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Hospitalists Should Refrain from Texting Patient Information
Refrain from Texting about Your Patients
Can I text my partners patient information?
–Stephen Henry, San Luis Obispo, Calif.
Dr. Hospitalist responds:
Can you? Sure. Do you? Probably. Should you? No.
Texting any patient information falls under the category of ePHI (Electronic Protected Health Information) as part of HIPAA. Technically, such patient-specific information must be protected at all times. Once you send a text, at least three copies are known to exist: one on each of the devices, plus one copy on the network it went through, adding for each network it has to cross. Sure, your phone may be password-protected, but is your partner’s? What about the carrier? How protected is their data?
HIPAA goes into excruciating technical detail about all the safeguards that must be present. You are more than welcome to read it (www.hhs.gov/ocr/privacy/hipaa/administrative/securityrule) to see if you meet all the standards. Or you can take my word for it: You don’t.
So you can see why most health organizations expressly prohibit the texting of patient information. If you rang up your local health-care or hospital lawyer, I’m sure they would tell you to never text patient information. Is that reasonable advice? In 2013, I doubt it.
So what’s the practical advice to follow? For starters, password-protect your phone, if you haven’t already. Nothing worse than losing your phone and having patient information on it. A lot of the OCR (Office for Civil Rights, a branch of Health and Human Services) fines for HIPAA violations stem from folks misplacing unencrypted devices with patient information on them.
Just as important, don’t text anything that you wouldn’t want to see blown up on a lawyer’s display board in court. I’ve seen some really egregious examples of communication between doctors that have no business being preserved electronically. Texting “Mr. X in Room 2101 is a meth-using, narcotic-seeking, half-naked, lunatic troll” is an absolutely stupid thing to do. For that matter, so are remarks that seem less offensive: “And his son is completely unreasonable.” Save your commentary and stick to the facts, because you just generated three copies forever.
If you receive an insensitive text, don’t reply. Simply call the sending physician to discuss any issues. Even being on a “secure” texting network won’t protect you from errors of commission.
If I were to text about a patient (purely hypothetically, mind you), I would limit the information as much as possible. Keep it simple and generic (what HIPAA likes to call “de-identified information”)—for example, “Room 428 is ready for discharge.”
Please, hold the subjective commentary. There is no good reason to have an extended text exchange about a patient; you are creating an electronic trail that has no good reason to exist and never really goes away. It’s just the same as writing in the chart, except that it has the illusion of privacy. And that’s all it is: an illusion.
At the end of the day, I’d probably worry more about the discoverable aspect of your text messages in a lawsuit than the possibility of a HIPAA fine, but neither one sounds like much fun to me.
Refrain from Texting about Your Patients
Can I text my partners patient information?
–Stephen Henry, San Luis Obispo, Calif.
Dr. Hospitalist responds:
Can you? Sure. Do you? Probably. Should you? No.
Texting any patient information falls under the category of ePHI (Electronic Protected Health Information) as part of HIPAA. Technically, such patient-specific information must be protected at all times. Once you send a text, at least three copies are known to exist: one on each of the devices, plus one copy on the network it went through, adding for each network it has to cross. Sure, your phone may be password-protected, but is your partner’s? What about the carrier? How protected is their data?
HIPAA goes into excruciating technical detail about all the safeguards that must be present. You are more than welcome to read it (www.hhs.gov/ocr/privacy/hipaa/administrative/securityrule) to see if you meet all the standards. Or you can take my word for it: You don’t.
So you can see why most health organizations expressly prohibit the texting of patient information. If you rang up your local health-care or hospital lawyer, I’m sure they would tell you to never text patient information. Is that reasonable advice? In 2013, I doubt it.
So what’s the practical advice to follow? For starters, password-protect your phone, if you haven’t already. Nothing worse than losing your phone and having patient information on it. A lot of the OCR (Office for Civil Rights, a branch of Health and Human Services) fines for HIPAA violations stem from folks misplacing unencrypted devices with patient information on them.
Just as important, don’t text anything that you wouldn’t want to see blown up on a lawyer’s display board in court. I’ve seen some really egregious examples of communication between doctors that have no business being preserved electronically. Texting “Mr. X in Room 2101 is a meth-using, narcotic-seeking, half-naked, lunatic troll” is an absolutely stupid thing to do. For that matter, so are remarks that seem less offensive: “And his son is completely unreasonable.” Save your commentary and stick to the facts, because you just generated three copies forever.
If you receive an insensitive text, don’t reply. Simply call the sending physician to discuss any issues. Even being on a “secure” texting network won’t protect you from errors of commission.
If I were to text about a patient (purely hypothetically, mind you), I would limit the information as much as possible. Keep it simple and generic (what HIPAA likes to call “de-identified information”)—for example, “Room 428 is ready for discharge.”
Please, hold the subjective commentary. There is no good reason to have an extended text exchange about a patient; you are creating an electronic trail that has no good reason to exist and never really goes away. It’s just the same as writing in the chart, except that it has the illusion of privacy. And that’s all it is: an illusion.
At the end of the day, I’d probably worry more about the discoverable aspect of your text messages in a lawsuit than the possibility of a HIPAA fine, but neither one sounds like much fun to me.
Refrain from Texting about Your Patients
Can I text my partners patient information?
–Stephen Henry, San Luis Obispo, Calif.
Dr. Hospitalist responds:
Can you? Sure. Do you? Probably. Should you? No.
Texting any patient information falls under the category of ePHI (Electronic Protected Health Information) as part of HIPAA. Technically, such patient-specific information must be protected at all times. Once you send a text, at least three copies are known to exist: one on each of the devices, plus one copy on the network it went through, adding for each network it has to cross. Sure, your phone may be password-protected, but is your partner’s? What about the carrier? How protected is their data?
HIPAA goes into excruciating technical detail about all the safeguards that must be present. You are more than welcome to read it (www.hhs.gov/ocr/privacy/hipaa/administrative/securityrule) to see if you meet all the standards. Or you can take my word for it: You don’t.
So you can see why most health organizations expressly prohibit the texting of patient information. If you rang up your local health-care or hospital lawyer, I’m sure they would tell you to never text patient information. Is that reasonable advice? In 2013, I doubt it.
So what’s the practical advice to follow? For starters, password-protect your phone, if you haven’t already. Nothing worse than losing your phone and having patient information on it. A lot of the OCR (Office for Civil Rights, a branch of Health and Human Services) fines for HIPAA violations stem from folks misplacing unencrypted devices with patient information on them.
Just as important, don’t text anything that you wouldn’t want to see blown up on a lawyer’s display board in court. I’ve seen some really egregious examples of communication between doctors that have no business being preserved electronically. Texting “Mr. X in Room 2101 is a meth-using, narcotic-seeking, half-naked, lunatic troll” is an absolutely stupid thing to do. For that matter, so are remarks that seem less offensive: “And his son is completely unreasonable.” Save your commentary and stick to the facts, because you just generated three copies forever.
If you receive an insensitive text, don’t reply. Simply call the sending physician to discuss any issues. Even being on a “secure” texting network won’t protect you from errors of commission.
If I were to text about a patient (purely hypothetically, mind you), I would limit the information as much as possible. Keep it simple and generic (what HIPAA likes to call “de-identified information”)—for example, “Room 428 is ready for discharge.”
Please, hold the subjective commentary. There is no good reason to have an extended text exchange about a patient; you are creating an electronic trail that has no good reason to exist and never really goes away. It’s just the same as writing in the chart, except that it has the illusion of privacy. And that’s all it is: an illusion.
At the end of the day, I’d probably worry more about the discoverable aspect of your text messages in a lawsuit than the possibility of a HIPAA fine, but neither one sounds like much fun to me.
Hospitalists Encouraged to Join Hospital Committees Early
Hospitalists Should Not Hesitate to Join Hospital Committees
What’s the story with hospital committee work? Is this part of my job?
–Timothy P. Young, Fort Worth, Texas
Dr. Hospitalist responds:
Yes. Allow me to explain. It’s 2013, and hospitalists are the physician workforce in the hospital. Yes, radiologists, anesthesiologists, and ED physicians are hospital-based, but their work is location-focused, not longitudinal and cross-discipline, as it is for general hospitalists. A hospital has a rather cumbersome administrative apparatus, and, as in any large organization, committees are its lifeblood. Your hospital leadership also will appreciate your contribution in a role outside of day-to-day clinical work.
The standing rule in our group is that every hospitalist must serve on at least one hospital committee. Here are three committees that strike me as most vital to our job:
Peer review: Arguably, this is the committee with the most impact in the hospital when it is run correctly. Although its stated objective is to review physician-related clinical concerns, don’t be surprised if offending physicians interpret clinical complaints as political grievances. This requires a thick skin and the ability to park your allegiances at the door. Physicians generally have done a pretty poor job policing themselves over the years, and while this committee does not need to be Draconian in nature, it should review complaints seriously and objectively. That also means recusing yourself from discussions involving your partners.
Credentialing: Another essential committee. I can’t tell you the number of times over the years we have hired a new physician with a specific start date in mind, only to miss that date over a delay with hospital credentialing. Talk about a morale killer—when everyone is overworked and the promised extra help doesn’t arrive ... ouch. Having a representative on this committee is no guarantee of punctual credentialing; however, it can help your group stay on top of expected deadlines and potential hiccups.
Information technology: EMR? Meaningful use? CPOE? Physician champion for IT issues? At the rate we’re going, it looks like all of us are going to work for the IT department someday. Lovely as these people are, they often have imperfect insight into the day-to-day workload of a hospitalist. Little things—such as the fact that a computer workstation also needs a telephone so you can answer pages—will never make it onto their radar screen without physician input.
Other committees of note: internal medicine, pharmacy and therapeutics (P&T), infection control, quality control, patient safety, ethics, and executive council. One caveat: The importance of these committees will vary greatly from hospital to hospital, so if you are new, take the time to ask around and get the lay of the land. My list and the rankings are by no means definitive.
Go ahead and join a committee, even if it does not happen to be your first choice. It does not mean that you will be on that committee for life, but it will grant you good exposure across multiple disciplines in the hospital. Overall, for your practice health, your group should be well represented on hospital committees.
Hospitalists Should Not Hesitate to Join Hospital Committees
What’s the story with hospital committee work? Is this part of my job?
