Editorial

After patients have experienced an illness requiring a hospital stay, they are increasingly finding that despite having received treatment in a hospital bed, they were never actually admitted—at least not from the perspective of their insurers. Instead, these patients were kept under observation, an outpatient designation that allows a hospital to bill for observation services without formally admitting a patient.

Recent studies have recorded significant increases in hospitals’ use of observation stays among the Medicare population,^1-3 raising concerns about the financial ramifications for patients. Under observation, patients are potentially responsible for a greater share of the cost and bear the financial consequences of inappropriate observation stays. Currently, around 6% of Medicare patients hospitalized as outpatients spend more than 48 hours (or two midnights) in observation, sometimes much longer, exposing them to significant out-of-pocket costs.³ In addition, liberal use of observation can lead to increased hospital stays, for example among lower-severity emergency department (ED) patients who could have been safely discharged but were instead kept for a costly observation stay.⁴ At the same time, hospitals do not necessarily benefit from this cost shifting; in fact, hospital margin is worse for patients under Medicare observation care.⁵ Yet hospitals are obligated to be compliant with CMS observation regulations and may try to avoid the consequences (eg, audits, non-payment) for inpatient stays that are deemed inappropriate by CMS.

While the nuances of how CMS finances observation stays have made the practice controversial, the use of observation care in other payer groups that may not have the same reimbursement policies, and its impact on patients, have not been well studied. In this issue of the Journal of Hospital Medicine, Nuckols et al.⁶ begins to address this gap by carefully exploring trends in observation stays in a multipayer data set.

The authors use data for four states (Georgia, Nebraska, South Carolina, and Tennessee) from the Healthcare Cost and Utilization Project (Agency for Healthcare Quality and Research) and the American Community Survey (US Census Bureau) to calculate population based rates of ED visits, observation stays, and inpatient admissions. To date, this is the first study to examine and compare the use of observation stays in an all-payer data set. Similar to prior work that examined the Medicare population, the authors find increased rates of treat-and-release ED visits and observation stays over time with a corresponding decline in inpatient admissions. As this study clearly shows, observation stays are comprising a greater fraction of the total hospital care delivered to patients with acute illnesses.

In many ways, the findings of Nuckols et al.⁶ raise more questions than they answer. For example, does the rise in observation stays represent a fundamental shift in how hospitals deliver care, an alternative to costly inpatient admissions? Are changing payer incentives driving hospitals to be more prudent in their inpatient admission practices, or are similar services simply being delivered under a new billing designation? And, most important, does this shift have any repercussions for the quality and safety of patient care?

Ultimately, the answer to these questions is, “It depends.” As the authors mention, most US hospitals admit observation patients to general medical wards, where they receive care at the admitting provider’s discretion instead of utilizing specific care pathways or observation protocols.⁷ In some of these hospitals, there may be little to no difference in how the observation patient is treated compared with a similar patient who is hospitalized as an inpatient.

However, a minority of hospitals has been more strategic in their delivery of observation care and have developed observation units. While observation units vary in design, common features include a dedicated location in the hospital with dedicated staff, reliance on clear inclusion-exclusion criteria for admission to the unit, and the use of rapid diagnostic or treatment protocols for a limited number of conditions. About half of these observation units are ED-based, reducing transitions of care between services. Protocol-driven observation units have the potential to prevent unnecessary inpatient admissions, standardize evidence-based practice, and reduce practice variation and resource use, apparently without increasing adverse events.⁸ In addition, they may also lead to better experiences of care for many patients compared with inpatient admissions.

Medicare’s own policy on observation hospital care succinctly describes ED observation units: “Observation services are commonly ordered for patients who present to the emergency department and who then require a significant period of treatment in order to make a decision concerning their admission or discharge…usually in less than 24 hours.” Due to regulatory changes and auditing pressure, observation care has expanded beyond this definition in length of stay, scope, and practice such that much of observation care now occurs on general hospital wards. Ideally, observation policy must be realigned with its original intent and investment made in ED observation units.

The shifting landscape of hospital-based care as described by Nuckols et al.⁶ highlights the need for a more strategic approach to the delivery of acute care. Unfortunately, to date, there has been a lack of attention among policymakers towards promoting a system of emergent and urgent care that is coordinated and efficient. Observation stays are one major area for which innovations in the acute care delivery system may result in meaningful improvement in patient outcomes and greater value for the healthcare system. Incentivizing a system of high-value observation care, such as promoting the use of observation units that employ evidence-based practices, should be a key priority when considering approaches to reducing the cost of hospital-based and other acute care.

One strategy is to better define and possibly expand the cohort of patients likely to benefit from care in an observation unit. Hospitals with significant experience using observation units treat not only common observation conditions like chest pain, asthma, or cellulitis, but also higher-risk inpatient conditions like syncope and diabetic ketoacidosis using rapid diagnostic and treatment protocols.

Identifying high-value observation care also will require developing patient outcome measures specific for observation stays. Observation-specific quality measures will allow a comparison of hospitals that use different care pathways for observation patients or treat certain populations of patients in observation units. This necessitates looking beyond resource use (costs and length of stay), which most studies on observation units have focused on, and examining a broader range of patient outcomes like time to symptomatic resolution, quality of life, or return to productivity after an acute illness.

Finally, observation care is also a good target for payment redesign. For example, incentive payments could be provided to hospitals that choose to develop observation units, employ observation units that utilize best known practices for observation care (such as protocols and clearly defined patient cohorts), or deliver particularly good acute care outcomes for patients with observation-amenable conditions. On the consumer side, value-based contracting could be used to shunt patients with acute conditions that require evaluation in an urgent care center or ED to hospitals that use observation units.

While the declines in inpatient admission and increases in treat-and-release ED patients have been well-documented over time, perhaps the biggest contribution of this study from Nuckols et al.⁶ lies in its identification of the changes in observation care, which have been increasing in all payer groups. Our opportunity now is to shape whether these shifts toward observation care deliver greater value for patients.

Acknowledgment

The authors thank Joanna Guo, BA, for her editorial and technical assistance.

Disclosure

Nothing to report.

After patients have experienced an illness requiring a hospital stay, they are increasingly finding that despite having received treatment in a hospital bed, they were never actually admitted—at least not from the perspective of their insurers. Instead, these patients were kept under observation, an outpatient designation that allows a hospital to bill for observation services without formally admitting a patient.

Recent studies have recorded significant increases in hospitals’ use of observation stays among the Medicare population,^1-3 raising concerns about the financial ramifications for patients. Under observation, patients are potentially responsible for a greater share of the cost and bear the financial consequences of inappropriate observation stays. Currently, around 6% of Medicare patients hospitalized as outpatients spend more than 48 hours (or two midnights) in observation, sometimes much longer, exposing them to significant out-of-pocket costs.³ In addition, liberal use of observation can lead to increased hospital stays, for example among lower-severity emergency department (ED) patients who could have been safely discharged but were instead kept for a costly observation stay.⁴ At the same time, hospitals do not necessarily benefit from this cost shifting; in fact, hospital margin is worse for patients under Medicare observation care.⁵ Yet hospitals are obligated to be compliant with CMS observation regulations and may try to avoid the consequences (eg, audits, non-payment) for inpatient stays that are deemed inappropriate by CMS.

While the nuances of how CMS finances observation stays have made the practice controversial, the use of observation care in other payer groups that may not have the same reimbursement policies, and its impact on patients, have not been well studied. In this issue of the Journal of Hospital Medicine, Nuckols et al.⁶ begins to address this gap by carefully exploring trends in observation stays in a multipayer data set.

The authors use data for four states (Georgia, Nebraska, South Carolina, and Tennessee) from the Healthcare Cost and Utilization Project (Agency for Healthcare Quality and Research) and the American Community Survey (US Census Bureau) to calculate population based rates of ED visits, observation stays, and inpatient admissions. To date, this is the first study to examine and compare the use of observation stays in an all-payer data set. Similar to prior work that examined the Medicare population, the authors find increased rates of treat-and-release ED visits and observation stays over time with a corresponding decline in inpatient admissions. As this study clearly shows, observation stays are comprising a greater fraction of the total hospital care delivered to patients with acute illnesses.

In many ways, the findings of Nuckols et al.⁶ raise more questions than they answer. For example, does the rise in observation stays represent a fundamental shift in how hospitals deliver care, an alternative to costly inpatient admissions? Are changing payer incentives driving hospitals to be more prudent in their inpatient admission practices, or are similar services simply being delivered under a new billing designation? And, most important, does this shift have any repercussions for the quality and safety of patient care?

Ultimately, the answer to these questions is, “It depends.” As the authors mention, most US hospitals admit observation patients to general medical wards, where they receive care at the admitting provider’s discretion instead of utilizing specific care pathways or observation protocols.⁷ In some of these hospitals, there may be little to no difference in how the observation patient is treated compared with a similar patient who is hospitalized as an inpatient.

However, a minority of hospitals has been more strategic in their delivery of observation care and have developed observation units. While observation units vary in design, common features include a dedicated location in the hospital with dedicated staff, reliance on clear inclusion-exclusion criteria for admission to the unit, and the use of rapid diagnostic or treatment protocols for a limited number of conditions. About half of these observation units are ED-based, reducing transitions of care between services. Protocol-driven observation units have the potential to prevent unnecessary inpatient admissions, standardize evidence-based practice, and reduce practice variation and resource use, apparently without increasing adverse events.⁸ In addition, they may also lead to better experiences of care for many patients compared with inpatient admissions.

Medicare’s own policy on observation hospital care succinctly describes ED observation units: “Observation services are commonly ordered for patients who present to the emergency department and who then require a significant period of treatment in order to make a decision concerning their admission or discharge…usually in less than 24 hours.” Due to regulatory changes and auditing pressure, observation care has expanded beyond this definition in length of stay, scope, and practice such that much of observation care now occurs on general hospital wards. Ideally, observation policy must be realigned with its original intent and investment made in ED observation units.

The shifting landscape of hospital-based care as described by Nuckols et al.⁶ highlights the need for a more strategic approach to the delivery of acute care. Unfortunately, to date, there has been a lack of attention among policymakers towards promoting a system of emergent and urgent care that is coordinated and efficient. Observation stays are one major area for which innovations in the acute care delivery system may result in meaningful improvement in patient outcomes and greater value for the healthcare system. Incentivizing a system of high-value observation care, such as promoting the use of observation units that employ evidence-based practices, should be a key priority when considering approaches to reducing the cost of hospital-based and other acute care.

One strategy is to better define and possibly expand the cohort of patients likely to benefit from care in an observation unit. Hospitals with significant experience using observation units treat not only common observation conditions like chest pain, asthma, or cellulitis, but also higher-risk inpatient conditions like syncope and diabetic ketoacidosis using rapid diagnostic and treatment protocols.

Identifying high-value observation care also will require developing patient outcome measures specific for observation stays. Observation-specific quality measures will allow a comparison of hospitals that use different care pathways for observation patients or treat certain populations of patients in observation units. This necessitates looking beyond resource use (costs and length of stay), which most studies on observation units have focused on, and examining a broader range of patient outcomes like time to symptomatic resolution, quality of life, or return to productivity after an acute illness.

Finally, observation care is also a good target for payment redesign. For example, incentive payments could be provided to hospitals that choose to develop observation units, employ observation units that utilize best known practices for observation care (such as protocols and clearly defined patient cohorts), or deliver particularly good acute care outcomes for patients with observation-amenable conditions. On the consumer side, value-based contracting could be used to shunt patients with acute conditions that require evaluation in an urgent care center or ED to hospitals that use observation units.

While the declines in inpatient admission and increases in treat-and-release ED patients have been well-documented over time, perhaps the biggest contribution of this study from Nuckols et al.⁶ lies in its identification of the changes in observation care, which have been increasing in all payer groups. Our opportunity now is to shape whether these shifts toward observation care deliver greater value for patients.

Acknowledgment

The authors thank Joanna Guo, BA, for her editorial and technical assistance.

Disclosure

Nothing to report.

After patients have experienced an illness requiring a hospital stay, they are increasingly finding that despite having received treatment in a hospital bed, they were never actually admitted—at least not from the perspective of their insurers. Instead, these patients were kept under observation, an outpatient designation that allows a hospital to bill for observation services without formally admitting a patient.

Recent studies have recorded significant increases in hospitals’ use of observation stays among the Medicare population,^1-3 raising concerns about the financial ramifications for patients. Under observation, patients are potentially responsible for a greater share of the cost and bear the financial consequences of inappropriate observation stays. Currently, around 6% of Medicare patients hospitalized as outpatients spend more than 48 hours (or two midnights) in observation, sometimes much longer, exposing them to significant out-of-pocket costs.³ In addition, liberal use of observation can lead to increased hospital stays, for example among lower-severity emergency department (ED) patients who could have been safely discharged but were instead kept for a costly observation stay.⁴ At the same time, hospitals do not necessarily benefit from this cost shifting; in fact, hospital margin is worse for patients under Medicare observation care.⁵ Yet hospitals are obligated to be compliant with CMS observation regulations and may try to avoid the consequences (eg, audits, non-payment) for inpatient stays that are deemed inappropriate by CMS.

While the nuances of how CMS finances observation stays have made the practice controversial, the use of observation care in other payer groups that may not have the same reimbursement policies, and its impact on patients, have not been well studied. In this issue of the Journal of Hospital Medicine, Nuckols et al.⁶ begins to address this gap by carefully exploring trends in observation stays in a multipayer data set.

The authors use data for four states (Georgia, Nebraska, South Carolina, and Tennessee) from the Healthcare Cost and Utilization Project (Agency for Healthcare Quality and Research) and the American Community Survey (US Census Bureau) to calculate population based rates of ED visits, observation stays, and inpatient admissions. To date, this is the first study to examine and compare the use of observation stays in an all-payer data set. Similar to prior work that examined the Medicare population, the authors find increased rates of treat-and-release ED visits and observation stays over time with a corresponding decline in inpatient admissions. As this study clearly shows, observation stays are comprising a greater fraction of the total hospital care delivered to patients with acute illnesses.

In many ways, the findings of Nuckols et al.⁶ raise more questions than they answer. For example, does the rise in observation stays represent a fundamental shift in how hospitals deliver care, an alternative to costly inpatient admissions? Are changing payer incentives driving hospitals to be more prudent in their inpatient admission practices, or are similar services simply being delivered under a new billing designation? And, most important, does this shift have any repercussions for the quality and safety of patient care?

Ultimately, the answer to these questions is, “It depends.” As the authors mention, most US hospitals admit observation patients to general medical wards, where they receive care at the admitting provider’s discretion instead of utilizing specific care pathways or observation protocols.⁷ In some of these hospitals, there may be little to no difference in how the observation patient is treated compared with a similar patient who is hospitalized as an inpatient.

