the need to spend more time dealing with issues arising from this uncertainty. Although most of the effects on patients were near‐misses and not adverse events, the details elicited in this study reveal the threats to patient safety that arise from ineffective communication.

Interestingly, verbal communication was not associated with better transmission of information in this study. One reason for this may be the almost universal use of verbal communication in the service change handoffs among hospitalists at the UCMC. The value of verbal communication is supported by other studies that suggest the benefits of verbal exchanges combined with typed information sheets.15

In our study, hospitalists spent a significant amount of time resolving issues that arose from incomplete communication at service change. The need to retrieve missing information from charts and electronic medical records is to be expected, even if the handoffs were complete, but the use of patients and their family as redundant sources of information may lead to delay and stakeholder dissatisfaction. Likewise, consulting physicians were sometimes frustrated by not having their recommendations passed on during hospitalist service changes and of being asked to repeat their recommendations to each new incoming hospitalist. Moreover, many patients and consulting physicians were not informed about upcoming service changes by hospitalists. Informing stakeholders of staffing changes may be an important component of handoffs that requires attention.4, 16

The frequent communication between the outgoing and incoming hospitalists, even after their original handoff communication, points to the possible benefit of an overlap period during which outgoing physicians remain available to fill gaps in information. The willingness of outgoing hospitalists in this study to initiate this interaction reveals an opportunity for an intervention and is contrary to existing concerns that hospitalists, as opposed to primary care physicians, absolve themselves of patient responsibilities when their shift is completed.17, 18

Ensuring that handoff communication is concise and systematic is essential to improving the quality of care provided by hospitalists. An all‐inclusive transmission of unprocessed information, no matter how detailed, does not improve completeness of communication. Instead, we find that the complete transmission of patient information consists of both the discussion of the salient factual information about the case and the outgoing physician's assessment and future plan. A new strategy to improve completeness of service change communication may involve the use of a checklist to ensure a comprehensive review of critical details, as well as the use of narratives to tie together a coherent plan.

Alternative cutpoints for the dichotomized Likert categories for uncertainty about the plan and completeness of the handoff were explored. For example, it is also reasonable to interpret the response somewhat certain, referring to the plan of care on the transition day, as belonging to the dichotomized category uncertain as opposed to certain. A broader definition of uncertain increased the number of responses in that category but the variable's associations with other item responses were not significantly different from the results presented. We chose the symmetrical dichotomization cutpoint to ensure similar number of answers in each category.

There are several limitations with this study. First, the study was limited to self‐reported data without confirmation by direct observation. Additionally, responses to survey questions that ask participants to recollect details of a past handoff communication are subject to recall bias. We tried to minimize this bias effect by adhering to a schedule that surveyed hospitalists almost exactly at 48 hours into their rotation. However, there may still be hindsight bias about the respondents' perceived completeness of the handoffs based on the events of those 48 hours.19 In addition, a service of difficult patients requiring more of the hospitalist's time could influence his or her perception of a poor handoff through reverse causation. The study is not immune to a Hawthorne effect during the 8 months study period.20 This was a single‐center study examining 1 clinical service. The small sample size limits the depth of our analysis, but this is the first work to describe this phenomenon and although the data is not definitive, it may stimulate further work in the area. Although our study focused on completeness as the sole measure of handoff adequacy, additional measures may be explored in future studies. Finally, our findings may not be generalizable because of the unique features of the UCMC's hospitalist program, such as the specialized patient population. An examination of other practice settings is indicated for future studies.

Significant variability exists in the methods used to conduct service changes. Although a previous qualitative study of handoffs at our institution yielded a theme of poor communication around specific individuals,21 consistently poor communicators did not emerge as a theme in this qualitative analysis. We believe that episodes of incomplete communication are not always attributable to individual deficits and suggest that solutions to the communication problem exist at the systems level. The development and implementation of future interventions to improve hospitalist service changes may incorporate some of the elements suggested here.

A growing number of reports indicate that communication failures among physicians at transitions of care are critical to patient safety.16 The practice of physician handoffs at shift and service changes are variable, with no standardized protocol shown to be effective at ensuring complete transmission of information.7 In 2006, the Joint Commission set a National Patient Safety Goal to implement a standardized approach to hand off communications.8 Hospitalists stand to be impacted by this decision due to the frequency of care transitions that are inherent in hospital practice. The Society of Hospital Medicine (SHM) recognizes safe transitions of care as a core competency of hospitalists and is actively exploring standardization of the process.9 While recent attention has focused on improved communication during shift changes, little data exists to guide handoffs among hospitalists at service changes.

Good service change communication is an essential skill of hospital medicine because frequent service handoffs are often unavoidable in hospitalist practices that seek to balance the demand for around‐the‐clock coverage for inpatients and the need to create sustainable schedules to avoid physician burnout.10 But the tradeoff between fewer hours worked and discontinuity of care is well recognized.7 Increasingly fragmented care without corresponding improvements in handoff communication may exacerbate the problem. This study aims to characterize communication practices among hospitalists during service changes and to describe adverse and near miss events that may occur as a result of poor handoffs during these vulnerable care transitions.

Methods

Results

Service Change Communication

Fifty‐six of 60 (93%) surveys evaluating service changes were completed and returned. All (17) eligible hospitalists participated. All but 1 completed survey indicated that some form of handoff communication took place between the incoming and the outgoing hospitalists. The median time category spent on service change communications was 6 to 15 minutes. Forty‐eight of 55 (87%) respondents who participated in handoff communication reported communicating on the day prior to the transition day, while the remainder communicated 2 or 3 days prior to, or on the transition day. Most communicated verbally, either by telephone (75%) or face to face (16%); 10% of respondents who did not speak with the outgoing physician received e‐mail as the main method of communication. The distribution of time spent on the service change communication is summarized in Figure 1A.

Figure 1

Discussion

To our knowledge, this is the first study of service changes among hospitalists. The results suggest that hospitalists in an academic medical center face obstacles to effective communication during service changes. A significant number of handoffs were described by hospitalists as incomplete and that missing information were associated with negative outcomes at the patient level. Reports of incomplete handoffs were associated with uncertainty by incoming physicians about the plan of care for patients and with the need to spend more time dealing with issues arising from this uncertainty. Although most of the effects on patients were near‐misses and not adverse events, the details elicited in this study reveal the threats to patient safety that arise from ineffective communication.

Interestingly, verbal communication was not associated with better transmission of information in this study. One reason for this may be the almost universal use of verbal communication in the service change handoffs among hospitalists at the UCMC. The value of verbal communication is supported by other studies that suggest the benefits of verbal exchanges combined with typed information sheets.15

In our study, hospitalists spent a significant amount of time resolving issues that arose from incomplete communication at service change. The need to retrieve missing information from charts and electronic medical records is to be expected, even if the handoffs were complete, but the use of patients and their family as redundant sources of information may lead to delay and stakeholder dissatisfaction. Likewise, consulting physicians were sometimes frustrated by not having their recommendations passed on during hospitalist service changes and of being asked to repeat their recommendations to each new incoming hospitalist. Moreover, many patients and consulting physicians were not informed about upcoming service changes by hospitalists. Informing stakeholders of staffing changes may be an important component of handoffs that requires attention.4, 16

The frequent communication between the outgoing and incoming hospitalists, even after their original handoff communication, points to the possible benefit of an overlap period during which outgoing physicians remain available to fill gaps in information. The willingness of outgoing hospitalists in this study to initiate this interaction reveals an opportunity for an intervention and is contrary to existing concerns that hospitalists, as opposed to primary care physicians, absolve themselves of patient responsibilities when their shift is completed.17, 18

Ensuring that handoff communication is concise and systematic is essential to improving the quality of care provided by hospitalists. An all‐inclusive transmission of unprocessed information, no matter how detailed, does not improve completeness of communication. Instead, we find that the complete transmission of patient information consists of both the discussion of the salient factual information about the case and the outgoing physician's assessment and future plan. A new strategy to improve completeness of service change communication may involve the use of a checklist to ensure a comprehensive review of critical details, as well as the use of narratives to tie together a coherent plan.

Alternative cutpoints for the dichotomized Likert categories for uncertainty about the plan and completeness of the handoff were explored. For example, it is also reasonable to interpret the response somewhat certain, referring to the plan of care on the transition day, as belonging to the dichotomized category uncertain as opposed to certain. A broader definition of uncertain increased the number of responses in that category but the variable's associations with other item responses were not significantly different from the results presented. We chose the symmetrical dichotomization cutpoint to ensure similar number of answers in each category.

