Joanne Kaldy

Representing hospital medicine on Capitol Hill is an opportunity for physicians to educate policy makers and have a hand in the legislative process. Hospitalists who have had such experiences say that it can also be nerve wracking, eye opening, surprising, and very satisfying.

Rifkin Answers a Call to Arms

William Rifkin, MD, assistant professor of medicine and associate director of the Yale Primary Care Residency Program at the Yale University School of Medicine, New Haven, Conn., started his road to Capitol Hill by answering an SHM call to arms. “SHM was looking for someone in Connecticut to appear before the state Health Committee regarding proposed legislation that sought to regulate communications between hospitalists and primary care physicians,” says Dr. Rifkin, who was also asked to address the issue of whether the use of hospitalists should be mandatory or voluntary.

The call originally came from the Connecticut Medical Society, which—along with SHM—helped prepare Dr. Rifkin for his testimony. These groups’ public policy staffs coached him about his audience, the hearing process, and the key issues. They agreed his approach would be educational and informative in nature. He would explain what “hospital medicine is, the advantages and disadvantages, what is happening now in the field, and the issues being addressed by SHM,” he recalls. “I gave the committee members lots of literature and background information.”

Dr. Rifkin had some challenges to overcome in getting his message across to the legislators. “There is no data showing that lack of communication between hospitalists and community physicians has caused serious problems,” he explains. “I had to explain the difference between factual data and anecdotal information.”

Additionally, he recalls, one legislator seemed skeptical about the hospitalist’s role and kept referring to a health system that mandates the use of hospitalists. “I had to sit back and explain how SHM supports a voluntary model,” he says. “She kept talking about a reported example of a hospital that forced patients to use hospitalists. It was awkward because I suspected that the story was untrue or at least was missing some facts.”

By calmly relating SHM’s position and its reasons for preferring a voluntary model, Dr. Rifkin believes he was able to diffuse some of the tension. After the hearing, he approached the legislator and handed her the literature and statements from SHM. “I offered to stay in touch and suggested we find out about this hospital supposedly mandating hospitalists,” he says “Ultimately, I discovered that this story wasn’t true.”

Making a good impression can help legislators see physicians as colleagues rather than adversaries. “After the hearing, the committee sent the communications bill to the Connecticut Department of Public Health Best Practices Committee. This body was charged with making recommendations on communications best practices,” says Dr. Rifkin, who was asked to talk before this group. In fact, he adds, “They’ve asked me back repeatedly. I’m sort of a regular on the committee now.”

He is honored to have input and to present the hospitalist’s point of view. “Their recommendations likely will be similar to what SHM says regarding inpatient/outpatient communication,” he explains.

In retrospect, Dr. Rifkin believes he made a difference. “I felt as if I brought them some new information and taught legislators some things about hospital medicine they didn’t know before,” he says. “I think I helped them see that it would be counterproductive to dictate the specifics of inpatient/outpatient physician communication.”

When it comes to presenting testimony, Dr. Rifkin suggests, “it is best to acknowledge where legislators are right and use this as an opportunity for education. You don’t want to come across as dogmatic.”

While Dr. Rifkin enjoyed his experience, it was not without some surprises. He explains, “I left shaking my head and marveling, ‘Is this really how laws are made?’ ” He was surprised “about the lack of knowledge about the issues and the willingness to act on anecdotal information.”

Reporting back to SHM, Dr. Rifkin says, “It was good that I was there because—absent that—we could have ended up with some onerous rule that we then would have to undo.”

Another surprise for Dr. Rifkin was how long and tedious the process could be. “I was one of the last speakers on the agenda, and I did lots of waiting,” he states, adding, “If I had been nervous, it would have been a torturous eight hours.” Once he was in front of the microphone, Dr. Rifkin had just a few minutes to get his points across. He then answered questions for several additional minutes. “I had to watch the clock, and it was a little nerve-wracking to try to say everything I wanted to in a short time. But for the most part, it was actually enjoyable,” he offers.

Being active in advocacy efforts is a valuable, satisfying experience, and Dr. Rifkin urges his colleagues to carry the gauntlet. “We need to watch for opportunities to have input on legislation nationally and statewide. Hopefully, we’ll be able to have the same impact we had in Connecticut in other states as well,” he says. “Physicians need to be willing to get involved.”

Feinbloom: Testimony on the Fly

David Feinbloom, MD, a hospitalist at Beth Israel Deaconess Medical Center in Boston, had only two hours to prepare for his testimony about computerized physician order entry before the Massachusetts State Joint Committees on Health Care Financing and Economic Development and Emerging Technologies. “They wanted a clinician to explain how this system would improve quality and result in cost-saving,” he says.

Despite his lack of preparation time, he was familiar enough with the subject to speak in detail and answer questions. “I was a little nervous,” he admits, adding, “I would have preferred to have time to prepare a formal presentation, especially since I ended up having to write something up afterward for the official records.”

Dr. Feinbloom was one of the last speakers, and this had some disadvantages. First of all, he had to wait for hours. Additionally, “Many of the points I wanted to make already had been addressed. I didn’t get a lot of questions because there wasn’t much left to ask,” he explains.

The biggest surprise for Dr. Feinbloom was that the legislative process “is a little more mundane than I expected. It’s not like when you watch the news, and they have rousing, heated discussions.”

Also surprising was how receptive the committee members were about the issue. “Because part of the funding was coming from Blue Cross/Blue Shield, there wasn’t even any real controversy or debate from a budgetary standpoint,” he says. “There also was a big study showing that the system will pay for itself.”

Like Dr. Rifkin, Dr. Feinbloom believes his testimony had a positive effect. “I think that I brought to bear a realistic, ground-level view. I also brought some clinical examples of where this system is powerful, and I don’t think people realized this,” he says. “One of the senators had diabetes and told me he was surprised about how messy drug delivery in the hospital can be and how computerized systems can help. My examples stuck in his head as something he could relate to.”

Seymann: Another Kind of Testimony

Hospitalists don’t have to present testimony before a governmental body to have a positive effect on legislation and make a strong impression on lawmakers. Ask Gregory Seymann, MD, associate clinical professor, Division of Hospital Medicine, Department of Medicine, University of California San Diego School of Medicine. While in Washington, D.C., for the 2006 SHM Annual Meeting, he visited his House and Senate representatives.

“Our goal was to educate lawmakers about hospitalists—who we are and what we do—not to ask for favors or handouts,” explains Dr. Seymann. “Several of us went as a group to our senator’s office, and it was a rather short visit. We met with a staff person, who listened briefly and took our materials but asked few questions.”

When he went alone to his House representative, Susan Davis’ (D-CA) office, Dr. Seymann had a much different experience. The representative’s staff was extremely welcoming. “They told me that she was still in session marking up a bill, but that she really wanted to meet me,” he recalls. “They asked me if I could wait; and eventually they took me over to another building to meet her.”

Dr. Seymann’s House representative met with him for half an hour. “She was very pleasant, and I felt comfortable talking with her. I just gave her the basics of who we [hospitalists] are and what we do. She admitted that she didn’t know much about hospitalists and seemed interested in what I had to say,” he says. Davis asked several questions, Dr. Seymann notes. “She mostly wanted to know about how our practice differs from general internists and the difference between hospital and outpatient-based medicine,” he recalls, adding, “I felt like she heard me. The meeting exceeded my expectations.”

The difference between the two visits was striking. Dr. Seymann explains that it is important to realize that “you never know when something you say will make a difference or have an impact. You have to try and, sometimes, keep trying.”

Follow-up is important for these visits. “I sent e-mails on returning home to thank them for their time and remind them that I would be happy to help on hospital medicine issues in the future,” he says.

While Dr. Seymann believes he helped educate legislators about hospital medicine and the hospitalist’s role, he also learned something himself. “I realized that one person can effectively engage in the legislative process and that Congress is interested in what we have to say,” he says. Additionally, he observes, “They take the input of their constituents pretty seriously, and we have a role to play in ensuring that our voices are heard on issues that affect our patients and our profession.” TH

Joanne Kaldy is based in Maryland.

Representing hospital medicine on Capitol Hill is an opportunity for physicians to educate policy makers and have a hand in the legislative process. Hospitalists who have had such experiences say that it can also be nerve wracking, eye opening, surprising, and very satisfying.

Rifkin Answers a Call to Arms

William Rifkin, MD, assistant professor of medicine and associate director of the Yale Primary Care Residency Program at the Yale University School of Medicine, New Haven, Conn., started his road to Capitol Hill by answering an SHM call to arms. “SHM was looking for someone in Connecticut to appear before the state Health Committee regarding proposed legislation that sought to regulate communications between hospitalists and primary care physicians,” says Dr. Rifkin, who was also asked to address the issue of whether the use of hospitalists should be mandatory or voluntary.

The call originally came from the Connecticut Medical Society, which—along with SHM—helped prepare Dr. Rifkin for his testimony. These groups’ public policy staffs coached him about his audience, the hearing process, and the key issues. They agreed his approach would be educational and informative in nature. He would explain what “hospital medicine is, the advantages and disadvantages, what is happening now in the field, and the issues being addressed by SHM,” he recalls. “I gave the committee members lots of literature and background information.”

Dr. Rifkin had some challenges to overcome in getting his message across to the legislators. “There is no data showing that lack of communication between hospitalists and community physicians has caused serious problems,” he explains. “I had to explain the difference between factual data and anecdotal information.”

Additionally, he recalls, one legislator seemed skeptical about the hospitalist’s role and kept referring to a health system that mandates the use of hospitalists. “I had to sit back and explain how SHM supports a voluntary model,” he says. “She kept talking about a reported example of a hospital that forced patients to use hospitalists. It was awkward because I suspected that the story was untrue or at least was missing some facts.”

By calmly relating SHM’s position and its reasons for preferring a voluntary model, Dr. Rifkin believes he was able to diffuse some of the tension. After the hearing, he approached the legislator and handed her the literature and statements from SHM. “I offered to stay in touch and suggested we find out about this hospital supposedly mandating hospitalists,” he says “Ultimately, I discovered that this story wasn’t true.”

Making a good impression can help legislators see physicians as colleagues rather than adversaries. “After the hearing, the committee sent the communications bill to the Connecticut Department of Public Health Best Practices Committee. This body was charged with making recommendations on communications best practices,” says Dr. Rifkin, who was asked to talk before this group. In fact, he adds, “They’ve asked me back repeatedly. I’m sort of a regular on the committee now.”

He is honored to have input and to present the hospitalist’s point of view. “Their recommendations likely will be similar to what SHM says regarding inpatient/outpatient communication,” he explains.

In retrospect, Dr. Rifkin believes he made a difference. “I felt as if I brought them some new information and taught legislators some things about hospital medicine they didn’t know before,” he says. “I think I helped them see that it would be counterproductive to dictate the specifics of inpatient/outpatient physician communication.”

When it comes to presenting testimony, Dr. Rifkin suggests, “it is best to acknowledge where legislators are right and use this as an opportunity for education. You don’t want to come across as dogmatic.”

While Dr. Rifkin enjoyed his experience, it was not without some surprises. He explains, “I left shaking my head and marveling, ‘Is this really how laws are made?’ ” He was surprised “about the lack of knowledge about the issues and the willingness to act on anecdotal information.”

Reporting back to SHM, Dr. Rifkin says, “It was good that I was there because—absent that—we could have ended up with some onerous rule that we then would have to undo.”

Another surprise for Dr. Rifkin was how long and tedious the process could be. “I was one of the last speakers on the agenda, and I did lots of waiting,” he states, adding, “If I had been nervous, it would have been a torturous eight hours.” Once he was in front of the microphone, Dr. Rifkin had just a few minutes to get his points across. He then answered questions for several additional minutes. “I had to watch the clock, and it was a little nerve-wracking to try to say everything I wanted to in a short time. But for the most part, it was actually enjoyable,” he offers.

Being active in advocacy efforts is a valuable, satisfying experience, and Dr. Rifkin urges his colleagues to carry the gauntlet. “We need to watch for opportunities to have input on legislation nationally and statewide. Hopefully, we’ll be able to have the same impact we had in Connecticut in other states as well,” he says. “Physicians need to be willing to get involved.”

Feinbloom: Testimony on the Fly

David Feinbloom, MD, a hospitalist at Beth Israel Deaconess Medical Center in Boston, had only two hours to prepare for his testimony about computerized physician order entry before the Massachusetts State Joint Committees on Health Care Financing and Economic Development and Emerging Technologies. “They wanted a clinician to explain how this system would improve quality and result in cost-saving,” he says.

Despite his lack of preparation time, he was familiar enough with the subject to speak in detail and answer questions. “I was a little nervous,” he admits, adding, “I would have preferred to have time to prepare a formal presentation, especially since I ended up having to write something up afterward for the official records.”

Dr. Feinbloom was one of the last speakers, and this had some disadvantages. First of all, he had to wait for hours. Additionally, “Many of the points I wanted to make already had been addressed. I didn’t get a lot of questions because there wasn’t much left to ask,” he explains.

The biggest surprise for Dr. Feinbloom was that the legislative process “is a little more mundane than I expected. It’s not like when you watch the news, and they have rousing, heated discussions.”

Also surprising was how receptive the committee members were about the issue. “Because part of the funding was coming from Blue Cross/Blue Shield, there wasn’t even any real controversy or debate from a budgetary standpoint,” he says. “There also was a big study showing that the system will pay for itself.”

Like Dr. Rifkin, Dr. Feinbloom believes his testimony had a positive effect. “I think that I brought to bear a realistic, ground-level view. I also brought some clinical examples of where this system is powerful, and I don’t think people realized this,” he says. “One of the senators had diabetes and told me he was surprised about how messy drug delivery in the hospital can be and how computerized systems can help. My examples stuck in his head as something he could relate to.”

Seymann: Another Kind of Testimony

Hospitalists don’t have to present testimony before a governmental body to have a positive effect on legislation and make a strong impression on lawmakers. Ask Gregory Seymann, MD, associate clinical professor, Division of Hospital Medicine, Department of Medicine, University of California San Diego School of Medicine. While in Washington, D.C., for the 2006 SHM Annual Meeting, he visited his House and Senate representatives.

“Our goal was to educate lawmakers about hospitalists—who we are and what we do—not to ask for favors or handouts,” explains Dr. Seymann. “Several of us went as a group to our senator’s office, and it was a rather short visit. We met with a staff person, who listened briefly and took our materials but asked few questions.”

When he went alone to his House representative, Susan Davis’ (D-CA) office, Dr. Seymann had a much different experience. The representative’s staff was extremely welcoming. “They told me that she was still in session marking up a bill, but that she really wanted to meet me,” he recalls. “They asked me if I could wait; and eventually they took me over to another building to meet her.”

Dr. Seymann’s House representative met with him for half an hour. “She was very pleasant, and I felt comfortable talking with her. I just gave her the basics of who we [hospitalists] are and what we do. She admitted that she didn’t know much about hospitalists and seemed interested in what I had to say,” he says. Davis asked several questions, Dr. Seymann notes. “She mostly wanted to know about how our practice differs from general internists and the difference between hospital and outpatient-based medicine,” he recalls, adding, “I felt like she heard me. The meeting exceeded my expectations.”

The difference between the two visits was striking. Dr. Seymann explains that it is important to realize that “you never know when something you say will make a difference or have an impact. You have to try and, sometimes, keep trying.”

Follow-up is important for these visits. “I sent e-mails on returning home to thank them for their time and remind them that I would be happy to help on hospital medicine issues in the future,” he says.

While Dr. Seymann believes he helped educate legislators about hospital medicine and the hospitalist’s role, he also learned something himself. “I realized that one person can effectively engage in the legislative process and that Congress is interested in what we have to say,” he says. Additionally, he observes, “They take the input of their constituents pretty seriously, and we have a role to play in ensuring that our voices are heard on issues that affect our patients and our profession.” TH

Joanne Kaldy is based in Maryland.

Representing hospital medicine on Capitol Hill is an opportunity for physicians to educate policy makers and have a hand in the legislative process. Hospitalists who have had such experiences say that it can also be nerve wracking, eye opening, surprising, and very satisfying.

Rifkin Answers a Call to Arms

William Rifkin, MD, assistant professor of medicine and associate director of the Yale Primary Care Residency Program at the Yale University School of Medicine, New Haven, Conn., started his road to Capitol Hill by answering an SHM call to arms. “SHM was looking for someone in Connecticut to appear before the state Health Committee regarding proposed legislation that sought to regulate communications between hospitalists and primary care physicians,” says Dr. Rifkin, who was also asked to address the issue of whether the use of hospitalists should be mandatory or voluntary.

The call originally came from the Connecticut Medical Society, which—along with SHM—helped prepare Dr. Rifkin for his testimony. These groups’ public policy staffs coached him about his audience, the hearing process, and the key issues. They agreed his approach would be educational and informative in nature. He would explain what “hospital medicine is, the advantages and disadvantages, what is happening now in the field, and the issues being addressed by SHM,” he recalls. “I gave the committee members lots of literature and background information.”

Dr. Rifkin had some challenges to overcome in getting his message across to the legislators. “There is no data showing that lack of communication between hospitalists and community physicians has caused serious problems,” he explains. “I had to explain the difference between factual data and anecdotal information.”

Additionally, he recalls, one legislator seemed skeptical about the hospitalist’s role and kept referring to a health system that mandates the use of hospitalists. “I had to sit back and explain how SHM supports a voluntary model,” he says. “She kept talking about a reported example of a hospital that forced patients to use hospitalists. It was awkward because I suspected that the story was untrue or at least was missing some facts.”

By calmly relating SHM’s position and its reasons for preferring a voluntary model, Dr. Rifkin believes he was able to diffuse some of the tension. After the hearing, he approached the legislator and handed her the literature and statements from SHM. “I offered to stay in touch and suggested we find out about this hospital supposedly mandating hospitalists,” he says “Ultimately, I discovered that this story wasn’t true.”

Making a good impression can help legislators see physicians as colleagues rather than adversaries. “After the hearing, the committee sent the communications bill to the Connecticut Department of Public Health Best Practices Committee. This body was charged with making recommendations on communications best practices,” says Dr. Rifkin, who was asked to talk before this group. In fact, he adds, “They’ve asked me back repeatedly. I’m sort of a regular on the committee now.”

He is honored to have input and to present the hospitalist’s point of view. “Their recommendations likely will be similar to what SHM says regarding inpatient/outpatient communication,” he explains.

In retrospect, Dr. Rifkin believes he made a difference. “I felt as if I brought them some new information and taught legislators some things about hospital medicine they didn’t know before,” he says. “I think I helped them see that it would be counterproductive to dictate the specifics of inpatient/outpatient physician communication.”

When it comes to presenting testimony, Dr. Rifkin suggests, “it is best to acknowledge where legislators are right and use this as an opportunity for education. You don’t want to come across as dogmatic.”

While Dr. Rifkin enjoyed his experience, it was not without some surprises. He explains, “I left shaking my head and marveling, ‘Is this really how laws are made?’ ” He was surprised “about the lack of knowledge about the issues and the willingness to act on anecdotal information.”

Reporting back to SHM, Dr. Rifkin says, “It was good that I was there because—absent that—we could have ended up with some onerous rule that we then would have to undo.”

Another surprise for Dr. Rifkin was how long and tedious the process could be. “I was one of the last speakers on the agenda, and I did lots of waiting,” he states, adding, “If I had been nervous, it would have been a torturous eight hours.” Once he was in front of the microphone, Dr. Rifkin had just a few minutes to get his points across. He then answered questions for several additional minutes. “I had to watch the clock, and it was a little nerve-wracking to try to say everything I wanted to in a short time. But for the most part, it was actually enjoyable,” he offers.

Being active in advocacy efforts is a valuable, satisfying experience, and Dr. Rifkin urges his colleagues to carry the gauntlet. “We need to watch for opportunities to have input on legislation nationally and statewide. Hopefully, we’ll be able to have the same impact we had in Connecticut in other states as well,” he says. “Physicians need to be willing to get involved.”

Feinbloom: Testimony on the Fly

David Feinbloom, MD, a hospitalist at Beth Israel Deaconess Medical Center in Boston, had only two hours to prepare for his testimony about computerized physician order entry before the Massachusetts State Joint Committees on Health Care Financing and Economic Development and Emerging Technologies. “They wanted a clinician to explain how this system would improve quality and result in cost-saving,” he says.

Despite his lack of preparation time, he was familiar enough with the subject to speak in detail and answer questions. “I was a little nervous,” he admits, adding, “I would have preferred to have time to prepare a formal presentation, especially since I ended up having to write something up afterward for the official records.”

Dr. Feinbloom was one of the last speakers, and this had some disadvantages. First of all, he had to wait for hours. Additionally, “Many of the points I wanted to make already had been addressed. I didn’t get a lot of questions because there wasn’t much left to ask,” he explains.

The biggest surprise for Dr. Feinbloom was that the legislative process “is a little more mundane than I expected. It’s not like when you watch the news, and they have rousing, heated discussions.”

Also surprising was how receptive the committee members were about the issue. “Because part of the funding was coming from Blue Cross/Blue Shield, there wasn’t even any real controversy or debate from a budgetary standpoint,” he says. “There also was a big study showing that the system will pay for itself.”

Like Dr. Rifkin, Dr. Feinbloom believes his testimony had a positive effect. “I think that I brought to bear a realistic, ground-level view. I also brought some clinical examples of where this system is powerful, and I don’t think people realized this,” he says. “One of the senators had diabetes and told me he was surprised about how messy drug delivery in the hospital can be and how computerized systems can help. My examples stuck in his head as something he could relate to.”

Seymann: Another Kind of Testimony

Hospitalists don’t have to present testimony before a governmental body to have a positive effect on legislation and make a strong impression on lawmakers. Ask Gregory Seymann, MD, associate clinical professor, Division of Hospital Medicine, Department of Medicine, University of California San Diego School of Medicine. While in Washington, D.C., for the 2006 SHM Annual Meeting, he visited his House and Senate representatives.

“Our goal was to educate lawmakers about hospitalists—who we are and what we do—not to ask for favors or handouts,” explains Dr. Seymann. “Several of us went as a group to our senator’s office, and it was a rather short visit. We met with a staff person, who listened briefly and took our materials but asked few questions.”

When he went alone to his House representative, Susan Davis’ (D-CA) office, Dr. Seymann had a much different experience. The representative’s staff was extremely welcoming. “They told me that she was still in session marking up a bill, but that she really wanted to meet me,” he recalls. “They asked me if I could wait; and eventually they took me over to another building to meet her.”

Dr. Seymann’s House representative met with him for half an hour. “She was very pleasant, and I felt comfortable talking with her. I just gave her the basics of who we [hospitalists] are and what we do. She admitted that she didn’t know much about hospitalists and seemed interested in what I had to say,” he says. Davis asked several questions, Dr. Seymann notes. “She mostly wanted to know about how our practice differs from general internists and the difference between hospital and outpatient-based medicine,” he recalls, adding, “I felt like she heard me. The meeting exceeded my expectations.”

The difference between the two visits was striking. Dr. Seymann explains that it is important to realize that “you never know when something you say will make a difference or have an impact. You have to try and, sometimes, keep trying.”

Follow-up is important for these visits. “I sent e-mails on returning home to thank them for their time and remind them that I would be happy to help on hospital medicine issues in the future,” he says.

While Dr. Seymann believes he helped educate legislators about hospital medicine and the hospitalist’s role, he also learned something himself. “I realized that one person can effectively engage in the legislative process and that Congress is interested in what we have to say,” he says. Additionally, he observes, “They take the input of their constituents pretty seriously, and we have a role to play in ensuring that our voices are heard on issues that affect our patients and our profession.” TH

Joanne Kaldy is based in Maryland.

Mary Ottolini, MD

Many physicians see being a hospitalist as an opportunity to focus on direct patient care. For Mary Ottolini, MD, it is a way to have it all. Every day, she cares for patients at Children’s National Medical Center in Washington, D.C., teaches at Children’s and at George Washington University School of Medicine in Washington, D.C., serves on a variety of committees and in numerous organizations, and works as a department head.

Early Start, Full Day

“It’s just another typical, crazy day,” says Dr. Ottolini, division chief of the hospitalist division and director of pediatric medical student education at Children’s National Medical Center and professor of pediatrics at George Washington, as she walks briskly down the hall at 9 a.m. on her way to radiology rounds. Her day actually starts at about 7 a.m., when she sees overnight admissions and addresses any urgent problems that require her attention. By 9 a.m., her day is in full swing.

During radiology rounds she and her team, which consists of residents, interns, and third-year medical students, review films from the previous day with the radiologist. The group addresses issues such as what additional tests might be useful. Sometimes they try to determine whether a condition is the result of an illness or injury.

Leaving radiology, Dr. Ottolini and her team head to the ward for patient rounds. As they walk to the first room, they pass cheerful murals featuring cartoon characters and several paintings and drawings created by children. A third-year resident leads the rounds, filling the group in on each patient’s condition and progress. Dr. Ottolini conducts the physical exams and talks to family members when they are present. When she offers her thoughts and comments to the group, the students listen attentively and take notes as she talks.

At one point, the team has to send for a translator for a non-English speaking family. Dr. Ottolini explains that this is common. In fact, Children’s has translators readily available who speak several common languages, including Spanish, French, and Japanese. Additionally, they have access to individuals who speak just about any language that arises.

Despite the ready availability of translators, these family discussions can be challenging. “When we have the translator, we are trying to balance efficiency with effective family communication,” explains Dr. Ottolini. “The translator adds a time factor because everything has to be repeated, and then there’s a lag time when we are looking at each other and waiting for the translation. It works, but it adds a layer of complexity to the situation, especially when you are trying to teach trainees while addressing parental concerns.”

Family Matters

Family communication is an important part of Dr. Ottolini’s daily activities. Because she doesn’t have a previous relationship with the patient or family, Dr. Ottolini faces the task of establishing rapport quickly—often in the midst of a crisis. “Especially when the child is seriously ill, it can be challenging to establish a level of trust,” she says. “For me, it’s a matter of trying to put myself in the parents’ shoes.”

Dr. Ottolini has also gained insights from being on the other side of the doctor-patient relationship. “I had an amazing relationship with a doctor who helped me tremendously, and I think of that,” she says. “Part of it is listening and trying to understand what is concerning the family the most. Sometimes, this is not what we think is the greatest concern. If we can get past what’s troubling them, it helps to move the care plan forward and establish a trusting relationship.

“There is no substitute for spending time with the family and getting to know them a little,” she continues. “It is important to understand how the illness is affecting the family’s routines, and helping to resolve these issues is useful as well.”

Dr. Ottolini’s concern for the family is evident in her interactions with them. She speaks with them gently, asks questions, and listens compassionately. Occasionally, Dr. Ottolini will schedule a family conference to address family concerns or other issues. “Family meetings are based on patient complexity—when there is multi-organ system involvement,” she says. “Sometimes, if the parents’ long-term expectations for their child’s prognosis are unrealistic, we want to have a meeting so that they can hear—from different sub-specialists involved—our rationale for what we are recommending— and [so that we can] clarify issues they don’t understand.”

Another level of concern involves families with limited resources. For example, “We have many recent immigrants for whom navigating the system is challenging,” says Dr. Ottolini. “We help them ensure that their child gets the best possible care, and we work to address work schedules and other issues.”

First and foremost, she and her team are patient and family advocates. “If we think it is important or necessary, we will keep a child here even if the insurance company says no,” she says.

Mary Ottolini, MD

Busy Afternoons, Late Days

By 1 p.m., Dr. Ottolini’s day is far from over. Her afternoon is filled with a variety of activities. In addition to seeing new patients, she spends time on billing and administrative activities, holds teaching sessions with medical students and residents at bedside and in the classroom, and writes notes.

“I still write my notes by hand,” she says. “However, this will be computerized in a year or so. When I finish with all of my clinical work and teaching responsibilities, I can catch up on administrative responsibilities or work on one of my research projects.”

Currently she is studying “ways to best conduct rounds and ensure that residents and students can take the information they get and put it all together to clinically problem solve and to see the big picture.”

Committee work is a big part of Dr. Ottolini’s work life. In addition to serving on several hospital committees, she also serves on the George Washington University faculty senate. Elsewhere, she is involved in several national organizations, including SHM.

Talking with families isn’t the only communication activity that takes Dr. Ottolini’s time. She works hard to keep referring physicians informed and to ensure they are involved in the patient’s care as necessary.

“We keep the patient’s pediatrician in the loop as much as possible. We make sure he or she understands how the disease process was managed, what new diagnoses arose, what prescription changes there were, and what follow-up is recommended,” Dr. Ottolini says. She especially wants to involve the pediatrician when a patient is critically ill or when the family is upset or in crisis. “Having a family voice to talk to helps the family feel as if they are getting support from someone they trust,” she explains. “This can be very reassuring for them.”

Dr. Ottolini encourages her students to appreciate the role and involvement of the pediatrician in a hospitalized patient’s care. “I try to make sure that residents and students have some sense of what it is like to be on the other side of things,” she offers. “I encourage them to think about how they would like to be treated if they were the pediatrician.”

Some physicians choose to become hospitalists because they want to spend the majority of their time on direct patient care. While Dr. Ottolini takes great satisfaction from this part of her work, it currently comprises only 30% of her professional time. Forty percent of her time involves medical education and research, which Dr. Ottolini greatly enjoys; administrative activities take up the remaining 30% of her time.

Many hospitalists appreciate the opportunities they have to teach, and Dr. Ottolini is no exception. She proudly observes that several physicians she has taught or mentored have become hospitalists: “For me, this is one of the most satisfying things.”

Admit and Discharge Issues

Dr. Ottolini has some involvement with admission and discharge issues. These decisions are simplified by the involvement of an expert team, however. For example, “We have case managers on rounds with us, and this helps them understand nuances of what we are doing that may not be exclusive in the notes and why it may be important for a patient to stay or appropriate for him or her to be discharged,” she says. “We look at patients’ criteria for discharge and anticipate, [on] the day before, any potential delays that could affect their release—such as getting tests performed and results back.”

Discharge planning is key. “We plan ahead for discharge and communicate goals to the family—such as getting the child off oxygen, getting cultures finalized, and so on,” says Dr. Ottolini. “We assign a discharge time the day before and make sure that the discharge summary, all necessary paperwork, and prescriptions are ready to go.”

For Dr. Ottolini, involvement in admission is limited. “The majority of our patients come through the emergency department,” she says. “However, we do admit patients coming in from the community, and we have input with community physicians if it’s not a clear-cut decision.”

The length of stay (LOS) for the nearly 300 beds in the hospital varies based on the patient’s condition. The average LOS for patients in the short-stay unit is three days. Facility-wide, the average LOS ranges from three to five days.

Challenges, Frustrations, Rewards, and Successes

“Challenges—such as dealing with very ill children who are not going to survive and addressing social situations where children are abused—also are rewarding, [and] we know we have worked in the best interest of the children,” says Dr. Ottolini. She and her team have the satisfaction of knowing they did everything they could to protect their patients, provide them with excellent care, and maximize their quality of life.

Dr. Ottolini says that she faces many of the same frustrations as others who work in a large organization. “With medically fragile children, a lot of coordination and communication needs to take place,” she says. “Sometimes, when lines of communication break down, you think something is happening when it isn’t. For example, after you have prepared a patient for an MRI, you find out that he or she has been bumped because of a more urgent situation. This frustrates the family and affects all of us.”

Pride of a Seasoned Hospitalist

A hospitalist since 1992, Dr. Ottolini is proud to have the title. She enjoys the teamwork she experiences on a daily basis, and even the challenges she experiences bring her tremendous professional and personal satisfaction.

While she sees herself as a generalist, Dr. Ottolini says her work “has enabled me to become especially good at those diagnoses we see a lot of—such as infectious disease problems and dehydration and fluid imbalance.”

An area in which Dr. Ottolini has become something of an expert is one that she would rather not have to see. “Sometimes we are lucky and see no abuse and neglect cases. The majority of the time, there is at least one admitted in a two-week period,” she says. “Out of necessity, I have learned quite a bit about abuse and neglect and caring for children who are abused and neglected. And, in presenting testimony on various cases, I have learned a bit about the court system.”

Helping students deal with this difficult reality is an important part of her teaching and mentoring activities. “From a clinical viewpoint, I help my students understand how to evaluate patients and look for red flags suggesting abuse or neglect,” she says. “However, it also is important for them to consider abuse in terms of different problems.”

Dr. Ottolini teaches her students “not to be closed-minded and not to be prejudiced concerning patients’ socieoeconomic status. They need to understand that abuse and neglect don’t just happen to poor children.”

From a personal standpoint, “we really need to focus on caring for children and not focus on who’s to blame. We want to work in a therapeutic relationship with parents as well as the child,” explains Dr. Ottolini. “It is not for us to figure out who is responsible for the abuse or neglect but to care for the child and work with the parent who is there. It is our job to make it clear to the police when abuse has occurred. Then we make sure that the situation to which the child is being sent when he or she leaves the hospital is reasonable and safe.”

A Happy Hospitalist

Dr. Ottolini rushes down the hall to see a patient as two residents hurry to keep up with her. They pepper her with questions as they walk, and she answers between glances at the chart in front of her. The smile on her face makes it clear that she is enjoying every minute of her “busy, crazy day.” TH

Joanne Kaldy writes regularly for The Hospitalist.

Mary Ottolini, MD

Many physicians see being a hospitalist as an opportunity to focus on direct patient care. For Mary Ottolini, MD, it is a way to have it all. Every day, she cares for patients at Children’s National Medical Center in Washington, D.C., teaches at Children’s and at George Washington University School of Medicine in Washington, D.C., serves on a variety of committees and in numerous organizations, and works as a department head.

Early Start, Full Day

“It’s just another typical, crazy day,” says Dr. Ottolini, division chief of the hospitalist division and director of pediatric medical student education at Children’s National Medical Center and professor of pediatrics at George Washington, as she walks briskly down the hall at 9 a.m. on her way to radiology rounds. Her day actually starts at about 7 a.m., when she sees overnight admissions and addresses any urgent problems that require her attention. By 9 a.m., her day is in full swing.

