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Benefits, drawbacks when hospitalists expand roles
Hospitalists can’t ‘fill all the cracks’ in primary care
As vice chair of the hospital medicine service at Northwell Health, Nick Fitterman, MD, FACP, SFHM, oversees 16 HM groups at 15 hospitals in New York. He says the duties of his hospitalist staff, like those of most U.S. hospitalists, are similar to what they have traditionally been – clinical care on the wards, teaching, comanagement of surgery, quality improvement, committee work, and research. But he has noticed a trend of late: rapid expansion of the hospitalist’s role.
Speaking at an education session at HM18 in Orlando, Dr. Fitterman said the role of the hospitalist is growing to include tasks that might not be as common, but are becoming more familiar all the time: working at infusion centers, caring for patients in skilled nursing facilities, specializing in electronic health record use, colocating in psychiatric hospitals, even being deployed to natural disasters. His list went on, and it was much longer than the list of traditional hospitalist responsibilities.
“Where do we draw the line and say, ‘Wait a minute, our primary site is going to suffer if we continue to get spread this thin. Can we really do it all?” Dr. Fitterman said. As the number of hats hospitalists wear grows ever bigger, he said more thought must be placed into how expansion happens.
The preop clinic
Efren Manjarrez, MD, SFHM, former chief of hospital medicine at the University of Miami, told a cautionary tale about a preoperative clinic staffed by hospitalists that appeared to provide a financial benefit to a hospital – helping to avoid costly last-minute cancellations of surgeries – but that ultimately was shuttered. The hospital, he said, loses $8,000-$10,000 for each case that gets canceled on the same day.
“Think about that just for a minute,” Dr. Manjarrez said. “If 100 cases are canceled during the year at the last minute, that’s a lot of money.”
A preoperative clinic seemed like a worthwhile role for hospitalists – the program was started in Miami by the same doctor who initiated a similar program at Cleveland Clinic. “Surgical cases are what support the hospital [financially], and we’re here to help them along,” Dr. Manjarrez said. “The purpose of hospitalists is to make sure that patients are medically optimized.”
The preop program concept, used in U.S. medicine since the 1990s, was originally started by anesthesiologists, but they may not always be the best fit to staff such programs.
“Anesthesiologists do not manage all beta blockers,” Dr. Manjarrez said. “They don’t manage ACE inhibitors by mouth. They don’t manage all oral diabetes agents, and they sure as heck don’t manage pills that are anticoagulants. That’s the domain of internal medicine. And as patients have become more complex, that’s where hospitalists who [work in] preop clinics have stepped in.”
Studies have found that hospitalists staffing preop clinics have improved quality metrics and some clinical outcomes, including lowering cancellation rates and more appropriate use of beta blockers, he said.
In the Miami program described by Dr. Manjarrez, hospitalists in the preop clinic at first saw only patients who’d been financially cleared as able to pay. But ultimately, a tiered system was developed, and hospitalists saw only patients who were higher risk – those with COPD or stroke patients, for example – without regard to ability to pay.
“The hospital would have to make up any financial deficit at the very end,” Dr. Manjarrez said. This meant there were no longer efficient 5-minute encounters with patients. Instead, visits lasted about 45 minutes, so fewer patients were seen.
The program was successful, in that the same-day cancellation rate for surgeries dropped to less than 0.1% – fewer than 1 in 1,000 – with the preop clinic up and running, Dr. Manjarrez. Still, the hospital decided to end the program. “The hospital no longer wanted to reimburse us,” he said.
A takeaway from this experience for Dr. Manjarrez was that hospitalists need to do a better job of showing the financial benefits in their expanding roles, if they want them to endure.
“At the end of the day, hospitalists do provide value in preoperative clinics,” he said. “But unfortunately, we’re not doing a great job of publishing our data and showing our value.”
At-home care
At Brigham and Women’s Hospital in Boston, hospitalists have demonstrated good results with a program to provide care at home rather than in the hospital.
David Levine, MD, MPH, MA, clinician and investigator at Brigham and Women’s and an instructor in medicine at Harvard Medical School, said that the structure of inpatient care has generally not changed much over decades, despite advances in technology.
“We round on them once a day – if they’re lucky, twice,” he said. “The medicines have changed and imaging has changed, but we really haven’t changed the structure of how we take care of acutely ill adults for almost a hundred years.”
Hospitalizing patients brings unintended consequences. Twenty percent of older adults will become delirious during their stay, 1 out of 3 will lose a level of functional status in the hospital that they’ll never regain, and 1 out of 10 hospitalized patients will experience an adverse event, like an infection or a medication error.
Brigham and Women’s program of at-home care involves “admitting” patients to their homes after being treated in the emergency department. The goal is to reduce costs by 20%, while maintaining quality and safety and improving patients’ quality of life and experience.
Researchers are studying their results. They randomized patients, after the ED determined they required admission, either to admission to the hospital or to their home. The decision on whether to admit was made before the study investigators became involved with the patients, Dr. Levine said.
The program is also intended to improve access to hospitals. Brigham and Women’s is often over 100% capacity in the general medical ward.
Patients in the study needed to live within a 5-mile radius of either Brigham and Women’s Hospital, or Brigham and Women’s Faulkner Hospital, a nearby community hospital. A physician and a registered nurse form the core team; they assess patient needs and ratchet care either up or down, perhaps adding a home health aide or social worker.
The home care team takes advantage of technology: Portable equipment allows a basic metabolic panel to be performed on the spot – for example, a hemoglobin and hematocrit can be produced within 2 minutes. Also, portable ultrasounds and x-rays are used. Doctors keep a “tackle box” of urgent medications such as antibiotics and diuretics.
“We showed a direct cost reduction taking care of patients at home,” Dr. Levine said. There was also a reduction in utilization of care, and an increase in patient activity, with patients taking about 1,800 steps at home, compared with 180 in the hospital. There were no significant changes in safety, quality, or patient experience, he said.
Postdischarge clinics
Lauren Doctoroff, MD, FHM – a hospitalist at Beth Israel Deaconness Medical Center in Boston and assistant professor of medicine at Harvard Medical School – explained another hospitalist-staffed project meant to improve access to care: her center’s postdischarge clinic, which was started in 2009 but is no longer operating.
The clinic tackled the problem of what to do with patients when you discharge them, Dr. Doctoroff said, and its goal was to foster more cooperation between hospitalists and the faculty primary care practice, as well as to improve postdischarge access for patients from that practice.
A dedicated group of hospitalists staffed the clinics, handling medication reconciliation, symptom management, pending tests, and other services the patients were supposed to be getting after discharge, Dr. Doctoroff said.
“We greatly improved access so that when you came to see us you generally saw a hospitalist a week before you would have seen your primary care doctor,” she said. “And that was mostly because we created open access in a clinic that did not have open access. So if a doctor discharging a patient really thought that the patient needed to be seen after discharge, they would often see us.”
Hospitalists considering starting such a clinic have several key questions to consider, Dr. Doctoroff said.
“You need to focus on who the patient population is, the clinic structure, how you plan to staff the clinic, and what your outcomes are – mainly how you will measure performance,” she said.
Dr. Doctoroff said hospitalists are good for this role because “we’re very comfortable with patients who are complicated, and we are very adept at accessing information from the hospitalization. I think, as a hospitalist who spent 5 years seeing patients in a discharge clinic, it greatly enhances my understanding of patients and their challenges at discharge.”
The clinic was closed, she said, in part because it was largely an extension of primary care, and the patient volume wasn’t big enough to justify continuing it.
“Postdischarge clinics are, in a very narrow sense, a bit of a Band-Aid for a really dysfunctional primary care system,” Dr. Doctoroff said. “Ideally, if all you’re doing is providing a postdischarge physician visit, then you really want primary care to be able to do that in order to reengage with their patient. I think this is because postdischarge clinics are construed in a very narrow way to address the simple need to see a patient after discharge. And this may lead to the failure of these clinics, or make them easy to replace. Also, often what patients really need is more than just a physician visit, so a discharge clinic may need to be designed to provide an enhanced array of services.”
Dr. Fitterman said that these stories show that not all role expansion in hospital medicine is good role expansion. The experiences described by Dr. Manjarrez, Dr. Levine, and Dr. Doctoroff demonstrate the challenges hospitalists face as they attempt expansions into new roles, he said.
“We can’t be expected to fill all the cracks in primary care,” Dr. Fitterman said. “As a country we need to really prop up primary care. This all can’t come under the roof of hospital medicine. We need to be part of a patient-centered medical home – but we are not the patient-centered medical home.”
He said the experience with the preop clinic described by Dr. Manjarrez also shows the need for buy-in from hospital or health system administration.
“While most of us are employed by hospitals and want to help meet their needs, we have to be more cautious. We have to look, I think, with a more critical eye, for the value; it may not always be in the dollars coming back in,” he said. “It might be in cost avoidance, such as reducing readmissions, or reducing same-day cancellations in an OR. Unless the C-suite appreciates that value, such programs will be short-lived.”
Hospitalists can’t ‘fill all the cracks’ in primary care
Hospitalists can’t ‘fill all the cracks’ in primary care
As vice chair of the hospital medicine service at Northwell Health, Nick Fitterman, MD, FACP, SFHM, oversees 16 HM groups at 15 hospitals in New York. He says the duties of his hospitalist staff, like those of most U.S. hospitalists, are similar to what they have traditionally been – clinical care on the wards, teaching, comanagement of surgery, quality improvement, committee work, and research. But he has noticed a trend of late: rapid expansion of the hospitalist’s role.
Speaking at an education session at HM18 in Orlando, Dr. Fitterman said the role of the hospitalist is growing to include tasks that might not be as common, but are becoming more familiar all the time: working at infusion centers, caring for patients in skilled nursing facilities, specializing in electronic health record use, colocating in psychiatric hospitals, even being deployed to natural disasters. His list went on, and it was much longer than the list of traditional hospitalist responsibilities.
“Where do we draw the line and say, ‘Wait a minute, our primary site is going to suffer if we continue to get spread this thin. Can we really do it all?” Dr. Fitterman said. As the number of hats hospitalists wear grows ever bigger, he said more thought must be placed into how expansion happens.
The preop clinic
Efren Manjarrez, MD, SFHM, former chief of hospital medicine at the University of Miami, told a cautionary tale about a preoperative clinic staffed by hospitalists that appeared to provide a financial benefit to a hospital – helping to avoid costly last-minute cancellations of surgeries – but that ultimately was shuttered. The hospital, he said, loses $8,000-$10,000 for each case that gets canceled on the same day.
“Think about that just for a minute,” Dr. Manjarrez said. “If 100 cases are canceled during the year at the last minute, that’s a lot of money.”
A preoperative clinic seemed like a worthwhile role for hospitalists – the program was started in Miami by the same doctor who initiated a similar program at Cleveland Clinic. “Surgical cases are what support the hospital [financially], and we’re here to help them along,” Dr. Manjarrez said. “The purpose of hospitalists is to make sure that patients are medically optimized.”
The preop program concept, used in U.S. medicine since the 1990s, was originally started by anesthesiologists, but they may not always be the best fit to staff such programs.
“Anesthesiologists do not manage all beta blockers,” Dr. Manjarrez said. “They don’t manage ACE inhibitors by mouth. They don’t manage all oral diabetes agents, and they sure as heck don’t manage pills that are anticoagulants. That’s the domain of internal medicine. And as patients have become more complex, that’s where hospitalists who [work in] preop clinics have stepped in.”
Studies have found that hospitalists staffing preop clinics have improved quality metrics and some clinical outcomes, including lowering cancellation rates and more appropriate use of beta blockers, he said.
In the Miami program described by Dr. Manjarrez, hospitalists in the preop clinic at first saw only patients who’d been financially cleared as able to pay. But ultimately, a tiered system was developed, and hospitalists saw only patients who were higher risk – those with COPD or stroke patients, for example – without regard to ability to pay.
“The hospital would have to make up any financial deficit at the very end,” Dr. Manjarrez said. This meant there were no longer efficient 5-minute encounters with patients. Instead, visits lasted about 45 minutes, so fewer patients were seen.
The program was successful, in that the same-day cancellation rate for surgeries dropped to less than 0.1% – fewer than 1 in 1,000 – with the preop clinic up and running, Dr. Manjarrez. Still, the hospital decided to end the program. “The hospital no longer wanted to reimburse us,” he said.
A takeaway from this experience for Dr. Manjarrez was that hospitalists need to do a better job of showing the financial benefits in their expanding roles, if they want them to endure.
“At the end of the day, hospitalists do provide value in preoperative clinics,” he said. “But unfortunately, we’re not doing a great job of publishing our data and showing our value.”
At-home care
At Brigham and Women’s Hospital in Boston, hospitalists have demonstrated good results with a program to provide care at home rather than in the hospital.
David Levine, MD, MPH, MA, clinician and investigator at Brigham and Women’s and an instructor in medicine at Harvard Medical School, said that the structure of inpatient care has generally not changed much over decades, despite advances in technology.
“We round on them once a day – if they’re lucky, twice,” he said. “The medicines have changed and imaging has changed, but we really haven’t changed the structure of how we take care of acutely ill adults for almost a hundred years.”
Hospitalizing patients brings unintended consequences. Twenty percent of older adults will become delirious during their stay, 1 out of 3 will lose a level of functional status in the hospital that they’ll never regain, and 1 out of 10 hospitalized patients will experience an adverse event, like an infection or a medication error.
Brigham and Women’s program of at-home care involves “admitting” patients to their homes after being treated in the emergency department. The goal is to reduce costs by 20%, while maintaining quality and safety and improving patients’ quality of life and experience.
