Gretchen Henkel

In an ideal world, the directors of hospitalist programs and residency programs would be perfectly aligned in their efforts to advance the hospital’s financial health, education initiatives, and quality of patient care. In reality, friction among them is common.

The roots of the tensions lie in their differing responsibilities.

“The goals for residency programs, which are governed by rules of the ACGME [Accreditation Council for Graduate Medical Education], don’t necessarily always match with those of the hospitalists for patient care delivery,” notes Alpesh Amin, MD, MBA, FACP, professor and chief, general internal medicine, executive director and founder of the hospitalist program at the University of California Irvine (UCI), and also associate program director of the UCI internal medicine residency program. Dr. Amin is also a member of SHM’s board of directors.

In teaching hospitals, residency program directors must ensure their residents comply with the ACGME work hour and patient load caps. These requirements limit residents to an 80-hour workweek and continuous on-site duty no longer than 24 consecutive hours, and multiresident internal medicine teams to no more than 24 patients at a time.

Compliance can pressure house staff hospitalists to pick up the slack. In addition, to advance the educational mission, a residency program director might want to have his or her residents read three hours a day. But the hospitalist, charged with caring for as many patients as possible, may want residents on his or her service to spend that time admitting, managing, and discharging patients.

William Iobst, MD, designated institutional official at Lehigh Valley Hospital in Allentown, Pa., and associate program director of the hospital medicine program, knows these issues firsthand. “The conflict usually comes up in that most hospitalist programs are put in place to provide streamlined and efficient service in the hospital,” he says. “To that end, they have targeted goals of improving efficiency, reducing length of stay, and using their expertise in repetitive treatments of the same condition [such as congestive heart failure or pneumonia] over time.”

Hospitalists, says Dr. Iobst, “get very efficient at providing care. In some ways, asking a hospitalist to serve as an educator potentially disrupts that charge of efficiency, quality, and rapid transit through the hospital. So, they may be put in a position of having conflicting bosses.”

Dual Roles

Some hospitalists work in both worlds: They serve as associate program directors for residency programs as well as directors of hospitalist programs. This can set the stage for conflicts.

Such is the case with Michael Pistoria, DO, chief of the division of hospital medicine at Lehigh Valley Hospital and associate program director for the free-standing medicine residency program.

“There are times when something in one area is impacting—sometimes adversely—the other areas for which I’m responsible,” he says. “One big issue that we really struggle with is how to deal with the [sometimes overwhelming] volume of patients when residents are able to do less and less according to ACGME rules.”

This is especially tricky, he says, when mapping coverage for overnight shifts. Not only are residents’ work hours capped, but the Residency Review Committee (RRC), which provides ACGME oversight, also stipulates that residents must have continuity with patients. They are not supposed to admit patients who won’t be seen by a resident the next day. This can create tension between the resident and hospitalist programs—especially when the latter face high patient loads.

One solution at Lehigh Valley has been to rotate resident teams admitting patients in the afternoon and evening hours, but only to their service. This ensures resident continuity for those patients and meets ACGME requirements. All other patients are admitted through the hospitalist service.

Capitalize on Uniqueness

It’s crucial to identify areas where hospitalists and program directors can dovetail efforts so the programs are not at loggerheads.

Program directors and medical directors can have a positive effect on meshing residency and private hospitalist programs. “We have to talk with our hospitalists, explain that we have no way around this [ACGME guideline], how it will impact them, and figure out a way [together] to help minimize that impact,” says Dr. Pistoria.

Dr. Amin believes the goals of the residency and hospital medicine programs can be mutually beneficial. “Some people may have inherent biases against the concept of hospital medicine,” he says. “But hopefully, as time goes on, you’ll find more and more hospitalists serving in program director or associate program director roles. My view is that the residency program ought to turn to the hospitalist when they’re looking for general inpatient, consultative, and perioperative curricular development. They could turn to hospitalists in the same way that they ask nephrology groups to help design a nephrology curriculum.”

The situation requires planning to make sure all stakeholders can accept the impact of having residents, Dr. Iobst points out. “The program director’s role is to work with the hospitalists and make sure that they understand that the residents have to adhere to their service caps,’’ he says. “The issue then would be to find other meaningful learning opportunities for residents that would not involve admitting patients.”

Dr. Iobst agrees with Dr. Amin. Some opportunities, he says, “are to ensure that a program director is capitalizing on what a hospitalist does.” If hospitalists are offering only “another general internal medicine inpatient service rotation to residents,” they are not capitalizing on their own uniqueness. Instead, hospitalists could offer hospital medicine as a senior rotation for residents. The residents could receive training and exposure to quality improvement; the business aspects of medicine, including the importance of length of stay and appropriate ICD-9 coding; and an evidence-based approach to care.

Embrace Teaching

Although ACGME work-hour caps sometimes create pressures, it’s up to hospitalists to be flexible with residents on their service, says Hasan Shabbir, MD, a hospitalist and associate medical director of quality at Emory Johns Creek Hospital in Duluth, Ga., and an assistant professor of medicine at Emory University in Atlanta.

This is especially true when particular residents are on night float rotation; admitting and managing patients into the early morning can bring them close to their work-hour caps. “We have to be cognizant of that [the ACGME guidelines], give them leeway, and let them go early whenever possible,” he says.

Having the right attitude toward residents is key. “I think we’ve approached [teaching residents] with the attitude that we’re quite fortunate to have residents to do a lot of the upfront work and to be able to help and teach them along the way,” explains Dr. Shabbir. “I think the negative feeling [about residents] is often tied to expectations. If one comes into our program, for example, and expects to just lie back and let the residents do all the work, that would be a bad expectation to have. All of us, having been [residents] at some point, can understand what residents go through. Not every hospitalist has the good fortune of having residents with them.”

There is value to having residents, agrees Dr. Iobst. “There’s the value of serving as a mentor; of training future colleagues; and the value for people who are enthused by the opportunity to teach. The key is to clearly establish all the boundaries and get them on the table to begin with, define which ones are absolutely required and are not flexible, and to ensure that the administration of the hospital that is supporting the hospitalists understands that need.”

Dr. Amin believes program directors need hospitalists to serve as faculty and that hospitalists need to take into account residency rules and regulations so the program can retain accreditation status.

“It’s a two-way street,” he says. “It doesn’t help anybody if the residency program is not accredited, and it doesn’t help anybody if the hospitalist faculty members don’t have good morale.” At UC Irvine, he says: “We try not to develop systems that overwhelm the residents; we also try not to develop systems that allow faculty to be overwhelmed. On the other hand, patient care is not predictable all the time, so some of the ACGME rules may put people into difficult situations.”

Goals and Relationships

Dr. Amin believes that if hospitalists and residency program directors can advocate for their own programs and work together for the greater good, they can craft an exponentially better team model.

One way to achieve this is to encourage more hospitalist directors to also serve as associate program directors/program directors of residency programs. This, he says, “could potentially help facilitate a stronger bridge between both programs.”

Within hospitalist groups, directors can encourage understanding about the dual sets of goals. It’s important for group leaders to involve everyone in the group when making decisions so people feel they are part of the process, says Alan L. Wang, MD, chief medical officer at Emory Johns Creek Hospital in Ga., and co-director of the hospitalist program.

Another tool for aligning hospitalists on their team with hospital goals, he says, is to share the patient workload. “One of the most important ways for medical directors to increase their credibility with the team members is to do shift work,” he asserts. “Getting in the trenches allows you to understand the day-to-day issues and problems that your hospitalists face.”

Dr. Shabbir notes that the burden of good relationship building should not fall solely to the group leaders. “There has to be an effort on all sides,” he says. “It can’t work with the leader alone trying. As a hospitalist, I think the focus has to be not only patient care, but also system efficiency, because, in the end, that makes for better overall patient care.”

Dr. Amin and others believe tensions between residency and hospitalist programs will resolve over time, in part due to hospitalists taking associate program director and program director roles, and in part to increased cooperation.

“The hospitalist could be the program director’s best friend and viewed as a vehicle for developing and training residents in system-based practice, competency-based learning and refinement of communication skills,” he says. TH

Gretchen Henkel is a frequent contributor to The Hospitalist.

In an ideal world, the directors of hospitalist programs and residency programs would be perfectly aligned in their efforts to advance the hospital’s financial health, education initiatives, and quality of patient care. In reality, friction among them is common.

The roots of the tensions lie in their differing responsibilities.

“The goals for residency programs, which are governed by rules of the ACGME [Accreditation Council for Graduate Medical Education], don’t necessarily always match with those of the hospitalists for patient care delivery,” notes Alpesh Amin, MD, MBA, FACP, professor and chief, general internal medicine, executive director and founder of the hospitalist program at the University of California Irvine (UCI), and also associate program director of the UCI internal medicine residency program. Dr. Amin is also a member of SHM’s board of directors.

In teaching hospitals, residency program directors must ensure their residents comply with the ACGME work hour and patient load caps. These requirements limit residents to an 80-hour workweek and continuous on-site duty no longer than 24 consecutive hours, and multiresident internal medicine teams to no more than 24 patients at a time.

Compliance can pressure house staff hospitalists to pick up the slack. In addition, to advance the educational mission, a residency program director might want to have his or her residents read three hours a day. But the hospitalist, charged with caring for as many patients as possible, may want residents on his or her service to spend that time admitting, managing, and discharging patients.

William Iobst, MD, designated institutional official at Lehigh Valley Hospital in Allentown, Pa., and associate program director of the hospital medicine program, knows these issues firsthand. “The conflict usually comes up in that most hospitalist programs are put in place to provide streamlined and efficient service in the hospital,” he says. “To that end, they have targeted goals of improving efficiency, reducing length of stay, and using their expertise in repetitive treatments of the same condition [such as congestive heart failure or pneumonia] over time.”

Hospitalists, says Dr. Iobst, “get very efficient at providing care. In some ways, asking a hospitalist to serve as an educator potentially disrupts that charge of efficiency, quality, and rapid transit through the hospital. So, they may be put in a position of having conflicting bosses.”

Dual Roles

Some hospitalists work in both worlds: They serve as associate program directors for residency programs as well as directors of hospitalist programs. This can set the stage for conflicts.

Such is the case with Michael Pistoria, DO, chief of the division of hospital medicine at Lehigh Valley Hospital and associate program director for the free-standing medicine residency program.

“There are times when something in one area is impacting—sometimes adversely—the other areas for which I’m responsible,” he says. “One big issue that we really struggle with is how to deal with the [sometimes overwhelming] volume of patients when residents are able to do less and less according to ACGME rules.”

This is especially tricky, he says, when mapping coverage for overnight shifts. Not only are residents’ work hours capped, but the Residency Review Committee (RRC), which provides ACGME oversight, also stipulates that residents must have continuity with patients. They are not supposed to admit patients who won’t be seen by a resident the next day. This can create tension between the resident and hospitalist programs—especially when the latter face high patient loads.

One solution at Lehigh Valley has been to rotate resident teams admitting patients in the afternoon and evening hours, but only to their service. This ensures resident continuity for those patients and meets ACGME requirements. All other patients are admitted through the hospitalist service.

Capitalize on Uniqueness

It’s crucial to identify areas where hospitalists and program directors can dovetail efforts so the programs are not at loggerheads.

Program directors and medical directors can have a positive effect on meshing residency and private hospitalist programs. “We have to talk with our hospitalists, explain that we have no way around this [ACGME guideline], how it will impact them, and figure out a way [together] to help minimize that impact,” says Dr. Pistoria.

Dr. Amin believes the goals of the residency and hospital medicine programs can be mutually beneficial. “Some people may have inherent biases against the concept of hospital medicine,” he says. “But hopefully, as time goes on, you’ll find more and more hospitalists serving in program director or associate program director roles. My view is that the residency program ought to turn to the hospitalist when they’re looking for general inpatient, consultative, and perioperative curricular development. They could turn to hospitalists in the same way that they ask nephrology groups to help design a nephrology curriculum.”

The situation requires planning to make sure all stakeholders can accept the impact of having residents, Dr. Iobst points out. “The program director’s role is to work with the hospitalists and make sure that they understand that the residents have to adhere to their service caps,’’ he says. “The issue then would be to find other meaningful learning opportunities for residents that would not involve admitting patients.”

Dr. Iobst agrees with Dr. Amin. Some opportunities, he says, “are to ensure that a program director is capitalizing on what a hospitalist does.” If hospitalists are offering only “another general internal medicine inpatient service rotation to residents,” they are not capitalizing on their own uniqueness. Instead, hospitalists could offer hospital medicine as a senior rotation for residents. The residents could receive training and exposure to quality improvement; the business aspects of medicine, including the importance of length of stay and appropriate ICD-9 coding; and an evidence-based approach to care.

Embrace Teaching

Although ACGME work-hour caps sometimes create pressures, it’s up to hospitalists to be flexible with residents on their service, says Hasan Shabbir, MD, a hospitalist and associate medical director of quality at Emory Johns Creek Hospital in Duluth, Ga., and an assistant professor of medicine at Emory University in Atlanta.

This is especially true when particular residents are on night float rotation; admitting and managing patients into the early morning can bring them close to their work-hour caps. “We have to be cognizant of that [the ACGME guidelines], give them leeway, and let them go early whenever possible,” he says.

Having the right attitude toward residents is key. “I think we’ve approached [teaching residents] with the attitude that we’re quite fortunate to have residents to do a lot of the upfront work and to be able to help and teach them along the way,” explains Dr. Shabbir. “I think the negative feeling [about residents] is often tied to expectations. If one comes into our program, for example, and expects to just lie back and let the residents do all the work, that would be a bad expectation to have. All of us, having been [residents] at some point, can understand what residents go through. Not every hospitalist has the good fortune of having residents with them.”

There is value to having residents, agrees Dr. Iobst. “There’s the value of serving as a mentor; of training future colleagues; and the value for people who are enthused by the opportunity to teach. The key is to clearly establish all the boundaries and get them on the table to begin with, define which ones are absolutely required and are not flexible, and to ensure that the administration of the hospital that is supporting the hospitalists understands that need.”

Dr. Amin believes program directors need hospitalists to serve as faculty and that hospitalists need to take into account residency rules and regulations so the program can retain accreditation status.

“It’s a two-way street,” he says. “It doesn’t help anybody if the residency program is not accredited, and it doesn’t help anybody if the hospitalist faculty members don’t have good morale.” At UC Irvine, he says: “We try not to develop systems that overwhelm the residents; we also try not to develop systems that allow faculty to be overwhelmed. On the other hand, patient care is not predictable all the time, so some of the ACGME rules may put people into difficult situations.”

Goals and Relationships

Dr. Amin believes that if hospitalists and residency program directors can advocate for their own programs and work together for the greater good, they can craft an exponentially better team model.

One way to achieve this is to encourage more hospitalist directors to also serve as associate program directors/program directors of residency programs. This, he says, “could potentially help facilitate a stronger bridge between both programs.”

Within hospitalist groups, directors can encourage understanding about the dual sets of goals. It’s important for group leaders to involve everyone in the group when making decisions so people feel they are part of the process, says Alan L. Wang, MD, chief medical officer at Emory Johns Creek Hospital in Ga., and co-director of the hospitalist program.

Another tool for aligning hospitalists on their team with hospital goals, he says, is to share the patient workload. “One of the most important ways for medical directors to increase their credibility with the team members is to do shift work,” he asserts. “Getting in the trenches allows you to understand the day-to-day issues and problems that your hospitalists face.”

Dr. Shabbir notes that the burden of good relationship building should not fall solely to the group leaders. “There has to be an effort on all sides,” he says. “It can’t work with the leader alone trying. As a hospitalist, I think the focus has to be not only patient care, but also system efficiency, because, in the end, that makes for better overall patient care.”

Dr. Amin and others believe tensions between residency and hospitalist programs will resolve over time, in part due to hospitalists taking associate program director and program director roles, and in part to increased cooperation.

“The hospitalist could be the program director’s best friend and viewed as a vehicle for developing and training residents in system-based practice, competency-based learning and refinement of communication skills,” he says. TH

Gretchen Henkel is a frequent contributor to The Hospitalist.

In an ideal world, the directors of hospitalist programs and residency programs would be perfectly aligned in their efforts to advance the hospital’s financial health, education initiatives, and quality of patient care. In reality, friction among them is common.

The roots of the tensions lie in their differing responsibilities.

“The goals for residency programs, which are governed by rules of the ACGME [Accreditation Council for Graduate Medical Education], don’t necessarily always match with those of the hospitalists for patient care delivery,” notes Alpesh Amin, MD, MBA, FACP, professor and chief, general internal medicine, executive director and founder of the hospitalist program at the University of California Irvine (UCI), and also associate program director of the UCI internal medicine residency program. Dr. Amin is also a member of SHM’s board of directors.

In teaching hospitals, residency program directors must ensure their residents comply with the ACGME work hour and patient load caps. These requirements limit residents to an 80-hour workweek and continuous on-site duty no longer than 24 consecutive hours, and multiresident internal medicine teams to no more than 24 patients at a time.

Compliance can pressure house staff hospitalists to pick up the slack. In addition, to advance the educational mission, a residency program director might want to have his or her residents read three hours a day. But the hospitalist, charged with caring for as many patients as possible, may want residents on his or her service to spend that time admitting, managing, and discharging patients.

William Iobst, MD, designated institutional official at Lehigh Valley Hospital in Allentown, Pa., and associate program director of the hospital medicine program, knows these issues firsthand. “The conflict usually comes up in that most hospitalist programs are put in place to provide streamlined and efficient service in the hospital,” he says. “To that end, they have targeted goals of improving efficiency, reducing length of stay, and using their expertise in repetitive treatments of the same condition [such as congestive heart failure or pneumonia] over time.”

Hospitalists, says Dr. Iobst, “get very efficient at providing care. In some ways, asking a hospitalist to serve as an educator potentially disrupts that charge of efficiency, quality, and rapid transit through the hospital. So, they may be put in a position of having conflicting bosses.”

Dual Roles

Some hospitalists work in both worlds: They serve as associate program directors for residency programs as well as directors of hospitalist programs. This can set the stage for conflicts.

Such is the case with Michael Pistoria, DO, chief of the division of hospital medicine at Lehigh Valley Hospital and associate program director for the free-standing medicine residency program.

“There are times when something in one area is impacting—sometimes adversely—the other areas for which I’m responsible,” he says. “One big issue that we really struggle with is how to deal with the [sometimes overwhelming] volume of patients when residents are able to do less and less according to ACGME rules.”

This is especially tricky, he says, when mapping coverage for overnight shifts. Not only are residents’ work hours capped, but the Residency Review Committee (RRC), which provides ACGME oversight, also stipulates that residents must have continuity with patients. They are not supposed to admit patients who won’t be seen by a resident the next day. This can create tension between the resident and hospitalist programs—especially when the latter face high patient loads.

One solution at Lehigh Valley has been to rotate resident teams admitting patients in the afternoon and evening hours, but only to their service. This ensures resident continuity for those patients and meets ACGME requirements. All other patients are admitted through the hospitalist service.

Capitalize on Uniqueness

It’s crucial to identify areas where hospitalists and program directors can dovetail efforts so the programs are not at loggerheads.

Program directors and medical directors can have a positive effect on meshing residency and private hospitalist programs. “We have to talk with our hospitalists, explain that we have no way around this [ACGME guideline], how it will impact them, and figure out a way [together] to help minimize that impact,” says Dr. Pistoria.

Dr. Amin believes the goals of the residency and hospital medicine programs can be mutually beneficial. “Some people may have inherent biases against the concept of hospital medicine,” he says. “But hopefully, as time goes on, you’ll find more and more hospitalists serving in program director or associate program director roles. My view is that the residency program ought to turn to the hospitalist when they’re looking for general inpatient, consultative, and perioperative curricular development. They could turn to hospitalists in the same way that they ask nephrology groups to help design a nephrology curriculum.”

The situation requires planning to make sure all stakeholders can accept the impact of having residents, Dr. Iobst points out. “The program director’s role is to work with the hospitalists and make sure that they understand that the residents have to adhere to their service caps,’’ he says. “The issue then would be to find other meaningful learning opportunities for residents that would not involve admitting patients.”

Dr. Iobst agrees with Dr. Amin. Some opportunities, he says, “are to ensure that a program director is capitalizing on what a hospitalist does.” If hospitalists are offering only “another general internal medicine inpatient service rotation to residents,” they are not capitalizing on their own uniqueness. Instead, hospitalists could offer hospital medicine as a senior rotation for residents. The residents could receive training and exposure to quality improvement; the business aspects of medicine, including the importance of length of stay and appropriate ICD-9 coding; and an evidence-based approach to care.

Embrace Teaching

Although ACGME work-hour caps sometimes create pressures, it’s up to hospitalists to be flexible with residents on their service, says Hasan Shabbir, MD, a hospitalist and associate medical director of quality at Emory Johns Creek Hospital in Duluth, Ga., and an assistant professor of medicine at Emory University in Atlanta.

This is especially true when particular residents are on night float rotation; admitting and managing patients into the early morning can bring them close to their work-hour caps. “We have to be cognizant of that [the ACGME guidelines], give them leeway, and let them go early whenever possible,” he says.

Having the right attitude toward residents is key. “I think we’ve approached [teaching residents] with the attitude that we’re quite fortunate to have residents to do a lot of the upfront work and to be able to help and teach them along the way,” explains Dr. Shabbir. “I think the negative feeling [about residents] is often tied to expectations. If one comes into our program, for example, and expects to just lie back and let the residents do all the work, that would be a bad expectation to have. All of us, having been [residents] at some point, can understand what residents go through. Not every hospitalist has the good fortune of having residents with them.”

There is value to having residents, agrees Dr. Iobst. “There’s the value of serving as a mentor; of training future colleagues; and the value for people who are enthused by the opportunity to teach. The key is to clearly establish all the boundaries and get them on the table to begin with, define which ones are absolutely required and are not flexible, and to ensure that the administration of the hospital that is supporting the hospitalists understands that need.”

Dr. Amin believes program directors need hospitalists to serve as faculty and that hospitalists need to take into account residency rules and regulations so the program can retain accreditation status.

“It’s a two-way street,” he says. “It doesn’t help anybody if the residency program is not accredited, and it doesn’t help anybody if the hospitalist faculty members don’t have good morale.” At UC Irvine, he says: “We try not to develop systems that overwhelm the residents; we also try not to develop systems that allow faculty to be overwhelmed. On the other hand, patient care is not predictable all the time, so some of the ACGME rules may put people into difficult situations.”

Goals and Relationships

Dr. Amin believes that if hospitalists and residency program directors can advocate for their own programs and work together for the greater good, they can craft an exponentially better team model.

One way to achieve this is to encourage more hospitalist directors to also serve as associate program directors/program directors of residency programs. This, he says, “could potentially help facilitate a stronger bridge between both programs.”

Within hospitalist groups, directors can encourage understanding about the dual sets of goals. It’s important for group leaders to involve everyone in the group when making decisions so people feel they are part of the process, says Alan L. Wang, MD, chief medical officer at Emory Johns Creek Hospital in Ga., and co-director of the hospitalist program.

Another tool for aligning hospitalists on their team with hospital goals, he says, is to share the patient workload. “One of the most important ways for medical directors to increase their credibility with the team members is to do shift work,” he asserts. “Getting in the trenches allows you to understand the day-to-day issues and problems that your hospitalists face.”

Dr. Shabbir notes that the burden of good relationship building should not fall solely to the group leaders. “There has to be an effort on all sides,” he says. “It can’t work with the leader alone trying. As a hospitalist, I think the focus has to be not only patient care, but also system efficiency, because, in the end, that makes for better overall patient care.”

Dr. Amin and others believe tensions between residency and hospitalist programs will resolve over time, in part due to hospitalists taking associate program director and program director roles, and in part to increased cooperation.

“The hospitalist could be the program director’s best friend and viewed as a vehicle for developing and training residents in system-based practice, competency-based learning and refinement of communication skills,” he says. TH

Gretchen Henkel is a frequent contributor to The Hospitalist.

In this first of a two-part series, we examine the implications of international medical graduates (IMGs) in hospital medicine groups, and explore how hospitalist group leaders can improve communications and integrate them into their medicine teams. Part 2 will feature stories from hospitalist IMGs as they establish themselves as professionals in their communities.

International medical graduates (IMGs) comprise 25% of the total U.S. physician workforce.1 Despite post-9/11 barriers to immigration, the number of IMGs entering internal medical residencies has risen in recent years.

In 2006, more than 6,500 physicians who graduated medical school in foreign countries entered accredited residency programs, according to the Association of American Medical Colleges. U.S.-born residents who have attended medical school in another country account for approximately 25% of the total IMGs in training.

Further, the proportion of foreign-educated residents who will go into primary care is higher than for U.S. medical graduates. In 2006, 50% of the physicians training in internal medicine residency programs were IMGs.

What do these trends mean for hospital medicine? In light of projected physician shortages IMGs will continue to be a vital part of the physician workforce.2 Because internal medicine is a primary feeder of hospital medicine, it’s likely many hospital medicine programs will also continue to see an increase in hospitalists who are IMGs.

Hoops, Hurdles, and Visas

Entry of foreign-born IMGs to the United States is governed by the Immigration and Nationality Act, administered by the U.S. Immigration and Naturalization Service.

The J-1 visa was set up as an educational exchange program and carries with it a requirement that the graduate return to his or her native country upon completion of residency. However, a waiver of the requirement to return to their country of origin can be obtained if the physicians agree to begin practice in a Health Professional Shortage Area.

These service areas are determined using a scoring system based on four variables: the ratio of primary medical care physicians per 1,000 population, infant mortality rates, percentage of the population with incomes below the federal poverty level, and percentage of the population over 65. The vast majority of J-1 waivers are administered through “Conrad 30” programs administered by individual states and the District of Columbia.

In recent years, AAMC’s Center for Workforce Studies has observed a shift to the H1-B, or temporary worker visa, allowing hospitals and group practices to hire IMGs in areas where there are physician shortages. This visa is employer-specific, and some hospitalist programs have become involved in helping their applicants secure this visa.

Visa issues present a range of financial, legal and personal hurdles for the IMG. In addition to obtaining legal entry into the country, IMGs applying to U.S. residency programs must obtain ECGMG certification, a multistep process that includes:

• Graduating from a medical school listed in the World Directory of Medical Schools;
• Obtaining a license to practice medicine within their own country;
• Passing the medical science examination (Step 1 and 2 of the United States Medical Licensing Examination);
• Passing the ECFMG English test or Test of English as a Foreign Language; and
• Passing the Clinical Skills Assessment component of the USMLE.

An IMG can apply for lawful permanent resident status based on a job offer, provided that he or she has passed parts 1 and 2 of the National Board of Medical Examiners examination, and has fulfilled the other ECFMG certification requirements.

For more information, visit the Web sites of the Accreditation Council for Graduate Medical Education (www.acgme.org) and the Educational Commission for Foreign Medical Graduates (www.ecfmg.org).—GH

Image - © POWERED BY LIGHT/ALAN SPENCER / ALAMY

What the Trends Show

“International medical school graduates have been and continue to be a major source of physicians in the U.S.,” says Edward Salsberg, director, Center for Workforce Studies at the Association of American Medical Colleges.

According to a survey this year in Health Affairs of IMG trends since 1981, most IMGs working in the United States come from India, the Philippines, Mexico, Pakistan, China, and the Republic of Korea. When starting full-time employment, most IMGs tend to gravitate to the East Coast, the Midwest (particularly Illinois, Ohio, and Michigan), and California.

Although the overall percentage of IMGs in the United States has remained about the same, more U.S. citizens graduate from medical schools outside this country, according to Salsberg. Noncitizen IMGs are gravitating toward the H1-B visa for foreign-born professionals for a duration of not more than six years instead of J-1, or exchange visitor visas.

A slightly higher percent of IMGs go into primary care. “International medical graduates have tended to go into the specialties that U.S. graduates were less interested in entering,” Salsberg notes. “They fill gaps because many are willing to go into some specialties in order to get into the U.S.”

Location, Location, Location

Entering residency, obtaining fellowships, and embarking on the practice of medicine all pose challenges for the foreign-born IMG. Throughout their residencies and into practice, IMGs can face biased perceptions from peers, attending physicians, and patients—especially if English has not been their primary language.

Rachel George, MD, regional medical director for Cogent Healthcare, is an international medical graduate, who received her medical degree from JJM Medical College in Kamataka, India. She observes that the challenges for IMGs and hospital medicine groups often depend on the predominant cultural mix of the surrounding community, as well as the hospital community culture.

For example, one program Dr. George oversees is situated within a culturally diverse community near Los Angeles. “Almost any international medical grad can go there, do very well, and be very comfortable, just because the rest of the community is very comfortable with international grads,” she says. However, the first employment for many IMGs here on J-1 visa waivers may be in medically underserved areas, which tend to be rural areas.

“When you go to those places, I think communication becomes much more of a challenge because people in the local area may not be used to interacting with people of different cultures with different accents,” Dr. George says. In some of those cases, Cogent has sent physicians to English classes to help improve communication skills.

Perception versus Reality

Dr. George notes that international medical graduates often face the perception that they are not as good as American graduates.

Much of this perception may be related to an IMG’s lack of English fluency, she says. But those familiar with the certification process for IMGs know they face multiple difficulties to attain the status of a practicing physician in this country.

“It might actually be harder for an international medical grad to be able to practice in this country,” notes Dr. George. “Your scores almost have to be twice as good as the scores of the American grad standing next to you to get into residency. Fellowships are also extremely difficult to obtain. Foreign medical grads have to jump through a lot more hoops to get into the system. And because of that, we actually probably have the cream of the crop here.”

For Salsberg, credentials count. “A graduate of an LCME [Liaison Committee for Medical Education]-accredited medical school provides a high degree of assurance to a residency program director that the physician has received a comprehensive, solid medical education,” Salsberg says. “This is not to suggest that foreign IMGs are not well prepared: Many of the IMGs that we’re getting now are really among the best and the brightest in the world.”

It might actually be harder for an international medical grad to be able to practice in this country. Your scores almost have to be twice as good as the scores of the American grad standing next to you to get into residency.

—Rachel George, MD, regional medical director for Cogent Healthcare

Issues that Surface

Program directors of ACGME-accredited residency programs rely on certification by the Educational Commission for Foreign Medical Graduates (ECGMG) to ensure that their prospective residents have met standards of eligibility.

ECGMG certification is also a prerequisite required by most states for licensure to practice medicine. Vijay Rajput, MD, associate professor of medicine and program director of Internal Medicine Residency at UMDNJ-Robert Wood Johnson Medical School in Camden, N.J., and senior hospitalist with Cooper Health System, acknowledges that depending upon their country of origin, IMGs may have difficulties becoming acculturated when it comes time to start practicing medicine. During his time as a residency program director, Dr. Rajput has encountered residents who have problems with hierarchical issues. “A resident may come from a part of the world where they do not like to take orders from women,” he says. “It will be difficult for them to work with peers who are women.”

Hospitalist directors need to exercise good judgment when hiring new members of their team, and ascertain the prospective candidate’s bedside skills with language, communication, and cultural competency, says Dr. Rajput. He believes that evaluation of residents’ interpersonal communications skills varies from program to program.

The “hard skills” pertaining to the resident’s breadth of medical knowledge and technological expertise are easily evaluated by in-service and board examinations, as well as procedures tests. However, the “soft skills” of communication, professionalism, and interpersonal skills are not as easily evaluated.

He suggests hospital program medical directors speak with program directors to glean important information about the candidates’ interpersonal skills, including areas where they might need improvement.

“I think the hospitalist director will have to recognize their own community and the cultural, language, and communication issues in their own hospital’s patient population and then acclimatize their younger hospitalists, providing specific training as part of CME,” Dr. Rajput advises. “The hospitalist director has to keep his or her eyes open and see whether their IMG might need extra training—whether it’s in cultural competencies or ethical principles—because even in our country there are different cultural issues in each community.”

Dr. Rajput, in collaboration with Gerry Whalen, MD, a former vice president at ECFMG, has conducted a pilot acculturation project for the past two years. It entails a one-day program for 40 to 50 IMG participants to acquaint them with challenges they will likely face. This “snapshot” provides an overview of Western medicine’s ethics, bedside skills, insurance issues, and peer-relationship issues.

Pave the Way

Experts suggest various ways leaders of hospital medicine groups can address perception and communication challenges when they surface.

IMGs can be encouraged, for instance, to open their dialogue when meeting patients for the first time by telling them they are welcome to ask questions if there are words or terms they do not understand. In addition, says Dr. George, IMGs can slow the pace of their conversation to be better understood.

Perhaps more important is how the hospital and the practice group introduce new members of the team to their communities. Dr. George advocates a hospital-wide announcement when a new physician joins the hospital medicine team. It’s important that the hospital clearly communicates to the hospital staff and the community at large that the IMG is a “well-trained physician, is highly regarded and respected, has good credentials, was chosen very carefully, and will be a great addition to the team.”

Communications consultant Douglas Leonard, PhD, advised Richard H. Bailey, MD, medical director of Inpatient Care and Hospitalist Services at Saint Clare’s Hospital in Wausau, Wis., to create a brochure to introduce new members of the hospitalist team. Dr. Bailey leads a team made up entirely of hospitalists who are foreign-born IMGs. He had received complaints about his hospitalists’ English skills from other specialists at the hospital and hired Dr. Leonard to perform a needs assessment of his team and other staff members with whom they interface.

Dr. Leonard found that nursing staff, because they liked the hospitalists and wanted to help them, had begun to act as interpreters between physicians and patients.

“Because these hospitalists had such good attitudes, the staff had learned to understand their accents and had really made an effort to work with these doctors effectively,” Dr. Leonard reports. Part of that effort was that nurses would often step in to interpret for the hospitalists when patients could not understand their accents.

Dr. Leonard recommended that the hospitalists become better communicators with patients—even if that means softening their accents—and that they avoid reliance on nurses interpreting with their patients. The latter, says Dr. Leonard, “makes the hospitalists seem like second-class citizens in the world of doctoring.” Although the nurses were happy to provide the service, he says “the hospitalists have got to establish their own ability to communicate with their patients.”

In a case like this, the medical director can work with hospital administration to provide language training. Dr. Bailey has been exploring the possibility of working with local outside resources, including a local technical college, for this service.

The technical college is willing to schedule classes at night or when the hospitalists overlap on changing shifts. In addition, “Classes might alternate with on-site, one-to-one coaching sessions in speaking skills,” says Dr. Leonard.

Two-Way Street

IMGs will continue to be a valuable resource and an increasing presence in hospitalist programs. The challenge for hospital medicine group leaders is to ensure that their talents are nurtured and respected.

Dr. Bailey sees his job as that of champion and advocate for his team. For one member of his team, he solicited involvement from his congressman to help resolve complications with visa and immigration issues.

He has also seen tensions erupt when his hospitalists interact with other physicians or patients who have misperceptions about their medical skills. “I’d put my physicians up against anybody—they just don’t speak as well,” he says.

There are times when Dr. Bailey becomes concerned about the welfare of his team. “My job as medical director is to create an environment in which they can be successful—and that’s a two-way street,” he says. “That means I have to help them to be able to communicate, but it also means that I have to back them up when their professional competency is being questioned by preconceived notions about their language and their accents.”

Dr. Rajput underscores this message. “Acculturation is a two-way street,” he agrees. “As international doctors get acculturated, we as a society also need to adjust and help these well-trained physicians to understand us as well. In the interests of providing the best possible patient care, education and training will be needed for both sets of stakeholders [the IMG physicians and their employers].” TH

Gretchen Henkel is a frequent contributor to The Hospitalist.

References

1. Hart LG, Skillman SM, Fordyce M, et al. International medical graduate physicians in the United States: changes since 1981. Health Aff. 2007 July/August;26(4):1159-1169.
2. Association of American Medical Colleges. Help wanted: more U.S. doctors. Available online at www.aamc.org/workforce/helpwanted.pdf. Last accessed Sept. 11, 2007.

In this first of a two-part series, we examine the implications of international medical graduates (IMGs) in hospital medicine groups, and explore how hospitalist group leaders can improve communications and integrate them into their medicine teams. Part 2 will feature stories from hospitalist IMGs as they establish themselves as professionals in their communities.

International medical graduates (IMGs) comprise 25% of the total U.S. physician workforce.1 Despite post-9/11 barriers to immigration, the number of IMGs entering internal medical residencies has risen in recent years.

In 2006, more than 6,500 physicians who graduated medical school in foreign countries entered accredited residency programs, according to the Association of American Medical Colleges. U.S.-born residents who have attended medical school in another country account for approximately 25% of the total IMGs in training.

Further, the proportion of foreign-educated residents who will go into primary care is higher than for U.S. medical graduates. In 2006, 50% of the physicians training in internal medicine residency programs were IMGs.

What do these trends mean for hospital medicine? In light of projected physician shortages IMGs will continue to be a vital part of the physician workforce.2 Because internal medicine is a primary feeder of hospital medicine, it’s likely many hospital medicine programs will also continue to see an increase in hospitalists who are IMGs.

Hoops, Hurdles, and Visas

Entry of foreign-born IMGs to the United States is governed by the Immigration and Nationality Act, administered by the U.S. Immigration and Naturalization Service.

The J-1 visa was set up as an educational exchange program and carries with it a requirement that the graduate return to his or her native country upon completion of residency. However, a waiver of the requirement to return to their country of origin can be obtained if the physicians agree to begin practice in a Health Professional Shortage Area.

These service areas are determined using a scoring system based on four variables: the ratio of primary medical care physicians per 1,000 population, infant mortality rates, percentage of the population with incomes below the federal poverty level, and percentage of the population over 65. The vast majority of J-1 waivers are administered through “Conrad 30” programs administered by individual states and the District of Columbia.

In recent years, AAMC’s Center for Workforce Studies has observed a shift to the H1-B, or temporary worker visa, allowing hospitals and group practices to hire IMGs in areas where there are physician shortages. This visa is employer-specific, and some hospitalist programs have become involved in helping their applicants secure this visa.

Visa issues present a range of financial, legal and personal hurdles for the IMG. In addition to obtaining legal entry into the country, IMGs applying to U.S. residency programs must obtain ECGMG certification, a multistep process that includes:

• Graduating from a medical school listed in the World Directory of Medical Schools;
• Obtaining a license to practice medicine within their own country;
• Passing the medical science examination (Step 1 and 2 of the United States Medical Licensing Examination);
• Passing the ECFMG English test or Test of English as a Foreign Language; and
• Passing the Clinical Skills Assessment component of the USMLE.

An IMG can apply for lawful permanent resident status based on a job offer, provided that he or she has passed parts 1 and 2 of the National Board of Medical Examiners examination, and has fulfilled the other ECFMG certification requirements.

For more information, visit the Web sites of the Accreditation Council for Graduate Medical Education (www.acgme.org) and the Educational Commission for Foreign Medical Graduates (www.ecfmg.org).—GH

Image - © POWERED BY LIGHT/ALAN SPENCER / ALAMY

What the Trends Show

“International medical school graduates have been and continue to be a major source of physicians in the U.S.,” says Edward Salsberg, director, Center for Workforce Studies at the Association of American Medical Colleges.

According to a survey this year in Health Affairs of IMG trends since 1981, most IMGs working in the United States come from India, the Philippines, Mexico, Pakistan, China, and the Republic of Korea. When starting full-time employment, most IMGs tend to gravitate to the East Coast, the Midwest (particularly Illinois, Ohio, and Michigan), and California.

