Editors’ note: During 2006 we will publish coverage of hospital practices in other countries. This and the article on Iraq (p. 28) are the third and fourth articles in that effort.

At the Ontario Hospital Association’s (OHA) CEO Forum in September 2003, Stephen Lewis, the United Nations Secretary General’s Special Envoy for HIV/AIDS in Africa, challenged Ontario’s hospital leaders to take a leadership role in the fight to treat and prevent the spread of HIV/AIDS in sub-Saharan Africa. Lewis’ compelling words evoked an outpouring of interest on the part of Ontario’s healthcare and hospital community, culminating in the launch of the OHAfrica Project in 2004 by the OHA and its affiliated health research foundation, The Change Foundation.

OHAfrica supports a small team of Ontario healthcare professionals working at the first public HIV/AIDS treatment center in the southern African country of Lesotho. The Tsepong “Place of Hope” Clinic is located in the town of Leribe. The Canadian team includes two physicians, one nurse practitioner, one registered nurse, one pharmacist, and one program administrator—all working alongside a small number of local staff.

The landlocked country of Lesotho was chosen at Lewis’ recommendation. The southern African Kingdom of Lesotho was selected as the focus of the OHAfrica project. Close to 30% of all Basotho people between ages 15 and 49 are infected with HIV, and Lesotho has the fourth-highest HIV prevalence rate in the world. More than 100,000 children have been orphaned by HIV/AIDS, and approximately 29,000 people in Lesotho die of AIDS every year.

Since OHAfrica was launched on World AIDS Day in December 2004 the project has accomplished a great deal. The Tsepong Clinic has become the largest antiretroviral (ARV) treatment center in the country, and the clinic enrolls more than half of all new patients put on ARVs in Lesotho each month.

Until recently, antiretroviral drugs were beyond the means of most people in Africa, costing between $12,000 and $15,000 per year. With newly available generic drugs, the cost to provide one person in Lesotho with ARV treatment for one year is now approximately $140—less than .40 cents per day.

The ARV drugs available at the Tsepong Clinic are provided to patients free of charge, thanks to an agreement between the government of Lesotho and the Global Fund to Fight AIDS, Tuberculosis and Malaria. In 2006 children on ARVs at Tsepong will benefit from a guaranteed pediatric drug supply for the entire year, thanks to generous support from The Clinton Foundation, created by former President Bill Clinton. The Clinton Foundation was instrumental in negotiating the deal with pharmaceuticals companies to allow for the sale of generic antiretroviral drugs, which in turn allowed third-world countries access to life-saving treatment. The Clinton Foundation has a particular focus on ensuring that children get access to antiretroviral drugs and has been supportive of pediatric drug supply in Lesotho.

When the OHAfrica team arrived at Tsepong in December 2004, there were only nine patients enrolled on ARVs and 116 patients registered at the clinic. By the end of December 2005, the Tsepong Clinic had enrolled 1,151 patients on ARV treatment and 3,649 HIV-positive clients were registered at the clinic.

The impact of the OHAfrica project and the work of the Tsepong Clinic is seen in the lives of individuals, in the atmosphere of the community, and in the growing support for programs assisting people living with HIV/AIDS in the region. Patients at Tsepong have a new sense of hope and optimism for their future. Since life-saving treatment became more readily available, more people are willing to be tested for HIV, and steps are being taken to help break the stigma and fear surrounding HIV/AIDS within the surrounding community and throughout Lesotho.

The primary goal of OHAfrica is to help Lesotho build a locally sustainable HIV/AIDS treatment program. This is a big challenge in a country where the healthcare system is overburdened and there is a shortage of medical professionals. In recent months, the OHAfrica team has been working with community-based primary care clinics in outlying areas to start the process of rolling out ARV treatment at the local level.

The first year of the OHAfrica project has been marked by many challenges, and ultimately many rewards. OHAfrica has brought together healthcare stakeholders from Ontario and Lesotho to address a health issue of global urgency.

The OHA staff marvels at the impact OHAfrica has made in such a short time. “We took a leap of faith, and we are all proud and grateful that our commitment has been met, through the significant efforts of so many people,” says Hilary Short, OHA president and CEO. TH

Homer is the manager for OHAfrica, The Change Foundation & the Ontario Hospital Association.

OHA is a voluntary organization representing approximately 157 public hospital corporations across 225 sites in Ontario. Founded in 1924 as an independent, non-profit organization, the OHA is the voice of Ontario’s hospitals. For more information about OHAfrica and how you can get involved, visit www.ohafrica.ca or call (416) 205-1463

Editors’ note: During 2006 we will publish coverage of hospital practices in other countries. This and the article on Iraq (p. 28) are the third and fourth articles in that effort.

At the Ontario Hospital Association’s (OHA) CEO Forum in September 2003, Stephen Lewis, the United Nations Secretary General’s Special Envoy for HIV/AIDS in Africa, challenged Ontario’s hospital leaders to take a leadership role in the fight to treat and prevent the spread of HIV/AIDS in sub-Saharan Africa. Lewis’ compelling words evoked an outpouring of interest on the part of Ontario’s healthcare and hospital community, culminating in the launch of the OHAfrica Project in 2004 by the OHA and its affiliated health research foundation, The Change Foundation.

OHAfrica supports a small team of Ontario healthcare professionals working at the first public HIV/AIDS treatment center in the southern African country of Lesotho. The Tsepong “Place of Hope” Clinic is located in the town of Leribe. The Canadian team includes two physicians, one nurse practitioner, one registered nurse, one pharmacist, and one program administrator—all working alongside a small number of local staff.

The landlocked country of Lesotho was chosen at Lewis’ recommendation. The southern African Kingdom of Lesotho was selected as the focus of the OHAfrica project. Close to 30% of all Basotho people between ages 15 and 49 are infected with HIV, and Lesotho has the fourth-highest HIV prevalence rate in the world. More than 100,000 children have been orphaned by HIV/AIDS, and approximately 29,000 people in Lesotho die of AIDS every year.

Since OHAfrica was launched on World AIDS Day in December 2004 the project has accomplished a great deal. The Tsepong Clinic has become the largest antiretroviral (ARV) treatment center in the country, and the clinic enrolls more than half of all new patients put on ARVs in Lesotho each month.

Until recently, antiretroviral drugs were beyond the means of most people in Africa, costing between $12,000 and $15,000 per year. With newly available generic drugs, the cost to provide one person in Lesotho with ARV treatment for one year is now approximately $140—less than .40 cents per day.

The ARV drugs available at the Tsepong Clinic are provided to patients free of charge, thanks to an agreement between the government of Lesotho and the Global Fund to Fight AIDS, Tuberculosis and Malaria. In 2006 children on ARVs at Tsepong will benefit from a guaranteed pediatric drug supply for the entire year, thanks to generous support from The Clinton Foundation, created by former President Bill Clinton. The Clinton Foundation was instrumental in negotiating the deal with pharmaceuticals companies to allow for the sale of generic antiretroviral drugs, which in turn allowed third-world countries access to life-saving treatment. The Clinton Foundation has a particular focus on ensuring that children get access to antiretroviral drugs and has been supportive of pediatric drug supply in Lesotho.

When the OHAfrica team arrived at Tsepong in December 2004, there were only nine patients enrolled on ARVs and 116 patients registered at the clinic. By the end of December 2005, the Tsepong Clinic had enrolled 1,151 patients on ARV treatment and 3,649 HIV-positive clients were registered at the clinic.

The impact of the OHAfrica project and the work of the Tsepong Clinic is seen in the lives of individuals, in the atmosphere of the community, and in the growing support for programs assisting people living with HIV/AIDS in the region. Patients at Tsepong have a new sense of hope and optimism for their future. Since life-saving treatment became more readily available, more people are willing to be tested for HIV, and steps are being taken to help break the stigma and fear surrounding HIV/AIDS within the surrounding community and throughout Lesotho.

The primary goal of OHAfrica is to help Lesotho build a locally sustainable HIV/AIDS treatment program. This is a big challenge in a country where the healthcare system is overburdened and there is a shortage of medical professionals. In recent months, the OHAfrica team has been working with community-based primary care clinics in outlying areas to start the process of rolling out ARV treatment at the local level.

The first year of the OHAfrica project has been marked by many challenges, and ultimately many rewards. OHAfrica has brought together healthcare stakeholders from Ontario and Lesotho to address a health issue of global urgency.

The OHA staff marvels at the impact OHAfrica has made in such a short time. “We took a leap of faith, and we are all proud and grateful that our commitment has been met, through the significant efforts of so many people,” says Hilary Short, OHA president and CEO. TH

Homer is the manager for OHAfrica, The Change Foundation & the Ontario Hospital Association.

OHA is a voluntary organization representing approximately 157 public hospital corporations across 225 sites in Ontario. Founded in 1924 as an independent, non-profit organization, the OHA is the voice of Ontario’s hospitals. For more information about OHAfrica and how you can get involved, visit www.ohafrica.ca or call (416) 205-1463

Editors’ note: During 2006 we will publish coverage of hospital practices in other countries. This and the article on Iraq (p. 28) are the third and fourth articles in that effort.

At the Ontario Hospital Association’s (OHA) CEO Forum in September 2003, Stephen Lewis, the United Nations Secretary General’s Special Envoy for HIV/AIDS in Africa, challenged Ontario’s hospital leaders to take a leadership role in the fight to treat and prevent the spread of HIV/AIDS in sub-Saharan Africa. Lewis’ compelling words evoked an outpouring of interest on the part of Ontario’s healthcare and hospital community, culminating in the launch of the OHAfrica Project in 2004 by the OHA and its affiliated health research foundation, The Change Foundation.

OHAfrica supports a small team of Ontario healthcare professionals working at the first public HIV/AIDS treatment center in the southern African country of Lesotho. The Tsepong “Place of Hope” Clinic is located in the town of Leribe. The Canadian team includes two physicians, one nurse practitioner, one registered nurse, one pharmacist, and one program administrator—all working alongside a small number of local staff.

The landlocked country of Lesotho was chosen at Lewis’ recommendation. The southern African Kingdom of Lesotho was selected as the focus of the OHAfrica project. Close to 30% of all Basotho people between ages 15 and 49 are infected with HIV, and Lesotho has the fourth-highest HIV prevalence rate in the world. More than 100,000 children have been orphaned by HIV/AIDS, and approximately 29,000 people in Lesotho die of AIDS every year.

Since OHAfrica was launched on World AIDS Day in December 2004 the project has accomplished a great deal. The Tsepong Clinic has become the largest antiretroviral (ARV) treatment center in the country, and the clinic enrolls more than half of all new patients put on ARVs in Lesotho each month.

Until recently, antiretroviral drugs were beyond the means of most people in Africa, costing between $12,000 and $15,000 per year. With newly available generic drugs, the cost to provide one person in Lesotho with ARV treatment for one year is now approximately $140—less than .40 cents per day.

The ARV drugs available at the Tsepong Clinic are provided to patients free of charge, thanks to an agreement between the government of Lesotho and the Global Fund to Fight AIDS, Tuberculosis and Malaria. In 2006 children on ARVs at Tsepong will benefit from a guaranteed pediatric drug supply for the entire year, thanks to generous support from The Clinton Foundation, created by former President Bill Clinton. The Clinton Foundation was instrumental in negotiating the deal with pharmaceuticals companies to allow for the sale of generic antiretroviral drugs, which in turn allowed third-world countries access to life-saving treatment. The Clinton Foundation has a particular focus on ensuring that children get access to antiretroviral drugs and has been supportive of pediatric drug supply in Lesotho.

When the OHAfrica team arrived at Tsepong in December 2004, there were only nine patients enrolled on ARVs and 116 patients registered at the clinic. By the end of December 2005, the Tsepong Clinic had enrolled 1,151 patients on ARV treatment and 3,649 HIV-positive clients were registered at the clinic.

The impact of the OHAfrica project and the work of the Tsepong Clinic is seen in the lives of individuals, in the atmosphere of the community, and in the growing support for programs assisting people living with HIV/AIDS in the region. Patients at Tsepong have a new sense of hope and optimism for their future. Since life-saving treatment became more readily available, more people are willing to be tested for HIV, and steps are being taken to help break the stigma and fear surrounding HIV/AIDS within the surrounding community and throughout Lesotho.

The primary goal of OHAfrica is to help Lesotho build a locally sustainable HIV/AIDS treatment program. This is a big challenge in a country where the healthcare system is overburdened and there is a shortage of medical professionals. In recent months, the OHAfrica team has been working with community-based primary care clinics in outlying areas to start the process of rolling out ARV treatment at the local level.

The first year of the OHAfrica project has been marked by many challenges, and ultimately many rewards. OHAfrica has brought together healthcare stakeholders from Ontario and Lesotho to address a health issue of global urgency.

The OHA staff marvels at the impact OHAfrica has made in such a short time. “We took a leap of faith, and we are all proud and grateful that our commitment has been met, through the significant efforts of so many people,” says Hilary Short, OHA president and CEO. TH

Homer is the manager for OHAfrica, The Change Foundation & the Ontario Hospital Association.

OHA is a voluntary organization representing approximately 157 public hospital corporations across 225 sites in Ontario. Founded in 1924 as an independent, non-profit organization, the OHA is the voice of Ontario’s hospitals. For more information about OHAfrica and how you can get involved, visit www.ohafrica.ca or call (416) 205-1463

It’s extremely hard being in a room with a family that is angry, confrontational, and hostile,” says clinical social worker Jane B. Hawgood, MSW, who often works with the hospitalist group on the General Medicine Service at the University of California at San Francisco Medical Center. “When you read about these cases in a textbook, it seems so clean and neat.”

Hospitalists have all encountered them: family members who, because of their behavior toward providers, come to be labeled as “difficult.” What are the best ways to deal with patients’ family members who are unresponsive, overbearing, or outright hostile to physicians and the care team? And how do you proceed to a treatment plan that is best for the patient?

The first step, believes Thomas Baudendistel, MD, FACP, associate program director of the Internal Medicine Residency Program at Sutter Health’s California Pacific Medical Center in San Francisco, and chair of SHM’s Ethics Committee, is to avoid using the term “difficult.”

“I think ‘difficult’ is a loaded term and kind of pejorative,” says Dr. Baudendistel. “When their loved ones are in the hospital, families are vulnerable. They don’t really know what to expect. I don’t know that I wouldn’t want my grandmother, or mother described as a ‘difficult patient,’ or a family member described as ‘difficult.’ Rather than saying, ‘this is a difficult family member,’ I would rather phrase it, ‘This is someone who has a lot of worries.’ ”

Hawgood employs a similar approach. “I like to define the situation as ‘a family member who is having difficulty dealing with the patient’s illness,’” she says. “If I hear, during rounds, that this family is difficult, I immediately begin asking myself, ‘Why are they having difficulty? Is this an interpersonal issue? Does this family member have a psychiatric history? Is there a history of a past problem with the medical system? Is it a financial issue?’ I really try not to presume things. I always try and keep an open mind about what a patient’s and family’s goals are, and what I can do to help. You need to clearly understand your goals and have good support from your team to redirect the energy.”

“Unrealistic expectations” might describe some of the encounters for Adrienne Bennett, MD, director for the Division of Hospital Medicine and associate clinical professor of medicine at Ohio State University. In her former post as founder and director of hospitalist services at Newton Wellesley, a community teaching hospital in the western suburbs of Boston, she and colleagues dealt with a relatively affluent patient population. Some of the patients and families, she says, “can sometimes be somewhat demanding and difficult if they feel they aren’t getting what they’re entitled to. In that sense, they can become ‘the angry daughter,’ as my colleague used to say.”

Building Trust

Because they do not have an ongoing history with patients, hospitalists may often be starting at a disadvantage in forming a new relationship. Dr. Baudendistel believes hospitalists can quickly learn the skill of reassuring patients and their families. One way to do that, he says, is to “link with the primary care physician.” He often calls the primary care physician and tells the family of his conversations with the family doctor, thus establishing a level of comfort for them. He makes it clear to the family that he is available to them, giving them phone and pager numbers so they can easily reach him.

Dr. Baudendistel also tries to accommodate family members’ schedules, setting up visits when working family members are able to come to the hospital or making sure to have daily telephone contact if it is not possible to synchronize in-person visits with them.

Most families, he has found, are then willing to listen and work with him. As familiarity with hospitalists increases, family concerns about a “stranger” caring for their loved one slowly diminish. “Patients and families generally accept the idea of seeing a new doctor in the hospital a little bit more easily each year that goes by,” he notes.

Another technique used at California Pacific Medical Center, Dr. Baudendistel adds, is to pair a hospitalist with the same patient if he or she is readmitted. “We really believe in the continuity of the relationship, so we try to preserve that as much as possible,” he says, “because the big obstacle for hospitalists is always handoffs.”

On the Same Page

Intrinsic to forming a relationship with the patient and family is to discuss their goals of care, says Hawgood. Shana Weber, DO, FAAP, a pediatric hospitalist at Alaska Native Medical Center in Anchorage, agrees.

“You need to be on the same page,” she says. “Without knowing what the parents are hoping to get from their child’s stay before discharge, you really cannot help them.”

For instance, says Dr. Weber, some parents may be surprised to learn that their child is going to be sent home with a feeding tube or other nursing care needs.

“It is important to find out what their agenda is and what yours is. Parents’ expectations can be very different from ours,” she explains. “Letting parents know you’re listening—whether or not you agree with what they’re saying—is half the battle. You need to verify their feelings, let them know you’re listening to them, and that you understand their concerns.”

Use Team Resources

Accessing the expertise of other providers may be necessary to complete discharge plans for complicated cases. Dr. Baudendistel recalls a 30-year-old woman with a progressive neurological condition who had previously been living in the community. Her condition had deteriorated to the extent that she would no longer be able to eat safely, and, thus, she would not be able to return home. The team brought in a speech therapist, physical therapist, social worker, and discharge planner to meet with the family and present options.

Hospitalists interviewed for this article agreed that clinical social workers bring a much-needed perspective to dealing with families. One recent case at UCSF Medical Center involved a woman in her late 50s whose cancer, after multiple treatments and treatment complications, had come back very aggressively. One of her daughters, a young woman in her 20s, “had developed a very deep religious faith that she could cure her mother through prayers and faith,” recalls Hawgood. “As her mother deteriorated, the daughter became more angry and hostile to the hospitalists.”

Hawgood approached the daughter and asked if she would sit down and talk with her, and tell her what had gone wrong in the past, and “how we could improve things in the future.” As she listened to the daughter, she realized how much the daughter loved her mother and how desperately frightened she was.

“If I could help you in one way, what would that be?” Hawgood asked the daughter.

After a silence, the daughter replied, “We need a refrigerator.”

It turned out that the family was financially unable to replace a broken refrigerator. To take her mother home, the daughter needed a way to refrigerate enteral feeding supplies. And Hawgood was able to secure a refrigerator for the family, and says that the incident underscored for her the importance of keeping an open mind.

Later, when the mother was dying, Hawgood was again asked by the team to provide support for the daughter so that hospitalists could care for their patient. “She was so angry, and it was directed at the hospitalists,” recalls Hawgood. “It was just her absolute inability to accept that her mother, who was the center in her life, was going to die. You have to give people credit and respect. You have to understand where they’re coming from and what’s going to work for them.”

Training Adequate?

According to a 2003-2004 survey conducted by the American Association of Medical Colleges, 124 out of 125 medical schools included communication skills as required courses for their medical students.1 However, Dr. Baudendistel points out that there are currently no national standards for proficiency in communications skills and that the field is in relative infancy at this time. Inclusion of interpersonal and communication skills as one of the Accreditation Council for Graduate Medical Education’s (ACGME) core competencies will help focus more attention on how to teach communication skills, he believes.2

“Communication is now one of the six core competencies,” he says. “It’s no longer secondary to being a smart doctor: It’s equally important in the view of the ACGME. So I think that will help.”

Beyond standardization of communication skills curricula, it is also necessary, he emphasizes, to verify providers’ proficiency in those skills. In the California Pacific Medical Center’s residency program residents receive 360-degree evaluations. These go beyond the typical evaluations in the past, wherein residents would be evaluated by supervising attending physicians and interns working under them. Now, evaluations of residents are sought from nurses—and from the patients themselves. Obtaining 360-degree feedback from all those who have interacted with the resident functions as a valuable teaching tool.

Experience: the Best Teacher

While most agree that training and required communications courses should be increased, Dr. Bennett points out that some of the hospitalist’s expertise with family communications will simply evolve with time and experience.

“I’ve learned a lot from situations in group meetings with a social worker or a patient ombudsperson, just watching how they manage the situation,” she says. At Newton Wellesley Hospital, social workers and chaplains were sometimes better able to find the right way to phrase something so it came across in a way the family could accept, recalls Dr. Bennett. She raises the a case of a 50-year-old man who came in with cardiac arrest and whom they needed to withdraw from life support. He had been born and raised Catholic, but had converted to Judaism, which was his ex-wife’s religion as well as that of his children. He had an extensive family (he was one of 10 children), who were concerned about his ability to receive Catholic last rites. The chaplain understood the implications for both religions and was able to negotiate a compromise that satisfied both sides and allowed life support to be withdrawn.

Dr. Weber, who completed her residency at DeVos Children’s Hospital in Grand Rapids, Mich., praised the training she received in doctor-patient communications while in medical school. However, once she arrived in Anchorage, she discovered that the cultural norms of Alaska native people required some on-the-job learning.

She once asked an adolescent girl with Crohn’s disease whether she had any belly pain. “She wasn’t answering me, and I thought, ‘Oh great—just another typical teenage girl’” remembers Dr. Weber. “Well, I thought she wasn’t answering me, but she was lifting her eyebrows, which means ‘yes.’ But I didn’t know that.”

Dr. Weber has found nurses and other long-time hospital staff to be very helpful in learning how to communicate with her patient population.

Context and History

Hawgood reminds hospitalists that families often come into hospitals with past histories of things gone wrong.

“The whole healthcare system is so volatile now,” she observes. “People feel rushed, they feel [they are being] rushed out of hospital. They don’t have adequate healthcare insurance; they don’t have adequate care in the community. We send people out with trachs, tube feeds, open wounds, and pain issues. People are dealing with limited money, trying to juggle work, children, and elderly parents. So they have reasons to be angry.”

Families feel frustrated when their loved one is sick, agrees Dr. Baudendistel. “It may be that your role is to just let them vent their frustration.”

Says Hawgood, “I tell the people I train that I have nothing to lose. The patients and their families have everything to lose. So, even if I get off on the wrong foot, I’ll go back and ask, ‘could I start again?’ And usually, people will say, ‘yes.’ It’s up to me to make it work.”

Dr. Weber recalls one family at ANMC with a special needs child who had been in a Seattle hospital, and was readmitted to their facility with kidney stones. He was not getting better and the physicians recommended that the family travel back to Seattle, where a pediatric urologist could remove the stones. The parents were uncomfortable with the recommendation that their son return to Seattle.

“We did need to bring in a mediator, and have several family care conferences with the parents, with social workers and discharge planners, and all involved providers,” says Dr. Weber.

In the course of the conferences, the family revealed that their child’s disabilities were due to a missed diagnosis of meningitis when he was a baby. “They harbored a lot of resentment toward the medical profession in general,” says Dr. Weber. “It was hard to work through that. They couldn’t let it go—and I don’t blame them—and it caused them to always question our motives and our intentions.”

During the care conferences, the team let the family tell their story of the meningitis case again. Just by listening to the family’s history with that event, the team was able to validate the family’s concerns. The parents agreed to take their son to Seattle for the procedure, and later sent a thank you card to the pediatric team at ANMC that had treated him.

Don’t Make Assumptions

Hawgood always cautions physicians to enter the patient’s room with an open mind and to be open to cues and clues about the family’s situation. She praises the UCSF hospitalists’ training of young residents.

“They let them take the lead in patient interviews, then we all discuss how that interview went, and how things could have been done better,” says Hawgood. For instance, she recommends that hospitalists “allow for some silence in the room. You don’t have to fill up every minute with conversation. Look for the non-verbal cues, the things that weren’t said.”

In Dr. Weber’s hospital, pediatric patients come from all over state. It is not unusual for a baby to be in the neonatal intensive care unit for a while before the parents come back to visit. It would be easy to question, she says, whether these people are going to be good parents. “But until you know their social situation, you really have no place saying that,” says Dr. Weber. “You may find that they have six other children at home and cannot be here because they have no other caregivers for their children, and their village is 200 miles away.”