There are several limitations with this study. First, the study was limited to self‐reported data without confirmation by direct observation. Additionally, responses to survey questions that ask participants to recollect details of a past handoff communication are subject to recall bias. We tried to minimize this bias effect by adhering to a schedule that surveyed hospitalists almost exactly at 48 hours into their rotation. However, there may still be hindsight bias about the respondents' perceived completeness of the handoffs based on the events of those 48 hours.19 In addition, a service of difficult patients requiring more of the hospitalist's time could influence his or her perception of a poor handoff through reverse causation. The study is not immune to a Hawthorne effect during the 8 months study period.20 This was a single‐center study examining 1 clinical service. The small sample size limits the depth of our analysis, but this is the first work to describe this phenomenon and although the data is not definitive, it may stimulate further work in the area. Although our study focused on completeness as the sole measure of handoff adequacy, additional measures may be explored in future studies. Finally, our findings may not be generalizable because of the unique features of the UCMC's hospitalist program, such as the specialized patient population. An examination of other practice settings is indicated for future studies.

Significant variability exists in the methods used to conduct service changes. Although a previous qualitative study of handoffs at our institution yielded a theme of poor communication around specific individuals,21 consistently poor communicators did not emerge as a theme in this qualitative analysis. We believe that episodes of incomplete communication are not always attributable to individual deficits and suggest that solutions to the communication problem exist at the systems level. The development and implementation of future interventions to improve hospitalist service changes may incorporate some of the elements suggested here.

I lay tossing and turning in the uncomfortable bed; the strange room with cables and stands strewn everywhere was very familiar but at the same time alien to me. I lay there thinking how I ended up here. Only a few short weeks ago I was on my way to a successful career as a hospitalist. I had just finished my chief residency, confident in my skills as a clinician. I considered myself to be a strong patient advocate and felt proud of the fact that I kept the patient above everything else. But I had no inkling of what the future had in store for me. I was not supposed to be a patient, I was young and healthy; surely this had to be a mistake. I realized that I just wasn't ready to handle the situation from the other side!

My nightmare started about a week before, when I woke up with excruciating abdominal pain, too weak to even call out for help. I eventually mustered enough strength to call Emergency Medical Services (EMS), the differential diagnosis of my symptoms going through my head. Surely I had perforated an ulcer! The increased proton pump inhibitor consumption wasn't just because of the rigors of the chief residency.

At the triage station, I could see the nurse looking at me, I knew that look, Great! She thinks I am a pain medication seeker. Even though it was a rude awakening, I realized I was disheveled, unkempt, and looked like anyone else on the street. Between spasms of pain and nursing my bruised ego, I blurted out, Can I have something for this pain!? I can't take it any more. All I got back was a blank stare and a dry, We will have to wait till the doctor sees you.

The Emergency Room (ER) physician recognized me as one of the new hospitalists. The demeanor of the staff changed perceptibly; I got the pain medications and the nurses paid close attention to my overall comfort. A battery of tests was ordered and an abdominal computed tomography (CT) scan revealed acute cholecystitis. I underwent an emergent cholecystectomy. On the third postoperative day I developed a nonproductive cough. The fever started within the next 24 hours. A CT scan revealed a large left lower lobe pneumonia.

God, why is this happening to me? I was in a daze while arrangements were being made to admit me. It was a different hospital, but here the treatment from the nurses was completely different. They had known me for almost 4 years, and had followed my progress from a green, wet‐behind‐the‐ears intern, to a chief resident, and eventually to an attending physician. Over the years they had learned to trust and respect me, but more importantly they had a bond with me that had developed over the years. This familiarity affected their interaction with me in this different role. I was astonished by how different our behaviors can be, based on our perception of the patient. As medical professionals we want to think that we look at people through the same lens, but our biases can creep up on us without us even realizing it.

I required a week of intravenous (IV) antibiotics before I was discharged home. Multiple blood draws, sometimes scheduled an hour apart; nurse evaluations in the middle of the night; and the nurse call light for the entire floor waking me up at odd hours exposed me to a new dimension of being hospitalized. This incident opened my eyes to a power differential that exists between patients and the healthcare providers. I realized that we are very quick to point out that we are doing what is best for a patient, even if it is uncomfortable or downright scarywithout ever considering the emotional and physical turmoil a patient is going through. My experience changed me; I recognize the anger a patient feels because of multiple blood draws every day. I now understand how the constant interruption of sleep cycles because of laboratory draws and vital sign monitoring would inexplicably make an octogenarian lose all bearings of time and place when hospitalized. I find myself asking if I really need to make my patients go through an entire battery of tests, or is there something else that I can do to make their hospital course any easier. I feel the need to sit down with my patients and ask them about small things, their pain control, and their sleep patterns during the hospitalization. I have realized that these small gestures can make a significant impact in the interaction between a physician and a patient.

As physicians and medical professionals, we come with our own set of biases, but our profession further jaundices our opinions about patient needs and demands. Biases are not just based on age, sex, or socioeconomic background, but also on our perception of the severity of a disease process. Perhaps words like frequent fliers and gomers are just a manifestation of this prejudice. We are taught to be objective in our daily interactions with patients, but this also indoctrinates a degree of cynicism. Slowly, this cynicism creeps into our daily patient interactions. We forget that patients with multiple medical problems and frequent admissions also need our help. A lack of tangible diagnosis does not mean the absence of disease. As physicians, we need to evaluate our interaction with patients closely. It is the frequent fliers and the old and debilitated individuals that need the closest scrutiny. If a patient with multiple admissions for pain has come in, we need to give them the benefit of the doubt when we address their complaints. I have realized that the occasional manipulative patient will let me down, but in order to practice this profession I have to leave skepticism out of any patient interaction. I recognize that I am not going to transform patient behavior, but I can try to give them the advantage whenever I can.

Our education system values compassion and professionalism, and we try to inculcate these values in our young physicians. Our curriculums try to incorporate compassion in our daily patient interactions, but I feel that simulated patient encounters and checklists make patient contact mechanical. We develop skills to diagnose diseases through repetition, but we fail to teach our students about the individuality of a patient. In the age of quality improvement and patient safety, the ethics and basic decency of our profession has taken a back seat. My illness has forced me to consider my role as a clinician‐educator. I feel that this experience was as important as any training I received in my journey as a physician. Looking at the spectrum of disease from the other side has opened new avenues for me as a physician. I have come to realize that as educators we have the responsibility to teach our students to become empathic and considerate healers.

Feedback surveys and simulated patient encounters give us an inaccurate assessment of student interaction with patients. These controlled environments can never take the place of a real patient. Time spent at the bedside with a patient or a family is becoming scarcer because of time constraints and work hour rules. But despite these changes we can devise new ways to stimulate critical thinking. Interaction of residents with patients can be outside of their daily responsibilities. Perhaps a rotation in which the residents review charts and interact with patients in a purely nonclinical role will force them to look at people as individuals rather than just patients. A desensitization at the end of residency to make them think as human beings first and physicians second might modify their decision making. Role reversals can serve as a valuable tool to achieve this goal. Perhaps our evaluation system needs to change from a retrospective subjective scrutiny of resident performance to a more objective analysis of patient care.

I strongly feel that we need to instill these virtues in our trainees. Perhaps they will never fully grasp the vulnerability a patient feels while lying in a hospital bed, but it is neither naive nor overly optimistic to suppose that this education can have a constructive effect on their behavior.

I lay tossing and turning in the uncomfortable bed; the strange room with cables and stands strewn everywhere was very familiar but at the same time alien to me. I lay there thinking how I ended up here. Only a few short weeks ago I was on my way to a successful career as a hospitalist. I had just finished my chief residency, confident in my skills as a clinician. I considered myself to be a strong patient advocate and felt proud of the fact that I kept the patient above everything else. But I had no inkling of what the future had in store for me. I was not supposed to be a patient, I was young and healthy; surely this had to be a mistake. I realized that I just wasn't ready to handle the situation from the other side!

My nightmare started about a week before, when I woke up with excruciating abdominal pain, too weak to even call out for help. I eventually mustered enough strength to call Emergency Medical Services (EMS), the differential diagnosis of my symptoms going through my head. Surely I had perforated an ulcer! The increased proton pump inhibitor consumption wasn't just because of the rigors of the chief residency.

At the triage station, I could see the nurse looking at me, I knew that look, Great! She thinks I am a pain medication seeker. Even though it was a rude awakening, I realized I was disheveled, unkempt, and looked like anyone else on the street. Between spasms of pain and nursing my bruised ego, I blurted out, Can I have something for this pain!? I can't take it any more. All I got back was a blank stare and a dry, We will have to wait till the doctor sees you.

The Emergency Room (ER) physician recognized me as one of the new hospitalists. The demeanor of the staff changed perceptibly; I got the pain medications and the nurses paid close attention to my overall comfort. A battery of tests was ordered and an abdominal computed tomography (CT) scan revealed acute cholecystitis. I underwent an emergent cholecystectomy. On the third postoperative day I developed a nonproductive cough. The fever started within the next 24 hours. A CT scan revealed a large left lower lobe pneumonia.

