As I walked around our office during the week after this year’s SHM Annual Meeting, there was a simple question on the minds of many: What’s next?

After the 12-month planning of “Hospital Medicine 2007”—which culminated in a week away from family, getting out of bed before 5 a.m., and falling asleep after midnight—I guess “What’s next?” is a pretty reasonable question. It’s not at all a surprising question considering the “blood, sweat, and tears” so many volunteer leaders and staff gave to put on an event befitting the fastest-growing specialty in modern healthcare.

“What’s next?” is a fair question for our members to ask of us as well. After all, like so many other organizations, much of what SHM does is designed to come on line, or culminate, during the annual meeting.

I wanted to use this month’s column to give you a small glimpse inside our answer to this simple—yet powerful—question.

One of the surprise stories from “Hospital Medicine 2007” was the success of our Annual Meeting Blog. Over the course of three days, several hospital medicine leaders, including Bob Wachter, MD, shared their experiences—in real time—from Dallas. Augmenting the posts from these contributors were audio podcast interviews with notables that included keynote speaker David Brailer, MD, the first national coordinator for health information technology with the Department of Health and Human Services.

More than 1,000 people visited SHM’s first foray into the blogosphere. Even more exciting is that the blog had hits from hospitalists unable to join us in Dallas.

It used to be that we would say that the biggest meeting in hospital medicine took place each year at the site of the SHM Annual Meeting. With the introduction of the blog, we can now say that is no longer the case. The biggest meeting takes place in more than one city, in more than one hospital, with the geographic location of the SHM Annual Meeting just the hub.

The blog is just the beginning of the answer to the question “What’s next?”

During the coming year, we will use our blogging success as a building block to bringing what many call “new media” squarely into the framework of SHM. You are starting to see the first steps of that effort with the redesign of our homepage, www.hospitalmedicine.org.

To us, new media serves several purposes:

• Inform: The blog showed us a powerful way to deliver real-time news without the delay some publications require;
• Educate: We’re working on creating Webinars—audio conferences coupled with Internet presentations—that will bring education directly to you, at your institution, throughout the year;
• Connect: Through online discussions with thought leaders, including authors from The Hospitalist, we want to celebrate the fact that the most powerful connection we can facilitate is from physician to physician; and
• Differentiate: By bringing these elements together, from blogs and podcasts to Webinars and new online resources, we want to make the question “Why SHM?” one of the easiest you’ll ever have to answer.

What’s next? It’s an interesting question. To us, a major part of the answer is the same it’s always been: to continue innovating by building on our successes and being the group committed to blazing new trails that are focused squarely, and solely, on delivering benefit to our members and the hospital medicine movement.

As I walked around our office during the week after this year’s SHM Annual Meeting, there was a simple question on the minds of many: What’s next?

After the 12-month planning of “Hospital Medicine 2007”—which culminated in a week away from family, getting out of bed before 5 a.m., and falling asleep after midnight—I guess “What’s next?” is a pretty reasonable question. It’s not at all a surprising question considering the “blood, sweat, and tears” so many volunteer leaders and staff gave to put on an event befitting the fastest-growing specialty in modern healthcare.

“What’s next?” is a fair question for our members to ask of us as well. After all, like so many other organizations, much of what SHM does is designed to come on line, or culminate, during the annual meeting.

I wanted to use this month’s column to give you a small glimpse inside our answer to this simple—yet powerful—question.

One of the surprise stories from “Hospital Medicine 2007” was the success of our Annual Meeting Blog. Over the course of three days, several hospital medicine leaders, including Bob Wachter, MD, shared their experiences—in real time—from Dallas. Augmenting the posts from these contributors were audio podcast interviews with notables that included keynote speaker David Brailer, MD, the first national coordinator for health information technology with the Department of Health and Human Services.

More than 1,000 people visited SHM’s first foray into the blogosphere. Even more exciting is that the blog had hits from hospitalists unable to join us in Dallas.

It used to be that we would say that the biggest meeting in hospital medicine took place each year at the site of the SHM Annual Meeting. With the introduction of the blog, we can now say that is no longer the case. The biggest meeting takes place in more than one city, in more than one hospital, with the geographic location of the SHM Annual Meeting just the hub.

The blog is just the beginning of the answer to the question “What’s next?”

During the coming year, we will use our blogging success as a building block to bringing what many call “new media” squarely into the framework of SHM. You are starting to see the first steps of that effort with the redesign of our homepage, www.hospitalmedicine.org.

To us, new media serves several purposes:

• Inform: The blog showed us a powerful way to deliver real-time news without the delay some publications require;
• Educate: We’re working on creating Webinars—audio conferences coupled with Internet presentations—that will bring education directly to you, at your institution, throughout the year;
• Connect: Through online discussions with thought leaders, including authors from The Hospitalist, we want to celebrate the fact that the most powerful connection we can facilitate is from physician to physician; and
• Differentiate: By bringing these elements together, from blogs and podcasts to Webinars and new online resources, we want to make the question “Why SHM?” one of the easiest you’ll ever have to answer.

What’s next? It’s an interesting question. To us, a major part of the answer is the same it’s always been: to continue innovating by building on our successes and being the group committed to blazing new trails that are focused squarely, and solely, on delivering benefit to our members and the hospital medicine movement.

As I walked around our office during the week after this year’s SHM Annual Meeting, there was a simple question on the minds of many: What’s next?

After the 12-month planning of “Hospital Medicine 2007”—which culminated in a week away from family, getting out of bed before 5 a.m., and falling asleep after midnight—I guess “What’s next?” is a pretty reasonable question. It’s not at all a surprising question considering the “blood, sweat, and tears” so many volunteer leaders and staff gave to put on an event befitting the fastest-growing specialty in modern healthcare.

“What’s next?” is a fair question for our members to ask of us as well. After all, like so many other organizations, much of what SHM does is designed to come on line, or culminate, during the annual meeting.

I wanted to use this month’s column to give you a small glimpse inside our answer to this simple—yet powerful—question.

One of the surprise stories from “Hospital Medicine 2007” was the success of our Annual Meeting Blog. Over the course of three days, several hospital medicine leaders, including Bob Wachter, MD, shared their experiences—in real time—from Dallas. Augmenting the posts from these contributors were audio podcast interviews with notables that included keynote speaker David Brailer, MD, the first national coordinator for health information technology with the Department of Health and Human Services.

More than 1,000 people visited SHM’s first foray into the blogosphere. Even more exciting is that the blog had hits from hospitalists unable to join us in Dallas.

It used to be that we would say that the biggest meeting in hospital medicine took place each year at the site of the SHM Annual Meeting. With the introduction of the blog, we can now say that is no longer the case. The biggest meeting takes place in more than one city, in more than one hospital, with the geographic location of the SHM Annual Meeting just the hub.

The blog is just the beginning of the answer to the question “What’s next?”

During the coming year, we will use our blogging success as a building block to bringing what many call “new media” squarely into the framework of SHM. You are starting to see the first steps of that effort with the redesign of our homepage, www.hospitalmedicine.org.

To us, new media serves several purposes:

• Inform: The blog showed us a powerful way to deliver real-time news without the delay some publications require;
• Educate: We’re working on creating Webinars—audio conferences coupled with Internet presentations—that will bring education directly to you, at your institution, throughout the year;
• Connect: Through online discussions with thought leaders, including authors from The Hospitalist, we want to celebrate the fact that the most powerful connection we can facilitate is from physician to physician; and
• Differentiate: By bringing these elements together, from blogs and podcasts to Webinars and new online resources, we want to make the question “Why SHM?” one of the easiest you’ll ever have to answer.

What’s next? It’s an interesting question. To us, a major part of the answer is the same it’s always been: to continue innovating by building on our successes and being the group committed to blazing new trails that are focused squarely, and solely, on delivering benefit to our members and the hospital medicine movement.

By the time a mortician in the northeast British town of Hyde, Greater Manchester, United Kingdom, noticed Dr. Harold Shipman’s patients were dying at an exorbitant rate, the doctor had probably killed close to 300 of them, according to Kenneth V. Iserson, MD, MBA, professor of emergency medicine at the University of Arizona College of Medicine and author of “Demon Doctors: Physicians as Serial Killers.”

Shipman, labeled ‘‘the most prolific serial killer in the history of the United Kingdom—and probably the world,’’ was officially convicted of killing 15 patients in 2000 and sentenced to 15 consecutive life sentences.1 In January 2004 he was found hanged in his prison cell.

Sometimes referred to as caregiver-associated serial killings, these incidents generate profound shock in the healthcare community. As repellent and relatively rare as this behavior is, and as controversial as the topic is, neither individuals nor institutions can afford to disassociate themselves from the subject. Hospitalists should not hide from this issue and should not feel they will be accused of “treason” if they educate themselves and bring suspicious behavior to the awareness of superiors, says Beatrice Crofts Yorker, JD, RN, MS, FAAN, dean of the College of Health and Human Services at California State University, Los Angeles. On the contrary, she says, “first, do no harm” also entails ensuring everyone else around you follows the same ethic.

Dr. Yorker, who has been studying this phenomenon since 1986, published the first examination of cases of serial murder by nurses in the American Journal of Nursing (AJN) in 1988. “It is a serious problem that has been under-recognized, and it is the right thing to blow the whistle when adverse patient incidents are associated with the presence of a specific healthcare provider,” says Dr. Yorker. “In fact, most of the cases came to the attention of authorities because a nurse blew the whistle. The sad thing is that some of the nurses were disciplined for their protective actions; however, they were ultimately vindicated.”

A veteran of the phenomenon urges continued vigilance. “As a general caveat, there needs to be a higher index of suspicion for these incidents,” says Kenneth W. Kizer, MD, MPH, the former head of the veterans healthcare system who had to deal with three incidents of serial murder at Veterans Affairs (VA) hospitals in the 1990s. “These incidents are grossly underreported.”

click for large version

Incidence and Cause of Death

Drs. Kizer and Yorker were two of the investigators who reviewed epidemiologic studies, toxicology evidence, and court transcripts for data on healthcare professionals prosecuted between 1970 and 2006.

“Dr. Robert Forrest, who was a forensic toxicologist getting a law degree and wrote his dissertation on the topic of serial murder by healthcare providers, contacted me after the AJN article came out,” says Dr. Yorker. Dr. Forrest has been the testifying expert in most of the U.K. cases. “After the Charles Cullen case hit the news, The New York Times and Modern Healthcare contacted me regarding my study in AJN and the Journal of Nursing Law. That is how Ken Kizer and Paula Lampe found me.” (Cullen, a registered nurse, received 11 consecutive life sentences in 2006 after pleading guilty to administering lethal doses of medication to more than 40 patients in New Jersey and Pennsylvania.)

Lampe, an author, had been studying cases in Europe. “Because both Robert and Paula provided additional data on some cases, they were co-authors—as was Ken—who provided data on the VA cases and an important public policy perspective,” says Dr. Yorker.

The search showed 90 criminal prosecutions of healthcare providers who met the criteria of serial murder of patients. Of those, 54 have been convicted—45 for serial murder, four for attempted murder, and five on lesser charges. Since the publication of their study, one more of the accused has received a sentence of life in prison, another has been convicted and sentenced to 20 years, one committed suicide in prison, and two additional nurses in Germany and the Czech Republic have been arrested and confessed to serial murder of patients. In addition, Dr. Yorker is continuing to follow two large-scale murder-for-profit prosecutions. There are four defendants in each case. Further, three individuals have been found liable for wrongful death in the amounts of $27 million, $8 million, and $450,000 in damages.

Injection was the main method used by healthcare killers, followed by suffocation, poisoning, and tampering with equipment. Prosecutions were reported in 20 countries, with 40% of the incidents taking place in the United States. Nursing personnel were 86% of the healthcare providers prosecuted; 12% were physicians, and 2% were allied health professionals. The number of patient deaths that resulted in a murder conviction is 317, and the number of suspicious patient deaths attributed to the 54 convicted caregivers is 2,113.

“Physicians as serial killers are remarkably uncommon,” says Dr. Iserson, who is also director of the Arizona Bioethics Program at the University of Arizona College of Medicine in Tucson. “Nurses [who are serial killers] are much more common, but of course there are more nurses in the hospital, just as there are ancillary people.” (See Figure 1, left.) Dr. Iserson, who practices emergency medicine and consults nationally on bioethics, advises maintaining caution when examining data of charges or suspicions that were never proved.

Most of these crimes (70%) occur in hospital units. (See Figure 2, left.) Victims are almost always female, as are almost half (49%) of convicted serial killers and 55% of the total number of prosecuted healthcare providers. Males are disproportionately represented among prosecuted nurses.

click for large version

Motives: Who Is Always There?

Although the motives are complex, some common threads connect these crimes. “There are some classical signs, if you will,” says Dr. Kizer.

When the same person repeatedly calls a code and always seems to be in the thick of it, that is one prime indicator. These people are usually legitimately present in those settings and circumstances—for example, they are on call or working a shift—which makes it more difficult to discern when something is awry. Commonly, the perpetrators have easy access to high-alert drugs without sufficient accountability. Sometimes, once an investigation has been launched it is discovered the person has falsified his or her credentials.

In hospitals, experts say, the “rescuer” or “hero” personality is often on display in those who kill patients—the first person there to give the patient drugs or attempt to save the patient.

“What you are going to see as a pattern,” says Dr. Iserson, “is that they need to be near death.” Codes or calls for respiratory arrest are the most common; patients who have cardiac arrests are much harder to save. Being the hero is not always the motive; the converse can also apply.

Such is the case with nurse Orville Lynn Majors, LPN, convicted of six murders at the Vermillion county hospital in Clinton, Ind. The deaths were consistent with injections of potassium chloride and epinephrine according to prosecutors. Majors’ coworkers were concerned that patients were coding in alarming numbers while in his care. Although this information did not come out until after he was apprehended, his coworkers had a good idea which of his patients would not survive: Patients who were whiny, demanding, or required a lot of work. “The scuttlebutt or rumor among his coworkers,” says Dr. Kizer, “is that they could almost predict which patients would have a demise under his care.”

Although a typical profile of the serial healthcare murderer has been demonstrated in many cases, in many other cases the demographics and behaviors of these killers have deviated widely from generalized assumptions.2 Therefore, before looking at people, look at the numbers.

An unusual number of calls and codes may occur in a particular area of the hospital. “In ICUs you expect a lot of [codes and calls], but not on general post-op wards or the pediatrics MICU,” Dr. Kizer says. “When this happens in these settings it should raise a red flag.”

Unfortunately, most hospitals don’t track mortality on a monthly basis per unit or ward or ICU, so they may not recognize when something is out of line in a timely manner. Also, the hospital committee assigned to review deaths may be remiss in its duty to meet regularly or otherwise perform according to policy.

Another factor that should raise a red flag is a disproportionate number of codes or deaths on the same shift—most often the night shift. Often, someone says, “Gee, it seems like there’s an awful lot of codes lately,” explains Dr. Kizer. An unusually high rate of successful codes is another sign.

For example, in the 1995-1996 case of Kristen Gilbert, an RN convicted of four murders at the Veterans Affairs Medical Center in Northampton, Mass., she was having an extramarital affair with a hospital security guard who worked the evening shift. Protocol required that security be called to all cardiopulmonary arrests. Gilbert used stimulant epinephrine to make their hearts race out of control. The epidemiologic data later showed that suspicious codes occurred when both were on duty. “The patients always seemed to recover and she was the hero,” says Dr. Kizer. “She wanted to look good for her boyfriend.”

Similarly, Richard Angelo, a charge nurse at Good Samaritan Hospital in West Islip, Long Island, N.Y., admitted that between 1987 and 1989 he injected patients with paralyzing drugs Pavulon (pancuronium) and Anectine (succinylcholine). He wanted his colleagues to admire him for performing well in a code. During his confession, he likened himself to volunteer firefighters who set fires. In fact, Dr. Iserson makes this same parallel. “From what we can tell,” he says, “these people don’t really care whether the person dies or not. They would rather they not [die], so they can be seen as the hero. It’s all about them.” As with instances of arson, he says, the perpetrator is “the first one to show up at the fire watch, over and over again.”

Obstacles to Disclosure

Even when healthcare workers and related personnel come forward with their suspicions, law enforcement may be a barrier to prosecution.

In the United Kingdom, a Manchester mortician took her observations about the excessive deaths and cremations in Harold Shipman’s practice to her father and brother, who were also in the family business. She also obtained the support of a local female general practitioner. The two women went to the police, explaining that most patients who had died had not been critically ill and noted that the doctor had exhibited peculiar behavior when he was questioned.

But, says Dr. Iserson, the response again was typical: “‘Oh, foolish women. That can’t be happening.’ And it wasn’t until Shipman killed the wrong person [a former town mayor, mother of a prominent lawyer] that things started to unravel for him.” When police finally looked at other deaths Shipman had certified, a pattern emerged. He would overdose patients with diamorphine, sign their death certificates, then forge medical records to indicate they were in poor health.

A second common response by institutions is just as much of a barrier to bringing these crimes to light and ultimately, prosecution. “In essence,” says Dr. Iserson, “that response is, ‘Well, maybe it is happening but, boy, it sure is going to put our institution in a bad light. So let’s just not say anything.’ ”

This was the case with Michael Swango, a doctor who worked in several states and a number of countries. He was charged with five murders and may have been involved in 126 deaths. Swango confessed to the deaths that occurred in a Veterans Affairs hospital in Northport, N.Y., where he reportedly injected three veterans with a drug that stopped their hearts. He had forged “do not resuscitate” orders for the three. He was sentenced to two life sentences. It is possible that he killed as many as 35-60 people in the United States and Zimbabwe. But before it was all out in the open, “some very prominent people were involved in sweeping it under the rug,” says Dr. Iserson, “and they didn’t even get a slap on the wrist.”

Hiring Practices

One of the most shocking aspects of the Cullen case was that institutional coverup and employee privacy policies meant his prior employers never revealed the problems to prospective employers.

“Identifying potential serial killers is not at all the total problem,” says Dr. Iserson. “The problem is getting the powers that be to act. What they typically do is pass the problem on to somebody else, in effect, saying, ‘We don’t want you to work here anymore. We won’t necessarily write you a good letter of recommendation, but we will say that you worked here, and basically we just want you to go away.’ ”

An investigation revealed that Cullen had a history of reported incidents at hospitals in Pennsylvania and New Jersey, but there were no tracking or disclosure systems in place as he moved from one hospital to another. His employment history included termination from several hospitals because of misconduct, hospitalizations for mental illness, and a criminal investigation regarding improper medication administration.

In an open letter published in The New York Times on March 14, 2004, Somerset Medical Center (Somerville, N.J.) asserted: “Mr. Cullen worked at nine other healthcare facilities over a 16-year period. His former work history problems were not revealed to us. Nor were any state agencies or licensing boards able to provide us with accurate information about his employment history.”

Cullen had been investigated by three hospitals, a nursing home, and two prosecutors for suspicious patient deaths. He was fired by five hospitals and one nursing home for suspected wrongdoing. But Cullen continued to find employment and kill patients.

“Confidentiality is essential [as is] not leaking to the media, which can taint the investigation,” says Dr. Yorker. “The Charles Cullen case should motivate hospitalists to [participate in helping to stop the systemic mechanism that made possible] his killing over 40 patients in nine different hospitals and a nursing home before being stopped. This erodes the public trust in hospitals.”

The Health Care Quality Improvement Act provides some immunity for reporters of adverse information, but it applies only to physicians—not communications between employers.

The American Society for Healthcare Risk Management (ASHRM) and Dr. Kizer and his colleagues are in alignment in advocating for the provision of more comprehensive immunity to help healthcare employees and patients when they report these incidents.3

“If you have information that a worker is harming patients, the institution should be able to tell prospective employers and not worry about getting sued,” says Dr. Yorker. A number of states have passed varying forms of legislation so far, and ASHRM is recommending this be a federal matter. Dr. Kizer and his group recommend that reporting of suspected serial murderers should be considered for coverage under Good Samaritan laws.

Other Complicating Factors

Another problem in bringing legitimate cases to prosecution is when providers are accused on trumped-up charges, which in Dr. Iserson’s view amounts to prosecutorial malpractice. Examples are cases post-Hurricane Katrina, when physicians and nurses were charged with patient deaths.

Internationally, an example is the case in Libya where the main defendants—a Palestinian doctor and five Bulgarian nurses—were charged with injecting 426 children with HIV in 1998, causing an epidemic at El-Fath Children’s Hospital in Benghazi. According to World Politics Watch, dozens of foreign medical professionals were arrested, with six eventually charged and forced to confess by Libyan authorities. Subsequent research published in the journal Nature indicated that viral strains present in the infected children were present at the hospital before 1998.

“This was a case of political blackmail,” says Dr. Iserson. These cases may not be clear-cut and may be open to negative interpretations that “make people skittish. That is why institutions are prone to say, ‘Gee, maybe it’s just one of those kinds of cases. We don’t want to make that kind of mistake.’ ”

Also problematic is the variable rate at which hospitals perform autopsies.

“Autopsy rates are down in many communities to 1% or 2% or even lower,” says Dr. Kizer. “When the data point to the possibility of a crime on a particular unit, the site needs to be treated as a crime scene. In most hospitals, when someone dies, you get them off the floor and you clean up as quickly as possible. That shouldn’t be the case if it is a suspected crime scene. Ideally there should be standardized processes or protocols whenever there is suspicion. And those protocols may be different than when a patient ordinarily dies.”

Seeking Solutions

Hospitalists and other professionals—especially nurses and ancillary personnel—have an obligation to be informed and astute regarding individual characteristics and signs of suspicious patient deaths. Appropriate epidemiological, toxicological, and psychological data must be collected and analyzed routinely.

“Data about this phenomenon need to be disseminated to heighten awareness that serial murder of patients is a significant concern that extends beyond a few shocking, isolated incidents,” write Drs. Yorker and Kizer and their co-authors.

Institutional hiring practices must be changed so balance is achieved between preventing wrongful discharge or denial-of-employment lawsuits and protecting patient safety. Existing state legislation and future federal legislation for institutional immunity is an important element of patient advocacy that hospitalists can support.

Ultimately, hospitalists must be informed, aware, and alert. “Most [suspicions] will not be anything,” says Dr. Iserson. “Just pay attention to it.” TH

Andrea Sattinger is a frequent contributor to The Hospitalist.

