Latest News for HOSP

In the March 2019 issue of The Hospitalist, I wrote about some key findings from a 2018 survey of U.S. physicians by The Physicians Foundation. It’s no surprise to anyone working in health care today that the survey found alarming levels of professional dissatisfaction, burnout, and pessimism about the future of medicine among respondent physicians. Sadly, it appears that much of that pessimism is directed toward hospitals and their leaders: 46% of survey respondents viewed the relationships between physicians and hospitals as somewhat or mostly negative and adversarial.

Several physicians posted comments online, and they deeply saddened me. My heart hurt for those doctors who wrote, “I loved medicine. It was good for my soul, but medicine left me. Doctors gave up most of their power and large corporations without an ethical foundation and no god, but money took over.” Or “They are waiting so all the senior physicians will retire. Nurses will become leaders who will follow administration’s lead and control physicians. Money and cost cutting is the major driver. Physicians are not valuable anymore because they have different opinions which cost a lot. There is a lot of window dressing, but they actually don’t care. They just want to run a business.” I also read “I was tossed out like dirty laundry water at age 59.” And “On a personal basis, I will try to reason with management exactly once before I bail.” Sigh.

These commenters are well-meaning physicians who had bad experiences with hospital leaders they saw as uncaring and unresponsive to their concerns as clinicians. Their experiences left them demoralized and embittered. I’m truly sorry for that.

I’m a recovering hospital administrator myself. My business partner John Nelson, MD, MHM, likes to tell people that he has successfully deprogrammed me from the way most administrators think about doctors, but he’s mostly joking (at least I think he is). I can tell you that most of the hospital leaders I have met – both when I was still an administrator and now in my consulting work – are well-intentioned people who care deeply about patients and their fellow health care professionals and are trying hard to do the right thing. Many of them could have earned more and had better career opportunities doing similar work in a field other than health care, but they chose health care out of a sincere desire to do good and help people.

A big part of the problem is that doctors and administrators come to health care from very different starting points, and so have very different perspectives. They generally function in separate silos, each paying attention to their own comfortable little part of that monster we call a health care delivery system. Often, neither administrators nor doctors have made enough effort to cross over and understand the issues and perspectives of people in other silos. As a result, it’s easy for assumptions and biases to creep in and poison our interactions.

When we interpret the behavior of others, we humans tend to overemphasize dispositional factors, such as personality or motives, and to discount situational factors, such as external stressors. Psychologists call this the fundamental attribution error or correspondence bias, and the result is usually heightened conflict as a result of presumed negative intentions on the part of others (“All she cares about is making a profit”) and discounting circumstantial factors that might be influencing others’ behavior (“She is facing reduced market share and a funding shortfall, and she’s fearful for the future of the institution”).

Add in another phenomenon known as the actor-observer bias, in which we tend to attribute others’ behavior to their dispositions but attribute our own behavior to the circumstances (“That administrator lost his temper because he’s a demanding jerk, but I only lost my temper because he pushed me over the edge”).

Is it possible that hospital leaders and doctors are reading each other inaccurately and that they’re making assumptions about each other’s intentions that get in the way of having constructive dialogue? How can we get to a place of greater trust? I don’t know the whole answer, of course, but I have a few ideas to offer.

Read the full post at hospitalleader.org.

In the March 2019 issue of The Hospitalist, I wrote about some key findings from a 2018 survey of U.S. physicians by The Physicians Foundation. It’s no surprise to anyone working in health care today that the survey found alarming levels of professional dissatisfaction, burnout, and pessimism about the future of medicine among respondent physicians. Sadly, it appears that much of that pessimism is directed toward hospitals and their leaders: 46% of survey respondents viewed the relationships between physicians and hospitals as somewhat or mostly negative and adversarial.

Several physicians posted comments online, and they deeply saddened me. My heart hurt for those doctors who wrote, “I loved medicine. It was good for my soul, but medicine left me. Doctors gave up most of their power and large corporations without an ethical foundation and no god, but money took over.” Or “They are waiting so all the senior physicians will retire. Nurses will become leaders who will follow administration’s lead and control physicians. Money and cost cutting is the major driver. Physicians are not valuable anymore because they have different opinions which cost a lot. There is a lot of window dressing, but they actually don’t care. They just want to run a business.” I also read “I was tossed out like dirty laundry water at age 59.” And “On a personal basis, I will try to reason with management exactly once before I bail.” Sigh.

These commenters are well-meaning physicians who had bad experiences with hospital leaders they saw as uncaring and unresponsive to their concerns as clinicians. Their experiences left them demoralized and embittered. I’m truly sorry for that.

I’m a recovering hospital administrator myself. My business partner John Nelson, MD, MHM, likes to tell people that he has successfully deprogrammed me from the way most administrators think about doctors, but he’s mostly joking (at least I think he is). I can tell you that most of the hospital leaders I have met – both when I was still an administrator and now in my consulting work – are well-intentioned people who care deeply about patients and their fellow health care professionals and are trying hard to do the right thing. Many of them could have earned more and had better career opportunities doing similar work in a field other than health care, but they chose health care out of a sincere desire to do good and help people.

A big part of the problem is that doctors and administrators come to health care from very different starting points, and so have very different perspectives. They generally function in separate silos, each paying attention to their own comfortable little part of that monster we call a health care delivery system. Often, neither administrators nor doctors have made enough effort to cross over and understand the issues and perspectives of people in other silos. As a result, it’s easy for assumptions and biases to creep in and poison our interactions.

When we interpret the behavior of others, we humans tend to overemphasize dispositional factors, such as personality or motives, and to discount situational factors, such as external stressors. Psychologists call this the fundamental attribution error or correspondence bias, and the result is usually heightened conflict as a result of presumed negative intentions on the part of others (“All she cares about is making a profit”) and discounting circumstantial factors that might be influencing others’ behavior (“She is facing reduced market share and a funding shortfall, and she’s fearful for the future of the institution”).

Add in another phenomenon known as the actor-observer bias, in which we tend to attribute others’ behavior to their dispositions but attribute our own behavior to the circumstances (“That administrator lost his temper because he’s a demanding jerk, but I only lost my temper because he pushed me over the edge”).

Is it possible that hospital leaders and doctors are reading each other inaccurately and that they’re making assumptions about each other’s intentions that get in the way of having constructive dialogue? How can we get to a place of greater trust? I don’t know the whole answer, of course, but I have a few ideas to offer.

Read the full post at hospitalleader.org.

In the March 2019 issue of The Hospitalist, I wrote about some key findings from a 2018 survey of U.S. physicians by The Physicians Foundation. It’s no surprise to anyone working in health care today that the survey found alarming levels of professional dissatisfaction, burnout, and pessimism about the future of medicine among respondent physicians. Sadly, it appears that much of that pessimism is directed toward hospitals and their leaders: 46% of survey respondents viewed the relationships between physicians and hospitals as somewhat or mostly negative and adversarial.

Several physicians posted comments online, and they deeply saddened me. My heart hurt for those doctors who wrote, “I loved medicine. It was good for my soul, but medicine left me. Doctors gave up most of their power and large corporations without an ethical foundation and no god, but money took over.” Or “They are waiting so all the senior physicians will retire. Nurses will become leaders who will follow administration’s lead and control physicians. Money and cost cutting is the major driver. Physicians are not valuable anymore because they have different opinions which cost a lot. There is a lot of window dressing, but they actually don’t care. They just want to run a business.” I also read “I was tossed out like dirty laundry water at age 59.” And “On a personal basis, I will try to reason with management exactly once before I bail.” Sigh.

These commenters are well-meaning physicians who had bad experiences with hospital leaders they saw as uncaring and unresponsive to their concerns as clinicians. Their experiences left them demoralized and embittered. I’m truly sorry for that.

I’m a recovering hospital administrator myself. My business partner John Nelson, MD, MHM, likes to tell people that he has successfully deprogrammed me from the way most administrators think about doctors, but he’s mostly joking (at least I think he is). I can tell you that most of the hospital leaders I have met – both when I was still an administrator and now in my consulting work – are well-intentioned people who care deeply about patients and their fellow health care professionals and are trying hard to do the right thing. Many of them could have earned more and had better career opportunities doing similar work in a field other than health care, but they chose health care out of a sincere desire to do good and help people.

A big part of the problem is that doctors and administrators come to health care from very different starting points, and so have very different perspectives. They generally function in separate silos, each paying attention to their own comfortable little part of that monster we call a health care delivery system. Often, neither administrators nor doctors have made enough effort to cross over and understand the issues and perspectives of people in other silos. As a result, it’s easy for assumptions and biases to creep in and poison our interactions.

When we interpret the behavior of others, we humans tend to overemphasize dispositional factors, such as personality or motives, and to discount situational factors, such as external stressors. Psychologists call this the fundamental attribution error or correspondence bias, and the result is usually heightened conflict as a result of presumed negative intentions on the part of others (“All she cares about is making a profit”) and discounting circumstantial factors that might be influencing others’ behavior (“She is facing reduced market share and a funding shortfall, and she’s fearful for the future of the institution”).

Add in another phenomenon known as the actor-observer bias, in which we tend to attribute others’ behavior to their dispositions but attribute our own behavior to the circumstances (“That administrator lost his temper because he’s a demanding jerk, but I only lost my temper because he pushed me over the edge”).

Is it possible that hospital leaders and doctors are reading each other inaccurately and that they’re making assumptions about each other’s intentions that get in the way of having constructive dialogue? How can we get to a place of greater trust? I don’t know the whole answer, of course, but I have a few ideas to offer.

Read the full post at hospitalleader.org.