During radiology rounds she and her team, which consists of residents, interns, and third-year medical students, review films from the previous day with the radiologist. The group addresses issues such as what additional tests might be useful. Sometimes they try to determine whether a condition is the result of an illness or injury.

Leaving radiology, Dr. Ottolini and her team head to the ward for patient rounds. As they walk to the first room, they pass cheerful murals featuring cartoon characters and several paintings and drawings created by children. A third-year resident leads the rounds, filling the group in on each patient’s condition and progress. Dr. Ottolini conducts the physical exams and talks to family members when they are present. When she offers her thoughts and comments to the group, the students listen attentively and take notes as she talks.

At one point, the team has to send for a translator for a non-English speaking family. Dr. Ottolini explains that this is common. In fact, Children’s has translators readily available who speak several common languages, including Spanish, French, and Japanese. Additionally, they have access to individuals who speak just about any language that arises.

Despite the ready availability of translators, these family discussions can be challenging. “When we have the translator, we are trying to balance efficiency with effective family communication,” explains Dr. Ottolini. “The translator adds a time factor because everything has to be repeated, and then there’s a lag time when we are looking at each other and waiting for the translation. It works, but it adds a layer of complexity to the situation, especially when you are trying to teach trainees while addressing parental concerns.”

Family Matters

Family communication is an important part of Dr. Ottolini’s daily activities. Because she doesn’t have a previous relationship with the patient or family, Dr. Ottolini faces the task of establishing rapport quickly—often in the midst of a crisis. “Especially when the child is seriously ill, it can be challenging to establish a level of trust,” she says. “For me, it’s a matter of trying to put myself in the parents’ shoes.”

Dr. Ottolini has also gained insights from being on the other side of the doctor-patient relationship. “I had an amazing relationship with a doctor who helped me tremendously, and I think of that,” she says. “Part of it is listening and trying to understand what is concerning the family the most. Sometimes, this is not what we think is the greatest concern. If we can get past what’s troubling them, it helps to move the care plan forward and establish a trusting relationship.

“There is no substitute for spending time with the family and getting to know them a little,” she continues. “It is important to understand how the illness is affecting the family’s routines, and helping to resolve these issues is useful as well.”

Dr. Ottolini’s concern for the family is evident in her interactions with them. She speaks with them gently, asks questions, and listens compassionately. Occasionally, Dr. Ottolini will schedule a family conference to address family concerns or other issues. “Family meetings are based on patient complexity—when there is multi-organ system involvement,” she says. “Sometimes, if the parents’ long-term expectations for their child’s prognosis are unrealistic, we want to have a meeting so that they can hear—from different sub-specialists involved—our rationale for what we are recommending— and [so that we can] clarify issues they don’t understand.”

Another level of concern involves families with limited resources. For example, “We have many recent immigrants for whom navigating the system is challenging,” says Dr. Ottolini. “We help them ensure that their child gets the best possible care, and we work to address work schedules and other issues.”

First and foremost, she and her team are patient and family advocates. “If we think it is important or necessary, we will keep a child here even if the insurance company says no,” she says.

Mary Ottolini, MD

Busy Afternoons, Late Days

By 1 p.m., Dr. Ottolini’s day is far from over. Her afternoon is filled with a variety of activities. In addition to seeing new patients, she spends time on billing and administrative activities, holds teaching sessions with medical students and residents at bedside and in the classroom, and writes notes.

“I still write my notes by hand,” she says. “However, this will be computerized in a year or so. When I finish with all of my clinical work and teaching responsibilities, I can catch up on administrative responsibilities or work on one of my research projects.”

Currently she is studying “ways to best conduct rounds and ensure that residents and students can take the information they get and put it all together to clinically problem solve and to see the big picture.”

Committee work is a big part of Dr. Ottolini’s work life. In addition to serving on several hospital committees, she also serves on the George Washington University faculty senate. Elsewhere, she is involved in several national organizations, including SHM.

Talking with families isn’t the only communication activity that takes Dr. Ottolini’s time. She works hard to keep referring physicians informed and to ensure they are involved in the patient’s care as necessary.

“We keep the patient’s pediatrician in the loop as much as possible. We make sure he or she understands how the disease process was managed, what new diagnoses arose, what prescription changes there were, and what follow-up is recommended,” Dr. Ottolini says. She especially wants to involve the pediatrician when a patient is critically ill or when the family is upset or in crisis. “Having a family voice to talk to helps the family feel as if they are getting support from someone they trust,” she explains. “This can be very reassuring for them.”

Dr. Ottolini encourages her students to appreciate the role and involvement of the pediatrician in a hospitalized patient’s care. “I try to make sure that residents and students have some sense of what it is like to be on the other side of things,” she offers. “I encourage them to think about how they would like to be treated if they were the pediatrician.”

Some physicians choose to become hospitalists because they want to spend the majority of their time on direct patient care. While Dr. Ottolini takes great satisfaction from this part of her work, it currently comprises only 30% of her professional time. Forty percent of her time involves medical education and research, which Dr. Ottolini greatly enjoys; administrative activities take up the remaining 30% of her time.

Many hospitalists appreciate the opportunities they have to teach, and Dr. Ottolini is no exception. She proudly observes that several physicians she has taught or mentored have become hospitalists: “For me, this is one of the most satisfying things.”

Admit and Discharge Issues

Dr. Ottolini has some involvement with admission and discharge issues. These decisions are simplified by the involvement of an expert team, however. For example, “We have case managers on rounds with us, and this helps them understand nuances of what we are doing that may not be exclusive in the notes and why it may be important for a patient to stay or appropriate for him or her to be discharged,” she says. “We look at patients’ criteria for discharge and anticipate, [on] the day before, any potential delays that could affect their release—such as getting tests performed and results back.”

Discharge planning is key. “We plan ahead for discharge and communicate goals to the family—such as getting the child off oxygen, getting cultures finalized, and so on,” says Dr. Ottolini. “We assign a discharge time the day before and make sure that the discharge summary, all necessary paperwork, and prescriptions are ready to go.”

For Dr. Ottolini, involvement in admission is limited. “The majority of our patients come through the emergency department,” she says. “However, we do admit patients coming in from the community, and we have input with community physicians if it’s not a clear-cut decision.”

The length of stay (LOS) for the nearly 300 beds in the hospital varies based on the patient’s condition. The average LOS for patients in the short-stay unit is three days. Facility-wide, the average LOS ranges from three to five days.

Challenges, Frustrations, Rewards, and Successes

“Challenges—such as dealing with very ill children who are not going to survive and addressing social situations where children are abused—also are rewarding, [and] we know we have worked in the best interest of the children,” says Dr. Ottolini. She and her team have the satisfaction of knowing they did everything they could to protect their patients, provide them with excellent care, and maximize their quality of life.

Dr. Ottolini says that she faces many of the same frustrations as others who work in a large organization. “With medically fragile children, a lot of coordination and communication needs to take place,” she says. “Sometimes, when lines of communication break down, you think something is happening when it isn’t. For example, after you have prepared a patient for an MRI, you find out that he or she has been bumped because of a more urgent situation. This frustrates the family and affects all of us.”

Pride of a Seasoned Hospitalist

A hospitalist since 1992, Dr. Ottolini is proud to have the title. She enjoys the teamwork she experiences on a daily basis, and even the challenges she experiences bring her tremendous professional and personal satisfaction.

While she sees herself as a generalist, Dr. Ottolini says her work “has enabled me to become especially good at those diagnoses we see a lot of—such as infectious disease problems and dehydration and fluid imbalance.”

An area in which Dr. Ottolini has become something of an expert is one that she would rather not have to see. “Sometimes we are lucky and see no abuse and neglect cases. The majority of the time, there is at least one admitted in a two-week period,” she says. “Out of necessity, I have learned quite a bit about abuse and neglect and caring for children who are abused and neglected. And, in presenting testimony on various cases, I have learned a bit about the court system.”

Helping students deal with this difficult reality is an important part of her teaching and mentoring activities. “From a clinical viewpoint, I help my students understand how to evaluate patients and look for red flags suggesting abuse or neglect,” she says. “However, it also is important for them to consider abuse in terms of different problems.”

Dr. Ottolini teaches her students “not to be closed-minded and not to be prejudiced concerning patients’ socieoeconomic status. They need to understand that abuse and neglect don’t just happen to poor children.”

From a personal standpoint, “we really need to focus on caring for children and not focus on who’s to blame. We want to work in a therapeutic relationship with parents as well as the child,” explains Dr. Ottolini. “It is not for us to figure out who is responsible for the abuse or neglect but to care for the child and work with the parent who is there. It is our job to make it clear to the police when abuse has occurred. Then we make sure that the situation to which the child is being sent when he or she leaves the hospital is reasonable and safe.”

A Happy Hospitalist

Dr. Ottolini rushes down the hall to see a patient as two residents hurry to keep up with her. They pepper her with questions as they walk, and she answers between glances at the chart in front of her. The smile on her face makes it clear that she is enjoying every minute of her “busy, crazy day.” TH

Joanne Kaldy writes regularly for The Hospitalist.

Mary Ottolini, MD

Many physicians see being a hospitalist as an opportunity to focus on direct patient care. For Mary Ottolini, MD, it is a way to have it all. Every day, she cares for patients at Children’s National Medical Center in Washington, D.C., teaches at Children’s and at George Washington University School of Medicine in Washington, D.C., serves on a variety of committees and in numerous organizations, and works as a department head.

Early Start, Full Day

“It’s just another typical, crazy day,” says Dr. Ottolini, division chief of the hospitalist division and director of pediatric medical student education at Children’s National Medical Center and professor of pediatrics at George Washington, as she walks briskly down the hall at 9 a.m. on her way to radiology rounds. Her day actually starts at about 7 a.m., when she sees overnight admissions and addresses any urgent problems that require her attention. By 9 a.m., her day is in full swing.

During radiology rounds she and her team, which consists of residents, interns, and third-year medical students, review films from the previous day with the radiologist. The group addresses issues such as what additional tests might be useful. Sometimes they try to determine whether a condition is the result of an illness or injury.

Leaving radiology, Dr. Ottolini and her team head to the ward for patient rounds. As they walk to the first room, they pass cheerful murals featuring cartoon characters and several paintings and drawings created by children. A third-year resident leads the rounds, filling the group in on each patient’s condition and progress. Dr. Ottolini conducts the physical exams and talks to family members when they are present. When she offers her thoughts and comments to the group, the students listen attentively and take notes as she talks.

At one point, the team has to send for a translator for a non-English speaking family. Dr. Ottolini explains that this is common. In fact, Children’s has translators readily available who speak several common languages, including Spanish, French, and Japanese. Additionally, they have access to individuals who speak just about any language that arises.

Despite the ready availability of translators, these family discussions can be challenging. “When we have the translator, we are trying to balance efficiency with effective family communication,” explains Dr. Ottolini. “The translator adds a time factor because everything has to be repeated, and then there’s a lag time when we are looking at each other and waiting for the translation. It works, but it adds a layer of complexity to the situation, especially when you are trying to teach trainees while addressing parental concerns.”

Family Matters

Family communication is an important part of Dr. Ottolini’s daily activities. Because she doesn’t have a previous relationship with the patient or family, Dr. Ottolini faces the task of establishing rapport quickly—often in the midst of a crisis. “Especially when the child is seriously ill, it can be challenging to establish a level of trust,” she says. “For me, it’s a matter of trying to put myself in the parents’ shoes.”

Dr. Ottolini has also gained insights from being on the other side of the doctor-patient relationship. “I had an amazing relationship with a doctor who helped me tremendously, and I think of that,” she says. “Part of it is listening and trying to understand what is concerning the family the most. Sometimes, this is not what we think is the greatest concern. If we can get past what’s troubling them, it helps to move the care plan forward and establish a trusting relationship.

“There is no substitute for spending time with the family and getting to know them a little,” she continues. “It is important to understand how the illness is affecting the family’s routines, and helping to resolve these issues is useful as well.”

Dr. Ottolini’s concern for the family is evident in her interactions with them. She speaks with them gently, asks questions, and listens compassionately. Occasionally, Dr. Ottolini will schedule a family conference to address family concerns or other issues. “Family meetings are based on patient complexity—when there is multi-organ system involvement,” she says. “Sometimes, if the parents’ long-term expectations for their child’s prognosis are unrealistic, we want to have a meeting so that they can hear—from different sub-specialists involved—our rationale for what we are recommending— and [so that we can] clarify issues they don’t understand.”

Another level of concern involves families with limited resources. For example, “We have many recent immigrants for whom navigating the system is challenging,” says Dr. Ottolini. “We help them ensure that their child gets the best possible care, and we work to address work schedules and other issues.”

First and foremost, she and her team are patient and family advocates. “If we think it is important or necessary, we will keep a child here even if the insurance company says no,” she says.

Mary Ottolini, MD

Busy Afternoons, Late Days

By 1 p.m., Dr. Ottolini’s day is far from over. Her afternoon is filled with a variety of activities. In addition to seeing new patients, she spends time on billing and administrative activities, holds teaching sessions with medical students and residents at bedside and in the classroom, and writes notes.

“I still write my notes by hand,” she says. “However, this will be computerized in a year or so. When I finish with all of my clinical work and teaching responsibilities, I can catch up on administrative responsibilities or work on one of my research projects.”

Currently she is studying “ways to best conduct rounds and ensure that residents and students can take the information they get and put it all together to clinically problem solve and to see the big picture.”

Committee work is a big part of Dr. Ottolini’s work life. In addition to serving on several hospital committees, she also serves on the George Washington University faculty senate. Elsewhere, she is involved in several national organizations, including SHM.

Talking with families isn’t the only communication activity that takes Dr. Ottolini’s time. She works hard to keep referring physicians informed and to ensure they are involved in the patient’s care as necessary.

“We keep the patient’s pediatrician in the loop as much as possible. We make sure he or she understands how the disease process was managed, what new diagnoses arose, what prescription changes there were, and what follow-up is recommended,” Dr. Ottolini says. She especially wants to involve the pediatrician when a patient is critically ill or when the family is upset or in crisis. “Having a family voice to talk to helps the family feel as if they are getting support from someone they trust,” she explains. “This can be very reassuring for them.”

Dr. Ottolini encourages her students to appreciate the role and involvement of the pediatrician in a hospitalized patient’s care. “I try to make sure that residents and students have some sense of what it is like to be on the other side of things,” she offers. “I encourage them to think about how they would like to be treated if they were the pediatrician.”

Some physicians choose to become hospitalists because they want to spend the majority of their time on direct patient care. While Dr. Ottolini takes great satisfaction from this part of her work, it currently comprises only 30% of her professional time. Forty percent of her time involves medical education and research, which Dr. Ottolini greatly enjoys; administrative activities take up the remaining 30% of her time.

Many hospitalists appreciate the opportunities they have to teach, and Dr. Ottolini is no exception. She proudly observes that several physicians she has taught or mentored have become hospitalists: “For me, this is one of the most satisfying things.”

Admit and Discharge Issues

Dr. Ottolini has some involvement with admission and discharge issues. These decisions are simplified by the involvement of an expert team, however. For example, “We have case managers on rounds with us, and this helps them understand nuances of what we are doing that may not be exclusive in the notes and why it may be important for a patient to stay or appropriate for him or her to be discharged,” she says. “We look at patients’ criteria for discharge and anticipate, [on] the day before, any potential delays that could affect their release—such as getting tests performed and results back.”

Discharge planning is key. “We plan ahead for discharge and communicate goals to the family—such as getting the child off oxygen, getting cultures finalized, and so on,” says Dr. Ottolini. “We assign a discharge time the day before and make sure that the discharge summary, all necessary paperwork, and prescriptions are ready to go.”

For Dr. Ottolini, involvement in admission is limited. “The majority of our patients come through the emergency department,” she says. “However, we do admit patients coming in from the community, and we have input with community physicians if it’s not a clear-cut decision.”

The length of stay (LOS) for the nearly 300 beds in the hospital varies based on the patient’s condition. The average LOS for patients in the short-stay unit is three days. Facility-wide, the average LOS ranges from three to five days.

Challenges, Frustrations, Rewards, and Successes

“Challenges—such as dealing with very ill children who are not going to survive and addressing social situations where children are abused—also are rewarding, [and] we know we have worked in the best interest of the children,” says Dr. Ottolini. She and her team have the satisfaction of knowing they did everything they could to protect their patients, provide them with excellent care, and maximize their quality of life.

Dr. Ottolini says that she faces many of the same frustrations as others who work in a large organization. “With medically fragile children, a lot of coordination and communication needs to take place,” she says. “Sometimes, when lines of communication break down, you think something is happening when it isn’t. For example, after you have prepared a patient for an MRI, you find out that he or she has been bumped because of a more urgent situation. This frustrates the family and affects all of us.”

Pride of a Seasoned Hospitalist

A hospitalist since 1992, Dr. Ottolini is proud to have the title. She enjoys the teamwork she experiences on a daily basis, and even the challenges she experiences bring her tremendous professional and personal satisfaction.

While she sees herself as a generalist, Dr. Ottolini says her work “has enabled me to become especially good at those diagnoses we see a lot of—such as infectious disease problems and dehydration and fluid imbalance.”

An area in which Dr. Ottolini has become something of an expert is one that she would rather not have to see. “Sometimes we are lucky and see no abuse and neglect cases. The majority of the time, there is at least one admitted in a two-week period,” she says. “Out of necessity, I have learned quite a bit about abuse and neglect and caring for children who are abused and neglected. And, in presenting testimony on various cases, I have learned a bit about the court system.”

Helping students deal with this difficult reality is an important part of her teaching and mentoring activities. “From a clinical viewpoint, I help my students understand how to evaluate patients and look for red flags suggesting abuse or neglect,” she says. “However, it also is important for them to consider abuse in terms of different problems.”

Dr. Ottolini teaches her students “not to be closed-minded and not to be prejudiced concerning patients’ socieoeconomic status. They need to understand that abuse and neglect don’t just happen to poor children.”

From a personal standpoint, “we really need to focus on caring for children and not focus on who’s to blame. We want to work in a therapeutic relationship with parents as well as the child,” explains Dr. Ottolini. “It is not for us to figure out who is responsible for the abuse or neglect but to care for the child and work with the parent who is there. It is our job to make it clear to the police when abuse has occurred. Then we make sure that the situation to which the child is being sent when he or she leaves the hospital is reasonable and safe.”

A Happy Hospitalist

Dr. Ottolini rushes down the hall to see a patient as two residents hurry to keep up with her. They pepper her with questions as they walk, and she answers between glances at the chart in front of her. The smile on her face makes it clear that she is enjoying every minute of her “busy, crazy day.” TH

Joanne Kaldy writes regularly for The Hospitalist.

With methamphetamine use spreading across the country like a flu epidemic, hospitalists see more meth addicts and deal increasingly with the physical and psychiatric conditions common in these individuals. In overcoming the challenges and frustrations of working with these patients, hospitalists in regions where meth use is rampant have become experts of sorts, and they have messages for their colleagues nationwide: Learn our lessons, because you could be next.

The Meth Evolution

Methamphetamine has become popular for obvious reasons. The drug is cheap, and because it is manufactured using common and easily obtained ingredients, it is accessible anywhere.

The meth epidemic is not a new phenomenon. It started in the 1970s in the American heartland—Iowa and parts of Missouri. Since then, it has spread from West to East—hitting California and Hawaii in the ’80s and moving to Southeastern states such as Georgia and South Carolina in the late ’90s.

According to Richard A. Rawson, PhD, associate director and professor-in-residence for the Integrated Substance Abuse Programs at the Semel Institute for Neuroscience and Human Behavior in the David Geffen School of Medicine at the University of California at Los Angeles, “The spread of meth in the U.S. looks much like that of an infectious disease. It has spread in a very systematic way.”

It is a particular problem in rural communities, where it’s easily accessible and cheap. In fact, Dr. Rawson suggests that the drug doesn’t really present a major problem in urban areas—with the exception of cities that have a concentration of gay men. “Meth use in this population is a unique phenomenon that doesn’t follow the same homogenous spread from west to east,” he says.

Compounding this problem is the fact that HIV and sexually transmitted diseases often accompany meth use. “The drug is uniquely connected to sexual behavior because it increases sex drive, sexual performance, and pleasure,” observes Dr. Rawson. At the same time, hepatitis C is a broad concern in communities in which users inject the drug instead of smoking it. In fact, he says, about 50% of meth injectors are hepatitis-C-positive.

Meth Addicts: Routine for Some Hospitalists

For those hospitalists who see many meth users, working with these patients is fairly routine. As Emory University, Atlanta, assistant professor of medicine and hospitalist J. Allen Garner, MD, says, “As many as 30% of the patients I deal with on any given day are addicted to something—cocaine, alcohol, meth. I can’t say it’s a greater burden than anything else.”

Establishing rapport with these patients can be challenging. “Some say, ‘I’m really strung out and need help.’ Many come in with some physical complaint and don’t tell me that they’re high on meth and haven’t slept for 72 hours,” says Dr. Garner. “Basically, this has to do with the denial that goes along with chemical dependency.

Even patients who readily admit that they have a problem are often in denial about the depth of their addiction. “They’ll say that they have it under control, that they only did it once, or that someone slipped them the drug—all ‘party lines’ that take the heat off of them,” he says.

Gaining the trust of meth addicts is a major challenge, “because the drug produces paranoia, agitation, and nervousness,” says Dr. Rawson, noting that “quick urine tests” can be used to identify meth users, and drug use shows up for hours. These tests are great because they only cost $5-$10 each.

Many meth patients come into the hospital because of a physical ailment. “They present with chest pain, palpitations, and/or shortness of breath, although these conditions clear up pretty quickly,” says Dr. Garner.

Tip-offs that the problem might be drug related include poor hygiene, disheveled appearance, and edgy, antsy behavior. Additionally, says Dr. Rawson, “Weight loss, skin sores and scabs, dental disorders, nervous behavior, and paranoid ideation are blue-ribbon signs of meth use. In places where users inject meth, look for needle marks. In regions where users smoke meth, pulmonary disease and coughing are common.”

In the patients Dr. Garner sees, meth’s lasting effects affect their physical health less than their mental health and quality of life. “Meth deteriorates them to the point that they can’t work, and they detach themselves from family, friends, and society as a whole,” he explains. “They require a lot of deep-seated [psychiatric] therapy to deal with multiple issues.”

While most of the meth users Dr. Garner sees are poorly educated and come from the working class, meth is increasingly popular among college students and professionals. In fact, he says, “I know of several doctors for whom meth was the drug of choice.” It is important for hospitalists to remember that addiction knows no socioeconomic boundaries. Many clinicians view meth addicts in an unsympathetic light and as people who have caused their own problems. This is a barrier that needs to be overcome, stresses Dr. Garner.

What Hospitalists Can Do

Meth users often aren’t even admitted to the hospital. “Treatment is mostly supportive. There is no drug you can give them to bring them down,” says Dr. Garner. “Withdrawal is a terrible thing—a sensation like Satan is crawling up their chest. We give them valium, but they basically have to weather it out.”

Even if the hospitalist addresses the physical effects and discusses treatment options with the meth user, it’s common for these patients to go back to their drug use when they leave the hospital. “Because meth doesn’t have life-threatening withdrawal symptoms—although you feel like you’re going to die—it’s easy for them to keep going back and using. Detox centers generally won’t touch these people,” says Dr. Garner. As a result, many patients end up in a catch-22, repeatedly going back to meth use.

While Dr. Garner does everything he can to help these patients, “they already are slaves to the drug by the time I see them,” he says. “Meth is highly addictive, and many people get hooked after using it just once or twice.”

This lack of available treatment for meth addicts is one of the greatest frustrations Dr. Garner faces as a hospitalist. “We keep putting resources into catching addicts as criminals and not getting them treatment and help before they become burdens on society,” he says.

He is pleased to note that this is changing in some states. “A few of the courts in our locale are starting to incorporate treatment programs through the court systems,” he explains.

Meth and Youth

While meth has become a popular drug among all age groups, “very few teens end up in the hospital because of meth,” says Wendy Wright, MD, a hospitalist at Rady Children’s Hospital in San Diego. “If kids are high on meth, they generally aren’t admitted when they are coming down. And, unlike many adults, they don’t have physical or medical issues that require hospitalization,” she explains. “Kids tolerate meth really well from the physical standpoint. We don’t see the arrhythmias or heart attacks that we see in adult addicts.”

When teen addicts do come in with medical conditions, Dr. Wright suggests, hospitalists often see problems such as skin or urinary tract infections. Teen meth users more frequently come to the hospital with psychiatric problems. “They have paranoid delusions, and some are fairly aggressive,” says Dr. Wright.

While hospitalists dealing with teens face the usual challenge of establishing rapport quickly, Dr. Wright observes that teens tend to be much more open than adults about their drug use. “They are pretty up front; they tell me right off the bat what drugs they use,” she says. “Of course I’m mostly seeing kids [who] aren’t living in an upper-class environment, and they’re not trying to hide things from their parents. The kids I see are streetwise and no nonsense. They have a sense of what their medical needs are and think nothing of asking for HIV or STD testing.”

Because of their youth and general good physical health, teens don’t necessarily create a burden for the hospitals and professionals who care for them. The biggest burden of meth-using teenagers, she suggests, “has to do with social issues. These kids often don’t grow into productive adults. They also have a lot of mental health issues such as bipolar disorder or severe depression, and these are the biggest burdens on the community as a whole. We also see a lot of chlamydia and gonorrhea in our kids.”

Although Dr. Wright strictly sees young patients, she acknowledges intergenerational meth use in families. Her facility sees many children who are brought into protective custody because their parents are meth users and unfit to care for them.

“These kids end up staying in the system, which is a bad place for them to be,” says Dr. Wright. “They grow up with a lot of insecurities and mental health issues, and many go on to be users themselves. While she sees many kids whose grandmothers and mothers are addicts, she believes the problem is situational and not hereditary. Nonetheless, “We’re not sure how to break this cycle,” she says.

Some kids are hospitalized because they are hurt or sick as a result of being in an unsafe environment where parents are meth users. These children are often malnourished or sick because of neglect.

Helping Hospitalists Manage Meth

It helps hospitalists if their facility has clear protocols for handling meth intoxication. “It is especially good to establish a procedure in the emergency department,” advises Dr. Rawson. He stresses that these procedures should address ways to de-escalate aggressive behavior. There are also clinical training techniques and brief interventions used to treat alcoholics that can be useful for dealing with meth addicts. These interventions involve efforts to change behaviors. Specifically, helping patients understand that their substance abuse is putting them at risk and encouraging them to reduce or stop their drug use altogether. The elements of brief interventions for substance abuse have been summarized in the acronym “FRAMES,” which stands for feedback, responsibility, advice, menu of options, empathy, and self-efficacy.

“These tools can help get people to talk about their meth problem[s] and deal with [them],” says Dr. Rawson. “Some of these brief interventions can be amazing in terms of deferring further drug use.”

Burdens of Meth

What hospitalists see in their meth-using patients depends on the maturity of the problem in their community. “In communities where the problem is newer, you are likely to see younger users and fewer physical problems,” says Dr. Rawson.

In areas where the problem has existed for years, hospitalists can expect to see older addicts with physical problems that range from heart conditions to widespread tooth decay (a condition known as “meth mouth”). The longer a community has had a meth problem, the more likely the epidemic is placing a financial burden on the healthcare system.

Dr. Garner urges his colleagues to learn about meth. “A couple of years ago, this was a nonexistent problem,” he says. “Now it has reached crisis proportions in many communities.”

Gina DiRenzo-Coffey, MD, director of inpatient pediatrics and a pediatric hospitalist at Alegent Health/Bergan Mercy Medical Center in Omaha, Neb., agrees: “You can lull yourself into believing that this can’t happen in your community. But no one has been able to stop meth use [among members of their community], and it keeps spreading. It is our job to learn everything we can about this drug and help meth addicts as much as we can.” TH

Joanne Kaldy also writes about a day in the life of a pediatric hospitalist in this issue.

With methamphetamine use spreading across the country like a flu epidemic, hospitalists see more meth addicts and deal increasingly with the physical and psychiatric conditions common in these individuals. In overcoming the challenges and frustrations of working with these patients, hospitalists in regions where meth use is rampant have become experts of sorts, and they have messages for their colleagues nationwide: Learn our lessons, because you could be next.

The Meth Evolution

Methamphetamine has become popular for obvious reasons. The drug is cheap, and because it is manufactured using common and easily obtained ingredients, it is accessible anywhere.

The meth epidemic is not a new phenomenon. It started in the 1970s in the American heartland—Iowa and parts of Missouri. Since then, it has spread from West to East—hitting California and Hawaii in the ’80s and moving to Southeastern states such as Georgia and South Carolina in the late ’90s.

According to Richard A. Rawson, PhD, associate director and professor-in-residence for the Integrated Substance Abuse Programs at the Semel Institute for Neuroscience and Human Behavior in the David Geffen School of Medicine at the University of California at Los Angeles, “The spread of meth in the U.S. looks much like that of an infectious disease. It has spread in a very systematic way.”

It is a particular problem in rural communities, where it’s easily accessible and cheap. In fact, Dr. Rawson suggests that the drug doesn’t really present a major problem in urban areas—with the exception of cities that have a concentration of gay men. “Meth use in this population is a unique phenomenon that doesn’t follow the same homogenous spread from west to east,” he says.

Compounding this problem is the fact that HIV and sexually transmitted diseases often accompany meth use. “The drug is uniquely connected to sexual behavior because it increases sex drive, sexual performance, and pleasure,” observes Dr. Rawson. At the same time, hepatitis C is a broad concern in communities in which users inject the drug instead of smoking it. In fact, he says, about 50% of meth injectors are hepatitis-C-positive.

Meth Addicts: Routine for Some Hospitalists

For those hospitalists who see many meth users, working with these patients is fairly routine. As Emory University, Atlanta, assistant professor of medicine and hospitalist J. Allen Garner, MD, says, “As many as 30% of the patients I deal with on any given day are addicted to something—cocaine, alcohol, meth. I can’t say it’s a greater burden than anything else.”

Establishing rapport with these patients can be challenging. “Some say, ‘I’m really strung out and need help.’ Many come in with some physical complaint and don’t tell me that they’re high on meth and haven’t slept for 72 hours,” says Dr. Garner. “Basically, this has to do with the denial that goes along with chemical dependency.

Even patients who readily admit that they have a problem are often in denial about the depth of their addiction. “They’ll say that they have it under control, that they only did it once, or that someone slipped them the drug—all ‘party lines’ that take the heat off of them,” he says.

Gaining the trust of meth addicts is a major challenge, “because the drug produces paranoia, agitation, and nervousness,” says Dr. Rawson, noting that “quick urine tests” can be used to identify meth users, and drug use shows up for hours. These tests are great because they only cost $5-$10 each.

Many meth patients come into the hospital because of a physical ailment. “They present with chest pain, palpitations, and/or shortness of breath, although these conditions clear up pretty quickly,” says Dr. Garner.

Tip-offs that the problem might be drug related include poor hygiene, disheveled appearance, and edgy, antsy behavior. Additionally, says Dr. Rawson, “Weight loss, skin sores and scabs, dental disorders, nervous behavior, and paranoid ideation are blue-ribbon signs of meth use. In places where users inject meth, look for needle marks. In regions where users smoke meth, pulmonary disease and coughing are common.”

In the patients Dr. Garner sees, meth’s lasting effects affect their physical health less than their mental health and quality of life. “Meth deteriorates them to the point that they can’t work, and they detach themselves from family, friends, and society as a whole,” he explains. “They require a lot of deep-seated [psychiatric] therapy to deal with multiple issues.”

While most of the meth users Dr. Garner sees are poorly educated and come from the working class, meth is increasingly popular among college students and professionals. In fact, he says, “I know of several doctors for whom meth was the drug of choice.” It is important for hospitalists to remember that addiction knows no socioeconomic boundaries. Many clinicians view meth addicts in an unsympathetic light and as people who have caused their own problems. This is a barrier that needs to be overcome, stresses Dr. Garner.

What Hospitalists Can Do

Meth users often aren’t even admitted to the hospital. “Treatment is mostly supportive. There is no drug you can give them to bring them down,” says Dr. Garner. “Withdrawal is a terrible thing—a sensation like Satan is crawling up their chest. We give them valium, but they basically have to weather it out.”

Even if the hospitalist addresses the physical effects and discusses treatment options with the meth user, it’s common for these patients to go back to their drug use when they leave the hospital. “Because meth doesn’t have life-threatening withdrawal symptoms—although you feel like you’re going to die—it’s easy for them to keep going back and using. Detox centers generally won’t touch these people,” says Dr. Garner. As a result, many patients end up in a catch-22, repeatedly going back to meth use.

While Dr. Garner does everything he can to help these patients, “they already are slaves to the drug by the time I see them,” he says. “Meth is highly addictive, and many people get hooked after using it just once or twice.”

This lack of available treatment for meth addicts is one of the greatest frustrations Dr. Garner faces as a hospitalist. “We keep putting resources into catching addicts as criminals and not getting them treatment and help before they become burdens on society,” he says.

He is pleased to note that this is changing in some states. “A few of the courts in our locale are starting to incorporate treatment programs through the court systems,” he explains.

Meth and Youth

While meth has become a popular drug among all age groups, “very few teens end up in the hospital because of meth,” says Wendy Wright, MD, a hospitalist at Rady Children’s Hospital in San Diego. “If kids are high on meth, they generally aren’t admitted when they are coming down. And, unlike many adults, they don’t have physical or medical issues that require hospitalization,” she explains. “Kids tolerate meth really well from the physical standpoint. We don’t see the arrhythmias or heart attacks that we see in adult addicts.”

When teen addicts do come in with medical conditions, Dr. Wright suggests, hospitalists often see problems such as skin or urinary tract infections. Teen meth users more frequently come to the hospital with psychiatric problems. “They have paranoid delusions, and some are fairly aggressive,” says Dr. Wright.

