An explosion of interest in managing hyperglycemia in the hospital has resulted from recent evidence that glycemic control can reduce mortality and other morbidities. Programs of intensification using historical controls for comparison and clinical trials demonstrating the ability of glycemic control to improve outcomes have mandated specific blood glucose thresholds for initiating intensive therapy in the ICU.1-12 These studies have convinced the world that in the ICU intravenous insulin infusion should supplant sliding scale.

A large body of observational data point to the likelihood that the benefits of glycemic control might extend to the general hospital ward.13,14 Although intravenous infusion of insulin might be more widely used in the future than it is now, the standard practice at most hospitals is to address glycemic control on general wards through the use of subcutaneous insulin.15,16

Two recent publications from Rush University Medical Center in Chicago and from St. Joseph’s/Candler Health System in Savannah, Ga., added weight to older literature and to a large body of long-held expert opinion that the anticipatory use of subcutaneous insulin in the hospital outperforms sliding scale.

Sliding Scale and Its Flaws

Throughout a half century of PubMed indexing, the medical literature has referred to sliding scale insulin.17 In its simplest form at a given blood glucose level, sliding scale delivers the same number of units of subcutaneous regular insulin to every patient. For example, it might require:

150-199     + 2

200-249     + 4

250-299     + 6

300-349     + 8

350-399     +10

400 and up     Call physician

Protocols attempting to improve upon the scale offer differing amounts of insulin at several assumed degrees of insulin sensitivity.18,19 However, these protocols still retain a reactive approach to glycemic management such that hyperglycemia will recur given the absence of adequate basal and nutritional insulin coverage. Under sliding scale the risk of ketoacidosis in type-1 diabetes is not addressed. Overcompensation for hyperglycemia results in hypoglycemia for some patients. By writing sliding scale orders physicians may create the appearance of having designed a detailed and attentive care plan, while in reality they neglect to individualize care to meet the patient’s needs.20

Discussions about sliding scale and correction dose insulin are frequently misinterpreted because of differences in use of terminology. Practitioners who disagree with use of sliding scale monotherapy nevertheless recommend using correction doses or supplements of insulin for patients already receiving anticipatory insulin.21 Some practitioners may refer to correction doses used in addition to anticipatory insulin as sliding scale insulin.22,23 Patients themselves sometimes use the term sliding scale.

A patient may, for example, use glargine and aspart and, when asked how she determines the dose of aspart, she may say she uses “sliding scale.” What she means, though, may be one of several possible management styles. She may mean that she uses aspart only for correction of hyperglycemia. She may mean that she has a table with two columns, showing paired blood glucose ranges and premeal aspart doses, such that the prandial and correction components of the aspart doses are bundled. She may mean that she practices advanced carbohydrate counting, utilizes an insulin-to-carbohydrate ratio to determine aspart coverage for the meal, and additionally calculates a premeal correction dose of aspart for hyperglycemia (i.e., she may practice basal-prandial-correction therapy).24-26

For purposes of this discussion, by “sliding scale” insulin, I mean monotherapy with sliding scale without concomitant anticipatory use of insulin (scheduled, routine, standing, or programmed insulin) or sliding scale with its faults, as described by Saul Genuth, MD.27

Evidence Against Sliding Scale

Relying on sliding scale insulin sometimes causes hypoglycemic events, severe hyperglycemic events, patient relapse after treatment of ketoacidosis, and the in-house development of diabetic ketoacidosis. In the study by Kathleen and colleagues, using sliding scale doses too high for patients with renal insufficiency was identified as the cause of six episodes of hypoglycemia.28

In the quality improvement project by Roman and colleagues, the use of quality indicators of a) BG < 40 mg/dL, b) BG > 450 mg/dL on two occasions, or c) BG > 45 with acetone, revealed that five cases were caused by physician failure to respond appropriately to hyperglycemia, despite administration of large amounts of additional regular insulin as coverage for capillary blood glucose (one of which resulted in the in-house development of ketoacidosis).29

In a retrospective review of management following ketoacidosis Gearhart and colleagues showed a higher median glucose among the patients treated with sliding scale than those treated proactively with insulin (prospective or anticipatory insulin), or treated with a combination of proactive insulin and “sliding scale” (correction dose insulin).30 Queale and colleagues showed that the use of either a standing dose of insulin or an oral hypoglycemic agent was associated with a reduced risk of hyperglycemic episodes, whereas sliding scale insulin regimens (when used without a standing dose of intermediate-acting insulin) were associated with an increased rate of hyperglycemic episodes.31

Baldwin and colleagues at Rush University Medical Center in Chicago recently reported the superiority of glycemic control among 88 patients for whom sliding scale was not allowed, in comparison with 98 well-matched controls from a historical comparison period.32 In the study group, standing orders for insulin were not permitted. House staff reviewed the results of glucose monitoring performed four times daily, and they twice daily reordered anticipatory insulin if appropriate. Glargine and rapid-acting analog were continued only for those patients already using such therapy prior to admission. Premixed insulins were not used. Oral agents were not used in combination with insulin and sometimes were discontinued for medical reasons.

In the control group, the percentages of patients with specific orders were: 100% sliding scale as defined by the authors, 32% twice-daily dosing with NPH/regular insulin, 37% orals agents, and 15% combination oral agents with NPH/regular insulin. In the study group, the percentages were: 0% sliding scale, 68% twice-daily NPH/regular insulin, 30% orals, and 0% combination NPH/regular with oral agents. For the study patients versus the historical controls, the mean blood glucose was 150 ± 37 mg/dL mg/dL versus 200 ± 51 mg/dL (p<0.01). The frequency of hypoglycemia between the two groups did not differ.

Schoeffler and colleagues in the St. Joseph’s/Candler Health System in Savannah, Ga., recently conducted a randomized study of 20 patients that reported the use of a 70/30 dose titration algorithm is superior to sliding scale insulin in achieving glycemic control.33 Patients were identified for possible enrollment through discovery of orders for sliding scale insulin in the pharmacy. After exclusion of patients receiving tube feeds or TPN and patients having type-1 diabetes, those consenting to be randomized either received the sliding scale as written by their physician or titration of 70/30 insulin given twice daily under algorithm. Hypoglycemia did not occur in either group. Downward trend over time and lower mean blood glucose (151.3 versus 175.6 mg/dL, p = 0.042) were observed in the 70/30 insulin group.

Anticipatory Use of Insulin in the Hospital

The components of anticipatory subcutaneous insulin order-writing have been described according to preference of several authors (having basal, nutritional, and correction components). But in the hospital no style has been validated as superior to any other.34-37 The anticipatory delivery of nutritional insulin must match the expected pattern of exposure to carbohydrate. Specific standing orders should include additional nursing directions such as “do not withhold” or “hold if NPO.” For abrupt discontinuation of carbohydrate exposure, change of organ function, or decline of insulin resistance, protections must be in place to guard against hypoglycemia.38

An essential aspect of management is the frequent review of orders for subcutaneous insulin and patient response. At least once every day, the caregiver must reconsider “today’s insulin dose.”

How to Get Rid of Sliding Scale

Computerized order entry for managing hyperglycemia now is widespread among hospitals. Under a misdirected allocation of resources, motivated by concern for quality and safety, institutions have embraced the programming of order-entry options for standardized sliding scales. The sliding scale menu may provide a quick link to order entry for point-of-care blood capillary glucose monitoring, call parameters, and treatment of hypoglycemia. Nurses and doctors may come to believe that it is impossible even to order blood glucose monitoring without an accompanying sliding scale. Thus the sliding scale menu may possess all the accoutrements of glycemic management program except the one element most needed—a provision for anticipatory insulin.

One study by Achtmeyer and colleagues reduced utilization of a computerized sliding scale order by attaching a warning that the order was not approved by endocrinology.39 Emphasizing the importance of physician education to the successful abolition of sliding scale insulin, the study by Baldwin details an intensive house staff re-education program on how to write anticipatory insulin orders.32 The computerized order entry options used at Rush University Medical Center in Chicago (one of the two better performers in the recent benchmarking study of the University HealthSystem Consortium) were presented by Baldwin at the Aug. 19, 2005, “Glycemic Control Knowledge Transfer Meeting of the Consortium in Chicago.”

Why has use of the sliding scale persisted in practice? Is it for fear of hypoglycemia? Is it for lack of evidence on the importance of glycemic control? Even before computerization was sliding scale the path of least resistance? Is it because no clear superiority has been demonstrated among various styles of writing anticipatory insulin plans? Is it because physicians do not know how to write insulin orders? Or is it all in a name?

It just might seem that ordering sliding scale is the easy thing to call for or is the sophisticated thing to order. After all, sliding scale is an in-group term. A newly graduated physician is not likely to reject the suggestion of an experienced nurse that an order is needed for sliding scale.

For the next 50 years what is the call for, and what are the orders? Quite simply we have seen the twilight of the sliding scale—and “today’s insulin” dawning. TH

Dr. Braithwaite is clinical professor of medicine at the University of North Carolina, Diabetes Care Center, Durham.

References

1. Zerr KJ, Furnary AP, Grunkemeier GL. Glucose control lowers the risk of wound infection in diabetics after open heart operations. Ann Thorac Surg. 1997;63:356-361.
2. Furnary AP, Zerr KJ, Grunkemeier GL, et al. Continuous intravenous insulin infusion reduces the incidence of deep sternal wound infection in diabetic patients after cardiac surgical procedures. Ann Thorac Surg. 1999;67:352-362.
3. Furnary AP, Wu Y, Bookin SO. Effect of hyperglycemia and continuous intravenous insulin infusions on outcomes of cardiac surgical procedures: the Portland diabetic project. Endocr Pract. 2004;10 (Suppl. 2):21-33.
4. Furnary AP, Gao G, Grunkemeier GL, et al. Continuous insulin infusion reduces mortality in patients with diabetes undergoing coronary artery bypass grafting. J Thorac Cardiovasc Surg. 2003;125(5):1007-1021.
5. Malmberg K, Rydén L, Efendic S, et al. Randomized trial of insulin-glucose infusion followed by subcutaneous insulin treatment in diabetic patients with acute myocardial infarction (DIGAMI study): effects on mortality at 1 year. J Am Coll Cardiol. 1995;26:57-65.
6. Malmberg K, Norhammar A, Wedel H, et al. Glycometabolic state at admission: important risk marker of mortality in conventionally treated patients with diabetes mellitus and acute myocardial infarction: long-term results from the diabetes and insulin-glucose infusion in acute myocardial infarction (DIGAMI) study. Circulation. 1999;99:2626-2632.
7. Malmberg K. (for the DIGAMI study group) Prospective randomised study of intensive insulin treatment on long term survival after acute myocardial infarction in patients with diabetes mellitus. BMJ. 1997;314:1512-1515.
8. Van den Berghe G, Wouters PJ, Bouillon R, et al. Outcome benefit of intensive insulin therapy in the critically ill: insulin dose versus glycemic control. Crit Care Med. 2003;31(2):359-366.
9. Van den Berghe G, Wouters P, Weekers F, et al. Intensive insulin therapy in critically ill patients. N Engl J Med. November 8, 2001;345(19):1359-1367.
10. Van den Berghe G, Schoonheydt K, Becx P, et al. Insulin therapy protects the central and peripheral nervous system of intensive care patients. Neurology. April 26, 2005;64(8):1348-1353.
11. Krinsley JS. Effect of an intensive glucose management protocol on the mortality of critically ill adult patients. Mayo Clin Proc. 2004:992-1000.
12. Krinsley JS. Association between hyperglycemia and increased hospital mortality in a heterogeneous population of critically ill patients Mayo Clin Proc. 2003;78:1471-1478.
13. Clement S, Braithwaite SS, Magee MF, et al. Management of diabetes and hyperglycemia in hospitals. Diabetes Care. 2004;27(2):553-591.
14. American College of Endocrinology Position Statement on Inpatient Diabetes and Metabolic Control. Endocr Pract. 2004;10(1):77-82.
15. Ku SY, Sayre CA, Hirsch IB, et al. New insulin infusion protocol improves blood glucose control in hospitalized patients without increasing hypoglycemia. Jt Comm J Qual Patient Saf. 2005;31(3):141-147.
16. Davidson PC, Steed RD, Bode BW. Glucommander: a computer-directed intravenous insulin system shown to be safe, simple, and effective in 120,618 h of operation. Diabetes Care. 2005;28(10):2418-2423.
17. Massie RW. Use of the sliding scale for determination of insulin dosage. J Tn State Med Assoc. 1958;51(10):423-425.
18. Hanish LR. Standardizing regimens for sliding-scale insulin. Am J Health Syst Pharm. May 1, 1997;54(9):1046-1047.
19. Raforth RJ. Standardizing sliding scale insulin orders. Am J Med Qual. 2002;17(5):169-170.
20. Kletter GG. Sliding scale fallacy. Arch Intern Med. July 13, 1998;158(13):1472.
21. Hirsch IB, Paauw DS, Brunzell J. Inpatient management of adults with diabetes. Diabetes Care. 1995;18(6):870-878.
22. Bergenstal RM, Fish LH, List S. The insulin sliding scale is not dead. Arch Intern Med. February 9, 1998;158(3):298.
23. Dickerson LM, Xiaobu Y, Sack JL. Glycemic control in medical inpatients with type 2 diabetes mellitus receiving sliding scale insulin regimens versus routine diabetes medications: a multicenter randomized controlled trial. Ann Fam Med. 2003;1(1):29-35.
24. Hirsch IB. Insulin analogues. N Engl J Med. January 13, 2005 ;352(2):174-183.
25. DeWitt DE, Hirsch IB. Outpatient insulin therapy in type 1 and type 2 diabetes mellitus: scientific review. JAMA. May 7, 2003;289(17):2254-2264.
26. DAFNE Study Group. Training in flexible, intensive insulin management to enable dietary freedom in people with type 1 diabetes: dose adjustment for normal eating (DAFNE) randomised controlled trial. BMJ. 2002;325(7367):746-752.
27. Genuth S. The automatic (regular insulin) sliding scale, or 2, 4, 6, 8—call H.O. Clinical Diabetes. 1994:40-42.
28. Fischer KF, Lees JA, Newman JH. Hypoglycemia in hospitalized patients. N Engl J Med. 1986;315:1245-1250.
29. Roman SH, Linekin PL, Stagnaro-Green A. An inpatient diabetes QI program. Jt Comm J Qual Improv. 1995;21(2):693-699.
30. Gearhart JG, Duncan JL, Replogle WH, et al. Efficacy of sliding-scale insulin therapy: a comparison with prospective regimens. Fam Pract Res J. 1994;14:313-322.
31. Queale WS, Seidler AJ, Brancati FL. Glycemic control and sliding scale insulin use in medical inpatients with diabetes mellitus. Arch Intern Med. 1997;157(5):545-552.
32. Baldwin D, Villanueva G, McNutt R, et al. Eliminating inpatient sliding-scale insulin: a reeducation project with medical house staff. Diabetes Care. 2005;28(5):1008-1011.
33. Schoeffler JM, Rice DAK, Gresham DG. 70/30 insulin algorithm versus sliding scale insulin. Ann Pharmacother. 2005;39(10):1606-1609.
34. Trence DL, Kelly JL, Hirsch IB. The rationale and management of hyperglycemia for in-patients with cardiovascular disease: time for change. J Clin Endocrinol Metab. 2003;88 2430-2437.
35. Magee MR, Clement S. Subcutaneous insulin therapy in the hospital setting: issues, concerns, and implementation. Endocr Pract. 2004;10 (suppl 2):81-88.
36. Thompson CL, Dunn KC, Menon MC, et al. Hyperglycemia in the hospital. Diabetes Spectr. 2005;18(1):20-27.
37. Campbell KB, Braithwaite SS. Hospital management of hyperglycemia. Clinical Diabetes. April 2004;22(2):81-88.
38. Braithwaite SS, Buie MM, Thompson CL, et al. Hospital hypoglycemia: not only treatment but also prevention. Endocr Pract. 2004;10 (Suppl 2):71-80.
39. Achtmeyer CE, Payne TH, Anawalt BD. Computer order entry system decreased use of sliding scale insulin regimens. Methods Inf Med. 2002;41:277-281.

An explosion of interest in managing hyperglycemia in the hospital has resulted from recent evidence that glycemic control can reduce mortality and other morbidities. Programs of intensification using historical controls for comparison and clinical trials demonstrating the ability of glycemic control to improve outcomes have mandated specific blood glucose thresholds for initiating intensive therapy in the ICU.1-12 These studies have convinced the world that in the ICU intravenous insulin infusion should supplant sliding scale.

A large body of observational data point to the likelihood that the benefits of glycemic control might extend to the general hospital ward.13,14 Although intravenous infusion of insulin might be more widely used in the future than it is now, the standard practice at most hospitals is to address glycemic control on general wards through the use of subcutaneous insulin.15,16

Two recent publications from Rush University Medical Center in Chicago and from St. Joseph’s/Candler Health System in Savannah, Ga., added weight to older literature and to a large body of long-held expert opinion that the anticipatory use of subcutaneous insulin in the hospital outperforms sliding scale.

Sliding Scale and Its Flaws

Throughout a half century of PubMed indexing, the medical literature has referred to sliding scale insulin.17 In its simplest form at a given blood glucose level, sliding scale delivers the same number of units of subcutaneous regular insulin to every patient. For example, it might require:

150-199     + 2

200-249     + 4

250-299     + 6

300-349     + 8

350-399     +10

400 and up     Call physician

Protocols attempting to improve upon the scale offer differing amounts of insulin at several assumed degrees of insulin sensitivity.18,19 However, these protocols still retain a reactive approach to glycemic management such that hyperglycemia will recur given the absence of adequate basal and nutritional insulin coverage. Under sliding scale the risk of ketoacidosis in type-1 diabetes is not addressed. Overcompensation for hyperglycemia results in hypoglycemia for some patients. By writing sliding scale orders physicians may create the appearance of having designed a detailed and attentive care plan, while in reality they neglect to individualize care to meet the patient’s needs.20

Discussions about sliding scale and correction dose insulin are frequently misinterpreted because of differences in use of terminology. Practitioners who disagree with use of sliding scale monotherapy nevertheless recommend using correction doses or supplements of insulin for patients already receiving anticipatory insulin.21 Some practitioners may refer to correction doses used in addition to anticipatory insulin as sliding scale insulin.22,23 Patients themselves sometimes use the term sliding scale.

A patient may, for example, use glargine and aspart and, when asked how she determines the dose of aspart, she may say she uses “sliding scale.” What she means, though, may be one of several possible management styles. She may mean that she uses aspart only for correction of hyperglycemia. She may mean that she has a table with two columns, showing paired blood glucose ranges and premeal aspart doses, such that the prandial and correction components of the aspart doses are bundled. She may mean that she practices advanced carbohydrate counting, utilizes an insulin-to-carbohydrate ratio to determine aspart coverage for the meal, and additionally calculates a premeal correction dose of aspart for hyperglycemia (i.e., she may practice basal-prandial-correction therapy).24-26

For purposes of this discussion, by “sliding scale” insulin, I mean monotherapy with sliding scale without concomitant anticipatory use of insulin (scheduled, routine, standing, or programmed insulin) or sliding scale with its faults, as described by Saul Genuth, MD.27

Evidence Against Sliding Scale

Relying on sliding scale insulin sometimes causes hypoglycemic events, severe hyperglycemic events, patient relapse after treatment of ketoacidosis, and the in-house development of diabetic ketoacidosis. In the study by Kathleen and colleagues, using sliding scale doses too high for patients with renal insufficiency was identified as the cause of six episodes of hypoglycemia.28

In the quality improvement project by Roman and colleagues, the use of quality indicators of a) BG < 40 mg/dL, b) BG > 450 mg/dL on two occasions, or c) BG > 45 with acetone, revealed that five cases were caused by physician failure to respond appropriately to hyperglycemia, despite administration of large amounts of additional regular insulin as coverage for capillary blood glucose (one of which resulted in the in-house development of ketoacidosis).29

In a retrospective review of management following ketoacidosis Gearhart and colleagues showed a higher median glucose among the patients treated with sliding scale than those treated proactively with insulin (prospective or anticipatory insulin), or treated with a combination of proactive insulin and “sliding scale” (correction dose insulin).30 Queale and colleagues showed that the use of either a standing dose of insulin or an oral hypoglycemic agent was associated with a reduced risk of hyperglycemic episodes, whereas sliding scale insulin regimens (when used without a standing dose of intermediate-acting insulin) were associated with an increased rate of hyperglycemic episodes.31

Baldwin and colleagues at Rush University Medical Center in Chicago recently reported the superiority of glycemic control among 88 patients for whom sliding scale was not allowed, in comparison with 98 well-matched controls from a historical comparison period.32 In the study group, standing orders for insulin were not permitted. House staff reviewed the results of glucose monitoring performed four times daily, and they twice daily reordered anticipatory insulin if appropriate. Glargine and rapid-acting analog were continued only for those patients already using such therapy prior to admission. Premixed insulins were not used. Oral agents were not used in combination with insulin and sometimes were discontinued for medical reasons.

In the control group, the percentages of patients with specific orders were: 100% sliding scale as defined by the authors, 32% twice-daily dosing with NPH/regular insulin, 37% orals agents, and 15% combination oral agents with NPH/regular insulin. In the study group, the percentages were: 0% sliding scale, 68% twice-daily NPH/regular insulin, 30% orals, and 0% combination NPH/regular with oral agents. For the study patients versus the historical controls, the mean blood glucose was 150 ± 37 mg/dL mg/dL versus 200 ± 51 mg/dL (p<0.01). The frequency of hypoglycemia between the two groups did not differ.

Schoeffler and colleagues in the St. Joseph’s/Candler Health System in Savannah, Ga., recently conducted a randomized study of 20 patients that reported the use of a 70/30 dose titration algorithm is superior to sliding scale insulin in achieving glycemic control.33 Patients were identified for possible enrollment through discovery of orders for sliding scale insulin in the pharmacy. After exclusion of patients receiving tube feeds or TPN and patients having type-1 diabetes, those consenting to be randomized either received the sliding scale as written by their physician or titration of 70/30 insulin given twice daily under algorithm. Hypoglycemia did not occur in either group. Downward trend over time and lower mean blood glucose (151.3 versus 175.6 mg/dL, p = 0.042) were observed in the 70/30 insulin group.

Anticipatory Use of Insulin in the Hospital

The components of anticipatory subcutaneous insulin order-writing have been described according to preference of several authors (having basal, nutritional, and correction components). But in the hospital no style has been validated as superior to any other.34-37 The anticipatory delivery of nutritional insulin must match the expected pattern of exposure to carbohydrate. Specific standing orders should include additional nursing directions such as “do not withhold” or “hold if NPO.” For abrupt discontinuation of carbohydrate exposure, change of organ function, or decline of insulin resistance, protections must be in place to guard against hypoglycemia.38

An essential aspect of management is the frequent review of orders for subcutaneous insulin and patient response. At least once every day, the caregiver must reconsider “today’s insulin dose.”

How to Get Rid of Sliding Scale

Computerized order entry for managing hyperglycemia now is widespread among hospitals. Under a misdirected allocation of resources, motivated by concern for quality and safety, institutions have embraced the programming of order-entry options for standardized sliding scales. The sliding scale menu may provide a quick link to order entry for point-of-care blood capillary glucose monitoring, call parameters, and treatment of hypoglycemia. Nurses and doctors may come to believe that it is impossible even to order blood glucose monitoring without an accompanying sliding scale. Thus the sliding scale menu may possess all the accoutrements of glycemic management program except the one element most needed—a provision for anticipatory insulin.

One study by Achtmeyer and colleagues reduced utilization of a computerized sliding scale order by attaching a warning that the order was not approved by endocrinology.39 Emphasizing the importance of physician education to the successful abolition of sliding scale insulin, the study by Baldwin details an intensive house staff re-education program on how to write anticipatory insulin orders.32 The computerized order entry options used at Rush University Medical Center in Chicago (one of the two better performers in the recent benchmarking study of the University HealthSystem Consortium) were presented by Baldwin at the Aug. 19, 2005, “Glycemic Control Knowledge Transfer Meeting of the Consortium in Chicago.”

Why has use of the sliding scale persisted in practice? Is it for fear of hypoglycemia? Is it for lack of evidence on the importance of glycemic control? Even before computerization was sliding scale the path of least resistance? Is it because no clear superiority has been demonstrated among various styles of writing anticipatory insulin plans? Is it because physicians do not know how to write insulin orders? Or is it all in a name?

It just might seem that ordering sliding scale is the easy thing to call for or is the sophisticated thing to order. After all, sliding scale is an in-group term. A newly graduated physician is not likely to reject the suggestion of an experienced nurse that an order is needed for sliding scale.

For the next 50 years what is the call for, and what are the orders? Quite simply we have seen the twilight of the sliding scale—and “today’s insulin” dawning. TH

Dr. Braithwaite is clinical professor of medicine at the University of North Carolina, Diabetes Care Center, Durham.

References

1. Zerr KJ, Furnary AP, Grunkemeier GL. Glucose control lowers the risk of wound infection in diabetics after open heart operations. Ann Thorac Surg. 1997;63:356-361.
2. Furnary AP, Zerr KJ, Grunkemeier GL, et al. Continuous intravenous insulin infusion reduces the incidence of deep sternal wound infection in diabetic patients after cardiac surgical procedures. Ann Thorac Surg. 1999;67:352-362.
3. Furnary AP, Wu Y, Bookin SO. Effect of hyperglycemia and continuous intravenous insulin infusions on outcomes of cardiac surgical procedures: the Portland diabetic project. Endocr Pract. 2004;10 (Suppl. 2):21-33.
4. Furnary AP, Gao G, Grunkemeier GL, et al. Continuous insulin infusion reduces mortality in patients with diabetes undergoing coronary artery bypass grafting. J Thorac Cardiovasc Surg. 2003;125(5):1007-1021.
5. Malmberg K, Rydén L, Efendic S, et al. Randomized trial of insulin-glucose infusion followed by subcutaneous insulin treatment in diabetic patients with acute myocardial infarction (DIGAMI study): effects on mortality at 1 year. J Am Coll Cardiol. 1995;26:57-65.
6. Malmberg K, Norhammar A, Wedel H, et al. Glycometabolic state at admission: important risk marker of mortality in conventionally treated patients with diabetes mellitus and acute myocardial infarction: long-term results from the diabetes and insulin-glucose infusion in acute myocardial infarction (DIGAMI) study. Circulation. 1999;99:2626-2632.
7. Malmberg K. (for the DIGAMI study group) Prospective randomised study of intensive insulin treatment on long term survival after acute myocardial infarction in patients with diabetes mellitus. BMJ. 1997;314:1512-1515.
8. Van den Berghe G, Wouters PJ, Bouillon R, et al. Outcome benefit of intensive insulin therapy in the critically ill: insulin dose versus glycemic control. Crit Care Med. 2003;31(2):359-366.
9. Van den Berghe G, Wouters P, Weekers F, et al. Intensive insulin therapy in critically ill patients. N Engl J Med. November 8, 2001;345(19):1359-1367.
10. Van den Berghe G, Schoonheydt K, Becx P, et al. Insulin therapy protects the central and peripheral nervous system of intensive care patients. Neurology. April 26, 2005;64(8):1348-1353.
11. Krinsley JS. Effect of an intensive glucose management protocol on the mortality of critically ill adult patients. Mayo Clin Proc. 2004:992-1000.
12. Krinsley JS. Association between hyperglycemia and increased hospital mortality in a heterogeneous population of critically ill patients Mayo Clin Proc. 2003;78:1471-1478.
13. Clement S, Braithwaite SS, Magee MF, et al. Management of diabetes and hyperglycemia in hospitals. Diabetes Care. 2004;27(2):553-591.
14. American College of Endocrinology Position Statement on Inpatient Diabetes and Metabolic Control. Endocr Pract. 2004;10(1):77-82.
15. Ku SY, Sayre CA, Hirsch IB, et al. New insulin infusion protocol improves blood glucose control in hospitalized patients without increasing hypoglycemia. Jt Comm J Qual Patient Saf. 2005;31(3):141-147.
16. Davidson PC, Steed RD, Bode BW. Glucommander: a computer-directed intravenous insulin system shown to be safe, simple, and effective in 120,618 h of operation. Diabetes Care. 2005;28(10):2418-2423.
17. Massie RW. Use of the sliding scale for determination of insulin dosage. J Tn State Med Assoc. 1958;51(10):423-425.
18. Hanish LR. Standardizing regimens for sliding-scale insulin. Am J Health Syst Pharm. May 1, 1997;54(9):1046-1047.
19. Raforth RJ. Standardizing sliding scale insulin orders. Am J Med Qual. 2002;17(5):169-170.
20. Kletter GG. Sliding scale fallacy. Arch Intern Med. July 13, 1998;158(13):1472.
21. Hirsch IB, Paauw DS, Brunzell J. Inpatient management of adults with diabetes. Diabetes Care. 1995;18(6):870-878.
22. Bergenstal RM, Fish LH, List S. The insulin sliding scale is not dead. Arch Intern Med. February 9, 1998;158(3):298.
23. Dickerson LM, Xiaobu Y, Sack JL. Glycemic control in medical inpatients with type 2 diabetes mellitus receiving sliding scale insulin regimens versus routine diabetes medications: a multicenter randomized controlled trial. Ann Fam Med. 2003;1(1):29-35.
24. Hirsch IB. Insulin analogues. N Engl J Med. January 13, 2005 ;352(2):174-183.
25. DeWitt DE, Hirsch IB. Outpatient insulin therapy in type 1 and type 2 diabetes mellitus: scientific review. JAMA. May 7, 2003;289(17):2254-2264.
26. DAFNE Study Group. Training in flexible, intensive insulin management to enable dietary freedom in people with type 1 diabetes: dose adjustment for normal eating (DAFNE) randomised controlled trial. BMJ. 2002;325(7367):746-752.
27. Genuth S. The automatic (regular insulin) sliding scale, or 2, 4, 6, 8—call H.O. Clinical Diabetes. 1994:40-42.
28. Fischer KF, Lees JA, Newman JH. Hypoglycemia in hospitalized patients. N Engl J Med. 1986;315:1245-1250.
29. Roman SH, Linekin PL, Stagnaro-Green A. An inpatient diabetes QI program. Jt Comm J Qual Improv. 1995;21(2):693-699.
30. Gearhart JG, Duncan JL, Replogle WH, et al. Efficacy of sliding-scale insulin therapy: a comparison with prospective regimens. Fam Pract Res J. 1994;14:313-322.
31. Queale WS, Seidler AJ, Brancati FL. Glycemic control and sliding scale insulin use in medical inpatients with diabetes mellitus. Arch Intern Med. 1997;157(5):545-552.
32. Baldwin D, Villanueva G, McNutt R, et al. Eliminating inpatient sliding-scale insulin: a reeducation project with medical house staff. Diabetes Care. 2005;28(5):1008-1011.
33. Schoeffler JM, Rice DAK, Gresham DG. 70/30 insulin algorithm versus sliding scale insulin. Ann Pharmacother. 2005;39(10):1606-1609.
34. Trence DL, Kelly JL, Hirsch IB. The rationale and management of hyperglycemia for in-patients with cardiovascular disease: time for change. J Clin Endocrinol Metab. 2003;88 2430-2437.
35. Magee MR, Clement S. Subcutaneous insulin therapy in the hospital setting: issues, concerns, and implementation. Endocr Pract. 2004;10 (suppl 2):81-88.
36. Thompson CL, Dunn KC, Menon MC, et al. Hyperglycemia in the hospital. Diabetes Spectr. 2005;18(1):20-27.
37. Campbell KB, Braithwaite SS. Hospital management of hyperglycemia. Clinical Diabetes. April 2004;22(2):81-88.
38. Braithwaite SS, Buie MM, Thompson CL, et al. Hospital hypoglycemia: not only treatment but also prevention. Endocr Pract. 2004;10 (Suppl 2):71-80.
39. Achtmeyer CE, Payne TH, Anawalt BD. Computer order entry system decreased use of sliding scale insulin regimens. Methods Inf Med. 2002;41:277-281.

An explosion of interest in managing hyperglycemia in the hospital has resulted from recent evidence that glycemic control can reduce mortality and other morbidities. Programs of intensification using historical controls for comparison and clinical trials demonstrating the ability of glycemic control to improve outcomes have mandated specific blood glucose thresholds for initiating intensive therapy in the ICU.1-12 These studies have convinced the world that in the ICU intravenous insulin infusion should supplant sliding scale.

A large body of observational data point to the likelihood that the benefits of glycemic control might extend to the general hospital ward.13,14 Although intravenous infusion of insulin might be more widely used in the future than it is now, the standard practice at most hospitals is to address glycemic control on general wards through the use of subcutaneous insulin.15,16

Two recent publications from Rush University Medical Center in Chicago and from St. Joseph’s/Candler Health System in Savannah, Ga., added weight to older literature and to a large body of long-held expert opinion that the anticipatory use of subcutaneous insulin in the hospital outperforms sliding scale.

Sliding Scale and Its Flaws

Throughout a half century of PubMed indexing, the medical literature has referred to sliding scale insulin.17 In its simplest form at a given blood glucose level, sliding scale delivers the same number of units of subcutaneous regular insulin to every patient. For example, it might require:

150-199     + 2

200-249     + 4

250-299     + 6

300-349     + 8

350-399     +10

400 and up     Call physician

Protocols attempting to improve upon the scale offer differing amounts of insulin at several assumed degrees of insulin sensitivity.18,19 However, these protocols still retain a reactive approach to glycemic management such that hyperglycemia will recur given the absence of adequate basal and nutritional insulin coverage. Under sliding scale the risk of ketoacidosis in type-1 diabetes is not addressed. Overcompensation for hyperglycemia results in hypoglycemia for some patients. By writing sliding scale orders physicians may create the appearance of having designed a detailed and attentive care plan, while in reality they neglect to individualize care to meet the patient’s needs.20

Discussions about sliding scale and correction dose insulin are frequently misinterpreted because of differences in use of terminology. Practitioners who disagree with use of sliding scale monotherapy nevertheless recommend using correction doses or supplements of insulin for patients already receiving anticipatory insulin.21 Some practitioners may refer to correction doses used in addition to anticipatory insulin as sliding scale insulin.22,23 Patients themselves sometimes use the term sliding scale.