Bryce Gartland, MD, was working as a full-time hospitalist at Emory University Hospital in Atlanta when hospital administrators first started asking him to take on administrative roles, such as clinical site director or medical director of care coordination.

Today, Dr. Gartland is hospital group president and cochief of clinical operations for Emory Healthcare, with responsibility for overall performance and achievement across all 11 Emory hospitals. In that role, he keeps his eyes open for similar talent and leadership potential in younger physicians.

Following internal medicine residency at Cedars-Sinai Medical Center in Los Angeles, Dr. Gartland moved into a traditional private practice setting in Beverly Hills. “Two years later, my wife and I decided to move back to my home town of Atlanta. This was 2005 and hospital medicine was a nascent movement in health care. I was intrigued, and Emory had a strong hospitalist program based in a major academic medical setting, which has since grown from approximately 20 physicians to over 120 across seven hospitals,” he said.

Senior leaders at Emory recognized something in Dr. Gartland and more administrative offers were forthcoming.

“After a year of practicing at Emory, the system’s chief financial officer knocked on my door to ask if I would be interested in becoming medical director for care coordination. This role afforded me tremendous opportunities to get involved in clinical/administrative activities at Emory – utilization review, hospice and palliative care, transitions of care, interface with managed care organizations. The role was very rewarding. In some ways, I became a kind of chief translator at the hospital for anything clinical that also had financial implications,” he recalled.

“Then we went through a reorganization and I was offered the opportunity to step into the chief operating officer position at Emory University Hospital. Shortly thereafter, there was leadership turnover within the division of hospital medicine and I was asked by the CEO of Emory Healthcare and chair of the department of medicine to serve as section head for hospital medicine.” Dr. Gartland wore both of those hats for about 2 years, later becoming the CEO of Emory University Hospital and two other facilities within the system. He was appointed to his current position as hospital group president and cochief of clinical operations for Emory Healthcare in 2018.

Consumed with administrative responsibilities, he largely had to step away from patient care, although with mixed emotions.

“Over the years, I worked hard to maintain a strong clinical role, but the reality is that if you are not delivering patient care routinely, it’s difficult to practice at the highest level of current medical practice,” he said. Nonetheless, Dr. Gartland tries to keep a hand in patient care by routinely rounding with hospitalist teams and attending care conferences.

Fixing the larger health care system

“I am a huge supporter of more physicians becoming actively engaged in administrative positions in health care. They are key to helping us best fix the larger health care system,” Dr. Gartland said. “However, we’ve all seen clinicians drafted into administrative positions who were not great administrators. One needs to be bilingual in both medicine and business. While some skills, such as strong communication, may cross over, it’s important to recognize that clinical strength and success do not necessarily equate to administrative achievement.”

Dr. Gartland also believes in the importance of mentorship in developing future leaders and in seeking and engaging mentors from other disciplines outside of one’s own specialty. “I’ve been fortunate to have a number of mentors who saw something in me and supported investment in my personal and professional development. I am now fortunate to be in the position to give back by mentoring a number of younger hospitalists who are interested in growing their nonclinical roles.”

“One bit of advice from a mentor that really resonated with me was: Don’t let the urgent get in the way of the important,” Dr. Gartland said. “Life is busy and full of urgent day-to-day fires. It’s important to take the time to pause and consider where you are going and what you are doing to enhance your career development. Are you getting the right kinds of feedback?” He explained that a coach or mentor who can provide constructive feedback is important and is something he has relied upon throughout his own professional development.

Different paths to learning business

Dr. Gartland did not pursue formal business training before the administrative opportunities started to multiply for him at Emory, although in college he had a strong interest in both business and medicine and at one time contemplated going into either.

“Over the years, my mentors have given me a lot of advice, one of which was that a medical degree can be a passport to a lot of different career paths, with real opportunities for merging business and medicine,” he said.

He has since intentionally pursued business training opportunities wherever they came up, such as courses offered by the American College of Physician Executives (now the American Association for Physician Leadership). “At one point, I considered going back to college in an MBA program, but that’s when John Fox – then Emory Healthcare’s CEO – called and said he wanted to send me to the Harvard Business School’s Managing Health Care Delivery executive education program, with an Emory team comprising the chief nurse executive, chief of human resources, and CEO for one of our hospitals.” Harvard’s roughly 9-month program involves 3 weeks on campus with assignments between the on-campus visits.

“In my current role as hospital group president, I have direct responsibility for our hospitals’ and system’s clinically essential services such as radiology, laboratory, pharmacy, and perioperative medicine. I also still serve as CEO for Emory University Hospital while we recruit my replacement,” Dr. Gartland said. “Overall, my work time breaks down roughly into thirds. One-third is spent on strategy and strategic initiatives – such as organizational and program design. Our system recently acquired a large community health system whose strategic and operational integration I am actively leading.”

Another third of his time is focused on operations, and the final third is focused on talent management and development. “People are truly the most valuable asset any organization has, particularly in health care,” he noted. “Being intentional about organizational design, coaching, and supporting the development and deployment of talent at all levels of the organization helps everyone achieve their full potential. It is one of the most important roles a leader can play.”

Dr. Gartland said that Emory is committed to Lean-based management systems, using both horizontal and vertical strategies for process improvement and waste reduction, with implementation beginning in urology, transplant, and heart and vascular services. Experts say Lean success starts at the very top, and Emory and Dr. Gartland are all in.

“These types of changes are measured in 5- to 7-year increments or more, not in months. We believe this is key to creating the best workplace to support the highest quality, experience, and value in health care delivery. It creates and supports the right culture within an organization, and we have made the commitment to following that path,” he said.

Recognizing leadership potential

What does Dr. Gartland look for in physicians with leadership potential?

“Are you someone who collaborates well?” he asked. “Someone who raises your hand at meetings or gets engaged with the issues? Do you volunteer to take on assignments? Are you someone with a balanced perspective, system minded in thinking and inquisitive, with a positive approach to problem solving?”

A lot of physicians might come to a meeting with the hospital or their boss and complain about all the things that aren’t working, he said, but “it’s rarer for them to come in and say: ‘I see these problems, and here’s where I think we can make improvements. How can I help?’ ” Dr. Gartland looks for evidence of emotional intelligence and the ability to effect change management across disciplines. Another skill with ever-greater importance is comfort with data and data-driven decision making.

“When our national health care system is experiencing so much change and upheaval, much of which is captured in newspaper headlines, it can sound scary,” he said. “I encourage people to see that complex, dynamic times like these, filled with so much change, are also a tremendous opportunity. Run towards and embrace the opportunity for change. Hospitalists, by nature, bring with them a tremendous background and experience set that is invaluable to help lead positive change in these dynamic times.”

The SHM has offerings for hospitalists wanting to advance in leadership positions, Dr. Gartland said, including its annual Leadership Academy. The next one is scheduled to be held in Nashville, Tenn., Nov. 4-7, 2019.

“The Leadership Academy is a great initial step for physicians, especially those early in their careers. Also, try to gain exposure to a variety of perspectives outside of hospital medicine,” he said. “I’d love to see further advances in leadership for our specialty – growing the number of hospitalists who serve as hospital CEOs or CMOs and in other leadership roles. We have more to learn collectively about leadership as a specialty, and I’d love to see us grow that capacity by offering further learning opportunities and bringing together hospitalists who have an interest in advancing leadership.”

Bryce Gartland, MD, was working as a full-time hospitalist at Emory University Hospital in Atlanta when hospital administrators first started asking him to take on administrative roles, such as clinical site director or medical director of care coordination.

Today, Dr. Gartland is hospital group president and cochief of clinical operations for Emory Healthcare, with responsibility for overall performance and achievement across all 11 Emory hospitals. In that role, he keeps his eyes open for similar talent and leadership potential in younger physicians.

Following internal medicine residency at Cedars-Sinai Medical Center in Los Angeles, Dr. Gartland moved into a traditional private practice setting in Beverly Hills. “Two years later, my wife and I decided to move back to my home town of Atlanta. This was 2005 and hospital medicine was a nascent movement in health care. I was intrigued, and Emory had a strong hospitalist program based in a major academic medical setting, which has since grown from approximately 20 physicians to over 120 across seven hospitals,” he said.

Senior leaders at Emory recognized something in Dr. Gartland and more administrative offers were forthcoming.

“After a year of practicing at Emory, the system’s chief financial officer knocked on my door to ask if I would be interested in becoming medical director for care coordination. This role afforded me tremendous opportunities to get involved in clinical/administrative activities at Emory – utilization review, hospice and palliative care, transitions of care, interface with managed care organizations. The role was very rewarding. In some ways, I became a kind of chief translator at the hospital for anything clinical that also had financial implications,” he recalled.

“Then we went through a reorganization and I was offered the opportunity to step into the chief operating officer position at Emory University Hospital. Shortly thereafter, there was leadership turnover within the division of hospital medicine and I was asked by the CEO of Emory Healthcare and chair of the department of medicine to serve as section head for hospital medicine.” Dr. Gartland wore both of those hats for about 2 years, later becoming the CEO of Emory University Hospital and two other facilities within the system. He was appointed to his current position as hospital group president and cochief of clinical operations for Emory Healthcare in 2018.

Consumed with administrative responsibilities, he largely had to step away from patient care, although with mixed emotions.

“Over the years, I worked hard to maintain a strong clinical role, but the reality is that if you are not delivering patient care routinely, it’s difficult to practice at the highest level of current medical practice,” he said. Nonetheless, Dr. Gartland tries to keep a hand in patient care by routinely rounding with hospitalist teams and attending care conferences.