Researchers are studying their results. They randomized patients, after the ED determined they required admission, either to admission to the hospital or to their home. The decision on whether to admit was made before the study investigators became involved with the patients, Dr. Levine said.
The program is also intended to improve access to hospitals. Brigham and Women’s is often over 100% capacity in the general medical ward.
Patients in the study needed to live within a 5-mile radius of either Brigham and Women’s Hospital, or Brigham and Women’s Faulkner Hospital, a nearby community hospital. A physician and a registered nurse form the core team; they assess patient needs and ratchet care either up or down, perhaps adding a home health aide or social worker.
The home care team takes advantage of technology: Portable equipment allows a basic metabolic panel to be performed on the spot – for example, a hemoglobin and hematocrit can be produced within 2 minutes. Also, portable ultrasounds and x-rays are used. Doctors keep a “tackle box” of urgent medications such as antibiotics and diuretics.
“We showed a direct cost reduction taking care of patients at home,” Dr. Levine said. There was also a reduction in utilization of care, and an increase in patient activity, with patients taking about 1,800 steps at home, compared with 180 in the hospital. There were no significant changes in safety, quality, or patient experience, he said.
Postdischarge clinics
Lauren Doctoroff, MD, FHM – a hospitalist at Beth Israel Deaconness Medical Center in Boston and assistant professor of medicine at Harvard Medical School – explained another hospitalist-staffed project meant to improve access to care: her center’s postdischarge clinic, which was started in 2009 but is no longer operating.
The clinic tackled the problem of what to do with patients when you discharge them, Dr. Doctoroff said, and its goal was to foster more cooperation between hospitalists and the faculty primary care practice, as well as to improve postdischarge access for patients from that practice.
A dedicated group of hospitalists staffed the clinics, handling medication reconciliation, symptom management, pending tests, and other services the patients were supposed to be getting after discharge, Dr. Doctoroff said.
“We greatly improved access so that when you came to see us you generally saw a hospitalist a week before you would have seen your primary care doctor,” she said. “And that was mostly because we created open access in a clinic that did not have open access. So if a doctor discharging a patient really thought that the patient needed to be seen after discharge, they would often see us.”
Hospitalists considering starting such a clinic have several key questions to consider, Dr. Doctoroff said.
“You need to focus on who the patient population is, the clinic structure, how you plan to staff the clinic, and what your outcomes are – mainly how you will measure performance,” she said.
Dr. Doctoroff said hospitalists are good for this role because “we’re very comfortable with patients who are complicated, and we are very adept at accessing information from the hospitalization. I think, as a hospitalist who spent 5 years seeing patients in a discharge clinic, it greatly enhances my understanding of patients and their challenges at discharge.”
The clinic was closed, she said, in part because it was largely an extension of primary care, and the patient volume wasn’t big enough to justify continuing it.
“Postdischarge clinics are, in a very narrow sense, a bit of a Band-Aid for a really dysfunctional primary care system,” Dr. Doctoroff said. “Ideally, if all you’re doing is providing a postdischarge physician visit, then you really want primary care to be able to do that in order to reengage with their patient. I think this is because postdischarge clinics are construed in a very narrow way to address the simple need to see a patient after discharge. And this may lead to the failure of these clinics, or make them easy to replace. Also, often what patients really need is more than just a physician visit, so a discharge clinic may need to be designed to provide an enhanced array of services.”
Dr. Fitterman said that these stories show that not all role expansion in hospital medicine is good role expansion. The experiences described by Dr. Manjarrez, Dr. Levine, and Dr. Doctoroff demonstrate the challenges hospitalists face as they attempt expansions into new roles, he said.
“We can’t be expected to fill all the cracks in primary care,” Dr. Fitterman said. “As a country we need to really prop up primary care. This all can’t come under the roof of hospital medicine. We need to be part of a patient-centered medical home – but we are not the patient-centered medical home.”
He said the experience with the preop clinic described by Dr. Manjarrez also shows the need for buy-in from hospital or health system administration.
“While most of us are employed by hospitals and want to help meet their needs, we have to be more cautious. We have to look, I think, with a more critical eye, for the value; it may not always be in the dollars coming back in,” he said. “It might be in cost avoidance, such as reducing readmissions, or reducing same-day cancellations in an OR. Unless the C-suite appreciates that value, such programs will be short-lived.”
As vice chair of the hospital medicine service at Northwell Health, Nick Fitterman, MD, FACP, SFHM, oversees 16 HM groups at 15 hospitals in New York. He says the duties of his hospitalist staff, like those of most U.S. hospitalists, are similar to what they have traditionally been – clinical care on the wards, teaching, comanagement of surgery, quality improvement, committee work, and research. But he has noticed a trend of late: rapid expansion of the hospitalist’s role.
Speaking at an education session at HM18 in Orlando, Dr. Fitterman said the role of the hospitalist is growing to include tasks that might not be as common, but are becoming more familiar all the time: working at infusion centers, caring for patients in skilled nursing facilities, specializing in electronic health record use, colocating in psychiatric hospitals, even being deployed to natural disasters. His list went on, and it was much longer than the list of traditional hospitalist responsibilities.
“Where do we draw the line and say, ‘Wait a minute, our primary site is going to suffer if we continue to get spread this thin. Can we really do it all?” Dr. Fitterman said. As the number of hats hospitalists wear grows ever bigger, he said more thought must be placed into how expansion happens.
The preop clinic
Efren Manjarrez, MD, SFHM, former chief of hospital medicine at the University of Miami, told a cautionary tale about a preoperative clinic staffed by hospitalists that appeared to provide a financial benefit to a hospital – helping to avoid costly last-minute cancellations of surgeries – but that ultimately was shuttered. The hospital, he said, loses $8,000-$10,000 for each case that gets canceled on the same day.
“Think about that just for a minute,” Dr. Manjarrez said. “If 100 cases are canceled during the year at the last minute, that’s a lot of money.”
A preoperative clinic seemed like a worthwhile role for hospitalists – the program was started in Miami by the same doctor who initiated a similar program at Cleveland Clinic. “Surgical cases are what support the hospital [financially], and we’re here to help them along,” Dr. Manjarrez said. “The purpose of hospitalists is to make sure that patients are medically optimized.”
The preop program concept, used in U.S. medicine since the 1990s, was originally started by anesthesiologists, but they may not always be the best fit to staff such programs.
“Anesthesiologists do not manage all beta blockers,” Dr. Manjarrez said. “They don’t manage ACE inhibitors by mouth. They don’t manage all oral diabetes agents, and they sure as heck don’t manage pills that are anticoagulants. That’s the domain of internal medicine. And as patients have become more complex, that’s where hospitalists who [work in] preop clinics have stepped in.”
Studies have found that hospitalists staffing preop clinics have improved quality metrics and some clinical outcomes, including lowering cancellation rates and more appropriate use of beta blockers, he said.
In the Miami program described by Dr. Manjarrez, hospitalists in the preop clinic at first saw only patients who’d been financially cleared as able to pay. But ultimately, a tiered system was developed, and hospitalists saw only patients who were higher risk – those with COPD or stroke patients, for example – without regard to ability to pay.
“The hospital would have to make up any financial deficit at the very end,” Dr. Manjarrez said. This meant there were no longer efficient 5-minute encounters with patients. Instead, visits lasted about 45 minutes, so fewer patients were seen.
The program was successful, in that the same-day cancellation rate for surgeries dropped to less than 0.1% – fewer than 1 in 1,000 – with the preop clinic up and running, Dr. Manjarrez. Still, the hospital decided to end the program. “The hospital no longer wanted to reimburse us,” he said.
A takeaway from this experience for Dr. Manjarrez was that hospitalists need to do a better job of showing the financial benefits in their expanding roles, if they want them to endure.
“At the end of the day, hospitalists do provide value in preoperative clinics,” he said. “But unfortunately, we’re not doing a great job of publishing our data and showing our value.”
At-home care
At Brigham and Women’s Hospital in Boston, hospitalists have demonstrated good results with a program to provide care at home rather than in the hospital.
David Levine, MD, MPH, MA, clinician and investigator at Brigham and Women’s and an instructor in medicine at Harvard Medical School, said that the structure of inpatient care has generally not changed much over decades, despite advances in technology.
“We round on them once a day – if they’re lucky, twice,” he said. “The medicines have changed and imaging has changed, but we really haven’t changed the structure of how we take care of acutely ill adults for almost a hundred years.”
Hospitalizing patients brings unintended consequences. Twenty percent of older adults will become delirious during their stay, 1 out of 3 will lose a level of functional status in the hospital that they’ll never regain, and 1 out of 10 hospitalized patients will experience an adverse event, like an infection or a medication error.
Brigham and Women’s program of at-home care involves “admitting” patients to their homes after being treated in the emergency department. The goal is to reduce costs by 20%, while maintaining quality and safety and improving patients’ quality of life and experience.
Researchers are studying their results. They randomized patients, after the ED determined they required admission, either to admission to the hospital or to their home. The decision on whether to admit was made before the study investigators became involved with the patients, Dr. Levine said.
The program is also intended to improve access to hospitals. Brigham and Women’s is often over 100% capacity in the general medical ward.
Patients in the study needed to live within a 5-mile radius of either Brigham and Women’s Hospital, or Brigham and Women’s Faulkner Hospital, a nearby community hospital. A physician and a registered nurse form the core team; they assess patient needs and ratchet care either up or down, perhaps adding a home health aide or social worker.
The home care team takes advantage of technology: Portable equipment allows a basic metabolic panel to be performed on the spot – for example, a hemoglobin and hematocrit can be produced within 2 minutes. Also, portable ultrasounds and x-rays are used. Doctors keep a “tackle box” of urgent medications such as antibiotics and diuretics.
“We showed a direct cost reduction taking care of patients at home,” Dr. Levine said. There was also a reduction in utilization of care, and an increase in patient activity, with patients taking about 1,800 steps at home, compared with 180 in the hospital. There were no significant changes in safety, quality, or patient experience, he said.
Postdischarge clinics
Lauren Doctoroff, MD, FHM – a hospitalist at Beth Israel Deaconness Medical Center in Boston and assistant professor of medicine at Harvard Medical School – explained another hospitalist-staffed project meant to improve access to care: her center’s postdischarge clinic, which was started in 2009 but is no longer operating.
The clinic tackled the problem of what to do with patients when you discharge them, Dr. Doctoroff said, and its goal was to foster more cooperation between hospitalists and the faculty primary care practice, as well as to improve postdischarge access for patients from that practice.
A dedicated group of hospitalists staffed the clinics, handling medication reconciliation, symptom management, pending tests, and other services the patients were supposed to be getting after discharge, Dr. Doctoroff said.
“We greatly improved access so that when you came to see us you generally saw a hospitalist a week before you would have seen your primary care doctor,” she said. “And that was mostly because we created open access in a clinic that did not have open access. So if a doctor discharging a patient really thought that the patient needed to be seen after discharge, they would often see us.”
Hospitalists considering starting such a clinic have several key questions to consider, Dr. Doctoroff said.
“You need to focus on who the patient population is, the clinic structure, how you plan to staff the clinic, and what your outcomes are – mainly how you will measure performance,” she said.
Dr. Doctoroff said hospitalists are good for this role because “we’re very comfortable with patients who are complicated, and we are very adept at accessing information from the hospitalization. I think, as a hospitalist who spent 5 years seeing patients in a discharge clinic, it greatly enhances my understanding of patients and their challenges at discharge.”
The clinic was closed, she said, in part because it was largely an extension of primary care, and the patient volume wasn’t big enough to justify continuing it.
“Postdischarge clinics are, in a very narrow sense, a bit of a Band-Aid for a really dysfunctional primary care system,” Dr. Doctoroff said. “Ideally, if all you’re doing is providing a postdischarge physician visit, then you really want primary care to be able to do that in order to reengage with their patient. I think this is because postdischarge clinics are construed in a very narrow way to address the simple need to see a patient after discharge. And this may lead to the failure of these clinics, or make them easy to replace. Also, often what patients really need is more than just a physician visit, so a discharge clinic may need to be designed to provide an enhanced array of services.”
Dr. Fitterman said that these stories show that not all role expansion in hospital medicine is good role expansion. The experiences described by Dr. Manjarrez, Dr. Levine, and Dr. Doctoroff demonstrate the challenges hospitalists face as they attempt expansions into new roles, he said.
“We can’t be expected to fill all the cracks in primary care,” Dr. Fitterman said. “As a country we need to really prop up primary care. This all can’t come under the roof of hospital medicine. We need to be part of a patient-centered medical home – but we are not the patient-centered medical home.”
He said the experience with the preop clinic described by Dr. Manjarrez also shows the need for buy-in from hospital or health system administration.
“While most of us are employed by hospitals and want to help meet their needs, we have to be more cautious. We have to look, I think, with a more critical eye, for the value; it may not always be in the dollars coming back in,” he said. “It might be in cost avoidance, such as reducing readmissions, or reducing same-day cancellations in an OR. Unless the C-suite appreciates that value, such programs will be short-lived.”
Health care, technology, and the future
Major forces combining to reshape care delivery
What will be the role of humans in the future health system?
At first blush, this is a peculiar question. Health care is all about humans. How could one doubt their presence or role? It is working with and for people that attracted many to this profession.
On the cusp of a significant health system reformulation, it is the very question that hospitalists now must ponder. Just as ATMs replaced bank cashiers, online shopping replaced retail stores, and autonomous cars will soon replace drivers, the human landscape of health care is about to change. What pressures will force the changes?