While hospitalists dealing with teens face the usual challenge of establishing rapport quickly, Dr. Wright observes that teens tend to be much more open than adults about their drug use. “They are pretty up front; they tell me right off the bat what drugs they use,” she says. “Of course I’m mostly seeing kids [who] aren’t living in an upper-class environment, and they’re not trying to hide things from their parents. The kids I see are streetwise and no nonsense. They have a sense of what their medical needs are and think nothing of asking for HIV or STD testing.”

Because of their youth and general good physical health, teens don’t necessarily create a burden for the hospitals and professionals who care for them. The biggest burden of meth-using teenagers, she suggests, “has to do with social issues. These kids often don’t grow into productive adults. They also have a lot of mental health issues such as bipolar disorder or severe depression, and these are the biggest burdens on the community as a whole. We also see a lot of chlamydia and gonorrhea in our kids.”

Although Dr. Wright strictly sees young patients, she acknowledges intergenerational meth use in families. Her facility sees many children who are brought into protective custody because their parents are meth users and unfit to care for them.

“These kids end up staying in the system, which is a bad place for them to be,” says Dr. Wright. “They grow up with a lot of insecurities and mental health issues, and many go on to be users themselves. While she sees many kids whose grandmothers and mothers are addicts, she believes the problem is situational and not hereditary. Nonetheless, “We’re not sure how to break this cycle,” she says.

Some kids are hospitalized because they are hurt or sick as a result of being in an unsafe environment where parents are meth users. These children are often malnourished or sick because of neglect.

Helping Hospitalists Manage Meth

It helps hospitalists if their facility has clear protocols for handling meth intoxication. “It is especially good to establish a procedure in the emergency department,” advises Dr. Rawson. He stresses that these procedures should address ways to de-escalate aggressive behavior. There are also clinical training techniques and brief interventions used to treat alcoholics that can be useful for dealing with meth addicts. These interventions involve efforts to change behaviors. Specifically, helping patients understand that their substance abuse is putting them at risk and encouraging them to reduce or stop their drug use altogether. The elements of brief interventions for substance abuse have been summarized in the acronym “FRAMES,” which stands for feedback, responsibility, advice, menu of options, empathy, and self-efficacy.

“These tools can help get people to talk about their meth problem[s] and deal with [them],” says Dr. Rawson. “Some of these brief interventions can be amazing in terms of deferring further drug use.”

Burdens of Meth

What hospitalists see in their meth-using patients depends on the maturity of the problem in their community. “In communities where the problem is newer, you are likely to see younger users and fewer physical problems,” says Dr. Rawson.

In areas where the problem has existed for years, hospitalists can expect to see older addicts with physical problems that range from heart conditions to widespread tooth decay (a condition known as “meth mouth”). The longer a community has had a meth problem, the more likely the epidemic is placing a financial burden on the healthcare system.

Dr. Garner urges his colleagues to learn about meth. “A couple of years ago, this was a nonexistent problem,” he says. “Now it has reached crisis proportions in many communities.”

Gina DiRenzo-Coffey, MD, director of inpatient pediatrics and a pediatric hospitalist at Alegent Health/Bergan Mercy Medical Center in Omaha, Neb., agrees: “You can lull yourself into believing that this can’t happen in your community. But no one has been able to stop meth use [among members of their community], and it keeps spreading. It is our job to learn everything we can about this drug and help meth addicts as much as we can.” TH

Joanne Kaldy also writes about a day in the life of a pediatric hospitalist in this issue.

With methamphetamine use spreading across the country like a flu epidemic, hospitalists see more meth addicts and deal increasingly with the physical and psychiatric conditions common in these individuals. In overcoming the challenges and frustrations of working with these patients, hospitalists in regions where meth use is rampant have become experts of sorts, and they have messages for their colleagues nationwide: Learn our lessons, because you could be next.

The Meth Evolution

Methamphetamine has become popular for obvious reasons. The drug is cheap, and because it is manufactured using common and easily obtained ingredients, it is accessible anywhere.

The meth epidemic is not a new phenomenon. It started in the 1970s in the American heartland—Iowa and parts of Missouri. Since then, it has spread from West to East—hitting California and Hawaii in the ’80s and moving to Southeastern states such as Georgia and South Carolina in the late ’90s.

According to Richard A. Rawson, PhD, associate director and professor-in-residence for the Integrated Substance Abuse Programs at the Semel Institute for Neuroscience and Human Behavior in the David Geffen School of Medicine at the University of California at Los Angeles, “The spread of meth in the U.S. looks much like that of an infectious disease. It has spread in a very systematic way.”

It is a particular problem in rural communities, where it’s easily accessible and cheap. In fact, Dr. Rawson suggests that the drug doesn’t really present a major problem in urban areas—with the exception of cities that have a concentration of gay men. “Meth use in this population is a unique phenomenon that doesn’t follow the same homogenous spread from west to east,” he says.

Compounding this problem is the fact that HIV and sexually transmitted diseases often accompany meth use. “The drug is uniquely connected to sexual behavior because it increases sex drive, sexual performance, and pleasure,” observes Dr. Rawson. At the same time, hepatitis C is a broad concern in communities in which users inject the drug instead of smoking it. In fact, he says, about 50% of meth injectors are hepatitis-C-positive.

Meth Addicts: Routine for Some Hospitalists

For those hospitalists who see many meth users, working with these patients is fairly routine. As Emory University, Atlanta, assistant professor of medicine and hospitalist J. Allen Garner, MD, says, “As many as 30% of the patients I deal with on any given day are addicted to something—cocaine, alcohol, meth. I can’t say it’s a greater burden than anything else.”

Establishing rapport with these patients can be challenging. “Some say, ‘I’m really strung out and need help.’ Many come in with some physical complaint and don’t tell me that they’re high on meth and haven’t slept for 72 hours,” says Dr. Garner. “Basically, this has to do with the denial that goes along with chemical dependency.

Even patients who readily admit that they have a problem are often in denial about the depth of their addiction. “They’ll say that they have it under control, that they only did it once, or that someone slipped them the drug—all ‘party lines’ that take the heat off of them,” he says.

Gaining the trust of meth addicts is a major challenge, “because the drug produces paranoia, agitation, and nervousness,” says Dr. Rawson, noting that “quick urine tests” can be used to identify meth users, and drug use shows up for hours. These tests are great because they only cost $5-$10 each.

Many meth patients come into the hospital because of a physical ailment. “They present with chest pain, palpitations, and/or shortness of breath, although these conditions clear up pretty quickly,” says Dr. Garner.

Tip-offs that the problem might be drug related include poor hygiene, disheveled appearance, and edgy, antsy behavior. Additionally, says Dr. Rawson, “Weight loss, skin sores and scabs, dental disorders, nervous behavior, and paranoid ideation are blue-ribbon signs of meth use. In places where users inject meth, look for needle marks. In regions where users smoke meth, pulmonary disease and coughing are common.”

In the patients Dr. Garner sees, meth’s lasting effects affect their physical health less than their mental health and quality of life. “Meth deteriorates them to the point that they can’t work, and they detach themselves from family, friends, and society as a whole,” he explains. “They require a lot of deep-seated [psychiatric] therapy to deal with multiple issues.”

While most of the meth users Dr. Garner sees are poorly educated and come from the working class, meth is increasingly popular among college students and professionals. In fact, he says, “I know of several doctors for whom meth was the drug of choice.” It is important for hospitalists to remember that addiction knows no socioeconomic boundaries. Many clinicians view meth addicts in an unsympathetic light and as people who have caused their own problems. This is a barrier that needs to be overcome, stresses Dr. Garner.

What Hospitalists Can Do

Meth users often aren’t even admitted to the hospital. “Treatment is mostly supportive. There is no drug you can give them to bring them down,” says Dr. Garner. “Withdrawal is a terrible thing—a sensation like Satan is crawling up their chest. We give them valium, but they basically have to weather it out.”

Even if the hospitalist addresses the physical effects and discusses treatment options with the meth user, it’s common for these patients to go back to their drug use when they leave the hospital. “Because meth doesn’t have life-threatening withdrawal symptoms—although you feel like you’re going to die—it’s easy for them to keep going back and using. Detox centers generally won’t touch these people,” says Dr. Garner. As a result, many patients end up in a catch-22, repeatedly going back to meth use.

While Dr. Garner does everything he can to help these patients, “they already are slaves to the drug by the time I see them,” he says. “Meth is highly addictive, and many people get hooked after using it just once or twice.”

This lack of available treatment for meth addicts is one of the greatest frustrations Dr. Garner faces as a hospitalist. “We keep putting resources into catching addicts as criminals and not getting them treatment and help before they become burdens on society,” he says.

He is pleased to note that this is changing in some states. “A few of the courts in our locale are starting to incorporate treatment programs through the court systems,” he explains.

Meth and Youth

While meth has become a popular drug among all age groups, “very few teens end up in the hospital because of meth,” says Wendy Wright, MD, a hospitalist at Rady Children’s Hospital in San Diego. “If kids are high on meth, they generally aren’t admitted when they are coming down. And, unlike many adults, they don’t have physical or medical issues that require hospitalization,” she explains. “Kids tolerate meth really well from the physical standpoint. We don’t see the arrhythmias or heart attacks that we see in adult addicts.”

When teen addicts do come in with medical conditions, Dr. Wright suggests, hospitalists often see problems such as skin or urinary tract infections. Teen meth users more frequently come to the hospital with psychiatric problems. “They have paranoid delusions, and some are fairly aggressive,” says Dr. Wright.

While hospitalists dealing with teens face the usual challenge of establishing rapport quickly, Dr. Wright observes that teens tend to be much more open than adults about their drug use. “They are pretty up front; they tell me right off the bat what drugs they use,” she says. “Of course I’m mostly seeing kids [who] aren’t living in an upper-class environment, and they’re not trying to hide things from their parents. The kids I see are streetwise and no nonsense. They have a sense of what their medical needs are and think nothing of asking for HIV or STD testing.”

Because of their youth and general good physical health, teens don’t necessarily create a burden for the hospitals and professionals who care for them. The biggest burden of meth-using teenagers, she suggests, “has to do with social issues. These kids often don’t grow into productive adults. They also have a lot of mental health issues such as bipolar disorder or severe depression, and these are the biggest burdens on the community as a whole. We also see a lot of chlamydia and gonorrhea in our kids.”

Although Dr. Wright strictly sees young patients, she acknowledges intergenerational meth use in families. Her facility sees many children who are brought into protective custody because their parents are meth users and unfit to care for them.

“These kids end up staying in the system, which is a bad place for them to be,” says Dr. Wright. “They grow up with a lot of insecurities and mental health issues, and many go on to be users themselves. While she sees many kids whose grandmothers and mothers are addicts, she believes the problem is situational and not hereditary. Nonetheless, “We’re not sure how to break this cycle,” she says.

Some kids are hospitalized because they are hurt or sick as a result of being in an unsafe environment where parents are meth users. These children are often malnourished or sick because of neglect.

Helping Hospitalists Manage Meth

It helps hospitalists if their facility has clear protocols for handling meth intoxication. “It is especially good to establish a procedure in the emergency department,” advises Dr. Rawson. He stresses that these procedures should address ways to de-escalate aggressive behavior. There are also clinical training techniques and brief interventions used to treat alcoholics that can be useful for dealing with meth addicts. These interventions involve efforts to change behaviors. Specifically, helping patients understand that their substance abuse is putting them at risk and encouraging them to reduce or stop their drug use altogether. The elements of brief interventions for substance abuse have been summarized in the acronym “FRAMES,” which stands for feedback, responsibility, advice, menu of options, empathy, and self-efficacy.

“These tools can help get people to talk about their meth problem[s] and deal with [them],” says Dr. Rawson. “Some of these brief interventions can be amazing in terms of deferring further drug use.”

Burdens of Meth

What hospitalists see in their meth-using patients depends on the maturity of the problem in their community. “In communities where the problem is newer, you are likely to see younger users and fewer physical problems,” says Dr. Rawson.

In areas where the problem has existed for years, hospitalists can expect to see older addicts with physical problems that range from heart conditions to widespread tooth decay (a condition known as “meth mouth”). The longer a community has had a meth problem, the more likely the epidemic is placing a financial burden on the healthcare system.

Dr. Garner urges his colleagues to learn about meth. “A couple of years ago, this was a nonexistent problem,” he says. “Now it has reached crisis proportions in many communities.”

Gina DiRenzo-Coffey, MD, director of inpatient pediatrics and a pediatric hospitalist at Alegent Health/Bergan Mercy Medical Center in Omaha, Neb., agrees: “You can lull yourself into believing that this can’t happen in your community. But no one has been able to stop meth use [among members of their community], and it keeps spreading. It is our job to learn everything we can about this drug and help meth addicts as much as we can.” TH

Joanne Kaldy also writes about a day in the life of a pediatric hospitalist in this issue.

Leon Reinstein, MD, has worked as a hospitalist for more than 20 years—long before the term “hospitalist” was commonly used.

Leon Reinstein, MD, was a hospitalist long before he even realized he was one. When he came to Sinai Hospital in Baltimore in 1985 to establish an inpatient rehabilitation unit, he became a staff physician. He enjoyed the opportunity to pay more attention to patient care and educational activities than to administration and business concerns, but he didn’t have a name for what he did. “I actually stumbled across the concept. I read an article about hospitalists,” he says. “And I realized that I was one.”

Following Dr. Reinstein through a day in his life as a hospitalist offers insight into what makes him so effective in his work and why—after 20 years—he continues to enjoy his role and to inspire other physicians to follow in his footsteps.

Round and Round

Dr. Reinstein, one of four hospitalists on the 46-bed unit, begins his day at 7:30 with rounds at the hospital. Unlike his colleagues in private practice, however, his hospital patients are just steps from his office. His rounds, involving mostly total joint replacement and fracture patients, take approximately 45 minutes, after which he returns to his office to write up notes. He also prepares for the daily 9:45 a.m. “morning report.” This meeting with Dr. Reinstein’s resident, Melita Moore, MD, along with representatives from nursing, social work, and physical therapy, is an opportunity to review any changes or developments from the previous evening.

One of the meeting’s goals is to prepare patients for discharge. With an average 10-day length of stay, the team has to address problems such as constipation or infections that could hinder patients’ progress and delay their release. Pain issues are also a common topic. Getting and keeping pain under control is a top priority for Dr. Reinstein and his team. When patients are comfortable, he notes, they are better able to participate in physical therapy and rehab, and they eat and sleep better.

Plugging into Patient Care

After the morning report, Dr. Reinstein gets on the computer to input some notes and check lab results. He can do this thanks to the hospital’s computerized physician order entry (CPOE) system. He loves having access to information “in a second at my fingertips.” For example, he looks up lab values for one patient and records them on a warfarin flow sheet. He then orders medication using a “quick orders” tab that gives him a choice of dosages. At the same time, he is able to view a chest X-ray for another patient.

“I’m not a computer geek, but I love this system. It’s very interactive and easy to use,” says Dr. Reinstein, adding, “It includes information on everything from allergies and patient alerts to diet, activities, and diagnostic tests.” He spends about 15%-20% of his day at the computer.

Leon Reinstein, MD, has worked as a hospitalist for more than 20 years—long before the term “hospitalist” was commonly used.

Afternoon: The Pace Picks up

After a quick lunch, during which he catches up with his fellow hospitalists and other colleagues, Dr. Reinstein begins his busy afternoon. On Wednesday, this starts with a 12:30 team conference. This is an important meeting in which all of the team members—social workers, physical therapists, occupational therapists, nurses, and Dr. Reinstein’s resident—meet to discuss every patient in detail and prepare each for discharge.

At the meeting, conversations focus on patient functioning, physical therapy progress, medical condition, and pain control. The group discusses arrangements for community support and/or family education needs for some patients and subacute care options for others. The team also addresses patient goals and how they can help meet these. For example, one patient has requested an assistive device. While the equipment is not considered medically necessary by the insurance company, the group discusses how to arrange this in order to satisfy the patient’s wishes.

Afternoon Consults

Following the team conference, Dr. Reinstein spends most of the afternoon on consults. Today, he has been asked to see a number of patients in order to determine if admission to the rehab unit is appropriate for each one. Patients’ attending physicians make these referrals, and Dr. Reinstein works with them to make a final decision. In a typical day, he sees five to six new consults—most of them the day after surgery. At the same time, he follows up with four to five patients a few days after he first saw them to check progress, finalize decisions, and—when appropriate—prepare them to transfer to the rehab unit.

“I try to see the patients first who will be admitted to our unit today. We want to do the admits earlier. There are staff onsite to help them settle in, and it frees a bed for the hospital,” explains Dr. Reinstein.

Each consult starts with the patient’s chart, which he reviews carefully. In addition to medical issues, he looks at relevant social information, such as whether the patient lives in an apartment or a two-story house. This can affect goals and how much rehab the patient will need to function post-discharge. Dr. Reinstein checks medication regimens, vital signs, lab data, and other information on a nearby COW (or computer on wheels). These are located throughout the facility for easy access by clinicians.

After pulling and reviewing the chart, Dr. Reinstein goes to the patient’s room armed with a special form he uses to record his assessments and final recommendation. Following a greeting, he conducts a brief physical exam and asks the patient about pain and other relevant issues. He also considers weight-bearing status, a big issue in rehab.

The consults, which can take several hours, usually result in some new admissions to the rehab unit and the need for some follow-up visits that he will have to conduct in two or three days.

Leon Reinstein, MD, has worked as a hospitalist for more than 20 years—long before the term “hospitalist” was commonly used.

System Challenges

Preparing patients for discharge can be like playing “Beat the Clock” for Dr. Reinstein and his team. “Insurance companies will only approve a certain number of days, and there have to be strong medical reasons for an extended stay before they will pay,” he says. He emphasizes that his decisions are based on several factors that have to do with the patient’s well being and health rather than on an insurance company’s criteria. He also stresses that the patient is part of this decision making.

In particular, he mentions one individual who was waiting for an assistive device and expressed concern about going home before she had it and could get used to it. “I’m not going to push someone like this out the door,” he says. “We have to weigh the pros and cons and—ultimately—do what is best for each individual patient.”

Most of Dr. Reinstein’s patients—the majority of whom are 65 and older—want to get back to their homes and communities, and the team works hard to make that happen. In fact, 80% of patients are discharged to the community, with 20% going to a nursing facility or subacute unit.

Private insurance companies require prior authorization before patients can be admitted to the rehab unit following surgery or a fracture. “The main problem here arises when the insurance company decides that the patient doesn’t need this level of rehab,” says Dr. Reinstein. “At this point, we have to sit down with patients and families [and discuss] the options—including self-pay or transfer to a less expensive subacute facility.”

Hospital rehab can be expensive—up to $1,000 per day—so payment plans are often part of the discussion.

The majority of Dr. Reinstein’s patients have Medicare insurance, and this has some advantages because these individuals don’t need prior authorization to enter the rehab unit after surgery. Of course, he adds, Medicare does have a right to conduct a post review.

With Medicare patients comes the Medicare prescription drug benefit, and this has presented some challenges for Dr. Reinstein. He recalls one patient whose drug plan refused coverage for a prescription medication. Frustrated and in pain, she called Dr. Reinstein in a panic. He contacted the drug plan and tried to wade quickly through the red tape, but was unable to help. In frustration, he finally suggested that the patient contact her Congressional representative. She called Dr. Reinstein back an hour later to say that she had gotten her prescription filled. “Sometimes you have to be persistent and creative to get things done,” he says.

Dr. Reinstein has a great deal of experience fighting claim denials and other insurance-related issues, and he is not afraid to go to bat for his patients. “If I think there is a medical reason to keep the patient here, I will do so,” says Dr. Reinstein. “And I will fight the insurance company later.”

Of course, dealing with insurance companies isn’t his only challenge. In fact, Dr. Reinstein notes that his major frustration is that “I set high standards for myself and others. Sometimes, things don’t work the way I would like them to. I want everything done right, and I can’t control all of the details.” He adds that such frustration “is not unique to this setting. It actually is a larger societal issue that we all face.”

Smooth the Way with Communication

Working—and potentially clashing—with private-practice physicians can be a challenge for many hospitalists. Dr. Reinstein has mastered this skill.

“The key to working with primary-care doctors is communication,” he says. “The first thing we do here is to write on the patient’s chart all of the physicians involved in his or her care—their specialt[ies], phone number[s], and so on. Then we keep these practitioners abreast and involved. The patient’s primary care doctor may have seen this person for 20 years and knows things that we don’t, so reviewing issues with this practitioner is key.”

Dr. Reinstein also stresses communication as part of ensuring a smooth transition from the hospital to community care. For example, “We type a discharge summary on discharge day,” he says. “We give a copy to the patient and fax or mail one to his or her referring physician. We also keep a computerized copy.”

He also has the patient’s family bring in the bottles for all of the medications the patient is taking, and he goes over every one to make sure prescriptions are up to date, filled as necessary, and not likely to interact with other medications. “This only takes a few minutes, and it is an important part of great patient care,” he explains.

What Keeps Him Going?

“I take a lot of personal satisfaction in my work here,” says Dr. Reinstein. “When patients come here, they can’t do much. When they leave, they are prepared to take care of themselves. We make sure that they have the level of functioning, medications, assistance, and personal confidence they need to continue their progress and resume their lives.”

Watching his community-based colleagues rush from the hospital back to their offices or to other hospitals, Dr. Reinstein appreciates the fact that he spends his entire day at one facility.

“I don’t have to spend time running around from place to place, so I get to spend more time on direct patient care,” he says. “That is a real plus for me.” At the same time, being part of an institution means that “everything happens right away. If someone has chest pains, I’m there in a few minutes. I can order tests, have them done, and get results back quickly.”

Dr. Reinstein likes the control he has over his schedule: “I don’t have the same time pressures that you do in private practice. Basically, by the end of the day, I need to have seen all consults and follow-ups. But I can pace myself.”

He also likes the abundance of educational opportunities he has at Sinai. “I can conduct and participate in educational activities without leaving the building,” he says. He also enjoys working with residents and providing hands-on teaching.

Not having to deal with the business aspects of private practice is another advantage for Dr. Reinstein. “I’m salaried by the hospital, and my position removes me from a lot of the economics of medicine,” he explains. “For example, I complete a billing form on each patient every day, but that’s my only dealing with the billing. I don’t have to worry about census, overhead, hiring or firing staff, or the bottom line.

“You’re not your own boss, and some see this as a disadvantage,” cautions Dr. Reinstein. “A lot people become physicians because they want to be their own boss. This is the antithesis of that. You are part of a company.”

Overall, however, the advantages of hospitalist life far outweigh the disadvantages. “I get a lot of personal satisfaction from my work, I get to work with a consistent team, and I get four weeks of vacation,” he says. He adds that when he goes on vacation, he doesn’t have to worry about his patients. He knows that they are cared for and that his department is running smoothly in his absence.

Despite his enthusiasm for his work as a hospitalist, not all of Dr. Reinstein’s residents follow in his footsteps. “The ambulatory/orthopedic field is very lucrative and more attractive to many,” he says. “Being a hospitalist is not for everyone, and some want the experience of being in private practice.”

The Day Is Done: Satisfaction

“You have to decide how you want to live your life and what you want to do. I follow my own pace,” says Dr. Reinstein. “I do work I love. I collect a steady paycheck and get to focus on caring for my patients.”

His work day is long; but at the end, he gets to go home to his wife of 39 years knowing he made a difference today and that he will return to the same place and work with the same team to make a difference tomorrow. TH

Joanne Kaldy is frequent contributor to The Hospitalist.

Leon Reinstein, MD, has worked as a hospitalist for more than 20 years—long before the term “hospitalist” was commonly used.

Leon Reinstein, MD, was a hospitalist long before he even realized he was one. When he came to Sinai Hospital in Baltimore in 1985 to establish an inpatient rehabilitation unit, he became a staff physician. He enjoyed the opportunity to pay more attention to patient care and educational activities than to administration and business concerns, but he didn’t have a name for what he did. “I actually stumbled across the concept. I read an article about hospitalists,” he says. “And I realized that I was one.”

Following Dr. Reinstein through a day in his life as a hospitalist offers insight into what makes him so effective in his work and why—after 20 years—he continues to enjoy his role and to inspire other physicians to follow in his footsteps.

Round and Round

Dr. Reinstein, one of four hospitalists on the 46-bed unit, begins his day at 7:30 with rounds at the hospital. Unlike his colleagues in private practice, however, his hospital patients are just steps from his office. His rounds, involving mostly total joint replacement and fracture patients, take approximately 45 minutes, after which he returns to his office to write up notes. He also prepares for the daily 9:45 a.m. “morning report.” This meeting with Dr. Reinstein’s resident, Melita Moore, MD, along with representatives from nursing, social work, and physical therapy, is an opportunity to review any changes or developments from the previous evening.

One of the meeting’s goals is to prepare patients for discharge. With an average 10-day length of stay, the team has to address problems such as constipation or infections that could hinder patients’ progress and delay their release. Pain issues are also a common topic. Getting and keeping pain under control is a top priority for Dr. Reinstein and his team. When patients are comfortable, he notes, they are better able to participate in physical therapy and rehab, and they eat and sleep better.

Plugging into Patient Care

After the morning report, Dr. Reinstein gets on the computer to input some notes and check lab results. He can do this thanks to the hospital’s computerized physician order entry (CPOE) system. He loves having access to information “in a second at my fingertips.” For example, he looks up lab values for one patient and records them on a warfarin flow sheet. He then orders medication using a “quick orders” tab that gives him a choice of dosages. At the same time, he is able to view a chest X-ray for another patient.

“I’m not a computer geek, but I love this system. It’s very interactive and easy to use,” says Dr. Reinstein, adding, “It includes information on everything from allergies and patient alerts to diet, activities, and diagnostic tests.” He spends about 15%-20% of his day at the computer.

Leon Reinstein, MD, has worked as a hospitalist for more than 20 years—long before the term “hospitalist” was commonly used.

Afternoon: The Pace Picks up

After a quick lunch, during which he catches up with his fellow hospitalists and other colleagues, Dr. Reinstein begins his busy afternoon. On Wednesday, this starts with a 12:30 team conference. This is an important meeting in which all of the team members—social workers, physical therapists, occupational therapists, nurses, and Dr. Reinstein’s resident—meet to discuss every patient in detail and prepare each for discharge.

At the meeting, conversations focus on patient functioning, physical therapy progress, medical condition, and pain control. The group discusses arrangements for community support and/or family education needs for some patients and subacute care options for others. The team also addresses patient goals and how they can help meet these. For example, one patient has requested an assistive device. While the equipment is not considered medically necessary by the insurance company, the group discusses how to arrange this in order to satisfy the patient’s wishes.

Afternoon Consults

Following the team conference, Dr. Reinstein spends most of the afternoon on consults. Today, he has been asked to see a number of patients in order to determine if admission to the rehab unit is appropriate for each one. Patients’ attending physicians make these referrals, and Dr. Reinstein works with them to make a final decision. In a typical day, he sees five to six new consults—most of them the day after surgery. At the same time, he follows up with four to five patients a few days after he first saw them to check progress, finalize decisions, and—when appropriate—prepare them to transfer to the rehab unit.

“I try to see the patients first who will be admitted to our unit today. We want to do the admits earlier. There are staff onsite to help them settle in, and it frees a bed for the hospital,” explains Dr. Reinstein.

Each consult starts with the patient’s chart, which he reviews carefully. In addition to medical issues, he looks at relevant social information, such as whether the patient lives in an apartment or a two-story house. This can affect goals and how much rehab the patient will need to function post-discharge. Dr. Reinstein checks medication regimens, vital signs, lab data, and other information on a nearby COW (or computer on wheels). These are located throughout the facility for easy access by clinicians.

After pulling and reviewing the chart, Dr. Reinstein goes to the patient’s room armed with a special form he uses to record his assessments and final recommendation. Following a greeting, he conducts a brief physical exam and asks the patient about pain and other relevant issues. He also considers weight-bearing status, a big issue in rehab.

The consults, which can take several hours, usually result in some new admissions to the rehab unit and the need for some follow-up visits that he will have to conduct in two or three days.

Leon Reinstein, MD, has worked as a hospitalist for more than 20 years—long before the term “hospitalist” was commonly used.

System Challenges

Preparing patients for discharge can be like playing “Beat the Clock” for Dr. Reinstein and his team. “Insurance companies will only approve a certain number of days, and there have to be strong medical reasons for an extended stay before they will pay,” he says. He emphasizes that his decisions are based on several factors that have to do with the patient’s well being and health rather than on an insurance company’s criteria. He also stresses that the patient is part of this decision making.

In particular, he mentions one individual who was waiting for an assistive device and expressed concern about going home before she had it and could get used to it. “I’m not going to push someone like this out the door,” he says. “We have to weigh the pros and cons and—ultimately—do what is best for each individual patient.”

Most of Dr. Reinstein’s patients—the majority of whom are 65 and older—want to get back to their homes and communities, and the team works hard to make that happen. In fact, 80% of patients are discharged to the community, with 20% going to a nursing facility or subacute unit.

Private insurance companies require prior authorization before patients can be admitted to the rehab unit following surgery or a fracture. “The main problem here arises when the insurance company decides that the patient doesn’t need this level of rehab,” says Dr. Reinstein. “At this point, we have to sit down with patients and families [and discuss] the options—including self-pay or transfer to a less expensive subacute facility.”

Hospital rehab can be expensive—up to $1,000 per day—so payment plans are often part of the discussion.

The majority of Dr. Reinstein’s patients have Medicare insurance, and this has some advantages because these individuals don’t need prior authorization to enter the rehab unit after surgery. Of course, he adds, Medicare does have a right to conduct a post review.

With Medicare patients comes the Medicare prescription drug benefit, and this has presented some challenges for Dr. Reinstein. He recalls one patient whose drug plan refused coverage for a prescription medication. Frustrated and in pain, she called Dr. Reinstein in a panic. He contacted the drug plan and tried to wade quickly through the red tape, but was unable to help. In frustration, he finally suggested that the patient contact her Congressional representative. She called Dr. Reinstein back an hour later to say that she had gotten her prescription filled. “Sometimes you have to be persistent and creative to get things done,” he says.

Dr. Reinstein has a great deal of experience fighting claim denials and other insurance-related issues, and he is not afraid to go to bat for his patients. “If I think there is a medical reason to keep the patient here, I will do so,” says Dr. Reinstein. “And I will fight the insurance company later.”

Of course, dealing with insurance companies isn’t his only challenge. In fact, Dr. Reinstein notes that his major frustration is that “I set high standards for myself and others. Sometimes, things don’t work the way I would like them to. I want everything done right, and I can’t control all of the details.” He adds that such frustration “is not unique to this setting. It actually is a larger societal issue that we all face.”

Smooth the Way with Communication

Working—and potentially clashing—with private-practice physicians can be a challenge for many hospitalists. Dr. Reinstein has mastered this skill.

“The key to working with primary-care doctors is communication,” he says. “The first thing we do here is to write on the patient’s chart all of the physicians involved in his or her care—their specialt[ies], phone number[s], and so on. Then we keep these practitioners abreast and involved. The patient’s primary care doctor may have seen this person for 20 years and knows things that we don’t, so reviewing issues with this practitioner is key.”

Dr. Reinstein also stresses communication as part of ensuring a smooth transition from the hospital to community care. For example, “We type a discharge summary on discharge day,” he says. “We give a copy to the patient and fax or mail one to his or her referring physician. We also keep a computerized copy.”

He also has the patient’s family bring in the bottles for all of the medications the patient is taking, and he goes over every one to make sure prescriptions are up to date, filled as necessary, and not likely to interact with other medications. “This only takes a few minutes, and it is an important part of great patient care,” he explains.

What Keeps Him Going?

“I take a lot of personal satisfaction in my work here,” says Dr. Reinstein. “When patients come here, they can’t do much. When they leave, they are prepared to take care of themselves. We make sure that they have the level of functioning, medications, assistance, and personal confidence they need to continue their progress and resume their lives.”

Watching his community-based colleagues rush from the hospital back to their offices or to other hospitals, Dr. Reinstein appreciates the fact that he spends his entire day at one facility.

“I don’t have to spend time running around from place to place, so I get to spend more time on direct patient care,” he says. “That is a real plus for me.” At the same time, being part of an institution means that “everything happens right away. If someone has chest pains, I’m there in a few minutes. I can order tests, have them done, and get results back quickly.”

Dr. Reinstein likes the control he has over his schedule: “I don’t have the same time pressures that you do in private practice. Basically, by the end of the day, I need to have seen all consults and follow-ups. But I can pace myself.”

He also likes the abundance of educational opportunities he has at Sinai. “I can conduct and participate in educational activities without leaving the building,” he says. He also enjoys working with residents and providing hands-on teaching.

Not having to deal with the business aspects of private practice is another advantage for Dr. Reinstein. “I’m salaried by the hospital, and my position removes me from a lot of the economics of medicine,” he explains. “For example, I complete a billing form on each patient every day, but that’s my only dealing with the billing. I don’t have to worry about census, overhead, hiring or firing staff, or the bottom line.

“You’re not your own boss, and some see this as a disadvantage,” cautions Dr. Reinstein. “A lot people become physicians because they want to be their own boss. This is the antithesis of that. You are part of a company.”

Overall, however, the advantages of hospitalist life far outweigh the disadvantages. “I get a lot of personal satisfaction from my work, I get to work with a consistent team, and I get four weeks of vacation,” he says. He adds that when he goes on vacation, he doesn’t have to worry about his patients. He knows that they are cared for and that his department is running smoothly in his absence.

Despite his enthusiasm for his work as a hospitalist, not all of Dr. Reinstein’s residents follow in his footsteps. “The ambulatory/orthopedic field is very lucrative and more attractive to many,” he says. “Being a hospitalist is not for everyone, and some want the experience of being in private practice.”

The Day Is Done: Satisfaction

“You have to decide how you want to live your life and what you want to do. I follow my own pace,” says Dr. Reinstein. “I do work I love. I collect a steady paycheck and get to focus on caring for my patients.”