Although the overall percentage of IMGs in the United States has remained about the same, more U.S. citizens graduate from medical schools outside this country, according to Salsberg. Noncitizen IMGs are gravitating toward the H1-B visa for foreign-born professionals for a duration of not more than six years instead of J-1, or exchange visitor visas.

A slightly higher percent of IMGs go into primary care. “International medical graduates have tended to go into the specialties that U.S. graduates were less interested in entering,” Salsberg notes. “They fill gaps because many are willing to go into some specialties in order to get into the U.S.”

Location, Location, Location

Entering residency, obtaining fellowships, and embarking on the practice of medicine all pose challenges for the foreign-born IMG. Throughout their residencies and into practice, IMGs can face biased perceptions from peers, attending physicians, and patients—especially if English has not been their primary language.

Rachel George, MD, regional medical director for Cogent Healthcare, is an international medical graduate, who received her medical degree from JJM Medical College in Kamataka, India. She observes that the challenges for IMGs and hospital medicine groups often depend on the predominant cultural mix of the surrounding community, as well as the hospital community culture.

For example, one program Dr. George oversees is situated within a culturally diverse community near Los Angeles. “Almost any international medical grad can go there, do very well, and be very comfortable, just because the rest of the community is very comfortable with international grads,” she says. However, the first employment for many IMGs here on J-1 visa waivers may be in medically underserved areas, which tend to be rural areas.

“When you go to those places, I think communication becomes much more of a challenge because people in the local area may not be used to interacting with people of different cultures with different accents,” Dr. George says. In some of those cases, Cogent has sent physicians to English classes to help improve communication skills.

Perception versus Reality

Dr. George notes that international medical graduates often face the perception that they are not as good as American graduates.

Much of this perception may be related to an IMG’s lack of English fluency, she says. But those familiar with the certification process for IMGs know they face multiple difficulties to attain the status of a practicing physician in this country.

“It might actually be harder for an international medical grad to be able to practice in this country,” notes Dr. George. “Your scores almost have to be twice as good as the scores of the American grad standing next to you to get into residency. Fellowships are also extremely difficult to obtain. Foreign medical grads have to jump through a lot more hoops to get into the system. And because of that, we actually probably have the cream of the crop here.”

For Salsberg, credentials count. “A graduate of an LCME [Liaison Committee for Medical Education]-accredited medical school provides a high degree of assurance to a residency program director that the physician has received a comprehensive, solid medical education,” Salsberg says. “This is not to suggest that foreign IMGs are not well prepared: Many of the IMGs that we’re getting now are really among the best and the brightest in the world.”

It might actually be harder for an international medical grad to be able to practice in this country. Your scores almost have to be twice as good as the scores of the American grad standing next to you to get into residency.

—Rachel George, MD, regional medical director for Cogent Healthcare

Issues that Surface

Program directors of ACGME-accredited residency programs rely on certification by the Educational Commission for Foreign Medical Graduates (ECGMG) to ensure that their prospective residents have met standards of eligibility.

ECGMG certification is also a prerequisite required by most states for licensure to practice medicine. Vijay Rajput, MD, associate professor of medicine and program director of Internal Medicine Residency at UMDNJ-Robert Wood Johnson Medical School in Camden, N.J., and senior hospitalist with Cooper Health System, acknowledges that depending upon their country of origin, IMGs may have difficulties becoming acculturated when it comes time to start practicing medicine. During his time as a residency program director, Dr. Rajput has encountered residents who have problems with hierarchical issues. “A resident may come from a part of the world where they do not like to take orders from women,” he says. “It will be difficult for them to work with peers who are women.”

Hospitalist directors need to exercise good judgment when hiring new members of their team, and ascertain the prospective candidate’s bedside skills with language, communication, and cultural competency, says Dr. Rajput. He believes that evaluation of residents’ interpersonal communications skills varies from program to program.

The “hard skills” pertaining to the resident’s breadth of medical knowledge and technological expertise are easily evaluated by in-service and board examinations, as well as procedures tests. However, the “soft skills” of communication, professionalism, and interpersonal skills are not as easily evaluated.

He suggests hospital program medical directors speak with program directors to glean important information about the candidates’ interpersonal skills, including areas where they might need improvement.

“I think the hospitalist director will have to recognize their own community and the cultural, language, and communication issues in their own hospital’s patient population and then acclimatize their younger hospitalists, providing specific training as part of CME,” Dr. Rajput advises. “The hospitalist director has to keep his or her eyes open and see whether their IMG might need extra training—whether it’s in cultural competencies or ethical principles—because even in our country there are different cultural issues in each community.”

Dr. Rajput, in collaboration with Gerry Whalen, MD, a former vice president at ECFMG, has conducted a pilot acculturation project for the past two years. It entails a one-day program for 40 to 50 IMG participants to acquaint them with challenges they will likely face. This “snapshot” provides an overview of Western medicine’s ethics, bedside skills, insurance issues, and peer-relationship issues.

Pave the Way

Experts suggest various ways leaders of hospital medicine groups can address perception and communication challenges when they surface.

IMGs can be encouraged, for instance, to open their dialogue when meeting patients for the first time by telling them they are welcome to ask questions if there are words or terms they do not understand. In addition, says Dr. George, IMGs can slow the pace of their conversation to be better understood.

Perhaps more important is how the hospital and the practice group introduce new members of the team to their communities. Dr. George advocates a hospital-wide announcement when a new physician joins the hospital medicine team. It’s important that the hospital clearly communicates to the hospital staff and the community at large that the IMG is a “well-trained physician, is highly regarded and respected, has good credentials, was chosen very carefully, and will be a great addition to the team.”

Communications consultant Douglas Leonard, PhD, advised Richard H. Bailey, MD, medical director of Inpatient Care and Hospitalist Services at Saint Clare’s Hospital in Wausau, Wis., to create a brochure to introduce new members of the hospitalist team. Dr. Bailey leads a team made up entirely of hospitalists who are foreign-born IMGs. He had received complaints about his hospitalists’ English skills from other specialists at the hospital and hired Dr. Leonard to perform a needs assessment of his team and other staff members with whom they interface.

Dr. Leonard found that nursing staff, because they liked the hospitalists and wanted to help them, had begun to act as interpreters between physicians and patients.

“Because these hospitalists had such good attitudes, the staff had learned to understand their accents and had really made an effort to work with these doctors effectively,” Dr. Leonard reports. Part of that effort was that nurses would often step in to interpret for the hospitalists when patients could not understand their accents.

Dr. Leonard recommended that the hospitalists become better communicators with patients—even if that means softening their accents—and that they avoid reliance on nurses interpreting with their patients. The latter, says Dr. Leonard, “makes the hospitalists seem like second-class citizens in the world of doctoring.” Although the nurses were happy to provide the service, he says “the hospitalists have got to establish their own ability to communicate with their patients.”

In a case like this, the medical director can work with hospital administration to provide language training. Dr. Bailey has been exploring the possibility of working with local outside resources, including a local technical college, for this service.

The technical college is willing to schedule classes at night or when the hospitalists overlap on changing shifts. In addition, “Classes might alternate with on-site, one-to-one coaching sessions in speaking skills,” says Dr. Leonard.

Two-Way Street

IMGs will continue to be a valuable resource and an increasing presence in hospitalist programs. The challenge for hospital medicine group leaders is to ensure that their talents are nurtured and respected.

Dr. Bailey sees his job as that of champion and advocate for his team. For one member of his team, he solicited involvement from his congressman to help resolve complications with visa and immigration issues.

He has also seen tensions erupt when his hospitalists interact with other physicians or patients who have misperceptions about their medical skills. “I’d put my physicians up against anybody—they just don’t speak as well,” he says.

There are times when Dr. Bailey becomes concerned about the welfare of his team. “My job as medical director is to create an environment in which they can be successful—and that’s a two-way street,” he says. “That means I have to help them to be able to communicate, but it also means that I have to back them up when their professional competency is being questioned by preconceived notions about their language and their accents.”

Dr. Rajput underscores this message. “Acculturation is a two-way street,” he agrees. “As international doctors get acculturated, we as a society also need to adjust and help these well-trained physicians to understand us as well. In the interests of providing the best possible patient care, education and training will be needed for both sets of stakeholders [the IMG physicians and their employers].” TH

Gretchen Henkel is a frequent contributor to The Hospitalist.

References

1. Hart LG, Skillman SM, Fordyce M, et al. International medical graduate physicians in the United States: changes since 1981. Health Aff. 2007 July/August;26(4):1159-1169.
2. Association of American Medical Colleges. Help wanted: more U.S. doctors. Available online at www.aamc.org/workforce/helpwanted.pdf. Last accessed Sept. 11, 2007.

In this first of a two-part series, we examine the implications of international medical graduates (IMGs) in hospital medicine groups, and explore how hospitalist group leaders can improve communications and integrate them into their medicine teams. Part 2 will feature stories from hospitalist IMGs as they establish themselves as professionals in their communities.

International medical graduates (IMGs) comprise 25% of the total U.S. physician workforce.1 Despite post-9/11 barriers to immigration, the number of IMGs entering internal medical residencies has risen in recent years.

In 2006, more than 6,500 physicians who graduated medical school in foreign countries entered accredited residency programs, according to the Association of American Medical Colleges. U.S.-born residents who have attended medical school in another country account for approximately 25% of the total IMGs in training.

Further, the proportion of foreign-educated residents who will go into primary care is higher than for U.S. medical graduates. In 2006, 50% of the physicians training in internal medicine residency programs were IMGs.

What do these trends mean for hospital medicine? In light of projected physician shortages IMGs will continue to be a vital part of the physician workforce.2 Because internal medicine is a primary feeder of hospital medicine, it’s likely many hospital medicine programs will also continue to see an increase in hospitalists who are IMGs.

Hoops, Hurdles, and Visas

Entry of foreign-born IMGs to the United States is governed by the Immigration and Nationality Act, administered by the U.S. Immigration and Naturalization Service.

The J-1 visa was set up as an educational exchange program and carries with it a requirement that the graduate return to his or her native country upon completion of residency. However, a waiver of the requirement to return to their country of origin can be obtained if the physicians agree to begin practice in a Health Professional Shortage Area.

These service areas are determined using a scoring system based on four variables: the ratio of primary medical care physicians per 1,000 population, infant mortality rates, percentage of the population with incomes below the federal poverty level, and percentage of the population over 65. The vast majority of J-1 waivers are administered through “Conrad 30” programs administered by individual states and the District of Columbia.

In recent years, AAMC’s Center for Workforce Studies has observed a shift to the H1-B, or temporary worker visa, allowing hospitals and group practices to hire IMGs in areas where there are physician shortages. This visa is employer-specific, and some hospitalist programs have become involved in helping their applicants secure this visa.

Visa issues present a range of financial, legal and personal hurdles for the IMG. In addition to obtaining legal entry into the country, IMGs applying to U.S. residency programs must obtain ECGMG certification, a multistep process that includes:

• Graduating from a medical school listed in the World Directory of Medical Schools;
• Obtaining a license to practice medicine within their own country;
• Passing the medical science examination (Step 1 and 2 of the United States Medical Licensing Examination);
• Passing the ECFMG English test or Test of English as a Foreign Language; and
• Passing the Clinical Skills Assessment component of the USMLE.

An IMG can apply for lawful permanent resident status based on a job offer, provided that he or she has passed parts 1 and 2 of the National Board of Medical Examiners examination, and has fulfilled the other ECFMG certification requirements.

For more information, visit the Web sites of the Accreditation Council for Graduate Medical Education (www.acgme.org) and the Educational Commission for Foreign Medical Graduates (www.ecfmg.org).—GH

Image - © POWERED BY LIGHT/ALAN SPENCER / ALAMY

What the Trends Show

“International medical school graduates have been and continue to be a major source of physicians in the U.S.,” says Edward Salsberg, director, Center for Workforce Studies at the Association of American Medical Colleges.

According to a survey this year in Health Affairs of IMG trends since 1981, most IMGs working in the United States come from India, the Philippines, Mexico, Pakistan, China, and the Republic of Korea. When starting full-time employment, most IMGs tend to gravitate to the East Coast, the Midwest (particularly Illinois, Ohio, and Michigan), and California.

Although the overall percentage of IMGs in the United States has remained about the same, more U.S. citizens graduate from medical schools outside this country, according to Salsberg. Noncitizen IMGs are gravitating toward the H1-B visa for foreign-born professionals for a duration of not more than six years instead of J-1, or exchange visitor visas.

A slightly higher percent of IMGs go into primary care. “International medical graduates have tended to go into the specialties that U.S. graduates were less interested in entering,” Salsberg notes. “They fill gaps because many are willing to go into some specialties in order to get into the U.S.”

Location, Location, Location

Entering residency, obtaining fellowships, and embarking on the practice of medicine all pose challenges for the foreign-born IMG. Throughout their residencies and into practice, IMGs can face biased perceptions from peers, attending physicians, and patients—especially if English has not been their primary language.

Rachel George, MD, regional medical director for Cogent Healthcare, is an international medical graduate, who received her medical degree from JJM Medical College in Kamataka, India. She observes that the challenges for IMGs and hospital medicine groups often depend on the predominant cultural mix of the surrounding community, as well as the hospital community culture.

For example, one program Dr. George oversees is situated within a culturally diverse community near Los Angeles. “Almost any international medical grad can go there, do very well, and be very comfortable, just because the rest of the community is very comfortable with international grads,” she says. However, the first employment for many IMGs here on J-1 visa waivers may be in medically underserved areas, which tend to be rural areas.

“When you go to those places, I think communication becomes much more of a challenge because people in the local area may not be used to interacting with people of different cultures with different accents,” Dr. George says. In some of those cases, Cogent has sent physicians to English classes to help improve communication skills.

Perception versus Reality

Dr. George notes that international medical graduates often face the perception that they are not as good as American graduates.

Much of this perception may be related to an IMG’s lack of English fluency, she says. But those familiar with the certification process for IMGs know they face multiple difficulties to attain the status of a practicing physician in this country.

“It might actually be harder for an international medical grad to be able to practice in this country,” notes Dr. George. “Your scores almost have to be twice as good as the scores of the American grad standing next to you to get into residency. Fellowships are also extremely difficult to obtain. Foreign medical grads have to jump through a lot more hoops to get into the system. And because of that, we actually probably have the cream of the crop here.”

For Salsberg, credentials count. “A graduate of an LCME [Liaison Committee for Medical Education]-accredited medical school provides a high degree of assurance to a residency program director that the physician has received a comprehensive, solid medical education,” Salsberg says. “This is not to suggest that foreign IMGs are not well prepared: Many of the IMGs that we’re getting now are really among the best and the brightest in the world.”

It might actually be harder for an international medical grad to be able to practice in this country. Your scores almost have to be twice as good as the scores of the American grad standing next to you to get into residency.

—Rachel George, MD, regional medical director for Cogent Healthcare

Issues that Surface

Program directors of ACGME-accredited residency programs rely on certification by the Educational Commission for Foreign Medical Graduates (ECGMG) to ensure that their prospective residents have met standards of eligibility.

ECGMG certification is also a prerequisite required by most states for licensure to practice medicine. Vijay Rajput, MD, associate professor of medicine and program director of Internal Medicine Residency at UMDNJ-Robert Wood Johnson Medical School in Camden, N.J., and senior hospitalist with Cooper Health System, acknowledges that depending upon their country of origin, IMGs may have difficulties becoming acculturated when it comes time to start practicing medicine. During his time as a residency program director, Dr. Rajput has encountered residents who have problems with hierarchical issues. “A resident may come from a part of the world where they do not like to take orders from women,” he says. “It will be difficult for them to work with peers who are women.”

Hospitalist directors need to exercise good judgment when hiring new members of their team, and ascertain the prospective candidate’s bedside skills with language, communication, and cultural competency, says Dr. Rajput. He believes that evaluation of residents’ interpersonal communications skills varies from program to program.

The “hard skills” pertaining to the resident’s breadth of medical knowledge and technological expertise are easily evaluated by in-service and board examinations, as well as procedures tests. However, the “soft skills” of communication, professionalism, and interpersonal skills are not as easily evaluated.

He suggests hospital program medical directors speak with program directors to glean important information about the candidates’ interpersonal skills, including areas where they might need improvement.

“I think the hospitalist director will have to recognize their own community and the cultural, language, and communication issues in their own hospital’s patient population and then acclimatize their younger hospitalists, providing specific training as part of CME,” Dr. Rajput advises. “The hospitalist director has to keep his or her eyes open and see whether their IMG might need extra training—whether it’s in cultural competencies or ethical principles—because even in our country there are different cultural issues in each community.”

Dr. Rajput, in collaboration with Gerry Whalen, MD, a former vice president at ECFMG, has conducted a pilot acculturation project for the past two years. It entails a one-day program for 40 to 50 IMG participants to acquaint them with challenges they will likely face. This “snapshot” provides an overview of Western medicine’s ethics, bedside skills, insurance issues, and peer-relationship issues.

Pave the Way

Experts suggest various ways leaders of hospital medicine groups can address perception and communication challenges when they surface.

IMGs can be encouraged, for instance, to open their dialogue when meeting patients for the first time by telling them they are welcome to ask questions if there are words or terms they do not understand. In addition, says Dr. George, IMGs can slow the pace of their conversation to be better understood.

Perhaps more important is how the hospital and the practice group introduce new members of the team to their communities. Dr. George advocates a hospital-wide announcement when a new physician joins the hospital medicine team. It’s important that the hospital clearly communicates to the hospital staff and the community at large that the IMG is a “well-trained physician, is highly regarded and respected, has good credentials, was chosen very carefully, and will be a great addition to the team.”

Communications consultant Douglas Leonard, PhD, advised Richard H. Bailey, MD, medical director of Inpatient Care and Hospitalist Services at Saint Clare’s Hospital in Wausau, Wis., to create a brochure to introduce new members of the hospitalist team. Dr. Bailey leads a team made up entirely of hospitalists who are foreign-born IMGs. He had received complaints about his hospitalists’ English skills from other specialists at the hospital and hired Dr. Leonard to perform a needs assessment of his team and other staff members with whom they interface.

Dr. Leonard found that nursing staff, because they liked the hospitalists and wanted to help them, had begun to act as interpreters between physicians and patients.

“Because these hospitalists had such good attitudes, the staff had learned to understand their accents and had really made an effort to work with these doctors effectively,” Dr. Leonard reports. Part of that effort was that nurses would often step in to interpret for the hospitalists when patients could not understand their accents.

Dr. Leonard recommended that the hospitalists become better communicators with patients—even if that means softening their accents—and that they avoid reliance on nurses interpreting with their patients. The latter, says Dr. Leonard, “makes the hospitalists seem like second-class citizens in the world of doctoring.” Although the nurses were happy to provide the service, he says “the hospitalists have got to establish their own ability to communicate with their patients.”

In a case like this, the medical director can work with hospital administration to provide language training. Dr. Bailey has been exploring the possibility of working with local outside resources, including a local technical college, for this service.

The technical college is willing to schedule classes at night or when the hospitalists overlap on changing shifts. In addition, “Classes might alternate with on-site, one-to-one coaching sessions in speaking skills,” says Dr. Leonard.

Two-Way Street

IMGs will continue to be a valuable resource and an increasing presence in hospitalist programs. The challenge for hospital medicine group leaders is to ensure that their talents are nurtured and respected.

Dr. Bailey sees his job as that of champion and advocate for his team. For one member of his team, he solicited involvement from his congressman to help resolve complications with visa and immigration issues.

He has also seen tensions erupt when his hospitalists interact with other physicians or patients who have misperceptions about their medical skills. “I’d put my physicians up against anybody—they just don’t speak as well,” he says.

There are times when Dr. Bailey becomes concerned about the welfare of his team. “My job as medical director is to create an environment in which they can be successful—and that’s a two-way street,” he says. “That means I have to help them to be able to communicate, but it also means that I have to back them up when their professional competency is being questioned by preconceived notions about their language and their accents.”

Dr. Rajput underscores this message. “Acculturation is a two-way street,” he agrees. “As international doctors get acculturated, we as a society also need to adjust and help these well-trained physicians to understand us as well. In the interests of providing the best possible patient care, education and training will be needed for both sets of stakeholders [the IMG physicians and their employers].” TH

Gretchen Henkel is a frequent contributor to The Hospitalist.

References

1. Hart LG, Skillman SM, Fordyce M, et al. International medical graduate physicians in the United States: changes since 1981. Health Aff. 2007 July/August;26(4):1159-1169.
2. Association of American Medical Colleges. Help wanted: more U.S. doctors. Available online at www.aamc.org/workforce/helpwanted.pdf. Last accessed Sept. 11, 2007.

As the field of hospital medicine grows, some hospitalists are gravitating toward subspecialty services. In recent years we’ve witnessed a proliferation of ‘ists’: There are now surgicalists, laborists, psychiatric hospitalists—even hepa-hospitalists.

The numbers of “hyphenate hospitalists” are not tracked by SHM, but the subspecialization trend highlights raises questions about hospital medicine’s evolution. Among the issues:

• What does this growth of hospitalist subspecialists foreshadow about the strength of the hospitalist movement?
• Does subspecialization always convey positive changes for the hospitalist?
• Do physicians risk trade-offs when their hospital medicine practices are rooted solely in one subspecialty?
• What about retaining the opportunity to see and treat a variety of patients and conditions—presumably one of the initial attractions of a career in internal medicine and family medicine?

The founder of hospital medicine, a noted pediatric hospitalist, the chair of the SHM’s membership committee, and a former hepa-hospitalist recently shared their experiences and views on these issues.

Success Spreads

Hospital medicine pioneer Robert M. Wachter, MD, has observed at his and other hospitals the increasing dependence on hospitalists’ services.

“Hospitalists have traditionally done more than just take care of medical patients,” says Dr. Wachter, professor and chief of the division of hospital medicine, associate chairman, department of medicine, chief of the medical service at the University of California San Francisco (UCSF), and author of the upcoming blog “Wachter’s World.” “They’ve always done medical consultations and helped to take care of sick patients with surgical, gynecological, and psychiatric issues.” But now, he says, “The demand for hospitalist services is almost limitless.”

At UCSF, he reports, hospitalists now manage the medical problems of patients on the complex heart failure service, the bone marrow transplant service, and the neurosurgical and orthopedic services. Dr. Wachter views the trend of using hospitalists in a variety of subspecialty services as “one of the most exciting developments for the field—it is taking the field to a whole new level of importance and growth.” That’s because it signals recognition that the concept of hospital medicine has value “for virtually every patient sick enough to be in the building,” he says.

Ambiguity of Terms

Not only are hospitalists increasingly present in subspecialty services, but some specialist services are reorganizing according to the hospitalist model. This may create complexities regarding hospital medicine’s core identity, according to Dr. Wachter.

For instance, at UCSF, there are generalist surgeons who have organized a hospitalist service, providing on-call responsiveness, triage for specialized surgical problems, and a breadth of care and coordination typical of the hospital medicine model. Separately, there are also internal medicine hospitalists who serve on the surgery service. “I think there is going to be some ambiguity about roles until we clean up the language,” remarks Dr. Wachter. For instance: “Is the hospitalist on the surgery service still a generalist who takes on the role of subspecialist by caring for a more specialized population? And, what do you call the specialist surgeon who takes on a more hospitalist role?”

Shaun Frost, MD, FACP, chair of SHM’s Membership Committee and regional medical director for Cogent Healthcare in St. Paul, Minn., considers whether the inclusion of various subspecialists fits with the SHM’s definition of hospitalists. “If you’re looking strictly at ‘definition,’ SHM considers a hospitalist to be a physician whose primary professional focus is the general medical care of hospitalized patients,” he says. “As hospitalist subspecialists are likely engaging in the management of hypertension, diabetes, chronic lung and cardiac disease, etc., I see no reason to believe that they would not fit the definition of a hospitalist.”

Best Use of Skills?

Although Drs. Wachter and Frost see inclusion of hospitalists on subspecialty services as a positive trend, others warn that hospitalists should be wary about the reasons for their enlistment.

Lauren M. Friedly, MD, a hospitalist at Marin General Hospital in Greenbrae, Calif., believes subspecialty hospitalist jobs are “ultimately untenable for solid, well-trained, dedicated hospitalists.” She developed this view after a frustrating two years on a liver transplant service—where she found she “wasn’t able to practice medicine in a way that was comfortable.”

Dr. Friedly explains that she chose to be a hospitalist because of her experience as a medical student at UCSF and as a resident at California Pacific Medical Center—watching and learning from the originators of the movement, such as Dr. Wachter and Masa Yukimoto, MD, former chief resident. All the reasons she chose hospital medicine—the pace, acuity of patients, ability to revisit patients and ruminate about their problems, and the opportunity to improve the quality of a patient’s in-hospital care by adhering to a “first do no harm” philosophy—were stymied when she became a hepa-hospitalist.

“The problems that can potentially exist in any subspecialty hospitalist group are magnified a hundredfold in a liver transplant program,” she explains. “There were philosophical differences in our approach to medical care of inpatients, and the hospitalists were, in some ways, considered the bottom of the food chain.

“Because of our position relative to the hepatologists and transplant surgeons, we were not provided the autonomy nor the resources with which to accomplish any of these things. For example, decreasing length of stay by discharging patients efficiently, which to a well-trained hospitalist may mean less risk of exposure to nosocomial infections and iatrogenic complications, was not necessarily valued by the transplant surgeons and hepatologists. Less is often more for a well-trained hospitalist, but this sentiment is in direct conflict with the maximalist approach used in transplant medicine.”

Satisfying in the Long Run?

Perhaps the most important question about subspecialization for the hospitalist is whether joining a subspecialist service is a good fit. Dr. Frost believes it’s important to consider whether a career in a subspecialty service would be satisfying in the long run. “For many of us,” he explains, “one main reason we chose to pursue careers in general internal medicine, general pediatrics, or family practice is that we enjoy variety. Personally, for example, I know that I would quickly become bored with solely focusing on one organ system or one special patient population. Therefore, I believe that there is probably a limited group of folks who would enjoy exclusively restricting the scope of their hospital medicine practice to a specific subspecialty area.”

Still, Dr. Friedly admits she will miss the challenges of dealing with complex pathology. On the liver transplant service, for instance, she cared for patients with complex gastrointestinal issues, including cancers. But, due to her time on that specialized service, she now finds herself having to refresh her more general internal medicine skills.

The Pediatrics Picture

The hospitalist model is increasingly common in pediatrics, where costs per patient and length of stay have been lowered when using the hospital medicine model to restructure academic pediatric inpatient services, and hospitalists have contributed to improved survival in pediatric intensive care units.1-2

In part because of lower patient volumes on pediatric hospitalist services, the trend toward subspecialization is not as evident in pediatric hospital medicine as it is in adult hospital medicine, according to Sanford M. Melzer, MD, senior vice president of strategic planning and business development at Seattle Children’s Hospital and Regional Medical Center, and a member of the American Academy of Pediatrics’ Committee for Hospital Care. However, with shortages of physicians in key specialty areas, that may be changing.

Dr. Melzer, who has been a clinical pediatric hospitalist for 20 years and has published research on the financial aspects of pediatric hospitalist programs, reports that his service is beginning to field requests for hospitalists from specialty programs to provide staffing—just as adult hospital medicine programs have noticed.3 For example, the oncology service at Seattle Children’s Hospital has started to explore using pediatric hospitalists to help manage its pediatric cancer unit, which treats 225 new diagnoses of childhood cancer annually.

In part because oncology treatment at Seattle Children’s tends to be “heavily protocolized,” Dr. Melzer believes pediatric hospitalists can provide quality inpatient care as inpatient generalists, in terms of palliative care and symptom management, if included on that service.

The other area in which pediatric hospitalists may provide “specialty” care is in neonatology, where shortages of specialists or costs of coverage result in hospitalists covering the delivery room or the neonatal intensive care unit (NICU).

Pediatric hospitalists, as generalists, typically provide care for many different types of illnesses and conditions. “This is one of the attractive features of the job for pediatricians choosing this career track,” Dr. Melzer says. “An increasing degree of specialization may make these positions somewhat less interesting, and may highlight discrepancies between hospitalist and specialist salaries.” On the other hand, he says, “Continued shortages in specialty areas in pediatrics will continue to drive the trends toward increased deployment of generalists in these services.”

One model employed in children’s hospitals is to utilize more physician extenders, such as nurse practitioners and physician assistants, to provide the needed coverage. How pediatric hospitalists will fit into this evolving care model is not clear, notes Dr. Melzer.

Future Configurations

To avoid the possible pitfalls hospitalists can encounter with subspecialist services will require innovative solutions, Dr. Friedly believes.

“Ultimately, I think the only way that it will be sustainable [as a long-term career choice] for any individual hospitalist to take a position within a subspecialty program will be to help create or to be part of the initial vision,” Dr. Friedly says. “Or, an already-established hospitalist group could approach the subspecialist and ask, ‘How can we help you deliver the highest quality standard of care to your patients while they’re here in the hospital?’ ”

As of July 1, the UCSF neurosurgery service has embraced the addition of core internal medicine hospitalists who help to manage the medical problems of the [typical census of] 60 neurosurgery patients. So far, Dr. Wachter reports, the hospitalists are enjoying their stint on the neurosurgery service. “They’re learning a lot because these patients have very unusual and specialized problems,’’ he says. “It only took three minutes for them to realize that they were making a difference because some of the patients are very sick and have many medical problems. The surgeons don’t focus on or keep up with medical management, and even if they did, they are in the OR all day long.”

Rotating hospitalists to specialty and subspecialty services for 25% of their time in the hospital, as the UCSF Neurosurgery hospitalists do, might be one way to preserve the traditional general medical model to which many internal medicine hospitalists still gravitate. “This could be an interesting, specialized niche practice, but would not be the bulk of what they do,” says Dr. Wachter.

Dr. Frost agrees that the key to addressing the challenge of subspecialization lies in building this type of work into the context of a larger hospital medicine program. “Rotating all members of a hospital medicine group through a subspecialty experience for a portion of their overall time may be the way to go,” he notes.

Dr. Friedly cautions that certain subspecialist services, such as liver transplant, may not embrace the multidisciplinary hospital medicine model, so it remains to be seen if the effort can evolve to be truly collaborative. Her advice to younger residents just entering hospital medicine? “Hospitalist medicine has unlimited possibilities as a career choice, especially if you enjoyed being an internal medicine resident. Be careful, however, to avoid a setting where you risk losing your hard-earned skills while also being treated like a ‘perma-resident.’ Starting out in a more traditional hospitalist program to learn solid hospitalist ‘tricks of the trade,’ then transitioning to a subspecialty program where you can offer your skills, rather than the other way around, may be the more sustainable, long-term option.” TH

Gretchen Henkel is a frequent contributor to The Hospitalist.

References

1. Ogershok PR, Li X, Palmer HC, et al. Restructuring an academic pediatric inpatient service using concepts developed by hospitalists.” Clin Pediatr. 2001 Dec.;40(12): 653-660.
2. Tenner PA, Dibrell H, Taylor RP. Improved survival with hospitalists in a pediatric intensive care unit.” Crit Care Med. 2003 Mar;31(3):847-852.
3. Melzer SM, Molteni, RA, Marcuse EK, et al. Characteristics and financial performance of a pediatric faculty inpatient attending service: a resource-based relative value scale analysis. Pediatrics. 2001 Jul;108(1);79-84.

As the field of hospital medicine grows, some hospitalists are gravitating toward subspecialty services. In recent years we’ve witnessed a proliferation of ‘ists’: There are now surgicalists, laborists, psychiatric hospitalists—even hepa-hospitalists.

The numbers of “hyphenate hospitalists” are not tracked by SHM, but the subspecialization trend highlights raises questions about hospital medicine’s evolution. Among the issues:

• What does this growth of hospitalist subspecialists foreshadow about the strength of the hospitalist movement?
• Does subspecialization always convey positive changes for the hospitalist?
• Do physicians risk trade-offs when their hospital medicine practices are rooted solely in one subspecialty?
• What about retaining the opportunity to see and treat a variety of patients and conditions—presumably one of the initial attractions of a career in internal medicine and family medicine?

The founder of hospital medicine, a noted pediatric hospitalist, the chair of the SHM’s membership committee, and a former hepa-hospitalist recently shared their experiences and views on these issues.

Success Spreads

Hospital medicine pioneer Robert M. Wachter, MD, has observed at his and other hospitals the increasing dependence on hospitalists’ services.

“Hospitalists have traditionally done more than just take care of medical patients,” says Dr. Wachter, professor and chief of the division of hospital medicine, associate chairman, department of medicine, chief of the medical service at the University of California San Francisco (UCSF), and author of the upcoming blog “Wachter’s World.” “They’ve always done medical consultations and helped to take care of sick patients with surgical, gynecological, and psychiatric issues.” But now, he says, “The demand for hospitalist services is almost limitless.”

At UCSF, he reports, hospitalists now manage the medical problems of patients on the complex heart failure service, the bone marrow transplant service, and the neurosurgical and orthopedic services. Dr. Wachter views the trend of using hospitalists in a variety of subspecialty services as “one of the most exciting developments for the field—it is taking the field to a whole new level of importance and growth.” That’s because it signals recognition that the concept of hospital medicine has value “for virtually every patient sick enough to be in the building,” he says.

Ambiguity of Terms

Not only are hospitalists increasingly present in subspecialty services, but some specialist services are reorganizing according to the hospitalist model. This may create complexities regarding hospital medicine’s core identity, according to Dr. Wachter.

For instance, at UCSF, there are generalist surgeons who have organized a hospitalist service, providing on-call responsiveness, triage for specialized surgical problems, and a breadth of care and coordination typical of the hospital medicine model. Separately, there are also internal medicine hospitalists who serve on the surgery service. “I think there is going to be some ambiguity about roles until we clean up the language,” remarks Dr. Wachter. For instance: “Is the hospitalist on the surgery service still a generalist who takes on the role of subspecialist by caring for a more specialized population? And, what do you call the specialist surgeon who takes on a more hospitalist role?”

Shaun Frost, MD, FACP, chair of SHM’s Membership Committee and regional medical director for Cogent Healthcare in St. Paul, Minn., considers whether the inclusion of various subspecialists fits with the SHM’s definition of hospitalists. “If you’re looking strictly at ‘definition,’ SHM considers a hospitalist to be a physician whose primary professional focus is the general medical care of hospitalized patients,” he says. “As hospitalist subspecialists are likely engaging in the management of hypertension, diabetes, chronic lung and cardiac disease, etc., I see no reason to believe that they would not fit the definition of a hospitalist.”

Best Use of Skills?

Although Drs. Wachter and Frost see inclusion of hospitalists on subspecialty services as a positive trend, others warn that hospitalists should be wary about the reasons for their enlistment.

Lauren M. Friedly, MD, a hospitalist at Marin General Hospital in Greenbrae, Calif., believes subspecialty hospitalist jobs are “ultimately untenable for solid, well-trained, dedicated hospitalists.” She developed this view after a frustrating two years on a liver transplant service—where she found she “wasn’t able to practice medicine in a way that was comfortable.”

Dr. Friedly explains that she chose to be a hospitalist because of her experience as a medical student at UCSF and as a resident at California Pacific Medical Center—watching and learning from the originators of the movement, such as Dr. Wachter and Masa Yukimoto, MD, former chief resident. All the reasons she chose hospital medicine—the pace, acuity of patients, ability to revisit patients and ruminate about their problems, and the opportunity to improve the quality of a patient’s in-hospital care by adhering to a “first do no harm” philosophy—were stymied when she became a hepa-hospitalist.

“The problems that can potentially exist in any subspecialty hospitalist group are magnified a hundredfold in a liver transplant program,” she explains. “There were philosophical differences in our approach to medical care of inpatients, and the hospitalists were, in some ways, considered the bottom of the food chain.

“Because of our position relative to the hepatologists and transplant surgeons, we were not provided the autonomy nor the resources with which to accomplish any of these things. For example, decreasing length of stay by discharging patients efficiently, which to a well-trained hospitalist may mean less risk of exposure to nosocomial infections and iatrogenic complications, was not necessarily valued by the transplant surgeons and hepatologists. Less is often more for a well-trained hospitalist, but this sentiment is in direct conflict with the maximalist approach used in transplant medicine.”

Satisfying in the Long Run?

Perhaps the most important question about subspecialization for the hospitalist is whether joining a subspecialist service is a good fit. Dr. Frost believes it’s important to consider whether a career in a subspecialty service would be satisfying in the long run. “For many of us,” he explains, “one main reason we chose to pursue careers in general internal medicine, general pediatrics, or family practice is that we enjoy variety. Personally, for example, I know that I would quickly become bored with solely focusing on one organ system or one special patient population. Therefore, I believe that there is probably a limited group of folks who would enjoy exclusively restricting the scope of their hospital medicine practice to a specific subspecialty area.”

Still, Dr. Friedly admits she will miss the challenges of dealing with complex pathology. On the liver transplant service, for instance, she cared for patients with complex gastrointestinal issues, including cancers. But, due to her time on that specialized service, she now finds herself having to refresh her more general internal medicine skills.

The Pediatrics Picture

The hospitalist model is increasingly common in pediatrics, where costs per patient and length of stay have been lowered when using the hospital medicine model to restructure academic pediatric inpatient services, and hospitalists have contributed to improved survival in pediatric intensive care units.1-2

In part because of lower patient volumes on pediatric hospitalist services, the trend toward subspecialization is not as evident in pediatric hospital medicine as it is in adult hospital medicine, according to Sanford M. Melzer, MD, senior vice president of strategic planning and business development at Seattle Children’s Hospital and Regional Medical Center, and a member of the American Academy of Pediatrics’ Committee for Hospital Care. However, with shortages of physicians in key specialty areas, that may be changing.

Dr. Melzer, who has been a clinical pediatric hospitalist for 20 years and has published research on the financial aspects of pediatric hospitalist programs, reports that his service is beginning to field requests for hospitalists from specialty programs to provide staffing—just as adult hospital medicine programs have noticed.3 For example, the oncology service at Seattle Children’s Hospital has started to explore using pediatric hospitalists to help manage its pediatric cancer unit, which treats 225 new diagnoses of childhood cancer annually.

In part because oncology treatment at Seattle Children’s tends to be “heavily protocolized,” Dr. Melzer believes pediatric hospitalists can provide quality inpatient care as inpatient generalists, in terms of palliative care and symptom management, if included on that service.

The other area in which pediatric hospitalists may provide “specialty” care is in neonatology, where shortages of specialists or costs of coverage result in hospitalists covering the delivery room or the neonatal intensive care unit (NICU).

Pediatric hospitalists, as generalists, typically provide care for many different types of illnesses and conditions. “This is one of the attractive features of the job for pediatricians choosing this career track,” Dr. Melzer says. “An increasing degree of specialization may make these positions somewhat less interesting, and may highlight discrepancies between hospitalist and specialist salaries.” On the other hand, he says, “Continued shortages in specialty areas in pediatrics will continue to drive the trends toward increased deployment of generalists in these services.”

One model employed in children’s hospitals is to utilize more physician extenders, such as nurse practitioners and physician assistants, to provide the needed coverage. How pediatric hospitalists will fit into this evolving care model is not clear, notes Dr. Melzer.

