User login
The A to Z of Intellectual Disability
It is estimated that 17% of children in the United States have a developmental disability and that 1% to 2% of children are diagnosed with mental retardation.1 Of interest to hospitalists: Those with intellectual disability (ID) use healthcare services more than those in the general population.
During a 12-month period, 16% of adults with ID were hospitalized, and 30% were seen in an emergency department (ED).2 Because the average age at death in this population has increased—to 66.1 years in one study—hospitalists must become familiar with the medical management of these patients.3 Achieving comprehensive care presents a challenge because of the atypical presentation of symptoms and the behavioral and communication problems found in many hospitalized patients with ID.
In this article, I will address some of the major clinical issues hospitalists confront when caring for this population.
Where to Begin
One key to understanding how to care for this population is ascertaining whether there is underlying etiology of ID. A diagnosis can be established in approximately 50% of patients who have ID.4 For example, patients with Down syndrome are more likely to have celiac disease, hypothyroidism, leukemia, atlantoaxial subluxation, obstructive sleep apnea, Alzheimer’s dementia, seizure disorder, and behavioral and psychiatric disorders than are patients in the general population.5
Table 1 (see p. 21) lists common medical conditions found in patients with ID. Hospitalists should make it a priority to obtain a comprehensive medical record from the patient’s healthcare provider or to gather the necessary information from a caregiver who knows the patient well; this person may assist the hospitalist in interpreting mannerisms of the nonverbal patient that reflect symptoms such as pain.
Swallowing Difficulties: Problems and Solutions
The risk of aspiration and subsequent mortality because of oral dysfunction and dysphagia is increased in patients with profound ID. The presence of choking and coughing during feeds identifies patients at significant risk of asphyxiation.6
In one study involving patients with severe ID, the absence of respiratory distress during meals or the lack of chronic lung disease identified 85% of patients who did not aspirate.7 Clinical assessment by speech-language therapists and the use of video fluoroscopy may be helpful in patients who experience either frequent aspiration pneumonias or episodes of coughing or choking during feeds. Cramming food into the mouth, eating too fast, and losing the bolus into the pharynx prematurely were factors predictive of asphyxiation risk.6 Speech-language therapists and nutritionists may assist hospitalists by recommending diet and feeding modifications that ensure the safe speed and size of bolus delivery, along with adjustment in food textures to reduce the risk of asphyxiation.
Patients with swallowing difficulties are also vulnerable to dehydration and malnutrition. In fact, more than 60% of children and adults with ID are underweight, with a body mass index less than or equal to 20. Food-intake surveys have demonstrated adequate protein intake but reduced fat, carbohydrate, and energy-food intake. Increasing energy-dense fats and sugar-containing foods, while monitoring for adequate fluid intake, is recommended in these individuals.8
In patients who have worsening dysphagia associated with pneumonia, insertion of an enteral feeding tube, such as a percutaneous endoscopic gastrostomy (PEG) tube, can provide adequate nutrition and may reduce the risk of future episodes of pneumonia (although this practice is controversial).
In one study, there was a 45% reduction in the incidence of pneumonia in the year following feeding-tube insertion.9 Other investigators have not found that gastrostomy tubes prevent pneumonia, however.10 Instead, the presence or absence of gastroesophageal reflux and whether or not the patient has a prior history of aspiration pneumonia seem to be more important factors in determining if episodes of pneumonia will occur after feeding-tube placement.
The prevalence of gastroesophageal reflux (GER) in 435 institutionalized patients with IQ <50 ID was 48.2%.11 Almost 70% of patients with GER had reflux esophagitis, while 14% had Barrett’s esophagus, and 3.9% had peptic strictures. Bui and colleagues studied 105 ID patients with feeding gastrostomy, 45 of whom had dysphagia but no history of aspiration pneumonia and 60 who had recurrent aspiration, either alone or with dysphagia.12 Only two of 45 (4.4%) patients with dysphagia alone developed aspiration pneumonia, while 15 of 60 (25.0%) with a prior history of aspiration pneumonia had a future event.12
Continued aspiration pneumonia may be due to oral secretions and gastric contents entering the respiratory tract. Preoperative GER has been associated with postoperative aspiration pneumonia.10 Elevating the head of the bed, avoiding bolus feeding, treating constipation, discontinuing feeding promptly in cases of respiratory distress or increased gastric residual volume, and treating gastroesophageal reflux pharmacologically may decrease further pneumonia events in these patients.9
Treating Seizures
Another common issue hospitalists must be attuned to in adult patients with ID is epilepsy. Prevalent in as many as 40% of adult patients with mental retardation and cerebral palsy, uncontrolled epilepsy has been associated with increased mortality.13,14 Clinical guidelines for the management of epilepsy in this population have been published.15 Recommended first-line treatments of generalized seizures include sodium valproate and lamotrigine. If these medications are unsuccessful, or if side effects prohibit continued usage, then topiramate and carbamazepine are suggested. Do not use carbamazepine in myoclonic or absence seizures. Lennox-Gastaut syndrome can be treated with lamotrigine, while topiramate and felbamate can be used as add-on therapy to reduce atonic seizures.
For treatment of partial seizures, valproate, carbamazepine, and lamotrigine are recommended first-line treatments. Levetiracetam can be used as add-on therapy. The guidelines suggest that studies of add-on therapy failed to differentiate among lamotrigine, gabapentin, topiramate and tiagabine.