God, why is this happening to me? I was in a daze while arrangements were being made to admit me. It was a different hospital, but here the treatment from the nurses was completely different. They had known me for almost 4 years, and had followed my progress from a green, wet‐behind‐the‐ears intern, to a chief resident, and eventually to an attending physician. Over the years they had learned to trust and respect me, but more importantly they had a bond with me that had developed over the years. This familiarity affected their interaction with me in this different role. I was astonished by how different our behaviors can be, based on our perception of the patient. As medical professionals we want to think that we look at people through the same lens, but our biases can creep up on us without us even realizing it.

I required a week of intravenous (IV) antibiotics before I was discharged home. Multiple blood draws, sometimes scheduled an hour apart; nurse evaluations in the middle of the night; and the nurse call light for the entire floor waking me up at odd hours exposed me to a new dimension of being hospitalized. This incident opened my eyes to a power differential that exists between patients and the healthcare providers. I realized that we are very quick to point out that we are doing what is best for a patient, even if it is uncomfortable or downright scarywithout ever considering the emotional and physical turmoil a patient is going through. My experience changed me; I recognize the anger a patient feels because of multiple blood draws every day. I now understand how the constant interruption of sleep cycles because of laboratory draws and vital sign monitoring would inexplicably make an octogenarian lose all bearings of time and place when hospitalized. I find myself asking if I really need to make my patients go through an entire battery of tests, or is there something else that I can do to make their hospital course any easier. I feel the need to sit down with my patients and ask them about small things, their pain control, and their sleep patterns during the hospitalization. I have realized that these small gestures can make a significant impact in the interaction between a physician and a patient.

As physicians and medical professionals, we come with our own set of biases, but our profession further jaundices our opinions about patient needs and demands. Biases are not just based on age, sex, or socioeconomic background, but also on our perception of the severity of a disease process. Perhaps words like frequent fliers and gomers are just a manifestation of this prejudice. We are taught to be objective in our daily interactions with patients, but this also indoctrinates a degree of cynicism. Slowly, this cynicism creeps into our daily patient interactions. We forget that patients with multiple medical problems and frequent admissions also need our help. A lack of tangible diagnosis does not mean the absence of disease. As physicians, we need to evaluate our interaction with patients closely. It is the frequent fliers and the old and debilitated individuals that need the closest scrutiny. If a patient with multiple admissions for pain has come in, we need to give them the benefit of the doubt when we address their complaints. I have realized that the occasional manipulative patient will let me down, but in order to practice this profession I have to leave skepticism out of any patient interaction. I recognize that I am not going to transform patient behavior, but I can try to give them the advantage whenever I can.

Our education system values compassion and professionalism, and we try to inculcate these values in our young physicians. Our curriculums try to incorporate compassion in our daily patient interactions, but I feel that simulated patient encounters and checklists make patient contact mechanical. We develop skills to diagnose diseases through repetition, but we fail to teach our students about the individuality of a patient. In the age of quality improvement and patient safety, the ethics and basic decency of our profession has taken a back seat. My illness has forced me to consider my role as a clinician‐educator. I feel that this experience was as important as any training I received in my journey as a physician. Looking at the spectrum of disease from the other side has opened new avenues for me as a physician. I have come to realize that as educators we have the responsibility to teach our students to become empathic and considerate healers.

Feedback surveys and simulated patient encounters give us an inaccurate assessment of student interaction with patients. These controlled environments can never take the place of a real patient. Time spent at the bedside with a patient or a family is becoming scarcer because of time constraints and work hour rules. But despite these changes we can devise new ways to stimulate critical thinking. Interaction of residents with patients can be outside of their daily responsibilities. Perhaps a rotation in which the residents review charts and interact with patients in a purely nonclinical role will force them to look at people as individuals rather than just patients. A desensitization at the end of residency to make them think as human beings first and physicians second might modify their decision making. Role reversals can serve as a valuable tool to achieve this goal. Perhaps our evaluation system needs to change from a retrospective subjective scrutiny of resident performance to a more objective analysis of patient care.

I strongly feel that we need to instill these virtues in our trainees. Perhaps they will never fully grasp the vulnerability a patient feels while lying in a hospital bed, but it is neither naive nor overly optimistic to suppose that this education can have a constructive effect on their behavior.

I lay tossing and turning in the uncomfortable bed; the strange room with cables and stands strewn everywhere was very familiar but at the same time alien to me. I lay there thinking how I ended up here. Only a few short weeks ago I was on my way to a successful career as a hospitalist. I had just finished my chief residency, confident in my skills as a clinician. I considered myself to be a strong patient advocate and felt proud of the fact that I kept the patient above everything else. But I had no inkling of what the future had in store for me. I was not supposed to be a patient, I was young and healthy; surely this had to be a mistake. I realized that I just wasn't ready to handle the situation from the other side!

My nightmare started about a week before, when I woke up with excruciating abdominal pain, too weak to even call out for help. I eventually mustered enough strength to call Emergency Medical Services (EMS), the differential diagnosis of my symptoms going through my head. Surely I had perforated an ulcer! The increased proton pump inhibitor consumption wasn't just because of the rigors of the chief residency.

At the triage station, I could see the nurse looking at me, I knew that look, Great! She thinks I am a pain medication seeker. Even though it was a rude awakening, I realized I was disheveled, unkempt, and looked like anyone else on the street. Between spasms of pain and nursing my bruised ego, I blurted out, Can I have something for this pain!? I can't take it any more. All I got back was a blank stare and a dry, We will have to wait till the doctor sees you.

The Emergency Room (ER) physician recognized me as one of the new hospitalists. The demeanor of the staff changed perceptibly; I got the pain medications and the nurses paid close attention to my overall comfort. A battery of tests was ordered and an abdominal computed tomography (CT) scan revealed acute cholecystitis. I underwent an emergent cholecystectomy. On the third postoperative day I developed a nonproductive cough. The fever started within the next 24 hours. A CT scan revealed a large left lower lobe pneumonia.

God, why is this happening to me? I was in a daze while arrangements were being made to admit me. It was a different hospital, but here the treatment from the nurses was completely different. They had known me for almost 4 years, and had followed my progress from a green, wet‐behind‐the‐ears intern, to a chief resident, and eventually to an attending physician. Over the years they had learned to trust and respect me, but more importantly they had a bond with me that had developed over the years. This familiarity affected their interaction with me in this different role. I was astonished by how different our behaviors can be, based on our perception of the patient. As medical professionals we want to think that we look at people through the same lens, but our biases can creep up on us without us even realizing it.

I required a week of intravenous (IV) antibiotics before I was discharged home. Multiple blood draws, sometimes scheduled an hour apart; nurse evaluations in the middle of the night; and the nurse call light for the entire floor waking me up at odd hours exposed me to a new dimension of being hospitalized. This incident opened my eyes to a power differential that exists between patients and the healthcare providers. I realized that we are very quick to point out that we are doing what is best for a patient, even if it is uncomfortable or downright scarywithout ever considering the emotional and physical turmoil a patient is going through. My experience changed me; I recognize the anger a patient feels because of multiple blood draws every day. I now understand how the constant interruption of sleep cycles because of laboratory draws and vital sign monitoring would inexplicably make an octogenarian lose all bearings of time and place when hospitalized. I find myself asking if I really need to make my patients go through an entire battery of tests, or is there something else that I can do to make their hospital course any easier. I feel the need to sit down with my patients and ask them about small things, their pain control, and their sleep patterns during the hospitalization. I have realized that these small gestures can make a significant impact in the interaction between a physician and a patient.

As physicians and medical professionals, we come with our own set of biases, but our profession further jaundices our opinions about patient needs and demands. Biases are not just based on age, sex, or socioeconomic background, but also on our perception of the severity of a disease process. Perhaps words like frequent fliers and gomers are just a manifestation of this prejudice. We are taught to be objective in our daily interactions with patients, but this also indoctrinates a degree of cynicism. Slowly, this cynicism creeps into our daily patient interactions. We forget that patients with multiple medical problems and frequent admissions also need our help. A lack of tangible diagnosis does not mean the absence of disease. As physicians, we need to evaluate our interaction with patients closely. It is the frequent fliers and the old and debilitated individuals that need the closest scrutiny. If a patient with multiple admissions for pain has come in, we need to give them the benefit of the doubt when we address their complaints. I have realized that the occasional manipulative patient will let me down, but in order to practice this profession I have to leave skepticism out of any patient interaction. I recognize that I am not going to transform patient behavior, but I can try to give them the advantage whenever I can.

Our education system values compassion and professionalism, and we try to inculcate these values in our young physicians. Our curriculums try to incorporate compassion in our daily patient interactions, but I feel that simulated patient encounters and checklists make patient contact mechanical. We develop skills to diagnose diseases through repetition, but we fail to teach our students about the individuality of a patient. In the age of quality improvement and patient safety, the ethics and basic decency of our profession has taken a back seat. My illness has forced me to consider my role as a clinician‐educator. I feel that this experience was as important as any training I received in my journey as a physician. Looking at the spectrum of disease from the other side has opened new avenues for me as a physician. I have come to realize that as educators we have the responsibility to teach our students to become empathic and considerate healers.