The Best You Can Do

Despite the care team’s best efforts, there will be a few cases, admits Dr. Bennett, where “you just can’t make much headway.” She recalls the case of an elderly man who had had a massive stroke, lived in a nursing home, and had not communicated for years. The man’s daughter was convinced, however, that he communicated with her and was “adamant that everything had to be done. We tried and tried,” explains Dr. Bennett, calling several group meetings and using hospital chaplains as allies, “but she just couldn’t hear it, and couldn’t see it [that her father would not get better]. She was too vested in believing that he did, in fact, communicate with her and that he would get better.”

In such cases the team may have to do the best they can to honor the patient’s and the family member’s value system and help them abide by that.

“There’s one other thing about difficult families and difficult patients: You have such an intense relationship with them that you don’t have with other people,” notes Hawgood. “If you can hang in there, they’re the best relationships you can have. You are so emotionally engaged in trying to make it work. I have chosen to work with hospitalists because of the approach they take. I think it’s the most efficient model you can use in a hospital. We really talk about the goals of care, and what we understand about the patient’s and family’s goals of care. We approach this from the point of view that they deserve care. What can we do to make a difference, so that it works for the patient and the families?” TH

Writer Gretchen Henkel lives in California.

References

• “Number of U.S. Medical Schools Teaching Selected Topics 2003-2004.” Compiled by the American Association of Medical Colleges Institutional Profile System. Available online at: http://services.aamc.org/currdir/section2/03-04hottopics.pdf. Last accessed January 26, 2006.
• General Competencies; ACGME Outcome Project. September, 1999. Available online at: www.acgme.org/outcome/comp/compMin.asp. Last accessed January 27, 2006.

It’s extremely hard being in a room with a family that is angry, confrontational, and hostile,” says clinical social worker Jane B. Hawgood, MSW, who often works with the hospitalist group on the General Medicine Service at the University of California at San Francisco Medical Center. “When you read about these cases in a textbook, it seems so clean and neat.”

Hospitalists have all encountered them: family members who, because of their behavior toward providers, come to be labeled as “difficult.” What are the best ways to deal with patients’ family members who are unresponsive, overbearing, or outright hostile to physicians and the care team? And how do you proceed to a treatment plan that is best for the patient?

The first step, believes Thomas Baudendistel, MD, FACP, associate program director of the Internal Medicine Residency Program at Sutter Health’s California Pacific Medical Center in San Francisco, and chair of SHM’s Ethics Committee, is to avoid using the term “difficult.”

“I think ‘difficult’ is a loaded term and kind of pejorative,” says Dr. Baudendistel. “When their loved ones are in the hospital, families are vulnerable. They don’t really know what to expect. I don’t know that I wouldn’t want my grandmother, or mother described as a ‘difficult patient,’ or a family member described as ‘difficult.’ Rather than saying, ‘this is a difficult family member,’ I would rather phrase it, ‘This is someone who has a lot of worries.’ ”

Hawgood employs a similar approach. “I like to define the situation as ‘a family member who is having difficulty dealing with the patient’s illness,’” she says. “If I hear, during rounds, that this family is difficult, I immediately begin asking myself, ‘Why are they having difficulty? Is this an interpersonal issue? Does this family member have a psychiatric history? Is there a history of a past problem with the medical system? Is it a financial issue?’ I really try not to presume things. I always try and keep an open mind about what a patient’s and family’s goals are, and what I can do to help. You need to clearly understand your goals and have good support from your team to redirect the energy.”

“Unrealistic expectations” might describe some of the encounters for Adrienne Bennett, MD, director for the Division of Hospital Medicine and associate clinical professor of medicine at Ohio State University. In her former post as founder and director of hospitalist services at Newton Wellesley, a community teaching hospital in the western suburbs of Boston, she and colleagues dealt with a relatively affluent patient population. Some of the patients and families, she says, “can sometimes be somewhat demanding and difficult if they feel they aren’t getting what they’re entitled to. In that sense, they can become ‘the angry daughter,’ as my colleague used to say.”

Building Trust

Because they do not have an ongoing history with patients, hospitalists may often be starting at a disadvantage in forming a new relationship. Dr. Baudendistel believes hospitalists can quickly learn the skill of reassuring patients and their families. One way to do that, he says, is to “link with the primary care physician.” He often calls the primary care physician and tells the family of his conversations with the family doctor, thus establishing a level of comfort for them. He makes it clear to the family that he is available to them, giving them phone and pager numbers so they can easily reach him.

Dr. Baudendistel also tries to accommodate family members’ schedules, setting up visits when working family members are able to come to the hospital or making sure to have daily telephone contact if it is not possible to synchronize in-person visits with them.

Most families, he has found, are then willing to listen and work with him. As familiarity with hospitalists increases, family concerns about a “stranger” caring for their loved one slowly diminish. “Patients and families generally accept the idea of seeing a new doctor in the hospital a little bit more easily each year that goes by,” he notes.

Another technique used at California Pacific Medical Center, Dr. Baudendistel adds, is to pair a hospitalist with the same patient if he or she is readmitted. “We really believe in the continuity of the relationship, so we try to preserve that as much as possible,” he says, “because the big obstacle for hospitalists is always handoffs.”

On the Same Page

Intrinsic to forming a relationship with the patient and family is to discuss their goals of care, says Hawgood. Shana Weber, DO, FAAP, a pediatric hospitalist at Alaska Native Medical Center in Anchorage, agrees.

“You need to be on the same page,” she says. “Without knowing what the parents are hoping to get from their child’s stay before discharge, you really cannot help them.”

For instance, says Dr. Weber, some parents may be surprised to learn that their child is going to be sent home with a feeding tube or other nursing care needs.

“It is important to find out what their agenda is and what yours is. Parents’ expectations can be very different from ours,” she explains. “Letting parents know you’re listening—whether or not you agree with what they’re saying—is half the battle. You need to verify their feelings, let them know you’re listening to them, and that you understand their concerns.”

Use Team Resources

Accessing the expertise of other providers may be necessary to complete discharge plans for complicated cases. Dr. Baudendistel recalls a 30-year-old woman with a progressive neurological condition who had previously been living in the community. Her condition had deteriorated to the extent that she would no longer be able to eat safely, and, thus, she would not be able to return home. The team brought in a speech therapist, physical therapist, social worker, and discharge planner to meet with the family and present options.

Hospitalists interviewed for this article agreed that clinical social workers bring a much-needed perspective to dealing with families. One recent case at UCSF Medical Center involved a woman in her late 50s whose cancer, after multiple treatments and treatment complications, had come back very aggressively. One of her daughters, a young woman in her 20s, “had developed a very deep religious faith that she could cure her mother through prayers and faith,” recalls Hawgood. “As her mother deteriorated, the daughter became more angry and hostile to the hospitalists.”

Hawgood approached the daughter and asked if she would sit down and talk with her, and tell her what had gone wrong in the past, and “how we could improve things in the future.” As she listened to the daughter, she realized how much the daughter loved her mother and how desperately frightened she was.

“If I could help you in one way, what would that be?” Hawgood asked the daughter.

After a silence, the daughter replied, “We need a refrigerator.”

It turned out that the family was financially unable to replace a broken refrigerator. To take her mother home, the daughter needed a way to refrigerate enteral feeding supplies. And Hawgood was able to secure a refrigerator for the family, and says that the incident underscored for her the importance of keeping an open mind.

Later, when the mother was dying, Hawgood was again asked by the team to provide support for the daughter so that hospitalists could care for their patient. “She was so angry, and it was directed at the hospitalists,” recalls Hawgood. “It was just her absolute inability to accept that her mother, who was the center in her life, was going to die. You have to give people credit and respect. You have to understand where they’re coming from and what’s going to work for them.”

Training Adequate?

According to a 2003-2004 survey conducted by the American Association of Medical Colleges, 124 out of 125 medical schools included communication skills as required courses for their medical students.1 However, Dr. Baudendistel points out that there are currently no national standards for proficiency in communications skills and that the field is in relative infancy at this time. Inclusion of interpersonal and communication skills as one of the Accreditation Council for Graduate Medical Education’s (ACGME) core competencies will help focus more attention on how to teach communication skills, he believes.2

“Communication is now one of the six core competencies,” he says. “It’s no longer secondary to being a smart doctor: It’s equally important in the view of the ACGME. So I think that will help.”

Beyond standardization of communication skills curricula, it is also necessary, he emphasizes, to verify providers’ proficiency in those skills. In the California Pacific Medical Center’s residency program residents receive 360-degree evaluations. These go beyond the typical evaluations in the past, wherein residents would be evaluated by supervising attending physicians and interns working under them. Now, evaluations of residents are sought from nurses—and from the patients themselves. Obtaining 360-degree feedback from all those who have interacted with the resident functions as a valuable teaching tool.

Experience: the Best Teacher

While most agree that training and required communications courses should be increased, Dr. Bennett points out that some of the hospitalist’s expertise with family communications will simply evolve with time and experience.

“I’ve learned a lot from situations in group meetings with a social worker or a patient ombudsperson, just watching how they manage the situation,” she says. At Newton Wellesley Hospital, social workers and chaplains were sometimes better able to find the right way to phrase something so it came across in a way the family could accept, recalls Dr. Bennett. She raises the a case of a 50-year-old man who came in with cardiac arrest and whom they needed to withdraw from life support. He had been born and raised Catholic, but had converted to Judaism, which was his ex-wife’s religion as well as that of his children. He had an extensive family (he was one of 10 children), who were concerned about his ability to receive Catholic last rites. The chaplain understood the implications for both religions and was able to negotiate a compromise that satisfied both sides and allowed life support to be withdrawn.

Dr. Weber, who completed her residency at DeVos Children’s Hospital in Grand Rapids, Mich., praised the training she received in doctor-patient communications while in medical school. However, once she arrived in Anchorage, she discovered that the cultural norms of Alaska native people required some on-the-job learning.

She once asked an adolescent girl with Crohn’s disease whether she had any belly pain. “She wasn’t answering me, and I thought, ‘Oh great—just another typical teenage girl’” remembers Dr. Weber. “Well, I thought she wasn’t answering me, but she was lifting her eyebrows, which means ‘yes.’ But I didn’t know that.”

Dr. Weber has found nurses and other long-time hospital staff to be very helpful in learning how to communicate with her patient population.

Context and History

Hawgood reminds hospitalists that families often come into hospitals with past histories of things gone wrong.

“The whole healthcare system is so volatile now,” she observes. “People feel rushed, they feel [they are being] rushed out of hospital. They don’t have adequate healthcare insurance; they don’t have adequate care in the community. We send people out with trachs, tube feeds, open wounds, and pain issues. People are dealing with limited money, trying to juggle work, children, and elderly parents. So they have reasons to be angry.”

Families feel frustrated when their loved one is sick, agrees Dr. Baudendistel. “It may be that your role is to just let them vent their frustration.”

Says Hawgood, “I tell the people I train that I have nothing to lose. The patients and their families have everything to lose. So, even if I get off on the wrong foot, I’ll go back and ask, ‘could I start again?’ And usually, people will say, ‘yes.’ It’s up to me to make it work.”

Dr. Weber recalls one family at ANMC with a special needs child who had been in a Seattle hospital, and was readmitted to their facility with kidney stones. He was not getting better and the physicians recommended that the family travel back to Seattle, where a pediatric urologist could remove the stones. The parents were uncomfortable with the recommendation that their son return to Seattle.

“We did need to bring in a mediator, and have several family care conferences with the parents, with social workers and discharge planners, and all involved providers,” says Dr. Weber.

In the course of the conferences, the family revealed that their child’s disabilities were due to a missed diagnosis of meningitis when he was a baby. “They harbored a lot of resentment toward the medical profession in general,” says Dr. Weber. “It was hard to work through that. They couldn’t let it go—and I don’t blame them—and it caused them to always question our motives and our intentions.”

During the care conferences, the team let the family tell their story of the meningitis case again. Just by listening to the family’s history with that event, the team was able to validate the family’s concerns. The parents agreed to take their son to Seattle for the procedure, and later sent a thank you card to the pediatric team at ANMC that had treated him.

Don’t Make Assumptions

Hawgood always cautions physicians to enter the patient’s room with an open mind and to be open to cues and clues about the family’s situation. She praises the UCSF hospitalists’ training of young residents.

“They let them take the lead in patient interviews, then we all discuss how that interview went, and how things could have been done better,” says Hawgood. For instance, she recommends that hospitalists “allow for some silence in the room. You don’t have to fill up every minute with conversation. Look for the non-verbal cues, the things that weren’t said.”

In Dr. Weber’s hospital, pediatric patients come from all over state. It is not unusual for a baby to be in the neonatal intensive care unit for a while before the parents come back to visit. It would be easy to question, she says, whether these people are going to be good parents. “But until you know their social situation, you really have no place saying that,” says Dr. Weber. “You may find that they have six other children at home and cannot be here because they have no other caregivers for their children, and their village is 200 miles away.”

The Best You Can Do

Despite the care team’s best efforts, there will be a few cases, admits Dr. Bennett, where “you just can’t make much headway.” She recalls the case of an elderly man who had had a massive stroke, lived in a nursing home, and had not communicated for years. The man’s daughter was convinced, however, that he communicated with her and was “adamant that everything had to be done. We tried and tried,” explains Dr. Bennett, calling several group meetings and using hospital chaplains as allies, “but she just couldn’t hear it, and couldn’t see it [that her father would not get better]. She was too vested in believing that he did, in fact, communicate with her and that he would get better.”

In such cases the team may have to do the best they can to honor the patient’s and the family member’s value system and help them abide by that.

“There’s one other thing about difficult families and difficult patients: You have such an intense relationship with them that you don’t have with other people,” notes Hawgood. “If you can hang in there, they’re the best relationships you can have. You are so emotionally engaged in trying to make it work. I have chosen to work with hospitalists because of the approach they take. I think it’s the most efficient model you can use in a hospital. We really talk about the goals of care, and what we understand about the patient’s and family’s goals of care. We approach this from the point of view that they deserve care. What can we do to make a difference, so that it works for the patient and the families?” TH

Writer Gretchen Henkel lives in California.

References

• “Number of U.S. Medical Schools Teaching Selected Topics 2003-2004.” Compiled by the American Association of Medical Colleges Institutional Profile System. Available online at: http://services.aamc.org/currdir/section2/03-04hottopics.pdf. Last accessed January 26, 2006.
• General Competencies; ACGME Outcome Project. September, 1999. Available online at: www.acgme.org/outcome/comp/compMin.asp. Last accessed January 27, 2006.

It’s extremely hard being in a room with a family that is angry, confrontational, and hostile,” says clinical social worker Jane B. Hawgood, MSW, who often works with the hospitalist group on the General Medicine Service at the University of California at San Francisco Medical Center. “When you read about these cases in a textbook, it seems so clean and neat.”

Hospitalists have all encountered them: family members who, because of their behavior toward providers, come to be labeled as “difficult.” What are the best ways to deal with patients’ family members who are unresponsive, overbearing, or outright hostile to physicians and the care team? And how do you proceed to a treatment plan that is best for the patient?

The first step, believes Thomas Baudendistel, MD, FACP, associate program director of the Internal Medicine Residency Program at Sutter Health’s California Pacific Medical Center in San Francisco, and chair of SHM’s Ethics Committee, is to avoid using the term “difficult.”

“I think ‘difficult’ is a loaded term and kind of pejorative,” says Dr. Baudendistel. “When their loved ones are in the hospital, families are vulnerable. They don’t really know what to expect. I don’t know that I wouldn’t want my grandmother, or mother described as a ‘difficult patient,’ or a family member described as ‘difficult.’ Rather than saying, ‘this is a difficult family member,’ I would rather phrase it, ‘This is someone who has a lot of worries.’ ”

Hawgood employs a similar approach. “I like to define the situation as ‘a family member who is having difficulty dealing with the patient’s illness,’” she says. “If I hear, during rounds, that this family is difficult, I immediately begin asking myself, ‘Why are they having difficulty? Is this an interpersonal issue? Does this family member have a psychiatric history? Is there a history of a past problem with the medical system? Is it a financial issue?’ I really try not to presume things. I always try and keep an open mind about what a patient’s and family’s goals are, and what I can do to help. You need to clearly understand your goals and have good support from your team to redirect the energy.”

“Unrealistic expectations” might describe some of the encounters for Adrienne Bennett, MD, director for the Division of Hospital Medicine and associate clinical professor of medicine at Ohio State University. In her former post as founder and director of hospitalist services at Newton Wellesley, a community teaching hospital in the western suburbs of Boston, she and colleagues dealt with a relatively affluent patient population. Some of the patients and families, she says, “can sometimes be somewhat demanding and difficult if they feel they aren’t getting what they’re entitled to. In that sense, they can become ‘the angry daughter,’ as my colleague used to say.”

Building Trust

Because they do not have an ongoing history with patients, hospitalists may often be starting at a disadvantage in forming a new relationship. Dr. Baudendistel believes hospitalists can quickly learn the skill of reassuring patients and their families. One way to do that, he says, is to “link with the primary care physician.” He often calls the primary care physician and tells the family of his conversations with the family doctor, thus establishing a level of comfort for them. He makes it clear to the family that he is available to them, giving them phone and pager numbers so they can easily reach him.

Dr. Baudendistel also tries to accommodate family members’ schedules, setting up visits when working family members are able to come to the hospital or making sure to have daily telephone contact if it is not possible to synchronize in-person visits with them.

Most families, he has found, are then willing to listen and work with him. As familiarity with hospitalists increases, family concerns about a “stranger” caring for their loved one slowly diminish. “Patients and families generally accept the idea of seeing a new doctor in the hospital a little bit more easily each year that goes by,” he notes.

Another technique used at California Pacific Medical Center, Dr. Baudendistel adds, is to pair a hospitalist with the same patient if he or she is readmitted. “We really believe in the continuity of the relationship, so we try to preserve that as much as possible,” he says, “because the big obstacle for hospitalists is always handoffs.”

On the Same Page

Intrinsic to forming a relationship with the patient and family is to discuss their goals of care, says Hawgood. Shana Weber, DO, FAAP, a pediatric hospitalist at Alaska Native Medical Center in Anchorage, agrees.

“You need to be on the same page,” she says. “Without knowing what the parents are hoping to get from their child’s stay before discharge, you really cannot help them.”

For instance, says Dr. Weber, some parents may be surprised to learn that their child is going to be sent home with a feeding tube or other nursing care needs.

“It is important to find out what their agenda is and what yours is. Parents’ expectations can be very different from ours,” she explains. “Letting parents know you’re listening—whether or not you agree with what they’re saying—is half the battle. You need to verify their feelings, let them know you’re listening to them, and that you understand their concerns.”

Use Team Resources

Accessing the expertise of other providers may be necessary to complete discharge plans for complicated cases. Dr. Baudendistel recalls a 30-year-old woman with a progressive neurological condition who had previously been living in the community. Her condition had deteriorated to the extent that she would no longer be able to eat safely, and, thus, she would not be able to return home. The team brought in a speech therapist, physical therapist, social worker, and discharge planner to meet with the family and present options.

Hospitalists interviewed for this article agreed that clinical social workers bring a much-needed perspective to dealing with families. One recent case at UCSF Medical Center involved a woman in her late 50s whose cancer, after multiple treatments and treatment complications, had come back very aggressively. One of her daughters, a young woman in her 20s, “had developed a very deep religious faith that she could cure her mother through prayers and faith,” recalls Hawgood. “As her mother deteriorated, the daughter became more angry and hostile to the hospitalists.”

Hawgood approached the daughter and asked if she would sit down and talk with her, and tell her what had gone wrong in the past, and “how we could improve things in the future.” As she listened to the daughter, she realized how much the daughter loved her mother and how desperately frightened she was.

“If I could help you in one way, what would that be?” Hawgood asked the daughter.

After a silence, the daughter replied, “We need a refrigerator.”

It turned out that the family was financially unable to replace a broken refrigerator. To take her mother home, the daughter needed a way to refrigerate enteral feeding supplies. And Hawgood was able to secure a refrigerator for the family, and says that the incident underscored for her the importance of keeping an open mind.

Later, when the mother was dying, Hawgood was again asked by the team to provide support for the daughter so that hospitalists could care for their patient. “She was so angry, and it was directed at the hospitalists,” recalls Hawgood. “It was just her absolute inability to accept that her mother, who was the center in her life, was going to die. You have to give people credit and respect. You have to understand where they’re coming from and what’s going to work for them.”

Training Adequate?

According to a 2003-2004 survey conducted by the American Association of Medical Colleges, 124 out of 125 medical schools included communication skills as required courses for their medical students.1 However, Dr. Baudendistel points out that there are currently no national standards for proficiency in communications skills and that the field is in relative infancy at this time. Inclusion of interpersonal and communication skills as one of the Accreditation Council for Graduate Medical Education’s (ACGME) core competencies will help focus more attention on how to teach communication skills, he believes.2

“Communication is now one of the six core competencies,” he says. “It’s no longer secondary to being a smart doctor: It’s equally important in the view of the ACGME. So I think that will help.”

Beyond standardization of communication skills curricula, it is also necessary, he emphasizes, to verify providers’ proficiency in those skills. In the California Pacific Medical Center’s residency program residents receive 360-degree evaluations. These go beyond the typical evaluations in the past, wherein residents would be evaluated by supervising attending physicians and interns working under them. Now, evaluations of residents are sought from nurses—and from the patients themselves. Obtaining 360-degree feedback from all those who have interacted with the resident functions as a valuable teaching tool.

Experience: the Best Teacher

While most agree that training and required communications courses should be increased, Dr. Bennett points out that some of the hospitalist’s expertise with family communications will simply evolve with time and experience.

“I’ve learned a lot from situations in group meetings with a social worker or a patient ombudsperson, just watching how they manage the situation,” she says. At Newton Wellesley Hospital, social workers and chaplains were sometimes better able to find the right way to phrase something so it came across in a way the family could accept, recalls Dr. Bennett. She raises the a case of a 50-year-old man who came in with cardiac arrest and whom they needed to withdraw from life support. He had been born and raised Catholic, but had converted to Judaism, which was his ex-wife’s religion as well as that of his children. He had an extensive family (he was one of 10 children), who were concerned about his ability to receive Catholic last rites. The chaplain understood the implications for both religions and was able to negotiate a compromise that satisfied both sides and allowed life support to be withdrawn.

Dr. Weber, who completed her residency at DeVos Children’s Hospital in Grand Rapids, Mich., praised the training she received in doctor-patient communications while in medical school. However, once she arrived in Anchorage, she discovered that the cultural norms of Alaska native people required some on-the-job learning.

She once asked an adolescent girl with Crohn’s disease whether she had any belly pain. “She wasn’t answering me, and I thought, ‘Oh great—just another typical teenage girl’” remembers Dr. Weber. “Well, I thought she wasn’t answering me, but she was lifting her eyebrows, which means ‘yes.’ But I didn’t know that.”

Dr. Weber has found nurses and other long-time hospital staff to be very helpful in learning how to communicate with her patient population.

Context and History

Hawgood reminds hospitalists that families often come into hospitals with past histories of things gone wrong.

“The whole healthcare system is so volatile now,” she observes. “People feel rushed, they feel [they are being] rushed out of hospital. They don’t have adequate healthcare insurance; they don’t have adequate care in the community. We send people out with trachs, tube feeds, open wounds, and pain issues. People are dealing with limited money, trying to juggle work, children, and elderly parents. So they have reasons to be angry.”

Families feel frustrated when their loved one is sick, agrees Dr. Baudendistel. “It may be that your role is to just let them vent their frustration.”

Says Hawgood, “I tell the people I train that I have nothing to lose. The patients and their families have everything to lose. So, even if I get off on the wrong foot, I’ll go back and ask, ‘could I start again?’ And usually, people will say, ‘yes.’ It’s up to me to make it work.”

Dr. Weber recalls one family at ANMC with a special needs child who had been in a Seattle hospital, and was readmitted to their facility with kidney stones. He was not getting better and the physicians recommended that the family travel back to Seattle, where a pediatric urologist could remove the stones. The parents were uncomfortable with the recommendation that their son return to Seattle.

“We did need to bring in a mediator, and have several family care conferences with the parents, with social workers and discharge planners, and all involved providers,” says Dr. Weber.