Fixing the larger health care system

“I am a huge supporter of more physicians becoming actively engaged in administrative positions in health care. They are key to helping us best fix the larger health care system,” Dr. Gartland said. “However, we’ve all seen clinicians drafted into administrative positions who were not great administrators. One needs to be bilingual in both medicine and business. While some skills, such as strong communication, may cross over, it’s important to recognize that clinical strength and success do not necessarily equate to administrative achievement.”

Dr. Gartland also believes in the importance of mentorship in developing future leaders and in seeking and engaging mentors from other disciplines outside of one’s own specialty. “I’ve been fortunate to have a number of mentors who saw something in me and supported investment in my personal and professional development. I am now fortunate to be in the position to give back by mentoring a number of younger hospitalists who are interested in growing their nonclinical roles.”

“One bit of advice from a mentor that really resonated with me was: Don’t let the urgent get in the way of the important,” Dr. Gartland said. “Life is busy and full of urgent day-to-day fires. It’s important to take the time to pause and consider where you are going and what you are doing to enhance your career development. Are you getting the right kinds of feedback?” He explained that a coach or mentor who can provide constructive feedback is important and is something he has relied upon throughout his own professional development.

Different paths to learning business

Dr. Gartland did not pursue formal business training before the administrative opportunities started to multiply for him at Emory, although in college he had a strong interest in both business and medicine and at one time contemplated going into either.

“Over the years, my mentors have given me a lot of advice, one of which was that a medical degree can be a passport to a lot of different career paths, with real opportunities for merging business and medicine,” he said.

He has since intentionally pursued business training opportunities wherever they came up, such as courses offered by the American College of Physician Executives (now the American Association for Physician Leadership). “At one point, I considered going back to college in an MBA program, but that’s when John Fox – then Emory Healthcare’s CEO – called and said he wanted to send me to the Harvard Business School’s Managing Health Care Delivery executive education program, with an Emory team comprising the chief nurse executive, chief of human resources, and CEO for one of our hospitals.” Harvard’s roughly 9-month program involves 3 weeks on campus with assignments between the on-campus visits.

“In my current role as hospital group president, I have direct responsibility for our hospitals’ and system’s clinically essential services such as radiology, laboratory, pharmacy, and perioperative medicine. I also still serve as CEO for Emory University Hospital while we recruit my replacement,” Dr. Gartland said. “Overall, my work time breaks down roughly into thirds. One-third is spent on strategy and strategic initiatives – such as organizational and program design. Our system recently acquired a large community health system whose strategic and operational integration I am actively leading.”

Another third of his time is focused on operations, and the final third is focused on talent management and development. “People are truly the most valuable asset any organization has, particularly in health care,” he noted. “Being intentional about organizational design, coaching, and supporting the development and deployment of talent at all levels of the organization helps everyone achieve their full potential. It is one of the most important roles a leader can play.”

Dr. Gartland said that Emory is committed to Lean-based management systems, using both horizontal and vertical strategies for process improvement and waste reduction, with implementation beginning in urology, transplant, and heart and vascular services. Experts say Lean success starts at the very top, and Emory and Dr. Gartland are all in.

“These types of changes are measured in 5- to 7-year increments or more, not in months. We believe this is key to creating the best workplace to support the highest quality, experience, and value in health care delivery. It creates and supports the right culture within an organization, and we have made the commitment to following that path,” he said.

Recognizing leadership potential

What does Dr. Gartland look for in physicians with leadership potential?

“Are you someone who collaborates well?” he asked. “Someone who raises your hand at meetings or gets engaged with the issues? Do you volunteer to take on assignments? Are you someone with a balanced perspective, system minded in thinking and inquisitive, with a positive approach to problem solving?”

A lot of physicians might come to a meeting with the hospital or their boss and complain about all the things that aren’t working, he said, but “it’s rarer for them to come in and say: ‘I see these problems, and here’s where I think we can make improvements. How can I help?’ ” Dr. Gartland looks for evidence of emotional intelligence and the ability to effect change management across disciplines. Another skill with ever-greater importance is comfort with data and data-driven decision making.

“When our national health care system is experiencing so much change and upheaval, much of which is captured in newspaper headlines, it can sound scary,” he said. “I encourage people to see that complex, dynamic times like these, filled with so much change, are also a tremendous opportunity. Run towards and embrace the opportunity for change. Hospitalists, by nature, bring with them a tremendous background and experience set that is invaluable to help lead positive change in these dynamic times.”

The SHM has offerings for hospitalists wanting to advance in leadership positions, Dr. Gartland said, including its annual Leadership Academy. The next one is scheduled to be held in Nashville, Tenn., Nov. 4-7, 2019.

“The Leadership Academy is a great initial step for physicians, especially those early in their careers. Also, try to gain exposure to a variety of perspectives outside of hospital medicine,” he said. “I’d love to see further advances in leadership for our specialty – growing the number of hospitalists who serve as hospital CEOs or CMOs and in other leadership roles. We have more to learn collectively about leadership as a specialty, and I’d love to see us grow that capacity by offering further learning opportunities and bringing together hospitalists who have an interest in advancing leadership.”

Bryce Gartland, MD, was working as a full-time hospitalist at Emory University Hospital in Atlanta when hospital administrators first started asking him to take on administrative roles, such as clinical site director or medical director of care coordination.

Today, Dr. Gartland is hospital group president and cochief of clinical operations for Emory Healthcare, with responsibility for overall performance and achievement across all 11 Emory hospitals. In that role, he keeps his eyes open for similar talent and leadership potential in younger physicians.

Following internal medicine residency at Cedars-Sinai Medical Center in Los Angeles, Dr. Gartland moved into a traditional private practice setting in Beverly Hills. “Two years later, my wife and I decided to move back to my home town of Atlanta. This was 2005 and hospital medicine was a nascent movement in health care. I was intrigued, and Emory had a strong hospitalist program based in a major academic medical setting, which has since grown from approximately 20 physicians to over 120 across seven hospitals,” he said.

Senior leaders at Emory recognized something in Dr. Gartland and more administrative offers were forthcoming.

“After a year of practicing at Emory, the system’s chief financial officer knocked on my door to ask if I would be interested in becoming medical director for care coordination. This role afforded me tremendous opportunities to get involved in clinical/administrative activities at Emory – utilization review, hospice and palliative care, transitions of care, interface with managed care organizations. The role was very rewarding. In some ways, I became a kind of chief translator at the hospital for anything clinical that also had financial implications,” he recalled.

“Then we went through a reorganization and I was offered the opportunity to step into the chief operating officer position at Emory University Hospital. Shortly thereafter, there was leadership turnover within the division of hospital medicine and I was asked by the CEO of Emory Healthcare and chair of the department of medicine to serve as section head for hospital medicine.” Dr. Gartland wore both of those hats for about 2 years, later becoming the CEO of Emory University Hospital and two other facilities within the system. He was appointed to his current position as hospital group president and cochief of clinical operations for Emory Healthcare in 2018.

Consumed with administrative responsibilities, he largely had to step away from patient care, although with mixed emotions.

“Over the years, I worked hard to maintain a strong clinical role, but the reality is that if you are not delivering patient care routinely, it’s difficult to practice at the highest level of current medical practice,” he said. Nonetheless, Dr. Gartland tries to keep a hand in patient care by routinely rounding with hospitalist teams and attending care conferences.

Fixing the larger health care system

“I am a huge supporter of more physicians becoming actively engaged in administrative positions in health care. They are key to helping us best fix the larger health care system,” Dr. Gartland said. “However, we’ve all seen clinicians drafted into administrative positions who were not great administrators. One needs to be bilingual in both medicine and business. While some skills, such as strong communication, may cross over, it’s important to recognize that clinical strength and success do not necessarily equate to administrative achievement.”

Dr. Gartland also believes in the importance of mentorship in developing future leaders and in seeking and engaging mentors from other disciplines outside of one’s own specialty. “I’ve been fortunate to have a number of mentors who saw something in me and supported investment in my personal and professional development. I am now fortunate to be in the position to give back by mentoring a number of younger hospitalists who are interested in growing their nonclinical roles.”

“One bit of advice from a mentor that really resonated with me was: Don’t let the urgent get in the way of the important,” Dr. Gartland said. “Life is busy and full of urgent day-to-day fires. It’s important to take the time to pause and consider where you are going and what you are doing to enhance your career development. Are you getting the right kinds of feedback?” He explained that a coach or mentor who can provide constructive feedback is important and is something he has relied upon throughout his own professional development.

Different paths to learning business

Dr. Gartland did not pursue formal business training before the administrative opportunities started to multiply for him at Emory, although in college he had a strong interest in both business and medicine and at one time contemplated going into either.

“Over the years, my mentors have given me a lot of advice, one of which was that a medical degree can be a passport to a lot of different career paths, with real opportunities for merging business and medicine,” he said.

He has since intentionally pursued business training opportunities wherever they came up, such as courses offered by the American College of Physician Executives (now the American Association for Physician Leadership). “At one point, I considered going back to college in an MBA program, but that’s when John Fox – then Emory Healthcare’s CEO – called and said he wanted to send me to the Harvard Business School’s Managing Health Care Delivery executive education program, with an Emory team comprising the chief nurse executive, chief of human resources, and CEO for one of our hospitals.” Harvard’s roughly 9-month program involves 3 weeks on campus with assignments between the on-campus visits.