His work day is long; but at the end, he gets to go home to his wife of 39 years knowing he made a difference today and that he will return to the same place and work with the same team to make a difference tomorrow. TH

Joanne Kaldy is frequent contributor to The Hospitalist.

Leon Reinstein, MD, has worked as a hospitalist for more than 20 years—long before the term “hospitalist” was commonly used.

Leon Reinstein, MD, was a hospitalist long before he even realized he was one. When he came to Sinai Hospital in Baltimore in 1985 to establish an inpatient rehabilitation unit, he became a staff physician. He enjoyed the opportunity to pay more attention to patient care and educational activities than to administration and business concerns, but he didn’t have a name for what he did. “I actually stumbled across the concept. I read an article about hospitalists,” he says. “And I realized that I was one.”

Following Dr. Reinstein through a day in his life as a hospitalist offers insight into what makes him so effective in his work and why—after 20 years—he continues to enjoy his role and to inspire other physicians to follow in his footsteps.

Round and Round

Dr. Reinstein, one of four hospitalists on the 46-bed unit, begins his day at 7:30 with rounds at the hospital. Unlike his colleagues in private practice, however, his hospital patients are just steps from his office. His rounds, involving mostly total joint replacement and fracture patients, take approximately 45 minutes, after which he returns to his office to write up notes. He also prepares for the daily 9:45 a.m. “morning report.” This meeting with Dr. Reinstein’s resident, Melita Moore, MD, along with representatives from nursing, social work, and physical therapy, is an opportunity to review any changes or developments from the previous evening.

One of the meeting’s goals is to prepare patients for discharge. With an average 10-day length of stay, the team has to address problems such as constipation or infections that could hinder patients’ progress and delay their release. Pain issues are also a common topic. Getting and keeping pain under control is a top priority for Dr. Reinstein and his team. When patients are comfortable, he notes, they are better able to participate in physical therapy and rehab, and they eat and sleep better.

Plugging into Patient Care

After the morning report, Dr. Reinstein gets on the computer to input some notes and check lab results. He can do this thanks to the hospital’s computerized physician order entry (CPOE) system. He loves having access to information “in a second at my fingertips.” For example, he looks up lab values for one patient and records them on a warfarin flow sheet. He then orders medication using a “quick orders” tab that gives him a choice of dosages. At the same time, he is able to view a chest X-ray for another patient.

“I’m not a computer geek, but I love this system. It’s very interactive and easy to use,” says Dr. Reinstein, adding, “It includes information on everything from allergies and patient alerts to diet, activities, and diagnostic tests.” He spends about 15%-20% of his day at the computer.

Leon Reinstein, MD, has worked as a hospitalist for more than 20 years—long before the term “hospitalist” was commonly used.

Afternoon: The Pace Picks up

After a quick lunch, during which he catches up with his fellow hospitalists and other colleagues, Dr. Reinstein begins his busy afternoon. On Wednesday, this starts with a 12:30 team conference. This is an important meeting in which all of the team members—social workers, physical therapists, occupational therapists, nurses, and Dr. Reinstein’s resident—meet to discuss every patient in detail and prepare each for discharge.

At the meeting, conversations focus on patient functioning, physical therapy progress, medical condition, and pain control. The group discusses arrangements for community support and/or family education needs for some patients and subacute care options for others. The team also addresses patient goals and how they can help meet these. For example, one patient has requested an assistive device. While the equipment is not considered medically necessary by the insurance company, the group discusses how to arrange this in order to satisfy the patient’s wishes.

Afternoon Consults

Following the team conference, Dr. Reinstein spends most of the afternoon on consults. Today, he has been asked to see a number of patients in order to determine if admission to the rehab unit is appropriate for each one. Patients’ attending physicians make these referrals, and Dr. Reinstein works with them to make a final decision. In a typical day, he sees five to six new consults—most of them the day after surgery. At the same time, he follows up with four to five patients a few days after he first saw them to check progress, finalize decisions, and—when appropriate—prepare them to transfer to the rehab unit.

“I try to see the patients first who will be admitted to our unit today. We want to do the admits earlier. There are staff onsite to help them settle in, and it frees a bed for the hospital,” explains Dr. Reinstein.

Each consult starts with the patient’s chart, which he reviews carefully. In addition to medical issues, he looks at relevant social information, such as whether the patient lives in an apartment or a two-story house. This can affect goals and how much rehab the patient will need to function post-discharge. Dr. Reinstein checks medication regimens, vital signs, lab data, and other information on a nearby COW (or computer on wheels). These are located throughout the facility for easy access by clinicians.

After pulling and reviewing the chart, Dr. Reinstein goes to the patient’s room armed with a special form he uses to record his assessments and final recommendation. Following a greeting, he conducts a brief physical exam and asks the patient about pain and other relevant issues. He also considers weight-bearing status, a big issue in rehab.

The consults, which can take several hours, usually result in some new admissions to the rehab unit and the need for some follow-up visits that he will have to conduct in two or three days.

Leon Reinstein, MD, has worked as a hospitalist for more than 20 years—long before the term “hospitalist” was commonly used.

System Challenges

Preparing patients for discharge can be like playing “Beat the Clock” for Dr. Reinstein and his team. “Insurance companies will only approve a certain number of days, and there have to be strong medical reasons for an extended stay before they will pay,” he says. He emphasizes that his decisions are based on several factors that have to do with the patient’s well being and health rather than on an insurance company’s criteria. He also stresses that the patient is part of this decision making.

In particular, he mentions one individual who was waiting for an assistive device and expressed concern about going home before she had it and could get used to it. “I’m not going to push someone like this out the door,” he says. “We have to weigh the pros and cons and—ultimately—do what is best for each individual patient.”

Most of Dr. Reinstein’s patients—the majority of whom are 65 and older—want to get back to their homes and communities, and the team works hard to make that happen. In fact, 80% of patients are discharged to the community, with 20% going to a nursing facility or subacute unit.

Private insurance companies require prior authorization before patients can be admitted to the rehab unit following surgery or a fracture. “The main problem here arises when the insurance company decides that the patient doesn’t need this level of rehab,” says Dr. Reinstein. “At this point, we have to sit down with patients and families [and discuss] the options—including self-pay or transfer to a less expensive subacute facility.”

Hospital rehab can be expensive—up to $1,000 per day—so payment plans are often part of the discussion.

The majority of Dr. Reinstein’s patients have Medicare insurance, and this has some advantages because these individuals don’t need prior authorization to enter the rehab unit after surgery. Of course, he adds, Medicare does have a right to conduct a post review.

With Medicare patients comes the Medicare prescription drug benefit, and this has presented some challenges for Dr. Reinstein. He recalls one patient whose drug plan refused coverage for a prescription medication. Frustrated and in pain, she called Dr. Reinstein in a panic. He contacted the drug plan and tried to wade quickly through the red tape, but was unable to help. In frustration, he finally suggested that the patient contact her Congressional representative. She called Dr. Reinstein back an hour later to say that she had gotten her prescription filled. “Sometimes you have to be persistent and creative to get things done,” he says.

Dr. Reinstein has a great deal of experience fighting claim denials and other insurance-related issues, and he is not afraid to go to bat for his patients. “If I think there is a medical reason to keep the patient here, I will do so,” says Dr. Reinstein. “And I will fight the insurance company later.”

Of course, dealing with insurance companies isn’t his only challenge. In fact, Dr. Reinstein notes that his major frustration is that “I set high standards for myself and others. Sometimes, things don’t work the way I would like them to. I want everything done right, and I can’t control all of the details.” He adds that such frustration “is not unique to this setting. It actually is a larger societal issue that we all face.”

Smooth the Way with Communication

Working—and potentially clashing—with private-practice physicians can be a challenge for many hospitalists. Dr. Reinstein has mastered this skill.

“The key to working with primary-care doctors is communication,” he says. “The first thing we do here is to write on the patient’s chart all of the physicians involved in his or her care—their specialt[ies], phone number[s], and so on. Then we keep these practitioners abreast and involved. The patient’s primary care doctor may have seen this person for 20 years and knows things that we don’t, so reviewing issues with this practitioner is key.”

Dr. Reinstein also stresses communication as part of ensuring a smooth transition from the hospital to community care. For example, “We type a discharge summary on discharge day,” he says. “We give a copy to the patient and fax or mail one to his or her referring physician. We also keep a computerized copy.”

He also has the patient’s family bring in the bottles for all of the medications the patient is taking, and he goes over every one to make sure prescriptions are up to date, filled as necessary, and not likely to interact with other medications. “This only takes a few minutes, and it is an important part of great patient care,” he explains.

What Keeps Him Going?

“I take a lot of personal satisfaction in my work here,” says Dr. Reinstein. “When patients come here, they can’t do much. When they leave, they are prepared to take care of themselves. We make sure that they have the level of functioning, medications, assistance, and personal confidence they need to continue their progress and resume their lives.”

Watching his community-based colleagues rush from the hospital back to their offices or to other hospitals, Dr. Reinstein appreciates the fact that he spends his entire day at one facility.

“I don’t have to spend time running around from place to place, so I get to spend more time on direct patient care,” he says. “That is a real plus for me.” At the same time, being part of an institution means that “everything happens right away. If someone has chest pains, I’m there in a few minutes. I can order tests, have them done, and get results back quickly.”

Dr. Reinstein likes the control he has over his schedule: “I don’t have the same time pressures that you do in private practice. Basically, by the end of the day, I need to have seen all consults and follow-ups. But I can pace myself.”

He also likes the abundance of educational opportunities he has at Sinai. “I can conduct and participate in educational activities without leaving the building,” he says. He also enjoys working with residents and providing hands-on teaching.

Not having to deal with the business aspects of private practice is another advantage for Dr. Reinstein. “I’m salaried by the hospital, and my position removes me from a lot of the economics of medicine,” he explains. “For example, I complete a billing form on each patient every day, but that’s my only dealing with the billing. I don’t have to worry about census, overhead, hiring or firing staff, or the bottom line.

“You’re not your own boss, and some see this as a disadvantage,” cautions Dr. Reinstein. “A lot people become physicians because they want to be their own boss. This is the antithesis of that. You are part of a company.”

Overall, however, the advantages of hospitalist life far outweigh the disadvantages. “I get a lot of personal satisfaction from my work, I get to work with a consistent team, and I get four weeks of vacation,” he says. He adds that when he goes on vacation, he doesn’t have to worry about his patients. He knows that they are cared for and that his department is running smoothly in his absence.

Despite his enthusiasm for his work as a hospitalist, not all of Dr. Reinstein’s residents follow in his footsteps. “The ambulatory/orthopedic field is very lucrative and more attractive to many,” he says. “Being a hospitalist is not for everyone, and some want the experience of being in private practice.”

The Day Is Done: Satisfaction

“You have to decide how you want to live your life and what you want to do. I follow my own pace,” says Dr. Reinstein. “I do work I love. I collect a steady paycheck and get to focus on caring for my patients.”

His work day is long; but at the end, he gets to go home to his wife of 39 years knowing he made a difference today and that he will return to the same place and work with the same team to make a difference tomorrow. TH

Joanne Kaldy is frequent contributor to The Hospitalist.

Dr. Pantilat

Increasingly, hospitals are making palliative care a priority; and more hospitalists are getting involved in providing these services and taking the lead on establishing and facilitating palliative care programs. Among the growing evidence that hospitalists are viewed as key players in the proliferation of hospital palliative care programs is the appointment of Steven Pantilat, MD, associate professor of clinical medicine, to the newly established Alan M. Kates and John M. Burnard Endowed Chair in Palliative Care at the University of California at San Francisco (UCSF).

The chair is the first palliative care chair in the University of California system and only the fifth nationwide. The endowment provides funding for salary support and efforts to build clinical, educational, research, and training components of the UCSF palliative care program. “This chair is important because hospitalists are often the main source of hospital palliative care services,” explains Dr. Pantilat. “Because I am a hospitalist, I understand the needs of these practitioners.”

Numerous Plans, Expectations

Dr. Pantilat has several expectations for what the chair will enable him to accomplish. “We hope to improve palliative care for patients, contribute to the field in terms of research and educational initiatives, and help UC advance in these areas,” he says. “Our main goal is to develop a world-class palliative care program that will advance the field in terms of education, research, and patient care and to provide the highest quality care to patients with life-threatening illness. This will provide seed money to develop educational and research programs that require some early investment when they are just ideas.”

There is a tremendous need for more and better palliative care in the hospital setting. “Patients have many needs, including management of symptoms such as shortness of breath, nausea, and fatigue,” he says. “There isn’t nearly enough research or information on these problems as compared to pain. We need more studies on the best way to treat symptoms.”

Additionally, Dr. Pantilat hopes to add to the body of literature on patient-physician communication, suggesting that hospitalists and other physicians need information about how to communicate sensitive issues such as bad news and how best to support patients and families throughout illnesses and fill their palliative care needs.

“We hope to develop and encourage more education and training on these topics,” he says. Stressing that there already are good educational programs about palliative care topics, Dr. Pantilat notes the need for more instruction specific to the unique needs of hospitalized patients and the hospitalists who care for them.

Create an Interdisciplinary System

“We need systems to provide palliative care. We also need to sensitize everyone who works in the hospital to comfort care issues,” says Dr. Pantilat, adding that there also is a need for programs and systems to ensure that patients and families will get the palliative care they need when they leave the hospital. “We need to work together to create a smooth transition from inpatient to outpatient palliative care. And we need to consider how we, as hospitalists, work with patients in the outpatient setting to ensure that someone is there to take care of them and their needs.”

Many of these needs require widespread education and training. “This grant will allow us to develop more robust and innovative educational efforts that engage ways to teach all team members about palliative care,” says Dr. Pantilat. “This will include projects such as using the Web to teach students.”

Expand the Definition

Dr. Pantilat also hopes to help expand the definition of palliative care and help people understand this as a broad concept of providing interdisciplinary care for people with terminal and chronic diseases. “An important point that we hope to emphasize is that palliative care is not just end-of-life care but something designed to improve life for people with illnesses—particularly chronic illnesses—either through the treatment of the diseases or the symptoms. It is an attempt to alleviate physical, emotional, and psychological suffering and promote the best possible quality of life,” he explains.

Helping people get “past the old limiting idea of palliative care” is another key goal. “A lot of palliative care can be provided while people are pursuing curative care,” explains Dr. Pantilat. “This is an important concept to promote.”

The Hospitalist’s Role

As a hospitalist, Dr. Pantilat also hopes to promote the growing recognition of the importance of hospitalists in palliative care programs: “The beautiful thing is that hospitalists are perfectly poised to handle palliative care programs, and with training they can become palliative care providers.”

The endowed chair reflects the importance of hospitalists in the palliative care field. “Hospitalists will be increasingly important in this area, and I hope to take a leadership role,” he says. While he is pleased and honored to have the chair at UCSF, he is confident that his work will have an impact well beyond his own university. “The chair will bring much recognition to our program but also to the field of palliative care in general and the role of hospitalists nationwide.” TH

Joanne Kaldy writes regularly for The Hospitalist.

Dr. Pantilat

Increasingly, hospitals are making palliative care a priority; and more hospitalists are getting involved in providing these services and taking the lead on establishing and facilitating palliative care programs. Among the growing evidence that hospitalists are viewed as key players in the proliferation of hospital palliative care programs is the appointment of Steven Pantilat, MD, associate professor of clinical medicine, to the newly established Alan M. Kates and John M. Burnard Endowed Chair in Palliative Care at the University of California at San Francisco (UCSF).

The chair is the first palliative care chair in the University of California system and only the fifth nationwide. The endowment provides funding for salary support and efforts to build clinical, educational, research, and training components of the UCSF palliative care program. “This chair is important because hospitalists are often the main source of hospital palliative care services,” explains Dr. Pantilat. “Because I am a hospitalist, I understand the needs of these practitioners.”

Numerous Plans, Expectations

Dr. Pantilat has several expectations for what the chair will enable him to accomplish. “We hope to improve palliative care for patients, contribute to the field in terms of research and educational initiatives, and help UC advance in these areas,” he says. “Our main goal is to develop a world-class palliative care program that will advance the field in terms of education, research, and patient care and to provide the highest quality care to patients with life-threatening illness. This will provide seed money to develop educational and research programs that require some early investment when they are just ideas.”

There is a tremendous need for more and better palliative care in the hospital setting. “Patients have many needs, including management of symptoms such as shortness of breath, nausea, and fatigue,” he says. “There isn’t nearly enough research or information on these problems as compared to pain. We need more studies on the best way to treat symptoms.”

Additionally, Dr. Pantilat hopes to add to the body of literature on patient-physician communication, suggesting that hospitalists and other physicians need information about how to communicate sensitive issues such as bad news and how best to support patients and families throughout illnesses and fill their palliative care needs.

“We hope to develop and encourage more education and training on these topics,” he says. Stressing that there already are good educational programs about palliative care topics, Dr. Pantilat notes the need for more instruction specific to the unique needs of hospitalized patients and the hospitalists who care for them.

Create an Interdisciplinary System

“We need systems to provide palliative care. We also need to sensitize everyone who works in the hospital to comfort care issues,” says Dr. Pantilat, adding that there also is a need for programs and systems to ensure that patients and families will get the palliative care they need when they leave the hospital. “We need to work together to create a smooth transition from inpatient to outpatient palliative care. And we need to consider how we, as hospitalists, work with patients in the outpatient setting to ensure that someone is there to take care of them and their needs.”

Many of these needs require widespread education and training. “This grant will allow us to develop more robust and innovative educational efforts that engage ways to teach all team members about palliative care,” says Dr. Pantilat. “This will include projects such as using the Web to teach students.”

Expand the Definition

Dr. Pantilat also hopes to help expand the definition of palliative care and help people understand this as a broad concept of providing interdisciplinary care for people with terminal and chronic diseases. “An important point that we hope to emphasize is that palliative care is not just end-of-life care but something designed to improve life for people with illnesses—particularly chronic illnesses—either through the treatment of the diseases or the symptoms. It is an attempt to alleviate physical, emotional, and psychological suffering and promote the best possible quality of life,” he explains.

Helping people get “past the old limiting idea of palliative care” is another key goal. “A lot of palliative care can be provided while people are pursuing curative care,” explains Dr. Pantilat. “This is an important concept to promote.”

The Hospitalist’s Role

As a hospitalist, Dr. Pantilat also hopes to promote the growing recognition of the importance of hospitalists in palliative care programs: “The beautiful thing is that hospitalists are perfectly poised to handle palliative care programs, and with training they can become palliative care providers.”

The endowed chair reflects the importance of hospitalists in the palliative care field. “Hospitalists will be increasingly important in this area, and I hope to take a leadership role,” he says. While he is pleased and honored to have the chair at UCSF, he is confident that his work will have an impact well beyond his own university. “The chair will bring much recognition to our program but also to the field of palliative care in general and the role of hospitalists nationwide.” TH

Joanne Kaldy writes regularly for The Hospitalist.

Dr. Pantilat

Increasingly, hospitals are making palliative care a priority; and more hospitalists are getting involved in providing these services and taking the lead on establishing and facilitating palliative care programs. Among the growing evidence that hospitalists are viewed as key players in the proliferation of hospital palliative care programs is the appointment of Steven Pantilat, MD, associate professor of clinical medicine, to the newly established Alan M. Kates and John M. Burnard Endowed Chair in Palliative Care at the University of California at San Francisco (UCSF).

The chair is the first palliative care chair in the University of California system and only the fifth nationwide. The endowment provides funding for salary support and efforts to build clinical, educational, research, and training components of the UCSF palliative care program. “This chair is important because hospitalists are often the main source of hospital palliative care services,” explains Dr. Pantilat. “Because I am a hospitalist, I understand the needs of these practitioners.”

Numerous Plans, Expectations

Dr. Pantilat has several expectations for what the chair will enable him to accomplish. “We hope to improve palliative care for patients, contribute to the field in terms of research and educational initiatives, and help UC advance in these areas,” he says. “Our main goal is to develop a world-class palliative care program that will advance the field in terms of education, research, and patient care and to provide the highest quality care to patients with life-threatening illness. This will provide seed money to develop educational and research programs that require some early investment when they are just ideas.”

There is a tremendous need for more and better palliative care in the hospital setting. “Patients have many needs, including management of symptoms such as shortness of breath, nausea, and fatigue,” he says. “There isn’t nearly enough research or information on these problems as compared to pain. We need more studies on the best way to treat symptoms.”

Additionally, Dr. Pantilat hopes to add to the body of literature on patient-physician communication, suggesting that hospitalists and other physicians need information about how to communicate sensitive issues such as bad news and how best to support patients and families throughout illnesses and fill their palliative care needs.

“We hope to develop and encourage more education and training on these topics,” he says. Stressing that there already are good educational programs about palliative care topics, Dr. Pantilat notes the need for more instruction specific to the unique needs of hospitalized patients and the hospitalists who care for them.

Create an Interdisciplinary System

“We need systems to provide palliative care. We also need to sensitize everyone who works in the hospital to comfort care issues,” says Dr. Pantilat, adding that there also is a need for programs and systems to ensure that patients and families will get the palliative care they need when they leave the hospital. “We need to work together to create a smooth transition from inpatient to outpatient palliative care. And we need to consider how we, as hospitalists, work with patients in the outpatient setting to ensure that someone is there to take care of them and their needs.”

Many of these needs require widespread education and training. “This grant will allow us to develop more robust and innovative educational efforts that engage ways to teach all team members about palliative care,” says Dr. Pantilat. “This will include projects such as using the Web to teach students.”

Expand the Definition

Dr. Pantilat also hopes to help expand the definition of palliative care and help people understand this as a broad concept of providing interdisciplinary care for people with terminal and chronic diseases. “An important point that we hope to emphasize is that palliative care is not just end-of-life care but something designed to improve life for people with illnesses—particularly chronic illnesses—either through the treatment of the diseases or the symptoms. It is an attempt to alleviate physical, emotional, and psychological suffering and promote the best possible quality of life,” he explains.

Helping people get “past the old limiting idea of palliative care” is another key goal. “A lot of palliative care can be provided while people are pursuing curative care,” explains Dr. Pantilat. “This is an important concept to promote.”

The Hospitalist’s Role

As a hospitalist, Dr. Pantilat also hopes to promote the growing recognition of the importance of hospitalists in palliative care programs: “The beautiful thing is that hospitalists are perfectly poised to handle palliative care programs, and with training they can become palliative care providers.”

The endowed chair reflects the importance of hospitalists in the palliative care field. “Hospitalists will be increasingly important in this area, and I hope to take a leadership role,” he says. While he is pleased and honored to have the chair at UCSF, he is confident that his work will have an impact well beyond his own university. “The chair will bring much recognition to our program but also to the field of palliative care in general and the role of hospitalists nationwide.” TH

Joanne Kaldy writes regularly for The Hospitalist.

Contrary to popular belief, conflicts are not necessarily bad. In fact, conflicts can spark discussions that can lead to improved processes and quality care. They also can help open lines of communication among practitioners and between physicians and patients.

Of course, not all conflict is positive and discord can be detrimental to patients and to relationships in the hospital. It behooves hospitalists to understand how to resolve conflicts constructively and communicate effectively in emotionally charged and controversial situations.

Good Conflict

When resolved effectively, conflicts can lead to positive changes, process improvements, and enhanced quality, says Leonard Marcus, PhD, founding director of the Program for Health Care Negotiation and Conflict Resolution at the Harvard School of Public Health (Boston). In fact, conflict sometimes is necessary because it:

• Raises and resolves problems;
• Focuses change efforts on the most urgent and appropriate issues;
• Motivates people to participate in efforts to create positive changes; and
• Helps people learn to benefit from and recognize their differences.

Conflict is problematic when it:

• Hampers productivity;
• Lowers morale and/or hurts relationships;
• Creates more and continued conflicts; and
• Causes inappropriate and/or dangerous behaviors.

Conflicts often arise from everyday occurrences. Poor communication is one of the most common causes of disputes. However, conflicts also may result from insufficient resources, personality clashes, and leadership problems (e.g., inconsistent, missing, dictatorial, or uninformed leadership).

Anatomy of a Conflict

A primary care physician, Dr. X, tells a patient, Mrs. Y, that she needs to be admitted to the hospital. If the hospitalist examines Mrs. Y and agrees that admission is necessary, there is no conflict. However, if the hospitalist determines that Mrs. Y doesn’t need to be admitted, the potential for conflict is ripe.

“This can create real tension,” says James W. Leyhane, MD, hospitalist director at Auburn Memorial Hospital, N.Y. “The hospitalist can find himself facing a conflict with the patient or the physician—or both.”

These situations can be highly charged and difficult to resolve. “Sometimes the person is adamant that he or she wants to be admitted,” says Dr. Leyhane. “And the stronger the relationship the patient has with the primary care physician, the greater the resistance they may have to what you are saying.”

The most common approach Dr. Leyhane takes to such a situation is to get on the physician’s side. “I will say something like, ‘I understand why Dr. Jones thought you should be admitted. However, after further examination, we now realize that admission is unnecessary,’” he explains.

Once the hospitalist addresses any anger or frustrations patients feel, most are relieved to avoid a hospitalization. But sometimes this approach doesn’t work, and some patients still insist on being admitted. In those cases, Dr. Leyhane will appeal to their pocketbook instead of their emotions. “I will tell them that I can admit them if they insist,” he says. “However, someone else will review their chart for insurance purposes, and they will have to pay out-of-pocket for the stay because it is not medically necessary. This is very persuasive.”

When Hospitalists and Attendings Clash

When such situations create conflict with physicians, they must be addressed carefully and resolved promptly. Dr. Marcus suggests that such conflicts can be minimized or eliminated altogether when “physicians negotiate expectations of their relationships” up front. “It is best for attendings and hospitalists to be communicating on an ongoing basis and understand each other’s positions before situations occur,” he offers.

Peter Prendergast, MD, chief hospitalist at St. Joseph’s Hospital and associate professor of Medicine at SUNY Upstate Medicine Center in Syracuse, New York, suggests that conflicts with physicians in these situations are not common. “Physicians overwhelmingly understand that we have more information by which to make admitting decisions,” says Dr. Prendergast. “We just need to make sure the patient understands that the physician makes the best possible decision with the data set he or she has and that we have access to more information and assessment tools and may draw a different conclusion.”

Nonetheless, Dr. Prendergast acknowledges that there are other situations that present the potential for attending-hospitalist conflict. “You may run into a problem with the primary care physician when the patient presents with a medical problem that previously was treated in the hospital that now is treated on an outpatient basis,” he notes.

Dr. Leyhane offers another common conflict with attendings. “Sometimes the physician will order a test or procedure that will not be reimbursed because it is unrelated to the patient’s reason for admission,” he says. “When this happens and the patient gets the bill, he or she is unhappy with the hospital and not the attending physician.”

These situations generally occur because the physician doesn’t realize that a service isn’t reimbursable or that a protocol has changed, Dr. Prendergast stresses, and not because the practitioner is being stubborn or contrary. Nonetheless, it presents a conflict.

“You need to let the physician know that there has been a change in treatment standards or that there is a reimbursement issue. Once he or she has the facts, you aren’t likely to have another problem,” says Dr. Prendergast. “The physician needs to get a phone call or at least a note in a timely manner.”

Dr. Marcus actually advises that hospitalists talk with the physician before communicating any information to the patient that conflicts with what the doctor has told him or her. “Otherwise,” he observes, “the conflict already has escalated.” Physicians, he says, don’t want to hear about a difference of opinion after the fact.

Hospitalist-Patient Conflicts

Roger Gildersleeve, MD, administrative hospitalist at Augusta Medical Center, Fishersville, Va., says conflicts with patients or family members are common situations for the hospitalist. “You may see conflicts when there is a disconnect between the patient’s or family’s expectations and the realities of the patient’s prognosis and outcomes,” he says. “We spend a lot of time trying to bring these two things closer together.”

One key to resolving these problems is to make a quick study of the situation. “You usually can read patients and families—by their body language and facial expressions—when you enter the room,” says Dr. Gildersleeve, “and you can detect tension and hostility.”

Dr. Prendergast agrees. “When you see patients and families in certain situations—such as 2 a.m. in the ER—you can make some reasonable assumptions about what they are thinking or feeling,” he says. “You can predict what these people’s concerns are, and you can address them even before they ask. Acknowledging their position and concerns is important.”

When possible, preparing for family and/or patient encounters can make a difference. “Before seeing a new patient, I try to learn as much as I can about him or her,” says Dr. Gildersleeve. “We have a good computer system, so it’s pretty easy. I use some of what I’ve learned in my opening comments, and this gives patients and families more confidence in me and my ability to deal with them as individuals.”

This is especially important for hospitalists, who have to establish patient relationships in a relatively short period of time.

Resolving Conflicts

Of course, it is impossible to prevent or avoid all conflicts. “To some degree, conflicts are inevitable,” says Dr. Marcus. “It’s the nature of medical practice.”

When conflicts occur, many of them can—and should—be resolved before they escalate into a dangerous confrontation or litigation. Listening is key to resolving conflicts quickly. “By listening, you can prevent a lot of conflicts from escalating or even starting,” says Dr. Prendergast. “We teach our physicians to listen, then repeat back what they heard—‘I’m hearing that you’re upset because … .’ If you get it right, the person knows that you are listening and that you understand their concerns. If you miss, they are likely to state their concern directly.”

Dr. Marcus believes conflict resolution may be particularly effective and satisfying when interest-based negotiation (IBN) is employed. IBN is a problem-solving strategy that focuses on satisfying as many interests or needs as possible for all involved parties. Because this technique addresses people’s needs and interests and separates people from the problem, it enables the parties to reach an integrative solution rather than creating a win-lose situation.

IBN enables those involved in a conflict to work together to reach a mutually satisfactory conclusion. The technique commonly results in creative and durable solutions, as well as enhanced relationships.

Conflict resolution efforts are more likely to fail, says Dr. Marcus, when the physicians and others involved apply position-based negotiations. With this conflict-management method, the parties argue only their positions, and their underlying interests may never be stated explicitly or understood. People are more likely to reach an impasse when they employ position-based negotiations, and they are more likely to see the situation as having a clear-cut winner and a loser.

“When you negotiate based on positions,” explains Dr. Marcus, “that is when situations are likely to escalate.”

While clear hospital policies and procedures can help resolve or prevent some conflicts involving physicians, more layers of policy are not necessarily the answer. “I think the time it would take to establish these policies would be better spent developing pathways for easier and better communication,” says Dr. Gildersleeve. “You see few of these hospitalist-physician conflicts when there is good communication between all the players.”

Professional mediator Pat Costello suggests that policy changes actually can help resolve some disputes. “Continued conflicts might suggest a need for a policy change or a new policy,” says Costello. “I have mediated a lot of situations that were resolved by policy changes.”

15 Seconds to Make an Impression

Hospitalists must remain cognizant of mistakes they can make that actually exacerbate conflicts with patients and families. “When physicians use an overbearing approach, they can’t accomplish as much,” says Dr. Marcus. “You have to take care to treat patients and families with care and concern and the same respect they afford their colleagues.”

It is important for hospitalists to be aware of how they come across to others, stressed Carole Houk, Esq., president of Carole Houk International, Alexandria, Va.

“You make a snap judgment of whether or not you like someone in about 15 seconds,” says Houk. “Studies show that physicians who use a dominant tone of voice are more likely to be sued than those who don’t.

“Explain what happens and why—and put a lot of focus on your tone of voice,” she says. “Rather than coming down imperiously, reach out to patients in a compassionate way. You need to be seen as someone with a heart and not a gatekeeper for the insurance company.”

When Hospitalists Can’t Resolve a Conflict

Unfortunately, some conflicts can’t be resolved easily. While hospitalists require some conflict resolution skills, they must also be willing and able to recognize when they need assistance. For example, suggests Houk, “We have ombudsmen in some hospitals who serve as conflict coaches. They are trained for this purpose. Hospitalists and others can go to these people for help resolving conflicts.”

Elsewhere, she notes, “We are training risk managers on conflict skills so that they can help resolve disputes in their hospitals and serve as informal mediators.”

On rare occasions, it may be necessary to seek the involvement of an independent professional mediator. Mediator Costello says this might be necessary in instances where there is an ongoing and escalating lack of communication, repeated conflicts (despite attempts to resolve them), physical altercations or threats of violence, and/or imminent risk to a patent’s safety.

While there may be conflicts that hospitalists cannot resolve, overall they are well equipped to communicate effectively in a way that minimizes disputes. “Many of us were attracted to this profession because of the opportunities and challenges of working with a wide range of situations and colleagues,” says Dr. Leyhane. “We know that communication skills are important, and we get a lot of practice during our interactions with physicians, families, patients, administrators, and ancillary staff.”

Houk agrees: “This field seems to attract people with big hearts. They understand the importance of understanding and acknowledging the needs and feelings of others.” TH

Joanne Kaldy writes regularly for The Hospitalist.

Contrary to popular belief, conflicts are not necessarily bad. In fact, conflicts can spark discussions that can lead to improved processes and quality care. They also can help open lines of communication among practitioners and between physicians and patients.

Of course, not all conflict is positive and discord can be detrimental to patients and to relationships in the hospital. It behooves hospitalists to understand how to resolve conflicts constructively and communicate effectively in emotionally charged and controversial situations.

Good Conflict

When resolved effectively, conflicts can lead to positive changes, process improvements, and enhanced quality, says Leonard Marcus, PhD, founding director of the Program for Health Care Negotiation and Conflict Resolution at the Harvard School of Public Health (Boston). In fact, conflict sometimes is necessary because it:

• Raises and resolves problems;
• Focuses change efforts on the most urgent and appropriate issues;
• Motivates people to participate in efforts to create positive changes; and
• Helps people learn to benefit from and recognize their differences.

Conflict is problematic when it:

• Hampers productivity;
• Lowers morale and/or hurts relationships;
• Creates more and continued conflicts; and
• Causes inappropriate and/or dangerous behaviors.

Conflicts often arise from everyday occurrences. Poor communication is one of the most common causes of disputes. However, conflicts also may result from insufficient resources, personality clashes, and leadership problems (e.g., inconsistent, missing, dictatorial, or uninformed leadership).