In the course of the conferences, the family revealed that their child’s disabilities were due to a missed diagnosis of meningitis when he was a baby. “They harbored a lot of resentment toward the medical profession in general,” says Dr. Weber. “It was hard to work through that. They couldn’t let it go—and I don’t blame them—and it caused them to always question our motives and our intentions.”

During the care conferences, the team let the family tell their story of the meningitis case again. Just by listening to the family’s history with that event, the team was able to validate the family’s concerns. The parents agreed to take their son to Seattle for the procedure, and later sent a thank you card to the pediatric team at ANMC that had treated him.

Don’t Make Assumptions

Hawgood always cautions physicians to enter the patient’s room with an open mind and to be open to cues and clues about the family’s situation. She praises the UCSF hospitalists’ training of young residents.

“They let them take the lead in patient interviews, then we all discuss how that interview went, and how things could have been done better,” says Hawgood. For instance, she recommends that hospitalists “allow for some silence in the room. You don’t have to fill up every minute with conversation. Look for the non-verbal cues, the things that weren’t said.”

In Dr. Weber’s hospital, pediatric patients come from all over state. It is not unusual for a baby to be in the neonatal intensive care unit for a while before the parents come back to visit. It would be easy to question, she says, whether these people are going to be good parents. “But until you know their social situation, you really have no place saying that,” says Dr. Weber. “You may find that they have six other children at home and cannot be here because they have no other caregivers for their children, and their village is 200 miles away.”

The Best You Can Do

Despite the care team’s best efforts, there will be a few cases, admits Dr. Bennett, where “you just can’t make much headway.” She recalls the case of an elderly man who had had a massive stroke, lived in a nursing home, and had not communicated for years. The man’s daughter was convinced, however, that he communicated with her and was “adamant that everything had to be done. We tried and tried,” explains Dr. Bennett, calling several group meetings and using hospital chaplains as allies, “but she just couldn’t hear it, and couldn’t see it [that her father would not get better]. She was too vested in believing that he did, in fact, communicate with her and that he would get better.”

In such cases the team may have to do the best they can to honor the patient’s and the family member’s value system and help them abide by that.

“There’s one other thing about difficult families and difficult patients: You have such an intense relationship with them that you don’t have with other people,” notes Hawgood. “If you can hang in there, they’re the best relationships you can have. You are so emotionally engaged in trying to make it work. I have chosen to work with hospitalists because of the approach they take. I think it’s the most efficient model you can use in a hospital. We really talk about the goals of care, and what we understand about the patient’s and family’s goals of care. We approach this from the point of view that they deserve care. What can we do to make a difference, so that it works for the patient and the families?” TH

Writer Gretchen Henkel lives in California.

References

• “Number of U.S. Medical Schools Teaching Selected Topics 2003-2004.” Compiled by the American Association of Medical Colleges Institutional Profile System. Available online at: http://services.aamc.org/currdir/section2/03-04hottopics.pdf. Last accessed January 26, 2006.
• General Competencies; ACGME Outcome Project. September, 1999. Available online at: www.acgme.org/outcome/comp/compMin.asp. Last accessed January 27, 2006.

Physician-assisted suicide and euthanasia (PAS/E) are contrary to the 2,500-year-old historic and vitally important professional ethic of caring and healing. The professional ethic of medicine is to care for the patient. Francis Peabody said in 1927, “The secret of caring for the patient is in caring for the patient.”1 This is not a tautology, but a truism. The proper response to a request for physician-assisted suicide or euthanasia is excellent end-of-life care.

The American Medical Association maintains an unequivocal position on this issue: “Physician-assisted suicide is fundamentally incompatible with the physician’s role as healer, would be difficult or impossible to control, and would pose serious societal risks. Instead of participating in assisted suicide, physicians must aggressively respond to the needs of patients at the end of life ... .”2

In both ancient and modern times some physicians have, on occasion, secretly assisted patients with suicide or have even administered lethal medication themselves when they felt extenuating circumstances justified an exception to the societal standard and the professional rule. Until Jack Kevorkian, MD, it was done in secret because this rule was recognized as valid.

Historically, there have been several periods of time when euthanasia was given serious public debate. But until 1984, when the Royal Dutch Medical Association took the revolutionary position that it was professionally acceptable for a physician to give a lethal injection to a patient under certain clearly defined circumstances, that debate was always silenced by returning to the professional ethic of healing and not killing.

Arguments in Favor of Physician-Assisted Suicide/Euthanasia

In the current debate about the legalization of assisted suicide, supporters offer three major arguments:

1. A patient has a right to self-determination;
2. It is the compassionate thing to do; and
3. It is working in the Netherlands and in Oregon, so we should allow it elsewhere, too.

The first two arguments have remained the same for more than 200 years.3

The right to self-determination: Proponents maintain, correctly, that a patient has a right to accept or refuse any treatment—even if that refusal leads to death. They go on to maintain that the patient should then have the right to request any treatment they want, even medical assistance with bringing about death.

Though a patient has a negative right to be left alone, I believe this does not translate into a positive right (an entitlement) to whatever he or she wants. If that were the case, there would be no need for laws to regulate prescription drugs; a patient could just buy whatever he or she felt was appropriate. Patient autonomy is not absolute any more than is a generic right to personal freedom. The U.S. Supreme Court has found there is no constitutional right to assisted suicide.

Compassion: Supporters of PAS/E often point out that “we shoot horses, don’t we?” implying that our compassionate response to animal suffering should be extended to include human suffering. This is only tenable in a worldview that concludes that there is no moral difference between humans and animals. If you believe, as do most people in Western society, that a) we have a greater obligation to human beings than we do to animals, and that b) human life is special and should be respected and protected whenever possible, then we are obligated to find a better solution to terminal suffering in humans.

Compassion, while perhaps more compelling than self-determination, is still not determinative. As Pellegrino has said, “ ... compassion is a virtue, not a principle. Morally weighty as it is, compassion can become maleficent unless it is constrained by principle.”4 Compassion means “to suffer with.” Compassionate patient care involves coming alongside patients who are suffering, being with them, and doing all we can to alleviate that suffering.

The Dutch example: Other supporters of PAS/E offer a more pragmatic defense of their position, suggesting that the Dutch have proven that regulated euthanasia can work; however, it is not always used as a “last resort.” In nearly 20% of cases available palliative measures were declined by the patient; 60% of cases were not reported truthfully; 50% of cases did not have the required consultation; and—most worrisome of all—25% of patients who were given a lethal injection did not request euthanasia.5

Conversely, only about one-third of patient requests for euthanasia are carried out by Dutch physicians. Thus, two-thirds of patients who request euthanasia are denied it, and one-quarter of patients who are euthanized did not request it, suggesting that it is not patient autonomy that drives the Dutch euthanasia program, but physician autonomy. We must conclude that the Dutch experiment with regulated euthanasia has failed.

Arguments Opposing Physician-Assisted Suicide/Euthanasia

In addition to these rebuttals to those arguments in favor of PAS/E, there are several specific arguments in opposition. These have been well articulated elsewhere.6-8 They will merely be summarized here in two groups:

1. Rule-based arguments: PAS/E goes against longstanding professional virtue and would change the nature of the patient-doctor relationship, perhaps even detracting from efforts at palliative care; and
2. Consequence-based arguments: PAS/E would be bad public policy because regulations cannot prevent abuses and expansions of the “indications” to include coerced “voluntary” PAS/E, surrogate non-voluntary PAS/E for those who have lost decision-making capacity, requests from patients who are suffering (but not terminally ill), and even discriminatory involuntary euthanasia as a cost-control measure.9

The Moral High Ground

If we accept that PAS/E are contrary to physician virtue and moral tradition, and further that legalization of such activities would be bad public policy, what then is the alternative? The alternative is excellent end-of-life care. This requires a commitment to compassion, a willingness to “suffer with” the patient. Good palliative/hospice care has the goal of helping the patient to live each day as well as possible. Patients who receive good end-of-life care rarely request that their physicians hasten death.10

If a terminally ill patient does make such a request, the physician must elicit the reason by saying, “I’m sorry you are suffering. How can I help to make it better?” In addition, the physician should give the patient as much control as possible over treatment options when the patient is ready to shift goals to comfort care. The physician must never say, “There is nothing more I can do for you.” Such a statement represents an immoral abandonment of the patient. Instead the physician should say, “There is nothing more we can do to stop or slow the disease process, but there is a lot more we can do for you.”

All of the patient’s physical needs must be thoroughly addressed. This means intensive symptom control of pain and dyspnea, the two most feared symptoms at the end of life, as well as the multitude of other symptoms experienced by patients as they approach death.

Psychological symptoms are almost universal in dying patients. Anxiety about the future is understandable. Depression is likewise to be expected in a significant percentage of patients. Both need treatment, whether that be drugs, counseling, or someone to sit with the patient. Ramsay has said that people who are dying need only two things, comfort (symptom control) and company (human presence).11

Social issues also need assessment and treatment. Many dying people are lonely. Friends often stop visiting because they are uncomfortable and do not know what to say. Even family members may distance themselves physically and emotionally from a patient who is approaching death. Patients may have “unfinished business” that causes them unspoken distress. Byock has observed that a person who is dying often needs to say one or more of the following five things: “Will you forgive me?” “I forgive you,” “Thank you,” “I love you,” and “Goodbye.”12

The final dimension in whole person care is the spiritual. While this is important in caring for any patient who is seriously ill, it becomes imperative in dying patients. When facing death, patients often ruminate on guilt about how they have lived their lives. Others may develop uncertainty or doubts about even longstanding beliefs. They may have many questions about the meaning of life and the meaning of death.

It is rare indeed that one professional is able to address all of the physical, psychological, social, and spiritual needs of dying patients. It requires a multidisciplinary team including nurses, physicians, therapists, counselors, pastoral care workers, social workers, and lay volunteers. Such a team is usually best mobilized through a formal hospice or palliative care program, but may at times be coordinated through a primary care physician’s office or a community or church organization.

The Imperative for Good Pain Management

In spite of excellent resources too numerous to cite, and in spite of practice guidelines and quality improvement guidelines, pain management is often inadequate.13-15 JCAHO has issued pain management standards that affirm both the patient’s right to appropriate assessment and management of pain and the institution’s responsibilities.16

Perhaps the most commonly asked ethical question about pain management at the end of life is concern about the inadvertent—or even the intentional—suppression of respiration with the use of high doses of opioids that could lead to an earlier death. Experts in pain management maintain that this rarely—if ever—happens because pain is a good respiratory stimulant. Even with good empiric evidence that narcotic use does not hasten death, this myth continues to discourage many physicians from fulfilling their obligation to relieve suffering.17

But let us consider the worst-case scenario: What if a terminally ill patient with overwhelming pain requires rapidly increasing doses of narcotics and does actually suffers from respiratory depression. Is the physician morally obligated to use ventilatory support to overcome this side effect? Thomas Aquinas (1224-1274) answered this question with his “rule of double effect”: It is morally permissible to do an act that has both a good effect and a bad effect if all of the following conditions exist:

1. The act must be inherently good, or at least morally neutral;
2. The bad effect may be anticipated, but not intended;
3. The good effect must not be achieved by means of the bad effect; and
4. There must be a proportionately grave reason for allowing the bad effect.

Using high doses of narcotics to relieve pain fits these criteria.

Terminal Sedation

Because of the continued legal and professional proscription against PAS/E, some have proposed the use of “terminal sedation”: the practice of giving sedation to a patient who is dying, expecting that he or she will die more quickly of dehydration. If the intention is clearly to hasten death, then this is euthanasia and, in my estimation, it is an immoral end-run around the current legal and professional prohibitions. If, however, maximal efforts have failed to adequately relieve the suffering of an imminently dying patient, it would be ethically permissible to render the patient unconscious in order to relieve pain, accepting the unintended side effect of an earlier death from dehydration. This too would be justifiable using the rule of double effect.

Conclusion

PSA/E have been outside the bounds of acceptable behavior for physicians for hundreds of years. The moral, legal, and professional acceptable alternative is excellent end-of-life care. TH

To cure, sometimes; to heal, often; to comfort, always.—15th century French proverb.

Dr. Orr is a clinical ethicist at the Fletcher Allen Health Care in Burlington, Vt.

References

1. Peabody F. The care of the patient. JAMA. 1927;88:877-882.
2. Code of Medical Ethics, AMA (1994). Opinion 2.211 “Physician Assisted Suicide”: 51.
3. Emanuel EJ. The history of euthanasia debates in the United States and Britain. Ann Intern Med. 1994;121(10):793-802.
4. Pellegrino ED. Compassion needs reason too. JAMA. 1993;270(7):870-873.
5. Jochemsen H, Keown J. Voluntary euthanasia under control? Further empirical evidence from the Netherlands. J Med Ethics. 1999;25(1):16-21.
6. Kass LR. Neither for love nor money: why doctors must not kill. The Public Interest. 1989;94:25-46.
7. Callahan D. When self-determination runs amok. Hastings Center Report. 1992;22(2):52-55.
8. Singer PA, Siegler M. Euthanasia—a critique. N Eng J Med. 1990;322(26):1881-1883.
9. Hendin H. Selling death and dignity. Hastings Center Report. 1995;25(3):19-23.
10. Brown JH, Hentelheff P, Barakat S, et al. Is it normal for terminally ill patients to desire death? Am J Psych. 1986;143(2):208-211.
11. Ramsay P. The Patient as Person. New Haven, Conn.: Yale University Press; 1970:113-164.
12. Byock I. The nature of suffering and the nature of opportunity at the end of life. Clin Geriatr Med. 1996;12(2):237-252.
13. Agency for Health Care Policy and Research. Management of Cancer Pain. Rockville, Md.: U.S. Department of Health and Human Services, 1994
14. American Pain Society Quality of Care Committee. Quality improvement guidelines for the treatment of acute pain and cancer pain. JAMA. 1995;274(23):1874-1880.
15. Cleeland CS. Undertreatment of cancer pain in elderly patients. JAMA. 1998;279(23):1914-1915.
16. Phillips DM. JACHO pain management standards are unveiled. JAMA. 2000;284(4):428-429.
17. Thorns A, Sykes N. Opioid use in the last week of life and implications for end-of-life decision making. Lancet. 2000;356:398-399.

Physician-assisted suicide and euthanasia (PAS/E) are contrary to the 2,500-year-old historic and vitally important professional ethic of caring and healing. The professional ethic of medicine is to care for the patient. Francis Peabody said in 1927, “The secret of caring for the patient is in caring for the patient.”1 This is not a tautology, but a truism. The proper response to a request for physician-assisted suicide or euthanasia is excellent end-of-life care.

The American Medical Association maintains an unequivocal position on this issue: “Physician-assisted suicide is fundamentally incompatible with the physician’s role as healer, would be difficult or impossible to control, and would pose serious societal risks. Instead of participating in assisted suicide, physicians must aggressively respond to the needs of patients at the end of life ... .”2

In both ancient and modern times some physicians have, on occasion, secretly assisted patients with suicide or have even administered lethal medication themselves when they felt extenuating circumstances justified an exception to the societal standard and the professional rule. Until Jack Kevorkian, MD, it was done in secret because this rule was recognized as valid.

Historically, there have been several periods of time when euthanasia was given serious public debate. But until 1984, when the Royal Dutch Medical Association took the revolutionary position that it was professionally acceptable for a physician to give a lethal injection to a patient under certain clearly defined circumstances, that debate was always silenced by returning to the professional ethic of healing and not killing.

Arguments in Favor of Physician-Assisted Suicide/Euthanasia

In the current debate about the legalization of assisted suicide, supporters offer three major arguments:

1. A patient has a right to self-determination;
2. It is the compassionate thing to do; and
3. It is working in the Netherlands and in Oregon, so we should allow it elsewhere, too.

The first two arguments have remained the same for more than 200 years.3

The right to self-determination: Proponents maintain, correctly, that a patient has a right to accept or refuse any treatment—even if that refusal leads to death. They go on to maintain that the patient should then have the right to request any treatment they want, even medical assistance with bringing about death.

Though a patient has a negative right to be left alone, I believe this does not translate into a positive right (an entitlement) to whatever he or she wants. If that were the case, there would be no need for laws to regulate prescription drugs; a patient could just buy whatever he or she felt was appropriate. Patient autonomy is not absolute any more than is a generic right to personal freedom. The U.S. Supreme Court has found there is no constitutional right to assisted suicide.

Compassion: Supporters of PAS/E often point out that “we shoot horses, don’t we?” implying that our compassionate response to animal suffering should be extended to include human suffering. This is only tenable in a worldview that concludes that there is no moral difference between humans and animals. If you believe, as do most people in Western society, that a) we have a greater obligation to human beings than we do to animals, and that b) human life is special and should be respected and protected whenever possible, then we are obligated to find a better solution to terminal suffering in humans.

Compassion, while perhaps more compelling than self-determination, is still not determinative. As Pellegrino has said, “ ... compassion is a virtue, not a principle. Morally weighty as it is, compassion can become maleficent unless it is constrained by principle.”4 Compassion means “to suffer with.” Compassionate patient care involves coming alongside patients who are suffering, being with them, and doing all we can to alleviate that suffering.

The Dutch example: Other supporters of PAS/E offer a more pragmatic defense of their position, suggesting that the Dutch have proven that regulated euthanasia can work; however, it is not always used as a “last resort.” In nearly 20% of cases available palliative measures were declined by the patient; 60% of cases were not reported truthfully; 50% of cases did not have the required consultation; and—most worrisome of all—25% of patients who were given a lethal injection did not request euthanasia.5

Conversely, only about one-third of patient requests for euthanasia are carried out by Dutch physicians. Thus, two-thirds of patients who request euthanasia are denied it, and one-quarter of patients who are euthanized did not request it, suggesting that it is not patient autonomy that drives the Dutch euthanasia program, but physician autonomy. We must conclude that the Dutch experiment with regulated euthanasia has failed.

Arguments Opposing Physician-Assisted Suicide/Euthanasia

In addition to these rebuttals to those arguments in favor of PAS/E, there are several specific arguments in opposition. These have been well articulated elsewhere.6-8 They will merely be summarized here in two groups:

1. Rule-based arguments: PAS/E goes against longstanding professional virtue and would change the nature of the patient-doctor relationship, perhaps even detracting from efforts at palliative care; and
2. Consequence-based arguments: PAS/E would be bad public policy because regulations cannot prevent abuses and expansions of the “indications” to include coerced “voluntary” PAS/E, surrogate non-voluntary PAS/E for those who have lost decision-making capacity, requests from patients who are suffering (but not terminally ill), and even discriminatory involuntary euthanasia as a cost-control measure.9

The Moral High Ground

If we accept that PAS/E are contrary to physician virtue and moral tradition, and further that legalization of such activities would be bad public policy, what then is the alternative? The alternative is excellent end-of-life care. This requires a commitment to compassion, a willingness to “suffer with” the patient. Good palliative/hospice care has the goal of helping the patient to live each day as well as possible. Patients who receive good end-of-life care rarely request that their physicians hasten death.10

If a terminally ill patient does make such a request, the physician must elicit the reason by saying, “I’m sorry you are suffering. How can I help to make it better?” In addition, the physician should give the patient as much control as possible over treatment options when the patient is ready to shift goals to comfort care. The physician must never say, “There is nothing more I can do for you.” Such a statement represents an immoral abandonment of the patient. Instead the physician should say, “There is nothing more we can do to stop or slow the disease process, but there is a lot more we can do for you.”

All of the patient’s physical needs must be thoroughly addressed. This means intensive symptom control of pain and dyspnea, the two most feared symptoms at the end of life, as well as the multitude of other symptoms experienced by patients as they approach death.

Psychological symptoms are almost universal in dying patients. Anxiety about the future is understandable. Depression is likewise to be expected in a significant percentage of patients. Both need treatment, whether that be drugs, counseling, or someone to sit with the patient. Ramsay has said that people who are dying need only two things, comfort (symptom control) and company (human presence).11

Social issues also need assessment and treatment. Many dying people are lonely. Friends often stop visiting because they are uncomfortable and do not know what to say. Even family members may distance themselves physically and emotionally from a patient who is approaching death. Patients may have “unfinished business” that causes them unspoken distress. Byock has observed that a person who is dying often needs to say one or more of the following five things: “Will you forgive me?” “I forgive you,” “Thank you,” “I love you,” and “Goodbye.”12

The final dimension in whole person care is the spiritual. While this is important in caring for any patient who is seriously ill, it becomes imperative in dying patients. When facing death, patients often ruminate on guilt about how they have lived their lives. Others may develop uncertainty or doubts about even longstanding beliefs. They may have many questions about the meaning of life and the meaning of death.

It is rare indeed that one professional is able to address all of the physical, psychological, social, and spiritual needs of dying patients. It requires a multidisciplinary team including nurses, physicians, therapists, counselors, pastoral care workers, social workers, and lay volunteers. Such a team is usually best mobilized through a formal hospice or palliative care program, but may at times be coordinated through a primary care physician’s office or a community or church organization.

The Imperative for Good Pain Management

In spite of excellent resources too numerous to cite, and in spite of practice guidelines and quality improvement guidelines, pain management is often inadequate.13-15 JCAHO has issued pain management standards that affirm both the patient’s right to appropriate assessment and management of pain and the institution’s responsibilities.16

Perhaps the most commonly asked ethical question about pain management at the end of life is concern about the inadvertent—or even the intentional—suppression of respiration with the use of high doses of opioids that could lead to an earlier death. Experts in pain management maintain that this rarely—if ever—happens because pain is a good respiratory stimulant. Even with good empiric evidence that narcotic use does not hasten death, this myth continues to discourage many physicians from fulfilling their obligation to relieve suffering.17

But let us consider the worst-case scenario: What if a terminally ill patient with overwhelming pain requires rapidly increasing doses of narcotics and does actually suffers from respiratory depression. Is the physician morally obligated to use ventilatory support to overcome this side effect? Thomas Aquinas (1224-1274) answered this question with his “rule of double effect”: It is morally permissible to do an act that has both a good effect and a bad effect if all of the following conditions exist:

1. The act must be inherently good, or at least morally neutral;
2. The bad effect may be anticipated, but not intended;
3. The good effect must not be achieved by means of the bad effect; and
4. There must be a proportionately grave reason for allowing the bad effect.

Using high doses of narcotics to relieve pain fits these criteria.

Terminal Sedation

Because of the continued legal and professional proscription against PAS/E, some have proposed the use of “terminal sedation”: the practice of giving sedation to a patient who is dying, expecting that he or she will die more quickly of dehydration. If the intention is clearly to hasten death, then this is euthanasia and, in my estimation, it is an immoral end-run around the current legal and professional prohibitions. If, however, maximal efforts have failed to adequately relieve the suffering of an imminently dying patient, it would be ethically permissible to render the patient unconscious in order to relieve pain, accepting the unintended side effect of an earlier death from dehydration. This too would be justifiable using the rule of double effect.

Conclusion

PSA/E have been outside the bounds of acceptable behavior for physicians for hundreds of years. The moral, legal, and professional acceptable alternative is excellent end-of-life care. TH

To cure, sometimes; to heal, often; to comfort, always.—15th century French proverb.

Dr. Orr is a clinical ethicist at the Fletcher Allen Health Care in Burlington, Vt.

References

1. Peabody F. The care of the patient. JAMA. 1927;88:877-882.
2. Code of Medical Ethics, AMA (1994). Opinion 2.211 “Physician Assisted Suicide”: 51.
3. Emanuel EJ. The history of euthanasia debates in the United States and Britain. Ann Intern Med. 1994;121(10):793-802.
4. Pellegrino ED. Compassion needs reason too. JAMA. 1993;270(7):870-873.
5. Jochemsen H, Keown J. Voluntary euthanasia under control? Further empirical evidence from the Netherlands. J Med Ethics. 1999;25(1):16-21.
6. Kass LR. Neither for love nor money: why doctors must not kill. The Public Interest. 1989;94:25-46.
7. Callahan D. When self-determination runs amok. Hastings Center Report. 1992;22(2):52-55.
8. Singer PA, Siegler M. Euthanasia—a critique. N Eng J Med. 1990;322(26):1881-1883.
9. Hendin H. Selling death and dignity. Hastings Center Report. 1995;25(3):19-23.
10. Brown JH, Hentelheff P, Barakat S, et al. Is it normal for terminally ill patients to desire death? Am J Psych. 1986;143(2):208-211.
11. Ramsay P. The Patient as Person. New Haven, Conn.: Yale University Press; 1970:113-164.
12. Byock I. The nature of suffering and the nature of opportunity at the end of life. Clin Geriatr Med. 1996;12(2):237-252.
13. Agency for Health Care Policy and Research. Management of Cancer Pain. Rockville, Md.: U.S. Department of Health and Human Services, 1994
14. American Pain Society Quality of Care Committee. Quality improvement guidelines for the treatment of acute pain and cancer pain. JAMA. 1995;274(23):1874-1880.
15. Cleeland CS. Undertreatment of cancer pain in elderly patients. JAMA. 1998;279(23):1914-1915.
16. Phillips DM. JACHO pain management standards are unveiled. JAMA. 2000;284(4):428-429.
17. Thorns A, Sykes N. Opioid use in the last week of life and implications for end-of-life decision making. Lancet. 2000;356:398-399.