A patient may, for example, use glargine and aspart and, when asked how she determines the dose of aspart, she may say she uses “sliding scale.” What she means, though, may be one of several possible management styles. She may mean that she uses aspart only for correction of hyperglycemia. She may mean that she has a table with two columns, showing paired blood glucose ranges and premeal aspart doses, such that the prandial and correction components of the aspart doses are bundled. She may mean that she practices advanced carbohydrate counting, utilizes an insulin-to-carbohydrate ratio to determine aspart coverage for the meal, and additionally calculates a premeal correction dose of aspart for hyperglycemia (i.e., she may practice basal-prandial-correction therapy).24-26

For purposes of this discussion, by “sliding scale” insulin, I mean monotherapy with sliding scale without concomitant anticipatory use of insulin (scheduled, routine, standing, or programmed insulin) or sliding scale with its faults, as described by Saul Genuth, MD.27

Evidence Against Sliding Scale

Relying on sliding scale insulin sometimes causes hypoglycemic events, severe hyperglycemic events, patient relapse after treatment of ketoacidosis, and the in-house development of diabetic ketoacidosis. In the study by Kathleen and colleagues, using sliding scale doses too high for patients with renal insufficiency was identified as the cause of six episodes of hypoglycemia.28

In the quality improvement project by Roman and colleagues, the use of quality indicators of a) BG < 40 mg/dL, b) BG > 450 mg/dL on two occasions, or c) BG > 45 with acetone, revealed that five cases were caused by physician failure to respond appropriately to hyperglycemia, despite administration of large amounts of additional regular insulin as coverage for capillary blood glucose (one of which resulted in the in-house development of ketoacidosis).29

In a retrospective review of management following ketoacidosis Gearhart and colleagues showed a higher median glucose among the patients treated with sliding scale than those treated proactively with insulin (prospective or anticipatory insulin), or treated with a combination of proactive insulin and “sliding scale” (correction dose insulin).30 Queale and colleagues showed that the use of either a standing dose of insulin or an oral hypoglycemic agent was associated with a reduced risk of hyperglycemic episodes, whereas sliding scale insulin regimens (when used without a standing dose of intermediate-acting insulin) were associated with an increased rate of hyperglycemic episodes.31

Baldwin and colleagues at Rush University Medical Center in Chicago recently reported the superiority of glycemic control among 88 patients for whom sliding scale was not allowed, in comparison with 98 well-matched controls from a historical comparison period.32 In the study group, standing orders for insulin were not permitted. House staff reviewed the results of glucose monitoring performed four times daily, and they twice daily reordered anticipatory insulin if appropriate. Glargine and rapid-acting analog were continued only for those patients already using such therapy prior to admission. Premixed insulins were not used. Oral agents were not used in combination with insulin and sometimes were discontinued for medical reasons.

In the control group, the percentages of patients with specific orders were: 100% sliding scale as defined by the authors, 32% twice-daily dosing with NPH/regular insulin, 37% orals agents, and 15% combination oral agents with NPH/regular insulin. In the study group, the percentages were: 0% sliding scale, 68% twice-daily NPH/regular insulin, 30% orals, and 0% combination NPH/regular with oral agents. For the study patients versus the historical controls, the mean blood glucose was 150 ± 37 mg/dL mg/dL versus 200 ± 51 mg/dL (p<0.01). The frequency of hypoglycemia between the two groups did not differ.

Schoeffler and colleagues in the St. Joseph’s/Candler Health System in Savannah, Ga., recently conducted a randomized study of 20 patients that reported the use of a 70/30 dose titration algorithm is superior to sliding scale insulin in achieving glycemic control.33 Patients were identified for possible enrollment through discovery of orders for sliding scale insulin in the pharmacy. After exclusion of patients receiving tube feeds or TPN and patients having type-1 diabetes, those consenting to be randomized either received the sliding scale as written by their physician or titration of 70/30 insulin given twice daily under algorithm. Hypoglycemia did not occur in either group. Downward trend over time and lower mean blood glucose (151.3 versus 175.6 mg/dL, p = 0.042) were observed in the 70/30 insulin group.

Anticipatory Use of Insulin in the Hospital

The components of anticipatory subcutaneous insulin order-writing have been described according to preference of several authors (having basal, nutritional, and correction components). But in the hospital no style has been validated as superior to any other.34-37 The anticipatory delivery of nutritional insulin must match the expected pattern of exposure to carbohydrate. Specific standing orders should include additional nursing directions such as “do not withhold” or “hold if NPO.” For abrupt discontinuation of carbohydrate exposure, change of organ function, or decline of insulin resistance, protections must be in place to guard against hypoglycemia.38

An essential aspect of management is the frequent review of orders for subcutaneous insulin and patient response. At least once every day, the caregiver must reconsider “today’s insulin dose.”

How to Get Rid of Sliding Scale

Computerized order entry for managing hyperglycemia now is widespread among hospitals. Under a misdirected allocation of resources, motivated by concern for quality and safety, institutions have embraced the programming of order-entry options for standardized sliding scales. The sliding scale menu may provide a quick link to order entry for point-of-care blood capillary glucose monitoring, call parameters, and treatment of hypoglycemia. Nurses and doctors may come to believe that it is impossible even to order blood glucose monitoring without an accompanying sliding scale. Thus the sliding scale menu may possess all the accoutrements of glycemic management program except the one element most needed—a provision for anticipatory insulin.

One study by Achtmeyer and colleagues reduced utilization of a computerized sliding scale order by attaching a warning that the order was not approved by endocrinology.39 Emphasizing the importance of physician education to the successful abolition of sliding scale insulin, the study by Baldwin details an intensive house staff re-education program on how to write anticipatory insulin orders.32 The computerized order entry options used at Rush University Medical Center in Chicago (one of the two better performers in the recent benchmarking study of the University HealthSystem Consortium) were presented by Baldwin at the Aug. 19, 2005, “Glycemic Control Knowledge Transfer Meeting of the Consortium in Chicago.”

Why has use of the sliding scale persisted in practice? Is it for fear of hypoglycemia? Is it for lack of evidence on the importance of glycemic control? Even before computerization was sliding scale the path of least resistance? Is it because no clear superiority has been demonstrated among various styles of writing anticipatory insulin plans? Is it because physicians do not know how to write insulin orders? Or is it all in a name?

It just might seem that ordering sliding scale is the easy thing to call for or is the sophisticated thing to order. After all, sliding scale is an in-group term. A newly graduated physician is not likely to reject the suggestion of an experienced nurse that an order is needed for sliding scale.

For the next 50 years what is the call for, and what are the orders? Quite simply we have seen the twilight of the sliding scale—and “today’s insulin” dawning. TH

Dr. Braithwaite is clinical professor of medicine at the University of North Carolina, Diabetes Care Center, Durham.

References

1. Zerr KJ, Furnary AP, Grunkemeier GL. Glucose control lowers the risk of wound infection in diabetics after open heart operations. Ann Thorac Surg. 1997;63:356-361.
2. Furnary AP, Zerr KJ, Grunkemeier GL, et al. Continuous intravenous insulin infusion reduces the incidence of deep sternal wound infection in diabetic patients after cardiac surgical procedures. Ann Thorac Surg. 1999;67:352-362.
3. Furnary AP, Wu Y, Bookin SO. Effect of hyperglycemia and continuous intravenous insulin infusions on outcomes of cardiac surgical procedures: the Portland diabetic project. Endocr Pract. 2004;10 (Suppl. 2):21-33.
4. Furnary AP, Gao G, Grunkemeier GL, et al. Continuous insulin infusion reduces mortality in patients with diabetes undergoing coronary artery bypass grafting. J Thorac Cardiovasc Surg. 2003;125(5):1007-1021.
5. Malmberg K, Rydén L, Efendic S, et al. Randomized trial of insulin-glucose infusion followed by subcutaneous insulin treatment in diabetic patients with acute myocardial infarction (DIGAMI study): effects on mortality at 1 year. J Am Coll Cardiol. 1995;26:57-65.
6. Malmberg K, Norhammar A, Wedel H, et al. Glycometabolic state at admission: important risk marker of mortality in conventionally treated patients with diabetes mellitus and acute myocardial infarction: long-term results from the diabetes and insulin-glucose infusion in acute myocardial infarction (DIGAMI) study. Circulation. 1999;99:2626-2632.
7. Malmberg K. (for the DIGAMI study group) Prospective randomised study of intensive insulin treatment on long term survival after acute myocardial infarction in patients with diabetes mellitus. BMJ. 1997;314:1512-1515.
8. Van den Berghe G, Wouters PJ, Bouillon R, et al. Outcome benefit of intensive insulin therapy in the critically ill: insulin dose versus glycemic control. Crit Care Med. 2003;31(2):359-366.
9. Van den Berghe G, Wouters P, Weekers F, et al. Intensive insulin therapy in critically ill patients. N Engl J Med. November 8, 2001;345(19):1359-1367.
10. Van den Berghe G, Schoonheydt K, Becx P, et al. Insulin therapy protects the central and peripheral nervous system of intensive care patients. Neurology. April 26, 2005;64(8):1348-1353.
11. Krinsley JS. Effect of an intensive glucose management protocol on the mortality of critically ill adult patients. Mayo Clin Proc. 2004:992-1000.
12. Krinsley JS. Association between hyperglycemia and increased hospital mortality in a heterogeneous population of critically ill patients Mayo Clin Proc. 2003;78:1471-1478.
13. Clement S, Braithwaite SS, Magee MF, et al. Management of diabetes and hyperglycemia in hospitals. Diabetes Care. 2004;27(2):553-591.
14. American College of Endocrinology Position Statement on Inpatient Diabetes and Metabolic Control. Endocr Pract. 2004;10(1):77-82.
15. Ku SY, Sayre CA, Hirsch IB, et al. New insulin infusion protocol improves blood glucose control in hospitalized patients without increasing hypoglycemia. Jt Comm J Qual Patient Saf. 2005;31(3):141-147.
16. Davidson PC, Steed RD, Bode BW. Glucommander: a computer-directed intravenous insulin system shown to be safe, simple, and effective in 120,618 h of operation. Diabetes Care. 2005;28(10):2418-2423.
17. Massie RW. Use of the sliding scale for determination of insulin dosage. J Tn State Med Assoc. 1958;51(10):423-425.
18. Hanish LR. Standardizing regimens for sliding-scale insulin. Am J Health Syst Pharm. May 1, 1997;54(9):1046-1047.
19. Raforth RJ. Standardizing sliding scale insulin orders. Am J Med Qual. 2002;17(5):169-170.
20. Kletter GG. Sliding scale fallacy. Arch Intern Med. July 13, 1998;158(13):1472.
21. Hirsch IB, Paauw DS, Brunzell J. Inpatient management of adults with diabetes. Diabetes Care. 1995;18(6):870-878.
22. Bergenstal RM, Fish LH, List S. The insulin sliding scale is not dead. Arch Intern Med. February 9, 1998;158(3):298.
23. Dickerson LM, Xiaobu Y, Sack JL. Glycemic control in medical inpatients with type 2 diabetes mellitus receiving sliding scale insulin regimens versus routine diabetes medications: a multicenter randomized controlled trial. Ann Fam Med. 2003;1(1):29-35.
24. Hirsch IB. Insulin analogues. N Engl J Med. January 13, 2005 ;352(2):174-183.
25. DeWitt DE, Hirsch IB. Outpatient insulin therapy in type 1 and type 2 diabetes mellitus: scientific review. JAMA. May 7, 2003;289(17):2254-2264.
26. DAFNE Study Group. Training in flexible, intensive insulin management to enable dietary freedom in people with type 1 diabetes: dose adjustment for normal eating (DAFNE) randomised controlled trial. BMJ. 2002;325(7367):746-752.
27. Genuth S. The automatic (regular insulin) sliding scale, or 2, 4, 6, 8—call H.O. Clinical Diabetes. 1994:40-42.
28. Fischer KF, Lees JA, Newman JH. Hypoglycemia in hospitalized patients. N Engl J Med. 1986;315:1245-1250.
29. Roman SH, Linekin PL, Stagnaro-Green A. An inpatient diabetes QI program. Jt Comm J Qual Improv. 1995;21(2):693-699.
30. Gearhart JG, Duncan JL, Replogle WH, et al. Efficacy of sliding-scale insulin therapy: a comparison with prospective regimens. Fam Pract Res J. 1994;14:313-322.
31. Queale WS, Seidler AJ, Brancati FL. Glycemic control and sliding scale insulin use in medical inpatients with diabetes mellitus. Arch Intern Med. 1997;157(5):545-552.
32. Baldwin D, Villanueva G, McNutt R, et al. Eliminating inpatient sliding-scale insulin: a reeducation project with medical house staff. Diabetes Care. 2005;28(5):1008-1011.
33. Schoeffler JM, Rice DAK, Gresham DG. 70/30 insulin algorithm versus sliding scale insulin. Ann Pharmacother. 2005;39(10):1606-1609.
34. Trence DL, Kelly JL, Hirsch IB. The rationale and management of hyperglycemia for in-patients with cardiovascular disease: time for change. J Clin Endocrinol Metab. 2003;88 2430-2437.
35. Magee MR, Clement S. Subcutaneous insulin therapy in the hospital setting: issues, concerns, and implementation. Endocr Pract. 2004;10 (suppl 2):81-88.
36. Thompson CL, Dunn KC, Menon MC, et al. Hyperglycemia in the hospital. Diabetes Spectr. 2005;18(1):20-27.
37. Campbell KB, Braithwaite SS. Hospital management of hyperglycemia. Clinical Diabetes. April 2004;22(2):81-88.
38. Braithwaite SS, Buie MM, Thompson CL, et al. Hospital hypoglycemia: not only treatment but also prevention. Endocr Pract. 2004;10 (Suppl 2):71-80.
39. Achtmeyer CE, Payne TH, Anawalt BD. Computer order entry system decreased use of sliding scale insulin regimens. Methods Inf Med. 2002;41:277-281.

Many studies have been published in recent years about the effect of hospitalists on outcomes, efficiency, and cost-effectiveness of care (see also “In the Literature,” p. 30). While the studies have demonstrated varying results, the majority suggest that hospitalists contribute positively to care. And the tremendous growth of hospitalist programs nationwide indicates that hospital administrators and others agree.

Does this mean that there have been enough studies about the cost-effectiveness and efficiency of hospitalists, and about outcomes relating to hospitalists? Also, where should hospitalist research go next?

Looking Back

To date, the results of studies regarding hospitalists and their effect on outcomes and cost-effectiveness have varied. Most suggest positive correlations:

• Diamond, Goldberg, and Janosky demonstrated a 54% decrease in hospital readmission rates and shorter LOS when a community teaching hospital implemented full-time faculty hospitalists.1
• Auerbach, Wachter, and colleagues studied 5,308 patients cared for by hospitalists and community physicians at a community teaching hospital. They found that the voluntary hospitalist service reduced lengths of stay and costs that were statistically significant in the second year the services were used.2
• Bellet and Whitaker compared traditional ward service with a hospitalist system of care at a pediatric teaching hospital and found that the average LOS was a day shorter for the patients care for by hospitalists.3
• A review of five years of evidence-based hospitalist studies showed an average 13.4% cost reduction, as well as a 16.6% LOS reduction.4
• Rifkin, et al, compared treatment provided by hospitalist and primary care physicians among patients with community-acquired pneumonia. The authors found that hospitalists’ patients had shorter LOS and reduced costs.5
• Wachter reviewed the data to date in 2002 and concluded that it supported the hypothesis that hospitalists can lead to improved efficiency without compromising patient outcomes or satisfaction.6
• Meltzer, et al, studied costs and outcomes associated with patients on an academic general medical service cared for by hospitalists and non-hospitalists. They found that the average adjusted costs were similar for hospitalists and non-hospitalists in the first year. However, hospitalist costs were reduced by $782 in year two. The authors also concluded that short-term mortality was lower for hospitalists as well, but, again, only in the second year.7
• Auerbach and Pantilat assessed the effects of hospitalists’ care on communication, care patterns, and outcomes of end-of-life patients. They found that hospitalists documented “substantial efforts” to communicate with their dying patients and their families; and this may have resulted in better care.8
• Hauer, et al, analyzed house staff and student evaluations of their attending physicians and internal medicine ward rotations at two university-affiliated teaching hospitals over a two-year period. They found that trainees reported they received more effective teaching and more satisfying inpatient rotations when supervised by hospitalists.9

Studies that “go under the hood and answer questions about the mechanisms by which hospitalists improve outcomes” also will be useful. “Hospitals need to realize that hospitalists aren’t a magic bullet. It’s not as simple as implementing a hospitalist model of care and costs go down.”

—Peter Lindenauer, MD, MSc

A few studies have indicated that hospitalists may have less impact on costs and outcomes. Among them:

• Smith, Westfall, and Nicholas performed a retrospective chart review of HMO critical care patients and found that the mean charge by primary care physicians ($5,680) was significantly lower than that of the hospitalists ($7,699). The authors suggested that “claims of better and cheaper care by hospitalists need further investigation” and that HMOs should not mandate the use of hospitalists.10
• Kearns, et al, compared clinical outcomes and care costs for patients treated by hospital- and clinic-based attending physicians. The researchers detected no difference in costs or clinical outcomes associated with either type of physician.11

Clearly, the majority of the studies suggest that hospitalists have a positive effect on outcomes, effectiveness, and/or costs. But can the research take credit for the growing popularity of hospitalists?

“The studies have gone a long way toward proving the value of hospitalist care. But the experiences of physicians and hospitals also have been very positive,” says Robert Wachter, MD, FACP, professor of medicine at the University of California, San Francisco, associate chairman of UCSF’s Department of Medicine, and chief of the Medical Service at UCSF Medical Center. He adds that the studies wouldn’t mean much if the experiences of hospitals didn’t back up their findings.

So what has been learned from hospitalist studies on costs and outcomes to date? The data “suggest that hospitalists have the greatest impact on efficiency,” says Dr. Wachter, in part because “it is much easier to measure lengths of stay than improvements in outcomes.” He states that data are “strong on cost-effectiveness and reducing lengths of stay.”

Dr. Wachter says that the greatest effect of hospitalist studies to date has been “the presence of a very large number of energetic, enthusiastic physicians who ‘live’ in the hospital and have embraced the notion that they are there not only to improve care but to benefit the hospital and contribute to making it a better place. We have seen hospitalists emerge as leaders on virtually every committee aimed at improving care.”

Peter Lindenauer, MD, MSc, a hospitalist at Baystate Medical Center in Springfield, Mass., and assistant professor of medicine at Tufts University School of Medical School, Boston, agrees.

“What’s been most astounding has been the growth of the field,” he says. “And one of the more interesting facets has been the extent to which hospitalists have fully integrated themselves into every aspect of hospital operations and care in a short period of time.

“It is now rare to find hospitals that do not have hospitalists,” continues Dr. Lindenauer. “It also is uncommon to see quality improvement, patient safety, patient satisfaction, and other activities at the hospital that don’t have a hospitalist as a key member.”

Nonetheless, there is always room for improvement. While the data “are quite clear that efficiency improves without harming quality, they are not strong enough to show definitively that hospitalists improve quality and safety,” cautions Dr. Wachter. “We need more data on this.”

He cautions that data involving mature hospitalist programs may not show the same increases in efficiency as studies about new or young programs. He refers to a study coming out next year that looks at six academic medical centers and mature hospitalists programs and doesn’t show the same increase in efficiency as earlier studies.

“It may be natural that some efficiency may wash away. As hospitalists become more dominant, they set the practice style and standards for their hospitals,” he says. “We need to continue to look for ways to improve.” However, he stresses that none of this takes away from the original argument that hospitalists improve efficiency.

The Next Generation of Hospitalist Studies

Dr. Wachter suggests that the next generation of hospitalist research will have greater impact and importance if it goes beyond examining efficiency and cost-effectiveness.

“I don’t think the studies we began years ago are very interesting anymore, and I don’t think the system is looking for more of them,” he says. Now, research needs to look at the role of hospitalists—the role of hospitalists in teaching hospitals, what physicians make the best hospitalists, and so on.

Dr. Lindenauer would like to see more studies about hospitalists’ impact on quality of care. “There remains a relative paucity of information on this,” he says. “To date, there have been mostly small observational studies on this.” There is a need “to learn more about the impact of hospitalists, especially on more clinical outcomes and quality.”

Studies that “go under the hood and answer questions about the mechanisms by which hospitalists improve outcomes” also will be useful predicts Dr. Lindenauer. “Hospitals need to realize that hospitalists aren’t a magic bullet. It’s not as simple as implementing a hospitalist model of care and costs go down.”

Results of such studies need to be shared with hospitals nationwide so they can make the best and most effective use of hospitalists.

Studies addressing hospitalists working in specialty areas also are likely to become more common in the future, says Michael Phy, DO, MSC, associate program director and assistant professor at Texas Tech University Health Sciences Center in Austin, Texas. Earlier this year, he and his colleagues published a study looking at the hospitalist’s impact on geriatric surgical patients.12 During a two-year period, Dr. Phy and his team studied 466 elderly patients admitted to a hospital for surgical repair of a hip fracture. They found that a hospitalist model decreased the time to surgery, as well as the time from surgery to discharge, without adversely affecting mortality.

Dr. Phy’s study has interested other hospitals around the country. “We’ve been invited to speak on the model. People want to know how we did it, what the flaws were,” he explains. “The say that they are interested in using this kind of model, and they want to learn how to do it.

“I would like to see more studies about patient satisfaction and hospitalists,” says Dr. Phy. He also thinks that more studies about the impact of hospitalists on resident education will be useful. “There are a lot of studies about hospitalist involvement with residents; I am more interested in hospitalist’s indirect impact on residents. Does resident education improve when they are not so overworked because they have hospitalists who help provide patient care?”

In contrast, David Meltzer, MD, PhD, a hospitalist and an associate professor of medicine, General Internal Medicine, at the University of Chicago, doesn’t see patient satisfaction as a priority for the future. “Patient satisfaction isn’t an unreasonable thing to study,” he asserts. “But I personally don’t think that this is the most important issue.

“I don’t know what future studies will look like. I would like to say that we will see more and bigger studies,” continues Dr. Meltzer. “I also think we’ll see more studies about hospitalists in the community environment, more studies on mechanisms, and more hospitalists doing research on hospital care.”

To date, “hospitalist studies have been messy and ask the wrong questions,” says Robert Centor, MD, director of the Division of Internal Medicine, professor of internal medicine, and associate dean at the Huntsville Regional Medical Center in Alabama. He suggests that future studies should “look at hospitalists as a function of years of experience—first-year hospitalists compared to second, third, and forth.” Another useful focus would be to compare hospitalists with non-hospitalists, looking at “volume and lengths of stay and where the curve straightens out.”

Hurdling the Barriers

Especially as they get larger and involve more facilities, hospitalist studies will face some challenges. “Different people define hospitalists in different ways. It’s hard to tell what definitions studies are using; so in looking at two studies or trying to compare a study to what is happening at your facility, you don’t know if you’re comparing apples to apples or apples to oranges,” says Dr. Centor.

The nature of studies addressing hospitalist quality also poses some challenges. “Quality improvement interventions are harder to measure and are more institutionally dependent. Results can’t necessarily be translated from one institution to another,” explains Dr. Lindenauer.

He suggests that identifying funding sources for hospitalist studies will be an ongoing challenge. Researchers will be competing for an already shrinking number of dollars.

“The funding base for producing knowledge is limited, especially for studies that are not intrinsically disease-focused,” agrees Dr. Meltzer.

There is some organizational support for hospitalist researchers. For example, Dr. Phy notes that the SHM Web site will soon have a page where “you can list yourself and your clinical research interests, with the goal of hooking up with collaborators or mentors.”

The Third Generation

“At a certain point, we will turn our attention away from ‘navel gazing’—constantly assessing our impact—and accept that the hospitalist model is here to stay. Then hospitalists will begin to conduct research about the management of common conditions we take care of on a day-to-day basis—asthma, pneumonia, heart failure, COPD, and so on,” says Dr. Lindenauer. This is the third generation of hospitalist research, he suggests, adding, “This is where I would like to see the field evolve.” TH

Contributing Writer Joanne Kaldy wrote about psychiatric hospitalists in the October 2005 issue.

References

1. Diamond HS, Goldberg E, Janosky JE. The effect of full-time faculty hospitalists on the efficiency of care at a community teaching hospital. Ann Intern Med. 1999;130:338-342.
2. Auerbach AD, Wachter RM, Katz P, et al. Implementation of a voluntary hospitalist service at a community teaching hospital: improved clinical efficiency and patient outcomes. Ann Intern Med. 2002:137;859-865.
3. Bellet PS, Whitaker RC. Evaluation of a pediatric hospitalist service: impact on length of stay and hospital charges. Pediatrics. 2000;105(3):478-484.
4. No author listed. Hospitalist prove their worth for capitated providers, plans. Capitation Manag Rep. 2002;Apr;9(4):62-64, 49.
5. Rifkin WD, Conner D, Silver A, et al. Comparison of processes and outcomes of pneumonia care between hospitalists and community-based primary care physicians. Mayo Clin Proc. 2002;77(10):1053-1058.
6. Wachter RM. The evolution of the hospitalist model in the United States. Med Clin North Am. 2002;86(4):687-706.
7. Meltzer D, Manning WG, Morrison J, et al. Effects of physician experience on costs and outcomes on an academic general medicine service: results of a trial of hospitalists. Ann Intern Med. 2002;137:866-874.
8. Auerbach AD, Pantilat SZ. End-of-life care in a voluntary hospitalist model: effects on communication, processes of care, and patient symptoms. Am J Med. 2004;116(10):669-675.
9. Hauer KE, Wachter RM, McCulloch CE, et al. Effects of hospitalist attending physicians on trainee satisfaction with teaching and with internal medicine rotations. Arch Intern Med. 2004;164(17):1866-1871.
10. Smith PC, Westfall JM, Nicholas RA. Primary care family physicians and two hospitalist models: comparison of outcomes, processes, and costs. J Fam Pract. 2002;51:1021-1027.
11. Kearns PJ, Wang CC, Morris WJ, et al. Hospital care by hospital-based and clinic-based faculty: a prospective, controlled trial. Arch Intern Med. 2001;161:235-241.

Many studies have been published in recent years about the effect of hospitalists on outcomes, efficiency, and cost-effectiveness of care (see also “In the Literature,” p. 30). While the studies have demonstrated varying results, the majority suggest that hospitalists contribute positively to care. And the tremendous growth of hospitalist programs nationwide indicates that hospital administrators and others agree.

Does this mean that there have been enough studies about the cost-effectiveness and efficiency of hospitalists, and about outcomes relating to hospitalists? Also, where should hospitalist research go next?

Looking Back

To date, the results of studies regarding hospitalists and their effect on outcomes and cost-effectiveness have varied. Most suggest positive correlations:

• Diamond, Goldberg, and Janosky demonstrated a 54% decrease in hospital readmission rates and shorter LOS when a community teaching hospital implemented full-time faculty hospitalists.1
• Auerbach, Wachter, and colleagues studied 5,308 patients cared for by hospitalists and community physicians at a community teaching hospital. They found that the voluntary hospitalist service reduced lengths of stay and costs that were statistically significant in the second year the services were used.2
• Bellet and Whitaker compared traditional ward service with a hospitalist system of care at a pediatric teaching hospital and found that the average LOS was a day shorter for the patients care for by hospitalists.3
• A review of five years of evidence-based hospitalist studies showed an average 13.4% cost reduction, as well as a 16.6% LOS reduction.4
• Rifkin, et al, compared treatment provided by hospitalist and primary care physicians among patients with community-acquired pneumonia. The authors found that hospitalists’ patients had shorter LOS and reduced costs.5
• Wachter reviewed the data to date in 2002 and concluded that it supported the hypothesis that hospitalists can lead to improved efficiency without compromising patient outcomes or satisfaction.6
• Meltzer, et al, studied costs and outcomes associated with patients on an academic general medical service cared for by hospitalists and non-hospitalists. They found that the average adjusted costs were similar for hospitalists and non-hospitalists in the first year. However, hospitalist costs were reduced by $782 in year two. The authors also concluded that short-term mortality was lower for hospitalists as well, but, again, only in the second year.7
• Auerbach and Pantilat assessed the effects of hospitalists’ care on communication, care patterns, and outcomes of end-of-life patients. They found that hospitalists documented “substantial efforts” to communicate with their dying patients and their families; and this may have resulted in better care.8
• Hauer, et al, analyzed house staff and student evaluations of their attending physicians and internal medicine ward rotations at two university-affiliated teaching hospitals over a two-year period. They found that trainees reported they received more effective teaching and more satisfying inpatient rotations when supervised by hospitalists.9

Studies that “go under the hood and answer questions about the mechanisms by which hospitalists improve outcomes” also will be useful. “Hospitals need to realize that hospitalists aren’t a magic bullet. It’s not as simple as implementing a hospitalist model of care and costs go down.”

—Peter Lindenauer, MD, MSc

A few studies have indicated that hospitalists may have less impact on costs and outcomes. Among them:

• Smith, Westfall, and Nicholas performed a retrospective chart review of HMO critical care patients and found that the mean charge by primary care physicians ($5,680) was significantly lower than that of the hospitalists ($7,699). The authors suggested that “claims of better and cheaper care by hospitalists need further investigation” and that HMOs should not mandate the use of hospitalists.10
• Kearns, et al, compared clinical outcomes and care costs for patients treated by hospital- and clinic-based attending physicians. The researchers detected no difference in costs or clinical outcomes associated with either type of physician.11

Clearly, the majority of the studies suggest that hospitalists have a positive effect on outcomes, effectiveness, and/or costs. But can the research take credit for the growing popularity of hospitalists?

“The studies have gone a long way toward proving the value of hospitalist care. But the experiences of physicians and hospitals also have been very positive,” says Robert Wachter, MD, FACP, professor of medicine at the University of California, San Francisco, associate chairman of UCSF’s Department of Medicine, and chief of the Medical Service at UCSF Medical Center. He adds that the studies wouldn’t mean much if the experiences of hospitals didn’t back up their findings.

So what has been learned from hospitalist studies on costs and outcomes to date? The data “suggest that hospitalists have the greatest impact on efficiency,” says Dr. Wachter, in part because “it is much easier to measure lengths of stay than improvements in outcomes.” He states that data are “strong on cost-effectiveness and reducing lengths of stay.”

Dr. Wachter says that the greatest effect of hospitalist studies to date has been “the presence of a very large number of energetic, enthusiastic physicians who ‘live’ in the hospital and have embraced the notion that they are there not only to improve care but to benefit the hospital and contribute to making it a better place. We have seen hospitalists emerge as leaders on virtually every committee aimed at improving care.”

Peter Lindenauer, MD, MSc, a hospitalist at Baystate Medical Center in Springfield, Mass., and assistant professor of medicine at Tufts University School of Medical School, Boston, agrees.

“What’s been most astounding has been the growth of the field,” he says. “And one of the more interesting facets has been the extent to which hospitalists have fully integrated themselves into every aspect of hospital operations and care in a short period of time.

“It is now rare to find hospitals that do not have hospitalists,” continues Dr. Lindenauer. “It also is uncommon to see quality improvement, patient safety, patient satisfaction, and other activities at the hospital that don’t have a hospitalist as a key member.”

Nonetheless, there is always room for improvement. While the data “are quite clear that efficiency improves without harming quality, they are not strong enough to show definitively that hospitalists improve quality and safety,” cautions Dr. Wachter. “We need more data on this.”

He cautions that data involving mature hospitalist programs may not show the same increases in efficiency as studies about new or young programs. He refers to a study coming out next year that looks at six academic medical centers and mature hospitalists programs and doesn’t show the same increase in efficiency as earlier studies.

“It may be natural that some efficiency may wash away. As hospitalists become more dominant, they set the practice style and standards for their hospitals,” he says. “We need to continue to look for ways to improve.” However, he stresses that none of this takes away from the original argument that hospitalists improve efficiency.

The Next Generation of Hospitalist Studies

Dr. Wachter suggests that the next generation of hospitalist research will have greater impact and importance if it goes beyond examining efficiency and cost-effectiveness.

“I don’t think the studies we began years ago are very interesting anymore, and I don’t think the system is looking for more of them,” he says. Now, research needs to look at the role of hospitalists—the role of hospitalists in teaching hospitals, what physicians make the best hospitalists, and so on.

Dr. Lindenauer would like to see more studies about hospitalists’ impact on quality of care. “There remains a relative paucity of information on this,” he says. “To date, there have been mostly small observational studies on this.” There is a need “to learn more about the impact of hospitalists, especially on more clinical outcomes and quality.”

Studies that “go under the hood and answer questions about the mechanisms by which hospitalists improve outcomes” also will be useful predicts Dr. Lindenauer. “Hospitals need to realize that hospitalists aren’t a magic bullet. It’s not as simple as implementing a hospitalist model of care and costs go down.”

Results of such studies need to be shared with hospitals nationwide so they can make the best and most effective use of hospitalists.

Studies addressing hospitalists working in specialty areas also are likely to become more common in the future, says Michael Phy, DO, MSC, associate program director and assistant professor at Texas Tech University Health Sciences Center in Austin, Texas. Earlier this year, he and his colleagues published a study looking at the hospitalist’s impact on geriatric surgical patients.12 During a two-year period, Dr. Phy and his team studied 466 elderly patients admitted to a hospital for surgical repair of a hip fracture. They found that a hospitalist model decreased the time to surgery, as well as the time from surgery to discharge, without adversely affecting mortality.

Dr. Phy’s study has interested other hospitals around the country. “We’ve been invited to speak on the model. People want to know how we did it, what the flaws were,” he explains. “The say that they are interested in using this kind of model, and they want to learn how to do it.

“I would like to see more studies about patient satisfaction and hospitalists,” says Dr. Phy. He also thinks that more studies about the impact of hospitalists on resident education will be useful. “There are a lot of studies about hospitalist involvement with residents; I am more interested in hospitalist’s indirect impact on residents. Does resident education improve when they are not so overworked because they have hospitalists who help provide patient care?”

In contrast, David Meltzer, MD, PhD, a hospitalist and an associate professor of medicine, General Internal Medicine, at the University of Chicago, doesn’t see patient satisfaction as a priority for the future. “Patient satisfaction isn’t an unreasonable thing to study,” he asserts. “But I personally don’t think that this is the most important issue.

“I don’t know what future studies will look like. I would like to say that we will see more and bigger studies,” continues Dr. Meltzer. “I also think we’ll see more studies about hospitalists in the community environment, more studies on mechanisms, and more hospitalists doing research on hospital care.”

To date, “hospitalist studies have been messy and ask the wrong questions,” says Robert Centor, MD, director of the Division of Internal Medicine, professor of internal medicine, and associate dean at the Huntsville Regional Medical Center in Alabama. He suggests that future studies should “look at hospitalists as a function of years of experience—first-year hospitalists compared to second, third, and forth.” Another useful focus would be to compare hospitalists with non-hospitalists, looking at “volume and lengths of stay and where the curve straightens out.”

Hurdling the Barriers

Especially as they get larger and involve more facilities, hospitalist studies will face some challenges. “Different people define hospitalists in different ways. It’s hard to tell what definitions studies are using; so in looking at two studies or trying to compare a study to what is happening at your facility, you don’t know if you’re comparing apples to apples or apples to oranges,” says Dr. Centor.

The nature of studies addressing hospitalist quality also poses some challenges. “Quality improvement interventions are harder to measure and are more institutionally dependent. Results can’t necessarily be translated from one institution to another,” explains Dr. Lindenauer.