–Timothy P. Young, Fort Worth, Texas
Dr. Hospitalist responds:
Yes. Allow me to explain. It’s 2013, and hospitalists are the physician workforce in the hospital. Yes, radiologists, anesthesiologists, and ED physicians are hospital-based, but their work is location-focused, not longitudinal and cross-discipline, as it is for general hospitalists. A hospital has a rather cumbersome administrative apparatus, and, as in any large organization, committees are its lifeblood. Your hospital leadership also will appreciate your contribution in a role outside of day-to-day clinical work.
The standing rule in our group is that every hospitalist must serve on at least one hospital committee. Here are three committees that strike me as most vital to our job:
Peer review: Arguably, this is the committee with the most impact in the hospital when it is run correctly. Although its stated objective is to review physician-related clinical concerns, don’t be surprised if offending physicians interpret clinical complaints as political grievances. This requires a thick skin and the ability to park your allegiances at the door. Physicians generally have done a pretty poor job policing themselves over the years, and while this committee does not need to be Draconian in nature, it should review complaints seriously and objectively. That also means recusing yourself from discussions involving your partners.
Credentialing: Another essential committee. I can’t tell you the number of times over the years we have hired a new physician with a specific start date in mind, only to miss that date over a delay with hospital credentialing. Talk about a morale killer—when everyone is overworked and the promised extra help doesn’t arrive ... ouch. Having a representative on this committee is no guarantee of punctual credentialing; however, it can help your group stay on top of expected deadlines and potential hiccups.
Information technology: EMR? Meaningful use? CPOE? Physician champion for IT issues? At the rate we’re going, it looks like all of us are going to work for the IT department someday. Lovely as these people are, they often have imperfect insight into the day-to-day workload of a hospitalist. Little things—such as the fact that a computer workstation also needs a telephone so you can answer pages—will never make it onto their radar screen without physician input.
Other committees of note: internal medicine, pharmacy and therapeutics (P&T), infection control, quality control, patient safety, ethics, and executive council. One caveat: The importance of these committees will vary greatly from hospital to hospital, so if you are new, take the time to ask around and get the lay of the land. My list and the rankings are by no means definitive.
Go ahead and join a committee, even if it does not happen to be your first choice. It does not mean that you will be on that committee for life, but it will grant you good exposure across multiple disciplines in the hospital. Overall, for your practice health, your group should be well represented on hospital committees.
Hospitalists Should Not Hesitate to Join Hospital Committees
What’s the story with hospital committee work? Is this part of my job?
–Timothy P. Young, Fort Worth, Texas
Dr. Hospitalist responds:
Yes. Allow me to explain. It’s 2013, and hospitalists are the physician workforce in the hospital. Yes, radiologists, anesthesiologists, and ED physicians are hospital-based, but their work is location-focused, not longitudinal and cross-discipline, as it is for general hospitalists. A hospital has a rather cumbersome administrative apparatus, and, as in any large organization, committees are its lifeblood. Your hospital leadership also will appreciate your contribution in a role outside of day-to-day clinical work.
The standing rule in our group is that every hospitalist must serve on at least one hospital committee. Here are three committees that strike me as most vital to our job:
Peer review: Arguably, this is the committee with the most impact in the hospital when it is run correctly. Although its stated objective is to review physician-related clinical concerns, don’t be surprised if offending physicians interpret clinical complaints as political grievances. This requires a thick skin and the ability to park your allegiances at the door. Physicians generally have done a pretty poor job policing themselves over the years, and while this committee does not need to be Draconian in nature, it should review complaints seriously and objectively. That also means recusing yourself from discussions involving your partners.
Credentialing: Another essential committee. I can’t tell you the number of times over the years we have hired a new physician with a specific start date in mind, only to miss that date over a delay with hospital credentialing. Talk about a morale killer—when everyone is overworked and the promised extra help doesn’t arrive ... ouch. Having a representative on this committee is no guarantee of punctual credentialing; however, it can help your group stay on top of expected deadlines and potential hiccups.
Information technology: EMR? Meaningful use? CPOE? Physician champion for IT issues? At the rate we’re going, it looks like all of us are going to work for the IT department someday. Lovely as these people are, they often have imperfect insight into the day-to-day workload of a hospitalist. Little things—such as the fact that a computer workstation also needs a telephone so you can answer pages—will never make it onto their radar screen without physician input.
Other committees of note: internal medicine, pharmacy and therapeutics (P&T), infection control, quality control, patient safety, ethics, and executive council. One caveat: The importance of these committees will vary greatly from hospital to hospital, so if you are new, take the time to ask around and get the lay of the land. My list and the rankings are by no means definitive.
Go ahead and join a committee, even if it does not happen to be your first choice. It does not mean that you will be on that committee for life, but it will grant you good exposure across multiple disciplines in the hospital. Overall, for your practice health, your group should be well represented on hospital committees.
Clarifying the Role of Hospitalists Focused on Family Medicine in the ICU
Clarifying Family-Practice Hospitalists’ Value, Focused-Practice Opportunities
I am writing regarding the letter and your response in the January 2013 issue of The Hospitalist regarding hospitalists trained in family medicine and practice in critical-care units. I am the chair of the Family Medicine Committee for SHM, a practicing hospitalist, and an SHM member for over 10 years. There is an error in your reply, in that physicians who are board-certified through the American Board of Family Medicine (ABFM) are indeed eligible to take the examination for Recognition of Focused Practice in Hospital Medicine (RFPHM). This examination is administered by the American Board of Internal Medicine (ABIM), and is the same examination for all physicians, regardless of whether their residency was completed in family or internal medicine.
I am proud to be among the six family physicians who took and passed the first examination in October 2010. Through 2012, there have been 28 family physicians who have passed this exam, and attained RFPHM (verbal communication from ABFM). According to the ABIM website, there have been 267 total physicians who have taken the examination through 2011, which includes family-medicine-trained physicians. There are a number of Maintenance of Certification (MOC) modules offered through the ABIM that are available to hospitalists trained in family medicine.
A prior study showed that 66% of hospitalists trained in family medicine practice in critical-care units (McElrath et al). You are correct that there is no current pathway for HTFM to pursue a critical-care fellowship or attain board certification by the SCCM, as diplomats of the ABFM are excluded. However, there are many hospitalists trained in family medicine providing excellent care to patients in critical-care units. There are clearly not enough board certified intensivists to provide the care.
—Kevin Ahern, MD, SFHM, chief hospitalist, Sound Physicians, Urbana, Ohio
Dr. Hospitalist responds:
You are absolutely correct in your point of clarification regarding the Recognition of Focused Practice in Hospital Medicine from the ABFM. I was aware of this at the time of the article; however, in my efforts to outline the proposed path from RFPHM to ICU certification, I focused solely on the ABIM pathway without mentioning the additional recognition available to family-practice physicians. In no way was this meant to denigrate the efforts or contributions of family-practice physicians to HM and SHM, but I could have been much more clear on this point. Having hired and worked alongside family-practice hospitalists, I know just how valuable you are.
The overall picture is consistent with what you described in that there are “clearly not enough board-certified intensivists” to fully staff ICUs. However, it is evident that it will be an uphill battle to sanction an alternate pathway that lets any hospitalist gain certification as an ICU physician. Truth be told, there are fundamental differences in the amount of ICU exposure between internal-medicine and family-practice training programs. As a result, in the current proposal there is no overt discussion of the role for family-practice hospitalists in the ICU. I think that this will continue to remain a conscious omission for both political and practical reasons.
Clarifying Family-Practice Hospitalists’ Value, Focused-Practice Opportunities
I am writing regarding the letter and your response in the January 2013 issue of The Hospitalist regarding hospitalists trained in family medicine and practice in critical-care units. I am the chair of the Family Medicine Committee for SHM, a practicing hospitalist, and an SHM member for over 10 years. There is an error in your reply, in that physicians who are board-certified through the American Board of Family Medicine (ABFM) are indeed eligible to take the examination for Recognition of Focused Practice in Hospital Medicine (RFPHM). This examination is administered by the American Board of Internal Medicine (ABIM), and is the same examination for all physicians, regardless of whether their residency was completed in family or internal medicine.
I am proud to be among the six family physicians who took and passed the first examination in October 2010. Through 2012, there have been 28 family physicians who have passed this exam, and attained RFPHM (verbal communication from ABFM). According to the ABIM website, there have been 267 total physicians who have taken the examination through 2011, which includes family-medicine-trained physicians. There are a number of Maintenance of Certification (MOC) modules offered through the ABIM that are available to hospitalists trained in family medicine.
A prior study showed that 66% of hospitalists trained in family medicine practice in critical-care units (McElrath et al). You are correct that there is no current pathway for HTFM to pursue a critical-care fellowship or attain board certification by the SCCM, as diplomats of the ABFM are excluded. However, there are many hospitalists trained in family medicine providing excellent care to patients in critical-care units. There are clearly not enough board certified intensivists to provide the care.
—Kevin Ahern, MD, SFHM, chief hospitalist, Sound Physicians, Urbana, Ohio
Dr. Hospitalist responds:
You are absolutely correct in your point of clarification regarding the Recognition of Focused Practice in Hospital Medicine from the ABFM. I was aware of this at the time of the article; however, in my efforts to outline the proposed path from RFPHM to ICU certification, I focused solely on the ABIM pathway without mentioning the additional recognition available to family-practice physicians. In no way was this meant to denigrate the efforts or contributions of family-practice physicians to HM and SHM, but I could have been much more clear on this point. Having hired and worked alongside family-practice hospitalists, I know just how valuable you are.
The overall picture is consistent with what you described in that there are “clearly not enough board-certified intensivists” to fully staff ICUs. However, it is evident that it will be an uphill battle to sanction an alternate pathway that lets any hospitalist gain certification as an ICU physician. Truth be told, there are fundamental differences in the amount of ICU exposure between internal-medicine and family-practice training programs. As a result, in the current proposal there is no overt discussion of the role for family-practice hospitalists in the ICU. I think that this will continue to remain a conscious omission for both political and practical reasons.
