Last month, I recommended considering new and innovative roles for the non-physician providers (NPPs) (see The Hospitalist, September 2008, p. 61.). In this column I’ll discuss the economic and patient satisfaction issues related to NPPs in hospitalist practice.

Economics of NPPs

My experience suggests many practices follow a similar line of reasoning when adding NPPs: “We have six physician hospitalist FTEs and need to expand further, yet recruiting additional MDs is difficult. Perhaps we should add one or more NPPs instead. That should work out well economically since NPPs have lower salaries. After all, it seems to work for heart surgeons and orthopedists.”

This kind of reasoning has two flaws. The practice is, in essence, deciding to add NPPs because that process may be easier than finding additional MDs. The practice should instead consider what work needs to be done and decide whether there is a genuinely valuable role for an NPP.

click for large version

Secondly, just because it makes financial sense for some specialties to add NPPs doesn’t mean it does for hospitalist groups. The salary gap between orthopedists or cardiac surgeons and NPPs is huge. The salary difference between a physician hospitalist and an NPP is much more modest.

From a strictly financial analysis, which ignores the many benefits of NPPs that don’t appear on financial statements, an NPP needs to increase the efficiency of an orthopedist or cardiac surgeon by only 10% to 20%. That same NPP would need to increase the efficiency of a hospitalist by more like 50%. (I estimated the percentages to illustrate the point. You should conduct a more-detailed analysis of your own situation to determine accurate percentages.)

I’ve worked with practices that have incorporated NPPs but failed to think carefully about their optimal roles. These staff end up functioning in a mostly clerical role, doing tasks such as faxing discharge information to PCPs, retrieving records from outside facilities, or handling billing functions for the doctors. Those practices should either change the NPPs’ roles or use the money to instead hire clerical help. That would leave money for other purposes, such as creating a more aggressive physician recruiting effort or hiring MDs to moonlight.

Local Factors Govern Economics, Practice

In addition to financial considerations surrounding NPPs, keep in mind licensure. Nurse practitioners are licensed as independent practitioners. Physician assistants are not. The laws governing scope of practice for both of these professionals vary from state to state. Additionally, hospital bylaws govern the boundaries of what NPPs can do without supervision. Two hospitals in the same community might have completely different rules. It is important to understand the state and individual hospital regulations that govern NPPs where you practice.

A PA’s work will nearly always require a physician being physically present during some portion of the patient visit and co-signing chart notes and orders. Nurse practitioners, on the other hand, may be able to perform certain patient-care activities independently. In the latter case, Medicare and other payers typically reimburse at 85% of the rate customarily paid to MDs for the same service.

Patient Perception of NPPs

Patients are increasingly more accepting of NPs and PAs. This seems especially true in settings with clear distinctions between the role of NPP and MD.

For example, my wife is perfectly happy to see a nurse practitioner for routine gynecological care, such as Pap smears. She knows the obstetrician handled the delivery of our children and is available anytime she’s needed.

My neighbor was pleased with his open-heart surgery experience and spoke glowingly of the NP who made rounds daily and assisted during the surgery. He knew the MD surgeon performed most of the operation but left the perioperative care up to the NP.

Patients on a hospitalist service may not see things the same way. My neighbor understood he was hospitalized for the purpose of open-heart surgery done by the MD. He looked at the perioperative care outside of the operation as a secondary issue.

Most medical admissions managed by hospitalists don’t have such clear marquee events in patients’ eyes. So it may be less natural for patients to feel OK about how the hospitalist and NPP divide up care responsibilities. Look at it this way: As hospitalists, we have limited face time with patients, and must make good use of it to establish trust and rapport. When we add an NPP to the care team, we ask patients to develop trust and rapport with two providers instead of just one.

Imagine a patient recently discharged from a hospitalist practice. Her friend asks how it went and which doctor she saw. The patient responds, “I couldn’t figure out who was really in charge of my care. Dr. Nelson’s name was on my armband, but I rarely saw him. Instead, I saw his assistant (the NPP) most of the time.” I suspect that patient will be much less likely to report high levels of satisfaction with her care than one who just saw a hospitalist.

Though I’m concerned that it might be more difficult to keep patients happy when NPPs are part of a hospitalist practice, most practices report this hasn’t been a problem. I’m not suggesting that concern about patient satisfaction means you shouldn’t use NPPs in your hospitalist practices. However, patient satisfaction is an issue to consider when organizing your practice—and an NPP’s role in it—to provide the greatest benefit to your patients. TH

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

Last month, I recommended considering new and innovative roles for the non-physician providers (NPPs) (see The Hospitalist, September 2008, p. 61.). In this column I’ll discuss the economic and patient satisfaction issues related to NPPs in hospitalist practice.

Economics of NPPs

My experience suggests many practices follow a similar line of reasoning when adding NPPs: “We have six physician hospitalist FTEs and need to expand further, yet recruiting additional MDs is difficult. Perhaps we should add one or more NPPs instead. That should work out well economically since NPPs have lower salaries. After all, it seems to work for heart surgeons and orthopedists.”

This kind of reasoning has two flaws. The practice is, in essence, deciding to add NPPs because that process may be easier than finding additional MDs. The practice should instead consider what work needs to be done and decide whether there is a genuinely valuable role for an NPP.

click for large version

Secondly, just because it makes financial sense for some specialties to add NPPs doesn’t mean it does for hospitalist groups. The salary gap between orthopedists or cardiac surgeons and NPPs is huge. The salary difference between a physician hospitalist and an NPP is much more modest.

From a strictly financial analysis, which ignores the many benefits of NPPs that don’t appear on financial statements, an NPP needs to increase the efficiency of an orthopedist or cardiac surgeon by only 10% to 20%. That same NPP would need to increase the efficiency of a hospitalist by more like 50%. (I estimated the percentages to illustrate the point. You should conduct a more-detailed analysis of your own situation to determine accurate percentages.)

I’ve worked with practices that have incorporated NPPs but failed to think carefully about their optimal roles. These staff end up functioning in a mostly clerical role, doing tasks such as faxing discharge information to PCPs, retrieving records from outside facilities, or handling billing functions for the doctors. Those practices should either change the NPPs’ roles or use the money to instead hire clerical help. That would leave money for other purposes, such as creating a more aggressive physician recruiting effort or hiring MDs to moonlight.

Local Factors Govern Economics, Practice

In addition to financial considerations surrounding NPPs, keep in mind licensure. Nurse practitioners are licensed as independent practitioners. Physician assistants are not. The laws governing scope of practice for both of these professionals vary from state to state. Additionally, hospital bylaws govern the boundaries of what NPPs can do without supervision. Two hospitals in the same community might have completely different rules. It is important to understand the state and individual hospital regulations that govern NPPs where you practice.

A PA’s work will nearly always require a physician being physically present during some portion of the patient visit and co-signing chart notes and orders. Nurse practitioners, on the other hand, may be able to perform certain patient-care activities independently. In the latter case, Medicare and other payers typically reimburse at 85% of the rate customarily paid to MDs for the same service.

Patient Perception of NPPs

Patients are increasingly more accepting of NPs and PAs. This seems especially true in settings with clear distinctions between the role of NPP and MD.

For example, my wife is perfectly happy to see a nurse practitioner for routine gynecological care, such as Pap smears. She knows the obstetrician handled the delivery of our children and is available anytime she’s needed.

My neighbor was pleased with his open-heart surgery experience and spoke glowingly of the NP who made rounds daily and assisted during the surgery. He knew the MD surgeon performed most of the operation but left the perioperative care up to the NP.

Patients on a hospitalist service may not see things the same way. My neighbor understood he was hospitalized for the purpose of open-heart surgery done by the MD. He looked at the perioperative care outside of the operation as a secondary issue.

Most medical admissions managed by hospitalists don’t have such clear marquee events in patients’ eyes. So it may be less natural for patients to feel OK about how the hospitalist and NPP divide up care responsibilities. Look at it this way: As hospitalists, we have limited face time with patients, and must make good use of it to establish trust and rapport. When we add an NPP to the care team, we ask patients to develop trust and rapport with two providers instead of just one.

Imagine a patient recently discharged from a hospitalist practice. Her friend asks how it went and which doctor she saw. The patient responds, “I couldn’t figure out who was really in charge of my care. Dr. Nelson’s name was on my armband, but I rarely saw him. Instead, I saw his assistant (the NPP) most of the time.” I suspect that patient will be much less likely to report high levels of satisfaction with her care than one who just saw a hospitalist.

Though I’m concerned that it might be more difficult to keep patients happy when NPPs are part of a hospitalist practice, most practices report this hasn’t been a problem. I’m not suggesting that concern about patient satisfaction means you shouldn’t use NPPs in your hospitalist practices. However, patient satisfaction is an issue to consider when organizing your practice—and an NPP’s role in it—to provide the greatest benefit to your patients. TH

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

Last month, I recommended considering new and innovative roles for the non-physician providers (NPPs) (see The Hospitalist, September 2008, p. 61.). In this column I’ll discuss the economic and patient satisfaction issues related to NPPs in hospitalist practice.

Economics of NPPs

My experience suggests many practices follow a similar line of reasoning when adding NPPs: “We have six physician hospitalist FTEs and need to expand further, yet recruiting additional MDs is difficult. Perhaps we should add one or more NPPs instead. That should work out well economically since NPPs have lower salaries. After all, it seems to work for heart surgeons and orthopedists.”

This kind of reasoning has two flaws. The practice is, in essence, deciding to add NPPs because that process may be easier than finding additional MDs. The practice should instead consider what work needs to be done and decide whether there is a genuinely valuable role for an NPP.

click for large version

Secondly, just because it makes financial sense for some specialties to add NPPs doesn’t mean it does for hospitalist groups. The salary gap between orthopedists or cardiac surgeons and NPPs is huge. The salary difference between a physician hospitalist and an NPP is much more modest.

From a strictly financial analysis, which ignores the many benefits of NPPs that don’t appear on financial statements, an NPP needs to increase the efficiency of an orthopedist or cardiac surgeon by only 10% to 20%. That same NPP would need to increase the efficiency of a hospitalist by more like 50%. (I estimated the percentages to illustrate the point. You should conduct a more-detailed analysis of your own situation to determine accurate percentages.)

I’ve worked with practices that have incorporated NPPs but failed to think carefully about their optimal roles. These staff end up functioning in a mostly clerical role, doing tasks such as faxing discharge information to PCPs, retrieving records from outside facilities, or handling billing functions for the doctors. Those practices should either change the NPPs’ roles or use the money to instead hire clerical help. That would leave money for other purposes, such as creating a more aggressive physician recruiting effort or hiring MDs to moonlight.

Local Factors Govern Economics, Practice

In addition to financial considerations surrounding NPPs, keep in mind licensure. Nurse practitioners are licensed as independent practitioners. Physician assistants are not. The laws governing scope of practice for both of these professionals vary from state to state. Additionally, hospital bylaws govern the boundaries of what NPPs can do without supervision. Two hospitals in the same community might have completely different rules. It is important to understand the state and individual hospital regulations that govern NPPs where you practice.

A PA’s work will nearly always require a physician being physically present during some portion of the patient visit and co-signing chart notes and orders. Nurse practitioners, on the other hand, may be able to perform certain patient-care activities independently. In the latter case, Medicare and other payers typically reimburse at 85% of the rate customarily paid to MDs for the same service.

Patient Perception of NPPs

Patients are increasingly more accepting of NPs and PAs. This seems especially true in settings with clear distinctions between the role of NPP and MD.

For example, my wife is perfectly happy to see a nurse practitioner for routine gynecological care, such as Pap smears. She knows the obstetrician handled the delivery of our children and is available anytime she’s needed.

My neighbor was pleased with his open-heart surgery experience and spoke glowingly of the NP who made rounds daily and assisted during the surgery. He knew the MD surgeon performed most of the operation but left the perioperative care up to the NP.

Patients on a hospitalist service may not see things the same way. My neighbor understood he was hospitalized for the purpose of open-heart surgery done by the MD. He looked at the perioperative care outside of the operation as a secondary issue.

Most medical admissions managed by hospitalists don’t have such clear marquee events in patients’ eyes. So it may be less natural for patients to feel OK about how the hospitalist and NPP divide up care responsibilities. Look at it this way: As hospitalists, we have limited face time with patients, and must make good use of it to establish trust and rapport. When we add an NPP to the care team, we ask patients to develop trust and rapport with two providers instead of just one.

Imagine a patient recently discharged from a hospitalist practice. Her friend asks how it went and which doctor she saw. The patient responds, “I couldn’t figure out who was really in charge of my care. Dr. Nelson’s name was on my armband, but I rarely saw him. Instead, I saw his assistant (the NPP) most of the time.” I suspect that patient will be much less likely to report high levels of satisfaction with her care than one who just saw a hospitalist.

Though I’m concerned that it might be more difficult to keep patients happy when NPPs are part of a hospitalist practice, most practices report this hasn’t been a problem. I’m not suggesting that concern about patient satisfaction means you shouldn’t use NPPs in your hospitalist practices. However, patient satisfaction is an issue to consider when organizing your practice—and an NPP’s role in it—to provide the greatest benefit to your patients. TH

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

How did I get myself into this and, more importantly, how could I get out of it?

I could act like I had inadvertently shown up at the wrong room, “so sorry to barge in, I’ll be on my way now.” Or, I could fake an important page that would require me to attend to an “emergency.” Or, I could just tell the group, “look, as much as I’d love to meet with you all for two straight days, I really have more important things to do with my time.”

Problem was I had been part of the decision to call this meeting in the first place. What was I thinking?

For years I’ve sat on a capacity management committee that met frequently and tackled various projects, such as reducing length of stay, discharging patients earlier in the day, and improving the discharge process—all of which fell under the rubric of efficiently moving patients through the system so we could create space for more patients. This not only makes good business, sense but also is good for our patients who benefit from getting out of the hospital earlier and back to the recuperative comfort of their homes.

The committee had met for hours on end, discussing new methods to tackle old problems. What if…we developed a follow-up clinic that could see patients back shortly after discharge, had a discharge nurse whose only responsibility was to discharge patients, had a lounge that could hold discharged patients waiting for a ride, and so on.

Hour after hour, meeting after meeting, we searched for the elusive Rosetta stone that would unlock the mystery of the timely discharge. We often implemented a large intervention, then met again only to find that our glorious idea came up short. We’d scratch our heads, find someone to pin the blame on for these shortcomings and move on to the next doomed project. Ideas were waning, patience was frayed and morale was at an all-time low.

At our wits end we decided to get thinner, reduce waste, make cars.

Ok, not literally make cars but to use the methodology of the Toyota Production System (TPS) to remove waste, to get lean. Sounded like a good idea until I settled into my hardback chair for the meeting that first morning. I quickly was filled with the ominous dread that only results from mixing consultants, a trough full of meeting-issue scrambled eggs congealing over a Sterno flame, and a roomful of sleepy-eyed participants. Sprinkle in a two-day agenda and we had all the ingredients for a scalding caldron of tedium, bubbling over with boredom.

Then something interesting happened.

I became interested.

Our consultants initiated our journey by discussing the basis of lean Toyota production—the theory of Kaizen, or “change (Kai) for the good (Zen).” The essence of the process included multi-day continuous sessions (yikes) utilizing a cross-functional team consisting of leadership and front-line staff from all hospital disciplines—from doctors to nurses to transport to janitorial staff. It also focused on fast, continuous, experimental change.

Then something interesting happened.

We left the room.

A meeting that didn’t meet? What was this strange Japanese system? Well it turns out that another key tenet of the TPS is “gemba,” meaning “shop floor.” The idea is to spend as much time as possible observing the actual processes, out on the shop floor, not in the board room. So, rather than wallowing away in a meeting discussing what we thought the problem was, we actually went to see what the problem was.

We split into teams and were instructed to observe various parts of the discharge process. Specifically, we were charged with differentiating between processes that add value—things people would pay for—and processes that did not add value—things people wouldn’t pay for.

It is estimated that up to 40% of a nurse’s day is spent “nursing” an inefficient system. Any hospitalist who has spent time holding on the phone, chasing down a CT scan report, or scouring the documentation vortex that mysteriously confiscate charts only to just as mysteriously cough them back up 20 minutes later, knows how much time is wasted in a typical day.

Then something interesting happened.

We realized broken systems, not people, were to blame for most of our problems.

After several hours of observation the teams reconvened and discussed their findings. We discovered that efficiently discharging patients earlier in the day could not be accomplished simply by imploring the physicians to write the orders earlier in the day, an intervention that had been continuously failing since I was an intern 12 years earlier.

In fact, the committee discovered there wasn’t a single unifying solution to this problem. Rather, hundreds of gremlins were dwelling within the recesses of our hospital, together gumming up the system. In just one day of observation, our teams identified 70 different contused processes causing our system to hemorrhage inefficiency.

Then something interesting happened.

It was time to go home; our first day was complete.

The second day of Kaizen centered on “tests of change” that could be implemented immediately and then studied for effect. Each group proffered ideas to solve identified problems and then began implementing these changes, taking time to alter the intervention whenever a better method was uncovered.

For example, an inability to timely locate wheelchairs was slowing the transport of discharged patients out of the hospital. This problem was resolved by designating two wheelchairs for this activity alone; a lack of communication with the patient, family and nursing about the timing of discharge was addressed by placing a whiteboard in the room that physicians would use to catalogue the benchmarks for discharge as well as an anticipated discharge date and time; delays in social work planning were tackled by a five-minute “lightning round” between the doctors and the social workers at 8 a.m. every morning; redundant paperwork required to discharge a patient was consolidated.

On and on it went, every additional step exorcising another discharge gremlin.

Then something interesting happened.

We realized the key to efficiency lie not in changing one or two giant unruly processes rather in effecting multiple very small changes.

No one individual or system was to blame for delayed discharges. Years of patches, work-arounds and waste had accumulated in our system like the layers of paint covering the grime on the walls of an old house. We would need to slowly—but surely—chip away at these layers if we were going to achieve our goals. None of us were convinced these immediate changes would solve our problem, but for the first time we felt empowered to make the kind of changes that would lead us to real systems improvement.

Then something interesting happened.

The second day ended. We’d made a ton of progress and I didn’t even need to invoke that fake emergency page. TH

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

How did I get myself into this and, more importantly, how could I get out of it?

I could act like I had inadvertently shown up at the wrong room, “so sorry to barge in, I’ll be on my way now.” Or, I could fake an important page that would require me to attend to an “emergency.” Or, I could just tell the group, “look, as much as I’d love to meet with you all for two straight days, I really have more important things to do with my time.”

Problem was I had been part of the decision to call this meeting in the first place. What was I thinking?

For years I’ve sat on a capacity management committee that met frequently and tackled various projects, such as reducing length of stay, discharging patients earlier in the day, and improving the discharge process—all of which fell under the rubric of efficiently moving patients through the system so we could create space for more patients. This not only makes good business, sense but also is good for our patients who benefit from getting out of the hospital earlier and back to the recuperative comfort of their homes.

The committee had met for hours on end, discussing new methods to tackle old problems. What if…we developed a follow-up clinic that could see patients back shortly after discharge, had a discharge nurse whose only responsibility was to discharge patients, had a lounge that could hold discharged patients waiting for a ride, and so on.

Hour after hour, meeting after meeting, we searched for the elusive Rosetta stone that would unlock the mystery of the timely discharge. We often implemented a large intervention, then met again only to find that our glorious idea came up short. We’d scratch our heads, find someone to pin the blame on for these shortcomings and move on to the next doomed project. Ideas were waning, patience was frayed and morale was at an all-time low.

At our wits end we decided to get thinner, reduce waste, make cars.

Ok, not literally make cars but to use the methodology of the Toyota Production System (TPS) to remove waste, to get lean. Sounded like a good idea until I settled into my hardback chair for the meeting that first morning. I quickly was filled with the ominous dread that only results from mixing consultants, a trough full of meeting-issue scrambled eggs congealing over a Sterno flame, and a roomful of sleepy-eyed participants. Sprinkle in a two-day agenda and we had all the ingredients for a scalding caldron of tedium, bubbling over with boredom.

Then something interesting happened.

I became interested.

Our consultants initiated our journey by discussing the basis of lean Toyota production—the theory of Kaizen, or “change (Kai) for the good (Zen).” The essence of the process included multi-day continuous sessions (yikes) utilizing a cross-functional team consisting of leadership and front-line staff from all hospital disciplines—from doctors to nurses to transport to janitorial staff. It also focused on fast, continuous, experimental change.

Then something interesting happened.

We left the room.

A meeting that didn’t meet? What was this strange Japanese system? Well it turns out that another key tenet of the TPS is “gemba,” meaning “shop floor.” The idea is to spend as much time as possible observing the actual processes, out on the shop floor, not in the board room. So, rather than wallowing away in a meeting discussing what we thought the problem was, we actually went to see what the problem was.

We split into teams and were instructed to observe various parts of the discharge process. Specifically, we were charged with differentiating between processes that add value—things people would pay for—and processes that did not add value—things people wouldn’t pay for.

It is estimated that up to 40% of a nurse’s day is spent “nursing” an inefficient system. Any hospitalist who has spent time holding on the phone, chasing down a CT scan report, or scouring the documentation vortex that mysteriously confiscate charts only to just as mysteriously cough them back up 20 minutes later, knows how much time is wasted in a typical day.

Then something interesting happened.

We realized broken systems, not people, were to blame for most of our problems.

After several hours of observation the teams reconvened and discussed their findings. We discovered that efficiently discharging patients earlier in the day could not be accomplished simply by imploring the physicians to write the orders earlier in the day, an intervention that had been continuously failing since I was an intern 12 years earlier.

In fact, the committee discovered there wasn’t a single unifying solution to this problem. Rather, hundreds of gremlins were dwelling within the recesses of our hospital, together gumming up the system. In just one day of observation, our teams identified 70 different contused processes causing our system to hemorrhage inefficiency.

Then something interesting happened.

It was time to go home; our first day was complete.

The second day of Kaizen centered on “tests of change” that could be implemented immediately and then studied for effect. Each group proffered ideas to solve identified problems and then began implementing these changes, taking time to alter the intervention whenever a better method was uncovered.

For example, an inability to timely locate wheelchairs was slowing the transport of discharged patients out of the hospital. This problem was resolved by designating two wheelchairs for this activity alone; a lack of communication with the patient, family and nursing about the timing of discharge was addressed by placing a whiteboard in the room that physicians would use to catalogue the benchmarks for discharge as well as an anticipated discharge date and time; delays in social work planning were tackled by a five-minute “lightning round” between the doctors and the social workers at 8 a.m. every morning; redundant paperwork required to discharge a patient was consolidated.

On and on it went, every additional step exorcising another discharge gremlin.

Then something interesting happened.

We realized the key to efficiency lie not in changing one or two giant unruly processes rather in effecting multiple very small changes.

No one individual or system was to blame for delayed discharges. Years of patches, work-arounds and waste had accumulated in our system like the layers of paint covering the grime on the walls of an old house. We would need to slowly—but surely—chip away at these layers if we were going to achieve our goals. None of us were convinced these immediate changes would solve our problem, but for the first time we felt empowered to make the kind of changes that would lead us to real systems improvement.

Then something interesting happened.

The second day ended. We’d made a ton of progress and I didn’t even need to invoke that fake emergency page. TH

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

How did I get myself into this and, more importantly, how could I get out of it?

I could act like I had inadvertently shown up at the wrong room, “so sorry to barge in, I’ll be on my way now.” Or, I could fake an important page that would require me to attend to an “emergency.” Or, I could just tell the group, “look, as much as I’d love to meet with you all for two straight days, I really have more important things to do with my time.”

Problem was I had been part of the decision to call this meeting in the first place. What was I thinking?

For years I’ve sat on a capacity management committee that met frequently and tackled various projects, such as reducing length of stay, discharging patients earlier in the day, and improving the discharge process—all of which fell under the rubric of efficiently moving patients through the system so we could create space for more patients. This not only makes good business, sense but also is good for our patients who benefit from getting out of the hospital earlier and back to the recuperative comfort of their homes.

The committee had met for hours on end, discussing new methods to tackle old problems. What if…we developed a follow-up clinic that could see patients back shortly after discharge, had a discharge nurse whose only responsibility was to discharge patients, had a lounge that could hold discharged patients waiting for a ride, and so on.

Hour after hour, meeting after meeting, we searched for the elusive Rosetta stone that would unlock the mystery of the timely discharge. We often implemented a large intervention, then met again only to find that our glorious idea came up short. We’d scratch our heads, find someone to pin the blame on for these shortcomings and move on to the next doomed project. Ideas were waning, patience was frayed and morale was at an all-time low.

At our wits end we decided to get thinner, reduce waste, make cars.

