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In Demand
Hospitalist Nhi Lan Pham, MD, accepted a signing/starting bonus to relocate to Texas after finishing her residency in internal medicine in the Detroit area in 2007. The accompanying relocation expenses helped Dr. Pham begin her career near her family in Austin, and the flexible work schedule she negotiated allowed her to spend time with her family.
Another hospitalist willing to relocate for the right job used the relocation budget to his advantage. Moving to take the right job cost $2,000. The employer had budgeted $5,000 for relocation expenses, and the physician was able to arrange to have the $3,000 difference added to his signing bonus.
Yet another physician, already established as a hospitalist in an underserved area of his state, was attracted to a new position. However, his original acceptance of a loan repayment from the state as an inducement to work in the underserved region precluded his applying for the new position. His arrangement with the state did not prevent his approaching the new hospital to see what might be possible. It was a wise move; the new hospital agreed to increase the hospitalist’s signing bonus by enough to reimburse the state for the loan repayment.
One foreign-born physician secured a commitment from his recruiter that his employer would sponsor him and his family for green cards. Another candidate agreed to a reduced starting salary in return for help in securing a visa.
With a projected need for 30,000 hospitalists by 2010, hospitalists find themselves in the driver’s seat when it comes to weighing offers. Incentives are increasingly enticing as hospitalist recruiters nationwide struggle to lure top talent.
Incentives, Perks
What does this mean in practical terms? It means not only rising salaries but also incentives and extra perks to attract candidates to this fast-growing specialty.
Financial benefits are widespread, including signing and performance bonuses. Many hospitalists can plan on a guaranteed income. Employers may agree to pay off student loans or reimburse tuition. Malpractice insurance and tail coverage are commonly covered. Some employers also allow part-time or temporary employment to give a new hospitalist an opportunity to decide about the future or to accommodate a personal schedule.
“There is often a laundry list of incentives from which to choose, as well as more of a cafeteria plan that a doctor and employer can customize to meet specific needs,” according to Mark Dotson, MD, senior director of recruitment at Brentwood, Tenn.-based Cogent Healthcare. Cogent is a recruiting firm dedicated to building and managing hospitalist programs.
By far, the most appealing incentives are flexibility of scheduling and workload that allow physicians to coordinate their work schedule with their lifestyle. In fact, Dan Polk, MD, chief of the division of hospital-based medicine at Children’s Memorial Hospital in Chicago, considers flexible scheduling the basis of his plan to retain staff and build job satisfaction.
“We support lifestyle choices and respect life situations,” Dr. Polk says. “We foster the idea of joining a great team, and we make the environment attractive enough to encourage people to stay. We try to work within the team to cover those who need help, such as maternity or family leave, and we compensate for extra time at a different rate. We embrace people who want to work part time or share a job. Our goals are to support people and to make them want to get up in the morning to come to work.”
Part of the attractiveness of schedule flexibility is fewer weekend and night hours. In addition, employers may allow hospitalists to limit their caseload. Some hospitalists, for example, request a cap of 15 to 18 patients a day.
While retaining experienced, motivated staff is a goal of hospitals, lower caseloads mean “more doctors to do the work if doctors work fewer hours,” says Rusty Holman, MD, Cogent’s chief operating officer and SHM’s immediate past president. To meet that need, hospitals are turning to community-based physicians, fellows, and residents to work weekends and evenings. This, in turn, offers the perk of part-time work for those who want more personal time in their schedule.
The demand for nocturnists also is growing (The Hospitalist, January 2008, p. 22). Nocturnists work at night and on weekends and usually work shorter hours. These physicians prefer this schedule so they can have their days free for family or other pursuits. They also enjoy higher compensation, fewer workdays per month, and lower productivity expectations.
In addition to the having the options of part-time hours, temporary work, or job sharing, hospitalists also can negotiate other schedule perks. Some request and receive a two-week-on, two-week-off schedule. Many ask about the shift model, which demands nothing beyond the full eight or 12 hours of work. Still other applicants find a swing shift fits their lifestyle. There are even short-term choices: the hospitalist program at the University of California at Irvine offers recent residents the opportunity to work for one year while deciding about their career. With scheduling choices as part of an incentive package, many hospitalists achieve Dr. Polk’s goal of being eager to come to work each morning.
Physicians are not the only beneficiaries of these perks. Cogent, for example, recruits physician assistants and nurse practitioners when forming hospitalist groups. These employees also enjoy incentives, including tuition for continuing education and the same schedule flexibility as hospitalists.
Seller’s Market
Hospital medicine faces a shortage of qualified applicants. The need for hospitalists far surpasses the supply of physicians, who are in the enviable position of sifting through incentives and perks when selecting a hospitalist job.
This has become a national concern, according to Vikas Parekh, MD, assistant director of the hospitalist program and assistant professor of medicine at the University of Michigan Health Center in Ann Arbor. “We’re not seeing a pool of applicants because top residents are not pursuing hospitalist careers,” Dr. Parekh says.
Alpesh Amin, MD, MBA, a member of SHM’s Board of Directors, concurs but also points out that the number of hospitalist jobs is growing. “The need for a few hundred hospitalists 10 years ago has grown to 20,000 to 30,000 today, thus creating a need much greater than the supply,” says Dr. Amin, professor and chief, general internal medicine, executive director and founder of the hospitalist program at the University of California Irvine.
Why the shortage? First, fewer physicians are choosing to practice general medicine, either as an internist, family practitioner, or hospitalist. A recent study found fewer medical students were planning to concentrate on internal and family medicine, and that those who did planned to go into a subspecialty later.1 Dr. Parekh attributes this to a combination of reasons. “Most internal medicine residents are subspecialty oriented and may have decided their specialty early on,” Dr. Parekh says. “They may choose a subspecialty for financial reasons or prestige,” he continues, “but they may also be unclear about what a hospitalist career really is.”
Second, hospitalist programs have begun to expand from large metropolitan regions to smaller and rural areas. The result is an even greater demand for hospitalists.
Meet the Need
“There are no saturated markets within hospital medicine,” Dr. Holman says. “That is, most groups are always actively recruiting. [Cogent develops] full hospitalist programs, including recruiting, employing, managing, and training for new and existing hospitalist groups.”
Who is being recruited? Many recruiters approach residents who have not chosen a subspecialty to offer a staff position after they finish the residency. Although a recruiting firm may not offer financial aid during the residency, an employer may provide some sort of stipend if the candidate commits to remain on staff for a specified time after residency. “Recruit and retain” is the operative phrase in these cases.
Recruiters also are approaching generalists just entering the market to point out the advantages of avoiding the startup costs of establishing an outpatient practice. Further, many hospitalists are emerging from the ranks of solo practitioners interested in the financial and personal advantages of belonging to hospitalist groups. Not only does that eliminate the practice overhead (including the burden of regulatory compliance), but it also may offer additional administrative and academic opportunities. As Dr. Amin says, “There are more MD-MBA combos out there.”
Are incentives the answer to the shortage? Perhaps for now. With time, hospital medicine’s built-in perks may end the shortage and the need for added incentives. TH
Ann Kepler is a medical writer based in Chicago.
Reference
- Croasdale M. Primary care doctors in demand; signing bonuses and higher pay for some. American Medical News. June 19, 2006. Available at www.ama-assn.org/amednews/site/free/prl10619.htm. Last accessed March 19, 2008.
Hospitalist Nhi Lan Pham, MD, accepted a signing/starting bonus to relocate to Texas after finishing her residency in internal medicine in the Detroit area in 2007. The accompanying relocation expenses helped Dr. Pham begin her career near her family in Austin, and the flexible work schedule she negotiated allowed her to spend time with her family.
Another hospitalist willing to relocate for the right job used the relocation budget to his advantage. Moving to take the right job cost $2,000. The employer had budgeted $5,000 for relocation expenses, and the physician was able to arrange to have the $3,000 difference added to his signing bonus.
Yet another physician, already established as a hospitalist in an underserved area of his state, was attracted to a new position. However, his original acceptance of a loan repayment from the state as an inducement to work in the underserved region precluded his applying for the new position. His arrangement with the state did not prevent his approaching the new hospital to see what might be possible. It was a wise move; the new hospital agreed to increase the hospitalist’s signing bonus by enough to reimburse the state for the loan repayment.
One foreign-born physician secured a commitment from his recruiter that his employer would sponsor him and his family for green cards. Another candidate agreed to a reduced starting salary in return for help in securing a visa.
With a projected need for 30,000 hospitalists by 2010, hospitalists find themselves in the driver’s seat when it comes to weighing offers. Incentives are increasingly enticing as hospitalist recruiters nationwide struggle to lure top talent.
Incentives, Perks
What does this mean in practical terms? It means not only rising salaries but also incentives and extra perks to attract candidates to this fast-growing specialty.
Financial benefits are widespread, including signing and performance bonuses. Many hospitalists can plan on a guaranteed income. Employers may agree to pay off student loans or reimburse tuition. Malpractice insurance and tail coverage are commonly covered. Some employers also allow part-time or temporary employment to give a new hospitalist an opportunity to decide about the future or to accommodate a personal schedule.
“There is often a laundry list of incentives from which to choose, as well as more of a cafeteria plan that a doctor and employer can customize to meet specific needs,” according to Mark Dotson, MD, senior director of recruitment at Brentwood, Tenn.-based Cogent Healthcare. Cogent is a recruiting firm dedicated to building and managing hospitalist programs.