On one hand, there is increasing demand. The Affordable Care Act opened the insurance door for people previously uncovered. Aging is delivering the baby boomer bubble into their sicker years. Hospitalists witness this phenomenon every day in the ballooning parade of patients they serve. At times, those pressures can overwhelm.
On the other hand, the political will to provide government subsidized health coverage is waning. Washington is tripping over itself to dismantle Obamacare with glancing concern for how it will inflate the ranks of the uninsured. Employers are eager to free themselves from the burden of providing increasingly expensive health coverage benefits. By removing the mandate to buy health care insurance, the current political health system architects are liberating the healthy paying population from their contributions to the overall insurance pool. Simply put, there is and will be less money and less of all that it buys.
Combine building demand with decreasing budget into a system that does not follow general market forces: You get that earthquake. A consumer can forgo that new phone in hard times but not that cardiac procedure. People will be caught in the fissures of the system. Waits, quality, burnout, morale problems, and financial losses will all trend in the wrong directions. The process will evolve in slow motion. Some might argue that we have already arrived.
Enter entrepreneurs, technologic advances, and a growing savvy and willingness to engage tech solutions to everyday problems. If Alexa can turn on your toaster, could it take your blood pressure? If a robot can vacuum your rug, could a different robot provide personal care services? And, if an algorithm can drive your car, could it similarly diagnose what ails you?
On Jan. 30, 2018, one of the greatest disrupters of all time, Amazon, announced that it is joining forces with Berkshire Hathaway and JPMorgan Chase to leap into health care. While they are initially experimenting with health care changes for their corporate employees, the ultimate marketwide goal is to apply technology to both reduce costs and improve patient care. Warren Buffet, Berkshire Hathaway’s founder, said in a statement, “The ballooning costs of health care act as a hungry tapeworm on the American economy.” (And yes, I imagine that many hospitalists would take umbrage with that characterization.) In addition to the Amazon alliance, CVS Health and Aetna also recently agreed to join forces.
The rising health care interest by Amazon begs the imagination. Technology already is far along in automating routine procedures, elevating patient safety protocols, and recalculating patient flows and information. This added corporate interest and investment will further expand new ideas and innovative technologies. And, for sure, it will challenge long held beliefs and practices that shape the health system we have today.
Hospitalist insight needed
What is the role of hospitalist leaders in this shifting equation? Hospitalists already can claim significant credit for introducing major changes in the landscape of hospital care in this country, with all the concomitant improvements in the efficiencies and quality of more integrated service delivery. Can you also guide the system in strategically selecting where and how technology can best be applied to automate and reconfigure service delivery?
The most important questions are: What is it that humans in health care uniquely do that cannot otherwise be accomplished? Are we able to hold onto the humane sides of health care, even as we seek to introduce cost-saving efficiencies?
Top of mind come the most personal sides of health service delivery: touch, empathy, understanding, and care itself. Next come human analysis, understanding, and translation. And beyond that, leadership, direction, and the vision to craft a health care system that meets our societal expectations – not just for the wealthy who cannot afford it – but for everyone.
It would be easy to dismiss this conversation. Society never decided whether those bank tellers, travel agents, or journalists were critical to our functioning. Along these same lines, you and your patients are more than mere algorithms.
As I often share in my leadership seminars, one key function of leaders is to identify and ask the right questions and to be at the decision-making table. What are those questions?
As a hospitalist leader, which part of your work and your activities could be eased by automation? Where might technology ease pressures and enhance your interactions with patients? How do we improve the efficiencies and effectiveness of health service delivery while we preserve the very human qualities that are fundamental to its values? No patient wants to speak to a physician who stares at a computer screen without eye contact, reassurance, or genuine interest. We can do better than that.
Business stakeholders in the system – and clearly, they are positioning and are powerful – will hold great sway on the contours of our future health care system. They could see humans – with all their costs, imperfections, and distractions – as replaceable.
Know that as you lead and pose your questions, there are people interested in listening. Certainly, the tech industry is looking for opportunities to generate broad market appeal. Similarly, health system decision makers looking to enhance how the system functions likewise seek guidance on what could – and could not – work. And who knows: Those decision makers could very well be you.
This is a conversation the country deserves. There is nothing more intimate, more personally important, and more professionally satisfying than the genuine person-to-person quality of what we do in health care. What we arrive at in the end should be achieved by intent, not by accident.
Dr. Marcus is coauthor of “Renegotiating Health Care: Resolving Conflict to Build Collaboration,” 2nd ed. (San Francisco: Jossey-Bass Publishers, 2011) and is director of the program for health care negotiation and conflict resolution, Harvard T.H. Chan School of Public Health, Boston. Dr. Marcus teaches regularly in the SHM Leadership Academy. He can be reached at [email protected].
Major forces combining to reshape care delivery
Major forces combining to reshape care delivery
What will be the role of humans in the future health system?
At first blush, this is a peculiar question. Health care is all about humans. How could one doubt their presence or role? It is working with and for people that attracted many to this profession.
On the cusp of a significant health system reformulation, it is the very question that hospitalists now must ponder. Just as ATMs replaced bank cashiers, online shopping replaced retail stores, and autonomous cars will soon replace drivers, the human landscape of health care is about to change. What pressures will force the changes?
On one hand, there is increasing demand. The Affordable Care Act opened the insurance door for people previously uncovered. Aging is delivering the baby boomer bubble into their sicker years. Hospitalists witness this phenomenon every day in the ballooning parade of patients they serve. At times, those pressures can overwhelm.
On the other hand, the political will to provide government subsidized health coverage is waning. Washington is tripping over itself to dismantle Obamacare with glancing concern for how it will inflate the ranks of the uninsured. Employers are eager to free themselves from the burden of providing increasingly expensive health coverage benefits. By removing the mandate to buy health care insurance, the current political health system architects are liberating the healthy paying population from their contributions to the overall insurance pool. Simply put, there is and will be less money and less of all that it buys.
Combine building demand with decreasing budget into a system that does not follow general market forces: You get that earthquake. A consumer can forgo that new phone in hard times but not that cardiac procedure. People will be caught in the fissures of the system. Waits, quality, burnout, morale problems, and financial losses will all trend in the wrong directions. The process will evolve in slow motion. Some might argue that we have already arrived.
Enter entrepreneurs, technologic advances, and a growing savvy and willingness to engage tech solutions to everyday problems. If Alexa can turn on your toaster, could it take your blood pressure? If a robot can vacuum your rug, could a different robot provide personal care services? And, if an algorithm can drive your car, could it similarly diagnose what ails you?
On Jan. 30, 2018, one of the greatest disrupters of all time, Amazon, announced that it is joining forces with Berkshire Hathaway and JPMorgan Chase to leap into health care. While they are initially experimenting with health care changes for their corporate employees, the ultimate marketwide goal is to apply technology to both reduce costs and improve patient care. Warren Buffet, Berkshire Hathaway’s founder, said in a statement, “The ballooning costs of health care act as a hungry tapeworm on the American economy.” (And yes, I imagine that many hospitalists would take umbrage with that characterization.) In addition to the Amazon alliance, CVS Health and Aetna also recently agreed to join forces.
The rising health care interest by Amazon begs the imagination. Technology already is far along in automating routine procedures, elevating patient safety protocols, and recalculating patient flows and information. This added corporate interest and investment will further expand new ideas and innovative technologies. And, for sure, it will challenge long held beliefs and practices that shape the health system we have today.
Hospitalist insight needed
What is the role of hospitalist leaders in this shifting equation? Hospitalists already can claim significant credit for introducing major changes in the landscape of hospital care in this country, with all the concomitant improvements in the efficiencies and quality of more integrated service delivery. Can you also guide the system in strategically selecting where and how technology can best be applied to automate and reconfigure service delivery?
The most important questions are: What is it that humans in health care uniquely do that cannot otherwise be accomplished? Are we able to hold onto the humane sides of health care, even as we seek to introduce cost-saving efficiencies?
Top of mind come the most personal sides of health service delivery: touch, empathy, understanding, and care itself. Next come human analysis, understanding, and translation. And beyond that, leadership, direction, and the vision to craft a health care system that meets our societal expectations – not just for the wealthy who cannot afford it – but for everyone.
It would be easy to dismiss this conversation. Society never decided whether those bank tellers, travel agents, or journalists were critical to our functioning. Along these same lines, you and your patients are more than mere algorithms.
As I often share in my leadership seminars, one key function of leaders is to identify and ask the right questions and to be at the decision-making table. What are those questions?
As a hospitalist leader, which part of your work and your activities could be eased by automation? Where might technology ease pressures and enhance your interactions with patients? How do we improve the efficiencies and effectiveness of health service delivery while we preserve the very human qualities that are fundamental to its values? No patient wants to speak to a physician who stares at a computer screen without eye contact, reassurance, or genuine interest. We can do better than that.
Business stakeholders in the system – and clearly, they are positioning and are powerful – will hold great sway on the contours of our future health care system. They could see humans – with all their costs, imperfections, and distractions – as replaceable.
Know that as you lead and pose your questions, there are people interested in listening. Certainly, the tech industry is looking for opportunities to generate broad market appeal. Similarly, health system decision makers looking to enhance how the system functions likewise seek guidance on what could – and could not – work. And who knows: Those decision makers could very well be you.
This is a conversation the country deserves. There is nothing more intimate, more personally important, and more professionally satisfying than the genuine person-to-person quality of what we do in health care. What we arrive at in the end should be achieved by intent, not by accident.
Dr. Marcus is coauthor of “Renegotiating Health Care: Resolving Conflict to Build Collaboration,” 2nd ed. (San Francisco: Jossey-Bass Publishers, 2011) and is director of the program for health care negotiation and conflict resolution, Harvard T.H. Chan School of Public Health, Boston. Dr. Marcus teaches regularly in the SHM Leadership Academy. He can be reached at [email protected].
What will be the role of humans in the future health system?
At first blush, this is a peculiar question. Health care is all about humans. How could one doubt their presence or role? It is working with and for people that attracted many to this profession.
On the cusp of a significant health system reformulation, it is the very question that hospitalists now must ponder. Just as ATMs replaced bank cashiers, online shopping replaced retail stores, and autonomous cars will soon replace drivers, the human landscape of health care is about to change. What pressures will force the changes?
On one hand, there is increasing demand. The Affordable Care Act opened the insurance door for people previously uncovered. Aging is delivering the baby boomer bubble into their sicker years. Hospitalists witness this phenomenon every day in the ballooning parade of patients they serve. At times, those pressures can overwhelm.
On the other hand, the political will to provide government subsidized health coverage is waning. Washington is tripping over itself to dismantle Obamacare with glancing concern for how it will inflate the ranks of the uninsured. Employers are eager to free themselves from the burden of providing increasingly expensive health coverage benefits. By removing the mandate to buy health care insurance, the current political health system architects are liberating the healthy paying population from their contributions to the overall insurance pool. Simply put, there is and will be less money and less of all that it buys.
Combine building demand with decreasing budget into a system that does not follow general market forces: You get that earthquake. A consumer can forgo that new phone in hard times but not that cardiac procedure. People will be caught in the fissures of the system. Waits, quality, burnout, morale problems, and financial losses will all trend in the wrong directions. The process will evolve in slow motion. Some might argue that we have already arrived.
Enter entrepreneurs, technologic advances, and a growing savvy and willingness to engage tech solutions to everyday problems. If Alexa can turn on your toaster, could it take your blood pressure? If a robot can vacuum your rug, could a different robot provide personal care services? And, if an algorithm can drive your car, could it similarly diagnose what ails you?
On Jan. 30, 2018, one of the greatest disrupters of all time, Amazon, announced that it is joining forces with Berkshire Hathaway and JPMorgan Chase to leap into health care. While they are initially experimenting with health care changes for their corporate employees, the ultimate marketwide goal is to apply technology to both reduce costs and improve patient care. Warren Buffet, Berkshire Hathaway’s founder, said in a statement, “The ballooning costs of health care act as a hungry tapeworm on the American economy.” (And yes, I imagine that many hospitalists would take umbrage with that characterization.) In addition to the Amazon alliance, CVS Health and Aetna also recently agreed to join forces.
The rising health care interest by Amazon begs the imagination. Technology already is far along in automating routine procedures, elevating patient safety protocols, and recalculating patient flows and information. This added corporate interest and investment will further expand new ideas and innovative technologies. And, for sure, it will challenge long held beliefs and practices that shape the health system we have today.
Hospitalist insight needed
What is the role of hospitalist leaders in this shifting equation? Hospitalists already can claim significant credit for introducing major changes in the landscape of hospital care in this country, with all the concomitant improvements in the efficiencies and quality of more integrated service delivery. Can you also guide the system in strategically selecting where and how technology can best be applied to automate and reconfigure service delivery?
The most important questions are: What is it that humans in health care uniquely do that cannot otherwise be accomplished? Are we able to hold onto the humane sides of health care, even as we seek to introduce cost-saving efficiencies?
Top of mind come the most personal sides of health service delivery: touch, empathy, understanding, and care itself. Next come human analysis, understanding, and translation. And beyond that, leadership, direction, and the vision to craft a health care system that meets our societal expectations – not just for the wealthy who cannot afford it – but for everyone.
It would be easy to dismiss this conversation. Society never decided whether those bank tellers, travel agents, or journalists were critical to our functioning. Along these same lines, you and your patients are more than mere algorithms.
As I often share in my leadership seminars, one key function of leaders is to identify and ask the right questions and to be at the decision-making table. What are those questions?