References

1. Yorker BC, Kizer KW, Lampe P, et al. Serial murder by healthcare professionals. J Forensic Sci. 2006 Nov;51(6):1362-1371.
2. Wolf BC, Lavezzi WA. Paths to destruction: the lives and crimes of two serial killers. J Forensic Sci. 2007 Jan;52(1):199-203.
3. ASHRM. American Society for Healthcare Risk Management. A call for federal immunity to protect health care employers … and patients. Chicago: Monograph; April 1, 2005; www.ashrm.org/ashrm/resources/files/Monograph.Immunity.pdf.

By the time a mortician in the northeast British town of Hyde, Greater Manchester, United Kingdom, noticed Dr. Harold Shipman’s patients were dying at an exorbitant rate, the doctor had probably killed close to 300 of them, according to Kenneth V. Iserson, MD, MBA, professor of emergency medicine at the University of Arizona College of Medicine and author of “Demon Doctors: Physicians as Serial Killers.”

Shipman, labeled ‘‘the most prolific serial killer in the history of the United Kingdom—and probably the world,’’ was officially convicted of killing 15 patients in 2000 and sentenced to 15 consecutive life sentences.1 In January 2004 he was found hanged in his prison cell.

Sometimes referred to as caregiver-associated serial killings, these incidents generate profound shock in the healthcare community. As repellent and relatively rare as this behavior is, and as controversial as the topic is, neither individuals nor institutions can afford to disassociate themselves from the subject. Hospitalists should not hide from this issue and should not feel they will be accused of “treason” if they educate themselves and bring suspicious behavior to the awareness of superiors, says Beatrice Crofts Yorker, JD, RN, MS, FAAN, dean of the College of Health and Human Services at California State University, Los Angeles. On the contrary, she says, “first, do no harm” also entails ensuring everyone else around you follows the same ethic.

Dr. Yorker, who has been studying this phenomenon since 1986, published the first examination of cases of serial murder by nurses in the American Journal of Nursing (AJN) in 1988. “It is a serious problem that has been under-recognized, and it is the right thing to blow the whistle when adverse patient incidents are associated with the presence of a specific healthcare provider,” says Dr. Yorker. “In fact, most of the cases came to the attention of authorities because a nurse blew the whistle. The sad thing is that some of the nurses were disciplined for their protective actions; however, they were ultimately vindicated.”

A veteran of the phenomenon urges continued vigilance. “As a general caveat, there needs to be a higher index of suspicion for these incidents,” says Kenneth W. Kizer, MD, MPH, the former head of the veterans healthcare system who had to deal with three incidents of serial murder at Veterans Affairs (VA) hospitals in the 1990s. “These incidents are grossly underreported.”

click for large version

Incidence and Cause of Death

Drs. Kizer and Yorker were two of the investigators who reviewed epidemiologic studies, toxicology evidence, and court transcripts for data on healthcare professionals prosecuted between 1970 and 2006.

“Dr. Robert Forrest, who was a forensic toxicologist getting a law degree and wrote his dissertation on the topic of serial murder by healthcare providers, contacted me after the AJN article came out,” says Dr. Yorker. Dr. Forrest has been the testifying expert in most of the U.K. cases. “After the Charles Cullen case hit the news, The New York Times and Modern Healthcare contacted me regarding my study in AJN and the Journal of Nursing Law. That is how Ken Kizer and Paula Lampe found me.” (Cullen, a registered nurse, received 11 consecutive life sentences in 2006 after pleading guilty to administering lethal doses of medication to more than 40 patients in New Jersey and Pennsylvania.)

Lampe, an author, had been studying cases in Europe. “Because both Robert and Paula provided additional data on some cases, they were co-authors—as was Ken—who provided data on the VA cases and an important public policy perspective,” says Dr. Yorker.

The search showed 90 criminal prosecutions of healthcare providers who met the criteria of serial murder of patients. Of those, 54 have been convicted—45 for serial murder, four for attempted murder, and five on lesser charges. Since the publication of their study, one more of the accused has received a sentence of life in prison, another has been convicted and sentenced to 20 years, one committed suicide in prison, and two additional nurses in Germany and the Czech Republic have been arrested and confessed to serial murder of patients. In addition, Dr. Yorker is continuing to follow two large-scale murder-for-profit prosecutions. There are four defendants in each case. Further, three individuals have been found liable for wrongful death in the amounts of $27 million, $8 million, and $450,000 in damages.

Injection was the main method used by healthcare killers, followed by suffocation, poisoning, and tampering with equipment. Prosecutions were reported in 20 countries, with 40% of the incidents taking place in the United States. Nursing personnel were 86% of the healthcare providers prosecuted; 12% were physicians, and 2% were allied health professionals. The number of patient deaths that resulted in a murder conviction is 317, and the number of suspicious patient deaths attributed to the 54 convicted caregivers is 2,113.

“Physicians as serial killers are remarkably uncommon,” says Dr. Iserson, who is also director of the Arizona Bioethics Program at the University of Arizona College of Medicine in Tucson. “Nurses [who are serial killers] are much more common, but of course there are more nurses in the hospital, just as there are ancillary people.” (See Figure 1, left.) Dr. Iserson, who practices emergency medicine and consults nationally on bioethics, advises maintaining caution when examining data of charges or suspicions that were never proved.

Most of these crimes (70%) occur in hospital units. (See Figure 2, left.) Victims are almost always female, as are almost half (49%) of convicted serial killers and 55% of the total number of prosecuted healthcare providers. Males are disproportionately represented among prosecuted nurses.

click for large version

Motives: Who Is Always There?

Although the motives are complex, some common threads connect these crimes. “There are some classical signs, if you will,” says Dr. Kizer.

When the same person repeatedly calls a code and always seems to be in the thick of it, that is one prime indicator. These people are usually legitimately present in those settings and circumstances—for example, they are on call or working a shift—which makes it more difficult to discern when something is awry. Commonly, the perpetrators have easy access to high-alert drugs without sufficient accountability. Sometimes, once an investigation has been launched it is discovered the person has falsified his or her credentials.

In hospitals, experts say, the “rescuer” or “hero” personality is often on display in those who kill patients—the first person there to give the patient drugs or attempt to save the patient.

“What you are going to see as a pattern,” says Dr. Iserson, “is that they need to be near death.” Codes or calls for respiratory arrest are the most common; patients who have cardiac arrests are much harder to save. Being the hero is not always the motive; the converse can also apply.

Such is the case with nurse Orville Lynn Majors, LPN, convicted of six murders at the Vermillion county hospital in Clinton, Ind. The deaths were consistent with injections of potassium chloride and epinephrine according to prosecutors. Majors’ coworkers were concerned that patients were coding in alarming numbers while in his care. Although this information did not come out until after he was apprehended, his coworkers had a good idea which of his patients would not survive: Patients who were whiny, demanding, or required a lot of work. “The scuttlebutt or rumor among his coworkers,” says Dr. Kizer, “is that they could almost predict which patients would have a demise under his care.”

Although a typical profile of the serial healthcare murderer has been demonstrated in many cases, in many other cases the demographics and behaviors of these killers have deviated widely from generalized assumptions.2 Therefore, before looking at people, look at the numbers.

An unusual number of calls and codes may occur in a particular area of the hospital. “In ICUs you expect a lot of [codes and calls], but not on general post-op wards or the pediatrics MICU,” Dr. Kizer says. “When this happens in these settings it should raise a red flag.”

Unfortunately, most hospitals don’t track mortality on a monthly basis per unit or ward or ICU, so they may not recognize when something is out of line in a timely manner. Also, the hospital committee assigned to review deaths may be remiss in its duty to meet regularly or otherwise perform according to policy.

Another factor that should raise a red flag is a disproportionate number of codes or deaths on the same shift—most often the night shift. Often, someone says, “Gee, it seems like there’s an awful lot of codes lately,” explains Dr. Kizer. An unusually high rate of successful codes is another sign.

For example, in the 1995-1996 case of Kristen Gilbert, an RN convicted of four murders at the Veterans Affairs Medical Center in Northampton, Mass., she was having an extramarital affair with a hospital security guard who worked the evening shift. Protocol required that security be called to all cardiopulmonary arrests. Gilbert used stimulant epinephrine to make their hearts race out of control. The epidemiologic data later showed that suspicious codes occurred when both were on duty. “The patients always seemed to recover and she was the hero,” says Dr. Kizer. “She wanted to look good for her boyfriend.”

Similarly, Richard Angelo, a charge nurse at Good Samaritan Hospital in West Islip, Long Island, N.Y., admitted that between 1987 and 1989 he injected patients with paralyzing drugs Pavulon (pancuronium) and Anectine (succinylcholine). He wanted his colleagues to admire him for performing well in a code. During his confession, he likened himself to volunteer firefighters who set fires. In fact, Dr. Iserson makes this same parallel. “From what we can tell,” he says, “these people don’t really care whether the person dies or not. They would rather they not [die], so they can be seen as the hero. It’s all about them.” As with instances of arson, he says, the perpetrator is “the first one to show up at the fire watch, over and over again.”

Obstacles to Disclosure

Even when healthcare workers and related personnel come forward with their suspicions, law enforcement may be a barrier to prosecution.

In the United Kingdom, a Manchester mortician took her observations about the excessive deaths and cremations in Harold Shipman’s practice to her father and brother, who were also in the family business. She also obtained the support of a local female general practitioner. The two women went to the police, explaining that most patients who had died had not been critically ill and noted that the doctor had exhibited peculiar behavior when he was questioned.

But, says Dr. Iserson, the response again was typical: “‘Oh, foolish women. That can’t be happening.’ And it wasn’t until Shipman killed the wrong person [a former town mayor, mother of a prominent lawyer] that things started to unravel for him.” When police finally looked at other deaths Shipman had certified, a pattern emerged. He would overdose patients with diamorphine, sign their death certificates, then forge medical records to indicate they were in poor health.

A second common response by institutions is just as much of a barrier to bringing these crimes to light and ultimately, prosecution. “In essence,” says Dr. Iserson, “that response is, ‘Well, maybe it is happening but, boy, it sure is going to put our institution in a bad light. So let’s just not say anything.’ ”

This was the case with Michael Swango, a doctor who worked in several states and a number of countries. He was charged with five murders and may have been involved in 126 deaths. Swango confessed to the deaths that occurred in a Veterans Affairs hospital in Northport, N.Y., where he reportedly injected three veterans with a drug that stopped their hearts. He had forged “do not resuscitate” orders for the three. He was sentenced to two life sentences. It is possible that he killed as many as 35-60 people in the United States and Zimbabwe. But before it was all out in the open, “some very prominent people were involved in sweeping it under the rug,” says Dr. Iserson, “and they didn’t even get a slap on the wrist.”

Hiring Practices

One of the most shocking aspects of the Cullen case was that institutional coverup and employee privacy policies meant his prior employers never revealed the problems to prospective employers.

“Identifying potential serial killers is not at all the total problem,” says Dr. Iserson. “The problem is getting the powers that be to act. What they typically do is pass the problem on to somebody else, in effect, saying, ‘We don’t want you to work here anymore. We won’t necessarily write you a good letter of recommendation, but we will say that you worked here, and basically we just want you to go away.’ ”

An investigation revealed that Cullen had a history of reported incidents at hospitals in Pennsylvania and New Jersey, but there were no tracking or disclosure systems in place as he moved from one hospital to another. His employment history included termination from several hospitals because of misconduct, hospitalizations for mental illness, and a criminal investigation regarding improper medication administration.

In an open letter published in The New York Times on March 14, 2004, Somerset Medical Center (Somerville, N.J.) asserted: “Mr. Cullen worked at nine other healthcare facilities over a 16-year period. His former work history problems were not revealed to us. Nor were any state agencies or licensing boards able to provide us with accurate information about his employment history.”

Cullen had been investigated by three hospitals, a nursing home, and two prosecutors for suspicious patient deaths. He was fired by five hospitals and one nursing home for suspected wrongdoing. But Cullen continued to find employment and kill patients.

“Confidentiality is essential [as is] not leaking to the media, which can taint the investigation,” says Dr. Yorker. “The Charles Cullen case should motivate hospitalists to [participate in helping to stop the systemic mechanism that made possible] his killing over 40 patients in nine different hospitals and a nursing home before being stopped. This erodes the public trust in hospitals.”

The Health Care Quality Improvement Act provides some immunity for reporters of adverse information, but it applies only to physicians—not communications between employers.

The American Society for Healthcare Risk Management (ASHRM) and Dr. Kizer and his colleagues are in alignment in advocating for the provision of more comprehensive immunity to help healthcare employees and patients when they report these incidents.3

“If you have information that a worker is harming patients, the institution should be able to tell prospective employers and not worry about getting sued,” says Dr. Yorker. A number of states have passed varying forms of legislation so far, and ASHRM is recommending this be a federal matter. Dr. Kizer and his group recommend that reporting of suspected serial murderers should be considered for coverage under Good Samaritan laws.

Other Complicating Factors

Another problem in bringing legitimate cases to prosecution is when providers are accused on trumped-up charges, which in Dr. Iserson’s view amounts to prosecutorial malpractice. Examples are cases post-Hurricane Katrina, when physicians and nurses were charged with patient deaths.

Internationally, an example is the case in Libya where the main defendants—a Palestinian doctor and five Bulgarian nurses—were charged with injecting 426 children with HIV in 1998, causing an epidemic at El-Fath Children’s Hospital in Benghazi. According to World Politics Watch, dozens of foreign medical professionals were arrested, with six eventually charged and forced to confess by Libyan authorities. Subsequent research published in the journal Nature indicated that viral strains present in the infected children were present at the hospital before 1998.

“This was a case of political blackmail,” says Dr. Iserson. These cases may not be clear-cut and may be open to negative interpretations that “make people skittish. That is why institutions are prone to say, ‘Gee, maybe it’s just one of those kinds of cases. We don’t want to make that kind of mistake.’ ”

Also problematic is the variable rate at which hospitals perform autopsies.

“Autopsy rates are down in many communities to 1% or 2% or even lower,” says Dr. Kizer. “When the data point to the possibility of a crime on a particular unit, the site needs to be treated as a crime scene. In most hospitals, when someone dies, you get them off the floor and you clean up as quickly as possible. That shouldn’t be the case if it is a suspected crime scene. Ideally there should be standardized processes or protocols whenever there is suspicion. And those protocols may be different than when a patient ordinarily dies.”

Seeking Solutions

Hospitalists and other professionals—especially nurses and ancillary personnel—have an obligation to be informed and astute regarding individual characteristics and signs of suspicious patient deaths. Appropriate epidemiological, toxicological, and psychological data must be collected and analyzed routinely.

“Data about this phenomenon need to be disseminated to heighten awareness that serial murder of patients is a significant concern that extends beyond a few shocking, isolated incidents,” write Drs. Yorker and Kizer and their co-authors.

Institutional hiring practices must be changed so balance is achieved between preventing wrongful discharge or denial-of-employment lawsuits and protecting patient safety. Existing state legislation and future federal legislation for institutional immunity is an important element of patient advocacy that hospitalists can support.

Ultimately, hospitalists must be informed, aware, and alert. “Most [suspicions] will not be anything,” says Dr. Iserson. “Just pay attention to it.” TH

Andrea Sattinger is a frequent contributor to The Hospitalist.

References

1. Yorker BC, Kizer KW, Lampe P, et al. Serial murder by healthcare professionals. J Forensic Sci. 2006 Nov;51(6):1362-1371.
2. Wolf BC, Lavezzi WA. Paths to destruction: the lives and crimes of two serial killers. J Forensic Sci. 2007 Jan;52(1):199-203.
3. ASHRM. American Society for Healthcare Risk Management. A call for federal immunity to protect health care employers … and patients. Chicago: Monograph; April 1, 2005; www.ashrm.org/ashrm/resources/files/Monograph.Immunity.pdf.

By the time a mortician in the northeast British town of Hyde, Greater Manchester, United Kingdom, noticed Dr. Harold Shipman’s patients were dying at an exorbitant rate, the doctor had probably killed close to 300 of them, according to Kenneth V. Iserson, MD, MBA, professor of emergency medicine at the University of Arizona College of Medicine and author of “Demon Doctors: Physicians as Serial Killers.”

Shipman, labeled ‘‘the most prolific serial killer in the history of the United Kingdom—and probably the world,’’ was officially convicted of killing 15 patients in 2000 and sentenced to 15 consecutive life sentences.1 In January 2004 he was found hanged in his prison cell.

Sometimes referred to as caregiver-associated serial killings, these incidents generate profound shock in the healthcare community. As repellent and relatively rare as this behavior is, and as controversial as the topic is, neither individuals nor institutions can afford to disassociate themselves from the subject. Hospitalists should not hide from this issue and should not feel they will be accused of “treason” if they educate themselves and bring suspicious behavior to the awareness of superiors, says Beatrice Crofts Yorker, JD, RN, MS, FAAN, dean of the College of Health and Human Services at California State University, Los Angeles. On the contrary, she says, “first, do no harm” also entails ensuring everyone else around you follows the same ethic.

Dr. Yorker, who has been studying this phenomenon since 1986, published the first examination of cases of serial murder by nurses in the American Journal of Nursing (AJN) in 1988. “It is a serious problem that has been under-recognized, and it is the right thing to blow the whistle when adverse patient incidents are associated with the presence of a specific healthcare provider,” says Dr. Yorker. “In fact, most of the cases came to the attention of authorities because a nurse blew the whistle. The sad thing is that some of the nurses were disciplined for their protective actions; however, they were ultimately vindicated.”

A veteran of the phenomenon urges continued vigilance. “As a general caveat, there needs to be a higher index of suspicion for these incidents,” says Kenneth W. Kizer, MD, MPH, the former head of the veterans healthcare system who had to deal with three incidents of serial murder at Veterans Affairs (VA) hospitals in the 1990s. “These incidents are grossly underreported.”

click for large version

Incidence and Cause of Death

Drs. Kizer and Yorker were two of the investigators who reviewed epidemiologic studies, toxicology evidence, and court transcripts for data on healthcare professionals prosecuted between 1970 and 2006.

“Dr. Robert Forrest, who was a forensic toxicologist getting a law degree and wrote his dissertation on the topic of serial murder by healthcare providers, contacted me after the AJN article came out,” says Dr. Yorker. Dr. Forrest has been the testifying expert in most of the U.K. cases. “After the Charles Cullen case hit the news, The New York Times and Modern Healthcare contacted me regarding my study in AJN and the Journal of Nursing Law. That is how Ken Kizer and Paula Lampe found me.” (Cullen, a registered nurse, received 11 consecutive life sentences in 2006 after pleading guilty to administering lethal doses of medication to more than 40 patients in New Jersey and Pennsylvania.)

Lampe, an author, had been studying cases in Europe. “Because both Robert and Paula provided additional data on some cases, they were co-authors—as was Ken—who provided data on the VA cases and an important public policy perspective,” says Dr. Yorker.

The search showed 90 criminal prosecutions of healthcare providers who met the criteria of serial murder of patients. Of those, 54 have been convicted—45 for serial murder, four for attempted murder, and five on lesser charges. Since the publication of their study, one more of the accused has received a sentence of life in prison, another has been convicted and sentenced to 20 years, one committed suicide in prison, and two additional nurses in Germany and the Czech Republic have been arrested and confessed to serial murder of patients. In addition, Dr. Yorker is continuing to follow two large-scale murder-for-profit prosecutions. There are four defendants in each case. Further, three individuals have been found liable for wrongful death in the amounts of $27 million, $8 million, and $450,000 in damages.

Injection was the main method used by healthcare killers, followed by suffocation, poisoning, and tampering with equipment. Prosecutions were reported in 20 countries, with 40% of the incidents taking place in the United States. Nursing personnel were 86% of the healthcare providers prosecuted; 12% were physicians, and 2% were allied health professionals. The number of patient deaths that resulted in a murder conviction is 317, and the number of suspicious patient deaths attributed to the 54 convicted caregivers is 2,113.

“Physicians as serial killers are remarkably uncommon,” says Dr. Iserson, who is also director of the Arizona Bioethics Program at the University of Arizona College of Medicine in Tucson. “Nurses [who are serial killers] are much more common, but of course there are more nurses in the hospital, just as there are ancillary people.” (See Figure 1, left.) Dr. Iserson, who practices emergency medicine and consults nationally on bioethics, advises maintaining caution when examining data of charges or suspicions that were never proved.

Most of these crimes (70%) occur in hospital units. (See Figure 2, left.) Victims are almost always female, as are almost half (49%) of convicted serial killers and 55% of the total number of prosecuted healthcare providers. Males are disproportionately represented among prosecuted nurses.

click for large version

Motives: Who Is Always There?

Although the motives are complex, some common threads connect these crimes. “There are some classical signs, if you will,” says Dr. Kizer.

When the same person repeatedly calls a code and always seems to be in the thick of it, that is one prime indicator. These people are usually legitimately present in those settings and circumstances—for example, they are on call or working a shift—which makes it more difficult to discern when something is awry. Commonly, the perpetrators have easy access to high-alert drugs without sufficient accountability. Sometimes, once an investigation has been launched it is discovered the person has falsified his or her credentials.

In hospitals, experts say, the “rescuer” or “hero” personality is often on display in those who kill patients—the first person there to give the patient drugs or attempt to save the patient.

“What you are going to see as a pattern,” says Dr. Iserson, “is that they need to be near death.” Codes or calls for respiratory arrest are the most common; patients who have cardiac arrests are much harder to save. Being the hero is not always the motive; the converse can also apply.

Such is the case with nurse Orville Lynn Majors, LPN, convicted of six murders at the Vermillion county hospital in Clinton, Ind. The deaths were consistent with injections of potassium chloride and epinephrine according to prosecutors. Majors’ coworkers were concerned that patients were coding in alarming numbers while in his care. Although this information did not come out until after he was apprehended, his coworkers had a good idea which of his patients would not survive: Patients who were whiny, demanding, or required a lot of work. “The scuttlebutt or rumor among his coworkers,” says Dr. Kizer, “is that they could almost predict which patients would have a demise under his care.”

Although a typical profile of the serial healthcare murderer has been demonstrated in many cases, in many other cases the demographics and behaviors of these killers have deviated widely from generalized assumptions.2 Therefore, before looking at people, look at the numbers.

An unusual number of calls and codes may occur in a particular area of the hospital. “In ICUs you expect a lot of [codes and calls], but not on general post-op wards or the pediatrics MICU,” Dr. Kizer says. “When this happens in these settings it should raise a red flag.”

Unfortunately, most hospitals don’t track mortality on a monthly basis per unit or ward or ICU, so they may not recognize when something is out of line in a timely manner. Also, the hospital committee assigned to review deaths may be remiss in its duty to meet regularly or otherwise perform according to policy.

