Eric Howell, MD, SFHM

Editor’s note: This article originally appeared on SHM’s official blog, “The Hospital Leader,” in June 2015.

“Tell me what you know about antibiotics.”

That’s the discussion I start with hospitalized patients all the time, right after they ask me to prescribe antibiotics for their simple cough or other viral-like illness.

And, from their perspective, asking for antibiotics makes sense. After all, antibiotics have been the physician’s knee-jerk reaction to a number of patient symptoms for decades, especially for a cough or upper respiratory infection. We have inadvertently trained our patients that there is an easy solution to almost any common medical problem.

But patients often answer my question with something like “not much,” coupled with a little surprise that I haven’t already started ordering the prescription.

That’s when I talk about the potential harms of antibiotics. And that’s also when their eyebrows go up. I start with the easy harms, like the fact that many antibiotics can cause diarrhea, a symptom nobody wants to deal with along with their runny nose. Then I move on to the big ones: Use of antibiotics today could make the patient resistant to antibiotics later in life, when they might really need them, and using antibiotics can lead to other painful and even fatal conditions, like Clostridium difficile.

After that, every patient agrees with my recommendations that we hold off on antibiotics for certain, particularly viral-like, ailments.

Change the Conversation. Change the Approach.

It’s a longer conversation, but it’s worth it. Overuse of antibiotics affects not only the patient in front of me, but also entire communities. By creating antibiotic-resistant bacteria, we make everyone more vulnerable to the very diseases the antibiotics were originally intended to treat, like tuberculosis, staph infections, and numerous others.

That’s why the hospitalists in my hospital at Johns Hopkins Bayview teamed up with the infectious diseases division to improve our approach to cellulitis and antibiotic use.

In short, cellulitis is a bacterial skin infection. The most feared bacterial skin infection is MRSA (methicillin-resistant Staphylococcus aureus), a “super bug” that requires highly selective antibiotics like vancomycin; however, other more common and less virulent bacteria also cause cellulitis, and they don’t need super bug fighter medications. Some types of skin ailments, like those caused by poor circulation in the legs, are not infectious at all but can look like cellulitis, even to experienced doctors.

Thanks to the collaboration between infectious disease doctors and hospitalists, the hospitalists are much less likely to prescribe inappropriate antibiotics. That’s a triple-win: It reduces the length of stay for the patient, the incidence of C. diff, and costs.

The Front Line

This concern isn’t limited to a single hospital. There are now more than 44,000 hospitalists nationwide, and every one of us plays an important role in antibiotic stewardship. The bedside is the front line of the fight against antibiotic resistance.

There are more than 5,000 hospitals across the country, and hospitalists in every one of them must take responsibility for the appropriate use of antibiotics for their patients.

Announcing SHM’s National Commitment to Antibiotic Stewardship

SHM was proud to join more than 150 major organizations at the White House Forum on Antibiotic Stewardship to announce commitments to implement changes over the next five years that will slow the emergence of antibiotic-resistant bacteria, detect resistant strains, preserve the efficacy of our existing antibiotics, and prevent the spread of resistant infections.

Specifically, SHM has committed to three national initiatives that are aligned with our organizational goal of providing the best possible care for the hospitalized patient and the federal government’s dedication to this important issue:

• Enhance hospitalists’ awareness of key antimicrobial stewardship best practices and ask them to formally commit to at least two behavior changes to reduce inappropriate antimicrobial use and antimicrobial resistance;
• Support national initiatives that advocate for the appropriate use of antimicrobials and promote strategies to reduce antimicrobial resistance; and
• Identify partnerships and other opportunities to support the development of a comprehensive program to implement antimicrobial stewardship best practices in America’s hospitals.

These commitments, which I shared with White House Forum participants, play to the strengths of hospitalists in healthcare: advocacy on behalf of patients and quality improvement and collaboration with others.

What Hospitalists Can Do Now

I also know, however, that you aren’t the kind of people to wait for official pronouncements and campaigns to start a program that will improve the care of hospitalized patients. That’s why SHM and I are recommending that all hospitalists begin to take steps immediately to address this national healthcare crisis:

• Start the conversation with your patients. It’s easy to prescribe antibiotics, but it can also be harmful. Talk with your patients about when antibiotics are medically appropriate and the potential harms they may cause.
• Prescribe antibiotics for specific diagnoses. Prescribing “just in case” is a prescription for antibiotic resistance. Make sure you understand the signs and symptoms of the conditions for which you’re prescribing antibiotics. As we learned at our hospital, cellulitis and venous insufficiency can look similar, but only one responds to antibiotic treatment.
• Work with your infectious disease colleagues. They can help you create systems and diagnose patients to help improve your hospital’s antibiotic stewardship.

After all, we are on the front lines, protecting our current and future patients. And we can’t afford to wait.

Dr. Howell is a veteran hospitalist at Johns Hopkins Bayview Hospital in Baltimore and a past president of SHM.

Editor’s note: This article originally appeared on SHM’s official blog, “The Hospital Leader,” in June 2015.

“Tell me what you know about antibiotics.”

That’s the discussion I start with hospitalized patients all the time, right after they ask me to prescribe antibiotics for their simple cough or other viral-like illness.

And, from their perspective, asking for antibiotics makes sense. After all, antibiotics have been the physician’s knee-jerk reaction to a number of patient symptoms for decades, especially for a cough or upper respiratory infection. We have inadvertently trained our patients that there is an easy solution to almost any common medical problem.

But patients often answer my question with something like “not much,” coupled with a little surprise that I haven’t already started ordering the prescription.

That’s when I talk about the potential harms of antibiotics. And that’s also when their eyebrows go up. I start with the easy harms, like the fact that many antibiotics can cause diarrhea, a symptom nobody wants to deal with along with their runny nose. Then I move on to the big ones: Use of antibiotics today could make the patient resistant to antibiotics later in life, when they might really need them, and using antibiotics can lead to other painful and even fatal conditions, like Clostridium difficile.

After that, every patient agrees with my recommendations that we hold off on antibiotics for certain, particularly viral-like, ailments.

Change the Conversation. Change the Approach.

It’s a longer conversation, but it’s worth it. Overuse of antibiotics affects not only the patient in front of me, but also entire communities. By creating antibiotic-resistant bacteria, we make everyone more vulnerable to the very diseases the antibiotics were originally intended to treat, like tuberculosis, staph infections, and numerous others.

That’s why the hospitalists in my hospital at Johns Hopkins Bayview teamed up with the infectious diseases division to improve our approach to cellulitis and antibiotic use.

In short, cellulitis is a bacterial skin infection. The most feared bacterial skin infection is MRSA (methicillin-resistant Staphylococcus aureus), a “super bug” that requires highly selective antibiotics like vancomycin; however, other more common and less virulent bacteria also cause cellulitis, and they don’t need super bug fighter medications. Some types of skin ailments, like those caused by poor circulation in the legs, are not infectious at all but can look like cellulitis, even to experienced doctors.

Thanks to the collaboration between infectious disease doctors and hospitalists, the hospitalists are much less likely to prescribe inappropriate antibiotics. That’s a triple-win: It reduces the length of stay for the patient, the incidence of C. diff, and costs.

The Front Line

This concern isn’t limited to a single hospital. There are now more than 44,000 hospitalists nationwide, and every one of us plays an important role in antibiotic stewardship. The bedside is the front line of the fight against antibiotic resistance.

There are more than 5,000 hospitals across the country, and hospitalists in every one of them must take responsibility for the appropriate use of antibiotics for their patients.

Announcing SHM’s National Commitment to Antibiotic Stewardship

SHM was proud to join more than 150 major organizations at the White House Forum on Antibiotic Stewardship to announce commitments to implement changes over the next five years that will slow the emergence of antibiotic-resistant bacteria, detect resistant strains, preserve the efficacy of our existing antibiotics, and prevent the spread of resistant infections.

Specifically, SHM has committed to three national initiatives that are aligned with our organizational goal of providing the best possible care for the hospitalized patient and the federal government’s dedication to this important issue:

• Enhance hospitalists’ awareness of key antimicrobial stewardship best practices and ask them to formally commit to at least two behavior changes to reduce inappropriate antimicrobial use and antimicrobial resistance;
• Support national initiatives that advocate for the appropriate use of antimicrobials and promote strategies to reduce antimicrobial resistance; and
• Identify partnerships and other opportunities to support the development of a comprehensive program to implement antimicrobial stewardship best practices in America’s hospitals.

These commitments, which I shared with White House Forum participants, play to the strengths of hospitalists in healthcare: advocacy on behalf of patients and quality improvement and collaboration with others.

What Hospitalists Can Do Now

I also know, however, that you aren’t the kind of people to wait for official pronouncements and campaigns to start a program that will improve the care of hospitalized patients. That’s why SHM and I are recommending that all hospitalists begin to take steps immediately to address this national healthcare crisis:

• Start the conversation with your patients. It’s easy to prescribe antibiotics, but it can also be harmful. Talk with your patients about when antibiotics are medically appropriate and the potential harms they may cause.
• Prescribe antibiotics for specific diagnoses. Prescribing “just in case” is a prescription for antibiotic resistance. Make sure you understand the signs and symptoms of the conditions for which you’re prescribing antibiotics. As we learned at our hospital, cellulitis and venous insufficiency can look similar, but only one responds to antibiotic treatment.
• Work with your infectious disease colleagues. They can help you create systems and diagnose patients to help improve your hospital’s antibiotic stewardship.

After all, we are on the front lines, protecting our current and future patients. And we can’t afford to wait.

Dr. Howell is a veteran hospitalist at Johns Hopkins Bayview Hospital in Baltimore and a past president of SHM.

Editor’s note: This article originally appeared on SHM’s official blog, “The Hospital Leader,” in June 2015.

“Tell me what you know about antibiotics.”

That’s the discussion I start with hospitalized patients all the time, right after they ask me to prescribe antibiotics for their simple cough or other viral-like illness.

And, from their perspective, asking for antibiotics makes sense. After all, antibiotics have been the physician’s knee-jerk reaction to a number of patient symptoms for decades, especially for a cough or upper respiratory infection. We have inadvertently trained our patients that there is an easy solution to almost any common medical problem.

But patients often answer my question with something like “not much,” coupled with a little surprise that I haven’t already started ordering the prescription.

That’s when I talk about the potential harms of antibiotics. And that’s also when their eyebrows go up. I start with the easy harms, like the fact that many antibiotics can cause diarrhea, a symptom nobody wants to deal with along with their runny nose. Then I move on to the big ones: Use of antibiotics today could make the patient resistant to antibiotics later in life, when they might really need them, and using antibiotics can lead to other painful and even fatal conditions, like Clostridium difficile.

After that, every patient agrees with my recommendations that we hold off on antibiotics for certain, particularly viral-like, ailments.

Change the Conversation. Change the Approach.

It’s a longer conversation, but it’s worth it. Overuse of antibiotics affects not only the patient in front of me, but also entire communities. By creating antibiotic-resistant bacteria, we make everyone more vulnerable to the very diseases the antibiotics were originally intended to treat, like tuberculosis, staph infections, and numerous others.

That’s why the hospitalists in my hospital at Johns Hopkins Bayview teamed up with the infectious diseases division to improve our approach to cellulitis and antibiotic use.

In short, cellulitis is a bacterial skin infection. The most feared bacterial skin infection is MRSA (methicillin-resistant Staphylococcus aureus), a “super bug” that requires highly selective antibiotics like vancomycin; however, other more common and less virulent bacteria also cause cellulitis, and they don’t need super bug fighter medications. Some types of skin ailments, like those caused by poor circulation in the legs, are not infectious at all but can look like cellulitis, even to experienced doctors.

Thanks to the collaboration between infectious disease doctors and hospitalists, the hospitalists are much less likely to prescribe inappropriate antibiotics. That’s a triple-win: It reduces the length of stay for the patient, the incidence of C. diff, and costs.

The Front Line

This concern isn’t limited to a single hospital. There are now more than 44,000 hospitalists nationwide, and every one of us plays an important role in antibiotic stewardship. The bedside is the front line of the fight against antibiotic resistance.

There are more than 5,000 hospitals across the country, and hospitalists in every one of them must take responsibility for the appropriate use of antibiotics for their patients.

Announcing SHM’s National Commitment to Antibiotic Stewardship

SHM was proud to join more than 150 major organizations at the White House Forum on Antibiotic Stewardship to announce commitments to implement changes over the next five years that will slow the emergence of antibiotic-resistant bacteria, detect resistant strains, preserve the efficacy of our existing antibiotics, and prevent the spread of resistant infections.

