Hospitalist Bradley Rosen, MD, has become something of a celebrity lately. Dr. Rosen, assistant director of the Procedures Center at Cedars-Sinai Medical Center in Los Angeles, is making news as the prime example of physicians carving new turf by becoming experts in performing medical procedures.

But it’s his center’s eye-popping statistics that are generating interest from patient safety groups and hospitals around the country. Dr. Rosen has documented a complication rate of less than 1% for procedures performed at the center. Published data for similar procedures done elsewhere sets the rate at between 3% and 5%.

The statistics don’t surprise Dr. Rosen. “The more you do something, the better you are going to be at it, and the better you are able to deal with the unexpected,” he explains.

Stories on proceduralists have also generated interest from hospitalists, who wonder if becoming experts in procedures can make them a more valuable part of the healthcare team and make their jobs more varied.

Safety Advantages

The evolution of proceduralists is first and foremost a patient safety measure. Many internists have given up doing procedures, concerned that they don’t do enough of them to stay proficient. In a study published in The Annals of Internal Medicine, internists reported that they do 50% fewer procedures today than they did 18 years ago. And the American Board of Internal Medicine has reduced the number of procedures required for certification, saying internists should focus on core procedures they are likely to do frequently. Proceduralists are moving in to fill the void.

Also driving the proceduralist movement is concern that residents don’t get enough experience in doing today’s more complicated procedures and are being trained by other residents.

“Unfortunately, training in procedures hasn’t progressed much from when I was a resident,” says Joseph Li, MD, director of the hospital medicine program at Beth Israel Deaconess Medical Center in Boston and assistant professor of medicine at the Harvard Medical School. “When I had to do a thoracentesis, for example, a junior resident was teaching me, and we would get three or four kits because I knew that I would screw up. We had no notion of cost, and although I felt bad sticking a patient a bunch of times, it was the way it worked in the teaching hospital. Unfortunately that is still the way it’s done in the overwhelming majority of medical schools today.”

The Trend Spreads

Simply put, proceduralists perform procedures. They may perform them all or part of the time and may teach others how to do them. Depending on where they work and how they’ve been trained, they perform thoracentesis, paracentesis, lumbar punctures, central line and arterial line placement, difficult IVs, percutaneous tracheostomy, chest tube insertion, skin biopsy, intubations, and conscious sedation.

Cedars-Sinai is the only hospital to establish a dedicated proceduralist center. Four proceduralists, with the help of a nurse practitioner and 14 nurses, perform about 24 medical procedures, according to Dr. Rosen.

The center was created in 1991 by Mark Ault, MD, FACEP, director of the division of general internal medicine at Cedars-Sinai, whom Dr. Rosen calls “the godfather of proceduralists.” Dr. Ault started the center after he found patients stayed in the hospital longer than necessary while waiting for procedures, Dr. Rosen says.

The early proceduralists came from critical and pulmonary care, and later from the academic hospitalists ranks. Proceduralists spend between 50% and 75% their time performing procedures and the rest on academic hospitalist duties such as supervising and teaching procedures to residents, working in clinics, rounding, and research.

In addition to working in the center, physicians perform procedures at the bedside using a mobile cart stocked with everything they need. “The advent of the portable ultrasound has really transformed vascular access and allows us to do procedures at the bedside, without having to move a patient,” Dr. Rosen says.

At Beth Israel Deaconess, 20 of the hospital’s 24 hospitalists have received advanced training and feel comfortable doing procedures. They also teach and supervise residents, according to Dr. Li.

“When a patient needs a procedure, the resident or physician pages 9-4-TAP, and we arrange a time to supervise the resident doing the procedure,” Dr. Li explains. “In about 80% of the cases, the resident does the procedure without my intervention. About 20% of the time I need to step in and do the procedure.”

The University of Chicago Pritzker School of Medicine started a procedures service five years ago, which is run by the critical care faculty and intensivists from 8 a.m. to 5 p.m. on weekdays. Hospitalists work as proceduralists to fill in the gaps at other times of the day and night and on weekends, according to Nilam Soni, MD, instructor of medicine in the school’s section of hospital medicine.

Dr. Soni received advanced training in procedures and says he enjoys doing procedures for the patients he sees as a hospitalist. “Being able to do procedures gives you a sense of confidence that you can take care of your patients without having to worry about finding someone to do a procedure,” Dr. Soni says.

Northwestern University Feinberg School of Medicine in Chicago is focusing on developing procedure-training programs for residents using advanced simulation, according to Jeffrey Barsuk, MD, FACP, assistant professor of medicine in the division of hospital medicine.

Small But Growing

The proceduralist movement makes up in enthusiasm what it lacks in numbers. There may be only 20 to 30 physicians in the country calling themselves proceduralists. However, countless physicians do procedures without the title. Interventional radiologists, intensivists, critical care physicians, pulmonologists, and surgeons to do procedures in larger hospitals. At small community hospitals, “Everyone does everything,” Dr. Soni says.

Fueled by patient safety concerns and the need for advanced training, there is a growing demand for experts to do procedures. Because hospitalists staff hospitals round the clock, they are the obvious physicians to move into the field. “Hospitalists are in the best position to take ownership of procedures because we are in the hospital 24/7,” Dr. Soni says. “We can zip down to the patients’ rooms and take care of a problem before it becomes serious.”

Another advantage is that a hospitalist is likely to have seen a patient before a procedure is needed. Dr. Soni believes it’s not as frightening for a patient to have a procedure done at bedside by someone they have met. “And we can educate patients about the procedure and answer follow-up questions because we are there,” he notes.

However, physicians doing procedures may not agree that hospitalists should take over the service. In some institutions the idea of establishing a proceduralist service or center has met roadblocks from physicians who see proceduralists an interlopers.

At Cedars-Sinai this hasn’t been a problem. “Our interventional radiologists and surgeons have been supportive because they have as much as they can handle,” Dr. Rosen explains. “They are content to focus on the more complicated procedures.”

Hospitalists specializing in procedures say it adds variety to their usual routines. “It takes a different mentality and different skills,” Dr. Rosen explains. “It’s much like surgery. You get a feeling of accomplishment when you’re done and then you go on to something else. It’s very satisfying,”

From a revenue standpoint, hospitalists can bill for the procedures they perform, although reimbursement for the typical procedure is not “jaw-dropping,” Dr. Rosen says.

For hospitalists, developing procedure skills may lead to career advancement. “The more you have to offer, the more valuable you are,” Dr. Soni advises. “By becoming a proceduralist you generate money for the hospital instead of being just an expense.”

Training and Standards

Whether hospitalists or other physicians do procedures, most of them agree there is a need for training and certifying of proceduralists. “Currently there are no standards for mastery in performing procedures,” Dr. Li says. “We measure mastery by personal belief. You ask me if I feel comfortable doing a certain procedure, and I say ‘Yes’ or ‘No.’ ”

SHM has identified performing procedures as one of the skills all hospitalists should be able to demonstrate, according to Dr. Li. To that end, an advanced procedures training course will be held at Hospital Medicine 2008, SHM’s Annual Meeting in April. For the first time, procedure experts will train hospitalists using different simulators, portable ultrasound, and other equipment.

“The future growth of proceduralist services and centers will come from being closely associated with and staffed by hospitalists,” Dr. Rosen says. He believes it’s an opportunity for hospitalists to supply another value-added service and have more variety in their work. TH

Barbara Dillard is a medical journalist based in Chicago.

Hospitalist Bradley Rosen, MD, has become something of a celebrity lately. Dr. Rosen, assistant director of the Procedures Center at Cedars-Sinai Medical Center in Los Angeles, is making news as the prime example of physicians carving new turf by becoming experts in performing medical procedures.

But it’s his center’s eye-popping statistics that are generating interest from patient safety groups and hospitals around the country. Dr. Rosen has documented a complication rate of less than 1% for procedures performed at the center. Published data for similar procedures done elsewhere sets the rate at between 3% and 5%.

The statistics don’t surprise Dr. Rosen. “The more you do something, the better you are going to be at it, and the better you are able to deal with the unexpected,” he explains.

Stories on proceduralists have also generated interest from hospitalists, who wonder if becoming experts in procedures can make them a more valuable part of the healthcare team and make their jobs more varied.

Safety Advantages

The evolution of proceduralists is first and foremost a patient safety measure. Many internists have given up doing procedures, concerned that they don’t do enough of them to stay proficient. In a study published in The Annals of Internal Medicine, internists reported that they do 50% fewer procedures today than they did 18 years ago. And the American Board of Internal Medicine has reduced the number of procedures required for certification, saying internists should focus on core procedures they are likely to do frequently. Proceduralists are moving in to fill the void.

Also driving the proceduralist movement is concern that residents don’t get enough experience in doing today’s more complicated procedures and are being trained by other residents.

“Unfortunately, training in procedures hasn’t progressed much from when I was a resident,” says Joseph Li, MD, director of the hospital medicine program at Beth Israel Deaconess Medical Center in Boston and assistant professor of medicine at the Harvard Medical School. “When I had to do a thoracentesis, for example, a junior resident was teaching me, and we would get three or four kits because I knew that I would screw up. We had no notion of cost, and although I felt bad sticking a patient a bunch of times, it was the way it worked in the teaching hospital. Unfortunately that is still the way it’s done in the overwhelming majority of medical schools today.”

The Trend Spreads

Simply put, proceduralists perform procedures. They may perform them all or part of the time and may teach others how to do them. Depending on where they work and how they’ve been trained, they perform thoracentesis, paracentesis, lumbar punctures, central line and arterial line placement, difficult IVs, percutaneous tracheostomy, chest tube insertion, skin biopsy, intubations, and conscious sedation.

Cedars-Sinai is the only hospital to establish a dedicated proceduralist center. Four proceduralists, with the help of a nurse practitioner and 14 nurses, perform about 24 medical procedures, according to Dr. Rosen.

The center was created in 1991 by Mark Ault, MD, FACEP, director of the division of general internal medicine at Cedars-Sinai, whom Dr. Rosen calls “the godfather of proceduralists.” Dr. Ault started the center after he found patients stayed in the hospital longer than necessary while waiting for procedures, Dr. Rosen says.

The early proceduralists came from critical and pulmonary care, and later from the academic hospitalists ranks. Proceduralists spend between 50% and 75% their time performing procedures and the rest on academic hospitalist duties such as supervising and teaching procedures to residents, working in clinics, rounding, and research.

In addition to working in the center, physicians perform procedures at the bedside using a mobile cart stocked with everything they need. “The advent of the portable ultrasound has really transformed vascular access and allows us to do procedures at the bedside, without having to move a patient,” Dr. Rosen says.

At Beth Israel Deaconess, 20 of the hospital’s 24 hospitalists have received advanced training and feel comfortable doing procedures. They also teach and supervise residents, according to Dr. Li.

“When a patient needs a procedure, the resident or physician pages 9-4-TAP, and we arrange a time to supervise the resident doing the procedure,” Dr. Li explains. “In about 80% of the cases, the resident does the procedure without my intervention. About 20% of the time I need to step in and do the procedure.”

The University of Chicago Pritzker School of Medicine started a procedures service five years ago, which is run by the critical care faculty and intensivists from 8 a.m. to 5 p.m. on weekdays. Hospitalists work as proceduralists to fill in the gaps at other times of the day and night and on weekends, according to Nilam Soni, MD, instructor of medicine in the school’s section of hospital medicine.

Dr. Soni received advanced training in procedures and says he enjoys doing procedures for the patients he sees as a hospitalist. “Being able to do procedures gives you a sense of confidence that you can take care of your patients without having to worry about finding someone to do a procedure,” Dr. Soni says.

Northwestern University Feinberg School of Medicine in Chicago is focusing on developing procedure-training programs for residents using advanced simulation, according to Jeffrey Barsuk, MD, FACP, assistant professor of medicine in the division of hospital medicine.

Small But Growing

The proceduralist movement makes up in enthusiasm what it lacks in numbers. There may be only 20 to 30 physicians in the country calling themselves proceduralists. However, countless physicians do procedures without the title. Interventional radiologists, intensivists, critical care physicians, pulmonologists, and surgeons to do procedures in larger hospitals. At small community hospitals, “Everyone does everything,” Dr. Soni says.

Fueled by patient safety concerns and the need for advanced training, there is a growing demand for experts to do procedures. Because hospitalists staff hospitals round the clock, they are the obvious physicians to move into the field. “Hospitalists are in the best position to take ownership of procedures because we are in the hospital 24/7,” Dr. Soni says. “We can zip down to the patients’ rooms and take care of a problem before it becomes serious.”

Another advantage is that a hospitalist is likely to have seen a patient before a procedure is needed. Dr. Soni believes it’s not as frightening for a patient to have a procedure done at bedside by someone they have met. “And we can educate patients about the procedure and answer follow-up questions because we are there,” he notes.

However, physicians doing procedures may not agree that hospitalists should take over the service. In some institutions the idea of establishing a proceduralist service or center has met roadblocks from physicians who see proceduralists an interlopers.

At Cedars-Sinai this hasn’t been a problem. “Our interventional radiologists and surgeons have been supportive because they have as much as they can handle,” Dr. Rosen explains. “They are content to focus on the more complicated procedures.”

Hospitalists specializing in procedures say it adds variety to their usual routines. “It takes a different mentality and different skills,” Dr. Rosen explains. “It’s much like surgery. You get a feeling of accomplishment when you’re done and then you go on to something else. It’s very satisfying,”

From a revenue standpoint, hospitalists can bill for the procedures they perform, although reimbursement for the typical procedure is not “jaw-dropping,” Dr. Rosen says.

For hospitalists, developing procedure skills may lead to career advancement. “The more you have to offer, the more valuable you are,” Dr. Soni advises. “By becoming a proceduralist you generate money for the hospital instead of being just an expense.”

Training and Standards

Whether hospitalists or other physicians do procedures, most of them agree there is a need for training and certifying of proceduralists. “Currently there are no standards for mastery in performing procedures,” Dr. Li says. “We measure mastery by personal belief. You ask me if I feel comfortable doing a certain procedure, and I say ‘Yes’ or ‘No.’ ”

SHM has identified performing procedures as one of the skills all hospitalists should be able to demonstrate, according to Dr. Li. To that end, an advanced procedures training course will be held at Hospital Medicine 2008, SHM’s Annual Meeting in April. For the first time, procedure experts will train hospitalists using different simulators, portable ultrasound, and other equipment.

“The future growth of proceduralist services and centers will come from being closely associated with and staffed by hospitalists,” Dr. Rosen says. He believes it’s an opportunity for hospitalists to supply another value-added service and have more variety in their work. TH

Barbara Dillard is a medical journalist based in Chicago.

Hospitalist Bradley Rosen, MD, has become something of a celebrity lately. Dr. Rosen, assistant director of the Procedures Center at Cedars-Sinai Medical Center in Los Angeles, is making news as the prime example of physicians carving new turf by becoming experts in performing medical procedures.

But it’s his center’s eye-popping statistics that are generating interest from patient safety groups and hospitals around the country. Dr. Rosen has documented a complication rate of less than 1% for procedures performed at the center. Published data for similar procedures done elsewhere sets the rate at between 3% and 5%.

The statistics don’t surprise Dr. Rosen. “The more you do something, the better you are going to be at it, and the better you are able to deal with the unexpected,” he explains.

Stories on proceduralists have also generated interest from hospitalists, who wonder if becoming experts in procedures can make them a more valuable part of the healthcare team and make their jobs more varied.

Safety Advantages

The evolution of proceduralists is first and foremost a patient safety measure. Many internists have given up doing procedures, concerned that they don’t do enough of them to stay proficient. In a study published in The Annals of Internal Medicine, internists reported that they do 50% fewer procedures today than they did 18 years ago. And the American Board of Internal Medicine has reduced the number of procedures required for certification, saying internists should focus on core procedures they are likely to do frequently. Proceduralists are moving in to fill the void.

Also driving the proceduralist movement is concern that residents don’t get enough experience in doing today’s more complicated procedures and are being trained by other residents.

“Unfortunately, training in procedures hasn’t progressed much from when I was a resident,” says Joseph Li, MD, director of the hospital medicine program at Beth Israel Deaconess Medical Center in Boston and assistant professor of medicine at the Harvard Medical School. “When I had to do a thoracentesis, for example, a junior resident was teaching me, and we would get three or four kits because I knew that I would screw up. We had no notion of cost, and although I felt bad sticking a patient a bunch of times, it was the way it worked in the teaching hospital. Unfortunately that is still the way it’s done in the overwhelming majority of medical schools today.”

The Trend Spreads

Simply put, proceduralists perform procedures. They may perform them all or part of the time and may teach others how to do them. Depending on where they work and how they’ve been trained, they perform thoracentesis, paracentesis, lumbar punctures, central line and arterial line placement, difficult IVs, percutaneous tracheostomy, chest tube insertion, skin biopsy, intubations, and conscious sedation.

Cedars-Sinai is the only hospital to establish a dedicated proceduralist center. Four proceduralists, with the help of a nurse practitioner and 14 nurses, perform about 24 medical procedures, according to Dr. Rosen.

The center was created in 1991 by Mark Ault, MD, FACEP, director of the division of general internal medicine at Cedars-Sinai, whom Dr. Rosen calls “the godfather of proceduralists.” Dr. Ault started the center after he found patients stayed in the hospital longer than necessary while waiting for procedures, Dr. Rosen says.

The early proceduralists came from critical and pulmonary care, and later from the academic hospitalists ranks. Proceduralists spend between 50% and 75% their time performing procedures and the rest on academic hospitalist duties such as supervising and teaching procedures to residents, working in clinics, rounding, and research.

In addition to working in the center, physicians perform procedures at the bedside using a mobile cart stocked with everything they need. “The advent of the portable ultrasound has really transformed vascular access and allows us to do procedures at the bedside, without having to move a patient,” Dr. Rosen says.

At Beth Israel Deaconess, 20 of the hospital’s 24 hospitalists have received advanced training and feel comfortable doing procedures. They also teach and supervise residents, according to Dr. Li.

“When a patient needs a procedure, the resident or physician pages 9-4-TAP, and we arrange a time to supervise the resident doing the procedure,” Dr. Li explains. “In about 80% of the cases, the resident does the procedure without my intervention. About 20% of the time I need to step in and do the procedure.”

The University of Chicago Pritzker School of Medicine started a procedures service five years ago, which is run by the critical care faculty and intensivists from 8 a.m. to 5 p.m. on weekdays. Hospitalists work as proceduralists to fill in the gaps at other times of the day and night and on weekends, according to Nilam Soni, MD, instructor of medicine in the school’s section of hospital medicine.

Dr. Soni received advanced training in procedures and says he enjoys doing procedures for the patients he sees as a hospitalist. “Being able to do procedures gives you a sense of confidence that you can take care of your patients without having to worry about finding someone to do a procedure,” Dr. Soni says.

Northwestern University Feinberg School of Medicine in Chicago is focusing on developing procedure-training programs for residents using advanced simulation, according to Jeffrey Barsuk, MD, FACP, assistant professor of medicine in the division of hospital medicine.

Small But Growing

The proceduralist movement makes up in enthusiasm what it lacks in numbers. There may be only 20 to 30 physicians in the country calling themselves proceduralists. However, countless physicians do procedures without the title. Interventional radiologists, intensivists, critical care physicians, pulmonologists, and surgeons to do procedures in larger hospitals. At small community hospitals, “Everyone does everything,” Dr. Soni says.

Fueled by patient safety concerns and the need for advanced training, there is a growing demand for experts to do procedures. Because hospitalists staff hospitals round the clock, they are the obvious physicians to move into the field. “Hospitalists are in the best position to take ownership of procedures because we are in the hospital 24/7,” Dr. Soni says. “We can zip down to the patients’ rooms and take care of a problem before it becomes serious.”

Another advantage is that a hospitalist is likely to have seen a patient before a procedure is needed. Dr. Soni believes it’s not as frightening for a patient to have a procedure done at bedside by someone they have met. “And we can educate patients about the procedure and answer follow-up questions because we are there,” he notes.

However, physicians doing procedures may not agree that hospitalists should take over the service. In some institutions the idea of establishing a proceduralist service or center has met roadblocks from physicians who see proceduralists an interlopers.

At Cedars-Sinai this hasn’t been a problem. “Our interventional radiologists and surgeons have been supportive because they have as much as they can handle,” Dr. Rosen explains. “They are content to focus on the more complicated procedures.”

Hospitalists specializing in procedures say it adds variety to their usual routines. “It takes a different mentality and different skills,” Dr. Rosen explains. “It’s much like surgery. You get a feeling of accomplishment when you’re done and then you go on to something else. It’s very satisfying,”

From a revenue standpoint, hospitalists can bill for the procedures they perform, although reimbursement for the typical procedure is not “jaw-dropping,” Dr. Rosen says.

For hospitalists, developing procedure skills may lead to career advancement. “The more you have to offer, the more valuable you are,” Dr. Soni advises. “By becoming a proceduralist you generate money for the hospital instead of being just an expense.”

Training and Standards

Whether hospitalists or other physicians do procedures, most of them agree there is a need for training and certifying of proceduralists. “Currently there are no standards for mastery in performing procedures,” Dr. Li says. “We measure mastery by personal belief. You ask me if I feel comfortable doing a certain procedure, and I say ‘Yes’ or ‘No.’ ”

SHM has identified performing procedures as one of the skills all hospitalists should be able to demonstrate, according to Dr. Li. To that end, an advanced procedures training course will be held at Hospital Medicine 2008, SHM’s Annual Meeting in April. For the first time, procedure experts will train hospitalists using different simulators, portable ultrasound, and other equipment.

“The future growth of proceduralist services and centers will come from being closely associated with and staffed by hospitalists,” Dr. Rosen says. He believes it’s an opportunity for hospitalists to supply another value-added service and have more variety in their work. TH

Barbara Dillard is a medical journalist based in Chicago.

Joseph Heaton, MD, a hospitalist with Kaiser Permanente practicing at Exempla Good Samaritan Medical Center in Lafayette, Colo., has spent the past three years helping develop an electronic medical record for the hospital.

The project includes computerized physician order entry (CPOE), which was rolled out Oct. 2. He estimates he has dedicated anywhere from 20% to 50% of his time to technology implementation.

“I’ve been the physician champion for the project, working alongside the IT (information technology) development team,” Dr. Heaton explains. “I was chosen not for any particular computer expertise but because of other leadership roles I have played as a hospitalist and my involvement in quality projects. I see CPOE and electronic medical records as obvious extensions of the other quality projects hospitalists participate in.”

Dr. Heaton’s experience in implementing a CPOE system highlights the barriers faced by those charged with advancing technology critical to hospital medicine.

He says he has learned a lot about computers along the way, but the technology is a snap compared with the challenges of managing change and making sure physicians are in tune with the new system.

“Not only was I representing other hospitalists, but also a broader group of physicians with privileges at the hospital, as well as other employees, including nurses and pharmacists,” he says. “Much of what I did was to translate language about workflow from the clinicians to IT, and then report back to the clinicians.”

But it wasn’t as easy at it sounds.

“Unfortunately, in this institution there is no single, agreed-upon communications venue for reaching all of the physicians who practice at the hospital,” says Dr. Heaton. “So we’ve had to use e-mail, voice mail, noon bag-lunch demos, mailings, departmental meetings and classes—multiple opportunities to make sure that physicians feel informed. That way, when they show up for their actual training in how to use the system, they’re not still asking questions like, ‘Why are we doing this?’ ”

Blessing or Curse?

CPOE, of course, refers to the process by which physicians and other clinicians directly enter medical orders into a computer application. CPOE can be independent of other computer applications or part of an electronic medical record or other computer system.

Standardized order sets, decision support tools, and other customized methods can make hospitalists’ jobs easier—if the system is well-designed. It’s not uncommon for CPOE to add time-consuming new tasks and functions. For example, hospitalists may be asked to enter information they’ve not previously been asked to supply. But CPOE is also touted as a way to reduce medical errors and improve quality.

“It’s a good thing to do,” Dr. Heaton concludes. “Six weeks into the implementation of CPOE here, medication delivery is much faster. There are efficiencies to be had. For the most part, the high-volume users, including hospitalists, are fine with it, even if they’re not taking full advantage of the system’s capabilities.”

But Campbell, et al., describe a number of unintended adverse consequences that have followed CPOE implementation.1 These downsides include unfavorable workflow issues, continuous demands for system change, untoward changes in communications patterns and practices, generation of new kinds of medical errors, and negative emotional responses to the system by clinicians. Physician resistance can derail costly, complex CPOE projects.

A widely cited example of such barriers comes from Cedars-Sinai Medical Center in Los Angeles. An institution known for its pioneering medical techniques and technologies, Cedars-Sinai was forced in 2003 to shut down implementation of CPOE after three months because of a full-blown staff rebellion, according to an article in The Washington Post.2 Various explanations have been offered for this failure, including inadequate training for users, intrusive decision support queries, and other provider frustrations with the system. The hospital’s public relations department declined a request to comment for this article or provide an update on the current status of CPOE at Cedars-Sinai.

Doing the Best We Can

The importance of CPOE to hospitalists is illustrated by Duane Spaulding, MD, FACP, president and executive contracting officer for Advantage Inpatient Medical Specialists, practicing at Penrose-St. Francis Hospital in Colorado Springs, Colo. Half of his 11-member hospitalist group could be considered “power users” of the hospital’s current, DOS-based CPOE system—but Dr. Spaulding is No. 1. “I enter more CPOE orders than any of the other 600-plus physicians on staff here,” he says.

For some hospitalists, computers are a passion. For others, “they are just a tool for getting from Point A to Point B,” he says. “I have probably spent 1,500 hours over the past decade on committee after committee, putting together computerized order sets and screens and the like.”