Physician-assisted suicide and euthanasia (PAS/E) are contrary to the 2,500-year-old historic and vitally important professional ethic of caring and healing. The professional ethic of medicine is to care for the patient. Francis Peabody said in 1927, “The secret of caring for the patient is in caring for the patient.”1 This is not a tautology, but a truism. The proper response to a request for physician-assisted suicide or euthanasia is excellent end-of-life care.

The American Medical Association maintains an unequivocal position on this issue: “Physician-assisted suicide is fundamentally incompatible with the physician’s role as healer, would be difficult or impossible to control, and would pose serious societal risks. Instead of participating in assisted suicide, physicians must aggressively respond to the needs of patients at the end of life ... .”2

In both ancient and modern times some physicians have, on occasion, secretly assisted patients with suicide or have even administered lethal medication themselves when they felt extenuating circumstances justified an exception to the societal standard and the professional rule. Until Jack Kevorkian, MD, it was done in secret because this rule was recognized as valid.

Historically, there have been several periods of time when euthanasia was given serious public debate. But until 1984, when the Royal Dutch Medical Association took the revolutionary position that it was professionally acceptable for a physician to give a lethal injection to a patient under certain clearly defined circumstances, that debate was always silenced by returning to the professional ethic of healing and not killing.

Arguments in Favor of Physician-Assisted Suicide/Euthanasia

In the current debate about the legalization of assisted suicide, supporters offer three major arguments:

1. A patient has a right to self-determination;
2. It is the compassionate thing to do; and
3. It is working in the Netherlands and in Oregon, so we should allow it elsewhere, too.

The first two arguments have remained the same for more than 200 years.3

The right to self-determination: Proponents maintain, correctly, that a patient has a right to accept or refuse any treatment—even if that refusal leads to death. They go on to maintain that the patient should then have the right to request any treatment they want, even medical assistance with bringing about death.

Though a patient has a negative right to be left alone, I believe this does not translate into a positive right (an entitlement) to whatever he or she wants. If that were the case, there would be no need for laws to regulate prescription drugs; a patient could just buy whatever he or she felt was appropriate. Patient autonomy is not absolute any more than is a generic right to personal freedom. The U.S. Supreme Court has found there is no constitutional right to assisted suicide.

Compassion: Supporters of PAS/E often point out that “we shoot horses, don’t we?” implying that our compassionate response to animal suffering should be extended to include human suffering. This is only tenable in a worldview that concludes that there is no moral difference between humans and animals. If you believe, as do most people in Western society, that a) we have a greater obligation to human beings than we do to animals, and that b) human life is special and should be respected and protected whenever possible, then we are obligated to find a better solution to terminal suffering in humans.

Compassion, while perhaps more compelling than self-determination, is still not determinative. As Pellegrino has said, “ ... compassion is a virtue, not a principle. Morally weighty as it is, compassion can become maleficent unless it is constrained by principle.”4 Compassion means “to suffer with.” Compassionate patient care involves coming alongside patients who are suffering, being with them, and doing all we can to alleviate that suffering.

The Dutch example: Other supporters of PAS/E offer a more pragmatic defense of their position, suggesting that the Dutch have proven that regulated euthanasia can work; however, it is not always used as a “last resort.” In nearly 20% of cases available palliative measures were declined by the patient; 60% of cases were not reported truthfully; 50% of cases did not have the required consultation; and—most worrisome of all—25% of patients who were given a lethal injection did not request euthanasia.5

Conversely, only about one-third of patient requests for euthanasia are carried out by Dutch physicians. Thus, two-thirds of patients who request euthanasia are denied it, and one-quarter of patients who are euthanized did not request it, suggesting that it is not patient autonomy that drives the Dutch euthanasia program, but physician autonomy. We must conclude that the Dutch experiment with regulated euthanasia has failed.

Arguments Opposing Physician-Assisted Suicide/Euthanasia

In addition to these rebuttals to those arguments in favor of PAS/E, there are several specific arguments in opposition. These have been well articulated elsewhere.6-8 They will merely be summarized here in two groups:

1. Rule-based arguments: PAS/E goes against longstanding professional virtue and would change the nature of the patient-doctor relationship, perhaps even detracting from efforts at palliative care; and
2. Consequence-based arguments: PAS/E would be bad public policy because regulations cannot prevent abuses and expansions of the “indications” to include coerced “voluntary” PAS/E, surrogate non-voluntary PAS/E for those who have lost decision-making capacity, requests from patients who are suffering (but not terminally ill), and even discriminatory involuntary euthanasia as a cost-control measure.9

The Moral High Ground

If we accept that PAS/E are contrary to physician virtue and moral tradition, and further that legalization of such activities would be bad public policy, what then is the alternative? The alternative is excellent end-of-life care. This requires a commitment to compassion, a willingness to “suffer with” the patient. Good palliative/hospice care has the goal of helping the patient to live each day as well as possible. Patients who receive good end-of-life care rarely request that their physicians hasten death.10

If a terminally ill patient does make such a request, the physician must elicit the reason by saying, “I’m sorry you are suffering. How can I help to make it better?” In addition, the physician should give the patient as much control as possible over treatment options when the patient is ready to shift goals to comfort care. The physician must never say, “There is nothing more I can do for you.” Such a statement represents an immoral abandonment of the patient. Instead the physician should say, “There is nothing more we can do to stop or slow the disease process, but there is a lot more we can do for you.”

All of the patient’s physical needs must be thoroughly addressed. This means intensive symptom control of pain and dyspnea, the two most feared symptoms at the end of life, as well as the multitude of other symptoms experienced by patients as they approach death.

Psychological symptoms are almost universal in dying patients. Anxiety about the future is understandable. Depression is likewise to be expected in a significant percentage of patients. Both need treatment, whether that be drugs, counseling, or someone to sit with the patient. Ramsay has said that people who are dying need only two things, comfort (symptom control) and company (human presence).11

Social issues also need assessment and treatment. Many dying people are lonely. Friends often stop visiting because they are uncomfortable and do not know what to say. Even family members may distance themselves physically and emotionally from a patient who is approaching death. Patients may have “unfinished business” that causes them unspoken distress. Byock has observed that a person who is dying often needs to say one or more of the following five things: “Will you forgive me?” “I forgive you,” “Thank you,” “I love you,” and “Goodbye.”12

The final dimension in whole person care is the spiritual. While this is important in caring for any patient who is seriously ill, it becomes imperative in dying patients. When facing death, patients often ruminate on guilt about how they have lived their lives. Others may develop uncertainty or doubts about even longstanding beliefs. They may have many questions about the meaning of life and the meaning of death.

It is rare indeed that one professional is able to address all of the physical, psychological, social, and spiritual needs of dying patients. It requires a multidisciplinary team including nurses, physicians, therapists, counselors, pastoral care workers, social workers, and lay volunteers. Such a team is usually best mobilized through a formal hospice or palliative care program, but may at times be coordinated through a primary care physician’s office or a community or church organization.

The Imperative for Good Pain Management

In spite of excellent resources too numerous to cite, and in spite of practice guidelines and quality improvement guidelines, pain management is often inadequate.13-15 JCAHO has issued pain management standards that affirm both the patient’s right to appropriate assessment and management of pain and the institution’s responsibilities.16

Perhaps the most commonly asked ethical question about pain management at the end of life is concern about the inadvertent—or even the intentional—suppression of respiration with the use of high doses of opioids that could lead to an earlier death. Experts in pain management maintain that this rarely—if ever—happens because pain is a good respiratory stimulant. Even with good empiric evidence that narcotic use does not hasten death, this myth continues to discourage many physicians from fulfilling their obligation to relieve suffering.17

But let us consider the worst-case scenario: What if a terminally ill patient with overwhelming pain requires rapidly increasing doses of narcotics and does actually suffers from respiratory depression. Is the physician morally obligated to use ventilatory support to overcome this side effect? Thomas Aquinas (1224-1274) answered this question with his “rule of double effect”: It is morally permissible to do an act that has both a good effect and a bad effect if all of the following conditions exist:

1. The act must be inherently good, or at least morally neutral;
2. The bad effect may be anticipated, but not intended;
3. The good effect must not be achieved by means of the bad effect; and
4. There must be a proportionately grave reason for allowing the bad effect.

Using high doses of narcotics to relieve pain fits these criteria.

Terminal Sedation

Because of the continued legal and professional proscription against PAS/E, some have proposed the use of “terminal sedation”: the practice of giving sedation to a patient who is dying, expecting that he or she will die more quickly of dehydration. If the intention is clearly to hasten death, then this is euthanasia and, in my estimation, it is an immoral end-run around the current legal and professional prohibitions. If, however, maximal efforts have failed to adequately relieve the suffering of an imminently dying patient, it would be ethically permissible to render the patient unconscious in order to relieve pain, accepting the unintended side effect of an earlier death from dehydration. This too would be justifiable using the rule of double effect.

Conclusion

PSA/E have been outside the bounds of acceptable behavior for physicians for hundreds of years. The moral, legal, and professional acceptable alternative is excellent end-of-life care. TH

To cure, sometimes; to heal, often; to comfort, always.—15th century French proverb.

Dr. Orr is a clinical ethicist at the Fletcher Allen Health Care in Burlington, Vt.

References

1. Peabody F. The care of the patient. JAMA. 1927;88:877-882.
2. Code of Medical Ethics, AMA (1994). Opinion 2.211 “Physician Assisted Suicide”: 51.
3. Emanuel EJ. The history of euthanasia debates in the United States and Britain. Ann Intern Med. 1994;121(10):793-802.
4. Pellegrino ED. Compassion needs reason too. JAMA. 1993;270(7):870-873.
5. Jochemsen H, Keown J. Voluntary euthanasia under control? Further empirical evidence from the Netherlands. J Med Ethics. 1999;25(1):16-21.
6. Kass LR. Neither for love nor money: why doctors must not kill. The Public Interest. 1989;94:25-46.
7. Callahan D. When self-determination runs amok. Hastings Center Report. 1992;22(2):52-55.
8. Singer PA, Siegler M. Euthanasia—a critique. N Eng J Med. 1990;322(26):1881-1883.
9. Hendin H. Selling death and dignity. Hastings Center Report. 1995;25(3):19-23.
10. Brown JH, Hentelheff P, Barakat S, et al. Is it normal for terminally ill patients to desire death? Am J Psych. 1986;143(2):208-211.
11. Ramsay P. The Patient as Person. New Haven, Conn.: Yale University Press; 1970:113-164.
12. Byock I. The nature of suffering and the nature of opportunity at the end of life. Clin Geriatr Med. 1996;12(2):237-252.
13. Agency for Health Care Policy and Research. Management of Cancer Pain. Rockville, Md.: U.S. Department of Health and Human Services, 1994
14. American Pain Society Quality of Care Committee. Quality improvement guidelines for the treatment of acute pain and cancer pain. JAMA. 1995;274(23):1874-1880.
15. Cleeland CS. Undertreatment of cancer pain in elderly patients. JAMA. 1998;279(23):1914-1915.
16. Phillips DM. JACHO pain management standards are unveiled. JAMA. 2000;284(4):428-429.
17. Thorns A, Sykes N. Opioid use in the last week of life and implications for end-of-life decision making. Lancet. 2000;356:398-399.

Two new insulin products were recently FDA-approved, Exubera (inhaled human insulin, Pfizer/Nektar) and Levemir (insulin detemir, Novo Nordisk). These new insulins are important to hospitalists because admitted patients may be receiving them, patients may ask about them, and other members of the healthcare team may have questions, as well.

Nektar Therapeutics has been developing noninvasive macromolecules for inhaled delivery systems for many years. To develop Exubera (their first FDA-approved product), they collaborated with Pfizer and Sanofi-Aventis. Other Nektar products are not as far along in the U.S. drug approval process.

Exubera (inhalation powder, insulin human) was FDA-approved on January 27, 2006, and is expected to be on pharmacy shelves in June or July of this year. Exubera was also recently approved in Europe but is not available there yet, either. Exubera is short-acting and was approved for use in Types 1 and 2 diabetes mellitus in conjunction with oral agents, or with a basal insulin for basal/bolus dosing.

Peak Exubera levels occur in ~49 minutes (range 30-90 minutes) compared with regular insulin with a peak in 105 minutes (range, 60-240 minutes). In an open-label, 12-week, randomized, controlled trial Exubera improved glycemic control when substituted for or added to oral combination therapy (n=309) in adult Type 2 diabetes patients. There was a small decrease in HbA1c of ~1.4% in the Exubera-treated monotherapy patients. When Exubera was combined with two oral agents (an insulin sensitizer and a secretagogue), the HbA1c decreased ~1.9%. Patients who used only oral agents had an insignificant decrease in HbA1c (0.2%).

Investigators offered Types 1 and 2 diabetics open-label use of inhaled insulin for up to four years. The patients have maintained long-term glycemic control.

The Exubera inhaler device weighs 4 ounces and is about the size of a closed eyeglass case. Carrying the device may be problematic for some because of its size. Common side effects include cough, shortness of breath, sore throat, dry mouth, and hypoglycemia. Exubera is not recommended for 1) patients who have recently quit smoking (within six months); 2) current smokers; 3) asthmatics; or 4) those with bronchitis or emphysema.

Because Exubera is a new product that has not been available in other countries, its long-term safety is unknown. Pfizer is, however, committed to long-term safety and efficacy studies. Monitoring parameters specific to Exubera include: 1) baseline pulmonary function tests (PFTs); and 2) follow-up PFTs every six-12 months until more is known about the drug’s pulmonary safety.

The Word on the Street

Exubera’s manufacturers will likely target this agent to the population that will provide them with the greatest market potential (largest profit). Likely candidates will be those with poorly controlled diabetes on >2 oral agents; these patients will likely need more than another oral agent to improve their glycemic control. Pfizer may choose to market Exubera against insulin sensitizers such as rosiglitazone or pioglitazone —especially when it comes to pharmacoeconomics because the ‘glitazones are not yet available generically and are thus higher cost items.

Ease of use for Exubera versus injected insulin may be the sole advantage for this new agent. Some say that if Exubera is used as a tool for diabetics to get insulin treatment earlier (versus injected insulin), diabetic complications may be minimized; however, medication compliance will play a large role. The medical literature is full of articles regarding non-compliance/non-adherence with asthma inhalers, including improper inhaler use and non-use of these devices. So unless inhaled insulin can significantly improve outcomes compared with the inexpensive injections and other available therapies (e.g., insulin sensitizers), its place on health-system formularies may be limited at best.

Another Inhaled Option

Novo Nordisk received initial FDA approval for its long-acting, basal insulin analog—insulin detemir—on June 17, 2005. Subsequent approval for use in the pediatric population came on October 20, 2005. Levemir is expected on U.S. pharmacy shelves any day. Levemir has been approved in 53 countries worldwide, and has been available in Europe since March 2004.

Levemir is a basal insulin, similar to Lantus (glargine, Sanofi-Aventis), and is approved for use in adults with Types 1 and 2 diabetes and in children with Type 1 diabetes.

It is recommended that Levemir be dosed once- or twice-daily subcutaneously. Pharmacokinetically Levemir has a relatively flat action profile with a mean duration of action ranging between 5.7–23.2 hours (data from clinical trials). Following subcutaneous administration, insulin detemir has a slower, more prolonged absorption over 24 hours compared with NPH insulin. Maximum serum concentrations occur within six to eight hours following administration.

A common side effect of insulin therapies is hypoglycemia. Other side effects common to human insulins include allergic reactions, injection site reactions, lipodystrophy, pruritus, and rash. A beneficial effect obtained in some of the Levemir clinical studies was weight loss (0.2 to 0.3-kg), which occurred in several Type 1 patients. Comparatively, the Type 1 patients who received NPH insulin noted weight gain (0.4 to 1.4-kg) over the six-12 month timeframe.

There are no specific monitoring parameters for insulin detemir, except for general management of the diabetic patient (e.g., fasting blood sugar, glycosylated hemoglobin, eye exam, podiatry).

At its launch, insulin detemir will be available in 10mL vials as well as in the Levemir FlexPen. The FlexPen will require the use of NovoFine 30- or 31-gauge disposable needles. TH

Michele Kaufman is based in New York City.

References—Exubera

• Hollander PA, Blonde L, Rowe R, et al. Efficacy and safety of inhaled insulin (Exubera) compared with subcutaneous insulin therapy in patients with Type 2 diabetes: Results of a 6-month, randomized, comparative trial. Diabetes Care. 2004;27:2356-2362.
• Skyler JS, Weinstock RS, Raskin P, et al. The Inhaled Insulin Phase III Type 1 Diabetes Study Group. Use of inhaled insulin in a basal/bolus insulin regimen in Type 1 diabetic subjects: a 6-month, randomized, comparative trial. Diabetes Care. 2005 Jul:28(7):1630-1635.
• Rosenstock J, Zinman B, Murphy LJ, et al. Inhaled insulin improves glycemic control when substituted for or added to oral combination therapy in Type 2 Diabetes—a randomized, controlled trial. Ann Intern Med. 2005 Oct 18;143(8):549-588.
• The Pink Sheet, February 14, 2006; Volume 68, Number 7.Available at www.fda.gov/bbs/topics/news/2006/NEW01304.html. Last accessed March 8, 2006.

References—Levemir

• Levemir (insulin detemir [rDNA origin] injection) package insert. Novo Nordisk, Inc. Princeton, NJ; October 2005.
• Goldman JD, Lee KW. Insulin detemir—a new basal insulin analog. nn Pharmacother. 2005;39:502-507.
• Home P, Bartley P, Russell-Jones D, et al. Insulin detemir offers improved glycemic control compared with NPH insulin in people with Type 1 diabetes—a randomized clinical trial. Diabetes Care. 2004;27:1081-1087. Available at http://press.novonordisk-us.com/internal.aspx?rid=318. Last accessed March 1, 2006.

Two new insulin products were recently FDA-approved, Exubera (inhaled human insulin, Pfizer/Nektar) and Levemir (insulin detemir, Novo Nordisk). These new insulins are important to hospitalists because admitted patients may be receiving them, patients may ask about them, and other members of the healthcare team may have questions, as well.

Nektar Therapeutics has been developing noninvasive macromolecules for inhaled delivery systems for many years. To develop Exubera (their first FDA-approved product), they collaborated with Pfizer and Sanofi-Aventis. Other Nektar products are not as far along in the U.S. drug approval process.

Exubera (inhalation powder, insulin human) was FDA-approved on January 27, 2006, and is expected to be on pharmacy shelves in June or July of this year. Exubera was also recently approved in Europe but is not available there yet, either. Exubera is short-acting and was approved for use in Types 1 and 2 diabetes mellitus in conjunction with oral agents, or with a basal insulin for basal/bolus dosing.

Peak Exubera levels occur in ~49 minutes (range 30-90 minutes) compared with regular insulin with a peak in 105 minutes (range, 60-240 minutes). In an open-label, 12-week, randomized, controlled trial Exubera improved glycemic control when substituted for or added to oral combination therapy (n=309) in adult Type 2 diabetes patients. There was a small decrease in HbA1c of ~1.4% in the Exubera-treated monotherapy patients. When Exubera was combined with two oral agents (an insulin sensitizer and a secretagogue), the HbA1c decreased ~1.9%. Patients who used only oral agents had an insignificant decrease in HbA1c (0.2%).

Investigators offered Types 1 and 2 diabetics open-label use of inhaled insulin for up to four years. The patients have maintained long-term glycemic control.

The Exubera inhaler device weighs 4 ounces and is about the size of a closed eyeglass case. Carrying the device may be problematic for some because of its size. Common side effects include cough, shortness of breath, sore throat, dry mouth, and hypoglycemia. Exubera is not recommended for 1) patients who have recently quit smoking (within six months); 2) current smokers; 3) asthmatics; or 4) those with bronchitis or emphysema.

Because Exubera is a new product that has not been available in other countries, its long-term safety is unknown. Pfizer is, however, committed to long-term safety and efficacy studies. Monitoring parameters specific to Exubera include: 1) baseline pulmonary function tests (PFTs); and 2) follow-up PFTs every six-12 months until more is known about the drug’s pulmonary safety.

The Word on the Street

Exubera’s manufacturers will likely target this agent to the population that will provide them with the greatest market potential (largest profit). Likely candidates will be those with poorly controlled diabetes on >2 oral agents; these patients will likely need more than another oral agent to improve their glycemic control. Pfizer may choose to market Exubera against insulin sensitizers such as rosiglitazone or pioglitazone —especially when it comes to pharmacoeconomics because the ‘glitazones are not yet available generically and are thus higher cost items.

Ease of use for Exubera versus injected insulin may be the sole advantage for this new agent. Some say that if Exubera is used as a tool for diabetics to get insulin treatment earlier (versus injected insulin), diabetic complications may be minimized; however, medication compliance will play a large role. The medical literature is full of articles regarding non-compliance/non-adherence with asthma inhalers, including improper inhaler use and non-use of these devices. So unless inhaled insulin can significantly improve outcomes compared with the inexpensive injections and other available therapies (e.g., insulin sensitizers), its place on health-system formularies may be limited at best.

Another Inhaled Option

Novo Nordisk received initial FDA approval for its long-acting, basal insulin analog—insulin detemir—on June 17, 2005. Subsequent approval for use in the pediatric population came on October 20, 2005. Levemir is expected on U.S. pharmacy shelves any day. Levemir has been approved in 53 countries worldwide, and has been available in Europe since March 2004.

Levemir is a basal insulin, similar to Lantus (glargine, Sanofi-Aventis), and is approved for use in adults with Types 1 and 2 diabetes and in children with Type 1 diabetes.

It is recommended that Levemir be dosed once- or twice-daily subcutaneously. Pharmacokinetically Levemir has a relatively flat action profile with a mean duration of action ranging between 5.7–23.2 hours (data from clinical trials). Following subcutaneous administration, insulin detemir has a slower, more prolonged absorption over 24 hours compared with NPH insulin. Maximum serum concentrations occur within six to eight hours following administration.

A common side effect of insulin therapies is hypoglycemia. Other side effects common to human insulins include allergic reactions, injection site reactions, lipodystrophy, pruritus, and rash. A beneficial effect obtained in some of the Levemir clinical studies was weight loss (0.2 to 0.3-kg), which occurred in several Type 1 patients. Comparatively, the Type 1 patients who received NPH insulin noted weight gain (0.4 to 1.4-kg) over the six-12 month timeframe.

There are no specific monitoring parameters for insulin detemir, except for general management of the diabetic patient (e.g., fasting blood sugar, glycosylated hemoglobin, eye exam, podiatry).

At its launch, insulin detemir will be available in 10mL vials as well as in the Levemir FlexPen. The FlexPen will require the use of NovoFine 30- or 31-gauge disposable needles. TH

Michele Kaufman is based in New York City.

References—Exubera

• Hollander PA, Blonde L, Rowe R, et al. Efficacy and safety of inhaled insulin (Exubera) compared with subcutaneous insulin therapy in patients with Type 2 diabetes: Results of a 6-month, randomized, comparative trial. Diabetes Care. 2004;27:2356-2362.
• Skyler JS, Weinstock RS, Raskin P, et al. The Inhaled Insulin Phase III Type 1 Diabetes Study Group. Use of inhaled insulin in a basal/bolus insulin regimen in Type 1 diabetic subjects: a 6-month, randomized, comparative trial. Diabetes Care. 2005 Jul:28(7):1630-1635.
• Rosenstock J, Zinman B, Murphy LJ, et al. Inhaled insulin improves glycemic control when substituted for or added to oral combination therapy in Type 2 Diabetes—a randomized, controlled trial. Ann Intern Med. 2005 Oct 18;143(8):549-588.
• The Pink Sheet, February 14, 2006; Volume 68, Number 7.Available at www.fda.gov/bbs/topics/news/2006/NEW01304.html. Last accessed March 8, 2006.