Anatomy of a Conflict

A primary care physician, Dr. X, tells a patient, Mrs. Y, that she needs to be admitted to the hospital. If the hospitalist examines Mrs. Y and agrees that admission is necessary, there is no conflict. However, if the hospitalist determines that Mrs. Y doesn’t need to be admitted, the potential for conflict is ripe.

“This can create real tension,” says James W. Leyhane, MD, hospitalist director at Auburn Memorial Hospital, N.Y. “The hospitalist can find himself facing a conflict with the patient or the physician—or both.”

These situations can be highly charged and difficult to resolve. “Sometimes the person is adamant that he or she wants to be admitted,” says Dr. Leyhane. “And the stronger the relationship the patient has with the primary care physician, the greater the resistance they may have to what you are saying.”

The most common approach Dr. Leyhane takes to such a situation is to get on the physician’s side. “I will say something like, ‘I understand why Dr. Jones thought you should be admitted. However, after further examination, we now realize that admission is unnecessary,’” he explains.

Once the hospitalist addresses any anger or frustrations patients feel, most are relieved to avoid a hospitalization. But sometimes this approach doesn’t work, and some patients still insist on being admitted. In those cases, Dr. Leyhane will appeal to their pocketbook instead of their emotions. “I will tell them that I can admit them if they insist,” he says. “However, someone else will review their chart for insurance purposes, and they will have to pay out-of-pocket for the stay because it is not medically necessary. This is very persuasive.”

When Hospitalists and Attendings Clash

When such situations create conflict with physicians, they must be addressed carefully and resolved promptly. Dr. Marcus suggests that such conflicts can be minimized or eliminated altogether when “physicians negotiate expectations of their relationships” up front. “It is best for attendings and hospitalists to be communicating on an ongoing basis and understand each other’s positions before situations occur,” he offers.

Peter Prendergast, MD, chief hospitalist at St. Joseph’s Hospital and associate professor of Medicine at SUNY Upstate Medicine Center in Syracuse, New York, suggests that conflicts with physicians in these situations are not common. “Physicians overwhelmingly understand that we have more information by which to make admitting decisions,” says Dr. Prendergast. “We just need to make sure the patient understands that the physician makes the best possible decision with the data set he or she has and that we have access to more information and assessment tools and may draw a different conclusion.”

Nonetheless, Dr. Prendergast acknowledges that there are other situations that present the potential for attending-hospitalist conflict. “You may run into a problem with the primary care physician when the patient presents with a medical problem that previously was treated in the hospital that now is treated on an outpatient basis,” he notes.

Dr. Leyhane offers another common conflict with attendings. “Sometimes the physician will order a test or procedure that will not be reimbursed because it is unrelated to the patient’s reason for admission,” he says. “When this happens and the patient gets the bill, he or she is unhappy with the hospital and not the attending physician.”

These situations generally occur because the physician doesn’t realize that a service isn’t reimbursable or that a protocol has changed, Dr. Prendergast stresses, and not because the practitioner is being stubborn or contrary. Nonetheless, it presents a conflict.

“You need to let the physician know that there has been a change in treatment standards or that there is a reimbursement issue. Once he or she has the facts, you aren’t likely to have another problem,” says Dr. Prendergast. “The physician needs to get a phone call or at least a note in a timely manner.”

Dr. Marcus actually advises that hospitalists talk with the physician before communicating any information to the patient that conflicts with what the doctor has told him or her. “Otherwise,” he observes, “the conflict already has escalated.” Physicians, he says, don’t want to hear about a difference of opinion after the fact.

Hospitalist-Patient Conflicts

Roger Gildersleeve, MD, administrative hospitalist at Augusta Medical Center, Fishersville, Va., says conflicts with patients or family members are common situations for the hospitalist. “You may see conflicts when there is a disconnect between the patient’s or family’s expectations and the realities of the patient’s prognosis and outcomes,” he says. “We spend a lot of time trying to bring these two things closer together.”

One key to resolving these problems is to make a quick study of the situation. “You usually can read patients and families—by their body language and facial expressions—when you enter the room,” says Dr. Gildersleeve, “and you can detect tension and hostility.”

Dr. Prendergast agrees. “When you see patients and families in certain situations—such as 2 a.m. in the ER—you can make some reasonable assumptions about what they are thinking or feeling,” he says. “You can predict what these people’s concerns are, and you can address them even before they ask. Acknowledging their position and concerns is important.”

When possible, preparing for family and/or patient encounters can make a difference. “Before seeing a new patient, I try to learn as much as I can about him or her,” says Dr. Gildersleeve. “We have a good computer system, so it’s pretty easy. I use some of what I’ve learned in my opening comments, and this gives patients and families more confidence in me and my ability to deal with them as individuals.”

This is especially important for hospitalists, who have to establish patient relationships in a relatively short period of time.

Resolving Conflicts

Of course, it is impossible to prevent or avoid all conflicts. “To some degree, conflicts are inevitable,” says Dr. Marcus. “It’s the nature of medical practice.”

When conflicts occur, many of them can—and should—be resolved before they escalate into a dangerous confrontation or litigation. Listening is key to resolving conflicts quickly. “By listening, you can prevent a lot of conflicts from escalating or even starting,” says Dr. Prendergast. “We teach our physicians to listen, then repeat back what they heard—‘I’m hearing that you’re upset because … .’ If you get it right, the person knows that you are listening and that you understand their concerns. If you miss, they are likely to state their concern directly.”

Dr. Marcus believes conflict resolution may be particularly effective and satisfying when interest-based negotiation (IBN) is employed. IBN is a problem-solving strategy that focuses on satisfying as many interests or needs as possible for all involved parties. Because this technique addresses people’s needs and interests and separates people from the problem, it enables the parties to reach an integrative solution rather than creating a win-lose situation.

IBN enables those involved in a conflict to work together to reach a mutually satisfactory conclusion. The technique commonly results in creative and durable solutions, as well as enhanced relationships.

Conflict resolution efforts are more likely to fail, says Dr. Marcus, when the physicians and others involved apply position-based negotiations. With this conflict-management method, the parties argue only their positions, and their underlying interests may never be stated explicitly or understood. People are more likely to reach an impasse when they employ position-based negotiations, and they are more likely to see the situation as having a clear-cut winner and a loser.

“When you negotiate based on positions,” explains Dr. Marcus, “that is when situations are likely to escalate.”

While clear hospital policies and procedures can help resolve or prevent some conflicts involving physicians, more layers of policy are not necessarily the answer. “I think the time it would take to establish these policies would be better spent developing pathways for easier and better communication,” says Dr. Gildersleeve. “You see few of these hospitalist-physician conflicts when there is good communication between all the players.”

Professional mediator Pat Costello suggests that policy changes actually can help resolve some disputes. “Continued conflicts might suggest a need for a policy change or a new policy,” says Costello. “I have mediated a lot of situations that were resolved by policy changes.”

15 Seconds to Make an Impression

Hospitalists must remain cognizant of mistakes they can make that actually exacerbate conflicts with patients and families. “When physicians use an overbearing approach, they can’t accomplish as much,” says Dr. Marcus. “You have to take care to treat patients and families with care and concern and the same respect they afford their colleagues.”

It is important for hospitalists to be aware of how they come across to others, stressed Carole Houk, Esq., president of Carole Houk International, Alexandria, Va.

“You make a snap judgment of whether or not you like someone in about 15 seconds,” says Houk. “Studies show that physicians who use a dominant tone of voice are more likely to be sued than those who don’t.

“Explain what happens and why—and put a lot of focus on your tone of voice,” she says. “Rather than coming down imperiously, reach out to patients in a compassionate way. You need to be seen as someone with a heart and not a gatekeeper for the insurance company.”

When Hospitalists Can’t Resolve a Conflict

Unfortunately, some conflicts can’t be resolved easily. While hospitalists require some conflict resolution skills, they must also be willing and able to recognize when they need assistance. For example, suggests Houk, “We have ombudsmen in some hospitals who serve as conflict coaches. They are trained for this purpose. Hospitalists and others can go to these people for help resolving conflicts.”

Elsewhere, she notes, “We are training risk managers on conflict skills so that they can help resolve disputes in their hospitals and serve as informal mediators.”

On rare occasions, it may be necessary to seek the involvement of an independent professional mediator. Mediator Costello says this might be necessary in instances where there is an ongoing and escalating lack of communication, repeated conflicts (despite attempts to resolve them), physical altercations or threats of violence, and/or imminent risk to a patent’s safety.

While there may be conflicts that hospitalists cannot resolve, overall they are well equipped to communicate effectively in a way that minimizes disputes. “Many of us were attracted to this profession because of the opportunities and challenges of working with a wide range of situations and colleagues,” says Dr. Leyhane. “We know that communication skills are important, and we get a lot of practice during our interactions with physicians, families, patients, administrators, and ancillary staff.”

Houk agrees: “This field seems to attract people with big hearts. They understand the importance of understanding and acknowledging the needs and feelings of others.” TH

Joanne Kaldy writes regularly for The Hospitalist.

Contrary to popular belief, conflicts are not necessarily bad. In fact, conflicts can spark discussions that can lead to improved processes and quality care. They also can help open lines of communication among practitioners and between physicians and patients.

Of course, not all conflict is positive and discord can be detrimental to patients and to relationships in the hospital. It behooves hospitalists to understand how to resolve conflicts constructively and communicate effectively in emotionally charged and controversial situations.

Good Conflict

When resolved effectively, conflicts can lead to positive changes, process improvements, and enhanced quality, says Leonard Marcus, PhD, founding director of the Program for Health Care Negotiation and Conflict Resolution at the Harvard School of Public Health (Boston). In fact, conflict sometimes is necessary because it:

• Raises and resolves problems;
• Focuses change efforts on the most urgent and appropriate issues;
• Motivates people to participate in efforts to create positive changes; and
• Helps people learn to benefit from and recognize their differences.

Conflict is problematic when it:

• Hampers productivity;
• Lowers morale and/or hurts relationships;
• Creates more and continued conflicts; and
• Causes inappropriate and/or dangerous behaviors.

Conflicts often arise from everyday occurrences. Poor communication is one of the most common causes of disputes. However, conflicts also may result from insufficient resources, personality clashes, and leadership problems (e.g., inconsistent, missing, dictatorial, or uninformed leadership).

Anatomy of a Conflict

A primary care physician, Dr. X, tells a patient, Mrs. Y, that she needs to be admitted to the hospital. If the hospitalist examines Mrs. Y and agrees that admission is necessary, there is no conflict. However, if the hospitalist determines that Mrs. Y doesn’t need to be admitted, the potential for conflict is ripe.

“This can create real tension,” says James W. Leyhane, MD, hospitalist director at Auburn Memorial Hospital, N.Y. “The hospitalist can find himself facing a conflict with the patient or the physician—or both.”

These situations can be highly charged and difficult to resolve. “Sometimes the person is adamant that he or she wants to be admitted,” says Dr. Leyhane. “And the stronger the relationship the patient has with the primary care physician, the greater the resistance they may have to what you are saying.”

The most common approach Dr. Leyhane takes to such a situation is to get on the physician’s side. “I will say something like, ‘I understand why Dr. Jones thought you should be admitted. However, after further examination, we now realize that admission is unnecessary,’” he explains.

Once the hospitalist addresses any anger or frustrations patients feel, most are relieved to avoid a hospitalization. But sometimes this approach doesn’t work, and some patients still insist on being admitted. In those cases, Dr. Leyhane will appeal to their pocketbook instead of their emotions. “I will tell them that I can admit them if they insist,” he says. “However, someone else will review their chart for insurance purposes, and they will have to pay out-of-pocket for the stay because it is not medically necessary. This is very persuasive.”

When Hospitalists and Attendings Clash

When such situations create conflict with physicians, they must be addressed carefully and resolved promptly. Dr. Marcus suggests that such conflicts can be minimized or eliminated altogether when “physicians negotiate expectations of their relationships” up front. “It is best for attendings and hospitalists to be communicating on an ongoing basis and understand each other’s positions before situations occur,” he offers.

Peter Prendergast, MD, chief hospitalist at St. Joseph’s Hospital and associate professor of Medicine at SUNY Upstate Medicine Center in Syracuse, New York, suggests that conflicts with physicians in these situations are not common. “Physicians overwhelmingly understand that we have more information by which to make admitting decisions,” says Dr. Prendergast. “We just need to make sure the patient understands that the physician makes the best possible decision with the data set he or she has and that we have access to more information and assessment tools and may draw a different conclusion.”

Nonetheless, Dr. Prendergast acknowledges that there are other situations that present the potential for attending-hospitalist conflict. “You may run into a problem with the primary care physician when the patient presents with a medical problem that previously was treated in the hospital that now is treated on an outpatient basis,” he notes.

Dr. Leyhane offers another common conflict with attendings. “Sometimes the physician will order a test or procedure that will not be reimbursed because it is unrelated to the patient’s reason for admission,” he says. “When this happens and the patient gets the bill, he or she is unhappy with the hospital and not the attending physician.”

These situations generally occur because the physician doesn’t realize that a service isn’t reimbursable or that a protocol has changed, Dr. Prendergast stresses, and not because the practitioner is being stubborn or contrary. Nonetheless, it presents a conflict.

“You need to let the physician know that there has been a change in treatment standards or that there is a reimbursement issue. Once he or she has the facts, you aren’t likely to have another problem,” says Dr. Prendergast. “The physician needs to get a phone call or at least a note in a timely manner.”

Dr. Marcus actually advises that hospitalists talk with the physician before communicating any information to the patient that conflicts with what the doctor has told him or her. “Otherwise,” he observes, “the conflict already has escalated.” Physicians, he says, don’t want to hear about a difference of opinion after the fact.

Hospitalist-Patient Conflicts

Roger Gildersleeve, MD, administrative hospitalist at Augusta Medical Center, Fishersville, Va., says conflicts with patients or family members are common situations for the hospitalist. “You may see conflicts when there is a disconnect between the patient’s or family’s expectations and the realities of the patient’s prognosis and outcomes,” he says. “We spend a lot of time trying to bring these two things closer together.”

One key to resolving these problems is to make a quick study of the situation. “You usually can read patients and families—by their body language and facial expressions—when you enter the room,” says Dr. Gildersleeve, “and you can detect tension and hostility.”

Dr. Prendergast agrees. “When you see patients and families in certain situations—such as 2 a.m. in the ER—you can make some reasonable assumptions about what they are thinking or feeling,” he says. “You can predict what these people’s concerns are, and you can address them even before they ask. Acknowledging their position and concerns is important.”

When possible, preparing for family and/or patient encounters can make a difference. “Before seeing a new patient, I try to learn as much as I can about him or her,” says Dr. Gildersleeve. “We have a good computer system, so it’s pretty easy. I use some of what I’ve learned in my opening comments, and this gives patients and families more confidence in me and my ability to deal with them as individuals.”

This is especially important for hospitalists, who have to establish patient relationships in a relatively short period of time.

Resolving Conflicts

Of course, it is impossible to prevent or avoid all conflicts. “To some degree, conflicts are inevitable,” says Dr. Marcus. “It’s the nature of medical practice.”

When conflicts occur, many of them can—and should—be resolved before they escalate into a dangerous confrontation or litigation. Listening is key to resolving conflicts quickly. “By listening, you can prevent a lot of conflicts from escalating or even starting,” says Dr. Prendergast. “We teach our physicians to listen, then repeat back what they heard—‘I’m hearing that you’re upset because … .’ If you get it right, the person knows that you are listening and that you understand their concerns. If you miss, they are likely to state their concern directly.”

Dr. Marcus believes conflict resolution may be particularly effective and satisfying when interest-based negotiation (IBN) is employed. IBN is a problem-solving strategy that focuses on satisfying as many interests or needs as possible for all involved parties. Because this technique addresses people’s needs and interests and separates people from the problem, it enables the parties to reach an integrative solution rather than creating a win-lose situation.

IBN enables those involved in a conflict to work together to reach a mutually satisfactory conclusion. The technique commonly results in creative and durable solutions, as well as enhanced relationships.

Conflict resolution efforts are more likely to fail, says Dr. Marcus, when the physicians and others involved apply position-based negotiations. With this conflict-management method, the parties argue only their positions, and their underlying interests may never be stated explicitly or understood. People are more likely to reach an impasse when they employ position-based negotiations, and they are more likely to see the situation as having a clear-cut winner and a loser.

“When you negotiate based on positions,” explains Dr. Marcus, “that is when situations are likely to escalate.”

While clear hospital policies and procedures can help resolve or prevent some conflicts involving physicians, more layers of policy are not necessarily the answer. “I think the time it would take to establish these policies would be better spent developing pathways for easier and better communication,” says Dr. Gildersleeve. “You see few of these hospitalist-physician conflicts when there is good communication between all the players.”

Professional mediator Pat Costello suggests that policy changes actually can help resolve some disputes. “Continued conflicts might suggest a need for a policy change or a new policy,” says Costello. “I have mediated a lot of situations that were resolved by policy changes.”

15 Seconds to Make an Impression

Hospitalists must remain cognizant of mistakes they can make that actually exacerbate conflicts with patients and families. “When physicians use an overbearing approach, they can’t accomplish as much,” says Dr. Marcus. “You have to take care to treat patients and families with care and concern and the same respect they afford their colleagues.”

It is important for hospitalists to be aware of how they come across to others, stressed Carole Houk, Esq., president of Carole Houk International, Alexandria, Va.

“You make a snap judgment of whether or not you like someone in about 15 seconds,” says Houk. “Studies show that physicians who use a dominant tone of voice are more likely to be sued than those who don’t.

“Explain what happens and why—and put a lot of focus on your tone of voice,” she says. “Rather than coming down imperiously, reach out to patients in a compassionate way. You need to be seen as someone with a heart and not a gatekeeper for the insurance company.”

When Hospitalists Can’t Resolve a Conflict

Unfortunately, some conflicts can’t be resolved easily. While hospitalists require some conflict resolution skills, they must also be willing and able to recognize when they need assistance. For example, suggests Houk, “We have ombudsmen in some hospitals who serve as conflict coaches. They are trained for this purpose. Hospitalists and others can go to these people for help resolving conflicts.”

Elsewhere, she notes, “We are training risk managers on conflict skills so that they can help resolve disputes in their hospitals and serve as informal mediators.”

On rare occasions, it may be necessary to seek the involvement of an independent professional mediator. Mediator Costello says this might be necessary in instances where there is an ongoing and escalating lack of communication, repeated conflicts (despite attempts to resolve them), physical altercations or threats of violence, and/or imminent risk to a patent’s safety.

While there may be conflicts that hospitalists cannot resolve, overall they are well equipped to communicate effectively in a way that minimizes disputes. “Many of us were attracted to this profession because of the opportunities and challenges of working with a wide range of situations and colleagues,” says Dr. Leyhane. “We know that communication skills are important, and we get a lot of practice during our interactions with physicians, families, patients, administrators, and ancillary staff.”

Houk agrees: “This field seems to attract people with big hearts. They understand the importance of understanding and acknowledging the needs and feelings of others.” TH

Joanne Kaldy writes regularly for The Hospitalist.

In the past decade numerous trends and influences have caused organized trauma surgery to re-examine our role in the care of all acutely ill surgical patients and the training of future general surgeons who will care for these patients.1 In this article we’ll briefly review the influences that brought us to this point, the issues we feel need to be addressed, and the solution that trauma surgery has proposed. In many ways, we believe these trends parallel the influences that led to the development of the hospitalists and, thus, call for a surgical equivalent.

Surgical Trends

The development of laparoscopic surgery has had profound influence on surgical practice. Cholecystectomies and appendectomies are generally 23-hour admissions. Even bariatric surgery is now little more than outpatient surgery, with the average length of stay at two days. Along with laparoscopy, breast surgery is now one of the fastest growing surgical subspecialties.

Many surgeons have tailored their practices to a largely outpatient base. There has been an explosion of free-standing surgery centers with a large shift of this low acuity patient population away from hospitals. This follows an overall shift in medicine to ambulatory practice, which is now projected to increase by 24% over the next five to 10 years. Thus, fewer and fewer surgeons have large inpatient practices. There is growing concern about the reluctance of many surgeons to deal with complex, high acuity patients. The obvious exceptions are transplant and trauma surgeons.

In the past decade profound changes in trauma care have also affected the practices of surgeons and the career choices of surgical residents.2 Following the peak of gun-related violence in the early 1990s, there has been a steady and significant decline in penetrating trauma with a concomitant decrease in operations. Slow but steady improvement in motor vehicle passive safety devices has also decreased the incidence of serious injury to the torso following car crashes.

When a solid organ (liver, spleen, kidney) injury does occur after car crash, fall, or assault, the management has largely shifted away from exploratory laparotomy to non-operative management. This has been made possible by improved imaging techniques, careful monitoring in the ICU and judicious use of interventional radiologic techniques of embolization and percutaneous drainage. Currently, some 60% to 80% of liver and spleen injuries are treated with observation or interventional techniques. Although most surgical residents enjoy the challenges of both trauma surgery and critical care, the decline in operative opportunities has limited the appeal of trauma/critical care as a career choice.2

Many trauma surgeons feel there is a convergence of these two issues—a group of patients that may be underserved and an opportunity to enhance the training and desirability of caring for acutely ill surgical patients.3-5 Either through years of experience or formal training, the vast majority of trauma surgeons are highly experienced in evaluating, operating upon, and providing post-operative care for critically ill and injured patients. In fact, the majority of surgical critical care fellowships are based at level 1 trauma centers and are run primarily by trauma surgeons. Thus, trauma surgeons are ideally situated to address these issues.

[A fellowship] all starts with a core group of people dedicated to hospital medicine. You need a group of people who see the future of hospital medicine and what it can be and who want to dive into different aspects of it. This is the minimum criteria for a successful hospitalist fellowship program.

—Rohit Uppal, MD, MBA

A New Specialty

In 2001 Ron V. Maier, MD, then president of the American Association for the Surgery of Trauma (AAST), commissioned a committee to address these issues and develop an action plan. With broad representation from numerous surgical societies, the committee met several times to consider various training and practice models as potential solutions. After much discussion, the group proposed a model based upon trauma surgery, emergency general surgery, and critical care. This process is outlined in a white paper authored by the committee in 2005.

Basically, the committee recommends the evolution of trauma surgery into a new specialty based on broad training in elective and emergency general surgery, trauma, and critical care surgery. Specific steps to accomplish this goal were outlined by the committee and considerable progress has already been made. After much debate regarding the name, including the consideration of “surgical hospitalists,” the AAST elected to support the name “acute care surgeon.” In fact, this model is how many of us trauma surgeons practice; we take trauma and emergency general surgery call and provide critical care services for these patients.

What was missing from the paradigm was a formal incorporation of emergency general surgery into the training of trauma/surgical critical care fellows and analysis of the benefits of such programs. While this practice paradigm has long been the model at many urban safety net hospitals in cities such as Atlanta, Dallas, Denver, Los Angeles, and Seattle, the practice of many trauma surgeons is often restrained at university hospitals and most level II trauma centers.

Strong Results

The trauma program at University of Pennsylvania, Pittsburgh, under the leadership of C. William Schwab, MD, the current president of the AAST, has taken the lead in documenting the value of incorporating emergency surgery into trauma/surgical critical care training. The addition of emergency general surgery into a trauma/surgical critical care fellowship increases operative experience and fellow satisfaction.3-6 Emergency general surgery now accounts for 57% of operations performed by their faculty. This helps maintain their operative experience despite a decline in operative trauma volume. Finally, with a careful analysis of performance improvement data, there is no compromise in trauma patient outcomes despite the increased patient load.4-5 This experience has been replicated at other trauma centers and strongly suggests that incorporating emergency general surgery into trauma training increases attractiveness to trainees and maintains high standards of patient care. The question is whether it meets an unfilled need.

Recent experience at Vanderbilt Medical Center suggests that the formal incorporation of emergency general surgery into a service has benefits for patients and the hospital.6 The service brings in more referrals from the surrounding community and increases trauma surgeon operative cases. The elective general surgeons also experience an increase in operations and admissions after removing the disruption of emergency admissions. The hospital benefits by the addition of new patients that frequently require operations and intensive care.

In a recent supplement to the The Hospitalist Larry Wellikson, MD, notes that hospitalists add value by (among other things):

• Providing measurable quality improvement;
• Creating seamless continuity from inpatient to outpatient care, from emergency department to floor, and from ICU to floor;
• Doing things other physicians had given up, such as indigent care and hospital committee functions;
• Creating healthcare teams to improve the working environment; and
• Taking care of acutely ill, complex hospitalized patients.7

We believe that trauma surgeons, or acute care surgeons, exemplify these values. We have provided these services to surgical patients for the past 25 years. Trauma surgeons have been leaders in quality improvement, as demonstrated by the American College of Surgeons Committee on Trauma verification program.

We take care of whoever comes through the door, regardless of acuity, time of day (or night), or payer status. We have always provided comprehensive care for our patients—from involvement in prehospital care and planning, through the emergency department, operating room, ICU, and even post-discharge rehabilitation. This requires an effective healthcare team and a truly multidisciplinary approach with other physicians (orthopedics, neurosurgery, anesthesia), nurses, and others, including respiratory, occupational, and physical therapy.

Conclusion

We see a synergy between hospitalist and acute-care surgeons. Both groups have stepped forward to fill a void in patient care. The redefining of trauma surgery as acute care surgery and the development of dedicated training programs will no doubt benefit current and future surgeons, but our patients will benefit the most. TH

Dr. Spain is professor of surgery and chief of Trauma, Emergency and Critical Care Surgery, Stanford University (California). He is also chairman of the Critical Care Committee, American Association for the Surgery of Trauma. Dr. Jurkovich is professor of surgery at the University of Washington, chief of Trauma and Emergency Surgical Services at Harborview Medical Center, and chairman of the Acute Care Surgeon Committee, American Association for the Surgery of Trauma.

References

1. Committee to Develop the Reorganized Specialty of Trauma, Surgical Critical Care, and Emergency Surgery. Acute care surgery: trauma, critical care, and emergency surgery. J Trauma. 2005;58:614-616.
2. Spain DA, Miller FB. Education and training of the future trauma surgeon in acute care surgery: trauma, critical care, and emergency surgery. Am J Surg. 2005;190:212-217.
3. Pryor JP, Reilly PM, Schwab CW, et al. Integrating emergency general surgery with a trauma service: impact on the care of injured patients. J Trauma. 2004 Sep;57(3):467-471.
4. Reilly PM, Schwab CW, Haut ER, et al. Training in trauma surgery: quantitative and qualitative aspects of a new paradigm for fellowship. Ann Surg. 2003 Oct;238(4):596-603.
5. Kim PK, Dabrowski GP, Reilly PM, et al. Redefining the future of trauma surgery as a comprehensive trauma and emergency general surgery service. J Am Coll Surg. 2004 Jul;199(1):96-101.
6. Austin MT, Diaz JJ Jr, Feurer ID, et al. Creating an emergency general surgery service enhances the productivity of trauma surgeons, general surgeons and the hospital. J Trauma. 2005 May;58(5):906-910.
7. Wellikson L. Hospitals recognize and reward value. The Hospitalist. 2005;9:3-5.

In the past decade numerous trends and influences have caused organized trauma surgery to re-examine our role in the care of all acutely ill surgical patients and the training of future general surgeons who will care for these patients.1 In this article we’ll briefly review the influences that brought us to this point, the issues we feel need to be addressed, and the solution that trauma surgery has proposed. In many ways, we believe these trends parallel the influences that led to the development of the hospitalists and, thus, call for a surgical equivalent.

Surgical Trends

The development of laparoscopic surgery has had profound influence on surgical practice. Cholecystectomies and appendectomies are generally 23-hour admissions. Even bariatric surgery is now little more than outpatient surgery, with the average length of stay at two days. Along with laparoscopy, breast surgery is now one of the fastest growing surgical subspecialties.

Many surgeons have tailored their practices to a largely outpatient base. There has been an explosion of free-standing surgery centers with a large shift of this low acuity patient population away from hospitals. This follows an overall shift in medicine to ambulatory practice, which is now projected to increase by 24% over the next five to 10 years. Thus, fewer and fewer surgeons have large inpatient practices. There is growing concern about the reluctance of many surgeons to deal with complex, high acuity patients. The obvious exceptions are transplant and trauma surgeons.

In the past decade profound changes in trauma care have also affected the practices of surgeons and the career choices of surgical residents.2 Following the peak of gun-related violence in the early 1990s, there has been a steady and significant decline in penetrating trauma with a concomitant decrease in operations. Slow but steady improvement in motor vehicle passive safety devices has also decreased the incidence of serious injury to the torso following car crashes.

When a solid organ (liver, spleen, kidney) injury does occur after car crash, fall, or assault, the management has largely shifted away from exploratory laparotomy to non-operative management. This has been made possible by improved imaging techniques, careful monitoring in the ICU and judicious use of interventional radiologic techniques of embolization and percutaneous drainage. Currently, some 60% to 80% of liver and spleen injuries are treated with observation or interventional techniques. Although most surgical residents enjoy the challenges of both trauma surgery and critical care, the decline in operative opportunities has limited the appeal of trauma/critical care as a career choice.2

Many trauma surgeons feel there is a convergence of these two issues—a group of patients that may be underserved and an opportunity to enhance the training and desirability of caring for acutely ill surgical patients.3-5 Either through years of experience or formal training, the vast majority of trauma surgeons are highly experienced in evaluating, operating upon, and providing post-operative care for critically ill and injured patients. In fact, the majority of surgical critical care fellowships are based at level 1 trauma centers and are run primarily by trauma surgeons. Thus, trauma surgeons are ideally situated to address these issues.

[A fellowship] all starts with a core group of people dedicated to hospital medicine. You need a group of people who see the future of hospital medicine and what it can be and who want to dive into different aspects of it. This is the minimum criteria for a successful hospitalist fellowship program.

—Rohit Uppal, MD, MBA

A New Specialty

In 2001 Ron V. Maier, MD, then president of the American Association for the Surgery of Trauma (AAST), commissioned a committee to address these issues and develop an action plan. With broad representation from numerous surgical societies, the committee met several times to consider various training and practice models as potential solutions. After much discussion, the group proposed a model based upon trauma surgery, emergency general surgery, and critical care. This process is outlined in a white paper authored by the committee in 2005.

Basically, the committee recommends the evolution of trauma surgery into a new specialty based on broad training in elective and emergency general surgery, trauma, and critical care surgery. Specific steps to accomplish this goal were outlined by the committee and considerable progress has already been made. After much debate regarding the name, including the consideration of “surgical hospitalists,” the AAST elected to support the name “acute care surgeon.” In fact, this model is how many of us trauma surgeons practice; we take trauma and emergency general surgery call and provide critical care services for these patients.

What was missing from the paradigm was a formal incorporation of emergency general surgery into the training of trauma/surgical critical care fellows and analysis of the benefits of such programs. While this practice paradigm has long been the model at many urban safety net hospitals in cities such as Atlanta, Dallas, Denver, Los Angeles, and Seattle, the practice of many trauma surgeons is often restrained at university hospitals and most level II trauma centers.

Strong Results

The trauma program at University of Pennsylvania, Pittsburgh, under the leadership of C. William Schwab, MD, the current president of the AAST, has taken the lead in documenting the value of incorporating emergency surgery into trauma/surgical critical care training. The addition of emergency general surgery into a trauma/surgical critical care fellowship increases operative experience and fellow satisfaction.3-6 Emergency general surgery now accounts for 57% of operations performed by their faculty. This helps maintain their operative experience despite a decline in operative trauma volume. Finally, with a careful analysis of performance improvement data, there is no compromise in trauma patient outcomes despite the increased patient load.4-5 This experience has been replicated at other trauma centers and strongly suggests that incorporating emergency general surgery into trauma training increases attractiveness to trainees and maintains high standards of patient care. The question is whether it meets an unfilled need.

Recent experience at Vanderbilt Medical Center suggests that the formal incorporation of emergency general surgery into a service has benefits for patients and the hospital.6 The service brings in more referrals from the surrounding community and increases trauma surgeon operative cases. The elective general surgeons also experience an increase in operations and admissions after removing the disruption of emergency admissions. The hospital benefits by the addition of new patients that frequently require operations and intensive care.

In a recent supplement to the The Hospitalist Larry Wellikson, MD, notes that hospitalists add value by (among other things):

• Providing measurable quality improvement;
• Creating seamless continuity from inpatient to outpatient care, from emergency department to floor, and from ICU to floor;
• Doing things other physicians had given up, such as indigent care and hospital committee functions;
• Creating healthcare teams to improve the working environment; and
• Taking care of acutely ill, complex hospitalized patients.7

We believe that trauma surgeons, or acute care surgeons, exemplify these values. We have provided these services to surgical patients for the past 25 years. Trauma surgeons have been leaders in quality improvement, as demonstrated by the American College of Surgeons Committee on Trauma verification program.

We take care of whoever comes through the door, regardless of acuity, time of day (or night), or payer status. We have always provided comprehensive care for our patients—from involvement in prehospital care and planning, through the emergency department, operating room, ICU, and even post-discharge rehabilitation. This requires an effective healthcare team and a truly multidisciplinary approach with other physicians (orthopedics, neurosurgery, anesthesia), nurses, and others, including respiratory, occupational, and physical therapy.

Conclusion

We see a synergy between hospitalist and acute-care surgeons. Both groups have stepped forward to fill a void in patient care. The redefining of trauma surgery as acute care surgery and the development of dedicated training programs will no doubt benefit current and future surgeons, but our patients will benefit the most. TH

Dr. Spain is professor of surgery and chief of Trauma, Emergency and Critical Care Surgery, Stanford University (California). He is also chairman of the Critical Care Committee, American Association for the Surgery of Trauma. Dr. Jurkovich is professor of surgery at the University of Washington, chief of Trauma and Emergency Surgical Services at Harborview Medical Center, and chairman of the Acute Care Surgeon Committee, American Association for the Surgery of Trauma.