Dr. Spaulding says the hospital’s current, antiquated system can be laborious to work with: “I can only do 50% of my orders on the system.” At the end of last year, Centura—the hospital’s parent health system—was preparing to implement a regional electronic medical record integrating CPOE and other applications.

“It is a gargantuan change,” he says. With rollout planned in phases, hospitalists at Penrose-St. Francis will lose access to CPOE for an estimated six to nine months, although the new CPOE system eventually will be accessed on a tablet PC.

Amid this stressful transition to new technology, the hospitalists have been trying to do the best they can with available resources, Dr. Spaulding notes. “We have come up with a paper-based Plan B for entering all of our orders until we get access to the new CPOE system,” he says. “We have been reminding everyone in the group how important it is to take care of each other, such as by putting in a PRN order set for every new patient, because we know we all will be taking our turn on-call.”

Arieh Rosenbaum, MD, hospitalist at California Pacific Medical Center (CPMC) in San Francisco, has for years been involved in technology issues at his hospital, which is developing a new electronic medical record with CPOE. It will replace a 15-year-old, DOS-based CPOE system he describes as “powerful but clunky.” However, CPMC’s parent, Sutter Health, is rolling out the new computer system gradually across its 40 Northern California facilities. It won’t reach CPMC until 2011.

“It’s an incredibly complex project,” Dr. Rosenbaum says. “To Sutter’s credit, they’re trying very hard to get physicians’ input, establishing structures for gathering feedback at the corporate and local levels. I am one of the physicians who will be involved at the local level, both building the clinical content and interface as well as gaining physicians’ acceptance and participation.”

Success depends on how the new system relates to physicians’ workflow. “Everybody knows the benefits of CPOE, but there are mitigating factors, such as what to do when the system crashes,” he says. “Hospitalists are the people who will be interacting with the new system the most. It’s our job to be leaders and to be aware that this is in our future.”

Head-On Approach

Timothy Hartzog, MD, a pediatric hospitalist and medical director of information technology/CPOE at Medical College of South Carolina (MUSC), Charleston, urges hospitalists to take CPOE seriously and view it as an opportunity.

“Implementation of CPOE, or electronic medical records, can be one of the most fundamental changes a hospital makes—affecting the workflow of everybody who works there,” he says. “As physicians, we each work a little differently. With the standardization imposed by CPOE, it’s going to make some physicians a little crazy, no matter how well it’s implemented.”

Dr. Hartzog encourages hospitalists to set aside any doubts they may have and get involved in creating workable CPOE solutions.

“Hospitalists don’t have to be experts in technology,” he stresses. “If you learned medicine, you can learn the technology—if you’re willing to put in some time, read a couple of books, take some training, and work with your IT people. Tackle CPOE head on—make sure your voice is heard. Be part of the build. But you need to have time dedicated for the IT project, and you need to do the work. If you are not present and if other people on the development group don’t know you and hear you speak, decisions will be made when you’re not in the room.”

For some physicians, Dr. Hartzog says, it could even be fun. “Especially if we can actually make the system work for us. We can actually create something that makes life better for our group.” TH

Larry Beresford is a regular contributor to The Hospitalist.

References

1. Campbell EM, Sittig, DF, Ash JS, et al. Types of unintended consequences related to computerized provider order entry. J Am Med Inform Assoc. 2006 Sept-Oct;13(5):547-556.
2. Connolly C. Cedars-Sinai doctors cling to pen and paper. The Washington Post, March 21, 2005:A1.

Joseph Heaton, MD, a hospitalist with Kaiser Permanente practicing at Exempla Good Samaritan Medical Center in Lafayette, Colo., has spent the past three years helping develop an electronic medical record for the hospital.

The project includes computerized physician order entry (CPOE), which was rolled out Oct. 2. He estimates he has dedicated anywhere from 20% to 50% of his time to technology implementation.

“I’ve been the physician champion for the project, working alongside the IT (information technology) development team,” Dr. Heaton explains. “I was chosen not for any particular computer expertise but because of other leadership roles I have played as a hospitalist and my involvement in quality projects. I see CPOE and electronic medical records as obvious extensions of the other quality projects hospitalists participate in.”

Dr. Heaton’s experience in implementing a CPOE system highlights the barriers faced by those charged with advancing technology critical to hospital medicine.

He says he has learned a lot about computers along the way, but the technology is a snap compared with the challenges of managing change and making sure physicians are in tune with the new system.

“Not only was I representing other hospitalists, but also a broader group of physicians with privileges at the hospital, as well as other employees, including nurses and pharmacists,” he says. “Much of what I did was to translate language about workflow from the clinicians to IT, and then report back to the clinicians.”

But it wasn’t as easy at it sounds.

“Unfortunately, in this institution there is no single, agreed-upon communications venue for reaching all of the physicians who practice at the hospital,” says Dr. Heaton. “So we’ve had to use e-mail, voice mail, noon bag-lunch demos, mailings, departmental meetings and classes—multiple opportunities to make sure that physicians feel informed. That way, when they show up for their actual training in how to use the system, they’re not still asking questions like, ‘Why are we doing this?’ ”

Blessing or Curse?

CPOE, of course, refers to the process by which physicians and other clinicians directly enter medical orders into a computer application. CPOE can be independent of other computer applications or part of an electronic medical record or other computer system.

Standardized order sets, decision support tools, and other customized methods can make hospitalists’ jobs easier—if the system is well-designed. It’s not uncommon for CPOE to add time-consuming new tasks and functions. For example, hospitalists may be asked to enter information they’ve not previously been asked to supply. But CPOE is also touted as a way to reduce medical errors and improve quality.

“It’s a good thing to do,” Dr. Heaton concludes. “Six weeks into the implementation of CPOE here, medication delivery is much faster. There are efficiencies to be had. For the most part, the high-volume users, including hospitalists, are fine with it, even if they’re not taking full advantage of the system’s capabilities.”

But Campbell, et al., describe a number of unintended adverse consequences that have followed CPOE implementation.1 These downsides include unfavorable workflow issues, continuous demands for system change, untoward changes in communications patterns and practices, generation of new kinds of medical errors, and negative emotional responses to the system by clinicians. Physician resistance can derail costly, complex CPOE projects.

A widely cited example of such barriers comes from Cedars-Sinai Medical Center in Los Angeles. An institution known for its pioneering medical techniques and technologies, Cedars-Sinai was forced in 2003 to shut down implementation of CPOE after three months because of a full-blown staff rebellion, according to an article in The Washington Post.2 Various explanations have been offered for this failure, including inadequate training for users, intrusive decision support queries, and other provider frustrations with the system. The hospital’s public relations department declined a request to comment for this article or provide an update on the current status of CPOE at Cedars-Sinai.

Doing the Best We Can

The importance of CPOE to hospitalists is illustrated by Duane Spaulding, MD, FACP, president and executive contracting officer for Advantage Inpatient Medical Specialists, practicing at Penrose-St. Francis Hospital in Colorado Springs, Colo. Half of his 11-member hospitalist group could be considered “power users” of the hospital’s current, DOS-based CPOE system—but Dr. Spaulding is No. 1. “I enter more CPOE orders than any of the other 600-plus physicians on staff here,” he says.

For some hospitalists, computers are a passion. For others, “they are just a tool for getting from Point A to Point B,” he says. “I have probably spent 1,500 hours over the past decade on committee after committee, putting together computerized order sets and screens and the like.”

Dr. Spaulding says the hospital’s current, antiquated system can be laborious to work with: “I can only do 50% of my orders on the system.” At the end of last year, Centura—the hospital’s parent health system—was preparing to implement a regional electronic medical record integrating CPOE and other applications.

“It is a gargantuan change,” he says. With rollout planned in phases, hospitalists at Penrose-St. Francis will lose access to CPOE for an estimated six to nine months, although the new CPOE system eventually will be accessed on a tablet PC.

Amid this stressful transition to new technology, the hospitalists have been trying to do the best they can with available resources, Dr. Spaulding notes. “We have come up with a paper-based Plan B for entering all of our orders until we get access to the new CPOE system,” he says. “We have been reminding everyone in the group how important it is to take care of each other, such as by putting in a PRN order set for every new patient, because we know we all will be taking our turn on-call.”

Arieh Rosenbaum, MD, hospitalist at California Pacific Medical Center (CPMC) in San Francisco, has for years been involved in technology issues at his hospital, which is developing a new electronic medical record with CPOE. It will replace a 15-year-old, DOS-based CPOE system he describes as “powerful but clunky.” However, CPMC’s parent, Sutter Health, is rolling out the new computer system gradually across its 40 Northern California facilities. It won’t reach CPMC until 2011.

“It’s an incredibly complex project,” Dr. Rosenbaum says. “To Sutter’s credit, they’re trying very hard to get physicians’ input, establishing structures for gathering feedback at the corporate and local levels. I am one of the physicians who will be involved at the local level, both building the clinical content and interface as well as gaining physicians’ acceptance and participation.”

Success depends on how the new system relates to physicians’ workflow. “Everybody knows the benefits of CPOE, but there are mitigating factors, such as what to do when the system crashes,” he says. “Hospitalists are the people who will be interacting with the new system the most. It’s our job to be leaders and to be aware that this is in our future.”

Head-On Approach

Timothy Hartzog, MD, a pediatric hospitalist and medical director of information technology/CPOE at Medical College of South Carolina (MUSC), Charleston, urges hospitalists to take CPOE seriously and view it as an opportunity.

“Implementation of CPOE, or electronic medical records, can be one of the most fundamental changes a hospital makes—affecting the workflow of everybody who works there,” he says. “As physicians, we each work a little differently. With the standardization imposed by CPOE, it’s going to make some physicians a little crazy, no matter how well it’s implemented.”

Dr. Hartzog encourages hospitalists to set aside any doubts they may have and get involved in creating workable CPOE solutions.

“Hospitalists don’t have to be experts in technology,” he stresses. “If you learned medicine, you can learn the technology—if you’re willing to put in some time, read a couple of books, take some training, and work with your IT people. Tackle CPOE head on—make sure your voice is heard. Be part of the build. But you need to have time dedicated for the IT project, and you need to do the work. If you are not present and if other people on the development group don’t know you and hear you speak, decisions will be made when you’re not in the room.”

For some physicians, Dr. Hartzog says, it could even be fun. “Especially if we can actually make the system work for us. We can actually create something that makes life better for our group.” TH

Larry Beresford is a regular contributor to The Hospitalist.

References

1. Campbell EM, Sittig, DF, Ash JS, et al. Types of unintended consequences related to computerized provider order entry. J Am Med Inform Assoc. 2006 Sept-Oct;13(5):547-556.
2. Connolly C. Cedars-Sinai doctors cling to pen and paper. The Washington Post, March 21, 2005:A1.

Joseph Heaton, MD, a hospitalist with Kaiser Permanente practicing at Exempla Good Samaritan Medical Center in Lafayette, Colo., has spent the past three years helping develop an electronic medical record for the hospital.

The project includes computerized physician order entry (CPOE), which was rolled out Oct. 2. He estimates he has dedicated anywhere from 20% to 50% of his time to technology implementation.

“I’ve been the physician champion for the project, working alongside the IT (information technology) development team,” Dr. Heaton explains. “I was chosen not for any particular computer expertise but because of other leadership roles I have played as a hospitalist and my involvement in quality projects. I see CPOE and electronic medical records as obvious extensions of the other quality projects hospitalists participate in.”

Dr. Heaton’s experience in implementing a CPOE system highlights the barriers faced by those charged with advancing technology critical to hospital medicine.

He says he has learned a lot about computers along the way, but the technology is a snap compared with the challenges of managing change and making sure physicians are in tune with the new system.

“Not only was I representing other hospitalists, but also a broader group of physicians with privileges at the hospital, as well as other employees, including nurses and pharmacists,” he says. “Much of what I did was to translate language about workflow from the clinicians to IT, and then report back to the clinicians.”

But it wasn’t as easy at it sounds.

“Unfortunately, in this institution there is no single, agreed-upon communications venue for reaching all of the physicians who practice at the hospital,” says Dr. Heaton. “So we’ve had to use e-mail, voice mail, noon bag-lunch demos, mailings, departmental meetings and classes—multiple opportunities to make sure that physicians feel informed. That way, when they show up for their actual training in how to use the system, they’re not still asking questions like, ‘Why are we doing this?’ ”

Blessing or Curse?

CPOE, of course, refers to the process by which physicians and other clinicians directly enter medical orders into a computer application. CPOE can be independent of other computer applications or part of an electronic medical record or other computer system.

Standardized order sets, decision support tools, and other customized methods can make hospitalists’ jobs easier—if the system is well-designed. It’s not uncommon for CPOE to add time-consuming new tasks and functions. For example, hospitalists may be asked to enter information they’ve not previously been asked to supply. But CPOE is also touted as a way to reduce medical errors and improve quality.

“It’s a good thing to do,” Dr. Heaton concludes. “Six weeks into the implementation of CPOE here, medication delivery is much faster. There are efficiencies to be had. For the most part, the high-volume users, including hospitalists, are fine with it, even if they’re not taking full advantage of the system’s capabilities.”

But Campbell, et al., describe a number of unintended adverse consequences that have followed CPOE implementation.1 These downsides include unfavorable workflow issues, continuous demands for system change, untoward changes in communications patterns and practices, generation of new kinds of medical errors, and negative emotional responses to the system by clinicians. Physician resistance can derail costly, complex CPOE projects.

A widely cited example of such barriers comes from Cedars-Sinai Medical Center in Los Angeles. An institution known for its pioneering medical techniques and technologies, Cedars-Sinai was forced in 2003 to shut down implementation of CPOE after three months because of a full-blown staff rebellion, according to an article in The Washington Post.2 Various explanations have been offered for this failure, including inadequate training for users, intrusive decision support queries, and other provider frustrations with the system. The hospital’s public relations department declined a request to comment for this article or provide an update on the current status of CPOE at Cedars-Sinai.

Doing the Best We Can

The importance of CPOE to hospitalists is illustrated by Duane Spaulding, MD, FACP, president and executive contracting officer for Advantage Inpatient Medical Specialists, practicing at Penrose-St. Francis Hospital in Colorado Springs, Colo. Half of his 11-member hospitalist group could be considered “power users” of the hospital’s current, DOS-based CPOE system—but Dr. Spaulding is No. 1. “I enter more CPOE orders than any of the other 600-plus physicians on staff here,” he says.

For some hospitalists, computers are a passion. For others, “they are just a tool for getting from Point A to Point B,” he says. “I have probably spent 1,500 hours over the past decade on committee after committee, putting together computerized order sets and screens and the like.”

Dr. Spaulding says the hospital’s current, antiquated system can be laborious to work with: “I can only do 50% of my orders on the system.” At the end of last year, Centura—the hospital’s parent health system—was preparing to implement a regional electronic medical record integrating CPOE and other applications.

“It is a gargantuan change,” he says. With rollout planned in phases, hospitalists at Penrose-St. Francis will lose access to CPOE for an estimated six to nine months, although the new CPOE system eventually will be accessed on a tablet PC.

Amid this stressful transition to new technology, the hospitalists have been trying to do the best they can with available resources, Dr. Spaulding notes. “We have come up with a paper-based Plan B for entering all of our orders until we get access to the new CPOE system,” he says. “We have been reminding everyone in the group how important it is to take care of each other, such as by putting in a PRN order set for every new patient, because we know we all will be taking our turn on-call.”

Arieh Rosenbaum, MD, hospitalist at California Pacific Medical Center (CPMC) in San Francisco, has for years been involved in technology issues at his hospital, which is developing a new electronic medical record with CPOE. It will replace a 15-year-old, DOS-based CPOE system he describes as “powerful but clunky.” However, CPMC’s parent, Sutter Health, is rolling out the new computer system gradually across its 40 Northern California facilities. It won’t reach CPMC until 2011.

“It’s an incredibly complex project,” Dr. Rosenbaum says. “To Sutter’s credit, they’re trying very hard to get physicians’ input, establishing structures for gathering feedback at the corporate and local levels. I am one of the physicians who will be involved at the local level, both building the clinical content and interface as well as gaining physicians’ acceptance and participation.”

Success depends on how the new system relates to physicians’ workflow. “Everybody knows the benefits of CPOE, but there are mitigating factors, such as what to do when the system crashes,” he says. “Hospitalists are the people who will be interacting with the new system the most. It’s our job to be leaders and to be aware that this is in our future.”

Head-On Approach

Timothy Hartzog, MD, a pediatric hospitalist and medical director of information technology/CPOE at Medical College of South Carolina (MUSC), Charleston, urges hospitalists to take CPOE seriously and view it as an opportunity.

“Implementation of CPOE, or electronic medical records, can be one of the most fundamental changes a hospital makes—affecting the workflow of everybody who works there,” he says. “As physicians, we each work a little differently. With the standardization imposed by CPOE, it’s going to make some physicians a little crazy, no matter how well it’s implemented.”

Dr. Hartzog encourages hospitalists to set aside any doubts they may have and get involved in creating workable CPOE solutions.

“Hospitalists don’t have to be experts in technology,” he stresses. “If you learned medicine, you can learn the technology—if you’re willing to put in some time, read a couple of books, take some training, and work with your IT people. Tackle CPOE head on—make sure your voice is heard. Be part of the build. But you need to have time dedicated for the IT project, and you need to do the work. If you are not present and if other people on the development group don’t know you and hear you speak, decisions will be made when you’re not in the room.”

For some physicians, Dr. Hartzog says, it could even be fun. “Especially if we can actually make the system work for us. We can actually create something that makes life better for our group.” TH

Larry Beresford is a regular contributor to The Hospitalist.

References

1. Campbell EM, Sittig, DF, Ash JS, et al. Types of unintended consequences related to computerized provider order entry. J Am Med Inform Assoc. 2006 Sept-Oct;13(5):547-556.
2. Connolly C. Cedars-Sinai doctors cling to pen and paper. The Washington Post, March 21, 2005:A1.

Sore Loser?

Question: I just heard Medicare will no longer pay for care if a patient develops a bedsore during their hospital stay. Is this true?

Concerned,

Austin, Texas

Dr. Hospitalist responds: Beginning Oct. 1, the Center for Medicare and Medicaid Services (CMS) rolled out the latest change to the Inpatient Prospective Payment System by implementing the following Present on Admission (POA) Indicators:

• Object left in patient after surgery;
• Air embolism;
• Blood incompatibility;
• Catheter-associated urinary tract infections;
• Pressure ulcers (decubitus ulcers);
• Vascular catheter-associated infection;
• Mediastinitis after coronary artery bypass graft;
• Hospital-acquired injuries (fractures, dislocations, intracranial injury); and
• Crushing injury, burn, and other unspecified effects of external causes.

What exactly does this mean? Simply put, if a patient develops any of these conditions during his/her hospital stay, CMS no longer will pay the hospital for additional services associated with treatment of these conditions.

As a healthcare consumer and taxpayer, I believe this measure is long overdue. No patient should ever receive incompatible blood or have an object left in after surgery. Why should we pay for such errors? As hospitalists, our challenge is to develop processes to ensure these events never occur in the hospital. This will require implementing systems as well as educating and training every individual who works in our hospitals.

Coding for these events began Oct. 1 of last year, but payment will not be restricted until Oct. 1 of this year. Coding these events will not only affect hospital payment but will allow for public reporting of hospital performance.

CMS has proposed adding several other conditions for the next fiscal year and is analyzing still more possible conditions.

Proposed for this October:

• DVT and PE;
• Staph aureus septicemia; and
• Ventilator associated pneumonia (VAP).

Conditions under consideration:

• Methicillin-resistant Staphylococcus aureus;
• C. difficile-associated disease; and
• Wrong surgery.

Hospitals are turning to hospitalists not only to help them comply, but to lead the development of systems to improve inpatient care. I encourage you to think about how you can do this at your hospital.

Heart Murmurs

Question: Can you explain why my hospital is asking me to change the way I document heart failure in the chart? They are telling me it is the result of some diagnosis-related group (DRG) rule changes at Medicare that affects how much the hospital gets paid. Is this accurate?

Taking Note,

Louisville, Ky.

Dr. Hospitalist responds: The changes in physician documentation of inpatients with heart failure are part of a larger change in Medicare’s Inpatient Prospective Payment System. The new changes, called Medicare Severity-Adjusted DRGs (MSDRGs), restructured the DRGs to more fully account for the severity of a patient’s medical condition. The change expanded the number of DRGs from 583 to 745 by splitting the DRGs into three tiers:

• Major complication/co-morbidity (MCC);
• -Complication/co-morbidity (CC); and
• No CC.

Physician documentation that reflects chronic systolic and/or diastolic heart failure represents a CC. Documentation of acute systolic and/or acute diastolic heart failure represents an MCC. Documentation that does not describe the type and acuity of a patient’s heart failure condition will result in no CC.

Each DRG has a payment weight assigned to it, based on the average resources used to treat Medicare patients in that DRG. A higher DRG weight represents a more medically complex patient and a correspondingly higher payment. These new classifications affect the heart failure DRG weight values as follows:

Old DRG, heart failure/shock: 1.0490.

New MSDRG, heart failure/shock:

• With MCC: 1.2565;
• With CC: 1.0134; and
• Without CC: 0.8765.

I recently spoke with a hospital administrator at a large urban teaching hospital. Nearly a quarter of the hospital’s Medicare inpatients have heart failure. How physicians document heart failure represents a significant opportunity for hospital revenue ($3 million to $5 million a year). Because of this, I expect you are not alone. Hospital administrators all over the country are likely speaking with their hospitalists about their documentation.

Talk Balk

Question: A pharmaceutical company offered an honorarium for me to give a talk. I heard from a colleague that the company is required to report this payment to the government, which makes this information publicly available. Is this true?

Keynote Doc,

Minneapolis, Minn.

Dr. Hospitalist responds: The answer presently depends on where you live. Five states (California, Maine, Minnesota, West Virginia, Vermont) and the District of Columbia have some form of mandatory disclosure of payments made to physicians by pharmaceutical companies.

Minnesota and Vermont make this information publicly available. Other states may not be far behind. In 2006, 11 states considered similar legislation. But according to Ross, et. al., “the Vermont and Minnesota laws requiring full disclosure of payments do not provide easy access to payment information for the public and are of limited quality once accessed.”1

Proposed federal legislation may resolve this issue. Last fall, Sen. Charles Grassley, R-Iowa, introduced a bill called the Physicians Payments Sunshine Act of 2007. This bill would require drug and device manufacturing companies with more than $25 million in annual revenues to report all gifts in excess of $25 in value to physicians and other prescribing clinicians.

Drug/device samples and payment for clinical trials would be exempt. This data would be available in a public, searchable online database. Companies that fail to disclose would face penalties $10,000 to $100,000 for each undisclosed physician payment.

Industry support has been and will continue to be a controversial issue. Many doctors do not believe honoraria influence prescribing. But it is clear financial payments from industry are facing increasing scrutiny. You’ll need to decide whether you’re comfortable accepting this honorarium if your name will be listed on a publicly available database. TH

Reference

1. Ross JS, Lackner JE, Lurie P, et al. Pharmaceutical company payments to physicians: early experiences with disclosure laws in Vermont and Minnesota. JAMA. 2007;297(11):1216-1223.

Sore Loser?

Question: I just heard Medicare will no longer pay for care if a patient develops a bedsore during their hospital stay. Is this true?

Concerned,

Austin, Texas

Dr. Hospitalist responds: Beginning Oct. 1, the Center for Medicare and Medicaid Services (CMS) rolled out the latest change to the Inpatient Prospective Payment System by implementing the following Present on Admission (POA) Indicators:

• Object left in patient after surgery;
• Air embolism;
• Blood incompatibility;
• Catheter-associated urinary tract infections;
• Pressure ulcers (decubitus ulcers);
• Vascular catheter-associated infection;
• Mediastinitis after coronary artery bypass graft;
• Hospital-acquired injuries (fractures, dislocations, intracranial injury); and
• Crushing injury, burn, and other unspecified effects of external causes.

What exactly does this mean? Simply put, if a patient develops any of these conditions during his/her hospital stay, CMS no longer will pay the hospital for additional services associated with treatment of these conditions.

As a healthcare consumer and taxpayer, I believe this measure is long overdue. No patient should ever receive incompatible blood or have an object left in after surgery. Why should we pay for such errors? As hospitalists, our challenge is to develop processes to ensure these events never occur in the hospital. This will require implementing systems as well as educating and training every individual who works in our hospitals.

Coding for these events began Oct. 1 of last year, but payment will not be restricted until Oct. 1 of this year. Coding these events will not only affect hospital payment but will allow for public reporting of hospital performance.

CMS has proposed adding several other conditions for the next fiscal year and is analyzing still more possible conditions.

Proposed for this October:

• DVT and PE;
• Staph aureus septicemia; and
• Ventilator associated pneumonia (VAP).

Conditions under consideration:

• Methicillin-resistant Staphylococcus aureus;
• C. difficile-associated disease; and
• Wrong surgery.

Hospitals are turning to hospitalists not only to help them comply, but to lead the development of systems to improve inpatient care. I encourage you to think about how you can do this at your hospital.

Heart Murmurs

Question: Can you explain why my hospital is asking me to change the way I document heart failure in the chart? They are telling me it is the result of some diagnosis-related group (DRG) rule changes at Medicare that affects how much the hospital gets paid. Is this accurate?

Taking Note,

Louisville, Ky.