Another factor that should raise a red flag is a disproportionate number of codes or deaths on the same shift—most often the night shift. Often, someone says, “Gee, it seems like there’s an awful lot of codes lately,” explains Dr. Kizer. An unusually high rate of successful codes is another sign.

For example, in the 1995-1996 case of Kristen Gilbert, an RN convicted of four murders at the Veterans Affairs Medical Center in Northampton, Mass., she was having an extramarital affair with a hospital security guard who worked the evening shift. Protocol required that security be called to all cardiopulmonary arrests. Gilbert used stimulant epinephrine to make their hearts race out of control. The epidemiologic data later showed that suspicious codes occurred when both were on duty. “The patients always seemed to recover and she was the hero,” says Dr. Kizer. “She wanted to look good for her boyfriend.”

Similarly, Richard Angelo, a charge nurse at Good Samaritan Hospital in West Islip, Long Island, N.Y., admitted that between 1987 and 1989 he injected patients with paralyzing drugs Pavulon (pancuronium) and Anectine (succinylcholine). He wanted his colleagues to admire him for performing well in a code. During his confession, he likened himself to volunteer firefighters who set fires. In fact, Dr. Iserson makes this same parallel. “From what we can tell,” he says, “these people don’t really care whether the person dies or not. They would rather they not [die], so they can be seen as the hero. It’s all about them.” As with instances of arson, he says, the perpetrator is “the first one to show up at the fire watch, over and over again.”

Obstacles to Disclosure

Even when healthcare workers and related personnel come forward with their suspicions, law enforcement may be a barrier to prosecution.

In the United Kingdom, a Manchester mortician took her observations about the excessive deaths and cremations in Harold Shipman’s practice to her father and brother, who were also in the family business. She also obtained the support of a local female general practitioner. The two women went to the police, explaining that most patients who had died had not been critically ill and noted that the doctor had exhibited peculiar behavior when he was questioned.

But, says Dr. Iserson, the response again was typical: “‘Oh, foolish women. That can’t be happening.’ And it wasn’t until Shipman killed the wrong person [a former town mayor, mother of a prominent lawyer] that things started to unravel for him.” When police finally looked at other deaths Shipman had certified, a pattern emerged. He would overdose patients with diamorphine, sign their death certificates, then forge medical records to indicate they were in poor health.

A second common response by institutions is just as much of a barrier to bringing these crimes to light and ultimately, prosecution. “In essence,” says Dr. Iserson, “that response is, ‘Well, maybe it is happening but, boy, it sure is going to put our institution in a bad light. So let’s just not say anything.’ ”

This was the case with Michael Swango, a doctor who worked in several states and a number of countries. He was charged with five murders and may have been involved in 126 deaths. Swango confessed to the deaths that occurred in a Veterans Affairs hospital in Northport, N.Y., where he reportedly injected three veterans with a drug that stopped their hearts. He had forged “do not resuscitate” orders for the three. He was sentenced to two life sentences. It is possible that he killed as many as 35-60 people in the United States and Zimbabwe. But before it was all out in the open, “some very prominent people were involved in sweeping it under the rug,” says Dr. Iserson, “and they didn’t even get a slap on the wrist.”

Hiring Practices

One of the most shocking aspects of the Cullen case was that institutional coverup and employee privacy policies meant his prior employers never revealed the problems to prospective employers.

“Identifying potential serial killers is not at all the total problem,” says Dr. Iserson. “The problem is getting the powers that be to act. What they typically do is pass the problem on to somebody else, in effect, saying, ‘We don’t want you to work here anymore. We won’t necessarily write you a good letter of recommendation, but we will say that you worked here, and basically we just want you to go away.’ ”

An investigation revealed that Cullen had a history of reported incidents at hospitals in Pennsylvania and New Jersey, but there were no tracking or disclosure systems in place as he moved from one hospital to another. His employment history included termination from several hospitals because of misconduct, hospitalizations for mental illness, and a criminal investigation regarding improper medication administration.

In an open letter published in The New York Times on March 14, 2004, Somerset Medical Center (Somerville, N.J.) asserted: “Mr. Cullen worked at nine other healthcare facilities over a 16-year period. His former work history problems were not revealed to us. Nor were any state agencies or licensing boards able to provide us with accurate information about his employment history.”

Cullen had been investigated by three hospitals, a nursing home, and two prosecutors for suspicious patient deaths. He was fired by five hospitals and one nursing home for suspected wrongdoing. But Cullen continued to find employment and kill patients.

“Confidentiality is essential [as is] not leaking to the media, which can taint the investigation,” says Dr. Yorker. “The Charles Cullen case should motivate hospitalists to [participate in helping to stop the systemic mechanism that made possible] his killing over 40 patients in nine different hospitals and a nursing home before being stopped. This erodes the public trust in hospitals.”

The Health Care Quality Improvement Act provides some immunity for reporters of adverse information, but it applies only to physicians—not communications between employers.

The American Society for Healthcare Risk Management (ASHRM) and Dr. Kizer and his colleagues are in alignment in advocating for the provision of more comprehensive immunity to help healthcare employees and patients when they report these incidents.3

“If you have information that a worker is harming patients, the institution should be able to tell prospective employers and not worry about getting sued,” says Dr. Yorker. A number of states have passed varying forms of legislation so far, and ASHRM is recommending this be a federal matter. Dr. Kizer and his group recommend that reporting of suspected serial murderers should be considered for coverage under Good Samaritan laws.

Other Complicating Factors

Another problem in bringing legitimate cases to prosecution is when providers are accused on trumped-up charges, which in Dr. Iserson’s view amounts to prosecutorial malpractice. Examples are cases post-Hurricane Katrina, when physicians and nurses were charged with patient deaths.

Internationally, an example is the case in Libya where the main defendants—a Palestinian doctor and five Bulgarian nurses—were charged with injecting 426 children with HIV in 1998, causing an epidemic at El-Fath Children’s Hospital in Benghazi. According to World Politics Watch, dozens of foreign medical professionals were arrested, with six eventually charged and forced to confess by Libyan authorities. Subsequent research published in the journal Nature indicated that viral strains present in the infected children were present at the hospital before 1998.

“This was a case of political blackmail,” says Dr. Iserson. These cases may not be clear-cut and may be open to negative interpretations that “make people skittish. That is why institutions are prone to say, ‘Gee, maybe it’s just one of those kinds of cases. We don’t want to make that kind of mistake.’ ”

Also problematic is the variable rate at which hospitals perform autopsies.

“Autopsy rates are down in many communities to 1% or 2% or even lower,” says Dr. Kizer. “When the data point to the possibility of a crime on a particular unit, the site needs to be treated as a crime scene. In most hospitals, when someone dies, you get them off the floor and you clean up as quickly as possible. That shouldn’t be the case if it is a suspected crime scene. Ideally there should be standardized processes or protocols whenever there is suspicion. And those protocols may be different than when a patient ordinarily dies.”

Seeking Solutions

Hospitalists and other professionals—especially nurses and ancillary personnel—have an obligation to be informed and astute regarding individual characteristics and signs of suspicious patient deaths. Appropriate epidemiological, toxicological, and psychological data must be collected and analyzed routinely.

“Data about this phenomenon need to be disseminated to heighten awareness that serial murder of patients is a significant concern that extends beyond a few shocking, isolated incidents,” write Drs. Yorker and Kizer and their co-authors.

Institutional hiring practices must be changed so balance is achieved between preventing wrongful discharge or denial-of-employment lawsuits and protecting patient safety. Existing state legislation and future federal legislation for institutional immunity is an important element of patient advocacy that hospitalists can support.

Ultimately, hospitalists must be informed, aware, and alert. “Most [suspicions] will not be anything,” says Dr. Iserson. “Just pay attention to it.” TH

Andrea Sattinger is a frequent contributor to The Hospitalist.

References

1. Yorker BC, Kizer KW, Lampe P, et al. Serial murder by healthcare professionals. J Forensic Sci. 2006 Nov;51(6):1362-1371.
2. Wolf BC, Lavezzi WA. Paths to destruction: the lives and crimes of two serial killers. J Forensic Sci. 2007 Jan;52(1):199-203.
3. ASHRM. American Society for Healthcare Risk Management. A call for federal immunity to protect health care employers … and patients. Chicago: Monograph; April 1, 2005; www.ashrm.org/ashrm/resources/files/Monograph.Immunity.pdf.

This is the third in a series of articles on the four pillars of career satisfaction in hospital medicine.

How much does your satisfaction with your job rely on your compensation level? What about your sense of being appreciated for what you do each day?

Many hospitalists would say the latter could be a key factor in their happiness with their career. This is confirmed in a new white paper from SHM, “A Challenge for a New Specialty: A White Paper on Hospitalist Career Satisfaction” (available online at www.hospitalmedicine.org). This document, created by SHM’s Career Satisfaction Task Force (CSTF), can be used by hospitalists and hospital medicine practices as a toolkit for improving or ensuring job satisfaction. It outlines the four pillars of career satisfaction, the third of which is reward/recognition.

The Third Pillar

The reward/recognition pillar includes not just financial rewards but also social rewards (appreciation by your colleagues, leaders, patients, and family) and intrinsic rewards (healing patients or working efficiently and productively).

Achieving on-the-job recognition requires practicing high-quality medicine, communicating this to all the groups above, and participating in professional development and leadership. It also entails building relationships with peers and allied health professionals, hospital executives, patients, and the community.

“Reward and recognition ties in a lot with the other pillars—especially community,” says CSTF member Adrienne Bennett, MD, PhD, Ohio State University Medical Center, Columbus. “Part of what makes or breaks any hospitalist job is the group you work with and how you get along. This has to do with how you’re viewed and how you’re rewarded and supported.”

The classic dichotomy of values in hospital medicine is salary versus quality of life. Some groups offer higher salaries with heavy workloads and/or many shifts, and others value time over money. But there are additional values that affect reward and recognition. For example, let’s say you want to build a career or reputation in patient safety and quality of care but you work for a hospital medicine group focused mainly on high-volume patient care that is not engaged in quality improvement work. Your group may not value or reward your efforts. This can lead to job dissatisfaction.

“Make sure the group you join has a culture that shares or at least respects and supports your other career interests,” advises Dr. Bennett. “Working with a group where you’re a good fit and that supports your career aspirations is the most important aspect of career satisfaction.”

An Example of Reward Issues

To illustrate how reward/recognition works, here’s a fictional example of a hospitalist faced with a decision regarding her career:

“I’m ready to find my first job in hospital medicine, and my husband just accepted a pulmonary fellowship at a Midwestern university hospital. There are five hospital medicine groups in the area to choose from. I have to decide which I’d prefer to work for. My main priority is that I want to be ‘a name’ in hospital medicine—I want a chance to build a good reputation nationally.”

According to the white paper, a hospitalist in this position should take several steps to ensure career satisfaction:

Step 1: Assess your choices. Use the series of questions provided in the white paper to compare programs, including compensation and benefits.

“This hospitalist seems to want something more out of her work than just the rewards that come from taking excellent care of her patients,” observes Dr. Bennett. “When she’s interviewing, she needs to ask very carefully about opportunities for leadership development and for building her local reputation, which is the first step toward larger recognition. She needs to find out if the group supports and values work on hospital and/or medical association committees. Many community-based groups do support this.”

Step 2: Once you’re hired, set short- and long-term performance goals. Understand what you want to be recognized for, and outline what you want to accomplish—whether it’s a research project, a leadership role on a committee, or simply a standard of patient care you set for yourself.

Step 3: Participate in SHM chapter meetings. Network with physicians from other hospital medicine groups, get involved, and make a name for yourself.

How Your Rewards Stack up

Whether you’re questioning the compensation package at your long-term hospitalist position or weighing a decision on taking a new job, you’ll turn to available benchmark data on hospital medicine.

“There are a lot ways that benchmarks help and hurt,” warns Dr. Bennett. “Some of it isn’t very good because it’s based on very small numbers. If you’re dealing with an employer that relies on data [for compensation levels], it’s important to know what data they’re using. A reliable employer should share that information. Even the SHM benchmark data—which is probably the best we have, since it’s based on several thousand practicing hospitalists in a variety of settings—can’t always tell you how your job compares.”

Many variations within groups and individual jobs make it hard to compare positions side by side. Differentiating factors include salary and other compensation factors, patient load, shifts and schedule (including nights and weekends), and job responsibilities.

“Sometimes you can use the number of work [relative value units] RVUs to compare workloads,” Dr. Bennett suggests.

As with all the pillars of career satisfaction, the rewards and recognitions that come with your job must be measured against what other hospitalist positions offer—but more importantly against your values and priorities. TH

Jane Jerrard has written for The Hospitalist since 2005.

This is the third in a series of articles on the four pillars of career satisfaction in hospital medicine.

How much does your satisfaction with your job rely on your compensation level? What about your sense of being appreciated for what you do each day?

Many hospitalists would say the latter could be a key factor in their happiness with their career. This is confirmed in a new white paper from SHM, “A Challenge for a New Specialty: A White Paper on Hospitalist Career Satisfaction” (available online at www.hospitalmedicine.org). This document, created by SHM’s Career Satisfaction Task Force (CSTF), can be used by hospitalists and hospital medicine practices as a toolkit for improving or ensuring job satisfaction. It outlines the four pillars of career satisfaction, the third of which is reward/recognition.

The Third Pillar

The reward/recognition pillar includes not just financial rewards but also social rewards (appreciation by your colleagues, leaders, patients, and family) and intrinsic rewards (healing patients or working efficiently and productively).

Achieving on-the-job recognition requires practicing high-quality medicine, communicating this to all the groups above, and participating in professional development and leadership. It also entails building relationships with peers and allied health professionals, hospital executives, patients, and the community.

“Reward and recognition ties in a lot with the other pillars—especially community,” says CSTF member Adrienne Bennett, MD, PhD, Ohio State University Medical Center, Columbus. “Part of what makes or breaks any hospitalist job is the group you work with and how you get along. This has to do with how you’re viewed and how you’re rewarded and supported.”

The classic dichotomy of values in hospital medicine is salary versus quality of life. Some groups offer higher salaries with heavy workloads and/or many shifts, and others value time over money. But there are additional values that affect reward and recognition. For example, let’s say you want to build a career or reputation in patient safety and quality of care but you work for a hospital medicine group focused mainly on high-volume patient care that is not engaged in quality improvement work. Your group may not value or reward your efforts. This can lead to job dissatisfaction.

“Make sure the group you join has a culture that shares or at least respects and supports your other career interests,” advises Dr. Bennett. “Working with a group where you’re a good fit and that supports your career aspirations is the most important aspect of career satisfaction.”

An Example of Reward Issues

To illustrate how reward/recognition works, here’s a fictional example of a hospitalist faced with a decision regarding her career:

“I’m ready to find my first job in hospital medicine, and my husband just accepted a pulmonary fellowship at a Midwestern university hospital. There are five hospital medicine groups in the area to choose from. I have to decide which I’d prefer to work for. My main priority is that I want to be ‘a name’ in hospital medicine—I want a chance to build a good reputation nationally.”

According to the white paper, a hospitalist in this position should take several steps to ensure career satisfaction:

Step 1: Assess your choices. Use the series of questions provided in the white paper to compare programs, including compensation and benefits.

“This hospitalist seems to want something more out of her work than just the rewards that come from taking excellent care of her patients,” observes Dr. Bennett. “When she’s interviewing, she needs to ask very carefully about opportunities for leadership development and for building her local reputation, which is the first step toward larger recognition. She needs to find out if the group supports and values work on hospital and/or medical association committees. Many community-based groups do support this.”

Step 2: Once you’re hired, set short- and long-term performance goals. Understand what you want to be recognized for, and outline what you want to accomplish—whether it’s a research project, a leadership role on a committee, or simply a standard of patient care you set for yourself.

Step 3: Participate in SHM chapter meetings. Network with physicians from other hospital medicine groups, get involved, and make a name for yourself.

How Your Rewards Stack up

Whether you’re questioning the compensation package at your long-term hospitalist position or weighing a decision on taking a new job, you’ll turn to available benchmark data on hospital medicine.

“There are a lot ways that benchmarks help and hurt,” warns Dr. Bennett. “Some of it isn’t very good because it’s based on very small numbers. If you’re dealing with an employer that relies on data [for compensation levels], it’s important to know what data they’re using. A reliable employer should share that information. Even the SHM benchmark data—which is probably the best we have, since it’s based on several thousand practicing hospitalists in a variety of settings—can’t always tell you how your job compares.”

Many variations within groups and individual jobs make it hard to compare positions side by side. Differentiating factors include salary and other compensation factors, patient load, shifts and schedule (including nights and weekends), and job responsibilities.

“Sometimes you can use the number of work [relative value units] RVUs to compare workloads,” Dr. Bennett suggests.

As with all the pillars of career satisfaction, the rewards and recognitions that come with your job must be measured against what other hospitalist positions offer—but more importantly against your values and priorities. TH

Jane Jerrard has written for The Hospitalist since 2005.

This is the third in a series of articles on the four pillars of career satisfaction in hospital medicine.

How much does your satisfaction with your job rely on your compensation level? What about your sense of being appreciated for what you do each day?

Many hospitalists would say the latter could be a key factor in their happiness with their career. This is confirmed in a new white paper from SHM, “A Challenge for a New Specialty: A White Paper on Hospitalist Career Satisfaction” (available online at www.hospitalmedicine.org). This document, created by SHM’s Career Satisfaction Task Force (CSTF), can be used by hospitalists and hospital medicine practices as a toolkit for improving or ensuring job satisfaction. It outlines the four pillars of career satisfaction, the third of which is reward/recognition.

The Third Pillar

The reward/recognition pillar includes not just financial rewards but also social rewards (appreciation by your colleagues, leaders, patients, and family) and intrinsic rewards (healing patients or working efficiently and productively).

Achieving on-the-job recognition requires practicing high-quality medicine, communicating this to all the groups above, and participating in professional development and leadership. It also entails building relationships with peers and allied health professionals, hospital executives, patients, and the community.

“Reward and recognition ties in a lot with the other pillars—especially community,” says CSTF member Adrienne Bennett, MD, PhD, Ohio State University Medical Center, Columbus. “Part of what makes or breaks any hospitalist job is the group you work with and how you get along. This has to do with how you’re viewed and how you’re rewarded and supported.”

The classic dichotomy of values in hospital medicine is salary versus quality of life. Some groups offer higher salaries with heavy workloads and/or many shifts, and others value time over money. But there are additional values that affect reward and recognition. For example, let’s say you want to build a career or reputation in patient safety and quality of care but you work for a hospital medicine group focused mainly on high-volume patient care that is not engaged in quality improvement work. Your group may not value or reward your efforts. This can lead to job dissatisfaction.

“Make sure the group you join has a culture that shares or at least respects and supports your other career interests,” advises Dr. Bennett. “Working with a group where you’re a good fit and that supports your career aspirations is the most important aspect of career satisfaction.”

An Example of Reward Issues

To illustrate how reward/recognition works, here’s a fictional example of a hospitalist faced with a decision regarding her career:

“I’m ready to find my first job in hospital medicine, and my husband just accepted a pulmonary fellowship at a Midwestern university hospital. There are five hospital medicine groups in the area to choose from. I have to decide which I’d prefer to work for. My main priority is that I want to be ‘a name’ in hospital medicine—I want a chance to build a good reputation nationally.”

According to the white paper, a hospitalist in this position should take several steps to ensure career satisfaction:

Step 1: Assess your choices. Use the series of questions provided in the white paper to compare programs, including compensation and benefits.

“This hospitalist seems to want something more out of her work than just the rewards that come from taking excellent care of her patients,” observes Dr. Bennett. “When she’s interviewing, she needs to ask very carefully about opportunities for leadership development and for building her local reputation, which is the first step toward larger recognition. She needs to find out if the group supports and values work on hospital and/or medical association committees. Many community-based groups do support this.”

Step 2: Once you’re hired, set short- and long-term performance goals. Understand what you want to be recognized for, and outline what you want to accomplish—whether it’s a research project, a leadership role on a committee, or simply a standard of patient care you set for yourself.

Step 3: Participate in SHM chapter meetings. Network with physicians from other hospital medicine groups, get involved, and make a name for yourself.

How Your Rewards Stack up

Whether you’re questioning the compensation package at your long-term hospitalist position or weighing a decision on taking a new job, you’ll turn to available benchmark data on hospital medicine.

“There are a lot ways that benchmarks help and hurt,” warns Dr. Bennett. “Some of it isn’t very good because it’s based on very small numbers. If you’re dealing with an employer that relies on data [for compensation levels], it’s important to know what data they’re using. A reliable employer should share that information. Even the SHM benchmark data—which is probably the best we have, since it’s based on several thousand practicing hospitalists in a variety of settings—can’t always tell you how your job compares.”

Many variations within groups and individual jobs make it hard to compare positions side by side. Differentiating factors include salary and other compensation factors, patient load, shifts and schedule (including nights and weekends), and job responsibilities.

“Sometimes you can use the number of work [relative value units] RVUs to compare workloads,” Dr. Bennett suggests.

As with all the pillars of career satisfaction, the rewards and recognitions that come with your job must be measured against what other hospitalist positions offer—but more importantly against your values and priorities. TH

Jane Jerrard has written for The Hospitalist since 2005.

The federal government is moving toward offering monetary rewards for reporting on specific performance indicators. When hospitals begin to seek those rewards, hospitalists will be integrally involved.

The Centers for Medicare and Medicaid Services (CMS) has been tasked with developing an approach to value-based purchasing (VBP) for Medicare hospital services beginning in fiscal year 2009. Once the proposal is complete and approved by Congress, hospitals will receive differential payments tied to their performance.

VBP is similar to pay for performance (P4P) in that it links a bonus payment to reporting on performance of specific procedures. But the payment in this case is awarded to a hospital rather than a physician. The goals for the CMS proposal include:

• Improve clinical quality;
• Address underuse, overuse, and misuse of services;
• Encourage patient-centered care;
• Reduce adverse events and improve patient safety;
• Avoid unnecessary costs;
• Stimulate investments in structural components and the re-engineering of care processes;
• Make performance results transparent to and usable by consumers; and
• Avoid creating additional disparities in healthcare and work to reduce existing disparities.

CMS has hosted two listening sessions on the VBP program, during which healthcare providers were able to directly offer suggestions and opinions. The latest information, including an options paper based on the first listening session, is available online at www.cms.hhs.gov/center/hospital.asp.

