A58-year-old white female presented with a two-week history of severe fatigue. She was admitted for acute renal failure (creatinine of 3.0 mg/dL with baseline 0.9 mg/dL two months prior) and anemia (hematocrit of 27.9 with baseline 37.5 two month prior). She had no prior history of renal failure. Her review of systems was otherwise negative. Her urine was orange and dipstick was positive for bilirubin but serum bilirubin was normal. (See photo at right.) Blood smear showed schistocytes and haptoglobin was undetectable. Physical exam showed yellow sclera, but was otherwise normal.

What is the most appropriate treatment for this patient?

1. Draw serum complement levels and spin urine for sediment analysis;
2. Order a STAT renal ultrasound;
3. Ask the patient about over-the-counter medication use;
4. Check urine porphyrin levels; or
5. Order immediate referral for plasmapheresis.

Discussion

The answer is C: Ask the patient about over-the-counter (OTC) medication use. This patient’s presentation was consistent with overuse of phenazopyridine. Phenazopyridine is an azo dye, which appears to exert a local anesthetic action on urinary tract mucosa. It’s reported adverse reactions include acute renal failure, hemolytic anemia, hepatitis, and methemoglobinemia, which have been reported after acute ingestions, chronic overdoses, and in chronically appropriate doses.1-7 The mechanism of these adverse reactions is not well understood. Although the differential diagnosis for renal failure and hemolytic anemia is extensive, yellow sclera and orange urine in the setting of a normal bilirubin level raised the suspicion of phenazopyridine use in this patient.

This case highlights the common overuse of over the counter medications, as well as global lack of knowledge of their potential adverse reactions. Although phenazopyridine is widely used, 50% of product consumers do not know that it is a urinary tract analgesic, and 80% do not know either the cause of their symptoms or the action of the drug.8

Additionally, although OTC medication use is reported by two-thirds of all hospitalized patients, documentation of them is present in only 10% of admission paperwork.9-10 Given that drug related hospitalizations account for 5%-8% of all hospital stays, it is essential that a complete OTC medication list be included as a routine part of the history obtained from all patients at the time of hospital admission.11-12 With history taking vigilance and patient education, adverse events from OTC medications can be minimized. TH

References

1. Gabor EP, Lowenstein L, De Leeuw NK. Hemolytic anemia induced by Phenylazo-Diamino-Pyridine (Pyridium). Can Med Assoc J. 1964 Oct;91:756-759.
2. Nathan DM, Siegel AJ, Bunn HF. Acute methemoglobinemia and hemolytic anemia with phenazopyridine: possible relation to acute renal failure. Arch Int Med. 1977 Nov;137(11):1636-1638.
3. Gavish D, Knobler H, Gottehrer N, et al. Methemoglobinemia, muscle damage and renal failure complicating phenazopyridine overdose. Isr J Med Sci. 1986 Jan;22(1):45-47.
4. Vega J. Acute Renal Failure caused by phenazopyridine. Rev Med Chil. 2003 May;131(5):541-544.
5. Kornowski R, Averbuch M, Jaffe A, et al. Sedural toxicity. Harefuah. 1991 Mar 15;120(6):324-325.
6. Thomas RJ, Doddabele S, Karnad AB. Chronic severe hemolytic anemia related to surreptitious phenazopyridine abuse. Ann Int Med. 1994;121:308.
7. Landman J, Kavaler E, Waterhouse R. Acquired methemoglobinemia possibly related to phenazopyridine in a woman with normal renal function. J Urol. 1997 Oct;158(4):1520-1521.
8. Chih-Wen S, Asch SM, Fielder E, et al. Consumer knowledge of over-the-counter phenazopyridine. Ann Fam Med. 2004 May-Jun;2(3):240-244.
9. Chrischilles EA, Foley DJ, Wallace RB, et al. Use of medications by persons 65 and over; data from the established populations for epidemiologic studies of the elderly. J Geront. 1992 Sep;47(5):M137-144.
10. Simons LA, Tett S, Simons J, et al. Multiple medication use in the elderly. Use of prescription and non-prescription drugs in an Australian community setting. Med J Aust. 1992 Aug 17;157(4):242-246.
11. Hallas J, Jensen KB, Grodum E, et al. Drug-related admissions to a department of medical gastroenterology. The role of self-medicated and prescribed drugs. Scand J Gastroenterol. 1991 Feb;26(2):174-180.
12. Pirmohamed M, James S, Meakin S, et al. Adverse drug reactions as cause of admission to hospital: prospective analysis of 18,820 patients. BMJ. 2004 Jul;329(7456):15-19.

A58-year-old white female presented with a two-week history of severe fatigue. She was admitted for acute renal failure (creatinine of 3.0 mg/dL with baseline 0.9 mg/dL two months prior) and anemia (hematocrit of 27.9 with baseline 37.5 two month prior). She had no prior history of renal failure. Her review of systems was otherwise negative. Her urine was orange and dipstick was positive for bilirubin but serum bilirubin was normal. (See photo at right.) Blood smear showed schistocytes and haptoglobin was undetectable. Physical exam showed yellow sclera, but was otherwise normal.

What is the most appropriate treatment for this patient?

1. Draw serum complement levels and spin urine for sediment analysis;
2. Order a STAT renal ultrasound;
3. Ask the patient about over-the-counter medication use;
4. Check urine porphyrin levels; or
5. Order immediate referral for plasmapheresis.

Discussion

The answer is C: Ask the patient about over-the-counter (OTC) medication use. This patient’s presentation was consistent with overuse of phenazopyridine. Phenazopyridine is an azo dye, which appears to exert a local anesthetic action on urinary tract mucosa. It’s reported adverse reactions include acute renal failure, hemolytic anemia, hepatitis, and methemoglobinemia, which have been reported after acute ingestions, chronic overdoses, and in chronically appropriate doses.1-7 The mechanism of these adverse reactions is not well understood. Although the differential diagnosis for renal failure and hemolytic anemia is extensive, yellow sclera and orange urine in the setting of a normal bilirubin level raised the suspicion of phenazopyridine use in this patient.

This case highlights the common overuse of over the counter medications, as well as global lack of knowledge of their potential adverse reactions. Although phenazopyridine is widely used, 50% of product consumers do not know that it is a urinary tract analgesic, and 80% do not know either the cause of their symptoms or the action of the drug.8

Additionally, although OTC medication use is reported by two-thirds of all hospitalized patients, documentation of them is present in only 10% of admission paperwork.9-10 Given that drug related hospitalizations account for 5%-8% of all hospital stays, it is essential that a complete OTC medication list be included as a routine part of the history obtained from all patients at the time of hospital admission.11-12 With history taking vigilance and patient education, adverse events from OTC medications can be minimized. TH

References

1. Gabor EP, Lowenstein L, De Leeuw NK. Hemolytic anemia induced by Phenylazo-Diamino-Pyridine (Pyridium). Can Med Assoc J. 1964 Oct;91:756-759.
2. Nathan DM, Siegel AJ, Bunn HF. Acute methemoglobinemia and hemolytic anemia with phenazopyridine: possible relation to acute renal failure. Arch Int Med. 1977 Nov;137(11):1636-1638.
3. Gavish D, Knobler H, Gottehrer N, et al. Methemoglobinemia, muscle damage and renal failure complicating phenazopyridine overdose. Isr J Med Sci. 1986 Jan;22(1):45-47.
4. Vega J. Acute Renal Failure caused by phenazopyridine. Rev Med Chil. 2003 May;131(5):541-544.
5. Kornowski R, Averbuch M, Jaffe A, et al. Sedural toxicity. Harefuah. 1991 Mar 15;120(6):324-325.
6. Thomas RJ, Doddabele S, Karnad AB. Chronic severe hemolytic anemia related to surreptitious phenazopyridine abuse. Ann Int Med. 1994;121:308.
7. Landman J, Kavaler E, Waterhouse R. Acquired methemoglobinemia possibly related to phenazopyridine in a woman with normal renal function. J Urol. 1997 Oct;158(4):1520-1521.
8. Chih-Wen S, Asch SM, Fielder E, et al. Consumer knowledge of over-the-counter phenazopyridine. Ann Fam Med. 2004 May-Jun;2(3):240-244.
9. Chrischilles EA, Foley DJ, Wallace RB, et al. Use of medications by persons 65 and over; data from the established populations for epidemiologic studies of the elderly. J Geront. 1992 Sep;47(5):M137-144.
10. Simons LA, Tett S, Simons J, et al. Multiple medication use in the elderly. Use of prescription and non-prescription drugs in an Australian community setting. Med J Aust. 1992 Aug 17;157(4):242-246.
11. Hallas J, Jensen KB, Grodum E, et al. Drug-related admissions to a department of medical gastroenterology. The role of self-medicated and prescribed drugs. Scand J Gastroenterol. 1991 Feb;26(2):174-180.
12. Pirmohamed M, James S, Meakin S, et al. Adverse drug reactions as cause of admission to hospital: prospective analysis of 18,820 patients. BMJ. 2004 Jul;329(7456):15-19.

A58-year-old white female presented with a two-week history of severe fatigue. She was admitted for acute renal failure (creatinine of 3.0 mg/dL with baseline 0.9 mg/dL two months prior) and anemia (hematocrit of 27.9 with baseline 37.5 two month prior). She had no prior history of renal failure. Her review of systems was otherwise negative. Her urine was orange and dipstick was positive for bilirubin but serum bilirubin was normal. (See photo at right.) Blood smear showed schistocytes and haptoglobin was undetectable. Physical exam showed yellow sclera, but was otherwise normal.

What is the most appropriate treatment for this patient?

1. Draw serum complement levels and spin urine for sediment analysis;
2. Order a STAT renal ultrasound;
3. Ask the patient about over-the-counter medication use;
4. Check urine porphyrin levels; or
5. Order immediate referral for plasmapheresis.

Discussion

The answer is C: Ask the patient about over-the-counter (OTC) medication use. This patient’s presentation was consistent with overuse of phenazopyridine. Phenazopyridine is an azo dye, which appears to exert a local anesthetic action on urinary tract mucosa. It’s reported adverse reactions include acute renal failure, hemolytic anemia, hepatitis, and methemoglobinemia, which have been reported after acute ingestions, chronic overdoses, and in chronically appropriate doses.1-7 The mechanism of these adverse reactions is not well understood. Although the differential diagnosis for renal failure and hemolytic anemia is extensive, yellow sclera and orange urine in the setting of a normal bilirubin level raised the suspicion of phenazopyridine use in this patient.

