Editor’s note: It has been several years since the story you are about to read took place, but my experiences as a hospitalist have given me a new perspective to this bittersweet tale.

My wife and I never contemplated a future without her. She was a part of our new family. Aside from a few rough black spots that needed to be removed, she seemed in perfect shape. She had been at our wedding, and we had spent countless days sunning on the beach and taking long drives with her through the Texas Hill Country spotting wildflowers. The Hill Country is where she got her nickname. Everyone called her Bluebonnet; the name just seemed to fit her. She brought special meaning to the number 69. People who saw her would just stop and wave. We were proud to be seen with her.

I left the house one fateful morning and found her in the street, motionless. I did everything I could to get her to move. I was sure she was dead. I could not get her to turn over. I ran inside and called for help. It seemed like forever until I could get someone on the phone. It was not long until the emergency vehicle arrived. A few quick maneuvers were made to get her going, but the efforts seemed doomed to failure. My wife and I watched sadly as she was carried away. Driving behind those eerie flashing lights, not a word was spoken.

We spent forever in a cheerless waiting room with antiquated magazines and lukewarm bitter coffee. The television mounted high on the wall blared a moronic game show. Imagining the worst-case scenario was far scarier than knowing the truth. Finally, a young man came to talk to us. His uniform was splattered with stains, and he looked like he hadn’t slept in a few days. He bellowed our name across the waiting room. I guessed there would be no privacy here.

He said that Bluebonnet was not going anywhere soon. He mentioned something about giving fluids and checking levels, but we did not understand the terminology. He said a specimen of fluid looked milky and the differential seemed abnormal and a pressure measurement was high. Was this supposed to mean something to us? He talked so fast, and no matter whether you know the lingo or not, when it’s a loved one it’s hard to concentrate.

Another hour went by. I stared at the receptionist, but she would not let me catch her eye. Sometime later, another man came out to meet with us. He wore a clean uniform and looked less harried. He said he was a Specialist in this kind of problem. What kind of problem was unclear to me. He never told us his name.

He started with the good news. He told us that Bluebonnet was responding now, that her balance was good, though her joints were worn out and that she had no gross motor abnormalities. It could be a disk problem, but probably not. This all seemed like good news. But then came the kicker; he had heard something strange during his evaluation. It was an odd rumbling sound and the Specialist wanted another opinion. He wanted the Expert.

By now we had accepted the fact that we were not going anywhere. We had been absorbed into the system, a fixture in the waiting room. Another set of pale faces was now illuminated by the television screen, searching for information, hoping for good news, but not expecting it. The coffee was starting to seem not that bad.

When the Expert came out he was friendly and invited us to watch while he made his comprehensive evaluation. He seemed thorough and competent. He did not ask us any questions; perhaps his colleagues had filled him in. Bluebonnet was not going to be doing any talking, that was obvious. The Expert’s nonchalant demeanor evaporated as he pulled his hand out from beneath her, his finger covered in something black and tarry. He suggested more testing and hooked her up to an erratically beeping monitor. He told us that his evaluation might take a while, and perhaps we should leave. He would call us when he had a better picture of what was going on. We sadly trudged home.

When we returned the next day we met with the Expert again. He said he had found the problem. Bluebonnet needed her valve replaced. As best I could understand it, there were two problems: The valve would not open completely so flow was obstructed, and the valve would not close completely either. I put my head on my wife’s more stoic shoulder and began to cry. We were not ready to make this kind of decision; Bluebonnet seemed too old for a procedure this aggressive.

We reminisced about the good times and the bad. We considered the cost and risks. There was no guarantee that a valve replacement would do the trick. A time comes in existence when the good memories can outweigh common sense. In the end, however, I had them remove her from the monitors. I drove her home, not knowing what to expect.

The next month was fairly quiet. I made sure she was turned over as much as possible. There were no problems, but she barely went out. It seemed like she was missing her usual spark. One warm Sunday, with much trepidation, I took her shopping. Half way to the mall she started to cough, then shook uncontrollably. I looked frantically around; what would I do if she died right in the street? I was in luck however, there was a small facility right on the corner and I nervously pulled into the entrance.

It was a small, private place. A few friends had gone there and were pleased with the results. It was run by an efficient young woman who immediately helped us. She ran the facility on her own—no big corporation telling her what to do and monitoring her bottom line. She listened to the whole story, and checked out Bluebonnet thoroughly. She patted Bluebonnet affectionately; you could tell she cared. She smiled as she told us that the new valve would last for years. It was not the valve at all, only bad gas.

We had several more years with her, and then she was gone. But we never forgot our time with our 1969 Cadillac convertible, Bluebonnet.

Rust in peace. TH

Jamie Newman, MD, FACP, is the physician editor of The Hospitalist, consultant, Hospital Internal Medicine, and assistant professor of internal medicine and medical history, Mayo Clinic College of Medicine, Rochester, Minn.

Editor’s note: It has been several years since the story you are about to read took place, but my experiences as a hospitalist have given me a new perspective to this bittersweet tale.

My wife and I never contemplated a future without her. She was a part of our new family. Aside from a few rough black spots that needed to be removed, she seemed in perfect shape. She had been at our wedding, and we had spent countless days sunning on the beach and taking long drives with her through the Texas Hill Country spotting wildflowers. The Hill Country is where she got her nickname. Everyone called her Bluebonnet; the name just seemed to fit her. She brought special meaning to the number 69. People who saw her would just stop and wave. We were proud to be seen with her.

I left the house one fateful morning and found her in the street, motionless. I did everything I could to get her to move. I was sure she was dead. I could not get her to turn over. I ran inside and called for help. It seemed like forever until I could get someone on the phone. It was not long until the emergency vehicle arrived. A few quick maneuvers were made to get her going, but the efforts seemed doomed to failure. My wife and I watched sadly as she was carried away. Driving behind those eerie flashing lights, not a word was spoken.

We spent forever in a cheerless waiting room with antiquated magazines and lukewarm bitter coffee. The television mounted high on the wall blared a moronic game show. Imagining the worst-case scenario was far scarier than knowing the truth. Finally, a young man came to talk to us. His uniform was splattered with stains, and he looked like he hadn’t slept in a few days. He bellowed our name across the waiting room. I guessed there would be no privacy here.

He said that Bluebonnet was not going anywhere soon. He mentioned something about giving fluids and checking levels, but we did not understand the terminology. He said a specimen of fluid looked milky and the differential seemed abnormal and a pressure measurement was high. Was this supposed to mean something to us? He talked so fast, and no matter whether you know the lingo or not, when it’s a loved one it’s hard to concentrate.

Another hour went by. I stared at the receptionist, but she would not let me catch her eye. Sometime later, another man came out to meet with us. He wore a clean uniform and looked less harried. He said he was a Specialist in this kind of problem. What kind of problem was unclear to me. He never told us his name.

He started with the good news. He told us that Bluebonnet was responding now, that her balance was good, though her joints were worn out and that she had no gross motor abnormalities. It could be a disk problem, but probably not. This all seemed like good news. But then came the kicker; he had heard something strange during his evaluation. It was an odd rumbling sound and the Specialist wanted another opinion. He wanted the Expert.

By now we had accepted the fact that we were not going anywhere. We had been absorbed into the system, a fixture in the waiting room. Another set of pale faces was now illuminated by the television screen, searching for information, hoping for good news, but not expecting it. The coffee was starting to seem not that bad.

When the Expert came out he was friendly and invited us to watch while he made his comprehensive evaluation. He seemed thorough and competent. He did not ask us any questions; perhaps his colleagues had filled him in. Bluebonnet was not going to be doing any talking, that was obvious. The Expert’s nonchalant demeanor evaporated as he pulled his hand out from beneath her, his finger covered in something black and tarry. He suggested more testing and hooked her up to an erratically beeping monitor. He told us that his evaluation might take a while, and perhaps we should leave. He would call us when he had a better picture of what was going on. We sadly trudged home.

When we returned the next day we met with the Expert again. He said he had found the problem. Bluebonnet needed her valve replaced. As best I could understand it, there were two problems: The valve would not open completely so flow was obstructed, and the valve would not close completely either. I put my head on my wife’s more stoic shoulder and began to cry. We were not ready to make this kind of decision; Bluebonnet seemed too old for a procedure this aggressive.

We reminisced about the good times and the bad. We considered the cost and risks. There was no guarantee that a valve replacement would do the trick. A time comes in existence when the good memories can outweigh common sense. In the end, however, I had them remove her from the monitors. I drove her home, not knowing what to expect.

The next month was fairly quiet. I made sure she was turned over as much as possible. There were no problems, but she barely went out. It seemed like she was missing her usual spark. One warm Sunday, with much trepidation, I took her shopping. Half way to the mall she started to cough, then shook uncontrollably. I looked frantically around; what would I do if she died right in the street? I was in luck however, there was a small facility right on the corner and I nervously pulled into the entrance.

It was a small, private place. A few friends had gone there and were pleased with the results. It was run by an efficient young woman who immediately helped us. She ran the facility on her own—no big corporation telling her what to do and monitoring her bottom line. She listened to the whole story, and checked out Bluebonnet thoroughly. She patted Bluebonnet affectionately; you could tell she cared. She smiled as she told us that the new valve would last for years. It was not the valve at all, only bad gas.

We had several more years with her, and then she was gone. But we never forgot our time with our 1969 Cadillac convertible, Bluebonnet.

Rust in peace. TH

Jamie Newman, MD, FACP, is the physician editor of The Hospitalist, consultant, Hospital Internal Medicine, and assistant professor of internal medicine and medical history, Mayo Clinic College of Medicine, Rochester, Minn.

Editor’s note: It has been several years since the story you are about to read took place, but my experiences as a hospitalist have given me a new perspective to this bittersweet tale.

My wife and I never contemplated a future without her. She was a part of our new family. Aside from a few rough black spots that needed to be removed, she seemed in perfect shape. She had been at our wedding, and we had spent countless days sunning on the beach and taking long drives with her through the Texas Hill Country spotting wildflowers. The Hill Country is where she got her nickname. Everyone called her Bluebonnet; the name just seemed to fit her. She brought special meaning to the number 69. People who saw her would just stop and wave. We were proud to be seen with her.

I left the house one fateful morning and found her in the street, motionless. I did everything I could to get her to move. I was sure she was dead. I could not get her to turn over. I ran inside and called for help. It seemed like forever until I could get someone on the phone. It was not long until the emergency vehicle arrived. A few quick maneuvers were made to get her going, but the efforts seemed doomed to failure. My wife and I watched sadly as she was carried away. Driving behind those eerie flashing lights, not a word was spoken.

We spent forever in a cheerless waiting room with antiquated magazines and lukewarm bitter coffee. The television mounted high on the wall blared a moronic game show. Imagining the worst-case scenario was far scarier than knowing the truth. Finally, a young man came to talk to us. His uniform was splattered with stains, and he looked like he hadn’t slept in a few days. He bellowed our name across the waiting room. I guessed there would be no privacy here.

He said that Bluebonnet was not going anywhere soon. He mentioned something about giving fluids and checking levels, but we did not understand the terminology. He said a specimen of fluid looked milky and the differential seemed abnormal and a pressure measurement was high. Was this supposed to mean something to us? He talked so fast, and no matter whether you know the lingo or not, when it’s a loved one it’s hard to concentrate.

Another hour went by. I stared at the receptionist, but she would not let me catch her eye. Sometime later, another man came out to meet with us. He wore a clean uniform and looked less harried. He said he was a Specialist in this kind of problem. What kind of problem was unclear to me. He never told us his name.

He started with the good news. He told us that Bluebonnet was responding now, that her balance was good, though her joints were worn out and that she had no gross motor abnormalities. It could be a disk problem, but probably not. This all seemed like good news. But then came the kicker; he had heard something strange during his evaluation. It was an odd rumbling sound and the Specialist wanted another opinion. He wanted the Expert.

By now we had accepted the fact that we were not going anywhere. We had been absorbed into the system, a fixture in the waiting room. Another set of pale faces was now illuminated by the television screen, searching for information, hoping for good news, but not expecting it. The coffee was starting to seem not that bad.

When the Expert came out he was friendly and invited us to watch while he made his comprehensive evaluation. He seemed thorough and competent. He did not ask us any questions; perhaps his colleagues had filled him in. Bluebonnet was not going to be doing any talking, that was obvious. The Expert’s nonchalant demeanor evaporated as he pulled his hand out from beneath her, his finger covered in something black and tarry. He suggested more testing and hooked her up to an erratically beeping monitor. He told us that his evaluation might take a while, and perhaps we should leave. He would call us when he had a better picture of what was going on. We sadly trudged home.

When we returned the next day we met with the Expert again. He said he had found the problem. Bluebonnet needed her valve replaced. As best I could understand it, there were two problems: The valve would not open completely so flow was obstructed, and the valve would not close completely either. I put my head on my wife’s more stoic shoulder and began to cry. We were not ready to make this kind of decision; Bluebonnet seemed too old for a procedure this aggressive.

We reminisced about the good times and the bad. We considered the cost and risks. There was no guarantee that a valve replacement would do the trick. A time comes in existence when the good memories can outweigh common sense. In the end, however, I had them remove her from the monitors. I drove her home, not knowing what to expect.

The next month was fairly quiet. I made sure she was turned over as much as possible. There were no problems, but she barely went out. It seemed like she was missing her usual spark. One warm Sunday, with much trepidation, I took her shopping. Half way to the mall she started to cough, then shook uncontrollably. I looked frantically around; what would I do if she died right in the street? I was in luck however, there was a small facility right on the corner and I nervously pulled into the entrance.

It was a small, private place. A few friends had gone there and were pleased with the results. It was run by an efficient young woman who immediately helped us. She ran the facility on her own—no big corporation telling her what to do and monitoring her bottom line. She listened to the whole story, and checked out Bluebonnet thoroughly. She patted Bluebonnet affectionately; you could tell she cared. She smiled as she told us that the new valve would last for years. It was not the valve at all, only bad gas.

We had several more years with her, and then she was gone. But we never forgot our time with our 1969 Cadillac convertible, Bluebonnet.

Rust in peace. TH

Jamie Newman, MD, FACP, is the physician editor of The Hospitalist, consultant, Hospital Internal Medicine, and assistant professor of internal medicine and medical history, Mayo Clinic College of Medicine, Rochester, Minn.

If a busy doctor is a happy doctor, then the hospitalists in the Methodist Medical Group at Methodist Hospital in Oak Ridge, Tenn., are ecstatic. Chris Frost, MD, the hospital medicine group’s chief hospitalist and medical director, has seen the group’s average daily census climb to 70, then 90, and now 100 patients. Fortunately, the group is growing, too, from nine full-time employees in late October 2005 to 12 before year-end, a projection for 15 by first quarter 2006, and several intensivists to help by March.

The hospital itself has grown as well: It’s in the midst of a $40 million renovation and expansion started in 2004. By August 2006, Methodist Medical will have 230 new private rooms, 12 beds in a new acute care unit, and an emergency department twice the size of its predecessor.

As a 24/7 hospitalist program, we help the medical community to be more profitable by enabling them to see more patients in the office and doing more procedures in the hospital. Better communication between physicians, patients, and their families benefits everyone and, we hope, will grow Methodist’s market share.

—Chris Frost, MD

How It Started

Methodist Medical Group has been shaped by Oak Ridge’s traditions and demographics. Nestled between the Great Smokey and Cumberland Mountains, Oak Ridge was one of three research and production sites for the Manhattan Project (an effort by the United States, in conjunction with Canada and the United Kingdom to develop nuclear weapons). At its height, Oak Ridge had 75,000 inhabitants. Now its population is 28,000, with a Medicare age group that comprises 42% more of its population than the average Tennessee city. It continues as a magnet for scientists, and its physicians—both office-based and hospitalists—form a close-knit community.

Above: Methodist Medical Group’s average daily census climbed from 70 to 100 patients. The group has grown, too, from nine full-time employees in late October 2005 to a projection for 15 by first quarter 2006, and several intensivists to help by March.

Given its dynamics and demographics, when Oak Ridge’s primary care physicians asked Methodist Hospital in 1993 for help in admitting their patients, the hospital responded affirmatively. Hospital President Jan McNally, BSN, MHA, recalls how things unfolded. “Dr. Richard Dew, a highly respected primary practice physician with a busy office, wanted to change his life. His son had died and he decided to close his office, but he wanted to stay in medicine in Oak Ridge. He agreed to practice inpatient medicine at Methodist,” she explains. “The beauty of it was that he was universally respected. Barriers to the program fell because the admitting doctors and the patients all knew him.”

When Dr. Dew retired in 2002, Anthony Garton, MD, who closed his solo practice to join Dr. Dew as Methodist’s second hospitalist, stayed on. Dr. Garton became a hospitalist because “office procedures just brought me to break even financially. Only the things I did that didn’t have office overhead, such as being medical director at a nursing home and doing physicals for Boeing, made sense financially.” Dr. Garton, who worked with a nephrology group for 13 years, made a smooth transition to a hospitalist career.

From the hospitalist program’s inception, Methodist turned to Team Health, Inc., of Knoxville, an outsourcer of medical personnel, for staffing. Team Health Vice President Kenneth Burns saw a natural fit; his firm already supplied Methodist’s emergency department physicians.

“We understood the problems faced by Methodist’s ED docs,” says Burns. “Patients got stuck there and couldn’t be admitted rapidly to inpatient floors.”

He identified the hospitalist’s necessary skills as an ability to cooperate with community physicians, and an interest in improving processes to boost care quality and decrease costs. Methodist’s hospitalists have been independent contractors since the program’s inception. They receive hourly wages plus incentives based on productivity and metrics negotiated with hospital administrators.

Team Health recently rethought the model as potential recruits balked. In 2006 Methodist’s hospitalists became employees, with health benefits and defined contribution plans. Hospitalist Helen Bidawid, MD, says being employees improves recruiting because many doctors—particularly those just out of residency—find getting loans, buying health insurance, and other business associated with independent contractor status troublesome.

Symbiosis

Above: Methodist Medical Group’s average daily census climbed from 70 to 100 patients. The group has grown, too, from nine full-time employees in late October 2005 to a projection for 15 by first quarter 2006, and several intensivists to help by March.

The relationship of Methodist’s hospitalist program to Oak Ridge’s community physicians has changed over the years. Early on the group hired a hospitalist Dr. Garton describes as “very bright, knew his medicine, and would wow them in academia, but he antagonized the local docs. He left after one year and that was good because our census got low.”

Tact wasn’t that hospitalist’s long suit, and the community doctors who were uncomfortable with him didn’t refer many patients to the hospitalists. With the odd man out, hiring new hospitalists such as Joel Perkerson, MD, put the program back on track.

Above: Methodist Medical Group’s average daily census climbed from 70 to 100 patients. The group has grown, too, from nine full-time employees in late October 2005 to a projection for 15 by first quarter 2006, and several intensivists to help by March.

Dr. Perkerson left an office practice he had been in for 12 years. “I was drowning in paperwork, and it was so frustrating,” he says. “I couldn’t get my homework done or help my son, who was struggling academically.”

Having been both an office- and a hospital-based physician in Oak Ridge, he says it’s too hectic to do both. Being a hospitalist is challenging enough.

“It’s like the movie ‘Field of Dreams.’ Build it, and they will come. Demand keeps growing for our services and we all work a lot of hours,” he says, crediting the increasing load both to Dr. Frost’s leadership, which has made the subspecialists comfortable with the hospitalists’ management of medically complex patients, and to ex-TennCare patients flooding the emergency department. (See “When Politics Collide with Healthcare,” p. 38.)

Under Dr. Frost’s direction (he took over as medical director in 2003 after being recruited as assistant medical director), the hospitalist program has thrived. Dr. Frost has built relationships with Oak Ridge’s subspecialists, particularly pulmonologists, hematologists, oncologists, gastroenterologists, and orthopedists. Typical of Dr. Frost’s leadership is his response to Oak Ridge’s only pulmonary group imploding from six physicians to two. The hospitalists now admit all the group’s patients and Dr. Frost worked with Team Health to recruit intensivists for those very ill patients.

“I’m very pleased with the growth of the hospitalist program,” says Dr. Frost. “We feel empowered that more and more primary care doctors and subspecialists are allowing us to admit and take an active role in managing their patients.”

Tackling one problem that has bedeviled other hospitalist programs, Jan McNally has added a mechanism to ensure cooperation from referring doctors. She expects referring subspecialists to come for consults ASAP when a hospitalist calls.

“We must have that commitment from specialists,” she says. “We have about 15 percent who are laggards, but we will impose disciplinary action if they don’t come when called.”

Dr. Frost favors specialists willing to turn their patients over to the hospitalists in order to improve care quality. He diligently writes care guidelines, focuses on core measures, has deepened discussion of end-of-life care issues, and built such strong esprit de corps that the hospitalists willingly work long and irregular schedules until more physicians arrive. Helen Bidawid, MD, who has been a Methodist hospitalist for about a year, enjoys the hospitalist group, doesn’t mind pitching in to support her colleagues, and says “we function very well together. We watch out for all of our patients, share our responsibilities, and ask each other for help.”

Dr. Bidawid, who was in a non-supportive hospitalist group before her current position, asked herself before she arrived at Methodist: “’Will I be nurtured here or thrown to the wolves?’ Fortunately, I found a very supportive environment.”

With the course set, Dr. Frost still has challenges ahead. There’s growing patient volume, more complex cases to co-manage, carve-outs such as cardiology, neurology, and stroke care, and TennCare disenrollees to contend with.

“Our goal is to add value to Methodist Medical Center,” he says. “As a 24/7 hospitalist program, we help the medical community to be more profitable by enabling them to see more patients in the office and doing more procedures in the hospital. Better communication between physicians, patients, and their families benefits everyone and, we hope, will grow Methodist’s market share.” TH

Marlene Piturro is based in New York.

Quality Counts

Above: Methodist Medical Group’s average daily census climbed from 70 to 100 patients. The group has grown, too, from nine full-time employees in late October 2005 to a projection for 15 by first quarter 2006, and several intensivists to help by March.

Above: Methodist Medical Group’s average daily census climbed from 70 to 100 patients. The group has grown, too, from nine full-time employees in late October 2005 to a projection for 15 by first quarter 2006, and several intensivists to help by March.