Future Configurations

To avoid the possible pitfalls hospitalists can encounter with subspecialist services will require innovative solutions, Dr. Friedly believes.

“Ultimately, I think the only way that it will be sustainable [as a long-term career choice] for any individual hospitalist to take a position within a subspecialty program will be to help create or to be part of the initial vision,” Dr. Friedly says. “Or, an already-established hospitalist group could approach the subspecialist and ask, ‘How can we help you deliver the highest quality standard of care to your patients while they’re here in the hospital?’ ”

As of July 1, the UCSF neurosurgery service has embraced the addition of core internal medicine hospitalists who help to manage the medical problems of the [typical census of] 60 neurosurgery patients. So far, Dr. Wachter reports, the hospitalists are enjoying their stint on the neurosurgery service. “They’re learning a lot because these patients have very unusual and specialized problems,’’ he says. “It only took three minutes for them to realize that they were making a difference because some of the patients are very sick and have many medical problems. The surgeons don’t focus on or keep up with medical management, and even if they did, they are in the OR all day long.”

Rotating hospitalists to specialty and subspecialty services for 25% of their time in the hospital, as the UCSF Neurosurgery hospitalists do, might be one way to preserve the traditional general medical model to which many internal medicine hospitalists still gravitate. “This could be an interesting, specialized niche practice, but would not be the bulk of what they do,” says Dr. Wachter.

Dr. Frost agrees that the key to addressing the challenge of subspecialization lies in building this type of work into the context of a larger hospital medicine program. “Rotating all members of a hospital medicine group through a subspecialty experience for a portion of their overall time may be the way to go,” he notes.

Dr. Friedly cautions that certain subspecialist services, such as liver transplant, may not embrace the multidisciplinary hospital medicine model, so it remains to be seen if the effort can evolve to be truly collaborative. Her advice to younger residents just entering hospital medicine? “Hospitalist medicine has unlimited possibilities as a career choice, especially if you enjoyed being an internal medicine resident. Be careful, however, to avoid a setting where you risk losing your hard-earned skills while also being treated like a ‘perma-resident.’ Starting out in a more traditional hospitalist program to learn solid hospitalist ‘tricks of the trade,’ then transitioning to a subspecialty program where you can offer your skills, rather than the other way around, may be the more sustainable, long-term option.” TH

Gretchen Henkel is a frequent contributor to The Hospitalist.

References

1. Ogershok PR, Li X, Palmer HC, et al. Restructuring an academic pediatric inpatient service using concepts developed by hospitalists.” Clin Pediatr. 2001 Dec.;40(12): 653-660.
2. Tenner PA, Dibrell H, Taylor RP. Improved survival with hospitalists in a pediatric intensive care unit.” Crit Care Med. 2003 Mar;31(3):847-852.
3. Melzer SM, Molteni, RA, Marcuse EK, et al. Characteristics and financial performance of a pediatric faculty inpatient attending service: a resource-based relative value scale analysis. Pediatrics. 2001 Jul;108(1);79-84.

As the field of hospital medicine grows, some hospitalists are gravitating toward subspecialty services. In recent years we’ve witnessed a proliferation of ‘ists’: There are now surgicalists, laborists, psychiatric hospitalists—even hepa-hospitalists.

The numbers of “hyphenate hospitalists” are not tracked by SHM, but the subspecialization trend highlights raises questions about hospital medicine’s evolution. Among the issues:

• What does this growth of hospitalist subspecialists foreshadow about the strength of the hospitalist movement?
• Does subspecialization always convey positive changes for the hospitalist?
• Do physicians risk trade-offs when their hospital medicine practices are rooted solely in one subspecialty?
• What about retaining the opportunity to see and treat a variety of patients and conditions—presumably one of the initial attractions of a career in internal medicine and family medicine?

The founder of hospital medicine, a noted pediatric hospitalist, the chair of the SHM’s membership committee, and a former hepa-hospitalist recently shared their experiences and views on these issues.

Success Spreads

Hospital medicine pioneer Robert M. Wachter, MD, has observed at his and other hospitals the increasing dependence on hospitalists’ services.

“Hospitalists have traditionally done more than just take care of medical patients,” says Dr. Wachter, professor and chief of the division of hospital medicine, associate chairman, department of medicine, chief of the medical service at the University of California San Francisco (UCSF), and author of the upcoming blog “Wachter’s World.” “They’ve always done medical consultations and helped to take care of sick patients with surgical, gynecological, and psychiatric issues.” But now, he says, “The demand for hospitalist services is almost limitless.”

At UCSF, he reports, hospitalists now manage the medical problems of patients on the complex heart failure service, the bone marrow transplant service, and the neurosurgical and orthopedic services. Dr. Wachter views the trend of using hospitalists in a variety of subspecialty services as “one of the most exciting developments for the field—it is taking the field to a whole new level of importance and growth.” That’s because it signals recognition that the concept of hospital medicine has value “for virtually every patient sick enough to be in the building,” he says.

Ambiguity of Terms

Not only are hospitalists increasingly present in subspecialty services, but some specialist services are reorganizing according to the hospitalist model. This may create complexities regarding hospital medicine’s core identity, according to Dr. Wachter.

For instance, at UCSF, there are generalist surgeons who have organized a hospitalist service, providing on-call responsiveness, triage for specialized surgical problems, and a breadth of care and coordination typical of the hospital medicine model. Separately, there are also internal medicine hospitalists who serve on the surgery service. “I think there is going to be some ambiguity about roles until we clean up the language,” remarks Dr. Wachter. For instance: “Is the hospitalist on the surgery service still a generalist who takes on the role of subspecialist by caring for a more specialized population? And, what do you call the specialist surgeon who takes on a more hospitalist role?”

Shaun Frost, MD, FACP, chair of SHM’s Membership Committee and regional medical director for Cogent Healthcare in St. Paul, Minn., considers whether the inclusion of various subspecialists fits with the SHM’s definition of hospitalists. “If you’re looking strictly at ‘definition,’ SHM considers a hospitalist to be a physician whose primary professional focus is the general medical care of hospitalized patients,” he says. “As hospitalist subspecialists are likely engaging in the management of hypertension, diabetes, chronic lung and cardiac disease, etc., I see no reason to believe that they would not fit the definition of a hospitalist.”

Best Use of Skills?

Although Drs. Wachter and Frost see inclusion of hospitalists on subspecialty services as a positive trend, others warn that hospitalists should be wary about the reasons for their enlistment.

Lauren M. Friedly, MD, a hospitalist at Marin General Hospital in Greenbrae, Calif., believes subspecialty hospitalist jobs are “ultimately untenable for solid, well-trained, dedicated hospitalists.” She developed this view after a frustrating two years on a liver transplant service—where she found she “wasn’t able to practice medicine in a way that was comfortable.”

Dr. Friedly explains that she chose to be a hospitalist because of her experience as a medical student at UCSF and as a resident at California Pacific Medical Center—watching and learning from the originators of the movement, such as Dr. Wachter and Masa Yukimoto, MD, former chief resident. All the reasons she chose hospital medicine—the pace, acuity of patients, ability to revisit patients and ruminate about their problems, and the opportunity to improve the quality of a patient’s in-hospital care by adhering to a “first do no harm” philosophy—were stymied when she became a hepa-hospitalist.

“The problems that can potentially exist in any subspecialty hospitalist group are magnified a hundredfold in a liver transplant program,” she explains. “There were philosophical differences in our approach to medical care of inpatients, and the hospitalists were, in some ways, considered the bottom of the food chain.

“Because of our position relative to the hepatologists and transplant surgeons, we were not provided the autonomy nor the resources with which to accomplish any of these things. For example, decreasing length of stay by discharging patients efficiently, which to a well-trained hospitalist may mean less risk of exposure to nosocomial infections and iatrogenic complications, was not necessarily valued by the transplant surgeons and hepatologists. Less is often more for a well-trained hospitalist, but this sentiment is in direct conflict with the maximalist approach used in transplant medicine.”

Satisfying in the Long Run?

Perhaps the most important question about subspecialization for the hospitalist is whether joining a subspecialist service is a good fit. Dr. Frost believes it’s important to consider whether a career in a subspecialty service would be satisfying in the long run. “For many of us,” he explains, “one main reason we chose to pursue careers in general internal medicine, general pediatrics, or family practice is that we enjoy variety. Personally, for example, I know that I would quickly become bored with solely focusing on one organ system or one special patient population. Therefore, I believe that there is probably a limited group of folks who would enjoy exclusively restricting the scope of their hospital medicine practice to a specific subspecialty area.”

Still, Dr. Friedly admits she will miss the challenges of dealing with complex pathology. On the liver transplant service, for instance, she cared for patients with complex gastrointestinal issues, including cancers. But, due to her time on that specialized service, she now finds herself having to refresh her more general internal medicine skills.

The Pediatrics Picture

The hospitalist model is increasingly common in pediatrics, where costs per patient and length of stay have been lowered when using the hospital medicine model to restructure academic pediatric inpatient services, and hospitalists have contributed to improved survival in pediatric intensive care units.1-2

In part because of lower patient volumes on pediatric hospitalist services, the trend toward subspecialization is not as evident in pediatric hospital medicine as it is in adult hospital medicine, according to Sanford M. Melzer, MD, senior vice president of strategic planning and business development at Seattle Children’s Hospital and Regional Medical Center, and a member of the American Academy of Pediatrics’ Committee for Hospital Care. However, with shortages of physicians in key specialty areas, that may be changing.

Dr. Melzer, who has been a clinical pediatric hospitalist for 20 years and has published research on the financial aspects of pediatric hospitalist programs, reports that his service is beginning to field requests for hospitalists from specialty programs to provide staffing—just as adult hospital medicine programs have noticed.3 For example, the oncology service at Seattle Children’s Hospital has started to explore using pediatric hospitalists to help manage its pediatric cancer unit, which treats 225 new diagnoses of childhood cancer annually.

In part because oncology treatment at Seattle Children’s tends to be “heavily protocolized,” Dr. Melzer believes pediatric hospitalists can provide quality inpatient care as inpatient generalists, in terms of palliative care and symptom management, if included on that service.

The other area in which pediatric hospitalists may provide “specialty” care is in neonatology, where shortages of specialists or costs of coverage result in hospitalists covering the delivery room or the neonatal intensive care unit (NICU).

Pediatric hospitalists, as generalists, typically provide care for many different types of illnesses and conditions. “This is one of the attractive features of the job for pediatricians choosing this career track,” Dr. Melzer says. “An increasing degree of specialization may make these positions somewhat less interesting, and may highlight discrepancies between hospitalist and specialist salaries.” On the other hand, he says, “Continued shortages in specialty areas in pediatrics will continue to drive the trends toward increased deployment of generalists in these services.”

One model employed in children’s hospitals is to utilize more physician extenders, such as nurse practitioners and physician assistants, to provide the needed coverage. How pediatric hospitalists will fit into this evolving care model is not clear, notes Dr. Melzer.

Future Configurations

To avoid the possible pitfalls hospitalists can encounter with subspecialist services will require innovative solutions, Dr. Friedly believes.

“Ultimately, I think the only way that it will be sustainable [as a long-term career choice] for any individual hospitalist to take a position within a subspecialty program will be to help create or to be part of the initial vision,” Dr. Friedly says. “Or, an already-established hospitalist group could approach the subspecialist and ask, ‘How can we help you deliver the highest quality standard of care to your patients while they’re here in the hospital?’ ”

As of July 1, the UCSF neurosurgery service has embraced the addition of core internal medicine hospitalists who help to manage the medical problems of the [typical census of] 60 neurosurgery patients. So far, Dr. Wachter reports, the hospitalists are enjoying their stint on the neurosurgery service. “They’re learning a lot because these patients have very unusual and specialized problems,’’ he says. “It only took three minutes for them to realize that they were making a difference because some of the patients are very sick and have many medical problems. The surgeons don’t focus on or keep up with medical management, and even if they did, they are in the OR all day long.”

Rotating hospitalists to specialty and subspecialty services for 25% of their time in the hospital, as the UCSF Neurosurgery hospitalists do, might be one way to preserve the traditional general medical model to which many internal medicine hospitalists still gravitate. “This could be an interesting, specialized niche practice, but would not be the bulk of what they do,” says Dr. Wachter.

Dr. Frost agrees that the key to addressing the challenge of subspecialization lies in building this type of work into the context of a larger hospital medicine program. “Rotating all members of a hospital medicine group through a subspecialty experience for a portion of their overall time may be the way to go,” he notes.

Dr. Friedly cautions that certain subspecialist services, such as liver transplant, may not embrace the multidisciplinary hospital medicine model, so it remains to be seen if the effort can evolve to be truly collaborative. Her advice to younger residents just entering hospital medicine? “Hospitalist medicine has unlimited possibilities as a career choice, especially if you enjoyed being an internal medicine resident. Be careful, however, to avoid a setting where you risk losing your hard-earned skills while also being treated like a ‘perma-resident.’ Starting out in a more traditional hospitalist program to learn solid hospitalist ‘tricks of the trade,’ then transitioning to a subspecialty program where you can offer your skills, rather than the other way around, may be the more sustainable, long-term option.” TH

Gretchen Henkel is a frequent contributor to The Hospitalist.

References

1. Ogershok PR, Li X, Palmer HC, et al. Restructuring an academic pediatric inpatient service using concepts developed by hospitalists.” Clin Pediatr. 2001 Dec.;40(12): 653-660.
2. Tenner PA, Dibrell H, Taylor RP. Improved survival with hospitalists in a pediatric intensive care unit.” Crit Care Med. 2003 Mar;31(3):847-852.
3. Melzer SM, Molteni, RA, Marcuse EK, et al. Characteristics and financial performance of a pediatric faculty inpatient attending service: a resource-based relative value scale analysis. Pediatrics. 2001 Jul;108(1);79-84.

The expansion of information technology (IT) in U.S. hospitals is an evolutionary process. Billing, collections, and admission and discharge records have long been computerized, but now electronic medical administration records, patient electronic health records, and computerized physician order entry (CPOE) systems are joining the ranks.

Hospitalists are more likely to encounter sophisticated IT systems in larger, urban, or teaching hospitals, according to a 2005 survey by the American Hospital Association.1

The Hospitalist’s first installment about hospital informatics (“Charts to Screens,” January 2007, p. 25) focused on the challenges of health IT and the barriers to effective adoption of computer-based documentation systems. This installment explores the potentially rich vein of data available to hospitalists from those information systems and the opportunities for research and QI applications.

The mechanics of conducting clinical research and QI projects will depend to a large extent on the progress each hospital medical group’s institution has made in the IT adoption process. Some say hospitalists have powerful contributions to make in influencing how the IT process evolves so their research opportunities will also improve.

QI Topics

Data in information systems differ from hospital to hospital, says Tejal K. Gandhi, MD, MPH, director of patient safety at Boston’s Brigham and Women’s Hospital (BWH) and assistant professor of medicine in the Department of Medicine at Harvard Medical School in Boston.

Dr. Gandhi’s research focuses on redesigning hospital and outpatient processes to improve patient safety. She notes that hospitalists can take advantage of data the hospital is collecting to satisfy its reporting requirements to spearhead more quality-improvement efforts.

“For example,” says Dr. Gandhi, “the hospital has to document how it’s doing on pneumonia measures, acute myocardial infarction measures (was the patient having a heart attack given aspirin and a beta-blocker?), and others. These are fruitful topics for quality-improvement projects.”

Hospitalist Andrew Karson, MD, MPH, associate director of the Decision Support and Quality Management Unit and associate program director for the Internal Medicine Residency Program at Massachusetts General Hospital, Boston, also focuses on patient safety issues in his research. Given hospitalists’ knowledge of decision-making systems in the hospital, they are in a unique situation to initiate such projects, he believes.

For example, Dr. Karson participated in a study initiated by colleague Christopher L. Roy, MD, associate director of the hospitalist program at BWH.2 Dr. Roy posited that pending test results could be an important patient safety issue and, at the very least, might affect continuity of care. The researchers identified 2,644 consecutive patients discharged from BWH and Massachusetts General between February and June 2004. During that time, a mixture of hospitalists and non-hospitalists were responsible for discharging patients on house staff and non-house-staff services. Using a Results Manager application integrated into each patient’s electronic medical record (EMR) at the hospitals, the team identified and tracked pending laboratory and/or radiologic test results that had been returned after the patients were discharged.

The team used physician reviewers to determine whether the pending test results were potentially actionable. They found that 41% (1,095) of the discharged patients had a total of 2,033 test results return after their discharge. Of those tests, the physician reviewer determined that 9.4% (191) were potentially actionable. Examples of actionable results of which discharging physicians had been unaware included a levofloxacin-resistant Klebsiella infection in a patient being treated with levofloxacin, and a thyroid-stimulating hormone level that was dangerously low in a patient with rapid atrial fibrillation. A coauthor of the study, Eric G. Poon, MD, MPH, Division of General Medicine and Primary Care at BWH, is working on a results-management system that will automatically alert hospitalists and other physicians in the process of discharging patients when those patients are awaiting test results.

Research Potential

CPOE systems afford opportunities to delve further into clinical research and QI projects.

The flow of care in hospitals is inextricably linked with writing orders—for medications, tests, consultations, or interventional care processes. “Interfacing with CPOEs, therefore, can help influence the way care is practiced more broadly for our patients,” says Dr. Karson. “By embedding rules and decision support elements within our CPOE systems, we can improve the quality and safety of the care that we provide.”

The effect of CPOE on ICU patient care was highlighted in a 2005 study conducted by intensivist Stephen P. Hoffmann, MD, medical director, ICU, and associate professor of medicine at Ohio State University Medical Center, Columbus, and his colleagues. The team compared orders for ICU care before and after modification of a CPOE system and found that use of higher-efficiency CPOE order paths led to significant reductions in orders for vasoactive infusions, sedative infusions, and ventilator management.3

Paul D. Hain, MD, interim chief of staff and director of the Pediatric Hospitalist Program at Monroe Carell Jr. Children’s Hospital at Vanderbilt, Nashville, Tenn., and his colleagues at Vanderbilt University’s School of Medicine have been able to use their institution’s advanced CPOE to increase adherence to evidence-based treatments.

With the help of IT support staff, Dr. Hain inserted a pop-up window into the CPOE to remind providers that bronchodilators (albuterol) and steroids are ineffective for the treatment of bronchiolitis. Working with a third-year medical student, Ryan Bailey, Dr. Hain compared orders for these treatments in the years preceding installation of his pop-up reminder with those afterward. There was a significant drop in the non-evidence-based treatments, he notes, based on the installation of the pop-up window. “The reminder actually worked!” he exclaims. “It got people to stop using inappropriate therapies.”

This type of quality improvement, says Dr. Hain, is good for the hospital, for the hospitalists, and for their non-hospitalist colleagues. “This type of reminder allows us to share evidence-based guidelines with other admitting physicians in real time, and it appears to be a much more effective way to communicate information, as evidenced by our success in decreasing non-evidence-based treatments for bronchiolitis,” he asserts. The pop-up window includes a link to the treatment guidelines, so it also offers users an educational opportunity.

Close the Loop

Dr. Hoffmann and others caution about the limitations of using CPOE data. Most CPOE systems, notes Dr. Hoffmann, do not have a way of capturing whether an order or intervention was actually carried out.

“With CPOE, you can get a very good handle on how many order sets for processes of care have been ordered, but it doesn’t complete the loop—it doesn’t tell you whether that process of care happened once it has been ordered,” Dr. Hoffman says. “If you use the CPOE data set alone and stop there, the process is going to be fraught with unreliable information.”

CPOE can be a good tool for organizing clinical improvement projects but may not be the perfect tool for verifying outcomes of the order set. This was underscored by a project Dr. Hoffmann and his team conducted in collaboration with the University HealthSystem Consortium (UHC) on ventilator-associated pneumonia (VAP). The team wrote policy and processes based on current evidence for preventing VAP—such as raising the heads of patients’ beds to 30 degrees when they are mechanically ventilated—and created a flowchart of those processes. The aim of the project was to tie these care processes to the order for a ventilator, so that each time one was ordered, the other care items were bundled with it to trigger changes at the bedside. Now, it won’t be possible for a provider to order a ventilator without at least reviewing and ordering the additional care processes.

For the UHC project, Dr. Hoffmann and his team had to manually review charts and documentation to verify that the VAP bundle had been ordered and then utilized. “We looked at what documentation needed to be done, and we have modified nursing and respiratory therapy documentation to ensure that all these bundled-care process steps are adequately documented,” he says. The next step will be to tie CPOE with bedside charting and decision support, so that verification of order sets will also be stored in the hospital system’s information warehouse and will be accessible to physician researchers. The project is ongoing, states Dr. Hoffmann, and another evaluation will be conducted manually after a six-month interval to validate the data collection points that will be most useful in the automation process.

There are other ways to verify CPOE implementation. At BWH, says Dr. Gandhi, the electronic medication administration record (eMAR) provides a powerful adjunct to the CPOE.

“The fact that we have eMAR data is really advantageous,” notes Dr. Gandhi, “because now we can actually tell what patients have received.” For example, she says, Narcan (naloxone hydrochloride) is usually ordered and kept at the bedside for a patient receiving opioids in case the patient develops respiratory depression. Before institution of the hospital’s eMAR, “we could never tell how much Narcan was actually being given without doing laborious chart reviews. Now, with our eMAR, we can easily track how many times it was given, and this supplies a much better indicator of potential problems with the use of narcotics.”

At Vanderbilt, says Dr. Hain, a dosage checker application installed behind the CPOE has allowed his colleague Neal Patel, MD, MPH, to verify that medication errors in the Pediatric ICU dropped dramatically after its implementation. But, on other projects, researchers must know in advance that they intend to follow up on order entries so that they can convert order entries into binary procedures. The CPOE and EMR systems have the capability of inserting text boxes, drop-down menus, and click buttons for verifying medications, procedures, or even safety check-offs. If the CPOE is not set up in advance for this feature, however, it’s back to manual extraction to confirm the data—“a painful process, just as it is from paper charts,” Dr. Hain notes.

Privacy and Other Issues

Are there privacy issues of which hospitalists should be aware when using their hospital information system databases for their research?

“In general, if you’re doing quality improvement projects solely for the sake of improving the quality of patient care at your institution,” says Dr. Karson, “you do not need IRB [institutional review board] approval.” Whenever hospitalists plan to publish or present the data to external audiences, however, prior IRB approval must be obtained to show that patients’ identities will be protected and that use of the data will cause no harm.

There could be wrinkles in following these guidelines if the results of a QI project reveal surprisingly good results or important lessons about quality patient care that researchers think are worth sharing. Although it is possible to apply post-hoc for IRB approval, Dr. Gandhi and others suggest obtaining approval prior to the start of the project if researchers think there is any chance they may want to share results externally. Researchers must also adhere to the quality rules during QI projects, asserts Dr. Hain, to make sure patients’ identities are protected.

The IT/MD Interface

Whether hospitals use off-the-shelf or custom-built, institution-specific CPOEs, hospitalists are well positioned to play important roles in enhancing their designs, believes Dr. Karson. “If you’re going to support [clinicians’] decisions with computerized decision support, then CPOE systems are a great way to broadly affect the care of patients,” he says.

As those CPOE systems are designed, they require decisions along the way so they will achieve the quality, safety, and efficiency goals for the hospital and for the patients that the hospital cares for. Who better to interface with information systems designers than process-oriented hospitalists? As a hospitalist, Dr. Karson is taking a lead role in updating the pneumonia order set in his hospital’s provider order entry system.

It is sometimes possible for hospitalists to extract data manually to effect a proof of concept as justification for an IT system upgrade, says Dr. Hain. For example, in Vanderbilt’s outpatient clinic, one physician wanted to know whether all diabetic patients received foot exams at their regular visits. They inserted a paper form with check boxes into patients’ charts and then aggregated these forms to show it was possible to track quality measures for diabetics. This has led to a diabetics dashboard on the outpatient clinic computers that tracks foot exams by the day, week, or month.

Hospitalists report varying degrees of expertise with IT. Dr. Hoffmann’s introduction to IT came when he assumed the medical directorship of Ohio State University’s ICU. Since that time, he has been charged with collaborating with the medical center’s information systems (IS) personnel to improve the CPOE. “We have a group here that embraces the system—so much so that the IS people sometimes are inundated with our enthusiasm to make changes,” Dr. Hoffman says.

Dr. Hain, who has a background in engineering, relies on IT support when designing changes to the CPOE. “Our IT department here has done a really good job of reaching out to its users,” he says. Several physicians in the medical informatics department specialize in the CPOE, as is the case in many academic institutions. “It’s important that the gap be bridged between computer programmers and MDs,” he says. “The best way to do that is to have MDs with master’s degrees in informatics working with the programmers, making it all the more seamless.” TH

Gretchen Henkel is a frequent contributor to The Hospitalist.

References

1. American Hospital Association. Forward momentum: hospital use of information technology. October 2005. Available at www.aha.org/aha/content/2005/pdf/FINALNonEmbITSurvey105.pdf. Last accessed April 10, 2007.
2. Roy CL, Poon EG, Karson AS, et al. Patient safety concerns arising from test results that return after hospital discharge. Ann Intern Med. 2005 Jul 19; 143(2):121-128.
3. Ali NA, Mekhjian HS, Kuehn PL, et al. Specificity of computerized physician order entry has a significant effect on the efficiency of workflow for critically ill patients. Crit Care Med. 2005 Jan;33(1):110-114.

The expansion of information technology (IT) in U.S. hospitals is an evolutionary process. Billing, collections, and admission and discharge records have long been computerized, but now electronic medical administration records, patient electronic health records, and computerized physician order entry (CPOE) systems are joining the ranks.

Hospitalists are more likely to encounter sophisticated IT systems in larger, urban, or teaching hospitals, according to a 2005 survey by the American Hospital Association.1

The Hospitalist’s first installment about hospital informatics (“Charts to Screens,” January 2007, p. 25) focused on the challenges of health IT and the barriers to effective adoption of computer-based documentation systems. This installment explores the potentially rich vein of data available to hospitalists from those information systems and the opportunities for research and QI applications.

The mechanics of conducting clinical research and QI projects will depend to a large extent on the progress each hospital medical group’s institution has made in the IT adoption process. Some say hospitalists have powerful contributions to make in influencing how the IT process evolves so their research opportunities will also improve.

QI Topics

Data in information systems differ from hospital to hospital, says Tejal K. Gandhi, MD, MPH, director of patient safety at Boston’s Brigham and Women’s Hospital (BWH) and assistant professor of medicine in the Department of Medicine at Harvard Medical School in Boston.

Dr. Gandhi’s research focuses on redesigning hospital and outpatient processes to improve patient safety. She notes that hospitalists can take advantage of data the hospital is collecting to satisfy its reporting requirements to spearhead more quality-improvement efforts.

“For example,” says Dr. Gandhi, “the hospital has to document how it’s doing on pneumonia measures, acute myocardial infarction measures (was the patient having a heart attack given aspirin and a beta-blocker?), and others. These are fruitful topics for quality-improvement projects.”

Hospitalist Andrew Karson, MD, MPH, associate director of the Decision Support and Quality Management Unit and associate program director for the Internal Medicine Residency Program at Massachusetts General Hospital, Boston, also focuses on patient safety issues in his research. Given hospitalists’ knowledge of decision-making systems in the hospital, they are in a unique situation to initiate such projects, he believes.

For example, Dr. Karson participated in a study initiated by colleague Christopher L. Roy, MD, associate director of the hospitalist program at BWH.2 Dr. Roy posited that pending test results could be an important patient safety issue and, at the very least, might affect continuity of care. The researchers identified 2,644 consecutive patients discharged from BWH and Massachusetts General between February and June 2004. During that time, a mixture of hospitalists and non-hospitalists were responsible for discharging patients on house staff and non-house-staff services. Using a Results Manager application integrated into each patient’s electronic medical record (EMR) at the hospitals, the team identified and tracked pending laboratory and/or radiologic test results that had been returned after the patients were discharged.

The team used physician reviewers to determine whether the pending test results were potentially actionable. They found that 41% (1,095) of the discharged patients had a total of 2,033 test results return after their discharge. Of those tests, the physician reviewer determined that 9.4% (191) were potentially actionable. Examples of actionable results of which discharging physicians had been unaware included a levofloxacin-resistant Klebsiella infection in a patient being treated with levofloxacin, and a thyroid-stimulating hormone level that was dangerously low in a patient with rapid atrial fibrillation. A coauthor of the study, Eric G. Poon, MD, MPH, Division of General Medicine and Primary Care at BWH, is working on a results-management system that will automatically alert hospitalists and other physicians in the process of discharging patients when those patients are awaiting test results.

Research Potential

CPOE systems afford opportunities to delve further into clinical research and QI projects.

The flow of care in hospitals is inextricably linked with writing orders—for medications, tests, consultations, or interventional care processes. “Interfacing with CPOEs, therefore, can help influence the way care is practiced more broadly for our patients,” says Dr. Karson. “By embedding rules and decision support elements within our CPOE systems, we can improve the quality and safety of the care that we provide.”

The effect of CPOE on ICU patient care was highlighted in a 2005 study conducted by intensivist Stephen P. Hoffmann, MD, medical director, ICU, and associate professor of medicine at Ohio State University Medical Center, Columbus, and his colleagues. The team compared orders for ICU care before and after modification of a CPOE system and found that use of higher-efficiency CPOE order paths led to significant reductions in orders for vasoactive infusions, sedative infusions, and ventilator management.3

Paul D. Hain, MD, interim chief of staff and director of the Pediatric Hospitalist Program at Monroe Carell Jr. Children’s Hospital at Vanderbilt, Nashville, Tenn., and his colleagues at Vanderbilt University’s School of Medicine have been able to use their institution’s advanced CPOE to increase adherence to evidence-based treatments.

With the help of IT support staff, Dr. Hain inserted a pop-up window into the CPOE to remind providers that bronchodilators (albuterol) and steroids are ineffective for the treatment of bronchiolitis. Working with a third-year medical student, Ryan Bailey, Dr. Hain compared orders for these treatments in the years preceding installation of his pop-up reminder with those afterward. There was a significant drop in the non-evidence-based treatments, he notes, based on the installation of the pop-up window. “The reminder actually worked!” he exclaims. “It got people to stop using inappropriate therapies.”

This type of quality improvement, says Dr. Hain, is good for the hospital, for the hospitalists, and for their non-hospitalist colleagues. “This type of reminder allows us to share evidence-based guidelines with other admitting physicians in real time, and it appears to be a much more effective way to communicate information, as evidenced by our success in decreasing non-evidence-based treatments for bronchiolitis,” he asserts. The pop-up window includes a link to the treatment guidelines, so it also offers users an educational opportunity.

Close the Loop

Dr. Hoffmann and others caution about the limitations of using CPOE data. Most CPOE systems, notes Dr. Hoffmann, do not have a way of capturing whether an order or intervention was actually carried out.

“With CPOE, you can get a very good handle on how many order sets for processes of care have been ordered, but it doesn’t complete the loop—it doesn’t tell you whether that process of care happened once it has been ordered,” Dr. Hoffman says. “If you use the CPOE data set alone and stop there, the process is going to be fraught with unreliable information.”

CPOE can be a good tool for organizing clinical improvement projects but may not be the perfect tool for verifying outcomes of the order set. This was underscored by a project Dr. Hoffmann and his team conducted in collaboration with the University HealthSystem Consortium (UHC) on ventilator-associated pneumonia (VAP). The team wrote policy and processes based on current evidence for preventing VAP—such as raising the heads of patients’ beds to 30 degrees when they are mechanically ventilated—and created a flowchart of those processes. The aim of the project was to tie these care processes to the order for a ventilator, so that each time one was ordered, the other care items were bundled with it to trigger changes at the bedside. Now, it won’t be possible for a provider to order a ventilator without at least reviewing and ordering the additional care processes.

For the UHC project, Dr. Hoffmann and his team had to manually review charts and documentation to verify that the VAP bundle had been ordered and then utilized. “We looked at what documentation needed to be done, and we have modified nursing and respiratory therapy documentation to ensure that all these bundled-care process steps are adequately documented,” he says. The next step will be to tie CPOE with bedside charting and decision support, so that verification of order sets will also be stored in the hospital system’s information warehouse and will be accessible to physician researchers. The project is ongoing, states Dr. Hoffmann, and another evaluation will be conducted manually after a six-month interval to validate the data collection points that will be most useful in the automation process.

There are other ways to verify CPOE implementation. At BWH, says Dr. Gandhi, the electronic medication administration record (eMAR) provides a powerful adjunct to the CPOE.

“The fact that we have eMAR data is really advantageous,” notes Dr. Gandhi, “because now we can actually tell what patients have received.” For example, she says, Narcan (naloxone hydrochloride) is usually ordered and kept at the bedside for a patient receiving opioids in case the patient develops respiratory depression. Before institution of the hospital’s eMAR, “we could never tell how much Narcan was actually being given without doing laborious chart reviews. Now, with our eMAR, we can easily track how many times it was given, and this supplies a much better indicator of potential problems with the use of narcotics.”

At Vanderbilt, says Dr. Hain, a dosage checker application installed behind the CPOE has allowed his colleague Neal Patel, MD, MPH, to verify that medication errors in the Pediatric ICU dropped dramatically after its implementation. But, on other projects, researchers must know in advance that they intend to follow up on order entries so that they can convert order entries into binary procedures. The CPOE and EMR systems have the capability of inserting text boxes, drop-down menus, and click buttons for verifying medications, procedures, or even safety check-offs. If the CPOE is not set up in advance for this feature, however, it’s back to manual extraction to confirm the data—“a painful process, just as it is from paper charts,” Dr. Hain notes.

Privacy and Other Issues

Are there privacy issues of which hospitalists should be aware when using their hospital information system databases for their research?

“In general, if you’re doing quality improvement projects solely for the sake of improving the quality of patient care at your institution,” says Dr. Karson, “you do not need IRB [institutional review board] approval.” Whenever hospitalists plan to publish or present the data to external audiences, however, prior IRB approval must be obtained to show that patients’ identities will be protected and that use of the data will cause no harm.

There could be wrinkles in following these guidelines if the results of a QI project reveal surprisingly good results or important lessons about quality patient care that researchers think are worth sharing. Although it is possible to apply post-hoc for IRB approval, Dr. Gandhi and others suggest obtaining approval prior to the start of the project if researchers think there is any chance they may want to share results externally. Researchers must also adhere to the quality rules during QI projects, asserts Dr. Hain, to make sure patients’ identities are protected.

The IT/MD Interface

Whether hospitals use off-the-shelf or custom-built, institution-specific CPOEs, hospitalists are well positioned to play important roles in enhancing their designs, believes Dr. Karson. “If you’re going to support [clinicians’] decisions with computerized decision support, then CPOE systems are a great way to broadly affect the care of patients,” he says.

As those CPOE systems are designed, they require decisions along the way so they will achieve the quality, safety, and efficiency goals for the hospital and for the patients that the hospital cares for. Who better to interface with information systems designers than process-oriented hospitalists? As a hospitalist, Dr. Karson is taking a lead role in updating the pneumonia order set in his hospital’s provider order entry system.

It is sometimes possible for hospitalists to extract data manually to effect a proof of concept as justification for an IT system upgrade, says Dr. Hain. For example, in Vanderbilt’s outpatient clinic, one physician wanted to know whether all diabetic patients received foot exams at their regular visits. They inserted a paper form with check boxes into patients’ charts and then aggregated these forms to show it was possible to track quality measures for diabetics. This has led to a diabetics dashboard on the outpatient clinic computers that tracks foot exams by the day, week, or month.

Hospitalists report varying degrees of expertise with IT. Dr. Hoffmann’s introduction to IT came when he assumed the medical directorship of Ohio State University’s ICU. Since that time, he has been charged with collaborating with the medical center’s information systems (IS) personnel to improve the CPOE. “We have a group here that embraces the system—so much so that the IS people sometimes are inundated with our enthusiasm to make changes,” Dr. Hoffman says.

Dr. Hain, who has a background in engineering, relies on IT support when designing changes to the CPOE. “Our IT department here has done a really good job of reaching out to its users,” he says. Several physicians in the medical informatics department specialize in the CPOE, as is the case in many academic institutions. “It’s important that the gap be bridged between computer programmers and MDs,” he says. “The best way to do that is to have MDs with master’s degrees in informatics working with the programmers, making it all the more seamless.” TH

Gretchen Henkel is a frequent contributor to The Hospitalist.

References

1. American Hospital Association. Forward momentum: hospital use of information technology. October 2005. Available at www.aha.org/aha/content/2005/pdf/FINALNonEmbITSurvey105.pdf. Last accessed April 10, 2007.
2. Roy CL, Poon EG, Karson AS, et al. Patient safety concerns arising from test results that return after hospital discharge. Ann Intern Med. 2005 Jul 19; 143(2):121-128.
3. Ali NA, Mekhjian HS, Kuehn PL, et al. Specificity of computerized physician order entry has a significant effect on the efficiency of workflow for critically ill patients. Crit Care Med. 2005 Jan;33(1):110-114.

The expansion of information technology (IT) in U.S. hospitals is an evolutionary process. Billing, collections, and admission and discharge records have long been computerized, but now electronic medical administration records, patient electronic health records, and computerized physician order entry (CPOE) systems are joining the ranks.

Hospitalists are more likely to encounter sophisticated IT systems in larger, urban, or teaching hospitals, according to a 2005 survey by the American Hospital Association.1

The Hospitalist’s first installment about hospital informatics (“Charts to Screens,” January 2007, p. 25) focused on the challenges of health IT and the barriers to effective adoption of computer-based documentation systems. This installment explores the potentially rich vein of data available to hospitalists from those information systems and the opportunities for research and QI applications.

The mechanics of conducting clinical research and QI projects will depend to a large extent on the progress each hospital medical group’s institution has made in the IT adoption process. Some say hospitalists have powerful contributions to make in influencing how the IT process evolves so their research opportunities will also improve.

QI Topics

Data in information systems differ from hospital to hospital, says Tejal K. Gandhi, MD, MPH, director of patient safety at Boston’s Brigham and Women’s Hospital (BWH) and assistant professor of medicine in the Department of Medicine at Harvard Medical School in Boston.

Dr. Gandhi’s research focuses on redesigning hospital and outpatient processes to improve patient safety. She notes that hospitalists can take advantage of data the hospital is collecting to satisfy its reporting requirements to spearhead more quality-improvement efforts.

“For example,” says Dr. Gandhi, “the hospital has to document how it’s doing on pneumonia measures, acute myocardial infarction measures (was the patient having a heart attack given aspirin and a beta-blocker?), and others. These are fruitful topics for quality-improvement projects.”

Hospitalist Andrew Karson, MD, MPH, associate director of the Decision Support and Quality Management Unit and associate program director for the Internal Medicine Residency Program at Massachusetts General Hospital, Boston, also focuses on patient safety issues in his research. Given hospitalists’ knowledge of decision-making systems in the hospital, they are in a unique situation to initiate such projects, he believes.

For example, Dr. Karson participated in a study initiated by colleague Christopher L. Roy, MD, associate director of the hospitalist program at BWH.2 Dr. Roy posited that pending test results could be an important patient safety issue and, at the very least, might affect continuity of care. The researchers identified 2,644 consecutive patients discharged from BWH and Massachusetts General between February and June 2004. During that time, a mixture of hospitalists and non-hospitalists were responsible for discharging patients on house staff and non-house-staff services. Using a Results Manager application integrated into each patient’s electronic medical record (EMR) at the hospitals, the team identified and tracked pending laboratory and/or radiologic test results that had been returned after the patients were discharged.