This case highlights the common overuse of over the counter medications, as well as global lack of knowledge of their potential adverse reactions. Although phenazopyridine is widely used, 50% of product consumers do not know that it is a urinary tract analgesic, and 80% do not know either the cause of their symptoms or the action of the drug.8

Additionally, although OTC medication use is reported by two-thirds of all hospitalized patients, documentation of them is present in only 10% of admission paperwork.9-10 Given that drug related hospitalizations account for 5%-8% of all hospital stays, it is essential that a complete OTC medication list be included as a routine part of the history obtained from all patients at the time of hospital admission.11-12 With history taking vigilance and patient education, adverse events from OTC medications can be minimized. TH

References

1. Gabor EP, Lowenstein L, De Leeuw NK. Hemolytic anemia induced by Phenylazo-Diamino-Pyridine (Pyridium). Can Med Assoc J. 1964 Oct;91:756-759.
2. Nathan DM, Siegel AJ, Bunn HF. Acute methemoglobinemia and hemolytic anemia with phenazopyridine: possible relation to acute renal failure. Arch Int Med. 1977 Nov;137(11):1636-1638.
3. Gavish D, Knobler H, Gottehrer N, et al. Methemoglobinemia, muscle damage and renal failure complicating phenazopyridine overdose. Isr J Med Sci. 1986 Jan;22(1):45-47.
4. Vega J. Acute Renal Failure caused by phenazopyridine. Rev Med Chil. 2003 May;131(5):541-544.
5. Kornowski R, Averbuch M, Jaffe A, et al. Sedural toxicity. Harefuah. 1991 Mar 15;120(6):324-325.
6. Thomas RJ, Doddabele S, Karnad AB. Chronic severe hemolytic anemia related to surreptitious phenazopyridine abuse. Ann Int Med. 1994;121:308.
7. Landman J, Kavaler E, Waterhouse R. Acquired methemoglobinemia possibly related to phenazopyridine in a woman with normal renal function. J Urol. 1997 Oct;158(4):1520-1521.
8. Chih-Wen S, Asch SM, Fielder E, et al. Consumer knowledge of over-the-counter phenazopyridine. Ann Fam Med. 2004 May-Jun;2(3):240-244.
9. Chrischilles EA, Foley DJ, Wallace RB, et al. Use of medications by persons 65 and over; data from the established populations for epidemiologic studies of the elderly. J Geront. 1992 Sep;47(5):M137-144.
10. Simons LA, Tett S, Simons J, et al. Multiple medication use in the elderly. Use of prescription and non-prescription drugs in an Australian community setting. Med J Aust. 1992 Aug 17;157(4):242-246.
11. Hallas J, Jensen KB, Grodum E, et al. Drug-related admissions to a department of medical gastroenterology. The role of self-medicated and prescribed drugs. Scand J Gastroenterol. 1991 Feb;26(2):174-180.
12. Pirmohamed M, James S, Meakin S, et al. Adverse drug reactions as cause of admission to hospital: prospective analysis of 18,820 patients. BMJ. 2004 Jul;329(7456):15-19.

An attorney approaches you about testifying as an expert witness on behalf of a patient against a physician in your area. How do you decide whether to testify?

The decision of whether to testify in a malpractice case is one of the most difficult, yet one of the most important non-patient care decisions a physician can make. Expert testimony is essential to medical malpractice litigation.

The physician expert, however, is often caught in the middle of conflicting tensions. The obligation to promote fairness, justice, and self-regulation of the profession are balanced against the professional and social pressure not to testify against colleagues and not to participate in a legal system that many physicians feel victimizes members of the profession. Nonetheless, the legal system relies on competent medical expertise to be just and fair, and relies on medical professionals to provide that expertise. An individual physician’s decision to participate in a medical malpractice case should be guided by careful consideration of their duties as applied to the specific situation.

What Is Expert Testimony, and Who Is an Expert?

A medical malpractice claim requires that the plaintiff show that the defendant(s) breached a duty to the plaintiff by failing to perform to the standard of care. The central issue in many malpractice cases involves defining the standard of care and determining whether the defendant(s) deviated from it. The only way for a jury to determine what is the standard of care is to listen to the opinions of experts and make a decision based on the persuasiveness and credibility of the experts.

Expert witnesses differ from other witnesses because expert witnesses can offer opinions while other witnesses can only testify to facts or their own personal experience.1 Expert witnesses must have specialized knowledge or experience to be allowed to offer opinion testimony. The U.S. Supreme Court has required that scientific testimony be relevant and reliable, and requires the judge presiding over a case to determine the validity of scientific testimony.2 If the judge decides that scientific testimony to be offered by an expert is not valid or reliable, the judge may refuse to allow it. Thus, the judge determines who may serve as an expert in front of the jury.

Licensed physicians are usually considered experts on the standard of care, regardless of the specialty or area of practice of the testifying expert. Tort reform in many states is focusing on expert testimony, including limiting judicial discretion in qualifying experts. For example, in Pennsylvania, only an expert in the field of the defendant may give expert testimony against him or her.

Given that most physicians are allowed by most judges to testify as to the standard of care, an expert may be testifying outside their scope of practice or the area in which they have actual specialized knowledge and experience. Further, once an expert is allowed to testify, there are no consequences for offering opinions that are unsupported by evidence or patently inaccurate. These are the areas where professional integrity is crucial, and professional societies can play a role in regulation and oversight of physicians serving as experts.3

Self-Regulation of Expert Witnesses

What do individuals and professional societies need to contribute to oversight of expert testimony? A physician’s obligation to participate in malpractice cases arises from the privilege of self-regulation enjoyed by the medical profession. As a result of the degree of specialized knowledge and skill needed to practice medicine, physicians have a duty to take action against other physicians who are impaired or incompetent.3 Professional societies promote the highest ethical and professional standards for members and therefore have a responsibility to discipline members who are irresponsible or unqualified in their expert legal involvement.

Physicians also have a duty to patients to provide expert testimony. In the event of harm caused by negligence, patients are denied any compensation at all if responsible physicians are unwilling to become involved as plaintiff’s experts. Physicians must uphold the duty to act in the best interest of patients and society and to promote justice in the system by rendering fair and honest opinions—even if that results in liability for a fellow physicians and despite the current atmosphere of negativity toward physicians testifying against other physicians.3

Based on these ethical principles, physicians have a duty to provide accurate and responsible expert testimony. Inaccurate expert testimony is damaging to the system in many ways: It increases malpractice costs, injures the reputation of individual practitioners, and adversely affects the standard of care by promoting false standards. Distinguishing irresponsible testimony from reasonable differences of opinion may be challenging. Any valid lawsuit will involve conflicting opinions as to whether the standard of care was met—otherwise there would be no need for expert testimony. To protect against overreaching, physicians should limit themselves to areas of their own academic and experiential expertise, and should limit their testimony to their scope of training or practice. Their opinions should be consistent with prevailing literature and good clinical practice. Offering an unusual opinion that contradicts the literature may be appropriate if the expert has good reason to believe the atypical opinion is correct and can provide evidence to support the claim.

Applying these principles to the practice of hospitalists requires special considerations. Hospital medicine is not a discrete specialty in the sense of having a certifying board or mandatory focused training requirements; however, hospitalists practice in a particular environment and should limit their expert testimony to that environment. Hospitalists have diverse practices and some practice outpatient medicine or primary care as well. Thus, it is particularly important for hospitalists to demonstrate responsibility and integrity in limiting their testimony to areas where they have genuine specialized knowledge and experience. Other physicians, attorneys, and judges must rely on hospitalists to enforce standards themselves because no single standard can be applied to all hospitalists.

As a further consideration in the interests of justice and professionalism, physicians should recuse themselves from any case with an actual or perceived conflict of interest. Prominent physicians, including public figures and society leaders, have the same duty regarding self-regulation in the profession and promotion of justice in the system as any other physician. Any reason to be personally predisposed to one side of the case or the other as a result of personal involvement or professional interests may make the physician an inappropriate expert. Unless testifying on behalf of the position of a society, a physician should not use society membership as direct evidence of expertise. Society leaders should be cautious about the appearance of conflict of interest, specifically that their status in the society confers special expert qualifications.

Professional societies have a special role in ensuring quality healthcare and a special role in the trust of society. Many societies, including the American Medical Association and the American Academy of Pediatrics have created guidelines for expert witnesses, and the AMA has further discussed the need for a more active role in expert oversight by professional societies.3 Societies need to establish standards for members who act as experts and create enforcement mechanisms for those standards. Further, societies should decide whether they intend to undertake formal disciplinary actions against physicians acting improperly by making the state disciplinary boards aware of their findings of improper conduct. Such standards and policies must be explicit, documented, and published. This is an expanded role for professional societies in the arena of explicit regulation and discipline of members, but there has been increasing recognition that professional societies are an ideal forum for increasing regulation and standards for expert testimony.4-5

The Verdict

The decision to participate in a medical malpractice case as an expert witness requires competence, accurate self-assessment, and integrity. A physician should testify only to what he or she genuinely believes to be the standard of care, regardless of which side approaches him or her. The physician should consider his or her current practice and expertise to decide if he or she can provide honest and accurate expert testimony.

He or she should keep in mind the interests of patients in having access to the courts and to fair compensation from injuries, and therefore physicians should have the courage and integrity to testify against colleagues when he or she genuinely believes that the colleague injured the plaintiff through a deviation from the standard of care. Society relies upon physicians to risk disfavor with colleagues in the interest of promoting justice and protecting patients when the physician believes that is the right thing to do. Physicians interested in policy issues around expert testimony should become involved in their professional societies to create and enforce quality standards for expert witnesses.

References

1. Federal Rules of Evidence 701, 702, 703.
2. Daubert v. Merrell Dow, 509 U.S. 579; 113 S. Ct. 2786; 125 L. Ed. 2d 469 (1993).
3. American Medical Association Code of Medical Ethics, Discipline in Medicine, E-9.04 Available at www.ama-assn.org. Last accessed May 25, 2006.
4. Feld AD, Carey WD. Expert witness malfeasance: how should specialty societies respond? Am J Gastroenterol. 2005 May;100(5):991-995.
5. Gomez JCB. Silencing the hired guns: ensuring honesty in medical testimony. J Leg Med. 2005 Sep;26(3):385-399.

SHM: BEHIND THE SCENES

SHM Online

By Scott Johnson

Last month, my next door neighbor at the office and SHM’s director of membership, Todd Von Deak, wrote a new column meant to share with you a “behind the scenes” look at SHM. I am pleased to carry the torch in this issue of The Hospitalist and give you a sneak peek at what’s next for SHM’s Web and IT initiatives.

First, let’s step back and look at some changes we’ve recently implemented and how each should benefit your membership.

Our database is key in our efforts to keep you up to date on not only the latest news from SHM, but also from the hospital medicine community at large. Over the past couple of months, we have completed a major review of our data-gathering processes and made changes to how we store your information. These changes will not only better protect your privacy, which is a major concern of ours, but also better enable us to reach you at your preferred address—whether at home or work.

Part of great customer service is listening. Many members have shared that they find it cumbersome to have to remember their member number in order to log onto SHM’s Web site. We’re pleased to announce that you can now access the SHM Web site with your own personalized username and password.

To create your own login and password, just visit www.hospitalmedicine.org/activate. Once online, you will be asked to enter your member number and last name, and then asked to choose a new username and password.

In addition to allowing you to create your own username and password, we’ve also streamlined the process to renew your membership or join online. Check it out when you get a chance. I’d love to hear your feedback.

Now that we have had our flashback, let’s discuss what we’ve got planned for the future. Since launching the new Career Center (www.hospitalmedicine.org/careercenter) we have begun working on projects to create a more personal experience for you as you visit the SHM Web site and receive our monthly e-mail newsletter.

The SHM Store, which launched in June, features a variety of SHM products and resources. Key educational products such as the results from our “Survey on the State of the Hospital Medicine Movement” will be available, as will favorites like SHM hats and golf shirts (both men’s and women’s).

The next evolution of SHM’s eNewsletter, our monthly e-mail newsletter, will occur this fall. In addition to a new look and feel, the eNewsletter will contain information unique for members and non-members and will be personalized to your areas of interest.