Methodist Medical ranks #1 in Tennessee on its compliance with Medicare core measures. Coletta Manning, RN, MHA, Methodist’s director of outcomes management, provided these data to show how they did it: (Table 1)

Manning cites this caveat in interpreting the data: When a patient is admitted and a diagnosis associated with a core measure is not made until the second day of hospitalization, the case isn’t considered in compliance. An example is abdominal pain that on further examination turns out to be caused by a myocardial infarction. If that were the case, the core measure of giving aspirin immediately would not be met because the diagnosis was not made within the first 24 hours of admission. “We get dinged sometimes,” says Manning.

Internally, the hospitalists measure their performance on compliance with the group’s own care design (critical pathway) utilization. Dr. Frost is pleased with the hospitalists’ growing acceptance of care designs and is working with Team Health on a sophisticated computer system to help the hospitalists use

If a busy doctor is a happy doctor, then the hospitalists in the Methodist Medical Group at Methodist Hospital in Oak Ridge, Tenn., are ecstatic. Chris Frost, MD, the hospital medicine group’s chief hospitalist and medical director, has seen the group’s average daily census climb to 70, then 90, and now 100 patients. Fortunately, the group is growing, too, from nine full-time employees in late October 2005 to 12 before year-end, a projection for 15 by first quarter 2006, and several intensivists to help by March.

The hospital itself has grown as well: It’s in the midst of a $40 million renovation and expansion started in 2004. By August 2006, Methodist Medical will have 230 new private rooms, 12 beds in a new acute care unit, and an emergency department twice the size of its predecessor.

As a 24/7 hospitalist program, we help the medical community to be more profitable by enabling them to see more patients in the office and doing more procedures in the hospital. Better communication between physicians, patients, and their families benefits everyone and, we hope, will grow Methodist’s market share.

—Chris Frost, MD

How It Started

Methodist Medical Group has been shaped by Oak Ridge’s traditions and demographics. Nestled between the Great Smokey and Cumberland Mountains, Oak Ridge was one of three research and production sites for the Manhattan Project (an effort by the United States, in conjunction with Canada and the United Kingdom to develop nuclear weapons). At its height, Oak Ridge had 75,000 inhabitants. Now its population is 28,000, with a Medicare age group that comprises 42% more of its population than the average Tennessee city. It continues as a magnet for scientists, and its physicians—both office-based and hospitalists—form a close-knit community.

Above: Methodist Medical Group’s average daily census climbed from 70 to 100 patients. The group has grown, too, from nine full-time employees in late October 2005 to a projection for 15 by first quarter 2006, and several intensivists to help by March.

Given its dynamics and demographics, when Oak Ridge’s primary care physicians asked Methodist Hospital in 1993 for help in admitting their patients, the hospital responded affirmatively. Hospital President Jan McNally, BSN, MHA, recalls how things unfolded. “Dr. Richard Dew, a highly respected primary practice physician with a busy office, wanted to change his life. His son had died and he decided to close his office, but he wanted to stay in medicine in Oak Ridge. He agreed to practice inpatient medicine at Methodist,” she explains. “The beauty of it was that he was universally respected. Barriers to the program fell because the admitting doctors and the patients all knew him.”

When Dr. Dew retired in 2002, Anthony Garton, MD, who closed his solo practice to join Dr. Dew as Methodist’s second hospitalist, stayed on. Dr. Garton became a hospitalist because “office procedures just brought me to break even financially. Only the things I did that didn’t have office overhead, such as being medical director at a nursing home and doing physicals for Boeing, made sense financially.” Dr. Garton, who worked with a nephrology group for 13 years, made a smooth transition to a hospitalist career.

From the hospitalist program’s inception, Methodist turned to Team Health, Inc., of Knoxville, an outsourcer of medical personnel, for staffing. Team Health Vice President Kenneth Burns saw a natural fit; his firm already supplied Methodist’s emergency department physicians.

“We understood the problems faced by Methodist’s ED docs,” says Burns. “Patients got stuck there and couldn’t be admitted rapidly to inpatient floors.”

He identified the hospitalist’s necessary skills as an ability to cooperate with community physicians, and an interest in improving processes to boost care quality and decrease costs. Methodist’s hospitalists have been independent contractors since the program’s inception. They receive hourly wages plus incentives based on productivity and metrics negotiated with hospital administrators.

Team Health recently rethought the model as potential recruits balked. In 2006 Methodist’s hospitalists became employees, with health benefits and defined contribution plans. Hospitalist Helen Bidawid, MD, says being employees improves recruiting because many doctors—particularly those just out of residency—find getting loans, buying health insurance, and other business associated with independent contractor status troublesome.

Symbiosis

Above: Methodist Medical Group’s average daily census climbed from 70 to 100 patients. The group has grown, too, from nine full-time employees in late October 2005 to a projection for 15 by first quarter 2006, and several intensivists to help by March.

The relationship of Methodist’s hospitalist program to Oak Ridge’s community physicians has changed over the years. Early on the group hired a hospitalist Dr. Garton describes as “very bright, knew his medicine, and would wow them in academia, but he antagonized the local docs. He left after one year and that was good because our census got low.”

Tact wasn’t that hospitalist’s long suit, and the community doctors who were uncomfortable with him didn’t refer many patients to the hospitalists. With the odd man out, hiring new hospitalists such as Joel Perkerson, MD, put the program back on track.

Above: Methodist Medical Group’s average daily census climbed from 70 to 100 patients. The group has grown, too, from nine full-time employees in late October 2005 to a projection for 15 by first quarter 2006, and several intensivists to help by March.

Dr. Perkerson left an office practice he had been in for 12 years. “I was drowning in paperwork, and it was so frustrating,” he says. “I couldn’t get my homework done or help my son, who was struggling academically.”

Having been both an office- and a hospital-based physician in Oak Ridge, he says it’s too hectic to do both. Being a hospitalist is challenging enough.

“It’s like the movie ‘Field of Dreams.’ Build it, and they will come. Demand keeps growing for our services and we all work a lot of hours,” he says, crediting the increasing load both to Dr. Frost’s leadership, which has made the subspecialists comfortable with the hospitalists’ management of medically complex patients, and to ex-TennCare patients flooding the emergency department. (See “When Politics Collide with Healthcare,” p. 38.)

Under Dr. Frost’s direction (he took over as medical director in 2003 after being recruited as assistant medical director), the hospitalist program has thrived. Dr. Frost has built relationships with Oak Ridge’s subspecialists, particularly pulmonologists, hematologists, oncologists, gastroenterologists, and orthopedists. Typical of Dr. Frost’s leadership is his response to Oak Ridge’s only pulmonary group imploding from six physicians to two. The hospitalists now admit all the group’s patients and Dr. Frost worked with Team Health to recruit intensivists for those very ill patients.

“I’m very pleased with the growth of the hospitalist program,” says Dr. Frost. “We feel empowered that more and more primary care doctors and subspecialists are allowing us to admit and take an active role in managing their patients.”

Tackling one problem that has bedeviled other hospitalist programs, Jan McNally has added a mechanism to ensure cooperation from referring doctors. She expects referring subspecialists to come for consults ASAP when a hospitalist calls.

“We must have that commitment from specialists,” she says. “We have about 15 percent who are laggards, but we will impose disciplinary action if they don’t come when called.”

Dr. Frost favors specialists willing to turn their patients over to the hospitalists in order to improve care quality. He diligently writes care guidelines, focuses on core measures, has deepened discussion of end-of-life care issues, and built such strong esprit de corps that the hospitalists willingly work long and irregular schedules until more physicians arrive. Helen Bidawid, MD, who has been a Methodist hospitalist for about a year, enjoys the hospitalist group, doesn’t mind pitching in to support her colleagues, and says “we function very well together. We watch out for all of our patients, share our responsibilities, and ask each other for help.”

Dr. Bidawid, who was in a non-supportive hospitalist group before her current position, asked herself before she arrived at Methodist: “’Will I be nurtured here or thrown to the wolves?’ Fortunately, I found a very supportive environment.”

With the course set, Dr. Frost still has challenges ahead. There’s growing patient volume, more complex cases to co-manage, carve-outs such as cardiology, neurology, and stroke care, and TennCare disenrollees to contend with.

“Our goal is to add value to Methodist Medical Center,” he says. “As a 24/7 hospitalist program, we help the medical community to be more profitable by enabling them to see more patients in the office and doing more procedures in the hospital. Better communication between physicians, patients, and their families benefits everyone and, we hope, will grow Methodist’s market share.” TH

Marlene Piturro is based in New York.

Quality Counts

Above: Methodist Medical Group’s average daily census climbed from 70 to 100 patients. The group has grown, too, from nine full-time employees in late October 2005 to a projection for 15 by first quarter 2006, and several intensivists to help by March.

Above: Methodist Medical Group’s average daily census climbed from 70 to 100 patients. The group has grown, too, from nine full-time employees in late October 2005 to a projection for 15 by first quarter 2006, and several intensivists to help by March.

Methodist Medical ranks #1 in Tennessee on its compliance with Medicare core measures. Coletta Manning, RN, MHA, Methodist’s director of outcomes management, provided these data to show how they did it: (Table 1)

Manning cites this caveat in interpreting the data: When a patient is admitted and a diagnosis associated with a core measure is not made until the second day of hospitalization, the case isn’t considered in compliance. An example is abdominal pain that on further examination turns out to be caused by a myocardial infarction. If that were the case, the core measure of giving aspirin immediately would not be met because the diagnosis was not made within the first 24 hours of admission. “We get dinged sometimes,” says Manning.

Internally, the hospitalists measure their performance on compliance with the group’s own care design (critical pathway) utilization. Dr. Frost is pleased with the hospitalists’ growing acceptance of care designs and is working with Team Health on a sophisticated computer system to help the hospitalists use

If a busy doctor is a happy doctor, then the hospitalists in the Methodist Medical Group at Methodist Hospital in Oak Ridge, Tenn., are ecstatic. Chris Frost, MD, the hospital medicine group’s chief hospitalist and medical director, has seen the group’s average daily census climb to 70, then 90, and now 100 patients. Fortunately, the group is growing, too, from nine full-time employees in late October 2005 to 12 before year-end, a projection for 15 by first quarter 2006, and several intensivists to help by March.

The hospital itself has grown as well: It’s in the midst of a $40 million renovation and expansion started in 2004. By August 2006, Methodist Medical will have 230 new private rooms, 12 beds in a new acute care unit, and an emergency department twice the size of its predecessor.

As a 24/7 hospitalist program, we help the medical community to be more profitable by enabling them to see more patients in the office and doing more procedures in the hospital. Better communication between physicians, patients, and their families benefits everyone and, we hope, will grow Methodist’s market share.

—Chris Frost, MD

How It Started

Methodist Medical Group has been shaped by Oak Ridge’s traditions and demographics. Nestled between the Great Smokey and Cumberland Mountains, Oak Ridge was one of three research and production sites for the Manhattan Project (an effort by the United States, in conjunction with Canada and the United Kingdom to develop nuclear weapons). At its height, Oak Ridge had 75,000 inhabitants. Now its population is 28,000, with a Medicare age group that comprises 42% more of its population than the average Tennessee city. It continues as a magnet for scientists, and its physicians—both office-based and hospitalists—form a close-knit community.

Above: Methodist Medical Group’s average daily census climbed from 70 to 100 patients. The group has grown, too, from nine full-time employees in late October 2005 to a projection for 15 by first quarter 2006, and several intensivists to help by March.

Given its dynamics and demographics, when Oak Ridge’s primary care physicians asked Methodist Hospital in 1993 for help in admitting their patients, the hospital responded affirmatively. Hospital President Jan McNally, BSN, MHA, recalls how things unfolded. “Dr. Richard Dew, a highly respected primary practice physician with a busy office, wanted to change his life. His son had died and he decided to close his office, but he wanted to stay in medicine in Oak Ridge. He agreed to practice inpatient medicine at Methodist,” she explains. “The beauty of it was that he was universally respected. Barriers to the program fell because the admitting doctors and the patients all knew him.”

When Dr. Dew retired in 2002, Anthony Garton, MD, who closed his solo practice to join Dr. Dew as Methodist’s second hospitalist, stayed on. Dr. Garton became a hospitalist because “office procedures just brought me to break even financially. Only the things I did that didn’t have office overhead, such as being medical director at a nursing home and doing physicals for Boeing, made sense financially.” Dr. Garton, who worked with a nephrology group for 13 years, made a smooth transition to a hospitalist career.

From the hospitalist program’s inception, Methodist turned to Team Health, Inc., of Knoxville, an outsourcer of medical personnel, for staffing. Team Health Vice President Kenneth Burns saw a natural fit; his firm already supplied Methodist’s emergency department physicians.

“We understood the problems faced by Methodist’s ED docs,” says Burns. “Patients got stuck there and couldn’t be admitted rapidly to inpatient floors.”

He identified the hospitalist’s necessary skills as an ability to cooperate with community physicians, and an interest in improving processes to boost care quality and decrease costs. Methodist’s hospitalists have been independent contractors since the program’s inception. They receive hourly wages plus incentives based on productivity and metrics negotiated with hospital administrators.

Team Health recently rethought the model as potential recruits balked. In 2006 Methodist’s hospitalists became employees, with health benefits and defined contribution plans. Hospitalist Helen Bidawid, MD, says being employees improves recruiting because many doctors—particularly those just out of residency—find getting loans, buying health insurance, and other business associated with independent contractor status troublesome.

Symbiosis

Above: Methodist Medical Group’s average daily census climbed from 70 to 100 patients. The group has grown, too, from nine full-time employees in late October 2005 to a projection for 15 by first quarter 2006, and several intensivists to help by March.

The relationship of Methodist’s hospitalist program to Oak Ridge’s community physicians has changed over the years. Early on the group hired a hospitalist Dr. Garton describes as “very bright, knew his medicine, and would wow them in academia, but he antagonized the local docs. He left after one year and that was good because our census got low.”

Tact wasn’t that hospitalist’s long suit, and the community doctors who were uncomfortable with him didn’t refer many patients to the hospitalists. With the odd man out, hiring new hospitalists such as Joel Perkerson, MD, put the program back on track.

Above: Methodist Medical Group’s average daily census climbed from 70 to 100 patients. The group has grown, too, from nine full-time employees in late October 2005 to a projection for 15 by first quarter 2006, and several intensivists to help by March.

Dr. Perkerson left an office practice he had been in for 12 years. “I was drowning in paperwork, and it was so frustrating,” he says. “I couldn’t get my homework done or help my son, who was struggling academically.”

Having been both an office- and a hospital-based physician in Oak Ridge, he says it’s too hectic to do both. Being a hospitalist is challenging enough.

“It’s like the movie ‘Field of Dreams.’ Build it, and they will come. Demand keeps growing for our services and we all work a lot of hours,” he says, crediting the increasing load both to Dr. Frost’s leadership, which has made the subspecialists comfortable with the hospitalists’ management of medically complex patients, and to ex-TennCare patients flooding the emergency department. (See “When Politics Collide with Healthcare,” p. 38.)

Under Dr. Frost’s direction (he took over as medical director in 2003 after being recruited as assistant medical director), the hospitalist program has thrived. Dr. Frost has built relationships with Oak Ridge’s subspecialists, particularly pulmonologists, hematologists, oncologists, gastroenterologists, and orthopedists. Typical of Dr. Frost’s leadership is his response to Oak Ridge’s only pulmonary group imploding from six physicians to two. The hospitalists now admit all the group’s patients and Dr. Frost worked with Team Health to recruit intensivists for those very ill patients.

“I’m very pleased with the growth of the hospitalist program,” says Dr. Frost. “We feel empowered that more and more primary care doctors and subspecialists are allowing us to admit and take an active role in managing their patients.”

Tackling one problem that has bedeviled other hospitalist programs, Jan McNally has added a mechanism to ensure cooperation from referring doctors. She expects referring subspecialists to come for consults ASAP when a hospitalist calls.

“We must have that commitment from specialists,” she says. “We have about 15 percent who are laggards, but we will impose disciplinary action if they don’t come when called.”

Dr. Frost favors specialists willing to turn their patients over to the hospitalists in order to improve care quality. He diligently writes care guidelines, focuses on core measures, has deepened discussion of end-of-life care issues, and built such strong esprit de corps that the hospitalists willingly work long and irregular schedules until more physicians arrive. Helen Bidawid, MD, who has been a Methodist hospitalist for about a year, enjoys the hospitalist group, doesn’t mind pitching in to support her colleagues, and says “we function very well together. We watch out for all of our patients, share our responsibilities, and ask each other for help.”

Dr. Bidawid, who was in a non-supportive hospitalist group before her current position, asked herself before she arrived at Methodist: “’Will I be nurtured here or thrown to the wolves?’ Fortunately, I found a very supportive environment.”

With the course set, Dr. Frost still has challenges ahead. There’s growing patient volume, more complex cases to co-manage, carve-outs such as cardiology, neurology, and stroke care, and TennCare disenrollees to contend with.

“Our goal is to add value to Methodist Medical Center,” he says. “As a 24/7 hospitalist program, we help the medical community to be more profitable by enabling them to see more patients in the office and doing more procedures in the hospital. Better communication between physicians, patients, and their families benefits everyone and, we hope, will grow Methodist’s market share.” TH

Marlene Piturro is based in New York.

Quality Counts

Above: Methodist Medical Group’s average daily census climbed from 70 to 100 patients. The group has grown, too, from nine full-time employees in late October 2005 to a projection for 15 by first quarter 2006, and several intensivists to help by March.

Above: Methodist Medical Group’s average daily census climbed from 70 to 100 patients. The group has grown, too, from nine full-time employees in late October 2005 to a projection for 15 by first quarter 2006, and several intensivists to help by March.

Methodist Medical ranks #1 in Tennessee on its compliance with Medicare core measures. Coletta Manning, RN, MHA, Methodist’s director of outcomes management, provided these data to show how they did it: (Table 1)

Manning cites this caveat in interpreting the data: When a patient is admitted and a diagnosis associated with a core measure is not made until the second day of hospitalization, the case isn’t considered in compliance. An example is abdominal pain that on further examination turns out to be caused by a myocardial infarction. If that were the case, the core measure of giving aspirin immediately would not be met because the diagnosis was not made within the first 24 hours of admission. “We get dinged sometimes,” says Manning.

Internally, the hospitalists measure their performance on compliance with the group’s own care design (critical pathway) utilization. Dr. Frost is pleased with the hospitalists’ growing acceptance of care designs and is working with Team Health on a sophisticated computer system to help the hospitalists use

What can you do with a quarter of a million dollars? In some places, that amount can buy a home that can shelter a family for decades. In other places, it is enough to pay annual malpractice insurance premiums for physicians practicing in high-risk specialties—with a little left over.

But if you wanted to use that money for an enduring healthcare project that would provide the most good for the most people, how would you do it? Hospitalists can look to the Agency for Healthcare Research and Quality (AHRQ) for stellar examples of well-invested dollars with excellent return.

AHRQ Funding

With a staff of approximately 300, the tiny AHRQ is the lead federal agency charged with improving the quality, safety, efficiency, and effectiveness of healthcare for all Americans. It creates a priority research agenda annually, and funds studies in areas where improvement is deemed most needed. These include patient safety, data development, pharmaceutical outcomes, and other areas described on its Web site (www.ahrq.gov/).

In 2005, AHRQ announced its Partnerships in Implementing Patient Safety (PIPS) and committed up to $9 million in total costs to fund new grants of less than $300,000 per year, lasting two years. AHRQ indicated that eligible safe practice intervention projects would be required to include “tool kits,” and a comprehensive implementation tool kit to help others overcome barriers and allay adoption concerns. AHRQ’s goal was and is to disseminate funded projects’ perfected tools widely for adaptation and/or adoption by diverse healthcare settings.

AHRQ asked that principal investigators (PIs) be experienced senior level individuals familiar with implementing change in healthcare settings. Their expectation was that PIs would devote at least 15% of their time to the project for its duration. Thus the competitive challenge to potential PIs was great:

• Select a worthy project from among the endless areas where healthcare needs improvement, and then plan specific, realistic, achievable interventions that could create measurable improvement over two years;
• Implement the program; and
• Develop a plan and tools so basic and user-friendly that they could feasibly be applied in not just the local practice setting, but in other healthcare settings.

Although the size and duration of the awards varied, many of the 17 projects they funded received slightly more than a quarter of a million dollars. Among the funded projects, two boast hospitalists as their PIs and address areas of obvious concern in most healthcare settings. Greg Maynard, MD, MS, at the University of California, San Diego, was funded to implement a venous thromboembolism (VTE) intervention program. And Mark V. Williams, MD, FACP, professor of medicine, Emory University School of Medicine, Atlanta, and editor of the Journal of Hospital Medicine, was funded to implement a discharge bundle of patient safety interventions respectively.

Stalking the Silent Killer

Dr. Maynard’s project, “Optimal Prevention of Hospital Acquired Venous Thromboembolism,” focuses on eliminating preventable hospital-acquired VTE at an academic healthcare facility that has a large population of Hispanic patients.

The project’s timeliness and utility is clear: Although the exact incidence of VTE is unknown, experts estimate that approximately 260,000 are clinically recognized annually in acutely hospitalized patients.1 Pulmonary embolism (PE) resulting from deep vein thrombosis (DVT) is the most common cause of preventable hospital death, the majority of hospitalized patients with risk factors for DVT receive no prophylaxis, and the rate of fatal PE more than doubles between age 50 and 80.2,3 The problem is easily recognizable, but “Getting people to do what they need to do to prevent VTE can be hard,” says Dr. Maynard.

This project was carefully planned. It used a rigorous quality improvement process, involving all appropriate clinicians, nurses, managers, and technical support personnel.

Dr. Maynard and his team anticipated roadblocks and negotiated in advance to reduce their effects. They accepted that when patients are hospitalized, things frequently happen that cause physicians to stop VTE prophylaxis: A hemoglobin or platelet count may fall, the patient may have difficulty taking the drug, or the patient’s status may change abruptly. Or the prophylaxis might be accidentally discontinued—perhaps when a patient is transferred.