“In my current role as hospital group president, I have direct responsibility for our hospitals’ and system’s clinically essential services such as radiology, laboratory, pharmacy, and perioperative medicine. I also still serve as CEO for Emory University Hospital while we recruit my replacement,” Dr. Gartland said. “Overall, my work time breaks down roughly into thirds. One-third is spent on strategy and strategic initiatives – such as organizational and program design. Our system recently acquired a large community health system whose strategic and operational integration I am actively leading.”

Another third of his time is focused on operations, and the final third is focused on talent management and development. “People are truly the most valuable asset any organization has, particularly in health care,” he noted. “Being intentional about organizational design, coaching, and supporting the development and deployment of talent at all levels of the organization helps everyone achieve their full potential. It is one of the most important roles a leader can play.”

Dr. Gartland said that Emory is committed to Lean-based management systems, using both horizontal and vertical strategies for process improvement and waste reduction, with implementation beginning in urology, transplant, and heart and vascular services. Experts say Lean success starts at the very top, and Emory and Dr. Gartland are all in.

“These types of changes are measured in 5- to 7-year increments or more, not in months. We believe this is key to creating the best workplace to support the highest quality, experience, and value in health care delivery. It creates and supports the right culture within an organization, and we have made the commitment to following that path,” he said.

Recognizing leadership potential

What does Dr. Gartland look for in physicians with leadership potential?

“Are you someone who collaborates well?” he asked. “Someone who raises your hand at meetings or gets engaged with the issues? Do you volunteer to take on assignments? Are you someone with a balanced perspective, system minded in thinking and inquisitive, with a positive approach to problem solving?”

A lot of physicians might come to a meeting with the hospital or their boss and complain about all the things that aren’t working, he said, but “it’s rarer for them to come in and say: ‘I see these problems, and here’s where I think we can make improvements. How can I help?’ ” Dr. Gartland looks for evidence of emotional intelligence and the ability to effect change management across disciplines. Another skill with ever-greater importance is comfort with data and data-driven decision making.

“When our national health care system is experiencing so much change and upheaval, much of which is captured in newspaper headlines, it can sound scary,” he said. “I encourage people to see that complex, dynamic times like these, filled with so much change, are also a tremendous opportunity. Run towards and embrace the opportunity for change. Hospitalists, by nature, bring with them a tremendous background and experience set that is invaluable to help lead positive change in these dynamic times.”

The SHM has offerings for hospitalists wanting to advance in leadership positions, Dr. Gartland said, including its annual Leadership Academy. The next one is scheduled to be held in Nashville, Tenn., Nov. 4-7, 2019.

“The Leadership Academy is a great initial step for physicians, especially those early in their careers. Also, try to gain exposure to a variety of perspectives outside of hospital medicine,” he said. “I’d love to see further advances in leadership for our specialty – growing the number of hospitalists who serve as hospital CEOs or CMOs and in other leadership roles. We have more to learn collectively about leadership as a specialty, and I’d love to see us grow that capacity by offering further learning opportunities and bringing together hospitalists who have an interest in advancing leadership.”

Background: Norepinephrine and epinephrine are the most commonly used vasopressors in clinical practice and in septic shock have been found to be equivalent in effectiveness. Their different physiological effects may influence their effectiveness in cardiogenic shock, and previous retrospective studies have suggested that epinephrine may have worse clinical outcomes in this setting.

Dr. Witt is an assistant professor of medicine in the division of hospital medicine at Emory University, Atlanta.

Background: Norepinephrine and epinephrine are the most commonly used vasopressors in clinical practice and in septic shock have been found to be equivalent in effectiveness. Their different physiological effects may influence their effectiveness in cardiogenic shock, and previous retrospective studies have suggested that epinephrine may have worse clinical outcomes in this setting.

Dr. Witt is an assistant professor of medicine in the division of hospital medicine at Emory University, Atlanta.

Background: Norepinephrine and epinephrine are the most commonly used vasopressors in clinical practice and in septic shock have been found to be equivalent in effectiveness. Their different physiological effects may influence their effectiveness in cardiogenic shock, and previous retrospective studies have suggested that epinephrine may have worse clinical outcomes in this setting.

Dr. Witt is an assistant professor of medicine in the division of hospital medicine at Emory University, Atlanta.

Background: As frequency of imaging studies increases, and those studies become more advanced, incidental findings on imaging are a growing concern. Incidentalomas can lead to anxiety for patients, increased testing, and possible interventions such as biopsies. Current literature does not provide adequate guidance for providers to discuss the risks of incidentalomas with patients, nor are there clear methods described to manage incidentalomas when discovered.

Limitations included variations in how primary study authors defined a positive result and in imaging protocols. Although the authors of this study used primary data extracted from the individual studies in the systematic reviews, they did not analyze the primary studies for inclusion based on methods.

Bottom line: This study provides guidance to clinicians regarding counseling patients on the risks of incidentalomas and how to manage those incidental findings.

Citation: O’Sullivan JW et al. Prevalence and outcomes of incidental imaging findings: umbrella review. BMJ. 2018 Jun 18. doi: 10.1136/bmj.k2387.

Dr. Witt is an assistant professor of medicine in the division of hospital medicine at Emory University, Atlanta.

Background: As frequency of imaging studies increases, and those studies become more advanced, incidental findings on imaging are a growing concern. Incidentalomas can lead to anxiety for patients, increased testing, and possible interventions such as biopsies. Current literature does not provide adequate guidance for providers to discuss the risks of incidentalomas with patients, nor are there clear methods described to manage incidentalomas when discovered.

Limitations included variations in how primary study authors defined a positive result and in imaging protocols. Although the authors of this study used primary data extracted from the individual studies in the systematic reviews, they did not analyze the primary studies for inclusion based on methods.

Bottom line: This study provides guidance to clinicians regarding counseling patients on the risks of incidentalomas and how to manage those incidental findings.

Citation: O’Sullivan JW et al. Prevalence and outcomes of incidental imaging findings: umbrella review. BMJ. 2018 Jun 18. doi: 10.1136/bmj.k2387.

Dr. Witt is an assistant professor of medicine in the division of hospital medicine at Emory University, Atlanta.

Background: As frequency of imaging studies increases, and those studies become more advanced, incidental findings on imaging are a growing concern. Incidentalomas can lead to anxiety for patients, increased testing, and possible interventions such as biopsies. Current literature does not provide adequate guidance for providers to discuss the risks of incidentalomas with patients, nor are there clear methods described to manage incidentalomas when discovered.

Limitations included variations in how primary study authors defined a positive result and in imaging protocols. Although the authors of this study used primary data extracted from the individual studies in the systematic reviews, they did not analyze the primary studies for inclusion based on methods.

Bottom line: This study provides guidance to clinicians regarding counseling patients on the risks of incidentalomas and how to manage those incidental findings.

Citation: O’Sullivan JW et al. Prevalence and outcomes of incidental imaging findings: umbrella review. BMJ. 2018 Jun 18. doi: 10.1136/bmj.k2387.

Dr. Witt is an assistant professor of medicine in the division of hospital medicine at Emory University, Atlanta.

Background: Studies abound on the accelerated cost and health care activities of patients toward the end of life. Previous analyses of Medicare trends of medical care at the time of death have been compiled in 2000, 2005, 2009, and 2011; this study reexamines recent trends.

Study design: Retrospective cohort of a random sample of Medicare Fee-for-Service and Medicare Advantage decedents during 2000-2015.

Setting: Medicare patients in acute care hospitals, home/community, hospice inpatient care units, or nursing homes.

Synopsis: Approximately 1.4 million Medicare Fee-for-Service decedents and 870,000 Medicare Advantage decedents were studied in a random sample that included 20% of Medicare Fee-for-Service recipients in the years 2000, 2005, 2009, 2011, and 2015 and 100% of Medicare Advantage patients in the years 2011 and 2015. Deaths of Medicare Fee-for-Service recipients occurring in acute care hospitals and nursing homes decreased from 32.6% (95% confidence interval, 32.4%-32.8%) in 2000 to 19.8% (95% CI, 19.6%-20.0%) in 2015. Patients who died while receiving hospice services increased from 21.6% (95% CI, 21.5%-21.8%) in 2000 to 50.4% (95% CI, 50.2%-50.6%) in 2015. Review of Medicare Advantage data demonstrated similar shifts.

Although there are concerns about the accuracy of reported location of community deaths and these results may not be generalizable to other, non-Medicare populations, the study overall adds statistical data on death trends and suggests an improvement in the use of palliative and hospice care services.

Bottom line: Compared with previous years, fewer Medicare beneficiaries are dying in acute care settings, and more beneficiaries are receiving hospice care in other settings.

Citation: Teno J et al. Site of death, place of care, and health care transitions among U. S. Medicare beneficiaries between 2000-2015. JAMA. 2018;320(3):264-71.

Dr. Smith is an assistant professor of medicine in the division of hospital medicine at Emory University, Atlanta.

Background: Studies abound on the accelerated cost and health care activities of patients toward the end of life. Previous analyses of Medicare trends of medical care at the time of death have been compiled in 2000, 2005, 2009, and 2011; this study reexamines recent trends.

Study design: Retrospective cohort of a random sample of Medicare Fee-for-Service and Medicare Advantage decedents during 2000-2015.

Setting: Medicare patients in acute care hospitals, home/community, hospice inpatient care units, or nursing homes.

Synopsis: Approximately 1.4 million Medicare Fee-for-Service decedents and 870,000 Medicare Advantage decedents were studied in a random sample that included 20% of Medicare Fee-for-Service recipients in the years 2000, 2005, 2009, 2011, and 2015 and 100% of Medicare Advantage patients in the years 2011 and 2015. Deaths of Medicare Fee-for-Service recipients occurring in acute care hospitals and nursing homes decreased from 32.6% (95% confidence interval, 32.4%-32.8%) in 2000 to 19.8% (95% CI, 19.6%-20.0%) in 2015. Patients who died while receiving hospice services increased from 21.6% (95% CI, 21.5%-21.8%) in 2000 to 50.4% (95% CI, 50.2%-50.6%) in 2015. Review of Medicare Advantage data demonstrated similar shifts.