References

1. Committee to Develop the Reorganized Specialty of Trauma, Surgical Critical Care, and Emergency Surgery. Acute care surgery: trauma, critical care, and emergency surgery. J Trauma. 2005;58:614-616.
2. Spain DA, Miller FB. Education and training of the future trauma surgeon in acute care surgery: trauma, critical care, and emergency surgery. Am J Surg. 2005;190:212-217.
3. Pryor JP, Reilly PM, Schwab CW, et al. Integrating emergency general surgery with a trauma service: impact on the care of injured patients. J Trauma. 2004 Sep;57(3):467-471.
4. Reilly PM, Schwab CW, Haut ER, et al. Training in trauma surgery: quantitative and qualitative aspects of a new paradigm for fellowship. Ann Surg. 2003 Oct;238(4):596-603.
5. Kim PK, Dabrowski GP, Reilly PM, et al. Redefining the future of trauma surgery as a comprehensive trauma and emergency general surgery service. J Am Coll Surg. 2004 Jul;199(1):96-101.
6. Austin MT, Diaz JJ Jr, Feurer ID, et al. Creating an emergency general surgery service enhances the productivity of trauma surgeons, general surgeons and the hospital. J Trauma. 2005 May;58(5):906-910.
7. Wellikson L. Hospitals recognize and reward value. The Hospitalist. 2005;9:3-5.

In the past decade numerous trends and influences have caused organized trauma surgery to re-examine our role in the care of all acutely ill surgical patients and the training of future general surgeons who will care for these patients.1 In this article we’ll briefly review the influences that brought us to this point, the issues we feel need to be addressed, and the solution that trauma surgery has proposed. In many ways, we believe these trends parallel the influences that led to the development of the hospitalists and, thus, call for a surgical equivalent.

Surgical Trends

The development of laparoscopic surgery has had profound influence on surgical practice. Cholecystectomies and appendectomies are generally 23-hour admissions. Even bariatric surgery is now little more than outpatient surgery, with the average length of stay at two days. Along with laparoscopy, breast surgery is now one of the fastest growing surgical subspecialties.

Many surgeons have tailored their practices to a largely outpatient base. There has been an explosion of free-standing surgery centers with a large shift of this low acuity patient population away from hospitals. This follows an overall shift in medicine to ambulatory practice, which is now projected to increase by 24% over the next five to 10 years. Thus, fewer and fewer surgeons have large inpatient practices. There is growing concern about the reluctance of many surgeons to deal with complex, high acuity patients. The obvious exceptions are transplant and trauma surgeons.

In the past decade profound changes in trauma care have also affected the practices of surgeons and the career choices of surgical residents.2 Following the peak of gun-related violence in the early 1990s, there has been a steady and significant decline in penetrating trauma with a concomitant decrease in operations. Slow but steady improvement in motor vehicle passive safety devices has also decreased the incidence of serious injury to the torso following car crashes.

When a solid organ (liver, spleen, kidney) injury does occur after car crash, fall, or assault, the management has largely shifted away from exploratory laparotomy to non-operative management. This has been made possible by improved imaging techniques, careful monitoring in the ICU and judicious use of interventional radiologic techniques of embolization and percutaneous drainage. Currently, some 60% to 80% of liver and spleen injuries are treated with observation or interventional techniques. Although most surgical residents enjoy the challenges of both trauma surgery and critical care, the decline in operative opportunities has limited the appeal of trauma/critical care as a career choice.2

Many trauma surgeons feel there is a convergence of these two issues—a group of patients that may be underserved and an opportunity to enhance the training and desirability of caring for acutely ill surgical patients.3-5 Either through years of experience or formal training, the vast majority of trauma surgeons are highly experienced in evaluating, operating upon, and providing post-operative care for critically ill and injured patients. In fact, the majority of surgical critical care fellowships are based at level 1 trauma centers and are run primarily by trauma surgeons. Thus, trauma surgeons are ideally situated to address these issues.

[A fellowship] all starts with a core group of people dedicated to hospital medicine. You need a group of people who see the future of hospital medicine and what it can be and who want to dive into different aspects of it. This is the minimum criteria for a successful hospitalist fellowship program.

—Rohit Uppal, MD, MBA

A New Specialty

In 2001 Ron V. Maier, MD, then president of the American Association for the Surgery of Trauma (AAST), commissioned a committee to address these issues and develop an action plan. With broad representation from numerous surgical societies, the committee met several times to consider various training and practice models as potential solutions. After much discussion, the group proposed a model based upon trauma surgery, emergency general surgery, and critical care. This process is outlined in a white paper authored by the committee in 2005.

Basically, the committee recommends the evolution of trauma surgery into a new specialty based on broad training in elective and emergency general surgery, trauma, and critical care surgery. Specific steps to accomplish this goal were outlined by the committee and considerable progress has already been made. After much debate regarding the name, including the consideration of “surgical hospitalists,” the AAST elected to support the name “acute care surgeon.” In fact, this model is how many of us trauma surgeons practice; we take trauma and emergency general surgery call and provide critical care services for these patients.

What was missing from the paradigm was a formal incorporation of emergency general surgery into the training of trauma/surgical critical care fellows and analysis of the benefits of such programs. While this practice paradigm has long been the model at many urban safety net hospitals in cities such as Atlanta, Dallas, Denver, Los Angeles, and Seattle, the practice of many trauma surgeons is often restrained at university hospitals and most level II trauma centers.

Strong Results

The trauma program at University of Pennsylvania, Pittsburgh, under the leadership of C. William Schwab, MD, the current president of the AAST, has taken the lead in documenting the value of incorporating emergency surgery into trauma/surgical critical care training. The addition of emergency general surgery into a trauma/surgical critical care fellowship increases operative experience and fellow satisfaction.3-6 Emergency general surgery now accounts for 57% of operations performed by their faculty. This helps maintain their operative experience despite a decline in operative trauma volume. Finally, with a careful analysis of performance improvement data, there is no compromise in trauma patient outcomes despite the increased patient load.4-5 This experience has been replicated at other trauma centers and strongly suggests that incorporating emergency general surgery into trauma training increases attractiveness to trainees and maintains high standards of patient care. The question is whether it meets an unfilled need.

Recent experience at Vanderbilt Medical Center suggests that the formal incorporation of emergency general surgery into a service has benefits for patients and the hospital.6 The service brings in more referrals from the surrounding community and increases trauma surgeon operative cases. The elective general surgeons also experience an increase in operations and admissions after removing the disruption of emergency admissions. The hospital benefits by the addition of new patients that frequently require operations and intensive care.

In a recent supplement to the The Hospitalist Larry Wellikson, MD, notes that hospitalists add value by (among other things):

• Providing measurable quality improvement;
• Creating seamless continuity from inpatient to outpatient care, from emergency department to floor, and from ICU to floor;
• Doing things other physicians had given up, such as indigent care and hospital committee functions;
• Creating healthcare teams to improve the working environment; and
• Taking care of acutely ill, complex hospitalized patients.7

We believe that trauma surgeons, or acute care surgeons, exemplify these values. We have provided these services to surgical patients for the past 25 years. Trauma surgeons have been leaders in quality improvement, as demonstrated by the American College of Surgeons Committee on Trauma verification program.

We take care of whoever comes through the door, regardless of acuity, time of day (or night), or payer status. We have always provided comprehensive care for our patients—from involvement in prehospital care and planning, through the emergency department, operating room, ICU, and even post-discharge rehabilitation. This requires an effective healthcare team and a truly multidisciplinary approach with other physicians (orthopedics, neurosurgery, anesthesia), nurses, and others, including respiratory, occupational, and physical therapy.

Conclusion

We see a synergy between hospitalist and acute-care surgeons. Both groups have stepped forward to fill a void in patient care. The redefining of trauma surgery as acute care surgery and the development of dedicated training programs will no doubt benefit current and future surgeons, but our patients will benefit the most. TH

Dr. Spain is professor of surgery and chief of Trauma, Emergency and Critical Care Surgery, Stanford University (California). He is also chairman of the Critical Care Committee, American Association for the Surgery of Trauma. Dr. Jurkovich is professor of surgery at the University of Washington, chief of Trauma and Emergency Surgical Services at Harborview Medical Center, and chairman of the Acute Care Surgeon Committee, American Association for the Surgery of Trauma.

References

1. Committee to Develop the Reorganized Specialty of Trauma, Surgical Critical Care, and Emergency Surgery. Acute care surgery: trauma, critical care, and emergency surgery. J Trauma. 2005;58:614-616.
2. Spain DA, Miller FB. Education and training of the future trauma surgeon in acute care surgery: trauma, critical care, and emergency surgery. Am J Surg. 2005;190:212-217.
3. Pryor JP, Reilly PM, Schwab CW, et al. Integrating emergency general surgery with a trauma service: impact on the care of injured patients. J Trauma. 2004 Sep;57(3):467-471.
4. Reilly PM, Schwab CW, Haut ER, et al. Training in trauma surgery: quantitative and qualitative aspects of a new paradigm for fellowship. Ann Surg. 2003 Oct;238(4):596-603.
5. Kim PK, Dabrowski GP, Reilly PM, et al. Redefining the future of trauma surgery as a comprehensive trauma and emergency general surgery service. J Am Coll Surg. 2004 Jul;199(1):96-101.
6. Austin MT, Diaz JJ Jr, Feurer ID, et al. Creating an emergency general surgery service enhances the productivity of trauma surgeons, general surgeons and the hospital. J Trauma. 2005 May;58(5):906-910.
7. Wellikson L. Hospitals recognize and reward value. The Hospitalist. 2005;9:3-5.

Five years ago, a medical resident interested in pursuing a career as a hospitalist had few opportunities to receive specialized training. Five years from now, residents likely will have numerous hospitalist training tracks and electives from which to choose. This is partly thanks to a small group of pioneers who have seen the value of specialized hospitalist training for residents. These individuals have carefully considered what skills, information, and experience residents need to practice as confident and competent hospitalists, and they have developed programs and courses that meet these needs.

Sharpening Residents’ Focus

“Actually, we don’t call them ‘tracks,’ ” says Andrew Rudmann, MD, assistant professor of medicine and chief of the Hospital Medicine Division at the University of Rochester Medical Center. “We don’t want students to think that they’re stuck in an area once they choose it.”

Nonetheless, he notes, students increasingly are choosing careers as hospitalists, and they are expressing an interest in gaining skills and knowledge to help them become hospitalists.

Dr. Rudmann adds that his students “are sorting out their career plans earlier,” so it is important to offer specialized focus area programs. He has divided these into three areas: general medicine inpatient (hospitalist), general medicine outpatient (primary care), and subspecialty (other specialties).

The focus area programs are still in the developmental stage, Dr. Rudmann stresses. “We are in the process of developing the curricula for these programs, all of which will be elective experiences,” he says. Determining course options will be a challenge because there are a limited number of hours available for these electives. Nonetheless, Dr. Rudmann has identified several activities essential to producing effective hospitalists. These include:

• Rotation at a community hospital. “This program will focus on communication issues with primary care physicians,” explains Dr. Rudmann. “The students also will spend time in primary care offices to focus on the transition of patients from hospital to community care.”
• Quality improvement (QI) project. Residents will work one-on-one with hospitalists and develop a QI project from their work that they will present at the end of the rotation. As hospitalists, says Dr. Rudmann, these individuals frequently will be involved in QI initiatives and committees, and it is important that residents be prepared for these activities.
• Billing, coding, documentation mentorship. Each student will have a mentor, who will be required to instruct residents (either one-on-one or in small groups) about these issues. While billing, coding, and documentation are not glamorous, they are important components of a hospitalist practice, so Dr. Rudmann wants to ensure that residents are comfortable handling these activities.

Hospitalist students also will have the opportunity to spend time shadowing healthcare professionals in other areas such as the detox unit and bronchoscopy suite.

“It’s useful for a resident to spend time learning what these people do and what happens in these areas,” says Dr. Rudmann. “Our current healthcare system tends to be fragmented, and this experience will help physicians ensure smooth transitions for patients from one site to the next.”

Dr. Rudmann says he will suggest that residents interested in being hospitalists spend time in the ED observation unit. Additionally, these residents will be exposed to patient safety and medico-legal issues through active participation in morbidity/mortality conferences.

Residents also will have the opportunity to take a research elective course. However, Dr. Rudmann notes that students will need a real interest or passion for research to participate in this option, as it will consume one-half of their elective hours.

Day in the Life

Providing exposure to many of the day-to-day aspects of hospitalist practice is a key component of the hospitalist elective program at Emory University in Georgia.

“We wanted to provide residents with an opportunity to get some clinical exposure that they don’t necessarily get during general residency training and give them a better sense of what hospital medicine is—aside from taking care of patients in the hospital,” says Dan Dressler, MD, MSc, director of hospitalist medicine at the Emory University School of Medicine (Atlanta).

Emory’s hospitalist electives also give residents an opportunity to “pick the brains” of hospitalists. “They get to ask about things like schedules, committee involvement, research activities, and so on,” explains Dr. Dressler. “Residents really like this opportunity. They can feel isolated in the academic setting, and this really broadens their horizons.”

click for large version

Building a Hospitalist Track from the Ground Up

In developing Emory’s hospitalist elective program, Dr. Dressler sought guidance from colleagues at the University of California at San Francisco and the Mayo Clinic (Rochester, Minn.) who already had established specialized hospitalist education opportunities.

Still, developing a good program is not as easy as copying someone else’s efforts. In fact, Dr. Rudmann says that most of the ideas for Rochester’s program came from “a thorough self-examination process.”

“You don’t have to look far,” he explains. “Just look at your own program and talk to your own residents.”

One of the challenges of developing a hospitalist track is the limited time available for elective programs. Dr. Dressler suggests starting by “assessing what you already are doing in your general residency program. You don’t want to duplicate efforts. Determine what is being done well at your program already and what could be done additionally—either based on what others are doing or what should be considered core competencies in hospital medicine. Then implement the missing pieces.”

Even after all of these planning and self-examination efforts, Dr. Dressler cautions, “you probably won’t have enough time to do everything you want to do.” At this point, he suggests concentrating on those issues or skills for which “you have someone who is able and willing to teach and teach well.” For example, he suggested, “if you want to include training on QI but don’t have anyone who can teach this well, you might want to keep this as a goal for down the road.”

Problem-Solving as a Goal

Sometimes, hospitalist training programs can help solve a specific problem. For example, Jason Gundersen, MD, director of the Family Medicine Hospitalist Service at the University of Massachusetts Medical Center, saw that “facilities often don’t want to hire family physicians as hospitalists because they lack hospital experience. [So I] wanted to give family practice residents extra training and experience in hospital medicine.”

The result was a hospitalist fellowship program, the goal of which “is to help improve employment opportunities. It enables graduates to go to employers with specific hospital medicine training,” says Dr. Gundersen. “This gives family physicians more experiences and abilities so they can navigate an uncertain market more successfully. There is a growing interest in hospitalist opportunities on the part of family physicians, and we need to prepare them to fill these roles.”

Despite the growing popularity of hospitalist training tracks and the enthusiasm many express about them, there are people who do not believe these programs are important or necessary. John Ford, MD, MPH, assistant professor of medicine at University of California at Los Angeles’ (UCLA) David Geffen School of Medicine, agrees.

“The first thing you have to understand is that internal medicine residency programs involve a tremendous amount of inpatient care anyway,” says Dr. Ford. “And a lot of what residents do is take care of hospital patients, so this training is adequate for a career choice as a hospitalist.”

“With the rise of hospitalists, people think that we need to emphasize hospital training more. But our residents already do a tremendous amount of hospital training,” he explains. “They do wards, ICU, and CCU; and even many of their electives—infectious disease and cardiology, for example—involve inpatient care. In addition, all of our residents have night float responsibilities, so they cover overflow patients and are in the hospital all night. We are training people pretty solidly for hospital practice.”

Dr. Ford believes it would a mistake for a resident to replace an ambulatory care rotation with a hospitalist track because he or she wants to be a hospitalist. “There is no question that hospitalists save money, lower lengths of stay, and improve patient outcomes and satisfaction,” he says. “But anyone can be a hospitalist. We aren’t an elite group of people.”

It is best to give hospitalists broad training, insists Dr. Ford, because “they still will need the actual job experience of working as a hospitalist to be effective in that role.” He adds that lack of a hospitalist program at UCLA in no way hurts his residents: “We are conventional here, but we do a superb job of education and training. Our residents are not at a disadvantage.”

His advice to residents who want to be hospitalists? “Pay attention—learn to do ambulatory medicine really well. This will help you tremendously when you perform as a hospitalist,” he explains. “You will have better sense of when someone can be discharged and who doesn’t need to come into hospital in the first place.”

Does Hospitalist Training Make a Difference?

“The feedback we’ve received so far makes it clear that this type of training helps people understand hospital medicine and better determine where they want to practice,” says Dr. Dressler. “Residents also have said that they like the variety of exposure to community settings. They said that they learned about activities and issues that they didn’t realize were part of physicians’ responsibilities, such as quality improvement and committee work.”

Dr. Dressler says that his health system has benefited from the program as well. “We have had some good residents stay to practice at one of our hospitals because their hospitalist training was such a positive experience,” he states.

Emory’s program has been in existence for only a few years. And while the number of participants remains small, Dr. Dressler says interest is growing: “We get about 5%-10% of residents in any given year. We are pleased with the turnout, and it has become more popular.”

Way of the Future

“We feel that all of this additional preparation is in our residents’ best interest,” states Dr. Rudmann. “We think it will be popular. Our residents are excited about it already.” He predicts that before long there will be many such programs around the nation. “Residency training programs will use these to gain a competitive edge to attract the best students.” TH

Writer Joanne Kaldy is based in Maryland.

Five years ago, a medical resident interested in pursuing a career as a hospitalist had few opportunities to receive specialized training. Five years from now, residents likely will have numerous hospitalist training tracks and electives from which to choose. This is partly thanks to a small group of pioneers who have seen the value of specialized hospitalist training for residents. These individuals have carefully considered what skills, information, and experience residents need to practice as confident and competent hospitalists, and they have developed programs and courses that meet these needs.

Sharpening Residents’ Focus

“Actually, we don’t call them ‘tracks,’ ” says Andrew Rudmann, MD, assistant professor of medicine and chief of the Hospital Medicine Division at the University of Rochester Medical Center. “We don’t want students to think that they’re stuck in an area once they choose it.”

Nonetheless, he notes, students increasingly are choosing careers as hospitalists, and they are expressing an interest in gaining skills and knowledge to help them become hospitalists.

Dr. Rudmann adds that his students “are sorting out their career plans earlier,” so it is important to offer specialized focus area programs. He has divided these into three areas: general medicine inpatient (hospitalist), general medicine outpatient (primary care), and subspecialty (other specialties).

The focus area programs are still in the developmental stage, Dr. Rudmann stresses. “We are in the process of developing the curricula for these programs, all of which will be elective experiences,” he says. Determining course options will be a challenge because there are a limited number of hours available for these electives. Nonetheless, Dr. Rudmann has identified several activities essential to producing effective hospitalists. These include:

• Rotation at a community hospital. “This program will focus on communication issues with primary care physicians,” explains Dr. Rudmann. “The students also will spend time in primary care offices to focus on the transition of patients from hospital to community care.”
• Quality improvement (QI) project. Residents will work one-on-one with hospitalists and develop a QI project from their work that they will present at the end of the rotation. As hospitalists, says Dr. Rudmann, these individuals frequently will be involved in QI initiatives and committees, and it is important that residents be prepared for these activities.
• Billing, coding, documentation mentorship. Each student will have a mentor, who will be required to instruct residents (either one-on-one or in small groups) about these issues. While billing, coding, and documentation are not glamorous, they are important components of a hospitalist practice, so Dr. Rudmann wants to ensure that residents are comfortable handling these activities.

Hospitalist students also will have the opportunity to spend time shadowing healthcare professionals in other areas such as the detox unit and bronchoscopy suite.

“It’s useful for a resident to spend time learning what these people do and what happens in these areas,” says Dr. Rudmann. “Our current healthcare system tends to be fragmented, and this experience will help physicians ensure smooth transitions for patients from one site to the next.”

Dr. Rudmann says he will suggest that residents interested in being hospitalists spend time in the ED observation unit. Additionally, these residents will be exposed to patient safety and medico-legal issues through active participation in morbidity/mortality conferences.

Residents also will have the opportunity to take a research elective course. However, Dr. Rudmann notes that students will need a real interest or passion for research to participate in this option, as it will consume one-half of their elective hours.

Day in the Life

Providing exposure to many of the day-to-day aspects of hospitalist practice is a key component of the hospitalist elective program at Emory University in Georgia.

“We wanted to provide residents with an opportunity to get some clinical exposure that they don’t necessarily get during general residency training and give them a better sense of what hospital medicine is—aside from taking care of patients in the hospital,” says Dan Dressler, MD, MSc, director of hospitalist medicine at the Emory University School of Medicine (Atlanta).

Emory’s hospitalist electives also give residents an opportunity to “pick the brains” of hospitalists. “They get to ask about things like schedules, committee involvement, research activities, and so on,” explains Dr. Dressler. “Residents really like this opportunity. They can feel isolated in the academic setting, and this really broadens their horizons.”

click for large version

Building a Hospitalist Track from the Ground Up

In developing Emory’s hospitalist elective program, Dr. Dressler sought guidance from colleagues at the University of California at San Francisco and the Mayo Clinic (Rochester, Minn.) who already had established specialized hospitalist education opportunities.

Still, developing a good program is not as easy as copying someone else’s efforts. In fact, Dr. Rudmann says that most of the ideas for Rochester’s program came from “a thorough self-examination process.”

“You don’t have to look far,” he explains. “Just look at your own program and talk to your own residents.”

One of the challenges of developing a hospitalist track is the limited time available for elective programs. Dr. Dressler suggests starting by “assessing what you already are doing in your general residency program. You don’t want to duplicate efforts. Determine what is being done well at your program already and what could be done additionally—either based on what others are doing or what should be considered core competencies in hospital medicine. Then implement the missing pieces.”

Even after all of these planning and self-examination efforts, Dr. Dressler cautions, “you probably won’t have enough time to do everything you want to do.” At this point, he suggests concentrating on those issues or skills for which “you have someone who is able and willing to teach and teach well.” For example, he suggested, “if you want to include training on QI but don’t have anyone who can teach this well, you might want to keep this as a goal for down the road.”

Problem-Solving as a Goal

Sometimes, hospitalist training programs can help solve a specific problem. For example, Jason Gundersen, MD, director of the Family Medicine Hospitalist Service at the University of Massachusetts Medical Center, saw that “facilities often don’t want to hire family physicians as hospitalists because they lack hospital experience. [So I] wanted to give family practice residents extra training and experience in hospital medicine.”

The result was a hospitalist fellowship program, the goal of which “is to help improve employment opportunities. It enables graduates to go to employers with specific hospital medicine training,” says Dr. Gundersen. “This gives family physicians more experiences and abilities so they can navigate an uncertain market more successfully. There is a growing interest in hospitalist opportunities on the part of family physicians, and we need to prepare them to fill these roles.”

Despite the growing popularity of hospitalist training tracks and the enthusiasm many express about them, there are people who do not believe these programs are important or necessary. John Ford, MD, MPH, assistant professor of medicine at University of California at Los Angeles’ (UCLA) David Geffen School of Medicine, agrees.

“The first thing you have to understand is that internal medicine residency programs involve a tremendous amount of inpatient care anyway,” says Dr. Ford. “And a lot of what residents do is take care of hospital patients, so this training is adequate for a career choice as a hospitalist.”

“With the rise of hospitalists, people think that we need to emphasize hospital training more. But our residents already do a tremendous amount of hospital training,” he explains. “They do wards, ICU, and CCU; and even many of their electives—infectious disease and cardiology, for example—involve inpatient care. In addition, all of our residents have night float responsibilities, so they cover overflow patients and are in the hospital all night. We are training people pretty solidly for hospital practice.”

Dr. Ford believes it would a mistake for a resident to replace an ambulatory care rotation with a hospitalist track because he or she wants to be a hospitalist. “There is no question that hospitalists save money, lower lengths of stay, and improve patient outcomes and satisfaction,” he says. “But anyone can be a hospitalist. We aren’t an elite group of people.”

It is best to give hospitalists broad training, insists Dr. Ford, because “they still will need the actual job experience of working as a hospitalist to be effective in that role.” He adds that lack of a hospitalist program at UCLA in no way hurts his residents: “We are conventional here, but we do a superb job of education and training. Our residents are not at a disadvantage.”

His advice to residents who want to be hospitalists? “Pay attention—learn to do ambulatory medicine really well. This will help you tremendously when you perform as a hospitalist,” he explains. “You will have better sense of when someone can be discharged and who doesn’t need to come into hospital in the first place.”

Does Hospitalist Training Make a Difference?

“The feedback we’ve received so far makes it clear that this type of training helps people understand hospital medicine and better determine where they want to practice,” says Dr. Dressler. “Residents also have said that they like the variety of exposure to community settings. They said that they learned about activities and issues that they didn’t realize were part of physicians’ responsibilities, such as quality improvement and committee work.”

Dr. Dressler says that his health system has benefited from the program as well. “We have had some good residents stay to practice at one of our hospitals because their hospitalist training was such a positive experience,” he states.

Emory’s program has been in existence for only a few years. And while the number of participants remains small, Dr. Dressler says interest is growing: “We get about 5%-10% of residents in any given year. We are pleased with the turnout, and it has become more popular.”

Way of the Future

“We feel that all of this additional preparation is in our residents’ best interest,” states Dr. Rudmann. “We think it will be popular. Our residents are excited about it already.” He predicts that before long there will be many such programs around the nation. “Residency training programs will use these to gain a competitive edge to attract the best students.” TH

Writer Joanne Kaldy is based in Maryland.

Five years ago, a medical resident interested in pursuing a career as a hospitalist had few opportunities to receive specialized training. Five years from now, residents likely will have numerous hospitalist training tracks and electives from which to choose. This is partly thanks to a small group of pioneers who have seen the value of specialized hospitalist training for residents. These individuals have carefully considered what skills, information, and experience residents need to practice as confident and competent hospitalists, and they have developed programs and courses that meet these needs.

Sharpening Residents’ Focus

“Actually, we don’t call them ‘tracks,’ ” says Andrew Rudmann, MD, assistant professor of medicine and chief of the Hospital Medicine Division at the University of Rochester Medical Center. “We don’t want students to think that they’re stuck in an area once they choose it.”

Nonetheless, he notes, students increasingly are choosing careers as hospitalists, and they are expressing an interest in gaining skills and knowledge to help them become hospitalists.

Dr. Rudmann adds that his students “are sorting out their career plans earlier,” so it is important to offer specialized focus area programs. He has divided these into three areas: general medicine inpatient (hospitalist), general medicine outpatient (primary care), and subspecialty (other specialties).

The focus area programs are still in the developmental stage, Dr. Rudmann stresses. “We are in the process of developing the curricula for these programs, all of which will be elective experiences,” he says. Determining course options will be a challenge because there are a limited number of hours available for these electives. Nonetheless, Dr. Rudmann has identified several activities essential to producing effective hospitalists. These include:

• Rotation at a community hospital. “This program will focus on communication issues with primary care physicians,” explains Dr. Rudmann. “The students also will spend time in primary care offices to focus on the transition of patients from hospital to community care.”
• Quality improvement (QI) project. Residents will work one-on-one with hospitalists and develop a QI project from their work that they will present at the end of the rotation. As hospitalists, says Dr. Rudmann, these individuals frequently will be involved in QI initiatives and committees, and it is important that residents be prepared for these activities.
• Billing, coding, documentation mentorship. Each student will have a mentor, who will be required to instruct residents (either one-on-one or in small groups) about these issues. While billing, coding, and documentation are not glamorous, they are important components of a hospitalist practice, so Dr. Rudmann wants to ensure that residents are comfortable handling these activities.

Hospitalist students also will have the opportunity to spend time shadowing healthcare professionals in other areas such as the detox unit and bronchoscopy suite.

“It’s useful for a resident to spend time learning what these people do and what happens in these areas,” says Dr. Rudmann. “Our current healthcare system tends to be fragmented, and this experience will help physicians ensure smooth transitions for patients from one site to the next.”

Dr. Rudmann says he will suggest that residents interested in being hospitalists spend time in the ED observation unit. Additionally, these residents will be exposed to patient safety and medico-legal issues through active participation in morbidity/mortality conferences.

Residents also will have the opportunity to take a research elective course. However, Dr. Rudmann notes that students will need a real interest or passion for research to participate in this option, as it will consume one-half of their elective hours.

Day in the Life

Providing exposure to many of the day-to-day aspects of hospitalist practice is a key component of the hospitalist elective program at Emory University in Georgia.

“We wanted to provide residents with an opportunity to get some clinical exposure that they don’t necessarily get during general residency training and give them a better sense of what hospital medicine is—aside from taking care of patients in the hospital,” says Dan Dressler, MD, MSc, director of hospitalist medicine at the Emory University School of Medicine (Atlanta).

Emory’s hospitalist electives also give residents an opportunity to “pick the brains” of hospitalists. “They get to ask about things like schedules, committee involvement, research activities, and so on,” explains Dr. Dressler. “Residents really like this opportunity. They can feel isolated in the academic setting, and this really broadens their horizons.”

click for large version

Building a Hospitalist Track from the Ground Up

In developing Emory’s hospitalist elective program, Dr. Dressler sought guidance from colleagues at the University of California at San Francisco and the Mayo Clinic (Rochester, Minn.) who already had established specialized hospitalist education opportunities.

Still, developing a good program is not as easy as copying someone else’s efforts. In fact, Dr. Rudmann says that most of the ideas for Rochester’s program came from “a thorough self-examination process.”

“You don’t have to look far,” he explains. “Just look at your own program and talk to your own residents.”

One of the challenges of developing a hospitalist track is the limited time available for elective programs. Dr. Dressler suggests starting by “assessing what you already are doing in your general residency program. You don’t want to duplicate efforts. Determine what is being done well at your program already and what could be done additionally—either based on what others are doing or what should be considered core competencies in hospital medicine. Then implement the missing pieces.”

Even after all of these planning and self-examination efforts, Dr. Dressler cautions, “you probably won’t have enough time to do everything you want to do.” At this point, he suggests concentrating on those issues or skills for which “you have someone who is able and willing to teach and teach well.” For example, he suggested, “if you want to include training on QI but don’t have anyone who can teach this well, you might want to keep this as a goal for down the road.”

Problem-Solving as a Goal

Sometimes, hospitalist training programs can help solve a specific problem. For example, Jason Gundersen, MD, director of the Family Medicine Hospitalist Service at the University of Massachusetts Medical Center, saw that “facilities often don’t want to hire family physicians as hospitalists because they lack hospital experience. [So I] wanted to give family practice residents extra training and experience in hospital medicine.”

The result was a hospitalist fellowship program, the goal of which “is to help improve employment opportunities. It enables graduates to go to employers with specific hospital medicine training,” says Dr. Gundersen. “This gives family physicians more experiences and abilities so they can navigate an uncertain market more successfully. There is a growing interest in hospitalist opportunities on the part of family physicians, and we need to prepare them to fill these roles.”

Despite the growing popularity of hospitalist training tracks and the enthusiasm many express about them, there are people who do not believe these programs are important or necessary. John Ford, MD, MPH, assistant professor of medicine at University of California at Los Angeles’ (UCLA) David Geffen School of Medicine, agrees.

“The first thing you have to understand is that internal medicine residency programs involve a tremendous amount of inpatient care anyway,” says Dr. Ford. “And a lot of what residents do is take care of hospital patients, so this training is adequate for a career choice as a hospitalist.”

“With the rise of hospitalists, people think that we need to emphasize hospital training more. But our residents already do a tremendous amount of hospital training,” he explains. “They do wards, ICU, and CCU; and even many of their electives—infectious disease and cardiology, for example—involve inpatient care. In addition, all of our residents have night float responsibilities, so they cover overflow patients and are in the hospital all night. We are training people pretty solidly for hospital practice.”

Dr. Ford believes it would a mistake for a resident to replace an ambulatory care rotation with a hospitalist track because he or she wants to be a hospitalist. “There is no question that hospitalists save money, lower lengths of stay, and improve patient outcomes and satisfaction,” he says. “But anyone can be a hospitalist. We aren’t an elite group of people.”

It is best to give hospitalists broad training, insists Dr. Ford, because “they still will need the actual job experience of working as a hospitalist to be effective in that role.” He adds that lack of a hospitalist program at UCLA in no way hurts his residents: “We are conventional here, but we do a superb job of education and training. Our residents are not at a disadvantage.”

His advice to residents who want to be hospitalists? “Pay attention—learn to do ambulatory medicine really well. This will help you tremendously when you perform as a hospitalist,” he explains. “You will have better sense of when someone can be discharged and who doesn’t need to come into hospital in the first place.”

Does Hospitalist Training Make a Difference?

“The feedback we’ve received so far makes it clear that this type of training helps people understand hospital medicine and better determine where they want to practice,” says Dr. Dressler. “Residents also have said that they like the variety of exposure to community settings. They said that they learned about activities and issues that they didn’t realize were part of physicians’ responsibilities, such as quality improvement and committee work.”

Dr. Dressler says that his health system has benefited from the program as well. “We have had some good residents stay to practice at one of our hospitals because their hospitalist training was such a positive experience,” he states.

Emory’s program has been in existence for only a few years. And while the number of participants remains small, Dr. Dressler says interest is growing: “We get about 5%-10% of residents in any given year. We are pleased with the turnout, and it has become more popular.”

Way of the Future

“We feel that all of this additional preparation is in our residents’ best interest,” states Dr. Rudmann. “We think it will be popular. Our residents are excited about it already.” He predicts that before long there will be many such programs around the nation. “Residency training programs will use these to gain a competitive edge to attract the best students.” TH

Writer Joanne Kaldy is based in Maryland.

As hospitalists become more prevalent in facilities nationwide, administrators and others increasingly seek out these practitioners to take a clinical leadership role. More than ever, this includes implementing clinical practice guidelines to maximize outcomes and standardize care processes. Guidelines may be called pathways, order sets, or protocols, but these evidence-based tools are being embraced by hospitals; and facilities leaders are encouraging physicians to jump on the bandwagon.