By far, the most appealing incentives are flexibility of scheduling and workload that allow physicians to coordinate their work schedule with their lifestyle. In fact, Dan Polk, MD, chief of the division of hospital-based medicine at Children’s Memorial Hospital in Chicago, considers flexible scheduling the basis of his plan to retain staff and build job satisfaction.
“We support lifestyle choices and respect life situations,” Dr. Polk says. “We foster the idea of joining a great team, and we make the environment attractive enough to encourage people to stay. We try to work within the team to cover those who need help, such as maternity or family leave, and we compensate for extra time at a different rate. We embrace people who want to work part time or share a job. Our goals are to support people and to make them want to get up in the morning to come to work.”
Part of the attractiveness of schedule flexibility is fewer weekend and night hours. In addition, employers may allow hospitalists to limit their caseload. Some hospitalists, for example, request a cap of 15 to 18 patients a day.
While retaining experienced, motivated staff is a goal of hospitals, lower caseloads mean “more doctors to do the work if doctors work fewer hours,” says Rusty Holman, MD, Cogent’s chief operating officer and SHM’s immediate past president. To meet that need, hospitals are turning to community-based physicians, fellows, and residents to work weekends and evenings. This, in turn, offers the perk of part-time work for those who want more personal time in their schedule.
The demand for nocturnists also is growing (The Hospitalist, January 2008, p. 22). Nocturnists work at night and on weekends and usually work shorter hours. These physicians prefer this schedule so they can have their days free for family or other pursuits. They also enjoy higher compensation, fewer workdays per month, and lower productivity expectations.
In addition to the having the options of part-time hours, temporary work, or job sharing, hospitalists also can negotiate other schedule perks. Some request and receive a two-week-on, two-week-off schedule. Many ask about the shift model, which demands nothing beyond the full eight or 12 hours of work. Still other applicants find a swing shift fits their lifestyle. There are even short-term choices: the hospitalist program at the University of California at Irvine offers recent residents the opportunity to work for one year while deciding about their career. With scheduling choices as part of an incentive package, many hospitalists achieve Dr. Polk’s goal of being eager to come to work each morning.
Physicians are not the only beneficiaries of these perks. Cogent, for example, recruits physician assistants and nurse practitioners when forming hospitalist groups. These employees also enjoy incentives, including tuition for continuing education and the same schedule flexibility as hospitalists.
Seller’s Market
Hospital medicine faces a shortage of qualified applicants. The need for hospitalists far surpasses the supply of physicians, who are in the enviable position of sifting through incentives and perks when selecting a hospitalist job.
This has become a national concern, according to Vikas Parekh, MD, assistant director of the hospitalist program and assistant professor of medicine at the University of Michigan Health Center in Ann Arbor. “We’re not seeing a pool of applicants because top residents are not pursuing hospitalist careers,” Dr. Parekh says.
Alpesh Amin, MD, MBA, a member of SHM’s Board of Directors, concurs but also points out that the number of hospitalist jobs is growing. “The need for a few hundred hospitalists 10 years ago has grown to 20,000 to 30,000 today, thus creating a need much greater than the supply,” says Dr. Amin, professor and chief, general internal medicine, executive director and founder of the hospitalist program at the University of California Irvine.
Why the shortage? First, fewer physicians are choosing to practice general medicine, either as an internist, family practitioner, or hospitalist. A recent study found fewer medical students were planning to concentrate on internal and family medicine, and that those who did planned to go into a subspecialty later.1 Dr. Parekh attributes this to a combination of reasons. “Most internal medicine residents are subspecialty oriented and may have decided their specialty early on,” Dr. Parekh says. “They may choose a subspecialty for financial reasons or prestige,” he continues, “but they may also be unclear about what a hospitalist career really is.”
Second, hospitalist programs have begun to expand from large metropolitan regions to smaller and rural areas. The result is an even greater demand for hospitalists.
Meet the Need
“There are no saturated markets within hospital medicine,” Dr. Holman says. “That is, most groups are always actively recruiting. [Cogent develops] full hospitalist programs, including recruiting, employing, managing, and training for new and existing hospitalist groups.”
Who is being recruited? Many recruiters approach residents who have not chosen a subspecialty to offer a staff position after they finish the residency. Although a recruiting firm may not offer financial aid during the residency, an employer may provide some sort of stipend if the candidate commits to remain on staff for a specified time after residency. “Recruit and retain” is the operative phrase in these cases.
Recruiters also are approaching generalists just entering the market to point out the advantages of avoiding the startup costs of establishing an outpatient practice. Further, many hospitalists are emerging from the ranks of solo practitioners interested in the financial and personal advantages of belonging to hospitalist groups. Not only does that eliminate the practice overhead (including the burden of regulatory compliance), but it also may offer additional administrative and academic opportunities. As Dr. Amin says, “There are more MD-MBA combos out there.”
Are incentives the answer to the shortage? Perhaps for now. With time, hospital medicine’s built-in perks may end the shortage and the need for added incentives. TH
Ann Kepler is a medical writer based in Chicago.
Reference
- Croasdale M. Primary care doctors in demand; signing bonuses and higher pay for some. American Medical News. June 19, 2006. Available at www.ama-assn.org/amednews/site/free/prl10619.htm. Last accessed March 19, 2008.
Hospitalist Nhi Lan Pham, MD, accepted a signing/starting bonus to relocate to Texas after finishing her residency in internal medicine in the Detroit area in 2007. The accompanying relocation expenses helped Dr. Pham begin her career near her family in Austin, and the flexible work schedule she negotiated allowed her to spend time with her family.
Another hospitalist willing to relocate for the right job used the relocation budget to his advantage. Moving to take the right job cost $2,000. The employer had budgeted $5,000 for relocation expenses, and the physician was able to arrange to have the $3,000 difference added to his signing bonus.
Yet another physician, already established as a hospitalist in an underserved area of his state, was attracted to a new position. However, his original acceptance of a loan repayment from the state as an inducement to work in the underserved region precluded his applying for the new position. His arrangement with the state did not prevent his approaching the new hospital to see what might be possible. It was a wise move; the new hospital agreed to increase the hospitalist’s signing bonus by enough to reimburse the state for the loan repayment.
One foreign-born physician secured a commitment from his recruiter that his employer would sponsor him and his family for green cards. Another candidate agreed to a reduced starting salary in return for help in securing a visa.
With a projected need for 30,000 hospitalists by 2010, hospitalists find themselves in the driver’s seat when it comes to weighing offers. Incentives are increasingly enticing as hospitalist recruiters nationwide struggle to lure top talent.
Incentives, Perks
What does this mean in practical terms? It means not only rising salaries but also incentives and extra perks to attract candidates to this fast-growing specialty.
Financial benefits are widespread, including signing and performance bonuses. Many hospitalists can plan on a guaranteed income. Employers may agree to pay off student loans or reimburse tuition. Malpractice insurance and tail coverage are commonly covered. Some employers also allow part-time or temporary employment to give a new hospitalist an opportunity to decide about the future or to accommodate a personal schedule.
“There is often a laundry list of incentives from which to choose, as well as more of a cafeteria plan that a doctor and employer can customize to meet specific needs,” according to Mark Dotson, MD, senior director of recruitment at Brentwood, Tenn.-based Cogent Healthcare. Cogent is a recruiting firm dedicated to building and managing hospitalist programs.
By far, the most appealing incentives are flexibility of scheduling and workload that allow physicians to coordinate their work schedule with their lifestyle. In fact, Dan Polk, MD, chief of the division of hospital-based medicine at Children’s Memorial Hospital in Chicago, considers flexible scheduling the basis of his plan to retain staff and build job satisfaction.
“We support lifestyle choices and respect life situations,” Dr. Polk says. “We foster the idea of joining a great team, and we make the environment attractive enough to encourage people to stay. We try to work within the team to cover those who need help, such as maternity or family leave, and we compensate for extra time at a different rate. We embrace people who want to work part time or share a job. Our goals are to support people and to make them want to get up in the morning to come to work.”
Part of the attractiveness of schedule flexibility is fewer weekend and night hours. In addition, employers may allow hospitalists to limit their caseload. Some hospitalists, for example, request a cap of 15 to 18 patients a day.
While retaining experienced, motivated staff is a goal of hospitals, lower caseloads mean “more doctors to do the work if doctors work fewer hours,” says Rusty Holman, MD, Cogent’s chief operating officer and SHM’s immediate past president. To meet that need, hospitals are turning to community-based physicians, fellows, and residents to work weekends and evenings. This, in turn, offers the perk of part-time work for those who want more personal time in their schedule.
The demand for nocturnists also is growing (The Hospitalist, January 2008, p. 22). Nocturnists work at night and on weekends and usually work shorter hours. These physicians prefer this schedule so they can have their days free for family or other pursuits. They also enjoy higher compensation, fewer workdays per month, and lower productivity expectations.
In addition to the having the options of part-time hours, temporary work, or job sharing, hospitalists also can negotiate other schedule perks. Some request and receive a two-week-on, two-week-off schedule. Many ask about the shift model, which demands nothing beyond the full eight or 12 hours of work. Still other applicants find a swing shift fits their lifestyle. There are even short-term choices: the hospitalist program at the University of California at Irvine offers recent residents the opportunity to work for one year while deciding about their career. With scheduling choices as part of an incentive package, many hospitalists achieve Dr. Polk’s goal of being eager to come to work each morning.