References—Levemir

• Levemir (insulin detemir [rDNA origin] injection) package insert. Novo Nordisk, Inc. Princeton, NJ; October 2005.
• Goldman JD, Lee KW. Insulin detemir—a new basal insulin analog. nn Pharmacother. 2005;39:502-507.
• Home P, Bartley P, Russell-Jones D, et al. Insulin detemir offers improved glycemic control compared with NPH insulin in people with Type 1 diabetes—a randomized clinical trial. Diabetes Care. 2004;27:1081-1087. Available at http://press.novonordisk-us.com/internal.aspx?rid=318. Last accessed March 1, 2006.

Two new insulin products were recently FDA-approved, Exubera (inhaled human insulin, Pfizer/Nektar) and Levemir (insulin detemir, Novo Nordisk). These new insulins are important to hospitalists because admitted patients may be receiving them, patients may ask about them, and other members of the healthcare team may have questions, as well.

Nektar Therapeutics has been developing noninvasive macromolecules for inhaled delivery systems for many years. To develop Exubera (their first FDA-approved product), they collaborated with Pfizer and Sanofi-Aventis. Other Nektar products are not as far along in the U.S. drug approval process.

Exubera (inhalation powder, insulin human) was FDA-approved on January 27, 2006, and is expected to be on pharmacy shelves in June or July of this year. Exubera was also recently approved in Europe but is not available there yet, either. Exubera is short-acting and was approved for use in Types 1 and 2 diabetes mellitus in conjunction with oral agents, or with a basal insulin for basal/bolus dosing.

Peak Exubera levels occur in ~49 minutes (range 30-90 minutes) compared with regular insulin with a peak in 105 minutes (range, 60-240 minutes). In an open-label, 12-week, randomized, controlled trial Exubera improved glycemic control when substituted for or added to oral combination therapy (n=309) in adult Type 2 diabetes patients. There was a small decrease in HbA1c of ~1.4% in the Exubera-treated monotherapy patients. When Exubera was combined with two oral agents (an insulin sensitizer and a secretagogue), the HbA1c decreased ~1.9%. Patients who used only oral agents had an insignificant decrease in HbA1c (0.2%).

Investigators offered Types 1 and 2 diabetics open-label use of inhaled insulin for up to four years. The patients have maintained long-term glycemic control.

The Exubera inhaler device weighs 4 ounces and is about the size of a closed eyeglass case. Carrying the device may be problematic for some because of its size. Common side effects include cough, shortness of breath, sore throat, dry mouth, and hypoglycemia. Exubera is not recommended for 1) patients who have recently quit smoking (within six months); 2) current smokers; 3) asthmatics; or 4) those with bronchitis or emphysema.

Because Exubera is a new product that has not been available in other countries, its long-term safety is unknown. Pfizer is, however, committed to long-term safety and efficacy studies. Monitoring parameters specific to Exubera include: 1) baseline pulmonary function tests (PFTs); and 2) follow-up PFTs every six-12 months until more is known about the drug’s pulmonary safety.

The Word on the Street

Exubera’s manufacturers will likely target this agent to the population that will provide them with the greatest market potential (largest profit). Likely candidates will be those with poorly controlled diabetes on >2 oral agents; these patients will likely need more than another oral agent to improve their glycemic control. Pfizer may choose to market Exubera against insulin sensitizers such as rosiglitazone or pioglitazone —especially when it comes to pharmacoeconomics because the ‘glitazones are not yet available generically and are thus higher cost items.

Ease of use for Exubera versus injected insulin may be the sole advantage for this new agent. Some say that if Exubera is used as a tool for diabetics to get insulin treatment earlier (versus injected insulin), diabetic complications may be minimized; however, medication compliance will play a large role. The medical literature is full of articles regarding non-compliance/non-adherence with asthma inhalers, including improper inhaler use and non-use of these devices. So unless inhaled insulin can significantly improve outcomes compared with the inexpensive injections and other available therapies (e.g., insulin sensitizers), its place on health-system formularies may be limited at best.

Another Inhaled Option

Novo Nordisk received initial FDA approval for its long-acting, basal insulin analog—insulin detemir—on June 17, 2005. Subsequent approval for use in the pediatric population came on October 20, 2005. Levemir is expected on U.S. pharmacy shelves any day. Levemir has been approved in 53 countries worldwide, and has been available in Europe since March 2004.

Levemir is a basal insulin, similar to Lantus (glargine, Sanofi-Aventis), and is approved for use in adults with Types 1 and 2 diabetes and in children with Type 1 diabetes.

It is recommended that Levemir be dosed once- or twice-daily subcutaneously. Pharmacokinetically Levemir has a relatively flat action profile with a mean duration of action ranging between 5.7–23.2 hours (data from clinical trials). Following subcutaneous administration, insulin detemir has a slower, more prolonged absorption over 24 hours compared with NPH insulin. Maximum serum concentrations occur within six to eight hours following administration.

A common side effect of insulin therapies is hypoglycemia. Other side effects common to human insulins include allergic reactions, injection site reactions, lipodystrophy, pruritus, and rash. A beneficial effect obtained in some of the Levemir clinical studies was weight loss (0.2 to 0.3-kg), which occurred in several Type 1 patients. Comparatively, the Type 1 patients who received NPH insulin noted weight gain (0.4 to 1.4-kg) over the six-12 month timeframe.

There are no specific monitoring parameters for insulin detemir, except for general management of the diabetic patient (e.g., fasting blood sugar, glycosylated hemoglobin, eye exam, podiatry).

At its launch, insulin detemir will be available in 10mL vials as well as in the Levemir FlexPen. The FlexPen will require the use of NovoFine 30- or 31-gauge disposable needles. TH

Michele Kaufman is based in New York City.

References—Exubera

• Hollander PA, Blonde L, Rowe R, et al. Efficacy and safety of inhaled insulin (Exubera) compared with subcutaneous insulin therapy in patients with Type 2 diabetes: Results of a 6-month, randomized, comparative trial. Diabetes Care. 2004;27:2356-2362.
• Skyler JS, Weinstock RS, Raskin P, et al. The Inhaled Insulin Phase III Type 1 Diabetes Study Group. Use of inhaled insulin in a basal/bolus insulin regimen in Type 1 diabetic subjects: a 6-month, randomized, comparative trial. Diabetes Care. 2005 Jul:28(7):1630-1635.
• Rosenstock J, Zinman B, Murphy LJ, et al. Inhaled insulin improves glycemic control when substituted for or added to oral combination therapy in Type 2 Diabetes—a randomized, controlled trial. Ann Intern Med. 2005 Oct 18;143(8):549-588.
• The Pink Sheet, February 14, 2006; Volume 68, Number 7.Available at www.fda.gov/bbs/topics/news/2006/NEW01304.html. Last accessed March 8, 2006.

References—Levemir

• Levemir (insulin detemir [rDNA origin] injection) package insert. Novo Nordisk, Inc. Princeton, NJ; October 2005.
• Goldman JD, Lee KW. Insulin detemir—a new basal insulin analog. nn Pharmacother. 2005;39:502-507.
• Home P, Bartley P, Russell-Jones D, et al. Insulin detemir offers improved glycemic control compared with NPH insulin in people with Type 1 diabetes—a randomized clinical trial. Diabetes Care. 2004;27:1081-1087. Available at http://press.novonordisk-us.com/internal.aspx?rid=318. Last accessed March 1, 2006.

Josef Leopold Auenbrugger: the inventor of percussion

Who more appropriate to discover percussion in the human form than a Viennese-trained physician? Josef Leopold Auenbrugger invented the technique of percussing the patient’s chest in 1754, just two years before Wolfgang Amadeus Mozart’s birth in 1756.

The son of an innkeeper, Auenbrugger is said to have tapped wine barrels in his father’s cellar as a boy to find out how full they were. Little would one expect that this percussive background would lead to a medical breakthrough. Later in life he became a composer and wrote an opera for Austrian Empress Marie Theresa.

Auenbrugger described the lung as sounding like a drum with a heavy cloth over it. When the lung is full, stated Auenbrugger, such as in the case of pneumonia, the sound is similar to tapping the fleshy part of the thigh. Auenbrugger practiced these techniques on cadavers. He injected fluid into the pleural cavity and created a science around when and where efforts should be made for its removal.

These observations were published in a small book, now considered a medical classic. Called Inventum Novum, the full English title is A New Discovery that Enables the Physician from the Percussion of the Human Thorax to Detect the Diseases Hidden Within the Chest (and hence, the shorter, more common title).

What is a great story—albeit true—without rejection and shame? His ideas rejected and forced to resign his commission in his current post, Auenbrugger showed understanding of human nature in the following statement: “I have not been unconscious of the dangers I must encounter, since it has always been the fate of those who have illustrated or improved the arts and sciences by their discovery, to be beset by envy, malice, hatred, detraction, and calumny.”

Auenbrugger’s work did eventually rise out of obscurity largely through the exposure of Jean Nicolas Corvisart, Napoleon’s favorite physician. Corvisart, who also influenced René-Théophile-Hyacinthe Laennec, inventor of the stethoscope, led a school of medicine that hoped to correlate the clinical exam to pathologic findings. Corvisart taught the method of percussion to his students and in 1808 translated and published the book with annotations—just a year before Auenbrugger’s death. Ironically, Auenbrugger may not have known about this translation that spread rapidly among the medical community.

To some the physical exam is defunct, supplanted by scans and lab. Two hundred and fifty years later, the technique of percussion is still a cornerstone of the art of the physical exam. Next time you percuss an ascitic abdomen or tap out the level of a pleural effusion, think back to Leopold Auenbrugger, his Inventum Novum, and the birth of the modern physical exam. TH

Josef Leopold Auenbrugger: the inventor of percussion

Who more appropriate to discover percussion in the human form than a Viennese-trained physician? Josef Leopold Auenbrugger invented the technique of percussing the patient’s chest in 1754, just two years before Wolfgang Amadeus Mozart’s birth in 1756.

The son of an innkeeper, Auenbrugger is said to have tapped wine barrels in his father’s cellar as a boy to find out how full they were. Little would one expect that this percussive background would lead to a medical breakthrough. Later in life he became a composer and wrote an opera for Austrian Empress Marie Theresa.

Auenbrugger described the lung as sounding like a drum with a heavy cloth over it. When the lung is full, stated Auenbrugger, such as in the case of pneumonia, the sound is similar to tapping the fleshy part of the thigh. Auenbrugger practiced these techniques on cadavers. He injected fluid into the pleural cavity and created a science around when and where efforts should be made for its removal.

These observations were published in a small book, now considered a medical classic. Called Inventum Novum, the full English title is A New Discovery that Enables the Physician from the Percussion of the Human Thorax to Detect the Diseases Hidden Within the Chest (and hence, the shorter, more common title).

What is a great story—albeit true—without rejection and shame? His ideas rejected and forced to resign his commission in his current post, Auenbrugger showed understanding of human nature in the following statement: “I have not been unconscious of the dangers I must encounter, since it has always been the fate of those who have illustrated or improved the arts and sciences by their discovery, to be beset by envy, malice, hatred, detraction, and calumny.”

Auenbrugger’s work did eventually rise out of obscurity largely through the exposure of Jean Nicolas Corvisart, Napoleon’s favorite physician. Corvisart, who also influenced René-Théophile-Hyacinthe Laennec, inventor of the stethoscope, led a school of medicine that hoped to correlate the clinical exam to pathologic findings. Corvisart taught the method of percussion to his students and in 1808 translated and published the book with annotations—just a year before Auenbrugger’s death. Ironically, Auenbrugger may not have known about this translation that spread rapidly among the medical community.

To some the physical exam is defunct, supplanted by scans and lab. Two hundred and fifty years later, the technique of percussion is still a cornerstone of the art of the physical exam. Next time you percuss an ascitic abdomen or tap out the level of a pleural effusion, think back to Leopold Auenbrugger, his Inventum Novum, and the birth of the modern physical exam. TH

Josef Leopold Auenbrugger: the inventor of percussion

Who more appropriate to discover percussion in the human form than a Viennese-trained physician? Josef Leopold Auenbrugger invented the technique of percussing the patient’s chest in 1754, just two years before Wolfgang Amadeus Mozart’s birth in 1756.

The son of an innkeeper, Auenbrugger is said to have tapped wine barrels in his father’s cellar as a boy to find out how full they were. Little would one expect that this percussive background would lead to a medical breakthrough. Later in life he became a composer and wrote an opera for Austrian Empress Marie Theresa.

Auenbrugger described the lung as sounding like a drum with a heavy cloth over it. When the lung is full, stated Auenbrugger, such as in the case of pneumonia, the sound is similar to tapping the fleshy part of the thigh. Auenbrugger practiced these techniques on cadavers. He injected fluid into the pleural cavity and created a science around when and where efforts should be made for its removal.

These observations were published in a small book, now considered a medical classic. Called Inventum Novum, the full English title is A New Discovery that Enables the Physician from the Percussion of the Human Thorax to Detect the Diseases Hidden Within the Chest (and hence, the shorter, more common title).

What is a great story—albeit true—without rejection and shame? His ideas rejected and forced to resign his commission in his current post, Auenbrugger showed understanding of human nature in the following statement: “I have not been unconscious of the dangers I must encounter, since it has always been the fate of those who have illustrated or improved the arts and sciences by their discovery, to be beset by envy, malice, hatred, detraction, and calumny.”

Auenbrugger’s work did eventually rise out of obscurity largely through the exposure of Jean Nicolas Corvisart, Napoleon’s favorite physician. Corvisart, who also influenced René-Théophile-Hyacinthe Laennec, inventor of the stethoscope, led a school of medicine that hoped to correlate the clinical exam to pathologic findings. Corvisart taught the method of percussion to his students and in 1808 translated and published the book with annotations—just a year before Auenbrugger’s death. Ironically, Auenbrugger may not have known about this translation that spread rapidly among the medical community.

To some the physical exam is defunct, supplanted by scans and lab. Two hundred and fifty years later, the technique of percussion is still a cornerstone of the art of the physical exam. Next time you percuss an ascitic abdomen or tap out the level of a pleural effusion, think back to Leopold Auenbrugger, his Inventum Novum, and the birth of the modern physical exam. TH

A24-year-old white female is admitted directly to the hospital by her cardiologist for a wound infection. She is a medical technology student who underwent a pacemaker implantation three weeks prior for persistent symptomatic bradycardia. She now complains of pain, redness, and swelling at the site of her pacemaker incision site. She reports fevers, chills, night sweats, and multiple other systemic symptoms.

On physical exam, she appears quite pleasant, in no apparent distress, and without any abnormalities in vital signs. Her incision site reveals an erythematous, geometric, annular patch with no edema, warmth, induration or discharge. (See photo.)

What is the most appropriate treatment for this patient?

1. Draw blood cultures, place central line, and begin broad-spectrum antibiotics.
2. Draw blood cultures, place central line, and begin broad-spectrum antibiotics and also itraconazole to cover atypical mycobacteria infection.
3. Schedule surgery to remove pacemaker.
4. Gently approach patient about stressors and possible underlying psychiatric issues and consult psychiatry.
5. Obtain wound cultures and apply mupirocin ointment twice daily.

Discussion

The correct answer is D: Gently approach patient about stressors and possible underlying psychiatric issues and consult psychiatry.

This patient had been applying an external agent (most likely makeup) to her wound site. On questioning, the patient and her family continued to deny any manipulation of the wound even when the substance was wiped away with an alcohol pad. (See photo above.) Additionally, a half-empty bottle of clonidine was found under her pillow. The clonidine was apparently used as an attempt to feign hypotension. She denied taking the medication, but the medical team suspected that the use of these antihypertensives led to her previous symptomatic bradycardia and eventual pacemaker implantation.

Despite gentle questioning and evaluation for stressors and signs of depression, the patient left the hospital against medical advice before psychiatric consult could be obtained. The patient eventually returned to the cardiology clinic complaining again of wound infection. A wound culture revealed Enterococcus faecalis consistent with fecal contamination of her incision site. Eventually, her pacemaker was removed. She did continue to see different physicians and visit different hospitals before being permanently lost to follow up.

This case of Munchausen syndrome demonstrates many of its defining characteristics. Munchausen syndrome was originally described by Asher in 1951 in Lancet. Its name is derived from Baron von Munchausen, a German nobleman who told humorous but outlandish tales about his travels, including riding on cannonballs, traveling to the moon, and discovering an island made of cheese. Munchausen syndrome is a factitious disorder (symptoms are intentionally produced), but unlike malingering there is no apparent secondary gain except to satisfy the psychological need to receive attention or support. These patients often undergo medical evaluations and multiple, invasive, surgical procedures simply to have them. The DSM-IV points out that the motivation for the behavior is only to assume the sick role.

Patients tend to be young adults and are more often male. They may describe and have physical findings of any number of illnesses. They may have undergone many prior surgical procedures and have several scars on physical exam. Classically, they have seen several different physicians and often have some medical knowledge including medical terminology.

Treatment is often difficult. It is appropriate to address any possible underlying organic disease by systemic approach to avoid overlooking any dangerous conditions. If none is found, the patient should be assessed for stressors, signs of psychosis or depression, and any possible financial or other secondary gains. It is important to recognize Munchausen syndrome as a factitious disorder as opposed to a somatoform disorder (somatization, conversion, hypochondriasis). A factitious disorder is produced artificially by the patient, whereas symptoms of a somatoform disorder are not under the patient’s control. TH

Bibliography

• Asher R. Munchausen’s syndrome. Lancet. 1951;1:339-341.
• Hammerschmidt DE. The adventures of Freiherr von Munchausen. J Lab Clin Med. 2004 Dec;144(6):320-321.
• Park TA, Borsch MA, Dyer AR, et al. Cardiopathia fantastica: the cardiac variant of Munchausen syndrome. South Med J. 2004;97(1):48-52;quiz 53.
• Reich P, Gottfried LA. Factitious disorders in a teaching hospital. Ann Intern Med. 1983;99:240–247.
• Lad SP, Jobe KW, Polley J, et al. Munchausen’s syndrome in neurosurgery: report of two cases and review of the literature. Neurosurgery. 2004 Dec;55(6):1436.
• Huffman JC, Stern TA. The diagnosis and treatment of Munchausen’s syndrome. General Hospital Psychiatry. 2003 Sept-Oct;25(5):358-363.

A24-year-old white female is admitted directly to the hospital by her cardiologist for a wound infection. She is a medical technology student who underwent a pacemaker implantation three weeks prior for persistent symptomatic bradycardia. She now complains of pain, redness, and swelling at the site of her pacemaker incision site. She reports fevers, chills, night sweats, and multiple other systemic symptoms.

On physical exam, she appears quite pleasant, in no apparent distress, and without any abnormalities in vital signs. Her incision site reveals an erythematous, geometric, annular patch with no edema, warmth, induration or discharge. (See photo.)

What is the most appropriate treatment for this patient?

1. Draw blood cultures, place central line, and begin broad-spectrum antibiotics.
2. Draw blood cultures, place central line, and begin broad-spectrum antibiotics and also itraconazole to cover atypical mycobacteria infection.
3. Schedule surgery to remove pacemaker.
4. Gently approach patient about stressors and possible underlying psychiatric issues and consult psychiatry.
5. Obtain wound cultures and apply mupirocin ointment twice daily.

Discussion

The correct answer is D: Gently approach patient about stressors and possible underlying psychiatric issues and consult psychiatry.

This patient had been applying an external agent (most likely makeup) to her wound site. On questioning, the patient and her family continued to deny any manipulation of the wound even when the substance was wiped away with an alcohol pad. (See photo above.) Additionally, a half-empty bottle of clonidine was found under her pillow. The clonidine was apparently used as an attempt to feign hypotension. She denied taking the medication, but the medical team suspected that the use of these antihypertensives led to her previous symptomatic bradycardia and eventual pacemaker implantation.

Despite gentle questioning and evaluation for stressors and signs of depression, the patient left the hospital against medical advice before psychiatric consult could be obtained. The patient eventually returned to the cardiology clinic complaining again of wound infection. A wound culture revealed Enterococcus faecalis consistent with fecal contamination of her incision site. Eventually, her pacemaker was removed. She did continue to see different physicians and visit different hospitals before being permanently lost to follow up.

This case of Munchausen syndrome demonstrates many of its defining characteristics. Munchausen syndrome was originally described by Asher in 1951 in Lancet. Its name is derived from Baron von Munchausen, a German nobleman who told humorous but outlandish tales about his travels, including riding on cannonballs, traveling to the moon, and discovering an island made of cheese. Munchausen syndrome is a factitious disorder (symptoms are intentionally produced), but unlike malingering there is no apparent secondary gain except to satisfy the psychological need to receive attention or support. These patients often undergo medical evaluations and multiple, invasive, surgical procedures simply to have them. The DSM-IV points out that the motivation for the behavior is only to assume the sick role.

Patients tend to be young adults and are more often male. They may describe and have physical findings of any number of illnesses. They may have undergone many prior surgical procedures and have several scars on physical exam. Classically, they have seen several different physicians and often have some medical knowledge including medical terminology.

Treatment is often difficult. It is appropriate to address any possible underlying organic disease by systemic approach to avoid overlooking any dangerous conditions. If none is found, the patient should be assessed for stressors, signs of psychosis or depression, and any possible financial or other secondary gains. It is important to recognize Munchausen syndrome as a factitious disorder as opposed to a somatoform disorder (somatization, conversion, hypochondriasis). A factitious disorder is produced artificially by the patient, whereas symptoms of a somatoform disorder are not under the patient’s control. TH

Bibliography

• Asher R. Munchausen’s syndrome. Lancet. 1951;1:339-341.
• Hammerschmidt DE. The adventures of Freiherr von Munchausen. J Lab Clin Med. 2004 Dec;144(6):320-321.
• Park TA, Borsch MA, Dyer AR, et al. Cardiopathia fantastica: the cardiac variant of Munchausen syndrome. South Med J. 2004;97(1):48-52;quiz 53.
• Reich P, Gottfried LA. Factitious disorders in a teaching hospital. Ann Intern Med. 1983;99:240–247.
• Lad SP, Jobe KW, Polley J, et al. Munchausen’s syndrome in neurosurgery: report of two cases and review of the literature. Neurosurgery. 2004 Dec;55(6):1436.
• Huffman JC, Stern TA. The diagnosis and treatment of Munchausen’s syndrome. General Hospital Psychiatry. 2003 Sept-Oct;25(5):358-363.

A24-year-old white female is admitted directly to the hospital by her cardiologist for a wound infection. She is a medical technology student who underwent a pacemaker implantation three weeks prior for persistent symptomatic bradycardia. She now complains of pain, redness, and swelling at the site of her pacemaker incision site. She reports fevers, chills, night sweats, and multiple other systemic symptoms.

On physical exam, she appears quite pleasant, in no apparent distress, and without any abnormalities in vital signs. Her incision site reveals an erythematous, geometric, annular patch with no edema, warmth, induration or discharge. (See photo.)

What is the most appropriate treatment for this patient?

1. Draw blood cultures, place central line, and begin broad-spectrum antibiotics.
2. Draw blood cultures, place central line, and begin broad-spectrum antibiotics and also itraconazole to cover atypical mycobacteria infection.
3. Schedule surgery to remove pacemaker.
4. Gently approach patient about stressors and possible underlying psychiatric issues and consult psychiatry.
5. Obtain wound cultures and apply mupirocin ointment twice daily.

Discussion

The correct answer is D: Gently approach patient about stressors and possible underlying psychiatric issues and consult psychiatry.

This patient had been applying an external agent (most likely makeup) to her wound site. On questioning, the patient and her family continued to deny any manipulation of the wound even when the substance was wiped away with an alcohol pad. (See photo above.) Additionally, a half-empty bottle of clonidine was found under her pillow. The clonidine was apparently used as an attempt to feign hypotension. She denied taking the medication, but the medical team suspected that the use of these antihypertensives led to her previous symptomatic bradycardia and eventual pacemaker implantation.

