One way to reduce medication errors in your hospital pharmacy is to put a robot in charge of stocking and dispensing medication doses. Roughly 300 U.S. hospitals have done just that and have, as a result, seen their in-pharmacy errors drop significantly. In this instance, robots simply don’t make mistakes.

Manufactured by McKesson Automation of Pittsburgh, Pa., ROBOT-Rx is the lead robot: McKesson estimates that 97% to 98% of hospital pharmacies with a medication-dispensing robot are using their product. ROBOT-Rx units installed in hospitals collectively dispense a half billion bar-coded doses, error-free, every year.

Meet Ernie

Evergreen Hospital Medical Center in Kirkland, Wash., is a 235-bed facility with an average daily census of 175. In March 2004, their pharmacy acquired a ROBOT-Rx, which dispenses up to 93% of all patient medications. Called Ernie (short for Evergreen Robot Noticeably Improving Efficiency), the robot does indeed improve pharmacy efficiency.

“Pharmacists still have to review orders, but the robot saves us time in the pharmacy,” says Bob Blanchard, pharmacy director at Evergreen. “Now they can be out on the floor more, where the orders occur, before mistakes happen.”

The biggest benefit of having the robot is an ongoing reduction in errors. “A good hospital pharmacy might have a 0.5% to 1% error rate,” says Blanchard, “but you have to look at the number of doses dispensed. In a busy hospital—like here—the pharmacy dispenses 1,200-1,300 doses a day. Translate that error rate, and you’ve got five or six errors each day.” Since Ernie took over the job of dispensing drugs, the number of medication errors has been reduced by 25%. It’s worth noting, though, that hospitalists and other doctors at Evergreen Hospital have no interaction with Ernie.

What Does It Take to Start Up a Robot?

Ordering and installing the robot and implementing a new system called for an overhaul of the pharmacy—in more ways than one. “It takes a bit of planning to start up,” admits Blanchard. “Very few med[ication]s are sent from the manufacturer with readable barcodes, except for IVs. We bought a couple of packaging machines, which went into the robot.”

The packaging machines are actually part of the robot. The robot is huge and is actually multiple machines working from a single “brain.” The machines parcel the bulk meds into single doses and barcode them as this happens.

A recent Food and Drug Administration (FDA) mandate requires pharmaceutical companies to include a bar code on packaging for medications, but that applies to bulk packages received at a pharmacy, not single doses.

Ernie takes up about 100 square feet in an octagon-shaped room in the hospital pharmacy. The room has 22 computerized drug-dispensing cabinets. In the center is an electronic arm that can rotate and use suction cups to pick up drug packets. The robot will grab a packet and laser-scan the bar code to ensure that it has picked the correct medication. If the bar code doesn’t match, the arm drops the packet on the floor or puts it in a bin for a pharmacist to check.

After verifying the correct bar code, the robot will place the dose into an envelope marked for a specific patient. The robot also restocks packaged doses that have been checked by pharmacists. Ernie receives the latest patient information automatically. “The robot directly interfaces with the pharmacy information system,” explains Rodger Fletcher, ROBOT-Rx product marketing manager at McKesson. “The robot … seamlessly integrates with nearly every other pharmacy information system.”

Take It to the Next Level

Evergreen Hospital has plans to further reduce their medication error rate. “Most errors occur after the drugs leave the pharmacy, on the hospital floor,” states Blanchard. “We see errors with wrong medications, wrong patients, and wrong times.”

The solution for reducing these errors is to implement additional technology. “We want to get bar coding at the bedside, where we scan the patient, medication, and nurse,” he explains. “This will catch any problem at that time, whether it’s the wrong medication, the wrong dose, or the wrong time.”

Getting Ernie installed was an integral part of this solution. “With the robot, we’re partway there. By the end of next year, we hope to have the bedside piece in place. We have all our medications bar-coded; we need basic technology at the bedside,” says Blanchard. “The selection and correct patient information are taken care of by the robot.”

Bar code scanning of medications at bedside is becoming more common. “We’re seeing a lot of momentum for this,” says Fletcher. “Industry statistics show that 7.5% to 10% of all hospitals have implemented [a bedside medication system], and others are universally planning one. The robot was developed with this in mind.”

For now, Evergreen Hospital is happy with the first stage in reducing medication errors: having Ernie sort and dispense patient meds. “It’s been a long time coming,” says Blanchard. TH

Jane Jerrard is a frequent contributor to The Hospitalist.

One way to reduce medication errors in your hospital pharmacy is to put a robot in charge of stocking and dispensing medication doses. Roughly 300 U.S. hospitals have done just that and have, as a result, seen their in-pharmacy errors drop significantly. In this instance, robots simply don’t make mistakes.

Manufactured by McKesson Automation of Pittsburgh, Pa., ROBOT-Rx is the lead robot: McKesson estimates that 97% to 98% of hospital pharmacies with a medication-dispensing robot are using their product. ROBOT-Rx units installed in hospitals collectively dispense a half billion bar-coded doses, error-free, every year.

Meet Ernie

Evergreen Hospital Medical Center in Kirkland, Wash., is a 235-bed facility with an average daily census of 175. In March 2004, their pharmacy acquired a ROBOT-Rx, which dispenses up to 93% of all patient medications. Called Ernie (short for Evergreen Robot Noticeably Improving Efficiency), the robot does indeed improve pharmacy efficiency.

“Pharmacists still have to review orders, but the robot saves us time in the pharmacy,” says Bob Blanchard, pharmacy director at Evergreen. “Now they can be out on the floor more, where the orders occur, before mistakes happen.”

The biggest benefit of having the robot is an ongoing reduction in errors. “A good hospital pharmacy might have a 0.5% to 1% error rate,” says Blanchard, “but you have to look at the number of doses dispensed. In a busy hospital—like here—the pharmacy dispenses 1,200-1,300 doses a day. Translate that error rate, and you’ve got five or six errors each day.” Since Ernie took over the job of dispensing drugs, the number of medication errors has been reduced by 25%. It’s worth noting, though, that hospitalists and other doctors at Evergreen Hospital have no interaction with Ernie.

What Does It Take to Start Up a Robot?

Ordering and installing the robot and implementing a new system called for an overhaul of the pharmacy—in more ways than one. “It takes a bit of planning to start up,” admits Blanchard. “Very few med[ication]s are sent from the manufacturer with readable barcodes, except for IVs. We bought a couple of packaging machines, which went into the robot.”

The packaging machines are actually part of the robot. The robot is huge and is actually multiple machines working from a single “brain.” The machines parcel the bulk meds into single doses and barcode them as this happens.

A recent Food and Drug Administration (FDA) mandate requires pharmaceutical companies to include a bar code on packaging for medications, but that applies to bulk packages received at a pharmacy, not single doses.

Ernie takes up about 100 square feet in an octagon-shaped room in the hospital pharmacy. The room has 22 computerized drug-dispensing cabinets. In the center is an electronic arm that can rotate and use suction cups to pick up drug packets. The robot will grab a packet and laser-scan the bar code to ensure that it has picked the correct medication. If the bar code doesn’t match, the arm drops the packet on the floor or puts it in a bin for a pharmacist to check.

After verifying the correct bar code, the robot will place the dose into an envelope marked for a specific patient. The robot also restocks packaged doses that have been checked by pharmacists. Ernie receives the latest patient information automatically. “The robot directly interfaces with the pharmacy information system,” explains Rodger Fletcher, ROBOT-Rx product marketing manager at McKesson. “The robot … seamlessly integrates with nearly every other pharmacy information system.”

Take It to the Next Level

Evergreen Hospital has plans to further reduce their medication error rate. “Most errors occur after the drugs leave the pharmacy, on the hospital floor,” states Blanchard. “We see errors with wrong medications, wrong patients, and wrong times.”

The solution for reducing these errors is to implement additional technology. “We want to get bar coding at the bedside, where we scan the patient, medication, and nurse,” he explains. “This will catch any problem at that time, whether it’s the wrong medication, the wrong dose, or the wrong time.”

Getting Ernie installed was an integral part of this solution. “With the robot, we’re partway there. By the end of next year, we hope to have the bedside piece in place. We have all our medications bar-coded; we need basic technology at the bedside,” says Blanchard. “The selection and correct patient information are taken care of by the robot.”

Bar code scanning of medications at bedside is becoming more common. “We’re seeing a lot of momentum for this,” says Fletcher. “Industry statistics show that 7.5% to 10% of all hospitals have implemented [a bedside medication system], and others are universally planning one. The robot was developed with this in mind.”

For now, Evergreen Hospital is happy with the first stage in reducing medication errors: having Ernie sort and dispense patient meds. “It’s been a long time coming,” says Blanchard. TH

Jane Jerrard is a frequent contributor to The Hospitalist.

One way to reduce medication errors in your hospital pharmacy is to put a robot in charge of stocking and dispensing medication doses. Roughly 300 U.S. hospitals have done just that and have, as a result, seen their in-pharmacy errors drop significantly. In this instance, robots simply don’t make mistakes.

Manufactured by McKesson Automation of Pittsburgh, Pa., ROBOT-Rx is the lead robot: McKesson estimates that 97% to 98% of hospital pharmacies with a medication-dispensing robot are using their product. ROBOT-Rx units installed in hospitals collectively dispense a half billion bar-coded doses, error-free, every year.

Meet Ernie

Evergreen Hospital Medical Center in Kirkland, Wash., is a 235-bed facility with an average daily census of 175. In March 2004, their pharmacy acquired a ROBOT-Rx, which dispenses up to 93% of all patient medications. Called Ernie (short for Evergreen Robot Noticeably Improving Efficiency), the robot does indeed improve pharmacy efficiency.

“Pharmacists still have to review orders, but the robot saves us time in the pharmacy,” says Bob Blanchard, pharmacy director at Evergreen. “Now they can be out on the floor more, where the orders occur, before mistakes happen.”

The biggest benefit of having the robot is an ongoing reduction in errors. “A good hospital pharmacy might have a 0.5% to 1% error rate,” says Blanchard, “but you have to look at the number of doses dispensed. In a busy hospital—like here—the pharmacy dispenses 1,200-1,300 doses a day. Translate that error rate, and you’ve got five or six errors each day.” Since Ernie took over the job of dispensing drugs, the number of medication errors has been reduced by 25%. It’s worth noting, though, that hospitalists and other doctors at Evergreen Hospital have no interaction with Ernie.

What Does It Take to Start Up a Robot?

Ordering and installing the robot and implementing a new system called for an overhaul of the pharmacy—in more ways than one. “It takes a bit of planning to start up,” admits Blanchard. “Very few med[ication]s are sent from the manufacturer with readable barcodes, except for IVs. We bought a couple of packaging machines, which went into the robot.”

The packaging machines are actually part of the robot. The robot is huge and is actually multiple machines working from a single “brain.” The machines parcel the bulk meds into single doses and barcode them as this happens.

A recent Food and Drug Administration (FDA) mandate requires pharmaceutical companies to include a bar code on packaging for medications, but that applies to bulk packages received at a pharmacy, not single doses.

Ernie takes up about 100 square feet in an octagon-shaped room in the hospital pharmacy. The room has 22 computerized drug-dispensing cabinets. In the center is an electronic arm that can rotate and use suction cups to pick up drug packets. The robot will grab a packet and laser-scan the bar code to ensure that it has picked the correct medication. If the bar code doesn’t match, the arm drops the packet on the floor or puts it in a bin for a pharmacist to check.

After verifying the correct bar code, the robot will place the dose into an envelope marked for a specific patient. The robot also restocks packaged doses that have been checked by pharmacists. Ernie receives the latest patient information automatically. “The robot directly interfaces with the pharmacy information system,” explains Rodger Fletcher, ROBOT-Rx product marketing manager at McKesson. “The robot … seamlessly integrates with nearly every other pharmacy information system.”

Take It to the Next Level

Evergreen Hospital has plans to further reduce their medication error rate. “Most errors occur after the drugs leave the pharmacy, on the hospital floor,” states Blanchard. “We see errors with wrong medications, wrong patients, and wrong times.”

The solution for reducing these errors is to implement additional technology. “We want to get bar coding at the bedside, where we scan the patient, medication, and nurse,” he explains. “This will catch any problem at that time, whether it’s the wrong medication, the wrong dose, or the wrong time.”

Getting Ernie installed was an integral part of this solution. “With the robot, we’re partway there. By the end of next year, we hope to have the bedside piece in place. We have all our medications bar-coded; we need basic technology at the bedside,” says Blanchard. “The selection and correct patient information are taken care of by the robot.”

Bar code scanning of medications at bedside is becoming more common. “We’re seeing a lot of momentum for this,” says Fletcher. “Industry statistics show that 7.5% to 10% of all hospitals have implemented [a bedside medication system], and others are universally planning one. The robot was developed with this in mind.”

For now, Evergreen Hospital is happy with the first stage in reducing medication errors: having Ernie sort and dispense patient meds. “It’s been a long time coming,” says Blanchard. TH

Jane Jerrard is a frequent contributor to The Hospitalist.

What happens when a person who speaks a language other than English enters a hospital? One who is fortunate enough to enter one of the one-quarter of American hospitals that offer professional interpreters or other language access services can expect to understand what is going on and to communicate comfortably with the care providers. For the approximately 75% of U.S. hospitals remaining, language access has become a common concern as increasing immigration levels expand ethnic groups.

Nearly 52 million people—one in 12—in the United States speak a language other than English at home. In fact, more than 300 languages are spoken in the United States. Basing their calculations on the 2000 census, demographers estimate that the number of people with limited English proficiency (LEP) ranges from 11 million (those who speak English “not well” or “not at all”) to more than 22 million (those who speak English less than “very well”). And those numbers are expected to continue to grow.

The Effects on Healthcare

The growing diversity of the United States population has a direct effect on healthcare providers. In order to provide appropriate and safe care, a provider must rely on accurate information from the patient. Simultaneously, the patient must be able to understand health instructions and treatment options in order to participate in his or her care. Language is the vital bridge in this process.

So what happens, for example, when an English-speaking emergency department physician faces a Spanish-speaking patient seeking medical care? Often, the hospital staff will turn to the patient’s family to act as interpreters. If that is not possible or advisable, the clinician may ask a bilingual staff member to help. This is commonly called dual-role or ad-hoc interpreting because the employee’s primary job in the healthcare organization (whether clinical or non-clinical) involves something other than interpreting.

While ad-hoc interpreters fulfill immediate needs by thoughtfully stepping in and helping out, many are asked to interpret outside their areas of expertise as they interrupt their own work. And an interpreter who has received no specialized training cannot be expected to achieve the same results as a professional interpreter. Simply being bilingual is not enough; professional medical interpreting is a learned skill.

Yet many healthcare organizations across the United States are not prepared to provide professional linguistic access for their patients. This is not to say that care providers would not like a professional interpreter program in the healthcare organization. Providers from a wide range of services have reported that language barriers and inadequate funding of language access services present major problems in ensuring both access to and quality of healthcare for LEP individuals. Funding, in particular, is one of the major reasons healthcare organizations hesitate to implement dedicated interpreter departments.

According to Cynthia Roat, MPH, a national consultant on language access in healthcare, the two major restrictions hindering the implementation of professional linguistic access programs in hospitals today are:

1. Lack of funding and
2. Lack of qualified interpreters.

“Fortunately the latter problem is being addressed,” she says. “We have established standards of practice for professional competence, and there are training programs for medical interpreters as well as for clinical staff who use interpreters.”

For example, the National Council on Interpreting in Health Care (NCIHC), a leading advocate of medical interpreting, has developed national standards to improve communication between the LEP patient and the healthcare provider. In addition, many technical and community colleges now offer medical interpreting classes, and some medical schools are beginning to offer seminars and courses designed to train clinical staff to work with interpreters. “Working with interpreters is a concrete, clinical skill,” says Roat.

Still, finding the money for this type of program can have a financial impact on healthcare organizations. Adding to that, accreditation agencies such as the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and the National Committee for Quality Assurance (NCQA) have set compliance standards for language access in terms of its contribution to quality care and patient safety. These compliance standards can also have a financial impact on healthcare organizations.

An even more significant effect may result from the federal government’s mandate to provide language services to LEP individuals. Specifically, Executive Order 13166, “Improving Access to Services for Persons with Limited English Proficiency,” stipulates that hospital and healthcare organizations receiving federal funds are required to provide interpretation services under Title VI of the Civil Rights Act of 1964. Denial of interpreter services to LEP patients is considered a form of discrimination.

In addition, the Office of Minority Health (OMH) within the U.S. Department of Health and Human Services has specified 14 National Standards for Culturally and Linguistically Appropriate Services in Health Care (CLAS) that direct healthcare organizations to make their practices more culturally and linguistically accessible. CLAS standards are organized by themes: Culturally Competent Care, Language Access, and Organizational Support for Cultural Competence. Within this framework, there are three types of obligation: mandates, guidelines, and recommendations. Mandates are current federal requirements for all recipients of federal funds; guidelines are activities recommended by OMH for adoption as mandates by accrediting agencies; and recommendations are standards suggested by OMH for voluntary adoption by healthcare organizations.