Adjust the initial anti-epileptic drug (AED) to the maximum tolerated dose before slowly introducing a second AED without tapering the first. If the patient responds to the second drug, consider a gradual tapering of the first drug. It is not uncommon for multiple AEDs to be used in patients with ID. In patients referred to a specialized epilepsy clinic, over 80% were on two or more AEDs; 43% became seizure-free for a year or more, while another 40% of patients had a 50% or greater reduction in seizure frequency.16
AEDs that induce the cytochrome P-450 system—particularly phenytoin—phenobarbital, and carbamazepine, have been associated with low bone mineral density (BMD) in patients with ID.17 Additional risk factors for low BMD, such as hypogonadism, low body mass, decreased mobility, and vitamin D deficiency may contribute to the increased incidence of non-traumatic fractures found in institutionalized adults with ID.18,19 In one study, the annual incidence of non-traumatic fracture was 7.3% among 391 institutionalized adults.18
In another study, however, researchers found that although 57% of patients who suffered a fracture were vitamin-D deficient there was no significant association between vitamin D deficiency and fractures.20 Although there are no specific guidelines designed to evaluate and treat bone-health-related issues in adults with ID, it seems prudent to ensure adequate calcium and vitamin D intake, to encourage exercise if possible, and, in patients who suffer non-traumatic fractures, to evaluate for osteoporosis and give appropriate therapy according to the recommendations of the National Institutes of Health Consensus Development Panel on Osteoporosis Prevention, Diagnosis, and Therapy.21
Self-Injurious Behavior and the Risk of Polypharmacy
Adults with ID who are nonverbal may demonstrate self-injurious behavior (SIB) as a manifestation of pain from fracture, constipation, or other medical illnesses. The prevalence of SIB in this population ranges from 2% to 50%.22 Psychotropic medications are frequently used to protect patients from self-injury.23 The challenge for hospitalists is to keep patients from injuring themselves without masking underlying pathologic conditions.
Several hypotheses have tried to explain why patients engage in SIB: These include increased level of endogenous opioids leading to pain insensitivity, opioid release due to low endogenous opioid levels caused by the SIB itself, and reaction to pain. Breau and colleagues concluded that children with ID who suffered chronic pain self-injured less body surface area and fewer body sites than children without chronic pain. Patients without chronic pain who engaged in SIB were more likely to self-injure their heads and hands.22
If a medical etiology cannot be ascertained for aggressive, self-injurious, and destructive behavior, psychotropic agents are frequently employed, with rates that range from 18% to 49% in patients with ID.24 These medications should be prescribed in a start-low/go-slow manner and only after a thorough assessment has been performed and the physician has determined that the behavior cannot be redirected and poses an imminent risk to the patient.25
Because of ID patients’ decreased communication skills, polypharmacy is a significant risk; side effects of psychotropic agents may be mistakenly treated with additional agents. According to Janowsky and colleagues, the mean lowest effective dose of conventional antipsychotics such as haloperidol was 5.9 mg/day to maintain symptom suppression of maladaptive behavior, with relapse of symptoms occurring at a mean dose of 3.8 mg/day in an ID population.23 Atypical antipsychotics are now more widely used in adults with ID, and although they are less likely to cause extrapyramidal side effects, they can still lead to weight gain, sedation, increased lipid levels, and activation of diabetes mellitus. In one study, low dose risperidone (2 mg/day) reduced aberrant behavior by half in 57% of patients with ID. Increased appetite and weight gain were common side effects.26
Other agents such as benzodiazepines have been reported to have behavioral side effects as high as 13% when used in patients with ID; in one study, time to onset of side effects averaged 23 days.27 This may erroneously lead outpatient physicians to prescribe additional agents to counteract the behavioral side effects of the drugs that were initiated in the hospital. If you prescribe benzodiazepines then the patient’s side effects may be mitigated by using lower doses of lorazepam (3 mg/day or less). You may also consider naltrexone to treat patients with SIB. A review of 86 ID patients with SIB concluded that naltrexone was effective in reducing self-injury in 80% of subjects, with nearly half of the patients experiencing a 50% reduction in these types of behavior. The dose most studied was 50 mg.28
Palliative Care
Hospitalists should also be familiar with the palliative-care needs of patients with ID. A recent survey of directors providing services to older adults with ID identified the following as frequently cited obstacles to end-of-life care: availability of direct care staff, availability of nursing/medical staff, staff untrained in end-of-life care, anxiety about responding to families, and liability concerns.29
Because many patients with ID are unable to make medical decisions about their care, a surrogate (e.g., a family member, a judicially appointed guardian, or a court) must decide to initiate or maintain medical interventions. The prevailing standard that applies to surrogate decision-making in the ID population is identifying the patient’s best interests. The medical course chosen may not necessarily be the best option, but it should not be “antithetical to the patient’s interests as to constitute neglect or abuse.”30
A clinical scenario hospitalists may face in patients with profound ID that addresses this legal reasoning involves seeing a patient with respiratory distress in the ED who needs intubation and mechanical ventilation to have a chance at survival. Later, this patient is found to have metastatic cancer and is in significant pain and discomfort. Applying the best interests standard, the hospitalist may elect to intubate and treat the patient. Once the cancer is discovered, however, the physician does not insist that the patient undergo invasive treatment and, instead, focuses his/her efforts on providing palliative care.