The team also looked at other institutions’ solutions. Then, using a basic understanding of the ways in which their process was missing VTE prophylaxis opportunities, they built interventions.

This team considered logistics carefully because it was clear that the only intervention that could decrease risk would have to be repetitive in nature. “The process we ultimately selected is very, very quick, yet valid,” says Dr. Maynard, while acknowledging that presenting any intervention repeatedly has the potential to interfere with care. “Other models require the physician to use math and add points. This one does not, and takes only seconds.”

Beginning April 19, 2006, the University of California, San Diego (UCSD) will introduce an intervention that presents a VTE risk assessment screen on every patient who is admitted. This process inquires about the need for prophylaxis every three days for the duration of hospitalization, and physicians cannot skip the screen. If risk factors are present and bleeding risk is not, the screen presents appropriate VTE options.

For example, the system will suggest enoxaparin 40 mg daily, enoxaparin 30 mg twice daily, or appropriately dosed warfarin for a high-risk orthopedic surgery patient who has no bleeding risk. Every three days, the process repeats itself, making explicit decisions or suggestions about appropriate prophylaxis. (Figure 1, below, shows a sample screen for a patient with moderately high risk.

Much evidence about VTE is still being gathered. For example, opinions vary about when to start prophylaxis or how long to continue it. Dr. Maynard and his team also addressed real versus relative contraindications—another area of debate among clinicians. Many clinicians are uncertain about how soon after surgery to restart VTE prophylaxis. After orthopedic spine surgery, for example, some might start it on day five, while others may not restart prophylaxis even after day 10. At UCSD, clinical stakeholders in the process came to consensus, and now all restart by day seven.

The tool kit UCSD is developing recognizes that every institution is unique. Those that choose to implement a similar program must identify their baseline rate of VTE and monitor change over time to determine if progress is being made. Every institution must define adequate VTE prophylaxis and tailor the tools appropriately.

click for large version

Wait? No Need

One compelling aspect of Dr. Maynard’s project is that some of UCSD’s VTE tools are already available on the SHM Web site in the “VTE Resource Room.” With or without AHRQ funding, UCSD planned to develop and implement a VTE awareness program. UCSD’s grant department provided the support Dr. Maynard and his colleagues needed to apply for the AHRQ funding, and Dr. Maynard says the funding they received helped UCSD “disseminate the program better and to carry it out with more rigor.”

UCSD worked with SHM to develop the tool kit. In return, SHM is providing and promoting the VTE tool kit at no charge to interested parties. Additionally, SHM recently received funding via an unrestricted sponsorship to create a mentored implementation project for the “VTE Resource Room.” Interested institutions will be mentored by UCSD staff who have experience with the tool kit.

Over time, Dr. Maynard will measure the effects of the intervention to ensure it is working. In addition to creating a malleable tool kit, UCSD research hospitalists will examine race, gender, and age to determine the effects of these on the likelihood of getting adequate prophylaxis.

Hospital Patient Safe-D(ischarge)

Dr. Williams and his colleagues at Emory University and the University of Ottawa received funding for “Hospital Patient Safe-D(ischarge): A Discharge Bundle for Patients,” a program that builds on previous AHRQ funding. This intervention implements a “discharge bundle” of patient safety interventions to improve patient transition from the hospital to home or another healthcare setting.

“We hope that every patient will undergo discharge, and of course the majority do, but the discharge process has almost been treated as an afterthought,” explains Dr. Williams. “Doctors spend a lot of time on diagnosis and treatment, but not on discharge. This process of transition from total care with a call button, lots of nursing attention, daily visits from the doctor, and delivered meals to greater independence, has not been well researched.”

What little research exists tends to indicate that discharge processes are very heterogeneous.

So far, Dr. Williams’ team’s examination of the process has produced only one surprise: The team has discovered that the discharge process is even more capricious than they suspected. As patients prepare to leave the hospital, what could and should be an orderly process that educates and prepares patients to assume responsibility for their own care in a new and better way is often interrupted or disjointed.

Preparing patients for discharge once fell to the nursing staff. As nursing faces staffing shortages and expanded roles, the discharge process often belongs to everyone and to no one. That physicians’ discharge visits pay much less than the time required to do it well also complicates the problem. The researchers were not surprised, however, to learn that many patients do not know their diagnosis or treatment plan as discharge is imminent. Their goal is to develop a consistent, comprehensive discharge process that will be a national model.

Here again, the precepts of continuous quality improvement are apparent. Dr. Williams’ team’s effort represents collaboration among physicians, pharmacists, nurses, and patients; involves SHM and several other professional organizations; and calls upon an advisory committee consisting of nationally recognized patient care and safety experts.

The discharge bundle of patient safety interventions—a concept advocated by the Joint Commission on Accreditation of Healthcare Organizations and other quality-promoting groups—adds a post-discharge continuity check to medication reconciliation and patient-centered education at discharge.

The four project phases—implement, evaluate, develop a tool, and disseminate the discharge bundle—overlap and ensure success.

Dr. Williams believes that the group of patients most likely to benefit from this intervention is the elderly. “The elderly bear the greatest burden of chronic disease and typically have several concurrent health problems,” he says.

Educating elders at the time of discharge should decrease the medication error rate and improve adherence to other treatments and recommended lifestyle changes. To gauge the appropriateness of the discharge bundle, John Banja, PhD, an expert in communication and safety, observes the discharge process directly. All communications must be patient-centered, and thus presented in a manner that patients will understand and appreciate. Banja relies on his background in patient safety and disability/rehabilitation to assess the discharge process.

Initial enrollment in this study seems successful. More than 50 patients have consented to participate, but Banja projects a need for 200 to complete the entire process. Recently, the team increased its planned maximum accrual to 300 to increase the statistical power of their findings. The participants like the program because most of them find discharge somewhat discomforting. Patients know they have knowledge gaps and appreciate clinicians’ efforts to fill those gaps seamlessly. A small investment of time can prevent problems after discharge.

Added Value

Clearly, the findings from these AHRQ-funded studies have the potential to reduce morbidity and mortality in a logarithmic manner as other institutions adapt these new tool kits. Dr. Williams indicates that recipients of PIPS funding receive more than just funding and the satisfaction of creating tools that will help all Americans.

“The AHRQ sponsors quarterly conference calls for all participants, regardless of their research topic, and an annual meeting in June to bring all investigators together,” he says.

The opportunity to learn how others address problems, plan interventions, and tackle hurdles proves invaluable. In addition, being privy to interim study results or learning how others handle research dilemmas helps hospitalists expand their skill sets.

Listening to Drs. Maynard and Williams is a not-so-subtle reminder that every hospital needs a well-structured quality improvement plan, and that hospitalists are essential in the plan’s success. Every hospitalist needs an understanding of the precepts these PIs used to earn this well-deserved funding: interdisciplinary and professional organization collaboration, good communication, realistic planning, managing change by measuring, and above all, sharing success. TH

Jeannette Yeznach Wick, RPh, MBA, FASCP, is a freelance medical writer based in Arlington, Va.

References

1. Anderson FA Jr, Wheeler HB, Goldberg RJ, et al. A population-based perspective of the hospital incidence and case-fatality rates of deep vein thrombosis and pulmonary embolism. The Worcester DVT Study. Arch Intern Med. 1991 May;151(5):933-938.
2. Clagett GP, Anderson FA Jr, Heit J, et al. Prevention of venous thromboembolism. Chest. 1995 Oct;108(4 Suppl):312S-334S.
3. Geerts WH, Heit JA, Clagett GP, et al. Prevention of venous thromboembolism. Chest. 2001;119(1 Suppl):132S-175S.

What can you do with a quarter of a million dollars? In some places, that amount can buy a home that can shelter a family for decades. In other places, it is enough to pay annual malpractice insurance premiums for physicians practicing in high-risk specialties—with a little left over.

But if you wanted to use that money for an enduring healthcare project that would provide the most good for the most people, how would you do it? Hospitalists can look to the Agency for Healthcare Research and Quality (AHRQ) for stellar examples of well-invested dollars with excellent return.

AHRQ Funding

With a staff of approximately 300, the tiny AHRQ is the lead federal agency charged with improving the quality, safety, efficiency, and effectiveness of healthcare for all Americans. It creates a priority research agenda annually, and funds studies in areas where improvement is deemed most needed. These include patient safety, data development, pharmaceutical outcomes, and other areas described on its Web site (www.ahrq.gov/).

In 2005, AHRQ announced its Partnerships in Implementing Patient Safety (PIPS) and committed up to $9 million in total costs to fund new grants of less than $300,000 per year, lasting two years. AHRQ indicated that eligible safe practice intervention projects would be required to include “tool kits,” and a comprehensive implementation tool kit to help others overcome barriers and allay adoption concerns. AHRQ’s goal was and is to disseminate funded projects’ perfected tools widely for adaptation and/or adoption by diverse healthcare settings.

AHRQ asked that principal investigators (PIs) be experienced senior level individuals familiar with implementing change in healthcare settings. Their expectation was that PIs would devote at least 15% of their time to the project for its duration. Thus the competitive challenge to potential PIs was great:

• Select a worthy project from among the endless areas where healthcare needs improvement, and then plan specific, realistic, achievable interventions that could create measurable improvement over two years;
• Implement the program; and
• Develop a plan and tools so basic and user-friendly that they could feasibly be applied in not just the local practice setting, but in other healthcare settings.

Although the size and duration of the awards varied, many of the 17 projects they funded received slightly more than a quarter of a million dollars. Among the funded projects, two boast hospitalists as their PIs and address areas of obvious concern in most healthcare settings. Greg Maynard, MD, MS, at the University of California, San Diego, was funded to implement a venous thromboembolism (VTE) intervention program. And Mark V. Williams, MD, FACP, professor of medicine, Emory University School of Medicine, Atlanta, and editor of the Journal of Hospital Medicine, was funded to implement a discharge bundle of patient safety interventions respectively.

Stalking the Silent Killer

Dr. Maynard’s project, “Optimal Prevention of Hospital Acquired Venous Thromboembolism,” focuses on eliminating preventable hospital-acquired VTE at an academic healthcare facility that has a large population of Hispanic patients.

The project’s timeliness and utility is clear: Although the exact incidence of VTE is unknown, experts estimate that approximately 260,000 are clinically recognized annually in acutely hospitalized patients.1 Pulmonary embolism (PE) resulting from deep vein thrombosis (DVT) is the most common cause of preventable hospital death, the majority of hospitalized patients with risk factors for DVT receive no prophylaxis, and the rate of fatal PE more than doubles between age 50 and 80.2,3 The problem is easily recognizable, but “Getting people to do what they need to do to prevent VTE can be hard,” says Dr. Maynard.

This project was carefully planned. It used a rigorous quality improvement process, involving all appropriate clinicians, nurses, managers, and technical support personnel.

Dr. Maynard and his team anticipated roadblocks and negotiated in advance to reduce their effects. They accepted that when patients are hospitalized, things frequently happen that cause physicians to stop VTE prophylaxis: A hemoglobin or platelet count may fall, the patient may have difficulty taking the drug, or the patient’s status may change abruptly. Or the prophylaxis might be accidentally discontinued—perhaps when a patient is transferred.

The team also looked at other institutions’ solutions. Then, using a basic understanding of the ways in which their process was missing VTE prophylaxis opportunities, they built interventions.

This team considered logistics carefully because it was clear that the only intervention that could decrease risk would have to be repetitive in nature. “The process we ultimately selected is very, very quick, yet valid,” says Dr. Maynard, while acknowledging that presenting any intervention repeatedly has the potential to interfere with care. “Other models require the physician to use math and add points. This one does not, and takes only seconds.”

Beginning April 19, 2006, the University of California, San Diego (UCSD) will introduce an intervention that presents a VTE risk assessment screen on every patient who is admitted. This process inquires about the need for prophylaxis every three days for the duration of hospitalization, and physicians cannot skip the screen. If risk factors are present and bleeding risk is not, the screen presents appropriate VTE options.

For example, the system will suggest enoxaparin 40 mg daily, enoxaparin 30 mg twice daily, or appropriately dosed warfarin for a high-risk orthopedic surgery patient who has no bleeding risk. Every three days, the process repeats itself, making explicit decisions or suggestions about appropriate prophylaxis. (Figure 1, below, shows a sample screen for a patient with moderately high risk.

Much evidence about VTE is still being gathered. For example, opinions vary about when to start prophylaxis or how long to continue it. Dr. Maynard and his team also addressed real versus relative contraindications—another area of debate among clinicians. Many clinicians are uncertain about how soon after surgery to restart VTE prophylaxis. After orthopedic spine surgery, for example, some might start it on day five, while others may not restart prophylaxis even after day 10. At UCSD, clinical stakeholders in the process came to consensus, and now all restart by day seven.

The tool kit UCSD is developing recognizes that every institution is unique. Those that choose to implement a similar program must identify their baseline rate of VTE and monitor change over time to determine if progress is being made. Every institution must define adequate VTE prophylaxis and tailor the tools appropriately.

click for large version

Wait? No Need

One compelling aspect of Dr. Maynard’s project is that some of UCSD’s VTE tools are already available on the SHM Web site in the “VTE Resource Room.” With or without AHRQ funding, UCSD planned to develop and implement a VTE awareness program. UCSD’s grant department provided the support Dr. Maynard and his colleagues needed to apply for the AHRQ funding, and Dr. Maynard says the funding they received helped UCSD “disseminate the program better and to carry it out with more rigor.”

UCSD worked with SHM to develop the tool kit. In return, SHM is providing and promoting the VTE tool kit at no charge to interested parties. Additionally, SHM recently received funding via an unrestricted sponsorship to create a mentored implementation project for the “VTE Resource Room.” Interested institutions will be mentored by UCSD staff who have experience with the tool kit.

Over time, Dr. Maynard will measure the effects of the intervention to ensure it is working. In addition to creating a malleable tool kit, UCSD research hospitalists will examine race, gender, and age to determine the effects of these on the likelihood of getting adequate prophylaxis.

Hospital Patient Safe-D(ischarge)

Dr. Williams and his colleagues at Emory University and the University of Ottawa received funding for “Hospital Patient Safe-D(ischarge): A Discharge Bundle for Patients,” a program that builds on previous AHRQ funding. This intervention implements a “discharge bundle” of patient safety interventions to improve patient transition from the hospital to home or another healthcare setting.

“We hope that every patient will undergo discharge, and of course the majority do, but the discharge process has almost been treated as an afterthought,” explains Dr. Williams. “Doctors spend a lot of time on diagnosis and treatment, but not on discharge. This process of transition from total care with a call button, lots of nursing attention, daily visits from the doctor, and delivered meals to greater independence, has not been well researched.”

What little research exists tends to indicate that discharge processes are very heterogeneous.

So far, Dr. Williams’ team’s examination of the process has produced only one surprise: The team has discovered that the discharge process is even more capricious than they suspected. As patients prepare to leave the hospital, what could and should be an orderly process that educates and prepares patients to assume responsibility for their own care in a new and better way is often interrupted or disjointed.

Preparing patients for discharge once fell to the nursing staff. As nursing faces staffing shortages and expanded roles, the discharge process often belongs to everyone and to no one. That physicians’ discharge visits pay much less than the time required to do it well also complicates the problem. The researchers were not surprised, however, to learn that many patients do not know their diagnosis or treatment plan as discharge is imminent. Their goal is to develop a consistent, comprehensive discharge process that will be a national model.

Here again, the precepts of continuous quality improvement are apparent. Dr. Williams’ team’s effort represents collaboration among physicians, pharmacists, nurses, and patients; involves SHM and several other professional organizations; and calls upon an advisory committee consisting of nationally recognized patient care and safety experts.

The discharge bundle of patient safety interventions—a concept advocated by the Joint Commission on Accreditation of Healthcare Organizations and other quality-promoting groups—adds a post-discharge continuity check to medication reconciliation and patient-centered education at discharge.

The four project phases—implement, evaluate, develop a tool, and disseminate the discharge bundle—overlap and ensure success.

Dr. Williams believes that the group of patients most likely to benefit from this intervention is the elderly. “The elderly bear the greatest burden of chronic disease and typically have several concurrent health problems,” he says.

Educating elders at the time of discharge should decrease the medication error rate and improve adherence to other treatments and recommended lifestyle changes. To gauge the appropriateness of the discharge bundle, John Banja, PhD, an expert in communication and safety, observes the discharge process directly. All communications must be patient-centered, and thus presented in a manner that patients will understand and appreciate. Banja relies on his background in patient safety and disability/rehabilitation to assess the discharge process.

Initial enrollment in this study seems successful. More than 50 patients have consented to participate, but Banja projects a need for 200 to complete the entire process. Recently, the team increased its planned maximum accrual to 300 to increase the statistical power of their findings. The participants like the program because most of them find discharge somewhat discomforting. Patients know they have knowledge gaps and appreciate clinicians’ efforts to fill those gaps seamlessly. A small investment of time can prevent problems after discharge.

Added Value

Clearly, the findings from these AHRQ-funded studies have the potential to reduce morbidity and mortality in a logarithmic manner as other institutions adapt these new tool kits. Dr. Williams indicates that recipients of PIPS funding receive more than just funding and the satisfaction of creating tools that will help all Americans.

“The AHRQ sponsors quarterly conference calls for all participants, regardless of their research topic, and an annual meeting in June to bring all investigators together,” he says.

The opportunity to learn how others address problems, plan interventions, and tackle hurdles proves invaluable. In addition, being privy to interim study results or learning how others handle research dilemmas helps hospitalists expand their skill sets.

Listening to Drs. Maynard and Williams is a not-so-subtle reminder that every hospital needs a well-structured quality improvement plan, and that hospitalists are essential in the plan’s success. Every hospitalist needs an understanding of the precepts these PIs used to earn this well-deserved funding: interdisciplinary and professional organization collaboration, good communication, realistic planning, managing change by measuring, and above all, sharing success. TH

Jeannette Yeznach Wick, RPh, MBA, FASCP, is a freelance medical writer based in Arlington, Va.

References

1. Anderson FA Jr, Wheeler HB, Goldberg RJ, et al. A population-based perspective of the hospital incidence and case-fatality rates of deep vein thrombosis and pulmonary embolism. The Worcester DVT Study. Arch Intern Med. 1991 May;151(5):933-938.
2. Clagett GP, Anderson FA Jr, Heit J, et al. Prevention of venous thromboembolism. Chest. 1995 Oct;108(4 Suppl):312S-334S.
3. Geerts WH, Heit JA, Clagett GP, et al. Prevention of venous thromboembolism. Chest. 2001;119(1 Suppl):132S-175S.

What can you do with a quarter of a million dollars? In some places, that amount can buy a home that can shelter a family for decades. In other places, it is enough to pay annual malpractice insurance premiums for physicians practicing in high-risk specialties—with a little left over.

But if you wanted to use that money for an enduring healthcare project that would provide the most good for the most people, how would you do it? Hospitalists can look to the Agency for Healthcare Research and Quality (AHRQ) for stellar examples of well-invested dollars with excellent return.

AHRQ Funding

With a staff of approximately 300, the tiny AHRQ is the lead federal agency charged with improving the quality, safety, efficiency, and effectiveness of healthcare for all Americans. It creates a priority research agenda annually, and funds studies in areas where improvement is deemed most needed. These include patient safety, data development, pharmaceutical outcomes, and other areas described on its Web site (www.ahrq.gov/).

In 2005, AHRQ announced its Partnerships in Implementing Patient Safety (PIPS) and committed up to $9 million in total costs to fund new grants of less than $300,000 per year, lasting two years. AHRQ indicated that eligible safe practice intervention projects would be required to include “tool kits,” and a comprehensive implementation tool kit to help others overcome barriers and allay adoption concerns. AHRQ’s goal was and is to disseminate funded projects’ perfected tools widely for adaptation and/or adoption by diverse healthcare settings.

AHRQ asked that principal investigators (PIs) be experienced senior level individuals familiar with implementing change in healthcare settings. Their expectation was that PIs would devote at least 15% of their time to the project for its duration. Thus the competitive challenge to potential PIs was great:

• Select a worthy project from among the endless areas where healthcare needs improvement, and then plan specific, realistic, achievable interventions that could create measurable improvement over two years;
• Implement the program; and
• Develop a plan and tools so basic and user-friendly that they could feasibly be applied in not just the local practice setting, but in other healthcare settings.

Although the size and duration of the awards varied, many of the 17 projects they funded received slightly more than a quarter of a million dollars. Among the funded projects, two boast hospitalists as their PIs and address areas of obvious concern in most healthcare settings. Greg Maynard, MD, MS, at the University of California, San Diego, was funded to implement a venous thromboembolism (VTE) intervention program. And Mark V. Williams, MD, FACP, professor of medicine, Emory University School of Medicine, Atlanta, and editor of the Journal of Hospital Medicine, was funded to implement a discharge bundle of patient safety interventions respectively.

Stalking the Silent Killer

Dr. Maynard’s project, “Optimal Prevention of Hospital Acquired Venous Thromboembolism,” focuses on eliminating preventable hospital-acquired VTE at an academic healthcare facility that has a large population of Hispanic patients.

The project’s timeliness and utility is clear: Although the exact incidence of VTE is unknown, experts estimate that approximately 260,000 are clinically recognized annually in acutely hospitalized patients.1 Pulmonary embolism (PE) resulting from deep vein thrombosis (DVT) is the most common cause of preventable hospital death, the majority of hospitalized patients with risk factors for DVT receive no prophylaxis, and the rate of fatal PE more than doubles between age 50 and 80.2,3 The problem is easily recognizable, but “Getting people to do what they need to do to prevent VTE can be hard,” says Dr. Maynard.

This project was carefully planned. It used a rigorous quality improvement process, involving all appropriate clinicians, nurses, managers, and technical support personnel.

Dr. Maynard and his team anticipated roadblocks and negotiated in advance to reduce their effects. They accepted that when patients are hospitalized, things frequently happen that cause physicians to stop VTE prophylaxis: A hemoglobin or platelet count may fall, the patient may have difficulty taking the drug, or the patient’s status may change abruptly. Or the prophylaxis might be accidentally discontinued—perhaps when a patient is transferred.