As a hospitalist leader, which part of your work and your activities could be eased by automation? Where might technology ease pressures and enhance your interactions with patients? How do we improve the efficiencies and effectiveness of health service delivery while we preserve the very human qualities that are fundamental to its values? No patient wants to speak to a physician who stares at a computer screen without eye contact, reassurance, or genuine interest. We can do better than that.
Business stakeholders in the system – and clearly, they are positioning and are powerful – will hold great sway on the contours of our future health care system. They could see humans – with all their costs, imperfections, and distractions – as replaceable.
Know that as you lead and pose your questions, there are people interested in listening. Certainly, the tech industry is looking for opportunities to generate broad market appeal. Similarly, health system decision makers looking to enhance how the system functions likewise seek guidance on what could – and could not – work. And who knows: Those decision makers could very well be you.
This is a conversation the country deserves. There is nothing more intimate, more personally important, and more professionally satisfying than the genuine person-to-person quality of what we do in health care. What we arrive at in the end should be achieved by intent, not by accident.
Dr. Marcus is coauthor of “Renegotiating Health Care: Resolving Conflict to Build Collaboration,” 2nd ed. (San Francisco: Jossey-Bass Publishers, 2011) and is director of the program for health care negotiation and conflict resolution, Harvard T.H. Chan School of Public Health, Boston. Dr. Marcus teaches regularly in the SHM Leadership Academy. He can be reached at [email protected].
‘You are what kind of doctor?’
Editor’s note: The Hospitalist is pleased to introduce a new recurring column: “The Legacies of Hospital Medicine.” This will be a recurring feature submitted by some of the best and brightest hospitalists in the field who have helped shape our specialty into what it is today. It will be a series of articles that will reflect on hospital medicine and it’s evolution over time from a variety of unique and innovative perspectives. We hope you enjoy this series, and we welcome any feedback as it evolves!
Hearkening back to my early time as a hospital-based physician, I recall the pleasure of waking every day and feeling like I belonged to an exclusive club. I felt passion for my work, along with a tiny cohort of similarly situated docs. We lacked a kinship with other medical organizations, however. We had no union of our own and were invisible upstarts.
And the question always came: “Tell me again ... you are what kind of doctor?”
The response changed every week. Ditto for my job responsibilities and charges. The memories are wonderful, though, and I have great affection for the early years.
Initially, I recall networking and attending national meetings – SGIM and ACP in particular – spreading the faith and talking up our bona fides. In addition to the registration fees, there came an earful of guff from irate physicians about the new breed of doctors, yet unnamed, who were destroying medicine. Likewise, I recall opinion columns from newspapers and peer-reviewed journals from a spate of “simple country docs.” The writing had a pretense of politeness but with a hint of disdain, predicting nothing less than the destruction of health care as we knew it. And to be standing next to them in conversation: “How dare you hospital docs exhale CO2!” We might as well have had “KICK ME” signs on our backs.
Inpatient medicine was upending the status quo – or so we believed – while also overturning a generations’ worth of dogma on how hospitals should do their business. Fate also played a role, and we could not have anticipated the arrival of health care consolidation, “To Err Is Human,” managed care, and payment reform – all of which upset practice conditions that had been in existence for decades. We walked a line between old and new, down a path whose purpose we felt but toward a destination we could not entirely envision.
That transformed with time.
Like most hospitalists, my ticket in began after some sleuthing and calls to Win Whitcomb, MD, and John Nelson, MD – still trusted friends today. They will make their marks in future columns, but as I am the inaugural contributor, let me be the first to state they both had a sixth sense steering our group of disciples. They became the obvious chiefs, along with Bob Wachter, MD, and took the lead in articulating what we aspired to be. Sounds saccharine now, but it did not then.
But lucky for us, hospital medicine took off. Our wise choices laid the groundwork for what is now a discipline in repose. “Hospitalist” no longer sounds like a neologism, and the term entered Merriam-Webster to seal our fate.
Twenty years out, hospital medicine still feels like a figurative case of Moore’s law. I cannot keep up with the strange faces at annual meetings and membership size, the throng of published articles (I used to pride myself on knowing all the hospitalist studies – no longer), and the lengthy list of initiatives and Society of Hospital Medicine resources on hand.
Without question, SHM has been the most rewarding part of my professional life. Hospital medicine mates sustain and keep me in good stead and have done so since training. Their insights teach me more than journals or any day on the job could impart and have given me a learning windfall for the cost of a song.
I initiated my hospitalist path as a 20-something tenderfoot, but from my interactions with colleagues both liberal and conservative, urban and rural, corporate and academic, and specialist and generalist, I developed into a seasoned craftsman.
Countless times I strode into an SHM activity thinking one way, and through the intellect and conviction of my peers, I got smart. Working in the same setting for most of my career, unchallenged, I could have assimilated a sclerotic worldview, but my hospital medicine colleagues would have none of that – kudos and thanks to them for it.
I could cite endless anecdotes – and they are swirling as I write. Crucial positions discussed and adopted, roads taken and those not, specialties angered and appeased, wonderful meals had, and on and on. They are and were the building blocks of a journey – and a joyful one.
As truly notable memories go, however, for me, there is only one.
By far, watching and absorbing the lessons of how an organization develops – goes from zero to sixty – has been a master class in enterprise and execution.
A PGY4 sees a president, CEO, board, ad hoc committees, staff, big budgets, and capital outlays make things happen and assumes it just is. But an operational charter with an instruction manual in-tow didn’t just drop from on high; that’s not how things go down. The right personnel selections, value choices (“SHM is a big tent” was not an accident), affiliate alliances, assessment of risks, and strategies pursued occurred for a reason; keen minds had the vision to set the board right.
The privilege of participating in the SHM project has been an education no grant or scholarship could equal. To say I had a tiny role in all of that is just reward.
Through SHM I have made lifelong friends, advanced my perspective and development as a healer, acquired a nifty board certification (one of 1,400 with a Focused Practice in Hospital Medicine), gained a mastership, and yes, met President Obama.
As odysseys go, how many docs can make such lofty claims?
Dr. Flansbaum works for Geisinger Health System in Danville, Pa., in both the divisions of hospital medicine and population health. He began working as a hospitalist in 1996 and is a founding member of the Society of Hospital Medicine.
Editor’s note: The Hospitalist is pleased to introduce a new recurring column: “The Legacies of Hospital Medicine.” This will be a recurring feature submitted by some of the best and brightest hospitalists in the field who have helped shape our specialty into what it is today. It will be a series of articles that will reflect on hospital medicine and it’s evolution over time from a variety of unique and innovative perspectives. We hope you enjoy this series, and we welcome any feedback as it evolves!
Hearkening back to my early time as a hospital-based physician, I recall the pleasure of waking every day and feeling like I belonged to an exclusive club. I felt passion for my work, along with a tiny cohort of similarly situated docs. We lacked a kinship with other medical organizations, however. We had no union of our own and were invisible upstarts.
And the question always came: “Tell me again ... you are what kind of doctor?”
The response changed every week. Ditto for my job responsibilities and charges. The memories are wonderful, though, and I have great affection for the early years.
Initially, I recall networking and attending national meetings – SGIM and ACP in particular – spreading the faith and talking up our bona fides. In addition to the registration fees, there came an earful of guff from irate physicians about the new breed of doctors, yet unnamed, who were destroying medicine. Likewise, I recall opinion columns from newspapers and peer-reviewed journals from a spate of “simple country docs.” The writing had a pretense of politeness but with a hint of disdain, predicting nothing less than the destruction of health care as we knew it. And to be standing next to them in conversation: “How dare you hospital docs exhale CO2!” We might as well have had “KICK ME” signs on our backs.
Inpatient medicine was upending the status quo – or so we believed – while also overturning a generations’ worth of dogma on how hospitals should do their business. Fate also played a role, and we could not have anticipated the arrival of health care consolidation, “To Err Is Human,” managed care, and payment reform – all of which upset practice conditions that had been in existence for decades. We walked a line between old and new, down a path whose purpose we felt but toward a destination we could not entirely envision.
That transformed with time.
Like most hospitalists, my ticket in began after some sleuthing and calls to Win Whitcomb, MD, and John Nelson, MD – still trusted friends today. They will make their marks in future columns, but as I am the inaugural contributor, let me be the first to state they both had a sixth sense steering our group of disciples. They became the obvious chiefs, along with Bob Wachter, MD, and took the lead in articulating what we aspired to be. Sounds saccharine now, but it did not then.
But lucky for us, hospital medicine took off. Our wise choices laid the groundwork for what is now a discipline in repose. “Hospitalist” no longer sounds like a neologism, and the term entered Merriam-Webster to seal our fate.
Twenty years out, hospital medicine still feels like a figurative case of Moore’s law. I cannot keep up with the strange faces at annual meetings and membership size, the throng of published articles (I used to pride myself on knowing all the hospitalist studies – no longer), and the lengthy list of initiatives and Society of Hospital Medicine resources on hand.
Without question, SHM has been the most rewarding part of my professional life. Hospital medicine mates sustain and keep me in good stead and have done so since training. Their insights teach me more than journals or any day on the job could impart and have given me a learning windfall for the cost of a song.
I initiated my hospitalist path as a 20-something tenderfoot, but from my interactions with colleagues both liberal and conservative, urban and rural, corporate and academic, and specialist and generalist, I developed into a seasoned craftsman.
Countless times I strode into an SHM activity thinking one way, and through the intellect and conviction of my peers, I got smart. Working in the same setting for most of my career, unchallenged, I could have assimilated a sclerotic worldview, but my hospital medicine colleagues would have none of that – kudos and thanks to them for it.
I could cite endless anecdotes – and they are swirling as I write. Crucial positions discussed and adopted, roads taken and those not, specialties angered and appeased, wonderful meals had, and on and on. They are and were the building blocks of a journey – and a joyful one.
As truly notable memories go, however, for me, there is only one.
By far, watching and absorbing the lessons of how an organization develops – goes from zero to sixty – has been a master class in enterprise and execution.
A PGY4 sees a president, CEO, board, ad hoc committees, staff, big budgets, and capital outlays make things happen and assumes it just is. But an operational charter with an instruction manual in-tow didn’t just drop from on high; that’s not how things go down. The right personnel selections, value choices (“SHM is a big tent” was not an accident), affiliate alliances, assessment of risks, and strategies pursued occurred for a reason; keen minds had the vision to set the board right.
The privilege of participating in the SHM project has been an education no grant or scholarship could equal. To say I had a tiny role in all of that is just reward.
Through SHM I have made lifelong friends, advanced my perspective and development as a healer, acquired a nifty board certification (one of 1,400 with a Focused Practice in Hospital Medicine), gained a mastership, and yes, met President Obama.
As odysseys go, how many docs can make such lofty claims?
Dr. Flansbaum works for Geisinger Health System in Danville, Pa., in both the divisions of hospital medicine and population health. He began working as a hospitalist in 1996 and is a founding member of the Society of Hospital Medicine.
Editor’s note: The Hospitalist is pleased to introduce a new recurring column: “The Legacies of Hospital Medicine.” This will be a recurring feature submitted by some of the best and brightest hospitalists in the field who have helped shape our specialty into what it is today. It will be a series of articles that will reflect on hospital medicine and it’s evolution over time from a variety of unique and innovative perspectives. We hope you enjoy this series, and we welcome any feedback as it evolves!
Hearkening back to my early time as a hospital-based physician, I recall the pleasure of waking every day and feeling like I belonged to an exclusive club. I felt passion for my work, along with a tiny cohort of similarly situated docs. We lacked a kinship with other medical organizations, however. We had no union of our own and were invisible upstarts.
And the question always came: “Tell me again ... you are what kind of doctor?”
The response changed every week. Ditto for my job responsibilities and charges. The memories are wonderful, though, and I have great affection for the early years.
Initially, I recall networking and attending national meetings – SGIM and ACP in particular – spreading the faith and talking up our bona fides. In addition to the registration fees, there came an earful of guff from irate physicians about the new breed of doctors, yet unnamed, who were destroying medicine. Likewise, I recall opinion columns from newspapers and peer-reviewed journals from a spate of “simple country docs.” The writing had a pretense of politeness but with a hint of disdain, predicting nothing less than the destruction of health care as we knew it. And to be standing next to them in conversation: “How dare you hospital docs exhale CO2!” We might as well have had “KICK ME” signs on our backs.
Inpatient medicine was upending the status quo – or so we believed – while also overturning a generations’ worth of dogma on how hospitals should do their business. Fate also played a role, and we could not have anticipated the arrival of health care consolidation, “To Err Is Human,” managed care, and payment reform – all of which upset practice conditions that had been in existence for decades. We walked a line between old and new, down a path whose purpose we felt but toward a destination we could not entirely envision.
That transformed with time.
Like most hospitalists, my ticket in began after some sleuthing and calls to Win Whitcomb, MD, and John Nelson, MD – still trusted friends today. They will make their marks in future columns, but as I am the inaugural contributor, let me be the first to state they both had a sixth sense steering our group of disciples. They became the obvious chiefs, along with Bob Wachter, MD, and took the lead in articulating what we aspired to be. Sounds saccharine now, but it did not then.
But lucky for us, hospital medicine took off. Our wise choices laid the groundwork for what is now a discipline in repose. “Hospitalist” no longer sounds like a neologism, and the term entered Merriam-Webster to seal our fate.