Physicians are not the only beneficiaries of these perks. Cogent, for example, recruits physician assistants and nurse practitioners when forming hospitalist groups. These employees also enjoy incentives, including tuition for continuing education and the same schedule flexibility as hospitalists.
Seller’s Market
Hospital medicine faces a shortage of qualified applicants. The need for hospitalists far surpasses the supply of physicians, who are in the enviable position of sifting through incentives and perks when selecting a hospitalist job.
This has become a national concern, according to Vikas Parekh, MD, assistant director of the hospitalist program and assistant professor of medicine at the University of Michigan Health Center in Ann Arbor. “We’re not seeing a pool of applicants because top residents are not pursuing hospitalist careers,” Dr. Parekh says.
Alpesh Amin, MD, MBA, a member of SHM’s Board of Directors, concurs but also points out that the number of hospitalist jobs is growing. “The need for a few hundred hospitalists 10 years ago has grown to 20,000 to 30,000 today, thus creating a need much greater than the supply,” says Dr. Amin, professor and chief, general internal medicine, executive director and founder of the hospitalist program at the University of California Irvine.
Why the shortage? First, fewer physicians are choosing to practice general medicine, either as an internist, family practitioner, or hospitalist. A recent study found fewer medical students were planning to concentrate on internal and family medicine, and that those who did planned to go into a subspecialty later.1 Dr. Parekh attributes this to a combination of reasons. “Most internal medicine residents are subspecialty oriented and may have decided their specialty early on,” Dr. Parekh says. “They may choose a subspecialty for financial reasons or prestige,” he continues, “but they may also be unclear about what a hospitalist career really is.”
Second, hospitalist programs have begun to expand from large metropolitan regions to smaller and rural areas. The result is an even greater demand for hospitalists.
Meet the Need
“There are no saturated markets within hospital medicine,” Dr. Holman says. “That is, most groups are always actively recruiting. [Cogent develops] full hospitalist programs, including recruiting, employing, managing, and training for new and existing hospitalist groups.”
Who is being recruited? Many recruiters approach residents who have not chosen a subspecialty to offer a staff position after they finish the residency. Although a recruiting firm may not offer financial aid during the residency, an employer may provide some sort of stipend if the candidate commits to remain on staff for a specified time after residency. “Recruit and retain” is the operative phrase in these cases.
Recruiters also are approaching generalists just entering the market to point out the advantages of avoiding the startup costs of establishing an outpatient practice. Further, many hospitalists are emerging from the ranks of solo practitioners interested in the financial and personal advantages of belonging to hospitalist groups. Not only does that eliminate the practice overhead (including the burden of regulatory compliance), but it also may offer additional administrative and academic opportunities. As Dr. Amin says, “There are more MD-MBA combos out there.”
Are incentives the answer to the shortage? Perhaps for now. With time, hospital medicine’s built-in perks may end the shortage and the need for added incentives. TH
Ann Kepler is a medical writer based in Chicago.
Reference
- Croasdale M. Primary care doctors in demand; signing bonuses and higher pay for some. American Medical News. June 19, 2006. Available at www.ama-assn.org/amednews/site/free/prl10619.htm. Last accessed March 19, 2008.
Patient Proxies
In the best interests of the patient. In accordance with the patient’s wishes. Preserving patient autonomy. These concepts are at the core of modern medical decision-making.
Traditionally medical decisions are made by hospitalists and communicated to patients. This approach has shifted to an emphasis on patient autonomy and input in decision-making.
But what about the patient unable to make decisions or provide input to the medical caregivers? How can the comatose or incompetent patient participate in his or her own care decisions? What happens when half of a team is no longer able to share team functions?
In these instances, hospitalists rely on surrogates. A surrogate is empowered not only to speak for but also to make legal decisions for a patient. The relationship becomes a triad of hospitalist, surrogate, and patient. This triad must include:
- A hospitalist who brings the same degree of trust, respect, and open communication to the new relationship;
- A surrogate who is an active participant rather than a passive spokesperson; and
- A patient whose interests are the primary goal.
Key Issues
The aging of the population and the increased prevalence of medical conditions causing cognitive impairment point up the need to take a closer look at the hospitalist-surrogate relationship. A study this year outlined four key issues:
- There are unique challenges for both parties in creating a hospitalist-surrogate relationship;
- The hospitalist and surrogate are dealing not only with each other but also with the decision-making role each will play in regard to the patient;
- The surrogate must understand that serving as a surrogate for a loved one is completely different from making decisions for oneself; and
- There may be more than one surrogate decision maker.1
The first challenge facing hospitalist and surrogate is establishing a foundation of trust, respect, and a treatment plan. Their perspectives play a critical role: The surrogate knows the patient as a lively, engaged, and interesting individual, while the hospitalist has seen the patient only in a nonresponsive, incapacitated state. Opening an immediate line of communication is the best way to assume their respective responsibilities.
Second, even after the hospitalist and surrogate develop an initial working relationship, they may still need to outline mutually satisfying ways to share decision-making with the patient. Both must balance their concern for the patient, their understanding of the patient’s status, and their perspectives of what the patient would want. With time pressures and the capabilities of modern technology, this mutual decision-making responsibility may seem daunting.
Third, surrogates may discover a conflict between their personal values and their patient’s. They may have to make a decision that reflects their patient’s wishes yet contradicts their own beliefs. Sometimes hospitalists can help the surrogate resolve this dilemma by suggesting consultations with other family members or professionals.
The fourth issue, multiple surrogates, may magnify the challenges but can also be an advantage. In most cases families, even those with members who have differing belief systems, tend to support each other during crises to reach a consensus in the patient’s best interests.
Tom Baudendistel, MD, a hospitalist at California Pacific Medical Center in San Francisco, says that although engaging in a dialogue with the multiple surrogates may reveal a family conflict, mistrust, or other issues, the problem is usually resolved. “One surrogate comes around after we make sure the one disagreeing sees in person what the patient is going through, the low quality of life,” says Dr. Baudendistel.
Howard Epstein, MD, medical director, Care Management and Palliative Care, Regions Hospital, St. Paul, Minn., suggests a different approach. “We ask the surrogate to imagine that if the patient could stand outside his or her body, hearing everything that is being said, what would he or she say?” says Dr. Epstein.
The Process
While these issues affect all hospitalists who work with surrogates, hospitalists often encounter additional circumstances that require special attention. These are not always problems but may be situations unique to the hospital setting or the hospitalist’s job.
The hospitalist’s first contact with a patient is often the patient’s admission to the hospital. The hospitalist is most often starting with a blank page with no background information. Gathering information quickly about an unknown patient is critical.
This duty often falls to hospitalists. Donald Krause, MD, medical director for quality assurance at St. Joseph Hospital in Bangor, Maine, and a hospitalist for 11 years, points out that “hospitalists take care of 90% of medical admissions and as part of this job arrange for surrogates if needed as well as anything else to help the patient.”
Beginning with the admission of a patient, the hospitalist may take on the responsibility of finding a surrogate.
Find a surrogate: When a patient is admitted, the hospitalist questions everyone connected to the patient about the existence of a surrogate or family spokesperson. If there is no information available, many hospitalists turn to other staff experts, such as social workers or chaplains, to seek people who know the patient.
Dr. Baudendistel says his medical center resuscitates “unbefriended” patients admitted to the emergency department to allow time to find a family member or surrogate. “Social workers then search the Internet, call shelters, and contact other hospitals and institutions to learn anything they can about the patient,” he says. If the search is unsuccessful, the hospitalist usually consults the institution’s ethics committee for additional suggestions.
Don C. Postema, PhD, ethics consultant for Regions Hospital, chair of the HealthPartners Ethics Committee, and ethicist-in-residence at Gillette Children’s Specialty HealthCare in St. Paul, Minn., proposes that an ethics committee look beyond the standard candidates in searching for a surrogate. “The legal relationship of a potential surrogate to the patient is secondary to what I consider to be the primary relationship, that is, the person who knows the patient best,” says Dr. Postema. “It could be the patient’s landlord or a neighbor who sees the patient on a regular basis.”
What about the patient whose family lives too far away to see the patient on a regular basis? Look into hiring a local geriatric case manager, Dr. Epstein advises.
There is one person who should not serve as a patient’s surrogate: the attending physician, whether a hospitalist or the primary caregiver. Erin Egan, MD, JD, assistant professor of hospital medicine, University of Colorado Hospitals, warns that a hospitalist acting as a surrogate has a conflict of interest. “Most states prohibit hospitalists from acting as surrogates,” Dr. Egan warns. “In some cases a doctor can presume consent for a short time before a surrogate is appointed in order to make an immediate medical decision. As a general rule, however, a clinician should never assume the surrogate’s role.”
Look for advance directives: Ideally, every patient’s file would contain an advance directive indicating a surrogate or a note that there is no surrogate.2 In addition, there should be a healthcare advance directive, also known as a healthcare power of attorney, that appoints a surrogate. It is often accompanied by a living will, an instruction sheet stipulating what treatment the patient wants if he or she is unable to speak or communicate. Unfortunately, many hospitalists cannot find these documents when they admit a patient.
In this case, the hospitalist must search. Most hospitals, nursing homes, or home healthcare agencies are required by the federal Patient Self-Determination Act (PSDA) to offer information about advance directives at the time of admission. This information states the patient’s healthcare decision-making rights under state law and the institution’s policy about adhering to advance directives. Contacting these agencies is a starting point.