Despite its mandates, standards, and recommendations, however, the U.S. government has not included provisions for or suggestions about paying for compliance.

Benefits of a Language Access Program

Nevertheless, in addition to complying with governmental regulations and meeting accreditation standards, hospitals can derive benefits from an interpreter program. First and foremost, using interpreters with LEP individuals allows a hospital to fulfill one of its most important professional obligations: providing the best care possible to each patient. The clinician understands the patient’s symptoms, and the patient understands the doctor’s diagnosis and instructions. Together they can form a partnership to meet the physical, psychological, and cultural needs of the patient and to afford a sense of satisfaction to the caregiver.

Secondly, providing linguistic access can make hospital services more cost effective. Visits are fewer and shorter. There are not as many follow-up appointments or repeat admissions because patients understand their physicians’ instructions. Clinicians avoid unnecessary, inadvisable, or inappropriate tests because they understand the patients’ symptoms. Overuse of emergency department services for primary care decreases because patients are comfortable establishing a more conventional primary care relationship. And, as Roat points out, “if a hospital can develop an access program that does not rely on ad-hoc interpreters, the organization can avoid the hidden costs of lower productivity and higher turnover among those ad-hoc interpreters who are asked to interrupt their regular work to provide language access.”

Finally, there are benefits associated with legal and liability issues. Among them: fewer mistakes in diagnoses and treatment because the patients can communicate with their care providers. Also, patients are able to follow directions correctly and understand the need for follow-up or referrals, thus averting an unnecessary tragedy or potential lawsuit. Glenn Flores, MD, director of the Center for the Advancement of Urban Children and professor of pediatrics, epidemiology, and health at the Medical College of Wisconsin, can cite examples of medical errors attributable to language misunderstandings.

“Lack of language services can affect instructions about giving medications, such as the mother who thought she should apply a cortisone cream to the child’s entire body rather than just to the facial rash,” he says. “There is also the problem of possible overdoses. And a single misinterpreted word in one case led to a $71 million lawsuit in Florida a few years ago. This is a major patient safety issue.”

Another safety issue for hospitals is informed consent. Hospitals that provide language services are more likely to ensure that their LEP patients understand and agree to sign the informed consent form.

Paying for Language Access Services

The benefits of offering language access services may be self-evident, but who pays for them? Certainly not private insurers. At least not yet. But, as professionals in the field, both Roat and Dr. Flores see a need for private insurers to assume part of the financial cost. Although Roat believes the costs should be shared among hospitals/clinics, public financing, and commercial insurers, “Advocates of language access need to start a dialogue with commercial insurers and point to HMOs as examples of how these services are being covered,” she says.

Multiple approaches may be necessary to set up coverage from private insurers. Dr. Flores suggests that one possible course is insurance reimbursement for professional interpreters, paid for by the hour or by the visit. Another alternative might involve establishing contract services with outside agencies, community organizations, or video- or teleconferencing companies to recruit, train, and assign medical interpreters for healthcare organizations. These groups could provide services and bill the insurer directly.

“There are also ways to use public funding,” observes Roat, “and there should be more pressure on the federal government to pony up more money for this.”

Dr. Flores agrees. “Under Medicaid and the State Children’s Health Insurance Program (SCHIP), states may pay for interpreting services and receive federal matching funds of 50% or more,” he says. “Yet only 13 states are taking advantage of this. The other 37 states are missing out on this money.”

Like many of his colleagues, Dr. Flores is also mystified about the government’s reluctance to fully fund interpretation services, pointing out that “a federal report from the Office of Management and Budget (OMB) in 2002 estimated that it would cost an average of $4.04 per physician visit to provide all LEP patients with full language access services.”

Then why hasn’t this been allocated? Dr. Flores acknowledges that there is some recognition and awareness of the situation in Congress, and he thinks there may be some political will as well. He has testified before the Senate about the Hispanic Health Improvement Act, yet the bill has yet to pass. At the moment, there are immigration issues that are impeding political action in these areas.

In the meantime, Dr. Flores suggests that there are other steps that healthcare organizations can take to ease language access problems:

• Recruit bilingual providers in areas with large ethnic populations and offer hiring bonuses for qualified individuals;
• Encourage medical schools to require—and even teach—proficiency in languages other than English. “We should require, as other countries do, that children learn foreign languages,” he says; and
• Do a better job of helping LEP individuals learn English.

Begin the last step by directing LEP patients to the Web site of the National Institute for Literacy and Partners, which matches applicants to literacy and ESL programs within their geographical area.1

“We must debunk the oft-repeated story that professional medical interpreters are too expensive to use, that they charge $400 an hour,” says Roat. “That figure came from an incident in which an interpreter was supposedly working in a very remote area on a weekend and charged for the time, distance, and unusual circumstances. In reality, qualified medical interpreters earn $20 to $25 per hour and are worth every penny. Plus, they save money by reducing time and costs to the institution.” TH

Ann Kepler is based in the Chicago area.

Reference

1. National Institute for Literacy, Literacy Directory. Available at: www.literacydirectory.org. Last accessed September 27,2006.

What happens when a person who speaks a language other than English enters a hospital? One who is fortunate enough to enter one of the one-quarter of American hospitals that offer professional interpreters or other language access services can expect to understand what is going on and to communicate comfortably with the care providers. For the approximately 75% of U.S. hospitals remaining, language access has become a common concern as increasing immigration levels expand ethnic groups.

Nearly 52 million people—one in 12—in the United States speak a language other than English at home. In fact, more than 300 languages are spoken in the United States. Basing their calculations on the 2000 census, demographers estimate that the number of people with limited English proficiency (LEP) ranges from 11 million (those who speak English “not well” or “not at all”) to more than 22 million (those who speak English less than “very well”). And those numbers are expected to continue to grow.

The Effects on Healthcare

The growing diversity of the United States population has a direct effect on healthcare providers. In order to provide appropriate and safe care, a provider must rely on accurate information from the patient. Simultaneously, the patient must be able to understand health instructions and treatment options in order to participate in his or her care. Language is the vital bridge in this process.

So what happens, for example, when an English-speaking emergency department physician faces a Spanish-speaking patient seeking medical care? Often, the hospital staff will turn to the patient’s family to act as interpreters. If that is not possible or advisable, the clinician may ask a bilingual staff member to help. This is commonly called dual-role or ad-hoc interpreting because the employee’s primary job in the healthcare organization (whether clinical or non-clinical) involves something other than interpreting.

While ad-hoc interpreters fulfill immediate needs by thoughtfully stepping in and helping out, many are asked to interpret outside their areas of expertise as they interrupt their own work. And an interpreter who has received no specialized training cannot be expected to achieve the same results as a professional interpreter. Simply being bilingual is not enough; professional medical interpreting is a learned skill.

Yet many healthcare organizations across the United States are not prepared to provide professional linguistic access for their patients. This is not to say that care providers would not like a professional interpreter program in the healthcare organization. Providers from a wide range of services have reported that language barriers and inadequate funding of language access services present major problems in ensuring both access to and quality of healthcare for LEP individuals. Funding, in particular, is one of the major reasons healthcare organizations hesitate to implement dedicated interpreter departments.

According to Cynthia Roat, MPH, a national consultant on language access in healthcare, the two major restrictions hindering the implementation of professional linguistic access programs in hospitals today are:

1. Lack of funding and
2. Lack of qualified interpreters.

“Fortunately the latter problem is being addressed,” she says. “We have established standards of practice for professional competence, and there are training programs for medical interpreters as well as for clinical staff who use interpreters.”

For example, the National Council on Interpreting in Health Care (NCIHC), a leading advocate of medical interpreting, has developed national standards to improve communication between the LEP patient and the healthcare provider. In addition, many technical and community colleges now offer medical interpreting classes, and some medical schools are beginning to offer seminars and courses designed to train clinical staff to work with interpreters. “Working with interpreters is a concrete, clinical skill,” says Roat.

Still, finding the money for this type of program can have a financial impact on healthcare organizations. Adding to that, accreditation agencies such as the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and the National Committee for Quality Assurance (NCQA) have set compliance standards for language access in terms of its contribution to quality care and patient safety. These compliance standards can also have a financial impact on healthcare organizations.

An even more significant effect may result from the federal government’s mandate to provide language services to LEP individuals. Specifically, Executive Order 13166, “Improving Access to Services for Persons with Limited English Proficiency,” stipulates that hospital and healthcare organizations receiving federal funds are required to provide interpretation services under Title VI of the Civil Rights Act of 1964. Denial of interpreter services to LEP patients is considered a form of discrimination.

In addition, the Office of Minority Health (OMH) within the U.S. Department of Health and Human Services has specified 14 National Standards for Culturally and Linguistically Appropriate Services in Health Care (CLAS) that direct healthcare organizations to make their practices more culturally and linguistically accessible. CLAS standards are organized by themes: Culturally Competent Care, Language Access, and Organizational Support for Cultural Competence. Within this framework, there are three types of obligation: mandates, guidelines, and recommendations. Mandates are current federal requirements for all recipients of federal funds; guidelines are activities recommended by OMH for adoption as mandates by accrediting agencies; and recommendations are standards suggested by OMH for voluntary adoption by healthcare organizations.

Despite its mandates, standards, and recommendations, however, the U.S. government has not included provisions for or suggestions about paying for compliance.

Benefits of a Language Access Program

Nevertheless, in addition to complying with governmental regulations and meeting accreditation standards, hospitals can derive benefits from an interpreter program. First and foremost, using interpreters with LEP individuals allows a hospital to fulfill one of its most important professional obligations: providing the best care possible to each patient. The clinician understands the patient’s symptoms, and the patient understands the doctor’s diagnosis and instructions. Together they can form a partnership to meet the physical, psychological, and cultural needs of the patient and to afford a sense of satisfaction to the caregiver.

Secondly, providing linguistic access can make hospital services more cost effective. Visits are fewer and shorter. There are not as many follow-up appointments or repeat admissions because patients understand their physicians’ instructions. Clinicians avoid unnecessary, inadvisable, or inappropriate tests because they understand the patients’ symptoms. Overuse of emergency department services for primary care decreases because patients are comfortable establishing a more conventional primary care relationship. And, as Roat points out, “if a hospital can develop an access program that does not rely on ad-hoc interpreters, the organization can avoid the hidden costs of lower productivity and higher turnover among those ad-hoc interpreters who are asked to interrupt their regular work to provide language access.”

Finally, there are benefits associated with legal and liability issues. Among them: fewer mistakes in diagnoses and treatment because the patients can communicate with their care providers. Also, patients are able to follow directions correctly and understand the need for follow-up or referrals, thus averting an unnecessary tragedy or potential lawsuit. Glenn Flores, MD, director of the Center for the Advancement of Urban Children and professor of pediatrics, epidemiology, and health at the Medical College of Wisconsin, can cite examples of medical errors attributable to language misunderstandings.

“Lack of language services can affect instructions about giving medications, such as the mother who thought she should apply a cortisone cream to the child’s entire body rather than just to the facial rash,” he says. “There is also the problem of possible overdoses. And a single misinterpreted word in one case led to a $71 million lawsuit in Florida a few years ago. This is a major patient safety issue.”

Another safety issue for hospitals is informed consent. Hospitals that provide language services are more likely to ensure that their LEP patients understand and agree to sign the informed consent form.

Paying for Language Access Services

The benefits of offering language access services may be self-evident, but who pays for them? Certainly not private insurers. At least not yet. But, as professionals in the field, both Roat and Dr. Flores see a need for private insurers to assume part of the financial cost. Although Roat believes the costs should be shared among hospitals/clinics, public financing, and commercial insurers, “Advocates of language access need to start a dialogue with commercial insurers and point to HMOs as examples of how these services are being covered,” she says.

Multiple approaches may be necessary to set up coverage from private insurers. Dr. Flores suggests that one possible course is insurance reimbursement for professional interpreters, paid for by the hour or by the visit. Another alternative might involve establishing contract services with outside agencies, community organizations, or video- or teleconferencing companies to recruit, train, and assign medical interpreters for healthcare organizations. These groups could provide services and bill the insurer directly.

“There are also ways to use public funding,” observes Roat, “and there should be more pressure on the federal government to pony up more money for this.”

Dr. Flores agrees. “Under Medicaid and the State Children’s Health Insurance Program (SCHIP), states may pay for interpreting services and receive federal matching funds of 50% or more,” he says. “Yet only 13 states are taking advantage of this. The other 37 states are missing out on this money.”

Like many of his colleagues, Dr. Flores is also mystified about the government’s reluctance to fully fund interpretation services, pointing out that “a federal report from the Office of Management and Budget (OMB) in 2002 estimated that it would cost an average of $4.04 per physician visit to provide all LEP patients with full language access services.”

Then why hasn’t this been allocated? Dr. Flores acknowledges that there is some recognition and awareness of the situation in Congress, and he thinks there may be some political will as well. He has testified before the Senate about the Hispanic Health Improvement Act, yet the bill has yet to pass. At the moment, there are immigration issues that are impeding political action in these areas.

In the meantime, Dr. Flores suggests that there are other steps that healthcare organizations can take to ease language access problems:

• Recruit bilingual providers in areas with large ethnic populations and offer hiring bonuses for qualified individuals;
• Encourage medical schools to require—and even teach—proficiency in languages other than English. “We should require, as other countries do, that children learn foreign languages,” he says; and
• Do a better job of helping LEP individuals learn English.

Begin the last step by directing LEP patients to the Web site of the National Institute for Literacy and Partners, which matches applicants to literacy and ESL programs within their geographical area.1

“We must debunk the oft-repeated story that professional medical interpreters are too expensive to use, that they charge $400 an hour,” says Roat. “That figure came from an incident in which an interpreter was supposedly working in a very remote area on a weekend and charged for the time, distance, and unusual circumstances. In reality, qualified medical interpreters earn $20 to $25 per hour and are worth every penny. Plus, they save money by reducing time and costs to the institution.” TH

Ann Kepler is based in the Chicago area.

Reference

1. National Institute for Literacy, Literacy Directory. Available at: www.literacydirectory.org. Last accessed September 27,2006.

What happens when a person who speaks a language other than English enters a hospital? One who is fortunate enough to enter one of the one-quarter of American hospitals that offer professional interpreters or other language access services can expect to understand what is going on and to communicate comfortably with the care providers. For the approximately 75% of U.S. hospitals remaining, language access has become a common concern as increasing immigration levels expand ethnic groups.

Nearly 52 million people—one in 12—in the United States speak a language other than English at home. In fact, more than 300 languages are spoken in the United States. Basing their calculations on the 2000 census, demographers estimate that the number of people with limited English proficiency (LEP) ranges from 11 million (those who speak English “not well” or “not at all”) to more than 22 million (those who speak English less than “very well”). And those numbers are expected to continue to grow.

The Effects on Healthcare

The growing diversity of the United States population has a direct effect on healthcare providers. In order to provide appropriate and safe care, a provider must rely on accurate information from the patient. Simultaneously, the patient must be able to understand health instructions and treatment options in order to participate in his or her care. Language is the vital bridge in this process.

So what happens, for example, when an English-speaking emergency department physician faces a Spanish-speaking patient seeking medical care? Often, the hospital staff will turn to the patient’s family to act as interpreters. If that is not possible or advisable, the clinician may ask a bilingual staff member to help. This is commonly called dual-role or ad-hoc interpreting because the employee’s primary job in the healthcare organization (whether clinical or non-clinical) involves something other than interpreting.

While ad-hoc interpreters fulfill immediate needs by thoughtfully stepping in and helping out, many are asked to interpret outside their areas of expertise as they interrupt their own work. And an interpreter who has received no specialized training cannot be expected to achieve the same results as a professional interpreter. Simply being bilingual is not enough; professional medical interpreting is a learned skill.

Yet many healthcare organizations across the United States are not prepared to provide professional linguistic access for their patients. This is not to say that care providers would not like a professional interpreter program in the healthcare organization. Providers from a wide range of services have reported that language barriers and inadequate funding of language access services present major problems in ensuring both access to and quality of healthcare for LEP individuals. Funding, in particular, is one of the major reasons healthcare organizations hesitate to implement dedicated interpreter departments.

According to Cynthia Roat, MPH, a national consultant on language access in healthcare, the two major restrictions hindering the implementation of professional linguistic access programs in hospitals today are:

1. Lack of funding and
2. Lack of qualified interpreters.

“Fortunately the latter problem is being addressed,” she says. “We have established standards of practice for professional competence, and there are training programs for medical interpreters as well as for clinical staff who use interpreters.”

For example, the National Council on Interpreting in Health Care (NCIHC), a leading advocate of medical interpreting, has developed national standards to improve communication between the LEP patient and the healthcare provider. In addition, many technical and community colleges now offer medical interpreting classes, and some medical schools are beginning to offer seminars and courses designed to train clinical staff to work with interpreters. “Working with interpreters is a concrete, clinical skill,” says Roat.

Still, finding the money for this type of program can have a financial impact on healthcare organizations. Adding to that, accreditation agencies such as the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and the National Committee for Quality Assurance (NCQA) have set compliance standards for language access in terms of its contribution to quality care and patient safety. These compliance standards can also have a financial impact on healthcare organizations.