“I was impressed with their responsiveness to the feedback they received at two listening sessions,” says Gregory B. Seymann, MD, associate clinical professor, University of California, San Diego School of Medicine, Division of Hospital Medicine, and a member of SHM’s Public Policy Committee. “I can see that the second options paper incorporates a lot of the comments from the first session.”

Aligning Measures

SHM has expressed support for CMS’ VBP proposal in a letter to the agency that also urged CMS to select candidate measures for hospitals that align with those for individual physicians under the Physician Quality Reporting Initiative (PQRI), which started July 1.

“These are very similar programs; one rewards hospitals for performing certain processes of care, and one rewards physicians for performing certain processes,” Dr. Seymann explains. “We’re simply asking CMS to make sure the measures [in VBP] match up with what physicians are asked to do. Many people voiced the same comment in the listening session.”

Although there are just 17 candidate measures proposed for the first year of the VBP program, the expectation is to add a considerable number as the program continues. Many candidate measures are similar or identical to those in the PQRI, such as giving aspirin on arrival and giving aspirin, beta-blockers, and ACE inhibitors on discharge for patients with acute myocardial infarction.

Additionally, the proposed measures are identical to those in the current P4P program most hospitals already participate in, known as Reporting Hospital Quality Data for Annual Payment Update (RHQDAPU). The difference will be that instead of getting credit just for reporting the data as they do now, starting in 2009 hospitals must report publicly and perform at a certain level to get a payment update.

“Physicians, especially hospitalists, will need to watch this closely, as it is expected that the PQRI program, which is similar to RHQDAPU on the hospital level, will ultimately transition to a pay-for-performance program such as VBP,” says Dr. Seymann. “We can learn from the bumps in the road in the hospitals’ experience, and hopefully SHM can be active in ensuring that similar problems are anticipated prior to a physician-level pay-for-performance rollout. Furthermore, measures that will apply to hospitalists will likely mirror the hospital VBP measures.”

Rewards Program

Hospitals participating in the proposed VBP program can earn rewards based on two different criteria.

“This aspect is far and away the most important part of this program coming from CMS,” says Dr. Seymann. “They’ve learned from experience with the Premier [Hospital Quality Incentive Demonstration] project on hospital value-based purchasing that the hospitals that started out doing the best got the lion’s share of the reward because they were already doing well. Unfortunately, those that started at the bottom showed greater overall improvement but didn’t reach the top performance threshold, so they saw no financial recognition.”

So in the proposed VBP program, hospitals can demonstrate quality through overall performance on specific measures or through improvement over time in specific measures.

“Hospitals that reach the benchmark—the median of the top decile of performance—get the maximum number of points toward achieving the reward,” explains Dr. Seymann. “But hospitals can gain some points as long as they fall within the attainment range [between the 50th percentile and the mean of the top decile], proportional to how well they do. You get points for both the amount of improvement and the absolute attainment, and whichever score is higher comprises your score on that measure.”

Dr. Seymann calls this adjustment in the incentive structure “the most positive piece of this program,” explaining, “All hospitals have the opportunity to participate and to earn rewards.”

What It Means for Hospitalists

When VBP becomes a reality, how will that affect hospitalists?

“A lot of what hospitalists do for hospitals is improve quality,” says Dr. Seymann. “They’re likely to be asked to partner with their hospitals to put protocols in place for value-based purchasing. … Hospitals can’t make this work without physician participation, and a lot of hospital medicine groups are aligned with their hospitals on quality-improvement measures.”

It seems inevitable PQRI will morph into a CMS P4P or value-based purchasing program—or both. Whatever happens with these demonstration projects, hospitalists will be reporting on measures, and SHM wants to ensure those measures are appropriate.

“There are only 17 measures now; that’s a narrow sample to define quality at a hospital,” Dr. Seymann points out regarding VBP. “SHM will want to be involved in identifying gaps in care and recommending more measures in the future—like care coordination.” TH

Jane Jerrard also writes “Career Development” for The Hospitalist.

The federal government is moving toward offering monetary rewards for reporting on specific performance indicators. When hospitals begin to seek those rewards, hospitalists will be integrally involved.

The Centers for Medicare and Medicaid Services (CMS) has been tasked with developing an approach to value-based purchasing (VBP) for Medicare hospital services beginning in fiscal year 2009. Once the proposal is complete and approved by Congress, hospitals will receive differential payments tied to their performance.

VBP is similar to pay for performance (P4P) in that it links a bonus payment to reporting on performance of specific procedures. But the payment in this case is awarded to a hospital rather than a physician. The goals for the CMS proposal include:

• Improve clinical quality;
• Address underuse, overuse, and misuse of services;
• Encourage patient-centered care;
• Reduce adverse events and improve patient safety;
• Avoid unnecessary costs;
• Stimulate investments in structural components and the re-engineering of care processes;
• Make performance results transparent to and usable by consumers; and
• Avoid creating additional disparities in healthcare and work to reduce existing disparities.

CMS has hosted two listening sessions on the VBP program, during which healthcare providers were able to directly offer suggestions and opinions. The latest information, including an options paper based on the first listening session, is available online at www.cms.hhs.gov/center/hospital.asp.

“I was impressed with their responsiveness to the feedback they received at two listening sessions,” says Gregory B. Seymann, MD, associate clinical professor, University of California, San Diego School of Medicine, Division of Hospital Medicine, and a member of SHM’s Public Policy Committee. “I can see that the second options paper incorporates a lot of the comments from the first session.”

Aligning Measures

SHM has expressed support for CMS’ VBP proposal in a letter to the agency that also urged CMS to select candidate measures for hospitals that align with those for individual physicians under the Physician Quality Reporting Initiative (PQRI), which started July 1.

“These are very similar programs; one rewards hospitals for performing certain processes of care, and one rewards physicians for performing certain processes,” Dr. Seymann explains. “We’re simply asking CMS to make sure the measures [in VBP] match up with what physicians are asked to do. Many people voiced the same comment in the listening session.”

Although there are just 17 candidate measures proposed for the first year of the VBP program, the expectation is to add a considerable number as the program continues. Many candidate measures are similar or identical to those in the PQRI, such as giving aspirin on arrival and giving aspirin, beta-blockers, and ACE inhibitors on discharge for patients with acute myocardial infarction.

Additionally, the proposed measures are identical to those in the current P4P program most hospitals already participate in, known as Reporting Hospital Quality Data for Annual Payment Update (RHQDAPU). The difference will be that instead of getting credit just for reporting the data as they do now, starting in 2009 hospitals must report publicly and perform at a certain level to get a payment update.

“Physicians, especially hospitalists, will need to watch this closely, as it is expected that the PQRI program, which is similar to RHQDAPU on the hospital level, will ultimately transition to a pay-for-performance program such as VBP,” says Dr. Seymann. “We can learn from the bumps in the road in the hospitals’ experience, and hopefully SHM can be active in ensuring that similar problems are anticipated prior to a physician-level pay-for-performance rollout. Furthermore, measures that will apply to hospitalists will likely mirror the hospital VBP measures.”

Rewards Program

Hospitals participating in the proposed VBP program can earn rewards based on two different criteria.

“This aspect is far and away the most important part of this program coming from CMS,” says Dr. Seymann. “They’ve learned from experience with the Premier [Hospital Quality Incentive Demonstration] project on hospital value-based purchasing that the hospitals that started out doing the best got the lion’s share of the reward because they were already doing well. Unfortunately, those that started at the bottom showed greater overall improvement but didn’t reach the top performance threshold, so they saw no financial recognition.”

So in the proposed VBP program, hospitals can demonstrate quality through overall performance on specific measures or through improvement over time in specific measures.

“Hospitals that reach the benchmark—the median of the top decile of performance—get the maximum number of points toward achieving the reward,” explains Dr. Seymann. “But hospitals can gain some points as long as they fall within the attainment range [between the 50th percentile and the mean of the top decile], proportional to how well they do. You get points for both the amount of improvement and the absolute attainment, and whichever score is higher comprises your score on that measure.”

Dr. Seymann calls this adjustment in the incentive structure “the most positive piece of this program,” explaining, “All hospitals have the opportunity to participate and to earn rewards.”

What It Means for Hospitalists

When VBP becomes a reality, how will that affect hospitalists?

“A lot of what hospitalists do for hospitals is improve quality,” says Dr. Seymann. “They’re likely to be asked to partner with their hospitals to put protocols in place for value-based purchasing. … Hospitals can’t make this work without physician participation, and a lot of hospital medicine groups are aligned with their hospitals on quality-improvement measures.”

It seems inevitable PQRI will morph into a CMS P4P or value-based purchasing program—or both. Whatever happens with these demonstration projects, hospitalists will be reporting on measures, and SHM wants to ensure those measures are appropriate.

“There are only 17 measures now; that’s a narrow sample to define quality at a hospital,” Dr. Seymann points out regarding VBP. “SHM will want to be involved in identifying gaps in care and recommending more measures in the future—like care coordination.” TH

Jane Jerrard also writes “Career Development” for The Hospitalist.

The federal government is moving toward offering monetary rewards for reporting on specific performance indicators. When hospitals begin to seek those rewards, hospitalists will be integrally involved.

The Centers for Medicare and Medicaid Services (CMS) has been tasked with developing an approach to value-based purchasing (VBP) for Medicare hospital services beginning in fiscal year 2009. Once the proposal is complete and approved by Congress, hospitals will receive differential payments tied to their performance.

VBP is similar to pay for performance (P4P) in that it links a bonus payment to reporting on performance of specific procedures. But the payment in this case is awarded to a hospital rather than a physician. The goals for the CMS proposal include:

• Improve clinical quality;
• Address underuse, overuse, and misuse of services;
• Encourage patient-centered care;
• Reduce adverse events and improve patient safety;
• Avoid unnecessary costs;
• Stimulate investments in structural components and the re-engineering of care processes;
• Make performance results transparent to and usable by consumers; and
• Avoid creating additional disparities in healthcare and work to reduce existing disparities.

CMS has hosted two listening sessions on the VBP program, during which healthcare providers were able to directly offer suggestions and opinions. The latest information, including an options paper based on the first listening session, is available online at www.cms.hhs.gov/center/hospital.asp.

“I was impressed with their responsiveness to the feedback they received at two listening sessions,” says Gregory B. Seymann, MD, associate clinical professor, University of California, San Diego School of Medicine, Division of Hospital Medicine, and a member of SHM’s Public Policy Committee. “I can see that the second options paper incorporates a lot of the comments from the first session.”

Aligning Measures

SHM has expressed support for CMS’ VBP proposal in a letter to the agency that also urged CMS to select candidate measures for hospitals that align with those for individual physicians under the Physician Quality Reporting Initiative (PQRI), which started July 1.

“These are very similar programs; one rewards hospitals for performing certain processes of care, and one rewards physicians for performing certain processes,” Dr. Seymann explains. “We’re simply asking CMS to make sure the measures [in VBP] match up with what physicians are asked to do. Many people voiced the same comment in the listening session.”

Although there are just 17 candidate measures proposed for the first year of the VBP program, the expectation is to add a considerable number as the program continues. Many candidate measures are similar or identical to those in the PQRI, such as giving aspirin on arrival and giving aspirin, beta-blockers, and ACE inhibitors on discharge for patients with acute myocardial infarction.

Additionally, the proposed measures are identical to those in the current P4P program most hospitals already participate in, known as Reporting Hospital Quality Data for Annual Payment Update (RHQDAPU). The difference will be that instead of getting credit just for reporting the data as they do now, starting in 2009 hospitals must report publicly and perform at a certain level to get a payment update.

“Physicians, especially hospitalists, will need to watch this closely, as it is expected that the PQRI program, which is similar to RHQDAPU on the hospital level, will ultimately transition to a pay-for-performance program such as VBP,” says Dr. Seymann. “We can learn from the bumps in the road in the hospitals’ experience, and hopefully SHM can be active in ensuring that similar problems are anticipated prior to a physician-level pay-for-performance rollout. Furthermore, measures that will apply to hospitalists will likely mirror the hospital VBP measures.”

Rewards Program

Hospitals participating in the proposed VBP program can earn rewards based on two different criteria.

“This aspect is far and away the most important part of this program coming from CMS,” says Dr. Seymann. “They’ve learned from experience with the Premier [Hospital Quality Incentive Demonstration] project on hospital value-based purchasing that the hospitals that started out doing the best got the lion’s share of the reward because they were already doing well. Unfortunately, those that started at the bottom showed greater overall improvement but didn’t reach the top performance threshold, so they saw no financial recognition.”

So in the proposed VBP program, hospitals can demonstrate quality through overall performance on specific measures or through improvement over time in specific measures.

“Hospitals that reach the benchmark—the median of the top decile of performance—get the maximum number of points toward achieving the reward,” explains Dr. Seymann. “But hospitals can gain some points as long as they fall within the attainment range [between the 50th percentile and the mean of the top decile], proportional to how well they do. You get points for both the amount of improvement and the absolute attainment, and whichever score is higher comprises your score on that measure.”

Dr. Seymann calls this adjustment in the incentive structure “the most positive piece of this program,” explaining, “All hospitals have the opportunity to participate and to earn rewards.”

What It Means for Hospitalists

When VBP becomes a reality, how will that affect hospitalists?

“A lot of what hospitalists do for hospitals is improve quality,” says Dr. Seymann. “They’re likely to be asked to partner with their hospitals to put protocols in place for value-based purchasing. … Hospitals can’t make this work without physician participation, and a lot of hospital medicine groups are aligned with their hospitals on quality-improvement measures.”

It seems inevitable PQRI will morph into a CMS P4P or value-based purchasing program—or both. Whatever happens with these demonstration projects, hospitalists will be reporting on measures, and SHM wants to ensure those measures are appropriate.

“There are only 17 measures now; that’s a narrow sample to define quality at a hospital,” Dr. Seymann points out regarding VBP. “SHM will want to be involved in identifying gaps in care and recommending more measures in the future—like care coordination.” TH

Jane Jerrard also writes “Career Development” for The Hospitalist.

Many speakers at the recent SHM annual meeting in Dallas focused on the many ways hospitalists enhance quality of care. The teamwork necessary to effectively render inpatient services was an especially important topic.

Hospitalists have compiled a significant amount of descriptive material about their working environments and the composition and workloads of hospitalist teams. However, there is not much material available quantifying the ways that various disciplines impact the overall care-delivery metrics of multidisciplinary hospitalist teams.

The SHM Non-Physician Provider Committee is interested in collecting information on multidisciplinary programs, their component disciplines and individual providers to help identify and describe teams that have integrated nurse practitioners, physician assistants, clinical pharmacists and pharmacologists, nurse clinical care coordinators, and other related disciplines into their practices. Our goal is to develop descriptions of successful and unsuccessful implementation models.

click for large version

We would also like to collect information measuring additional domains of interest to major stakeholders. Such domains might include the clinical utilization of non-physician providers in relationship to both scope-of-practice and delegation of authority, the influence of multidisciplinary integration on patient-centered care and patient satisfaction, process and outcomes quality metrics, throughput and efficiency measures, documentation practices, hospital privileges for non-physicians, medical education in the multidisciplinary environment, risk management and, of course, reimbursement.

One might ask why the collection and analysis of such data should be of interest to hospitalists and to SHM. There are several immediate answers:

• The first reason involves manpower. Hospital medicine has become a growing discipline for physicians—one that did not exist on the radar screens of physician planners 10 years ago. However, given the growing demand for hospitalists there may be a significant shortage. To address this deficit, hospital medicine practices will need to attract new associates in the form of nurse practitioners and physician assistants. It is therefore imperative that hospitalists proactively identify barriers to the integration of non-physician providers into their practices and have successful implementation models to guide this effort.
• The second reason centers on the fact that hospitalists will continue to lead efforts to enhance quality of care. Incorporating a multidisciplinary approach—whether through the pre-rounding and follow-up of nurse clinical care coordinators, the counsel of clinical pharmacists, or the hands-on care of other disciplines—will facilitate throughput and improve quality as well as enhance patient satisfaction and communication. Identifying best practices in these particular domains will provide information crucial to success in these areas.
• The third reason is related to the cost of services. With declining reimbursements coupled with increasing costs, hospital medicine programs must identify and implement measures aimed at expense control and maximization of services. Used appropriately, non-physician providers provide a lower-cost alternative to a physician-only model. When one-to-one pairing occurs, physician/NPP team-care can be delivered in a parallel-versus-linear fashion, thus allowing for increased census as well as expedition of care.

The future of hospital medicine is one of continued growth with the demand for hospital medicine physicians far outstripping the available supply to meet the ever-increasing needs. SHM is committed to researching and sharing best practices, and views the use of multidisciplinary teams as an important model of care. Together, we can all achieve more.

If you are interested in being a part of this project or feel that this data would be of benefit to your practice, please contact the Non-Physician Provider Committee at [email protected].

Chapter Reports

Nashville

Quite a bit of networking took place before the Medtronic-sponsored presentation at Ruth’s Chris in Nashville on April 26. The SHM Nashville Chapter has re-energized itself under the co-direction of Steven Embry, MD, and Kimberly Bell, MD. Eleven Nashville-area healthcare organizations were represented by more than 28 attendees. The attendees were a multidisciplinary mix of physicians, nurses, and administrators. Shashank Desai, MD, engaged the audience with his presentation “Simple to Complex: Advances in the Management of CHF.” Dr. Desai is the medical director of the Heart Failure and Transplant Program at Inova Fairfax Hospital.

Pacific Northwest

The latest Pacific Northwest Chapter meeting of SHM was held in Seattle on May 15. A change of venue and a new focus on speakers provided local hospitalists with information they won’t find elsewhere. Joseph Bennet, MD, former president of the local chapter, gave a presentation detailing his 15 months practicing hospitalist medicine in Dunedin, New Zealand. In addition to stunning photos of the terrain, Dr. Bennet delivered a thought-provoking presentation comparing New Zealand with the United States regarding culture, medical system financing, drug and care delivery, physician training, end-of-life issues, and many more aspects.

Pittsburgh

The Pittsburgh Chapter had a meeting May 10 at Morton’s Steakhouse. The speaker for the event was Rene Alvarez, MD, director of the Critical Care Unit at University of Pittsburgh Medical Center. Dr. Alvarez discussed “Strategies for Optimal Management of Patients with Heart Failure,” which generated an excellent discussion. Various hospital medicine topics including incentives, program structures, and 24/7 programs were also discussed. Attendees included hospitalists from six local hospitals. The next meeting will be held Oct. 30. For more information on the Pittsburgh Chapter, contact Michael Cratty, MD, PhD, at [email protected].

Rocky Mountain

The Rocky Mountain Chapter held its spring meeting May 3 at the Denver Colorado Downtown Aquarium. Chapter President Eugene Chu, MD, welcomed attendees and was followed by an update from the Rocky Mountain Chapter Public Policy Committee presented by Bob Brockmann, MD, MSc. Guest speakers for the night were Edward Maa, MD, who spoke about “Seizure Management in Hospitalized Patients” and Daniel Mogyoros, MD, whose presentation was titled “Updates in Infectious Disease for Hospital Medicine.” Attendees received two AMA PRA [Physician’s Recognition Award] Category 1 credits.

San Diego

At its June 5 meeting, San Diego’s chapter discussed real-time, evidence-based practice as a means to improve patient care and share new clinical evidence with colleagues. Online access during the presentation allowed the group to review several evidence resources: PubMed, the Physician’s Information and Education Resource, the American College of Physicians Journal Club, and National Guideline Clearing House using real patient cases. Dinner was served by Blue Coral Seafood and Spirits, and Novartis sponsored the event.

Upstate South Carolina

The second meeting of the Upstate S.C. Chapter was held May 15, with close to 20 physicians representing five hospitals in upstate South Carolina. Kenneth Leeper, MD, pulmonologist, presented information on ventilator-associated pneumonia. Following the presentation, the business meeting was opened by outgoing President Raja Paladugu, MD.

The following officers were elected for 2007:

• President: Zafar Hossain, MD;
• Vice President: Imran Shaikh, MD; and
• Secretary: Shawn Morrow, MD.

The group decided to meet on a quarterly basis, with the next meeting to be held in September. TH

Many speakers at the recent SHM annual meeting in Dallas focused on the many ways hospitalists enhance quality of care. The teamwork necessary to effectively render inpatient services was an especially important topic.

Hospitalists have compiled a significant amount of descriptive material about their working environments and the composition and workloads of hospitalist teams. However, there is not much material available quantifying the ways that various disciplines impact the overall care-delivery metrics of multidisciplinary hospitalist teams.

The SHM Non-Physician Provider Committee is interested in collecting information on multidisciplinary programs, their component disciplines and individual providers to help identify and describe teams that have integrated nurse practitioners, physician assistants, clinical pharmacists and pharmacologists, nurse clinical care coordinators, and other related disciplines into their practices. Our goal is to develop descriptions of successful and unsuccessful implementation models.

click for large version

We would also like to collect information measuring additional domains of interest to major stakeholders. Such domains might include the clinical utilization of non-physician providers in relationship to both scope-of-practice and delegation of authority, the influence of multidisciplinary integration on patient-centered care and patient satisfaction, process and outcomes quality metrics, throughput and efficiency measures, documentation practices, hospital privileges for non-physicians, medical education in the multidisciplinary environment, risk management and, of course, reimbursement.

One might ask why the collection and analysis of such data should be of interest to hospitalists and to SHM. There are several immediate answers:

• The first reason involves manpower. Hospital medicine has become a growing discipline for physicians—one that did not exist on the radar screens of physician planners 10 years ago. However, given the growing demand for hospitalists there may be a significant shortage. To address this deficit, hospital medicine practices will need to attract new associates in the form of nurse practitioners and physician assistants. It is therefore imperative that hospitalists proactively identify barriers to the integration of non-physician providers into their practices and have successful implementation models to guide this effort.
• The second reason centers on the fact that hospitalists will continue to lead efforts to enhance quality of care. Incorporating a multidisciplinary approach—whether through the pre-rounding and follow-up of nurse clinical care coordinators, the counsel of clinical pharmacists, or the hands-on care of other disciplines—will facilitate throughput and improve quality as well as enhance patient satisfaction and communication. Identifying best practices in these particular domains will provide information crucial to success in these areas.
• The third reason is related to the cost of services. With declining reimbursements coupled with increasing costs, hospital medicine programs must identify and implement measures aimed at expense control and maximization of services. Used appropriately, non-physician providers provide a lower-cost alternative to a physician-only model. When one-to-one pairing occurs, physician/NPP team-care can be delivered in a parallel-versus-linear fashion, thus allowing for increased census as well as expedition of care.

