Career

NEW YORK (Reuters Health) - Dabigatran and warfarin offer similar stroke-prevention efficacy in patients with atrial fibrillation (AF), but their side effect profiles differ, according to a systematic review and meta-analysis of real-world clinical practice.

"There could be many reasons for the differences in our findings, such as differences in the quality of evidence of observational studies and randomized controlled trials (RCTs) or differences in the included study populations between the observational studies in our review and the RE-LY trial," Dr. Robert J. Romanelli from Palo Alto Medical Foundation Research Institute, California, told Reuters Health by email.

The RE-LY trial is the only RCT to have evaluated dabigatran in stroke prevention, and RCTs are prone to selection biases less likely to be present in well designed observational studies, Dr. Romanelli and colleagues note in Circulation:Cardiovascular and Quality Outcomes, online January 26.

The team used data from seven retrospective cohort studies to compare the effectiveness and safety of dabigatran and warfarin among more than 348,750 patients with nonvalvular AF.

During an overall mean follow-up of 794 days, dabigatran 150mg or 110 mg was similar to warfarin in ischemic stroke prevention.

Both the higher and lower dabigatran doses had significantly lower hazards of intracranial bleeding compared with warfarin (pooled hazard ratio, 0.44 and 0.49, respectively). But the hazard of gastrointestinal bleeding was significantly greater for dabigatran 150 mg (but not for 110 mg) than for warfarin (pHR, 1.23). The 110 mg dose of dabigatran was only available during the trial; it's now sold in 150 mg or 75 mg capsules.

The increased risk of gastrointestinal bleeding with the higher dose of dabigatran was significant only in older populations (75 years or older).

"Data presented in this review reflect relative risk, which is not always clinically meaningful," the researchers caution. "It is important to bear in mind that event rates for the outcome of interest are low under standard treatment."

"I don't think the findings from this one reviewshould change clinical practice," Dr. Romanelli said. "If anything, this study revealed areas for future research.

NEW YORK (Reuters Health) - Dabigatran and warfarin offer similar stroke-prevention efficacy in patients with atrial fibrillation (AF), but their side effect profiles differ, according to a systematic review and meta-analysis of real-world clinical practice.

"There could be many reasons for the differences in our findings, such as differences in the quality of evidence of observational studies and randomized controlled trials (RCTs) or differences in the included study populations between the observational studies in our review and the RE-LY trial," Dr. Robert J. Romanelli from Palo Alto Medical Foundation Research Institute, California, told Reuters Health by email.

The RE-LY trial is the only RCT to have evaluated dabigatran in stroke prevention, and RCTs are prone to selection biases less likely to be present in well designed observational studies, Dr. Romanelli and colleagues note in Circulation:Cardiovascular and Quality Outcomes, online January 26.

The team used data from seven retrospective cohort studies to compare the effectiveness and safety of dabigatran and warfarin among more than 348,750 patients with nonvalvular AF.

During an overall mean follow-up of 794 days, dabigatran 150mg or 110 mg was similar to warfarin in ischemic stroke prevention.

Both the higher and lower dabigatran doses had significantly lower hazards of intracranial bleeding compared with warfarin (pooled hazard ratio, 0.44 and 0.49, respectively). But the hazard of gastrointestinal bleeding was significantly greater for dabigatran 150 mg (but not for 110 mg) than for warfarin (pHR, 1.23). The 110 mg dose of dabigatran was only available during the trial; it's now sold in 150 mg or 75 mg capsules.

The increased risk of gastrointestinal bleeding with the higher dose of dabigatran was significant only in older populations (75 years or older).

"Data presented in this review reflect relative risk, which is not always clinically meaningful," the researchers caution. "It is important to bear in mind that event rates for the outcome of interest are low under standard treatment."

"I don't think the findings from this one reviewshould change clinical practice," Dr. Romanelli said. "If anything, this study revealed areas for future research.

NEW YORK (Reuters Health) - Dabigatran and warfarin offer similar stroke-prevention efficacy in patients with atrial fibrillation (AF), but their side effect profiles differ, according to a systematic review and meta-analysis of real-world clinical practice.

"There could be many reasons for the differences in our findings, such as differences in the quality of evidence of observational studies and randomized controlled trials (RCTs) or differences in the included study populations between the observational studies in our review and the RE-LY trial," Dr. Robert J. Romanelli from Palo Alto Medical Foundation Research Institute, California, told Reuters Health by email.

The RE-LY trial is the only RCT to have evaluated dabigatran in stroke prevention, and RCTs are prone to selection biases less likely to be present in well designed observational studies, Dr. Romanelli and colleagues note in Circulation:Cardiovascular and Quality Outcomes, online January 26.

The team used data from seven retrospective cohort studies to compare the effectiveness and safety of dabigatran and warfarin among more than 348,750 patients with nonvalvular AF.

During an overall mean follow-up of 794 days, dabigatran 150mg or 110 mg was similar to warfarin in ischemic stroke prevention.

Both the higher and lower dabigatran doses had significantly lower hazards of intracranial bleeding compared with warfarin (pooled hazard ratio, 0.44 and 0.49, respectively). But the hazard of gastrointestinal bleeding was significantly greater for dabigatran 150 mg (but not for 110 mg) than for warfarin (pHR, 1.23). The 110 mg dose of dabigatran was only available during the trial; it's now sold in 150 mg or 75 mg capsules.

The increased risk of gastrointestinal bleeding with the higher dose of dabigatran was significant only in older populations (75 years or older).

"Data presented in this review reflect relative risk, which is not always clinically meaningful," the researchers caution. "It is important to bear in mind that event rates for the outcome of interest are low under standard treatment."

"I don't think the findings from this one reviewshould change clinical practice," Dr. Romanelli said. "If anything, this study revealed areas for future research.

University of California-San Diego med-peds hospitalist Weijen Chang, MD, SFHM, and Shawn Ralson, MD, vice chair of clinical affairs, Children's Hospital at Dartmouth-Hitchcock in Lebanon, N.H., discuss the factors that went into their hospital medicine career choices, and why they find hospitalist careers so fascinating.

University of California-San Diego med-peds hospitalist Weijen Chang, MD, SFHM, and Shawn Ralson, MD, vice chair of clinical affairs, Children's Hospital at Dartmouth-Hitchcock in Lebanon, N.H., discuss the factors that went into their hospital medicine career choices, and why they find hospitalist careers so fascinating.

University of California-San Diego med-peds hospitalist Weijen Chang, MD, SFHM, and Shawn Ralson, MD, vice chair of clinical affairs, Children's Hospital at Dartmouth-Hitchcock in Lebanon, N.H., discuss the factors that went into their hospital medicine career choices, and why they find hospitalist careers so fascinating.