We are also creating a personally tailored Web site where you can create your own “My SHM” page. Once live, this new benefit will enable you to select topics of interest and have related articles, stories, and links automatically appear on your own “My SHM” page.

Having worked with healthcare associations for almost seven years I recognize how important your time is and the value of having the best and most current information at your fingertips. Our goal is to not only create a place where you can find the information you need to excel in your field, but to find ways in which you can “pull” the information relevant to you to your inbox, PDA, or iPod.

For the moment, we are focused on improving and enhancing the current tools in SHM’s tool belt. But on the not-too-distant horizon you’ll be hearing more about our plans to use new tools, such as PDAs and iPods, to provide you with even more information and resources. We’re confident that these resources will help you enhance the quality of care you provide to your patients and their families.

Steve Jobs, CEO of Apple Computer, once said, “The journey is the reward.” In the time I have spent with SHM it has already been quite a rewarding journey and I am excited about the landscape that lies before us.

Next month, you’ll hear from Geri Barnes, our director of education and quality initiatives. Geri is leading the charge to keep our education program in its current position as the most informative and innovative set of offerings within our specialty.

If you ever have any questions about our Web-based offerings, or feedback on how we can improve existing products and programs, please e-mail me at [email protected].

Johnson is SHM’s director of information services.

New Leadership AcademyOffering to Debut in Nashville

Level II track created in response to demand

SHM is pleased to announce the expansion of its cutting edge leadership program, with the debut of a Level II track as part of the Leadership Academy Sept. 11-14 in Nashville, Tenn.

Over the course of four days, the Leadership Academy will provide hospitalist leaders with the skills and resources required to successfully lead and manage a hospital medicine program now and in the future.

Topics that will be addressed include:

• Leadership challenges in hospital medicine;
• Finance and the hospitalist;
• Leading recruitment, retention, and staff development; and
• Leading and managing change.

This course was created in response to feedback from previous Leadership Academy attendees and is designed to give them the opportunity to build on the time they’ve spent back at the hospital since attending a Leadership Academy. Level II offers an in-depth look at how to finance a hospital, insight on how to lead recruitment, retention, and staff development. It also presents advanced skills in negotiation.

Because Level II is considered an advanced course, attendees must have participated in a previous leadership academy or have completed an MBA program to be accepted.

As with any SHM educational event, ample time will be set aside for interaction with faculty and participants so you can get answers to your pressing questions and make connections for the future.

“The fact that learning takes place both inside and outside of the classroom is one of the things that makes SHM’s Leadership Academies so powerful,” says Larry Wellikson, CEO of SHM.

According to Scott Enderby, a Leadership Academy graduate, “This is the only medical conference I’ve ever gone to where I went to every meeting and still wanted more.”

The September venue—the Gaylord Nashville Resort & Convention Center in Nashville—offers ample opportunity to relax in the midst of your intense learning experience. From tours aboard the hotel’s Delta Flatboats to the chance to play 18 holes at the Grand Ole Opry Course, there is something for everyone, including your family.

To register for the September Leadership Academy, visit www.hospitalmedicine.org or call (800) 843-3360.

Can’t join us in Nashville? Mark your calendars for our winter Leadership Academy, Feb. 26-March 1, 2007, in Orlando, Fla. TH

An attorney approaches you about testifying as an expert witness on behalf of a patient against a physician in your area. How do you decide whether to testify?

The decision of whether to testify in a malpractice case is one of the most difficult, yet one of the most important non-patient care decisions a physician can make. Expert testimony is essential to medical malpractice litigation.

The physician expert, however, is often caught in the middle of conflicting tensions. The obligation to promote fairness, justice, and self-regulation of the profession are balanced against the professional and social pressure not to testify against colleagues and not to participate in a legal system that many physicians feel victimizes members of the profession. Nonetheless, the legal system relies on competent medical expertise to be just and fair, and relies on medical professionals to provide that expertise. An individual physician’s decision to participate in a medical malpractice case should be guided by careful consideration of their duties as applied to the specific situation.

What Is Expert Testimony, and Who Is an Expert?

A medical malpractice claim requires that the plaintiff show that the defendant(s) breached a duty to the plaintiff by failing to perform to the standard of care. The central issue in many malpractice cases involves defining the standard of care and determining whether the defendant(s) deviated from it. The only way for a jury to determine what is the standard of care is to listen to the opinions of experts and make a decision based on the persuasiveness and credibility of the experts.

Expert witnesses differ from other witnesses because expert witnesses can offer opinions while other witnesses can only testify to facts or their own personal experience.1 Expert witnesses must have specialized knowledge or experience to be allowed to offer opinion testimony. The U.S. Supreme Court has required that scientific testimony be relevant and reliable, and requires the judge presiding over a case to determine the validity of scientific testimony.2 If the judge decides that scientific testimony to be offered by an expert is not valid or reliable, the judge may refuse to allow it. Thus, the judge determines who may serve as an expert in front of the jury.

Licensed physicians are usually considered experts on the standard of care, regardless of the specialty or area of practice of the testifying expert. Tort reform in many states is focusing on expert testimony, including limiting judicial discretion in qualifying experts. For example, in Pennsylvania, only an expert in the field of the defendant may give expert testimony against him or her.

Given that most physicians are allowed by most judges to testify as to the standard of care, an expert may be testifying outside their scope of practice or the area in which they have actual specialized knowledge and experience. Further, once an expert is allowed to testify, there are no consequences for offering opinions that are unsupported by evidence or patently inaccurate. These are the areas where professional integrity is crucial, and professional societies can play a role in regulation and oversight of physicians serving as experts.3

Self-Regulation of Expert Witnesses

What do individuals and professional societies need to contribute to oversight of expert testimony? A physician’s obligation to participate in malpractice cases arises from the privilege of self-regulation enjoyed by the medical profession. As a result of the degree of specialized knowledge and skill needed to practice medicine, physicians have a duty to take action against other physicians who are impaired or incompetent.3 Professional societies promote the highest ethical and professional standards for members and therefore have a responsibility to discipline members who are irresponsible or unqualified in their expert legal involvement.

Physicians also have a duty to patients to provide expert testimony. In the event of harm caused by negligence, patients are denied any compensation at all if responsible physicians are unwilling to become involved as plaintiff’s experts. Physicians must uphold the duty to act in the best interest of patients and society and to promote justice in the system by rendering fair and honest opinions—even if that results in liability for a fellow physicians and despite the current atmosphere of negativity toward physicians testifying against other physicians.3

Based on these ethical principles, physicians have a duty to provide accurate and responsible expert testimony. Inaccurate expert testimony is damaging to the system in many ways: It increases malpractice costs, injures the reputation of individual practitioners, and adversely affects the standard of care by promoting false standards. Distinguishing irresponsible testimony from reasonable differences of opinion may be challenging. Any valid lawsuit will involve conflicting opinions as to whether the standard of care was met—otherwise there would be no need for expert testimony. To protect against overreaching, physicians should limit themselves to areas of their own academic and experiential expertise, and should limit their testimony to their scope of training or practice. Their opinions should be consistent with prevailing literature and good clinical practice. Offering an unusual opinion that contradicts the literature may be appropriate if the expert has good reason to believe the atypical opinion is correct and can provide evidence to support the claim.

Applying these principles to the practice of hospitalists requires special considerations. Hospital medicine is not a discrete specialty in the sense of having a certifying board or mandatory focused training requirements; however, hospitalists practice in a particular environment and should limit their expert testimony to that environment. Hospitalists have diverse practices and some practice outpatient medicine or primary care as well. Thus, it is particularly important for hospitalists to demonstrate responsibility and integrity in limiting their testimony to areas where they have genuine specialized knowledge and experience. Other physicians, attorneys, and judges must rely on hospitalists to enforce standards themselves because no single standard can be applied to all hospitalists.

As a further consideration in the interests of justice and professionalism, physicians should recuse themselves from any case with an actual or perceived conflict of interest. Prominent physicians, including public figures and society leaders, have the same duty regarding self-regulation in the profession and promotion of justice in the system as any other physician. Any reason to be personally predisposed to one side of the case or the other as a result of personal involvement or professional interests may make the physician an inappropriate expert. Unless testifying on behalf of the position of a society, a physician should not use society membership as direct evidence of expertise. Society leaders should be cautious about the appearance of conflict of interest, specifically that their status in the society confers special expert qualifications.

Professional societies have a special role in ensuring quality healthcare and a special role in the trust of society. Many societies, including the American Medical Association and the American Academy of Pediatrics have created guidelines for expert witnesses, and the AMA has further discussed the need for a more active role in expert oversight by professional societies.3 Societies need to establish standards for members who act as experts and create enforcement mechanisms for those standards. Further, societies should decide whether they intend to undertake formal disciplinary actions against physicians acting improperly by making the state disciplinary boards aware of their findings of improper conduct. Such standards and policies must be explicit, documented, and published. This is an expanded role for professional societies in the arena of explicit regulation and discipline of members, but there has been increasing recognition that professional societies are an ideal forum for increasing regulation and standards for expert testimony.4-5

The Verdict

The decision to participate in a medical malpractice case as an expert witness requires competence, accurate self-assessment, and integrity. A physician should testify only to what he or she genuinely believes to be the standard of care, regardless of which side approaches him or her. The physician should consider his or her current practice and expertise to decide if he or she can provide honest and accurate expert testimony.

He or she should keep in mind the interests of patients in having access to the courts and to fair compensation from injuries, and therefore physicians should have the courage and integrity to testify against colleagues when he or she genuinely believes that the colleague injured the plaintiff through a deviation from the standard of care. Society relies upon physicians to risk disfavor with colleagues in the interest of promoting justice and protecting patients when the physician believes that is the right thing to do. Physicians interested in policy issues around expert testimony should become involved in their professional societies to create and enforce quality standards for expert witnesses.

References

1. Federal Rules of Evidence 701, 702, 703.
2. Daubert v. Merrell Dow, 509 U.S. 579; 113 S. Ct. 2786; 125 L. Ed. 2d 469 (1993).
3. American Medical Association Code of Medical Ethics, Discipline in Medicine, E-9.04 Available at www.ama-assn.org. Last accessed May 25, 2006.
4. Feld AD, Carey WD. Expert witness malfeasance: how should specialty societies respond? Am J Gastroenterol. 2005 May;100(5):991-995.
5. Gomez JCB. Silencing the hired guns: ensuring honesty in medical testimony. J Leg Med. 2005 Sep;26(3):385-399.

SHM: BEHIND THE SCENES

SHM Online

By Scott Johnson

Last month, my next door neighbor at the office and SHM’s director of membership, Todd Von Deak, wrote a new column meant to share with you a “behind the scenes” look at SHM. I am pleased to carry the torch in this issue of The Hospitalist and give you a sneak peek at what’s next for SHM’s Web and IT initiatives.

First, let’s step back and look at some changes we’ve recently implemented and how each should benefit your membership.

Our database is key in our efforts to keep you up to date on not only the latest news from SHM, but also from the hospital medicine community at large. Over the past couple of months, we have completed a major review of our data-gathering processes and made changes to how we store your information. These changes will not only better protect your privacy, which is a major concern of ours, but also better enable us to reach you at your preferred address—whether at home or work.

Part of great customer service is listening. Many members have shared that they find it cumbersome to have to remember their member number in order to log onto SHM’s Web site. We’re pleased to announce that you can now access the SHM Web site with your own personalized username and password.