Dr. Hospitalist responds: The changes in physician documentation of inpatients with heart failure are part of a larger change in Medicare’s Inpatient Prospective Payment System. The new changes, called Medicare Severity-Adjusted DRGs (MSDRGs), restructured the DRGs to more fully account for the severity of a patient’s medical condition. The change expanded the number of DRGs from 583 to 745 by splitting the DRGs into three tiers:

• Major complication/co-morbidity (MCC);
• -Complication/co-morbidity (CC); and
• No CC.

Physician documentation that reflects chronic systolic and/or diastolic heart failure represents a CC. Documentation of acute systolic and/or acute diastolic heart failure represents an MCC. Documentation that does not describe the type and acuity of a patient’s heart failure condition will result in no CC.

Each DRG has a payment weight assigned to it, based on the average resources used to treat Medicare patients in that DRG. A higher DRG weight represents a more medically complex patient and a correspondingly higher payment. These new classifications affect the heart failure DRG weight values as follows:

Old DRG, heart failure/shock: 1.0490.

New MSDRG, heart failure/shock:

• With MCC: 1.2565;
• With CC: 1.0134; and
• Without CC: 0.8765.

I recently spoke with a hospital administrator at a large urban teaching hospital. Nearly a quarter of the hospital’s Medicare inpatients have heart failure. How physicians document heart failure represents a significant opportunity for hospital revenue ($3 million to $5 million a year). Because of this, I expect you are not alone. Hospital administrators all over the country are likely speaking with their hospitalists about their documentation.

Talk Balk

Question: A pharmaceutical company offered an honorarium for me to give a talk. I heard from a colleague that the company is required to report this payment to the government, which makes this information publicly available. Is this true?

Keynote Doc,

Minneapolis, Minn.

Dr. Hospitalist responds: The answer presently depends on where you live. Five states (California, Maine, Minnesota, West Virginia, Vermont) and the District of Columbia have some form of mandatory disclosure of payments made to physicians by pharmaceutical companies.

Minnesota and Vermont make this information publicly available. Other states may not be far behind. In 2006, 11 states considered similar legislation. But according to Ross, et. al., “the Vermont and Minnesota laws requiring full disclosure of payments do not provide easy access to payment information for the public and are of limited quality once accessed.”1

Proposed federal legislation may resolve this issue. Last fall, Sen. Charles Grassley, R-Iowa, introduced a bill called the Physicians Payments Sunshine Act of 2007. This bill would require drug and device manufacturing companies with more than $25 million in annual revenues to report all gifts in excess of $25 in value to physicians and other prescribing clinicians.

Drug/device samples and payment for clinical trials would be exempt. This data would be available in a public, searchable online database. Companies that fail to disclose would face penalties $10,000 to $100,000 for each undisclosed physician payment.

Industry support has been and will continue to be a controversial issue. Many doctors do not believe honoraria influence prescribing. But it is clear financial payments from industry are facing increasing scrutiny. You’ll need to decide whether you’re comfortable accepting this honorarium if your name will be listed on a publicly available database. TH

Reference

1. Ross JS, Lackner JE, Lurie P, et al. Pharmaceutical company payments to physicians: early experiences with disclosure laws in Vermont and Minnesota. JAMA. 2007;297(11):1216-1223.

Sore Loser?

Question: I just heard Medicare will no longer pay for care if a patient develops a bedsore during their hospital stay. Is this true?

Concerned,

Austin, Texas

Dr. Hospitalist responds: Beginning Oct. 1, the Center for Medicare and Medicaid Services (CMS) rolled out the latest change to the Inpatient Prospective Payment System by implementing the following Present on Admission (POA) Indicators:

• Object left in patient after surgery;
• Air embolism;
• Blood incompatibility;
• Catheter-associated urinary tract infections;
• Pressure ulcers (decubitus ulcers);
• Vascular catheter-associated infection;
• Mediastinitis after coronary artery bypass graft;
• Hospital-acquired injuries (fractures, dislocations, intracranial injury); and
• Crushing injury, burn, and other unspecified effects of external causes.

What exactly does this mean? Simply put, if a patient develops any of these conditions during his/her hospital stay, CMS no longer will pay the hospital for additional services associated with treatment of these conditions.

As a healthcare consumer and taxpayer, I believe this measure is long overdue. No patient should ever receive incompatible blood or have an object left in after surgery. Why should we pay for such errors? As hospitalists, our challenge is to develop processes to ensure these events never occur in the hospital. This will require implementing systems as well as educating and training every individual who works in our hospitals.

Coding for these events began Oct. 1 of last year, but payment will not be restricted until Oct. 1 of this year. Coding these events will not only affect hospital payment but will allow for public reporting of hospital performance.

CMS has proposed adding several other conditions for the next fiscal year and is analyzing still more possible conditions.

Proposed for this October:

• DVT and PE;
• Staph aureus septicemia; and
• Ventilator associated pneumonia (VAP).

Conditions under consideration:

• Methicillin-resistant Staphylococcus aureus;
• C. difficile-associated disease; and
• Wrong surgery.

Hospitals are turning to hospitalists not only to help them comply, but to lead the development of systems to improve inpatient care. I encourage you to think about how you can do this at your hospital.

Heart Murmurs

Question: Can you explain why my hospital is asking me to change the way I document heart failure in the chart? They are telling me it is the result of some diagnosis-related group (DRG) rule changes at Medicare that affects how much the hospital gets paid. Is this accurate?

Taking Note,

Louisville, Ky.

Dr. Hospitalist responds: The changes in physician documentation of inpatients with heart failure are part of a larger change in Medicare’s Inpatient Prospective Payment System. The new changes, called Medicare Severity-Adjusted DRGs (MSDRGs), restructured the DRGs to more fully account for the severity of a patient’s medical condition. The change expanded the number of DRGs from 583 to 745 by splitting the DRGs into three tiers:

• Major complication/co-morbidity (MCC);
• -Complication/co-morbidity (CC); and
• No CC.

Physician documentation that reflects chronic systolic and/or diastolic heart failure represents a CC. Documentation of acute systolic and/or acute diastolic heart failure represents an MCC. Documentation that does not describe the type and acuity of a patient’s heart failure condition will result in no CC.

Each DRG has a payment weight assigned to it, based on the average resources used to treat Medicare patients in that DRG. A higher DRG weight represents a more medically complex patient and a correspondingly higher payment. These new classifications affect the heart failure DRG weight values as follows:

Old DRG, heart failure/shock: 1.0490.

New MSDRG, heart failure/shock:

• With MCC: 1.2565;
• With CC: 1.0134; and
• Without CC: 0.8765.

I recently spoke with a hospital administrator at a large urban teaching hospital. Nearly a quarter of the hospital’s Medicare inpatients have heart failure. How physicians document heart failure represents a significant opportunity for hospital revenue ($3 million to $5 million a year). Because of this, I expect you are not alone. Hospital administrators all over the country are likely speaking with their hospitalists about their documentation.

Talk Balk

Question: A pharmaceutical company offered an honorarium for me to give a talk. I heard from a colleague that the company is required to report this payment to the government, which makes this information publicly available. Is this true?

Keynote Doc,

Minneapolis, Minn.

Dr. Hospitalist responds: The answer presently depends on where you live. Five states (California, Maine, Minnesota, West Virginia, Vermont) and the District of Columbia have some form of mandatory disclosure of payments made to physicians by pharmaceutical companies.

Minnesota and Vermont make this information publicly available. Other states may not be far behind. In 2006, 11 states considered similar legislation. But according to Ross, et. al., “the Vermont and Minnesota laws requiring full disclosure of payments do not provide easy access to payment information for the public and are of limited quality once accessed.”1

Proposed federal legislation may resolve this issue. Last fall, Sen. Charles Grassley, R-Iowa, introduced a bill called the Physicians Payments Sunshine Act of 2007. This bill would require drug and device manufacturing companies with more than $25 million in annual revenues to report all gifts in excess of $25 in value to physicians and other prescribing clinicians.

Drug/device samples and payment for clinical trials would be exempt. This data would be available in a public, searchable online database. Companies that fail to disclose would face penalties $10,000 to $100,000 for each undisclosed physician payment.

Industry support has been and will continue to be a controversial issue. Many doctors do not believe honoraria influence prescribing. But it is clear financial payments from industry are facing increasing scrutiny. You’ll need to decide whether you’re comfortable accepting this honorarium if your name will be listed on a publicly available database. TH

Reference

1. Ross JS, Lackner JE, Lurie P, et al. Pharmaceutical company payments to physicians: early experiences with disclosure laws in Vermont and Minnesota. JAMA. 2007;297(11):1216-1223.

A colleague once told me his theory that we are all born with the capacity to work a predetermined number of night shifts.

Think of this as a physiologic parameter similar to women being born with a fixed number of ova that can’t be replenished or increased after birth. While there seems to be significant variation in the number of night shifts each of us has to offer at the start of our career, it seems nearly everyone has a maximum number that is almost genetically determined. The only control we have is how quickly we use them up.

After careful consideration, I’ve realized I’ve used up all—or nearly all—my night shifts. And I have to admit it appears I was born with a fairly small number of night shifts in my genetic code.

The way a hospitalist practice addresses night work can be critical to whether it offers a sustainable career for hospitalists and good care for patients. Night coverage for many non-teaching practices usually evolves based on the size of the practice. For example:

Small practices (on-call from home):

• Fewer than six providers: Moonlighters (often local primary care physicians) are paid to help hospitalists with night coverage; or
• Six to eight providers: Hospitalists handle call from home with minimal or no help from non-hospitalist moonlighters.

Medium to large practices (in-house coverage):

• Eight to 10 providers: A hospitalist stays in-house all night. All members of the practice usually rotate responsibility for this coverage. The nocturnist on duty doesn’t work the day before or after a night shift; or
• More than 10 providers: Dedicated nocturnists might work only, or almost exclusively, at night.

There are many reasonable approaches to night coverage, and I don’t intend to suggest a given practice evolve through the above steps as it grows. It would be reasonable to skip some steps or use different size thresholds when moving from one system to another. In my experience, small practices nearly always provide night coverage on-call from home because of low night-shift productivity. As the night shift gets busier, they usually switch to in-house coverage.

I think every practice of more than about eight providers should seriously consider adding dedicated nocturnists. Most or all night shifts could be covered by the nocturnists, and the other docs in the practice wouldn’t have to rotate between day and night work. This can provide a substantial recruiting advantage and enhance career sustainability for the daytime hospitalists.

Where to Find Them

People often tell me they’d love to add nocturnists to their practice but can’t imagine where they could find people willing to do the work.

There are many potential nocturnists who might be available, including hospitalists in your practice. You just have to ensure they have a better “juice-to-squeeze ratio” than others in the practice. Usually this means offering them some combination of more pay and/or less work than others in your practice. Many people are attracted to hospitalist work because they want an interesting job that provides a lot of time off. By having nocturnists work less than others in the practice, they can have more time to pursue other interests.

There is no perfect way to gauge the appropriate adjustments in workload and compensation that will attract people to a nocturnist position in your practice. Estimate what seems equitable and see if any of your doctors would be willing to become a dedicated nocturnist. If none find the deal attractive enough to consider seriously, the chances are a new doctor you try to recruit will come to the same conclusion.

While a good “juice-to-squeeze ratio” is most important in attracting nocturnists, you could also consider a nocturnist recruitment ad that screams at the top “Never work another day in your life!” That might attract a lot of attention amid competing ads that describe the wonderful schools, quality of life, and proximity to shopping, lakes, and recreation other positions offer.

How to Pay Them

Where can you find the money to pay the nocturnist well for doing less work than his or her daytime counterparts? Most practices can appeal to their “sponsoring” hospital for more money to support this valuable component of the practice. If doctors in the practice want to be relieved of night work badly enough, they might give up some salary that can be put toward the nocturnist position.

Ask your hospital to match the contribution the doctors make. For example, each of the eight doctors in the practice might accept a $5,000 reduction in annual compensation to be relieved of all night shifts. That $40,000 could be matched 100% by the hospital for a total of $80,000. Each of two nocturnists hired by the group could split that $80,000 so they could be paid the same salary as the day doctors plus $40,000.

The Long View

Nearly everyone tires of working the night shift eventually—even if it does mean less work and more pay. Two to five years of working solely as a nocturnist might be as long as most people can do it, so plan for relatively frequent turnover. But I know of several hospitalists who have worked only at night for more than 10 years, provide excellent patient care, and seem quite happy to continue working nights. 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.” This column represents his views and is not intended to reflect an official position of SHM.

A colleague once told me his theory that we are all born with the capacity to work a predetermined number of night shifts.

Think of this as a physiologic parameter similar to women being born with a fixed number of ova that can’t be replenished or increased after birth. While there seems to be significant variation in the number of night shifts each of us has to offer at the start of our career, it seems nearly everyone has a maximum number that is almost genetically determined. The only control we have is how quickly we use them up.

After careful consideration, I’ve realized I’ve used up all—or nearly all—my night shifts. And I have to admit it appears I was born with a fairly small number of night shifts in my genetic code.

The way a hospitalist practice addresses night work can be critical to whether it offers a sustainable career for hospitalists and good care for patients. Night coverage for many non-teaching practices usually evolves based on the size of the practice. For example:

Small practices (on-call from home):

• Fewer than six providers: Moonlighters (often local primary care physicians) are paid to help hospitalists with night coverage; or
• Six to eight providers: Hospitalists handle call from home with minimal or no help from non-hospitalist moonlighters.

Medium to large practices (in-house coverage):

• Eight to 10 providers: A hospitalist stays in-house all night. All members of the practice usually rotate responsibility for this coverage. The nocturnist on duty doesn’t work the day before or after a night shift; or
• More than 10 providers: Dedicated nocturnists might work only, or almost exclusively, at night.

There are many reasonable approaches to night coverage, and I don’t intend to suggest a given practice evolve through the above steps as it grows. It would be reasonable to skip some steps or use different size thresholds when moving from one system to another. In my experience, small practices nearly always provide night coverage on-call from home because of low night-shift productivity. As the night shift gets busier, they usually switch to in-house coverage.

I think every practice of more than about eight providers should seriously consider adding dedicated nocturnists. Most or all night shifts could be covered by the nocturnists, and the other docs in the practice wouldn’t have to rotate between day and night work. This can provide a substantial recruiting advantage and enhance career sustainability for the daytime hospitalists.

Where to Find Them

People often tell me they’d love to add nocturnists to their practice but can’t imagine where they could find people willing to do the work.

There are many potential nocturnists who might be available, including hospitalists in your practice. You just have to ensure they have a better “juice-to-squeeze ratio” than others in the practice. Usually this means offering them some combination of more pay and/or less work than others in your practice. Many people are attracted to hospitalist work because they want an interesting job that provides a lot of time off. By having nocturnists work less than others in the practice, they can have more time to pursue other interests.

There is no perfect way to gauge the appropriate adjustments in workload and compensation that will attract people to a nocturnist position in your practice. Estimate what seems equitable and see if any of your doctors would be willing to become a dedicated nocturnist. If none find the deal attractive enough to consider seriously, the chances are a new doctor you try to recruit will come to the same conclusion.

While a good “juice-to-squeeze ratio” is most important in attracting nocturnists, you could also consider a nocturnist recruitment ad that screams at the top “Never work another day in your life!” That might attract a lot of attention amid competing ads that describe the wonderful schools, quality of life, and proximity to shopping, lakes, and recreation other positions offer.

How to Pay Them

Where can you find the money to pay the nocturnist well for doing less work than his or her daytime counterparts? Most practices can appeal to their “sponsoring” hospital for more money to support this valuable component of the practice. If doctors in the practice want to be relieved of night work badly enough, they might give up some salary that can be put toward the nocturnist position.

Ask your hospital to match the contribution the doctors make. For example, each of the eight doctors in the practice might accept a $5,000 reduction in annual compensation to be relieved of all night shifts. That $40,000 could be matched 100% by the hospital for a total of $80,000. Each of two nocturnists hired by the group could split that $80,000 so they could be paid the same salary as the day doctors plus $40,000.

The Long View

Nearly everyone tires of working the night shift eventually—even if it does mean less work and more pay. Two to five years of working solely as a nocturnist might be as long as most people can do it, so plan for relatively frequent turnover. But I know of several hospitalists who have worked only at night for more than 10 years, provide excellent patient care, and seem quite happy to continue working nights. 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.” This column represents his views and is not intended to reflect an official position of SHM.

A colleague once told me his theory that we are all born with the capacity to work a predetermined number of night shifts.

Think of this as a physiologic parameter similar to women being born with a fixed number of ova that can’t be replenished or increased after birth. While there seems to be significant variation in the number of night shifts each of us has to offer at the start of our career, it seems nearly everyone has a maximum number that is almost genetically determined. The only control we have is how quickly we use them up.

After careful consideration, I’ve realized I’ve used up all—or nearly all—my night shifts. And I have to admit it appears I was born with a fairly small number of night shifts in my genetic code.

The way a hospitalist practice addresses night work can be critical to whether it offers a sustainable career for hospitalists and good care for patients. Night coverage for many non-teaching practices usually evolves based on the size of the practice. For example:

Small practices (on-call from home):

• Fewer than six providers: Moonlighters (often local primary care physicians) are paid to help hospitalists with night coverage; or
• Six to eight providers: Hospitalists handle call from home with minimal or no help from non-hospitalist moonlighters.

Medium to large practices (in-house coverage):

• Eight to 10 providers: A hospitalist stays in-house all night. All members of the practice usually rotate responsibility for this coverage. The nocturnist on duty doesn’t work the day before or after a night shift; or
• More than 10 providers: Dedicated nocturnists might work only, or almost exclusively, at night.

There are many reasonable approaches to night coverage, and I don’t intend to suggest a given practice evolve through the above steps as it grows. It would be reasonable to skip some steps or use different size thresholds when moving from one system to another. In my experience, small practices nearly always provide night coverage on-call from home because of low night-shift productivity. As the night shift gets busier, they usually switch to in-house coverage.

I think every practice of more than about eight providers should seriously consider adding dedicated nocturnists. Most or all night shifts could be covered by the nocturnists, and the other docs in the practice wouldn’t have to rotate between day and night work. This can provide a substantial recruiting advantage and enhance career sustainability for the daytime hospitalists.

Where to Find Them

People often tell me they’d love to add nocturnists to their practice but can’t imagine where they could find people willing to do the work.

There are many potential nocturnists who might be available, including hospitalists in your practice. You just have to ensure they have a better “juice-to-squeeze ratio” than others in the practice. Usually this means offering them some combination of more pay and/or less work than others in your practice. Many people are attracted to hospitalist work because they want an interesting job that provides a lot of time off. By having nocturnists work less than others in the practice, they can have more time to pursue other interests.

There is no perfect way to gauge the appropriate adjustments in workload and compensation that will attract people to a nocturnist position in your practice. Estimate what seems equitable and see if any of your doctors would be willing to become a dedicated nocturnist. If none find the deal attractive enough to consider seriously, the chances are a new doctor you try to recruit will come to the same conclusion.

While a good “juice-to-squeeze ratio” is most important in attracting nocturnists, you could also consider a nocturnist recruitment ad that screams at the top “Never work another day in your life!” That might attract a lot of attention amid competing ads that describe the wonderful schools, quality of life, and proximity to shopping, lakes, and recreation other positions offer.

How to Pay Them

Where can you find the money to pay the nocturnist well for doing less work than his or her daytime counterparts? Most practices can appeal to their “sponsoring” hospital for more money to support this valuable component of the practice. If doctors in the practice want to be relieved of night work badly enough, they might give up some salary that can be put toward the nocturnist position.

Ask your hospital to match the contribution the doctors make. For example, each of the eight doctors in the practice might accept a $5,000 reduction in annual compensation to be relieved of all night shifts. That $40,000 could be matched 100% by the hospital for a total of $80,000. Each of two nocturnists hired by the group could split that $80,000 so they could be paid the same salary as the day doctors plus $40,000.

The Long View

Nearly everyone tires of working the night shift eventually—even if it does mean less work and more pay. Two to five years of working solely as a nocturnist might be as long as most people can do it, so plan for relatively frequent turnover. But I know of several hospitalists who have worked only at night for more than 10 years, provide excellent patient care, and seem quite happy to continue working nights. 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.” This column represents his views and is not intended to reflect an official position of SHM.

Armed with a cup of coffee, with my dogs walked and fed and the sun rising into view, I eased into my home office chair and contentedly folded open the pages of The Wall Street Journal.

My ritual early-morning glance at the local and national papers usually provides little more than a glum outlook for my favorite sports teams, a glummer view of my financial investments, and a few seeds to cultivate into elevator small talk.

This morning, however, I was struck by this headline: “‘Hospitalists’ Are Seen as Help.”1 I happily noted the subheading, which referred to us as “specialists.” I reveled in the general tone of the article, which indicated that we reduce hospital length of stay and costs.

The article reported the findings of a New England Journal of Medicine paper by Lindenauer, et al., that showed a 0.4-day reduction in length of stay (LOS) and a net savings of $268 per patient compared with non-hospitalist general internist providers.2 Good news for the field, indeed.

Or was it? What was not highlighted in The Wall Street Journal was that while hospitalists also reduced LOS 0.4 days versus non-hospitalist family physicians, there was no statistically significant reduction in cost versus this cohort. Further, there was no difference in hospital mortality or 14-day readmission rate versus either non-hospitalist set of providers.

While not the greatest markers of quality, mortality and readmission rate are two of the easiest and most recognized markers of effective care. Dr. Lindenauer’s paper found no benefit from the hospitalist model.

Granted, other studies have shown a benefit of the hospitalist model in areas such as co-management of orthopedic patients. But these effects were modest and primarily limited to process measures, not quality-of-care outcomes.

Another recent paper by Auerbach, et al., reported that general medical consultation by hospitalists on surgical patients did not result in better glycemic control, use of perioperative beta blockade, or venous thromboembolism prophylaxis versus surgical care alone.­

In a healthcare system that the Institute of Medicine claims is responsible for unfathomable rates of medication errors and upward of 100,000 avoidable inpatient deaths every year, it sounds as though hospitalists are missing the chance to fulfill their promise.

The promise of the hospital medicine movement is that hospitalists will do it better: cheaper, faster, and safer. If we accept this, then these new data appear to paint a picture of a movement that is chugging off course.

I don’t think it’s that simple. Rather, this speaks to two key elements in the maturation process of the hospitalist field.

First, changing the fundamentals of healthcare delivery is difficult work. This is especially true for a young group of providers, who struggle with overwhelming growth, constant understaffing, and a business model that favors patient encounters over process improvement.

On top of this, we are asked to change behavior in a complex system where instituting change often involves altering the practice of others outside your group, such as nurses or other physician groups.

Add to this significant undertraining in patient safety and process improvement, and a lack of time for quality improvement work or rewards to encourage it.

It’s little wonder we haven’t moved the quality needle much. Viewed through this lens, the fact that we have accomplished even modest improvements is impressive.

Second, we need to do a better job of measuring our benefit. Mortality and readmission are important outcomes, and we should always aim to improve these quality indicators. However, they’re both downstream markers that are easy to measure but difficult to budge.

We must acknowledge, however, that we haven’t done a good job of measuring our effect on the value-added aspects of hospital medicine: nursing happiness, hospital leadership, team work, staff education, patient satisfaction, protocol development, and our willingness to take on work others are not keen to do, such as unassigned emergency department call.

How do we put a price on the value of being available for a patient in extremis, a nurse with a question, a committee chairpersonship? How do we measure the downstream benefit of offloading our surgical and medical subspecialty colleagues so they can perform more procedures while we care for their recently proceduralized patients?

This is difficult material to measure, especially in a scientific manner. In this regard, it is incumbent on local leaders to ensure these data are collected and available for presentation to those who subsidize our practices.

Short of this, groups are exposed to a serious threat from a hospital chief financial officer armed with a directive to cut costs and the Dec. 20 edition of The Wall Street Journal.

Hospital medicine is a work in progress. We need to do a better job of measuring our value-added benefits. However, we should strive to exceed what is acceptable. While it is reasonable to accept little documented improvement in quality indicators today, it should not be acceptable in the near future.

The field will need to move toward improving, documenting, and rewarding improvements in clinical outcomes. This means elemental change toward developing practice standards and models of care for common disease states, standardizing care throughout the hospital and actively engaging in improving quality at every turn.

Hospitalists will need to agree to be measured, participate in measurement, and be held accountable for achieving quality benchmarks.

This transformation necessitates that hospitalist educators (both residency and post-residency) better prepare hospitalists to lead change in areas of quality improvement.

These educators must impart the basic tenets of change management, process improvement, and patient safety.

These changes will take provider time—time that will need to be supported by hospitals and group leaders in the form of accepting less revenue per provider, which will in turn require inspired leadership to negotiate this time and build a new sustainable business model centered around quality.

As the field matures it is becoming clearer that our business can no longer be predicated on cost savings and efficiency alone.

While we need to be ever mindful of these metrics, we need to evolve beyond this model to one with quality at its core.

We should expect and reward superior patient outcomes at the expense of quantity. Anything short of this squanders one of the purest opportunities to positively affect the U.S. healthcare system for generations to come. TH

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

References

1. Levitz J. Hospitalists are seen as help. The Wall Street Journal. Dec. 20, 2007:D7.
2. Lindenauer PK, Rothberg MB, Pekow PS, Kenwood C, Benjamin EM, Auerbach AD et al. Outcomes of care by hospitalists, general internists, and family physicians. N Engl J Med. 2007 Dec 20; 357(25):2589-2600.
3. Auerbach AD, Rasic MA, Sehgal N, Ide B, Stone B, Maselli Jet al. Opportunity missed: medical consultation, resource use, and quality of care of patients undergoing major surgery. Arch Intern Med. 2007 Nov. 26;167(21): 2338-2344.

Armed with a cup of coffee, with my dogs walked and fed and the sun rising into view, I eased into my home office chair and contentedly folded open the pages of The Wall Street Journal.