Conclusion
As the number of patients with ID transitioning from pediatrics to medicine increases, hospitalists will be looked upon to develop a comprehensive approach to ensure their overall well-being. A systematic approach to caring for hospitalized adults is suggested in Table 2 (see p. 22). TH
Dr. Geskey is assistant professor, Pediatrics and Medicine, Penn State, Milton S. Hershey Medical Center, Penn State College of Medicine, Department of Pediatrics & Internal Medicine.
References
- Boyle CA, Decouflé P, Yeargin-Allsopp M. Prevalence and health impact of developmental disabilities in US children. Pediatrics. 1994;93(3):399-403.
- Janicki MP, Davidson PW, Henderson CM, et al. Health characteristics and health services utilization in older adults with intellectual disabilities living in community residences. J Intellect Disabil Res. 2002;46:287-298.
- Janicki MP, Dalton AJ, Henderson CM, et al. Mortality and morbidity among older adults with intellectual disability: health services considerations. Disabil Rehabil. 1999;21(5-6):284-294.
- van Karnebeek CD, Scheper FY, Abeling NG, et al. Etiology of mental retardation in children referred to a tertiary care center: a prospective study. Am J Ment Retard. 2005;110(4):253-267.
- Roizen NJ, Patterson D. Down’s syndrome. Lancet. 2003 Apr;361(9365):1281-1289. Comment in Lancet, 2003 Jul; 362(9365):1281-80-81.
- Samuels R, Chadwick DD. Predictors of asphyxiation risk in adults with intellectual disabilities and dysphagia. J Intellect Disabil Res. 2006 May;50(Pt 5):362-370.
- Rogers B, Stratton P, Msall M, et al. Long-term morbidity and management strategies of tracheal aspiration in adults with severe developmental disabilities. Am J Ment Retard. 1994 Jan:98(4):490-498.
- Kennedy M, McCombie L, Dawes P, et al. Nutritional support for patients with intellectual disability and nutrition/dysphagia disorders in community care. J Intellect Disabil Res. 1997 Oct;41(Pt 5):430-436.
- Gray DS, Kimmel D. Enteral tube feeding and pneumonia. Am J Ment Retard. 2006 Mar;111(2):113-120.
- Hassett JM, Sunby C, Flint LM. No elimination of aspiration pneumonia in neurologically disabled patients with feeding gastrostomy. Surg Gynecol Obstet. 1988 Nov;167(5):383-388.
- Böhmer CJM, Niezen-de Boer MC, Klinkenberg-Knol EC, et al. The prevalence of gastroesophageal reflux disease in institutionalized intellectually disabled individuals. Am J Gastroenterol. 1999;94(3):804-810.
- Bui HD, Dang CV, Chaney RH, et al. Does gastrostomy and fundoplication prevent aspiration pneumonia in mentally retarded persons? Am J Ment Retard. 1989 Jul;94(1):16-19.
- McDermott S, Moran R, Platt T, et al. Prevalence of epilepsy in adults with mental retardation and related disabilities in primary care. Am J Ment Retard. 2005 Jan;110(1):48-56.
- Forsgren L, Edvinsson SO, Nyström L, et al. Influence of epilepsy on mortality in mental retardation: an epidemiologic study. Epilepsia. 1996;37(19):956-963.
- Working group of the International Association of the Scientific Study of Intellectual Disability. Clinical guidelines for the management of epilepsy in adults with an intellectual disability. Seizure. 2001 Sep;10(6):401-409.
- Kelly K, Stephen LJ, Brodie MJ. Pharmacological outcomes in people with mental retardation and epilepsy. Epilepsy Behav. 2004 Feb;5(1):67-71.
- Sheth RD. Metabolic concerns associated with antiepileptic drugs. Neurology. 2004;63(Suppl 4):S24-29.
- Ryder KM, Williams J, Womack C, et al. Appendicular fractures: a significant problem among institutionalized adults with developmental disabilities. Am J Ment Retard. 2003 Sep;108(5):340-346.
- Jaffe JS, Timell AM, Elolia R, et al. Risk factors for low bone mineral density in individuals residing in a facility for the people with intellectual disability. J Intellect Disabil Res. 2005Jun;49(Pt 6):457-462.
- Vanlint S, Nugent N. Vitamin D and fractures in people with intellectual disability. J Intellect Disabil Res. 2006 Oct; 50(Pt 10):761-767.
- NIH Consensus Development Panel on Osteoporosis Prevention, Diagnosis, and Therapy. Osteoporosis prevention, diagnosis, and therapy. JAMA. 2001;285:785-795.
- Breau LM, Camfield CS, Symons FJ, et al. Relation between pain and self-injurious behavior in nonverbal children with severe cognitive impairments. J Pediatr. 2003 May;142(5):498-503.
- Janowsky DS, Barnhill LJ, Shetty M, et al. Minimally effective doses of conventional antipsychotic medications used to treat aggression, self-injurious and destructive behaviors in mentally retarded adults. J Clin Psychopharmacol. 2005 Feb;25(1):19-25.
- Valdovinos MG, Schroeder SR, Kim G. Prevalence and correlates of psychotropic medication use among adults with developmental disabilities: 1970-2000. Int Rev Res Ment Retard. 2003;26:175-220.