To create your own login and password, just visit www.hospitalmedicine.org/activate. Once online, you will be asked to enter your member number and last name, and then asked to choose a new username and password.

In addition to allowing you to create your own username and password, we’ve also streamlined the process to renew your membership or join online. Check it out when you get a chance. I’d love to hear your feedback.

Now that we have had our flashback, let’s discuss what we’ve got planned for the future. Since launching the new Career Center (www.hospitalmedicine.org/careercenter) we have begun working on projects to create a more personal experience for you as you visit the SHM Web site and receive our monthly e-mail newsletter.

The SHM Store, which launched in June, features a variety of SHM products and resources. Key educational products such as the results from our “Survey on the State of the Hospital Medicine Movement” will be available, as will favorites like SHM hats and golf shirts (both men’s and women’s).

The next evolution of SHM’s eNewsletter, our monthly e-mail newsletter, will occur this fall. In addition to a new look and feel, the eNewsletter will contain information unique for members and non-members and will be personalized to your areas of interest.

We are also creating a personally tailored Web site where you can create your own “My SHM” page. Once live, this new benefit will enable you to select topics of interest and have related articles, stories, and links automatically appear on your own “My SHM” page.

Having worked with healthcare associations for almost seven years I recognize how important your time is and the value of having the best and most current information at your fingertips. Our goal is to not only create a place where you can find the information you need to excel in your field, but to find ways in which you can “pull” the information relevant to you to your inbox, PDA, or iPod.

For the moment, we are focused on improving and enhancing the current tools in SHM’s tool belt. But on the not-too-distant horizon you’ll be hearing more about our plans to use new tools, such as PDAs and iPods, to provide you with even more information and resources. We’re confident that these resources will help you enhance the quality of care you provide to your patients and their families.

Steve Jobs, CEO of Apple Computer, once said, “The journey is the reward.” In the time I have spent with SHM it has already been quite a rewarding journey and I am excited about the landscape that lies before us.

Next month, you’ll hear from Geri Barnes, our director of education and quality initiatives. Geri is leading the charge to keep our education program in its current position as the most informative and innovative set of offerings within our specialty.

If you ever have any questions about our Web-based offerings, or feedback on how we can improve existing products and programs, please e-mail me at [email protected].

Johnson is SHM’s director of information services.

New Leadership AcademyOffering to Debut in Nashville

Level II track created in response to demand

SHM is pleased to announce the expansion of its cutting edge leadership program, with the debut of a Level II track as part of the Leadership Academy Sept. 11-14 in Nashville, Tenn.

Over the course of four days, the Leadership Academy will provide hospitalist leaders with the skills and resources required to successfully lead and manage a hospital medicine program now and in the future.

Topics that will be addressed include:

• Leadership challenges in hospital medicine;
• Finance and the hospitalist;
• Leading recruitment, retention, and staff development; and
• Leading and managing change.

This course was created in response to feedback from previous Leadership Academy attendees and is designed to give them the opportunity to build on the time they’ve spent back at the hospital since attending a Leadership Academy. Level II offers an in-depth look at how to finance a hospital, insight on how to lead recruitment, retention, and staff development. It also presents advanced skills in negotiation.

Because Level II is considered an advanced course, attendees must have participated in a previous leadership academy or have completed an MBA program to be accepted.

As with any SHM educational event, ample time will be set aside for interaction with faculty and participants so you can get answers to your pressing questions and make connections for the future.

“The fact that learning takes place both inside and outside of the classroom is one of the things that makes SHM’s Leadership Academies so powerful,” says Larry Wellikson, CEO of SHM.

According to Scott Enderby, a Leadership Academy graduate, “This is the only medical conference I’ve ever gone to where I went to every meeting and still wanted more.”

The September venue—the Gaylord Nashville Resort & Convention Center in Nashville—offers ample opportunity to relax in the midst of your intense learning experience. From tours aboard the hotel’s Delta Flatboats to the chance to play 18 holes at the Grand Ole Opry Course, there is something for everyone, including your family.

To register for the September Leadership Academy, visit www.hospitalmedicine.org or call (800) 843-3360.

Can’t join us in Nashville? Mark your calendars for our winter Leadership Academy, Feb. 26-March 1, 2007, in Orlando, Fla. TH

An attorney approaches you about testifying as an expert witness on behalf of a patient against a physician in your area. How do you decide whether to testify?

The decision of whether to testify in a malpractice case is one of the most difficult, yet one of the most important non-patient care decisions a physician can make. Expert testimony is essential to medical malpractice litigation.

The physician expert, however, is often caught in the middle of conflicting tensions. The obligation to promote fairness, justice, and self-regulation of the profession are balanced against the professional and social pressure not to testify against colleagues and not to participate in a legal system that many physicians feel victimizes members of the profession. Nonetheless, the legal system relies on competent medical expertise to be just and fair, and relies on medical professionals to provide that expertise. An individual physician’s decision to participate in a medical malpractice case should be guided by careful consideration of their duties as applied to the specific situation.

What Is Expert Testimony, and Who Is an Expert?

A medical malpractice claim requires that the plaintiff show that the defendant(s) breached a duty to the plaintiff by failing to perform to the standard of care. The central issue in many malpractice cases involves defining the standard of care and determining whether the defendant(s) deviated from it. The only way for a jury to determine what is the standard of care is to listen to the opinions of experts and make a decision based on the persuasiveness and credibility of the experts.

Expert witnesses differ from other witnesses because expert witnesses can offer opinions while other witnesses can only testify to facts or their own personal experience.1 Expert witnesses must have specialized knowledge or experience to be allowed to offer opinion testimony. The U.S. Supreme Court has required that scientific testimony be relevant and reliable, and requires the judge presiding over a case to determine the validity of scientific testimony.2 If the judge decides that scientific testimony to be offered by an expert is not valid or reliable, the judge may refuse to allow it. Thus, the judge determines who may serve as an expert in front of the jury.

Licensed physicians are usually considered experts on the standard of care, regardless of the specialty or area of practice of the testifying expert. Tort reform in many states is focusing on expert testimony, including limiting judicial discretion in qualifying experts. For example, in Pennsylvania, only an expert in the field of the defendant may give expert testimony against him or her.

Given that most physicians are allowed by most judges to testify as to the standard of care, an expert may be testifying outside their scope of practice or the area in which they have actual specialized knowledge and experience. Further, once an expert is allowed to testify, there are no consequences for offering opinions that are unsupported by evidence or patently inaccurate. These are the areas where professional integrity is crucial, and professional societies can play a role in regulation and oversight of physicians serving as experts.3

Self-Regulation of Expert Witnesses

What do individuals and professional societies need to contribute to oversight of expert testimony? A physician’s obligation to participate in malpractice cases arises from the privilege of self-regulation enjoyed by the medical profession. As a result of the degree of specialized knowledge and skill needed to practice medicine, physicians have a duty to take action against other physicians who are impaired or incompetent.3 Professional societies promote the highest ethical and professional standards for members and therefore have a responsibility to discipline members who are irresponsible or unqualified in their expert legal involvement.

Physicians also have a duty to patients to provide expert testimony. In the event of harm caused by negligence, patients are denied any compensation at all if responsible physicians are unwilling to become involved as plaintiff’s experts. Physicians must uphold the duty to act in the best interest of patients and society and to promote justice in the system by rendering fair and honest opinions—even if that results in liability for a fellow physicians and despite the current atmosphere of negativity toward physicians testifying against other physicians.3

Based on these ethical principles, physicians have a duty to provide accurate and responsible expert testimony. Inaccurate expert testimony is damaging to the system in many ways: It increases malpractice costs, injures the reputation of individual practitioners, and adversely affects the standard of care by promoting false standards. Distinguishing irresponsible testimony from reasonable differences of opinion may be challenging. Any valid lawsuit will involve conflicting opinions as to whether the standard of care was met—otherwise there would be no need for expert testimony. To protect against overreaching, physicians should limit themselves to areas of their own academic and experiential expertise, and should limit their testimony to their scope of training or practice. Their opinions should be consistent with prevailing literature and good clinical practice. Offering an unusual opinion that contradicts the literature may be appropriate if the expert has good reason to believe the atypical opinion is correct and can provide evidence to support the claim.

Applying these principles to the practice of hospitalists requires special considerations. Hospital medicine is not a discrete specialty in the sense of having a certifying board or mandatory focused training requirements; however, hospitalists practice in a particular environment and should limit their expert testimony to that environment. Hospitalists have diverse practices and some practice outpatient medicine or primary care as well. Thus, it is particularly important for hospitalists to demonstrate responsibility and integrity in limiting their testimony to areas where they have genuine specialized knowledge and experience. Other physicians, attorneys, and judges must rely on hospitalists to enforce standards themselves because no single standard can be applied to all hospitalists.

As a further consideration in the interests of justice and professionalism, physicians should recuse themselves from any case with an actual or perceived conflict of interest. Prominent physicians, including public figures and society leaders, have the same duty regarding self-regulation in the profession and promotion of justice in the system as any other physician. Any reason to be personally predisposed to one side of the case or the other as a result of personal involvement or professional interests may make the physician an inappropriate expert. Unless testifying on behalf of the position of a society, a physician should not use society membership as direct evidence of expertise. Society leaders should be cautious about the appearance of conflict of interest, specifically that their status in the society confers special expert qualifications.

Professional societies have a special role in ensuring quality healthcare and a special role in the trust of society. Many societies, including the American Medical Association and the American Academy of Pediatrics have created guidelines for expert witnesses, and the AMA has further discussed the need for a more active role in expert oversight by professional societies.3 Societies need to establish standards for members who act as experts and create enforcement mechanisms for those standards. Further, societies should decide whether they intend to undertake formal disciplinary actions against physicians acting improperly by making the state disciplinary boards aware of their findings of improper conduct. Such standards and policies must be explicit, documented, and published. This is an expanded role for professional societies in the arena of explicit regulation and discipline of members, but there has been increasing recognition that professional societies are an ideal forum for increasing regulation and standards for expert testimony.4-5

The Verdict

The decision to participate in a medical malpractice case as an expert witness requires competence, accurate self-assessment, and integrity. A physician should testify only to what he or she genuinely believes to be the standard of care, regardless of which side approaches him or her. The physician should consider his or her current practice and expertise to decide if he or she can provide honest and accurate expert testimony.

He or she should keep in mind the interests of patients in having access to the courts and to fair compensation from injuries, and therefore physicians should have the courage and integrity to testify against colleagues when he or she genuinely believes that the colleague injured the plaintiff through a deviation from the standard of care. Society relies upon physicians to risk disfavor with colleagues in the interest of promoting justice and protecting patients when the physician believes that is the right thing to do. Physicians interested in policy issues around expert testimony should become involved in their professional societies to create and enforce quality standards for expert witnesses.

References

1. Federal Rules of Evidence 701, 702, 703.
2. Daubert v. Merrell Dow, 509 U.S. 579; 113 S. Ct. 2786; 125 L. Ed. 2d 469 (1993).
3. American Medical Association Code of Medical Ethics, Discipline in Medicine, E-9.04 Available at www.ama-assn.org. Last accessed May 25, 2006.
4. Feld AD, Carey WD. Expert witness malfeasance: how should specialty societies respond? Am J Gastroenterol. 2005 May;100(5):991-995.
5. Gomez JCB. Silencing the hired guns: ensuring honesty in medical testimony. J Leg Med. 2005 Sep;26(3):385-399.