Specifically, SHM has committed to three national initiatives that are aligned with our organizational goal of providing the best possible care for the hospitalized patient and the federal government’s dedication to this important issue:

• Enhance hospitalists’ awareness of key antimicrobial stewardship best practices and ask them to formally commit to at least two behavior changes to reduce inappropriate antimicrobial use and antimicrobial resistance;
• Support national initiatives that advocate for the appropriate use of antimicrobials and promote strategies to reduce antimicrobial resistance; and
• Identify partnerships and other opportunities to support the development of a comprehensive program to implement antimicrobial stewardship best practices in America’s hospitals.

These commitments, which I shared with White House Forum participants, play to the strengths of hospitalists in healthcare: advocacy on behalf of patients and quality improvement and collaboration with others.

What Hospitalists Can Do Now

I also know, however, that you aren’t the kind of people to wait for official pronouncements and campaigns to start a program that will improve the care of hospitalized patients. That’s why SHM and I are recommending that all hospitalists begin to take steps immediately to address this national healthcare crisis:

• Start the conversation with your patients. It’s easy to prescribe antibiotics, but it can also be harmful. Talk with your patients about when antibiotics are medically appropriate and the potential harms they may cause.
• Prescribe antibiotics for specific diagnoses. Prescribing “just in case” is a prescription for antibiotic resistance. Make sure you understand the signs and symptoms of the conditions for which you’re prescribing antibiotics. As we learned at our hospital, cellulitis and venous insufficiency can look similar, but only one responds to antibiotic treatment.
• Work with your infectious disease colleagues. They can help you create systems and diagnose patients to help improve your hospital’s antibiotic stewardship.

After all, we are on the front lines, protecting our current and future patients. And we can’t afford to wait.

Dr. Howell is a veteran hospitalist at Johns Hopkins Bayview Hospital in Baltimore and a past president of SHM.

We were still climbing from the airport tarmac, and the movie on my iPad, “Star Trek II: The Wrath of Khan,” was at an exciting point where Klingons are attacking the USS Enterprise when it came: “Is there a doctor on the plane?”

If you talk to your physician and healthcare colleagues who fly, you’ll hear about this scenario enough to know that it is not a rare event. Healthcare providers who fly routinely are more likely to tend to a sick airline passenger than they are to diagnose pheochromocytoma in their day jobs. Pheo is a two-in-a-million disease, but getting ill on a plane happens to one to two people in every 20,000. In fact, the sick airline passenger is relatively common, with an FAA study estimating 13 events per day in the 1990s (Anesthesiology. 2008;108(4):749-755). There have been a number of interesting articles written about the doctor-on-the-plane scenario. Our own Bob Wachter, MD, MHM, blogged about it in his usual humorous and insightful way a few years ago here, (http://community.the-hospitalist.org/2010/08/22/if-there-s-a-doctor-on-board-please-ring-your-call-button), and The New England Journal of Medicine published a perspective on it at www.nejm.org/doi/full/10.1056/NEJMp1006331?query=TOC (NEJM; 2010;363(21):1988-1989).

My most recent experience happened on a flight just before the New Year, and because many of us will be flying to and from the annual meeting in Las Vegas and it seems to fit naturally (in many cases) with what we do as hospitalists, I thought I’d put pen to paper regarding the sick airline passenger in flight.

Fasten Your Seatbelt

As I was walked up to the first row, the flight attendant said a passenger had almost passed out. A doctor was tending to the sick woman already, as were two very concerned flight attendants. I have been through this before, so I knew I couldn’t go back to my seat just yet. I asked the physician if everything was OK and if he needed help. In my previous experiences, the initial doctor was often a specialist, or retired, or both. They often were relieved to see a hospitalist and happily handed over the care of the airline patient once they heard I’m a hospitalist. Sound familiar from your day job?

This episode was no different: Although pleasant and concerned, the initial doctor was retired, and he made it clear this was outside of his area of expertise. He didn’t exactly sprint back to his seat, but you get the picture.

The patient was pale, looked ill, and was semi-conscious. She was about 70 (later confirmed at 73) and was sitting with her son, who worriedly showed me the auto-blood pressure cuff they had brought with her; it read 81/60. She denied chest pain or shortness of breath. Her pulse was 65, and her breathing was not labored.

For a hospitalist, attending to the ill airline passenger can be quite rewarding. Most diagnoses are those we see every day: syncope/pre-syncope, respiratory, and GI complaints make up more than half of the calls. Death is rare (0.3%), and other “big” decisions, like whether to force the plane to land early (landing a plane still full of fuel or at a smaller airport is not to be taken lightly), are uncommon (7.3%). Still, the illnesses can be real, and more than a quarter of aircraft patients are transported to a hospital upon landing (N Engl J Med. 2013;368(22):2075-2083). Our skills at diagnosis are undoubtedly valuable in the air.

Also, as Dr. Wachter said in his blog on the subject, tending to the ill airline passenger is “one of the purest expressions of our Hippocratic oath, and our professionalism. We have no obligation to respond, and no contractual relationship.  It’s just you, armed with your wits and experience, a sick and scared patient and family member, and about 200 interested observers.”

We broke open the aircraft medical kit, which was surprisingly well supplied, complete with a manual BP cuff and medications any registered respiratory therapist or code responder would find familiar. Bronchodilators, epinephrine and lidocaine, the usual aspirin, even IV tubing and needles. The one thing I was shocked to find was that there is limited supplemental oxygen: only enough to supply a nasal cannula at 4L max, and that for only a few hours.

As with the vast majority of medical cases, a thorough history of my 73-year-old air traveler proved invaluable. She felt light-headed but never lost consciousness. She had no other symptoms. Her past medical history was significant for hypertension but no heart disease. Was there anything else? She had been discharged from a hospital three days before for severe hypertension. Her ACE inhibitor and beta-blocker doses had been doubled and HCTZ added (her hospitalist had done an excellent job educating her on her disease, her medication changes, and possible side effects).

Anything else? She had been traveling more than 12 hours with little to drink, but she had taken all of her meds just before boarding the flight. After some oral rehydration, leaning back, and elevating her feet, her blood pressure increased to 125/71. I checked on her frequently for the rest of the flight, and she was talking happily to neighbors and her son long before we deplaned. They were en route to Boston, where she was moving and had no doctor, but she had an appointment scheduled with a new one soon. I gave her my card and my cell number and instructed them to call me if there were any problems. She and her son were thankful (and her neighbors were too!), and I was glad to have helped.

The Aftermath

The only thing left was the administrative paperwork for the airline. Would I please sign here? What was my license number (they were confused as to whether to take my NPI, my state license number, or DEA number, so I gave them all three), and where was I employed?

After getting home and recovering from my jet lag, I did some research on this topic. Colleagues of mine expressed concern over the legal liability of providing assistance in flight, but, compared to our day jobs, that concern seems to be unwarranted. The Aviation Medical Assistance Act of 1998 (www.gpo.gov) protects healthcare providers who render care in good faith.

As of the 2008 article by Ruskin, no physician providing care for an airline patient had been successfully sued. I learned that the medical kits are fairly well stocked and are set up for the physician/medical professional. I also learned that supplemental oxygen, so ubiquitous in the hospital, is more limited on an airplane. And, I found out that, while airlines contract with ground-based medical services, half of all emergencies are cared for by Good Samaritan doctors, licensed providers, nurses, and EMTs.

So, before my next flight, in addition to packing my iPad and thumb drive, boarding pass, and ID, I plan to pack those reference articles by Ruskin and Peterson.

We were still climbing from the airport tarmac, and the movie on my iPad, “Star Trek II: The Wrath of Khan,” was at an exciting point where Klingons are attacking the USS Enterprise when it came: “Is there a doctor on the plane?”

If you talk to your physician and healthcare colleagues who fly, you’ll hear about this scenario enough to know that it is not a rare event. Healthcare providers who fly routinely are more likely to tend to a sick airline passenger than they are to diagnose pheochromocytoma in their day jobs. Pheo is a two-in-a-million disease, but getting ill on a plane happens to one to two people in every 20,000. In fact, the sick airline passenger is relatively common, with an FAA study estimating 13 events per day in the 1990s (Anesthesiology. 2008;108(4):749-755). There have been a number of interesting articles written about the doctor-on-the-plane scenario. Our own Bob Wachter, MD, MHM, blogged about it in his usual humorous and insightful way a few years ago here, (http://community.the-hospitalist.org/2010/08/22/if-there-s-a-doctor-on-board-please-ring-your-call-button), and The New England Journal of Medicine published a perspective on it at www.nejm.org/doi/full/10.1056/NEJMp1006331?query=TOC (NEJM; 2010;363(21):1988-1989).

My most recent experience happened on a flight just before the New Year, and because many of us will be flying to and from the annual meeting in Las Vegas and it seems to fit naturally (in many cases) with what we do as hospitalists, I thought I’d put pen to paper regarding the sick airline passenger in flight.

Fasten Your Seatbelt

As I was walked up to the first row, the flight attendant said a passenger had almost passed out. A doctor was tending to the sick woman already, as were two very concerned flight attendants. I have been through this before, so I knew I couldn’t go back to my seat just yet. I asked the physician if everything was OK and if he needed help. In my previous experiences, the initial doctor was often a specialist, or retired, or both. They often were relieved to see a hospitalist and happily handed over the care of the airline patient once they heard I’m a hospitalist. Sound familiar from your day job?

This episode was no different: Although pleasant and concerned, the initial doctor was retired, and he made it clear this was outside of his area of expertise. He didn’t exactly sprint back to his seat, but you get the picture.

The patient was pale, looked ill, and was semi-conscious. She was about 70 (later confirmed at 73) and was sitting with her son, who worriedly showed me the auto-blood pressure cuff they had brought with her; it read 81/60. She denied chest pain or shortness of breath. Her pulse was 65, and her breathing was not labored.

For a hospitalist, attending to the ill airline passenger can be quite rewarding. Most diagnoses are those we see every day: syncope/pre-syncope, respiratory, and GI complaints make up more than half of the calls. Death is rare (0.3%), and other “big” decisions, like whether to force the plane to land early (landing a plane still full of fuel or at a smaller airport is not to be taken lightly), are uncommon (7.3%). Still, the illnesses can be real, and more than a quarter of aircraft patients are transported to a hospital upon landing (N Engl J Med. 2013;368(22):2075-2083). Our skills at diagnosis are undoubtedly valuable in the air.

Also, as Dr. Wachter said in his blog on the subject, tending to the ill airline passenger is “one of the purest expressions of our Hippocratic oath, and our professionalism. We have no obligation to respond, and no contractual relationship.  It’s just you, armed with your wits and experience, a sick and scared patient and family member, and about 200 interested observers.”

We broke open the aircraft medical kit, which was surprisingly well supplied, complete with a manual BP cuff and medications any registered respiratory therapist or code responder would find familiar. Bronchodilators, epinephrine and lidocaine, the usual aspirin, even IV tubing and needles. The one thing I was shocked to find was that there is limited supplemental oxygen: only enough to supply a nasal cannula at 4L max, and that for only a few hours.

As with the vast majority of medical cases, a thorough history of my 73-year-old air traveler proved invaluable. She felt light-headed but never lost consciousness. She had no other symptoms. Her past medical history was significant for hypertension but no heart disease. Was there anything else? She had been discharged from a hospital three days before for severe hypertension. Her ACE inhibitor and beta-blocker doses had been doubled and HCTZ added (her hospitalist had done an excellent job educating her on her disease, her medication changes, and possible side effects).

Anything else? She had been traveling more than 12 hours with little to drink, but she had taken all of her meds just before boarding the flight. After some oral rehydration, leaning back, and elevating her feet, her blood pressure increased to 125/71. I checked on her frequently for the rest of the flight, and she was talking happily to neighbors and her son long before we deplaned. They were en route to Boston, where she was moving and had no doctor, but she had an appointment scheduled with a new one soon. I gave her my card and my cell number and instructed them to call me if there were any problems. She and her son were thankful (and her neighbors were too!), and I was glad to have helped.

The Aftermath

The only thing left was the administrative paperwork for the airline. Would I please sign here? What was my license number (they were confused as to whether to take my NPI, my state license number, or DEA number, so I gave them all three), and where was I employed?

After getting home and recovering from my jet lag, I did some research on this topic. Colleagues of mine expressed concern over the legal liability of providing assistance in flight, but, compared to our day jobs, that concern seems to be unwarranted. The Aviation Medical Assistance Act of 1998 (www.gpo.gov) protects healthcare providers who render care in good faith.