Clarifying Family-Practice Hospitalists’ Value, Focused-Practice Opportunities
I am writing regarding the letter and your response in the January 2013 issue of The Hospitalist regarding hospitalists trained in family medicine and practice in critical-care units. I am the chair of the Family Medicine Committee for SHM, a practicing hospitalist, and an SHM member for over 10 years. There is an error in your reply, in that physicians who are board-certified through the American Board of Family Medicine (ABFM) are indeed eligible to take the examination for Recognition of Focused Practice in Hospital Medicine (RFPHM). This examination is administered by the American Board of Internal Medicine (ABIM), and is the same examination for all physicians, regardless of whether their residency was completed in family or internal medicine.
I am proud to be among the six family physicians who took and passed the first examination in October 2010. Through 2012, there have been 28 family physicians who have passed this exam, and attained RFPHM (verbal communication from ABFM). According to the ABIM website, there have been 267 total physicians who have taken the examination through 2011, which includes family-medicine-trained physicians. There are a number of Maintenance of Certification (MOC) modules offered through the ABIM that are available to hospitalists trained in family medicine.
A prior study showed that 66% of hospitalists trained in family medicine practice in critical-care units (McElrath et al). You are correct that there is no current pathway for HTFM to pursue a critical-care fellowship or attain board certification by the SCCM, as diplomats of the ABFM are excluded. However, there are many hospitalists trained in family medicine providing excellent care to patients in critical-care units. There are clearly not enough board certified intensivists to provide the care.
—Kevin Ahern, MD, SFHM, chief hospitalist, Sound Physicians, Urbana, Ohio
Dr. Hospitalist responds:
You are absolutely correct in your point of clarification regarding the Recognition of Focused Practice in Hospital Medicine from the ABFM. I was aware of this at the time of the article; however, in my efforts to outline the proposed path from RFPHM to ICU certification, I focused solely on the ABIM pathway without mentioning the additional recognition available to family-practice physicians. In no way was this meant to denigrate the efforts or contributions of family-practice physicians to HM and SHM, but I could have been much more clear on this point. Having hired and worked alongside family-practice hospitalists, I know just how valuable you are.
The overall picture is consistent with what you described in that there are “clearly not enough board-certified intensivists” to fully staff ICUs. However, it is evident that it will be an uphill battle to sanction an alternate pathway that lets any hospitalist gain certification as an ICU physician. Truth be told, there are fundamental differences in the amount of ICU exposure between internal-medicine and family-practice training programs. As a result, in the current proposal there is no overt discussion of the role for family-practice hospitalists in the ICU. I think that this will continue to remain a conscious omission for both political and practical reasons.
Hospital Medicine Group Leaders Strive to Balance Administrative, Clinical Tasks
Balance Is Key to HM Group Leaders’ Clinical Load
Should the leader of my hospitalist group have a lighter clinical load?
Cheryl Clinkenbeard, DO, MPH, Bartlesville, Okla.
Dr. Hospitalist responds:
This is an incredibly tough question, and it applies to pretty much every hospitalist program in existence. Big, small, private, teaching—every program needs leaders.
For starters, being a hospitalist program leader is generally a thankless job. It involves a heck of a lot of meetings, administrative hassles, and parsing of complaints. In my experience, it also tends to be a horrifically underpaid position. There generally is no waiting list of clinicians begging to be the group leader. Given all the time demands, I think it is perfectly reasonable to expect a leader to have a lighter clinical load. There is no way to fulfill both clinical and administrative duties while working full time, unless the group is very small (less than six FTEs). On the other hand, having a leader do no clinical work is pretty much a recipe for disaster. If your group leader is a clinician and does a lot less, or no clinical work, they will lose credibility with colleagues quickly. Group leaders focused solely on administration also lose sight of the day-to-day morale and activem issues facing the group.
The crux is trying to find the balance between admin and clinical duties. I think it is preferable to have a leader work fewer shifts but take an equivalent clinical load on those days. That allows group leaders to be viewed as “one of the team,” with the same shift responsibilities as everyone else—just not as many shifts. It’s a better way to understand the day-to-day variations and concerns of the job.
The other option is to have the leader work the same number of shifts but take a smaller census. I think this is a bad idea, mainly from the standpoint that HM is nothing if not unpredictable, and trying to protect one person’s census on a busy day is an impossible task. Either the leader will end up taking on too much clinical work (to help even the census) or the rest of the group will feel bitter that the group leader is not always available to help. I’ve seen both sides of this equation, and it is just not a good working environment.
Another factor to consider are the “undesirable” shifts. Whether it is nights or weekends, there are always shifts that folks would rather not do. A leader should continue to work these shifts, even at a reduced number, for the same reasons. Becoming an HM leader is not an excuse to design the perfect, protected schedule at the expense of the other physicians.
On balance, I think the hospitalist group leader ends up with more work, similar schedule obligations, and an inadequate pay structure. That does not make the position particularly attractive, as has been my experience over the years. However, given the opportunity to modify those variables, I think the shifts should be kept “whole” and reduced only in number, with the remainder of the compensation for the work coming in the form of increased pay. How much, you ask? Well, have a seat; this could take a while.
Balance Is Key to HM Group Leaders’ Clinical Load
Should the leader of my hospitalist group have a lighter clinical load?
Cheryl Clinkenbeard, DO, MPH, Bartlesville, Okla.
Dr. Hospitalist responds:
This is an incredibly tough question, and it applies to pretty much every hospitalist program in existence. Big, small, private, teaching—every program needs leaders.
For starters, being a hospitalist program leader is generally a thankless job. It involves a heck of a lot of meetings, administrative hassles, and parsing of complaints. In my experience, it also tends to be a horrifically underpaid position. There generally is no waiting list of clinicians begging to be the group leader. Given all the time demands, I think it is perfectly reasonable to expect a leader to have a lighter clinical load. There is no way to fulfill both clinical and administrative duties while working full time, unless the group is very small (less than six FTEs). On the other hand, having a leader do no clinical work is pretty much a recipe for disaster. If your group leader is a clinician and does a lot less, or no clinical work, they will lose credibility with colleagues quickly. Group leaders focused solely on administration also lose sight of the day-to-day morale and activem issues facing the group.
The crux is trying to find the balance between admin and clinical duties. I think it is preferable to have a leader work fewer shifts but take an equivalent clinical load on those days. That allows group leaders to be viewed as “one of the team,” with the same shift responsibilities as everyone else—just not as many shifts. It’s a better way to understand the day-to-day variations and concerns of the job.
The other option is to have the leader work the same number of shifts but take a smaller census. I think this is a bad idea, mainly from the standpoint that HM is nothing if not unpredictable, and trying to protect one person’s census on a busy day is an impossible task. Either the leader will end up taking on too much clinical work (to help even the census) or the rest of the group will feel bitter that the group leader is not always available to help. I’ve seen both sides of this equation, and it is just not a good working environment.
Another factor to consider are the “undesirable” shifts. Whether it is nights or weekends, there are always shifts that folks would rather not do. A leader should continue to work these shifts, even at a reduced number, for the same reasons. Becoming an HM leader is not an excuse to design the perfect, protected schedule at the expense of the other physicians.
On balance, I think the hospitalist group leader ends up with more work, similar schedule obligations, and an inadequate pay structure. That does not make the position particularly attractive, as has been my experience over the years. However, given the opportunity to modify those variables, I think the shifts should be kept “whole” and reduced only in number, with the remainder of the compensation for the work coming in the form of increased pay. How much, you ask? Well, have a seat; this could take a while.
Balance Is Key to HM Group Leaders’ Clinical Load
Should the leader of my hospitalist group have a lighter clinical load?
Cheryl Clinkenbeard, DO, MPH, Bartlesville, Okla.
Dr. Hospitalist responds:
This is an incredibly tough question, and it applies to pretty much every hospitalist program in existence. Big, small, private, teaching—every program needs leaders.
For starters, being a hospitalist program leader is generally a thankless job. It involves a heck of a lot of meetings, administrative hassles, and parsing of complaints. In my experience, it also tends to be a horrifically underpaid position. There generally is no waiting list of clinicians begging to be the group leader. Given all the time demands, I think it is perfectly reasonable to expect a leader to have a lighter clinical load. There is no way to fulfill both clinical and administrative duties while working full time, unless the group is very small (less than six FTEs). On the other hand, having a leader do no clinical work is pretty much a recipe for disaster. If your group leader is a clinician and does a lot less, or no clinical work, they will lose credibility with colleagues quickly. Group leaders focused solely on administration also lose sight of the day-to-day morale and activem issues facing the group.
The crux is trying to find the balance between admin and clinical duties. I think it is preferable to have a leader work fewer shifts but take an equivalent clinical load on those days. That allows group leaders to be viewed as “one of the team,” with the same shift responsibilities as everyone else—just not as many shifts. It’s a better way to understand the day-to-day variations and concerns of the job.
The other option is to have the leader work the same number of shifts but take a smaller census. I think this is a bad idea, mainly from the standpoint that HM is nothing if not unpredictable, and trying to protect one person’s census on a busy day is an impossible task. Either the leader will end up taking on too much clinical work (to help even the census) or the rest of the group will feel bitter that the group leader is not always available to help. I’ve seen both sides of this equation, and it is just not a good working environment.
Another factor to consider are the “undesirable” shifts. Whether it is nights or weekends, there are always shifts that folks would rather not do. A leader should continue to work these shifts, even at a reduced number, for the same reasons. Becoming an HM leader is not an excuse to design the perfect, protected schedule at the expense of the other physicians.
On balance, I think the hospitalist group leader ends up with more work, similar schedule obligations, and an inadequate pay structure. That does not make the position particularly attractive, as has been my experience over the years. However, given the opportunity to modify those variables, I think the shifts should be kept “whole” and reduced only in number, with the remainder of the compensation for the work coming in the form of increased pay. How much, you ask? Well, have a seat; this could take a while.
New Anticoagulants Offer Promise, but Obstacles Remain
I see more and more people taking one of the newer anticoagulants. I’ve also seen a few disasters with these drugs. What’s the story?
Stacy M. Harper, Green Bay, Wis.
Dr. Hospitalist responds:
Although warfarin (Coumadin) has been a mainstay anticoagulant for decades, it can often be a frustrating medicine to manage due to its myriad drug interactions and the constant need for therapeutic testing. Recently, we have seen new medications hit the market (with one more likely to be approved soon), each with its pros and cons. Here’s an overview:
- Dabigatran (Pradaxa): It’s a direct thrombin inhibitor, taken twice daily. It has been approved for use in stroke prevention for atrial fibrillation (afib) (RELY trial) at 150 mg bid. It’s also been extensively studied for VTE prevention after orthopedic surgery, but it has not yet been approved in the U.S. for this indication.