My ritual early-morning glance at the local and national papers usually provides little more than a glum outlook for my favorite sports teams, a glummer view of my financial investments, and a few seeds to cultivate into elevator small talk.

This morning, however, I was struck by this headline: “‘Hospitalists’ Are Seen as Help.”1 I happily noted the subheading, which referred to us as “specialists.” I reveled in the general tone of the article, which indicated that we reduce hospital length of stay and costs.

The article reported the findings of a New England Journal of Medicine paper by Lindenauer, et al., that showed a 0.4-day reduction in length of stay (LOS) and a net savings of $268 per patient compared with non-hospitalist general internist providers.2 Good news for the field, indeed.

Or was it? What was not highlighted in The Wall Street Journal was that while hospitalists also reduced LOS 0.4 days versus non-hospitalist family physicians, there was no statistically significant reduction in cost versus this cohort. Further, there was no difference in hospital mortality or 14-day readmission rate versus either non-hospitalist set of providers.

While not the greatest markers of quality, mortality and readmission rate are two of the easiest and most recognized markers of effective care. Dr. Lindenauer’s paper found no benefit from the hospitalist model.

Granted, other studies have shown a benefit of the hospitalist model in areas such as co-management of orthopedic patients. But these effects were modest and primarily limited to process measures, not quality-of-care outcomes.

Another recent paper by Auerbach, et al., reported that general medical consultation by hospitalists on surgical patients did not result in better glycemic control, use of perioperative beta blockade, or venous thromboembolism prophylaxis versus surgical care alone.­

In a healthcare system that the Institute of Medicine claims is responsible for unfathomable rates of medication errors and upward of 100,000 avoidable inpatient deaths every year, it sounds as though hospitalists are missing the chance to fulfill their promise.

The promise of the hospital medicine movement is that hospitalists will do it better: cheaper, faster, and safer. If we accept this, then these new data appear to paint a picture of a movement that is chugging off course.

I don’t think it’s that simple. Rather, this speaks to two key elements in the maturation process of the hospitalist field.

First, changing the fundamentals of healthcare delivery is difficult work. This is especially true for a young group of providers, who struggle with overwhelming growth, constant understaffing, and a business model that favors patient encounters over process improvement.

On top of this, we are asked to change behavior in a complex system where instituting change often involves altering the practice of others outside your group, such as nurses or other physician groups.

Add to this significant undertraining in patient safety and process improvement, and a lack of time for quality improvement work or rewards to encourage it.

It’s little wonder we haven’t moved the quality needle much. Viewed through this lens, the fact that we have accomplished even modest improvements is impressive.

Second, we need to do a better job of measuring our benefit. Mortality and readmission are important outcomes, and we should always aim to improve these quality indicators. However, they’re both downstream markers that are easy to measure but difficult to budge.

We must acknowledge, however, that we haven’t done a good job of measuring our effect on the value-added aspects of hospital medicine: nursing happiness, hospital leadership, team work, staff education, patient satisfaction, protocol development, and our willingness to take on work others are not keen to do, such as unassigned emergency department call.

How do we put a price on the value of being available for a patient in extremis, a nurse with a question, a committee chairpersonship? How do we measure the downstream benefit of offloading our surgical and medical subspecialty colleagues so they can perform more procedures while we care for their recently proceduralized patients?

This is difficult material to measure, especially in a scientific manner. In this regard, it is incumbent on local leaders to ensure these data are collected and available for presentation to those who subsidize our practices.

Short of this, groups are exposed to a serious threat from a hospital chief financial officer armed with a directive to cut costs and the Dec. 20 edition of The Wall Street Journal.

Hospital medicine is a work in progress. We need to do a better job of measuring our value-added benefits. However, we should strive to exceed what is acceptable. While it is reasonable to accept little documented improvement in quality indicators today, it should not be acceptable in the near future.

The field will need to move toward improving, documenting, and rewarding improvements in clinical outcomes. This means elemental change toward developing practice standards and models of care for common disease states, standardizing care throughout the hospital and actively engaging in improving quality at every turn.

Hospitalists will need to agree to be measured, participate in measurement, and be held accountable for achieving quality benchmarks.

This transformation necessitates that hospitalist educators (both residency and post-residency) better prepare hospitalists to lead change in areas of quality improvement.

These educators must impart the basic tenets of change management, process improvement, and patient safety.

These changes will take provider time—time that will need to be supported by hospitals and group leaders in the form of accepting less revenue per provider, which will in turn require inspired leadership to negotiate this time and build a new sustainable business model centered around quality.

As the field matures it is becoming clearer that our business can no longer be predicated on cost savings and efficiency alone.

While we need to be ever mindful of these metrics, we need to evolve beyond this model to one with quality at its core.

We should expect and reward superior patient outcomes at the expense of quantity. Anything short of this squanders one of the purest opportunities to positively affect the U.S. healthcare system for generations to come. TH

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

References

1. Levitz J. Hospitalists are seen as help. The Wall Street Journal. Dec. 20, 2007:D7.
2. Lindenauer PK, Rothberg MB, Pekow PS, Kenwood C, Benjamin EM, Auerbach AD et al. Outcomes of care by hospitalists, general internists, and family physicians. N Engl J Med. 2007 Dec 20; 357(25):2589-2600.
3. Auerbach AD, Rasic MA, Sehgal N, Ide B, Stone B, Maselli Jet al. Opportunity missed: medical consultation, resource use, and quality of care of patients undergoing major surgery. Arch Intern Med. 2007 Nov. 26;167(21): 2338-2344.

Armed with a cup of coffee, with my dogs walked and fed and the sun rising into view, I eased into my home office chair and contentedly folded open the pages of The Wall Street Journal.

My ritual early-morning glance at the local and national papers usually provides little more than a glum outlook for my favorite sports teams, a glummer view of my financial investments, and a few seeds to cultivate into elevator small talk.

This morning, however, I was struck by this headline: “‘Hospitalists’ Are Seen as Help.”1 I happily noted the subheading, which referred to us as “specialists.” I reveled in the general tone of the article, which indicated that we reduce hospital length of stay and costs.

The article reported the findings of a New England Journal of Medicine paper by Lindenauer, et al., that showed a 0.4-day reduction in length of stay (LOS) and a net savings of $268 per patient compared with non-hospitalist general internist providers.2 Good news for the field, indeed.

Or was it? What was not highlighted in The Wall Street Journal was that while hospitalists also reduced LOS 0.4 days versus non-hospitalist family physicians, there was no statistically significant reduction in cost versus this cohort. Further, there was no difference in hospital mortality or 14-day readmission rate versus either non-hospitalist set of providers.

While not the greatest markers of quality, mortality and readmission rate are two of the easiest and most recognized markers of effective care. Dr. Lindenauer’s paper found no benefit from the hospitalist model.

Granted, other studies have shown a benefit of the hospitalist model in areas such as co-management of orthopedic patients. But these effects were modest and primarily limited to process measures, not quality-of-care outcomes.

Another recent paper by Auerbach, et al., reported that general medical consultation by hospitalists on surgical patients did not result in better glycemic control, use of perioperative beta blockade, or venous thromboembolism prophylaxis versus surgical care alone.­

In a healthcare system that the Institute of Medicine claims is responsible for unfathomable rates of medication errors and upward of 100,000 avoidable inpatient deaths every year, it sounds as though hospitalists are missing the chance to fulfill their promise.

The promise of the hospital medicine movement is that hospitalists will do it better: cheaper, faster, and safer. If we accept this, then these new data appear to paint a picture of a movement that is chugging off course.

I don’t think it’s that simple. Rather, this speaks to two key elements in the maturation process of the hospitalist field.

First, changing the fundamentals of healthcare delivery is difficult work. This is especially true for a young group of providers, who struggle with overwhelming growth, constant understaffing, and a business model that favors patient encounters over process improvement.

On top of this, we are asked to change behavior in a complex system where instituting change often involves altering the practice of others outside your group, such as nurses or other physician groups.

Add to this significant undertraining in patient safety and process improvement, and a lack of time for quality improvement work or rewards to encourage it.

It’s little wonder we haven’t moved the quality needle much. Viewed through this lens, the fact that we have accomplished even modest improvements is impressive.

Second, we need to do a better job of measuring our benefit. Mortality and readmission are important outcomes, and we should always aim to improve these quality indicators. However, they’re both downstream markers that are easy to measure but difficult to budge.

We must acknowledge, however, that we haven’t done a good job of measuring our effect on the value-added aspects of hospital medicine: nursing happiness, hospital leadership, team work, staff education, patient satisfaction, protocol development, and our willingness to take on work others are not keen to do, such as unassigned emergency department call.

How do we put a price on the value of being available for a patient in extremis, a nurse with a question, a committee chairpersonship? How do we measure the downstream benefit of offloading our surgical and medical subspecialty colleagues so they can perform more procedures while we care for their recently proceduralized patients?

This is difficult material to measure, especially in a scientific manner. In this regard, it is incumbent on local leaders to ensure these data are collected and available for presentation to those who subsidize our practices.

Short of this, groups are exposed to a serious threat from a hospital chief financial officer armed with a directive to cut costs and the Dec. 20 edition of The Wall Street Journal.

Hospital medicine is a work in progress. We need to do a better job of measuring our value-added benefits. However, we should strive to exceed what is acceptable. While it is reasonable to accept little documented improvement in quality indicators today, it should not be acceptable in the near future.

The field will need to move toward improving, documenting, and rewarding improvements in clinical outcomes. This means elemental change toward developing practice standards and models of care for common disease states, standardizing care throughout the hospital and actively engaging in improving quality at every turn.

Hospitalists will need to agree to be measured, participate in measurement, and be held accountable for achieving quality benchmarks.

This transformation necessitates that hospitalist educators (both residency and post-residency) better prepare hospitalists to lead change in areas of quality improvement.

These educators must impart the basic tenets of change management, process improvement, and patient safety.

These changes will take provider time—time that will need to be supported by hospitals and group leaders in the form of accepting less revenue per provider, which will in turn require inspired leadership to negotiate this time and build a new sustainable business model centered around quality.

As the field matures it is becoming clearer that our business can no longer be predicated on cost savings and efficiency alone.

While we need to be ever mindful of these metrics, we need to evolve beyond this model to one with quality at its core.

We should expect and reward superior patient outcomes at the expense of quantity. Anything short of this squanders one of the purest opportunities to positively affect the U.S. healthcare system for generations to come. TH

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

References

1. Levitz J. Hospitalists are seen as help. The Wall Street Journal. Dec. 20, 2007:D7.
2. Lindenauer PK, Rothberg MB, Pekow PS, Kenwood C, Benjamin EM, Auerbach AD et al. Outcomes of care by hospitalists, general internists, and family physicians. N Engl J Med. 2007 Dec 20; 357(25):2589-2600.
3. Auerbach AD, Rasic MA, Sehgal N, Ide B, Stone B, Maselli Jet al. Opportunity missed: medical consultation, resource use, and quality of care of patients undergoing major surgery. Arch Intern Med. 2007 Nov. 26;167(21): 2338-2344.

Dear Hillary (or Rudy or Mitt or Barack):

I know you have a lot on your mind, what with not knowing whether you are in New Hampshire or South Carolina half the time during the campaign. But I wanted to drop you a note and let you know there is a big mess in healthcare.

Hospitalists are a growing army that can bring our country patient-centered care and measurable quality outcomes, all delivered by teams of health professionals—if you and Congress can give us some help.

In case you are not totally familiar with the concept, hospital medicine is the fastest-growing specialty in American medical history. We are more than 20,000 strong, and we treat more than 30% of medical inpatients in the country. Hospitalists are right where the action is in healthcare.

We know we can do our part to change our health communities, starting with our hospitals. But we need to improve the economics of healthcare—both what we pay for and what we reward—if we are to get the right physicians to go into hospital medicine and make this a sustainable career.

So here is our wish list.

Insure All Americans

There are about 50 million people without health insurance, give or take a million. Everyone knows these people are sicker and die quicker. I guess the good news is that when they eventually show up in distress at our hospitals, we hospitalists jump in and do the best we can—regardless of whether they can pay for their care or not.

The problem is these uninsured patients often should have seen us days or weeks earlier, which makes it harder for us to help them. If we are fortunate enough to get a handle on the crisis, too often lack of insurance makes it harder to find doctors in the community to follow up with these needy patients.

We are working with the American Cancer Society, which has recognized that even for those who think they have insurance coverage, many times it is inadequate. If you’re unlucky enough to get the “big C” you may end up with a choice between the best care and bankruptcy—or both.

I don’t know whether the solution is to:

• Expand the State Children’s Health Insurance Program to include all kids;
• Extend Medicare to people at age 55 (as Sen. Joe Biden, D-Del., has suggested); or
• Extend Medicare to those as young as 15 to get everybody covered.

I do know the time for talk is well past. It is time for leadership and action.

If you get a chance you might take a look at the November/December 2007 issue of Health Affairs. In it, experts like Victor Fuchs, Bill Roper, Bob Berenson, Len Schaeffer, and many others frame the issues of health reform in practical terms. At the very least direct your health staffer to get a copy.

Reform Payment

People should expect value in healthcare, as we do in almost everything else we buy and need. We have an outmoded payment system that insists on rewarding the doing of anything. We have to start paying for what we want.

We have to stop paying for the unit of the visit or unit of the procedure, which just leads to more visits or more procedures—even if they produce no appreciable improvement in outcomes or quality of care. We have to start figuring out what outcomes we want and reward those healthcare professionals who can produce. If we want our diabetics in good control, pay for that. Don’t pay for just seeing the diabetic patient.

The cornerstone of value-based purchasing—which is our goal—is performance measurement. Hospitalists are at the head of the line in agreeing to be measured and in working with other health professionals and patients to set goals for ideal hospital care. We don’t mind being held accountable for our performance; we just want to be involved in ensuring we’re measured on what matters and that we have a plan for and a part in our improvement.

We also question if measuring performance at the individual doctor level makes sense. We believe healthcare is a team sport. We view our role as working with the entire healthcare team to deliver measurable, quality care. Our teams and hospitals need to be held accountable for performance and outcomes—and payment for care should be commensurate with performance.

We can talk about whether this takes the form of case rates or diagnosis-related groups for physician care: Both can reward efficiency and systems improvement. Or perhaps we should aim for pay for performance or pay for outcomes that would reward effectiveness and value. The recent decree by the Centers for Medicare and Medicaid Services not to pay hospitals for so-called “never” events (hospitalization errors that should never happen) is a good start. But we need to plow those savings back into rewards for high performance.

In the short term, if you can’t change the structure of the current payment system, at least stop these annual 5% to 10% reimbursement cuts. We are young physicians at the lower end of the pay scale, and there is little room for us to cut our expenses or stop paying our medical school loans. We are the front-line doctors essential to caring for the acutely ill, especially the elderly, and we need a payment system that makes it attractive for other young doctors to join us. Throwing out across-the-board payment cuts makes it more likely the new, younger physicians will continue to choose higher-paying specialties like anesthesiology and dermatology—just when we need many more hospitalists.

Reward What You Want

We are stuck in this payment system where we only pay for direct, face-to-face, one-on-one patient care. While this is still necessary, patients, employers, and the system cry out for a different approach.

The system needs to be reworked with improved throughput and efficiency. Seamless communication and coordination of care are primary goals. Reformed infrastructure and culture should foster development of highly effective teams of healthcare professionals. Time must be built into the work day for end-of-life care, palliative care, and joint decision-making by patients and their families.

All this takes dedication, expertise, professionalism, and—most of all—time. But in a payment system that rewards scoping an orifice or cutting out a skin lesion and still hasn’t figured out how to pay for changing the system or building a team, where do you think most physicians’ work time is driven?

Nowhere is it truer than in healthcare that you get what you pay for. There is plenty of money in the U.S. healthcare system—more than $2 trillion annually. The problem is we’re funding a system that may have worked in the 1950s, and we expect it to meet 21st-century needs.

Hospitalists are young, energetic, and optimistic. We want to be part of the solution, not another self-interest group demanding our needs be met and the heck with the dysfunction they might create. We also have most of our professional lives ahead of us, and we have seen that when we work extra hard to correct our local hospital’s glitches, it helps us function better.

The problems won’t go away if we ignore them. We have no choice but to step up and take a chance at change. We challenge you to step up, be a leader, and dare to make a difference. We suggest you:

• Figure out a way to get all Americans insured;
• Create a value proposition in healthcare and set up a new payment system that rewards value, efficiency, and effectiveness; and
• Reward and incentivize a new paradigm of healthcare delivered by teams of health professionals performing in functional systems of care.

There are many entrenched institutions and constituencies that will see any change as a prescription for them to lose. Hospitalists are the future. We embrace change and accept that staying in a system that is not working is not an option. We can’t predict the outcome, but when you look for partners to take the healthcare system forward, hospitalists are ready to do their share and more. But we need your help, and we need it now. TH

Dr. Wellikson is CEO of SHM.

Dear Hillary (or Rudy or Mitt or Barack):

I know you have a lot on your mind, what with not knowing whether you are in New Hampshire or South Carolina half the time during the campaign. But I wanted to drop you a note and let you know there is a big mess in healthcare.

Hospitalists are a growing army that can bring our country patient-centered care and measurable quality outcomes, all delivered by teams of health professionals—if you and Congress can give us some help.

In case you are not totally familiar with the concept, hospital medicine is the fastest-growing specialty in American medical history. We are more than 20,000 strong, and we treat more than 30% of medical inpatients in the country. Hospitalists are right where the action is in healthcare.

We know we can do our part to change our health communities, starting with our hospitals. But we need to improve the economics of healthcare—both what we pay for and what we reward—if we are to get the right physicians to go into hospital medicine and make this a sustainable career.

So here is our wish list.

Insure All Americans

There are about 50 million people without health insurance, give or take a million. Everyone knows these people are sicker and die quicker. I guess the good news is that when they eventually show up in distress at our hospitals, we hospitalists jump in and do the best we can—regardless of whether they can pay for their care or not.

The problem is these uninsured patients often should have seen us days or weeks earlier, which makes it harder for us to help them. If we are fortunate enough to get a handle on the crisis, too often lack of insurance makes it harder to find doctors in the community to follow up with these needy patients.

We are working with the American Cancer Society, which has recognized that even for those who think they have insurance coverage, many times it is inadequate. If you’re unlucky enough to get the “big C” you may end up with a choice between the best care and bankruptcy—or both.

I don’t know whether the solution is to:

• Expand the State Children’s Health Insurance Program to include all kids;
• Extend Medicare to people at age 55 (as Sen. Joe Biden, D-Del., has suggested); or
• Extend Medicare to those as young as 15 to get everybody covered.

I do know the time for talk is well past. It is time for leadership and action.

If you get a chance you might take a look at the November/December 2007 issue of Health Affairs. In it, experts like Victor Fuchs, Bill Roper, Bob Berenson, Len Schaeffer, and many others frame the issues of health reform in practical terms. At the very least direct your health staffer to get a copy.

Reform Payment

People should expect value in healthcare, as we do in almost everything else we buy and need. We have an outmoded payment system that insists on rewarding the doing of anything. We have to start paying for what we want.

We have to stop paying for the unit of the visit or unit of the procedure, which just leads to more visits or more procedures—even if they produce no appreciable improvement in outcomes or quality of care. We have to start figuring out what outcomes we want and reward those healthcare professionals who can produce. If we want our diabetics in good control, pay for that. Don’t pay for just seeing the diabetic patient.

The cornerstone of value-based purchasing—which is our goal—is performance measurement. Hospitalists are at the head of the line in agreeing to be measured and in working with other health professionals and patients to set goals for ideal hospital care. We don’t mind being held accountable for our performance; we just want to be involved in ensuring we’re measured on what matters and that we have a plan for and a part in our improvement.

We also question if measuring performance at the individual doctor level makes sense. We believe healthcare is a team sport. We view our role as working with the entire healthcare team to deliver measurable, quality care. Our teams and hospitals need to be held accountable for performance and outcomes—and payment for care should be commensurate with performance.

We can talk about whether this takes the form of case rates or diagnosis-related groups for physician care: Both can reward efficiency and systems improvement. Or perhaps we should aim for pay for performance or pay for outcomes that would reward effectiveness and value. The recent decree by the Centers for Medicare and Medicaid Services not to pay hospitals for so-called “never” events (hospitalization errors that should never happen) is a good start. But we need to plow those savings back into rewards for high performance.

In the short term, if you can’t change the structure of the current payment system, at least stop these annual 5% to 10% reimbursement cuts. We are young physicians at the lower end of the pay scale, and there is little room for us to cut our expenses or stop paying our medical school loans. We are the front-line doctors essential to caring for the acutely ill, especially the elderly, and we need a payment system that makes it attractive for other young doctors to join us. Throwing out across-the-board payment cuts makes it more likely the new, younger physicians will continue to choose higher-paying specialties like anesthesiology and dermatology—just when we need many more hospitalists.

Reward What You Want

We are stuck in this payment system where we only pay for direct, face-to-face, one-on-one patient care. While this is still necessary, patients, employers, and the system cry out for a different approach.

The system needs to be reworked with improved throughput and efficiency. Seamless communication and coordination of care are primary goals. Reformed infrastructure and culture should foster development of highly effective teams of healthcare professionals. Time must be built into the work day for end-of-life care, palliative care, and joint decision-making by patients and their families.

All this takes dedication, expertise, professionalism, and—most of all—time. But in a payment system that rewards scoping an orifice or cutting out a skin lesion and still hasn’t figured out how to pay for changing the system or building a team, where do you think most physicians’ work time is driven?

Nowhere is it truer than in healthcare that you get what you pay for. There is plenty of money in the U.S. healthcare system—more than $2 trillion annually. The problem is we’re funding a system that may have worked in the 1950s, and we expect it to meet 21st-century needs.

Hospitalists are young, energetic, and optimistic. We want to be part of the solution, not another self-interest group demanding our needs be met and the heck with the dysfunction they might create. We also have most of our professional lives ahead of us, and we have seen that when we work extra hard to correct our local hospital’s glitches, it helps us function better.

The problems won’t go away if we ignore them. We have no choice but to step up and take a chance at change. We challenge you to step up, be a leader, and dare to make a difference. We suggest you:

• Figure out a way to get all Americans insured;
• Create a value proposition in healthcare and set up a new payment system that rewards value, efficiency, and effectiveness; and
• Reward and incentivize a new paradigm of healthcare delivered by teams of health professionals performing in functional systems of care.

There are many entrenched institutions and constituencies that will see any change as a prescription for them to lose. Hospitalists are the future. We embrace change and accept that staying in a system that is not working is not an option. We can’t predict the outcome, but when you look for partners to take the healthcare system forward, hospitalists are ready to do their share and more. But we need your help, and we need it now. TH

Dr. Wellikson is CEO of SHM.

Dear Hillary (or Rudy or Mitt or Barack):

I know you have a lot on your mind, what with not knowing whether you are in New Hampshire or South Carolina half the time during the campaign. But I wanted to drop you a note and let you know there is a big mess in healthcare.

Hospitalists are a growing army that can bring our country patient-centered care and measurable quality outcomes, all delivered by teams of health professionals—if you and Congress can give us some help.

In case you are not totally familiar with the concept, hospital medicine is the fastest-growing specialty in American medical history. We are more than 20,000 strong, and we treat more than 30% of medical inpatients in the country. Hospitalists are right where the action is in healthcare.

We know we can do our part to change our health communities, starting with our hospitals. But we need to improve the economics of healthcare—both what we pay for and what we reward—if we are to get the right physicians to go into hospital medicine and make this a sustainable career.

So here is our wish list.

Insure All Americans

There are about 50 million people without health insurance, give or take a million. Everyone knows these people are sicker and die quicker. I guess the good news is that when they eventually show up in distress at our hospitals, we hospitalists jump in and do the best we can—regardless of whether they can pay for their care or not.

The problem is these uninsured patients often should have seen us days or weeks earlier, which makes it harder for us to help them. If we are fortunate enough to get a handle on the crisis, too often lack of insurance makes it harder to find doctors in the community to follow up with these needy patients.

We are working with the American Cancer Society, which has recognized that even for those who think they have insurance coverage, many times it is inadequate. If you’re unlucky enough to get the “big C” you may end up with a choice between the best care and bankruptcy—or both.

I don’t know whether the solution is to:

• Expand the State Children’s Health Insurance Program to include all kids;
• Extend Medicare to people at age 55 (as Sen. Joe Biden, D-Del., has suggested); or
• Extend Medicare to those as young as 15 to get everybody covered.

I do know the time for talk is well past. It is time for leadership and action.

If you get a chance you might take a look at the November/December 2007 issue of Health Affairs. In it, experts like Victor Fuchs, Bill Roper, Bob Berenson, Len Schaeffer, and many others frame the issues of health reform in practical terms. At the very least direct your health staffer to get a copy.

Reform Payment

People should expect value in healthcare, as we do in almost everything else we buy and need. We have an outmoded payment system that insists on rewarding the doing of anything. We have to start paying for what we want.

We have to stop paying for the unit of the visit or unit of the procedure, which just leads to more visits or more procedures—even if they produce no appreciable improvement in outcomes or quality of care. We have to start figuring out what outcomes we want and reward those healthcare professionals who can produce. If we want our diabetics in good control, pay for that. Don’t pay for just seeing the diabetic patient.

The cornerstone of value-based purchasing—which is our goal—is performance measurement. Hospitalists are at the head of the line in agreeing to be measured and in working with other health professionals and patients to set goals for ideal hospital care. We don’t mind being held accountable for our performance; we just want to be involved in ensuring we’re measured on what matters and that we have a plan for and a part in our improvement.