However, a minority of hospitals has been more strategic in their delivery of observation care and have developed observation units. While observation units vary in design, common features include a dedicated location in the hospital with dedicated staff, reliance on clear inclusion-exclusion criteria for admission to the unit, and the use of rapid diagnostic or treatment protocols for a limited number of conditions. About half of these observation units are ED-based, reducing transitions of care between services. Protocol-driven observation units have the potential to prevent unnecessary inpatient admissions, standardize evidence-based practice, and reduce practice variation and resource use, apparently without increasing adverse events.⁸ In addition, they may also lead to better experiences of care for many patients compared with inpatient admissions.

Medicare’s own policy on observation hospital care succinctly describes ED observation units: “Observation services are commonly ordered for patients who present to the emergency department and who then require a significant period of treatment in order to make a decision concerning their admission or discharge…usually in less than 24 hours.” Due to regulatory changes and auditing pressure, observation care has expanded beyond this definition in length of stay, scope, and practice such that much of observation care now occurs on general hospital wards. Ideally, observation policy must be realigned with its original intent and investment made in ED observation units.

The shifting landscape of hospital-based care as described by Nuckols et al.⁶ highlights the need for a more strategic approach to the delivery of acute care. Unfortunately, to date, there has been a lack of attention among policymakers towards promoting a system of emergent and urgent care that is coordinated and efficient. Observation stays are one major area for which innovations in the acute care delivery system may result in meaningful improvement in patient outcomes and greater value for the healthcare system. Incentivizing a system of high-value observation care, such as promoting the use of observation units that employ evidence-based practices, should be a key priority when considering approaches to reducing the cost of hospital-based and other acute care.

One strategy is to better define and possibly expand the cohort of patients likely to benefit from care in an observation unit. Hospitals with significant experience using observation units treat not only common observation conditions like chest pain, asthma, or cellulitis, but also higher-risk inpatient conditions like syncope and diabetic ketoacidosis using rapid diagnostic and treatment protocols.

Identifying high-value observation care also will require developing patient outcome measures specific for observation stays. Observation-specific quality measures will allow a comparison of hospitals that use different care pathways for observation patients or treat certain populations of patients in observation units. This necessitates looking beyond resource use (costs and length of stay), which most studies on observation units have focused on, and examining a broader range of patient outcomes like time to symptomatic resolution, quality of life, or return to productivity after an acute illness.

Finally, observation care is also a good target for payment redesign. For example, incentive payments could be provided to hospitals that choose to develop observation units, employ observation units that utilize best known practices for observation care (such as protocols and clearly defined patient cohorts), or deliver particularly good acute care outcomes for patients with observation-amenable conditions. On the consumer side, value-based contracting could be used to shunt patients with acute conditions that require evaluation in an urgent care center or ED to hospitals that use observation units.

While the declines in inpatient admission and increases in treat-and-release ED patients have been well-documented over time, perhaps the biggest contribution of this study from Nuckols et al.⁶ lies in its identification of the changes in observation care, which have been increasing in all payer groups. Our opportunity now is to shape whether these shifts toward observation care deliver greater value for patients.

Acknowledgment

The authors thank Joanna Guo, BA, for her editorial and technical assistance.

Disclosure

Nothing to report.

Monitor watcher personnel are frequently used to assist nurses with identifying meaningful events on telemetry monitors. Although effectiveness of monitor watchers on patient outcomes has not been demonstrated conclusively,¹ as many as 60% of United States hospitals may be using monitor watchers in some capacity.² Presumed benefits of monitor watchers include prompt recognition of changes in patients’ conditions and the potential to reduce alarm fatigue among hospital staff. Alarm fatigue is desensitization resulting from overexposure to alarm signals that are either invalid or clinically irrelevant. Alarm fatigue has resulted in missed patient events and preventable deaths.³ In this issue of the Journal of Hospital Medicine, Palchaudhuri et al.⁴ report findings from their observational study of telemetry monitor alarms intercepted by monitor watchers as a mechanism for reducing both nurses’ exposure to alarm signals and subsequent alarm fatigue.

To our knowledge, the study by Palchaudhuri et al.⁴ is the first to report the effect of monitor watchers on nurses’ exposure to alarm signals. In this study, over a 2-month period monitor watchers intercepted 87% of alarms before they were sent to the nurse’s telephone. Monitor watchers intercepted over 90% of bradycardia and tachycardia alarms, indicating that they believed these alarms to be clinically irrelevant. Monitor watchers also intercepted about 75% of alarms for lethal arrhythmias, indicating that they believed these alarms to be invalid.

In this study, decisions about alarm validity and relevance were made through close communication between monitor watchers and nursing staff. If an alarm was sounding and the monitor watcher had already spoken with the nurse about it and established that the nurse was addressing the problem, the monitor watcher would intercept subsequent alarms for that issue or event (according to personal communication with S. Palchaudhuri). The results of the study not only indicate that monitor watchers can reduce the number of alarms to which a nurse is exposed, but also support previous findings that few alarms are valid or clinically relevant.^5-7 The results of this study also suggest that “nuisance” alarms should include not only clinically irrelevant alarms, but also relevant alarms for which the nurse is actively seeking a solution. Monitor watchers may have an important role in addressing these alarms.

The study raises important considerations regarding monitor watcher practice and alarm fatigue. If monitor watchers are to be effective in reducing nurses’ exposure to alarms, they must use good judgment to determine when to intercept an alarm, call the nurse, or both. In the absence of proper judgment, monitor watchers may inadvertently increase nurses’ fatigue through redundant calls or inappropriately suppress valid relevant alarms. In free-text responses to our national monitor watcher survey, nurses expressed frustration over redundant calls from monitor watchers for invalid and irrelevant alarms.² Research suggests that monitor watchers may not identify potentially dangerous alarms with complete accuracy. In a recent study reported in The Journal of the American Medical Society (JAMA), monitor watchers missed about 18% of patients with detectable rhythm or rate changes on telemetry in the hour before an emergency response team was activated.⁸

Several factors and conditions may affect monitor watchers’ judgment: 1) education and training, 2) location and access to contextual patient information, and 3) fatigue. First, across the US, the level of education required for monitor watcher positions ranges from a high school diploma to licensure as a registered nurse. The content and frequency of in-service training required also varies.² These differing requirements may influence monitor watchers’ ability to interpret alarms.

Second, most monitor watchers are located off the patient care unit,² which influences their access to information. Even in remote locations, monitor watchers can assess alarm validity by reviewing parameter waveforms for artifact. However, determining the relevance of an alarm to a particular patient is a more complex task requiring contextual information about the patient.⁹ Monitor watchers must work closely with clinicians at the bedside to determine the relevance of alarms, and repeated contact between monitor watchers and nurses over alarm conditions may itself increase nurses’ alarm fatigue.

Finally, fatigue may affect monitor watchers themselves and reduce their effectiveness. This issue was raised by Palchaudhuri et al. Both the number of monitors watched and the length of the monitor watcher’s shift likely influence alertness and effectiveness. In a simulation study, Segall et al.¹⁰ found that monitor watchers’ recognition of serious arrhythmias was significantly delayed when they were responsible for more than 40 patient monitors. Monitor watchers often work 12-hour shifts,² and although no research has been reported on their shift-related alertness, this is a long time to remain attentive.

Given these potential challenges, future research should specifically address adverse patient outcomes and missed clinically relevant alarms. Only two of the seven patients who arrested during the study by Palchaudhuri et al.⁴ were on telemetry, and neither arrested due to lethal arrhythmias. While this is an important indication that no alarms for lethal arrhythmias were inadvertently suppressed, it is difficult to achieve adequate statistical power to assess rare outcomes like cardiac arrests. In a future study, alarms intercepted by monitor watchers could be assessed for accuracy and relevance to patient care to determine whether important alarms were inadvertently suppressed.

In summary, the study by Palchaudhuri et al.⁴ represents a preliminary step in considering the potential utility of monitor watchers for reducing invalid and clinically irrelevant alarms as well as subsequent alarm fatigue. As the authors note, dedicated monitor watchers can screen alarms much more quickly than nurses who may be engaged in other activities when an alarm signals. The study raises interesting questions about how monitor watchers should be incorporated into workflow. Should their only responsibility be to call regarding potentially critical events, or should they be able to prevent alarms from reaching the nurse? Could monitor watchers provide guidance to reduce alarm fatigue, such as suggesting parameter changes when they see trends in irrelevant alarms? Future research is warranted to understand how monitor watchers can be used most effectively to reduce alarm fatigue, and which characteristics of monitor watchers and their practice result in the best patient outcomes.

Disclosure

Nothing to report.

Monitor watcher personnel are frequently used to assist nurses with identifying meaningful events on telemetry monitors. Although effectiveness of monitor watchers on patient outcomes has not been demonstrated conclusively,¹ as many as 60% of United States hospitals may be using monitor watchers in some capacity.² Presumed benefits of monitor watchers include prompt recognition of changes in patients’ conditions and the potential to reduce alarm fatigue among hospital staff. Alarm fatigue is desensitization resulting from overexposure to alarm signals that are either invalid or clinically irrelevant. Alarm fatigue has resulted in missed patient events and preventable deaths.³ In this issue of the Journal of Hospital Medicine, Palchaudhuri et al.⁴ report findings from their observational study of telemetry monitor alarms intercepted by monitor watchers as a mechanism for reducing both nurses’ exposure to alarm signals and subsequent alarm fatigue.

To our knowledge, the study by Palchaudhuri et al.⁴ is the first to report the effect of monitor watchers on nurses’ exposure to alarm signals. In this study, over a 2-month period monitor watchers intercepted 87% of alarms before they were sent to the nurse’s telephone. Monitor watchers intercepted over 90% of bradycardia and tachycardia alarms, indicating that they believed these alarms to be clinically irrelevant. Monitor watchers also intercepted about 75% of alarms for lethal arrhythmias, indicating that they believed these alarms to be invalid.

In this study, decisions about alarm validity and relevance were made through close communication between monitor watchers and nursing staff. If an alarm was sounding and the monitor watcher had already spoken with the nurse about it and established that the nurse was addressing the problem, the monitor watcher would intercept subsequent alarms for that issue or event (according to personal communication with S. Palchaudhuri). The results of the study not only indicate that monitor watchers can reduce the number of alarms to which a nurse is exposed, but also support previous findings that few alarms are valid or clinically relevant.^5-7 The results of this study also suggest that “nuisance” alarms should include not only clinically irrelevant alarms, but also relevant alarms for which the nurse is actively seeking a solution. Monitor watchers may have an important role in addressing these alarms.

The study raises important considerations regarding monitor watcher practice and alarm fatigue. If monitor watchers are to be effective in reducing nurses’ exposure to alarms, they must use good judgment to determine when to intercept an alarm, call the nurse, or both. In the absence of proper judgment, monitor watchers may inadvertently increase nurses’ fatigue through redundant calls or inappropriately suppress valid relevant alarms. In free-text responses to our national monitor watcher survey, nurses expressed frustration over redundant calls from monitor watchers for invalid and irrelevant alarms.² Research suggests that monitor watchers may not identify potentially dangerous alarms with complete accuracy. In a recent study reported in The Journal of the American Medical Society (JAMA), monitor watchers missed about 18% of patients with detectable rhythm or rate changes on telemetry in the hour before an emergency response team was activated.⁸

Several factors and conditions may affect monitor watchers’ judgment: 1) education and training, 2) location and access to contextual patient information, and 3) fatigue. First, across the US, the level of education required for monitor watcher positions ranges from a high school diploma to licensure as a registered nurse. The content and frequency of in-service training required also varies.² These differing requirements may influence monitor watchers’ ability to interpret alarms.

Second, most monitor watchers are located off the patient care unit,² which influences their access to information. Even in remote locations, monitor watchers can assess alarm validity by reviewing parameter waveforms for artifact. However, determining the relevance of an alarm to a particular patient is a more complex task requiring contextual information about the patient.⁹ Monitor watchers must work closely with clinicians at the bedside to determine the relevance of alarms, and repeated contact between monitor watchers and nurses over alarm conditions may itself increase nurses’ alarm fatigue.

Finally, fatigue may affect monitor watchers themselves and reduce their effectiveness. This issue was raised by Palchaudhuri et al. Both the number of monitors watched and the length of the monitor watcher’s shift likely influence alertness and effectiveness. In a simulation study, Segall et al.¹⁰ found that monitor watchers’ recognition of serious arrhythmias was significantly delayed when they were responsible for more than 40 patient monitors. Monitor watchers often work 12-hour shifts,² and although no research has been reported on their shift-related alertness, this is a long time to remain attentive.

Given these potential challenges, future research should specifically address adverse patient outcomes and missed clinically relevant alarms. Only two of the seven patients who arrested during the study by Palchaudhuri et al.⁴ were on telemetry, and neither arrested due to lethal arrhythmias. While this is an important indication that no alarms for lethal arrhythmias were inadvertently suppressed, it is difficult to achieve adequate statistical power to assess rare outcomes like cardiac arrests. In a future study, alarms intercepted by monitor watchers could be assessed for accuracy and relevance to patient care to determine whether important alarms were inadvertently suppressed.

In summary, the study by Palchaudhuri et al.⁴ represents a preliminary step in considering the potential utility of monitor watchers for reducing invalid and clinically irrelevant alarms as well as subsequent alarm fatigue. As the authors note, dedicated monitor watchers can screen alarms much more quickly than nurses who may be engaged in other activities when an alarm signals. The study raises interesting questions about how monitor watchers should be incorporated into workflow. Should their only responsibility be to call regarding potentially critical events, or should they be able to prevent alarms from reaching the nurse? Could monitor watchers provide guidance to reduce alarm fatigue, such as suggesting parameter changes when they see trends in irrelevant alarms? Future research is warranted to understand how monitor watchers can be used most effectively to reduce alarm fatigue, and which characteristics of monitor watchers and their practice result in the best patient outcomes.

Disclosure

Nothing to report.

Monitor watcher personnel are frequently used to assist nurses with identifying meaningful events on telemetry monitors. Although effectiveness of monitor watchers on patient outcomes has not been demonstrated conclusively,¹ as many as 60% of United States hospitals may be using monitor watchers in some capacity.² Presumed benefits of monitor watchers include prompt recognition of changes in patients’ conditions and the potential to reduce alarm fatigue among hospital staff. Alarm fatigue is desensitization resulting from overexposure to alarm signals that are either invalid or clinically irrelevant. Alarm fatigue has resulted in missed patient events and preventable deaths.³ In this issue of the Journal of Hospital Medicine, Palchaudhuri et al.⁴ report findings from their observational study of telemetry monitor alarms intercepted by monitor watchers as a mechanism for reducing both nurses’ exposure to alarm signals and subsequent alarm fatigue.