As of the 2008 article by Ruskin, no physician providing care for an airline patient had been successfully sued. I learned that the medical kits are fairly well stocked and are set up for the physician/medical professional. I also learned that supplemental oxygen, so ubiquitous in the hospital, is more limited on an airplane. And, I found out that, while airlines contract with ground-based medical services, half of all emergencies are cared for by Good Samaritan doctors, licensed providers, nurses, and EMTs.

So, before my next flight, in addition to packing my iPad and thumb drive, boarding pass, and ID, I plan to pack those reference articles by Ruskin and Peterson.

We were still climbing from the airport tarmac, and the movie on my iPad, “Star Trek II: The Wrath of Khan,” was at an exciting point where Klingons are attacking the USS Enterprise when it came: “Is there a doctor on the plane?”

If you talk to your physician and healthcare colleagues who fly, you’ll hear about this scenario enough to know that it is not a rare event. Healthcare providers who fly routinely are more likely to tend to a sick airline passenger than they are to diagnose pheochromocytoma in their day jobs. Pheo is a two-in-a-million disease, but getting ill on a plane happens to one to two people in every 20,000. In fact, the sick airline passenger is relatively common, with an FAA study estimating 13 events per day in the 1990s (Anesthesiology. 2008;108(4):749-755). There have been a number of interesting articles written about the doctor-on-the-plane scenario. Our own Bob Wachter, MD, MHM, blogged about it in his usual humorous and insightful way a few years ago here, (http://community.the-hospitalist.org/2010/08/22/if-there-s-a-doctor-on-board-please-ring-your-call-button), and The New England Journal of Medicine published a perspective on it at www.nejm.org/doi/full/10.1056/NEJMp1006331?query=TOC (NEJM; 2010;363(21):1988-1989).

My most recent experience happened on a flight just before the New Year, and because many of us will be flying to and from the annual meeting in Las Vegas and it seems to fit naturally (in many cases) with what we do as hospitalists, I thought I’d put pen to paper regarding the sick airline passenger in flight.

Fasten Your Seatbelt

As I was walked up to the first row, the flight attendant said a passenger had almost passed out. A doctor was tending to the sick woman already, as were two very concerned flight attendants. I have been through this before, so I knew I couldn’t go back to my seat just yet. I asked the physician if everything was OK and if he needed help. In my previous experiences, the initial doctor was often a specialist, or retired, or both. They often were relieved to see a hospitalist and happily handed over the care of the airline patient once they heard I’m a hospitalist. Sound familiar from your day job?

This episode was no different: Although pleasant and concerned, the initial doctor was retired, and he made it clear this was outside of his area of expertise. He didn’t exactly sprint back to his seat, but you get the picture.

The patient was pale, looked ill, and was semi-conscious. She was about 70 (later confirmed at 73) and was sitting with her son, who worriedly showed me the auto-blood pressure cuff they had brought with her; it read 81/60. She denied chest pain or shortness of breath. Her pulse was 65, and her breathing was not labored.

For a hospitalist, attending to the ill airline passenger can be quite rewarding. Most diagnoses are those we see every day: syncope/pre-syncope, respiratory, and GI complaints make up more than half of the calls. Death is rare (0.3%), and other “big” decisions, like whether to force the plane to land early (landing a plane still full of fuel or at a smaller airport is not to be taken lightly), are uncommon (7.3%). Still, the illnesses can be real, and more than a quarter of aircraft patients are transported to a hospital upon landing (N Engl J Med. 2013;368(22):2075-2083). Our skills at diagnosis are undoubtedly valuable in the air.

Also, as Dr. Wachter said in his blog on the subject, tending to the ill airline passenger is “one of the purest expressions of our Hippocratic oath, and our professionalism. We have no obligation to respond, and no contractual relationship.  It’s just you, armed with your wits and experience, a sick and scared patient and family member, and about 200 interested observers.”

We broke open the aircraft medical kit, which was surprisingly well supplied, complete with a manual BP cuff and medications any registered respiratory therapist or code responder would find familiar. Bronchodilators, epinephrine and lidocaine, the usual aspirin, even IV tubing and needles. The one thing I was shocked to find was that there is limited supplemental oxygen: only enough to supply a nasal cannula at 4L max, and that for only a few hours.

As with the vast majority of medical cases, a thorough history of my 73-year-old air traveler proved invaluable. She felt light-headed but never lost consciousness. She had no other symptoms. Her past medical history was significant for hypertension but no heart disease. Was there anything else? She had been discharged from a hospital three days before for severe hypertension. Her ACE inhibitor and beta-blocker doses had been doubled and HCTZ added (her hospitalist had done an excellent job educating her on her disease, her medication changes, and possible side effects).

Anything else? She had been traveling more than 12 hours with little to drink, but she had taken all of her meds just before boarding the flight. After some oral rehydration, leaning back, and elevating her feet, her blood pressure increased to 125/71. I checked on her frequently for the rest of the flight, and she was talking happily to neighbors and her son long before we deplaned. They were en route to Boston, where she was moving and had no doctor, but she had an appointment scheduled with a new one soon. I gave her my card and my cell number and instructed them to call me if there were any problems. She and her son were thankful (and her neighbors were too!), and I was glad to have helped.

The Aftermath

The only thing left was the administrative paperwork for the airline. Would I please sign here? What was my license number (they were confused as to whether to take my NPI, my state license number, or DEA number, so I gave them all three), and where was I employed?

After getting home and recovering from my jet lag, I did some research on this topic. Colleagues of mine expressed concern over the legal liability of providing assistance in flight, but, compared to our day jobs, that concern seems to be unwarranted. The Aviation Medical Assistance Act of 1998 (www.gpo.gov) protects healthcare providers who render care in good faith.

As of the 2008 article by Ruskin, no physician providing care for an airline patient had been successfully sued. I learned that the medical kits are fairly well stocked and are set up for the physician/medical professional. I also learned that supplemental oxygen, so ubiquitous in the hospital, is more limited on an airplane. And, I found out that, while airlines contract with ground-based medical services, half of all emergencies are cared for by Good Samaritan doctors, licensed providers, nurses, and EMTs.

So, before my next flight, in addition to packing my iPad and thumb drive, boarding pass, and ID, I plan to pack those reference articles by Ruskin and Peterson.

Dr. Howell

I just got back from a trip to SHM headquarters in Philadelphia, and all I can say is “wow.” I was visiting there for a meeting with the staff, many SHM members and committee leaders, and the SHM board of directors. The first day we all went into a big, modern, beautiful room at SHM headquarters—there must have been more than 100 people—and we went around the room and introduced ourselves. The diversity of the staff that support our society, and the diversity of the members there, was truly breathtaking. What I saw was a microcosm of our society and our specialty.

Looking around the room, it was easy to see some aspects of our diverse organization: both genders and a variety of ethnicities and age groups were well represented. These traditional measures of diversity are critical to a healthy environment, in my opinion, and the data bear out the idea that a diverse workforce can reduce turnover and be more creative and qualified.^1,2 Our diversity is not an accident. It is part of a larger, deliberate strategy by SHM to be “the home” for healthcare professionals who provide hospital-based patient care. SHM embraces diversity, whether it’s skin deep or deeply cognitive.

Although we are continually working to enrich the traditional aspects of diversity, we are also very hard at work to make SHM a place of professional diversity.

Open and Inclusive

Over the past several years, SHM has worked hard to be openly inclusive. Many of the committees and sections within the society have been developed specifically to embrace important aspects of hospital medicine that have special or common interests, characteristics, or needs. Examples include the international section, med-peds section, administrators’ committee, and the nurse practitioner and physician assistant committee. These venues allow individuals under a Big Tent to find others with similar interests or training, so that they can address unique aspects of hospital medicine as it relates directly to them. SHM’s virtual world is following our committee and section structure, which has some of the most actively growing HMXchange communities coming from the “administrators” community and the “NP/PA” community.

SHM has put its money where its mouth is, dedicating significant resources for educational programs that will help benefit professionals with a variety of backgrounds. Some are focused on the special needs of our diverse physician population, including the Academic Hospitalist Academy, the Quality and Safety Educators Academy, and the Pediatric Hospital Medicine annual meeting (through a partnership with the American Academy of Pediatrics, the AAP Section on Hospital Medicine, and the Academic Pediatric Association). Other events are focused specifically on helping our non-physician colleagues, like the boot camp that is presented in collaboration with the American Academy of Physician Assistants and American Association of Nurse Practitioners. The SHM Leadership Academies attract a venerable alphabet soup of professional designations, including many MDs and DOs, of course, but also increasing numbers of PAs and NPs, a growing number of administrators, and now even a few ED and OB docs! Now that’s a Big Tent.

My understanding is that these events are always popular and often sold out.

Maybe the most powerful evidence that our Big Tent philosophy is working is found in the relationships SHM has forged with other hospital-based specialties, like obstetrics, neurology, and surgery. The president of the Society of OB/GYN Hospitalists (societyofobgynhospitalists.com) has attended the SHM annual meeting and at least one of the Leadership Academies. Although “traditional” hospitalists like me may not be able to help in the OR or birthing suite, we have a lot of experience in quality improvement, leadership, and, of course, addressing the needs of a new and growing professional segment. The emergence and growth of these “specialty hospitalists” offers a unique opportunity for traditional hospitalists to partner with our subspecialty colleagues in a new way, so that together we can continue to improve patient care within the hospital across multiple disciplines.

What’s Ahead?

Based on the data I recently saw while at SHM headquarters, the Big Tent philosophy is a measurable success. Membership for NPs, PAs, and administrators is growing, with nearly 200 new members in those categories combined. Incredibly, we have ED physicians joining our organization—albeit, at a number dwarfed by internists—and the relationships with the specialty hospitalists are moving forward in a meaningful way. Looking at committees and committee chairs, there is plenty of ethnic, professional, and gender diversity.

What does all of this focus outside of internal medicine and physician groups mean for us internists? Will we be left behind? Fret not. Physicians make up more than 85% of our 12,000-plus members, with internists outnumbering—by a huge number—all of the other segments of our society combined. There is no Big Tent so large that physicians, or even internists, will ever be in jeopardy. We occupy plenty of space under this Big Tent and still have lots of room to spare for our colleagues. In welcoming others, we all strengthen our own standing, by elevating the entire field.

As a terrific mentor once said, a rising tide floats all boats. And the way to raise the tide of hospital medicine can be through partnerships whose gravity is a strong pull on the hospital medicine tide, as the moon pulls the ocean’s tides.

One area in which our society plans to place more effort in expanding the Big Tent is with trainees. Students and housestaff are one of the smallest groups in our organization, with the smallest growth. Those statistics are cause for concern. The need for future hospitalist growth, both in numbers and skill set, makes attracting this segment of paramount importance, in my view.

Fortunately, SHM is developing a strategy to make our society a valuable home to trainees. I have touched on those strategies previously, including a Physicians in Training Committee, free membership for students, $100 memberships for housestaff, and our “1,000 Challenge” to recruit 1,000 students and housestaff in the coming months.

In Sum

I am a firm believer in professional and personal diversity. I am proud to work in a society that also embraces this philosophy, places real value on it, and works hard to be inclusive. So, the next time you meet an NP, PA, student, or even a hospital-based OB physician, bring them under the SHM Big Tent, and encourage them to join us in making the hospital world a better place. They, we, and our patients will be better off for it.

Dr. Howell is president of SHM, chief of the division of hospital medicine at Johns Hopkins Bayview in Baltimore, and spends a significant part of his time and research on hospital operations. Email questions or comments to ehowell@jhmi.edu.

References

1. Egan ME. Global diversity and inclusion: Fostering innovation through a diverse workforce. Forbes Insights. Forbes website. Available at: http://images.forbes.com/forbesinsights/StudyPDFs/Innovation_Through_Diversity.pdf. Accessed October 23, 2013.
2. Kerby S, Burns C. The top 10 economic facts of diversity in the workplace. Center for American Progress website. Available at: http://www.americanprogress.org/issues/labor/news/2012/07/12/11900/the-top-10-economic-facts-of-diversity-in-the-workplace. Accessed October 23, 2013.

Dr. Howell

I just got back from a trip to SHM headquarters in Philadelphia, and all I can say is “wow.” I was visiting there for a meeting with the staff, many SHM members and committee leaders, and the SHM board of directors. The first day we all went into a big, modern, beautiful room at SHM headquarters—there must have been more than 100 people—and we went around the room and introduced ourselves. The diversity of the staff that support our society, and the diversity of the members there, was truly breathtaking. What I saw was a microcosm of our society and our specialty.