Feedback surveys and simulated patient encounters give us an inaccurate assessment of student interaction with patients. These controlled environments can never take the place of a real patient. Time spent at the bedside with a patient or a family is becoming scarcer because of time constraints and work hour rules. But despite these changes we can devise new ways to stimulate critical thinking. Interaction of residents with patients can be outside of their daily responsibilities. Perhaps a rotation in which the residents review charts and interact with patients in a purely nonclinical role will force them to look at people as individuals rather than just patients. A desensitization at the end of residency to make them think as human beings first and physicians second might modify their decision making. Role reversals can serve as a valuable tool to achieve this goal. Perhaps our evaluation system needs to change from a retrospective subjective scrutiny of resident performance to a more objective analysis of patient care.

I strongly feel that we need to instill these virtues in our trainees. Perhaps they will never fully grasp the vulnerability a patient feels while lying in a hospital bed, but it is neither naive nor overly optimistic to suppose that this education can have a constructive effect on their behavior.

Two weeks after returning from missionary work in Haiti, a 53‐year‐old woman with no significant past medical history presented with 5 days of worsening fevers, chills, diaphoresis, myalgias, and severe nausea. Notably, she did not take malaria prophylaxis while in Haiti.

Her temperature was 40.1C, her blood pressure was 100/58 mm Hg, and her heart rate was 102 beats per minute. Physical examination was remarkable only for her ill appearance. Initial lab work revealed anemia (hemoglobin, 10.4 g/dL; hematocrit, 29.4%), thrombocytopenia (23,000/mm),³ and evidence of acute renal failure (blood urea nitrogen, 58 mg/dL; creatinine, 4.2 mg/dL). Other labs were within normal limits.

Malaria was considered high on the differential diagnosis. A parasite smear was therefore obtained, and the findings were consistent with Plasmodium falciparum infection (5.5% parasitemia).

She was admitted to the intensive care unit for hydration and initiation of antimalarial therapy. Her severe nausea prevented administration of oral medications; therefore, the infectious disease consultant recommended treatment with intravenous quinidine.

Prior to initiation of quinidine, an electrocardiogram (ECG) was obtained (Figure 1). No prior ECGs were available for comparison. Prominent ST segment elevation was noted, prompting reassessment of the patient. She denied chest pain. Cardiac enzymes were normal, and an urgent echocardiogram demonstrated normal ventricular function with mild mitral regurgitation. Given that suspicion for acute coronary syndrome was low, the ECG findings were managed conservatively.

Figure 1

Overnight, she defervesced and appeared to improve clinically. Cardiac enzymes remained negative. A repeat ECG obtained several hours after admission revealed complete resolution of the ST elevation (Figure 2). Repeat ECGs remained normal through the time of discharge, and no ventricular arrhythmias were noted on telemetry.

Figure 2

On the basis of the characteristic ECG appearance, a presumptive diagnosis of Brugada syndrome was made. The patient did not have a history of presyncope, syncope, or agonal night‐time breathing or a family history of sudden death. Two weeks following discharge, she was seen in the outpatient electrophysiology clinic to discuss further risk stratification. A procainamide challenge, followed by programmed ventricular stimulation (electrophysiology study), was recommended. The procainamide challenge revealed ST segment changes consistent with Brugada syndrome. She was not inducible for ventricular arrhythmias during the electrophysiology study. On the basis of these findings as well as her lack of symptoms, there was no indication for an implantable cardioverter defibrillator.

Discussion

The finding of ST segment elevation in a critically ill patient raises concern for a variety of processes, including myocardial infarction, coronary vasospasm, myocarditis, pericarditis, and electrolyte abnormalities. Our patient's presentation was not consistent with any of these diagnoses, and the ST segment changes had the highly characteristic coved appearance seen in patients with Brugada syndrome.

Brugada syndrome, which was first described in 1992,1 is an inherited cardiac channelopathy. It is most commonly associated with loss‐of‐function mutations in SCN5A, the gene that encodes the subunit of the cardiac sodium channel. The syndrome displays autosomal dominant inheritance with variable penetrance, and affected individuals are at increased risk of sudden death due to ventricular fibrillation.

The classic ECG manifestations of Brugada syndrome consist of an RSR pattern (pseudo‐RBBB) with a 2‐mm convex (coved) ST segment elevation and T wave inversion in leads V1 to V3 (Figure 1). There are also 2 less common patterns that display a saddle‐back ST‐T configuration with lesser ST segment elevation and upright or biphasic T waves. All 3 patterns can be transient, and their expression can be modulated by a number of factors, including autonomic tone, electrolyte abnormalities, ischemia, drugs, and body temperature.

The ECG appearance of Brugada syndrome is the result of the decreased function of the cardiac sodium channel. The inward flow of sodium through this channel is what depolarizes the cell. When this flow is blunted, the repolarizing effect of the transient outward potassium current is left relatively unopposed, and the action potential duration (APD) is shortened. This effect is prominent in the right ventricular outflow tract epicardium (which is why the ECG changes are noted in the precordial leads overlying this territory). Because the APD determines the refractory period of a cell (ie, how soon the cell can be re‐excited), the shortening of the APD allows epicardial cells to return to an excitable state while neighboring cells in the other myocardial layers are still refractory. This phenomenon, which is known as transmural dispersion of refractoriness, creates a voltage gradient between cellular layers and provides an ideal substrate for the precipitation of sustained reentrant ventricular arrhythmias.2

Two issues related to our case bear further explanation. First, on the basis of quinidine's sodium channel blocking properties (it is a class I antiarrhythmic), one would predict that it would exacerbate Brugada syndrome. Although this is true of other class I drugs, quinidine also is a potent blocker of transient outward potassium current, and this effect can actually lead to normalization of the ECG.2 Second, febrile illness can cause premature inactivation of the sodium channel in patients with Brugada syndrome,3 and fever can unmask the ECG changes and even promote arrhythmias in susceptible patients.4 We postulate that our patient had her underlying Brugada syndrome unmasked by her febrile illness and that the initiation of quinidine (blockade of transient outward potassium current) and defervescence (improved sodium current) contributed to the normalization of her ECG.

Although the details of our patient's presentation are somewhat unusual, we hope that this case highlights the dilemma created by the incidental discovery of a Brugada‐pattern ECG. Clinicians need to be aware that the cornerstone of the evaluation centers on determining whether the patient has any risk factors for sudden death: ventricular arrhythmias, a family history of sudden death, or symptoms suggestive of aborted sudden death (syncope, seizures, or nocturnal agonal respiration). In the absence of any of these risk factors, asymptomatic individuals are likely at low risk and can be followed clinically. If the diagnosis is in question, the typical ECG pattern can be elicited by challenge with a sodium channel blocking agent (most commonly procainamide). Although many patients will often undergo further invasive risk stratification, the utility of this approach is the subject of controversy. Finally, screening of family members should be considered.

Two weeks after returning from missionary work in Haiti, a 53‐year‐old woman with no significant past medical history presented with 5 days of worsening fevers, chills, diaphoresis, myalgias, and severe nausea. Notably, she did not take malaria prophylaxis while in Haiti.

Her temperature was 40.1C, her blood pressure was 100/58 mm Hg, and her heart rate was 102 beats per minute. Physical examination was remarkable only for her ill appearance. Initial lab work revealed anemia (hemoglobin, 10.4 g/dL; hematocrit, 29.4%), thrombocytopenia (23,000/mm),³ and evidence of acute renal failure (blood urea nitrogen, 58 mg/dL; creatinine, 4.2 mg/dL). Other labs were within normal limits.

Malaria was considered high on the differential diagnosis. A parasite smear was therefore obtained, and the findings were consistent with Plasmodium falciparum infection (5.5% parasitemia).

She was admitted to the intensive care unit for hydration and initiation of antimalarial therapy. Her severe nausea prevented administration of oral medications; therefore, the infectious disease consultant recommended treatment with intravenous quinidine.

Prior to initiation of quinidine, an electrocardiogram (ECG) was obtained (Figure 1). No prior ECGs were available for comparison. Prominent ST segment elevation was noted, prompting reassessment of the patient. She denied chest pain. Cardiac enzymes were normal, and an urgent echocardiogram demonstrated normal ventricular function with mild mitral regurgitation. Given that suspicion for acute coronary syndrome was low, the ECG findings were managed conservatively.

Figure 1

Overnight, she defervesced and appeared to improve clinically. Cardiac enzymes remained negative. A repeat ECG obtained several hours after admission revealed complete resolution of the ST elevation (Figure 2). Repeat ECGs remained normal through the time of discharge, and no ventricular arrhythmias were noted on telemetry.