SHM: BEHIND THE SCENES

SHM Online

By Scott Johnson

Last month, my next door neighbor at the office and SHM’s director of membership, Todd Von Deak, wrote a new column meant to share with you a “behind the scenes” look at SHM. I am pleased to carry the torch in this issue of The Hospitalist and give you a sneak peek at what’s next for SHM’s Web and IT initiatives.

First, let’s step back and look at some changes we’ve recently implemented and how each should benefit your membership.

Our database is key in our efforts to keep you up to date on not only the latest news from SHM, but also from the hospital medicine community at large. Over the past couple of months, we have completed a major review of our data-gathering processes and made changes to how we store your information. These changes will not only better protect your privacy, which is a major concern of ours, but also better enable us to reach you at your preferred address—whether at home or work.

Part of great customer service is listening. Many members have shared that they find it cumbersome to have to remember their member number in order to log onto SHM’s Web site. We’re pleased to announce that you can now access the SHM Web site with your own personalized username and password.

To create your own login and password, just visit www.hospitalmedicine.org/activate. Once online, you will be asked to enter your member number and last name, and then asked to choose a new username and password.

In addition to allowing you to create your own username and password, we’ve also streamlined the process to renew your membership or join online. Check it out when you get a chance. I’d love to hear your feedback.

Now that we have had our flashback, let’s discuss what we’ve got planned for the future. Since launching the new Career Center (www.hospitalmedicine.org/careercenter) we have begun working on projects to create a more personal experience for you as you visit the SHM Web site and receive our monthly e-mail newsletter.

The SHM Store, which launched in June, features a variety of SHM products and resources. Key educational products such as the results from our “Survey on the State of the Hospital Medicine Movement” will be available, as will favorites like SHM hats and golf shirts (both men’s and women’s).

The next evolution of SHM’s eNewsletter, our monthly e-mail newsletter, will occur this fall. In addition to a new look and feel, the eNewsletter will contain information unique for members and non-members and will be personalized to your areas of interest.

We are also creating a personally tailored Web site where you can create your own “My SHM” page. Once live, this new benefit will enable you to select topics of interest and have related articles, stories, and links automatically appear on your own “My SHM” page.

Having worked with healthcare associations for almost seven years I recognize how important your time is and the value of having the best and most current information at your fingertips. Our goal is to not only create a place where you can find the information you need to excel in your field, but to find ways in which you can “pull” the information relevant to you to your inbox, PDA, or iPod.

For the moment, we are focused on improving and enhancing the current tools in SHM’s tool belt. But on the not-too-distant horizon you’ll be hearing more about our plans to use new tools, such as PDAs and iPods, to provide you with even more information and resources. We’re confident that these resources will help you enhance the quality of care you provide to your patients and their families.

Steve Jobs, CEO of Apple Computer, once said, “The journey is the reward.” In the time I have spent with SHM it has already been quite a rewarding journey and I am excited about the landscape that lies before us.

Next month, you’ll hear from Geri Barnes, our director of education and quality initiatives. Geri is leading the charge to keep our education program in its current position as the most informative and innovative set of offerings within our specialty.

If you ever have any questions about our Web-based offerings, or feedback on how we can improve existing products and programs, please e-mail me at [email protected].

Johnson is SHM’s director of information services.

New Leadership AcademyOffering to Debut in Nashville

Level II track created in response to demand

SHM is pleased to announce the expansion of its cutting edge leadership program, with the debut of a Level II track as part of the Leadership Academy Sept. 11-14 in Nashville, Tenn.

Over the course of four days, the Leadership Academy will provide hospitalist leaders with the skills and resources required to successfully lead and manage a hospital medicine program now and in the future.

Topics that will be addressed include:

• Leadership challenges in hospital medicine;
• Finance and the hospitalist;
• Leading recruitment, retention, and staff development; and
• Leading and managing change.

This course was created in response to feedback from previous Leadership Academy attendees and is designed to give them the opportunity to build on the time they’ve spent back at the hospital since attending a Leadership Academy. Level II offers an in-depth look at how to finance a hospital, insight on how to lead recruitment, retention, and staff development. It also presents advanced skills in negotiation.

Because Level II is considered an advanced course, attendees must have participated in a previous leadership academy or have completed an MBA program to be accepted.

As with any SHM educational event, ample time will be set aside for interaction with faculty and participants so you can get answers to your pressing questions and make connections for the future.

“The fact that learning takes place both inside and outside of the classroom is one of the things that makes SHM’s Leadership Academies so powerful,” says Larry Wellikson, CEO of SHM.

According to Scott Enderby, a Leadership Academy graduate, “This is the only medical conference I’ve ever gone to where I went to every meeting and still wanted more.”

The September venue—the Gaylord Nashville Resort & Convention Center in Nashville—offers ample opportunity to relax in the midst of your intense learning experience. From tours aboard the hotel’s Delta Flatboats to the chance to play 18 holes at the Grand Ole Opry Course, there is something for everyone, including your family.

To register for the September Leadership Academy, visit www.hospitalmedicine.org or call (800) 843-3360.

Can’t join us in Nashville? Mark your calendars for our winter Leadership Academy, Feb. 26-March 1, 2007, in Orlando, Fla. TH

He who has no faith in others shall find no faith in them.—Lao Tzu

We hear a lot about leading. There are best-selling books on the topic, courses in leading, articles on leading, and admonishments to lead. But is there an art to following? Many of us work on our leadership skills. We spend time trying to better understand those around us and their motivations and interests. We attempt to identify their strengths and engage them in projects that match their skills. We learn to give feedback in constructive ways so that others can improve. We try to understand the other’s perspective.

But when it’s our turn to follow, are we as diligent?

Regardless of our role at the hospital, within our group or in our medical community, we need to follow as well as lead. We may be a leader of our group, but a follower with the rest of the medical staff. We may lead some aspects of patient care, but follow on other aspects. How does our performance as a follower affect the group’s outcomes? Does it matter?

Some would say that there are four fundamental responsibilities of a follower.

Responsibility #1: Don’t act like a victim

As a project or program gets underway don’t be defensive or whine. Attempt to understand the rationale behind the project. Most leaders don’t wake up and invent things to keep people busy. They have a goal that usually addresses underperformance in some area. Operating room turnaround time may not seem important to you—discover why it matters to someone else. When a plan is presented, approach it with an open mind and suggest ways to improve the plan or its implementation. Even if the advantages of change are not apparent to you, give them a try before you make up your mind; you might discover that the new way is an improvement. Be straightforward with your concerns, but once the decision is made, play with the team.

We all knew families of brothers who seemed to fight among themselves. But if an outsider picked on one of them, the group banded together to defend each other. Make sure your team knows that they can count on you. Withdrawing from participation is certain to sabotage a project. Once your behaviors establish your reputation as a person who acts like a victim, you can be sure to be excluded from future projects or participation.

Worse than withdrawing is commiserating with others about your bad situation and demoralizing the group you are in. If you believe that the activity is unfair or dishonest, get outside opinions from other colleagues. Someone who is in another group or another field can be very helpful. In other disciplines (business, agriculture, manufacturing, and law), what you are being asked to do may be accepted as part of change. Solicit several opinions (and not just your family members). And when all is said and done, give it a try. Nothing is forever and every great journey starts with a single step—you might be in for a pleasant surprise.

Responsibility #2: Engage Yourself

Almost no one gets it right from the start. If you have ideas on improvement, not only speak up—take responsibility. Work with the project leader to supervise some part of it or assist in creating a monitoring tool or feedback loop. Every project has a number of tasks that need to be completed; volunteer to take responsibility for some part.

Engage others in finding ways to improve the process. Hospital-based processes are extremely complex and involve many stakeholders, entities, and professions. A number of pieces usually need attention. As the project progresses, be creative. Solve problems with open discussion and make improvements along the way. Focus on the end goal and suggest, implement, and monitor adjustments. Any sizable project will take time. Hospitalists and other physicians are used to seeing action and immediate reaction: Lasix relieves heart failure; nebulizers relieve shortness of breath. However, projects that really change organizations are long and arduous. They are multimonth and many times multiyear. This is quite a learning curve for many practitioners.

Responsibility #3: Do What you say

We certainly expect this of our leaders; we should expect it of ourselves as followers. It is difficult to lead a project when others on the team are late on deadlines or fail to show up. Volunteer to do only what you can. If you are overextended and don’t complete your part, the project can be crippled. Budget your time and energy to successfully meet expectations. If you get stuck on an assignment, ask for help. Delaying until the project is greatly behind can result in loss of your credibility and the whole project coming to a halt. Identify what you don’t know and identify ways to get the information you need. Many facilities and groups have a number of resources to assist you. They have members with experience expertise and other references available. SHM provides resources and online help at your fingertips.

Responsibility #4: stay the course

As mentioned above, the timelines on many projects take weeks and months. Don’t be discouraged if your progress is not as smooth as expected. Remember, you are remaking healthcare. Focus on your strategic priorities: Are they aligned with your patient care values? If you are off track, reanalyze. Look for the ways that the process is failing and revise the process. Maybe the wrong person is assigned to a task that is not to their strength. Review what you were trying to achieve. Maybe there is another path to get there. Follow directions and processes and support the design.

These are some ideas about the responsibilities of a follower. Keep in mind that others need you to follow just as you need them to lead. Performing as a good follower has some outcomes that help you. You can learn important successes with the right leader. The group’s goals can be accomplished more readily. If you can follow others and assist them in being successful with their goals, you can expect them to follow you in return. Have some faith in your leader; work at being a good follower and then you’ll be leading, too!

I would like to recognize the Petrous Group (www.petrous.net) for sharing their material for this column. TH

Dr. Gorman is the president of SHM.

He who has no faith in others shall find no faith in them.—Lao Tzu

We hear a lot about leading. There are best-selling books on the topic, courses in leading, articles on leading, and admonishments to lead. But is there an art to following? Many of us work on our leadership skills. We spend time trying to better understand those around us and their motivations and interests. We attempt to identify their strengths and engage them in projects that match their skills. We learn to give feedback in constructive ways so that others can improve. We try to understand the other’s perspective.

But when it’s our turn to follow, are we as diligent?

Regardless of our role at the hospital, within our group or in our medical community, we need to follow as well as lead. We may be a leader of our group, but a follower with the rest of the medical staff. We may lead some aspects of patient care, but follow on other aspects. How does our performance as a follower affect the group’s outcomes? Does it matter?

Some would say that there are four fundamental responsibilities of a follower.

Responsibility #1: Don’t act like a victim

As a project or program gets underway don’t be defensive or whine. Attempt to understand the rationale behind the project. Most leaders don’t wake up and invent things to keep people busy. They have a goal that usually addresses underperformance in some area. Operating room turnaround time may not seem important to you—discover why it matters to someone else. When a plan is presented, approach it with an open mind and suggest ways to improve the plan or its implementation. Even if the advantages of change are not apparent to you, give them a try before you make up your mind; you might discover that the new way is an improvement. Be straightforward with your concerns, but once the decision is made, play with the team.

We all knew families of brothers who seemed to fight among themselves. But if an outsider picked on one of them, the group banded together to defend each other. Make sure your team knows that they can count on you. Withdrawing from participation is certain to sabotage a project. Once your behaviors establish your reputation as a person who acts like a victim, you can be sure to be excluded from future projects or participation.