To our knowledge, the study by Palchaudhuri et al.⁴ is the first to report the effect of monitor watchers on nurses’ exposure to alarm signals. In this study, over a 2-month period monitor watchers intercepted 87% of alarms before they were sent to the nurse’s telephone. Monitor watchers intercepted over 90% of bradycardia and tachycardia alarms, indicating that they believed these alarms to be clinically irrelevant. Monitor watchers also intercepted about 75% of alarms for lethal arrhythmias, indicating that they believed these alarms to be invalid.

In this study, decisions about alarm validity and relevance were made through close communication between monitor watchers and nursing staff. If an alarm was sounding and the monitor watcher had already spoken with the nurse about it and established that the nurse was addressing the problem, the monitor watcher would intercept subsequent alarms for that issue or event (according to personal communication with S. Palchaudhuri). The results of the study not only indicate that monitor watchers can reduce the number of alarms to which a nurse is exposed, but also support previous findings that few alarms are valid or clinically relevant.^5-7 The results of this study also suggest that “nuisance” alarms should include not only clinically irrelevant alarms, but also relevant alarms for which the nurse is actively seeking a solution. Monitor watchers may have an important role in addressing these alarms.

The study raises important considerations regarding monitor watcher practice and alarm fatigue. If monitor watchers are to be effective in reducing nurses’ exposure to alarms, they must use good judgment to determine when to intercept an alarm, call the nurse, or both. In the absence of proper judgment, monitor watchers may inadvertently increase nurses’ fatigue through redundant calls or inappropriately suppress valid relevant alarms. In free-text responses to our national monitor watcher survey, nurses expressed frustration over redundant calls from monitor watchers for invalid and irrelevant alarms.² Research suggests that monitor watchers may not identify potentially dangerous alarms with complete accuracy. In a recent study reported in The Journal of the American Medical Society (JAMA), monitor watchers missed about 18% of patients with detectable rhythm or rate changes on telemetry in the hour before an emergency response team was activated.⁸

Several factors and conditions may affect monitor watchers’ judgment: 1) education and training, 2) location and access to contextual patient information, and 3) fatigue. First, across the US, the level of education required for monitor watcher positions ranges from a high school diploma to licensure as a registered nurse. The content and frequency of in-service training required also varies.² These differing requirements may influence monitor watchers’ ability to interpret alarms.

Second, most monitor watchers are located off the patient care unit,² which influences their access to information. Even in remote locations, monitor watchers can assess alarm validity by reviewing parameter waveforms for artifact. However, determining the relevance of an alarm to a particular patient is a more complex task requiring contextual information about the patient.⁹ Monitor watchers must work closely with clinicians at the bedside to determine the relevance of alarms, and repeated contact between monitor watchers and nurses over alarm conditions may itself increase nurses’ alarm fatigue.

Finally, fatigue may affect monitor watchers themselves and reduce their effectiveness. This issue was raised by Palchaudhuri et al. Both the number of monitors watched and the length of the monitor watcher’s shift likely influence alertness and effectiveness. In a simulation study, Segall et al.¹⁰ found that monitor watchers’ recognition of serious arrhythmias was significantly delayed when they were responsible for more than 40 patient monitors. Monitor watchers often work 12-hour shifts,² and although no research has been reported on their shift-related alertness, this is a long time to remain attentive.

Given these potential challenges, future research should specifically address adverse patient outcomes and missed clinically relevant alarms. Only two of the seven patients who arrested during the study by Palchaudhuri et al.⁴ were on telemetry, and neither arrested due to lethal arrhythmias. While this is an important indication that no alarms for lethal arrhythmias were inadvertently suppressed, it is difficult to achieve adequate statistical power to assess rare outcomes like cardiac arrests. In a future study, alarms intercepted by monitor watchers could be assessed for accuracy and relevance to patient care to determine whether important alarms were inadvertently suppressed.

In summary, the study by Palchaudhuri et al.⁴ represents a preliminary step in considering the potential utility of monitor watchers for reducing invalid and clinically irrelevant alarms as well as subsequent alarm fatigue. As the authors note, dedicated monitor watchers can screen alarms much more quickly than nurses who may be engaged in other activities when an alarm signals. The study raises interesting questions about how monitor watchers should be incorporated into workflow. Should their only responsibility be to call regarding potentially critical events, or should they be able to prevent alarms from reaching the nurse? Could monitor watchers provide guidance to reduce alarm fatigue, such as suggesting parameter changes when they see trends in irrelevant alarms? Future research is warranted to understand how monitor watchers can be used most effectively to reduce alarm fatigue, and which characteristics of monitor watchers and their practice result in the best patient outcomes.

Disclosure

Nothing to report.

As a medical student, I understood that dealing with death was part of the practice of medicine. I was prepared to help my patients face the end of life from disease and old age and had steeled myself against the inevitable losses I would see from trauma and infection. However, I had no sense of the incredible burden that opioid addiction and death from unintentional overdose would one day cause.

See related article

MORE DEATHS FROM OVERDOSE THAN FROM MOTOR VEHICLE ACCIDENTS

To highlight the point, unintentional overdose deaths in 2008 exceeded motor vehicle accidents as the leading cause of accidental death in the United States.¹ Since then, the problem has only worsened; by 2014 the US Centers for Disease Control and Prevention reported that 78 Americans were dying each day from unintentional opioid overdose.²

Yet the scourge of deaths from opioid overdose is only the most obvious way that opioid use disorder destroys the lives of patients suffering from addiction, as well as their friends and family. Among many other heartaches, opioid use disorder is associated with severely impaired social function, increased rates of hepatitis C and human immunodeficiency virus (HIV) infection, and serious legal consequences and incarceration.³ Sadly, opioid use disorder has torn apart countless families. Addiction may be a brain disease, but its scope of morbidity extends far beyond the individual with the affliction.

PLENTY OF BLAME TO GO AROUND

To some extent, physicians are culpable in propagating this epidemic, and not just in their obvious role as opioid suppliers. To be certain, opioid overprescribing is a tremendous problem; in 2014, more than 240 million prescriptions for opioids were issued, enough for every American adult to have his or her own bottle of pills.⁴

However, there is plenty of blame to go around in the medical system for the problems of overprescribing and inappropriate opioid use. Among other factors, medical schools have historically failed to teach young physicians how to treat pain or prescribe opioids safely,⁵ and pain specialists are often inaccessible to primary care providers.⁶ Additionally, pharmaceutical companies have been found guilty of marketing opioids to prescribers in misleading ways,⁷ and well-intentioned but misguided campaigns such as the “pain as a fifth vital sign” movement may have inadvertently contributed to opioid overprescribing as well.⁸

TACKLING THE CHALLENGE

Prescribers need to tackle these challenges by educating themselves about when and how to prescribe opioids for chronic pain. Breaking the cycle of overprescribing can be achieved by learning to prescribe opioids rationally, cautiously, and as part of a comprehensive multimodal pain management plan with a commitment to risk assessment and harm reduction. It also means having an exit strategy at the start of opioid therapy. This must include recognizing problematic opioid use when it occurs and having options to offer patients when opioid use disorder becomes the primary problem.

Recognizing the problem

Physicians are notoriously poor at predicting and detecting the presence of aberrant drug use behaviors and opioid use disorder. For example, in a study of patients clinicians thought were not at risk for misuse of medications, 60% had urine drug tests showing either the presence of illicit drugs or no evidence of the prescribed drug.⁹

The prevalence of problematic opioid use in patients on chronic opioid therapy for pain has been variably reported in the literature, but one systematic review found that misuse rates ranged from 21% to 29% (95% confidence interval 13%–38%) and addiction rates averaged 8% to 12% (3%–17%).¹⁰ These numbers are alarming, and prescribers need to know how to screen for and diagnose opioid addiction when they see it.

Importantly, there is a wide spectrum of opioid misuse behaviors, and the wise prescriber will thoughtfully consider each circumstance before assuming a patient has a substance use disorder. For example, one patient may skip doses and “hoard” unused pills for fear that he or she will run out of medication during a pain flare, while another may use opioids for nonmedical reasons such as to get high. Both examples represent aberrant drug use, but in the first case patient education may sufficiently address the problem, while the second may herald a more dangerous and less correctable problem.

Simply recognizing that a problem exists is not enough. Once we identify problematic opioid use, we also need to know how to address it.

Managing opioid misuse behaviors requires empathy, and prescribers should consider a patient’s motivation and emotive response to counsel. For instance, the patient who skips doses and hoards pills may fear that their well-controlled pain will suddenly worsen if their doctor’s opioid prescribing becomes more restrictive as new guidelines are released.

The lesson is that safe opioid prescribing may require a more restrictive approach than was understood in prior years, but rational prescribing also means careful consideration before arbitrarily tapering or discontinuing opioids in a patient who has demonstrated benefit without evidence of harm, even if new guidelines now recommend against starting opioid therapy for similar pain syndromes. For example, the American College of Physicians released a guideline earlier this year that recommended against opioids to treat low back pain, but it did not recommend stopping opioids if patients were already taking them and benefiting from their use.¹¹

Sometimes the best course of action is to discontinue opioid therapy. This decision may trigger a grief-like reaction in some patients and there can be distinct communication challenges during each coping phase.¹² The prescriber should frame opioid prescribing discussions on the changing balance of perceived benefits, risks, and harms; in some cases, the treatment may have “failed” or no longer be appropriate, but the patient may still be suffering from pain. Further, the patient may now need help with a newly recognized substance use disorder and may be particularly vulnerable during this time.

The wrong approach, in my opinion, is to discharge the patient from care because of addiction. This approach may seem justified to the provider who feels betrayed by a patient who has used a prescription differently than intended and has thus placed everyone at risk. However, providers should not take it personally; by definition, a patient with addiction has lost control over use of a drug and may have a stronger relationship with the drug than with you. Instead, we should attempt to intervene to protect a patient’s health and chances of survival. It is critical that physicians learn to leverage treatment resources to provide the support patients need to start the long process of recovery. This may involve detoxification and rehabilitation programs, but in many cases opioid agonist therapy also has a role.

Medication-assisted therapy

Medication-assisted therapy with methadone or buprenorphine can be an extremely important part of this process and is a strategy that Modesto-Lowe et al explore in this issue of the Journal.¹³ As they point out, patients and providers often misunderstand the use of opioid agonists to treat opioid use disorder; many perceive this as merely substituting one form of addiction for another. However, compelling data support this approach. Studies have shown that opioid agonist therapy is associated with decreased illicit opioid use, better retention in substance use treatment programs, reduced hepatitis C and HIV seroconversion, reduced rates of criminal activity and incarceration, decreased overdose risk, and improved survival.¹⁴

Opioid agonists are not a cure-all and come with their own challenges, but for many patients they can “create the space” needed to do the real work of recovery—healing their damaged relationships with themselves, their family, and their society.

Providers need to educate themselves regarding the options available and when and how to use them. They should familiarize themselves with methadone and buprenorphine treatment programs in their community. Better yet, with only 8 hours of additional training, primary care physicians can become waivered to prescribe buprenorphine to treat opioid addiction right in the office. Treating addiction is quickly becoming part of primary care, and clinicians in practice can no longer turn a blind eye toward this problem.

As a medical student, I understood that dealing with death was part of the practice of medicine. I was prepared to help my patients face the end of life from disease and old age and had steeled myself against the inevitable losses I would see from trauma and infection. However, I had no sense of the incredible burden that opioid addiction and death from unintentional overdose would one day cause.

See related article

MORE DEATHS FROM OVERDOSE THAN FROM MOTOR VEHICLE ACCIDENTS

To highlight the point, unintentional overdose deaths in 2008 exceeded motor vehicle accidents as the leading cause of accidental death in the United States.¹ Since then, the problem has only worsened; by 2014 the US Centers for Disease Control and Prevention reported that 78 Americans were dying each day from unintentional opioid overdose.²

Yet the scourge of deaths from opioid overdose is only the most obvious way that opioid use disorder destroys the lives of patients suffering from addiction, as well as their friends and family. Among many other heartaches, opioid use disorder is associated with severely impaired social function, increased rates of hepatitis C and human immunodeficiency virus (HIV) infection, and serious legal consequences and incarceration.³ Sadly, opioid use disorder has torn apart countless families. Addiction may be a brain disease, but its scope of morbidity extends far beyond the individual with the affliction.

PLENTY OF BLAME TO GO AROUND

To some extent, physicians are culpable in propagating this epidemic, and not just in their obvious role as opioid suppliers. To be certain, opioid overprescribing is a tremendous problem; in 2014, more than 240 million prescriptions for opioids were issued, enough for every American adult to have his or her own bottle of pills.⁴

However, there is plenty of blame to go around in the medical system for the problems of overprescribing and inappropriate opioid use. Among other factors, medical schools have historically failed to teach young physicians how to treat pain or prescribe opioids safely,⁵ and pain specialists are often inaccessible to primary care providers.⁶ Additionally, pharmaceutical companies have been found guilty of marketing opioids to prescribers in misleading ways,⁷ and well-intentioned but misguided campaigns such as the “pain as a fifth vital sign” movement may have inadvertently contributed to opioid overprescribing as well.⁸

TACKLING THE CHALLENGE

Prescribers need to tackle these challenges by educating themselves about when and how to prescribe opioids for chronic pain. Breaking the cycle of overprescribing can be achieved by learning to prescribe opioids rationally, cautiously, and as part of a comprehensive multimodal pain management plan with a commitment to risk assessment and harm reduction. It also means having an exit strategy at the start of opioid therapy. This must include recognizing problematic opioid use when it occurs and having options to offer patients when opioid use disorder becomes the primary problem.

Recognizing the problem

Physicians are notoriously poor at predicting and detecting the presence of aberrant drug use behaviors and opioid use disorder. For example, in a study of patients clinicians thought were not at risk for misuse of medications, 60% had urine drug tests showing either the presence of illicit drugs or no evidence of the prescribed drug.⁹

The prevalence of problematic opioid use in patients on chronic opioid therapy for pain has been variably reported in the literature, but one systematic review found that misuse rates ranged from 21% to 29% (95% confidence interval 13%–38%) and addiction rates averaged 8% to 12% (3%–17%).¹⁰ These numbers are alarming, and prescribers need to know how to screen for and diagnose opioid addiction when they see it.

Importantly, there is a wide spectrum of opioid misuse behaviors, and the wise prescriber will thoughtfully consider each circumstance before assuming a patient has a substance use disorder. For example, one patient may skip doses and “hoard” unused pills for fear that he or she will run out of medication during a pain flare, while another may use opioids for nonmedical reasons such as to get high. Both examples represent aberrant drug use, but in the first case patient education may sufficiently address the problem, while the second may herald a more dangerous and less correctable problem.