The team also looked at other institutions’ solutions. Then, using a basic understanding of the ways in which their process was missing VTE prophylaxis opportunities, they built interventions.

This team considered logistics carefully because it was clear that the only intervention that could decrease risk would have to be repetitive in nature. “The process we ultimately selected is very, very quick, yet valid,” says Dr. Maynard, while acknowledging that presenting any intervention repeatedly has the potential to interfere with care. “Other models require the physician to use math and add points. This one does not, and takes only seconds.”

Beginning April 19, 2006, the University of California, San Diego (UCSD) will introduce an intervention that presents a VTE risk assessment screen on every patient who is admitted. This process inquires about the need for prophylaxis every three days for the duration of hospitalization, and physicians cannot skip the screen. If risk factors are present and bleeding risk is not, the screen presents appropriate VTE options.

For example, the system will suggest enoxaparin 40 mg daily, enoxaparin 30 mg twice daily, or appropriately dosed warfarin for a high-risk orthopedic surgery patient who has no bleeding risk. Every three days, the process repeats itself, making explicit decisions or suggestions about appropriate prophylaxis. (Figure 1, below, shows a sample screen for a patient with moderately high risk.

Much evidence about VTE is still being gathered. For example, opinions vary about when to start prophylaxis or how long to continue it. Dr. Maynard and his team also addressed real versus relative contraindications—another area of debate among clinicians. Many clinicians are uncertain about how soon after surgery to restart VTE prophylaxis. After orthopedic spine surgery, for example, some might start it on day five, while others may not restart prophylaxis even after day 10. At UCSD, clinical stakeholders in the process came to consensus, and now all restart by day seven.

The tool kit UCSD is developing recognizes that every institution is unique. Those that choose to implement a similar program must identify their baseline rate of VTE and monitor change over time to determine if progress is being made. Every institution must define adequate VTE prophylaxis and tailor the tools appropriately.

click for large version

Wait? No Need

One compelling aspect of Dr. Maynard’s project is that some of UCSD’s VTE tools are already available on the SHM Web site in the “VTE Resource Room.” With or without AHRQ funding, UCSD planned to develop and implement a VTE awareness program. UCSD’s grant department provided the support Dr. Maynard and his colleagues needed to apply for the AHRQ funding, and Dr. Maynard says the funding they received helped UCSD “disseminate the program better and to carry it out with more rigor.”

UCSD worked with SHM to develop the tool kit. In return, SHM is providing and promoting the VTE tool kit at no charge to interested parties. Additionally, SHM recently received funding via an unrestricted sponsorship to create a mentored implementation project for the “VTE Resource Room.” Interested institutions will be mentored by UCSD staff who have experience with the tool kit.

Over time, Dr. Maynard will measure the effects of the intervention to ensure it is working. In addition to creating a malleable tool kit, UCSD research hospitalists will examine race, gender, and age to determine the effects of these on the likelihood of getting adequate prophylaxis.

Hospital Patient Safe-D(ischarge)

Dr. Williams and his colleagues at Emory University and the University of Ottawa received funding for “Hospital Patient Safe-D(ischarge): A Discharge Bundle for Patients,” a program that builds on previous AHRQ funding. This intervention implements a “discharge bundle” of patient safety interventions to improve patient transition from the hospital to home or another healthcare setting.

“We hope that every patient will undergo discharge, and of course the majority do, but the discharge process has almost been treated as an afterthought,” explains Dr. Williams. “Doctors spend a lot of time on diagnosis and treatment, but not on discharge. This process of transition from total care with a call button, lots of nursing attention, daily visits from the doctor, and delivered meals to greater independence, has not been well researched.”

What little research exists tends to indicate that discharge processes are very heterogeneous.

So far, Dr. Williams’ team’s examination of the process has produced only one surprise: The team has discovered that the discharge process is even more capricious than they suspected. As patients prepare to leave the hospital, what could and should be an orderly process that educates and prepares patients to assume responsibility for their own care in a new and better way is often interrupted or disjointed.

Preparing patients for discharge once fell to the nursing staff. As nursing faces staffing shortages and expanded roles, the discharge process often belongs to everyone and to no one. That physicians’ discharge visits pay much less than the time required to do it well also complicates the problem. The researchers were not surprised, however, to learn that many patients do not know their diagnosis or treatment plan as discharge is imminent. Their goal is to develop a consistent, comprehensive discharge process that will be a national model.

Here again, the precepts of continuous quality improvement are apparent. Dr. Williams’ team’s effort represents collaboration among physicians, pharmacists, nurses, and patients; involves SHM and several other professional organizations; and calls upon an advisory committee consisting of nationally recognized patient care and safety experts.

The discharge bundle of patient safety interventions—a concept advocated by the Joint Commission on Accreditation of Healthcare Organizations and other quality-promoting groups—adds a post-discharge continuity check to medication reconciliation and patient-centered education at discharge.

The four project phases—implement, evaluate, develop a tool, and disseminate the discharge bundle—overlap and ensure success.

Dr. Williams believes that the group of patients most likely to benefit from this intervention is the elderly. “The elderly bear the greatest burden of chronic disease and typically have several concurrent health problems,” he says.

Educating elders at the time of discharge should decrease the medication error rate and improve adherence to other treatments and recommended lifestyle changes. To gauge the appropriateness of the discharge bundle, John Banja, PhD, an expert in communication and safety, observes the discharge process directly. All communications must be patient-centered, and thus presented in a manner that patients will understand and appreciate. Banja relies on his background in patient safety and disability/rehabilitation to assess the discharge process.

Initial enrollment in this study seems successful. More than 50 patients have consented to participate, but Banja projects a need for 200 to complete the entire process. Recently, the team increased its planned maximum accrual to 300 to increase the statistical power of their findings. The participants like the program because most of them find discharge somewhat discomforting. Patients know they have knowledge gaps and appreciate clinicians’ efforts to fill those gaps seamlessly. A small investment of time can prevent problems after discharge.

Added Value

Clearly, the findings from these AHRQ-funded studies have the potential to reduce morbidity and mortality in a logarithmic manner as other institutions adapt these new tool kits. Dr. Williams indicates that recipients of PIPS funding receive more than just funding and the satisfaction of creating tools that will help all Americans.

“The AHRQ sponsors quarterly conference calls for all participants, regardless of their research topic, and an annual meeting in June to bring all investigators together,” he says.

The opportunity to learn how others address problems, plan interventions, and tackle hurdles proves invaluable. In addition, being privy to interim study results or learning how others handle research dilemmas helps hospitalists expand their skill sets.

Listening to Drs. Maynard and Williams is a not-so-subtle reminder that every hospital needs a well-structured quality improvement plan, and that hospitalists are essential in the plan’s success. Every hospitalist needs an understanding of the precepts these PIs used to earn this well-deserved funding: interdisciplinary and professional organization collaboration, good communication, realistic planning, managing change by measuring, and above all, sharing success. TH

Jeannette Yeznach Wick, RPh, MBA, FASCP, is a freelance medical writer based in Arlington, Va.

References

1. Anderson FA Jr, Wheeler HB, Goldberg RJ, et al. A population-based perspective of the hospital incidence and case-fatality rates of deep vein thrombosis and pulmonary embolism. The Worcester DVT Study. Arch Intern Med. 1991 May;151(5):933-938.
2. Clagett GP, Anderson FA Jr, Heit J, et al. Prevention of venous thromboembolism. Chest. 1995 Oct;108(4 Suppl):312S-334S.
3. Geerts WH, Heit JA, Clagett GP, et al. Prevention of venous thromboembolism. Chest. 2001;119(1 Suppl):132S-175S.

When an elderly person is admitted to the hospital, Adrienne Green, MD, sees an opportunity for something beyond addressing the medical issues at hand.

“One of the key issues that is important for practical, everyday care is trying to figure out how the elderly are not functioning well at home,” says Dr. Green, an associate clinical professor of medicine at the University of California at San Francisco and a member of UCSF’s hospitalist group. “I think we do a great job of managing their diseases, but what we don’t do very well is helping them out with other things [such as coping with] their losses and the fact that they may be just barely hanging on at home in terms of their ability to care for themselves; and this hospitalization may really have set them back.”

Eva Chittenden, MD, an assistant clinical professor of medicine, also at UCSF, agrees. “Many hospitalists are so focused on the hospital that they’re not thinking about the ‘before the hospital’ and the ‘after the hospital,’” she says.

But after identifying the challenges that elderly patients face, communication itself may be challenging. Elderly individuals struggle with issues of control and allowing people to tell them what they need to change in their lives may not be an easy task. What are the best ways to communicate with hospitalized elderly patients to facilitate the best “whole-person” care?

When you bring an older person who already has a heightened sensitivity toward losing control into the hospital—this complex, technological world of medicine—and they have the cumulative disadvantage of being sick, it’s important to remember that there will probably be no other state that they’ll be in … where they will feel so out of control.

—David Solie, MS, PA

Under the Radar Screen

The hospitalists interviewed for this article agreed that getting a broader picture of an elderly patient’s health and well-being involves discovering how they are really doing at home. Dr. Green asks simple questions, particularly about activities of daily living, such as whether they’re doing their own shopping and cooking. She also involves the family, “because very frequently the patient will say, ‘I’m doing fine,’ and the family member is in the background shaking their head.”

She also looks for clues about whether the patient needs more help at home, whether they are compliant with their medications, and if not, why (e.g., can they open their medicine bottles)?

“I frequently have the elderly patients evaluated for home care just to get someone into their house … ,” says Dr. Green. “I think that probably 80% of our patients who are over 80 who come into the hospital have things in their homes that are not safe, such as throw rugs.” Even if patients are basically doing OK, “if I can get some home care for them, I know we’ll uncover a ton [of things that can be improved],” she says. “These patients may have … kind of snuck under the radar screen of their families and their primary [care physician], and I think the hospitalization kind of opens that up in some ways.”

Facing Resistance

Even if issues are uncovered by means of interviews and home-health visits, however, many elderly patients present a particular communication challenge. This, says David Solie, MS, PA, author of How to Say It to Seniors: Closing the Communication Gap with Our Elders, is because of the difference in circumstances and current experiences between the elderly and their hospitalist providers.1 It is common knowledge that younger people go through stages of development, but the elderly do, too, says Solie, who is medical director and CEO of Second Opinion Insurance Services in Woodland Hills, Calif., a brokerage that specializes in the insurance needs of impaired-risk, elderly individuals.

The last human developmental stage compels elderly adults to work hard at maintaining control over their lives in the face of almost daily losses. A big part of the losses they experience involve their health and functioning, and the ways different patients cope with loss and the perceived stresses of healthcare have been analyzed and categorized.2-5

But in addition to loss of control, the elderly also face the daunting task of discovering what their legacy will be—what will live on after they die. “The way our elders communicate contains clues to the urgency they feel in trying to resolve these items on their agendas,” writes Solie. “In almost every conversation with older adults, control and legacy issues rise to the surface.”

A Matter of Loss

By the time a person is old (over 70) or old-old (over 85) their losses may have manifested in many areas: They’ve lost:

• Parents;
• Other relatives—perhaps including children;
• Friends;
• Places of residence (both homes and the familiarity of cities or towns);
• Possessions;
• Other relationships (sometimes other healthcare providers);
• Careers;
• Consultative authority (“ours is not a culture that values the wisdom of our elders,” writes Solie);
• Identity;
• Financial independence;
• Habits and pleasures;
• Physical space (the room at their son or daughter’s or in assisted living or the nursing home can’t compare to the homes, gardens, and expanses of view they may have had as younger people), and, of course; and
• Physical and mental capacities.

Sometimes the losses elders sustain occur in rapid-fire sequence, with little or no recovery time in between.1,6

It is no wonder that older adults, in one way or another, exhibit what we consider resistance to their changing lives. In terms of a hospitalization, this may mean saying “no” to medications, individual providers, tests, surgery, home-health visits, or something as small as being talked to or touched in what they perceive as a disturbing, overly familiar, or mechanized manner.

“Many patients are resistant to having people come into their homes and help them, and at the same time they are resistant to going to a skilled nursing care facility,” says Dr. Green, “and it has to do with their [feelings of the] loss of independence and control over their lives.”

“It’s very easy if you’re in medicine to normalize your context of the hospital,” says Solie. “In other words, the hospital seems familiar to you and you’re very comfortable moving around there, and mainly because you’re in control. You’re the doctor … and you move in the hospital in order to make things happen and you never feel all that threatened. But when you bring an older person who already has a heightened sensitivity toward losing control into the hospital—this complex, technological world of medicine—and they have the cumulative disadvantage of being sick,” says Solie, “it’s really important to remember that there will probably be no other state that they’ll be in, except maybe nursing home care, where they will feel so out of control.”

A good first step in communicating with older patients is to quickly develop a rapport with them and show them you recognize what they’re up against.7 “They really want to know whether or not I get it,” says Solie.

The way you communicate that you get it, he says, is fairly straightforward: When I’m first interacting with the patient, I say, “if you are like my [other] elderly patients … I’m sure you’re feeling a lot of anxiety over [not having much] control and, first of all, I want to assure you that I’m going to make sure you understand the choices and help you make all the decisions. And … I’m definitely going to … put everything in a language that you understand. But if I’m not successful, I’m going to employ someone from your family. We’re going to work together. Even though you’re hospitalized and even though you’re fighting this illness (or whatever the condition might be), you still [have] the right to make choices, and my goal is to partner with you. My expertise is medicine, but you have an expertise in your life.”

In other words, you are signaling that you recognize that control is the issue. Acknowledge the loss, ask about the value of the event or decision to the patient, ask what you can do to help them deal with their feelings or make up their minds. It also allows you to remind an older patient’s children that control is a big and normal concern for their mother or father.

Many people who are hospitalists—who are even in their late 20s, 30s, 40s—have been totally healthy their whole life, so it is hard to relate to what it’s like to be older and to be losing function, losing friends who are also dying, losing their house … it can be helpful for the hospitalist to take time and explore those issues [of loss and legacy].

—Eva Chittenden, MD

Hospitalists at a Different Time and Place

The elderly desperately need people who can serve them as natural healers, who are not constantly in a hurry, and who care what they are thinking and feeling. How can hospitalists relate to those who are in the midst of life review and who are hanging on to an escaping control? How can they serve their patients in a way that meets all needs?

Fighting—with denial or ignorance—the resistance that patients might put up will more than likely provoke them. A fight for control can undermine and sabotage the best intentions of the provider and the greatest wishes for the patient to experience comfort or regain health and well-being. Rather than justifying wresting control from elderly patients because it’s for their own good, advises Solie, what we must do instead is to “step back, hand them the control baton, and allow them to run with it.”1

A person’s admission to the hospital “might be such a huge crisis for them, whereas for us it’s our routine work,” says Dr. Chittenden, who practices as a hospitalist and also works on her institution’s inpatient palliative care service. “And many people who are hospitalists—who are even in their late 20s, 30s, 40s—have been totally healthy their whole life, so it is hard to relate to what it’s like to be older and to be losing function, losing friends who are also dying, losing their house … . I think that it can be very helpful for the hospitalist to take a little more time and explore some of those issues [of loss and legacy]. I try to meet the person where they’re at and try to understand what their goals, needs, ... and fears are [as well as] their functional status.”

Allowing older patients to engage with you about their lives and their pasts is a privilege for any healthcare provider. Engaging with them in a way that will help facilitate their loosening the reins on control may expedite and allow greater quality into their healthcare. It may provide an opening whereby you can order that home-health visit with less struggle.

Create Openings

“There are a lot of different ‘on-ramps’ to asking the life-review questions, which are extremely comforting,” says Solie. “For example, you might say, ‘Mary, I notice that you were born in Iowa. You know, my family on my father’s side came from Iowa. Where were you raised?’ And ‘Do you have a big family on your farm, because my aunt had cows.’”

Once you get a response that engages the patient, then you “are in the slipstream. Physicians have such a high experience curve, they see so many patients,” he says. “They don’t have to go very far into their inventory of experiences [to find one] that essentially matches up with that patient.”

Any kind of comment that will key you in to their background experience can help establish some kind of foundation for relationship. Another example: “You know, Mary, I was working with this woman who was about your age and she was raised in the Midwest and was dealing with some of these issues of congestive heart failure, and one of her big concerns was something that I didn’t appreciate until I understood what an impact it was having on her life.”

This kind of communication, says Solie, can help to relieve some of the patient’s control anxieties, “because she feels that if I ‘get it,’ she’s open to what I have to say, such as, ‘The first thing, we have to deal with is there is too much fluid going on in your body and it’s putting a big strain on your heart, so the first couple days all we did for that [other] woman was try to pull some fluid off and keep everything in balance.’”

You’ve communicated that you have a plan, that you can be trusted, and that you will help her to exercise as much control as possible. Creating and accessing those openings is also “the ideal way to weave the family into this whole life-review process, which is where the patient lives, psychologically and emotionally, when outside the hospital environment,” he says. “We become so myopic when we’re caught in the hospital environment that the world becomes a narrow tunnel and we forget the greater matrix outside that we’re all connected to.”

The Boon of Biology

Whereas the physiology and anatomy of humans deteriorate with time, some of the changes in mental processes in old age may actually enhance the ability to reflect and make informed judgments. Solie’s view is that what younger people may view as slow behavior, confusing speech patterns, and physical frailty don’t hinder the tasks that are before the elderly. On the contrary, they assist the fulfillment of their developmental agendas to feel in control when they’re losing control and to let go enough to reveal the legacy that will survive after they go.

Research on the aging brain indicates that changes in brain chemistry facilitate the life-review process.1,6 In general, reflection is the normal mode of existence for elderly adults and their primary focus. Thus, viewing them as diminished because they communicate differently than younger people do is doing them a disservice.

Those slowed mental processes, Dr. Chittenden concurs, “are conducive to reflection. Someone younger will pathologize it. … I agree that we don’t value the slowing down process, but I also think that when this population is in the hospital we are tending to look at loss of functional status or the quick mental traits that we value as opposed to [that which is] adaptive [and] that enables them to look at things differently and reflect.”

The key to connecting the dots of where they are and where they need to be (both medically and psychosocially), as well as how they occur to their providers and their families as opposed to how they occur to themselves, is to listen to and speak with them by making use of what you know about this stage of their life as it affects their communication. You can do this, says Solie, by invoking the “access code,” which is “to clearly understand that at the top of their agenda—no matter what else is happening—is the need for control and the need to develop and go after a legacy, and that means life review. If you know that, you will never lose your reference point with them.”

Communication Habits of the Elderly

Solie identifies some verbal behaviors that are common in older people. In many cases these behaviors may reveal something between the lines.

1. Lack of urgency. Older people need more time to decide things. Accept that slower pace as normal. Don’t take it personally. Adjust your schedule to allow time to deliver news or ask for choices and then allow time for them to discuss with their families or contemplate on their own; return to them at a later time. Become expert at spontaneous facilitation. Use your access code to get their attention and gain their trust.
2. Nonlinear conversations. Although older patients may appear to wander off topic, they may do so in the urge to ground themselves in what their priorities are, what their feelings are, what their choices will be. Signal you’re willing to listen and that you’re tuned in to the content, even if you don’t know where it is leading. (Obviously, someone who is demented or delirious presents a different scenario altogether, and depression is common and frequently overlooked.) Listen for patterns and themes. Nonlinear conversations can lead to spontaneous revelations and great insights for your patients and for yourself and can help patients revisit life dramas that test and clarify values. This, too, is a part of healthcare.
3. Repetition and attention to details. In situations when dementia is ruled out, a patient’s repetition may indicate a means to emphasize an important point or value. Keep in mind, too, that as we age, we all repeat stories to some degree. Details in stories may be the means by which older adults connect to their pasts and may also serve as clues to what is important to these people. Don’t assume details demand any action on your part. You are only being asked to listen as the older person sorts things out.
4. Uncoupling. Solie describes uncoupling as any time an older person appears to disconnect from you in the course of a conversation. For a professional, this can feel as if you are dismissed or ignored just when you think you’ve hit the mark with a comment or question. Go back and assess the information you’ve gathered by doing some verification. Rethink the objective: Any action that works against their maintaining control and discovering a legacy will produce uncoupling.

“I try to be aware of when I’m losing people,” says Dr. Chittenden of this phenomenon. “I would say, ‘I seem to be losing you and I’m wondering what you’re thinking right now.’ I would try to find out where they’re at and if it was something I said that didn’t gel with them, didn’t make sense to them, or wasn’t their priority.” This is something, she emphasizes, that a hospitalist needs to watch for with patients of all ages. “Whether you’re older or younger,” she says, the communication can be complicated because “you’re … in the hospital culture and the priorities of doctors are so often different from the priorities of patients.”

Conclusion

Older and especially old-old individuals in some ways live in an era other than the one traversed by the young and middle-aged.6 Their purposes, agendas, and mission are different and the slowing down of their functioning can facilitate their attempts to put their lives into perspective and manage what control they can still exercise or are still allowed. Viewing older patients with the utmost respect and acknowledging the challenges they face at these last phases of their lives can better help you to partner with them and their families in their care. TH

Andrea Sattinger also writes about the importance of apology in this issue.

References

1. Solie D. How to Say it to Seniors: Closing the Communication Gap with Our Elders. New York: Prentice Hall Press; 2004.
2. Chochinov HM, Cann BJ. Interventions to enhance the spiritual aspects of dying. J Palliat Med. 2005;8:Suppl 1:S103-115.
3. Dennis KE. Patients' control and the information imperative: clarification and confirmation. Nurs Res. 1990;39(3):162-166.
4. Kiesler DJ, Auerbach SM. Integrating measurement of control and affiliation in studies of physician-patient interaction: the interpersonal circumplex. Soc Sci Med. 2003;57(9):1707-1722.
5. Breemhaar B, Visser AP, Kleijnen JG. Perceptions and behaviour among elderly hospital patients: description and explanation of age differences in satisfaction, knowledge, emotions and behaviour. Soc Sci Med. 1990;31(12):1377-1385.
6. Pipher M. Another Country: Navigating the Emotional Terrain of Our Elders. New York: Riverhead Books; 1999.
7. Barnett PB. Rapport and the hospitalist. Am J Med. 2001;111:31S-35S.