The team used physician reviewers to determine whether the pending test results were potentially actionable. They found that 41% (1,095) of the discharged patients had a total of 2,033 test results return after their discharge. Of those tests, the physician reviewer determined that 9.4% (191) were potentially actionable. Examples of actionable results of which discharging physicians had been unaware included a levofloxacin-resistant Klebsiella infection in a patient being treated with levofloxacin, and a thyroid-stimulating hormone level that was dangerously low in a patient with rapid atrial fibrillation. A coauthor of the study, Eric G. Poon, MD, MPH, Division of General Medicine and Primary Care at BWH, is working on a results-management system that will automatically alert hospitalists and other physicians in the process of discharging patients when those patients are awaiting test results.

Research Potential

CPOE systems afford opportunities to delve further into clinical research and QI projects.

The flow of care in hospitals is inextricably linked with writing orders—for medications, tests, consultations, or interventional care processes. “Interfacing with CPOEs, therefore, can help influence the way care is practiced more broadly for our patients,” says Dr. Karson. “By embedding rules and decision support elements within our CPOE systems, we can improve the quality and safety of the care that we provide.”

The effect of CPOE on ICU patient care was highlighted in a 2005 study conducted by intensivist Stephen P. Hoffmann, MD, medical director, ICU, and associate professor of medicine at Ohio State University Medical Center, Columbus, and his colleagues. The team compared orders for ICU care before and after modification of a CPOE system and found that use of higher-efficiency CPOE order paths led to significant reductions in orders for vasoactive infusions, sedative infusions, and ventilator management.3

Paul D. Hain, MD, interim chief of staff and director of the Pediatric Hospitalist Program at Monroe Carell Jr. Children’s Hospital at Vanderbilt, Nashville, Tenn., and his colleagues at Vanderbilt University’s School of Medicine have been able to use their institution’s advanced CPOE to increase adherence to evidence-based treatments.

With the help of IT support staff, Dr. Hain inserted a pop-up window into the CPOE to remind providers that bronchodilators (albuterol) and steroids are ineffective for the treatment of bronchiolitis. Working with a third-year medical student, Ryan Bailey, Dr. Hain compared orders for these treatments in the years preceding installation of his pop-up reminder with those afterward. There was a significant drop in the non-evidence-based treatments, he notes, based on the installation of the pop-up window. “The reminder actually worked!” he exclaims. “It got people to stop using inappropriate therapies.”

This type of quality improvement, says Dr. Hain, is good for the hospital, for the hospitalists, and for their non-hospitalist colleagues. “This type of reminder allows us to share evidence-based guidelines with other admitting physicians in real time, and it appears to be a much more effective way to communicate information, as evidenced by our success in decreasing non-evidence-based treatments for bronchiolitis,” he asserts. The pop-up window includes a link to the treatment guidelines, so it also offers users an educational opportunity.

Close the Loop

Dr. Hoffmann and others caution about the limitations of using CPOE data. Most CPOE systems, notes Dr. Hoffmann, do not have a way of capturing whether an order or intervention was actually carried out.

“With CPOE, you can get a very good handle on how many order sets for processes of care have been ordered, but it doesn’t complete the loop—it doesn’t tell you whether that process of care happened once it has been ordered,” Dr. Hoffman says. “If you use the CPOE data set alone and stop there, the process is going to be fraught with unreliable information.”

CPOE can be a good tool for organizing clinical improvement projects but may not be the perfect tool for verifying outcomes of the order set. This was underscored by a project Dr. Hoffmann and his team conducted in collaboration with the University HealthSystem Consortium (UHC) on ventilator-associated pneumonia (VAP). The team wrote policy and processes based on current evidence for preventing VAP—such as raising the heads of patients’ beds to 30 degrees when they are mechanically ventilated—and created a flowchart of those processes. The aim of the project was to tie these care processes to the order for a ventilator, so that each time one was ordered, the other care items were bundled with it to trigger changes at the bedside. Now, it won’t be possible for a provider to order a ventilator without at least reviewing and ordering the additional care processes.

For the UHC project, Dr. Hoffmann and his team had to manually review charts and documentation to verify that the VAP bundle had been ordered and then utilized. “We looked at what documentation needed to be done, and we have modified nursing and respiratory therapy documentation to ensure that all these bundled-care process steps are adequately documented,” he says. The next step will be to tie CPOE with bedside charting and decision support, so that verification of order sets will also be stored in the hospital system’s information warehouse and will be accessible to physician researchers. The project is ongoing, states Dr. Hoffmann, and another evaluation will be conducted manually after a six-month interval to validate the data collection points that will be most useful in the automation process.

There are other ways to verify CPOE implementation. At BWH, says Dr. Gandhi, the electronic medication administration record (eMAR) provides a powerful adjunct to the CPOE.

“The fact that we have eMAR data is really advantageous,” notes Dr. Gandhi, “because now we can actually tell what patients have received.” For example, she says, Narcan (naloxone hydrochloride) is usually ordered and kept at the bedside for a patient receiving opioids in case the patient develops respiratory depression. Before institution of the hospital’s eMAR, “we could never tell how much Narcan was actually being given without doing laborious chart reviews. Now, with our eMAR, we can easily track how many times it was given, and this supplies a much better indicator of potential problems with the use of narcotics.”

At Vanderbilt, says Dr. Hain, a dosage checker application installed behind the CPOE has allowed his colleague Neal Patel, MD, MPH, to verify that medication errors in the Pediatric ICU dropped dramatically after its implementation. But, on other projects, researchers must know in advance that they intend to follow up on order entries so that they can convert order entries into binary procedures. The CPOE and EMR systems have the capability of inserting text boxes, drop-down menus, and click buttons for verifying medications, procedures, or even safety check-offs. If the CPOE is not set up in advance for this feature, however, it’s back to manual extraction to confirm the data—“a painful process, just as it is from paper charts,” Dr. Hain notes.

Privacy and Other Issues

Are there privacy issues of which hospitalists should be aware when using their hospital information system databases for their research?

“In general, if you’re doing quality improvement projects solely for the sake of improving the quality of patient care at your institution,” says Dr. Karson, “you do not need IRB [institutional review board] approval.” Whenever hospitalists plan to publish or present the data to external audiences, however, prior IRB approval must be obtained to show that patients’ identities will be protected and that use of the data will cause no harm.

There could be wrinkles in following these guidelines if the results of a QI project reveal surprisingly good results or important lessons about quality patient care that researchers think are worth sharing. Although it is possible to apply post-hoc for IRB approval, Dr. Gandhi and others suggest obtaining approval prior to the start of the project if researchers think there is any chance they may want to share results externally. Researchers must also adhere to the quality rules during QI projects, asserts Dr. Hain, to make sure patients’ identities are protected.

The IT/MD Interface

Whether hospitals use off-the-shelf or custom-built, institution-specific CPOEs, hospitalists are well positioned to play important roles in enhancing their designs, believes Dr. Karson. “If you’re going to support [clinicians’] decisions with computerized decision support, then CPOE systems are a great way to broadly affect the care of patients,” he says.

As those CPOE systems are designed, they require decisions along the way so they will achieve the quality, safety, and efficiency goals for the hospital and for the patients that the hospital cares for. Who better to interface with information systems designers than process-oriented hospitalists? As a hospitalist, Dr. Karson is taking a lead role in updating the pneumonia order set in his hospital’s provider order entry system.

It is sometimes possible for hospitalists to extract data manually to effect a proof of concept as justification for an IT system upgrade, says Dr. Hain. For example, in Vanderbilt’s outpatient clinic, one physician wanted to know whether all diabetic patients received foot exams at their regular visits. They inserted a paper form with check boxes into patients’ charts and then aggregated these forms to show it was possible to track quality measures for diabetics. This has led to a diabetics dashboard on the outpatient clinic computers that tracks foot exams by the day, week, or month.

Hospitalists report varying degrees of expertise with IT. Dr. Hoffmann’s introduction to IT came when he assumed the medical directorship of Ohio State University’s ICU. Since that time, he has been charged with collaborating with the medical center’s information systems (IS) personnel to improve the CPOE. “We have a group here that embraces the system—so much so that the IS people sometimes are inundated with our enthusiasm to make changes,” Dr. Hoffman says.

Dr. Hain, who has a background in engineering, relies on IT support when designing changes to the CPOE. “Our IT department here has done a really good job of reaching out to its users,” he says. Several physicians in the medical informatics department specialize in the CPOE, as is the case in many academic institutions. “It’s important that the gap be bridged between computer programmers and MDs,” he says. “The best way to do that is to have MDs with master’s degrees in informatics working with the programmers, making it all the more seamless.” TH

Gretchen Henkel is a frequent contributor to The Hospitalist.

References

1. American Hospital Association. Forward momentum: hospital use of information technology. October 2005. Available at www.aha.org/aha/content/2005/pdf/FINALNonEmbITSurvey105.pdf. Last accessed April 10, 2007.
2. Roy CL, Poon EG, Karson AS, et al. Patient safety concerns arising from test results that return after hospital discharge. Ann Intern Med. 2005 Jul 19; 143(2):121-128.
3. Ali NA, Mekhjian HS, Kuehn PL, et al. Specificity of computerized physician order entry has a significant effect on the efficiency of workflow for critically ill patients. Crit Care Med. 2005 Jan;33(1):110-114.

This is the second in a two-part series. Part 1 appeared in the July issue, p. 29.

While the HIV/AIDS epidemic rages worldwide—an estimated 40 million people have the virus—the lifespan for many HIV-positive patients in the U.S. continues to improve.

Patients on highly active antiretroviral therapy (HAART) live long enough to develop common age-related illnesses. Those without sufficient resources and/or social supports continue to present with AIDS-defining syndromes seen at the beginning of the epidemic. Hospitalists must face these different populations of HIV/AIDS patients and their unique challenges.

In the second part of our series, we address:

• The ramifications for hospitalists of the Centers for Disease Control and Prevention’s (CDC) revised HIV testing guidelines;
• Challenges specific to managing children with HIV; and
• Ways hospitalists can make a difference with HIV patients through social services collaboration, education, and counseling.

Testing Guidelines Shift

On Sept. 22, 2006, the CDC issued revised recommendations for HIV testing of adults, adolescents, and pregnant women in healthcare settings.1 Testing had previously been recommended only for high-risk individuals, such as injection drug users or those with multiple sex partners. The new recommendations advise testing all individuals 13 through 64 in all healthcare settings. In its rationale for extended testing, the CDC notes that of the 1 million to 1.2 million people thought to be living with HIV in the United States, nearly 25% are unaware of their infected status. Expansion of testing, the CDC argues, would mean earlier access to life-extending treatments and reduced transmission risk.

Expanded testing is a good idea, says Theresa Barton, MD, assistant professor of pediatrics at the University of Texas Southwestern Medical Center in Dallas. Dr. Barton is also a pediatric hospitalist and director of the AIDS Related Medical Services (ARM) Clinic at UT.

“According to the CDC, a large number of newly diagnosed HIV patients have no risk factor at all [other than sexual contact with a partner],” Dr. Barton says. “Many people, particularly heterosexuals, do not perceive having sex as a risk factor. That’s certainly the case for women who are pregnant. They report they have no risk factor when you know they have a risk factor by default because they’re pregnant.”

Testing should be offered to everyone in the hospital, agrees George Mathew, MD, a hospitalist with infectious disease training at Emory University Hospital in Atlanta, and instructor of medicine at Emory University Medical School. However, testing everyone who comes to the hospital may be impractical for two reasons, he believes:

• Hospitalists feel time constraints with other components of diagnosing and admitting patients; and
• Hospitalists will not be impelled to offer patients routine HIV testing unless it is mandated by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) as a core measure.

“Hospitalists will need help [from their institutions] in the introduction of this recommendation, maybe as an inclusion on a general admission form or as a prompt during computerized physician order entry (CPOE),” Dr. Mathew says.

Until universal testing of all inpatients is instituted, it is still advisable for hospitalists to include HIV testing in the diagnostic workup. Neil Winawer, MD, director of the hospitalist program at Grady Memorial, one of Emory University’s affiliated hospitals in Atlanta, advises that hospitalists “should always keep the diagnosis of HIV and AIDS on their radar screen in this day and age. There can be certain things in a patient’s profile that trigger you to think about testing for HIV, such as lymphopenia, recurrent infections, subtle evidence of weight loss, or alopecia.”

Theresa Barton, MD

Hospitalists should also heed how they introduce the need for the test. “To be honest, I think in many ways we have made the testing process too scary,” says Dr. Barton. She believes patients and their families may become unduly alarmed because of the emphasis on informed consent, as well as the secrecy of results. Her approach with families in the hospital or at the clinic is to tell parents she wants to do an HIV test to “make sure that every stone is uncovered” in making a diagnosis. “We should all do our best to explain to families what our plan is or what kind of testing we will be doing, whether it’s an HIV test or not,” she says.

Dr. Barton also cautions pediatric hospitalist colleagues to be sensitive to parents’ wishes when a diagnostic work-up includes a CD4 count or HIV test. If the child has been seen in an outpatient setting, it is possible the parents have not yet told their child that he or she is HIV-infected. “Try to be cognizant of the parents’ involvement and wishes,” she advises. “To have a perfect stranger [the hospitalist] tell you that you’re HIV-infected can be shocking.”

George Mathew, MD

HIV in Children

The numbers of children with HIV in the United States tend to be small in comparison with the world’s estimated 2.5 million children under 15 living with the virus. From the start of the epidemic until 2002, 9,300 U.S. children under 13 had been reported to the CDC as living with HIV/AIDS. The majority of those children acquired the virus from their mothers before or during birth or through breast-feeding.

Most cases of HIV infection in infants are diagnosed at birth, according to Dr. Barton. With the advent of AZT (zidovudine) and HAART, only 92 new cases of pediatric AIDS were reported in 2002. The patterns of pediatric HIV/AIDS rates parallel those in adult groups: rates are higher among minority and economically disadvantaged inner-city populations.2

As with adult HIV populations, healthy children with HIV do not often present in the hospital setting because their condition is well controlled. However, Dr. Barton is seeing teenagers with acute retroviral syndrome—which occurs in those recently infected—and immigrant children with HIV-related diseases. The latter group, she says, do not have access to ongoing outpatient care, and their disease has gone undiagnosed until it brings them to the hospital.

The incidence of opportunistic infections differs in children, where pneumoncystis pneumonia (PCP) and cytomegalovirus (CMV) are primary infections. In adults these diseases usually result from the reactivation of latent infections. Lymphocytic interstitial pneumonitis is more common in children than in adults. Severe candidiasis, a yeast infection, can cause constant diaper rash or manifest as oral thrush.

Dr. Barton emphasizes that pediatric hospitalists should keep a low threshold for thinking about HIV when diagnosing children. Possible reasons to test for HIV include:

• Failure to thrive;
• Delayed developmental milestones, such as crawling, walking, and talking;
• Severe presentation of common illnesses, such as diarrhea;
• Chronic appearance of common illnesses, such as colds; and
• Seizures, fever, dehydration, and pneumonia.

Finding appropriate drug regimens for children with HIV can be even more of a challenge than for adult HIV patients. Children with HIV are treated with HAART. Many drugs approved for adults are not available in liquid form for younger children. Even if children can swallow pills, the dose may be too high for them. HAART in the pediatric setting also carries risks of multiple toxicities and drug resistance.

Drug interactions become a factor when, as is common, children develop seizures, says Dr. Barton. “It’s sometimes difficult to find drugs that don’t have a lot of interactions, so obtaining the advice of the pharmacist is really crucial,” she says.

Adolescents are a particularly troublesome subset of growing HIV cases. “By nature of their being adolescents, they do not routinely access care,” notes Dr. Barton. “There is a long window of time—often many years—before a patient becomes symptomatic, so they may not present until they are severely ill.”

Neil Winawer, MD

Inpatient Management

If and how hospitalists interact with HIV/AIDS patients depends on their institution’s resources, catchment area, and formal affiliations with teaching hospitals. Tomas Villanueva, DO, is a hospitalist at Baptist Hospital of Miami, a 650-bed not-for-profit hospital in South Florida.

“I’m one of those very spoiled hospitalists because I have everything and everybody available to me,” he says. “I have the good fortune to work with infectious disease doctors and with clinical pharmacologists.” Access to these consultants, he says, helps with admitting HIV patients taking antiretrovirals, especially when withdrawing oral nutrition is indicated.

“Atlanta has a large HIV-positive population,” notes Dr. Mathew. As in many U.S. urban centers, patients in Atlanta often present with opportunistic infections and end-stage AIDS. Dr. Mathew advises hospitalists to consult with the infectious disease specialist when HIV/AIDS patients are admitted. “You call the nephrologist when you have an end-stage renal disease patient, so you should call the ID [infectious disease] specialist when you have an HIV patient,” he says. “There are multiple presentations of antiretroviral toxicities, which most hospitalists do not know how to handle. Yet it is also not advisable to take them off their HAART presumptuously.” Dr. Mathew also observes that many HIV patients consider ID specialists their primary care providers, so it is important to respect that bond while patients are in the hospital.

Tomas Villanueva, DO

Accessing the expertise of ID specialists who work on the teaching service can help hospitalists stay abreast of treatment trends, notes Dr. Winawer. Because of Grady Memorial’s affiliation with Emory University, house staff can access the expertise of the university’s world-renowned ID program through the teaching service. As a result, house staff are more aware of issues related to treating HIV/AIDS, he says.

Hospitalists likely will not be the lead physicians for managing HIV/AIDS patients once admitted, especially if their institutions are affiliated with university teaching hospitals. However, hospitalists can still have an impact on providing essential public health messages and improving the quality of care. HIV and ID specialist Harry Hollander, MD, program director for the University of California at San Francisco Internal Medicine Residency Program and professor of Clinical Medicine at UCSF, notes that hospitalists can play a reinforcing role by educating patients to modify risk behaviors. For instance, he says, “If patients are admitted with complications of risk behaviors that may be associated with HIV infection—such as sexually transmitted infections, or medical problems related to injection drug use—addressing those issues becomes as important as imparting a smoking cessation message to someone who comes in with pneumonia or pulmonary problems.”

Emphasizing links to care is another key role for hospitalists. At Grady, reports Dr. Winawer, at least 60 inpatients with HIV/AIDS are being treated at any given time by the four immunology service teams run by the Department of Infectious Diseases, as well as 12 ward teams and four ICU teams.

Most indigent patients do not have strong social support, so Dr. Winawer emphasizes how hospitalists can provide compassionate care by collaborating with social workers. For example, HIV patients admitted to the hospital with respiratory illnesses might be placed in isolation to rule out tuberculosis. “Many times these patients do not have good family or other social support, and they are left in their room to dwell on their diagnosis. It can feel very isolating and demoralizing if they do not have knowledge of services that can be offered to them. So it is critical to involve social services at that time.”

Make a Difference at Discharge

Can hospitalists do a better job of acquainting themselves with community resources available to discharged patients? Dr. Mathew believes so but concedes hospitalists may not have the time. He notes that funding for HIV/AIDS outpatient clinics is at an all-time high, and social workers are expert in linking patients with outside resources.

Social workers at [an] ID clinic, he said, “are very, very attentive to the needs of their patients.”

Strong alliances with social workers are critical for hospitalists who see large numbers of indigent HIV/AIDS patients, says Dr. Winawer. “These patients often use the hospital as their primary care center,” he notes. “So the inpatient social workers know them better than their colleagues in the ID clinic do. A lot of the ‘bounce-backs’ we see are related to non-compliance [with therapy regimens], to substance abuse, or to other issues related to housing and environments that are not conducive to taking their medications.

“There are a lot of factors that cause our patients to not receive the best care upon their discharge. From my perspective as a hospitalist, once they no longer have criteria for hospitalization, much depends on patients’ willingness to do the things that you try to promote. Social services can play a big part so that [patients] don’t fall through the cracks due to their inability to afford medication or proper housing. From our experience, a highly functional network of social support is critical.”

Any encounter with the healthcare system is an opportunity for education. Dr. Villanueva includes education as one of his primary roles in dealing with HIV-positive patients. “I’m working now not only on education, but communication,” he says. “We pretty much have to be the physician champions in making sure we communicate with all parties.” TH

References

1. Revised recommendations for HIV testing of adults, adolescents and pregnant women in health-care settings. Morbidity and Mortality Weekly Report, September 22, 2006/ 55(RR14); 1-17. Available online at www.cdc.gov/mmwr/preview/mmwrhtml/rr5514a1.htm. Last accessed April 27, 2007.
2. HIV infection in infants and children. National Institute of Allergy and Infectious Diseases Fact Sheet, July 2004. Available at www.niaid.nih.gov/factsheets/hivchildren.htm. Last accessed May 22, 2007.

This is the second in a two-part series. Part 1 appeared in the July issue, p. 29.

While the HIV/AIDS epidemic rages worldwide—an estimated 40 million people have the virus—the lifespan for many HIV-positive patients in the U.S. continues to improve.

Patients on highly active antiretroviral therapy (HAART) live long enough to develop common age-related illnesses. Those without sufficient resources and/or social supports continue to present with AIDS-defining syndromes seen at the beginning of the epidemic. Hospitalists must face these different populations of HIV/AIDS patients and their unique challenges.

In the second part of our series, we address:

• The ramifications for hospitalists of the Centers for Disease Control and Prevention’s (CDC) revised HIV testing guidelines;
• Challenges specific to managing children with HIV; and
• Ways hospitalists can make a difference with HIV patients through social services collaboration, education, and counseling.

Testing Guidelines Shift

On Sept. 22, 2006, the CDC issued revised recommendations for HIV testing of adults, adolescents, and pregnant women in healthcare settings.1 Testing had previously been recommended only for high-risk individuals, such as injection drug users or those with multiple sex partners. The new recommendations advise testing all individuals 13 through 64 in all healthcare settings. In its rationale for extended testing, the CDC notes that of the 1 million to 1.2 million people thought to be living with HIV in the United States, nearly 25% are unaware of their infected status. Expansion of testing, the CDC argues, would mean earlier access to life-extending treatments and reduced transmission risk.

Expanded testing is a good idea, says Theresa Barton, MD, assistant professor of pediatrics at the University of Texas Southwestern Medical Center in Dallas. Dr. Barton is also a pediatric hospitalist and director of the AIDS Related Medical Services (ARM) Clinic at UT.

“According to the CDC, a large number of newly diagnosed HIV patients have no risk factor at all [other than sexual contact with a partner],” Dr. Barton says. “Many people, particularly heterosexuals, do not perceive having sex as a risk factor. That’s certainly the case for women who are pregnant. They report they have no risk factor when you know they have a risk factor by default because they’re pregnant.”

Testing should be offered to everyone in the hospital, agrees George Mathew, MD, a hospitalist with infectious disease training at Emory University Hospital in Atlanta, and instructor of medicine at Emory University Medical School. However, testing everyone who comes to the hospital may be impractical for two reasons, he believes:

• Hospitalists feel time constraints with other components of diagnosing and admitting patients; and
• Hospitalists will not be impelled to offer patients routine HIV testing unless it is mandated by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) as a core measure.

“Hospitalists will need help [from their institutions] in the introduction of this recommendation, maybe as an inclusion on a general admission form or as a prompt during computerized physician order entry (CPOE),” Dr. Mathew says.

Until universal testing of all inpatients is instituted, it is still advisable for hospitalists to include HIV testing in the diagnostic workup. Neil Winawer, MD, director of the hospitalist program at Grady Memorial, one of Emory University’s affiliated hospitals in Atlanta, advises that hospitalists “should always keep the diagnosis of HIV and AIDS on their radar screen in this day and age. There can be certain things in a patient’s profile that trigger you to think about testing for HIV, such as lymphopenia, recurrent infections, subtle evidence of weight loss, or alopecia.”

Theresa Barton, MD

Hospitalists should also heed how they introduce the need for the test. “To be honest, I think in many ways we have made the testing process too scary,” says Dr. Barton. She believes patients and their families may become unduly alarmed because of the emphasis on informed consent, as well as the secrecy of results. Her approach with families in the hospital or at the clinic is to tell parents she wants to do an HIV test to “make sure that every stone is uncovered” in making a diagnosis. “We should all do our best to explain to families what our plan is or what kind of testing we will be doing, whether it’s an HIV test or not,” she says.

Dr. Barton also cautions pediatric hospitalist colleagues to be sensitive to parents’ wishes when a diagnostic work-up includes a CD4 count or HIV test. If the child has been seen in an outpatient setting, it is possible the parents have not yet told their child that he or she is HIV-infected. “Try to be cognizant of the parents’ involvement and wishes,” she advises. “To have a perfect stranger [the hospitalist] tell you that you’re HIV-infected can be shocking.”

George Mathew, MD

HIV in Children

The numbers of children with HIV in the United States tend to be small in comparison with the world’s estimated 2.5 million children under 15 living with the virus. From the start of the epidemic until 2002, 9,300 U.S. children under 13 had been reported to the CDC as living with HIV/AIDS. The majority of those children acquired the virus from their mothers before or during birth or through breast-feeding.

Most cases of HIV infection in infants are diagnosed at birth, according to Dr. Barton. With the advent of AZT (zidovudine) and HAART, only 92 new cases of pediatric AIDS were reported in 2002. The patterns of pediatric HIV/AIDS rates parallel those in adult groups: rates are higher among minority and economically disadvantaged inner-city populations.2

As with adult HIV populations, healthy children with HIV do not often present in the hospital setting because their condition is well controlled. However, Dr. Barton is seeing teenagers with acute retroviral syndrome—which occurs in those recently infected—and immigrant children with HIV-related diseases. The latter group, she says, do not have access to ongoing outpatient care, and their disease has gone undiagnosed until it brings them to the hospital.

The incidence of opportunistic infections differs in children, where pneumoncystis pneumonia (PCP) and cytomegalovirus (CMV) are primary infections. In adults these diseases usually result from the reactivation of latent infections. Lymphocytic interstitial pneumonitis is more common in children than in adults. Severe candidiasis, a yeast infection, can cause constant diaper rash or manifest as oral thrush.

Dr. Barton emphasizes that pediatric hospitalists should keep a low threshold for thinking about HIV when diagnosing children. Possible reasons to test for HIV include:

• Failure to thrive;
• Delayed developmental milestones, such as crawling, walking, and talking;
• Severe presentation of common illnesses, such as diarrhea;
• Chronic appearance of common illnesses, such as colds; and
• Seizures, fever, dehydration, and pneumonia.

Finding appropriate drug regimens for children with HIV can be even more of a challenge than for adult HIV patients. Children with HIV are treated with HAART. Many drugs approved for adults are not available in liquid form for younger children. Even if children can swallow pills, the dose may be too high for them. HAART in the pediatric setting also carries risks of multiple toxicities and drug resistance.

Drug interactions become a factor when, as is common, children develop seizures, says Dr. Barton. “It’s sometimes difficult to find drugs that don’t have a lot of interactions, so obtaining the advice of the pharmacist is really crucial,” she says.

Adolescents are a particularly troublesome subset of growing HIV cases. “By nature of their being adolescents, they do not routinely access care,” notes Dr. Barton. “There is a long window of time—often many years—before a patient becomes symptomatic, so they may not present until they are severely ill.”

Neil Winawer, MD

Inpatient Management

If and how hospitalists interact with HIV/AIDS patients depends on their institution’s resources, catchment area, and formal affiliations with teaching hospitals. Tomas Villanueva, DO, is a hospitalist at Baptist Hospital of Miami, a 650-bed not-for-profit hospital in South Florida.

“I’m one of those very spoiled hospitalists because I have everything and everybody available to me,” he says. “I have the good fortune to work with infectious disease doctors and with clinical pharmacologists.” Access to these consultants, he says, helps with admitting HIV patients taking antiretrovirals, especially when withdrawing oral nutrition is indicated.

“Atlanta has a large HIV-positive population,” notes Dr. Mathew. As in many U.S. urban centers, patients in Atlanta often present with opportunistic infections and end-stage AIDS. Dr. Mathew advises hospitalists to consult with the infectious disease specialist when HIV/AIDS patients are admitted. “You call the nephrologist when you have an end-stage renal disease patient, so you should call the ID [infectious disease] specialist when you have an HIV patient,” he says. “There are multiple presentations of antiretroviral toxicities, which most hospitalists do not know how to handle. Yet it is also not advisable to take them off their HAART presumptuously.” Dr. Mathew also observes that many HIV patients consider ID specialists their primary care providers, so it is important to respect that bond while patients are in the hospital.

Tomas Villanueva, DO

Accessing the expertise of ID specialists who work on the teaching service can help hospitalists stay abreast of treatment trends, notes Dr. Winawer. Because of Grady Memorial’s affiliation with Emory University, house staff can access the expertise of the university’s world-renowned ID program through the teaching service. As a result, house staff are more aware of issues related to treating HIV/AIDS, he says.

Hospitalists likely will not be the lead physicians for managing HIV/AIDS patients once admitted, especially if their institutions are affiliated with university teaching hospitals. However, hospitalists can still have an impact on providing essential public health messages and improving the quality of care. HIV and ID specialist Harry Hollander, MD, program director for the University of California at San Francisco Internal Medicine Residency Program and professor of Clinical Medicine at UCSF, notes that hospitalists can play a reinforcing role by educating patients to modify risk behaviors. For instance, he says, “If patients are admitted with complications of risk behaviors that may be associated with HIV infection—such as sexually transmitted infections, or medical problems related to injection drug use—addressing those issues becomes as important as imparting a smoking cessation message to someone who comes in with pneumonia or pulmonary problems.”

Emphasizing links to care is another key role for hospitalists. At Grady, reports Dr. Winawer, at least 60 inpatients with HIV/AIDS are being treated at any given time by the four immunology service teams run by the Department of Infectious Diseases, as well as 12 ward teams and four ICU teams.

Most indigent patients do not have strong social support, so Dr. Winawer emphasizes how hospitalists can provide compassionate care by collaborating with social workers. For example, HIV patients admitted to the hospital with respiratory illnesses might be placed in isolation to rule out tuberculosis. “Many times these patients do not have good family or other social support, and they are left in their room to dwell on their diagnosis. It can feel very isolating and demoralizing if they do not have knowledge of services that can be offered to them. So it is critical to involve social services at that time.”

Make a Difference at Discharge

Can hospitalists do a better job of acquainting themselves with community resources available to discharged patients? Dr. Mathew believes so but concedes hospitalists may not have the time. He notes that funding for HIV/AIDS outpatient clinics is at an all-time high, and social workers are expert in linking patients with outside resources.

Social workers at [an] ID clinic, he said, “are very, very attentive to the needs of their patients.”

Strong alliances with social workers are critical for hospitalists who see large numbers of indigent HIV/AIDS patients, says Dr. Winawer. “These patients often use the hospital as their primary care center,” he notes. “So the inpatient social workers know them better than their colleagues in the ID clinic do. A lot of the ‘bounce-backs’ we see are related to non-compliance [with therapy regimens], to substance abuse, or to other issues related to housing and environments that are not conducive to taking their medications.

“There are a lot of factors that cause our patients to not receive the best care upon their discharge. From my perspective as a hospitalist, once they no longer have criteria for hospitalization, much depends on patients’ willingness to do the things that you try to promote. Social services can play a big part so that [patients] don’t fall through the cracks due to their inability to afford medication or proper housing. From our experience, a highly functional network of social support is critical.”

Any encounter with the healthcare system is an opportunity for education. Dr. Villanueva includes education as one of his primary roles in dealing with HIV-positive patients. “I’m working now not only on education, but communication,” he says. “We pretty much have to be the physician champions in making sure we communicate with all parties.” TH

References

1. Revised recommendations for HIV testing of adults, adolescents and pregnant women in health-care settings. Morbidity and Mortality Weekly Report, September 22, 2006/ 55(RR14); 1-17. Available online at www.cdc.gov/mmwr/preview/mmwrhtml/rr5514a1.htm. Last accessed April 27, 2007.
2. HIV infection in infants and children. National Institute of Allergy and Infectious Diseases Fact Sheet, July 2004. Available at www.niaid.nih.gov/factsheets/hivchildren.htm. Last accessed May 22, 2007.

This is the second in a two-part series. Part 1 appeared in the July issue, p. 29.

While the HIV/AIDS epidemic rages worldwide—an estimated 40 million people have the virus—the lifespan for many HIV-positive patients in the U.S. continues to improve.

Patients on highly active antiretroviral therapy (HAART) live long enough to develop common age-related illnesses. Those without sufficient resources and/or social supports continue to present with AIDS-defining syndromes seen at the beginning of the epidemic. Hospitalists must face these different populations of HIV/AIDS patients and their unique challenges.

In the second part of our series, we address:

• The ramifications for hospitalists of the Centers for Disease Control and Prevention’s (CDC) revised HIV testing guidelines;
• Challenges specific to managing children with HIV; and
• Ways hospitalists can make a difference with HIV patients through social services collaboration, education, and counseling.

Testing Guidelines Shift

On Sept. 22, 2006, the CDC issued revised recommendations for HIV testing of adults, adolescents, and pregnant women in healthcare settings.1 Testing had previously been recommended only for high-risk individuals, such as injection drug users or those with multiple sex partners. The new recommendations advise testing all individuals 13 through 64 in all healthcare settings. In its rationale for extended testing, the CDC notes that of the 1 million to 1.2 million people thought to be living with HIV in the United States, nearly 25% are unaware of their infected status. Expansion of testing, the CDC argues, would mean earlier access to life-extending treatments and reduced transmission risk.

Expanded testing is a good idea, says Theresa Barton, MD, assistant professor of pediatrics at the University of Texas Southwestern Medical Center in Dallas. Dr. Barton is also a pediatric hospitalist and director of the AIDS Related Medical Services (ARM) Clinic at UT.

“According to the CDC, a large number of newly diagnosed HIV patients have no risk factor at all [other than sexual contact with a partner],” Dr. Barton says. “Many people, particularly heterosexuals, do not perceive having sex as a risk factor. That’s certainly the case for women who are pregnant. They report they have no risk factor when you know they have a risk factor by default because they’re pregnant.”

Testing should be offered to everyone in the hospital, agrees George Mathew, MD, a hospitalist with infectious disease training at Emory University Hospital in Atlanta, and instructor of medicine at Emory University Medical School. However, testing everyone who comes to the hospital may be impractical for two reasons, he believes:

• Hospitalists feel time constraints with other components of diagnosing and admitting patients; and
• Hospitalists will not be impelled to offer patients routine HIV testing unless it is mandated by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) as a core measure.

“Hospitalists will need help [from their institutions] in the introduction of this recommendation, maybe as an inclusion on a general admission form or as a prompt during computerized physician order entry (CPOE),” Dr. Mathew says.

Until universal testing of all inpatients is instituted, it is still advisable for hospitalists to include HIV testing in the diagnostic workup. Neil Winawer, MD, director of the hospitalist program at Grady Memorial, one of Emory University’s affiliated hospitals in Atlanta, advises that hospitalists “should always keep the diagnosis of HIV and AIDS on their radar screen in this day and age. There can be certain things in a patient’s profile that trigger you to think about testing for HIV, such as lymphopenia, recurrent infections, subtle evidence of weight loss, or alopecia.”

Theresa Barton, MD

Hospitalists should also heed how they introduce the need for the test. “To be honest, I think in many ways we have made the testing process too scary,” says Dr. Barton. She believes patients and their families may become unduly alarmed because of the emphasis on informed consent, as well as the secrecy of results. Her approach with families in the hospital or at the clinic is to tell parents she wants to do an HIV test to “make sure that every stone is uncovered” in making a diagnosis. “We should all do our best to explain to families what our plan is or what kind of testing we will be doing, whether it’s an HIV test or not,” she says.

Dr. Barton also cautions pediatric hospitalist colleagues to be sensitive to parents’ wishes when a diagnostic work-up includes a CD4 count or HIV test. If the child has been seen in an outpatient setting, it is possible the parents have not yet told their child that he or she is HIV-infected. “Try to be cognizant of the parents’ involvement and wishes,” she advises. “To have a perfect stranger [the hospitalist] tell you that you’re HIV-infected can be shocking.”

George Mathew, MD

HIV in Children

The numbers of children with HIV in the United States tend to be small in comparison with the world’s estimated 2.5 million children under 15 living with the virus. From the start of the epidemic until 2002, 9,300 U.S. children under 13 had been reported to the CDC as living with HIV/AIDS. The majority of those children acquired the virus from their mothers before or during birth or through breast-feeding.

Most cases of HIV infection in infants are diagnosed at birth, according to Dr. Barton. With the advent of AZT (zidovudine) and HAART, only 92 new cases of pediatric AIDS were reported in 2002. The patterns of pediatric HIV/AIDS rates parallel those in adult groups: rates are higher among minority and economically disadvantaged inner-city populations.2

As with adult HIV populations, healthy children with HIV do not often present in the hospital setting because their condition is well controlled. However, Dr. Barton is seeing teenagers with acute retroviral syndrome—which occurs in those recently infected—and immigrant children with HIV-related diseases. The latter group, she says, do not have access to ongoing outpatient care, and their disease has gone undiagnosed until it brings them to the hospital.

The incidence of opportunistic infections differs in children, where pneumoncystis pneumonia (PCP) and cytomegalovirus (CMV) are primary infections. In adults these diseases usually result from the reactivation of latent infections. Lymphocytic interstitial pneumonitis is more common in children than in adults. Severe candidiasis, a yeast infection, can cause constant diaper rash or manifest as oral thrush.

Dr. Barton emphasizes that pediatric hospitalists should keep a low threshold for thinking about HIV when diagnosing children. Possible reasons to test for HIV include:

• Failure to thrive;
• Delayed developmental milestones, such as crawling, walking, and talking;
• Severe presentation of common illnesses, such as diarrhea;
• Chronic appearance of common illnesses, such as colds; and
• Seizures, fever, dehydration, and pneumonia.

Finding appropriate drug regimens for children with HIV can be even more of a challenge than for adult HIV patients. Children with HIV are treated with HAART. Many drugs approved for adults are not available in liquid form for younger children. Even if children can swallow pills, the dose may be too high for them. HAART in the pediatric setting also carries risks of multiple toxicities and drug resistance.

Drug interactions become a factor when, as is common, children develop seizures, says Dr. Barton. “It’s sometimes difficult to find drugs that don’t have a lot of interactions, so obtaining the advice of the pharmacist is really crucial,” she says.

Adolescents are a particularly troublesome subset of growing HIV cases. “By nature of their being adolescents, they do not routinely access care,” notes Dr. Barton. “There is a long window of time—often many years—before a patient becomes symptomatic, so they may not present until they are severely ill.”

Neil Winawer, MD

Inpatient Management

If and how hospitalists interact with HIV/AIDS patients depends on their institution’s resources, catchment area, and formal affiliations with teaching hospitals. Tomas Villanueva, DO, is a hospitalist at Baptist Hospital of Miami, a 650-bed not-for-profit hospital in South Florida.

“I’m one of those very spoiled hospitalists because I have everything and everybody available to me,” he says. “I have the good fortune to work with infectious disease doctors and with clinical pharmacologists.” Access to these consultants, he says, helps with admitting HIV patients taking antiretrovirals, especially when withdrawing oral nutrition is indicated.