Make difficult decisions: While some advance directives carry legal power, they often are not helpful to hospitalists or surrogates making end-of-life decisions. Because a medical crisis cannot always be predicted and treatment options change rapidly, a specific directive may not be as helpful as a written description of a patient’s beliefs, religious convictions, and cultural values. Equally valuable are notes about conversations among patients, family members, friends, and caregivers.3 This creates a picture of the patient’s feelings about quality of life, treatment preferences, and end-of-life outcomes.
The hospitalist’s role in this situation is to facilitate such discussions among all family and friends involved. The goal is to develop an accurate picture of the patient to make appropriate decisions. The hospitalist should explore the cultural values and religious beliefs of the patient, surrogate, family, and friends. “Different ethnic groups view medical care differently,” says Richard L. Heinrich, MD, medical director of Hospice of the Lakes, Bloomington, Minn. “Some religions believe that suffering in this life is rewarded in the next life, which makes a difference when making treatment decisions,” he says. “We must honor and work with cultural values unless in our view the individual is suffering needlessly.”
The hospitalist should be alert to the need for an interpreter and anything else that will promote a meaningful discussion. And, the hospitalist and the medical staff should be prepared to share as much medical information as is possible, including individual staff opinions, the rationale behind recommendations, and the pros and cons of each suggestion. The surrogate and family cannot make any meaningful contribution without all the pertinent information.
The goal should be a consensus about the patient’s best interests, how certain medical decisions will provide benefit or burden to the patient, and if the decision is what the patient would want. It’s especially critical to call a family conference to allow everyone the opportunity to discuss the patient’s concept of his or her death.
“Most people are afraid of getting caught in an end-of-life situation where they lose control,” says Dr. Postema. TH
Ann Kepler is a medical writer based in Chicago.
References
- Torke AM, Alexander GC, Lantos J, et al. The physician-surrogate relationship. Arch Intern Med. 2007 Jun 11;167(11):1117-1121.
- Wenger NS, Rosenfeld K. Quality indicators for end-of-life care in vulnerable elders. Ann Intern Med. 2001 Oct 16;135(8):677-685.
- Bloche MG. Managing conflict at the end of life. N Engl J Med. 2005 Jun 9;352:2371-2373.
In the best interests of the patient. In accordance with the patient’s wishes. Preserving patient autonomy. These concepts are at the core of modern medical decision-making.
Traditionally medical decisions are made by hospitalists and communicated to patients. This approach has shifted to an emphasis on patient autonomy and input in decision-making.
But what about the patient unable to make decisions or provide input to the medical caregivers? How can the comatose or incompetent patient participate in his or her own care decisions? What happens when half of a team is no longer able to share team functions?
In these instances, hospitalists rely on surrogates. A surrogate is empowered not only to speak for but also to make legal decisions for a patient. The relationship becomes a triad of hospitalist, surrogate, and patient. This triad must include:
- A hospitalist who brings the same degree of trust, respect, and open communication to the new relationship;
- A surrogate who is an active participant rather than a passive spokesperson; and
- A patient whose interests are the primary goal.
Key Issues
The aging of the population and the increased prevalence of medical conditions causing cognitive impairment point up the need to take a closer look at the hospitalist-surrogate relationship. A study this year outlined four key issues:
- There are unique challenges for both parties in creating a hospitalist-surrogate relationship;
- The hospitalist and surrogate are dealing not only with each other but also with the decision-making role each will play in regard to the patient;
- The surrogate must understand that serving as a surrogate for a loved one is completely different from making decisions for oneself; and
- There may be more than one surrogate decision maker.1
The first challenge facing hospitalist and surrogate is establishing a foundation of trust, respect, and a treatment plan. Their perspectives play a critical role: The surrogate knows the patient as a lively, engaged, and interesting individual, while the hospitalist has seen the patient only in a nonresponsive, incapacitated state. Opening an immediate line of communication is the best way to assume their respective responsibilities.
Second, even after the hospitalist and surrogate develop an initial working relationship, they may still need to outline mutually satisfying ways to share decision-making with the patient. Both must balance their concern for the patient, their understanding of the patient’s status, and their perspectives of what the patient would want. With time pressures and the capabilities of modern technology, this mutual decision-making responsibility may seem daunting.
Third, surrogates may discover a conflict between their personal values and their patient’s. They may have to make a decision that reflects their patient’s wishes yet contradicts their own beliefs. Sometimes hospitalists can help the surrogate resolve this dilemma by suggesting consultations with other family members or professionals.
The fourth issue, multiple surrogates, may magnify the challenges but can also be an advantage. In most cases families, even those with members who have differing belief systems, tend to support each other during crises to reach a consensus in the patient’s best interests.
Tom Baudendistel, MD, a hospitalist at California Pacific Medical Center in San Francisco, says that although engaging in a dialogue with the multiple surrogates may reveal a family conflict, mistrust, or other issues, the problem is usually resolved. “One surrogate comes around after we make sure the one disagreeing sees in person what the patient is going through, the low quality of life,” says Dr. Baudendistel.
Howard Epstein, MD, medical director, Care Management and Palliative Care, Regions Hospital, St. Paul, Minn., suggests a different approach. “We ask the surrogate to imagine that if the patient could stand outside his or her body, hearing everything that is being said, what would he or she say?” says Dr. Epstein.
The Process
While these issues affect all hospitalists who work with surrogates, hospitalists often encounter additional circumstances that require special attention. These are not always problems but may be situations unique to the hospital setting or the hospitalist’s job.
The hospitalist’s first contact with a patient is often the patient’s admission to the hospital. The hospitalist is most often starting with a blank page with no background information. Gathering information quickly about an unknown patient is critical.
This duty often falls to hospitalists. Donald Krause, MD, medical director for quality assurance at St. Joseph Hospital in Bangor, Maine, and a hospitalist for 11 years, points out that “hospitalists take care of 90% of medical admissions and as part of this job arrange for surrogates if needed as well as anything else to help the patient.”
Beginning with the admission of a patient, the hospitalist may take on the responsibility of finding a surrogate.
Find a surrogate: When a patient is admitted, the hospitalist questions everyone connected to the patient about the existence of a surrogate or family spokesperson. If there is no information available, many hospitalists turn to other staff experts, such as social workers or chaplains, to seek people who know the patient.
Dr. Baudendistel says his medical center resuscitates “unbefriended” patients admitted to the emergency department to allow time to find a family member or surrogate. “Social workers then search the Internet, call shelters, and contact other hospitals and institutions to learn anything they can about the patient,” he says. If the search is unsuccessful, the hospitalist usually consults the institution’s ethics committee for additional suggestions.
Don C. Postema, PhD, ethics consultant for Regions Hospital, chair of the HealthPartners Ethics Committee, and ethicist-in-residence at Gillette Children’s Specialty HealthCare in St. Paul, Minn., proposes that an ethics committee look beyond the standard candidates in searching for a surrogate. “The legal relationship of a potential surrogate to the patient is secondary to what I consider to be the primary relationship, that is, the person who knows the patient best,” says Dr. Postema. “It could be the patient’s landlord or a neighbor who sees the patient on a regular basis.”
What about the patient whose family lives too far away to see the patient on a regular basis? Look into hiring a local geriatric case manager, Dr. Epstein advises.
There is one person who should not serve as a patient’s surrogate: the attending physician, whether a hospitalist or the primary caregiver. Erin Egan, MD, JD, assistant professor of hospital medicine, University of Colorado Hospitals, warns that a hospitalist acting as a surrogate has a conflict of interest. “Most states prohibit hospitalists from acting as surrogates,” Dr. Egan warns. “In some cases a doctor can presume consent for a short time before a surrogate is appointed in order to make an immediate medical decision. As a general rule, however, a clinician should never assume the surrogate’s role.”
Look for advance directives: Ideally, every patient’s file would contain an advance directive indicating a surrogate or a note that there is no surrogate.2 In addition, there should be a healthcare advance directive, also known as a healthcare power of attorney, that appoints a surrogate. It is often accompanied by a living will, an instruction sheet stipulating what treatment the patient wants if he or she is unable to speak or communicate. Unfortunately, many hospitalists cannot find these documents when they admit a patient.
In this case, the hospitalist must search. Most hospitals, nursing homes, or home healthcare agencies are required by the federal Patient Self-Determination Act (PSDA) to offer information about advance directives at the time of admission. This information states the patient’s healthcare decision-making rights under state law and the institution’s policy about adhering to advance directives. Contacting these agencies is a starting point.
Make difficult decisions: While some advance directives carry legal power, they often are not helpful to hospitalists or surrogates making end-of-life decisions. Because a medical crisis cannot always be predicted and treatment options change rapidly, a specific directive may not be as helpful as a written description of a patient’s beliefs, religious convictions, and cultural values. Equally valuable are notes about conversations among patients, family members, friends, and caregivers.3 This creates a picture of the patient’s feelings about quality of life, treatment preferences, and end-of-life outcomes.
The hospitalist’s role in this situation is to facilitate such discussions among all family and friends involved. The goal is to develop an accurate picture of the patient to make appropriate decisions. The hospitalist should explore the cultural values and religious beliefs of the patient, surrogate, family, and friends. “Different ethnic groups view medical care differently,” says Richard L. Heinrich, MD, medical director of Hospice of the Lakes, Bloomington, Minn. “Some religions believe that suffering in this life is rewarded in the next life, which makes a difference when making treatment decisions,” he says. “We must honor and work with cultural values unless in our view the individual is suffering needlessly.”