He suggests that identifying funding sources for hospitalist studies will be an ongoing challenge. Researchers will be competing for an already shrinking number of dollars.

“The funding base for producing knowledge is limited, especially for studies that are not intrinsically disease-focused,” agrees Dr. Meltzer.

There is some organizational support for hospitalist researchers. For example, Dr. Phy notes that the SHM Web site will soon have a page where “you can list yourself and your clinical research interests, with the goal of hooking up with collaborators or mentors.”

The Third Generation

“At a certain point, we will turn our attention away from ‘navel gazing’—constantly assessing our impact—and accept that the hospitalist model is here to stay. Then hospitalists will begin to conduct research about the management of common conditions we take care of on a day-to-day basis—asthma, pneumonia, heart failure, COPD, and so on,” says Dr. Lindenauer. This is the third generation of hospitalist research, he suggests, adding, “This is where I would like to see the field evolve.” TH

Contributing Writer Joanne Kaldy wrote about psychiatric hospitalists in the October 2005 issue.

References

1. Diamond HS, Goldberg E, Janosky JE. The effect of full-time faculty hospitalists on the efficiency of care at a community teaching hospital. Ann Intern Med. 1999;130:338-342.
2. Auerbach AD, Wachter RM, Katz P, et al. Implementation of a voluntary hospitalist service at a community teaching hospital: improved clinical efficiency and patient outcomes. Ann Intern Med. 2002:137;859-865.
3. Bellet PS, Whitaker RC. Evaluation of a pediatric hospitalist service: impact on length of stay and hospital charges. Pediatrics. 2000;105(3):478-484.
4. No author listed. Hospitalist prove their worth for capitated providers, plans. Capitation Manag Rep. 2002;Apr;9(4):62-64, 49.
5. Rifkin WD, Conner D, Silver A, et al. Comparison of processes and outcomes of pneumonia care between hospitalists and community-based primary care physicians. Mayo Clin Proc. 2002;77(10):1053-1058.
6. Wachter RM. The evolution of the hospitalist model in the United States. Med Clin North Am. 2002;86(4):687-706.
7. Meltzer D, Manning WG, Morrison J, et al. Effects of physician experience on costs and outcomes on an academic general medicine service: results of a trial of hospitalists. Ann Intern Med. 2002;137:866-874.
8. Auerbach AD, Pantilat SZ. End-of-life care in a voluntary hospitalist model: effects on communication, processes of care, and patient symptoms. Am J Med. 2004;116(10):669-675.
9. Hauer KE, Wachter RM, McCulloch CE, et al. Effects of hospitalist attending physicians on trainee satisfaction with teaching and with internal medicine rotations. Arch Intern Med. 2004;164(17):1866-1871.
10. Smith PC, Westfall JM, Nicholas RA. Primary care family physicians and two hospitalist models: comparison of outcomes, processes, and costs. J Fam Pract. 2002;51:1021-1027.
11. Kearns PJ, Wang CC, Morris WJ, et al. Hospital care by hospital-based and clinic-based faculty: a prospective, controlled trial. Arch Intern Med. 2001;161:235-241.

Many studies have been published in recent years about the effect of hospitalists on outcomes, efficiency, and cost-effectiveness of care (see also “In the Literature,” p. 30). While the studies have demonstrated varying results, the majority suggest that hospitalists contribute positively to care. And the tremendous growth of hospitalist programs nationwide indicates that hospital administrators and others agree.

Does this mean that there have been enough studies about the cost-effectiveness and efficiency of hospitalists, and about outcomes relating to hospitalists? Also, where should hospitalist research go next?

Looking Back

To date, the results of studies regarding hospitalists and their effect on outcomes and cost-effectiveness have varied. Most suggest positive correlations:

• Diamond, Goldberg, and Janosky demonstrated a 54% decrease in hospital readmission rates and shorter LOS when a community teaching hospital implemented full-time faculty hospitalists.1
• Auerbach, Wachter, and colleagues studied 5,308 patients cared for by hospitalists and community physicians at a community teaching hospital. They found that the voluntary hospitalist service reduced lengths of stay and costs that were statistically significant in the second year the services were used.2
• Bellet and Whitaker compared traditional ward service with a hospitalist system of care at a pediatric teaching hospital and found that the average LOS was a day shorter for the patients care for by hospitalists.3
• A review of five years of evidence-based hospitalist studies showed an average 13.4% cost reduction, as well as a 16.6% LOS reduction.4
• Rifkin, et al, compared treatment provided by hospitalist and primary care physicians among patients with community-acquired pneumonia. The authors found that hospitalists’ patients had shorter LOS and reduced costs.5
• Wachter reviewed the data to date in 2002 and concluded that it supported the hypothesis that hospitalists can lead to improved efficiency without compromising patient outcomes or satisfaction.6
• Meltzer, et al, studied costs and outcomes associated with patients on an academic general medical service cared for by hospitalists and non-hospitalists. They found that the average adjusted costs were similar for hospitalists and non-hospitalists in the first year. However, hospitalist costs were reduced by $782 in year two. The authors also concluded that short-term mortality was lower for hospitalists as well, but, again, only in the second year.7
• Auerbach and Pantilat assessed the effects of hospitalists’ care on communication, care patterns, and outcomes of end-of-life patients. They found that hospitalists documented “substantial efforts” to communicate with their dying patients and their families; and this may have resulted in better care.8
• Hauer, et al, analyzed house staff and student evaluations of their attending physicians and internal medicine ward rotations at two university-affiliated teaching hospitals over a two-year period. They found that trainees reported they received more effective teaching and more satisfying inpatient rotations when supervised by hospitalists.9

Studies that “go under the hood and answer questions about the mechanisms by which hospitalists improve outcomes” also will be useful. “Hospitals need to realize that hospitalists aren’t a magic bullet. It’s not as simple as implementing a hospitalist model of care and costs go down.”

—Peter Lindenauer, MD, MSc

A few studies have indicated that hospitalists may have less impact on costs and outcomes. Among them:

• Smith, Westfall, and Nicholas performed a retrospective chart review of HMO critical care patients and found that the mean charge by primary care physicians ($5,680) was significantly lower than that of the hospitalists ($7,699). The authors suggested that “claims of better and cheaper care by hospitalists need further investigation” and that HMOs should not mandate the use of hospitalists.10
• Kearns, et al, compared clinical outcomes and care costs for patients treated by hospital- and clinic-based attending physicians. The researchers detected no difference in costs or clinical outcomes associated with either type of physician.11

Clearly, the majority of the studies suggest that hospitalists have a positive effect on outcomes, effectiveness, and/or costs. But can the research take credit for the growing popularity of hospitalists?

“The studies have gone a long way toward proving the value of hospitalist care. But the experiences of physicians and hospitals also have been very positive,” says Robert Wachter, MD, FACP, professor of medicine at the University of California, San Francisco, associate chairman of UCSF’s Department of Medicine, and chief of the Medical Service at UCSF Medical Center. He adds that the studies wouldn’t mean much if the experiences of hospitals didn’t back up their findings.

So what has been learned from hospitalist studies on costs and outcomes to date? The data “suggest that hospitalists have the greatest impact on efficiency,” says Dr. Wachter, in part because “it is much easier to measure lengths of stay than improvements in outcomes.” He states that data are “strong on cost-effectiveness and reducing lengths of stay.”

Dr. Wachter says that the greatest effect of hospitalist studies to date has been “the presence of a very large number of energetic, enthusiastic physicians who ‘live’ in the hospital and have embraced the notion that they are there not only to improve care but to benefit the hospital and contribute to making it a better place. We have seen hospitalists emerge as leaders on virtually every committee aimed at improving care.”

Peter Lindenauer, MD, MSc, a hospitalist at Baystate Medical Center in Springfield, Mass., and assistant professor of medicine at Tufts University School of Medical School, Boston, agrees.

“What’s been most astounding has been the growth of the field,” he says. “And one of the more interesting facets has been the extent to which hospitalists have fully integrated themselves into every aspect of hospital operations and care in a short period of time.

“It is now rare to find hospitals that do not have hospitalists,” continues Dr. Lindenauer. “It also is uncommon to see quality improvement, patient safety, patient satisfaction, and other activities at the hospital that don’t have a hospitalist as a key member.”

Nonetheless, there is always room for improvement. While the data “are quite clear that efficiency improves without harming quality, they are not strong enough to show definitively that hospitalists improve quality and safety,” cautions Dr. Wachter. “We need more data on this.”

He cautions that data involving mature hospitalist programs may not show the same increases in efficiency as studies about new or young programs. He refers to a study coming out next year that looks at six academic medical centers and mature hospitalists programs and doesn’t show the same increase in efficiency as earlier studies.

“It may be natural that some efficiency may wash away. As hospitalists become more dominant, they set the practice style and standards for their hospitals,” he says. “We need to continue to look for ways to improve.” However, he stresses that none of this takes away from the original argument that hospitalists improve efficiency.

The Next Generation of Hospitalist Studies

Dr. Wachter suggests that the next generation of hospitalist research will have greater impact and importance if it goes beyond examining efficiency and cost-effectiveness.

“I don’t think the studies we began years ago are very interesting anymore, and I don’t think the system is looking for more of them,” he says. Now, research needs to look at the role of hospitalists—the role of hospitalists in teaching hospitals, what physicians make the best hospitalists, and so on.

Dr. Lindenauer would like to see more studies about hospitalists’ impact on quality of care. “There remains a relative paucity of information on this,” he says. “To date, there have been mostly small observational studies on this.” There is a need “to learn more about the impact of hospitalists, especially on more clinical outcomes and quality.”

Studies that “go under the hood and answer questions about the mechanisms by which hospitalists improve outcomes” also will be useful predicts Dr. Lindenauer. “Hospitals need to realize that hospitalists aren’t a magic bullet. It’s not as simple as implementing a hospitalist model of care and costs go down.”

Results of such studies need to be shared with hospitals nationwide so they can make the best and most effective use of hospitalists.

Studies addressing hospitalists working in specialty areas also are likely to become more common in the future, says Michael Phy, DO, MSC, associate program director and assistant professor at Texas Tech University Health Sciences Center in Austin, Texas. Earlier this year, he and his colleagues published a study looking at the hospitalist’s impact on geriatric surgical patients.12 During a two-year period, Dr. Phy and his team studied 466 elderly patients admitted to a hospital for surgical repair of a hip fracture. They found that a hospitalist model decreased the time to surgery, as well as the time from surgery to discharge, without adversely affecting mortality.

Dr. Phy’s study has interested other hospitals around the country. “We’ve been invited to speak on the model. People want to know how we did it, what the flaws were,” he explains. “The say that they are interested in using this kind of model, and they want to learn how to do it.

“I would like to see more studies about patient satisfaction and hospitalists,” says Dr. Phy. He also thinks that more studies about the impact of hospitalists on resident education will be useful. “There are a lot of studies about hospitalist involvement with residents; I am more interested in hospitalist’s indirect impact on residents. Does resident education improve when they are not so overworked because they have hospitalists who help provide patient care?”

In contrast, David Meltzer, MD, PhD, a hospitalist and an associate professor of medicine, General Internal Medicine, at the University of Chicago, doesn’t see patient satisfaction as a priority for the future. “Patient satisfaction isn’t an unreasonable thing to study,” he asserts. “But I personally don’t think that this is the most important issue.

“I don’t know what future studies will look like. I would like to say that we will see more and bigger studies,” continues Dr. Meltzer. “I also think we’ll see more studies about hospitalists in the community environment, more studies on mechanisms, and more hospitalists doing research on hospital care.”

To date, “hospitalist studies have been messy and ask the wrong questions,” says Robert Centor, MD, director of the Division of Internal Medicine, professor of internal medicine, and associate dean at the Huntsville Regional Medical Center in Alabama. He suggests that future studies should “look at hospitalists as a function of years of experience—first-year hospitalists compared to second, third, and forth.” Another useful focus would be to compare hospitalists with non-hospitalists, looking at “volume and lengths of stay and where the curve straightens out.”

Hurdling the Barriers

Especially as they get larger and involve more facilities, hospitalist studies will face some challenges. “Different people define hospitalists in different ways. It’s hard to tell what definitions studies are using; so in looking at two studies or trying to compare a study to what is happening at your facility, you don’t know if you’re comparing apples to apples or apples to oranges,” says Dr. Centor.

The nature of studies addressing hospitalist quality also poses some challenges. “Quality improvement interventions are harder to measure and are more institutionally dependent. Results can’t necessarily be translated from one institution to another,” explains Dr. Lindenauer.

He suggests that identifying funding sources for hospitalist studies will be an ongoing challenge. Researchers will be competing for an already shrinking number of dollars.

“The funding base for producing knowledge is limited, especially for studies that are not intrinsically disease-focused,” agrees Dr. Meltzer.

There is some organizational support for hospitalist researchers. For example, Dr. Phy notes that the SHM Web site will soon have a page where “you can list yourself and your clinical research interests, with the goal of hooking up with collaborators or mentors.”

The Third Generation

“At a certain point, we will turn our attention away from ‘navel gazing’—constantly assessing our impact—and accept that the hospitalist model is here to stay. Then hospitalists will begin to conduct research about the management of common conditions we take care of on a day-to-day basis—asthma, pneumonia, heart failure, COPD, and so on,” says Dr. Lindenauer. This is the third generation of hospitalist research, he suggests, adding, “This is where I would like to see the field evolve.” TH

Contributing Writer Joanne Kaldy wrote about psychiatric hospitalists in the October 2005 issue.

References

1. Diamond HS, Goldberg E, Janosky JE. The effect of full-time faculty hospitalists on the efficiency of care at a community teaching hospital. Ann Intern Med. 1999;130:338-342.
2. Auerbach AD, Wachter RM, Katz P, et al. Implementation of a voluntary hospitalist service at a community teaching hospital: improved clinical efficiency and patient outcomes. Ann Intern Med. 2002:137;859-865.
3. Bellet PS, Whitaker RC. Evaluation of a pediatric hospitalist service: impact on length of stay and hospital charges. Pediatrics. 2000;105(3):478-484.
4. No author listed. Hospitalist prove their worth for capitated providers, plans. Capitation Manag Rep. 2002;Apr;9(4):62-64, 49.
5. Rifkin WD, Conner D, Silver A, et al. Comparison of processes and outcomes of pneumonia care between hospitalists and community-based primary care physicians. Mayo Clin Proc. 2002;77(10):1053-1058.
6. Wachter RM. The evolution of the hospitalist model in the United States. Med Clin North Am. 2002;86(4):687-706.
7. Meltzer D, Manning WG, Morrison J, et al. Effects of physician experience on costs and outcomes on an academic general medicine service: results of a trial of hospitalists. Ann Intern Med. 2002;137:866-874.
8. Auerbach AD, Pantilat SZ. End-of-life care in a voluntary hospitalist model: effects on communication, processes of care, and patient symptoms. Am J Med. 2004;116(10):669-675.
9. Hauer KE, Wachter RM, McCulloch CE, et al. Effects of hospitalist attending physicians on trainee satisfaction with teaching and with internal medicine rotations. Arch Intern Med. 2004;164(17):1866-1871.
10. Smith PC, Westfall JM, Nicholas RA. Primary care family physicians and two hospitalist models: comparison of outcomes, processes, and costs. J Fam Pract. 2002;51:1021-1027.
11. Kearns PJ, Wang CC, Morris WJ, et al. Hospital care by hospital-based and clinic-based faculty: a prospective, controlled trial. Arch Intern Med. 2001;161:235-241.

A61-year-old farmer from Iowa with a medical history significant for non-Hodgkin’s lymphoma in remission presented for evaluation and treatment of two ulcerating lesions, located on his left forearm and left thigh of two months’ duration. He denied a history of pulmonary symptoms, fever, or unintentional weight loss. Physical examination was negative for lymphadenopathy or splenomegaly. Two large, beefy hyperkeratotic plaques with an underlying border with pustules were noted. The lesion shown is on the left lateral leg and is 5.3 x 4.0 cm.

What is your diagnosis:

1. Cutaneous sarcoidosis;
2. Recurrent lymphoma with skin metastasis;
3. Blastomycosis;
4. Pyoderma gangrenosum; or
5. Anthrax.

Discussion

The answer is C: blastomycosis. A pathology specimen from a left arm skin punch biopsy was read as pseudoepitheliomatous hyperplasia, dermal abscess, and broad-based yeast organisms suggestive of blastomycosis. Fungal cultures grew a white-like colony of hyphae suggestive of blastomycosis. DNA probe was positive for blastomycosis dermatitidis. Interestingly, his fungal serologies were negative. The patient was started on itraconazole 200 mg twice daily.

Blastomycosis typically presents in one of two ways:

1. Pulmonary infection and/or
2. Cutaneous infection.

Typically, the spores of Blastomyces dermatitidis are inhaled from the soil, decomposed vegetation, or rotting wood, and the respiratory system is the first site of infection. Occupations with frequent outdoor exposure in highly endemic areas (including the southeastern states of the United States) connote increased risk. Case series have documented inoculation arising after outdoor activities in the woods near water sources.

Although pulmonary infection is subclinical in 50% of inhalational cases, one study found that pulmonary manifestations were present in 154 of 170 cases (91%) with cough (90%), fever (75%), night sweats (68%), weight loss (66%), chest pain (63%), dyspnea (54%), and aches (50%). Therefore, respiratory symptoms may signal the disease.

According to another review of 100 cases in an endemic area, pulmonary blastomycosis should be considered for any pulmonary infiltrate, especially in the upper lobes. For this patient, because there were no pulmonary symptoms or cutaneous trauma, the most likely etiology is via hematogenous spread. However, whereas the chest radiograph did not show classic signs of blastomycosis (one or more densely consolidated areas of pneumonia or nodular infiltrates), it did show slight fibrosis and pleural thickenings in the apices that is occasionally associated with blastomycosis infection.

As in this case, a presenting cutaneous lesion may be the first sign of disease. The cutaneous findings are usually the result of hematogenous spread; however, uncommon primary cutaneous blastomycosis can occur after direct inoculation from trauma to the skin. Classically, they are described as well-demarcated papulopustules and verrucous plaques with central scarring and black crusting. But the skin lesions can present in many forms and often confound the differential diagnosis. Other cutaneous infectious etiologies include verrucae, nocardiosis, cutaneous tuberculosis, and other dimorphic fungi. However, other dimorphic fungi are less likely to infect the skin. Inflammatory conditions, such as pyoderma gangrenosum and sarcoidosis, must be considered. Ulcerating squamous cell carcinoma is also a consideration.

Blastomycosis is recognized histologically by its broad-based budding and thick, double-contoured walls of the yeast forms found at body temperature (37º C) while it grows as tan or white mold at room temperature. Cultures can be drawn from sputum, pus, or urine. Severe disease often requires systemic antifungal treatment, whereas more moderate to mild disease can be treated topically. TH

References

1. Baumgardner DJ, Halsmer SE, Eagan G. Symptoms of pulmonary blastomycosis: northern Wisconsin, United States. Wilderness Environ Med. 2004;15:250-256.
2. Patel RG, Patel B, Petrini MF, et al. Clinical presentation, radiographic findings, and diagnostic methods of pulmonary blastomycosis: a review of 100 consecutive cases. South Med J. 1999;92:289-295.
3. Bolognia J, ed. Dermatology. Barcelona, Spain: Mosby; 2003.
4. Kasper DL, ed. Harrison’s Online Principles of Internal Medicine. 16th ed. New York: McGraw-Hill; 2005.

A61-year-old farmer from Iowa with a medical history significant for non-Hodgkin’s lymphoma in remission presented for evaluation and treatment of two ulcerating lesions, located on his left forearm and left thigh of two months’ duration. He denied a history of pulmonary symptoms, fever, or unintentional weight loss. Physical examination was negative for lymphadenopathy or splenomegaly. Two large, beefy hyperkeratotic plaques with an underlying border with pustules were noted. The lesion shown is on the left lateral leg and is 5.3 x 4.0 cm.

What is your diagnosis:

1. Cutaneous sarcoidosis;
2. Recurrent lymphoma with skin metastasis;
3. Blastomycosis;
4. Pyoderma gangrenosum; or
5. Anthrax.

Discussion

The answer is C: blastomycosis. A pathology specimen from a left arm skin punch biopsy was read as pseudoepitheliomatous hyperplasia, dermal abscess, and broad-based yeast organisms suggestive of blastomycosis. Fungal cultures grew a white-like colony of hyphae suggestive of blastomycosis. DNA probe was positive for blastomycosis dermatitidis. Interestingly, his fungal serologies were negative. The patient was started on itraconazole 200 mg twice daily.

Blastomycosis typically presents in one of two ways:

1. Pulmonary infection and/or
2. Cutaneous infection.

Typically, the spores of Blastomyces dermatitidis are inhaled from the soil, decomposed vegetation, or rotting wood, and the respiratory system is the first site of infection. Occupations with frequent outdoor exposure in highly endemic areas (including the southeastern states of the United States) connote increased risk. Case series have documented inoculation arising after outdoor activities in the woods near water sources.

Although pulmonary infection is subclinical in 50% of inhalational cases, one study found that pulmonary manifestations were present in 154 of 170 cases (91%) with cough (90%), fever (75%), night sweats (68%), weight loss (66%), chest pain (63%), dyspnea (54%), and aches (50%). Therefore, respiratory symptoms may signal the disease.

According to another review of 100 cases in an endemic area, pulmonary blastomycosis should be considered for any pulmonary infiltrate, especially in the upper lobes. For this patient, because there were no pulmonary symptoms or cutaneous trauma, the most likely etiology is via hematogenous spread. However, whereas the chest radiograph did not show classic signs of blastomycosis (one or more densely consolidated areas of pneumonia or nodular infiltrates), it did show slight fibrosis and pleural thickenings in the apices that is occasionally associated with blastomycosis infection.

As in this case, a presenting cutaneous lesion may be the first sign of disease. The cutaneous findings are usually the result of hematogenous spread; however, uncommon primary cutaneous blastomycosis can occur after direct inoculation from trauma to the skin. Classically, they are described as well-demarcated papulopustules and verrucous plaques with central scarring and black crusting. But the skin lesions can present in many forms and often confound the differential diagnosis. Other cutaneous infectious etiologies include verrucae, nocardiosis, cutaneous tuberculosis, and other dimorphic fungi. However, other dimorphic fungi are less likely to infect the skin. Inflammatory conditions, such as pyoderma gangrenosum and sarcoidosis, must be considered. Ulcerating squamous cell carcinoma is also a consideration.

Blastomycosis is recognized histologically by its broad-based budding and thick, double-contoured walls of the yeast forms found at body temperature (37º C) while it grows as tan or white mold at room temperature. Cultures can be drawn from sputum, pus, or urine. Severe disease often requires systemic antifungal treatment, whereas more moderate to mild disease can be treated topically. TH

References

1. Baumgardner DJ, Halsmer SE, Eagan G. Symptoms of pulmonary blastomycosis: northern Wisconsin, United States. Wilderness Environ Med. 2004;15:250-256.
2. Patel RG, Patel B, Petrini MF, et al. Clinical presentation, radiographic findings, and diagnostic methods of pulmonary blastomycosis: a review of 100 consecutive cases. South Med J. 1999;92:289-295.
3. Bolognia J, ed. Dermatology. Barcelona, Spain: Mosby; 2003.
4. Kasper DL, ed. Harrison’s Online Principles of Internal Medicine. 16th ed. New York: McGraw-Hill; 2005.

A61-year-old farmer from Iowa with a medical history significant for non-Hodgkin’s lymphoma in remission presented for evaluation and treatment of two ulcerating lesions, located on his left forearm and left thigh of two months’ duration. He denied a history of pulmonary symptoms, fever, or unintentional weight loss. Physical examination was negative for lymphadenopathy or splenomegaly. Two large, beefy hyperkeratotic plaques with an underlying border with pustules were noted. The lesion shown is on the left lateral leg and is 5.3 x 4.0 cm.

What is your diagnosis:

1. Cutaneous sarcoidosis;
2. Recurrent lymphoma with skin metastasis;
3. Blastomycosis;
4. Pyoderma gangrenosum; or
5. Anthrax.

Discussion

The answer is C: blastomycosis. A pathology specimen from a left arm skin punch biopsy was read as pseudoepitheliomatous hyperplasia, dermal abscess, and broad-based yeast organisms suggestive of blastomycosis. Fungal cultures grew a white-like colony of hyphae suggestive of blastomycosis. DNA probe was positive for blastomycosis dermatitidis. Interestingly, his fungal serologies were negative. The patient was started on itraconazole 200 mg twice daily.

Blastomycosis typically presents in one of two ways:

1. Pulmonary infection and/or
2. Cutaneous infection.

Typically, the spores of Blastomyces dermatitidis are inhaled from the soil, decomposed vegetation, or rotting wood, and the respiratory system is the first site of infection. Occupations with frequent outdoor exposure in highly endemic areas (including the southeastern states of the United States) connote increased risk. Case series have documented inoculation arising after outdoor activities in the woods near water sources.

Although pulmonary infection is subclinical in 50% of inhalational cases, one study found that pulmonary manifestations were present in 154 of 170 cases (91%) with cough (90%), fever (75%), night sweats (68%), weight loss (66%), chest pain (63%), dyspnea (54%), and aches (50%). Therefore, respiratory symptoms may signal the disease.

According to another review of 100 cases in an endemic area, pulmonary blastomycosis should be considered for any pulmonary infiltrate, especially in the upper lobes. For this patient, because there were no pulmonary symptoms or cutaneous trauma, the most likely etiology is via hematogenous spread. However, whereas the chest radiograph did not show classic signs of blastomycosis (one or more densely consolidated areas of pneumonia or nodular infiltrates), it did show slight fibrosis and pleural thickenings in the apices that is occasionally associated with blastomycosis infection.

As in this case, a presenting cutaneous lesion may be the first sign of disease. The cutaneous findings are usually the result of hematogenous spread; however, uncommon primary cutaneous blastomycosis can occur after direct inoculation from trauma to the skin. Classically, they are described as well-demarcated papulopustules and verrucous plaques with central scarring and black crusting. But the skin lesions can present in many forms and often confound the differential diagnosis. Other cutaneous infectious etiologies include verrucae, nocardiosis, cutaneous tuberculosis, and other dimorphic fungi. However, other dimorphic fungi are less likely to infect the skin. Inflammatory conditions, such as pyoderma gangrenosum and sarcoidosis, must be considered. Ulcerating squamous cell carcinoma is also a consideration.

Blastomycosis is recognized histologically by its broad-based budding and thick, double-contoured walls of the yeast forms found at body temperature (37º C) while it grows as tan or white mold at room temperature. Cultures can be drawn from sputum, pus, or urine. Severe disease often requires systemic antifungal treatment, whereas more moderate to mild disease can be treated topically. TH

References

1. Baumgardner DJ, Halsmer SE, Eagan G. Symptoms of pulmonary blastomycosis: northern Wisconsin, United States. Wilderness Environ Med. 2004;15:250-256.
2. Patel RG, Patel B, Petrini MF, et al. Clinical presentation, radiographic findings, and diagnostic methods of pulmonary blastomycosis: a review of 100 consecutive cases. South Med J. 1999;92:289-295.
3. Bolognia J, ed. Dermatology. Barcelona, Spain: Mosby; 2003.
4. Kasper DL, ed. Harrison’s Online Principles of Internal Medicine. 16th ed. New York: McGraw-Hill; 2005.

Garlic

In 2002, the NIH surveyed more than 30,000 U.S. adults regarding their use of complementary and alternative medicine (CAM).1 This survey revealed that approximately 40% of U.S. adults had used some form of CAM in the past year. When one excludes prayer as a CAM modality, the most common modality used was the category of natural products (i.e., herbs and dietary supplements).

This has significant implications for all healthcare providers, but especially for those who practice in the hospital environment. Herbs can be potentially toxic in their own right and can cause drug-herb interactions as well. Such adverse effects may be particularly important in hospitalized patients undergoing surgery or who are acutely ill and exposed to a number of narrow-window therapeutic pharmaceuticals. Thus, it is imperative for hospital physicians to have a basic understanding of some of the risks, challenges, and potential benefits of herbs.

Garlic

Use of Herbs by Hospitalized Patients

Surveys performed in the United States and around the world consistently demonstrate that the use of dietary supplements and herbs tends to be higher (as is all CAM usage) in individuals with chronic or incurable diseases. This is especially true for conditions such as HIV, diabetes, heart disease, and cancer.2–6 Thus, considering the complexity of illness of most hospitalized patients, it should not be surprising that use of herbs and dietary supplements is high in the hospital population. This has been borne out in several national and international studies.

A study reported in the Annals of Emergency Medicine in 2000 found that 56% of ED patients had tried alternative therapies in the past.7 The most frequently tried alternative therapies were massage therapy (31%), chiropractic (30%), and herbs (24%). Interestingly, 70% of the respondents who had tried these alternative therapies did not inform their physicians, highlighting a challenge for physicians and caregivers in the hospital setting.

Kay and colleagues reported 1,017 patients presenting for a preanesthetic evaluation prior to surgery.8 They found that 482 of 755 (64%) of patients had used at least one natural product. The majority of these were vitamin users, but several herbs with potential importance in the hospital setting were used as well: garlic extract (43%), ginkgo (32%), St. John’s wort (30%), ephedra (18%), and echinacea (12%).

Pediatric patients are not immune to the use of herbs and dietary supplement either. A survey at Children’s Hospital in Boston looked at 1,100 patients younger than 18 during their preoperative visit.9 A total of 1,021 surveys were completed and, of these, 30% patients indicated that they had tried one or more complementary and alternative therapies in the past year before surgery. Importantly, 13% had used herbal remedies before surgery.

Finally, international studies confirm similar usage patterns in adult hospital patients in Germany, Spain, Hong Kong, and Australia.10–13 Thus, it appears well established that the use of dietary supplements has become a fixed part of conventional healthcare. Recognizing that a significant percentage of patients under our care are using herbs is the first step in bringing critically needed information and guidance to our patients.

Garlic

Herb Toxicity and Herb–Drug Interactions

There are many well-recognized herbal toxicities and/or drug-herb interactions with which all clinicians should have some degree of familiarity. For example, St. John’s wort stimulation of the cytochrome P450 enzyme system resulting in enhanced metabolism of several pharmaceutical drugs has been well reported. Ephedra’s ability to induce elevated blood pressure, stroke, and MI also received a great deal of publicity. (Note: Ephedra sales were banned by the FDA in 2004. However the prohibition excluded ephedra-containing teas, and—despite the ban—many internet sites still have ephedra available for purchase. Thus, be aware that your patients may still have access to ephedra.)

Which herbs might have specific importance in the hospital setting? This question was answered to some degree by researchers at the University of Chicago in 2001.14 The authors reviewed the literature on commonly used herbal medications in the context of the perioperative period and attempted to provide rationale strategies for managing their preoperative use. They identified echinacea, ephedra, garlic, ginkgo, ginseng, kava, St. John’s wort, and valerian as commonly used herbal medications that could pose a concern during the perioperative period.

Direct effects include bleeding from garlic, ginkgo, and ginseng; cardiovascular instability from ephedra; and hypoglycemia from ginseng. Pharmacodynamic herb-drug interactions include potentiation of the sedative effects of anesthetic by kava and valerian. Pharmacokinetic herb-drug interactions include increased metabolism of many drugs used in the perioperative period by St. John’s wort. (The findings are outlined in “Table 1. Clinically Important Effects and Perioperative Concerns of Eight Herbal Medicines and Recommendations for Discontinuation of Use Before Surgery,” p. 16.)

These authors concluded, “during the preoperative evaluation, physicians should explicitly elicit and document a history of herbal medication use. Physicians should be familiar with the potential perioperative effects of the commonly used herbal medications to prevent, recognize, and treat potentially serious problems associated with their use and discontinuation.”

However, it is quite clear that the numbers of herbs that patients can encounter seem almost limitless, and there is no way for any clinician to maintain currency with every potential toxicity or other adverse event. Because of the phenomenon of new herbs becoming popular almost on a monthly basis, the use of textbooks to assist the hospital clinician in identifying potentially toxic herbs or drug–herb interactions has limited utility.

For the most part, databases that maintain greater currency of such reports are most helpful. Some of this information can be found in nonproprietary sites (see “Table 2. Helpful Herbal Databases,” to right), whereas others require a subscription. In the latter category, Natural Medicines Comprehensive Database (www.naturaldatabase.com) is a helpful and extremely comprehensive resource. It is laid out in a systematic fashion that makes it easy to identify an herb of interest, discover if there are potential adverse effects, and also provide patient handout information to patients.

Future Directions

Some of the bloom is off the rose in terms of enthusiasm for dietary supplements and herbs as a panacea for all human ills. Increasingly, consumers are becoming savvy with regard to challenges related to quality of products including contamination and lack of standardization. In addition, the common mythologies that “herbs are natural and therefore safe” or that “if two doses of an herb are good, 10 must be better” are slowly becoming recognized as the dangerous platitudes that they are. A more rationale approach to herbal use is slowly emerging.

With a more informed public and better resources for physicians to counsel patients and consumers, it is possible that we will see beneficial dietary supplements and herbs assume a helpful role in managing common problems. For example, valerian may be of significant benefit in helping restructure sleep patterns in patients with insomnia (possibly with fewer side effects than benzodiazepines and less expense than some of the newer hypnotics). Still, long-term studies are generally lacking, so final determination of the role of valerian in the physician’s armamentarium await such studies.

At the Mayo Clinic, many such studies are under way. The use of valerian as a sleep aid for patients undergoing chemotherapy is nearing completion. Another study looking at the role of American ginseng (Panax quinquefolius) as a treatment for cancer-related fatigue has just gotten under way. As these and dozens of similar studies at research institutions across the country are completed, the missing pieces in the herb story will begin to be filled in.

Until all the answers are in, clinicians need to remember that herbs are popular and will probably be part of our healthcare system for the foreseeable future. Although many herbs have promising data to suggest we may welcome them into our repertoire of agents, the focus in the hospital (for now) must be to make sure our patients do not suffer harm from such agents. By working with them in a collaborative partnership and sharing the data we do have at hand, we can ensure that our patients have the information they need to make informed decisions about their decision to use (or not to use) herbs. TH

Brent Bauer, MD, is consultant director for the Complementary and Alternative Medicine Program, Mayo Clinic Rochester.