Although there are concerns about the accuracy of reported location of community deaths and these results may not be generalizable to other, non-Medicare populations, the study overall adds statistical data on death trends and suggests an improvement in the use of palliative and hospice care services.

Bottom line: Compared with previous years, fewer Medicare beneficiaries are dying in acute care settings, and more beneficiaries are receiving hospice care in other settings.

Citation: Teno J et al. Site of death, place of care, and health care transitions among U. S. Medicare beneficiaries between 2000-2015. JAMA. 2018;320(3):264-71.

Dr. Smith is an assistant professor of medicine in the division of hospital medicine at Emory University, Atlanta.

Background: Studies abound on the accelerated cost and health care activities of patients toward the end of life. Previous analyses of Medicare trends of medical care at the time of death have been compiled in 2000, 2005, 2009, and 2011; this study reexamines recent trends.

Study design: Retrospective cohort of a random sample of Medicare Fee-for-Service and Medicare Advantage decedents during 2000-2015.

Setting: Medicare patients in acute care hospitals, home/community, hospice inpatient care units, or nursing homes.

Synopsis: Approximately 1.4 million Medicare Fee-for-Service decedents and 870,000 Medicare Advantage decedents were studied in a random sample that included 20% of Medicare Fee-for-Service recipients in the years 2000, 2005, 2009, 2011, and 2015 and 100% of Medicare Advantage patients in the years 2011 and 2015. Deaths of Medicare Fee-for-Service recipients occurring in acute care hospitals and nursing homes decreased from 32.6% (95% confidence interval, 32.4%-32.8%) in 2000 to 19.8% (95% CI, 19.6%-20.0%) in 2015. Patients who died while receiving hospice services increased from 21.6% (95% CI, 21.5%-21.8%) in 2000 to 50.4% (95% CI, 50.2%-50.6%) in 2015. Review of Medicare Advantage data demonstrated similar shifts.

Although there are concerns about the accuracy of reported location of community deaths and these results may not be generalizable to other, non-Medicare populations, the study overall adds statistical data on death trends and suggests an improvement in the use of palliative and hospice care services.

Bottom line: Compared with previous years, fewer Medicare beneficiaries are dying in acute care settings, and more beneficiaries are receiving hospice care in other settings.

Citation: Teno J et al. Site of death, place of care, and health care transitions among U. S. Medicare beneficiaries between 2000-2015. JAMA. 2018;320(3):264-71.

Dr. Smith is an assistant professor of medicine in the division of hospital medicine at Emory University, Atlanta.

Clinical question: What is the association between exposure to statin medications and histologically confirmed idiopathic inflammatory myositis?

Background: More than 200 million people worldwide use statin therapy, mostly for cardiovascular risk reduction. There is mounting evidence of an infrequent side effect known as idiopathic inflammatory myositis (IIM), that requires immunosuppressive therapy rather than just discontinuation of the medication. While there is a recently described association of statin use with an immune-mediated necrotizing myositis through the formation of an autoantibody against HMG-CoA Reductase, this epidemiological study aimed to look at the incidence of statin use against all confirmed cases of IIM.

Study design: Retrospective, population-based, case-control study.

Setting: Northwest Adelaide Health Study in Adelaide, Australia.

Synopsis: A retrospective, population-based, case-control study was conducted that compared the incidence of histologically confirmed IIM identified from the South Australian Myositis Database in patients 40 years or older with known statin exposure (n = 221) against population-based controls obtained from the North West Adelaide Health Study. The unadjusted and adjusted odds ratios and 95% confidence intervals were calculated using the conditional logistic regression analysis for the risk of statin exposure associated with IIM. There was an almost twofold (79%) increased likelihood of statin exposure in patients with IIM by comparison with controls (adjusted OR, 1.79; 95% CI, 1.23-2.60; P = .001). This study’s results indicate that patients with histologically confirmed IIM had a significantly increased likelihood of statin exposure, compared with population-based matched controls. Results were similar even when excluding necrotizing myositis, which already has a known association with statin use, which suggests that statin use could be associated with all types of IIM.

Bottom line: There was a statistically significant association between statin use and the incidence of idiopathic inflammatory myositis, which suggests that this condition is a potential serious side effect of statin therapy.

Citation: Caughey GE et al. Association of statin exposure with histologically confirmed idiopathic inflammatory myositis in an Australian population. JAMA Intern Med. 2018 Jul 30. doi: 10.1001/jamainternmed.2018.2859.

Dr. Nave is an assistant professor of medicine in the division of hospital medicine at Emory University, Atlanta.

Clinical question: What is the association between exposure to statin medications and histologically confirmed idiopathic inflammatory myositis?

Background: More than 200 million people worldwide use statin therapy, mostly for cardiovascular risk reduction. There is mounting evidence of an infrequent side effect known as idiopathic inflammatory myositis (IIM), that requires immunosuppressive therapy rather than just discontinuation of the medication. While there is a recently described association of statin use with an immune-mediated necrotizing myositis through the formation of an autoantibody against HMG-CoA Reductase, this epidemiological study aimed to look at the incidence of statin use against all confirmed cases of IIM.

Study design: Retrospective, population-based, case-control study.

Setting: Northwest Adelaide Health Study in Adelaide, Australia.

Synopsis: A retrospective, population-based, case-control study was conducted that compared the incidence of histologically confirmed IIM identified from the South Australian Myositis Database in patients 40 years or older with known statin exposure (n = 221) against population-based controls obtained from the North West Adelaide Health Study. The unadjusted and adjusted odds ratios and 95% confidence intervals were calculated using the conditional logistic regression analysis for the risk of statin exposure associated with IIM. There was an almost twofold (79%) increased likelihood of statin exposure in patients with IIM by comparison with controls (adjusted OR, 1.79; 95% CI, 1.23-2.60; P = .001). This study’s results indicate that patients with histologically confirmed IIM had a significantly increased likelihood of statin exposure, compared with population-based matched controls. Results were similar even when excluding necrotizing myositis, which already has a known association with statin use, which suggests that statin use could be associated with all types of IIM.

Bottom line: There was a statistically significant association between statin use and the incidence of idiopathic inflammatory myositis, which suggests that this condition is a potential serious side effect of statin therapy.

Citation: Caughey GE et al. Association of statin exposure with histologically confirmed idiopathic inflammatory myositis in an Australian population. JAMA Intern Med. 2018 Jul 30. doi: 10.1001/jamainternmed.2018.2859.

Dr. Nave is an assistant professor of medicine in the division of hospital medicine at Emory University, Atlanta.

Clinical question: What is the association between exposure to statin medications and histologically confirmed idiopathic inflammatory myositis?

Background: More than 200 million people worldwide use statin therapy, mostly for cardiovascular risk reduction. There is mounting evidence of an infrequent side effect known as idiopathic inflammatory myositis (IIM), that requires immunosuppressive therapy rather than just discontinuation of the medication. While there is a recently described association of statin use with an immune-mediated necrotizing myositis through the formation of an autoantibody against HMG-CoA Reductase, this epidemiological study aimed to look at the incidence of statin use against all confirmed cases of IIM.

Study design: Retrospective, population-based, case-control study.

Setting: Northwest Adelaide Health Study in Adelaide, Australia.

Synopsis: A retrospective, population-based, case-control study was conducted that compared the incidence of histologically confirmed IIM identified from the South Australian Myositis Database in patients 40 years or older with known statin exposure (n = 221) against population-based controls obtained from the North West Adelaide Health Study. The unadjusted and adjusted odds ratios and 95% confidence intervals were calculated using the conditional logistic regression analysis for the risk of statin exposure associated with IIM. There was an almost twofold (79%) increased likelihood of statin exposure in patients with IIM by comparison with controls (adjusted OR, 1.79; 95% CI, 1.23-2.60; P = .001). This study’s results indicate that patients with histologically confirmed IIM had a significantly increased likelihood of statin exposure, compared with population-based matched controls. Results were similar even when excluding necrotizing myositis, which already has a known association with statin use, which suggests that statin use could be associated with all types of IIM.

Bottom line: There was a statistically significant association between statin use and the incidence of idiopathic inflammatory myositis, which suggests that this condition is a potential serious side effect of statin therapy.

Citation: Caughey GE et al. Association of statin exposure with histologically confirmed idiopathic inflammatory myositis in an Australian population. JAMA Intern Med. 2018 Jul 30. doi: 10.1001/jamainternmed.2018.2859.

Dr. Nave is an assistant professor of medicine in the division of hospital medicine at Emory University, Atlanta.

Our profession continues to experience steady growth, and demand for hospitalist physicians exceeds supply. In a recent article in The Hospitalist, Andrew White, MD, SFHM, highlighted the fact that most hospital medicine groups (HMGs) are constantly recruiting and open positions are not uncommon.

When we think about recruitment and staffing, I bet many of us think principally of physicians trained in the general medicine specialties of internal medicine, family medicine, and pediatrics. Yet, to help meet demand for hospital-based clinicians, HMGs sometimes turn to physicians certified in emergency medicine, critical care, geriatric medicine, palliative care, and other fields.