The future of hospital medicine is one of continued growth with the demand for hospital medicine physicians far outstripping the available supply to meet the ever-increasing needs. SHM is committed to researching and sharing best practices, and views the use of multidisciplinary teams as an important model of care. Together, we can all achieve more.

If you are interested in being a part of this project or feel that this data would be of benefit to your practice, please contact the Non-Physician Provider Committee at [email protected].

Chapter Reports

Nashville

Quite a bit of networking took place before the Medtronic-sponsored presentation at Ruth’s Chris in Nashville on April 26. The SHM Nashville Chapter has re-energized itself under the co-direction of Steven Embry, MD, and Kimberly Bell, MD. Eleven Nashville-area healthcare organizations were represented by more than 28 attendees. The attendees were a multidisciplinary mix of physicians, nurses, and administrators. Shashank Desai, MD, engaged the audience with his presentation “Simple to Complex: Advances in the Management of CHF.” Dr. Desai is the medical director of the Heart Failure and Transplant Program at Inova Fairfax Hospital.

Pacific Northwest

The latest Pacific Northwest Chapter meeting of SHM was held in Seattle on May 15. A change of venue and a new focus on speakers provided local hospitalists with information they won’t find elsewhere. Joseph Bennet, MD, former president of the local chapter, gave a presentation detailing his 15 months practicing hospitalist medicine in Dunedin, New Zealand. In addition to stunning photos of the terrain, Dr. Bennet delivered a thought-provoking presentation comparing New Zealand with the United States regarding culture, medical system financing, drug and care delivery, physician training, end-of-life issues, and many more aspects.

Pittsburgh

The Pittsburgh Chapter had a meeting May 10 at Morton’s Steakhouse. The speaker for the event was Rene Alvarez, MD, director of the Critical Care Unit at University of Pittsburgh Medical Center. Dr. Alvarez discussed “Strategies for Optimal Management of Patients with Heart Failure,” which generated an excellent discussion. Various hospital medicine topics including incentives, program structures, and 24/7 programs were also discussed. Attendees included hospitalists from six local hospitals. The next meeting will be held Oct. 30. For more information on the Pittsburgh Chapter, contact Michael Cratty, MD, PhD, at [email protected].

Rocky Mountain

The Rocky Mountain Chapter held its spring meeting May 3 at the Denver Colorado Downtown Aquarium. Chapter President Eugene Chu, MD, welcomed attendees and was followed by an update from the Rocky Mountain Chapter Public Policy Committee presented by Bob Brockmann, MD, MSc. Guest speakers for the night were Edward Maa, MD, who spoke about “Seizure Management in Hospitalized Patients” and Daniel Mogyoros, MD, whose presentation was titled “Updates in Infectious Disease for Hospital Medicine.” Attendees received two AMA PRA [Physician’s Recognition Award] Category 1 credits.

San Diego

At its June 5 meeting, San Diego’s chapter discussed real-time, evidence-based practice as a means to improve patient care and share new clinical evidence with colleagues. Online access during the presentation allowed the group to review several evidence resources: PubMed, the Physician’s Information and Education Resource, the American College of Physicians Journal Club, and National Guideline Clearing House using real patient cases. Dinner was served by Blue Coral Seafood and Spirits, and Novartis sponsored the event.

Upstate South Carolina

The second meeting of the Upstate S.C. Chapter was held May 15, with close to 20 physicians representing five hospitals in upstate South Carolina. Kenneth Leeper, MD, pulmonologist, presented information on ventilator-associated pneumonia. Following the presentation, the business meeting was opened by outgoing President Raja Paladugu, MD.

The following officers were elected for 2007:

• President: Zafar Hossain, MD;
• Vice President: Imran Shaikh, MD; and
• Secretary: Shawn Morrow, MD.

The group decided to meet on a quarterly basis, with the next meeting to be held in September. TH

Many speakers at the recent SHM annual meeting in Dallas focused on the many ways hospitalists enhance quality of care. The teamwork necessary to effectively render inpatient services was an especially important topic.

Hospitalists have compiled a significant amount of descriptive material about their working environments and the composition and workloads of hospitalist teams. However, there is not much material available quantifying the ways that various disciplines impact the overall care-delivery metrics of multidisciplinary hospitalist teams.

The SHM Non-Physician Provider Committee is interested in collecting information on multidisciplinary programs, their component disciplines and individual providers to help identify and describe teams that have integrated nurse practitioners, physician assistants, clinical pharmacists and pharmacologists, nurse clinical care coordinators, and other related disciplines into their practices. Our goal is to develop descriptions of successful and unsuccessful implementation models.

click for large version

We would also like to collect information measuring additional domains of interest to major stakeholders. Such domains might include the clinical utilization of non-physician providers in relationship to both scope-of-practice and delegation of authority, the influence of multidisciplinary integration on patient-centered care and patient satisfaction, process and outcomes quality metrics, throughput and efficiency measures, documentation practices, hospital privileges for non-physicians, medical education in the multidisciplinary environment, risk management and, of course, reimbursement.

One might ask why the collection and analysis of such data should be of interest to hospitalists and to SHM. There are several immediate answers:

• The first reason involves manpower. Hospital medicine has become a growing discipline for physicians—one that did not exist on the radar screens of physician planners 10 years ago. However, given the growing demand for hospitalists there may be a significant shortage. To address this deficit, hospital medicine practices will need to attract new associates in the form of nurse practitioners and physician assistants. It is therefore imperative that hospitalists proactively identify barriers to the integration of non-physician providers into their practices and have successful implementation models to guide this effort.
• The second reason centers on the fact that hospitalists will continue to lead efforts to enhance quality of care. Incorporating a multidisciplinary approach—whether through the pre-rounding and follow-up of nurse clinical care coordinators, the counsel of clinical pharmacists, or the hands-on care of other disciplines—will facilitate throughput and improve quality as well as enhance patient satisfaction and communication. Identifying best practices in these particular domains will provide information crucial to success in these areas.
• The third reason is related to the cost of services. With declining reimbursements coupled with increasing costs, hospital medicine programs must identify and implement measures aimed at expense control and maximization of services. Used appropriately, non-physician providers provide a lower-cost alternative to a physician-only model. When one-to-one pairing occurs, physician/NPP team-care can be delivered in a parallel-versus-linear fashion, thus allowing for increased census as well as expedition of care.

The future of hospital medicine is one of continued growth with the demand for hospital medicine physicians far outstripping the available supply to meet the ever-increasing needs. SHM is committed to researching and sharing best practices, and views the use of multidisciplinary teams as an important model of care. Together, we can all achieve more.

If you are interested in being a part of this project or feel that this data would be of benefit to your practice, please contact the Non-Physician Provider Committee at [email protected].

Chapter Reports

Nashville

Quite a bit of networking took place before the Medtronic-sponsored presentation at Ruth’s Chris in Nashville on April 26. The SHM Nashville Chapter has re-energized itself under the co-direction of Steven Embry, MD, and Kimberly Bell, MD. Eleven Nashville-area healthcare organizations were represented by more than 28 attendees. The attendees were a multidisciplinary mix of physicians, nurses, and administrators. Shashank Desai, MD, engaged the audience with his presentation “Simple to Complex: Advances in the Management of CHF.” Dr. Desai is the medical director of the Heart Failure and Transplant Program at Inova Fairfax Hospital.

Pacific Northwest

The latest Pacific Northwest Chapter meeting of SHM was held in Seattle on May 15. A change of venue and a new focus on speakers provided local hospitalists with information they won’t find elsewhere. Joseph Bennet, MD, former president of the local chapter, gave a presentation detailing his 15 months practicing hospitalist medicine in Dunedin, New Zealand. In addition to stunning photos of the terrain, Dr. Bennet delivered a thought-provoking presentation comparing New Zealand with the United States regarding culture, medical system financing, drug and care delivery, physician training, end-of-life issues, and many more aspects.

Pittsburgh

The Pittsburgh Chapter had a meeting May 10 at Morton’s Steakhouse. The speaker for the event was Rene Alvarez, MD, director of the Critical Care Unit at University of Pittsburgh Medical Center. Dr. Alvarez discussed “Strategies for Optimal Management of Patients with Heart Failure,” which generated an excellent discussion. Various hospital medicine topics including incentives, program structures, and 24/7 programs were also discussed. Attendees included hospitalists from six local hospitals. The next meeting will be held Oct. 30. For more information on the Pittsburgh Chapter, contact Michael Cratty, MD, PhD, at [email protected].

Rocky Mountain

The Rocky Mountain Chapter held its spring meeting May 3 at the Denver Colorado Downtown Aquarium. Chapter President Eugene Chu, MD, welcomed attendees and was followed by an update from the Rocky Mountain Chapter Public Policy Committee presented by Bob Brockmann, MD, MSc. Guest speakers for the night were Edward Maa, MD, who spoke about “Seizure Management in Hospitalized Patients” and Daniel Mogyoros, MD, whose presentation was titled “Updates in Infectious Disease for Hospital Medicine.” Attendees received two AMA PRA [Physician’s Recognition Award] Category 1 credits.

San Diego

At its June 5 meeting, San Diego’s chapter discussed real-time, evidence-based practice as a means to improve patient care and share new clinical evidence with colleagues. Online access during the presentation allowed the group to review several evidence resources: PubMed, the Physician’s Information and Education Resource, the American College of Physicians Journal Club, and National Guideline Clearing House using real patient cases. Dinner was served by Blue Coral Seafood and Spirits, and Novartis sponsored the event.

Upstate South Carolina

The second meeting of the Upstate S.C. Chapter was held May 15, with close to 20 physicians representing five hospitals in upstate South Carolina. Kenneth Leeper, MD, pulmonologist, presented information on ventilator-associated pneumonia. Following the presentation, the business meeting was opened by outgoing President Raja Paladugu, MD.

The following officers were elected for 2007:

• President: Zafar Hossain, MD;
• Vice President: Imran Shaikh, MD; and
• Secretary: Shawn Morrow, MD.

The group decided to meet on a quarterly basis, with the next meeting to be held in September. TH

There are more than 20,000 practicing hospitalists in the United States, and yet from every corner of hospital medicine it seems everyone is looking for more hospitalists.

While SHM has been touting that there will be 30,000 hospitalists in the next five years, others are now calling for 40,000 and more. At the SHM Annual Meeting in Dallas in May, Bob Wachter, MD, predicted a specialty with as many as 50,000 hospitalists. What is driving this logarithmic growth in hospital medicine?

Initial studies by Jon Lurie, MD, of Dartmouth Medical School, Hanover, N.H., and others dating back to the late 1990s cited the need for “only” 20,000 hospitalists. Ten years later, those studies seem almost primitive.

Originally, hospitalists were perceived necessary to replace the inpatient work for a small percentage of family practitioners and general internists—mainly at larger hospitals. While there was initial resistance from primary care physicians (PCP) in the early years of hospital medicine, the rapid adoption of hospital medicine by most PCPs has driven our rapid growth. Now, hospital administrators are frequently besieged by their PCP base to “get us some hospitalists” rather than to block hospitalists from the medical staff. And this occurs at not only 500-bed hospitals but at many hospitals with fewer than 100 beds.

More recently hospitalists have been active in co-managing surgical patients, handling glycemic control, preventing DVT, and writing scrips for the antibiotics. This frees the surgeon to concentrate on operative and post-operative surgical aspects of the case. This division of labor allows specialists to use their unique talents, which can lead to better patient outcomes. Hospitalists frequently also staff a pre-admission clinic to evaluate elective surgical patients prior to admission to the hospital. Surgical co-management also is happening with orthopedics and neurosurgery at community hospitals and major academic medical centers.

The increasing role of hospitalists in what was traditionally subspecialty cases is further fueling the growth of hospital medicine. Hospitalists now admit more heart failure patients than cardiologists, manage more inpatient diabetic cases than endocrinologists, and have virtually replaced neurologists to manage inpatient stroke patients. Once again this allows specialists to focus their expertise as best they can, while hospitalists manage the aspects of these complex cases that fall under their purview.

Hospitalists also find themselves with an expanded role in the critical care arena, working with an inadequate supply of intensivists to help manage patients in extremis. And hospitalists are being called into the emergency department (ED), where they serve as in-house consultant, improve the movement of patients out of the ED, and take over some or all the responsibilities of managing the observation units.

Add to this clinical work the time hospitalists must spend on quality improvement, team building, systems changing, and education. The workload is expanding all the time as the hospitalist job description grows and grows.

With the prospect that almost every hospital is starting and growing its hospital medicine group (HMG)—therefore expanding the scope of hospital medicine—it is no wonder predictions of the need for 50,000 hospitalists are becoming credible.

And almost every hospital medicine company is growing. At this year’s SHM Annual Meeting in Dallas I talked to leaders from Emcare (Dallas), Cogent Healthcare (Irvine, Calif.), TeamHealth (Knoxville, Tenn.), Sound Inpatient Physicians (Tacoma, Wash.), Eagle Hospital Physicians (Atlanta), PrimeDoc (Asheville, N.C.), IPC–The Hospitalist Company (North Hollywood, Calif.), and other large employers of hospitalists. Every one of them saw their organizations adding HMGs, needing more hospitalists, and wondering where they will find them.

SHM has benefited by this recruitment feeding frenzy. Just look at the ads in this issue of The Hospitalist, surf SHM’s Online Career Center, or visit our meeting’s Exhibit Hall to see the tangible expression of the need to find more hospitalists. This cannot be solved by hospitalists jumping from one place to another. We need to find a way to attract a new wave of qualified hospitalists into our specialty.

Where will these new hospitalists come from?

Right now about 8% of internal medicine residency graduates enter hospital medicine. While this is a steady stream of new hospitalists, the flow is but a trickle and we need a rapid current. Is it time for hospital medicine to develop a more aggressive recruitment strategy geared to third-year medical students to pull them into hospital medicine with offers of a job or loan repayment?

In addition, some general internists move into hospital medicine each year, but this is a shrinking pool of potential new hospitalists. While 3% of hospitalists have been trained as family practitioners, there are no good statistics on how many family practitioner residents select hospital medicine as a career or how many family practitioners in practice come to hospital medicine. While the guess is that the pool of family practitioners presents an opportunity for future hospitalists, there are some concerns about how well today’s family practitioner residency training prepares young physicians to step right into the role of a hospitalist.

There are other sources for hospitalist physicians from overseas. Currently 25% of the U.S. physician workforce is made up of international medical graduates (IMGs).1 Further, 35% of internal medicine residents and fellows are graduates of medical schools outside the United States.2 SHM’s surveys indicate that approximately 26% of hospitalists are IMGs. That said, hiring physicians from outside the U.S. can present residency and visa issues that complicate employment. Will hospital medicine employers need to look abroad in the same way the U.S. has become a major importer of RNs and other health professionals?

Speaking of nonphysician providers, 5% of hospitalists are PAs and NPs, and this segment appears to be growing. Are there strategies that allow for increased use of nonphysicians in the hospital medicine workforce that can allow a group of hospitalists to be more productive and meet all their stretch goals?

While the question is clear—where will the next 20,000 to 30,000 hospitalists come from?—the answer is somewhat muddled. With this in mind, SHM will hold the National Summit on Hospital Medicine Workforce Issues in late 2007. This will be a practical work group made up of the key national leaders of hospital medicine employers along with key decision makers from medical schools, family practice, pediatrics, internal medicine residency programs, the nonphysician provider community, and others who can help set a direction to solve what is rapidly becoming a crisis in manpower. From this summit SHM hopes to have clear, actionable strategies to create an environment for continued growth and maturation of hospital medicine and deliver on the promise of better healthcare for the patients and the communities we serve. TH

Dr. Wellikson is the CEO of SHM.

References

1. Mullan F. The metrics of the physician brain drain. N Engl J Med. 2005 Oct 27;353(17):1810-1818.
2. Brotherton SE, Rockey PH, Etzel SI. US graduate medical education, 2004-2005: Trends in primary care specialties. JAMA. 2005 Sep 7;294(9):1075-1082.

There are more than 20,000 practicing hospitalists in the United States, and yet from every corner of hospital medicine it seems everyone is looking for more hospitalists.

While SHM has been touting that there will be 30,000 hospitalists in the next five years, others are now calling for 40,000 and more. At the SHM Annual Meeting in Dallas in May, Bob Wachter, MD, predicted a specialty with as many as 50,000 hospitalists. What is driving this logarithmic growth in hospital medicine?

Initial studies by Jon Lurie, MD, of Dartmouth Medical School, Hanover, N.H., and others dating back to the late 1990s cited the need for “only” 20,000 hospitalists. Ten years later, those studies seem almost primitive.

Originally, hospitalists were perceived necessary to replace the inpatient work for a small percentage of family practitioners and general internists—mainly at larger hospitals. While there was initial resistance from primary care physicians (PCP) in the early years of hospital medicine, the rapid adoption of hospital medicine by most PCPs has driven our rapid growth. Now, hospital administrators are frequently besieged by their PCP base to “get us some hospitalists” rather than to block hospitalists from the medical staff. And this occurs at not only 500-bed hospitals but at many hospitals with fewer than 100 beds.

More recently hospitalists have been active in co-managing surgical patients, handling glycemic control, preventing DVT, and writing scrips for the antibiotics. This frees the surgeon to concentrate on operative and post-operative surgical aspects of the case. This division of labor allows specialists to use their unique talents, which can lead to better patient outcomes. Hospitalists frequently also staff a pre-admission clinic to evaluate elective surgical patients prior to admission to the hospital. Surgical co-management also is happening with orthopedics and neurosurgery at community hospitals and major academic medical centers.

The increasing role of hospitalists in what was traditionally subspecialty cases is further fueling the growth of hospital medicine. Hospitalists now admit more heart failure patients than cardiologists, manage more inpatient diabetic cases than endocrinologists, and have virtually replaced neurologists to manage inpatient stroke patients. Once again this allows specialists to focus their expertise as best they can, while hospitalists manage the aspects of these complex cases that fall under their purview.

Hospitalists also find themselves with an expanded role in the critical care arena, working with an inadequate supply of intensivists to help manage patients in extremis. And hospitalists are being called into the emergency department (ED), where they serve as in-house consultant, improve the movement of patients out of the ED, and take over some or all the responsibilities of managing the observation units.

Add to this clinical work the time hospitalists must spend on quality improvement, team building, systems changing, and education. The workload is expanding all the time as the hospitalist job description grows and grows.

With the prospect that almost every hospital is starting and growing its hospital medicine group (HMG)—therefore expanding the scope of hospital medicine—it is no wonder predictions of the need for 50,000 hospitalists are becoming credible.

And almost every hospital medicine company is growing. At this year’s SHM Annual Meeting in Dallas I talked to leaders from Emcare (Dallas), Cogent Healthcare (Irvine, Calif.), TeamHealth (Knoxville, Tenn.), Sound Inpatient Physicians (Tacoma, Wash.), Eagle Hospital Physicians (Atlanta), PrimeDoc (Asheville, N.C.), IPC–The Hospitalist Company (North Hollywood, Calif.), and other large employers of hospitalists. Every one of them saw their organizations adding HMGs, needing more hospitalists, and wondering where they will find them.

SHM has benefited by this recruitment feeding frenzy. Just look at the ads in this issue of The Hospitalist, surf SHM’s Online Career Center, or visit our meeting’s Exhibit Hall to see the tangible expression of the need to find more hospitalists. This cannot be solved by hospitalists jumping from one place to another. We need to find a way to attract a new wave of qualified hospitalists into our specialty.

Where will these new hospitalists come from?

Right now about 8% of internal medicine residency graduates enter hospital medicine. While this is a steady stream of new hospitalists, the flow is but a trickle and we need a rapid current. Is it time for hospital medicine to develop a more aggressive recruitment strategy geared to third-year medical students to pull them into hospital medicine with offers of a job or loan repayment?

In addition, some general internists move into hospital medicine each year, but this is a shrinking pool of potential new hospitalists. While 3% of hospitalists have been trained as family practitioners, there are no good statistics on how many family practitioner residents select hospital medicine as a career or how many family practitioners in practice come to hospital medicine. While the guess is that the pool of family practitioners presents an opportunity for future hospitalists, there are some concerns about how well today’s family practitioner residency training prepares young physicians to step right into the role of a hospitalist.

There are other sources for hospitalist physicians from overseas. Currently 25% of the U.S. physician workforce is made up of international medical graduates (IMGs).1 Further, 35% of internal medicine residents and fellows are graduates of medical schools outside the United States.2 SHM’s surveys indicate that approximately 26% of hospitalists are IMGs. That said, hiring physicians from outside the U.S. can present residency and visa issues that complicate employment. Will hospital medicine employers need to look abroad in the same way the U.S. has become a major importer of RNs and other health professionals?

Speaking of nonphysician providers, 5% of hospitalists are PAs and NPs, and this segment appears to be growing. Are there strategies that allow for increased use of nonphysicians in the hospital medicine workforce that can allow a group of hospitalists to be more productive and meet all their stretch goals?

While the question is clear—where will the next 20,000 to 30,000 hospitalists come from?—the answer is somewhat muddled. With this in mind, SHM will hold the National Summit on Hospital Medicine Workforce Issues in late 2007. This will be a practical work group made up of the key national leaders of hospital medicine employers along with key decision makers from medical schools, family practice, pediatrics, internal medicine residency programs, the nonphysician provider community, and others who can help set a direction to solve what is rapidly becoming a crisis in manpower. From this summit SHM hopes to have clear, actionable strategies to create an environment for continued growth and maturation of hospital medicine and deliver on the promise of better healthcare for the patients and the communities we serve. TH

Dr. Wellikson is the CEO of SHM.

References

1. Mullan F. The metrics of the physician brain drain. N Engl J Med. 2005 Oct 27;353(17):1810-1818.
2. Brotherton SE, Rockey PH, Etzel SI. US graduate medical education, 2004-2005: Trends in primary care specialties. JAMA. 2005 Sep 7;294(9):1075-1082.

There are more than 20,000 practicing hospitalists in the United States, and yet from every corner of hospital medicine it seems everyone is looking for more hospitalists.

While SHM has been touting that there will be 30,000 hospitalists in the next five years, others are now calling for 40,000 and more. At the SHM Annual Meeting in Dallas in May, Bob Wachter, MD, predicted a specialty with as many as 50,000 hospitalists. What is driving this logarithmic growth in hospital medicine?