An even more significant effect may result from the federal government’s mandate to provide language services to LEP individuals. Specifically, Executive Order 13166, “Improving Access to Services for Persons with Limited English Proficiency,” stipulates that hospital and healthcare organizations receiving federal funds are required to provide interpretation services under Title VI of the Civil Rights Act of 1964. Denial of interpreter services to LEP patients is considered a form of discrimination.

In addition, the Office of Minority Health (OMH) within the U.S. Department of Health and Human Services has specified 14 National Standards for Culturally and Linguistically Appropriate Services in Health Care (CLAS) that direct healthcare organizations to make their practices more culturally and linguistically accessible. CLAS standards are organized by themes: Culturally Competent Care, Language Access, and Organizational Support for Cultural Competence. Within this framework, there are three types of obligation: mandates, guidelines, and recommendations. Mandates are current federal requirements for all recipients of federal funds; guidelines are activities recommended by OMH for adoption as mandates by accrediting agencies; and recommendations are standards suggested by OMH for voluntary adoption by healthcare organizations.

Despite its mandates, standards, and recommendations, however, the U.S. government has not included provisions for or suggestions about paying for compliance.

Benefits of a Language Access Program

Nevertheless, in addition to complying with governmental regulations and meeting accreditation standards, hospitals can derive benefits from an interpreter program. First and foremost, using interpreters with LEP individuals allows a hospital to fulfill one of its most important professional obligations: providing the best care possible to each patient. The clinician understands the patient’s symptoms, and the patient understands the doctor’s diagnosis and instructions. Together they can form a partnership to meet the physical, psychological, and cultural needs of the patient and to afford a sense of satisfaction to the caregiver.

Secondly, providing linguistic access can make hospital services more cost effective. Visits are fewer and shorter. There are not as many follow-up appointments or repeat admissions because patients understand their physicians’ instructions. Clinicians avoid unnecessary, inadvisable, or inappropriate tests because they understand the patients’ symptoms. Overuse of emergency department services for primary care decreases because patients are comfortable establishing a more conventional primary care relationship. And, as Roat points out, “if a hospital can develop an access program that does not rely on ad-hoc interpreters, the organization can avoid the hidden costs of lower productivity and higher turnover among those ad-hoc interpreters who are asked to interrupt their regular work to provide language access.”

Finally, there are benefits associated with legal and liability issues. Among them: fewer mistakes in diagnoses and treatment because the patients can communicate with their care providers. Also, patients are able to follow directions correctly and understand the need for follow-up or referrals, thus averting an unnecessary tragedy or potential lawsuit. Glenn Flores, MD, director of the Center for the Advancement of Urban Children and professor of pediatrics, epidemiology, and health at the Medical College of Wisconsin, can cite examples of medical errors attributable to language misunderstandings.

“Lack of language services can affect instructions about giving medications, such as the mother who thought she should apply a cortisone cream to the child’s entire body rather than just to the facial rash,” he says. “There is also the problem of possible overdoses. And a single misinterpreted word in one case led to a $71 million lawsuit in Florida a few years ago. This is a major patient safety issue.”

Another safety issue for hospitals is informed consent. Hospitals that provide language services are more likely to ensure that their LEP patients understand and agree to sign the informed consent form.

Paying for Language Access Services

The benefits of offering language access services may be self-evident, but who pays for them? Certainly not private insurers. At least not yet. But, as professionals in the field, both Roat and Dr. Flores see a need for private insurers to assume part of the financial cost. Although Roat believes the costs should be shared among hospitals/clinics, public financing, and commercial insurers, “Advocates of language access need to start a dialogue with commercial insurers and point to HMOs as examples of how these services are being covered,” she says.

Multiple approaches may be necessary to set up coverage from private insurers. Dr. Flores suggests that one possible course is insurance reimbursement for professional interpreters, paid for by the hour or by the visit. Another alternative might involve establishing contract services with outside agencies, community organizations, or video- or teleconferencing companies to recruit, train, and assign medical interpreters for healthcare organizations. These groups could provide services and bill the insurer directly.

“There are also ways to use public funding,” observes Roat, “and there should be more pressure on the federal government to pony up more money for this.”

Dr. Flores agrees. “Under Medicaid and the State Children’s Health Insurance Program (SCHIP), states may pay for interpreting services and receive federal matching funds of 50% or more,” he says. “Yet only 13 states are taking advantage of this. The other 37 states are missing out on this money.”

Like many of his colleagues, Dr. Flores is also mystified about the government’s reluctance to fully fund interpretation services, pointing out that “a federal report from the Office of Management and Budget (OMB) in 2002 estimated that it would cost an average of $4.04 per physician visit to provide all LEP patients with full language access services.”

Then why hasn’t this been allocated? Dr. Flores acknowledges that there is some recognition and awareness of the situation in Congress, and he thinks there may be some political will as well. He has testified before the Senate about the Hispanic Health Improvement Act, yet the bill has yet to pass. At the moment, there are immigration issues that are impeding political action in these areas.

In the meantime, Dr. Flores suggests that there are other steps that healthcare organizations can take to ease language access problems:

• Recruit bilingual providers in areas with large ethnic populations and offer hiring bonuses for qualified individuals;
• Encourage medical schools to require—and even teach—proficiency in languages other than English. “We should require, as other countries do, that children learn foreign languages,” he says; and
• Do a better job of helping LEP individuals learn English.

Begin the last step by directing LEP patients to the Web site of the National Institute for Literacy and Partners, which matches applicants to literacy and ESL programs within their geographical area.1

“We must debunk the oft-repeated story that professional medical interpreters are too expensive to use, that they charge $400 an hour,” says Roat. “That figure came from an incident in which an interpreter was supposedly working in a very remote area on a weekend and charged for the time, distance, and unusual circumstances. In reality, qualified medical interpreters earn $20 to $25 per hour and are worth every penny. Plus, they save money by reducing time and costs to the institution.” TH

Ann Kepler is based in the Chicago area.

Reference

1. National Institute for Literacy, Literacy Directory. Available at: www.literacydirectory.org. Last accessed September 27,2006.

In the early 20th century, postcards quickly gained importance as an economical and rapid form of communication. A small card, often with a colorful image of a city’s most important or beautiful structures and just enough space for a brief message and address, could be sent across town in less than a day for a cent or two.

While postcards became popular collectibles a century ago, interest in them continues today. The Radbill Collection of Hospital Postcards, housed in the Blocker History of Medicine Collections at the Moody Medical Library, University of Texas (UT) Medical Branch, Galveston, documents changing styles in hospital architecture from 1904 to 1994. It also gives an intriguing peek into the lives of the correspondents as they chronicle both daily experiences and traumatic illnesses.

The collection contains approximately 5,400 cards depicting primarily U.S. hospitals and medical centers. Each provides a visual record of a hospital, an asylum, a sanatorium, a health resort, a medical school, or a related building. Many [of these places] no longer exist. All 50 states and nearly 1,100 cities are represented. The work of famous publishers such as Curt Teich of Chicago and E.C. Kropp of Milwaukee can be found.

The oldest card in the collection illustrates Santa Rosa Hospital in San Antonio. It is a “Private Mailing Card,” published between May 19, 1898, and December 24, 1901. Many ways exist to determine the age of a card, including special markings, the amount of postage, and the size of the card itself.

The cards come in many forms, some black and white, others hand colored. Most are standard size, while a few depict longer, panoramic scenes. There are even night views, decorated with glitter to represent stars and moonlight.

The postcard collection dates from 1984, when the library acquired the cards of Samuel X. Radbill, MD, a Philadelphia pediatrician and medical historian. It has grown gradually through donations from individuals, including William H. Helfand of New York City, pharmacist, collector, and consultant to the National Library of Medicine. In 1993, the library welcomed a gift of more than 3,500 cards from Morris M. Weiss, MD, a cardiologist in Louisville, Ky.

The collection is available to researchers interested in the social and architectural history of hospitals as well as the history of patient care and the health sciences in general. A personal computer database allows users to access different types of information. A user may search the database using terms associated with the cards, including hospital name, city and state, and type of hospital.

The Moody Medical Library advances the education, research, patient care, and public service programs of the university by obtaining, applying, and disseminating biomedical information and the tools for its management and use. The library traces its history to the beginnings of the school in 1891, making it the oldest of its kind in Texas. Today, it is the primary source of biomedical information for students and faculty associated with the UT School of Medicine, the Graduate School of Biomedical Sciences, the School of Allied Health Sciences, the School of Nursing, the Marine Biomedical Institute, and the Institute for the Medical Humanities. The library invites inquiries about the postcard collection. For further information, please contact The Blocker History of Medicine Collections, The Moody Medical Library via phone at (409) 772-2397 or via e-mail at [email protected]. TH

Sarita Oertling is a medical history librarian at The Blocker Collection in Galveston, Texas.

Acknowledgements

The three postcards are from the Radbill Collection of Hospital Postcards, housed in the Blocker History of Medicine Collections, Moody Medical Library, The University of Texas Medical Branch, Galveston, Texas.

Thanks also to Kathleen O’Guinn and Arlene Reynolds of St. Mary’s Medical Center and Kathleen Howat of the Historical Society of Long Beach, Calif. All provided information on the Long Beach Sanitarium card.

Christina Santiago in New York kindly assisted with the research on the Bellevue Hospital card.

I have also learned much from the book Postcards in the Library, edited by Norman D. Stevens (New York: The Haworth Press, Inc.; 1995), and the Internet site “Tips for determining when a U.S. postcard was published,” created by the Center of Southwest Studies at Fort Lewis College, Durango, Colo. Available at: http://swcenter.fortlewis.edu/Images/M194/PostcardDating.htm. Accessed on September 18, 2006.

In the early 20th century, postcards quickly gained importance as an economical and rapid form of communication. A small card, often with a colorful image of a city’s most important or beautiful structures and just enough space for a brief message and address, could be sent across town in less than a day for a cent or two.

While postcards became popular collectibles a century ago, interest in them continues today. The Radbill Collection of Hospital Postcards, housed in the Blocker History of Medicine Collections at the Moody Medical Library, University of Texas (UT) Medical Branch, Galveston, documents changing styles in hospital architecture from 1904 to 1994. It also gives an intriguing peek into the lives of the correspondents as they chronicle both daily experiences and traumatic illnesses.

The collection contains approximately 5,400 cards depicting primarily U.S. hospitals and medical centers. Each provides a visual record of a hospital, an asylum, a sanatorium, a health resort, a medical school, or a related building. Many [of these places] no longer exist. All 50 states and nearly 1,100 cities are represented. The work of famous publishers such as Curt Teich of Chicago and E.C. Kropp of Milwaukee can be found.

The oldest card in the collection illustrates Santa Rosa Hospital in San Antonio. It is a “Private Mailing Card,” published between May 19, 1898, and December 24, 1901. Many ways exist to determine the age of a card, including special markings, the amount of postage, and the size of the card itself.

The cards come in many forms, some black and white, others hand colored. Most are standard size, while a few depict longer, panoramic scenes. There are even night views, decorated with glitter to represent stars and moonlight.

The postcard collection dates from 1984, when the library acquired the cards of Samuel X. Radbill, MD, a Philadelphia pediatrician and medical historian. It has grown gradually through donations from individuals, including William H. Helfand of New York City, pharmacist, collector, and consultant to the National Library of Medicine. In 1993, the library welcomed a gift of more than 3,500 cards from Morris M. Weiss, MD, a cardiologist in Louisville, Ky.

The collection is available to researchers interested in the social and architectural history of hospitals as well as the history of patient care and the health sciences in general. A personal computer database allows users to access different types of information. A user may search the database using terms associated with the cards, including hospital name, city and state, and type of hospital.

The Moody Medical Library advances the education, research, patient care, and public service programs of the university by obtaining, applying, and disseminating biomedical information and the tools for its management and use. The library traces its history to the beginnings of the school in 1891, making it the oldest of its kind in Texas. Today, it is the primary source of biomedical information for students and faculty associated with the UT School of Medicine, the Graduate School of Biomedical Sciences, the School of Allied Health Sciences, the School of Nursing, the Marine Biomedical Institute, and the Institute for the Medical Humanities. The library invites inquiries about the postcard collection. For further information, please contact The Blocker History of Medicine Collections, The Moody Medical Library via phone at (409) 772-2397 or via e-mail at [email protected]. TH

Sarita Oertling is a medical history librarian at The Blocker Collection in Galveston, Texas.

Acknowledgements

The three postcards are from the Radbill Collection of Hospital Postcards, housed in the Blocker History of Medicine Collections, Moody Medical Library, The University of Texas Medical Branch, Galveston, Texas.

Thanks also to Kathleen O’Guinn and Arlene Reynolds of St. Mary’s Medical Center and Kathleen Howat of the Historical Society of Long Beach, Calif. All provided information on the Long Beach Sanitarium card.

Christina Santiago in New York kindly assisted with the research on the Bellevue Hospital card.

I have also learned much from the book Postcards in the Library, edited by Norman D. Stevens (New York: The Haworth Press, Inc.; 1995), and the Internet site “Tips for determining when a U.S. postcard was published,” created by the Center of Southwest Studies at Fort Lewis College, Durango, Colo. Available at: http://swcenter.fortlewis.edu/Images/M194/PostcardDating.htm. Accessed on September 18, 2006.

In the early 20th century, postcards quickly gained importance as an economical and rapid form of communication. A small card, often with a colorful image of a city’s most important or beautiful structures and just enough space for a brief message and address, could be sent across town in less than a day for a cent or two.

While postcards became popular collectibles a century ago, interest in them continues today. The Radbill Collection of Hospital Postcards, housed in the Blocker History of Medicine Collections at the Moody Medical Library, University of Texas (UT) Medical Branch, Galveston, documents changing styles in hospital architecture from 1904 to 1994. It also gives an intriguing peek into the lives of the correspondents as they chronicle both daily experiences and traumatic illnesses.

The collection contains approximately 5,400 cards depicting primarily U.S. hospitals and medical centers. Each provides a visual record of a hospital, an asylum, a sanatorium, a health resort, a medical school, or a related building. Many [of these places] no longer exist. All 50 states and nearly 1,100 cities are represented. The work of famous publishers such as Curt Teich of Chicago and E.C. Kropp of Milwaukee can be found.

The oldest card in the collection illustrates Santa Rosa Hospital in San Antonio. It is a “Private Mailing Card,” published between May 19, 1898, and December 24, 1901. Many ways exist to determine the age of a card, including special markings, the amount of postage, and the size of the card itself.

The cards come in many forms, some black and white, others hand colored. Most are standard size, while a few depict longer, panoramic scenes. There are even night views, decorated with glitter to represent stars and moonlight.

The postcard collection dates from 1984, when the library acquired the cards of Samuel X. Radbill, MD, a Philadelphia pediatrician and medical historian. It has grown gradually through donations from individuals, including William H. Helfand of New York City, pharmacist, collector, and consultant to the National Library of Medicine. In 1993, the library welcomed a gift of more than 3,500 cards from Morris M. Weiss, MD, a cardiologist in Louisville, Ky.

The collection is available to researchers interested in the social and architectural history of hospitals as well as the history of patient care and the health sciences in general. A personal computer database allows users to access different types of information. A user may search the database using terms associated with the cards, including hospital name, city and state, and type of hospital.

The Moody Medical Library advances the education, research, patient care, and public service programs of the university by obtaining, applying, and disseminating biomedical information and the tools for its management and use. The library traces its history to the beginnings of the school in 1891, making it the oldest of its kind in Texas. Today, it is the primary source of biomedical information for students and faculty associated with the UT School of Medicine, the Graduate School of Biomedical Sciences, the School of Allied Health Sciences, the School of Nursing, the Marine Biomedical Institute, and the Institute for the Medical Humanities. The library invites inquiries about the postcard collection. For further information, please contact The Blocker History of Medicine Collections, The Moody Medical Library via phone at (409) 772-2397 or via e-mail at [email protected]. TH

Sarita Oertling is a medical history librarian at The Blocker Collection in Galveston, Texas.

Acknowledgements

The three postcards are from the Radbill Collection of Hospital Postcards, housed in the Blocker History of Medicine Collections, Moody Medical Library, The University of Texas Medical Branch, Galveston, Texas.

Thanks also to Kathleen O’Guinn and Arlene Reynolds of St. Mary’s Medical Center and Kathleen Howat of the Historical Society of Long Beach, Calif. All provided information on the Long Beach Sanitarium card.

Christina Santiago in New York kindly assisted with the research on the Bellevue Hospital card.

I have also learned much from the book Postcards in the Library, edited by Norman D. Stevens (New York: The Haworth Press, Inc.; 1995), and the Internet site “Tips for determining when a U.S. postcard was published,” created by the Center of Southwest Studies at Fort Lewis College, Durango, Colo. Available at: http://swcenter.fortlewis.edu/Images/M194/PostcardDating.htm. Accessed on September 18, 2006.

A 29-year-old male warehouse worker noticed pain in his right lower quadrant. The pain was intense and poorly localized (arrow) and increased with lifting or resisted hip flexion. Appendicitis was diagnosed, but pain persisted post-operatively. Necrotizing fasciitis was suspected, but repeated debridements failed to relieve the pain.