Ok, not literally make cars but to use the methodology of the Toyota Production System (TPS) to remove waste, to get lean. Sounded like a good idea until I settled into my hardback chair for the meeting that first morning. I quickly was filled with the ominous dread that only results from mixing consultants, a trough full of meeting-issue scrambled eggs congealing over a Sterno flame, and a roomful of sleepy-eyed participants. Sprinkle in a two-day agenda and we had all the ingredients for a scalding caldron of tedium, bubbling over with boredom.

Then something interesting happened.

I became interested.

Our consultants initiated our journey by discussing the basis of lean Toyota production—the theory of Kaizen, or “change (Kai) for the good (Zen).” The essence of the process included multi-day continuous sessions (yikes) utilizing a cross-functional team consisting of leadership and front-line staff from all hospital disciplines—from doctors to nurses to transport to janitorial staff. It also focused on fast, continuous, experimental change.

Then something interesting happened.

We left the room.

A meeting that didn’t meet? What was this strange Japanese system? Well it turns out that another key tenet of the TPS is “gemba,” meaning “shop floor.” The idea is to spend as much time as possible observing the actual processes, out on the shop floor, not in the board room. So, rather than wallowing away in a meeting discussing what we thought the problem was, we actually went to see what the problem was.

We split into teams and were instructed to observe various parts of the discharge process. Specifically, we were charged with differentiating between processes that add value—things people would pay for—and processes that did not add value—things people wouldn’t pay for.

It is estimated that up to 40% of a nurse’s day is spent “nursing” an inefficient system. Any hospitalist who has spent time holding on the phone, chasing down a CT scan report, or scouring the documentation vortex that mysteriously confiscate charts only to just as mysteriously cough them back up 20 minutes later, knows how much time is wasted in a typical day.

Then something interesting happened.

We realized broken systems, not people, were to blame for most of our problems.

After several hours of observation the teams reconvened and discussed their findings. We discovered that efficiently discharging patients earlier in the day could not be accomplished simply by imploring the physicians to write the orders earlier in the day, an intervention that had been continuously failing since I was an intern 12 years earlier.

In fact, the committee discovered there wasn’t a single unifying solution to this problem. Rather, hundreds of gremlins were dwelling within the recesses of our hospital, together gumming up the system. In just one day of observation, our teams identified 70 different contused processes causing our system to hemorrhage inefficiency.

Then something interesting happened.

It was time to go home; our first day was complete.

The second day of Kaizen centered on “tests of change” that could be implemented immediately and then studied for effect. Each group proffered ideas to solve identified problems and then began implementing these changes, taking time to alter the intervention whenever a better method was uncovered.

For example, an inability to timely locate wheelchairs was slowing the transport of discharged patients out of the hospital. This problem was resolved by designating two wheelchairs for this activity alone; a lack of communication with the patient, family and nursing about the timing of discharge was addressed by placing a whiteboard in the room that physicians would use to catalogue the benchmarks for discharge as well as an anticipated discharge date and time; delays in social work planning were tackled by a five-minute “lightning round” between the doctors and the social workers at 8 a.m. every morning; redundant paperwork required to discharge a patient was consolidated.

On and on it went, every additional step exorcising another discharge gremlin.

Then something interesting happened.

We realized the key to efficiency lie not in changing one or two giant unruly processes rather in effecting multiple very small changes.

No one individual or system was to blame for delayed discharges. Years of patches, work-arounds and waste had accumulated in our system like the layers of paint covering the grime on the walls of an old house. We would need to slowly—but surely—chip away at these layers if we were going to achieve our goals. None of us were convinced these immediate changes would solve our problem, but for the first time we felt empowered to make the kind of changes that would lead us to real systems improvement.

Then something interesting happened.

The second day ended. We’d made a ton of progress and I didn’t even need to invoke that fake emergency page. TH

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

As the holiday season fast approaches, our minds increasingly turn to gift giving. This season, I have given extensive thought to the needs of hospitalists, so if you are looking for that perfect gift, look no further.

I know that many of you have gift advice as well, so don’t hesitate to e-mail me your ideas. I will include those in a future column.

Without further delay, here are the Top 10 Gift Ideas for Hospitalists:

1. Improved Vital Sign Alert System: Nothing bothers a hospitalist more than a false alarm or, worse, no alert at all. Hospitalists need better knowledge of vital sign changes, particularly one that takes into effect rate of change.

2. Accurate respiratory rate: This is for the hospitalist who is particularly perturbed about the fact that 90 percent of one’s patients have a respiratory rate of 18. If you haven’t seen the new technology by Hoana Medical, check it out. If this technology pans out, my wish list would be for every hospitalist patient to be monitored and the respiratory rate tied into a sophisticated alert system.

3. An army of physical therapists: This will be hard to gift wrap, but given the fact that deconditioning sets in so fast in hospitalized patients, particularly in elderly patients, this gift is aimed at getting patients moving and preventing the deconditioning from starting.

4. Better nutrition: There is no greater cliché than hospital food. Any improvement would be appreciated. This is not only for the patients, but the physicians, as well. Too many hospitals have a plethora of fast food options, instead of a focus on wholesome choices.

5. Palliative Care: The ideal gift is fairly comprehensive, but it can be separated into several gifts over time. The first and easiest is teaching hospitalists palliative care skills. The second phase is having hospital personnel correctly identify--at admission--patients who need palliative care. The final phase, and the most elusive, is improving physician knowledge of which patients are good candidates for palliation and the correct action steps. This last gift is aimed at the hospitalist who has just admitted a severely demented bed bound patient with AIDs who is still on antiretroviral therapy but no hospice care. Or perhaps the patient with severe CHF admitted for the fifth time this month that is on the correct medications and does weigh himself daily, but also without hospice, or worse, no family understanding that he is dying.

6. More data to understand your practice: This is self explanatory, but many hospitalists are unable to obtain the clinical or financial data they need to understand their practice. Sometimes the data is present, but a better explanation of the data is necessary.

7. EMR that incorporates ALL data: If you can find this gift, please contact me immediately. I am willing to pay top dollar. The Information Technology (IT) department tells me it exists, but I have never actually put my hands on it. This is a single sign-on Electronic Medical Record that has all the clinical data that a hospitalist needs presented in an intuitive interface. And, it’s easily accessible from outside the hospital network.

8. Networked EMR: Link all those EMRs to hospitals across the country.

9. Comprehensive approach to delirium in hospitalized patients: This is for the hospitalist who has just spent the last two hours stopping all delirium provoking medications in a post-surgical elderly patient and talked at length to the family about the fact that this altered mentation is not permanent, not a stroke, and, yes, the anti-psychotic medications are the best medicine.

10. Maintenance of correct attending: This is for the hospitalist whose 15 patients all have a different attending assigned. This gift would ensure that the IT system has my name attached to all my patients at all times. Again, if you receive this gift, please contact me immediately.

In the spirit of being a tad more comprehensive, here are a few gift ideas for hospital medicine in general:

• More primary care physicians. Hospitalists know good primary care prevents hospitalization, but having a physician to refer a patient to after discharge is key.
• Hospital coverage for all U.S. citizens.
• A full understanding of hospital medicine by all hospital administrators.
• Uniform assessment of hospitals, so one can accurately grade/compare hospitals.
• Continued improvement in hospitalist leader skills.
• Continued better pay for hospitalists.
• More mid-level providers in hospital medicine.
• Continued improvement in teamwork amongst hospital personnel.
• Continued improvement in quality and patient safety.

And finally, the best gift of all…more hospitalists!

Happy Holidays! TH

Dr. Cawley is president of SHM.

As the holiday season fast approaches, our minds increasingly turn to gift giving. This season, I have given extensive thought to the needs of hospitalists, so if you are looking for that perfect gift, look no further.

I know that many of you have gift advice as well, so don’t hesitate to e-mail me your ideas. I will include those in a future column.

Without further delay, here are the Top 10 Gift Ideas for Hospitalists:

1. Improved Vital Sign Alert System: Nothing bothers a hospitalist more than a false alarm or, worse, no alert at all. Hospitalists need better knowledge of vital sign changes, particularly one that takes into effect rate of change.

2. Accurate respiratory rate: This is for the hospitalist who is particularly perturbed about the fact that 90 percent of one’s patients have a respiratory rate of 18. If you haven’t seen the new technology by Hoana Medical, check it out. If this technology pans out, my wish list would be for every hospitalist patient to be monitored and the respiratory rate tied into a sophisticated alert system.

3. An army of physical therapists: This will be hard to gift wrap, but given the fact that deconditioning sets in so fast in hospitalized patients, particularly in elderly patients, this gift is aimed at getting patients moving and preventing the deconditioning from starting.

4. Better nutrition: There is no greater cliché than hospital food. Any improvement would be appreciated. This is not only for the patients, but the physicians, as well. Too many hospitals have a plethora of fast food options, instead of a focus on wholesome choices.

5. Palliative Care: The ideal gift is fairly comprehensive, but it can be separated into several gifts over time. The first and easiest is teaching hospitalists palliative care skills. The second phase is having hospital personnel correctly identify--at admission--patients who need palliative care. The final phase, and the most elusive, is improving physician knowledge of which patients are good candidates for palliation and the correct action steps. This last gift is aimed at the hospitalist who has just admitted a severely demented bed bound patient with AIDs who is still on antiretroviral therapy but no hospice care. Or perhaps the patient with severe CHF admitted for the fifth time this month that is on the correct medications and does weigh himself daily, but also without hospice, or worse, no family understanding that he is dying.

6. More data to understand your practice: This is self explanatory, but many hospitalists are unable to obtain the clinical or financial data they need to understand their practice. Sometimes the data is present, but a better explanation of the data is necessary.

7. EMR that incorporates ALL data: If you can find this gift, please contact me immediately. I am willing to pay top dollar. The Information Technology (IT) department tells me it exists, but I have never actually put my hands on it. This is a single sign-on Electronic Medical Record that has all the clinical data that a hospitalist needs presented in an intuitive interface. And, it’s easily accessible from outside the hospital network.

8. Networked EMR: Link all those EMRs to hospitals across the country.

9. Comprehensive approach to delirium in hospitalized patients: This is for the hospitalist who has just spent the last two hours stopping all delirium provoking medications in a post-surgical elderly patient and talked at length to the family about the fact that this altered mentation is not permanent, not a stroke, and, yes, the anti-psychotic medications are the best medicine.

10. Maintenance of correct attending: This is for the hospitalist whose 15 patients all have a different attending assigned. This gift would ensure that the IT system has my name attached to all my patients at all times. Again, if you receive this gift, please contact me immediately.

In the spirit of being a tad more comprehensive, here are a few gift ideas for hospital medicine in general:

• More primary care physicians. Hospitalists know good primary care prevents hospitalization, but having a physician to refer a patient to after discharge is key.
• Hospital coverage for all U.S. citizens.
• A full understanding of hospital medicine by all hospital administrators.
• Uniform assessment of hospitals, so one can accurately grade/compare hospitals.
• Continued improvement in hospitalist leader skills.
• Continued better pay for hospitalists.
• More mid-level providers in hospital medicine.
• Continued improvement in teamwork amongst hospital personnel.
• Continued improvement in quality and patient safety.

And finally, the best gift of all…more hospitalists!

Happy Holidays! TH

Dr. Cawley is president of SHM.

As the holiday season fast approaches, our minds increasingly turn to gift giving. This season, I have given extensive thought to the needs of hospitalists, so if you are looking for that perfect gift, look no further.

I know that many of you have gift advice as well, so don’t hesitate to e-mail me your ideas. I will include those in a future column.

Without further delay, here are the Top 10 Gift Ideas for Hospitalists:

1. Improved Vital Sign Alert System: Nothing bothers a hospitalist more than a false alarm or, worse, no alert at all. Hospitalists need better knowledge of vital sign changes, particularly one that takes into effect rate of change.

2. Accurate respiratory rate: This is for the hospitalist who is particularly perturbed about the fact that 90 percent of one’s patients have a respiratory rate of 18. If you haven’t seen the new technology by Hoana Medical, check it out. If this technology pans out, my wish list would be for every hospitalist patient to be monitored and the respiratory rate tied into a sophisticated alert system.

3. An army of physical therapists: This will be hard to gift wrap, but given the fact that deconditioning sets in so fast in hospitalized patients, particularly in elderly patients, this gift is aimed at getting patients moving and preventing the deconditioning from starting.

4. Better nutrition: There is no greater cliché than hospital food. Any improvement would be appreciated. This is not only for the patients, but the physicians, as well. Too many hospitals have a plethora of fast food options, instead of a focus on wholesome choices.

5. Palliative Care: The ideal gift is fairly comprehensive, but it can be separated into several gifts over time. The first and easiest is teaching hospitalists palliative care skills. The second phase is having hospital personnel correctly identify--at admission--patients who need palliative care. The final phase, and the most elusive, is improving physician knowledge of which patients are good candidates for palliation and the correct action steps. This last gift is aimed at the hospitalist who has just admitted a severely demented bed bound patient with AIDs who is still on antiretroviral therapy but no hospice care. Or perhaps the patient with severe CHF admitted for the fifth time this month that is on the correct medications and does weigh himself daily, but also without hospice, or worse, no family understanding that he is dying.

6. More data to understand your practice: This is self explanatory, but many hospitalists are unable to obtain the clinical or financial data they need to understand their practice. Sometimes the data is present, but a better explanation of the data is necessary.

7. EMR that incorporates ALL data: If you can find this gift, please contact me immediately. I am willing to pay top dollar. The Information Technology (IT) department tells me it exists, but I have never actually put my hands on it. This is a single sign-on Electronic Medical Record that has all the clinical data that a hospitalist needs presented in an intuitive interface. And, it’s easily accessible from outside the hospital network.

8. Networked EMR: Link all those EMRs to hospitals across the country.

9. Comprehensive approach to delirium in hospitalized patients: This is for the hospitalist who has just spent the last two hours stopping all delirium provoking medications in a post-surgical elderly patient and talked at length to the family about the fact that this altered mentation is not permanent, not a stroke, and, yes, the anti-psychotic medications are the best medicine.

10. Maintenance of correct attending: This is for the hospitalist whose 15 patients all have a different attending assigned. This gift would ensure that the IT system has my name attached to all my patients at all times. Again, if you receive this gift, please contact me immediately.

In the spirit of being a tad more comprehensive, here are a few gift ideas for hospital medicine in general:

• More primary care physicians. Hospitalists know good primary care prevents hospitalization, but having a physician to refer a patient to after discharge is key.
• Hospital coverage for all U.S. citizens.
• A full understanding of hospital medicine by all hospital administrators.
• Uniform assessment of hospitals, so one can accurately grade/compare hospitals.
• Continued improvement in hospitalist leader skills.
• Continued better pay for hospitalists.
• More mid-level providers in hospital medicine.
• Continued improvement in teamwork amongst hospital personnel.
• Continued improvement in quality and patient safety.

And finally, the best gift of all…more hospitalists!

Happy Holidays! TH

Dr. Cawley is president of SHM.

The young specialty of hospital medicine has an even younger sibling—pediatric hospital medicine. “Just seven years ago, when I put on my pediatric hospitalist badge, people would ask me, ‘What is that?’” Douglas Carlson, MD, an associate professor at the Washington University School of Medicine in St. Louis, says. “They don’t do that anymore.”

Times certainly are a changing.

With an estimated 1,500 practitioners, pediatric hospitalists make up about 9% of the total hospitalist workforce in the United States. Growth in the pediatric field has been fueled by the need for expertise in treating hospitalized pediatric patients, the increasing complexity of hospitalized cases, mandates to reduce hospital costs and readmission rates, and the curtailment of resident hours.

“The biggest thing is the whole field is blossoming,” says SHM treasurer Jack Percelay, MD.

What Lies Ahead?

Pediatric hospital medicine may be young in years, but the primary focus is on the future. Such was the theme of the Pediatric Hospital Medicine Conference held by SHM, the American Academy of Pediatrics and the Academic Pediatrics Association in July in Denver.

“We are responsible for the future of hospital medicine,” keynote speaker Sanford Melzer, MD, of the University of Washington and Children’s Memorial Hospital and Regional Medical Center of Seattle says in an interview with The Hospitalist. “So what should that future look like?”

Pediatric hospitalists are in an ideal position to improve care, Dr. Melzer said. He outlined six crucial areas for action:

• Set standards of evidence-based patient care in areas not historically addressed, such as feeding tubes and severe reflux;
• Implement safety standards for issues such as medical errors, blood infections and hand-offs to other providers;
• Develop leaders who will work to bring about these changes;
• Stabilize the workforce by better defining pediatric hospital medicine as a career path;
• Create value for hospitals;
• Promote a holistic view of hospital care as a small part of the continuum of care for chronically ill children.

As Dr. Melzer succinctly puts it, “I am here to improve the whole system, not just to give kids meds and get them out.”

“I think our evolution in hospital medicine will follow that of ER physicians very closely,” says Dr. Carlson, who started out as an ER doctor. “Within 30 years, with fellowships and training, their specialty evolved.”

A similar progression is occurring with pediatric hospitalists. Carlson said he remembers when hospitalists would complain that their colleagues in other subspecialties would “treat them like glorified residents.” Not anymore. “We are now seen as equals,” he said.

Pediatric hospitalists bring a lot to the table, Dr. Carlson said, such as broad experience in treating acutely or chronically ill hospitalized children; the ability to coordinate care; knowledge in negotiating hospital routines and protocols; and the capacity to manage family fears.

But to survive and prosper, pediatric hospitalists must create value for their institutions, Dr. Melzer said. And value is exactly what evidence-based medicine can generate, he added. Establishing evidence-based guidelines for the treatment of the 10 most common conditions affecting 80% of patients would be a huge step forward in improving patient care, Melzer explained. It would create value for patients and, ultimately, the hospital.

Lending an Ear

Communication is another key, and can be particularly important in caring for children with life-threatening or terminal illnesses, said another speaker, Margaret Hood, MD, of Orlando Healthcare and Palliative Healthcare. Listening to patients and their families is a critical part of end-of-life care.

“The palliative care offered by pediatric hospitalists becomes a lifeline to patients and their families,” she explained. “Sensitive communications can foster hope, even when the news is bad.”

Dr. Hood told the poignant story of a baby born with a lethal heart problem. “I asked her parents, “What do you want?” she said. “They told me, ‘We want her heart to get better.’”

The doctor—and the family—knew that the baby would never get better. “What else would you like?” she asked. “To hold my little girl,” the mother answered. “I have only held her twice in two months.”

“We can do that.” Dr. Hood quickly replied.

Hope comes in many forms—this time in a mother’s arms, as she finally held her daughter before she died.

Frank Talk on Stress and Career Satisfaction

The 24/7 connection hospitalists have with their institutions is the basis for much of their expertise. Then again, that same 24/7 connection can be a source of extraordinary stress.

“It is variable work, with highs and lows in volume and in unscheduled care,” Dr. Carlson explained. “For hospitalized patients, we always need call coverage. That means odd hours—or being on-call in odd hours. It means night work or evening work. Stress carries risks of unplanned turnover, absenteeism, judgment and action errors, conflicts with colleagues, physical illness and mental fatigue.

“Hospitalists may be burning out even quicker than those in other specialties,” Dr. Carlson added. “Hospitalists love clinical care, they love what they do, but they are working in an environment where they must do more and more. We have to learn how to balance enthusiasm for taking care of patients with the demands of the job.”

One area of concern among hospitals and their pediatric hospitalists is workforce stability. Young women make up the majority of the workforce, and hospitals are “dealing continuously with women who are having families,” Dr. Melzer said.

“I have some people using it as a stepping stone to other specialties,” Dr. Carlson said. “They work as pediatric hospitalists while children are young, for flexibility.”

Both Carlson and Melzer believe a sharper definition of the pediatric hospital medicine career track would make a difference. “How do we get others in the hospital to make this job satisfactory?” Dr. Carlson asked. “Hospitalists enjoy the work, but want to balance it … and make a career out of this.”

Recognition from other medical colleagues is critical to job satisfaction. More and more, pediatric hospitalists are playing key leadership roles. “We are increasingly seen as the experts for hospitalized patients,” Dr. Carlson said. “I believe we can do things better than many specialists and many generalists, because we know how hospitals work—and we are there all the time.”

What’s Next?

Implementing plans for the future of pediatric hospital medicine will require collaboration among the many specialists and groups involved in the care of children. Dr. Melzer suggests convening a “leadership summit” for representatives from all of these associations.

Dr. Percelay agreed.

“It’s exciting,” he says. “The fact that the president of the American Board of Pediatrics came and spoke to our community, along with the presidents of SHM, the American Academy of Pediatrics, and the Academic Pediatric Association, is testimony to the role we are playing in the care of hospitalized children in the United States. We need to take a lot of care to make sure we maintain links between pediatric hospitalists and primary care pediatricians.”

That would be in the best interests of all children. TH

Carol Berczuk’s is a medical journalist based in New York.

The young specialty of hospital medicine has an even younger sibling—pediatric hospital medicine. “Just seven years ago, when I put on my pediatric hospitalist badge, people would ask me, ‘What is that?’” Douglas Carlson, MD, an associate professor at the Washington University School of Medicine in St. Louis, says. “They don’t do that anymore.”

Times certainly are a changing.

With an estimated 1,500 practitioners, pediatric hospitalists make up about 9% of the total hospitalist workforce in the United States. Growth in the pediatric field has been fueled by the need for expertise in treating hospitalized pediatric patients, the increasing complexity of hospitalized cases, mandates to reduce hospital costs and readmission rates, and the curtailment of resident hours.

“The biggest thing is the whole field is blossoming,” says SHM treasurer Jack Percelay, MD.

What Lies Ahead?

Pediatric hospital medicine may be young in years, but the primary focus is on the future. Such was the theme of the Pediatric Hospital Medicine Conference held by SHM, the American Academy of Pediatrics and the Academic Pediatrics Association in July in Denver.

“We are responsible for the future of hospital medicine,” keynote speaker Sanford Melzer, MD, of the University of Washington and Children’s Memorial Hospital and Regional Medical Center of Seattle says in an interview with The Hospitalist. “So what should that future look like?”

Pediatric hospitalists are in an ideal position to improve care, Dr. Melzer said. He outlined six crucial areas for action:

• Set standards of evidence-based patient care in areas not historically addressed, such as feeding tubes and severe reflux;
• Implement safety standards for issues such as medical errors, blood infections and hand-offs to other providers;
• Develop leaders who will work to bring about these changes;
• Stabilize the workforce by better defining pediatric hospital medicine as a career path;
• Create value for hospitals;
• Promote a holistic view of hospital care as a small part of the continuum of care for chronically ill children.

As Dr. Melzer succinctly puts it, “I am here to improve the whole system, not just to give kids meds and get them out.”

“I think our evolution in hospital medicine will follow that of ER physicians very closely,” says Dr. Carlson, who started out as an ER doctor. “Within 30 years, with fellowships and training, their specialty evolved.”

A similar progression is occurring with pediatric hospitalists. Carlson said he remembers when hospitalists would complain that their colleagues in other subspecialties would “treat them like glorified residents.” Not anymore. “We are now seen as equals,” he said.

Pediatric hospitalists bring a lot to the table, Dr. Carlson said, such as broad experience in treating acutely or chronically ill hospitalized children; the ability to coordinate care; knowledge in negotiating hospital routines and protocols; and the capacity to manage family fears.

But to survive and prosper, pediatric hospitalists must create value for their institutions, Dr. Melzer said. And value is exactly what evidence-based medicine can generate, he added. Establishing evidence-based guidelines for the treatment of the 10 most common conditions affecting 80% of patients would be a huge step forward in improving patient care, Melzer explained. It would create value for patients and, ultimately, the hospital.

Lending an Ear

Communication is another key, and can be particularly important in caring for children with life-threatening or terminal illnesses, said another speaker, Margaret Hood, MD, of Orlando Healthcare and Palliative Healthcare. Listening to patients and their families is a critical part of end-of-life care.

“The palliative care offered by pediatric hospitalists becomes a lifeline to patients and their families,” she explained. “Sensitive communications can foster hope, even when the news is bad.”

Dr. Hood told the poignant story of a baby born with a lethal heart problem. “I asked her parents, “What do you want?” she said. “They told me, ‘We want her heart to get better.’”

The doctor—and the family—knew that the baby would never get better. “What else would you like?” she asked. “To hold my little girl,” the mother answered. “I have only held her twice in two months.”

“We can do that.” Dr. Hood quickly replied.

Hope comes in many forms—this time in a mother’s arms, as she finally held her daughter before she died.

Frank Talk on Stress and Career Satisfaction

The 24/7 connection hospitalists have with their institutions is the basis for much of their expertise. Then again, that same 24/7 connection can be a source of extraordinary stress.

“It is variable work, with highs and lows in volume and in unscheduled care,” Dr. Carlson explained. “For hospitalized patients, we always need call coverage. That means odd hours—or being on-call in odd hours. It means night work or evening work. Stress carries risks of unplanned turnover, absenteeism, judgment and action errors, conflicts with colleagues, physical illness and mental fatigue.