As with all of these drugs, there is no reversal agent and there are no levels to measure. A recent report noted an increased risk of bleeding in patients who are older, have a low BMI, or have renal dysfunction. The manufacturer recommends a dose of 75 mg bid for patients with renal dysfunction, defined as a GFR of 15 to 30 mL/min; however, that dosing regimen was never explicitly studied.
Overall, it’s become quite a popular drug with the cardiologists in my neck of the woods. GERD can be a bothersome side effect. I avoid using it in patients older than 80, or in a patient with any renal dysfunction. Also, remember that it is not approved for VTE prevention or treatment.
- Rivaroxaban (Xarelto): An oral factor Xa inhibitor. Usually taken once daily at 10 mg for VTE prevention (RECORD trials). It is dosed at 20 mg/day for stroke prevention in afib (ROCKET-AF trial). Just recently, it was approved by the FDA for use in the acute treatment of DVT and PE (EINSTEIN trial), dosed at 15 mg BID for the first 21 days, and then continued at 20 mg daily after the initial period (see “Game-Changer,” p. 41). It is more hepatically metabolized than dabigatran, but it still has a significant renal clearance component. When compared to lovenox in orthopedic patients, it’s as effective but with a slightly higher risk of bleeding. I would avoid using it in any patients with significant renal or hepatic dysfunction.
- Apixaban (Eliquis): Another oral factor Xa inhibitor. Studied at 2.5 mg BID for VTE prevention in orthopedic patients (ADVANCE trials). Studied at 5 mg BID for stroke prevention in afib (ARISTOTLE trial). It is not yet approved in the U.S for any indication, but a final decision is expected from the FDA by March. Overall, the data are fairly compelling, and it looks like a strong candidate. The data show a drug that is potentially more effective than lovenox, with less risk of bleeding for orthopedic patients. It is mainly hepatically metabolized.
So, with no drug company relationships to disclose, here are my general observations: For starters, I think dabigatran is being overused in older patients with renal dysfunction. I seem to stop it more than I recommend it, and it is far from my favorite drug. With rivaroxaban, it looks appropriate for VTE prevention, and now having the option of being able to transition patients who develop a clot onto a treatment dose of the drug is appealing. Apixaban’s data look the best out of all three agents in terms of both efficacy and bleeding, and although it is yet to be approved here, I imagine that will change in the near future. For all of these drugs, remember that we have no long-term safety data, and no reversal agents. It will be interesting to see how this plays out and which of these drugs have staying power. For all of warfarin’s faults, at least we know how to measure it and how to stop it.
I see more and more people taking one of the newer anticoagulants. I’ve also seen a few disasters with these drugs. What’s the story?
Stacy M. Harper, Green Bay, Wis.
Dr. Hospitalist responds:
Although warfarin (Coumadin) has been a mainstay anticoagulant for decades, it can often be a frustrating medicine to manage due to its myriad drug interactions and the constant need for therapeutic testing. Recently, we have seen new medications hit the market (with one more likely to be approved soon), each with its pros and cons. Here’s an overview:
- Dabigatran (Pradaxa): It’s a direct thrombin inhibitor, taken twice daily. It has been approved for use in stroke prevention for atrial fibrillation (afib) (RELY trial) at 150 mg bid. It’s also been extensively studied for VTE prevention after orthopedic surgery, but it has not yet been approved in the U.S. for this indication.
As with all of these drugs, there is no reversal agent and there are no levels to measure. A recent report noted an increased risk of bleeding in patients who are older, have a low BMI, or have renal dysfunction. The manufacturer recommends a dose of 75 mg bid for patients with renal dysfunction, defined as a GFR of 15 to 30 mL/min; however, that dosing regimen was never explicitly studied.
Overall, it’s become quite a popular drug with the cardiologists in my neck of the woods. GERD can be a bothersome side effect. I avoid using it in patients older than 80, or in a patient with any renal dysfunction. Also, remember that it is not approved for VTE prevention or treatment.
- Rivaroxaban (Xarelto): An oral factor Xa inhibitor. Usually taken once daily at 10 mg for VTE prevention (RECORD trials). It is dosed at 20 mg/day for stroke prevention in afib (ROCKET-AF trial). Just recently, it was approved by the FDA for use in the acute treatment of DVT and PE (EINSTEIN trial), dosed at 15 mg BID for the first 21 days, and then continued at 20 mg daily after the initial period (see “Game-Changer,” p. 41). It is more hepatically metabolized than dabigatran, but it still has a significant renal clearance component. When compared to lovenox in orthopedic patients, it’s as effective but with a slightly higher risk of bleeding. I would avoid using it in any patients with significant renal or hepatic dysfunction.
- Apixaban (Eliquis): Another oral factor Xa inhibitor. Studied at 2.5 mg BID for VTE prevention in orthopedic patients (ADVANCE trials). Studied at 5 mg BID for stroke prevention in afib (ARISTOTLE trial). It is not yet approved in the U.S for any indication, but a final decision is expected from the FDA by March. Overall, the data are fairly compelling, and it looks like a strong candidate. The data show a drug that is potentially more effective than lovenox, with less risk of bleeding for orthopedic patients. It is mainly hepatically metabolized.
So, with no drug company relationships to disclose, here are my general observations: For starters, I think dabigatran is being overused in older patients with renal dysfunction. I seem to stop it more than I recommend it, and it is far from my favorite drug. With rivaroxaban, it looks appropriate for VTE prevention, and now having the option of being able to transition patients who develop a clot onto a treatment dose of the drug is appealing. Apixaban’s data look the best out of all three agents in terms of both efficacy and bleeding, and although it is yet to be approved here, I imagine that will change in the near future. For all of these drugs, remember that we have no long-term safety data, and no reversal agents. It will be interesting to see how this plays out and which of these drugs have staying power. For all of warfarin’s faults, at least we know how to measure it and how to stop it.
I see more and more people taking one of the newer anticoagulants. I’ve also seen a few disasters with these drugs. What’s the story?
Stacy M. Harper, Green Bay, Wis.
Dr. Hospitalist responds:
Although warfarin (Coumadin) has been a mainstay anticoagulant for decades, it can often be a frustrating medicine to manage due to its myriad drug interactions and the constant need for therapeutic testing. Recently, we have seen new medications hit the market (with one more likely to be approved soon), each with its pros and cons. Here’s an overview:
- Dabigatran (Pradaxa): It’s a direct thrombin inhibitor, taken twice daily. It has been approved for use in stroke prevention for atrial fibrillation (afib) (RELY trial) at 150 mg bid. It’s also been extensively studied for VTE prevention after orthopedic surgery, but it has not yet been approved in the U.S. for this indication.
As with all of these drugs, there is no reversal agent and there are no levels to measure. A recent report noted an increased risk of bleeding in patients who are older, have a low BMI, or have renal dysfunction. The manufacturer recommends a dose of 75 mg bid for patients with renal dysfunction, defined as a GFR of 15 to 30 mL/min; however, that dosing regimen was never explicitly studied.
Overall, it’s become quite a popular drug with the cardiologists in my neck of the woods. GERD can be a bothersome side effect. I avoid using it in patients older than 80, or in a patient with any renal dysfunction. Also, remember that it is not approved for VTE prevention or treatment.
- Rivaroxaban (Xarelto): An oral factor Xa inhibitor. Usually taken once daily at 10 mg for VTE prevention (RECORD trials). It is dosed at 20 mg/day for stroke prevention in afib (ROCKET-AF trial). Just recently, it was approved by the FDA for use in the acute treatment of DVT and PE (EINSTEIN trial), dosed at 15 mg BID for the first 21 days, and then continued at 20 mg daily after the initial period (see “Game-Changer,” p. 41). It is more hepatically metabolized than dabigatran, but it still has a significant renal clearance component. When compared to lovenox in orthopedic patients, it’s as effective but with a slightly higher risk of bleeding. I would avoid using it in any patients with significant renal or hepatic dysfunction.
- Apixaban (Eliquis): Another oral factor Xa inhibitor. Studied at 2.5 mg BID for VTE prevention in orthopedic patients (ADVANCE trials). Studied at 5 mg BID for stroke prevention in afib (ARISTOTLE trial). It is not yet approved in the U.S for any indication, but a final decision is expected from the FDA by March. Overall, the data are fairly compelling, and it looks like a strong candidate. The data show a drug that is potentially more effective than lovenox, with less risk of bleeding for orthopedic patients. It is mainly hepatically metabolized.
So, with no drug company relationships to disclose, here are my general observations: For starters, I think dabigatran is being overused in older patients with renal dysfunction. I seem to stop it more than I recommend it, and it is far from my favorite drug. With rivaroxaban, it looks appropriate for VTE prevention, and now having the option of being able to transition patients who develop a clot onto a treatment dose of the drug is appealing. Apixaban’s data look the best out of all three agents in terms of both efficacy and bleeding, and although it is yet to be approved here, I imagine that will change in the near future. For all of these drugs, remember that we have no long-term safety data, and no reversal agents. It will be interesting to see how this plays out and which of these drugs have staying power. For all of warfarin’s faults, at least we know how to measure it and how to stop it.
Position Paper on Critical-Care Debate Did Not Address Family Practice Physicians in ICU
Position Paper Did Not Address Family Practice Physicians in ICU
I just finished reading “The Critical-Care Debate” article in The Hospitalist’s October issue. I was quite interested in getting further follow-up and comments regarding family practice physicians’ role in critical care. Now that some hospitalist programs are utilized as “intensivists,” what are SHM and the Society of Critical Care Medicine’s (SCCM) opinions of family practitioners who are hospitalists acting in this manner? The TH article says that internal-medicine programs are insufficient for preparing internists; what are SHM and SCCM’s positions and opinions of family practice physicians being utilized as intensivists?