When an elderly person is admitted to the hospital, Adrienne Green, MD, sees an opportunity for something beyond addressing the medical issues at hand.

“One of the key issues that is important for practical, everyday care is trying to figure out how the elderly are not functioning well at home,” says Dr. Green, an associate clinical professor of medicine at the University of California at San Francisco and a member of UCSF’s hospitalist group. “I think we do a great job of managing their diseases, but what we don’t do very well is helping them out with other things [such as coping with] their losses and the fact that they may be just barely hanging on at home in terms of their ability to care for themselves; and this hospitalization may really have set them back.”

Eva Chittenden, MD, an assistant clinical professor of medicine, also at UCSF, agrees. “Many hospitalists are so focused on the hospital that they’re not thinking about the ‘before the hospital’ and the ‘after the hospital,’” she says.

But after identifying the challenges that elderly patients face, communication itself may be challenging. Elderly individuals struggle with issues of control and allowing people to tell them what they need to change in their lives may not be an easy task. What are the best ways to communicate with hospitalized elderly patients to facilitate the best “whole-person” care?

When you bring an older person who already has a heightened sensitivity toward losing control into the hospital—this complex, technological world of medicine—and they have the cumulative disadvantage of being sick, it’s important to remember that there will probably be no other state that they’ll be in … where they will feel so out of control.

—David Solie, MS, PA

Under the Radar Screen

The hospitalists interviewed for this article agreed that getting a broader picture of an elderly patient’s health and well-being involves discovering how they are really doing at home. Dr. Green asks simple questions, particularly about activities of daily living, such as whether they’re doing their own shopping and cooking. She also involves the family, “because very frequently the patient will say, ‘I’m doing fine,’ and the family member is in the background shaking their head.”

She also looks for clues about whether the patient needs more help at home, whether they are compliant with their medications, and if not, why (e.g., can they open their medicine bottles)?

“I frequently have the elderly patients evaluated for home care just to get someone into their house … ,” says Dr. Green. “I think that probably 80% of our patients who are over 80 who come into the hospital have things in their homes that are not safe, such as throw rugs.” Even if patients are basically doing OK, “if I can get some home care for them, I know we’ll uncover a ton [of things that can be improved],” she says. “These patients may have … kind of snuck under the radar screen of their families and their primary [care physician], and I think the hospitalization kind of opens that up in some ways.”

Facing Resistance

Even if issues are uncovered by means of interviews and home-health visits, however, many elderly patients present a particular communication challenge. This, says David Solie, MS, PA, author of How to Say It to Seniors: Closing the Communication Gap with Our Elders, is because of the difference in circumstances and current experiences between the elderly and their hospitalist providers.1 It is common knowledge that younger people go through stages of development, but the elderly do, too, says Solie, who is medical director and CEO of Second Opinion Insurance Services in Woodland Hills, Calif., a brokerage that specializes in the insurance needs of impaired-risk, elderly individuals.

The last human developmental stage compels elderly adults to work hard at maintaining control over their lives in the face of almost daily losses. A big part of the losses they experience involve their health and functioning, and the ways different patients cope with loss and the perceived stresses of healthcare have been analyzed and categorized.2-5

But in addition to loss of control, the elderly also face the daunting task of discovering what their legacy will be—what will live on after they die. “The way our elders communicate contains clues to the urgency they feel in trying to resolve these items on their agendas,” writes Solie. “In almost every conversation with older adults, control and legacy issues rise to the surface.”

A Matter of Loss

By the time a person is old (over 70) or old-old (over 85) their losses may have manifested in many areas: They’ve lost:

• Parents;
• Other relatives—perhaps including children;
• Friends;
• Places of residence (both homes and the familiarity of cities or towns);
• Possessions;
• Other relationships (sometimes other healthcare providers);
• Careers;
• Consultative authority (“ours is not a culture that values the wisdom of our elders,” writes Solie);
• Identity;
• Financial independence;
• Habits and pleasures;
• Physical space (the room at their son or daughter’s or in assisted living or the nursing home can’t compare to the homes, gardens, and expanses of view they may have had as younger people), and, of course; and
• Physical and mental capacities.

Sometimes the losses elders sustain occur in rapid-fire sequence, with little or no recovery time in between.1,6

It is no wonder that older adults, in one way or another, exhibit what we consider resistance to their changing lives. In terms of a hospitalization, this may mean saying “no” to medications, individual providers, tests, surgery, home-health visits, or something as small as being talked to or touched in what they perceive as a disturbing, overly familiar, or mechanized manner.

“Many patients are resistant to having people come into their homes and help them, and at the same time they are resistant to going to a skilled nursing care facility,” says Dr. Green, “and it has to do with their [feelings of the] loss of independence and control over their lives.”

“It’s very easy if you’re in medicine to normalize your context of the hospital,” says Solie. “In other words, the hospital seems familiar to you and you’re very comfortable moving around there, and mainly because you’re in control. You’re the doctor … and you move in the hospital in order to make things happen and you never feel all that threatened. But when you bring an older person who already has a heightened sensitivity toward losing control into the hospital—this complex, technological world of medicine—and they have the cumulative disadvantage of being sick,” says Solie, “it’s really important to remember that there will probably be no other state that they’ll be in, except maybe nursing home care, where they will feel so out of control.”

A good first step in communicating with older patients is to quickly develop a rapport with them and show them you recognize what they’re up against.7 “They really want to know whether or not I get it,” says Solie.

The way you communicate that you get it, he says, is fairly straightforward: When I’m first interacting with the patient, I say, “if you are like my [other] elderly patients … I’m sure you’re feeling a lot of anxiety over [not having much] control and, first of all, I want to assure you that I’m going to make sure you understand the choices and help you make all the decisions. And … I’m definitely going to … put everything in a language that you understand. But if I’m not successful, I’m going to employ someone from your family. We’re going to work together. Even though you’re hospitalized and even though you’re fighting this illness (or whatever the condition might be), you still [have] the right to make choices, and my goal is to partner with you. My expertise is medicine, but you have an expertise in your life.”

In other words, you are signaling that you recognize that control is the issue. Acknowledge the loss, ask about the value of the event or decision to the patient, ask what you can do to help them deal with their feelings or make up their minds. It also allows you to remind an older patient’s children that control is a big and normal concern for their mother or father.

Many people who are hospitalists—who are even in their late 20s, 30s, 40s—have been totally healthy their whole life, so it is hard to relate to what it’s like to be older and to be losing function, losing friends who are also dying, losing their house … it can be helpful for the hospitalist to take time and explore those issues [of loss and legacy].

—Eva Chittenden, MD

Hospitalists at a Different Time and Place

The elderly desperately need people who can serve them as natural healers, who are not constantly in a hurry, and who care what they are thinking and feeling. How can hospitalists relate to those who are in the midst of life review and who are hanging on to an escaping control? How can they serve their patients in a way that meets all needs?

Fighting—with denial or ignorance—the resistance that patients might put up will more than likely provoke them. A fight for control can undermine and sabotage the best intentions of the provider and the greatest wishes for the patient to experience comfort or regain health and well-being. Rather than justifying wresting control from elderly patients because it’s for their own good, advises Solie, what we must do instead is to “step back, hand them the control baton, and allow them to run with it.”1

A person’s admission to the hospital “might be such a huge crisis for them, whereas for us it’s our routine work,” says Dr. Chittenden, who practices as a hospitalist and also works on her institution’s inpatient palliative care service. “And many people who are hospitalists—who are even in their late 20s, 30s, 40s—have been totally healthy their whole life, so it is hard to relate to what it’s like to be older and to be losing function, losing friends who are also dying, losing their house … . I think that it can be very helpful for the hospitalist to take a little more time and explore some of those issues [of loss and legacy]. I try to meet the person where they’re at and try to understand what their goals, needs, ... and fears are [as well as] their functional status.”

Allowing older patients to engage with you about their lives and their pasts is a privilege for any healthcare provider. Engaging with them in a way that will help facilitate their loosening the reins on control may expedite and allow greater quality into their healthcare. It may provide an opening whereby you can order that home-health visit with less struggle.

Create Openings

“There are a lot of different ‘on-ramps’ to asking the life-review questions, which are extremely comforting,” says Solie. “For example, you might say, ‘Mary, I notice that you were born in Iowa. You know, my family on my father’s side came from Iowa. Where were you raised?’ And ‘Do you have a big family on your farm, because my aunt had cows.’”

Once you get a response that engages the patient, then you “are in the slipstream. Physicians have such a high experience curve, they see so many patients,” he says. “They don’t have to go very far into their inventory of experiences [to find one] that essentially matches up with that patient.”

Any kind of comment that will key you in to their background experience can help establish some kind of foundation for relationship. Another example: “You know, Mary, I was working with this woman who was about your age and she was raised in the Midwest and was dealing with some of these issues of congestive heart failure, and one of her big concerns was something that I didn’t appreciate until I understood what an impact it was having on her life.”

This kind of communication, says Solie, can help to relieve some of the patient’s control anxieties, “because she feels that if I ‘get it,’ she’s open to what I have to say, such as, ‘The first thing, we have to deal with is there is too much fluid going on in your body and it’s putting a big strain on your heart, so the first couple days all we did for that [other] woman was try to pull some fluid off and keep everything in balance.’”

You’ve communicated that you have a plan, that you can be trusted, and that you will help her to exercise as much control as possible. Creating and accessing those openings is also “the ideal way to weave the family into this whole life-review process, which is where the patient lives, psychologically and emotionally, when outside the hospital environment,” he says. “We become so myopic when we’re caught in the hospital environment that the world becomes a narrow tunnel and we forget the greater matrix outside that we’re all connected to.”

The Boon of Biology

Whereas the physiology and anatomy of humans deteriorate with time, some of the changes in mental processes in old age may actually enhance the ability to reflect and make informed judgments. Solie’s view is that what younger people may view as slow behavior, confusing speech patterns, and physical frailty don’t hinder the tasks that are before the elderly. On the contrary, they assist the fulfillment of their developmental agendas to feel in control when they’re losing control and to let go enough to reveal the legacy that will survive after they go.

Research on the aging brain indicates that changes in brain chemistry facilitate the life-review process.1,6 In general, reflection is the normal mode of existence for elderly adults and their primary focus. Thus, viewing them as diminished because they communicate differently than younger people do is doing them a disservice.

Those slowed mental processes, Dr. Chittenden concurs, “are conducive to reflection. Someone younger will pathologize it. … I agree that we don’t value the slowing down process, but I also think that when this population is in the hospital we are tending to look at loss of functional status or the quick mental traits that we value as opposed to [that which is] adaptive [and] that enables them to look at things differently and reflect.”

The key to connecting the dots of where they are and where they need to be (both medically and psychosocially), as well as how they occur to their providers and their families as opposed to how they occur to themselves, is to listen to and speak with them by making use of what you know about this stage of their life as it affects their communication. You can do this, says Solie, by invoking the “access code,” which is “to clearly understand that at the top of their agenda—no matter what else is happening—is the need for control and the need to develop and go after a legacy, and that means life review. If you know that, you will never lose your reference point with them.”

Communication Habits of the Elderly

Solie identifies some verbal behaviors that are common in older people. In many cases these behaviors may reveal something between the lines.

1. Lack of urgency. Older people need more time to decide things. Accept that slower pace as normal. Don’t take it personally. Adjust your schedule to allow time to deliver news or ask for choices and then allow time for them to discuss with their families or contemplate on their own; return to them at a later time. Become expert at spontaneous facilitation. Use your access code to get their attention and gain their trust.
2. Nonlinear conversations. Although older patients may appear to wander off topic, they may do so in the urge to ground themselves in what their priorities are, what their feelings are, what their choices will be. Signal you’re willing to listen and that you’re tuned in to the content, even if you don’t know where it is leading. (Obviously, someone who is demented or delirious presents a different scenario altogether, and depression is common and frequently overlooked.) Listen for patterns and themes. Nonlinear conversations can lead to spontaneous revelations and great insights for your patients and for yourself and can help patients revisit life dramas that test and clarify values. This, too, is a part of healthcare.
3. Repetition and attention to details. In situations when dementia is ruled out, a patient’s repetition may indicate a means to emphasize an important point or value. Keep in mind, too, that as we age, we all repeat stories to some degree. Details in stories may be the means by which older adults connect to their pasts and may also serve as clues to what is important to these people. Don’t assume details demand any action on your part. You are only being asked to listen as the older person sorts things out.
4. Uncoupling. Solie describes uncoupling as any time an older person appears to disconnect from you in the course of a conversation. For a professional, this can feel as if you are dismissed or ignored just when you think you’ve hit the mark with a comment or question. Go back and assess the information you’ve gathered by doing some verification. Rethink the objective: Any action that works against their maintaining control and discovering a legacy will produce uncoupling.

“I try to be aware of when I’m losing people,” says Dr. Chittenden of this phenomenon. “I would say, ‘I seem to be losing you and I’m wondering what you’re thinking right now.’ I would try to find out where they’re at and if it was something I said that didn’t gel with them, didn’t make sense to them, or wasn’t their priority.” This is something, she emphasizes, that a hospitalist needs to watch for with patients of all ages. “Whether you’re older or younger,” she says, the communication can be complicated because “you’re … in the hospital culture and the priorities of doctors are so often different from the priorities of patients.”

Conclusion

Older and especially old-old individuals in some ways live in an era other than the one traversed by the young and middle-aged.6 Their purposes, agendas, and mission are different and the slowing down of their functioning can facilitate their attempts to put their lives into perspective and manage what control they can still exercise or are still allowed. Viewing older patients with the utmost respect and acknowledging the challenges they face at these last phases of their lives can better help you to partner with them and their families in their care. TH

Andrea Sattinger also writes about the importance of apology in this issue.

References

1. Solie D. How to Say it to Seniors: Closing the Communication Gap with Our Elders. New York: Prentice Hall Press; 2004.
2. Chochinov HM, Cann BJ. Interventions to enhance the spiritual aspects of dying. J Palliat Med. 2005;8:Suppl 1:S103-115.
3. Dennis KE. Patients' control and the information imperative: clarification and confirmation. Nurs Res. 1990;39(3):162-166.
4. Kiesler DJ, Auerbach SM. Integrating measurement of control and affiliation in studies of physician-patient interaction: the interpersonal circumplex. Soc Sci Med. 2003;57(9):1707-1722.
5. Breemhaar B, Visser AP, Kleijnen JG. Perceptions and behaviour among elderly hospital patients: description and explanation of age differences in satisfaction, knowledge, emotions and behaviour. Soc Sci Med. 1990;31(12):1377-1385.
6. Pipher M. Another Country: Navigating the Emotional Terrain of Our Elders. New York: Riverhead Books; 1999.
7. Barnett PB. Rapport and the hospitalist. Am J Med. 2001;111:31S-35S.

When an elderly person is admitted to the hospital, Adrienne Green, MD, sees an opportunity for something beyond addressing the medical issues at hand.

“One of the key issues that is important for practical, everyday care is trying to figure out how the elderly are not functioning well at home,” says Dr. Green, an associate clinical professor of medicine at the University of California at San Francisco and a member of UCSF’s hospitalist group. “I think we do a great job of managing their diseases, but what we don’t do very well is helping them out with other things [such as coping with] their losses and the fact that they may be just barely hanging on at home in terms of their ability to care for themselves; and this hospitalization may really have set them back.”

Eva Chittenden, MD, an assistant clinical professor of medicine, also at UCSF, agrees. “Many hospitalists are so focused on the hospital that they’re not thinking about the ‘before the hospital’ and the ‘after the hospital,’” she says.

But after identifying the challenges that elderly patients face, communication itself may be challenging. Elderly individuals struggle with issues of control and allowing people to tell them what they need to change in their lives may not be an easy task. What are the best ways to communicate with hospitalized elderly patients to facilitate the best “whole-person” care?

When you bring an older person who already has a heightened sensitivity toward losing control into the hospital—this complex, technological world of medicine—and they have the cumulative disadvantage of being sick, it’s important to remember that there will probably be no other state that they’ll be in … where they will feel so out of control.

—David Solie, MS, PA

Under the Radar Screen

The hospitalists interviewed for this article agreed that getting a broader picture of an elderly patient’s health and well-being involves discovering how they are really doing at home. Dr. Green asks simple questions, particularly about activities of daily living, such as whether they’re doing their own shopping and cooking. She also involves the family, “because very frequently the patient will say, ‘I’m doing fine,’ and the family member is in the background shaking their head.”

She also looks for clues about whether the patient needs more help at home, whether they are compliant with their medications, and if not, why (e.g., can they open their medicine bottles)?

“I frequently have the elderly patients evaluated for home care just to get someone into their house … ,” says Dr. Green. “I think that probably 80% of our patients who are over 80 who come into the hospital have things in their homes that are not safe, such as throw rugs.” Even if patients are basically doing OK, “if I can get some home care for them, I know we’ll uncover a ton [of things that can be improved],” she says. “These patients may have … kind of snuck under the radar screen of their families and their primary [care physician], and I think the hospitalization kind of opens that up in some ways.”

Facing Resistance

Even if issues are uncovered by means of interviews and home-health visits, however, many elderly patients present a particular communication challenge. This, says David Solie, MS, PA, author of How to Say It to Seniors: Closing the Communication Gap with Our Elders, is because of the difference in circumstances and current experiences between the elderly and their hospitalist providers.1 It is common knowledge that younger people go through stages of development, but the elderly do, too, says Solie, who is medical director and CEO of Second Opinion Insurance Services in Woodland Hills, Calif., a brokerage that specializes in the insurance needs of impaired-risk, elderly individuals.

The last human developmental stage compels elderly adults to work hard at maintaining control over their lives in the face of almost daily losses. A big part of the losses they experience involve their health and functioning, and the ways different patients cope with loss and the perceived stresses of healthcare have been analyzed and categorized.2-5

But in addition to loss of control, the elderly also face the daunting task of discovering what their legacy will be—what will live on after they die. “The way our elders communicate contains clues to the urgency they feel in trying to resolve these items on their agendas,” writes Solie. “In almost every conversation with older adults, control and legacy issues rise to the surface.”

A Matter of Loss

By the time a person is old (over 70) or old-old (over 85) their losses may have manifested in many areas: They’ve lost:

• Parents;
• Other relatives—perhaps including children;
• Friends;
• Places of residence (both homes and the familiarity of cities or towns);
• Possessions;
• Other relationships (sometimes other healthcare providers);
• Careers;
• Consultative authority (“ours is not a culture that values the wisdom of our elders,” writes Solie);
• Identity;
• Financial independence;
• Habits and pleasures;
• Physical space (the room at their son or daughter’s or in assisted living or the nursing home can’t compare to the homes, gardens, and expanses of view they may have had as younger people), and, of course; and
• Physical and mental capacities.

Sometimes the losses elders sustain occur in rapid-fire sequence, with little or no recovery time in between.1,6

It is no wonder that older adults, in one way or another, exhibit what we consider resistance to their changing lives. In terms of a hospitalization, this may mean saying “no” to medications, individual providers, tests, surgery, home-health visits, or something as small as being talked to or touched in what they perceive as a disturbing, overly familiar, or mechanized manner.

“Many patients are resistant to having people come into their homes and help them, and at the same time they are resistant to going to a skilled nursing care facility,” says Dr. Green, “and it has to do with their [feelings of the] loss of independence and control over their lives.”

“It’s very easy if you’re in medicine to normalize your context of the hospital,” says Solie. “In other words, the hospital seems familiar to you and you’re very comfortable moving around there, and mainly because you’re in control. You’re the doctor … and you move in the hospital in order to make things happen and you never feel all that threatened. But when you bring an older person who already has a heightened sensitivity toward losing control into the hospital—this complex, technological world of medicine—and they have the cumulative disadvantage of being sick,” says Solie, “it’s really important to remember that there will probably be no other state that they’ll be in, except maybe nursing home care, where they will feel so out of control.”

A good first step in communicating with older patients is to quickly develop a rapport with them and show them you recognize what they’re up against.7 “They really want to know whether or not I get it,” says Solie.

The way you communicate that you get it, he says, is fairly straightforward: When I’m first interacting with the patient, I say, “if you are like my [other] elderly patients … I’m sure you’re feeling a lot of anxiety over [not having much] control and, first of all, I want to assure you that I’m going to make sure you understand the choices and help you make all the decisions. And … I’m definitely going to … put everything in a language that you understand. But if I’m not successful, I’m going to employ someone from your family. We’re going to work together. Even though you’re hospitalized and even though you’re fighting this illness (or whatever the condition might be), you still [have] the right to make choices, and my goal is to partner with you. My expertise is medicine, but you have an expertise in your life.”

In other words, you are signaling that you recognize that control is the issue. Acknowledge the loss, ask about the value of the event or decision to the patient, ask what you can do to help them deal with their feelings or make up their minds. It also allows you to remind an older patient’s children that control is a big and normal concern for their mother or father.

Many people who are hospitalists—who are even in their late 20s, 30s, 40s—have been totally healthy their whole life, so it is hard to relate to what it’s like to be older and to be losing function, losing friends who are also dying, losing their house … it can be helpful for the hospitalist to take time and explore those issues [of loss and legacy].

—Eva Chittenden, MD

Hospitalists at a Different Time and Place

The elderly desperately need people who can serve them as natural healers, who are not constantly in a hurry, and who care what they are thinking and feeling. How can hospitalists relate to those who are in the midst of life review and who are hanging on to an escaping control? How can they serve their patients in a way that meets all needs?

Fighting—with denial or ignorance—the resistance that patients might put up will more than likely provoke them. A fight for control can undermine and sabotage the best intentions of the provider and the greatest wishes for the patient to experience comfort or regain health and well-being. Rather than justifying wresting control from elderly patients because it’s for their own good, advises Solie, what we must do instead is to “step back, hand them the control baton, and allow them to run with it.”1

A person’s admission to the hospital “might be such a huge crisis for them, whereas for us it’s our routine work,” says Dr. Chittenden, who practices as a hospitalist and also works on her institution’s inpatient palliative care service. “And many people who are hospitalists—who are even in their late 20s, 30s, 40s—have been totally healthy their whole life, so it is hard to relate to what it’s like to be older and to be losing function, losing friends who are also dying, losing their house … . I think that it can be very helpful for the hospitalist to take a little more time and explore some of those issues [of loss and legacy]. I try to meet the person where they’re at and try to understand what their goals, needs, ... and fears are [as well as] their functional status.”