“Atlanta has a large HIV-positive population,” notes Dr. Mathew. As in many U.S. urban centers, patients in Atlanta often present with opportunistic infections and end-stage AIDS. Dr. Mathew advises hospitalists to consult with the infectious disease specialist when HIV/AIDS patients are admitted. “You call the nephrologist when you have an end-stage renal disease patient, so you should call the ID [infectious disease] specialist when you have an HIV patient,” he says. “There are multiple presentations of antiretroviral toxicities, which most hospitalists do not know how to handle. Yet it is also not advisable to take them off their HAART presumptuously.” Dr. Mathew also observes that many HIV patients consider ID specialists their primary care providers, so it is important to respect that bond while patients are in the hospital.

Tomas Villanueva, DO

Accessing the expertise of ID specialists who work on the teaching service can help hospitalists stay abreast of treatment trends, notes Dr. Winawer. Because of Grady Memorial’s affiliation with Emory University, house staff can access the expertise of the university’s world-renowned ID program through the teaching service. As a result, house staff are more aware of issues related to treating HIV/AIDS, he says.

Hospitalists likely will not be the lead physicians for managing HIV/AIDS patients once admitted, especially if their institutions are affiliated with university teaching hospitals. However, hospitalists can still have an impact on providing essential public health messages and improving the quality of care. HIV and ID specialist Harry Hollander, MD, program director for the University of California at San Francisco Internal Medicine Residency Program and professor of Clinical Medicine at UCSF, notes that hospitalists can play a reinforcing role by educating patients to modify risk behaviors. For instance, he says, “If patients are admitted with complications of risk behaviors that may be associated with HIV infection—such as sexually transmitted infections, or medical problems related to injection drug use—addressing those issues becomes as important as imparting a smoking cessation message to someone who comes in with pneumonia or pulmonary problems.”

Emphasizing links to care is another key role for hospitalists. At Grady, reports Dr. Winawer, at least 60 inpatients with HIV/AIDS are being treated at any given time by the four immunology service teams run by the Department of Infectious Diseases, as well as 12 ward teams and four ICU teams.

Most indigent patients do not have strong social support, so Dr. Winawer emphasizes how hospitalists can provide compassionate care by collaborating with social workers. For example, HIV patients admitted to the hospital with respiratory illnesses might be placed in isolation to rule out tuberculosis. “Many times these patients do not have good family or other social support, and they are left in their room to dwell on their diagnosis. It can feel very isolating and demoralizing if they do not have knowledge of services that can be offered to them. So it is critical to involve social services at that time.”

Make a Difference at Discharge

Can hospitalists do a better job of acquainting themselves with community resources available to discharged patients? Dr. Mathew believes so but concedes hospitalists may not have the time. He notes that funding for HIV/AIDS outpatient clinics is at an all-time high, and social workers are expert in linking patients with outside resources.

Social workers at [an] ID clinic, he said, “are very, very attentive to the needs of their patients.”

Strong alliances with social workers are critical for hospitalists who see large numbers of indigent HIV/AIDS patients, says Dr. Winawer. “These patients often use the hospital as their primary care center,” he notes. “So the inpatient social workers know them better than their colleagues in the ID clinic do. A lot of the ‘bounce-backs’ we see are related to non-compliance [with therapy regimens], to substance abuse, or to other issues related to housing and environments that are not conducive to taking their medications.

“There are a lot of factors that cause our patients to not receive the best care upon their discharge. From my perspective as a hospitalist, once they no longer have criteria for hospitalization, much depends on patients’ willingness to do the things that you try to promote. Social services can play a big part so that [patients] don’t fall through the cracks due to their inability to afford medication or proper housing. From our experience, a highly functional network of social support is critical.”

Any encounter with the healthcare system is an opportunity for education. Dr. Villanueva includes education as one of his primary roles in dealing with HIV-positive patients. “I’m working now not only on education, but communication,” he says. “We pretty much have to be the physician champions in making sure we communicate with all parties.” TH

References

1. Revised recommendations for HIV testing of adults, adolescents and pregnant women in health-care settings. Morbidity and Mortality Weekly Report, September 22, 2006/ 55(RR14); 1-17. Available online at www.cdc.gov/mmwr/preview/mmwrhtml/rr5514a1.htm. Last accessed April 27, 2007.
2. HIV infection in infants and children. National Institute of Allergy and Infectious Diseases Fact Sheet, July 2004. Available at www.niaid.nih.gov/factsheets/hivchildren.htm. Last accessed May 22, 2007.

Early in his career, hospitalist Richard Bailey, MD, encountered a widow from the inner city with no family. She was blind, and had been weakened and debilitated by a very challenging hospital course with many iatrogenic complications. “I was first struck, walking into her room,” recalls Dr. Bailey, “that she had a Bible on the table next to her bed. While making conversation, I mentioned this and instinctively asked her if she needed someone to read it to her. She smiled, and asked if I would oblige. I closed the door, sat down, and read her some of her favorite passages. This went on for several days until I went off service.”

Now medical director of Inpatient Care and Hospitalist Services at Saint Clare’s Hospital, a Catholic hospital in Wausau, Wis., Dr. Bailey says he is not an overtly religious person and that his spiritual life is rather private. “But I do like to have that depth of connection with my patients,” he says.

So if a patient or a family member asks him to pray with them, Dr. Bailey does so. “I cannot separate my humanness, which includes spirituality, from my work,” he explains.

When faced with serious or life-threatening medical conditions, patients and their family members are more likely to invoke their faith to cope with the attendant anxieties.

William D. Atchley Jr., MD, medical director of the Division of Hospital Medicine for Sentara Medical Group in Hampton, Va., believes that joining his patients in prayer, when asked, “helps develop a better relationship with the family and patient.”

Many Americans tend to “live in the here and now,” notes Carol R. Taylor, RN, MSN, PhD, director of the Center for Clinical Bioethics at Georgetown University. “They usually do not ask the bigger questions so long as life is good. But when life as we know it is threatened by illness, the bigger questions can become very important: ‘Is there anything beyond the here and now? And if so, where do I stand in relation to that God or higher power?’ ”

Prayer is a common response when patients face perilous medical situations.

“The vast majority of patients who are feeling imperiled due to a severe diagnosis or potential mortality is going to be praying,” says Stephen G. Post, PhD, professor and associate director for educational programs, department of bioethics at Case Western Reserve University, Cleveland. “In a way, you can’t get away from those requests.”

Are hospitalists and their institutions fully equipped to respond to the spiritual aspect of caregiving? Some researchers note that biomedicine often regards faith and spiritual world views as relevant only when they obstruct implementation of scientifically sound medical care.1 Studies have also shown healthcare professionals are less likely than their patients to actively practice a religion.

“There’s very often a mismatch between patients and families who would value that intervention and our comfort in being able to be responsive,” says Dr. Taylor, who is also an assistant professor of nursing.

Dr. Taylor and other bioethicists increasingly urge medical practitioners to include spiritual needs when they take a patient’s history. Timely referrals to chaplaincy services, knowledge of the dominant faiths and ethnic traditions in their hospitals’ catchment areas, and improvement of interpersonal skills can allow hospitalists to compassionately and ethically address their patients’ spiritual concerns.

Need to Do a Better Job

The holistic view of medicine defines health as a multidimensional construct that includes the physical, emotional, and social aspects of the patient. This view should be matched with a holistic approach to healthcare delivery that encompasses patients’ subjective illness experience, says Dr. Post.

Dr. Taylor concedes that the medical community’s recognition of patients’ spiritual needs is growing. And yet, she says, practitioners are not held accountable for delivering spiritual care, “which I think is a failing of healthcare as it is practiced today.”

Many reports have indicated patients are unhappy with the low referral rates to pastoral clinical care, adds Dr. Post.2

Assessment Essential

Incorporate a spiritual-needs assessment when taking each patient’s history upon admittance, the two bioethicists agree. This assessment usually takes the form of questions such as:

• What is your source of strength?
• Is spirituality/religion important to you? (If the patient answers “yes,” proceed to the next question.)
• How would you like us to facilitate your needs?
• Would you like a referral to pastoral care?

Once patients indicate they would like to speak with a chaplain, referral to appropriate clergy trained in pastoral care is essential.

“All physicians need to be respectful of these kinds of appeals,” says Dr. Post. “But they should feel free to make a referral to those who are, in fact, competently trained to deal with this specific area of life.”

While opposed to professional separatism, Dr. Post does argue for keeping “friendly, knee-high white fences” between physicians and pastoral counselors to maintain professional boundaries.3

Marc B. Westle, DO, FACP, president and managing partner of Asheville Hospitalist Group, PA, in North Carolina, agrees with this approach. “As a professional, I completely respect and empathize with the patient’s and the family’s spiritual needs as part of the total care of the patient,” he says. “Just as in other areas where I may not have expertise, I refer to our in-house professionals. We have an excellent chaplaincy service that we involve all the time, on a routine basis.” He says the chaplaincy service at Mission Hospital is in-house 24/7, just as the hospitalists are, and make rounds as the physicians do.

Availability of trained clergy differs from institution to institution, notes Dr. Taylor. She recently visited a metropolitan research institution where the two staff chaplains estimate there are nearly 1,000 daily patient contacts. With this many patients flowing through the facility, the chaplains rely on medical staff to triage patients’ and families’ needs so they can be referred to families who will benefit most from their help. In busy urban hospitals, pastoral coverage may not always be available, and the burden of addressing spiritual requests can fall to the hospital medicine team.

The Comfort Zone

The question of whether to pray with a patient or family member depends on the physician’s comfort with doing so.

• Rule No. 1 when it comes to the question of prayer with/for a patient or family: Clinicians should never proselytize or initiate the prayer. This can constitute a serious breach of professional boundaries.4
• Balancing the need to support patients’ emotional needs while respecting one’s integrity can be difficult. If a physician feels comfortable, it is appropriate to pray with a patient. Or, a physician can offer to sit quietly while a patient prays. If uncomfortable with this scenario, offering to keep the patient in your thoughts is one way to still be supportive while maintaining the integrity of your beliefs.3

“I think most physicians try to be very sensitive to these matters,” says Dr. Post.

Dr. Westle notes he has provided more companionate care (“hugging family and patients, sitting and talking about the good old days”) than spiritual guidance.

“Some patients and families feel supported simply by their doctor or nurse joining in a moment of silence or even holding hands during a spoken prayer,” adds Dr. Taylor. “Some of us are better than others at identifying and responding to spiritual needs. But I do think it’s a shared responsibility. The more people we can engage in identifying and responding to spiritual needs, the better patient, family, and medical team will be served. Hospitalists are in an excellent position to identify those needs because of their everyday contact. And if they simply make the right referrals, they’ve done a really good job.” TH

Gretchen Henkel writes frequently for The Hospitalist.

References

1. Barnes LL, Plotnikoff GA, Fox K, et al. Spirituality, religion, and pediatrics: intersecting worlds of healing. Pediatrics 2000 Oct;106(4 Suppl):899-908.
2. Post SG, Puchalski CM, Larson DB. Physicians and Patient Spirituality: Professional Boundaries, Competency, and Ethics. Ann Intern Med. 2000 April 4;132(7):578-583. Comment in: Ann Intern Med. 2000 Dec 5;133(11):920-1; Ann Intern Med. 2000 Nov 7;133(9):748-9.
3. Kwiatkowski K, Arnold B, Barnard D. Physicians and Prayer Requests. Fast Fact and Concept #120. Available at www.eperc.mcw.edu/fastFact/ff_120.htm. Last accessed April 5, 2007.
4. Taylor C, Lillis C, LeMone P. Fundamentals of Nursing: The Art and Science of Nursing Care, 5th ed. 2005. Philadelphia: Lippincott, Williams & Wilkins; 2005.

Early in his career, hospitalist Richard Bailey, MD, encountered a widow from the inner city with no family. She was blind, and had been weakened and debilitated by a very challenging hospital course with many iatrogenic complications. “I was first struck, walking into her room,” recalls Dr. Bailey, “that she had a Bible on the table next to her bed. While making conversation, I mentioned this and instinctively asked her if she needed someone to read it to her. She smiled, and asked if I would oblige. I closed the door, sat down, and read her some of her favorite passages. This went on for several days until I went off service.”

Now medical director of Inpatient Care and Hospitalist Services at Saint Clare’s Hospital, a Catholic hospital in Wausau, Wis., Dr. Bailey says he is not an overtly religious person and that his spiritual life is rather private. “But I do like to have that depth of connection with my patients,” he says.

So if a patient or a family member asks him to pray with them, Dr. Bailey does so. “I cannot separate my humanness, which includes spirituality, from my work,” he explains.

When faced with serious or life-threatening medical conditions, patients and their family members are more likely to invoke their faith to cope with the attendant anxieties.

William D. Atchley Jr., MD, medical director of the Division of Hospital Medicine for Sentara Medical Group in Hampton, Va., believes that joining his patients in prayer, when asked, “helps develop a better relationship with the family and patient.”

Many Americans tend to “live in the here and now,” notes Carol R. Taylor, RN, MSN, PhD, director of the Center for Clinical Bioethics at Georgetown University. “They usually do not ask the bigger questions so long as life is good. But when life as we know it is threatened by illness, the bigger questions can become very important: ‘Is there anything beyond the here and now? And if so, where do I stand in relation to that God or higher power?’ ”

Prayer is a common response when patients face perilous medical situations.

“The vast majority of patients who are feeling imperiled due to a severe diagnosis or potential mortality is going to be praying,” says Stephen G. Post, PhD, professor and associate director for educational programs, department of bioethics at Case Western Reserve University, Cleveland. “In a way, you can’t get away from those requests.”

Are hospitalists and their institutions fully equipped to respond to the spiritual aspect of caregiving? Some researchers note that biomedicine often regards faith and spiritual world views as relevant only when they obstruct implementation of scientifically sound medical care.1 Studies have also shown healthcare professionals are less likely than their patients to actively practice a religion.

“There’s very often a mismatch between patients and families who would value that intervention and our comfort in being able to be responsive,” says Dr. Taylor, who is also an assistant professor of nursing.

Dr. Taylor and other bioethicists increasingly urge medical practitioners to include spiritual needs when they take a patient’s history. Timely referrals to chaplaincy services, knowledge of the dominant faiths and ethnic traditions in their hospitals’ catchment areas, and improvement of interpersonal skills can allow hospitalists to compassionately and ethically address their patients’ spiritual concerns.

Need to Do a Better Job

The holistic view of medicine defines health as a multidimensional construct that includes the physical, emotional, and social aspects of the patient. This view should be matched with a holistic approach to healthcare delivery that encompasses patients’ subjective illness experience, says Dr. Post.

Dr. Taylor concedes that the medical community’s recognition of patients’ spiritual needs is growing. And yet, she says, practitioners are not held accountable for delivering spiritual care, “which I think is a failing of healthcare as it is practiced today.”

Many reports have indicated patients are unhappy with the low referral rates to pastoral clinical care, adds Dr. Post.2

Assessment Essential

Incorporate a spiritual-needs assessment when taking each patient’s history upon admittance, the two bioethicists agree. This assessment usually takes the form of questions such as:

• What is your source of strength?
• Is spirituality/religion important to you? (If the patient answers “yes,” proceed to the next question.)
• How would you like us to facilitate your needs?
• Would you like a referral to pastoral care?

Once patients indicate they would like to speak with a chaplain, referral to appropriate clergy trained in pastoral care is essential.

“All physicians need to be respectful of these kinds of appeals,” says Dr. Post. “But they should feel free to make a referral to those who are, in fact, competently trained to deal with this specific area of life.”

While opposed to professional separatism, Dr. Post does argue for keeping “friendly, knee-high white fences” between physicians and pastoral counselors to maintain professional boundaries.3

Marc B. Westle, DO, FACP, president and managing partner of Asheville Hospitalist Group, PA, in North Carolina, agrees with this approach. “As a professional, I completely respect and empathize with the patient’s and the family’s spiritual needs as part of the total care of the patient,” he says. “Just as in other areas where I may not have expertise, I refer to our in-house professionals. We have an excellent chaplaincy service that we involve all the time, on a routine basis.” He says the chaplaincy service at Mission Hospital is in-house 24/7, just as the hospitalists are, and make rounds as the physicians do.

Availability of trained clergy differs from institution to institution, notes Dr. Taylor. She recently visited a metropolitan research institution where the two staff chaplains estimate there are nearly 1,000 daily patient contacts. With this many patients flowing through the facility, the chaplains rely on medical staff to triage patients’ and families’ needs so they can be referred to families who will benefit most from their help. In busy urban hospitals, pastoral coverage may not always be available, and the burden of addressing spiritual requests can fall to the hospital medicine team.

The Comfort Zone

The question of whether to pray with a patient or family member depends on the physician’s comfort with doing so.

• Rule No. 1 when it comes to the question of prayer with/for a patient or family: Clinicians should never proselytize or initiate the prayer. This can constitute a serious breach of professional boundaries.4
• Balancing the need to support patients’ emotional needs while respecting one’s integrity can be difficult. If a physician feels comfortable, it is appropriate to pray with a patient. Or, a physician can offer to sit quietly while a patient prays. If uncomfortable with this scenario, offering to keep the patient in your thoughts is one way to still be supportive while maintaining the integrity of your beliefs.3

“I think most physicians try to be very sensitive to these matters,” says Dr. Post.

Dr. Westle notes he has provided more companionate care (“hugging family and patients, sitting and talking about the good old days”) than spiritual guidance.

“Some patients and families feel supported simply by their doctor or nurse joining in a moment of silence or even holding hands during a spoken prayer,” adds Dr. Taylor. “Some of us are better than others at identifying and responding to spiritual needs. But I do think it’s a shared responsibility. The more people we can engage in identifying and responding to spiritual needs, the better patient, family, and medical team will be served. Hospitalists are in an excellent position to identify those needs because of their everyday contact. And if they simply make the right referrals, they’ve done a really good job.” TH

Gretchen Henkel writes frequently for The Hospitalist.

References

1. Barnes LL, Plotnikoff GA, Fox K, et al. Spirituality, religion, and pediatrics: intersecting worlds of healing. Pediatrics 2000 Oct;106(4 Suppl):899-908.
2. Post SG, Puchalski CM, Larson DB. Physicians and Patient Spirituality: Professional Boundaries, Competency, and Ethics. Ann Intern Med. 2000 April 4;132(7):578-583. Comment in: Ann Intern Med. 2000 Dec 5;133(11):920-1; Ann Intern Med. 2000 Nov 7;133(9):748-9.
3. Kwiatkowski K, Arnold B, Barnard D. Physicians and Prayer Requests. Fast Fact and Concept #120. Available at www.eperc.mcw.edu/fastFact/ff_120.htm. Last accessed April 5, 2007.
4. Taylor C, Lillis C, LeMone P. Fundamentals of Nursing: The Art and Science of Nursing Care, 5th ed. 2005. Philadelphia: Lippincott, Williams & Wilkins; 2005.

Early in his career, hospitalist Richard Bailey, MD, encountered a widow from the inner city with no family. She was blind, and had been weakened and debilitated by a very challenging hospital course with many iatrogenic complications. “I was first struck, walking into her room,” recalls Dr. Bailey, “that she had a Bible on the table next to her bed. While making conversation, I mentioned this and instinctively asked her if she needed someone to read it to her. She smiled, and asked if I would oblige. I closed the door, sat down, and read her some of her favorite passages. This went on for several days until I went off service.”

Now medical director of Inpatient Care and Hospitalist Services at Saint Clare’s Hospital, a Catholic hospital in Wausau, Wis., Dr. Bailey says he is not an overtly religious person and that his spiritual life is rather private. “But I do like to have that depth of connection with my patients,” he says.

So if a patient or a family member asks him to pray with them, Dr. Bailey does so. “I cannot separate my humanness, which includes spirituality, from my work,” he explains.

When faced with serious or life-threatening medical conditions, patients and their family members are more likely to invoke their faith to cope with the attendant anxieties.

William D. Atchley Jr., MD, medical director of the Division of Hospital Medicine for Sentara Medical Group in Hampton, Va., believes that joining his patients in prayer, when asked, “helps develop a better relationship with the family and patient.”

Many Americans tend to “live in the here and now,” notes Carol R. Taylor, RN, MSN, PhD, director of the Center for Clinical Bioethics at Georgetown University. “They usually do not ask the bigger questions so long as life is good. But when life as we know it is threatened by illness, the bigger questions can become very important: ‘Is there anything beyond the here and now? And if so, where do I stand in relation to that God or higher power?’ ”

Prayer is a common response when patients face perilous medical situations.

“The vast majority of patients who are feeling imperiled due to a severe diagnosis or potential mortality is going to be praying,” says Stephen G. Post, PhD, professor and associate director for educational programs, department of bioethics at Case Western Reserve University, Cleveland. “In a way, you can’t get away from those requests.”

Are hospitalists and their institutions fully equipped to respond to the spiritual aspect of caregiving? Some researchers note that biomedicine often regards faith and spiritual world views as relevant only when they obstruct implementation of scientifically sound medical care.1 Studies have also shown healthcare professionals are less likely than their patients to actively practice a religion.

“There’s very often a mismatch between patients and families who would value that intervention and our comfort in being able to be responsive,” says Dr. Taylor, who is also an assistant professor of nursing.

Dr. Taylor and other bioethicists increasingly urge medical practitioners to include spiritual needs when they take a patient’s history. Timely referrals to chaplaincy services, knowledge of the dominant faiths and ethnic traditions in their hospitals’ catchment areas, and improvement of interpersonal skills can allow hospitalists to compassionately and ethically address their patients’ spiritual concerns.

Need to Do a Better Job

The holistic view of medicine defines health as a multidimensional construct that includes the physical, emotional, and social aspects of the patient. This view should be matched with a holistic approach to healthcare delivery that encompasses patients’ subjective illness experience, says Dr. Post.

Dr. Taylor concedes that the medical community’s recognition of patients’ spiritual needs is growing. And yet, she says, practitioners are not held accountable for delivering spiritual care, “which I think is a failing of healthcare as it is practiced today.”

Many reports have indicated patients are unhappy with the low referral rates to pastoral clinical care, adds Dr. Post.2

Assessment Essential

Incorporate a spiritual-needs assessment when taking each patient’s history upon admittance, the two bioethicists agree. This assessment usually takes the form of questions such as:

• What is your source of strength?
• Is spirituality/religion important to you? (If the patient answers “yes,” proceed to the next question.)
• How would you like us to facilitate your needs?
• Would you like a referral to pastoral care?

Once patients indicate they would like to speak with a chaplain, referral to appropriate clergy trained in pastoral care is essential.

“All physicians need to be respectful of these kinds of appeals,” says Dr. Post. “But they should feel free to make a referral to those who are, in fact, competently trained to deal with this specific area of life.”

While opposed to professional separatism, Dr. Post does argue for keeping “friendly, knee-high white fences” between physicians and pastoral counselors to maintain professional boundaries.3

Marc B. Westle, DO, FACP, president and managing partner of Asheville Hospitalist Group, PA, in North Carolina, agrees with this approach. “As a professional, I completely respect and empathize with the patient’s and the family’s spiritual needs as part of the total care of the patient,” he says. “Just as in other areas where I may not have expertise, I refer to our in-house professionals. We have an excellent chaplaincy service that we involve all the time, on a routine basis.” He says the chaplaincy service at Mission Hospital is in-house 24/7, just as the hospitalists are, and make rounds as the physicians do.

Availability of trained clergy differs from institution to institution, notes Dr. Taylor. She recently visited a metropolitan research institution where the two staff chaplains estimate there are nearly 1,000 daily patient contacts. With this many patients flowing through the facility, the chaplains rely on medical staff to triage patients’ and families’ needs so they can be referred to families who will benefit most from their help. In busy urban hospitals, pastoral coverage may not always be available, and the burden of addressing spiritual requests can fall to the hospital medicine team.

The Comfort Zone

The question of whether to pray with a patient or family member depends on the physician’s comfort with doing so.

• Rule No. 1 when it comes to the question of prayer with/for a patient or family: Clinicians should never proselytize or initiate the prayer. This can constitute a serious breach of professional boundaries.4
• Balancing the need to support patients’ emotional needs while respecting one’s integrity can be difficult. If a physician feels comfortable, it is appropriate to pray with a patient. Or, a physician can offer to sit quietly while a patient prays. If uncomfortable with this scenario, offering to keep the patient in your thoughts is one way to still be supportive while maintaining the integrity of your beliefs.3

“I think most physicians try to be very sensitive to these matters,” says Dr. Post.

Dr. Westle notes he has provided more companionate care (“hugging family and patients, sitting and talking about the good old days”) than spiritual guidance.

“Some patients and families feel supported simply by their doctor or nurse joining in a moment of silence or even holding hands during a spoken prayer,” adds Dr. Taylor. “Some of us are better than others at identifying and responding to spiritual needs. But I do think it’s a shared responsibility. The more people we can engage in identifying and responding to spiritual needs, the better patient, family, and medical team will be served. Hospitalists are in an excellent position to identify those needs because of their everyday contact. And if they simply make the right referrals, they’ve done a really good job.” TH

Gretchen Henkel writes frequently for The Hospitalist.

References

1. Barnes LL, Plotnikoff GA, Fox K, et al. Spirituality, religion, and pediatrics: intersecting worlds of healing. Pediatrics 2000 Oct;106(4 Suppl):899-908.
2. Post SG, Puchalski CM, Larson DB. Physicians and Patient Spirituality: Professional Boundaries, Competency, and Ethics. Ann Intern Med. 2000 April 4;132(7):578-583. Comment in: Ann Intern Med. 2000 Dec 5;133(11):920-1; Ann Intern Med. 2000 Nov 7;133(9):748-9.
3. Kwiatkowski K, Arnold B, Barnard D. Physicians and Prayer Requests. Fast Fact and Concept #120. Available at www.eperc.mcw.edu/fastFact/ff_120.htm. Last accessed April 5, 2007.
4. Taylor C, Lillis C, LeMone P. Fundamentals of Nursing: The Art and Science of Nursing Care, 5th ed. 2005. Philadelphia: Lippincott, Williams & Wilkins; 2005.

This is the first of a two-part series on care of the HIV/AIDS patient. Part 2 will address the public health and counseling aspects of HIV management, as well as the care of children with HIV.

It’s been a little more than a quarter-century since acquired immune deficiency syndrome (AIDS) was first identified. Since 1981, many facets of our understanding and management of HIV/AIDS have changed.

In some populations, HIV (when well-controlled) has been transformed to a chronic disease state, with few episodes of the AIDS-defining conditions (opportunistic infections, Kaposi’s sarcoma, wasting syndromes) seen in the early years of the epidemic. However, when treating underserved and indigent populations, hospitalists may still encounter the common symptoms of advanced disease in their HIV-positive patients.

What are the common presenting scenarios of HIV/AIDS seen by hospitalists in the current era of highly active antiretroviral therapy (HAART), and how does antiretroviral therapy affect hospitalists’ management of these patients? The Hospitalist recently interviewed HIV/AIDS specialists and practicing hospitalists to learn find out.

The Differential Diagnosis: Think Broadly

The Centers for Disease Control and Prevention estimates 1.04 million to 1.19 million people live with HIV/AIDS in the United States. The CDC also estimates approximately 40,000 people become infected with HIV each year.1

The conditions that bring HIV-positive patients to the hospital run the gamut. There is a broad range of presenting symptoms, noted Sigall K. Bell, MD, the Division of Infectious Diseases and General Medicine at Harvard Medical School and Beth Israel Deaconess Medical Center in Boston. “The differential diagnoses for patients who are HIV-infected—depending on their immunological status—can be dramatically expanded compared to HIV-negative patients,” says Dr. Bell. “For any given presenting symptom, one needs to think about whether the person’s HIV itself, an opportunistic infection secondary to the HIV, or HIV medication effects are playing into potential explanations for the presenting symptoms.”

Even the demographics of the hospital’s catchment area can be associated with patients’ problems. “The types of problems seen in hospitalized HIV-infected patients largely depends on the degree of access to care that people have,” says HIV and infectious disease specialist Harry Hollander, MD, program director for the University of California, San Francisco Internal Medicine Residency Program, and professor of Clinical Medicine at UCSF. In areas where care systems are not robust, explains Dr. Hollander, people admitted to the hospital will most likely have the same problems seen at the beginning of the epidemic.

If hospitalists are practicing in areas with highly developed systems of care and good penetration of care, people with HIV are just as likely to be admitted to the hospital with problems completely unrelated to their HIV status. In the pre-antiretroviral era, according to Dr. Hollander, hospital physicians typically saw three or four common types of presentations in these patients. “My biggest message these days,” he says, “is to think broadly about the problems these patients present with, and to generate parallel thinking about HIV-related causes as well as causes not related to HIV. Many patients with well-controlled HIV are more likely to wind up in the hospital because of other routine medical problems. If you only consider the HIV status, you may be missing other important, related and treatable conditions.”

Thomas Baudendistel, MD, who is associate residency program director at California Pacific Medical Center, a community-based hospital in San Francisco operated by Sutter Health, confirms that as HIV patients are getting healthier, “their immune systems are being kept intact [with CD4 counts in the normal range] for longer periods of time. We don’t see issues of HIV-related conditions in hospitalization as much as we did 20, 10, or even five years ago. The life-threatening opportunistic infections, although still there, have receded as cause for hospitalization. When an HIV patient gets admitted, it’s just as likely to be a noninfectious condition, such as lymphoma, or hematologic complications. Or, the patients may be old enough to have heart disease or COPD.”

Dr. Sabharwal

Other hospitalists practice in areas where the opposite is true. Aman D. Sabharwal, MD, is associate medical director, Inpatient and Hospitalist Services for Jackson Health Systems and practices primarily at Jackson Memorial Hospital, which serves a large indigent population in south Florida. While he agrees that some HIV patients are being well-managed because of advances in antiretroviral therapy, these are not the patients seen by hospitalists in his group.

“A majority of our HIV-positive patients come in for illnesses or opportunistic infections that are due to their HIV,” he says. “Most of these patients are either noncompliant with their medications or have low CD4 counts. Generally, the acute issue for which they are admitted is generally unrelated to the medication itself—it is probably due more so to the lack of medication.”

Dr. Bell

Dr. Baudendistel reports that he and fellow hospitalists at California Pacific Medical Center are also seeing more immune reconstitution illness, in which the reconstituted immune system exhibits an “overexuberant” reaction, causing unique presentations. For example, patients with low CD4 counts who have clinically silent infection with Mycobacterium Avium Complex, hepatitis B, or a variety of infectious agents may experience a significant boost in their CD4 count with antiretroviral therapy. The resurgent immune system can then mount a response to these previously quiescent pathogens, causing a flare-up of symptoms.

“If the primary site of occult disease is the lungs, a respiratory exacerbation will occur; if in the liver, as in the example of hepatitis B, a significant hepatitis can ensue,” says Dr. Baudendistel.

Call in Consultants: Keep a Low Threshold

As the management of HIV becomes more sophisticated, hospitalists should frequently consult infectious-disease and consulting pharmacy colleagues. “I think the hospitalist is very well-equipped to deal with the acute illnesses that these patients have,” notes Dr. Hollander. “Most hospitalists feel less comfortable with the details of managing the chronic medical regimen—particularly the antiretroviral drugs, which they don’t have an opportunity to prescribe, manage, and monitor over time.”

Dr. Baudendistel concurs: “As a hospitalist, what I face with these patients—especially if they come in with an illness unrelated to HIV—is trying to figure out how a drug I am thinking of prescribing for their heart disease or kidney failure will impact their HAART therapy. Is there going to be some hidden interaction that I’m not aware of because I don’t deal with those medications every day?”

It is precisely when weighing those questions about chronic therapy when hospitalists would be best served to quickly consider consulting either a primary physician or the appropriate consultant about the details of the medication regimen. “In most cases, you’re going to want to continue that regimen during hospitalization for other intercurrent problems,” he says.

When possible, it’s a good idea for the hospitalist to touch base with the primary HIV provider, says Dr. Bell. “There are sometimes subtleties to the care that are not necessarily transmitted in a faxed document or in information the patient brings to the hospital. Those subtleties—about doses of antiretroviral drugs or changes in regimen—can make big differences.”

Hospitalists should inform themselves of the potentially harmful effects of antiretroviral drugs, as well as the potential harm in stopping them. “It takes an awareness of knowing what the potential problems are to know when to utilize a consultant,” says Dr. Bell. “As doctors, we are appropriately aware of the power of medications, and it’s not uncommon when the clinical picture is unclear for physicians to think, ‘First do no harm—let me stop these medications.’ One has to be aware of the fact that stopping a medication doesn’t happen in a vacuum.”

Nuances of HAART Require Vigilance

“Highly active antiretroviral therapy has resulted in improved immunological status for many HIV-positive patients, but the therapy has also introduced several potential complications and consequences of which hospitalists should be aware,” says Dr. Bell. Most notable among those consequences: the effects of starting and stopping medications.

“It used to be,” says Dr. Baudendistel, “that we would say, ‘The patients are only going to be here in the hospital for a few days; let’s just stop their highly active HIV treatment.’ Now we know that is not a good idea, because stopping treatment can create resistant viruses.”

Dr. Bell explains one such example: Each of the classes of antiretroviral drugs has a different half-life. If a physician stops all antiretroviral therapy at the same time, the nucleoside/nucleotide reverse transcriptase inhibitor (NRTI) may wash out of the system more quickly than does the nonnucleoside reverse transcriptase inhibitor (NNRTI). The result will be NNRTI monotherapy, and drug resistance can occur quickly in that setting, says Dr. Bell. (Note: not all patients are on NNRTIs; some may be on protease inhibitors or fusion inhibitors, which all have potentially adverse events and drug-drug interactions.)

As another example, if a patient has co-infection with hepatitis B, stopping an NRTI with activity against hepatitis B (such as lamivudine or tenofovir), may cause hepatitis to flare up. Finally, several studies now suggest that the long-term consequences of starting and stopping therapy (structured treatment interruptions) are also detrimental.2

Hospitalists can incorporate into their diagnosis and treatment of these patients other management strategies beyond potential drug-drug interactions and consequences of incurring resistance when stopping antiretroviral medication. For instance:

Dr. Sabharwal

• Screen for other problems that may be attributable to long-term antiretroviral therapy, such as dyslipidemia, diabetes, and osteoporosis if the patient has adhered to HAART.3 Because mounting data suggest an increased incidence of cardiovascular disease, aggressive management of other underlying cardiovascular risk factors is an important part of care.
• Ensure electronic medication orders do not automatically default to inappropriate doses. For instance, ritonavir, a protease inhibitor, is most commonly used as a booster dose and not at full dose—but electronic pharmacy ordering systems may not reflect this current knowledge.
• Raise nursing and physician staff awareness to confirm that HAART doses are not missed (e.g., if a patient is off the floor for extended periods of time). Reconcile medication orders and the medication administration record to ensure all ordered medications are given. For example, if there is a delay in accessing one of the patient’s usual medications, it may be harmful to administer just the other two until the third is available. Alternative arrangements would be required.
• Consider orders allowing patients to use their own supply of medications if the hospital pharmacy is not able to supply the exact drug needed for their specific HAART regimen.

It is also advisable to ask HIV patients about their use of alternative therapies, says Dr. Hollander, because studies have shown that a substantial minority of people with HIV infection do, in fact, take alternative therapies.4 “We also know,” he says, “that some of these therapies cause adverse reactions and toxicities that you would not ordinarily consider, unless you had obtained that history.”

Education, Education, Education

Dr. Bell notes that there is wide variability in adherence to medication and follow-up clinic visits among those infected with HIV. “It’s important for hospitalists to emphasize links to care,” she says. “A hospital visit is an important time to emphasize education, and to make sure that those patients have the appropriate follow-up.”

The role of hospitalist as patient educator takes on more prominence in settings with a larger percentage of more indigent patients. “I think the key is education, education, education,” Dr. Sabharwal asserts.

He and hospitalists in his group make patient counseling a key component in their treatment, from the time they encounter patients until discharge. They emphasize that with today’s therapies, a 60-year-old HIV-positive patient may avoid hospitalization, while those who do not take their medications risk the severe sequelae of AIDS-defining conditions.

“It’s very important that physicians not be in a hurry to go from patient to patient,” he says. “A lot of times what’s lacking is for physicians to take the time to sit down with the patient and go over the severity of the disease in its later stages. We counsel patients every single time.”

Dr. Baudendistel’s counsel to fellow hospitalists is that although they may still be attuned to treating HIV complications, such as PCP or TB, HIV is now a chronic disease. And as such, “It’s not something that the casual generalist can manage independently,” he says. “When I was in training, I was very well-versed in managing HIV disease. With the initial drug treatments and the common opportunistic infections, treatment was pretty straightforward. But now I wouldn’t feel comfortable managing the HIV part of the illness on my own. HIV is a subspecialist disease now, and it is important to have a colleague with HIV expertise with whom they can consult.” TH

Gretchen Henkel is a frequent contributor to The Hospitalist.

References

1. CDC HIV/AIDS Fact Sheet, “A Glance at the HIV/AIDS Epidemic.” January 2007. Available online at http://www.cdc.gov/hiv. Last accessed April 2007.
2. Pai NP, Lawrence J, Reingold AL, et al. Structured treatment interruptions (STI) in chronic unsuppressed HIV infection in adults. Cochran Database Syst Rev. 2006 Jul 19;3:CD006148.
3. Agins BD, Alexander CS, Bartlett JG. Metabolic Complications of Antiretroviral Therapy. A Guide to Primary Care of People with HIV/AIDS, 2004 Ed. Available online at http://hab.hrsa.gov/tools/primarycareguide. Last accessed May 21, 2007.
4. Wutoh AK, Brown CM, Kumoji EK, et al. Antiretroviral adherence and use of alternative therapies among older HIV-infected adults. J Natl Med Assoc. 2001 Jul-Aug;93(7-8):243-250.

This is the first of a two-part series on care of the HIV/AIDS patient. Part 2 will address the public health and counseling aspects of HIV management, as well as the care of children with HIV.

It’s been a little more than a quarter-century since acquired immune deficiency syndrome (AIDS) was first identified. Since 1981, many facets of our understanding and management of HIV/AIDS have changed.

In some populations, HIV (when well-controlled) has been transformed to a chronic disease state, with few episodes of the AIDS-defining conditions (opportunistic infections, Kaposi’s sarcoma, wasting syndromes) seen in the early years of the epidemic. However, when treating underserved and indigent populations, hospitalists may still encounter the common symptoms of advanced disease in their HIV-positive patients.

What are the common presenting scenarios of HIV/AIDS seen by hospitalists in the current era of highly active antiretroviral therapy (HAART), and how does antiretroviral therapy affect hospitalists’ management of these patients? The Hospitalist recently interviewed HIV/AIDS specialists and practicing hospitalists to learn find out.