NEW YORK (Reuters Health) - Stent-retriever therapy for the treatment of acute ischemic stroke improves the rate of functional independence at 90 days, according to a systematic

review and meta-analysis.

Stent retrievers are deployed in an occluded vessel, temporarily expanded into the body of a thrombus, and then retracted along with the thrombus.

Dr. Mark J. Eisenberg, from Jewish General Hospital/McGill University, Montreal, Quebec, Canada, and colleagues compared stent retrievers with intravenous recombinant tissue plasminogen activator (rtPA) versus rtPA alone for the treatment of acute ischemic stroke in their systematic review and meta-analysis of five randomized controlled trials (RCTs) with a total of 1,287 patients.

In all five trials, patients randomized to stent-retriever therapy had significantly better functional independence (a modified Rankin Scale (mRS) score of 0-2) at 90 days than did patients randomized to rtPA alone.

Stent-retriever therapy also doubled the likelihood of a one-unit improvement in mRS score at 90 days, according to the January 25 JAMA Neurology online report.

In pooled analyses, there were no significant differences between treatment groups in all-cause mortality, intracranial hemorrhage, or parenchymal hematoma rates at 90 days.

The number needed to treat to achieve an mRS score of 0 to 2 at 90 days was six.

"Given the totality of the evidence regarding the benefits and risks of stent retrievers, our results suggest that the use of these devices in patients with acute ischemic stroke is warranted," the researchers conclude.

Dr. Raphael A. Carandang, from the University of Massachusetts Medical School, Worcester, who wrote an editorial related to this report, told Reuters Health by email, "The data from these five RCTs (as the meta-analysis confirms) provides level 1 class A evidence that in the properly selected patients, stent retriever treatment is superior to the current standard of care with intravenous rtPA and would endorse that it should be considered in all acute ischemic stroke patients that are eligible for it. As with any therapy, proper patient selection is needed, but I do think it changes the landscape of acute stroke treatment going forward. I think that systems of care should be organized in stroke centers around this new therapy."

"The current technology for acute stroke care has reached the point where effective interventional therapies are clearly and unequivocally beneficial in the properly selected patients, but the key takeaway is still that the patients need to be selected properly, and the biggest factor continues to be time to recanalization, which means that all practitioners and systems of care need to focus on getting patients to treatment sooner than ever before," Dr. Carandang concluded.

Dr. Woong Yoon, from Chonnam National University Hospital, Gwangju, Korea, recently found no improvement in outcomes with stent-retriever therapy for patients with acute anterior circulation stroke (http://bit.ly/1OT7M5I). He told Reuters Health by email, "Not all patients with acute ischemic stroke can benefit from this new treatment. Patients with acute stroke due to occlusions of intracranial large vessels such as internal carotid artery, middle cerebral artery, or basilar artery and who presented within six-eight hours of stroke onset can benefit from thrombectomy with stent retrievers."

"We should realize that we are facing the moment of change in the paradigm for acute stroke treatment," Dr. Yoon concluded."Further refinement in the patient selection for stent retrieverthrombectomy is needed in the near future."

Dr. Mayank Goyal, from the University of Calgary, Alberta, Canada, coauthored two of the studies included in the current review. He told Reuters Health by email," There are several additional data coming out on this issue in the near future, which will in fact be more powerful than what is mentioned in this study."

Dr. Goyal said, "However, the key issues going into the future are: how should those patients who were not included in the current trials be treated; how should we as a collective evaluate new devices/technologies; and how do societies/countries who cannot afford stent retrievers implement endovascular stroke treatment."

Dr. Eisenberg was unavailable for comment.

The authors reported no funding. Three coauthors reported disclosures.

NEW YORK (Reuters Health) - Stent-retriever therapy for the treatment of acute ischemic stroke improves the rate of functional independence at 90 days, according to a systematic

review and meta-analysis.

Stent retrievers are deployed in an occluded vessel, temporarily expanded into the body of a thrombus, and then retracted along with the thrombus.

Dr. Mark J. Eisenberg, from Jewish General Hospital/McGill University, Montreal, Quebec, Canada, and colleagues compared stent retrievers with intravenous recombinant tissue plasminogen activator (rtPA) versus rtPA alone for the treatment of acute ischemic stroke in their systematic review and meta-analysis of five randomized controlled trials (RCTs) with a total of 1,287 patients.

In all five trials, patients randomized to stent-retriever therapy had significantly better functional independence (a modified Rankin Scale (mRS) score of 0-2) at 90 days than did patients randomized to rtPA alone.

Stent-retriever therapy also doubled the likelihood of a one-unit improvement in mRS score at 90 days, according to the January 25 JAMA Neurology online report.

In pooled analyses, there were no significant differences between treatment groups in all-cause mortality, intracranial hemorrhage, or parenchymal hematoma rates at 90 days.

The number needed to treat to achieve an mRS score of 0 to 2 at 90 days was six.

"Given the totality of the evidence regarding the benefits and risks of stent retrievers, our results suggest that the use of these devices in patients with acute ischemic stroke is warranted," the researchers conclude.

Dr. Raphael A. Carandang, from the University of Massachusetts Medical School, Worcester, who wrote an editorial related to this report, told Reuters Health by email, "The data from these five RCTs (as the meta-analysis confirms) provides level 1 class A evidence that in the properly selected patients, stent retriever treatment is superior to the current standard of care with intravenous rtPA and would endorse that it should be considered in all acute ischemic stroke patients that are eligible for it. As with any therapy, proper patient selection is needed, but I do think it changes the landscape of acute stroke treatment going forward. I think that systems of care should be organized in stroke centers around this new therapy."

"The current technology for acute stroke care has reached the point where effective interventional therapies are clearly and unequivocally beneficial in the properly selected patients, but the key takeaway is still that the patients need to be selected properly, and the biggest factor continues to be time to recanalization, which means that all practitioners and systems of care need to focus on getting patients to treatment sooner than ever before," Dr. Carandang concluded.

Dr. Woong Yoon, from Chonnam National University Hospital, Gwangju, Korea, recently found no improvement in outcomes with stent-retriever therapy for patients with acute anterior circulation stroke (http://bit.ly/1OT7M5I). He told Reuters Health by email, "Not all patients with acute ischemic stroke can benefit from this new treatment. Patients with acute stroke due to occlusions of intracranial large vessels such as internal carotid artery, middle cerebral artery, or basilar artery and who presented within six-eight hours of stroke onset can benefit from thrombectomy with stent retrievers."

"We should realize that we are facing the moment of change in the paradigm for acute stroke treatment," Dr. Yoon concluded."Further refinement in the patient selection for stent retrieverthrombectomy is needed in the near future."

Dr. Mayank Goyal, from the University of Calgary, Alberta, Canada, coauthored two of the studies included in the current review. He told Reuters Health by email," There are several additional data coming out on this issue in the near future, which will in fact be more powerful than what is mentioned in this study."

