At the insistence of her family, a woman comes to you complaining of a cough that has lasted several weeks. Many experts would urge a thorough diagnostic investigation, justifying this action with a presumed shorter course of treatment. But is an involved work-up really necessary? Would a quicker, less expensive approach serve the patient just as well? We designed our study to answer these questions.

“Test all, then treat” is expensive

In the management of patients with chronic cough, most algorithms have advocated the approach of “test all, then treat.”^1-6 This is an expensive approach and one that delays relief for the patient, though a confirmative diagnosis may decrease the overall duration of treatment. In most cases, however, this approach may be unnecessary. And because few of the underlying disorders are acutely debilitating or rapidly progressive, even misdiagnosis and resultant inappropriate treatment pose little risk to patients.

The less common approach is a sequence of trial-and-error treatments based on a presumptive hierarchy of possible diagnoses.⁶ The advantage with this strategy is a 3-to 5-fold cost savings.⁶ And we suspected that the associated length of treatment would be acceptable.

We proposed that the management of patients with chronic cough begin with a presumptive diagnosis, thus simplifying the initial evaluation, keeping costs low, and offering earlier treatment.

We developed an algorithm for the treatment of patients with chronic cough that relies on minimal diagnostic investigations, regardless of the confirmed diagnosis. We evaluated our approach from the perspectives of the presumptive diagnosis and the therapeutic response period.

Methods

Treatment algorithm reflects experience and local resources

Initially, we designed the algorithm to follow findings in the literature on the treatment of patients with chronic cough. We then simplified and modified the algorithm to reflect the experiences of doctors from the pulmonology clinic in our hospital, and to take into account local patient characteristics and available medical equipment and resources.

Subjects were otherwise healthy

Between January 1 and December 31, 2005, at the internal medicine clinic of Cheju National University Hospital, we enrolled 378 patients whose chief complaint was cough persisting for more than 4 weeks and who had no abnormalities detected on auscultation by a physician, chest radiography (posterior–anterior view and left lateral view), or complete blood cell counts. Each patient had a complete blood count to detect anemia, hematologic disorders, or inflammatory conditions. Current users of angiotensin-converting enzyme (ACE) inhibitors were excluded.

All of the patients we enrolled were adults living in Jeju, Korea, and the mean age was 51 years. One hundred eighty-six (49%) were men. The median reported cough duration was 2 months (range, 1–36 months) (TABLE 1).

We instructed the patients on our algorithmic approach to treating chronic cough and encouraged them to follow the algorithm through to telephone notification of the next visit.

TABLE 1
Characteristics of the 378 enrolled patients

Men/women	186/192 (49/51%)
Age, years	51.2±16.12
Cough duration in months, median (range)	2 (1–36)

How we determined treatment outcomes

Patients graded their cough severity subjectively at each visit using a visual analogue scale (VAS) from 1 (no cough at all) to 10 (cough severity same as that remembered during first visit to the clinic). We recorded their reports on a questionnaire.

Successful responders were patients who reported a subjective grade of cough severity less than 3. Partial responders and nonresponders were defined, respectively, as those reporting VAS scores from 3 to 6 and more than 6.

We defined the response period as the number of days from enrollment until the next visit in which the patient first reported a VAS score of cough severity less than 3.

Algorithm: Addressing the 3 most common causes of chronic cough

 

1. Postnasal drip syndrome. Patients first underwent a rhinoscopic examination (FIGURE). When clinicians detected redness or abnormal discharge on the nasal mucosa, they prescribed a 5-day course of antihistamine (10 mg/day ebastine [Ebastel] orally), pseudoephedrine (30 mg 3 times daily, orally), and intranasal corticosteroid (triamcinolone acetonide [Nasacort] 110 mcg twice daily intranasally). Patients without symptoms of rhinitis were referred to the next diagnostic phase.

With completion of the prescribed medication 5 days after the first visit, we graded the severity of cough by questionnaire. Patients in the successful and partial responder categories received a presumptive diagnosis of postnasal drip syndrome, and we asked them to continue using the medication for at least 2 weeks. We had each nonresponder stop the medication.

2. Asthma syndrome. Partial responder and nonresponder patients entered the next diagnostic phase: a methacholine bronchial provocation test (MPT)⁷ and eosinophil count with induced sputum by hypertonic saline (3% NaCl).⁸ We defined a positive MPT result as <10 mg/ mL of methacholine causing a 20% fall in FEV₁ from baseline (PC₂₀). Patients with more than 3% eosinophils in the induced sputum specimen or with a positive MPT received a 1-week prescription for inhaled budesonide 160 mcg twice daily and inhaled formoterol (Symbicort) 4.5 mcg twice daily. Patients who did not exhibit these asthma indicators were referred to the next step.

At the next visit, we again graded the severity of cough. Patients in the successful and partial responder categories received a presumptive diagnosis of asthma syndrome. We asked successful and partial responders to continue the medication for at least 2 weeks. Those classed as nonresponders were asked to stop their medication. We referred all patients with positive MPT test results to a special clinic for asthma, regardless of responses to this therapeutic trial or eosinophil count in the induced sputum.

3. Reflux syndrome. Partial responders and nonresponders then received a 2-week prescription for a proton pump inhibitor, pantoprazole (Pantoloc), 40 mg orally once daily.⁹ At the next visit 2 weeks later, we graded the severity of cough. Successful and partial responders were given a presumptive diagnosis of reflux syndrome, but only successful responders were asked to continue the same medication for at least 6 weeks. At the discretion of their physicians, partial and nonresponders underwent other diagnostic investigations, including high-resolution computerized tomography (CT) of the lungs, bronchoscopic examination, sputum smear and culture for acid fast bacilli, sputum culture for ordinary bacteria and fungi, and a serological test for human immunodeficiency virus.

FIGURE
A presumptive-diagnosis algorithm

Chronic cough resolved for more than 90% of patients treated according to this algorithm.
MPT, methacholine bronchial provocation test; VAS, visual analog scale.

Results

Presumptive diagnoses

Among 378 patients, 346 (91%) showed erythematous mucosa or abnormal discharge in rhinoscopic examinations and received empiric medication for 5 days. The successful-responder category included 176 patients (47%); 79 (21%) were classed as partial responders, and 255 (67%) received the presumptive diagnosis of postnasal drip syndrome. Among the 346 treated patients, 91 (24% of those enrolled, or 26% of treated) showed no response.

Thirty-two patients with normal rhinoscopic findings and 170 categorized as partial or nonresponders in the first step underwent an MPT and eosinophil count of induced sputum. One hundred forty-four showed positive results and received empiric treatment for 1 week. Among these, 141 were deemed successful responders (37% of enrolled, or 98% of treated), 3 partial responders (1% of enrolled, or 2% of treated), and none were nonresponders.

In all, 61 patients had empiric treatment for reflux syndrome for 2 weeks; 58 had normal findings for both the MPT and sputum eosinophil count, and 3 were classified as partial responders in the previous therapeutic trial. Twenty-nine patients (8% of enrolled, or 47% of treated) were classified as successful responders after 2 weeks (TABLE 2).

TABLE 2
Presumptive diagnoses corresponded to expected frequency (and occasionally co-existed)

DIAGNOSIS	NO. OF PATIENTS (%)* N=378
Postnasal drip syndrome	255 (67.5)
Asthma syndrome	144 (38.1)
Reflux syndrome	29 (7.7)
CO-EXISTING PATHOLOGIES	82 (21.7)
Postnasal drip syndrome and asthma syndrome	52 (13.8)
Postnasal drip syndrome and reflux syndrome	7 (1.9)
Postnasal drip syndrome and other diagnosis	20 (5.3)
Asthma syndrome and other diagnosis	3 (0.8)
* The percentage of patients under "Diagnosis" does not add up to 100% because some patients had more than one condition, accounted for under "Co-existing pathologies."

Therapeutic response period for successful responders

Within 5 days of beginning the course determined by the algorithm (Figure), 176 patients (47%) who received treatment for presumed postnasal drip syndrome experienced resolution of their chronic cough.

 

Another 141 patients (37%) diagnosed with asthma syndrome (with or without postnasal drip syndrome) reported cough resolution following successful treatment between 7 and 12 days.

Another 29 patients (8%) with re-flux syndrome were successfully treated between 14 and 26 days.

Treatment of chronic cough by the algorithm

After application of the therapeutic algorithm, the chronic cough of 346 patients (92%) resolved. Thirty-two patients (8.5%) underwent other diagnostic investigations.

Final diagnoses after further diagnostic testing

Ten patients reported that they stopped coughing spontaneously while awaiting additional diagnostic investigations. Seven patients had mycobacterial infections confirmed by acid fast bacilli smears or culture of sputum or bronchoscopic washings. Six patients had localized or diffuse bronchiectasis confirmed by high-resolution CT, the results of which were used retrospectively to reassess normal or equivocal findings in the initial diagnostic investigations. Finally, the coughs of 12 patients were judged to be idiopathic or psychogenic.

Discussion

Cough is a symptom not easily assessed objectively. Previous studies measured severity of cough with daily diaries and visual analog scales, which are subjective measurement tools. We, too, used the visual analog scale to measure cough severity and treatment response. We did not pursue a definitive diagnosis of the cause of chronic cough. Rather, our algorithmic approach made presumptive diagnoses that were confirmed or refuted by patients’ successive reports of cough severity in response to treatment.

The logic behind our algorithm

Because studies in Korea have shown that postnasal drip is the most frequent cause of chronic cough, we chose rhinoscopy as the first diagnostic investigation. The second and third steps of our approach investigated asthma syndrome and reflux syndrome, respectively.

We did not take into account whether patients smoked cigarettes. Some investigators rightly point out that smoking might contribute to chronic cough. However, we have not met many smokers willing to quit because of a cough, and our algorithm is designed for practical clinical use. In contrast, patients with chronic cough secondary to ACE inhibitor therapy have readily accepted trials of different antihypertensive medications.

Our assumptions proved true

Patients with any abnormality of the nasal mucosa were treated for postnasal drip syndrome. Though the proportion of abnormal mucosal findings was greater than that reported in previous investigations of the same ethnic subjects, the eventual treatment response showed that the presumptive diagnosis of postnasal drip was equivalent to that in other studies.^10,11

Postnasal drip syndrome did indeed turn out to be the most common presumptive cause of cough in our study. However, roughly one third of these patients proved to have an additional presumptive disorder. Previous investigations have also reported dual or multiple pathologies in patients with a chronic cough.^11,12

If treatment succeeded at any step in our algorithm, we asked patients to stop taking medication—with the exception of those who had positive results on methacholine bronchial provocation test. Asthma is a chronic inflammatory disorder that needs persistent therapy to prevent exacerbations and declining lung function.^13,14 Challenge studies with methacholine or histamine are sensitive tests and provide high negative predictive values for the diagnosis of asthma and cough variant asthma.^15,16

What have other studies shown?

The natural course of chronic cough is still in question, primarily because of the heterogeneity of its etiology. The natural course of many common diseases has been investigated, of course, but few studies have focused on duration of symptoms such as cough. Park et al¹⁷ investigated the natural course of eosinophilic bronchitis, a common underlying disorder in chronic cough. In a 48-month follow-up of 36 patients diagnosed with eosinophilic bronchitis, 14% experienced recurrence after treatment. And patients with a higher percentage of eosinophils in the sputum had a risk for developing airway hyperresponsiveness.

Ours et al⁹ reported that, for patients without asthma or postnasal drip, an empiric 2-week trial of high-dose proton pump inhibitors was more reliable and cost effective for chronic cough than was treatment after esophageal manometry or 24 hours dual probe pH monitoring. Besides the expense of manometry and pH monitoring, both procedures are invasive and unavailable in many localities such as ours. Our algorithm supposes, for one thing, minimum availability of medical equipment in many locales.

The algorithm makes sense

Our approach decreased medical expenses and therapeutic response periods. Cough resolved for more than 90% of our patients. This success rate was equivalent to that reported by previous studies, most of which revealed no definitive diagnosis during the therapeutic response period.^2-4,18 Half of all patients in our study experienced cough resolution within 5 days, and more than 80% did so within 12 days.

 

Development of algorithms similar to ours should take into account not just findings in the literature but the experiences of local doctors and available medical equipment and options.

At the insistence of her family, a woman comes to you complaining of a cough that has lasted several weeks. Many experts would urge a thorough diagnostic investigation, justifying this action with a presumed shorter course of treatment. But is an involved work-up really necessary? Would a quicker, less expensive approach serve the patient just as well? We designed our study to answer these questions.

“Test all, then treat” is expensive

In the management of patients with chronic cough, most algorithms have advocated the approach of “test all, then treat.”^1-6 This is an expensive approach and one that delays relief for the patient, though a confirmative diagnosis may decrease the overall duration of treatment. In most cases, however, this approach may be unnecessary. And because few of the underlying disorders are acutely debilitating or rapidly progressive, even misdiagnosis and resultant inappropriate treatment pose little risk to patients.

The less common approach is a sequence of trial-and-error treatments based on a presumptive hierarchy of possible diagnoses.⁶ The advantage with this strategy is a 3-to 5-fold cost savings.⁶ And we suspected that the associated length of treatment would be acceptable.

We proposed that the management of patients with chronic cough begin with a presumptive diagnosis, thus simplifying the initial evaluation, keeping costs low, and offering earlier treatment.

We developed an algorithm for the treatment of patients with chronic cough that relies on minimal diagnostic investigations, regardless of the confirmed diagnosis. We evaluated our approach from the perspectives of the presumptive diagnosis and the therapeutic response period.

Methods

Treatment algorithm reflects experience and local resources

Initially, we designed the algorithm to follow findings in the literature on the treatment of patients with chronic cough. We then simplified and modified the algorithm to reflect the experiences of doctors from the pulmonology clinic in our hospital, and to take into account local patient characteristics and available medical equipment and resources.

Subjects were otherwise healthy

Between January 1 and December 31, 2005, at the internal medicine clinic of Cheju National University Hospital, we enrolled 378 patients whose chief complaint was cough persisting for more than 4 weeks and who had no abnormalities detected on auscultation by a physician, chest radiography (posterior–anterior view and left lateral view), or complete blood cell counts. Each patient had a complete blood count to detect anemia, hematologic disorders, or inflammatory conditions. Current users of angiotensin-converting enzyme (ACE) inhibitors were excluded.

All of the patients we enrolled were adults living in Jeju, Korea, and the mean age was 51 years. One hundred eighty-six (49%) were men. The median reported cough duration was 2 months (range, 1–36 months) (TABLE 1).

We instructed the patients on our algorithmic approach to treating chronic cough and encouraged them to follow the algorithm through to telephone notification of the next visit.

TABLE 1
Characteristics of the 378 enrolled patients

Men/women	186/192 (49/51%)
Age, years	51.2±16.12
Cough duration in months, median (range)	2 (1–36)

How we determined treatment outcomes

Patients graded their cough severity subjectively at each visit using a visual analogue scale (VAS) from 1 (no cough at all) to 10 (cough severity same as that remembered during first visit to the clinic). We recorded their reports on a questionnaire.

Successful responders were patients who reported a subjective grade of cough severity less than 3. Partial responders and nonresponders were defined, respectively, as those reporting VAS scores from 3 to 6 and more than 6.

We defined the response period as the number of days from enrollment until the next visit in which the patient first reported a VAS score of cough severity less than 3.

Algorithm: Addressing the 3 most common causes of chronic cough

 

1. Postnasal drip syndrome. Patients first underwent a rhinoscopic examination (FIGURE). When clinicians detected redness or abnormal discharge on the nasal mucosa, they prescribed a 5-day course of antihistamine (10 mg/day ebastine [Ebastel] orally), pseudoephedrine (30 mg 3 times daily, orally), and intranasal corticosteroid (triamcinolone acetonide [Nasacort] 110 mcg twice daily intranasally). Patients without symptoms of rhinitis were referred to the next diagnostic phase.

With completion of the prescribed medication 5 days after the first visit, we graded the severity of cough by questionnaire. Patients in the successful and partial responder categories received a presumptive diagnosis of postnasal drip syndrome, and we asked them to continue using the medication for at least 2 weeks. We had each nonresponder stop the medication.

2. Asthma syndrome. Partial responder and nonresponder patients entered the next diagnostic phase: a methacholine bronchial provocation test (MPT)⁷ and eosinophil count with induced sputum by hypertonic saline (3% NaCl).⁸ We defined a positive MPT result as <10 mg/ mL of methacholine causing a 20% fall in FEV₁ from baseline (PC₂₀). Patients with more than 3% eosinophils in the induced sputum specimen or with a positive MPT received a 1-week prescription for inhaled budesonide 160 mcg twice daily and inhaled formoterol (Symbicort) 4.5 mcg twice daily. Patients who did not exhibit these asthma indicators were referred to the next step.

At the next visit, we again graded the severity of cough. Patients in the successful and partial responder categories received a presumptive diagnosis of asthma syndrome. We asked successful and partial responders to continue the medication for at least 2 weeks. Those classed as nonresponders were asked to stop their medication. We referred all patients with positive MPT test results to a special clinic for asthma, regardless of responses to this therapeutic trial or eosinophil count in the induced sputum.

3. Reflux syndrome. Partial responders and nonresponders then received a 2-week prescription for a proton pump inhibitor, pantoprazole (Pantoloc), 40 mg orally once daily.⁹ At the next visit 2 weeks later, we graded the severity of cough. Successful and partial responders were given a presumptive diagnosis of reflux syndrome, but only successful responders were asked to continue the same medication for at least 6 weeks. At the discretion of their physicians, partial and nonresponders underwent other diagnostic investigations, including high-resolution computerized tomography (CT) of the lungs, bronchoscopic examination, sputum smear and culture for acid fast bacilli, sputum culture for ordinary bacteria and fungi, and a serological test for human immunodeficiency virus.

FIGURE
A presumptive-diagnosis algorithm

Chronic cough resolved for more than 90% of patients treated according to this algorithm.
MPT, methacholine bronchial provocation test; VAS, visual analog scale.

Results

Presumptive diagnoses

Among 378 patients, 346 (91%) showed erythematous mucosa or abnormal discharge in rhinoscopic examinations and received empiric medication for 5 days. The successful-responder category included 176 patients (47%); 79 (21%) were classed as partial responders, and 255 (67%) received the presumptive diagnosis of postnasal drip syndrome. Among the 346 treated patients, 91 (24% of those enrolled, or 26% of treated) showed no response.

Thirty-two patients with normal rhinoscopic findings and 170 categorized as partial or nonresponders in the first step underwent an MPT and eosinophil count of induced sputum. One hundred forty-four showed positive results and received empiric treatment for 1 week. Among these, 141 were deemed successful responders (37% of enrolled, or 98% of treated), 3 partial responders (1% of enrolled, or 2% of treated), and none were nonresponders.

In all, 61 patients had empiric treatment for reflux syndrome for 2 weeks; 58 had normal findings for both the MPT and sputum eosinophil count, and 3 were classified as partial responders in the previous therapeutic trial. Twenty-nine patients (8% of enrolled, or 47% of treated) were classified as successful responders after 2 weeks (TABLE 2).

TABLE 2
Presumptive diagnoses corresponded to expected frequency (and occasionally co-existed)

DIAGNOSIS	NO. OF PATIENTS (%)* N=378
Postnasal drip syndrome	255 (67.5)
Asthma syndrome	144 (38.1)
Reflux syndrome	29 (7.7)
CO-EXISTING PATHOLOGIES	82 (21.7)
Postnasal drip syndrome and asthma syndrome	52 (13.8)
Postnasal drip syndrome and reflux syndrome	7 (1.9)
Postnasal drip syndrome and other diagnosis	20 (5.3)
Asthma syndrome and other diagnosis	3 (0.8)
* The percentage of patients under "Diagnosis" does not add up to 100% because some patients had more than one condition, accounted for under "Co-existing pathologies."

Therapeutic response period for successful responders

Within 5 days of beginning the course determined by the algorithm (Figure), 176 patients (47%) who received treatment for presumed postnasal drip syndrome experienced resolution of their chronic cough.

 

Another 141 patients (37%) diagnosed with asthma syndrome (with or without postnasal drip syndrome) reported cough resolution following successful treatment between 7 and 12 days.

Another 29 patients (8%) with re-flux syndrome were successfully treated between 14 and 26 days.

Treatment of chronic cough by the algorithm

After application of the therapeutic algorithm, the chronic cough of 346 patients (92%) resolved. Thirty-two patients (8.5%) underwent other diagnostic investigations.

Final diagnoses after further diagnostic testing

Ten patients reported that they stopped coughing spontaneously while awaiting additional diagnostic investigations. Seven patients had mycobacterial infections confirmed by acid fast bacilli smears or culture of sputum or bronchoscopic washings. Six patients had localized or diffuse bronchiectasis confirmed by high-resolution CT, the results of which were used retrospectively to reassess normal or equivocal findings in the initial diagnostic investigations. Finally, the coughs of 12 patients were judged to be idiopathic or psychogenic.

Discussion

Cough is a symptom not easily assessed objectively. Previous studies measured severity of cough with daily diaries and visual analog scales, which are subjective measurement tools. We, too, used the visual analog scale to measure cough severity and treatment response. We did not pursue a definitive diagnosis of the cause of chronic cough. Rather, our algorithmic approach made presumptive diagnoses that were confirmed or refuted by patients’ successive reports of cough severity in response to treatment.

The logic behind our algorithm

Because studies in Korea have shown that postnasal drip is the most frequent cause of chronic cough, we chose rhinoscopy as the first diagnostic investigation. The second and third steps of our approach investigated asthma syndrome and reflux syndrome, respectively.

We did not take into account whether patients smoked cigarettes. Some investigators rightly point out that smoking might contribute to chronic cough. However, we have not met many smokers willing to quit because of a cough, and our algorithm is designed for practical clinical use. In contrast, patients with chronic cough secondary to ACE inhibitor therapy have readily accepted trials of different antihypertensive medications.

Our assumptions proved true

Patients with any abnormality of the nasal mucosa were treated for postnasal drip syndrome. Though the proportion of abnormal mucosal findings was greater than that reported in previous investigations of the same ethnic subjects, the eventual treatment response showed that the presumptive diagnosis of postnasal drip was equivalent to that in other studies.^10,11

Postnasal drip syndrome did indeed turn out to be the most common presumptive cause of cough in our study. However, roughly one third of these patients proved to have an additional presumptive disorder. Previous investigations have also reported dual or multiple pathologies in patients with a chronic cough.^11,12

If treatment succeeded at any step in our algorithm, we asked patients to stop taking medication—with the exception of those who had positive results on methacholine bronchial provocation test. Asthma is a chronic inflammatory disorder that needs persistent therapy to prevent exacerbations and declining lung function.^13,14 Challenge studies with methacholine or histamine are sensitive tests and provide high negative predictive values for the diagnosis of asthma and cough variant asthma.^15,16

What have other studies shown?

The natural course of chronic cough is still in question, primarily because of the heterogeneity of its etiology. The natural course of many common diseases has been investigated, of course, but few studies have focused on duration of symptoms such as cough. Park et al¹⁷ investigated the natural course of eosinophilic bronchitis, a common underlying disorder in chronic cough. In a 48-month follow-up of 36 patients diagnosed with eosinophilic bronchitis, 14% experienced recurrence after treatment. And patients with a higher percentage of eosinophils in the sputum had a risk for developing airway hyperresponsiveness.

Ours et al⁹ reported that, for patients without asthma or postnasal drip, an empiric 2-week trial of high-dose proton pump inhibitors was more reliable and cost effective for chronic cough than was treatment after esophageal manometry or 24 hours dual probe pH monitoring. Besides the expense of manometry and pH monitoring, both procedures are invasive and unavailable in many localities such as ours. Our algorithm supposes, for one thing, minimum availability of medical equipment in many locales.