The hospitalist should be alert to the need for an interpreter and anything else that will promote a meaningful discussion. And, the hospitalist and the medical staff should be prepared to share as much medical information as is possible, including individual staff opinions, the rationale behind recommendations, and the pros and cons of each suggestion. The surrogate and family cannot make any meaningful contribution without all the pertinent information.
The goal should be a consensus about the patient’s best interests, how certain medical decisions will provide benefit or burden to the patient, and if the decision is what the patient would want. It’s especially critical to call a family conference to allow everyone the opportunity to discuss the patient’s concept of his or her death.
“Most people are afraid of getting caught in an end-of-life situation where they lose control,” says Dr. Postema. TH
Ann Kepler is a medical writer based in Chicago.
References
- Torke AM, Alexander GC, Lantos J, et al. The physician-surrogate relationship. Arch Intern Med. 2007 Jun 11;167(11):1117-1121.
- Wenger NS, Rosenfeld K. Quality indicators for end-of-life care in vulnerable elders. Ann Intern Med. 2001 Oct 16;135(8):677-685.
- Bloche MG. Managing conflict at the end of life. N Engl J Med. 2005 Jun 9;352:2371-2373.
In the best interests of the patient. In accordance with the patient’s wishes. Preserving patient autonomy. These concepts are at the core of modern medical decision-making.
Traditionally medical decisions are made by hospitalists and communicated to patients. This approach has shifted to an emphasis on patient autonomy and input in decision-making.
But what about the patient unable to make decisions or provide input to the medical caregivers? How can the comatose or incompetent patient participate in his or her own care decisions? What happens when half of a team is no longer able to share team functions?
In these instances, hospitalists rely on surrogates. A surrogate is empowered not only to speak for but also to make legal decisions for a patient. The relationship becomes a triad of hospitalist, surrogate, and patient. This triad must include:
- A hospitalist who brings the same degree of trust, respect, and open communication to the new relationship;
- A surrogate who is an active participant rather than a passive spokesperson; and
- A patient whose interests are the primary goal.
Key Issues
The aging of the population and the increased prevalence of medical conditions causing cognitive impairment point up the need to take a closer look at the hospitalist-surrogate relationship. A study this year outlined four key issues:
- There are unique challenges for both parties in creating a hospitalist-surrogate relationship;
- The hospitalist and surrogate are dealing not only with each other but also with the decision-making role each will play in regard to the patient;
- The surrogate must understand that serving as a surrogate for a loved one is completely different from making decisions for oneself; and
- There may be more than one surrogate decision maker.1
The first challenge facing hospitalist and surrogate is establishing a foundation of trust, respect, and a treatment plan. Their perspectives play a critical role: The surrogate knows the patient as a lively, engaged, and interesting individual, while the hospitalist has seen the patient only in a nonresponsive, incapacitated state. Opening an immediate line of communication is the best way to assume their respective responsibilities.
Second, even after the hospitalist and surrogate develop an initial working relationship, they may still need to outline mutually satisfying ways to share decision-making with the patient. Both must balance their concern for the patient, their understanding of the patient’s status, and their perspectives of what the patient would want. With time pressures and the capabilities of modern technology, this mutual decision-making responsibility may seem daunting.
Third, surrogates may discover a conflict between their personal values and their patient’s. They may have to make a decision that reflects their patient’s wishes yet contradicts their own beliefs. Sometimes hospitalists can help the surrogate resolve this dilemma by suggesting consultations with other family members or professionals.
The fourth issue, multiple surrogates, may magnify the challenges but can also be an advantage. In most cases families, even those with members who have differing belief systems, tend to support each other during crises to reach a consensus in the patient’s best interests.
Tom Baudendistel, MD, a hospitalist at California Pacific Medical Center in San Francisco, says that although engaging in a dialogue with the multiple surrogates may reveal a family conflict, mistrust, or other issues, the problem is usually resolved. “One surrogate comes around after we make sure the one disagreeing sees in person what the patient is going through, the low quality of life,” says Dr. Baudendistel.
Howard Epstein, MD, medical director, Care Management and Palliative Care, Regions Hospital, St. Paul, Minn., suggests a different approach. “We ask the surrogate to imagine that if the patient could stand outside his or her body, hearing everything that is being said, what would he or she say?” says Dr. Epstein.
The Process
While these issues affect all hospitalists who work with surrogates, hospitalists often encounter additional circumstances that require special attention. These are not always problems but may be situations unique to the hospital setting or the hospitalist’s job.
The hospitalist’s first contact with a patient is often the patient’s admission to the hospital. The hospitalist is most often starting with a blank page with no background information. Gathering information quickly about an unknown patient is critical.
This duty often falls to hospitalists. Donald Krause, MD, medical director for quality assurance at St. Joseph Hospital in Bangor, Maine, and a hospitalist for 11 years, points out that “hospitalists take care of 90% of medical admissions and as part of this job arrange for surrogates if needed as well as anything else to help the patient.”
Beginning with the admission of a patient, the hospitalist may take on the responsibility of finding a surrogate.
Find a surrogate: When a patient is admitted, the hospitalist questions everyone connected to the patient about the existence of a surrogate or family spokesperson. If there is no information available, many hospitalists turn to other staff experts, such as social workers or chaplains, to seek people who know the patient.
Dr. Baudendistel says his medical center resuscitates “unbefriended” patients admitted to the emergency department to allow time to find a family member or surrogate. “Social workers then search the Internet, call shelters, and contact other hospitals and institutions to learn anything they can about the patient,” he says. If the search is unsuccessful, the hospitalist usually consults the institution’s ethics committee for additional suggestions.
Don C. Postema, PhD, ethics consultant for Regions Hospital, chair of the HealthPartners Ethics Committee, and ethicist-in-residence at Gillette Children’s Specialty HealthCare in St. Paul, Minn., proposes that an ethics committee look beyond the standard candidates in searching for a surrogate. “The legal relationship of a potential surrogate to the patient is secondary to what I consider to be the primary relationship, that is, the person who knows the patient best,” says Dr. Postema. “It could be the patient’s landlord or a neighbor who sees the patient on a regular basis.”
What about the patient whose family lives too far away to see the patient on a regular basis? Look into hiring a local geriatric case manager, Dr. Epstein advises.
There is one person who should not serve as a patient’s surrogate: the attending physician, whether a hospitalist or the primary caregiver. Erin Egan, MD, JD, assistant professor of hospital medicine, University of Colorado Hospitals, warns that a hospitalist acting as a surrogate has a conflict of interest. “Most states prohibit hospitalists from acting as surrogates,” Dr. Egan warns. “In some cases a doctor can presume consent for a short time before a surrogate is appointed in order to make an immediate medical decision. As a general rule, however, a clinician should never assume the surrogate’s role.”
Look for advance directives: Ideally, every patient’s file would contain an advance directive indicating a surrogate or a note that there is no surrogate.2 In addition, there should be a healthcare advance directive, also known as a healthcare power of attorney, that appoints a surrogate. It is often accompanied by a living will, an instruction sheet stipulating what treatment the patient wants if he or she is unable to speak or communicate. Unfortunately, many hospitalists cannot find these documents when they admit a patient.
In this case, the hospitalist must search. Most hospitals, nursing homes, or home healthcare agencies are required by the federal Patient Self-Determination Act (PSDA) to offer information about advance directives at the time of admission. This information states the patient’s healthcare decision-making rights under state law and the institution’s policy about adhering to advance directives. Contacting these agencies is a starting point.
Make difficult decisions: While some advance directives carry legal power, they often are not helpful to hospitalists or surrogates making end-of-life decisions. Because a medical crisis cannot always be predicted and treatment options change rapidly, a specific directive may not be as helpful as a written description of a patient’s beliefs, religious convictions, and cultural values. Equally valuable are notes about conversations among patients, family members, friends, and caregivers.3 This creates a picture of the patient’s feelings about quality of life, treatment preferences, and end-of-life outcomes.
The hospitalist’s role in this situation is to facilitate such discussions among all family and friends involved. The goal is to develop an accurate picture of the patient to make appropriate decisions. The hospitalist should explore the cultural values and religious beliefs of the patient, surrogate, family, and friends. “Different ethnic groups view medical care differently,” says Richard L. Heinrich, MD, medical director of Hospice of the Lakes, Bloomington, Minn. “Some religions believe that suffering in this life is rewarded in the next life, which makes a difference when making treatment decisions,” he says. “We must honor and work with cultural values unless in our view the individual is suffering needlessly.”
The hospitalist should be alert to the need for an interpreter and anything else that will promote a meaningful discussion. And, the hospitalist and the medical staff should be prepared to share as much medical information as is possible, including individual staff opinions, the rationale behind recommendations, and the pros and cons of each suggestion. The surrogate and family cannot make any meaningful contribution without all the pertinent information.
The goal should be a consensus about the patient’s best interests, how certain medical decisions will provide benefit or burden to the patient, and if the decision is what the patient would want. It’s especially critical to call a family conference to allow everyone the opportunity to discuss the patient’s concept of his or her death.