Initial studies by Jon Lurie, MD, of Dartmouth Medical School, Hanover, N.H., and others dating back to the late 1990s cited the need for “only” 20,000 hospitalists. Ten years later, those studies seem almost primitive.

Originally, hospitalists were perceived necessary to replace the inpatient work for a small percentage of family practitioners and general internists—mainly at larger hospitals. While there was initial resistance from primary care physicians (PCP) in the early years of hospital medicine, the rapid adoption of hospital medicine by most PCPs has driven our rapid growth. Now, hospital administrators are frequently besieged by their PCP base to “get us some hospitalists” rather than to block hospitalists from the medical staff. And this occurs at not only 500-bed hospitals but at many hospitals with fewer than 100 beds.

More recently hospitalists have been active in co-managing surgical patients, handling glycemic control, preventing DVT, and writing scrips for the antibiotics. This frees the surgeon to concentrate on operative and post-operative surgical aspects of the case. This division of labor allows specialists to use their unique talents, which can lead to better patient outcomes. Hospitalists frequently also staff a pre-admission clinic to evaluate elective surgical patients prior to admission to the hospital. Surgical co-management also is happening with orthopedics and neurosurgery at community hospitals and major academic medical centers.

The increasing role of hospitalists in what was traditionally subspecialty cases is further fueling the growth of hospital medicine. Hospitalists now admit more heart failure patients than cardiologists, manage more inpatient diabetic cases than endocrinologists, and have virtually replaced neurologists to manage inpatient stroke patients. Once again this allows specialists to focus their expertise as best they can, while hospitalists manage the aspects of these complex cases that fall under their purview.

Hospitalists also find themselves with an expanded role in the critical care arena, working with an inadequate supply of intensivists to help manage patients in extremis. And hospitalists are being called into the emergency department (ED), where they serve as in-house consultant, improve the movement of patients out of the ED, and take over some or all the responsibilities of managing the observation units.

Add to this clinical work the time hospitalists must spend on quality improvement, team building, systems changing, and education. The workload is expanding all the time as the hospitalist job description grows and grows.

With the prospect that almost every hospital is starting and growing its hospital medicine group (HMG)—therefore expanding the scope of hospital medicine—it is no wonder predictions of the need for 50,000 hospitalists are becoming credible.

And almost every hospital medicine company is growing. At this year’s SHM Annual Meeting in Dallas I talked to leaders from Emcare (Dallas), Cogent Healthcare (Irvine, Calif.), TeamHealth (Knoxville, Tenn.), Sound Inpatient Physicians (Tacoma, Wash.), Eagle Hospital Physicians (Atlanta), PrimeDoc (Asheville, N.C.), IPC–The Hospitalist Company (North Hollywood, Calif.), and other large employers of hospitalists. Every one of them saw their organizations adding HMGs, needing more hospitalists, and wondering where they will find them.

SHM has benefited by this recruitment feeding frenzy. Just look at the ads in this issue of The Hospitalist, surf SHM’s Online Career Center, or visit our meeting’s Exhibit Hall to see the tangible expression of the need to find more hospitalists. This cannot be solved by hospitalists jumping from one place to another. We need to find a way to attract a new wave of qualified hospitalists into our specialty.

Where will these new hospitalists come from?

Right now about 8% of internal medicine residency graduates enter hospital medicine. While this is a steady stream of new hospitalists, the flow is but a trickle and we need a rapid current. Is it time for hospital medicine to develop a more aggressive recruitment strategy geared to third-year medical students to pull them into hospital medicine with offers of a job or loan repayment?

In addition, some general internists move into hospital medicine each year, but this is a shrinking pool of potential new hospitalists. While 3% of hospitalists have been trained as family practitioners, there are no good statistics on how many family practitioner residents select hospital medicine as a career or how many family practitioners in practice come to hospital medicine. While the guess is that the pool of family practitioners presents an opportunity for future hospitalists, there are some concerns about how well today’s family practitioner residency training prepares young physicians to step right into the role of a hospitalist.

There are other sources for hospitalist physicians from overseas. Currently 25% of the U.S. physician workforce is made up of international medical graduates (IMGs).1 Further, 35% of internal medicine residents and fellows are graduates of medical schools outside the United States.2 SHM’s surveys indicate that approximately 26% of hospitalists are IMGs. That said, hiring physicians from outside the U.S. can present residency and visa issues that complicate employment. Will hospital medicine employers need to look abroad in the same way the U.S. has become a major importer of RNs and other health professionals?

Speaking of nonphysician providers, 5% of hospitalists are PAs and NPs, and this segment appears to be growing. Are there strategies that allow for increased use of nonphysicians in the hospital medicine workforce that can allow a group of hospitalists to be more productive and meet all their stretch goals?

While the question is clear—where will the next 20,000 to 30,000 hospitalists come from?—the answer is somewhat muddled. With this in mind, SHM will hold the National Summit on Hospital Medicine Workforce Issues in late 2007. This will be a practical work group made up of the key national leaders of hospital medicine employers along with key decision makers from medical schools, family practice, pediatrics, internal medicine residency programs, the nonphysician provider community, and others who can help set a direction to solve what is rapidly becoming a crisis in manpower. From this summit SHM hopes to have clear, actionable strategies to create an environment for continued growth and maturation of hospital medicine and deliver on the promise of better healthcare for the patients and the communities we serve. TH

Dr. Wellikson is the CEO of SHM.

References

1. Mullan F. The metrics of the physician brain drain. N Engl J Med. 2005 Oct 27;353(17):1810-1818.
2. Brotherton SE, Rockey PH, Etzel SI. US graduate medical education, 2004-2005: Trends in primary care specialties. JAMA. 2005 Sep 7;294(9):1075-1082.

Jane Jerrard covered some potential career paths for academic hospitalists in her article “How to Navigate Hospital Medicine” (May 2007, p. 9). But I believe her account was incomplete. I would like to add detail to the opportunities in community-based and other programs.

Community-based medical groups offer a number of opportunities in hospitals or hospital systems. These include:

• Committee chairman. Most hospitals want interested, dedicated individuals to chair traditional medical staff committees. Hospitalists are well suited because our unique perspective lets us identify processes or products that can help many patients. Begin by serving on a committee, such as ethics, pharmacy and therapeutics, IRB, or departmental peer review. As you get comfortable, discuss potential chairmanships with the chief of staff or the vice president of medical affairs (VPMA). Don’t expect to advance if you don’t show up or don’t come prepared to committee meetings.
• Department chairperson. These positions are often elected and may allow one to serve on the credentials committee and the medical executive committee.
• Medical staff officers. Hospitalists often are elected to these key positions and gain access to administration and various committees.
• Project manager. Installing and using electronic medical records and devices calls for physician involvement in design and support. These are great chances to work on interesting projects and affect the tools you work with.
• Hospital administrative positions. Many hospitals have a VPMA or a chief medical officer (CMO), and some are developing the role of vice president of quality. These can be full- or part-time positions. You will be expected to help members of the medical staff implement change, and you should have experience and proven effectiveness in prior roles. Several predict that hospital COOs and CEOs of the future will be hospitalists.

Another path of opportunity is within your organization, depending on your employer. These roles may overlap with hospital positions:

• Group leader. Generally responsible for working on scheduling, recruitment, and organizational structure. The job may involve responsibility for one or more facilities.
• Compliance officer. Someone in the group must understand billing, coding, and proper use of rules and legislation.
• Quality and safety officer.
• Group president.

Hospitalists can also participate on committees that deal with such areas as pension plans, contracts, or other business.

Health insurance companies provide opportunities for individuals to practice part-time and serve as medical directors. They also have career paths for VPMAs and CMOs.

Also, many healthcare companies have been started and run by physicians. Invent something; start a company. The opportunities are endless.

Some other tips:

• Educate yourself. Take courses like the SHM Leadership Academy. Learn how to interact in a businesslike manner. Some on-the-job training is OK, but management and leadership are new fields that require new learning.
• Read. There are many great books on being an executive. Learn how to run a meeting, make an agenda, work with other professionals, and delegate.
• Ask for help. Find an individual or individuals with whom you can discuss ideas. Some of your best mentors will be managers in other fields.

Mary Jo Gorman, MD, MBA

Immediate Past President, SHM

Consequences of Locum Tenens Work

I feel one piece of advice in the Career Development section in the May issue of The Hospitalist (“How to Navigate Hospital Medicine,” p. 9) is not complete and may adversely affect a new hospitalist’s career.

The article recommends exploring locum tenens work. We have found two unintended consequences of such action. First, the locum companies usually have a buyout clause for the physician. Should he decide he likes a location and wishes to stay, the potential employer faces an additional cost in the $20,000-$30,000 range. It makes budgeting difficult. Also, there is usually a clause in the locum contract that this policy is in place for two years after leaving the locum company.

Second, frequent job changes lead to prolonged processing of credentials at hospitals as they verify good standing at all previous practice sites. This means delays that force a hospitalist company to look for more readily available docs. The physician may be unable to find hospitals in highly desirable areas.

The article was otherwise well balanced and timely.

George Block, MD

CMO, Galen Inpatient Physicians Medical Group

Emeryville, Calif.

Jane Jerrard covered some potential career paths for academic hospitalists in her article “How to Navigate Hospital Medicine” (May 2007, p. 9). But I believe her account was incomplete. I would like to add detail to the opportunities in community-based and other programs.

Community-based medical groups offer a number of opportunities in hospitals or hospital systems. These include:

• Committee chairman. Most hospitals want interested, dedicated individuals to chair traditional medical staff committees. Hospitalists are well suited because our unique perspective lets us identify processes or products that can help many patients. Begin by serving on a committee, such as ethics, pharmacy and therapeutics, IRB, or departmental peer review. As you get comfortable, discuss potential chairmanships with the chief of staff or the vice president of medical affairs (VPMA). Don’t expect to advance if you don’t show up or don’t come prepared to committee meetings.
• Department chairperson. These positions are often elected and may allow one to serve on the credentials committee and the medical executive committee.
• Medical staff officers. Hospitalists often are elected to these key positions and gain access to administration and various committees.
• Project manager. Installing and using electronic medical records and devices calls for physician involvement in design and support. These are great chances to work on interesting projects and affect the tools you work with.
• Hospital administrative positions. Many hospitals have a VPMA or a chief medical officer (CMO), and some are developing the role of vice president of quality. These can be full- or part-time positions. You will be expected to help members of the medical staff implement change, and you should have experience and proven effectiveness in prior roles. Several predict that hospital COOs and CEOs of the future will be hospitalists.

Another path of opportunity is within your organization, depending on your employer. These roles may overlap with hospital positions:

• Group leader. Generally responsible for working on scheduling, recruitment, and organizational structure. The job may involve responsibility for one or more facilities.
• Compliance officer. Someone in the group must understand billing, coding, and proper use of rules and legislation.
• Quality and safety officer.
• Group president.

Hospitalists can also participate on committees that deal with such areas as pension plans, contracts, or other business.

Health insurance companies provide opportunities for individuals to practice part-time and serve as medical directors. They also have career paths for VPMAs and CMOs.

Also, many healthcare companies have been started and run by physicians. Invent something; start a company. The opportunities are endless.

Some other tips:

• Educate yourself. Take courses like the SHM Leadership Academy. Learn how to interact in a businesslike manner. Some on-the-job training is OK, but management and leadership are new fields that require new learning.
• Read. There are many great books on being an executive. Learn how to run a meeting, make an agenda, work with other professionals, and delegate.
• Ask for help. Find an individual or individuals with whom you can discuss ideas. Some of your best mentors will be managers in other fields.

Mary Jo Gorman, MD, MBA

Immediate Past President, SHM

Consequences of Locum Tenens Work

I feel one piece of advice in the Career Development section in the May issue of The Hospitalist (“How to Navigate Hospital Medicine,” p. 9) is not complete and may adversely affect a new hospitalist’s career.

The article recommends exploring locum tenens work. We have found two unintended consequences of such action. First, the locum companies usually have a buyout clause for the physician. Should he decide he likes a location and wishes to stay, the potential employer faces an additional cost in the $20,000-$30,000 range. It makes budgeting difficult. Also, there is usually a clause in the locum contract that this policy is in place for two years after leaving the locum company.

Second, frequent job changes lead to prolonged processing of credentials at hospitals as they verify good standing at all previous practice sites. This means delays that force a hospitalist company to look for more readily available docs. The physician may be unable to find hospitals in highly desirable areas.

The article was otherwise well balanced and timely.

George Block, MD

CMO, Galen Inpatient Physicians Medical Group

Emeryville, Calif.

Jane Jerrard covered some potential career paths for academic hospitalists in her article “How to Navigate Hospital Medicine” (May 2007, p. 9). But I believe her account was incomplete. I would like to add detail to the opportunities in community-based and other programs.

Community-based medical groups offer a number of opportunities in hospitals or hospital systems. These include:

• Committee chairman. Most hospitals want interested, dedicated individuals to chair traditional medical staff committees. Hospitalists are well suited because our unique perspective lets us identify processes or products that can help many patients. Begin by serving on a committee, such as ethics, pharmacy and therapeutics, IRB, or departmental peer review. As you get comfortable, discuss potential chairmanships with the chief of staff or the vice president of medical affairs (VPMA). Don’t expect to advance if you don’t show up or don’t come prepared to committee meetings.
• Department chairperson. These positions are often elected and may allow one to serve on the credentials committee and the medical executive committee.
• Medical staff officers. Hospitalists often are elected to these key positions and gain access to administration and various committees.
• Project manager. Installing and using electronic medical records and devices calls for physician involvement in design and support. These are great chances to work on interesting projects and affect the tools you work with.
• Hospital administrative positions. Many hospitals have a VPMA or a chief medical officer (CMO), and some are developing the role of vice president of quality. These can be full- or part-time positions. You will be expected to help members of the medical staff implement change, and you should have experience and proven effectiveness in prior roles. Several predict that hospital COOs and CEOs of the future will be hospitalists.

Another path of opportunity is within your organization, depending on your employer. These roles may overlap with hospital positions:

• Group leader. Generally responsible for working on scheduling, recruitment, and organizational structure. The job may involve responsibility for one or more facilities.
• Compliance officer. Someone in the group must understand billing, coding, and proper use of rules and legislation.
• Quality and safety officer.
• Group president.

Hospitalists can also participate on committees that deal with such areas as pension plans, contracts, or other business.

Health insurance companies provide opportunities for individuals to practice part-time and serve as medical directors. They also have career paths for VPMAs and CMOs.

Also, many healthcare companies have been started and run by physicians. Invent something; start a company. The opportunities are endless.

Some other tips:

• Educate yourself. Take courses like the SHM Leadership Academy. Learn how to interact in a businesslike manner. Some on-the-job training is OK, but management and leadership are new fields that require new learning.
• Read. There are many great books on being an executive. Learn how to run a meeting, make an agenda, work with other professionals, and delegate.
• Ask for help. Find an individual or individuals with whom you can discuss ideas. Some of your best mentors will be managers in other fields.

Mary Jo Gorman, MD, MBA

Immediate Past President, SHM

Consequences of Locum Tenens Work

I feel one piece of advice in the Career Development section in the May issue of The Hospitalist (“How to Navigate Hospital Medicine,” p. 9) is not complete and may adversely affect a new hospitalist’s career.

The article recommends exploring locum tenens work. We have found two unintended consequences of such action. First, the locum companies usually have a buyout clause for the physician. Should he decide he likes a location and wishes to stay, the potential employer faces an additional cost in the $20,000-$30,000 range. It makes budgeting difficult. Also, there is usually a clause in the locum contract that this policy is in place for two years after leaving the locum company.

Second, frequent job changes lead to prolonged processing of credentials at hospitals as they verify good standing at all previous practice sites. This means delays that force a hospitalist company to look for more readily available docs. The physician may be unable to find hospitals in highly desirable areas.

The article was otherwise well balanced and timely.

George Block, MD

CMO, Galen Inpatient Physicians Medical Group

Emeryville, Calif.

On the last day of SHM’s Annual Meeting in May, attendees started their morning with an overview of three exciting projects in hospital medicine, with “Best of Research, Innovations and Clinical Vignettes in 2007.”

Boosting Hospitalists’ Research Efforts

Although hospital medicine programs in academic medical centers are growing rapidly, the role of hospitalist-researchers remains underdeveloped, said Scott A. Flanders, MD, clinical assistant professor, University of Michigan Health Systems, Ann Arbor, by way of introducing “Jumpstarting Hospitalist Clinical Research: The Specialist-Hospitalist Allied Research Program (SHARP).”

“The problem is that our clinical roles dominate over research,” he said. “Also, many hospitalists lack formal research training.” Hospitalists may also lack expertise in clinical areas and are less likely than specialists to become involved in the diagnosis, treatment, and follow-up of complex hospitalized patients. Specialists are also more likely to have access to extramural funding for disease-based clinical research.

For these reasons, Dr. Flanders and his colleagues implemented SHARP. Their purpose was to jumpstart inpatient-based clinical and translational research in academic medical centers by pairing specialists with hospitalists.

SHARP is designed to facilitate pilot projects and preliminary data collection, which can lead to funding. Ultimately, they hope to disseminate research activities to other institutions.

The SHARP infrastructure partners an academic hospitalist as principle investigator (PI) with an academic cardiologist serving as co-PI. The team also includes a hospitalist investigator, a research associate, a clinical epidemiologist, and other personnel as needed.

SHARP is overseen by the PI and co-PI along with an executive from the University of Michigan Health System, vice chair of the Department of Medicine, and the associate dean for Clinical and Translational Research. This oversight group meets semi-annually and facilitates project selection and program development. It also monitors all program metrics.

“Every SHARP project developed is expected to apply for extramural support,” explained Dr. Flanders. SHARP projects and personnel are funded through these sources for pilot data and utilize revenue from the hospital medicine program.

To date, SHARP has resulted in a number of Internal Review Board-approved projects; a number of grants have been submitted, and some have been funded. In addition, peer-reviewed manuscripts have been submitted and accepted.

“Clinical research is underdeveloped at most academic hospitalist programs,” pronounced Dr. Flanders. “Partnering hospitalists with specialists can facilitate collaborative research and, in turn, identify the best way to care for inpatients. I encourage everyone to borrow this idea for their own institution.”

How Do Hospitalists Stack up?

In the short time hospitalists have been around, research has consistently shown that their addition has a positive or neutral effect on factors including length and cost of stay, patient mortality, and readmission rates. However, studies have been limited in scope—something Peter K. Lindenauer, MD, MSc, and his colleagues at Baystate Medical Center, Tufts University School of Medicine, Springfield, Mass., sought to correct in their own study, “Outcomes of Patients Treated by Hospitalists, General Internists and Family Physicians.”

The hospitalist-researchers wanted to compare outcomes for patients treated by three groups across a range of practice settings: hospitalists, non-hospitalist general internists, and family physicians.

The project they undertook was a retrospective cohort study that included patients admitted to 45 U.S. hospitals between September 2002 and July 2005. Patients were all at least 18 years old and had any of seven diagnoses: pneumonia, heart failure, chest pain, ischemic stroke, urinary tract infection, acute exacerbation of COPD, or acute myocardial infarction.

The total number of patients in the study was 76,926. Of these, 284 were cared for by a hospitalist, 993 by a general internist, and 971 by a family physician.

Dr. Lindenauer and his colleagues found that patients in all groups had similar patterns of comorbidities, although hospitalists were more likely to have patients who were covered by managed-care plans and not covered by traditional Medicare.

As for length of stay (LOS), patients cared for by hospitalists had an LOS 0.6 days shorter than internists and 0.4 days shorter than family physicians. Similarly, hospitalists’ patients had an adjusted cost per case approximately $404 less than that of general internists and on a par with family physicians.

The researchers found no significant differences in mortality or readmission rates among patients in the three physician groups.

Dr. Lindenauer wondered if the higher volume of patients seen by hospitalists would explain the differences in patient outcomes. However, when the researchers compared data for hospitalists with similar high-volume general internists and family physicians, they found similar differences in LOS and costs as they had found previously—suggesting other factors may be responsible for hospitalist effect.

Glycemic Control Issues

“Can we have our sugar-free cake and eat it too?” asked Greg Maynard, MD, MS, chief of the Division of Hospital Medicine, University of California, San Diego, when he presented his team’s project on inpatient glycemic control, “Effect of a Standardized Subcutaneous Insulin Order Set and an Insulin Management Protocol.”

“Inpatient diabetes and hyperglycemia is very common,” Dr. Maynard pointed out, “and poor control is associated with poor outcomes.” Although a standardized subcutaneous insulin order set (SQIO) is recommended, its impact is not yet proven.

Therefore, Dr. Maynard’s team set out to test the effectiveness of a standardized order set on adult inpatients in non-critical care wards with point-of-care glucose testing, in academic medical centers with more than 400 beds. Between November 2002 and October 2003, the group put together a baseline for insulin use patterns, glycemic control, and hypoglycemia. They then implemented a standardized SQIO set, which lasted for a year and a half, followed by a second intervention to monitor the incremental effect of an insulin management protocol.

In the first intervention, the researchers introduced basal, nutritional, and correction dose terminology to clinicians. They made a multiple correction dose scale available (based on total insulin dose required), discouraged sliding-scale-only regimens, instituted check-box simplicity, provided guidance for dosing, and incorporated hypoglycemia protocol. Order sets were produced in print first, then as computerized physician order entries.

The second stage, insulin management protocol, included a one-page algorithm, a glycemic target, a prompt for A1C, guidance on dosing including adjustments, and suggested regimens for patients who are eating, non-eating patients, and patients on enteral nutrition. This intervention was introduced with case-based teaching.

Within three months of implementing the SQIO, the use of sliding-scale-only regimens decreased as clinicians switched to regimens with some scheduled basal insulin.

The percentage of patients with a mean glucose lower than 180 mg a day was 62% at baseline and rose to 69% with the implementation of the SQIO. When the algorithm was used, it rose to 73%. The percentage of patient days with completely controlled glucose (between 60 and 180 mg/day) rose from 44% at baseline, to 48% with the SQIO, to 53% with the algorithm.

“But what about hypoglycemia?” asked Dr. Maynard. “The percentage of patient days with hypoglycemia decreased by 30% and 31%, respectively.” The addition of a standardized SQIO with an insulin management protocol improved glycemic control, reduced hypoglycemia, and changed insulin use patterns. TH

On the last day of SHM’s Annual Meeting in May, attendees started their morning with an overview of three exciting projects in hospital medicine, with “Best of Research, Innovations and Clinical Vignettes in 2007.”