Twenty years out, hospital medicine still feels like a figurative case of Moore’s law. I cannot keep up with the strange faces at annual meetings and membership size, the throng of published articles (I used to pride myself on knowing all the hospitalist studies – no longer), and the lengthy list of initiatives and Society of Hospital Medicine resources on hand.
Without question, SHM has been the most rewarding part of my professional life. Hospital medicine mates sustain and keep me in good stead and have done so since training. Their insights teach me more than journals or any day on the job could impart and have given me a learning windfall for the cost of a song.
I initiated my hospitalist path as a 20-something tenderfoot, but from my interactions with colleagues both liberal and conservative, urban and rural, corporate and academic, and specialist and generalist, I developed into a seasoned craftsman.
Countless times I strode into an SHM activity thinking one way, and through the intellect and conviction of my peers, I got smart. Working in the same setting for most of my career, unchallenged, I could have assimilated a sclerotic worldview, but my hospital medicine colleagues would have none of that – kudos and thanks to them for it.
I could cite endless anecdotes – and they are swirling as I write. Crucial positions discussed and adopted, roads taken and those not, specialties angered and appeased, wonderful meals had, and on and on. They are and were the building blocks of a journey – and a joyful one.
As truly notable memories go, however, for me, there is only one.
By far, watching and absorbing the lessons of how an organization develops – goes from zero to sixty – has been a master class in enterprise and execution.
A PGY4 sees a president, CEO, board, ad hoc committees, staff, big budgets, and capital outlays make things happen and assumes it just is. But an operational charter with an instruction manual in-tow didn’t just drop from on high; that’s not how things go down. The right personnel selections, value choices (“SHM is a big tent” was not an accident), affiliate alliances, assessment of risks, and strategies pursued occurred for a reason; keen minds had the vision to set the board right.
The privilege of participating in the SHM project has been an education no grant or scholarship could equal. To say I had a tiny role in all of that is just reward.
Through SHM I have made lifelong friends, advanced my perspective and development as a healer, acquired a nifty board certification (one of 1,400 with a Focused Practice in Hospital Medicine), gained a mastership, and yes, met President Obama.
As odysseys go, how many docs can make such lofty claims?
Dr. Flansbaum works for Geisinger Health System in Danville, Pa., in both the divisions of hospital medicine and population health. He began working as a hospitalist in 1996 and is a founding member of the Society of Hospital Medicine.
Physician learning must evolve as industry transforms
Editor’s Note: This column was provided by the Doctors Company, the exclusively endorsed medical malpractice carrier for the Society of Hospital Medicine. Neither SHM nor Frontline Medical Communications was involved in its production.
In medical school, students are trained on skills that will make them better future physicians, team members, and care givers. It’s a curious thing: Once we make headway into our medical careers and our days are filled with patient visits and paperwork, we rarely have the opportunity to assess our skill sets in the same way, despite the fact that new technologies and approaches to treatment have emerged since many of us attended medical school.
That’s why I was so excited when I had the chance to participate in three standardized patient encounters training scenarios designed for me and my 22 hospitalist colleagues to improve our communication skills; this training was funded by a grant from the Doctors Company Foundation. A standardized patient encounter is essentially a live simulation in a clinical setting with trained actors.
To start the simulation, a physician is given a short prompt about the patient scenario. They may also be provided with some basic information, such as a diagnosis or a relevant imaging study, prior to entering the room. Once the testing center provides a signal, physicians are allowed to enter the room. An introduction of our role on the medical team is provided, and a discussion ensues. The actors provide relevant history, incorporate true emotional response to questioning, and display any behavioral or physical prompts that a real patient would. This allows physicians to react in real time to the needs of the patient. The use of standardized patients can also be adapted to desired testing scenarios, which might deal with issues like communication, clinical reasoning, or establishing a differential diagnosis.
Like many hospitals, we have a program in place aimed at assessing how we educate students and younger physicians. But Mount Sinai is the first hospital in New York that has established a program designed specifically to assess and address some of the unique communication challenges we face as hospitalists to improve patient care.
As hospitalists, we’ve never met patients or families before beginning conversations at critical points of care. It takes sensitivity and particular thoughtfulness to create rapport and share substantial information with a patient even without having a prior relationship.
During the training, my colleagues and I each encountered three different standardized patients in key scenarios: one at daily rounds, one upset over a missed diagnosis, and one at discharge, when the potential for errors and miscommunication is greatest. We were videotaped during the encounters for our personal review, and we received direct feedback afterward from the patient.
We discovered that we as physicians have become great at taking care of patients, but we also discovered that we don’t have enough opportunities to investigate which elements of our day-to-day communication need adjustment – or what good behaviors need reinforcing.
It was extremely helpful to be able to watch the videos and ask ourselves, “Do I use medical jargon that’s hard for the patient to understand? Do I say things that aren’t warm and welcoming to the patient?” Then, by adding in patient feedback, we learned how we performed across core domains, such as treating patients with courtesy and respect, using listening skills, and explaining complex topics in an understandable way.
Strengthening these individual communication skills is paramount to improving patient comprehension, which in turn can improve patient follow-though on discharge instructions and reduce risk of readmission. And as educators, our takeaways from the training can empower others in the health care system at large to better communicate with their patients.
Mount Sinai is proud to spearhead this innovative training effort in New York. In fact, since the initial date of the training, the three modules have expanded into a program run by the Morchand Center for Clinical Competence at the Icahn School of Medicine at Mount Sinai. So far, the Morchand Center has adapted the standardized patient methodology used for hospitalists to train 1,845 additional residents in various specialties across New York.
Nationwide, the entire medical community stands to benefit from continuous physician learning and the partnerships that facilitate it, such as the Doctors Company, which make trainings like this possible. At a time of tremendous change for health care, having a well-trained physician workforce is more important than ever before. Our patients deserve to be cared for by physicians whose knowledge evolves alongside the transformation of care delivery.
Physician learning must keep pace with our industry’s transformation. By setting the bar higher for what patients should expect on a patient communication level, we increase patient safety, raise levels of patient satisfaction, and drive quality care – no matter what the future of health care delivery looks like.
Dr. Barna is an associate residency program director for inpatient medicine in the Division of Hospital Medicine/Samuel Bronfman Department of Medicine in the Icahn School of Medicine at Mount Sinai, New York.
Editor’s Note: This column was provided by the Doctors Company, the exclusively endorsed medical malpractice carrier for the Society of Hospital Medicine. Neither SHM nor Frontline Medical Communications was involved in its production.
In medical school, students are trained on skills that will make them better future physicians, team members, and care givers. It’s a curious thing: Once we make headway into our medical careers and our days are filled with patient visits and paperwork, we rarely have the opportunity to assess our skill sets in the same way, despite the fact that new technologies and approaches to treatment have emerged since many of us attended medical school.
That’s why I was so excited when I had the chance to participate in three standardized patient encounters training scenarios designed for me and my 22 hospitalist colleagues to improve our communication skills; this training was funded by a grant from the Doctors Company Foundation. A standardized patient encounter is essentially a live simulation in a clinical setting with trained actors.
To start the simulation, a physician is given a short prompt about the patient scenario. They may also be provided with some basic information, such as a diagnosis or a relevant imaging study, prior to entering the room. Once the testing center provides a signal, physicians are allowed to enter the room. An introduction of our role on the medical team is provided, and a discussion ensues. The actors provide relevant history, incorporate true emotional response to questioning, and display any behavioral or physical prompts that a real patient would. This allows physicians to react in real time to the needs of the patient. The use of standardized patients can also be adapted to desired testing scenarios, which might deal with issues like communication, clinical reasoning, or establishing a differential diagnosis.
Like many hospitals, we have a program in place aimed at assessing how we educate students and younger physicians. But Mount Sinai is the first hospital in New York that has established a program designed specifically to assess and address some of the unique communication challenges we face as hospitalists to improve patient care.
As hospitalists, we’ve never met patients or families before beginning conversations at critical points of care. It takes sensitivity and particular thoughtfulness to create rapport and share substantial information with a patient even without having a prior relationship.
During the training, my colleagues and I each encountered three different standardized patients in key scenarios: one at daily rounds, one upset over a missed diagnosis, and one at discharge, when the potential for errors and miscommunication is greatest. We were videotaped during the encounters for our personal review, and we received direct feedback afterward from the patient.
We discovered that we as physicians have become great at taking care of patients, but we also discovered that we don’t have enough opportunities to investigate which elements of our day-to-day communication need adjustment – or what good behaviors need reinforcing.
It was extremely helpful to be able to watch the videos and ask ourselves, “Do I use medical jargon that’s hard for the patient to understand? Do I say things that aren’t warm and welcoming to the patient?” Then, by adding in patient feedback, we learned how we performed across core domains, such as treating patients with courtesy and respect, using listening skills, and explaining complex topics in an understandable way.
Strengthening these individual communication skills is paramount to improving patient comprehension, which in turn can improve patient follow-though on discharge instructions and reduce risk of readmission. And as educators, our takeaways from the training can empower others in the health care system at large to better communicate with their patients.
Mount Sinai is proud to spearhead this innovative training effort in New York. In fact, since the initial date of the training, the three modules have expanded into a program run by the Morchand Center for Clinical Competence at the Icahn School of Medicine at Mount Sinai. So far, the Morchand Center has adapted the standardized patient methodology used for hospitalists to train 1,845 additional residents in various specialties across New York.
Nationwide, the entire medical community stands to benefit from continuous physician learning and the partnerships that facilitate it, such as the Doctors Company, which make trainings like this possible. At a time of tremendous change for health care, having a well-trained physician workforce is more important than ever before. Our patients deserve to be cared for by physicians whose knowledge evolves alongside the transformation of care delivery.
Physician learning must keep pace with our industry’s transformation. By setting the bar higher for what patients should expect on a patient communication level, we increase patient safety, raise levels of patient satisfaction, and drive quality care – no matter what the future of health care delivery looks like.
Dr. Barna is an associate residency program director for inpatient medicine in the Division of Hospital Medicine/Samuel Bronfman Department of Medicine in the Icahn School of Medicine at Mount Sinai, New York.
Editor’s Note: This column was provided by the Doctors Company, the exclusively endorsed medical malpractice carrier for the Society of Hospital Medicine. Neither SHM nor Frontline Medical Communications was involved in its production.
In medical school, students are trained on skills that will make them better future physicians, team members, and care givers. It’s a curious thing: Once we make headway into our medical careers and our days are filled with patient visits and paperwork, we rarely have the opportunity to assess our skill sets in the same way, despite the fact that new technologies and approaches to treatment have emerged since many of us attended medical school.
That’s why I was so excited when I had the chance to participate in three standardized patient encounters training scenarios designed for me and my 22 hospitalist colleagues to improve our communication skills; this training was funded by a grant from the Doctors Company Foundation. A standardized patient encounter is essentially a live simulation in a clinical setting with trained actors.
To start the simulation, a physician is given a short prompt about the patient scenario. They may also be provided with some basic information, such as a diagnosis or a relevant imaging study, prior to entering the room. Once the testing center provides a signal, physicians are allowed to enter the room. An introduction of our role on the medical team is provided, and a discussion ensues. The actors provide relevant history, incorporate true emotional response to questioning, and display any behavioral or physical prompts that a real patient would. This allows physicians to react in real time to the needs of the patient. The use of standardized patients can also be adapted to desired testing scenarios, which might deal with issues like communication, clinical reasoning, or establishing a differential diagnosis.
Like many hospitals, we have a program in place aimed at assessing how we educate students and younger physicians. But Mount Sinai is the first hospital in New York that has established a program designed specifically to assess and address some of the unique communication challenges we face as hospitalists to improve patient care.
As hospitalists, we’ve never met patients or families before beginning conversations at critical points of care. It takes sensitivity and particular thoughtfulness to create rapport and share substantial information with a patient even without having a prior relationship.
During the training, my colleagues and I each encountered three different standardized patients in key scenarios: one at daily rounds, one upset over a missed diagnosis, and one at discharge, when the potential for errors and miscommunication is greatest. We were videotaped during the encounters for our personal review, and we received direct feedback afterward from the patient.
We discovered that we as physicians have become great at taking care of patients, but we also discovered that we don’t have enough opportunities to investigate which elements of our day-to-day communication need adjustment – or what good behaviors need reinforcing.
It was extremely helpful to be able to watch the videos and ask ourselves, “Do I use medical jargon that’s hard for the patient to understand? Do I say things that aren’t warm and welcoming to the patient?” Then, by adding in patient feedback, we learned how we performed across core domains, such as treating patients with courtesy and respect, using listening skills, and explaining complex topics in an understandable way.
Strengthening these individual communication skills is paramount to improving patient comprehension, which in turn can improve patient follow-though on discharge instructions and reduce risk of readmission. And as educators, our takeaways from the training can empower others in the health care system at large to better communicate with their patients.
Mount Sinai is proud to spearhead this innovative training effort in New York. In fact, since the initial date of the training, the three modules have expanded into a program run by the Morchand Center for Clinical Competence at the Icahn School of Medicine at Mount Sinai. So far, the Morchand Center has adapted the standardized patient methodology used for hospitalists to train 1,845 additional residents in various specialties across New York.
Nationwide, the entire medical community stands to benefit from continuous physician learning and the partnerships that facilitate it, such as the Doctors Company, which make trainings like this possible. At a time of tremendous change for health care, having a well-trained physician workforce is more important than ever before. Our patients deserve to be cared for by physicians whose knowledge evolves alongside the transformation of care delivery.
Physician learning must keep pace with our industry’s transformation. By setting the bar higher for what patients should expect on a patient communication level, we increase patient safety, raise levels of patient satisfaction, and drive quality care – no matter what the future of health care delivery looks like.