References

1. Barnes P, Powell-Griner E, McFann K, et al. CDC Advance Data Report #343. Complementary and alternative medicine use among adults: United States, 2002; May 27, 2004.
2. Hsiao AF, Wong MD, Kanouse DE, et al. Complementary and alternative medicine use and substitution for conventional therapy by HIV-infected patients. J Acquir Immune Defic Syndr. 2003;33:157-165.
3. Yeh GY, Eisenberg DM, Davis RB, et al. Use of complementary and alternative medicine among persons with diabetes mellitus: results of a national survey. Am J Public Health. 2002;92:1648-1652.
4. Wood MJ, Stewart RL, Merry H, et al. Use of complementary and alternative medical therapies in patients with cardiovascular disease. Am Heart J. 2003;145:806-812.
5. Liu EH, Turner LM, Lin SX, et al. Use of alternative medicine by patients undergoing cardiac surgery. J Thorac Cardiovasc Surg. 2000;120:335-341.
6. Richardson MA, Sanders T, Palmer JL, et al. Complementary/alternative medicine use in a comprehensive cancer center and the implications for oncology. J Clin Oncol. 2000;18:2505-2514.
7. Gulla J, Singer AJ. Use of alternative therapies among emergency department patients. Ann Emerg Med. 2000;35:226-228.
8. Kaye AD, Clarke RC, Sabar R, et al. Herbal medicines: current trends in anesthesiology practice—a hospital survey. J Clin Anesth. 2000;12:468-471.
9. Lin YC, Bioteau AB, Ferrari LR, et al. The use of herbs and complementary and alternative medicine in pediatric preoperative patients. J Clin Anesth. 2004;16:4-6.
10. Huber R, Koch D, Beiser I, et al. Experience and attitudes towards CAM—a survey of internal and psychosomatic patients in a German university hospital. Altern Ther Health Med. 2004;10:32-36.
11. Valencia Orgaz O, Orts Castro A, Castells Armenter MV, et al. Assessing preoperative use of medicinal plants during preanesthetic interviews. Rev Esp Anestesiol Reanim. 2005;52:453-458. Spanish.
12. Critchley LA, Chen DQ, Lee A, et al. A survey of Chinese herbal medicine intake amongst preoperative patients in Hong Kong. Anaesth Intensive Care. 2005;33:506-513.
13. Grauer RP, Thomas RD, Tronson MD, et al. Preoperative use of herbal medicines and vitamin supplements. Anaesth Intensive Care. 2004;32:173-177.
14. Ang-Lee MK, Moss J, Yuan CS. Herbal medicines and perioperative care. JAMA. 2001;286:208-216.

Garlic

In 2002, the NIH surveyed more than 30,000 U.S. adults regarding their use of complementary and alternative medicine (CAM).1 This survey revealed that approximately 40% of U.S. adults had used some form of CAM in the past year. When one excludes prayer as a CAM modality, the most common modality used was the category of natural products (i.e., herbs and dietary supplements).

This has significant implications for all healthcare providers, but especially for those who practice in the hospital environment. Herbs can be potentially toxic in their own right and can cause drug-herb interactions as well. Such adverse effects may be particularly important in hospitalized patients undergoing surgery or who are acutely ill and exposed to a number of narrow-window therapeutic pharmaceuticals. Thus, it is imperative for hospital physicians to have a basic understanding of some of the risks, challenges, and potential benefits of herbs.

Garlic

Use of Herbs by Hospitalized Patients

Surveys performed in the United States and around the world consistently demonstrate that the use of dietary supplements and herbs tends to be higher (as is all CAM usage) in individuals with chronic or incurable diseases. This is especially true for conditions such as HIV, diabetes, heart disease, and cancer.2–6 Thus, considering the complexity of illness of most hospitalized patients, it should not be surprising that use of herbs and dietary supplements is high in the hospital population. This has been borne out in several national and international studies.

A study reported in the Annals of Emergency Medicine in 2000 found that 56% of ED patients had tried alternative therapies in the past.7 The most frequently tried alternative therapies were massage therapy (31%), chiropractic (30%), and herbs (24%). Interestingly, 70% of the respondents who had tried these alternative therapies did not inform their physicians, highlighting a challenge for physicians and caregivers in the hospital setting.

Kay and colleagues reported 1,017 patients presenting for a preanesthetic evaluation prior to surgery.8 They found that 482 of 755 (64%) of patients had used at least one natural product. The majority of these were vitamin users, but several herbs with potential importance in the hospital setting were used as well: garlic extract (43%), ginkgo (32%), St. John’s wort (30%), ephedra (18%), and echinacea (12%).

Pediatric patients are not immune to the use of herbs and dietary supplement either. A survey at Children’s Hospital in Boston looked at 1,100 patients younger than 18 during their preoperative visit.9 A total of 1,021 surveys were completed and, of these, 30% patients indicated that they had tried one or more complementary and alternative therapies in the past year before surgery. Importantly, 13% had used herbal remedies before surgery.

Finally, international studies confirm similar usage patterns in adult hospital patients in Germany, Spain, Hong Kong, and Australia.10–13 Thus, it appears well established that the use of dietary supplements has become a fixed part of conventional healthcare. Recognizing that a significant percentage of patients under our care are using herbs is the first step in bringing critically needed information and guidance to our patients.

Garlic

Herb Toxicity and Herb–Drug Interactions

There are many well-recognized herbal toxicities and/or drug-herb interactions with which all clinicians should have some degree of familiarity. For example, St. John’s wort stimulation of the cytochrome P450 enzyme system resulting in enhanced metabolism of several pharmaceutical drugs has been well reported. Ephedra’s ability to induce elevated blood pressure, stroke, and MI also received a great deal of publicity. (Note: Ephedra sales were banned by the FDA in 2004. However the prohibition excluded ephedra-containing teas, and—despite the ban—many internet sites still have ephedra available for purchase. Thus, be aware that your patients may still have access to ephedra.)

Which herbs might have specific importance in the hospital setting? This question was answered to some degree by researchers at the University of Chicago in 2001.14 The authors reviewed the literature on commonly used herbal medications in the context of the perioperative period and attempted to provide rationale strategies for managing their preoperative use. They identified echinacea, ephedra, garlic, ginkgo, ginseng, kava, St. John’s wort, and valerian as commonly used herbal medications that could pose a concern during the perioperative period.

Direct effects include bleeding from garlic, ginkgo, and ginseng; cardiovascular instability from ephedra; and hypoglycemia from ginseng. Pharmacodynamic herb-drug interactions include potentiation of the sedative effects of anesthetic by kava and valerian. Pharmacokinetic herb-drug interactions include increased metabolism of many drugs used in the perioperative period by St. John’s wort. (The findings are outlined in “Table 1. Clinically Important Effects and Perioperative Concerns of Eight Herbal Medicines and Recommendations for Discontinuation of Use Before Surgery,” p. 16.)

These authors concluded, “during the preoperative evaluation, physicians should explicitly elicit and document a history of herbal medication use. Physicians should be familiar with the potential perioperative effects of the commonly used herbal medications to prevent, recognize, and treat potentially serious problems associated with their use and discontinuation.”

However, it is quite clear that the numbers of herbs that patients can encounter seem almost limitless, and there is no way for any clinician to maintain currency with every potential toxicity or other adverse event. Because of the phenomenon of new herbs becoming popular almost on a monthly basis, the use of textbooks to assist the hospital clinician in identifying potentially toxic herbs or drug–herb interactions has limited utility.

For the most part, databases that maintain greater currency of such reports are most helpful. Some of this information can be found in nonproprietary sites (see “Table 2. Helpful Herbal Databases,” to right), whereas others require a subscription. In the latter category, Natural Medicines Comprehensive Database (www.naturaldatabase.com) is a helpful and extremely comprehensive resource. It is laid out in a systematic fashion that makes it easy to identify an herb of interest, discover if there are potential adverse effects, and also provide patient handout information to patients.

Future Directions

Some of the bloom is off the rose in terms of enthusiasm for dietary supplements and herbs as a panacea for all human ills. Increasingly, consumers are becoming savvy with regard to challenges related to quality of products including contamination and lack of standardization. In addition, the common mythologies that “herbs are natural and therefore safe” or that “if two doses of an herb are good, 10 must be better” are slowly becoming recognized as the dangerous platitudes that they are. A more rationale approach to herbal use is slowly emerging.

With a more informed public and better resources for physicians to counsel patients and consumers, it is possible that we will see beneficial dietary supplements and herbs assume a helpful role in managing common problems. For example, valerian may be of significant benefit in helping restructure sleep patterns in patients with insomnia (possibly with fewer side effects than benzodiazepines and less expense than some of the newer hypnotics). Still, long-term studies are generally lacking, so final determination of the role of valerian in the physician’s armamentarium await such studies.

At the Mayo Clinic, many such studies are under way. The use of valerian as a sleep aid for patients undergoing chemotherapy is nearing completion. Another study looking at the role of American ginseng (Panax quinquefolius) as a treatment for cancer-related fatigue has just gotten under way. As these and dozens of similar studies at research institutions across the country are completed, the missing pieces in the herb story will begin to be filled in.

Until all the answers are in, clinicians need to remember that herbs are popular and will probably be part of our healthcare system for the foreseeable future. Although many herbs have promising data to suggest we may welcome them into our repertoire of agents, the focus in the hospital (for now) must be to make sure our patients do not suffer harm from such agents. By working with them in a collaborative partnership and sharing the data we do have at hand, we can ensure that our patients have the information they need to make informed decisions about their decision to use (or not to use) herbs. TH

Brent Bauer, MD, is consultant director for the Complementary and Alternative Medicine Program, Mayo Clinic Rochester.

References

1. Barnes P, Powell-Griner E, McFann K, et al. CDC Advance Data Report #343. Complementary and alternative medicine use among adults: United States, 2002; May 27, 2004.
2. Hsiao AF, Wong MD, Kanouse DE, et al. Complementary and alternative medicine use and substitution for conventional therapy by HIV-infected patients. J Acquir Immune Defic Syndr. 2003;33:157-165.
3. Yeh GY, Eisenberg DM, Davis RB, et al. Use of complementary and alternative medicine among persons with diabetes mellitus: results of a national survey. Am J Public Health. 2002;92:1648-1652.
4. Wood MJ, Stewart RL, Merry H, et al. Use of complementary and alternative medical therapies in patients with cardiovascular disease. Am Heart J. 2003;145:806-812.
5. Liu EH, Turner LM, Lin SX, et al. Use of alternative medicine by patients undergoing cardiac surgery. J Thorac Cardiovasc Surg. 2000;120:335-341.
6. Richardson MA, Sanders T, Palmer JL, et al. Complementary/alternative medicine use in a comprehensive cancer center and the implications for oncology. J Clin Oncol. 2000;18:2505-2514.
7. Gulla J, Singer AJ. Use of alternative therapies among emergency department patients. Ann Emerg Med. 2000;35:226-228.
8. Kaye AD, Clarke RC, Sabar R, et al. Herbal medicines: current trends in anesthesiology practice—a hospital survey. J Clin Anesth. 2000;12:468-471.
9. Lin YC, Bioteau AB, Ferrari LR, et al. The use of herbs and complementary and alternative medicine in pediatric preoperative patients. J Clin Anesth. 2004;16:4-6.
10. Huber R, Koch D, Beiser I, et al. Experience and attitudes towards CAM—a survey of internal and psychosomatic patients in a German university hospital. Altern Ther Health Med. 2004;10:32-36.
11. Valencia Orgaz O, Orts Castro A, Castells Armenter MV, et al. Assessing preoperative use of medicinal plants during preanesthetic interviews. Rev Esp Anestesiol Reanim. 2005;52:453-458. Spanish.
12. Critchley LA, Chen DQ, Lee A, et al. A survey of Chinese herbal medicine intake amongst preoperative patients in Hong Kong. Anaesth Intensive Care. 2005;33:506-513.
13. Grauer RP, Thomas RD, Tronson MD, et al. Preoperative use of herbal medicines and vitamin supplements. Anaesth Intensive Care. 2004;32:173-177.
14. Ang-Lee MK, Moss J, Yuan CS. Herbal medicines and perioperative care. JAMA. 2001;286:208-216.

Garlic

In 2002, the NIH surveyed more than 30,000 U.S. adults regarding their use of complementary and alternative medicine (CAM).1 This survey revealed that approximately 40% of U.S. adults had used some form of CAM in the past year. When one excludes prayer as a CAM modality, the most common modality used was the category of natural products (i.e., herbs and dietary supplements).

This has significant implications for all healthcare providers, but especially for those who practice in the hospital environment. Herbs can be potentially toxic in their own right and can cause drug-herb interactions as well. Such adverse effects may be particularly important in hospitalized patients undergoing surgery or who are acutely ill and exposed to a number of narrow-window therapeutic pharmaceuticals. Thus, it is imperative for hospital physicians to have a basic understanding of some of the risks, challenges, and potential benefits of herbs.

Garlic

Use of Herbs by Hospitalized Patients

Surveys performed in the United States and around the world consistently demonstrate that the use of dietary supplements and herbs tends to be higher (as is all CAM usage) in individuals with chronic or incurable diseases. This is especially true for conditions such as HIV, diabetes, heart disease, and cancer.2–6 Thus, considering the complexity of illness of most hospitalized patients, it should not be surprising that use of herbs and dietary supplements is high in the hospital population. This has been borne out in several national and international studies.

A study reported in the Annals of Emergency Medicine in 2000 found that 56% of ED patients had tried alternative therapies in the past.7 The most frequently tried alternative therapies were massage therapy (31%), chiropractic (30%), and herbs (24%). Interestingly, 70% of the respondents who had tried these alternative therapies did not inform their physicians, highlighting a challenge for physicians and caregivers in the hospital setting.

Kay and colleagues reported 1,017 patients presenting for a preanesthetic evaluation prior to surgery.8 They found that 482 of 755 (64%) of patients had used at least one natural product. The majority of these were vitamin users, but several herbs with potential importance in the hospital setting were used as well: garlic extract (43%), ginkgo (32%), St. John’s wort (30%), ephedra (18%), and echinacea (12%).

Pediatric patients are not immune to the use of herbs and dietary supplement either. A survey at Children’s Hospital in Boston looked at 1,100 patients younger than 18 during their preoperative visit.9 A total of 1,021 surveys were completed and, of these, 30% patients indicated that they had tried one or more complementary and alternative therapies in the past year before surgery. Importantly, 13% had used herbal remedies before surgery.

Finally, international studies confirm similar usage patterns in adult hospital patients in Germany, Spain, Hong Kong, and Australia.10–13 Thus, it appears well established that the use of dietary supplements has become a fixed part of conventional healthcare. Recognizing that a significant percentage of patients under our care are using herbs is the first step in bringing critically needed information and guidance to our patients.

Garlic

Herb Toxicity and Herb–Drug Interactions

There are many well-recognized herbal toxicities and/or drug-herb interactions with which all clinicians should have some degree of familiarity. For example, St. John’s wort stimulation of the cytochrome P450 enzyme system resulting in enhanced metabolism of several pharmaceutical drugs has been well reported. Ephedra’s ability to induce elevated blood pressure, stroke, and MI also received a great deal of publicity. (Note: Ephedra sales were banned by the FDA in 2004. However the prohibition excluded ephedra-containing teas, and—despite the ban—many internet sites still have ephedra available for purchase. Thus, be aware that your patients may still have access to ephedra.)

Which herbs might have specific importance in the hospital setting? This question was answered to some degree by researchers at the University of Chicago in 2001.14 The authors reviewed the literature on commonly used herbal medications in the context of the perioperative period and attempted to provide rationale strategies for managing their preoperative use. They identified echinacea, ephedra, garlic, ginkgo, ginseng, kava, St. John’s wort, and valerian as commonly used herbal medications that could pose a concern during the perioperative period.

Direct effects include bleeding from garlic, ginkgo, and ginseng; cardiovascular instability from ephedra; and hypoglycemia from ginseng. Pharmacodynamic herb-drug interactions include potentiation of the sedative effects of anesthetic by kava and valerian. Pharmacokinetic herb-drug interactions include increased metabolism of many drugs used in the perioperative period by St. John’s wort. (The findings are outlined in “Table 1. Clinically Important Effects and Perioperative Concerns of Eight Herbal Medicines and Recommendations for Discontinuation of Use Before Surgery,” p. 16.)

These authors concluded, “during the preoperative evaluation, physicians should explicitly elicit and document a history of herbal medication use. Physicians should be familiar with the potential perioperative effects of the commonly used herbal medications to prevent, recognize, and treat potentially serious problems associated with their use and discontinuation.”

However, it is quite clear that the numbers of herbs that patients can encounter seem almost limitless, and there is no way for any clinician to maintain currency with every potential toxicity or other adverse event. Because of the phenomenon of new herbs becoming popular almost on a monthly basis, the use of textbooks to assist the hospital clinician in identifying potentially toxic herbs or drug–herb interactions has limited utility.

For the most part, databases that maintain greater currency of such reports are most helpful. Some of this information can be found in nonproprietary sites (see “Table 2. Helpful Herbal Databases,” to right), whereas others require a subscription. In the latter category, Natural Medicines Comprehensive Database (www.naturaldatabase.com) is a helpful and extremely comprehensive resource. It is laid out in a systematic fashion that makes it easy to identify an herb of interest, discover if there are potential adverse effects, and also provide patient handout information to patients.

Future Directions

Some of the bloom is off the rose in terms of enthusiasm for dietary supplements and herbs as a panacea for all human ills. Increasingly, consumers are becoming savvy with regard to challenges related to quality of products including contamination and lack of standardization. In addition, the common mythologies that “herbs are natural and therefore safe” or that “if two doses of an herb are good, 10 must be better” are slowly becoming recognized as the dangerous platitudes that they are. A more rationale approach to herbal use is slowly emerging.

With a more informed public and better resources for physicians to counsel patients and consumers, it is possible that we will see beneficial dietary supplements and herbs assume a helpful role in managing common problems. For example, valerian may be of significant benefit in helping restructure sleep patterns in patients with insomnia (possibly with fewer side effects than benzodiazepines and less expense than some of the newer hypnotics). Still, long-term studies are generally lacking, so final determination of the role of valerian in the physician’s armamentarium await such studies.

At the Mayo Clinic, many such studies are under way. The use of valerian as a sleep aid for patients undergoing chemotherapy is nearing completion. Another study looking at the role of American ginseng (Panax quinquefolius) as a treatment for cancer-related fatigue has just gotten under way. As these and dozens of similar studies at research institutions across the country are completed, the missing pieces in the herb story will begin to be filled in.

Until all the answers are in, clinicians need to remember that herbs are popular and will probably be part of our healthcare system for the foreseeable future. Although many herbs have promising data to suggest we may welcome them into our repertoire of agents, the focus in the hospital (for now) must be to make sure our patients do not suffer harm from such agents. By working with them in a collaborative partnership and sharing the data we do have at hand, we can ensure that our patients have the information they need to make informed decisions about their decision to use (or not to use) herbs. TH

Brent Bauer, MD, is consultant director for the Complementary and Alternative Medicine Program, Mayo Clinic Rochester.

References

1. Barnes P, Powell-Griner E, McFann K, et al. CDC Advance Data Report #343. Complementary and alternative medicine use among adults: United States, 2002; May 27, 2004.
2. Hsiao AF, Wong MD, Kanouse DE, et al. Complementary and alternative medicine use and substitution for conventional therapy by HIV-infected patients. J Acquir Immune Defic Syndr. 2003;33:157-165.
3. Yeh GY, Eisenberg DM, Davis RB, et al. Use of complementary and alternative medicine among persons with diabetes mellitus: results of a national survey. Am J Public Health. 2002;92:1648-1652.
4. Wood MJ, Stewart RL, Merry H, et al. Use of complementary and alternative medical therapies in patients with cardiovascular disease. Am Heart J. 2003;145:806-812.
5. Liu EH, Turner LM, Lin SX, et al. Use of alternative medicine by patients undergoing cardiac surgery. J Thorac Cardiovasc Surg. 2000;120:335-341.
6. Richardson MA, Sanders T, Palmer JL, et al. Complementary/alternative medicine use in a comprehensive cancer center and the implications for oncology. J Clin Oncol. 2000;18:2505-2514.
7. Gulla J, Singer AJ. Use of alternative therapies among emergency department patients. Ann Emerg Med. 2000;35:226-228.
8. Kaye AD, Clarke RC, Sabar R, et al. Herbal medicines: current trends in anesthesiology practice—a hospital survey. J Clin Anesth. 2000;12:468-471.
9. Lin YC, Bioteau AB, Ferrari LR, et al. The use of herbs and complementary and alternative medicine in pediatric preoperative patients. J Clin Anesth. 2004;16:4-6.
10. Huber R, Koch D, Beiser I, et al. Experience and attitudes towards CAM—a survey of internal and psychosomatic patients in a German university hospital. Altern Ther Health Med. 2004;10:32-36.
11. Valencia Orgaz O, Orts Castro A, Castells Armenter MV, et al. Assessing preoperative use of medicinal plants during preanesthetic interviews. Rev Esp Anestesiol Reanim. 2005;52:453-458. Spanish.
12. Critchley LA, Chen DQ, Lee A, et al. A survey of Chinese herbal medicine intake amongst preoperative patients in Hong Kong. Anaesth Intensive Care. 2005;33:506-513.
13. Grauer RP, Thomas RD, Tronson MD, et al. Preoperative use of herbal medicines and vitamin supplements. Anaesth Intensive Care. 2004;32:173-177.
14. Ang-Lee MK, Moss J, Yuan CS. Herbal medicines and perioperative care. JAMA. 2001;286:208-216.

We evaluate the validity of a study before examining its results because it will generally be inappropriate to apply the results of a biased study to our patients. If we cannot trust that the results reflect a reasonable estimation of the truth we seek to address, how can we then use those results to guide patient care? However, if we are satisfied with a study’s validity we need to know what the results mean and what to do with them.

In this segment of the evidence-based medicine series, we discuss several commonly reported study measures and how we can ultimately apply study findings for the good of patients. This is, after all, why we ask clinical questions in the first place.

Measures of Treatment Effect

For many types of clinical questions, the proportion of patients in each group experiencing an outcome is the most commonly reported result. This can be presented in several ways, each with subtly different effects.

For example, suppose a hypothetical trial of perioperative beta-blockade finds a postoperative mortality of 5% in the treatment group and 15% in the control group. In this study, the absolute risk reduction (ARR) is 0.15-0.05 = 0.10, and the relative risk (RR) of death is 0.05/0.15 = 0.33. In other words, the risk of death in the treatment group is one-third the risk of death in the control group, whereas the difference in risk between treated and untreated patients is 0.10, or 10%. The relative risk reduction (RRR) is (1-RR) x 100% = 67%, meaning that perioperative beta-blockers reduce the risk of death by 67%.

Although these numbers all seem quite different from one another, they are derived from the same study results: a difference in the proportion of deaths between the intervention groups. However, taken together they provide far more information than any individual result.

To illustrate this, suppose you knew the relative risk of death found in Study A was 10%, meaning the relative risk reduction was 90%. This may sound quite striking, until you later learn that the risk in the treatment group was 0.0001 and the risk in the control group was 0.001. This is quite different from Study B, in which the risk of death in the treatment group was 10% and the risk in the control group was 100%, even though the RR was still 10%. This difference is captured in the ARR. For the first study, the ARR was 0.0009 (or 0.09%), whereas in the second study the ARR was 0.90 (or 90%).

It can be difficult to communicate these differences clearly using terms such as ARR, but the number needed to treat (NNT) provides a more accessible means of reporting effects. The NNT is the number of patients you would need to treat to prevent one adverse event, or achieve one more successful outcome and is calculated as 1/ARR.

For Study A the NNT is 1,111, meaning we would need to treat more than 1,000 patients to prevent a single death. For many treatments, this would prove prohibitively costly and perhaps even dangerous depending on the frequency and severity of side effects. Study B, on the other hand, has an NNT of just over 1, meaning that nearly every treated case represents an averted death: Even though the relative risks are identical, the full meaning of the results is drastically different.

Other measures of treatment effect include odds ratios, commonly reported in case–control studies but actually appropriate in any comparative study, and hazard ratios, commonly reported in survival studies. We do not address these measures in more detail here, but loosely speaking the same principles discussed for relative risks apply.

Measures from Studies of Diagnostic Tests

When we order a diagnostic study, we are trying to gain information about the patient’s underlying probability of a disorder. That is, the diagnostic test moves us from a pre-test probability to a post-test probability. Historically, terms such as sensitivity and specificity have been used to describe the properties of a diagnostic test. But these terms have significant limitations, one of which is that they do not consider the pre-test probability at all.

Likelihood ratios overcome this limitation. Basically, a likelihood ratio (LR) converts pre-test odds to post-test odds. Because we think in terms of probabilities rather than odds, we can either use a nomogram to make the conversion for us or recall that for a probability p, odds = p/(1 - p) and p = odds/(1 + odds).

For example, suppose we suspect that a patient may have iron-deficiency anemia and quantify this suspicion with a pre-test probability of 25%. If the ferritin is 8 mcg/L, we can apply the likelihood ratio of 55 found from a literature search locating Guyatt, et al. (1992). The pre-test odds is one-third, which when multiplied by the LR of 55 yields a post-test odds of 18.3. This then can be converted back to a post-test probability of 95%. Alternatively, the widely available nomograms give the same result.

Clearly, this diagnostic test has drastically affected our sense of whether the patient has iron-deficiency anemia. Likelihood ratios for many common problems may be found in the recommended readings.

Perhaps the greatest stumbling block to the use of likelihood ratios is how to determine pre-test probabilities. This really should not be a major worry because it is our business to estimate probabilities of disease every time we see a patient. However, this estimation can be strengthened by using evidence-based principles to find literature to support your chosen pre-test probabilities. This further emphasizes that EBM affects all aspects of clinical decision-making.

Measures of Precision

Each of the measures discussed thus far is a point estimate of the true effect based on the study data. Because the true effect for all humans can never be known, we need some way of describing how precise our point estimates are. Statistically, confidence intervals (CIs) provide this information. An accurate definition of this measure of precision is not intuitive, but in practice the CI can provide answers to two key questions. First, does the CI cross the point of no effect (e.g., a relative risk of 1 or an absolute risk reduction of 0)? Second, how wide is the CI?

If the answer to the first question is yes, we cannot state with any certainty that there really is an effect of the treatment: a finding of “no effect” is considered plausible, because it is contained within the CI. If the CI is very wide, the true effect could be any value across a wide range of possibilities. This makes decision making problematic, unless the entire range of the CI represents a clinically important effect.

We will talk in more detail about CIs in a later segment, but the important message here is that a point estimate requires a CI before meaningful conclusions affecting patient care may be reached.

Applying Results to Patient Care

Once validity issues have been addressed and results have been processed, the key determinants of whether a study’s results can be applied to your patient are whether the study population was reasonably similar to your patient and whether the study setting was reasonably similar to your own. This need not be exact, but if a study enrolled only men, application of the results to women may not be supported.

On the other hand, if a study excluded individuals younger than 60 and your patient is 59 you may still feel comfortable applying the findings of this study to your patient’s care. The application of study results to individual patients is often not a simple decision. A general recommendation is to carefully determine whether there is a compelling reason to suggest that the study results might not apply to your patient. If not, generalizing the results is likely reasonable.

Additional considerations include the balance between benefits and risks, costs, and, of course, patient and provider values. If a treatment promotes survival but may have a negative impact on quality of life (for a recent example, see the MADIT II trial of AICD implantation in patients with prior MI and heart failure), patients and providers must carefully evaluate their priorities in determining the best course of action. Also, a costly treatment having a small but significant benefit may not be justified in an era of limited resources. These issues are at the heart of medicine and are best addressed by collaborative decision-making among patients, care providers, insurers, policy makers, and all other members of our healthcare system.

Summary

The results of a study can be reported in many ways, with different measures fitting different clinical questions. The keys to look for are a point estimate and a measure of the precision of that estimate. Applying results to patient care requires complex decisions that go well beyond the numbers from any study. In the upcoming segments of this series, we will focus more attention on how results are evaluated statistically. This will provide additional depth to the discussion of study results and how they inform our clinical decisions. TH

Dr. West practices in the Division of General Internal Medicine, Mayo Clinic College of Medicine, Rochester, Minn.

We evaluate the validity of a study before examining its results because it will generally be inappropriate to apply the results of a biased study to our patients. If we cannot trust that the results reflect a reasonable estimation of the truth we seek to address, how can we then use those results to guide patient care? However, if we are satisfied with a study’s validity we need to know what the results mean and what to do with them.

In this segment of the evidence-based medicine series, we discuss several commonly reported study measures and how we can ultimately apply study findings for the good of patients. This is, after all, why we ask clinical questions in the first place.

Measures of Treatment Effect

For many types of clinical questions, the proportion of patients in each group experiencing an outcome is the most commonly reported result. This can be presented in several ways, each with subtly different effects.

For example, suppose a hypothetical trial of perioperative beta-blockade finds a postoperative mortality of 5% in the treatment group and 15% in the control group. In this study, the absolute risk reduction (ARR) is 0.15-0.05 = 0.10, and the relative risk (RR) of death is 0.05/0.15 = 0.33. In other words, the risk of death in the treatment group is one-third the risk of death in the control group, whereas the difference in risk between treated and untreated patients is 0.10, or 10%. The relative risk reduction (RRR) is (1-RR) x 100% = 67%, meaning that perioperative beta-blockers reduce the risk of death by 67%.

Although these numbers all seem quite different from one another, they are derived from the same study results: a difference in the proportion of deaths between the intervention groups. However, taken together they provide far more information than any individual result.

To illustrate this, suppose you knew the relative risk of death found in Study A was 10%, meaning the relative risk reduction was 90%. This may sound quite striking, until you later learn that the risk in the treatment group was 0.0001 and the risk in the control group was 0.001. This is quite different from Study B, in which the risk of death in the treatment group was 10% and the risk in the control group was 100%, even though the RR was still 10%. This difference is captured in the ARR. For the first study, the ARR was 0.0009 (or 0.09%), whereas in the second study the ARR was 0.90 (or 90%).

It can be difficult to communicate these differences clearly using terms such as ARR, but the number needed to treat (NNT) provides a more accessible means of reporting effects. The NNT is the number of patients you would need to treat to prevent one adverse event, or achieve one more successful outcome and is calculated as 1/ARR.

For Study A the NNT is 1,111, meaning we would need to treat more than 1,000 patients to prevent a single death. For many treatments, this would prove prohibitively costly and perhaps even dangerous depending on the frequency and severity of side effects. Study B, on the other hand, has an NNT of just over 1, meaning that nearly every treated case represents an averted death: Even though the relative risks are identical, the full meaning of the results is drastically different.

Other measures of treatment effect include odds ratios, commonly reported in case–control studies but actually appropriate in any comparative study, and hazard ratios, commonly reported in survival studies. We do not address these measures in more detail here, but loosely speaking the same principles discussed for relative risks apply.

Measures from Studies of Diagnostic Tests

When we order a diagnostic study, we are trying to gain information about the patient’s underlying probability of a disorder. That is, the diagnostic test moves us from a pre-test probability to a post-test probability. Historically, terms such as sensitivity and specificity have been used to describe the properties of a diagnostic test. But these terms have significant limitations, one of which is that they do not consider the pre-test probability at all.

Likelihood ratios overcome this limitation. Basically, a likelihood ratio (LR) converts pre-test odds to post-test odds. Because we think in terms of probabilities rather than odds, we can either use a nomogram to make the conversion for us or recall that for a probability p, odds = p/(1 - p) and p = odds/(1 + odds).

For example, suppose we suspect that a patient may have iron-deficiency anemia and quantify this suspicion with a pre-test probability of 25%. If the ferritin is 8 mcg/L, we can apply the likelihood ratio of 55 found from a literature search locating Guyatt, et al. (1992). The pre-test odds is one-third, which when multiplied by the LR of 55 yields a post-test odds of 18.3. This then can be converted back to a post-test probability of 95%. Alternatively, the widely available nomograms give the same result.

Clearly, this diagnostic test has drastically affected our sense of whether the patient has iron-deficiency anemia. Likelihood ratios for many common problems may be found in the recommended readings.

Perhaps the greatest stumbling block to the use of likelihood ratios is how to determine pre-test probabilities. This really should not be a major worry because it is our business to estimate probabilities of disease every time we see a patient. However, this estimation can be strengthened by using evidence-based principles to find literature to support your chosen pre-test probabilities. This further emphasizes that EBM affects all aspects of clinical decision-making.

Measures of Precision

Each of the measures discussed thus far is a point estimate of the true effect based on the study data. Because the true effect for all humans can never be known, we need some way of describing how precise our point estimates are. Statistically, confidence intervals (CIs) provide this information. An accurate definition of this measure of precision is not intuitive, but in practice the CI can provide answers to two key questions. First, does the CI cross the point of no effect (e.g., a relative risk of 1 or an absolute risk reduction of 0)? Second, how wide is the CI?

If the answer to the first question is yes, we cannot state with any certainty that there really is an effect of the treatment: a finding of “no effect” is considered plausible, because it is contained within the CI. If the CI is very wide, the true effect could be any value across a wide range of possibilities. This makes decision making problematic, unless the entire range of the CI represents a clinically important effect.

We will talk in more detail about CIs in a later segment, but the important message here is that a point estimate requires a CI before meaningful conclusions affecting patient care may be reached.

Applying Results to Patient Care

Once validity issues have been addressed and results have been processed, the key determinants of whether a study’s results can be applied to your patient are whether the study population was reasonably similar to your patient and whether the study setting was reasonably similar to your own. This need not be exact, but if a study enrolled only men, application of the results to women may not be supported.

On the other hand, if a study excluded individuals younger than 60 and your patient is 59 you may still feel comfortable applying the findings of this study to your patient’s care. The application of study results to individual patients is often not a simple decision. A general recommendation is to carefully determine whether there is a compelling reason to suggest that the study results might not apply to your patient. If not, generalizing the results is likely reasonable.

Additional considerations include the balance between benefits and risks, costs, and, of course, patient and provider values. If a treatment promotes survival but may have a negative impact on quality of life (for a recent example, see the MADIT II trial of AICD implantation in patients with prior MI and heart failure), patients and providers must carefully evaluate their priorities in determining the best course of action. Also, a costly treatment having a small but significant benefit may not be justified in an era of limited resources. These issues are at the heart of medicine and are best addressed by collaborative decision-making among patients, care providers, insurers, policy makers, and all other members of our healthcare system.

Summary

The results of a study can be reported in many ways, with different measures fitting different clinical questions. The keys to look for are a point estimate and a measure of the precision of that estimate. Applying results to patient care requires complex decisions that go well beyond the numbers from any study. In the upcoming segments of this series, we will focus more attention on how results are evaluated statistically. This will provide additional depth to the discussion of study results and how they inform our clinical decisions. TH

Dr. West practices in the Division of General Internal Medicine, Mayo Clinic College of Medicine, Rochester, Minn.

We evaluate the validity of a study before examining its results because it will generally be inappropriate to apply the results of a biased study to our patients. If we cannot trust that the results reflect a reasonable estimation of the truth we seek to address, how can we then use those results to guide patient care? However, if we are satisfied with a study’s validity we need to know what the results mean and what to do with them.

In this segment of the evidence-based medicine series, we discuss several commonly reported study measures and how we can ultimately apply study findings for the good of patients. This is, after all, why we ask clinical questions in the first place.