We also question if measuring performance at the individual doctor level makes sense. We believe healthcare is a team sport. We view our role as working with the entire healthcare team to deliver measurable, quality care. Our teams and hospitals need to be held accountable for performance and outcomes—and payment for care should be commensurate with performance.

We can talk about whether this takes the form of case rates or diagnosis-related groups for physician care: Both can reward efficiency and systems improvement. Or perhaps we should aim for pay for performance or pay for outcomes that would reward effectiveness and value. The recent decree by the Centers for Medicare and Medicaid Services not to pay hospitals for so-called “never” events (hospitalization errors that should never happen) is a good start. But we need to plow those savings back into rewards for high performance.

In the short term, if you can’t change the structure of the current payment system, at least stop these annual 5% to 10% reimbursement cuts. We are young physicians at the lower end of the pay scale, and there is little room for us to cut our expenses or stop paying our medical school loans. We are the front-line doctors essential to caring for the acutely ill, especially the elderly, and we need a payment system that makes it attractive for other young doctors to join us. Throwing out across-the-board payment cuts makes it more likely the new, younger physicians will continue to choose higher-paying specialties like anesthesiology and dermatology—just when we need many more hospitalists.

Reward What You Want

We are stuck in this payment system where we only pay for direct, face-to-face, one-on-one patient care. While this is still necessary, patients, employers, and the system cry out for a different approach.

The system needs to be reworked with improved throughput and efficiency. Seamless communication and coordination of care are primary goals. Reformed infrastructure and culture should foster development of highly effective teams of healthcare professionals. Time must be built into the work day for end-of-life care, palliative care, and joint decision-making by patients and their families.

All this takes dedication, expertise, professionalism, and—most of all—time. But in a payment system that rewards scoping an orifice or cutting out a skin lesion and still hasn’t figured out how to pay for changing the system or building a team, where do you think most physicians’ work time is driven?

Nowhere is it truer than in healthcare that you get what you pay for. There is plenty of money in the U.S. healthcare system—more than $2 trillion annually. The problem is we’re funding a system that may have worked in the 1950s, and we expect it to meet 21st-century needs.

Hospitalists are young, energetic, and optimistic. We want to be part of the solution, not another self-interest group demanding our needs be met and the heck with the dysfunction they might create. We also have most of our professional lives ahead of us, and we have seen that when we work extra hard to correct our local hospital’s glitches, it helps us function better.

The problems won’t go away if we ignore them. We have no choice but to step up and take a chance at change. We challenge you to step up, be a leader, and dare to make a difference. We suggest you:

• Figure out a way to get all Americans insured;
• Create a value proposition in healthcare and set up a new payment system that rewards value, efficiency, and effectiveness; and
• Reward and incentivize a new paradigm of healthcare delivered by teams of health professionals performing in functional systems of care.

There are many entrenched institutions and constituencies that will see any change as a prescription for them to lose. Hospitalists are the future. We embrace change and accept that staying in a system that is not working is not an option. We can’t predict the outcome, but when you look for partners to take the healthcare system forward, hospitalists are ready to do their share and more. But we need your help, and we need it now. TH

Dr. Wellikson is CEO of SHM.

Pediatric hospitalist Patrick Conway, MD, MSc, has become the first hospitalist accepted into The White House Fellows Program, a spokeswoman for the program says.

Dr. Conway had just reported to a new job at Cincinnati Children’s Hospital Medical Center when he found out he’d been accepted into the White House program. He’s serving with 14 other fellows, including one other medical professional, until August. He’ll return to Cincinnati with a deeper understanding of how physicians can affect federal health policy.

“It’s a once-in-a-lifetime learning experience, to see policy setting at the highest level of government,” Dr. Conway says.

Throughout the year, Dr. Conway, 33, will work in the office of Michael Leavitt, secretary of Health and Human Services (HHS), and with Carolyn Clancy, MD, director of the Agency for Healthcare Research and Quality (AHRQ).

“He’s an amazingly sharp physician who brings a great wealth of expertise, both because of the research he’s done but also in a clinical sense,” says Dr. Clancy, one of Dr. Conway’s mentors in the program. “He has a great grasp of policy.”

Dr. Conway has had to hit the ground running in his new role.

“We’re involving him directly in a number of very high-priority areas” including the improvement of healthcare quality and value, Dr. Clancy says. “He’ll be doing some research and a lot of trying to distill what we know from research to try and influence policy.”

The year will also bring another achievement: Dr. Conway will become a dad for the first time; his wife, Heather, is due March 30.

“I’m sort of peripherally involved,” he says ruefully. “I haven’t made it to any OB appointments.”

Dr. Conway, originally from College Station, Texas, received a master’s in health services research from the University of Pennsylvania. He earned his MD from Baylor College of Medicine and did his pediatrics residency at Children’s Hospital Boston, the primary pediatric teaching hospital for Harvard Medical School. He worked with healthcare clients as a management consultant at McKinsey & Company in Chicago, and he was a Robert Wood Johnson Clinical Scholar from 2005 to 2007. He’s done volunteer work in Nicaragua, the Dominican Republic, Bolivia, and Ghana. When he returns to Cincinnati Children’s, he’ll resume work as assistant professor in the Center for Health Care Quality and the Division of General Pediatrics.

On the Radar

While a Robert Wood Johnson scholar, Dr. Conway’s primary mentor was Ron Keren, MD, MPH, attending physician and director of the General Pediatrics Fellowship Program at the Children’s Hospital of Philadelphia. They worked together on a study of the use of prophylactic antibiotics in recurrent urinary tract infections in children, published last summer in the Journal of the American Medical Association (JAMA). The study found that, contrary to expectations, prophylactic antibiotics are not associated with a lower risk of recurrent infections and are associated with a higher risk of resistant infections.1

Dr. Keren was one of the people who recommended Dr. Conway on his application for the White House fellowship.

“Patrick … is intense,” says Dr. Keren, laughing. “But not in an obvious way. He’s very mild-mannered and polite and easy going on the outside. But when he starts a project, he is pretty aggressive as far as setting a very ambitious timeline, pushing things forward, and working as hard as possible. I just had to point him in the right direction every now and then, and he got the job done.”

Dr. Conway, lead author of the JAMA study, also contributed to a video news release and podcasts about its results. He impressed some of Dr. Clancy’s colleagues at the AHRQ with his ability to make the information easy to understand for people without a clinical medical background, Dr. Clancy says. That skill made him a good candidate for the fellowship.

“My goal is that he would get a lot of exposure to how healthcare policy is made, and that he would go back to Cincinnati Children’s understanding how physicians can play a more vital role in making sure that we get health policy right,” Dr. Clancy says. “To do that, you’ve got to be bilingual both in policy and in medicine—and there aren’t enough people who have that skill.”

And there’s something else to look forward to. “Supposedly we get the opportunity to ride mountain bikes with the president if we’re good enough,” Dr. Conway says. “I bike, but not extensively, so I’m working up to that. I need to make sure I don’t embarrass myself.”

Hospitalist Goals

Dr. Conway says one of his focuses is on the implementation of health information technology that better serves physicians and patients.

“We are interested in the alignment of incentive payments to physicians who use information technology to improve the care delivered to patients,” including electronic medical records and interoperability of data, he says. “In the last five years or so, there’s been increased interest in pay for performance, and now we’re moving toward thinking about how to structure these programs to pay for and enable quality improvement and the effective utilization of information technology.

“From a hospitalist perspective, I think one of the important issues is that many of these quality measures are directly related to the care delivered in hospitals by, primarily, hospitalists, so therefore it’s important for hospitalists to be involved in these processes.”

He’s also working with HHS on a value-driven healthcare initiative, intended “to bring transparency around quality and cost in healthcare and to enable quality improvement,” Dr. Conway says. “In this case, transparency for all stakeholders, so for consumers, for providers, for payers. We can criticize the process from the outside or we can get involved. We need to get involved.”

He has had a clearer idea than most about his career plan from the start, said Chris Landrigan, MD, MPH, research and fellowship director, inpatient pediatrics service, and assistant professor of pediatrics at Children’s Hospital Boston, where Dr. Conway interned. The two found they had a lot in common: Both were interested in the operations of the health system and in finding ways to improve it through clinical work, research, and policy, Dr. Landrigan says.

“Most of our work together has revolved around looking at the variations in care in hospital systems,” Dr. Landrigan says. “Some of my work has been in trying to set up a research network for pediatric hospitalists, and to try and improve the care of hospitalized children.”

Dr. Landrigan was surveying pediatric hospitalists about how they treat several common conditions, looking for variations, when Dr. Conway arrived at Children’s.

“He immediately said, ‘How do we know how this compares to what pediatricians do?’ ” Dr. Landrigan says. “I said, ‘Well, we don’t,’ So he set out on a project and asked a random sample of pediatricians around the country.”

Dr. Conway’s work revealed greater variations of care among pediatricians than among pediatric hospitalists—a finding Dr. Conway brought all the way to publication.2

HHS and AHRQ “have been very focused on issues that are near and dear to Patrick’s heart,” Dr. Landrigan says. “I think he’s got the experience and the intelligence to really make substantial contributions there. There’s no question in my mind that he’ll end up a leader in healthcare.”

One of those contributions has been to educate high-level decision-makers on a vital question.

“I have to explain every time I meet somebody what a hospitalist is,” Dr. Conway says. “We meet with everybody, from President Bush to Cabinet secretaries, and at all those meetings I say, ‘I practice generally as a pediatric hospitalist,’ at which point they say, ‘What’s a hospitalist?’ ”

That’s not likely to remain a problem as more hospitalists get involved at high levels.

“I would fully expect that we’re going to see hospitalists play a major role in assessing patient care and quality, and I hope that Patrick’s being named a White House fellow is a harbinger of that,” Dr. Clancy says. “We’re thrilled to have him here, and I hope to see more physicians taking a very serious interest in healthcare policy.” TH

Liz Tascio is a journalist based in New York.

References

1. Conway PH, Cnann A, Zaoutis T, et al. Recurrent Urinary Tract Infections in Children: Risk Factors and Association With Prophylactic Antimicrobials. JAMA. 2007 July 11;298(2):179-186.
2. Conway PH, Edwards S, Stucky ER, et al. Variations in management of common inpatient pediatric illnesses: hospitalists and community pediatricians. Pediatrics. 2006 Aug;118(2):441-447.

Pediatric hospitalist Patrick Conway, MD, MSc, has become the first hospitalist accepted into The White House Fellows Program, a spokeswoman for the program says.

Dr. Conway had just reported to a new job at Cincinnati Children’s Hospital Medical Center when he found out he’d been accepted into the White House program. He’s serving with 14 other fellows, including one other medical professional, until August. He’ll return to Cincinnati with a deeper understanding of how physicians can affect federal health policy.

“It’s a once-in-a-lifetime learning experience, to see policy setting at the highest level of government,” Dr. Conway says.

Throughout the year, Dr. Conway, 33, will work in the office of Michael Leavitt, secretary of Health and Human Services (HHS), and with Carolyn Clancy, MD, director of the Agency for Healthcare Research and Quality (AHRQ).

“He’s an amazingly sharp physician who brings a great wealth of expertise, both because of the research he’s done but also in a clinical sense,” says Dr. Clancy, one of Dr. Conway’s mentors in the program. “He has a great grasp of policy.”

Dr. Conway has had to hit the ground running in his new role.

“We’re involving him directly in a number of very high-priority areas” including the improvement of healthcare quality and value, Dr. Clancy says. “He’ll be doing some research and a lot of trying to distill what we know from research to try and influence policy.”

The year will also bring another achievement: Dr. Conway will become a dad for the first time; his wife, Heather, is due March 30.

“I’m sort of peripherally involved,” he says ruefully. “I haven’t made it to any OB appointments.”

Dr. Conway, originally from College Station, Texas, received a master’s in health services research from the University of Pennsylvania. He earned his MD from Baylor College of Medicine and did his pediatrics residency at Children’s Hospital Boston, the primary pediatric teaching hospital for Harvard Medical School. He worked with healthcare clients as a management consultant at McKinsey & Company in Chicago, and he was a Robert Wood Johnson Clinical Scholar from 2005 to 2007. He’s done volunteer work in Nicaragua, the Dominican Republic, Bolivia, and Ghana. When he returns to Cincinnati Children’s, he’ll resume work as assistant professor in the Center for Health Care Quality and the Division of General Pediatrics.

On the Radar

While a Robert Wood Johnson scholar, Dr. Conway’s primary mentor was Ron Keren, MD, MPH, attending physician and director of the General Pediatrics Fellowship Program at the Children’s Hospital of Philadelphia. They worked together on a study of the use of prophylactic antibiotics in recurrent urinary tract infections in children, published last summer in the Journal of the American Medical Association (JAMA). The study found that, contrary to expectations, prophylactic antibiotics are not associated with a lower risk of recurrent infections and are associated with a higher risk of resistant infections.1

Dr. Keren was one of the people who recommended Dr. Conway on his application for the White House fellowship.

“Patrick … is intense,” says Dr. Keren, laughing. “But not in an obvious way. He’s very mild-mannered and polite and easy going on the outside. But when he starts a project, he is pretty aggressive as far as setting a very ambitious timeline, pushing things forward, and working as hard as possible. I just had to point him in the right direction every now and then, and he got the job done.”

Dr. Conway, lead author of the JAMA study, also contributed to a video news release and podcasts about its results. He impressed some of Dr. Clancy’s colleagues at the AHRQ with his ability to make the information easy to understand for people without a clinical medical background, Dr. Clancy says. That skill made him a good candidate for the fellowship.

“My goal is that he would get a lot of exposure to how healthcare policy is made, and that he would go back to Cincinnati Children’s understanding how physicians can play a more vital role in making sure that we get health policy right,” Dr. Clancy says. “To do that, you’ve got to be bilingual both in policy and in medicine—and there aren’t enough people who have that skill.”

And there’s something else to look forward to. “Supposedly we get the opportunity to ride mountain bikes with the president if we’re good enough,” Dr. Conway says. “I bike, but not extensively, so I’m working up to that. I need to make sure I don’t embarrass myself.”

Hospitalist Goals

Dr. Conway says one of his focuses is on the implementation of health information technology that better serves physicians and patients.

“We are interested in the alignment of incentive payments to physicians who use information technology to improve the care delivered to patients,” including electronic medical records and interoperability of data, he says. “In the last five years or so, there’s been increased interest in pay for performance, and now we’re moving toward thinking about how to structure these programs to pay for and enable quality improvement and the effective utilization of information technology.

“From a hospitalist perspective, I think one of the important issues is that many of these quality measures are directly related to the care delivered in hospitals by, primarily, hospitalists, so therefore it’s important for hospitalists to be involved in these processes.”

He’s also working with HHS on a value-driven healthcare initiative, intended “to bring transparency around quality and cost in healthcare and to enable quality improvement,” Dr. Conway says. “In this case, transparency for all stakeholders, so for consumers, for providers, for payers. We can criticize the process from the outside or we can get involved. We need to get involved.”

He has had a clearer idea than most about his career plan from the start, said Chris Landrigan, MD, MPH, research and fellowship director, inpatient pediatrics service, and assistant professor of pediatrics at Children’s Hospital Boston, where Dr. Conway interned. The two found they had a lot in common: Both were interested in the operations of the health system and in finding ways to improve it through clinical work, research, and policy, Dr. Landrigan says.

“Most of our work together has revolved around looking at the variations in care in hospital systems,” Dr. Landrigan says. “Some of my work has been in trying to set up a research network for pediatric hospitalists, and to try and improve the care of hospitalized children.”

Dr. Landrigan was surveying pediatric hospitalists about how they treat several common conditions, looking for variations, when Dr. Conway arrived at Children’s.

“He immediately said, ‘How do we know how this compares to what pediatricians do?’ ” Dr. Landrigan says. “I said, ‘Well, we don’t,’ So he set out on a project and asked a random sample of pediatricians around the country.”

Dr. Conway’s work revealed greater variations of care among pediatricians than among pediatric hospitalists—a finding Dr. Conway brought all the way to publication.2

HHS and AHRQ “have been very focused on issues that are near and dear to Patrick’s heart,” Dr. Landrigan says. “I think he’s got the experience and the intelligence to really make substantial contributions there. There’s no question in my mind that he’ll end up a leader in healthcare.”

One of those contributions has been to educate high-level decision-makers on a vital question.

“I have to explain every time I meet somebody what a hospitalist is,” Dr. Conway says. “We meet with everybody, from President Bush to Cabinet secretaries, and at all those meetings I say, ‘I practice generally as a pediatric hospitalist,’ at which point they say, ‘What’s a hospitalist?’ ”

That’s not likely to remain a problem as more hospitalists get involved at high levels.

“I would fully expect that we’re going to see hospitalists play a major role in assessing patient care and quality, and I hope that Patrick’s being named a White House fellow is a harbinger of that,” Dr. Clancy says. “We’re thrilled to have him here, and I hope to see more physicians taking a very serious interest in healthcare policy.” TH

Liz Tascio is a journalist based in New York.

References

1. Conway PH, Cnann A, Zaoutis T, et al. Recurrent Urinary Tract Infections in Children: Risk Factors and Association With Prophylactic Antimicrobials. JAMA. 2007 July 11;298(2):179-186.
2. Conway PH, Edwards S, Stucky ER, et al. Variations in management of common inpatient pediatric illnesses: hospitalists and community pediatricians. Pediatrics. 2006 Aug;118(2):441-447.

Pediatric hospitalist Patrick Conway, MD, MSc, has become the first hospitalist accepted into The White House Fellows Program, a spokeswoman for the program says.

Dr. Conway had just reported to a new job at Cincinnati Children’s Hospital Medical Center when he found out he’d been accepted into the White House program. He’s serving with 14 other fellows, including one other medical professional, until August. He’ll return to Cincinnati with a deeper understanding of how physicians can affect federal health policy.

“It’s a once-in-a-lifetime learning experience, to see policy setting at the highest level of government,” Dr. Conway says.

Throughout the year, Dr. Conway, 33, will work in the office of Michael Leavitt, secretary of Health and Human Services (HHS), and with Carolyn Clancy, MD, director of the Agency for Healthcare Research and Quality (AHRQ).

“He’s an amazingly sharp physician who brings a great wealth of expertise, both because of the research he’s done but also in a clinical sense,” says Dr. Clancy, one of Dr. Conway’s mentors in the program. “He has a great grasp of policy.”

Dr. Conway has had to hit the ground running in his new role.

“We’re involving him directly in a number of very high-priority areas” including the improvement of healthcare quality and value, Dr. Clancy says. “He’ll be doing some research and a lot of trying to distill what we know from research to try and influence policy.”

The year will also bring another achievement: Dr. Conway will become a dad for the first time; his wife, Heather, is due March 30.

“I’m sort of peripherally involved,” he says ruefully. “I haven’t made it to any OB appointments.”

Dr. Conway, originally from College Station, Texas, received a master’s in health services research from the University of Pennsylvania. He earned his MD from Baylor College of Medicine and did his pediatrics residency at Children’s Hospital Boston, the primary pediatric teaching hospital for Harvard Medical School. He worked with healthcare clients as a management consultant at McKinsey & Company in Chicago, and he was a Robert Wood Johnson Clinical Scholar from 2005 to 2007. He’s done volunteer work in Nicaragua, the Dominican Republic, Bolivia, and Ghana. When he returns to Cincinnati Children’s, he’ll resume work as assistant professor in the Center for Health Care Quality and the Division of General Pediatrics.

On the Radar

While a Robert Wood Johnson scholar, Dr. Conway’s primary mentor was Ron Keren, MD, MPH, attending physician and director of the General Pediatrics Fellowship Program at the Children’s Hospital of Philadelphia. They worked together on a study of the use of prophylactic antibiotics in recurrent urinary tract infections in children, published last summer in the Journal of the American Medical Association (JAMA). The study found that, contrary to expectations, prophylactic antibiotics are not associated with a lower risk of recurrent infections and are associated with a higher risk of resistant infections.1

Dr. Keren was one of the people who recommended Dr. Conway on his application for the White House fellowship.

“Patrick … is intense,” says Dr. Keren, laughing. “But not in an obvious way. He’s very mild-mannered and polite and easy going on the outside. But when he starts a project, he is pretty aggressive as far as setting a very ambitious timeline, pushing things forward, and working as hard as possible. I just had to point him in the right direction every now and then, and he got the job done.”

Dr. Conway, lead author of the JAMA study, also contributed to a video news release and podcasts about its results. He impressed some of Dr. Clancy’s colleagues at the AHRQ with his ability to make the information easy to understand for people without a clinical medical background, Dr. Clancy says. That skill made him a good candidate for the fellowship.

“My goal is that he would get a lot of exposure to how healthcare policy is made, and that he would go back to Cincinnati Children’s understanding how physicians can play a more vital role in making sure that we get health policy right,” Dr. Clancy says. “To do that, you’ve got to be bilingual both in policy and in medicine—and there aren’t enough people who have that skill.”

And there’s something else to look forward to. “Supposedly we get the opportunity to ride mountain bikes with the president if we’re good enough,” Dr. Conway says. “I bike, but not extensively, so I’m working up to that. I need to make sure I don’t embarrass myself.”

Hospitalist Goals

Dr. Conway says one of his focuses is on the implementation of health information technology that better serves physicians and patients.

“We are interested in the alignment of incentive payments to physicians who use information technology to improve the care delivered to patients,” including electronic medical records and interoperability of data, he says. “In the last five years or so, there’s been increased interest in pay for performance, and now we’re moving toward thinking about how to structure these programs to pay for and enable quality improvement and the effective utilization of information technology.

“From a hospitalist perspective, I think one of the important issues is that many of these quality measures are directly related to the care delivered in hospitals by, primarily, hospitalists, so therefore it’s important for hospitalists to be involved in these processes.”

He’s also working with HHS on a value-driven healthcare initiative, intended “to bring transparency around quality and cost in healthcare and to enable quality improvement,” Dr. Conway says. “In this case, transparency for all stakeholders, so for consumers, for providers, for payers. We can criticize the process from the outside or we can get involved. We need to get involved.”

He has had a clearer idea than most about his career plan from the start, said Chris Landrigan, MD, MPH, research and fellowship director, inpatient pediatrics service, and assistant professor of pediatrics at Children’s Hospital Boston, where Dr. Conway interned. The two found they had a lot in common: Both were interested in the operations of the health system and in finding ways to improve it through clinical work, research, and policy, Dr. Landrigan says.

“Most of our work together has revolved around looking at the variations in care in hospital systems,” Dr. Landrigan says. “Some of my work has been in trying to set up a research network for pediatric hospitalists, and to try and improve the care of hospitalized children.”

Dr. Landrigan was surveying pediatric hospitalists about how they treat several common conditions, looking for variations, when Dr. Conway arrived at Children’s.

“He immediately said, ‘How do we know how this compares to what pediatricians do?’ ” Dr. Landrigan says. “I said, ‘Well, we don’t,’ So he set out on a project and asked a random sample of pediatricians around the country.”

Dr. Conway’s work revealed greater variations of care among pediatricians than among pediatric hospitalists—a finding Dr. Conway brought all the way to publication.2

HHS and AHRQ “have been very focused on issues that are near and dear to Patrick’s heart,” Dr. Landrigan says. “I think he’s got the experience and the intelligence to really make substantial contributions there. There’s no question in my mind that he’ll end up a leader in healthcare.”

One of those contributions has been to educate high-level decision-makers on a vital question.

“I have to explain every time I meet somebody what a hospitalist is,” Dr. Conway says. “We meet with everybody, from President Bush to Cabinet secretaries, and at all those meetings I say, ‘I practice generally as a pediatric hospitalist,’ at which point they say, ‘What’s a hospitalist?’ ”

That’s not likely to remain a problem as more hospitalists get involved at high levels.

“I would fully expect that we’re going to see hospitalists play a major role in assessing patient care and quality, and I hope that Patrick’s being named a White House fellow is a harbinger of that,” Dr. Clancy says. “We’re thrilled to have him here, and I hope to see more physicians taking a very serious interest in healthcare policy.” TH

Liz Tascio is a journalist based in New York.

References

1. Conway PH, Cnann A, Zaoutis T, et al. Recurrent Urinary Tract Infections in Children: Risk Factors and Association With Prophylactic Antimicrobials. JAMA. 2007 July 11;298(2):179-186.
2. Conway PH, Edwards S, Stucky ER, et al. Variations in management of common inpatient pediatric illnesses: hospitalists and community pediatricians. Pediatrics. 2006 Aug;118(2):441-447.

Case

The orthopedic service asks you to evaluate a 76-year-old woman with a hip fracture. She has diabetes, hypertension, and hyperlipidemia but no known coronary artery disease (CAD). She says she can carry a bag of groceries up one flight of stairs without chest symptoms.

Her physical exam is significant only for a shortened, internally rotated right hip. Her blood pressure is 160/88 mm/hg, her pulse is 75 beats per minute, and her respiratory rate is 16 breaths a minute with an oxygen saturation of 95% on one liter. Her creatinine is 1.2 mg/dL, and her fasting glucose is 106 mg/dL. An electrocardiogram reveals normal sinus rhythm without evidence of prior myocardial infarction (MI).

Her medications are lisinopril, atorvastatin, aspirin, fluoxetine, and diazepam. She is scheduled for the operating room tomorrow. What is the best strategy to evaluate and minimize her perioperative cardiac risk, and does it include a beta-blocker?