To gain a better understanding of the diversity within our profession, the Society of Hospital Medicine’s State of Hospital Medicine survey asked HMGs whether they employ at least one physician in these various specialties. Results published in the recently released 2018 State of Hospital Medicine (SoHM) Report show significant differences among groups, affected by location, group size, and type of employer.

At the core of our profession are physicians trained in internal medicine, present in 99.2% of adult medicine HMGs throughout the United States. No surprise given that our field was founded by internists and remains a popular career choice for IM residency graduates. Family physicians follow, with the highest percentage of groups employing at least one FP located in the southern United States at 70.3% and lowest in the west at 54.7%. Small-sized groups – fewer than 10 full-time equivalents (FTEs) – were also more likely to employ FPs.

This speaks to the challenge – often faced by smaller hospitals – of covering both adult and pediatric patient populations and limited workforce availability. Pediatrics- and internal medicine/pediatrics–trained physicians help meet this need and were prevalent within small-sized groups. Another distinction found in the report is that, while 92.1% of multistate hospitalist management companies employed family physicians, only 28.8% of academic university settings did so. Partly because of Accreditation Council for Graduate Medical Education requirements for IM-certified teaching attending for internal medicine residents, FP and other specialties are filling some non–teaching hospitalist positions within our academic programs.

What may be surprising is that emergency medicine and critical care had the largest increase in representation in hospital medicine. The two specialties showed similar growth trends, with a larger presence in the South and Midwest states and 56% of multistate hospitalist management companies employing them. Small- to medium-sized groups of up to 20 FTEs were also more likely to have physicians from these fields, with up to 44% of groups doing so. This is a significant change from 2016, when less than 3.4% of all HMGs overall had a physician certified in emergency or critical care medicine.

This finding seems to coincide with the growth in hospital medicine groups who are covering both ED and inpatient services. For small and rural hospitals, it has become necessary and beneficial to have physicians capable of covering both clinical settings.

Contrast this with geriatric medicine and palliative care. Here, we saw these two specialties to be present in our academic institutions at 26.8% and 22.5%, respectively. Large-sized HMGs were more likely to employ them, whereas their presence in multistate management groups or private multispecialty/primary care groups was quite low. Compared with our last survey in 2016, their overall prevalence in HMGs hasn’t changed significantly. Whether this will be different in the future with our aging population will be interesting to follow.

Published biannually, the SoHM report provides insight into these and other market-based dynamics that shape hospital medicine. The demand for hospital-based clinicians and the demands of acute inpatient care are leading to the broad and inclusive nature of hospital medicine. Our staffing will continue to be met not only by internal medicine and family medicine physicians but also through these other specialties joining our ranks and adding diversity to our profession.

Dr. Sites is the executive medical director of acute medicine at Providence St. Joseph Health, Oregon, and a member of SHM’s Practice Analysis Committee. She leads the hospital medicine programs and is involved in strategy development and alignment of acute inpatient medicine services at eight member hospitals. She has been a practicing hospitalist for 20 years and volunteers on medical mission trips to Guatemala annually.

Our profession continues to experience steady growth, and demand for hospitalist physicians exceeds supply. In a recent article in The Hospitalist, Andrew White, MD, SFHM, highlighted the fact that most hospital medicine groups (HMGs) are constantly recruiting and open positions are not uncommon.

When we think about recruitment and staffing, I bet many of us think principally of physicians trained in the general medicine specialties of internal medicine, family medicine, and pediatrics. Yet, to help meet demand for hospital-based clinicians, HMGs sometimes turn to physicians certified in emergency medicine, critical care, geriatric medicine, palliative care, and other fields.

To gain a better understanding of the diversity within our profession, the Society of Hospital Medicine’s State of Hospital Medicine survey asked HMGs whether they employ at least one physician in these various specialties. Results published in the recently released 2018 State of Hospital Medicine (SoHM) Report show significant differences among groups, affected by location, group size, and type of employer.

At the core of our profession are physicians trained in internal medicine, present in 99.2% of adult medicine HMGs throughout the United States. No surprise given that our field was founded by internists and remains a popular career choice for IM residency graduates. Family physicians follow, with the highest percentage of groups employing at least one FP located in the southern United States at 70.3% and lowest in the west at 54.7%. Small-sized groups – fewer than 10 full-time equivalents (FTEs) – were also more likely to employ FPs.

This speaks to the challenge – often faced by smaller hospitals – of covering both adult and pediatric patient populations and limited workforce availability. Pediatrics- and internal medicine/pediatrics–trained physicians help meet this need and were prevalent within small-sized groups. Another distinction found in the report is that, while 92.1% of multistate hospitalist management companies employed family physicians, only 28.8% of academic university settings did so. Partly because of Accreditation Council for Graduate Medical Education requirements for IM-certified teaching attending for internal medicine residents, FP and other specialties are filling some non–teaching hospitalist positions within our academic programs.

What may be surprising is that emergency medicine and critical care had the largest increase in representation in hospital medicine. The two specialties showed similar growth trends, with a larger presence in the South and Midwest states and 56% of multistate hospitalist management companies employing them. Small- to medium-sized groups of up to 20 FTEs were also more likely to have physicians from these fields, with up to 44% of groups doing so. This is a significant change from 2016, when less than 3.4% of all HMGs overall had a physician certified in emergency or critical care medicine.

This finding seems to coincide with the growth in hospital medicine groups who are covering both ED and inpatient services. For small and rural hospitals, it has become necessary and beneficial to have physicians capable of covering both clinical settings.

Contrast this with geriatric medicine and palliative care. Here, we saw these two specialties to be present in our academic institutions at 26.8% and 22.5%, respectively. Large-sized HMGs were more likely to employ them, whereas their presence in multistate management groups or private multispecialty/primary care groups was quite low. Compared with our last survey in 2016, their overall prevalence in HMGs hasn’t changed significantly. Whether this will be different in the future with our aging population will be interesting to follow.

Published biannually, the SoHM report provides insight into these and other market-based dynamics that shape hospital medicine. The demand for hospital-based clinicians and the demands of acute inpatient care are leading to the broad and inclusive nature of hospital medicine. Our staffing will continue to be met not only by internal medicine and family medicine physicians but also through these other specialties joining our ranks and adding diversity to our profession.

Dr. Sites is the executive medical director of acute medicine at Providence St. Joseph Health, Oregon, and a member of SHM’s Practice Analysis Committee. She leads the hospital medicine programs and is involved in strategy development and alignment of acute inpatient medicine services at eight member hospitals. She has been a practicing hospitalist for 20 years and volunteers on medical mission trips to Guatemala annually.

Our profession continues to experience steady growth, and demand for hospitalist physicians exceeds supply. In a recent article in The Hospitalist, Andrew White, MD, SFHM, highlighted the fact that most hospital medicine groups (HMGs) are constantly recruiting and open positions are not uncommon.

When we think about recruitment and staffing, I bet many of us think principally of physicians trained in the general medicine specialties of internal medicine, family medicine, and pediatrics. Yet, to help meet demand for hospital-based clinicians, HMGs sometimes turn to physicians certified in emergency medicine, critical care, geriatric medicine, palliative care, and other fields.

To gain a better understanding of the diversity within our profession, the Society of Hospital Medicine’s State of Hospital Medicine survey asked HMGs whether they employ at least one physician in these various specialties. Results published in the recently released 2018 State of Hospital Medicine (SoHM) Report show significant differences among groups, affected by location, group size, and type of employer.

At the core of our profession are physicians trained in internal medicine, present in 99.2% of adult medicine HMGs throughout the United States. No surprise given that our field was founded by internists and remains a popular career choice for IM residency graduates. Family physicians follow, with the highest percentage of groups employing at least one FP located in the southern United States at 70.3% and lowest in the west at 54.7%. Small-sized groups – fewer than 10 full-time equivalents (FTEs) – were also more likely to employ FPs.

This speaks to the challenge – often faced by smaller hospitals – of covering both adult and pediatric patient populations and limited workforce availability. Pediatrics- and internal medicine/pediatrics–trained physicians help meet this need and were prevalent within small-sized groups. Another distinction found in the report is that, while 92.1% of multistate hospitalist management companies employed family physicians, only 28.8% of academic university settings did so. Partly because of Accreditation Council for Graduate Medical Education requirements for IM-certified teaching attending for internal medicine residents, FP and other specialties are filling some non–teaching hospitalist positions within our academic programs.

What may be surprising is that emergency medicine and critical care had the largest increase in representation in hospital medicine. The two specialties showed similar growth trends, with a larger presence in the South and Midwest states and 56% of multistate hospitalist management companies employing them. Small- to medium-sized groups of up to 20 FTEs were also more likely to have physicians from these fields, with up to 44% of groups doing so. This is a significant change from 2016, when less than 3.4% of all HMGs overall had a physician certified in emergency or critical care medicine.

This finding seems to coincide with the growth in hospital medicine groups who are covering both ED and inpatient services. For small and rural hospitals, it has become necessary and beneficial to have physicians capable of covering both clinical settings.

Contrast this with geriatric medicine and palliative care. Here, we saw these two specialties to be present in our academic institutions at 26.8% and 22.5%, respectively. Large-sized HMGs were more likely to employ them, whereas their presence in multistate management groups or private multispecialty/primary care groups was quite low. Compared with our last survey in 2016, their overall prevalence in HMGs hasn’t changed significantly. Whether this will be different in the future with our aging population will be interesting to follow.

Published biannually, the SoHM report provides insight into these and other market-based dynamics that shape hospital medicine. The demand for hospital-based clinicians and the demands of acute inpatient care are leading to the broad and inclusive nature of hospital medicine. Our staffing will continue to be met not only by internal medicine and family medicine physicians but also through these other specialties joining our ranks and adding diversity to our profession.