Measures of Treatment Effect

For many types of clinical questions, the proportion of patients in each group experiencing an outcome is the most commonly reported result. This can be presented in several ways, each with subtly different effects.

For example, suppose a hypothetical trial of perioperative beta-blockade finds a postoperative mortality of 5% in the treatment group and 15% in the control group. In this study, the absolute risk reduction (ARR) is 0.15-0.05 = 0.10, and the relative risk (RR) of death is 0.05/0.15 = 0.33. In other words, the risk of death in the treatment group is one-third the risk of death in the control group, whereas the difference in risk between treated and untreated patients is 0.10, or 10%. The relative risk reduction (RRR) is (1-RR) x 100% = 67%, meaning that perioperative beta-blockers reduce the risk of death by 67%.

Although these numbers all seem quite different from one another, they are derived from the same study results: a difference in the proportion of deaths between the intervention groups. However, taken together they provide far more information than any individual result.

To illustrate this, suppose you knew the relative risk of death found in Study A was 10%, meaning the relative risk reduction was 90%. This may sound quite striking, until you later learn that the risk in the treatment group was 0.0001 and the risk in the control group was 0.001. This is quite different from Study B, in which the risk of death in the treatment group was 10% and the risk in the control group was 100%, even though the RR was still 10%. This difference is captured in the ARR. For the first study, the ARR was 0.0009 (or 0.09%), whereas in the second study the ARR was 0.90 (or 90%).

It can be difficult to communicate these differences clearly using terms such as ARR, but the number needed to treat (NNT) provides a more accessible means of reporting effects. The NNT is the number of patients you would need to treat to prevent one adverse event, or achieve one more successful outcome and is calculated as 1/ARR.

For Study A the NNT is 1,111, meaning we would need to treat more than 1,000 patients to prevent a single death. For many treatments, this would prove prohibitively costly and perhaps even dangerous depending on the frequency and severity of side effects. Study B, on the other hand, has an NNT of just over 1, meaning that nearly every treated case represents an averted death: Even though the relative risks are identical, the full meaning of the results is drastically different.

Other measures of treatment effect include odds ratios, commonly reported in case–control studies but actually appropriate in any comparative study, and hazard ratios, commonly reported in survival studies. We do not address these measures in more detail here, but loosely speaking the same principles discussed for relative risks apply.

Measures from Studies of Diagnostic Tests

When we order a diagnostic study, we are trying to gain information about the patient’s underlying probability of a disorder. That is, the diagnostic test moves us from a pre-test probability to a post-test probability. Historically, terms such as sensitivity and specificity have been used to describe the properties of a diagnostic test. But these terms have significant limitations, one of which is that they do not consider the pre-test probability at all.

Likelihood ratios overcome this limitation. Basically, a likelihood ratio (LR) converts pre-test odds to post-test odds. Because we think in terms of probabilities rather than odds, we can either use a nomogram to make the conversion for us or recall that for a probability p, odds = p/(1 - p) and p = odds/(1 + odds).

For example, suppose we suspect that a patient may have iron-deficiency anemia and quantify this suspicion with a pre-test probability of 25%. If the ferritin is 8 mcg/L, we can apply the likelihood ratio of 55 found from a literature search locating Guyatt, et al. (1992). The pre-test odds is one-third, which when multiplied by the LR of 55 yields a post-test odds of 18.3. This then can be converted back to a post-test probability of 95%. Alternatively, the widely available nomograms give the same result.

Clearly, this diagnostic test has drastically affected our sense of whether the patient has iron-deficiency anemia. Likelihood ratios for many common problems may be found in the recommended readings.

Perhaps the greatest stumbling block to the use of likelihood ratios is how to determine pre-test probabilities. This really should not be a major worry because it is our business to estimate probabilities of disease every time we see a patient. However, this estimation can be strengthened by using evidence-based principles to find literature to support your chosen pre-test probabilities. This further emphasizes that EBM affects all aspects of clinical decision-making.

Measures of Precision

Each of the measures discussed thus far is a point estimate of the true effect based on the study data. Because the true effect for all humans can never be known, we need some way of describing how precise our point estimates are. Statistically, confidence intervals (CIs) provide this information. An accurate definition of this measure of precision is not intuitive, but in practice the CI can provide answers to two key questions. First, does the CI cross the point of no effect (e.g., a relative risk of 1 or an absolute risk reduction of 0)? Second, how wide is the CI?

If the answer to the first question is yes, we cannot state with any certainty that there really is an effect of the treatment: a finding of “no effect” is considered plausible, because it is contained within the CI. If the CI is very wide, the true effect could be any value across a wide range of possibilities. This makes decision making problematic, unless the entire range of the CI represents a clinically important effect.

We will talk in more detail about CIs in a later segment, but the important message here is that a point estimate requires a CI before meaningful conclusions affecting patient care may be reached.

Applying Results to Patient Care

Once validity issues have been addressed and results have been processed, the key determinants of whether a study’s results can be applied to your patient are whether the study population was reasonably similar to your patient and whether the study setting was reasonably similar to your own. This need not be exact, but if a study enrolled only men, application of the results to women may not be supported.

On the other hand, if a study excluded individuals younger than 60 and your patient is 59 you may still feel comfortable applying the findings of this study to your patient’s care. The application of study results to individual patients is often not a simple decision. A general recommendation is to carefully determine whether there is a compelling reason to suggest that the study results might not apply to your patient. If not, generalizing the results is likely reasonable.

Additional considerations include the balance between benefits and risks, costs, and, of course, patient and provider values. If a treatment promotes survival but may have a negative impact on quality of life (for a recent example, see the MADIT II trial of AICD implantation in patients with prior MI and heart failure), patients and providers must carefully evaluate their priorities in determining the best course of action. Also, a costly treatment having a small but significant benefit may not be justified in an era of limited resources. These issues are at the heart of medicine and are best addressed by collaborative decision-making among patients, care providers, insurers, policy makers, and all other members of our healthcare system.

Summary

The results of a study can be reported in many ways, with different measures fitting different clinical questions. The keys to look for are a point estimate and a measure of the precision of that estimate. Applying results to patient care requires complex decisions that go well beyond the numbers from any study. In the upcoming segments of this series, we will focus more attention on how results are evaluated statistically. This will provide additional depth to the discussion of study results and how they inform our clinical decisions. TH

Dr. West practices in the Division of General Internal Medicine, Mayo Clinic College of Medicine, Rochester, Minn.

For most of recent history, it has been standard practice to tolerate hyperglycemia and expect some hypoglycemia when caring for diabetic patients in the hospital. This attitude stems from the many barriers to controlling glucose levels in hospitalized patients (e.g., the stress of acute illness and the changes in diet and medications that occur on admission to the hospital). In addition, most diabetic patients are hospitalized for illness other than their diabetes. In these situations, glycemic control may not be a priority, and fear of hypoglycemia may be prominent.

However, in recent years, there has been a change in attitude regarding glycemic control in the hospitalized patient. Recently, clinical studies have shown that hyperglycemia leads to poor outcomes in some hospitalized patients, prompting the American College of Endocrinology and the American Association of Clinical Endocrinologists to publish a position statement on inpatient diabetes and metabolic control.1 In addition, best practice strategies for controlling glucose levels in hospitalized patients have been recently reviewed.2

At the same time, hospitalists have emerged on the scene, bringing with them a new awareness of the gaps between the best practice and real practice. In real practice, both hyperglycemia and hypoglycemia are common, and insulin use in the hospital is often guided by strategies that are based on simplicity, instead of strategies that are based on established principles of diabetes management. There has been remarkably little attention given to the management of diabetes and hyperglycemia in noncritically ill hospitalized patients, and glucose levels are often far outside of the recommended range in this group.

SHM’s Glycemic Control Task Force

The Glycemic Control Task Force was assembled with the intent of improving glycemic control in hospitals nationally by providing hospitalists with an understanding of the best practice of glycemic control in the hospital, and by providing them with the tools and skills to make real changes in their own systems. With the assistance of a grant from Sanofi-Aventis, the Glycemic Control Summit was held on Oct. 20, 2005, in Chicago. A distinguished panel of experts attended, including hospitalists, endocrinologists, nurses, case managers, diabetes educators, and pharmacists. The goals of the meeting were as follows:

1. To identify the currently available resources pertinent to glycemic control in the hospital (e.g., resources related to best practice, education, quality improvement, awareness, clinical tools, research, metrics/quality parameters);
2. To identify the gaps in those resources; and
3. To assemble several focused work groups to address the major gaps in the existing resources, and to determine specific interventions or products that could fill those gaps.

The meeting spawned several smaller work groups that will address the major barriers to improving glycemic control in hospitalized patients. These groups were formed in direct response to the gaps that were identified during the meeting. A description of each of the work groups is provided below, highlighting the major gaps that were identified and the strategies being considered to overcome them.

Education: This group will focus on creating case-based, educational materials that will provide physicians, nurses, and other providers with pragmatic examples illustrating the best practice of glycemic control and insulin management in the hospital and at the transition of care. In addition, this group will address patient education issues, educational metrics, and other issues.

Potential deliverables from this group include Web-based, case-based educational modules applicable to CME or to support quality improvement efforts at individual institutions and patient education materials.

Quality improvement process: This group will focus on formulating a how-to resource for performing quality improvement projects related to glycemic control. This group will attempt to provide hospitalists with a practical guideline to help them successfully implement changes in their own institutions. Topics will include forming and leading a multidisciplinary team, setting goals, defining metrics, and identifying process analysis and evaluation methods.

Deliverables from this group will likely include a glycemic control quality improvement workbook that will guide individuals through the complex process of performing robust quality improvement projects in their own hospitals. This workbook will be similar in format to one that is currently available in the “VTE Quality Improvement Resource Room” on the SHM Web site.

Clinical tools: This group will focus on compiling and appraising already existing clinical tools (e.g., standardized order sets, protocols) and identifying the key features of these tools and the differences among them. The emphasis will be on either compiling or creating ready-to-use clinical tools.

Potential deliverables from this group include a collection of tools that will have substantial built-in decision support and will be useful in a range of settings. These might include standardized order sets, protocols, and charting tools.

Metrics: This group will focus on defining useful metrics for performing glycemic control research and quality improvement projects. This group intends to define the best ways to measure glycemic control, balancing measures, process measures, and other specific outcomes. These metrics will allow hospitals to examine their current performance and to develop quality standards for inpatient glycemic control.

Care transitions: This group is charged with beginning to identify and address the many challenges that are faced when diabetic and/or hyperglycemic patients move from one care setting to another (e.g., ICU to general ward, hospital to outpatient setting). The work done by this group is likely to have an impact on all of the other groups.

Potential deliverables from this group include a set of standards that can be applied to care transitions. There may also be specific clinical tools developed to improve the process of these care transitions, such as checklists, order sets, and protocols.

Promotional: This group will focus on creating national awareness of the importance of glycemic control in hospitals, particularly at the administrative level. This may include efforts to partner with relevant medical societies, regulatory agencies, and other professional organizations focused on improving glycemic control.

Goals and Timelines

The three-month goal is for each of the focus groups is to further delineate the gaps in the existing resources, and to further refine the specific deliverables that they will produce. Each group will need to determine specific goals and timelines.

An intermediate-term goal is the formation of a white paper that will describe, in detail, the existing glycemic control resources, the gaps in these resources, and the need for additional work in these areas.

In addition, work on the glycemic control quality improvement workbook is under way, and this resource will be used in the “Quality Improvement Precourse” that will take place May 3, 2006, at the SHM Annual Meeting.

The work being done by this task force will lead to a collection of high-quality, user-friendly resources that will enhance awareness of the issue of inpatient glycemic control and facilitate the implementation of effective inpatient diabetes quality improvement across the nation. The longer term goal will be to bring about demonstration projects in the area of inpatient glycemic control and advance the science of diabetes care in the hospital.

References

1. American College of Endocrinology Task Force on Inpatient Diabetes and Metabolic Control. American College of Endocrinology position statement on inpatient diabetes and metabolic control. Endocr Prac. 2004;10:77-82.
2. Clement S, Braithwaite SS, Magee MF, et al. Management of diabetes and hyperglycemia in hospitals. Diabetes Care. 2004;27:553-591.

Non-Physician Provider Task Force Progress

Annual meeting workshop plans, plus continued Web development

Shm’s Non-Physician Provider Task Force has continued to meet via conference calls on a regular basis. The task force now has representation from the ranks of nurse practitioners, physician assistants, hospitalist clinical care coordinators, health systems pharmacists, and hospitalist physicians. We realize that there are many other professionals vital to hospital medicine and plan to recruit more representatives from the SHM member ranks as qualified individuals are brought to our attention.

Task force members will provide important contributions to the annual meeting. The special interest forum on non-physician providers in hospital medicine has been growing each year. This forum is an important venue for exchanging ideas and meeting fellow professionals. It also gives the task force members a chance to make contact with individuals who want to get involved in Non-Physician Provider Task Force activities.

This year task force members Scarlett Blue, RNC, MSN, CNA, and Ryan Genzink, PAC, will lead the forum. Mitchell Wilson, MD, will lead a workshop, “Integrating Non-Physician Providers into Hospital Medicine Services.” National trends that include decreasing availability of generalist physicians, decreasing workloads for resident physicians, and the rapid growth in hospital medicine as a specialty will make this workshop vital to SHM members faced with these pressures.

The task force remains interested in developing a network for communication within the community of professionals in hospital medicine who have an interest in non-physician provider issues and practice. The Hub-and-Spoke initiative is intended to provide a network to allow more individuals to provide input to the task force. The forum at the annual meeting will be an opportunity to meet task force members, exchange e-mail addresses, and discuss how to become involved.

SHM’s Web site has a link for “Non-Physician Provider Resources,” and the task force has continued to work on the content of this site. The priorities for expansion include adding staffing models, billing and documentation resources, value added by non-physician providers, and FAQs. The task force welcomes SHM members to submit documents for posting to the resource center.

For most of recent history, it has been standard practice to tolerate hyperglycemia and expect some hypoglycemia when caring for diabetic patients in the hospital. This attitude stems from the many barriers to controlling glucose levels in hospitalized patients (e.g., the stress of acute illness and the changes in diet and medications that occur on admission to the hospital). In addition, most diabetic patients are hospitalized for illness other than their diabetes. In these situations, glycemic control may not be a priority, and fear of hypoglycemia may be prominent.

However, in recent years, there has been a change in attitude regarding glycemic control in the hospitalized patient. Recently, clinical studies have shown that hyperglycemia leads to poor outcomes in some hospitalized patients, prompting the American College of Endocrinology and the American Association of Clinical Endocrinologists to publish a position statement on inpatient diabetes and metabolic control.1 In addition, best practice strategies for controlling glucose levels in hospitalized patients have been recently reviewed.2

At the same time, hospitalists have emerged on the scene, bringing with them a new awareness of the gaps between the best practice and real practice. In real practice, both hyperglycemia and hypoglycemia are common, and insulin use in the hospital is often guided by strategies that are based on simplicity, instead of strategies that are based on established principles of diabetes management. There has been remarkably little attention given to the management of diabetes and hyperglycemia in noncritically ill hospitalized patients, and glucose levels are often far outside of the recommended range in this group.

SHM’s Glycemic Control Task Force

The Glycemic Control Task Force was assembled with the intent of improving glycemic control in hospitals nationally by providing hospitalists with an understanding of the best practice of glycemic control in the hospital, and by providing them with the tools and skills to make real changes in their own systems. With the assistance of a grant from Sanofi-Aventis, the Glycemic Control Summit was held on Oct. 20, 2005, in Chicago. A distinguished panel of experts attended, including hospitalists, endocrinologists, nurses, case managers, diabetes educators, and pharmacists. The goals of the meeting were as follows:

1. To identify the currently available resources pertinent to glycemic control in the hospital (e.g., resources related to best practice, education, quality improvement, awareness, clinical tools, research, metrics/quality parameters);
2. To identify the gaps in those resources; and
3. To assemble several focused work groups to address the major gaps in the existing resources, and to determine specific interventions or products that could fill those gaps.

The meeting spawned several smaller work groups that will address the major barriers to improving glycemic control in hospitalized patients. These groups were formed in direct response to the gaps that were identified during the meeting. A description of each of the work groups is provided below, highlighting the major gaps that were identified and the strategies being considered to overcome them.

Education: This group will focus on creating case-based, educational materials that will provide physicians, nurses, and other providers with pragmatic examples illustrating the best practice of glycemic control and insulin management in the hospital and at the transition of care. In addition, this group will address patient education issues, educational metrics, and other issues.

Potential deliverables from this group include Web-based, case-based educational modules applicable to CME or to support quality improvement efforts at individual institutions and patient education materials.

Quality improvement process: This group will focus on formulating a how-to resource for performing quality improvement projects related to glycemic control. This group will attempt to provide hospitalists with a practical guideline to help them successfully implement changes in their own institutions. Topics will include forming and leading a multidisciplinary team, setting goals, defining metrics, and identifying process analysis and evaluation methods.

Deliverables from this group will likely include a glycemic control quality improvement workbook that will guide individuals through the complex process of performing robust quality improvement projects in their own hospitals. This workbook will be similar in format to one that is currently available in the “VTE Quality Improvement Resource Room” on the SHM Web site.

Clinical tools: This group will focus on compiling and appraising already existing clinical tools (e.g., standardized order sets, protocols) and identifying the key features of these tools and the differences among them. The emphasis will be on either compiling or creating ready-to-use clinical tools.

Potential deliverables from this group include a collection of tools that will have substantial built-in decision support and will be useful in a range of settings. These might include standardized order sets, protocols, and charting tools.

Metrics: This group will focus on defining useful metrics for performing glycemic control research and quality improvement projects. This group intends to define the best ways to measure glycemic control, balancing measures, process measures, and other specific outcomes. These metrics will allow hospitals to examine their current performance and to develop quality standards for inpatient glycemic control.

Care transitions: This group is charged with beginning to identify and address the many challenges that are faced when diabetic and/or hyperglycemic patients move from one care setting to another (e.g., ICU to general ward, hospital to outpatient setting). The work done by this group is likely to have an impact on all of the other groups.

Potential deliverables from this group include a set of standards that can be applied to care transitions. There may also be specific clinical tools developed to improve the process of these care transitions, such as checklists, order sets, and protocols.

Promotional: This group will focus on creating national awareness of the importance of glycemic control in hospitals, particularly at the administrative level. This may include efforts to partner with relevant medical societies, regulatory agencies, and other professional organizations focused on improving glycemic control.

Goals and Timelines

The three-month goal is for each of the focus groups is to further delineate the gaps in the existing resources, and to further refine the specific deliverables that they will produce. Each group will need to determine specific goals and timelines.

An intermediate-term goal is the formation of a white paper that will describe, in detail, the existing glycemic control resources, the gaps in these resources, and the need for additional work in these areas.

In addition, work on the glycemic control quality improvement workbook is under way, and this resource will be used in the “Quality Improvement Precourse” that will take place May 3, 2006, at the SHM Annual Meeting.

The work being done by this task force will lead to a collection of high-quality, user-friendly resources that will enhance awareness of the issue of inpatient glycemic control and facilitate the implementation of effective inpatient diabetes quality improvement across the nation. The longer term goal will be to bring about demonstration projects in the area of inpatient glycemic control and advance the science of diabetes care in the hospital.

References

1. American College of Endocrinology Task Force on Inpatient Diabetes and Metabolic Control. American College of Endocrinology position statement on inpatient diabetes and metabolic control. Endocr Prac. 2004;10:77-82.
2. Clement S, Braithwaite SS, Magee MF, et al. Management of diabetes and hyperglycemia in hospitals. Diabetes Care. 2004;27:553-591.

Non-Physician Provider Task Force Progress

Annual meeting workshop plans, plus continued Web development

Shm’s Non-Physician Provider Task Force has continued to meet via conference calls on a regular basis. The task force now has representation from the ranks of nurse practitioners, physician assistants, hospitalist clinical care coordinators, health systems pharmacists, and hospitalist physicians. We realize that there are many other professionals vital to hospital medicine and plan to recruit more representatives from the SHM member ranks as qualified individuals are brought to our attention.

Task force members will provide important contributions to the annual meeting. The special interest forum on non-physician providers in hospital medicine has been growing each year. This forum is an important venue for exchanging ideas and meeting fellow professionals. It also gives the task force members a chance to make contact with individuals who want to get involved in Non-Physician Provider Task Force activities.

This year task force members Scarlett Blue, RNC, MSN, CNA, and Ryan Genzink, PAC, will lead the forum. Mitchell Wilson, MD, will lead a workshop, “Integrating Non-Physician Providers into Hospital Medicine Services.” National trends that include decreasing availability of generalist physicians, decreasing workloads for resident physicians, and the rapid growth in hospital medicine as a specialty will make this workshop vital to SHM members faced with these pressures.

The task force remains interested in developing a network for communication within the community of professionals in hospital medicine who have an interest in non-physician provider issues and practice. The Hub-and-Spoke initiative is intended to provide a network to allow more individuals to provide input to the task force. The forum at the annual meeting will be an opportunity to meet task force members, exchange e-mail addresses, and discuss how to become involved.

SHM’s Web site has a link for “Non-Physician Provider Resources,” and the task force has continued to work on the content of this site. The priorities for expansion include adding staffing models, billing and documentation resources, value added by non-physician providers, and FAQs. The task force welcomes SHM members to submit documents for posting to the resource center.

For most of recent history, it has been standard practice to tolerate hyperglycemia and expect some hypoglycemia when caring for diabetic patients in the hospital. This attitude stems from the many barriers to controlling glucose levels in hospitalized patients (e.g., the stress of acute illness and the changes in diet and medications that occur on admission to the hospital). In addition, most diabetic patients are hospitalized for illness other than their diabetes. In these situations, glycemic control may not be a priority, and fear of hypoglycemia may be prominent.

However, in recent years, there has been a change in attitude regarding glycemic control in the hospitalized patient. Recently, clinical studies have shown that hyperglycemia leads to poor outcomes in some hospitalized patients, prompting the American College of Endocrinology and the American Association of Clinical Endocrinologists to publish a position statement on inpatient diabetes and metabolic control.1 In addition, best practice strategies for controlling glucose levels in hospitalized patients have been recently reviewed.2

At the same time, hospitalists have emerged on the scene, bringing with them a new awareness of the gaps between the best practice and real practice. In real practice, both hyperglycemia and hypoglycemia are common, and insulin use in the hospital is often guided by strategies that are based on simplicity, instead of strategies that are based on established principles of diabetes management. There has been remarkably little attention given to the management of diabetes and hyperglycemia in noncritically ill hospitalized patients, and glucose levels are often far outside of the recommended range in this group.

SHM’s Glycemic Control Task Force

The Glycemic Control Task Force was assembled with the intent of improving glycemic control in hospitals nationally by providing hospitalists with an understanding of the best practice of glycemic control in the hospital, and by providing them with the tools and skills to make real changes in their own systems. With the assistance of a grant from Sanofi-Aventis, the Glycemic Control Summit was held on Oct. 20, 2005, in Chicago. A distinguished panel of experts attended, including hospitalists, endocrinologists, nurses, case managers, diabetes educators, and pharmacists. The goals of the meeting were as follows:

1. To identify the currently available resources pertinent to glycemic control in the hospital (e.g., resources related to best practice, education, quality improvement, awareness, clinical tools, research, metrics/quality parameters);
2. To identify the gaps in those resources; and
3. To assemble several focused work groups to address the major gaps in the existing resources, and to determine specific interventions or products that could fill those gaps.

The meeting spawned several smaller work groups that will address the major barriers to improving glycemic control in hospitalized patients. These groups were formed in direct response to the gaps that were identified during the meeting. A description of each of the work groups is provided below, highlighting the major gaps that were identified and the strategies being considered to overcome them.

Education: This group will focus on creating case-based, educational materials that will provide physicians, nurses, and other providers with pragmatic examples illustrating the best practice of glycemic control and insulin management in the hospital and at the transition of care. In addition, this group will address patient education issues, educational metrics, and other issues.

Potential deliverables from this group include Web-based, case-based educational modules applicable to CME or to support quality improvement efforts at individual institutions and patient education materials.

Quality improvement process: This group will focus on formulating a how-to resource for performing quality improvement projects related to glycemic control. This group will attempt to provide hospitalists with a practical guideline to help them successfully implement changes in their own institutions. Topics will include forming and leading a multidisciplinary team, setting goals, defining metrics, and identifying process analysis and evaluation methods.

Deliverables from this group will likely include a glycemic control quality improvement workbook that will guide individuals through the complex process of performing robust quality improvement projects in their own hospitals. This workbook will be similar in format to one that is currently available in the “VTE Quality Improvement Resource Room” on the SHM Web site.

Clinical tools: This group will focus on compiling and appraising already existing clinical tools (e.g., standardized order sets, protocols) and identifying the key features of these tools and the differences among them. The emphasis will be on either compiling or creating ready-to-use clinical tools.

Potential deliverables from this group include a collection of tools that will have substantial built-in decision support and will be useful in a range of settings. These might include standardized order sets, protocols, and charting tools.

Metrics: This group will focus on defining useful metrics for performing glycemic control research and quality improvement projects. This group intends to define the best ways to measure glycemic control, balancing measures, process measures, and other specific outcomes. These metrics will allow hospitals to examine their current performance and to develop quality standards for inpatient glycemic control.

Care transitions: This group is charged with beginning to identify and address the many challenges that are faced when diabetic and/or hyperglycemic patients move from one care setting to another (e.g., ICU to general ward, hospital to outpatient setting). The work done by this group is likely to have an impact on all of the other groups.

Potential deliverables from this group include a set of standards that can be applied to care transitions. There may also be specific clinical tools developed to improve the process of these care transitions, such as checklists, order sets, and protocols.

Promotional: This group will focus on creating national awareness of the importance of glycemic control in hospitals, particularly at the administrative level. This may include efforts to partner with relevant medical societies, regulatory agencies, and other professional organizations focused on improving glycemic control.

Goals and Timelines

The three-month goal is for each of the focus groups is to further delineate the gaps in the existing resources, and to further refine the specific deliverables that they will produce. Each group will need to determine specific goals and timelines.

An intermediate-term goal is the formation of a white paper that will describe, in detail, the existing glycemic control resources, the gaps in these resources, and the need for additional work in these areas.

In addition, work on the glycemic control quality improvement workbook is under way, and this resource will be used in the “Quality Improvement Precourse” that will take place May 3, 2006, at the SHM Annual Meeting.

The work being done by this task force will lead to a collection of high-quality, user-friendly resources that will enhance awareness of the issue of inpatient glycemic control and facilitate the implementation of effective inpatient diabetes quality improvement across the nation. The longer term goal will be to bring about demonstration projects in the area of inpatient glycemic control and advance the science of diabetes care in the hospital.

References

1. American College of Endocrinology Task Force on Inpatient Diabetes and Metabolic Control. American College of Endocrinology position statement on inpatient diabetes and metabolic control. Endocr Prac. 2004;10:77-82.
2. Clement S, Braithwaite SS, Magee MF, et al. Management of diabetes and hyperglycemia in hospitals. Diabetes Care. 2004;27:553-591.

Non-Physician Provider Task Force Progress

Annual meeting workshop plans, plus continued Web development

Shm’s Non-Physician Provider Task Force has continued to meet via conference calls on a regular basis. The task force now has representation from the ranks of nurse practitioners, physician assistants, hospitalist clinical care coordinators, health systems pharmacists, and hospitalist physicians. We realize that there are many other professionals vital to hospital medicine and plan to recruit more representatives from the SHM member ranks as qualified individuals are brought to our attention.

Task force members will provide important contributions to the annual meeting. The special interest forum on non-physician providers in hospital medicine has been growing each year. This forum is an important venue for exchanging ideas and meeting fellow professionals. It also gives the task force members a chance to make contact with individuals who want to get involved in Non-Physician Provider Task Force activities.

This year task force members Scarlett Blue, RNC, MSN, CNA, and Ryan Genzink, PAC, will lead the forum. Mitchell Wilson, MD, will lead a workshop, “Integrating Non-Physician Providers into Hospital Medicine Services.” National trends that include decreasing availability of generalist physicians, decreasing workloads for resident physicians, and the rapid growth in hospital medicine as a specialty will make this workshop vital to SHM members faced with these pressures.

The task force remains interested in developing a network for communication within the community of professionals in hospital medicine who have an interest in non-physician provider issues and practice. The Hub-and-Spoke initiative is intended to provide a network to allow more individuals to provide input to the task force. The forum at the annual meeting will be an opportunity to meet task force members, exchange e-mail addresses, and discuss how to become involved.

SHM’s Web site has a link for “Non-Physician Provider Resources,” and the task force has continued to work on the content of this site. The priorities for expansion include adding staffing models, billing and documentation resources, value added by non-physician providers, and FAQs. The task force welcomes SHM members to submit documents for posting to the resource center.

The 100 hospitalists who gathered in September at the Vail Cascade Hotel and Spa among Vail, Colorado’s high peaks for SHM’s second Hospitalist Medicine Leadership Academy showed their character early during a simulation led by David Javitch, PhD, a Harvard University instructor. The exercise usually goes like this: The leader auctions $1 bills, with bidders paying their highest bid whether they win or lose. Participants’ aggressive juices flow and someone usually pays $5 or $10 for the lone dollar. Then they realize that their irrational bidding behavior is fueled by their need to compete rather than to cooperate, and the leader discusses the value of cooperation over greed.

But the SHM Leadership Academy hospitalists played the game differently. Dr. Javitch earmarked the proceeds of the auction for a pediatric AIDS foundation. After early bids to $5, one Mississippi doctor who had worked in a hospital without water and electricity during Hurricane Katrina bid $100. The bidding ceased abruptly. Spontaneously, several groups took up collections to boost the donation’s size. This stopped the facilitator in his tracks.

Instead of giving the participants a lesson on the destructive power of greed and competition, the facilitator got a lesson about hospitalist altruism—a dedication to serving people that is transforming how patients are treated in America’s medical centers. This exercise revealed both the pros and the cons of hospitalists’ leadership tendencies.

The Academy Format

Working at round tables of 10, the hospitalists spent all four days in the same small group. Each group was led by a facilitator who guided its exercises, kept the discussion on track, and encouraged participation in feedback and Q&A sessions. The hospitalists were put through their paces by experts in various disciplines relating to hospital medicine, learning about the field’s leadership challenges, its business metrics, strategic planning, understanding various personality traits and communication styles, and managing change and transformation efforts.

The SHM Leadership Academy, which limits attendance to 100, balances lectures with exercises, simulations, personality and communication inventories, and time for questions and sharing about professional issues. There was also time set aside for networking, including at a cocktail party hosted by IPC: The Hospitalist Company, North Hollywood, Calif., as well as sightseeing, biking, and visits to Vail Village to explore local shops and restaurants

Who Attended

The hospitalist attendees came to the Leadership Academy from diverse paths and at various stages of their careers. Some physicians started hospitalist programs fresh from residency, some worked in large teams, some had been in solo and group practice before becoming hospitalists, some were employed by hospitalist groups and health plans, and one started as a community-based solo practice hospitalist. They work in a wide range of settings, from rural and suburban community hospitals to academic medical centers, and in cities large and small.

Russell (“Rusty”) Holman, MD, and Cogent Healthcare’s, Irvine, Calif., national medical director, spelled out the Leadership Academy’s goals: for hospitalists to run their programs more efficiently, improve morale within their groups, maximize team efficiency, and identify critical drivers of success.

“Our goal at this conference is for you to learn new things, to improve your skills as leaders, and to learn how to continually demonstrate value to your CEOs and CFOs,” says Dr. Holman, who also led participants through the analytic steps of a strategic plan in their small groups.

Leadership Challenges

Laurence Wellikson, MD, SHM CEO, spelled out the challenges confronting hospital medicine.

“In a nation that spent $1.7 trillion on healthcare in 2003, or 15.3% of the nation’s GDP, with rising insurance premiums and out-of-pocket costs to consumers, hospitalists will be part of a systemic solution to controlling costs and providing high quality care,” says Dr. Wellikson.

He points out that hospitals are changing rapidly, requiring hospitalists to adapt to work environments in flux. The 20% annual turnover in nursing staffs, PCPs giving up inpatient care, subspecialists narrowing their hospital work, and overcrowded emergency departments all create both opportunities and challenges for hospitalists.

“Hospital medicine is growing rapidly and so are the demands on hospitalists,” adds Dr. Wellikson, who articulated SHM’s goal of helping hospitalists develop their leadership skills in a rapidly changing and complex field. He urges participants to transcend medicine’s “cult of uniqueness among individual doctors” and to lead teams that will reform hospitals internally and provide measurable improvements in patient care quality and reduce waste.

These trends are playing out in a healthcare system that’s forced to do more with less. Michael Guthrie, MD, MBA, executive in residence at the University of Colorado at Denver, points out that hospitalists must assume their CEOs and CFOs mindsets to understand the myriad challenges that arise from the swelling number of uninsured patients, the demands of aging baby boomers, malpractice liability, competition, rapid changes in technology, the need for new buildings, and the emphasis on patient satisfaction and safety. The rise of consumer-directed care resulting from employers shifting healthcare costs to employees has raised concerns about how “shopping around” among hospitals might affect clinical performance.

Dr. Guthrie stresses that value is in the eyes of the beholder and that the hospitalist’s work greatly affects other care team members’ satisfaction, relationships with other physicians, patient satisfaction and safety, and the hospital’s business interests.

“Hospitalists use their knowledge, ideas, skills, and expertise with process improvement to get things done with and through other people,” he explains. “When we understand what problems need to be solved and what our measures of success are we can have the rapture of accomplishment.”

Turmoil throughout the healthcare system and rapid growth of the hospitalist movement provided an apt backdrop for remarks Jack Silversin, DMD, DrPh, made in a session titled, “Leading and Managing Change.” Dr. Silversin is the president of Amicus Inc., a consultant firm based in Cambridge, Mass. He urges physicians to transcend their traditional roles as protectors of the status quo to become sponsors of change instead. Physicians as change agents publicly demonstrate their commitment to being leaders in several important ways.

“Change is definitely more work than maintaining the status quo,” says Dr. Silversin, “but organizations need doctors who sponsor change rather than resist it.”

Working through a simulation of a headstrong hospitalist trying to strong-arm her way to a 24/7 schedule for hospitalists rather than having the medical staff or moonlighters taking night call, participants developed their own insights into handling change.

“You’ve got to start small and gain credibility with little victories rather than doing something major right away,” said one attendee.

Trying to get non-hospitalists to support change was another idea: “Leadership doesn’t always have an MD credential attached to it,” added Dr. Silversin.