—Ray Nowaczyk, DO
Dr. Hospitalist responds:
Boy, and we thought this issue was politically charged before you asked that question. From my reading of the position paper (J Hosp Med. 2012;7:359-364) cited in the article, the role of family practice physicians is only alluded to, and not addressed except by its absence. The main thrust of the paper focuses specifically on physicians trained in internal medicine (IM) and how they could become “qualified” to provide ICU care. A few items stand out:
- The baseline assumption is that these would be IM-trained physicians, not family practice physicians.
- The requirements to entry wouldinclude: a) completion of IM residency; b) three years’ clinical practice as a hospitalist; and c) enrollment in the ABIM Focused Practice in Hospital Medicine Maintenance of Certification process, which, by definition, requires board certification in internal medicine.
Judging by the vocal backlash from the American College of Chest Physicians (ACCP), I imagine that even getting consensus on the points above required some fairly heavy lifting. Addressing the issue of family practitioners in HM likely was not a topic they felt could gain traction
You are absolutely correct, though, in that plenty of family practitioners practice full time as adult hospitalists (and are doing a fine job). As the paper notes, it is estimated that 6% to 8% of all hospitalists are familypractice- trained. Unfortunately, there is very little objective documentation that will allow them to demonstrate their clinical quality other than direct clinical practice or observation. There is no formal “bridge” to cross for a family practice physician wanting to receive certification in hospital medicine; this currently can only happen through ABIM.
At the same time, I do not believe that the absence of formal certification disqualifies any family practitioner from practicing quality medicine in the hospital. In fact, in my market, there are some fantastic family practice hospitalists who have been in practice in a busy, urban, Level I hospital for more than 10 years. They clearly have the clinical experience and skills that would vastly outweigh those of almost any new graduate of an internal-medicine program. Can they prove it? Not today.
I think it’s a similar discussion with IM-trained hospitalists providing ICU care. I have colleagues who actively seek to accept and care for ICU patients when it comes time for admissions, and these physicians spend much more time in direct patient care in the ICU than even some of our intensivists. Can they prove their skills? Not today. However, as noted in the Leapfrog data, at this point, only 4% of ICUs have 24/7 dedicated intensivists, so who are we kidding? We need hospitalists to provide competent ICU care. Whether we provide a pathway for objective recognition or not, it is still going to happen. It sure would be nice if it happened in a sensible way with input from the stakeholders—just as was suggested in the position paper.
Here’s a little anecdote: Many years ago, there was an ortho PA (we’ll call him Jimmy John) in our hospital, but when you called his pager number, which he also gave out routinely to patients, the message said, “You’ve reached the pager of Doctor John.” He was no doctor. Well, one of us finally asked him about it, and he replied, with a straight face: “Oh, I used to be a vet.” OK.
The point is, we all need to recognize our own skills and limitations and be able to communicate those same skills and limitations to others, especially to patients, honestly. Since honesty has its limits, then independent objective measurement is a useful adjunct. Just look at your office walls.
Position Paper Did Not Address Family Practice Physicians in ICU
I just finished reading “The Critical-Care Debate” article in The Hospitalist’s October issue. I was quite interested in getting further follow-up and comments regarding family practice physicians’ role in critical care. Now that some hospitalist programs are utilized as “intensivists,” what are SHM and the Society of Critical Care Medicine’s (SCCM) opinions of family practitioners who are hospitalists acting in this manner? The TH article says that internal-medicine programs are insufficient for preparing internists; what are SHM and SCCM’s positions and opinions of family practice physicians being utilized as intensivists?
—Ray Nowaczyk, DO
Dr. Hospitalist responds:
Boy, and we thought this issue was politically charged before you asked that question. From my reading of the position paper (J Hosp Med. 2012;7:359-364) cited in the article, the role of family practice physicians is only alluded to, and not addressed except by its absence. The main thrust of the paper focuses specifically on physicians trained in internal medicine (IM) and how they could become “qualified” to provide ICU care. A few items stand out:
- The baseline assumption is that these would be IM-trained physicians, not family practice physicians.
- The requirements to entry wouldinclude: a) completion of IM residency; b) three years’ clinical practice as a hospitalist; and c) enrollment in the ABIM Focused Practice in Hospital Medicine Maintenance of Certification process, which, by definition, requires board certification in internal medicine.
Judging by the vocal backlash from the American College of Chest Physicians (ACCP), I imagine that even getting consensus on the points above required some fairly heavy lifting. Addressing the issue of family practitioners in HM likely was not a topic they felt could gain traction
You are absolutely correct, though, in that plenty of family practitioners practice full time as adult hospitalists (and are doing a fine job). As the paper notes, it is estimated that 6% to 8% of all hospitalists are familypractice- trained. Unfortunately, there is very little objective documentation that will allow them to demonstrate their clinical quality other than direct clinical practice or observation. There is no formal “bridge” to cross for a family practice physician wanting to receive certification in hospital medicine; this currently can only happen through ABIM.
At the same time, I do not believe that the absence of formal certification disqualifies any family practitioner from practicing quality medicine in the hospital. In fact, in my market, there are some fantastic family practice hospitalists who have been in practice in a busy, urban, Level I hospital for more than 10 years. They clearly have the clinical experience and skills that would vastly outweigh those of almost any new graduate of an internal-medicine program. Can they prove it? Not today.
I think it’s a similar discussion with IM-trained hospitalists providing ICU care. I have colleagues who actively seek to accept and care for ICU patients when it comes time for admissions, and these physicians spend much more time in direct patient care in the ICU than even some of our intensivists. Can they prove their skills? Not today. However, as noted in the Leapfrog data, at this point, only 4% of ICUs have 24/7 dedicated intensivists, so who are we kidding? We need hospitalists to provide competent ICU care. Whether we provide a pathway for objective recognition or not, it is still going to happen. It sure would be nice if it happened in a sensible way with input from the stakeholders—just as was suggested in the position paper.
Here’s a little anecdote: Many years ago, there was an ortho PA (we’ll call him Jimmy John) in our hospital, but when you called his pager number, which he also gave out routinely to patients, the message said, “You’ve reached the pager of Doctor John.” He was no doctor. Well, one of us finally asked him about it, and he replied, with a straight face: “Oh, I used to be a vet.” OK.
The point is, we all need to recognize our own skills and limitations and be able to communicate those same skills and limitations to others, especially to patients, honestly. Since honesty has its limits, then independent objective measurement is a useful adjunct. Just look at your office walls.
Position Paper Did Not Address Family Practice Physicians in ICU
I just finished reading “The Critical-Care Debate” article in The Hospitalist’s October issue. I was quite interested in getting further follow-up and comments regarding family practice physicians’ role in critical care. Now that some hospitalist programs are utilized as “intensivists,” what are SHM and the Society of Critical Care Medicine’s (SCCM) opinions of family practitioners who are hospitalists acting in this manner? The TH article says that internal-medicine programs are insufficient for preparing internists; what are SHM and SCCM’s positions and opinions of family practice physicians being utilized as intensivists?
—Ray Nowaczyk, DO
Dr. Hospitalist responds:
Boy, and we thought this issue was politically charged before you asked that question. From my reading of the position paper (J Hosp Med. 2012;7:359-364) cited in the article, the role of family practice physicians is only alluded to, and not addressed except by its absence. The main thrust of the paper focuses specifically on physicians trained in internal medicine (IM) and how they could become “qualified” to provide ICU care. A few items stand out:
- The baseline assumption is that these would be IM-trained physicians, not family practice physicians.
- The requirements to entry wouldinclude: a) completion of IM residency; b) three years’ clinical practice as a hospitalist; and c) enrollment in the ABIM Focused Practice in Hospital Medicine Maintenance of Certification process, which, by definition, requires board certification in internal medicine.
Judging by the vocal backlash from the American College of Chest Physicians (ACCP), I imagine that even getting consensus on the points above required some fairly heavy lifting. Addressing the issue of family practitioners in HM likely was not a topic they felt could gain traction
You are absolutely correct, though, in that plenty of family practitioners practice full time as adult hospitalists (and are doing a fine job). As the paper notes, it is estimated that 6% to 8% of all hospitalists are familypractice- trained. Unfortunately, there is very little objective documentation that will allow them to demonstrate their clinical quality other than direct clinical practice or observation. There is no formal “bridge” to cross for a family practice physician wanting to receive certification in hospital medicine; this currently can only happen through ABIM.
At the same time, I do not believe that the absence of formal certification disqualifies any family practitioner from practicing quality medicine in the hospital. In fact, in my market, there are some fantastic family practice hospitalists who have been in practice in a busy, urban, Level I hospital for more than 10 years. They clearly have the clinical experience and skills that would vastly outweigh those of almost any new graduate of an internal-medicine program. Can they prove it? Not today.
I think it’s a similar discussion with IM-trained hospitalists providing ICU care. I have colleagues who actively seek to accept and care for ICU patients when it comes time for admissions, and these physicians spend much more time in direct patient care in the ICU than even some of our intensivists. Can they prove their skills? Not today. However, as noted in the Leapfrog data, at this point, only 4% of ICUs have 24/7 dedicated intensivists, so who are we kidding? We need hospitalists to provide competent ICU care. Whether we provide a pathway for objective recognition or not, it is still going to happen. It sure would be nice if it happened in a sensible way with input from the stakeholders—just as was suggested in the position paper.
Here’s a little anecdote: Many years ago, there was an ortho PA (we’ll call him Jimmy John) in our hospital, but when you called his pager number, which he also gave out routinely to patients, the message said, “You’ve reached the pager of Doctor John.” He was no doctor. Well, one of us finally asked him about it, and he replied, with a straight face: “Oh, I used to be a vet.” OK.
The point is, we all need to recognize our own skills and limitations and be able to communicate those same skills and limitations to others, especially to patients, honestly. Since honesty has its limits, then independent objective measurement is a useful adjunct. Just look at your office walls.
Consider Patient Safety, Outcomes Risk before Prescribing Off-Label Drugs
Consider Patient Safety, Outcomes Risk before Prescribing “Off-Label”
What is the story with off-label drug use? I have seen some other physicians in my group use dabigatran for VTE prophylaxis, which I know it is not an approved indication. Am I taking on risk by continuing this treatment?
—Fabian Harris, Tuscaloosa, Ala.
Dr. Hospitalist responds:
Our friends at the FDA are in the business of approving drugs for use, but they do not regulate medical practice. So the short answer to your question is that off-label drug use is perfectly acceptable. Once a drug has been approved for use, if, in your clinical judgment, there are other indications for which it could be beneficial, then you are well within your rights to prescribe it. The FDA does not dictate how you practice medicine.