Physical Exam

The inguinal ligament runs parallel to the inguinal crease (pink pencil line—see right). About midway in its length, the ligament became difficult to identify due to an exquisitely tender doughy area (arrow). Palpation of this area reproduced the patent’s symptoms, along with poorly localized lower abdominal pain. An attempted sit-up caused similar symptoms.

Anatomy

The iliopsoas bursa is located where the inguinal ligament, the iliopsoas tendon, and the transversus tendon intersect. An inflamed iliopsoas bursa is palpable as a doughy mass below the midpoint of the length of the inguinal ligament, lateral to the femoral artery. Most often the opposite, unaffected side demonstrates a normal, pencil-thin, easily defined, non-tender inguinal ligament.

Iliopsoas Bursitis/Tendonitis

The iliopsoas bursa is the largest bursa in the body and communicates with the hip joint in 15% of patients. Bursitis/tendonitis is caused by overuse and friction as the tendon rides over the iliopectineal eminence of the pubis. The condition is associated with lifting, unloading trucks, and participating in sports requiring extensive use of the hip flexors (e.g., soccer, ballet, uphill running, hurdling, jumping). Iliopsoas bursitis/tendonitis is characterized by deep groin pain, sometimes radiating to the anterior hip or thigh, and is often accompanied by a snapping sensation. The patient may limp.

The pain is difficult for patients to localize and challenging for clinicians to reproduce. In fact, the average time from the onset of symptoms to diagnosis is 31 to 42 months. It is common for many other diagnoses to be entertained and treated with no improvement. Physical examination will reveal pain on deep palpation over the femoral triangle, where the musculotendinous junction of the iliopsoas can be palpated as a doughy diffuse area of tenderness at the midpoint of the inguinal ligament.

Pain may also be produced when the affected hip is extended or when the supine patient raises his or her heels off the table at about 15 degrees. In the latter position, the only active hip flexor is the iliopsoas.

Imaging

Although these procedures are not necessary for diagnosis, iliopsoas bursitis is best visualized using ultrasound or MRI—either of which will reveal a collection of fluid adjacent to the muscle. Treatment is conservative and consists of rest followed by stretching of the hip flexors and rotators, then strengthening and gradual return to work or sport. As in any overuse injury, biomechanical abnormalities must be sought and corrected. While most patients resolve spontaneously, corticosteroid injections are helpful in about one-third of patients. Rarely, surgical management of recalcitrant cases is warranted.

Iliopsoas Bursitis/Tendonitis Injection

The following procedure should be followed when administering a corticosteroid injection. With the fingers of one hand, identify and isolate the inguinal ligament in the area of doughy discomfort. With the other hand, insert a 1.5-inch needle to its hub, parallel to the ligament, and inject a steroid and lidocaine mixture slowly while withdrawing the needle to avoid inadvertently injecting the ligament or any tendons.

A medium-acting depot steroid gives good, long-lasting relief. A mixture of lidocaine or bupivacaine and the steroid allows for immediate relief, as well as confirmation that the steroid reached its target. TH

Gerhart is a third-year medical student at the Mayo Clinic College of Medicine, and Dr. Ficalora is an associate professor in internal medicine at the Mayo Clinic College of Medicine.

A 29-year-old male warehouse worker noticed pain in his right lower quadrant. The pain was intense and poorly localized (arrow) and increased with lifting or resisted hip flexion. Appendicitis was diagnosed, but pain persisted post-operatively. Necrotizing fasciitis was suspected, but repeated debridements failed to relieve the pain.

Physical Exam

The inguinal ligament runs parallel to the inguinal crease (pink pencil line—see right). About midway in its length, the ligament became difficult to identify due to an exquisitely tender doughy area (arrow). Palpation of this area reproduced the patent’s symptoms, along with poorly localized lower abdominal pain. An attempted sit-up caused similar symptoms.

Anatomy

The iliopsoas bursa is located where the inguinal ligament, the iliopsoas tendon, and the transversus tendon intersect. An inflamed iliopsoas bursa is palpable as a doughy mass below the midpoint of the length of the inguinal ligament, lateral to the femoral artery. Most often the opposite, unaffected side demonstrates a normal, pencil-thin, easily defined, non-tender inguinal ligament.

Iliopsoas Bursitis/Tendonitis

The iliopsoas bursa is the largest bursa in the body and communicates with the hip joint in 15% of patients. Bursitis/tendonitis is caused by overuse and friction as the tendon rides over the iliopectineal eminence of the pubis. The condition is associated with lifting, unloading trucks, and participating in sports requiring extensive use of the hip flexors (e.g., soccer, ballet, uphill running, hurdling, jumping). Iliopsoas bursitis/tendonitis is characterized by deep groin pain, sometimes radiating to the anterior hip or thigh, and is often accompanied by a snapping sensation. The patient may limp.

The pain is difficult for patients to localize and challenging for clinicians to reproduce. In fact, the average time from the onset of symptoms to diagnosis is 31 to 42 months. It is common for many other diagnoses to be entertained and treated with no improvement. Physical examination will reveal pain on deep palpation over the femoral triangle, where the musculotendinous junction of the iliopsoas can be palpated as a doughy diffuse area of tenderness at the midpoint of the inguinal ligament.

Pain may also be produced when the affected hip is extended or when the supine patient raises his or her heels off the table at about 15 degrees. In the latter position, the only active hip flexor is the iliopsoas.

Imaging

Although these procedures are not necessary for diagnosis, iliopsoas bursitis is best visualized using ultrasound or MRI—either of which will reveal a collection of fluid adjacent to the muscle. Treatment is conservative and consists of rest followed by stretching of the hip flexors and rotators, then strengthening and gradual return to work or sport. As in any overuse injury, biomechanical abnormalities must be sought and corrected. While most patients resolve spontaneously, corticosteroid injections are helpful in about one-third of patients. Rarely, surgical management of recalcitrant cases is warranted.

Iliopsoas Bursitis/Tendonitis Injection

The following procedure should be followed when administering a corticosteroid injection. With the fingers of one hand, identify and isolate the inguinal ligament in the area of doughy discomfort. With the other hand, insert a 1.5-inch needle to its hub, parallel to the ligament, and inject a steroid and lidocaine mixture slowly while withdrawing the needle to avoid inadvertently injecting the ligament or any tendons.

A medium-acting depot steroid gives good, long-lasting relief. A mixture of lidocaine or bupivacaine and the steroid allows for immediate relief, as well as confirmation that the steroid reached its target. TH

Gerhart is a third-year medical student at the Mayo Clinic College of Medicine, and Dr. Ficalora is an associate professor in internal medicine at the Mayo Clinic College of Medicine.

A 29-year-old male warehouse worker noticed pain in his right lower quadrant. The pain was intense and poorly localized (arrow) and increased with lifting or resisted hip flexion. Appendicitis was diagnosed, but pain persisted post-operatively. Necrotizing fasciitis was suspected, but repeated debridements failed to relieve the pain.

Physical Exam

The inguinal ligament runs parallel to the inguinal crease (pink pencil line—see right). About midway in its length, the ligament became difficult to identify due to an exquisitely tender doughy area (arrow). Palpation of this area reproduced the patent’s symptoms, along with poorly localized lower abdominal pain. An attempted sit-up caused similar symptoms.

Anatomy

The iliopsoas bursa is located where the inguinal ligament, the iliopsoas tendon, and the transversus tendon intersect. An inflamed iliopsoas bursa is palpable as a doughy mass below the midpoint of the length of the inguinal ligament, lateral to the femoral artery. Most often the opposite, unaffected side demonstrates a normal, pencil-thin, easily defined, non-tender inguinal ligament.

Iliopsoas Bursitis/Tendonitis

The iliopsoas bursa is the largest bursa in the body and communicates with the hip joint in 15% of patients. Bursitis/tendonitis is caused by overuse and friction as the tendon rides over the iliopectineal eminence of the pubis. The condition is associated with lifting, unloading trucks, and participating in sports requiring extensive use of the hip flexors (e.g., soccer, ballet, uphill running, hurdling, jumping). Iliopsoas bursitis/tendonitis is characterized by deep groin pain, sometimes radiating to the anterior hip or thigh, and is often accompanied by a snapping sensation. The patient may limp.

The pain is difficult for patients to localize and challenging for clinicians to reproduce. In fact, the average time from the onset of symptoms to diagnosis is 31 to 42 months. It is common for many other diagnoses to be entertained and treated with no improvement. Physical examination will reveal pain on deep palpation over the femoral triangle, where the musculotendinous junction of the iliopsoas can be palpated as a doughy diffuse area of tenderness at the midpoint of the inguinal ligament.

Pain may also be produced when the affected hip is extended or when the supine patient raises his or her heels off the table at about 15 degrees. In the latter position, the only active hip flexor is the iliopsoas.

Imaging

Although these procedures are not necessary for diagnosis, iliopsoas bursitis is best visualized using ultrasound or MRI—either of which will reveal a collection of fluid adjacent to the muscle. Treatment is conservative and consists of rest followed by stretching of the hip flexors and rotators, then strengthening and gradual return to work or sport. As in any overuse injury, biomechanical abnormalities must be sought and corrected. While most patients resolve spontaneously, corticosteroid injections are helpful in about one-third of patients. Rarely, surgical management of recalcitrant cases is warranted.

Iliopsoas Bursitis/Tendonitis Injection

The following procedure should be followed when administering a corticosteroid injection. With the fingers of one hand, identify and isolate the inguinal ligament in the area of doughy discomfort. With the other hand, insert a 1.5-inch needle to its hub, parallel to the ligament, and inject a steroid and lidocaine mixture slowly while withdrawing the needle to avoid inadvertently injecting the ligament or any tendons.

A medium-acting depot steroid gives good, long-lasting relief. A mixture of lidocaine or bupivacaine and the steroid allows for immediate relief, as well as confirmation that the steroid reached its target. TH

Gerhart is a third-year medical student at the Mayo Clinic College of Medicine, and Dr. Ficalora is an associate professor in internal medicine at the Mayo Clinic College of Medicine.

What do the Japanese military, a Dutch microbiologist, sick chickens, and rice polishers have in common?

In the 1800s, Europeans colonizing Asia brought with them steam-powered machines that completely polished rice. This rice, which was thought to be superior to unpolished rice, became very popular. As Far Eastern society’s main source of thiamine was polished to oblivion, beriberi became more prevalent and problematic.

At that time, micronutrient deficiency states were still a mystery to physicians. Kanehiro Takaki (October 30, 1849–April 13, 1920), surgeon general of the Japanese Imperial Navy, noticed a connection between sailors’ diets and their development of beriberi. White rice was replaced with barley, vegetables, fish, and meat. The incidence of beriberi dropped swiftly and was eliminated in the Japanese Navy, within six years.

Kanehiro Takaki

Meanwhile, in the Dutch Indies, beriberi was endemic and crippling. Christiaan Eijkman, a Dutch microbiologist (August 11, 1858–November 5, 1930) who had studied with bacteriologist Robert Koch (December 11, 1843-May 27, 1910) in Berlin, was sent to research the disease in Java. Eijkman was unaware of Takaki’s findings and was convinced that beriberi was an infection.

Eijkman tried to infect chickens with a microorganism isolated from the corpses of two beriberi-related deaths. While he was striving to find the causative pathogen, Eijkman noticed that all chickens, even those having no contact with either the microorganism or other chickens, developed “a disease, in many respects strikingly similar to beriberi in man.” In fact, they had developed polyneuritis. Then, miraculously, they recovered spontaneously.

Christiaan Eijkman

Eijkman was bewildered by this sequence of events and set out to solve the poultry mystery. He discovered that the chickens, during the time that they had been ill, had been eating leftover cooked, polished white rice from the hospital kitchen. When the cook left, however, his replacement refused to relinquish leftover rice, and they were thereafter given raw, unpolished rice. After this dietary change, the chickens recovered. Eijkman concluded that a substance in unpolished rice protected chickens against infection—he was still searching for the elusive microscopic culprit—and he called this protective substance the “anti-beriberi factor.” He thought unpolished rice contained an antidote to a bacterial toxin.

In 1906, Frederick Hopkins (1861–1947) demonstrated “accessory factors” in food, those nutrients necessary to maintain good health in addition to the carbohydrates, fats, proteins, and minerals that had previously been acknowledged as vital. In 1912, a Polish biochemist, Casimir Funk (1884–1967), thought he had isolated the anti-beriberi factor and named his discovery vitamine, from “vital amine.” Although he hadn’t isolated anti-beriberi factor—it is believed that he isolated nicotinic acid—the name vitamine remained. Eventually, in 1926, researchers were able to isolate the anti-beriberi factor in rice bran extracts. In 1929, Hopkins and Eijkman were awarded the Nobel Prize in Physiology or Medicine for the discovery of vitamins.

Frederick Hopkins

Clinicians are now well aware of alcohol abuse and the development of Wernicke’s encephalopathy or Korsakoff amnestic syndrome. Phrases like wet (high output heart failure) and dry (peripheral neuropathy) beriberi were once commonly found on board exams. The clinical presentation of thiamine deficiency isn’t limited to alcoholics. For example, there is evidence that patients with end-stage renal disease on hemodialysis are at risk of becoming thiamine deficient and of developing “unexplained” encephalopathies.1 Patients who suffer congestive heart failure while on long-term diuretics are also at increased risk for thiamine deficiency.2

This account is a classic example of the fascinating way in which the discovery of these essential nutrients has evolved and serves as a wake-up call that emphasizes the current epidemic of malnutrition in hospitalized patients.

Protein energy malnutrition in hospitalized patients is very common. Many studies have demonstrated that the prevalence runs between 30% and 60%, depending on the patient population studied and the assessment tools used. Hospital malnutrition, independent of disease activity, has been linked to increased length of stay and heightened morbidity and mortality. It is disturbing to think that many patients are actually worse off at time of dismissal than they were at admission. Malnutrition often goes unrecognized and even when the problem is acknowledged adequate nutrition is often not provided. Patients are commonly permitted to subsist on very low nutrient intakes.3 The problem of malnutrition is likely grossly underestimated because most studies have not considered micronutrients such as trace elements and vitamins. In addition, the presence of subclinical, yet clinically important, deficiency is expected to be highly prevalent.

Early screening improves the recognition of malnourished patients and provides the opportunity to start treatment at an early stage of hospitalization. Nutritional therapy as part of a comprehensive treatment modality may result in improvement of healthcare quality. In some countries it is also a criterion for assessing the performance of hospitals. In the U.S., for example, nutritional screening in hospitals is required for accreditation by the Joint Commission on Accreditation of Healthcare Organizations and is part of the Minimal Data Set documentation in long-term care facilities.

In most institutions, nutritional screening refers to a rapid and general test that is undertaken by nursing, medical, and other staff, often at first contact with patients. This is in contrast to the detailed nutritional evaluation that is undertaken by nutrition specialists (e.g., dietitians, specialist nutrition nurses, or physicians with an interest in nutrition), often for complex problems and often following nutritional screening. The introduction of a nutrition screening program and documentation of nutritional status may also increase diagnosis-related group (DRG)-based reimbursement.

Unfortunately, a lack of standardized sensitive and specific methodologies to assess for macro- or micronutrient deficiencies makes it difficult to determine how best to screen patients. Recent literature suggests, however, that the use of a short nutrition questionnaire and an undemanding treatment plan improved nutritional care during a hospital stay.4 The use of this strategy reduced the duration of the hospital stay in a subgroup of frail malnourished patients, offering potential improvements in morbidity as well as financial benefits for the hospital.

The lessons of past discoveries should not be lost on modern medicine. Malnutrition can be made a condition of the past through the use of simple screening procedures and uncomplicated treatments. The results will benefit both patients and hospitals. TH

Michelle Schneider is a medical student at the Royal College of Surgeons in Dublin, Ireland. Dr. Egger is a senior associate consultant at the Mayo Clinic College of Medicine.

References

1. Hung SC, Hung SH, Tarng DC, et al. Thiamine deficiency and unexplained encephalopathy in hemodialysis and peritoneal dialysis patients. Am J Kidney Dis. 2001;38:941-947.
2. Hanninen SA, Darling PB, Sole MJ, et al. The prevalence of thiamin deficiency in hospitalized patients with congestive heart failure. J Am Coll Cardiol. 2006 Jan 17;47(2):354-361.
3. Sullivan DH, Sun S, Walls RC. Protein-energy undernutrition among elderly hospitalized patients: a prospective study. JAMA. 1999 Jun;281(21):2013-2019.
4. Kruizenga HM, Van Tulder MW, Seidell JC, et al. Effectiveness and cost-effectiveness of early screening and treatment of malnourished patients. Am J Clin Nutr. 2005;82(5):1082-1089.

What do the Japanese military, a Dutch microbiologist, sick chickens, and rice polishers have in common?

In the 1800s, Europeans colonizing Asia brought with them steam-powered machines that completely polished rice. This rice, which was thought to be superior to unpolished rice, became very popular. As Far Eastern society’s main source of thiamine was polished to oblivion, beriberi became more prevalent and problematic.