Figure 2

On the basis of the characteristic ECG appearance, a presumptive diagnosis of Brugada syndrome was made. The patient did not have a history of presyncope, syncope, or agonal night‐time breathing or a family history of sudden death. Two weeks following discharge, she was seen in the outpatient electrophysiology clinic to discuss further risk stratification. A procainamide challenge, followed by programmed ventricular stimulation (electrophysiology study), was recommended. The procainamide challenge revealed ST segment changes consistent with Brugada syndrome. She was not inducible for ventricular arrhythmias during the electrophysiology study. On the basis of these findings as well as her lack of symptoms, there was no indication for an implantable cardioverter defibrillator.

Discussion

The finding of ST segment elevation in a critically ill patient raises concern for a variety of processes, including myocardial infarction, coronary vasospasm, myocarditis, pericarditis, and electrolyte abnormalities. Our patient's presentation was not consistent with any of these diagnoses, and the ST segment changes had the highly characteristic coved appearance seen in patients with Brugada syndrome.

Brugada syndrome, which was first described in 1992,1 is an inherited cardiac channelopathy. It is most commonly associated with loss‐of‐function mutations in SCN5A, the gene that encodes the subunit of the cardiac sodium channel. The syndrome displays autosomal dominant inheritance with variable penetrance, and affected individuals are at increased risk of sudden death due to ventricular fibrillation.

The classic ECG manifestations of Brugada syndrome consist of an RSR pattern (pseudo‐RBBB) with a 2‐mm convex (coved) ST segment elevation and T wave inversion in leads V1 to V3 (Figure 1). There are also 2 less common patterns that display a saddle‐back ST‐T configuration with lesser ST segment elevation and upright or biphasic T waves. All 3 patterns can be transient, and their expression can be modulated by a number of factors, including autonomic tone, electrolyte abnormalities, ischemia, drugs, and body temperature.

The ECG appearance of Brugada syndrome is the result of the decreased function of the cardiac sodium channel. The inward flow of sodium through this channel is what depolarizes the cell. When this flow is blunted, the repolarizing effect of the transient outward potassium current is left relatively unopposed, and the action potential duration (APD) is shortened. This effect is prominent in the right ventricular outflow tract epicardium (which is why the ECG changes are noted in the precordial leads overlying this territory). Because the APD determines the refractory period of a cell (ie, how soon the cell can be re‐excited), the shortening of the APD allows epicardial cells to return to an excitable state while neighboring cells in the other myocardial layers are still refractory. This phenomenon, which is known as transmural dispersion of refractoriness, creates a voltage gradient between cellular layers and provides an ideal substrate for the precipitation of sustained reentrant ventricular arrhythmias.2

Two issues related to our case bear further explanation. First, on the basis of quinidine's sodium channel blocking properties (it is a class I antiarrhythmic), one would predict that it would exacerbate Brugada syndrome. Although this is true of other class I drugs, quinidine also is a potent blocker of transient outward potassium current, and this effect can actually lead to normalization of the ECG.2 Second, febrile illness can cause premature inactivation of the sodium channel in patients with Brugada syndrome,3 and fever can unmask the ECG changes and even promote arrhythmias in susceptible patients.4 We postulate that our patient had her underlying Brugada syndrome unmasked by her febrile illness and that the initiation of quinidine (blockade of transient outward potassium current) and defervescence (improved sodium current) contributed to the normalization of her ECG.

Although the details of our patient's presentation are somewhat unusual, we hope that this case highlights the dilemma created by the incidental discovery of a Brugada‐pattern ECG. Clinicians need to be aware that the cornerstone of the evaluation centers on determining whether the patient has any risk factors for sudden death: ventricular arrhythmias, a family history of sudden death, or symptoms suggestive of aborted sudden death (syncope, seizures, or nocturnal agonal respiration). In the absence of any of these risk factors, asymptomatic individuals are likely at low risk and can be followed clinically. If the diagnosis is in question, the typical ECG pattern can be elicited by challenge with a sodium channel blocking agent (most commonly procainamide). Although many patients will often undergo further invasive risk stratification, the utility of this approach is the subject of controversy. Finally, screening of family members should be considered.

Two weeks after returning from missionary work in Haiti, a 53‐year‐old woman with no significant past medical history presented with 5 days of worsening fevers, chills, diaphoresis, myalgias, and severe nausea. Notably, she did not take malaria prophylaxis while in Haiti.

Her temperature was 40.1C, her blood pressure was 100/58 mm Hg, and her heart rate was 102 beats per minute. Physical examination was remarkable only for her ill appearance. Initial lab work revealed anemia (hemoglobin, 10.4 g/dL; hematocrit, 29.4%), thrombocytopenia (23,000/mm),³ and evidence of acute renal failure (blood urea nitrogen, 58 mg/dL; creatinine, 4.2 mg/dL). Other labs were within normal limits.

Malaria was considered high on the differential diagnosis. A parasite smear was therefore obtained, and the findings were consistent with Plasmodium falciparum infection (5.5% parasitemia).

She was admitted to the intensive care unit for hydration and initiation of antimalarial therapy. Her severe nausea prevented administration of oral medications; therefore, the infectious disease consultant recommended treatment with intravenous quinidine.

Prior to initiation of quinidine, an electrocardiogram (ECG) was obtained (Figure 1). No prior ECGs were available for comparison. Prominent ST segment elevation was noted, prompting reassessment of the patient. She denied chest pain. Cardiac enzymes were normal, and an urgent echocardiogram demonstrated normal ventricular function with mild mitral regurgitation. Given that suspicion for acute coronary syndrome was low, the ECG findings were managed conservatively.

Figure 1

Overnight, she defervesced and appeared to improve clinically. Cardiac enzymes remained negative. A repeat ECG obtained several hours after admission revealed complete resolution of the ST elevation (Figure 2). Repeat ECGs remained normal through the time of discharge, and no ventricular arrhythmias were noted on telemetry.

Figure 2

On the basis of the characteristic ECG appearance, a presumptive diagnosis of Brugada syndrome was made. The patient did not have a history of presyncope, syncope, or agonal night‐time breathing or a family history of sudden death. Two weeks following discharge, she was seen in the outpatient electrophysiology clinic to discuss further risk stratification. A procainamide challenge, followed by programmed ventricular stimulation (electrophysiology study), was recommended. The procainamide challenge revealed ST segment changes consistent with Brugada syndrome. She was not inducible for ventricular arrhythmias during the electrophysiology study. On the basis of these findings as well as her lack of symptoms, there was no indication for an implantable cardioverter defibrillator.

Discussion

The finding of ST segment elevation in a critically ill patient raises concern for a variety of processes, including myocardial infarction, coronary vasospasm, myocarditis, pericarditis, and electrolyte abnormalities. Our patient's presentation was not consistent with any of these diagnoses, and the ST segment changes had the highly characteristic coved appearance seen in patients with Brugada syndrome.

Brugada syndrome, which was first described in 1992,1 is an inherited cardiac channelopathy. It is most commonly associated with loss‐of‐function mutations in SCN5A, the gene that encodes the subunit of the cardiac sodium channel. The syndrome displays autosomal dominant inheritance with variable penetrance, and affected individuals are at increased risk of sudden death due to ventricular fibrillation.

The classic ECG manifestations of Brugada syndrome consist of an RSR pattern (pseudo‐RBBB) with a 2‐mm convex (coved) ST segment elevation and T wave inversion in leads V1 to V3 (Figure 1). There are also 2 less common patterns that display a saddle‐back ST‐T configuration with lesser ST segment elevation and upright or biphasic T waves. All 3 patterns can be transient, and their expression can be modulated by a number of factors, including autonomic tone, electrolyte abnormalities, ischemia, drugs, and body temperature.

The ECG appearance of Brugada syndrome is the result of the decreased function of the cardiac sodium channel. The inward flow of sodium through this channel is what depolarizes the cell. When this flow is blunted, the repolarizing effect of the transient outward potassium current is left relatively unopposed, and the action potential duration (APD) is shortened. This effect is prominent in the right ventricular outflow tract epicardium (which is why the ECG changes are noted in the precordial leads overlying this territory). Because the APD determines the refractory period of a cell (ie, how soon the cell can be re‐excited), the shortening of the APD allows epicardial cells to return to an excitable state while neighboring cells in the other myocardial layers are still refractory. This phenomenon, which is known as transmural dispersion of refractoriness, creates a voltage gradient between cellular layers and provides an ideal substrate for the precipitation of sustained reentrant ventricular arrhythmias.2

Two issues related to our case bear further explanation. First, on the basis of quinidine's sodium channel blocking properties (it is a class I antiarrhythmic), one would predict that it would exacerbate Brugada syndrome. Although this is true of other class I drugs, quinidine also is a potent blocker of transient outward potassium current, and this effect can actually lead to normalization of the ECG.2 Second, febrile illness can cause premature inactivation of the sodium channel in patients with Brugada syndrome,3 and fever can unmask the ECG changes and even promote arrhythmias in susceptible patients.4 We postulate that our patient had her underlying Brugada syndrome unmasked by her febrile illness and that the initiation of quinidine (blockade of transient outward potassium current) and defervescence (improved sodium current) contributed to the normalization of her ECG.