- Szymanski L, King BH. Summary of the Practice Parameters for the Assessment and Treatment of Children, Adolescents, and Adults with Mental Retardation and Comorbid Mental Disorders. American Academy of Child and Adolescent Psychiatry. J Am Acad Child Adolesc Psychiatry. 1999;38:1606-1610.
- Hellings JA, Zarcone JR, Reese RM, et al. A crossover study of risperidone in children, adolescents and adults with mental retardation. J Autism Dev Disord. 2006;36(3):401-411.
- Kalachnik JE, Hanzel TE, Sevenich R, et al. Benzodiazepine behavioral side effects: review and implications for individuals with mental retardation. Am J Ment Retard. 2002 Sep;107(5):376-410.
- Symons FJ, Thompson A, Rodriguez MC. Self-injurious behavior and the efficacy of naltrexone treatment: a quantitative synthesis. Ment Retard Dev Disabil Res Rev. 2004;10(3):193-200.
- Botsford AL. Status of end of life care in organizations providing services for older people with a developmental disability. Am J Ment Retard. 2004;109(5):421-428.
- Cantor NL. The bane of surrogate decision-making defining the best interests of never-competent persons. J Leg Med. 2005 Jun;26(2):155-205.
It is estimated that 17% of children in the United States have a developmental disability and that 1% to 2% of children are diagnosed with mental retardation.1 Of interest to hospitalists: Those with intellectual disability (ID) use healthcare services more than those in the general population.
During a 12-month period, 16% of adults with ID were hospitalized, and 30% were seen in an emergency department (ED).2 Because the average age at death in this population has increased—to 66.1 years in one study—hospitalists must become familiar with the medical management of these patients.3 Achieving comprehensive care presents a challenge because of the atypical presentation of symptoms and the behavioral and communication problems found in many hospitalized patients with ID.
In this article, I will address some of the major clinical issues hospitalists confront when caring for this population.
Where to Begin
One key to understanding how to care for this population is ascertaining whether there is underlying etiology of ID. A diagnosis can be established in approximately 50% of patients who have ID.4 For example, patients with Down syndrome are more likely to have celiac disease, hypothyroidism, leukemia, atlantoaxial subluxation, obstructive sleep apnea, Alzheimer’s dementia, seizure disorder, and behavioral and psychiatric disorders than are patients in the general population.5
Table 1 (see p. 21) lists common medical conditions found in patients with ID. Hospitalists should make it a priority to obtain a comprehensive medical record from the patient’s healthcare provider or to gather the necessary information from a caregiver who knows the patient well; this person may assist the hospitalist in interpreting mannerisms of the nonverbal patient that reflect symptoms such as pain.
Swallowing Difficulties: Problems and Solutions
The risk of aspiration and subsequent mortality because of oral dysfunction and dysphagia is increased in patients with profound ID. The presence of choking and coughing during feeds identifies patients at significant risk of asphyxiation.6
In one study involving patients with severe ID, the absence of respiratory distress during meals or the lack of chronic lung disease identified 85% of patients who did not aspirate.7 Clinical assessment by speech-language therapists and the use of video fluoroscopy may be helpful in patients who experience either frequent aspiration pneumonias or episodes of coughing or choking during feeds. Cramming food into the mouth, eating too fast, and losing the bolus into the pharynx prematurely were factors predictive of asphyxiation risk.6 Speech-language therapists and nutritionists may assist hospitalists by recommending diet and feeding modifications that ensure the safe speed and size of bolus delivery, along with adjustment in food textures to reduce the risk of asphyxiation.
Patients with swallowing difficulties are also vulnerable to dehydration and malnutrition. In fact, more than 60% of children and adults with ID are underweight, with a body mass index less than or equal to 20. Food-intake surveys have demonstrated adequate protein intake but reduced fat, carbohydrate, and energy-food intake. Increasing energy-dense fats and sugar-containing foods, while monitoring for adequate fluid intake, is recommended in these individuals.8
In patients who have worsening dysphagia associated with pneumonia, insertion of an enteral feeding tube, such as a percutaneous endoscopic gastrostomy (PEG) tube, can provide adequate nutrition and may reduce the risk of future episodes of pneumonia (although this practice is controversial).
In one study, there was a 45% reduction in the incidence of pneumonia in the year following feeding-tube insertion.9 Other investigators have not found that gastrostomy tubes prevent pneumonia, however.10 Instead, the presence or absence of gastroesophageal reflux and whether or not the patient has a prior history of aspiration pneumonia seem to be more important factors in determining if episodes of pneumonia will occur after feeding-tube placement.