Looking around the room, it was easy to see some aspects of our diverse organization: both genders and a variety of ethnicities and age groups were well represented. These traditional measures of diversity are critical to a healthy environment, in my opinion, and the data bear out the idea that a diverse workforce can reduce turnover and be more creative and qualified.^1,2 Our diversity is not an accident. It is part of a larger, deliberate strategy by SHM to be “the home” for healthcare professionals who provide hospital-based patient care. SHM embraces diversity, whether it’s skin deep or deeply cognitive.

Although we are continually working to enrich the traditional aspects of diversity, we are also very hard at work to make SHM a place of professional diversity.

Open and Inclusive

Over the past several years, SHM has worked hard to be openly inclusive. Many of the committees and sections within the society have been developed specifically to embrace important aspects of hospital medicine that have special or common interests, characteristics, or needs. Examples include the international section, med-peds section, administrators’ committee, and the nurse practitioner and physician assistant committee. These venues allow individuals under a Big Tent to find others with similar interests or training, so that they can address unique aspects of hospital medicine as it relates directly to them. SHM’s virtual world is following our committee and section structure, which has some of the most actively growing HMXchange communities coming from the “administrators” community and the “NP/PA” community.

SHM has put its money where its mouth is, dedicating significant resources for educational programs that will help benefit professionals with a variety of backgrounds. Some are focused on the special needs of our diverse physician population, including the Academic Hospitalist Academy, the Quality and Safety Educators Academy, and the Pediatric Hospital Medicine annual meeting (through a partnership with the American Academy of Pediatrics, the AAP Section on Hospital Medicine, and the Academic Pediatric Association). Other events are focused specifically on helping our non-physician colleagues, like the boot camp that is presented in collaboration with the American Academy of Physician Assistants and American Association of Nurse Practitioners. The SHM Leadership Academies attract a venerable alphabet soup of professional designations, including many MDs and DOs, of course, but also increasing numbers of PAs and NPs, a growing number of administrators, and now even a few ED and OB docs! Now that’s a Big Tent.

My understanding is that these events are always popular and often sold out.

Maybe the most powerful evidence that our Big Tent philosophy is working is found in the relationships SHM has forged with other hospital-based specialties, like obstetrics, neurology, and surgery. The president of the Society of OB/GYN Hospitalists (societyofobgynhospitalists.com) has attended the SHM annual meeting and at least one of the Leadership Academies. Although “traditional” hospitalists like me may not be able to help in the OR or birthing suite, we have a lot of experience in quality improvement, leadership, and, of course, addressing the needs of a new and growing professional segment. The emergence and growth of these “specialty hospitalists” offers a unique opportunity for traditional hospitalists to partner with our subspecialty colleagues in a new way, so that together we can continue to improve patient care within the hospital across multiple disciplines.

What’s Ahead?

Based on the data I recently saw while at SHM headquarters, the Big Tent philosophy is a measurable success. Membership for NPs, PAs, and administrators is growing, with nearly 200 new members in those categories combined. Incredibly, we have ED physicians joining our organization—albeit, at a number dwarfed by internists—and the relationships with the specialty hospitalists are moving forward in a meaningful way. Looking at committees and committee chairs, there is plenty of ethnic, professional, and gender diversity.

What does all of this focus outside of internal medicine and physician groups mean for us internists? Will we be left behind? Fret not. Physicians make up more than 85% of our 12,000-plus members, with internists outnumbering—by a huge number—all of the other segments of our society combined. There is no Big Tent so large that physicians, or even internists, will ever be in jeopardy. We occupy plenty of space under this Big Tent and still have lots of room to spare for our colleagues. In welcoming others, we all strengthen our own standing, by elevating the entire field.

As a terrific mentor once said, a rising tide floats all boats. And the way to raise the tide of hospital medicine can be through partnerships whose gravity is a strong pull on the hospital medicine tide, as the moon pulls the ocean’s tides.

One area in which our society plans to place more effort in expanding the Big Tent is with trainees. Students and housestaff are one of the smallest groups in our organization, with the smallest growth. Those statistics are cause for concern. The need for future hospitalist growth, both in numbers and skill set, makes attracting this segment of paramount importance, in my view.

Fortunately, SHM is developing a strategy to make our society a valuable home to trainees. I have touched on those strategies previously, including a Physicians in Training Committee, free membership for students, $100 memberships for housestaff, and our “1,000 Challenge” to recruit 1,000 students and housestaff in the coming months.

In Sum

I am a firm believer in professional and personal diversity. I am proud to work in a society that also embraces this philosophy, places real value on it, and works hard to be inclusive. So, the next time you meet an NP, PA, student, or even a hospital-based OB physician, bring them under the SHM Big Tent, and encourage them to join us in making the hospital world a better place. They, we, and our patients will be better off for it.

Dr. Howell is president of SHM, chief of the division of hospital medicine at Johns Hopkins Bayview in Baltimore, and spends a significant part of his time and research on hospital operations. Email questions or comments to ehowell@jhmi.edu.

References

1. Egan ME. Global diversity and inclusion: Fostering innovation through a diverse workforce. Forbes Insights. Forbes website. Available at: http://images.forbes.com/forbesinsights/StudyPDFs/Innovation_Through_Diversity.pdf. Accessed October 23, 2013.
2. Kerby S, Burns C. The top 10 economic facts of diversity in the workplace. Center for American Progress website. Available at: http://www.americanprogress.org/issues/labor/news/2012/07/12/11900/the-top-10-economic-facts-of-diversity-in-the-workplace. Accessed October 23, 2013.

Dr. Howell

I just got back from a trip to SHM headquarters in Philadelphia, and all I can say is “wow.” I was visiting there for a meeting with the staff, many SHM members and committee leaders, and the SHM board of directors. The first day we all went into a big, modern, beautiful room at SHM headquarters—there must have been more than 100 people—and we went around the room and introduced ourselves. The diversity of the staff that support our society, and the diversity of the members there, was truly breathtaking. What I saw was a microcosm of our society and our specialty.

Looking around the room, it was easy to see some aspects of our diverse organization: both genders and a variety of ethnicities and age groups were well represented. These traditional measures of diversity are critical to a healthy environment, in my opinion, and the data bear out the idea that a diverse workforce can reduce turnover and be more creative and qualified.^1,2 Our diversity is not an accident. It is part of a larger, deliberate strategy by SHM to be “the home” for healthcare professionals who provide hospital-based patient care. SHM embraces diversity, whether it’s skin deep or deeply cognitive.

Although we are continually working to enrich the traditional aspects of diversity, we are also very hard at work to make SHM a place of professional diversity.

Open and Inclusive

Over the past several years, SHM has worked hard to be openly inclusive. Many of the committees and sections within the society have been developed specifically to embrace important aspects of hospital medicine that have special or common interests, characteristics, or needs. Examples include the international section, med-peds section, administrators’ committee, and the nurse practitioner and physician assistant committee. These venues allow individuals under a Big Tent to find others with similar interests or training, so that they can address unique aspects of hospital medicine as it relates directly to them. SHM’s virtual world is following our committee and section structure, which has some of the most actively growing HMXchange communities coming from the “administrators” community and the “NP/PA” community.

SHM has put its money where its mouth is, dedicating significant resources for educational programs that will help benefit professionals with a variety of backgrounds. Some are focused on the special needs of our diverse physician population, including the Academic Hospitalist Academy, the Quality and Safety Educators Academy, and the Pediatric Hospital Medicine annual meeting (through a partnership with the American Academy of Pediatrics, the AAP Section on Hospital Medicine, and the Academic Pediatric Association). Other events are focused specifically on helping our non-physician colleagues, like the boot camp that is presented in collaboration with the American Academy of Physician Assistants and American Association of Nurse Practitioners. The SHM Leadership Academies attract a venerable alphabet soup of professional designations, including many MDs and DOs, of course, but also increasing numbers of PAs and NPs, a growing number of administrators, and now even a few ED and OB docs! Now that’s a Big Tent.

My understanding is that these events are always popular and often sold out.

Maybe the most powerful evidence that our Big Tent philosophy is working is found in the relationships SHM has forged with other hospital-based specialties, like obstetrics, neurology, and surgery. The president of the Society of OB/GYN Hospitalists (societyofobgynhospitalists.com) has attended the SHM annual meeting and at least one of the Leadership Academies. Although “traditional” hospitalists like me may not be able to help in the OR or birthing suite, we have a lot of experience in quality improvement, leadership, and, of course, addressing the needs of a new and growing professional segment. The emergence and growth of these “specialty hospitalists” offers a unique opportunity for traditional hospitalists to partner with our subspecialty colleagues in a new way, so that together we can continue to improve patient care within the hospital across multiple disciplines.

What’s Ahead?

Based on the data I recently saw while at SHM headquarters, the Big Tent philosophy is a measurable success. Membership for NPs, PAs, and administrators is growing, with nearly 200 new members in those categories combined. Incredibly, we have ED physicians joining our organization—albeit, at a number dwarfed by internists—and the relationships with the specialty hospitalists are moving forward in a meaningful way. Looking at committees and committee chairs, there is plenty of ethnic, professional, and gender diversity.

What does all of this focus outside of internal medicine and physician groups mean for us internists? Will we be left behind? Fret not. Physicians make up more than 85% of our 12,000-plus members, with internists outnumbering—by a huge number—all of the other segments of our society combined. There is no Big Tent so large that physicians, or even internists, will ever be in jeopardy. We occupy plenty of space under this Big Tent and still have lots of room to spare for our colleagues. In welcoming others, we all strengthen our own standing, by elevating the entire field.

As a terrific mentor once said, a rising tide floats all boats. And the way to raise the tide of hospital medicine can be through partnerships whose gravity is a strong pull on the hospital medicine tide, as the moon pulls the ocean’s tides.

One area in which our society plans to place more effort in expanding the Big Tent is with trainees. Students and housestaff are one of the smallest groups in our organization, with the smallest growth. Those statistics are cause for concern. The need for future hospitalist growth, both in numbers and skill set, makes attracting this segment of paramount importance, in my view.

Fortunately, SHM is developing a strategy to make our society a valuable home to trainees. I have touched on those strategies previously, including a Physicians in Training Committee, free membership for students, $100 memberships for housestaff, and our “1,000 Challenge” to recruit 1,000 students and housestaff in the coming months.

In Sum

I am a firm believer in professional and personal diversity. I am proud to work in a society that also embraces this philosophy, places real value on it, and works hard to be inclusive. So, the next time you meet an NP, PA, student, or even a hospital-based OB physician, bring them under the SHM Big Tent, and encourage them to join us in making the hospital world a better place. They, we, and our patients will be better off for it.

Dr. Howell is president of SHM, chief of the division of hospital medicine at Johns Hopkins Bayview in Baltimore, and spends a significant part of his time and research on hospital operations. Email questions or comments to ehowell@jhmi.edu.

References

1. Egan ME. Global diversity and inclusion: Fostering innovation through a diverse workforce. Forbes Insights. Forbes website. Available at: http://images.forbes.com/forbesinsights/StudyPDFs/Innovation_Through_Diversity.pdf. Accessed October 23, 2013.
2. Kerby S, Burns C. The top 10 economic facts of diversity in the workplace. Center for American Progress website. Available at: http://www.americanprogress.org/issues/labor/news/2012/07/12/11900/the-top-10-economic-facts-of-diversity-in-the-workplace. Accessed October 23, 2013.

Wikipedia defines “industrial engineering” as a branch of engineering that deals with the optimization of complex processes or systems. It goes on to link industrial engineering to “operations” and use of quantitative methods to “specify, predict, and evaluate” results. Any hospitalist that’s been tapped to reduce length of stay, help manage readmissions, implement an electronic health record, or increase the quality of care likely can relate to that definition. It seems to me that hospitalists often are the de facto industrial engineers in many of our hospitals.

The hospitalist as an industrial engineer makes perfect sense. What other group of physicians, nurse practitioners, and physician assistants provide services in virtually any clinical venue, from ED to DC, from (occasionally) PACU to ICU, the wards, and even post-discharge? Hospitalists see it all, from the first few hours of life (pediatrics) to life’s last stages (palliative care) and all stages in between. As a parody to “there’s an app for that,” Dr. Mindy Kantsiper, a hospitalist in Columbia, Md., says if there’s something that needs to be fixed, “there’s a hospitalist for that.” We are the Swiss Army knives of the medical world.

Looking through the HMX “Practice Management” discussions on the SHM website (www.hospitalmedicine.com/xchange) confirms my belief. Topics are as varied as using RNs in hospitalist practices, medication reconciliation, billing, outpatient orders (!!) after discharge, and patient-centered care/patient satisfaction. And that was just the last two weeks!