Dr. Sites is the executive medical director of acute medicine at Providence St. Joseph Health, Oregon, and a member of SHM’s Practice Analysis Committee. She leads the hospital medicine programs and is involved in strategy development and alignment of acute inpatient medicine services at eight member hospitals. She has been a practicing hospitalist for 20 years and volunteers on medical mission trips to Guatemala annually.

Clinical question: Is an oral direct factor Xa inhibitor an effective alternative to low-molecular-weight heparin (LMWH) in treating cancer related venous thromboembolism (VTE)?

Background: LMWH has been the standard of care for treatment in patients with VTE and cancer. A newer class of drug, the direct factor Xa inhibitors, have been shown to be noninferior to vitamin K antagonists (VKAs) in treatment of VTE in noncancer patients, but little is known about their use in patients with cancer.

Study Design: Randomized, open-label, multicenter pilot trial.

Setting: United Kingdom; patients were recruited through the Clinical Trials Unit at the University of Warwick, Coventry.

Synopsis: The authors randomly assigned 406 cancer patients with diagnosed VTE either to the LMWH group or to the oral direct factor Xa inhibitor group to evaluate the primary endpoint of VTE reoccurrence and secondary endpoints of major bleeding or clinically relevant but not major bleeding (CRNMB). Rivaroxaban was noninferior to dalteparin in preventing VTE reoccurrence, with a 6-month VTE reoccurrence rate for dalteparin of 11% (95% confidence interval, 7%-16%) and a reoccurrence rate of 6% for rivaroxaban (95% CI, 2%-9%). Rates of major bleeding events were similar, although patients with esophageal or gastroesophageal cancers tended to experience more major bleeds with rivaroxaban than with dalteparin (4 of 11 vs. 1 of 19). CRNMB was 4% for dalteparin and 13% for rivaroxaban (hazard ratio, 3.76; 95% CI, 1.64-8.69). Limitations include slow recruitment, high mortality rate, and the treatment length being only 6 months.

Bottom line: In this small study, rivaroxaban was equally effective at reducing the rate of reoccurrence of cancer related VTE at 6 months but had higher rates of CRNMB. Patients with GI cancers may be at higher risk for major GI bleeding with rivaroxaban.

Citation: Young AM et al. Comparison of an oral factor Xa inhibitor with low molecular weight heparin in patients with cancer with venous thromboembolism: Results of a randomized trial (SELECT-D). J Clin Oncol. 2018 Jul 10. 36(20):2017-23.

Dr. Marten is an assistant professor of medicine in the division of hospital medicine at Emory University, Atlanta.

Clinical question: Is an oral direct factor Xa inhibitor an effective alternative to low-molecular-weight heparin (LMWH) in treating cancer related venous thromboembolism (VTE)?

Background: LMWH has been the standard of care for treatment in patients with VTE and cancer. A newer class of drug, the direct factor Xa inhibitors, have been shown to be noninferior to vitamin K antagonists (VKAs) in treatment of VTE in noncancer patients, but little is known about their use in patients with cancer.

Study Design: Randomized, open-label, multicenter pilot trial.

Setting: United Kingdom; patients were recruited through the Clinical Trials Unit at the University of Warwick, Coventry.

Synopsis: The authors randomly assigned 406 cancer patients with diagnosed VTE either to the LMWH group or to the oral direct factor Xa inhibitor group to evaluate the primary endpoint of VTE reoccurrence and secondary endpoints of major bleeding or clinically relevant but not major bleeding (CRNMB). Rivaroxaban was noninferior to dalteparin in preventing VTE reoccurrence, with a 6-month VTE reoccurrence rate for dalteparin of 11% (95% confidence interval, 7%-16%) and a reoccurrence rate of 6% for rivaroxaban (95% CI, 2%-9%). Rates of major bleeding events were similar, although patients with esophageal or gastroesophageal cancers tended to experience more major bleeds with rivaroxaban than with dalteparin (4 of 11 vs. 1 of 19). CRNMB was 4% for dalteparin and 13% for rivaroxaban (hazard ratio, 3.76; 95% CI, 1.64-8.69). Limitations include slow recruitment, high mortality rate, and the treatment length being only 6 months.

Bottom line: In this small study, rivaroxaban was equally effective at reducing the rate of reoccurrence of cancer related VTE at 6 months but had higher rates of CRNMB. Patients with GI cancers may be at higher risk for major GI bleeding with rivaroxaban.

Citation: Young AM et al. Comparison of an oral factor Xa inhibitor with low molecular weight heparin in patients with cancer with venous thromboembolism: Results of a randomized trial (SELECT-D). J Clin Oncol. 2018 Jul 10. 36(20):2017-23.

Dr. Marten is an assistant professor of medicine in the division of hospital medicine at Emory University, Atlanta.

Clinical question: Is an oral direct factor Xa inhibitor an effective alternative to low-molecular-weight heparin (LMWH) in treating cancer related venous thromboembolism (VTE)?

Background: LMWH has been the standard of care for treatment in patients with VTE and cancer. A newer class of drug, the direct factor Xa inhibitors, have been shown to be noninferior to vitamin K antagonists (VKAs) in treatment of VTE in noncancer patients, but little is known about their use in patients with cancer.

Study Design: Randomized, open-label, multicenter pilot trial.

Setting: United Kingdom; patients were recruited through the Clinical Trials Unit at the University of Warwick, Coventry.

Synopsis: The authors randomly assigned 406 cancer patients with diagnosed VTE either to the LMWH group or to the oral direct factor Xa inhibitor group to evaluate the primary endpoint of VTE reoccurrence and secondary endpoints of major bleeding or clinically relevant but not major bleeding (CRNMB). Rivaroxaban was noninferior to dalteparin in preventing VTE reoccurrence, with a 6-month VTE reoccurrence rate for dalteparin of 11% (95% confidence interval, 7%-16%) and a reoccurrence rate of 6% for rivaroxaban (95% CI, 2%-9%). Rates of major bleeding events were similar, although patients with esophageal or gastroesophageal cancers tended to experience more major bleeds with rivaroxaban than with dalteparin (4 of 11 vs. 1 of 19). CRNMB was 4% for dalteparin and 13% for rivaroxaban (hazard ratio, 3.76; 95% CI, 1.64-8.69). Limitations include slow recruitment, high mortality rate, and the treatment length being only 6 months.

Bottom line: In this small study, rivaroxaban was equally effective at reducing the rate of reoccurrence of cancer related VTE at 6 months but had higher rates of CRNMB. Patients with GI cancers may be at higher risk for major GI bleeding with rivaroxaban.

Citation: Young AM et al. Comparison of an oral factor Xa inhibitor with low molecular weight heparin in patients with cancer with venous thromboembolism: Results of a randomized trial (SELECT-D). J Clin Oncol. 2018 Jul 10. 36(20):2017-23.

Dr. Marten is an assistant professor of medicine in the division of hospital medicine at Emory University, Atlanta.

Clinical question: Does early renal replacement therapy (RRT) initiation affect clinical outcomes in patients with severe acute kidney injury (AKI) in the setting of septic shock or acute respiratory distress syndrome (ARDS)?

Background: Critically ill patients with AKI can benefit from RRT via improvement of electrolyte abnormalities, volume overload, and acid-base status. Potential harm from RRT includes complications of central venous access, intradialytic hypotension, and the bleeding risk of anticoagulation. The optimal timing of the elective initiation of RRT for AKI in septic shock or ARDS is unknown.

Study design: A post hoc subgroup study of a randomized, controlled trial.

Setting: Thirty-one ICUs in France.

Synopsis: Using data from the Artificial Kidney Initiation in Kidney Injury trial, the authors evaluated 619 patients with severe AKI and requirement for catecholamine infusion and/or invasive mechanical ventilation. Patients were randomly given RRT in an early or a delayed time frame. The early strategy involved RRT as soon as possible after randomization. In addition to the other parameters, the patients in the delayed group were given RRT for the following: anuria/oliguria 72 hours after randomization, blood urea nitrogen greater than 112 mg/dL, serum potassium greater than 6 mmol/L, metabolic acidosis with pH less than 7.15, or pulmonary edema from fluid overload causing severe hypoxia.

Early RRT did not show significant improvement in 60-day mortality, length of mechanical ventilation, or length of stay, compared with delayed RRT. The delayed RRT strategy was significantly associated with renal function recovery, with hazard ratios of 1.7 in ARDS (P = .009) and 1.9 in septic shock (P less than .001). Additionally, the likelihood of adequate urinary output was greater in the delayed RRT group.

Bottom line: A delayed RRT strategy in those with severe AKI and septic shock or ARDS may safely afford time for renal recovery in some patients.

Citation: Gaudry S et al. Timing of renal support and outcome of septic shock and acute respiratory distress syndrome. A post hoc analysis of the AKIKI randomized clinical trial. Am J Respir Crit Care Med. 2018;198(1):58-66.

Dr. James is a hospitalist at Emory University Hospital Midtown and an assistant professor at Emory University, both in Atlanta.

Clinical question: Does early renal replacement therapy (RRT) initiation affect clinical outcomes in patients with severe acute kidney injury (AKI) in the setting of septic shock or acute respiratory distress syndrome (ARDS)?

Background: Critically ill patients with AKI can benefit from RRT via improvement of electrolyte abnormalities, volume overload, and acid-base status. Potential harm from RRT includes complications of central venous access, intradialytic hypotension, and the bleeding risk of anticoagulation. The optimal timing of the elective initiation of RRT for AKI in septic shock or ARDS is unknown.