At that time, micronutrient deficiency states were still a mystery to physicians. Kanehiro Takaki (October 30, 1849–April 13, 1920), surgeon general of the Japanese Imperial Navy, noticed a connection between sailors’ diets and their development of beriberi. White rice was replaced with barley, vegetables, fish, and meat. The incidence of beriberi dropped swiftly and was eliminated in the Japanese Navy, within six years.

Kanehiro Takaki

Meanwhile, in the Dutch Indies, beriberi was endemic and crippling. Christiaan Eijkman, a Dutch microbiologist (August 11, 1858–November 5, 1930) who had studied with bacteriologist Robert Koch (December 11, 1843-May 27, 1910) in Berlin, was sent to research the disease in Java. Eijkman was unaware of Takaki’s findings and was convinced that beriberi was an infection.

Eijkman tried to infect chickens with a microorganism isolated from the corpses of two beriberi-related deaths. While he was striving to find the causative pathogen, Eijkman noticed that all chickens, even those having no contact with either the microorganism or other chickens, developed “a disease, in many respects strikingly similar to beriberi in man.” In fact, they had developed polyneuritis. Then, miraculously, they recovered spontaneously.

Christiaan Eijkman

Eijkman was bewildered by this sequence of events and set out to solve the poultry mystery. He discovered that the chickens, during the time that they had been ill, had been eating leftover cooked, polished white rice from the hospital kitchen. When the cook left, however, his replacement refused to relinquish leftover rice, and they were thereafter given raw, unpolished rice. After this dietary change, the chickens recovered. Eijkman concluded that a substance in unpolished rice protected chickens against infection—he was still searching for the elusive microscopic culprit—and he called this protective substance the “anti-beriberi factor.” He thought unpolished rice contained an antidote to a bacterial toxin.

In 1906, Frederick Hopkins (1861–1947) demonstrated “accessory factors” in food, those nutrients necessary to maintain good health in addition to the carbohydrates, fats, proteins, and minerals that had previously been acknowledged as vital. In 1912, a Polish biochemist, Casimir Funk (1884–1967), thought he had isolated the anti-beriberi factor and named his discovery vitamine, from “vital amine.” Although he hadn’t isolated anti-beriberi factor—it is believed that he isolated nicotinic acid—the name vitamine remained. Eventually, in 1926, researchers were able to isolate the anti-beriberi factor in rice bran extracts. In 1929, Hopkins and Eijkman were awarded the Nobel Prize in Physiology or Medicine for the discovery of vitamins.

Frederick Hopkins

Clinicians are now well aware of alcohol abuse and the development of Wernicke’s encephalopathy or Korsakoff amnestic syndrome. Phrases like wet (high output heart failure) and dry (peripheral neuropathy) beriberi were once commonly found on board exams. The clinical presentation of thiamine deficiency isn’t limited to alcoholics. For example, there is evidence that patients with end-stage renal disease on hemodialysis are at risk of becoming thiamine deficient and of developing “unexplained” encephalopathies.1 Patients who suffer congestive heart failure while on long-term diuretics are also at increased risk for thiamine deficiency.2

This account is a classic example of the fascinating way in which the discovery of these essential nutrients has evolved and serves as a wake-up call that emphasizes the current epidemic of malnutrition in hospitalized patients.

Protein energy malnutrition in hospitalized patients is very common. Many studies have demonstrated that the prevalence runs between 30% and 60%, depending on the patient population studied and the assessment tools used. Hospital malnutrition, independent of disease activity, has been linked to increased length of stay and heightened morbidity and mortality. It is disturbing to think that many patients are actually worse off at time of dismissal than they were at admission. Malnutrition often goes unrecognized and even when the problem is acknowledged adequate nutrition is often not provided. Patients are commonly permitted to subsist on very low nutrient intakes.3 The problem of malnutrition is likely grossly underestimated because most studies have not considered micronutrients such as trace elements and vitamins. In addition, the presence of subclinical, yet clinically important, deficiency is expected to be highly prevalent.

Early screening improves the recognition of malnourished patients and provides the opportunity to start treatment at an early stage of hospitalization. Nutritional therapy as part of a comprehensive treatment modality may result in improvement of healthcare quality. In some countries it is also a criterion for assessing the performance of hospitals. In the U.S., for example, nutritional screening in hospitals is required for accreditation by the Joint Commission on Accreditation of Healthcare Organizations and is part of the Minimal Data Set documentation in long-term care facilities.

In most institutions, nutritional screening refers to a rapid and general test that is undertaken by nursing, medical, and other staff, often at first contact with patients. This is in contrast to the detailed nutritional evaluation that is undertaken by nutrition specialists (e.g., dietitians, specialist nutrition nurses, or physicians with an interest in nutrition), often for complex problems and often following nutritional screening. The introduction of a nutrition screening program and documentation of nutritional status may also increase diagnosis-related group (DRG)-based reimbursement.

Unfortunately, a lack of standardized sensitive and specific methodologies to assess for macro- or micronutrient deficiencies makes it difficult to determine how best to screen patients. Recent literature suggests, however, that the use of a short nutrition questionnaire and an undemanding treatment plan improved nutritional care during a hospital stay.4 The use of this strategy reduced the duration of the hospital stay in a subgroup of frail malnourished patients, offering potential improvements in morbidity as well as financial benefits for the hospital.

The lessons of past discoveries should not be lost on modern medicine. Malnutrition can be made a condition of the past through the use of simple screening procedures and uncomplicated treatments. The results will benefit both patients and hospitals. TH

Michelle Schneider is a medical student at the Royal College of Surgeons in Dublin, Ireland. Dr. Egger is a senior associate consultant at the Mayo Clinic College of Medicine.

References

1. Hung SC, Hung SH, Tarng DC, et al. Thiamine deficiency and unexplained encephalopathy in hemodialysis and peritoneal dialysis patients. Am J Kidney Dis. 2001;38:941-947.
2. Hanninen SA, Darling PB, Sole MJ, et al. The prevalence of thiamin deficiency in hospitalized patients with congestive heart failure. J Am Coll Cardiol. 2006 Jan 17;47(2):354-361.
3. Sullivan DH, Sun S, Walls RC. Protein-energy undernutrition among elderly hospitalized patients: a prospective study. JAMA. 1999 Jun;281(21):2013-2019.
4. Kruizenga HM, Van Tulder MW, Seidell JC, et al. Effectiveness and cost-effectiveness of early screening and treatment of malnourished patients. Am J Clin Nutr. 2005;82(5):1082-1089.

What do the Japanese military, a Dutch microbiologist, sick chickens, and rice polishers have in common?

In the 1800s, Europeans colonizing Asia brought with them steam-powered machines that completely polished rice. This rice, which was thought to be superior to unpolished rice, became very popular. As Far Eastern society’s main source of thiamine was polished to oblivion, beriberi became more prevalent and problematic.

At that time, micronutrient deficiency states were still a mystery to physicians. Kanehiro Takaki (October 30, 1849–April 13, 1920), surgeon general of the Japanese Imperial Navy, noticed a connection between sailors’ diets and their development of beriberi. White rice was replaced with barley, vegetables, fish, and meat. The incidence of beriberi dropped swiftly and was eliminated in the Japanese Navy, within six years.

Kanehiro Takaki

Meanwhile, in the Dutch Indies, beriberi was endemic and crippling. Christiaan Eijkman, a Dutch microbiologist (August 11, 1858–November 5, 1930) who had studied with bacteriologist Robert Koch (December 11, 1843-May 27, 1910) in Berlin, was sent to research the disease in Java. Eijkman was unaware of Takaki’s findings and was convinced that beriberi was an infection.

Eijkman tried to infect chickens with a microorganism isolated from the corpses of two beriberi-related deaths. While he was striving to find the causative pathogen, Eijkman noticed that all chickens, even those having no contact with either the microorganism or other chickens, developed “a disease, in many respects strikingly similar to beriberi in man.” In fact, they had developed polyneuritis. Then, miraculously, they recovered spontaneously.

Christiaan Eijkman

Eijkman was bewildered by this sequence of events and set out to solve the poultry mystery. He discovered that the chickens, during the time that they had been ill, had been eating leftover cooked, polished white rice from the hospital kitchen. When the cook left, however, his replacement refused to relinquish leftover rice, and they were thereafter given raw, unpolished rice. After this dietary change, the chickens recovered. Eijkman concluded that a substance in unpolished rice protected chickens against infection—he was still searching for the elusive microscopic culprit—and he called this protective substance the “anti-beriberi factor.” He thought unpolished rice contained an antidote to a bacterial toxin.

In 1906, Frederick Hopkins (1861–1947) demonstrated “accessory factors” in food, those nutrients necessary to maintain good health in addition to the carbohydrates, fats, proteins, and minerals that had previously been acknowledged as vital. In 1912, a Polish biochemist, Casimir Funk (1884–1967), thought he had isolated the anti-beriberi factor and named his discovery vitamine, from “vital amine.” Although he hadn’t isolated anti-beriberi factor—it is believed that he isolated nicotinic acid—the name vitamine remained. Eventually, in 1926, researchers were able to isolate the anti-beriberi factor in rice bran extracts. In 1929, Hopkins and Eijkman were awarded the Nobel Prize in Physiology or Medicine for the discovery of vitamins.

Frederick Hopkins

Clinicians are now well aware of alcohol abuse and the development of Wernicke’s encephalopathy or Korsakoff amnestic syndrome. Phrases like wet (high output heart failure) and dry (peripheral neuropathy) beriberi were once commonly found on board exams. The clinical presentation of thiamine deficiency isn’t limited to alcoholics. For example, there is evidence that patients with end-stage renal disease on hemodialysis are at risk of becoming thiamine deficient and of developing “unexplained” encephalopathies.1 Patients who suffer congestive heart failure while on long-term diuretics are also at increased risk for thiamine deficiency.2

This account is a classic example of the fascinating way in which the discovery of these essential nutrients has evolved and serves as a wake-up call that emphasizes the current epidemic of malnutrition in hospitalized patients.

Protein energy malnutrition in hospitalized patients is very common. Many studies have demonstrated that the prevalence runs between 30% and 60%, depending on the patient population studied and the assessment tools used. Hospital malnutrition, independent of disease activity, has been linked to increased length of stay and heightened morbidity and mortality. It is disturbing to think that many patients are actually worse off at time of dismissal than they were at admission. Malnutrition often goes unrecognized and even when the problem is acknowledged adequate nutrition is often not provided. Patients are commonly permitted to subsist on very low nutrient intakes.3 The problem of malnutrition is likely grossly underestimated because most studies have not considered micronutrients such as trace elements and vitamins. In addition, the presence of subclinical, yet clinically important, deficiency is expected to be highly prevalent.

Early screening improves the recognition of malnourished patients and provides the opportunity to start treatment at an early stage of hospitalization. Nutritional therapy as part of a comprehensive treatment modality may result in improvement of healthcare quality. In some countries it is also a criterion for assessing the performance of hospitals. In the U.S., for example, nutritional screening in hospitals is required for accreditation by the Joint Commission on Accreditation of Healthcare Organizations and is part of the Minimal Data Set documentation in long-term care facilities.

In most institutions, nutritional screening refers to a rapid and general test that is undertaken by nursing, medical, and other staff, often at first contact with patients. This is in contrast to the detailed nutritional evaluation that is undertaken by nutrition specialists (e.g., dietitians, specialist nutrition nurses, or physicians with an interest in nutrition), often for complex problems and often following nutritional screening. The introduction of a nutrition screening program and documentation of nutritional status may also increase diagnosis-related group (DRG)-based reimbursement.

Unfortunately, a lack of standardized sensitive and specific methodologies to assess for macro- or micronutrient deficiencies makes it difficult to determine how best to screen patients. Recent literature suggests, however, that the use of a short nutrition questionnaire and an undemanding treatment plan improved nutritional care during a hospital stay.4 The use of this strategy reduced the duration of the hospital stay in a subgroup of frail malnourished patients, offering potential improvements in morbidity as well as financial benefits for the hospital.

The lessons of past discoveries should not be lost on modern medicine. Malnutrition can be made a condition of the past through the use of simple screening procedures and uncomplicated treatments. The results will benefit both patients and hospitals. TH

Michelle Schneider is a medical student at the Royal College of Surgeons in Dublin, Ireland. Dr. Egger is a senior associate consultant at the Mayo Clinic College of Medicine.

References

1. Hung SC, Hung SH, Tarng DC, et al. Thiamine deficiency and unexplained encephalopathy in hemodialysis and peritoneal dialysis patients. Am J Kidney Dis. 2001;38:941-947.
2. Hanninen SA, Darling PB, Sole MJ, et al. The prevalence of thiamin deficiency in hospitalized patients with congestive heart failure. J Am Coll Cardiol. 2006 Jan 17;47(2):354-361.
3. Sullivan DH, Sun S, Walls RC. Protein-energy undernutrition among elderly hospitalized patients: a prospective study. JAMA. 1999 Jun;281(21):2013-2019.
4. Kruizenga HM, Van Tulder MW, Seidell JC, et al. Effectiveness and cost-effectiveness of early screening and treatment of malnourished patients. Am J Clin Nutr. 2005;82(5):1082-1089.

How prepared are you to negotiate the best possible contract for your next position? Do you know what you can realistically ask for? If the salary offered seems too low, do other factors make the job a perfect fit?

In order to get the most beneficial contract with your next hospitalist position, you must have confidence in your negotiation skills. Here are some steps that may help.

1. Recognize Your Priorities

Before you set foot in your first interview with an organization, you must know your own mind—what exactly do you want to “win” in a contract negotiation?

“Your first step should be quiet reflection, where you figure out what you want and what [part] of that is non-negotiable,” advises Fred A. McCurdy, MD, PhD, MBA, FAAP, CPE, professor and regional chairman of the department of pediatrics, Texas Tech University Health Sciences Center at Amarillo. Most people focus on money when they anticipate negotiating employment, but there are other factors to consider, such as schedule (on-duty and on-call hours); opportunities for advancement, including research, project management, and teaching; and, of course, benefits, including insurance and retirement packages. Consider carefully which factors matter most to you, then rank them to organize your personal priorities.

Dr. McCurdy recommends the process he uses for all the negotiations he participates in as part of his job. “I think through the principles of each negotiation situation and write them out,” he says. “I pick out the non-negotiable items as well as the items I hope to achieve.”

2. Do Your Homework

It’s tough to negotiate your salary or your benefits when you don’t know the market. “Don’t walk in without knowing your facts,” warns Dr. McCurdy. “Do your homework to see what the market is and how payment systems work.”

Research the potential employer to find out what they’re paying other physicians and how they pay. “You can ask [the interviewers], ‘What are you currently paying your other hospitalists?’ ” says Dr. McCurdy. “You might get [them to tell you] a pay range.”

Ask questions in your interviews, and conduct independent research on the organization and on the market.

“You can obtain a lot of information on your own,” he explains. “The MGMA [Medical Group Management Association] and the Association of American Medical Colleges (AAMC) have salary scales available. Salaries are public information for people who work in public institutions like university hospitals.”

SHM also provides up-to-date salary information in its “Bi-Annual Survey on the State of the Hospital Medicine Movement,” available at www.hospitalmedicine.org.

3. Know Your Strengths

Another homework assignment before the interview process: Know your strongest selling points. Whether you have an excellent record as a faculty member or a strong background in heading up task forces, your unique strengths will be your strongest argument in negotiating your contract.

“The most effective way to negotiate is to talk about the value-added,” says Dr. McCurdy. “Find out what they want, and speak to that. You’ll have to figure that out as you go.”

It might be what you can do to improve the organization’s bottom line; it might be specific skills or expertise you bring to the table, such as teaching proficiency or research skills.

What about recent graduates who are seeking their first job as a hospitalist? “People right out of training seem to have distinct advantages that they don’t emphasize,” says Dr. McCurdy. “They’re young and have a high energy level, for one thing. Their knowledge base is very current, so they’re cutting edge, and they have quality of training—they were recently instructed by cutting-edge teachers.”

4. Look Beyond Salary

Of course you’ll want to negotiate for as much money as you can, but other factors may make a lower salary worthwhile to you. “Lots of organizations have a lot of non-tangibles to offer, but many physicians go into this ill informed” about what they can get, says Dr. McCurdy. You might ask for “some equity holding in the organization you’re looking to become part of” if it’s a privately held hospital medicine group.

“Think about various trade-offs,” urges Dr. McCurdy. “For example, you might accept a lower salary for less on-call time. Or if you’re considering a position in academic medicine, you know that your residents will take most of your night hours—is that worth a lower salary to you?”

You might also consider “access to a foundation that could help you leverage a project you want to do or a situation where you have a chance to spin off intellectual property where you keep the proceeds,” he suggests. “It all depends on the organization. What do they have that would be valuable to you?”

5. Practice Your Negotiation Skills

One last piece of homework before you walk into the final interview: Do a practice run of how the meeting might go.

Physicians don’t always practice negotiation conversations, says Dr. McCurdy. “Find someone who will practice with you, who will throw a lot of questions at you. I used a personal coach. She had me practicing ‘how to deal with Fred when he’s in conflict.’ I hated it, and I’m so glad I did it!”