Overview

There are many ways to identify patients at risk for perioperative cardiac complications—but few simple, safe, evidence-based means of mitigating risk.1

Over the past 10 years, the general approach has been that preoperative revascularization is beneficial in a limited number of clinical scenarios. Further, beta-blockers reduce risk in nearly all other high- and intermediate-risk patients. Unfortunately, routine perioperative administration of beta-blockers to intermediate-risk patients is not supported by trial evidence and may expose these patients to increased risk of adverse outcomes—including death and stroke.

Review of the Data

Intermediate-risk patients: Inter-mediate risk patients have recently been redefined as patients with a Revised Cardiac Risk Index (RCRI) score of two or one (See Table 1, p. 27).2,3 Older guidelines suggested noninvasive testing for such patients if they had poor functional capacity (less than four metabolic equivalents [METS]) and were undergoing intermediate-risk surgery, including orthopedic, peritoneal, and thoracic procedures.

Unfortunately, this situation is common, leading to frequent testing and unclear benefit to patients. Omission of a noninvasive evaluation in intermediate-risk orthopedic surgery patients is not associated with an increase in perioperative cardiac events.4 Most events occur in patients who did not meet criteria for preoperative testing.

The 2007 ACC/AHA Guidelines for Perioperative Evaluation and Care address this by recommending noninvasive testing only “if it will change management.” But they offer little guidance in unclear clinical situations, such as the urgent hip-fracture repair needed by our patient.

Preoperative revascularization: While it makes intuitive sense that preoperative revascularization of high-risk patients would decrease their risk of perioperative cardiac complications, evidence countering this idea is nearly definitive. In a study by McFalls, revascularization prior to major vascular surgery did not decrease the risk of perioperative MI or 30-day mortality; however, it delayed the surgical procedure, even in patients with high-risk noninvasive test results.5,6 It is generally accepted that if these high-risk patients can safely undergo major vascular surgery without revascularization, a lower-risk patient such as ours can do so at even lower risk.

In these trials, revascularization occurred in addition to medical management of coronary disease, including aspirin, statin, and—particularly in the study by Poldermans,6 where beta-blockers were started and titrated well before surgery—beta-blocker therapy.

click for large version

Patients with active cardiac symptoms or signs or uncharacterized anginal symptoms should have elective surgery delayed. However, delay is rarely an option for the hospitalist, who is typically asked to address a patient’s risk shortly before urgent or emergent surgery. These difficult situations require one to weigh the cardiac risk of surgery in a patient who is not optimized versus the risk of delaying surgery to address the more urgent cardiac situation.

Timing of perioperative percutaneous intervention: For patients with coronary artery disease (CAD) or coronary lesions, the interval between percutaneous revascularization (via stent or percutaneous transluminal coronary angioplasty [PTCA]) and surgery affects rates of postoperative cardiac events.7

The recommended interval bet­ween stent placement and noncardiac surgery for patients receiving bare-metal and drug-eluting stents is six weeks and one year, respectively.8 Surgery within two weeks of stent placement can carry mortality rates as high as 40%, and this risk appears to decrease out to one year.9,10 If a new stent is in place, any potential benefit appears to be offset by the increased risk of in-stent thrombosis with subsequent MI and possible death. PTCA may not be a safe alternative, although some recommend using PTCA if the patient has unstable cardiac symptoms and needs urgent/emergent surgery.11

Perioperative discontinuation of dual antiplatelet agents (e.g., clopidogrel and aspirin) is common and appears to increase thrombosis risk. This presents a challenge when patients with recent stent placement present for urgent surgery. Minimizing the interruption of dual antiplatelet therapy is the most important intervention a hospitalist can perform. Interruption is associated with increased risk of stent thrombosis, MI, and death. If clopidogrel must be discontinued in the perioperative period, continuation of aspirin is recommended and intravenous glycoprotein 2b/3a inhi­bitors can be considered.12

click for large version

Perioperative beta-blocker: Studies on the outcomes of perioperative beta blockade strongly suggested benefits initially. But a number of randomized trials in the past three years have not shown a positive effect.

In a landmark study published in 1996, Mangano showed that initiation of beta blockade just prior to surgery reduced perioperative MI and cardiac death in a mixed surgical population.13 Similar findings were seen with initiation of beta-blocker one month prior to vascular surgery.14 Additionally, higher doses of beta-blocker and lower heart rates in the perioperative period seem to be associated with decreased troponin release.15 Finally, perioperative beta blockade was associated with decreased mortality in high-risk patients (RCRI of three or greater), but higher mortality in lower-risk patients (e.g., RCRI of zero or one).16

More recent data reveal less benefit for perioperative beta blockade. Yang, et al., suggested that initiation of beta-blockers just prior to surgery did not decrease postoperative cardiac complications in vascular surgery patients.17 Similar results were found in a cohort of diabetic patients undergoing major surgery.18 A subsequent meta-analysis concluded that, in the aggregate, perioperative beta blockade was neither beneficial nor harmful.19

Further data have shown increased mortality with perioperative beta blockade in low-risk patients. Most recently, an abstract from the largest randomized controlled trial to date, the POISE study, suggested that preoperative beta blockade decreased MI and cardiac death, but increased the risk of stroke and produced higher overall mortality.20

It is challenging to reconcile this newer evidence with the previous data. While it seems intuitive that blunting the catecholamine response would minimize cardiac workload and therefore decrease perioperative infarcts, surgical patients are also at risk for poor pain control, sepsis, hypovolemia, and venous thromboembolism. Beta blockade can obscure their clinical manifestations, delaying diagnosis or complicating therapy. Inconsistencies among studies and published guidelines make them difficult to apply broadly, particularly with the intermediate-risk patient. Finally, perioperative beta blockade is poorly defined in terms of timing of initiation, target heart rate, and duration of postoperative use.

Until more definitive trial data are published, it seems most prudent to continue beta-blockers in patients already using them. Start them as far in advance of surgery as possible in patients with high-risk features (such as a positive stress test). After surgery, pay close attention to volume status, pain, signs of sepsis, or other noncardiac complications.

click for large version

Back to the Case

As per the 2007 ACC/AHA guidelines, this patient with one clinical risk factor (diabetes) and good functional capacity can proceed to the operating room without further intervention. While it is likely a patient with diabetes and hyperlipidemia has some degree of CAD, including possible vulnerable plaques, the best medical evidence offers little to decrease her operative cardiac risk. Perioperative beta blockade is not indicated at her level of risk (RCRI of one) given the inconsistent benefits and possible harm to patients like this seen in trials to date.

If she were limited in terms of functional capacity (i.e., less than four METS), the 2007 ACC/AHA algorithm suggests preoperative noninvasive testing “if it would change management.”

How might a positive stress test change management in this case? Revascularization with stenting in close proximity to noncardiac surgery is not safe, and there appears to be no benefit to preoperative revascularization before high-risk vascular surgery. However, ischemia on preoperative testing is an indication for a beta-blocker. A brief delay in her surgery to allow dose titration and use of telemetry monitoring after surgery would increase the safety of beta-blockers after surgery. How long to continue beta-blockers is an open question, but at least 30 days would seem adequate, tapering rather than abruptly discontinuing the dose. TH

Dr. Carter is an assistant professor of medicine at the University of Colorado Denver in the Section of Hospital Medicine, where he directs the Medicine Consult Service. Dr. Auerbach is an associate professor of medicine in residence, associate director of the general medicine research fellowship, director of quality improvement for the UCSF Department of Medicine, and director of the surgical care Improvement program at UCSF. His research interests include perioperative medicine and quality improvement.

References

1. Lee TH, Marcantonio ER, Mangione CM, et al. Derivation and prospective validation of a simple index for prediction of cardiac risk of major noncardiac surgery. Circulation. 1999;100(10):1043-1049.
2. Eagle KA, Berger PB, Calkins H, et al. ACC/AHA Guideline update for perioperative cardiovascular evaluation for noncardiac surgery—executive summary. Circulation 2002;105:1257-1267.
3. Fleischer LA, Beckman JA, Brown KA, et al. ACC/AHA Guidelines on Perioperative Cardiovascular Evaluation and Care for noncardiac surgery: executive summary. Circulation. 2007;116:1971-1996.
4. Salerno SM, Carlson DW, Soh EK, et al. Impact of perioperative cardiac assessment guidelines on management of orthopedic surgery patients. Am J Med. 2007;120(2):185.
5. McFalls EO, Ward HB, Moritz TE, et al. Coronary artery revascularization before elective major vascular surgery. N Engl J Med. 2004;351:2795-2804.
6. Poldermans D, Schouten O, Vidakovic R, et al. A clinical randomized trial to evaluate the safety of a noninvasive approach in high-risk patients undergoing major vascular surgery: The DECREASE-V Pilot Study. J Am Coll Cardiol. 2007;49(17):1763-1769.
7. Wilson, SH, Fasseas P, Orford JL, et al. Clinical outcomes of patients undergoing non-cardiac surgery in the two months following coronary stenting. J Am Coll Cardiol. 2003;42(2):234-240.
8. Grines, CL, Bonow RO, Casey DE Jr, et al. Prevention of premature discontinuation of dual antiplatelet therapy in patients with coronary artery stents. Circulation. 2007; 115:813-818.
9. Kaluza GL, Joseph J, Lee JR, et al. Catastrophic outcomes of noncardiac surgery soon after coronary stenting. Am J Coll Cardiol. 2000;35(5):1288-1294.
10. Schouten O, Bax JJ, Damen J, et al. Coronary stent placement immediately before non cardiac surgery: a potential risk? Anesthesiology 106(5);2007:1067.
11. Leibowitz D, Cohen M, Planer D, et al. Comparison of cardiovascular risk of noncardiac surgery following coronary angioplasty with versus without stenting. Am J Cardiol. 2006;97(8):1188-1191.
12. Auerbach A, Goldman L. Assessing and reducing the cardiac risk of noncardiac surgery. Circulation 2006;113:1361-1376.
13. Mangano DT, Layug EL, Wallace A, et al. Effect of atenolol on mortality and cardiovascular morbidity after noncardiac surgery. N Engl J Med. 1996;335(23):1713-1720.
14. Poldermans D, Boersma E, Bax JJ, et al. The effect of bisoprolol on perioperative mortality and myocardial infarction in high-risk patients undergoing vascular surgery. N Engl J Med. 1999;341(24):1789-1794.
15. Feringa HH, Bax JJ, Boersma E, et al. High dose b-blockers and tight heart rate control reduce myocardial ischemia and troponin T release in vascular surgery patients. Circulation. 2006;114(supp):I344.
16. Lindenauer PK Pekow P, Wang K, et al. Perioperative beta-blocker therapy and mortality after major noncardiac surgery. N Engl J Med. 2005;353(4):349-361.
17. Yang H, Raymer K, Butler R, et al. The effects of perioperative beta blockade: results of the Metoprolol after Vascular Surgery (MaVS) study, a randomized controlled trial. Am Heart J. 2006;152(5):983-990.
18. Juul AB, Wetterslev J, Gluud C, et al. Effect of perioperative ß blockade in patients with diabetes undergoing major non-cardiac surgery: randomized placebo controlled, blinded multicentre trial. BMJ. 2006 June;332:1482.
19. Devereaux PJ, Beattie WS, Choi PT, et al. How strong is the evidence for the use of perioperative ß blockers in noncardiac surgery? Systematic review and meta-analysis of randomized controlled trials. BMJ. 2005;331:313.
20. Devereaux PJ. POISE Abstract. American Heart Association Annual Scientific Session, Orlando, Fla., November 2007.

Case

The orthopedic service asks you to evaluate a 76-year-old woman with a hip fracture. She has diabetes, hypertension, and hyperlipidemia but no known coronary artery disease (CAD). She says she can carry a bag of groceries up one flight of stairs without chest symptoms.

Her physical exam is significant only for a shortened, internally rotated right hip. Her blood pressure is 160/88 mm/hg, her pulse is 75 beats per minute, and her respiratory rate is 16 breaths a minute with an oxygen saturation of 95% on one liter. Her creatinine is 1.2 mg/dL, and her fasting glucose is 106 mg/dL. An electrocardiogram reveals normal sinus rhythm without evidence of prior myocardial infarction (MI).

Her medications are lisinopril, atorvastatin, aspirin, fluoxetine, and diazepam. She is scheduled for the operating room tomorrow. What is the best strategy to evaluate and minimize her perioperative cardiac risk, and does it include a beta-blocker?

Overview

There are many ways to identify patients at risk for perioperative cardiac complications—but few simple, safe, evidence-based means of mitigating risk.1

Over the past 10 years, the general approach has been that preoperative revascularization is beneficial in a limited number of clinical scenarios. Further, beta-blockers reduce risk in nearly all other high- and intermediate-risk patients. Unfortunately, routine perioperative administration of beta-blockers to intermediate-risk patients is not supported by trial evidence and may expose these patients to increased risk of adverse outcomes—including death and stroke.

Review of the Data

Intermediate-risk patients: Inter-mediate risk patients have recently been redefined as patients with a Revised Cardiac Risk Index (RCRI) score of two or one (See Table 1, p. 27).2,3 Older guidelines suggested noninvasive testing for such patients if they had poor functional capacity (less than four metabolic equivalents [METS]) and were undergoing intermediate-risk surgery, including orthopedic, peritoneal, and thoracic procedures.

Unfortunately, this situation is common, leading to frequent testing and unclear benefit to patients. Omission of a noninvasive evaluation in intermediate-risk orthopedic surgery patients is not associated with an increase in perioperative cardiac events.4 Most events occur in patients who did not meet criteria for preoperative testing.

The 2007 ACC/AHA Guidelines for Perioperative Evaluation and Care address this by recommending noninvasive testing only “if it will change management.” But they offer little guidance in unclear clinical situations, such as the urgent hip-fracture repair needed by our patient.

Preoperative revascularization: While it makes intuitive sense that preoperative revascularization of high-risk patients would decrease their risk of perioperative cardiac complications, evidence countering this idea is nearly definitive. In a study by McFalls, revascularization prior to major vascular surgery did not decrease the risk of perioperative MI or 30-day mortality; however, it delayed the surgical procedure, even in patients with high-risk noninvasive test results.5,6 It is generally accepted that if these high-risk patients can safely undergo major vascular surgery without revascularization, a lower-risk patient such as ours can do so at even lower risk.

In these trials, revascularization occurred in addition to medical management of coronary disease, including aspirin, statin, and—particularly in the study by Poldermans,6 where beta-blockers were started and titrated well before surgery—beta-blocker therapy.

click for large version

Patients with active cardiac symptoms or signs or uncharacterized anginal symptoms should have elective surgery delayed. However, delay is rarely an option for the hospitalist, who is typically asked to address a patient’s risk shortly before urgent or emergent surgery. These difficult situations require one to weigh the cardiac risk of surgery in a patient who is not optimized versus the risk of delaying surgery to address the more urgent cardiac situation.

Timing of perioperative percutaneous intervention: For patients with coronary artery disease (CAD) or coronary lesions, the interval between percutaneous revascularization (via stent or percutaneous transluminal coronary angioplasty [PTCA]) and surgery affects rates of postoperative cardiac events.7

The recommended interval bet­ween stent placement and noncardiac surgery for patients receiving bare-metal and drug-eluting stents is six weeks and one year, respectively.8 Surgery within two weeks of stent placement can carry mortality rates as high as 40%, and this risk appears to decrease out to one year.9,10 If a new stent is in place, any potential benefit appears to be offset by the increased risk of in-stent thrombosis with subsequent MI and possible death. PTCA may not be a safe alternative, although some recommend using PTCA if the patient has unstable cardiac symptoms and needs urgent/emergent surgery.11

Perioperative discontinuation of dual antiplatelet agents (e.g., clopidogrel and aspirin) is common and appears to increase thrombosis risk. This presents a challenge when patients with recent stent placement present for urgent surgery. Minimizing the interruption of dual antiplatelet therapy is the most important intervention a hospitalist can perform. Interruption is associated with increased risk of stent thrombosis, MI, and death. If clopidogrel must be discontinued in the perioperative period, continuation of aspirin is recommended and intravenous glycoprotein 2b/3a inhi­bitors can be considered.12

click for large version

Perioperative beta-blocker: Studies on the outcomes of perioperative beta blockade strongly suggested benefits initially. But a number of randomized trials in the past three years have not shown a positive effect.

In a landmark study published in 1996, Mangano showed that initiation of beta blockade just prior to surgery reduced perioperative MI and cardiac death in a mixed surgical population.13 Similar findings were seen with initiation of beta-blocker one month prior to vascular surgery.14 Additionally, higher doses of beta-blocker and lower heart rates in the perioperative period seem to be associated with decreased troponin release.15 Finally, perioperative beta blockade was associated with decreased mortality in high-risk patients (RCRI of three or greater), but higher mortality in lower-risk patients (e.g., RCRI of zero or one).16

More recent data reveal less benefit for perioperative beta blockade. Yang, et al., suggested that initiation of beta-blockers just prior to surgery did not decrease postoperative cardiac complications in vascular surgery patients.17 Similar results were found in a cohort of diabetic patients undergoing major surgery.18 A subsequent meta-analysis concluded that, in the aggregate, perioperative beta blockade was neither beneficial nor harmful.19

Further data have shown increased mortality with perioperative beta blockade in low-risk patients. Most recently, an abstract from the largest randomized controlled trial to date, the POISE study, suggested that preoperative beta blockade decreased MI and cardiac death, but increased the risk of stroke and produced higher overall mortality.20

It is challenging to reconcile this newer evidence with the previous data. While it seems intuitive that blunting the catecholamine response would minimize cardiac workload and therefore decrease perioperative infarcts, surgical patients are also at risk for poor pain control, sepsis, hypovolemia, and venous thromboembolism. Beta blockade can obscure their clinical manifestations, delaying diagnosis or complicating therapy. Inconsistencies among studies and published guidelines make them difficult to apply broadly, particularly with the intermediate-risk patient. Finally, perioperative beta blockade is poorly defined in terms of timing of initiation, target heart rate, and duration of postoperative use.

Until more definitive trial data are published, it seems most prudent to continue beta-blockers in patients already using them. Start them as far in advance of surgery as possible in patients with high-risk features (such as a positive stress test). After surgery, pay close attention to volume status, pain, signs of sepsis, or other noncardiac complications.

click for large version

Back to the Case

As per the 2007 ACC/AHA guidelines, this patient with one clinical risk factor (diabetes) and good functional capacity can proceed to the operating room without further intervention. While it is likely a patient with diabetes and hyperlipidemia has some degree of CAD, including possible vulnerable plaques, the best medical evidence offers little to decrease her operative cardiac risk. Perioperative beta blockade is not indicated at her level of risk (RCRI of one) given the inconsistent benefits and possible harm to patients like this seen in trials to date.

If she were limited in terms of functional capacity (i.e., less than four METS), the 2007 ACC/AHA algorithm suggests preoperative noninvasive testing “if it would change management.”

How might a positive stress test change management in this case? Revascularization with stenting in close proximity to noncardiac surgery is not safe, and there appears to be no benefit to preoperative revascularization before high-risk vascular surgery. However, ischemia on preoperative testing is an indication for a beta-blocker. A brief delay in her surgery to allow dose titration and use of telemetry monitoring after surgery would increase the safety of beta-blockers after surgery. How long to continue beta-blockers is an open question, but at least 30 days would seem adequate, tapering rather than abruptly discontinuing the dose. TH

Dr. Carter is an assistant professor of medicine at the University of Colorado Denver in the Section of Hospital Medicine, where he directs the Medicine Consult Service. Dr. Auerbach is an associate professor of medicine in residence, associate director of the general medicine research fellowship, director of quality improvement for the UCSF Department of Medicine, and director of the surgical care Improvement program at UCSF. His research interests include perioperative medicine and quality improvement.

References

1. Lee TH, Marcantonio ER, Mangione CM, et al. Derivation and prospective validation of a simple index for prediction of cardiac risk of major noncardiac surgery. Circulation. 1999;100(10):1043-1049.
2. Eagle KA, Berger PB, Calkins H, et al. ACC/AHA Guideline update for perioperative cardiovascular evaluation for noncardiac surgery—executive summary. Circulation 2002;105:1257-1267.
3. Fleischer LA, Beckman JA, Brown KA, et al. ACC/AHA Guidelines on Perioperative Cardiovascular Evaluation and Care for noncardiac surgery: executive summary. Circulation. 2007;116:1971-1996.
4. Salerno SM, Carlson DW, Soh EK, et al. Impact of perioperative cardiac assessment guidelines on management of orthopedic surgery patients. Am J Med. 2007;120(2):185.
5. McFalls EO, Ward HB, Moritz TE, et al. Coronary artery revascularization before elective major vascular surgery. N Engl J Med. 2004;351:2795-2804.
6. Poldermans D, Schouten O, Vidakovic R, et al. A clinical randomized trial to evaluate the safety of a noninvasive approach in high-risk patients undergoing major vascular surgery: The DECREASE-V Pilot Study. J Am Coll Cardiol. 2007;49(17):1763-1769.
7. Wilson, SH, Fasseas P, Orford JL, et al. Clinical outcomes of patients undergoing non-cardiac surgery in the two months following coronary stenting. J Am Coll Cardiol. 2003;42(2):234-240.
8. Grines, CL, Bonow RO, Casey DE Jr, et al. Prevention of premature discontinuation of dual antiplatelet therapy in patients with coronary artery stents. Circulation. 2007; 115:813-818.
9. Kaluza GL, Joseph J, Lee JR, et al. Catastrophic outcomes of noncardiac surgery soon after coronary stenting. Am J Coll Cardiol. 2000;35(5):1288-1294.
10. Schouten O, Bax JJ, Damen J, et al. Coronary stent placement immediately before non cardiac surgery: a potential risk? Anesthesiology 106(5);2007:1067.
11. Leibowitz D, Cohen M, Planer D, et al. Comparison of cardiovascular risk of noncardiac surgery following coronary angioplasty with versus without stenting. Am J Cardiol. 2006;97(8):1188-1191.
12. Auerbach A, Goldman L. Assessing and reducing the cardiac risk of noncardiac surgery. Circulation 2006;113:1361-1376.
13. Mangano DT, Layug EL, Wallace A, et al. Effect of atenolol on mortality and cardiovascular morbidity after noncardiac surgery. N Engl J Med. 1996;335(23):1713-1720.
14. Poldermans D, Boersma E, Bax JJ, et al. The effect of bisoprolol on perioperative mortality and myocardial infarction in high-risk patients undergoing vascular surgery. N Engl J Med. 1999;341(24):1789-1794.
15. Feringa HH, Bax JJ, Boersma E, et al. High dose b-blockers and tight heart rate control reduce myocardial ischemia and troponin T release in vascular surgery patients. Circulation. 2006;114(supp):I344.
16. Lindenauer PK Pekow P, Wang K, et al. Perioperative beta-blocker therapy and mortality after major noncardiac surgery. N Engl J Med. 2005;353(4):349-361.
17. Yang H, Raymer K, Butler R, et al. The effects of perioperative beta blockade: results of the Metoprolol after Vascular Surgery (MaVS) study, a randomized controlled trial. Am Heart J. 2006;152(5):983-990.
18. Juul AB, Wetterslev J, Gluud C, et al. Effect of perioperative ß blockade in patients with diabetes undergoing major non-cardiac surgery: randomized placebo controlled, blinded multicentre trial. BMJ. 2006 June;332:1482.
19. Devereaux PJ, Beattie WS, Choi PT, et al. How strong is the evidence for the use of perioperative ß blockers in noncardiac surgery? Systematic review and meta-analysis of randomized controlled trials. BMJ. 2005;331:313.
20. Devereaux PJ. POISE Abstract. American Heart Association Annual Scientific Session, Orlando, Fla., November 2007.

Case

The orthopedic service asks you to evaluate a 76-year-old woman with a hip fracture. She has diabetes, hypertension, and hyperlipidemia but no known coronary artery disease (CAD). She says she can carry a bag of groceries up one flight of stairs without chest symptoms.

Her physical exam is significant only for a shortened, internally rotated right hip. Her blood pressure is 160/88 mm/hg, her pulse is 75 beats per minute, and her respiratory rate is 16 breaths a minute with an oxygen saturation of 95% on one liter. Her creatinine is 1.2 mg/dL, and her fasting glucose is 106 mg/dL. An electrocardiogram reveals normal sinus rhythm without evidence of prior myocardial infarction (MI).

Her medications are lisinopril, atorvastatin, aspirin, fluoxetine, and diazepam. She is scheduled for the operating room tomorrow. What is the best strategy to evaluate and minimize her perioperative cardiac risk, and does it include a beta-blocker?

Overview

There are many ways to identify patients at risk for perioperative cardiac complications—but few simple, safe, evidence-based means of mitigating risk.1

Over the past 10 years, the general approach has been that preoperative revascularization is beneficial in a limited number of clinical scenarios. Further, beta-blockers reduce risk in nearly all other high- and intermediate-risk patients. Unfortunately, routine perioperative administration of beta-blockers to intermediate-risk patients is not supported by trial evidence and may expose these patients to increased risk of adverse outcomes—including death and stroke.

Review of the Data

Intermediate-risk patients: Inter-mediate risk patients have recently been redefined as patients with a Revised Cardiac Risk Index (RCRI) score of two or one (See Table 1, p. 27).2,3 Older guidelines suggested noninvasive testing for such patients if they had poor functional capacity (less than four metabolic equivalents [METS]) and were undergoing intermediate-risk surgery, including orthopedic, peritoneal, and thoracic procedures.

Unfortunately, this situation is common, leading to frequent testing and unclear benefit to patients. Omission of a noninvasive evaluation in intermediate-risk orthopedic surgery patients is not associated with an increase in perioperative cardiac events.4 Most events occur in patients who did not meet criteria for preoperative testing.