Despite gentle questioning and evaluation for stressors and signs of depression, the patient left the hospital against medical advice before psychiatric consult could be obtained. The patient eventually returned to the cardiology clinic complaining again of wound infection. A wound culture revealed Enterococcus faecalis consistent with fecal contamination of her incision site. Eventually, her pacemaker was removed. She did continue to see different physicians and visit different hospitals before being permanently lost to follow up.

This case of Munchausen syndrome demonstrates many of its defining characteristics. Munchausen syndrome was originally described by Asher in 1951 in Lancet. Its name is derived from Baron von Munchausen, a German nobleman who told humorous but outlandish tales about his travels, including riding on cannonballs, traveling to the moon, and discovering an island made of cheese. Munchausen syndrome is a factitious disorder (symptoms are intentionally produced), but unlike malingering there is no apparent secondary gain except to satisfy the psychological need to receive attention or support. These patients often undergo medical evaluations and multiple, invasive, surgical procedures simply to have them. The DSM-IV points out that the motivation for the behavior is only to assume the sick role.

Patients tend to be young adults and are more often male. They may describe and have physical findings of any number of illnesses. They may have undergone many prior surgical procedures and have several scars on physical exam. Classically, they have seen several different physicians and often have some medical knowledge including medical terminology.

Treatment is often difficult. It is appropriate to address any possible underlying organic disease by systemic approach to avoid overlooking any dangerous conditions. If none is found, the patient should be assessed for stressors, signs of psychosis or depression, and any possible financial or other secondary gains. It is important to recognize Munchausen syndrome as a factitious disorder as opposed to a somatoform disorder (somatization, conversion, hypochondriasis). A factitious disorder is produced artificially by the patient, whereas symptoms of a somatoform disorder are not under the patient’s control. TH

Bibliography

• Asher R. Munchausen’s syndrome. Lancet. 1951;1:339-341.
• Hammerschmidt DE. The adventures of Freiherr von Munchausen. J Lab Clin Med. 2004 Dec;144(6):320-321.
• Park TA, Borsch MA, Dyer AR, et al. Cardiopathia fantastica: the cardiac variant of Munchausen syndrome. South Med J. 2004;97(1):48-52;quiz 53.
• Reich P, Gottfried LA. Factitious disorders in a teaching hospital. Ann Intern Med. 1983;99:240–247.
• Lad SP, Jobe KW, Polley J, et al. Munchausen’s syndrome in neurosurgery: report of two cases and review of the literature. Neurosurgery. 2004 Dec;55(6):1436.
• Huffman JC, Stern TA. The diagnosis and treatment of Munchausen’s syndrome. General Hospital Psychiatry. 2003 Sept-Oct;25(5):358-363.

Recruiting hospitalists—or any other medical personnel—is all about supply and demand. Right now, the demand for hospitalists exceeds the supply. Many hospital medicine groups are growing rapidly, and more such groups are being created across the country. These groups are aggressively recruiting residents and physicians from the relatively small pool of hospitalists for hire, even as they lament the lack of candidates.

“Recruiting hospitalists is as competitive as I’ve ever seen,” says Vikas Parekh, MD, assistant professor and director, Non-House-staff Hospitalist Services, Department of Internal Medicine, University of Michigan, Ann Arbor. “This even trumps the primary care crisis of years ago.”

The Carrot: Repayment of Student Loans

Like many healthcare organizations today, the University of Michigan’s Department of Internal Medicine has a fast-growing hospitalist program, and continues to seek out additional physicians. “Our group of hospitalists went from zero to 16 by the end of this year—all in two years,” explains Dr. Parekh. “We’ve literally doubled each year.”

The university has implemented a unique method that provides an advantage against competition in recruiting new hospitalists. Beginning in 2006, they are offering a “loan forgiveness” program for new hires to their hospitalist program. Any hospitalist who joins the program this year can get up to $50,000 of student loans paid off by the university.

“The university did this about 10 years ago, when primary care had a similar problem,” recalls Dr. Parekh. “It was very successful.”

Hospitalists at the University of Michigan believe they have a unique benefit for recruitment. “I don’t know if any other hospitalist programs are doing this—there aren’t many [loan forgiveness programs] for physicians in general,” says Dr. Parekh.

How Loan Forgiveness Works

The University of Michigan loan forgiveness program will pay back any student loans—with a limit of $10,000 per year for five years. The university makes direct payments to the loaning institutions, which are typically federal government agencies. The newly hired physician is not under contract to stay until his or her loan is paid. “It works year to year,” explains Dr. Parekh.

The value of loan forgiveness can be overlooked. “People negotiate salary, but they don’t think of this,” says Scott A. Flanders, MD, associate professor and director, Hospitalist Program, Department of Internal Medicine, University of Michigan. “When you add up the value of benefits and loan forgiveness, that can add up to $50,000 to your compensation.”

Offering loan forgiveness on a set amount is more economical than offering a higher starting salary. The employer can set the cap on how much they’re willing to pay, thus controlling the investment in each new hire.

Recruitment Realities

The University of Michigan hospitalist program has been recruiting physicians through the university’s residency program, as well as advertisements in national journals.

“We’ve had a lot of success locally, but we’ve also seen response from around the country,” says Dr. Parekh. “We’ve had good success already; we’ve already recruited 75% of the physicians, in part due to the loan forgiveness program.”

The concept of lifting student loans from the shoulders of new physicians is a perfect fit for hospitalists in particular. “Hospital medicine is a young field, so by definition the physicians are young,” Dr. Parekh points out.

Dr. Flanders adds, “You’re not going to attract 40- or 50-year-old physicians who want to go into academics. But this [might] apply to someone shifting from one academic field to another.”

One problem that loan forgiveness can’t solve, however, is the number of residents choosing hospital medicine. “Internal medicine needs to get more people to pursue hospital medicine,” says Dr. Flanders. “And as it is, there’s only a small trickle of people pursuing internal medicine.”

The short supply of trained hospitalists severely affects the ability of hospital medicine groups to find and hire new physicians. Investing in value-added offerings such as loan forgiveness may prove worth the cost, if the investment brings quality candidates to your group. TH

Contributor Jane Jerrard regularly writes for “Career Development.”

Recruiting hospitalists—or any other medical personnel—is all about supply and demand. Right now, the demand for hospitalists exceeds the supply. Many hospital medicine groups are growing rapidly, and more such groups are being created across the country. These groups are aggressively recruiting residents and physicians from the relatively small pool of hospitalists for hire, even as they lament the lack of candidates.

“Recruiting hospitalists is as competitive as I’ve ever seen,” says Vikas Parekh, MD, assistant professor and director, Non-House-staff Hospitalist Services, Department of Internal Medicine, University of Michigan, Ann Arbor. “This even trumps the primary care crisis of years ago.”

The Carrot: Repayment of Student Loans

Like many healthcare organizations today, the University of Michigan’s Department of Internal Medicine has a fast-growing hospitalist program, and continues to seek out additional physicians. “Our group of hospitalists went from zero to 16 by the end of this year—all in two years,” explains Dr. Parekh. “We’ve literally doubled each year.”

The university has implemented a unique method that provides an advantage against competition in recruiting new hospitalists. Beginning in 2006, they are offering a “loan forgiveness” program for new hires to their hospitalist program. Any hospitalist who joins the program this year can get up to $50,000 of student loans paid off by the university.

“The university did this about 10 years ago, when primary care had a similar problem,” recalls Dr. Parekh. “It was very successful.”

Hospitalists at the University of Michigan believe they have a unique benefit for recruitment. “I don’t know if any other hospitalist programs are doing this—there aren’t many [loan forgiveness programs] for physicians in general,” says Dr. Parekh.

How Loan Forgiveness Works

The University of Michigan loan forgiveness program will pay back any student loans—with a limit of $10,000 per year for five years. The university makes direct payments to the loaning institutions, which are typically federal government agencies. The newly hired physician is not under contract to stay until his or her loan is paid. “It works year to year,” explains Dr. Parekh.

The value of loan forgiveness can be overlooked. “People negotiate salary, but they don’t think of this,” says Scott A. Flanders, MD, associate professor and director, Hospitalist Program, Department of Internal Medicine, University of Michigan. “When you add up the value of benefits and loan forgiveness, that can add up to $50,000 to your compensation.”

Offering loan forgiveness on a set amount is more economical than offering a higher starting salary. The employer can set the cap on how much they’re willing to pay, thus controlling the investment in each new hire.

Recruitment Realities

The University of Michigan hospitalist program has been recruiting physicians through the university’s residency program, as well as advertisements in national journals.

“We’ve had a lot of success locally, but we’ve also seen response from around the country,” says Dr. Parekh. “We’ve had good success already; we’ve already recruited 75% of the physicians, in part due to the loan forgiveness program.”

The concept of lifting student loans from the shoulders of new physicians is a perfect fit for hospitalists in particular. “Hospital medicine is a young field, so by definition the physicians are young,” Dr. Parekh points out.

Dr. Flanders adds, “You’re not going to attract 40- or 50-year-old physicians who want to go into academics. But this [might] apply to someone shifting from one academic field to another.”

One problem that loan forgiveness can’t solve, however, is the number of residents choosing hospital medicine. “Internal medicine needs to get more people to pursue hospital medicine,” says Dr. Flanders. “And as it is, there’s only a small trickle of people pursuing internal medicine.”

The short supply of trained hospitalists severely affects the ability of hospital medicine groups to find and hire new physicians. Investing in value-added offerings such as loan forgiveness may prove worth the cost, if the investment brings quality candidates to your group. TH

Contributor Jane Jerrard regularly writes for “Career Development.”

Recruiting hospitalists—or any other medical personnel—is all about supply and demand. Right now, the demand for hospitalists exceeds the supply. Many hospital medicine groups are growing rapidly, and more such groups are being created across the country. These groups are aggressively recruiting residents and physicians from the relatively small pool of hospitalists for hire, even as they lament the lack of candidates.

“Recruiting hospitalists is as competitive as I’ve ever seen,” says Vikas Parekh, MD, assistant professor and director, Non-House-staff Hospitalist Services, Department of Internal Medicine, University of Michigan, Ann Arbor. “This even trumps the primary care crisis of years ago.”

The Carrot: Repayment of Student Loans

Like many healthcare organizations today, the University of Michigan’s Department of Internal Medicine has a fast-growing hospitalist program, and continues to seek out additional physicians. “Our group of hospitalists went from zero to 16 by the end of this year—all in two years,” explains Dr. Parekh. “We’ve literally doubled each year.”

The university has implemented a unique method that provides an advantage against competition in recruiting new hospitalists. Beginning in 2006, they are offering a “loan forgiveness” program for new hires to their hospitalist program. Any hospitalist who joins the program this year can get up to $50,000 of student loans paid off by the university.

“The university did this about 10 years ago, when primary care had a similar problem,” recalls Dr. Parekh. “It was very successful.”

Hospitalists at the University of Michigan believe they have a unique benefit for recruitment. “I don’t know if any other hospitalist programs are doing this—there aren’t many [loan forgiveness programs] for physicians in general,” says Dr. Parekh.

How Loan Forgiveness Works

The University of Michigan loan forgiveness program will pay back any student loans—with a limit of $10,000 per year for five years. The university makes direct payments to the loaning institutions, which are typically federal government agencies. The newly hired physician is not under contract to stay until his or her loan is paid. “It works year to year,” explains Dr. Parekh.

The value of loan forgiveness can be overlooked. “People negotiate salary, but they don’t think of this,” says Scott A. Flanders, MD, associate professor and director, Hospitalist Program, Department of Internal Medicine, University of Michigan. “When you add up the value of benefits and loan forgiveness, that can add up to $50,000 to your compensation.”

Offering loan forgiveness on a set amount is more economical than offering a higher starting salary. The employer can set the cap on how much they’re willing to pay, thus controlling the investment in each new hire.

Recruitment Realities

The University of Michigan hospitalist program has been recruiting physicians through the university’s residency program, as well as advertisements in national journals.

“We’ve had a lot of success locally, but we’ve also seen response from around the country,” says Dr. Parekh. “We’ve had good success already; we’ve already recruited 75% of the physicians, in part due to the loan forgiveness program.”

The concept of lifting student loans from the shoulders of new physicians is a perfect fit for hospitalists in particular. “Hospital medicine is a young field, so by definition the physicians are young,” Dr. Parekh points out.

Dr. Flanders adds, “You’re not going to attract 40- or 50-year-old physicians who want to go into academics. But this [might] apply to someone shifting from one academic field to another.”

One problem that loan forgiveness can’t solve, however, is the number of residents choosing hospital medicine. “Internal medicine needs to get more people to pursue hospital medicine,” says Dr. Flanders. “And as it is, there’s only a small trickle of people pursuing internal medicine.”

The short supply of trained hospitalists severely affects the ability of hospital medicine groups to find and hire new physicians. Investing in value-added offerings such as loan forgiveness may prove worth the cost, if the investment brings quality candidates to your group. TH

Contributor Jane Jerrard regularly writes for “Career Development.”

Spring is in the air: Flowers are blooming, trees are budding, and the SHM Annual Meeting is fast approaching.

Held Wednesday, May 3, through Friday, May 5, 2006, in Washington, D.C., the 9th Annual Meeting will include comprehensive education designed for hospitalists, networking with physicians from around the country, and chatting with your representatives in Congress. (See “Legislative Advocacy Day Debuts,” p. 10.)

“The SHM Annual Meeting is the largest gathering of all the stakeholders in hospital medicine, presenting a unique networking opportunity,” says Larry Wellikson, MD, FACP, CEO of SHM. “In 2006 we’re using the meeting’s location in our nation’s capitol to help hospitalists to be advocates for their patients and their specialty by meeting with their elected Members of Congress.”

The focus of the meeting, as always, will be the education offered. “Whatever your specialty, this meeting allows you to get something out of it,” says Alpesh Amin, MD, course director for the Annual Meeting. “There will be something for beginning hospitalists as well as more mature hospitalists. We’ll cover a lot of core topics.”

Education Covers Core Competencies

The basis for all education offered during the meeting is SHM’s new core competencies, developed by the Education Committee and released in January 2006. (The Core Competencies in Hospital Medicine: A Framework for Curriculum Development debuted in a supplement to the first issue of the Journal of Hospital Medicine.) The goal is to have these core competencies serve as the backbone for how hospitalists are recruited, trained, and certified in hospital medicine, as well as to standardize expectations for learning and proficiency.

“Our goal was to include [the core competencies] as a base for developing sessions, workshops, and lectures” at the Annual Meeting, says Dr. Amin. “We’re asking speakers to incorporate relevant core competencies into their lectures.”

To learn more about the new framework, Annual Meeting attendees can come to a session about the core competencies offered on Thursday, May 4 from 10:10 to 10:35 a.m.

Choose from Multiple Learning Tracks

Attendees at the Annual Meeting can customize their educational experience by choosing sessions from one or more of six general tracks:

Adult clinical: This track emphasizes recent advances that should be incorporated into the hospitalist’s approach to clinical care delivery. Sessions will cover diabetes management, acute coronary syndromes, chronic heart failure, addiction medicine, resuscitation, and much more.

Pediatric clinical: This track covers pediatric hospitalist practice management as well as current clinical issues. Sessions will cover controversies surrounding management of respiratory illnesses and the febrile infant, as well as practice management topics such as contract and salary negotiation and billing and coding.

Academic: This track covers the unique challenges faced by hospitalists in academic medical centers, including dealing with the 80-hour workweek and developing a curriculum for quality improvement and patient safety. The track also covers how to structure a research project and how to write for scientific publications.

Quality: This track addresses the imperative around development and implementation of improvement efforts in the hospital. Practical sessions cover improving physician/nurse communication, rapid response teams, and improving VTE prophylaxis.

Operational: This track covers some of the latest information and ideas for organizational infrastructure in topics such as value-added services, hospitalist burnout, performance management and advances in staffing projections.

New track! Developmental: This new track focuses on career satisfaction, building palliative care services, creating a hospitalist procedure service, and developing and implementing a perioperative care and consultative medicine program.

Regardless of which track or tracks you choose, you’ll have ample opportunity to improve your clinical skills, address operational issues with possible solutions for your hospital medicine group, and be prepared to lead change and innovation at your hospital.

Attendees should also note: You can earn a maximum of 13.25 category 1 credits toward the AMA Physician’s Recognition Award—plus additional credits for pre-courses. (See “Four Pre-Courses Offer In-Depth Education,” above.)

Nationwide Networking

In addition to dozens of educational sessions, the Annual Meeting includes many opportunities to network with colleagues from across the country, including leading experts and trendsetters. Networking events provide natural settings to search for a job or potential candidate, make connections, and get answers to clinical and organizational dilemmas. You can also network with more than 100 exhibitors in the Exhibit Hall to find new information and solutions.

“The networking aspect is beneficial,” says Dr. Amin. “The Mentorship Breakfast on the second day is particularly valuable.” The Mentorship Breakfast matches new or aspiring hospitalists—or those experiencing new challenges in their practice—with experienced hospitalist mentors for small-group discussions. Pre-registration is required for the breakfast. (For more information, visit www.hospitalmedicine.org.)

Another excellent event for networking is Thursday afternoon’s Special Interest Forums. Meet hospitalists with similar interests:

• Community-based hospitalists;
• Medical directors/leadership;
• Pediatric hospitalists;
• Family practice hospitalists;
• Geriatric hospitalists;
• Women in hospital medicine;
• Early career hospitalists;
• Nurse practitioners and physician assistants;
• Education;
• Research; and
• History of medicine.

In addition to the Special Interest Forums, you’ll have the opportunity to meet other hospitalists at a “town hall meeting.” Scheduled for Friday, the town hall meeting will feature a facilitated discussion of pressing topics in hospital medicine, as chosen by those in attendance.

Whether you attend the meeting or not, rest assured that everyone who comes to Washington, D.C., in May will help to advance the profession through learning the new core competencies, through sharing ideas and solutions, and through continuing to make an impact as hospitalists.

For more information on the Annual Meeting and to register online, visit www.hospitalmedicine.org. TH

Spring is in the air: Flowers are blooming, trees are budding, and the SHM Annual Meeting is fast approaching.

Held Wednesday, May 3, through Friday, May 5, 2006, in Washington, D.C., the 9th Annual Meeting will include comprehensive education designed for hospitalists, networking with physicians from around the country, and chatting with your representatives in Congress. (See “Legislative Advocacy Day Debuts,” p. 10.)

“The SHM Annual Meeting is the largest gathering of all the stakeholders in hospital medicine, presenting a unique networking opportunity,” says Larry Wellikson, MD, FACP, CEO of SHM. “In 2006 we’re using the meeting’s location in our nation’s capitol to help hospitalists to be advocates for their patients and their specialty by meeting with their elected Members of Congress.”

The focus of the meeting, as always, will be the education offered. “Whatever your specialty, this meeting allows you to get something out of it,” says Alpesh Amin, MD, course director for the Annual Meeting. “There will be something for beginning hospitalists as well as more mature hospitalists. We’ll cover a lot of core topics.”

Education Covers Core Competencies

The basis for all education offered during the meeting is SHM’s new core competencies, developed by the Education Committee and released in January 2006. (The Core Competencies in Hospital Medicine: A Framework for Curriculum Development debuted in a supplement to the first issue of the Journal of Hospital Medicine.) The goal is to have these core competencies serve as the backbone for how hospitalists are recruited, trained, and certified in hospital medicine, as well as to standardize expectations for learning and proficiency.

“Our goal was to include [the core competencies] as a base for developing sessions, workshops, and lectures” at the Annual Meeting, says Dr. Amin. “We’re asking speakers to incorporate relevant core competencies into their lectures.”

To learn more about the new framework, Annual Meeting attendees can come to a session about the core competencies offered on Thursday, May 4 from 10:10 to 10:35 a.m.

Choose from Multiple Learning Tracks

Attendees at the Annual Meeting can customize their educational experience by choosing sessions from one or more of six general tracks:

Adult clinical: This track emphasizes recent advances that should be incorporated into the hospitalist’s approach to clinical care delivery. Sessions will cover diabetes management, acute coronary syndromes, chronic heart failure, addiction medicine, resuscitation, and much more.

Pediatric clinical: This track covers pediatric hospitalist practice management as well as current clinical issues. Sessions will cover controversies surrounding management of respiratory illnesses and the febrile infant, as well as practice management topics such as contract and salary negotiation and billing and coding.

Academic: This track covers the unique challenges faced by hospitalists in academic medical centers, including dealing with the 80-hour workweek and developing a curriculum for quality improvement and patient safety. The track also covers how to structure a research project and how to write for scientific publications.

Quality: This track addresses the imperative around development and implementation of improvement efforts in the hospital. Practical sessions cover improving physician/nurse communication, rapid response teams, and improving VTE prophylaxis.

Operational: This track covers some of the latest information and ideas for organizational infrastructure in topics such as value-added services, hospitalist burnout, performance management and advances in staffing projections.

New track! Developmental: This new track focuses on career satisfaction, building palliative care services, creating a hospitalist procedure service, and developing and implementing a perioperative care and consultative medicine program.

Regardless of which track or tracks you choose, you’ll have ample opportunity to improve your clinical skills, address operational issues with possible solutions for your hospital medicine group, and be prepared to lead change and innovation at your hospital.

Attendees should also note: You can earn a maximum of 13.25 category 1 credits toward the AMA Physician’s Recognition Award—plus additional credits for pre-courses. (See “Four Pre-Courses Offer In-Depth Education,” above.)

Nationwide Networking

In addition to dozens of educational sessions, the Annual Meeting includes many opportunities to network with colleagues from across the country, including leading experts and trendsetters. Networking events provide natural settings to search for a job or potential candidate, make connections, and get answers to clinical and organizational dilemmas. You can also network with more than 100 exhibitors in the Exhibit Hall to find new information and solutions.

“The networking aspect is beneficial,” says Dr. Amin. “The Mentorship Breakfast on the second day is particularly valuable.” The Mentorship Breakfast matches new or aspiring hospitalists—or those experiencing new challenges in their practice—with experienced hospitalist mentors for small-group discussions. Pre-registration is required for the breakfast. (For more information, visit www.hospitalmedicine.org.)

Another excellent event for networking is Thursday afternoon’s Special Interest Forums. Meet hospitalists with similar interests:

• Community-based hospitalists;
• Medical directors/leadership;
• Pediatric hospitalists;
• Family practice hospitalists;
• Geriatric hospitalists;
• Women in hospital medicine;
• Early career hospitalists;
• Nurse practitioners and physician assistants;
• Education;
• Research; and
• History of medicine.

In addition to the Special Interest Forums, you’ll have the opportunity to meet other hospitalists at a “town hall meeting.” Scheduled for Friday, the town hall meeting will feature a facilitated discussion of pressing topics in hospital medicine, as chosen by those in attendance.

Whether you attend the meeting or not, rest assured that everyone who comes to Washington, D.C., in May will help to advance the profession through learning the new core competencies, through sharing ideas and solutions, and through continuing to make an impact as hospitalists.

For more information on the Annual Meeting and to register online, visit www.hospitalmedicine.org. TH

Spring is in the air: Flowers are blooming, trees are budding, and the SHM Annual Meeting is fast approaching.

Held Wednesday, May 3, through Friday, May 5, 2006, in Washington, D.C., the 9th Annual Meeting will include comprehensive education designed for hospitalists, networking with physicians from around the country, and chatting with your representatives in Congress. (See “Legislative Advocacy Day Debuts,” p. 10.)

“The SHM Annual Meeting is the largest gathering of all the stakeholders in hospital medicine, presenting a unique networking opportunity,” says Larry Wellikson, MD, FACP, CEO of SHM. “In 2006 we’re using the meeting’s location in our nation’s capitol to help hospitalists to be advocates for their patients and their specialty by meeting with their elected Members of Congress.”

The focus of the meeting, as always, will be the education offered. “Whatever your specialty, this meeting allows you to get something out of it,” says Alpesh Amin, MD, course director for the Annual Meeting. “There will be something for beginning hospitalists as well as more mature hospitalists. We’ll cover a lot of core topics.”