Type “hospitalist” into PubMed, and the words that auto-populate are: model, care, quality, discharge, communication, program, and handoff—all words I think of as system-related issues. Oh, sure, there are clinical-related topics, too, of course, just like for the “organ-based” specialties. However, none of the common organ-based specialties had any words auto-populate in PubMed that could be deemed related to “industrial engineering.”

Engineer Training

Like all engineers, we de facto industrial engineers need tools and skills to be effective at in our new engineering role. While we may not need slide rules and calculus like a more traditional engineer, many of the new skills we will need as industrial engineers were not taught in medical school, and the tools were not readily available for us to use in our training.

Fortunately, there are a plethora of options for us budding, de facto industrial engineers. Here are the ones I believe you will need and where to get them:

Skill No. 1: Negotiation.

HM is a team sport, and teams bring interpersonal dynamics and tension and conflict. Effective negotiation skills can help hospitalists use conflict to spur team growth and development rather than team dysfunction.

Tools: SHM’s Leadership Academies have effective negotiation modules in each of the leveled courses. If you can’t spare the time, then books to read include “Getting to Yes” by Fisher and Ury, or “Renegotiating Health Care” by Leonard Marcus (he lectures at SHM’s leadership academies).

Skill No. 2: Data analytics.

All engineers, including industrial engineers, need to be able to evaluate. Whether it’s quality and safety, clinical operations, or financial improvement, if you don’t measure it, you can’t change it. Some of the data will be handed to you, and you need to know the strengths and weaknesses to best interpret it. Some data you will need to define and develop measurement systems for on your own, and even basic dashboard development requires understanding data.

Tools: Wow. There are a lot here, so I am only going to mention the highlights. You could get your MBA, or MPH, or even a PhD! You certainly could train to become a “true” diploma-carrying industrial engineer. And I know of a few insightful hospitals that employ them. A less in-depth, but cheaper and faster, option is to take specific courses related to your area of interest.

The SHM-AAIM Quality and Safety Educators Academy and SHM’s Leadership Academies are two great examples. Participating in a mentored project (i.e., Project BOOST) provides structure and an experienced mentor with a cadre of experts to back them up. Many institutions have courses on data analytics, basic finance, and quality improvement. The easiest, cheapest, and probably the most common is to find a mentor at your own institution. CFOs, CNOs, CQOs, and CMOs often are eager to partner with clinicians—and frequently are delighted to talk about their areas of expertise.

Skill No. 3: Leadership.

I don’t know many leaders who were born that way. Most learned through experience and continuous self-improvement. Understanding your personality traits, the traits of others (as an introvert, I still am trying to understand how extroverts work, especially my wife), and how to get all of those different personalities to work together as a team is an important component of any team-based engineering success.

Tools: I have found the books “From Good to Great” by Jim Collins and “Switch” by Chip and Dan Heath to be invaluable. I think another one of my recent reads, “Drive” by Daniel Pink, had important lessons, too. Formal courses, such as SHM’s Leadership Academies, QSEA, and those offered by the American Hospital Association, are designed to provide hospitalists with the leadership skills they need in a variety of hospital environments.

Skill No. 4: Thinking “system” instead of “individual.”

So many of us were trained that to make improvements, we just need to “be better,” to know more, try harder, and to work longer. Good industrial engineers design systems that make it easier for our doctors, healthcare providers, and patients to succeed. Of course, we need to be accountable, too, but supportive systems are a key component to successful individuals. The airline industry learned this long ago.

Tools: I really think “Switch” is an excellent read for those of us trying to help re-engineer our complex systems. It discusses how humans are both rational and emotional, and how our environment can help both sides succeed. Another helpful tool for me is asking “why” whenever someone says “if only they would do something differently for a better outcome…”

For example, “if only the hospitalists would discharge before 2 p.m.,” or “if only the ED didn’t clump their admissions,” or “if only the nurse didn’t call during rounds”—these are all classic systems problems, not people problems, and the solution isn’t to mandate 2 p.m. discharges, or stand up in a meeting finger pointing at the ED, or admonish a nurse for calling during rounds. The solution is to find out why these behaviors occur, then eliminate, change, or minimize the reasons.

Hospitalists don’t discharge by 2 p.m. often because they are waiting on tests; ED docs work in an environment that has highly variable workloads, coupled with dysfunctional systems that promote “batching” work patterns; and nurses may not be included in rounds but still need to be able to manage minute-to-minute patient-care needs. Sure, there are a few bad apples that need to be scolded, but I bet most of the issues at your hospital aren’t related to evildoers but good people who are often trapped in dysfunctional, antiquated systems and are just trying to do the best they can for their patients.

In Closing

I’d like to say thank you to all of the “de facto” industrial engineers out there. Keep up the critically important work of that most complex system—the hospital.

Dr. Howell is president of SHM, chief of the division of hospital medicine at Johns Hopkins Bayview in Baltimore, and spends a significant part of his time and research on hospital operations. Email questions or comments to ehowell@jhmi.edu.

Wikipedia defines “industrial engineering” as a branch of engineering that deals with the optimization of complex processes or systems. It goes on to link industrial engineering to “operations” and use of quantitative methods to “specify, predict, and evaluate” results. Any hospitalist that’s been tapped to reduce length of stay, help manage readmissions, implement an electronic health record, or increase the quality of care likely can relate to that definition. It seems to me that hospitalists often are the de facto industrial engineers in many of our hospitals.

The hospitalist as an industrial engineer makes perfect sense. What other group of physicians, nurse practitioners, and physician assistants provide services in virtually any clinical venue, from ED to DC, from (occasionally) PACU to ICU, the wards, and even post-discharge? Hospitalists see it all, from the first few hours of life (pediatrics) to life’s last stages (palliative care) and all stages in between. As a parody to “there’s an app for that,” Dr. Mindy Kantsiper, a hospitalist in Columbia, Md., says if there’s something that needs to be fixed, “there’s a hospitalist for that.” We are the Swiss Army knives of the medical world.

Looking through the HMX “Practice Management” discussions on the SHM website (www.hospitalmedicine.com/xchange) confirms my belief. Topics are as varied as using RNs in hospitalist practices, medication reconciliation, billing, outpatient orders (!!) after discharge, and patient-centered care/patient satisfaction. And that was just the last two weeks!

Type “hospitalist” into PubMed, and the words that auto-populate are: model, care, quality, discharge, communication, program, and handoff—all words I think of as system-related issues. Oh, sure, there are clinical-related topics, too, of course, just like for the “organ-based” specialties. However, none of the common organ-based specialties had any words auto-populate in PubMed that could be deemed related to “industrial engineering.”

Engineer Training

Like all engineers, we de facto industrial engineers need tools and skills to be effective at in our new engineering role. While we may not need slide rules and calculus like a more traditional engineer, many of the new skills we will need as industrial engineers were not taught in medical school, and the tools were not readily available for us to use in our training.

Fortunately, there are a plethora of options for us budding, de facto industrial engineers. Here are the ones I believe you will need and where to get them:

Skill No. 1: Negotiation.

HM is a team sport, and teams bring interpersonal dynamics and tension and conflict. Effective negotiation skills can help hospitalists use conflict to spur team growth and development rather than team dysfunction.

Tools: SHM’s Leadership Academies have effective negotiation modules in each of the leveled courses. If you can’t spare the time, then books to read include “Getting to Yes” by Fisher and Ury, or “Renegotiating Health Care” by Leonard Marcus (he lectures at SHM’s leadership academies).

Skill No. 2: Data analytics.

All engineers, including industrial engineers, need to be able to evaluate. Whether it’s quality and safety, clinical operations, or financial improvement, if you don’t measure it, you can’t change it. Some of the data will be handed to you, and you need to know the strengths and weaknesses to best interpret it. Some data you will need to define and develop measurement systems for on your own, and even basic dashboard development requires understanding data.

Tools: Wow. There are a lot here, so I am only going to mention the highlights. You could get your MBA, or MPH, or even a PhD! You certainly could train to become a “true” diploma-carrying industrial engineer. And I know of a few insightful hospitals that employ them. A less in-depth, but cheaper and faster, option is to take specific courses related to your area of interest.

The SHM-AAIM Quality and Safety Educators Academy and SHM’s Leadership Academies are two great examples. Participating in a mentored project (i.e., Project BOOST) provides structure and an experienced mentor with a cadre of experts to back them up. Many institutions have courses on data analytics, basic finance, and quality improvement. The easiest, cheapest, and probably the most common is to find a mentor at your own institution. CFOs, CNOs, CQOs, and CMOs often are eager to partner with clinicians—and frequently are delighted to talk about their areas of expertise.

Skill No. 3: Leadership.

I don’t know many leaders who were born that way. Most learned through experience and continuous self-improvement. Understanding your personality traits, the traits of others (as an introvert, I still am trying to understand how extroverts work, especially my wife), and how to get all of those different personalities to work together as a team is an important component of any team-based engineering success.

Tools: I have found the books “From Good to Great” by Jim Collins and “Switch” by Chip and Dan Heath to be invaluable. I think another one of my recent reads, “Drive” by Daniel Pink, had important lessons, too. Formal courses, such as SHM’s Leadership Academies, QSEA, and those offered by the American Hospital Association, are designed to provide hospitalists with the leadership skills they need in a variety of hospital environments.

Skill No. 4: Thinking “system” instead of “individual.”

So many of us were trained that to make improvements, we just need to “be better,” to know more, try harder, and to work longer. Good industrial engineers design systems that make it easier for our doctors, healthcare providers, and patients to succeed. Of course, we need to be accountable, too, but supportive systems are a key component to successful individuals. The airline industry learned this long ago.

Tools: I really think “Switch” is an excellent read for those of us trying to help re-engineer our complex systems. It discusses how humans are both rational and emotional, and how our environment can help both sides succeed. Another helpful tool for me is asking “why” whenever someone says “if only they would do something differently for a better outcome…”

For example, “if only the hospitalists would discharge before 2 p.m.,” or “if only the ED didn’t clump their admissions,” or “if only the nurse didn’t call during rounds”—these are all classic systems problems, not people problems, and the solution isn’t to mandate 2 p.m. discharges, or stand up in a meeting finger pointing at the ED, or admonish a nurse for calling during rounds. The solution is to find out why these behaviors occur, then eliminate, change, or minimize the reasons.

Hospitalists don’t discharge by 2 p.m. often because they are waiting on tests; ED docs work in an environment that has highly variable workloads, coupled with dysfunctional systems that promote “batching” work patterns; and nurses may not be included in rounds but still need to be able to manage minute-to-minute patient-care needs. Sure, there are a few bad apples that need to be scolded, but I bet most of the issues at your hospital aren’t related to evildoers but good people who are often trapped in dysfunctional, antiquated systems and are just trying to do the best they can for their patients.

In Closing

I’d like to say thank you to all of the “de facto” industrial engineers out there. Keep up the critically important work of that most complex system—the hospital.

Dr. Howell is president of SHM, chief of the division of hospital medicine at Johns Hopkins Bayview in Baltimore, and spends a significant part of his time and research on hospital operations. Email questions or comments to ehowell@jhmi.edu.

Wikipedia defines “industrial engineering” as a branch of engineering that deals with the optimization of complex processes or systems. It goes on to link industrial engineering to “operations” and use of quantitative methods to “specify, predict, and evaluate” results. Any hospitalist that’s been tapped to reduce length of stay, help manage readmissions, implement an electronic health record, or increase the quality of care likely can relate to that definition. It seems to me that hospitalists often are the de facto industrial engineers in many of our hospitals.

The hospitalist as an industrial engineer makes perfect sense. What other group of physicians, nurse practitioners, and physician assistants provide services in virtually any clinical venue, from ED to DC, from (occasionally) PACU to ICU, the wards, and even post-discharge? Hospitalists see it all, from the first few hours of life (pediatrics) to life’s last stages (palliative care) and all stages in between. As a parody to “there’s an app for that,” Dr. Mindy Kantsiper, a hospitalist in Columbia, Md., says if there’s something that needs to be fixed, “there’s a hospitalist for that.” We are the Swiss Army knives of the medical world.

Looking through the HMX “Practice Management” discussions on the SHM website (www.hospitalmedicine.com/xchange) confirms my belief. Topics are as varied as using RNs in hospitalist practices, medication reconciliation, billing, outpatient orders (!!) after discharge, and patient-centered care/patient satisfaction. And that was just the last two weeks!