So do your homework and be prepared to argue your strengths, stick up for your non-negotiables, and resign yourself to giving in on some of your other points. With insight, information, and practice, you’ll be in an excellent position to walk away from the table with most—if not all—of what you want in your next contract. TH

Jane Jerrard writes “Career Management” monthly for The Hospitalist.

How prepared are you to negotiate the best possible contract for your next position? Do you know what you can realistically ask for? If the salary offered seems too low, do other factors make the job a perfect fit?

In order to get the most beneficial contract with your next hospitalist position, you must have confidence in your negotiation skills. Here are some steps that may help.

1. Recognize Your Priorities

Before you set foot in your first interview with an organization, you must know your own mind—what exactly do you want to “win” in a contract negotiation?

“Your first step should be quiet reflection, where you figure out what you want and what [part] of that is non-negotiable,” advises Fred A. McCurdy, MD, PhD, MBA, FAAP, CPE, professor and regional chairman of the department of pediatrics, Texas Tech University Health Sciences Center at Amarillo. Most people focus on money when they anticipate negotiating employment, but there are other factors to consider, such as schedule (on-duty and on-call hours); opportunities for advancement, including research, project management, and teaching; and, of course, benefits, including insurance and retirement packages. Consider carefully which factors matter most to you, then rank them to organize your personal priorities.

Dr. McCurdy recommends the process he uses for all the negotiations he participates in as part of his job. “I think through the principles of each negotiation situation and write them out,” he says. “I pick out the non-negotiable items as well as the items I hope to achieve.”

2. Do Your Homework

It’s tough to negotiate your salary or your benefits when you don’t know the market. “Don’t walk in without knowing your facts,” warns Dr. McCurdy. “Do your homework to see what the market is and how payment systems work.”

Research the potential employer to find out what they’re paying other physicians and how they pay. “You can ask [the interviewers], ‘What are you currently paying your other hospitalists?’ ” says Dr. McCurdy. “You might get [them to tell you] a pay range.”

Ask questions in your interviews, and conduct independent research on the organization and on the market.

“You can obtain a lot of information on your own,” he explains. “The MGMA [Medical Group Management Association] and the Association of American Medical Colleges (AAMC) have salary scales available. Salaries are public information for people who work in public institutions like university hospitals.”

SHM also provides up-to-date salary information in its “Bi-Annual Survey on the State of the Hospital Medicine Movement,” available at www.hospitalmedicine.org.

3. Know Your Strengths

Another homework assignment before the interview process: Know your strongest selling points. Whether you have an excellent record as a faculty member or a strong background in heading up task forces, your unique strengths will be your strongest argument in negotiating your contract.

“The most effective way to negotiate is to talk about the value-added,” says Dr. McCurdy. “Find out what they want, and speak to that. You’ll have to figure that out as you go.”

It might be what you can do to improve the organization’s bottom line; it might be specific skills or expertise you bring to the table, such as teaching proficiency or research skills.

What about recent graduates who are seeking their first job as a hospitalist? “People right out of training seem to have distinct advantages that they don’t emphasize,” says Dr. McCurdy. “They’re young and have a high energy level, for one thing. Their knowledge base is very current, so they’re cutting edge, and they have quality of training—they were recently instructed by cutting-edge teachers.”

4. Look Beyond Salary

Of course you’ll want to negotiate for as much money as you can, but other factors may make a lower salary worthwhile to you. “Lots of organizations have a lot of non-tangibles to offer, but many physicians go into this ill informed” about what they can get, says Dr. McCurdy. You might ask for “some equity holding in the organization you’re looking to become part of” if it’s a privately held hospital medicine group.

“Think about various trade-offs,” urges Dr. McCurdy. “For example, you might accept a lower salary for less on-call time. Or if you’re considering a position in academic medicine, you know that your residents will take most of your night hours—is that worth a lower salary to you?”

You might also consider “access to a foundation that could help you leverage a project you want to do or a situation where you have a chance to spin off intellectual property where you keep the proceeds,” he suggests. “It all depends on the organization. What do they have that would be valuable to you?”

5. Practice Your Negotiation Skills

One last piece of homework before you walk into the final interview: Do a practice run of how the meeting might go.

Physicians don’t always practice negotiation conversations, says Dr. McCurdy. “Find someone who will practice with you, who will throw a lot of questions at you. I used a personal coach. She had me practicing ‘how to deal with Fred when he’s in conflict.’ I hated it, and I’m so glad I did it!”

So do your homework and be prepared to argue your strengths, stick up for your non-negotiables, and resign yourself to giving in on some of your other points. With insight, information, and practice, you’ll be in an excellent position to walk away from the table with most—if not all—of what you want in your next contract. TH

Jane Jerrard writes “Career Management” monthly for The Hospitalist.

How prepared are you to negotiate the best possible contract for your next position? Do you know what you can realistically ask for? If the salary offered seems too low, do other factors make the job a perfect fit?

In order to get the most beneficial contract with your next hospitalist position, you must have confidence in your negotiation skills. Here are some steps that may help.

1. Recognize Your Priorities

Before you set foot in your first interview with an organization, you must know your own mind—what exactly do you want to “win” in a contract negotiation?

“Your first step should be quiet reflection, where you figure out what you want and what [part] of that is non-negotiable,” advises Fred A. McCurdy, MD, PhD, MBA, FAAP, CPE, professor and regional chairman of the department of pediatrics, Texas Tech University Health Sciences Center at Amarillo. Most people focus on money when they anticipate negotiating employment, but there are other factors to consider, such as schedule (on-duty and on-call hours); opportunities for advancement, including research, project management, and teaching; and, of course, benefits, including insurance and retirement packages. Consider carefully which factors matter most to you, then rank them to organize your personal priorities.

Dr. McCurdy recommends the process he uses for all the negotiations he participates in as part of his job. “I think through the principles of each negotiation situation and write them out,” he says. “I pick out the non-negotiable items as well as the items I hope to achieve.”

2. Do Your Homework

It’s tough to negotiate your salary or your benefits when you don’t know the market. “Don’t walk in without knowing your facts,” warns Dr. McCurdy. “Do your homework to see what the market is and how payment systems work.”

Research the potential employer to find out what they’re paying other physicians and how they pay. “You can ask [the interviewers], ‘What are you currently paying your other hospitalists?’ ” says Dr. McCurdy. “You might get [them to tell you] a pay range.”

Ask questions in your interviews, and conduct independent research on the organization and on the market.

“You can obtain a lot of information on your own,” he explains. “The MGMA [Medical Group Management Association] and the Association of American Medical Colleges (AAMC) have salary scales available. Salaries are public information for people who work in public institutions like university hospitals.”

SHM also provides up-to-date salary information in its “Bi-Annual Survey on the State of the Hospital Medicine Movement,” available at www.hospitalmedicine.org.

3. Know Your Strengths

Another homework assignment before the interview process: Know your strongest selling points. Whether you have an excellent record as a faculty member or a strong background in heading up task forces, your unique strengths will be your strongest argument in negotiating your contract.

“The most effective way to negotiate is to talk about the value-added,” says Dr. McCurdy. “Find out what they want, and speak to that. You’ll have to figure that out as you go.”

It might be what you can do to improve the organization’s bottom line; it might be specific skills or expertise you bring to the table, such as teaching proficiency or research skills.

What about recent graduates who are seeking their first job as a hospitalist? “People right out of training seem to have distinct advantages that they don’t emphasize,” says Dr. McCurdy. “They’re young and have a high energy level, for one thing. Their knowledge base is very current, so they’re cutting edge, and they have quality of training—they were recently instructed by cutting-edge teachers.”

4. Look Beyond Salary

Of course you’ll want to negotiate for as much money as you can, but other factors may make a lower salary worthwhile to you. “Lots of organizations have a lot of non-tangibles to offer, but many physicians go into this ill informed” about what they can get, says Dr. McCurdy. You might ask for “some equity holding in the organization you’re looking to become part of” if it’s a privately held hospital medicine group.

“Think about various trade-offs,” urges Dr. McCurdy. “For example, you might accept a lower salary for less on-call time. Or if you’re considering a position in academic medicine, you know that your residents will take most of your night hours—is that worth a lower salary to you?”

You might also consider “access to a foundation that could help you leverage a project you want to do or a situation where you have a chance to spin off intellectual property where you keep the proceeds,” he suggests. “It all depends on the organization. What do they have that would be valuable to you?”

5. Practice Your Negotiation Skills

One last piece of homework before you walk into the final interview: Do a practice run of how the meeting might go.

Physicians don’t always practice negotiation conversations, says Dr. McCurdy. “Find someone who will practice with you, who will throw a lot of questions at you. I used a personal coach. She had me practicing ‘how to deal with Fred when he’s in conflict.’ I hated it, and I’m so glad I did it!”

So do your homework and be prepared to argue your strengths, stick up for your non-negotiables, and resign yourself to giving in on some of your other points. With insight, information, and practice, you’ll be in an excellent position to walk away from the table with most—if not all—of what you want in your next contract. TH

Jane Jerrard writes “Career Management” monthly for The Hospitalist.

A63-year-old female with a history of hypertension and nicotine dependence presented with acute substernal chest pain. The patient reported that the pain was a dull pressure, 5/10 in severity, which radiated into her neck and left arm and was associated with dyspnea.

The patient was on atenolol for hypertension. She reported a 30-year smoking history. A physical exam revealed an anxious, hypertensive (180/95), tachycardic (123 bpm) female. Findings on cardiovascular exam were otherwise unremarkable. Electrocardiogram revealed a 2-3 mm ST-segment elevation in leads V2-V6. Laboratory tests revealed an elevated troponin T level (0.32 ng/mL [nl < 0.03 ng/mL]) and an elevated creatinine kinase-MB fraction (8.2 ng/mL [nl < 6.2 ng/mL]).

Using the above information, the diagnosis of an ST-segment elevation MI was made. The patient went in for urgent cardiac catheterization, which revealed normal coronary anatomy. A left ventriculogram demonstrated moderate hypokinesis of the apical segment and a left ventricular ejection fraction of 34%. TH

This patient’s symptoms are caused by left ventricular apical ballooning syndrome.

What is the most likely cause of the patient’s ECG changes, elevated cardiac biomarkers, and reduced left ventricular function?

1. Left ventricular aneurysm
2. ST-segment elevation myocardial infarction
3. Left ventricular apical ballooning syndrome
4. Myocarditis
5. Amyloidosis

Discussion

The answer is C: left ventricular apical ballooning syndrome. Transient left ventricular apical ballooning syndrome is a recently described cardiac condition that mimics the clinical presentation of atherosclerotic acute coronary syndrome. Also known as Takotsubo cardiomyopathy, after a round-bottomed, narrow-necked Japanese fishing pot used for trapping octopus, transient left ventricular apical ballooning syndrome was first described in Japan by Dote and colleagues more than a decade ago.1

Typical findings include patients with ischemia-like chest pain and dyspnea, ST-segment elevation and evolutionary T-wave inversion noted on ECG, mildly elevated levels of cardiac biomarkers, and transient apical wall motion abnormalities. These findings occur in the absence of obstructive coronary atherosclerosis. The condition is predominantly seen in postmenopausal women, and most episodes occur after an event causing physical or emotional stress.

The etiology of this condition is widely debated. Many feel that an exaggerated sympathetic response is the critical mechanism of this syndrome. One study has shown that patients with this syndrome had supraphysiologic levels of plasma catecholamines and stress-related neuropeptides.

Treatment is mainly supportive once ST-segment elevation myocardial infarction has been ruled out with a coronary angiogram. Beta-blocker therapy may be appropriate due to presumed catecholamine surge. Short-term cardiac monitoring is also prudent to evaluate for dysrhythmia. Finally, anticoagulation may be considered to prevent mural thrombosis formation.

The prognosis for patients with transient left ventricular apical ballooning syndrome is favorable, with most patients regaining normal systolic ventricular function within several months, and recurrence is rare. Follow-up echocardiographic evaluation is commonly conducted to ensure adequate resolution of systolic left ventricular dysfunction.

Universal diagnostic criteria for transient left ventricular apical ballooning syndrome have not been established. One diagnostic algorithm recently published includes four criteria: 1) transient regional wall motion abnormalities of the left ventricular apical and midventricular segments; 2) absence of obstructive coronary disease or plaque rupture; 3) new ST-segment elevation and/or T-wave inversion; and 4) absence of an obvious alternative cause (e.g., recent head trauma, extensive intracranial bleeding, myocarditis, pheochromocytoma, hypertrophic cardiomyopathy). To make the diagnosis of transient left ventricular apical ballooning syndrome, all four criteria must be met.

As awareness of transient left ventricular apical ballooning syndrome increases, and as evaluation of left ventricular function becomes standard, this diagnosis is becoming more common. In patients presenting with ST-segment elevation and suspected acute coronary syndromes, one must keep apical ballooning syndrome in the differential. Prompt recognition and aggressive supportive treatment are indicated, and recovery of systolic function can be expected. TH

References

1. Dote K, Sato H, Tateishi H, et al. Myocardial stunning due to simultaneous multivessel coronary spasms: a review of 5 cases [in Japanese]. J Cardiol. 1991;21(2):203-214.

A63-year-old female with a history of hypertension and nicotine dependence presented with acute substernal chest pain. The patient reported that the pain was a dull pressure, 5/10 in severity, which radiated into her neck and left arm and was associated with dyspnea.

The patient was on atenolol for hypertension. She reported a 30-year smoking history. A physical exam revealed an anxious, hypertensive (180/95), tachycardic (123 bpm) female. Findings on cardiovascular exam were otherwise unremarkable. Electrocardiogram revealed a 2-3 mm ST-segment elevation in leads V2-V6. Laboratory tests revealed an elevated troponin T level (0.32 ng/mL [nl < 0.03 ng/mL]) and an elevated creatinine kinase-MB fraction (8.2 ng/mL [nl < 6.2 ng/mL]).

Using the above information, the diagnosis of an ST-segment elevation MI was made. The patient went in for urgent cardiac catheterization, which revealed normal coronary anatomy. A left ventriculogram demonstrated moderate hypokinesis of the apical segment and a left ventricular ejection fraction of 34%. TH

This patient’s symptoms are caused by left ventricular apical ballooning syndrome.

What is the most likely cause of the patient’s ECG changes, elevated cardiac biomarkers, and reduced left ventricular function?

1. Left ventricular aneurysm
2. ST-segment elevation myocardial infarction
3. Left ventricular apical ballooning syndrome
4. Myocarditis
5. Amyloidosis

Discussion

The answer is C: left ventricular apical ballooning syndrome. Transient left ventricular apical ballooning syndrome is a recently described cardiac condition that mimics the clinical presentation of atherosclerotic acute coronary syndrome. Also known as Takotsubo cardiomyopathy, after a round-bottomed, narrow-necked Japanese fishing pot used for trapping octopus, transient left ventricular apical ballooning syndrome was first described in Japan by Dote and colleagues more than a decade ago.1

Typical findings include patients with ischemia-like chest pain and dyspnea, ST-segment elevation and evolutionary T-wave inversion noted on ECG, mildly elevated levels of cardiac biomarkers, and transient apical wall motion abnormalities. These findings occur in the absence of obstructive coronary atherosclerosis. The condition is predominantly seen in postmenopausal women, and most episodes occur after an event causing physical or emotional stress.

The etiology of this condition is widely debated. Many feel that an exaggerated sympathetic response is the critical mechanism of this syndrome. One study has shown that patients with this syndrome had supraphysiologic levels of plasma catecholamines and stress-related neuropeptides.

Treatment is mainly supportive once ST-segment elevation myocardial infarction has been ruled out with a coronary angiogram. Beta-blocker therapy may be appropriate due to presumed catecholamine surge. Short-term cardiac monitoring is also prudent to evaluate for dysrhythmia. Finally, anticoagulation may be considered to prevent mural thrombosis formation.

The prognosis for patients with transient left ventricular apical ballooning syndrome is favorable, with most patients regaining normal systolic ventricular function within several months, and recurrence is rare. Follow-up echocardiographic evaluation is commonly conducted to ensure adequate resolution of systolic left ventricular dysfunction.

Universal diagnostic criteria for transient left ventricular apical ballooning syndrome have not been established. One diagnostic algorithm recently published includes four criteria: 1) transient regional wall motion abnormalities of the left ventricular apical and midventricular segments; 2) absence of obstructive coronary disease or plaque rupture; 3) new ST-segment elevation and/or T-wave inversion; and 4) absence of an obvious alternative cause (e.g., recent head trauma, extensive intracranial bleeding, myocarditis, pheochromocytoma, hypertrophic cardiomyopathy). To make the diagnosis of transient left ventricular apical ballooning syndrome, all four criteria must be met.

As awareness of transient left ventricular apical ballooning syndrome increases, and as evaluation of left ventricular function becomes standard, this diagnosis is becoming more common. In patients presenting with ST-segment elevation and suspected acute coronary syndromes, one must keep apical ballooning syndrome in the differential. Prompt recognition and aggressive supportive treatment are indicated, and recovery of systolic function can be expected. TH

References

1. Dote K, Sato H, Tateishi H, et al. Myocardial stunning due to simultaneous multivessel coronary spasms: a review of 5 cases [in Japanese]. J Cardiol. 1991;21(2):203-214.