Worse than withdrawing is commiserating with others about your bad situation and demoralizing the group you are in. If you believe that the activity is unfair or dishonest, get outside opinions from other colleagues. Someone who is in another group or another field can be very helpful. In other disciplines (business, agriculture, manufacturing, and law), what you are being asked to do may be accepted as part of change. Solicit several opinions (and not just your family members). And when all is said and done, give it a try. Nothing is forever and every great journey starts with a single step—you might be in for a pleasant surprise.

Responsibility #2: Engage Yourself

Almost no one gets it right from the start. If you have ideas on improvement, not only speak up—take responsibility. Work with the project leader to supervise some part of it or assist in creating a monitoring tool or feedback loop. Every project has a number of tasks that need to be completed; volunteer to take responsibility for some part.

Engage others in finding ways to improve the process. Hospital-based processes are extremely complex and involve many stakeholders, entities, and professions. A number of pieces usually need attention. As the project progresses, be creative. Solve problems with open discussion and make improvements along the way. Focus on the end goal and suggest, implement, and monitor adjustments. Any sizable project will take time. Hospitalists and other physicians are used to seeing action and immediate reaction: Lasix relieves heart failure; nebulizers relieve shortness of breath. However, projects that really change organizations are long and arduous. They are multimonth and many times multiyear. This is quite a learning curve for many practitioners.

Responsibility #3: Do What you say

We certainly expect this of our leaders; we should expect it of ourselves as followers. It is difficult to lead a project when others on the team are late on deadlines or fail to show up. Volunteer to do only what you can. If you are overextended and don’t complete your part, the project can be crippled. Budget your time and energy to successfully meet expectations. If you get stuck on an assignment, ask for help. Delaying until the project is greatly behind can result in loss of your credibility and the whole project coming to a halt. Identify what you don’t know and identify ways to get the information you need. Many facilities and groups have a number of resources to assist you. They have members with experience expertise and other references available. SHM provides resources and online help at your fingertips.

Responsibility #4: stay the course

As mentioned above, the timelines on many projects take weeks and months. Don’t be discouraged if your progress is not as smooth as expected. Remember, you are remaking healthcare. Focus on your strategic priorities: Are they aligned with your patient care values? If you are off track, reanalyze. Look for the ways that the process is failing and revise the process. Maybe the wrong person is assigned to a task that is not to their strength. Review what you were trying to achieve. Maybe there is another path to get there. Follow directions and processes and support the design.

These are some ideas about the responsibilities of a follower. Keep in mind that others need you to follow just as you need them to lead. Performing as a good follower has some outcomes that help you. You can learn important successes with the right leader. The group’s goals can be accomplished more readily. If you can follow others and assist them in being successful with their goals, you can expect them to follow you in return. Have some faith in your leader; work at being a good follower and then you’ll be leading, too!

I would like to recognize the Petrous Group (www.petrous.net) for sharing their material for this column. TH

Dr. Gorman is the president of SHM.

He who has no faith in others shall find no faith in them.—Lao Tzu

We hear a lot about leading. There are best-selling books on the topic, courses in leading, articles on leading, and admonishments to lead. But is there an art to following? Many of us work on our leadership skills. We spend time trying to better understand those around us and their motivations and interests. We attempt to identify their strengths and engage them in projects that match their skills. We learn to give feedback in constructive ways so that others can improve. We try to understand the other’s perspective.

But when it’s our turn to follow, are we as diligent?

Regardless of our role at the hospital, within our group or in our medical community, we need to follow as well as lead. We may be a leader of our group, but a follower with the rest of the medical staff. We may lead some aspects of patient care, but follow on other aspects. How does our performance as a follower affect the group’s outcomes? Does it matter?

Some would say that there are four fundamental responsibilities of a follower.

Responsibility #1: Don’t act like a victim

As a project or program gets underway don’t be defensive or whine. Attempt to understand the rationale behind the project. Most leaders don’t wake up and invent things to keep people busy. They have a goal that usually addresses underperformance in some area. Operating room turnaround time may not seem important to you—discover why it matters to someone else. When a plan is presented, approach it with an open mind and suggest ways to improve the plan or its implementation. Even if the advantages of change are not apparent to you, give them a try before you make up your mind; you might discover that the new way is an improvement. Be straightforward with your concerns, but once the decision is made, play with the team.

We all knew families of brothers who seemed to fight among themselves. But if an outsider picked on one of them, the group banded together to defend each other. Make sure your team knows that they can count on you. Withdrawing from participation is certain to sabotage a project. Once your behaviors establish your reputation as a person who acts like a victim, you can be sure to be excluded from future projects or participation.

Worse than withdrawing is commiserating with others about your bad situation and demoralizing the group you are in. If you believe that the activity is unfair or dishonest, get outside opinions from other colleagues. Someone who is in another group or another field can be very helpful. In other disciplines (business, agriculture, manufacturing, and law), what you are being asked to do may be accepted as part of change. Solicit several opinions (and not just your family members). And when all is said and done, give it a try. Nothing is forever and every great journey starts with a single step—you might be in for a pleasant surprise.

Responsibility #2: Engage Yourself

Almost no one gets it right from the start. If you have ideas on improvement, not only speak up—take responsibility. Work with the project leader to supervise some part of it or assist in creating a monitoring tool or feedback loop. Every project has a number of tasks that need to be completed; volunteer to take responsibility for some part.

Engage others in finding ways to improve the process. Hospital-based processes are extremely complex and involve many stakeholders, entities, and professions. A number of pieces usually need attention. As the project progresses, be creative. Solve problems with open discussion and make improvements along the way. Focus on the end goal and suggest, implement, and monitor adjustments. Any sizable project will take time. Hospitalists and other physicians are used to seeing action and immediate reaction: Lasix relieves heart failure; nebulizers relieve shortness of breath. However, projects that really change organizations are long and arduous. They are multimonth and many times multiyear. This is quite a learning curve for many practitioners.

Responsibility #3: Do What you say

We certainly expect this of our leaders; we should expect it of ourselves as followers. It is difficult to lead a project when others on the team are late on deadlines or fail to show up. Volunteer to do only what you can. If you are overextended and don’t complete your part, the project can be crippled. Budget your time and energy to successfully meet expectations. If you get stuck on an assignment, ask for help. Delaying until the project is greatly behind can result in loss of your credibility and the whole project coming to a halt. Identify what you don’t know and identify ways to get the information you need. Many facilities and groups have a number of resources to assist you. They have members with experience expertise and other references available. SHM provides resources and online help at your fingertips.

Responsibility #4: stay the course

As mentioned above, the timelines on many projects take weeks and months. Don’t be discouraged if your progress is not as smooth as expected. Remember, you are remaking healthcare. Focus on your strategic priorities: Are they aligned with your patient care values? If you are off track, reanalyze. Look for the ways that the process is failing and revise the process. Maybe the wrong person is assigned to a task that is not to their strength. Review what you were trying to achieve. Maybe there is another path to get there. Follow directions and processes and support the design.

These are some ideas about the responsibilities of a follower. Keep in mind that others need you to follow just as you need them to lead. Performing as a good follower has some outcomes that help you. You can learn important successes with the right leader. The group’s goals can be accomplished more readily. If you can follow others and assist them in being successful with their goals, you can expect them to follow you in return. Have some faith in your leader; work at being a good follower and then you’ll be leading, too!

I would like to recognize the Petrous Group (www.petrous.net) for sharing their material for this column. TH

Dr. Gorman is the president of SHM.

Machines hum and alarms beep. Televisions squawk and telephones ring; overhead pagers blare out names. Equipment travels on squeaking, groaning carts, and people shout their conversations so they can be heard above the din.

Welcome to the hospital.

Noise has been a problem in hospitals at least since the 19th century, when Florence Nightingale described it as a “cruel absence of care.” In the nearly 150 years since she wrote that statement, the problem has only gotten worse, reflecting the increasing reliance on technology and an older and sicker patient population.

A Growing Problem

The average level of daytime hospital noise has risen from 57 decibels in 1960 to 72 decibels in 2005. Night-time noise increased from 42 to 60 decibels in the same time period. These levels are well above World Health Organization recommendations of no more than 40 decibels during the day and 30 to 35 decibels at night.

“It’s like being about 100 meters from a busy highway,” says Ilene Busch-Vishniac, PhD, professor of mechanical engineering at Johns Hopkins University (Baltimore) and a co-investigator in an ongoing study on hospital noise.

Despite the longstanding complaints of patients and hospital staff, little formal documentation of the problem existed until three years ago, when Stephanie L. Reel, vice president and chief information officer for Johns Hopkins Medicine learned from nurses that the noise level in the pediatric intensive care unit was a major source of complaints. To assess the problem she turned to two acoustical engineers: Busch-Vishniac, and James E. West, PhD, research professor in electrical and computer engineering.

Over the next year, they and their associates measured the noise at five wards on several floors in the hospital, including the PICU. The average sound levels in all five units ranged from 50 to 60 decibels, with the PICU being the loudest.

These findings reflect the pattern of a general rise in the sound level in hospitals worldwide, the investigators wrote (Busch-Vishniac IJ, West JE, Barnhill C, et al. Noise levels in Johns Hopkins Hospital. J Acoust Soc Am. 2005;118(6):3629-3645).

Since then, West and Busch-Vishniac have performed similar measurements in the emergency department and virtually all of the operating rooms at Johns Hopkins Hospital, with similar results. West recounts anecdotes of nurses retreating into the bathroom to have a quiet place to think, and taking patient records home so they can prepare them in peace.

Perhaps the biggest reason for concern is the potential impact on patient safety. “If instructions are misunderstood because of the high noise levels, it can lead to all sorts of safety problems,” adds West. “What’s most disturbing to me is that the noise level will continue to rise if something isn’t done about it.”

Sound Solutions:

Innovative Ways to Reduce Noise

Noise-abatement strategies need not be expensive or high-tech. “We asked, ‘what kinds of changes can we make without going through a lot of red tape?’” says Cmiel. Among the solutions that St. Mary’s came up with:

• Make people aware of the problem. Post signs reminding them to keep their voices down and close the doors to patients’ rooms;
• Hold training sessions on noise abatement for ancillary staff members including the cleaning crew.
• Put foam padding on the bottom of chart holders.
• Identify patients who don’t need nighttime care—and don’t disturb them.
• Replace paper towel rolls in or near patient rooms with quieter, folded-towel dispensers.
• Eliminate the use of overhead paging systems—at least during nighttime hours. Consider equipping doctors and nurses with tiny individual pagers that can be worn around the neck.*
• Lower the volume of telephone ringers and other equipment wherever possible.
• Gain the cooperation of other departments. The St. Mary’s team finally persuaded the surgical department to revise its schedule so it could stop ordering X-rays at 3 a.m.

At Montefiore Hospital in New York City, the Silent Hospitals Help Healing (SHHH) program is employing many of these techniques. Signs reading “SHHH” decorate the hallways, and patients, staff, and even visitors sport buttons showing a nurse holding a finger to her lips. Intercoms are turned down, and staff members are asked to keep their beepers on vibrate mode. Equipment is kept lubricated and in good repair to minimize squeaks and rattles.

It’s all paying off: Noise levels have decreased markedly since the program’s inception in March. Elodia Mercier, RN, the administrative nurse manager who developed the program, reports that patients tell her they are sleeping better, and the house staff finds the environment less stressful.—NM

For more information, contact Vocera Communications Inc. in Cupertino, Calif. (www.vocera.com).