The Differential Diagnosis: Think Broadly

The Centers for Disease Control and Prevention estimates 1.04 million to 1.19 million people live with HIV/AIDS in the United States. The CDC also estimates approximately 40,000 people become infected with HIV each year.1

The conditions that bring HIV-positive patients to the hospital run the gamut. There is a broad range of presenting symptoms, noted Sigall K. Bell, MD, the Division of Infectious Diseases and General Medicine at Harvard Medical School and Beth Israel Deaconess Medical Center in Boston. “The differential diagnoses for patients who are HIV-infected—depending on their immunological status—can be dramatically expanded compared to HIV-negative patients,” says Dr. Bell. “For any given presenting symptom, one needs to think about whether the person’s HIV itself, an opportunistic infection secondary to the HIV, or HIV medication effects are playing into potential explanations for the presenting symptoms.”

Even the demographics of the hospital’s catchment area can be associated with patients’ problems. “The types of problems seen in hospitalized HIV-infected patients largely depends on the degree of access to care that people have,” says HIV and infectious disease specialist Harry Hollander, MD, program director for the University of California, San Francisco Internal Medicine Residency Program, and professor of Clinical Medicine at UCSF. In areas where care systems are not robust, explains Dr. Hollander, people admitted to the hospital will most likely have the same problems seen at the beginning of the epidemic.

If hospitalists are practicing in areas with highly developed systems of care and good penetration of care, people with HIV are just as likely to be admitted to the hospital with problems completely unrelated to their HIV status. In the pre-antiretroviral era, according to Dr. Hollander, hospital physicians typically saw three or four common types of presentations in these patients. “My biggest message these days,” he says, “is to think broadly about the problems these patients present with, and to generate parallel thinking about HIV-related causes as well as causes not related to HIV. Many patients with well-controlled HIV are more likely to wind up in the hospital because of other routine medical problems. If you only consider the HIV status, you may be missing other important, related and treatable conditions.”

Thomas Baudendistel, MD, who is associate residency program director at California Pacific Medical Center, a community-based hospital in San Francisco operated by Sutter Health, confirms that as HIV patients are getting healthier, “their immune systems are being kept intact [with CD4 counts in the normal range] for longer periods of time. We don’t see issues of HIV-related conditions in hospitalization as much as we did 20, 10, or even five years ago. The life-threatening opportunistic infections, although still there, have receded as cause for hospitalization. When an HIV patient gets admitted, it’s just as likely to be a noninfectious condition, such as lymphoma, or hematologic complications. Or, the patients may be old enough to have heart disease or COPD.”

Dr. Sabharwal

Other hospitalists practice in areas where the opposite is true. Aman D. Sabharwal, MD, is associate medical director, Inpatient and Hospitalist Services for Jackson Health Systems and practices primarily at Jackson Memorial Hospital, which serves a large indigent population in south Florida. While he agrees that some HIV patients are being well-managed because of advances in antiretroviral therapy, these are not the patients seen by hospitalists in his group.

“A majority of our HIV-positive patients come in for illnesses or opportunistic infections that are due to their HIV,” he says. “Most of these patients are either noncompliant with their medications or have low CD4 counts. Generally, the acute issue for which they are admitted is generally unrelated to the medication itself—it is probably due more so to the lack of medication.”

Dr. Bell

Dr. Baudendistel reports that he and fellow hospitalists at California Pacific Medical Center are also seeing more immune reconstitution illness, in which the reconstituted immune system exhibits an “overexuberant” reaction, causing unique presentations. For example, patients with low CD4 counts who have clinically silent infection with Mycobacterium Avium Complex, hepatitis B, or a variety of infectious agents may experience a significant boost in their CD4 count with antiretroviral therapy. The resurgent immune system can then mount a response to these previously quiescent pathogens, causing a flare-up of symptoms.

“If the primary site of occult disease is the lungs, a respiratory exacerbation will occur; if in the liver, as in the example of hepatitis B, a significant hepatitis can ensue,” says Dr. Baudendistel.

Call in Consultants: Keep a Low Threshold

As the management of HIV becomes more sophisticated, hospitalists should frequently consult infectious-disease and consulting pharmacy colleagues. “I think the hospitalist is very well-equipped to deal with the acute illnesses that these patients have,” notes Dr. Hollander. “Most hospitalists feel less comfortable with the details of managing the chronic medical regimen—particularly the antiretroviral drugs, which they don’t have an opportunity to prescribe, manage, and monitor over time.”

Dr. Baudendistel concurs: “As a hospitalist, what I face with these patients—especially if they come in with an illness unrelated to HIV—is trying to figure out how a drug I am thinking of prescribing for their heart disease or kidney failure will impact their HAART therapy. Is there going to be some hidden interaction that I’m not aware of because I don’t deal with those medications every day?”

It is precisely when weighing those questions about chronic therapy when hospitalists would be best served to quickly consider consulting either a primary physician or the appropriate consultant about the details of the medication regimen. “In most cases, you’re going to want to continue that regimen during hospitalization for other intercurrent problems,” he says.

When possible, it’s a good idea for the hospitalist to touch base with the primary HIV provider, says Dr. Bell. “There are sometimes subtleties to the care that are not necessarily transmitted in a faxed document or in information the patient brings to the hospital. Those subtleties—about doses of antiretroviral drugs or changes in regimen—can make big differences.”

Hospitalists should inform themselves of the potentially harmful effects of antiretroviral drugs, as well as the potential harm in stopping them. “It takes an awareness of knowing what the potential problems are to know when to utilize a consultant,” says Dr. Bell. “As doctors, we are appropriately aware of the power of medications, and it’s not uncommon when the clinical picture is unclear for physicians to think, ‘First do no harm—let me stop these medications.’ One has to be aware of the fact that stopping a medication doesn’t happen in a vacuum.”

Nuances of HAART Require Vigilance

“Highly active antiretroviral therapy has resulted in improved immunological status for many HIV-positive patients, but the therapy has also introduced several potential complications and consequences of which hospitalists should be aware,” says Dr. Bell. Most notable among those consequences: the effects of starting and stopping medications.

“It used to be,” says Dr. Baudendistel, “that we would say, ‘The patients are only going to be here in the hospital for a few days; let’s just stop their highly active HIV treatment.’ Now we know that is not a good idea, because stopping treatment can create resistant viruses.”

Dr. Bell explains one such example: Each of the classes of antiretroviral drugs has a different half-life. If a physician stops all antiretroviral therapy at the same time, the nucleoside/nucleotide reverse transcriptase inhibitor (NRTI) may wash out of the system more quickly than does the nonnucleoside reverse transcriptase inhibitor (NNRTI). The result will be NNRTI monotherapy, and drug resistance can occur quickly in that setting, says Dr. Bell. (Note: not all patients are on NNRTIs; some may be on protease inhibitors or fusion inhibitors, which all have potentially adverse events and drug-drug interactions.)

As another example, if a patient has co-infection with hepatitis B, stopping an NRTI with activity against hepatitis B (such as lamivudine or tenofovir), may cause hepatitis to flare up. Finally, several studies now suggest that the long-term consequences of starting and stopping therapy (structured treatment interruptions) are also detrimental.2

Hospitalists can incorporate into their diagnosis and treatment of these patients other management strategies beyond potential drug-drug interactions and consequences of incurring resistance when stopping antiretroviral medication. For instance:

Dr. Sabharwal

• Screen for other problems that may be attributable to long-term antiretroviral therapy, such as dyslipidemia, diabetes, and osteoporosis if the patient has adhered to HAART.3 Because mounting data suggest an increased incidence of cardiovascular disease, aggressive management of other underlying cardiovascular risk factors is an important part of care.
• Ensure electronic medication orders do not automatically default to inappropriate doses. For instance, ritonavir, a protease inhibitor, is most commonly used as a booster dose and not at full dose—but electronic pharmacy ordering systems may not reflect this current knowledge.
• Raise nursing and physician staff awareness to confirm that HAART doses are not missed (e.g., if a patient is off the floor for extended periods of time). Reconcile medication orders and the medication administration record to ensure all ordered medications are given. For example, if there is a delay in accessing one of the patient’s usual medications, it may be harmful to administer just the other two until the third is available. Alternative arrangements would be required.
• Consider orders allowing patients to use their own supply of medications if the hospital pharmacy is not able to supply the exact drug needed for their specific HAART regimen.

It is also advisable to ask HIV patients about their use of alternative therapies, says Dr. Hollander, because studies have shown that a substantial minority of people with HIV infection do, in fact, take alternative therapies.4 “We also know,” he says, “that some of these therapies cause adverse reactions and toxicities that you would not ordinarily consider, unless you had obtained that history.”

Education, Education, Education

Dr. Bell notes that there is wide variability in adherence to medication and follow-up clinic visits among those infected with HIV. “It’s important for hospitalists to emphasize links to care,” she says. “A hospital visit is an important time to emphasize education, and to make sure that those patients have the appropriate follow-up.”

The role of hospitalist as patient educator takes on more prominence in settings with a larger percentage of more indigent patients. “I think the key is education, education, education,” Dr. Sabharwal asserts.

He and hospitalists in his group make patient counseling a key component in their treatment, from the time they encounter patients until discharge. They emphasize that with today’s therapies, a 60-year-old HIV-positive patient may avoid hospitalization, while those who do not take their medications risk the severe sequelae of AIDS-defining conditions.

“It’s very important that physicians not be in a hurry to go from patient to patient,” he says. “A lot of times what’s lacking is for physicians to take the time to sit down with the patient and go over the severity of the disease in its later stages. We counsel patients every single time.”

Dr. Baudendistel’s counsel to fellow hospitalists is that although they may still be attuned to treating HIV complications, such as PCP or TB, HIV is now a chronic disease. And as such, “It’s not something that the casual generalist can manage independently,” he says. “When I was in training, I was very well-versed in managing HIV disease. With the initial drug treatments and the common opportunistic infections, treatment was pretty straightforward. But now I wouldn’t feel comfortable managing the HIV part of the illness on my own. HIV is a subspecialist disease now, and it is important to have a colleague with HIV expertise with whom they can consult.” TH

Gretchen Henkel is a frequent contributor to The Hospitalist.

References

1. CDC HIV/AIDS Fact Sheet, “A Glance at the HIV/AIDS Epidemic.” January 2007. Available online at http://www.cdc.gov/hiv. Last accessed April 2007.
2. Pai NP, Lawrence J, Reingold AL, et al. Structured treatment interruptions (STI) in chronic unsuppressed HIV infection in adults. Cochran Database Syst Rev. 2006 Jul 19;3:CD006148.
3. Agins BD, Alexander CS, Bartlett JG. Metabolic Complications of Antiretroviral Therapy. A Guide to Primary Care of People with HIV/AIDS, 2004 Ed. Available online at http://hab.hrsa.gov/tools/primarycareguide. Last accessed May 21, 2007.
4. Wutoh AK, Brown CM, Kumoji EK, et al. Antiretroviral adherence and use of alternative therapies among older HIV-infected adults. J Natl Med Assoc. 2001 Jul-Aug;93(7-8):243-250.

This is the first of a two-part series on care of the HIV/AIDS patient. Part 2 will address the public health and counseling aspects of HIV management, as well as the care of children with HIV.

It’s been a little more than a quarter-century since acquired immune deficiency syndrome (AIDS) was first identified. Since 1981, many facets of our understanding and management of HIV/AIDS have changed.

In some populations, HIV (when well-controlled) has been transformed to a chronic disease state, with few episodes of the AIDS-defining conditions (opportunistic infections, Kaposi’s sarcoma, wasting syndromes) seen in the early years of the epidemic. However, when treating underserved and indigent populations, hospitalists may still encounter the common symptoms of advanced disease in their HIV-positive patients.

What are the common presenting scenarios of HIV/AIDS seen by hospitalists in the current era of highly active antiretroviral therapy (HAART), and how does antiretroviral therapy affect hospitalists’ management of these patients? The Hospitalist recently interviewed HIV/AIDS specialists and practicing hospitalists to learn find out.

The Differential Diagnosis: Think Broadly

The Centers for Disease Control and Prevention estimates 1.04 million to 1.19 million people live with HIV/AIDS in the United States. The CDC also estimates approximately 40,000 people become infected with HIV each year.1

The conditions that bring HIV-positive patients to the hospital run the gamut. There is a broad range of presenting symptoms, noted Sigall K. Bell, MD, the Division of Infectious Diseases and General Medicine at Harvard Medical School and Beth Israel Deaconess Medical Center in Boston. “The differential diagnoses for patients who are HIV-infected—depending on their immunological status—can be dramatically expanded compared to HIV-negative patients,” says Dr. Bell. “For any given presenting symptom, one needs to think about whether the person’s HIV itself, an opportunistic infection secondary to the HIV, or HIV medication effects are playing into potential explanations for the presenting symptoms.”

Even the demographics of the hospital’s catchment area can be associated with patients’ problems. “The types of problems seen in hospitalized HIV-infected patients largely depends on the degree of access to care that people have,” says HIV and infectious disease specialist Harry Hollander, MD, program director for the University of California, San Francisco Internal Medicine Residency Program, and professor of Clinical Medicine at UCSF. In areas where care systems are not robust, explains Dr. Hollander, people admitted to the hospital will most likely have the same problems seen at the beginning of the epidemic.

If hospitalists are practicing in areas with highly developed systems of care and good penetration of care, people with HIV are just as likely to be admitted to the hospital with problems completely unrelated to their HIV status. In the pre-antiretroviral era, according to Dr. Hollander, hospital physicians typically saw three or four common types of presentations in these patients. “My biggest message these days,” he says, “is to think broadly about the problems these patients present with, and to generate parallel thinking about HIV-related causes as well as causes not related to HIV. Many patients with well-controlled HIV are more likely to wind up in the hospital because of other routine medical problems. If you only consider the HIV status, you may be missing other important, related and treatable conditions.”

Thomas Baudendistel, MD, who is associate residency program director at California Pacific Medical Center, a community-based hospital in San Francisco operated by Sutter Health, confirms that as HIV patients are getting healthier, “their immune systems are being kept intact [with CD4 counts in the normal range] for longer periods of time. We don’t see issues of HIV-related conditions in hospitalization as much as we did 20, 10, or even five years ago. The life-threatening opportunistic infections, although still there, have receded as cause for hospitalization. When an HIV patient gets admitted, it’s just as likely to be a noninfectious condition, such as lymphoma, or hematologic complications. Or, the patients may be old enough to have heart disease or COPD.”

Dr. Sabharwal

Other hospitalists practice in areas where the opposite is true. Aman D. Sabharwal, MD, is associate medical director, Inpatient and Hospitalist Services for Jackson Health Systems and practices primarily at Jackson Memorial Hospital, which serves a large indigent population in south Florida. While he agrees that some HIV patients are being well-managed because of advances in antiretroviral therapy, these are not the patients seen by hospitalists in his group.

“A majority of our HIV-positive patients come in for illnesses or opportunistic infections that are due to their HIV,” he says. “Most of these patients are either noncompliant with their medications or have low CD4 counts. Generally, the acute issue for which they are admitted is generally unrelated to the medication itself—it is probably due more so to the lack of medication.”

Dr. Bell

Dr. Baudendistel reports that he and fellow hospitalists at California Pacific Medical Center are also seeing more immune reconstitution illness, in which the reconstituted immune system exhibits an “overexuberant” reaction, causing unique presentations. For example, patients with low CD4 counts who have clinically silent infection with Mycobacterium Avium Complex, hepatitis B, or a variety of infectious agents may experience a significant boost in their CD4 count with antiretroviral therapy. The resurgent immune system can then mount a response to these previously quiescent pathogens, causing a flare-up of symptoms.

“If the primary site of occult disease is the lungs, a respiratory exacerbation will occur; if in the liver, as in the example of hepatitis B, a significant hepatitis can ensue,” says Dr. Baudendistel.

Call in Consultants: Keep a Low Threshold

As the management of HIV becomes more sophisticated, hospitalists should frequently consult infectious-disease and consulting pharmacy colleagues. “I think the hospitalist is very well-equipped to deal with the acute illnesses that these patients have,” notes Dr. Hollander. “Most hospitalists feel less comfortable with the details of managing the chronic medical regimen—particularly the antiretroviral drugs, which they don’t have an opportunity to prescribe, manage, and monitor over time.”

Dr. Baudendistel concurs: “As a hospitalist, what I face with these patients—especially if they come in with an illness unrelated to HIV—is trying to figure out how a drug I am thinking of prescribing for their heart disease or kidney failure will impact their HAART therapy. Is there going to be some hidden interaction that I’m not aware of because I don’t deal with those medications every day?”

It is precisely when weighing those questions about chronic therapy when hospitalists would be best served to quickly consider consulting either a primary physician or the appropriate consultant about the details of the medication regimen. “In most cases, you’re going to want to continue that regimen during hospitalization for other intercurrent problems,” he says.

When possible, it’s a good idea for the hospitalist to touch base with the primary HIV provider, says Dr. Bell. “There are sometimes subtleties to the care that are not necessarily transmitted in a faxed document or in information the patient brings to the hospital. Those subtleties—about doses of antiretroviral drugs or changes in regimen—can make big differences.”

Hospitalists should inform themselves of the potentially harmful effects of antiretroviral drugs, as well as the potential harm in stopping them. “It takes an awareness of knowing what the potential problems are to know when to utilize a consultant,” says Dr. Bell. “As doctors, we are appropriately aware of the power of medications, and it’s not uncommon when the clinical picture is unclear for physicians to think, ‘First do no harm—let me stop these medications.’ One has to be aware of the fact that stopping a medication doesn’t happen in a vacuum.”

Nuances of HAART Require Vigilance

“Highly active antiretroviral therapy has resulted in improved immunological status for many HIV-positive patients, but the therapy has also introduced several potential complications and consequences of which hospitalists should be aware,” says Dr. Bell. Most notable among those consequences: the effects of starting and stopping medications.

“It used to be,” says Dr. Baudendistel, “that we would say, ‘The patients are only going to be here in the hospital for a few days; let’s just stop their highly active HIV treatment.’ Now we know that is not a good idea, because stopping treatment can create resistant viruses.”

Dr. Bell explains one such example: Each of the classes of antiretroviral drugs has a different half-life. If a physician stops all antiretroviral therapy at the same time, the nucleoside/nucleotide reverse transcriptase inhibitor (NRTI) may wash out of the system more quickly than does the nonnucleoside reverse transcriptase inhibitor (NNRTI). The result will be NNRTI monotherapy, and drug resistance can occur quickly in that setting, says Dr. Bell. (Note: not all patients are on NNRTIs; some may be on protease inhibitors or fusion inhibitors, which all have potentially adverse events and drug-drug interactions.)

As another example, if a patient has co-infection with hepatitis B, stopping an NRTI with activity against hepatitis B (such as lamivudine or tenofovir), may cause hepatitis to flare up. Finally, several studies now suggest that the long-term consequences of starting and stopping therapy (structured treatment interruptions) are also detrimental.2

Hospitalists can incorporate into their diagnosis and treatment of these patients other management strategies beyond potential drug-drug interactions and consequences of incurring resistance when stopping antiretroviral medication. For instance:

Dr. Sabharwal

• Screen for other problems that may be attributable to long-term antiretroviral therapy, such as dyslipidemia, diabetes, and osteoporosis if the patient has adhered to HAART.3 Because mounting data suggest an increased incidence of cardiovascular disease, aggressive management of other underlying cardiovascular risk factors is an important part of care.
• Ensure electronic medication orders do not automatically default to inappropriate doses. For instance, ritonavir, a protease inhibitor, is most commonly used as a booster dose and not at full dose—but electronic pharmacy ordering systems may not reflect this current knowledge.
• Raise nursing and physician staff awareness to confirm that HAART doses are not missed (e.g., if a patient is off the floor for extended periods of time). Reconcile medication orders and the medication administration record to ensure all ordered medications are given. For example, if there is a delay in accessing one of the patient’s usual medications, it may be harmful to administer just the other two until the third is available. Alternative arrangements would be required.
• Consider orders allowing patients to use their own supply of medications if the hospital pharmacy is not able to supply the exact drug needed for their specific HAART regimen.

It is also advisable to ask HIV patients about their use of alternative therapies, says Dr. Hollander, because studies have shown that a substantial minority of people with HIV infection do, in fact, take alternative therapies.4 “We also know,” he says, “that some of these therapies cause adverse reactions and toxicities that you would not ordinarily consider, unless you had obtained that history.”

Education, Education, Education

Dr. Bell notes that there is wide variability in adherence to medication and follow-up clinic visits among those infected with HIV. “It’s important for hospitalists to emphasize links to care,” she says. “A hospital visit is an important time to emphasize education, and to make sure that those patients have the appropriate follow-up.”

The role of hospitalist as patient educator takes on more prominence in settings with a larger percentage of more indigent patients. “I think the key is education, education, education,” Dr. Sabharwal asserts.

He and hospitalists in his group make patient counseling a key component in their treatment, from the time they encounter patients until discharge. They emphasize that with today’s therapies, a 60-year-old HIV-positive patient may avoid hospitalization, while those who do not take their medications risk the severe sequelae of AIDS-defining conditions.

“It’s very important that physicians not be in a hurry to go from patient to patient,” he says. “A lot of times what’s lacking is for physicians to take the time to sit down with the patient and go over the severity of the disease in its later stages. We counsel patients every single time.”

Dr. Baudendistel’s counsel to fellow hospitalists is that although they may still be attuned to treating HIV complications, such as PCP or TB, HIV is now a chronic disease. And as such, “It’s not something that the casual generalist can manage independently,” he says. “When I was in training, I was very well-versed in managing HIV disease. With the initial drug treatments and the common opportunistic infections, treatment was pretty straightforward. But now I wouldn’t feel comfortable managing the HIV part of the illness on my own. HIV is a subspecialist disease now, and it is important to have a colleague with HIV expertise with whom they can consult.” TH

Gretchen Henkel is a frequent contributor to The Hospitalist.

References

1. CDC HIV/AIDS Fact Sheet, “A Glance at the HIV/AIDS Epidemic.” January 2007. Available online at http://www.cdc.gov/hiv. Last accessed April 2007.
2. Pai NP, Lawrence J, Reingold AL, et al. Structured treatment interruptions (STI) in chronic unsuppressed HIV infection in adults. Cochran Database Syst Rev. 2006 Jul 19;3:CD006148.
3. Agins BD, Alexander CS, Bartlett JG. Metabolic Complications of Antiretroviral Therapy. A Guide to Primary Care of People with HIV/AIDS, 2004 Ed. Available online at http://hab.hrsa.gov/tools/primarycareguide. Last accessed May 21, 2007.
4. Wutoh AK, Brown CM, Kumoji EK, et al. Antiretroviral adherence and use of alternative therapies among older HIV-infected adults. J Natl Med Assoc. 2001 Jul-Aug;93(7-8):243-250.

Hospitalization can be risky business for geriatric patients. Americans 65 and older make up 13% of the population but account for 48% of inpatient days of care and 78% of hospital deaths. While in the hospital, patients 75 and older are at high risk for deconditioning and functional decline, medication errors, delirium, and falls.1,2

For geriatric patients not closely monitored, notes geriatrician Don Murphy, MD, co-principal of Senior Care of Colorado, a large primary care geriatrics group in Denver, going to the hospital can be like disappearing into a black hole.

As the U.S. population ages, hospitalists will be caring for an increasing number of geriatric patients. They will have to address patients’ acute medical conditions without compromising their functional status.

The Hospitalist asked several leading geriatricians to identify valuable tools and strategies for delivering comprehensive geriatric care in the hospital. Even in the absence of formal geriatric care units, they say, hospitalists are positioned for adopting the principles of quality geriatric care. Many of those principles align with the central mission of hospital medicine: promoting high-quality, patient-centered care, working as a team, and developing clear lines of communication between the hospitalist and the primary care teams.

A Survey of Interventions

“There’s no question that it’s becoming extraordinarily difficult to do good care,” says John Morley, MD, professor of medicine and chief of the Division of Geriatrics and Endocrinology at Saint Louis University Health Sciences Center in Missouri. “Taking care of an older person in the hospital is a team sport—the physician can’t do it alone.”

It’s clear the team approach is a crucial foundation for interventions that target at-risk geriatric patients, agrees Edgar Pierluissi, MD, associate clinical professor of medicine and medical director of the recently established ACE unit at San Francisco General Hospital. Reducing the incidence of delirium, for instance, cannot be accomplished simply by utilizing a geriatric consultation. Once established, acute confusion can be intractable. “The idea is to try to prevent delirium, and research has shown that single-person types of interventions in these massively impervious-to-change facilities don’t work,” he says.

Clinical trials have demonstrated that interventions, including interdisciplinary and collaborative teams, targeted patient-centered therapies, and comprehensive geriatric assessment can improve outcomes of hospitalization in geriatric patients. Four major interventions include:

• Acute Care for Elders (ACE) units based on interdisciplinary team rounds, discharge planning, and medical review in a prepared environment to foster patient self-care and improve function. Randomized clinical trials have shown ACE units can reduce the length of stay, the risk of nursing home admissions, and the use of physical restraints while improving providers’ satisfaction with patient care.3,4
• The Hospital Elder Life Program (HELP), led by a geriatrics resource nurse, is an intervention designed to reduce the incidence of delirium by adjusting environmental elements, such as dimming lights and keeping the floor quiet at night. HELP also introduces non-pharmacologic interventions, including massages and warm tea at night and promotes mobility and hydration during the day.
• Incidence of delirium is reduced and cost savings are realized using the HELP.5 (Visit http://elderlife.med.yale.edu/public for more information.)
• Geriatric Evaluation and Management (GEM) units also emphasize a multidisciplinary comprehensive approach using geriatrician-led teams. The intervention can reduce long-term costs, while improving physical functioning and general health domains in the SF-36.6
• Use of advanced practice nurses in comprehensive discharge planning interventions, including nursing home visits for older patients with risk factors for poor outcomes post-discharge, has been shown to reduce readmissions.7

Assessment Is the Bottom Line

Robert Palmer, MD, head of the Section of Geriatric Medicine and professor of medicine at Cleveland Clinic Lerner College of Medicine of Case Western Reserve University in Ohio, is known for his work with ACE units. He and his colleagues have tracked patients following discharge and have identified the highest priority issues that should be addressed to avoid deleterious geriatric syndromes in the hospital. Although he advocates what he calls a minimalist approach to conducting a geriatric assessment, Dr. Palmer underlines the idea that it must also be a deliberate and structured approach. Assessing and acting upon key indicators in four to five major domains, he notes, can make a big difference for patients’ hospital trajectories.8 Here are a few domains to consider:

1 Focus on activities of daily living (ADLs). Function and performance of ADLs can predict post-hospital outcome and help the physician prioritize elements of the patient’s trajectory and goals while in the hospital. “If a person was able to independently bathe, dress, toilet, walk, and transfer—from bed to chair, for instance—before the acute illness, then he or she should be able to get back to that point after the illness has been treated,” says Dr. Palmer. The ability to transfer independently is an important predictor of discharge status because if the patient requires assistance to transfer, he or she will need a different level of care upon discharge. The hospitalist should seek information —from the patient, family member or primary caregiver, or primary care physician—about the patient’s ADLs before he or she got sick. Again, recovery of ADLs may be possible if the patient was performing these independently before the acute episode.

2 Cognitive assessments are also key. Dr. Morley places assessment for delirium at the top of his list. Research shows that approximately one third of patients over 70 in the hospital will develop the condition. Delirium, or acute confusion, is also a predictor of decline in ADLs, notes Dr. Palmer. Dr. Morley recommends the use of the Confusion Assessment Method (CAM) because the Mini Mental State Exam can be time-consuming. (A CAM form is available free online as part of SHM’s “Clinical Toolbox for Geriatric Care.” Go to www.hospitalmedicine.org, click on “Resource Center” and then “Geriatric Special Interest Area” to find the Toolbox.) According to Dr. Palmer, the physician should also use common sense when initially examining the patient: Observe whether the patient is confused, distracted, or inappropriate in conversation. If so, the next step is to use the simple Digit Span test: Say a random set of four to five numbers, and ask the patient to repeat them. Inability to do this is consistent with delirium as a cause of cognitive impairment.

For assessing cognitive impairment, Dr. Morley prefers the St. Louis University Mental Status Exam (SLUMS) to the Mini Mental Status Exam. The SLUMS, developed in collaboration with the Department of Veterans Affairs (and available free online at: http://medschool.slu.edu/agingsuccessfully/pdfsurveys/slumsexam_05.pdf) successfully picks up even mild cognitive impairment, according to Dr. Morley. This is important information not just for the hospital trajectory but also for discharge planning: Inability to follow discharge instructions due to cognitive impairment could result in a readmission.

3 Malnutrition is associated with mortality. Dr. Morley uses the four questions of the Simplified Nutrition Assessment Questionnaire (SNAQ), which correlate well with future weight loss and poor outcomes.9

If the SNAQ is positive, the use of a lengthier questionnaire may be warranted. Dr. Palmer suggests that a review of the patient’s comprehensive metabolic panel to judge kidney and liver function and a bedside evaluation using the Subjective Global Assessment (SGA) can yield results just as usable as the more complex and time-consuming textbook nutritional assessments.

4 Mood and affect also play a role in patients’ outcomes. Research has shown that depressed patients have poor outcomes, so physicians should always assess for depression. While the Geriatric Depression Scale (see “Clinical Toolbox for Geriatric Care” on the SHM Web site) can help quantify the extent of the patient’s symptoms, simply asking the patient, “Are you depressed, sad, or blue?” can often elicit enough information about the patient’s psychological status to direct interventions.

5 Mobility is sometimes classified as a stand-alone domain. However, walking and balance may be included in the assessment of ADLs. A patient who can walk independently—even with a cane or a walker—has a good chance to return home, says Dr. Palmer. Requiring another person to help with walking most likely indicates the patient will need short-term rehabilitation in a skilled nursing facility before returning home.

6 Social and living situation are important. The physician must identify the extent and quality of the patient’s support network. If, for instance, a patient has mild dementia but has a network of 10 extended family members who act as caregivers, discharge to home may be possible. If the patient was admitted to the hospital from a nursing home, however, it is most likely he or she will return there.

Revisit Daily Goals

Dr. Palmer advises hospitalists to follow the geriatric assessment with a translation of the information into what he calls a functional trajectory for the patient’s hospital stay. This includes an estimate of the patient’s anticipated length of stay and the expected discharge site. Interventions and consultations from allied health providers will be keyed to the patient’s individualized needs and to the goals of the functional trajectory.

To head off problems, Dr. Palmer advocates consultations from allied health professionals early in the hospital trajectory. For instance, if the patient is having trouble transferring from bed to chair upon admission, a consult with physical therapy may be warranted immediately rather than right before discharge, as is usually the case.

“We should not be depending on physical therapists at the end of hospitalization, when patients are already deconditioned and can’t get out of bed and need to go to a nursing home,” he explains. “The ideal time to bring in the physical therapist or technician is when you’ve identified—on day one—that the patient needs assistance with transfers, so that you can preserve mobility and shorten hospital stay.”

In the same vein, knowing the patient’s living situation will allow involvement of the discharge planner from day one of the hospitalization to plan with the patient or family for the patient’s return to home or to an alternate site. If the patient has been on a complex drug regimen, involving the pharmacist to help straighten out medications can head off potential drug-drug interactions. (SHM’s Geriatric Toolbox also has a list of medications to avoid in geriatric patients.)

It is important to review the functional trajectory on a daily basis. Input from other members of the health team will be invaluable. “Each day you identify barriers to that successful plan of the outcome, and you take care of them one at a time,” says Dr. Palmer. “If the patient is not on track with that daily goal, the team goes back to the drawing board and asks, ‘What are we missing here?’ Then you do a reassessment of ADLs, nutrition, and cognition.”

Hospitalists must also include the patient’s family members and primary caregivers as the patient moves toward discharge, asserts Dr. Morley. Clear, unambiguous written instructions must always be given to the patient or the primary caregiver when the patient leaves the hospital. (You can also find a discharge instruction sheet in SHM’s Toolbox.) If a patient appears to be facing the end of life, the hospitalist should schedule a conference with members of the primary care team, the hospitalist team, and all family stakeholders.

Transportable SKILLS

Some experts maintain that quality care for geriatric patients can be accomplished without a specialized geriatrics unit.

“I never conceived of the ACE intervention as being done exclusively on a unit,” says Dr. Palmer. “The idea was to develop the skills on a unit and then transport those skills to all units.” Although the protocols developed for ACE units are good for teaching, he says the team has been the key.

Dr. Morley agrees: “It’s not the physical part of the ACE unit that works. You must have team interactions. Finding a way to communicate between the different team members is absolutely key to good outcomes.”

Involving healthcare providers from different disciplines only enhances the care of geriatric patients. “Even though hospitalists may not have the depth of knowledge of geriatrics that a geriatrician has, they certainly have the knowledge of acute care medicine that we have, so they can manage the medical problems,” says Dr. Palmer. “What they need to do is think systematically, in a structured way, and to work collaboratively with key players. This only takes a few minutes each day, but more importantly, it saves time. You have fewer phone calls and fewer angry family members when you manage the care in a structured manner, working with a team of health professionals.”

Dr. Morley and his team have developed a form for their ACE unit that allows them to assess a patient’s status and goals in two to three minutes.

Dr. Pierluissi has experienced firsthand the benefits of working as a member of the interdisciplinary team. “Essentially,” he says, working in teams to treat the geriatric patient means there are “more heads in the game, more people trying to work in the patient’s best interest. You [the clinician] really do feel supported, and it makes your day more enjoyable and more productive.” TH

Gretchen Henkel is a medical journalist based in California.

Resources

1. Kozak LJ, Hall MJ, Owings MF. Hospitalization fact sheet. In: National Hospital Discharge Survey: 2000 Annual summary with detailed diagnosis and procedure data. Hyattsville, Maryland: National Center for Health Statistics. Vital Health Stat. 2002;13(153).
2. Covinsky KE, Palmer RM, Fortinsky RH, et al. Loss of independence in activities of daily living in older adults hospitalized with medical illnesses: increased vulnerability with age. J Am Geriatr Soc. 2003 Apr;51(4):451-458.
3. Landefeld CS, Palmer RM, Kresevic DM, et al. A randomized trial of care in a hospital medical unit especially designed to improve the functional outcomes of acutely ill older patients. N Engl J Med. 1995 May;332(20):1338-1344. Comments in: ACP J Club. 1995 Nov-Dec; 123(3):69 and N Engl J Med. 1995 May 18; 332(20):1376-1378.
4. Counsell SR, Holder CM, Liebenauer LL, et al. Effects of a multicomponent intervention on functional outcomes and process of care in hospitalized older patients: a randomized controlled trial of acute care for Elders (ACE) in a community hospital. J Am Geriatr Soc. 2000 Dec;48:1572-1581.
5. Inouye SK, Bogardus ST Jr, Charpentier PA, et al. A multicomponent intervention to prevent delirium in hospitalized older patients. N Engl J Med. 1999 Mar 4;340(9):669-676. Comments in: N Engl J Med. 1999 Jul 29; 341(5):369-370; author reply 370 and N Engl J Med. 1999 Mar 4; 340(9):720-721.
6. Cohen HJ, Feussner JR, Weinberger M, et al. A controlled trial of inpatient and outpatient geriatric evaluation and management. N Engl J Med. 2002 Mar 21;346(12):905-912. Comments in: Curr Surg. 2004 May-Jun;61(3):266-274; N Engl J Med. 2002 Aug 1;347(5):371-373; author reply 371-373 & N Engl J Med. 2002 Mar 21;346(12):874.
7. Naylor MD, Brooten DA, Campbell RL, et al. Transitional care of older adults hospitalized with heart failure: a randomized, controlled trial. J Am Geriatr Soc. 2004 May;52(5):675-684. Erratum in J Am Geriatr Soc. 2004 Jul; 52(7):1228. Comment in Evid Based Nurs. 2004 Oct;7(4):116.
8. Palmer RM. Acute hospital care of the elderly: making a difference. Caring for the Hospitalized Elderly [special supplement to The Hospitalist]. 2004. Available at: www.hospitalmedicine.org/AM/Template.cfm?Section=The_Hospitalist&Template=/CM/ContentDisplay.cfm&ContentFileID=1447. Last accessed March 14, 2007.
9. Wilson MM, Thomas DR, Rubenstein LZ, et al. Appetite assessment: simple appetite questionnaire predicts weight loss in community-dwelling adults and nursing home residents. Am J Clin Nutr. 2005 Nov;82(5):1074-1081.

Hospitalization can be risky business for geriatric patients. Americans 65 and older make up 13% of the population but account for 48% of inpatient days of care and 78% of hospital deaths. While in the hospital, patients 75 and older are at high risk for deconditioning and functional decline, medication errors, delirium, and falls.1,2

For geriatric patients not closely monitored, notes geriatrician Don Murphy, MD, co-principal of Senior Care of Colorado, a large primary care geriatrics group in Denver, going to the hospital can be like disappearing into a black hole.

As the U.S. population ages, hospitalists will be caring for an increasing number of geriatric patients. They will have to address patients’ acute medical conditions without compromising their functional status.

The Hospitalist asked several leading geriatricians to identify valuable tools and strategies for delivering comprehensive geriatric care in the hospital. Even in the absence of formal geriatric care units, they say, hospitalists are positioned for adopting the principles of quality geriatric care. Many of those principles align with the central mission of hospital medicine: promoting high-quality, patient-centered care, working as a team, and developing clear lines of communication between the hospitalist and the primary care teams.

A Survey of Interventions

“There’s no question that it’s becoming extraordinarily difficult to do good care,” says John Morley, MD, professor of medicine and chief of the Division of Geriatrics and Endocrinology at Saint Louis University Health Sciences Center in Missouri. “Taking care of an older person in the hospital is a team sport—the physician can’t do it alone.”

It’s clear the team approach is a crucial foundation for interventions that target at-risk geriatric patients, agrees Edgar Pierluissi, MD, associate clinical professor of medicine and medical director of the recently established ACE unit at San Francisco General Hospital. Reducing the incidence of delirium, for instance, cannot be accomplished simply by utilizing a geriatric consultation. Once established, acute confusion can be intractable. “The idea is to try to prevent delirium, and research has shown that single-person types of interventions in these massively impervious-to-change facilities don’t work,” he says.

Clinical trials have demonstrated that interventions, including interdisciplinary and collaborative teams, targeted patient-centered therapies, and comprehensive geriatric assessment can improve outcomes of hospitalization in geriatric patients. Four major interventions include:

• Acute Care for Elders (ACE) units based on interdisciplinary team rounds, discharge planning, and medical review in a prepared environment to foster patient self-care and improve function. Randomized clinical trials have shown ACE units can reduce the length of stay, the risk of nursing home admissions, and the use of physical restraints while improving providers’ satisfaction with patient care.3,4
• The Hospital Elder Life Program (HELP), led by a geriatrics resource nurse, is an intervention designed to reduce the incidence of delirium by adjusting environmental elements, such as dimming lights and keeping the floor quiet at night. HELP also introduces non-pharmacologic interventions, including massages and warm tea at night and promotes mobility and hydration during the day.
• Incidence of delirium is reduced and cost savings are realized using the HELP.5 (Visit http://elderlife.med.yale.edu/public for more information.)
• Geriatric Evaluation and Management (GEM) units also emphasize a multidisciplinary comprehensive approach using geriatrician-led teams. The intervention can reduce long-term costs, while improving physical functioning and general health domains in the SF-36.6
• Use of advanced practice nurses in comprehensive discharge planning interventions, including nursing home visits for older patients with risk factors for poor outcomes post-discharge, has been shown to reduce readmissions.7

Assessment Is the Bottom Line

Robert Palmer, MD, head of the Section of Geriatric Medicine and professor of medicine at Cleveland Clinic Lerner College of Medicine of Case Western Reserve University in Ohio, is known for his work with ACE units. He and his colleagues have tracked patients following discharge and have identified the highest priority issues that should be addressed to avoid deleterious geriatric syndromes in the hospital. Although he advocates what he calls a minimalist approach to conducting a geriatric assessment, Dr. Palmer underlines the idea that it must also be a deliberate and structured approach. Assessing and acting upon key indicators in four to five major domains, he notes, can make a big difference for patients’ hospital trajectories.8 Here are a few domains to consider:

1 Focus on activities of daily living (ADLs). Function and performance of ADLs can predict post-hospital outcome and help the physician prioritize elements of the patient’s trajectory and goals while in the hospital. “If a person was able to independently bathe, dress, toilet, walk, and transfer—from bed to chair, for instance—before the acute illness, then he or she should be able to get back to that point after the illness has been treated,” says Dr. Palmer. The ability to transfer independently is an important predictor of discharge status because if the patient requires assistance to transfer, he or she will need a different level of care upon discharge. The hospitalist should seek information —from the patient, family member or primary caregiver, or primary care physician—about the patient’s ADLs before he or she got sick. Again, recovery of ADLs may be possible if the patient was performing these independently before the acute episode.