However, you will still be held to the community standard when it comes to your medical practice. As an example, gabapentin is used all the time for neuropathic pain syndromes, though technically it is only approved for seizures and post-herpetic neuralgia. Although the FDA won’t restrict your prescribing, it does prohibit pharmaceutical companies from marketing their drugs for anything other than their approved indications. In fact, Pfizer settled a case in 2004 on this very drug due to the promotion of prescribing it for nonapproved indications. I think at this point it’s fairly well accepted that lots of physicians use gabapentin for neuropathic pain, so you would not be too far out on a limb in prescribing it yourself in this manner.
For newer drugs, I might proceed with a little more caution. Anyone out there remember trovofloxacin (Trovan)? It was a new antibiotic approved in the late 1990s, with a coverage spectrum similar to levofloxacin, but with even more weight toward the gram positives. A wonder drug! Oral! As a result, it got prescribed like water, but not for the serious infections it was designed for: It got prescribed “off label” for common URIs and sinusitis. Unfortunately, it also caused a fair amount of liver failure and was summarily pulled from the market.
Does this mean dabigatran is a bad drug? No, but we don’t have much history with it, either. So while it might seem to be an innocuous extension to prescribe it for VTE prevention when it has already been approved for stroke prevention in afib, I think you carry some risk by doing this. In addition, some insurers will not cover a drug being prescribed in this manner, so you might be exposing your patient to added costs as well. Additionally, there’s nothing about off-label prescribing that says you have to tell the patient that’s what you’re doing. However, if you put together the factors of not informing a patient about an off-label use, and a patient having to pay out of pocket for that medicine, with an adverse outcome ... well, let’s just say that might not end too well.
Ultimately, I think you will need to consider the safety profile of the drug, the risk for an adverse outcome, your own risk tolerance, and the current state of medical practice before you consistently agree to use a drug “off label.” Given the slow-moving jungle of FDA approval, I can understand the desire to use a newer drug in an off-label manner, but it’s probably best to stop and think about the alternatives before proceeding. If you’re practicing in a group, then it’s just as important to come to a consensus with your partners about which drugs you will comfortably use off-label and which ones you won’t, especially as newer drugs come into the marketplace.
Consider Patient Safety, Outcomes Risk before Prescribing “Off-Label”
What is the story with off-label drug use? I have seen some other physicians in my group use dabigatran for VTE prophylaxis, which I know it is not an approved indication. Am I taking on risk by continuing this treatment?
—Fabian Harris, Tuscaloosa, Ala.
Dr. Hospitalist responds:
Our friends at the FDA are in the business of approving drugs for use, but they do not regulate medical practice. So the short answer to your question is that off-label drug use is perfectly acceptable. Once a drug has been approved for use, if, in your clinical judgment, there are other indications for which it could be beneficial, then you are well within your rights to prescribe it. The FDA does not dictate how you practice medicine.
However, you will still be held to the community standard when it comes to your medical practice. As an example, gabapentin is used all the time for neuropathic pain syndromes, though technically it is only approved for seizures and post-herpetic neuralgia. Although the FDA won’t restrict your prescribing, it does prohibit pharmaceutical companies from marketing their drugs for anything other than their approved indications. In fact, Pfizer settled a case in 2004 on this very drug due to the promotion of prescribing it for nonapproved indications. I think at this point it’s fairly well accepted that lots of physicians use gabapentin for neuropathic pain, so you would not be too far out on a limb in prescribing it yourself in this manner.
For newer drugs, I might proceed with a little more caution. Anyone out there remember trovofloxacin (Trovan)? It was a new antibiotic approved in the late 1990s, with a coverage spectrum similar to levofloxacin, but with even more weight toward the gram positives. A wonder drug! Oral! As a result, it got prescribed like water, but not for the serious infections it was designed for: It got prescribed “off label” for common URIs and sinusitis. Unfortunately, it also caused a fair amount of liver failure and was summarily pulled from the market.
Does this mean dabigatran is a bad drug? No, but we don’t have much history with it, either. So while it might seem to be an innocuous extension to prescribe it for VTE prevention when it has already been approved for stroke prevention in afib, I think you carry some risk by doing this. In addition, some insurers will not cover a drug being prescribed in this manner, so you might be exposing your patient to added costs as well. Additionally, there’s nothing about off-label prescribing that says you have to tell the patient that’s what you’re doing. However, if you put together the factors of not informing a patient about an off-label use, and a patient having to pay out of pocket for that medicine, with an adverse outcome ... well, let’s just say that might not end too well.
Ultimately, I think you will need to consider the safety profile of the drug, the risk for an adverse outcome, your own risk tolerance, and the current state of medical practice before you consistently agree to use a drug “off label.” Given the slow-moving jungle of FDA approval, I can understand the desire to use a newer drug in an off-label manner, but it’s probably best to stop and think about the alternatives before proceeding. If you’re practicing in a group, then it’s just as important to come to a consensus with your partners about which drugs you will comfortably use off-label and which ones you won’t, especially as newer drugs come into the marketplace.
Consider Patient Safety, Outcomes Risk before Prescribing “Off-Label”
What is the story with off-label drug use? I have seen some other physicians in my group use dabigatran for VTE prophylaxis, which I know it is not an approved indication. Am I taking on risk by continuing this treatment?
—Fabian Harris, Tuscaloosa, Ala.
Dr. Hospitalist responds:
Our friends at the FDA are in the business of approving drugs for use, but they do not regulate medical practice. So the short answer to your question is that off-label drug use is perfectly acceptable. Once a drug has been approved for use, if, in your clinical judgment, there are other indications for which it could be beneficial, then you are well within your rights to prescribe it. The FDA does not dictate how you practice medicine.
However, you will still be held to the community standard when it comes to your medical practice. As an example, gabapentin is used all the time for neuropathic pain syndromes, though technically it is only approved for seizures and post-herpetic neuralgia. Although the FDA won’t restrict your prescribing, it does prohibit pharmaceutical companies from marketing their drugs for anything other than their approved indications. In fact, Pfizer settled a case in 2004 on this very drug due to the promotion of prescribing it for nonapproved indications. I think at this point it’s fairly well accepted that lots of physicians use gabapentin for neuropathic pain, so you would not be too far out on a limb in prescribing it yourself in this manner.
For newer drugs, I might proceed with a little more caution. Anyone out there remember trovofloxacin (Trovan)? It was a new antibiotic approved in the late 1990s, with a coverage spectrum similar to levofloxacin, but with even more weight toward the gram positives. A wonder drug! Oral! As a result, it got prescribed like water, but not for the serious infections it was designed for: It got prescribed “off label” for common URIs and sinusitis. Unfortunately, it also caused a fair amount of liver failure and was summarily pulled from the market.
Does this mean dabigatran is a bad drug? No, but we don’t have much history with it, either. So while it might seem to be an innocuous extension to prescribe it for VTE prevention when it has already been approved for stroke prevention in afib, I think you carry some risk by doing this. In addition, some insurers will not cover a drug being prescribed in this manner, so you might be exposing your patient to added costs as well. Additionally, there’s nothing about off-label prescribing that says you have to tell the patient that’s what you’re doing. However, if you put together the factors of not informing a patient about an off-label use, and a patient having to pay out of pocket for that medicine, with an adverse outcome ... well, let’s just say that might not end too well.
Ultimately, I think you will need to consider the safety profile of the drug, the risk for an adverse outcome, your own risk tolerance, and the current state of medical practice before you consistently agree to use a drug “off label.” Given the slow-moving jungle of FDA approval, I can understand the desire to use a newer drug in an off-label manner, but it’s probably best to stop and think about the alternatives before proceeding. If you’re practicing in a group, then it’s just as important to come to a consensus with your partners about which drugs you will comfortably use off-label and which ones you won’t, especially as newer drugs come into the marketplace.
Clarification of Consult-Code Usage
In July, I was CC’d on an email from a reader that asked for further explanation of billing for patients in the ED. I mentioned briefly in the May 2012 issue of The Hospitalist that, in the ED, a consult on a patient that ends up being sent home can be billed with CPT code 99281-99288. Another author for another hospitalist publication had previously written that hospitalists do not have consultation codes for patients evaluated in the ED, then sent home. The reader basically wanted to know how to bill for this encounter.
It should be noted that this is billing for a visit in the ED for which the patient is not admitted. It is not a consult code, as those effectively have been eliminated from the CPT manual.
Here’s some further explanation:
Effective Jan. 1, 2010, the Centers for Medicare & Medicaid Services (CMS) eliminated the use of the codes 99241-99245 (outpatient consultation) and 99215-99255 (inpatient consultation) for use with Medicare Part B beneficiaries. Those codes are now either 99201-99205 (office outpatient visit) or 99221-99223 (initial inpatient visit).
Although this might seem confusing, CMS actually made it simpler. If you or your group is seeing a patient for the first time, as either an admission or an inpatient consult, you use the 99221-99223 codes. So now there are three codes to use instead of eight. Just to note, though, this applies specifically to Medicare patients.
Similarly, if you evaluate a patient in the ED and they are not admitted to the hospital, then you use the 99281-99288 codes. Yes, these are the same E/M codes that the attending ED physician will use for their care. If you personally evaluate the patient in the ED, document as required, and if the patient is admitted, then it reverts back to the 99221-99223 codes. However, if the patient does go home from the ED (never admitted as an inpatient or under observation status), then you use the 80s codes referenced above.
Just to add one more layer of complexity, please remember that there are specific codes for patients admitted under observation status (99217-99220), as well as for patients that are admitted and discharged in the same calendar day (99234-99236). Those are distinct from what is described above.
All in all, don’t take my word for it. Here’s the link to the actual CMS bulletin:
It’s readable, too, which is nice.
In July, I was CC’d on an email from a reader that asked for further explanation of billing for patients in the ED. I mentioned briefly in the May 2012 issue of The Hospitalist that, in the ED, a consult on a patient that ends up being sent home can be billed with CPT code 99281-99288. Another author for another hospitalist publication had previously written that hospitalists do not have consultation codes for patients evaluated in the ED, then sent home. The reader basically wanted to know how to bill for this encounter.