A63-year-old female with a history of hypertension and nicotine dependence presented with acute substernal chest pain. The patient reported that the pain was a dull pressure, 5/10 in severity, which radiated into her neck and left arm and was associated with dyspnea.

The patient was on atenolol for hypertension. She reported a 30-year smoking history. A physical exam revealed an anxious, hypertensive (180/95), tachycardic (123 bpm) female. Findings on cardiovascular exam were otherwise unremarkable. Electrocardiogram revealed a 2-3 mm ST-segment elevation in leads V2-V6. Laboratory tests revealed an elevated troponin T level (0.32 ng/mL [nl < 0.03 ng/mL]) and an elevated creatinine kinase-MB fraction (8.2 ng/mL [nl < 6.2 ng/mL]).

Using the above information, the diagnosis of an ST-segment elevation MI was made. The patient went in for urgent cardiac catheterization, which revealed normal coronary anatomy. A left ventriculogram demonstrated moderate hypokinesis of the apical segment and a left ventricular ejection fraction of 34%. TH

This patient’s symptoms are caused by left ventricular apical ballooning syndrome.

What is the most likely cause of the patient’s ECG changes, elevated cardiac biomarkers, and reduced left ventricular function?

1. Left ventricular aneurysm
2. ST-segment elevation myocardial infarction
3. Left ventricular apical ballooning syndrome
4. Myocarditis
5. Amyloidosis

Discussion

The answer is C: left ventricular apical ballooning syndrome. Transient left ventricular apical ballooning syndrome is a recently described cardiac condition that mimics the clinical presentation of atherosclerotic acute coronary syndrome. Also known as Takotsubo cardiomyopathy, after a round-bottomed, narrow-necked Japanese fishing pot used for trapping octopus, transient left ventricular apical ballooning syndrome was first described in Japan by Dote and colleagues more than a decade ago.1

Typical findings include patients with ischemia-like chest pain and dyspnea, ST-segment elevation and evolutionary T-wave inversion noted on ECG, mildly elevated levels of cardiac biomarkers, and transient apical wall motion abnormalities. These findings occur in the absence of obstructive coronary atherosclerosis. The condition is predominantly seen in postmenopausal women, and most episodes occur after an event causing physical or emotional stress.

The etiology of this condition is widely debated. Many feel that an exaggerated sympathetic response is the critical mechanism of this syndrome. One study has shown that patients with this syndrome had supraphysiologic levels of plasma catecholamines and stress-related neuropeptides.

Treatment is mainly supportive once ST-segment elevation myocardial infarction has been ruled out with a coronary angiogram. Beta-blocker therapy may be appropriate due to presumed catecholamine surge. Short-term cardiac monitoring is also prudent to evaluate for dysrhythmia. Finally, anticoagulation may be considered to prevent mural thrombosis formation.

The prognosis for patients with transient left ventricular apical ballooning syndrome is favorable, with most patients regaining normal systolic ventricular function within several months, and recurrence is rare. Follow-up echocardiographic evaluation is commonly conducted to ensure adequate resolution of systolic left ventricular dysfunction.

Universal diagnostic criteria for transient left ventricular apical ballooning syndrome have not been established. One diagnostic algorithm recently published includes four criteria: 1) transient regional wall motion abnormalities of the left ventricular apical and midventricular segments; 2) absence of obstructive coronary disease or plaque rupture; 3) new ST-segment elevation and/or T-wave inversion; and 4) absence of an obvious alternative cause (e.g., recent head trauma, extensive intracranial bleeding, myocarditis, pheochromocytoma, hypertrophic cardiomyopathy). To make the diagnosis of transient left ventricular apical ballooning syndrome, all four criteria must be met.

As awareness of transient left ventricular apical ballooning syndrome increases, and as evaluation of left ventricular function becomes standard, this diagnosis is becoming more common. In patients presenting with ST-segment elevation and suspected acute coronary syndromes, one must keep apical ballooning syndrome in the differential. Prompt recognition and aggressive supportive treatment are indicated, and recovery of systolic function can be expected. TH

References

1. Dote K, Sato H, Tateishi H, et al. Myocardial stunning due to simultaneous multivessel coronary spasms: a review of 5 cases [in Japanese]. J Cardiol. 1991;21(2):203-214.

Heart failure (HF) afflicts almost 5 million individuals in the United States and ranks among the most costly inpatient conditions, with hospital costs for 2004 estimated between $14 and $20 billion. Approximately 25% of heart failure patients are readmitted within 30 days of hospital discharge, and more than 50% of elderly patients with HF are readmitted to the hospital within six months. SHM believes that hospitalists are well positioned to improve adherence to published guidelines for the care of congestive HF and are ideal candidates for developing and studying strategies for providing safer, more effective care for patients hospitalized with HF.

In May 2005, SHM disseminated a request for applications for the Heart Failure Research Program. The program, which was made possible by an unrestricted educational grant from Scios, Inc. (a biopharmaceutical company), offered two-year grants to support prospective evaluations of hospitalist-led initiatives designed to improve quality of care for patients hospitalized with HF. A 15-member scientific review group, chaired by Andrew Auerbach, MD, and convened in conjunction with the SHM Research Committee and the SHM Executive Board, reviewed the 18 submitted applications and selected two excellent studies for funding.

The Cardiology Quality of Care Study is a collaborative effort between the sections of General Internal Medicine and Cardiology and the University of Chicago Hospitals. Under the direction of principal investigator Chad Whelan, MD, the study team will evaluate a cost-effective system of improving compliance with the well-validated Centers for Medicare and Medicaid Services (CMS) quality indicators for HF. Trained research assistants will perform chart reviews on all hospitalized patients with HF. If a chart review reveals that certain CMS measures have not been met, the research assistant will send a notification e-mail to the clinical team to alert them that a potentially indicated therapy has not been implemented. Follow-up telephone interviews with patients and post-discharge hospital chart abstractions will be used to evaluate the effectiveness of the intervention. The process may be an effective and inexpensive method for hospitals across the country to use to improve compliance with evidence-based, guideline-supported quality of care measures.

The second study, Improving Quality and Efficiency of Heart Failure Care at Hospital Discharge, is being conducted at the Cleveland Clinic Foundation under the direction of Dr. Christopher Phillips. This single-center, randomized, controlled trial will study changes in 30-day readmission rates resulting from an educational intervention designed to enhance self-care behavior in patients discharged with a primary diagnosis of HF. An RN cardiovascular specialist will contact patients weekly by phone for four weeks after hospital discharge. The calls will focus on identifying and correcting deficits in knowledge, motivation, and behavior with respect to HF self-care. Study findings may improve our understanding of patients’ ability to translate HF education and counseling into motivation to adhere to recommended HF self-care behaviors during the post-discharge period. Improved insight into these processes will inform efforts aimed at optimizing the transition from acute hospital care to home, a process that is a major determinant of early readmission.

Both studies are evaluating novel, practical, reproducible means of improving HF care. We look forward to seeing the results. TH

Heart failure (HF) afflicts almost 5 million individuals in the United States and ranks among the most costly inpatient conditions, with hospital costs for 2004 estimated between $14 and $20 billion. Approximately 25% of heart failure patients are readmitted within 30 days of hospital discharge, and more than 50% of elderly patients with HF are readmitted to the hospital within six months. SHM believes that hospitalists are well positioned to improve adherence to published guidelines for the care of congestive HF and are ideal candidates for developing and studying strategies for providing safer, more effective care for patients hospitalized with HF.

In May 2005, SHM disseminated a request for applications for the Heart Failure Research Program. The program, which was made possible by an unrestricted educational grant from Scios, Inc. (a biopharmaceutical company), offered two-year grants to support prospective evaluations of hospitalist-led initiatives designed to improve quality of care for patients hospitalized with HF. A 15-member scientific review group, chaired by Andrew Auerbach, MD, and convened in conjunction with the SHM Research Committee and the SHM Executive Board, reviewed the 18 submitted applications and selected two excellent studies for funding.

The Cardiology Quality of Care Study is a collaborative effort between the sections of General Internal Medicine and Cardiology and the University of Chicago Hospitals. Under the direction of principal investigator Chad Whelan, MD, the study team will evaluate a cost-effective system of improving compliance with the well-validated Centers for Medicare and Medicaid Services (CMS) quality indicators for HF. Trained research assistants will perform chart reviews on all hospitalized patients with HF. If a chart review reveals that certain CMS measures have not been met, the research assistant will send a notification e-mail to the clinical team to alert them that a potentially indicated therapy has not been implemented. Follow-up telephone interviews with patients and post-discharge hospital chart abstractions will be used to evaluate the effectiveness of the intervention. The process may be an effective and inexpensive method for hospitals across the country to use to improve compliance with evidence-based, guideline-supported quality of care measures.

The second study, Improving Quality and Efficiency of Heart Failure Care at Hospital Discharge, is being conducted at the Cleveland Clinic Foundation under the direction of Dr. Christopher Phillips. This single-center, randomized, controlled trial will study changes in 30-day readmission rates resulting from an educational intervention designed to enhance self-care behavior in patients discharged with a primary diagnosis of HF. An RN cardiovascular specialist will contact patients weekly by phone for four weeks after hospital discharge. The calls will focus on identifying and correcting deficits in knowledge, motivation, and behavior with respect to HF self-care. Study findings may improve our understanding of patients’ ability to translate HF education and counseling into motivation to adhere to recommended HF self-care behaviors during the post-discharge period. Improved insight into these processes will inform efforts aimed at optimizing the transition from acute hospital care to home, a process that is a major determinant of early readmission.

Both studies are evaluating novel, practical, reproducible means of improving HF care. We look forward to seeing the results. TH

Heart failure (HF) afflicts almost 5 million individuals in the United States and ranks among the most costly inpatient conditions, with hospital costs for 2004 estimated between $14 and $20 billion. Approximately 25% of heart failure patients are readmitted within 30 days of hospital discharge, and more than 50% of elderly patients with HF are readmitted to the hospital within six months. SHM believes that hospitalists are well positioned to improve adherence to published guidelines for the care of congestive HF and are ideal candidates for developing and studying strategies for providing safer, more effective care for patients hospitalized with HF.

In May 2005, SHM disseminated a request for applications for the Heart Failure Research Program. The program, which was made possible by an unrestricted educational grant from Scios, Inc. (a biopharmaceutical company), offered two-year grants to support prospective evaluations of hospitalist-led initiatives designed to improve quality of care for patients hospitalized with HF. A 15-member scientific review group, chaired by Andrew Auerbach, MD, and convened in conjunction with the SHM Research Committee and the SHM Executive Board, reviewed the 18 submitted applications and selected two excellent studies for funding.

The Cardiology Quality of Care Study is a collaborative effort between the sections of General Internal Medicine and Cardiology and the University of Chicago Hospitals. Under the direction of principal investigator Chad Whelan, MD, the study team will evaluate a cost-effective system of improving compliance with the well-validated Centers for Medicare and Medicaid Services (CMS) quality indicators for HF. Trained research assistants will perform chart reviews on all hospitalized patients with HF. If a chart review reveals that certain CMS measures have not been met, the research assistant will send a notification e-mail to the clinical team to alert them that a potentially indicated therapy has not been implemented. Follow-up telephone interviews with patients and post-discharge hospital chart abstractions will be used to evaluate the effectiveness of the intervention. The process may be an effective and inexpensive method for hospitals across the country to use to improve compliance with evidence-based, guideline-supported quality of care measures.

The second study, Improving Quality and Efficiency of Heart Failure Care at Hospital Discharge, is being conducted at the Cleveland Clinic Foundation under the direction of Dr. Christopher Phillips. This single-center, randomized, controlled trial will study changes in 30-day readmission rates resulting from an educational intervention designed to enhance self-care behavior in patients discharged with a primary diagnosis of HF. An RN cardiovascular specialist will contact patients weekly by phone for four weeks after hospital discharge. The calls will focus on identifying and correcting deficits in knowledge, motivation, and behavior with respect to HF self-care. Study findings may improve our understanding of patients’ ability to translate HF education and counseling into motivation to adhere to recommended HF self-care behaviors during the post-discharge period. Improved insight into these processes will inform efforts aimed at optimizing the transition from acute hospital care to home, a process that is a major determinant of early readmission.

Both studies are evaluating novel, practical, reproducible means of improving HF care. We look forward to seeing the results. TH

SHM intensified its advocacy efforts over the past several months in support of proposed changes to the Medicare physician fee schedule that would significantly increase payments to hospitalists for many services next year, if adopted by the Centers for Medicare and Medicaid Services (CMS). In June, CMS proposed to make the largest increase in the work relative value units (RVUs) assigned to evaluation and management (E/M) services since Medicare implemented the physician fee schedule in 1992. E/M codes, which represent the time and effort that physicians spend to evaluate patient conditions, have long been viewed as undervalued. Since the release of the proposed rule, SHM has voiced its strong support for CMS’ proposed changes. (See “Calculating the Future of Medicare Payments,” Oct., p. 1).

In an August 18 letter, SHM joined the American College of Physicians (ACP) and 12 other physician groups in urging CMS Administrator Mark McClellan, MD, to include in the final rule the proposed increases in the RVUs assigned to office and hospital visits, and consultations. The groups applauded CMS’ decision to accept the recommendations made by the AMA Relative Value Scale Update Committee (RUC) regarding the evaluation and management codes under the five-year review. “We support the decision to include them in this proposed rule and we strongly urge CMS to include the same proposed work relative value units (RVUs) in the final rule,” the letter stated.

The RUC was careful to ensure that these codes went through the standard survey process and that the data supporting the changes was very strong. The letter emphasized: “The RUC approval of these recommendations, which requires support from at least two-thirds of the RUC members, indicates wide recognition of the work changes in evaluation and management in the 10 years since CMS last reviewed the codes. During our investigation into the increased intensity of evaluation and management services and throughout the RUC process for determining accurate, current work RVUs, we became increasingly aware that enormous changes in patient and physician practice characteristics necessitated these changes.”

In addition, the letter urged CMS to make the required budget neutrality adjustments that result from the five-year review to the conversion factor rather than by an adjustment to the work RVUs. CMS is required by law to offset increases in costs with a mandatory adjustment to keep 2007 expenditures roughly equal to their 2006 level. In the proposed rule, the agency recommended cutting work RVUs by 10% in order to achieve budget neutrality.

SHM joined the AMA and more than 70 other physician organizations in a separate letter. That letter asked CMS not to apply a 10% cut to the work component of the fee schedule, but instead to make an adjustment to the Medicare conversion factor.

“Applying budget neutrality to the work RVUs to offset the improvements in E/M and other services is a step backward and we strongly urge CMS to instead apply any necessary adjustments to the conversion factor,” the organizations said in an August 21 letter to CMS.

When the agency reduced the work RVUs in the past, it created confusion among private insurers, the letter said. Since 1998, similar reductions have been applied to the conversion factor. “CMS does not explain why it proposes to alter this long utilized method and move backward to an approach that the agency itself remarked was inappropriate.”

SHM and the physician community have also lobbied Congress to block a 5.1% cut in the Medicare physician fee schedule that will take effect on January 1, 2007, unless lawmakers take action this fall.

For more news on the five-year review, the 2007 update, and other issues, visit the advocacy and policy section of the SHM Web site at www.hospitalmedicine.org.

Allendorf is senior advisor of Advocacy and Government Affairs for SHM.

SHM intensified its advocacy efforts over the past several months in support of proposed changes to the Medicare physician fee schedule that would significantly increase payments to hospitalists for many services next year, if adopted by the Centers for Medicare and Medicaid Services (CMS). In June, CMS proposed to make the largest increase in the work relative value units (RVUs) assigned to evaluation and management (E/M) services since Medicare implemented the physician fee schedule in 1992. E/M codes, which represent the time and effort that physicians spend to evaluate patient conditions, have long been viewed as undervalued. Since the release of the proposed rule, SHM has voiced its strong support for CMS’ proposed changes. (See “Calculating the Future of Medicare Payments,” Oct., p. 1).

In an August 18 letter, SHM joined the American College of Physicians (ACP) and 12 other physician groups in urging CMS Administrator Mark McClellan, MD, to include in the final rule the proposed increases in the RVUs assigned to office and hospital visits, and consultations. The groups applauded CMS’ decision to accept the recommendations made by the AMA Relative Value Scale Update Committee (RUC) regarding the evaluation and management codes under the five-year review. “We support the decision to include them in this proposed rule and we strongly urge CMS to include the same proposed work relative value units (RVUs) in the final rule,” the letter stated.

The RUC was careful to ensure that these codes went through the standard survey process and that the data supporting the changes was very strong. The letter emphasized: “The RUC approval of these recommendations, which requires support from at least two-thirds of the RUC members, indicates wide recognition of the work changes in evaluation and management in the 10 years since CMS last reviewed the codes. During our investigation into the increased intensity of evaluation and management services and throughout the RUC process for determining accurate, current work RVUs, we became increasingly aware that enormous changes in patient and physician practice characteristics necessitated these changes.”