Education Covers Core Competencies

The basis for all education offered during the meeting is SHM’s new core competencies, developed by the Education Committee and released in January 2006. (The Core Competencies in Hospital Medicine: A Framework for Curriculum Development debuted in a supplement to the first issue of the Journal of Hospital Medicine.) The goal is to have these core competencies serve as the backbone for how hospitalists are recruited, trained, and certified in hospital medicine, as well as to standardize expectations for learning and proficiency.

“Our goal was to include [the core competencies] as a base for developing sessions, workshops, and lectures” at the Annual Meeting, says Dr. Amin. “We’re asking speakers to incorporate relevant core competencies into their lectures.”

To learn more about the new framework, Annual Meeting attendees can come to a session about the core competencies offered on Thursday, May 4 from 10:10 to 10:35 a.m.

Choose from Multiple Learning Tracks

Attendees at the Annual Meeting can customize their educational experience by choosing sessions from one or more of six general tracks:

Adult clinical: This track emphasizes recent advances that should be incorporated into the hospitalist’s approach to clinical care delivery. Sessions will cover diabetes management, acute coronary syndromes, chronic heart failure, addiction medicine, resuscitation, and much more.

Pediatric clinical: This track covers pediatric hospitalist practice management as well as current clinical issues. Sessions will cover controversies surrounding management of respiratory illnesses and the febrile infant, as well as practice management topics such as contract and salary negotiation and billing and coding.

Academic: This track covers the unique challenges faced by hospitalists in academic medical centers, including dealing with the 80-hour workweek and developing a curriculum for quality improvement and patient safety. The track also covers how to structure a research project and how to write for scientific publications.

Quality: This track addresses the imperative around development and implementation of improvement efforts in the hospital. Practical sessions cover improving physician/nurse communication, rapid response teams, and improving VTE prophylaxis.

Operational: This track covers some of the latest information and ideas for organizational infrastructure in topics such as value-added services, hospitalist burnout, performance management and advances in staffing projections.

New track! Developmental: This new track focuses on career satisfaction, building palliative care services, creating a hospitalist procedure service, and developing and implementing a perioperative care and consultative medicine program.

Regardless of which track or tracks you choose, you’ll have ample opportunity to improve your clinical skills, address operational issues with possible solutions for your hospital medicine group, and be prepared to lead change and innovation at your hospital.

Attendees should also note: You can earn a maximum of 13.25 category 1 credits toward the AMA Physician’s Recognition Award—plus additional credits for pre-courses. (See “Four Pre-Courses Offer In-Depth Education,” above.)

Nationwide Networking

In addition to dozens of educational sessions, the Annual Meeting includes many opportunities to network with colleagues from across the country, including leading experts and trendsetters. Networking events provide natural settings to search for a job or potential candidate, make connections, and get answers to clinical and organizational dilemmas. You can also network with more than 100 exhibitors in the Exhibit Hall to find new information and solutions.

“The networking aspect is beneficial,” says Dr. Amin. “The Mentorship Breakfast on the second day is particularly valuable.” The Mentorship Breakfast matches new or aspiring hospitalists—or those experiencing new challenges in their practice—with experienced hospitalist mentors for small-group discussions. Pre-registration is required for the breakfast. (For more information, visit www.hospitalmedicine.org.)

Another excellent event for networking is Thursday afternoon’s Special Interest Forums. Meet hospitalists with similar interests:

• Community-based hospitalists;
• Medical directors/leadership;
• Pediatric hospitalists;
• Family practice hospitalists;
• Geriatric hospitalists;
• Women in hospital medicine;
• Early career hospitalists;
• Nurse practitioners and physician assistants;
• Education;
• Research; and
• History of medicine.

In addition to the Special Interest Forums, you’ll have the opportunity to meet other hospitalists at a “town hall meeting.” Scheduled for Friday, the town hall meeting will feature a facilitated discussion of pressing topics in hospital medicine, as chosen by those in attendance.

Whether you attend the meeting or not, rest assured that everyone who comes to Washington, D.C., in May will help to advance the profession through learning the new core competencies, through sharing ideas and solutions, and through continuing to make an impact as hospitalists.

For more information on the Annual Meeting and to register online, visit www.hospitalmedicine.org. TH

Always searching for new ways to enhance the value of SHM membership, the SHM Membership Committee has created several task forces to work on special projects.

Designed to build upon the success of the Annual Meeting’s Mentorship Breakfast (a one-time opportunity for SHM members to meet with experienced hospitalist clinicians and leaders), the Mentorship Task Force was convened to study opportunities to expand the use of mentoring programs for SHM members. The task force has suggested mechanisms on how to assist SHM local chapter leaders, suggestions that have resulted in the creation of recurrent conference calls between members of the Midwest Region Council and local chapter leaders in the Midwest. The Task Force has also studied creating a yearlong longitudinal mentoring program on leadership skills and continues to work on this project.

The Industry Support of Local Chapters Task Force is critically looking at the role of industry sponsorship of local chapter activities. This task force (comprising participants from the SHM Ethics and Membership Committees, Regional Councils, and local chapters) is studying two issues:

1. How to assist local leaders in finding and securing sponsorship for chapter functions, and
2. How to create a process to review industry sponsored grants to support local chapter meetings.

Preliminary recommendations from this task force include additions and revisions to the SHM Local Chapter Handbook about strategies and techniques to employ when negotiating with industry representatives.

Finally, the Family Practice Task Force was recently convened to study how family practice hospitalists differ from their internal-medicine-trained colleagues. Initial efforts will focus on gathering data about family-practice-trained hospitalists, defining the unique skill set that family practice has to offer hospital medicine, and reviewing the post-graduate medical training needs of family practitioner hospital medicine physicians.

In addition to these task forces, the Membership Committee will launch a new research initiative. During 2006 SHM members will be invited to share their opinions on a variety of topics via electronic surveys. Data from each survey will be regularly shared with SHM leadership for review and use in future planning.

Your support of SHM has played a vital role in helping the society to assume the leadership position that it currently holds in the hospital medicine community. Your continued support will enable us to continue to grow and provide each member with the tools they need to best serve their patients and grow their practices in the process.

Ethics Policies Revised

Real and potential conflicts addressed in revisions

By Tom Baudendistel, MD, FACP, chair, SHM Ethics Committee

Conflicts of interest have been the major theme of the SHM Ethics Committee this past year. As SHM has grown into a major force shaping healthcare policy, the need for transparency in all of the organization’s endeavors has never been greater. Rather than being reactive to individual issues that arise, the ethics committee has adopted a proactive stance in identifying potential areas of tension. Building on the general guidelines of the 2003 SHM “Principles for Organizational Relationships,” this year’s ethics committee has refined SHM policies to address the latest real and potential conflicts of interest in several areas: the Annual Meeting Abstract competitions, the Journal of Hospital Medicine, and the SHM Board.

Prior to the 2005 Annual Meeting, chairs of the Research, Innovations, and Vignettes (RIV) Committees augmented previous disclosure policy in requiring more transparent and detailed statements of disclosure from authors submitting abstracts to the national meeting. Anjala Tess, MD, and Sunil Kripilani, MD, took the lead in this initiative, preserving the integrity of the academic process while shielding the SHM RIV competition from potential misuse by third parties.

Later in 2005, in preparation for publication of the Journal of Hospital Medicine, the ethics committee worked with the editors to develop a policy regarding potential conflicts of interest between the journal’s editors, editorial board, reviewers, and authors. Ethical dilemmas within academic journals generally arise in two main areas: academic or financial. An example of the former would include an editor or a reviewer who might benefit from affiliation with the authors or from the publication of material contained in a manuscript. Financial conflicts might arise when, for instance, an editor or author receives monetary support from an industry source and selectively publishes only manuscripts that cast the sponsoring company in a favorable light.

The SHM Ethics committee contacted editors from major journals, including Annals of Internal Medicine, Journal of the American Medical Association, The New England Journal of Medicine, and The American Journal of Medicine, and consulted the International Committee of Medical Journal Editors before crafting a policy for the Journal of Hospital Medicine’s Editorial Board. This policy directs JHM to obtain annual disclosure of potential academic and financial conflicts from its editors and editorial board members, and requests similar information from its authors and reviewers on an article-by-article basis. Thanks to Brian Harte, MD, and Don Krause, MD, for their leadership in this process.

More recently, the SHM Ethics Committee was asked to join the SHM Task Force to identify areas of potential conflict for the SHM Board. As leaders of a major organization in U.S. medical care, members of the board are obvious targets of outside interests including healthcare or pharmaceutical industry, legal associations, and other organizations to represent those outside parties’ viewpoints—either implicitly or explicitly. Should the leaders of SHM participate in malpractice litigation involving hospitalists? What restrictions should SHM place on its board members pertaining to relationships with outside academic and industry organizations? Should SHM accept funding from industry to support regional and national meetings? Should the SHM board endorse pay-for-performance initiatives? How should hospitalist scope of practice be defined?

The answers to these and similar questions will guide SHM policy in the coming years, and the SHM Ethics Committee will be there every step of the way.

The SHM Ethics Committee is now 15 members strong and continues to convene regularly via conference calls and as a group at the Annual Meeting. Check out the recent article by Erin Egan, MD, in The Hospitalist discussing the safe and ethical care of disaster victims (Jan. 2006, p. 10), or attend the “Ethical Dilemmas in the ICU” talk at the upcoming critical care precourse at the Annual Meeting on May 3 at 9 a.m. to catch other glimpses of the committee’s work. With the continued support and membership from SHM members, the committee aims to chart a clear and ethically acceptable course for SHM for years to come.

Quality of Work-Life Tools

An interim report from the SHM Career Satisfaction Task Force

By Sylvia McKean, MD, Tosha Wetterneck, MD, and Win Whitcomb, MD

A variety of career satisfaction issues threaten the evolution of hospital medicine as a specialty. These issues are analogous to the experience of other, well-established specialties essential to the smooth functioning of a hospital, including critical care and emergency medicine.

Hospitalists encounter daily disruptions in their workflow due to the unpredictability of acute medical illness, paging interruptions that require immediate attention, and an increasing variety of other demands on their time in an already stressed healthcare system. In addition, hospitalist services staffed with junior physicians may not have input into the patients triaged to their service or how the service is structured. They may encounter changing job descriptions as hospital administrators in charge of their salaries rely upon them to solve important problems.

Hospitalists face conflict as they try to control their work life. The role of the hospitalist has evolved from direct patient care, to improving throughput and related outcomes, and increasingly to one of leadership, quality improvement, and teaching. The challenges of this discipline continue to expand exponentially. In addition, community hospitals rely upon academic hospitalist programs to train and recruit physicians into the field of hospital medicine. Academic hospitalist services, therefore, need to ensure time to mentor trainees and serve as role models that hospital medicine is a satisfying, respected, and sustainable career.

In 2005 SHM’s career satisfaction task force reviewed available literature and started developing a series of chapters relating to the following “domains” related to job satisfaction:

• Control/autonomy;
• Workload/schedule;
• Reward/recognition; and
• Community/environment.

These chapters acknowledge that on-the-job challenges should be viewed from two different but related perspectives: the individual hospitalist and the hospital medicine group/service. Neither the individual nor the hospitalist service can work independently of the other because cohesiveness among hospitalist members is critical to promoting job satisfaction for the service. The task force is developing a career satisfaction tool kit consisting of individual and group self-assessment questionnaires and preventive strategies. Specific case examples from the academic and community settings will be provided to avoid pitfalls and false starts when seeking a job in hospital medicine or when responding to pressures in the hospital.

SHM has also funded additional research into career satisfaction under the leadership of Tosha Wetterneck, MD, from the University of Wisconsin Hospital and Clinic. Joe Miller, SHM senior vice president, and professional writer Phyllis Hanlon have joined the Career Satisfaction Task Force to translate our findings into a workable document for physician leaders and hospitalists. They were the editors of the supplement to The Hospitalist on “value added services” of hospitalists (vol. 9, suppl. 1, 2005).

The goals of these papers are to assist hospital administrators and hospitalist services to recruit and retain hospitalists and to help individual hospitalists to find new, more rewarding employment opportunities. The document will include practical tools for self and program analysis. As more information becomes available through survey research results and focus group analysis, the tools will be refined.

The goals of the Career Satisfaction Task Force for 2006-2007 include:

1. Complete the focused interviews;
2. Complete the first draft of the SHM Career Satisfaction Tool Kit;
3. Start the survey process at the 2006 SHM Annual Meeting;
4. Hold a workshop at the SHM Annual Meeting;
5. Utilize additional research data to modify the tool kit; and
6. Position the tool kit as a working document for structuring hospitalist programs and as a self-assessment tool for practicing hospitalists. TH

Always searching for new ways to enhance the value of SHM membership, the SHM Membership Committee has created several task forces to work on special projects.

Designed to build upon the success of the Annual Meeting’s Mentorship Breakfast (a one-time opportunity for SHM members to meet with experienced hospitalist clinicians and leaders), the Mentorship Task Force was convened to study opportunities to expand the use of mentoring programs for SHM members. The task force has suggested mechanisms on how to assist SHM local chapter leaders, suggestions that have resulted in the creation of recurrent conference calls between members of the Midwest Region Council and local chapter leaders in the Midwest. The Task Force has also studied creating a yearlong longitudinal mentoring program on leadership skills and continues to work on this project.

The Industry Support of Local Chapters Task Force is critically looking at the role of industry sponsorship of local chapter activities. This task force (comprising participants from the SHM Ethics and Membership Committees, Regional Councils, and local chapters) is studying two issues:

1. How to assist local leaders in finding and securing sponsorship for chapter functions, and
2. How to create a process to review industry sponsored grants to support local chapter meetings.

Preliminary recommendations from this task force include additions and revisions to the SHM Local Chapter Handbook about strategies and techniques to employ when negotiating with industry representatives.

Finally, the Family Practice Task Force was recently convened to study how family practice hospitalists differ from their internal-medicine-trained colleagues. Initial efforts will focus on gathering data about family-practice-trained hospitalists, defining the unique skill set that family practice has to offer hospital medicine, and reviewing the post-graduate medical training needs of family practitioner hospital medicine physicians.

In addition to these task forces, the Membership Committee will launch a new research initiative. During 2006 SHM members will be invited to share their opinions on a variety of topics via electronic surveys. Data from each survey will be regularly shared with SHM leadership for review and use in future planning.

Your support of SHM has played a vital role in helping the society to assume the leadership position that it currently holds in the hospital medicine community. Your continued support will enable us to continue to grow and provide each member with the tools they need to best serve their patients and grow their practices in the process.

Ethics Policies Revised

Real and potential conflicts addressed in revisions

By Tom Baudendistel, MD, FACP, chair, SHM Ethics Committee

Conflicts of interest have been the major theme of the SHM Ethics Committee this past year. As SHM has grown into a major force shaping healthcare policy, the need for transparency in all of the organization’s endeavors has never been greater. Rather than being reactive to individual issues that arise, the ethics committee has adopted a proactive stance in identifying potential areas of tension. Building on the general guidelines of the 2003 SHM “Principles for Organizational Relationships,” this year’s ethics committee has refined SHM policies to address the latest real and potential conflicts of interest in several areas: the Annual Meeting Abstract competitions, the Journal of Hospital Medicine, and the SHM Board.

Prior to the 2005 Annual Meeting, chairs of the Research, Innovations, and Vignettes (RIV) Committees augmented previous disclosure policy in requiring more transparent and detailed statements of disclosure from authors submitting abstracts to the national meeting. Anjala Tess, MD, and Sunil Kripilani, MD, took the lead in this initiative, preserving the integrity of the academic process while shielding the SHM RIV competition from potential misuse by third parties.

Later in 2005, in preparation for publication of the Journal of Hospital Medicine, the ethics committee worked with the editors to develop a policy regarding potential conflicts of interest between the journal’s editors, editorial board, reviewers, and authors. Ethical dilemmas within academic journals generally arise in two main areas: academic or financial. An example of the former would include an editor or a reviewer who might benefit from affiliation with the authors or from the publication of material contained in a manuscript. Financial conflicts might arise when, for instance, an editor or author receives monetary support from an industry source and selectively publishes only manuscripts that cast the sponsoring company in a favorable light.

The SHM Ethics committee contacted editors from major journals, including Annals of Internal Medicine, Journal of the American Medical Association, The New England Journal of Medicine, and The American Journal of Medicine, and consulted the International Committee of Medical Journal Editors before crafting a policy for the Journal of Hospital Medicine’s Editorial Board. This policy directs JHM to obtain annual disclosure of potential academic and financial conflicts from its editors and editorial board members, and requests similar information from its authors and reviewers on an article-by-article basis. Thanks to Brian Harte, MD, and Don Krause, MD, for their leadership in this process.

More recently, the SHM Ethics Committee was asked to join the SHM Task Force to identify areas of potential conflict for the SHM Board. As leaders of a major organization in U.S. medical care, members of the board are obvious targets of outside interests including healthcare or pharmaceutical industry, legal associations, and other organizations to represent those outside parties’ viewpoints—either implicitly or explicitly. Should the leaders of SHM participate in malpractice litigation involving hospitalists? What restrictions should SHM place on its board members pertaining to relationships with outside academic and industry organizations? Should SHM accept funding from industry to support regional and national meetings? Should the SHM board endorse pay-for-performance initiatives? How should hospitalist scope of practice be defined?

The answers to these and similar questions will guide SHM policy in the coming years, and the SHM Ethics Committee will be there every step of the way.

The SHM Ethics Committee is now 15 members strong and continues to convene regularly via conference calls and as a group at the Annual Meeting. Check out the recent article by Erin Egan, MD, in The Hospitalist discussing the safe and ethical care of disaster victims (Jan. 2006, p. 10), or attend the “Ethical Dilemmas in the ICU” talk at the upcoming critical care precourse at the Annual Meeting on May 3 at 9 a.m. to catch other glimpses of the committee’s work. With the continued support and membership from SHM members, the committee aims to chart a clear and ethically acceptable course for SHM for years to come.

Quality of Work-Life Tools

An interim report from the SHM Career Satisfaction Task Force

By Sylvia McKean, MD, Tosha Wetterneck, MD, and Win Whitcomb, MD

A variety of career satisfaction issues threaten the evolution of hospital medicine as a specialty. These issues are analogous to the experience of other, well-established specialties essential to the smooth functioning of a hospital, including critical care and emergency medicine.

Hospitalists encounter daily disruptions in their workflow due to the unpredictability of acute medical illness, paging interruptions that require immediate attention, and an increasing variety of other demands on their time in an already stressed healthcare system. In addition, hospitalist services staffed with junior physicians may not have input into the patients triaged to their service or how the service is structured. They may encounter changing job descriptions as hospital administrators in charge of their salaries rely upon them to solve important problems.

Hospitalists face conflict as they try to control their work life. The role of the hospitalist has evolved from direct patient care, to improving throughput and related outcomes, and increasingly to one of leadership, quality improvement, and teaching. The challenges of this discipline continue to expand exponentially. In addition, community hospitals rely upon academic hospitalist programs to train and recruit physicians into the field of hospital medicine. Academic hospitalist services, therefore, need to ensure time to mentor trainees and serve as role models that hospital medicine is a satisfying, respected, and sustainable career.

In 2005 SHM’s career satisfaction task force reviewed available literature and started developing a series of chapters relating to the following “domains” related to job satisfaction:

• Control/autonomy;
• Workload/schedule;
• Reward/recognition; and
• Community/environment.

These chapters acknowledge that on-the-job challenges should be viewed from two different but related perspectives: the individual hospitalist and the hospital medicine group/service. Neither the individual nor the hospitalist service can work independently of the other because cohesiveness among hospitalist members is critical to promoting job satisfaction for the service. The task force is developing a career satisfaction tool kit consisting of individual and group self-assessment questionnaires and preventive strategies. Specific case examples from the academic and community settings will be provided to avoid pitfalls and false starts when seeking a job in hospital medicine or when responding to pressures in the hospital.

SHM has also funded additional research into career satisfaction under the leadership of Tosha Wetterneck, MD, from the University of Wisconsin Hospital and Clinic. Joe Miller, SHM senior vice president, and professional writer Phyllis Hanlon have joined the Career Satisfaction Task Force to translate our findings into a workable document for physician leaders and hospitalists. They were the editors of the supplement to The Hospitalist on “value added services” of hospitalists (vol. 9, suppl. 1, 2005).

The goals of these papers are to assist hospital administrators and hospitalist services to recruit and retain hospitalists and to help individual hospitalists to find new, more rewarding employment opportunities. The document will include practical tools for self and program analysis. As more information becomes available through survey research results and focus group analysis, the tools will be refined.

The goals of the Career Satisfaction Task Force for 2006-2007 include:

1. Complete the focused interviews;
2. Complete the first draft of the SHM Career Satisfaction Tool Kit;
3. Start the survey process at the 2006 SHM Annual Meeting;
4. Hold a workshop at the SHM Annual Meeting;
5. Utilize additional research data to modify the tool kit; and
6. Position the tool kit as a working document for structuring hospitalist programs and as a self-assessment tool for practicing hospitalists. TH

Always searching for new ways to enhance the value of SHM membership, the SHM Membership Committee has created several task forces to work on special projects.

Designed to build upon the success of the Annual Meeting’s Mentorship Breakfast (a one-time opportunity for SHM members to meet with experienced hospitalist clinicians and leaders), the Mentorship Task Force was convened to study opportunities to expand the use of mentoring programs for SHM members. The task force has suggested mechanisms on how to assist SHM local chapter leaders, suggestions that have resulted in the creation of recurrent conference calls between members of the Midwest Region Council and local chapter leaders in the Midwest. The Task Force has also studied creating a yearlong longitudinal mentoring program on leadership skills and continues to work on this project.

The Industry Support of Local Chapters Task Force is critically looking at the role of industry sponsorship of local chapter activities. This task force (comprising participants from the SHM Ethics and Membership Committees, Regional Councils, and local chapters) is studying two issues:

1. How to assist local leaders in finding and securing sponsorship for chapter functions, and
2. How to create a process to review industry sponsored grants to support local chapter meetings.

Preliminary recommendations from this task force include additions and revisions to the SHM Local Chapter Handbook about strategies and techniques to employ when negotiating with industry representatives.

Finally, the Family Practice Task Force was recently convened to study how family practice hospitalists differ from their internal-medicine-trained colleagues. Initial efforts will focus on gathering data about family-practice-trained hospitalists, defining the unique skill set that family practice has to offer hospital medicine, and reviewing the post-graduate medical training needs of family practitioner hospital medicine physicians.

In addition to these task forces, the Membership Committee will launch a new research initiative. During 2006 SHM members will be invited to share their opinions on a variety of topics via electronic surveys. Data from each survey will be regularly shared with SHM leadership for review and use in future planning.

Your support of SHM has played a vital role in helping the society to assume the leadership position that it currently holds in the hospital medicine community. Your continued support will enable us to continue to grow and provide each member with the tools they need to best serve their patients and grow their practices in the process.

Ethics Policies Revised

Real and potential conflicts addressed in revisions

By Tom Baudendistel, MD, FACP, chair, SHM Ethics Committee

Conflicts of interest have been the major theme of the SHM Ethics Committee this past year. As SHM has grown into a major force shaping healthcare policy, the need for transparency in all of the organization’s endeavors has never been greater. Rather than being reactive to individual issues that arise, the ethics committee has adopted a proactive stance in identifying potential areas of tension. Building on the general guidelines of the 2003 SHM “Principles for Organizational Relationships,” this year’s ethics committee has refined SHM policies to address the latest real and potential conflicts of interest in several areas: the Annual Meeting Abstract competitions, the Journal of Hospital Medicine, and the SHM Board.

Prior to the 2005 Annual Meeting, chairs of the Research, Innovations, and Vignettes (RIV) Committees augmented previous disclosure policy in requiring more transparent and detailed statements of disclosure from authors submitting abstracts to the national meeting. Anjala Tess, MD, and Sunil Kripilani, MD, took the lead in this initiative, preserving the integrity of the academic process while shielding the SHM RIV competition from potential misuse by third parties.

Later in 2005, in preparation for publication of the Journal of Hospital Medicine, the ethics committee worked with the editors to develop a policy regarding potential conflicts of interest between the journal’s editors, editorial board, reviewers, and authors. Ethical dilemmas within academic journals generally arise in two main areas: academic or financial. An example of the former would include an editor or a reviewer who might benefit from affiliation with the authors or from the publication of material contained in a manuscript. Financial conflicts might arise when, for instance, an editor or author receives monetary support from an industry source and selectively publishes only manuscripts that cast the sponsoring company in a favorable light.