“Most people are afraid of getting caught in an end-of-life situation where they lose control,” says Dr. Postema. TH
Ann Kepler is a medical writer based in Chicago.
References
- Torke AM, Alexander GC, Lantos J, et al. The physician-surrogate relationship. Arch Intern Med. 2007 Jun 11;167(11):1117-1121.
- Wenger NS, Rosenfeld K. Quality indicators for end-of-life care in vulnerable elders. Ann Intern Med. 2001 Oct 16;135(8):677-685.
- Bloche MG. Managing conflict at the end of life. N Engl J Med. 2005 Jun 9;352:2371-2373.
Lost in Translation
What happens when a person who speaks a language other than English enters a hospital? One who is fortunate enough to enter one of the one-quarter of American hospitals that offer professional interpreters or other language access services can expect to understand what is going on and to communicate comfortably with the care providers. For the approximately 75% of U.S. hospitals remaining, language access has become a common concern as increasing immigration levels expand ethnic groups.
Nearly 52 million people—one in 12—in the United States speak a language other than English at home. In fact, more than 300 languages are spoken in the United States. Basing their calculations on the 2000 census, demographers estimate that the number of people with limited English proficiency (LEP) ranges from 11 million (those who speak English “not well” or “not at all”) to more than 22 million (those who speak English less than “very well”). And those numbers are expected to continue to grow.
The Effects on Healthcare
The growing diversity of the United States population has a direct effect on healthcare providers. In order to provide appropriate and safe care, a provider must rely on accurate information from the patient. Simultaneously, the patient must be able to understand health instructions and treatment options in order to participate in his or her care. Language is the vital bridge in this process.
So what happens, for example, when an English-speaking emergency department physician faces a Spanish-speaking patient seeking medical care? Often, the hospital staff will turn to the patient’s family to act as interpreters. If that is not possible or advisable, the clinician may ask a bilingual staff member to help. This is commonly called dual-role or ad-hoc interpreting because the employee’s primary job in the healthcare organization (whether clinical or non-clinical) involves something other than interpreting.
While ad-hoc interpreters fulfill immediate needs by thoughtfully stepping in and helping out, many are asked to interpret outside their areas of expertise as they interrupt their own work. And an interpreter who has received no specialized training cannot be expected to achieve the same results as a professional interpreter. Simply being bilingual is not enough; professional medical interpreting is a learned skill.
Yet many healthcare organizations across the United States are not prepared to provide professional linguistic access for their patients. This is not to say that care providers would not like a professional interpreter program in the healthcare organization. Providers from a wide range of services have reported that language barriers and inadequate funding of language access services present major problems in ensuring both access to and quality of healthcare for LEP individuals. Funding, in particular, is one of the major reasons healthcare organizations hesitate to implement dedicated interpreter departments.
According to Cynthia Roat, MPH, a national consultant on language access in healthcare, the two major restrictions hindering the implementation of professional linguistic access programs in hospitals today are:
- Lack of funding and
- Lack of qualified interpreters.
“Fortunately the latter problem is being addressed,” she says. “We have established standards of practice for professional competence, and there are training programs for medical interpreters as well as for clinical staff who use interpreters.”
For example, the National Council on Interpreting in Health Care (NCIHC), a leading advocate of medical interpreting, has developed national standards to improve communication between the LEP patient and the healthcare provider. In addition, many technical and community colleges now offer medical interpreting classes, and some medical schools are beginning to offer seminars and courses designed to train clinical staff to work with interpreters. “Working with interpreters is a concrete, clinical skill,” says Roat.
Still, finding the money for this type of program can have a financial impact on healthcare organizations. Adding to that, accreditation agencies such as the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and the National Committee for Quality Assurance (NCQA) have set compliance standards for language access in terms of its contribution to quality care and patient safety. These compliance standards can also have a financial impact on healthcare organizations.
An even more significant effect may result from the federal government’s mandate to provide language services to LEP individuals. Specifically, Executive Order 13166, “Improving Access to Services for Persons with Limited English Proficiency,” stipulates that hospital and healthcare organizations receiving federal funds are required to provide interpretation services under Title VI of the Civil Rights Act of 1964. Denial of interpreter services to LEP patients is considered a form of discrimination.
In addition, the Office of Minority Health (OMH) within the U.S. Department of Health and Human Services has specified 14 National Standards for Culturally and Linguistically Appropriate Services in Health Care (CLAS) that direct healthcare organizations to make their practices more culturally and linguistically accessible. CLAS standards are organized by themes: Culturally Competent Care, Language Access, and Organizational Support for Cultural Competence. Within this framework, there are three types of obligation: mandates, guidelines, and recommendations. Mandates are current federal requirements for all recipients of federal funds; guidelines are activities recommended by OMH for adoption as mandates by accrediting agencies; and recommendations are standards suggested by OMH for voluntary adoption by healthcare organizations.
Despite its mandates, standards, and recommendations, however, the U.S. government has not included provisions for or suggestions about paying for compliance.
Benefits of a Language Access Program
Nevertheless, in addition to complying with governmental regulations and meeting accreditation standards, hospitals can derive benefits from an interpreter program. First and foremost, using interpreters with LEP individuals allows a hospital to fulfill one of its most important professional obligations: providing the best care possible to each patient. The clinician understands the patient’s symptoms, and the patient understands the doctor’s diagnosis and instructions. Together they can form a partnership to meet the physical, psychological, and cultural needs of the patient and to afford a sense of satisfaction to the caregiver.
Secondly, providing linguistic access can make hospital services more cost effective. Visits are fewer and shorter. There are not as many follow-up appointments or repeat admissions because patients understand their physicians’ instructions. Clinicians avoid unnecessary, inadvisable, or inappropriate tests because they understand the patients’ symptoms. Overuse of emergency department services for primary care decreases because patients are comfortable establishing a more conventional primary care relationship. And, as Roat points out, “if a hospital can develop an access program that does not rely on ad-hoc interpreters, the organization can avoid the hidden costs of lower productivity and higher turnover among those ad-hoc interpreters who are asked to interrupt their regular work to provide language access.”
Finally, there are benefits associated with legal and liability issues. Among them: fewer mistakes in diagnoses and treatment because the patients can communicate with their care providers. Also, patients are able to follow directions correctly and understand the need for follow-up or referrals, thus averting an unnecessary tragedy or potential lawsuit. Glenn Flores, MD, director of the Center for the Advancement of Urban Children and professor of pediatrics, epidemiology, and health at the Medical College of Wisconsin, can cite examples of medical errors attributable to language misunderstandings.
“Lack of language services can affect instructions about giving medications, such as the mother who thought she should apply a cortisone cream to the child’s entire body rather than just to the facial rash,” he says. “There is also the problem of possible overdoses. And a single misinterpreted word in one case led to a $71 million lawsuit in Florida a few years ago. This is a major patient safety issue.”
Another safety issue for hospitals is informed consent. Hospitals that provide language services are more likely to ensure that their LEP patients understand and agree to sign the informed consent form.
Paying for Language Access Services
The benefits of offering language access services may be self-evident, but who pays for them? Certainly not private insurers. At least not yet. But, as professionals in the field, both Roat and Dr. Flores see a need for private insurers to assume part of the financial cost. Although Roat believes the costs should be shared among hospitals/clinics, public financing, and commercial insurers, “Advocates of language access need to start a dialogue with commercial insurers and point to HMOs as examples of how these services are being covered,” she says.
Multiple approaches may be necessary to set up coverage from private insurers. Dr. Flores suggests that one possible course is insurance reimbursement for professional interpreters, paid for by the hour or by the visit. Another alternative might involve establishing contract services with outside agencies, community organizations, or video- or teleconferencing companies to recruit, train, and assign medical interpreters for healthcare organizations. These groups could provide services and bill the insurer directly.
“There are also ways to use public funding,” observes Roat, “and there should be more pressure on the federal government to pony up more money for this.”
Dr. Flores agrees. “Under Medicaid and the State Children’s Health Insurance Program (SCHIP), states may pay for interpreting services and receive federal matching funds of 50% or more,” he says. “Yet only 13 states are taking advantage of this. The other 37 states are missing out on this money.”
Like many of his colleagues, Dr. Flores is also mystified about the government’s reluctance to fully fund interpretation services, pointing out that “a federal report from the Office of Management and Budget (OMB) in 2002 estimated that it would cost an average of $4.04 per physician visit to provide all LEP patients with full language access services.”
Then why hasn’t this been allocated? Dr. Flores acknowledges that there is some recognition and awareness of the situation in Congress, and he thinks there may be some political will as well. He has testified before the Senate about the Hispanic Health Improvement Act, yet the bill has yet to pass. At the moment, there are immigration issues that are impeding political action in these areas.
In the meantime, Dr. Flores suggests that there are other steps that healthcare organizations can take to ease language access problems:
- Recruit bilingual providers in areas with large ethnic populations and offer hiring bonuses for qualified individuals;
- Encourage medical schools to require—and even teach—proficiency in languages other than English. “We should require, as other countries do, that children learn foreign languages,” he says; and
- Do a better job of helping LEP individuals learn English.
Begin the last step by directing LEP patients to the Web site of the National Institute for Literacy and Partners, which matches applicants to literacy and ESL programs within their geographical area.1
“We must debunk the oft-repeated story that professional medical interpreters are too expensive to use, that they charge $400 an hour,” says Roat. “That figure came from an incident in which an interpreter was supposedly working in a very remote area on a weekend and charged for the time, distance, and unusual circumstances. In reality, qualified medical interpreters earn $20 to $25 per hour and are worth every penny. Plus, they save money by reducing time and costs to the institution.” TH
Ann Kepler is based in the Chicago area.