“Hospitalists may be burning out even quicker than those in other specialties,” Dr. Carlson added. “Hospitalists love clinical care, they love what they do, but they are working in an environment where they must do more and more. We have to learn how to balance enthusiasm for taking care of patients with the demands of the job.”

One area of concern among hospitals and their pediatric hospitalists is workforce stability. Young women make up the majority of the workforce, and hospitals are “dealing continuously with women who are having families,” Dr. Melzer said.

“I have some people using it as a stepping stone to other specialties,” Dr. Carlson said. “They work as pediatric hospitalists while children are young, for flexibility.”

Both Carlson and Melzer believe a sharper definition of the pediatric hospital medicine career track would make a difference. “How do we get others in the hospital to make this job satisfactory?” Dr. Carlson asked. “Hospitalists enjoy the work, but want to balance it … and make a career out of this.”

Recognition from other medical colleagues is critical to job satisfaction. More and more, pediatric hospitalists are playing key leadership roles. “We are increasingly seen as the experts for hospitalized patients,” Dr. Carlson said. “I believe we can do things better than many specialists and many generalists, because we know how hospitals work—and we are there all the time.”

What’s Next?

Implementing plans for the future of pediatric hospital medicine will require collaboration among the many specialists and groups involved in the care of children. Dr. Melzer suggests convening a “leadership summit” for representatives from all of these associations.

Dr. Percelay agreed.

“It’s exciting,” he says. “The fact that the president of the American Board of Pediatrics came and spoke to our community, along with the presidents of SHM, the American Academy of Pediatrics, and the Academic Pediatric Association, is testimony to the role we are playing in the care of hospitalized children in the United States. We need to take a lot of care to make sure we maintain links between pediatric hospitalists and primary care pediatricians.”

That would be in the best interests of all children. TH

Carol Berczuk’s is a medical journalist based in New York.

The young specialty of hospital medicine has an even younger sibling—pediatric hospital medicine. “Just seven years ago, when I put on my pediatric hospitalist badge, people would ask me, ‘What is that?’” Douglas Carlson, MD, an associate professor at the Washington University School of Medicine in St. Louis, says. “They don’t do that anymore.”

Times certainly are a changing.

With an estimated 1,500 practitioners, pediatric hospitalists make up about 9% of the total hospitalist workforce in the United States. Growth in the pediatric field has been fueled by the need for expertise in treating hospitalized pediatric patients, the increasing complexity of hospitalized cases, mandates to reduce hospital costs and readmission rates, and the curtailment of resident hours.

“The biggest thing is the whole field is blossoming,” says SHM treasurer Jack Percelay, MD.

What Lies Ahead?

Pediatric hospital medicine may be young in years, but the primary focus is on the future. Such was the theme of the Pediatric Hospital Medicine Conference held by SHM, the American Academy of Pediatrics and the Academic Pediatrics Association in July in Denver.

“We are responsible for the future of hospital medicine,” keynote speaker Sanford Melzer, MD, of the University of Washington and Children’s Memorial Hospital and Regional Medical Center of Seattle says in an interview with The Hospitalist. “So what should that future look like?”

Pediatric hospitalists are in an ideal position to improve care, Dr. Melzer said. He outlined six crucial areas for action:

• Set standards of evidence-based patient care in areas not historically addressed, such as feeding tubes and severe reflux;
• Implement safety standards for issues such as medical errors, blood infections and hand-offs to other providers;
• Develop leaders who will work to bring about these changes;
• Stabilize the workforce by better defining pediatric hospital medicine as a career path;
• Create value for hospitals;
• Promote a holistic view of hospital care as a small part of the continuum of care for chronically ill children.

As Dr. Melzer succinctly puts it, “I am here to improve the whole system, not just to give kids meds and get them out.”

“I think our evolution in hospital medicine will follow that of ER physicians very closely,” says Dr. Carlson, who started out as an ER doctor. “Within 30 years, with fellowships and training, their specialty evolved.”

A similar progression is occurring with pediatric hospitalists. Carlson said he remembers when hospitalists would complain that their colleagues in other subspecialties would “treat them like glorified residents.” Not anymore. “We are now seen as equals,” he said.

Pediatric hospitalists bring a lot to the table, Dr. Carlson said, such as broad experience in treating acutely or chronically ill hospitalized children; the ability to coordinate care; knowledge in negotiating hospital routines and protocols; and the capacity to manage family fears.

But to survive and prosper, pediatric hospitalists must create value for their institutions, Dr. Melzer said. And value is exactly what evidence-based medicine can generate, he added. Establishing evidence-based guidelines for the treatment of the 10 most common conditions affecting 80% of patients would be a huge step forward in improving patient care, Melzer explained. It would create value for patients and, ultimately, the hospital.

Lending an Ear

Communication is another key, and can be particularly important in caring for children with life-threatening or terminal illnesses, said another speaker, Margaret Hood, MD, of Orlando Healthcare and Palliative Healthcare. Listening to patients and their families is a critical part of end-of-life care.

“The palliative care offered by pediatric hospitalists becomes a lifeline to patients and their families,” she explained. “Sensitive communications can foster hope, even when the news is bad.”

Dr. Hood told the poignant story of a baby born with a lethal heart problem. “I asked her parents, “What do you want?” she said. “They told me, ‘We want her heart to get better.’”

The doctor—and the family—knew that the baby would never get better. “What else would you like?” she asked. “To hold my little girl,” the mother answered. “I have only held her twice in two months.”

“We can do that.” Dr. Hood quickly replied.

Hope comes in many forms—this time in a mother’s arms, as she finally held her daughter before she died.

Frank Talk on Stress and Career Satisfaction

The 24/7 connection hospitalists have with their institutions is the basis for much of their expertise. Then again, that same 24/7 connection can be a source of extraordinary stress.

“It is variable work, with highs and lows in volume and in unscheduled care,” Dr. Carlson explained. “For hospitalized patients, we always need call coverage. That means odd hours—or being on-call in odd hours. It means night work or evening work. Stress carries risks of unplanned turnover, absenteeism, judgment and action errors, conflicts with colleagues, physical illness and mental fatigue.

“Hospitalists may be burning out even quicker than those in other specialties,” Dr. Carlson added. “Hospitalists love clinical care, they love what they do, but they are working in an environment where they must do more and more. We have to learn how to balance enthusiasm for taking care of patients with the demands of the job.”

One area of concern among hospitals and their pediatric hospitalists is workforce stability. Young women make up the majority of the workforce, and hospitals are “dealing continuously with women who are having families,” Dr. Melzer said.

“I have some people using it as a stepping stone to other specialties,” Dr. Carlson said. “They work as pediatric hospitalists while children are young, for flexibility.”

Both Carlson and Melzer believe a sharper definition of the pediatric hospital medicine career track would make a difference. “How do we get others in the hospital to make this job satisfactory?” Dr. Carlson asked. “Hospitalists enjoy the work, but want to balance it … and make a career out of this.”

Recognition from other medical colleagues is critical to job satisfaction. More and more, pediatric hospitalists are playing key leadership roles. “We are increasingly seen as the experts for hospitalized patients,” Dr. Carlson said. “I believe we can do things better than many specialists and many generalists, because we know how hospitals work—and we are there all the time.”

What’s Next?

Implementing plans for the future of pediatric hospital medicine will require collaboration among the many specialists and groups involved in the care of children. Dr. Melzer suggests convening a “leadership summit” for representatives from all of these associations.

Dr. Percelay agreed.

“It’s exciting,” he says. “The fact that the president of the American Board of Pediatrics came and spoke to our community, along with the presidents of SHM, the American Academy of Pediatrics, and the Academic Pediatric Association, is testimony to the role we are playing in the care of hospitalized children in the United States. We need to take a lot of care to make sure we maintain links between pediatric hospitalists and primary care pediatricians.”

That would be in the best interests of all children. TH

Carol Berczuk’s is a medical journalist based in New York.

Several years ago, a patient at Virtua West Jersey Hospital Marlton, in Marlton, N.J., was diagnosed with metastatic colon cancer with spinal metastases. The patient was septic, bleeding from a spinal wound, and was experiencing kidney failure. Hospitalists recommended stopping treatment and moving the patient to hospice care. The patient’s family refused, and told hospitalists that, according to their Christian faith, suffering was the only true path to heaven. Hospitalists kept the patient as comfortable as possible, but blood pressure problems and hypotension made it difficult for them to administer pain medication.

Hospitalists held numerous meetings with the family and medical and nursing staff to discuss the ethical implications of the situation. Two months later, the patient suffered cardiac arrest and died.

“The medical staff and family were continuously at odds because the patient was suffering so much,” says Marianne Holler, DO, a hospitalist at University of Medicine and Dentistry of New Jersey School of Osteopathic Medicine, who was part of the patient’s medical team. “We were never able to discontinue life support throughout [the patient’s] hospital stay.”

Whether planning a routine procedure or end-of-life care, hospitalists may be called into religious discussions with patients, their families, spiritual advisors, and hospital chaplains. While many hospitalists have received ethics and other professional training to prepare them for these conversations, some say the intersection of religion and medicine remains a challenging and multifaceted aspect of their practice.

A Hospitalist’s Belief

Hospitalists’ brief relationships with patients may influence the degree of knowledge they have about an individual’s religious beliefs, says Scott Enderby, DO, a hospitalist at Alta Bates Summit Medical Center in Berkeley, Calif. Over the years, primary care physicians may become less involved with a patient’s acute medical needs as they use hospitalist services to manage their inpatients, Dr. Enderby says. This means hospitalists must discuss patients’ wishes regarding code status and resuscitation, end-of-life care, and other necessary treatments.

When discussing religion and treatment, hospitalists must put aside their personal beliefs, and this may not always be easy, says Dr. Thomas McIlraith, MD, medical director of Hospital Medicine at Mercy Medical Group in Sacramento, Calif. Dr. McIlraith recalls a Jehovah’s Witness patient who cited religious beliefs when refusing a blood transfusion following a massive post-partum hemorrhage. The patient was severely anemic, and her hemoglobin levels plunged dangerously to 2 gm/dL. Leaders from the patient’s church asked Dr. McIlraith to try hemoglobin substitutes, but he was unable to do so because these substitutes still were experimental and associated with significant complications, he says.

Dr. McIlraith had to act fast. He instructed the obstetrician on the case to stop drawing hemoglobin levels; the patient needed every drop of blood she had to carry oxygen. He administered erythropoietin and iron to stimulate red blood cell production. He also put the patient on high flow oxygen to help saturate the plasma. The patient survived without a blood transfusion or significant complications.

“I didn’t think [the patient] was going to make it,” says Dr. McIlraith. “This was a very difficult situation because I knew they would have benefited from a blood transfusion. But, I presented them with their options and respected their wishes.”

Religious Diversity

Religious diversity can be another challenging aspect of patient care. In its 2008 U.S. Religious Landscapes Survey, the Pew Forum on Religion and Public Life interviewed 35,000 Americans age 18 and older and found “religious affiliation in the U.S. is both very diverse and extremely fluid.” The survey also found “people who are unaffiliated with any particular religion (16.1%) also exhibit remarkable internal diversity.”

Asking questions is the key to understanding a patient’s religious and spiritual needs, says the Rev. Peter Yuichi Clark, PhD, chaplain administrator at Alta Bates Summit Medical Center in Berkeley, Calif., who works closely with medical teams to assess and respond to these needs.

“I don’t assume I know what a patient’s religious needs are—even if I know what religion they profess to be,” Clark says. “Some patients may be very devout but do not practice certain aspects of their religion, while others follow a religion in name only but look for religious support during a time of crisis.”

Manish Patel, MD, a hospitalist and assistant professor with the division of General Internal Medicine at University of Medicine and Dentistry of New Jersey-Robert Wood Johnson Medical School, says it is impossible to predict an individual’s religious beliefs and how that may affect their hospital stay—even when the physician practices the same religion as the patient. For example, Dr. Patel knows that some, but not all, Hindus observe a strict vegetarian diet and that Vitamin B12 deficiencies are more prevalent in vegetarian populations. However, diet may not be the cause of this deficiency if the patient is not a vegetarian. Rather than assume, it’s important to ask Hindu patients if they observe a vegetarian diet, Dr. Patel says.

Some hospitalists find it difficult to engage patients in conversations about religion. In a study published in the June 2007 edition of the Journal of Palliative Medicine, researchers found physicians’ knowledge of factors relating to end-of-life care, which included patients’ religious and spiritual concerns and whether they affect decisions regarding end-of-life care, is poor.1

Hospitalists don’t have much time to get to know the person, so it’s even more important for them to have conversations about religion and end-of-life-care, says the study’s lead author Susan DesHarnais, PhD, of Pennsylvania State University’s Hershey Department of Public Health Sciences, Milton S. Hershey Medical Center College of Medicine. As important as these conversations are, Dr. DesHarnais learned hospitalists rarely have them.

When asked why she thinks these conversations rarely occur, Dr. DesHarnais said the research did not directly address that question, but she suspects the physicians don’t have a lot of time. Also, end-of-life decision-making is difficult, and some people are not comfortable talking about it, she says.

“Another factor may be that hospitalists are used to using technology for medical intervention more than they are used to working with people when not much more can be done,” she says.

Dr. Holler, who worked as a social worker before attending medical school, agrees that many physicians are uncomfortable with end-of-life decisions.

“Many physicians are 25 to 30 years old during their training,” says Dr. Holler. “They have been in school for many years. Some are discovering their own spiritual identity at the same time they are dealing, or learning to deal, with patients and families and where they are spiritually or religiously. Many haven’t dealt with these issues in their own personal lives yet.”

While Dr. Holler says she believes most doctors are caring and compassionate, end-of-life and religious discussions use different skill sets than those that preserve and extend life. “Often times we are not taught when enough is enough and how to convey that to patients and families,” says Dr. Holler. “Many doctors are afraid that they are conveying that they are giving up or that it isn’t worth it in the long run. So, many physicians find it easier to ‘keep going.’ ”

The Medical Community’s Response

The medical community is responding to shifting cultural and religious demographics, and more doctors are paying attention to religious diversity, Clark says. But a 2003 Joint Commision study of 60 public and private hospitals across the country, “Hospitals, Language and Culture: A Snapshot of the Nation,” found that hospitals still have work to do in this area.

“We found that hospitals are collecting data on patients’ religion, but it’s just not clear how they use it to improve services,” says Amy Wilson-Stronks, project director for health disparities with the Joint Commission and principal investigator of the study.

The current Joint Commission standards require hospitals to respect patients’ spiritual needs, beliefs, and values. Spiritual care issues first appeared in the 1969 accreditation manual and were adopted into standards in 1992, Wilson-Stronks says.

Accomodating Patients

Awareness and communication can benefit patients, hospitalists, and medical staff as a whole. For example, Alta Bates Summit’s intensive care unit staff in Berkely, Calif., turned to Chaplaincy Services about Muslim patients’ requests to continue their daily prayers, which include thorough washing of their hands, forearms, and other parts of their bodies (even when intravenous lines are attached). Chaplaincy Services reached out to an Islamic network group for advice and learned patients could rub a stone across their bodies to wash themselves. Chaplaincy Services now makes these stones available for staff and patients, Clark says.

Medical staff also works with Chaplaincy Services to accommodate Muslim patients’ wishes to face in the direction of Mecca during prayer, which can require maneuvering beds and other equipment, he says.

Some patients and their families may not understand how their religious tradition addresses code status, resuscitation, and when it is appropriate to withhold treatment, says Richard Rohr, MD, vice president of medical affairs at Cortland Regional Medical Center in Cortland, N.Y. While working as a hospitalist, Dr. Rohr suggested moving a terminal patient to palliative care and seeking a do not resuscitate (DNR) order. The patient’s family refused, and told Dr. Rohr they were Catholic and a DNR would violate their religious beliefs.

According to Dr. Rohr, DNR status and palliative care are described in the code of ethics adopted by the Catholic Health Association, and this type of care is generally provided at Catholic hospitals.

“I gently told them that this was within their religion, but they said no to palliative care and the DNR,” Dr. Rohr says. “The patient eventually died but it was much more difficult for them. They were subjected to active treatment that they couldn’t really benefit from.”

Families often seek the advice of spiritual advisors when making difficult decisions about code status and DNR orders. Barbara Egan, MD, a hospitalist at Memorial Sloan-Kettering Cancer Center in New York City, recalls treating an Orthodox Jewish patient who was suffering from end-stage disease. Death was imminent, and hospitalists recommended palliative care. The patient’s family members balked at the recommendation and insisted hospitalists “do everything possible” to treat their loved one. Soon after, the family’s rabbi arrived to counsel the family. After visiting the patient and speaking to medical staff about the prognosis, the rabbi urged the family not to pursue further treatment or artificial resuscitation. The patient was moved to a palliative care unit and passed away within a few days.

“The family’s rabbi told them exactly what I had: that there were no useful medical interventions for the patient,” Dr. Egan says. “But they really needed to hear it from him before they could come to an agreement on a DNR.”

Physicians’ reactions to religion at the bedside have evolved the past 25 years, says Kenneth Patrick, MD, ICU director at Chestnut Hill Hospital in Philadelphia. Physicians were more paternalistic then, and believed they knew what was best for their patients—and their families—regardless of their patient’s religious beliefs.

While serving as a fellow at Memorial Sloan-Kettering Cancer Center, Dr. Patrick worked with a terminally ill Buddhist patient in the intensive care unit. When death was imminent, the ICU director allowed Buddhist monks to light candles and pray in the room during the hours leading up to the patient’s death. At the time, this was not something that was normally done in a hospital, Dr. Patrick says. While the ritual may have kept medical staff from checking vital signs as often as they would have normally, he says this did not affect the patient’s treatment.

“I believe it is incumbent on the hospitalist to adjust his or her beliefs to be more accepting of our patients’ values,” Dr. Patrick says. “I can agree to any request I find to be reasonable and in the patient’s best interest, even if it is different than what I believe.” TH

Gina Gotsill is a journalist based in California.

Reference

1. DesHarnais S, Carter RE, Hennessy W, Kurent JE, Carter C. Lack of concordance between physicians and patient: Reports on end-of-life care discussions. J Pall Med. 2007 June;10(3):728-740.

Several years ago, a patient at Virtua West Jersey Hospital Marlton, in Marlton, N.J., was diagnosed with metastatic colon cancer with spinal metastases. The patient was septic, bleeding from a spinal wound, and was experiencing kidney failure. Hospitalists recommended stopping treatment and moving the patient to hospice care. The patient’s family refused, and told hospitalists that, according to their Christian faith, suffering was the only true path to heaven. Hospitalists kept the patient as comfortable as possible, but blood pressure problems and hypotension made it difficult for them to administer pain medication.

Hospitalists held numerous meetings with the family and medical and nursing staff to discuss the ethical implications of the situation. Two months later, the patient suffered cardiac arrest and died.

“The medical staff and family were continuously at odds because the patient was suffering so much,” says Marianne Holler, DO, a hospitalist at University of Medicine and Dentistry of New Jersey School of Osteopathic Medicine, who was part of the patient’s medical team. “We were never able to discontinue life support throughout [the patient’s] hospital stay.”

Whether planning a routine procedure or end-of-life care, hospitalists may be called into religious discussions with patients, their families, spiritual advisors, and hospital chaplains. While many hospitalists have received ethics and other professional training to prepare them for these conversations, some say the intersection of religion and medicine remains a challenging and multifaceted aspect of their practice.

A Hospitalist’s Belief

Hospitalists’ brief relationships with patients may influence the degree of knowledge they have about an individual’s religious beliefs, says Scott Enderby, DO, a hospitalist at Alta Bates Summit Medical Center in Berkeley, Calif. Over the years, primary care physicians may become less involved with a patient’s acute medical needs as they use hospitalist services to manage their inpatients, Dr. Enderby says. This means hospitalists must discuss patients’ wishes regarding code status and resuscitation, end-of-life care, and other necessary treatments.

When discussing religion and treatment, hospitalists must put aside their personal beliefs, and this may not always be easy, says Dr. Thomas McIlraith, MD, medical director of Hospital Medicine at Mercy Medical Group in Sacramento, Calif. Dr. McIlraith recalls a Jehovah’s Witness patient who cited religious beliefs when refusing a blood transfusion following a massive post-partum hemorrhage. The patient was severely anemic, and her hemoglobin levels plunged dangerously to 2 gm/dL. Leaders from the patient’s church asked Dr. McIlraith to try hemoglobin substitutes, but he was unable to do so because these substitutes still were experimental and associated with significant complications, he says.

Dr. McIlraith had to act fast. He instructed the obstetrician on the case to stop drawing hemoglobin levels; the patient needed every drop of blood she had to carry oxygen. He administered erythropoietin and iron to stimulate red blood cell production. He also put the patient on high flow oxygen to help saturate the plasma. The patient survived without a blood transfusion or significant complications.

“I didn’t think [the patient] was going to make it,” says Dr. McIlraith. “This was a very difficult situation because I knew they would have benefited from a blood transfusion. But, I presented them with their options and respected their wishes.”

Religious Diversity

Religious diversity can be another challenging aspect of patient care. In its 2008 U.S. Religious Landscapes Survey, the Pew Forum on Religion and Public Life interviewed 35,000 Americans age 18 and older and found “religious affiliation in the U.S. is both very diverse and extremely fluid.” The survey also found “people who are unaffiliated with any particular religion (16.1%) also exhibit remarkable internal diversity.”

Asking questions is the key to understanding a patient’s religious and spiritual needs, says the Rev. Peter Yuichi Clark, PhD, chaplain administrator at Alta Bates Summit Medical Center in Berkeley, Calif., who works closely with medical teams to assess and respond to these needs.

“I don’t assume I know what a patient’s religious needs are—even if I know what religion they profess to be,” Clark says. “Some patients may be very devout but do not practice certain aspects of their religion, while others follow a religion in name only but look for religious support during a time of crisis.”

Manish Patel, MD, a hospitalist and assistant professor with the division of General Internal Medicine at University of Medicine and Dentistry of New Jersey-Robert Wood Johnson Medical School, says it is impossible to predict an individual’s religious beliefs and how that may affect their hospital stay—even when the physician practices the same religion as the patient. For example, Dr. Patel knows that some, but not all, Hindus observe a strict vegetarian diet and that Vitamin B12 deficiencies are more prevalent in vegetarian populations. However, diet may not be the cause of this deficiency if the patient is not a vegetarian. Rather than assume, it’s important to ask Hindu patients if they observe a vegetarian diet, Dr. Patel says.

Some hospitalists find it difficult to engage patients in conversations about religion. In a study published in the June 2007 edition of the Journal of Palliative Medicine, researchers found physicians’ knowledge of factors relating to end-of-life care, which included patients’ religious and spiritual concerns and whether they affect decisions regarding end-of-life care, is poor.1

Hospitalists don’t have much time to get to know the person, so it’s even more important for them to have conversations about religion and end-of-life-care, says the study’s lead author Susan DesHarnais, PhD, of Pennsylvania State University’s Hershey Department of Public Health Sciences, Milton S. Hershey Medical Center College of Medicine. As important as these conversations are, Dr. DesHarnais learned hospitalists rarely have them.

When asked why she thinks these conversations rarely occur, Dr. DesHarnais said the research did not directly address that question, but she suspects the physicians don’t have a lot of time. Also, end-of-life decision-making is difficult, and some people are not comfortable talking about it, she says.

“Another factor may be that hospitalists are used to using technology for medical intervention more than they are used to working with people when not much more can be done,” she says.

Dr. Holler, who worked as a social worker before attending medical school, agrees that many physicians are uncomfortable with end-of-life decisions.

“Many physicians are 25 to 30 years old during their training,” says Dr. Holler. “They have been in school for many years. Some are discovering their own spiritual identity at the same time they are dealing, or learning to deal, with patients and families and where they are spiritually or religiously. Many haven’t dealt with these issues in their own personal lives yet.”

While Dr. Holler says she believes most doctors are caring and compassionate, end-of-life and religious discussions use different skill sets than those that preserve and extend life. “Often times we are not taught when enough is enough and how to convey that to patients and families,” says Dr. Holler. “Many doctors are afraid that they are conveying that they are giving up or that it isn’t worth it in the long run. So, many physicians find it easier to ‘keep going.’ ”

The Medical Community’s Response

The medical community is responding to shifting cultural and religious demographics, and more doctors are paying attention to religious diversity, Clark says. But a 2003 Joint Commision study of 60 public and private hospitals across the country, “Hospitals, Language and Culture: A Snapshot of the Nation,” found that hospitals still have work to do in this area.

“We found that hospitals are collecting data on patients’ religion, but it’s just not clear how they use it to improve services,” says Amy Wilson-Stronks, project director for health disparities with the Joint Commission and principal investigator of the study.