The algorithm makes sense

Our approach decreased medical expenses and therapeutic response periods. Cough resolved for more than 90% of our patients. This success rate was equivalent to that reported by previous studies, most of which revealed no definitive diagnosis during the therapeutic response period.^2-4,18 Half of all patients in our study experienced cough resolution within 5 days, and more than 80% did so within 12 days.

 

Development of algorithms similar to ours should take into account not just findings in the literature but the experiences of local doctors and available medical equipment and options.

At the insistence of her family, a woman comes to you complaining of a cough that has lasted several weeks. Many experts would urge a thorough diagnostic investigation, justifying this action with a presumed shorter course of treatment. But is an involved work-up really necessary? Would a quicker, less expensive approach serve the patient just as well? We designed our study to answer these questions.

“Test all, then treat” is expensive

In the management of patients with chronic cough, most algorithms have advocated the approach of “test all, then treat.”^1-6 This is an expensive approach and one that delays relief for the patient, though a confirmative diagnosis may decrease the overall duration of treatment. In most cases, however, this approach may be unnecessary. And because few of the underlying disorders are acutely debilitating or rapidly progressive, even misdiagnosis and resultant inappropriate treatment pose little risk to patients.

The less common approach is a sequence of trial-and-error treatments based on a presumptive hierarchy of possible diagnoses.⁶ The advantage with this strategy is a 3-to 5-fold cost savings.⁶ And we suspected that the associated length of treatment would be acceptable.

We proposed that the management of patients with chronic cough begin with a presumptive diagnosis, thus simplifying the initial evaluation, keeping costs low, and offering earlier treatment.

We developed an algorithm for the treatment of patients with chronic cough that relies on minimal diagnostic investigations, regardless of the confirmed diagnosis. We evaluated our approach from the perspectives of the presumptive diagnosis and the therapeutic response period.

Methods

Treatment algorithm reflects experience and local resources

Initially, we designed the algorithm to follow findings in the literature on the treatment of patients with chronic cough. We then simplified and modified the algorithm to reflect the experiences of doctors from the pulmonology clinic in our hospital, and to take into account local patient characteristics and available medical equipment and resources.

Subjects were otherwise healthy

Between January 1 and December 31, 2005, at the internal medicine clinic of Cheju National University Hospital, we enrolled 378 patients whose chief complaint was cough persisting for more than 4 weeks and who had no abnormalities detected on auscultation by a physician, chest radiography (posterior–anterior view and left lateral view), or complete blood cell counts. Each patient had a complete blood count to detect anemia, hematologic disorders, or inflammatory conditions. Current users of angiotensin-converting enzyme (ACE) inhibitors were excluded.

All of the patients we enrolled were adults living in Jeju, Korea, and the mean age was 51 years. One hundred eighty-six (49%) were men. The median reported cough duration was 2 months (range, 1–36 months) (TABLE 1).

We instructed the patients on our algorithmic approach to treating chronic cough and encouraged them to follow the algorithm through to telephone notification of the next visit.

TABLE 1
Characteristics of the 378 enrolled patients

Men/women	186/192 (49/51%)
Age, years	51.2±16.12
Cough duration in months, median (range)	2 (1–36)

How we determined treatment outcomes

Patients graded their cough severity subjectively at each visit using a visual analogue scale (VAS) from 1 (no cough at all) to 10 (cough severity same as that remembered during first visit to the clinic). We recorded their reports on a questionnaire.

Successful responders were patients who reported a subjective grade of cough severity less than 3. Partial responders and nonresponders were defined, respectively, as those reporting VAS scores from 3 to 6 and more than 6.

We defined the response period as the number of days from enrollment until the next visit in which the patient first reported a VAS score of cough severity less than 3.

Algorithm: Addressing the 3 most common causes of chronic cough

 

1. Postnasal drip syndrome. Patients first underwent a rhinoscopic examination (FIGURE). When clinicians detected redness or abnormal discharge on the nasal mucosa, they prescribed a 5-day course of antihistamine (10 mg/day ebastine [Ebastel] orally), pseudoephedrine (30 mg 3 times daily, orally), and intranasal corticosteroid (triamcinolone acetonide [Nasacort] 110 mcg twice daily intranasally). Patients without symptoms of rhinitis were referred to the next diagnostic phase.

With completion of the prescribed medication 5 days after the first visit, we graded the severity of cough by questionnaire. Patients in the successful and partial responder categories received a presumptive diagnosis of postnasal drip syndrome, and we asked them to continue using the medication for at least 2 weeks. We had each nonresponder stop the medication.

2. Asthma syndrome. Partial responder and nonresponder patients entered the next diagnostic phase: a methacholine bronchial provocation test (MPT)⁷ and eosinophil count with induced sputum by hypertonic saline (3% NaCl).⁸ We defined a positive MPT result as <10 mg/ mL of methacholine causing a 20% fall in FEV₁ from baseline (PC₂₀). Patients with more than 3% eosinophils in the induced sputum specimen or with a positive MPT received a 1-week prescription for inhaled budesonide 160 mcg twice daily and inhaled formoterol (Symbicort) 4.5 mcg twice daily. Patients who did not exhibit these asthma indicators were referred to the next step.

At the next visit, we again graded the severity of cough. Patients in the successful and partial responder categories received a presumptive diagnosis of asthma syndrome. We asked successful and partial responders to continue the medication for at least 2 weeks. Those classed as nonresponders were asked to stop their medication. We referred all patients with positive MPT test results to a special clinic for asthma, regardless of responses to this therapeutic trial or eosinophil count in the induced sputum.

3. Reflux syndrome. Partial responders and nonresponders then received a 2-week prescription for a proton pump inhibitor, pantoprazole (Pantoloc), 40 mg orally once daily.⁹ At the next visit 2 weeks later, we graded the severity of cough. Successful and partial responders were given a presumptive diagnosis of reflux syndrome, but only successful responders were asked to continue the same medication for at least 6 weeks. At the discretion of their physicians, partial and nonresponders underwent other diagnostic investigations, including high-resolution computerized tomography (CT) of the lungs, bronchoscopic examination, sputum smear and culture for acid fast bacilli, sputum culture for ordinary bacteria and fungi, and a serological test for human immunodeficiency virus.

FIGURE
A presumptive-diagnosis algorithm

Chronic cough resolved for more than 90% of patients treated according to this algorithm.
MPT, methacholine bronchial provocation test; VAS, visual analog scale.

Results

Presumptive diagnoses

Among 378 patients, 346 (91%) showed erythematous mucosa or abnormal discharge in rhinoscopic examinations and received empiric medication for 5 days. The successful-responder category included 176 patients (47%); 79 (21%) were classed as partial responders, and 255 (67%) received the presumptive diagnosis of postnasal drip syndrome. Among the 346 treated patients, 91 (24% of those enrolled, or 26% of treated) showed no response.

Thirty-two patients with normal rhinoscopic findings and 170 categorized as partial or nonresponders in the first step underwent an MPT and eosinophil count of induced sputum. One hundred forty-four showed positive results and received empiric treatment for 1 week. Among these, 141 were deemed successful responders (37% of enrolled, or 98% of treated), 3 partial responders (1% of enrolled, or 2% of treated), and none were nonresponders.

In all, 61 patients had empiric treatment for reflux syndrome for 2 weeks; 58 had normal findings for both the MPT and sputum eosinophil count, and 3 were classified as partial responders in the previous therapeutic trial. Twenty-nine patients (8% of enrolled, or 47% of treated) were classified as successful responders after 2 weeks (TABLE 2).

TABLE 2
Presumptive diagnoses corresponded to expected frequency (and occasionally co-existed)

DIAGNOSIS	NO. OF PATIENTS (%)* N=378
Postnasal drip syndrome	255 (67.5)
Asthma syndrome	144 (38.1)
Reflux syndrome	29 (7.7)
CO-EXISTING PATHOLOGIES	82 (21.7)
Postnasal drip syndrome and asthma syndrome	52 (13.8)
Postnasal drip syndrome and reflux syndrome	7 (1.9)
Postnasal drip syndrome and other diagnosis	20 (5.3)
Asthma syndrome and other diagnosis	3 (0.8)
* The percentage of patients under "Diagnosis" does not add up to 100% because some patients had more than one condition, accounted for under "Co-existing pathologies."

Therapeutic response period for successful responders

Within 5 days of beginning the course determined by the algorithm (Figure), 176 patients (47%) who received treatment for presumed postnasal drip syndrome experienced resolution of their chronic cough.

 

Another 141 patients (37%) diagnosed with asthma syndrome (with or without postnasal drip syndrome) reported cough resolution following successful treatment between 7 and 12 days.

Another 29 patients (8%) with re-flux syndrome were successfully treated between 14 and 26 days.

Treatment of chronic cough by the algorithm

After application of the therapeutic algorithm, the chronic cough of 346 patients (92%) resolved. Thirty-two patients (8.5%) underwent other diagnostic investigations.

Final diagnoses after further diagnostic testing

Ten patients reported that they stopped coughing spontaneously while awaiting additional diagnostic investigations. Seven patients had mycobacterial infections confirmed by acid fast bacilli smears or culture of sputum or bronchoscopic washings. Six patients had localized or diffuse bronchiectasis confirmed by high-resolution CT, the results of which were used retrospectively to reassess normal or equivocal findings in the initial diagnostic investigations. Finally, the coughs of 12 patients were judged to be idiopathic or psychogenic.

Discussion

Cough is a symptom not easily assessed objectively. Previous studies measured severity of cough with daily diaries and visual analog scales, which are subjective measurement tools. We, too, used the visual analog scale to measure cough severity and treatment response. We did not pursue a definitive diagnosis of the cause of chronic cough. Rather, our algorithmic approach made presumptive diagnoses that were confirmed or refuted by patients’ successive reports of cough severity in response to treatment.

The logic behind our algorithm

Because studies in Korea have shown that postnasal drip is the most frequent cause of chronic cough, we chose rhinoscopy as the first diagnostic investigation. The second and third steps of our approach investigated asthma syndrome and reflux syndrome, respectively.

We did not take into account whether patients smoked cigarettes. Some investigators rightly point out that smoking might contribute to chronic cough. However, we have not met many smokers willing to quit because of a cough, and our algorithm is designed for practical clinical use. In contrast, patients with chronic cough secondary to ACE inhibitor therapy have readily accepted trials of different antihypertensive medications.

Our assumptions proved true

Patients with any abnormality of the nasal mucosa were treated for postnasal drip syndrome. Though the proportion of abnormal mucosal findings was greater than that reported in previous investigations of the same ethnic subjects, the eventual treatment response showed that the presumptive diagnosis of postnasal drip was equivalent to that in other studies.^10,11

Postnasal drip syndrome did indeed turn out to be the most common presumptive cause of cough in our study. However, roughly one third of these patients proved to have an additional presumptive disorder. Previous investigations have also reported dual or multiple pathologies in patients with a chronic cough.^11,12

If treatment succeeded at any step in our algorithm, we asked patients to stop taking medication—with the exception of those who had positive results on methacholine bronchial provocation test. Asthma is a chronic inflammatory disorder that needs persistent therapy to prevent exacerbations and declining lung function.^13,14 Challenge studies with methacholine or histamine are sensitive tests and provide high negative predictive values for the diagnosis of asthma and cough variant asthma.^15,16

What have other studies shown?

The natural course of chronic cough is still in question, primarily because of the heterogeneity of its etiology. The natural course of many common diseases has been investigated, of course, but few studies have focused on duration of symptoms such as cough. Park et al¹⁷ investigated the natural course of eosinophilic bronchitis, a common underlying disorder in chronic cough. In a 48-month follow-up of 36 patients diagnosed with eosinophilic bronchitis, 14% experienced recurrence after treatment. And patients with a higher percentage of eosinophils in the sputum had a risk for developing airway hyperresponsiveness.

Ours et al⁹ reported that, for patients without asthma or postnasal drip, an empiric 2-week trial of high-dose proton pump inhibitors was more reliable and cost effective for chronic cough than was treatment after esophageal manometry or 24 hours dual probe pH monitoring. Besides the expense of manometry and pH monitoring, both procedures are invasive and unavailable in many localities such as ours. Our algorithm supposes, for one thing, minimum availability of medical equipment in many locales.

The algorithm makes sense

Our approach decreased medical expenses and therapeutic response periods. Cough resolved for more than 90% of our patients. This success rate was equivalent to that reported by previous studies, most of which revealed no definitive diagnosis during the therapeutic response period.^2-4,18 Half of all patients in our study experienced cough resolution within 5 days, and more than 80% did so within 12 days.

 

Development of algorithms similar to ours should take into account not just findings in the literature but the experiences of local doctors and available medical equipment and options.

Woman prescribed a stimulant suffers stroke and disability

Harris County (TX) District Court

A 39-year-old patient was diagnosed with attention-deficit/hyperactivity disorder (ADHD) by a psychologist, who referred her to a psychiatrist. The psychiatrist prescribed amphetamine/dextroamphetamine, which the patient took for 9 months. During this time her blood pressure and other vital signs were not monitored. The patient then suffered a stroke, is now a paraplegic, and must use a wheelchair.

The patient claimed that negligent misdiagnosis and monitoring caused the stroke. The psychiatrist maintained that diagnosis and monitoring were appropriate, and the drug did not cause the stroke. The psychiatrist also claimed that the patient had a transient ischemic attack (TIA) before taking amphetamine/dextroamphetamine and another stroke after discontinuing the drug.

• A defense verdict was returned
  

Improper dose of lamotrigine blamed for liver failure

San Diego County (CA) Superior Court

The patient, age 35, was involuntarily admitted to an inpatient psychiatric facility after the police found her acting bizarrely and hallucinating. The admitting and treating psychiatrist learned that the patient had been admitted for psychiatric treatment 9 times in the previous 12 months, had a long history of polysubstance abuse, and had been largely nonadherent with medication. The psychiatrist diagnosed rapid-cycling bipolar disorder and started the patient on lamotrigine with an escalating dosage schedule. The patient was released from the psychiatric facility.

Later that month, the patient developed a urinary tract infection and was readmitted to the hospital. She agreed to lab testing and all results were within normal limits, but throughout a 2-month stay the patient intermittently complained of a sore throat, cough, and nausea. Two weeks later, the psychiatrist reviewed lab tests that showed a mild elevation of the patient’s liver enzymes.

The next day the patient reported a rash on her chest and a high fever. She was transferred to an acute care facility. The patient’s liver enzymes continued to rise, and the psychiatrist discontinued lamotrigine. The patient continued to deteriorate and was transferred to another hospital to consult with a liver specialist. About 3 weeks later the patient went into a coma and died.

Autopsy showed massive liver necrosis. The patient’s family claimed the psychiatrist was negligent in giving the patient lamotrigine, which caused the liver failure. They contended the dose prescribed was too high, the patient was not properly monitored, and other psychiatric drugs could have been used with more gradual increases.

The psychiatrist maintained that the lamotrigine dosage used was appropriate, lamotrigine was not known to cause liver problems, and it did not cause the patient’s liver failure.

• A defense verdict was returned
  

Dr. Grant’s observations

These cases reflect a clinician’s worst nightmare—using an appropriate medication, experiencing a disastrous outcome, and then being sued for malpractice. Clinicians need to remember:

• anyone can be sued
  
• a lawsuit does not mean that the clinician did anything inappropriate.
  

It is unfortunate that such lawsuits are brought, and their presence may indicate many problems within the legal system. Although clinicians who do nothing wrong should not have to endure unnecessary and unfounded lawsuits (the issue of tort reform within the legal system is beyond the scope of this column), these cases prompt psychiatrists to consider ways to protect themselves from such claims. Some practices might help protect you from successful malpractice claims, but there are no guarantees.

Meeting standards of care

Medical malpractice claims could be based on a physician diverging from 1 of 2 standards of care:

• The “average practitioner” or “customary practice” standard means the treatment practice is consistent with others in the field. Courts might allow the medical profession to define the standard of care according to medical custom.
  
• The “reasonably prudent physician” standard means what a reasonable physician would have done under the circumstances. The jury determines if the physician acted reasonably, not whether the physician conformed to existing standards.¹
  

States are split on which standard the courts must apply and in many areas, the standard of care is based on local—not state or national—practices.²

In these cases, using amphetamine/ dextroamphetamine for ADHD and lamotrigine for bipolar disorder appears to meet either standard. These 2 drugs are FDA-approved to treat the disorders for which they were prescribed. Although we do not know what doses the physicians prescribed in these 2 cases, in general if the dosing adheres to the FDA-approved range or can be based on credible research, the treatment will meet the 2 standards.

Choosing a treatment plan

The American Psychiatric Association’s practice guidelines (available at http://www.psych.org/psych_pract/treatg/pg/prac_guide.cfm) state “the ultimate judgment regarding a particular clinical procedure or treatment plan must be made by the psychiatrist in light of the clinical data presented by the patient and the diagnostic and treatment options available.”³

 

Regardless of the treatment used—even if the medication is “off-label” and not FDA-approved for a particular disorder or the dose is not within the FDA-approved dosing range—you should be able to document your rationale for using a medication and dosing by showing that it is part of good clinical practice.

A clinician’s scientific rationale for medication and dosing choice should be based on the psychiatric evaluation and known risks and benefits of the treatment. In addition, the patient should:

• understand pertinent information regarding the medication and its side effects
  
• and freely give consent to treatment.⁴
  

Then document in the patient’s chart that you had this discussion with the patient and obtained consent.

Monitoring for side effects

In these cases, the court also had to determine whether clinicians’ monitoring for side effects was appropriate. For several years, case reports have raised speculation about a link between strokes and amphetamine/ dextroamphetamine^4,5 In 2005, Adderall XR was taken off the Canadian market because of reports of strokes and sudden deaths.⁷

The FDA’s Adverse Event Reporting System database identified 12 cases of sudden death in pediatric patents treated for ADHD with Adderall or Adderall XR.⁸ lthough the drug has returned to the Canadian market and a clear link between stroke or sudden death and Adderall has not been established, The Physicians’ Desk Reference (PDR)⁹ advises physicians to monitor blood pressure in individuals taking amphetamine/dextroamphetamine, particularly those with hypertension. The FDA has issued new labeling instructions for all stimulants advising prescribing clinicians to monitor blood pressure regularly.¹⁰

Adverse side effects are possible with any number of medications. Clinicians might need to change assessments and monitoring practices as new information—such as FDA or pharmaceutical company reporting or new studies in professional journals—becomes available.

Even so, if you fail to monitor blood pressure and a patient has a stroke—such as in the first case—you are not necessarily negligent. Successful malpractice cases need to demonstrate causation. The plaintiff must prove:

• The physician’s act or omission was the cause-in-fact of the harm. Without the act, the harm would not have occurred.
  
• The act was the proximate cause of the harm. In a natural, unbroken sequence of events, the act produces a foreseeable result. A physician should not be liable for the far-reaching and improbable consequences of an act or omission.¹
  

Plaintiffs cannot prove proximate cause if there is:

• lack of foreseeability—the consequences of the act were not reasonably foreseeable, or
  
• an intervening event that supersedes all others in causing the injury.¹
  

Foreseeability

A defendant may be liable only if the consequences of the act or omission were reasonably foreseeable. Foreseeability is a vague legal concept and is not the same as predictability. Foreseeability should be understood in context of what information was available at the time. For example, the FDA black box warnings about the link between stimulants and stroke or sudden death did not appear until 2006.¹¹ What light be considered foreseeable now might not have been before 2006 (it is unclear when the above case was litigated).

Intervening events

An intervening event is one that takes effect after the defendant’s negligence and breaks the chain of causation. In the first case, the patient had a history of TIAs before taking amphetamine/dextroamphetamine. The condition that caused the TIAs, such as atherosclerosis in an artery, may also have caused the stroke independent of the use of stimulants, and therefore could be considered an intervening event.

In the lamotrigine case, elevations of aspartate transaminase and alanine transaminase are infrequent or rare. Several case reports have discussed possible hepatotoxicity associated with the drug.¹³

A reasonably prudent physician should warn patients about and monitor for symptoms of Stevens-Johnson syndrome, a serious disorder of the skin and mucous membranes sometimes seen with lamotrigine that can begin with cough, fever, and sore throat. Although hepatitis is a possible complication of Stevens-Johnson, the first step of treatment is to hospitalize the patient in an intensive care unit, which the physician did. The PDR and FDA guidelines do not recommend monitoring liver function tests as a way to assess for Stevens-Johnson or for liver dysfunction as an independent problem with lamotrigine.^9,12

Given the lack of guidelines and the scant literature on this topic, the psychiatrist in this case would not have been expected to monitor liver function, which would meet either the “average practitioner” or “reasonably prudent physician” standard. Although the literature suggests that liver toxicity might have been foreseeable, the patient had a history of polysubstance abuse, which may be determined to be an intervening event. Substance abuse could have caused liver toxicity, depending on the drugs the patient abused.

 

Drug brand names

• Amphetamine/Dextroamphetamine • Adderall
  
• Lamotrigine • Lamictal
  

Woman prescribed a stimulant suffers stroke and disability

Harris County (TX) District Court

A 39-year-old patient was diagnosed with attention-deficit/hyperactivity disorder (ADHD) by a psychologist, who referred her to a psychiatrist. The psychiatrist prescribed amphetamine/dextroamphetamine, which the patient took for 9 months. During this time her blood pressure and other vital signs were not monitored. The patient then suffered a stroke, is now a paraplegic, and must use a wheelchair.

The patient claimed that negligent misdiagnosis and monitoring caused the stroke. The psychiatrist maintained that diagnosis and monitoring were appropriate, and the drug did not cause the stroke. The psychiatrist also claimed that the patient had a transient ischemic attack (TIA) before taking amphetamine/dextroamphetamine and another stroke after discontinuing the drug.

• A defense verdict was returned
  

Improper dose of lamotrigine blamed for liver failure

San Diego County (CA) Superior Court

The patient, age 35, was involuntarily admitted to an inpatient psychiatric facility after the police found her acting bizarrely and hallucinating. The admitting and treating psychiatrist learned that the patient had been admitted for psychiatric treatment 9 times in the previous 12 months, had a long history of polysubstance abuse, and had been largely nonadherent with medication. The psychiatrist diagnosed rapid-cycling bipolar disorder and started the patient on lamotrigine with an escalating dosage schedule. The patient was released from the psychiatric facility.

Later that month, the patient developed a urinary tract infection and was readmitted to the hospital. She agreed to lab testing and all results were within normal limits, but throughout a 2-month stay the patient intermittently complained of a sore throat, cough, and nausea. Two weeks later, the psychiatrist reviewed lab tests that showed a mild elevation of the patient’s liver enzymes.

The next day the patient reported a rash on her chest and a high fever. She was transferred to an acute care facility. The patient’s liver enzymes continued to rise, and the psychiatrist discontinued lamotrigine. The patient continued to deteriorate and was transferred to another hospital to consult with a liver specialist. About 3 weeks later the patient went into a coma and died.

Autopsy showed massive liver necrosis. The patient’s family claimed the psychiatrist was negligent in giving the patient lamotrigine, which caused the liver failure. They contended the dose prescribed was too high, the patient was not properly monitored, and other psychiatric drugs could have been used with more gradual increases.

The psychiatrist maintained that the lamotrigine dosage used was appropriate, lamotrigine was not known to cause liver problems, and it did not cause the patient’s liver failure.

• A defense verdict was returned
  

Dr. Grant’s observations

These cases reflect a clinician’s worst nightmare—using an appropriate medication, experiencing a disastrous outcome, and then being sued for malpractice. Clinicians need to remember:

• anyone can be sued
  
• a lawsuit does not mean that the clinician did anything inappropriate.
  

It is unfortunate that such lawsuits are brought, and their presence may indicate many problems within the legal system. Although clinicians who do nothing wrong should not have to endure unnecessary and unfounded lawsuits (the issue of tort reform within the legal system is beyond the scope of this column), these cases prompt psychiatrists to consider ways to protect themselves from such claims. Some practices might help protect you from successful malpractice claims, but there are no guarantees.