Although the details of our patient's presentation are somewhat unusual, we hope that this case highlights the dilemma created by the incidental discovery of a Brugada‐pattern ECG. Clinicians need to be aware that the cornerstone of the evaluation centers on determining whether the patient has any risk factors for sudden death: ventricular arrhythmias, a family history of sudden death, or symptoms suggestive of aborted sudden death (syncope, seizures, or nocturnal agonal respiration). In the absence of any of these risk factors, asymptomatic individuals are likely at low risk and can be followed clinically. If the diagnosis is in question, the typical ECG pattern can be elicited by challenge with a sodium channel blocking agent (most commonly procainamide). Although many patients will often undergo further invasive risk stratification, the utility of this approach is the subject of controversy. Finally, screening of family members should be considered.

Major natural disasters, such as Hurricane Rita and Hurricane Katrina in 2005, have reinforced the reality that health care workers may be asked to treat patients outside the traditional hospital setting.1 The emergence of H5N1 avian influenza in Southeast Asia has also raised concerns about a potential worldwide pandemic influenza.2 Since 2003, the number of avian influenza cases in humans has totaled 387, with 245 deaths.3 While H5N1 influenza has thus far been largely confined to avian populations, the virulence of this strain has raised concern regarding the possible emergence of enhanced human transmission.4 While impossible to accurately forecast the devastation of the next pandemic on the health system, anything similar to the pandemics of the past century will require a large coordinated response by the health system. The most severe pandemic in the past century occurred in 1918 to 1919. The estimated deaths attributed to this worldwide ranges from 20 to 100 million persons,57 with >500,000 of these deaths in the United States.6, 7 In comparison, the annual rate of deaths related to influenza in the United States ranges from 30,000 to 50,000.2, 5 It has been estimated that the next pandemic influenza could cause 75 to 100 million people to become ill, and lead to as many as 1.9 million deaths in the United States.8 In response, the Department of Health and Human Services (HHS) has stressed the importance of advanced planning,9 and the most recent Homeland Security Presidential Directive (HSPD‐21) directs health care organizations and the federal government to develop preparedness plans to provide surge capacity care in times of a catastrophic health event.10 A previous report by one of the authors emphasized the need for hospitalists to play a major role in institutional planning for a pandemic influenza.11

The Alternate Care Center

The concept of offsite care in an influenza pandemic has previously been described, and we will refer to these as Alternate Care Centers (ACCs). Although the literature describes different models of care at an ACC (Table 1),12 we believe an ACC should be activated as an extension of the supporting hospital, once the hospital becomes over capacity despite measures to grow its inpatient service volume.

Our health system is a large academic medical center, and we have been working with our state to develop a plan to establish and operate an ACC for the next pandemic influenza. Our plans call for an ACC to be activated as an overflow hospital once our hospitals are beyond 120% capacity. We have gone through several functional and tabletop exercises to help identify critical issues that are likely to arise during a real pandemic. Subsequent to these exercises, we have convened an ACC Planning Work Group, reviewed the available literature on surge hospitals, and have focused our recent efforts on several key areas.13 First, it will be important to clearly outline the general services that will be available at this offsite location (Table 2), and this information should be disseminated to the local medical community and the general public. An informed public, with a clear understanding that the ACC is an extension of the hospital with hospitalists in charge of medical care, is more likely to accept getting healthcare in this setting.

Second, hospitals and the ACCas an extension to the main hospitalwill be asked to provide care to patients referred from several external facilities. Thus, the relationship between the ACC and the main hospital is critical. In a situation where local and even national health care assets will be overwhelmed, having a traditional hospital take full ownership of the ACC and facilitate the transport of patients in and out of the center will be vital to the maintenance of operations. Figure 1 illustrates an example of how patients may be transitioned from 1 site of care to another.

Figure 1

Third, the logistics of establishing an ACC should include details regarding: (1) securing a location that is able to accommodate the needs of the ACC; (2) predetermining the scope of care that can be provided; (3) procuring the necessary equipment and supplies; (4) planning for an adequate number of workforce and staff members; and (5) ensuring a reliable communication plan within the local health system and with state and federal public health officials.14 Staffing shortages and communication barriers are worthy of further emphasis. Given conservative estimates that up to 35% of staff may become ill, refuse to work, or remain home to care for ill family members,15 it is essential that hospitals and regional emergency planners develop a staffing model for the ACC, well in advance of a pandemic. These may include scenarios in which the recommended provider‐to‐patient ratio can not be met. Among the essential lessons learned from the severe acute respiratory syndrome (SARS) outbreak in Toronto (Ontario, Canada) was the importance of developing redundant and reliable communication plans among the healthcare providers.16, 17

Last, healthcare workers' concerns about occupational health and safety must be addressed, and strict measures to protect providers in the ACC need to be implemented.16 This includes providing all exposed staff with adequate personal protective equipment (eg, N‐95 masks), ensuring that all staff are vaccinated against the influenza virus, and implementing strict infection control (eg, hand washing) practices.

For more information, we refer the reader to references that contain further details on our ACC exercises13 and documents that outline concepts of operations in an ACC, developed by the Joint Commission and a multiagency working group.1, 14

The Hospitalist Physician and the ACC

During an influenza pandemic, physicians from all specialties will be vital to the success of the health systems' response. General internists,18 family practitioners, and pediatricians will be overextended in the ambulatory setting to provide intravenous (IV) fluids, antibiotics, and vaccines. Emergency physicians will be called upon to provide care for a burgeoning number of patient arrivals to the Emergency Department (ED), whose acuity is higher than in nonpandemic times. These physicians' clinical expertise at their sites of practice may be severely tested. Hospitalists, given their inpatient focus will be ideally suited to provide medical care to patients admitted to the ACC.

Previous physician leadership at surge hospitals has come from multiple specialties. Case studies describing the heroic physician leadership after Hurricane Katrina and Hurricane Rita represented pediatricians, family physicians, emergency department physicians, and internists.1 In an influenza pandemic, patients in the ACC will require medical care that would, under nonsurge situations, warrant inpatient care. Hospitalists are well poised to lead the response in the ACC for pandemic flu. Hospitalists have expanded their presence into many clinical and administrative responsibilities in their local health systems,19 and the specialty of hospital medicine has evolved to incorporate many of the skills and expertise that would be required of physician leaders who manage an ACC during an influenza pandemic.

While the actual morbidity and mortality associated with the next pandemic are uncertain, it is likely that the number of patients who seek out medical care will exceed current capacity. With constrained space and resources, patients will require appropriate and safe transition to and from the hospital and the ACC. Hospitalists have become leaders in developing and promoting quality transition of care out of acute care settings.20, 21 Their expertise in optimizing this vulnerable time period in patients' healthcare experience should help hospitalists make efficient and appropriate transition care decisions even during busy times and in an alternate care location. Many hospitalists have also developed local and national expertise in quality improvement (QI) and patient safety (PS) initiatives in acute care settings.22 Hospitalists can lead the efforts to apply QI and PS practices in the ACC. These interventions should focus on the potential to be effective in improving patient care, but also consider issues such as ease of implementation, cost, and potential for harm.23

An influenza pandemic will require all levels of the healthcare system to work together to develop a coordinated approach to patient care. Previously, Kisuule et al.24 described how hospitalists can expand their role to include public health. The hospitalists' leadership in the ACC fits well with their descriptions, and hospitalists should work with local, state, and national public health officials in pandemic flu planning. Their scope of practice and clinical expertise will call on them to play key roles in recognition of the development of a pandemic; help lead the response efforts; provide education to staff, patients, and family members; develop clinical care guidelines and pathways for patients; utilize best practices in the use of antimicrobial therapy; and provide appropriate palliative care. Depending on the severity of the influenza pandemic, mortality could be considerable. Many hospitalists have expertise in palliative care at their hospitals,2527 and this skill set will be invaluable in providing compassionate end‐of‐life care to patients in the ACC.

In a pandemic, the most vulnerable patient populations will likely be disproportionately affected, including the elderly, children, and the immune‐compromised. Hospitalists who care regularly for these diverse groups of patients through the spectrum of illness and recovery will be able to address the variety of clinical and nonclinical issues that arise. If the ACC will provide care for children, hospitalists with training in pediatrics, medicine‐pediatrics, or family medicine should be available.