Simply recognizing that a problem exists is not enough. Once we identify problematic opioid use, we also need to know how to address it.

Managing opioid misuse behaviors requires empathy, and prescribers should consider a patient’s motivation and emotive response to counsel. For instance, the patient who skips doses and hoards pills may fear that their well-controlled pain will suddenly worsen if their doctor’s opioid prescribing becomes more restrictive as new guidelines are released.

The lesson is that safe opioid prescribing may require a more restrictive approach than was understood in prior years, but rational prescribing also means careful consideration before arbitrarily tapering or discontinuing opioids in a patient who has demonstrated benefit without evidence of harm, even if new guidelines now recommend against starting opioid therapy for similar pain syndromes. For example, the American College of Physicians released a guideline earlier this year that recommended against opioids to treat low back pain, but it did not recommend stopping opioids if patients were already taking them and benefiting from their use.¹¹

Sometimes the best course of action is to discontinue opioid therapy. This decision may trigger a grief-like reaction in some patients and there can be distinct communication challenges during each coping phase.¹² The prescriber should frame opioid prescribing discussions on the changing balance of perceived benefits, risks, and harms; in some cases, the treatment may have “failed” or no longer be appropriate, but the patient may still be suffering from pain. Further, the patient may now need help with a newly recognized substance use disorder and may be particularly vulnerable during this time.

The wrong approach, in my opinion, is to discharge the patient from care because of addiction. This approach may seem justified to the provider who feels betrayed by a patient who has used a prescription differently than intended and has thus placed everyone at risk. However, providers should not take it personally; by definition, a patient with addiction has lost control over use of a drug and may have a stronger relationship with the drug than with you. Instead, we should attempt to intervene to protect a patient’s health and chances of survival. It is critical that physicians learn to leverage treatment resources to provide the support patients need to start the long process of recovery. This may involve detoxification and rehabilitation programs, but in many cases opioid agonist therapy also has a role.

Medication-assisted therapy

Medication-assisted therapy with methadone or buprenorphine can be an extremely important part of this process and is a strategy that Modesto-Lowe et al explore in this issue of the Journal.¹³ As they point out, patients and providers often misunderstand the use of opioid agonists to treat opioid use disorder; many perceive this as merely substituting one form of addiction for another. However, compelling data support this approach. Studies have shown that opioid agonist therapy is associated with decreased illicit opioid use, better retention in substance use treatment programs, reduced hepatitis C and HIV seroconversion, reduced rates of criminal activity and incarceration, decreased overdose risk, and improved survival.¹⁴

Opioid agonists are not a cure-all and come with their own challenges, but for many patients they can “create the space” needed to do the real work of recovery—healing their damaged relationships with themselves, their family, and their society.

Providers need to educate themselves regarding the options available and when and how to use them. They should familiarize themselves with methadone and buprenorphine treatment programs in their community. Better yet, with only 8 hours of additional training, primary care physicians can become waivered to prescribe buprenorphine to treat opioid addiction right in the office. Treating addiction is quickly becoming part of primary care, and clinicians in practice can no longer turn a blind eye toward this problem.

As a medical student, I understood that dealing with death was part of the practice of medicine. I was prepared to help my patients face the end of life from disease and old age and had steeled myself against the inevitable losses I would see from trauma and infection. However, I had no sense of the incredible burden that opioid addiction and death from unintentional overdose would one day cause.

See related article

MORE DEATHS FROM OVERDOSE THAN FROM MOTOR VEHICLE ACCIDENTS

To highlight the point, unintentional overdose deaths in 2008 exceeded motor vehicle accidents as the leading cause of accidental death in the United States.¹ Since then, the problem has only worsened; by 2014 the US Centers for Disease Control and Prevention reported that 78 Americans were dying each day from unintentional opioid overdose.²

Yet the scourge of deaths from opioid overdose is only the most obvious way that opioid use disorder destroys the lives of patients suffering from addiction, as well as their friends and family. Among many other heartaches, opioid use disorder is associated with severely impaired social function, increased rates of hepatitis C and human immunodeficiency virus (HIV) infection, and serious legal consequences and incarceration.³ Sadly, opioid use disorder has torn apart countless families. Addiction may be a brain disease, but its scope of morbidity extends far beyond the individual with the affliction.

PLENTY OF BLAME TO GO AROUND

To some extent, physicians are culpable in propagating this epidemic, and not just in their obvious role as opioid suppliers. To be certain, opioid overprescribing is a tremendous problem; in 2014, more than 240 million prescriptions for opioids were issued, enough for every American adult to have his or her own bottle of pills.⁴

However, there is plenty of blame to go around in the medical system for the problems of overprescribing and inappropriate opioid use. Among other factors, medical schools have historically failed to teach young physicians how to treat pain or prescribe opioids safely,⁵ and pain specialists are often inaccessible to primary care providers.⁶ Additionally, pharmaceutical companies have been found guilty of marketing opioids to prescribers in misleading ways,⁷ and well-intentioned but misguided campaigns such as the “pain as a fifth vital sign” movement may have inadvertently contributed to opioid overprescribing as well.⁸

TACKLING THE CHALLENGE

Prescribers need to tackle these challenges by educating themselves about when and how to prescribe opioids for chronic pain. Breaking the cycle of overprescribing can be achieved by learning to prescribe opioids rationally, cautiously, and as part of a comprehensive multimodal pain management plan with a commitment to risk assessment and harm reduction. It also means having an exit strategy at the start of opioid therapy. This must include recognizing problematic opioid use when it occurs and having options to offer patients when opioid use disorder becomes the primary problem.

Recognizing the problem

Physicians are notoriously poor at predicting and detecting the presence of aberrant drug use behaviors and opioid use disorder. For example, in a study of patients clinicians thought were not at risk for misuse of medications, 60% had urine drug tests showing either the presence of illicit drugs or no evidence of the prescribed drug.⁹

The prevalence of problematic opioid use in patients on chronic opioid therapy for pain has been variably reported in the literature, but one systematic review found that misuse rates ranged from 21% to 29% (95% confidence interval 13%–38%) and addiction rates averaged 8% to 12% (3%–17%).¹⁰ These numbers are alarming, and prescribers need to know how to screen for and diagnose opioid addiction when they see it.

Importantly, there is a wide spectrum of opioid misuse behaviors, and the wise prescriber will thoughtfully consider each circumstance before assuming a patient has a substance use disorder. For example, one patient may skip doses and “hoard” unused pills for fear that he or she will run out of medication during a pain flare, while another may use opioids for nonmedical reasons such as to get high. Both examples represent aberrant drug use, but in the first case patient education may sufficiently address the problem, while the second may herald a more dangerous and less correctable problem.

Simply recognizing that a problem exists is not enough. Once we identify problematic opioid use, we also need to know how to address it.

Managing opioid misuse behaviors requires empathy, and prescribers should consider a patient’s motivation and emotive response to counsel. For instance, the patient who skips doses and hoards pills may fear that their well-controlled pain will suddenly worsen if their doctor’s opioid prescribing becomes more restrictive as new guidelines are released.

The lesson is that safe opioid prescribing may require a more restrictive approach than was understood in prior years, but rational prescribing also means careful consideration before arbitrarily tapering or discontinuing opioids in a patient who has demonstrated benefit without evidence of harm, even if new guidelines now recommend against starting opioid therapy for similar pain syndromes. For example, the American College of Physicians released a guideline earlier this year that recommended against opioids to treat low back pain, but it did not recommend stopping opioids if patients were already taking them and benefiting from their use.¹¹

Sometimes the best course of action is to discontinue opioid therapy. This decision may trigger a grief-like reaction in some patients and there can be distinct communication challenges during each coping phase.¹² The prescriber should frame opioid prescribing discussions on the changing balance of perceived benefits, risks, and harms; in some cases, the treatment may have “failed” or no longer be appropriate, but the patient may still be suffering from pain. Further, the patient may now need help with a newly recognized substance use disorder and may be particularly vulnerable during this time.

The wrong approach, in my opinion, is to discharge the patient from care because of addiction. This approach may seem justified to the provider who feels betrayed by a patient who has used a prescription differently than intended and has thus placed everyone at risk. However, providers should not take it personally; by definition, a patient with addiction has lost control over use of a drug and may have a stronger relationship with the drug than with you. Instead, we should attempt to intervene to protect a patient’s health and chances of survival. It is critical that physicians learn to leverage treatment resources to provide the support patients need to start the long process of recovery. This may involve detoxification and rehabilitation programs, but in many cases opioid agonist therapy also has a role.

Medication-assisted therapy

Medication-assisted therapy with methadone or buprenorphine can be an extremely important part of this process and is a strategy that Modesto-Lowe et al explore in this issue of the Journal.¹³ As they point out, patients and providers often misunderstand the use of opioid agonists to treat opioid use disorder; many perceive this as merely substituting one form of addiction for another. However, compelling data support this approach. Studies have shown that opioid agonist therapy is associated with decreased illicit opioid use, better retention in substance use treatment programs, reduced hepatitis C and HIV seroconversion, reduced rates of criminal activity and incarceration, decreased overdose risk, and improved survival.¹⁴

Opioid agonists are not a cure-all and come with their own challenges, but for many patients they can “create the space” needed to do the real work of recovery—healing their damaged relationships with themselves, their family, and their society.

Providers need to educate themselves regarding the options available and when and how to use them. They should familiarize themselves with methadone and buprenorphine treatment programs in their community. Better yet, with only 8 hours of additional training, primary care physicians can become waivered to prescribe buprenorphine to treat opioid addiction right in the office. Treating addiction is quickly becoming part of primary care, and clinicians in practice can no longer turn a blind eye toward this problem.

Islam is the second most common religion in the world, and there are 1.6 billion Muslims, many in areas where diabetes is prevalent. Each year observant Muslims fast during the daylight hours for the holy month of Ramadan. It is estimated that 50 million diabetic people fast between dawn and sundown during Ramadan, and Muslims are not the only group of patients who fast for religious or other reasons. It is important for healthcare providers to guide patients with diabetes in avoiding problems related to prolonged fasting.

See related article

In this issue of the Cleveland Clinic Journal of Medicine, Drs. A.V. and Zagar address management of diabetes specifically relating to Ramadan fasting, with considerations that also apply to other diabetic patients who fast for religious or for medical reasons.

Fortunately, we now have antihyperglycemic agents that are unlikely to cause hypoglycemia if used alone or in combination, as long as the regimen does not include insulin or a sulfonylurea. These include:

• Metformin and thiazolidinediones (pioglitazone and rosig­litazone), which improve insulin sensitivity
• Glucagon-like peptide 1 (GLP-1) agonists (exenatide, liraglutide, dulaglutide, and albaglutide), which facilitate insulin release in a glucose-dependent fashion
• Dipeptidyl peptidase 4 inhibitors (sitagliptin, saxagliptin, alogliptin, and linagliptin), which augment endogenous incretin hormones, primarily GLP-1, and also facilitate insulin production in a glucose-dependent fashion
• Alpha glucosidase inhibitors (acarbose and miglitol), which slow carbohydrate absorption.

Introduced in recent years, the sodium-glucose cotransporter 2 (SGLT-2) inhibitors canagliflozin, dapagliflozin, and empagliflozin lower blood glucose by reducing the renal threshold for reabsorption of glucose, coupled with reabsorption of sodium leading to daily urinary excretion of about 200 calories. These agents alone or taken with any of the agents above should not cause hypoglycemia. However, they can lead to dehydration if fasting precludes the intake of water as well as food.

The primary concern during fasting is hypoglycemia when diabetes regimens involve insulin or insulin secretagogues, most commonly sulfonylureas. Long-acting basal insulin should not require adjustment during fasting if the dose is not excessive. The amount and timing of short-acting analogues administered before meals should be adjusted to the timing of meals, and doses should be adjusted proportionally to the anticipated carbohydrate intake. Premixed insulins such as intermediate-acting (protamine suspension) insulin and a short-acting insulin in 70/30, 75/25, or 50/50 ratios should be avoided. They do not lend themselves to changes in timing, and the short-acting component is fixed and cannot be changed for varied intake without changing the intermediate-acting portion, which functions as the basal insulin.

Sulfonylurea doses can be reduced or the larger dose moved to before the evening meal, but these agents still pose a risk of hypoglycemia during fasting hours. And as Drs. A.V. and Zagar state, glimepiride, glipizide, and gliclazide are the only agents in the class that should be considered; glyburide (ie, glibenclamide) poses too great a risk of hypoglycemia. On the other hand, the short-acting secretagogue nateglinide can be used safely before meals without much risk of hypoglycemia.

We have focused primarily on hypoglycemia risk. But if antihyperglycemic agents are halted completely or if the reduction is too severe, patients are at risk for hyperglycemia and even diabetic ketoacidosis. Careful monitoring of blood glucose levels during the fasting period is most important for patients taking agents that can cause hypoglycemia, and patients should be advised to break the fast if dangerously low glycemic levels occur. Similarly, if severe hyperglycemia or ketoacidosis develops, patients should be advised to seek medical advice promptly.

Islam is the second most common religion in the world, and there are 1.6 billion Muslims, many in areas where diabetes is prevalent. Each year observant Muslims fast during the daylight hours for the holy month of Ramadan. It is estimated that 50 million diabetic people fast between dawn and sundown during Ramadan, and Muslims are not the only group of patients who fast for religious or other reasons. It is important for healthcare providers to guide patients with diabetes in avoiding problems related to prolonged fasting.

See related article

In this issue of the Cleveland Clinic Journal of Medicine, Drs. A.V. and Zagar address management of diabetes specifically relating to Ramadan fasting, with considerations that also apply to other diabetic patients who fast for religious or for medical reasons.

Fortunately, we now have antihyperglycemic agents that are unlikely to cause hypoglycemia if used alone or in combination, as long as the regimen does not include insulin or a sulfonylurea. These include:

• Metformin and thiazolidinediones (pioglitazone and rosig­litazone), which improve insulin sensitivity
• Glucagon-like peptide 1 (GLP-1) agonists (exenatide, liraglutide, dulaglutide, and albaglutide), which facilitate insulin release in a glucose-dependent fashion
• Dipeptidyl peptidase 4 inhibitors (sitagliptin, saxagliptin, alogliptin, and linagliptin), which augment endogenous incretin hormones, primarily GLP-1, and also facilitate insulin production in a glucose-dependent fashion
• Alpha glucosidase inhibitors (acarbose and miglitol), which slow carbohydrate absorption.

Introduced in recent years, the sodium-glucose cotransporter 2 (SGLT-2) inhibitors canagliflozin, dapagliflozin, and empagliflozin lower blood glucose by reducing the renal threshold for reabsorption of glucose, coupled with reabsorption of sodium leading to daily urinary excretion of about 200 calories. These agents alone or taken with any of the agents above should not cause hypoglycemia. However, they can lead to dehydration if fasting precludes the intake of water as well as food.