Boosting Hospitalists’ Research Efforts

Although hospital medicine programs in academic medical centers are growing rapidly, the role of hospitalist-researchers remains underdeveloped, said Scott A. Flanders, MD, clinical assistant professor, University of Michigan Health Systems, Ann Arbor, by way of introducing “Jumpstarting Hospitalist Clinical Research: The Specialist-Hospitalist Allied Research Program (SHARP).”

“The problem is that our clinical roles dominate over research,” he said. “Also, many hospitalists lack formal research training.” Hospitalists may also lack expertise in clinical areas and are less likely than specialists to become involved in the diagnosis, treatment, and follow-up of complex hospitalized patients. Specialists are also more likely to have access to extramural funding for disease-based clinical research.

For these reasons, Dr. Flanders and his colleagues implemented SHARP. Their purpose was to jumpstart inpatient-based clinical and translational research in academic medical centers by pairing specialists with hospitalists.

SHARP is designed to facilitate pilot projects and preliminary data collection, which can lead to funding. Ultimately, they hope to disseminate research activities to other institutions.

The SHARP infrastructure partners an academic hospitalist as principle investigator (PI) with an academic cardiologist serving as co-PI. The team also includes a hospitalist investigator, a research associate, a clinical epidemiologist, and other personnel as needed.

SHARP is overseen by the PI and co-PI along with an executive from the University of Michigan Health System, vice chair of the Department of Medicine, and the associate dean for Clinical and Translational Research. This oversight group meets semi-annually and facilitates project selection and program development. It also monitors all program metrics.

“Every SHARP project developed is expected to apply for extramural support,” explained Dr. Flanders. SHARP projects and personnel are funded through these sources for pilot data and utilize revenue from the hospital medicine program.

To date, SHARP has resulted in a number of Internal Review Board-approved projects; a number of grants have been submitted, and some have been funded. In addition, peer-reviewed manuscripts have been submitted and accepted.

“Clinical research is underdeveloped at most academic hospitalist programs,” pronounced Dr. Flanders. “Partnering hospitalists with specialists can facilitate collaborative research and, in turn, identify the best way to care for inpatients. I encourage everyone to borrow this idea for their own institution.”

How Do Hospitalists Stack up?

In the short time hospitalists have been around, research has consistently shown that their addition has a positive or neutral effect on factors including length and cost of stay, patient mortality, and readmission rates. However, studies have been limited in scope—something Peter K. Lindenauer, MD, MSc, and his colleagues at Baystate Medical Center, Tufts University School of Medicine, Springfield, Mass., sought to correct in their own study, “Outcomes of Patients Treated by Hospitalists, General Internists and Family Physicians.”

The hospitalist-researchers wanted to compare outcomes for patients treated by three groups across a range of practice settings: hospitalists, non-hospitalist general internists, and family physicians.

The project they undertook was a retrospective cohort study that included patients admitted to 45 U.S. hospitals between September 2002 and July 2005. Patients were all at least 18 years old and had any of seven diagnoses: pneumonia, heart failure, chest pain, ischemic stroke, urinary tract infection, acute exacerbation of COPD, or acute myocardial infarction.

The total number of patients in the study was 76,926. Of these, 284 were cared for by a hospitalist, 993 by a general internist, and 971 by a family physician.

Dr. Lindenauer and his colleagues found that patients in all groups had similar patterns of comorbidities, although hospitalists were more likely to have patients who were covered by managed-care plans and not covered by traditional Medicare.

As for length of stay (LOS), patients cared for by hospitalists had an LOS 0.6 days shorter than internists and 0.4 days shorter than family physicians. Similarly, hospitalists’ patients had an adjusted cost per case approximately $404 less than that of general internists and on a par with family physicians.

The researchers found no significant differences in mortality or readmission rates among patients in the three physician groups.

Dr. Lindenauer wondered if the higher volume of patients seen by hospitalists would explain the differences in patient outcomes. However, when the researchers compared data for hospitalists with similar high-volume general internists and family physicians, they found similar differences in LOS and costs as they had found previously—suggesting other factors may be responsible for hospitalist effect.

Glycemic Control Issues

“Can we have our sugar-free cake and eat it too?” asked Greg Maynard, MD, MS, chief of the Division of Hospital Medicine, University of California, San Diego, when he presented his team’s project on inpatient glycemic control, “Effect of a Standardized Subcutaneous Insulin Order Set and an Insulin Management Protocol.”

“Inpatient diabetes and hyperglycemia is very common,” Dr. Maynard pointed out, “and poor control is associated with poor outcomes.” Although a standardized subcutaneous insulin order set (SQIO) is recommended, its impact is not yet proven.

Therefore, Dr. Maynard’s team set out to test the effectiveness of a standardized order set on adult inpatients in non-critical care wards with point-of-care glucose testing, in academic medical centers with more than 400 beds. Between November 2002 and October 2003, the group put together a baseline for insulin use patterns, glycemic control, and hypoglycemia. They then implemented a standardized SQIO set, which lasted for a year and a half, followed by a second intervention to monitor the incremental effect of an insulin management protocol.

In the first intervention, the researchers introduced basal, nutritional, and correction dose terminology to clinicians. They made a multiple correction dose scale available (based on total insulin dose required), discouraged sliding-scale-only regimens, instituted check-box simplicity, provided guidance for dosing, and incorporated hypoglycemia protocol. Order sets were produced in print first, then as computerized physician order entries.

The second stage, insulin management protocol, included a one-page algorithm, a glycemic target, a prompt for A1C, guidance on dosing including adjustments, and suggested regimens for patients who are eating, non-eating patients, and patients on enteral nutrition. This intervention was introduced with case-based teaching.

Within three months of implementing the SQIO, the use of sliding-scale-only regimens decreased as clinicians switched to regimens with some scheduled basal insulin.

The percentage of patients with a mean glucose lower than 180 mg a day was 62% at baseline and rose to 69% with the implementation of the SQIO. When the algorithm was used, it rose to 73%. The percentage of patient days with completely controlled glucose (between 60 and 180 mg/day) rose from 44% at baseline, to 48% with the SQIO, to 53% with the algorithm.

“But what about hypoglycemia?” asked Dr. Maynard. “The percentage of patient days with hypoglycemia decreased by 30% and 31%, respectively.” The addition of a standardized SQIO with an insulin management protocol improved glycemic control, reduced hypoglycemia, and changed insulin use patterns. TH

On the last day of SHM’s Annual Meeting in May, attendees started their morning with an overview of three exciting projects in hospital medicine, with “Best of Research, Innovations and Clinical Vignettes in 2007.”

Boosting Hospitalists’ Research Efforts

Although hospital medicine programs in academic medical centers are growing rapidly, the role of hospitalist-researchers remains underdeveloped, said Scott A. Flanders, MD, clinical assistant professor, University of Michigan Health Systems, Ann Arbor, by way of introducing “Jumpstarting Hospitalist Clinical Research: The Specialist-Hospitalist Allied Research Program (SHARP).”

“The problem is that our clinical roles dominate over research,” he said. “Also, many hospitalists lack formal research training.” Hospitalists may also lack expertise in clinical areas and are less likely than specialists to become involved in the diagnosis, treatment, and follow-up of complex hospitalized patients. Specialists are also more likely to have access to extramural funding for disease-based clinical research.

For these reasons, Dr. Flanders and his colleagues implemented SHARP. Their purpose was to jumpstart inpatient-based clinical and translational research in academic medical centers by pairing specialists with hospitalists.

SHARP is designed to facilitate pilot projects and preliminary data collection, which can lead to funding. Ultimately, they hope to disseminate research activities to other institutions.

The SHARP infrastructure partners an academic hospitalist as principle investigator (PI) with an academic cardiologist serving as co-PI. The team also includes a hospitalist investigator, a research associate, a clinical epidemiologist, and other personnel as needed.

SHARP is overseen by the PI and co-PI along with an executive from the University of Michigan Health System, vice chair of the Department of Medicine, and the associate dean for Clinical and Translational Research. This oversight group meets semi-annually and facilitates project selection and program development. It also monitors all program metrics.

“Every SHARP project developed is expected to apply for extramural support,” explained Dr. Flanders. SHARP projects and personnel are funded through these sources for pilot data and utilize revenue from the hospital medicine program.

To date, SHARP has resulted in a number of Internal Review Board-approved projects; a number of grants have been submitted, and some have been funded. In addition, peer-reviewed manuscripts have been submitted and accepted.

“Clinical research is underdeveloped at most academic hospitalist programs,” pronounced Dr. Flanders. “Partnering hospitalists with specialists can facilitate collaborative research and, in turn, identify the best way to care for inpatients. I encourage everyone to borrow this idea for their own institution.”

How Do Hospitalists Stack up?

In the short time hospitalists have been around, research has consistently shown that their addition has a positive or neutral effect on factors including length and cost of stay, patient mortality, and readmission rates. However, studies have been limited in scope—something Peter K. Lindenauer, MD, MSc, and his colleagues at Baystate Medical Center, Tufts University School of Medicine, Springfield, Mass., sought to correct in their own study, “Outcomes of Patients Treated by Hospitalists, General Internists and Family Physicians.”

The hospitalist-researchers wanted to compare outcomes for patients treated by three groups across a range of practice settings: hospitalists, non-hospitalist general internists, and family physicians.

The project they undertook was a retrospective cohort study that included patients admitted to 45 U.S. hospitals between September 2002 and July 2005. Patients were all at least 18 years old and had any of seven diagnoses: pneumonia, heart failure, chest pain, ischemic stroke, urinary tract infection, acute exacerbation of COPD, or acute myocardial infarction.

The total number of patients in the study was 76,926. Of these, 284 were cared for by a hospitalist, 993 by a general internist, and 971 by a family physician.

Dr. Lindenauer and his colleagues found that patients in all groups had similar patterns of comorbidities, although hospitalists were more likely to have patients who were covered by managed-care plans and not covered by traditional Medicare.

As for length of stay (LOS), patients cared for by hospitalists had an LOS 0.6 days shorter than internists and 0.4 days shorter than family physicians. Similarly, hospitalists’ patients had an adjusted cost per case approximately $404 less than that of general internists and on a par with family physicians.

The researchers found no significant differences in mortality or readmission rates among patients in the three physician groups.

Dr. Lindenauer wondered if the higher volume of patients seen by hospitalists would explain the differences in patient outcomes. However, when the researchers compared data for hospitalists with similar high-volume general internists and family physicians, they found similar differences in LOS and costs as they had found previously—suggesting other factors may be responsible for hospitalist effect.

Glycemic Control Issues

“Can we have our sugar-free cake and eat it too?” asked Greg Maynard, MD, MS, chief of the Division of Hospital Medicine, University of California, San Diego, when he presented his team’s project on inpatient glycemic control, “Effect of a Standardized Subcutaneous Insulin Order Set and an Insulin Management Protocol.”

“Inpatient diabetes and hyperglycemia is very common,” Dr. Maynard pointed out, “and poor control is associated with poor outcomes.” Although a standardized subcutaneous insulin order set (SQIO) is recommended, its impact is not yet proven.

Therefore, Dr. Maynard’s team set out to test the effectiveness of a standardized order set on adult inpatients in non-critical care wards with point-of-care glucose testing, in academic medical centers with more than 400 beds. Between November 2002 and October 2003, the group put together a baseline for insulin use patterns, glycemic control, and hypoglycemia. They then implemented a standardized SQIO set, which lasted for a year and a half, followed by a second intervention to monitor the incremental effect of an insulin management protocol.

In the first intervention, the researchers introduced basal, nutritional, and correction dose terminology to clinicians. They made a multiple correction dose scale available (based on total insulin dose required), discouraged sliding-scale-only regimens, instituted check-box simplicity, provided guidance for dosing, and incorporated hypoglycemia protocol. Order sets were produced in print first, then as computerized physician order entries.

The second stage, insulin management protocol, included a one-page algorithm, a glycemic target, a prompt for A1C, guidance on dosing including adjustments, and suggested regimens for patients who are eating, non-eating patients, and patients on enteral nutrition. This intervention was introduced with case-based teaching.

Within three months of implementing the SQIO, the use of sliding-scale-only regimens decreased as clinicians switched to regimens with some scheduled basal insulin.

The percentage of patients with a mean glucose lower than 180 mg a day was 62% at baseline and rose to 69% with the implementation of the SQIO. When the algorithm was used, it rose to 73%. The percentage of patient days with completely controlled glucose (between 60 and 180 mg/day) rose from 44% at baseline, to 48% with the SQIO, to 53% with the algorithm.

“But what about hypoglycemia?” asked Dr. Maynard. “The percentage of patient days with hypoglycemia decreased by 30% and 31%, respectively.” The addition of a standardized SQIO with an insulin management protocol improved glycemic control, reduced hypoglycemia, and changed insulin use patterns. TH

Nobody thought it was possible. Could all indoor workplaces in Ireland—including pubs—be made smoke-free? Now, a law enacted in 2004 is seen as a triumph for public health policy worldwide.1

Smoking kills 438,000 people a year in the United States, and 8.6 million have a serious smoking-related illness.2 Research shows many outpatient physicians do not judge it worthwhile to talk with their patients about quitting smoking because they assume they will have no effect. The assumption is that even if patients quit, they will relapse.

Yet ample evidence suggests hospitalists can have a positive effect by intervening during a patient’s hospital visit.

Data also show that an individual will relapse an average of seven times before being able to take the step for the long term. Relapse is a part of the process, each time teaching an individual something about his or her motivation and behavior.

“Doctors who address smoking with patients can double or even triple the chances of their quitting,” says Shawn Ralston, MD, pediatric hospitalist at Presbyterian Hospital in Albuquerque, N.M. A few pointed questions and a show of compassion to the patient in the hospital could make a world of difference.

Golden Opportunity

Stephen Liu, MD, MPH, a hospitalist and an assistant program director at Dartmouth-Hitchcock Medical Center (DHMC) in Lebanon, N.H., has been interested in smoking-cessation interventions since his residency in DHMC’s Leadership Preventive Medicine Residency Program in 2003, where he worked on improving care for pneumonia patients. His efforts took off as a result of the Centers for Medicare and Medicaid Services (CMS) pay-for-performance measures, which made smoking-cessation counseling a key component of admission and discharge documentation for a number of disease states.

The approach used with adult patients at DHMC is the brainchild of Colleen Warren, a registered nurse on the medicine unit on which Dr. Liu worked.

“The more times that smokers hear the message [about quitting], the more likely they are to try to quit,” says Dr. Liu. “We capitalized on that [point when] we developed a tobacco treatment team in our hospital. The team, which includes two to five motivated nurses, social workers, or care managers in most units of the hospital, pursued training including an online tobacco treatment course through U Mass Medical Center.”

In January 2006, DHMC was awarded a grant from the New Hampshire Department of Health and Human Services to standardize the treatment of hospitalized smokers. This includes conducting tobacco screening, assessing a patient’s readiness to quit, providing brief counseling, documenting the status and stage of change into the electronic medical record, and referring the patient to community resources upon discharge. The funding allowed the institution to support Warren and Dr. Liu as they coordinated the team and its work. These efforts, including counseling, nicotine replacement therapy, and cessation medications, are also available free to DHMC employees.

DHMC is participating in the CMS demonstration project, in which the hospital publicly reports performance measures for several conditions on the CMS Web site. In addition, many more performance measures are publicly reported on the DHMC quality-measures Web site. Although the team initially targeted the intervention to performance measures related to pneumonia and heart failure hospitalizations, they decided to offer interventions to all patients admitted to the hospital. Of these patients, about 20% are smokers, Dr. Liu says.

Because financial support wasn’t available at first and staff time was voluntary, the work was more difficult. Data from a six-month pilot intervention on two inpatient floors at DHMC showed patient assessments increased from 2% to 85%. In addition, the percentage of eligible heart failure and pneumonia patients receiving smoking cessation advice or counseling prior to discharge has risen from 30% before 2005 to 80% to 90%.

“We have found that hospitalization is a golden opportunity to address smoking cessation in patients in that they become acutely aware of how the smoking has affected their health,” says Dr. Liu. Because patients frequently go without smoking for several days while hospitalized, they learn they can live without smoking and feel much better.

“The key for our kind of intervention is not only assessing it and addressing it while they are hospitalized, but making sure that we link them to resources after they leave,” Dr. Liu says. Those resources include telephone quit lines or local support groups and/or local cessation clinics.

Counseling patients can be personally and professionally fulfilling, says Dr. Liu. He recalls a 50-year-old man—a lifelong smoker—admitted for pancreatitis. The day he was discharged, he showed Dr. Liu a hospital-produced packet of information. The patient said he had been reading it during his stay, decided he was motivated to quit, and had called the quit line.

Dr. Liu and his team use what they call the five A’s:

• Ask (does the patient smoke and has he/she tried to quit?);
• Advise the patient to quit;
• Assess (if the patient is ready to try to quit);
• Assist (the patient in planning treatment and referrals); and
• Arrange for a follow-up visit.

As part of their counseling, DHMC team members ask patients whether they have used assistive medication, such as nicotine-replacement therapy, bupropion (Wellbutrin) or varenicline (Chantix), in their attempts. They find out what patients have and have not tried. Then they ask, “How can we as a hospital help so that you will not restart smoking when you get home?”

A slightly longer counseling session with a motivated patient means a provider can explore whether they know their triggers for smoking, such as stress, alcohol use, or being around other smokers, and help the patient develop a proactive plan for when they are re-exposed to triggers upon discharge.

Counseling Parents of Hospitalized Children

In Dr. Ralston’s case, her research and the research of others inspired her to begin counseling the parents of hospitalized children.3-4 She was conducting research on respiratory illness, specifically bronchiolitis—the most common reason children are hospitalized.

She noticed the vast majority of children had had secondary smoke exposure. The work of C. Andrew Aligne, MD, formerly in the department of general pediatrics at the University of Rochester (N.Y.) Medical Center, inspired her.5-6 His analyses of attributable risk data revealed that the major and preventable cause of death in children is secondary smoke from parents.

But the issue really crystallized for Dr. Ralston when she encountered the work of Jonathan Winickoff, MD, MPH, an assistant professor of pediatrics at Harvard Medical School and a researcher with the Massachusetts General Hospital Center for Child and Adolescent Health Policy in Boston.

“The AHRQ guidelines show a huge amount of literature that say hospitalization is a great time to address smoking in adults,” says Dr. Ralston. “The [quit rate in office patients] will move from 5% to 12% or 15%, depending on the message. But in hospitalized adults, the quit rate can rise to 25% or 27%. Dr. Winickoff said, ‘Why can’t hospitalization for children be a teachable moment for parents?’ ”7

Another researcher who inspired Dr. Ralston was William R. Miller, PhD, who created the motivational interviewing model. Motivational interviewing is used with individuals to elicit and examine the ambivalence surrounding their unhealthy behaviors. Dr. Miller, retiring this year from the University of New Mexico (Albuquerque), began his work in the area of alcohol abuse. He and his colleagues have increasingly used motivational interviewing in other areas of addiction.

Dr. Ralston says what she has learned from motivational interviewing—and how she counsels parents of hospitalized children differently because of it—primarily pertains to her willingness to talk to people about a difficult subject. Instead of bombarding parents with facts about how smoking is bad for their children—which they already believe but don’t want to talk about—she learned to focus on the parents’ needs instead of the effects on the child.

“And there is the issue of bringing it up when this is not technically your patient,” she says. But after fine-tuning and developing her technique, she now assumes a value-neutral, nonjudgmental, open-ended approach using motivational interviewing. “Eventually it becomes easy to do.”

When approaching a parent to offer help, says Dr. Ralston, “I will lead by acknowledging that the experience the parent is having is extremely stressful. Then, after addressing the primary illness of the child and what the plan is for that, I say, ‘I see [from our records] that you are smoking. Have you tried to quit? Are you interested in quitting now? What might I be able to do to help you?’ If there is an opening, then I’ll go into more extensive counseling.

“You don’t need all the data behind you. I use my expertise more to motivate pediatricians, not the parents.” Another tack she takes to motivate pediatricians to empathically address smoking is to ask them to think of something they do that they know is bad for them but that they continue to do.

Conclusion

“There have been some studies that have shown [disappointing] outcomes when we intervene with hospitalized patients, but I’m more optimistic,” says Dr. Liu. “I feel that as long as we can make a difference in some people’s lives and get them to quit after they leave the hospital, then it’s worth the effort.”

Look at what you are willing to do, advises Dr. Ralston. “If that is a brief message and then a referral to a quit line, that’s fabulous,” she says. “You still might double the quit rate.” Given the temporal nature of the hospitalist-patient relationship, there may be a good number of ways hospitalists could effect change by offering a few encouraging words. TH

Andrea Sattinger is a frequent contributor to The Hospitalist.

References

1. Koh HK, Joossens LX, Connolly GN. Making smoking history worldwide. N Engl J Med. 2007 Apr 12;356(15):1496-1498.
2. Centers for Disease Control and Prevention. Targeting Tobacco Use: The Nation’s Leading Cause of Preventable Death, 2007. Available at www.cdc.gov/Tobacco/basic_information/00_pdfs/AAGTobacco2007.pdf. Last accessed June 18, 2007.
3. Ralston S, Kellett N, Williams RL, et al. Practice-based assessment of tobacco usage in southwestern primary care patients: a Research Involving Outpatient Settings Network (RIOS Net) study. J Am Board Fam Med. 2007;20(2):174-180.
4. Ralston S, Mahshid R. The pediatric hospitalist and the smoking parent. Pediatric Research Day 2006. Available at http://hsc.unm.edu/pedsresearch/ORAL%20PRESENTATIONS.htm Albuquerque: Office of Research and Creative Endeavors, Department of Pediatrics, University of New Mexico Health Sciences Center; 2006. Last accessed June 18, 2007.
5. Aligne CA, Stoddard JJ. Tobacco and children. An economic evaluation of the medical effects of parental smoking. Arch Pediatr Adolesc Med. 1997 Jul;151(7):648-653. Erratum in: Arch Pediatr Adolesc Med 1997 Oct;151(10):988. Comment in: Arch Pediatr Adolesc Med. 1997 Dec;151(12):1269. Arch Pediatr Adolesc Med. 2000 Aug;154(8):850.
6. Leonard K, Mosquera M, Aligne CA. Pediatrics in the community: Taking a collective breath to help children who have asthma. Pediatr Rev. 2007;28:152-153.
7. Winickoff JP, Hillis VJ, Palfrey JS, et al. A smoking cessation intervention for parents of children who are hospitalized for respiratory illness: the stop tobacco outreach program. Pediatrics. 2003 Jan;111(1):140-145.