Additional Considerations

While many unanswered questions remain about how to best utilize the ACC, hospitalists are ideally suited to help lead planning efforts for an ACC for pandemic flu. Other issues that may require additional considerations include: (1) whether to strictly care for patients with influenza symptoms and influenza‐related illnesses or to provide care for all patients at the ACC; (2) what to do when patients refuse transfer to and from the ACC; (3) determining the optimal staffing model for patient care providers and to provide care for a wide range of age groups; (4) how the ACC will be funded; (5) how and where to store stockpiles; (6) developing redundant and coordinated communication plans; and (7) planning for reliable access to information and technology from the ACC.

Conclusions

We have introduced the concept of the ACC for the hospitalist community, and emphasized the benefits of engaging hospitalists to lead the ACC initiative at their own health organizations during pandemic flu. As hospitalists currently serve in many of these roles and possess the skills to provide care and lead these initiatives, we encourage hospitalists to contact their hospital administrators to volunteer to assist with preparation efforts.

Major natural disasters, such as Hurricane Rita and Hurricane Katrina in 2005, have reinforced the reality that health care workers may be asked to treat patients outside the traditional hospital setting.1 The emergence of H5N1 avian influenza in Southeast Asia has also raised concerns about a potential worldwide pandemic influenza.2 Since 2003, the number of avian influenza cases in humans has totaled 387, with 245 deaths.3 While H5N1 influenza has thus far been largely confined to avian populations, the virulence of this strain has raised concern regarding the possible emergence of enhanced human transmission.4 While impossible to accurately forecast the devastation of the next pandemic on the health system, anything similar to the pandemics of the past century will require a large coordinated response by the health system. The most severe pandemic in the past century occurred in 1918 to 1919. The estimated deaths attributed to this worldwide ranges from 20 to 100 million persons,57 with >500,000 of these deaths in the United States.6, 7 In comparison, the annual rate of deaths related to influenza in the United States ranges from 30,000 to 50,000.2, 5 It has been estimated that the next pandemic influenza could cause 75 to 100 million people to become ill, and lead to as many as 1.9 million deaths in the United States.8 In response, the Department of Health and Human Services (HHS) has stressed the importance of advanced planning,9 and the most recent Homeland Security Presidential Directive (HSPD‐21) directs health care organizations and the federal government to develop preparedness plans to provide surge capacity care in times of a catastrophic health event.10 A previous report by one of the authors emphasized the need for hospitalists to play a major role in institutional planning for a pandemic influenza.11

The Alternate Care Center

The concept of offsite care in an influenza pandemic has previously been described, and we will refer to these as Alternate Care Centers (ACCs). Although the literature describes different models of care at an ACC (Table 1),12 we believe an ACC should be activated as an extension of the supporting hospital, once the hospital becomes over capacity despite measures to grow its inpatient service volume.

Our health system is a large academic medical center, and we have been working with our state to develop a plan to establish and operate an ACC for the next pandemic influenza. Our plans call for an ACC to be activated as an overflow hospital once our hospitals are beyond 120% capacity. We have gone through several functional and tabletop exercises to help identify critical issues that are likely to arise during a real pandemic. Subsequent to these exercises, we have convened an ACC Planning Work Group, reviewed the available literature on surge hospitals, and have focused our recent efforts on several key areas.13 First, it will be important to clearly outline the general services that will be available at this offsite location (Table 2), and this information should be disseminated to the local medical community and the general public. An informed public, with a clear understanding that the ACC is an extension of the hospital with hospitalists in charge of medical care, is more likely to accept getting healthcare in this setting.

Second, hospitals and the ACCas an extension to the main hospitalwill be asked to provide care to patients referred from several external facilities. Thus, the relationship between the ACC and the main hospital is critical. In a situation where local and even national health care assets will be overwhelmed, having a traditional hospital take full ownership of the ACC and facilitate the transport of patients in and out of the center will be vital to the maintenance of operations. Figure 1 illustrates an example of how patients may be transitioned from 1 site of care to another.

Figure 1

Third, the logistics of establishing an ACC should include details regarding: (1) securing a location that is able to accommodate the needs of the ACC; (2) predetermining the scope of care that can be provided; (3) procuring the necessary equipment and supplies; (4) planning for an adequate number of workforce and staff members; and (5) ensuring a reliable communication plan within the local health system and with state and federal public health officials.14 Staffing shortages and communication barriers are worthy of further emphasis. Given conservative estimates that up to 35% of staff may become ill, refuse to work, or remain home to care for ill family members,15 it is essential that hospitals and regional emergency planners develop a staffing model for the ACC, well in advance of a pandemic. These may include scenarios in which the recommended provider‐to‐patient ratio can not be met. Among the essential lessons learned from the severe acute respiratory syndrome (SARS) outbreak in Toronto (Ontario, Canada) was the importance of developing redundant and reliable communication plans among the healthcare providers.16, 17

Last, healthcare workers' concerns about occupational health and safety must be addressed, and strict measures to protect providers in the ACC need to be implemented.16 This includes providing all exposed staff with adequate personal protective equipment (eg, N‐95 masks), ensuring that all staff are vaccinated against the influenza virus, and implementing strict infection control (eg, hand washing) practices.

For more information, we refer the reader to references that contain further details on our ACC exercises13 and documents that outline concepts of operations in an ACC, developed by the Joint Commission and a multiagency working group.1, 14

The Hospitalist Physician and the ACC

During an influenza pandemic, physicians from all specialties will be vital to the success of the health systems' response. General internists,18 family practitioners, and pediatricians will be overextended in the ambulatory setting to provide intravenous (IV) fluids, antibiotics, and vaccines. Emergency physicians will be called upon to provide care for a burgeoning number of patient arrivals to the Emergency Department (ED), whose acuity is higher than in nonpandemic times. These physicians' clinical expertise at their sites of practice may be severely tested. Hospitalists, given their inpatient focus will be ideally suited to provide medical care to patients admitted to the ACC.

Previous physician leadership at surge hospitals has come from multiple specialties. Case studies describing the heroic physician leadership after Hurricane Katrina and Hurricane Rita represented pediatricians, family physicians, emergency department physicians, and internists.1 In an influenza pandemic, patients in the ACC will require medical care that would, under nonsurge situations, warrant inpatient care. Hospitalists are well poised to lead the response in the ACC for pandemic flu. Hospitalists have expanded their presence into many clinical and administrative responsibilities in their local health systems,19 and the specialty of hospital medicine has evolved to incorporate many of the skills and expertise that would be required of physician leaders who manage an ACC during an influenza pandemic.

While the actual morbidity and mortality associated with the next pandemic are uncertain, it is likely that the number of patients who seek out medical care will exceed current capacity. With constrained space and resources, patients will require appropriate and safe transition to and from the hospital and the ACC. Hospitalists have become leaders in developing and promoting quality transition of care out of acute care settings.20, 21 Their expertise in optimizing this vulnerable time period in patients' healthcare experience should help hospitalists make efficient and appropriate transition care decisions even during busy times and in an alternate care location. Many hospitalists have also developed local and national expertise in quality improvement (QI) and patient safety (PS) initiatives in acute care settings.22 Hospitalists can lead the efforts to apply QI and PS practices in the ACC. These interventions should focus on the potential to be effective in improving patient care, but also consider issues such as ease of implementation, cost, and potential for harm.23

An influenza pandemic will require all levels of the healthcare system to work together to develop a coordinated approach to patient care. Previously, Kisuule et al.24 described how hospitalists can expand their role to include public health. The hospitalists' leadership in the ACC fits well with their descriptions, and hospitalists should work with local, state, and national public health officials in pandemic flu planning. Their scope of practice and clinical expertise will call on them to play key roles in recognition of the development of a pandemic; help lead the response efforts; provide education to staff, patients, and family members; develop clinical care guidelines and pathways for patients; utilize best practices in the use of antimicrobial therapy; and provide appropriate palliative care. Depending on the severity of the influenza pandemic, mortality could be considerable. Many hospitalists have expertise in palliative care at their hospitals,2527 and this skill set will be invaluable in providing compassionate end‐of‐life care to patients in the ACC.

In a pandemic, the most vulnerable patient populations will likely be disproportionately affected, including the elderly, children, and the immune‐compromised. Hospitalists who care regularly for these diverse groups of patients through the spectrum of illness and recovery will be able to address the variety of clinical and nonclinical issues that arise. If the ACC will provide care for children, hospitalists with training in pediatrics, medicine‐pediatrics, or family medicine should be available.

Additional Considerations

While many unanswered questions remain about how to best utilize the ACC, hospitalists are ideally suited to help lead planning efforts for an ACC for pandemic flu. Other issues that may require additional considerations include: (1) whether to strictly care for patients with influenza symptoms and influenza‐related illnesses or to provide care for all patients at the ACC; (2) what to do when patients refuse transfer to and from the ACC; (3) determining the optimal staffing model for patient care providers and to provide care for a wide range of age groups; (4) how the ACC will be funded; (5) how and where to store stockpiles; (6) developing redundant and coordinated communication plans; and (7) planning for reliable access to information and technology from the ACC.