Meeting standards of care

Medical malpractice claims could be based on a physician diverging from 1 of 2 standards of care:

• The “average practitioner” or “customary practice” standard means the treatment practice is consistent with others in the field. Courts might allow the medical profession to define the standard of care according to medical custom.
  
• The “reasonably prudent physician” standard means what a reasonable physician would have done under the circumstances. The jury determines if the physician acted reasonably, not whether the physician conformed to existing standards.¹
  

States are split on which standard the courts must apply and in many areas, the standard of care is based on local—not state or national—practices.²

In these cases, using amphetamine/ dextroamphetamine for ADHD and lamotrigine for bipolar disorder appears to meet either standard. These 2 drugs are FDA-approved to treat the disorders for which they were prescribed. Although we do not know what doses the physicians prescribed in these 2 cases, in general if the dosing adheres to the FDA-approved range or can be based on credible research, the treatment will meet the 2 standards.

Choosing a treatment plan

The American Psychiatric Association’s practice guidelines (available at http://www.psych.org/psych_pract/treatg/pg/prac_guide.cfm) state “the ultimate judgment regarding a particular clinical procedure or treatment plan must be made by the psychiatrist in light of the clinical data presented by the patient and the diagnostic and treatment options available.”³

 

Regardless of the treatment used—even if the medication is “off-label” and not FDA-approved for a particular disorder or the dose is not within the FDA-approved dosing range—you should be able to document your rationale for using a medication and dosing by showing that it is part of good clinical practice.

A clinician’s scientific rationale for medication and dosing choice should be based on the psychiatric evaluation and known risks and benefits of the treatment. In addition, the patient should:

• understand pertinent information regarding the medication and its side effects
  
• and freely give consent to treatment.⁴
  

Then document in the patient’s chart that you had this discussion with the patient and obtained consent.

Monitoring for side effects

In these cases, the court also had to determine whether clinicians’ monitoring for side effects was appropriate. For several years, case reports have raised speculation about a link between strokes and amphetamine/ dextroamphetamine^4,5 In 2005, Adderall XR was taken off the Canadian market because of reports of strokes and sudden deaths.⁷

The FDA’s Adverse Event Reporting System database identified 12 cases of sudden death in pediatric patents treated for ADHD with Adderall or Adderall XR.⁸ lthough the drug has returned to the Canadian market and a clear link between stroke or sudden death and Adderall has not been established, The Physicians’ Desk Reference (PDR)⁹ advises physicians to monitor blood pressure in individuals taking amphetamine/dextroamphetamine, particularly those with hypertension. The FDA has issued new labeling instructions for all stimulants advising prescribing clinicians to monitor blood pressure regularly.¹⁰

Adverse side effects are possible with any number of medications. Clinicians might need to change assessments and monitoring practices as new information—such as FDA or pharmaceutical company reporting or new studies in professional journals—becomes available.

Even so, if you fail to monitor blood pressure and a patient has a stroke—such as in the first case—you are not necessarily negligent. Successful malpractice cases need to demonstrate causation. The plaintiff must prove:

• The physician’s act or omission was the cause-in-fact of the harm. Without the act, the harm would not have occurred.
  
• The act was the proximate cause of the harm. In a natural, unbroken sequence of events, the act produces a foreseeable result. A physician should not be liable for the far-reaching and improbable consequences of an act or omission.¹
  

Plaintiffs cannot prove proximate cause if there is:

• lack of foreseeability—the consequences of the act were not reasonably foreseeable, or
  
• an intervening event that supersedes all others in causing the injury.¹
  

Foreseeability

A defendant may be liable only if the consequences of the act or omission were reasonably foreseeable. Foreseeability is a vague legal concept and is not the same as predictability. Foreseeability should be understood in context of what information was available at the time. For example, the FDA black box warnings about the link between stimulants and stroke or sudden death did not appear until 2006.¹¹ What light be considered foreseeable now might not have been before 2006 (it is unclear when the above case was litigated).

Intervening events

An intervening event is one that takes effect after the defendant’s negligence and breaks the chain of causation. In the first case, the patient had a history of TIAs before taking amphetamine/dextroamphetamine. The condition that caused the TIAs, such as atherosclerosis in an artery, may also have caused the stroke independent of the use of stimulants, and therefore could be considered an intervening event.

In the lamotrigine case, elevations of aspartate transaminase and alanine transaminase are infrequent or rare. Several case reports have discussed possible hepatotoxicity associated with the drug.¹³

A reasonably prudent physician should warn patients about and monitor for symptoms of Stevens-Johnson syndrome, a serious disorder of the skin and mucous membranes sometimes seen with lamotrigine that can begin with cough, fever, and sore throat. Although hepatitis is a possible complication of Stevens-Johnson, the first step of treatment is to hospitalize the patient in an intensive care unit, which the physician did. The PDR and FDA guidelines do not recommend monitoring liver function tests as a way to assess for Stevens-Johnson or for liver dysfunction as an independent problem with lamotrigine.^9,12

Given the lack of guidelines and the scant literature on this topic, the psychiatrist in this case would not have been expected to monitor liver function, which would meet either the “average practitioner” or “reasonably prudent physician” standard. Although the literature suggests that liver toxicity might have been foreseeable, the patient had a history of polysubstance abuse, which may be determined to be an intervening event. Substance abuse could have caused liver toxicity, depending on the drugs the patient abused.

 

Drug brand names

• Amphetamine/Dextroamphetamine • Adderall
  
• Lamotrigine • Lamictal
  

Woman prescribed a stimulant suffers stroke and disability

Harris County (TX) District Court

A 39-year-old patient was diagnosed with attention-deficit/hyperactivity disorder (ADHD) by a psychologist, who referred her to a psychiatrist. The psychiatrist prescribed amphetamine/dextroamphetamine, which the patient took for 9 months. During this time her blood pressure and other vital signs were not monitored. The patient then suffered a stroke, is now a paraplegic, and must use a wheelchair.

The patient claimed that negligent misdiagnosis and monitoring caused the stroke. The psychiatrist maintained that diagnosis and monitoring were appropriate, and the drug did not cause the stroke. The psychiatrist also claimed that the patient had a transient ischemic attack (TIA) before taking amphetamine/dextroamphetamine and another stroke after discontinuing the drug.

• A defense verdict was returned
  

Improper dose of lamotrigine blamed for liver failure

San Diego County (CA) Superior Court

The patient, age 35, was involuntarily admitted to an inpatient psychiatric facility after the police found her acting bizarrely and hallucinating. The admitting and treating psychiatrist learned that the patient had been admitted for psychiatric treatment 9 times in the previous 12 months, had a long history of polysubstance abuse, and had been largely nonadherent with medication. The psychiatrist diagnosed rapid-cycling bipolar disorder and started the patient on lamotrigine with an escalating dosage schedule. The patient was released from the psychiatric facility.

Later that month, the patient developed a urinary tract infection and was readmitted to the hospital. She agreed to lab testing and all results were within normal limits, but throughout a 2-month stay the patient intermittently complained of a sore throat, cough, and nausea. Two weeks later, the psychiatrist reviewed lab tests that showed a mild elevation of the patient’s liver enzymes.

The next day the patient reported a rash on her chest and a high fever. She was transferred to an acute care facility. The patient’s liver enzymes continued to rise, and the psychiatrist discontinued lamotrigine. The patient continued to deteriorate and was transferred to another hospital to consult with a liver specialist. About 3 weeks later the patient went into a coma and died.

Autopsy showed massive liver necrosis. The patient’s family claimed the psychiatrist was negligent in giving the patient lamotrigine, which caused the liver failure. They contended the dose prescribed was too high, the patient was not properly monitored, and other psychiatric drugs could have been used with more gradual increases.

The psychiatrist maintained that the lamotrigine dosage used was appropriate, lamotrigine was not known to cause liver problems, and it did not cause the patient’s liver failure.

• A defense verdict was returned
  

Dr. Grant’s observations

These cases reflect a clinician’s worst nightmare—using an appropriate medication, experiencing a disastrous outcome, and then being sued for malpractice. Clinicians need to remember:

• anyone can be sued
  
• a lawsuit does not mean that the clinician did anything inappropriate.
  

It is unfortunate that such lawsuits are brought, and their presence may indicate many problems within the legal system. Although clinicians who do nothing wrong should not have to endure unnecessary and unfounded lawsuits (the issue of tort reform within the legal system is beyond the scope of this column), these cases prompt psychiatrists to consider ways to protect themselves from such claims. Some practices might help protect you from successful malpractice claims, but there are no guarantees.

Meeting standards of care

Medical malpractice claims could be based on a physician diverging from 1 of 2 standards of care:

• The “average practitioner” or “customary practice” standard means the treatment practice is consistent with others in the field. Courts might allow the medical profession to define the standard of care according to medical custom.
  
• The “reasonably prudent physician” standard means what a reasonable physician would have done under the circumstances. The jury determines if the physician acted reasonably, not whether the physician conformed to existing standards.¹
  

States are split on which standard the courts must apply and in many areas, the standard of care is based on local—not state or national—practices.²

In these cases, using amphetamine/ dextroamphetamine for ADHD and lamotrigine for bipolar disorder appears to meet either standard. These 2 drugs are FDA-approved to treat the disorders for which they were prescribed. Although we do not know what doses the physicians prescribed in these 2 cases, in general if the dosing adheres to the FDA-approved range or can be based on credible research, the treatment will meet the 2 standards.

Choosing a treatment plan

The American Psychiatric Association’s practice guidelines (available at http://www.psych.org/psych_pract/treatg/pg/prac_guide.cfm) state “the ultimate judgment regarding a particular clinical procedure or treatment plan must be made by the psychiatrist in light of the clinical data presented by the patient and the diagnostic and treatment options available.”³

 

Regardless of the treatment used—even if the medication is “off-label” and not FDA-approved for a particular disorder or the dose is not within the FDA-approved dosing range—you should be able to document your rationale for using a medication and dosing by showing that it is part of good clinical practice.

A clinician’s scientific rationale for medication and dosing choice should be based on the psychiatric evaluation and known risks and benefits of the treatment. In addition, the patient should:

• understand pertinent information regarding the medication and its side effects
  
• and freely give consent to treatment.⁴
  

Then document in the patient’s chart that you had this discussion with the patient and obtained consent.

Monitoring for side effects

In these cases, the court also had to determine whether clinicians’ monitoring for side effects was appropriate. For several years, case reports have raised speculation about a link between strokes and amphetamine/ dextroamphetamine^4,5 In 2005, Adderall XR was taken off the Canadian market because of reports of strokes and sudden deaths.⁷

The FDA’s Adverse Event Reporting System database identified 12 cases of sudden death in pediatric patents treated for ADHD with Adderall or Adderall XR.⁸ lthough the drug has returned to the Canadian market and a clear link between stroke or sudden death and Adderall has not been established, The Physicians’ Desk Reference (PDR)⁹ advises physicians to monitor blood pressure in individuals taking amphetamine/dextroamphetamine, particularly those with hypertension. The FDA has issued new labeling instructions for all stimulants advising prescribing clinicians to monitor blood pressure regularly.¹⁰

Adverse side effects are possible with any number of medications. Clinicians might need to change assessments and monitoring practices as new information—such as FDA or pharmaceutical company reporting or new studies in professional journals—becomes available.

Even so, if you fail to monitor blood pressure and a patient has a stroke—such as in the first case—you are not necessarily negligent. Successful malpractice cases need to demonstrate causation. The plaintiff must prove:

• The physician’s act or omission was the cause-in-fact of the harm. Without the act, the harm would not have occurred.
  
• The act was the proximate cause of the harm. In a natural, unbroken sequence of events, the act produces a foreseeable result. A physician should not be liable for the far-reaching and improbable consequences of an act or omission.¹
  

Plaintiffs cannot prove proximate cause if there is:

• lack of foreseeability—the consequences of the act were not reasonably foreseeable, or
  
• an intervening event that supersedes all others in causing the injury.¹
  

Foreseeability

A defendant may be liable only if the consequences of the act or omission were reasonably foreseeable. Foreseeability is a vague legal concept and is not the same as predictability. Foreseeability should be understood in context of what information was available at the time. For example, the FDA black box warnings about the link between stimulants and stroke or sudden death did not appear until 2006.¹¹ What light be considered foreseeable now might not have been before 2006 (it is unclear when the above case was litigated).

Intervening events

An intervening event is one that takes effect after the defendant’s negligence and breaks the chain of causation. In the first case, the patient had a history of TIAs before taking amphetamine/dextroamphetamine. The condition that caused the TIAs, such as atherosclerosis in an artery, may also have caused the stroke independent of the use of stimulants, and therefore could be considered an intervening event.

In the lamotrigine case, elevations of aspartate transaminase and alanine transaminase are infrequent or rare. Several case reports have discussed possible hepatotoxicity associated with the drug.¹³

A reasonably prudent physician should warn patients about and monitor for symptoms of Stevens-Johnson syndrome, a serious disorder of the skin and mucous membranes sometimes seen with lamotrigine that can begin with cough, fever, and sore throat. Although hepatitis is a possible complication of Stevens-Johnson, the first step of treatment is to hospitalize the patient in an intensive care unit, which the physician did. The PDR and FDA guidelines do not recommend monitoring liver function tests as a way to assess for Stevens-Johnson or for liver dysfunction as an independent problem with lamotrigine.^9,12

Given the lack of guidelines and the scant literature on this topic, the psychiatrist in this case would not have been expected to monitor liver function, which would meet either the “average practitioner” or “reasonably prudent physician” standard. Although the literature suggests that liver toxicity might have been foreseeable, the patient had a history of polysubstance abuse, which may be determined to be an intervening event. Substance abuse could have caused liver toxicity, depending on the drugs the patient abused.

 

Drug brand names

• Amphetamine/Dextroamphetamine • Adderall
  
• Lamotrigine • Lamictal
  

VIENNA—Long-term treatment with eculizumab, a recombinant humanized monoclonal antibody, significantly reduces the risk of thrombosis in patients with paroxysmal nocturnal hemoglobinuria (PNH), according to the results of a recent multicenter study.

Peter Hillmen, MD, of the Leeds Teaching Hospitals NHS Trust, reported the results of the study at the 12th Congress of the European Hematology Association in June 2007.

Dr Hillmen and colleagues prospectively examined the aggregate thromboembolism (TE) event rate in eculizumab-treated patients from 3 recent parent studies, as well as a subsequent common extension study. They compared those rates to the TE rate in the same patients’ pre-eculizumab treatment.

Eculizumab, which is designed to inhibit activation of terminal complement components that have been implicated in the development of PNH, reduced the TE rate in each of the three parent studies.

Most importantly, the aggregate TE event rate during eculizumab treatment was significantly reduced by 85% (P=<0.001), when compared with the same patients before eculizumab treatment.

With restriction of the pretreatment observation period to the 12 months immediately preceding eculizumab treatment, the TE event rate during treatment was reduced by 94% (P=0.002). The TE event rate in patients with TE prior to the trials was also reduced by 89% (P=<0.001).

Most TE events prior to eculizumab treatment occurred in patients receiving antithrombotics, either therapeutically or prophylactically. This indicates that the therapy may be insufficient to prevent thrombosis.

Pre-eculizumab treatment, 195 patients experienced 124 TE events. Of the 195 patients, 103 were on antithrombotics.

Of the 103 patients on antithrombotics, there were 54 TE events in 30 patients pre-eculizumab, compared to 1 TE event during eculizumab treatment. This demonstrates that eculizumab significantly reduces the risk of thrombosis in PNH patients, despite treatment with antithrombotics (P=<0.001).

Pre-eculizumab, TE was frequent in patients with lower levels of hemolysis and with mild anemia. Eculizumab significantly reduced TE across these and other subgroups (P=<0.001).

Dr Hillman said these data demonstrate the efficacy of long-term eculizumab treatment in its ability to significantly reduce the occurrence of thrombosis in PNH patients. Because TE accounts for the majority of deaths in PNH, it is reasonable to expect that eculizumab treatment, by decreasing the risk of TE, will increase the life-expectancy in PNH.

PNH is a rare, acquired, and potentially life-threatening disease of the blood characterized by hemolytic anemia, thrombosis, and red-colored urine, resulting from the breakdown of red blood cells.

TE is one of the most feared complications associated with PNH and accounts for approximately 45% of PNH patient deaths. The disease can occur even in individuals who have no previous history of thrombosis.

Patients with PNH are usually treated with anticoagulants on a prophylactic basis. However, these anticoagulants increase the risk of life-threatening hemorrhage without eliminating the potential for thrombosis, which can occur in as many as 30% of the patients who receive anticoagulant treatment. 

VIENNA—Long-term treatment with eculizumab, a recombinant humanized monoclonal antibody, significantly reduces the risk of thrombosis in patients with paroxysmal nocturnal hemoglobinuria (PNH), according to the results of a recent multicenter study.

Peter Hillmen, MD, of the Leeds Teaching Hospitals NHS Trust, reported the results of the study at the 12th Congress of the European Hematology Association in June 2007.

Dr Hillmen and colleagues prospectively examined the aggregate thromboembolism (TE) event rate in eculizumab-treated patients from 3 recent parent studies, as well as a subsequent common extension study. They compared those rates to the TE rate in the same patients’ pre-eculizumab treatment.

Eculizumab, which is designed to inhibit activation of terminal complement components that have been implicated in the development of PNH, reduced the TE rate in each of the three parent studies.

Most importantly, the aggregate TE event rate during eculizumab treatment was significantly reduced by 85% (P=<0.001), when compared with the same patients before eculizumab treatment.

With restriction of the pretreatment observation period to the 12 months immediately preceding eculizumab treatment, the TE event rate during treatment was reduced by 94% (P=0.002). The TE event rate in patients with TE prior to the trials was also reduced by 89% (P=<0.001).

Most TE events prior to eculizumab treatment occurred in patients receiving antithrombotics, either therapeutically or prophylactically. This indicates that the therapy may be insufficient to prevent thrombosis.

Pre-eculizumab treatment, 195 patients experienced 124 TE events. Of the 195 patients, 103 were on antithrombotics.

Of the 103 patients on antithrombotics, there were 54 TE events in 30 patients pre-eculizumab, compared to 1 TE event during eculizumab treatment. This demonstrates that eculizumab significantly reduces the risk of thrombosis in PNH patients, despite treatment with antithrombotics (P=<0.001).

Pre-eculizumab, TE was frequent in patients with lower levels of hemolysis and with mild anemia. Eculizumab significantly reduced TE across these and other subgroups (P=<0.001).

Dr Hillman said these data demonstrate the efficacy of long-term eculizumab treatment in its ability to significantly reduce the occurrence of thrombosis in PNH patients. Because TE accounts for the majority of deaths in PNH, it is reasonable to expect that eculizumab treatment, by decreasing the risk of TE, will increase the life-expectancy in PNH.

PNH is a rare, acquired, and potentially life-threatening disease of the blood characterized by hemolytic anemia, thrombosis, and red-colored urine, resulting from the breakdown of red blood cells.

TE is one of the most feared complications associated with PNH and accounts for approximately 45% of PNH patient deaths. The disease can occur even in individuals who have no previous history of thrombosis.

Patients with PNH are usually treated with anticoagulants on a prophylactic basis. However, these anticoagulants increase the risk of life-threatening hemorrhage without eliminating the potential for thrombosis, which can occur in as many as 30% of the patients who receive anticoagulant treatment. 

VIENNA—Long-term treatment with eculizumab, a recombinant humanized monoclonal antibody, significantly reduces the risk of thrombosis in patients with paroxysmal nocturnal hemoglobinuria (PNH), according to the results of a recent multicenter study.

Peter Hillmen, MD, of the Leeds Teaching Hospitals NHS Trust, reported the results of the study at the 12th Congress of the European Hematology Association in June 2007.

Dr Hillmen and colleagues prospectively examined the aggregate thromboembolism (TE) event rate in eculizumab-treated patients from 3 recent parent studies, as well as a subsequent common extension study. They compared those rates to the TE rate in the same patients’ pre-eculizumab treatment.

Eculizumab, which is designed to inhibit activation of terminal complement components that have been implicated in the development of PNH, reduced the TE rate in each of the three parent studies.

Most importantly, the aggregate TE event rate during eculizumab treatment was significantly reduced by 85% (P=<0.001), when compared with the same patients before eculizumab treatment.

With restriction of the pretreatment observation period to the 12 months immediately preceding eculizumab treatment, the TE event rate during treatment was reduced by 94% (P=0.002). The TE event rate in patients with TE prior to the trials was also reduced by 89% (P=<0.001).

Most TE events prior to eculizumab treatment occurred in patients receiving antithrombotics, either therapeutically or prophylactically. This indicates that the therapy may be insufficient to prevent thrombosis.

Pre-eculizumab treatment, 195 patients experienced 124 TE events. Of the 195 patients, 103 were on antithrombotics.

Of the 103 patients on antithrombotics, there were 54 TE events in 30 patients pre-eculizumab, compared to 1 TE event during eculizumab treatment. This demonstrates that eculizumab significantly reduces the risk of thrombosis in PNH patients, despite treatment with antithrombotics (P=<0.001).

Pre-eculizumab, TE was frequent in patients with lower levels of hemolysis and with mild anemia. Eculizumab significantly reduced TE across these and other subgroups (P=<0.001).

Dr Hillman said these data demonstrate the efficacy of long-term eculizumab treatment in its ability to significantly reduce the occurrence of thrombosis in PNH patients. Because TE accounts for the majority of deaths in PNH, it is reasonable to expect that eculizumab treatment, by decreasing the risk of TE, will increase the life-expectancy in PNH.

PNH is a rare, acquired, and potentially life-threatening disease of the blood characterized by hemolytic anemia, thrombosis, and red-colored urine, resulting from the breakdown of red blood cells.

TE is one of the most feared complications associated with PNH and accounts for approximately 45% of PNH patient deaths. The disease can occur even in individuals who have no previous history of thrombosis.

Patients with PNH are usually treated with anticoagulants on a prophylactic basis. However, these anticoagulants increase the risk of life-threatening hemorrhage without eliminating the potential for thrombosis, which can occur in as many as 30% of the patients who receive anticoagulant treatment. 

On March 16, the John A. Hartford Foundation awarded SHM a $1.4 million grant to develop interventions to improve care transitions for older adults at the time of hospital discharge.

One of the core values of SHM and hospital medicine is to implement changes that improve the care older Americans receive. With this grant support from The Hartford Foundation, SHM can help define and set standards for best practices in discharge and provide a continuum of training opportunities to support those practices.

As part of this three-year project, SHM will partner with national leaders in care coordination to form a national advisory board, create clinical tools, implement guidelines, and provide technical support and training tools to hospitals across the U.S. The project aims to build capacity in at least 200 hospital sites to improve the discharge process and, ultimately, health outcomes for older adults.

National Advisory Board AND Project Team

SHM has assembled a national advisory board to inform and guide the project. The board will be chaired by Eric Coleman, MD, MPH, associate professor of medicine within the divisions of healthcare policy and research and geriatric medicine at the University of Colorado Health Sciences Center in Aurora. At press time, members included:

• Barbara Berkman, DSW, PhD, professor of health and mental health, University School of Social Work, Mount Sinai School of Medicine;
• Tom Bookwalter, PharmD, clinical pharmacist, American Society of Health-System Pharmacists (ASHP);
• Alan Korn, MD, chief medical officer and senior vice president for clinical affairs, Blue Cross Blue Shield Association;
• Chuck Denham, MD, chair, National Quality Forum (NQF);
• Gavin Hougham, PhD, senior program officer, John A. Hartford Foundation;
• Seth Landefeld, MD, director, American Geriatrics Society (AGS);
• Cheri Lattimer, RN, BSN, executive director, Case Management Society of America (CMSA);
• William Lyons, MD, AGS; Nebraska Medical Center in Omaha;
• Lorraine Mion, PhD, RN, FAAN, director of nursing services for geriatrics, Metro Health Medical Center in Cleveland, Ohio;
• Mary Naylor, PhD, RN, FAANS, Marian S. Ware professor in gerontology, University of Pennsylvania;
• Gail Povar, MD, MPH, chair, George Washington School of Medicine, Cameron Medical Group;
• Deborah Queenan, national advisory council coordinator, Agency for Healthcare Research and Quality (AHRQ);
• Pat Rutherford, RN, MS, vice president, Institute for Healthcare Improvement (IHI), Transforming Care at the Bedside (TCAB);
• Eric Warm, MD, Society General Internal Medicine (SGIM); and
• Larry Wellikson, MD, CEO of SHM.