Dr. Goyal said, "However, the key issues going into the future are: how should those patients who were not included in the current trials be treated; how should we as a collective evaluate new devices/technologies; and how do societies/countries who cannot afford stent retrievers implement endovascular stroke treatment."

Dr. Eisenberg was unavailable for comment.

The authors reported no funding. Three coauthors reported disclosures.

NEW YORK (Reuters Health) - Stent-retriever therapy for the treatment of acute ischemic stroke improves the rate of functional independence at 90 days, according to a systematic

review and meta-analysis.

Stent retrievers are deployed in an occluded vessel, temporarily expanded into the body of a thrombus, and then retracted along with the thrombus.

Dr. Mark J. Eisenberg, from Jewish General Hospital/McGill University, Montreal, Quebec, Canada, and colleagues compared stent retrievers with intravenous recombinant tissue plasminogen activator (rtPA) versus rtPA alone for the treatment of acute ischemic stroke in their systematic review and meta-analysis of five randomized controlled trials (RCTs) with a total of 1,287 patients.

In all five trials, patients randomized to stent-retriever therapy had significantly better functional independence (a modified Rankin Scale (mRS) score of 0-2) at 90 days than did patients randomized to rtPA alone.

Stent-retriever therapy also doubled the likelihood of a one-unit improvement in mRS score at 90 days, according to the January 25 JAMA Neurology online report.

In pooled analyses, there were no significant differences between treatment groups in all-cause mortality, intracranial hemorrhage, or parenchymal hematoma rates at 90 days.

The number needed to treat to achieve an mRS score of 0 to 2 at 90 days was six.

"Given the totality of the evidence regarding the benefits and risks of stent retrievers, our results suggest that the use of these devices in patients with acute ischemic stroke is warranted," the researchers conclude.

Dr. Raphael A. Carandang, from the University of Massachusetts Medical School, Worcester, who wrote an editorial related to this report, told Reuters Health by email, "The data from these five RCTs (as the meta-analysis confirms) provides level 1 class A evidence that in the properly selected patients, stent retriever treatment is superior to the current standard of care with intravenous rtPA and would endorse that it should be considered in all acute ischemic stroke patients that are eligible for it. As with any therapy, proper patient selection is needed, but I do think it changes the landscape of acute stroke treatment going forward. I think that systems of care should be organized in stroke centers around this new therapy."

"The current technology for acute stroke care has reached the point where effective interventional therapies are clearly and unequivocally beneficial in the properly selected patients, but the key takeaway is still that the patients need to be selected properly, and the biggest factor continues to be time to recanalization, which means that all practitioners and systems of care need to focus on getting patients to treatment sooner than ever before," Dr. Carandang concluded.

Dr. Woong Yoon, from Chonnam National University Hospital, Gwangju, Korea, recently found no improvement in outcomes with stent-retriever therapy for patients with acute anterior circulation stroke (http://bit.ly/1OT7M5I). He told Reuters Health by email, "Not all patients with acute ischemic stroke can benefit from this new treatment. Patients with acute stroke due to occlusions of intracranial large vessels such as internal carotid artery, middle cerebral artery, or basilar artery and who presented within six-eight hours of stroke onset can benefit from thrombectomy with stent retrievers."

"We should realize that we are facing the moment of change in the paradigm for acute stroke treatment," Dr. Yoon concluded."Further refinement in the patient selection for stent retrieverthrombectomy is needed in the near future."

Dr. Mayank Goyal, from the University of Calgary, Alberta, Canada, coauthored two of the studies included in the current review. He told Reuters Health by email," There are several additional data coming out on this issue in the near future, which will in fact be more powerful than what is mentioned in this study."

Dr. Goyal said, "However, the key issues going into the future are: how should those patients who were not included in the current trials be treated; how should we as a collective evaluate new devices/technologies; and how do societies/countries who cannot afford stent retrievers implement endovascular stroke treatment."

Dr. Eisenberg was unavailable for comment.

The authors reported no funding. Three coauthors reported disclosures.

Kendall Rogers, MD, SFHM, chair of SHM’s Health IT Committee, discusses HM16 having a separate track for health IT, to whom the track is geared, and translating tech-savviness into actually being effective in helping to develop practical health IT.

Kendall Rogers, MD, SFHM, chair of SHM’s Health IT Committee, discusses HM16 having a separate track for health IT, to whom the track is geared, and translating tech-savviness into actually being effective in helping to develop practical health IT.

Kendall Rogers, MD, SFHM, chair of SHM’s Health IT Committee, discusses HM16 having a separate track for health IT, to whom the track is geared, and translating tech-savviness into actually being effective in helping to develop practical health IT.

Course Director Melissa Mattison, MD, SFHM, assistant professor of medicine at Harvard Medical School, talks about the SHM annual meeting's new emphasis on work-life balance and on how her past experience at the annual meeting influenced how she helped shape this year's meeting.

Course Director Melissa Mattison, MD, SFHM, assistant professor of medicine at Harvard Medical School, talks about the SHM annual meeting's new emphasis on work-life balance and on how her past experience at the annual meeting influenced how she helped shape this year's meeting.

Course Director Melissa Mattison, MD, SFHM, assistant professor of medicine at Harvard Medical School, talks about the SHM annual meeting's new emphasis on work-life balance and on how her past experience at the annual meeting influenced how she helped shape this year's meeting.

NEW YORK (Reuters Health) - An early invasive strategy provides better outcomes than a conservative strategy in octogenarians with non-ST-elevation myocardial infarction

(NSTEMI) or unstable angina, according to the After Eighty clinical trial.

"Management of the very elderly with myocardial infarction (NSTE-ACS) is challenging, because they often present later, have atypical symptoms, and are a more heterogeneous group dueto comorbidities," Dr. Bjorn Bendz and Dr. Nicolai Tegn from Oslo University Hospital in Norway told Reuters Health in a joint email. "These factors may reduce the benefits and increase the risk of complications from invasive treatment."

Large randomized trials have demonstrated the superiority of an invasive strategy in this setting, but patients aged 80 years and over are underrepresented in these studies.

Dr. Bendz and Dr. Tegn and colleagues from 16 hospitals in Norway investigated whether patients aged 80 years or older would benefit from an early invasive strategy versus a

conservative strategy in terms of a composite primary endpoint of MI, need for urgent revascularization, and death.

The invasive strategy (n=229) included early coronary angiography with immediate assessment for ad hoc percutaneous coronary intervention (PCI), coronary artery bypass graft (CABG), or optimal medical treatment, whereas the conservative strategy (n=228) included optimal medical treatment alone.

In the invasive group, 107 underwent PCI and six had CABG, the researchers report in The Lancet, online January 12.