The prevalence of gastroesophageal reflux (GER) in 435 institutionalized patients with IQ <50 ID was 48.2%.11 Almost 70% of patients with GER had reflux esophagitis, while 14% had Barrett’s esophagus, and 3.9% had peptic strictures. Bui and colleagues studied 105 ID patients with feeding gastrostomy, 45 of whom had dysphagia but no history of aspiration pneumonia and 60 who had recurrent aspiration, either alone or with dysphagia.12 Only two of 45 (4.4%) patients with dysphagia alone developed aspiration pneumonia, while 15 of 60 (25.0%) with a prior history of aspiration pneumonia had a future event.12
Continued aspiration pneumonia may be due to oral secretions and gastric contents entering the respiratory tract. Preoperative GER has been associated with postoperative aspiration pneumonia.10 Elevating the head of the bed, avoiding bolus feeding, treating constipation, discontinuing feeding promptly in cases of respiratory distress or increased gastric residual volume, and treating gastroesophageal reflux pharmacologically may decrease further pneumonia events in these patients.9
Treating Seizures
Another common issue hospitalists must be attuned to in adult patients with ID is epilepsy. Prevalent in as many as 40% of adult patients with mental retardation and cerebral palsy, uncontrolled epilepsy has been associated with increased mortality.13,14 Clinical guidelines for the management of epilepsy in this population have been published.15 Recommended first-line treatments of generalized seizures include sodium valproate and lamotrigine. If these medications are unsuccessful, or if side effects prohibit continued usage, then topiramate and carbamazepine are suggested. Do not use carbamazepine in myoclonic or absence seizures. Lennox-Gastaut syndrome can be treated with lamotrigine, while topiramate and felbamate can be used as add-on therapy to reduce atonic seizures.
For treatment of partial seizures, valproate, carbamazepine, and lamotrigine are recommended first-line treatments. Levetiracetam can be used as add-on therapy. The guidelines suggest that studies of add-on therapy failed to differentiate among lamotrigine, gabapentin, topiramate and tiagabine.
Adjust the initial anti-epileptic drug (AED) to the maximum tolerated dose before slowly introducing a second AED without tapering the first. If the patient responds to the second drug, consider a gradual tapering of the first drug. It is not uncommon for multiple AEDs to be used in patients with ID. In patients referred to a specialized epilepsy clinic, over 80% were on two or more AEDs; 43% became seizure-free for a year or more, while another 40% of patients had a 50% or greater reduction in seizure frequency.16
AEDs that induce the cytochrome P-450 system—particularly phenytoin—phenobarbital, and carbamazepine, have been associated with low bone mineral density (BMD) in patients with ID.17 Additional risk factors for low BMD, such as hypogonadism, low body mass, decreased mobility, and vitamin D deficiency may contribute to the increased incidence of non-traumatic fractures found in institutionalized adults with ID.18,19 In one study, the annual incidence of non-traumatic fracture was 7.3% among 391 institutionalized adults.18
In another study, however, researchers found that although 57% of patients who suffered a fracture were vitamin-D deficient there was no significant association between vitamin D deficiency and fractures.20 Although there are no specific guidelines designed to evaluate and treat bone-health-related issues in adults with ID, it seems prudent to ensure adequate calcium and vitamin D intake, to encourage exercise if possible, and, in patients who suffer non-traumatic fractures, to evaluate for osteoporosis and give appropriate therapy according to the recommendations of the National Institutes of Health Consensus Development Panel on Osteoporosis Prevention, Diagnosis, and Therapy.21
Self-Injurious Behavior and the Risk of Polypharmacy
Adults with ID who are nonverbal may demonstrate self-injurious behavior (SIB) as a manifestation of pain from fracture, constipation, or other medical illnesses. The prevalence of SIB in this population ranges from 2% to 50%.22 Psychotropic medications are frequently used to protect patients from self-injury.23 The challenge for hospitalists is to keep patients from injuring themselves without masking underlying pathologic conditions.
Several hypotheses have tried to explain why patients engage in SIB: These include increased level of endogenous opioids leading to pain insensitivity, opioid release due to low endogenous opioid levels caused by the SIB itself, and reaction to pain. Breau and colleagues concluded that children with ID who suffered chronic pain self-injured less body surface area and fewer body sites than children without chronic pain. Patients without chronic pain who engaged in SIB were more likely to self-injure their heads and hands.22
If a medical etiology cannot be ascertained for aggressive, self-injurious, and destructive behavior, psychotropic agents are frequently employed, with rates that range from 18% to 49% in patients with ID.24 These medications should be prescribed in a start-low/go-slow manner and only after a thorough assessment has been performed and the physician has determined that the behavior cannot be redirected and poses an imminent risk to the patient.25
Because of ID patients’ decreased communication skills, polypharmacy is a significant risk; side effects of psychotropic agents may be mistakenly treated with additional agents. According to Janowsky and colleagues, the mean lowest effective dose of conventional antipsychotics such as haloperidol was 5.9 mg/day to maintain symptom suppression of maladaptive behavior, with relapse of symptoms occurring at a mean dose of 3.8 mg/day in an ID population.23 Atypical antipsychotics are now more widely used in adults with ID, and although they are less likely to cause extrapyramidal side effects, they can still lead to weight gain, sedation, increased lipid levels, and activation of diabetes mellitus. In one study, low dose risperidone (2 mg/day) reduced aberrant behavior by half in 57% of patients with ID. Increased appetite and weight gain were common side effects.26
Other agents such as benzodiazepines have been reported to have behavioral side effects as high as 13% when used in patients with ID; in one study, time to onset of side effects averaged 23 days.27 This may erroneously lead outpatient physicians to prescribe additional agents to counteract the behavioral side effects of the drugs that were initiated in the hospital. If you prescribe benzodiazepines then the patient’s side effects may be mitigated by using lower doses of lorazepam (3 mg/day or less). You may also consider naltrexone to treat patients with SIB. A review of 86 ID patients with SIB concluded that naltrexone was effective in reducing self-injury in 80% of subjects, with nearly half of the patients experiencing a 50% reduction in these types of behavior. The dose most studied was 50 mg.28
Palliative Care
Hospitalists should also be familiar with the palliative-care needs of patients with ID. A recent survey of directors providing services to older adults with ID identified the following as frequently cited obstacles to end-of-life care: availability of direct care staff, availability of nursing/medical staff, staff untrained in end-of-life care, anxiety about responding to families, and liability concerns.29
Because many patients with ID are unable to make medical decisions about their care, a surrogate (e.g., a family member, a judicially appointed guardian, or a court) must decide to initiate or maintain medical interventions. The prevailing standard that applies to surrogate decision-making in the ID population is identifying the patient’s best interests. The medical course chosen may not necessarily be the best option, but it should not be “antithetical to the patient’s interests as to constitute neglect or abuse.”30
A clinical scenario hospitalists may face in patients with profound ID that addresses this legal reasoning involves seeing a patient with respiratory distress in the ED who needs intubation and mechanical ventilation to have a chance at survival. Later, this patient is found to have metastatic cancer and is in significant pain and discomfort. Applying the best interests standard, the hospitalist may elect to intubate and treat the patient. Once the cancer is discovered, however, the physician does not insist that the patient undergo invasive treatment and, instead, focuses his/her efforts on providing palliative care.