2 Cognitive assessments are also key. Dr. Morley places assessment for delirium at the top of his list. Research shows that approximately one third of patients over 70 in the hospital will develop the condition. Delirium, or acute confusion, is also a predictor of decline in ADLs, notes Dr. Palmer. Dr. Morley recommends the use of the Confusion Assessment Method (CAM) because the Mini Mental State Exam can be time-consuming. (A CAM form is available free online as part of SHM’s “Clinical Toolbox for Geriatric Care.” Go to www.hospitalmedicine.org, click on “Resource Center” and then “Geriatric Special Interest Area” to find the Toolbox.) According to Dr. Palmer, the physician should also use common sense when initially examining the patient: Observe whether the patient is confused, distracted, or inappropriate in conversation. If so, the next step is to use the simple Digit Span test: Say a random set of four to five numbers, and ask the patient to repeat them. Inability to do this is consistent with delirium as a cause of cognitive impairment.

For assessing cognitive impairment, Dr. Morley prefers the St. Louis University Mental Status Exam (SLUMS) to the Mini Mental Status Exam. The SLUMS, developed in collaboration with the Department of Veterans Affairs (and available free online at: http://medschool.slu.edu/agingsuccessfully/pdfsurveys/slumsexam_05.pdf) successfully picks up even mild cognitive impairment, according to Dr. Morley. This is important information not just for the hospital trajectory but also for discharge planning: Inability to follow discharge instructions due to cognitive impairment could result in a readmission.

3 Malnutrition is associated with mortality. Dr. Morley uses the four questions of the Simplified Nutrition Assessment Questionnaire (SNAQ), which correlate well with future weight loss and poor outcomes.9

If the SNAQ is positive, the use of a lengthier questionnaire may be warranted. Dr. Palmer suggests that a review of the patient’s comprehensive metabolic panel to judge kidney and liver function and a bedside evaluation using the Subjective Global Assessment (SGA) can yield results just as usable as the more complex and time-consuming textbook nutritional assessments.

4 Mood and affect also play a role in patients’ outcomes. Research has shown that depressed patients have poor outcomes, so physicians should always assess for depression. While the Geriatric Depression Scale (see “Clinical Toolbox for Geriatric Care” on the SHM Web site) can help quantify the extent of the patient’s symptoms, simply asking the patient, “Are you depressed, sad, or blue?” can often elicit enough information about the patient’s psychological status to direct interventions.

5 Mobility is sometimes classified as a stand-alone domain. However, walking and balance may be included in the assessment of ADLs. A patient who can walk independently—even with a cane or a walker—has a good chance to return home, says Dr. Palmer. Requiring another person to help with walking most likely indicates the patient will need short-term rehabilitation in a skilled nursing facility before returning home.

6 Social and living situation are important. The physician must identify the extent and quality of the patient’s support network. If, for instance, a patient has mild dementia but has a network of 10 extended family members who act as caregivers, discharge to home may be possible. If the patient was admitted to the hospital from a nursing home, however, it is most likely he or she will return there.

Revisit Daily Goals

Dr. Palmer advises hospitalists to follow the geriatric assessment with a translation of the information into what he calls a functional trajectory for the patient’s hospital stay. This includes an estimate of the patient’s anticipated length of stay and the expected discharge site. Interventions and consultations from allied health providers will be keyed to the patient’s individualized needs and to the goals of the functional trajectory.

To head off problems, Dr. Palmer advocates consultations from allied health professionals early in the hospital trajectory. For instance, if the patient is having trouble transferring from bed to chair upon admission, a consult with physical therapy may be warranted immediately rather than right before discharge, as is usually the case.

“We should not be depending on physical therapists at the end of hospitalization, when patients are already deconditioned and can’t get out of bed and need to go to a nursing home,” he explains. “The ideal time to bring in the physical therapist or technician is when you’ve identified—on day one—that the patient needs assistance with transfers, so that you can preserve mobility and shorten hospital stay.”

In the same vein, knowing the patient’s living situation will allow involvement of the discharge planner from day one of the hospitalization to plan with the patient or family for the patient’s return to home or to an alternate site. If the patient has been on a complex drug regimen, involving the pharmacist to help straighten out medications can head off potential drug-drug interactions. (SHM’s Geriatric Toolbox also has a list of medications to avoid in geriatric patients.)

It is important to review the functional trajectory on a daily basis. Input from other members of the health team will be invaluable. “Each day you identify barriers to that successful plan of the outcome, and you take care of them one at a time,” says Dr. Palmer. “If the patient is not on track with that daily goal, the team goes back to the drawing board and asks, ‘What are we missing here?’ Then you do a reassessment of ADLs, nutrition, and cognition.”

Hospitalists must also include the patient’s family members and primary caregivers as the patient moves toward discharge, asserts Dr. Morley. Clear, unambiguous written instructions must always be given to the patient or the primary caregiver when the patient leaves the hospital. (You can also find a discharge instruction sheet in SHM’s Toolbox.) If a patient appears to be facing the end of life, the hospitalist should schedule a conference with members of the primary care team, the hospitalist team, and all family stakeholders.

Transportable SKILLS

Some experts maintain that quality care for geriatric patients can be accomplished without a specialized geriatrics unit.

“I never conceived of the ACE intervention as being done exclusively on a unit,” says Dr. Palmer. “The idea was to develop the skills on a unit and then transport those skills to all units.” Although the protocols developed for ACE units are good for teaching, he says the team has been the key.

Dr. Morley agrees: “It’s not the physical part of the ACE unit that works. You must have team interactions. Finding a way to communicate between the different team members is absolutely key to good outcomes.”

Involving healthcare providers from different disciplines only enhances the care of geriatric patients. “Even though hospitalists may not have the depth of knowledge of geriatrics that a geriatrician has, they certainly have the knowledge of acute care medicine that we have, so they can manage the medical problems,” says Dr. Palmer. “What they need to do is think systematically, in a structured way, and to work collaboratively with key players. This only takes a few minutes each day, but more importantly, it saves time. You have fewer phone calls and fewer angry family members when you manage the care in a structured manner, working with a team of health professionals.”

Dr. Morley and his team have developed a form for their ACE unit that allows them to assess a patient’s status and goals in two to three minutes.

Dr. Pierluissi has experienced firsthand the benefits of working as a member of the interdisciplinary team. “Essentially,” he says, working in teams to treat the geriatric patient means there are “more heads in the game, more people trying to work in the patient’s best interest. You [the clinician] really do feel supported, and it makes your day more enjoyable and more productive.” TH

Gretchen Henkel is a medical journalist based in California.

Resources

1. Kozak LJ, Hall MJ, Owings MF. Hospitalization fact sheet. In: National Hospital Discharge Survey: 2000 Annual summary with detailed diagnosis and procedure data. Hyattsville, Maryland: National Center for Health Statistics. Vital Health Stat. 2002;13(153).
2. Covinsky KE, Palmer RM, Fortinsky RH, et al. Loss of independence in activities of daily living in older adults hospitalized with medical illnesses: increased vulnerability with age. J Am Geriatr Soc. 2003 Apr;51(4):451-458.
3. Landefeld CS, Palmer RM, Kresevic DM, et al. A randomized trial of care in a hospital medical unit especially designed to improve the functional outcomes of acutely ill older patients. N Engl J Med. 1995 May;332(20):1338-1344. Comments in: ACP J Club. 1995 Nov-Dec; 123(3):69 and N Engl J Med. 1995 May 18; 332(20):1376-1378.
4. Counsell SR, Holder CM, Liebenauer LL, et al. Effects of a multicomponent intervention on functional outcomes and process of care in hospitalized older patients: a randomized controlled trial of acute care for Elders (ACE) in a community hospital. J Am Geriatr Soc. 2000 Dec;48:1572-1581.
5. Inouye SK, Bogardus ST Jr, Charpentier PA, et al. A multicomponent intervention to prevent delirium in hospitalized older patients. N Engl J Med. 1999 Mar 4;340(9):669-676. Comments in: N Engl J Med. 1999 Jul 29; 341(5):369-370; author reply 370 and N Engl J Med. 1999 Mar 4; 340(9):720-721.
6. Cohen HJ, Feussner JR, Weinberger M, et al. A controlled trial of inpatient and outpatient geriatric evaluation and management. N Engl J Med. 2002 Mar 21;346(12):905-912. Comments in: Curr Surg. 2004 May-Jun;61(3):266-274; N Engl J Med. 2002 Aug 1;347(5):371-373; author reply 371-373 & N Engl J Med. 2002 Mar 21;346(12):874.
7. Naylor MD, Brooten DA, Campbell RL, et al. Transitional care of older adults hospitalized with heart failure: a randomized, controlled trial. J Am Geriatr Soc. 2004 May;52(5):675-684. Erratum in J Am Geriatr Soc. 2004 Jul; 52(7):1228. Comment in Evid Based Nurs. 2004 Oct;7(4):116.
8. Palmer RM. Acute hospital care of the elderly: making a difference. Caring for the Hospitalized Elderly [special supplement to The Hospitalist]. 2004. Available at: www.hospitalmedicine.org/AM/Template.cfm?Section=The_Hospitalist&Template=/CM/ContentDisplay.cfm&ContentFileID=1447. Last accessed March 14, 2007.
9. Wilson MM, Thomas DR, Rubenstein LZ, et al. Appetite assessment: simple appetite questionnaire predicts weight loss in community-dwelling adults and nursing home residents. Am J Clin Nutr. 2005 Nov;82(5):1074-1081.

Hospitalization can be risky business for geriatric patients. Americans 65 and older make up 13% of the population but account for 48% of inpatient days of care and 78% of hospital deaths. While in the hospital, patients 75 and older are at high risk for deconditioning and functional decline, medication errors, delirium, and falls.1,2

For geriatric patients not closely monitored, notes geriatrician Don Murphy, MD, co-principal of Senior Care of Colorado, a large primary care geriatrics group in Denver, going to the hospital can be like disappearing into a black hole.

As the U.S. population ages, hospitalists will be caring for an increasing number of geriatric patients. They will have to address patients’ acute medical conditions without compromising their functional status.

The Hospitalist asked several leading geriatricians to identify valuable tools and strategies for delivering comprehensive geriatric care in the hospital. Even in the absence of formal geriatric care units, they say, hospitalists are positioned for adopting the principles of quality geriatric care. Many of those principles align with the central mission of hospital medicine: promoting high-quality, patient-centered care, working as a team, and developing clear lines of communication between the hospitalist and the primary care teams.

A Survey of Interventions

“There’s no question that it’s becoming extraordinarily difficult to do good care,” says John Morley, MD, professor of medicine and chief of the Division of Geriatrics and Endocrinology at Saint Louis University Health Sciences Center in Missouri. “Taking care of an older person in the hospital is a team sport—the physician can’t do it alone.”

It’s clear the team approach is a crucial foundation for interventions that target at-risk geriatric patients, agrees Edgar Pierluissi, MD, associate clinical professor of medicine and medical director of the recently established ACE unit at San Francisco General Hospital. Reducing the incidence of delirium, for instance, cannot be accomplished simply by utilizing a geriatric consultation. Once established, acute confusion can be intractable. “The idea is to try to prevent delirium, and research has shown that single-person types of interventions in these massively impervious-to-change facilities don’t work,” he says.

Clinical trials have demonstrated that interventions, including interdisciplinary and collaborative teams, targeted patient-centered therapies, and comprehensive geriatric assessment can improve outcomes of hospitalization in geriatric patients. Four major interventions include:

• Acute Care for Elders (ACE) units based on interdisciplinary team rounds, discharge planning, and medical review in a prepared environment to foster patient self-care and improve function. Randomized clinical trials have shown ACE units can reduce the length of stay, the risk of nursing home admissions, and the use of physical restraints while improving providers’ satisfaction with patient care.3,4
• The Hospital Elder Life Program (HELP), led by a geriatrics resource nurse, is an intervention designed to reduce the incidence of delirium by adjusting environmental elements, such as dimming lights and keeping the floor quiet at night. HELP also introduces non-pharmacologic interventions, including massages and warm tea at night and promotes mobility and hydration during the day.
• Incidence of delirium is reduced and cost savings are realized using the HELP.5 (Visit http://elderlife.med.yale.edu/public for more information.)
• Geriatric Evaluation and Management (GEM) units also emphasize a multidisciplinary comprehensive approach using geriatrician-led teams. The intervention can reduce long-term costs, while improving physical functioning and general health domains in the SF-36.6
• Use of advanced practice nurses in comprehensive discharge planning interventions, including nursing home visits for older patients with risk factors for poor outcomes post-discharge, has been shown to reduce readmissions.7

Assessment Is the Bottom Line

Robert Palmer, MD, head of the Section of Geriatric Medicine and professor of medicine at Cleveland Clinic Lerner College of Medicine of Case Western Reserve University in Ohio, is known for his work with ACE units. He and his colleagues have tracked patients following discharge and have identified the highest priority issues that should be addressed to avoid deleterious geriatric syndromes in the hospital. Although he advocates what he calls a minimalist approach to conducting a geriatric assessment, Dr. Palmer underlines the idea that it must also be a deliberate and structured approach. Assessing and acting upon key indicators in four to five major domains, he notes, can make a big difference for patients’ hospital trajectories.8 Here are a few domains to consider:

1 Focus on activities of daily living (ADLs). Function and performance of ADLs can predict post-hospital outcome and help the physician prioritize elements of the patient’s trajectory and goals while in the hospital. “If a person was able to independently bathe, dress, toilet, walk, and transfer—from bed to chair, for instance—before the acute illness, then he or she should be able to get back to that point after the illness has been treated,” says Dr. Palmer. The ability to transfer independently is an important predictor of discharge status because if the patient requires assistance to transfer, he or she will need a different level of care upon discharge. The hospitalist should seek information —from the patient, family member or primary caregiver, or primary care physician—about the patient’s ADLs before he or she got sick. Again, recovery of ADLs may be possible if the patient was performing these independently before the acute episode.

2 Cognitive assessments are also key. Dr. Morley places assessment for delirium at the top of his list. Research shows that approximately one third of patients over 70 in the hospital will develop the condition. Delirium, or acute confusion, is also a predictor of decline in ADLs, notes Dr. Palmer. Dr. Morley recommends the use of the Confusion Assessment Method (CAM) because the Mini Mental State Exam can be time-consuming. (A CAM form is available free online as part of SHM’s “Clinical Toolbox for Geriatric Care.” Go to www.hospitalmedicine.org, click on “Resource Center” and then “Geriatric Special Interest Area” to find the Toolbox.) According to Dr. Palmer, the physician should also use common sense when initially examining the patient: Observe whether the patient is confused, distracted, or inappropriate in conversation. If so, the next step is to use the simple Digit Span test: Say a random set of four to five numbers, and ask the patient to repeat them. Inability to do this is consistent with delirium as a cause of cognitive impairment.

For assessing cognitive impairment, Dr. Morley prefers the St. Louis University Mental Status Exam (SLUMS) to the Mini Mental Status Exam. The SLUMS, developed in collaboration with the Department of Veterans Affairs (and available free online at: http://medschool.slu.edu/agingsuccessfully/pdfsurveys/slumsexam_05.pdf) successfully picks up even mild cognitive impairment, according to Dr. Morley. This is important information not just for the hospital trajectory but also for discharge planning: Inability to follow discharge instructions due to cognitive impairment could result in a readmission.

3 Malnutrition is associated with mortality. Dr. Morley uses the four questions of the Simplified Nutrition Assessment Questionnaire (SNAQ), which correlate well with future weight loss and poor outcomes.9

If the SNAQ is positive, the use of a lengthier questionnaire may be warranted. Dr. Palmer suggests that a review of the patient’s comprehensive metabolic panel to judge kidney and liver function and a bedside evaluation using the Subjective Global Assessment (SGA) can yield results just as usable as the more complex and time-consuming textbook nutritional assessments.

4 Mood and affect also play a role in patients’ outcomes. Research has shown that depressed patients have poor outcomes, so physicians should always assess for depression. While the Geriatric Depression Scale (see “Clinical Toolbox for Geriatric Care” on the SHM Web site) can help quantify the extent of the patient’s symptoms, simply asking the patient, “Are you depressed, sad, or blue?” can often elicit enough information about the patient’s psychological status to direct interventions.

5 Mobility is sometimes classified as a stand-alone domain. However, walking and balance may be included in the assessment of ADLs. A patient who can walk independently—even with a cane or a walker—has a good chance to return home, says Dr. Palmer. Requiring another person to help with walking most likely indicates the patient will need short-term rehabilitation in a skilled nursing facility before returning home.

6 Social and living situation are important. The physician must identify the extent and quality of the patient’s support network. If, for instance, a patient has mild dementia but has a network of 10 extended family members who act as caregivers, discharge to home may be possible. If the patient was admitted to the hospital from a nursing home, however, it is most likely he or she will return there.

Revisit Daily Goals

Dr. Palmer advises hospitalists to follow the geriatric assessment with a translation of the information into what he calls a functional trajectory for the patient’s hospital stay. This includes an estimate of the patient’s anticipated length of stay and the expected discharge site. Interventions and consultations from allied health providers will be keyed to the patient’s individualized needs and to the goals of the functional trajectory.

To head off problems, Dr. Palmer advocates consultations from allied health professionals early in the hospital trajectory. For instance, if the patient is having trouble transferring from bed to chair upon admission, a consult with physical therapy may be warranted immediately rather than right before discharge, as is usually the case.

“We should not be depending on physical therapists at the end of hospitalization, when patients are already deconditioned and can’t get out of bed and need to go to a nursing home,” he explains. “The ideal time to bring in the physical therapist or technician is when you’ve identified—on day one—that the patient needs assistance with transfers, so that you can preserve mobility and shorten hospital stay.”

In the same vein, knowing the patient’s living situation will allow involvement of the discharge planner from day one of the hospitalization to plan with the patient or family for the patient’s return to home or to an alternate site. If the patient has been on a complex drug regimen, involving the pharmacist to help straighten out medications can head off potential drug-drug interactions. (SHM’s Geriatric Toolbox also has a list of medications to avoid in geriatric patients.)

It is important to review the functional trajectory on a daily basis. Input from other members of the health team will be invaluable. “Each day you identify barriers to that successful plan of the outcome, and you take care of them one at a time,” says Dr. Palmer. “If the patient is not on track with that daily goal, the team goes back to the drawing board and asks, ‘What are we missing here?’ Then you do a reassessment of ADLs, nutrition, and cognition.”

Hospitalists must also include the patient’s family members and primary caregivers as the patient moves toward discharge, asserts Dr. Morley. Clear, unambiguous written instructions must always be given to the patient or the primary caregiver when the patient leaves the hospital. (You can also find a discharge instruction sheet in SHM’s Toolbox.) If a patient appears to be facing the end of life, the hospitalist should schedule a conference with members of the primary care team, the hospitalist team, and all family stakeholders.

Transportable SKILLS

Some experts maintain that quality care for geriatric patients can be accomplished without a specialized geriatrics unit.

“I never conceived of the ACE intervention as being done exclusively on a unit,” says Dr. Palmer. “The idea was to develop the skills on a unit and then transport those skills to all units.” Although the protocols developed for ACE units are good for teaching, he says the team has been the key.

Dr. Morley agrees: “It’s not the physical part of the ACE unit that works. You must have team interactions. Finding a way to communicate between the different team members is absolutely key to good outcomes.”

Involving healthcare providers from different disciplines only enhances the care of geriatric patients. “Even though hospitalists may not have the depth of knowledge of geriatrics that a geriatrician has, they certainly have the knowledge of acute care medicine that we have, so they can manage the medical problems,” says Dr. Palmer. “What they need to do is think systematically, in a structured way, and to work collaboratively with key players. This only takes a few minutes each day, but more importantly, it saves time. You have fewer phone calls and fewer angry family members when you manage the care in a structured manner, working with a team of health professionals.”

Dr. Morley and his team have developed a form for their ACE unit that allows them to assess a patient’s status and goals in two to three minutes.

Dr. Pierluissi has experienced firsthand the benefits of working as a member of the interdisciplinary team. “Essentially,” he says, working in teams to treat the geriatric patient means there are “more heads in the game, more people trying to work in the patient’s best interest. You [the clinician] really do feel supported, and it makes your day more enjoyable and more productive.” TH

Gretchen Henkel is a medical journalist based in California.

Resources

1. Kozak LJ, Hall MJ, Owings MF. Hospitalization fact sheet. In: National Hospital Discharge Survey: 2000 Annual summary with detailed diagnosis and procedure data. Hyattsville, Maryland: National Center for Health Statistics. Vital Health Stat. 2002;13(153).
2. Covinsky KE, Palmer RM, Fortinsky RH, et al. Loss of independence in activities of daily living in older adults hospitalized with medical illnesses: increased vulnerability with age. J Am Geriatr Soc. 2003 Apr;51(4):451-458.
3. Landefeld CS, Palmer RM, Kresevic DM, et al. A randomized trial of care in a hospital medical unit especially designed to improve the functional outcomes of acutely ill older patients. N Engl J Med. 1995 May;332(20):1338-1344. Comments in: ACP J Club. 1995 Nov-Dec; 123(3):69 and N Engl J Med. 1995 May 18; 332(20):1376-1378.
4. Counsell SR, Holder CM, Liebenauer LL, et al. Effects of a multicomponent intervention on functional outcomes and process of care in hospitalized older patients: a randomized controlled trial of acute care for Elders (ACE) in a community hospital. J Am Geriatr Soc. 2000 Dec;48:1572-1581.
5. Inouye SK, Bogardus ST Jr, Charpentier PA, et al. A multicomponent intervention to prevent delirium in hospitalized older patients. N Engl J Med. 1999 Mar 4;340(9):669-676. Comments in: N Engl J Med. 1999 Jul 29; 341(5):369-370; author reply 370 and N Engl J Med. 1999 Mar 4; 340(9):720-721.
6. Cohen HJ, Feussner JR, Weinberger M, et al. A controlled trial of inpatient and outpatient geriatric evaluation and management. N Engl J Med. 2002 Mar 21;346(12):905-912. Comments in: Curr Surg. 2004 May-Jun;61(3):266-274; N Engl J Med. 2002 Aug 1;347(5):371-373; author reply 371-373 & N Engl J Med. 2002 Mar 21;346(12):874.
7. Naylor MD, Brooten DA, Campbell RL, et al. Transitional care of older adults hospitalized with heart failure: a randomized, controlled trial. J Am Geriatr Soc. 2004 May;52(5):675-684. Erratum in J Am Geriatr Soc. 2004 Jul; 52(7):1228. Comment in Evid Based Nurs. 2004 Oct;7(4):116.
8. Palmer RM. Acute hospital care of the elderly: making a difference. Caring for the Hospitalized Elderly [special supplement to The Hospitalist]. 2004. Available at: www.hospitalmedicine.org/AM/Template.cfm?Section=The_Hospitalist&Template=/CM/ContentDisplay.cfm&ContentFileID=1447. Last accessed March 14, 2007.
9. Wilson MM, Thomas DR, Rubenstein LZ, et al. Appetite assessment: simple appetite questionnaire predicts weight loss in community-dwelling adults and nursing home residents. Am J Clin Nutr. 2005 Nov;82(5):1074-1081.

Whether obligatory or voluntary, service on committees is a reality for most hospitalists. “The 2005-2006 SHM Survey: State of the Hospital Medicine Movement” found that, for 92% of respondents, committee participation topped the list of non-clinical activities.1 Hospital medicine group leaders, consultants, and administrators interviewed for this article say time-pressed hospitalists must become more effective committee participants.

Civic Duty or Career Advancement?

Because of growing presence at the hospital and their knowledge of hospital operations, hospitalists are a logical choice for committee assignments. These can range from committees dedicated to care delivery (e.g., pharmacy and therapeutics) to the hospital board’s governance committees.

“Hospitalists, with their perspective of hospital operations and clinical care, could be a great part of broadening the perspective of the board, informing their decision-making and helping them to formulate policies,” says John Combes, MD, president of the Center for Healthcare Governance in Chicago, a subsidiary committee of the American Hospital Association.

Mark V. Williams, MD, professor of medicine and director, Emory Hospital Medicine Unit in Atlanta, and editor in chief of the Journal of Hospital Medicine, does not consider committee participation optional.

“I strongly encourage—if not almost require—all of the hospitalists in our group to be involved in at least one committee,” says Dr. Williams. “My belief is that hospitalists are integral to the functioning of the hospital, and as part of their responsibility, they need to be actively involved in committee work to move projects forward.”

Leslie Flores, MHA, co-principal of Nelson/Flores Associates, LLC, agrees. “It’s in the hospitalists’ best interest to be involved in committees,” she says. “Hospitalists are often in the best position to see what needs to be fixed, and they have the potential to have a significant impact on how effectively their hospital operates, which can make their own jobs easier.”

Further, she points out, “If the hospital, which is financially supporting them, is more successful and effective, there’s likely to be less financial pressure on their practice.”

Hospitalists’ perceptions about committee participation can be influenced by each hospitalist’s employment model. If one is working directly for the hospital and giving 110% to that employer, being asked to volunteer additional time to serve on a committee might be viewed as a burden. On the other hand, an independent hospital medicine group (HMG) contracting with the hospital to deliver services may view committee participation as an avenue for ensuring the group’s success. Whatever the employment model, and whatever the career goals of individual hospitalists, it often pays to target one’s participation in committees.

Make Participation Count

Hospitalists will be playing more key roles in medical staff leadership, according to William D. Atchley Jr., MD, medical director of the Division of Hospital Medicine for Sentara Medical Group in Hampton, Va. His concern is that hospitalists will be asked to serve on more than one or two committees. He advises younger hospitalists to notify the president of the medical staff of which committees they would be interested in working on. Dr. Atchley is also a member of the SHM Board of Directors.

“It could be peer review, performance improvement, or ad hoc committees focused on developing evidence-based order sets, improving through-put or disaster preparedness,” says Dr. Atchley. Whatever the pick, “it should be something that they’re going to find enjoyable and that they feel will advance their stature within the hospital.”

To be an effective member of a hospital board committee, a hospitalist must represent the greater interests of all stakeholders—not just his or her own self-interest, cautions Dr. Combes. However, “as physicians become more stressed and production-oriented, giving up clinical time to participate in governance activities becomes more and more difficult,” he concedes. Hospitalists should choose committee assignments based on their interests and expertise.

Dr. Williams encourages hospitalists in his group to pick one committee—preferably one focused on care delivery (quality improvement, pharmacy and therapeutics, utilization review) and take an active role. “Then, over time, I encourage them to try to chair committees to obtain leadership experience,” he says.

Taking on too many extracurricular committee tasks can be counterproductive. To avoid this, Flores advises younger hospitalists to ask themselves the following:

• What will my committee participation do to support the goals of the committee and the organization?
• By participating in this committee, can I expand my own knowledge or understanding of the culture and politics of the organization?
• Can I become more comfortable interacting on an organizational level?
• Can I network and get to know people I wouldn’t otherwise encounter, who can be helpful to me personally?

In addition, Dr. Atchley believes rotating committee assignments is also beneficial, especially for the younger hospitalist. In his tenure as a hospitalist, Dr. Atchley has served as chairman of the Department of Medicine’s credentials and quality assurance committees, and as vice president of the medical staff. Each committee furnishes hospitalists with a different perspective about how the hospital functions.

“I think hospitalists should understand the medical staff bylaws and procedures,” says Dr. Atchley. “Each hospital medicine staff has this governance structure, and I have found it beneficial in resolving conflicts about patient care and interaction between physicians.”

Mary A. Dallas, MD, has seen the committee situation from both sides of the fence. She is medical information officer for Presbyterian Healthcare Services, an integrated healthcare delivery network in Albuquerque, N.M., but served as medical director of Presbyterian’s hospitalist group for five years before that.

“Hospitalists have a vested interest in making sure their work area is protected, so they need to plant some people in strategic places for the governance and medical staff,” says Dr. Dallas. “In order to be effective in the governance of the hospital, you have to be part of that medical substructure and get involved.”

For instance, as medical director, she sat on the hospital’s credential committee and found it allowed her to keep tabs on new HMG hires going through the credentialing process. “This [the hospital] is your work environment,” she explains. “You are here day in and day out, and you should shape that environment, have a say in policies and rules, so that you can make your job more successful and make patient care better.”

The Quandary over Compensation

Many hospitalists feel frustrated when committee obligations impinge on clinical duties. Is compensation the answer for filling committee slots? Opinions are mixed.

Dr. Williams says he is “a little uncomfortable with the concept of people getting paid every time they attend a committee meeting. For hospitalists who receive funding from the hospital to support their programs, it’s important for the leader [of the HMG] to ensure that they’re collaborating with hospital administration. The hospital has the expectation that, as part of our salary structure, we will be members of committees. That needs to be part of the job.”

Dr. Dallas agrees: “Regardless of whether you’re getting paid or not, this is your work environment. I think it’s very important to be involved, so that your voice is heard and so that you can help make the [hospital] structure better.”

Compensating physicians for their time does communicate that their time is valued and respected, says Dr. Combes, but payment does not necessarily guarantee a high level of committee members’ engagement. In addition, he says, if physicians are being compensated directly by the hospital for serving on committees, “this can threaten the perception of their objectivity, in terms of bringing an independent perspective to the board.” A better solution might be for the hospital medicine group to build its own compensation structure for non-clinical work so members retain independence when voicing opinions to the hospital board.

Dr. Atchley admits it’s sometimes a struggle to find people willing to serve on medical staff committees. He advocates compensation for those duties on a per-meeting or hourly basis. His hospital meets attendance requirements by giving credit to doctors who participate on selected medical staff committees.

Through her consulting assignments, Flores has observed that in some organizations where hospitalists are paid based on productivity, committee participation can be assigned a relative value unit so hospitalists are compensated on the same basis as for clinical work.

Flores concurs with Drs. Dallas and Williams: “In most organizations, a certain minimum level of participation in medical staff activities is expected of all staff members. I think that hospitalists should expect to do that to the same degree as other medical staff members, on a voluntary basis.

“If hospitalists truly want to impact how the medical staff and the hospital operate, and to be considered for high-level leadership positions, then their best way of becoming known and respected in the medical community is by participating on committees.” TH

Gretchen Henkel writes frequently for The Hospitalist.

Reference

1. SHM’s “2005-2006 Survey: State of the Hospital Medicine Movement, 2006.” Available online at www.hospitalmedicine.org Last accessed April 5, 2007.

Whether obligatory or voluntary, service on committees is a reality for most hospitalists. “The 2005-2006 SHM Survey: State of the Hospital Medicine Movement” found that, for 92% of respondents, committee participation topped the list of non-clinical activities.1 Hospital medicine group leaders, consultants, and administrators interviewed for this article say time-pressed hospitalists must become more effective committee participants.

Civic Duty or Career Advancement?

Because of growing presence at the hospital and their knowledge of hospital operations, hospitalists are a logical choice for committee assignments. These can range from committees dedicated to care delivery (e.g., pharmacy and therapeutics) to the hospital board’s governance committees.

“Hospitalists, with their perspective of hospital operations and clinical care, could be a great part of broadening the perspective of the board, informing their decision-making and helping them to formulate policies,” says John Combes, MD, president of the Center for Healthcare Governance in Chicago, a subsidiary committee of the American Hospital Association.

Mark V. Williams, MD, professor of medicine and director, Emory Hospital Medicine Unit in Atlanta, and editor in chief of the Journal of Hospital Medicine, does not consider committee participation optional.

“I strongly encourage—if not almost require—all of the hospitalists in our group to be involved in at least one committee,” says Dr. Williams. “My belief is that hospitalists are integral to the functioning of the hospital, and as part of their responsibility, they need to be actively involved in committee work to move projects forward.”

Leslie Flores, MHA, co-principal of Nelson/Flores Associates, LLC, agrees. “It’s in the hospitalists’ best interest to be involved in committees,” she says. “Hospitalists are often in the best position to see what needs to be fixed, and they have the potential to have a significant impact on how effectively their hospital operates, which can make their own jobs easier.”

Further, she points out, “If the hospital, which is financially supporting them, is more successful and effective, there’s likely to be less financial pressure on their practice.”

Hospitalists’ perceptions about committee participation can be influenced by each hospitalist’s employment model. If one is working directly for the hospital and giving 110% to that employer, being asked to volunteer additional time to serve on a committee might be viewed as a burden. On the other hand, an independent hospital medicine group (HMG) contracting with the hospital to deliver services may view committee participation as an avenue for ensuring the group’s success. Whatever the employment model, and whatever the career goals of individual hospitalists, it often pays to target one’s participation in committees.

Make Participation Count

Hospitalists will be playing more key roles in medical staff leadership, according to William D. Atchley Jr., MD, medical director of the Division of Hospital Medicine for Sentara Medical Group in Hampton, Va. His concern is that hospitalists will be asked to serve on more than one or two committees. He advises younger hospitalists to notify the president of the medical staff of which committees they would be interested in working on. Dr. Atchley is also a member of the SHM Board of Directors.

“It could be peer review, performance improvement, or ad hoc committees focused on developing evidence-based order sets, improving through-put or disaster preparedness,” says Dr. Atchley. Whatever the pick, “it should be something that they’re going to find enjoyable and that they feel will advance their stature within the hospital.”

To be an effective member of a hospital board committee, a hospitalist must represent the greater interests of all stakeholders—not just his or her own self-interest, cautions Dr. Combes. However, “as physicians become more stressed and production-oriented, giving up clinical time to participate in governance activities becomes more and more difficult,” he concedes. Hospitalists should choose committee assignments based on their interests and expertise.

Dr. Williams encourages hospitalists in his group to pick one committee—preferably one focused on care delivery (quality improvement, pharmacy and therapeutics, utilization review) and take an active role. “Then, over time, I encourage them to try to chair committees to obtain leadership experience,” he says.

Taking on too many extracurricular committee tasks can be counterproductive. To avoid this, Flores advises younger hospitalists to ask themselves the following:

• What will my committee participation do to support the goals of the committee and the organization?
• By participating in this committee, can I expand my own knowledge or understanding of the culture and politics of the organization?
• Can I become more comfortable interacting on an organizational level?
• Can I network and get to know people I wouldn’t otherwise encounter, who can be helpful to me personally?

In addition, Dr. Atchley believes rotating committee assignments is also beneficial, especially for the younger hospitalist. In his tenure as a hospitalist, Dr. Atchley has served as chairman of the Department of Medicine’s credentials and quality assurance committees, and as vice president of the medical staff. Each committee furnishes hospitalists with a different perspective about how the hospital functions.

“I think hospitalists should understand the medical staff bylaws and procedures,” says Dr. Atchley. “Each hospital medicine staff has this governance structure, and I have found it beneficial in resolving conflicts about patient care and interaction between physicians.”

Mary A. Dallas, MD, has seen the committee situation from both sides of the fence. She is medical information officer for Presbyterian Healthcare Services, an integrated healthcare delivery network in Albuquerque, N.M., but served as medical director of Presbyterian’s hospitalist group for five years before that.

“Hospitalists have a vested interest in making sure their work area is protected, so they need to plant some people in strategic places for the governance and medical staff,” says Dr. Dallas. “In order to be effective in the governance of the hospital, you have to be part of that medical substructure and get involved.”

For instance, as medical director, she sat on the hospital’s credential committee and found it allowed her to keep tabs on new HMG hires going through the credentialing process. “This [the hospital] is your work environment,” she explains. “You are here day in and day out, and you should shape that environment, have a say in policies and rules, so that you can make your job more successful and make patient care better.”

The Quandary over Compensation

Many hospitalists feel frustrated when committee obligations impinge on clinical duties. Is compensation the answer for filling committee slots? Opinions are mixed.

Dr. Williams says he is “a little uncomfortable with the concept of people getting paid every time they attend a committee meeting. For hospitalists who receive funding from the hospital to support their programs, it’s important for the leader [of the HMG] to ensure that they’re collaborating with hospital administration. The hospital has the expectation that, as part of our salary structure, we will be members of committees. That needs to be part of the job.”

Dr. Dallas agrees: “Regardless of whether you’re getting paid or not, this is your work environment. I think it’s very important to be involved, so that your voice is heard and so that you can help make the [hospital] structure better.”

Compensating physicians for their time does communicate that their time is valued and respected, says Dr. Combes, but payment does not necessarily guarantee a high level of committee members’ engagement. In addition, he says, if physicians are being compensated directly by the hospital for serving on committees, “this can threaten the perception of their objectivity, in terms of bringing an independent perspective to the board.” A better solution might be for the hospital medicine group to build its own compensation structure for non-clinical work so members retain independence when voicing opinions to the hospital board.

Dr. Atchley admits it’s sometimes a struggle to find people willing to serve on medical staff committees. He advocates compensation for those duties on a per-meeting or hourly basis. His hospital meets attendance requirements by giving credit to doctors who participate on selected medical staff committees.

Through her consulting assignments, Flores has observed that in some organizations where hospitalists are paid based on productivity, committee participation can be assigned a relative value unit so hospitalists are compensated on the same basis as for clinical work.

Flores concurs with Drs. Dallas and Williams: “In most organizations, a certain minimum level of participation in medical staff activities is expected of all staff members. I think that hospitalists should expect to do that to the same degree as other medical staff members, on a voluntary basis.

“If hospitalists truly want to impact how the medical staff and the hospital operate, and to be considered for high-level leadership positions, then their best way of becoming known and respected in the medical community is by participating on committees.” TH

Gretchen Henkel writes frequently for The Hospitalist.

Reference

1. SHM’s “2005-2006 Survey: State of the Hospital Medicine Movement, 2006.” Available online at www.hospitalmedicine.org Last accessed April 5, 2007.

Whether obligatory or voluntary, service on committees is a reality for most hospitalists. “The 2005-2006 SHM Survey: State of the Hospital Medicine Movement” found that, for 92% of respondents, committee participation topped the list of non-clinical activities.1 Hospital medicine group leaders, consultants, and administrators interviewed for this article say time-pressed hospitalists must become more effective committee participants.

Civic Duty or Career Advancement?