The primary concern during fasting is hypoglycemia when diabetes regimens involve insulin or insulin secretagogues, most commonly sulfonylureas. Long-acting basal insulin should not require adjustment during fasting if the dose is not excessive. The amount and timing of short-acting analogues administered before meals should be adjusted to the timing of meals, and doses should be adjusted proportionally to the anticipated carbohydrate intake. Premixed insulins such as intermediate-acting (protamine suspension) insulin and a short-acting insulin in 70/30, 75/25, or 50/50 ratios should be avoided. They do not lend themselves to changes in timing, and the short-acting component is fixed and cannot be changed for varied intake without changing the intermediate-acting portion, which functions as the basal insulin.

Sulfonylurea doses can be reduced or the larger dose moved to before the evening meal, but these agents still pose a risk of hypoglycemia during fasting hours. And as Drs. A.V. and Zagar state, glimepiride, glipizide, and gliclazide are the only agents in the class that should be considered; glyburide (ie, glibenclamide) poses too great a risk of hypoglycemia. On the other hand, the short-acting secretagogue nateglinide can be used safely before meals without much risk of hypoglycemia.

We have focused primarily on hypoglycemia risk. But if antihyperglycemic agents are halted completely or if the reduction is too severe, patients are at risk for hyperglycemia and even diabetic ketoacidosis. Careful monitoring of blood glucose levels during the fasting period is most important for patients taking agents that can cause hypoglycemia, and patients should be advised to break the fast if dangerously low glycemic levels occur. Similarly, if severe hyperglycemia or ketoacidosis develops, patients should be advised to seek medical advice promptly.

Islam is the second most common religion in the world, and there are 1.6 billion Muslims, many in areas where diabetes is prevalent. Each year observant Muslims fast during the daylight hours for the holy month of Ramadan. It is estimated that 50 million diabetic people fast between dawn and sundown during Ramadan, and Muslims are not the only group of patients who fast for religious or other reasons. It is important for healthcare providers to guide patients with diabetes in avoiding problems related to prolonged fasting.

See related article

In this issue of the Cleveland Clinic Journal of Medicine, Drs. A.V. and Zagar address management of diabetes specifically relating to Ramadan fasting, with considerations that also apply to other diabetic patients who fast for religious or for medical reasons.

Fortunately, we now have antihyperglycemic agents that are unlikely to cause hypoglycemia if used alone or in combination, as long as the regimen does not include insulin or a sulfonylurea. These include:

• Metformin and thiazolidinediones (pioglitazone and rosig­litazone), which improve insulin sensitivity
• Glucagon-like peptide 1 (GLP-1) agonists (exenatide, liraglutide, dulaglutide, and albaglutide), which facilitate insulin release in a glucose-dependent fashion
• Dipeptidyl peptidase 4 inhibitors (sitagliptin, saxagliptin, alogliptin, and linagliptin), which augment endogenous incretin hormones, primarily GLP-1, and also facilitate insulin production in a glucose-dependent fashion
• Alpha glucosidase inhibitors (acarbose and miglitol), which slow carbohydrate absorption.

Introduced in recent years, the sodium-glucose cotransporter 2 (SGLT-2) inhibitors canagliflozin, dapagliflozin, and empagliflozin lower blood glucose by reducing the renal threshold for reabsorption of glucose, coupled with reabsorption of sodium leading to daily urinary excretion of about 200 calories. These agents alone or taken with any of the agents above should not cause hypoglycemia. However, they can lead to dehydration if fasting precludes the intake of water as well as food.

The primary concern during fasting is hypoglycemia when diabetes regimens involve insulin or insulin secretagogues, most commonly sulfonylureas. Long-acting basal insulin should not require adjustment during fasting if the dose is not excessive. The amount and timing of short-acting analogues administered before meals should be adjusted to the timing of meals, and doses should be adjusted proportionally to the anticipated carbohydrate intake. Premixed insulins such as intermediate-acting (protamine suspension) insulin and a short-acting insulin in 70/30, 75/25, or 50/50 ratios should be avoided. They do not lend themselves to changes in timing, and the short-acting component is fixed and cannot be changed for varied intake without changing the intermediate-acting portion, which functions as the basal insulin.

Sulfonylurea doses can be reduced or the larger dose moved to before the evening meal, but these agents still pose a risk of hypoglycemia during fasting hours. And as Drs. A.V. and Zagar state, glimepiride, glipizide, and gliclazide are the only agents in the class that should be considered; glyburide (ie, glibenclamide) poses too great a risk of hypoglycemia. On the other hand, the short-acting secretagogue nateglinide can be used safely before meals without much risk of hypoglycemia.

We have focused primarily on hypoglycemia risk. But if antihyperglycemic agents are halted completely or if the reduction is too severe, patients are at risk for hyperglycemia and even diabetic ketoacidosis. Careful monitoring of blood glucose levels during the fasting period is most important for patients taking agents that can cause hypoglycemia, and patients should be advised to break the fast if dangerously low glycemic levels occur. Similarly, if severe hyperglycemia or ketoacidosis develops, patients should be advised to seek medical advice promptly.

In this issue of the Journal of Hospital Medicine, Lusica et al.¹ discuss the utility of urine eosinophils (UEs) in evaluating for acute interstitial nephritis (AIN) in patients with acute kidney injury (AKI), an important and oft-confused concern in medicine. I can’t think of a more appropriate topic for the “Things We Do for No Reason” (TWDFNR) series. Numerous tests are ordered in the evaluation of AKI.² Many, such as batteries of serological tests, are unnecessary and add little diagnostic information. Some, such as UEs and fractional excretion of sodium (FENa), provide misinformation. And others, such as contrast-enhanced computed tomography scans, are potentially harmful.² In a previous TWDFNR article, the limitations of FENa in the evaluation of AKI were reviewed.³ There are common threads linking the shortcomings of UEs and FENa and even new diagnostic tests. What are the lessons from these studies, and how might clinicians best apply them in their practice?

As reviewed in this issue, UE testing is employed in AKI to evaluate for hospital-acquired AIN. Small initial studies led to widespread use of this test, despite methodological flaws.⁴ A later, definitive study involving 566 patients who had both UEs and kidney biopsies performed within the same week demonstrated that UEs offered no diagnostic value in AKI.⁵ The same pattern occurred in the increased use of FENa to distinguish prerenal azotemia from acute tubular necrosis in AKI patients.³ Small studies in highly select patients supported its use for this purpose.⁶ Subsequently, larger studies in more diverse populations noted that FENa was associated with many false positive and negative results,⁶ likely due to more widespread use of this test in disease states such as cirrhosis, congestive heart failure, chronic kidney disease, and diabetes, which were not included in initial studies.

It is apparent that clinicians have been led astray by small, flawed positive studies employed in highly selected populations. These initial positive studies based on excessively large effect size estimates were subsequently shown to be negative in larger studies with more plausible effect sizes. Examples of this error are seen in publications involving prophylactic measures to reduce contrast nephrotoxicity.⁷ Early studies on N-acetylcysteine administration prior to radiocontrast exposure showed positive results. Examination of these studies, however, demonstrates 2 key problems: 1) inclusion of small numbers of patients due to power calculations based on excessively large effect sizes, and 2) use of clinically unimportant endpoints such as serum creatinine changes.⁷ The same issue complicates studies evaluating isotonic sodium bicarbonate vs. normal saline for contrast prophylaxis.⁷

The past 10-plus years have seen a proliferation of studies evaluating the utility of novel biomarkers for early diagnosis and prognosis in AKI. Have we fallen down the same rabbit hole in evaluating these new diagnostic tests for AKI? There is reason for concern if we examine published studies of novel biomarkers in other areas of medicine. To this point, many highly cited novel biomarker studies used for various diagnostic purposes (eg, cancer, infection, cardiovascular disease) employed excessively large effect size estimates for postulated associations that resulted in small, underpowered studies with initially positive results.⁸ Subsequent large studies and meta-analyses reported negative or modestly positive test results when examining these same associations.⁸ But we may be moving in the right direction. An early urine biomarker publication from a small, single center study⁹ revealed overly optimistic results (area under the curve [AUC], 0.998; sensitivity, 100%; specificity, 98%) for AKI prediction. Subsequent large, multicenter biomarker studies showed only modest improvement in their discriminative value when compared with traditional clinical models.¹⁰ These results precluded U.S. Food and Drug Administration (FDA) approval of most novel biomarkers for clinical practice and they were not adopted. In 2014, the FDA approved the point-of-care urinary biomarker TIMP-2/IGFBP7 (NephroCheck^®) for predicting risk of AKI based on fairly rigorous testing using larger numbers of patients, heterogeneous populations, and important clinical endpoints.¹¹ In a 522-patient discovery cohort, this biomarker had an AUC of 0.80 for AKI prediction, which was validated in a 722-patient cohort and subsequently followed by a 420-patient multicenter cohort study revealing similar test characteristics (AUC, 0.82; sensitivity, 92%; specificity, 46%).¹¹ A study involving 382 critically ill AKI patients noted that this biomarker had a hazard ratio of 2.16 (95% confidence interval [CI] 1.32 to 3.53) for predicting dialysis requirement or death.¹¹ And while this test has yet to find its clinical niche, its operating characteristics are well-studied and likely valid. While predicting AKI earlier does not currently result in effective therapy, it may allow more timely discontinuation or avoidance of potentially nephrotoxic medications, ultimately reducing the severity of AKI and its consequences.

In summary, clinicians should be aware of the strengths and limitations of diagnostic tests ordered in AKI patients, as seen with the overly optimistic results in small, flawed UE and FENa studies. While we have taken a step in the right direction with diagnostic and prognostic biomarkers for AKI, we must apply rigorous study design to diagnostic tests under evaluation before adopting them into clinical practice. Only then can we move the field forward and improve patient care.

Disclosure

Nothing to report.

In this issue of the Journal of Hospital Medicine, Lusica et al.¹ discuss the utility of urine eosinophils (UEs) in evaluating for acute interstitial nephritis (AIN) in patients with acute kidney injury (AKI), an important and oft-confused concern in medicine. I can’t think of a more appropriate topic for the “Things We Do for No Reason” (TWDFNR) series. Numerous tests are ordered in the evaluation of AKI.² Many, such as batteries of serological tests, are unnecessary and add little diagnostic information. Some, such as UEs and fractional excretion of sodium (FENa), provide misinformation. And others, such as contrast-enhanced computed tomography scans, are potentially harmful.² In a previous TWDFNR article, the limitations of FENa in the evaluation of AKI were reviewed.³ There are common threads linking the shortcomings of UEs and FENa and even new diagnostic tests. What are the lessons from these studies, and how might clinicians best apply them in their practice?

As reviewed in this issue, UE testing is employed in AKI to evaluate for hospital-acquired AIN. Small initial studies led to widespread use of this test, despite methodological flaws.⁴ A later, definitive study involving 566 patients who had both UEs and kidney biopsies performed within the same week demonstrated that UEs offered no diagnostic value in AKI.⁵ The same pattern occurred in the increased use of FENa to distinguish prerenal azotemia from acute tubular necrosis in AKI patients.³ Small studies in highly select patients supported its use for this purpose.⁶ Subsequently, larger studies in more diverse populations noted that FENa was associated with many false positive and negative results,⁶ likely due to more widespread use of this test in disease states such as cirrhosis, congestive heart failure, chronic kidney disease, and diabetes, which were not included in initial studies.

It is apparent that clinicians have been led astray by small, flawed positive studies employed in highly selected populations. These initial positive studies based on excessively large effect size estimates were subsequently shown to be negative in larger studies with more plausible effect sizes. Examples of this error are seen in publications involving prophylactic measures to reduce contrast nephrotoxicity.⁷ Early studies on N-acetylcysteine administration prior to radiocontrast exposure showed positive results. Examination of these studies, however, demonstrates 2 key problems: 1) inclusion of small numbers of patients due to power calculations based on excessively large effect sizes, and 2) use of clinically unimportant endpoints such as serum creatinine changes.⁷ The same issue complicates studies evaluating isotonic sodium bicarbonate vs. normal saline for contrast prophylaxis.⁷

The past 10-plus years have seen a proliferation of studies evaluating the utility of novel biomarkers for early diagnosis and prognosis in AKI. Have we fallen down the same rabbit hole in evaluating these new diagnostic tests for AKI? There is reason for concern if we examine published studies of novel biomarkers in other areas of medicine. To this point, many highly cited novel biomarker studies used for various diagnostic purposes (eg, cancer, infection, cardiovascular disease) employed excessively large effect size estimates for postulated associations that resulted in small, underpowered studies with initially positive results.⁸ Subsequent large studies and meta-analyses reported negative or modestly positive test results when examining these same associations.⁸ But we may be moving in the right direction. An early urine biomarker publication from a small, single center study⁹ revealed overly optimistic results (area under the curve [AUC], 0.998; sensitivity, 100%; specificity, 98%) for AKI prediction. Subsequent large, multicenter biomarker studies showed only modest improvement in their discriminative value when compared with traditional clinical models.¹⁰ These results precluded U.S. Food and Drug Administration (FDA) approval of most novel biomarkers for clinical practice and they were not adopted. In 2014, the FDA approved the point-of-care urinary biomarker TIMP-2/IGFBP7 (NephroCheck^®) for predicting risk of AKI based on fairly rigorous testing using larger numbers of patients, heterogeneous populations, and important clinical endpoints.¹¹ In a 522-patient discovery cohort, this biomarker had an AUC of 0.80 for AKI prediction, which was validated in a 722-patient cohort and subsequently followed by a 420-patient multicenter cohort study revealing similar test characteristics (AUC, 0.82; sensitivity, 92%; specificity, 46%).¹¹ A study involving 382 critically ill AKI patients noted that this biomarker had a hazard ratio of 2.16 (95% confidence interval [CI] 1.32 to 3.53) for predicting dialysis requirement or death.¹¹ And while this test has yet to find its clinical niche, its operating characteristics are well-studied and likely valid. While predicting AKI earlier does not currently result in effective therapy, it may allow more timely discontinuation or avoidance of potentially nephrotoxic medications, ultimately reducing the severity of AKI and its consequences.

In summary, clinicians should be aware of the strengths and limitations of diagnostic tests ordered in AKI patients, as seen with the overly optimistic results in small, flawed UE and FENa studies. While we have taken a step in the right direction with diagnostic and prognostic biomarkers for AKI, we must apply rigorous study design to diagnostic tests under evaluation before adopting them into clinical practice. Only then can we move the field forward and improve patient care.

Disclosure

Nothing to report.