The current Joint Commission standards require hospitals to respect patients’ spiritual needs, beliefs, and values. Spiritual care issues first appeared in the 1969 accreditation manual and were adopted into standards in 1992, Wilson-Stronks says.

Accomodating Patients

Awareness and communication can benefit patients, hospitalists, and medical staff as a whole. For example, Alta Bates Summit’s intensive care unit staff in Berkely, Calif., turned to Chaplaincy Services about Muslim patients’ requests to continue their daily prayers, which include thorough washing of their hands, forearms, and other parts of their bodies (even when intravenous lines are attached). Chaplaincy Services reached out to an Islamic network group for advice and learned patients could rub a stone across their bodies to wash themselves. Chaplaincy Services now makes these stones available for staff and patients, Clark says.

Medical staff also works with Chaplaincy Services to accommodate Muslim patients’ wishes to face in the direction of Mecca during prayer, which can require maneuvering beds and other equipment, he says.

Some patients and their families may not understand how their religious tradition addresses code status, resuscitation, and when it is appropriate to withhold treatment, says Richard Rohr, MD, vice president of medical affairs at Cortland Regional Medical Center in Cortland, N.Y. While working as a hospitalist, Dr. Rohr suggested moving a terminal patient to palliative care and seeking a do not resuscitate (DNR) order. The patient’s family refused, and told Dr. Rohr they were Catholic and a DNR would violate their religious beliefs.

According to Dr. Rohr, DNR status and palliative care are described in the code of ethics adopted by the Catholic Health Association, and this type of care is generally provided at Catholic hospitals.

“I gently told them that this was within their religion, but they said no to palliative care and the DNR,” Dr. Rohr says. “The patient eventually died but it was much more difficult for them. They were subjected to active treatment that they couldn’t really benefit from.”

Families often seek the advice of spiritual advisors when making difficult decisions about code status and DNR orders. Barbara Egan, MD, a hospitalist at Memorial Sloan-Kettering Cancer Center in New York City, recalls treating an Orthodox Jewish patient who was suffering from end-stage disease. Death was imminent, and hospitalists recommended palliative care. The patient’s family members balked at the recommendation and insisted hospitalists “do everything possible” to treat their loved one. Soon after, the family’s rabbi arrived to counsel the family. After visiting the patient and speaking to medical staff about the prognosis, the rabbi urged the family not to pursue further treatment or artificial resuscitation. The patient was moved to a palliative care unit and passed away within a few days.

“The family’s rabbi told them exactly what I had: that there were no useful medical interventions for the patient,” Dr. Egan says. “But they really needed to hear it from him before they could come to an agreement on a DNR.”

Physicians’ reactions to religion at the bedside have evolved the past 25 years, says Kenneth Patrick, MD, ICU director at Chestnut Hill Hospital in Philadelphia. Physicians were more paternalistic then, and believed they knew what was best for their patients—and their families—regardless of their patient’s religious beliefs.

While serving as a fellow at Memorial Sloan-Kettering Cancer Center, Dr. Patrick worked with a terminally ill Buddhist patient in the intensive care unit. When death was imminent, the ICU director allowed Buddhist monks to light candles and pray in the room during the hours leading up to the patient’s death. At the time, this was not something that was normally done in a hospital, Dr. Patrick says. While the ritual may have kept medical staff from checking vital signs as often as they would have normally, he says this did not affect the patient’s treatment.

“I believe it is incumbent on the hospitalist to adjust his or her beliefs to be more accepting of our patients’ values,” Dr. Patrick says. “I can agree to any request I find to be reasonable and in the patient’s best interest, even if it is different than what I believe.” TH

Gina Gotsill is a journalist based in California.

Reference

1. DesHarnais S, Carter RE, Hennessy W, Kurent JE, Carter C. Lack of concordance between physicians and patient: Reports on end-of-life care discussions. J Pall Med. 2007 June;10(3):728-740.

Several years ago, a patient at Virtua West Jersey Hospital Marlton, in Marlton, N.J., was diagnosed with metastatic colon cancer with spinal metastases. The patient was septic, bleeding from a spinal wound, and was experiencing kidney failure. Hospitalists recommended stopping treatment and moving the patient to hospice care. The patient’s family refused, and told hospitalists that, according to their Christian faith, suffering was the only true path to heaven. Hospitalists kept the patient as comfortable as possible, but blood pressure problems and hypotension made it difficult for them to administer pain medication.

Hospitalists held numerous meetings with the family and medical and nursing staff to discuss the ethical implications of the situation. Two months later, the patient suffered cardiac arrest and died.

“The medical staff and family were continuously at odds because the patient was suffering so much,” says Marianne Holler, DO, a hospitalist at University of Medicine and Dentistry of New Jersey School of Osteopathic Medicine, who was part of the patient’s medical team. “We were never able to discontinue life support throughout [the patient’s] hospital stay.”

Whether planning a routine procedure or end-of-life care, hospitalists may be called into religious discussions with patients, their families, spiritual advisors, and hospital chaplains. While many hospitalists have received ethics and other professional training to prepare them for these conversations, some say the intersection of religion and medicine remains a challenging and multifaceted aspect of their practice.

A Hospitalist’s Belief

Hospitalists’ brief relationships with patients may influence the degree of knowledge they have about an individual’s religious beliefs, says Scott Enderby, DO, a hospitalist at Alta Bates Summit Medical Center in Berkeley, Calif. Over the years, primary care physicians may become less involved with a patient’s acute medical needs as they use hospitalist services to manage their inpatients, Dr. Enderby says. This means hospitalists must discuss patients’ wishes regarding code status and resuscitation, end-of-life care, and other necessary treatments.

When discussing religion and treatment, hospitalists must put aside their personal beliefs, and this may not always be easy, says Dr. Thomas McIlraith, MD, medical director of Hospital Medicine at Mercy Medical Group in Sacramento, Calif. Dr. McIlraith recalls a Jehovah’s Witness patient who cited religious beliefs when refusing a blood transfusion following a massive post-partum hemorrhage. The patient was severely anemic, and her hemoglobin levels plunged dangerously to 2 gm/dL. Leaders from the patient’s church asked Dr. McIlraith to try hemoglobin substitutes, but he was unable to do so because these substitutes still were experimental and associated with significant complications, he says.

Dr. McIlraith had to act fast. He instructed the obstetrician on the case to stop drawing hemoglobin levels; the patient needed every drop of blood she had to carry oxygen. He administered erythropoietin and iron to stimulate red blood cell production. He also put the patient on high flow oxygen to help saturate the plasma. The patient survived without a blood transfusion or significant complications.

“I didn’t think [the patient] was going to make it,” says Dr. McIlraith. “This was a very difficult situation because I knew they would have benefited from a blood transfusion. But, I presented them with their options and respected their wishes.”

Religious Diversity

Religious diversity can be another challenging aspect of patient care. In its 2008 U.S. Religious Landscapes Survey, the Pew Forum on Religion and Public Life interviewed 35,000 Americans age 18 and older and found “religious affiliation in the U.S. is both very diverse and extremely fluid.” The survey also found “people who are unaffiliated with any particular religion (16.1%) also exhibit remarkable internal diversity.”

Asking questions is the key to understanding a patient’s religious and spiritual needs, says the Rev. Peter Yuichi Clark, PhD, chaplain administrator at Alta Bates Summit Medical Center in Berkeley, Calif., who works closely with medical teams to assess and respond to these needs.

“I don’t assume I know what a patient’s religious needs are—even if I know what religion they profess to be,” Clark says. “Some patients may be very devout but do not practice certain aspects of their religion, while others follow a religion in name only but look for religious support during a time of crisis.”

Manish Patel, MD, a hospitalist and assistant professor with the division of General Internal Medicine at University of Medicine and Dentistry of New Jersey-Robert Wood Johnson Medical School, says it is impossible to predict an individual’s religious beliefs and how that may affect their hospital stay—even when the physician practices the same religion as the patient. For example, Dr. Patel knows that some, but not all, Hindus observe a strict vegetarian diet and that Vitamin B12 deficiencies are more prevalent in vegetarian populations. However, diet may not be the cause of this deficiency if the patient is not a vegetarian. Rather than assume, it’s important to ask Hindu patients if they observe a vegetarian diet, Dr. Patel says.

Some hospitalists find it difficult to engage patients in conversations about religion. In a study published in the June 2007 edition of the Journal of Palliative Medicine, researchers found physicians’ knowledge of factors relating to end-of-life care, which included patients’ religious and spiritual concerns and whether they affect decisions regarding end-of-life care, is poor.1

Hospitalists don’t have much time to get to know the person, so it’s even more important for them to have conversations about religion and end-of-life-care, says the study’s lead author Susan DesHarnais, PhD, of Pennsylvania State University’s Hershey Department of Public Health Sciences, Milton S. Hershey Medical Center College of Medicine. As important as these conversations are, Dr. DesHarnais learned hospitalists rarely have them.

When asked why she thinks these conversations rarely occur, Dr. DesHarnais said the research did not directly address that question, but she suspects the physicians don’t have a lot of time. Also, end-of-life decision-making is difficult, and some people are not comfortable talking about it, she says.

“Another factor may be that hospitalists are used to using technology for medical intervention more than they are used to working with people when not much more can be done,” she says.

Dr. Holler, who worked as a social worker before attending medical school, agrees that many physicians are uncomfortable with end-of-life decisions.

“Many physicians are 25 to 30 years old during their training,” says Dr. Holler. “They have been in school for many years. Some are discovering their own spiritual identity at the same time they are dealing, or learning to deal, with patients and families and where they are spiritually or religiously. Many haven’t dealt with these issues in their own personal lives yet.”

While Dr. Holler says she believes most doctors are caring and compassionate, end-of-life and religious discussions use different skill sets than those that preserve and extend life. “Often times we are not taught when enough is enough and how to convey that to patients and families,” says Dr. Holler. “Many doctors are afraid that they are conveying that they are giving up or that it isn’t worth it in the long run. So, many physicians find it easier to ‘keep going.’ ”

The Medical Community’s Response

The medical community is responding to shifting cultural and religious demographics, and more doctors are paying attention to religious diversity, Clark says. But a 2003 Joint Commision study of 60 public and private hospitals across the country, “Hospitals, Language and Culture: A Snapshot of the Nation,” found that hospitals still have work to do in this area.

“We found that hospitals are collecting data on patients’ religion, but it’s just not clear how they use it to improve services,” says Amy Wilson-Stronks, project director for health disparities with the Joint Commission and principal investigator of the study.

The current Joint Commission standards require hospitals to respect patients’ spiritual needs, beliefs, and values. Spiritual care issues first appeared in the 1969 accreditation manual and were adopted into standards in 1992, Wilson-Stronks says.

Accomodating Patients

Awareness and communication can benefit patients, hospitalists, and medical staff as a whole. For example, Alta Bates Summit’s intensive care unit staff in Berkely, Calif., turned to Chaplaincy Services about Muslim patients’ requests to continue their daily prayers, which include thorough washing of their hands, forearms, and other parts of their bodies (even when intravenous lines are attached). Chaplaincy Services reached out to an Islamic network group for advice and learned patients could rub a stone across their bodies to wash themselves. Chaplaincy Services now makes these stones available for staff and patients, Clark says.

Medical staff also works with Chaplaincy Services to accommodate Muslim patients’ wishes to face in the direction of Mecca during prayer, which can require maneuvering beds and other equipment, he says.

Some patients and their families may not understand how their religious tradition addresses code status, resuscitation, and when it is appropriate to withhold treatment, says Richard Rohr, MD, vice president of medical affairs at Cortland Regional Medical Center in Cortland, N.Y. While working as a hospitalist, Dr. Rohr suggested moving a terminal patient to palliative care and seeking a do not resuscitate (DNR) order. The patient’s family refused, and told Dr. Rohr they were Catholic and a DNR would violate their religious beliefs.

According to Dr. Rohr, DNR status and palliative care are described in the code of ethics adopted by the Catholic Health Association, and this type of care is generally provided at Catholic hospitals.

“I gently told them that this was within their religion, but they said no to palliative care and the DNR,” Dr. Rohr says. “The patient eventually died but it was much more difficult for them. They were subjected to active treatment that they couldn’t really benefit from.”

Families often seek the advice of spiritual advisors when making difficult decisions about code status and DNR orders. Barbara Egan, MD, a hospitalist at Memorial Sloan-Kettering Cancer Center in New York City, recalls treating an Orthodox Jewish patient who was suffering from end-stage disease. Death was imminent, and hospitalists recommended palliative care. The patient’s family members balked at the recommendation and insisted hospitalists “do everything possible” to treat their loved one. Soon after, the family’s rabbi arrived to counsel the family. After visiting the patient and speaking to medical staff about the prognosis, the rabbi urged the family not to pursue further treatment or artificial resuscitation. The patient was moved to a palliative care unit and passed away within a few days.

“The family’s rabbi told them exactly what I had: that there were no useful medical interventions for the patient,” Dr. Egan says. “But they really needed to hear it from him before they could come to an agreement on a DNR.”

Physicians’ reactions to religion at the bedside have evolved the past 25 years, says Kenneth Patrick, MD, ICU director at Chestnut Hill Hospital in Philadelphia. Physicians were more paternalistic then, and believed they knew what was best for their patients—and their families—regardless of their patient’s religious beliefs.

While serving as a fellow at Memorial Sloan-Kettering Cancer Center, Dr. Patrick worked with a terminally ill Buddhist patient in the intensive care unit. When death was imminent, the ICU director allowed Buddhist monks to light candles and pray in the room during the hours leading up to the patient’s death. At the time, this was not something that was normally done in a hospital, Dr. Patrick says. While the ritual may have kept medical staff from checking vital signs as often as they would have normally, he says this did not affect the patient’s treatment.

“I believe it is incumbent on the hospitalist to adjust his or her beliefs to be more accepting of our patients’ values,” Dr. Patrick says. “I can agree to any request I find to be reasonable and in the patient’s best interest, even if it is different than what I believe.” TH

Gina Gotsill is a journalist based in California.

Reference

1. DesHarnais S, Carter RE, Hennessy W, Kurent JE, Carter C. Lack of concordance between physicians and patient: Reports on end-of-life care discussions. J Pall Med. 2007 June;10(3):728-740.

Hospitals, insurers, and regulators today direct unparalleled time and resources toward battling medical errors. According to research from Saul Weiner, MD, a teacher and hospitalist at the University of Illinois, Chicago, one type of error is being ignored.

“I found that contextual errors are as least as common and probably even more serious in inpatient care,” Dr. Weiner says. Contextual errors occur when physicians neglect to recognize the crucial role a patient’s life plays in care planning, he says. “I would argue that there are contextual issues in virtually every admission,” he adds.

Dr. Weiner and his team are trying to prove the importance of systematizing how physicians learn to contextualize care. For their research, published in the September 2007 issue of Medical Decision Making, the doctors trained actors to present scenarios in which contextual information was essential to planning appropriate care. They then tested 54 internal medicine residents to see how many would provide contextually appropriate care. More than half made serious errors.1

Why Now?

From the time Dr. Weiner started precepting residents in 1997, he noticed many were quick to fit patients into categories where they could apply evidence-based approaches to care. “But I sometimes sensed that there was something not so straightforward about a particular patient’s situation, some unexplained issue for why the patient wasn’t taking his asthma meds properly, or was coming in today of all days,” he says. When he and the residents would re-question such patients, “key factors often arose that made everything change about the way we wanted to manage them.”

For him, the seminal case occurred in 2002 when a patient who came to the preoperative testing clinic for bariatric surgery. She qualified for surgery, although because of history of adhesions, the surgery was going to be open rather than laparoscopic. When she said she was looking forward to getting the surgery so she could better care for her son, a red flag went up for Dr. Weiner.

“Patients don’t typically offer such reflections,” he says. Further probing revealed that she had a son in his 20s with a fatal disease, she was the sole caregiver, and her husband was an alcoholic. “She really hadn’t processed the fact that she would not be able to do anything for 40 days,” Dr. Weiner says. “Suddenly, when she got that, she wound up canceling surgery.”

The importance of learning a patietn’s contextual factors depends on the setting and the availability of resources, such as case managers, social workers, and outpatient chronic disease teams. Even with those resources, the onus still is on the hospitalist to determine an effective plan of care using context, he says.

How Well Do Hospitalists Spot Red Flags?

Tuning up the radar to prevent these errors comes down to providers asking one question and listening to one answer: What is the best thing I can do for this patient at this time? Watch for red flags, statements patients make or actions they take that may signal something lying beneath the surface that could make a huge difference in outcomes, Dr. Weiner says.

Spotting red flags isn’t always easy for hospitalists, who don’t see the same patients on a regular basis, says William Stinnette, MD, hospitalist with Kaiser Permanente in San Rafael, Calif. “Unless patients are a part of that ‘revolving door,’ with frequent visits to the hospital, we have to work up most of our patients with limited background knowledge,” he says.

Dr. Stinnette, who has worked in hospital medicine groups in both small and large facilities, believes the ability to ferret out contextual factors depends on the setting and teh availability of resources, such as case managers, social workers, and outpatient chornic disease teams. Even with those resources, the onus is still on the hospitalist to determine an effective plan of care using context, he says.

Dr. Weiner agrees. “Clinical decision-making,” he writes in the Medical Decision Making article, “requires two distinct skills: the ability to classify patients’ conditions into diagnostic and management categories that permit the application of research evidence, and the ability to individualize (contextualize) care for patients whose circumstances and needs require variation from a standardized approach.”1

Though most hospitalists recognize the importance of doing this, according to Dr. Weiner, they lack a systematic and coherent way to do so.2

Standardized Training

Physicians are well trained in assessing biomedical information, but not in listening for contextual red flags. “When you need to know what’s unique about a particular patient that might be relevant to the case, you don’t really know what you’re searching for,” Dr. Weiner says. “You just need clarity, and that is theory-building or inductive reasoning, a very different skill.”

Since July, with support from the National Board of Medical Examiners, the University of Illinois, Chicago, team has been testing a contextual-care curriculum for fourth-year medical students to complete during their inpatient medical sub-internships. In the randomized controlled trial, half of the trainees receive the intervention, half do not. Those getting trained learn that when they intuitively feel there is more to a patient’s story, they should return to the patient to find out why.

They also learn to conduct a contextual history by asking simple, straightforward questions, keeping in mind potential areas of context, including the patient’s emotional state and cultural beliefs (see sidebar, “Cases of Context”). Through this process, the residents learn to identify ways to avoid contextual errors in their patients’ care.

At the end of the month-long curriculum, all trainees are tested in the patient laboratory. “The simulated patients are trained to present with complex histories,” Dr. Weiner says. If residents don’t probe properly, the patients don’t reveal the context. Both groups—those who’ve had the intervention and those who have not—interview the patients, and the study is tracking which physicians get the cases ‘correct.’ ”

The Cost of Errors

For a next phase of research, the university has enrolled about 100 physicians from multiple centers in the Chicago/Milwaukee area to participate in visits by undercover actors simulating real patients. The cases require uncovering contextual information to avoid making errors when planning their care.

After each visit, the team downloads and scores the physician’s note, identifying both unnecessary tests and missed opportunities. Using Medicare reimbursement data, the team assigns a dollar amount to these errors that would have occurred had the patients been real. Dr. Weiner predicts publicizing the financial costs will bring more attention to the problem.

Access to Care Issues

Actually, physicians should talk to their patients about the cost of their care, says David O. Meltzer, MD, PhD, associate professor and chief of the Section of Hospital Medicine at the University of Chicago Medical Center. In research published in the Journal of the American Medical Association in 2003, Dr. Meltzer and colleagues found patient costs may be associated with medication nonadherence and considerable economic burden.3

“You have to ask a patient the type of questions that will be most revealing, including the broader questions, such as ‘Are there any challenges in your life to getting the care that we’ve discussed after you leave the hospital?’ ” Dr. Stinnette, of Kaiser, says.

In their study, Dr. Meltzer and colleagues also showed that although physicians and patients agree it is important to talk about money issues, it doesn’t commonly happen.3

“In a public hospital where there are greater numbers of uninsured patients, I expect it is much more a frequent topic of conversation,” Dr. Meltzer says. “My suspicion is that the people at greatest risk are uninsured patients who are hospitalized in settings where most patients are insured, and physicians are not attuned to bringing up this issue.”

Although a great deal of literature now deals with physician-patient communication, the techniques seem too scripted to Dr. Weiner. “When you engage with the patient simply as one person who is concerned about another,” he says, “you much more naturally find out what you could do that might help them.”

References

1. Weiner SJ, Schwartz A, Yudkowsky R, et al. Evaluating physician performance at individualizing care: A pilot study tracking contextual errors in medical decision-making. Med Decis Making 2007;27(6):726-34.
2. Weiner SJ. Contextualizing medical decisions to individualize care: Lessons from the qualitative sciences. J Gen Intern Med 2004;19(3):281-5.
3. Alexander GC, Casalino LP, Meltzer DO. Patient-physician communication about out-of-pocket costs. JAMA 2003;290(7):953-958.

Hospitals, insurers, and regulators today direct unparalleled time and resources toward battling medical errors. According to research from Saul Weiner, MD, a teacher and hospitalist at the University of Illinois, Chicago, one type of error is being ignored.

“I found that contextual errors are as least as common and probably even more serious in inpatient care,” Dr. Weiner says. Contextual errors occur when physicians neglect to recognize the crucial role a patient’s life plays in care planning, he says. “I would argue that there are contextual issues in virtually every admission,” he adds.

Dr. Weiner and his team are trying to prove the importance of systematizing how physicians learn to contextualize care. For their research, published in the September 2007 issue of Medical Decision Making, the doctors trained actors to present scenarios in which contextual information was essential to planning appropriate care. They then tested 54 internal medicine residents to see how many would provide contextually appropriate care. More than half made serious errors.1

Why Now?

From the time Dr. Weiner started precepting residents in 1997, he noticed many were quick to fit patients into categories where they could apply evidence-based approaches to care. “But I sometimes sensed that there was something not so straightforward about a particular patient’s situation, some unexplained issue for why the patient wasn’t taking his asthma meds properly, or was coming in today of all days,” he says. When he and the residents would re-question such patients, “key factors often arose that made everything change about the way we wanted to manage them.”

For him, the seminal case occurred in 2002 when a patient who came to the preoperative testing clinic for bariatric surgery. She qualified for surgery, although because of history of adhesions, the surgery was going to be open rather than laparoscopic. When she said she was looking forward to getting the surgery so she could better care for her son, a red flag went up for Dr. Weiner.

“Patients don’t typically offer such reflections,” he says. Further probing revealed that she had a son in his 20s with a fatal disease, she was the sole caregiver, and her husband was an alcoholic. “She really hadn’t processed the fact that she would not be able to do anything for 40 days,” Dr. Weiner says. “Suddenly, when she got that, she wound up canceling surgery.”

The importance of learning a patietn’s contextual factors depends on the setting and the availability of resources, such as case managers, social workers, and outpatient chronic disease teams. Even with those resources, the onus still is on the hospitalist to determine an effective plan of care using context, he says.

How Well Do Hospitalists Spot Red Flags?

Tuning up the radar to prevent these errors comes down to providers asking one question and listening to one answer: What is the best thing I can do for this patient at this time? Watch for red flags, statements patients make or actions they take that may signal something lying beneath the surface that could make a huge difference in outcomes, Dr. Weiner says.

Spotting red flags isn’t always easy for hospitalists, who don’t see the same patients on a regular basis, says William Stinnette, MD, hospitalist with Kaiser Permanente in San Rafael, Calif. “Unless patients are a part of that ‘revolving door,’ with frequent visits to the hospital, we have to work up most of our patients with limited background knowledge,” he says.

Dr. Stinnette, who has worked in hospital medicine groups in both small and large facilities, believes the ability to ferret out contextual factors depends on the setting and teh availability of resources, such as case managers, social workers, and outpatient chornic disease teams. Even with those resources, the onus is still on the hospitalist to determine an effective plan of care using context, he says.

Dr. Weiner agrees. “Clinical decision-making,” he writes in the Medical Decision Making article, “requires two distinct skills: the ability to classify patients’ conditions into diagnostic and management categories that permit the application of research evidence, and the ability to individualize (contextualize) care for patients whose circumstances and needs require variation from a standardized approach.”1

Though most hospitalists recognize the importance of doing this, according to Dr. Weiner, they lack a systematic and coherent way to do so.2

Standardized Training

Physicians are well trained in assessing biomedical information, but not in listening for contextual red flags. “When you need to know what’s unique about a particular patient that might be relevant to the case, you don’t really know what you’re searching for,” Dr. Weiner says. “You just need clarity, and that is theory-building or inductive reasoning, a very different skill.”

Since July, with support from the National Board of Medical Examiners, the University of Illinois, Chicago, team has been testing a contextual-care curriculum for fourth-year medical students to complete during their inpatient medical sub-internships. In the randomized controlled trial, half of the trainees receive the intervention, half do not. Those getting trained learn that when they intuitively feel there is more to a patient’s story, they should return to the patient to find out why.