Allowing older patients to engage with you about their lives and their pasts is a privilege for any healthcare provider. Engaging with them in a way that will help facilitate their loosening the reins on control may expedite and allow greater quality into their healthcare. It may provide an opening whereby you can order that home-health visit with less struggle.

Create Openings

“There are a lot of different ‘on-ramps’ to asking the life-review questions, which are extremely comforting,” says Solie. “For example, you might say, ‘Mary, I notice that you were born in Iowa. You know, my family on my father’s side came from Iowa. Where were you raised?’ And ‘Do you have a big family on your farm, because my aunt had cows.’”

Once you get a response that engages the patient, then you “are in the slipstream. Physicians have such a high experience curve, they see so many patients,” he says. “They don’t have to go very far into their inventory of experiences [to find one] that essentially matches up with that patient.”

Any kind of comment that will key you in to their background experience can help establish some kind of foundation for relationship. Another example: “You know, Mary, I was working with this woman who was about your age and she was raised in the Midwest and was dealing with some of these issues of congestive heart failure, and one of her big concerns was something that I didn’t appreciate until I understood what an impact it was having on her life.”

This kind of communication, says Solie, can help to relieve some of the patient’s control anxieties, “because she feels that if I ‘get it,’ she’s open to what I have to say, such as, ‘The first thing, we have to deal with is there is too much fluid going on in your body and it’s putting a big strain on your heart, so the first couple days all we did for that [other] woman was try to pull some fluid off and keep everything in balance.’”

You’ve communicated that you have a plan, that you can be trusted, and that you will help her to exercise as much control as possible. Creating and accessing those openings is also “the ideal way to weave the family into this whole life-review process, which is where the patient lives, psychologically and emotionally, when outside the hospital environment,” he says. “We become so myopic when we’re caught in the hospital environment that the world becomes a narrow tunnel and we forget the greater matrix outside that we’re all connected to.”

The Boon of Biology

Whereas the physiology and anatomy of humans deteriorate with time, some of the changes in mental processes in old age may actually enhance the ability to reflect and make informed judgments. Solie’s view is that what younger people may view as slow behavior, confusing speech patterns, and physical frailty don’t hinder the tasks that are before the elderly. On the contrary, they assist the fulfillment of their developmental agendas to feel in control when they’re losing control and to let go enough to reveal the legacy that will survive after they go.

Research on the aging brain indicates that changes in brain chemistry facilitate the life-review process.1,6 In general, reflection is the normal mode of existence for elderly adults and their primary focus. Thus, viewing them as diminished because they communicate differently than younger people do is doing them a disservice.

Those slowed mental processes, Dr. Chittenden concurs, “are conducive to reflection. Someone younger will pathologize it. … I agree that we don’t value the slowing down process, but I also think that when this population is in the hospital we are tending to look at loss of functional status or the quick mental traits that we value as opposed to [that which is] adaptive [and] that enables them to look at things differently and reflect.”

The key to connecting the dots of where they are and where they need to be (both medically and psychosocially), as well as how they occur to their providers and their families as opposed to how they occur to themselves, is to listen to and speak with them by making use of what you know about this stage of their life as it affects their communication. You can do this, says Solie, by invoking the “access code,” which is “to clearly understand that at the top of their agenda—no matter what else is happening—is the need for control and the need to develop and go after a legacy, and that means life review. If you know that, you will never lose your reference point with them.”

Communication Habits of the Elderly

Solie identifies some verbal behaviors that are common in older people. In many cases these behaviors may reveal something between the lines.

1. Lack of urgency. Older people need more time to decide things. Accept that slower pace as normal. Don’t take it personally. Adjust your schedule to allow time to deliver news or ask for choices and then allow time for them to discuss with their families or contemplate on their own; return to them at a later time. Become expert at spontaneous facilitation. Use your access code to get their attention and gain their trust.
2. Nonlinear conversations. Although older patients may appear to wander off topic, they may do so in the urge to ground themselves in what their priorities are, what their feelings are, what their choices will be. Signal you’re willing to listen and that you’re tuned in to the content, even if you don’t know where it is leading. (Obviously, someone who is demented or delirious presents a different scenario altogether, and depression is common and frequently overlooked.) Listen for patterns and themes. Nonlinear conversations can lead to spontaneous revelations and great insights for your patients and for yourself and can help patients revisit life dramas that test and clarify values. This, too, is a part of healthcare.
3. Repetition and attention to details. In situations when dementia is ruled out, a patient’s repetition may indicate a means to emphasize an important point or value. Keep in mind, too, that as we age, we all repeat stories to some degree. Details in stories may be the means by which older adults connect to their pasts and may also serve as clues to what is important to these people. Don’t assume details demand any action on your part. You are only being asked to listen as the older person sorts things out.
4. Uncoupling. Solie describes uncoupling as any time an older person appears to disconnect from you in the course of a conversation. For a professional, this can feel as if you are dismissed or ignored just when you think you’ve hit the mark with a comment or question. Go back and assess the information you’ve gathered by doing some verification. Rethink the objective: Any action that works against their maintaining control and discovering a legacy will produce uncoupling.

“I try to be aware of when I’m losing people,” says Dr. Chittenden of this phenomenon. “I would say, ‘I seem to be losing you and I’m wondering what you’re thinking right now.’ I would try to find out where they’re at and if it was something I said that didn’t gel with them, didn’t make sense to them, or wasn’t their priority.” This is something, she emphasizes, that a hospitalist needs to watch for with patients of all ages. “Whether you’re older or younger,” she says, the communication can be complicated because “you’re … in the hospital culture and the priorities of doctors are so often different from the priorities of patients.”

Conclusion

Older and especially old-old individuals in some ways live in an era other than the one traversed by the young and middle-aged.6 Their purposes, agendas, and mission are different and the slowing down of their functioning can facilitate their attempts to put their lives into perspective and manage what control they can still exercise or are still allowed. Viewing older patients with the utmost respect and acknowledging the challenges they face at these last phases of their lives can better help you to partner with them and their families in their care. TH

Andrea Sattinger also writes about the importance of apology in this issue.

References

1. Solie D. How to Say it to Seniors: Closing the Communication Gap with Our Elders. New York: Prentice Hall Press; 2004.
2. Chochinov HM, Cann BJ. Interventions to enhance the spiritual aspects of dying. J Palliat Med. 2005;8:Suppl 1:S103-115.
3. Dennis KE. Patients' control and the information imperative: clarification and confirmation. Nurs Res. 1990;39(3):162-166.
4. Kiesler DJ, Auerbach SM. Integrating measurement of control and affiliation in studies of physician-patient interaction: the interpersonal circumplex. Soc Sci Med. 2003;57(9):1707-1722.
5. Breemhaar B, Visser AP, Kleijnen JG. Perceptions and behaviour among elderly hospital patients: description and explanation of age differences in satisfaction, knowledge, emotions and behaviour. Soc Sci Med. 1990;31(12):1377-1385.
6. Pipher M. Another Country: Navigating the Emotional Terrain of Our Elders. New York: Riverhead Books; 1999.
7. Barnett PB. Rapport and the hospitalist. Am J Med. 2001;111:31S-35S.

Contrary to popular belief, conflicts are not necessarily bad. In fact, conflicts can spark discussions that can lead to improved processes and quality care. They also can help open lines of communication among practitioners and between physicians and patients.

Of course, not all conflict is positive and discord can be detrimental to patients and to relationships in the hospital. It behooves hospitalists to understand how to resolve conflicts constructively and communicate effectively in emotionally charged and controversial situations.

Good Conflict

When resolved effectively, conflicts can lead to positive changes, process improvements, and enhanced quality, says Leonard Marcus, PhD, founding director of the Program for Health Care Negotiation and Conflict Resolution at the Harvard School of Public Health (Boston). In fact, conflict sometimes is necessary because it:

• Raises and resolves problems;
• Focuses change efforts on the most urgent and appropriate issues;
• Motivates people to participate in efforts to create positive changes; and
• Helps people learn to benefit from and recognize their differences.

Conflict is problematic when it:

• Hampers productivity;
• Lowers morale and/or hurts relationships;
• Creates more and continued conflicts; and
• Causes inappropriate and/or dangerous behaviors.

Conflicts often arise from everyday occurrences. Poor communication is one of the most common causes of disputes. However, conflicts also may result from insufficient resources, personality clashes, and leadership problems (e.g., inconsistent, missing, dictatorial, or uninformed leadership).

Anatomy of a Conflict

A primary care physician, Dr. X, tells a patient, Mrs. Y, that she needs to be admitted to the hospital. If the hospitalist examines Mrs. Y and agrees that admission is necessary, there is no conflict. However, if the hospitalist determines that Mrs. Y doesn’t need to be admitted, the potential for conflict is ripe.

“This can create real tension,” says James W. Leyhane, MD, hospitalist director at Auburn Memorial Hospital, N.Y. “The hospitalist can find himself facing a conflict with the patient or the physician—or both.”

These situations can be highly charged and difficult to resolve. “Sometimes the person is adamant that he or she wants to be admitted,” says Dr. Leyhane. “And the stronger the relationship the patient has with the primary care physician, the greater the resistance they may have to what you are saying.”

The most common approach Dr. Leyhane takes to such a situation is to get on the physician’s side. “I will say something like, ‘I understand why Dr. Jones thought you should be admitted. However, after further examination, we now realize that admission is unnecessary,’” he explains.

Once the hospitalist addresses any anger or frustrations patients feel, most are relieved to avoid a hospitalization. But sometimes this approach doesn’t work, and some patients still insist on being admitted. In those cases, Dr. Leyhane will appeal to their pocketbook instead of their emotions. “I will tell them that I can admit them if they insist,” he says. “However, someone else will review their chart for insurance purposes, and they will have to pay out-of-pocket for the stay because it is not medically necessary. This is very persuasive.”

When Hospitalists and Attendings Clash

When such situations create conflict with physicians, they must be addressed carefully and resolved promptly. Dr. Marcus suggests that such conflicts can be minimized or eliminated altogether when “physicians negotiate expectations of their relationships” up front. “It is best for attendings and hospitalists to be communicating on an ongoing basis and understand each other’s positions before situations occur,” he offers.

Peter Prendergast, MD, chief hospitalist at St. Joseph’s Hospital and associate professor of Medicine at SUNY Upstate Medicine Center in Syracuse, New York, suggests that conflicts with physicians in these situations are not common. “Physicians overwhelmingly understand that we have more information by which to make admitting decisions,” says Dr. Prendergast. “We just need to make sure the patient understands that the physician makes the best possible decision with the data set he or she has and that we have access to more information and assessment tools and may draw a different conclusion.”

Nonetheless, Dr. Prendergast acknowledges that there are other situations that present the potential for attending-hospitalist conflict. “You may run into a problem with the primary care physician when the patient presents with a medical problem that previously was treated in the hospital that now is treated on an outpatient basis,” he notes.

Dr. Leyhane offers another common conflict with attendings. “Sometimes the physician will order a test or procedure that will not be reimbursed because it is unrelated to the patient’s reason for admission,” he says. “When this happens and the patient gets the bill, he or she is unhappy with the hospital and not the attending physician.”

These situations generally occur because the physician doesn’t realize that a service isn’t reimbursable or that a protocol has changed, Dr. Prendergast stresses, and not because the practitioner is being stubborn or contrary. Nonetheless, it presents a conflict.

“You need to let the physician know that there has been a change in treatment standards or that there is a reimbursement issue. Once he or she has the facts, you aren’t likely to have another problem,” says Dr. Prendergast. “The physician needs to get a phone call or at least a note in a timely manner.”

Dr. Marcus actually advises that hospitalists talk with the physician before communicating any information to the patient that conflicts with what the doctor has told him or her. “Otherwise,” he observes, “the conflict already has escalated.” Physicians, he says, don’t want to hear about a difference of opinion after the fact.

Hospitalist-Patient Conflicts

Roger Gildersleeve, MD, administrative hospitalist at Augusta Medical Center, Fishersville, Va., says conflicts with patients or family members are common situations for the hospitalist. “You may see conflicts when there is a disconnect between the patient’s or family’s expectations and the realities of the patient’s prognosis and outcomes,” he says. “We spend a lot of time trying to bring these two things closer together.”

One key to resolving these problems is to make a quick study of the situation. “You usually can read patients and families—by their body language and facial expressions—when you enter the room,” says Dr. Gildersleeve, “and you can detect tension and hostility.”

Dr. Prendergast agrees. “When you see patients and families in certain situations—such as 2 a.m. in the ER—you can make some reasonable assumptions about what they are thinking or feeling,” he says. “You can predict what these people’s concerns are, and you can address them even before they ask. Acknowledging their position and concerns is important.”

When possible, preparing for family and/or patient encounters can make a difference. “Before seeing a new patient, I try to learn as much as I can about him or her,” says Dr. Gildersleeve. “We have a good computer system, so it’s pretty easy. I use some of what I’ve learned in my opening comments, and this gives patients and families more confidence in me and my ability to deal with them as individuals.”

This is especially important for hospitalists, who have to establish patient relationships in a relatively short period of time.

Resolving Conflicts

Of course, it is impossible to prevent or avoid all conflicts. “To some degree, conflicts are inevitable,” says Dr. Marcus. “It’s the nature of medical practice.”

When conflicts occur, many of them can—and should—be resolved before they escalate into a dangerous confrontation or litigation. Listening is key to resolving conflicts quickly. “By listening, you can prevent a lot of conflicts from escalating or even starting,” says Dr. Prendergast. “We teach our physicians to listen, then repeat back what they heard—‘I’m hearing that you’re upset because … .’ If you get it right, the person knows that you are listening and that you understand their concerns. If you miss, they are likely to state their concern directly.”

Dr. Marcus believes conflict resolution may be particularly effective and satisfying when interest-based negotiation (IBN) is employed. IBN is a problem-solving strategy that focuses on satisfying as many interests or needs as possible for all involved parties. Because this technique addresses people’s needs and interests and separates people from the problem, it enables the parties to reach an integrative solution rather than creating a win-lose situation.

IBN enables those involved in a conflict to work together to reach a mutually satisfactory conclusion. The technique commonly results in creative and durable solutions, as well as enhanced relationships.

Conflict resolution efforts are more likely to fail, says Dr. Marcus, when the physicians and others involved apply position-based negotiations. With this conflict-management method, the parties argue only their positions, and their underlying interests may never be stated explicitly or understood. People are more likely to reach an impasse when they employ position-based negotiations, and they are more likely to see the situation as having a clear-cut winner and a loser.

“When you negotiate based on positions,” explains Dr. Marcus, “that is when situations are likely to escalate.”

While clear hospital policies and procedures can help resolve or prevent some conflicts involving physicians, more layers of policy are not necessarily the answer. “I think the time it would take to establish these policies would be better spent developing pathways for easier and better communication,” says Dr. Gildersleeve. “You see few of these hospitalist-physician conflicts when there is good communication between all the players.”

Professional mediator Pat Costello suggests that policy changes actually can help resolve some disputes. “Continued conflicts might suggest a need for a policy change or a new policy,” says Costello. “I have mediated a lot of situations that were resolved by policy changes.”

15 Seconds to Make an Impression

Hospitalists must remain cognizant of mistakes they can make that actually exacerbate conflicts with patients and families. “When physicians use an overbearing approach, they can’t accomplish as much,” says Dr. Marcus. “You have to take care to treat patients and families with care and concern and the same respect they afford their colleagues.”

It is important for hospitalists to be aware of how they come across to others, stressed Carole Houk, Esq., president of Carole Houk International, Alexandria, Va.

“You make a snap judgment of whether or not you like someone in about 15 seconds,” says Houk. “Studies show that physicians who use a dominant tone of voice are more likely to be sued than those who don’t.

“Explain what happens and why—and put a lot of focus on your tone of voice,” she says. “Rather than coming down imperiously, reach out to patients in a compassionate way. You need to be seen as someone with a heart and not a gatekeeper for the insurance company.”

When Hospitalists Can’t Resolve a Conflict

Unfortunately, some conflicts can’t be resolved easily. While hospitalists require some conflict resolution skills, they must also be willing and able to recognize when they need assistance. For example, suggests Houk, “We have ombudsmen in some hospitals who serve as conflict coaches. They are trained for this purpose. Hospitalists and others can go to these people for help resolving conflicts.”

Elsewhere, she notes, “We are training risk managers on conflict skills so that they can help resolve disputes in their hospitals and serve as informal mediators.”

On rare occasions, it may be necessary to seek the involvement of an independent professional mediator. Mediator Costello says this might be necessary in instances where there is an ongoing and escalating lack of communication, repeated conflicts (despite attempts to resolve them), physical altercations or threats of violence, and/or imminent risk to a patent’s safety.

While there may be conflicts that hospitalists cannot resolve, overall they are well equipped to communicate effectively in a way that minimizes disputes. “Many of us were attracted to this profession because of the opportunities and challenges of working with a wide range of situations and colleagues,” says Dr. Leyhane. “We know that communication skills are important, and we get a lot of practice during our interactions with physicians, families, patients, administrators, and ancillary staff.”

Houk agrees: “This field seems to attract people with big hearts. They understand the importance of understanding and acknowledging the needs and feelings of others.” TH

Joanne Kaldy writes regularly for The Hospitalist.

Contrary to popular belief, conflicts are not necessarily bad. In fact, conflicts can spark discussions that can lead to improved processes and quality care. They also can help open lines of communication among practitioners and between physicians and patients.

Of course, not all conflict is positive and discord can be detrimental to patients and to relationships in the hospital. It behooves hospitalists to understand how to resolve conflicts constructively and communicate effectively in emotionally charged and controversial situations.

Good Conflict

When resolved effectively, conflicts can lead to positive changes, process improvements, and enhanced quality, says Leonard Marcus, PhD, founding director of the Program for Health Care Negotiation and Conflict Resolution at the Harvard School of Public Health (Boston). In fact, conflict sometimes is necessary because it:

• Raises and resolves problems;
• Focuses change efforts on the most urgent and appropriate issues;
• Motivates people to participate in efforts to create positive changes; and
• Helps people learn to benefit from and recognize their differences.

Conflict is problematic when it:

• Hampers productivity;
• Lowers morale and/or hurts relationships;
• Creates more and continued conflicts; and
• Causes inappropriate and/or dangerous behaviors.

Conflicts often arise from everyday occurrences. Poor communication is one of the most common causes of disputes. However, conflicts also may result from insufficient resources, personality clashes, and leadership problems (e.g., inconsistent, missing, dictatorial, or uninformed leadership).

Anatomy of a Conflict

A primary care physician, Dr. X, tells a patient, Mrs. Y, that she needs to be admitted to the hospital. If the hospitalist examines Mrs. Y and agrees that admission is necessary, there is no conflict. However, if the hospitalist determines that Mrs. Y doesn’t need to be admitted, the potential for conflict is ripe.

“This can create real tension,” says James W. Leyhane, MD, hospitalist director at Auburn Memorial Hospital, N.Y. “The hospitalist can find himself facing a conflict with the patient or the physician—or both.”

These situations can be highly charged and difficult to resolve. “Sometimes the person is adamant that he or she wants to be admitted,” says Dr. Leyhane. “And the stronger the relationship the patient has with the primary care physician, the greater the resistance they may have to what you are saying.”

The most common approach Dr. Leyhane takes to such a situation is to get on the physician’s side. “I will say something like, ‘I understand why Dr. Jones thought you should be admitted. However, after further examination, we now realize that admission is unnecessary,’” he explains.

Once the hospitalist addresses any anger or frustrations patients feel, most are relieved to avoid a hospitalization. But sometimes this approach doesn’t work, and some patients still insist on being admitted. In those cases, Dr. Leyhane will appeal to their pocketbook instead of their emotions. “I will tell them that I can admit them if they insist,” he says. “However, someone else will review their chart for insurance purposes, and they will have to pay out-of-pocket for the stay because it is not medically necessary. This is very persuasive.”

When Hospitalists and Attendings Clash

When such situations create conflict with physicians, they must be addressed carefully and resolved promptly. Dr. Marcus suggests that such conflicts can be minimized or eliminated altogether when “physicians negotiate expectations of their relationships” up front. “It is best for attendings and hospitalists to be communicating on an ongoing basis and understand each other’s positions before situations occur,” he offers.

Peter Prendergast, MD, chief hospitalist at St. Joseph’s Hospital and associate professor of Medicine at SUNY Upstate Medicine Center in Syracuse, New York, suggests that conflicts with physicians in these situations are not common. “Physicians overwhelmingly understand that we have more information by which to make admitting decisions,” says Dr. Prendergast. “We just need to make sure the patient understands that the physician makes the best possible decision with the data set he or she has and that we have access to more information and assessment tools and may draw a different conclusion.”

Nonetheless, Dr. Prendergast acknowledges that there are other situations that present the potential for attending-hospitalist conflict. “You may run into a problem with the primary care physician when the patient presents with a medical problem that previously was treated in the hospital that now is treated on an outpatient basis,” he notes.

Dr. Leyhane offers another common conflict with attendings. “Sometimes the physician will order a test or procedure that will not be reimbursed because it is unrelated to the patient’s reason for admission,” he says. “When this happens and the patient gets the bill, he or she is unhappy with the hospital and not the attending physician.”

These situations generally occur because the physician doesn’t realize that a service isn’t reimbursable or that a protocol has changed, Dr. Prendergast stresses, and not because the practitioner is being stubborn or contrary. Nonetheless, it presents a conflict.

“You need to let the physician know that there has been a change in treatment standards or that there is a reimbursement issue. Once he or she has the facts, you aren’t likely to have another problem,” says Dr. Prendergast. “The physician needs to get a phone call or at least a note in a timely manner.”

Dr. Marcus actually advises that hospitalists talk with the physician before communicating any information to the patient that conflicts with what the doctor has told him or her. “Otherwise,” he observes, “the conflict already has escalated.” Physicians, he says, don’t want to hear about a difference of opinion after the fact.