It should be noted that this is billing for a visit in the ED for which the patient is not admitted. It is not a consult code, as those effectively have been eliminated from the CPT manual.
Here’s some further explanation:
Effective Jan. 1, 2010, the Centers for Medicare & Medicaid Services (CMS) eliminated the use of the codes 99241-99245 (outpatient consultation) and 99215-99255 (inpatient consultation) for use with Medicare Part B beneficiaries. Those codes are now either 99201-99205 (office outpatient visit) or 99221-99223 (initial inpatient visit).
Although this might seem confusing, CMS actually made it simpler. If you or your group is seeing a patient for the first time, as either an admission or an inpatient consult, you use the 99221-99223 codes. So now there are three codes to use instead of eight. Just to note, though, this applies specifically to Medicare patients.
Similarly, if you evaluate a patient in the ED and they are not admitted to the hospital, then you use the 99281-99288 codes. Yes, these are the same E/M codes that the attending ED physician will use for their care. If you personally evaluate the patient in the ED, document as required, and if the patient is admitted, then it reverts back to the 99221-99223 codes. However, if the patient does go home from the ED (never admitted as an inpatient or under observation status), then you use the 80s codes referenced above.
Just to add one more layer of complexity, please remember that there are specific codes for patients admitted under observation status (99217-99220), as well as for patients that are admitted and discharged in the same calendar day (99234-99236). Those are distinct from what is described above.
All in all, don’t take my word for it. Here’s the link to the actual CMS bulletin:
It’s readable, too, which is nice.
In July, I was CC’d on an email from a reader that asked for further explanation of billing for patients in the ED. I mentioned briefly in the May 2012 issue of The Hospitalist that, in the ED, a consult on a patient that ends up being sent home can be billed with CPT code 99281-99288. Another author for another hospitalist publication had previously written that hospitalists do not have consultation codes for patients evaluated in the ED, then sent home. The reader basically wanted to know how to bill for this encounter.
It should be noted that this is billing for a visit in the ED for which the patient is not admitted. It is not a consult code, as those effectively have been eliminated from the CPT manual.
Here’s some further explanation:
Effective Jan. 1, 2010, the Centers for Medicare & Medicaid Services (CMS) eliminated the use of the codes 99241-99245 (outpatient consultation) and 99215-99255 (inpatient consultation) for use with Medicare Part B beneficiaries. Those codes are now either 99201-99205 (office outpatient visit) or 99221-99223 (initial inpatient visit).
Although this might seem confusing, CMS actually made it simpler. If you or your group is seeing a patient for the first time, as either an admission or an inpatient consult, you use the 99221-99223 codes. So now there are three codes to use instead of eight. Just to note, though, this applies specifically to Medicare patients.
Similarly, if you evaluate a patient in the ED and they are not admitted to the hospital, then you use the 99281-99288 codes. Yes, these are the same E/M codes that the attending ED physician will use for their care. If you personally evaluate the patient in the ED, document as required, and if the patient is admitted, then it reverts back to the 99221-99223 codes. However, if the patient does go home from the ED (never admitted as an inpatient or under observation status), then you use the 80s codes referenced above.
Just to add one more layer of complexity, please remember that there are specific codes for patients admitted under observation status (99217-99220), as well as for patients that are admitted and discharged in the same calendar day (99234-99236). Those are distinct from what is described above.
All in all, don’t take my word for it. Here’s the link to the actual CMS bulletin:
It’s readable, too, which is nice.
Rules of Engagement Necessary for Comanagement of Orthopedic Patients
One of our providers wants to use adult hospitalists for coverage of inpatient orthopedic surgery patients. Is this acceptable practice? Are there qualifiers?
–Libby Gardner
Dr. Hospitalist responds:
Let’s see how far we can tackle this open-ended question. There has been lots of discussion on the topic of comanagement in the past by people eminently more qualified than I am. Still, it never hurts to take a fresh look at things.
For one, on the subject of admissions, I am a firm believer that hospitalists should admit all adult hip fractures. The overwhelming majority of the time, these patients are elderly with comorbid conditions. Sure, they are going to get their hip fixed, because the alternative is usually unacceptable, but some thought needs to go into the process. The orthopedic surgeon sees a hip that needs fixing and not much else. When issues like renal failure, afib, CHF, prior DVT, or dementia are present, hospitalists should take charge of the case. It is the best way to ensure that the patient receives optimal medical care and the documentation that goes along with it. I love our orthopedic surgeons, but I don’t want them primarily admitting, managing, and discharging my elderly patients. Let the surgeon do what they do best, which is operate, and leave the rest to us.
On the subject of orthopedic trauma, I take the exact opposite tack—this is not something for which I or most of my colleagues have expertise. A young, healthy patient with trauma should be admitted by the orthopedic service; that patient population’s complications are much more likely to be directly related to their trauma.
When it comes to elective surgery, when the admitting surgeon (orthopedic or otherwise) wants the help of a hospitalist, then I think it is of paramount importance to have clear “rules of engagement.” I think with good expectations, you can have a fantastic working relationship with your surgeons. Without them, it becomes a nightmare.
Here are my HM group’s rules for elective orthopedic surgery:
- Orthopedics handles all pain medications and VTE prophylaxis, including discharge prescriptions.
- Medicine handles all admit and discharge medication reconciliation (“med rec”).
- There is shared discussion on:
- Need for transfusion; and
- The VTE prophylaxis when a patient already is on chronic anticoagulation.
We do not vary from this protocol. I never adjust a patient’s pain medications. Even the floor nurses know this. Because I’m doing the admit med rec, it also means that the patient doesn’t have their HCTZ continued after 600cc of EBL and spinal anesthesia.
The system works because the rules are clear and the communication is consistent. This does not mean that we cover the orthopedic service at night. They are equally responsible for their patients under the items outlined above. In my view—and this might sound simplistic—the surgeon caused the post-op pain, so they should be responsible for managing it. On VTE prophylaxis, I might take a more nuanced view, but for our surgeons, they own the wound and the post-op follow-up, so they get the choice on what agent to use.
Would I accept an arrangement in which I covered all the orthopedic issues out of regular hours? Nope—not when they have primary responsibility for the case; they should always be directly available to the nurse. I think that anything else would be a system ripe for abuse.
Our exact rules will not work for every situation, but I would strongly encourage the two basic tenets from above: No. 1, the hospitalist should primarily admit and manage elderly hip fractures, and No. 2, clear rules of engagement should be established with your orthopedic or surgery group. It’s a discussion worth having during daylight hours, because trying to figure out the rules at 3 in the morning rarely ends well.
One of our providers wants to use adult hospitalists for coverage of inpatient orthopedic surgery patients. Is this acceptable practice? Are there qualifiers?
–Libby Gardner
Dr. Hospitalist responds:
Let’s see how far we can tackle this open-ended question. There has been lots of discussion on the topic of comanagement in the past by people eminently more qualified than I am. Still, it never hurts to take a fresh look at things.
For one, on the subject of admissions, I am a firm believer that hospitalists should admit all adult hip fractures. The overwhelming majority of the time, these patients are elderly with comorbid conditions. Sure, they are going to get their hip fixed, because the alternative is usually unacceptable, but some thought needs to go into the process. The orthopedic surgeon sees a hip that needs fixing and not much else. When issues like renal failure, afib, CHF, prior DVT, or dementia are present, hospitalists should take charge of the case. It is the best way to ensure that the patient receives optimal medical care and the documentation that goes along with it. I love our orthopedic surgeons, but I don’t want them primarily admitting, managing, and discharging my elderly patients. Let the surgeon do what they do best, which is operate, and leave the rest to us.
On the subject of orthopedic trauma, I take the exact opposite tack—this is not something for which I or most of my colleagues have expertise. A young, healthy patient with trauma should be admitted by the orthopedic service; that patient population’s complications are much more likely to be directly related to their trauma.
When it comes to elective surgery, when the admitting surgeon (orthopedic or otherwise) wants the help of a hospitalist, then I think it is of paramount importance to have clear “rules of engagement.” I think with good expectations, you can have a fantastic working relationship with your surgeons. Without them, it becomes a nightmare.
Here are my HM group’s rules for elective orthopedic surgery:
- Orthopedics handles all pain medications and VTE prophylaxis, including discharge prescriptions.
- Medicine handles all admit and discharge medication reconciliation (“med rec”).
- There is shared discussion on:
- Need for transfusion; and
- The VTE prophylaxis when a patient already is on chronic anticoagulation.
We do not vary from this protocol. I never adjust a patient’s pain medications. Even the floor nurses know this. Because I’m doing the admit med rec, it also means that the patient doesn’t have their HCTZ continued after 600cc of EBL and spinal anesthesia.
The system works because the rules are clear and the communication is consistent. This does not mean that we cover the orthopedic service at night. They are equally responsible for their patients under the items outlined above. In my view—and this might sound simplistic—the surgeon caused the post-op pain, so they should be responsible for managing it. On VTE prophylaxis, I might take a more nuanced view, but for our surgeons, they own the wound and the post-op follow-up, so they get the choice on what agent to use.
Would I accept an arrangement in which I covered all the orthopedic issues out of regular hours? Nope—not when they have primary responsibility for the case; they should always be directly available to the nurse. I think that anything else would be a system ripe for abuse.
Our exact rules will not work for every situation, but I would strongly encourage the two basic tenets from above: No. 1, the hospitalist should primarily admit and manage elderly hip fractures, and No. 2, clear rules of engagement should be established with your orthopedic or surgery group. It’s a discussion worth having during daylight hours, because trying to figure out the rules at 3 in the morning rarely ends well.
One of our providers wants to use adult hospitalists for coverage of inpatient orthopedic surgery patients. Is this acceptable practice? Are there qualifiers?
–Libby Gardner
Dr. Hospitalist responds:
Let’s see how far we can tackle this open-ended question. There has been lots of discussion on the topic of comanagement in the past by people eminently more qualified than I am. Still, it never hurts to take a fresh look at things.