Conclusion
As the number of patients with ID transitioning from pediatrics to medicine increases, hospitalists will be looked upon to develop a comprehensive approach to ensure their overall well-being. A systematic approach to caring for hospitalized adults is suggested in Table 2 (see p. 22). TH
Dr. Geskey is assistant professor, Pediatrics and Medicine, Penn State, Milton S. Hershey Medical Center, Penn State College of Medicine, Department of Pediatrics & Internal Medicine.
References
- Boyle CA, Decouflé P, Yeargin-Allsopp M. Prevalence and health impact of developmental disabilities in US children. Pediatrics. 1994;93(3):399-403.
- Janicki MP, Davidson PW, Henderson CM, et al. Health characteristics and health services utilization in older adults with intellectual disabilities living in community residences. J Intellect Disabil Res. 2002;46:287-298.
- Janicki MP, Dalton AJ, Henderson CM, et al. Mortality and morbidity among older adults with intellectual disability: health services considerations. Disabil Rehabil. 1999;21(5-6):284-294.
- van Karnebeek CD, Scheper FY, Abeling NG, et al. Etiology of mental retardation in children referred to a tertiary care center: a prospective study. Am J Ment Retard. 2005;110(4):253-267.
- Roizen NJ, Patterson D. Down’s syndrome. Lancet. 2003 Apr;361(9365):1281-1289. Comment in Lancet, 2003 Jul; 362(9365):1281-80-81.
- Samuels R, Chadwick DD. Predictors of asphyxiation risk in adults with intellectual disabilities and dysphagia. J Intellect Disabil Res. 2006 May;50(Pt 5):362-370.
- Rogers B, Stratton P, Msall M, et al. Long-term morbidity and management strategies of tracheal aspiration in adults with severe developmental disabilities. Am J Ment Retard. 1994 Jan:98(4):490-498.
- Kennedy M, McCombie L, Dawes P, et al. Nutritional support for patients with intellectual disability and nutrition/dysphagia disorders in community care. J Intellect Disabil Res. 1997 Oct;41(Pt 5):430-436.
- Gray DS, Kimmel D. Enteral tube feeding and pneumonia. Am J Ment Retard. 2006 Mar;111(2):113-120.
- Hassett JM, Sunby C, Flint LM. No elimination of aspiration pneumonia in neurologically disabled patients with feeding gastrostomy. Surg Gynecol Obstet. 1988 Nov;167(5):383-388.
- Böhmer CJM, Niezen-de Boer MC, Klinkenberg-Knol EC, et al. The prevalence of gastroesophageal reflux disease in institutionalized intellectually disabled individuals. Am J Gastroenterol. 1999;94(3):804-810.
- Bui HD, Dang CV, Chaney RH, et al. Does gastrostomy and fundoplication prevent aspiration pneumonia in mentally retarded persons? Am J Ment Retard. 1989 Jul;94(1):16-19.
- McDermott S, Moran R, Platt T, et al. Prevalence of epilepsy in adults with mental retardation and related disabilities in primary care. Am J Ment Retard. 2005 Jan;110(1):48-56.
- Forsgren L, Edvinsson SO, Nyström L, et al. Influence of epilepsy on mortality in mental retardation: an epidemiologic study. Epilepsia. 1996;37(19):956-963.
- Working group of the International Association of the Scientific Study of Intellectual Disability. Clinical guidelines for the management of epilepsy in adults with an intellectual disability. Seizure. 2001 Sep;10(6):401-409.
- Kelly K, Stephen LJ, Brodie MJ. Pharmacological outcomes in people with mental retardation and epilepsy. Epilepsy Behav. 2004 Feb;5(1):67-71.
- Sheth RD. Metabolic concerns associated with antiepileptic drugs. Neurology. 2004;63(Suppl 4):S24-29.
- Ryder KM, Williams J, Womack C, et al. Appendicular fractures: a significant problem among institutionalized adults with developmental disabilities. Am J Ment Retard. 2003 Sep;108(5):340-346.