Hospitalist-Patient Conflicts

Roger Gildersleeve, MD, administrative hospitalist at Augusta Medical Center, Fishersville, Va., says conflicts with patients or family members are common situations for the hospitalist. “You may see conflicts when there is a disconnect between the patient’s or family’s expectations and the realities of the patient’s prognosis and outcomes,” he says. “We spend a lot of time trying to bring these two things closer together.”

One key to resolving these problems is to make a quick study of the situation. “You usually can read patients and families—by their body language and facial expressions—when you enter the room,” says Dr. Gildersleeve, “and you can detect tension and hostility.”

Dr. Prendergast agrees. “When you see patients and families in certain situations—such as 2 a.m. in the ER—you can make some reasonable assumptions about what they are thinking or feeling,” he says. “You can predict what these people’s concerns are, and you can address them even before they ask. Acknowledging their position and concerns is important.”

When possible, preparing for family and/or patient encounters can make a difference. “Before seeing a new patient, I try to learn as much as I can about him or her,” says Dr. Gildersleeve. “We have a good computer system, so it’s pretty easy. I use some of what I’ve learned in my opening comments, and this gives patients and families more confidence in me and my ability to deal with them as individuals.”

This is especially important for hospitalists, who have to establish patient relationships in a relatively short period of time.

Resolving Conflicts

Of course, it is impossible to prevent or avoid all conflicts. “To some degree, conflicts are inevitable,” says Dr. Marcus. “It’s the nature of medical practice.”

When conflicts occur, many of them can—and should—be resolved before they escalate into a dangerous confrontation or litigation. Listening is key to resolving conflicts quickly. “By listening, you can prevent a lot of conflicts from escalating or even starting,” says Dr. Prendergast. “We teach our physicians to listen, then repeat back what they heard—‘I’m hearing that you’re upset because … .’ If you get it right, the person knows that you are listening and that you understand their concerns. If you miss, they are likely to state their concern directly.”

Dr. Marcus believes conflict resolution may be particularly effective and satisfying when interest-based negotiation (IBN) is employed. IBN is a problem-solving strategy that focuses on satisfying as many interests or needs as possible for all involved parties. Because this technique addresses people’s needs and interests and separates people from the problem, it enables the parties to reach an integrative solution rather than creating a win-lose situation.

IBN enables those involved in a conflict to work together to reach a mutually satisfactory conclusion. The technique commonly results in creative and durable solutions, as well as enhanced relationships.

Conflict resolution efforts are more likely to fail, says Dr. Marcus, when the physicians and others involved apply position-based negotiations. With this conflict-management method, the parties argue only their positions, and their underlying interests may never be stated explicitly or understood. People are more likely to reach an impasse when they employ position-based negotiations, and they are more likely to see the situation as having a clear-cut winner and a loser.

“When you negotiate based on positions,” explains Dr. Marcus, “that is when situations are likely to escalate.”

While clear hospital policies and procedures can help resolve or prevent some conflicts involving physicians, more layers of policy are not necessarily the answer. “I think the time it would take to establish these policies would be better spent developing pathways for easier and better communication,” says Dr. Gildersleeve. “You see few of these hospitalist-physician conflicts when there is good communication between all the players.”

Professional mediator Pat Costello suggests that policy changes actually can help resolve some disputes. “Continued conflicts might suggest a need for a policy change or a new policy,” says Costello. “I have mediated a lot of situations that were resolved by policy changes.”

15 Seconds to Make an Impression

Hospitalists must remain cognizant of mistakes they can make that actually exacerbate conflicts with patients and families. “When physicians use an overbearing approach, they can’t accomplish as much,” says Dr. Marcus. “You have to take care to treat patients and families with care and concern and the same respect they afford their colleagues.”

It is important for hospitalists to be aware of how they come across to others, stressed Carole Houk, Esq., president of Carole Houk International, Alexandria, Va.

“You make a snap judgment of whether or not you like someone in about 15 seconds,” says Houk. “Studies show that physicians who use a dominant tone of voice are more likely to be sued than those who don’t.

“Explain what happens and why—and put a lot of focus on your tone of voice,” she says. “Rather than coming down imperiously, reach out to patients in a compassionate way. You need to be seen as someone with a heart and not a gatekeeper for the insurance company.”

When Hospitalists Can’t Resolve a Conflict

Unfortunately, some conflicts can’t be resolved easily. While hospitalists require some conflict resolution skills, they must also be willing and able to recognize when they need assistance. For example, suggests Houk, “We have ombudsmen in some hospitals who serve as conflict coaches. They are trained for this purpose. Hospitalists and others can go to these people for help resolving conflicts.”

Elsewhere, she notes, “We are training risk managers on conflict skills so that they can help resolve disputes in their hospitals and serve as informal mediators.”

On rare occasions, it may be necessary to seek the involvement of an independent professional mediator. Mediator Costello says this might be necessary in instances where there is an ongoing and escalating lack of communication, repeated conflicts (despite attempts to resolve them), physical altercations or threats of violence, and/or imminent risk to a patent’s safety.

While there may be conflicts that hospitalists cannot resolve, overall they are well equipped to communicate effectively in a way that minimizes disputes. “Many of us were attracted to this profession because of the opportunities and challenges of working with a wide range of situations and colleagues,” says Dr. Leyhane. “We know that communication skills are important, and we get a lot of practice during our interactions with physicians, families, patients, administrators, and ancillary staff.”

Houk agrees: “This field seems to attract people with big hearts. They understand the importance of understanding and acknowledging the needs and feelings of others.” TH

Joanne Kaldy writes regularly for The Hospitalist.

Contrary to popular belief, conflicts are not necessarily bad. In fact, conflicts can spark discussions that can lead to improved processes and quality care. They also can help open lines of communication among practitioners and between physicians and patients.

Of course, not all conflict is positive and discord can be detrimental to patients and to relationships in the hospital. It behooves hospitalists to understand how to resolve conflicts constructively and communicate effectively in emotionally charged and controversial situations.

Good Conflict

When resolved effectively, conflicts can lead to positive changes, process improvements, and enhanced quality, says Leonard Marcus, PhD, founding director of the Program for Health Care Negotiation and Conflict Resolution at the Harvard School of Public Health (Boston). In fact, conflict sometimes is necessary because it:

• Raises and resolves problems;
• Focuses change efforts on the most urgent and appropriate issues;
• Motivates people to participate in efforts to create positive changes; and
• Helps people learn to benefit from and recognize their differences.

Conflict is problematic when it:

• Hampers productivity;
• Lowers morale and/or hurts relationships;
• Creates more and continued conflicts; and
• Causes inappropriate and/or dangerous behaviors.

Conflicts often arise from everyday occurrences. Poor communication is one of the most common causes of disputes. However, conflicts also may result from insufficient resources, personality clashes, and leadership problems (e.g., inconsistent, missing, dictatorial, or uninformed leadership).

Anatomy of a Conflict

A primary care physician, Dr. X, tells a patient, Mrs. Y, that she needs to be admitted to the hospital. If the hospitalist examines Mrs. Y and agrees that admission is necessary, there is no conflict. However, if the hospitalist determines that Mrs. Y doesn’t need to be admitted, the potential for conflict is ripe.

“This can create real tension,” says James W. Leyhane, MD, hospitalist director at Auburn Memorial Hospital, N.Y. “The hospitalist can find himself facing a conflict with the patient or the physician—or both.”

These situations can be highly charged and difficult to resolve. “Sometimes the person is adamant that he or she wants to be admitted,” says Dr. Leyhane. “And the stronger the relationship the patient has with the primary care physician, the greater the resistance they may have to what you are saying.”

The most common approach Dr. Leyhane takes to such a situation is to get on the physician’s side. “I will say something like, ‘I understand why Dr. Jones thought you should be admitted. However, after further examination, we now realize that admission is unnecessary,’” he explains.

Once the hospitalist addresses any anger or frustrations patients feel, most are relieved to avoid a hospitalization. But sometimes this approach doesn’t work, and some patients still insist on being admitted. In those cases, Dr. Leyhane will appeal to their pocketbook instead of their emotions. “I will tell them that I can admit them if they insist,” he says. “However, someone else will review their chart for insurance purposes, and they will have to pay out-of-pocket for the stay because it is not medically necessary. This is very persuasive.”

When Hospitalists and Attendings Clash

When such situations create conflict with physicians, they must be addressed carefully and resolved promptly. Dr. Marcus suggests that such conflicts can be minimized or eliminated altogether when “physicians negotiate expectations of their relationships” up front. “It is best for attendings and hospitalists to be communicating on an ongoing basis and understand each other’s positions before situations occur,” he offers.

Peter Prendergast, MD, chief hospitalist at St. Joseph’s Hospital and associate professor of Medicine at SUNY Upstate Medicine Center in Syracuse, New York, suggests that conflicts with physicians in these situations are not common. “Physicians overwhelmingly understand that we have more information by which to make admitting decisions,” says Dr. Prendergast. “We just need to make sure the patient understands that the physician makes the best possible decision with the data set he or she has and that we have access to more information and assessment tools and may draw a different conclusion.”

Nonetheless, Dr. Prendergast acknowledges that there are other situations that present the potential for attending-hospitalist conflict. “You may run into a problem with the primary care physician when the patient presents with a medical problem that previously was treated in the hospital that now is treated on an outpatient basis,” he notes.

Dr. Leyhane offers another common conflict with attendings. “Sometimes the physician will order a test or procedure that will not be reimbursed because it is unrelated to the patient’s reason for admission,” he says. “When this happens and the patient gets the bill, he or she is unhappy with the hospital and not the attending physician.”

These situations generally occur because the physician doesn’t realize that a service isn’t reimbursable or that a protocol has changed, Dr. Prendergast stresses, and not because the practitioner is being stubborn or contrary. Nonetheless, it presents a conflict.

“You need to let the physician know that there has been a change in treatment standards or that there is a reimbursement issue. Once he or she has the facts, you aren’t likely to have another problem,” says Dr. Prendergast. “The physician needs to get a phone call or at least a note in a timely manner.”

Dr. Marcus actually advises that hospitalists talk with the physician before communicating any information to the patient that conflicts with what the doctor has told him or her. “Otherwise,” he observes, “the conflict already has escalated.” Physicians, he says, don’t want to hear about a difference of opinion after the fact.

Hospitalist-Patient Conflicts

Roger Gildersleeve, MD, administrative hospitalist at Augusta Medical Center, Fishersville, Va., says conflicts with patients or family members are common situations for the hospitalist. “You may see conflicts when there is a disconnect between the patient’s or family’s expectations and the realities of the patient’s prognosis and outcomes,” he says. “We spend a lot of time trying to bring these two things closer together.”

One key to resolving these problems is to make a quick study of the situation. “You usually can read patients and families—by their body language and facial expressions—when you enter the room,” says Dr. Gildersleeve, “and you can detect tension and hostility.”

Dr. Prendergast agrees. “When you see patients and families in certain situations—such as 2 a.m. in the ER—you can make some reasonable assumptions about what they are thinking or feeling,” he says. “You can predict what these people’s concerns are, and you can address them even before they ask. Acknowledging their position and concerns is important.”

When possible, preparing for family and/or patient encounters can make a difference. “Before seeing a new patient, I try to learn as much as I can about him or her,” says Dr. Gildersleeve. “We have a good computer system, so it’s pretty easy. I use some of what I’ve learned in my opening comments, and this gives patients and families more confidence in me and my ability to deal with them as individuals.”

This is especially important for hospitalists, who have to establish patient relationships in a relatively short period of time.

Resolving Conflicts

Of course, it is impossible to prevent or avoid all conflicts. “To some degree, conflicts are inevitable,” says Dr. Marcus. “It’s the nature of medical practice.”

When conflicts occur, many of them can—and should—be resolved before they escalate into a dangerous confrontation or litigation. Listening is key to resolving conflicts quickly. “By listening, you can prevent a lot of conflicts from escalating or even starting,” says Dr. Prendergast. “We teach our physicians to listen, then repeat back what they heard—‘I’m hearing that you’re upset because … .’ If you get it right, the person knows that you are listening and that you understand their concerns. If you miss, they are likely to state their concern directly.”

Dr. Marcus believes conflict resolution may be particularly effective and satisfying when interest-based negotiation (IBN) is employed. IBN is a problem-solving strategy that focuses on satisfying as many interests or needs as possible for all involved parties. Because this technique addresses people’s needs and interests and separates people from the problem, it enables the parties to reach an integrative solution rather than creating a win-lose situation.

IBN enables those involved in a conflict to work together to reach a mutually satisfactory conclusion. The technique commonly results in creative and durable solutions, as well as enhanced relationships.

Conflict resolution efforts are more likely to fail, says Dr. Marcus, when the physicians and others involved apply position-based negotiations. With this conflict-management method, the parties argue only their positions, and their underlying interests may never be stated explicitly or understood. People are more likely to reach an impasse when they employ position-based negotiations, and they are more likely to see the situation as having a clear-cut winner and a loser.

“When you negotiate based on positions,” explains Dr. Marcus, “that is when situations are likely to escalate.”

While clear hospital policies and procedures can help resolve or prevent some conflicts involving physicians, more layers of policy are not necessarily the answer. “I think the time it would take to establish these policies would be better spent developing pathways for easier and better communication,” says Dr. Gildersleeve. “You see few of these hospitalist-physician conflicts when there is good communication between all the players.”

Professional mediator Pat Costello suggests that policy changes actually can help resolve some disputes. “Continued conflicts might suggest a need for a policy change or a new policy,” says Costello. “I have mediated a lot of situations that were resolved by policy changes.”

15 Seconds to Make an Impression

Hospitalists must remain cognizant of mistakes they can make that actually exacerbate conflicts with patients and families. “When physicians use an overbearing approach, they can’t accomplish as much,” says Dr. Marcus. “You have to take care to treat patients and families with care and concern and the same respect they afford their colleagues.”

It is important for hospitalists to be aware of how they come across to others, stressed Carole Houk, Esq., president of Carole Houk International, Alexandria, Va.

“You make a snap judgment of whether or not you like someone in about 15 seconds,” says Houk. “Studies show that physicians who use a dominant tone of voice are more likely to be sued than those who don’t.

“Explain what happens and why—and put a lot of focus on your tone of voice,” she says. “Rather than coming down imperiously, reach out to patients in a compassionate way. You need to be seen as someone with a heart and not a gatekeeper for the insurance company.”

When Hospitalists Can’t Resolve a Conflict

Unfortunately, some conflicts can’t be resolved easily. While hospitalists require some conflict resolution skills, they must also be willing and able to recognize when they need assistance. For example, suggests Houk, “We have ombudsmen in some hospitals who serve as conflict coaches. They are trained for this purpose. Hospitalists and others can go to these people for help resolving conflicts.”

Elsewhere, she notes, “We are training risk managers on conflict skills so that they can help resolve disputes in their hospitals and serve as informal mediators.”

On rare occasions, it may be necessary to seek the involvement of an independent professional mediator. Mediator Costello says this might be necessary in instances where there is an ongoing and escalating lack of communication, repeated conflicts (despite attempts to resolve them), physical altercations or threats of violence, and/or imminent risk to a patent’s safety.

While there may be conflicts that hospitalists cannot resolve, overall they are well equipped to communicate effectively in a way that minimizes disputes. “Many of us were attracted to this profession because of the opportunities and challenges of working with a wide range of situations and colleagues,” says Dr. Leyhane. “We know that communication skills are important, and we get a lot of practice during our interactions with physicians, families, patients, administrators, and ancillary staff.”

Houk agrees: “This field seems to attract people with big hearts. They understand the importance of understanding and acknowledging the needs and feelings of others.” TH

Joanne Kaldy writes regularly for The Hospitalist.

Apologizing to a patient is the right thing to do,” says Michael S. Woods, MD, a general surgeon at St. Vincent’s Regional Medical Center in Santa Fe, N.M. “It is the respectful thing in any relationship in terms of trust whenever there is a violation, whether it is real or perceived.” Dr. Woods, the author of Healing Words: The Power of Apology in Medicine, teaches and consults with corporations around the country about apology as well as physician leadership.1-2 In fact, his study of apology stemmed from examining the subject of physician leadership, and he and other experts consider the vital components of leadership to be effective communication, integrity, honesty, and respectful treatment of other individuals.3,4

Dr. Woods also works with Doug Wojcieszak, a public relations consultant whose victims’ rights group proposed “Sorry Works!” This program recommends apologies and settlements when medical mistakes occur. (See “A History of Sorry Works!” p. 26.) Dr. Woods says Wojcieszak comes from an interesting angle that he supports. “Something I increasingly try to hammer home when I speak is that one of the most important components of the apology law has nothing to do with the backhand of the reduction of litigation as much as the fact that it gives the physician the green light to say ‘I’m sorry,’” says Dr. Woods.

The Benefit of Healing

Providers may be less than open when things go terribly wrong because of feelings of fear, shame, and guilt regarding the consequences to the patient as well as to themselves.1,3 Apology heals by restoring the patient’s dignity and self-respect, providing assurance of shared values, and assuring patients that they are not at fault, they are now safe, and that the caregiver shares their suffering.4,7

Two Senses of Apology

There are circumstances other than when errors occur in which a physician’s apology may carry the power to improve patient care. Peter Barnett, MD, MPH, a clinical associate professor of medicine at the University of New Mexico in Albuquerque, says that in general there are two senses of apology.

“The first sense of apology regards the situation,” he says. For example, you might say, ‘I’m sorry you have cancer,’ or ‘I’m sorry that our system doesn’t allow your family doctor to be taking care of you in the hospital.’ It’s an expression of sympathy, but I think apology works better.”

The other sense of apology regards responsibility, says Dr. Barnett, citing the example, “I’m sorry I gave you the wrong drug.”

Situational needs for apology include when patients have been waiting a long time, such as when a hospitalist meets them in the emergency department. “In those cases you would say, ‘I’m sorry that you had to wait so long,’” says Dr. Barnett. “It’s not my fault, but I really am sorry.”

Bridging the Gap

Dr. Barnett, who practices hospital medicine part-time along with his major focus in addiction medicine, was formerly the director of the UNM hospitalist team. He explains that one of the primary reasons hospitalists may need to apologize to patients is that the hospitalist and patient have no prior relationship that could serve as a foundation for interpreting each other’s behavior.8

He believes apologizing for the delays and inconveniences that happen in the hospital “can help bridge the relationship gap in hospital medicine. Because what people believe about their primary care physicians is that they know and care about them,” he says. “To minimize their anxiety about you, show them that you do care about them by getting to know them well, and apology is the one of the best ways of doing that.”

When asked to elaborate what he means by “getting to know them well,” Dr. Barnett says, “I might tell someone, ‘I’d like to get to know you better; what can you tell me about yourself that would help bring me up to speed?’” It’s open-ended, he says, and you let the patient choose the topic. “Most people will say something. … It’s empathic inquiry with really good reflective listening; that is probably the simplest way of summarizing what it takes.”

Dr. Barnett suggests this kind of inquiry can mitigate the gaps in relationships that may lead to misunderstandings, edgy situations, and errors that may later call for apology. He recommends asking or saying some of the following to patients:

• What do you know about your illness?
• What do you believe about your illness?
• What are your feelings, values, beliefs, and preferences about/for your treatment?
• What can you tell me about your experiences in the hospital?

For patients who have been ill many times and have had a lot of medical experience, you could ask:

• Could you tell me about your doctors?
• What do you like about doctors?
• What don’t you like about your doctors?

These questions can help you discern who they are as a patient, and it gives patients the opportunity to be candid with you.

“It’s not about finding information that’s embarrassing or critical to your predecessor physicians, but it allows you to not make the same mistakes inadvertently,” says Dr. Barnett, who considers it concrete information. “I want them to have good medical care. I don’t want to make them unhappy. I want to avoid pitfalls. I think the two of us—the patient and I—should avoid pitfalls together.”

Asking the patient in a straightforward way what they want and don’t want gives the patient an opportunity to give the physician advice on how to stay out of trouble with them.

Apology When Disclosing Errors

The matter of assuming responsibility for errors is more complicated as it pertains to the use of apology, but it is an “idea whose time has come.”9 Although it is hard to quantify, plenty of evidence shows that apologizing for errors reduces the number of lawsuits and may reduce the settlement value of malpractice claims.3,5-7,10-26 Although there is not always agreement about the specifics of full disclosure, above all patients have the right to know what happens during their medical care and, therefore, restricting the information that is given to a patient can have legal ramifications.

Beyond this, writes Lucian Leape, MD, adjunct professor of health policy at the Harvard School of Public Health and an internationally recognized leader in the patient safety movement, wrote in the March-April issue of Physician Executive that apology is a “therapeutic necessity” that allows the patient to recognize a physician’s humanity and fallibility as well as his or her remorse at having caused harm.9 In the long run, apologizing to patients defuses more situations than it aggravates, and it pays off emotionally, financially, and in practice morale.5,6,9

Data from studies of medical practices that issue apologies in circumstances where accountability is clearly established show that litigation claims are reduced. In one 1992 study, 24% of people who sued physicians said they did so because the doctor was dishonest and withheld information. Nineteen percent said that they either sued to deter subsequent malpractice or for revenge.11,12 In each case of legal action, the investigators hypothesized that the doctor could have avoided the lawsuit by taking responsibility and apologizing up front and making amends at that time. It has been estimated that more than half of claims relegated to litigation could be avoided with use of prudent disclosure and apology.3,21

“My mantra, if you will,” says Dr. Woods, “is that [when] you apologize because it’s the right thing to do, all the benefits naturally ensue.”

Anticipating Apology

The issue of complications, adverse events, and errors carries its own protocol in terms of whether and how apology is offered. “Hopefully some of these have been anticipated,” says Dr. Barnett. “For instance, when you spoke with the patient about their pneumonia, you’ve said something about the possibility that pneumonias could become complicated, and [they] might have some kind of complications; or if they’ve had a heart attack, [you mentioned that] they might have some complications. So you’re actually already warning people about what could happen and you’ve said you’re going to try to prevent it, but it could [still happen].”

Apology can be appropriately offered when those events do occur and you genuinely express disappointment that you and the patient share.

“There are some quite complicated systematic problems [related to apology and hospital medicine],” says Dr. Barnett. “Some are communication aspects and some are legal ones. What I have heard from the attorneys is that you want to keep the apology relatively simple, … and it shouldn’t include any statements about other people who may have been involved, such as pharmacy or nurses.”