They also learn to conduct a contextual history by asking simple, straightforward questions, keeping in mind potential areas of context, including the patient’s emotional state and cultural beliefs (see sidebar, “Cases of Context”). Through this process, the residents learn to identify ways to avoid contextual errors in their patients’ care.

At the end of the month-long curriculum, all trainees are tested in the patient laboratory. “The simulated patients are trained to present with complex histories,” Dr. Weiner says. If residents don’t probe properly, the patients don’t reveal the context. Both groups—those who’ve had the intervention and those who have not—interview the patients, and the study is tracking which physicians get the cases ‘correct.’ ”

The Cost of Errors

For a next phase of research, the university has enrolled about 100 physicians from multiple centers in the Chicago/Milwaukee area to participate in visits by undercover actors simulating real patients. The cases require uncovering contextual information to avoid making errors when planning their care.

After each visit, the team downloads and scores the physician’s note, identifying both unnecessary tests and missed opportunities. Using Medicare reimbursement data, the team assigns a dollar amount to these errors that would have occurred had the patients been real. Dr. Weiner predicts publicizing the financial costs will bring more attention to the problem.

Access to Care Issues

Actually, physicians should talk to their patients about the cost of their care, says David O. Meltzer, MD, PhD, associate professor and chief of the Section of Hospital Medicine at the University of Chicago Medical Center. In research published in the Journal of the American Medical Association in 2003, Dr. Meltzer and colleagues found patient costs may be associated with medication nonadherence and considerable economic burden.3

“You have to ask a patient the type of questions that will be most revealing, including the broader questions, such as ‘Are there any challenges in your life to getting the care that we’ve discussed after you leave the hospital?’ ” Dr. Stinnette, of Kaiser, says.

In their study, Dr. Meltzer and colleagues also showed that although physicians and patients agree it is important to talk about money issues, it doesn’t commonly happen.3

“In a public hospital where there are greater numbers of uninsured patients, I expect it is much more a frequent topic of conversation,” Dr. Meltzer says. “My suspicion is that the people at greatest risk are uninsured patients who are hospitalized in settings where most patients are insured, and physicians are not attuned to bringing up this issue.”

Although a great deal of literature now deals with physician-patient communication, the techniques seem too scripted to Dr. Weiner. “When you engage with the patient simply as one person who is concerned about another,” he says, “you much more naturally find out what you could do that might help them.”

References

1. Weiner SJ, Schwartz A, Yudkowsky R, et al. Evaluating physician performance at individualizing care: A pilot study tracking contextual errors in medical decision-making. Med Decis Making 2007;27(6):726-34.
2. Weiner SJ. Contextualizing medical decisions to individualize care: Lessons from the qualitative sciences. J Gen Intern Med 2004;19(3):281-5.
3. Alexander GC, Casalino LP, Meltzer DO. Patient-physician communication about out-of-pocket costs. JAMA 2003;290(7):953-958.

Hospitals, insurers, and regulators today direct unparalleled time and resources toward battling medical errors. According to research from Saul Weiner, MD, a teacher and hospitalist at the University of Illinois, Chicago, one type of error is being ignored.

“I found that contextual errors are as least as common and probably even more serious in inpatient care,” Dr. Weiner says. Contextual errors occur when physicians neglect to recognize the crucial role a patient’s life plays in care planning, he says. “I would argue that there are contextual issues in virtually every admission,” he adds.

Dr. Weiner and his team are trying to prove the importance of systematizing how physicians learn to contextualize care. For their research, published in the September 2007 issue of Medical Decision Making, the doctors trained actors to present scenarios in which contextual information was essential to planning appropriate care. They then tested 54 internal medicine residents to see how many would provide contextually appropriate care. More than half made serious errors.1

Why Now?

From the time Dr. Weiner started precepting residents in 1997, he noticed many were quick to fit patients into categories where they could apply evidence-based approaches to care. “But I sometimes sensed that there was something not so straightforward about a particular patient’s situation, some unexplained issue for why the patient wasn’t taking his asthma meds properly, or was coming in today of all days,” he says. When he and the residents would re-question such patients, “key factors often arose that made everything change about the way we wanted to manage them.”

For him, the seminal case occurred in 2002 when a patient who came to the preoperative testing clinic for bariatric surgery. She qualified for surgery, although because of history of adhesions, the surgery was going to be open rather than laparoscopic. When she said she was looking forward to getting the surgery so she could better care for her son, a red flag went up for Dr. Weiner.

“Patients don’t typically offer such reflections,” he says. Further probing revealed that she had a son in his 20s with a fatal disease, she was the sole caregiver, and her husband was an alcoholic. “She really hadn’t processed the fact that she would not be able to do anything for 40 days,” Dr. Weiner says. “Suddenly, when she got that, she wound up canceling surgery.”

The importance of learning a patietn’s contextual factors depends on the setting and the availability of resources, such as case managers, social workers, and outpatient chronic disease teams. Even with those resources, the onus still is on the hospitalist to determine an effective plan of care using context, he says.

How Well Do Hospitalists Spot Red Flags?

Tuning up the radar to prevent these errors comes down to providers asking one question and listening to one answer: What is the best thing I can do for this patient at this time? Watch for red flags, statements patients make or actions they take that may signal something lying beneath the surface that could make a huge difference in outcomes, Dr. Weiner says.

Spotting red flags isn’t always easy for hospitalists, who don’t see the same patients on a regular basis, says William Stinnette, MD, hospitalist with Kaiser Permanente in San Rafael, Calif. “Unless patients are a part of that ‘revolving door,’ with frequent visits to the hospital, we have to work up most of our patients with limited background knowledge,” he says.

Dr. Stinnette, who has worked in hospital medicine groups in both small and large facilities, believes the ability to ferret out contextual factors depends on the setting and teh availability of resources, such as case managers, social workers, and outpatient chornic disease teams. Even with those resources, the onus is still on the hospitalist to determine an effective plan of care using context, he says.

Dr. Weiner agrees. “Clinical decision-making,” he writes in the Medical Decision Making article, “requires two distinct skills: the ability to classify patients’ conditions into diagnostic and management categories that permit the application of research evidence, and the ability to individualize (contextualize) care for patients whose circumstances and needs require variation from a standardized approach.”1

Though most hospitalists recognize the importance of doing this, according to Dr. Weiner, they lack a systematic and coherent way to do so.2

Standardized Training

Physicians are well trained in assessing biomedical information, but not in listening for contextual red flags. “When you need to know what’s unique about a particular patient that might be relevant to the case, you don’t really know what you’re searching for,” Dr. Weiner says. “You just need clarity, and that is theory-building or inductive reasoning, a very different skill.”

Since July, with support from the National Board of Medical Examiners, the University of Illinois, Chicago, team has been testing a contextual-care curriculum for fourth-year medical students to complete during their inpatient medical sub-internships. In the randomized controlled trial, half of the trainees receive the intervention, half do not. Those getting trained learn that when they intuitively feel there is more to a patient’s story, they should return to the patient to find out why.

They also learn to conduct a contextual history by asking simple, straightforward questions, keeping in mind potential areas of context, including the patient’s emotional state and cultural beliefs (see sidebar, “Cases of Context”). Through this process, the residents learn to identify ways to avoid contextual errors in their patients’ care.

At the end of the month-long curriculum, all trainees are tested in the patient laboratory. “The simulated patients are trained to present with complex histories,” Dr. Weiner says. If residents don’t probe properly, the patients don’t reveal the context. Both groups—those who’ve had the intervention and those who have not—interview the patients, and the study is tracking which physicians get the cases ‘correct.’ ”

The Cost of Errors

For a next phase of research, the university has enrolled about 100 physicians from multiple centers in the Chicago/Milwaukee area to participate in visits by undercover actors simulating real patients. The cases require uncovering contextual information to avoid making errors when planning their care.

After each visit, the team downloads and scores the physician’s note, identifying both unnecessary tests and missed opportunities. Using Medicare reimbursement data, the team assigns a dollar amount to these errors that would have occurred had the patients been real. Dr. Weiner predicts publicizing the financial costs will bring more attention to the problem.

Access to Care Issues

Actually, physicians should talk to their patients about the cost of their care, says David O. Meltzer, MD, PhD, associate professor and chief of the Section of Hospital Medicine at the University of Chicago Medical Center. In research published in the Journal of the American Medical Association in 2003, Dr. Meltzer and colleagues found patient costs may be associated with medication nonadherence and considerable economic burden.3

“You have to ask a patient the type of questions that will be most revealing, including the broader questions, such as ‘Are there any challenges in your life to getting the care that we’ve discussed after you leave the hospital?’ ” Dr. Stinnette, of Kaiser, says.

In their study, Dr. Meltzer and colleagues also showed that although physicians and patients agree it is important to talk about money issues, it doesn’t commonly happen.3

“In a public hospital where there are greater numbers of uninsured patients, I expect it is much more a frequent topic of conversation,” Dr. Meltzer says. “My suspicion is that the people at greatest risk are uninsured patients who are hospitalized in settings where most patients are insured, and physicians are not attuned to bringing up this issue.”

Although a great deal of literature now deals with physician-patient communication, the techniques seem too scripted to Dr. Weiner. “When you engage with the patient simply as one person who is concerned about another,” he says, “you much more naturally find out what you could do that might help them.”

References

1. Weiner SJ, Schwartz A, Yudkowsky R, et al. Evaluating physician performance at individualizing care: A pilot study tracking contextual errors in medical decision-making. Med Decis Making 2007;27(6):726-34.
2. Weiner SJ. Contextualizing medical decisions to individualize care: Lessons from the qualitative sciences. J Gen Intern Med 2004;19(3):281-5.
3. Alexander GC, Casalino LP, Meltzer DO. Patient-physician communication about out-of-pocket costs. JAMA 2003;290(7):953-958.

Case

A 72-year-old retired nurse with known nonischemic dilated cardiomyopathy with an ejection fraction of approximately 20% and status-post cardiac resynchronization therapy presents to the emergency department with dyspnea with minimal activity, three-pillow orthopnea, and paroxysmal nocturnal dyspnea.

She had been hospitalized twice during the past 60 days for similar symptoms. Her medications included losartan (20 mg po q daily), carvedilol (3.125 mg twice daily), spironolactone (25 mg daily), digoxin (0.125 mg daily), and furosemide (80 mg twice daily). Vital signs are notable for a blood pressure of 90/50 mmHg and an irregular pulse of 90 beats per minute. Physical examination is notable for marked jugular venous distension, lungs clear to auscultation bilaterally, biventricular heaves, a markedly displaced left ventricular point of maximal impulse, and a prominent S3 gallop.

Despite treatment with intravenous furosemide and temporary withdrawal of carvedilol, the patient remains symptomatic with persistent jugular venous distension.

Should she be given a vasoactive agent?

Overview

Acute heart failure syndrome (AHFS), defined as a gradual or rapid change in heart failure signs and symptoms, is the most common cause of hospitalization in the United States1. It is associated with an average in-hospital mortality of 4% to 5%, a 30-day mortality of 7% to11%, and a one-year mortality of 33%2.

In patients with previously established myocardial dysfunction, AHFS commonly reflects exacerbation of symptoms after a period of stability. The clinical presentation and severity of AHFS may range from mild volume overload to life-threatening cardiogenic shock and multi-organ failure unresponsive to pharmacologic therapy.2

Initial management of AHFS depends on definition of the patient’s hemodynamic profile. To guide initial therapy, classify patients into one of four hemodynamic profiles during a brief bedside assessment that relies on evaluation of filling pressures (wet or dry) and adequacy of perfusion (hot or cold) (see figure 1).3

Treating volume overload or elevated filling pressures generally begins with diuretics. Diuretics have been shown to provide symptomatic relief, though they have not yet been proven safe.4 Initial treatment can include a loop diuretic at a dose higher than the patient’s chronic dose, with intravenous dosing offering greater bio-absorption and rapidity in onset of action.5 If perfusion is inadequate, escalate therapy beyond diuretics to include vasoactive agents.

Review of the Data

The use of vasoactive medications is largely based on anecdotal experiences and physiologic assumptions rather than on adequately powered prospective randomized controlled trials.6 Vasoactive therapy includes vasodilator and inotropic support and is generally limited for use in patients with advanced disease not responding to standard medical treatment and diuresis. The physiologic premise rests in the expected improvement in ventricular filling pressures and cardiac output with reduction in afterload and/or preload. Vasodilators counteract vascular constriction, reducing both preload and afterload. Positive inotropic agents amplify cardiac output by increasing the strength of myocardial contraction.

Vasodilators

The Heart Failure Society of America (HFSA) 2006 Comprehensive Heart Failure Practice Guidelines state, “In the absence of symptomatic hypotension, intravenous vasodilators (nitroglycerin, nitroprusside, or nesiritide) may be considered as an addition to diuretic therapy for rapid improvement of congestive symptoms.”7 The clinical utility of nesiritide remains in question with clinical and hemodynamic improvement demonstrated in three randomized trials 8-10; but tempered against meta-analyses 11-12 of selected trials, demonstrating a non-significant trend toward increased kidney dysfunction and death within 30 days (35/485 [7.2%] vs. 15/377 [4.0%] patients; risk ratio from meta-analyses, 1.74; 95% confidence interval, 0.97-3.12; p=0.059). In a randomized trial of 489 in-patients with dyspnea at rest from AHFS, treatment with three hours of intravenous nesiritide resulted in a significant improvement in dyspnea compared with placebo (p=0.03). Similar improvement was observed with intravenous nitroglycerin and did not differ statistically from that observed with nesiritide.8 Nitroprusside, an attractive option among those with hypertension and cardiogenic pulmonary edema, is limited by the need for invasive hemodynamic monitoring and potential for either cyanide toxicity or worsening myocardial ischemia.

click for large version

Inotropes

Again, there is little evidence from adequately powered randomized controlled trials guiding the use of inotropes. Their use is generally limited to the following indications (see figure 2): (1) Short-term treatment for AHFS that is unresponsive to adequate doses of diuretics and especially when associated with systemic hypotension, (2) Bridge to recovery (as following myocarditis) or to definitive treatment (as with transplant), or (3) For palliation when symptomatic relief is the agreed upon goal.13 The HFSA 2006 guideline states: “Intravenous inotropes may be considered to relieve symptoms and improve end-organ function in patients with advanced HF characterized by left ventricle dilation, reduced left ventricular ejection fraction, and diminished peripheral perfusion or end-organ dysfunction, particularly if these patients have marginal systolic blood pressure, have symptomatic hypotension despite adequate filling pressures, or are unresponsive to, or intolerant of, intravenous vasodilators.”7

Dobutamine and milrinone are the most commonly used IV inotropes for the treatment of AHFS and increase contractility by increasing intracellular levels of cyclic adenylate monophosphate (cAMP). Dobutamine is a catechlamine agonist that increases cAMP production through stimulation of adenylate cyclase. Milrinone selectively inhibits phosphodiesterase III, which catalyzes the breakdown of cAMP.

Despite their frequent use when traditional treatments have failed, the data supporting the use of dobutamine and milrinone is limited. The largest registry of patients with AHFS to date associated excess mortality with intravenous inotrope use compared to nitroglycerin or nesiritide.14 In a study population of 255 patients randomized to receive either intravenous nesiritide or intravenous dobutamine, Burger et al.15 demonstrated that dobutamine significantly increased the mean number of ventricular tachycardia events per 24 hours (p=0.001), suggesting increased arrhythmogenicity associated with inotrope use. Nonetheless, in a randomized trial of 15 patients admitted with AHFS, functional class improved in six of eight dobutamine-treated patients, but in only two of seven patients treated with placebo, suggesting clinical improvement as a consequence of inotropic stimulation.16 Unverferth et al. demonstrated a similar sustained functional improvement up to 10 weeks following a 72-hour infusion of intravenous dobutamine. 17

The Outcomes of a Prospective Trial of Intravenous Milrinone for Exacerbations of Chronic Heart Failure trial (OPTIME-CHF), randomized 951 patients with AHFS to receive either intravenous milrinone or placebo within 48 hours of hospitalization.18 Compared to placebo, milrinone was associated with a significant increase in sustained hypotension requiring intervention (10.7% vs. 3.2%; p<.001) and new atrial arrhythmias (4.6% vs. 1.5%; p=0.004), along with a non-significant trend toward increased mortality (3.8% vs. 2.3%; p=0.19). However, as measured by a visual analog scale, milrinone-treated patients reported feeling better than those treated with placebo at 30 days post-randomization (p=0.02).

Although there are not randomized data comparing the efficacy of milrinone and dobutamine in AHFS, a retrospective analysis of 329 patients compared the hemodynamic and clinical effects of these two inotropes.19 Milrinone consistently was associated with a more favorable hemodynamic response, including lower systemic vascular resistance (p=0.01); lower pulmonary artery wedge pressure (p<0.001); larger percentage increase in cardiac index (p=0.03); and larger percentage decrease in pulmonary vascular resistance (p=0.0001). In-hospital mortality (dobutamine 7.8% vs. milrinone 10%) was not significantly different.

Conclusion

Clearly, vasoactive and inotropic agents are available when AHFS is refractory to traditional diuresis and may offer short-term symptomatic relief, palliation in the context of end-of-life care, or bridge to recovery or more definitive treatment. Unfortunately, sufficient and robust evidence that supports the safety and efficacy of such agents is lacking and their use is largely guided by historical practices, clinical experience, and anticipation of theoretic physiologic changes. While adequately powered prospective randomized data emerge, newer agents such as vasopressin receptor antagonists, cardiac myosin activators, calcium sensitizers, and adenosine-receptor antagonists will offer additional pharmacologic options.20 When continued pharmacologic support becomes ineffective, device therapy is available to aid in the treatment of AHFS and includes ultrafiltration to reduce filling pressures and intra-aortic balloon pump counterpulsation or left ventricular assist device placement for pharmacologically resistant cardiogenic shock.21

Back to the Case

Despite maximal medical therapy for her chronic heart failure and biventricular pacing, the patient continued to have markedly limited functional status and repeated hospitalizations for AHFS. Given her advanced age and poor nutritional status, she was not a candidate for cardiac transplantation or placement of a left ventricular assist device. To allow for palliative tailored therapy, right heart catheterization was performed. Right heart catheterization revealed elevated filling pressures, as follows: right atrium, 20 mmHg; pulmonary artery, 63/34 mmHg (mean 47 mmHg); and pulmonary capillary wedge, 29 mmHg. Her mixed venous oxygen saturation was only 41% with a calculated cardiac output of 2.9 liters per minute and cardiac index of 2 liters per minute per meter squared.

As she expressed symptomatic relief as her goal, she was started on intravenous milrinone at 0.2 micrograms per kilogram per minute. This was done with the understanding her symptoms would likely would improve, at the expense of worsening longevity and prognosis. With uptitration of her intravenous milrinone and a continuous infusion of furosemide, she demonstrated the following filling pressures within 24 hours: right atrium, 18 mmHg; pulmonary artery, 63/33 mmHg (mean 43 mmHg); and pulmonary capillary wedge, 24. Importantly, her mixed venous oxygen saturation improved to 68% with a calculated cardiac output of 3.4 liters per minute and cardiac index of 2.4 liters per minute per meter squared. These favorable hemodynamic changes were accompanied by modest improvement in symptoms. After continued intravenous diuresis, she was transitioned back to an oral diuretic regimen and was ultimately discharged to home with a continuous infusion of milrinone for palliation. TH

Drs. Vaishnava, McKean, Nohria, and Baughman are from Brigham and Women’s Hospital and Harvard Medical School in Boston, Mass.

REFERENCES:

1. Thom T, Haase N, Rosamond W, et al. Heart disease and stroke statistics – 2006 update: a report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation. 2006;113:85-151.
2. Iong P, Vowinckel E, Liu PP, Gong Y, Tu JV. Prognosis and determinants of survival in patients newly hospitalized for heart failure: a population-based study. Arch Intern Med. 2002;162:1689-94.
3. Nohria A, Lewis EF, Stevenson LW. Medical management of advanced heart failure. JAMA. 2002;287;628-40.
4. Faris R, Flather MD, Purcell H, et al. Diuretics for heart failure. Cochrane Database Syst Rev. 2006;1;CD003838.
5. Wang DJ and Gottlieb SS. Diuretics: Still the mainstay of treatment. Crit Care Med. 2008;36(Suppl.):S89-S94.
6. Fares WH. Management of acute decompensated heart failure in an evidence-based era: What is the evidence behind the current standard of care? Heart & Lung. 2008;37(3):173-8.
7. Adams KF, Lindenfield J, Arnold J, et al. Executive summary: HFSA 2006 comprehensive heart failure practice guidelines. J Card Fail. 2006;12:10-38.
8. Publication Committee for the VMAC Investigators (Vasodilatation in the Management of Acute CHF). Intravenous nesiritide vs nitroglycerin for treatment of decompensated congestive heart failure: a randomized controlled trial. JAMA. 2002;297:1531-40.
9. Peacock WF, Enerman CL, Silver MA, on behalf of the PROACTION Study Group. Am J Emerg Med. 2005;23:327-31.
10. Cotter G, Metzkor E, Kaluski E, et al. Randomized trial of high-dose isosorbide dinitrate plus low-dose furosemide versus high-dose furosemide plus low-dose isosorbide dinitrate in severe pulmonary edema. Lancet. 1998;351:389-93.
11. Sackner-Bernstein JD, Kowalski M, Fox M, Aaronson K. Short-term risk of death after treatment with nesiritide for decompensated heart failure: a pooled analysis of randomized controlled trials. JAMA. 2005;293:1900-5.
12. Sackner-Bernstein JD, Skopicki HA, Aaronson K. Risk of worsening renal function with nesiritide in patients with acutely decompensated heart failure. Circulation. 2005;111:1487-91.
13. Felker GM and O’Connor CM. Inotropic therapy for heart failure: An evidence-based approach. American Heart Journal. 2001; 142:393-401.
14. Abrahm WT, Adams KF, Fonarow GC, et al. In-hospital mortality in patients with acute decompensated heart failure requiring intravenous vasoactive medications: an analysis from the Acute Decompensated Heart Failure National Registry (ADHERE). J Am Coll Cardiol. 2005;46:57-64.
15. Burger AJ, Houton DP, LeJemtel T, et al. Effect of nesiritide and dobutamine on ventricular arrhythmias in the treatment of patients with acutely decompensated congestive heart failure: the PRECEDENT study. American Heart Journal. 2002;144:1102-8.
16. Liang CS, Sherman LG, Doherty JU, et al. Sustained improvement of cardiac function in patients with congestive heart failure after short-term infusion of dobutamine. Circulation. 1984;69:113-9.
17. Unverferth DV, Magorien RD, Lewis RP, et al. Long-term benefit of dobutamine in patients with congestive cardiomyopathy. American Heart Journal. 1980;100:622-30.
18. Cuffe MS, Califf RM, Adams KF Jr, et al. Outcomes of a Prospective Trial of Intravenous Milrinone for Exacerbations of Chronic Heart Failure (OPTIME-CHF) Investigators. Short-term intravenous milrinone for acute exacerbation of chronic heart failure: a randomized controlled trial. JAMA. 2002;287:1541-7.
19. Yamani MH, Haji SA, Starling RC, et al. Comparison of dobutamine-based and milrinone-based therapy for advanced decompensated congestive heart failure: Hemodynamic efficacy, clinical outcome, and economic impact. American Heart Journal. 2001;142:998-1002.
20. Shin, DD, Brandimarte F, De Luca L, et al. Review of current and investigational pharmacologic agents for acute heart failure syndromes. Am J Cardiol. 2007;99(suppl):4A-23A.
21. Kale P and Fang JC. Devices in acute heart failure. Crit Care Med. 2008;36(Suppl.):S121-128.

Case

A 72-year-old retired nurse with known nonischemic dilated cardiomyopathy with an ejection fraction of approximately 20% and status-post cardiac resynchronization therapy presents to the emergency department with dyspnea with minimal activity, three-pillow orthopnea, and paroxysmal nocturnal dyspnea.

She had been hospitalized twice during the past 60 days for similar symptoms. Her medications included losartan (20 mg po q daily), carvedilol (3.125 mg twice daily), spironolactone (25 mg daily), digoxin (0.125 mg daily), and furosemide (80 mg twice daily). Vital signs are notable for a blood pressure of 90/50 mmHg and an irregular pulse of 90 beats per minute. Physical examination is notable for marked jugular venous distension, lungs clear to auscultation bilaterally, biventricular heaves, a markedly displaced left ventricular point of maximal impulse, and a prominent S3 gallop.

Despite treatment with intravenous furosemide and temporary withdrawal of carvedilol, the patient remains symptomatic with persistent jugular venous distension.

Should she be given a vasoactive agent?