Dr. Williams will serve as principal investigator, leading a team of co-investigators including Jeffrey Greenwald, MD, (Boston University co-investigator, AHRQ, Project ReEngineering Discharge); Eric Howell, MD (Johns Hopkins Bayview, SHM/Hartford Safe Steps Demonstration Project); Param Dedhia, MD (Johns Hopkins Bayview, SHM/Hartford Safe STEPS Demonstration Project); Lakshmi Halasyamani, MD (St. Joseph Mercy Hospital); Kathleen Kerr (SHM); and Tina Budnitz, MPH (SHM).

The project team includes investigators from the SHM/Hartford Foundation Safe STEPS project and two AHRQ-funded projects. All three projects aim to pilot test discharge-planning toolkits and interventions and develop implementation strategies for adoption. The current project will leverage the findings of all three projects with the insights of the advisory board to create a transitions bundle to optimize the discharge process. Following development of this bundle, SHM will develop a toolkit for implementation with corresponding training programs, and other technical support.

 

click for large version

Capacity Building Via Continuum of Training Options

SHM has designed a range of technical support and training options to meet the needs of member institutions aiming to implement and sustain the transitions bundle. Strategies include:

• A Web-based resource room for care transitions in older adults: The transitions bundle, field guide, and related interventional materials will be freely available in the SHM online resource room.
• A Quality Pre-Course for QI Teams: The course is scheduled for 2008 and 2009 SHM Annual Meetings.
• A Transition Planning Mentored Implementation Program (TPMI): This yearlong mentoring program will support sites as they implement and evaluate transitions bundle interventions. The program includes a training conference, monthly teleconferences with expert mentors and peer support mechanisms.
• A consultation service: This will provide on-site consultation and technical assistance to sites planning, implementing, and evaluating discharge interventions. The service includes site visit, follow-up report of findings, recommendations and resources, and post-visit follow-up to review progress, successes and unforeseen barriers.

These support mechanisms are intended to assist those who lead improvement teams at their institutions. Enrollment will begin in the fall. For more information, contact [email protected].

 

 

---

 

 

A Seat at the Table

SHM active in shaping new performance standards

By Jane Jerrard

Healthcare providers are in the midst of important changes in how they work and how they’re rewarded for that work. Recent initiatives including Medicare’s Physician Quality Reporting Initiative and a Medicare hospital value-based purchasing program mandated by the Deficit Reduction Act spell change for practitioners, including hospitalists.

SHM is working to add a hospitalist voice to discussions and decisions that shape these initiatives. By participating in organizations such as the American Medical Association’s (AMA) Physician consortium for Performance Improvement (PCPI), SHM has a seat at the table where decisions are made.

How Participation Works

The PCPI was convened in 2001 by the AMA, with the mission of physician-led performance improvement. While the primary focus is on improving quality, the Consortium’s performance measures are ultimately those used in CMS and other pay-for-performance (P4P) programs and value-based purchasing initiatives.

SHM didn’t get involved when the PCPI was first formed because the issues weren’t relevant to hospitalists. “SHM was invited to participate at that time, but the focus was really on outpatient care,” says Patrick J. Torcson, MD, MMM, FACP, director of hospital medicine at St. Tammany Parish Hospital in Covington, La. “More recently, when the PCPI began looking at the relation between hospital-level measures and physician-level measures, SHM CEO Larry Wellikson said we need to get involved.”

Dr. Torcson is SHM’s representative on the consortium. “For the last year and a half, I’ve been attending the PCPI meetings to represent SHM and have been involved in various PCPI work groups,” he says. “I had previously served on the SHM HQPS [Healthcare Quality and Patient Safety Task Force] and now serve on the PPC [Public Policy Committee], and I think the SHM leadership thought that combination of interests would be good for a PCPI representative.”

What about the Work Groups?

Work groups within the PCPI are assigned specific areas. These groups are responsible for creating performance measures within an area, which are then reviewed by the entire consortium.

“I participated on a work group to develop performance measures for emergency medicine physicians,” says Dr. Torcson. “This group thought that the current disease-specific measures weren’t relevant for them, and that the current hospital measures were also not relevant. I provided a hospitalist’s perspective on hand-offs and discharge which was really focused on a process of care that begins in the ED [emergency department].”

 

Each work group has representation from various areas of healthcare. “My work group had about 20 or 25 people, which is probably typical,” says Dr. Torcson. “The AMA provided a methodologist, and there was a CMS representative on the work group.” The work group first met face to face to review relevant evidence-based clinical guidelines and scame up with five to eight measures. These were then reworked through phone calls and e-mails before going before the entire PCPI for approval.

Other SHM representatives participated in relevant PCPI work groups as well. “PPC member Greg Seymann from San Diego participated in a geriatric work group that was convened for the same reason” as the ED group, says Dr. Torcson. “His group looked at creating a number of measures that were relative to both inpatient and outpatient geriatric patients. Some of these measures are now part of the Medicare Physician Quality Reporting Initiative.”

Another SHM member, James C. Pile. MD, FACP, participated in a work group on developing measures for outpatient administration of IV antibiotics. Pile is a staff physician in the Department of General Internal Medicine, Section of Hospital Medicine, at The Cleveland Clinic in Ohio.

In each group, SHM representatives were able to help shape measures that reflect the unique knowledge and perspective of hospital medicine.

“A hospitalist brings the perspective of having seen how these measures are actually incorporated into a practice, how they are actually applied to patient care,” Dr. Torcson points out. “These work groups to develop additional performance measures are ongoing. The PCPI has a rigorous agenda for what they want to accomplish over the next few years.”

SHM to Lead the Way on Care Transitions

The PCPI has asked SHM to be the lead organization for a performance measure development work group on care coordination and care transitions.

“This will be groundbreaking work around this important aspect of care that is very process-focused as opposed to disease-focused,” says Dr. Torcson. “It’s very appropriate that SHM was asked to be the lead group for this. This area of performance improvement is perfect for what hospitalists do.”

The PCPI plans to have care transition performance measures ready for adoption by 2009.

SHM and the Big Three

CMS is also collaborating with the National Quality Forum (NQF) and Ambulatory Quality Alliance (AQA). “The PCPI, AQA, and NQF are the most influential organizations right now for quality and performance measures,” says Dr. Torcson.

The NQF, a unique public and private collaborative, develops consensus standards on different measures submitted to it. “I have had the opportunity to participate on an NQF Steering Committee for performance measure endorsement,” says Dr. Torcson.

The AQA is responsible for standardizing performance measurement and reporting, and developing measures for efficiency to be included in forthcoming Medicare P4P programs. “The AQA is charged with implementing performance measures and bringing them to the marketplace,” explains Dr. Torcson. “SHM is not involved in the AQA process yet.”

Membership in SHM means you are able to access the latest information on issues like CMS reporting initiatives and have representation in the decision-making process.

“I think it’s the responsibility of a professional society to not only be informed on what’s happening on a national level, but to have some influence,” says Dr. Torcson. “And SHM has done a great job in being well-positioned to influence the national agenda on quality and performance improvement.” TH

Jane Jerrard writes frequently for The Hospitalist.

On March 16, the John A. Hartford Foundation awarded SHM a $1.4 million grant to develop interventions to improve care transitions for older adults at the time of hospital discharge.

One of the core values of SHM and hospital medicine is to implement changes that improve the care older Americans receive. With this grant support from The Hartford Foundation, SHM can help define and set standards for best practices in discharge and provide a continuum of training opportunities to support those practices.

As part of this three-year project, SHM will partner with national leaders in care coordination to form a national advisory board, create clinical tools, implement guidelines, and provide technical support and training tools to hospitals across the U.S. The project aims to build capacity in at least 200 hospital sites to improve the discharge process and, ultimately, health outcomes for older adults.

National Advisory Board AND Project Team

SHM has assembled a national advisory board to inform and guide the project. The board will be chaired by Eric Coleman, MD, MPH, associate professor of medicine within the divisions of healthcare policy and research and geriatric medicine at the University of Colorado Health Sciences Center in Aurora. At press time, members included:

• Barbara Berkman, DSW, PhD, professor of health and mental health, University School of Social Work, Mount Sinai School of Medicine;
• Tom Bookwalter, PharmD, clinical pharmacist, American Society of Health-System Pharmacists (ASHP);
• Alan Korn, MD, chief medical officer and senior vice president for clinical affairs, Blue Cross Blue Shield Association;
• Chuck Denham, MD, chair, National Quality Forum (NQF);
• Gavin Hougham, PhD, senior program officer, John A. Hartford Foundation;
• Seth Landefeld, MD, director, American Geriatrics Society (AGS);
• Cheri Lattimer, RN, BSN, executive director, Case Management Society of America (CMSA);
• William Lyons, MD, AGS; Nebraska Medical Center in Omaha;
• Lorraine Mion, PhD, RN, FAAN, director of nursing services for geriatrics, Metro Health Medical Center in Cleveland, Ohio;
• Mary Naylor, PhD, RN, FAANS, Marian S. Ware professor in gerontology, University of Pennsylvania;
• Gail Povar, MD, MPH, chair, George Washington School of Medicine, Cameron Medical Group;
• Deborah Queenan, national advisory council coordinator, Agency for Healthcare Research and Quality (AHRQ);
• Pat Rutherford, RN, MS, vice president, Institute for Healthcare Improvement (IHI), Transforming Care at the Bedside (TCAB);
• Eric Warm, MD, Society General Internal Medicine (SGIM); and
• Larry Wellikson, MD, CEO of SHM.

Dr. Williams will serve as principal investigator, leading a team of co-investigators including Jeffrey Greenwald, MD, (Boston University co-investigator, AHRQ, Project ReEngineering Discharge); Eric Howell, MD (Johns Hopkins Bayview, SHM/Hartford Safe Steps Demonstration Project); Param Dedhia, MD (Johns Hopkins Bayview, SHM/Hartford Safe STEPS Demonstration Project); Lakshmi Halasyamani, MD (St. Joseph Mercy Hospital); Kathleen Kerr (SHM); and Tina Budnitz, MPH (SHM).

The project team includes investigators from the SHM/Hartford Foundation Safe STEPS project and two AHRQ-funded projects. All three projects aim to pilot test discharge-planning toolkits and interventions and develop implementation strategies for adoption. The current project will leverage the findings of all three projects with the insights of the advisory board to create a transitions bundle to optimize the discharge process. Following development of this bundle, SHM will develop a toolkit for implementation with corresponding training programs, and other technical support.

 

click for large version

Capacity Building Via Continuum of Training Options

SHM has designed a range of technical support and training options to meet the needs of member institutions aiming to implement and sustain the transitions bundle. Strategies include:

• A Web-based resource room for care transitions in older adults: The transitions bundle, field guide, and related interventional materials will be freely available in the SHM online resource room.
• A Quality Pre-Course for QI Teams: The course is scheduled for 2008 and 2009 SHM Annual Meetings.
• A Transition Planning Mentored Implementation Program (TPMI): This yearlong mentoring program will support sites as they implement and evaluate transitions bundle interventions. The program includes a training conference, monthly teleconferences with expert mentors and peer support mechanisms.
• A consultation service: This will provide on-site consultation and technical assistance to sites planning, implementing, and evaluating discharge interventions. The service includes site visit, follow-up report of findings, recommendations and resources, and post-visit follow-up to review progress, successes and unforeseen barriers.

These support mechanisms are intended to assist those who lead improvement teams at their institutions. Enrollment will begin in the fall. For more information, contact [email protected].

 

 

---

 

 

A Seat at the Table

SHM active in shaping new performance standards

By Jane Jerrard

Healthcare providers are in the midst of important changes in how they work and how they’re rewarded for that work. Recent initiatives including Medicare’s Physician Quality Reporting Initiative and a Medicare hospital value-based purchasing program mandated by the Deficit Reduction Act spell change for practitioners, including hospitalists.

SHM is working to add a hospitalist voice to discussions and decisions that shape these initiatives. By participating in organizations such as the American Medical Association’s (AMA) Physician consortium for Performance Improvement (PCPI), SHM has a seat at the table where decisions are made.

How Participation Works

The PCPI was convened in 2001 by the AMA, with the mission of physician-led performance improvement. While the primary focus is on improving quality, the Consortium’s performance measures are ultimately those used in CMS and other pay-for-performance (P4P) programs and value-based purchasing initiatives.

SHM didn’t get involved when the PCPI was first formed because the issues weren’t relevant to hospitalists. “SHM was invited to participate at that time, but the focus was really on outpatient care,” says Patrick J. Torcson, MD, MMM, FACP, director of hospital medicine at St. Tammany Parish Hospital in Covington, La. “More recently, when the PCPI began looking at the relation between hospital-level measures and physician-level measures, SHM CEO Larry Wellikson said we need to get involved.”

Dr. Torcson is SHM’s representative on the consortium. “For the last year and a half, I’ve been attending the PCPI meetings to represent SHM and have been involved in various PCPI work groups,” he says. “I had previously served on the SHM HQPS [Healthcare Quality and Patient Safety Task Force] and now serve on the PPC [Public Policy Committee], and I think the SHM leadership thought that combination of interests would be good for a PCPI representative.”

What about the Work Groups?

Work groups within the PCPI are assigned specific areas. These groups are responsible for creating performance measures within an area, which are then reviewed by the entire consortium.

“I participated on a work group to develop performance measures for emergency medicine physicians,” says Dr. Torcson. “This group thought that the current disease-specific measures weren’t relevant for them, and that the current hospital measures were also not relevant. I provided a hospitalist’s perspective on hand-offs and discharge which was really focused on a process of care that begins in the ED [emergency department].”

 

Each work group has representation from various areas of healthcare. “My work group had about 20 or 25 people, which is probably typical,” says Dr. Torcson. “The AMA provided a methodologist, and there was a CMS representative on the work group.” The work group first met face to face to review relevant evidence-based clinical guidelines and scame up with five to eight measures. These were then reworked through phone calls and e-mails before going before the entire PCPI for approval.

Other SHM representatives participated in relevant PCPI work groups as well. “PPC member Greg Seymann from San Diego participated in a geriatric work group that was convened for the same reason” as the ED group, says Dr. Torcson. “His group looked at creating a number of measures that were relative to both inpatient and outpatient geriatric patients. Some of these measures are now part of the Medicare Physician Quality Reporting Initiative.”

Another SHM member, James C. Pile. MD, FACP, participated in a work group on developing measures for outpatient administration of IV antibiotics. Pile is a staff physician in the Department of General Internal Medicine, Section of Hospital Medicine, at The Cleveland Clinic in Ohio.

In each group, SHM representatives were able to help shape measures that reflect the unique knowledge and perspective of hospital medicine.

“A hospitalist brings the perspective of having seen how these measures are actually incorporated into a practice, how they are actually applied to patient care,” Dr. Torcson points out. “These work groups to develop additional performance measures are ongoing. The PCPI has a rigorous agenda for what they want to accomplish over the next few years.”

SHM to Lead the Way on Care Transitions

The PCPI has asked SHM to be the lead organization for a performance measure development work group on care coordination and care transitions.

“This will be groundbreaking work around this important aspect of care that is very process-focused as opposed to disease-focused,” says Dr. Torcson. “It’s very appropriate that SHM was asked to be the lead group for this. This area of performance improvement is perfect for what hospitalists do.”

The PCPI plans to have care transition performance measures ready for adoption by 2009.

SHM and the Big Three

CMS is also collaborating with the National Quality Forum (NQF) and Ambulatory Quality Alliance (AQA). “The PCPI, AQA, and NQF are the most influential organizations right now for quality and performance measures,” says Dr. Torcson.

The NQF, a unique public and private collaborative, develops consensus standards on different measures submitted to it. “I have had the opportunity to participate on an NQF Steering Committee for performance measure endorsement,” says Dr. Torcson.

The AQA is responsible for standardizing performance measurement and reporting, and developing measures for efficiency to be included in forthcoming Medicare P4P programs. “The AQA is charged with implementing performance measures and bringing them to the marketplace,” explains Dr. Torcson. “SHM is not involved in the AQA process yet.”

Membership in SHM means you are able to access the latest information on issues like CMS reporting initiatives and have representation in the decision-making process.

“I think it’s the responsibility of a professional society to not only be informed on what’s happening on a national level, but to have some influence,” says Dr. Torcson. “And SHM has done a great job in being well-positioned to influence the national agenda on quality and performance improvement.” TH

Jane Jerrard writes frequently for The Hospitalist.

On March 16, the John A. Hartford Foundation awarded SHM a $1.4 million grant to develop interventions to improve care transitions for older adults at the time of hospital discharge.

One of the core values of SHM and hospital medicine is to implement changes that improve the care older Americans receive. With this grant support from The Hartford Foundation, SHM can help define and set standards for best practices in discharge and provide a continuum of training opportunities to support those practices.

As part of this three-year project, SHM will partner with national leaders in care coordination to form a national advisory board, create clinical tools, implement guidelines, and provide technical support and training tools to hospitals across the U.S. The project aims to build capacity in at least 200 hospital sites to improve the discharge process and, ultimately, health outcomes for older adults.

National Advisory Board AND Project Team

SHM has assembled a national advisory board to inform and guide the project. The board will be chaired by Eric Coleman, MD, MPH, associate professor of medicine within the divisions of healthcare policy and research and geriatric medicine at the University of Colorado Health Sciences Center in Aurora. At press time, members included:

• Barbara Berkman, DSW, PhD, professor of health and mental health, University School of Social Work, Mount Sinai School of Medicine;
• Tom Bookwalter, PharmD, clinical pharmacist, American Society of Health-System Pharmacists (ASHP);
• Alan Korn, MD, chief medical officer and senior vice president for clinical affairs, Blue Cross Blue Shield Association;
• Chuck Denham, MD, chair, National Quality Forum (NQF);
• Gavin Hougham, PhD, senior program officer, John A. Hartford Foundation;
• Seth Landefeld, MD, director, American Geriatrics Society (AGS);
• Cheri Lattimer, RN, BSN, executive director, Case Management Society of America (CMSA);
• William Lyons, MD, AGS; Nebraska Medical Center in Omaha;
• Lorraine Mion, PhD, RN, FAAN, director of nursing services for geriatrics, Metro Health Medical Center in Cleveland, Ohio;
• Mary Naylor, PhD, RN, FAANS, Marian S. Ware professor in gerontology, University of Pennsylvania;
• Gail Povar, MD, MPH, chair, George Washington School of Medicine, Cameron Medical Group;
• Deborah Queenan, national advisory council coordinator, Agency for Healthcare Research and Quality (AHRQ);
• Pat Rutherford, RN, MS, vice president, Institute for Healthcare Improvement (IHI), Transforming Care at the Bedside (TCAB);
• Eric Warm, MD, Society General Internal Medicine (SGIM); and
• Larry Wellikson, MD, CEO of SHM.

Dr. Williams will serve as principal investigator, leading a team of co-investigators including Jeffrey Greenwald, MD, (Boston University co-investigator, AHRQ, Project ReEngineering Discharge); Eric Howell, MD (Johns Hopkins Bayview, SHM/Hartford Safe Steps Demonstration Project); Param Dedhia, MD (Johns Hopkins Bayview, SHM/Hartford Safe STEPS Demonstration Project); Lakshmi Halasyamani, MD (St. Joseph Mercy Hospital); Kathleen Kerr (SHM); and Tina Budnitz, MPH (SHM).

The project team includes investigators from the SHM/Hartford Foundation Safe STEPS project and two AHRQ-funded projects. All three projects aim to pilot test discharge-planning toolkits and interventions and develop implementation strategies for adoption. The current project will leverage the findings of all three projects with the insights of the advisory board to create a transitions bundle to optimize the discharge process. Following development of this bundle, SHM will develop a toolkit for implementation with corresponding training programs, and other technical support.

 

click for large version

Capacity Building Via Continuum of Training Options

SHM has designed a range of technical support and training options to meet the needs of member institutions aiming to implement and sustain the transitions bundle. Strategies include:

• A Web-based resource room for care transitions in older adults: The transitions bundle, field guide, and related interventional materials will be freely available in the SHM online resource room.
• A Quality Pre-Course for QI Teams: The course is scheduled for 2008 and 2009 SHM Annual Meetings.
• A Transition Planning Mentored Implementation Program (TPMI): This yearlong mentoring program will support sites as they implement and evaluate transitions bundle interventions. The program includes a training conference, monthly teleconferences with expert mentors and peer support mechanisms.
• A consultation service: This will provide on-site consultation and technical assistance to sites planning, implementing, and evaluating discharge interventions. The service includes site visit, follow-up report of findings, recommendations and resources, and post-visit follow-up to review progress, successes and unforeseen barriers.

These support mechanisms are intended to assist those who lead improvement teams at their institutions. Enrollment will begin in the fall. For more information, contact [email protected].

 

 

---

 

 

A Seat at the Table

SHM active in shaping new performance standards

By Jane Jerrard

Healthcare providers are in the midst of important changes in how they work and how they’re rewarded for that work. Recent initiatives including Medicare’s Physician Quality Reporting Initiative and a Medicare hospital value-based purchasing program mandated by the Deficit Reduction Act spell change for practitioners, including hospitalists.

SHM is working to add a hospitalist voice to discussions and decisions that shape these initiatives. By participating in organizations such as the American Medical Association’s (AMA) Physician consortium for Performance Improvement (PCPI), SHM has a seat at the table where decisions are made.

How Participation Works

The PCPI was convened in 2001 by the AMA, with the mission of physician-led performance improvement. While the primary focus is on improving quality, the Consortium’s performance measures are ultimately those used in CMS and other pay-for-performance (P4P) programs and value-based purchasing initiatives.

SHM didn’t get involved when the PCPI was first formed because the issues weren’t relevant to hospitalists. “SHM was invited to participate at that time, but the focus was really on outpatient care,” says Patrick J. Torcson, MD, MMM, FACP, director of hospital medicine at St. Tammany Parish Hospital in Covington, La. “More recently, when the PCPI began looking at the relation between hospital-level measures and physician-level measures, SHM CEO Larry Wellikson said we need to get involved.”

Dr. Torcson is SHM’s representative on the consortium. “For the last year and a half, I’ve been attending the PCPI meetings to represent SHM and have been involved in various PCPI work groups,” he says. “I had previously served on the SHM HQPS [Healthcare Quality and Patient Safety Task Force] and now serve on the PPC [Public Policy Committee], and I think the SHM leadership thought that combination of interests would be good for a PCPI representative.”

What about the Work Groups?

Work groups within the PCPI are assigned specific areas. These groups are responsible for creating performance measures within an area, which are then reviewed by the entire consortium.

“I participated on a work group to develop performance measures for emergency medicine physicians,” says Dr. Torcson. “This group thought that the current disease-specific measures weren’t relevant for them, and that the current hospital measures were also not relevant. I provided a hospitalist’s perspective on hand-offs and discharge which was really focused on a process of care that begins in the ED [emergency department].”

 

Each work group has representation from various areas of healthcare. “My work group had about 20 or 25 people, which is probably typical,” says Dr. Torcson. “The AMA provided a methodologist, and there was a CMS representative on the work group.” The work group first met face to face to review relevant evidence-based clinical guidelines and scame up with five to eight measures. These were then reworked through phone calls and e-mails before going before the entire PCPI for approval.

Other SHM representatives participated in relevant PCPI work groups as well. “PPC member Greg Seymann from San Diego participated in a geriatric work group that was convened for the same reason” as the ED group, says Dr. Torcson. “His group looked at creating a number of measures that were relative to both inpatient and outpatient geriatric patients. Some of these measures are now part of the Medicare Physician Quality Reporting Initiative.”