Type “hospitalist” into PubMed, and the words that auto-populate are: model, care, quality, discharge, communication, program, and handoff—all words I think of as system-related issues. Oh, sure, there are clinical-related topics, too, of course, just like for the “organ-based” specialties. However, none of the common organ-based specialties had any words auto-populate in PubMed that could be deemed related to “industrial engineering.”

Engineer Training

Like all engineers, we de facto industrial engineers need tools and skills to be effective at in our new engineering role. While we may not need slide rules and calculus like a more traditional engineer, many of the new skills we will need as industrial engineers were not taught in medical school, and the tools were not readily available for us to use in our training.

Fortunately, there are a plethora of options for us budding, de facto industrial engineers. Here are the ones I believe you will need and where to get them:

Skill No. 1: Negotiation.

HM is a team sport, and teams bring interpersonal dynamics and tension and conflict. Effective negotiation skills can help hospitalists use conflict to spur team growth and development rather than team dysfunction.

Tools: SHM’s Leadership Academies have effective negotiation modules in each of the leveled courses. If you can’t spare the time, then books to read include “Getting to Yes” by Fisher and Ury, or “Renegotiating Health Care” by Leonard Marcus (he lectures at SHM’s leadership academies).

Skill No. 2: Data analytics.

All engineers, including industrial engineers, need to be able to evaluate. Whether it’s quality and safety, clinical operations, or financial improvement, if you don’t measure it, you can’t change it. Some of the data will be handed to you, and you need to know the strengths and weaknesses to best interpret it. Some data you will need to define and develop measurement systems for on your own, and even basic dashboard development requires understanding data.

Tools: Wow. There are a lot here, so I am only going to mention the highlights. You could get your MBA, or MPH, or even a PhD! You certainly could train to become a “true” diploma-carrying industrial engineer. And I know of a few insightful hospitals that employ them. A less in-depth, but cheaper and faster, option is to take specific courses related to your area of interest.

The SHM-AAIM Quality and Safety Educators Academy and SHM’s Leadership Academies are two great examples. Participating in a mentored project (i.e., Project BOOST) provides structure and an experienced mentor with a cadre of experts to back them up. Many institutions have courses on data analytics, basic finance, and quality improvement. The easiest, cheapest, and probably the most common is to find a mentor at your own institution. CFOs, CNOs, CQOs, and CMOs often are eager to partner with clinicians—and frequently are delighted to talk about their areas of expertise.

Skill No. 3: Leadership.

I don’t know many leaders who were born that way. Most learned through experience and continuous self-improvement. Understanding your personality traits, the traits of others (as an introvert, I still am trying to understand how extroverts work, especially my wife), and how to get all of those different personalities to work together as a team is an important component of any team-based engineering success.

Tools: I have found the books “From Good to Great” by Jim Collins and “Switch” by Chip and Dan Heath to be invaluable. I think another one of my recent reads, “Drive” by Daniel Pink, had important lessons, too. Formal courses, such as SHM’s Leadership Academies, QSEA, and those offered by the American Hospital Association, are designed to provide hospitalists with the leadership skills they need in a variety of hospital environments.

Skill No. 4: Thinking “system” instead of “individual.”

So many of us were trained that to make improvements, we just need to “be better,” to know more, try harder, and to work longer. Good industrial engineers design systems that make it easier for our doctors, healthcare providers, and patients to succeed. Of course, we need to be accountable, too, but supportive systems are a key component to successful individuals. The airline industry learned this long ago.

Tools: I really think “Switch” is an excellent read for those of us trying to help re-engineer our complex systems. It discusses how humans are both rational and emotional, and how our environment can help both sides succeed. Another helpful tool for me is asking “why” whenever someone says “if only they would do something differently for a better outcome…”

For example, “if only the hospitalists would discharge before 2 p.m.,” or “if only the ED didn’t clump their admissions,” or “if only the nurse didn’t call during rounds”—these are all classic systems problems, not people problems, and the solution isn’t to mandate 2 p.m. discharges, or stand up in a meeting finger pointing at the ED, or admonish a nurse for calling during rounds. The solution is to find out why these behaviors occur, then eliminate, change, or minimize the reasons.

Hospitalists don’t discharge by 2 p.m. often because they are waiting on tests; ED docs work in an environment that has highly variable workloads, coupled with dysfunctional systems that promote “batching” work patterns; and nurses may not be included in rounds but still need to be able to manage minute-to-minute patient-care needs. Sure, there are a few bad apples that need to be scolded, but I bet most of the issues at your hospital aren’t related to evildoers but good people who are often trapped in dysfunctional, antiquated systems and are just trying to do the best they can for their patients.

In Closing

I’d like to say thank you to all of the “de facto” industrial engineers out there. Keep up the critically important work of that most complex system—the hospital.

Dr. Howell is president of SHM, chief of the division of hospital medicine at Johns Hopkins Bayview in Baltimore, and spends a significant part of his time and research on hospital operations. Email questions or comments to ehowell@jhmi.edu.

Although it was more than a decade ago (the last century, in fact), I remember it like it was yesterday. It was my first month as chief resident at Johns Hopkins Bayview Medical Center in Baltimore, our 335-bed hospital, with the ED chair and my chair of medicine in a heated argument. Very heated. There was no yelling; it was the kind of discussion where, even as a kid, you knew the severely stern voices meant that this was beyond the yelling stage.

“Medicine patients clog up my ED. Your docs take hours to arrive and then hours more on the workup,” the ED chair said. “They block and delay. Patients are suffering.”

“If your ED knew who to admit to which service, we wouldn’t have to spend hours figuring out where to admit them. We have a lot of work upstairs; we’re not sitting around waiting for the ED to call,” my chair replied.

They both were right, of course.

The ED chair had internal data that showed medicine did, in fact, cause delays, hours and hours of delays, every day. The department of medicine had concrete examples of less-than-ideal disposition decisions that, in hindsight, could have been done better (and sometimes a lot better).

This was the late 1990s, and all of us were just beginning to understand the adverse impact that ED boarding (admissions stuck in the ED) has on patients and our institution. Over the last decade, a number of studies have proved the fears we had in the 1990s right: From increased pain to higher mortality, admitted patients suffer when they need to be “upstairs” but are stuck in the ED.^1-4

Prior to this meeting of chairmen, we tried multiple “ED fixes” over the years. Like so many other institutions, we mandated medicine physician response times to the ED, drew policies, sent memos, and even gave the ED admitting privileges to medicine. None of them worked. Culture and cultural divide trumped policy every time, and the more than 100 house staff and attendings, both in the ED and in medicine, never made a change that positively impacted ED boarding during my entire three-year residency.

In hindsight, that’s not surprising. There has been a lot of study on ED flow and quality improvement (QI) more broadly.^5-8 To expect individuals to “do better” in a broken system is asking for failure. Asking hundreds of physicians to change behavior is an exercise in futility, especially when resources are limited and systems force “silo” behavior. Even drastic measures, such as expanding total ED capacity, don’t impact ED flow favorably. Institutions must find ways to open the “admission door.”

To the Rescue

Mirroring the rest of the country, in the late 1990s, a new group of doctors were being hired at my hospital. Ex-chief residents were staying on a year or two to run a new inpatient service. Although hospitalists were still new at the time, the idea to give them the “admission problem” took about a nanosecond.

Hospitalists across the country have become adept at tackling many institutional challenges, from readmissions (think Project BOOST) to teaching attendings from comanagement to neuromanagement. If it happens inside the walls of the hospital (and sometimes outside), hospitalists likely have played an important role in making it better somewhere.

Our hospitalists became a vital partner with the ED and within our own department of medicine, of course. We did the usual: seeing inpatients. But we also began experimenting with new and radical ways to get admitted patients out of the ED and upstairs as quickly as possible. We tried a number of admission systems, and many failed initially. We learned important lessons from the failures and continued to innovate.

Soon, hospitalists were successfully triaging admitted patients to all of general medicine using a combination of telephone and in-person triage based on the needs of the patient. This process had the triage hospitalist doing a limited ED assessment and then assigning the admission duties, often done after transfer upstairs to the best available medicine team, including the four house staff inpatient teams and hospitalist group. Later, this hospitalist admission process was expanded to all of medicine, using hospitalists to triage to the ICUs as well as specialty units in addition to general medicine. The hospital dedicated large amounts of money to allow a dedicated triage shift 24-7, staffed exclusively by hospitalists. A few years later, the hospitalists developed an in-house Web-based triage program, allowing accurate tracking of the more than 14,000 admissions annually.

The results have been better than anyone could have imagined 15 years ago. ED length of stay for admitted patients has continued to decrease dramatically—by hours, not minutes. Certain types of ambulance diversion (red alert in the state of Maryland) that were commonplace a decade ago, to the tune of 2,000-plus hours a year, virtually have been eliminated. Since ambulance diversion is known to harm patients and drive away business, this was a true win for patients as well as our hospital.⁹ Our ED volumes continued to grow, and patient-care indicators show the care provided by the current admissions process is at least as safe as before.

Hospitalists partnering with EDs to improve the admissions process are not isolated to Johns Hopkins Bayview. Many hospitalist leaders recognize that there are a variety of options for improving the care our patients get during the admissions process:

• Virginia Commonwealth University’s hospitalist group, led by Dr. Heather Masters, has worked tirelessly for years on a triage program.
• Dr. Melinda Kantsiper has done something similar at Howard County General Hospital in Maryland.
• Dr. MaryEllen Pfeiffer of Wellspan in York, Pa., is launching a triage program for admissions in the fall, and Dr. Christine Soong has focused on educating her house staff on the triage process at Mount Sinai in Toronto.

The Institute of Medicine reports that 91% of EDs are crowded routinely, an issue unlikely to go away on its own. I believe that hospitalists hold the key to unlocking the “admission door.” Hospitalists are critical partners in quality improvement, including ED flow, and can positively impact our patients, our institutions, and our specialty.

If that’s not enough to convince you, then let me tell you the true story of how the Hopkins Bayview ED physicians and hospitalists became close colleagues and the time I had Thanksgiving dinner at the ED chairman’s house. It was a lovely dinner, really.

Dr. Howell is president of SHM, chief of the division of hospital medicine at Johns Hopkins Bayview in Baltimore, and spends a significant part of his time and research on hospital operations. Email questions or comments to ehowell@jhmi.edu.

References

1. Chaflin DB, Trzeciak S, Likourezos A, Baumann BM, Dellinger RP. Impact of delayed transfer of critically ill patients from the ED to the ICU. Crit Care Med. 2007;35(6):1477-1483.
2. Duke G, Green J, Briedis J. Survival of critically ill patients is time-critical. Crit Care Resusc. 2004;6(4):261-267.
3. Scheulen JJ, Li G, Kelen GD. Impact of ambulance diversion policies in urban, suburban and rural areas of central Maryland. Acad Emerg Med. 2001;8(1):36-40.
4. Sikka R, Metha S, Kaucky C, Kulstad EB. ED crowding is associated with increased time to pneumonia treatment. Am J of Emerg Med. 2010; 28(7):809-812.
5. Holroyd BR, Bullard MJ, Latoszek K. Impact of a triage physician on emergency department overcrowding and throughput: a randomized trial. Acad Emerg Med. 2007;14(8)702-708.
6. Han JH, Zhou C, France DJ. The effect of emergency department expansion on emergency department overcrowding. Acad Emerg Med. 2007;14(4)338-343.
7. Howell E, Bessman E, Kravet S, Kolodner K, Marshall R, Wright S. Active bed management by hospitalists and emergency department throughput. Ann Intern Med. 2008;149(11):804-811.
8. Briones A, Markoff B, Kathuria N. A model of a hospitalist role in the care of admitted patients in the emergency department. J Hosp Med. 2010;5(6):360-364.
9. Nicholl J, West J, Goodacre S, Turner J. The relationship between distance to hospital and patient mortality in emergencies: an observational study. Emerg Med J. 2007; 24(9):665-668.

Although it was more than a decade ago (the last century, in fact), I remember it like it was yesterday. It was my first month as chief resident at Johns Hopkins Bayview Medical Center in Baltimore, our 335-bed hospital, with the ED chair and my chair of medicine in a heated argument. Very heated. There was no yelling; it was the kind of discussion where, even as a kid, you knew the severely stern voices meant that this was beyond the yelling stage.

“Medicine patients clog up my ED. Your docs take hours to arrive and then hours more on the workup,” the ED chair said. “They block and delay. Patients are suffering.”

“If your ED knew who to admit to which service, we wouldn’t have to spend hours figuring out where to admit them. We have a lot of work upstairs; we’re not sitting around waiting for the ED to call,” my chair replied.