Dr. Barna is an associate residency program director for inpatient medicine in the Division of Hospital Medicine/Samuel Bronfman Department of Medicine in the Icahn School of Medicine at Mount Sinai, New York.
Do hospitalists improve inpatient outcomes?
Long continues the debate on what impact hospitalists have on inpatient outcomes. This issue has been playing out in the medical literature for 20 years, since the coining of the term in 1997. In a recent iteration of the debate, a study was published in JAMA Internal Medicine entitled “Comparison of Hospital Resource Use and Outcomes Among Hospitalists, Primary Care Physicians, and Other Generalists.”
The study retrospectively evaluated health care resources and outcomes from over a half-million Medicare beneficiaries hospitalized in 2013 for 20 common diagnosis-related groups, by type of physician provider (hospitalist, their primary care physician, or other generalist). The study found that nonhospitalists used more consultations and had longer lengths of stays, compared with hospitalists. In addition, relative to hospitalists, PCPs were more likely to discharge patients to home, had similar readmission rates, and lower 30-day mortality rates, but generalists were less likely to discharge patients home, had higher readmission rates, and higher mortality rates.
As hospitalists, we need to understand and acknowledge that most of our patients are “brand new” to us, and it is paramount that we use all available resources to gain a deep understanding of the patient in as short a time as possible. For example, ensuring all medical records available are reviewed, at least as much as possible, including a medical list (including a medication reconciliation). Interviewing family members or caregivers is also obviously a “best practice.” As well, having the insight of the PCP in these patients’ care is unquestionably good for us, for the PCP, and for the patient.
With good communication processes and an eye for excellence in care transitions, hospitalists can and should achieve the best outcomes for all of their patients. I look forward to more research in this arena, including a better understanding of the mechanisms by which we can all reliably produce excellent outcomes for the patients we serve.
Read the full post at hospitalleader.org.
Also on The Hospital Leader …
• Locums vs. F/T Hospitalists: Do Temps Stack Up? by Brad Flansbaum, DO, MPH, MHM
• Rounds: Are We Spinning Our Wheels? by Vineet Arora, MD, MPP, MHM
• Up Your Game in APP Integration by Tracy Cardin, ACNP-BC, SFHM
Long continues the debate on what impact hospitalists have on inpatient outcomes. This issue has been playing out in the medical literature for 20 years, since the coining of the term in 1997. In a recent iteration of the debate, a study was published in JAMA Internal Medicine entitled “Comparison of Hospital Resource Use and Outcomes Among Hospitalists, Primary Care Physicians, and Other Generalists.”
The study retrospectively evaluated health care resources and outcomes from over a half-million Medicare beneficiaries hospitalized in 2013 for 20 common diagnosis-related groups, by type of physician provider (hospitalist, their primary care physician, or other generalist). The study found that nonhospitalists used more consultations and had longer lengths of stays, compared with hospitalists. In addition, relative to hospitalists, PCPs were more likely to discharge patients to home, had similar readmission rates, and lower 30-day mortality rates, but generalists were less likely to discharge patients home, had higher readmission rates, and higher mortality rates.
As hospitalists, we need to understand and acknowledge that most of our patients are “brand new” to us, and it is paramount that we use all available resources to gain a deep understanding of the patient in as short a time as possible. For example, ensuring all medical records available are reviewed, at least as much as possible, including a medical list (including a medication reconciliation). Interviewing family members or caregivers is also obviously a “best practice.” As well, having the insight of the PCP in these patients’ care is unquestionably good for us, for the PCP, and for the patient.
With good communication processes and an eye for excellence in care transitions, hospitalists can and should achieve the best outcomes for all of their patients. I look forward to more research in this arena, including a better understanding of the mechanisms by which we can all reliably produce excellent outcomes for the patients we serve.
Read the full post at hospitalleader.org.
Also on The Hospital Leader …
• Locums vs. F/T Hospitalists: Do Temps Stack Up? by Brad Flansbaum, DO, MPH, MHM
• Rounds: Are We Spinning Our Wheels? by Vineet Arora, MD, MPP, MHM
• Up Your Game in APP Integration by Tracy Cardin, ACNP-BC, SFHM
Long continues the debate on what impact hospitalists have on inpatient outcomes. This issue has been playing out in the medical literature for 20 years, since the coining of the term in 1997. In a recent iteration of the debate, a study was published in JAMA Internal Medicine entitled “Comparison of Hospital Resource Use and Outcomes Among Hospitalists, Primary Care Physicians, and Other Generalists.”
The study retrospectively evaluated health care resources and outcomes from over a half-million Medicare beneficiaries hospitalized in 2013 for 20 common diagnosis-related groups, by type of physician provider (hospitalist, their primary care physician, or other generalist). The study found that nonhospitalists used more consultations and had longer lengths of stays, compared with hospitalists. In addition, relative to hospitalists, PCPs were more likely to discharge patients to home, had similar readmission rates, and lower 30-day mortality rates, but generalists were less likely to discharge patients home, had higher readmission rates, and higher mortality rates.
As hospitalists, we need to understand and acknowledge that most of our patients are “brand new” to us, and it is paramount that we use all available resources to gain a deep understanding of the patient in as short a time as possible. For example, ensuring all medical records available are reviewed, at least as much as possible, including a medical list (including a medication reconciliation). Interviewing family members or caregivers is also obviously a “best practice.” As well, having the insight of the PCP in these patients’ care is unquestionably good for us, for the PCP, and for the patient.
With good communication processes and an eye for excellence in care transitions, hospitalists can and should achieve the best outcomes for all of their patients. I look forward to more research in this arena, including a better understanding of the mechanisms by which we can all reliably produce excellent outcomes for the patients we serve.
Read the full post at hospitalleader.org.
Also on The Hospital Leader …
• Locums vs. F/T Hospitalists: Do Temps Stack Up? by Brad Flansbaum, DO, MPH, MHM
• Rounds: Are We Spinning Our Wheels? by Vineet Arora, MD, MPP, MHM
• Up Your Game in APP Integration by Tracy Cardin, ACNP-BC, SFHM
Video: SHM provides resources and community for practice administrators
ORLANDO – In a video interview, Ms. Tiffani Panek, SFHM, CLHM, who is the division manager of administration at the Johns Hopkins Bayview Medical Center, Baltimore, discussed the scope of SHM resources available for practice administrators.
She details how there are “an incredible number of resources for practice administrators that are available from SHM,” and she recommends the SHM website’s practice administrator’s page, with helpful links, including to their mentorship program. She describes how, just this year, “we are launching a podcast series called ‘The Leadership Launchpad Essentials.’ ”
In addition: “We [also] have our own HMX [Hospital Medicine Exchange] community, and I would say of any resource the practice administrator should access on a regular basis, that would be the one.” That’s the place that practice managers can go to network with their community, according to Ms. Panek.
ORLANDO – In a video interview, Ms. Tiffani Panek, SFHM, CLHM, who is the division manager of administration at the Johns Hopkins Bayview Medical Center, Baltimore, discussed the scope of SHM resources available for practice administrators.
She details how there are “an incredible number of resources for practice administrators that are available from SHM,” and she recommends the SHM website’s practice administrator’s page, with helpful links, including to their mentorship program. She describes how, just this year, “we are launching a podcast series called ‘The Leadership Launchpad Essentials.’ ”
In addition: “We [also] have our own HMX [Hospital Medicine Exchange] community, and I would say of any resource the practice administrator should access on a regular basis, that would be the one.” That’s the place that practice managers can go to network with their community, according to Ms. Panek.
ORLANDO – In a video interview, Ms. Tiffani Panek, SFHM, CLHM, who is the division manager of administration at the Johns Hopkins Bayview Medical Center, Baltimore, discussed the scope of SHM resources available for practice administrators.
She details how there are “an incredible number of resources for practice administrators that are available from SHM,” and she recommends the SHM website’s practice administrator’s page, with helpful links, including to their mentorship program. She describes how, just this year, “we are launching a podcast series called ‘The Leadership Launchpad Essentials.’ ”
In addition: “We [also] have our own HMX [Hospital Medicine Exchange] community, and I would say of any resource the practice administrator should access on a regular basis, that would be the one.” That’s the place that practice managers can go to network with their community, according to Ms. Panek.
REPORTING FROM HM18
Tackling gender disparities in hospital medicine
ORLANDO – If you think enough progress is being made to fix gender disparity in medical leadership, consider this observation made in an HM18 session on Tuesday by speaker Elizabeth Harry, MD, SFHM, assistant program director, internal medicine residency: director of wellness, Brigham and Women’s Hospital, Boston.*
“One might say, ‘Well, that’s okay, we’ll just let it even itself out. I mean, it’s getting better and we’re getting more women positions of leadership,’ ” she said. “But if we continue at the current rate that we are at, of women getting positions of leadership, we will get gender parity in leadership in 67 years – so the year 2085 ... I’m hoping that we as a group can say, ‘That’s a little too slow for our taste. We would like to accelerate this process a little bit.’ ”
The jarring number came near the start of the “Gender Disparities in Hospital Medicine: Where Do We Stand?” session, in which Dr. Harry explored the ways in which gender disparity manifests itself and coaxed ideas for improvement from the audience.
But that was just one of the jarring numbers. Even though women make up 78% of the health care workforce, only 14% of executive officers are women, Dr. Harry said.
And it’s not that large numbers of women joining the physician workforce is a relatively recent phenomenon. There is close to a 50/50 gender split in medical school applicants, students, and residents. But, after that, the parity falls away. Only 38% of medical school faculty members are women, only 21% of full professors are women, and only 16% of deans (Pediatr Res. 2015 Nov;78[5]:589-93).
“There’s definitely a leaky pipeline here,” Dr. Harry said.
She highlighted the ways in which gender disparity seems to be baked into medical education, research, and culture. One study found that women used professional titles 95% of the time when introducing men at internal medicine grand rounds, compared with 49% when men were introducing women (J Womens Health 2017 May;26[5]:413-9).
In hospital medicine, a 2015 study found that women make $14,000 a year less than men, and about $30,000 less in pediatrics. (J Hosp Med. 2015 Aug;10[8]:486-90).
Dr. Harry told the audience to think about the gender disparity problem in a structured way, similar to a design process, by defining the problem, thinking of ideas, developing prototypes to put those ideas into action, and testing them.
During this session, audience members made some suggestions to simplify some of life’s logistics: creating rooms in which physicians could nurse their babies, with a phone and a laptop to make use of the room more practical; building flexible schedules to allow for picking up children and running errands; and – Dr. Harry’s favorite – installing an Amazon locker at hospitals that would allow doctors to pick up packages and make returns.
One audience member asked why the tenor of the conversation seemed to involve an implicit acceptance that it was up to women to handle errands, wondering, “Why are we anchoring on to that?” Dr. Harry agreed that it is up to each household to decide how to divide those responsibilities, and that, personally, she and her husband divide them evenly.
“So what I want to encourage you to do is actually take one of these prototypes home and try it – and it’s not going to work the first time,” Dr. Harry said. “This is culture change, and culture change is really, really hard. That means it takes time and means you’ll have to knock on lots of doors to get to where you want to be eventually.”
Correction, 4/11/18: An earlier version of this article misstated Dr. Harry's position at Brigham and Women's.
ORLANDO – If you think enough progress is being made to fix gender disparity in medical leadership, consider this observation made in an HM18 session on Tuesday by speaker Elizabeth Harry, MD, SFHM, assistant program director, internal medicine residency: director of wellness, Brigham and Women’s Hospital, Boston.*
“One might say, ‘Well, that’s okay, we’ll just let it even itself out. I mean, it’s getting better and we’re getting more women positions of leadership,’ ” she said. “But if we continue at the current rate that we are at, of women getting positions of leadership, we will get gender parity in leadership in 67 years – so the year 2085 ... I’m hoping that we as a group can say, ‘That’s a little too slow for our taste. We would like to accelerate this process a little bit.’ ”
The jarring number came near the start of the “Gender Disparities in Hospital Medicine: Where Do We Stand?” session, in which Dr. Harry explored the ways in which gender disparity manifests itself and coaxed ideas for improvement from the audience.
But that was just one of the jarring numbers. Even though women make up 78% of the health care workforce, only 14% of executive officers are women, Dr. Harry said.
And it’s not that large numbers of women joining the physician workforce is a relatively recent phenomenon. There is close to a 50/50 gender split in medical school applicants, students, and residents. But, after that, the parity falls away. Only 38% of medical school faculty members are women, only 21% of full professors are women, and only 16% of deans (Pediatr Res. 2015 Nov;78[5]:589-93).
“There’s definitely a leaky pipeline here,” Dr. Harry said.
She highlighted the ways in which gender disparity seems to be baked into medical education, research, and culture. One study found that women used professional titles 95% of the time when introducing men at internal medicine grand rounds, compared with 49% when men were introducing women (J Womens Health 2017 May;26[5]:413-9).
In hospital medicine, a 2015 study found that women make $14,000 a year less than men, and about $30,000 less in pediatrics. (J Hosp Med. 2015 Aug;10[8]:486-90).
Dr. Harry told the audience to think about the gender disparity problem in a structured way, similar to a design process, by defining the problem, thinking of ideas, developing prototypes to put those ideas into action, and testing them.
During this session, audience members made some suggestions to simplify some of life’s logistics: creating rooms in which physicians could nurse their babies, with a phone and a laptop to make use of the room more practical; building flexible schedules to allow for picking up children and running errands; and – Dr. Harry’s favorite – installing an Amazon locker at hospitals that would allow doctors to pick up packages and make returns.