During follow-up, patients in the invasive group were significantly less likely to experience the primary endpoint (41% vs. 61%, p=0.0001).

Compared with patients in the conservative-strategy group, those in the invasive-strategy group were 48% less likely to experience MI and 81% less likely to require urgent revascularization. They were also 40% less likely to have a stroke and 11% less likely to die, but these latter differences were not significant.

Minor bleeding complications (but not major bleeding complications) were somewhat more common in the invasive strategy group (10%) than in the conservative strategy group (7%).

"The present results support an invasive strategy in patients over 80 years with NSTEMI and unstable angina," Dr.Bendz and Dr. Tegn said. "However, the efficacy was less with increasing age, and for patients older than 90 years we cannot conclude if an invasive strategy is beneficial. Thus, management of acute coronary syndrome (ACS) patients over 90 must be individually tailored, considering life expectancy, comorbid illnesses, bleeding risk, cognitive and functional status, and patient preference."

Dr. Peter Psaltis from the University of Adelaide in South Australia, who co-wrote an accompanying editorial, told Reuters Health by email, "The After-80 study now provides the direct

evidence we needed to support this 'early invasive' approach. Given how difficult it is to recruit very elderly patients to clinical studies - and this was reflected by the fact that almost 80% of screened patients were not actually enrolled into After-80 - the investigators deserve credit for taking this study on. Their study is especially important because in developed countries, we see so many 'very old' patients admitted to our cardiology and general medicine wards with ACS."

"In extrapolating the results of After-80 to real-world clinical practice, we firstly have to remember that 70-80% of patients who were screened for this study were ultimately not

enrolled," he reiterated. "There would have been many reasons why so many patients were excluded, but it does emphasize that the study's findings won't apply to everyone over the age of 80 who presents with ACS."

"As always, the decision making process needs to be individually tailored," Dr. Psaltis said. "The patient's pre-existing comorbid status, quality of life, cognitive function and personal wishes are all important factors that need to be taken into account."

"Moreover, we should not just consider its potential benefits in terms of whether it will reduce mortality or risk of recurrent infarcts," Dr. Psaltis added. "In certain individuals >90, an invasive approach may be taken to improve quality of life and symptom burden, help to keep patients in independent living at home, or reduce readmission rates to hospital or even

the use of anti-anginal medications that can be associated with debilitating side-effects."

Dr. Paul Erne from the University of Zurich in Switzerland, who heads the steering committee of the Acute Myocardial Infarction in Sweden (AMIS), stressed, "Conservative treatment

does not result in a poor outcome in every patient and we need to know much more about differential approach."

"However, active treatment remains a great option for part of the elderly patients," regardless of age, he told Reuters Health by email. "Please note the increasing number of patients

treated at age above 100 years which proves to be a good option if the patients want to live actively."

Dr. Rahul Potluri, founder of the ACALM (Algorithm for Comorbidities, Associations, Length of Stay and Mortality) Study Unit, Birmingham, U.K., recently reviewed the role of

angioplasty in octogenarian ACS patients.

He told Reuters Health by email, "This study is the most conclusive evidence to date, showing the benefits of an invasive approach in patients above the age of 80 with the most common types of ACS (namely NSTEMI and unstable angina). The findings are most surprising given that both the groups were very similar in terms of patient characteristics and medications taken, thus delineating the true benefit of the invasive strategy in the most controlled fashion and in a short follow-up period."

The study did not have commercial funding and the researchers declared no competing interests.

NEW YORK (Reuters Health) - An early invasive strategy provides better outcomes than a conservative strategy in octogenarians with non-ST-elevation myocardial infarction

(NSTEMI) or unstable angina, according to the After Eighty clinical trial.

"Management of the very elderly with myocardial infarction (NSTE-ACS) is challenging, because they often present later, have atypical symptoms, and are a more heterogeneous group dueto comorbidities," Dr. Bjorn Bendz and Dr. Nicolai Tegn from Oslo University Hospital in Norway told Reuters Health in a joint email. "These factors may reduce the benefits and increase the risk of complications from invasive treatment."

Large randomized trials have demonstrated the superiority of an invasive strategy in this setting, but patients aged 80 years and over are underrepresented in these studies.

Dr. Bendz and Dr. Tegn and colleagues from 16 hospitals in Norway investigated whether patients aged 80 years or older would benefit from an early invasive strategy versus a

conservative strategy in terms of a composite primary endpoint of MI, need for urgent revascularization, and death.

The invasive strategy (n=229) included early coronary angiography with immediate assessment for ad hoc percutaneous coronary intervention (PCI), coronary artery bypass graft (CABG), or optimal medical treatment, whereas the conservative strategy (n=228) included optimal medical treatment alone.

In the invasive group, 107 underwent PCI and six had CABG, the researchers report in The Lancet, online January 12.

During follow-up, patients in the invasive group were significantly less likely to experience the primary endpoint (41% vs. 61%, p=0.0001).

Compared with patients in the conservative-strategy group, those in the invasive-strategy group were 48% less likely to experience MI and 81% less likely to require urgent revascularization. They were also 40% less likely to have a stroke and 11% less likely to die, but these latter differences were not significant.

Minor bleeding complications (but not major bleeding complications) were somewhat more common in the invasive strategy group (10%) than in the conservative strategy group (7%).

"The present results support an invasive strategy in patients over 80 years with NSTEMI and unstable angina," Dr.Bendz and Dr. Tegn said. "However, the efficacy was less with increasing age, and for patients older than 90 years we cannot conclude if an invasive strategy is beneficial. Thus, management of acute coronary syndrome (ACS) patients over 90 must be individually tailored, considering life expectancy, comorbid illnesses, bleeding risk, cognitive and functional status, and patient preference."

Dr. Peter Psaltis from the University of Adelaide in South Australia, who co-wrote an accompanying editorial, told Reuters Health by email, "The After-80 study now provides the direct

evidence we needed to support this 'early invasive' approach. Given how difficult it is to recruit very elderly patients to clinical studies - and this was reflected by the fact that almost 80% of screened patients were not actually enrolled into After-80 - the investigators deserve credit for taking this study on. Their study is especially important because in developed countries, we see so many 'very old' patients admitted to our cardiology and general medicine wards with ACS."

"In extrapolating the results of After-80 to real-world clinical practice, we firstly have to remember that 70-80% of patients who were screened for this study were ultimately not

enrolled," he reiterated. "There would have been many reasons why so many patients were excluded, but it does emphasize that the study's findings won't apply to everyone over the age of 80 who presents with ACS."

"As always, the decision making process needs to be individually tailored," Dr. Psaltis said. "The patient's pre-existing comorbid status, quality of life, cognitive function and personal wishes are all important factors that need to be taken into account."