Another SHM member, James C. Pile. MD, FACP, participated in a work group on developing measures for outpatient administration of IV antibiotics. Pile is a staff physician in the Department of General Internal Medicine, Section of Hospital Medicine, at The Cleveland Clinic in Ohio.

In each group, SHM representatives were able to help shape measures that reflect the unique knowledge and perspective of hospital medicine.

“A hospitalist brings the perspective of having seen how these measures are actually incorporated into a practice, how they are actually applied to patient care,” Dr. Torcson points out. “These work groups to develop additional performance measures are ongoing. The PCPI has a rigorous agenda for what they want to accomplish over the next few years.”

SHM to Lead the Way on Care Transitions

The PCPI has asked SHM to be the lead organization for a performance measure development work group on care coordination and care transitions.

“This will be groundbreaking work around this important aspect of care that is very process-focused as opposed to disease-focused,” says Dr. Torcson. “It’s very appropriate that SHM was asked to be the lead group for this. This area of performance improvement is perfect for what hospitalists do.”

The PCPI plans to have care transition performance measures ready for adoption by 2009.

SHM and the Big Three

CMS is also collaborating with the National Quality Forum (NQF) and Ambulatory Quality Alliance (AQA). “The PCPI, AQA, and NQF are the most influential organizations right now for quality and performance measures,” says Dr. Torcson.

The NQF, a unique public and private collaborative, develops consensus standards on different measures submitted to it. “I have had the opportunity to participate on an NQF Steering Committee for performance measure endorsement,” says Dr. Torcson.

The AQA is responsible for standardizing performance measurement and reporting, and developing measures for efficiency to be included in forthcoming Medicare P4P programs. “The AQA is charged with implementing performance measures and bringing them to the marketplace,” explains Dr. Torcson. “SHM is not involved in the AQA process yet.”

Membership in SHM means you are able to access the latest information on issues like CMS reporting initiatives and have representation in the decision-making process.

“I think it’s the responsibility of a professional society to not only be informed on what’s happening on a national level, but to have some influence,” says Dr. Torcson. “And SHM has done a great job in being well-positioned to influence the national agenda on quality and performance improvement.” TH

Jane Jerrard writes frequently for The Hospitalist.

I remember the 10th anniversary of SHM back in 2007. The growth of the hospitalist field seemed remarkable back then, but little did we know it was just the beginning.

Even then, as I recall, the field had grown from a few hundred physicians in the mid-’90s to about 20,000, and SHM—which began literally on the back of a napkin in 1997—had more than 6,000 members. But it still felt like adolescence. We had new muscles and our voice was changing, but we were still a bit gangly and didn’t quite know what would become of us.

But these past 10 years have been truly something. Without question, the “co-management” thing has really turbocharged our growth. There are now more than 50,000 hospitalists in the United States and burgeoning hospitalist movements in several other countries. It’s amazing to think that the care of nonmedical patients was only a small portion of what hospitalists did in the early years. But, starting about 2005 or so, one specialty after another began asking hospitalists to provide hospital care and coordination: first orthopedic surgery, then neurosurgery, then all of surgery, then neurology, cardiology, and transplant services.

In the big teaching hospitals, the early diffusion was caused, in part, by the original limits on resident duty hours—to 80 hours a week, believe it or not. That seems like an awful lot now that residents are limited to 56 hours per week. Today, all these specialties have recognized that having hospitalists manage the medical aspects of hospital care and coordinate the rest with their interdisciplinary teams isn’t just about replacing residents; hospitalists create better outcomes at lower costs. And because everybody’s now paid based on their Value Score (quality and patient satisfaction divided by efficiency) everybody needs hospitalists.

Speaking of the Value Score: Boy, has quality measurement changed. Remember getting graded on whether we gave Pneumovax to hospitalized patients with pneumonia? Kind of silly, but that was all we knew. Now, our pneumonia care is judged on whether our patient is alive, ambulatory, and free of dyspnea four weeks after discharge—adjusted for all relevant comorbidities. And those data are collected automatically through our electronic medical record and immediately posted to the Web, where everybody sees it—including the folks at Medicare II (which now insures everybody in the U.S.), who adjust payment rates every month based on Value Scores.

Luckily, every hospital in the U.S. is computerized and has computerized physician order entry. Information gathered at the point of care—vital signs, blood sugars—flows wirelessly into the GUR (Google Universal Record), which can be accessed anywhere. Decision support is really impressive. When I say “pneumonia” to the computer (no, nobody types any more), it automatically suggests the best evidence-based workup and therapy. The no-brainers—DVT prophylaxis, pneumococcal vaccine injection, smoking cessation counseling—just happen. (I really like the interactive smoking counseling video that patients watch on their in-room plasma monitors.)

Although some docs used to fret that computers would make hospitalists obsolete, I think having the computer handle the rote, mundane stuff is great. There is certainly enough complex decision-making and coordination left to do. I now spend a lot more time in the patient’s room. The patient, the family, several consultants, and I are on the split-screen monitor discussing the patient’s case and developing a care plan. Most of the consultants are from my hospital, although we’re starting to use a few with good Value Scores based in India.

 

Some folks still take hospitalist jobs for a year or two and then go on to something else. But now that there are hospitalist training programs and board certification, most hospitalists are in it for the long haul. Because they are crucial to the success of the entire system, they are well compensated, have a reasonable schedule, and have tremendous opportunities for career advancement. For example, it seems like virtually every chief medical officer or information technology (IT) director (and a pretty good number of hospital CEOs) is a hospitalist.

All in all, the past 10 years have been terrific for our field. In 2007, after seeing the field’s early and unprecedented successes, some folks thought we had peaked. But one thing I’ve learned in the 20 years since I first wrote the word “hospitalist” (if I had just trademarked that term, I’d be on the golf course in Maui, not in assisted living here in Boca): Given a choice whether to bet on growth or stasis, when it comes to hospitalists, the bet should always be on bigger and better. TH

Dr. Wachter is professor of medicine at the University of California, San Francisco, associate chairman of UCSF’s Department of Medicine, and chief of the Medical Service at UCSF Medical Center. He was the first elected president of SHM.

I remember the 10th anniversary of SHM back in 2007. The growth of the hospitalist field seemed remarkable back then, but little did we know it was just the beginning.

Even then, as I recall, the field had grown from a few hundred physicians in the mid-’90s to about 20,000, and SHM—which began literally on the back of a napkin in 1997—had more than 6,000 members. But it still felt like adolescence. We had new muscles and our voice was changing, but we were still a bit gangly and didn’t quite know what would become of us.

But these past 10 years have been truly something. Without question, the “co-management” thing has really turbocharged our growth. There are now more than 50,000 hospitalists in the United States and burgeoning hospitalist movements in several other countries. It’s amazing to think that the care of nonmedical patients was only a small portion of what hospitalists did in the early years. But, starting about 2005 or so, one specialty after another began asking hospitalists to provide hospital care and coordination: first orthopedic surgery, then neurosurgery, then all of surgery, then neurology, cardiology, and transplant services.

In the big teaching hospitals, the early diffusion was caused, in part, by the original limits on resident duty hours—to 80 hours a week, believe it or not. That seems like an awful lot now that residents are limited to 56 hours per week. Today, all these specialties have recognized that having hospitalists manage the medical aspects of hospital care and coordinate the rest with their interdisciplinary teams isn’t just about replacing residents; hospitalists create better outcomes at lower costs. And because everybody’s now paid based on their Value Score (quality and patient satisfaction divided by efficiency) everybody needs hospitalists.

Speaking of the Value Score: Boy, has quality measurement changed. Remember getting graded on whether we gave Pneumovax to hospitalized patients with pneumonia? Kind of silly, but that was all we knew. Now, our pneumonia care is judged on whether our patient is alive, ambulatory, and free of dyspnea four weeks after discharge—adjusted for all relevant comorbidities. And those data are collected automatically through our electronic medical record and immediately posted to the Web, where everybody sees it—including the folks at Medicare II (which now insures everybody in the U.S.), who adjust payment rates every month based on Value Scores.

Luckily, every hospital in the U.S. is computerized and has computerized physician order entry. Information gathered at the point of care—vital signs, blood sugars—flows wirelessly into the GUR (Google Universal Record), which can be accessed anywhere. Decision support is really impressive. When I say “pneumonia” to the computer (no, nobody types any more), it automatically suggests the best evidence-based workup and therapy. The no-brainers—DVT prophylaxis, pneumococcal vaccine injection, smoking cessation counseling—just happen. (I really like the interactive smoking counseling video that patients watch on their in-room plasma monitors.)

Although some docs used to fret that computers would make hospitalists obsolete, I think having the computer handle the rote, mundane stuff is great. There is certainly enough complex decision-making and coordination left to do. I now spend a lot more time in the patient’s room. The patient, the family, several consultants, and I are on the split-screen monitor discussing the patient’s case and developing a care plan. Most of the consultants are from my hospital, although we’re starting to use a few with good Value Scores based in India.

 

Some folks still take hospitalist jobs for a year or two and then go on to something else. But now that there are hospitalist training programs and board certification, most hospitalists are in it for the long haul. Because they are crucial to the success of the entire system, they are well compensated, have a reasonable schedule, and have tremendous opportunities for career advancement. For example, it seems like virtually every chief medical officer or information technology (IT) director (and a pretty good number of hospital CEOs) is a hospitalist.

All in all, the past 10 years have been terrific for our field. In 2007, after seeing the field’s early and unprecedented successes, some folks thought we had peaked. But one thing I’ve learned in the 20 years since I first wrote the word “hospitalist” (if I had just trademarked that term, I’d be on the golf course in Maui, not in assisted living here in Boca): Given a choice whether to bet on growth or stasis, when it comes to hospitalists, the bet should always be on bigger and better. TH

Dr. Wachter is professor of medicine at the University of California, San Francisco, associate chairman of UCSF’s Department of Medicine, and chief of the Medical Service at UCSF Medical Center. He was the first elected president of SHM.

I remember the 10th anniversary of SHM back in 2007. The growth of the hospitalist field seemed remarkable back then, but little did we know it was just the beginning.

Even then, as I recall, the field had grown from a few hundred physicians in the mid-’90s to about 20,000, and SHM—which began literally on the back of a napkin in 1997—had more than 6,000 members. But it still felt like adolescence. We had new muscles and our voice was changing, but we were still a bit gangly and didn’t quite know what would become of us.

But these past 10 years have been truly something. Without question, the “co-management” thing has really turbocharged our growth. There are now more than 50,000 hospitalists in the United States and burgeoning hospitalist movements in several other countries. It’s amazing to think that the care of nonmedical patients was only a small portion of what hospitalists did in the early years. But, starting about 2005 or so, one specialty after another began asking hospitalists to provide hospital care and coordination: first orthopedic surgery, then neurosurgery, then all of surgery, then neurology, cardiology, and transplant services.

In the big teaching hospitals, the early diffusion was caused, in part, by the original limits on resident duty hours—to 80 hours a week, believe it or not. That seems like an awful lot now that residents are limited to 56 hours per week. Today, all these specialties have recognized that having hospitalists manage the medical aspects of hospital care and coordinate the rest with their interdisciplinary teams isn’t just about replacing residents; hospitalists create better outcomes at lower costs. And because everybody’s now paid based on their Value Score (quality and patient satisfaction divided by efficiency) everybody needs hospitalists.

Speaking of the Value Score: Boy, has quality measurement changed. Remember getting graded on whether we gave Pneumovax to hospitalized patients with pneumonia? Kind of silly, but that was all we knew. Now, our pneumonia care is judged on whether our patient is alive, ambulatory, and free of dyspnea four weeks after discharge—adjusted for all relevant comorbidities. And those data are collected automatically through our electronic medical record and immediately posted to the Web, where everybody sees it—including the folks at Medicare II (which now insures everybody in the U.S.), who adjust payment rates every month based on Value Scores.

Luckily, every hospital in the U.S. is computerized and has computerized physician order entry. Information gathered at the point of care—vital signs, blood sugars—flows wirelessly into the GUR (Google Universal Record), which can be accessed anywhere. Decision support is really impressive. When I say “pneumonia” to the computer (no, nobody types any more), it automatically suggests the best evidence-based workup and therapy. The no-brainers—DVT prophylaxis, pneumococcal vaccine injection, smoking cessation counseling—just happen. (I really like the interactive smoking counseling video that patients watch on their in-room plasma monitors.)

Although some docs used to fret that computers would make hospitalists obsolete, I think having the computer handle the rote, mundane stuff is great. There is certainly enough complex decision-making and coordination left to do. I now spend a lot more time in the patient’s room. The patient, the family, several consultants, and I are on the split-screen monitor discussing the patient’s case and developing a care plan. Most of the consultants are from my hospital, although we’re starting to use a few with good Value Scores based in India.

 

Some folks still take hospitalist jobs for a year or two and then go on to something else. But now that there are hospitalist training programs and board certification, most hospitalists are in it for the long haul. Because they are crucial to the success of the entire system, they are well compensated, have a reasonable schedule, and have tremendous opportunities for career advancement. For example, it seems like virtually every chief medical officer or information technology (IT) director (and a pretty good number of hospital CEOs) is a hospitalist.

All in all, the past 10 years have been terrific for our field. In 2007, after seeing the field’s early and unprecedented successes, some folks thought we had peaked. But one thing I’ve learned in the 20 years since I first wrote the word “hospitalist” (if I had just trademarked that term, I’d be on the golf course in Maui, not in assisted living here in Boca): Given a choice whether to bet on growth or stasis, when it comes to hospitalists, the bet should always be on bigger and better. TH

Dr. Wachter is professor of medicine at the University of California, San Francisco, associate chairman of UCSF’s Department of Medicine, and chief of the Medical Service at UCSF Medical Center. He was the first elected president of SHM.

I have been practicing medicine for 21 years. I had a private practice for 17 years before beginning a hospitalist program at our local hospital four years ago. I found “Final Exam?” (April 2007, p. 25) very interesting.

Most interesting were Dr. Andrew Bomback’s comments. He might consider that those “retired physicians” are realistic in their critique. Most physicians, if not all trained prior to the mandated 80-hour workweeks, had just as much paperwork and carried pagers. In fact, many worked past the magical 12-hour shift and carried extensive hours into practice from residency. Few had the ancillary support available today. While it is true the physical exam has evolved, it is no less important in these days of technology.

The accurate history and physical exam suggest a differential diagnosis, from which we order tests to confirm or dispute. In the days of my residency training, internists were known to be the physicians who wrote the most orders, and there was a certain ill-found pride in seeing what obscure but pertinent tests one could order. Managed care, for all its problems, has made us focus on efficiency. It is there that the history and physical exam shine. In my opinion, they are paramount for cost-effective management of patients.

A recent example: I was asked to see a 47-year-old patient in the ED last week who presented with dyspnea. The ED physician had done a cursory exam and ordered the initial workup. The [chest X-ray] demonstrated cardiomegaly and pulmonary vascular congestion. The patient’s cardiac enzymes were normal, and his BNP was 82. The ED physician told me the EKG did not demonstrate new ST or T wave changes. A d-dimer was elevated, so he ordered a CT pulmonary angiogram. I arrived to see the patient prior to the patient leaving for CT. The patient had jugular venous distention, his heart tones were muffled, and he had pulsus paradoxicus. As I left the room, the patient went for CT. This was negative for PE but showed a large pericardial effusion. The echo I ordered confirmed the findings of tamponade. The physical exam should have led to the echocardiogram, thus eliminating the need for CT—a significant saving for the patient.

One of the benefits hospitalists offer is time spent with patients, as opposed to private practice physicians coming from their offices to see patients. There is no better time spent for physician and patient than the history and physical.

Al Caccavale, DO, FACOI

Chairman, Board of Trustees

Yavapai Regional Medical Center, Prescott, Ariz.

I have been practicing medicine for 21 years. I had a private practice for 17 years before beginning a hospitalist program at our local hospital four years ago. I found “Final Exam?” (April 2007, p. 25) very interesting.

Most interesting were Dr. Andrew Bomback’s comments. He might consider that those “retired physicians” are realistic in their critique. Most physicians, if not all trained prior to the mandated 80-hour workweeks, had just as much paperwork and carried pagers. In fact, many worked past the magical 12-hour shift and carried extensive hours into practice from residency. Few had the ancillary support available today. While it is true the physical exam has evolved, it is no less important in these days of technology.

The accurate history and physical exam suggest a differential diagnosis, from which we order tests to confirm or dispute. In the days of my residency training, internists were known to be the physicians who wrote the most orders, and there was a certain ill-found pride in seeing what obscure but pertinent tests one could order. Managed care, for all its problems, has made us focus on efficiency. It is there that the history and physical exam shine. In my opinion, they are paramount for cost-effective management of patients.

A recent example: I was asked to see a 47-year-old patient in the ED last week who presented with dyspnea. The ED physician had done a cursory exam and ordered the initial workup. The [chest X-ray] demonstrated cardiomegaly and pulmonary vascular congestion. The patient’s cardiac enzymes were normal, and his BNP was 82. The ED physician told me the EKG did not demonstrate new ST or T wave changes. A d-dimer was elevated, so he ordered a CT pulmonary angiogram. I arrived to see the patient prior to the patient leaving for CT. The patient had jugular venous distention, his heart tones were muffled, and he had pulsus paradoxicus. As I left the room, the patient went for CT. This was negative for PE but showed a large pericardial effusion. The echo I ordered confirmed the findings of tamponade. The physical exam should have led to the echocardiogram, thus eliminating the need for CT—a significant saving for the patient.

One of the benefits hospitalists offer is time spent with patients, as opposed to private practice physicians coming from their offices to see patients. There is no better time spent for physician and patient than the history and physical.

Al Caccavale, DO, FACOI

Chairman, Board of Trustees

Yavapai Regional Medical Center, Prescott, Ariz.

I have been practicing medicine for 21 years. I had a private practice for 17 years before beginning a hospitalist program at our local hospital four years ago. I found “Final Exam?” (April 2007, p. 25) very interesting.

Most interesting were Dr. Andrew Bomback’s comments. He might consider that those “retired physicians” are realistic in their critique. Most physicians, if not all trained prior to the mandated 80-hour workweeks, had just as much paperwork and carried pagers. In fact, many worked past the magical 12-hour shift and carried extensive hours into practice from residency. Few had the ancillary support available today. While it is true the physical exam has evolved, it is no less important in these days of technology.

The accurate history and physical exam suggest a differential diagnosis, from which we order tests to confirm or dispute. In the days of my residency training, internists were known to be the physicians who wrote the most orders, and there was a certain ill-found pride in seeing what obscure but pertinent tests one could order. Managed care, for all its problems, has made us focus on efficiency. It is there that the history and physical exam shine. In my opinion, they are paramount for cost-effective management of patients.

A recent example: I was asked to see a 47-year-old patient in the ED last week who presented with dyspnea. The ED physician had done a cursory exam and ordered the initial workup. The [chest X-ray] demonstrated cardiomegaly and pulmonary vascular congestion. The patient’s cardiac enzymes were normal, and his BNP was 82. The ED physician told me the EKG did not demonstrate new ST or T wave changes. A d-dimer was elevated, so he ordered a CT pulmonary angiogram. I arrived to see the patient prior to the patient leaving for CT. The patient had jugular venous distention, his heart tones were muffled, and he had pulsus paradoxicus. As I left the room, the patient went for CT. This was negative for PE but showed a large pericardial effusion. The echo I ordered confirmed the findings of tamponade. The physical exam should have led to the echocardiogram, thus eliminating the need for CT—a significant saving for the patient.

One of the benefits hospitalists offer is time spent with patients, as opposed to private practice physicians coming from their offices to see patients. There is no better time spent for physician and patient than the history and physical.

Al Caccavale, DO, FACOI

Chairman, Board of Trustees

Yavapai Regional Medical Center, Prescott, Ariz.

A70-year-old female was admitted for management of progressive cellulitis and evaluation of a lower leg laceration after she fell from a motorized scooter. She had initially failed outpatient management with cephalexin and was treated with vancomycin and piperacillin and tazobactam while hospitalized. Her cellulitis resolved, and plastic surgery helped repair the laceration with skin grafting from her right thigh.

Three days after the procedure, the woman’s electrolyte panel read plasma glucose 110 mg/dL, blood urea nitrogen 11 mg/dL, serum creatinine 0.8 mg/dL, sodium 138 mEq/L, potassium 5.7 mEq/L, chloride 101 mEq/L, bicarbonate 28 mEq/L, magnesium 2.1 mg/dl, and calcium 8.9 mg/dl.

She was taking:

• Citalopram 20 mg PO QD;
• HCTZ 25 mg PO QD;
• Docusate 100 mg PO twice daily;
• Oxycodone 5 mg PO Q6 hours PRN pain;
• Acetaminophen 500 mg PO Q6 hours scheduled;
• Heparin 5,000 units SQ q eight hours;
• Levothyroxine 25 mcg PO QAM;
• Intravenous fluid D5NS at 80 cc/hour; and
• Trazodone 50 mg PO PRN insomnia.

Her urinalysis showed:

• pH 6.8;
• Na 155 meq/L;
• K 20 meq/L; and
• Urine osmolality 447.

Which of the following is the most appropriate action for this patient?

a) Sodium polystyrene sulfonate 30 gm orally every 4 hours; four doses

b) Sodium polystyrene sulfonate enema 60 gm

c) Discontinue citalopram

d) Discontinue oxycodone

e) Discontinue heparin

Discussion

The answer is E: Discontinue heparin. This patient has hyperkalemia with low urinary excretion of potassium and no evidence of acidosis. Many medications can cause hyperkalemia, most notably angiotensin-converting enzyme inhibitors, K-sparing diuretics, NSAIDs, and beta-blockers.

When an obvious cause is not present, such as over-supplementation of potassium chloride via oral or intravenous route, a search for less obvious causes, such as renal tubular acidosis, is warranted. In this patient none of these causes is present.

Heparin has many potential side effects, both directly from anticoagulation, such as retroperitoneal hemorrhage, or immunologically, such as heparin-induced thrombocytopenia (HIT). In this case the patient has heparin-induced hypoaldosteronism causing secondary hyperkalemia. This can occur with all types of heparin, usually at doses greater then 5,000 units/day. This emphasizes the point that when an unexpected phenomenon is noted in a hospitalized patient, a search should always include medications’ side effects.

Subcutaneous heparin was discontinued, and the patient was placed on aspirin, TED hose stockings, and sequential compression devices for deep vein thrombosis (DVT) prophylaxis. A repeat electrolyte panel obtained afterward showed resolution of the patient’s hyperkalemia. TH

Dr. Newman and Herber practice at the Department of Medicine, Mayo Graduate School of Medical Education, Mayo Clinic, Rochester, Minn.

A70-year-old female was admitted for management of progressive cellulitis and evaluation of a lower leg laceration after she fell from a motorized scooter. She had initially failed outpatient management with cephalexin and was treated with vancomycin and piperacillin and tazobactam while hospitalized. Her cellulitis resolved, and plastic surgery helped repair the laceration with skin grafting from her right thigh.

Three days after the procedure, the woman’s electrolyte panel read plasma glucose 110 mg/dL, blood urea nitrogen 11 mg/dL, serum creatinine 0.8 mg/dL, sodium 138 mEq/L, potassium 5.7 mEq/L, chloride 101 mEq/L, bicarbonate 28 mEq/L, magnesium 2.1 mg/dl, and calcium 8.9 mg/dl.

She was taking:

• Citalopram 20 mg PO QD;
• HCTZ 25 mg PO QD;
• Docusate 100 mg PO twice daily;
• Oxycodone 5 mg PO Q6 hours PRN pain;
• Acetaminophen 500 mg PO Q6 hours scheduled;
• Heparin 5,000 units SQ q eight hours;
• Levothyroxine 25 mcg PO QAM;
• Intravenous fluid D5NS at 80 cc/hour; and
• Trazodone 50 mg PO PRN insomnia.