The 2007 ACC/AHA Guidelines for Perioperative Evaluation and Care address this by recommending noninvasive testing only “if it will change management.” But they offer little guidance in unclear clinical situations, such as the urgent hip-fracture repair needed by our patient.

Preoperative revascularization: While it makes intuitive sense that preoperative revascularization of high-risk patients would decrease their risk of perioperative cardiac complications, evidence countering this idea is nearly definitive. In a study by McFalls, revascularization prior to major vascular surgery did not decrease the risk of perioperative MI or 30-day mortality; however, it delayed the surgical procedure, even in patients with high-risk noninvasive test results.5,6 It is generally accepted that if these high-risk patients can safely undergo major vascular surgery without revascularization, a lower-risk patient such as ours can do so at even lower risk.

In these trials, revascularization occurred in addition to medical management of coronary disease, including aspirin, statin, and—particularly in the study by Poldermans,6 where beta-blockers were started and titrated well before surgery—beta-blocker therapy.

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Patients with active cardiac symptoms or signs or uncharacterized anginal symptoms should have elective surgery delayed. However, delay is rarely an option for the hospitalist, who is typically asked to address a patient’s risk shortly before urgent or emergent surgery. These difficult situations require one to weigh the cardiac risk of surgery in a patient who is not optimized versus the risk of delaying surgery to address the more urgent cardiac situation.

Timing of perioperative percutaneous intervention: For patients with coronary artery disease (CAD) or coronary lesions, the interval between percutaneous revascularization (via stent or percutaneous transluminal coronary angioplasty [PTCA]) and surgery affects rates of postoperative cardiac events.7

The recommended interval bet­ween stent placement and noncardiac surgery for patients receiving bare-metal and drug-eluting stents is six weeks and one year, respectively.8 Surgery within two weeks of stent placement can carry mortality rates as high as 40%, and this risk appears to decrease out to one year.9,10 If a new stent is in place, any potential benefit appears to be offset by the increased risk of in-stent thrombosis with subsequent MI and possible death. PTCA may not be a safe alternative, although some recommend using PTCA if the patient has unstable cardiac symptoms and needs urgent/emergent surgery.11

Perioperative discontinuation of dual antiplatelet agents (e.g., clopidogrel and aspirin) is common and appears to increase thrombosis risk. This presents a challenge when patients with recent stent placement present for urgent surgery. Minimizing the interruption of dual antiplatelet therapy is the most important intervention a hospitalist can perform. Interruption is associated with increased risk of stent thrombosis, MI, and death. If clopidogrel must be discontinued in the perioperative period, continuation of aspirin is recommended and intravenous glycoprotein 2b/3a inhi­bitors can be considered.12

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Perioperative beta-blocker: Studies on the outcomes of perioperative beta blockade strongly suggested benefits initially. But a number of randomized trials in the past three years have not shown a positive effect.

In a landmark study published in 1996, Mangano showed that initiation of beta blockade just prior to surgery reduced perioperative MI and cardiac death in a mixed surgical population.13 Similar findings were seen with initiation of beta-blocker one month prior to vascular surgery.14 Additionally, higher doses of beta-blocker and lower heart rates in the perioperative period seem to be associated with decreased troponin release.15 Finally, perioperative beta blockade was associated with decreased mortality in high-risk patients (RCRI of three or greater), but higher mortality in lower-risk patients (e.g., RCRI of zero or one).16

More recent data reveal less benefit for perioperative beta blockade. Yang, et al., suggested that initiation of beta-blockers just prior to surgery did not decrease postoperative cardiac complications in vascular surgery patients.17 Similar results were found in a cohort of diabetic patients undergoing major surgery.18 A subsequent meta-analysis concluded that, in the aggregate, perioperative beta blockade was neither beneficial nor harmful.19

Further data have shown increased mortality with perioperative beta blockade in low-risk patients. Most recently, an abstract from the largest randomized controlled trial to date, the POISE study, suggested that preoperative beta blockade decreased MI and cardiac death, but increased the risk of stroke and produced higher overall mortality.20

It is challenging to reconcile this newer evidence with the previous data. While it seems intuitive that blunting the catecholamine response would minimize cardiac workload and therefore decrease perioperative infarcts, surgical patients are also at risk for poor pain control, sepsis, hypovolemia, and venous thromboembolism. Beta blockade can obscure their clinical manifestations, delaying diagnosis or complicating therapy. Inconsistencies among studies and published guidelines make them difficult to apply broadly, particularly with the intermediate-risk patient. Finally, perioperative beta blockade is poorly defined in terms of timing of initiation, target heart rate, and duration of postoperative use.

Until more definitive trial data are published, it seems most prudent to continue beta-blockers in patients already using them. Start them as far in advance of surgery as possible in patients with high-risk features (such as a positive stress test). After surgery, pay close attention to volume status, pain, signs of sepsis, or other noncardiac complications.

click for large version

Back to the Case

As per the 2007 ACC/AHA guidelines, this patient with one clinical risk factor (diabetes) and good functional capacity can proceed to the operating room without further intervention. While it is likely a patient with diabetes and hyperlipidemia has some degree of CAD, including possible vulnerable plaques, the best medical evidence offers little to decrease her operative cardiac risk. Perioperative beta blockade is not indicated at her level of risk (RCRI of one) given the inconsistent benefits and possible harm to patients like this seen in trials to date.

If she were limited in terms of functional capacity (i.e., less than four METS), the 2007 ACC/AHA algorithm suggests preoperative noninvasive testing “if it would change management.”

How might a positive stress test change management in this case? Revascularization with stenting in close proximity to noncardiac surgery is not safe, and there appears to be no benefit to preoperative revascularization before high-risk vascular surgery. However, ischemia on preoperative testing is an indication for a beta-blocker. A brief delay in her surgery to allow dose titration and use of telemetry monitoring after surgery would increase the safety of beta-blockers after surgery. How long to continue beta-blockers is an open question, but at least 30 days would seem adequate, tapering rather than abruptly discontinuing the dose. TH

Dr. Carter is an assistant professor of medicine at the University of Colorado Denver in the Section of Hospital Medicine, where he directs the Medicine Consult Service. Dr. Auerbach is an associate professor of medicine in residence, associate director of the general medicine research fellowship, director of quality improvement for the UCSF Department of Medicine, and director of the surgical care Improvement program at UCSF. His research interests include perioperative medicine and quality improvement.

References

1. Lee TH, Marcantonio ER, Mangione CM, et al. Derivation and prospective validation of a simple index for prediction of cardiac risk of major noncardiac surgery. Circulation. 1999;100(10):1043-1049.
2. Eagle KA, Berger PB, Calkins H, et al. ACC/AHA Guideline update for perioperative cardiovascular evaluation for noncardiac surgery—executive summary. Circulation 2002;105:1257-1267.
3. Fleischer LA, Beckman JA, Brown KA, et al. ACC/AHA Guidelines on Perioperative Cardiovascular Evaluation and Care for noncardiac surgery: executive summary. Circulation. 2007;116:1971-1996.
4. Salerno SM, Carlson DW, Soh EK, et al. Impact of perioperative cardiac assessment guidelines on management of orthopedic surgery patients. Am J Med. 2007;120(2):185.
5. McFalls EO, Ward HB, Moritz TE, et al. Coronary artery revascularization before elective major vascular surgery. N Engl J Med. 2004;351:2795-2804.
6. Poldermans D, Schouten O, Vidakovic R, et al. A clinical randomized trial to evaluate the safety of a noninvasive approach in high-risk patients undergoing major vascular surgery: The DECREASE-V Pilot Study. J Am Coll Cardiol. 2007;49(17):1763-1769.
7. Wilson, SH, Fasseas P, Orford JL, et al. Clinical outcomes of patients undergoing non-cardiac surgery in the two months following coronary stenting. J Am Coll Cardiol. 2003;42(2):234-240.
8. Grines, CL, Bonow RO, Casey DE Jr, et al. Prevention of premature discontinuation of dual antiplatelet therapy in patients with coronary artery stents. Circulation. 2007; 115:813-818.
9. Kaluza GL, Joseph J, Lee JR, et al. Catastrophic outcomes of noncardiac surgery soon after coronary stenting. Am J Coll Cardiol. 2000;35(5):1288-1294.
10. Schouten O, Bax JJ, Damen J, et al. Coronary stent placement immediately before non cardiac surgery: a potential risk? Anesthesiology 106(5);2007:1067.
11. Leibowitz D, Cohen M, Planer D, et al. Comparison of cardiovascular risk of noncardiac surgery following coronary angioplasty with versus without stenting. Am J Cardiol. 2006;97(8):1188-1191.
12. Auerbach A, Goldman L. Assessing and reducing the cardiac risk of noncardiac surgery. Circulation 2006;113:1361-1376.
13. Mangano DT, Layug EL, Wallace A, et al. Effect of atenolol on mortality and cardiovascular morbidity after noncardiac surgery. N Engl J Med. 1996;335(23):1713-1720.
14. Poldermans D, Boersma E, Bax JJ, et al. The effect of bisoprolol on perioperative mortality and myocardial infarction in high-risk patients undergoing vascular surgery. N Engl J Med. 1999;341(24):1789-1794.
15. Feringa HH, Bax JJ, Boersma E, et al. High dose b-blockers and tight heart rate control reduce myocardial ischemia and troponin T release in vascular surgery patients. Circulation. 2006;114(supp):I344.
16. Lindenauer PK Pekow P, Wang K, et al. Perioperative beta-blocker therapy and mortality after major noncardiac surgery. N Engl J Med. 2005;353(4):349-361.
17. Yang H, Raymer K, Butler R, et al. The effects of perioperative beta blockade: results of the Metoprolol after Vascular Surgery (MaVS) study, a randomized controlled trial. Am Heart J. 2006;152(5):983-990.
18. Juul AB, Wetterslev J, Gluud C, et al. Effect of perioperative ß blockade in patients with diabetes undergoing major non-cardiac surgery: randomized placebo controlled, blinded multicentre trial. BMJ. 2006 June;332:1482.
19. Devereaux PJ, Beattie WS, Choi PT, et al. How strong is the evidence for the use of perioperative ß blockers in noncardiac surgery? Systematic review and meta-analysis of randomized controlled trials. BMJ. 2005;331:313.
20. Devereaux PJ. POISE Abstract. American Heart Association Annual Scientific Session, Orlando, Fla., November 2007.

Although hospitalists may work alongside neurological specialists, they are increasingly on their own when responding to neurological emergencies, such as strokes, in hospitalized patients.

There are times the neurologist may be in the clinic, out of the hospital after hours, or otherwise unavailable, so responsibility for managing neurological conditions falls back on the hospitalist. But he or she may not have received sufficient exposure to neurology during medical training.

S. Andrew Josephson, MD, of the neurovascular division, director of the neurohospitalist program and assistant professor of neurology at the University of California-San Francisco (UCSF), regularly speaks on neurological issues to hospitalist audiences.

“I ask how many hospitalists in the room are primary caregivers for stroke in their hospital, and a surprising proportion raise their hands,” he says. “We do a good job of teaching neurology residents and fellows how to treat strokes. But it is important that we train internal medicine doctors as well, as they are seeing the majority of these patients nationwide.”

Depending on the setting, there may be wide variation in the hospitalist’s responsibility for neurological cases. “Here at UCSF, hospitalists almost never see stroke patients because we have a dedicated stroke service staffed by neurology attendings and residents,” Dr. Josephson says. “But at many community hospitals, they [care for neurological patients] all the time.”

David Likosky, MD, director of the stroke program at Evergreen Hospital Medical Center in Kirkland, Wash., concurs. “Neurology training in internal medicine residencies can be fairly limited,” he says. “After entering practice, these doctors are on the front lines in the hospital managing patients, many times without readily available neurologist backup.”

Dr. Likosky’s colleague at Evergreen, hospitalist Tony Yen, MD, says there are several neurological issues hospitalists are likely to encounter on a regular basis.

“Often the first responder to a stroke is the emergency department [ED] doctor or the hospitalist,” notes Dr. Yen. “Strokes are a time-critical, high-volume condition for our community hospitalist practice.”

Another important diagnosis is uncontrolled seizure (status epilepticus) that is unremitting for 10 minutes or more. Prompt response is critical.

Dr. Yen recalls the case of a young woman who collapsed while playing soccer. She was brought to the hospital and found to have suffered a brain-stem stroke. Physicians had three hours from the onset of symptoms to decide whether the patient was a candidate for tissue plasminogen activator (t-PA), a thrombolytic clot buster.

“I worked alongside the interventional radiologist and neurologist,” Dr. Yen recalls. “We were able to quickly establish a definitive diagnosis and then treat with intra-arterial t-PA.” The patient had a prolonged stay in intensive care and was on a ventilator for a couple of weeks but eventually recovered and walked out of the hospital.

Common Conditions

Stroke: The most common neurological emergency hospitalists are likely to see, whether on the floor or through the ED, is acute stroke, Dr. Josephson notes. “The evaluation of stroke requires a non-contrast computed tomography (CT) scan of the head to exclude intracerebral hemorrhage,” he says. “You can’t tell by looking at the patient whether it’s an ischemic stroke, the more common variety, or hemorrhagic stroke. But the difference is crucial because drugs to treat ischemic stroke can make hemorrhage worse. We view stroke as such a time-sensitive emergency that it always gets priority in the radiology department.”

It is also important to ascertain, as much as possible, when symptoms first began or when the patient was last observed to be normal. The treatment of choice in the first three hours following an ischemic stroke is intravenous t-PA. From hours three through six or eight, endovascular therapies (intra-arterial thrombolysis or mechanical clot retrieval) are an option. Signs suggesting a possible stroke include a new unilateral weakness, one-sided numbness, vertigo or imbalance, visual changes, inability to talk, and new headaches—although indications of a stroke can be subtle. The National Institutes of Health has issued a stroke scale, with training modules, accessible at www.strokecenter.org/trials/scales/nihss.html.

Seizures: Prolonged seizures that don’t resolve on their own within a reasonable amount of time require attention because the longer they last, the more likely they are to cause brain damage, Dr. Josephson says. Medications to treat the seizure work more effectively the earlier they are administered. He recommends a protocol for treating status epilepticus that starts with lorazepam (Ativan), proceeds to fosphenytoin (Cerebyx), and is followed by a general anesthetic such as midazolam (Versed) or propofol (Diprivan).

Intracranial pressure (ICP): This could be the result of a stroke or hemorrhage, brain tumor, or trauma. Fast action to control ICP is important because permanent brain injury can result. “I emphasize to hospitalists who are used to targeting ICP that it is better to look at cerebral perfusion pressure (CPP),” Dr. Josephson says, offering the following equation: CPP equals mean arterial pressure minus ICP. He also emphasizes raising the head of the patient’s bed, hyperventilation in early stages of treatment, and using osmotic agents such as mannitol to remove water from the brain.

Neuro-muscular emergencies: Acute disorders of the peripheral nerves, including Guillain-Barre Syndrome (an autoimmune neuropathy often triggered by infection), present a subacute onset of weakness and numbness. “We have good treatments for Guillain-Barre, such as plasmapheresis and administration of intravenous immunoglobulin,” Dr. Josephson says. “But recognition is important because the breathing may be affected. If the disorder reaches the diaphragm, it could kill the patient.” Disorders such as Guillain-Barre commonly present with ascending weakness, from the toes up.

A lumbar puncture (demonstrating few if any cells with an elevated protein) or an electromyogram (EMG) may be required for diagnosis. Hospitalists also are urged to watch for impending respiratory weakness, which can be measured by forced vital capacity or mean inspiratory flow. “Consider this diagnosis for anyone presenting with general weakness,” he says.

Exams on the Run

There is a standard technique for assessing and diagnosing neurological conditions, called the neurological examination. Unfortunately, a full, detailed neurological exam can be time-consuming and unrealistic, given caseload demands and field judgments required from the working hospitalist.

“As a hospitalist, you don’t have to perform an hourlong neurological examination,” Dr. Josephson says. “But for patients presenting neurological symptoms, you need to do a screening examination tied to their specific complaint. Your hypothesis-driven exam can be done in a few minutes if you know which elements are high-yield screening tests.”

These brief screening tests can be part of a routine assessment of the patient, Dr. Likosky adds.

Hospitalists can learn a lot just by walking into the patient’s room. “The bulk of such a neurological exam can be performed while talking to the patient, if you pay attention,” he notes. “There may be subtle signs of weakness. For example, when the patient is lying in bed, the feet should point straight up.” Note if one foot points to the side, or if the patient uses both sides of the face equally when talking.

“You can do sensory exams and test reflexes very briefly, as well,” Dr. Likosky says. “If those issues are on your radar screen, you can do much of the screening work in a stepwise fashion. The rest depends on clinical observation.”

There is not a huge spectrum of neurological disorders likely to confront the hospitalist, but it is important to know about the most common conditions and remember that time is of the essence, Dr. Likosky says. “Most neurological conditions are garden variety, but keep in mind the differential diagnoses, for example, for weakness and headache—common conditions that may rarely have an uncommon cause.”

Beef Up Training

Heather A. Harris, MD, a hospitalist at UCSF, illustrates the divide between academic medical centers and community hospitals when it comes to management of neurological diseases. She did her internal medicine training at UCSF and in 2003 went to a community hospital, Eden Medical Center in suburban Castro Valley, Calif., to help establish a hospitalist group. Suddenly, she was seeing lots of neurological cases.

“I’ll be frank: My internal medicine training at a wonderful medical institution had not prepared me for the reality that many new hospitalists face regarding neurological disorders,” says Dr. Harris. “You may see strokes as a resident, but it’s very different when you are the physician primarily managing strokes as they roll in. Yes, you may have a neurologist back-up, but they can’t always come in right away. The first time you see a patient with a stroke, it can be quite intimidating. You’re really learning on the fly. Plus, stroke management has advanced substantially in the last few years and there may be controversy, for example, over the use of t-PA in a community hospital setting.”

Feeling that her exposure to neurology was insufficient, Dr. Harris sought additional training at SHM meetings and talked to hospitalist colleagues in other community settings. “Hospitalists like me were trying to beef up our neurological knowledge and skill set.”

Dr. Harris developed a keen personal interest in neurology. In 2007, she returned to UCSF, where many of the hospitalists rarely see neurological patients. But she joined a new co-management service where hospitalists work alongside neuro-surgeons, helping manage the inevitable medical issues that arise in these patients.

Based on her first-hand appreciation for what hospitalists in community settings need to learn, Dr. Harris is also part of a team developing a new, hands-on training curriculum at UCSF for working hospitalists from community settings. That team is making sure neurology is adequately covered in UCSF’s curriculum.

“My overall experience is that if you’re going to be a hospitalist in a community setting, you’ll have to face a wide range of neurological emergencies,” Dr. Harris concludes. “It behooves us as hospitalists to learn the skill sets to manage these issues. There are also medical-legal issues that may put hospitalists out on a limb for doing too much too far outside of their knowledge and training. These are issues for SHM and our specialty to address.” TH

Larry Beresford is a regular contributor to The Hospitalist.

Although hospitalists may work alongside neurological specialists, they are increasingly on their own when responding to neurological emergencies, such as strokes, in hospitalized patients.

There are times the neurologist may be in the clinic, out of the hospital after hours, or otherwise unavailable, so responsibility for managing neurological conditions falls back on the hospitalist. But he or she may not have received sufficient exposure to neurology during medical training.

S. Andrew Josephson, MD, of the neurovascular division, director of the neurohospitalist program and assistant professor of neurology at the University of California-San Francisco (UCSF), regularly speaks on neurological issues to hospitalist audiences.

“I ask how many hospitalists in the room are primary caregivers for stroke in their hospital, and a surprising proportion raise their hands,” he says. “We do a good job of teaching neurology residents and fellows how to treat strokes. But it is important that we train internal medicine doctors as well, as they are seeing the majority of these patients nationwide.”

Depending on the setting, there may be wide variation in the hospitalist’s responsibility for neurological cases. “Here at UCSF, hospitalists almost never see stroke patients because we have a dedicated stroke service staffed by neurology attendings and residents,” Dr. Josephson says. “But at many community hospitals, they [care for neurological patients] all the time.”

David Likosky, MD, director of the stroke program at Evergreen Hospital Medical Center in Kirkland, Wash., concurs. “Neurology training in internal medicine residencies can be fairly limited,” he says. “After entering practice, these doctors are on the front lines in the hospital managing patients, many times without readily available neurologist backup.”

Dr. Likosky’s colleague at Evergreen, hospitalist Tony Yen, MD, says there are several neurological issues hospitalists are likely to encounter on a regular basis.

“Often the first responder to a stroke is the emergency department [ED] doctor or the hospitalist,” notes Dr. Yen. “Strokes are a time-critical, high-volume condition for our community hospitalist practice.”

Another important diagnosis is uncontrolled seizure (status epilepticus) that is unremitting for 10 minutes or more. Prompt response is critical.

Dr. Yen recalls the case of a young woman who collapsed while playing soccer. She was brought to the hospital and found to have suffered a brain-stem stroke. Physicians had three hours from the onset of symptoms to decide whether the patient was a candidate for tissue plasminogen activator (t-PA), a thrombolytic clot buster.

“I worked alongside the interventional radiologist and neurologist,” Dr. Yen recalls. “We were able to quickly establish a definitive diagnosis and then treat with intra-arterial t-PA.” The patient had a prolonged stay in intensive care and was on a ventilator for a couple of weeks but eventually recovered and walked out of the hospital.

Common Conditions

Stroke: The most common neurological emergency hospitalists are likely to see, whether on the floor or through the ED, is acute stroke, Dr. Josephson notes. “The evaluation of stroke requires a non-contrast computed tomography (CT) scan of the head to exclude intracerebral hemorrhage,” he says. “You can’t tell by looking at the patient whether it’s an ischemic stroke, the more common variety, or hemorrhagic stroke. But the difference is crucial because drugs to treat ischemic stroke can make hemorrhage worse. We view stroke as such a time-sensitive emergency that it always gets priority in the radiology department.”

It is also important to ascertain, as much as possible, when symptoms first began or when the patient was last observed to be normal. The treatment of choice in the first three hours following an ischemic stroke is intravenous t-PA. From hours three through six or eight, endovascular therapies (intra-arterial thrombolysis or mechanical clot retrieval) are an option. Signs suggesting a possible stroke include a new unilateral weakness, one-sided numbness, vertigo or imbalance, visual changes, inability to talk, and new headaches—although indications of a stroke can be subtle. The National Institutes of Health has issued a stroke scale, with training modules, accessible at www.strokecenter.org/trials/scales/nihss.html.

Seizures: Prolonged seizures that don’t resolve on their own within a reasonable amount of time require attention because the longer they last, the more likely they are to cause brain damage, Dr. Josephson says. Medications to treat the seizure work more effectively the earlier they are administered. He recommends a protocol for treating status epilepticus that starts with lorazepam (Ativan), proceeds to fosphenytoin (Cerebyx), and is followed by a general anesthetic such as midazolam (Versed) or propofol (Diprivan).

Intracranial pressure (ICP): This could be the result of a stroke or hemorrhage, brain tumor, or trauma. Fast action to control ICP is important because permanent brain injury can result. “I emphasize to hospitalists who are used to targeting ICP that it is better to look at cerebral perfusion pressure (CPP),” Dr. Josephson says, offering the following equation: CPP equals mean arterial pressure minus ICP. He also emphasizes raising the head of the patient’s bed, hyperventilation in early stages of treatment, and using osmotic agents such as mannitol to remove water from the brain.

Neuro-muscular emergencies: Acute disorders of the peripheral nerves, including Guillain-Barre Syndrome (an autoimmune neuropathy often triggered by infection), present a subacute onset of weakness and numbness. “We have good treatments for Guillain-Barre, such as plasmapheresis and administration of intravenous immunoglobulin,” Dr. Josephson says. “But recognition is important because the breathing may be affected. If the disorder reaches the diaphragm, it could kill the patient.” Disorders such as Guillain-Barre commonly present with ascending weakness, from the toes up.

A lumbar puncture (demonstrating few if any cells with an elevated protein) or an electromyogram (EMG) may be required for diagnosis. Hospitalists also are urged to watch for impending respiratory weakness, which can be measured by forced vital capacity or mean inspiratory flow. “Consider this diagnosis for anyone presenting with general weakness,” he says.

Exams on the Run

There is a standard technique for assessing and diagnosing neurological conditions, called the neurological examination. Unfortunately, a full, detailed neurological exam can be time-consuming and unrealistic, given caseload demands and field judgments required from the working hospitalist.

“As a hospitalist, you don’t have to perform an hourlong neurological examination,” Dr. Josephson says. “But for patients presenting neurological symptoms, you need to do a screening examination tied to their specific complaint. Your hypothesis-driven exam can be done in a few minutes if you know which elements are high-yield screening tests.”

These brief screening tests can be part of a routine assessment of the patient, Dr. Likosky adds.

Hospitalists can learn a lot just by walking into the patient’s room. “The bulk of such a neurological exam can be performed while talking to the patient, if you pay attention,” he notes. “There may be subtle signs of weakness. For example, when the patient is lying in bed, the feet should point straight up.” Note if one foot points to the side, or if the patient uses both sides of the face equally when talking.

“You can do sensory exams and test reflexes very briefly, as well,” Dr. Likosky says. “If those issues are on your radar screen, you can do much of the screening work in a stepwise fashion. The rest depends on clinical observation.”

There is not a huge spectrum of neurological disorders likely to confront the hospitalist, but it is important to know about the most common conditions and remember that time is of the essence, Dr. Likosky says. “Most neurological conditions are garden variety, but keep in mind the differential diagnoses, for example, for weakness and headache—common conditions that may rarely have an uncommon cause.”