Being a change agent means looking inward as well as outward, and to that end attendees at the Leadership Academy spent time exploring their personal strengths and communication styles. Having completed a “Strength Deployment Inventory,” a self-scored test published by Personal Strength Publishing of Carlsbad, Calif., that measures an individual’s motives and values, prior to the conference, the hospitalists—led by Dr. Javitch—determined their strengths and weaknesses on altruism, assertiveness, and analysis. Small groups and dyads role-played situations where a colleague, an administrator, or a subordinate had a vastly different approach to problem-solving and decision-making.

“There are no right or wrong answers here, just a growing awareness of what our strengths are and things we need to guard against,” says Javitch.

Timothy Keogh, PhD, clinical associate professor of Managerial Communication at Tulane University, New Orleans, discussed that effective communication—both spoken and nonverbal—is a key tool skill mastered by good leaders. Explaining that everyone’s façade masks things that are hidden consciously or unconsciously, self-awareness can help us “enlarge our arena and tap into talents that can flower.” He also points out that 80% of our communication style is due to our personality and 20% to environment, and that it “costs us energy to flex.”

Dr. Keogh encouraged attendees to adapt to other communication styles so the listener can hear what is being said. For example, someone with a dominant communication style might be perceived as pushy by a one with a conscientious perfecting style. Completing the DiSC, a self-scored communication and personality style inventory from Inscape Publishing of Minneapolis, 22% of the hospitalists were predominantly creative, while 18% were perfectionists, and 12% inspirational communicators. Dr. Keogh says that this pattern is consistent with norms for physicians, and urged attendees to study how personality types can improve their handling of emotions, goals, values, fears, and judgments.

Throughout the sessions hospitalists raised issues, some of which mesh with others in the hospital, such as top administrators, and some of which don’t mesh. Many spoke candidly about their difficulties growing a hospitalist program beyond an admitting service into a full-blown inpatient medicine service—particularly with office-based colleagues waiting in the wings to be relieved of hospital work. Physician recruitment and retention were very much on their minds, as were rocky relationships with subspecialists, turnover in top administration that results in having to “resell” the hospitalist program to new leaders, and constant pressures to seek new ways to reduce average length of stay and emergency department throughput. Achieving a balance of patient care, committee responsibilities, and teaching and research for physicians interested in those areas were also mentioned.

Looking to the future, Mary Jo Gorman, MD, MD, SHM president-elect and chief medical officer of IPC: The Hospitalist Company, indicates her organizational vision: “It isn’t easy to build something brand new in only one year, so I plan to build on SHM’s momentum. My goal is to keep defining and building hospital medicine as a career rather than as an extension of the house officer path.”

Conclusion

With 100 hospitalists now armed with a new tool kit, Dr. Wellikson outlined SHM’s plans for upcoming Leadership Academies: “Our next Academy is Jan 9-12, 2006 in Tucson [Ariz.], and we’ve added a medical directors’ forum for managing burnout.” An advanced Leadership Academy is also planned for 2006. TH

The 100 hospitalists who gathered in September at the Vail Cascade Hotel and Spa among Vail, Colorado’s high peaks for SHM’s second Hospitalist Medicine Leadership Academy showed their character early during a simulation led by David Javitch, PhD, a Harvard University instructor. The exercise usually goes like this: The leader auctions $1 bills, with bidders paying their highest bid whether they win or lose. Participants’ aggressive juices flow and someone usually pays $5 or $10 for the lone dollar. Then they realize that their irrational bidding behavior is fueled by their need to compete rather than to cooperate, and the leader discusses the value of cooperation over greed.

But the SHM Leadership Academy hospitalists played the game differently. Dr. Javitch earmarked the proceeds of the auction for a pediatric AIDS foundation. After early bids to $5, one Mississippi doctor who had worked in a hospital without water and electricity during Hurricane Katrina bid $100. The bidding ceased abruptly. Spontaneously, several groups took up collections to boost the donation’s size. This stopped the facilitator in his tracks.

Instead of giving the participants a lesson on the destructive power of greed and competition, the facilitator got a lesson about hospitalist altruism—a dedication to serving people that is transforming how patients are treated in America’s medical centers. This exercise revealed both the pros and the cons of hospitalists’ leadership tendencies.

The Academy Format

Working at round tables of 10, the hospitalists spent all four days in the same small group. Each group was led by a facilitator who guided its exercises, kept the discussion on track, and encouraged participation in feedback and Q&A sessions. The hospitalists were put through their paces by experts in various disciplines relating to hospital medicine, learning about the field’s leadership challenges, its business metrics, strategic planning, understanding various personality traits and communication styles, and managing change and transformation efforts.

The SHM Leadership Academy, which limits attendance to 100, balances lectures with exercises, simulations, personality and communication inventories, and time for questions and sharing about professional issues. There was also time set aside for networking, including at a cocktail party hosted by IPC: The Hospitalist Company, North Hollywood, Calif., as well as sightseeing, biking, and visits to Vail Village to explore local shops and restaurants

Who Attended

The hospitalist attendees came to the Leadership Academy from diverse paths and at various stages of their careers. Some physicians started hospitalist programs fresh from residency, some worked in large teams, some had been in solo and group practice before becoming hospitalists, some were employed by hospitalist groups and health plans, and one started as a community-based solo practice hospitalist. They work in a wide range of settings, from rural and suburban community hospitals to academic medical centers, and in cities large and small.

Russell (“Rusty”) Holman, MD, and Cogent Healthcare’s, Irvine, Calif., national medical director, spelled out the Leadership Academy’s goals: for hospitalists to run their programs more efficiently, improve morale within their groups, maximize team efficiency, and identify critical drivers of success.

“Our goal at this conference is for you to learn new things, to improve your skills as leaders, and to learn how to continually demonstrate value to your CEOs and CFOs,” says Dr. Holman, who also led participants through the analytic steps of a strategic plan in their small groups.

Leadership Challenges

Laurence Wellikson, MD, SHM CEO, spelled out the challenges confronting hospital medicine.

“In a nation that spent $1.7 trillion on healthcare in 2003, or 15.3% of the nation’s GDP, with rising insurance premiums and out-of-pocket costs to consumers, hospitalists will be part of a systemic solution to controlling costs and providing high quality care,” says Dr. Wellikson.

He points out that hospitals are changing rapidly, requiring hospitalists to adapt to work environments in flux. The 20% annual turnover in nursing staffs, PCPs giving up inpatient care, subspecialists narrowing their hospital work, and overcrowded emergency departments all create both opportunities and challenges for hospitalists.

“Hospital medicine is growing rapidly and so are the demands on hospitalists,” adds Dr. Wellikson, who articulated SHM’s goal of helping hospitalists develop their leadership skills in a rapidly changing and complex field. He urges participants to transcend medicine’s “cult of uniqueness among individual doctors” and to lead teams that will reform hospitals internally and provide measurable improvements in patient care quality and reduce waste.

These trends are playing out in a healthcare system that’s forced to do more with less. Michael Guthrie, MD, MBA, executive in residence at the University of Colorado at Denver, points out that hospitalists must assume their CEOs and CFOs mindsets to understand the myriad challenges that arise from the swelling number of uninsured patients, the demands of aging baby boomers, malpractice liability, competition, rapid changes in technology, the need for new buildings, and the emphasis on patient satisfaction and safety. The rise of consumer-directed care resulting from employers shifting healthcare costs to employees has raised concerns about how “shopping around” among hospitals might affect clinical performance.

Dr. Guthrie stresses that value is in the eyes of the beholder and that the hospitalist’s work greatly affects other care team members’ satisfaction, relationships with other physicians, patient satisfaction and safety, and the hospital’s business interests.

“Hospitalists use their knowledge, ideas, skills, and expertise with process improvement to get things done with and through other people,” he explains. “When we understand what problems need to be solved and what our measures of success are we can have the rapture of accomplishment.”

Turmoil throughout the healthcare system and rapid growth of the hospitalist movement provided an apt backdrop for remarks Jack Silversin, DMD, DrPh, made in a session titled, “Leading and Managing Change.” Dr. Silversin is the president of Amicus Inc., a consultant firm based in Cambridge, Mass. He urges physicians to transcend their traditional roles as protectors of the status quo to become sponsors of change instead. Physicians as change agents publicly demonstrate their commitment to being leaders in several important ways.

“Change is definitely more work than maintaining the status quo,” says Dr. Silversin, “but organizations need doctors who sponsor change rather than resist it.”

Working through a simulation of a headstrong hospitalist trying to strong-arm her way to a 24/7 schedule for hospitalists rather than having the medical staff or moonlighters taking night call, participants developed their own insights into handling change.

“You’ve got to start small and gain credibility with little victories rather than doing something major right away,” said one attendee.

Trying to get non-hospitalists to support change was another idea: “Leadership doesn’t always have an MD credential attached to it,” added Dr. Silversin.

Being a change agent means looking inward as well as outward, and to that end attendees at the Leadership Academy spent time exploring their personal strengths and communication styles. Having completed a “Strength Deployment Inventory,” a self-scored test published by Personal Strength Publishing of Carlsbad, Calif., that measures an individual’s motives and values, prior to the conference, the hospitalists—led by Dr. Javitch—determined their strengths and weaknesses on altruism, assertiveness, and analysis. Small groups and dyads role-played situations where a colleague, an administrator, or a subordinate had a vastly different approach to problem-solving and decision-making.

“There are no right or wrong answers here, just a growing awareness of what our strengths are and things we need to guard against,” says Javitch.

Timothy Keogh, PhD, clinical associate professor of Managerial Communication at Tulane University, New Orleans, discussed that effective communication—both spoken and nonverbal—is a key tool skill mastered by good leaders. Explaining that everyone’s façade masks things that are hidden consciously or unconsciously, self-awareness can help us “enlarge our arena and tap into talents that can flower.” He also points out that 80% of our communication style is due to our personality and 20% to environment, and that it “costs us energy to flex.”

Dr. Keogh encouraged attendees to adapt to other communication styles so the listener can hear what is being said. For example, someone with a dominant communication style might be perceived as pushy by a one with a conscientious perfecting style. Completing the DiSC, a self-scored communication and personality style inventory from Inscape Publishing of Minneapolis, 22% of the hospitalists were predominantly creative, while 18% were perfectionists, and 12% inspirational communicators. Dr. Keogh says that this pattern is consistent with norms for physicians, and urged attendees to study how personality types can improve their handling of emotions, goals, values, fears, and judgments.

Throughout the sessions hospitalists raised issues, some of which mesh with others in the hospital, such as top administrators, and some of which don’t mesh. Many spoke candidly about their difficulties growing a hospitalist program beyond an admitting service into a full-blown inpatient medicine service—particularly with office-based colleagues waiting in the wings to be relieved of hospital work. Physician recruitment and retention were very much on their minds, as were rocky relationships with subspecialists, turnover in top administration that results in having to “resell” the hospitalist program to new leaders, and constant pressures to seek new ways to reduce average length of stay and emergency department throughput. Achieving a balance of patient care, committee responsibilities, and teaching and research for physicians interested in those areas were also mentioned.

Looking to the future, Mary Jo Gorman, MD, MD, SHM president-elect and chief medical officer of IPC: The Hospitalist Company, indicates her organizational vision: “It isn’t easy to build something brand new in only one year, so I plan to build on SHM’s momentum. My goal is to keep defining and building hospital medicine as a career rather than as an extension of the house officer path.”

Conclusion

With 100 hospitalists now armed with a new tool kit, Dr. Wellikson outlined SHM’s plans for upcoming Leadership Academies: “Our next Academy is Jan 9-12, 2006 in Tucson [Ariz.], and we’ve added a medical directors’ forum for managing burnout.” An advanced Leadership Academy is also planned for 2006. TH

The 100 hospitalists who gathered in September at the Vail Cascade Hotel and Spa among Vail, Colorado’s high peaks for SHM’s second Hospitalist Medicine Leadership Academy showed their character early during a simulation led by David Javitch, PhD, a Harvard University instructor. The exercise usually goes like this: The leader auctions $1 bills, with bidders paying their highest bid whether they win or lose. Participants’ aggressive juices flow and someone usually pays $5 or $10 for the lone dollar. Then they realize that their irrational bidding behavior is fueled by their need to compete rather than to cooperate, and the leader discusses the value of cooperation over greed.

But the SHM Leadership Academy hospitalists played the game differently. Dr. Javitch earmarked the proceeds of the auction for a pediatric AIDS foundation. After early bids to $5, one Mississippi doctor who had worked in a hospital without water and electricity during Hurricane Katrina bid $100. The bidding ceased abruptly. Spontaneously, several groups took up collections to boost the donation’s size. This stopped the facilitator in his tracks.

Instead of giving the participants a lesson on the destructive power of greed and competition, the facilitator got a lesson about hospitalist altruism—a dedication to serving people that is transforming how patients are treated in America’s medical centers. This exercise revealed both the pros and the cons of hospitalists’ leadership tendencies.

The Academy Format

Working at round tables of 10, the hospitalists spent all four days in the same small group. Each group was led by a facilitator who guided its exercises, kept the discussion on track, and encouraged participation in feedback and Q&A sessions. The hospitalists were put through their paces by experts in various disciplines relating to hospital medicine, learning about the field’s leadership challenges, its business metrics, strategic planning, understanding various personality traits and communication styles, and managing change and transformation efforts.

The SHM Leadership Academy, which limits attendance to 100, balances lectures with exercises, simulations, personality and communication inventories, and time for questions and sharing about professional issues. There was also time set aside for networking, including at a cocktail party hosted by IPC: The Hospitalist Company, North Hollywood, Calif., as well as sightseeing, biking, and visits to Vail Village to explore local shops and restaurants

Who Attended

The hospitalist attendees came to the Leadership Academy from diverse paths and at various stages of their careers. Some physicians started hospitalist programs fresh from residency, some worked in large teams, some had been in solo and group practice before becoming hospitalists, some were employed by hospitalist groups and health plans, and one started as a community-based solo practice hospitalist. They work in a wide range of settings, from rural and suburban community hospitals to academic medical centers, and in cities large and small.

Russell (“Rusty”) Holman, MD, and Cogent Healthcare’s, Irvine, Calif., national medical director, spelled out the Leadership Academy’s goals: for hospitalists to run their programs more efficiently, improve morale within their groups, maximize team efficiency, and identify critical drivers of success.

“Our goal at this conference is for you to learn new things, to improve your skills as leaders, and to learn how to continually demonstrate value to your CEOs and CFOs,” says Dr. Holman, who also led participants through the analytic steps of a strategic plan in their small groups.

Leadership Challenges

Laurence Wellikson, MD, SHM CEO, spelled out the challenges confronting hospital medicine.

“In a nation that spent $1.7 trillion on healthcare in 2003, or 15.3% of the nation’s GDP, with rising insurance premiums and out-of-pocket costs to consumers, hospitalists will be part of a systemic solution to controlling costs and providing high quality care,” says Dr. Wellikson.

He points out that hospitals are changing rapidly, requiring hospitalists to adapt to work environments in flux. The 20% annual turnover in nursing staffs, PCPs giving up inpatient care, subspecialists narrowing their hospital work, and overcrowded emergency departments all create both opportunities and challenges for hospitalists.

“Hospital medicine is growing rapidly and so are the demands on hospitalists,” adds Dr. Wellikson, who articulated SHM’s goal of helping hospitalists develop their leadership skills in a rapidly changing and complex field. He urges participants to transcend medicine’s “cult of uniqueness among individual doctors” and to lead teams that will reform hospitals internally and provide measurable improvements in patient care quality and reduce waste.

These trends are playing out in a healthcare system that’s forced to do more with less. Michael Guthrie, MD, MBA, executive in residence at the University of Colorado at Denver, points out that hospitalists must assume their CEOs and CFOs mindsets to understand the myriad challenges that arise from the swelling number of uninsured patients, the demands of aging baby boomers, malpractice liability, competition, rapid changes in technology, the need for new buildings, and the emphasis on patient satisfaction and safety. The rise of consumer-directed care resulting from employers shifting healthcare costs to employees has raised concerns about how “shopping around” among hospitals might affect clinical performance.

Dr. Guthrie stresses that value is in the eyes of the beholder and that the hospitalist’s work greatly affects other care team members’ satisfaction, relationships with other physicians, patient satisfaction and safety, and the hospital’s business interests.

“Hospitalists use their knowledge, ideas, skills, and expertise with process improvement to get things done with and through other people,” he explains. “When we understand what problems need to be solved and what our measures of success are we can have the rapture of accomplishment.”

Turmoil throughout the healthcare system and rapid growth of the hospitalist movement provided an apt backdrop for remarks Jack Silversin, DMD, DrPh, made in a session titled, “Leading and Managing Change.” Dr. Silversin is the president of Amicus Inc., a consultant firm based in Cambridge, Mass. He urges physicians to transcend their traditional roles as protectors of the status quo to become sponsors of change instead. Physicians as change agents publicly demonstrate their commitment to being leaders in several important ways.

“Change is definitely more work than maintaining the status quo,” says Dr. Silversin, “but organizations need doctors who sponsor change rather than resist it.”

Working through a simulation of a headstrong hospitalist trying to strong-arm her way to a 24/7 schedule for hospitalists rather than having the medical staff or moonlighters taking night call, participants developed their own insights into handling change.

“You’ve got to start small and gain credibility with little victories rather than doing something major right away,” said one attendee.

Trying to get non-hospitalists to support change was another idea: “Leadership doesn’t always have an MD credential attached to it,” added Dr. Silversin.

Being a change agent means looking inward as well as outward, and to that end attendees at the Leadership Academy spent time exploring their personal strengths and communication styles. Having completed a “Strength Deployment Inventory,” a self-scored test published by Personal Strength Publishing of Carlsbad, Calif., that measures an individual’s motives and values, prior to the conference, the hospitalists—led by Dr. Javitch—determined their strengths and weaknesses on altruism, assertiveness, and analysis. Small groups and dyads role-played situations where a colleague, an administrator, or a subordinate had a vastly different approach to problem-solving and decision-making.

“There are no right or wrong answers here, just a growing awareness of what our strengths are and things we need to guard against,” says Javitch.

Timothy Keogh, PhD, clinical associate professor of Managerial Communication at Tulane University, New Orleans, discussed that effective communication—both spoken and nonverbal—is a key tool skill mastered by good leaders. Explaining that everyone’s façade masks things that are hidden consciously or unconsciously, self-awareness can help us “enlarge our arena and tap into talents that can flower.” He also points out that 80% of our communication style is due to our personality and 20% to environment, and that it “costs us energy to flex.”

Dr. Keogh encouraged attendees to adapt to other communication styles so the listener can hear what is being said. For example, someone with a dominant communication style might be perceived as pushy by a one with a conscientious perfecting style. Completing the DiSC, a self-scored communication and personality style inventory from Inscape Publishing of Minneapolis, 22% of the hospitalists were predominantly creative, while 18% were perfectionists, and 12% inspirational communicators. Dr. Keogh says that this pattern is consistent with norms for physicians, and urged attendees to study how personality types can improve their handling of emotions, goals, values, fears, and judgments.

Throughout the sessions hospitalists raised issues, some of which mesh with others in the hospital, such as top administrators, and some of which don’t mesh. Many spoke candidly about their difficulties growing a hospitalist program beyond an admitting service into a full-blown inpatient medicine service—particularly with office-based colleagues waiting in the wings to be relieved of hospital work. Physician recruitment and retention were very much on their minds, as were rocky relationships with subspecialists, turnover in top administration that results in having to “resell” the hospitalist program to new leaders, and constant pressures to seek new ways to reduce average length of stay and emergency department throughput. Achieving a balance of patient care, committee responsibilities, and teaching and research for physicians interested in those areas were also mentioned.

Looking to the future, Mary Jo Gorman, MD, MD, SHM president-elect and chief medical officer of IPC: The Hospitalist Company, indicates her organizational vision: “It isn’t easy to build something brand new in only one year, so I plan to build on SHM’s momentum. My goal is to keep defining and building hospital medicine as a career rather than as an extension of the house officer path.”

Conclusion

With 100 hospitalists now armed with a new tool kit, Dr. Wellikson outlined SHM’s plans for upcoming Leadership Academies: “Our next Academy is Jan 9-12, 2006 in Tucson [Ariz.], and we’ve added a medical directors’ forum for managing burnout.” An advanced Leadership Academy is also planned for 2006. TH

H­as the time come for a major overhaul of internal medicine training to better prepare new physicians for the reality of medical practice they will face in the 21st century? Has hospital medicine’s rapid growth been one indication that the roles internists are being asked to perform are in many ways different from just a decade earlier? Are these concerns just as applicable for young family practitioners and pediatricians?

On Dec. 2, 2005, the Alliance for Academic Internal Medicine (AAIM) and the American Board of Internal Medicine (ABIM) brought together more than 40 of the key opinion leaders in internal medicine to look into these very issues. This watershed meeting included the top leaders at ABIM, the American College of Physicians (ACP), the Association of Program Directors in Internal Medicine (APDIM), the Association of Professors of Medicine (APM), all of the medical subspecialty societies, the American Medical Association (AMA), the AMA/Specialty Society RVS Update Committee (RUC), and the American Association of Medical Colleges (AAMC). And, yes, SHM, was well represented.

In addition to agreeing that an overhaul of internal medicine residency training is long overdue, part of this meeting was also devoted to potential changes in the maintenance of certification process to allow for formal recognition of expertise in hospital medicine and ambulatory internal medicine. More about that later.

APDIM and APM, representing the collective organizations in AAIM, presented a plan for revision in training that would identify a core of internal medicine that could form the basis for the front end of training (e.g., possibly the first two years) and allow for a concentration in the later stages of internal medicine residencies. This might take the form of a third year with an emphasis in hospital medicine, ambulatory medicine, traditional internal medicine, or one of the medical subspecialties.

Amazingly, this approach was almost universally accepted by the attendees at the Dec. 2 meeting. With this broad support, AAIM plans to push forward in the coming months, disseminating details of their plan with an opportunity for a broader comment on just what would constitute the “core” of internal medicine. APM and APDIM then plan to take this input and come back by midyear with a more fleshed out proposal.

Of interest is that SHM is publishing the Core Competencies in Hospital Medicine as a supplement to the first issue of the Journal of Hospital Medicine. The work hospitalist thought leaders have put into defining these core competencies over the last few years should be helpful in providing the hospital medicine slant on the core of internal medicine as well as forming the basis for the curriculum with concentration in hospital medicine in the third year of training.

While the goal is to allow training to reflect the career choices of today’s internists and to better prepare them for their professional lives, the devil is truly in the details. Besides serving as a platform for education, internal medicine residency has evolved into a major service load supporting many health systems. Any revision to internal medicine residency needs to accommodate for the service load. In addition, any changes need to be blended into subspecialty fellowship training.

Weaved into this entire discussion was the evolving reshaping of internal medicine. At one time the well-trained general internist was the consummate well-rounded physician serving as a consultant on many diseases to surgeons and other physicians. The last quarter of the 20th century saw the blossoming of many subspecialties in internal medicine and in the last decade a further sub-subspecialization with endoscopists, electrophysiologists, and the like. As the complexity and demands increased in recent years in both the hospital and the outpatient arena, some internists chose to limit their practice to the hospital or the office, and hospital medicine grew and its competencies became more defined.

As internists further refined their skills and narrowed their professional focus, their expectations of their certification and especially their maintenance of certification (MOC) by the ABIM became an issue. Is the MOC process relevant to what they feel they do and should know?

In addition, many subspecialty societies have concerns about how maintaining a basis in internal medicine fits in with MOC in their subspecialties. At this meeting it became clear that many subspecialists feel there is a core of internal medicine they should continue to know and be evaluated on without being expected to know everything a practicing hospitalist or ambulatory internist knows. For example, a cardiologist may be expected to know when their diabetic patients are getting into trouble and need consultation but may not need to know the intricacies of managing extremes in glycemic control.

Many at this meeting felt that the time is now here for using the MOC process to offer those initially credentialed in general internal medicine to have their MOC evaluation tailored to their real-life practice as a hospitalist or an internist with an ambulatory practice and to allow for them to be identified as having expertise in hospital or ambulatory medicine. This was a recognition that these aspects of what have traditionally been lumped together as general internal medicine have key defined skills and knowledge and needs to be recognized as more than just an internist who is not a subspecialist.

Once again there is still much work to be done. SHM, ACP, SGIM, and others will need to work with ABIM and RUC and others to define the skills and the competencies that would form the basis for the training and evaluation of new and improved internists in the 21st century.

The good news from the Dec. 2, 2005, meeting in Dallas is that the national leadership in internal medicine recognizes the need to change internal medicine residency training and to have an MOC process that is relevant to all internists—general internists, subspecialists, and hospitalists. There was also a sense that this process needs to move forward with reasoned speed. We don’t need to write another white paper and declare victory. Today’s and tomorrow’s internists and our patients need us to provide the leadership to produce the best trained and motivated internists and subspecialists to meet the increasing needs of a sophisticated and aging population.

As always SHM will be there, playing an active role. Whatever we come up with for internal medicine I hope can be applicable to family practice and pediatrics as well. Because this is the professional world you will live in, we will continue to invite your input and ideas. TH

Dr. Wellikson has been CEO of SHM since 2000.

H­as the time come for a major overhaul of internal medicine training to better prepare new physicians for the reality of medical practice they will face in the 21st century? Has hospital medicine’s rapid growth been one indication that the roles internists are being asked to perform are in many ways different from just a decade earlier? Are these concerns just as applicable for young family practitioners and pediatricians?

On Dec. 2, 2005, the Alliance for Academic Internal Medicine (AAIM) and the American Board of Internal Medicine (ABIM) brought together more than 40 of the key opinion leaders in internal medicine to look into these very issues. This watershed meeting included the top leaders at ABIM, the American College of Physicians (ACP), the Association of Program Directors in Internal Medicine (APDIM), the Association of Professors of Medicine (APM), all of the medical subspecialty societies, the American Medical Association (AMA), the AMA/Specialty Society RVS Update Committee (RUC), and the American Association of Medical Colleges (AAMC). And, yes, SHM, was well represented.

In addition to agreeing that an overhaul of internal medicine residency training is long overdue, part of this meeting was also devoted to potential changes in the maintenance of certification process to allow for formal recognition of expertise in hospital medicine and ambulatory internal medicine. More about that later.

APDIM and APM, representing the collective organizations in AAIM, presented a plan for revision in training that would identify a core of internal medicine that could form the basis for the front end of training (e.g., possibly the first two years) and allow for a concentration in the later stages of internal medicine residencies. This might take the form of a third year with an emphasis in hospital medicine, ambulatory medicine, traditional internal medicine, or one of the medical subspecialties.

Amazingly, this approach was almost universally accepted by the attendees at the Dec. 2 meeting. With this broad support, AAIM plans to push forward in the coming months, disseminating details of their plan with an opportunity for a broader comment on just what would constitute the “core” of internal medicine. APM and APDIM then plan to take this input and come back by midyear with a more fleshed out proposal.

Of interest is that SHM is publishing the Core Competencies in Hospital Medicine as a supplement to the first issue of the Journal of Hospital Medicine. The work hospitalist thought leaders have put into defining these core competencies over the last few years should be helpful in providing the hospital medicine slant on the core of internal medicine as well as forming the basis for the curriculum with concentration in hospital medicine in the third year of training.

While the goal is to allow training to reflect the career choices of today’s internists and to better prepare them for their professional lives, the devil is truly in the details. Besides serving as a platform for education, internal medicine residency has evolved into a major service load supporting many health systems. Any revision to internal medicine residency needs to accommodate for the service load. In addition, any changes need to be blended into subspecialty fellowship training.

Weaved into this entire discussion was the evolving reshaping of internal medicine. At one time the well-trained general internist was the consummate well-rounded physician serving as a consultant on many diseases to surgeons and other physicians. The last quarter of the 20th century saw the blossoming of many subspecialties in internal medicine and in the last decade a further sub-subspecialization with endoscopists, electrophysiologists, and the like. As the complexity and demands increased in recent years in both the hospital and the outpatient arena, some internists chose to limit their practice to the hospital or the office, and hospital medicine grew and its competencies became more defined.

As internists further refined their skills and narrowed their professional focus, their expectations of their certification and especially their maintenance of certification (MOC) by the ABIM became an issue. Is the MOC process relevant to what they feel they do and should know?

In addition, many subspecialty societies have concerns about how maintaining a basis in internal medicine fits in with MOC in their subspecialties. At this meeting it became clear that many subspecialists feel there is a core of internal medicine they should continue to know and be evaluated on without being expected to know everything a practicing hospitalist or ambulatory internist knows. For example, a cardiologist may be expected to know when their diabetic patients are getting into trouble and need consultation but may not need to know the intricacies of managing extremes in glycemic control.

Many at this meeting felt that the time is now here for using the MOC process to offer those initially credentialed in general internal medicine to have their MOC evaluation tailored to their real-life practice as a hospitalist or an internist with an ambulatory practice and to allow for them to be identified as having expertise in hospital or ambulatory medicine. This was a recognition that these aspects of what have traditionally been lumped together as general internal medicine have key defined skills and knowledge and needs to be recognized as more than just an internist who is not a subspecialist.

Once again there is still much work to be done. SHM, ACP, SGIM, and others will need to work with ABIM and RUC and others to define the skills and the competencies that would form the basis for the training and evaluation of new and improved internists in the 21st century.

The good news from the Dec. 2, 2005, meeting in Dallas is that the national leadership in internal medicine recognizes the need to change internal medicine residency training and to have an MOC process that is relevant to all internists—general internists, subspecialists, and hospitalists. There was also a sense that this process needs to move forward with reasoned speed. We don’t need to write another white paper and declare victory. Today’s and tomorrow’s internists and our patients need us to provide the leadership to produce the best trained and motivated internists and subspecialists to meet the increasing needs of a sophisticated and aging population.

As always SHM will be there, playing an active role. Whatever we come up with for internal medicine I hope can be applicable to family practice and pediatrics as well. Because this is the professional world you will live in, we will continue to invite your input and ideas. TH

Dr. Wellikson has been CEO of SHM since 2000.

H­as the time come for a major overhaul of internal medicine training to better prepare new physicians for the reality of medical practice they will face in the 21st century? Has hospital medicine’s rapid growth been one indication that the roles internists are being asked to perform are in many ways different from just a decade earlier? Are these concerns just as applicable for young family practitioners and pediatricians?

On Dec. 2, 2005, the Alliance for Academic Internal Medicine (AAIM) and the American Board of Internal Medicine (ABIM) brought together more than 40 of the key opinion leaders in internal medicine to look into these very issues. This watershed meeting included the top leaders at ABIM, the American College of Physicians (ACP), the Association of Program Directors in Internal Medicine (APDIM), the Association of Professors of Medicine (APM), all of the medical subspecialty societies, the American Medical Association (AMA), the AMA/Specialty Society RVS Update Committee (RUC), and the American Association of Medical Colleges (AAMC). And, yes, SHM, was well represented.

In addition to agreeing that an overhaul of internal medicine residency training is long overdue, part of this meeting was also devoted to potential changes in the maintenance of certification process to allow for formal recognition of expertise in hospital medicine and ambulatory internal medicine. More about that later.

APDIM and APM, representing the collective organizations in AAIM, presented a plan for revision in training that would identify a core of internal medicine that could form the basis for the front end of training (e.g., possibly the first two years) and allow for a concentration in the later stages of internal medicine residencies. This might take the form of a third year with an emphasis in hospital medicine, ambulatory medicine, traditional internal medicine, or one of the medical subspecialties.

Amazingly, this approach was almost universally accepted by the attendees at the Dec. 2 meeting. With this broad support, AAIM plans to push forward in the coming months, disseminating details of their plan with an opportunity for a broader comment on just what would constitute the “core” of internal medicine. APM and APDIM then plan to take this input and come back by midyear with a more fleshed out proposal.

Of interest is that SHM is publishing the Core Competencies in Hospital Medicine as a supplement to the first issue of the Journal of Hospital Medicine. The work hospitalist thought leaders have put into defining these core competencies over the last few years should be helpful in providing the hospital medicine slant on the core of internal medicine as well as forming the basis for the curriculum with concentration in hospital medicine in the third year of training.

While the goal is to allow training to reflect the career choices of today’s internists and to better prepare them for their professional lives, the devil is truly in the details. Besides serving as a platform for education, internal medicine residency has evolved into a major service load supporting many health systems. Any revision to internal medicine residency needs to accommodate for the service load. In addition, any changes need to be blended into subspecialty fellowship training.

Weaved into this entire discussion was the evolving reshaping of internal medicine. At one time the well-trained general internist was the consummate well-rounded physician serving as a consultant on many diseases to surgeons and other physicians. The last quarter of the 20th century saw the blossoming of many subspecialties in internal medicine and in the last decade a further sub-subspecialization with endoscopists, electrophysiologists, and the like. As the complexity and demands increased in recent years in both the hospital and the outpatient arena, some internists chose to limit their practice to the hospital or the office, and hospital medicine grew and its competencies became more defined.

As internists further refined their skills and narrowed their professional focus, their expectations of their certification and especially their maintenance of certification (MOC) by the ABIM became an issue. Is the MOC process relevant to what they feel they do and should know?

In addition, many subspecialty societies have concerns about how maintaining a basis in internal medicine fits in with MOC in their subspecialties. At this meeting it became clear that many subspecialists feel there is a core of internal medicine they should continue to know and be evaluated on without being expected to know everything a practicing hospitalist or ambulatory internist knows. For example, a cardiologist may be expected to know when their diabetic patients are getting into trouble and need consultation but may not need to know the intricacies of managing extremes in glycemic control.

Many at this meeting felt that the time is now here for using the MOC process to offer those initially credentialed in general internal medicine to have their MOC evaluation tailored to their real-life practice as a hospitalist or an internist with an ambulatory practice and to allow for them to be identified as having expertise in hospital or ambulatory medicine. This was a recognition that these aspects of what have traditionally been lumped together as general internal medicine have key defined skills and knowledge and needs to be recognized as more than just an internist who is not a subspecialist.

Once again there is still much work to be done. SHM, ACP, SGIM, and others will need to work with ABIM and RUC and others to define the skills and the competencies that would form the basis for the training and evaluation of new and improved internists in the 21st century.

The good news from the Dec. 2, 2005, meeting in Dallas is that the national leadership in internal medicine recognizes the need to change internal medicine residency training and to have an MOC process that is relevant to all internists—general internists, subspecialists, and hospitalists. There was also a sense that this process needs to move forward with reasoned speed. We don’t need to write another white paper and declare victory. Today’s and tomorrow’s internists and our patients need us to provide the leadership to produce the best trained and motivated internists and subspecialists to meet the increasing needs of a sophisticated and aging population.

As always SHM will be there, playing an active role. Whatever we come up with for internal medicine I hope can be applicable to family practice and pediatrics as well. Because this is the professional world you will live in, we will continue to invite your input and ideas. TH

Dr. Wellikson has been CEO of SHM since 2000.

When I meet new people, I’m commonly asked, “So what do you do?” The first answer is easy: “I’m a doctor.” It’s the follow-up question that’s tricky: “What kind of doctor?”