Reference
- National Institute for Literacy, Literacy Directory. Available at: www.literacydirectory.org. Last accessed September 27,2006.
What happens when a person who speaks a language other than English enters a hospital? One who is fortunate enough to enter one of the one-quarter of American hospitals that offer professional interpreters or other language access services can expect to understand what is going on and to communicate comfortably with the care providers. For the approximately 75% of U.S. hospitals remaining, language access has become a common concern as increasing immigration levels expand ethnic groups.
Nearly 52 million people—one in 12—in the United States speak a language other than English at home. In fact, more than 300 languages are spoken in the United States. Basing their calculations on the 2000 census, demographers estimate that the number of people with limited English proficiency (LEP) ranges from 11 million (those who speak English “not well” or “not at all”) to more than 22 million (those who speak English less than “very well”). And those numbers are expected to continue to grow.
The Effects on Healthcare
The growing diversity of the United States population has a direct effect on healthcare providers. In order to provide appropriate and safe care, a provider must rely on accurate information from the patient. Simultaneously, the patient must be able to understand health instructions and treatment options in order to participate in his or her care. Language is the vital bridge in this process.
So what happens, for example, when an English-speaking emergency department physician faces a Spanish-speaking patient seeking medical care? Often, the hospital staff will turn to the patient’s family to act as interpreters. If that is not possible or advisable, the clinician may ask a bilingual staff member to help. This is commonly called dual-role or ad-hoc interpreting because the employee’s primary job in the healthcare organization (whether clinical or non-clinical) involves something other than interpreting.
While ad-hoc interpreters fulfill immediate needs by thoughtfully stepping in and helping out, many are asked to interpret outside their areas of expertise as they interrupt their own work. And an interpreter who has received no specialized training cannot be expected to achieve the same results as a professional interpreter. Simply being bilingual is not enough; professional medical interpreting is a learned skill.
Yet many healthcare organizations across the United States are not prepared to provide professional linguistic access for their patients. This is not to say that care providers would not like a professional interpreter program in the healthcare organization. Providers from a wide range of services have reported that language barriers and inadequate funding of language access services present major problems in ensuring both access to and quality of healthcare for LEP individuals. Funding, in particular, is one of the major reasons healthcare organizations hesitate to implement dedicated interpreter departments.
According to Cynthia Roat, MPH, a national consultant on language access in healthcare, the two major restrictions hindering the implementation of professional linguistic access programs in hospitals today are:
- Lack of funding and
- Lack of qualified interpreters.
“Fortunately the latter problem is being addressed,” she says. “We have established standards of practice for professional competence, and there are training programs for medical interpreters as well as for clinical staff who use interpreters.”
For example, the National Council on Interpreting in Health Care (NCIHC), a leading advocate of medical interpreting, has developed national standards to improve communication between the LEP patient and the healthcare provider. In addition, many technical and community colleges now offer medical interpreting classes, and some medical schools are beginning to offer seminars and courses designed to train clinical staff to work with interpreters. “Working with interpreters is a concrete, clinical skill,” says Roat.
Still, finding the money for this type of program can have a financial impact on healthcare organizations. Adding to that, accreditation agencies such as the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and the National Committee for Quality Assurance (NCQA) have set compliance standards for language access in terms of its contribution to quality care and patient safety. These compliance standards can also have a financial impact on healthcare organizations.
An even more significant effect may result from the federal government’s mandate to provide language services to LEP individuals. Specifically, Executive Order 13166, “Improving Access to Services for Persons with Limited English Proficiency,” stipulates that hospital and healthcare organizations receiving federal funds are required to provide interpretation services under Title VI of the Civil Rights Act of 1964. Denial of interpreter services to LEP patients is considered a form of discrimination.
In addition, the Office of Minority Health (OMH) within the U.S. Department of Health and Human Services has specified 14 National Standards for Culturally and Linguistically Appropriate Services in Health Care (CLAS) that direct healthcare organizations to make their practices more culturally and linguistically accessible. CLAS standards are organized by themes: Culturally Competent Care, Language Access, and Organizational Support for Cultural Competence. Within this framework, there are three types of obligation: mandates, guidelines, and recommendations. Mandates are current federal requirements for all recipients of federal funds; guidelines are activities recommended by OMH for adoption as mandates by accrediting agencies; and recommendations are standards suggested by OMH for voluntary adoption by healthcare organizations.
Despite its mandates, standards, and recommendations, however, the U.S. government has not included provisions for or suggestions about paying for compliance.
Benefits of a Language Access Program
Nevertheless, in addition to complying with governmental regulations and meeting accreditation standards, hospitals can derive benefits from an interpreter program. First and foremost, using interpreters with LEP individuals allows a hospital to fulfill one of its most important professional obligations: providing the best care possible to each patient. The clinician understands the patient’s symptoms, and the patient understands the doctor’s diagnosis and instructions. Together they can form a partnership to meet the physical, psychological, and cultural needs of the patient and to afford a sense of satisfaction to the caregiver.
Secondly, providing linguistic access can make hospital services more cost effective. Visits are fewer and shorter. There are not as many follow-up appointments or repeat admissions because patients understand their physicians’ instructions. Clinicians avoid unnecessary, inadvisable, or inappropriate tests because they understand the patients’ symptoms. Overuse of emergency department services for primary care decreases because patients are comfortable establishing a more conventional primary care relationship. And, as Roat points out, “if a hospital can develop an access program that does not rely on ad-hoc interpreters, the organization can avoid the hidden costs of lower productivity and higher turnover among those ad-hoc interpreters who are asked to interrupt their regular work to provide language access.”
Finally, there are benefits associated with legal and liability issues. Among them: fewer mistakes in diagnoses and treatment because the patients can communicate with their care providers. Also, patients are able to follow directions correctly and understand the need for follow-up or referrals, thus averting an unnecessary tragedy or potential lawsuit. Glenn Flores, MD, director of the Center for the Advancement of Urban Children and professor of pediatrics, epidemiology, and health at the Medical College of Wisconsin, can cite examples of medical errors attributable to language misunderstandings.
“Lack of language services can affect instructions about giving medications, such as the mother who thought she should apply a cortisone cream to the child’s entire body rather than just to the facial rash,” he says. “There is also the problem of possible overdoses. And a single misinterpreted word in one case led to a $71 million lawsuit in Florida a few years ago. This is a major patient safety issue.”
Another safety issue for hospitals is informed consent. Hospitals that provide language services are more likely to ensure that their LEP patients understand and agree to sign the informed consent form.
Paying for Language Access Services
The benefits of offering language access services may be self-evident, but who pays for them? Certainly not private insurers. At least not yet. But, as professionals in the field, both Roat and Dr. Flores see a need for private insurers to assume part of the financial cost. Although Roat believes the costs should be shared among hospitals/clinics, public financing, and commercial insurers, “Advocates of language access need to start a dialogue with commercial insurers and point to HMOs as examples of how these services are being covered,” she says.
Multiple approaches may be necessary to set up coverage from private insurers. Dr. Flores suggests that one possible course is insurance reimbursement for professional interpreters, paid for by the hour or by the visit. Another alternative might involve establishing contract services with outside agencies, community organizations, or video- or teleconferencing companies to recruit, train, and assign medical interpreters for healthcare organizations. These groups could provide services and bill the insurer directly.
“There are also ways to use public funding,” observes Roat, “and there should be more pressure on the federal government to pony up more money for this.”
Dr. Flores agrees. “Under Medicaid and the State Children’s Health Insurance Program (SCHIP), states may pay for interpreting services and receive federal matching funds of 50% or more,” he says. “Yet only 13 states are taking advantage of this. The other 37 states are missing out on this money.”
Like many of his colleagues, Dr. Flores is also mystified about the government’s reluctance to fully fund interpretation services, pointing out that “a federal report from the Office of Management and Budget (OMB) in 2002 estimated that it would cost an average of $4.04 per physician visit to provide all LEP patients with full language access services.”
Then why hasn’t this been allocated? Dr. Flores acknowledges that there is some recognition and awareness of the situation in Congress, and he thinks there may be some political will as well. He has testified before the Senate about the Hispanic Health Improvement Act, yet the bill has yet to pass. At the moment, there are immigration issues that are impeding political action in these areas.
In the meantime, Dr. Flores suggests that there are other steps that healthcare organizations can take to ease language access problems:
- Recruit bilingual providers in areas with large ethnic populations and offer hiring bonuses for qualified individuals;
- Encourage medical schools to require—and even teach—proficiency in languages other than English. “We should require, as other countries do, that children learn foreign languages,” he says; and
- Do a better job of helping LEP individuals learn English.
Begin the last step by directing LEP patients to the Web site of the National Institute for Literacy and Partners, which matches applicants to literacy and ESL programs within their geographical area.1
“We must debunk the oft-repeated story that professional medical interpreters are too expensive to use, that they charge $400 an hour,” says Roat. “That figure came from an incident in which an interpreter was supposedly working in a very remote area on a weekend and charged for the time, distance, and unusual circumstances. In reality, qualified medical interpreters earn $20 to $25 per hour and are worth every penny. Plus, they save money by reducing time and costs to the institution.” TH
Ann Kepler is based in the Chicago area.