- Jaffe JS, Timell AM, Elolia R, et al. Risk factors for low bone mineral density in individuals residing in a facility for the people with intellectual disability. J Intellect Disabil Res. 2005Jun;49(Pt 6):457-462.
- Vanlint S, Nugent N. Vitamin D and fractures in people with intellectual disability. J Intellect Disabil Res. 2006 Oct; 50(Pt 10):761-767.
- NIH Consensus Development Panel on Osteoporosis Prevention, Diagnosis, and Therapy. Osteoporosis prevention, diagnosis, and therapy. JAMA. 2001;285:785-795.
- Breau LM, Camfield CS, Symons FJ, et al. Relation between pain and self-injurious behavior in nonverbal children with severe cognitive impairments. J Pediatr. 2003 May;142(5):498-503.
- Janowsky DS, Barnhill LJ, Shetty M, et al. Minimally effective doses of conventional antipsychotic medications used to treat aggression, self-injurious and destructive behaviors in mentally retarded adults. J Clin Psychopharmacol. 2005 Feb;25(1):19-25.
- Valdovinos MG, Schroeder SR, Kim G. Prevalence and correlates of psychotropic medication use among adults with developmental disabilities: 1970-2000. Int Rev Res Ment Retard. 2003;26:175-220.
- Szymanski L, King BH. Summary of the Practice Parameters for the Assessment and Treatment of Children, Adolescents, and Adults with Mental Retardation and Comorbid Mental Disorders. American Academy of Child and Adolescent Psychiatry. J Am Acad Child Adolesc Psychiatry. 1999;38:1606-1610.
- Hellings JA, Zarcone JR, Reese RM, et al. A crossover study of risperidone in children, adolescents and adults with mental retardation. J Autism Dev Disord. 2006;36(3):401-411.
- Kalachnik JE, Hanzel TE, Sevenich R, et al. Benzodiazepine behavioral side effects: review and implications for individuals with mental retardation. Am J Ment Retard. 2002 Sep;107(5):376-410.
- Symons FJ, Thompson A, Rodriguez MC. Self-injurious behavior and the efficacy of naltrexone treatment: a quantitative synthesis. Ment Retard Dev Disabil Res Rev. 2004;10(3):193-200.
- Botsford AL. Status of end of life care in organizations providing services for older people with a developmental disability. Am J Ment Retard. 2004;109(5):421-428.
- Cantor NL. The bane of surrogate decision-making defining the best interests of never-competent persons. J Leg Med. 2005 Jun;26(2):155-205.
It is estimated that 17% of children in the United States have a developmental disability and that 1% to 2% of children are diagnosed with mental retardation.1 Of interest to hospitalists: Those with intellectual disability (ID) use healthcare services more than those in the general population.
During a 12-month period, 16% of adults with ID were hospitalized, and 30% were seen in an emergency department (ED).2 Because the average age at death in this population has increased—to 66.1 years in one study—hospitalists must become familiar with the medical management of these patients.3 Achieving comprehensive care presents a challenge because of the atypical presentation of symptoms and the behavioral and communication problems found in many hospitalized patients with ID.
In this article, I will address some of the major clinical issues hospitalists confront when caring for this population.
Where to Begin
One key to understanding how to care for this population is ascertaining whether there is underlying etiology of ID. A diagnosis can be established in approximately 50% of patients who have ID.4 For example, patients with Down syndrome are more likely to have celiac disease, hypothyroidism, leukemia, atlantoaxial subluxation, obstructive sleep apnea, Alzheimer’s dementia, seizure disorder, and behavioral and psychiatric disorders than are patients in the general population.5
Table 1 (see p. 21) lists common medical conditions found in patients with ID. Hospitalists should make it a priority to obtain a comprehensive medical record from the patient’s healthcare provider or to gather the necessary information from a caregiver who knows the patient well; this person may assist the hospitalist in interpreting mannerisms of the nonverbal patient that reflect symptoms such as pain.
Swallowing Difficulties: Problems and Solutions
The risk of aspiration and subsequent mortality because of oral dysfunction and dysphagia is increased in patients with profound ID. The presence of choking and coughing during feeds identifies patients at significant risk of asphyxiation.6
In one study involving patients with severe ID, the absence of respiratory distress during meals or the lack of chronic lung disease identified 85% of patients who did not aspirate.7 Clinical assessment by speech-language therapists and the use of video fluoroscopy may be helpful in patients who experience either frequent aspiration pneumonias or episodes of coughing or choking during feeds. Cramming food into the mouth, eating too fast, and losing the bolus into the pharynx prematurely were factors predictive of asphyxiation risk.6 Speech-language therapists and nutritionists may assist hospitalists by recommending diet and feeding modifications that ensure the safe speed and size of bolus delivery, along with adjustment in food textures to reduce the risk of asphyxiation.
Patients with swallowing difficulties are also vulnerable to dehydration and malnutrition. In fact, more than 60% of children and adults with ID are underweight, with a body mass index less than or equal to 20. Food-intake surveys have demonstrated adequate protein intake but reduced fat, carbohydrate, and energy-food intake. Increasing energy-dense fats and sugar-containing foods, while monitoring for adequate fluid intake, is recommended in these individuals.8
In patients who have worsening dysphagia associated with pneumonia, insertion of an enteral feeding tube, such as a percutaneous endoscopic gastrostomy (PEG) tube, can provide adequate nutrition and may reduce the risk of future episodes of pneumonia (although this practice is controversial).