The SHM Ethics committee contacted editors from major journals, including Annals of Internal Medicine, Journal of the American Medical Association, The New England Journal of Medicine, and The American Journal of Medicine, and consulted the International Committee of Medical Journal Editors before crafting a policy for the Journal of Hospital Medicine’s Editorial Board. This policy directs JHM to obtain annual disclosure of potential academic and financial conflicts from its editors and editorial board members, and requests similar information from its authors and reviewers on an article-by-article basis. Thanks to Brian Harte, MD, and Don Krause, MD, for their leadership in this process.

More recently, the SHM Ethics Committee was asked to join the SHM Task Force to identify areas of potential conflict for the SHM Board. As leaders of a major organization in U.S. medical care, members of the board are obvious targets of outside interests including healthcare or pharmaceutical industry, legal associations, and other organizations to represent those outside parties’ viewpoints—either implicitly or explicitly. Should the leaders of SHM participate in malpractice litigation involving hospitalists? What restrictions should SHM place on its board members pertaining to relationships with outside academic and industry organizations? Should SHM accept funding from industry to support regional and national meetings? Should the SHM board endorse pay-for-performance initiatives? How should hospitalist scope of practice be defined?

The answers to these and similar questions will guide SHM policy in the coming years, and the SHM Ethics Committee will be there every step of the way.

The SHM Ethics Committee is now 15 members strong and continues to convene regularly via conference calls and as a group at the Annual Meeting. Check out the recent article by Erin Egan, MD, in The Hospitalist discussing the safe and ethical care of disaster victims (Jan. 2006, p. 10), or attend the “Ethical Dilemmas in the ICU” talk at the upcoming critical care precourse at the Annual Meeting on May 3 at 9 a.m. to catch other glimpses of the committee’s work. With the continued support and membership from SHM members, the committee aims to chart a clear and ethically acceptable course for SHM for years to come.

Quality of Work-Life Tools

An interim report from the SHM Career Satisfaction Task Force

By Sylvia McKean, MD, Tosha Wetterneck, MD, and Win Whitcomb, MD

A variety of career satisfaction issues threaten the evolution of hospital medicine as a specialty. These issues are analogous to the experience of other, well-established specialties essential to the smooth functioning of a hospital, including critical care and emergency medicine.

Hospitalists encounter daily disruptions in their workflow due to the unpredictability of acute medical illness, paging interruptions that require immediate attention, and an increasing variety of other demands on their time in an already stressed healthcare system. In addition, hospitalist services staffed with junior physicians may not have input into the patients triaged to their service or how the service is structured. They may encounter changing job descriptions as hospital administrators in charge of their salaries rely upon them to solve important problems.

Hospitalists face conflict as they try to control their work life. The role of the hospitalist has evolved from direct patient care, to improving throughput and related outcomes, and increasingly to one of leadership, quality improvement, and teaching. The challenges of this discipline continue to expand exponentially. In addition, community hospitals rely upon academic hospitalist programs to train and recruit physicians into the field of hospital medicine. Academic hospitalist services, therefore, need to ensure time to mentor trainees and serve as role models that hospital medicine is a satisfying, respected, and sustainable career.

In 2005 SHM’s career satisfaction task force reviewed available literature and started developing a series of chapters relating to the following “domains” related to job satisfaction:

• Control/autonomy;
• Workload/schedule;
• Reward/recognition; and
• Community/environment.

These chapters acknowledge that on-the-job challenges should be viewed from two different but related perspectives: the individual hospitalist and the hospital medicine group/service. Neither the individual nor the hospitalist service can work independently of the other because cohesiveness among hospitalist members is critical to promoting job satisfaction for the service. The task force is developing a career satisfaction tool kit consisting of individual and group self-assessment questionnaires and preventive strategies. Specific case examples from the academic and community settings will be provided to avoid pitfalls and false starts when seeking a job in hospital medicine or when responding to pressures in the hospital.

SHM has also funded additional research into career satisfaction under the leadership of Tosha Wetterneck, MD, from the University of Wisconsin Hospital and Clinic. Joe Miller, SHM senior vice president, and professional writer Phyllis Hanlon have joined the Career Satisfaction Task Force to translate our findings into a workable document for physician leaders and hospitalists. They were the editors of the supplement to The Hospitalist on “value added services” of hospitalists (vol. 9, suppl. 1, 2005).

The goals of these papers are to assist hospital administrators and hospitalist services to recruit and retain hospitalists and to help individual hospitalists to find new, more rewarding employment opportunities. The document will include practical tools for self and program analysis. As more information becomes available through survey research results and focus group analysis, the tools will be refined.

The goals of the Career Satisfaction Task Force for 2006-2007 include:

1. Complete the focused interviews;
2. Complete the first draft of the SHM Career Satisfaction Tool Kit;
3. Start the survey process at the 2006 SHM Annual Meeting;
4. Hold a workshop at the SHM Annual Meeting;
5. Utilize additional research data to modify the tool kit; and
6. Position the tool kit as a working document for structuring hospitalist programs and as a self-assessment tool for practicing hospitalists. TH

Have you ever looked out your window and wondered, “When did that tree get planted?” Or wonder when you pass a new building that wasn’t there last week, “When did they build that?” Or remember a time when everyone didn’t have an iPod or a Treo Smartphone or Blackberry?

Well, hospital medicine and SHM are rapidly becoming the iPods of healthcare. We are still catching some by surprise. Others think we are everywhere, touching everything, and sometimes leaving them asking the universal question from Butch Cassidy and the Sundance Kids, “Who are those guys?”

Most of you know that while the adoption of hospital medicine and its meteoric rise seems at times a force of nature on a random and indeterminate course, the all too true reality is that many of the “sudden” advances by SHM have been many years in the planning. More than that, they have required key partnerships and significant behind the scenes activity.

It is very much akin to the sudden stardom of veteran performers who have been honing their craft under a smaller spotlight waiting for their time to come. The time for hospital medicine is now.

This is all the more important because hospital medicine has been getting by as a growth story for a while now and it is time to add the substance that will propel our specialty forward as a permanent part of the medical landscape and a key partner in improvement strategies for hospitals and our patients’ care.

Hospital medicine has its own repository now for our contributions to science and the formulation of the hospital of the future in the Journal of Hospital Medicine. The inaugural issue has met with accolades and acceptance. The second issue is on the way and soon it will seem like there has always been a JHM.

The first issue of JHM was all the more important and noteworthy because it was accompanied by a supplement: The Core Competencies in Hospital Medicine. Years in the making, this thoughtful document put SHM’s nickel down and said “Here is what makes hospital medicine unique: an evolving specialty, emanating from our roots in internal medicine, family practice, and pediatrics, but with a relevance to the practice of medicine in our nation’s hospitals in the 21st century.”

Fully accepting the hospitalists’ role in building teams, improving quality, driving hospital efficiencies, and promoting effective care, we hope the Competencies will be part of our road map as we participate in such important but disparate efforts as redesigning internal medicine training, developing a unique credential for hospitalists, and planning the hospital of the future.

These efforts, like JHM or The Core Competencies just a few years ago, are concepts today that will form the reality in the near term. As they develop I will use this space to bring you new developments and prepare all of us for our active roles in defining, participating in, and implementing the new future.

Recognition of Hospitalists

For several years SHM has been talking with the thought leaders in internal medicine including American Board of Internal Medicine (ABIM), American College of Physicians (ACP), Alliance for Academic Internal Medicine (AAIM), and others about not only the growth in size of hospital medicine, but the unique practice of hospitalists that defines us as related and as distinct from the rest of internal medicine as cardiology or critical care.

We started with internal medicine because more than 85% of hospitalists are trained as internists. But our strategy is to soon follow on with discussions with the American Board of Family Practice (ABFP), the American Board of Pediatrics (ABP), osteopathic certification organizations, and others who oversee any part of credentialing hospitalists.

The ABIM with the support of the ACP, the AAIM, SHM, and others has embarked on a process to use the Maintenance of Certification (MOC) to create a unique recognition for hospital medicine without requiring additional formal training beyond current residencies. The plan for now is that all graduates of an internal medicine residency would take the same initial certification, but that after entering practice and sometime within the first 10 years of practice, hospitalists could use the elements of the MOC process (e.g., self assessment, a quality improvement process, and a secure test—all specific to hospital medicine practice) to create a recognition of them as hospitalists. Presently, the ABIM has formed a Hospital Medicine Task Force to develop the details that will make this rigorous and meaningful to the key stakeholders (e.g., hospitals, patients, hospitalist employers, referring physicians, and hospitalists).

Getting this far was not in any way a slam dunk or a rubber stamp. SHM didn’t just send in a postcard asking for a credential for hospitalists and ABIM said, “Fine.” This has taken several years of reasoned conversations, meetings to clarify our position, and opportunities to understand the broader aspects of the emergence of hospital medicine’s effect on the rest of medicine. More recently it has taken the courageous leadership and vision of the ABIM, the ACP, the AAIM, and others to meet their missions of promoting quality of care for our patients.

Work still needs to be done and the devil is always in the details. But the current direction is forward, and that is surely welcome.

Working to Improve Quality

There has been much heat and fury around quality—defining it, measuring it, even possibly paying for it, instead of just paying for units of work whether they are any good or not. For many years the role of the professional medical society in the quality arena was to pull together the smartest people in their specialty, latch on to the diseases they knew the most about, define quality, write guidelines, issue a white paper, and declare victory.

From its beginning SHM has taken a different tactic. We believe many smart people have already defined the best quality for DVT or diabetes or CHF, but the remaining gaps have been in implementation strategies to export all these great ideas to 5,000 hospitals and the millions of patients who occupy them.

With this in mind SHM has sought funding in the diseases defined in our Core Competencies such as DVT, diabetes, CHF, and others, and we have looked for ways to provide hospitalists with key tools as well as looking for implementation strategies (e.g., mentorship, training courses in leadership and the quality improvement process, demonstration projects) to make a measurable difference. And as hospitalists begin to become change agents at their hospitals, we hope to use our meetings and our publications to report your successes and the barriers to success.

Once again SHM will not be able to do much on our own. Therefore, our strategy has been to involve very early on the leaders in nursing, pharmacy, case management, and relevant specialties of medicine. In fashioning a strategy for glycemic control in the hospital, for example, SHM works with the American Association of Clinical Endocrinologists, the American Diabetic Association, and others. Once again as early vague ideas take shape and become real programs, it seems as if they have appeared fully formed in short order. But SHM has been working on many of these for years, and we expect that we will be in the quality improvement implementation realm for many years to come. We are just getting started.

But here is where you are so important. At its best SHM is not much more than an aggregator of good ideas and the developer of strategies. You make it happen. We can design the Ferrari and maybe even provide a shopping list for parts and an instruction manual for assembling and operating. But you have to assemble the car and take it out on the road. It is our nation’s hospitalists, along with key partners and team members at their local institutions, who will provide the coefficients for change and the impetus for improvement.

Once you do this, SHM will have a role to praise, reward, and even prod you and to shine a bright light on all your work so others will be encouraged to take their shot and make great things happen.

SHM, like the hospitalists who form us, is a paradox. On first glance, we are patient and thoughtful with a longer look at the future and all the changes that will be required. At the same time we want to take our innovations and put them in place this week. We think the fearlessness of youth and open-box thinking is just what we need in healthcare today. We rely on our partners to temper our rush to action with their experience and wisdom and additional perspectives. The times require change. Together we can make sure it is a change for the better. TH

Dr. Wellikson has been CEO of SHM since 2000.

Have you ever looked out your window and wondered, “When did that tree get planted?” Or wonder when you pass a new building that wasn’t there last week, “When did they build that?” Or remember a time when everyone didn’t have an iPod or a Treo Smartphone or Blackberry?

Well, hospital medicine and SHM are rapidly becoming the iPods of healthcare. We are still catching some by surprise. Others think we are everywhere, touching everything, and sometimes leaving them asking the universal question from Butch Cassidy and the Sundance Kids, “Who are those guys?”

Most of you know that while the adoption of hospital medicine and its meteoric rise seems at times a force of nature on a random and indeterminate course, the all too true reality is that many of the “sudden” advances by SHM have been many years in the planning. More than that, they have required key partnerships and significant behind the scenes activity.

It is very much akin to the sudden stardom of veteran performers who have been honing their craft under a smaller spotlight waiting for their time to come. The time for hospital medicine is now.

This is all the more important because hospital medicine has been getting by as a growth story for a while now and it is time to add the substance that will propel our specialty forward as a permanent part of the medical landscape and a key partner in improvement strategies for hospitals and our patients’ care.

Hospital medicine has its own repository now for our contributions to science and the formulation of the hospital of the future in the Journal of Hospital Medicine. The inaugural issue has met with accolades and acceptance. The second issue is on the way and soon it will seem like there has always been a JHM.

The first issue of JHM was all the more important and noteworthy because it was accompanied by a supplement: The Core Competencies in Hospital Medicine. Years in the making, this thoughtful document put SHM’s nickel down and said “Here is what makes hospital medicine unique: an evolving specialty, emanating from our roots in internal medicine, family practice, and pediatrics, but with a relevance to the practice of medicine in our nation’s hospitals in the 21st century.”

Fully accepting the hospitalists’ role in building teams, improving quality, driving hospital efficiencies, and promoting effective care, we hope the Competencies will be part of our road map as we participate in such important but disparate efforts as redesigning internal medicine training, developing a unique credential for hospitalists, and planning the hospital of the future.

These efforts, like JHM or The Core Competencies just a few years ago, are concepts today that will form the reality in the near term. As they develop I will use this space to bring you new developments and prepare all of us for our active roles in defining, participating in, and implementing the new future.

Recognition of Hospitalists

For several years SHM has been talking with the thought leaders in internal medicine including American Board of Internal Medicine (ABIM), American College of Physicians (ACP), Alliance for Academic Internal Medicine (AAIM), and others about not only the growth in size of hospital medicine, but the unique practice of hospitalists that defines us as related and as distinct from the rest of internal medicine as cardiology or critical care.

We started with internal medicine because more than 85% of hospitalists are trained as internists. But our strategy is to soon follow on with discussions with the American Board of Family Practice (ABFP), the American Board of Pediatrics (ABP), osteopathic certification organizations, and others who oversee any part of credentialing hospitalists.

The ABIM with the support of the ACP, the AAIM, SHM, and others has embarked on a process to use the Maintenance of Certification (MOC) to create a unique recognition for hospital medicine without requiring additional formal training beyond current residencies. The plan for now is that all graduates of an internal medicine residency would take the same initial certification, but that after entering practice and sometime within the first 10 years of practice, hospitalists could use the elements of the MOC process (e.g., self assessment, a quality improvement process, and a secure test—all specific to hospital medicine practice) to create a recognition of them as hospitalists. Presently, the ABIM has formed a Hospital Medicine Task Force to develop the details that will make this rigorous and meaningful to the key stakeholders (e.g., hospitals, patients, hospitalist employers, referring physicians, and hospitalists).

Getting this far was not in any way a slam dunk or a rubber stamp. SHM didn’t just send in a postcard asking for a credential for hospitalists and ABIM said, “Fine.” This has taken several years of reasoned conversations, meetings to clarify our position, and opportunities to understand the broader aspects of the emergence of hospital medicine’s effect on the rest of medicine. More recently it has taken the courageous leadership and vision of the ABIM, the ACP, the AAIM, and others to meet their missions of promoting quality of care for our patients.

Work still needs to be done and the devil is always in the details. But the current direction is forward, and that is surely welcome.

Working to Improve Quality

There has been much heat and fury around quality—defining it, measuring it, even possibly paying for it, instead of just paying for units of work whether they are any good or not. For many years the role of the professional medical society in the quality arena was to pull together the smartest people in their specialty, latch on to the diseases they knew the most about, define quality, write guidelines, issue a white paper, and declare victory.

From its beginning SHM has taken a different tactic. We believe many smart people have already defined the best quality for DVT or diabetes or CHF, but the remaining gaps have been in implementation strategies to export all these great ideas to 5,000 hospitals and the millions of patients who occupy them.

With this in mind SHM has sought funding in the diseases defined in our Core Competencies such as DVT, diabetes, CHF, and others, and we have looked for ways to provide hospitalists with key tools as well as looking for implementation strategies (e.g., mentorship, training courses in leadership and the quality improvement process, demonstration projects) to make a measurable difference. And as hospitalists begin to become change agents at their hospitals, we hope to use our meetings and our publications to report your successes and the barriers to success.

Once again SHM will not be able to do much on our own. Therefore, our strategy has been to involve very early on the leaders in nursing, pharmacy, case management, and relevant specialties of medicine. In fashioning a strategy for glycemic control in the hospital, for example, SHM works with the American Association of Clinical Endocrinologists, the American Diabetic Association, and others. Once again as early vague ideas take shape and become real programs, it seems as if they have appeared fully formed in short order. But SHM has been working on many of these for years, and we expect that we will be in the quality improvement implementation realm for many years to come. We are just getting started.

But here is where you are so important. At its best SHM is not much more than an aggregator of good ideas and the developer of strategies. You make it happen. We can design the Ferrari and maybe even provide a shopping list for parts and an instruction manual for assembling and operating. But you have to assemble the car and take it out on the road. It is our nation’s hospitalists, along with key partners and team members at their local institutions, who will provide the coefficients for change and the impetus for improvement.

Once you do this, SHM will have a role to praise, reward, and even prod you and to shine a bright light on all your work so others will be encouraged to take their shot and make great things happen.

SHM, like the hospitalists who form us, is a paradox. On first glance, we are patient and thoughtful with a longer look at the future and all the changes that will be required. At the same time we want to take our innovations and put them in place this week. We think the fearlessness of youth and open-box thinking is just what we need in healthcare today. We rely on our partners to temper our rush to action with their experience and wisdom and additional perspectives. The times require change. Together we can make sure it is a change for the better. TH

Dr. Wellikson has been CEO of SHM since 2000.

Have you ever looked out your window and wondered, “When did that tree get planted?” Or wonder when you pass a new building that wasn’t there last week, “When did they build that?” Or remember a time when everyone didn’t have an iPod or a Treo Smartphone or Blackberry?

Well, hospital medicine and SHM are rapidly becoming the iPods of healthcare. We are still catching some by surprise. Others think we are everywhere, touching everything, and sometimes leaving them asking the universal question from Butch Cassidy and the Sundance Kids, “Who are those guys?”

Most of you know that while the adoption of hospital medicine and its meteoric rise seems at times a force of nature on a random and indeterminate course, the all too true reality is that many of the “sudden” advances by SHM have been many years in the planning. More than that, they have required key partnerships and significant behind the scenes activity.

It is very much akin to the sudden stardom of veteran performers who have been honing their craft under a smaller spotlight waiting for their time to come. The time for hospital medicine is now.

This is all the more important because hospital medicine has been getting by as a growth story for a while now and it is time to add the substance that will propel our specialty forward as a permanent part of the medical landscape and a key partner in improvement strategies for hospitals and our patients’ care.

Hospital medicine has its own repository now for our contributions to science and the formulation of the hospital of the future in the Journal of Hospital Medicine. The inaugural issue has met with accolades and acceptance. The second issue is on the way and soon it will seem like there has always been a JHM.

The first issue of JHM was all the more important and noteworthy because it was accompanied by a supplement: The Core Competencies in Hospital Medicine. Years in the making, this thoughtful document put SHM’s nickel down and said “Here is what makes hospital medicine unique: an evolving specialty, emanating from our roots in internal medicine, family practice, and pediatrics, but with a relevance to the practice of medicine in our nation’s hospitals in the 21st century.”

Fully accepting the hospitalists’ role in building teams, improving quality, driving hospital efficiencies, and promoting effective care, we hope the Competencies will be part of our road map as we participate in such important but disparate efforts as redesigning internal medicine training, developing a unique credential for hospitalists, and planning the hospital of the future.

These efforts, like JHM or The Core Competencies just a few years ago, are concepts today that will form the reality in the near term. As they develop I will use this space to bring you new developments and prepare all of us for our active roles in defining, participating in, and implementing the new future.

Recognition of Hospitalists

For several years SHM has been talking with the thought leaders in internal medicine including American Board of Internal Medicine (ABIM), American College of Physicians (ACP), Alliance for Academic Internal Medicine (AAIM), and others about not only the growth in size of hospital medicine, but the unique practice of hospitalists that defines us as related and as distinct from the rest of internal medicine as cardiology or critical care.

We started with internal medicine because more than 85% of hospitalists are trained as internists. But our strategy is to soon follow on with discussions with the American Board of Family Practice (ABFP), the American Board of Pediatrics (ABP), osteopathic certification organizations, and others who oversee any part of credentialing hospitalists.

The ABIM with the support of the ACP, the AAIM, SHM, and others has embarked on a process to use the Maintenance of Certification (MOC) to create a unique recognition for hospital medicine without requiring additional formal training beyond current residencies. The plan for now is that all graduates of an internal medicine residency would take the same initial certification, but that after entering practice and sometime within the first 10 years of practice, hospitalists could use the elements of the MOC process (e.g., self assessment, a quality improvement process, and a secure test—all specific to hospital medicine practice) to create a recognition of them as hospitalists. Presently, the ABIM has formed a Hospital Medicine Task Force to develop the details that will make this rigorous and meaningful to the key stakeholders (e.g., hospitals, patients, hospitalist employers, referring physicians, and hospitalists).

Getting this far was not in any way a slam dunk or a rubber stamp. SHM didn’t just send in a postcard asking for a credential for hospitalists and ABIM said, “Fine.” This has taken several years of reasoned conversations, meetings to clarify our position, and opportunities to understand the broader aspects of the emergence of hospital medicine’s effect on the rest of medicine. More recently it has taken the courageous leadership and vision of the ABIM, the ACP, the AAIM, and others to meet their missions of promoting quality of care for our patients.

Work still needs to be done and the devil is always in the details. But the current direction is forward, and that is surely welcome.

Working to Improve Quality

There has been much heat and fury around quality—defining it, measuring it, even possibly paying for it, instead of just paying for units of work whether they are any good or not. For many years the role of the professional medical society in the quality arena was to pull together the smartest people in their specialty, latch on to the diseases they knew the most about, define quality, write guidelines, issue a white paper, and declare victory.

From its beginning SHM has taken a different tactic. We believe many smart people have already defined the best quality for DVT or diabetes or CHF, but the remaining gaps have been in implementation strategies to export all these great ideas to 5,000 hospitals and the millions of patients who occupy them.

With this in mind SHM has sought funding in the diseases defined in our Core Competencies such as DVT, diabetes, CHF, and others, and we have looked for ways to provide hospitalists with key tools as well as looking for implementation strategies (e.g., mentorship, training courses in leadership and the quality improvement process, demonstration projects) to make a measurable difference. And as hospitalists begin to become change agents at their hospitals, we hope to use our meetings and our publications to report your successes and the barriers to success.

Once again SHM will not be able to do much on our own. Therefore, our strategy has been to involve very early on the leaders in nursing, pharmacy, case management, and relevant specialties of medicine. In fashioning a strategy for glycemic control in the hospital, for example, SHM works with the American Association of Clinical Endocrinologists, the American Diabetic Association, and others. Once again as early vague ideas take shape and become real programs, it seems as if they have appeared fully formed in short order. But SHM has been working on many of these for years, and we expect that we will be in the quality improvement implementation realm for many years to come. We are just getting started.

But here is where you are so important. At its best SHM is not much more than an aggregator of good ideas and the developer of strategies. You make it happen. We can design the Ferrari and maybe even provide a shopping list for parts and an instruction manual for assembling and operating. But you have to assemble the car and take it out on the road. It is our nation’s hospitalists, along with key partners and team members at their local institutions, who will provide the coefficients for change and the impetus for improvement.

Once you do this, SHM will have a role to praise, reward, and even prod you and to shine a bright light on all your work so others will be encouraged to take their shot and make great things happen.

SHM, like the hospitalists who form us, is a paradox. On first glance, we are patient and thoughtful with a longer look at the future and all the changes that will be required. At the same time we want to take our innovations and put them in place this week. We think the fearlessness of youth and open-box thinking is just what we need in healthcare today. We rely on our partners to temper our rush to action with their experience and wisdom and additional perspectives. The times require change. Together we can make sure it is a change for the better. TH

Dr. Wellikson has been CEO of SHM since 2000.