In addition, the letter urged CMS to make the required budget neutrality adjustments that result from the five-year review to the conversion factor rather than by an adjustment to the work RVUs. CMS is required by law to offset increases in costs with a mandatory adjustment to keep 2007 expenditures roughly equal to their 2006 level. In the proposed rule, the agency recommended cutting work RVUs by 10% in order to achieve budget neutrality.

SHM joined the AMA and more than 70 other physician organizations in a separate letter. That letter asked CMS not to apply a 10% cut to the work component of the fee schedule, but instead to make an adjustment to the Medicare conversion factor.

“Applying budget neutrality to the work RVUs to offset the improvements in E/M and other services is a step backward and we strongly urge CMS to instead apply any necessary adjustments to the conversion factor,” the organizations said in an August 21 letter to CMS.

When the agency reduced the work RVUs in the past, it created confusion among private insurers, the letter said. Since 1998, similar reductions have been applied to the conversion factor. “CMS does not explain why it proposes to alter this long utilized method and move backward to an approach that the agency itself remarked was inappropriate.”

SHM and the physician community have also lobbied Congress to block a 5.1% cut in the Medicare physician fee schedule that will take effect on January 1, 2007, unless lawmakers take action this fall.

For more news on the five-year review, the 2007 update, and other issues, visit the advocacy and policy section of the SHM Web site at www.hospitalmedicine.org.

Allendorf is senior advisor of Advocacy and Government Affairs for SHM.

SHM intensified its advocacy efforts over the past several months in support of proposed changes to the Medicare physician fee schedule that would significantly increase payments to hospitalists for many services next year, if adopted by the Centers for Medicare and Medicaid Services (CMS). In June, CMS proposed to make the largest increase in the work relative value units (RVUs) assigned to evaluation and management (E/M) services since Medicare implemented the physician fee schedule in 1992. E/M codes, which represent the time and effort that physicians spend to evaluate patient conditions, have long been viewed as undervalued. Since the release of the proposed rule, SHM has voiced its strong support for CMS’ proposed changes. (See “Calculating the Future of Medicare Payments,” Oct., p. 1).

In an August 18 letter, SHM joined the American College of Physicians (ACP) and 12 other physician groups in urging CMS Administrator Mark McClellan, MD, to include in the final rule the proposed increases in the RVUs assigned to office and hospital visits, and consultations. The groups applauded CMS’ decision to accept the recommendations made by the AMA Relative Value Scale Update Committee (RUC) regarding the evaluation and management codes under the five-year review. “We support the decision to include them in this proposed rule and we strongly urge CMS to include the same proposed work relative value units (RVUs) in the final rule,” the letter stated.

The RUC was careful to ensure that these codes went through the standard survey process and that the data supporting the changes was very strong. The letter emphasized: “The RUC approval of these recommendations, which requires support from at least two-thirds of the RUC members, indicates wide recognition of the work changes in evaluation and management in the 10 years since CMS last reviewed the codes. During our investigation into the increased intensity of evaluation and management services and throughout the RUC process for determining accurate, current work RVUs, we became increasingly aware that enormous changes in patient and physician practice characteristics necessitated these changes.”

In addition, the letter urged CMS to make the required budget neutrality adjustments that result from the five-year review to the conversion factor rather than by an adjustment to the work RVUs. CMS is required by law to offset increases in costs with a mandatory adjustment to keep 2007 expenditures roughly equal to their 2006 level. In the proposed rule, the agency recommended cutting work RVUs by 10% in order to achieve budget neutrality.

SHM joined the AMA and more than 70 other physician organizations in a separate letter. That letter asked CMS not to apply a 10% cut to the work component of the fee schedule, but instead to make an adjustment to the Medicare conversion factor.

“Applying budget neutrality to the work RVUs to offset the improvements in E/M and other services is a step backward and we strongly urge CMS to instead apply any necessary adjustments to the conversion factor,” the organizations said in an August 21 letter to CMS.

When the agency reduced the work RVUs in the past, it created confusion among private insurers, the letter said. Since 1998, similar reductions have been applied to the conversion factor. “CMS does not explain why it proposes to alter this long utilized method and move backward to an approach that the agency itself remarked was inappropriate.”

SHM and the physician community have also lobbied Congress to block a 5.1% cut in the Medicare physician fee schedule that will take effect on January 1, 2007, unless lawmakers take action this fall.

For more news on the five-year review, the 2007 update, and other issues, visit the advocacy and policy section of the SHM Web site at www.hospitalmedicine.org.

Allendorf is senior advisor of Advocacy and Government Affairs for SHM.

I joined SHM earlier this year to work with SHM’s Membership and Marketing staff. My role at SHM is to manage our growing organization’s communications. So what does that mean in real terms? Most importantly, we have been tasked with understanding what is important to our members and what value SHM membership needs to provide to you. We’re also working to build a strong foundation for the SHM brand, so keep an eye out for an updated, consistent look to our communications—both online and off.

Feedback from our members and the hospital medicine community at large is vital to us. Samuel Johnson (1709-1764), an often-quoted English writer, once said, “The next best thing to knowing something is knowing where to find it.” One common thread among those I have talked to over the past few months has been concern that although our Web site is comprehensive, finding specific information can be challenging. Quickly making the Web site user-friendly became a priority and, along with our resident Web design guru Bruce Hansen, we have created a navigation system designed to get you to our site’s most popular information in the fewest number of clicks.

Looking for a link to the Journal of Hospital Medicine pages? The Hospitalist Web site? Our new Career Center? Or our Resource Rooms? Look no further than the top of our homepage (www.hospitalmedicine.org). Our new clickable banner will get you where you need to go in no time.

In a few short clicks, you can read pages from the Journal, including expert articles by leading practitioners on current and future trends in hospital medicine. Surf over to The Hospitalist Web site for the latest issue of our monthly newsmagazine. Have a story idea or want to contact the editor? You can do it all on The Hospitalist Web site.

Find your first or next hospitalist job at our new SHM Career Center. This one-of-a-kind forum for those looking for jobs and those with positions to fill helps you to avoid the excess of other career sites by focusing on our specific industry. Our Resource Rooms provide you with access to expert advice and information on every aspect of your practice. We’ve got the tools you need, and our Resource Rooms are the toolbox.

Of course, we hope you won’t forget the rest of our Web site: Look for the latest in advocacy and policy updates, our online discussion communities, and breaking news in the field of hospital medicine.

We hope you will set aside a few minutes each month to review our revamped SHM eNewsletter. Kudos again to Bruce for its ultra-sleek, contemporary design, which both pleases the eye and improves the readability of the articles. Research has shown us that most people read our articles online, as opposed to printing them out and reading them, so look for larger fonts and a clean layout.

We’ve introduced many new columns that will become a regular part of the SHM eNewsletter, including our Career Center Job of the Month, Clinical News, Advocacy News, upcoming articles from The Hospitalist—and more. We are also proud to introduce our featured product of the month from our newly launched SHM Store. Looking for a way to show your hospitalist pride? Why not grab one of our SHM polo shirts, scrub tops, or a baseball cap? The SHM store also features educational products. Looking for an extra copy of The Core Competencies or the ““Bi-Annual Survey on the State of the Hospital Medicine Movement”? You’ll find them, along with nearly 100 other items, at the SHM Store.

These are just a few of the changes we have made to transform SHM into your organization. Keep watching, and you will find that SHM, ground central for the hospital medicine movement, is the best place to turn for anything and everything relating to hospital medicine.

If you should have any questions or comments, our doors and ears are always open and ready to welcome you. Feel free to give us a call at (800) 843-3360.

Stay tuned for next month’s SHM staff member report from Tina Budnitz, SHM’s senior advisor for quality initiatives.

Sanders is the marketing manager for SHM.

SHM CHAPTER REPORTS

Lake Erie

SHM’s Lake Erie Chapter met at Morton’s Steakhouse in Cleveland on August 9. The guest speaker was Ron J. Kattoo, MD, associate director of intensive care at Henry Ford Hospital and Health System in Detroit. Dr. Kattoo spoke about the management options for healthcare and ventilator-associated pneumonia, followed by a discussion about the role of hospitalists in the management of this severe condition. The meeting was sponsored by Pfizer Pharmaceutical Company. For more information on the Lake Erie Chapter of SHM, please contact Christopher Whinney, MD, at [email protected].

Long Island

SHM’s Long Island (N.Y.) Chapter held a meeting on August 24 at Burton & Doyle Steakhouse in East Great Neck, N.Y. A presentation titled “Sleep Disorders: How They Affect Patients and Providers” was given by Sonia Ancoli-Israel, PhD, a University of California at San Diego School of Medicine professor of psychiatry. At the conclusion of the presentation, Dr. Ancoli-Israel fielded questions.

I joined SHM earlier this year to work with SHM’s Membership and Marketing staff. My role at SHM is to manage our growing organization’s communications. So what does that mean in real terms? Most importantly, we have been tasked with understanding what is important to our members and what value SHM membership needs to provide to you. We’re also working to build a strong foundation for the SHM brand, so keep an eye out for an updated, consistent look to our communications—both online and off.

Feedback from our members and the hospital medicine community at large is vital to us. Samuel Johnson (1709-1764), an often-quoted English writer, once said, “The next best thing to knowing something is knowing where to find it.” One common thread among those I have talked to over the past few months has been concern that although our Web site is comprehensive, finding specific information can be challenging. Quickly making the Web site user-friendly became a priority and, along with our resident Web design guru Bruce Hansen, we have created a navigation system designed to get you to our site’s most popular information in the fewest number of clicks.

Looking for a link to the Journal of Hospital Medicine pages? The Hospitalist Web site? Our new Career Center? Or our Resource Rooms? Look no further than the top of our homepage (www.hospitalmedicine.org). Our new clickable banner will get you where you need to go in no time.

In a few short clicks, you can read pages from the Journal, including expert articles by leading practitioners on current and future trends in hospital medicine. Surf over to The Hospitalist Web site for the latest issue of our monthly newsmagazine. Have a story idea or want to contact the editor? You can do it all on The Hospitalist Web site.

Find your first or next hospitalist job at our new SHM Career Center. This one-of-a-kind forum for those looking for jobs and those with positions to fill helps you to avoid the excess of other career sites by focusing on our specific industry. Our Resource Rooms provide you with access to expert advice and information on every aspect of your practice. We’ve got the tools you need, and our Resource Rooms are the toolbox.

Of course, we hope you won’t forget the rest of our Web site: Look for the latest in advocacy and policy updates, our online discussion communities, and breaking news in the field of hospital medicine.

We hope you will set aside a few minutes each month to review our revamped SHM eNewsletter. Kudos again to Bruce for its ultra-sleek, contemporary design, which both pleases the eye and improves the readability of the articles. Research has shown us that most people read our articles online, as opposed to printing them out and reading them, so look for larger fonts and a clean layout.

We’ve introduced many new columns that will become a regular part of the SHM eNewsletter, including our Career Center Job of the Month, Clinical News, Advocacy News, upcoming articles from The Hospitalist—and more. We are also proud to introduce our featured product of the month from our newly launched SHM Store. Looking for a way to show your hospitalist pride? Why not grab one of our SHM polo shirts, scrub tops, or a baseball cap? The SHM store also features educational products. Looking for an extra copy of The Core Competencies or the ““Bi-Annual Survey on the State of the Hospital Medicine Movement”? You’ll find them, along with nearly 100 other items, at the SHM Store.

These are just a few of the changes we have made to transform SHM into your organization. Keep watching, and you will find that SHM, ground central for the hospital medicine movement, is the best place to turn for anything and everything relating to hospital medicine.

If you should have any questions or comments, our doors and ears are always open and ready to welcome you. Feel free to give us a call at (800) 843-3360.

Stay tuned for next month’s SHM staff member report from Tina Budnitz, SHM’s senior advisor for quality initiatives.

Sanders is the marketing manager for SHM.

SHM CHAPTER REPORTS

Lake Erie

SHM’s Lake Erie Chapter met at Morton’s Steakhouse in Cleveland on August 9. The guest speaker was Ron J. Kattoo, MD, associate director of intensive care at Henry Ford Hospital and Health System in Detroit. Dr. Kattoo spoke about the management options for healthcare and ventilator-associated pneumonia, followed by a discussion about the role of hospitalists in the management of this severe condition. The meeting was sponsored by Pfizer Pharmaceutical Company. For more information on the Lake Erie Chapter of SHM, please contact Christopher Whinney, MD, at [email protected].

Long Island

SHM’s Long Island (N.Y.) Chapter held a meeting on August 24 at Burton & Doyle Steakhouse in East Great Neck, N.Y. A presentation titled “Sleep Disorders: How They Affect Patients and Providers” was given by Sonia Ancoli-Israel, PhD, a University of California at San Diego School of Medicine professor of psychiatry. At the conclusion of the presentation, Dr. Ancoli-Israel fielded questions.

I joined SHM earlier this year to work with SHM’s Membership and Marketing staff. My role at SHM is to manage our growing organization’s communications. So what does that mean in real terms? Most importantly, we have been tasked with understanding what is important to our members and what value SHM membership needs to provide to you. We’re also working to build a strong foundation for the SHM brand, so keep an eye out for an updated, consistent look to our communications—both online and off.

Feedback from our members and the hospital medicine community at large is vital to us. Samuel Johnson (1709-1764), an often-quoted English writer, once said, “The next best thing to knowing something is knowing where to find it.” One common thread among those I have talked to over the past few months has been concern that although our Web site is comprehensive, finding specific information can be challenging. Quickly making the Web site user-friendly became a priority and, along with our resident Web design guru Bruce Hansen, we have created a navigation system designed to get you to our site’s most popular information in the fewest number of clicks.

Looking for a link to the Journal of Hospital Medicine pages? The Hospitalist Web site? Our new Career Center? Or our Resource Rooms? Look no further than the top of our homepage (www.hospitalmedicine.org). Our new clickable banner will get you where you need to go in no time.

In a few short clicks, you can read pages from the Journal, including expert articles by leading practitioners on current and future trends in hospital medicine. Surf over to The Hospitalist Web site for the latest issue of our monthly newsmagazine. Have a story idea or want to contact the editor? You can do it all on The Hospitalist Web site.

Find your first or next hospitalist job at our new SHM Career Center. This one-of-a-kind forum for those looking for jobs and those with positions to fill helps you to avoid the excess of other career sites by focusing on our specific industry. Our Resource Rooms provide you with access to expert advice and information on every aspect of your practice. We’ve got the tools you need, and our Resource Rooms are the toolbox.

Of course, we hope you won’t forget the rest of our Web site: Look for the latest in advocacy and policy updates, our online discussion communities, and breaking news in the field of hospital medicine.

We hope you will set aside a few minutes each month to review our revamped SHM eNewsletter. Kudos again to Bruce for its ultra-sleek, contemporary design, which both pleases the eye and improves the readability of the articles. Research has shown us that most people read our articles online, as opposed to printing them out and reading them, so look for larger fonts and a clean layout.

We’ve introduced many new columns that will become a regular part of the SHM eNewsletter, including our Career Center Job of the Month, Clinical News, Advocacy News, upcoming articles from The Hospitalist—and more. We are also proud to introduce our featured product of the month from our newly launched SHM Store. Looking for a way to show your hospitalist pride? Why not grab one of our SHM polo shirts, scrub tops, or a baseball cap? The SHM store also features educational products. Looking for an extra copy of The Core Competencies or the ““Bi-Annual Survey on the State of the Hospital Medicine Movement”? You’ll find them, along with nearly 100 other items, at the SHM Store.

These are just a few of the changes we have made to transform SHM into your organization. Keep watching, and you will find that SHM, ground central for the hospital medicine movement, is the best place to turn for anything and everything relating to hospital medicine.

If you should have any questions or comments, our doors and ears are always open and ready to welcome you. Feel free to give us a call at (800) 843-3360.

Stay tuned for next month’s SHM staff member report from Tina Budnitz, SHM’s senior advisor for quality initiatives.

Sanders is the marketing manager for SHM.

SHM CHAPTER REPORTS

Lake Erie

SHM’s Lake Erie Chapter met at Morton’s Steakhouse in Cleveland on August 9. The guest speaker was Ron J. Kattoo, MD, associate director of intensive care at Henry Ford Hospital and Health System in Detroit. Dr. Kattoo spoke about the management options for healthcare and ventilator-associated pneumonia, followed by a discussion about the role of hospitalists in the management of this severe condition. The meeting was sponsored by Pfizer Pharmaceutical Company. For more information on the Lake Erie Chapter of SHM, please contact Christopher Whinney, MD, at [email protected].

Long Island

SHM’s Long Island (N.Y.) Chapter held a meeting on August 24 at Burton & Doyle Steakhouse in East Great Neck, N.Y. A presentation titled “Sleep Disorders: How They Affect Patients and Providers” was given by Sonia Ancoli-Israel, PhD, a University of California at San Diego School of Medicine professor of psychiatry. At the conclusion of the presentation, Dr. Ancoli-Israel fielded questions.