They both were right, of course.

The ED chair had internal data that showed medicine did, in fact, cause delays, hours and hours of delays, every day. The department of medicine had concrete examples of less-than-ideal disposition decisions that, in hindsight, could have been done better (and sometimes a lot better).

This was the late 1990s, and all of us were just beginning to understand the adverse impact that ED boarding (admissions stuck in the ED) has on patients and our institution. Over the last decade, a number of studies have proved the fears we had in the 1990s right: From increased pain to higher mortality, admitted patients suffer when they need to be “upstairs” but are stuck in the ED.^1-4

Prior to this meeting of chairmen, we tried multiple “ED fixes” over the years. Like so many other institutions, we mandated medicine physician response times to the ED, drew policies, sent memos, and even gave the ED admitting privileges to medicine. None of them worked. Culture and cultural divide trumped policy every time, and the more than 100 house staff and attendings, both in the ED and in medicine, never made a change that positively impacted ED boarding during my entire three-year residency.

In hindsight, that’s not surprising. There has been a lot of study on ED flow and quality improvement (QI) more broadly.^5-8 To expect individuals to “do better” in a broken system is asking for failure. Asking hundreds of physicians to change behavior is an exercise in futility, especially when resources are limited and systems force “silo” behavior. Even drastic measures, such as expanding total ED capacity, don’t impact ED flow favorably. Institutions must find ways to open the “admission door.”

To the Rescue

Mirroring the rest of the country, in the late 1990s, a new group of doctors were being hired at my hospital. Ex-chief residents were staying on a year or two to run a new inpatient service. Although hospitalists were still new at the time, the idea to give them the “admission problem” took about a nanosecond.

Hospitalists across the country have become adept at tackling many institutional challenges, from readmissions (think Project BOOST) to teaching attendings from comanagement to neuromanagement. If it happens inside the walls of the hospital (and sometimes outside), hospitalists likely have played an important role in making it better somewhere.

Our hospitalists became a vital partner with the ED and within our own department of medicine, of course. We did the usual: seeing inpatients. But we also began experimenting with new and radical ways to get admitted patients out of the ED and upstairs as quickly as possible. We tried a number of admission systems, and many failed initially. We learned important lessons from the failures and continued to innovate.

Soon, hospitalists were successfully triaging admitted patients to all of general medicine using a combination of telephone and in-person triage based on the needs of the patient. This process had the triage hospitalist doing a limited ED assessment and then assigning the admission duties, often done after transfer upstairs to the best available medicine team, including the four house staff inpatient teams and hospitalist group. Later, this hospitalist admission process was expanded to all of medicine, using hospitalists to triage to the ICUs as well as specialty units in addition to general medicine. The hospital dedicated large amounts of money to allow a dedicated triage shift 24-7, staffed exclusively by hospitalists. A few years later, the hospitalists developed an in-house Web-based triage program, allowing accurate tracking of the more than 14,000 admissions annually.

The results have been better than anyone could have imagined 15 years ago. ED length of stay for admitted patients has continued to decrease dramatically—by hours, not minutes. Certain types of ambulance diversion (red alert in the state of Maryland) that were commonplace a decade ago, to the tune of 2,000-plus hours a year, virtually have been eliminated. Since ambulance diversion is known to harm patients and drive away business, this was a true win for patients as well as our hospital.⁹ Our ED volumes continued to grow, and patient-care indicators show the care provided by the current admissions process is at least as safe as before.

Hospitalists partnering with EDs to improve the admissions process are not isolated to Johns Hopkins Bayview. Many hospitalist leaders recognize that there are a variety of options for improving the care our patients get during the admissions process:

• Virginia Commonwealth University’s hospitalist group, led by Dr. Heather Masters, has worked tirelessly for years on a triage program.
• Dr. Melinda Kantsiper has done something similar at Howard County General Hospital in Maryland.
• Dr. MaryEllen Pfeiffer of Wellspan in York, Pa., is launching a triage program for admissions in the fall, and Dr. Christine Soong has focused on educating her house staff on the triage process at Mount Sinai in Toronto.

The Institute of Medicine reports that 91% of EDs are crowded routinely, an issue unlikely to go away on its own. I believe that hospitalists hold the key to unlocking the “admission door.” Hospitalists are critical partners in quality improvement, including ED flow, and can positively impact our patients, our institutions, and our specialty.

If that’s not enough to convince you, then let me tell you the true story of how the Hopkins Bayview ED physicians and hospitalists became close colleagues and the time I had Thanksgiving dinner at the ED chairman’s house. It was a lovely dinner, really.

Dr. Howell is president of SHM, chief of the division of hospital medicine at Johns Hopkins Bayview in Baltimore, and spends a significant part of his time and research on hospital operations. Email questions or comments to ehowell@jhmi.edu.

References

1. Chaflin DB, Trzeciak S, Likourezos A, Baumann BM, Dellinger RP. Impact of delayed transfer of critically ill patients from the ED to the ICU. Crit Care Med. 2007;35(6):1477-1483.
2. Duke G, Green J, Briedis J. Survival of critically ill patients is time-critical. Crit Care Resusc. 2004;6(4):261-267.
3. Scheulen JJ, Li G, Kelen GD. Impact of ambulance diversion policies in urban, suburban and rural areas of central Maryland. Acad Emerg Med. 2001;8(1):36-40.
4. Sikka R, Metha S, Kaucky C, Kulstad EB. ED crowding is associated with increased time to pneumonia treatment. Am J of Emerg Med. 2010; 28(7):809-812.
5. Holroyd BR, Bullard MJ, Latoszek K. Impact of a triage physician on emergency department overcrowding and throughput: a randomized trial. Acad Emerg Med. 2007;14(8)702-708.
6. Han JH, Zhou C, France DJ. The effect of emergency department expansion on emergency department overcrowding. Acad Emerg Med. 2007;14(4)338-343.
7. Howell E, Bessman E, Kravet S, Kolodner K, Marshall R, Wright S. Active bed management by hospitalists and emergency department throughput. Ann Intern Med. 2008;149(11):804-811.
8. Briones A, Markoff B, Kathuria N. A model of a hospitalist role in the care of admitted patients in the emergency department. J Hosp Med. 2010;5(6):360-364.
9. Nicholl J, West J, Goodacre S, Turner J. The relationship between distance to hospital and patient mortality in emergencies: an observational study. Emerg Med J. 2007; 24(9):665-668.

Although it was more than a decade ago (the last century, in fact), I remember it like it was yesterday. It was my first month as chief resident at Johns Hopkins Bayview Medical Center in Baltimore, our 335-bed hospital, with the ED chair and my chair of medicine in a heated argument. Very heated. There was no yelling; it was the kind of discussion where, even as a kid, you knew the severely stern voices meant that this was beyond the yelling stage.

“Medicine patients clog up my ED. Your docs take hours to arrive and then hours more on the workup,” the ED chair said. “They block and delay. Patients are suffering.”

“If your ED knew who to admit to which service, we wouldn’t have to spend hours figuring out where to admit them. We have a lot of work upstairs; we’re not sitting around waiting for the ED to call,” my chair replied.

They both were right, of course.

The ED chair had internal data that showed medicine did, in fact, cause delays, hours and hours of delays, every day. The department of medicine had concrete examples of less-than-ideal disposition decisions that, in hindsight, could have been done better (and sometimes a lot better).

This was the late 1990s, and all of us were just beginning to understand the adverse impact that ED boarding (admissions stuck in the ED) has on patients and our institution. Over the last decade, a number of studies have proved the fears we had in the 1990s right: From increased pain to higher mortality, admitted patients suffer when they need to be “upstairs” but are stuck in the ED.^1-4

Prior to this meeting of chairmen, we tried multiple “ED fixes” over the years. Like so many other institutions, we mandated medicine physician response times to the ED, drew policies, sent memos, and even gave the ED admitting privileges to medicine. None of them worked. Culture and cultural divide trumped policy every time, and the more than 100 house staff and attendings, both in the ED and in medicine, never made a change that positively impacted ED boarding during my entire three-year residency.

In hindsight, that’s not surprising. There has been a lot of study on ED flow and quality improvement (QI) more broadly.^5-8 To expect individuals to “do better” in a broken system is asking for failure. Asking hundreds of physicians to change behavior is an exercise in futility, especially when resources are limited and systems force “silo” behavior. Even drastic measures, such as expanding total ED capacity, don’t impact ED flow favorably. Institutions must find ways to open the “admission door.”

To the Rescue

Mirroring the rest of the country, in the late 1990s, a new group of doctors were being hired at my hospital. Ex-chief residents were staying on a year or two to run a new inpatient service. Although hospitalists were still new at the time, the idea to give them the “admission problem” took about a nanosecond.

Hospitalists across the country have become adept at tackling many institutional challenges, from readmissions (think Project BOOST) to teaching attendings from comanagement to neuromanagement. If it happens inside the walls of the hospital (and sometimes outside), hospitalists likely have played an important role in making it better somewhere.

Our hospitalists became a vital partner with the ED and within our own department of medicine, of course. We did the usual: seeing inpatients. But we also began experimenting with new and radical ways to get admitted patients out of the ED and upstairs as quickly as possible. We tried a number of admission systems, and many failed initially. We learned important lessons from the failures and continued to innovate.

Soon, hospitalists were successfully triaging admitted patients to all of general medicine using a combination of telephone and in-person triage based on the needs of the patient. This process had the triage hospitalist doing a limited ED assessment and then assigning the admission duties, often done after transfer upstairs to the best available medicine team, including the four house staff inpatient teams and hospitalist group. Later, this hospitalist admission process was expanded to all of medicine, using hospitalists to triage to the ICUs as well as specialty units in addition to general medicine. The hospital dedicated large amounts of money to allow a dedicated triage shift 24-7, staffed exclusively by hospitalists. A few years later, the hospitalists developed an in-house Web-based triage program, allowing accurate tracking of the more than 14,000 admissions annually.

The results have been better than anyone could have imagined 15 years ago. ED length of stay for admitted patients has continued to decrease dramatically—by hours, not minutes. Certain types of ambulance diversion (red alert in the state of Maryland) that were commonplace a decade ago, to the tune of 2,000-plus hours a year, virtually have been eliminated. Since ambulance diversion is known to harm patients and drive away business, this was a true win for patients as well as our hospital.⁹ Our ED volumes continued to grow, and patient-care indicators show the care provided by the current admissions process is at least as safe as before.

Hospitalists partnering with EDs to improve the admissions process are not isolated to Johns Hopkins Bayview. Many hospitalist leaders recognize that there are a variety of options for improving the care our patients get during the admissions process:

• Virginia Commonwealth University’s hospitalist group, led by Dr. Heather Masters, has worked tirelessly for years on a triage program.
• Dr. Melinda Kantsiper has done something similar at Howard County General Hospital in Maryland.
• Dr. MaryEllen Pfeiffer of Wellspan in York, Pa., is launching a triage program for admissions in the fall, and Dr. Christine Soong has focused on educating her house staff on the triage process at Mount Sinai in Toronto.

The Institute of Medicine reports that 91% of EDs are crowded routinely, an issue unlikely to go away on its own. I believe that hospitalists hold the key to unlocking the “admission door.” Hospitalists are critical partners in quality improvement, including ED flow, and can positively impact our patients, our institutions, and our specialty.

If that’s not enough to convince you, then let me tell you the true story of how the Hopkins Bayview ED physicians and hospitalists became close colleagues and the time I had Thanksgiving dinner at the ED chairman’s house. It was a lovely dinner, really.

Dr. Howell is president of SHM, chief of the division of hospital medicine at Johns Hopkins Bayview in Baltimore, and spends a significant part of his time and research on hospital operations. Email questions or comments to ehowell@jhmi.edu.

References

1. Chaflin DB, Trzeciak S, Likourezos A, Baumann BM, Dellinger RP. Impact of delayed transfer of critically ill patients from the ED to the ICU. Crit Care Med. 2007;35(6):1477-1483.
2. Duke G, Green J, Briedis J. Survival of critically ill patients is time-critical. Crit Care Resusc. 2004;6(4):261-267.
3. Scheulen JJ, Li G, Kelen GD. Impact of ambulance diversion policies in urban, suburban and rural areas of central Maryland. Acad Emerg Med. 2001;8(1):36-40.
4. Sikka R, Metha S, Kaucky C, Kulstad EB. ED crowding is associated with increased time to pneumonia treatment. Am J of Emerg Med. 2010; 28(7):809-812.
5. Holroyd BR, Bullard MJ, Latoszek K. Impact of a triage physician on emergency department overcrowding and throughput: a randomized trial. Acad Emerg Med. 2007;14(8)702-708.
6. Han JH, Zhou C, France DJ. The effect of emergency department expansion on emergency department overcrowding. Acad Emerg Med. 2007;14(4)338-343.
7. Howell E, Bessman E, Kravet S, Kolodner K, Marshall R, Wright S. Active bed management by hospitalists and emergency department throughput. Ann Intern Med. 2008;149(11):804-811.
8. Briones A, Markoff B, Kathuria N. A model of a hospitalist role in the care of admitted patients in the emergency department. J Hosp Med. 2010;5(6):360-364.
9. Nicholl J, West J, Goodacre S, Turner J. The relationship between distance to hospital and patient mortality in emergencies: an observational study. Emerg Med J. 2007; 24(9):665-668.