Her urinalysis showed:

• pH 6.8;
• Na 155 meq/L;
• K 20 meq/L; and
• Urine osmolality 447.

Which of the following is the most appropriate action for this patient?

a) Sodium polystyrene sulfonate 30 gm orally every 4 hours; four doses

b) Sodium polystyrene sulfonate enema 60 gm

c) Discontinue citalopram

d) Discontinue oxycodone

e) Discontinue heparin

Discussion

The answer is E: Discontinue heparin. This patient has hyperkalemia with low urinary excretion of potassium and no evidence of acidosis. Many medications can cause hyperkalemia, most notably angiotensin-converting enzyme inhibitors, K-sparing diuretics, NSAIDs, and beta-blockers.

When an obvious cause is not present, such as over-supplementation of potassium chloride via oral or intravenous route, a search for less obvious causes, such as renal tubular acidosis, is warranted. In this patient none of these causes is present.

Heparin has many potential side effects, both directly from anticoagulation, such as retroperitoneal hemorrhage, or immunologically, such as heparin-induced thrombocytopenia (HIT). In this case the patient has heparin-induced hypoaldosteronism causing secondary hyperkalemia. This can occur with all types of heparin, usually at doses greater then 5,000 units/day. This emphasizes the point that when an unexpected phenomenon is noted in a hospitalized patient, a search should always include medications’ side effects.

Subcutaneous heparin was discontinued, and the patient was placed on aspirin, TED hose stockings, and sequential compression devices for deep vein thrombosis (DVT) prophylaxis. A repeat electrolyte panel obtained afterward showed resolution of the patient’s hyperkalemia. TH

Dr. Newman and Herber practice at the Department of Medicine, Mayo Graduate School of Medical Education, Mayo Clinic, Rochester, Minn.

A70-year-old female was admitted for management of progressive cellulitis and evaluation of a lower leg laceration after she fell from a motorized scooter. She had initially failed outpatient management with cephalexin and was treated with vancomycin and piperacillin and tazobactam while hospitalized. Her cellulitis resolved, and plastic surgery helped repair the laceration with skin grafting from her right thigh.

Three days after the procedure, the woman’s electrolyte panel read plasma glucose 110 mg/dL, blood urea nitrogen 11 mg/dL, serum creatinine 0.8 mg/dL, sodium 138 mEq/L, potassium 5.7 mEq/L, chloride 101 mEq/L, bicarbonate 28 mEq/L, magnesium 2.1 mg/dl, and calcium 8.9 mg/dl.

She was taking:

• Citalopram 20 mg PO QD;
• HCTZ 25 mg PO QD;
• Docusate 100 mg PO twice daily;
• Oxycodone 5 mg PO Q6 hours PRN pain;
• Acetaminophen 500 mg PO Q6 hours scheduled;
• Heparin 5,000 units SQ q eight hours;
• Levothyroxine 25 mcg PO QAM;
• Intravenous fluid D5NS at 80 cc/hour; and
• Trazodone 50 mg PO PRN insomnia.

Her urinalysis showed:

• pH 6.8;
• Na 155 meq/L;
• K 20 meq/L; and
• Urine osmolality 447.

Which of the following is the most appropriate action for this patient?

a) Sodium polystyrene sulfonate 30 gm orally every 4 hours; four doses

b) Sodium polystyrene sulfonate enema 60 gm

c) Discontinue citalopram

d) Discontinue oxycodone

e) Discontinue heparin

Discussion

The answer is E: Discontinue heparin. This patient has hyperkalemia with low urinary excretion of potassium and no evidence of acidosis. Many medications can cause hyperkalemia, most notably angiotensin-converting enzyme inhibitors, K-sparing diuretics, NSAIDs, and beta-blockers.

When an obvious cause is not present, such as over-supplementation of potassium chloride via oral or intravenous route, a search for less obvious causes, such as renal tubular acidosis, is warranted. In this patient none of these causes is present.

Heparin has many potential side effects, both directly from anticoagulation, such as retroperitoneal hemorrhage, or immunologically, such as heparin-induced thrombocytopenia (HIT). In this case the patient has heparin-induced hypoaldosteronism causing secondary hyperkalemia. This can occur with all types of heparin, usually at doses greater then 5,000 units/day. This emphasizes the point that when an unexpected phenomenon is noted in a hospitalized patient, a search should always include medications’ side effects.

Subcutaneous heparin was discontinued, and the patient was placed on aspirin, TED hose stockings, and sequential compression devices for deep vein thrombosis (DVT) prophylaxis. A repeat electrolyte panel obtained afterward showed resolution of the patient’s hyperkalemia. TH

Dr. Newman and Herber practice at the Department of Medicine, Mayo Graduate School of Medical Education, Mayo Clinic, Rochester, Minn.

As I follow Mary Jo Gorman, MD, MBA, as president of SHM, it might be tempting for me to simply follow the leading rule of the “organizational” Hippocratic Oath and “First do no harm.”

Put another way, in the context of the success SHM has enjoyed for the past 10 years, there is a case to be made for standing out of the way of our society’s positive momentum. But I believe we can—and will—do better than that. None of us can afford to be spectators in this arena.

We often speak of teamwork in healthcare, but precious few of us intuitively know what this means—much less have any education in its principles. During my training, the idea of teamwork amounted to little more than relying on a medical assistant to obtain daily weights or counting on the pharmacist to calculate and follow the appropriate dosing schedule for gentamicin. Common sense led me to understand that building an amicable relationship with the nursing staff made my working life easier.

Slowly, the advantages of structuring a more organized team in the hospital setting became more evident and helped encourage me to find ways of exploiting this concept further. As I look back, it was Jeff Dichter, MD, past president of SHM and director of the hospitalist program at Ball Memorial Hospital in Muncie, Ind., who emerged as one of the true champions for teamwork as an optimal model for inpatient care. Jeff would talk about it to everyone who would listen, in every venue he could reach. He wrote about it in this very column. He charged our meeting planners and committee chairs with integrating teamwork principles into our educational content as well as our advocacy and membership development initiatives. His vision of a true team galvanized SHM’s commitment to supporting a broad constituency, extending well beyond hospitalist physicians. Jeff knew care is never delivered by an individual; it’s always a team. And he believed this framework to be fully realized by way of building from a strong organizational agenda for quality improvement.

Speaking of quality in healthcare, I look no further than Mark Williams, MD, editor of the Journal of Hospital Medicine, for having built that agenda for our society through his own efforts as well as collaboration with the Institute for Healthcare Improvement (IHI) and other national entities. As another past president of SHM, Mark brought a level of organizational focus and rigor around quality improvement and patient safety that rose to the challenges outlined in two Institute of Medicine reports, “To Err is Human” and “Crossing the Quality Chasm.” He helped move “quality” from something we talk about to something we do. He pushed it from an espoused value to a core commitment of our specialty. Quality improvement is now inseparable from what I consider to be the true promise of hospital medicine: that care organized in well-orchestrated, well-resourced teams can deliver our patients remarkable improvements in the quality, safety, and experience of healthcare.

But how do we get this done? How do we take a relatively abstract notion of a team, channel its activities to drive measurable improvements in quality, and change the arcane systems of inpatient care so as to sustain and hardwire those improvements?

Leadership. Like it or not, each of you is regarded as one of—if not the—most important leaders in the hospital. Nursing, case management, physical therapy, patients, and families look to you to provide leadership for clinical and operational systems. You are the person most able to make meaningful decisions at the front-line level that directly affect the patient experience. You are called upon to lead and manage change in a volatile environment, to resolve the inevitable conflicts that change provokes, and to reconcile hospital business drivers with quality and safety imperatives.

 

Our immediate past president, Dr. Gorman, emphasized the crucial role we serve as leaders. Recognizing the tremendous development needs for skills and knowledge to effectively lead, SHM has created Leadership Academies and is working on e-discussion forums and mentoring programs to promote longitudinal learning. While we must unlearn some of the behaviors and beliefs seared into our brains during our traditional medical training, we must position ourselves to forge high-performing teams and lead the quality agenda.

At a dinner during the SHM Annual Meeting in May, I sat with a senior leader from the American Medical Association’s Organized Medical Staff Section (AMA OMSS). He had flown in with other AMA representatives to meet with us on common interests. By the end of the evening, the late-career surgeon took me aside and said: “I have to tell you how touched I am by your organization. The passion, drive, and commitment of your membership is what’s missing in so many professional societies today. You must bring this passion to the larger house of medicine.”

As SHM enjoys 10 years of explosive growth and remarkable success, we need to balance the right to celebrate success with the duty not to rest on laurels. Much has been accomplished, but more than a life’s work lies before us. The road is complex and fraught with uncertainty. We might become frustrated with mounting complexity, tired with resistance to change, and fatigued with leading against the status quo. It is hard—and lonely—to confront the systems and issues that desperately need to be confronted on our journey to transform care. And it might be easy for us to become distracted from our core commitments to teamwork and leading quality by allowing our medical society to become more of a guild that defends our professional incomes and way of life. Yet I believe—I know—a much brighter future lies ahead than emerging as a casualty of temptation.

If the best predictor of behavior is past behavior, then our future will mirror the spirit in which SHM was founded. It’s the spirit an invited guest observed in a few short hours at our annual meeting. It’s the spirit that binds teamwork, quality improvement, and leadership into a unified approach to our professional endeavors. That spirit has a name: accountability. It’s the fundamental understanding that we are answerable to others, including patients, families, the community, hospital and medical staff, as well as each other, for the performance of the care systems in which we work.

Being accountable means we must rebuild trust of the broader public in hospital care, and that we follow through on the promise of hospital medicine. It means we own our mistakes, we agree that transparency and measurement will lead to better outcomes, and we commit to being part of the solution.

Accountability also mandates that we eliminate blame and “victimhood.” We cannot first think of ourselves as victims of a broken reimbursement model, or a lack of data or a hospital administration that “just doesn’t get it.” The real questions are: What can I do today about improving management of scarce resources? About the nursing shortage? About incorporating patient-safety principles into a new facility? About access to care and overcrowding? About the needless hospital deaths due to ventilator-assisted pneumonia (VAP), acute myocardial infarction, and methicillin-resistant Staphylococcus aureus? About ensuring seamless transitions of patients throughout the care continuum?

Several years ago I spoke with Brent James, MD, executive director of the Institute for Health Care Delivery Research and vice president of medical research and continuing medical education at InterMountain Healthcare in Salt Lake City, Utah. At the time, I was trying to learn quality improvement methods and practices. He reminded me of a quote Sir William Osler, the father of internal medicine, made at the end of his career when he gave an address at the Phipps Clinic in England to a group of young physicians who had recently completed training. They were about to embark on their careers early in the 20th century. “I am sorry for you young men of this generation,” he told the physicians. “Oh, you’ll do great things. You’ll have great victories, and standing on our shoulders you’ll see far. But you can never have our sensations. To have lived through a revolution, to have seen a new birth of science, new dispensation of health, redesigned medical training, remodeled hospitals, a new outlook for humanity. That is not given to every generation.”

 

While it seems appropriate in retrospect that these young physicians were indeed entering a time after which tremendous change and transformation had taken place, it seems equally appropriate to consider ourselves one of those generations that must lead and drive change of the magnitude of which Osler spoke. As we lead teams in the hospital to revolutionize the state of healthcare quality, we must begin every thought, every action, by holding ourselves and each other accountable for being part of the solution. To begin, we need look no further than ourselves. TH

Dr. Holman is president of SHM.

As I follow Mary Jo Gorman, MD, MBA, as president of SHM, it might be tempting for me to simply follow the leading rule of the “organizational” Hippocratic Oath and “First do no harm.”

Put another way, in the context of the success SHM has enjoyed for the past 10 years, there is a case to be made for standing out of the way of our society’s positive momentum. But I believe we can—and will—do better than that. None of us can afford to be spectators in this arena.

We often speak of teamwork in healthcare, but precious few of us intuitively know what this means—much less have any education in its principles. During my training, the idea of teamwork amounted to little more than relying on a medical assistant to obtain daily weights or counting on the pharmacist to calculate and follow the appropriate dosing schedule for gentamicin. Common sense led me to understand that building an amicable relationship with the nursing staff made my working life easier.

Slowly, the advantages of structuring a more organized team in the hospital setting became more evident and helped encourage me to find ways of exploiting this concept further. As I look back, it was Jeff Dichter, MD, past president of SHM and director of the hospitalist program at Ball Memorial Hospital in Muncie, Ind., who emerged as one of the true champions for teamwork as an optimal model for inpatient care. Jeff would talk about it to everyone who would listen, in every venue he could reach. He wrote about it in this very column. He charged our meeting planners and committee chairs with integrating teamwork principles into our educational content as well as our advocacy and membership development initiatives. His vision of a true team galvanized SHM’s commitment to supporting a broad constituency, extending well beyond hospitalist physicians. Jeff knew care is never delivered by an individual; it’s always a team. And he believed this framework to be fully realized by way of building from a strong organizational agenda for quality improvement.

Speaking of quality in healthcare, I look no further than Mark Williams, MD, editor of the Journal of Hospital Medicine, for having built that agenda for our society through his own efforts as well as collaboration with the Institute for Healthcare Improvement (IHI) and other national entities. As another past president of SHM, Mark brought a level of organizational focus and rigor around quality improvement and patient safety that rose to the challenges outlined in two Institute of Medicine reports, “To Err is Human” and “Crossing the Quality Chasm.” He helped move “quality” from something we talk about to something we do. He pushed it from an espoused value to a core commitment of our specialty. Quality improvement is now inseparable from what I consider to be the true promise of hospital medicine: that care organized in well-orchestrated, well-resourced teams can deliver our patients remarkable improvements in the quality, safety, and experience of healthcare.

But how do we get this done? How do we take a relatively abstract notion of a team, channel its activities to drive measurable improvements in quality, and change the arcane systems of inpatient care so as to sustain and hardwire those improvements?

Leadership. Like it or not, each of you is regarded as one of—if not the—most important leaders in the hospital. Nursing, case management, physical therapy, patients, and families look to you to provide leadership for clinical and operational systems. You are the person most able to make meaningful decisions at the front-line level that directly affect the patient experience. You are called upon to lead and manage change in a volatile environment, to resolve the inevitable conflicts that change provokes, and to reconcile hospital business drivers with quality and safety imperatives.

 

Our immediate past president, Dr. Gorman, emphasized the crucial role we serve as leaders. Recognizing the tremendous development needs for skills and knowledge to effectively lead, SHM has created Leadership Academies and is working on e-discussion forums and mentoring programs to promote longitudinal learning. While we must unlearn some of the behaviors and beliefs seared into our brains during our traditional medical training, we must position ourselves to forge high-performing teams and lead the quality agenda.

At a dinner during the SHM Annual Meeting in May, I sat with a senior leader from the American Medical Association’s Organized Medical Staff Section (AMA OMSS). He had flown in with other AMA representatives to meet with us on common interests. By the end of the evening, the late-career surgeon took me aside and said: “I have to tell you how touched I am by your organization. The passion, drive, and commitment of your membership is what’s missing in so many professional societies today. You must bring this passion to the larger house of medicine.”

As SHM enjoys 10 years of explosive growth and remarkable success, we need to balance the right to celebrate success with the duty not to rest on laurels. Much has been accomplished, but more than a life’s work lies before us. The road is complex and fraught with uncertainty. We might become frustrated with mounting complexity, tired with resistance to change, and fatigued with leading against the status quo. It is hard—and lonely—to confront the systems and issues that desperately need to be confronted on our journey to transform care. And it might be easy for us to become distracted from our core commitments to teamwork and leading quality by allowing our medical society to become more of a guild that defends our professional incomes and way of life. Yet I believe—I know—a much brighter future lies ahead than emerging as a casualty of temptation.

If the best predictor of behavior is past behavior, then our future will mirror the spirit in which SHM was founded. It’s the spirit an invited guest observed in a few short hours at our annual meeting. It’s the spirit that binds teamwork, quality improvement, and leadership into a unified approach to our professional endeavors. That spirit has a name: accountability. It’s the fundamental understanding that we are answerable to others, including patients, families, the community, hospital and medical staff, as well as each other, for the performance of the care systems in which we work.

Being accountable means we must rebuild trust of the broader public in hospital care, and that we follow through on the promise of hospital medicine. It means we own our mistakes, we agree that transparency and measurement will lead to better outcomes, and we commit to being part of the solution.

Accountability also mandates that we eliminate blame and “victimhood.” We cannot first think of ourselves as victims of a broken reimbursement model, or a lack of data or a hospital administration that “just doesn’t get it.” The real questions are: What can I do today about improving management of scarce resources? About the nursing shortage? About incorporating patient-safety principles into a new facility? About access to care and overcrowding? About the needless hospital deaths due to ventilator-assisted pneumonia (VAP), acute myocardial infarction, and methicillin-resistant Staphylococcus aureus? About ensuring seamless transitions of patients throughout the care continuum?

Several years ago I spoke with Brent James, MD, executive director of the Institute for Health Care Delivery Research and vice president of medical research and continuing medical education at InterMountain Healthcare in Salt Lake City, Utah. At the time, I was trying to learn quality improvement methods and practices. He reminded me of a quote Sir William Osler, the father of internal medicine, made at the end of his career when he gave an address at the Phipps Clinic in England to a group of young physicians who had recently completed training. They were about to embark on their careers early in the 20th century. “I am sorry for you young men of this generation,” he told the physicians. “Oh, you’ll do great things. You’ll have great victories, and standing on our shoulders you’ll see far. But you can never have our sensations. To have lived through a revolution, to have seen a new birth of science, new dispensation of health, redesigned medical training, remodeled hospitals, a new outlook for humanity. That is not given to every generation.”

 

While it seems appropriate in retrospect that these young physicians were indeed entering a time after which tremendous change and transformation had taken place, it seems equally appropriate to consider ourselves one of those generations that must lead and drive change of the magnitude of which Osler spoke. As we lead teams in the hospital to revolutionize the state of healthcare quality, we must begin every thought, every action, by holding ourselves and each other accountable for being part of the solution. To begin, we need look no further than ourselves. TH

Dr. Holman is president of SHM.

As I follow Mary Jo Gorman, MD, MBA, as president of SHM, it might be tempting for me to simply follow the leading rule of the “organizational” Hippocratic Oath and “First do no harm.”

Put another way, in the context of the success SHM has enjoyed for the past 10 years, there is a case to be made for standing out of the way of our society’s positive momentum. But I believe we can—and will—do better than that. None of us can afford to be spectators in this arena.

We often speak of teamwork in healthcare, but precious few of us intuitively know what this means—much less have any education in its principles. During my training, the idea of teamwork amounted to little more than relying on a medical assistant to obtain daily weights or counting on the pharmacist to calculate and follow the appropriate dosing schedule for gentamicin. Common sense led me to understand that building an amicable relationship with the nursing staff made my working life easier.

Slowly, the advantages of structuring a more organized team in the hospital setting became more evident and helped encourage me to find ways of exploiting this concept further. As I look back, it was Jeff Dichter, MD, past president of SHM and director of the hospitalist program at Ball Memorial Hospital in Muncie, Ind., who emerged as one of the true champions for teamwork as an optimal model for inpatient care. Jeff would talk about it to everyone who would listen, in every venue he could reach. He wrote about it in this very column. He charged our meeting planners and committee chairs with integrating teamwork principles into our educational content as well as our advocacy and membership development initiatives. His vision of a true team galvanized SHM’s commitment to supporting a broad constituency, extending well beyond hospitalist physicians. Jeff knew care is never delivered by an individual; it’s always a team. And he believed this framework to be fully realized by way of building from a strong organizational agenda for quality improvement.

Speaking of quality in healthcare, I look no further than Mark Williams, MD, editor of the Journal of Hospital Medicine, for having built that agenda for our society through his own efforts as well as collaboration with the Institute for Healthcare Improvement (IHI) and other national entities. As another past president of SHM, Mark brought a level of organizational focus and rigor around quality improvement and patient safety that rose to the challenges outlined in two Institute of Medicine reports, “To Err is Human” and “Crossing the Quality Chasm.” He helped move “quality” from something we talk about to something we do. He pushed it from an espoused value to a core commitment of our specialty. Quality improvement is now inseparable from what I consider to be the true promise of hospital medicine: that care organized in well-orchestrated, well-resourced teams can deliver our patients remarkable improvements in the quality, safety, and experience of healthcare.

But how do we get this done? How do we take a relatively abstract notion of a team, channel its activities to drive measurable improvements in quality, and change the arcane systems of inpatient care so as to sustain and hardwire those improvements?

Leadership. Like it or not, each of you is regarded as one of—if not the—most important leaders in the hospital. Nursing, case management, physical therapy, patients, and families look to you to provide leadership for clinical and operational systems. You are the person most able to make meaningful decisions at the front-line level that directly affect the patient experience. You are called upon to lead and manage change in a volatile environment, to resolve the inevitable conflicts that change provokes, and to reconcile hospital business drivers with quality and safety imperatives.

 

Our immediate past president, Dr. Gorman, emphasized the crucial role we serve as leaders. Recognizing the tremendous development needs for skills and knowledge to effectively lead, SHM has created Leadership Academies and is working on e-discussion forums and mentoring programs to promote longitudinal learning. While we must unlearn some of the behaviors and beliefs seared into our brains during our traditional medical training, we must position ourselves to forge high-performing teams and lead the quality agenda.

At a dinner during the SHM Annual Meeting in May, I sat with a senior leader from the American Medical Association’s Organized Medical Staff Section (AMA OMSS). He had flown in with other AMA representatives to meet with us on common interests. By the end of the evening, the late-career surgeon took me aside and said: “I have to tell you how touched I am by your organization. The passion, drive, and commitment of your membership is what’s missing in so many professional societies today. You must bring this passion to the larger house of medicine.”

As SHM enjoys 10 years of explosive growth and remarkable success, we need to balance the right to celebrate success with the duty not to rest on laurels. Much has been accomplished, but more than a life’s work lies before us. The road is complex and fraught with uncertainty. We might become frustrated with mounting complexity, tired with resistance to change, and fatigued with leading against the status quo. It is hard—and lonely—to confront the systems and issues that desperately need to be confronted on our journey to transform care. And it might be easy for us to become distracted from our core commitments to teamwork and leading quality by allowing our medical society to become more of a guild that defends our professional incomes and way of life. Yet I believe—I know—a much brighter future lies ahead than emerging as a casualty of temptation.

If the best predictor of behavior is past behavior, then our future will mirror the spirit in which SHM was founded. It’s the spirit an invited guest observed in a few short hours at our annual meeting. It’s the spirit that binds teamwork, quality improvement, and leadership into a unified approach to our professional endeavors. That spirit has a name: accountability. It’s the fundamental understanding that we are answerable to others, including patients, families, the community, hospital and medical staff, as well as each other, for the performance of the care systems in which we work.

Being accountable means we must rebuild trust of the broader public in hospital care, and that we follow through on the promise of hospital medicine. It means we own our mistakes, we agree that transparency and measurement will lead to better outcomes, and we commit to being part of the solution.

Accountability also mandates that we eliminate blame and “victimhood.” We cannot first think of ourselves as victims of a broken reimbursement model, or a lack of data or a hospital administration that “just doesn’t get it.” The real questions are: What can I do today about improving management of scarce resources? About the nursing shortage? About incorporating patient-safety principles into a new facility? About access to care and overcrowding? About the needless hospital deaths due to ventilator-assisted pneumonia (VAP), acute myocardial infarction, and methicillin-resistant Staphylococcus aureus? About ensuring seamless transitions of patients throughout the care continuum?