Overview

Acute heart failure syndrome (AHFS), defined as a gradual or rapid change in heart failure signs and symptoms, is the most common cause of hospitalization in the United States1. It is associated with an average in-hospital mortality of 4% to 5%, a 30-day mortality of 7% to11%, and a one-year mortality of 33%2.

In patients with previously established myocardial dysfunction, AHFS commonly reflects exacerbation of symptoms after a period of stability. The clinical presentation and severity of AHFS may range from mild volume overload to life-threatening cardiogenic shock and multi-organ failure unresponsive to pharmacologic therapy.2

Initial management of AHFS depends on definition of the patient’s hemodynamic profile. To guide initial therapy, classify patients into one of four hemodynamic profiles during a brief bedside assessment that relies on evaluation of filling pressures (wet or dry) and adequacy of perfusion (hot or cold) (see figure 1).3

Treating volume overload or elevated filling pressures generally begins with diuretics. Diuretics have been shown to provide symptomatic relief, though they have not yet been proven safe.4 Initial treatment can include a loop diuretic at a dose higher than the patient’s chronic dose, with intravenous dosing offering greater bio-absorption and rapidity in onset of action.5 If perfusion is inadequate, escalate therapy beyond diuretics to include vasoactive agents.

Review of the Data

The use of vasoactive medications is largely based on anecdotal experiences and physiologic assumptions rather than on adequately powered prospective randomized controlled trials.6 Vasoactive therapy includes vasodilator and inotropic support and is generally limited for use in patients with advanced disease not responding to standard medical treatment and diuresis. The physiologic premise rests in the expected improvement in ventricular filling pressures and cardiac output with reduction in afterload and/or preload. Vasodilators counteract vascular constriction, reducing both preload and afterload. Positive inotropic agents amplify cardiac output by increasing the strength of myocardial contraction.

Vasodilators

The Heart Failure Society of America (HFSA) 2006 Comprehensive Heart Failure Practice Guidelines state, “In the absence of symptomatic hypotension, intravenous vasodilators (nitroglycerin, nitroprusside, or nesiritide) may be considered as an addition to diuretic therapy for rapid improvement of congestive symptoms.”7 The clinical utility of nesiritide remains in question with clinical and hemodynamic improvement demonstrated in three randomized trials 8-10; but tempered against meta-analyses 11-12 of selected trials, demonstrating a non-significant trend toward increased kidney dysfunction and death within 30 days (35/485 [7.2%] vs. 15/377 [4.0%] patients; risk ratio from meta-analyses, 1.74; 95% confidence interval, 0.97-3.12; p=0.059). In a randomized trial of 489 in-patients with dyspnea at rest from AHFS, treatment with three hours of intravenous nesiritide resulted in a significant improvement in dyspnea compared with placebo (p=0.03). Similar improvement was observed with intravenous nitroglycerin and did not differ statistically from that observed with nesiritide.8 Nitroprusside, an attractive option among those with hypertension and cardiogenic pulmonary edema, is limited by the need for invasive hemodynamic monitoring and potential for either cyanide toxicity or worsening myocardial ischemia.

click for large version

Inotropes

Again, there is little evidence from adequately powered randomized controlled trials guiding the use of inotropes. Their use is generally limited to the following indications (see figure 2): (1) Short-term treatment for AHFS that is unresponsive to adequate doses of diuretics and especially when associated with systemic hypotension, (2) Bridge to recovery (as following myocarditis) or to definitive treatment (as with transplant), or (3) For palliation when symptomatic relief is the agreed upon goal.13 The HFSA 2006 guideline states: “Intravenous inotropes may be considered to relieve symptoms and improve end-organ function in patients with advanced HF characterized by left ventricle dilation, reduced left ventricular ejection fraction, and diminished peripheral perfusion or end-organ dysfunction, particularly if these patients have marginal systolic blood pressure, have symptomatic hypotension despite adequate filling pressures, or are unresponsive to, or intolerant of, intravenous vasodilators.”7

Dobutamine and milrinone are the most commonly used IV inotropes for the treatment of AHFS and increase contractility by increasing intracellular levels of cyclic adenylate monophosphate (cAMP). Dobutamine is a catechlamine agonist that increases cAMP production through stimulation of adenylate cyclase. Milrinone selectively inhibits phosphodiesterase III, which catalyzes the breakdown of cAMP.

Despite their frequent use when traditional treatments have failed, the data supporting the use of dobutamine and milrinone is limited. The largest registry of patients with AHFS to date associated excess mortality with intravenous inotrope use compared to nitroglycerin or nesiritide.14 In a study population of 255 patients randomized to receive either intravenous nesiritide or intravenous dobutamine, Burger et al.15 demonstrated that dobutamine significantly increased the mean number of ventricular tachycardia events per 24 hours (p=0.001), suggesting increased arrhythmogenicity associated with inotrope use. Nonetheless, in a randomized trial of 15 patients admitted with AHFS, functional class improved in six of eight dobutamine-treated patients, but in only two of seven patients treated with placebo, suggesting clinical improvement as a consequence of inotropic stimulation.16 Unverferth et al. demonstrated a similar sustained functional improvement up to 10 weeks following a 72-hour infusion of intravenous dobutamine. 17

The Outcomes of a Prospective Trial of Intravenous Milrinone for Exacerbations of Chronic Heart Failure trial (OPTIME-CHF), randomized 951 patients with AHFS to receive either intravenous milrinone or placebo within 48 hours of hospitalization.18 Compared to placebo, milrinone was associated with a significant increase in sustained hypotension requiring intervention (10.7% vs. 3.2%; p<.001) and new atrial arrhythmias (4.6% vs. 1.5%; p=0.004), along with a non-significant trend toward increased mortality (3.8% vs. 2.3%; p=0.19). However, as measured by a visual analog scale, milrinone-treated patients reported feeling better than those treated with placebo at 30 days post-randomization (p=0.02).

Although there are not randomized data comparing the efficacy of milrinone and dobutamine in AHFS, a retrospective analysis of 329 patients compared the hemodynamic and clinical effects of these two inotropes.19 Milrinone consistently was associated with a more favorable hemodynamic response, including lower systemic vascular resistance (p=0.01); lower pulmonary artery wedge pressure (p<0.001); larger percentage increase in cardiac index (p=0.03); and larger percentage decrease in pulmonary vascular resistance (p=0.0001). In-hospital mortality (dobutamine 7.8% vs. milrinone 10%) was not significantly different.

Conclusion

Clearly, vasoactive and inotropic agents are available when AHFS is refractory to traditional diuresis and may offer short-term symptomatic relief, palliation in the context of end-of-life care, or bridge to recovery or more definitive treatment. Unfortunately, sufficient and robust evidence that supports the safety and efficacy of such agents is lacking and their use is largely guided by historical practices, clinical experience, and anticipation of theoretic physiologic changes. While adequately powered prospective randomized data emerge, newer agents such as vasopressin receptor antagonists, cardiac myosin activators, calcium sensitizers, and adenosine-receptor antagonists will offer additional pharmacologic options.20 When continued pharmacologic support becomes ineffective, device therapy is available to aid in the treatment of AHFS and includes ultrafiltration to reduce filling pressures and intra-aortic balloon pump counterpulsation or left ventricular assist device placement for pharmacologically resistant cardiogenic shock.21

Back to the Case

Despite maximal medical therapy for her chronic heart failure and biventricular pacing, the patient continued to have markedly limited functional status and repeated hospitalizations for AHFS. Given her advanced age and poor nutritional status, she was not a candidate for cardiac transplantation or placement of a left ventricular assist device. To allow for palliative tailored therapy, right heart catheterization was performed. Right heart catheterization revealed elevated filling pressures, as follows: right atrium, 20 mmHg; pulmonary artery, 63/34 mmHg (mean 47 mmHg); and pulmonary capillary wedge, 29 mmHg. Her mixed venous oxygen saturation was only 41% with a calculated cardiac output of 2.9 liters per minute and cardiac index of 2 liters per minute per meter squared.

As she expressed symptomatic relief as her goal, she was started on intravenous milrinone at 0.2 micrograms per kilogram per minute. This was done with the understanding her symptoms would likely would improve, at the expense of worsening longevity and prognosis. With uptitration of her intravenous milrinone and a continuous infusion of furosemide, she demonstrated the following filling pressures within 24 hours: right atrium, 18 mmHg; pulmonary artery, 63/33 mmHg (mean 43 mmHg); and pulmonary capillary wedge, 24. Importantly, her mixed venous oxygen saturation improved to 68% with a calculated cardiac output of 3.4 liters per minute and cardiac index of 2.4 liters per minute per meter squared. These favorable hemodynamic changes were accompanied by modest improvement in symptoms. After continued intravenous diuresis, she was transitioned back to an oral diuretic regimen and was ultimately discharged to home with a continuous infusion of milrinone for palliation. TH

Drs. Vaishnava, McKean, Nohria, and Baughman are from Brigham and Women’s Hospital and Harvard Medical School in Boston, Mass.

REFERENCES:

1. Thom T, Haase N, Rosamond W, et al. Heart disease and stroke statistics – 2006 update: a report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation. 2006;113:85-151.
2. Iong P, Vowinckel E, Liu PP, Gong Y, Tu JV. Prognosis and determinants of survival in patients newly hospitalized for heart failure: a population-based study. Arch Intern Med. 2002;162:1689-94.
3. Nohria A, Lewis EF, Stevenson LW. Medical management of advanced heart failure. JAMA. 2002;287;628-40.
4. Faris R, Flather MD, Purcell H, et al. Diuretics for heart failure. Cochrane Database Syst Rev. 2006;1;CD003838.
5. Wang DJ and Gottlieb SS. Diuretics: Still the mainstay of treatment. Crit Care Med. 2008;36(Suppl.):S89-S94.
6. Fares WH. Management of acute decompensated heart failure in an evidence-based era: What is the evidence behind the current standard of care? Heart & Lung. 2008;37(3):173-8.
7. Adams KF, Lindenfield J, Arnold J, et al. Executive summary: HFSA 2006 comprehensive heart failure practice guidelines. J Card Fail. 2006;12:10-38.
8. Publication Committee for the VMAC Investigators (Vasodilatation in the Management of Acute CHF). Intravenous nesiritide vs nitroglycerin for treatment of decompensated congestive heart failure: a randomized controlled trial. JAMA. 2002;297:1531-40.
9. Peacock WF, Enerman CL, Silver MA, on behalf of the PROACTION Study Group. Am J Emerg Med. 2005;23:327-31.
10. Cotter G, Metzkor E, Kaluski E, et al. Randomized trial of high-dose isosorbide dinitrate plus low-dose furosemide versus high-dose furosemide plus low-dose isosorbide dinitrate in severe pulmonary edema. Lancet. 1998;351:389-93.
11. Sackner-Bernstein JD, Kowalski M, Fox M, Aaronson K. Short-term risk of death after treatment with nesiritide for decompensated heart failure: a pooled analysis of randomized controlled trials. JAMA. 2005;293:1900-5.
12. Sackner-Bernstein JD, Skopicki HA, Aaronson K. Risk of worsening renal function with nesiritide in patients with acutely decompensated heart failure. Circulation. 2005;111:1487-91.
13. Felker GM and O’Connor CM. Inotropic therapy for heart failure: An evidence-based approach. American Heart Journal. 2001; 142:393-401.
14. Abrahm WT, Adams KF, Fonarow GC, et al. In-hospital mortality in patients with acute decompensated heart failure requiring intravenous vasoactive medications: an analysis from the Acute Decompensated Heart Failure National Registry (ADHERE). J Am Coll Cardiol. 2005;46:57-64.
15. Burger AJ, Houton DP, LeJemtel T, et al. Effect of nesiritide and dobutamine on ventricular arrhythmias in the treatment of patients with acutely decompensated congestive heart failure: the PRECEDENT study. American Heart Journal. 2002;144:1102-8.
16. Liang CS, Sherman LG, Doherty JU, et al. Sustained improvement of cardiac function in patients with congestive heart failure after short-term infusion of dobutamine. Circulation. 1984;69:113-9.
17. Unverferth DV, Magorien RD, Lewis RP, et al. Long-term benefit of dobutamine in patients with congestive cardiomyopathy. American Heart Journal. 1980;100:622-30.
18. Cuffe MS, Califf RM, Adams KF Jr, et al. Outcomes of a Prospective Trial of Intravenous Milrinone for Exacerbations of Chronic Heart Failure (OPTIME-CHF) Investigators. Short-term intravenous milrinone for acute exacerbation of chronic heart failure: a randomized controlled trial. JAMA. 2002;287:1541-7.
19. Yamani MH, Haji SA, Starling RC, et al. Comparison of dobutamine-based and milrinone-based therapy for advanced decompensated congestive heart failure: Hemodynamic efficacy, clinical outcome, and economic impact. American Heart Journal. 2001;142:998-1002.
20. Shin, DD, Brandimarte F, De Luca L, et al. Review of current and investigational pharmacologic agents for acute heart failure syndromes. Am J Cardiol. 2007;99(suppl):4A-23A.
21. Kale P and Fang JC. Devices in acute heart failure. Crit Care Med. 2008;36(Suppl.):S121-128.

Case

A 72-year-old retired nurse with known nonischemic dilated cardiomyopathy with an ejection fraction of approximately 20% and status-post cardiac resynchronization therapy presents to the emergency department with dyspnea with minimal activity, three-pillow orthopnea, and paroxysmal nocturnal dyspnea.

She had been hospitalized twice during the past 60 days for similar symptoms. Her medications included losartan (20 mg po q daily), carvedilol (3.125 mg twice daily), spironolactone (25 mg daily), digoxin (0.125 mg daily), and furosemide (80 mg twice daily). Vital signs are notable for a blood pressure of 90/50 mmHg and an irregular pulse of 90 beats per minute. Physical examination is notable for marked jugular venous distension, lungs clear to auscultation bilaterally, biventricular heaves, a markedly displaced left ventricular point of maximal impulse, and a prominent S3 gallop.

Despite treatment with intravenous furosemide and temporary withdrawal of carvedilol, the patient remains symptomatic with persistent jugular venous distension.

Should she be given a vasoactive agent?

Overview

Acute heart failure syndrome (AHFS), defined as a gradual or rapid change in heart failure signs and symptoms, is the most common cause of hospitalization in the United States1. It is associated with an average in-hospital mortality of 4% to 5%, a 30-day mortality of 7% to11%, and a one-year mortality of 33%2.

In patients with previously established myocardial dysfunction, AHFS commonly reflects exacerbation of symptoms after a period of stability. The clinical presentation and severity of AHFS may range from mild volume overload to life-threatening cardiogenic shock and multi-organ failure unresponsive to pharmacologic therapy.2

Initial management of AHFS depends on definition of the patient’s hemodynamic profile. To guide initial therapy, classify patients into one of four hemodynamic profiles during a brief bedside assessment that relies on evaluation of filling pressures (wet or dry) and adequacy of perfusion (hot or cold) (see figure 1).3

Treating volume overload or elevated filling pressures generally begins with diuretics. Diuretics have been shown to provide symptomatic relief, though they have not yet been proven safe.4 Initial treatment can include a loop diuretic at a dose higher than the patient’s chronic dose, with intravenous dosing offering greater bio-absorption and rapidity in onset of action.5 If perfusion is inadequate, escalate therapy beyond diuretics to include vasoactive agents.

Review of the Data

The use of vasoactive medications is largely based on anecdotal experiences and physiologic assumptions rather than on adequately powered prospective randomized controlled trials.6 Vasoactive therapy includes vasodilator and inotropic support and is generally limited for use in patients with advanced disease not responding to standard medical treatment and diuresis. The physiologic premise rests in the expected improvement in ventricular filling pressures and cardiac output with reduction in afterload and/or preload. Vasodilators counteract vascular constriction, reducing both preload and afterload. Positive inotropic agents amplify cardiac output by increasing the strength of myocardial contraction.

Vasodilators

The Heart Failure Society of America (HFSA) 2006 Comprehensive Heart Failure Practice Guidelines state, “In the absence of symptomatic hypotension, intravenous vasodilators (nitroglycerin, nitroprusside, or nesiritide) may be considered as an addition to diuretic therapy for rapid improvement of congestive symptoms.”7 The clinical utility of nesiritide remains in question with clinical and hemodynamic improvement demonstrated in three randomized trials 8-10; but tempered against meta-analyses 11-12 of selected trials, demonstrating a non-significant trend toward increased kidney dysfunction and death within 30 days (35/485 [7.2%] vs. 15/377 [4.0%] patients; risk ratio from meta-analyses, 1.74; 95% confidence interval, 0.97-3.12; p=0.059). In a randomized trial of 489 in-patients with dyspnea at rest from AHFS, treatment with three hours of intravenous nesiritide resulted in a significant improvement in dyspnea compared with placebo (p=0.03). Similar improvement was observed with intravenous nitroglycerin and did not differ statistically from that observed with nesiritide.8 Nitroprusside, an attractive option among those with hypertension and cardiogenic pulmonary edema, is limited by the need for invasive hemodynamic monitoring and potential for either cyanide toxicity or worsening myocardial ischemia.

click for large version

Inotropes

Again, there is little evidence from adequately powered randomized controlled trials guiding the use of inotropes. Their use is generally limited to the following indications (see figure 2): (1) Short-term treatment for AHFS that is unresponsive to adequate doses of diuretics and especially when associated with systemic hypotension, (2) Bridge to recovery (as following myocarditis) or to definitive treatment (as with transplant), or (3) For palliation when symptomatic relief is the agreed upon goal.13 The HFSA 2006 guideline states: “Intravenous inotropes may be considered to relieve symptoms and improve end-organ function in patients with advanced HF characterized by left ventricle dilation, reduced left ventricular ejection fraction, and diminished peripheral perfusion or end-organ dysfunction, particularly if these patients have marginal systolic blood pressure, have symptomatic hypotension despite adequate filling pressures, or are unresponsive to, or intolerant of, intravenous vasodilators.”7

Dobutamine and milrinone are the most commonly used IV inotropes for the treatment of AHFS and increase contractility by increasing intracellular levels of cyclic adenylate monophosphate (cAMP). Dobutamine is a catechlamine agonist that increases cAMP production through stimulation of adenylate cyclase. Milrinone selectively inhibits phosphodiesterase III, which catalyzes the breakdown of cAMP.

Despite their frequent use when traditional treatments have failed, the data supporting the use of dobutamine and milrinone is limited. The largest registry of patients with AHFS to date associated excess mortality with intravenous inotrope use compared to nitroglycerin or nesiritide.14 In a study population of 255 patients randomized to receive either intravenous nesiritide or intravenous dobutamine, Burger et al.15 demonstrated that dobutamine significantly increased the mean number of ventricular tachycardia events per 24 hours (p=0.001), suggesting increased arrhythmogenicity associated with inotrope use. Nonetheless, in a randomized trial of 15 patients admitted with AHFS, functional class improved in six of eight dobutamine-treated patients, but in only two of seven patients treated with placebo, suggesting clinical improvement as a consequence of inotropic stimulation.16 Unverferth et al. demonstrated a similar sustained functional improvement up to 10 weeks following a 72-hour infusion of intravenous dobutamine. 17

The Outcomes of a Prospective Trial of Intravenous Milrinone for Exacerbations of Chronic Heart Failure trial (OPTIME-CHF), randomized 951 patients with AHFS to receive either intravenous milrinone or placebo within 48 hours of hospitalization.18 Compared to placebo, milrinone was associated with a significant increase in sustained hypotension requiring intervention (10.7% vs. 3.2%; p<.001) and new atrial arrhythmias (4.6% vs. 1.5%; p=0.004), along with a non-significant trend toward increased mortality (3.8% vs. 2.3%; p=0.19). However, as measured by a visual analog scale, milrinone-treated patients reported feeling better than those treated with placebo at 30 days post-randomization (p=0.02).

Although there are not randomized data comparing the efficacy of milrinone and dobutamine in AHFS, a retrospective analysis of 329 patients compared the hemodynamic and clinical effects of these two inotropes.19 Milrinone consistently was associated with a more favorable hemodynamic response, including lower systemic vascular resistance (p=0.01); lower pulmonary artery wedge pressure (p<0.001); larger percentage increase in cardiac index (p=0.03); and larger percentage decrease in pulmonary vascular resistance (p=0.0001). In-hospital mortality (dobutamine 7.8% vs. milrinone 10%) was not significantly different.

Conclusion

Clearly, vasoactive and inotropic agents are available when AHFS is refractory to traditional diuresis and may offer short-term symptomatic relief, palliation in the context of end-of-life care, or bridge to recovery or more definitive treatment. Unfortunately, sufficient and robust evidence that supports the safety and efficacy of such agents is lacking and their use is largely guided by historical practices, clinical experience, and anticipation of theoretic physiologic changes. While adequately powered prospective randomized data emerge, newer agents such as vasopressin receptor antagonists, cardiac myosin activators, calcium sensitizers, and adenosine-receptor antagonists will offer additional pharmacologic options.20 When continued pharmacologic support becomes ineffective, device therapy is available to aid in the treatment of AHFS and includes ultrafiltration to reduce filling pressures and intra-aortic balloon pump counterpulsation or left ventricular assist device placement for pharmacologically resistant cardiogenic shock.21

Back to the Case

Despite maximal medical therapy for her chronic heart failure and biventricular pacing, the patient continued to have markedly limited functional status and repeated hospitalizations for AHFS. Given her advanced age and poor nutritional status, she was not a candidate for cardiac transplantation or placement of a left ventricular assist device. To allow for palliative tailored therapy, right heart catheterization was performed. Right heart catheterization revealed elevated filling pressures, as follows: right atrium, 20 mmHg; pulmonary artery, 63/34 mmHg (mean 47 mmHg); and pulmonary capillary wedge, 29 mmHg. Her mixed venous oxygen saturation was only 41% with a calculated cardiac output of 2.9 liters per minute and cardiac index of 2 liters per minute per meter squared.

As she expressed symptomatic relief as her goal, she was started on intravenous milrinone at 0.2 micrograms per kilogram per minute. This was done with the understanding her symptoms would likely would improve, at the expense of worsening longevity and prognosis. With uptitration of her intravenous milrinone and a continuous infusion of furosemide, she demonstrated the following filling pressures within 24 hours: right atrium, 18 mmHg; pulmonary artery, 63/33 mmHg (mean 43 mmHg); and pulmonary capillary wedge, 24. Importantly, her mixed venous oxygen saturation improved to 68% with a calculated cardiac output of 3.4 liters per minute and cardiac index of 2.4 liters per minute per meter squared. These favorable hemodynamic changes were accompanied by modest improvement in symptoms. After continued intravenous diuresis, she was transitioned back to an oral diuretic regimen and was ultimately discharged to home with a continuous infusion of milrinone for palliation. TH

Drs. Vaishnava, McKean, Nohria, and Baughman are from Brigham and Women’s Hospital and Harvard Medical School in Boston, Mass.