Why Use Guidelines?

Studies already show that hospitalists have a positive effect on lengths of stay and efficiency of care, and some have documented a correlation between hospitalist programs and outcomes. So why are guidelines necessary?

Guidelines use a foundation of evidence-based medicine, which promotes the use of proven practices and interventions. “Evidence-based medicine is tough to refute,” says Ken Simone, DO, founder and president of Hospitalist and Practice Solutions in Brewer, Maine. “Typically, when you see evidence-based medicine within a guideline, you can assume that you are improving medicine if you use the tool accurately.”

There are two reasons to employ guidelines, according to Richard Rubin, MD, MBA, chief medical officer, Seton Health Systems, Troy, N.Y. One is to ensure efficiency in providing care that is clinically based. The second reason is to ensure consistent quality by preventing variations in care from practitioner to practitioner.

“These tools serve as a road map, giving you an idea of where to go and how to get there,” says Dr. Rubin.

There are limited data from the literature documenting the value of guidelines in the hospital setting. However, one study looked at the effect of a clinical pathway on six outcomes of care in patients hospitalized for community-acquired pneumonia.1 The authors found that those patients managed by using a pathway were significantly less likely to die in-hospital compared with non-pathway patients. Pathway patients also were more likely to receive blood cultures and appropriate antibiotic therapy.

In patients with the most severe pneumonia, those managed via pathway had an 80% reduction in the odds of respiratory therapy requiring mechanical ventilation. Overall, the authors concluded that patients who were managed using a clinical pathway for pneumonia were more likely to experience positive outcomes than patients treated without these tools.

Another study looked a multidisciplinary approach to creating “templated” order sets for chemotherapy. The authors concluded that such tools reduced the duplication of effort by significantly lowering the number of changes made during the order verification process.2

Dr. Rubin undertook an internal study at his facility that found that using order sets was linked to shorter lengths of stay. He discovered that pathways were used 18% of the time for cases with the longest lengths of stays and 54% of the time with the shortest.

“There’s not much I don’t like about order sets,” says Dr. Rubin.

Todd Popp, MD, clinical partner, Critical Care and Pulmonary Consultants, Denver, agrees. “Of course, we want to use tools that help patients, and effective order sets help improve quality and efficiency,” he says.

Dr. Popp adds that guideline use has an added advantage for hospitalists. Those practitioners, he notes, who have a demonstrated ability to develop and implement order sets increasingly will be in demand.

“There is a fair amount of competition between hospitalist groups. If you can prove that you can develop, implement, and use these standards,” he says, “it helps hospitals and their patients, and it helps hospitalists get better contracts and have solid relationships with their facilities.”

In fact, says Dr. Simone, hospitalists who have experience and knowledge about guideline development and implementation will be considered tremendous assets by hospitals. “If the nationwide use of guidelines in hospitals isn’t common yet, it will be in the coming years. And hospitalists are perfectly positioned to take the lead on the effective development and use of these tools,” he offers.

Tools that Teach

Guidelines encourage standardization of care and help physicians and other clinicians quickly select appropriate assessments and interventions for various conditions. They also help prescribers make appropriate medication and dosage selections quickly and accurately. For example, an order set for admissions to a coronary care unit (CCU) for acute coronary syndrome likely will address considerations such as nursing orders, IVs, medications, diagnostic tests, consults, discharge planning, and primary care follow-up.

Used properly, these tools do not promote “cookbook” or “cookie cutter” medicine—as some opponents suggest; instead, they guide decision-making and enable practical, evidence-based choices for each patient.

Hospitals and hospitalists most frequently employ guidelines regarding the clinical conditions that most commonly lead to ED visits or hospital stays. These include community-acquired pneumonia, COPD, CHF, chest pain, MI, and stroke.

In choosing topics on which to implement guidelines, Dr. Simone suggests considering the demographics, needs, and challenges of the particular facility. For example, “if you have guidelines addressing diagnoses for which patients generally are put on 24-hour observation prior to hospital admission, you can ferret out who needs to be admitted and who doesn’t,” he says, adding, “and you can make these decisions in a consistent manner.”

Buy-in and Barriers

Hospitalists who use guidelines agree that they are natural leaders when it comes to the development, implementation, and use of these tools.

“As a hospitalist, I am employed by the hospital and have more of a stake in overall quality and cost-effectiveness of care,” says Justin Psaila, MD, of St. Luke’s Hospital in Bethlehem, Pa. “Some of the private attendings are doing their own thing and just see guidelines as creating more work.”

“Hospitals are looking for more standardized approaches to medical care via guidelines and order sets, and hospitalists can deliver this,” says Alex Strachan, Jr., MD, medical director for the Hospitalist Program at St. Joseph Hospital in Eureka, Calif., and medical director of Team Health West Hospital Medicine Programs. “There is a tremendous amount of teamwork involved in guideline implementation and use, and hospitalists are natural team players.”

In addition to working with facilities to develop and implement guidelines, hospitalists can help increase buy-in from other clinicians. This may involve working with facility leadership to develop materials to promote the guidelines to stakeholders, such as letters to attending physicians that outline how the guidelines will work, where they can obtain copies, how they can obtain electronic versions (if available), the advantages of using these tools, what to do if they don’t follow a step in the guideline (e.g., document the patient’s refusal to receive a particular treatment), and who to contact if they have questions about the guideline.

Despite all of the positives about guidelines and the growing number of physicians who use and embrace them, there continues to be some resistance to guideline use. “Many physicians still are hesitant to use guidelines,” explains Dr. Simone. “They feel as if they will lose some creativity and that it may obligate them to go in a particular direction.”

Even when a facility’s hospitalists are on board with guidelines, attending physicians—who usually are in the majority—who resist can prevent the documents from having a positive impact. Dr. Strachan offers an example: “If you have 50-100 medical staff admitting, they will use the antibiotics that they are most comfortable with—regardless of cost, staff time involved in medication administration, and so on. If even half of these buy into a guideline addressing antibiotic use, it can streamline medication management, administration, and costs considerably.”

Some physicians worry that guidelines put them at risk for lawsuits. “One physician said, ‘You put my back to the wall if I don’t do these things,’” says Dr. Simone. “However, good guidelines don’t set you up; they protect you. If you don’t follow a step or recommendation, you just need to document why.”

Often, some basic revisions can help overcome objections to guideline use. As Dr. Simone explains, “We had an order set that was five pages in length, and physicians balked at using it. They said that it was too complicated. So we winnowed it down to two to three concise pages, and now they all use it.”

He cautions that if guidelines are too confusing, complex, or long, they seem overwhelming and are less likely to be used.

Birth of a Hospitalist Guideline

While there are many clinical practice guidelines in existence that address a range of clinical issues and conditions, hospitalists and other physicians are more likely to use a tool they have helped create. Arun Tewari, MD, program director of the Hospitalist Program, Ball Memorial Hospital Medical Consultants, Muncie, Ind., has experienced this first-hand and has been involved in guideline development at his facility for the past three years.

“We’re just starting to track data, but we’ve already realized a reduced length of stay for all the pathways we use, including stroke, CHF, COPD, pneumonia, chest pains, MI, and GI bleed,” he says. “To date, the numbers are only statistically significant for pneumonia. However, we expect to see significant results in the other areas over time.”

Dr. Tewari and his group use a multidisciplinary approach to pathway development. “We invite key individuals from different disciplines and specialties to serve on a committee that is run by a physician and a nurse leader. These individuals are responsible for reviewing articles and other information and performing specific assigned tasks,” he explains.

The group starts with a tremendous amount of information. In addition to articles from the literature, they review national guidelines on the topic being addressed, as well as pathways used by other facilities or organizations.

The group takes the best clinical evidence and information they find, and they incorporate it into a tool that is useful and practical for the hospital.

“To be truly effective, these tools have to be institutionalized to your facility and practical in terms of what can be done or handled in this setting,” suggests Dr. Tewari.

Once the group reaches consensus on a completed draft, the document goes to several hospital committees for review. The original group then compiles the comments, makes any revisions or additions deemed necessary, and produces a final pathway. “This isn’t a short process,” cautions Dr. Tewari. On average it takes six months to a year from start to finish.

The final pathways are posted online, and physicians can print copies. Elsewhere, the pathways are available on the floors and in the emergency department as well. Currently, the pathways aren’t available for electronic applications such as PDAs. However, Dr. Tewari doesn’t rule this out as a possibility for the future.

Of course, Dr. Tewari emphasizes, just publishing a pathway or making it available to clinical staff isn’t enough. “You have to educate people about the pathways and gain their buy-in,” he notes. At his facility, each clinical department staff meeting involves a representative who will talk about pathways and spell out how to use them. This also presents another opportunity for practitioners and team leaders to have input on the tools.

The pathways aren’t mandatory, Dr. Tewari emphasizes, but they are strongly encouraged. “We don’t have statistics yet, but throughout the hospital, utilization probably is at about 50%. Within our hospitalist group, utilization is close to 100%. We hope to have some hard numbers soon to back this up.”

No Crystal Balls Needed: Guidelines Have a Future

Guidelines soundly rooted in evidence-based medicine have a future, predicts Dr. Simone.

“I think these are essential for the Medicare pay-for-performance measures that are coming down the pike. Medicare is likely to identify three to five different diagnoses to look at and may want hospitals to develop guidelines for these. Hospitals—as well as hospitalists and other physicians—will be rewarded if their performance is good in these areas based on these guidelines.”

Some hospitals already are using guidelines or order sets to prove quality. “We put our order sets together partly because we are part of a CMS [Centers for Medicare and Medicaid Services] pay-for-performance project,” says Dr. Psaila.

Guidelines that are commonly available via laptop or PDA also are coming. “Hospitalists tend to use technology more than other physicians, and they increasingly will want guideline applications for handheld devices,” notes Dr. Strachan.

There already are several companies offering such products. “Some of these are really useful tools,” he continues. “They allow you to pull up an order set for a particular illness and use it. You can click on medications and check the evidence basis for their use. You then can print out this information or transmit it electronically.”

The real future is to have electronic medical record solutions that interface with orders, predicts Dr. Strachan. However, he suggests that current availability and use of such systems is less than 10% of hospitals and hospitalists.

“I feel that it is essential that we develop various guidelines and use them in the hospital setting,” concludes Dr. Strachan. “We need to standardize our practice so that we can measure outcomes and quality of care doesn’t vary from one practitioner to another.” TH

Writer Joanne Kaldy also writes about hospitalist programs in this issue.

References

1. Hauck LD, Adler LM, Mulla ZD. Clinical pathway care improves outcomes among patients hospitalized for community-acquired pneumonia. Ann Epidemiol. 2004;14(9):669-675.
2. Dinning C, Branowicki P, O’Neill JB, et al. Chemotherapy error reduction: a multidisciplinary approach to create templated order sets. J Pediatr Oncol Nurs. 2005;22(1):20-30.

As hospitalists become more prevalent in facilities nationwide, administrators and others increasingly seek out these practitioners to take a clinical leadership role. More than ever, this includes implementing clinical practice guidelines to maximize outcomes and standardize care processes. Guidelines may be called pathways, order sets, or protocols, but these evidence-based tools are being embraced by hospitals; and facilities leaders are encouraging physicians to jump on the bandwagon.

Why Use Guidelines?

Studies already show that hospitalists have a positive effect on lengths of stay and efficiency of care, and some have documented a correlation between hospitalist programs and outcomes. So why are guidelines necessary?

Guidelines use a foundation of evidence-based medicine, which promotes the use of proven practices and interventions. “Evidence-based medicine is tough to refute,” says Ken Simone, DO, founder and president of Hospitalist and Practice Solutions in Brewer, Maine. “Typically, when you see evidence-based medicine within a guideline, you can assume that you are improving medicine if you use the tool accurately.”

There are two reasons to employ guidelines, according to Richard Rubin, MD, MBA, chief medical officer, Seton Health Systems, Troy, N.Y. One is to ensure efficiency in providing care that is clinically based. The second reason is to ensure consistent quality by preventing variations in care from practitioner to practitioner.

“These tools serve as a road map, giving you an idea of where to go and how to get there,” says Dr. Rubin.

There are limited data from the literature documenting the value of guidelines in the hospital setting. However, one study looked at the effect of a clinical pathway on six outcomes of care in patients hospitalized for community-acquired pneumonia.1 The authors found that those patients managed by using a pathway were significantly less likely to die in-hospital compared with non-pathway patients. Pathway patients also were more likely to receive blood cultures and appropriate antibiotic therapy.

In patients with the most severe pneumonia, those managed via pathway had an 80% reduction in the odds of respiratory therapy requiring mechanical ventilation. Overall, the authors concluded that patients who were managed using a clinical pathway for pneumonia were more likely to experience positive outcomes than patients treated without these tools.

Another study looked a multidisciplinary approach to creating “templated” order sets for chemotherapy. The authors concluded that such tools reduced the duplication of effort by significantly lowering the number of changes made during the order verification process.2

Dr. Rubin undertook an internal study at his facility that found that using order sets was linked to shorter lengths of stay. He discovered that pathways were used 18% of the time for cases with the longest lengths of stays and 54% of the time with the shortest.

“There’s not much I don’t like about order sets,” says Dr. Rubin.

Todd Popp, MD, clinical partner, Critical Care and Pulmonary Consultants, Denver, agrees. “Of course, we want to use tools that help patients, and effective order sets help improve quality and efficiency,” he says.

Dr. Popp adds that guideline use has an added advantage for hospitalists. Those practitioners, he notes, who have a demonstrated ability to develop and implement order sets increasingly will be in demand.

“There is a fair amount of competition between hospitalist groups. If you can prove that you can develop, implement, and use these standards,” he says, “it helps hospitals and their patients, and it helps hospitalists get better contracts and have solid relationships with their facilities.”

In fact, says Dr. Simone, hospitalists who have experience and knowledge about guideline development and implementation will be considered tremendous assets by hospitals. “If the nationwide use of guidelines in hospitals isn’t common yet, it will be in the coming years. And hospitalists are perfectly positioned to take the lead on the effective development and use of these tools,” he offers.

Tools that Teach

Guidelines encourage standardization of care and help physicians and other clinicians quickly select appropriate assessments and interventions for various conditions. They also help prescribers make appropriate medication and dosage selections quickly and accurately. For example, an order set for admissions to a coronary care unit (CCU) for acute coronary syndrome likely will address considerations such as nursing orders, IVs, medications, diagnostic tests, consults, discharge planning, and primary care follow-up.

Used properly, these tools do not promote “cookbook” or “cookie cutter” medicine—as some opponents suggest; instead, they guide decision-making and enable practical, evidence-based choices for each patient.

Hospitals and hospitalists most frequently employ guidelines regarding the clinical conditions that most commonly lead to ED visits or hospital stays. These include community-acquired pneumonia, COPD, CHF, chest pain, MI, and stroke.

In choosing topics on which to implement guidelines, Dr. Simone suggests considering the demographics, needs, and challenges of the particular facility. For example, “if you have guidelines addressing diagnoses for which patients generally are put on 24-hour observation prior to hospital admission, you can ferret out who needs to be admitted and who doesn’t,” he says, adding, “and you can make these decisions in a consistent manner.”

Buy-in and Barriers

Hospitalists who use guidelines agree that they are natural leaders when it comes to the development, implementation, and use of these tools.

“As a hospitalist, I am employed by the hospital and have more of a stake in overall quality and cost-effectiveness of care,” says Justin Psaila, MD, of St. Luke’s Hospital in Bethlehem, Pa. “Some of the private attendings are doing their own thing and just see guidelines as creating more work.”

“Hospitals are looking for more standardized approaches to medical care via guidelines and order sets, and hospitalists can deliver this,” says Alex Strachan, Jr., MD, medical director for the Hospitalist Program at St. Joseph Hospital in Eureka, Calif., and medical director of Team Health West Hospital Medicine Programs. “There is a tremendous amount of teamwork involved in guideline implementation and use, and hospitalists are natural team players.”

In addition to working with facilities to develop and implement guidelines, hospitalists can help increase buy-in from other clinicians. This may involve working with facility leadership to develop materials to promote the guidelines to stakeholders, such as letters to attending physicians that outline how the guidelines will work, where they can obtain copies, how they can obtain electronic versions (if available), the advantages of using these tools, what to do if they don’t follow a step in the guideline (e.g., document the patient’s refusal to receive a particular treatment), and who to contact if they have questions about the guideline.

Despite all of the positives about guidelines and the growing number of physicians who use and embrace them, there continues to be some resistance to guideline use. “Many physicians still are hesitant to use guidelines,” explains Dr. Simone. “They feel as if they will lose some creativity and that it may obligate them to go in a particular direction.”

Even when a facility’s hospitalists are on board with guidelines, attending physicians—who usually are in the majority—who resist can prevent the documents from having a positive impact. Dr. Strachan offers an example: “If you have 50-100 medical staff admitting, they will use the antibiotics that they are most comfortable with—regardless of cost, staff time involved in medication administration, and so on. If even half of these buy into a guideline addressing antibiotic use, it can streamline medication management, administration, and costs considerably.”

Some physicians worry that guidelines put them at risk for lawsuits. “One physician said, ‘You put my back to the wall if I don’t do these things,’” says Dr. Simone. “However, good guidelines don’t set you up; they protect you. If you don’t follow a step or recommendation, you just need to document why.”

Often, some basic revisions can help overcome objections to guideline use. As Dr. Simone explains, “We had an order set that was five pages in length, and physicians balked at using it. They said that it was too complicated. So we winnowed it down to two to three concise pages, and now they all use it.”

He cautions that if guidelines are too confusing, complex, or long, they seem overwhelming and are less likely to be used.

Birth of a Hospitalist Guideline

While there are many clinical practice guidelines in existence that address a range of clinical issues and conditions, hospitalists and other physicians are more likely to use a tool they have helped create. Arun Tewari, MD, program director of the Hospitalist Program, Ball Memorial Hospital Medical Consultants, Muncie, Ind., has experienced this first-hand and has been involved in guideline development at his facility for the past three years.

“We’re just starting to track data, but we’ve already realized a reduced length of stay for all the pathways we use, including stroke, CHF, COPD, pneumonia, chest pains, MI, and GI bleed,” he says. “To date, the numbers are only statistically significant for pneumonia. However, we expect to see significant results in the other areas over time.”

Dr. Tewari and his group use a multidisciplinary approach to pathway development. “We invite key individuals from different disciplines and specialties to serve on a committee that is run by a physician and a nurse leader. These individuals are responsible for reviewing articles and other information and performing specific assigned tasks,” he explains.

The group starts with a tremendous amount of information. In addition to articles from the literature, they review national guidelines on the topic being addressed, as well as pathways used by other facilities or organizations.

The group takes the best clinical evidence and information they find, and they incorporate it into a tool that is useful and practical for the hospital.

“To be truly effective, these tools have to be institutionalized to your facility and practical in terms of what can be done or handled in this setting,” suggests Dr. Tewari.

Once the group reaches consensus on a completed draft, the document goes to several hospital committees for review. The original group then compiles the comments, makes any revisions or additions deemed necessary, and produces a final pathway. “This isn’t a short process,” cautions Dr. Tewari. On average it takes six months to a year from start to finish.

The final pathways are posted online, and physicians can print copies. Elsewhere, the pathways are available on the floors and in the emergency department as well. Currently, the pathways aren’t available for electronic applications such as PDAs. However, Dr. Tewari doesn’t rule this out as a possibility for the future.

Of course, Dr. Tewari emphasizes, just publishing a pathway or making it available to clinical staff isn’t enough. “You have to educate people about the pathways and gain their buy-in,” he notes. At his facility, each clinical department staff meeting involves a representative who will talk about pathways and spell out how to use them. This also presents another opportunity for practitioners and team leaders to have input on the tools.

The pathways aren’t mandatory, Dr. Tewari emphasizes, but they are strongly encouraged. “We don’t have statistics yet, but throughout the hospital, utilization probably is at about 50%. Within our hospitalist group, utilization is close to 100%. We hope to have some hard numbers soon to back this up.”

No Crystal Balls Needed: Guidelines Have a Future

Guidelines soundly rooted in evidence-based medicine have a future, predicts Dr. Simone.

“I think these are essential for the Medicare pay-for-performance measures that are coming down the pike. Medicare is likely to identify three to five different diagnoses to look at and may want hospitals to develop guidelines for these. Hospitals—as well as hospitalists and other physicians—will be rewarded if their performance is good in these areas based on these guidelines.”

Some hospitals already are using guidelines or order sets to prove quality. “We put our order sets together partly because we are part of a CMS [Centers for Medicare and Medicaid Services] pay-for-performance project,” says Dr. Psaila.

Guidelines that are commonly available via laptop or PDA also are coming. “Hospitalists tend to use technology more than other physicians, and they increasingly will want guideline applications for handheld devices,” notes Dr. Strachan.

There already are several companies offering such products. “Some of these are really useful tools,” he continues. “They allow you to pull up an order set for a particular illness and use it. You can click on medications and check the evidence basis for their use. You then can print out this information or transmit it electronically.”

The real future is to have electronic medical record solutions that interface with orders, predicts Dr. Strachan. However, he suggests that current availability and use of such systems is less than 10% of hospitals and hospitalists.

“I feel that it is essential that we develop various guidelines and use them in the hospital setting,” concludes Dr. Strachan. “We need to standardize our practice so that we can measure outcomes and quality of care doesn’t vary from one practitioner to another.” TH

Writer Joanne Kaldy also writes about hospitalist programs in this issue.

References

1. Hauck LD, Adler LM, Mulla ZD. Clinical pathway care improves outcomes among patients hospitalized for community-acquired pneumonia. Ann Epidemiol. 2004;14(9):669-675.
2. Dinning C, Branowicki P, O’Neill JB, et al. Chemotherapy error reduction: a multidisciplinary approach to create templated order sets. J Pediatr Oncol Nurs. 2005;22(1):20-30.

As hospitalists become more prevalent in facilities nationwide, administrators and others increasingly seek out these practitioners to take a clinical leadership role. More than ever, this includes implementing clinical practice guidelines to maximize outcomes and standardize care processes. Guidelines may be called pathways, order sets, or protocols, but these evidence-based tools are being embraced by hospitals; and facilities leaders are encouraging physicians to jump on the bandwagon.

Why Use Guidelines?

Studies already show that hospitalists have a positive effect on lengths of stay and efficiency of care, and some have documented a correlation between hospitalist programs and outcomes. So why are guidelines necessary?

Guidelines use a foundation of evidence-based medicine, which promotes the use of proven practices and interventions. “Evidence-based medicine is tough to refute,” says Ken Simone, DO, founder and president of Hospitalist and Practice Solutions in Brewer, Maine. “Typically, when you see evidence-based medicine within a guideline, you can assume that you are improving medicine if you use the tool accurately.”

There are two reasons to employ guidelines, according to Richard Rubin, MD, MBA, chief medical officer, Seton Health Systems, Troy, N.Y. One is to ensure efficiency in providing care that is clinically based. The second reason is to ensure consistent quality by preventing variations in care from practitioner to practitioner.

“These tools serve as a road map, giving you an idea of where to go and how to get there,” says Dr. Rubin.

There are limited data from the literature documenting the value of guidelines in the hospital setting. However, one study looked at the effect of a clinical pathway on six outcomes of care in patients hospitalized for community-acquired pneumonia.1 The authors found that those patients managed by using a pathway were significantly less likely to die in-hospital compared with non-pathway patients. Pathway patients also were more likely to receive blood cultures and appropriate antibiotic therapy.

In patients with the most severe pneumonia, those managed via pathway had an 80% reduction in the odds of respiratory therapy requiring mechanical ventilation. Overall, the authors concluded that patients who were managed using a clinical pathway for pneumonia were more likely to experience positive outcomes than patients treated without these tools.

Another study looked a multidisciplinary approach to creating “templated” order sets for chemotherapy. The authors concluded that such tools reduced the duplication of effort by significantly lowering the number of changes made during the order verification process.2

Dr. Rubin undertook an internal study at his facility that found that using order sets was linked to shorter lengths of stay. He discovered that pathways were used 18% of the time for cases with the longest lengths of stays and 54% of the time with the shortest.

“There’s not much I don’t like about order sets,” says Dr. Rubin.

Todd Popp, MD, clinical partner, Critical Care and Pulmonary Consultants, Denver, agrees. “Of course, we want to use tools that help patients, and effective order sets help improve quality and efficiency,” he says.

Dr. Popp adds that guideline use has an added advantage for hospitalists. Those practitioners, he notes, who have a demonstrated ability to develop and implement order sets increasingly will be in demand.

“There is a fair amount of competition between hospitalist groups. If you can prove that you can develop, implement, and use these standards,” he says, “it helps hospitals and their patients, and it helps hospitalists get better contracts and have solid relationships with their facilities.”

In fact, says Dr. Simone, hospitalists who have experience and knowledge about guideline development and implementation will be considered tremendous assets by hospitals. “If the nationwide use of guidelines in hospitals isn’t common yet, it will be in the coming years. And hospitalists are perfectly positioned to take the lead on the effective development and use of these tools,” he offers.

Tools that Teach

Guidelines encourage standardization of care and help physicians and other clinicians quickly select appropriate assessments and interventions for various conditions. They also help prescribers make appropriate medication and dosage selections quickly and accurately. For example, an order set for admissions to a coronary care unit (CCU) for acute coronary syndrome likely will address considerations such as nursing orders, IVs, medications, diagnostic tests, consults, discharge planning, and primary care follow-up.

Used properly, these tools do not promote “cookbook” or “cookie cutter” medicine—as some opponents suggest; instead, they guide decision-making and enable practical, evidence-based choices for each patient.

Hospitals and hospitalists most frequently employ guidelines regarding the clinical conditions that most commonly lead to ED visits or hospital stays. These include community-acquired pneumonia, COPD, CHF, chest pain, MI, and stroke.

In choosing topics on which to implement guidelines, Dr. Simone suggests considering the demographics, needs, and challenges of the particular facility. For example, “if you have guidelines addressing diagnoses for which patients generally are put on 24-hour observation prior to hospital admission, you can ferret out who needs to be admitted and who doesn’t,” he says, adding, “and you can make these decisions in a consistent manner.”

Buy-in and Barriers

Hospitalists who use guidelines agree that they are natural leaders when it comes to the development, implementation, and use of these tools.

“As a hospitalist, I am employed by the hospital and have more of a stake in overall quality and cost-effectiveness of care,” says Justin Psaila, MD, of St. Luke’s Hospital in Bethlehem, Pa. “Some of the private attendings are doing their own thing and just see guidelines as creating more work.”

“Hospitals are looking for more standardized approaches to medical care via guidelines and order sets, and hospitalists can deliver this,” says Alex Strachan, Jr., MD, medical director for the Hospitalist Program at St. Joseph Hospital in Eureka, Calif., and medical director of Team Health West Hospital Medicine Programs. “There is a tremendous amount of teamwork involved in guideline implementation and use, and hospitalists are natural team players.”

In addition to working with facilities to develop and implement guidelines, hospitalists can help increase buy-in from other clinicians. This may involve working with facility leadership to develop materials to promote the guidelines to stakeholders, such as letters to attending physicians that outline how the guidelines will work, where they can obtain copies, how they can obtain electronic versions (if available), the advantages of using these tools, what to do if they don’t follow a step in the guideline (e.g., document the patient’s refusal to receive a particular treatment), and who to contact if they have questions about the guideline.

Despite all of the positives about guidelines and the growing number of physicians who use and embrace them, there continues to be some resistance to guideline use. “Many physicians still are hesitant to use guidelines,” explains Dr. Simone. “They feel as if they will lose some creativity and that it may obligate them to go in a particular direction.”

Even when a facility’s hospitalists are on board with guidelines, attending physicians—who usually are in the majority—who resist can prevent the documents from having a positive impact. Dr. Strachan offers an example: “If you have 50-100 medical staff admitting, they will use the antibiotics that they are most comfortable with—regardless of cost, staff time involved in medication administration, and so on. If even half of these buy into a guideline addressing antibiotic use, it can streamline medication management, administration, and costs considerably.”

Some physicians worry that guidelines put them at risk for lawsuits. “One physician said, ‘You put my back to the wall if I don’t do these things,’” says Dr. Simone. “However, good guidelines don’t set you up; they protect you. If you don’t follow a step or recommendation, you just need to document why.”

Often, some basic revisions can help overcome objections to guideline use. As Dr. Simone explains, “We had an order set that was five pages in length, and physicians balked at using it. They said that it was too complicated. So we winnowed it down to two to three concise pages, and now they all use it.”

He cautions that if guidelines are too confusing, complex, or long, they seem overwhelming and are less likely to be used.

Birth of a Hospitalist Guideline

While there are many clinical practice guidelines in existence that address a range of clinical issues and conditions, hospitalists and other physicians are more likely to use a tool they have helped create. Arun Tewari, MD, program director of the Hospitalist Program, Ball Memorial Hospital Medical Consultants, Muncie, Ind., has experienced this first-hand and has been involved in guideline development at his facility for the past three years.

“We’re just starting to track data, but we’ve already realized a reduced length of stay for all the pathways we use, including stroke, CHF, COPD, pneumonia, chest pains, MI, and GI bleed,” he says. “To date, the numbers are only statistically significant for pneumonia. However, we expect to see significant results in the other areas over time.”

Dr. Tewari and his group use a multidisciplinary approach to pathway development. “We invite key individuals from different disciplines and specialties to serve on a committee that is run by a physician and a nurse leader. These individuals are responsible for reviewing articles and other information and performing specific assigned tasks,” he explains.

The group starts with a tremendous amount of information. In addition to articles from the literature, they review national guidelines on the topic being addressed, as well as pathways used by other facilities or organizations.

The group takes the best clinical evidence and information they find, and they incorporate it into a tool that is useful and practical for the hospital.

“To be truly effective, these tools have to be institutionalized to your facility and practical in terms of what can be done or handled in this setting,” suggests Dr. Tewari.

Once the group reaches consensus on a completed draft, the document goes to several hospital committees for review. The original group then compiles the comments, makes any revisions or additions deemed necessary, and produces a final pathway. “This isn’t a short process,” cautions Dr. Tewari. On average it takes six months to a year from start to finish.

The final pathways are posted online, and physicians can print copies. Elsewhere, the pathways are available on the floors and in the emergency department as well. Currently, the pathways aren’t available for electronic applications such as PDAs. However, Dr. Tewari doesn’t rule this out as a possibility for the future.

Of course, Dr. Tewari emphasizes, just publishing a pathway or making it available to clinical staff isn’t enough. “You have to educate people about the pathways and gain their buy-in,” he notes. At his facility, each clinical department staff meeting involves a representative who will talk about pathways and spell out how to use them. This also presents another opportunity for practitioners and team leaders to have input on the tools.

The pathways aren’t mandatory, Dr. Tewari emphasizes, but they are strongly encouraged. “We don’t have statistics yet, but throughout the hospital, utilization probably is at about 50%. Within our hospitalist group, utilization is close to 100%. We hope to have some hard numbers soon to back this up.”

No Crystal Balls Needed: Guidelines Have a Future

Guidelines soundly rooted in evidence-based medicine have a future, predicts Dr. Simone.

“I think these are essential for the Medicare pay-for-performance measures that are coming down the pike. Medicare is likely to identify three to five different diagnoses to look at and may want hospitals to develop guidelines for these. Hospitals—as well as hospitalists and other physicians—will be rewarded if their performance is good in these areas based on these guidelines.”

Some hospitals already are using guidelines or order sets to prove quality. “We put our order sets together partly because we are part of a CMS [Centers for Medicare and Medicaid Services] pay-for-performance project,” says Dr. Psaila.

Guidelines that are commonly available via laptop or PDA also are coming. “Hospitalists tend to use technology more than other physicians, and they increasingly will want guideline applications for handheld devices,” notes Dr. Strachan.

There already are several companies offering such products. “Some of these are really useful tools,” he continues. “They allow you to pull up an order set for a particular illness and use it. You can click on medications and check the evidence basis for their use. You then can print out this information or transmit it electronically.”

The real future is to have electronic medical record solutions that interface with orders, predicts Dr. Strachan. However, he suggests that current availability and use of such systems is less than 10% of hospitals and hospitalists.

“I feel that it is essential that we develop various guidelines and use them in the hospital setting,” concludes Dr. Strachan. “We need to standardize our practice so that we can measure outcomes and quality of care doesn’t vary from one practitioner to another.” TH

Writer Joanne Kaldy also writes about hospitalist programs in this issue.

References

1. Hauck LD, Adler LM, Mulla ZD. Clinical pathway care improves outcomes among patients hospitalized for community-acquired pneumonia. Ann Epidemiol. 2004;14(9):669-675.
2. Dinning C, Branowicki P, O’Neill JB, et al. Chemotherapy error reduction: a multidisciplinary approach to create templated order sets. J Pediatr Oncol Nurs. 2005;22(1):20-30.

Many studies have been published in recent years about the effect of hospitalists on outcomes, efficiency, and cost-effectiveness of care (see also “In the Literature,” p. 30). While the studies have demonstrated varying results, the majority suggest that hospitalists contribute positively to care. And the tremendous growth of hospitalist programs nationwide indicates that hospital administrators and others agree.

Does this mean that there have been enough studies about the cost-effectiveness and efficiency of hospitalists, and about outcomes relating to hospitalists? Also, where should hospitalist research go next?