Conclusions

We have introduced the concept of the ACC for the hospitalist community, and emphasized the benefits of engaging hospitalists to lead the ACC initiative at their own health organizations during pandemic flu. As hospitalists currently serve in many of these roles and possess the skills to provide care and lead these initiatives, we encourage hospitalists to contact their hospital administrators to volunteer to assist with preparation efforts.

Major natural disasters, such as Hurricane Rita and Hurricane Katrina in 2005, have reinforced the reality that health care workers may be asked to treat patients outside the traditional hospital setting.1 The emergence of H5N1 avian influenza in Southeast Asia has also raised concerns about a potential worldwide pandemic influenza.2 Since 2003, the number of avian influenza cases in humans has totaled 387, with 245 deaths.3 While H5N1 influenza has thus far been largely confined to avian populations, the virulence of this strain has raised concern regarding the possible emergence of enhanced human transmission.4 While impossible to accurately forecast the devastation of the next pandemic on the health system, anything similar to the pandemics of the past century will require a large coordinated response by the health system. The most severe pandemic in the past century occurred in 1918 to 1919. The estimated deaths attributed to this worldwide ranges from 20 to 100 million persons,57 with >500,000 of these deaths in the United States.6, 7 In comparison, the annual rate of deaths related to influenza in the United States ranges from 30,000 to 50,000.2, 5 It has been estimated that the next pandemic influenza could cause 75 to 100 million people to become ill, and lead to as many as 1.9 million deaths in the United States.8 In response, the Department of Health and Human Services (HHS) has stressed the importance of advanced planning,9 and the most recent Homeland Security Presidential Directive (HSPD‐21) directs health care organizations and the federal government to develop preparedness plans to provide surge capacity care in times of a catastrophic health event.10 A previous report by one of the authors emphasized the need for hospitalists to play a major role in institutional planning for a pandemic influenza.11

The Alternate Care Center

The concept of offsite care in an influenza pandemic has previously been described, and we will refer to these as Alternate Care Centers (ACCs). Although the literature describes different models of care at an ACC (Table 1),12 we believe an ACC should be activated as an extension of the supporting hospital, once the hospital becomes over capacity despite measures to grow its inpatient service volume.

Our health system is a large academic medical center, and we have been working with our state to develop a plan to establish and operate an ACC for the next pandemic influenza. Our plans call for an ACC to be activated as an overflow hospital once our hospitals are beyond 120% capacity. We have gone through several functional and tabletop exercises to help identify critical issues that are likely to arise during a real pandemic. Subsequent to these exercises, we have convened an ACC Planning Work Group, reviewed the available literature on surge hospitals, and have focused our recent efforts on several key areas.13 First, it will be important to clearly outline the general services that will be available at this offsite location (Table 2), and this information should be disseminated to the local medical community and the general public. An informed public, with a clear understanding that the ACC is an extension of the hospital with hospitalists in charge of medical care, is more likely to accept getting healthcare in this setting.

Second, hospitals and the ACCas an extension to the main hospitalwill be asked to provide care to patients referred from several external facilities. Thus, the relationship between the ACC and the main hospital is critical. In a situation where local and even national health care assets will be overwhelmed, having a traditional hospital take full ownership of the ACC and facilitate the transport of patients in and out of the center will be vital to the maintenance of operations. Figure 1 illustrates an example of how patients may be transitioned from 1 site of care to another.

Figure 1

Third, the logistics of establishing an ACC should include details regarding: (1) securing a location that is able to accommodate the needs of the ACC; (2) predetermining the scope of care that can be provided; (3) procuring the necessary equipment and supplies; (4) planning for an adequate number of workforce and staff members; and (5) ensuring a reliable communication plan within the local health system and with state and federal public health officials.14 Staffing shortages and communication barriers are worthy of further emphasis. Given conservative estimates that up to 35% of staff may become ill, refuse to work, or remain home to care for ill family members,15 it is essential that hospitals and regional emergency planners develop a staffing model for the ACC, well in advance of a pandemic. These may include scenarios in which the recommended provider‐to‐patient ratio can not be met. Among the essential lessons learned from the severe acute respiratory syndrome (SARS) outbreak in Toronto (Ontario, Canada) was the importance of developing redundant and reliable communication plans among the healthcare providers.16, 17

Last, healthcare workers' concerns about occupational health and safety must be addressed, and strict measures to protect providers in the ACC need to be implemented.16 This includes providing all exposed staff with adequate personal protective equipment (eg, N‐95 masks), ensuring that all staff are vaccinated against the influenza virus, and implementing strict infection control (eg, hand washing) practices.

For more information, we refer the reader to references that contain further details on our ACC exercises13 and documents that outline concepts of operations in an ACC, developed by the Joint Commission and a multiagency working group.1, 14

The Hospitalist Physician and the ACC

During an influenza pandemic, physicians from all specialties will be vital to the success of the health systems' response. General internists,18 family practitioners, and pediatricians will be overextended in the ambulatory setting to provide intravenous (IV) fluids, antibiotics, and vaccines. Emergency physicians will be called upon to provide care for a burgeoning number of patient arrivals to the Emergency Department (ED), whose acuity is higher than in nonpandemic times. These physicians' clinical expertise at their sites of practice may be severely tested. Hospitalists, given their inpatient focus will be ideally suited to provide medical care to patients admitted to the ACC.

Previous physician leadership at surge hospitals has come from multiple specialties. Case studies describing the heroic physician leadership after Hurricane Katrina and Hurricane Rita represented pediatricians, family physicians, emergency department physicians, and internists.1 In an influenza pandemic, patients in the ACC will require medical care that would, under nonsurge situations, warrant inpatient care. Hospitalists are well poised to lead the response in the ACC for pandemic flu. Hospitalists have expanded their presence into many clinical and administrative responsibilities in their local health systems,19 and the specialty of hospital medicine has evolved to incorporate many of the skills and expertise that would be required of physician leaders who manage an ACC during an influenza pandemic.

While the actual morbidity and mortality associated with the next pandemic are uncertain, it is likely that the number of patients who seek out medical care will exceed current capacity. With constrained space and resources, patients will require appropriate and safe transition to and from the hospital and the ACC. Hospitalists have become leaders in developing and promoting quality transition of care out of acute care settings.20, 21 Their expertise in optimizing this vulnerable time period in patients' healthcare experience should help hospitalists make efficient and appropriate transition care decisions even during busy times and in an alternate care location. Many hospitalists have also developed local and national expertise in quality improvement (QI) and patient safety (PS) initiatives in acute care settings.22 Hospitalists can lead the efforts to apply QI and PS practices in the ACC. These interventions should focus on the potential to be effective in improving patient care, but also consider issues such as ease of implementation, cost, and potential for harm.23

An influenza pandemic will require all levels of the healthcare system to work together to develop a coordinated approach to patient care. Previously, Kisuule et al.24 described how hospitalists can expand their role to include public health. The hospitalists' leadership in the ACC fits well with their descriptions, and hospitalists should work with local, state, and national public health officials in pandemic flu planning. Their scope of practice and clinical expertise will call on them to play key roles in recognition of the development of a pandemic; help lead the response efforts; provide education to staff, patients, and family members; develop clinical care guidelines and pathways for patients; utilize best practices in the use of antimicrobial therapy; and provide appropriate palliative care. Depending on the severity of the influenza pandemic, mortality could be considerable. Many hospitalists have expertise in palliative care at their hospitals,2527 and this skill set will be invaluable in providing compassionate end‐of‐life care to patients in the ACC.

In a pandemic, the most vulnerable patient populations will likely be disproportionately affected, including the elderly, children, and the immune‐compromised. Hospitalists who care regularly for these diverse groups of patients through the spectrum of illness and recovery will be able to address the variety of clinical and nonclinical issues that arise. If the ACC will provide care for children, hospitalists with training in pediatrics, medicine‐pediatrics, or family medicine should be available.

Additional Considerations

While many unanswered questions remain about how to best utilize the ACC, hospitalists are ideally suited to help lead planning efforts for an ACC for pandemic flu. Other issues that may require additional considerations include: (1) whether to strictly care for patients with influenza symptoms and influenza‐related illnesses or to provide care for all patients at the ACC; (2) what to do when patients refuse transfer to and from the ACC; (3) determining the optimal staffing model for patient care providers and to provide care for a wide range of age groups; (4) how the ACC will be funded; (5) how and where to store stockpiles; (6) developing redundant and coordinated communication plans; and (7) planning for reliable access to information and technology from the ACC.

Conclusions

We have introduced the concept of the ACC for the hospitalist community, and emphasized the benefits of engaging hospitalists to lead the ACC initiative at their own health organizations during pandemic flu. As hospitalists currently serve in many of these roles and possess the skills to provide care and lead these initiatives, we encourage hospitalists to contact their hospital administrators to volunteer to assist with preparation efforts.