Dr. Howell is president of SHM.

By the time you read this, SHM will have completed another amazing annual meeting, very likely smashing some records in the process. Pre-courses have been taught, Washington’s Capitol Hill “visited,” lectures communicated, Bob Wachter’s update … updated. Staff at SHM will be busy crunching numbers and analyzing data so they can quantify the success and uniqueness of HM13.

It was at HM13 that I was lucky enough to meet many of you who are hospitalists just like me. Between Bob Wachter and Larry Wellikson, I also was able to muscle in on stage for a few minutes and share a glimpse of what I am passionate about. If you were there, you know I challenged our society to double the number of student and house staff members to 1,000. I launched the effort by inducting a special medical student (at least to me!), my sister, Lesley Sutherland (see “I Am No. 1,000,” below), bringing the new total number needed down to 999. I plan to repeatedly induct students and housestaff over the next year, and I hope many of you will, too.

As a society, we have had phenomenal membership growth over the past 15 years, expanding from a few hundred members to more than 11,000. SHM’s growth is a tremendous success story; in all of health care’s history, no other medical specialty’s ranks have grown as quickly as HM has.

But virtually all of our growth has come from board-certified (BC) or board-eligible (BE) physicians; very little has come from house officers or students. Over the last four years alone, the society has gone from 9,850 to 11,731 total members, an impressive 16% increase. However, during that same period, housestaff members have remained at about 400. This year, student members barely number 100.

This surprises me.

The Connection: Students and House Officers

It surprises me because, as best I can tell, HM is a career path that meets many of the interests of the new generation of students and house officers. Based on my totally unscientific analysis (I asked my sister, her colleagues, and the house officers with whom I work), many are interested in shorter training, flexible schedules, work-life balance, excitement, and a decent salary. Some report wanting to focus on patient safety, teaching, leadership, and teamwork. If those aren’t what drew the “BC/BE” physicians to HM in droves, I don’t know what did.

That leads me to believe that SHM and, more broadly, HM have exactly what students are looking for.

But HM isn’t just good for medical students and house officers. More students and house officers are also good for the specialty. There continues to be a constant demand for hospitalists in hospitals across the country, and growing SHM’s ranks clearly has a positive benefit for all of our members.

Most important, though: Attracting more students and house officers to HM is good for health care and patients. Hospitalists have proven their value as trusted caregivers for patients and stewards of the hospital. And more hospitalists can only help to achieve our common goal of truly transforming health care and revolutionizing patient care.

All we need to do is to connect students and house officers to our society. Fortunately, many in SHM already are working on just that.

How SHM Members are Connecting, and How You Can, Too

The Physicians in Training (PIT) Committee has been focusing on this topic for the past year. Through the leadership of Drs. Vineet “Vinny” Arora and Darlene Tad-y, PIT has developed a multistep approach to increase student and house officer involvement, including outreach, educational programs, and trainee-specific SHM offerings (e.g. a student/resident section).

Some regional chapters, such as the Boston-area chapter of SHM, have begun to provide awards to trainees, complete with money to travel to the annual meeting. I also know that the Greater Baltimore-area chapter has put on a job fair each year for the past two years. SHM, the staff, and PIT are expanding these ideas, with plans to make SHM a professional home for students and house officers alike.

But local chapters, SHM staff, and even the PIT Committee likely cannot meet the challenge to increase student and resident membership to 1,000 by HM14 alone. We will need the broader participation of the SHM membership—and that means you!

If you’re a hospitalist with teaching responsibilities, make sure your team knows that you are a hospitalist! If you have contact with residents or students, invite them to a local chapter meeting. At the very least, email them a link to SHM and the ZDoggMD video shown at HM13—they’ll love it.

Tell them that student membership is free, and the resident membership fee is the lowest it has ever been: $100 annually, one of the lowest fees for residents of a professional society. With that membership comes a world of networking, opportunities for professional growth, and the opportunity to be a part of something special.

There are more than 64,000 students and 25,000 house staff across the country. Help me connect just 999 more of them to SHM.

Dr. Howell is president of SHM.

By the time you read this, SHM will have completed another amazing annual meeting, very likely smashing some records in the process. Pre-courses have been taught, Washington’s Capitol Hill “visited,” lectures communicated, Bob Wachter’s update … updated. Staff at SHM will be busy crunching numbers and analyzing data so they can quantify the success and uniqueness of HM13.

It was at HM13 that I was lucky enough to meet many of you who are hospitalists just like me. Between Bob Wachter and Larry Wellikson, I also was able to muscle in on stage for a few minutes and share a glimpse of what I am passionate about. If you were there, you know I challenged our society to double the number of student and house staff members to 1,000. I launched the effort by inducting a special medical student (at least to me!), my sister, Lesley Sutherland (see “I Am No. 1,000,” below), bringing the new total number needed down to 999. I plan to repeatedly induct students and housestaff over the next year, and I hope many of you will, too.

As a society, we have had phenomenal membership growth over the past 15 years, expanding from a few hundred members to more than 11,000. SHM’s growth is a tremendous success story; in all of health care’s history, no other medical specialty’s ranks have grown as quickly as HM has.

But virtually all of our growth has come from board-certified (BC) or board-eligible (BE) physicians; very little has come from house officers or students. Over the last four years alone, the society has gone from 9,850 to 11,731 total members, an impressive 16% increase. However, during that same period, housestaff members have remained at about 400. This year, student members barely number 100.

This surprises me.

The Connection: Students and House Officers

It surprises me because, as best I can tell, HM is a career path that meets many of the interests of the new generation of students and house officers. Based on my totally unscientific analysis (I asked my sister, her colleagues, and the house officers with whom I work), many are interested in shorter training, flexible schedules, work-life balance, excitement, and a decent salary. Some report wanting to focus on patient safety, teaching, leadership, and teamwork. If those aren’t what drew the “BC/BE” physicians to HM in droves, I don’t know what did.

That leads me to believe that SHM and, more broadly, HM have exactly what students are looking for.

But HM isn’t just good for medical students and house officers. More students and house officers are also good for the specialty. There continues to be a constant demand for hospitalists in hospitals across the country, and growing SHM’s ranks clearly has a positive benefit for all of our members.

Most important, though: Attracting more students and house officers to HM is good for health care and patients. Hospitalists have proven their value as trusted caregivers for patients and stewards of the hospital. And more hospitalists can only help to achieve our common goal of truly transforming health care and revolutionizing patient care.

All we need to do is to connect students and house officers to our society. Fortunately, many in SHM already are working on just that.

How SHM Members are Connecting, and How You Can, Too

The Physicians in Training (PIT) Committee has been focusing on this topic for the past year. Through the leadership of Drs. Vineet “Vinny” Arora and Darlene Tad-y, PIT has developed a multistep approach to increase student and house officer involvement, including outreach, educational programs, and trainee-specific SHM offerings (e.g. a student/resident section).

Some regional chapters, such as the Boston-area chapter of SHM, have begun to provide awards to trainees, complete with money to travel to the annual meeting. I also know that the Greater Baltimore-area chapter has put on a job fair each year for the past two years. SHM, the staff, and PIT are expanding these ideas, with plans to make SHM a professional home for students and house officers alike.

But local chapters, SHM staff, and even the PIT Committee likely cannot meet the challenge to increase student and resident membership to 1,000 by HM14 alone. We will need the broader participation of the SHM membership—and that means you!

If you’re a hospitalist with teaching responsibilities, make sure your team knows that you are a hospitalist! If you have contact with residents or students, invite them to a local chapter meeting. At the very least, email them a link to SHM and the ZDoggMD video shown at HM13—they’ll love it.

Tell them that student membership is free, and the resident membership fee is the lowest it has ever been: $100 annually, one of the lowest fees for residents of a professional society. With that membership comes a world of networking, opportunities for professional growth, and the opportunity to be a part of something special.

There are more than 64,000 students and 25,000 house staff across the country. Help me connect just 999 more of them to SHM.

Dr. Howell is president of SHM.

By the time you read this, SHM will have completed another amazing annual meeting, very likely smashing some records in the process. Pre-courses have been taught, Washington’s Capitol Hill “visited,” lectures communicated, Bob Wachter’s update … updated. Staff at SHM will be busy crunching numbers and analyzing data so they can quantify the success and uniqueness of HM13.

It was at HM13 that I was lucky enough to meet many of you who are hospitalists just like me. Between Bob Wachter and Larry Wellikson, I also was able to muscle in on stage for a few minutes and share a glimpse of what I am passionate about. If you were there, you know I challenged our society to double the number of student and house staff members to 1,000. I launched the effort by inducting a special medical student (at least to me!), my sister, Lesley Sutherland (see “I Am No. 1,000,” below), bringing the new total number needed down to 999. I plan to repeatedly induct students and housestaff over the next year, and I hope many of you will, too.

As a society, we have had phenomenal membership growth over the past 15 years, expanding from a few hundred members to more than 11,000. SHM’s growth is a tremendous success story; in all of health care’s history, no other medical specialty’s ranks have grown as quickly as HM has.

But virtually all of our growth has come from board-certified (BC) or board-eligible (BE) physicians; very little has come from house officers or students. Over the last four years alone, the society has gone from 9,850 to 11,731 total members, an impressive 16% increase. However, during that same period, housestaff members have remained at about 400. This year, student members barely number 100.

This surprises me.

The Connection: Students and House Officers

It surprises me because, as best I can tell, HM is a career path that meets many of the interests of the new generation of students and house officers. Based on my totally unscientific analysis (I asked my sister, her colleagues, and the house officers with whom I work), many are interested in shorter training, flexible schedules, work-life balance, excitement, and a decent salary. Some report wanting to focus on patient safety, teaching, leadership, and teamwork. If those aren’t what drew the “BC/BE” physicians to HM in droves, I don’t know what did.

That leads me to believe that SHM and, more broadly, HM have exactly what students are looking for.

But HM isn’t just good for medical students and house officers. More students and house officers are also good for the specialty. There continues to be a constant demand for hospitalists in hospitals across the country, and growing SHM’s ranks clearly has a positive benefit for all of our members.

Most important, though: Attracting more students and house officers to HM is good for health care and patients. Hospitalists have proven their value as trusted caregivers for patients and stewards of the hospital. And more hospitalists can only help to achieve our common goal of truly transforming health care and revolutionizing patient care.

All we need to do is to connect students and house officers to our society. Fortunately, many in SHM already are working on just that.

How SHM Members are Connecting, and How You Can, Too

The Physicians in Training (PIT) Committee has been focusing on this topic for the past year. Through the leadership of Drs. Vineet “Vinny” Arora and Darlene Tad-y, PIT has developed a multistep approach to increase student and house officer involvement, including outreach, educational programs, and trainee-specific SHM offerings (e.g. a student/resident section).

Some regional chapters, such as the Boston-area chapter of SHM, have begun to provide awards to trainees, complete with money to travel to the annual meeting. I also know that the Greater Baltimore-area chapter has put on a job fair each year for the past two years. SHM, the staff, and PIT are expanding these ideas, with plans to make SHM a professional home for students and house officers alike.

But local chapters, SHM staff, and even the PIT Committee likely cannot meet the challenge to increase student and resident membership to 1,000 by HM14 alone. We will need the broader participation of the SHM membership—and that means you!

If you’re a hospitalist with teaching responsibilities, make sure your team knows that you are a hospitalist! If you have contact with residents or students, invite them to a local chapter meeting. At the very least, email them a link to SHM and the ZDoggMD video shown at HM13—they’ll love it.

Tell them that student membership is free, and the resident membership fee is the lowest it has ever been: $100 annually, one of the lowest fees for residents of a professional society. With that membership comes a world of networking, opportunities for professional growth, and the opportunity to be a part of something special.

There are more than 64,000 students and 25,000 house staff across the country. Help me connect just 999 more of them to SHM.