Looking Back

To date, the results of studies regarding hospitalists and their effect on outcomes and cost-effectiveness have varied. Most suggest positive correlations:

• Diamond, Goldberg, and Janosky demonstrated a 54% decrease in hospital readmission rates and shorter LOS when a community teaching hospital implemented full-time faculty hospitalists.1
• Auerbach, Wachter, and colleagues studied 5,308 patients cared for by hospitalists and community physicians at a community teaching hospital. They found that the voluntary hospitalist service reduced lengths of stay and costs that were statistically significant in the second year the services were used.2
• Bellet and Whitaker compared traditional ward service with a hospitalist system of care at a pediatric teaching hospital and found that the average LOS was a day shorter for the patients care for by hospitalists.3
• A review of five years of evidence-based hospitalist studies showed an average 13.4% cost reduction, as well as a 16.6% LOS reduction.4
• Rifkin, et al, compared treatment provided by hospitalist and primary care physicians among patients with community-acquired pneumonia. The authors found that hospitalists’ patients had shorter LOS and reduced costs.5
• Wachter reviewed the data to date in 2002 and concluded that it supported the hypothesis that hospitalists can lead to improved efficiency without compromising patient outcomes or satisfaction.6
• Meltzer, et al, studied costs and outcomes associated with patients on an academic general medical service cared for by hospitalists and non-hospitalists. They found that the average adjusted costs were similar for hospitalists and non-hospitalists in the first year. However, hospitalist costs were reduced by $782 in year two. The authors also concluded that short-term mortality was lower for hospitalists as well, but, again, only in the second year.7
• Auerbach and Pantilat assessed the effects of hospitalists’ care on communication, care patterns, and outcomes of end-of-life patients. They found that hospitalists documented “substantial efforts” to communicate with their dying patients and their families; and this may have resulted in better care.8
• Hauer, et al, analyzed house staff and student evaluations of their attending physicians and internal medicine ward rotations at two university-affiliated teaching hospitals over a two-year period. They found that trainees reported they received more effective teaching and more satisfying inpatient rotations when supervised by hospitalists.9

Studies that “go under the hood and answer questions about the mechanisms by which hospitalists improve outcomes” also will be useful. “Hospitals need to realize that hospitalists aren’t a magic bullet. It’s not as simple as implementing a hospitalist model of care and costs go down.”

—Peter Lindenauer, MD, MSc

A few studies have indicated that hospitalists may have less impact on costs and outcomes. Among them:

• Smith, Westfall, and Nicholas performed a retrospective chart review of HMO critical care patients and found that the mean charge by primary care physicians ($5,680) was significantly lower than that of the hospitalists ($7,699). The authors suggested that “claims of better and cheaper care by hospitalists need further investigation” and that HMOs should not mandate the use of hospitalists.10
• Kearns, et al, compared clinical outcomes and care costs for patients treated by hospital- and clinic-based attending physicians. The researchers detected no difference in costs or clinical outcomes associated with either type of physician.11

Clearly, the majority of the studies suggest that hospitalists have a positive effect on outcomes, effectiveness, and/or costs. But can the research take credit for the growing popularity of hospitalists?

“The studies have gone a long way toward proving the value of hospitalist care. But the experiences of physicians and hospitals also have been very positive,” says Robert Wachter, MD, FACP, professor of medicine at the University of California, San Francisco, associate chairman of UCSF’s Department of Medicine, and chief of the Medical Service at UCSF Medical Center. He adds that the studies wouldn’t mean much if the experiences of hospitals didn’t back up their findings.

So what has been learned from hospitalist studies on costs and outcomes to date? The data “suggest that hospitalists have the greatest impact on efficiency,” says Dr. Wachter, in part because “it is much easier to measure lengths of stay than improvements in outcomes.” He states that data are “strong on cost-effectiveness and reducing lengths of stay.”

Dr. Wachter says that the greatest effect of hospitalist studies to date has been “the presence of a very large number of energetic, enthusiastic physicians who ‘live’ in the hospital and have embraced the notion that they are there not only to improve care but to benefit the hospital and contribute to making it a better place. We have seen hospitalists emerge as leaders on virtually every committee aimed at improving care.”

Peter Lindenauer, MD, MSc, a hospitalist at Baystate Medical Center in Springfield, Mass., and assistant professor of medicine at Tufts University School of Medical School, Boston, agrees.

“What’s been most astounding has been the growth of the field,” he says. “And one of the more interesting facets has been the extent to which hospitalists have fully integrated themselves into every aspect of hospital operations and care in a short period of time.

“It is now rare to find hospitals that do not have hospitalists,” continues Dr. Lindenauer. “It also is uncommon to see quality improvement, patient safety, patient satisfaction, and other activities at the hospital that don’t have a hospitalist as a key member.”

Nonetheless, there is always room for improvement. While the data “are quite clear that efficiency improves without harming quality, they are not strong enough to show definitively that hospitalists improve quality and safety,” cautions Dr. Wachter. “We need more data on this.”

He cautions that data involving mature hospitalist programs may not show the same increases in efficiency as studies about new or young programs. He refers to a study coming out next year that looks at six academic medical centers and mature hospitalists programs and doesn’t show the same increase in efficiency as earlier studies.

“It may be natural that some efficiency may wash away. As hospitalists become more dominant, they set the practice style and standards for their hospitals,” he says. “We need to continue to look for ways to improve.” However, he stresses that none of this takes away from the original argument that hospitalists improve efficiency.

The Next Generation of Hospitalist Studies

Dr. Wachter suggests that the next generation of hospitalist research will have greater impact and importance if it goes beyond examining efficiency and cost-effectiveness.

“I don’t think the studies we began years ago are very interesting anymore, and I don’t think the system is looking for more of them,” he says. Now, research needs to look at the role of hospitalists—the role of hospitalists in teaching hospitals, what physicians make the best hospitalists, and so on.

Dr. Lindenauer would like to see more studies about hospitalists’ impact on quality of care. “There remains a relative paucity of information on this,” he says. “To date, there have been mostly small observational studies on this.” There is a need “to learn more about the impact of hospitalists, especially on more clinical outcomes and quality.”

Studies that “go under the hood and answer questions about the mechanisms by which hospitalists improve outcomes” also will be useful predicts Dr. Lindenauer. “Hospitals need to realize that hospitalists aren’t a magic bullet. It’s not as simple as implementing a hospitalist model of care and costs go down.”

Results of such studies need to be shared with hospitals nationwide so they can make the best and most effective use of hospitalists.

Studies addressing hospitalists working in specialty areas also are likely to become more common in the future, says Michael Phy, DO, MSC, associate program director and assistant professor at Texas Tech University Health Sciences Center in Austin, Texas. Earlier this year, he and his colleagues published a study looking at the hospitalist’s impact on geriatric surgical patients.12 During a two-year period, Dr. Phy and his team studied 466 elderly patients admitted to a hospital for surgical repair of a hip fracture. They found that a hospitalist model decreased the time to surgery, as well as the time from surgery to discharge, without adversely affecting mortality.

Dr. Phy’s study has interested other hospitals around the country. “We’ve been invited to speak on the model. People want to know how we did it, what the flaws were,” he explains. “The say that they are interested in using this kind of model, and they want to learn how to do it.

“I would like to see more studies about patient satisfaction and hospitalists,” says Dr. Phy. He also thinks that more studies about the impact of hospitalists on resident education will be useful. “There are a lot of studies about hospitalist involvement with residents; I am more interested in hospitalist’s indirect impact on residents. Does resident education improve when they are not so overworked because they have hospitalists who help provide patient care?”

In contrast, David Meltzer, MD, PhD, a hospitalist and an associate professor of medicine, General Internal Medicine, at the University of Chicago, doesn’t see patient satisfaction as a priority for the future. “Patient satisfaction isn’t an unreasonable thing to study,” he asserts. “But I personally don’t think that this is the most important issue.

“I don’t know what future studies will look like. I would like to say that we will see more and bigger studies,” continues Dr. Meltzer. “I also think we’ll see more studies about hospitalists in the community environment, more studies on mechanisms, and more hospitalists doing research on hospital care.”

To date, “hospitalist studies have been messy and ask the wrong questions,” says Robert Centor, MD, director of the Division of Internal Medicine, professor of internal medicine, and associate dean at the Huntsville Regional Medical Center in Alabama. He suggests that future studies should “look at hospitalists as a function of years of experience—first-year hospitalists compared to second, third, and forth.” Another useful focus would be to compare hospitalists with non-hospitalists, looking at “volume and lengths of stay and where the curve straightens out.”

Hurdling the Barriers

Especially as they get larger and involve more facilities, hospitalist studies will face some challenges. “Different people define hospitalists in different ways. It’s hard to tell what definitions studies are using; so in looking at two studies or trying to compare a study to what is happening at your facility, you don’t know if you’re comparing apples to apples or apples to oranges,” says Dr. Centor.

The nature of studies addressing hospitalist quality also poses some challenges. “Quality improvement interventions are harder to measure and are more institutionally dependent. Results can’t necessarily be translated from one institution to another,” explains Dr. Lindenauer.

He suggests that identifying funding sources for hospitalist studies will be an ongoing challenge. Researchers will be competing for an already shrinking number of dollars.

“The funding base for producing knowledge is limited, especially for studies that are not intrinsically disease-focused,” agrees Dr. Meltzer.

There is some organizational support for hospitalist researchers. For example, Dr. Phy notes that the SHM Web site will soon have a page where “you can list yourself and your clinical research interests, with the goal of hooking up with collaborators or mentors.”

The Third Generation

“At a certain point, we will turn our attention away from ‘navel gazing’—constantly assessing our impact—and accept that the hospitalist model is here to stay. Then hospitalists will begin to conduct research about the management of common conditions we take care of on a day-to-day basis—asthma, pneumonia, heart failure, COPD, and so on,” says Dr. Lindenauer. This is the third generation of hospitalist research, he suggests, adding, “This is where I would like to see the field evolve.” TH

Contributing Writer Joanne Kaldy wrote about psychiatric hospitalists in the October 2005 issue.

References

1. Diamond HS, Goldberg E, Janosky JE. The effect of full-time faculty hospitalists on the efficiency of care at a community teaching hospital. Ann Intern Med. 1999;130:338-342.
2. Auerbach AD, Wachter RM, Katz P, et al. Implementation of a voluntary hospitalist service at a community teaching hospital: improved clinical efficiency and patient outcomes. Ann Intern Med. 2002:137;859-865.
3. Bellet PS, Whitaker RC. Evaluation of a pediatric hospitalist service: impact on length of stay and hospital charges. Pediatrics. 2000;105(3):478-484.
4. No author listed. Hospitalist prove their worth for capitated providers, plans. Capitation Manag Rep. 2002;Apr;9(4):62-64, 49.
5. Rifkin WD, Conner D, Silver A, et al. Comparison of processes and outcomes of pneumonia care between hospitalists and community-based primary care physicians. Mayo Clin Proc. 2002;77(10):1053-1058.
6. Wachter RM. The evolution of the hospitalist model in the United States. Med Clin North Am. 2002;86(4):687-706.
7. Meltzer D, Manning WG, Morrison J, et al. Effects of physician experience on costs and outcomes on an academic general medicine service: results of a trial of hospitalists. Ann Intern Med. 2002;137:866-874.
8. Auerbach AD, Pantilat SZ. End-of-life care in a voluntary hospitalist model: effects on communication, processes of care, and patient symptoms. Am J Med. 2004;116(10):669-675.
9. Hauer KE, Wachter RM, McCulloch CE, et al. Effects of hospitalist attending physicians on trainee satisfaction with teaching and with internal medicine rotations. Arch Intern Med. 2004;164(17):1866-1871.
10. Smith PC, Westfall JM, Nicholas RA. Primary care family physicians and two hospitalist models: comparison of outcomes, processes, and costs. J Fam Pract. 2002;51:1021-1027.
11. Kearns PJ, Wang CC, Morris WJ, et al. Hospital care by hospital-based and clinic-based faculty: a prospective, controlled trial. Arch Intern Med. 2001;161:235-241.

Many studies have been published in recent years about the effect of hospitalists on outcomes, efficiency, and cost-effectiveness of care (see also “In the Literature,” p. 30). While the studies have demonstrated varying results, the majority suggest that hospitalists contribute positively to care. And the tremendous growth of hospitalist programs nationwide indicates that hospital administrators and others agree.

Does this mean that there have been enough studies about the cost-effectiveness and efficiency of hospitalists, and about outcomes relating to hospitalists? Also, where should hospitalist research go next?

Looking Back

To date, the results of studies regarding hospitalists and their effect on outcomes and cost-effectiveness have varied. Most suggest positive correlations:

• Diamond, Goldberg, and Janosky demonstrated a 54% decrease in hospital readmission rates and shorter LOS when a community teaching hospital implemented full-time faculty hospitalists.1
• Auerbach, Wachter, and colleagues studied 5,308 patients cared for by hospitalists and community physicians at a community teaching hospital. They found that the voluntary hospitalist service reduced lengths of stay and costs that were statistically significant in the second year the services were used.2
• Bellet and Whitaker compared traditional ward service with a hospitalist system of care at a pediatric teaching hospital and found that the average LOS was a day shorter for the patients care for by hospitalists.3
• A review of five years of evidence-based hospitalist studies showed an average 13.4% cost reduction, as well as a 16.6% LOS reduction.4
• Rifkin, et al, compared treatment provided by hospitalist and primary care physicians among patients with community-acquired pneumonia. The authors found that hospitalists’ patients had shorter LOS and reduced costs.5
• Wachter reviewed the data to date in 2002 and concluded that it supported the hypothesis that hospitalists can lead to improved efficiency without compromising patient outcomes or satisfaction.6
• Meltzer, et al, studied costs and outcomes associated with patients on an academic general medical service cared for by hospitalists and non-hospitalists. They found that the average adjusted costs were similar for hospitalists and non-hospitalists in the first year. However, hospitalist costs were reduced by $782 in year two. The authors also concluded that short-term mortality was lower for hospitalists as well, but, again, only in the second year.7
• Auerbach and Pantilat assessed the effects of hospitalists’ care on communication, care patterns, and outcomes of end-of-life patients. They found that hospitalists documented “substantial efforts” to communicate with their dying patients and their families; and this may have resulted in better care.8
• Hauer, et al, analyzed house staff and student evaluations of their attending physicians and internal medicine ward rotations at two university-affiliated teaching hospitals over a two-year period. They found that trainees reported they received more effective teaching and more satisfying inpatient rotations when supervised by hospitalists.9

Studies that “go under the hood and answer questions about the mechanisms by which hospitalists improve outcomes” also will be useful. “Hospitals need to realize that hospitalists aren’t a magic bullet. It’s not as simple as implementing a hospitalist model of care and costs go down.”

—Peter Lindenauer, MD, MSc

A few studies have indicated that hospitalists may have less impact on costs and outcomes. Among them:

• Smith, Westfall, and Nicholas performed a retrospective chart review of HMO critical care patients and found that the mean charge by primary care physicians ($5,680) was significantly lower than that of the hospitalists ($7,699). The authors suggested that “claims of better and cheaper care by hospitalists need further investigation” and that HMOs should not mandate the use of hospitalists.10
• Kearns, et al, compared clinical outcomes and care costs for patients treated by hospital- and clinic-based attending physicians. The researchers detected no difference in costs or clinical outcomes associated with either type of physician.11

Clearly, the majority of the studies suggest that hospitalists have a positive effect on outcomes, effectiveness, and/or costs. But can the research take credit for the growing popularity of hospitalists?

“The studies have gone a long way toward proving the value of hospitalist care. But the experiences of physicians and hospitals also have been very positive,” says Robert Wachter, MD, FACP, professor of medicine at the University of California, San Francisco, associate chairman of UCSF’s Department of Medicine, and chief of the Medical Service at UCSF Medical Center. He adds that the studies wouldn’t mean much if the experiences of hospitals didn’t back up their findings.

So what has been learned from hospitalist studies on costs and outcomes to date? The data “suggest that hospitalists have the greatest impact on efficiency,” says Dr. Wachter, in part because “it is much easier to measure lengths of stay than improvements in outcomes.” He states that data are “strong on cost-effectiveness and reducing lengths of stay.”

Dr. Wachter says that the greatest effect of hospitalist studies to date has been “the presence of a very large number of energetic, enthusiastic physicians who ‘live’ in the hospital and have embraced the notion that they are there not only to improve care but to benefit the hospital and contribute to making it a better place. We have seen hospitalists emerge as leaders on virtually every committee aimed at improving care.”

Peter Lindenauer, MD, MSc, a hospitalist at Baystate Medical Center in Springfield, Mass., and assistant professor of medicine at Tufts University School of Medical School, Boston, agrees.

“What’s been most astounding has been the growth of the field,” he says. “And one of the more interesting facets has been the extent to which hospitalists have fully integrated themselves into every aspect of hospital operations and care in a short period of time.

“It is now rare to find hospitals that do not have hospitalists,” continues Dr. Lindenauer. “It also is uncommon to see quality improvement, patient safety, patient satisfaction, and other activities at the hospital that don’t have a hospitalist as a key member.”

Nonetheless, there is always room for improvement. While the data “are quite clear that efficiency improves without harming quality, they are not strong enough to show definitively that hospitalists improve quality and safety,” cautions Dr. Wachter. “We need more data on this.”

He cautions that data involving mature hospitalist programs may not show the same increases in efficiency as studies about new or young programs. He refers to a study coming out next year that looks at six academic medical centers and mature hospitalists programs and doesn’t show the same increase in efficiency as earlier studies.

“It may be natural that some efficiency may wash away. As hospitalists become more dominant, they set the practice style and standards for their hospitals,” he says. “We need to continue to look for ways to improve.” However, he stresses that none of this takes away from the original argument that hospitalists improve efficiency.

The Next Generation of Hospitalist Studies

Dr. Wachter suggests that the next generation of hospitalist research will have greater impact and importance if it goes beyond examining efficiency and cost-effectiveness.

“I don’t think the studies we began years ago are very interesting anymore, and I don’t think the system is looking for more of them,” he says. Now, research needs to look at the role of hospitalists—the role of hospitalists in teaching hospitals, what physicians make the best hospitalists, and so on.

Dr. Lindenauer would like to see more studies about hospitalists’ impact on quality of care. “There remains a relative paucity of information on this,” he says. “To date, there have been mostly small observational studies on this.” There is a need “to learn more about the impact of hospitalists, especially on more clinical outcomes and quality.”

Studies that “go under the hood and answer questions about the mechanisms by which hospitalists improve outcomes” also will be useful predicts Dr. Lindenauer. “Hospitals need to realize that hospitalists aren’t a magic bullet. It’s not as simple as implementing a hospitalist model of care and costs go down.”

Results of such studies need to be shared with hospitals nationwide so they can make the best and most effective use of hospitalists.

Studies addressing hospitalists working in specialty areas also are likely to become more common in the future, says Michael Phy, DO, MSC, associate program director and assistant professor at Texas Tech University Health Sciences Center in Austin, Texas. Earlier this year, he and his colleagues published a study looking at the hospitalist’s impact on geriatric surgical patients.12 During a two-year period, Dr. Phy and his team studied 466 elderly patients admitted to a hospital for surgical repair of a hip fracture. They found that a hospitalist model decreased the time to surgery, as well as the time from surgery to discharge, without adversely affecting mortality.

Dr. Phy’s study has interested other hospitals around the country. “We’ve been invited to speak on the model. People want to know how we did it, what the flaws were,” he explains. “The say that they are interested in using this kind of model, and they want to learn how to do it.

“I would like to see more studies about patient satisfaction and hospitalists,” says Dr. Phy. He also thinks that more studies about the impact of hospitalists on resident education will be useful. “There are a lot of studies about hospitalist involvement with residents; I am more interested in hospitalist’s indirect impact on residents. Does resident education improve when they are not so overworked because they have hospitalists who help provide patient care?”

In contrast, David Meltzer, MD, PhD, a hospitalist and an associate professor of medicine, General Internal Medicine, at the University of Chicago, doesn’t see patient satisfaction as a priority for the future. “Patient satisfaction isn’t an unreasonable thing to study,” he asserts. “But I personally don’t think that this is the most important issue.

“I don’t know what future studies will look like. I would like to say that we will see more and bigger studies,” continues Dr. Meltzer. “I also think we’ll see more studies about hospitalists in the community environment, more studies on mechanisms, and more hospitalists doing research on hospital care.”

To date, “hospitalist studies have been messy and ask the wrong questions,” says Robert Centor, MD, director of the Division of Internal Medicine, professor of internal medicine, and associate dean at the Huntsville Regional Medical Center in Alabama. He suggests that future studies should “look at hospitalists as a function of years of experience—first-year hospitalists compared to second, third, and forth.” Another useful focus would be to compare hospitalists with non-hospitalists, looking at “volume and lengths of stay and where the curve straightens out.”

Hurdling the Barriers

Especially as they get larger and involve more facilities, hospitalist studies will face some challenges. “Different people define hospitalists in different ways. It’s hard to tell what definitions studies are using; so in looking at two studies or trying to compare a study to what is happening at your facility, you don’t know if you’re comparing apples to apples or apples to oranges,” says Dr. Centor.

The nature of studies addressing hospitalist quality also poses some challenges. “Quality improvement interventions are harder to measure and are more institutionally dependent. Results can’t necessarily be translated from one institution to another,” explains Dr. Lindenauer.

He suggests that identifying funding sources for hospitalist studies will be an ongoing challenge. Researchers will be competing for an already shrinking number of dollars.

“The funding base for producing knowledge is limited, especially for studies that are not intrinsically disease-focused,” agrees Dr. Meltzer.

There is some organizational support for hospitalist researchers. For example, Dr. Phy notes that the SHM Web site will soon have a page where “you can list yourself and your clinical research interests, with the goal of hooking up with collaborators or mentors.”

The Third Generation

“At a certain point, we will turn our attention away from ‘navel gazing’—constantly assessing our impact—and accept that the hospitalist model is here to stay. Then hospitalists will begin to conduct research about the management of common conditions we take care of on a day-to-day basis—asthma, pneumonia, heart failure, COPD, and so on,” says Dr. Lindenauer. This is the third generation of hospitalist research, he suggests, adding, “This is where I would like to see the field evolve.” TH

Contributing Writer Joanne Kaldy wrote about psychiatric hospitalists in the October 2005 issue.

References

1. Diamond HS, Goldberg E, Janosky JE. The effect of full-time faculty hospitalists on the efficiency of care at a community teaching hospital. Ann Intern Med. 1999;130:338-342.
2. Auerbach AD, Wachter RM, Katz P, et al. Implementation of a voluntary hospitalist service at a community teaching hospital: improved clinical efficiency and patient outcomes. Ann Intern Med. 2002:137;859-865.
3. Bellet PS, Whitaker RC. Evaluation of a pediatric hospitalist service: impact on length of stay and hospital charges. Pediatrics. 2000;105(3):478-484.
4. No author listed. Hospitalist prove their worth for capitated providers, plans. Capitation Manag Rep. 2002;Apr;9(4):62-64, 49.
5. Rifkin WD, Conner D, Silver A, et al. Comparison of processes and outcomes of pneumonia care between hospitalists and community-based primary care physicians. Mayo Clin Proc. 2002;77(10):1053-1058.
6. Wachter RM. The evolution of the hospitalist model in the United States. Med Clin North Am. 2002;86(4):687-706.
7. Meltzer D, Manning WG, Morrison J, et al. Effects of physician experience on costs and outcomes on an academic general medicine service: results of a trial of hospitalists. Ann Intern Med. 2002;137:866-874.
8. Auerbach AD, Pantilat SZ. End-of-life care in a voluntary hospitalist model: effects on communication, processes of care, and patient symptoms. Am J Med. 2004;116(10):669-675.
9. Hauer KE, Wachter RM, McCulloch CE, et al. Effects of hospitalist attending physicians on trainee satisfaction with teaching and with internal medicine rotations. Arch Intern Med. 2004;164(17):1866-1871.
10. Smith PC, Westfall JM, Nicholas RA. Primary care family physicians and two hospitalist models: comparison of outcomes, processes, and costs. J Fam Pract. 2002;51:1021-1027.
11. Kearns PJ, Wang CC, Morris WJ, et al. Hospital care by hospital-based and clinic-based faculty: a prospective, controlled trial. Arch Intern Med. 2001;161:235-241.

Many studies have been published in recent years about the effect of hospitalists on outcomes, efficiency, and cost-effectiveness of care (see also “In the Literature,” p. 30). While the studies have demonstrated varying results, the majority suggest that hospitalists contribute positively to care. And the tremendous growth of hospitalist programs nationwide indicates that hospital administrators and others agree.

Does this mean that there have been enough studies about the cost-effectiveness and efficiency of hospitalists, and about outcomes relating to hospitalists? Also, where should hospitalist research go next?

Looking Back

To date, the results of studies regarding hospitalists and their effect on outcomes and cost-effectiveness have varied. Most suggest positive correlations:

• Diamond, Goldberg, and Janosky demonstrated a 54% decrease in hospital readmission rates and shorter LOS when a community teaching hospital implemented full-time faculty hospitalists.1
• Auerbach, Wachter, and colleagues studied 5,308 patients cared for by hospitalists and community physicians at a community teaching hospital. They found that the voluntary hospitalist service reduced lengths of stay and costs that were statistically significant in the second year the services were used.2
• Bellet and Whitaker compared traditional ward service with a hospitalist system of care at a pediatric teaching hospital and found that the average LOS was a day shorter for the patients care for by hospitalists.3
• A review of five years of evidence-based hospitalist studies showed an average 13.4% cost reduction, as well as a 16.6% LOS reduction.4
• Rifkin, et al, compared treatment provided by hospitalist and primary care physicians among patients with community-acquired pneumonia. The authors found that hospitalists’ patients had shorter LOS and reduced costs.5
• Wachter reviewed the data to date in 2002 and concluded that it supported the hypothesis that hospitalists can lead to improved efficiency without compromising patient outcomes or satisfaction.6
• Meltzer, et al, studied costs and outcomes associated with patients on an academic general medical service cared for by hospitalists and non-hospitalists. They found that the average adjusted costs were similar for hospitalists and non-hospitalists in the first year. However, hospitalist costs were reduced by $782 in year two. The authors also concluded that short-term mortality was lower for hospitalists as well, but, again, only in the second year.7
• Auerbach and Pantilat assessed the effects of hospitalists’ care on communication, care patterns, and outcomes of end-of-life patients. They found that hospitalists documented “substantial efforts” to communicate with their dying patients and their families; and this may have resulted in better care.8
• Hauer, et al, analyzed house staff and student evaluations of their attending physicians and internal medicine ward rotations at two university-affiliated teaching hospitals over a two-year period. They found that trainees reported they received more effective teaching and more satisfying inpatient rotations when supervised by hospitalists.9

Studies that “go under the hood and answer questions about the mechanisms by which hospitalists improve outcomes” also will be useful. “Hospitals need to realize that hospitalists aren’t a magic bullet. It’s not as simple as implementing a hospitalist model of care and costs go down.”

—Peter Lindenauer, MD, MSc

A few studies have indicated that hospitalists may have less impact on costs and outcomes. Among them:

• Smith, Westfall, and Nicholas performed a retrospective chart review of HMO critical care patients and found that the mean charge by primary care physicians ($5,680) was significantly lower than that of the hospitalists ($7,699). The authors suggested that “claims of better and cheaper care by hospitalists need further investigation” and that HMOs should not mandate the use of hospitalists.10
• Kearns, et al, compared clinical outcomes and care costs for patients treated by hospital- and clinic-based attending physicians. The researchers detected no difference in costs or clinical outcomes associated with either type of physician.11

Clearly, the majority of the studies suggest that hospitalists have a positive effect on outcomes, effectiveness, and/or costs. But can the research take credit for the growing popularity of hospitalists?

“The studies have gone a long way toward proving the value of hospitalist care. But the experiences of physicians and hospitals also have been very positive,” says Robert Wachter, MD, FACP, professor of medicine at the University of California, San Francisco, associate chairman of UCSF’s Department of Medicine, and chief of the Medical Service at UCSF Medical Center. He adds that the studies wouldn’t mean much if the experiences of hospitals didn’t back up their findings.

So what has been learned from hospitalist studies on costs and outcomes to date? The data “suggest that hospitalists have the greatest impact on efficiency,” says Dr. Wachter, in part because “it is much easier to measure lengths of stay than improvements in outcomes.” He states that data are “strong on cost-effectiveness and reducing lengths of stay.”

Dr. Wachter says that the greatest effect of hospitalist studies to date has been “the presence of a very large number of energetic, enthusiastic physicians who ‘live’ in the hospital and have embraced the notion that they are there not only to improve care but to benefit the hospital and contribute to making it a better place. We have seen hospitalists emerge as leaders on virtually every committee aimed at improving care.”

Peter Lindenauer, MD, MSc, a hospitalist at Baystate Medical Center in Springfield, Mass., and assistant professor of medicine at Tufts University School of Medical School, Boston, agrees.

“What’s been most astounding has been the growth of the field,” he says. “And one of the more interesting facets has been the extent to which hospitalists have fully integrated themselves into every aspect of hospital operations and care in a short period of time.

“It is now rare to find hospitals that do not have hospitalists,” continues Dr. Lindenauer. “It also is uncommon to see quality improvement, patient safety, patient satisfaction, and other activities at the hospital that don’t have a hospitalist as a key member.”

Nonetheless, there is always room for improvement. While the data “are quite clear that efficiency improves without harming quality, they are not strong enough to show definitively that hospitalists improve quality and safety,” cautions Dr. Wachter. “We need more data on this.”

He cautions that data involving mature hospitalist programs may not show the same increases in efficiency as studies about new or young programs. He refers to a study coming out next year that looks at six academic medical centers and mature hospitalists programs and doesn’t show the same increase in efficiency as earlier studies.

“It may be natural that some efficiency may wash away. As hospitalists become more dominant, they set the practice style and standards for their hospitals,” he says. “We need to continue to look for ways to improve.” However, he stresses that none of this takes away from the original argument that hospitalists improve efficiency.

The Next Generation of Hospitalist Studies

Dr. Wachter suggests that the next generation of hospitalist research will have greater impact and importance if it goes beyond examining efficiency and cost-effectiveness.

“I don’t think the studies we began years ago are very interesting anymore, and I don’t think the system is looking for more of them,” he says. Now, research needs to look at the role of hospitalists—the role of hospitalists in teaching hospitals, what physicians make the best hospitalists, and so on.

Dr. Lindenauer would like to see more studies about hospitalists’ impact on quality of care. “There remains a relative paucity of information on this,” he says. “To date, there have been mostly small observational studies on this.” There is a need “to learn more about the impact of hospitalists, especially on more clinical outcomes and quality.”

Studies that “go under the hood and answer questions about the mechanisms by which hospitalists improve outcomes” also will be useful predicts Dr. Lindenauer. “Hospitals need to realize that hospitalists aren’t a magic bullet. It’s not as simple as implementing a hospitalist model of care and costs go down.”

Results of such studies need to be shared with hospitals nationwide so they can make the best and most effective use of hospitalists.

Studies addressing hospitalists working in specialty areas also are likely to become more common in the future, says Michael Phy, DO, MSC, associate program director and assistant professor at Texas Tech University Health Sciences Center in Austin, Texas. Earlier this year, he and his colleagues published a study looking at the hospitalist’s impact on geriatric surgical patients.12 During a two-year period, Dr. Phy and his team studied 466 elderly patients admitted to a hospital for surgical repair of a hip fracture. They found that a hospitalist model decreased the time to surgery, as well as the time from surgery to discharge, without adversely affecting mortality.

Dr. Phy’s study has interested other hospitals around the country. “We’ve been invited to speak on the model. People want to know how we did it, what the flaws were,” he explains. “The say that they are interested in using this kind of model, and they want to learn how to do it.

“I would like to see more studies about patient satisfaction and hospitalists,” says Dr. Phy. He also thinks that more studies about the impact of hospitalists on resident education will be useful. “There are a lot of studies about hospitalist involvement with residents; I am more interested in hospitalist’s indirect impact on residents. Does resident education improve when they are not so overworked because they have hospitalists who help provide patient care?”

In contrast, David Meltzer, MD, PhD, a hospitalist and an associate professor of medicine, General Internal Medicine, at the University of Chicago, doesn’t see patient satisfaction as a priority for the future. “Patient satisfaction isn’t an unreasonable thing to study,” he asserts. “But I personally don’t think that this is the most important issue.

“I don’t know what future studies will look like. I would like to say that we will see more and bigger studies,” continues Dr. Meltzer. “I also think we’ll see more studies about hospitalists in the community environment, more studies on mechanisms, and more hospitalists doing research on hospital care.”

To date, “hospitalist studies have been messy and ask the wrong questions,” says Robert Centor, MD, director of the Division of Internal Medicine, professor of internal medicine, and associate dean at the Huntsville Regional Medical Center in Alabama. He suggests that future studies should “look at hospitalists as a function of years of experience—first-year hospitalists compared to second, third, and forth.” Another useful focus would be to compare hospitalists with non-hospitalists, looking at “volume and lengths of stay and where the curve straightens out.”

Hurdling the Barriers

Especially as they get larger and involve more facilities, hospitalist studies will face some challenges. “Different people define hospitalists in different ways. It’s hard to tell what definitions studies are using; so in looking at two studies or trying to compare a study to what is happening at your facility, you don’t know if you’re comparing apples to apples or apples to oranges,” says Dr. Centor.

The nature of studies addressing hospitalist quality also poses some challenges. “Quality improvement interventions are harder to measure and are more institutionally dependent. Results can’t necessarily be translated from one institution to another,” explains Dr. Lindenauer.

He suggests that identifying funding sources for hospitalist studies will be an ongoing challenge. Researchers will be competing for an already shrinking number of dollars.

“The funding base for producing knowledge is limited, especially for studies that are not intrinsically disease-focused,” agrees Dr. Meltzer.

There is some organizational support for hospitalist researchers. For example, Dr. Phy notes that the SHM Web site will soon have a page where “you can list yourself and your clinical research interests, with the goal of hooking up with collaborators or mentors.”

The Third Generation

“At a certain point, we will turn our attention away from ‘navel gazing’—constantly assessing our impact—and accept that the hospitalist model is here to stay. Then hospitalists will begin to conduct research about the management of common conditions we take care of on a day-to-day basis—asthma, pneumonia, heart failure, COPD, and so on,” says Dr. Lindenauer. This is the third generation of hospitalist research, he suggests, adding, “This is where I would like to see the field evolve.” TH

Contributing Writer Joanne Kaldy wrote about psychiatric hospitalists in the October 2005 issue.

References

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