REFERENCES:

1. Thom T, Haase N, Rosamond W, et al. Heart disease and stroke statistics – 2006 update: a report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation. 2006;113:85-151.
2. Iong P, Vowinckel E, Liu PP, Gong Y, Tu JV. Prognosis and determinants of survival in patients newly hospitalized for heart failure: a population-based study. Arch Intern Med. 2002;162:1689-94.
3. Nohria A, Lewis EF, Stevenson LW. Medical management of advanced heart failure. JAMA. 2002;287;628-40.
4. Faris R, Flather MD, Purcell H, et al. Diuretics for heart failure. Cochrane Database Syst Rev. 2006;1;CD003838.
5. Wang DJ and Gottlieb SS. Diuretics: Still the mainstay of treatment. Crit Care Med. 2008;36(Suppl.):S89-S94.
6. Fares WH. Management of acute decompensated heart failure in an evidence-based era: What is the evidence behind the current standard of care? Heart & Lung. 2008;37(3):173-8.
7. Adams KF, Lindenfield J, Arnold J, et al. Executive summary: HFSA 2006 comprehensive heart failure practice guidelines. J Card Fail. 2006;12:10-38.
8. Publication Committee for the VMAC Investigators (Vasodilatation in the Management of Acute CHF). Intravenous nesiritide vs nitroglycerin for treatment of decompensated congestive heart failure: a randomized controlled trial. JAMA. 2002;297:1531-40.
9. Peacock WF, Enerman CL, Silver MA, on behalf of the PROACTION Study Group. Am J Emerg Med. 2005;23:327-31.
10. Cotter G, Metzkor E, Kaluski E, et al. Randomized trial of high-dose isosorbide dinitrate plus low-dose furosemide versus high-dose furosemide plus low-dose isosorbide dinitrate in severe pulmonary edema. Lancet. 1998;351:389-93.
11. Sackner-Bernstein JD, Kowalski M, Fox M, Aaronson K. Short-term risk of death after treatment with nesiritide for decompensated heart failure: a pooled analysis of randomized controlled trials. JAMA. 2005;293:1900-5.
12. Sackner-Bernstein JD, Skopicki HA, Aaronson K. Risk of worsening renal function with nesiritide in patients with acutely decompensated heart failure. Circulation. 2005;111:1487-91.
13. Felker GM and O’Connor CM. Inotropic therapy for heart failure: An evidence-based approach. American Heart Journal. 2001; 142:393-401.
14. Abrahm WT, Adams KF, Fonarow GC, et al. In-hospital mortality in patients with acute decompensated heart failure requiring intravenous vasoactive medications: an analysis from the Acute Decompensated Heart Failure National Registry (ADHERE). J Am Coll Cardiol. 2005;46:57-64.
15. Burger AJ, Houton DP, LeJemtel T, et al. Effect of nesiritide and dobutamine on ventricular arrhythmias in the treatment of patients with acutely decompensated congestive heart failure: the PRECEDENT study. American Heart Journal. 2002;144:1102-8.
16. Liang CS, Sherman LG, Doherty JU, et al. Sustained improvement of cardiac function in patients with congestive heart failure after short-term infusion of dobutamine. Circulation. 1984;69:113-9.
17. Unverferth DV, Magorien RD, Lewis RP, et al. Long-term benefit of dobutamine in patients with congestive cardiomyopathy. American Heart Journal. 1980;100:622-30.
18. Cuffe MS, Califf RM, Adams KF Jr, et al. Outcomes of a Prospective Trial of Intravenous Milrinone for Exacerbations of Chronic Heart Failure (OPTIME-CHF) Investigators. Short-term intravenous milrinone for acute exacerbation of chronic heart failure: a randomized controlled trial. JAMA. 2002;287:1541-7.
19. Yamani MH, Haji SA, Starling RC, et al. Comparison of dobutamine-based and milrinone-based therapy for advanced decompensated congestive heart failure: Hemodynamic efficacy, clinical outcome, and economic impact. American Heart Journal. 2001;142:998-1002.
20. Shin, DD, Brandimarte F, De Luca L, et al. Review of current and investigational pharmacologic agents for acute heart failure syndromes. Am J Cardiol. 2007;99(suppl):4A-23A.
21. Kale P and Fang JC. Devices in acute heart failure. Crit Care Med. 2008;36(Suppl.):S121-128.

Hospitalists who work in teaching hospitals need to understand the teaching physician (TP) rules, to know what qualifies for payment and how to document to receive that payment. TP services are payable when they are furnished by a physician who is not a resident or a resident with a teaching physician physically present during the critical or key portions of the service.

This article will focus on the documentation guidelines for inpatient services provided by the hospitalist in a teaching setting.

Evaluation and Management Services

Teaching physicians participate in evaluation and management (E/M) services with residents in several different ways. Below, three scenarios discuss documentation requirements:

Scenario One: The Stand-Alone Service. In this scenario, the teaching physician independently performs the entire service (i.e., all required elements of the billed visit) though the resident also may have seen the patient that same day. The TP may choose to document as if the care took place in a non-teaching setting. This documentation stands alone and independently supports the reported visit level.

Alternatively, the teaching physician may use the resident’s note. He or she does this by first documenting involvement in patient management and performance of the critical or key portion(s) of the service, and then linking to the resident’s note. The teaching physician selects the visit level based on the combined documentation (i.e., that of the teaching physician and the resident).

When referencing resident documentation, the teaching physician should use Medicare-approved linkage statements. Common examples include the following:

• “I performed a history and physical examination of the patient and discussed his management with the resident. I reviewed the resident’s note and agree with the documented findings and plan of care.”
• “I saw and evaluated the patient. I agree with the findings and the plan of care as documented in the resident’s note.”
• “I saw and examined the patient. I agree with the resident’s note except the heart murmur is louder than documented, so I will obtain an echo to evaluate.”

Although all of these examples are acceptable, the last one best identifies the teaching physician’s involvement in patient management, which is a requirement of TP documentation.

Scenario Two: The Supervised Service. In this scenario, resident and teaching physician provide services simultaneously. The teaching physician either may supervise the resident’s performance of required service elements or personally perform some of them.

Documentation includes information about the teaching physician’s presence during the encounter, performance of the critical or key portions of the service and involvement in patient management, as well as a reference to the resident’s note. As in scenario one, the teaching physician selects the visit level based on the combined documentation.

Teaching physician statements associated with scenario two and accepted by Medicare reviewers include the following:

• “I was present with the resident during the history and exam. I discussed the case with the resident and agree with the findings and plan as documented in the resident’s note.”
• “I saw the patient with the resident and agree with the resident’s findings and plan.”

Scenario two examples contain generalized statements considered acceptable for billing under teaching physician rules. Documenting patient-specific elements of the assessment and plan, however, not only demonstrate teaching physician involvement in patient care, but also evidence better quality of care.

Scenario Three: The Shared Service. In this case, the resident performs a portion or all of the required service elements without the teaching physician present and then documents the services. The teaching physician independently performs only the critical, or key, portions of the service and, as appropriate, discusses the case with the resident. Similar to scenario two, the TP references the resident’s note and documents presence during the encounter, performance of the critical or key portions of the service and involvement in patient management.

Remember, the teaching physician can not link to a resident note that does not exist. In other words, if the resident’s note is not available when the teaching physician is documenting, the note cannot be considered for billing purposes. When documented appropriately, as in the scenarios above, the teaching physician selects the visit level based on the combined documentation.

Medicare-approved linkage statements for use by teaching physicians in this scenario include the following:

• “I saw and evaluated the patient. I reviewed the resident’s note and agree, except that the picture is more consistent with pericarditis than myocardial ischemia. Will begin NSAIDs.”
• “I saw and evaluated the patient. Discussed with resident and agree with resident’s findings and plan as documented in the resident’s note.”
• “See resident’s note for details. I saw and evaluated the patient and agree with the resident’s finding and plans as written.”
• “I saw and evaluated the patient. Agree with resident’s note but lower extremities are weaker, now 3/5; MRI of L/S spine today.”

Documentation of teaching physician presence and participation provided solely by the resident is not sufficient to support the teaching physician service. Some examples of unacceptable documentation include:

• “Agree with above,” followed by legible countersignature or identity;
• “Rounded, Reviewed, Agree,” followed by legible countersignature or identity;
• “Discussed with resident. Agree,” followed by legible countersignature or identity;
• “Seen and agree,” followed by legible countersignature or identity;
• “Patient seen and evaluated,” followed by legible countersignature or identity; and
• Legible countersignature or identity alone.

Time-Based Services

Time-based E/M services require the teaching physician be present for the entire period for which the claim is made. Medical record documentation should reflect the teaching physician’s total visit time (i.e., spent on the unit/floor for inpatient services), including face-to-face time with the patient.

Time spent by the resident without the presence of the teaching physician does not count toward the teaching physician’s time, nor does time the TP spends teaching activities unrelated to patient care. Examples of time-based services typically provided by hospitalists include:

• Critical-care services (CPT codes 99291-99292);
• Hospital discharge day management (CPT codes 99238-99239);
• E/M codes in which counseling and/or coordination of care dominates (more than 50% of) the encounter, and time is considered the key or controlling factor to qualify for a particular level of E/M service; and
• Prolonged services (CPT codes 99358-99359).

Surgical Services

Surgical services, which are defined as minor or major, also are subject to teaching physician rules. Teaching physician regulations identify minor procedures as those that take five minutes or less to complete and involve relatively little decision making once the need for the service is determined. Appropriate billing and payment hinges on the teaching physician’s presence for the entire procedure. Documentation should include a statement of presence, written and signed by the teaching physician.

Services that require more than five minutes are considered major surgical services, requiring teaching physician presence only during the (physician-determined) critical and key portions of the procedure. However, the teaching physician must be available to return to the procedure area during the surgery’s entirety, and not be involved in another procedure. Arrangements must be made to have another qualified physician available should the teaching physician get called away. TH

Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center, Philadelphia. She also is on the faculty of SHM’s inpatient coding course.

References:

1. Centers for Medicare & Medicaid Services. Medicare Claims Processing Manual: Chapter 12, Section 100, www.cms.hhs.gov/manuals/downloads/clm104c12.pdf.

2. Centers for Medicare & Medicaid Services. Medicare Benefit Policy Manual: Chapter 15, Section 30.2, www.cms.hhs.gov/manuals/Downloads/bp102c15.pdf.

3. Centers for Medicare & Medicaid Services. Guidelines for Teaching Physicians, Interns, Residents, www.cms.hhs.gov/MLNProducts/downloads/gdelinesteachgresfctsht.pdf.

4. Manaker, S. Teaching Physician Regulations. Coding for Chest Medicine 2008, American College of Chest Physicians, 2008; 279-285.

5. Pohlig, C. Evaluation & Management Services: An Overview. Coding for Chest Medicine 2008, American College of Chest Physicians, 2008;57-69.

6. American Medical Association. cpt® 2008, Current Procedural Terminology Professional Edition. American Medical Association, 2007; 9-16.

Hospitalists who work in teaching hospitals need to understand the teaching physician (TP) rules, to know what qualifies for payment and how to document to receive that payment. TP services are payable when they are furnished by a physician who is not a resident or a resident with a teaching physician physically present during the critical or key portions of the service.

This article will focus on the documentation guidelines for inpatient services provided by the hospitalist in a teaching setting.

Evaluation and Management Services

Teaching physicians participate in evaluation and management (E/M) services with residents in several different ways. Below, three scenarios discuss documentation requirements:

Scenario One: The Stand-Alone Service. In this scenario, the teaching physician independently performs the entire service (i.e., all required elements of the billed visit) though the resident also may have seen the patient that same day. The TP may choose to document as if the care took place in a non-teaching setting. This documentation stands alone and independently supports the reported visit level.

Alternatively, the teaching physician may use the resident’s note. He or she does this by first documenting involvement in patient management and performance of the critical or key portion(s) of the service, and then linking to the resident’s note. The teaching physician selects the visit level based on the combined documentation (i.e., that of the teaching physician and the resident).

When referencing resident documentation, the teaching physician should use Medicare-approved linkage statements. Common examples include the following:

• “I performed a history and physical examination of the patient and discussed his management with the resident. I reviewed the resident’s note and agree with the documented findings and plan of care.”
• “I saw and evaluated the patient. I agree with the findings and the plan of care as documented in the resident’s note.”
• “I saw and examined the patient. I agree with the resident’s note except the heart murmur is louder than documented, so I will obtain an echo to evaluate.”

Although all of these examples are acceptable, the last one best identifies the teaching physician’s involvement in patient management, which is a requirement of TP documentation.

Scenario Two: The Supervised Service. In this scenario, resident and teaching physician provide services simultaneously. The teaching physician either may supervise the resident’s performance of required service elements or personally perform some of them.

Documentation includes information about the teaching physician’s presence during the encounter, performance of the critical or key portions of the service and involvement in patient management, as well as a reference to the resident’s note. As in scenario one, the teaching physician selects the visit level based on the combined documentation.

Teaching physician statements associated with scenario two and accepted by Medicare reviewers include the following:

• “I was present with the resident during the history and exam. I discussed the case with the resident and agree with the findings and plan as documented in the resident’s note.”
• “I saw the patient with the resident and agree with the resident’s findings and plan.”

Scenario two examples contain generalized statements considered acceptable for billing under teaching physician rules. Documenting patient-specific elements of the assessment and plan, however, not only demonstrate teaching physician involvement in patient care, but also evidence better quality of care.

Scenario Three: The Shared Service. In this case, the resident performs a portion or all of the required service elements without the teaching physician present and then documents the services. The teaching physician independently performs only the critical, or key, portions of the service and, as appropriate, discusses the case with the resident. Similar to scenario two, the TP references the resident’s note and documents presence during the encounter, performance of the critical or key portions of the service and involvement in patient management.

Remember, the teaching physician can not link to a resident note that does not exist. In other words, if the resident’s note is not available when the teaching physician is documenting, the note cannot be considered for billing purposes. When documented appropriately, as in the scenarios above, the teaching physician selects the visit level based on the combined documentation.

Medicare-approved linkage statements for use by teaching physicians in this scenario include the following:

• “I saw and evaluated the patient. I reviewed the resident’s note and agree, except that the picture is more consistent with pericarditis than myocardial ischemia. Will begin NSAIDs.”
• “I saw and evaluated the patient. Discussed with resident and agree with resident’s findings and plan as documented in the resident’s note.”
• “See resident’s note for details. I saw and evaluated the patient and agree with the resident’s finding and plans as written.”
• “I saw and evaluated the patient. Agree with resident’s note but lower extremities are weaker, now 3/5; MRI of L/S spine today.”

Documentation of teaching physician presence and participation provided solely by the resident is not sufficient to support the teaching physician service. Some examples of unacceptable documentation include:

• “Agree with above,” followed by legible countersignature or identity;
• “Rounded, Reviewed, Agree,” followed by legible countersignature or identity;
• “Discussed with resident. Agree,” followed by legible countersignature or identity;
• “Seen and agree,” followed by legible countersignature or identity;
• “Patient seen and evaluated,” followed by legible countersignature or identity; and
• Legible countersignature or identity alone.

Time-Based Services

Time-based E/M services require the teaching physician be present for the entire period for which the claim is made. Medical record documentation should reflect the teaching physician’s total visit time (i.e., spent on the unit/floor for inpatient services), including face-to-face time with the patient.

Time spent by the resident without the presence of the teaching physician does not count toward the teaching physician’s time, nor does time the TP spends teaching activities unrelated to patient care. Examples of time-based services typically provided by hospitalists include:

• Critical-care services (CPT codes 99291-99292);
• Hospital discharge day management (CPT codes 99238-99239);
• E/M codes in which counseling and/or coordination of care dominates (more than 50% of) the encounter, and time is considered the key or controlling factor to qualify for a particular level of E/M service; and
• Prolonged services (CPT codes 99358-99359).

Surgical Services

Surgical services, which are defined as minor or major, also are subject to teaching physician rules. Teaching physician regulations identify minor procedures as those that take five minutes or less to complete and involve relatively little decision making once the need for the service is determined. Appropriate billing and payment hinges on the teaching physician’s presence for the entire procedure. Documentation should include a statement of presence, written and signed by the teaching physician.

Services that require more than five minutes are considered major surgical services, requiring teaching physician presence only during the (physician-determined) critical and key portions of the procedure. However, the teaching physician must be available to return to the procedure area during the surgery’s entirety, and not be involved in another procedure. Arrangements must be made to have another qualified physician available should the teaching physician get called away. TH

Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center, Philadelphia. She also is on the faculty of SHM’s inpatient coding course.

References:

1. Centers for Medicare & Medicaid Services. Medicare Claims Processing Manual: Chapter 12, Section 100, www.cms.hhs.gov/manuals/downloads/clm104c12.pdf.

2. Centers for Medicare & Medicaid Services. Medicare Benefit Policy Manual: Chapter 15, Section 30.2, www.cms.hhs.gov/manuals/Downloads/bp102c15.pdf.

3. Centers for Medicare & Medicaid Services. Guidelines for Teaching Physicians, Interns, Residents, www.cms.hhs.gov/MLNProducts/downloads/gdelinesteachgresfctsht.pdf.

4. Manaker, S. Teaching Physician Regulations. Coding for Chest Medicine 2008, American College of Chest Physicians, 2008; 279-285.

5. Pohlig, C. Evaluation & Management Services: An Overview. Coding for Chest Medicine 2008, American College of Chest Physicians, 2008;57-69.

6. American Medical Association. cpt® 2008, Current Procedural Terminology Professional Edition. American Medical Association, 2007; 9-16.

Hospitalists who work in teaching hospitals need to understand the teaching physician (TP) rules, to know what qualifies for payment and how to document to receive that payment. TP services are payable when they are furnished by a physician who is not a resident or a resident with a teaching physician physically present during the critical or key portions of the service.

This article will focus on the documentation guidelines for inpatient services provided by the hospitalist in a teaching setting.

Evaluation and Management Services

Teaching physicians participate in evaluation and management (E/M) services with residents in several different ways. Below, three scenarios discuss documentation requirements:

Scenario One: The Stand-Alone Service. In this scenario, the teaching physician independently performs the entire service (i.e., all required elements of the billed visit) though the resident also may have seen the patient that same day. The TP may choose to document as if the care took place in a non-teaching setting. This documentation stands alone and independently supports the reported visit level.

Alternatively, the teaching physician may use the resident’s note. He or she does this by first documenting involvement in patient management and performance of the critical or key portion(s) of the service, and then linking to the resident’s note. The teaching physician selects the visit level based on the combined documentation (i.e., that of the teaching physician and the resident).

When referencing resident documentation, the teaching physician should use Medicare-approved linkage statements. Common examples include the following:

• “I performed a history and physical examination of the patient and discussed his management with the resident. I reviewed the resident’s note and agree with the documented findings and plan of care.”
• “I saw and evaluated the patient. I agree with the findings and the plan of care as documented in the resident’s note.”
• “I saw and examined the patient. I agree with the resident’s note except the heart murmur is louder than documented, so I will obtain an echo to evaluate.”

Although all of these examples are acceptable, the last one best identifies the teaching physician’s involvement in patient management, which is a requirement of TP documentation.

Scenario Two: The Supervised Service. In this scenario, resident and teaching physician provide services simultaneously. The teaching physician either may supervise the resident’s performance of required service elements or personally perform some of them.

Documentation includes information about the teaching physician’s presence during the encounter, performance of the critical or key portions of the service and involvement in patient management, as well as a reference to the resident’s note. As in scenario one, the teaching physician selects the visit level based on the combined documentation.

Teaching physician statements associated with scenario two and accepted by Medicare reviewers include the following:

• “I was present with the resident during the history and exam. I discussed the case with the resident and agree with the findings and plan as documented in the resident’s note.”
• “I saw the patient with the resident and agree with the resident’s findings and plan.”

Scenario two examples contain generalized statements considered acceptable for billing under teaching physician rules. Documenting patient-specific elements of the assessment and plan, however, not only demonstrate teaching physician involvement in patient care, but also evidence better quality of care.

Scenario Three: The Shared Service. In this case, the resident performs a portion or all of the required service elements without the teaching physician present and then documents the services. The teaching physician independently performs only the critical, or key, portions of the service and, as appropriate, discusses the case with the resident. Similar to scenario two, the TP references the resident’s note and documents presence during the encounter, performance of the critical or key portions of the service and involvement in patient management.

Remember, the teaching physician can not link to a resident note that does not exist. In other words, if the resident’s note is not available when the teaching physician is documenting, the note cannot be considered for billing purposes. When documented appropriately, as in the scenarios above, the teaching physician selects the visit level based on the combined documentation.

Medicare-approved linkage statements for use by teaching physicians in this scenario include the following:

• “I saw and evaluated the patient. I reviewed the resident’s note and agree, except that the picture is more consistent with pericarditis than myocardial ischemia. Will begin NSAIDs.”
• “I saw and evaluated the patient. Discussed with resident and agree with resident’s findings and plan as documented in the resident’s note.”
• “See resident’s note for details. I saw and evaluated the patient and agree with the resident’s finding and plans as written.”
• “I saw and evaluated the patient. Agree with resident’s note but lower extremities are weaker, now 3/5; MRI of L/S spine today.”

Documentation of teaching physician presence and participation provided solely by the resident is not sufficient to support the teaching physician service. Some examples of unacceptable documentation include:

• “Agree with above,” followed by legible countersignature or identity;
• “Rounded, Reviewed, Agree,” followed by legible countersignature or identity;
• “Discussed with resident. Agree,” followed by legible countersignature or identity;
• “Seen and agree,” followed by legible countersignature or identity;
• “Patient seen and evaluated,” followed by legible countersignature or identity; and
• Legible countersignature or identity alone.

Time-Based Services

Time-based E/M services require the teaching physician be present for the entire period for which the claim is made. Medical record documentation should reflect the teaching physician’s total visit time (i.e., spent on the unit/floor for inpatient services), including face-to-face time with the patient.

Time spent by the resident without the presence of the teaching physician does not count toward the teaching physician’s time, nor does time the TP spends teaching activities unrelated to patient care. Examples of time-based services typically provided by hospitalists include:

• Critical-care services (CPT codes 99291-99292);
• Hospital discharge day management (CPT codes 99238-99239);
• E/M codes in which counseling and/or coordination of care dominates (more than 50% of) the encounter, and time is considered the key or controlling factor to qualify for a particular level of E/M service; and
• Prolonged services (CPT codes 99358-99359).

Surgical Services

Surgical services, which are defined as minor or major, also are subject to teaching physician rules. Teaching physician regulations identify minor procedures as those that take five minutes or less to complete and involve relatively little decision making once the need for the service is determined. Appropriate billing and payment hinges on the teaching physician’s presence for the entire procedure. Documentation should include a statement of presence, written and signed by the teaching physician.

Services that require more than five minutes are considered major surgical services, requiring teaching physician presence only during the (physician-determined) critical and key portions of the procedure. However, the teaching physician must be available to return to the procedure area during the surgery’s entirety, and not be involved in another procedure. Arrangements must be made to have another qualified physician available should the teaching physician get called away. TH

Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center, Philadelphia. She also is on the faculty of SHM’s inpatient coding course.

References:

1. Centers for Medicare & Medicaid Services. Medicare Claims Processing Manual: Chapter 12, Section 100, www.cms.hhs.gov/manuals/downloads/clm104c12.pdf.

2. Centers for Medicare & Medicaid Services. Medicare Benefit Policy Manual: Chapter 15, Section 30.2, www.cms.hhs.gov/manuals/Downloads/bp102c15.pdf.

3. Centers for Medicare & Medicaid Services. Guidelines for Teaching Physicians, Interns, Residents, www.cms.hhs.gov/MLNProducts/downloads/gdelinesteachgresfctsht.pdf.

4. Manaker, S. Teaching Physician Regulations. Coding for Chest Medicine 2008, American College of Chest Physicians, 2008; 279-285.

5. Pohlig, C. Evaluation & Management Services: An Overview. Coding for Chest Medicine 2008, American College of Chest Physicians, 2008;57-69.

6. American Medical Association. cpt® 2008, Current Procedural Terminology Professional Edition. American Medical Association, 2007; 9-16.

Congress made history in July when it passed legislation that makes Medicare’s voluntary pay-for-reporting program permanent.

The program, the Physician Quality Reporting Initiative, or PQRI, which began in 2007 as a six-month trial and was continued through 2008, rewards physicians who successfully report on specific applicable quality measures with a cash bonus. The new bill, the Medicare Improvement for Patients and Providers Act (MIPPA), extends the Centers for Medicare and Medicaid (CMS) program beyond 2010.

“PQRI is now a permanent program, even though the details have only been provided through 2010,” says Michael Rapp, MD, of the CMS Office of Clinical Standards and Quality.

Here, is a look at PQRI past, present, and future, from a hospitalist’s point of view.

Pay-for-Performance Pilot Proves Worthwhile

In August, CMS released statistics on that first pay-for-reporting period. During the trial, 101,138 physicians submitted a quality-data code. Of those, 70,207 reported on at least one measure, and 56,722 earned a bonus.

Asked about those numbers, Patrick J. Torcson, MD, MMM, FACP, director of hospital medicine at St. Tammany Parish Hospital in Covington, La., and chair of SHM’s Performance and Standards Committee, says: “I think the folks at Medicare were pleased with that level of participation. This data helped convince them that the program should be permanent.”

What to Expect in 2009

The PQRI for 2009 is subject to revisions until the 2009 Physician Fee Schedule Final Rule is published sometime around Nov. 1. (Find the latest information on CMS Web site at www.cms.hhs.gov/pqri.) A number of proposed enhancements make it attractive and important to physicians, Dr. Torcson says.

CMS proposed 175 quality measures for physicians to report on, and MIPPA boosts payment for successful reporting of data on those measures. For 2009 and 2010, physicians who participate in the PQRI can earn an incentive payment of 2% (up from 1.5%) of their total allowed charges for Physician Fee Schedule (PFS) covered professional services.

However, except for a bigger check from CMS, hospitalists who currently report may not see much difference next year. “Overall, for hospitalists, PQRI will look pretty similar to 2007 and 2008,” Dr. Torcson warns. “The bonus is going to increase and the measures will be the same. That means that all of the background and education that SHM has provided on PQRI reporting remains relevant.”

One addition for 2009 is the use of patient registries to avoid claims systems for certain outpatient measures. “I don’t see the registry-reporting option being available to hospitalists in the short term,” Dr. Torcson says, “but it’s worth watching for the future.”

Beginning in 2009 and continuing through the next four years, Medicare also will provide incentive payments to eligible professionals who are successful electronic prescribers. (See the “Public Policy” article on p. 15 of the September 2008 The Hospitalist.) The e-prescribing measure in the 2008 PQRI will be removed for next year and used wholesale for a separate pay-for-reporting initiative pending changes from the Department of Health & Human Services. Unfortunately, none of the 2008 coding specifications for e-prescribing are available for hospitalist reporting.