“I’m a hospitalist,” I say.

“What’s that?”

I imagine that each of us faces similar questions almost daily from friends, family, patients, or strangers we meet. This tells me people are still learning who we are and what we are. I also imagine each of us has developed a standard way of answering that second question.

I like to say that a hospitalist is “a doctor who is an expert in taking care of people in the hospital.” Though not necessarily comprehensive, my definition usually does the job in casual conversation. In many ways I find this explanation easier than when I tried to describe myself as an “internist,” for which I never developed an easy definition. My favorite one-liner for internist was “pediatrician for adults,” but even that prompted blank stares or polite nods.

Early Definitions of Hospitalists

My definition certainly works in casual conversation. But the question gets to the heart of who we are, what we do, and what our field is about. Our ability to define these issues is critical to clarifying what hospitalists and hospital medicine are about.

It is interesting to look at early definitions of hospitalists. The first time the word hospitalist was published in 1996, hospitalists were defined as “specialists in inpatient medicine ... who will be responsible for managing the care of hospitalized patients in the same way that primary care physicians are responsible for managing the care of outpatients.”1

At the beginning there was a need to compare what hospitalists do, or will do, to something that was already known. The concept was so new that it needed an analogy to be explained. Even in 1999, a paper published in Annals of Internal Medicine defined hospitalists as “physicians who assume the care of hospitalized patients in place of the patients’ primary care provider.”2

Three years after the term was first coined, hospitalists were still being defined in relationship to other physicians. Another paper in Annals of Internal Medicine in 1999 defined a hospitalist as “a physician who spends at least 25% of his or her time serving as the physician-of-record for inpatients, during which time he or she accepts ‘hand-offs’ of hospitalized patients from primary care providers, returning patients to their primary care providers at the time of hospital discharge.”3 Of course that definition was quite a mouthful when explaining what you do to, say, your mother. But there were two important issues wrapped up in that definition.

The first was recognizing that some hospitalists were primarily engaged in research or leadership positions and did not provide a great deal of direct patient care, yet clearly defined themselves as hospitalists. The second was that we were still defined by our relationship to the primary care physician role. Our field was too new to be defined on its own and had to be explained in terms of the existing paradigm.

What became clear was that hospitalists should not be defined by the amount of inpatient care we provided but by our professional focus. For many hospitalists, the thought of caring for hospitalized patients only 25% of the time seemed ridiculous. To others involved in leadership or research who focused exclusively on hospital medicine yet did little patient care the definition seemed too restrictive.

In the end, any definition of hospitalists that depended on time could not encompass the wide range of roles and responsibilities that hospitalists held. Finally, a few months ago, hospitalist was included in the dictionary for the first time. The 2005 update of the Eleventh edition of Merriam-Webster’s Collegiate Dictionary defines a hospitalist as “a physician who specializes in treating hospitalized patients of other physicians in order to minimize the number of hospital visits by other physicians.” Although I am delighted to see hospitalist in the dictionary, this definition is too limited to be useful or accurate. It is certainly true that the presence of hospitalists means other physicians can come to the hospital less, but that is far from what hospitalists or hospital medicine are about.

SHM Definition of Hospitalists

Our society has an official definition of hospitalists: “Physicians whose primary professional focus is the general medical care of hospitalized patients. Their activities include patient care, teaching, research, and leadership related to hospital medicine.”

I wish the dictionary had used this definition because it gets to the heart of what hospitalists are and defines us in a positive way, on our own terms, and not in relation to other physicians. This definition embraces the broad range of professional activities that hospitalists perform. Our definition even allows for hospitalists to engage in nonhospital-based activities such as outpatient care. The key to this definition is the emphasis of our professional focus being the care of hospitalized patients.

The Big Tent

What the SHM definition of hospitalists recognizes is the great diversity of physicians who serve as hospitalists and the wide variety of roles we all play in the service of caring for hospitalized patients. Both MDs and DOs serve as hospitalists, and they do so as internists, family physicians, and pediatricians. That all these physicians can come together in the same professional organization speaks to the importance of the unifying goal of caring for hospitalized patients that defines what each of us does.

Further, hospitalists can be involved exclusively in patient care, research, teaching, or leadership or in a combination of these roles. Once again the common principle is the focus on the care of hospitalized patients. In fact our society and field are better, more robust, more innovative, and more responsive to the needs of patients because we represent such a broad range of physicians in so many roles.

Our coming together in one organization creates a “big tent” for hospital medicine and allows for cross-fertilization of ideas. However, like any big tent, the strength of our diversity also creates challenges. For example, from an educational standpoint, we need to design programs and materials that meet the needs of all hospitalists. We have found that we share much, regardless of the setting in which we practice, the age of our patients, or the type of work we do. Patient safety, leadership, palliative care, and quality improvement are just a sample of the issues that pertain to all hospitalists.

Additionally, understanding these issues and addressing them takes people who are experts in patient care, teaching, research, and leadership—precisely the job descriptions found within the SHM. I am proud that SHM is one of the only professional societies to include internists, family physicians, and pediatricians from community practice, academia, and industry. Our big tent even extends beyond physicians to include nurse practitioners, physician assistants, pharmacists, nurses, and others who enrich our society and strengthen our field. In fact, our name—the Society of Hospital Medicine—was deliberately chosen to reflect the big tent. We specifically rejected a name that focused on the word hospitalist—not because we are not proud of it, but because we wanted all of those who work to improve the care of hospitalized patients to feel welcome in our society and to join in our mission.

Hospitalist Takes Hold

The phenomenon we now see is the emergence of “surgical” and “OB” hospitalists who care for hospitalized patients who otherwise do not have access to such physicians. Whether these physicians will assume the role of improving the system to provide better care to all inpatients or serve solely as technicians who work a shift and go home remains to be seen.

What is clear, however, is that in just 10 short years we have moved from having hospitalists defined in relationship to other physicians to having other physicians defined in relationship to hospitalists. This evolution is good for our field as we emerge from being the new kids on the block to being part of the existing paradigm.

Hope for the Future

The evolved definition of hospitalist reflects the maturing of our field and leaves me optimistic and hopeful for the future of hospitalists and hospital medicine. I hope that the dictionary will adopt our definition of hospitalist. I hope that one day hospitalist will be as well-known a word as pediatrician. I hope that as our field matures we never lose our enthusiasm and energy. And finally, I hope that our field stays unified and that the SHM continues to represent the broad range of physicians who work as hospitalists. Our field will be stronger and our achievements greater when we stand together, recognizing all that we share in common as hospitalists and respectful of the diversity that adds richness to our field. TH

SHM President Dr. Pantilat is an associate professor of clinical medicine at the University of California at San Francisco.

References

1. Wachter RM, Goldman L. The emerging role of "hospitalists" in the American health care system. N Engl J Med. 1996;335:514-517.
2. Lindenauer PK, Pantilat SZ, Katz PP, et al. Hospitalists and the practice of inpatient medicine: results of a survey of the National Association of Inpatient Physicians. Ann Intern Med. 1999;130(4Pt2):343-349.
3. Wachter RM. An introduction to the hospitalist model. Ann Intern Med. 1999;130(4Pt2):338-342.

When I meet new people, I’m commonly asked, “So what do you do?” The first answer is easy: “I’m a doctor.” It’s the follow-up question that’s tricky: “What kind of doctor?”

“I’m a hospitalist,” I say.

“What’s that?”

I imagine that each of us faces similar questions almost daily from friends, family, patients, or strangers we meet. This tells me people are still learning who we are and what we are. I also imagine each of us has developed a standard way of answering that second question.

I like to say that a hospitalist is “a doctor who is an expert in taking care of people in the hospital.” Though not necessarily comprehensive, my definition usually does the job in casual conversation. In many ways I find this explanation easier than when I tried to describe myself as an “internist,” for which I never developed an easy definition. My favorite one-liner for internist was “pediatrician for adults,” but even that prompted blank stares or polite nods.

Early Definitions of Hospitalists

My definition certainly works in casual conversation. But the question gets to the heart of who we are, what we do, and what our field is about. Our ability to define these issues is critical to clarifying what hospitalists and hospital medicine are about.

It is interesting to look at early definitions of hospitalists. The first time the word hospitalist was published in 1996, hospitalists were defined as “specialists in inpatient medicine ... who will be responsible for managing the care of hospitalized patients in the same way that primary care physicians are responsible for managing the care of outpatients.”1

At the beginning there was a need to compare what hospitalists do, or will do, to something that was already known. The concept was so new that it needed an analogy to be explained. Even in 1999, a paper published in Annals of Internal Medicine defined hospitalists as “physicians who assume the care of hospitalized patients in place of the patients’ primary care provider.”2

Three years after the term was first coined, hospitalists were still being defined in relationship to other physicians. Another paper in Annals of Internal Medicine in 1999 defined a hospitalist as “a physician who spends at least 25% of his or her time serving as the physician-of-record for inpatients, during which time he or she accepts ‘hand-offs’ of hospitalized patients from primary care providers, returning patients to their primary care providers at the time of hospital discharge.”3 Of course that definition was quite a mouthful when explaining what you do to, say, your mother. But there were two important issues wrapped up in that definition.

The first was recognizing that some hospitalists were primarily engaged in research or leadership positions and did not provide a great deal of direct patient care, yet clearly defined themselves as hospitalists. The second was that we were still defined by our relationship to the primary care physician role. Our field was too new to be defined on its own and had to be explained in terms of the existing paradigm.

What became clear was that hospitalists should not be defined by the amount of inpatient care we provided but by our professional focus. For many hospitalists, the thought of caring for hospitalized patients only 25% of the time seemed ridiculous. To others involved in leadership or research who focused exclusively on hospital medicine yet did little patient care the definition seemed too restrictive.

In the end, any definition of hospitalists that depended on time could not encompass the wide range of roles and responsibilities that hospitalists held. Finally, a few months ago, hospitalist was included in the dictionary for the first time. The 2005 update of the Eleventh edition of Merriam-Webster’s Collegiate Dictionary defines a hospitalist as “a physician who specializes in treating hospitalized patients of other physicians in order to minimize the number of hospital visits by other physicians.” Although I am delighted to see hospitalist in the dictionary, this definition is too limited to be useful or accurate. It is certainly true that the presence of hospitalists means other physicians can come to the hospital less, but that is far from what hospitalists or hospital medicine are about.

SHM Definition of Hospitalists

Our society has an official definition of hospitalists: “Physicians whose primary professional focus is the general medical care of hospitalized patients. Their activities include patient care, teaching, research, and leadership related to hospital medicine.”

I wish the dictionary had used this definition because it gets to the heart of what hospitalists are and defines us in a positive way, on our own terms, and not in relation to other physicians. This definition embraces the broad range of professional activities that hospitalists perform. Our definition even allows for hospitalists to engage in nonhospital-based activities such as outpatient care. The key to this definition is the emphasis of our professional focus being the care of hospitalized patients.

The Big Tent

What the SHM definition of hospitalists recognizes is the great diversity of physicians who serve as hospitalists and the wide variety of roles we all play in the service of caring for hospitalized patients. Both MDs and DOs serve as hospitalists, and they do so as internists, family physicians, and pediatricians. That all these physicians can come together in the same professional organization speaks to the importance of the unifying goal of caring for hospitalized patients that defines what each of us does.

Further, hospitalists can be involved exclusively in patient care, research, teaching, or leadership or in a combination of these roles. Once again the common principle is the focus on the care of hospitalized patients. In fact our society and field are better, more robust, more innovative, and more responsive to the needs of patients because we represent such a broad range of physicians in so many roles.

Our coming together in one organization creates a “big tent” for hospital medicine and allows for cross-fertilization of ideas. However, like any big tent, the strength of our diversity also creates challenges. For example, from an educational standpoint, we need to design programs and materials that meet the needs of all hospitalists. We have found that we share much, regardless of the setting in which we practice, the age of our patients, or the type of work we do. Patient safety, leadership, palliative care, and quality improvement are just a sample of the issues that pertain to all hospitalists.

Additionally, understanding these issues and addressing them takes people who are experts in patient care, teaching, research, and leadership—precisely the job descriptions found within the SHM. I am proud that SHM is one of the only professional societies to include internists, family physicians, and pediatricians from community practice, academia, and industry. Our big tent even extends beyond physicians to include nurse practitioners, physician assistants, pharmacists, nurses, and others who enrich our society and strengthen our field. In fact, our name—the Society of Hospital Medicine—was deliberately chosen to reflect the big tent. We specifically rejected a name that focused on the word hospitalist—not because we are not proud of it, but because we wanted all of those who work to improve the care of hospitalized patients to feel welcome in our society and to join in our mission.

Hospitalist Takes Hold

The phenomenon we now see is the emergence of “surgical” and “OB” hospitalists who care for hospitalized patients who otherwise do not have access to such physicians. Whether these physicians will assume the role of improving the system to provide better care to all inpatients or serve solely as technicians who work a shift and go home remains to be seen.

What is clear, however, is that in just 10 short years we have moved from having hospitalists defined in relationship to other physicians to having other physicians defined in relationship to hospitalists. This evolution is good for our field as we emerge from being the new kids on the block to being part of the existing paradigm.

Hope for the Future

The evolved definition of hospitalist reflects the maturing of our field and leaves me optimistic and hopeful for the future of hospitalists and hospital medicine. I hope that the dictionary will adopt our definition of hospitalist. I hope that one day hospitalist will be as well-known a word as pediatrician. I hope that as our field matures we never lose our enthusiasm and energy. And finally, I hope that our field stays unified and that the SHM continues to represent the broad range of physicians who work as hospitalists. Our field will be stronger and our achievements greater when we stand together, recognizing all that we share in common as hospitalists and respectful of the diversity that adds richness to our field. TH

SHM President Dr. Pantilat is an associate professor of clinical medicine at the University of California at San Francisco.

References

1. Wachter RM, Goldman L. The emerging role of "hospitalists" in the American health care system. N Engl J Med. 1996;335:514-517.
2. Lindenauer PK, Pantilat SZ, Katz PP, et al. Hospitalists and the practice of inpatient medicine: results of a survey of the National Association of Inpatient Physicians. Ann Intern Med. 1999;130(4Pt2):343-349.
3. Wachter RM. An introduction to the hospitalist model. Ann Intern Med. 1999;130(4Pt2):338-342.

When I meet new people, I’m commonly asked, “So what do you do?” The first answer is easy: “I’m a doctor.” It’s the follow-up question that’s tricky: “What kind of doctor?”

“I’m a hospitalist,” I say.

“What’s that?”

I imagine that each of us faces similar questions almost daily from friends, family, patients, or strangers we meet. This tells me people are still learning who we are and what we are. I also imagine each of us has developed a standard way of answering that second question.

I like to say that a hospitalist is “a doctor who is an expert in taking care of people in the hospital.” Though not necessarily comprehensive, my definition usually does the job in casual conversation. In many ways I find this explanation easier than when I tried to describe myself as an “internist,” for which I never developed an easy definition. My favorite one-liner for internist was “pediatrician for adults,” but even that prompted blank stares or polite nods.

Early Definitions of Hospitalists

My definition certainly works in casual conversation. But the question gets to the heart of who we are, what we do, and what our field is about. Our ability to define these issues is critical to clarifying what hospitalists and hospital medicine are about.

It is interesting to look at early definitions of hospitalists. The first time the word hospitalist was published in 1996, hospitalists were defined as “specialists in inpatient medicine ... who will be responsible for managing the care of hospitalized patients in the same way that primary care physicians are responsible for managing the care of outpatients.”1

At the beginning there was a need to compare what hospitalists do, or will do, to something that was already known. The concept was so new that it needed an analogy to be explained. Even in 1999, a paper published in Annals of Internal Medicine defined hospitalists as “physicians who assume the care of hospitalized patients in place of the patients’ primary care provider.”2

Three years after the term was first coined, hospitalists were still being defined in relationship to other physicians. Another paper in Annals of Internal Medicine in 1999 defined a hospitalist as “a physician who spends at least 25% of his or her time serving as the physician-of-record for inpatients, during which time he or she accepts ‘hand-offs’ of hospitalized patients from primary care providers, returning patients to their primary care providers at the time of hospital discharge.”3 Of course that definition was quite a mouthful when explaining what you do to, say, your mother. But there were two important issues wrapped up in that definition.

The first was recognizing that some hospitalists were primarily engaged in research or leadership positions and did not provide a great deal of direct patient care, yet clearly defined themselves as hospitalists. The second was that we were still defined by our relationship to the primary care physician role. Our field was too new to be defined on its own and had to be explained in terms of the existing paradigm.

What became clear was that hospitalists should not be defined by the amount of inpatient care we provided but by our professional focus. For many hospitalists, the thought of caring for hospitalized patients only 25% of the time seemed ridiculous. To others involved in leadership or research who focused exclusively on hospital medicine yet did little patient care the definition seemed too restrictive.

In the end, any definition of hospitalists that depended on time could not encompass the wide range of roles and responsibilities that hospitalists held. Finally, a few months ago, hospitalist was included in the dictionary for the first time. The 2005 update of the Eleventh edition of Merriam-Webster’s Collegiate Dictionary defines a hospitalist as “a physician who specializes in treating hospitalized patients of other physicians in order to minimize the number of hospital visits by other physicians.” Although I am delighted to see hospitalist in the dictionary, this definition is too limited to be useful or accurate. It is certainly true that the presence of hospitalists means other physicians can come to the hospital less, but that is far from what hospitalists or hospital medicine are about.

SHM Definition of Hospitalists

Our society has an official definition of hospitalists: “Physicians whose primary professional focus is the general medical care of hospitalized patients. Their activities include patient care, teaching, research, and leadership related to hospital medicine.”

I wish the dictionary had used this definition because it gets to the heart of what hospitalists are and defines us in a positive way, on our own terms, and not in relation to other physicians. This definition embraces the broad range of professional activities that hospitalists perform. Our definition even allows for hospitalists to engage in nonhospital-based activities such as outpatient care. The key to this definition is the emphasis of our professional focus being the care of hospitalized patients.

The Big Tent

What the SHM definition of hospitalists recognizes is the great diversity of physicians who serve as hospitalists and the wide variety of roles we all play in the service of caring for hospitalized patients. Both MDs and DOs serve as hospitalists, and they do so as internists, family physicians, and pediatricians. That all these physicians can come together in the same professional organization speaks to the importance of the unifying goal of caring for hospitalized patients that defines what each of us does.

Further, hospitalists can be involved exclusively in patient care, research, teaching, or leadership or in a combination of these roles. Once again the common principle is the focus on the care of hospitalized patients. In fact our society and field are better, more robust, more innovative, and more responsive to the needs of patients because we represent such a broad range of physicians in so many roles.

Our coming together in one organization creates a “big tent” for hospital medicine and allows for cross-fertilization of ideas. However, like any big tent, the strength of our diversity also creates challenges. For example, from an educational standpoint, we need to design programs and materials that meet the needs of all hospitalists. We have found that we share much, regardless of the setting in which we practice, the age of our patients, or the type of work we do. Patient safety, leadership, palliative care, and quality improvement are just a sample of the issues that pertain to all hospitalists.

Additionally, understanding these issues and addressing them takes people who are experts in patient care, teaching, research, and leadership—precisely the job descriptions found within the SHM. I am proud that SHM is one of the only professional societies to include internists, family physicians, and pediatricians from community practice, academia, and industry. Our big tent even extends beyond physicians to include nurse practitioners, physician assistants, pharmacists, nurses, and others who enrich our society and strengthen our field. In fact, our name—the Society of Hospital Medicine—was deliberately chosen to reflect the big tent. We specifically rejected a name that focused on the word hospitalist—not because we are not proud of it, but because we wanted all of those who work to improve the care of hospitalized patients to feel welcome in our society and to join in our mission.

Hospitalist Takes Hold

The phenomenon we now see is the emergence of “surgical” and “OB” hospitalists who care for hospitalized patients who otherwise do not have access to such physicians. Whether these physicians will assume the role of improving the system to provide better care to all inpatients or serve solely as technicians who work a shift and go home remains to be seen.

What is clear, however, is that in just 10 short years we have moved from having hospitalists defined in relationship to other physicians to having other physicians defined in relationship to hospitalists. This evolution is good for our field as we emerge from being the new kids on the block to being part of the existing paradigm.

Hope for the Future

The evolved definition of hospitalist reflects the maturing of our field and leaves me optimistic and hopeful for the future of hospitalists and hospital medicine. I hope that the dictionary will adopt our definition of hospitalist. I hope that one day hospitalist will be as well-known a word as pediatrician. I hope that as our field matures we never lose our enthusiasm and energy. And finally, I hope that our field stays unified and that the SHM continues to represent the broad range of physicians who work as hospitalists. Our field will be stronger and our achievements greater when we stand together, recognizing all that we share in common as hospitalists and respectful of the diversity that adds richness to our field. TH

SHM President Dr. Pantilat is an associate professor of clinical medicine at the University of California at San Francisco.

References

1. Wachter RM, Goldman L. The emerging role of "hospitalists" in the American health care system. N Engl J Med. 1996;335:514-517.
2. Lindenauer PK, Pantilat SZ, Katz PP, et al. Hospitalists and the practice of inpatient medicine: results of a survey of the National Association of Inpatient Physicians. Ann Intern Med. 1999;130(4Pt2):343-349.
3. Wachter RM. An introduction to the hospitalist model. Ann Intern Med. 1999;130(4Pt2):338-342.

[H]ospitalists are in a very litigation-intensive and volatile environment. … [T]hey are practicing in a niche that has not been fully accepted by the medical community. There’s a lot of tension on various specialty groups as to the role of hospitalists, the value of hospitalists, whether for a variety of reasons they are creating impediments [to] the quality of care, possibly raising competitive concerns. And so the best trained, the best intentioned, and most capable hospitalist is choosing … a dangerous area of practice from a liability perspective.

—Barry Halpern, JD, Snell and Wilmer Law Offices, expert in medical malpractice law

As hospitalists move from patient to patient, consult to consult, and decision to decision, risk management—proactively identifying, assessing, and prioritizing risks with a goal of minimizing their negative consequences—may not stay uppermost in their minds. Yet for hospitalists, by virtue of their constant location and activity in hospitals, risks lurk at every corner, and the potential for being judged at fault is real and potentially costly.

What are the hospitalist’s risks of being sued for malpractice? How can hospitalists best protect themselves against malpractice claims? Does being liable for patient care ever cause hospitalists to handicap themselves, to hold back in some ways?

What Risks Do Hospitalists Face?

“I think the issue that hospitalists are facing from a medical-legal standpoint is there is not a lot of cumulative experience with case law, precedent, in the field of hospital medicine,” says Tom Baudendistel, MD, a hospitalist and associate program director at California Pacific Medical Center in San Francisco.

Besides errors of medical practice, hospitalists are at risk when they:

• Practice beyond the scope of their specialty;
• Fail to communicate or communicate poorly with patients, families, staff, and referring physicians; and
• Fail to exercise independent medical judgment.

Hospitalists work with sicker, more complicated patients in an environment where more things can go wrong. (See The Hospitalist, July/August 2002, “Hospitalists and the Malpractice Insurance Crisis.”) All things considered, hospital-based physicians are at greater risk of being sued than their colleagues who work in offices.

Case #1: The hospitalist failed to detect a vertebral artery dissection in a younger patient. Should they have been able to detect that? It’s a rather unusual stroke presentation. A neurologist would have picked it up—and certainly would have been held liable or negligent if they’d missed that diagnosis. During their training neurologists would have certainly seen this condition as a cause of stroke in someone below age 45. But internists, in general, don’t receive good neurologic training as part of their residencies, and in community hospitals there is no set neurology service.

Neurologists have now become more office-based and allow the hospitalists to do more. By doing more, they’re also exposed to more legal risk. Should the hospitalist be held negligent for missing an unusual stroke? It depends on what you think is a hospitalist’s scope of practice.

—Dr. Baudendistel

Scope of Practice

A hospitalist’s scope of practice is somewhat difficult to define, although the classification “hospitalist” is gaining clarity (including with insurance underwriters), and the hospitalist model is becoming more recognized as a subspecialty. (See “A Malpractice Primer,” The Hospitalist, Dec. 2005, p. 1.)

One challenge in defining the hospitalist’s scope of practice is that hospitalists do a variety of things and work in different departments of the hospital: Some spend more time in acute care, some are more in general care, and some of them are mostly in trauma care.

It is generally acknowledged that healthcare practitioners must employ the same degree of diligence and skill commonly possessed by other members of the healthcare profession who are engaged in the same kind of work in similar locales. Thus, hospitalists need to be acutely aware of how other hospitalists practice in similar settings with similar resources available.

Hospitalists in rural and suburban hospitals, which have fewer and less specialized staff readily available for consults, should expect to have a different scope of practice. In time further clarification of the roles, responsibilities, and clinical skills of hospitalists will be established so that the scope of practice is more clearly defined.

Dr. Baudendistel believes that residents tracking to specialize in hospital medicine could benefit from having more education in certain areas: neurology, perioperative medicine, and critical care.

SHM has recognized the need for better risk management strategies to protect hospitalists and will provide this information and continuing education in The Core Competencies in Hospital Medicine to be published the January/February 2006 issue of the Journal of Hospital Medicine.

Case #2: A male patient came into the ED at a rural hospital with an altered mental status. He had a history of falls and the CT scan in the ED showed a large subdural hematoma.

“We need to admit this patient to the hospital,” said the ED doc. “Call the hospitalist.”

“What does neurosurgery want to do?” asked the hospitalist.

The hospitalist tried to reach the neurosurgeon. And the ED doc wasn’t able to obtain neurosurgery consult because the neurosurgeon said that he wasn’t on call for that hospital. So the hospitalist was … left responsible without neurosurgery backup.

Ultimately, the patient worsened. The hospitalist called a different neurosurgeon at a different hospital who clearly wasn’t in charge of the patient. That doctor said, “Get the patient over to us, and we’ll take care of it.”

There was a 12-hour delay, and the patient finally got transferred to the other hospital, had surgery, and did OK. But he was definitely deteriorating.

The neurosurgeon who said he wasn’t on call for that hospital was wrong. He was lying or just didn’t know of his group’s call coverage. It was a clear violation. And it left the hospital in a situation that isn’t all that unfamiliar.

In this case, the hospitalist wasn’t at fault. There was clear chart documentation [provided as evidence] that said, “I called the neurosurgeon three times and they’re not calling back. Finally they called back the fourth time and said that they’re not coming in.” —Dr. Baudendistel

Communication

Communication is crucial in a clinician’s provision of quality care and also provides a safety net to help prevent liability. Communication with patients, families, staff, and other physicians—particularly their inpatients’ primary care physicians—provides the strongest armor against malpractice assaults. Timeliness and the urgency of the issue are key to patient care and are also are examined by those who review malpractice claims.

In recent years medical malpractice claims payouts have increased substantially for both jury verdicts and settlements. For monetary awards involving doctor-patient relations, which are largely predicated upon communication, the median payout is $230,000.1

Some hot-button areas that carry higher risk and call for meticulous communication between providers include:

1. Inpatient postoperative care;
2. Post-discharge communication (hand-offs);
3. Diagnosis and treatment of a patient for whom there is an incomplete history; and
4. Acceptance for treatment of patients whose medical conditions may either be unfamiliar to hospitalists or for which they have had limited or no training.

Communication with Patients

Communication—every aspect of it—is essential for the patient’s health, attitude, and satisfaction. Interestingly, legal data show that most patients who have bad outcomes don’t file suit.2 Although patients litigate for a variety of reasons, chief among them is when they perceive they have suffered because of administrative errors, rude practitioners or support staff, or the denial of tests and referrals they had requested and thought were reasonable.3 Data from a number of studies conducted within the past two decades show that although no particular communication skills can be directly associated with reducing malpractice claims, when patients perceive that their providers treat them genuinely and fairly, and update them honestly and regularly, they are less likely to sue.4-9

One-on-One with Barry Halpern, JD

My law firm practices throughout the western United States, and one of the areas that I see as a general pattern is when … continuity of care becomes an issue. The cases that are sometimes the most troublesome are those in which the hospitalist is involved.

There’s never a real clear demarcation of responsibility between, for instance, the surgery service and the hospitalist. Orders are written and then interpreted by the nursing staff in ways that, in retrospect, even the surgical service or the hospitalist are not pleased with. Yet the physicians aren’t talking to each other, and the documentation in the medical record is intermittent … .

Those kinds of situations, particularly where there is later alleged to have been, for instance, a medication error, become very difficult to defend. Because from the perspective of the lay jury that will be looking at the case, it’s easy for a plaintiff lawyer to depict a very disjointed and uncoordinated approach to care, when—in fact—the reality of practices is that they don’t always go perfectly and things aren’t always documented the instant that they are done.

And sometimes bad things happen despite everybody’s best efforts. But when you have a rough interface between the hospitalist and the other physicians with regard to responsibility for a patient, you are inviting a legal problem.

—Halpern is an attorney with Snell and Wilmer Law Offices, Phoenix

Case #3: A 72-year-old female who was pretty healthy (she had some high blood pressure) came in with abdominal pain. The ED doctor drew the laboratories, which suggested pancreatitis, and then investigated why she had pancreatitis. The ultrasound ordered by the ED doc showed gallstones. The physician then correctly inferred that she had gallstones causing her pancreatitis.

A hospitalist was called [and] admitted the patient. Surgery and GI consultants were called. The GI consultant first ordered an endoscopic retrograde cholangiopancreatography to clean the gallstones from the common bile duct. That went fine, and the next day the patient looked a little better. The GI service said, “Anticipated to go home in a couple days.” Surgery felt the same.

Then the consensus was to remove her gallbladder because eventually she would need to have it done. And that’s when things started to go badly.

On postoperative day two, the patient started having pain out of proportion to what should be expected. The internist (the hospitalist) raised that question in his note. The surgeon said, “No, that’s still postoperative pain,” and increased the pain medicine.

The hospitalist said, “I’m really concerned about this; I’ll talk to the surgeon.”

Again the surgeon said, “There’s nothing to worry about. I’ll at least order a HIDA scan.”

Initially the patient refused the scan, but the next day—postoperative day three—she was still having pain and was clearly worse. She had a high fever; her blood pressure dropped; and her white blood cell count climbed from 10,000 to 20,000, indicating infection/inflammation. Finally the hospitalist ordered a CT scan, which shows a perforation caused by the surgery.

The patient went to surgery for repair. As was predicted, she had a rocky hospital course and ultimately died a month later.

The surgeon was clearly in the wrong. … I was consulted and was asked, “What would you do with the hospitalist? What was their role in that case? Do you think he failed to meet the standard of care?”

—Dr. Baudendistel

Communication with Other Clinicians

“Communication between physicians is critical,” says Sally Whitaker, RN, BSN, risk manager with Rex Healthcare in Raleigh, N.C. “[Hospitalists] shouldn’t just rely on knowing they’ve put their notes on the discharge summary.”

At Rex Hospital (one of Rex Healthcare’s six facilities) where Whitaker works, when seminal events (those big bad things that happen) occur and result in severe trauma or death, the appropriate people meet to backtrack through the steps and scenarios that led to the breakdown.

“Fortunately we don’t have seminal events every day, but every day we do have things that go wrong,” she says. “ … And when we look at our Group Cause Analysis meetings, three-quarters of them [involve] communication issues.”

Exercise Independent Medical Judgment

Hospitalists should read their insurance and employer contracts carefully (especially those with a managed care organization) to ensure that the contract includes a statement allowing the physician to exercise independent medical judgment in the treatment of all patients. If that statement is not present, the hospitalist should request a revision in the contract to include such a statement.

In medical residency programs, a distinction is often made between being a consultant and being a co-manager, says Dr. Baudendistel, but “you have to assume there’s no legal difference between [the two].” Case #3 , he says, was a challenge to decide because the responsibilities of the surgeon and hospitalist in postoperative care were not clearly demarcated.

“I think the surgeon was probably saying, ‘I see this all the time and this is within the realm of what happens after one of these surgeries; let’s not be too worried yet,’” he says. “And I think the internist [hospitalist] ultimately pulled the trigger correctly and the [controversy later on pertained to] whether it should have been done a day or two earlier and whether that have mattered.”

This case illustrates that, although hospitalists are members of teams and partner with consultants and primary physicians, in the end they are managers of patient care and may (we hope rarely) have to break ranks to make aggressive care decisions.

“I think that the other thing that was in [the hospitalist’s] favor,” says Dr. Baudendistel of the case, “was that he was writing very thorough notes, [and] really was discussing everything with the family and everyone was on board. He was doing a very compassionate job … trying to manage this care.”

To Dr. Baudendistel, who is the chair of SHM’s ethics committee, this went a long way toward showing good faith.

Reducing Risks: Concern for the Medical Record

If the medical record is found deficient or illuminating in a negative way, it may serve the plaintiff attorney’s strategy well for establishing negligence or wrongdoing. The chart notes documented by nurses, attending staff, consultants, other residents, and therapists could either portray a smoothly managed case or a chronology of errors and omissions. The chart should never be cosigned and never merely assumed to be accurate.

When Things Go Wrong

Whitaker advises hospitalists to keep the lines of communication open. “Especially after something unexpected has happened,” she says. “So many times I think the human tendency is to just withdraw, or you feel terrible and you don’t know what to say, or you’re afraid you’re going to get emotional while you’re talking with the family.”

This is normal human response in these circumstances, but if you act on the impulse to withdraw and avoid the patient and family, or hold back, which may eventually lead to a filed claim from a family that feels abandoned.

“Until now the number of lawsuits has been really steady and the amount that we were paying in lawsuits was increasing,” says Whitaker. “However, we’re trying to work with the families earlier on so if we make a mistake and we realize that we made a mistake then we admit that. And we try to do what we can to make it right for that patient and their family.”

This often means reaching a fair and reasonable settlement, says Whitaker, “and [examining fair and reasonable means reviewing] the communication at the time the event occurred. Did we acknowledge that we made a mistake? Did we let them know we’d be willing to work with them? And did we let them know we [have since] made these changes … so they’ll … be reassured [that] hopefully it won’t happen again?”

Who’s in Charge?

Linda Greenwald, RN, MS, editor of risk management publications at ProMutual Insurance Group in Boston, wrote in the company’s newsletter, Perspectives on Clinical Risk Management, that in prior times, the question, “Who’s in charge?” was rhetorical.10 These days any number of generalists or specialists might claim that role. And therein lies the rub: Greenwald says that in many cases involving hospitalists the lines of responsibility are unclear and one or more systems may fail. If so, Greenwald writes, the result may be a malpractice claim alleging:

• Failure to diagnose when each of two physicians assumes the other has responsibility for follow-up;
• Negligence in treatment when one physician fails to monitor on an outpatient basis the medication first prescribed by another physician when the patient was an inpatient; and/or
• Negligent care when a patient misinterprets the information one physician asks him or her to relay to another physician.10

Halpern concurs that the modern mix of professionals working as a team on hospital care can be a major challenge.