One audience member asked why the tenor of the conversation seemed to involve an implicit acceptance that it was up to women to handle errands, wondering, “Why are we anchoring on to that?” Dr. Harry agreed that it is up to each household to decide how to divide those responsibilities, and that, personally, she and her husband divide them evenly.
“So what I want to encourage you to do is actually take one of these prototypes home and try it – and it’s not going to work the first time,” Dr. Harry said. “This is culture change, and culture change is really, really hard. That means it takes time and means you’ll have to knock on lots of doors to get to where you want to be eventually.”
Correction, 4/11/18: An earlier version of this article misstated Dr. Harry's position at Brigham and Women's.
ORLANDO – If you think enough progress is being made to fix gender disparity in medical leadership, consider this observation made in an HM18 session on Tuesday by speaker Elizabeth Harry, MD, SFHM, assistant program director, internal medicine residency: director of wellness, Brigham and Women’s Hospital, Boston.*
“One might say, ‘Well, that’s okay, we’ll just let it even itself out. I mean, it’s getting better and we’re getting more women positions of leadership,’ ” she said. “But if we continue at the current rate that we are at, of women getting positions of leadership, we will get gender parity in leadership in 67 years – so the year 2085 ... I’m hoping that we as a group can say, ‘That’s a little too slow for our taste. We would like to accelerate this process a little bit.’ ”
The jarring number came near the start of the “Gender Disparities in Hospital Medicine: Where Do We Stand?” session, in which Dr. Harry explored the ways in which gender disparity manifests itself and coaxed ideas for improvement from the audience.
But that was just one of the jarring numbers. Even though women make up 78% of the health care workforce, only 14% of executive officers are women, Dr. Harry said.
And it’s not that large numbers of women joining the physician workforce is a relatively recent phenomenon. There is close to a 50/50 gender split in medical school applicants, students, and residents. But, after that, the parity falls away. Only 38% of medical school faculty members are women, only 21% of full professors are women, and only 16% of deans (Pediatr Res. 2015 Nov;78[5]:589-93).
“There’s definitely a leaky pipeline here,” Dr. Harry said.
She highlighted the ways in which gender disparity seems to be baked into medical education, research, and culture. One study found that women used professional titles 95% of the time when introducing men at internal medicine grand rounds, compared with 49% when men were introducing women (J Womens Health 2017 May;26[5]:413-9).
In hospital medicine, a 2015 study found that women make $14,000 a year less than men, and about $30,000 less in pediatrics. (J Hosp Med. 2015 Aug;10[8]:486-90).
Dr. Harry told the audience to think about the gender disparity problem in a structured way, similar to a design process, by defining the problem, thinking of ideas, developing prototypes to put those ideas into action, and testing them.
During this session, audience members made some suggestions to simplify some of life’s logistics: creating rooms in which physicians could nurse their babies, with a phone and a laptop to make use of the room more practical; building flexible schedules to allow for picking up children and running errands; and – Dr. Harry’s favorite – installing an Amazon locker at hospitals that would allow doctors to pick up packages and make returns.
One audience member asked why the tenor of the conversation seemed to involve an implicit acceptance that it was up to women to handle errands, wondering, “Why are we anchoring on to that?” Dr. Harry agreed that it is up to each household to decide how to divide those responsibilities, and that, personally, she and her husband divide them evenly.
“So what I want to encourage you to do is actually take one of these prototypes home and try it – and it’s not going to work the first time,” Dr. Harry said. “This is culture change, and culture change is really, really hard. That means it takes time and means you’ll have to knock on lots of doors to get to where you want to be eventually.”
Correction, 4/11/18: An earlier version of this article misstated Dr. Harry's position at Brigham and Women's.
REPORTING FROM HM18
RIV awards go to studies of interhospital transfers and ‘virtual hospitalists’
ORLANDO – The top award in the research arm of the Research, Innovations and Clinical Vignettes (RIV) competition, bestowed Monday night at HM18, went to investigators at Brigham and Women’s Hospital in Boston, who looked for trouble spots in interhospital transfers across more than 24,000 cases.
In the innovations category, also awarded Tuesday night, the top award went to clinicians and researchers at the University of Iowa in Iowa City, who attempted to use “virtual hospitalists” to improve local care at rural, critical-access hospitals.
The winning study in the research arm set out to pinpoint problems that could be attributed to process in cases of patients being transferred from one acute care facility to another, and was presented by Stephanie Mueller, MD, MPH, SFHM, associate physician in the hospital medicine unit at Brigham and Women’s.
Dr. Mueller and her colleagues looked at transfers to the hospital from 2005 to 2013. They analyzed the effects that three factors – day of the week, time of day, and admission team “busyness” on the day of the transfer – had on transfers to intensive care within 48 hours and on 30-day mortality. They looked at data for Monday through Thursday, compared with Friday through Sunday, at day, evening, and night transfers as well as the number of patient admissions and discharges to the admitting team on that day.
They found that nighttime arrival was linked with an increased chance of being transferred to the ICU and with 30-day mortality. They also found that weekday arrival was associated with lower odds of mortality among patients getting cardiothoracic and gastrointestinal surgery.
“I think that these are potential targets in which we can actually do something to mitigate the outcomes for these patients,” Dr. Mueller said. “I’m working on a number of studies related to this topic and so it’s sort of validating that this is an important topic and that I should continue doing what I’m doing.”
Raj Sehgal, MD, FHM, a judge in the research arm and associate professor at University of Texas, San Antonio, praised the relevance of the project.
“Interhospital transfer is a topic that a lot of hospitals are dealing with right now,” he said. “It’s always a group of patients that we worry about.”
“One of the strongest things about this poster was the strong methodology,” said another judge, Vineet Gupta, MD, FHM, assistant clinical professor at the University of California, San Diego. “The statistical analysis was really good, very strong, very robust.”
The innovations award–winning study, presented by Ethan Kuperman, MD, MSc, FHM, clinical assistant professor at the University of Iowa, involved an attempt to reduce transfers from the emergency departments of critical-access hospitals in rural Iowa to urban medical centers by providing care with “virtual hospitalists” using tablets.
“Our goal was to treat more patients locally, to keep those patients happy in their communities. That’s what patients get out of it,” Dr. Kuperman told judges. “The hospitals get to keep their family practice doctors doing primary care, stay open, and get more patients. Win, win, win.”
At the critical-access hospital pilot site, virtual hospitalists at the University of Iowa handled all inpatient and observation admissions, with the assistance of local advance practice professionals. The percentage of outside transfers from the emergency department over 64 weeks after implementation was 12.9%, a statistically significant drop from the 16.6% seen in a 24-week baseline period. This did not lead to another goal – a higher daily census at the hospital – though, because there was also a drop in ED visits that ended in a hospital admission.
At two other sites, where virtual hospitalists provided fewer services – at one site, they also helped with preoperative work – there was less of an impact, Dr. Kuperman said. He said he was encouraged that the mean time reported by virtual hospitalists for patient care and documentation was just 2.8 hours a day, but there were days when that hit 12 hours, so there could be a need for “surge” coverage.
He said he’s gratified that the award draws more attention to attempts to improve the care at rural hospitals and that he plans to continue to develop the program.
“Hopefully, this helps get the word out,” Dr. Kuperman said. “I think a lot of work still needs to be done.”
The awards capped a 2-hour competition in which judges went from poster to poster, hearing short presentations from researchers and asking rapid-fire questions. The decisions were difficult in both categories, the judges said. The judges in the innovations category, for instance, deliberated at a table outside the exhibit hall for about 20 minutes before coming to a decision.
The pool of 20 finalists – 10 in each category – were chosen from hundreds of submissions considered during the final two rounds of judging on Tuesday night. In the research category, 261 abstracts were accepted from the 319 submitted; in the innovations category, 140 were accepted from the 207 submitted.
ORLANDO – The top award in the research arm of the Research, Innovations and Clinical Vignettes (RIV) competition, bestowed Monday night at HM18, went to investigators at Brigham and Women’s Hospital in Boston, who looked for trouble spots in interhospital transfers across more than 24,000 cases.
In the innovations category, also awarded Tuesday night, the top award went to clinicians and researchers at the University of Iowa in Iowa City, who attempted to use “virtual hospitalists” to improve local care at rural, critical-access hospitals.
The winning study in the research arm set out to pinpoint problems that could be attributed to process in cases of patients being transferred from one acute care facility to another, and was presented by Stephanie Mueller, MD, MPH, SFHM, associate physician in the hospital medicine unit at Brigham and Women’s.
Dr. Mueller and her colleagues looked at transfers to the hospital from 2005 to 2013. They analyzed the effects that three factors – day of the week, time of day, and admission team “busyness” on the day of the transfer – had on transfers to intensive care within 48 hours and on 30-day mortality. They looked at data for Monday through Thursday, compared with Friday through Sunday, at day, evening, and night transfers as well as the number of patient admissions and discharges to the admitting team on that day.
They found that nighttime arrival was linked with an increased chance of being transferred to the ICU and with 30-day mortality. They also found that weekday arrival was associated with lower odds of mortality among patients getting cardiothoracic and gastrointestinal surgery.
“I think that these are potential targets in which we can actually do something to mitigate the outcomes for these patients,” Dr. Mueller said. “I’m working on a number of studies related to this topic and so it’s sort of validating that this is an important topic and that I should continue doing what I’m doing.”
Raj Sehgal, MD, FHM, a judge in the research arm and associate professor at University of Texas, San Antonio, praised the relevance of the project.
“Interhospital transfer is a topic that a lot of hospitals are dealing with right now,” he said. “It’s always a group of patients that we worry about.”
“One of the strongest things about this poster was the strong methodology,” said another judge, Vineet Gupta, MD, FHM, assistant clinical professor at the University of California, San Diego. “The statistical analysis was really good, very strong, very robust.”
The innovations award–winning study, presented by Ethan Kuperman, MD, MSc, FHM, clinical assistant professor at the University of Iowa, involved an attempt to reduce transfers from the emergency departments of critical-access hospitals in rural Iowa to urban medical centers by providing care with “virtual hospitalists” using tablets.
“Our goal was to treat more patients locally, to keep those patients happy in their communities. That’s what patients get out of it,” Dr. Kuperman told judges. “The hospitals get to keep their family practice doctors doing primary care, stay open, and get more patients. Win, win, win.”
At the critical-access hospital pilot site, virtual hospitalists at the University of Iowa handled all inpatient and observation admissions, with the assistance of local advance practice professionals. The percentage of outside transfers from the emergency department over 64 weeks after implementation was 12.9%, a statistically significant drop from the 16.6% seen in a 24-week baseline period. This did not lead to another goal – a higher daily census at the hospital – though, because there was also a drop in ED visits that ended in a hospital admission.
At two other sites, where virtual hospitalists provided fewer services – at one site, they also helped with preoperative work – there was less of an impact, Dr. Kuperman said. He said he was encouraged that the mean time reported by virtual hospitalists for patient care and documentation was just 2.8 hours a day, but there were days when that hit 12 hours, so there could be a need for “surge” coverage.
He said he’s gratified that the award draws more attention to attempts to improve the care at rural hospitals and that he plans to continue to develop the program.
“Hopefully, this helps get the word out,” Dr. Kuperman said. “I think a lot of work still needs to be done.”
The awards capped a 2-hour competition in which judges went from poster to poster, hearing short presentations from researchers and asking rapid-fire questions. The decisions were difficult in both categories, the judges said. The judges in the innovations category, for instance, deliberated at a table outside the exhibit hall for about 20 minutes before coming to a decision.
The pool of 20 finalists – 10 in each category – were chosen from hundreds of submissions considered during the final two rounds of judging on Tuesday night. In the research category, 261 abstracts were accepted from the 319 submitted; in the innovations category, 140 were accepted from the 207 submitted.
ORLANDO – The top award in the research arm of the Research, Innovations and Clinical Vignettes (RIV) competition, bestowed Monday night at HM18, went to investigators at Brigham and Women’s Hospital in Boston, who looked for trouble spots in interhospital transfers across more than 24,000 cases.
In the innovations category, also awarded Tuesday night, the top award went to clinicians and researchers at the University of Iowa in Iowa City, who attempted to use “virtual hospitalists” to improve local care at rural, critical-access hospitals.
The winning study in the research arm set out to pinpoint problems that could be attributed to process in cases of patients being transferred from one acute care facility to another, and was presented by Stephanie Mueller, MD, MPH, SFHM, associate physician in the hospital medicine unit at Brigham and Women’s.
Dr. Mueller and her colleagues looked at transfers to the hospital from 2005 to 2013. They analyzed the effects that three factors – day of the week, time of day, and admission team “busyness” on the day of the transfer – had on transfers to intensive care within 48 hours and on 30-day mortality. They looked at data for Monday through Thursday, compared with Friday through Sunday, at day, evening, and night transfers as well as the number of patient admissions and discharges to the admitting team on that day.
They found that nighttime arrival was linked with an increased chance of being transferred to the ICU and with 30-day mortality. They also found that weekday arrival was associated with lower odds of mortality among patients getting cardiothoracic and gastrointestinal surgery.
“I think that these are potential targets in which we can actually do something to mitigate the outcomes for these patients,” Dr. Mueller said. “I’m working on a number of studies related to this topic and so it’s sort of validating that this is an important topic and that I should continue doing what I’m doing.”
Raj Sehgal, MD, FHM, a judge in the research arm and associate professor at University of Texas, San Antonio, praised the relevance of the project.
“Interhospital transfer is a topic that a lot of hospitals are dealing with right now,” he said. “It’s always a group of patients that we worry about.”
“One of the strongest things about this poster was the strong methodology,” said another judge, Vineet Gupta, MD, FHM, assistant clinical professor at the University of California, San Diego. “The statistical analysis was really good, very strong, very robust.”
The innovations award–winning study, presented by Ethan Kuperman, MD, MSc, FHM, clinical assistant professor at the University of Iowa, involved an attempt to reduce transfers from the emergency departments of critical-access hospitals in rural Iowa to urban medical centers by providing care with “virtual hospitalists” using tablets.
“Our goal was to treat more patients locally, to keep those patients happy in their communities. That’s what patients get out of it,” Dr. Kuperman told judges. “The hospitals get to keep their family practice doctors doing primary care, stay open, and get more patients. Win, win, win.”
At the critical-access hospital pilot site, virtual hospitalists at the University of Iowa handled all inpatient and observation admissions, with the assistance of local advance practice professionals. The percentage of outside transfers from the emergency department over 64 weeks after implementation was 12.9%, a statistically significant drop from the 16.6% seen in a 24-week baseline period. This did not lead to another goal – a higher daily census at the hospital – though, because there was also a drop in ED visits that ended in a hospital admission.
At two other sites, where virtual hospitalists provided fewer services – at one site, they also helped with preoperative work – there was less of an impact, Dr. Kuperman said. He said he was encouraged that the mean time reported by virtual hospitalists for patient care and documentation was just 2.8 hours a day, but there were days when that hit 12 hours, so there could be a need for “surge” coverage.
He said he’s gratified that the award draws more attention to attempts to improve the care at rural hospitals and that he plans to continue to develop the program.
“Hopefully, this helps get the word out,” Dr. Kuperman said. “I think a lot of work still needs to be done.”
The awards capped a 2-hour competition in which judges went from poster to poster, hearing short presentations from researchers and asking rapid-fire questions. The decisions were difficult in both categories, the judges said. The judges in the innovations category, for instance, deliberated at a table outside the exhibit hall for about 20 minutes before coming to a decision.
The pool of 20 finalists – 10 in each category – were chosen from hundreds of submissions considered during the final two rounds of judging on Tuesday night. In the research category, 261 abstracts were accepted from the 319 submitted; in the innovations category, 140 were accepted from the 207 submitted.
REPORTING FROM HM18
Video: The SHM Physicians in Training Committee – increasing the hospitalist pipeline
ORLANDO – In a video interview, Brian Kwan, MD, SFHM, of the University of California, San Diego, discusses the role of the SHM Physicians in Training Committee in “increasing the hospitalist pipeline.”
In discussing the work of the committee, Dr. Kwan describes how “a lot of our initiatives really focus on the training and development and basically nurturing them from becoming students to residents to early-career hospitalists.”
Two of the key programs he discusses are the Student Scholarship Program and the “new-this-year” Resident Travel Grant, among other initiatives that the committee is exploring.
ORLANDO – In a video interview, Brian Kwan, MD, SFHM, of the University of California, San Diego, discusses the role of the SHM Physicians in Training Committee in “increasing the hospitalist pipeline.”
In discussing the work of the committee, Dr. Kwan describes how “a lot of our initiatives really focus on the training and development and basically nurturing them from becoming students to residents to early-career hospitalists.”
Two of the key programs he discusses are the Student Scholarship Program and the “new-this-year” Resident Travel Grant, among other initiatives that the committee is exploring.
ORLANDO – In a video interview, Brian Kwan, MD, SFHM, of the University of California, San Diego, discusses the role of the SHM Physicians in Training Committee in “increasing the hospitalist pipeline.”
In discussing the work of the committee, Dr. Kwan describes how “a lot of our initiatives really focus on the training and development and basically nurturing them from becoming students to residents to early-career hospitalists.”
Two of the key programs he discusses are the Student Scholarship Program and the “new-this-year” Resident Travel Grant, among other initiatives that the committee is exploring.
REPORTING FROM HOSPITAL MEDICINE 2018
Winners chosen at the SHM Clinical Vignettes competition
ORLANDO – Researchers presenting a case of starving ketoacidosis in a woman who was on a “Paleo” diet while breastfeeding won the Clinical Vignettes competition held Monday at HM18. The announcement capped a flurry of presenting and judging of posters on single cases that were captivating in both the stories they told and the lessons they taught.
The trainee award winner in the competition were presenters of a case of licorice-induced hypokalemia that, clinicians learned, was brought about by the drinking of an obscure kind of tea. The two others that made it into the final round of judging were on cases of syphilitic hepatitis and cardiac amyloidosis.
By chance, both of the winners highlighted dietary triggers, said Stephanie Sherman, MD, chair of the annual meeting’s clinical vignettes committee.
“The common themes in both of these were the importance of dietary history when interviewing patients,” Dr. Sherman said. “And then both had a beautiful review of the physiology that’s normal and how it gets broken in these situations.”
The Clinical Vignettes portion of the RIV competition, which also includes research and innovations categories, was separate this year because of space constraints, Dr. Sherman said.
Judges said they looked not only at how interesting and applicable each case was, but also the quality of the oral presentation and the poster’s visual appeal and clarity.
The ketoacidosis case, presented by Timothy Judson, MD, a resident at University of California, San Francisco, involved a 40-year-old woman who was previously healthy and had given birth 9 weeks earlier. Since the birth, the woman had been on a Paleo diet, a low-carbohydrate, ketogenic diet. She also was breastfeeding her newborn and continuing to breastfeed her 2-year-old son.
She presented with nonbilious, nonbloody emesis. On physical exam, she was found to be tachycardic, with diffuse tenderness of the abdomen. She was positive for ketones and had an elevated acetone level and elevated osmolar gap, the difference between the measured and calculated solutes in the serum.
Clinicians identified that low carbohydrate intake, high fat intake, and a high metabolic state, such as that brought on by breastfeeding, can contribute to ketoacidosis. She was treated with IV glucose-containing fluids, bicarbonate, fomepizole, and thiamine.
The case shows that patients should be warned about ketoacidosis risk when they start an ultra-low carbohydrate diet, especially if they are breastfeeding or lactating, Dr. Hudson said.
“Usually they’re safe, but they may not be if you’re in a high metabolic state,” he told judges.
“We take care of so many patients on a daily basis and we rarely get to tell their stories,” he said. “To be able to tell the story of the patients and give the learning points that we took away to others, I think is very rewarding.”
The winner of the trainee award, Maxwell Bressman, MD, a resident at Montefiore Medical Center in New York, presented the case of a 62-year-old woman with hypertension who had profound generalized weakness and an inability to walk.
“She actually came to the hospital because she couldn’t lift a cup of tea,” Dr. Bressman told judges.
Clinicians traced her problem to that very tea – a licorice-containing brew – after an ECG indicated hypokalemia. A breakdown product of licorice, glycyrrhizic acid, can prevent the breakdown of cortisol into cortisone, causing increased absorption of sodium in exchange for potassium, he explained.
“I really like interesting cases – it’s something I’ve thought about throughout medical school,” Dr. Bressman said. “It’s been incredibly fun. We have great cases at Montefiore. ... It’s taught me to think very broadly and with an expansive differential.”
ORLANDO – Researchers presenting a case of starving ketoacidosis in a woman who was on a “Paleo” diet while breastfeeding won the Clinical Vignettes competition held Monday at HM18. The announcement capped a flurry of presenting and judging of posters on single cases that were captivating in both the stories they told and the lessons they taught.
The trainee award winner in the competition were presenters of a case of licorice-induced hypokalemia that, clinicians learned, was brought about by the drinking of an obscure kind of tea. The two others that made it into the final round of judging were on cases of syphilitic hepatitis and cardiac amyloidosis.
By chance, both of the winners highlighted dietary triggers, said Stephanie Sherman, MD, chair of the annual meeting’s clinical vignettes committee.
“The common themes in both of these were the importance of dietary history when interviewing patients,” Dr. Sherman said. “And then both had a beautiful review of the physiology that’s normal and how it gets broken in these situations.”
The Clinical Vignettes portion of the RIV competition, which also includes research and innovations categories, was separate this year because of space constraints, Dr. Sherman said.
Judges said they looked not only at how interesting and applicable each case was, but also the quality of the oral presentation and the poster’s visual appeal and clarity.
The ketoacidosis case, presented by Timothy Judson, MD, a resident at University of California, San Francisco, involved a 40-year-old woman who was previously healthy and had given birth 9 weeks earlier. Since the birth, the woman had been on a Paleo diet, a low-carbohydrate, ketogenic diet. She also was breastfeeding her newborn and continuing to breastfeed her 2-year-old son.
She presented with nonbilious, nonbloody emesis. On physical exam, she was found to be tachycardic, with diffuse tenderness of the abdomen. She was positive for ketones and had an elevated acetone level and elevated osmolar gap, the difference between the measured and calculated solutes in the serum.
Clinicians identified that low carbohydrate intake, high fat intake, and a high metabolic state, such as that brought on by breastfeeding, can contribute to ketoacidosis. She was treated with IV glucose-containing fluids, bicarbonate, fomepizole, and thiamine.
The case shows that patients should be warned about ketoacidosis risk when they start an ultra-low carbohydrate diet, especially if they are breastfeeding or lactating, Dr. Hudson said.
“Usually they’re safe, but they may not be if you’re in a high metabolic state,” he told judges.
“We take care of so many patients on a daily basis and we rarely get to tell their stories,” he said. “To be able to tell the story of the patients and give the learning points that we took away to others, I think is very rewarding.”
The winner of the trainee award, Maxwell Bressman, MD, a resident at Montefiore Medical Center in New York, presented the case of a 62-year-old woman with hypertension who had profound generalized weakness and an inability to walk.
“She actually came to the hospital because she couldn’t lift a cup of tea,” Dr. Bressman told judges.
Clinicians traced her problem to that very tea – a licorice-containing brew – after an ECG indicated hypokalemia. A breakdown product of licorice, glycyrrhizic acid, can prevent the breakdown of cortisol into cortisone, causing increased absorption of sodium in exchange for potassium, he explained.
“I really like interesting cases – it’s something I’ve thought about throughout medical school,” Dr. Bressman said. “It’s been incredibly fun. We have great cases at Montefiore. ... It’s taught me to think very broadly and with an expansive differential.”
ORLANDO – Researchers presenting a case of starving ketoacidosis in a woman who was on a “Paleo” diet while breastfeeding won the Clinical Vignettes competition held Monday at HM18. The announcement capped a flurry of presenting and judging of posters on single cases that were captivating in both the stories they told and the lessons they taught.
The trainee award winner in the competition were presenters of a case of licorice-induced hypokalemia that, clinicians learned, was brought about by the drinking of an obscure kind of tea. The two others that made it into the final round of judging were on cases of syphilitic hepatitis and cardiac amyloidosis.
By chance, both of the winners highlighted dietary triggers, said Stephanie Sherman, MD, chair of the annual meeting’s clinical vignettes committee.
“The common themes in both of these were the importance of dietary history when interviewing patients,” Dr. Sherman said. “And then both had a beautiful review of the physiology that’s normal and how it gets broken in these situations.”
The Clinical Vignettes portion of the RIV competition, which also includes research and innovations categories, was separate this year because of space constraints, Dr. Sherman said.
Judges said they looked not only at how interesting and applicable each case was, but also the quality of the oral presentation and the poster’s visual appeal and clarity.
The ketoacidosis case, presented by Timothy Judson, MD, a resident at University of California, San Francisco, involved a 40-year-old woman who was previously healthy and had given birth 9 weeks earlier. Since the birth, the woman had been on a Paleo diet, a low-carbohydrate, ketogenic diet. She also was breastfeeding her newborn and continuing to breastfeed her 2-year-old son.
She presented with nonbilious, nonbloody emesis. On physical exam, she was found to be tachycardic, with diffuse tenderness of the abdomen. She was positive for ketones and had an elevated acetone level and elevated osmolar gap, the difference between the measured and calculated solutes in the serum.
Clinicians identified that low carbohydrate intake, high fat intake, and a high metabolic state, such as that brought on by breastfeeding, can contribute to ketoacidosis. She was treated with IV glucose-containing fluids, bicarbonate, fomepizole, and thiamine.
The case shows that patients should be warned about ketoacidosis risk when they start an ultra-low carbohydrate diet, especially if they are breastfeeding or lactating, Dr. Hudson said.
“Usually they’re safe, but they may not be if you’re in a high metabolic state,” he told judges.
“We take care of so many patients on a daily basis and we rarely get to tell their stories,” he said. “To be able to tell the story of the patients and give the learning points that we took away to others, I think is very rewarding.”
The winner of the trainee award, Maxwell Bressman, MD, a resident at Montefiore Medical Center in New York, presented the case of a 62-year-old woman with hypertension who had profound generalized weakness and an inability to walk.
“She actually came to the hospital because she couldn’t lift a cup of tea,” Dr. Bressman told judges.
Clinicians traced her problem to that very tea – a licorice-containing brew – after an ECG indicated hypokalemia. A breakdown product of licorice, glycyrrhizic acid, can prevent the breakdown of cortisol into cortisone, causing increased absorption of sodium in exchange for potassium, he explained.
“I really like interesting cases – it’s something I’ve thought about throughout medical school,” Dr. Bressman said. “It’s been incredibly fun. We have great cases at Montefiore. ... It’s taught me to think very broadly and with an expansive differential.”
REPORTING FROM HOSPITAL MEDICINE 2018