“A lot of [the PQRI] measures have been created from the perspective of the cottage-industry model of an office-based private practice,” Dr. Torcson explains. “This 2008 (e-prescribing) measure was geared for an office-based physician practice—and the unforeseen consequence of the measure is that it’s not inclusive of patients being discharged from the hospital.”

Where Hospital Medicine Fits

By now, hospitalists should be resigned to the idea that many measures in PQRI don’t apply to their patients. However, SHM continues to work toward more inclusion for hospital-based physicians, by commenting on proposed rules and participating in the National Quality Forum and the American Medical Association’s Physician Consortium for Performance Improvement.

“We have been advocating for including performance measures for care processes, including transitions of care,” Dr. Torcson says. “This will probably come into play more in 2010 than 2009.”

SHM also has submitted comments on the proposed e-prescribing measures. Dr. Torcson says the organization is lobbying to make e-prescribing applicable to all hospital-based physicians, including ER doctors, and for discharged patients. “We want the whole process to harmonize with a comprehensive and safe discharge process that includes medication reconciliation,” he says.

To Report or Not to Report?

Regardless of whether lobbying efforts succeed in making more reporting applicable to hospital medicine, should groups start reporting in 2009? “It’s going to be a tough decision,” Dr. Torcson admits. “There’s a pretty significant investment in time and infrastructure to set this up. For the groups I know, the return on investment was negative.” In other words, PQRI does not pay for itself in a hospital medicine setting.

He says any hospital medicine group that wants to report should have in place a computerized system, and be willing to start slowly. “I’m convinced that it’s going to take an electronic coding/documentation system, as well as designated support staff within the hospital medicine group to pull it off,” he says. “This almost requires a full-time person.”

Dr. Torcson recommends starting with the reporting of three or four measures. “If you’re using a manual process or a homegrown system,” he says, “then the fewer measures the better, in terms of doing PQRI right to reach the 80% threshold.”

If you’re interested in reporting under the 2009 PQRI, go to SHM’s Web site at www.hospitalmedicine.org/ and type “PQRI 2008” into the advanced search bar. The article, “Information on PQRI 2008,” from May 17, 2007, provides important details about the program, including which measures apply to hospitalists. TH

Jane Jerrard is a medical writer based in Chicago.

Congress made history in July when it passed legislation that makes Medicare’s voluntary pay-for-reporting program permanent.

The program, the Physician Quality Reporting Initiative, or PQRI, which began in 2007 as a six-month trial and was continued through 2008, rewards physicians who successfully report on specific applicable quality measures with a cash bonus. The new bill, the Medicare Improvement for Patients and Providers Act (MIPPA), extends the Centers for Medicare and Medicaid (CMS) program beyond 2010.

“PQRI is now a permanent program, even though the details have only been provided through 2010,” says Michael Rapp, MD, of the CMS Office of Clinical Standards and Quality.

Here, is a look at PQRI past, present, and future, from a hospitalist’s point of view.

Pay-for-Performance Pilot Proves Worthwhile

In August, CMS released statistics on that first pay-for-reporting period. During the trial, 101,138 physicians submitted a quality-data code. Of those, 70,207 reported on at least one measure, and 56,722 earned a bonus.

Asked about those numbers, Patrick J. Torcson, MD, MMM, FACP, director of hospital medicine at St. Tammany Parish Hospital in Covington, La., and chair of SHM’s Performance and Standards Committee, says: “I think the folks at Medicare were pleased with that level of participation. This data helped convince them that the program should be permanent.”

What to Expect in 2009

The PQRI for 2009 is subject to revisions until the 2009 Physician Fee Schedule Final Rule is published sometime around Nov. 1. (Find the latest information on CMS Web site at www.cms.hhs.gov/pqri.) A number of proposed enhancements make it attractive and important to physicians, Dr. Torcson says.

CMS proposed 175 quality measures for physicians to report on, and MIPPA boosts payment for successful reporting of data on those measures. For 2009 and 2010, physicians who participate in the PQRI can earn an incentive payment of 2% (up from 1.5%) of their total allowed charges for Physician Fee Schedule (PFS) covered professional services.

However, except for a bigger check from CMS, hospitalists who currently report may not see much difference next year. “Overall, for hospitalists, PQRI will look pretty similar to 2007 and 2008,” Dr. Torcson warns. “The bonus is going to increase and the measures will be the same. That means that all of the background and education that SHM has provided on PQRI reporting remains relevant.”

One addition for 2009 is the use of patient registries to avoid claims systems for certain outpatient measures. “I don’t see the registry-reporting option being available to hospitalists in the short term,” Dr. Torcson says, “but it’s worth watching for the future.”

Beginning in 2009 and continuing through the next four years, Medicare also will provide incentive payments to eligible professionals who are successful electronic prescribers. (See the “Public Policy” article on p. 15 of the September 2008 The Hospitalist.) The e-prescribing measure in the 2008 PQRI will be removed for next year and used wholesale for a separate pay-for-reporting initiative pending changes from the Department of Health & Human Services. Unfortunately, none of the 2008 coding specifications for e-prescribing are available for hospitalist reporting.

“A lot of [the PQRI] measures have been created from the perspective of the cottage-industry model of an office-based private practice,” Dr. Torcson explains. “This 2008 (e-prescribing) measure was geared for an office-based physician practice—and the unforeseen consequence of the measure is that it’s not inclusive of patients being discharged from the hospital.”

Where Hospital Medicine Fits

By now, hospitalists should be resigned to the idea that many measures in PQRI don’t apply to their patients. However, SHM continues to work toward more inclusion for hospital-based physicians, by commenting on proposed rules and participating in the National Quality Forum and the American Medical Association’s Physician Consortium for Performance Improvement.

“We have been advocating for including performance measures for care processes, including transitions of care,” Dr. Torcson says. “This will probably come into play more in 2010 than 2009.”

SHM also has submitted comments on the proposed e-prescribing measures. Dr. Torcson says the organization is lobbying to make e-prescribing applicable to all hospital-based physicians, including ER doctors, and for discharged patients. “We want the whole process to harmonize with a comprehensive and safe discharge process that includes medication reconciliation,” he says.

To Report or Not to Report?

Regardless of whether lobbying efforts succeed in making more reporting applicable to hospital medicine, should groups start reporting in 2009? “It’s going to be a tough decision,” Dr. Torcson admits. “There’s a pretty significant investment in time and infrastructure to set this up. For the groups I know, the return on investment was negative.” In other words, PQRI does not pay for itself in a hospital medicine setting.

He says any hospital medicine group that wants to report should have in place a computerized system, and be willing to start slowly. “I’m convinced that it’s going to take an electronic coding/documentation system, as well as designated support staff within the hospital medicine group to pull it off,” he says. “This almost requires a full-time person.”

Dr. Torcson recommends starting with the reporting of three or four measures. “If you’re using a manual process or a homegrown system,” he says, “then the fewer measures the better, in terms of doing PQRI right to reach the 80% threshold.”

If you’re interested in reporting under the 2009 PQRI, go to SHM’s Web site at www.hospitalmedicine.org/ and type “PQRI 2008” into the advanced search bar. The article, “Information on PQRI 2008,” from May 17, 2007, provides important details about the program, including which measures apply to hospitalists. TH

Jane Jerrard is a medical writer based in Chicago.

Congress made history in July when it passed legislation that makes Medicare’s voluntary pay-for-reporting program permanent.

The program, the Physician Quality Reporting Initiative, or PQRI, which began in 2007 as a six-month trial and was continued through 2008, rewards physicians who successfully report on specific applicable quality measures with a cash bonus. The new bill, the Medicare Improvement for Patients and Providers Act (MIPPA), extends the Centers for Medicare and Medicaid (CMS) program beyond 2010.

“PQRI is now a permanent program, even though the details have only been provided through 2010,” says Michael Rapp, MD, of the CMS Office of Clinical Standards and Quality.

Here, is a look at PQRI past, present, and future, from a hospitalist’s point of view.

Pay-for-Performance Pilot Proves Worthwhile

In August, CMS released statistics on that first pay-for-reporting period. During the trial, 101,138 physicians submitted a quality-data code. Of those, 70,207 reported on at least one measure, and 56,722 earned a bonus.

Asked about those numbers, Patrick J. Torcson, MD, MMM, FACP, director of hospital medicine at St. Tammany Parish Hospital in Covington, La., and chair of SHM’s Performance and Standards Committee, says: “I think the folks at Medicare were pleased with that level of participation. This data helped convince them that the program should be permanent.”

What to Expect in 2009

The PQRI for 2009 is subject to revisions until the 2009 Physician Fee Schedule Final Rule is published sometime around Nov. 1. (Find the latest information on CMS Web site at www.cms.hhs.gov/pqri.) A number of proposed enhancements make it attractive and important to physicians, Dr. Torcson says.

CMS proposed 175 quality measures for physicians to report on, and MIPPA boosts payment for successful reporting of data on those measures. For 2009 and 2010, physicians who participate in the PQRI can earn an incentive payment of 2% (up from 1.5%) of their total allowed charges for Physician Fee Schedule (PFS) covered professional services.

However, except for a bigger check from CMS, hospitalists who currently report may not see much difference next year. “Overall, for hospitalists, PQRI will look pretty similar to 2007 and 2008,” Dr. Torcson warns. “The bonus is going to increase and the measures will be the same. That means that all of the background and education that SHM has provided on PQRI reporting remains relevant.”

One addition for 2009 is the use of patient registries to avoid claims systems for certain outpatient measures. “I don’t see the registry-reporting option being available to hospitalists in the short term,” Dr. Torcson says, “but it’s worth watching for the future.”

Beginning in 2009 and continuing through the next four years, Medicare also will provide incentive payments to eligible professionals who are successful electronic prescribers. (See the “Public Policy” article on p. 15 of the September 2008 The Hospitalist.) The e-prescribing measure in the 2008 PQRI will be removed for next year and used wholesale for a separate pay-for-reporting initiative pending changes from the Department of Health & Human Services. Unfortunately, none of the 2008 coding specifications for e-prescribing are available for hospitalist reporting.

“A lot of [the PQRI] measures have been created from the perspective of the cottage-industry model of an office-based private practice,” Dr. Torcson explains. “This 2008 (e-prescribing) measure was geared for an office-based physician practice—and the unforeseen consequence of the measure is that it’s not inclusive of patients being discharged from the hospital.”

Where Hospital Medicine Fits

By now, hospitalists should be resigned to the idea that many measures in PQRI don’t apply to their patients. However, SHM continues to work toward more inclusion for hospital-based physicians, by commenting on proposed rules and participating in the National Quality Forum and the American Medical Association’s Physician Consortium for Performance Improvement.

“We have been advocating for including performance measures for care processes, including transitions of care,” Dr. Torcson says. “This will probably come into play more in 2010 than 2009.”

SHM also has submitted comments on the proposed e-prescribing measures. Dr. Torcson says the organization is lobbying to make e-prescribing applicable to all hospital-based physicians, including ER doctors, and for discharged patients. “We want the whole process to harmonize with a comprehensive and safe discharge process that includes medication reconciliation,” he says.

To Report or Not to Report?

Regardless of whether lobbying efforts succeed in making more reporting applicable to hospital medicine, should groups start reporting in 2009? “It’s going to be a tough decision,” Dr. Torcson admits. “There’s a pretty significant investment in time and infrastructure to set this up. For the groups I know, the return on investment was negative.” In other words, PQRI does not pay for itself in a hospital medicine setting.

He says any hospital medicine group that wants to report should have in place a computerized system, and be willing to start slowly. “I’m convinced that it’s going to take an electronic coding/documentation system, as well as designated support staff within the hospital medicine group to pull it off,” he says. “This almost requires a full-time person.”

Dr. Torcson recommends starting with the reporting of three or four measures. “If you’re using a manual process or a homegrown system,” he says, “then the fewer measures the better, in terms of doing PQRI right to reach the 80% threshold.”

If you’re interested in reporting under the 2009 PQRI, go to SHM’s Web site at www.hospitalmedicine.org/ and type “PQRI 2008” into the advanced search bar. The article, “Information on PQRI 2008,” from May 17, 2007, provides important details about the program, including which measures apply to hospitalists. TH

Jane Jerrard is a medical writer based in Chicago.

You’re unhappy with your workload or schedule.

Your spouse has been transferred to a different state.

You simply want a change of scenery.

Regardless of the reason, you’re looking for a new job. In hospital medicine, how and when is it appropriate to give notice? To maintain good relations with your current employer now and in the future, make sure you consider your departure from both sides of the desk.

Timing is Everything

Before you start skimming classified ads and phoning friends in the field to ask about job openings, consider how much time your employer needs to fill your position.

“When you’re thinking about leaving a group, you have to realize that the timing for getting your replacement is longer than you might think,” says Heather A. Harris, MD, a hospitalist who splits her time between the University of California, San Francisco and the Palo Alto Medical Foundation. “The traditional two-week notice in other jobs is tough for most [hospital medicine] groups to handle—unless it’s a really big group or already overstaffed, which is never the case.”

Dr. Harris, who hired many hospitalists when she was director of Eden Inpatient Services, Eden Medical Center, Castro Valley, Calif., recommends giving a minimum of two months notice. “That gives your group time to figure out what to do,” she says. “Otherwise, you’re putting the entire group in a bind.”

Other physicians suggest an even longer timeframe. “My preference would be that a hospitalist give me no less than six months notification,” says Fred A. McCurdy, MD, PhD, MBA, associate dean for faculty development, Texas Tech University Health Sciences Center at Amarillo. “That’s a best-case scenario for finding a replacement. It could take longer than that.”

The issue is workload for the doctors left behind: “The other hospitalists are going to have to cover the slack in the meantime,” Dr. Harris points out. “Keep that in mind when you’re giving notice; you’re putting everyone else in a position where they have to cover the work.”

A lengthy timeframe actually could dovetail with your own transition. “You’ll have to get credentialed at that new hospital,” Dr. Harris says. “It’s important to realize when you get that job offer that group might want you to start the next day, but you have to wait until the credentialing process is complete.” Depending on the hospital, that could take as long as three months.

It’s important to know the specifics of your new hospital’s credential process. “You don’t want to leave a job before you have the means to enter a new job,” Dr. McCurdy warns. “Make sure you understand when you can actually start the work.”

Meanwhile, your current employer will need time to move your replacement through the same process. “Some hospitals are slower than others,” Dr. Harris says, “but even if I have a hospitalist in mind who’s available to start right away, they won’t be able to step in until the hospital’s credentialing is complete.”

Speak Up

When you decide to leave a job, tell your immediate supervisor directly and be open about your job search. “Ideally, the person who is leaving would sit down with me and tell me their intention to leave, where they intend to go, and the circumstances of their leaving,” Dr. McCurdy says. “I don’t want to hear about it third hand or through the grapevine, and I don’t want to find out that it’s some sort of negotiating tactic.”

If you want a new job because you’re unhappy with the one you have, consider whether the issues causing your discontent can be rectified. Dr. McCurdy says he would make every effort to keep a hospitalist in his group. “Obviously, there are some things I can’t help with,” he says. “I can’t change the weather, I can’t change the school systems, but I might be able to help with work issues.”

Build Bridges, Don’t Burn Them

It should go without saying that once you officially give notice, you should make every effort to maintain good relations with your employer and colleagues, by continuing to do your job well and remaining an active, positive member of your group, Dr. Harris says. This is particularly important if you stay in the same geographic area.

“There is a lot of fluidity in hospital medicine; people move from place to place,” she says. “It’s a small community and people know each other.”

If you feel comfortable doing so, offer to help your old employer find your replacement. Dr. McCurdy asks departing physicians for this favor. “I’d ask if they know someone who would be a good fit here,” he says. “The hospitalist community is small and pretty cohesive, so they may know someone.” Helping fill your position is a great way to stay connected and to show your good will toward the group.

If your employer asks you to stay a few weeks longer than you planned, consider whether you can jockey your upcoming start date to accommodate the request—but not at the price of being unhappy or risking your new job. “I might try to get someone to stay on a bit longer, but I’m not going to twist their arm if they aren’t interested,” Dr. McCurdy says. “It’s better to be without a physician than to have a disgruntled one.”

When you decide to move on to a new job, remember that you have a long career ahead of you. Be thoughtful and professional about how and when you leave. This small consideration can help maintain your reputation and connections for years to come. TH

Jane Jerrard also writes “Public Policy” for The Hospitalist.

You’re unhappy with your workload or schedule.

Your spouse has been transferred to a different state.

You simply want a change of scenery.

Regardless of the reason, you’re looking for a new job. In hospital medicine, how and when is it appropriate to give notice? To maintain good relations with your current employer now and in the future, make sure you consider your departure from both sides of the desk.

Timing is Everything

Before you start skimming classified ads and phoning friends in the field to ask about job openings, consider how much time your employer needs to fill your position.

“When you’re thinking about leaving a group, you have to realize that the timing for getting your replacement is longer than you might think,” says Heather A. Harris, MD, a hospitalist who splits her time between the University of California, San Francisco and the Palo Alto Medical Foundation. “The traditional two-week notice in other jobs is tough for most [hospital medicine] groups to handle—unless it’s a really big group or already overstaffed, which is never the case.”

Dr. Harris, who hired many hospitalists when she was director of Eden Inpatient Services, Eden Medical Center, Castro Valley, Calif., recommends giving a minimum of two months notice. “That gives your group time to figure out what to do,” she says. “Otherwise, you’re putting the entire group in a bind.”

Other physicians suggest an even longer timeframe. “My preference would be that a hospitalist give me no less than six months notification,” says Fred A. McCurdy, MD, PhD, MBA, associate dean for faculty development, Texas Tech University Health Sciences Center at Amarillo. “That’s a best-case scenario for finding a replacement. It could take longer than that.”

The issue is workload for the doctors left behind: “The other hospitalists are going to have to cover the slack in the meantime,” Dr. Harris points out. “Keep that in mind when you’re giving notice; you’re putting everyone else in a position where they have to cover the work.”

A lengthy timeframe actually could dovetail with your own transition. “You’ll have to get credentialed at that new hospital,” Dr. Harris says. “It’s important to realize when you get that job offer that group might want you to start the next day, but you have to wait until the credentialing process is complete.” Depending on the hospital, that could take as long as three months.

It’s important to know the specifics of your new hospital’s credential process. “You don’t want to leave a job before you have the means to enter a new job,” Dr. McCurdy warns. “Make sure you understand when you can actually start the work.”

Meanwhile, your current employer will need time to move your replacement through the same process. “Some hospitals are slower than others,” Dr. Harris says, “but even if I have a hospitalist in mind who’s available to start right away, they won’t be able to step in until the hospital’s credentialing is complete.”

Speak Up

When you decide to leave a job, tell your immediate supervisor directly and be open about your job search. “Ideally, the person who is leaving would sit down with me and tell me their intention to leave, where they intend to go, and the circumstances of their leaving,” Dr. McCurdy says. “I don’t want to hear about it third hand or through the grapevine, and I don’t want to find out that it’s some sort of negotiating tactic.”

If you want a new job because you’re unhappy with the one you have, consider whether the issues causing your discontent can be rectified. Dr. McCurdy says he would make every effort to keep a hospitalist in his group. “Obviously, there are some things I can’t help with,” he says. “I can’t change the weather, I can’t change the school systems, but I might be able to help with work issues.”

Build Bridges, Don’t Burn Them

It should go without saying that once you officially give notice, you should make every effort to maintain good relations with your employer and colleagues, by continuing to do your job well and remaining an active, positive member of your group, Dr. Harris says. This is particularly important if you stay in the same geographic area.

“There is a lot of fluidity in hospital medicine; people move from place to place,” she says. “It’s a small community and people know each other.”

If you feel comfortable doing so, offer to help your old employer find your replacement. Dr. McCurdy asks departing physicians for this favor. “I’d ask if they know someone who would be a good fit here,” he says. “The hospitalist community is small and pretty cohesive, so they may know someone.” Helping fill your position is a great way to stay connected and to show your good will toward the group.

If your employer asks you to stay a few weeks longer than you planned, consider whether you can jockey your upcoming start date to accommodate the request—but not at the price of being unhappy or risking your new job. “I might try to get someone to stay on a bit longer, but I’m not going to twist their arm if they aren’t interested,” Dr. McCurdy says. “It’s better to be without a physician than to have a disgruntled one.”

When you decide to move on to a new job, remember that you have a long career ahead of you. Be thoughtful and professional about how and when you leave. This small consideration can help maintain your reputation and connections for years to come. TH

Jane Jerrard also writes “Public Policy” for The Hospitalist.

You’re unhappy with your workload or schedule.

Your spouse has been transferred to a different state.

You simply want a change of scenery.

Regardless of the reason, you’re looking for a new job. In hospital medicine, how and when is it appropriate to give notice? To maintain good relations with your current employer now and in the future, make sure you consider your departure from both sides of the desk.

Timing is Everything

Before you start skimming classified ads and phoning friends in the field to ask about job openings, consider how much time your employer needs to fill your position.

“When you’re thinking about leaving a group, you have to realize that the timing for getting your replacement is longer than you might think,” says Heather A. Harris, MD, a hospitalist who splits her time between the University of California, San Francisco and the Palo Alto Medical Foundation. “The traditional two-week notice in other jobs is tough for most [hospital medicine] groups to handle—unless it’s a really big group or already overstaffed, which is never the case.”

Dr. Harris, who hired many hospitalists when she was director of Eden Inpatient Services, Eden Medical Center, Castro Valley, Calif., recommends giving a minimum of two months notice. “That gives your group time to figure out what to do,” she says. “Otherwise, you’re putting the entire group in a bind.”

Other physicians suggest an even longer timeframe. “My preference would be that a hospitalist give me no less than six months notification,” says Fred A. McCurdy, MD, PhD, MBA, associate dean for faculty development, Texas Tech University Health Sciences Center at Amarillo. “That’s a best-case scenario for finding a replacement. It could take longer than that.”

The issue is workload for the doctors left behind: “The other hospitalists are going to have to cover the slack in the meantime,” Dr. Harris points out. “Keep that in mind when you’re giving notice; you’re putting everyone else in a position where they have to cover the work.”

A lengthy timeframe actually could dovetail with your own transition. “You’ll have to get credentialed at that new hospital,” Dr. Harris says. “It’s important to realize when you get that job offer that group might want you to start the next day, but you have to wait until the credentialing process is complete.” Depending on the hospital, that could take as long as three months.

It’s important to know the specifics of your new hospital’s credential process. “You don’t want to leave a job before you have the means to enter a new job,” Dr. McCurdy warns. “Make sure you understand when you can actually start the work.”

Meanwhile, your current employer will need time to move your replacement through the same process. “Some hospitals are slower than others,” Dr. Harris says, “but even if I have a hospitalist in mind who’s available to start right away, they won’t be able to step in until the hospital’s credentialing is complete.”

Speak Up

When you decide to leave a job, tell your immediate supervisor directly and be open about your job search. “Ideally, the person who is leaving would sit down with me and tell me their intention to leave, where they intend to go, and the circumstances of their leaving,” Dr. McCurdy says. “I don’t want to hear about it third hand or through the grapevine, and I don’t want to find out that it’s some sort of negotiating tactic.”

If you want a new job because you’re unhappy with the one you have, consider whether the issues causing your discontent can be rectified. Dr. McCurdy says he would make every effort to keep a hospitalist in his group. “Obviously, there are some things I can’t help with,” he says. “I can’t change the weather, I can’t change the school systems, but I might be able to help with work issues.”

Build Bridges, Don’t Burn Them

It should go without saying that once you officially give notice, you should make every effort to maintain good relations with your employer and colleagues, by continuing to do your job well and remaining an active, positive member of your group, Dr. Harris says. This is particularly important if you stay in the same geographic area.

“There is a lot of fluidity in hospital medicine; people move from place to place,” she says. “It’s a small community and people know each other.”

If you feel comfortable doing so, offer to help your old employer find your replacement. Dr. McCurdy asks departing physicians for this favor. “I’d ask if they know someone who would be a good fit here,” he says. “The hospitalist community is small and pretty cohesive, so they may know someone.” Helping fill your position is a great way to stay connected and to show your good will toward the group.

If your employer asks you to stay a few weeks longer than you planned, consider whether you can jockey your upcoming start date to accommodate the request—but not at the price of being unhappy or risking your new job. “I might try to get someone to stay on a bit longer, but I’m not going to twist their arm if they aren’t interested,” Dr. McCurdy says. “It’s better to be without a physician than to have a disgruntled one.”

When you decide to move on to a new job, remember that you have a long career ahead of you. Be thoughtful and professional about how and when you leave. This small consideration can help maintain your reputation and connections for years to come. TH

Jane Jerrard also writes “Public Policy” for The Hospitalist.