“In olden days, when a primary care physician referred to a surgeon, and the surgeon performed surgery, and the surgeon took responsibility for postoperative care, and occasionally brought in a consultant, the lines were relatively clear,” says Halpern. “When a hospitalist is injected into the mix, unless the hospital has really clear procedures and unless everybody is comfortable with the system and everybody is talking to each other and agreeing on the lines of demarcation, you’re creating a soup that plaintiff lawyers would be happy to stir.”

The more murky the communication, the greater the liability. “And when you have murky lines of communication, murky lines of responsibility, and a medical catastrophe,” says Halpern, “human nature compounds the problem by frequently causing a finger-pointing contest, where each component of the patient care team circles its own wagons [and] points in a different direction. And that is the absolute worst thing that can happen when trying to deal with a patient injury claim.”

Summary

The hospitalist’s primary risk for malpractice claims may be inadequate or absent patient follow-up resulting from a lack of communication. The best means of protection from claims is for hospitalists to incorporate a comprehensive risk management program into their practice.

Several strategies have proved successful to help prevent litigation. In general, hospitalists should make sure that their hospital has clearly delineated policies regarding responsibility for patients; clearly understand—and ensure that your coworkers, colleagues, and referring physicians understand—the hospital’s systems and protocols; exercise good communication skills; conform to the standard of care; know your own scope of care to the best of your ability; and exercise independent medical judgment, even when partnering with others. TH

Andrea Sattinger also writes the “Alliances” department for The Hospitalist.

References

1. Mello MM, Studdert DM, Brennan TA. The new medical malpractice crisis. New Engl J Med. 2003;348:2281-2284.
2. Virshup BB, Oppenberg MPH, Coleman MM. Strategic risk management: reducing malpractice claims through more effective patient-doctor communication. Am J Med Quality. 1999;14:153-159.
3. Gurwitz JH, Terry S, Field TS, et al. Incidence and preventability of adverse drug events among older persons in the ambulatory setting. JAMA. 2003;289:1107-1116.
4. Shapiro RS, Simpson DE, Lawrence SL, et al.. A survey of sued and nonsued physicians and suing patients. Arch Intern Med. 1989;149:2190-2196.
5. Levinson W, Roter D, Mullooly JP, et al. Physician-patient communication: the relationship with malpractice claims among primary care physicians and surgeons. JAMA. 1997;227:558-559.
6. Beckman HB, Markakis KM, Suchman AL, et al. The doctor-patient relationship and malpractice. Lessons from plaintiff depositions. Arch Intern Med. 1994;154:1365-1370.
7. Cohen JR. Apology and organizations: exploring an example from medical practice. Fordham Urban Law Journal. 2000;27:1447-1482.
8. Cohen JR. Advising clients to apologize. Southern California Law Review. 1999;72:1009-1069.
9. Entman SS, Glass CA, Hickson GB, et al. The relationship between malpractice claims history and subsequent obstetric care JAMA. 1994;272:1588-1591.
10. Greenwald L. Who's in charge? Perspectives on Clinical Risk Management. Boston, Mass: ProMutual Group Risk Management Services; Fall 2000.
11. Alpers A. Key legal principles for hospitalists. Am J Med. 2001;111:5-9.

[H]ospitalists are in a very litigation-intensive and volatile environment. … [T]hey are practicing in a niche that has not been fully accepted by the medical community. There’s a lot of tension on various specialty groups as to the role of hospitalists, the value of hospitalists, whether for a variety of reasons they are creating impediments [to] the quality of care, possibly raising competitive concerns. And so the best trained, the best intentioned, and most capable hospitalist is choosing … a dangerous area of practice from a liability perspective.

—Barry Halpern, JD, Snell and Wilmer Law Offices, expert in medical malpractice law

As hospitalists move from patient to patient, consult to consult, and decision to decision, risk management—proactively identifying, assessing, and prioritizing risks with a goal of minimizing their negative consequences—may not stay uppermost in their minds. Yet for hospitalists, by virtue of their constant location and activity in hospitals, risks lurk at every corner, and the potential for being judged at fault is real and potentially costly.

What are the hospitalist’s risks of being sued for malpractice? How can hospitalists best protect themselves against malpractice claims? Does being liable for patient care ever cause hospitalists to handicap themselves, to hold back in some ways?

What Risks Do Hospitalists Face?

“I think the issue that hospitalists are facing from a medical-legal standpoint is there is not a lot of cumulative experience with case law, precedent, in the field of hospital medicine,” says Tom Baudendistel, MD, a hospitalist and associate program director at California Pacific Medical Center in San Francisco.

Besides errors of medical practice, hospitalists are at risk when they:

• Practice beyond the scope of their specialty;
• Fail to communicate or communicate poorly with patients, families, staff, and referring physicians; and
• Fail to exercise independent medical judgment.

Hospitalists work with sicker, more complicated patients in an environment where more things can go wrong. (See The Hospitalist, July/August 2002, “Hospitalists and the Malpractice Insurance Crisis.”) All things considered, hospital-based physicians are at greater risk of being sued than their colleagues who work in offices.

Case #1: The hospitalist failed to detect a vertebral artery dissection in a younger patient. Should they have been able to detect that? It’s a rather unusual stroke presentation. A neurologist would have picked it up—and certainly would have been held liable or negligent if they’d missed that diagnosis. During their training neurologists would have certainly seen this condition as a cause of stroke in someone below age 45. But internists, in general, don’t receive good neurologic training as part of their residencies, and in community hospitals there is no set neurology service.

Neurologists have now become more office-based and allow the hospitalists to do more. By doing more, they’re also exposed to more legal risk. Should the hospitalist be held negligent for missing an unusual stroke? It depends on what you think is a hospitalist’s scope of practice.

—Dr. Baudendistel

Scope of Practice

A hospitalist’s scope of practice is somewhat difficult to define, although the classification “hospitalist” is gaining clarity (including with insurance underwriters), and the hospitalist model is becoming more recognized as a subspecialty. (See “A Malpractice Primer,” The Hospitalist, Dec. 2005, p. 1.)

One challenge in defining the hospitalist’s scope of practice is that hospitalists do a variety of things and work in different departments of the hospital: Some spend more time in acute care, some are more in general care, and some of them are mostly in trauma care.

It is generally acknowledged that healthcare practitioners must employ the same degree of diligence and skill commonly possessed by other members of the healthcare profession who are engaged in the same kind of work in similar locales. Thus, hospitalists need to be acutely aware of how other hospitalists practice in similar settings with similar resources available.

Hospitalists in rural and suburban hospitals, which have fewer and less specialized staff readily available for consults, should expect to have a different scope of practice. In time further clarification of the roles, responsibilities, and clinical skills of hospitalists will be established so that the scope of practice is more clearly defined.

Dr. Baudendistel believes that residents tracking to specialize in hospital medicine could benefit from having more education in certain areas: neurology, perioperative medicine, and critical care.

SHM has recognized the need for better risk management strategies to protect hospitalists and will provide this information and continuing education in The Core Competencies in Hospital Medicine to be published the January/February 2006 issue of the Journal of Hospital Medicine.

Case #2: A male patient came into the ED at a rural hospital with an altered mental status. He had a history of falls and the CT scan in the ED showed a large subdural hematoma.

“We need to admit this patient to the hospital,” said the ED doc. “Call the hospitalist.”

“What does neurosurgery want to do?” asked the hospitalist.

The hospitalist tried to reach the neurosurgeon. And the ED doc wasn’t able to obtain neurosurgery consult because the neurosurgeon said that he wasn’t on call for that hospital. So the hospitalist was … left responsible without neurosurgery backup.

Ultimately, the patient worsened. The hospitalist called a different neurosurgeon at a different hospital who clearly wasn’t in charge of the patient. That doctor said, “Get the patient over to us, and we’ll take care of it.”

There was a 12-hour delay, and the patient finally got transferred to the other hospital, had surgery, and did OK. But he was definitely deteriorating.

The neurosurgeon who said he wasn’t on call for that hospital was wrong. He was lying or just didn’t know of his group’s call coverage. It was a clear violation. And it left the hospital in a situation that isn’t all that unfamiliar.

In this case, the hospitalist wasn’t at fault. There was clear chart documentation [provided as evidence] that said, “I called the neurosurgeon three times and they’re not calling back. Finally they called back the fourth time and said that they’re not coming in.” —Dr. Baudendistel

Communication

Communication is crucial in a clinician’s provision of quality care and also provides a safety net to help prevent liability. Communication with patients, families, staff, and other physicians—particularly their inpatients’ primary care physicians—provides the strongest armor against malpractice assaults. Timeliness and the urgency of the issue are key to patient care and are also are examined by those who review malpractice claims.

In recent years medical malpractice claims payouts have increased substantially for both jury verdicts and settlements. For monetary awards involving doctor-patient relations, which are largely predicated upon communication, the median payout is $230,000.1

Some hot-button areas that carry higher risk and call for meticulous communication between providers include:

1. Inpatient postoperative care;
2. Post-discharge communication (hand-offs);
3. Diagnosis and treatment of a patient for whom there is an incomplete history; and
4. Acceptance for treatment of patients whose medical conditions may either be unfamiliar to hospitalists or for which they have had limited or no training.

Communication with Patients

Communication—every aspect of it—is essential for the patient’s health, attitude, and satisfaction. Interestingly, legal data show that most patients who have bad outcomes don’t file suit.2 Although patients litigate for a variety of reasons, chief among them is when they perceive they have suffered because of administrative errors, rude practitioners or support staff, or the denial of tests and referrals they had requested and thought were reasonable.3 Data from a number of studies conducted within the past two decades show that although no particular communication skills can be directly associated with reducing malpractice claims, when patients perceive that their providers treat them genuinely and fairly, and update them honestly and regularly, they are less likely to sue.4-9

One-on-One with Barry Halpern, JD

My law firm practices throughout the western United States, and one of the areas that I see as a general pattern is when … continuity of care becomes an issue. The cases that are sometimes the most troublesome are those in which the hospitalist is involved.

There’s never a real clear demarcation of responsibility between, for instance, the surgery service and the hospitalist. Orders are written and then interpreted by the nursing staff in ways that, in retrospect, even the surgical service or the hospitalist are not pleased with. Yet the physicians aren’t talking to each other, and the documentation in the medical record is intermittent … .

Those kinds of situations, particularly where there is later alleged to have been, for instance, a medication error, become very difficult to defend. Because from the perspective of the lay jury that will be looking at the case, it’s easy for a plaintiff lawyer to depict a very disjointed and uncoordinated approach to care, when—in fact—the reality of practices is that they don’t always go perfectly and things aren’t always documented the instant that they are done.

And sometimes bad things happen despite everybody’s best efforts. But when you have a rough interface between the hospitalist and the other physicians with regard to responsibility for a patient, you are inviting a legal problem.

—Halpern is an attorney with Snell and Wilmer Law Offices, Phoenix

Case #3: A 72-year-old female who was pretty healthy (she had some high blood pressure) came in with abdominal pain. The ED doctor drew the laboratories, which suggested pancreatitis, and then investigated why she had pancreatitis. The ultrasound ordered by the ED doc showed gallstones. The physician then correctly inferred that she had gallstones causing her pancreatitis.

A hospitalist was called [and] admitted the patient. Surgery and GI consultants were called. The GI consultant first ordered an endoscopic retrograde cholangiopancreatography to clean the gallstones from the common bile duct. That went fine, and the next day the patient looked a little better. The GI service said, “Anticipated to go home in a couple days.” Surgery felt the same.

Then the consensus was to remove her gallbladder because eventually she would need to have it done. And that’s when things started to go badly.

On postoperative day two, the patient started having pain out of proportion to what should be expected. The internist (the hospitalist) raised that question in his note. The surgeon said, “No, that’s still postoperative pain,” and increased the pain medicine.

The hospitalist said, “I’m really concerned about this; I’ll talk to the surgeon.”

Again the surgeon said, “There’s nothing to worry about. I’ll at least order a HIDA scan.”

Initially the patient refused the scan, but the next day—postoperative day three—she was still having pain and was clearly worse. She had a high fever; her blood pressure dropped; and her white blood cell count climbed from 10,000 to 20,000, indicating infection/inflammation. Finally the hospitalist ordered a CT scan, which shows a perforation caused by the surgery.

The patient went to surgery for repair. As was predicted, she had a rocky hospital course and ultimately died a month later.

The surgeon was clearly in the wrong. … I was consulted and was asked, “What would you do with the hospitalist? What was their role in that case? Do you think he failed to meet the standard of care?”

—Dr. Baudendistel

Communication with Other Clinicians

“Communication between physicians is critical,” says Sally Whitaker, RN, BSN, risk manager with Rex Healthcare in Raleigh, N.C. “[Hospitalists] shouldn’t just rely on knowing they’ve put their notes on the discharge summary.”

At Rex Hospital (one of Rex Healthcare’s six facilities) where Whitaker works, when seminal events (those big bad things that happen) occur and result in severe trauma or death, the appropriate people meet to backtrack through the steps and scenarios that led to the breakdown.

“Fortunately we don’t have seminal events every day, but every day we do have things that go wrong,” she says. “ … And when we look at our Group Cause Analysis meetings, three-quarters of them [involve] communication issues.”

Exercise Independent Medical Judgment

Hospitalists should read their insurance and employer contracts carefully (especially those with a managed care organization) to ensure that the contract includes a statement allowing the physician to exercise independent medical judgment in the treatment of all patients. If that statement is not present, the hospitalist should request a revision in the contract to include such a statement.

In medical residency programs, a distinction is often made between being a consultant and being a co-manager, says Dr. Baudendistel, but “you have to assume there’s no legal difference between [the two].” Case #3 , he says, was a challenge to decide because the responsibilities of the surgeon and hospitalist in postoperative care were not clearly demarcated.

“I think the surgeon was probably saying, ‘I see this all the time and this is within the realm of what happens after one of these surgeries; let’s not be too worried yet,’” he says. “And I think the internist [hospitalist] ultimately pulled the trigger correctly and the [controversy later on pertained to] whether it should have been done a day or two earlier and whether that have mattered.”

This case illustrates that, although hospitalists are members of teams and partner with consultants and primary physicians, in the end they are managers of patient care and may (we hope rarely) have to break ranks to make aggressive care decisions.

“I think that the other thing that was in [the hospitalist’s] favor,” says Dr. Baudendistel of the case, “was that he was writing very thorough notes, [and] really was discussing everything with the family and everyone was on board. He was doing a very compassionate job … trying to manage this care.”

To Dr. Baudendistel, who is the chair of SHM’s ethics committee, this went a long way toward showing good faith.

Reducing Risks: Concern for the Medical Record

If the medical record is found deficient or illuminating in a negative way, it may serve the plaintiff attorney’s strategy well for establishing negligence or wrongdoing. The chart notes documented by nurses, attending staff, consultants, other residents, and therapists could either portray a smoothly managed case or a chronology of errors and omissions. The chart should never be cosigned and never merely assumed to be accurate.

When Things Go Wrong

Whitaker advises hospitalists to keep the lines of communication open. “Especially after something unexpected has happened,” she says. “So many times I think the human tendency is to just withdraw, or you feel terrible and you don’t know what to say, or you’re afraid you’re going to get emotional while you’re talking with the family.”

This is normal human response in these circumstances, but if you act on the impulse to withdraw and avoid the patient and family, or hold back, which may eventually lead to a filed claim from a family that feels abandoned.

“Until now the number of lawsuits has been really steady and the amount that we were paying in lawsuits was increasing,” says Whitaker. “However, we’re trying to work with the families earlier on so if we make a mistake and we realize that we made a mistake then we admit that. And we try to do what we can to make it right for that patient and their family.”

This often means reaching a fair and reasonable settlement, says Whitaker, “and [examining fair and reasonable means reviewing] the communication at the time the event occurred. Did we acknowledge that we made a mistake? Did we let them know we’d be willing to work with them? And did we let them know we [have since] made these changes … so they’ll … be reassured [that] hopefully it won’t happen again?”

Who’s in Charge?

Linda Greenwald, RN, MS, editor of risk management publications at ProMutual Insurance Group in Boston, wrote in the company’s newsletter, Perspectives on Clinical Risk Management, that in prior times, the question, “Who’s in charge?” was rhetorical.10 These days any number of generalists or specialists might claim that role. And therein lies the rub: Greenwald says that in many cases involving hospitalists the lines of responsibility are unclear and one or more systems may fail. If so, Greenwald writes, the result may be a malpractice claim alleging:

• Failure to diagnose when each of two physicians assumes the other has responsibility for follow-up;
• Negligence in treatment when one physician fails to monitor on an outpatient basis the medication first prescribed by another physician when the patient was an inpatient; and/or
• Negligent care when a patient misinterprets the information one physician asks him or her to relay to another physician.10

Halpern concurs that the modern mix of professionals working as a team on hospital care can be a major challenge.

“In olden days, when a primary care physician referred to a surgeon, and the surgeon performed surgery, and the surgeon took responsibility for postoperative care, and occasionally brought in a consultant, the lines were relatively clear,” says Halpern. “When a hospitalist is injected into the mix, unless the hospital has really clear procedures and unless everybody is comfortable with the system and everybody is talking to each other and agreeing on the lines of demarcation, you’re creating a soup that plaintiff lawyers would be happy to stir.”

The more murky the communication, the greater the liability. “And when you have murky lines of communication, murky lines of responsibility, and a medical catastrophe,” says Halpern, “human nature compounds the problem by frequently causing a finger-pointing contest, where each component of the patient care team circles its own wagons [and] points in a different direction. And that is the absolute worst thing that can happen when trying to deal with a patient injury claim.”

Summary

The hospitalist’s primary risk for malpractice claims may be inadequate or absent patient follow-up resulting from a lack of communication. The best means of protection from claims is for hospitalists to incorporate a comprehensive risk management program into their practice.

Several strategies have proved successful to help prevent litigation. In general, hospitalists should make sure that their hospital has clearly delineated policies regarding responsibility for patients; clearly understand—and ensure that your coworkers, colleagues, and referring physicians understand—the hospital’s systems and protocols; exercise good communication skills; conform to the standard of care; know your own scope of care to the best of your ability; and exercise independent medical judgment, even when partnering with others. TH

Andrea Sattinger also writes the “Alliances” department for The Hospitalist.

References

1. Mello MM, Studdert DM, Brennan TA. The new medical malpractice crisis. New Engl J Med. 2003;348:2281-2284.
2. Virshup BB, Oppenberg MPH, Coleman MM. Strategic risk management: reducing malpractice claims through more effective patient-doctor communication. Am J Med Quality. 1999;14:153-159.
3. Gurwitz JH, Terry S, Field TS, et al. Incidence and preventability of adverse drug events among older persons in the ambulatory setting. JAMA. 2003;289:1107-1116.
4. Shapiro RS, Simpson DE, Lawrence SL, et al.. A survey of sued and nonsued physicians and suing patients. Arch Intern Med. 1989;149:2190-2196.
5. Levinson W, Roter D, Mullooly JP, et al. Physician-patient communication: the relationship with malpractice claims among primary care physicians and surgeons. JAMA. 1997;227:558-559.
6. Beckman HB, Markakis KM, Suchman AL, et al. The doctor-patient relationship and malpractice. Lessons from plaintiff depositions. Arch Intern Med. 1994;154:1365-1370.
7. Cohen JR. Apology and organizations: exploring an example from medical practice. Fordham Urban Law Journal. 2000;27:1447-1482.
8. Cohen JR. Advising clients to apologize. Southern California Law Review. 1999;72:1009-1069.
9. Entman SS, Glass CA, Hickson GB, et al. The relationship between malpractice claims history and subsequent obstetric care JAMA. 1994;272:1588-1591.
10. Greenwald L. Who's in charge? Perspectives on Clinical Risk Management. Boston, Mass: ProMutual Group Risk Management Services; Fall 2000.
11. Alpers A. Key legal principles for hospitalists. Am J Med. 2001;111:5-9.

[H]ospitalists are in a very litigation-intensive and volatile environment. … [T]hey are practicing in a niche that has not been fully accepted by the medical community. There’s a lot of tension on various specialty groups as to the role of hospitalists, the value of hospitalists, whether for a variety of reasons they are creating impediments [to] the quality of care, possibly raising competitive concerns. And so the best trained, the best intentioned, and most capable hospitalist is choosing … a dangerous area of practice from a liability perspective.

—Barry Halpern, JD, Snell and Wilmer Law Offices, expert in medical malpractice law

As hospitalists move from patient to patient, consult to consult, and decision to decision, risk management—proactively identifying, assessing, and prioritizing risks with a goal of minimizing their negative consequences—may not stay uppermost in their minds. Yet for hospitalists, by virtue of their constant location and activity in hospitals, risks lurk at every corner, and the potential for being judged at fault is real and potentially costly.

What are the hospitalist’s risks of being sued for malpractice? How can hospitalists best protect themselves against malpractice claims? Does being liable for patient care ever cause hospitalists to handicap themselves, to hold back in some ways?

What Risks Do Hospitalists Face?

“I think the issue that hospitalists are facing from a medical-legal standpoint is there is not a lot of cumulative experience with case law, precedent, in the field of hospital medicine,” says Tom Baudendistel, MD, a hospitalist and associate program director at California Pacific Medical Center in San Francisco.

Besides errors of medical practice, hospitalists are at risk when they:

• Practice beyond the scope of their specialty;
• Fail to communicate or communicate poorly with patients, families, staff, and referring physicians; and
• Fail to exercise independent medical judgment.

Hospitalists work with sicker, more complicated patients in an environment where more things can go wrong. (See The Hospitalist, July/August 2002, “Hospitalists and the Malpractice Insurance Crisis.”) All things considered, hospital-based physicians are at greater risk of being sued than their colleagues who work in offices.

Case #1: The hospitalist failed to detect a vertebral artery dissection in a younger patient. Should they have been able to detect that? It’s a rather unusual stroke presentation. A neurologist would have picked it up—and certainly would have been held liable or negligent if they’d missed that diagnosis. During their training neurologists would have certainly seen this condition as a cause of stroke in someone below age 45. But internists, in general, don’t receive good neurologic training as part of their residencies, and in community hospitals there is no set neurology service.

Neurologists have now become more office-based and allow the hospitalists to do more. By doing more, they’re also exposed to more legal risk. Should the hospitalist be held negligent for missing an unusual stroke? It depends on what you think is a hospitalist’s scope of practice.

—Dr. Baudendistel

Scope of Practice

A hospitalist’s scope of practice is somewhat difficult to define, although the classification “hospitalist” is gaining clarity (including with insurance underwriters), and the hospitalist model is becoming more recognized as a subspecialty. (See “A Malpractice Primer,” The Hospitalist, Dec. 2005, p. 1.)

One challenge in defining the hospitalist’s scope of practice is that hospitalists do a variety of things and work in different departments of the hospital: Some spend more time in acute care, some are more in general care, and some of them are mostly in trauma care.

It is generally acknowledged that healthcare practitioners must employ the same degree of diligence and skill commonly possessed by other members of the healthcare profession who are engaged in the same kind of work in similar locales. Thus, hospitalists need to be acutely aware of how other hospitalists practice in similar settings with similar resources available.

Hospitalists in rural and suburban hospitals, which have fewer and less specialized staff readily available for consults, should expect to have a different scope of practice. In time further clarification of the roles, responsibilities, and clinical skills of hospitalists will be established so that the scope of practice is more clearly defined.

Dr. Baudendistel believes that residents tracking to specialize in hospital medicine could benefit from having more education in certain areas: neurology, perioperative medicine, and critical care.

SHM has recognized the need for better risk management strategies to protect hospitalists and will provide this information and continuing education in The Core Competencies in Hospital Medicine to be published the January/February 2006 issue of the Journal of Hospital Medicine.

Case #2: A male patient came into the ED at a rural hospital with an altered mental status. He had a history of falls and the CT scan in the ED showed a large subdural hematoma.

“We need to admit this patient to the hospital,” said the ED doc. “Call the hospitalist.”

“What does neurosurgery want to do?” asked the hospitalist.

The hospitalist tried to reach the neurosurgeon. And the ED doc wasn’t able to obtain neurosurgery consult because the neurosurgeon said that he wasn’t on call for that hospital. So the hospitalist was … left responsible without neurosurgery backup.

Ultimately, the patient worsened. The hospitalist called a different neurosurgeon at a different hospital who clearly wasn’t in charge of the patient. That doctor said, “Get the patient over to us, and we’ll take care of it.”

There was a 12-hour delay, and the patient finally got transferred to the other hospital, had surgery, and did OK. But he was definitely deteriorating.

The neurosurgeon who said he wasn’t on call for that hospital was wrong. He was lying or just didn’t know of his group’s call coverage. It was a clear violation. And it left the hospital in a situation that isn’t all that unfamiliar.

In this case, the hospitalist wasn’t at fault. There was clear chart documentation [provided as evidence] that said, “I called the neurosurgeon three times and they’re not calling back. Finally they called back the fourth time and said that they’re not coming in.” —Dr. Baudendistel

Communication

Communication is crucial in a clinician’s provision of quality care and also provides a safety net to help prevent liability. Communication with patients, families, staff, and other physicians—particularly their inpatients’ primary care physicians—provides the strongest armor against malpractice assaults. Timeliness and the urgency of the issue are key to patient care and are also are examined by those who review malpractice claims.

In recent years medical malpractice claims payouts have increased substantially for both jury verdicts and settlements. For monetary awards involving doctor-patient relations, which are largely predicated upon communication, the median payout is $230,000.1

Some hot-button areas that carry higher risk and call for meticulous communication between providers include:

1. Inpatient postoperative care;
2. Post-discharge communication (hand-offs);
3. Diagnosis and treatment of a patient for whom there is an incomplete history; and
4. Acceptance for treatment of patients whose medical conditions may either be unfamiliar to hospitalists or for which they have had limited or no training.

Communication with Patients

Communication—every aspect of it—is essential for the patient’s health, attitude, and satisfaction. Interestingly, legal data show that most patients who have bad outcomes don’t file suit.2 Although patients litigate for a variety of reasons, chief among them is when they perceive they have suffered because of administrative errors, rude practitioners or support staff, or the denial of tests and referrals they had requested and thought were reasonable.3 Data from a number of studies conducted within the past two decades show that although no particular communication skills can be directly associated with reducing malpractice claims, when patients perceive that their providers treat them genuinely and fairly, and update them honestly and regularly, they are less likely to sue.4-9

One-on-One with Barry Halpern, JD

My law firm practices throughout the western United States, and one of the areas that I see as a general pattern is when … continuity of care becomes an issue. The cases that are sometimes the most troublesome are those in which the hospitalist is involved.

There’s never a real clear demarcation of responsibility between, for instance, the surgery service and the hospitalist. Orders are written and then interpreted by the nursing staff in ways that, in retrospect, even the surgical service or the hospitalist are not pleased with. Yet the physicians aren’t talking to each other, and the documentation in the medical record is intermittent … .

Those kinds of situations, particularly where there is later alleged to have been, for instance, a medication error, become very difficult to defend. Because from the perspective of the lay jury that will be looking at the case, it’s easy for a plaintiff lawyer to depict a very disjointed and uncoordinated approach to care, when—in fact—the reality of practices is that they don’t always go perfectly and things aren’t always documented the instant that they are done.

And sometimes bad things happen despite everybody’s best efforts. But when you have a rough interface between the hospitalist and the other physicians with regard to responsibility for a patient, you are inviting a legal problem.

—Halpern is an attorney with Snell and Wilmer Law Offices, Phoenix

Case #3: A 72-year-old female who was pretty healthy (she had some high blood pressure) came in with abdominal pain. The ED doctor drew the laboratories, which suggested pancreatitis, and then investigated why she had pancreatitis. The ultrasound ordered by the ED doc showed gallstones. The physician then correctly inferred that she had gallstones causing her pancreatitis.

A hospitalist was called [and] admitted the patient. Surgery and GI consultants were called. The GI consultant first ordered an endoscopic retrograde cholangiopancreatography to clean the gallstones from the common bile duct. That went fine, and the next day the patient looked a little better. The GI service said, “Anticipated to go home in a couple days.” Surgery felt the same.

Then the consensus was to remove her gallbladder because eventually she would need to have it done. And that’s when things started to go badly.

On postoperative day two, the patient started having pain out of proportion to what should be expected. The internist (the hospitalist) raised that question in his note. The surgeon said, “No, that’s still postoperative pain,” and increased the pain medicine.

The hospitalist said, “I’m really concerned about this; I’ll talk to the surgeon.”

Again the surgeon said, “There’s nothing to worry about. I’ll at least order a HIDA scan.”

Initially the patient refused the scan, but the next day—postoperative day three—she was still having pain and was clearly worse. She had a high fever; her blood pressure dropped; and her white blood cell count climbed from 10,000 to 20,000, indicating infection/inflammation. Finally the hospitalist ordered a CT scan, which shows a perforation caused by the surgery.

The patient went to surgery for repair. As was predicted, she had a rocky hospital course and ultimately died a month later.

The surgeon was clearly in the wrong. … I was consulted and was asked, “What would you do with the hospitalist? What was their role in that case? Do you think he failed to meet the standard of care?”

—Dr. Baudendistel

Communication with Other Clinicians

“Communication between physicians is critical,” says Sally Whitaker, RN, BSN, risk manager with Rex Healthcare in Raleigh, N.C. “[Hospitalists] shouldn’t just rely on knowing they’ve put their notes on the discharge summary.”

At Rex Hospital (one of Rex Healthcare’s six facilities) where Whitaker works, when seminal events (those big bad things that happen) occur and result in severe trauma or death, the appropriate people meet to backtrack through the steps and scenarios that led to the breakdown.

“Fortunately we don’t have seminal events every day, but every day we do have things that go wrong,” she says. “ … And when we look at our Group Cause Analysis meetings, three-quarters of them [involve] communication issues.”

Exercise Independent Medical Judgment

Hospitalists should read their insurance and employer contracts carefully (especially those with a managed care organization) to ensure that the contract includes a statement allowing the physician to exercise independent medical judgment in the treatment of all patients. If that statement is not present, the hospitalist should request a revision in the contract to include such a statement.

In medical residency programs, a distinction is often made between being a consultant and being a co-manager, says Dr. Baudendistel, but “you have to assume there’s no legal difference between [the two].” Case #3 , he says, was a challenge to decide because the responsibilities of the surgeon and hospitalist in postoperative care were not clearly demarcated.

“I think the surgeon was probably saying, ‘I see this all the time and this is within the realm of what happens after one of these surgeries; let’s not be too worried yet,’” he says. “And I think the internist [hospitalist] ultimately pulled the trigger correctly and the [controversy later on pertained to] whether it should have been done a day or two earlier and whether that have mattered.”

This case illustrates that, although hospitalists are members of teams and partner with consultants and primary physicians, in the end they are managers of patient care and may (we hope rarely) have to break ranks to make aggressive care decisions.

“I think that the other thing that was in [the hospitalist’s] favor,” says Dr. Baudendistel of the case, “was that he was writing very thorough notes, [and] really was discussing everything with the family and everyone was on board. He was doing a very compassionate job … trying to manage this care.”

To Dr. Baudendistel, who is the chair of SHM’s ethics committee, this went a long way toward showing good faith.

Reducing Risks: Concern for the Medical Record

If the medical record is found deficient or illuminating in a negative way, it may serve the plaintiff attorney’s strategy well for establishing negligence or wrongdoing. The chart notes documented by nurses, attending staff, consultants, other residents, and therapists could either portray a smoothly managed case or a chronology of errors and omissions. The chart should never be cosigned and never merely assumed to be accurate.

When Things Go Wrong

Whitaker advises hospitalists to keep the lines of communication open. “Especially after something unexpected has happened,” she says. “So many times I think the human tendency is to just withdraw, or you feel terrible and you don’t know what to say, or you’re afraid you’re going to get emotional while you’re talking with the family.”

This is normal human response in these circumstances, but if you act on the impulse to withdraw and avoid the patient and family, or hold back, which may eventually lead to a filed claim from a family that feels abandoned.

“Until now the number of lawsuits has been really steady and the amount that we were paying in lawsuits was increasing,” says Whitaker. “However, we’re trying to work with the families earlier on so if we make a mistake and we realize that we made a mistake then we admit that. And we try to do what we can to make it right for that patient and their family.”

This often means reaching a fair and reasonable settlement, says Whitaker, “and [examining fair and reasonable means reviewing] the communication at the time the event occurred. Did we acknowledge that we made a mistake? Did we let them know we’d be willing to work with them? And did we let them know we [have since] made these changes … so they’ll … be reassured [that] hopefully it won’t happen again?”

Who’s in Charge?

Linda Greenwald, RN, MS, editor of risk management publications at ProMutual Insurance Group in Boston, wrote in the company’s newsletter, Perspectives on Clinical Risk Management, that in prior times, the question, “Who’s in charge?” was rhetorical.10 These days any number of generalists or specialists might claim that role. And therein lies the rub: Greenwald says that in many cases involving hospitalists the lines of responsibility are unclear and one or more systems may fail. If so, Greenwald writes, the result may be a malpractice claim alleging:

• Failure to diagnose when each of two physicians assumes the other has responsibility for follow-up;
• Negligence in treatment when one physician fails to monitor on an outpatient basis the medication first prescribed by another physician when the patient was an inpatient; and/or
• Negligent care when a patient misinterprets the information one physician asks him or her to relay to another physician.10

Halpern concurs that the modern mix of professionals working as a team on hospital care can be a major challenge.

“In olden days, when a primary care physician referred to a surgeon, and the surgeon performed surgery, and the surgeon took responsibility for postoperative care, and occasionally brought in a consultant, the lines were relatively clear,” says Halpern. “When a hospitalist is injected into the mix, unless the hospital has really clear procedures and unless everybody is comfortable with the system and everybody is talking to each other and agreeing on the lines of demarcation, you’re creating a soup that plaintiff lawyers would be happy to stir.”

The more murky the communication, the greater the liability. “And when you have murky lines of communication, murky lines of responsibility, and a medical catastrophe,” says Halpern, “human nature compounds the problem by frequently causing a finger-pointing contest, where each component of the patient care team circles its own wagons [and] points in a different direction. And that is the absolute worst thing that can happen when trying to deal with a patient injury claim.”

Summary

The hospitalist’s primary risk for malpractice claims may be inadequate or absent patient follow-up resulting from a lack of communication. The best means of protection from claims is for hospitalists to incorporate a comprehensive risk management program into their practice.

Several strategies have proved successful to help prevent litigation. In general, hospitalists should make sure that their hospital has clearly delineated policies regarding responsibility for patients; clearly understand—and ensure that your coworkers, colleagues, and referring physicians understand—the hospital’s systems and protocols; exercise good communication skills; conform to the standard of care; know your own scope of care to the best of your ability; and exercise independent medical judgment, even when partnering with others. TH

Andrea Sattinger also writes the “Alliances” department for The Hospitalist.

References

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