For one, on the subject of admissions, I am a firm believer that hospitalists should admit all adult hip fractures. The overwhelming majority of the time, these patients are elderly with comorbid conditions. Sure, they are going to get their hip fixed, because the alternative is usually unacceptable, but some thought needs to go into the process. The orthopedic surgeon sees a hip that needs fixing and not much else. When issues like renal failure, afib, CHF, prior DVT, or dementia are present, hospitalists should take charge of the case. It is the best way to ensure that the patient receives optimal medical care and the documentation that goes along with it. I love our orthopedic surgeons, but I don’t want them primarily admitting, managing, and discharging my elderly patients. Let the surgeon do what they do best, which is operate, and leave the rest to us.
On the subject of orthopedic trauma, I take the exact opposite tack—this is not something for which I or most of my colleagues have expertise. A young, healthy patient with trauma should be admitted by the orthopedic service; that patient population’s complications are much more likely to be directly related to their trauma.
When it comes to elective surgery, when the admitting surgeon (orthopedic or otherwise) wants the help of a hospitalist, then I think it is of paramount importance to have clear “rules of engagement.” I think with good expectations, you can have a fantastic working relationship with your surgeons. Without them, it becomes a nightmare.
Here are my HM group’s rules for elective orthopedic surgery:
- Orthopedics handles all pain medications and VTE prophylaxis, including discharge prescriptions.
- Medicine handles all admit and discharge medication reconciliation (“med rec”).
- There is shared discussion on:
- Need for transfusion; and
- The VTE prophylaxis when a patient already is on chronic anticoagulation.
We do not vary from this protocol. I never adjust a patient’s pain medications. Even the floor nurses know this. Because I’m doing the admit med rec, it also means that the patient doesn’t have their HCTZ continued after 600cc of EBL and spinal anesthesia.
The system works because the rules are clear and the communication is consistent. This does not mean that we cover the orthopedic service at night. They are equally responsible for their patients under the items outlined above. In my view—and this might sound simplistic—the surgeon caused the post-op pain, so they should be responsible for managing it. On VTE prophylaxis, I might take a more nuanced view, but for our surgeons, they own the wound and the post-op follow-up, so they get the choice on what agent to use.
Would I accept an arrangement in which I covered all the orthopedic issues out of regular hours? Nope—not when they have primary responsibility for the case; they should always be directly available to the nurse. I think that anything else would be a system ripe for abuse.
Our exact rules will not work for every situation, but I would strongly encourage the two basic tenets from above: No. 1, the hospitalist should primarily admit and manage elderly hip fractures, and No. 2, clear rules of engagement should be established with your orthopedic or surgery group. It’s a discussion worth having during daylight hours, because trying to figure out the rules at 3 in the morning rarely ends well.
Dr. Hospitalist: Your Hospital Medicine Questions Answered
What’s up with the dress code in hospitals these days? Some of my colleagues wear white coats, some wear ties, some have short-sleeved shirts. Some even wear scrubs in the daytime, and they swear they are right as to “the most clinically appropriate attire.” Any thoughts?
Attirely Concerned in Los Angeles
Dr. Hospitalist responds:
There are a lot of suggestions out there regarding attire. The United Kingdom’s National Health Service is probably most famous for instituting a “bare below elbows” (BBE for short) dress code in 2007.
Although lots of studies have shown bacterial colonization on the items doctors wear or carry (e.g. pagers, pens, neckties, coats, scrubs), none of them truly show causality. The Journal of Hospital Medicine just published a study on scrubs versus white coats, which showed no real difference in contamination.1
Even the BBE policy was meant to promote hand-washing more than anything else. On that point, there is little disagreement, as there is a substantial amount of data to show that good hand hygiene is a patient-care imperative. We all should spend more time thinking about “clean in/clean out” when it comes to patient rooms than deciding which article of clothing carries the fewest bacteria.
There is another issue at play here, though, and that is the question of how hospitalists are expected to dress. Certainly, there is some regional variation. I don’t think you’ll find that physicians at the Mayo Clinic in Rochester, Minn., are going to dress the same as physicians in San Diego or Hawaii.
So, setting aside the cultural expectations for your region, I do think it’s a good idea for your group to agree on some standards. These policies might vary from white coats for everyone to scrubs after hours, or that blue jeans are OK only on weekends.
Why bother?
Well, for starters, a little consistency will promote the professionalism of your group, and it also sets some baseline expectations for everyone involved. Think about how many healthcare providers wander into a patient’s room during the day: You want to be readily identifiable as the treating physician. No, it’s not just how you dress (a voice, a name badge, and putting your name on the white board also count), but it is part of the picture.
As a hospitalist, not only are you a professional, but, by definition, you are going to meet patients with whom you have no prior relationship. Like it or not, perception matters, and when you need to quickly gain the trust of a patient (and a family) to make urgent clinical decisions, being dressed professionally will help. Looking like a slob won’t.
My advice? First, wash your hands where the patient can see you. If you have to use that gel 40 times a day, you might as well make a show of it. Two, dress professionally within the parameters that your group outlines.
Beyond that, I don’t think you need to autoclave your peripherals and go through a decontamination room just yet.
Reference
- Burden M, Cervantes L, Weed D, Keniston A, Price CS, Albert RK. Newly cleaned physician uniforms and infrequently washed white coats have similar rates of bacterial contamination after an 8-hour workday: A randomized controlled trial. J Hosp Med. 2011;6(4):177-182.
What’s up with the dress code in hospitals these days? Some of my colleagues wear white coats, some wear ties, some have short-sleeved shirts. Some even wear scrubs in the daytime, and they swear they are right as to “the most clinically appropriate attire.” Any thoughts?
Attirely Concerned in Los Angeles
Dr. Hospitalist responds:
There are a lot of suggestions out there regarding attire. The United Kingdom’s National Health Service is probably most famous for instituting a “bare below elbows” (BBE for short) dress code in 2007.
Although lots of studies have shown bacterial colonization on the items doctors wear or carry (e.g. pagers, pens, neckties, coats, scrubs), none of them truly show causality. The Journal of Hospital Medicine just published a study on scrubs versus white coats, which showed no real difference in contamination.1
Even the BBE policy was meant to promote hand-washing more than anything else. On that point, there is little disagreement, as there is a substantial amount of data to show that good hand hygiene is a patient-care imperative. We all should spend more time thinking about “clean in/clean out” when it comes to patient rooms than deciding which article of clothing carries the fewest bacteria.
There is another issue at play here, though, and that is the question of how hospitalists are expected to dress. Certainly, there is some regional variation. I don’t think you’ll find that physicians at the Mayo Clinic in Rochester, Minn., are going to dress the same as physicians in San Diego or Hawaii.
So, setting aside the cultural expectations for your region, I do think it’s a good idea for your group to agree on some standards. These policies might vary from white coats for everyone to scrubs after hours, or that blue jeans are OK only on weekends.
Why bother?
Well, for starters, a little consistency will promote the professionalism of your group, and it also sets some baseline expectations for everyone involved. Think about how many healthcare providers wander into a patient’s room during the day: You want to be readily identifiable as the treating physician. No, it’s not just how you dress (a voice, a name badge, and putting your name on the white board also count), but it is part of the picture.
As a hospitalist, not only are you a professional, but, by definition, you are going to meet patients with whom you have no prior relationship. Like it or not, perception matters, and when you need to quickly gain the trust of a patient (and a family) to make urgent clinical decisions, being dressed professionally will help. Looking like a slob won’t.
My advice? First, wash your hands where the patient can see you. If you have to use that gel 40 times a day, you might as well make a show of it. Two, dress professionally within the parameters that your group outlines.
Beyond that, I don’t think you need to autoclave your peripherals and go through a decontamination room just yet.
Reference
- Burden M, Cervantes L, Weed D, Keniston A, Price CS, Albert RK. Newly cleaned physician uniforms and infrequently washed white coats have similar rates of bacterial contamination after an 8-hour workday: A randomized controlled trial. J Hosp Med. 2011;6(4):177-182.
What’s up with the dress code in hospitals these days? Some of my colleagues wear white coats, some wear ties, some have short-sleeved shirts. Some even wear scrubs in the daytime, and they swear they are right as to “the most clinically appropriate attire.” Any thoughts?
Attirely Concerned in Los Angeles
Dr. Hospitalist responds:
There are a lot of suggestions out there regarding attire. The United Kingdom’s National Health Service is probably most famous for instituting a “bare below elbows” (BBE for short) dress code in 2007.
Although lots of studies have shown bacterial colonization on the items doctors wear or carry (e.g. pagers, pens, neckties, coats, scrubs), none of them truly show causality. The Journal of Hospital Medicine just published a study on scrubs versus white coats, which showed no real difference in contamination.1
Even the BBE policy was meant to promote hand-washing more than anything else. On that point, there is little disagreement, as there is a substantial amount of data to show that good hand hygiene is a patient-care imperative. We all should spend more time thinking about “clean in/clean out” when it comes to patient rooms than deciding which article of clothing carries the fewest bacteria.
There is another issue at play here, though, and that is the question of how hospitalists are expected to dress. Certainly, there is some regional variation. I don’t think you’ll find that physicians at the Mayo Clinic in Rochester, Minn., are going to dress the same as physicians in San Diego or Hawaii.
So, setting aside the cultural expectations for your region, I do think it’s a good idea for your group to agree on some standards. These policies might vary from white coats for everyone to scrubs after hours, or that blue jeans are OK only on weekends.
Why bother?
Well, for starters, a little consistency will promote the professionalism of your group, and it also sets some baseline expectations for everyone involved. Think about how many healthcare providers wander into a patient’s room during the day: You want to be readily identifiable as the treating physician. No, it’s not just how you dress (a voice, a name badge, and putting your name on the white board also count), but it is part of the picture.
As a hospitalist, not only are you a professional, but, by definition, you are going to meet patients with whom you have no prior relationship. Like it or not, perception matters, and when you need to quickly gain the trust of a patient (and a family) to make urgent clinical decisions, being dressed professionally will help. Looking like a slob won’t.
My advice? First, wash your hands where the patient can see you. If you have to use that gel 40 times a day, you might as well make a show of it. Two, dress professionally within the parameters that your group outlines.
Beyond that, I don’t think you need to autoclave your peripherals and go through a decontamination room just yet.
Reference
- Burden M, Cervantes L, Weed D, Keniston A, Price CS, Albert RK. Newly cleaned physician uniforms and infrequently washed white coats have similar rates of bacterial contamination after an 8-hour workday: A randomized controlled trial. J Hosp Med. 2011;6(4):177-182.