Reference
- National Institute for Literacy, Literacy Directory. Available at: www.literacydirectory.org. Last accessed September 27,2006.
What happens when a person who speaks a language other than English enters a hospital? One who is fortunate enough to enter one of the one-quarter of American hospitals that offer professional interpreters or other language access services can expect to understand what is going on and to communicate comfortably with the care providers. For the approximately 75% of U.S. hospitals remaining, language access has become a common concern as increasing immigration levels expand ethnic groups.
Nearly 52 million people—one in 12—in the United States speak a language other than English at home. In fact, more than 300 languages are spoken in the United States. Basing their calculations on the 2000 census, demographers estimate that the number of people with limited English proficiency (LEP) ranges from 11 million (those who speak English “not well” or “not at all”) to more than 22 million (those who speak English less than “very well”). And those numbers are expected to continue to grow.
The Effects on Healthcare
The growing diversity of the United States population has a direct effect on healthcare providers. In order to provide appropriate and safe care, a provider must rely on accurate information from the patient. Simultaneously, the patient must be able to understand health instructions and treatment options in order to participate in his or her care. Language is the vital bridge in this process.
So what happens, for example, when an English-speaking emergency department physician faces a Spanish-speaking patient seeking medical care? Often, the hospital staff will turn to the patient’s family to act as interpreters. If that is not possible or advisable, the clinician may ask a bilingual staff member to help. This is commonly called dual-role or ad-hoc interpreting because the employee’s primary job in the healthcare organization (whether clinical or non-clinical) involves something other than interpreting.
While ad-hoc interpreters fulfill immediate needs by thoughtfully stepping in and helping out, many are asked to interpret outside their areas of expertise as they interrupt their own work. And an interpreter who has received no specialized training cannot be expected to achieve the same results as a professional interpreter. Simply being bilingual is not enough; professional medical interpreting is a learned skill.
Yet many healthcare organizations across the United States are not prepared to provide professional linguistic access for their patients. This is not to say that care providers would not like a professional interpreter program in the healthcare organization. Providers from a wide range of services have reported that language barriers and inadequate funding of language access services present major problems in ensuring both access to and quality of healthcare for LEP individuals. Funding, in particular, is one of the major reasons healthcare organizations hesitate to implement dedicated interpreter departments.
According to Cynthia Roat, MPH, a national consultant on language access in healthcare, the two major restrictions hindering the implementation of professional linguistic access programs in hospitals today are:
- Lack of funding and
- Lack of qualified interpreters.
“Fortunately the latter problem is being addressed,” she says. “We have established standards of practice for professional competence, and there are training programs for medical interpreters as well as for clinical staff who use interpreters.”
For example, the National Council on Interpreting in Health Care (NCIHC), a leading advocate of medical interpreting, has developed national standards to improve communication between the LEP patient and the healthcare provider. In addition, many technical and community colleges now offer medical interpreting classes, and some medical schools are beginning to offer seminars and courses designed to train clinical staff to work with interpreters. “Working with interpreters is a concrete, clinical skill,” says Roat.
Still, finding the money for this type of program can have a financial impact on healthcare organizations. Adding to that, accreditation agencies such as the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and the National Committee for Quality Assurance (NCQA) have set compliance standards for language access in terms of its contribution to quality care and patient safety. These compliance standards can also have a financial impact on healthcare organizations.
An even more significant effect may result from the federal government’s mandate to provide language services to LEP individuals. Specifically, Executive Order 13166, “Improving Access to Services for Persons with Limited English Proficiency,” stipulates that hospital and healthcare organizations receiving federal funds are required to provide interpretation services under Title VI of the Civil Rights Act of 1964. Denial of interpreter services to LEP patients is considered a form of discrimination.
In addition, the Office of Minority Health (OMH) within the U.S. Department of Health and Human Services has specified 14 National Standards for Culturally and Linguistically Appropriate Services in Health Care (CLAS) that direct healthcare organizations to make their practices more culturally and linguistically accessible. CLAS standards are organized by themes: Culturally Competent Care, Language Access, and Organizational Support for Cultural Competence. Within this framework, there are three types of obligation: mandates, guidelines, and recommendations. Mandates are current federal requirements for all recipients of federal funds; guidelines are activities recommended by OMH for adoption as mandates by accrediting agencies; and recommendations are standards suggested by OMH for voluntary adoption by healthcare organizations.
Despite its mandates, standards, and recommendations, however, the U.S. government has not included provisions for or suggestions about paying for compliance.
Benefits of a Language Access Program
Nevertheless, in addition to complying with governmental regulations and meeting accreditation standards, hospitals can derive benefits from an interpreter program. First and foremost, using interpreters with LEP individuals allows a hospital to fulfill one of its most important professional obligations: providing the best care possible to each patient. The clinician understands the patient’s symptoms, and the patient understands the doctor’s diagnosis and instructions. Together they can form a partnership to meet the physical, psychological, and cultural needs of the patient and to afford a sense of satisfaction to the caregiver.
Secondly, providing linguistic access can make hospital services more cost effective. Visits are fewer and shorter. There are not as many follow-up appointments or repeat admissions because patients understand their physicians’ instructions. Clinicians avoid unnecessary, inadvisable, or inappropriate tests because they understand the patients’ symptoms. Overuse of emergency department services for primary care decreases because patients are comfortable establishing a more conventional primary care relationship. And, as Roat points out, “if a hospital can develop an access program that does not rely on ad-hoc interpreters, the organization can avoid the hidden costs of lower productivity and higher turnover among those ad-hoc interpreters who are asked to interrupt their regular work to provide language access.”
Finally, there are benefits associated with legal and liability issues. Among them: fewer mistakes in diagnoses and treatment because the patients can communicate with their care providers. Also, patients are able to follow directions correctly and understand the need for follow-up or referrals, thus averting an unnecessary tragedy or potential lawsuit. Glenn Flores, MD, director of the Center for the Advancement of Urban Children and professor of pediatrics, epidemiology, and health at the Medical College of Wisconsin, can cite examples of medical errors attributable to language misunderstandings.
“Lack of language services can affect instructions about giving medications, such as the mother who thought she should apply a cortisone cream to the child’s entire body rather than just to the facial rash,” he says. “There is also the problem of possible overdoses. And a single misinterpreted word in one case led to a $71 million lawsuit in Florida a few years ago. This is a major patient safety issue.”
Another safety issue for hospitals is informed consent. Hospitals that provide language services are more likely to ensure that their LEP patients understand and agree to sign the informed consent form.
Paying for Language Access Services
The benefits of offering language access services may be self-evident, but who pays for them? Certainly not private insurers. At least not yet. But, as professionals in the field, both Roat and Dr. Flores see a need for private insurers to assume part of the financial cost. Although Roat believes the costs should be shared among hospitals/clinics, public financing, and commercial insurers, “Advocates of language access need to start a dialogue with commercial insurers and point to HMOs as examples of how these services are being covered,” she says.
Multiple approaches may be necessary to set up coverage from private insurers. Dr. Flores suggests that one possible course is insurance reimbursement for professional interpreters, paid for by the hour or by the visit. Another alternative might involve establishing contract services with outside agencies, community organizations, or video- or teleconferencing companies to recruit, train, and assign medical interpreters for healthcare organizations. These groups could provide services and bill the insurer directly.
“There are also ways to use public funding,” observes Roat, “and there should be more pressure on the federal government to pony up more money for this.”
Dr. Flores agrees. “Under Medicaid and the State Children’s Health Insurance Program (SCHIP), states may pay for interpreting services and receive federal matching funds of 50% or more,” he says. “Yet only 13 states are taking advantage of this. The other 37 states are missing out on this money.”
Like many of his colleagues, Dr. Flores is also mystified about the government’s reluctance to fully fund interpretation services, pointing out that “a federal report from the Office of Management and Budget (OMB) in 2002 estimated that it would cost an average of $4.04 per physician visit to provide all LEP patients with full language access services.”
Then why hasn’t this been allocated? Dr. Flores acknowledges that there is some recognition and awareness of the situation in Congress, and he thinks there may be some political will as well. He has testified before the Senate about the Hispanic Health Improvement Act, yet the bill has yet to pass. At the moment, there are immigration issues that are impeding political action in these areas.
In the meantime, Dr. Flores suggests that there are other steps that healthcare organizations can take to ease language access problems:
- Recruit bilingual providers in areas with large ethnic populations and offer hiring bonuses for qualified individuals;
- Encourage medical schools to require—and even teach—proficiency in languages other than English. “We should require, as other countries do, that children learn foreign languages,” he says; and
- Do a better job of helping LEP individuals learn English.
Begin the last step by directing LEP patients to the Web site of the National Institute for Literacy and Partners, which matches applicants to literacy and ESL programs within their geographical area.1
“We must debunk the oft-repeated story that professional medical interpreters are too expensive to use, that they charge $400 an hour,” says Roat. “That figure came from an incident in which an interpreter was supposedly working in a very remote area on a weekend and charged for the time, distance, and unusual circumstances. In reality, qualified medical interpreters earn $20 to $25 per hour and are worth every penny. Plus, they save money by reducing time and costs to the institution.” TH
Ann Kepler is based in the Chicago area.
Reference
- National Institute for Literacy, Literacy Directory. Available at: www.literacydirectory.org. Last accessed September 27,2006.