The other important issue related to hospitalists and apology, says Dr. Barnett, is that because of the lack of relationship, the severity of illness of the patients you are treating, and the strangeness of systems, people come to the hospital expecting errors. They expect them and may be afraid of them. In particular, when a medication error is made, they expect those errors to be disclosed to them.7,27 Dr. Barnett believes patients are waiting and watching, and hoping that nothing happens to them. Complicating the issue, he says, is that “many hospitalists are fairly guarded in this respect. The emotional deck is sort of stacked against everybody, so if the hospitalist is sensitive about the situation, that tends actually to make the situation worse. If you can apologize sincerely and simply, the patient may be reassured that you’re not trying to conceal anything, you’re honest, you’re on top of it, and you’ll do your best to deal with it,” he says, adding, “they know that that stuff happens; they hope that it is not hidden, ignored, or mismanaged.”

Start Early and Let It Flow

Dr. Woods’ advice is to offer apology earlier rather than later and to widen the spectrum of those to whom you wish to show your empathy, sympathy, respect, and compassion.

“What I promote to organizations is that they drive this into the consciousness of the organization by getting people to apologize for the least infraction—not waiting for the grave errors.” He interprets this as apologizing “when you’re running 30 minutes late, apologize when you’ve interrupted the patient or the family when they’re speaking. These are the things we would do for our spouse or our significant other or our family members; why is it any different at work?”

He also believes it is inherent for doctors as leaders to “apologize to your staff members, apologize to the nurses.” Because the image you express serves as a role model in this regard and will permeate your practice culture. Drive respectful treatment as a basic common social courtesy into the organizational consciousness, says Dr. Woods, and then in any circumstance where an apology is offered, it is perceived as authentic.

Conclusion

Hospitalists may find a need to apologize to patients and families for situations and circumstances in the hospital environment as well as the gap in relationship that exists when hospitalists and patients first encounter each other. Apologizing early rather than later as well as simply and authentically goes a long way to help achieve the ethical and business objectives held by most hospital physicians. TH

Andrea Sattinger wrote about error reporting in the May issue.

References

1. Woods MS, Star JI. Healing Words: The Power of Apology in Medicine. Santa Fe, N.M.: Doctors in Touch; 2004.
2. Woods MS. Applying Personal Leadership Principles to Health Care: The DEPO Principle. Orlando, Fl.: American College of Physician Executives; 2001.
3. Leape LL. National Patient Safety Foundation. Understanding the power of apology: how saying “I’m sorry" helps heal patients and caregivers. Focus on Patient Safety. 2005;8:1-3.
4. Lazare A. On Apology. Oxford, U.K.: Oxford University Press; 2004.
5. Boothman RC. Apologies and a strong defense at the University of Michigan Health System. Physician Exec. 2006 Mar-Apr; 32(2):7-10.
6. Weber DO. Who’s sorry now? Special report: patient trust and safety. Physician Exec. 2006 Mar-Apr:32(2)6-14.
7. When Things Go Wrong: Responding to Adverse Events. A Consensus Statement of the Harvard Hospitals. Burlington, Massachusetts: Massachusetts Coalition for the Prevention of Medical Errors; 2006.
8. Barnett PB. Rapport and the hospitalist. Am J Med. 2001;111:31S-35S.
9. Leape LL. Full disclosure and apology—an idea whose time has come. Physician Exec. Mar-Apr 2006 32:16-18.
10. Beckman HB, Markakis KM, Suchman AL, et al. The doctor-patient relationship and malpractice. Lessons from plaintiff depositions. Arch Intern Med. Jun 27 1994;154(12):1365-1370.
11. Cohen JR. Apology and organizations: Exploring an example from medical practice. Fordham Urban Law J. 2000;27(5):1447-1482.
12. Cohen JR. Advising clients to apologize. South Calif Law Rev. 1999;72:1009-1069.
13. Entman SS, Glass CA, Hickson GB, et al. The relationship between malpractice claims history and subsequent obstetric care. JAMA. 1994 Nov 23-30;272(20):1588-1591.
14. Gesensway D. Hospitalists and the malpractice insurance crisis. The Hospitalist. 2002Jul/Aug;11-13.
15. Levinson W, Roter D, Mullooly JP, et al. Physician-patient communication: the relationship with malpractice claims among primary care physicians and surgeons. JAMA. 1997 Feb19;227(7):553-559.
16. Lo B. Ethical and policy implications of hospitalist systems. Dis Mon. 2002 Apr;48(4):281-290.
17. Mello MM, Studdert DM, Brennan TA. The new medical malpractice crisis. New Engl J Med. 2003 Jun 5;348(23):2281-2284.
18. Shapiro RS, Simpson DE, Lawrence SL, et al. A survey of sued and nonsued physicians and suing patients. Arch Intern Med. 1989 Oct;149(10):2190-2196.
19. Zimmerman R. Doctors' new tool to fight lawsuits: saying 'I'm sorry.' Malpractice insurers find owning up to errors soothes patient anger. 'The risks are extraordinary.' J Okla State Med Assoc. 2004 Jun;97(6):245-247.
20. Ambady N, LaPlante D, Nguyen T, et al. Surgeons' tone of voice: a clue to malpractice history. Surgery. 2002 Jul;132(1):5-9.
21. Wu AW. Handling hospital errors: is disclosure the best defense? Ann Intern Med. 1999 Dec 21;131(12):970-972.
22. Localio AR, Lawthers AG, Brennan TA, et al. Relation between malpractice claims and adverse events due to negligence. Results of the Harvard Medical Practice Study III. N Engl J Med. 1991 Jul 25;325(4):245-251.
23. Brennan TA, Sox CM, Burstin HR. Relation between negligent adverse events and the outcomes of medical-malpractice litigation. N Engl J Med. 1996 Dec;335(26):1963-1967.
24. Hickson GB, Federspiel CF, Pichert JW, et al. Patient complaints and malpractice risk. JAMA. 2002 Jun 12;287(22):2951-1957.
25. Stelfox HT, Gandhi TK, Orav EJ, et al. The relation of patient satisfaction with complaints against physicians and malpractice lawsuits. Am J Med. 2005 Oct;118(10):1126-1133.
26. Pham HH, Devers KJ, Kuo S, et al. Health care market trends and the evolution of hospitalist use and roles. J Gen Intern Med. 2005 Feb;20(2):101-107.
27. Harris Interactive(R). Telephone survey conducted for the American Academy on Physician and Patient, March 3-6, 2006.

Apologizing to a patient is the right thing to do,” says Michael S. Woods, MD, a general surgeon at St. Vincent’s Regional Medical Center in Santa Fe, N.M. “It is the respectful thing in any relationship in terms of trust whenever there is a violation, whether it is real or perceived.” Dr. Woods, the author of Healing Words: The Power of Apology in Medicine, teaches and consults with corporations around the country about apology as well as physician leadership.1-2 In fact, his study of apology stemmed from examining the subject of physician leadership, and he and other experts consider the vital components of leadership to be effective communication, integrity, honesty, and respectful treatment of other individuals.3,4

Dr. Woods also works with Doug Wojcieszak, a public relations consultant whose victims’ rights group proposed “Sorry Works!” This program recommends apologies and settlements when medical mistakes occur. (See “A History of Sorry Works!” p. 26.) Dr. Woods says Wojcieszak comes from an interesting angle that he supports. “Something I increasingly try to hammer home when I speak is that one of the most important components of the apology law has nothing to do with the backhand of the reduction of litigation as much as the fact that it gives the physician the green light to say ‘I’m sorry,’” says Dr. Woods.

The Benefit of Healing

Providers may be less than open when things go terribly wrong because of feelings of fear, shame, and guilt regarding the consequences to the patient as well as to themselves.1,3 Apology heals by restoring the patient’s dignity and self-respect, providing assurance of shared values, and assuring patients that they are not at fault, they are now safe, and that the caregiver shares their suffering.4,7

Two Senses of Apology

There are circumstances other than when errors occur in which a physician’s apology may carry the power to improve patient care. Peter Barnett, MD, MPH, a clinical associate professor of medicine at the University of New Mexico in Albuquerque, says that in general there are two senses of apology.

“The first sense of apology regards the situation,” he says. For example, you might say, ‘I’m sorry you have cancer,’ or ‘I’m sorry that our system doesn’t allow your family doctor to be taking care of you in the hospital.’ It’s an expression of sympathy, but I think apology works better.”

The other sense of apology regards responsibility, says Dr. Barnett, citing the example, “I’m sorry I gave you the wrong drug.”

Situational needs for apology include when patients have been waiting a long time, such as when a hospitalist meets them in the emergency department. “In those cases you would say, ‘I’m sorry that you had to wait so long,’” says Dr. Barnett. “It’s not my fault, but I really am sorry.”

Bridging the Gap

Dr. Barnett, who practices hospital medicine part-time along with his major focus in addiction medicine, was formerly the director of the UNM hospitalist team. He explains that one of the primary reasons hospitalists may need to apologize to patients is that the hospitalist and patient have no prior relationship that could serve as a foundation for interpreting each other’s behavior.8

He believes apologizing for the delays and inconveniences that happen in the hospital “can help bridge the relationship gap in hospital medicine. Because what people believe about their primary care physicians is that they know and care about them,” he says. “To minimize their anxiety about you, show them that you do care about them by getting to know them well, and apology is the one of the best ways of doing that.”

When asked to elaborate what he means by “getting to know them well,” Dr. Barnett says, “I might tell someone, ‘I’d like to get to know you better; what can you tell me about yourself that would help bring me up to speed?’” It’s open-ended, he says, and you let the patient choose the topic. “Most people will say something. … It’s empathic inquiry with really good reflective listening; that is probably the simplest way of summarizing what it takes.”

Dr. Barnett suggests this kind of inquiry can mitigate the gaps in relationships that may lead to misunderstandings, edgy situations, and errors that may later call for apology. He recommends asking or saying some of the following to patients:

• What do you know about your illness?
• What do you believe about your illness?
• What are your feelings, values, beliefs, and preferences about/for your treatment?
• What can you tell me about your experiences in the hospital?

For patients who have been ill many times and have had a lot of medical experience, you could ask:

• Could you tell me about your doctors?
• What do you like about doctors?
• What don’t you like about your doctors?

These questions can help you discern who they are as a patient, and it gives patients the opportunity to be candid with you.

“It’s not about finding information that’s embarrassing or critical to your predecessor physicians, but it allows you to not make the same mistakes inadvertently,” says Dr. Barnett, who considers it concrete information. “I want them to have good medical care. I don’t want to make them unhappy. I want to avoid pitfalls. I think the two of us—the patient and I—should avoid pitfalls together.”

Asking the patient in a straightforward way what they want and don’t want gives the patient an opportunity to give the physician advice on how to stay out of trouble with them.

Apology When Disclosing Errors

The matter of assuming responsibility for errors is more complicated as it pertains to the use of apology, but it is an “idea whose time has come.”9 Although it is hard to quantify, plenty of evidence shows that apologizing for errors reduces the number of lawsuits and may reduce the settlement value of malpractice claims.3,5-7,10-26 Although there is not always agreement about the specifics of full disclosure, above all patients have the right to know what happens during their medical care and, therefore, restricting the information that is given to a patient can have legal ramifications.

Beyond this, writes Lucian Leape, MD, adjunct professor of health policy at the Harvard School of Public Health and an internationally recognized leader in the patient safety movement, wrote in the March-April issue of Physician Executive that apology is a “therapeutic necessity” that allows the patient to recognize a physician’s humanity and fallibility as well as his or her remorse at having caused harm.9 In the long run, apologizing to patients defuses more situations than it aggravates, and it pays off emotionally, financially, and in practice morale.5,6,9

Data from studies of medical practices that issue apologies in circumstances where accountability is clearly established show that litigation claims are reduced. In one 1992 study, 24% of people who sued physicians said they did so because the doctor was dishonest and withheld information. Nineteen percent said that they either sued to deter subsequent malpractice or for revenge.11,12 In each case of legal action, the investigators hypothesized that the doctor could have avoided the lawsuit by taking responsibility and apologizing up front and making amends at that time. It has been estimated that more than half of claims relegated to litigation could be avoided with use of prudent disclosure and apology.3,21

“My mantra, if you will,” says Dr. Woods, “is that [when] you apologize because it’s the right thing to do, all the benefits naturally ensue.”

Anticipating Apology

The issue of complications, adverse events, and errors carries its own protocol in terms of whether and how apology is offered. “Hopefully some of these have been anticipated,” says Dr. Barnett. “For instance, when you spoke with the patient about their pneumonia, you’ve said something about the possibility that pneumonias could become complicated, and [they] might have some kind of complications; or if they’ve had a heart attack, [you mentioned that] they might have some complications. So you’re actually already warning people about what could happen and you’ve said you’re going to try to prevent it, but it could [still happen].”

Apology can be appropriately offered when those events do occur and you genuinely express disappointment that you and the patient share.

“There are some quite complicated systematic problems [related to apology and hospital medicine],” says Dr. Barnett. “Some are communication aspects and some are legal ones. What I have heard from the attorneys is that you want to keep the apology relatively simple, … and it shouldn’t include any statements about other people who may have been involved, such as pharmacy or nurses.”

The other important issue related to hospitalists and apology, says Dr. Barnett, is that because of the lack of relationship, the severity of illness of the patients you are treating, and the strangeness of systems, people come to the hospital expecting errors. They expect them and may be afraid of them. In particular, when a medication error is made, they expect those errors to be disclosed to them.7,27 Dr. Barnett believes patients are waiting and watching, and hoping that nothing happens to them. Complicating the issue, he says, is that “many hospitalists are fairly guarded in this respect. The emotional deck is sort of stacked against everybody, so if the hospitalist is sensitive about the situation, that tends actually to make the situation worse. If you can apologize sincerely and simply, the patient may be reassured that you’re not trying to conceal anything, you’re honest, you’re on top of it, and you’ll do your best to deal with it,” he says, adding, “they know that that stuff happens; they hope that it is not hidden, ignored, or mismanaged.”

Start Early and Let It Flow

Dr. Woods’ advice is to offer apology earlier rather than later and to widen the spectrum of those to whom you wish to show your empathy, sympathy, respect, and compassion.

“What I promote to organizations is that they drive this into the consciousness of the organization by getting people to apologize for the least infraction—not waiting for the grave errors.” He interprets this as apologizing “when you’re running 30 minutes late, apologize when you’ve interrupted the patient or the family when they’re speaking. These are the things we would do for our spouse or our significant other or our family members; why is it any different at work?”

He also believes it is inherent for doctors as leaders to “apologize to your staff members, apologize to the nurses.” Because the image you express serves as a role model in this regard and will permeate your practice culture. Drive respectful treatment as a basic common social courtesy into the organizational consciousness, says Dr. Woods, and then in any circumstance where an apology is offered, it is perceived as authentic.

Conclusion

Hospitalists may find a need to apologize to patients and families for situations and circumstances in the hospital environment as well as the gap in relationship that exists when hospitalists and patients first encounter each other. Apologizing early rather than later as well as simply and authentically goes a long way to help achieve the ethical and business objectives held by most hospital physicians. TH

Andrea Sattinger wrote about error reporting in the May issue.

References

1. Woods MS, Star JI. Healing Words: The Power of Apology in Medicine. Santa Fe, N.M.: Doctors in Touch; 2004.
2. Woods MS. Applying Personal Leadership Principles to Health Care: The DEPO Principle. Orlando, Fl.: American College of Physician Executives; 2001.
3. Leape LL. National Patient Safety Foundation. Understanding the power of apology: how saying “I’m sorry" helps heal patients and caregivers. Focus on Patient Safety. 2005;8:1-3.
4. Lazare A. On Apology. Oxford, U.K.: Oxford University Press; 2004.
5. Boothman RC. Apologies and a strong defense at the University of Michigan Health System. Physician Exec. 2006 Mar-Apr; 32(2):7-10.
6. Weber DO. Who’s sorry now? Special report: patient trust and safety. Physician Exec. 2006 Mar-Apr:32(2)6-14.
7. When Things Go Wrong: Responding to Adverse Events. A Consensus Statement of the Harvard Hospitals. Burlington, Massachusetts: Massachusetts Coalition for the Prevention of Medical Errors; 2006.
8. Barnett PB. Rapport and the hospitalist. Am J Med. 2001;111:31S-35S.
9. Leape LL. Full disclosure and apology—an idea whose time has come. Physician Exec. Mar-Apr 2006 32:16-18.
10. Beckman HB, Markakis KM, Suchman AL, et al. The doctor-patient relationship and malpractice. Lessons from plaintiff depositions. Arch Intern Med. Jun 27 1994;154(12):1365-1370.
11. Cohen JR. Apology and organizations: Exploring an example from medical practice. Fordham Urban Law J. 2000;27(5):1447-1482.
12. Cohen JR. Advising clients to apologize. South Calif Law Rev. 1999;72:1009-1069.
13. Entman SS, Glass CA, Hickson GB, et al. The relationship between malpractice claims history and subsequent obstetric care. JAMA. 1994 Nov 23-30;272(20):1588-1591.
14. Gesensway D. Hospitalists and the malpractice insurance crisis. The Hospitalist. 2002Jul/Aug;11-13.
15. Levinson W, Roter D, Mullooly JP, et al. Physician-patient communication: the relationship with malpractice claims among primary care physicians and surgeons. JAMA. 1997 Feb19;227(7):553-559.
16. Lo B. Ethical and policy implications of hospitalist systems. Dis Mon. 2002 Apr;48(4):281-290.
17. Mello MM, Studdert DM, Brennan TA. The new medical malpractice crisis. New Engl J Med. 2003 Jun 5;348(23):2281-2284.
18. Shapiro RS, Simpson DE, Lawrence SL, et al. A survey of sued and nonsued physicians and suing patients. Arch Intern Med. 1989 Oct;149(10):2190-2196.
19. Zimmerman R. Doctors' new tool to fight lawsuits: saying 'I'm sorry.' Malpractice insurers find owning up to errors soothes patient anger. 'The risks are extraordinary.' J Okla State Med Assoc. 2004 Jun;97(6):245-247.
20. Ambady N, LaPlante D, Nguyen T, et al. Surgeons' tone of voice: a clue to malpractice history. Surgery. 2002 Jul;132(1):5-9.
21. Wu AW. Handling hospital errors: is disclosure the best defense? Ann Intern Med. 1999 Dec 21;131(12):970-972.
22. Localio AR, Lawthers AG, Brennan TA, et al. Relation between malpractice claims and adverse events due to negligence. Results of the Harvard Medical Practice Study III. N Engl J Med. 1991 Jul 25;325(4):245-251.
23. Brennan TA, Sox CM, Burstin HR. Relation between negligent adverse events and the outcomes of medical-malpractice litigation. N Engl J Med. 1996 Dec;335(26):1963-1967.
24. Hickson GB, Federspiel CF, Pichert JW, et al. Patient complaints and malpractice risk. JAMA. 2002 Jun 12;287(22):2951-1957.
25. Stelfox HT, Gandhi TK, Orav EJ, et al. The relation of patient satisfaction with complaints against physicians and malpractice lawsuits. Am J Med. 2005 Oct;118(10):1126-1133.
26. Pham HH, Devers KJ, Kuo S, et al. Health care market trends and the evolution of hospitalist use and roles. J Gen Intern Med. 2005 Feb;20(2):101-107.
27. Harris Interactive(R). Telephone survey conducted for the American Academy on Physician and Patient, March 3-6, 2006.

Apologizing to a patient is the right thing to do,” says Michael S. Woods, MD, a general surgeon at St. Vincent’s Regional Medical Center in Santa Fe, N.M. “It is the respectful thing in any relationship in terms of trust whenever there is a violation, whether it is real or perceived.” Dr. Woods, the author of Healing Words: The Power of Apology in Medicine, teaches and consults with corporations around the country about apology as well as physician leadership.1-2 In fact, his study of apology stemmed from examining the subject of physician leadership, and he and other experts consider the vital components of leadership to be effective communication, integrity, honesty, and respectful treatment of other individuals.3,4

Dr. Woods also works with Doug Wojcieszak, a public relations consultant whose victims’ rights group proposed “Sorry Works!” This program recommends apologies and settlements when medical mistakes occur. (See “A History of Sorry Works!” p. 26.) Dr. Woods says Wojcieszak comes from an interesting angle that he supports. “Something I increasingly try to hammer home when I speak is that one of the most important components of the apology law has nothing to do with the backhand of the reduction of litigation as much as the fact that it gives the physician the green light to say ‘I’m sorry,’” says Dr. Woods.

The Benefit of Healing

Providers may be less than open when things go terribly wrong because of feelings of fear, shame, and guilt regarding the consequences to the patient as well as to themselves.1,3 Apology heals by restoring the patient’s dignity and self-respect, providing assurance of shared values, and assuring patients that they are not at fault, they are now safe, and that the caregiver shares their suffering.4,7

Two Senses of Apology

There are circumstances other than when errors occur in which a physician’s apology may carry the power to improve patient care. Peter Barnett, MD, MPH, a clinical associate professor of medicine at the University of New Mexico in Albuquerque, says that in general there are two senses of apology.

“The first sense of apology regards the situation,” he says. For example, you might say, ‘I’m sorry you have cancer,’ or ‘I’m sorry that our system doesn’t allow your family doctor to be taking care of you in the hospital.’ It’s an expression of sympathy, but I think apology works better.”

The other sense of apology regards responsibility, says Dr. Barnett, citing the example, “I’m sorry I gave you the wrong drug.”

Situational needs for apology include when patients have been waiting a long time, such as when a hospitalist meets them in the emergency department. “In those cases you would say, ‘I’m sorry that you had to wait so long,’” says Dr. Barnett. “It’s not my fault, but I really am sorry.”

Bridging the Gap

Dr. Barnett, who practices hospital medicine part-time along with his major focus in addiction medicine, was formerly the director of the UNM hospitalist team. He explains that one of the primary reasons hospitalists may need to apologize to patients is that the hospitalist and patient have no prior relationship that could serve as a foundation for interpreting each other’s behavior.8