Several years ago I spoke with Brent James, MD, executive director of the Institute for Health Care Delivery Research and vice president of medical research and continuing medical education at InterMountain Healthcare in Salt Lake City, Utah. At the time, I was trying to learn quality improvement methods and practices. He reminded me of a quote Sir William Osler, the father of internal medicine, made at the end of his career when he gave an address at the Phipps Clinic in England to a group of young physicians who had recently completed training. They were about to embark on their careers early in the 20th century. “I am sorry for you young men of this generation,” he told the physicians. “Oh, you’ll do great things. You’ll have great victories, and standing on our shoulders you’ll see far. But you can never have our sensations. To have lived through a revolution, to have seen a new birth of science, new dispensation of health, redesigned medical training, remodeled hospitals, a new outlook for humanity. That is not given to every generation.”

 

While it seems appropriate in retrospect that these young physicians were indeed entering a time after which tremendous change and transformation had taken place, it seems equally appropriate to consider ourselves one of those generations that must lead and drive change of the magnitude of which Osler spoke. As we lead teams in the hospital to revolutionize the state of healthcare quality, we must begin every thought, every action, by holding ourselves and each other accountable for being part of the solution. To begin, we need look no further than ourselves. TH

Dr. Holman is president of SHM.

Emergency care in the U.S. has been called a system in crisis, and the data are startling. From 1994 to 2004, the number of hospitals and emergency departments (EDs) decreased, the latter by 9%, but the number of ED visits increased by more than 1 million annually.1 (See Figure 1, p. 17)

According to the Centers for Disease Control and Prevention’s (CDC) National Center for Health Statistics, between 40% and 50% of U.S. hospitals experience crowded conditions in the ED, with almost two-thirds of metropolitan EDs experiencing crowding at times.2

Source: Kellermann AL. Crisis in the emergency department. N Engl J Med. 2006 Sep 28;355(13):1300-1303.

Hospitalists and emergency medicine physicians asked about their complex relationship—the good, the bad, and the not yet solved—praised their ability to work together.

“In general, our relationship with hospitalists has been fantastic,” says James Hoekstra, MD, president of the Society of Academic Emergency Medicine. “To have physicians who are willing to take patients with a lot of different disease states that are not necessarily procedure oriented, don’t necessarily fit into a specific specialty, or are somewhat undifferentiated in their presentation—for us that is an absolute joy.”

The number of hospitalists and emergency medicine physicians might be said to be running in parallel, says Alpesh Amin, MD, MBA, FACP, executive director of the hospitalist program and vice chair for clinical affairs and quality in the department of medicine at the University of California, Irvine. He tends to refer to this ratio as 30-30, meaning that, within a few years, there will be roughly 30,000 hospitalists, while there are currently that many emergency medicine physicians.3 In addition, emergency medicine and hospital medicine are site-based specialties, says Dr. Amin, so bridging their separateness is crucial to patient care.

Source: McCaig LF, Burt CW. National Hospital Ambulatory Medical Care Survey: 2003 Outpatient Department Summary. National Center for Health Statistics, Hyattsville, Md;2005;358.

“Aside from a small proportion of direct [patient] admissions,” says Jasen W. Gundersen, MD, chief of hospital medicine at the U. Mass. Medical Center in Worcester, “we are an extension of the ER, and the ER is an extension of us. We need to all be on the same page so that what’s said in the ER matches what happens on the floor, which matches what we send out to the primary [care physician].”

Optimizing patient flow is primarily a function of communication, says Marc Newquist, MD, FACEP, a hospitalist, an emergency medicine physician, and program director of the hospitalist division of The Schumacher Group in Lafayette, La. “The better that these communication systems can be standardized, the better hospitalists and their emergency medicine colleagues can promote a seamless integration between the two specialties as patients journey through their hospital stays,” he says.

“As medicine becomes more fragmented and hospital medicine does, let’s face it, fragment care,” adds Dr. Gundersen. “We also have to make sure that information flows from the primary-care physician who may send the patient to the ER. Everybody is a partner, and everybody needs to communicate back and forth and understand that if the ER wants to get someone admitted, timely communication with the hospitalist and understanding how the flow of the hospital works is really important.”

Source: Burt CW, McCaig LF. Staffing, capacity, and ambulance diversion in emergency departments: United States, 2003-04. Adv Data. 2006 Sep 27;(376):1-23.

 

Interactions and Roles

“Far and away the most common type of interaction between hospitalists and ED docs is admissions,” says David M. Pressel, MD, PhD, director, Inpatient Service, General Pediatrics at Alfred I. duPont Hospital for Children in Wilmington, Del. The next most common interaction will depend upon the institution and its style, but, primarily, interactions include consults, and—in some institutions—patient discharge.

Dr. Pressel works at a tertiary-care referral center where residents staff the ED and his unit. “But at a community hospital where you generally have ED medicine-trained docs—not pediatricians who have ED

medicine fellowships—they have less experience with pediatrics, so they may be more likely to consult us on a patient,” he says. The development of care pathways to facilitate care is another important interaction between emergency medicine physicians and hospitalists.

An example of a protocol development the hospitalist and the ED should do together, says Dr. Pressel, is when patients come in with certain symptoms that would indicate a possible communicable disease for which the patient might need special isolation on an inpatient unit. That issue may more likely be foremost in hospitalist’s mind, and he or she can perform an evaluation early to determine what isolation may be needed. If the hospitalist suspects a patient has varicella or active pulmonary tuberculosis, for instance, “those kinds of [isolation] rooms are limited,” says Dr. Pressel. “Hospitals don’t have a lot of them, so you have to make sure you’re getting beds assigned well.”

Our interviews say the major roles of the hospitalist in managing relationships with emergency medicine physicians involve professionalism. “The hospitalist needs to understand the needs of the ER physician in terms of the needs of the [overall] ER: timing, flow, and getting patients seen in a prompt manner,” says Dr. Gundersen. “There’s a give and take, and both sides need to understand the other side of the job to maximize that collegiality and to maximize that sense of teamwork.”

Dr. Gundersen, who works full time as a hospitalist and moonlights as an ED physician, says that “what at times the ED doesn’t realize is that the time it takes for them to do something in the ED is not the same as it takes for us to do something on the floor. If they order a CT scan in the ED, it happens right away. If they say, ‘You can just get the CT scan on the floor,’ well, we don’t have as much priority in terms of getting lab draws and diagnostic tests done as fast as they do.”

Stepping on toes is always a danger.

“One of the key things for the relationship is to realize that you’re not walking in the other person’s shoes,” says Dr. Pressel. “I’ve witnessed [situations] where a hospitalist on the receiving end scoffs at the management in the ED—either because, number one, the patient was perceived to be not sick enough to merit hospitalization according to the hospitalist, or, number two, because of over-workup and overdiagnosis or under-workup and under- or misdiagnosis.”

Both groups need to realize that the patient’s condition evolves over time. “What the ED saw three hours ago may not be what’s being seen now, and that’s true in the reverse,” he says. “If the patient looked great three hours ago, now [their condition may be life-threatening].”

 

Therefore, feedback between ED doctors and hospitalists should be provided in a “respectful, collegial, follow-up type of manner,” says Dr. Pressel. A beneficial means of communication involves feedback that is “telling it as an evolving story,” he says, as opposed to assuming the ED doctor is wrong. That is, “collaborating and adding to the story and the end diagnosis and recognizing that the ED doc’s job is not necessarily to make the final diagnosis.”

Dr. Pressel thinks it comes down to politeness, plain and simple. “I hope that when I miss something, someone will be kind enough to [be polite] to me, [to phrase it as] ‘I’m sure you were thinking of this but the clues looked this way and we went on to do further evaluation.’ ”

That kind of interaction happens all the time, he says. “And ultimately it’s best for the patient, number one, because everybody learns that way, and, number two, if you make yourself obnoxious with your colleagues, they’re not necessarily going to want to call you.”

The Nature of the Beast

Most interactions with their ED colleagues go smoothly, our hospitalists say, but sometimes there are bumps in the road—most often involving flow and the transfer of care.

Jason R. Orlinick, MD, PhD, chief, Section of Hospital Medicine at Norwalk Hospital, Conn., and clinical instructor of medicine at Yale University (New Haven, Conn.), probably represents the bulk of his hospitalist colleagues when he says he and the emergency medicine physicians with whom he works have a cordial relationship overall. But “there is always some level of tension between the hospitalists and the emergency department—at least at the institutions I’ve been at. To some extent, it depends on the mentality of the ED docs where you’re working.”

Debra L. Burgy, MD, a hospitalist at Abbott Northwestern Hospital in Minneapolis, puts it this way: “The interface between hospitalists and the ED is sometimes tense because the ED physicians are regularly bombarded with patients, which is completely unpredictable, and they do not have adequate support staff, such as social workers and psychiatric assessment workers, to create a safe disposition for patients who could otherwise go home.

“The path of least resistance, and the least time-consuming route, is to admit patients. The chain reaction continues with the hospitalist service being overwhelmed.”

It is common for the ED to get a large volume of patients in the afternoon, our hospitalists remark. (See Figure 2, left) “We sometimes get hit with this huge bolus of patients,” Dr. Gundersen says. The biggest challenges involve “promptly identifying those patients who are identified for admission and maintaining a more open communication because when we get three, four, five admissions at once, we have difficulty working down that backlog.”

In the medical residency program at Dr. Orlinick’s institution, the bolus phenomenon can overwhelm residents’ and attendings’ capacities to see patients in a timely manner. “Unfortunately, we’ve not had a lot of success with that,” he says, and recently, his institution approached the hospitalists to work on a solution.

The timing of handoffs represents a large part of the breakdown in patient flow. “This is because of the ED physician who works until 4 p.m. or 6 p.m. and then tries to get all their patients whom they’re not sending home admitted right away before [the hospitalists] go off service,” Dr. Gundersen says. “It’s not uncommon that I get called or paged every three minutes—if I don’t answer right away—because they are trying to get someone admitted seconds after they call. The ER needs the beds, we haven’t been able to discharge the patients, everything gets bottlenecked.”

 

Although Dr. Gundersen recognizes that this problem is unavoidable at times, he suggests it would help “if the ED physicians were cognizant that there may be just one or two hospitalists who are admitting for the day, and giving them five admissions all at once, for instance, is going to take time to get through.”

On the other side, “Hospitalists rely on ED physicians to have the patient worked up and know which service they belong to,” explains Dr. Gundersen. “Succinct transfer of care is [paramount] so that critical information is brought to the attention of the accepting physician.” For the most part, he says, his ED colleagues do a good job.

Because the ED is always in a rush to get patients admitted and a disposition made, “there is the tendency to hamstring what’s happening on the floor. I think that big downstream effect from everything that begins in the ER transitions through the patient’s whole length of stay in the hospital,” says Dr. Gundersen.

All the interviewed hospitalists realize that the hospitalists and ED physicians need to have an understanding of what the other group faces. “We have to be understanding of the ER position that there are a lot of patients to be seen, and they’re trying to do the best they can in that period of time,” says Dr. Gundersen. A 2006 study revealed that interruptions within the ED were prevalent and diverse in nature and—on average—there was an interruption every nine and 14 minutes, respectively, for the attending emergency medicine physicians and residents.5

“And ED physicians have to realize that whatever patient they give to us, we then deal with,” says Dr. Gundersen, “and we [continue] to deal with all the issues, moving them through tests and studies [and] getting them discharged, so sometimes there are delays on both ends. It’s just the nature of the beast.”

A Sense of Control

The benefits of maintaining collegiality with ED physicians go beyond the norm, says Jeff Glasheen, MD, director of both the hospital medicine program and inpatient clinical services in the department of medicine at the University of Colorado at Denver Health Sciences Center. Dr. Glasheen has conducted some research on burnout—mostly in residents.6-7

“One of the main things that leads to burnout is lack of control and feeling like you don’t have control over your daily job,” he says. “One of the things that comes out of this relationship with the ER is that it’s no longer like someone’s just dumping on us. They’re very reasonable when we say, ‘That sounds like somebody who could go home; let me come down and see the patient, and let’s see if we can get this patient discharged.’ You begin to feel like you have control over your day, control over the patients who are admitted to you, and—quite honestly—it’s more fun. That kind of professional interaction is hard to put a price on, but I think it’s priceless.”TH

Andrea Sattinger is a frequent contributor to The Hospitalist.

References

1. Kellermann AL. Crisis in the emergency department. N Engl J Med. 2006 Sep 28;355(13):1300-1303.
2. Burt CW, McCaig LF. Staffing, capacity, and ambulance diversion in emergency departments: United States, 2003-04. Adv Data. 2006 Sep 27;(376):1-23. Available at www.cdc.gov/nchs/data/ad/ad376.pdf. Last accessed April 10, 2007.
3. Freed DH. Hospitalists: evolution, evidence, and eventualities. Health Care Manag. 2004 Jul-Sep;23(3):238-256;1-38.
4. McCaig LF, Burt CW. National Hospital Ambulatory Medical Care Survey: 2003 emergency department summary. Adv Data. 2005;(358):1-38. Available at www.cdc.gov/nchs/data/ad/ad358.pdf. Last accessed April 10, 2007.
5. Laxmisan A, Hakimzada F, Sayan OR, et al. The multitasking clinician: decision-making and cognitive demand during and after team handoffs in emergency care. Int J Med Inform. 2006 Oct 21. [Epub ahead of print.]
6. Gopal RK, Carreira F, Baker WA, et al. Internal medicine residents reject “longer and gentler” training. J Gen Intern Med. 2007 Jan;22(1):102-106.
7. Gopal R, Glasheen JJ, Miyoshi TJ, et al. Burnout and internal medicine resident work-hour restrictions. Arch Intern Med. 2005 Dec 12-26;165(22):2595-2600. Comment in Arch Intern Med. 2005 Dec 12-26; 165(22):2561-2562. Arch Intern Med. 2006 Jul 10;166(13):1423; author reply 1423-1425.

 

Emergency care in the U.S. has been called a system in crisis, and the data are startling. From 1994 to 2004, the number of hospitals and emergency departments (EDs) decreased, the latter by 9%, but the number of ED visits increased by more than 1 million annually.1 (See Figure 1, p. 17)

According to the Centers for Disease Control and Prevention’s (CDC) National Center for Health Statistics, between 40% and 50% of U.S. hospitals experience crowded conditions in the ED, with almost two-thirds of metropolitan EDs experiencing crowding at times.2

Source: Kellermann AL. Crisis in the emergency department. N Engl J Med. 2006 Sep 28;355(13):1300-1303.

Hospitalists and emergency medicine physicians asked about their complex relationship—the good, the bad, and the not yet solved—praised their ability to work together.

“In general, our relationship with hospitalists has been fantastic,” says James Hoekstra, MD, president of the Society of Academic Emergency Medicine. “To have physicians who are willing to take patients with a lot of different disease states that are not necessarily procedure oriented, don’t necessarily fit into a specific specialty, or are somewhat undifferentiated in their presentation—for us that is an absolute joy.”

The number of hospitalists and emergency medicine physicians might be said to be running in parallel, says Alpesh Amin, MD, MBA, FACP, executive director of the hospitalist program and vice chair for clinical affairs and quality in the department of medicine at the University of California, Irvine. He tends to refer to this ratio as 30-30, meaning that, within a few years, there will be roughly 30,000 hospitalists, while there are currently that many emergency medicine physicians.3 In addition, emergency medicine and hospital medicine are site-based specialties, says Dr. Amin, so bridging their separateness is crucial to patient care.

Source: McCaig LF, Burt CW. National Hospital Ambulatory Medical Care Survey: 2003 Outpatient Department Summary. National Center for Health Statistics, Hyattsville, Md;2005;358.

“Aside from a small proportion of direct [patient] admissions,” says Jasen W. Gundersen, MD, chief of hospital medicine at the U. Mass. Medical Center in Worcester, “we are an extension of the ER, and the ER is an extension of us. We need to all be on the same page so that what’s said in the ER matches what happens on the floor, which matches what we send out to the primary [care physician].”

Optimizing patient flow is primarily a function of communication, says Marc Newquist, MD, FACEP, a hospitalist, an emergency medicine physician, and program director of the hospitalist division of The Schumacher Group in Lafayette, La. “The better that these communication systems can be standardized, the better hospitalists and their emergency medicine colleagues can promote a seamless integration between the two specialties as patients journey through their hospital stays,” he says.

“As medicine becomes more fragmented and hospital medicine does, let’s face it, fragment care,” adds Dr. Gundersen. “We also have to make sure that information flows from the primary-care physician who may send the patient to the ER. Everybody is a partner, and everybody needs to communicate back and forth and understand that if the ER wants to get someone admitted, timely communication with the hospitalist and understanding how the flow of the hospital works is really important.”

Source: Burt CW, McCaig LF. Staffing, capacity, and ambulance diversion in emergency departments: United States, 2003-04. Adv Data. 2006 Sep 27;(376):1-23.

 

Interactions and Roles

“Far and away the most common type of interaction between hospitalists and ED docs is admissions,” says David M. Pressel, MD, PhD, director, Inpatient Service, General Pediatrics at Alfred I. duPont Hospital for Children in Wilmington, Del. The next most common interaction will depend upon the institution and its style, but, primarily, interactions include consults, and—in some institutions—patient discharge.

Dr. Pressel works at a tertiary-care referral center where residents staff the ED and his unit. “But at a community hospital where you generally have ED medicine-trained docs—not pediatricians who have ED

medicine fellowships—they have less experience with pediatrics, so they may be more likely to consult us on a patient,” he says. The development of care pathways to facilitate care is another important interaction between emergency medicine physicians and hospitalists.

An example of a protocol development the hospitalist and the ED should do together, says Dr. Pressel, is when patients come in with certain symptoms that would indicate a possible communicable disease for which the patient might need special isolation on an inpatient unit. That issue may more likely be foremost in hospitalist’s mind, and he or she can perform an evaluation early to determine what isolation may be needed. If the hospitalist suspects a patient has varicella or active pulmonary tuberculosis, for instance, “those kinds of [isolation] rooms are limited,” says Dr. Pressel. “Hospitals don’t have a lot of them, so you have to make sure you’re getting beds assigned well.”

Our interviews say the major roles of the hospitalist in managing relationships with emergency medicine physicians involve professionalism. “The hospitalist needs to understand the needs of the ER physician in terms of the needs of the [overall] ER: timing, flow, and getting patients seen in a prompt manner,” says Dr. Gundersen. “There’s a give and take, and both sides need to understand the other side of the job to maximize that collegiality and to maximize that sense of teamwork.”

Dr. Gundersen, who works full time as a hospitalist and moonlights as an ED physician, says that “what at times the ED doesn’t realize is that the time it takes for them to do something in the ED is not the same as it takes for us to do something on the floor. If they order a CT scan in the ED, it happens right away. If they say, ‘You can just get the CT scan on the floor,’ well, we don’t have as much priority in terms of getting lab draws and diagnostic tests done as fast as they do.”

Stepping on toes is always a danger.

“One of the key things for the relationship is to realize that you’re not walking in the other person’s shoes,” says Dr. Pressel. “I’ve witnessed [situations] where a hospitalist on the receiving end scoffs at the management in the ED—either because, number one, the patient was perceived to be not sick enough to merit hospitalization according to the hospitalist, or, number two, because of over-workup and overdiagnosis or under-workup and under- or misdiagnosis.”

Both groups need to realize that the patient’s condition evolves over time. “What the ED saw three hours ago may not be what’s being seen now, and that’s true in the reverse,” he says. “If the patient looked great three hours ago, now [their condition may be life-threatening].”

 

Therefore, feedback between ED doctors and hospitalists should be provided in a “respectful, collegial, follow-up type of manner,” says Dr. Pressel. A beneficial means of communication involves feedback that is “telling it as an evolving story,” he says, as opposed to assuming the ED doctor is wrong. That is, “collaborating and adding to the story and the end diagnosis and recognizing that the ED doc’s job is not necessarily to make the final diagnosis.”

Dr. Pressel thinks it comes down to politeness, plain and simple. “I hope that when I miss something, someone will be kind enough to [be polite] to me, [to phrase it as] ‘I’m sure you were thinking of this but the clues looked this way and we went on to do further evaluation.’ ”

That kind of interaction happens all the time, he says. “And ultimately it’s best for the patient, number one, because everybody learns that way, and, number two, if you make yourself obnoxious with your colleagues, they’re not necessarily going to want to call you.”

The Nature of the Beast

Most interactions with their ED colleagues go smoothly, our hospitalists say, but sometimes there are bumps in the road—most often involving flow and the transfer of care.

Jason R. Orlinick, MD, PhD, chief, Section of Hospital Medicine at Norwalk Hospital, Conn., and clinical instructor of medicine at Yale University (New Haven, Conn.), probably represents the bulk of his hospitalist colleagues when he says he and the emergency medicine physicians with whom he works have a cordial relationship overall. But “there is always some level of tension between the hospitalists and the emergency department—at least at the institutions I’ve been at. To some extent, it depends on the mentality of the ED docs where you’re working.”

Debra L. Burgy, MD, a hospitalist at Abbott Northwestern Hospital in Minneapolis, puts it this way: “The interface between hospitalists and the ED is sometimes tense because the ED physicians are regularly bombarded with patients, which is completely unpredictable, and they do not have adequate support staff, such as social workers and psychiatric assessment workers, to create a safe disposition for patients who could otherwise go home.

“The path of least resistance, and the least time-consuming route, is to admit patients. The chain reaction continues with the hospitalist service being overwhelmed.”

It is common for the ED to get a large volume of patients in the afternoon, our hospitalists remark. (See Figure 2, left) “We sometimes get hit with this huge bolus of patients,” Dr. Gundersen says. The biggest challenges involve “promptly identifying those patients who are identified for admission and maintaining a more open communication because when we get three, four, five admissions at once, we have difficulty working down that backlog.”

In the medical residency program at Dr. Orlinick’s institution, the bolus phenomenon can overwhelm residents’ and attendings’ capacities to see patients in a timely manner. “Unfortunately, we’ve not had a lot of success with that,” he says, and recently, his institution approached the hospitalists to work on a solution.

The timing of handoffs represents a large part of the breakdown in patient flow. “This is because of the ED physician who works until 4 p.m. or 6 p.m. and then tries to get all their patients whom they’re not sending home admitted right away before [the hospitalists] go off service,” Dr. Gundersen says. “It’s not uncommon that I get called or paged every three minutes—if I don’t answer right away—because they are trying to get someone admitted seconds after they call. The ER needs the beds, we haven’t been able to discharge the patients, everything gets bottlenecked.”

 

Although Dr. Gundersen recognizes that this problem is unavoidable at times, he suggests it would help “if the ED physicians were cognizant that there may be just one or two hospitalists who are admitting for the day, and giving them five admissions all at once, for instance, is going to take time to get through.”

On the other side, “Hospitalists rely on ED physicians to have the patient worked up and know which service they belong to,” explains Dr. Gundersen. “Succinct transfer of care is [paramount] so that critical information is brought to the attention of the accepting physician.” For the most part, he says, his ED colleagues do a good job.

Because the ED is always in a rush to get patients admitted and a disposition made, “there is the tendency to hamstring what’s happening on the floor. I think that big downstream effect from everything that begins in the ER transitions through the patient’s whole length of stay in the hospital,” says Dr. Gundersen.

All the interviewed hospitalists realize that the hospitalists and ED physicians need to have an understanding of what the other group faces. “We have to be understanding of the ER position that there are a lot of patients to be seen, and they’re trying to do the best they can in that period of time,” says Dr. Gundersen. A 2006 study revealed that interruptions within the ED were prevalent and diverse in nature and—on average—there was an interruption every nine and 14 minutes, respectively, for the attending emergency medicine physicians and residents.5

“And ED physicians have to realize that whatever patient they give to us, we then deal with,” says Dr. Gundersen, “and we [continue] to deal with all the issues, moving them through tests and studies [and] getting them discharged, so sometimes there are delays on both ends. It’s just the nature of the beast.”