Nobody thought it was possible. Could all indoor workplaces in Ireland—including pubs—be made smoke-free? Now, a law enacted in 2004 is seen as a triumph for public health policy worldwide.1

Smoking kills 438,000 people a year in the United States, and 8.6 million have a serious smoking-related illness.2 Research shows many outpatient physicians do not judge it worthwhile to talk with their patients about quitting smoking because they assume they will have no effect. The assumption is that even if patients quit, they will relapse.

Yet ample evidence suggests hospitalists can have a positive effect by intervening during a patient’s hospital visit.

Data also show that an individual will relapse an average of seven times before being able to take the step for the long term. Relapse is a part of the process, each time teaching an individual something about his or her motivation and behavior.

“Doctors who address smoking with patients can double or even triple the chances of their quitting,” says Shawn Ralston, MD, pediatric hospitalist at Presbyterian Hospital in Albuquerque, N.M. A few pointed questions and a show of compassion to the patient in the hospital could make a world of difference.

Golden Opportunity

Stephen Liu, MD, MPH, a hospitalist and an assistant program director at Dartmouth-Hitchcock Medical Center (DHMC) in Lebanon, N.H., has been interested in smoking-cessation interventions since his residency in DHMC’s Leadership Preventive Medicine Residency Program in 2003, where he worked on improving care for pneumonia patients. His efforts took off as a result of the Centers for Medicare and Medicaid Services (CMS) pay-for-performance measures, which made smoking-cessation counseling a key component of admission and discharge documentation for a number of disease states.

The approach used with adult patients at DHMC is the brainchild of Colleen Warren, a registered nurse on the medicine unit on which Dr. Liu worked.

“The more times that smokers hear the message [about quitting], the more likely they are to try to quit,” says Dr. Liu. “We capitalized on that [point when] we developed a tobacco treatment team in our hospital. The team, which includes two to five motivated nurses, social workers, or care managers in most units of the hospital, pursued training including an online tobacco treatment course through U Mass Medical Center.”

In January 2006, DHMC was awarded a grant from the New Hampshire Department of Health and Human Services to standardize the treatment of hospitalized smokers. This includes conducting tobacco screening, assessing a patient’s readiness to quit, providing brief counseling, documenting the status and stage of change into the electronic medical record, and referring the patient to community resources upon discharge. The funding allowed the institution to support Warren and Dr. Liu as they coordinated the team and its work. These efforts, including counseling, nicotine replacement therapy, and cessation medications, are also available free to DHMC employees.

DHMC is participating in the CMS demonstration project, in which the hospital publicly reports performance measures for several conditions on the CMS Web site. In addition, many more performance measures are publicly reported on the DHMC quality-measures Web site. Although the team initially targeted the intervention to performance measures related to pneumonia and heart failure hospitalizations, they decided to offer interventions to all patients admitted to the hospital. Of these patients, about 20% are smokers, Dr. Liu says.

Because financial support wasn’t available at first and staff time was voluntary, the work was more difficult. Data from a six-month pilot intervention on two inpatient floors at DHMC showed patient assessments increased from 2% to 85%. In addition, the percentage of eligible heart failure and pneumonia patients receiving smoking cessation advice or counseling prior to discharge has risen from 30% before 2005 to 80% to 90%.

“We have found that hospitalization is a golden opportunity to address smoking cessation in patients in that they become acutely aware of how the smoking has affected their health,” says Dr. Liu. Because patients frequently go without smoking for several days while hospitalized, they learn they can live without smoking and feel much better.

“The key for our kind of intervention is not only assessing it and addressing it while they are hospitalized, but making sure that we link them to resources after they leave,” Dr. Liu says. Those resources include telephone quit lines or local support groups and/or local cessation clinics.

Counseling patients can be personally and professionally fulfilling, says Dr. Liu. He recalls a 50-year-old man—a lifelong smoker—admitted for pancreatitis. The day he was discharged, he showed Dr. Liu a hospital-produced packet of information. The patient said he had been reading it during his stay, decided he was motivated to quit, and had called the quit line.

Dr. Liu and his team use what they call the five A’s:

• Ask (does the patient smoke and has he/she tried to quit?);
• Advise the patient to quit;
• Assess (if the patient is ready to try to quit);
• Assist (the patient in planning treatment and referrals); and
• Arrange for a follow-up visit.

As part of their counseling, DHMC team members ask patients whether they have used assistive medication, such as nicotine-replacement therapy, bupropion (Wellbutrin) or varenicline (Chantix), in their attempts. They find out what patients have and have not tried. Then they ask, “How can we as a hospital help so that you will not restart smoking when you get home?”

A slightly longer counseling session with a motivated patient means a provider can explore whether they know their triggers for smoking, such as stress, alcohol use, or being around other smokers, and help the patient develop a proactive plan for when they are re-exposed to triggers upon discharge.

Counseling Parents of Hospitalized Children

In Dr. Ralston’s case, her research and the research of others inspired her to begin counseling the parents of hospitalized children.3-4 She was conducting research on respiratory illness, specifically bronchiolitis—the most common reason children are hospitalized.

She noticed the vast majority of children had had secondary smoke exposure. The work of C. Andrew Aligne, MD, formerly in the department of general pediatrics at the University of Rochester (N.Y.) Medical Center, inspired her.5-6 His analyses of attributable risk data revealed that the major and preventable cause of death in children is secondary smoke from parents.

But the issue really crystallized for Dr. Ralston when she encountered the work of Jonathan Winickoff, MD, MPH, an assistant professor of pediatrics at Harvard Medical School and a researcher with the Massachusetts General Hospital Center for Child and Adolescent Health Policy in Boston.

“The AHRQ guidelines show a huge amount of literature that say hospitalization is a great time to address smoking in adults,” says Dr. Ralston. “The [quit rate in office patients] will move from 5% to 12% or 15%, depending on the message. But in hospitalized adults, the quit rate can rise to 25% or 27%. Dr. Winickoff said, ‘Why can’t hospitalization for children be a teachable moment for parents?’ ”7

Another researcher who inspired Dr. Ralston was William R. Miller, PhD, who created the motivational interviewing model. Motivational interviewing is used with individuals to elicit and examine the ambivalence surrounding their unhealthy behaviors. Dr. Miller, retiring this year from the University of New Mexico (Albuquerque), began his work in the area of alcohol abuse. He and his colleagues have increasingly used motivational interviewing in other areas of addiction.

Dr. Ralston says what she has learned from motivational interviewing—and how she counsels parents of hospitalized children differently because of it—primarily pertains to her willingness to talk to people about a difficult subject. Instead of bombarding parents with facts about how smoking is bad for their children—which they already believe but don’t want to talk about—she learned to focus on the parents’ needs instead of the effects on the child.

“And there is the issue of bringing it up when this is not technically your patient,” she says. But after fine-tuning and developing her technique, she now assumes a value-neutral, nonjudgmental, open-ended approach using motivational interviewing. “Eventually it becomes easy to do.”

When approaching a parent to offer help, says Dr. Ralston, “I will lead by acknowledging that the experience the parent is having is extremely stressful. Then, after addressing the primary illness of the child and what the plan is for that, I say, ‘I see [from our records] that you are smoking. Have you tried to quit? Are you interested in quitting now? What might I be able to do to help you?’ If there is an opening, then I’ll go into more extensive counseling.

“You don’t need all the data behind you. I use my expertise more to motivate pediatricians, not the parents.” Another tack she takes to motivate pediatricians to empathically address smoking is to ask them to think of something they do that they know is bad for them but that they continue to do.

Conclusion

“There have been some studies that have shown [disappointing] outcomes when we intervene with hospitalized patients, but I’m more optimistic,” says Dr. Liu. “I feel that as long as we can make a difference in some people’s lives and get them to quit after they leave the hospital, then it’s worth the effort.”

Look at what you are willing to do, advises Dr. Ralston. “If that is a brief message and then a referral to a quit line, that’s fabulous,” she says. “You still might double the quit rate.” Given the temporal nature of the hospitalist-patient relationship, there may be a good number of ways hospitalists could effect change by offering a few encouraging words. TH

Andrea Sattinger is a frequent contributor to The Hospitalist.

References

1. Koh HK, Joossens LX, Connolly GN. Making smoking history worldwide. N Engl J Med. 2007 Apr 12;356(15):1496-1498.
2. Centers for Disease Control and Prevention. Targeting Tobacco Use: The Nation’s Leading Cause of Preventable Death, 2007. Available at www.cdc.gov/Tobacco/basic_information/00_pdfs/AAGTobacco2007.pdf. Last accessed June 18, 2007.
3. Ralston S, Kellett N, Williams RL, et al. Practice-based assessment of tobacco usage in southwestern primary care patients: a Research Involving Outpatient Settings Network (RIOS Net) study. J Am Board Fam Med. 2007;20(2):174-180.
4. Ralston S, Mahshid R. The pediatric hospitalist and the smoking parent. Pediatric Research Day 2006. Available at http://hsc.unm.edu/pedsresearch/ORAL%20PRESENTATIONS.htm Albuquerque: Office of Research and Creative Endeavors, Department of Pediatrics, University of New Mexico Health Sciences Center; 2006. Last accessed June 18, 2007.
5. Aligne CA, Stoddard JJ. Tobacco and children. An economic evaluation of the medical effects of parental smoking. Arch Pediatr Adolesc Med. 1997 Jul;151(7):648-653. Erratum in: Arch Pediatr Adolesc Med 1997 Oct;151(10):988. Comment in: Arch Pediatr Adolesc Med. 1997 Dec;151(12):1269. Arch Pediatr Adolesc Med. 2000 Aug;154(8):850.
6. Leonard K, Mosquera M, Aligne CA. Pediatrics in the community: Taking a collective breath to help children who have asthma. Pediatr Rev. 2007;28:152-153.
7. Winickoff JP, Hillis VJ, Palfrey JS, et al. A smoking cessation intervention for parents of children who are hospitalized for respiratory illness: the stop tobacco outreach program. Pediatrics. 2003 Jan;111(1):140-145.

Nobody thought it was possible. Could all indoor workplaces in Ireland—including pubs—be made smoke-free? Now, a law enacted in 2004 is seen as a triumph for public health policy worldwide.1

Smoking kills 438,000 people a year in the United States, and 8.6 million have a serious smoking-related illness.2 Research shows many outpatient physicians do not judge it worthwhile to talk with their patients about quitting smoking because they assume they will have no effect. The assumption is that even if patients quit, they will relapse.

Yet ample evidence suggests hospitalists can have a positive effect by intervening during a patient’s hospital visit.

Data also show that an individual will relapse an average of seven times before being able to take the step for the long term. Relapse is a part of the process, each time teaching an individual something about his or her motivation and behavior.

“Doctors who address smoking with patients can double or even triple the chances of their quitting,” says Shawn Ralston, MD, pediatric hospitalist at Presbyterian Hospital in Albuquerque, N.M. A few pointed questions and a show of compassion to the patient in the hospital could make a world of difference.

Golden Opportunity

Stephen Liu, MD, MPH, a hospitalist and an assistant program director at Dartmouth-Hitchcock Medical Center (DHMC) in Lebanon, N.H., has been interested in smoking-cessation interventions since his residency in DHMC’s Leadership Preventive Medicine Residency Program in 2003, where he worked on improving care for pneumonia patients. His efforts took off as a result of the Centers for Medicare and Medicaid Services (CMS) pay-for-performance measures, which made smoking-cessation counseling a key component of admission and discharge documentation for a number of disease states.

The approach used with adult patients at DHMC is the brainchild of Colleen Warren, a registered nurse on the medicine unit on which Dr. Liu worked.

“The more times that smokers hear the message [about quitting], the more likely they are to try to quit,” says Dr. Liu. “We capitalized on that [point when] we developed a tobacco treatment team in our hospital. The team, which includes two to five motivated nurses, social workers, or care managers in most units of the hospital, pursued training including an online tobacco treatment course through U Mass Medical Center.”

In January 2006, DHMC was awarded a grant from the New Hampshire Department of Health and Human Services to standardize the treatment of hospitalized smokers. This includes conducting tobacco screening, assessing a patient’s readiness to quit, providing brief counseling, documenting the status and stage of change into the electronic medical record, and referring the patient to community resources upon discharge. The funding allowed the institution to support Warren and Dr. Liu as they coordinated the team and its work. These efforts, including counseling, nicotine replacement therapy, and cessation medications, are also available free to DHMC employees.

DHMC is participating in the CMS demonstration project, in which the hospital publicly reports performance measures for several conditions on the CMS Web site. In addition, many more performance measures are publicly reported on the DHMC quality-measures Web site. Although the team initially targeted the intervention to performance measures related to pneumonia and heart failure hospitalizations, they decided to offer interventions to all patients admitted to the hospital. Of these patients, about 20% are smokers, Dr. Liu says.

Because financial support wasn’t available at first and staff time was voluntary, the work was more difficult. Data from a six-month pilot intervention on two inpatient floors at DHMC showed patient assessments increased from 2% to 85%. In addition, the percentage of eligible heart failure and pneumonia patients receiving smoking cessation advice or counseling prior to discharge has risen from 30% before 2005 to 80% to 90%.

“We have found that hospitalization is a golden opportunity to address smoking cessation in patients in that they become acutely aware of how the smoking has affected their health,” says Dr. Liu. Because patients frequently go without smoking for several days while hospitalized, they learn they can live without smoking and feel much better.

“The key for our kind of intervention is not only assessing it and addressing it while they are hospitalized, but making sure that we link them to resources after they leave,” Dr. Liu says. Those resources include telephone quit lines or local support groups and/or local cessation clinics.

Counseling patients can be personally and professionally fulfilling, says Dr. Liu. He recalls a 50-year-old man—a lifelong smoker—admitted for pancreatitis. The day he was discharged, he showed Dr. Liu a hospital-produced packet of information. The patient said he had been reading it during his stay, decided he was motivated to quit, and had called the quit line.

Dr. Liu and his team use what they call the five A’s:

• Ask (does the patient smoke and has he/she tried to quit?);
• Advise the patient to quit;
• Assess (if the patient is ready to try to quit);
• Assist (the patient in planning treatment and referrals); and
• Arrange for a follow-up visit.

As part of their counseling, DHMC team members ask patients whether they have used assistive medication, such as nicotine-replacement therapy, bupropion (Wellbutrin) or varenicline (Chantix), in their attempts. They find out what patients have and have not tried. Then they ask, “How can we as a hospital help so that you will not restart smoking when you get home?”

A slightly longer counseling session with a motivated patient means a provider can explore whether they know their triggers for smoking, such as stress, alcohol use, or being around other smokers, and help the patient develop a proactive plan for when they are re-exposed to triggers upon discharge.

Counseling Parents of Hospitalized Children

In Dr. Ralston’s case, her research and the research of others inspired her to begin counseling the parents of hospitalized children.3-4 She was conducting research on respiratory illness, specifically bronchiolitis—the most common reason children are hospitalized.

She noticed the vast majority of children had had secondary smoke exposure. The work of C. Andrew Aligne, MD, formerly in the department of general pediatrics at the University of Rochester (N.Y.) Medical Center, inspired her.5-6 His analyses of attributable risk data revealed that the major and preventable cause of death in children is secondary smoke from parents.

But the issue really crystallized for Dr. Ralston when she encountered the work of Jonathan Winickoff, MD, MPH, an assistant professor of pediatrics at Harvard Medical School and a researcher with the Massachusetts General Hospital Center for Child and Adolescent Health Policy in Boston.

“The AHRQ guidelines show a huge amount of literature that say hospitalization is a great time to address smoking in adults,” says Dr. Ralston. “The [quit rate in office patients] will move from 5% to 12% or 15%, depending on the message. But in hospitalized adults, the quit rate can rise to 25% or 27%. Dr. Winickoff said, ‘Why can’t hospitalization for children be a teachable moment for parents?’ ”7

Another researcher who inspired Dr. Ralston was William R. Miller, PhD, who created the motivational interviewing model. Motivational interviewing is used with individuals to elicit and examine the ambivalence surrounding their unhealthy behaviors. Dr. Miller, retiring this year from the University of New Mexico (Albuquerque), began his work in the area of alcohol abuse. He and his colleagues have increasingly used motivational interviewing in other areas of addiction.

Dr. Ralston says what she has learned from motivational interviewing—and how she counsels parents of hospitalized children differently because of it—primarily pertains to her willingness to talk to people about a difficult subject. Instead of bombarding parents with facts about how smoking is bad for their children—which they already believe but don’t want to talk about—she learned to focus on the parents’ needs instead of the effects on the child.

“And there is the issue of bringing it up when this is not technically your patient,” she says. But after fine-tuning and developing her technique, she now assumes a value-neutral, nonjudgmental, open-ended approach using motivational interviewing. “Eventually it becomes easy to do.”

When approaching a parent to offer help, says Dr. Ralston, “I will lead by acknowledging that the experience the parent is having is extremely stressful. Then, after addressing the primary illness of the child and what the plan is for that, I say, ‘I see [from our records] that you are smoking. Have you tried to quit? Are you interested in quitting now? What might I be able to do to help you?’ If there is an opening, then I’ll go into more extensive counseling.

“You don’t need all the data behind you. I use my expertise more to motivate pediatricians, not the parents.” Another tack she takes to motivate pediatricians to empathically address smoking is to ask them to think of something they do that they know is bad for them but that they continue to do.

Conclusion

“There have been some studies that have shown [disappointing] outcomes when we intervene with hospitalized patients, but I’m more optimistic,” says Dr. Liu. “I feel that as long as we can make a difference in some people’s lives and get them to quit after they leave the hospital, then it’s worth the effort.”

Look at what you are willing to do, advises Dr. Ralston. “If that is a brief message and then a referral to a quit line, that’s fabulous,” she says. “You still might double the quit rate.” Given the temporal nature of the hospitalist-patient relationship, there may be a good number of ways hospitalists could effect change by offering a few encouraging words. TH

Andrea Sattinger is a frequent contributor to The Hospitalist.

References

1. Koh HK, Joossens LX, Connolly GN. Making smoking history worldwide. N Engl J Med. 2007 Apr 12;356(15):1496-1498.
2. Centers for Disease Control and Prevention. Targeting Tobacco Use: The Nation’s Leading Cause of Preventable Death, 2007. Available at www.cdc.gov/Tobacco/basic_information/00_pdfs/AAGTobacco2007.pdf. Last accessed June 18, 2007.
3. Ralston S, Kellett N, Williams RL, et al. Practice-based assessment of tobacco usage in southwestern primary care patients: a Research Involving Outpatient Settings Network (RIOS Net) study. J Am Board Fam Med. 2007;20(2):174-180.
4. Ralston S, Mahshid R. The pediatric hospitalist and the smoking parent. Pediatric Research Day 2006. Available at http://hsc.unm.edu/pedsresearch/ORAL%20PRESENTATIONS.htm Albuquerque: Office of Research and Creative Endeavors, Department of Pediatrics, University of New Mexico Health Sciences Center; 2006. Last accessed June 18, 2007.
5. Aligne CA, Stoddard JJ. Tobacco and children. An economic evaluation of the medical effects of parental smoking. Arch Pediatr Adolesc Med. 1997 Jul;151(7):648-653. Erratum in: Arch Pediatr Adolesc Med 1997 Oct;151(10):988. Comment in: Arch Pediatr Adolesc Med. 1997 Dec;151(12):1269. Arch Pediatr Adolesc Med. 2000 Aug;154(8):850.
6. Leonard K, Mosquera M, Aligne CA. Pediatrics in the community: Taking a collective breath to help children who have asthma. Pediatr Rev. 2007;28:152-153.
7. Winickoff JP, Hillis VJ, Palfrey JS, et al. A smoking cessation intervention for parents of children who are hospitalized for respiratory illness: the stop tobacco outreach program. Pediatrics. 2003 Jan;111(1):140-145.

Supplement Editors:
Susan J. Rehm, MD, and Alpesh N. Amin, MD, MBA

Contents

Infections in hospitalized patients: What is happening and who can help?
Alpesh N. Amin, MD, MBA, and Susan J. Rehm, MD

Impact of community-acquired methicillin-resistant Staphylococcus aureus in the hospital setting
Thomas M. File, Jr., MD

Emerging issues in the management of infections caused by multidrug-resistant gram-negative bacteria
Louis B. Rice, MD

Complicated skin and soft-tissue infections: Diagnostic approach and empiric treatment options
James I. Merlino, MD, and Mark A. Malangoni, MD

Empiric treatment options in the management of complicated intra-abdominal infections
John A. Weigelt, MD

Antibacterial treatment strategies in hospitalized patients: What role for pharmacoeconomics?
Morton P. Goldman, PharmD, BCPS, and Radhika Nair, PhD

Supplement Editors:
Susan J. Rehm, MD, and Alpesh N. Amin, MD, MBA

Contents

Infections in hospitalized patients: What is happening and who can help?
Alpesh N. Amin, MD, MBA, and Susan J. Rehm, MD

Impact of community-acquired methicillin-resistant Staphylococcus aureus in the hospital setting
Thomas M. File, Jr., MD

Emerging issues in the management of infections caused by multidrug-resistant gram-negative bacteria
Louis B. Rice, MD

Complicated skin and soft-tissue infections: Diagnostic approach and empiric treatment options
James I. Merlino, MD, and Mark A. Malangoni, MD

Empiric treatment options in the management of complicated intra-abdominal infections
John A. Weigelt, MD

Antibacterial treatment strategies in hospitalized patients: What role for pharmacoeconomics?
Morton P. Goldman, PharmD, BCPS, and Radhika Nair, PhD

Supplement Editors:
Susan J. Rehm, MD, and Alpesh N. Amin, MD, MBA

Contents

Infections in hospitalized patients: What is happening and who can help?
Alpesh N. Amin, MD, MBA, and Susan J. Rehm, MD

Impact of community-acquired methicillin-resistant Staphylococcus aureus in the hospital setting
Thomas M. File, Jr., MD

Emerging issues in the management of infections caused by multidrug-resistant gram-negative bacteria
Louis B. Rice, MD

Complicated skin and soft-tissue infections: Diagnostic approach and empiric treatment options
James I. Merlino, MD, and Mark A. Malangoni, MD

Empiric treatment options in the management of complicated intra-abdominal infections
John A. Weigelt, MD

Antibacterial treatment strategies in hospitalized patients: What role for pharmacoeconomics?
Morton P. Goldman, PharmD, BCPS, and Radhika Nair, PhD