Because of growing presence at the hospital and their knowledge of hospital operations, hospitalists are a logical choice for committee assignments. These can range from committees dedicated to care delivery (e.g., pharmacy and therapeutics) to the hospital board’s governance committees.

“Hospitalists, with their perspective of hospital operations and clinical care, could be a great part of broadening the perspective of the board, informing their decision-making and helping them to formulate policies,” says John Combes, MD, president of the Center for Healthcare Governance in Chicago, a subsidiary committee of the American Hospital Association.

Mark V. Williams, MD, professor of medicine and director, Emory Hospital Medicine Unit in Atlanta, and editor in chief of the Journal of Hospital Medicine, does not consider committee participation optional.

“I strongly encourage—if not almost require—all of the hospitalists in our group to be involved in at least one committee,” says Dr. Williams. “My belief is that hospitalists are integral to the functioning of the hospital, and as part of their responsibility, they need to be actively involved in committee work to move projects forward.”

Leslie Flores, MHA, co-principal of Nelson/Flores Associates, LLC, agrees. “It’s in the hospitalists’ best interest to be involved in committees,” she says. “Hospitalists are often in the best position to see what needs to be fixed, and they have the potential to have a significant impact on how effectively their hospital operates, which can make their own jobs easier.”

Further, she points out, “If the hospital, which is financially supporting them, is more successful and effective, there’s likely to be less financial pressure on their practice.”

Hospitalists’ perceptions about committee participation can be influenced by each hospitalist’s employment model. If one is working directly for the hospital and giving 110% to that employer, being asked to volunteer additional time to serve on a committee might be viewed as a burden. On the other hand, an independent hospital medicine group (HMG) contracting with the hospital to deliver services may view committee participation as an avenue for ensuring the group’s success. Whatever the employment model, and whatever the career goals of individual hospitalists, it often pays to target one’s participation in committees.

Make Participation Count

Hospitalists will be playing more key roles in medical staff leadership, according to William D. Atchley Jr., MD, medical director of the Division of Hospital Medicine for Sentara Medical Group in Hampton, Va. His concern is that hospitalists will be asked to serve on more than one or two committees. He advises younger hospitalists to notify the president of the medical staff of which committees they would be interested in working on. Dr. Atchley is also a member of the SHM Board of Directors.

“It could be peer review, performance improvement, or ad hoc committees focused on developing evidence-based order sets, improving through-put or disaster preparedness,” says Dr. Atchley. Whatever the pick, “it should be something that they’re going to find enjoyable and that they feel will advance their stature within the hospital.”

To be an effective member of a hospital board committee, a hospitalist must represent the greater interests of all stakeholders—not just his or her own self-interest, cautions Dr. Combes. However, “as physicians become more stressed and production-oriented, giving up clinical time to participate in governance activities becomes more and more difficult,” he concedes. Hospitalists should choose committee assignments based on their interests and expertise.

Dr. Williams encourages hospitalists in his group to pick one committee—preferably one focused on care delivery (quality improvement, pharmacy and therapeutics, utilization review) and take an active role. “Then, over time, I encourage them to try to chair committees to obtain leadership experience,” he says.

Taking on too many extracurricular committee tasks can be counterproductive. To avoid this, Flores advises younger hospitalists to ask themselves the following:

• What will my committee participation do to support the goals of the committee and the organization?
• By participating in this committee, can I expand my own knowledge or understanding of the culture and politics of the organization?
• Can I become more comfortable interacting on an organizational level?
• Can I network and get to know people I wouldn’t otherwise encounter, who can be helpful to me personally?

In addition, Dr. Atchley believes rotating committee assignments is also beneficial, especially for the younger hospitalist. In his tenure as a hospitalist, Dr. Atchley has served as chairman of the Department of Medicine’s credentials and quality assurance committees, and as vice president of the medical staff. Each committee furnishes hospitalists with a different perspective about how the hospital functions.

“I think hospitalists should understand the medical staff bylaws and procedures,” says Dr. Atchley. “Each hospital medicine staff has this governance structure, and I have found it beneficial in resolving conflicts about patient care and interaction between physicians.”

Mary A. Dallas, MD, has seen the committee situation from both sides of the fence. She is medical information officer for Presbyterian Healthcare Services, an integrated healthcare delivery network in Albuquerque, N.M., but served as medical director of Presbyterian’s hospitalist group for five years before that.

“Hospitalists have a vested interest in making sure their work area is protected, so they need to plant some people in strategic places for the governance and medical staff,” says Dr. Dallas. “In order to be effective in the governance of the hospital, you have to be part of that medical substructure and get involved.”

For instance, as medical director, she sat on the hospital’s credential committee and found it allowed her to keep tabs on new HMG hires going through the credentialing process. “This [the hospital] is your work environment,” she explains. “You are here day in and day out, and you should shape that environment, have a say in policies and rules, so that you can make your job more successful and make patient care better.”

The Quandary over Compensation

Many hospitalists feel frustrated when committee obligations impinge on clinical duties. Is compensation the answer for filling committee slots? Opinions are mixed.

Dr. Williams says he is “a little uncomfortable with the concept of people getting paid every time they attend a committee meeting. For hospitalists who receive funding from the hospital to support their programs, it’s important for the leader [of the HMG] to ensure that they’re collaborating with hospital administration. The hospital has the expectation that, as part of our salary structure, we will be members of committees. That needs to be part of the job.”

Dr. Dallas agrees: “Regardless of whether you’re getting paid or not, this is your work environment. I think it’s very important to be involved, so that your voice is heard and so that you can help make the [hospital] structure better.”

Compensating physicians for their time does communicate that their time is valued and respected, says Dr. Combes, but payment does not necessarily guarantee a high level of committee members’ engagement. In addition, he says, if physicians are being compensated directly by the hospital for serving on committees, “this can threaten the perception of their objectivity, in terms of bringing an independent perspective to the board.” A better solution might be for the hospital medicine group to build its own compensation structure for non-clinical work so members retain independence when voicing opinions to the hospital board.

Dr. Atchley admits it’s sometimes a struggle to find people willing to serve on medical staff committees. He advocates compensation for those duties on a per-meeting or hourly basis. His hospital meets attendance requirements by giving credit to doctors who participate on selected medical staff committees.

Through her consulting assignments, Flores has observed that in some organizations where hospitalists are paid based on productivity, committee participation can be assigned a relative value unit so hospitalists are compensated on the same basis as for clinical work.

Flores concurs with Drs. Dallas and Williams: “In most organizations, a certain minimum level of participation in medical staff activities is expected of all staff members. I think that hospitalists should expect to do that to the same degree as other medical staff members, on a voluntary basis.

“If hospitalists truly want to impact how the medical staff and the hospital operate, and to be considered for high-level leadership positions, then their best way of becoming known and respected in the medical community is by participating on committees.” TH

Gretchen Henkel writes frequently for The Hospitalist.

Reference

1. SHM’s “2005-2006 Survey: State of the Hospital Medicine Movement, 2006.” Available online at www.hospitalmedicine.org Last accessed April 5, 2007.

Hospitalists are no strangers to performance measurement. Every day, their performance is measured, formally and informally, by their sponsoring organizations, by third-party payers, and by patients.

But many hospitalists are not engaged in producing or reviewing that performance data.

“Historically, hospitalist groups have relied on the hospital to collect the data and present it to them—and still do, to a great extent, even today,” says Marc B. Westle, DO, FACP, president and managing partner for a large private hospital medicine group (HMG), Asheville Hospitalist Group in North Carolina.

This often puts hospitalists at a disadvantage, says Dr. Westle. If hospitalist groups don’t get involved with data reporting and analysis, they can’t have meaningful discussions with their hospitals.

With a background in hospital administration, Leslie Flores, MHA, co-principal of Nelson/Flores Associates, LLC, is well acquainted with the challenges of collecting and reporting hospital data. Through her consulting work with partner John Nelson, MD, she has found that sponsoring organizations often don’t review performance data with hospitalists. Hospitalists may examine their performance one way, while the hospital uses a different set of metrics, or analytical techniques. This disconnect, she notes, “leads to differences in interpretations and understandings that can occur between the hospital folks and the doctors when they try to present information.”

A new white paper produced by SHM’s Benchmarks Committee, “Measuring Hospitalist Performance: Metrics, Reports, and Dashboards,” aims to change these scenarios by encouraging hospitalists to take charge of their performance reporting. Geared to multiple levels of expertise with performance metrics, the white paper offers “some real, practical advice as to how you capture this information and then how you look at it,” says Joe Miller, SHM senior vice president and staff liaison to the Benchmarks Committee.

Select a Metric

The Benchmarks Committee used a Delphi process to rank the importance of various metrics and produced a list of 10 on which they would focus. The clearly written introduction walks readers through a step-by-step process intended to help HMGs decide which performance metrics they will measure.

Flores, editor of the white paper project, cautions that the “magic 10” metrics selected by the committee don’t necessarily represent the most important metrics for each practice. “We wanted to stimulate hospitalists to think about how they view their own performance and to create a common language and understanding of what some key issues and expectations should be for hospitalists’ performance monitoring,” she says. “They can use this document as a starting point and then come up with performance metrics that really matter to their practice.”

Choosing metrics to measure and report on for the hospitalist service will depend on a variety of variables particular to that group, including:

• The HMG’s original mission;
• The expectations of the hospital or other sponsoring organization (such as a multispecialty group) for the return on their investment;
• Key outcomes and/or performance measures sought by payers, regulators, and other stakeholders; and
• The practice’s high-priority issues.

Regarding the last item, Flores recalls one HMG that decided to include on its dashboard a survey of how it used consulting physicians from the community. This component was chosen to address the concerns of other specialists in the community, who feared the hospitalists were using only their own medical group’s specialists for consultations.

To further guide choices of metrics, the white paper uses a uniform template to organize each section. Whether the metric is descriptive (volume, data, case mix), operational (hospital cost, productivity, provider satisfaction, length of stay, patient satisfaction), or clinical (mortality data, readmission rate, JCAHO core measures), the user finds a description in each section titled, “Why this metric is important.”

Daniel Rauch, MD, FAAP, explains why a pediatric hospitalist group might choose to focus on referring provider satisfaction rather than volume data—perhaps a more critical metric for adult hospitalist groups.

“Our volume data [a descriptive metric] will depend on who’s referring to us and the availability of subspecialists, as opposed to market share and the notability of the institution in the local environment,” he notes.

Dr. Rauch, director of the Pediatric Hospitalist Program at New York University School of Medicine in New York City and editor of the Provider Satisfaction section of the white paper, co-presented the pediatric hospitalist perspective on the white paper with Flores at the Annual Meeting.

Much more critical to the success of a pediatric hospitalist service is nurturing relationships with local pediatricians, who traditionally want to retain their ability to manage patients under all circumstances. As a result, the pediatric hospitalist group might choose to survey its referring providers to learn how it can provide better service and take advantage of positive survey responses to market its service. (These interventions are outlined in “Performance Metric Seven: Provider Satisfaction.”)

Finding the Data

Once a group has selected its performance metrics, it faces many logistical and political challenges to obtain the pertinent data. Again, the white paper’s template furnishes clear direction on data sources for each metric.

To begin, hospitalists must understand their practicing environment. Many smaller rural or freestanding hospitals do not have the IT decision-support resources to generate customized reports for hospitalists. “For instance, the hospital may be able to furnish information about length of stay for the hospital in general, but [may] not [be able] to break out LOS numbers for the hospitalist group compared to other physicians,” explains Flores. In addition, some billing services can’t or won’t provide information on volume, charges, and collections to the hospitalist group.

“The other challenge is more of a cultural or philosophical one,” says Flores. “Very often, hospitals or other sponsoring entities are reluctant to share financial information, in particular, with the hospitalists, because they are afraid that the hospitalists will use the information inappropriately—or that they’ll somehow become more powerful by virtue of having that information. And, in fact, that’s what we really want: to be more powerful—but in a constructive, positive way.”

In this case, HMGs may need to invest time to ensure organizations that the information won’t be used against them and that its only goal is to improve practice performance.

“Finding the data is not always easy,” concedes Burke T. Kealey, MD, assistant medical director of hospital medicine for HealthPartners Medical Group in St. Paul, Minn., and chair of SHM’s Benchmarks Committee. “Some organizations can give you a lot of these data sets pretty easily, and some are not going to produce many of them at all. And, when you cross organizational boundaries, there are political considerations. For example, if you’re a national hospitalist company trying to get data from individual hospitals, it might be difficult.” (Dr. Kealey co-presented at the workshop on the white paper for adult HMGs with Flores at the 2007 SHM Annual Meeting in Dallas.)

Sources of data will vary from metric to metric. To obtain data for measuring volume (often used as an indicator for staffing requirements and scheduling), hospitalists need to access hospital admission/discharge/transfer systems, health-plan data systems, or the hospital medicine service billing system. For an operational metric like provider satisfaction, the hospitalist group may have to float its own referring provider survey (by mail, by phone, or in person) to gain understanding of how it is viewed by referring physicians.

How to Interpret the Data

Obtaining the data is only half the battle. Another core tool in the white paper is the template section “Unique Measurement and Analysis Considerations,” which guides hospitalists as they attempt to verify the validity of their data and ensure valid comparisons.

Dr. Westle’s group has studiously tracked its performance metrics for years; other groups may have little experience in this domain. Another critical step in creating dashboard reports, he states, is understanding how the data are collected and ensuring the data are accurate and attributed appropriately.

“The way clinical cases are coded ought to be the subject of some concern and scrutiny,” says John Novotny, MD, director of the Section of Hospital Medicine of the Allen Division at Columbia University Medical Center in New York City and another Benchmarks Committee member. “There may be a natural inclination to accept the performance information provided to us by the hospital, but the processes that generated these data need to be well understood to gauge the accuracy and acceptability of any conclusions drawn.”

With a background in statistics and information technology, Dr. Novotny cautions that “some assessment of the validity of comparisons within or between groups or to benchmark figures should be included in every analysis or report—to justify any conclusions drawn and to avoid the statistical pitfalls common to these data.”

He advises HMGs to run the numbers by someone with expertise in data interpretation, especially before reports are published or submitted for public review. These issues come up frequently in the analysis of frequency data, such as the number of deaths occurring in a group for a particular diagnosis over a period of time, where the numbers might be relatively small.

For example, if five deaths are observed in a subset of 20 patients, the statistic of a 25% death rate comes with such low precision that the true underlying death rate might fall anywhere between 8% and 50%.

“This is a limitation inherent in drawing conclusions from relatively small data sets, akin to driving down a narrow highway with a very loose steering wheel—avoiding the ravines is a challenge,” he says.

Dr. Novotny contributed the section on mortality metrics for the white paper. Although a group’s raw mortality data may be easily obtained, “HMGs should be wary of the smaller numbers resulting from stratifying the data by service, DRG [diagnosis-related group], or time periods,” he explains.

Instead, as suggested in the “Interventions” section, the HMG might want to take the additional approach of documenting the use of processes thought to have a positive impact on the risk of mortality in hospitalized patients. Potentially useful processes under development and discussion in the literature include interdisciplinary rounds, effective inter-provider communication, and ventilator care protocols, among others.

“We need to show that not only do we track our mortality figures, we analyze and respond to them by improving our patient care,” Dr. Novotny says. “We need to show that we’re making patient care safer.”

At the Ochsner Health Center in New Orleans, the HMG decided to track readmission rates for congestive heart failure—the primary DRG for inpatient care, and compare its rates with those of other services. Because heart failure is traditionally the bailiwick of cardiology, “you might think that the cardiology service would have the best outcomes,” says Steven Deitelzweig, MD, vice president of medical affairs and system chairman.

But, using order sets that align with JCAHO standards and best care as demonstrated by evidence in cardiology, Dr. Deitelzweig’s hospitalist group “was able to demonstrate statistically and objectively that our outcomes were better, adjusting for case mix.”

Make Your Own Case

Once the infrastructure for tracking and reporting productivity is in place, hospitalists can use performance metrics to build their own case, remarks Dr. Kealey. The white paper furnishes several examples of customized dashboards. Some use a visual display to illustrate improvement or maintenance in key performance areas.

Dr. Westle notes that metrics reports can be used in a variety of ways, including:

• Negotiating with the hospital;
• Managing a practice internally (i.e., tracking the productivity of established and new full-time equivalent employees (FTEs) and compensating physicians for their productivity); and
• Negotiating with third-party payers who increasingly rely on pay-for-performance measures. For instance, Dr. Westle says, if a group can track its cost per case for the top 15 DRGs and show those costs are less than the national average, this “puts the hospitalist group at a significant advantage when talking to insurance companies about pay for performance.”

Dr. Deitelzweig reports that his HMG at the Ochsner Health Center posts monthly updates of its dashboard results in the halls of its department and others. “Whether it’s readmission rates, patient satisfaction, or hand washing, it’s up there for all to see,” he says. He believes that this type of transparency is not only a good reminder for staff but benefits patients, as well. “It’s helpful because it highlights for your department members the goals of the department and that those are aligned with patient satisfaction and best outcomes.”

Conclusion

“If hospitalists can work with their hospitals to understand how various data elements are defined, collected and reported,” says Flores, “this will enable them to develop a greater understanding of what the information means, correct any misinterpretations on the hospital’s part, and gain a greater confidence in the information’s credibility and reliability. Hospitalists should work closely with their sponsoring organizations to define metrics and reports that are mutually credible and meaningful, so that all parties are looking at the same things and understanding them the same way.”

Participating in the white paper project gave Dr. Rauch a better appreciation of the value of measuring performance. His advice to first-timers: “It may seem overwhelming at first to do an all-encompassing dashboard, but even if you pick just a couple things to start with, this puts down on paper what your worth is. When you can point to how your services are improving or maintaining over time, that’s the picture that says a thousand words.” TH

Gretchen Henkel is a frequent contributor to The Hospitalist.

Hospitalists are no strangers to performance measurement. Every day, their performance is measured, formally and informally, by their sponsoring organizations, by third-party payers, and by patients.

But many hospitalists are not engaged in producing or reviewing that performance data.

“Historically, hospitalist groups have relied on the hospital to collect the data and present it to them—and still do, to a great extent, even today,” says Marc B. Westle, DO, FACP, president and managing partner for a large private hospital medicine group (HMG), Asheville Hospitalist Group in North Carolina.

This often puts hospitalists at a disadvantage, says Dr. Westle. If hospitalist groups don’t get involved with data reporting and analysis, they can’t have meaningful discussions with their hospitals.

With a background in hospital administration, Leslie Flores, MHA, co-principal of Nelson/Flores Associates, LLC, is well acquainted with the challenges of collecting and reporting hospital data. Through her consulting work with partner John Nelson, MD, she has found that sponsoring organizations often don’t review performance data with hospitalists. Hospitalists may examine their performance one way, while the hospital uses a different set of metrics, or analytical techniques. This disconnect, she notes, “leads to differences in interpretations and understandings that can occur between the hospital folks and the doctors when they try to present information.”

A new white paper produced by SHM’s Benchmarks Committee, “Measuring Hospitalist Performance: Metrics, Reports, and Dashboards,” aims to change these scenarios by encouraging hospitalists to take charge of their performance reporting. Geared to multiple levels of expertise with performance metrics, the white paper offers “some real, practical advice as to how you capture this information and then how you look at it,” says Joe Miller, SHM senior vice president and staff liaison to the Benchmarks Committee.

Select a Metric

The Benchmarks Committee used a Delphi process to rank the importance of various metrics and produced a list of 10 on which they would focus. The clearly written introduction walks readers through a step-by-step process intended to help HMGs decide which performance metrics they will measure.

Flores, editor of the white paper project, cautions that the “magic 10” metrics selected by the committee don’t necessarily represent the most important metrics for each practice. “We wanted to stimulate hospitalists to think about how they view their own performance and to create a common language and understanding of what some key issues and expectations should be for hospitalists’ performance monitoring,” she says. “They can use this document as a starting point and then come up with performance metrics that really matter to their practice.”

Choosing metrics to measure and report on for the hospitalist service will depend on a variety of variables particular to that group, including:

• The HMG’s original mission;
• The expectations of the hospital or other sponsoring organization (such as a multispecialty group) for the return on their investment;
• Key outcomes and/or performance measures sought by payers, regulators, and other stakeholders; and
• The practice’s high-priority issues.

Regarding the last item, Flores recalls one HMG that decided to include on its dashboard a survey of how it used consulting physicians from the community. This component was chosen to address the concerns of other specialists in the community, who feared the hospitalists were using only their own medical group’s specialists for consultations.

To further guide choices of metrics, the white paper uses a uniform template to organize each section. Whether the metric is descriptive (volume, data, case mix), operational (hospital cost, productivity, provider satisfaction, length of stay, patient satisfaction), or clinical (mortality data, readmission rate, JCAHO core measures), the user finds a description in each section titled, “Why this metric is important.”

Daniel Rauch, MD, FAAP, explains why a pediatric hospitalist group might choose to focus on referring provider satisfaction rather than volume data—perhaps a more critical metric for adult hospitalist groups.

“Our volume data [a descriptive metric] will depend on who’s referring to us and the availability of subspecialists, as opposed to market share and the notability of the institution in the local environment,” he notes.

Dr. Rauch, director of the Pediatric Hospitalist Program at New York University School of Medicine in New York City and editor of the Provider Satisfaction section of the white paper, co-presented the pediatric hospitalist perspective on the white paper with Flores at the Annual Meeting.

Much more critical to the success of a pediatric hospitalist service is nurturing relationships with local pediatricians, who traditionally want to retain their ability to manage patients under all circumstances. As a result, the pediatric hospitalist group might choose to survey its referring providers to learn how it can provide better service and take advantage of positive survey responses to market its service. (These interventions are outlined in “Performance Metric Seven: Provider Satisfaction.”)

Finding the Data

Once a group has selected its performance metrics, it faces many logistical and political challenges to obtain the pertinent data. Again, the white paper’s template furnishes clear direction on data sources for each metric.

To begin, hospitalists must understand their practicing environment. Many smaller rural or freestanding hospitals do not have the IT decision-support resources to generate customized reports for hospitalists. “For instance, the hospital may be able to furnish information about length of stay for the hospital in general, but [may] not [be able] to break out LOS numbers for the hospitalist group compared to other physicians,” explains Flores. In addition, some billing services can’t or won’t provide information on volume, charges, and collections to the hospitalist group.

“The other challenge is more of a cultural or philosophical one,” says Flores. “Very often, hospitals or other sponsoring entities are reluctant to share financial information, in particular, with the hospitalists, because they are afraid that the hospitalists will use the information inappropriately—or that they’ll somehow become more powerful by virtue of having that information. And, in fact, that’s what we really want: to be more powerful—but in a constructive, positive way.”

In this case, HMGs may need to invest time to ensure organizations that the information won’t be used against them and that its only goal is to improve practice performance.

“Finding the data is not always easy,” concedes Burke T. Kealey, MD, assistant medical director of hospital medicine for HealthPartners Medical Group in St. Paul, Minn., and chair of SHM’s Benchmarks Committee. “Some organizations can give you a lot of these data sets pretty easily, and some are not going to produce many of them at all. And, when you cross organizational boundaries, there are political considerations. For example, if you’re a national hospitalist company trying to get data from individual hospitals, it might be difficult.” (Dr. Kealey co-presented at the workshop on the white paper for adult HMGs with Flores at the 2007 SHM Annual Meeting in Dallas.)

Sources of data will vary from metric to metric. To obtain data for measuring volume (often used as an indicator for staffing requirements and scheduling), hospitalists need to access hospital admission/discharge/transfer systems, health-plan data systems, or the hospital medicine service billing system. For an operational metric like provider satisfaction, the hospitalist group may have to float its own referring provider survey (by mail, by phone, or in person) to gain understanding of how it is viewed by referring physicians.

How to Interpret the Data

Obtaining the data is only half the battle. Another core tool in the white paper is the template section “Unique Measurement and Analysis Considerations,” which guides hospitalists as they attempt to verify the validity of their data and ensure valid comparisons.

Dr. Westle’s group has studiously tracked its performance metrics for years; other groups may have little experience in this domain. Another critical step in creating dashboard reports, he states, is understanding how the data are collected and ensuring the data are accurate and attributed appropriately.

“The way clinical cases are coded ought to be the subject of some concern and scrutiny,” says John Novotny, MD, director of the Section of Hospital Medicine of the Allen Division at Columbia University Medical Center in New York City and another Benchmarks Committee member. “There may be a natural inclination to accept the performance information provided to us by the hospital, but the processes that generated these data need to be well understood to gauge the accuracy and acceptability of any conclusions drawn.”

With a background in statistics and information technology, Dr. Novotny cautions that “some assessment of the validity of comparisons within or between groups or to benchmark figures should be included in every analysis or report—to justify any conclusions drawn and to avoid the statistical pitfalls common to these data.”

He advises HMGs to run the numbers by someone with expertise in data interpretation, especially before reports are published or submitted for public review. These issues come up frequently in the analysis of frequency data, such as the number of deaths occurring in a group for a particular diagnosis over a period of time, where the numbers might be relatively small.

For example, if five deaths are observed in a subset of 20 patients, the statistic of a 25% death rate comes with such low precision that the true underlying death rate might fall anywhere between 8% and 50%.

“This is a limitation inherent in drawing conclusions from relatively small data sets, akin to driving down a narrow highway with a very loose steering wheel—avoiding the ravines is a challenge,” he says.

Dr. Novotny contributed the section on mortality metrics for the white paper. Although a group’s raw mortality data may be easily obtained, “HMGs should be wary of the smaller numbers resulting from stratifying the data by service, DRG [diagnosis-related group], or time periods,” he explains.

Instead, as suggested in the “Interventions” section, the HMG might want to take the additional approach of documenting the use of processes thought to have a positive impact on the risk of mortality in hospitalized patients. Potentially useful processes under development and discussion in the literature include interdisciplinary rounds, effective inter-provider communication, and ventilator care protocols, among others.

“We need to show that not only do we track our mortality figures, we analyze and respond to them by improving our patient care,” Dr. Novotny says. “We need to show that we’re making patient care safer.”

At the Ochsner Health Center in New Orleans, the HMG decided to track readmission rates for congestive heart failure—the primary DRG for inpatient care, and compare its rates with those of other services. Because heart failure is traditionally the bailiwick of cardiology, “you might think that the cardiology service would have the best outcomes,” says Steven Deitelzweig, MD, vice president of medical affairs and system chairman.

But, using order sets that align with JCAHO standards and best care as demonstrated by evidence in cardiology, Dr. Deitelzweig’s hospitalist group “was able to demonstrate statistically and objectively that our outcomes were better, adjusting for case mix.”

Make Your Own Case

Once the infrastructure for tracking and reporting productivity is in place, hospitalists can use performance metrics to build their own case, remarks Dr. Kealey. The white paper furnishes several examples of customized dashboards. Some use a visual display to illustrate improvement or maintenance in key performance areas.

Dr. Westle notes that metrics reports can be used in a variety of ways, including:

• Negotiating with the hospital;
• Managing a practice internally (i.e., tracking the productivity of established and new full-time equivalent employees (FTEs) and compensating physicians for their productivity); and
• Negotiating with third-party payers who increasingly rely on pay-for-performance measures. For instance, Dr. Westle says, if a group can track its cost per case for the top 15 DRGs and show those costs are less than the national average, this “puts the hospitalist group at a significant advantage when talking to insurance companies about pay for performance.”

Dr. Deitelzweig reports that his HMG at the Ochsner Health Center posts monthly updates of its dashboard results in the halls of its department and others. “Whether it’s readmission rates, patient satisfaction, or hand washing, it’s up there for all to see,” he says. He believes that this type of transparency is not only a good reminder for staff but benefits patients, as well. “It’s helpful because it highlights for your department members the goals of the department and that those are aligned with patient satisfaction and best outcomes.”

Conclusion

“If hospitalists can work with their hospitals to understand how various data elements are defined, collected and reported,” says Flores, “this will enable them to develop a greater understanding of what the information means, correct any misinterpretations on the hospital’s part, and gain a greater confidence in the information’s credibility and reliability. Hospitalists should work closely with their sponsoring organizations to define metrics and reports that are mutually credible and meaningful, so that all parties are looking at the same things and understanding them the same way.”

Participating in the white paper project gave Dr. Rauch a better appreciation of the value of measuring performance. His advice to first-timers: “It may seem overwhelming at first to do an all-encompassing dashboard, but even if you pick just a couple things to start with, this puts down on paper what your worth is. When you can point to how your services are improving or maintaining over time, that’s the picture that says a thousand words.” TH

Gretchen Henkel is a frequent contributor to The Hospitalist.

Hospitalists are no strangers to performance measurement. Every day, their performance is measured, formally and informally, by their sponsoring organizations, by third-party payers, and by patients.

But many hospitalists are not engaged in producing or reviewing that performance data.

“Historically, hospitalist groups have relied on the hospital to collect the data and present it to them—and still do, to a great extent, even today,” says Marc B. Westle, DO, FACP, president and managing partner for a large private hospital medicine group (HMG), Asheville Hospitalist Group in North Carolina.

This often puts hospitalists at a disadvantage, says Dr. Westle. If hospitalist groups don’t get involved with data reporting and analysis, they can’t have meaningful discussions with their hospitals.

With a background in hospital administration, Leslie Flores, MHA, co-principal of Nelson/Flores Associates, LLC, is well acquainted with the challenges of collecting and reporting hospital data. Through her consulting work with partner John Nelson, MD, she has found that sponsoring organizations often don’t review performance data with hospitalists. Hospitalists may examine their performance one way, while the hospital uses a different set of metrics, or analytical techniques. This disconnect, she notes, “leads to differences in interpretations and understandings that can occur between the hospital folks and the doctors when they try to present information.”

A new white paper produced by SHM’s Benchmarks Committee, “Measuring Hospitalist Performance: Metrics, Reports, and Dashboards,” aims to change these scenarios by encouraging hospitalists to take charge of their performance reporting. Geared to multiple levels of expertise with performance metrics, the white paper offers “some real, practical advice as to how you capture this information and then how you look at it,” says Joe Miller, SHM senior vice president and staff liaison to the Benchmarks Committee.

Select a Metric

The Benchmarks Committee used a Delphi process to rank the importance of various metrics and produced a list of 10 on which they would focus. The clearly written introduction walks readers through a step-by-step process intended to help HMGs decide which performance metrics they will measure.

Flores, editor of the white paper project, cautions that the “magic 10” metrics selected by the committee don’t necessarily represent the most important metrics for each practice. “We wanted to stimulate hospitalists to think about how they view their own performance and to create a common language and understanding of what some key issues and expectations should be for hospitalists’ performance monitoring,” she says. “They can use this document as a starting point and then come up with performance metrics that really matter to their practice.”

Choosing metrics to measure and report on for the hospitalist service will depend on a variety of variables particular to that group, including:

• The HMG’s original mission;
• The expectations of the hospital or other sponsoring organization (such as a multispecialty group) for the return on their investment;
• Key outcomes and/or performance measures sought by payers, regulators, and other stakeholders; and
• The practice’s high-priority issues.

Regarding the last item, Flores recalls one HMG that decided to include on its dashboard a survey of how it used consulting physicians from the community. This component was chosen to address the concerns of other specialists in the community, who feared the hospitalists were using only their own medical group’s specialists for consultations.

To further guide choices of metrics, the white paper uses a uniform template to organize each section. Whether the metric is descriptive (volume, data, case mix), operational (hospital cost, productivity, provider satisfaction, length of stay, patient satisfaction), or clinical (mortality data, readmission rate, JCAHO core measures), the user finds a description in each section titled, “Why this metric is important.”

Daniel Rauch, MD, FAAP, explains why a pediatric hospitalist group might choose to focus on referring provider satisfaction rather than volume data—perhaps a more critical metric for adult hospitalist groups.

“Our volume data [a descriptive metric] will depend on who’s referring to us and the availability of subspecialists, as opposed to market share and the notability of the institution in the local environment,” he notes.

Dr. Rauch, director of the Pediatric Hospitalist Program at New York University School of Medicine in New York City and editor of the Provider Satisfaction section of the white paper, co-presented the pediatric hospitalist perspective on the white paper with Flores at the Annual Meeting.

Much more critical to the success of a pediatric hospitalist service is nurturing relationships with local pediatricians, who traditionally want to retain their ability to manage patients under all circumstances. As a result, the pediatric hospitalist group might choose to survey its referring providers to learn how it can provide better service and take advantage of positive survey responses to market its service. (These interventions are outlined in “Performance Metric Seven: Provider Satisfaction.”)

Finding the Data

Once a group has selected its performance metrics, it faces many logistical and political challenges to obtain the pertinent data. Again, the white paper’s template furnishes clear direction on data sources for each metric.

To begin, hospitalists must understand their practicing environment. Many smaller rural or freestanding hospitals do not have the IT decision-support resources to generate customized reports for hospitalists. “For instance, the hospital may be able to furnish information about length of stay for the hospital in general, but [may] not [be able] to break out LOS numbers for the hospitalist group compared to other physicians,” explains Flores. In addition, some billing services can’t or won’t provide information on volume, charges, and collections to the hospitalist group.

“The other challenge is more of a cultural or philosophical one,” says Flores. “Very often, hospitals or other sponsoring entities are reluctant to share financial information, in particular, with the hospitalists, because they are afraid that the hospitalists will use the information inappropriately—or that they’ll somehow become more powerful by virtue of having that information. And, in fact, that’s what we really want: to be more powerful—but in a constructive, positive way.”

In this case, HMGs may need to invest time to ensure organizations that the information won’t be used against them and that its only goal is to improve practice performance.

“Finding the data is not always easy,” concedes Burke T. Kealey, MD, assistant medical director of hospital medicine for HealthPartners Medical Group in St. Paul, Minn., and chair of SHM’s Benchmarks Committee. “Some organizations can give you a lot of these data sets pretty easily, and some are not going to produce many of them at all. And, when you cross organizational boundaries, there are political considerations. For example, if you’re a national hospitalist company trying to get data from individual hospitals, it might be difficult.” (Dr. Kealey co-presented at the workshop on the white paper for adult HMGs with Flores at the 2007 SHM Annual Meeting in Dallas.)

Sources of data will vary from metric to metric. To obtain data for measuring volume (often used as an indicator for staffing requirements and scheduling), hospitalists need to access hospital admission/discharge/transfer systems, health-plan data systems, or the hospital medicine service billing system. For an operational metric like provider satisfaction, the hospitalist group may have to float its own referring provider survey (by mail, by phone, or in person) to gain understanding of how it is viewed by referring physicians.

How to Interpret the Data

Obtaining the data is only half the battle. Another core tool in the white paper is the template section “Unique Measurement and Analysis Considerations,” which guides hospitalists as they attempt to verify the validity of their data and ensure valid comparisons.

Dr. Westle’s group has studiously tracked its performance metrics for years; other groups may have little experience in this domain. Another critical step in creating dashboard reports, he states, is understanding how the data are collected and ensuring the data are accurate and attributed appropriately.

“The way clinical cases are coded ought to be the subject of some concern and scrutiny,” says John Novotny, MD, director of the Section of Hospital Medicine of the Allen Division at Columbia University Medical Center in New York City and another Benchmarks Committee member. “There may be a natural inclination to accept the performance information provided to us by the hospital, but the processes that generated these data need to be well understood to gauge the accuracy and acceptability of any conclusions drawn.”

With a background in statistics and information technology, Dr. Novotny cautions that “some assessment of the validity of comparisons within or between groups or to benchmark figures should be included in every analysis or report—to justify any conclusions drawn and to avoid the statistical pitfalls common to these data.”

He advises HMGs to run the numbers by someone with expertise in data interpretation, especially before reports are published or submitted for public review. These issues come up frequently in the analysis of frequency data, such as the number of deaths occurring in a group for a particular diagnosis over a period of time, where the numbers might be relatively small.

For example, if five deaths are observed in a subset of 20 patients, the statistic of a 25% death rate comes with such low precision that the true underlying death rate might fall anywhere between 8% and 50%.

“This is a limitation inherent in drawing conclusions from relatively small data sets, akin to driving down a narrow highway with a very loose steering wheel—avoiding the ravines is a challenge,” he says.

Dr. Novotny contributed the section on mortality metrics for the white paper. Although a group’s raw mortality data may be easily obtained, “HMGs should be wary of the smaller numbers resulting from stratifying the data by service, DRG [diagnosis-related group], or time periods,” he explains.

Instead, as suggested in the “Interventions” section, the HMG might want to take the additional approach of documenting the use of processes thought to have a positive impact on the risk of mortality in hospitalized patients. Potentially useful processes under development and discussion in the literature include interdisciplinary rounds, effective inter-provider communication, and ventilator care protocols, among others.

“We need to show that not only do we track our mortality figures, we analyze and respond to them by improving our patient care,” Dr. Novotny says. “We need to show that we’re making patient care safer.”

At the Ochsner Health Center in New Orleans, the HMG decided to track readmission rates for congestive heart failure—the primary DRG for inpatient care, and compare its rates with those of other services. Because heart failure is traditionally the bailiwick of cardiology, “you might think that the cardiology service would have the best outcomes,” says Steven Deitelzweig, MD, vice president of medical affairs and system chairman.

But, using order sets that align with JCAHO standards and best care as demonstrated by evidence in cardiology, Dr. Deitelzweig’s hospitalist group “was able to demonstrate statistically and objectively that our outcomes were better, adjusting for case mix.”

Make Your Own Case

Once the infrastructure for tracking and reporting productivity is in place, hospitalists can use performance metrics to build their own case, remarks Dr. Kealey. The white paper furnishes several examples of customized dashboards. Some use a visual display to illustrate improvement or maintenance in key performance areas.

Dr. Westle notes that metrics reports can be used in a variety of ways, including:

• Negotiating with the hospital;
• Managing a practice internally (i.e., tracking the productivity of established and new full-time equivalent employees (FTEs) and compensating physicians for their productivity); and
• Negotiating with third-party payers who increasingly rely on pay-for-performance measures. For instance, Dr. Westle says, if a group can track its cost per case for the top 15 DRGs and show those costs are less than the national average, this “puts the hospitalist group at a significant advantage when talking to insurance companies about pay for performance.”

Dr. Deitelzweig reports that his HMG at the Ochsner Health Center posts monthly updates of its dashboard results in the halls of its department and others. “Whether it’s readmission rates, patient satisfaction, or hand washing, it’s up there for all to see,” he says. He believes that this type of transparency is not only a good reminder for staff but benefits patients, as well. “It’s helpful because it highlights for your department members the goals of the department and that those are aligned with patient satisfaction and best outcomes.”

Conclusion

“If hospitalists can work with their hospitals to understand how various data elements are defined, collected and reported,” says Flores, “this will enable them to develop a greater understanding of what the information means, correct any misinterpretations on the hospital’s part, and gain a greater confidence in the information’s credibility and reliability. Hospitalists should work closely with their sponsoring organizations to define metrics and reports that are mutually credible and meaningful, so that all parties are looking at the same things and understanding them the same way.”

Participating in the white paper project gave Dr. Rauch a better appreciation of the value of measuring performance. His advice to first-timers: “It may seem overwhelming at first to do an all-encompassing dashboard, but even if you pick just a couple things to start with, this puts down on paper what your worth is. When you can point to how your services are improving or maintaining over time, that’s the picture that says a thousand words.” TH

Gretchen Henkel is a frequent contributor to The Hospitalist.