"Moreover, we should not just consider its potential benefits in terms of whether it will reduce mortality or risk of recurrent infarcts," Dr. Psaltis added. "In certain individuals >90, an invasive approach may be taken to improve quality of life and symptom burden, help to keep patients in independent living at home, or reduce readmission rates to hospital or even

the use of anti-anginal medications that can be associated with debilitating side-effects."

Dr. Paul Erne from the University of Zurich in Switzerland, who heads the steering committee of the Acute Myocardial Infarction in Sweden (AMIS), stressed, "Conservative treatment

does not result in a poor outcome in every patient and we need to know much more about differential approach."

"However, active treatment remains a great option for part of the elderly patients," regardless of age, he told Reuters Health by email. "Please note the increasing number of patients

treated at age above 100 years which proves to be a good option if the patients want to live actively."

Dr. Rahul Potluri, founder of the ACALM (Algorithm for Comorbidities, Associations, Length of Stay and Mortality) Study Unit, Birmingham, U.K., recently reviewed the role of

angioplasty in octogenarian ACS patients.

He told Reuters Health by email, "This study is the most conclusive evidence to date, showing the benefits of an invasive approach in patients above the age of 80 with the most common types of ACS (namely NSTEMI and unstable angina). The findings are most surprising given that both the groups were very similar in terms of patient characteristics and medications taken, thus delineating the true benefit of the invasive strategy in the most controlled fashion and in a short follow-up period."

The study did not have commercial funding and the researchers declared no competing interests.

NEW YORK (Reuters Health) - An early invasive strategy provides better outcomes than a conservative strategy in octogenarians with non-ST-elevation myocardial infarction

(NSTEMI) or unstable angina, according to the After Eighty clinical trial.

"Management of the very elderly with myocardial infarction (NSTE-ACS) is challenging, because they often present later, have atypical symptoms, and are a more heterogeneous group dueto comorbidities," Dr. Bjorn Bendz and Dr. Nicolai Tegn from Oslo University Hospital in Norway told Reuters Health in a joint email. "These factors may reduce the benefits and increase the risk of complications from invasive treatment."

Large randomized trials have demonstrated the superiority of an invasive strategy in this setting, but patients aged 80 years and over are underrepresented in these studies.

Dr. Bendz and Dr. Tegn and colleagues from 16 hospitals in Norway investigated whether patients aged 80 years or older would benefit from an early invasive strategy versus a

conservative strategy in terms of a composite primary endpoint of MI, need for urgent revascularization, and death.

The invasive strategy (n=229) included early coronary angiography with immediate assessment for ad hoc percutaneous coronary intervention (PCI), coronary artery bypass graft (CABG), or optimal medical treatment, whereas the conservative strategy (n=228) included optimal medical treatment alone.

In the invasive group, 107 underwent PCI and six had CABG, the researchers report in The Lancet, online January 12.

During follow-up, patients in the invasive group were significantly less likely to experience the primary endpoint (41% vs. 61%, p=0.0001).

Compared with patients in the conservative-strategy group, those in the invasive-strategy group were 48% less likely to experience MI and 81% less likely to require urgent revascularization. They were also 40% less likely to have a stroke and 11% less likely to die, but these latter differences were not significant.

Minor bleeding complications (but not major bleeding complications) were somewhat more common in the invasive strategy group (10%) than in the conservative strategy group (7%).

"The present results support an invasive strategy in patients over 80 years with NSTEMI and unstable angina," Dr.Bendz and Dr. Tegn said. "However, the efficacy was less with increasing age, and for patients older than 90 years we cannot conclude if an invasive strategy is beneficial. Thus, management of acute coronary syndrome (ACS) patients over 90 must be individually tailored, considering life expectancy, comorbid illnesses, bleeding risk, cognitive and functional status, and patient preference."

Dr. Peter Psaltis from the University of Adelaide in South Australia, who co-wrote an accompanying editorial, told Reuters Health by email, "The After-80 study now provides the direct

evidence we needed to support this 'early invasive' approach. Given how difficult it is to recruit very elderly patients to clinical studies - and this was reflected by the fact that almost 80% of screened patients were not actually enrolled into After-80 - the investigators deserve credit for taking this study on. Their study is especially important because in developed countries, we see so many 'very old' patients admitted to our cardiology and general medicine wards with ACS."

"In extrapolating the results of After-80 to real-world clinical practice, we firstly have to remember that 70-80% of patients who were screened for this study were ultimately not

enrolled," he reiterated. "There would have been many reasons why so many patients were excluded, but it does emphasize that the study's findings won't apply to everyone over the age of 80 who presents with ACS."

"As always, the decision making process needs to be individually tailored," Dr. Psaltis said. "The patient's pre-existing comorbid status, quality of life, cognitive function and personal wishes are all important factors that need to be taken into account."

"Moreover, we should not just consider its potential benefits in terms of whether it will reduce mortality or risk of recurrent infarcts," Dr. Psaltis added. "In certain individuals >90, an invasive approach may be taken to improve quality of life and symptom burden, help to keep patients in independent living at home, or reduce readmission rates to hospital or even

the use of anti-anginal medications that can be associated with debilitating side-effects."

Dr. Paul Erne from the University of Zurich in Switzerland, who heads the steering committee of the Acute Myocardial Infarction in Sweden (AMIS), stressed, "Conservative treatment

does not result in a poor outcome in every patient and we need to know much more about differential approach."

"However, active treatment remains a great option for part of the elderly patients," regardless of age, he told Reuters Health by email. "Please note the increasing number of patients

treated at age above 100 years which proves to be a good option if the patients want to live actively."

Dr. Rahul Potluri, founder of the ACALM (Algorithm for Comorbidities, Associations, Length of Stay and Mortality) Study Unit, Birmingham, U.K., recently reviewed the role of

angioplasty in octogenarian ACS patients.

He told Reuters Health by email, "This study is the most conclusive evidence to date, showing the benefits of an invasive approach in patients above the age of 80 with the most common types of ACS (namely NSTEMI and unstable angina). The findings are most surprising given that both the groups were very similar in terms of patient characteristics and medications taken, thus delineating the true benefit of the invasive strategy in the most controlled fashion and in a short follow-up period."

The study did not have commercial funding and the researchers declared no competing interests.

NEW YORK (Reuters Health) - Rates of kidney stones have increased substantially over the past 20 years, particularly among children, adolescents, females, and blacks, according to a population-based study in South Carolina.

Historically, the highest rates of kidney stone disease have been in middle-aged white men, but the new findings underscore emerging changes in this pattern. Prior studies have found that prevalent kidney stone disease has nearly doubled in the United States over the past two decades. The extent to which specific groups of patients have been affected has been less clear, although there have been reports of increasing frequency of kidney stones among youth.