Beef Up Training

Heather A. Harris, MD, a hospitalist at UCSF, illustrates the divide between academic medical centers and community hospitals when it comes to management of neurological diseases. She did her internal medicine training at UCSF and in 2003 went to a community hospital, Eden Medical Center in suburban Castro Valley, Calif., to help establish a hospitalist group. Suddenly, she was seeing lots of neurological cases.

“I’ll be frank: My internal medicine training at a wonderful medical institution had not prepared me for the reality that many new hospitalists face regarding neurological disorders,” says Dr. Harris. “You may see strokes as a resident, but it’s very different when you are the physician primarily managing strokes as they roll in. Yes, you may have a neurologist back-up, but they can’t always come in right away. The first time you see a patient with a stroke, it can be quite intimidating. You’re really learning on the fly. Plus, stroke management has advanced substantially in the last few years and there may be controversy, for example, over the use of t-PA in a community hospital setting.”

Feeling that her exposure to neurology was insufficient, Dr. Harris sought additional training at SHM meetings and talked to hospitalist colleagues in other community settings. “Hospitalists like me were trying to beef up our neurological knowledge and skill set.”

Dr. Harris developed a keen personal interest in neurology. In 2007, she returned to UCSF, where many of the hospitalists rarely see neurological patients. But she joined a new co-management service where hospitalists work alongside neuro-surgeons, helping manage the inevitable medical issues that arise in these patients.

Based on her first-hand appreciation for what hospitalists in community settings need to learn, Dr. Harris is also part of a team developing a new, hands-on training curriculum at UCSF for working hospitalists from community settings. That team is making sure neurology is adequately covered in UCSF’s curriculum.

“My overall experience is that if you’re going to be a hospitalist in a community setting, you’ll have to face a wide range of neurological emergencies,” Dr. Harris concludes. “It behooves us as hospitalists to learn the skill sets to manage these issues. There are also medical-legal issues that may put hospitalists out on a limb for doing too much too far outside of their knowledge and training. These are issues for SHM and our specialty to address.” TH

Larry Beresford is a regular contributor to The Hospitalist.

Although hospitalists may work alongside neurological specialists, they are increasingly on their own when responding to neurological emergencies, such as strokes, in hospitalized patients.

There are times the neurologist may be in the clinic, out of the hospital after hours, or otherwise unavailable, so responsibility for managing neurological conditions falls back on the hospitalist. But he or she may not have received sufficient exposure to neurology during medical training.

S. Andrew Josephson, MD, of the neurovascular division, director of the neurohospitalist program and assistant professor of neurology at the University of California-San Francisco (UCSF), regularly speaks on neurological issues to hospitalist audiences.

“I ask how many hospitalists in the room are primary caregivers for stroke in their hospital, and a surprising proportion raise their hands,” he says. “We do a good job of teaching neurology residents and fellows how to treat strokes. But it is important that we train internal medicine doctors as well, as they are seeing the majority of these patients nationwide.”

Depending on the setting, there may be wide variation in the hospitalist’s responsibility for neurological cases. “Here at UCSF, hospitalists almost never see stroke patients because we have a dedicated stroke service staffed by neurology attendings and residents,” Dr. Josephson says. “But at many community hospitals, they [care for neurological patients] all the time.”

David Likosky, MD, director of the stroke program at Evergreen Hospital Medical Center in Kirkland, Wash., concurs. “Neurology training in internal medicine residencies can be fairly limited,” he says. “After entering practice, these doctors are on the front lines in the hospital managing patients, many times without readily available neurologist backup.”

Dr. Likosky’s colleague at Evergreen, hospitalist Tony Yen, MD, says there are several neurological issues hospitalists are likely to encounter on a regular basis.

“Often the first responder to a stroke is the emergency department [ED] doctor or the hospitalist,” notes Dr. Yen. “Strokes are a time-critical, high-volume condition for our community hospitalist practice.”

Another important diagnosis is uncontrolled seizure (status epilepticus) that is unremitting for 10 minutes or more. Prompt response is critical.

Dr. Yen recalls the case of a young woman who collapsed while playing soccer. She was brought to the hospital and found to have suffered a brain-stem stroke. Physicians had three hours from the onset of symptoms to decide whether the patient was a candidate for tissue plasminogen activator (t-PA), a thrombolytic clot buster.

“I worked alongside the interventional radiologist and neurologist,” Dr. Yen recalls. “We were able to quickly establish a definitive diagnosis and then treat with intra-arterial t-PA.” The patient had a prolonged stay in intensive care and was on a ventilator for a couple of weeks but eventually recovered and walked out of the hospital.

Common Conditions

Stroke: The most common neurological emergency hospitalists are likely to see, whether on the floor or through the ED, is acute stroke, Dr. Josephson notes. “The evaluation of stroke requires a non-contrast computed tomography (CT) scan of the head to exclude intracerebral hemorrhage,” he says. “You can’t tell by looking at the patient whether it’s an ischemic stroke, the more common variety, or hemorrhagic stroke. But the difference is crucial because drugs to treat ischemic stroke can make hemorrhage worse. We view stroke as such a time-sensitive emergency that it always gets priority in the radiology department.”

It is also important to ascertain, as much as possible, when symptoms first began or when the patient was last observed to be normal. The treatment of choice in the first three hours following an ischemic stroke is intravenous t-PA. From hours three through six or eight, endovascular therapies (intra-arterial thrombolysis or mechanical clot retrieval) are an option. Signs suggesting a possible stroke include a new unilateral weakness, one-sided numbness, vertigo or imbalance, visual changes, inability to talk, and new headaches—although indications of a stroke can be subtle. The National Institutes of Health has issued a stroke scale, with training modules, accessible at www.strokecenter.org/trials/scales/nihss.html.

Seizures: Prolonged seizures that don’t resolve on their own within a reasonable amount of time require attention because the longer they last, the more likely they are to cause brain damage, Dr. Josephson says. Medications to treat the seizure work more effectively the earlier they are administered. He recommends a protocol for treating status epilepticus that starts with lorazepam (Ativan), proceeds to fosphenytoin (Cerebyx), and is followed by a general anesthetic such as midazolam (Versed) or propofol (Diprivan).

Intracranial pressure (ICP): This could be the result of a stroke or hemorrhage, brain tumor, or trauma. Fast action to control ICP is important because permanent brain injury can result. “I emphasize to hospitalists who are used to targeting ICP that it is better to look at cerebral perfusion pressure (CPP),” Dr. Josephson says, offering the following equation: CPP equals mean arterial pressure minus ICP. He also emphasizes raising the head of the patient’s bed, hyperventilation in early stages of treatment, and using osmotic agents such as mannitol to remove water from the brain.

Neuro-muscular emergencies: Acute disorders of the peripheral nerves, including Guillain-Barre Syndrome (an autoimmune neuropathy often triggered by infection), present a subacute onset of weakness and numbness. “We have good treatments for Guillain-Barre, such as plasmapheresis and administration of intravenous immunoglobulin,” Dr. Josephson says. “But recognition is important because the breathing may be affected. If the disorder reaches the diaphragm, it could kill the patient.” Disorders such as Guillain-Barre commonly present with ascending weakness, from the toes up.

A lumbar puncture (demonstrating few if any cells with an elevated protein) or an electromyogram (EMG) may be required for diagnosis. Hospitalists also are urged to watch for impending respiratory weakness, which can be measured by forced vital capacity or mean inspiratory flow. “Consider this diagnosis for anyone presenting with general weakness,” he says.

Exams on the Run

There is a standard technique for assessing and diagnosing neurological conditions, called the neurological examination. Unfortunately, a full, detailed neurological exam can be time-consuming and unrealistic, given caseload demands and field judgments required from the working hospitalist.

“As a hospitalist, you don’t have to perform an hourlong neurological examination,” Dr. Josephson says. “But for patients presenting neurological symptoms, you need to do a screening examination tied to their specific complaint. Your hypothesis-driven exam can be done in a few minutes if you know which elements are high-yield screening tests.”

These brief screening tests can be part of a routine assessment of the patient, Dr. Likosky adds.

Hospitalists can learn a lot just by walking into the patient’s room. “The bulk of such a neurological exam can be performed while talking to the patient, if you pay attention,” he notes. “There may be subtle signs of weakness. For example, when the patient is lying in bed, the feet should point straight up.” Note if one foot points to the side, or if the patient uses both sides of the face equally when talking.

“You can do sensory exams and test reflexes very briefly, as well,” Dr. Likosky says. “If those issues are on your radar screen, you can do much of the screening work in a stepwise fashion. The rest depends on clinical observation.”

There is not a huge spectrum of neurological disorders likely to confront the hospitalist, but it is important to know about the most common conditions and remember that time is of the essence, Dr. Likosky says. “Most neurological conditions are garden variety, but keep in mind the differential diagnoses, for example, for weakness and headache—common conditions that may rarely have an uncommon cause.”

Beef Up Training

Heather A. Harris, MD, a hospitalist at UCSF, illustrates the divide between academic medical centers and community hospitals when it comes to management of neurological diseases. She did her internal medicine training at UCSF and in 2003 went to a community hospital, Eden Medical Center in suburban Castro Valley, Calif., to help establish a hospitalist group. Suddenly, she was seeing lots of neurological cases.

“I’ll be frank: My internal medicine training at a wonderful medical institution had not prepared me for the reality that many new hospitalists face regarding neurological disorders,” says Dr. Harris. “You may see strokes as a resident, but it’s very different when you are the physician primarily managing strokes as they roll in. Yes, you may have a neurologist back-up, but they can’t always come in right away. The first time you see a patient with a stroke, it can be quite intimidating. You’re really learning on the fly. Plus, stroke management has advanced substantially in the last few years and there may be controversy, for example, over the use of t-PA in a community hospital setting.”

Feeling that her exposure to neurology was insufficient, Dr. Harris sought additional training at SHM meetings and talked to hospitalist colleagues in other community settings. “Hospitalists like me were trying to beef up our neurological knowledge and skill set.”

Dr. Harris developed a keen personal interest in neurology. In 2007, she returned to UCSF, where many of the hospitalists rarely see neurological patients. But she joined a new co-management service where hospitalists work alongside neuro-surgeons, helping manage the inevitable medical issues that arise in these patients.

Based on her first-hand appreciation for what hospitalists in community settings need to learn, Dr. Harris is also part of a team developing a new, hands-on training curriculum at UCSF for working hospitalists from community settings. That team is making sure neurology is adequately covered in UCSF’s curriculum.

“My overall experience is that if you’re going to be a hospitalist in a community setting, you’ll have to face a wide range of neurological emergencies,” Dr. Harris concludes. “It behooves us as hospitalists to learn the skill sets to manage these issues. There are also medical-legal issues that may put hospitalists out on a limb for doing too much too far outside of their knowledge and training. These are issues for SHM and our specialty to address.” TH

Larry Beresford is a regular contributor to The Hospitalist.

One day, you’re sitting in your office when a stranger appears and asks, “Are you Dr. Smith?” When you say yes, the stranger hands you a sheaf of papers. You open the papers and see you’ve been “commanded” to attend a deposition at a lawyer’s office next week. How do you prepare?

The Basics

Black’s Law Dictionary gives a long definition of a deposition. But the shorter, more practical definition is that a deposition is a witness’s sworn out-of-court testimony. When a physician gives a deposition in a lawyer’s office, this testimony has the same legal effect as though the physician were testifying in court.

Lawyers typically view depositions as one of two types:

• Discovery depositions: These allow lawyers to discover the substance of a witness’s testimony before trial. They can touch upon a number of subjects that seem tangential to the case. A lawyer taking a discovery deposition is putting together the pieces of the case and may or may not ask the witness to testify at trial; and
• Perpetuation depositions: These let lawyers present the testimony of a witness who cannot appear at trial. Perpetuation depositions substitute for the examinations and cross-examinations that would normally occur in the courtroom. Perpetuation depositions are generally shorter and more focused than discovery depositions.

In all depositions, lawyers ask questions of the witness and can object to legally improper questions. The lawyers can ask the witness to refer to documents or other exhibits during the deposition. A court reporter will transcribe the questions and answers and condense them into a written transcript. A judge is normally not present for a deposition but can be called during the deposition to make rulings.

Know Your Role

Perhaps the most important thing you can do in preparing for a deposition is understand your role in the lawsuit. Generally, physicians serve in one of three potential roles as deponents:

Medical malpractice defendant: When a patient sues a physician for malpractice, the patient’s attorney normally will take the physician’s deposition. In this highly adversarial process, the patient’s attorney attempts to demonstrate that the physician’s negligence injured the patient. A physician being deposed as a defendant must prepare by meeting with his attorney and reviewing the issues likely to arise during the proceedings. If you are a defendant in a lawsuit, you must set aside adequate time to prepare for the deposition with your attorney;

Retained expert witness: The rules of evidence allow people with specialized knowledge to testify as experts in fields normally beyond the average juror’s experience. Because they have specialized knowledge, experts are allowed to state opinions in their testimony, such as whether a physician’s conduct complied with the applicable standards of care. Attorneys generally hire expert witnesses to present opinions in a case and will provide a summary of the expert’s testimony before the deposition; and

Treating physician: Many physicians are deposed concerning the care they provided to a patient in lawsuits that implicate the patient’s health (auto accident, work injury, disability suit). These depositions focus on the substance of treatment, the patient’s medical condition, and the patient’s prognosis. The physician normally does not have any interest in how the lawsuit is resolved. A treating physician is often compensated for his time in the deposition, even though he was not retained as an expert to testify in the lawsuit.

Golden Rules

Because depositions are stressful, lawyers ask witnesses to remember only three rules.

Tell the truth: Your only job as a witness is to tell the truth. If you follow this rule, you have discharged your obligation to the legal system.

However, keep some things in mind when telling the truth. In particular, your ability to tell the truth is subject to the limitations of your memory and the fact that your deposition may be occurring several years after you provided care. “I don’t know” and “I don’t remember” are absolutely acceptable answers in a deposition. In fact, they are preferable to inaccurate or untruthful testimony. If reviewing a document (such as the patient’s medical records) will help you provide accurate and truthful testimony, don’t be shy about asking to review them. In any situation where you are guessing or providing your best recollection, make sure the lawyer knows you are doing your best but that you can’t remember all the details.

Make sure you understand the question: This rule seems self-evident, but many lawyers ask convoluted or compound questions. Lawyers may also use language unfamiliar to you as an outsider to the legal process. For example, when lawyers use the phrase “standard of care,” it has a fairly precise definition (it is an action a reasonably careful physician would undertake under the same or similar circumstances). Ask for clarification of any question that is not clear. It’s the lawyer’s job to ask an understandable question, not the physician’s job to answer a question that doesn’t make sense. Be extra careful when the opposing lawyer objects to a question. While the lawyer’s objection does not relieve you from answering, it should signal you that the question is potentially flawed or beyond the scope of your knowledge.

Answer only what you’re asked: Invariably, physicians struggle most when they don’t focus their answers on the question posed to them.

The majority of questions in a deposition can be answered “Yes,” “No,” “I don’t know,” and “I don’t remember.” Yet many physicians tend to volunteer additional information to explain their answers. Because lawyers are trained to recognize and follow up on nonresponsive answers, the physician’s deposition becomes longer and more challenging. To provide a better answer, don’t think out loud. Ponder the question and mentally prepare your answer. Doing so lets you respond more precisely. Answer only the question you are asked. If there is an area that needs more explanation, the other party’s attorney (or your attorney) will have an opportunity to allow you to clarify the record.

To help you follow the rules, use this decision tree during your deposition (see Figure 1, left).

Regardless of the purpose of a deposition or your perceived role in it, consult with an attorney before being deposed. Even if you believe you are being deposed only as a treating provider, a deposition could lead to potential claims or raise concerns about your records. If served with a subpoena, contact your insurance company, which may retain an attorney to assist you. TH

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

One day, you’re sitting in your office when a stranger appears and asks, “Are you Dr. Smith?” When you say yes, the stranger hands you a sheaf of papers. You open the papers and see you’ve been “commanded” to attend a deposition at a lawyer’s office next week. How do you prepare?

The Basics

Black’s Law Dictionary gives a long definition of a deposition. But the shorter, more practical definition is that a deposition is a witness’s sworn out-of-court testimony. When a physician gives a deposition in a lawyer’s office, this testimony has the same legal effect as though the physician were testifying in court.

Lawyers typically view depositions as one of two types:

• Discovery depositions: These allow lawyers to discover the substance of a witness’s testimony before trial. They can touch upon a number of subjects that seem tangential to the case. A lawyer taking a discovery deposition is putting together the pieces of the case and may or may not ask the witness to testify at trial; and
• Perpetuation depositions: These let lawyers present the testimony of a witness who cannot appear at trial. Perpetuation depositions substitute for the examinations and cross-examinations that would normally occur in the courtroom. Perpetuation depositions are generally shorter and more focused than discovery depositions.

In all depositions, lawyers ask questions of the witness and can object to legally improper questions. The lawyers can ask the witness to refer to documents or other exhibits during the deposition. A court reporter will transcribe the questions and answers and condense them into a written transcript. A judge is normally not present for a deposition but can be called during the deposition to make rulings.

Know Your Role

Perhaps the most important thing you can do in preparing for a deposition is understand your role in the lawsuit. Generally, physicians serve in one of three potential roles as deponents:

Medical malpractice defendant: When a patient sues a physician for malpractice, the patient’s attorney normally will take the physician’s deposition. In this highly adversarial process, the patient’s attorney attempts to demonstrate that the physician’s negligence injured the patient. A physician being deposed as a defendant must prepare by meeting with his attorney and reviewing the issues likely to arise during the proceedings. If you are a defendant in a lawsuit, you must set aside adequate time to prepare for the deposition with your attorney;

Retained expert witness: The rules of evidence allow people with specialized knowledge to testify as experts in fields normally beyond the average juror’s experience. Because they have specialized knowledge, experts are allowed to state opinions in their testimony, such as whether a physician’s conduct complied with the applicable standards of care. Attorneys generally hire expert witnesses to present opinions in a case and will provide a summary of the expert’s testimony before the deposition; and

Treating physician: Many physicians are deposed concerning the care they provided to a patient in lawsuits that implicate the patient’s health (auto accident, work injury, disability suit). These depositions focus on the substance of treatment, the patient’s medical condition, and the patient’s prognosis. The physician normally does not have any interest in how the lawsuit is resolved. A treating physician is often compensated for his time in the deposition, even though he was not retained as an expert to testify in the lawsuit.

Golden Rules

Because depositions are stressful, lawyers ask witnesses to remember only three rules.

Tell the truth: Your only job as a witness is to tell the truth. If you follow this rule, you have discharged your obligation to the legal system.

However, keep some things in mind when telling the truth. In particular, your ability to tell the truth is subject to the limitations of your memory and the fact that your deposition may be occurring several years after you provided care. “I don’t know” and “I don’t remember” are absolutely acceptable answers in a deposition. In fact, they are preferable to inaccurate or untruthful testimony. If reviewing a document (such as the patient’s medical records) will help you provide accurate and truthful testimony, don’t be shy about asking to review them. In any situation where you are guessing or providing your best recollection, make sure the lawyer knows you are doing your best but that you can’t remember all the details.

Make sure you understand the question: This rule seems self-evident, but many lawyers ask convoluted or compound questions. Lawyers may also use language unfamiliar to you as an outsider to the legal process. For example, when lawyers use the phrase “standard of care,” it has a fairly precise definition (it is an action a reasonably careful physician would undertake under the same or similar circumstances). Ask for clarification of any question that is not clear. It’s the lawyer’s job to ask an understandable question, not the physician’s job to answer a question that doesn’t make sense. Be extra careful when the opposing lawyer objects to a question. While the lawyer’s objection does not relieve you from answering, it should signal you that the question is potentially flawed or beyond the scope of your knowledge.

Answer only what you’re asked: Invariably, physicians struggle most when they don’t focus their answers on the question posed to them.

The majority of questions in a deposition can be answered “Yes,” “No,” “I don’t know,” and “I don’t remember.” Yet many physicians tend to volunteer additional information to explain their answers. Because lawyers are trained to recognize and follow up on nonresponsive answers, the physician’s deposition becomes longer and more challenging. To provide a better answer, don’t think out loud. Ponder the question and mentally prepare your answer. Doing so lets you respond more precisely. Answer only the question you are asked. If there is an area that needs more explanation, the other party’s attorney (or your attorney) will have an opportunity to allow you to clarify the record.

To help you follow the rules, use this decision tree during your deposition (see Figure 1, left).

Regardless of the purpose of a deposition or your perceived role in it, consult with an attorney before being deposed. Even if you believe you are being deposed only as a treating provider, a deposition could lead to potential claims or raise concerns about your records. If served with a subpoena, contact your insurance company, which may retain an attorney to assist you. TH

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

One day, you’re sitting in your office when a stranger appears and asks, “Are you Dr. Smith?” When you say yes, the stranger hands you a sheaf of papers. You open the papers and see you’ve been “commanded” to attend a deposition at a lawyer’s office next week. How do you prepare?

The Basics

Black’s Law Dictionary gives a long definition of a deposition. But the shorter, more practical definition is that a deposition is a witness’s sworn out-of-court testimony. When a physician gives a deposition in a lawyer’s office, this testimony has the same legal effect as though the physician were testifying in court.

Lawyers typically view depositions as one of two types:

• Discovery depositions: These allow lawyers to discover the substance of a witness’s testimony before trial. They can touch upon a number of subjects that seem tangential to the case. A lawyer taking a discovery deposition is putting together the pieces of the case and may or may not ask the witness to testify at trial; and
• Perpetuation depositions: These let lawyers present the testimony of a witness who cannot appear at trial. Perpetuation depositions substitute for the examinations and cross-examinations that would normally occur in the courtroom. Perpetuation depositions are generally shorter and more focused than discovery depositions.

In all depositions, lawyers ask questions of the witness and can object to legally improper questions. The lawyers can ask the witness to refer to documents or other exhibits during the deposition. A court reporter will transcribe the questions and answers and condense them into a written transcript. A judge is normally not present for a deposition but can be called during the deposition to make rulings.

Know Your Role

Perhaps the most important thing you can do in preparing for a deposition is understand your role in the lawsuit. Generally, physicians serve in one of three potential roles as deponents:

Medical malpractice defendant: When a patient sues a physician for malpractice, the patient’s attorney normally will take the physician’s deposition. In this highly adversarial process, the patient’s attorney attempts to demonstrate that the physician’s negligence injured the patient. A physician being deposed as a defendant must prepare by meeting with his attorney and reviewing the issues likely to arise during the proceedings. If you are a defendant in a lawsuit, you must set aside adequate time to prepare for the deposition with your attorney;

Retained expert witness: The rules of evidence allow people with specialized knowledge to testify as experts in fields normally beyond the average juror’s experience. Because they have specialized knowledge, experts are allowed to state opinions in their testimony, such as whether a physician’s conduct complied with the applicable standards of care. Attorneys generally hire expert witnesses to present opinions in a case and will provide a summary of the expert’s testimony before the deposition; and

Treating physician: Many physicians are deposed concerning the care they provided to a patient in lawsuits that implicate the patient’s health (auto accident, work injury, disability suit). These depositions focus on the substance of treatment, the patient’s medical condition, and the patient’s prognosis. The physician normally does not have any interest in how the lawsuit is resolved. A treating physician is often compensated for his time in the deposition, even though he was not retained as an expert to testify in the lawsuit.

Golden Rules

Because depositions are stressful, lawyers ask witnesses to remember only three rules.

Tell the truth: Your only job as a witness is to tell the truth. If you follow this rule, you have discharged your obligation to the legal system.

However, keep some things in mind when telling the truth. In particular, your ability to tell the truth is subject to the limitations of your memory and the fact that your deposition may be occurring several years after you provided care. “I don’t know” and “I don’t remember” are absolutely acceptable answers in a deposition. In fact, they are preferable to inaccurate or untruthful testimony. If reviewing a document (such as the patient’s medical records) will help you provide accurate and truthful testimony, don’t be shy about asking to review them. In any situation where you are guessing or providing your best recollection, make sure the lawyer knows you are doing your best but that you can’t remember all the details.

Make sure you understand the question: This rule seems self-evident, but many lawyers ask convoluted or compound questions. Lawyers may also use language unfamiliar to you as an outsider to the legal process. For example, when lawyers use the phrase “standard of care,” it has a fairly precise definition (it is an action a reasonably careful physician would undertake under the same or similar circumstances). Ask for clarification of any question that is not clear. It’s the lawyer’s job to ask an understandable question, not the physician’s job to answer a question that doesn’t make sense. Be extra careful when the opposing lawyer objects to a question. While the lawyer’s objection does not relieve you from answering, it should signal you that the question is potentially flawed or beyond the scope of your knowledge.

Answer only what you’re asked: Invariably, physicians struggle most when they don’t focus their answers on the question posed to them.

The majority of questions in a deposition can be answered “Yes,” “No,” “I don’t know,” and “I don’t remember.” Yet many physicians tend to volunteer additional information to explain their answers. Because lawyers are trained to recognize and follow up on nonresponsive answers, the physician’s deposition becomes longer and more challenging. To provide a better answer, don’t think out loud. Ponder the question and mentally prepare your answer. Doing so lets you respond more precisely. Answer only the question you are asked. If there is an area that needs more explanation, the other party’s attorney (or your attorney) will have an opportunity to allow you to clarify the record.

To help you follow the rules, use this decision tree during your deposition (see Figure 1, left).

Regardless of the purpose of a deposition or your perceived role in it, consult with an attorney before being deposed. Even if you believe you are being deposed only as a treating provider, a deposition could lead to potential claims or raise concerns about your records. If served with a subpoena, contact your insurance company, which may retain an attorney to assist you. TH

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