In this issue of the Journal of Hospital Medicine, Lusica et al.¹ discuss the utility of urine eosinophils (UEs) in evaluating for acute interstitial nephritis (AIN) in patients with acute kidney injury (AKI), an important and oft-confused concern in medicine. I can’t think of a more appropriate topic for the “Things We Do for No Reason” (TWDFNR) series. Numerous tests are ordered in the evaluation of AKI.² Many, such as batteries of serological tests, are unnecessary and add little diagnostic information. Some, such as UEs and fractional excretion of sodium (FENa), provide misinformation. And others, such as contrast-enhanced computed tomography scans, are potentially harmful.² In a previous TWDFNR article, the limitations of FENa in the evaluation of AKI were reviewed.³ There are common threads linking the shortcomings of UEs and FENa and even new diagnostic tests. What are the lessons from these studies, and how might clinicians best apply them in their practice?

As reviewed in this issue, UE testing is employed in AKI to evaluate for hospital-acquired AIN. Small initial studies led to widespread use of this test, despite methodological flaws.⁴ A later, definitive study involving 566 patients who had both UEs and kidney biopsies performed within the same week demonstrated that UEs offered no diagnostic value in AKI.⁵ The same pattern occurred in the increased use of FENa to distinguish prerenal azotemia from acute tubular necrosis in AKI patients.³ Small studies in highly select patients supported its use for this purpose.⁶ Subsequently, larger studies in more diverse populations noted that FENa was associated with many false positive and negative results,⁶ likely due to more widespread use of this test in disease states such as cirrhosis, congestive heart failure, chronic kidney disease, and diabetes, which were not included in initial studies.

It is apparent that clinicians have been led astray by small, flawed positive studies employed in highly selected populations. These initial positive studies based on excessively large effect size estimates were subsequently shown to be negative in larger studies with more plausible effect sizes. Examples of this error are seen in publications involving prophylactic measures to reduce contrast nephrotoxicity.⁷ Early studies on N-acetylcysteine administration prior to radiocontrast exposure showed positive results. Examination of these studies, however, demonstrates 2 key problems: 1) inclusion of small numbers of patients due to power calculations based on excessively large effect sizes, and 2) use of clinically unimportant endpoints such as serum creatinine changes.⁷ The same issue complicates studies evaluating isotonic sodium bicarbonate vs. normal saline for contrast prophylaxis.⁷

The past 10-plus years have seen a proliferation of studies evaluating the utility of novel biomarkers for early diagnosis and prognosis in AKI. Have we fallen down the same rabbit hole in evaluating these new diagnostic tests for AKI? There is reason for concern if we examine published studies of novel biomarkers in other areas of medicine. To this point, many highly cited novel biomarker studies used for various diagnostic purposes (eg, cancer, infection, cardiovascular disease) employed excessively large effect size estimates for postulated associations that resulted in small, underpowered studies with initially positive results.⁸ Subsequent large studies and meta-analyses reported negative or modestly positive test results when examining these same associations.⁸ But we may be moving in the right direction. An early urine biomarker publication from a small, single center study⁹ revealed overly optimistic results (area under the curve [AUC], 0.998; sensitivity, 100%; specificity, 98%) for AKI prediction. Subsequent large, multicenter biomarker studies showed only modest improvement in their discriminative value when compared with traditional clinical models.¹⁰ These results precluded U.S. Food and Drug Administration (FDA) approval of most novel biomarkers for clinical practice and they were not adopted. In 2014, the FDA approved the point-of-care urinary biomarker TIMP-2/IGFBP7 (NephroCheck^®) for predicting risk of AKI based on fairly rigorous testing using larger numbers of patients, heterogeneous populations, and important clinical endpoints.¹¹ In a 522-patient discovery cohort, this biomarker had an AUC of 0.80 for AKI prediction, which was validated in a 722-patient cohort and subsequently followed by a 420-patient multicenter cohort study revealing similar test characteristics (AUC, 0.82; sensitivity, 92%; specificity, 46%).¹¹ A study involving 382 critically ill AKI patients noted that this biomarker had a hazard ratio of 2.16 (95% confidence interval [CI] 1.32 to 3.53) for predicting dialysis requirement or death.¹¹ And while this test has yet to find its clinical niche, its operating characteristics are well-studied and likely valid. While predicting AKI earlier does not currently result in effective therapy, it may allow more timely discontinuation or avoidance of potentially nephrotoxic medications, ultimately reducing the severity of AKI and its consequences.

In summary, clinicians should be aware of the strengths and limitations of diagnostic tests ordered in AKI patients, as seen with the overly optimistic results in small, flawed UE and FENa studies. While we have taken a step in the right direction with diagnostic and prognostic biomarkers for AKI, we must apply rigorous study design to diagnostic tests under evaluation before adopting them into clinical practice. Only then can we move the field forward and improve patient care.

Disclosure

Nothing to report.

We both attend on the Infectious Disease consult team in Veterans Affairs (VA) Hospitals, and predictably the conversation on afternoon rounds often revolves around antibiotics. When we have those discussions, our focus is not on a need to “preserve antibiotics” so they might be available to some unknown patient in the future. Rather, we are working with the primary team to provide the very best treatment for the patient entrusted to our care in the bed right in front of us. We believe it is in this context—providing optimal patient care—that the current efforts in the United States to improve antibiotic use should be viewed.

The growing challenges posed by antibiotic-resistant infections and the related threat of Clostridium difficile infection combine to sicken more than 2 million people each year and contribute to the deaths of more than 25,000 patients.¹ Improving antibiotic use through antibiotic stewardship is often proposed to hospitalists as an important part of stemming this tide. While this is true, even as infectious disease specialists with strong interests in antimicrobial stewardship we do not find that pitch compelling when we are on clinical service.

What motivates us to optimize antibiotic use for our patients is the evidence that doing so will have direct and immediate benefits to the patients under our care. Improving antibiotic use has been proven to decrease a patient’s risk of acquiring C. difficile infection or an antibiotic-resistant infection not at some ill-defined time in the future, but during their current hospital stay.^2,3 Even more important, support from antibiotic stewardship programs has been proven to improve infection cure rates and reduce the risk of treatment failure for hospitalized patients.⁴ The bottom line of antibiotic stewardship is better patient care. Sometimes that means narrowing or stopping antibiotics to reduce the risks of adverse events. In other cases, like in the treatment of suspected sepsis, it means ensuring patients get broad spectrum antibiotics quickly.

The patient care benefits of improving antibiotic use led the Centers for Disease Control and Prevention (CDC) to issue a call in 2014 for all hospitals to have antibiotic stewardship programs, and to the development of The Core Elements of Hospital Antibiotic Stewardship Programs to support that effort. As of January 1, 2017, antibiotic stewardship programs that incorporate all the CDC core elements became an accreditation requirement of The Joint Commission, and the Centers for Medicare and Medicaid Services has proposed making the same requirement of all hospitals that participate in their payment programs.

This means the question is no longer whether we should have antibiotic stewardship efforts in hospitals, but how we can do this most effectively. As the physicians who provide the most care in hospitals, hospitalists are best positioned to turn stewardship theories into practice. The article from Graber et al.⁵ in this issue of the Journal of Hospital Medicine provides some important information that can help busy hospitalists incorporate stewardship into daily practice. The authors reviewed their experience with implementing stewardship efforts in VA hospitals to see which specific interventions were most likely to translate into improved antibiotic use. Based on their findings, we offer some suggestions for three conditions: pneumonia, urinary tract infection (UTI), and skin and soft tissue infection (SSTI). Together, these conditions drive roughly two-thirds of all antibiotic use in US hospitals.⁶

The literature on treatment of pneumonia is increasingly demonstrating that shorter use of antibiotics is often better.⁷ Even though current guidelines recommend 5 to 7 days of antibiotics for uncomplicated community-acquired pneumonia, average durations of therapy are often longer.⁸ Previous work published in the Journal of Hospital Medicine focused on improving antimicrobial documentation as well as access to local clinical guidelines and implementing a 72-hour antimicrobial “time out” by hospitalists.⁹ When these multimodal interventions tailored for hospitalists were in place, utilization of antibiotics improved. Graber et al.⁵ also found that facility educational programs for prudent antimicrobial use and frequency of de-escalation review were associated with decreased overall antimicrobial use. Providing vague recommendations on antibiotic course, or none at all, at discharge or sign-out can lead to unnecessary antibiotics or an extended course of them. Pneumonia-specific interventions could target duration by outlining antibiotic course in hospitalist progress notes and at hand-off.

Misuse of antibiotics in UTI often stems from overtreatment of asymptomatic bacteriuria or unneeded diagnostic testing. Often, the pivotal step in avoiding unnecessary treatment lies in the ordering of the urine culture.¹⁰ Graber et al.⁵ showed that order sets were associated with decreased antimicrobial use. In the case of UTI, hospitalists could work with the stewardship team to design order sets that guide providers to appropriate reasons for ordering a urine culture. Order sets could also help providers recognize important patient-specific risks for certain antibiotics, such as the risk of C. difficile with fluoroquinolones in an elderly patient. Targeting different steps in overutilization of antibiotics would encompass more prescribers and could lead to reducing other unnecessary testing, which is a current focus for many hospitalists.

Skin and soft tissue infections (SSTI) also offer a specific disease state to use order sets and education to improve duration of antibiotics, decrease overuse of broad spectrum antibiotics, and reduce unnecessary diagnostic studies. For example, gram negative and/or anaerobic coverage are rarely indicated in treating SSTIs but are often used. SSTI-specific order sets and guidelines have already been shown to improve both diagnostic work-up and antibiotic treatment.¹¹ As the providers who manage most of these infections in hospitals, hospitalists are ideally positioned to inform the development of SSTI order sets and pathways. The work by Graber et al.⁵ provides some important insights into how we can effectively implement interventions to improve antibiotic use. These insights have never been more important as more hospitals move toward starting or expanding antibiotic stewardship programs. As leaders in patient safety and quality, and as the most important antibiotic prescribers in hospitals, hospitalists must play a central role in stewardship if we are to make meaningful progress.

Disclosure

Nothing to report.

We both attend on the Infectious Disease consult team in Veterans Affairs (VA) Hospitals, and predictably the conversation on afternoon rounds often revolves around antibiotics. When we have those discussions, our focus is not on a need to “preserve antibiotics” so they might be available to some unknown patient in the future. Rather, we are working with the primary team to provide the very best treatment for the patient entrusted to our care in the bed right in front of us. We believe it is in this context—providing optimal patient care—that the current efforts in the United States to improve antibiotic use should be viewed.

The growing challenges posed by antibiotic-resistant infections and the related threat of Clostridium difficile infection combine to sicken more than 2 million people each year and contribute to the deaths of more than 25,000 patients.¹ Improving antibiotic use through antibiotic stewardship is often proposed to hospitalists as an important part of stemming this tide. While this is true, even as infectious disease specialists with strong interests in antimicrobial stewardship we do not find that pitch compelling when we are on clinical service.

What motivates us to optimize antibiotic use for our patients is the evidence that doing so will have direct and immediate benefits to the patients under our care. Improving antibiotic use has been proven to decrease a patient’s risk of acquiring C. difficile infection or an antibiotic-resistant infection not at some ill-defined time in the future, but during their current hospital stay.^2,3 Even more important, support from antibiotic stewardship programs has been proven to improve infection cure rates and reduce the risk of treatment failure for hospitalized patients.⁴ The bottom line of antibiotic stewardship is better patient care. Sometimes that means narrowing or stopping antibiotics to reduce the risks of adverse events. In other cases, like in the treatment of suspected sepsis, it means ensuring patients get broad spectrum antibiotics quickly.

The patient care benefits of improving antibiotic use led the Centers for Disease Control and Prevention (CDC) to issue a call in 2014 for all hospitals to have antibiotic stewardship programs, and to the development of The Core Elements of Hospital Antibiotic Stewardship Programs to support that effort. As of January 1, 2017, antibiotic stewardship programs that incorporate all the CDC core elements became an accreditation requirement of The Joint Commission, and the Centers for Medicare and Medicaid Services has proposed making the same requirement of all hospitals that participate in their payment programs.

This means the question is no longer whether we should have antibiotic stewardship efforts in hospitals, but how we can do this most effectively. As the physicians who provide the most care in hospitals, hospitalists are best positioned to turn stewardship theories into practice. The article from Graber et al.⁵ in this issue of the Journal of Hospital Medicine provides some important information that can help busy hospitalists incorporate stewardship into daily practice. The authors reviewed their experience with implementing stewardship efforts in VA hospitals to see which specific interventions were most likely to translate into improved antibiotic use. Based on their findings, we offer some suggestions for three conditions: pneumonia, urinary tract infection (UTI), and skin and soft tissue infection (SSTI). Together, these conditions drive roughly two-thirds of all antibiotic use in US hospitals.⁶

The literature on treatment of pneumonia is increasingly demonstrating that shorter use of antibiotics is often better.⁷ Even though current guidelines recommend 5 to 7 days of antibiotics for uncomplicated community-acquired pneumonia, average durations of therapy are often longer.⁸ Previous work published in the Journal of Hospital Medicine focused on improving antimicrobial documentation as well as access to local clinical guidelines and implementing a 72-hour antimicrobial “time out” by hospitalists.⁹ When these multimodal interventions tailored for hospitalists were in place, utilization of antibiotics improved. Graber et al.⁵ also found that facility educational programs for prudent antimicrobial use and frequency of de-escalation review were associated with decreased overall antimicrobial use. Providing vague recommendations on antibiotic course, or none at all, at discharge or sign-out can lead to unnecessary antibiotics or an extended course of them. Pneumonia-specific interventions could target duration by outlining antibiotic course in hospitalist progress notes and at hand-off.

Misuse of antibiotics in UTI often stems from overtreatment of asymptomatic bacteriuria or unneeded diagnostic testing. Often, the pivotal step in avoiding unnecessary treatment lies in the ordering of the urine culture.¹⁰ Graber et al.⁵ showed that order sets were associated with decreased antimicrobial use. In the case of UTI, hospitalists could work with the stewardship team to design order sets that guide providers to appropriate reasons for ordering a urine culture. Order sets could also help providers recognize important patient-specific risks for certain antibiotics, such as the risk of C. difficile with fluoroquinolones in an elderly patient. Targeting different steps in overutilization of antibiotics would encompass more prescribers and could lead to reducing other unnecessary testing, which is a current focus for many hospitalists.