"My colleagues and I wondered if kidney stones were increasing preferentially among adolescents more than in other age groups," lead researcher Dr. Gregory Tasian, of the University of Pennsylvania Perelman School of Medicine in Philadelphia, told Reuters Health by email.

To estimate the annual kidney stone incidence in South Carolina in their repeated cross-sectional study, the researchers used U.S. Census data and data from the South Carolina Medical Encounter Data and Financial Reports, which includes information on all surgeries, emergency department visits, and inpatient hospitalizations in the state from 1997 to 2012. Using linear mixed models, they also sought to identify the patient groups in whom the rate of stones has increased the most.

Nearly 153,000 adult and pediatric patients among a state population of about 4.6 million received care for kidney stones from 1997 to 2012, the researchers reported online January 14 in the Clinical Journal of the American Society of Nephrology.

The annual incidence increased 16% during that time, with the largest increases occurring in teens, blacks, and women.  Teens 15 to 19 years comprised the age group with the largest increase in incidence of kidney stones from 1997 (an age-specific rate of nearly 80 per 100,000) to 2012 (about 155 per 100,000).

Overall, teens 15 to 19 experienced a 26% increase per five years (incidence rate ratio, 1.26), after adjusting for sex and race. The increase was substantially greater among teen girls,

with an annual incidence 52% higher than for teen boys.

Increases in cumulative risk of kidney stones during childhood were similar for girls (87%) and boys (90%), although the risks in 2012 were "modest," at 0.9% (for girls) and 0.6% (for boys), the researchers say. They note that the "emergence of nephrolithiasis as a disease that begins in childhood is worrisome because there is limited evidence about how to best treat children" with the condition.

After adjusting for age and race, incidence of kidney stones  increased an estimated 15% per five years (IRR, 1.15) among females of all ages during the study period, but was stable among males (IRR, 0.99). The estimated lifetime risk for women increased from 10.5% in 1997 to 15.2% in 2012, but remained unchanged for men at about 23%. Incidence of kidney stones among blacks rose an estimated 15% per five years (IRR, 1.15) during the study period, compared with an estimated 3% among whites (IRR, 1.03).

"We were not surprised by the high occurrence of kidney  stones among adolescents and females (5% and 3% per year), which is consistent with other studies reported to date," Dr. Tasian

said. "We were, however, surprised by how much kidney stones were increasing in African-Americans, as previous studies have not really studied differences in kidney stone occurrence among different racial groups."

Although the study focused on kidney stone disease in South Carolina, it's likely that similar patterns exist across the nation, he said.

"Kidney stones have increased 70% over the last 30 years in adults in the U.S., and we are also seeing higher rates of kidney stones in children across the U.S.," Dr. Tasian said.

However, even though kidney stones are also increasing in many areas in the world, for many reasons, the results should not be generalized beyond the United States, he noted.

"This study is an important step forward in understanding the changing epidemiology of kidney stone disease," Dr. Charles D. Scales, of Duke University Medical Center in Durham, North Carolina, told Reuters Health by email. The underlying causes of the increase are unclear. "In adults, it may be related to the tidal wave of obesity and diabetes in the United States," said Dr. Scales, an expert in kidney stones who was not involved with the study.

These epidemiologic trends provide more support for the concept that "chronic and poorly understood metabolic derangements are likely causing all of these new stones in previously low-risk individuals," he said.

Increased consumption of high-sodium processed food and dehydration also may be contributing factors, he added. "Emerging evidence suggests that a kidney stone may foreshadow future medical problems, such as heart disease, bone density loss, and chronic kidney disease," Dr. Scales said. "So from the public-health perspective, the worst may be yet to come as these teenagers with stones become adults."

The study had no commercial funding and the authors reported no disclosures.

NEW YORK (Reuters Health) - Rates of kidney stones have increased substantially over the past 20 years, particularly among children, adolescents, females, and blacks, according to a population-based study in South Carolina.

Historically, the highest rates of kidney stone disease have been in middle-aged white men, but the new findings underscore emerging changes in this pattern. Prior studies have found that prevalent kidney stone disease has nearly doubled in the United States over the past two decades. The extent to which specific groups of patients have been affected has been less clear, although there have been reports of increasing frequency of kidney stones among youth.

"My colleagues and I wondered if kidney stones were increasing preferentially among adolescents more than in other age groups," lead researcher Dr. Gregory Tasian, of the University of Pennsylvania Perelman School of Medicine in Philadelphia, told Reuters Health by email.

To estimate the annual kidney stone incidence in South Carolina in their repeated cross-sectional study, the researchers used U.S. Census data and data from the South Carolina Medical Encounter Data and Financial Reports, which includes information on all surgeries, emergency department visits, and inpatient hospitalizations in the state from 1997 to 2012. Using linear mixed models, they also sought to identify the patient groups in whom the rate of stones has increased the most.

Nearly 153,000 adult and pediatric patients among a state population of about 4.6 million received care for kidney stones from 1997 to 2012, the researchers reported online January 14 in the Clinical Journal of the American Society of Nephrology.

The annual incidence increased 16% during that time, with the largest increases occurring in teens, blacks, and women.  Teens 15 to 19 years comprised the age group with the largest increase in incidence of kidney stones from 1997 (an age-specific rate of nearly 80 per 100,000) to 2012 (about 155 per 100,000).

Overall, teens 15 to 19 experienced a 26% increase per five years (incidence rate ratio, 1.26), after adjusting for sex and race. The increase was substantially greater among teen girls,

with an annual incidence 52% higher than for teen boys.

Increases in cumulative risk of kidney stones during childhood were similar for girls (87%) and boys (90%), although the risks in 2012 were "modest," at 0.9% (for girls) and 0.6% (for boys), the researchers say. They note that the "emergence of nephrolithiasis as a disease that begins in childhood is worrisome because there is limited evidence about how to best treat children" with the condition.

After adjusting for age and race, incidence of kidney stones  increased an estimated 15% per five years (IRR, 1.15) among females of all ages during the study period, but was stable among males (IRR, 0.99). The estimated lifetime risk for women increased from 10.5% in 1997 to 15.2% in 2012, but remained unchanged for men at about 23%. Incidence of kidney stones among blacks rose an estimated 15% per five years (IRR, 1.15) during the study period, compared with an estimated 3% among whites (IRR, 1.03).

"We were not surprised by the high occurrence of kidney  stones among adolescents and females (5% and 3% per year), which is consistent with other studies reported to date," Dr. Tasian

said. "We were, however, surprised by how much kidney stones were increasing in African-Americans, as previous studies have not really studied differences in kidney stone occurrence among different racial groups."

Although the study focused on kidney stone disease in South Carolina, it's likely that similar patterns exist across the nation, he said.

"Kidney stones have increased 70% over the last 30 years in adults in the U.S., and we are also seeing higher rates of kidney stones in children across the U.S.," Dr. Tasian said.