A Sense of Control

The benefits of maintaining collegiality with ED physicians go beyond the norm, says Jeff Glasheen, MD, director of both the hospital medicine program and inpatient clinical services in the department of medicine at the University of Colorado at Denver Health Sciences Center. Dr. Glasheen has conducted some research on burnout—mostly in residents.6-7

“One of the main things that leads to burnout is lack of control and feeling like you don’t have control over your daily job,” he says. “One of the things that comes out of this relationship with the ER is that it’s no longer like someone’s just dumping on us. They’re very reasonable when we say, ‘That sounds like somebody who could go home; let me come down and see the patient, and let’s see if we can get this patient discharged.’ You begin to feel like you have control over your day, control over the patients who are admitted to you, and—quite honestly—it’s more fun. That kind of professional interaction is hard to put a price on, but I think it’s priceless.”TH

Andrea Sattinger is a frequent contributor to The Hospitalist.

References

1. Kellermann AL. Crisis in the emergency department. N Engl J Med. 2006 Sep 28;355(13):1300-1303.
2. Burt CW, McCaig LF. Staffing, capacity, and ambulance diversion in emergency departments: United States, 2003-04. Adv Data. 2006 Sep 27;(376):1-23. Available at www.cdc.gov/nchs/data/ad/ad376.pdf. Last accessed April 10, 2007.
3. Freed DH. Hospitalists: evolution, evidence, and eventualities. Health Care Manag. 2004 Jul-Sep;23(3):238-256;1-38.
4. McCaig LF, Burt CW. National Hospital Ambulatory Medical Care Survey: 2003 emergency department summary. Adv Data. 2005;(358):1-38. Available at www.cdc.gov/nchs/data/ad/ad358.pdf. Last accessed April 10, 2007.
5. Laxmisan A, Hakimzada F, Sayan OR, et al. The multitasking clinician: decision-making and cognitive demand during and after team handoffs in emergency care. Int J Med Inform. 2006 Oct 21. [Epub ahead of print.]
6. Gopal RK, Carreira F, Baker WA, et al. Internal medicine residents reject “longer and gentler” training. J Gen Intern Med. 2007 Jan;22(1):102-106.
7. Gopal R, Glasheen JJ, Miyoshi TJ, et al. Burnout and internal medicine resident work-hour restrictions. Arch Intern Med. 2005 Dec 12-26;165(22):2595-2600. Comment in Arch Intern Med. 2005 Dec 12-26; 165(22):2561-2562. Arch Intern Med. 2006 Jul 10;166(13):1423; author reply 1423-1425.

 

Emergency care in the U.S. has been called a system in crisis, and the data are startling. From 1994 to 2004, the number of hospitals and emergency departments (EDs) decreased, the latter by 9%, but the number of ED visits increased by more than 1 million annually.1 (See Figure 1, p. 17)

According to the Centers for Disease Control and Prevention’s (CDC) National Center for Health Statistics, between 40% and 50% of U.S. hospitals experience crowded conditions in the ED, with almost two-thirds of metropolitan EDs experiencing crowding at times.2

Source: Kellermann AL. Crisis in the emergency department. N Engl J Med. 2006 Sep 28;355(13):1300-1303.

Hospitalists and emergency medicine physicians asked about their complex relationship—the good, the bad, and the not yet solved—praised their ability to work together.

“In general, our relationship with hospitalists has been fantastic,” says James Hoekstra, MD, president of the Society of Academic Emergency Medicine. “To have physicians who are willing to take patients with a lot of different disease states that are not necessarily procedure oriented, don’t necessarily fit into a specific specialty, or are somewhat undifferentiated in their presentation—for us that is an absolute joy.”

The number of hospitalists and emergency medicine physicians might be said to be running in parallel, says Alpesh Amin, MD, MBA, FACP, executive director of the hospitalist program and vice chair for clinical affairs and quality in the department of medicine at the University of California, Irvine. He tends to refer to this ratio as 30-30, meaning that, within a few years, there will be roughly 30,000 hospitalists, while there are currently that many emergency medicine physicians.3 In addition, emergency medicine and hospital medicine are site-based specialties, says Dr. Amin, so bridging their separateness is crucial to patient care.

Source: McCaig LF, Burt CW. National Hospital Ambulatory Medical Care Survey: 2003 Outpatient Department Summary. National Center for Health Statistics, Hyattsville, Md;2005;358.

“Aside from a small proportion of direct [patient] admissions,” says Jasen W. Gundersen, MD, chief of hospital medicine at the U. Mass. Medical Center in Worcester, “we are an extension of the ER, and the ER is an extension of us. We need to all be on the same page so that what’s said in the ER matches what happens on the floor, which matches what we send out to the primary [care physician].”

Optimizing patient flow is primarily a function of communication, says Marc Newquist, MD, FACEP, a hospitalist, an emergency medicine physician, and program director of the hospitalist division of The Schumacher Group in Lafayette, La. “The better that these communication systems can be standardized, the better hospitalists and their emergency medicine colleagues can promote a seamless integration between the two specialties as patients journey through their hospital stays,” he says.

“As medicine becomes more fragmented and hospital medicine does, let’s face it, fragment care,” adds Dr. Gundersen. “We also have to make sure that information flows from the primary-care physician who may send the patient to the ER. Everybody is a partner, and everybody needs to communicate back and forth and understand that if the ER wants to get someone admitted, timely communication with the hospitalist and understanding how the flow of the hospital works is really important.”

Source: Burt CW, McCaig LF. Staffing, capacity, and ambulance diversion in emergency departments: United States, 2003-04. Adv Data. 2006 Sep 27;(376):1-23.

 

Interactions and Roles

“Far and away the most common type of interaction between hospitalists and ED docs is admissions,” says David M. Pressel, MD, PhD, director, Inpatient Service, General Pediatrics at Alfred I. duPont Hospital for Children in Wilmington, Del. The next most common interaction will depend upon the institution and its style, but, primarily, interactions include consults, and—in some institutions—patient discharge.

Dr. Pressel works at a tertiary-care referral center where residents staff the ED and his unit. “But at a community hospital where you generally have ED medicine-trained docs—not pediatricians who have ED

medicine fellowships—they have less experience with pediatrics, so they may be more likely to consult us on a patient,” he says. The development of care pathways to facilitate care is another important interaction between emergency medicine physicians and hospitalists.

An example of a protocol development the hospitalist and the ED should do together, says Dr. Pressel, is when patients come in with certain symptoms that would indicate a possible communicable disease for which the patient might need special isolation on an inpatient unit. That issue may more likely be foremost in hospitalist’s mind, and he or she can perform an evaluation early to determine what isolation may be needed. If the hospitalist suspects a patient has varicella or active pulmonary tuberculosis, for instance, “those kinds of [isolation] rooms are limited,” says Dr. Pressel. “Hospitals don’t have a lot of them, so you have to make sure you’re getting beds assigned well.”

Our interviews say the major roles of the hospitalist in managing relationships with emergency medicine physicians involve professionalism. “The hospitalist needs to understand the needs of the ER physician in terms of the needs of the [overall] ER: timing, flow, and getting patients seen in a prompt manner,” says Dr. Gundersen. “There’s a give and take, and both sides need to understand the other side of the job to maximize that collegiality and to maximize that sense of teamwork.”

Dr. Gundersen, who works full time as a hospitalist and moonlights as an ED physician, says that “what at times the ED doesn’t realize is that the time it takes for them to do something in the ED is not the same as it takes for us to do something on the floor. If they order a CT scan in the ED, it happens right away. If they say, ‘You can just get the CT scan on the floor,’ well, we don’t have as much priority in terms of getting lab draws and diagnostic tests done as fast as they do.”

Stepping on toes is always a danger.

“One of the key things for the relationship is to realize that you’re not walking in the other person’s shoes,” says Dr. Pressel. “I’ve witnessed [situations] where a hospitalist on the receiving end scoffs at the management in the ED—either because, number one, the patient was perceived to be not sick enough to merit hospitalization according to the hospitalist, or, number two, because of over-workup and overdiagnosis or under-workup and under- or misdiagnosis.”

Both groups need to realize that the patient’s condition evolves over time. “What the ED saw three hours ago may not be what’s being seen now, and that’s true in the reverse,” he says. “If the patient looked great three hours ago, now [their condition may be life-threatening].”

 

Therefore, feedback between ED doctors and hospitalists should be provided in a “respectful, collegial, follow-up type of manner,” says Dr. Pressel. A beneficial means of communication involves feedback that is “telling it as an evolving story,” he says, as opposed to assuming the ED doctor is wrong. That is, “collaborating and adding to the story and the end diagnosis and recognizing that the ED doc’s job is not necessarily to make the final diagnosis.”

Dr. Pressel thinks it comes down to politeness, plain and simple. “I hope that when I miss something, someone will be kind enough to [be polite] to me, [to phrase it as] ‘I’m sure you were thinking of this but the clues looked this way and we went on to do further evaluation.’ ”

That kind of interaction happens all the time, he says. “And ultimately it’s best for the patient, number one, because everybody learns that way, and, number two, if you make yourself obnoxious with your colleagues, they’re not necessarily going to want to call you.”

The Nature of the Beast

Most interactions with their ED colleagues go smoothly, our hospitalists say, but sometimes there are bumps in the road—most often involving flow and the transfer of care.

Jason R. Orlinick, MD, PhD, chief, Section of Hospital Medicine at Norwalk Hospital, Conn., and clinical instructor of medicine at Yale University (New Haven, Conn.), probably represents the bulk of his hospitalist colleagues when he says he and the emergency medicine physicians with whom he works have a cordial relationship overall. But “there is always some level of tension between the hospitalists and the emergency department—at least at the institutions I’ve been at. To some extent, it depends on the mentality of the ED docs where you’re working.”

Debra L. Burgy, MD, a hospitalist at Abbott Northwestern Hospital in Minneapolis, puts it this way: “The interface between hospitalists and the ED is sometimes tense because the ED physicians are regularly bombarded with patients, which is completely unpredictable, and they do not have adequate support staff, such as social workers and psychiatric assessment workers, to create a safe disposition for patients who could otherwise go home.

“The path of least resistance, and the least time-consuming route, is to admit patients. The chain reaction continues with the hospitalist service being overwhelmed.”

It is common for the ED to get a large volume of patients in the afternoon, our hospitalists remark. (See Figure 2, left) “We sometimes get hit with this huge bolus of patients,” Dr. Gundersen says. The biggest challenges involve “promptly identifying those patients who are identified for admission and maintaining a more open communication because when we get three, four, five admissions at once, we have difficulty working down that backlog.”

In the medical residency program at Dr. Orlinick’s institution, the bolus phenomenon can overwhelm residents’ and attendings’ capacities to see patients in a timely manner. “Unfortunately, we’ve not had a lot of success with that,” he says, and recently, his institution approached the hospitalists to work on a solution.

The timing of handoffs represents a large part of the breakdown in patient flow. “This is because of the ED physician who works until 4 p.m. or 6 p.m. and then tries to get all their patients whom they’re not sending home admitted right away before [the hospitalists] go off service,” Dr. Gundersen says. “It’s not uncommon that I get called or paged every three minutes—if I don’t answer right away—because they are trying to get someone admitted seconds after they call. The ER needs the beds, we haven’t been able to discharge the patients, everything gets bottlenecked.”

 

Although Dr. Gundersen recognizes that this problem is unavoidable at times, he suggests it would help “if the ED physicians were cognizant that there may be just one or two hospitalists who are admitting for the day, and giving them five admissions all at once, for instance, is going to take time to get through.”

On the other side, “Hospitalists rely on ED physicians to have the patient worked up and know which service they belong to,” explains Dr. Gundersen. “Succinct transfer of care is [paramount] so that critical information is brought to the attention of the accepting physician.” For the most part, he says, his ED colleagues do a good job.

Because the ED is always in a rush to get patients admitted and a disposition made, “there is the tendency to hamstring what’s happening on the floor. I think that big downstream effect from everything that begins in the ER transitions through the patient’s whole length of stay in the hospital,” says Dr. Gundersen.

All the interviewed hospitalists realize that the hospitalists and ED physicians need to have an understanding of what the other group faces. “We have to be understanding of the ER position that there are a lot of patients to be seen, and they’re trying to do the best they can in that period of time,” says Dr. Gundersen. A 2006 study revealed that interruptions within the ED were prevalent and diverse in nature and—on average—there was an interruption every nine and 14 minutes, respectively, for the attending emergency medicine physicians and residents.5

“And ED physicians have to realize that whatever patient they give to us, we then deal with,” says Dr. Gundersen, “and we [continue] to deal with all the issues, moving them through tests and studies [and] getting them discharged, so sometimes there are delays on both ends. It’s just the nature of the beast.”

A Sense of Control

The benefits of maintaining collegiality with ED physicians go beyond the norm, says Jeff Glasheen, MD, director of both the hospital medicine program and inpatient clinical services in the department of medicine at the University of Colorado at Denver Health Sciences Center. Dr. Glasheen has conducted some research on burnout—mostly in residents.6-7

“One of the main things that leads to burnout is lack of control and feeling like you don’t have control over your daily job,” he says. “One of the things that comes out of this relationship with the ER is that it’s no longer like someone’s just dumping on us. They’re very reasonable when we say, ‘That sounds like somebody who could go home; let me come down and see the patient, and let’s see if we can get this patient discharged.’ You begin to feel like you have control over your day, control over the patients who are admitted to you, and—quite honestly—it’s more fun. That kind of professional interaction is hard to put a price on, but I think it’s priceless.”TH

Andrea Sattinger is a frequent contributor to The Hospitalist.

References

1. Kellermann AL. Crisis in the emergency department. N Engl J Med. 2006 Sep 28;355(13):1300-1303.
2. Burt CW, McCaig LF. Staffing, capacity, and ambulance diversion in emergency departments: United States, 2003-04. Adv Data. 2006 Sep 27;(376):1-23. Available at www.cdc.gov/nchs/data/ad/ad376.pdf. Last accessed April 10, 2007.
3. Freed DH. Hospitalists: evolution, evidence, and eventualities. Health Care Manag. 2004 Jul-Sep;23(3):238-256;1-38.
4. McCaig LF, Burt CW. National Hospital Ambulatory Medical Care Survey: 2003 emergency department summary. Adv Data. 2005;(358):1-38. Available at www.cdc.gov/nchs/data/ad/ad358.pdf. Last accessed April 10, 2007.
5. Laxmisan A, Hakimzada F, Sayan OR, et al. The multitasking clinician: decision-making and cognitive demand during and after team handoffs in emergency care. Int J Med Inform. 2006 Oct 21. [Epub ahead of print.]
6. Gopal RK, Carreira F, Baker WA, et al. Internal medicine residents reject “longer and gentler” training. J Gen Intern Med. 2007 Jan;22(1):102-106.
7. Gopal R, Glasheen JJ, Miyoshi TJ, et al. Burnout and internal medicine resident work-hour restrictions. Arch Intern Med. 2005 Dec 12-26;165(22):2595-2600. Comment in Arch Intern Med. 2005 Dec 12-26; 165(22):2561-2562. Arch Intern Med. 2006 Jul 10;166(13):1423; author reply 1423-1425.

 

The online version of the Oxford English Dictionary (OED) is the latest in a string of dictionaries to include the word “hospitalist” among its entries.

“This is just another sign that “hospitalist” has become another part of the landscape, and that we’ve arrived and will be here for a very long time,” says Larry Wellikson, MD, CEO of SHM. “I think SHM has been working on defining what a hospitalist is in textbooks and other reference materials since I got here in 2000.”

Asked if SHM solicited the OED staff to include hospitalist in its entries, Dr. Wellikson said it wasn’t necessary. “No, we didn’t lobby them,” he says. “They did it totally on their own. If you Google hospitalist, you’ll see thousands of stories that have been written during the past 10 years, including by such publications as the The Wall Street Journal.”

Dr. Wellikson noted that CNN’s Larry King mentioned hospitalists during a segment in 2005. “[The word hospitalist] has turned up in so many places,” he says.

To date, “hospitalist” has been included in print editions of The American Heritage Dictionary of the English Language, Merriam-Webster’s collegiate and medical dictionaries, as well as other print medical dictionaries and some online dictionaries. The American Heritage Dictionary appears to be the first to have included the word in a print edition in 2000, according to a spokesman for the publication.

The process of selecting a new word for inclusion in a dictionary appears fairly constant in the industry.

“It can include suggestions from our readership or people in a particular industry who might suggest that a new word unique to their profession should be included,” says Katherine Martin, senior assistant editor at OED’s New York offices. “It also includes our own (staff) study to ascertain if a certain word that is tested over time will have continued longevity.”

Tested over time indeed. Martin and other dictionary staff members say it can sometimes take up to 10 years for a new word to be included in a dictionary.

That’s how long it took to include hospitalist in Merriam-Webster’s Collegiate Dictionary, according to a spokesman for that publication. And while hospitalist was included in the OED’s online version in December 2006, it’s uncertain if it will ever get into the print version, according to Martin.

The OED’s second edition was last printed in 1989, Martin says, and because of the huge cost involved, “We haven’t even begun discussing the possibility of printing a third edition.”

Access to the 20-volume print edition is available to subscribers to the OED’s fee-based online version, Martin says.

The term hospitalist was first introduced in 1996 in an article by Robert M. Wachter, MD, and Lee Goldman, MD, to describe physicians who devote much of their professional time and focus to the care of hospitalized patients.

Merriam-Webster began monitoring the term when the article first appeared in the New England Journal of Medicine, according to Peter Sokolowski, associate editor. He says hospitalist made it into the company’s collegiate dictionary in 2005, and the medical dictionary a year later.

For the most part, both print and online dictionaries give a relatively simple definition of hospitalist: “A physician specializing in the care of hospital in-patients,” says the OED’s online version. Merriam-Webster’s dictionaries define the term as “a physician who specializes in treating hospitalized patients of other physicians in order to minimize the number of hospital visits by other physicians.”

Perhaps the most extensive definition online appears in Wikipedia, the free online encyclopedia. In addition to the definition, Wikipedia also provides information on the specialty under various subtitles, including Training and History. TH

 

Tom Giordano is a freelance journalist based in Connecticut

The online version of the Oxford English Dictionary (OED) is the latest in a string of dictionaries to include the word “hospitalist” among its entries.

“This is just another sign that “hospitalist” has become another part of the landscape, and that we’ve arrived and will be here for a very long time,” says Larry Wellikson, MD, CEO of SHM. “I think SHM has been working on defining what a hospitalist is in textbooks and other reference materials since I got here in 2000.”

Asked if SHM solicited the OED staff to include hospitalist in its entries, Dr. Wellikson said it wasn’t necessary. “No, we didn’t lobby them,” he says. “They did it totally on their own. If you Google hospitalist, you’ll see thousands of stories that have been written during the past 10 years, including by such publications as the The Wall Street Journal.”

Dr. Wellikson noted that CNN’s Larry King mentioned hospitalists during a segment in 2005. “[The word hospitalist] has turned up in so many places,” he says.

To date, “hospitalist” has been included in print editions of The American Heritage Dictionary of the English Language, Merriam-Webster’s collegiate and medical dictionaries, as well as other print medical dictionaries and some online dictionaries. The American Heritage Dictionary appears to be the first to have included the word in a print edition in 2000, according to a spokesman for the publication.

The process of selecting a new word for inclusion in a dictionary appears fairly constant in the industry.

“It can include suggestions from our readership or people in a particular industry who might suggest that a new word unique to their profession should be included,” says Katherine Martin, senior assistant editor at OED’s New York offices. “It also includes our own (staff) study to ascertain if a certain word that is tested over time will have continued longevity.”

Tested over time indeed. Martin and other dictionary staff members say it can sometimes take up to 10 years for a new word to be included in a dictionary.

That’s how long it took to include hospitalist in Merriam-Webster’s Collegiate Dictionary, according to a spokesman for that publication. And while hospitalist was included in the OED’s online version in December 2006, it’s uncertain if it will ever get into the print version, according to Martin.

The OED’s second edition was last printed in 1989, Martin says, and because of the huge cost involved, “We haven’t even begun discussing the possibility of printing a third edition.”

Access to the 20-volume print edition is available to subscribers to the OED’s fee-based online version, Martin says.

The term hospitalist was first introduced in 1996 in an article by Robert M. Wachter, MD, and Lee Goldman, MD, to describe physicians who devote much of their professional time and focus to the care of hospitalized patients.

Merriam-Webster began monitoring the term when the article first appeared in the New England Journal of Medicine, according to Peter Sokolowski, associate editor. He says hospitalist made it into the company’s collegiate dictionary in 2005, and the medical dictionary a year later.

For the most part, both print and online dictionaries give a relatively simple definition of hospitalist: “A physician specializing in the care of hospital in-patients,” says the OED’s online version. Merriam-Webster’s dictionaries define the term as “a physician who specializes in treating hospitalized patients of other physicians in order to minimize the number of hospital visits by other physicians.”

Perhaps the most extensive definition online appears in Wikipedia, the free online encyclopedia. In addition to the definition, Wikipedia also provides information on the specialty under various subtitles, including Training and History. TH

 

Tom Giordano is a freelance journalist based in Connecticut

The online version of the Oxford English Dictionary (OED) is the latest in a string of dictionaries to include the word “hospitalist” among its entries.

“This is just another sign that “hospitalist” has become another part of the landscape, and that we’ve arrived and will be here for a very long time,” says Larry Wellikson, MD, CEO of SHM. “I think SHM has been working on defining what a hospitalist is in textbooks and other reference materials since I got here in 2000.”

Asked if SHM solicited the OED staff to include hospitalist in its entries, Dr. Wellikson said it wasn’t necessary. “No, we didn’t lobby them,” he says. “They did it totally on their own. If you Google hospitalist, you’ll see thousands of stories that have been written during the past 10 years, including by such publications as the The Wall Street Journal.”

Dr. Wellikson noted that CNN’s Larry King mentioned hospitalists during a segment in 2005. “[The word hospitalist] has turned up in so many places,” he says.

To date, “hospitalist” has been included in print editions of The American Heritage Dictionary of the English Language, Merriam-Webster’s collegiate and medical dictionaries, as well as other print medical dictionaries and some online dictionaries. The American Heritage Dictionary appears to be the first to have included the word in a print edition in 2000, according to a spokesman for the publication.

The process of selecting a new word for inclusion in a dictionary appears fairly constant in the industry.

“It can include suggestions from our readership or people in a particular industry who might suggest that a new word unique to their profession should be included,” says Katherine Martin, senior assistant editor at OED’s New York offices. “It also includes our own (staff) study to ascertain if a certain word that is tested over time will have continued longevity.”

Tested over time indeed. Martin and other dictionary staff members say it can sometimes take up to 10 years for a new word to be included in a dictionary.

That’s how long it took to include hospitalist in Merriam-Webster’s Collegiate Dictionary, according to a spokesman for that publication. And while hospitalist was included in the OED’s online version in December 2006, it’s uncertain if it will ever get into the print version, according to Martin.

The OED’s second edition was last printed in 1989, Martin says, and because of the huge cost involved, “We haven’t even begun discussing the possibility of printing a third edition.”

Access to the 20-volume print edition is available to subscribers to the OED’s fee-based online version, Martin says.

The term hospitalist was first introduced in 1996 in an article by Robert M. Wachter, MD, and Lee Goldman, MD, to describe physicians who devote much of their professional time and focus to the care of hospitalized patients.

Merriam-Webster began monitoring the term when the article first appeared in the New England Journal of Medicine, according to Peter Sokolowski, associate editor. He says hospitalist made it into the company’s collegiate dictionary in 2005, and the medical dictionary a year later.

For the most part, both print and online dictionaries give a relatively simple definition of hospitalist: “A physician specializing in the care of hospital in-patients,” says the OED’s online version. Merriam-Webster’s dictionaries define the term as “a physician who specializes in treating hospitalized patients of other physicians in order to minimize the number of hospital visits by other physicians.”

Perhaps the most extensive definition online appears in Wikipedia, the free online encyclopedia. In addition to the definition, Wikipedia also provides information on the specialty under various subtitles, including Training and History. TH

 

Tom Giordano is a freelance journalist based in Connecticut