Skin and soft tissue infections (SSTI) also offer a specific disease state to use order sets and education to improve duration of antibiotics, decrease overuse of broad spectrum antibiotics, and reduce unnecessary diagnostic studies. For example, gram negative and/or anaerobic coverage are rarely indicated in treating SSTIs but are often used. SSTI-specific order sets and guidelines have already been shown to improve both diagnostic work-up and antibiotic treatment.¹¹ As the providers who manage most of these infections in hospitals, hospitalists are ideally positioned to inform the development of SSTI order sets and pathways. The work by Graber et al.⁵ provides some important insights into how we can effectively implement interventions to improve antibiotic use. These insights have never been more important as more hospitals move toward starting or expanding antibiotic stewardship programs. As leaders in patient safety and quality, and as the most important antibiotic prescribers in hospitals, hospitalists must play a central role in stewardship if we are to make meaningful progress.

Disclosure

Nothing to report.

We both attend on the Infectious Disease consult team in Veterans Affairs (VA) Hospitals, and predictably the conversation on afternoon rounds often revolves around antibiotics. When we have those discussions, our focus is not on a need to “preserve antibiotics” so they might be available to some unknown patient in the future. Rather, we are working with the primary team to provide the very best treatment for the patient entrusted to our care in the bed right in front of us. We believe it is in this context—providing optimal patient care—that the current efforts in the United States to improve antibiotic use should be viewed.

The growing challenges posed by antibiotic-resistant infections and the related threat of Clostridium difficile infection combine to sicken more than 2 million people each year and contribute to the deaths of more than 25,000 patients.¹ Improving antibiotic use through antibiotic stewardship is often proposed to hospitalists as an important part of stemming this tide. While this is true, even as infectious disease specialists with strong interests in antimicrobial stewardship we do not find that pitch compelling when we are on clinical service.

What motivates us to optimize antibiotic use for our patients is the evidence that doing so will have direct and immediate benefits to the patients under our care. Improving antibiotic use has been proven to decrease a patient’s risk of acquiring C. difficile infection or an antibiotic-resistant infection not at some ill-defined time in the future, but during their current hospital stay.^2,3 Even more important, support from antibiotic stewardship programs has been proven to improve infection cure rates and reduce the risk of treatment failure for hospitalized patients.⁴ The bottom line of antibiotic stewardship is better patient care. Sometimes that means narrowing or stopping antibiotics to reduce the risks of adverse events. In other cases, like in the treatment of suspected sepsis, it means ensuring patients get broad spectrum antibiotics quickly.

The patient care benefits of improving antibiotic use led the Centers for Disease Control and Prevention (CDC) to issue a call in 2014 for all hospitals to have antibiotic stewardship programs, and to the development of The Core Elements of Hospital Antibiotic Stewardship Programs to support that effort. As of January 1, 2017, antibiotic stewardship programs that incorporate all the CDC core elements became an accreditation requirement of The Joint Commission, and the Centers for Medicare and Medicaid Services has proposed making the same requirement of all hospitals that participate in their payment programs.

This means the question is no longer whether we should have antibiotic stewardship efforts in hospitals, but how we can do this most effectively. As the physicians who provide the most care in hospitals, hospitalists are best positioned to turn stewardship theories into practice. The article from Graber et al.⁵ in this issue of the Journal of Hospital Medicine provides some important information that can help busy hospitalists incorporate stewardship into daily practice. The authors reviewed their experience with implementing stewardship efforts in VA hospitals to see which specific interventions were most likely to translate into improved antibiotic use. Based on their findings, we offer some suggestions for three conditions: pneumonia, urinary tract infection (UTI), and skin and soft tissue infection (SSTI). Together, these conditions drive roughly two-thirds of all antibiotic use in US hospitals.⁶

The literature on treatment of pneumonia is increasingly demonstrating that shorter use of antibiotics is often better.⁷ Even though current guidelines recommend 5 to 7 days of antibiotics for uncomplicated community-acquired pneumonia, average durations of therapy are often longer.⁸ Previous work published in the Journal of Hospital Medicine focused on improving antimicrobial documentation as well as access to local clinical guidelines and implementing a 72-hour antimicrobial “time out” by hospitalists.⁹ When these multimodal interventions tailored for hospitalists were in place, utilization of antibiotics improved. Graber et al.⁵ also found that facility educational programs for prudent antimicrobial use and frequency of de-escalation review were associated with decreased overall antimicrobial use. Providing vague recommendations on antibiotic course, or none at all, at discharge or sign-out can lead to unnecessary antibiotics or an extended course of them. Pneumonia-specific interventions could target duration by outlining antibiotic course in hospitalist progress notes and at hand-off.

Misuse of antibiotics in UTI often stems from overtreatment of asymptomatic bacteriuria or unneeded diagnostic testing. Often, the pivotal step in avoiding unnecessary treatment lies in the ordering of the urine culture.¹⁰ Graber et al.⁵ showed that order sets were associated with decreased antimicrobial use. In the case of UTI, hospitalists could work with the stewardship team to design order sets that guide providers to appropriate reasons for ordering a urine culture. Order sets could also help providers recognize important patient-specific risks for certain antibiotics, such as the risk of C. difficile with fluoroquinolones in an elderly patient. Targeting different steps in overutilization of antibiotics would encompass more prescribers and could lead to reducing other unnecessary testing, which is a current focus for many hospitalists.

Skin and soft tissue infections (SSTI) also offer a specific disease state to use order sets and education to improve duration of antibiotics, decrease overuse of broad spectrum antibiotics, and reduce unnecessary diagnostic studies. For example, gram negative and/or anaerobic coverage are rarely indicated in treating SSTIs but are often used. SSTI-specific order sets and guidelines have already been shown to improve both diagnostic work-up and antibiotic treatment.¹¹ As the providers who manage most of these infections in hospitals, hospitalists are ideally positioned to inform the development of SSTI order sets and pathways. The work by Graber et al.⁵ provides some important insights into how we can effectively implement interventions to improve antibiotic use. These insights have never been more important as more hospitals move toward starting or expanding antibiotic stewardship programs. As leaders in patient safety and quality, and as the most important antibiotic prescribers in hospitals, hospitalists must play a central role in stewardship if we are to make meaningful progress.

Disclosure

Nothing to report.

“... with the rapid extension of laboratory tests of greater accuracy, there is a tendency for some clinicians and hence for some students in reaching a diagnosis to rely more on laboratory reports and less on the history of the illness, the examination and behavior of the patient and clinical judgment. While in many cases laboratory findings are invaluable for reaching correct conclusions, the student should never be allowed to forget that it takes a man, not a machine, to understand a man.”

—Raymond B. Allen, MD, PhD, 1946¹

From Hippocrates onward, accurate diagnosis has always been the prerequisite for prognosis and treatment. Physicians typically diagnosed through astute interviewing, deductive reasoning, and skillful use of observation and touch. Then, in the past 250 years they added 2 more tools to their diagnostic skill set: percussion and auscultation, the dual foundation of bedside assessment. Intriguingly, both these skills were first envisioned by multifaceted minds: percussion by Leopold Auenbrugger, an Austrian music-lover who even wrote librettos for operas; and stethoscopy by René Laennec, a Breton flutist, poet, and dancer—not exactly the kind of doctors we tend to produce today.

See related article

Still, the point of this preamble is not to say that eclecticism may help creativity (it does), but to remind ourselves that it has only been for a century or so that physicians have been able to rely on laboratory and radiologic studies. In fact, the now ubiquitous and almost obligatory imaging tests (computed tomography, magnetic resonance imaging, positron-emission tomography, and ultrasonography) have been available to practitioners for only threescore years or less. Yet tests have become so dominant in our culture that it is hard to imagine a time when physicians could count only on their wit and senses.

CLINICAL SKILLS ARE STILL RELEVANT

Ironically, many studies tell us that history and bedside examination can still deliver most diagnoses.^2,3 In fact, clinical skills can solve even the most perplexing dilemmas. In an automated analysis of the clinicopathologic conference cases presented in the New England Journal of Medicine,⁴ history and physical examination still yielded a correct diagnosis in 64% of those very challenging patients.

Bedside examination may be especially important in the hospital. In a study of inpatients,⁵ physical examination detected crucial findings in one-fourth of the cases and prompted management changes in many others. As the authors concluded, sick patients need careful examination, the more skilled the better.

Unfortunately, errors in physical examination are common. In a recent review of 208 cases, 63% of oversights were due to failure to perform an examination, while 25% were either missed or misinterpreted findings.⁶ These errors interfered with diagnosis in three-fourths of the cases, and with treatment in half.

Which brings us to the interesting observation by Kondo et al,⁷ who in this issue of the Journal report how the lowly physical examination proved more helpful than expensive magnetic resonance imaging in evaluating a perplexing case of refractory shoulder pain.

This is not an isolated instance. To get back to Laennec, whose stethoscope just turned 200, auscultation too can help the 21st-century physician. For example, posturally induced crackles, a recently discovered phenomenon, are the third-best predictor of outcome following myocardial infarction, immediately after the number of diseased vessels and pulmonary capillary wedge pressure.⁸

The time-honored art of observation can also yield new and important clues. From the earlobe crease of Dr. Frank, to the elfin face of Dr. Williams, there are lots of diseases out there waiting for our name—if only we could see them. As William Osler put it, “The whole art of medicine is in observation.”⁹

But how can residents truly “observe” when they have to spend 40% of their time looking at computer screens and only 12% looking at people?¹⁰ To quote Osler again, “To educate the eye to see, the ear to hear, and the finger to feel takes time.”⁹ Yet time in medicine is at a premium. In a large national survey, the average ambulatory care visit to a general practitioner lasted 16 minutes,¹¹ which makes it difficult to use inexpensive but time-consuming maneuvers. Detection of posturally induced crackles, for example, may require as much as 9 minutes, and a thorough breast examination up to 10.¹² On the other hand, ordering tests costs little time to the physician but a huge sum to patients and society. Paradoxically, “tests” may be quite profitable for the medical-industrial complex. Hence the erosion of clinical skills.

Overreliance on diagnostic technology is particularly concerning when the cost of medicine has skyrocketed. The United States now spends $3.2 trillion a year for healthcare, and much of this money goes into technology.

In fact, high-tech might hurt us even more than in the pocket. It is a sad fact of modern medicine that when unguided by clinical skills, technology can take us down a rabbit hole, wherein tests beget tests, and where at the end there is usually a surgeon, often a lawyer, and sometimes even an undertaker. The literature is full of such cases, to the point that the risk of unnecessary tests has spawned a charming new acronym: VOMIT (victims of modern imaging technology).¹³

I’m not suggesting that we discard appropriate laboratory and radiologic testing. To the contrary. Yet contributions like those of Kondo et al remind us that even in today’s medicine, the bedside remains not only the royal road to diagnosis, but also the best filter for a more judicious and cost-effective use of technology.

That filter starts with history-taking (“Listen to the patient” said Osler, “he is telling you the diagnosis.”),⁹ and continues with the physical examination. In fact, the history typically guides the physical examination. Hence, when the patient’s symptoms point away from a particular organ, the examination of that organ may be reduced to a minimum. For instance, in neurologic patients whose history made certain findings unlikely, a Canadian group was able to cut in half the number of core items of their neurologic examination.¹⁴

Yet when the history flags a system, the clinician needs to go deeper into the examination. It’s very much what we do with laboratory tests, moving from screening tests to more advanced inquiries as we tailor our diagnostic studies to the patient’s presentation. For that we need validated maneuvers. Recent efforts in this direction have turned the art of physical examination into a science.¹⁵

Lastly, patients expect to be examined, and in fact they resent when this doesn’t happen.¹⁶ Lewis Thomas called touching our “real professional secret” and “the oldest and most effective art of doctors.”¹⁷ It may even have therapeutic value.

TEACHING BEDSIDE DIAGNOSIS

So, if bedside diagnosis is important, what can we do to rekindle it? Probably anything but continue in the old ways. Studies have consistently shown that auscultation does not improve with years of training, and that in fact attending physicians may be no more proficient than third-year medical students.¹⁸ Other areas of the examination have shown similarly depressing trends,¹⁹ thus suggesting that the traditional apprenticeship mode of learning from both faculty and senior trainees may not be helpful. In fact, it may be akin to Bruegel the Elder’s painting of the blind leading the blind, and all ending up in a ditch.

Advanced physical diagnosis courses have thus been advocated, and indeed implemented at many institutions, but usually as electives. Faculty development programs have also been recommended. Still, these interventions may not suffice.

Cutting the cord to technology by serving in a developing country

My hunch is that the rekindling of physical diagnosis may require extreme measures, like putting ourselves in a zero-tech, zero-tests environment. Years ago, I had that kind of cold-turkey experience when I spent a month in a remote Nepali clinic with neither electricity nor running water—and, of course, no cell phone and no Internet. In fact, my only tools were a translator, a stethoscope, and my brain and senses. It was both terrifying and instructive, very much like the time my uncle tried to teach me how to swim by suddenly throwing me into the Mediterranean.

Maybe we should offer that kind of “immersion” to our students. A senior rotation in a technology-depleted country might do a lot of good for a young medical mind. For one, it could remind students that physicians are not only the “natural attorneys of the poor,” as Virchow famously put it,²⁰ but also the ultimate citizens of the world. To quote Dr. Osler again, “Distinctions of race, nationality, color, and creed are unknown within the portals of the temple of Æsculapius.”²¹ Such an experience might also foster empathy and tolerance for ambiguity, 2 other traits whose absence we lament in today’s medicine. More importantly, if preceded by an advanced physical diagnosis course, a rotation in a developing country could work miracles for honing bedside skills, especially if the students are accompanied by a faculty member who can be both inspiring and gifted in the art and science of bedside diagnosis.

Ultimately, this experience could remind our young that the art of medicine is much harder to acquire than the science, and that medicine is indeed a calling and not a trade. Osler said it too, and these are indeed provocative thoughts, but short of provocations and out-of-the-box ideas, the tail will continue to wag the dog. And in the end it will cost us more than money. It will cost us the art of medicine.

“... with the rapid extension of laboratory tests of greater accuracy, there is a tendency for some clinicians and hence for some students in reaching a diagnosis to rely more on laboratory reports and less on the history of the illness, the examination and behavior of the patient and clinical judgment. While in many cases laboratory findings are invaluable for reaching correct conclusions, the student should never be allowed to forget that it takes a man, not a machine, to understand a man.”

—Raymond B. Allen, MD, PhD, 1946¹

From Hippocrates onward, accurate diagnosis has always been the prerequisite for prognosis and treatment. Physicians typically diagnosed through astute interviewing, deductive reasoning, and skillful use of observation and touch. Then, in the past 250 years they added 2 more tools to their diagnostic skill set: percussion and auscultation, the dual foundation of bedside assessment. Intriguingly, both these skills were first envisioned by multifaceted minds: percussion by Leopold Auenbrugger, an Austrian music-lover who even wrote librettos for operas; and stethoscopy by René Laennec, a Breton flutist, poet, and dancer—not exactly the kind of doctors we tend to produce today.