However, even though kidney stones are also increasing in many areas in the world, for many reasons, the results should not be generalized beyond the United States, he noted.

"This study is an important step forward in understanding the changing epidemiology of kidney stone disease," Dr. Charles D. Scales, of Duke University Medical Center in Durham, North Carolina, told Reuters Health by email. The underlying causes of the increase are unclear. "In adults, it may be related to the tidal wave of obesity and diabetes in the United States," said Dr. Scales, an expert in kidney stones who was not involved with the study.

These epidemiologic trends provide more support for the concept that "chronic and poorly understood metabolic derangements are likely causing all of these new stones in previously low-risk individuals," he said.

Increased consumption of high-sodium processed food and dehydration also may be contributing factors, he added. "Emerging evidence suggests that a kidney stone may foreshadow future medical problems, such as heart disease, bone density loss, and chronic kidney disease," Dr. Scales said. "So from the public-health perspective, the worst may be yet to come as these teenagers with stones become adults."

The study had no commercial funding and the authors reported no disclosures.

NEW YORK (Reuters Health) - Rates of kidney stones have increased substantially over the past 20 years, particularly among children, adolescents, females, and blacks, according to a population-based study in South Carolina.

Historically, the highest rates of kidney stone disease have been in middle-aged white men, but the new findings underscore emerging changes in this pattern. Prior studies have found that prevalent kidney stone disease has nearly doubled in the United States over the past two decades. The extent to which specific groups of patients have been affected has been less clear, although there have been reports of increasing frequency of kidney stones among youth.

"My colleagues and I wondered if kidney stones were increasing preferentially among adolescents more than in other age groups," lead researcher Dr. Gregory Tasian, of the University of Pennsylvania Perelman School of Medicine in Philadelphia, told Reuters Health by email.

To estimate the annual kidney stone incidence in South Carolina in their repeated cross-sectional study, the researchers used U.S. Census data and data from the South Carolina Medical Encounter Data and Financial Reports, which includes information on all surgeries, emergency department visits, and inpatient hospitalizations in the state from 1997 to 2012. Using linear mixed models, they also sought to identify the patient groups in whom the rate of stones has increased the most.

Nearly 153,000 adult and pediatric patients among a state population of about 4.6 million received care for kidney stones from 1997 to 2012, the researchers reported online January 14 in the Clinical Journal of the American Society of Nephrology.

The annual incidence increased 16% during that time, with the largest increases occurring in teens, blacks, and women.  Teens 15 to 19 years comprised the age group with the largest increase in incidence of kidney stones from 1997 (an age-specific rate of nearly 80 per 100,000) to 2012 (about 155 per 100,000).

Overall, teens 15 to 19 experienced a 26% increase per five years (incidence rate ratio, 1.26), after adjusting for sex and race. The increase was substantially greater among teen girls,

with an annual incidence 52% higher than for teen boys.

Increases in cumulative risk of kidney stones during childhood were similar for girls (87%) and boys (90%), although the risks in 2012 were "modest," at 0.9% (for girls) and 0.6% (for boys), the researchers say. They note that the "emergence of nephrolithiasis as a disease that begins in childhood is worrisome because there is limited evidence about how to best treat children" with the condition.

After adjusting for age and race, incidence of kidney stones  increased an estimated 15% per five years (IRR, 1.15) among females of all ages during the study period, but was stable among males (IRR, 0.99). The estimated lifetime risk for women increased from 10.5% in 1997 to 15.2% in 2012, but remained unchanged for men at about 23%. Incidence of kidney stones among blacks rose an estimated 15% per five years (IRR, 1.15) during the study period, compared with an estimated 3% among whites (IRR, 1.03).

"We were not surprised by the high occurrence of kidney  stones among adolescents and females (5% and 3% per year), which is consistent with other studies reported to date," Dr. Tasian

said. "We were, however, surprised by how much kidney stones were increasing in African-Americans, as previous studies have not really studied differences in kidney stone occurrence among different racial groups."

Although the study focused on kidney stone disease in South Carolina, it's likely that similar patterns exist across the nation, he said.

"Kidney stones have increased 70% over the last 30 years in adults in the U.S., and we are also seeing higher rates of kidney stones in children across the U.S.," Dr. Tasian said.

However, even though kidney stones are also increasing in many areas in the world, for many reasons, the results should not be generalized beyond the United States, he noted.

"This study is an important step forward in understanding the changing epidemiology of kidney stone disease," Dr. Charles D. Scales, of Duke University Medical Center in Durham, North Carolina, told Reuters Health by email. The underlying causes of the increase are unclear. "In adults, it may be related to the tidal wave of obesity and diabetes in the United States," said Dr. Scales, an expert in kidney stones who was not involved with the study.

These epidemiologic trends provide more support for the concept that "chronic and poorly understood metabolic derangements are likely causing all of these new stones in previously low-risk individuals," he said.

Increased consumption of high-sodium processed food and dehydration also may be contributing factors, he added. "Emerging evidence suggests that a kidney stone may foreshadow future medical problems, such as heart disease, bone density loss, and chronic kidney disease," Dr. Scales said. "So from the public-health perspective, the worst may be yet to come as these teenagers with stones become adults."

The study had no commercial funding and the authors reported no disclosures.

Nocturnists Daniele Olveczky, MD, MS, of Beth Israel Deaconess Medical Center in Boston, and Eric Martin, MD, of the University of Colorado, provide insight and tips for tackling night shifts and avoiding burnout.

Nocturnists Daniele Olveczky, MD, MS, of Beth Israel Deaconess Medical Center in Boston, and Eric Martin, MD, of the University of Colorado, provide insight and tips for tackling night shifts and avoiding burnout.

Nocturnists Daniele Olveczky, MD, MS, of Beth Israel Deaconess Medical Center in Boston, and Eric Martin, MD, of the University of Colorado, provide insight and tips for tackling night shifts and avoiding burnout.

Dear Dr. Hospitalist:

Over the past several years, we have had a problem with physician retention, especially with nocturnists, in our medium-sized hospitalist group. Do you have any suggestions (beyond the obvious “more money”) to help us retain our hospitalists?

Missing My Friends in the Midwest

Dr. Hospitalist responds:

Since its inception, hospital medicine has been a very attractive field for practicing medicine, and although growth was phenomenal for many years (especially 2000–2010), it has leveled off over the past five years. With this exceptional growth have come increased salaries, geographically diverse job locations, and more opportunities for career development.

One of the most significant changes over the past 10 years is that hospital medicine is no longer seen as a bridge from residency to fellowship or as a stopover while waiting on the ideal job. Physicians now see hospital medicine as a career choice and are more likely to search for the “ideal” hospitalist job.

Although competitive salaries are important and a necessary starting point, to attract and keep career hospitalists, HM groups (HMGs) will need to offer opportunities for professional growth and leadership as well as flexible schedules.