Study design: A post hoc subgroup study of a randomized, controlled trial.

Setting: Thirty-one ICUs in France.

Synopsis: Using data from the Artificial Kidney Initiation in Kidney Injury trial, the authors evaluated 619 patients with severe AKI and requirement for catecholamine infusion and/or invasive mechanical ventilation. Patients were randomly given RRT in an early or a delayed time frame. The early strategy involved RRT as soon as possible after randomization. In addition to the other parameters, the patients in the delayed group were given RRT for the following: anuria/oliguria 72 hours after randomization, blood urea nitrogen greater than 112 mg/dL, serum potassium greater than 6 mmol/L, metabolic acidosis with pH less than 7.15, or pulmonary edema from fluid overload causing severe hypoxia.

Early RRT did not show significant improvement in 60-day mortality, length of mechanical ventilation, or length of stay, compared with delayed RRT. The delayed RRT strategy was significantly associated with renal function recovery, with hazard ratios of 1.7 in ARDS (P = .009) and 1.9 in septic shock (P less than .001). Additionally, the likelihood of adequate urinary output was greater in the delayed RRT group.

Bottom line: A delayed RRT strategy in those with severe AKI and septic shock or ARDS may safely afford time for renal recovery in some patients.

Citation: Gaudry S et al. Timing of renal support and outcome of septic shock and acute respiratory distress syndrome. A post hoc analysis of the AKIKI randomized clinical trial. Am J Respir Crit Care Med. 2018;198(1):58-66.

Dr. James is a hospitalist at Emory University Hospital Midtown and an assistant professor at Emory University, both in Atlanta.

Clinical question: Does early renal replacement therapy (RRT) initiation affect clinical outcomes in patients with severe acute kidney injury (AKI) in the setting of septic shock or acute respiratory distress syndrome (ARDS)?

Background: Critically ill patients with AKI can benefit from RRT via improvement of electrolyte abnormalities, volume overload, and acid-base status. Potential harm from RRT includes complications of central venous access, intradialytic hypotension, and the bleeding risk of anticoagulation. The optimal timing of the elective initiation of RRT for AKI in septic shock or ARDS is unknown.

Study design: A post hoc subgroup study of a randomized, controlled trial.

Setting: Thirty-one ICUs in France.

Synopsis: Using data from the Artificial Kidney Initiation in Kidney Injury trial, the authors evaluated 619 patients with severe AKI and requirement for catecholamine infusion and/or invasive mechanical ventilation. Patients were randomly given RRT in an early or a delayed time frame. The early strategy involved RRT as soon as possible after randomization. In addition to the other parameters, the patients in the delayed group were given RRT for the following: anuria/oliguria 72 hours after randomization, blood urea nitrogen greater than 112 mg/dL, serum potassium greater than 6 mmol/L, metabolic acidosis with pH less than 7.15, or pulmonary edema from fluid overload causing severe hypoxia.

Early RRT did not show significant improvement in 60-day mortality, length of mechanical ventilation, or length of stay, compared with delayed RRT. The delayed RRT strategy was significantly associated with renal function recovery, with hazard ratios of 1.7 in ARDS (P = .009) and 1.9 in septic shock (P less than .001). Additionally, the likelihood of adequate urinary output was greater in the delayed RRT group.

Bottom line: A delayed RRT strategy in those with severe AKI and septic shock or ARDS may safely afford time for renal recovery in some patients.

Citation: Gaudry S et al. Timing of renal support and outcome of septic shock and acute respiratory distress syndrome. A post hoc analysis of the AKIKI randomized clinical trial. Am J Respir Crit Care Med. 2018;198(1):58-66.

Dr. James is a hospitalist at Emory University Hospital Midtown and an assistant professor at Emory University, both in Atlanta.

Clinical question: Does sodium bicarbonate treatment improve clinical outcomes in critically ill patients with severe metabolic acidosis?

Background: Severe acidemia is associated with impaired cardiac function, decreased perfusion, and increased mortality. Many physicians use sodium bicarbonate to improve hemodynamic stability in critically ill patients with acidemia. However, the use of sodium bicarbonate in this role remains controversial because the evidence to support it is limited.

Study design: Multicenter, open-label, randomized, controlled trial.

Setting: Twenty-six ICUs in France.

Synopsis: Investigators randomized 389 adult patients with severe acidemia and Sequential Organ Failure Assessment (SOFA) scores of 4 or greater or serum lactate level of 2 mmol/L or greater to receive either no sodium bicarbonate or 4.2% intravenous sodium bicarbonate. The primary composite outcome was at least organ failure at day 7 or mortality by day 28.

When compared as a whole, the treatment group did not demonstrate improvement in the primary outcome. However, patients with Acute Kidney Injury Network scores of 2 or 3 at enrollment who received bicarbonate had lower rates of the composite primary outcome (70% vs. 82%; P = .462). Additionally, 35% of the treatment group utilized a renal replacement therapy (RRT) during their ICU stay versus 52% of the control group (P = .0009).

Limitations of the study included unblinding of the ICU physicians and the lack of a control intravenous solution. Notably, 47 of the 194 patients in the control group received sodium bicarbonate as salvage therapy.

Bottom line: Sodium bicarbonate treatment may decrease the need for RRT in patients with significant metabolic acidemia and may decrease the likelihood of death or organ failure in those with severe acute kidney injury.

Citation: Jaber S et al. Sodium bicarbonate therapy for patients with severe metabolic acidaemia in the intensive care unit (BICAR-ICU): A multicentre, open-label, randomised controlled, phase 3 trial. Lancet. 2018;392(10141):31-40.

Dr. James is a hospitalist at Emory University Hospital Midtown and an assistant professor at Emory University, both in Atlanta

Clinical question: Does sodium bicarbonate treatment improve clinical outcomes in critically ill patients with severe metabolic acidosis?

Background: Severe acidemia is associated with impaired cardiac function, decreased perfusion, and increased mortality. Many physicians use sodium bicarbonate to improve hemodynamic stability in critically ill patients with acidemia. However, the use of sodium bicarbonate in this role remains controversial because the evidence to support it is limited.

Study design: Multicenter, open-label, randomized, controlled trial.

Setting: Twenty-six ICUs in France.

Synopsis: Investigators randomized 389 adult patients with severe acidemia and Sequential Organ Failure Assessment (SOFA) scores of 4 or greater or serum lactate level of 2 mmol/L or greater to receive either no sodium bicarbonate or 4.2% intravenous sodium bicarbonate. The primary composite outcome was at least organ failure at day 7 or mortality by day 28.

When compared as a whole, the treatment group did not demonstrate improvement in the primary outcome. However, patients with Acute Kidney Injury Network scores of 2 or 3 at enrollment who received bicarbonate had lower rates of the composite primary outcome (70% vs. 82%; P = .462). Additionally, 35% of the treatment group utilized a renal replacement therapy (RRT) during their ICU stay versus 52% of the control group (P = .0009).

Limitations of the study included unblinding of the ICU physicians and the lack of a control intravenous solution. Notably, 47 of the 194 patients in the control group received sodium bicarbonate as salvage therapy.

Bottom line: Sodium bicarbonate treatment may decrease the need for RRT in patients with significant metabolic acidemia and may decrease the likelihood of death or organ failure in those with severe acute kidney injury.

Citation: Jaber S et al. Sodium bicarbonate therapy for patients with severe metabolic acidaemia in the intensive care unit (BICAR-ICU): A multicentre, open-label, randomised controlled, phase 3 trial. Lancet. 2018;392(10141):31-40.

Dr. James is a hospitalist at Emory University Hospital Midtown and an assistant professor at Emory University, both in Atlanta

Clinical question: Does sodium bicarbonate treatment improve clinical outcomes in critically ill patients with severe metabolic acidosis?

Background: Severe acidemia is associated with impaired cardiac function, decreased perfusion, and increased mortality. Many physicians use sodium bicarbonate to improve hemodynamic stability in critically ill patients with acidemia. However, the use of sodium bicarbonate in this role remains controversial because the evidence to support it is limited.

Study design: Multicenter, open-label, randomized, controlled trial.

Setting: Twenty-six ICUs in France.

Synopsis: Investigators randomized 389 adult patients with severe acidemia and Sequential Organ Failure Assessment (SOFA) scores of 4 or greater or serum lactate level of 2 mmol/L or greater to receive either no sodium bicarbonate or 4.2% intravenous sodium bicarbonate. The primary composite outcome was at least organ failure at day 7 or mortality by day 28.

When compared as a whole, the treatment group did not demonstrate improvement in the primary outcome. However, patients with Acute Kidney Injury Network scores of 2 or 3 at enrollment who received bicarbonate had lower rates of the composite primary outcome (70% vs. 82%; P = .462). Additionally, 35% of the treatment group utilized a renal replacement therapy (RRT) during their ICU stay versus 52% of the control group (P = .0009).

Limitations of the study included unblinding of the ICU physicians and the lack of a control intravenous solution. Notably, 47 of the 194 patients in the control group received sodium bicarbonate as salvage therapy.

Bottom line: Sodium bicarbonate treatment may decrease the need for RRT in patients with significant metabolic acidemia and may decrease the likelihood of death or organ failure in those with severe acute kidney injury.

Citation: Jaber S et al. Sodium bicarbonate therapy for patients with severe metabolic acidaemia in the intensive care unit (BICAR-ICU): A multicentre, open-label, randomised controlled, phase 3 trial. Lancet. 2018;392(10141):31-40.

Dr. James is a hospitalist at Emory University Hospital Midtown and an assistant professor at Emory University, both in Atlanta