None of this is a surprise to hospitalists. “I’ve discussed this with at least 30 employees in hospitals—especially nurses—and they all agree it’s a problem,” says Douglas Cutler, MD, regional medical director, Phoenix and Tucson, for IPC The Hospitalist Company.

Indeed, Dr. Cutler could hardly be heard during a telephone interview. In the background phones rang, announcements blared, and people talked and laughed loudly. He was calling from the nurses’ station, an area he estimated at about five feet square and which contained—at that moment—at least seven people.

“I think it’s a terrible problem, but so far it’s been pretty much ignored,” says Burke Kealey, MD, chief of professional services for hospital medicine at Regions Hospital in St. Paul, Minn.

Regions is now building a new hospital (see The Hospitalist March 2006, p. 30), and Dr. Kealey has raised the issue in design sessions, so far with little success. Money is tight, and noise-reducing materials and designs are seen as expendable. “It’s way down on the list of priorities,” he notes.

Worst Offenders

In the Johns Hopkins study, the air-conditioning and overhead paging systems were among the biggest culprits. Human speech was also at the top of the list.

Lakshmi Halasyamani, MD, chair of the Hospital Quality and Patient Safety Committee for SHM, recalls one instance in which she and a resident couldn’t talk to a patient because of a loud conversation about another patient that occurred in the hallway just outside the room. In fact, the incident made her take a new look at patient privacy and confidentiality issues. She now makes a point of including patients in all such conferences whenever possible.

These may be the worst offenders, but anything that hums, rattles, vibrates, squeaks, beeps, ticks, or otherwise makes itself heard contributes to the general racket. Even something as innocuous as placing a chart in its holder can be disruptive, says Cheryl Ann Cmiel, BAN, RN, a staff nurse on the surgical thoracic intermediate care nursing unit at St. Mary’s Hospital, a Mayo Clinic-affiliated hospital in Rochester, Minn.

Cmiel and another team member, Dawn Marie Gasser, ASN, RN, spent an informative—and sleepless—night in a patient room as part of a sleep-promotion study. She found a portable chest X-ray unit to be the biggest single problem, especially because the technician wheeled it in at 3:15 a.m. In general, the noise was loudest during shift changes (AJN. 2004;104(2):40-48).

Squeaky Wheels

Perhaps the best way to start a noise-reduction program is by asking patients what bothers them the most. “Staff members kind of filter out the noise, so we don’t hear it all the time,” Cmiel tells The Hospitalist.

The next step is to remain vigilant and use common sense. “As we move forward with team-based care, noise will become more of a problem,” says Dr. Halasyamani. At night, “we must remember that the patient’s goal is to sleep, unless they’re having an acute problem.”

Remind staff members to keep their voices down. On wards, keep all conversations patient-centered and include the patients in them whenever you can. If possible, designate certain areas away from patient rooms as areas for collegial staff chats.

Simply remembering to close a patient’s door can make a difference, adds Dr. Kealey. Whenever it’s appropriate, he also orders that a patient not have her vital signs checked or receive medication at night. If a patient requires particularly close watching or is at risk of wandering or falling, he recommends video monitors, centralized alarms that sound at the nurses’ station rather than the bedside, and low beds that minimize the risk of falls. He and his colleagues are also trying to emphasize to residents the importance of keeping the noise level down.

Administrators require data before they’ll consider major, system-wide changes, Dr. Cutler warns. Noise-reducing strategies that involve significant sums of money are viewed as a capital expense, “and [administrators] have to balance that against other capital expenses. If there was evidence that it affected patient outcomes, the trend would be for hospitals to improve [their efforts at noise control],” he explains.

Dr. Busch-Vishniac agrees that more research is needed. “That there aren’t more people working in this area is disturbing,” she observes. “We were really surprised at our findings. We thought it would be a quick fix and walk away.” TH

Norra MacReady is based in Southern California.

Machines hum and alarms beep. Televisions squawk and telephones ring; overhead pagers blare out names. Equipment travels on squeaking, groaning carts, and people shout their conversations so they can be heard above the din.

Welcome to the hospital.

Noise has been a problem in hospitals at least since the 19th century, when Florence Nightingale described it as a “cruel absence of care.” In the nearly 150 years since she wrote that statement, the problem has only gotten worse, reflecting the increasing reliance on technology and an older and sicker patient population.

A Growing Problem

The average level of daytime hospital noise has risen from 57 decibels in 1960 to 72 decibels in 2005. Night-time noise increased from 42 to 60 decibels in the same time period. These levels are well above World Health Organization recommendations of no more than 40 decibels during the day and 30 to 35 decibels at night.

“It’s like being about 100 meters from a busy highway,” says Ilene Busch-Vishniac, PhD, professor of mechanical engineering at Johns Hopkins University (Baltimore) and a co-investigator in an ongoing study on hospital noise.

Despite the longstanding complaints of patients and hospital staff, little formal documentation of the problem existed until three years ago, when Stephanie L. Reel, vice president and chief information officer for Johns Hopkins Medicine learned from nurses that the noise level in the pediatric intensive care unit was a major source of complaints. To assess the problem she turned to two acoustical engineers: Busch-Vishniac, and James E. West, PhD, research professor in electrical and computer engineering.

Over the next year, they and their associates measured the noise at five wards on several floors in the hospital, including the PICU. The average sound levels in all five units ranged from 50 to 60 decibels, with the PICU being the loudest.

These findings reflect the pattern of a general rise in the sound level in hospitals worldwide, the investigators wrote (Busch-Vishniac IJ, West JE, Barnhill C, et al. Noise levels in Johns Hopkins Hospital. J Acoust Soc Am. 2005;118(6):3629-3645).

Since then, West and Busch-Vishniac have performed similar measurements in the emergency department and virtually all of the operating rooms at Johns Hopkins Hospital, with similar results. West recounts anecdotes of nurses retreating into the bathroom to have a quiet place to think, and taking patient records home so they can prepare them in peace.

Perhaps the biggest reason for concern is the potential impact on patient safety. “If instructions are misunderstood because of the high noise levels, it can lead to all sorts of safety problems,” adds West. “What’s most disturbing to me is that the noise level will continue to rise if something isn’t done about it.”

Sound Solutions:

Innovative Ways to Reduce Noise

Noise-abatement strategies need not be expensive or high-tech. “We asked, ‘what kinds of changes can we make without going through a lot of red tape?’” says Cmiel. Among the solutions that St. Mary’s came up with:

• Make people aware of the problem. Post signs reminding them to keep their voices down and close the doors to patients’ rooms;
• Hold training sessions on noise abatement for ancillary staff members including the cleaning crew.
• Put foam padding on the bottom of chart holders.
• Identify patients who don’t need nighttime care—and don’t disturb them.
• Replace paper towel rolls in or near patient rooms with quieter, folded-towel dispensers.
• Eliminate the use of overhead paging systems—at least during nighttime hours. Consider equipping doctors and nurses with tiny individual pagers that can be worn around the neck.*
• Lower the volume of telephone ringers and other equipment wherever possible.
• Gain the cooperation of other departments. The St. Mary’s team finally persuaded the surgical department to revise its schedule so it could stop ordering X-rays at 3 a.m.

At Montefiore Hospital in New York City, the Silent Hospitals Help Healing (SHHH) program is employing many of these techniques. Signs reading “SHHH” decorate the hallways, and patients, staff, and even visitors sport buttons showing a nurse holding a finger to her lips. Intercoms are turned down, and staff members are asked to keep their beepers on vibrate mode. Equipment is kept lubricated and in good repair to minimize squeaks and rattles.

It’s all paying off: Noise levels have decreased markedly since the program’s inception in March. Elodia Mercier, RN, the administrative nurse manager who developed the program, reports that patients tell her they are sleeping better, and the house staff finds the environment less stressful.—NM

For more information, contact Vocera Communications Inc. in Cupertino, Calif. (www.vocera.com).

None of this is a surprise to hospitalists. “I’ve discussed this with at least 30 employees in hospitals—especially nurses—and they all agree it’s a problem,” says Douglas Cutler, MD, regional medical director, Phoenix and Tucson, for IPC The Hospitalist Company.

Indeed, Dr. Cutler could hardly be heard during a telephone interview. In the background phones rang, announcements blared, and people talked and laughed loudly. He was calling from the nurses’ station, an area he estimated at about five feet square and which contained—at that moment—at least seven people.

“I think it’s a terrible problem, but so far it’s been pretty much ignored,” says Burke Kealey, MD, chief of professional services for hospital medicine at Regions Hospital in St. Paul, Minn.

Regions is now building a new hospital (see The Hospitalist March 2006, p. 30), and Dr. Kealey has raised the issue in design sessions, so far with little success. Money is tight, and noise-reducing materials and designs are seen as expendable. “It’s way down on the list of priorities,” he notes.

Worst Offenders

In the Johns Hopkins study, the air-conditioning and overhead paging systems were among the biggest culprits. Human speech was also at the top of the list.

Lakshmi Halasyamani, MD, chair of the Hospital Quality and Patient Safety Committee for SHM, recalls one instance in which she and a resident couldn’t talk to a patient because of a loud conversation about another patient that occurred in the hallway just outside the room. In fact, the incident made her take a new look at patient privacy and confidentiality issues. She now makes a point of including patients in all such conferences whenever possible.

These may be the worst offenders, but anything that hums, rattles, vibrates, squeaks, beeps, ticks, or otherwise makes itself heard contributes to the general racket. Even something as innocuous as placing a chart in its holder can be disruptive, says Cheryl Ann Cmiel, BAN, RN, a staff nurse on the surgical thoracic intermediate care nursing unit at St. Mary’s Hospital, a Mayo Clinic-affiliated hospital in Rochester, Minn.

Cmiel and another team member, Dawn Marie Gasser, ASN, RN, spent an informative—and sleepless—night in a patient room as part of a sleep-promotion study. She found a portable chest X-ray unit to be the biggest single problem, especially because the technician wheeled it in at 3:15 a.m. In general, the noise was loudest during shift changes (AJN. 2004;104(2):40-48).

Squeaky Wheels

Perhaps the best way to start a noise-reduction program is by asking patients what bothers them the most. “Staff members kind of filter out the noise, so we don’t hear it all the time,” Cmiel tells The Hospitalist.

The next step is to remain vigilant and use common sense. “As we move forward with team-based care, noise will become more of a problem,” says Dr. Halasyamani. At night, “we must remember that the patient’s goal is to sleep, unless they’re having an acute problem.”

Remind staff members to keep their voices down. On wards, keep all conversations patient-centered and include the patients in them whenever you can. If possible, designate certain areas away from patient rooms as areas for collegial staff chats.

Simply remembering to close a patient’s door can make a difference, adds Dr. Kealey. Whenever it’s appropriate, he also orders that a patient not have her vital signs checked or receive medication at night. If a patient requires particularly close watching or is at risk of wandering or falling, he recommends video monitors, centralized alarms that sound at the nurses’ station rather than the bedside, and low beds that minimize the risk of falls. He and his colleagues are also trying to emphasize to residents the importance of keeping the noise level down.

Administrators require data before they’ll consider major, system-wide changes, Dr. Cutler warns. Noise-reducing strategies that involve significant sums of money are viewed as a capital expense, “and [administrators] have to balance that against other capital expenses. If there was evidence that it affected patient outcomes, the trend would be for hospitals to improve [their efforts at noise control],” he explains.

Dr. Busch-Vishniac agrees that more research is needed. “That there aren’t more people working in this area is disturbing,” she observes. “We were really surprised at our findings. We thought it would be a quick fix and walk away.” TH

Norra MacReady is based in Southern California.

Machines hum and alarms beep. Televisions squawk and telephones ring; overhead pagers blare out names. Equipment travels on squeaking, groaning carts, and people shout their conversations so they can be heard above the din.

Welcome to the hospital.

Noise has been a problem in hospitals at least since the 19th century, when Florence Nightingale described it as a “cruel absence of care.” In the nearly 150 years since she wrote that statement, the problem has only gotten worse, reflecting the increasing reliance on technology and an older and sicker patient population.

A Growing Problem

The average level of daytime hospital noise has risen from 57 decibels in 1960 to 72 decibels in 2005. Night-time noise increased from 42 to 60 decibels in the same time period. These levels are well above World Health Organization recommendations of no more than 40 decibels during the day and 30 to 35 decibels at night.

“It’s like being about 100 meters from a busy highway,” says Ilene Busch-Vishniac, PhD, professor of mechanical engineering at Johns Hopkins University (Baltimore) and a co-investigator in an ongoing study on hospital noise.

Despite the longstanding complaints of patients and hospital staff, little formal documentation of the problem existed until three years ago, when Stephanie L. Reel, vice president and chief information officer for Johns Hopkins Medicine learned from nurses that the noise level in the pediatric intensive care unit was a major source of complaints. To assess the problem she turned to two acoustical engineers: Busch-Vishniac, and James E. West, PhD, research professor in electrical and computer engineering.

Over the next year, they and their associates measured the noise at five wards on several floors in the hospital, including the PICU. The average sound levels in all five units ranged from 50 to 60 decibels, with the PICU being the loudest.

These findings reflect the pattern of a general rise in the sound level in hospitals worldwide, the investigators wrote (Busch-Vishniac IJ, West JE, Barnhill C, et al. Noise levels in Johns Hopkins Hospital. J Acoust Soc Am. 2005;118(6):3629-3645).

Since then, West and Busch-Vishniac have performed similar measurements in the emergency department and virtually all of the operating rooms at Johns Hopkins Hospital, with similar results. West recounts anecdotes of nurses retreating into the bathroom to have a quiet place to think, and taking patient records home so they can prepare them in peace.

Perhaps the biggest reason for concern is the potential impact on patient safety. “If instructions are misunderstood because of the high noise levels, it can lead to all sorts of safety problems,” adds West. “What’s most disturbing to me is that the noise level will continue to rise if something isn’t done about it.”

Sound Solutions:

Innovative Ways to Reduce Noise

Noise-abatement strategies need not be expensive or high-tech. “We asked, ‘what kinds of changes can we make without going through a lot of red tape?’” says Cmiel. Among the solutions that St. Mary’s came up with:

• Make people aware of the problem. Post signs reminding them to keep their voices down and close the doors to patients’ rooms;
• Hold training sessions on noise abatement for ancillary staff members including the cleaning crew.
• Put foam padding on the bottom of chart holders.
• Identify patients who don’t need nighttime care—and don’t disturb them.
• Replace paper towel rolls in or near patient rooms with quieter, folded-towel dispensers.
• Eliminate the use of overhead paging systems—at least during nighttime hours. Consider equipping doctors and nurses with tiny individual pagers that can be worn around the neck.*
• Lower the volume of telephone ringers and other equipment wherever possible.
• Gain the cooperation of other departments. The St. Mary’s team finally persuaded the surgical department to revise its schedule so it could stop ordering X-rays at 3 a.m.

At Montefiore Hospital in New York City, the Silent Hospitals Help Healing (SHHH) program is employing many of these techniques. Signs reading “SHHH” decorate the hallways, and patients, staff, and even visitors sport buttons showing a nurse holding a finger to her lips. Intercoms are turned down, and staff members are asked to keep their beepers on vibrate mode. Equipment is kept lubricated and in good repair to minimize squeaks and rattles.

It’s all paying off: Noise levels have decreased markedly since the program’s inception in March. Elodia Mercier, RN, the administrative nurse manager who developed the program, reports that patients tell her they are sleeping better, and the house staff finds the environment less stressful.—NM

For more information, contact Vocera Communications Inc. in Cupertino, Calif. (www.vocera.com).

None of this is a surprise to hospitalists. “I’ve discussed this with at least 30 employees in hospitals—especially nurses—and they all agree it’s a problem,” says Douglas Cutler, MD, regional medical director, Phoenix and Tucson, for IPC The Hospitalist Company.

Indeed, Dr. Cutler could hardly be heard during a telephone interview. In the background phones rang, announcements blared, and people talked and laughed loudly. He was calling from the nurses’ station, an area he estimated at about five feet square and which contained—at that moment—at least seven people.

“I think it’s a terrible problem, but so far it’s been pretty much ignored,” says Burke Kealey, MD, chief of professional services for hospital medicine at Regions Hospital in St. Paul, Minn.

Regions is now building a new hospital (see The Hospitalist March 2006, p. 30), and Dr. Kealey has raised the issue in design sessions, so far with little success. Money is tight, and noise-reducing materials and designs are seen as expendable. “It’s way down on the list of priorities,” he notes.

Worst Offenders

In the Johns Hopkins study, the air-conditioning and overhead paging systems were among the biggest culprits. Human speech was also at the top of the list.

Lakshmi Halasyamani, MD, chair of the Hospital Quality and Patient Safety Committee for SHM, recalls one instance in which she and a resident couldn’t talk to a patient because of a loud conversation about another patient that occurred in the hallway just outside the room. In fact, the incident made her take a new look at patient privacy and confidentiality issues. She now makes a point of including patients in all such conferences whenever possible.

These may be the worst offenders, but anything that hums, rattles, vibrates, squeaks, beeps, ticks, or otherwise makes itself heard contributes to the general racket. Even something as innocuous as placing a chart in its holder can be disruptive, says Cheryl Ann Cmiel, BAN, RN, a staff nurse on the surgical thoracic intermediate care nursing unit at St. Mary’s Hospital, a Mayo Clinic-affiliated hospital in Rochester, Minn.

Cmiel and another team member, Dawn Marie Gasser, ASN, RN, spent an informative—and sleepless—night in a patient room as part of a sleep-promotion study. She found a portable chest X-ray unit to be the biggest single problem, especially because the technician wheeled it in at 3:15 a.m. In general, the noise was loudest during shift changes (AJN. 2004;104(2):40-48).

Squeaky Wheels

Perhaps the best way to start a noise-reduction program is by asking patients what bothers them the most. “Staff members kind of filter out the noise, so we don’t hear it all the time,” Cmiel tells The Hospitalist.

The next step is to remain vigilant and use common sense. “As we move forward with team-based care, noise will become more of a problem,” says Dr. Halasyamani. At night, “we must remember that the patient’s goal is to sleep, unless they’re having an acute problem.”

Remind staff members to keep their voices down. On wards, keep all conversations patient-centered and include the patients in them whenever you can. If possible, designate certain areas away from patient rooms as areas for collegial staff chats.

Simply remembering to close a patient’s door can make a difference, adds Dr. Kealey. Whenever it’s appropriate, he also orders that a patient not have her vital signs checked or receive medication at night. If a patient requires particularly close watching or is at risk of wandering or falling, he recommends video monitors, centralized alarms that sound at the nurses’ station rather than the bedside, and low beds that minimize the risk of falls. He and his colleagues are also trying to emphasize to residents the importance of keeping the noise level down.

Administrators require data before they’ll consider major, system-wide changes, Dr. Cutler warns. Noise-reducing strategies that involve significant sums of money are viewed as a capital expense, “and [administrators] have to balance that against other capital expenses. If there was evidence that it affected patient outcomes, the trend would be for hospitals to improve [their efforts at noise control],” he explains.

Dr. Busch-Vishniac agrees that more research is needed. “That there aren’t more people working in this area is disturbing,” she observes. “We were really surprised at our findings. We thought it would be a quick fix and walk away.” TH

Norra MacReady is based in Southern California.

Q What CPT code should I use for marsupialization of Gartner’s duct cyst?

A If the cyst was excised, code 57135 (excision of vaginal cyst or tumor), is appropriate.

But if it was a marsupialization procedure in which the cyst was drained first and then the walls of the cyst were sewn in place to form a pouch, then the procedure should be coded using the unlisted code, 58999 (unlisted procedure, female genital system [nonobstetrical]).

The Gartner’s duct is usually located in the lateral wall of the vagina, so the code to report marsupialization of a Bartholin gland cyst, 56440, would not apply.

Be sure to let the payer know that the procedure is very similar to the 2 codes 56440 (Bartholin’s) and 57135 (excision). Code 56440 has 4.89 RVUs, while 57135 has 5.25 RVUs.

Ms. Witt, former program manager in the Department of Coding and Nomenclature at the American College of Obstetricians and Gynecologists, is an independent coding and documentation consultant. Reimbursement Adviser reflects the most commonly accepted interpretations of CPT-4 and ICD-9-CM coding. When in doubt on a coding or billing matter, check with your individual payer.

Q What CPT code should I use for marsupialization of Gartner’s duct cyst?

A If the cyst was excised, code 57135 (excision of vaginal cyst or tumor), is appropriate.

But if it was a marsupialization procedure in which the cyst was drained first and then the walls of the cyst were sewn in place to form a pouch, then the procedure should be coded using the unlisted code, 58999 (unlisted procedure, female genital system [nonobstetrical]).

The Gartner’s duct is usually located in the lateral wall of the vagina, so the code to report marsupialization of a Bartholin gland cyst, 56440, would not apply.

Be sure to let the payer know that the procedure is very similar to the 2 codes 56440 (Bartholin’s) and 57135 (excision). Code 56440 has 4.89 RVUs, while 57135 has 5.25 RVUs.

Ms. Witt, former program manager in the Department of Coding and Nomenclature at the American College of Obstetricians and Gynecologists, is an independent coding and documentation consultant. Reimbursement Adviser reflects the most commonly accepted interpretations of CPT-4 and ICD-9-CM coding. When in doubt on a coding or billing matter, check with your individual payer.

Q What CPT code should I use for marsupialization of Gartner’s duct cyst?

A If the cyst was excised, code 57135 (excision of vaginal cyst or tumor), is appropriate.

But if it was a marsupialization procedure in which the cyst was drained first and then the walls of the cyst were sewn in place to form a pouch, then the procedure should be coded using the unlisted code, 58999 (unlisted procedure, female genital system [nonobstetrical]).

The Gartner’s duct is usually located in the lateral wall of the vagina, so the code to report marsupialization of a Bartholin gland cyst, 56440, would not apply.

Be sure to let the payer know that the procedure is very similar to the 2 codes 56440 (Bartholin’s) and 57135 (excision). Code 56440 has 4.89 RVUs, while 57135 has 5.25 RVUs.

Ms. Witt, former program manager in the Department of Coding and Nomenclature at the American College of Obstetricians and Gynecologists, is an independent coding and documentation consultant. Reimbursement Adviser reflects the most commonly accepted interpretations of CPT-4 and ICD-9-CM coding. When in doubt on a coding or billing matter, check with your individual payer.