Many larger HMGs offer several different schedule models, from the ubiquitous seven-on/seven-off schedule (54%, according to the 2014 State of Hospital Medicine report) to the more traditional five-day workweek with vacation time. Many also choose to work part- or full-time as a nocturnist and, in doing so, earn substantially more money (15%–20% differential). The flexible schedule and the ability to work part- or full-time have been very attractive to those clinicians just starting families or attaining another degree (MBAs are becoming very popular).

While there have always been the “check-in, check-out” docs who did their seven and didn’t want to be bothered during their time off, there were typically enough gunners around to pick up the slack. With the Millennial generation’s pervasive aim for work-life balance, it might become more difficult to find even a few who are willing to go the extra mile in hopes of career advancement. Mix in a very robust job market with a proclivity to travel, and you have a recipe for high attrition.

Like any new profession or specialty, HM will have to evolve and adjust to keep these new docs anchored. We will need to consider offering vacation time, especially for those who are willing to work a traditional Monday–Friday schedule. For those in academia with an interest in promotion, there should be real opportunities for advancement instead of the traditional “time in rank” and other nebulous requirements. There should be robust mentoring for all docs and especially for those just out of residency. The clinicians who express an interest in having an office in the C-Suite should be given a clear path and guidance.

I think with some innovation and recognition, most HMGs will have little problem retaining high-quality physicians. We must also recognize a changing value system and accept that some people will change jobs just because! TH

Dear Dr. Hospitalist:

Over the past several years, we have had a problem with physician retention, especially with nocturnists, in our medium-sized hospitalist group. Do you have any suggestions (beyond the obvious “more money”) to help us retain our hospitalists?

Missing My Friends in the Midwest

Dr. Hospitalist responds:

Since its inception, hospital medicine has been a very attractive field for practicing medicine, and although growth was phenomenal for many years (especially 2000–2010), it has leveled off over the past five years. With this exceptional growth have come increased salaries, geographically diverse job locations, and more opportunities for career development.

One of the most significant changes over the past 10 years is that hospital medicine is no longer seen as a bridge from residency to fellowship or as a stopover while waiting on the ideal job. Physicians now see hospital medicine as a career choice and are more likely to search for the “ideal” hospitalist job.

Although competitive salaries are important and a necessary starting point, to attract and keep career hospitalists, HM groups (HMGs) will need to offer opportunities for professional growth and leadership as well as flexible schedules.

Many larger HMGs offer several different schedule models, from the ubiquitous seven-on/seven-off schedule (54%, according to the 2014 State of Hospital Medicine report) to the more traditional five-day workweek with vacation time. Many also choose to work part- or full-time as a nocturnist and, in doing so, earn substantially more money (15%–20% differential). The flexible schedule and the ability to work part- or full-time have been very attractive to those clinicians just starting families or attaining another degree (MBAs are becoming very popular).

While there have always been the “check-in, check-out” docs who did their seven and didn’t want to be bothered during their time off, there were typically enough gunners around to pick up the slack. With the Millennial generation’s pervasive aim for work-life balance, it might become more difficult to find even a few who are willing to go the extra mile in hopes of career advancement. Mix in a very robust job market with a proclivity to travel, and you have a recipe for high attrition.

Like any new profession or specialty, HM will have to evolve and adjust to keep these new docs anchored. We will need to consider offering vacation time, especially for those who are willing to work a traditional Monday–Friday schedule. For those in academia with an interest in promotion, there should be real opportunities for advancement instead of the traditional “time in rank” and other nebulous requirements. There should be robust mentoring for all docs and especially for those just out of residency. The clinicians who express an interest in having an office in the C-Suite should be given a clear path and guidance.

I think with some innovation and recognition, most HMGs will have little problem retaining high-quality physicians. We must also recognize a changing value system and accept that some people will change jobs just because! TH

Dear Dr. Hospitalist:

Over the past several years, we have had a problem with physician retention, especially with nocturnists, in our medium-sized hospitalist group. Do you have any suggestions (beyond the obvious “more money”) to help us retain our hospitalists?

Missing My Friends in the Midwest

Dr. Hospitalist responds:

Since its inception, hospital medicine has been a very attractive field for practicing medicine, and although growth was phenomenal for many years (especially 2000–2010), it has leveled off over the past five years. With this exceptional growth have come increased salaries, geographically diverse job locations, and more opportunities for career development.

One of the most significant changes over the past 10 years is that hospital medicine is no longer seen as a bridge from residency to fellowship or as a stopover while waiting on the ideal job. Physicians now see hospital medicine as a career choice and are more likely to search for the “ideal” hospitalist job.

Although competitive salaries are important and a necessary starting point, to attract and keep career hospitalists, HM groups (HMGs) will need to offer opportunities for professional growth and leadership as well as flexible schedules.

Many larger HMGs offer several different schedule models, from the ubiquitous seven-on/seven-off schedule (54%, according to the 2014 State of Hospital Medicine report) to the more traditional five-day workweek with vacation time. Many also choose to work part- or full-time as a nocturnist and, in doing so, earn substantially more money (15%–20% differential). The flexible schedule and the ability to work part- or full-time have been very attractive to those clinicians just starting families or attaining another degree (MBAs are becoming very popular).

While there have always been the “check-in, check-out” docs who did their seven and didn’t want to be bothered during their time off, there were typically enough gunners around to pick up the slack. With the Millennial generation’s pervasive aim for work-life balance, it might become more difficult to find even a few who are willing to go the extra mile in hopes of career advancement. Mix in a very robust job market with a proclivity to travel, and you have a recipe for high attrition.

Like any new profession or specialty, HM will have to evolve and adjust to keep these new docs anchored. We will need to consider offering vacation time, especially for those who are willing to work a traditional Monday–Friday schedule. For those in academia with an interest in promotion, there should be real opportunities for advancement instead of the traditional “time in rank” and other nebulous requirements. There should be robust mentoring for all docs and especially for those just out of residency. The clinicians who express an interest in having an office in the C-Suite should be given a clear path and guidance.

I think with some innovation and recognition, most HMGs will have little problem retaining high-quality physicians. We must also recognize a changing value system and accept that some people will change jobs just because! TH

Movement is key to hospitalist Jaime Upegui, MD,  who says riding a motorcycle is a lot like yoga, "you have to focus on the moment, the task at hand." Listen to more of our interview:

Movement is key to hospitalist Jaime Upegui, MD,  who says riding a motorcycle is a lot like yoga, "you have to focus on the moment, the task at hand." Listen to more of our interview:

Movement is key to hospitalist Jaime Upegui, MD,  who says riding a motorcycle is a lot like yoga, "you have to focus on the moment, the task at hand." Listen to more of our interview: