Andrea M. Sattinger

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The Constant and Familiar Face

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Editors’ note: “Alliances” is a series written about the relationships that hospitalists have with members of the clinical care team, from the team members’ points of view. It’s our hope that each installment of “Alliances” will provide valuable, revealing feedback that hospitalists can use to continually improve their intrateam relationships and, ultimately, patient care.

Nancy Perovic, RN, BSN, quality improvement and innovations coordinator with the hospitalist program at the University of Chicago Medical Center, says this quote from In Our Hands: How Hospital Leaders Can Build a Thriving Workforce is a statement she refers to often in her work and teaching: “Mutual respect between nurses and physicians for each other’s knowledge and competence, coupled with a mutual concern that quality patient care will be provided, are key organizational elements of work environments that attract and retain nurses.”1

In hospitals around the United States, in efforts to improve patient safety and in other initiatives including nurse recruitment and retention, one consistent element is optimizing communication among providers.2-4 Barbara Blakeney, MS, RN, president of the American Nurses Association, interviewed for the publication Web Morbidity and Mortality by its editor, hospitalist Robert Wachter, MD, says that when nurses are not properly supported in the work environment by other staff, and when there are not enough nurses, “it becomes a catch-22—the fewer nurses you have, the more difficult is the working environment, which leads to fewer nurses.”5

Blakeney recommends mutual training for physicians and nurses to improve patient care and safety focus on a number of key areas:

Understanding and appreciating each other’s skill sets and knowledge base;

Properly handing off patients and information; and

Nurturing “a culture in which safety is considered a problem-solving situation and not a punishment situation.”6

“Nurses comprise the surveillance system in hospitals for errors and adverse occurrences,” emphasizes Blakeney, and “the effectiveness of nurse surveillance is influenced by factors that include the quality of the work environment.”5

As essential members of hospital teams, hospitalists play a big role in nurses’ work environments, and mutual support between hospitalists and nurses affects patient care and outcomes, and physician and nurse job satisfaction.6,7 In general, nurses give hospitalists high marks for communication, nurse support, and teamwork.

“From a communication perspective, working with hospitalists makes patient care a lot safer because you don’t have to think of everything that you need to tell attending physicians when they are making their daily rounds,” says Scarlett Blue, RNC, MSN, administrative director, Hospitalist Services for FirstHealth of the Carolinas, Pinehurst, N.C. “With hospitalists you know you can do real-time communication, real-time information. That’s not saying you can’t do that with other physicians who are not in the hospital, but it certainly does make it a lot easier when they’re right here.”

Nurses report that compared with other physicians hospitalists are more accessible, more approachable, and more appreciative of the value of the nurse’s role.

Make Contact

One way that hospitalists support their nurse colleagues is by their ready availability to answer questions about patient care. Julie Koppel, RN, BSN, patient care manager on the General Medicine floor at the University of California at San Francisco Medical Center, has worked exclusively with the hospitalist model in her five years of nursing. She is complimentary about hospitalists’ communication skills and refers to them as “the constant and familiar face.” Koppel relates an instance where the attending hospitalist was already off service and yet she still paged him. “He got back to me promptly and still addressed the issues even though he wasn’t on service anymore and it was about something that had happened a month ago. I still feel hospitalists are available when they’re not even here.”

Many nurses don’t have a second thought about calling a hospitalist about a patient care issue, but may still be afraid of “bothering” the hospitalist when he or she is busy. Blue says her colleagues have worked with their nursing staff to overcome that reluctance. “Call them because if they’re talking with a family or if they’re in the middle of a physical exam or if it’s something where they can’t talk, they’re going to put the hold button on,” she tells her staff. “So when you hear the Muzak, the elevator music, then you know that you need to call them back. And it’s worked.”

It’s especially important, Blue says, that nurses surmount any reluctance they feel to initiate a call so that they will do so easily in urgent situations such as alerting rapid response teams and reporting medical errors.4 Blue believes the following anecdote illustrates the perspective of most hospitalists about this issue.

“We just started rapid response teams here,” she says, “And I heard one of the hospitalists say, ‘We’ve had five rapid response team calls so far and we were looking at whether or not the calls met the criteria and were appropriate.’ And one of the other hospitalists said, ‘You know, this really wasn’t a rapid response team call, but I want the nurses to feel free to call and I think that when we’re first starting out, we just want them to call. And then we can work on fine tuning it later. I don’t want to stifle them so they feel they cannot call.”

Heedful interrelating is based on true mutual respect, which is almost more important over agreement. And in heedless interrelating, only one view of the situation is considered correct. It represents your classic arrogant physician.

—Mark Williams, MD

Clear and to the Point

What are the best means to improve communication between hospitalists and nurses? Three major areas for attention include developing relationships, defining communication strategies, and packaging information for clarity.7

Blue often advises nurses to speak with clarity. “Probably the best thing from a hospitalist’s perspective is to be real clear about what you are asking or what it is that you need,” she says. “The clearer that you can be in your requests, the better off you’re going to be in the long run.”

But, Blue says “hospitalists have to understand that one of the greatest benefits from a nurse’s perspective about the hospitalist program is access, immediate access, and dealing with a nurse who does not communicate well might sometimes come along with it.”

The mismatched communication styles of most physicians and nurses are well recognized by a committee at the University of Chicago in which Nancy Perovic is involved. Vineet Arora, MD, MA, a hospitalist and associate program director for the Internal Medicine Residency Program at the University of Chicago, is one of the three hospitalist members on a committee working to improve nurse-physician communication.

“We know that nurses and physicians communicate differently,” says Dr. Arora. “Physicians communicate in more of a task-oriented way and nurses are trained to communicate in a descriptive way. And that’s part of the problem, because nurses might report that physicians don’t respond to them when they need to be responded to; they might not prioritize a patient that the nurse believes is very sick. And a physician might say, ‘I didn’t know that patient was really sick’ because he was given a description such as, ‘They’re not doing OK.’”

Also, Dr. Arora says, “part of the problem that nurses and physicians may have in communicating with each other can be traced to a difference in how they were trained. Physicians are trained to interact with other physicians and nurses are trained by other nurses.”

The committee at Chicago has adopted what is referred to as the Situation-Background-Assessment-Recommendation (SBAR) technique, a tool that the U.S. Navy has used to improve communication on aircraft carriers.8 Developed by Michael Leonard, MD, physician coordinator of clinical informatics, and others at Kaiser Permanente of Colorado, the SBAR technique has been implemented widely at health systems to provide a standard framework for members of the healthcare team when communicating about a patient’s condition.

“What nurses are not very good at is being assertive,” says Perovic. “We’re getting better as we’re getting more modern, but sometimes nurses talk in a more holistic, narrative fashion and doctors just want: what’s the problem, pinpoint it, let me know what it is.”

Chicago’s Perovic and her colleagues plan to educate nurses to use the SBAR technique so they can “talk in the way that doctors are trained to accept information and respond,” she says. “For example, this might sound like, ‘This is this patient with this diagnosis and these vital signs; this is what’s happening: they’re going down, their blood pressure’s dropped, I’m really concerned, this is a different change, I suggest that we do this and that, and I need you here in 10 minutes.’”

Perovic says nurses are then instructed to “make a recommendation; so the hospitalist can prioritize from all the other patients he has to see, to answer the questions: What does this patient need right now? When do I need to see this patient? and What can the nurse do until I get there?”

Literature on the SBAR technique and the tool itself are available online at www.ihi.org/IHI/Topics/PatientSafety/SafetyGeneral/Tools/SBARTechniqueforCommunicationASituationalBriefingModel.htm.8

The best ways to improve communication between hospitalists and nurses involve three major areas: Developing relationships, defining communication strategies, and packaging information for clarity

Heedful Versus Heedless Interrelating

Exactly how hospitalists affect outcomes and influence system issues is being addressed in research led by Mark V. Williams, MD, and Tracy Scott, PhD, at Emory University Medical Center, Atlanta. Dr. Williams, who is the director of the medicine unit at Emory Hospital, the editor-in-chief of the Journal of Hospital Medicine, and a past president of SHM, spoke to The Hospitalist about the exploratory research his team is doing to assess the impact hospitalists have in nurse-physician relationships in two hospitals in Atlanta, and to particularly examine how these relationships affect patient safety.

High Reliability Organization theory, which elucidates causal pathways between work relationships and reduced error, may provide a framework for how hospitalists affect hospital functioning. “Heedful interrelating,” the theory postulates, creates an organization “mind” and through facilitating teamwork is more alert to and capable of dealing with unexpected occurrences. In fact, says Dr. Williams, data from operating rooms, emergency departments, and ICUs suggest that a lack of teamwork adversely affects patient care and increases medical errors. Research along this vein has been absent on general medical floors.

The research design explores the degree of “heedful interrelating” as opposed to “heedless interrelating” between physicians and nurses and whether hospitalists have different relationships with nurses than do other physicians.

“In heedful interrelating,” explains Dr. Williams, “the physician heeds what the nurse is saying and doing and, likewise, the nurse heeds what the physician is saying and doing.” To date, the investigators have interviewed 45 nurses (half in a university hospital setting and half in a community hospital) and 24 physicians of whom half are hospitalists.

The study examines multiple components, but an example is that “heedful interrelating is based on true mutual respect, which is almost more important over agreement,” says Dr. Williams. “And in heedless interrelating, only one view of the situation is considered correct. It represents your classic arrogant physician.”

Another example of heedful interrelating is that “it advances the goals of the whole team; in heedless interrelating, you think only of your own role,” he says. Nurses in the study reported that compared with other physicians hospitalists are more accessible, more approachable, and more appreciative of the value of the nurse’s role.

The investigators conclude that hospitalists improve the nurse-physician relationship through heedful interrelating and thereby may improve patient safety. In addition, “the nurses emphasized the need for more collaboration and perceived that physicians were not proactive in asking them about their knowledge of the patient, and lacked a holistic view of the patient’s needs. Most importantly, about half the nurses mentioned specific instances where problems in their communication with physicians led directly to problems in patient care.

Dr. Williams believes that the ideal system for communication between hospitalists and nurses would include a means for them to do their patient rounds together. Nurses want hospitalists to develop a system to deliver the patient care plans quickly and reliably, include them in formal and informal educational efforts, and acknowledge them.

Timely Distribution of Care Plans

Blue says that hospitalists at her institution, FirstHealth Moore Regional Hospital (Pinehurst, N.C.), a 385-bed acute care, nonprofit hospital that serves as the referral center for a 15-county region in the mid-Carolinas, work often and closely with the nurses on issues of outcomes. “And outcomes here are like discharge planning utilization review,” she says. “We have a report every morning and there’s a representative from that department who’s online sending out the plans for the patients for the day to the other outcomes managers. That’s already in the works, and we’re not waiting for the hospitalist to get up to the floor to see the patient.”

Overall, however, nurses in other (e.g., larger) settings may not have as good a system in place to distribute care plans. Perovic says that in focus groups she facilitates, she often hears frustration from nurses because “doctors in general—although hospitalists are better at it—do not give nurses the plan of the day or the plan of care in a timely, organized fashion so they can do their care appropriately and prepare themselves and the patient.”

Some of the problem is due to the systems of an academic medical center, Perovic says, where “doctors make rounds at various times of the day and sometimes one team can make four rounds a day. What happens is that the plan for patient care changes each time new rounds are completed because you either get new information or discover you didn’t do something.” But although the team doctors are good at communicating plan modifications among themselves, she says, “what they fail to do is always communicate that well to the nurses.”

Perovic says there is an ideal and then a real solution. “Ideally, it would be great if patient rounds were at a certain time of the day every day so that the nurse can pass her meds and then be available for rounding,” she says. “You could say to nurses, ‘Rounds are between 10 and 11; take care of your patients’ needs and then be on call and ready to go to your rounds when possible.’ Or another solution is what we do in the pediatric hospital: We have a charge nurse who has no patients and she is able to round with all the teams and all the doctors and then give the individual nurse that plan for her patients.”

Hiring a charge nurse in this vein is a human resource issue, Perovic says, and an individual hospital has to decide that it wants to pay a nurse to not have patients. In that case, she says, it is an expensive but good fix. However, accommodating nurses to accompany hospitalists on rounds is logistically almost impossible. “Because if a nurse on the general medicine ward has five patients,” Perovic says, “she might have five different teams of doctors. But depending on the diagnosis of each patient, it won’t be the same team of doctors rounding on them. She might not catch A, B, and C at the same time that D and E are making their rounds. And she could be doing a blood draw on patient D when D team comes, or giving a bath to patient A when team E comes.”

Perovic and her coworkers have tried the call light method, where the doctor comes into the room, the attending presses the call light, and the nurse knows rounds are happening and to join them at that room. But that, as well as other avenues they tried, failed because neither the nurse nor the team can necessarily count on their times of availability coinciding. Still, Dr. Arora says, “we learned a lot about trying to work together and how to understand each other. And we used some of that information to continue thinking about how to best improve physician-nurse communication.”

The team at Chicago is now considering how to design and evaluate “an intervention for more of an interdisciplinary educational process where physicians and nurses would be trained on how to communicate with each other using this standard language,” says Dr. Arora. “Nurses would understand that they could potentially use the SBAR tool to communicate with physicians, and physicians would understand that the nurses need to be included in the plan for the day and would make time to incorporate nurse suggestions and input for the plan.”

Acknowledgment

In some hospital settings what has been described as a two-class system can exist for providers.9 A culture that encourages patient safety is threatened by the nature of the hierarchy or the segregation that is established, even subtly, where nurses are treated as unequals.6,9 In the hospital culture, the “invisibility of nursing” has historically been perpetuated by a number of factors, not the least of which are differences in gender and income.6 In this atmosphere, nurses are not as likely to share from their skills and knowledge. Their lack of assertiveness with hospitalists or other physicians may take its toll in many ways, including increased risks to patient outcomes and to provider morale and satisfaction.7

Linda Aiken, PhD, FAAN, FRCN, RN, the Claire M. Fagin Leadership Professor of Nursing and director of the Center for Health Outcomes and Policy Research at the University of Pennsylvania (Philadelphia), has extensively investigated the dynamics between nurses and their co-workers. “Nurse-physician relationships are one of the most important drivers of the work environment,”9 she writes. There are also data that demonstrate the association of nurse-doctor relationships on cost, lower morbidity and mortality, retention of nurses, higher quality of care, and improved hospital reimbursement and/or market share.9

In other words, “healthy nurse-physician relationships are not just a nice thing to have,” writes Dr. Aiken. “They are a competitive advantage.”

Given the association of these relationships to so many outcomes, it is unfortunate that many nurses crave greater acknowledgment for what they bring to their work. One benefit for nursing is that because hospitalists are around the hospital more than an average attending, they know the nurses better.

“As a nurse, what I need from hospitalists is for them to recognize and teach their residents and interns that the nurse is a constant player at the bedside in the hospital, with many more years of experience,” says Perovic. “Even though she doesn’t have as much medical training as a doctor or resident, she has enough clinical-nursing hospital experience. Doctors need to appreciate that nurses are experts at hospital care and bedside care, and [doctors] need to show that respect when we’re teaching our residents because we can learn a lot from the nurses, and the nurses can actually make the doctors’ lives easier.”

In a study of a multidisciplinary intervention tested on an acute inpatient medical unit, the effect of the intervention—to improve communication and collaboration—was strongest among house staff, who reported significant increases in collaborative efforts with nurses.10 This finding underlines the importance for hospitalists to serve as models to students, interns, and residents because the most effective time to learn collaborative practice is during early training when experienced nurses can assist inexperienced interns.10 Hospitalists can also consciously reject the traditional “doctor-nurse game,” whereby patterns of behavior suggest that doctors are the dominant players and nurses must defer to them.

“Ask nurses for their opinion,” advises Blue. “Treat them like an equal, which is another one of the beauties of this program, because hospitalists certainly do that. When it comes down to it, people want to be appreciated, respected, and acknowledged for their contribution.”

Blue and her team also encourage hospitalists to share with the nurses if they happen to hear news of their patients’ progress. “If we have follow-up on somebody from the primary care provider after that patient has left the hospital, for example, we try to share that with the nursing staff because they’re our patients. They’re not just my patients and they’re not your patients; they’re our patients.”

Conclusion

The quality of the nurse-hospitalist relationship is central to patient care. The methods, means, and styles of individual and team communication all influence the effectiveness of a hospital team. Retraining providers to traverse the gap of different communication styles is a way to approach the issues that exist. Mutual training for physicians and nurses, as well as training nurses to communicate in ways that more approximate how physicians communicate, will better serve patient and provider needs.

Hospitalists can encourage nurses to overcome hesitancies to initiate calls, clarify their preferences for how nurses should contact them, and work with nurses to seek workable ways to perform patient rounds in concert. Most of all, nurses need timely care plan distribution and acknowledgment for their contributions to teamwork and patient care. TH

Writer Andrea Sattinger will write about occupational therapists’ experiences with hospitalists in the January issue.

References

ANA Commission on Workforce for Hospitals and Health Systems. In our hands: how hospital leaders can build a thriving workforce. American Hospital Association; Chicago; 2002;55:30-31.

Aiken LH. The unfinished patient safety agenda. In: Wachter R, ed. Morbidity and Mortality Rounds on the Web: Agency for Healthcare Research and Quality; 2005. Accessed August. 29, 2005 at http://webmm.ahrq.gov/perspective.aspx?perspectiveID=7&searchStr=The+unfinished+patient+safety+agenda

Aiken LH, Clarke SP, Sloane DM. International Hospital Outcomes Research Consortium. Hospital staffing, organization, and quality of care: cross-national findings. Int J Qual Health Care. 2002;14:5-13.

Friesen MA, Farquhar MB, Hughes R. The nurse’s role in promoting a culture of safety: American Nurses Association Continuing Education, Center for American Nurses; 2005.

Wachter R. In conversation with … Barbara A. Blakeney, MS, RN. In: Wachter R, ed. Morbidity and Mortality Rounds on the Web. Agency for Healthcare Research and Quality; 2005. Accessed Aug. 29, 2005 at http://webmm.ahrq.gov/perspective.aspx?perspectiveID=8&searchStr=Blakeney

Lindeke LL, Sieckert AM. Nurse-physician workplace collaboration. Online J Issues Nurs. 2005;10:5.

Burke M, Boal J, Mitchell R. Communicating for better care: improving nurse-physician communication. Am J Nurs. 2004;104:40-47

SBAR initiative to improve staff communication. Healthcare Benchmarks Qual Improv. 2005;12:40-41.

Smith AP. Partners at the bedside: the importance of nurse-physician relationships. Nurs Econ. 2004;22:161-164.

Vazirani S, Hays RD, Shapiro MF, et al. Effect of a multidisciplinary intervention on communication and collaboration among physicians and nurses. Am J Crit Care. 2005;14:71-77.

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Blakeney recommends mutual training for physicians and nurses to improve patient care and safety focus on a number of key areas:

Understanding and appreciating each other’s skill sets and knowledge base;

Properly handing off patients and information; and

Nurturing “a culture in which safety is considered a problem-solving situation and not a punishment situation.”6

Nurses report that compared with other physicians hospitalists are more accessible, more approachable, and more appreciative of the value of the nurse’s role.

Make Contact

—Mark Williams, MD

Clear and to the Point

Literature on the SBAR technique and the tool itself are available online at www.ihi.org/IHI/Topics/PatientSafety/SafetyGeneral/Tools/SBARTechniqueforCommunicationASituationalBriefingModel.htm.8

The best ways to improve communication between hospitalists and nurses involve three major areas: Developing relationships, defining communication strategies, and packaging information for clarity

Heedful Versus Heedless Interrelating

Timely Distribution of Care Plans

Acknowledgment

In other words, “healthy nurse-physician relationships are not just a nice thing to have,” writes Dr. Aiken. “They are a competitive advantage.”

Conclusion

Writer Andrea Sattinger will write about occupational therapists’ experiences with hospitalists in the January issue.

References

ANA Commission on Workforce for Hospitals and Health Systems. In our hands: how hospital leaders can build a thriving workforce. American Hospital Association; Chicago; 2002;55:30-31.

Aiken LH. The unfinished patient safety agenda. In: Wachter R, ed. Morbidity and Mortality Rounds on the Web: Agency for Healthcare Research and Quality; 2005. Accessed August. 29, 2005 at http://webmm.ahrq.gov/perspective.aspx?perspectiveID=7&searchStr=The+unfinished+patient+safety+agenda

Aiken LH, Clarke SP, Sloane DM. International Hospital Outcomes Research Consortium. Hospital staffing, organization, and quality of care: cross-national findings. Int J Qual Health Care. 2002;14:5-13.

Friesen MA, Farquhar MB, Hughes R. The nurse’s role in promoting a culture of safety: American Nurses Association Continuing Education, Center for American Nurses; 2005.

Wachter R. In conversation with … Barbara A. Blakeney, MS, RN. In: Wachter R, ed. Morbidity and Mortality Rounds on the Web. Agency for Healthcare Research and Quality; 2005. Accessed Aug. 29, 2005 at http://webmm.ahrq.gov/perspective.aspx?perspectiveID=8&searchStr=Blakeney

Lindeke LL, Sieckert AM. Nurse-physician workplace collaboration. Online J Issues Nurs. 2005;10:5.

Burke M, Boal J, Mitchell R. Communicating for better care: improving nurse-physician communication. Am J Nurs. 2004;104:40-47

SBAR initiative to improve staff communication. Healthcare Benchmarks Qual Improv. 2005;12:40-41.

Smith AP. Partners at the bedside: the importance of nurse-physician relationships. Nurs Econ. 2004;22:161-164.

Vazirani S, Hays RD, Shapiro MF, et al. Effect of a multidisciplinary intervention on communication and collaboration among physicians and nurses. Am J Crit Care. 2005;14:71-77.

Blakeney recommends mutual training for physicians and nurses to improve patient care and safety focus on a number of key areas:

Understanding and appreciating each other’s skill sets and knowledge base;

Properly handing off patients and information; and

Nurturing “a culture in which safety is considered a problem-solving situation and not a punishment situation.”6

Nurses report that compared with other physicians hospitalists are more accessible, more approachable, and more appreciative of the value of the nurse’s role.

Make Contact

—Mark Williams, MD

Clear and to the Point

Literature on the SBAR technique and the tool itself are available online at www.ihi.org/IHI/Topics/PatientSafety/SafetyGeneral/Tools/SBARTechniqueforCommunicationASituationalBriefingModel.htm.8

The best ways to improve communication between hospitalists and nurses involve three major areas: Developing relationships, defining communication strategies, and packaging information for clarity

Heedful Versus Heedless Interrelating

Timely Distribution of Care Plans

Acknowledgment

In other words, “healthy nurse-physician relationships are not just a nice thing to have,” writes Dr. Aiken. “They are a competitive advantage.”

Conclusion

Writer Andrea Sattinger will write about occupational therapists’ experiences with hospitalists in the January issue.

References

ANA Commission on Workforce for Hospitals and Health Systems. In our hands: how hospital leaders can build a thriving workforce. American Hospital Association; Chicago; 2002;55:30-31.

Aiken LH. The unfinished patient safety agenda. In: Wachter R, ed. Morbidity and Mortality Rounds on the Web: Agency for Healthcare Research and Quality; 2005. Accessed August. 29, 2005 at http://webmm.ahrq.gov/perspective.aspx?perspectiveID=7&searchStr=The+unfinished+patient+safety+agenda

Aiken LH, Clarke SP, Sloane DM. International Hospital Outcomes Research Consortium. Hospital staffing, organization, and quality of care: cross-national findings. Int J Qual Health Care. 2002;14:5-13.

Friesen MA, Farquhar MB, Hughes R. The nurse’s role in promoting a culture of safety: American Nurses Association Continuing Education, Center for American Nurses; 2005.

Wachter R. In conversation with … Barbara A. Blakeney, MS, RN. In: Wachter R, ed. Morbidity and Mortality Rounds on the Web. Agency for Healthcare Research and Quality; 2005. Accessed Aug. 29, 2005 at http://webmm.ahrq.gov/perspective.aspx?perspectiveID=8&searchStr=Blakeney

Lindeke LL, Sieckert AM. Nurse-physician workplace collaboration. Online J Issues Nurs. 2005;10:5.

Burke M, Boal J, Mitchell R. Communicating for better care: improving nurse-physician communication. Am J Nurs. 2004;104:40-47

SBAR initiative to improve staff communication. Healthcare Benchmarks Qual Improv. 2005;12:40-41.

Smith AP. Partners at the bedside: the importance of nurse-physician relationships. Nurs Econ. 2004;22:161-164.

Vazirani S, Hays RD, Shapiro MF, et al. Effect of a multidisciplinary intervention on communication and collaboration among physicians and nurses. Am J Crit Care. 2005;14:71-77.

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Mack Lipkin, MD, the founding president of the American Academy on Physician and Patient, a society dedicated to research, education, and professional standards in patient-physician communication, reported some interesting data in a PowerPoint presentation he gave in 2000 at the working conference on Diversity and Communication in Healthcare sponsored in part by the U.S. Office of Minority Health. Dr. Lipkin said that physicians’ lowest level of communication skills are reached during their medical residencies; even medical students’ skills were rated higher. Dr. Lipkin, who is also director of the Division of Primary Care in the Department of Medicine at New York University School of Medicine, New York City, went on to explain that, typically, physicians will recover some capacity with communication as they enter practice and years of experience ensue, but they never reach the level they possessed before they entered medical school.

While some hospitalists may consider this a startling claim, few are likely to find it shocking. Although hospitalists believe using good communication skills is an important part of their work, their skills may not necessarily match their beliefs or intentions. Research in progress by hospitalist Paul Mueller, MD, and his colleagues at the Mayo Clinic College of Medicine, Rochester, Minn., reveals that a majority of new internal medicine faculty—regardless of years in practice or background—believe they could benefit from and desire additional training in communication; yet these individuals teach communication skills to medical students (personal communication, 2005).

Medical education curriculum experts nationwide are pumping up their coverage of physician-patient communication to supply the demand stemming from a surge of interest in this topic in recent decades. Some reasons for this include reports and investigations into medical errors, an explosion of medical and health information easily accessible to patients and families, the rise of a vital consumer advocacy and empowerment movement, the reliance on outcomes assessments that include patient satisfaction ratings, a growing emphasis on patient- or relationship-centered care, and the reduced time for medical encounters caused at least in part by cost-containment initiatives.

The relationship between communication and medical outcomes is being increasingly explored, including the effects on physician satisfaction.1-5 But what are the further, personal effects to the individual hospitalist when he or she perpetuates poor communication skills?

If you don’t [communicate] with patients and patient families [about] what is going on [in their care], those relationships very quickly can turn antagonistic. And then the very thing most of us like about medicine—relationships with patients and families—becomes something that people tend to avoid.

—Robert Trowbridge, MD

Communication With Patients And Families

The work of hospitalists depends acutely on communication.

“It’s part of the role of the hospitalist to explain and help shepherd [patients] through the healthcare system,” says Robert Trowbridge, MD, a hospitalist and assistant professor of medicine, University of Vermont College of Medicine, Maine Medical Center, Portland.

Professionals whose medical practice is based on short clinical visits or performing procedures may or may not be good communicators, but it’s probably not as integral to the way they or the situations their patients are going through will be perceived. The conventional wisdom in professional and lay circles tends to be, “He may be a lousy communicator, but he’s a hellava surgeon,” says Dr. Trowbridge.

But most patients expect good communication from their primary care physician and because they are serving that function when a patient is hospitalized, hospitalists should understand that patients and families expect those skills of them. “And if the [hospitalists] don’t do well [in communicating], there can be much more stress on the patients and physicians,” explains Dr. Trowbridge.

What Constitutes Poor Communication?

“First, on one level, poor communication skills are inefficient in talking with patients,” says Steven Pantilat, MD, SHM president. “So, I think it makes your work harder.”

Some examples of communication inefficiency (or ineffectiveness) for a clinician include:2,4,5,6-8

Lacking the ability to articulate ideas adequately;

Transferring insufficient information between the provider and the patient, including inadequate elicitation of key facts from the patient;

Failing to assess the current level of information before supplying new information;

Taking too much or too little time in regard to the needs of the situation;

Overusing medical terms and not recognizing when patients cannot decipher them;

Using little eye contact and appropriate touch;

Using closed body language;

Being inattentive to the patient’s body language;

Using inappropriately open or closed questions when the circumstance calls for the opposite;

Not using a patient’s own words when doing so would be helpful to diagnosis or management;

Exhibiting a lack of empathy, compassion, understanding, and support;

Being inattentive or insensitive to a patient’s feelings;

Being inattentive to cognitive, psychosocial, and affective needs;

Disregarding the need for shared decision-making;

Lacking the skill for or failing to use active listening;

Failing to use timeliness in feedback or reporting test results;

Neglecting to seek feedback regarding whether cultural, regional, or language/accent differences (both the doctor’s and the patient’s) impede communication; or

Using an angry, anxious, or dominant tone of voice.

The second effect of poor communication that Dr. Pantilat cites is that “patients are less satisfied with their care and … to the extent that the relationship with the physician actually has an impact on how patients feel, patients may not ‘get better,’ ” he says. “And I don’t mean, for instance, that with a patient who has pneumonia, their pneumonia won’t get better; but there are a lot of other conditions where feeling like someone is listening to you, feeling like you’ve been heard, feeling like someone has communicated clearly can make you feel better.”7 (See also The Hospitalist, “Patient Satisfaction: The Hospitalist’s Role,” July/August 2005.)8

Inpatient communication tends to be a different kind of communication than that used in some other medical settings—more intense in a shorter time period and conducted between people who are strangers at the time of the patient’s admission. “It’s not that the stakes are higher, but it’s actually just the intensity of it is different,” says Arpana Vidyarthi, MD, a hospitalist who is the director of quality inpatient medicine at the University of California, San Francisco Medical Center.

“Time constraints are a major reason for poor communication skills happening,” says Dr. Trowbridge, whose hospitalist practice involves 60% clinical work with the Maine Hospitalist Group and 40% administrative work involving medical students and faculty development with the Department of Medicine at Maine Medical Center. “Relationships are really what many physicians most enjoy in medicine: with colleagues, … with patients, … with families. Having poor communication skills has a huge impact on job satisfaction and then personal satisfaction,” in many instances because of the heightened levels of stress.

“People are not here because they’re trying to get their lipids down,” says Dr. Vidyarthi. “They’re here because they’re [acutely ill]. When people are very, very ill, or when they’re having an intense experience, they tend to hang on every word.”

For the physician, she says, “there are so many things to communicate and because it is often very complicated, the relationship and the trust have to be built quickly, and information has to be transferred very quickly. Poor communication will lead to potentially not being able to build that alliance with the patient during that short period of time of their hospital experience.”

Hospitalists must be on the lookout for how the constraints of time affect the way they practice and relate to their patients because every nuance of behavior or tone of voice can make a difference to how a patient perceives his or her doctor.

For example, in a study conducted at Harvard University in 2002, investigators used audiotapes of 57 surgeons, 36 of whom had had two or more malpractice claims filed against them.9 Patients were asked to listen to two 20-second clips of audio between these surgeons and two patients. Those surgeons who were judged by the tone of their voices as “high dominance” and “low concern/anxiety” correlated with those who had had previous malpractice claims.

Because there is no continuity of relationship to help steady what might be an emotional response when things go wrong in the patient’s treatment or when patients and families are upset by circumstances, hospitalists may be subjected to blame, resentment, fear, and displaced anger concerning their communications with patients and families.

“Especially if you’re harried in an incredible time crunch, if you don’t [communicate] with patients and patient families [about] what is going on [in their care], those relationships very quickly can turn antagonistic,” says Dr. Trowbridge. “And then the very thing most of us like about medicine—relationships with patients and families—becomes something that people tend to avoid.”

Dr. Trowbridge says that this can become somewhat of a vicious cycle whereby a certain extent of inadvertently “avoiding the patient and family may lead to further communication faults.” On the flip side, using good communication can be a circular process but in a positive way: A good communicator may experience better well-being, which in turn, leads to better communication skills.2,5 Also, on a practical level, the data are clear that bad communication puts you at risk for malpractice litigation.9,10

Communication with Colleagues

“People that don’t have very good communication skills tend not to be successful,” says Dr. Vidyarthi, who practices with the hospitalist group at UCSF and is also an assistant professor there. Her definition of success is closely linked to the quality of relationships; that is, “being well liked by the nurses, building working relationships with … the nurses,” as well as others, including the hospital administrator. “Hospitalists are almost always … doing quality work or performance improvement,” she explained. “They’re on committees. That is the nature of what we do. … Not learning what those [communication skills] are and [not] being able to communicate at [effective] levels would … be a detriment to one’s personal job advancement, but absolutely to one’s job satisfaction as well.”

Collegiality, in fact, is one component cited as a “powerful engine of socialization” in organizational structures more likely to foster the lifelong learning and commitment that are inherent to medical professionalism.1,3-5,11,12

Many of the components of effective communication with colleagues parallel those that are best used with patients. “Communication is what holds that team together,” says Dr. Vidyarthi, whose interests include information transfer and communication as a form for team-building. “In academic medicine, poor communication can impact the teaching environment, the experience of the students and the residents, and that team cohesion. And that can lead to poor patient care, it can definitely lead to a poor educational experience, and it is not enjoyable, so job satisfaction suffers.”

Dr. Pantilat, who is associate professor of clinical medicine and director, Palliative Care Service and Palliative Care Leadership Center at UCSF, theorizes that when interacting with colleagues such as other hospitalists and physicians, nurses, social workers, case managers, and pharmacists, poor communication skills can make the physician’s work tougher. “Poor communication makes your life difficult with your colleagues,” says Dr. Pantilat. “People don’t like talking to you or interacting with you … and your job can generally be more difficult.”

In a 2002 study conducted at Harvard University, investigators used audiotapes of 57 surgeons, 36 of whom had had two or more malpractice claims filed against them. Patients were asked to listen to two 20-second clips of audio between these surgeons and two patients. Those surgeons who were judged by the tone of their voices as “high dominance” and “low concern/anxiety” correlated with those who had had previous malpractice claims.

Post-Discharge Communication

In the traditional medical model, a primary care physician would see patients in her/his office, the hospital, or rehabilitation. With the expansion in hospital medicine, patients are now “handed off” and seen by a number of providers. Hand-off fumbles can mean critical information may be lost, leading to poorer outcomes and greater readmission rates.13-15

Forging and maintaining effective communication with colleagues following the discharge of patients is an area where few in-house physicians do well, says Dr. Vidyarthi, who has it on her agenda to tackle this “huge problem” for her institution in the coming year. There are two pieces to that problem, she says. One is to accurately identify the patients’ primary care physicians and the other is to make contact with them.

“You could page them, but they’re in clinic, and they can’t take five minutes out when you can’t take five minutes out,” says Dr. Vidyarthi. “The communication with the primary care physician is actually a field in and of itself.”15

Part of her plan is to devise some means of “physician-independent generated communication,” perhaps a letter or e-mail sent from the hospital to report to a primary care physician that his/her patient has been admitted to the hospital.

“That raises a flag to that primary so they can try to find the hospitalist, which is usually very easy … because we’re always in the hospital,” says Dr. Vidyarthi. “And it’s the first stage of the communication: Now that person is aware. If I can find them, if I can access them, they’ll be able to take that time out, because they know their patient’s there.”

In her work as a senior fellow at the Center for Health Professions at UCSF, Dr. Vidyarthi strives to “embed communication into the larger framework of organizational change.” And what does a hospitalist do if an institution’s post-discharge communications system is not up to par? There are three basic things you can do to help overcome this source of frustration, she says. The first is to continually build relationships with primary care providers.

“If I send an e-mail to somebody and they know who I am, they are much more likely to respond to that because they know me,” says Dr. Vidyarthi.

Next, find a system that works for you. “Don’t wait for the rest of the systems to be put in place,” she says. “This is about personal practice. And if that means you take five minutes in the morning to send an e-mail or five minutes in the evening, whatever it is, find [a system] that really works and figure out a way to evaluate it.”

A good way to do this, Dr. Vidyarthi suggests, is to take a quick survey in the midst of talking to that primary care physician to ask whether the medium, content, and timing that you used to contact him/her worked well.

“Then,” she says, “if you have five primaries that you talked to [who] maybe said, ‘Yes, that was helpful to me,’ or ‘Not so much really, I had all that info already,’ at least you have data. Asking ‘Do you think this will help your patients when they come to see you in the office?’ is a great question [to solidify] performance improvement. In other words, find out if what you’re doing is being effective.”

The final step to overcome a lack of an effective institutional system for post-discharge communication is to share what you’ve learned with others. “These little pieces can really empower others to make a difference,” says Dr. Vidyarthi. “Trying to change and overhaul an entire system will turn off even the most motivated of people who want to improve the system, so focus on your own personal practice models. Change it, figure out what works, and then try to disseminate it. That makes it feel and seem much more doable.”

Conclusion

Hospitalists who exercise poor communication skills with patients, families, and colleagues can experience multiple negative effects, including poor patient-related outcomes and an increased risk of malpractice litigation. Personally, consistently using poor communication may make work more difficult, reduce job satisfaction, and reduce work success and enjoyment with hospital teams and primary care physicians. TH

Contributor Andrea Sattinger makes good communication a priority every day.

References

Finset KB, Gude T, Hem E, et al. Which young physicians are satisfied with their work? A prospective nationwide study in Norway. BMC Med Educ. 2005;5:19.

Roter DL, Stewart M, Putnam SM, et al. Communication patterns of primary care physicians. JAMA. 1997;277:350-356.

Konrad TR, Williams ES, Linzer M, et al. SGIM Career Satisfaction Study Group. Society of General Internal Medicine. Measuring physician job satisfaction in a changing workplace and a challenging environment. Med Care. 1999;37:1174-1182.

Shanafelt TD, West C, Zhao X, et al. Relationship between increased personal well-being and enhanced empathy among internal medicine residents. J Gen Intern Med. 2005;20:559-564.

Shanafelt TD, Sloan JA, Habermann TM. The well-being of physicians. Am J Med. 2003;114:513-519.

Novack DH, Suchman AL, Clark W, et al. Calibrating the physician. Personal awareness and effective patient care. Working Group on Promoting Physician Personal Awareness, American Academy on Physician and Patient. JAMA. 1997;278:502-509.

Greenfield S, Kaplan S, Ware WE Jr. Expanding patient involvement in care: effects on patient outcomes. Ann Intern Med. 1985;102:520-528.

Torcson PJ. Patient satisfaction: the hospitalist’s role. The Hospitalist. 2005;July/Aug:27-30.

Ambady N, LaPlante D, Nguyen T. Surgeons’ tone of voice: a clue to malpractice history. Surgery. 2002;132:5-9.

Levinson W, Roter DL, Mullooly JP. Physician-patient communication. The relationship with malpractice claims among primary care physicians and surgeons. JAMA. 1997;277:553-559.

Frankford DM, Patterson MA, Konrad TR. Transforming practice organizations to foster lifelong learning and commitment to medical professionalism. Acad Med. 2000;75:708-17.

Falkum E, Vaglum P. The relationship between interpersonal problems and occupational stress in physicians. Gen Hosp Psychiatry. 2005;27:285-291.

Coleman EA, Smith JD, Min SJ, et al. Post-hospital medicine discrepancies; prevalence, types, and contributing factors. Paper presented at the Society of Hospital Medicine Annual Meeting; April 29-30; Chicago, Illinois: Society of Hospital Medicine 2005.

Burniske GM, Burnett A, Greenwald J, et al. Post-discharge follow-up telephone call by a pharmacist and impact on patient care. Paper presented at the Society of Hospital Medicine Annual Meeting. April 29-30; Chicago.

Wachter R, Shojania K. Internal Bleeding: The Truth Behind America's Terrifying Epidemic of Medical Mistakes. New York, NY: Rugged Land; 2004.

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—Robert Trowbridge, MD

Communication With Patients And Families

The work of hospitalists depends acutely on communication.

What Constitutes Poor Communication?

“First, on one level, poor communication skills are inefficient in talking with patients,” says Steven Pantilat, MD, SHM president. “So, I think it makes your work harder.”

Some examples of communication inefficiency (or ineffectiveness) for a clinician include:2,4,5,6-8

Lacking the ability to articulate ideas adequately;

Transferring insufficient information between the provider and the patient, including inadequate elicitation of key facts from the patient;

Failing to assess the current level of information before supplying new information;

Taking too much or too little time in regard to the needs of the situation;

Overusing medical terms and not recognizing when patients cannot decipher them;

Using little eye contact and appropriate touch;

Using closed body language;

Being inattentive to the patient’s body language;

Using inappropriately open or closed questions when the circumstance calls for the opposite;

Not using a patient’s own words when doing so would be helpful to diagnosis or management;

Exhibiting a lack of empathy, compassion, understanding, and support;

Being inattentive or insensitive to a patient’s feelings;

Being inattentive to cognitive, psychosocial, and affective needs;

Disregarding the need for shared decision-making;

Lacking the skill for or failing to use active listening;

Failing to use timeliness in feedback or reporting test results;

Neglecting to seek feedback regarding whether cultural, regional, or language/accent differences (both the doctor’s and the patient’s) impede communication; or

Using an angry, anxious, or dominant tone of voice.

Communication with Colleagues

Post-Discharge Communication

“If I send an e-mail to somebody and they know who I am, they are much more likely to respond to that because they know me,” says Dr. Vidyarthi.

Conclusion

Contributor Andrea Sattinger makes good communication a priority every day.

References

Finset KB, Gude T, Hem E, et al. Which young physicians are satisfied with their work? A prospective nationwide study in Norway. BMC Med Educ. 2005;5:19.

Roter DL, Stewart M, Putnam SM, et al. Communication patterns of primary care physicians. JAMA. 1997;277:350-356.

Konrad TR, Williams ES, Linzer M, et al. SGIM Career Satisfaction Study Group. Society of General Internal Medicine. Measuring physician job satisfaction in a changing workplace and a challenging environment. Med Care. 1999;37:1174-1182.

Shanafelt TD, West C, Zhao X, et al. Relationship between increased personal well-being and enhanced empathy among internal medicine residents. J Gen Intern Med. 2005;20:559-564.

Shanafelt TD, Sloan JA, Habermann TM. The well-being of physicians. Am J Med. 2003;114:513-519.

Novack DH, Suchman AL, Clark W, et al. Calibrating the physician. Personal awareness and effective patient care. Working Group on Promoting Physician Personal Awareness, American Academy on Physician and Patient. JAMA. 1997;278:502-509.

Greenfield S, Kaplan S, Ware WE Jr. Expanding patient involvement in care: effects on patient outcomes. Ann Intern Med. 1985;102:520-528.

Torcson PJ. Patient satisfaction: the hospitalist’s role. The Hospitalist. 2005;July/Aug:27-30.

Ambady N, LaPlante D, Nguyen T. Surgeons’ tone of voice: a clue to malpractice history. Surgery. 2002;132:5-9.

Levinson W, Roter DL, Mullooly JP. Physician-patient communication. The relationship with malpractice claims among primary care physicians and surgeons. JAMA. 1997;277:553-559.

Frankford DM, Patterson MA, Konrad TR. Transforming practice organizations to foster lifelong learning and commitment to medical professionalism. Acad Med. 2000;75:708-17.

Falkum E, Vaglum P. The relationship between interpersonal problems and occupational stress in physicians. Gen Hosp Psychiatry. 2005;27:285-291.

Coleman EA, Smith JD, Min SJ, et al. Post-hospital medicine discrepancies; prevalence, types, and contributing factors. Paper presented at the Society of Hospital Medicine Annual Meeting; April 29-30; Chicago, Illinois: Society of Hospital Medicine 2005.

Burniske GM, Burnett A, Greenwald J, et al. Post-discharge follow-up telephone call by a pharmacist and impact on patient care. Paper presented at the Society of Hospital Medicine Annual Meeting. April 29-30; Chicago.

Wachter R, Shojania K. Internal Bleeding: The Truth Behind America's Terrifying Epidemic of Medical Mistakes. New York, NY: Rugged Land; 2004.

—Robert Trowbridge, MD

Communication With Patients And Families

The work of hospitalists depends acutely on communication.

What Constitutes Poor Communication?

“First, on one level, poor communication skills are inefficient in talking with patients,” says Steven Pantilat, MD, SHM president. “So, I think it makes your work harder.”

Some examples of communication inefficiency (or ineffectiveness) for a clinician include:2,4,5,6-8

Lacking the ability to articulate ideas adequately;

Transferring insufficient information between the provider and the patient, including inadequate elicitation of key facts from the patient;

Failing to assess the current level of information before supplying new information;

Taking too much or too little time in regard to the needs of the situation;

Overusing medical terms and not recognizing when patients cannot decipher them;

Using little eye contact and appropriate touch;

Using closed body language;

Being inattentive to the patient’s body language;

Using inappropriately open or closed questions when the circumstance calls for the opposite;

Not using a patient’s own words when doing so would be helpful to diagnosis or management;

Exhibiting a lack of empathy, compassion, understanding, and support;

Being inattentive or insensitive to a patient’s feelings;

Being inattentive to cognitive, psychosocial, and affective needs;

Disregarding the need for shared decision-making;

Lacking the skill for or failing to use active listening;

Failing to use timeliness in feedback or reporting test results;

Neglecting to seek feedback regarding whether cultural, regional, or language/accent differences (both the doctor’s and the patient’s) impede communication; or

Using an angry, anxious, or dominant tone of voice.

Communication with Colleagues

Post-Discharge Communication

“If I send an e-mail to somebody and they know who I am, they are much more likely to respond to that because they know me,” says Dr. Vidyarthi.

Conclusion

Contributor Andrea Sattinger makes good communication a priority every day.

References

Finset KB, Gude T, Hem E, et al. Which young physicians are satisfied with their work? A prospective nationwide study in Norway. BMC Med Educ. 2005;5:19.

Roter DL, Stewart M, Putnam SM, et al. Communication patterns of primary care physicians. JAMA. 1997;277:350-356.

Konrad TR, Williams ES, Linzer M, et al. SGIM Career Satisfaction Study Group. Society of General Internal Medicine. Measuring physician job satisfaction in a changing workplace and a challenging environment. Med Care. 1999;37:1174-1182.

Shanafelt TD, West C, Zhao X, et al. Relationship between increased personal well-being and enhanced empathy among internal medicine residents. J Gen Intern Med. 2005;20:559-564.

Shanafelt TD, Sloan JA, Habermann TM. The well-being of physicians. Am J Med. 2003;114:513-519.

Novack DH, Suchman AL, Clark W, et al. Calibrating the physician. Personal awareness and effective patient care. Working Group on Promoting Physician Personal Awareness, American Academy on Physician and Patient. JAMA. 1997;278:502-509.

Greenfield S, Kaplan S, Ware WE Jr. Expanding patient involvement in care: effects on patient outcomes. Ann Intern Med. 1985;102:520-528.

Torcson PJ. Patient satisfaction: the hospitalist’s role. The Hospitalist. 2005;July/Aug:27-30.

Ambady N, LaPlante D, Nguyen T. Surgeons’ tone of voice: a clue to malpractice history. Surgery. 2002;132:5-9.

Levinson W, Roter DL, Mullooly JP. Physician-patient communication. The relationship with malpractice claims among primary care physicians and surgeons. JAMA. 1997;277:553-559.

Frankford DM, Patterson MA, Konrad TR. Transforming practice organizations to foster lifelong learning and commitment to medical professionalism. Acad Med. 2000;75:708-17.

Falkum E, Vaglum P. The relationship between interpersonal problems and occupational stress in physicians. Gen Hosp Psychiatry. 2005;27:285-291.

Coleman EA, Smith JD, Min SJ, et al. Post-hospital medicine discrepancies; prevalence, types, and contributing factors. Paper presented at the Society of Hospital Medicine Annual Meeting; April 29-30; Chicago, Illinois: Society of Hospital Medicine 2005.

Burniske GM, Burnett A, Greenwald J, et al. Post-discharge follow-up telephone call by a pharmacist and impact on patient care. Paper presented at the Society of Hospital Medicine Annual Meeting. April 29-30; Chicago.

Wachter R, Shojania K. Internal Bleeding: The Truth Behind America's Terrifying Epidemic of Medical Mistakes. New York, NY: Rugged Land; 2004.

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In a 2001 Hospital Practice article Robert Wachter, MD, named malpractice as one of the top 10 issues that require consideration as it relates to the hospitalist movement.1 There are many areas to consider when looking at malpractice insurance for hospitalists as opposed to other physician specialties. Just one area being reviewed by insurance carriers: Underwriters are grouping hospitalists with internal medicine physicians because hospitalists do not yet have their own classification code.

“When physicians spend 85% to 100% of their time in the office,” wrote Dr. Wachter, “it seems prudent to base assessments of competence on the quality of the office practice rather than that of the hospital practice. As in other situations, the hospitalist movement has exposed the inadequacies of the earlier system.” This assessment seems applicable to the area of insurance as well. There may be a need to create means by which hospitalists can be better protected from malpractice risk and coverage inadequacy. This area, like all others associated with hospital medicine, is evolving.

In this article we highlight malpractice insurance for hospitalists: what you should consider now and in the future regarding policy coverage. policies Available to Hospitalists

The types of malpractice insurance available to hospitalists include:

Policies provided under your employer’s policy or purchased for yourself;

Policies that cover you when any event actually occurs or when the claim is filed; and

Policies purchased by hospitals where the payouts for claims are made either by the insurance company (the carrier) or by the employer (the hospital).

Most hospitalists are covered by institutional or group employers. In most cases, hospitalists are hired directly by hospitals or by an agency that contracts with hospitalists and administrates this relationship with the hospital.

“We recommend that the hospitals employ the hospitalists and that they put them on their hospital malpractice policy,” says Pam Kirks, insurance broker with the Gallagher Health Insurance Company in Raleigh, N.C., “because that’s the cheapest way to go for the hospitalist. There are different types of coverage out there that they can get; they can get their own coverage certainly. But I think the majority of them are becoming hospital employees.”

The right fit: Hospitalists don't fit into just any ol' malpractice policy coverage. Know the differences between policies in order to tailor one to your individual needs. And although you may be covered under your hospital's insurance policy, everyone can benefit from understanding the nuances of malpractice coverage.

Occurrence or Claims Made

The types of medical malpractice insurance available to hospitalists are either “occurrence” or “claims-made” policies. An occurrence policy is one in which the policy that responds to a claim is the one that was in effect when the incident actually occurred. A claims-made policy that responds to a claim is the one that is in effect when the claim is made—provided that you also had continuous coverage from the time that the incident occurred.

Joe Zorola, director of underwriting at ProMutual Insurance Company in Boston, further explains the claims-made policy. “For instance, let’s say you have a policy this year and something happens tomorrow and five years down the line [the patient] file[s] a claim because of what happened tomorrow,” he explains. “You should have continued this policy through the next five years so that there’s no lapse of coverage, but the policy that will respond will be the policy five years from now.”

Of the 52 hospitals and 14,000 people that ProMutual insures, half of the policies are individual policies and half are group policies.

“The majority of [policies] are in Massachusetts and so are written under an occurrence basis,” says Zorola. “The ones outside of Massachusetts—and those are the group policies that we do have—are claims made.”

Physicians and insurance carriers each have preferences between the two types. “The occurrence policy is the policy that a lot of physicians like because they understand that if they did something today, [they can think] ‘I never have to worry about having insurance in the future for it,’” says Zorola. “The claims-made policy is the one that we as [insurance] companies like because it allows us to close our books on each policy year much sooner because we know that we aren’t going to have any more claims attached to the policy this year or in another year or two.”

Fully Insured or Self Insured?

Malpractice policies available through employers are either fully insured or self insured. The difference between the two types involves who is responsible for the claims payouts. With fully insured plans, the employer pays a premium to an insurer and the insurer pays claims out of the pool of premiums it collects from everyone it insures. Under a self-insured plan, the employer is responsible for paying all claims out of company assets. The Employee Retirement Income Security Act (ERISA) regulates self-insured plans; the plans are then under the jurisdiction of the U.S. Department of Labor.

“The hospitalists that we do [under]write [fully insured policies] for tend to be in the smaller community hospitals, which may not necessarily have the huge need for hospitalists; whereas the larger institutions may have a larger need for hospitalists [and] they usually tend to be self-insured,” says Zorola.

Controlled Risk Insurance Company of Vermont, known as CRICO and located in Cambridge, Mass, is one example of a self-insured system. “We only have one [malpractice insurance] product for a closed system where our clients are the Harvard teaching hospitals” says Karen O’Rourke, senior vice president of CRICO.

While experts report that lawsuits against hospitalists are scarce, they also reference the lack of classification code specifically created for the hospitalist and his/her duties. Without it, it’s impossible to distinguish in data when and in how many cases hospitalists were named.

Individual Policies for Certain Circumstances

Hospitalists who take out individual policies are usually practicing part-time or moonlighting and have another policy with a carrier that is covering their primary practice. “And this is true across the country,” says Zorola. “Most carriers will have some sort of part-time credit that they will provide [to] the people who come to them for policies. Now there are some carriers, and these are usually the large hospital carriers, who won’t provide individual policies to physicians. They only provide coverage for the hospital and the hospital’s employees.”

Hospitalists who take out their own individual policies usually get coverage from one of the local Physician Insurers Association of America carriers.

Why Are Hospitalists Sued?

In general, hospitalists are infrequently sued for medical malpractice. They may be named in initial claims, but many are dropped before the case is resolved. However, while experts report that lawsuits against hospitalists are scarce, they also reference the lack of classification code specifically created for the hospitalist and his/her duties. Without it, it’s impossible to distinguish in data to learn when and in how many cases hospitalists were named.

O’Rourke says that internists in ambulatory or outpatient practice settings are usually at risk for claims of failure to diagnose—mostly failure to diagnose cancer or myocardial infarctions. In contrast, “the hospitalists’ failures come in the communication area,” she says, “because that’s primarily what they’re there for is to make sure that the patient receives the medical care that they’re supposed to in a hospital setting.”

O’Rourke, who directs the management of underwriting claims as part of her work at CRICO, believes there is a vast difference between the reasons for claims for internists versus hospitalists.3

“We receive so many failure-to-diagnose cases with internal medicine physicians,” she elaborates. “There have been huge losses associated with them throughout other systems that we’ve seen—some of our own, such as increases in [the rates of] breast cancer or colorectal cancer. You’re not going to see that with a hospitalist unless there’s a post-op complication—bleeding that isn’t caught and failure to diagnose—that kind of issue—soon enough. But they’re still under a surgeon’s care normally.”

O’Rourke recognizes that the care of the hospital patient is a team effort. “So it’s going to be a question of how the hospital defines the hospitalist role for each and every condition or [for] surgical patients,” she says.

The Cost of Insurance

Hospitalists don’t appear to be experiencing the negative effects of what the insurance industry, in general, is suffering—that many insurers are pulling out of the market because of the untenable costs of remaining in business. That is because a lot of hospitalists are covered by the hospital policy and the hospital, therefore, assumes the burden of paying their premiums. However, some hospitalists may have the same affordability issues that some of the practitioners who are paying their own malpractice premiums.

“The publicity around affordability tends to be in the higher-rated classifications such as with surgeons and OB/GYNs,” says Zorola, “and since we charge hospitalists considerably lower rates, we don’t hear as much from them.”

Some states are only claims-made states, and some offer occurrence and claims-made policies. “If you … compare apples to apples, claims-made is probably the rate to use because every state will have a claims-made rate,” Zorola explains. “The hospitalist at $1 million/$3 million annual aggregate on a matured claims-made basis in Massachusetts would be paying $12,908. Sometimes the hospital pays that, sometimes the hospitalist. The part-time hospitalists … are usually paying half of that. A general surgeon, on the other hand, in comparison, pays $39,474. And this is in Massachusetts. Whereas an OB/GYN would pay $105,006.” —AS

If the Hospitalist Sees the Patient

A new claim that ProMutual recently received involves a hospitalist. The allegation is “failure to monitor a patient for suicide.” The claim states that the patient attempted suicide twice by trying to hang herself. The patient was admitted to the psychiatric unit of the hospital. Although a medical consultation must be done any time a patient is admitted, the hospitalist was not consulted to assess for suicide precautions. The hospitalist’s next involvement was after the attempted suicide when she responded to the code and admitted the patient to the ICU.

Given the lines of protocol, it is likely to be decided that the named psychiatrist was responsible for noting the risks with this patient and the hospitalist’s name will be dropped from the claim. The important thing for hospitalists to know is that because the hospitalist was listed as seeing the patient, she was named in the claim and this is customary procedure.

“A lot of times the plaintiff attorney will note every doctor who has seen the patient over the last number of years,” says Zorola, “because they probably don’t know a lot about the claim either, at that point. So until the investigation is done, and you can perform the depositions and find out exactly who was responsible for what,” the hospitalist will be a part of this process.

The Classification of Hospitalists

The growing trend is that insurance underwriters are creating a separate hospitalist classification. ProMutual underwriters established a classification for hospitalist and placed it in the same rate group as internal medicine physicians. But then the underwriters listened to what some of the hospitalists were saying: that because they are more specialized and are seeing patients who are more aware of the care that should be provided in the hospital, being grouped with physicians who spend most of the their time in office practice was not an accurate way to classify them.

Zorola and his colleagues now see that “setting up a separate classification for [hospitalists] allows us in the future to review their experience and determine whether they ought to be grouped with internal medicines or whether they belong in a lower or higher classification.” Hospitalists might belong in a higher, risk-associated classification “because they are seeing sick patients whereas internal medicine and family practice doctors have a mixture of sick and well patients,” he notes.

In fact, the common assumption is that hospitalists are doing riskier work simply because they work in places in which they have more opportunities to encounter risk. O’Rourke can’t say definitively how many hospitalists CRICO insures. But she can say that few claims involve hospitalists.

“We thought they were a riskier group for a while, but we couldn’t find any evidence of that in our data,” she explains. “We had a couple of claims involving people who were hospitalists, but nothing of concern.”

Whether hospitalists prove to be a riskier group in future research will depend on first determining more precisely what hospitalists do.

What Do Hospitalists Really Do?

“I can imagine that some of [the answer to this question] is that you go find out what works best for the systems you already have in place and develop systems that are needed to really quantify what [hospitalists] are supposed to do,” says O’Rourke. “And that will vary from institution to institution depending on whether it’s a teaching hospital or not.”

But there are other factors and issues at play, some of which are entirely out of control of the insured hospitalist. Barry Halpern, an attorney with Snell and Wilmer Law Firm, whose insured clients are spread over the western half of the United States, says “malpractice insurers, for a variety of reasons, … have many, many classifications for underwriting purposes and others [have] not very many at all. There are marketing issues associated with that and they don’t have a lot to do with the aspects of the specialty.”4

Your Policy Type May Matter

“[A]s you look at this from an insurance perspective, there are pros and cons for having separate insurance for hospitalists and the hospital,” says Halpern. “Where there is separate insurance, there is sometimes greater potential for conflict tension among the provider team than when the insurance is provided on an entity basis, particularly when entity claims against hospitals are a [somewhat] growing trend.”

Halpern notes that, in general, the courts are delivering their verdicts without considering the actual relationship between a hospital and a staff physician.3 “Of course,” he adds, “the courts are hunting for ways to make hospitals responsible on an entity basis rather than specifically for negligence in credentialing, or negligence in supervising, or negligence in providing staff and tools.”

Halpern thinks that in lawsuits where any staff physician is considered as part of the entity of the hospital institution, “it may make sense for the hospitalist to be insured under the hospital’s coverage, so that you minimize the potential for finger-pointing within the hospital-based team.” Besides creating potential tension within the group, Halpern says, “there may be indemnity agreements entered into between the hospitalists and the hospital that shift legal responsibility in a way that is sometimes not as carefully considered at the front end of an arrangement than at the back end, when a problem occurs.”

Halpern says that those kinds of situations must be looked at carefully. “[T]hose kinds of indemnity agreements can lead to a whole world of collateral claims litigation and can sometimes compromise insurance coverage,” he says. “For instance, if a hospitalist group signs an indemnity contract with the hospital without clearing it with the hospitalist’s insurer, the insurer might look at that and say, ‘We didn’t underwrite that additional obligation to defend and pay damages for the benefit of the hospital. And therefore, we deny coverage.’”

What Should Hospitalists Do?

If you are an individual hospitalist and your hospital provides your coverage, our experts have some suggestions on how to best protect yourself from surprises later about your liability insurance.

“[Y]ou certainly ought to get a copy of the policy,” says Halpern, and “focus very carefully on several things: 1) what’s covered, 2) what’s excluded, 3) what are the limits, and 4) who’s providing the coverage?”

You need to be able to feel that you can say “yes” to the question, “Is this a company that I can be confident will be there when it’s needed?”

If after a careful review of your policy, you have areas you would like to discuss with the hospital, it’s a matter of negotiation. And when you have the “negotiation muscle” to get what you need for protection, says Halpern, you’re in a better position.

“Frankly, most hospitals are interested in maintaining quality staff, quality relations with physicians—both employed and on the consulting staff,” says Halpern. “[They] are not typically in the business of muscling people and treating them badly. So if the hospitalist finds a legitimate gap in coverage or a concern, by and large hospitals look to be fair in working those things out. If they’re not, there are two basic approaches, and one is to not continue in the relationship.” (In other words, quit). “The second [approach] is to insure over the gap by going to an insurance broker and seeing if you can find coverage.”

Conclusion

Although most hospitalists are covered under their hospital policies, all hospitalists would benefit from understanding the specifics of their malpractice coverage. The dynamics of the hospitalist model will require changes in many areas including malpractice insurance. The trend of insurance carriers to establish a separate classification for hospitalists is likely to provide more precisely written coverage that accounts for the particulars of hospital medicine practice TH

Writer Andrea Sattinger will write about risk management for hospitalists in the Jan. ’06 issue.

References

Wachter RM. The hospitalist movement: ten issues to consider. Hosp Pract. 1999;34(2):104-106.

Entman SS, Glass CA, Hickson GB, et al. The relationship between malpractice claims history and subsequent obstetric care JAMA. 1994;272:1588-1591.

Alpers A. Key legal principles for hospitalists. Am J Med. 2001;111:5-9.

Pham HH, Devers KJ, Kuo S, et al. Health care market trends and the evolution of hospitalist use and roles. J Gen Intern Med. 2005;20:101-107.

How Are You Insured and What Are You Insured For?

One of the hospitalist groups covered by ProMutual is Southern New Hampshire Medical Center, Nashua, where Stewart Fulton, DO, is the head of that group. The hospitalist department is three years old. In fact, the day The Hospitalist talked to Dr. Fulton was the first day hospitalists were providing 24-hour hospital coverage, seven days a week.

Although Dr. Fulton began as the only hospitalist, there are now 10 in the department They are classified as part of a multispecialty group and did not actively participate in choosing their malpractice insurance. He says there have been few legal issues so far.

“I think what is important to us is 1) the reassurance that [the policy is] there and 2) that there is additional coverage … an umbrella policy that will protect us in addition to … our malpractice [policy].”

But does their hospital-provided malpractice insurance address the particulars of a hospitalist’s work such that the hospitalist team feels reassured with the details of their coverage?

“I don’t think I have an answer to that question,” says Dr. Fulton. “I haven’t personally looked through my policy in regard to the coverage and how it relates to my specific practice. Certainly it’s not a traditional internal medicine practice and I don’t know from that perspective what the underwriters would consider [regarding hospitalists] when they weigh their policy for the traditional practice.”

Think on This: Malpractice Recommendations

Determine roles and accountabilities for yourself and the colleagues with whom you will communicate and work. Establish an institutional administrative policy for the hospitalist’s scope of practice. Supply this information to your risk manager to factor in when discussing your insurance coverage with insurance brokers or carriers.
“I believe that whether it’s a teaching hospital or a community hospital, they have to figure out how to do it best for themselves,” says O’Rourke, referring to how hospitalists and other providers will need to share responsibilities for a patient’s care. “You have to have everyone buy in. For instance, if you have hospitalists working on a surgical floor, you better have the surgeons understand what’s going on. If you work on the medical floor, you’ve got to have your attendings and the admitting physician, … the PCPs—everyone—understand what you have there.” And she adds, “If I were running a hospital, I’d be touting [having hospitalists] as a real benefit.”

Recognize that malpractice insurance, too, is an area affected by the evolving dynamics of hospital medicine. “Concern surrounds the myriad organizational and clinical issues that inevitably appear whenever there is a major change in our extraordinarily dynamic healthcare system,” wrote Dr. Wachter. “As with the initial debate about whether to embrace the hospitalist model, one hopes that many of these issues will be settled on the basis of rigorous analysis informed by relevant data.”1

Read your policy. Discuss concerns with your employer’s risk manager. “This conversation is encouraging me to go investigate what our policy is and what the coverage is and what the reasoning and thoughts were that generated the policy and whether it’s sufficient,” says Dr. Fulton. “Certainly as our area of medicine grows … we need to be considering all of those issues—malpractice [and] sufficient coverage for what we do.” —AS

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In this article we highlight malpractice insurance for hospitalists: what you should consider now and in the future regarding policy coverage. policies Available to Hospitalists

The types of malpractice insurance available to hospitalists include:

Policies provided under your employer’s policy or purchased for yourself;

Policies that cover you when any event actually occurs or when the claim is filed; and

Policies purchased by hospitals where the payouts for claims are made either by the insurance company (the carrier) or by the employer (the hospital).

Occurrence or Claims Made

Of the 52 hospitals and 14,000 people that ProMutual insures, half of the policies are individual policies and half are group policies.

Fully Insured or Self Insured?

Individual Policies for Certain Circumstances

Hospitalists who take out their own individual policies usually get coverage from one of the local Physician Insurers Association of America carriers.

Why Are Hospitalists Sued?

O’Rourke, who directs the management of underwriting claims as part of her work at CRICO, believes there is a vast difference between the reasons for claims for internists versus hospitalists.3

The Cost of Insurance

If the Hospitalist Sees the Patient

The Classification of Hospitalists

Whether hospitalists prove to be a riskier group in future research will depend on first determining more precisely what hospitalists do.

What Do Hospitalists Really Do?

Your Policy Type May Matter

What Should Hospitalists Do?

If you are an individual hospitalist and your hospital provides your coverage, our experts have some suggestions on how to best protect yourself from surprises later about your liability insurance.

You need to be able to feel that you can say “yes” to the question, “Is this a company that I can be confident will be there when it’s needed?”

Conclusion

Writer Andrea Sattinger will write about risk management for hospitalists in the Jan. ’06 issue.

References

Wachter RM. The hospitalist movement: ten issues to consider. Hosp Pract. 1999;34(2):104-106.

Entman SS, Glass CA, Hickson GB, et al. The relationship between malpractice claims history and subsequent obstetric care JAMA. 1994;272:1588-1591.

Alpers A. Key legal principles for hospitalists. Am J Med. 2001;111:5-9.

Pham HH, Devers KJ, Kuo S, et al. Health care market trends and the evolution of hospitalist use and roles. J Gen Intern Med. 2005;20:101-107.

How Are You Insured and What Are You Insured For?

But does their hospital-provided malpractice insurance address the particulars of a hospitalist’s work such that the hospitalist team feels reassured with the details of their coverage?

Think on This: Malpractice Recommendations

Determine roles and accountabilities for yourself and the colleagues with whom you will communicate and work. Establish an institutional administrative policy for the hospitalist’s scope of practice. Supply this information to your risk manager to factor in when discussing your insurance coverage with insurance brokers or carriers.
“I believe that whether it’s a teaching hospital or a community hospital, they have to figure out how to do it best for themselves,” says O’Rourke, referring to how hospitalists and other providers will need to share responsibilities for a patient’s care. “You have to have everyone buy in. For instance, if you have hospitalists working on a surgical floor, you better have the surgeons understand what’s going on. If you work on the medical floor, you’ve got to have your attendings and the admitting physician, … the PCPs—everyone—understand what you have there.” And she adds, “If I were running a hospital, I’d be touting [having hospitalists] as a real benefit.”

Recognize that malpractice insurance, too, is an area affected by the evolving dynamics of hospital medicine. “Concern surrounds the myriad organizational and clinical issues that inevitably appear whenever there is a major change in our extraordinarily dynamic healthcare system,” wrote Dr. Wachter. “As with the initial debate about whether to embrace the hospitalist model, one hopes that many of these issues will be settled on the basis of rigorous analysis informed by relevant data.”1

Read your policy. Discuss concerns with your employer’s risk manager. “This conversation is encouraging me to go investigate what our policy is and what the coverage is and what the reasoning and thoughts were that generated the policy and whether it’s sufficient,” says Dr. Fulton. “Certainly as our area of medicine grows … we need to be considering all of those issues—malpractice [and] sufficient coverage for what we do.” —AS

In this article we highlight malpractice insurance for hospitalists: what you should consider now and in the future regarding policy coverage. policies Available to Hospitalists

The types of malpractice insurance available to hospitalists include:

Policies provided under your employer’s policy or purchased for yourself;

Policies that cover you when any event actually occurs or when the claim is filed; and

Policies purchased by hospitals where the payouts for claims are made either by the insurance company (the carrier) or by the employer (the hospital).

Occurrence or Claims Made

Of the 52 hospitals and 14,000 people that ProMutual insures, half of the policies are individual policies and half are group policies.

Fully Insured or Self Insured?

Individual Policies for Certain Circumstances

Hospitalists who take out their own individual policies usually get coverage from one of the local Physician Insurers Association of America carriers.

Why Are Hospitalists Sued?

O’Rourke, who directs the management of underwriting claims as part of her work at CRICO, believes there is a vast difference between the reasons for claims for internists versus hospitalists.3

The Cost of Insurance

If the Hospitalist Sees the Patient

The Classification of Hospitalists

Whether hospitalists prove to be a riskier group in future research will depend on first determining more precisely what hospitalists do.

What Do Hospitalists Really Do?

Your Policy Type May Matter

What Should Hospitalists Do?

If you are an individual hospitalist and your hospital provides your coverage, our experts have some suggestions on how to best protect yourself from surprises later about your liability insurance.

You need to be able to feel that you can say “yes” to the question, “Is this a company that I can be confident will be there when it’s needed?”

Conclusion

Writer Andrea Sattinger will write about risk management for hospitalists in the Jan. ’06 issue.

References

Wachter RM. The hospitalist movement: ten issues to consider. Hosp Pract. 1999;34(2):104-106.

Entman SS, Glass CA, Hickson GB, et al. The relationship between malpractice claims history and subsequent obstetric care JAMA. 1994;272:1588-1591.

Alpers A. Key legal principles for hospitalists. Am J Med. 2001;111:5-9.

Pham HH, Devers KJ, Kuo S, et al. Health care market trends and the evolution of hospitalist use and roles. J Gen Intern Med. 2005;20:101-107.

How Are You Insured and What Are You Insured For?

But does their hospital-provided malpractice insurance address the particulars of a hospitalist’s work such that the hospitalist team feels reassured with the details of their coverage?

Think on This: Malpractice Recommendations

Determine roles and accountabilities for yourself and the colleagues with whom you will communicate and work. Establish an institutional administrative policy for the hospitalist’s scope of practice. Supply this information to your risk manager to factor in when discussing your insurance coverage with insurance brokers or carriers.
“I believe that whether it’s a teaching hospital or a community hospital, they have to figure out how to do it best for themselves,” says O’Rourke, referring to how hospitalists and other providers will need to share responsibilities for a patient’s care. “You have to have everyone buy in. For instance, if you have hospitalists working on a surgical floor, you better have the surgeons understand what’s going on. If you work on the medical floor, you’ve got to have your attendings and the admitting physician, … the PCPs—everyone—understand what you have there.” And she adds, “If I were running a hospital, I’d be touting [having hospitalists] as a real benefit.”

Recognize that malpractice insurance, too, is an area affected by the evolving dynamics of hospital medicine. “Concern surrounds the myriad organizational and clinical issues that inevitably appear whenever there is a major change in our extraordinarily dynamic healthcare system,” wrote Dr. Wachter. “As with the initial debate about whether to embrace the hospitalist model, one hopes that many of these issues will be settled on the basis of rigorous analysis informed by relevant data.”1

Read your policy. Discuss concerns with your employer’s risk manager. “This conversation is encouraging me to go investigate what our policy is and what the coverage is and what the reasoning and thoughts were that generated the policy and whether it’s sufficient,” says Dr. Fulton. “Certainly as our area of medicine grows … we need to be considering all of those issues—malpractice [and] sufficient coverage for what we do.” —AS

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The Role of Hospitalists in Stroke Management

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The Role of Hospitalists in Stroke Management

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Distinguishing the evolving role of the hospitalist in managing patients with stroke requires exploring a number of challenges, a couple of controversies, and some clear opportunities.

Challenges

Hospitalists and their specialist colleagues face a number of challenges associated with stroke management, including the nature of provider teamwork, whether patients present within the window of time for thrombolytic administration, whether hospitalists should administer those agents, and also the care of patients with intracerebral hemorrhage (ICH).

Specialty Support

Traditionally the neurologist has been the key clinician involved in the diagnosis and treatment of patients with stroke. And because a great many neurologists prefer to practice almost exclusively in the outpatient setting, a team of providers in the hospital must handle the current stroke care volume.

Developing protocols and care pathways is an avenue for hospitalists to take a leadership role in implementing evidence-based care, in co-ordinating care between different services, and eventually affecting resource utilization, quality of care, and patient satisfaction in a positive way.

“Coming to the hospital can be a challenge for some of them, although there is a subset of neurologists who really like to be inside the hospital and look after acute issues with respect to neurology,” says Sandeep Sachdeva, MD, Swedish Medical Center in Seattle. “In our institution we’ve had enough neurologists, but most of them are busy with their outpatient practices so they’re not able to spend substantial time [in the hospital]. By default we have to look at the hospitalist program here as a resource for taking care of stroke patients.”1

Emergent evaluation and treatment of acute ischemic stroke is a hot-button issue, especially for community-based hospitals. Some neurologists can leave their office and attend to an acute ischemic stroke presenting to the emergency department, while others can’t. To address this issue some hospitals have developed stroke teams that usually consist of highly trained nurses/advanced registered nurse practitioners (ARNPs) working under the direction of a neurologist, as is the case at Swedish Medical Center. These stroke teams respond to acute strokes presenting in the emergency department and then assist the emergency department physician in expediting the patient evaluation and ensuring that no protocol violation occurs while emergent therapy, such as IV tPA, is administered.

The final decision for administering this medication rests with the emergency department physician and, in some instances, with the neurologist if he or she is able to evaluate the patient in the emergency department. Hospitalists must evaluate their comfort level, knowledge, and experience—and then discuss with their neurologists and emergency department physicians the development of—a care algorithm commensurate with national and local standards of care as it pertains to caring for patients who present with acute stroke.

With relatively little specialty support available, it becomes more important for communication between providers to be clear and reliable; and practitioners must determine the local standard of care.

“I think with stroke it’s a particularly vexing issue, especially when you get outside of metropolitan areas,” says Larry Goldstein, MD, director of the Duke University Stroke Center, Durham, N.C. “In metropolitan areas there may be hospitals with different capabilities that are not too far from one another. And it may make sense in that situation for one hospital to decide on their own: ‘We just don’t have the resources to be able to treat a specific condition, … and it might be better … for patients to not come here for that since we can’t offer the appropriate level of care for that condition.’”

But in rural and other less populated areas, he says “ … that community hospital may be the only game in town. And even though they … wouldn’t have everything that a tertiary care [or] quaternary care academic center would have, they could identify areas that are critically important for the acute care patients they are serving and develop the appropriate levels of competency in that area.”

Administering Thrombolytics

What is the standard by which an individual hospitalist is expected to practice, especially concerning the administration of tPA?

In that regard—without a doubt—patient safety comes first. “Whenever there’s confusion in my mind, I always think … first, do no harm,” says Dr. Sachdeva. “If this is an urban area and other hospitalists are not [administering] tPA, then they are not expected to do so and that may not meet the standard of care for that area. Rural hospitals have successfully been giving tPA to patients with acute ischemic stroke.

The caveat here is that appropriate planning as well as training of caregivers has to take place prior to starting IV tPA administration. “Rural hospitals that have the IV tPA capability usually do so in collaboration with larger regional institutions, academic or otherwise, where services of neurologists and neurosurgeons are available,” says Dr. Sachdeva. “Size of the institution should not be an impediment to IV tPA administration.”

As baby boomers age, the demand for better stroke care will increase, and hospitals as well as caregivers need to be prepared to meet the expectations of patients.

David Thurber, MD, medical director of the Cary Hospital Medicine Service, a division of Wake Medical Center, Cary, N.C., speaks of the need for specialty backup at community hospitals.

“For those people who practice in community hospitals, including myself,” he says, “it’s like being the pitcher on a baseball team: If you can’t field the outfield, you shouldn’t be pitching the ball because there’s nobody out there to catch it. So if you can’t get the backup of a neurologist, or of a neurosurgeon in the case of hemorrhagic stroke, in my opinion you have no business pushing tPA. Your obligation is to try, as many community hospitals have done with invasive cardiac procedures, such as emergent use of percutaneous coronary artery intervention, to transfer the patient to a facility where those can be done in a timely fashion.”

What should hospitalists do if they are expected to administer tPA and are unsure of their skill level?

“I would take this issue back to the administration of the hospital,” says Dr. Sachdeva, “and come up with a plan where the neurologists or the emergency department physicians feel motivated to give tPA.”

The most important element to consider when making the decision of whether to administer tPA is the quality of the history. “If there is any doubt about the time or the mechanism of stroke onset, then as practitioners we are very well justified in not giving tPA,” says Dr. Sachdeva, who believes there are more lawsuits for not giving tPA than for giving it. But if you withhold tPA and justify the decision with appropriate reasoning, that certainly places the individual on steadier legal ground.

Training and Competence

Stroke management is not a universally strong topic in medical education. “Not every medical school requires a rotation in the neurosciences or exposure to stroke treatment,” says Dr. Goldstein, “and it’s the same thing in residency programs, depending on which residency program you go through, be it as an internist or as an emergency physician. … So it begins in medical school and follows through residency, but as we know, our training only begins in those formal settings. In medicine, training is a lifelong activity. Things change all the time. And it would [take] appropriate levels of continuing education directly related to cerebrovascular disease to be able to understand modern diagnosis and modern therapeutics.”

Another issue is whether an institution will receive patients for stroke treatment. “Just as hospitals credential people to [perform] procedures, not every hospital can offer every therapy to every patient at the same level,” says Dr. Goldstein. “The thing that is inappropriate is to force people to do things for which they’re not trained.”

Although that is also partially an institutional decision, “institutions can’t have it both ways,” he explains. “They can’t say well, we’re going to be taking care of patients with X, Y, or Z, but then not have the facilities and personnel available to be able to acutely treat and stabilize patients even if they do require more advanced care somewhere else.”

Dr. Sachdeva’s team had to cover a considerable knowledge gap to bring his colleagues up to speed and competence by talking directly to the hospitalists and arranging CMEs for them, as well as by encouraging them to get certified in using the National Institutes of Health (NIH) stroke scale.

“The key is for hospitalists to make sure when they’re taking on an area of patient care that they feel comfortable doing that and not themselves be the default for any medical or surgical conditions,” says David Likosky, MD, who is board certified in neurology and internal medicine, and is the director of the Stroke Program of Evergreen Healthcare, Kirkland, Wash.

One way to become better prepared to manage stroke is to familiarize oneself with the National Institutes of Health (NIH) stroke scale. Online training for the NIH Stroke Scale (approved for two hours of category 1 CME credit from the NIH) is available at www.ninds.nih.gov/doctors/NIH_Stroke_Scale.pdf.).

Excellent resources for developing protocols include the American Stroke Association/American Heart Association, the work of the Brain Attack Coalition (a group of professional, voluntary, and governmental entities dedicated to reducing the occurrence, disabilities, and death associated with stroke—www.stroke-site.org/), and the Web site (www.strokecenter.org), produced out of Washington University in St. Louis. SHM (www.hospitalmedicine.org), which is in the process of creating a Web-based stroke resource room, which—at press time—was scheduled to be live by August 1.

If you [in a community hospital] can’t get the backup of a neurologist, or of a neurosurgeon in the case of hemorrhagic stroke, in my opinion you have no business pushing tPA.

—David Thurber, MD

Systems and Monitoring

Having the right systems in place enables smooth patient assessment and treatment. First establish a means for education in stroke care for hospitalists and all support staff. Other important systems include having protocols for admitting [patients] for stroke care; setting up communication pathways for various disciplines involved in stroke care; having systems to gather, analyze, and monitor data; and having particularly good teamwork and response time.

William Likosky, MD, director of the Stroke Program at the Swedish Medical Center, Seattle, strongly believes in systems and processes of care, whereby a well-designed system should not only be able to prevent mistakes by an individual caregiver, but also to facilitate optimal evidence-based care in every case. As an institution Swedish Medical draws inspiration from the Institute of Healthcare Improvement’s campaign to prevent 100,000 avoidable deaths nationwide in its hospitalized patients. Since its inception at Swedish Medical two years ago, the stroke program is credited with preventing 22 deaths.

Of course any protocol’s worth will vary according to the effectiveness with which it is implemented. Developing protocols and care pathways is an avenue for hospitalists to take a leadership role in implementing evidence-based care, in co-ordinating care between different services, and eventually affecting resource utilization, quality of care, and patient satisfaction positively.

Protocols or pathways fail when they’re not patient-centered, when input isn’t solicited from other caregivers during the development phase, or when their implementation is not monitored. To Dr. Sachdeva, “the main issue is how you implement [the protocol], how you monitor the implementation, and how you fix the glitches or the problems that usually ensue when you’re rolling out a new protocol.”

FAST FACTS

Of the 700,000 strokes that occur each year 200,000 are recurrent. Increasing age is the main risk factor for stroke.

Response and Feedback

Another imperative of any stroke program is its response time. “We monitor very closely our emergency department evaluation times for patients coming in within the window for giving tPA,” says Dr. Sachdeva. “We are strict about this because we want every patient to be evaluated within 45 minutes—anybody who is a candidate for possible intervention with acute thrombolytics—either IV or IA. Those times are monitored, and any time that 45-minute window is missed, we have an individual conversation with the people who were responsible, not as a confrontation, but [to ask], ‘What can we do to help you?’ And each time we do that we learn something new.

“Usually in these cases, there were things that were happening that were out of control and sometimes you can control them and sometimes you can’t,” he says. “Next time we try to manage the variables better. So we do have a hands-on continuous monitoring process that is not intrusive, and it gives us an idea of how we are holding up with certain quality parameters.”

Teamwork and Communication

One of the important systems is how well all involved work as a team. “Most of the time, IV tPA is given in the emergency department and the emergency department doctors now are very comfortable giving IV tPA with the telephonic help from a neurologist,” says Dr. Sachdeva. “But they also receive assistance from the stroke nurse, who consults on every stroke patient who is a candidate for emergent intervention in the emergency department.”

Swedish Medical maintains dedicated stroke nurses who act as facilitators to ensure everybody holds up their end of the bargain in stroke care. This includes a combination of nurses and nurse practitioners. But ultimately it is the emergency department physician’s decision in consultation with the neurologist by phone.

Part of their facilitation involves negotiating to cut down on time. “We don’t … rush our patients, but we cut down on avoidable delays,” says Dr. Sachdeva. “We try to get all the pertinent workup done as fast as we can, and then collate the data, make sure the data are disseminated to the parties that need the data, and decisions are made and appropriate treatment algorithms applied.”

These dedicated nurses are available in person for any acute stroke that falls within the window for an emergent intervention. “But if it is [an] acute stroke outside the window,” says Dr. Sachdeva, “they will consult telephonically to help you get certain things started, and then consult on the patient the next business day. They are available 24/7 both to the emergency department and to any floor area of the hospital. Anyplace that stroke can happen … they are there in a heartbeat. And the stroke nurses have been invaluable in assisting the hospitalists in day-to-day care of the stroke patients as well as in educating patients and their families.”

Controversies in Stroke Management

Although many hospitalists are uncomfortable treating ischemic strokes, far more may show discomfort at the idea of treating hemorrhagic strokes.

“Bleeding within the head carries a morbidity and mortality that sometimes is exaggerated in terms of its perception,” he says, “and once again, one has to look at the training that was given to most hospitalists during their residency. It was insufficient with respect to managing intracranial hemorrhages.”

Treating hemorrhagic strokes has traditionally been the preserve of neurosurgeons. “Some neurosurgeons are of the opinion that if there is no indication for surgical intervention for a particular ICH case, then the patient should be on the medical service,” says Dr. Sachdeva. “The medical side is feeling thoroughly unprepared to handle these.”

His team is looking at this issue at their institution to come up with appropriate algorithms regarding triage and care of patients with ICH.

Hospitalists and Stroke Management: Opportunities

One advantage of the hospitalist system in managing stroke is that hospitalists are readily available. Monitoring patients’ recovery for any emergent complications is also an important role for the hospitalist. Most often these complications are urinary tract infections, aspiration pneumonia, and deep venous thrombosis.

The team at Swedish refers to these high-risk complications as “dashboards,” likening them to the dashboard of an automobile that must be carefully watched.

Swedish Medical has seven markers for quality of care that the stroke team monitors. They have a statistician, people who gather the data, people who analyze the data, and those who then put the data in a graph format for the team to review trends reflecting quality of care.

This secondary prevention comes into play while coordinating care at the time of discharge. Hospitalists can start the ball rolling so a primary care physician or the facility to which the patient may next be transferred will continue the appropriate care for these patients.

Hospitalists could also take leadership role within their institutions in formulating pathways for emergent evaluation of strokes that occur in hospitalized patients.

“This is what most hospitalists should be able to do with adequate training,” says Dr. Sachdeva. “At the very least, hospitalists can positively impact stroke care by setting into place protocols, processes, and systems of care to ensure prevention DVTs, UTIs, aspiration pneumonias, and initiation of appropriate secondary prevention modalities for patients admitted with a diagnosis of stroke.”

Any institution that prevents these complications from developing should see an automatic benefit of those quality parameters in decreased length of stay, decreased utilization of resources, and improved patient satisfaction.

Follow-Up and Compliance

Having the undivided attention of the patient and his or her family at the time of hospitalization is a golden opportunity.

“We start patients on a vigorous, evidence-based secondary prevention regimen and by opening a dialogue with the patient and the family,” says Dr. Sachdeva. “Realize you’ve started something good; it needs to be followed up and reinforced on a regular basis either through their primary care provider or through a dedicated stroke follow-up clinic.”

The plan for handling a potential future brain attack is also outlined. One of the most noteworthy programs for secondary prevention of strokes is the one out of the University of California, Los Angeles called PROTECT—Preventing Recurrence of Thromboembolic Events through Coordinated Treatment (http://strokeprotect.mednet.ucla.edu/). (See p. 22.)2

Dr. Thurber, who is also president of the Piedmont Chapter of SHM, hopes that secondary prevention work by stroke teams around the country and the results of public education campaigns can help reduce the number of patients who present for stroke treatment outside the time window for thrombolytic therapy.

FAST FACTS

Annually about 300,000 Americans suffer TIAs. One-third of them will develop a stroke. Risk factors include hypertension, cigarette smoking, diabetes mellitus, hyperlipidemia, obesity, and heart disease.

Communication with PCPs

If you have a dedicated group of primary care physicians that you work with, then they are, in effect, your customers. They should develop that program so they can give their input as how they would like communication and they can know what kind of care their patients will receive once admitted to the hospitalists or the hospitalist-neurologist team.

Call the primary care physicians at the time of discharge in order to convey the highlights of hospitalization and review key follow-up issues. Information can fall through the cracks, but the PROTECT program shows that this is rare if you use the tools provided as part of the program.1 Their data show that initiating secondary prevention modalities while the patient is hospitalized is important, but following up on them is just as important to good outcomes.

The discharging physician must partner with the primary care providers to maintain the momentum with respect to secondary prevention, re-enforcing education, and monitoring for development of side effects from the medications initiated during hospitalization.

Future Trends

Given the trends of an expanding hospitalist system, increasing time limitations for specialists, the relative dearth of neurologists, and uninviting circumstances for practice and compensation, neurologists will need to partner with a group of physicians who are structured to be available 24/7.

In his coauthored letter to the editor of Stroke, published in June 2005, Dr. Likosky challenged neurologists to avoid being “asleep at the wheel” in stroke prevention.1 “If neurologists want to be the ones taking care of stroke patients,” he said, “then they need to decide what role they want to play, because otherwise it’s going to be taken over by hospitalists, which may be the most appropriate thing.”

Conclusion

Challenges and opportunities characterize the work of hospitalists involved in stroke care. Good, ongoing training is imperative as are effective institutional systems and efficient monitoring of those systems. Protocols can be adapted to best serve an individual institution; the nature of their implementation and the teamwork or lack thereof will make the difference in the benefit to medical and institutional outcomes.

Recommendations for best performance in stroke care include keeping open channels of communication and good feedback systems, discussing controversies in order to seek resolutions and improve systems, and using the advantage of access to patients and their families to best begin follow-up and secondary prevention efforts. TH

Writer Andrea M. Sattinger will cover the malpractice crisis in healthcare in future issues of The Hospitalist.

References

Likosky DJ. Who will care for our hospitalized patients? Stroke. 2005;36:1113-1114.

Ovbiagele B, Saver JL, Fredieu A, et al. PROTECT: A coordinated stroke treatment program to prevent recurrent thromboembolic events. Neurology. 2004;63:1217-1222.

PROTECTing Stroke Patients

The role of hospitalists in UCLA’s program

Hospitalists have a substantial and an important role to play in enhancing the follow-up of stroke patients, particularly in hospitals that don’t have the primary stroke service.

Bruce Ovbiagele, MD, director of UCLA’s PROTECT program, spoke to The Hospitalist about the lessons and future objectives of the program.2

“For our program, we have a primary stroke service. However, we are trying to extend this to the whole of the UCLA Medical Center because, of course, there are stroke patients who are admitted to the hospital in different services [and] these patients are not benefiting from the kind of follow-up that we [do] within the PROTECT program. Most hospitals don’t have a primary stroke service and patients are admitted to the general medicine ward[s] anyway, so the hospitalists have a very substantial and an important role to play in enhancing the follow-up of stroke patients, particularly in hospitals that don’t have the primary stroke service.

“Not only that, but because many of the primary care physicians who will probably be seeing these patients for follow-up … are primary care physicians themselves, the rapport between the hospitalists and these patients, at least in my experience, tends to be much better than if they went a neurologist who would try to convey information to the primary care physician. For whatever reason, there seems to be a much better and more accepted communication between the internists or family care physician or hospitalist and the primary care physician on the outside. So we have good compliance rates, but this is within our system, which is primary stroke, making sure that we have the patients follow up with the neurologists. But in the real world—not a tertiary medical center or when they don’t have a primary stroke service or don’t have a neurologist seeing patients very consistently on the inpatient service—this might be a little bit of an issue. So in that kind of institution, the hospitalist is just perfect [for initiating secondary prevention].

“There have been so many lessons [from the program], but more than anything else [we’ve learned] that involving the patient, educating the patient, empowers the patient and is really the best tool for improving outcomes. … Once the patients know what the goals are, they are willing to participate in their own care to an extent that is quite remarkable. Of all the things we’ve learned, that has been the eye-opener for us. Also, once you can key in with somebody in the family, you find that that is really the most effective tool in making sure that compliance is optimal.”

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Distinguishing the evolving role of the hospitalist in managing patients with stroke requires exploring a number of challenges, a couple of controversies, and some clear opportunities.

Challenges

Specialty Support

Administering Thrombolytics

What is the standard by which an individual hospitalist is expected to practice, especially concerning the administration of tPA?

As baby boomers age, the demand for better stroke care will increase, and hospitals as well as caregivers need to be prepared to meet the expectations of patients.

David Thurber, MD, medical director of the Cary Hospital Medicine Service, a division of Wake Medical Center, Cary, N.C., speaks of the need for specialty backup at community hospitals.

What should hospitalists do if they are expected to administer tPA and are unsure of their skill level?

Training and Competence

If you [in a community hospital] can’t get the backup of a neurologist, or of a neurosurgeon in the case of hemorrhagic stroke, in my opinion you have no business pushing tPA.

—David Thurber, MD

Systems and Monitoring

FAST FACTS

Of the 700,000 strokes that occur each year 200,000 are recurrent. Increasing age is the main risk factor for stroke.

Response and Feedback

Teamwork and Communication

Controversies in Stroke Management

Although many hospitalists are uncomfortable treating ischemic strokes, far more may show discomfort at the idea of treating hemorrhagic strokes.

His team is looking at this issue at their institution to come up with appropriate algorithms regarding triage and care of patients with ICH.

Hospitalists and Stroke Management: Opportunities

The team at Swedish refers to these high-risk complications as “dashboards,” likening them to the dashboard of an automobile that must be carefully watched.

Hospitalists could also take leadership role within their institutions in formulating pathways for emergent evaluation of strokes that occur in hospitalized patients.

Follow-Up and Compliance

Having the undivided attention of the patient and his or her family at the time of hospitalization is a golden opportunity.

FAST FACTS

Communication with PCPs

Future Trends

Conclusion

Writer Andrea M. Sattinger will cover the malpractice crisis in healthcare in future issues of The Hospitalist.

References

Likosky DJ. Who will care for our hospitalized patients? Stroke. 2005;36:1113-1114.

Ovbiagele B, Saver JL, Fredieu A, et al. PROTECT: A coordinated stroke treatment program to prevent recurrent thromboembolic events. Neurology. 2004;63:1217-1222.

PROTECTing Stroke Patients

The role of hospitalists in UCLA’s program

Hospitalists have a substantial and an important role to play in enhancing the follow-up of stroke patients, particularly in hospitals that don’t have the primary stroke service.

Bruce Ovbiagele, MD, director of UCLA’s PROTECT program, spoke to The Hospitalist about the lessons and future objectives of the program.2

Distinguishing the evolving role of the hospitalist in managing patients with stroke requires exploring a number of challenges, a couple of controversies, and some clear opportunities.

Challenges

Specialty Support

Administering Thrombolytics

What is the standard by which an individual hospitalist is expected to practice, especially concerning the administration of tPA?

As baby boomers age, the demand for better stroke care will increase, and hospitals as well as caregivers need to be prepared to meet the expectations of patients.

David Thurber, MD, medical director of the Cary Hospital Medicine Service, a division of Wake Medical Center, Cary, N.C., speaks of the need for specialty backup at community hospitals.

What should hospitalists do if they are expected to administer tPA and are unsure of their skill level?

Training and Competence

If you [in a community hospital] can’t get the backup of a neurologist, or of a neurosurgeon in the case of hemorrhagic stroke, in my opinion you have no business pushing tPA.

—David Thurber, MD

Systems and Monitoring

FAST FACTS

Of the 700,000 strokes that occur each year 200,000 are recurrent. Increasing age is the main risk factor for stroke.

Response and Feedback

Teamwork and Communication

Controversies in Stroke Management

Although many hospitalists are uncomfortable treating ischemic strokes, far more may show discomfort at the idea of treating hemorrhagic strokes.

His team is looking at this issue at their institution to come up with appropriate algorithms regarding triage and care of patients with ICH.

Hospitalists and Stroke Management: Opportunities

The team at Swedish refers to these high-risk complications as “dashboards,” likening them to the dashboard of an automobile that must be carefully watched.

Hospitalists could also take leadership role within their institutions in formulating pathways for emergent evaluation of strokes that occur in hospitalized patients.

Follow-Up and Compliance

Having the undivided attention of the patient and his or her family at the time of hospitalization is a golden opportunity.

FAST FACTS

Communication with PCPs

Future Trends

Conclusion

Writer Andrea M. Sattinger will cover the malpractice crisis in healthcare in future issues of The Hospitalist.

References

Likosky DJ. Who will care for our hospitalized patients? Stroke. 2005;36:1113-1114.

Ovbiagele B, Saver JL, Fredieu A, et al. PROTECT: A coordinated stroke treatment program to prevent recurrent thromboembolic events. Neurology. 2004;63:1217-1222.

PROTECTing Stroke Patients

The role of hospitalists in UCLA’s program

Hospitalists have a substantial and an important role to play in enhancing the follow-up of stroke patients, particularly in hospitals that don’t have the primary stroke service.

Bruce Ovbiagele, MD, director of UCLA’s PROTECT program, spoke to The Hospitalist about the lessons and future objectives of the program.2

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