See related article

Still, the point of this preamble is not to say that eclecticism may help creativity (it does), but to remind ourselves that it has only been for a century or so that physicians have been able to rely on laboratory and radiologic studies. In fact, the now ubiquitous and almost obligatory imaging tests (computed tomography, magnetic resonance imaging, positron-emission tomography, and ultrasonography) have been available to practitioners for only threescore years or less. Yet tests have become so dominant in our culture that it is hard to imagine a time when physicians could count only on their wit and senses.

CLINICAL SKILLS ARE STILL RELEVANT

Ironically, many studies tell us that history and bedside examination can still deliver most diagnoses.^2,3 In fact, clinical skills can solve even the most perplexing dilemmas. In an automated analysis of the clinicopathologic conference cases presented in the New England Journal of Medicine,⁴ history and physical examination still yielded a correct diagnosis in 64% of those very challenging patients.

Bedside examination may be especially important in the hospital. In a study of inpatients,⁵ physical examination detected crucial findings in one-fourth of the cases and prompted management changes in many others. As the authors concluded, sick patients need careful examination, the more skilled the better.

Unfortunately, errors in physical examination are common. In a recent review of 208 cases, 63% of oversights were due to failure to perform an examination, while 25% were either missed or misinterpreted findings.⁶ These errors interfered with diagnosis in three-fourths of the cases, and with treatment in half.

Which brings us to the interesting observation by Kondo et al,⁷ who in this issue of the Journal report how the lowly physical examination proved more helpful than expensive magnetic resonance imaging in evaluating a perplexing case of refractory shoulder pain.

This is not an isolated instance. To get back to Laennec, whose stethoscope just turned 200, auscultation too can help the 21st-century physician. For example, posturally induced crackles, a recently discovered phenomenon, are the third-best predictor of outcome following myocardial infarction, immediately after the number of diseased vessels and pulmonary capillary wedge pressure.⁸

The time-honored art of observation can also yield new and important clues. From the earlobe crease of Dr. Frank, to the elfin face of Dr. Williams, there are lots of diseases out there waiting for our name—if only we could see them. As William Osler put it, “The whole art of medicine is in observation.”⁹

But how can residents truly “observe” when they have to spend 40% of their time looking at computer screens and only 12% looking at people?¹⁰ To quote Osler again, “To educate the eye to see, the ear to hear, and the finger to feel takes time.”⁹ Yet time in medicine is at a premium. In a large national survey, the average ambulatory care visit to a general practitioner lasted 16 minutes,¹¹ which makes it difficult to use inexpensive but time-consuming maneuvers. Detection of posturally induced crackles, for example, may require as much as 9 minutes, and a thorough breast examination up to 10.¹² On the other hand, ordering tests costs little time to the physician but a huge sum to patients and society. Paradoxically, “tests” may be quite profitable for the medical-industrial complex. Hence the erosion of clinical skills.

Overreliance on diagnostic technology is particularly concerning when the cost of medicine has skyrocketed. The United States now spends $3.2 trillion a year for healthcare, and much of this money goes into technology.

In fact, high-tech might hurt us even more than in the pocket. It is a sad fact of modern medicine that when unguided by clinical skills, technology can take us down a rabbit hole, wherein tests beget tests, and where at the end there is usually a surgeon, often a lawyer, and sometimes even an undertaker. The literature is full of such cases, to the point that the risk of unnecessary tests has spawned a charming new acronym: VOMIT (victims of modern imaging technology).¹³

I’m not suggesting that we discard appropriate laboratory and radiologic testing. To the contrary. Yet contributions like those of Kondo et al remind us that even in today’s medicine, the bedside remains not only the royal road to diagnosis, but also the best filter for a more judicious and cost-effective use of technology.

That filter starts with history-taking (“Listen to the patient” said Osler, “he is telling you the diagnosis.”),⁹ and continues with the physical examination. In fact, the history typically guides the physical examination. Hence, when the patient’s symptoms point away from a particular organ, the examination of that organ may be reduced to a minimum. For instance, in neurologic patients whose history made certain findings unlikely, a Canadian group was able to cut in half the number of core items of their neurologic examination.¹⁴

Yet when the history flags a system, the clinician needs to go deeper into the examination. It’s very much what we do with laboratory tests, moving from screening tests to more advanced inquiries as we tailor our diagnostic studies to the patient’s presentation. For that we need validated maneuvers. Recent efforts in this direction have turned the art of physical examination into a science.¹⁵

Lastly, patients expect to be examined, and in fact they resent when this doesn’t happen.¹⁶ Lewis Thomas called touching our “real professional secret” and “the oldest and most effective art of doctors.”¹⁷ It may even have therapeutic value.

TEACHING BEDSIDE DIAGNOSIS

So, if bedside diagnosis is important, what can we do to rekindle it? Probably anything but continue in the old ways. Studies have consistently shown that auscultation does not improve with years of training, and that in fact attending physicians may be no more proficient than third-year medical students.¹⁸ Other areas of the examination have shown similarly depressing trends,¹⁹ thus suggesting that the traditional apprenticeship mode of learning from both faculty and senior trainees may not be helpful. In fact, it may be akin to Bruegel the Elder’s painting of the blind leading the blind, and all ending up in a ditch.

Advanced physical diagnosis courses have thus been advocated, and indeed implemented at many institutions, but usually as electives. Faculty development programs have also been recommended. Still, these interventions may not suffice.

Cutting the cord to technology by serving in a developing country

My hunch is that the rekindling of physical diagnosis may require extreme measures, like putting ourselves in a zero-tech, zero-tests environment. Years ago, I had that kind of cold-turkey experience when I spent a month in a remote Nepali clinic with neither electricity nor running water—and, of course, no cell phone and no Internet. In fact, my only tools were a translator, a stethoscope, and my brain and senses. It was both terrifying and instructive, very much like the time my uncle tried to teach me how to swim by suddenly throwing me into the Mediterranean.

Maybe we should offer that kind of “immersion” to our students. A senior rotation in a technology-depleted country might do a lot of good for a young medical mind. For one, it could remind students that physicians are not only the “natural attorneys of the poor,” as Virchow famously put it,²⁰ but also the ultimate citizens of the world. To quote Dr. Osler again, “Distinctions of race, nationality, color, and creed are unknown within the portals of the temple of Æsculapius.”²¹ Such an experience might also foster empathy and tolerance for ambiguity, 2 other traits whose absence we lament in today’s medicine. More importantly, if preceded by an advanced physical diagnosis course, a rotation in a developing country could work miracles for honing bedside skills, especially if the students are accompanied by a faculty member who can be both inspiring and gifted in the art and science of bedside diagnosis.

Ultimately, this experience could remind our young that the art of medicine is much harder to acquire than the science, and that medicine is indeed a calling and not a trade. Osler said it too, and these are indeed provocative thoughts, but short of provocations and out-of-the-box ideas, the tail will continue to wag the dog. And in the end it will cost us more than money. It will cost us the art of medicine.

“... with the rapid extension of laboratory tests of greater accuracy, there is a tendency for some clinicians and hence for some students in reaching a diagnosis to rely more on laboratory reports and less on the history of the illness, the examination and behavior of the patient and clinical judgment. While in many cases laboratory findings are invaluable for reaching correct conclusions, the student should never be allowed to forget that it takes a man, not a machine, to understand a man.”

—Raymond B. Allen, MD, PhD, 1946¹

From Hippocrates onward, accurate diagnosis has always been the prerequisite for prognosis and treatment. Physicians typically diagnosed through astute interviewing, deductive reasoning, and skillful use of observation and touch. Then, in the past 250 years they added 2 more tools to their diagnostic skill set: percussion and auscultation, the dual foundation of bedside assessment. Intriguingly, both these skills were first envisioned by multifaceted minds: percussion by Leopold Auenbrugger, an Austrian music-lover who even wrote librettos for operas; and stethoscopy by René Laennec, a Breton flutist, poet, and dancer—not exactly the kind of doctors we tend to produce today.

See related article

Still, the point of this preamble is not to say that eclecticism may help creativity (it does), but to remind ourselves that it has only been for a century or so that physicians have been able to rely on laboratory and radiologic studies. In fact, the now ubiquitous and almost obligatory imaging tests (computed tomography, magnetic resonance imaging, positron-emission tomography, and ultrasonography) have been available to practitioners for only threescore years or less. Yet tests have become so dominant in our culture that it is hard to imagine a time when physicians could count only on their wit and senses.

CLINICAL SKILLS ARE STILL RELEVANT

Ironically, many studies tell us that history and bedside examination can still deliver most diagnoses.^2,3 In fact, clinical skills can solve even the most perplexing dilemmas. In an automated analysis of the clinicopathologic conference cases presented in the New England Journal of Medicine,⁴ history and physical examination still yielded a correct diagnosis in 64% of those very challenging patients.

Bedside examination may be especially important in the hospital. In a study of inpatients,⁵ physical examination detected crucial findings in one-fourth of the cases and prompted management changes in many others. As the authors concluded, sick patients need careful examination, the more skilled the better.

Unfortunately, errors in physical examination are common. In a recent review of 208 cases, 63% of oversights were due to failure to perform an examination, while 25% were either missed or misinterpreted findings.⁶ These errors interfered with diagnosis in three-fourths of the cases, and with treatment in half.

Which brings us to the interesting observation by Kondo et al,⁷ who in this issue of the Journal report how the lowly physical examination proved more helpful than expensive magnetic resonance imaging in evaluating a perplexing case of refractory shoulder pain.

This is not an isolated instance. To get back to Laennec, whose stethoscope just turned 200, auscultation too can help the 21st-century physician. For example, posturally induced crackles, a recently discovered phenomenon, are the third-best predictor of outcome following myocardial infarction, immediately after the number of diseased vessels and pulmonary capillary wedge pressure.⁸

The time-honored art of observation can also yield new and important clues. From the earlobe crease of Dr. Frank, to the elfin face of Dr. Williams, there are lots of diseases out there waiting for our name—if only we could see them. As William Osler put it, “The whole art of medicine is in observation.”⁹

But how can residents truly “observe” when they have to spend 40% of their time looking at computer screens and only 12% looking at people?¹⁰ To quote Osler again, “To educate the eye to see, the ear to hear, and the finger to feel takes time.”⁹ Yet time in medicine is at a premium. In a large national survey, the average ambulatory care visit to a general practitioner lasted 16 minutes,¹¹ which makes it difficult to use inexpensive but time-consuming maneuvers. Detection of posturally induced crackles, for example, may require as much as 9 minutes, and a thorough breast examination up to 10.¹² On the other hand, ordering tests costs little time to the physician but a huge sum to patients and society. Paradoxically, “tests” may be quite profitable for the medical-industrial complex. Hence the erosion of clinical skills.

Overreliance on diagnostic technology is particularly concerning when the cost of medicine has skyrocketed. The United States now spends $3.2 trillion a year for healthcare, and much of this money goes into technology.

In fact, high-tech might hurt us even more than in the pocket. It is a sad fact of modern medicine that when unguided by clinical skills, technology can take us down a rabbit hole, wherein tests beget tests, and where at the end there is usually a surgeon, often a lawyer, and sometimes even an undertaker. The literature is full of such cases, to the point that the risk of unnecessary tests has spawned a charming new acronym: VOMIT (victims of modern imaging technology).¹³

I’m not suggesting that we discard appropriate laboratory and radiologic testing. To the contrary. Yet contributions like those of Kondo et al remind us that even in today’s medicine, the bedside remains not only the royal road to diagnosis, but also the best filter for a more judicious and cost-effective use of technology.

That filter starts with history-taking (“Listen to the patient” said Osler, “he is telling you the diagnosis.”),⁹ and continues with the physical examination. In fact, the history typically guides the physical examination. Hence, when the patient’s symptoms point away from a particular organ, the examination of that organ may be reduced to a minimum. For instance, in neurologic patients whose history made certain findings unlikely, a Canadian group was able to cut in half the number of core items of their neurologic examination.¹⁴

Yet when the history flags a system, the clinician needs to go deeper into the examination. It’s very much what we do with laboratory tests, moving from screening tests to more advanced inquiries as we tailor our diagnostic studies to the patient’s presentation. For that we need validated maneuvers. Recent efforts in this direction have turned the art of physical examination into a science.¹⁵

Lastly, patients expect to be examined, and in fact they resent when this doesn’t happen.¹⁶ Lewis Thomas called touching our “real professional secret” and “the oldest and most effective art of doctors.”¹⁷ It may even have therapeutic value.

TEACHING BEDSIDE DIAGNOSIS

So, if bedside diagnosis is important, what can we do to rekindle it? Probably anything but continue in the old ways. Studies have consistently shown that auscultation does not improve with years of training, and that in fact attending physicians may be no more proficient than third-year medical students.¹⁸ Other areas of the examination have shown similarly depressing trends,¹⁹ thus suggesting that the traditional apprenticeship mode of learning from both faculty and senior trainees may not be helpful. In fact, it may be akin to Bruegel the Elder’s painting of the blind leading the blind, and all ending up in a ditch.

Advanced physical diagnosis courses have thus been advocated, and indeed implemented at many institutions, but usually as electives. Faculty development programs have also been recommended. Still, these interventions may not suffice.

Cutting the cord to technology by serving in a developing country

My hunch is that the rekindling of physical diagnosis may require extreme measures, like putting ourselves in a zero-tech, zero-tests environment. Years ago, I had that kind of cold-turkey experience when I spent a month in a remote Nepali clinic with neither electricity nor running water—and, of course, no cell phone and no Internet. In fact, my only tools were a translator, a stethoscope, and my brain and senses. It was both terrifying and instructive, very much like the time my uncle tried to teach me how to swim by suddenly throwing me into the Mediterranean.

Maybe we should offer that kind of “immersion” to our students. A senior rotation in a technology-depleted country might do a lot of good for a young medical mind. For one, it could remind students that physicians are not only the “natural attorneys of the poor,” as Virchow famously put it,²⁰ but also the ultimate citizens of the world. To quote Dr. Osler again, “Distinctions of race, nationality, color, and creed are unknown within the portals of the temple of Æsculapius.”²¹ Such an experience might also foster empathy and tolerance for ambiguity, 2 other traits whose absence we lament in today’s medicine. More importantly, if preceded by an advanced physical diagnosis course, a rotation in a developing country could work miracles for honing bedside skills, especially if the students are accompanied by a faculty member who can be both inspiring and gifted in the art and science of bedside diagnosis.

Ultimately, this experience could remind our young that the art of medicine is much harder to acquire than the science, and that medicine is indeed a calling and not a trade. Osler said it too, and these are indeed provocative thoughts, but short of provocations and out-of-the-box ideas, the tail will continue to wag the dog. And in the end it will cost us more than money. It will cost us the art of medicine.