In one study, there was a 45% reduction in the incidence of pneumonia in the year following feeding-tube insertion.9 Other investigators have not found that gastrostomy tubes prevent pneumonia, however.10 Instead, the presence or absence of gastroesophageal reflux and whether or not the patient has a prior history of aspiration pneumonia seem to be more important factors in determining if episodes of pneumonia will occur after feeding-tube placement.
The prevalence of gastroesophageal reflux (GER) in 435 institutionalized patients with IQ <50 ID was 48.2%.11 Almost 70% of patients with GER had reflux esophagitis, while 14% had Barrett’s esophagus, and 3.9% had peptic strictures. Bui and colleagues studied 105 ID patients with feeding gastrostomy, 45 of whom had dysphagia but no history of aspiration pneumonia and 60 who had recurrent aspiration, either alone or with dysphagia.12 Only two of 45 (4.4%) patients with dysphagia alone developed aspiration pneumonia, while 15 of 60 (25.0%) with a prior history of aspiration pneumonia had a future event.12
Continued aspiration pneumonia may be due to oral secretions and gastric contents entering the respiratory tract. Preoperative GER has been associated with postoperative aspiration pneumonia.10 Elevating the head of the bed, avoiding bolus feeding, treating constipation, discontinuing feeding promptly in cases of respiratory distress or increased gastric residual volume, and treating gastroesophageal reflux pharmacologically may decrease further pneumonia events in these patients.9
Treating Seizures
Another common issue hospitalists must be attuned to in adult patients with ID is epilepsy. Prevalent in as many as 40% of adult patients with mental retardation and cerebral palsy, uncontrolled epilepsy has been associated with increased mortality.13,14 Clinical guidelines for the management of epilepsy in this population have been published.15 Recommended first-line treatments of generalized seizures include sodium valproate and lamotrigine. If these medications are unsuccessful, or if side effects prohibit continued usage, then topiramate and carbamazepine are suggested. Do not use carbamazepine in myoclonic or absence seizures. Lennox-Gastaut syndrome can be treated with lamotrigine, while topiramate and felbamate can be used as add-on therapy to reduce atonic seizures.
For treatment of partial seizures, valproate, carbamazepine, and lamotrigine are recommended first-line treatments. Levetiracetam can be used as add-on therapy. The guidelines suggest that studies of add-on therapy failed to differentiate among lamotrigine, gabapentin, topiramate and tiagabine.
Adjust the initial anti-epileptic drug (AED) to the maximum tolerated dose before slowly introducing a second AED without tapering the first. If the patient responds to the second drug, consider a gradual tapering of the first drug. It is not uncommon for multiple AEDs to be used in patients with ID. In patients referred to a specialized epilepsy clinic, over 80% were on two or more AEDs; 43% became seizure-free for a year or more, while another 40% of patients had a 50% or greater reduction in seizure frequency.16
AEDs that induce the cytochrome P-450 system—particularly phenytoin—phenobarbital, and carbamazepine, have been associated with low bone mineral density (BMD) in patients with ID.17 Additional risk factors for low BMD, such as hypogonadism, low body mass, decreased mobility, and vitamin D deficiency may contribute to the increased incidence of non-traumatic fractures found in institutionalized adults with ID.18,19 In one study, the annual incidence of non-traumatic fracture was 7.3% among 391 institutionalized adults.18
In another study, however, researchers found that although 57% of patients who suffered a fracture were vitamin-D deficient there was no significant association between vitamin D deficiency and fractures.20 Although there are no specific guidelines designed to evaluate and treat bone-health-related issues in adults with ID, it seems prudent to ensure adequate calcium and vitamin D intake, to encourage exercise if possible, and, in patients who suffer non-traumatic fractures, to evaluate for osteoporosis and give appropriate therapy according to the recommendations of the National Institutes of Health Consensus Development Panel on Osteoporosis Prevention, Diagnosis, and Therapy.21
Self-Injurious Behavior and the Risk of Polypharmacy
Adults with ID who are nonverbal may demonstrate self-injurious behavior (SIB) as a manifestation of pain from fracture, constipation, or other medical illnesses. The prevalence of SIB in this population ranges from 2% to 50%.22 Psychotropic medications are frequently used to protect patients from self-injury.23 The challenge for hospitalists is to keep patients from injuring themselves without masking underlying pathologic conditions.
Several hypotheses have tried to explain why patients engage in SIB: These include increased level of endogenous opioids leading to pain insensitivity, opioid release due to low endogenous opioid levels caused by the SIB itself, and reaction to pain. Breau and colleagues concluded that children with ID who suffered chronic pain self-injured less body surface area and fewer body sites than children without chronic pain. Patients without chronic pain who engaged in SIB were more likely to self-injure their heads and hands.22
If a medical etiology cannot be ascertained for aggressive, self-injurious, and destructive behavior, psychotropic agents are frequently employed, with rates that range from 18% to 49% in patients with ID.24 These medications should be prescribed in a start-low/go-slow manner and only after a thorough assessment has been performed and the physician has determined that the behavior cannot be redirected and poses an imminent risk to the patient.25
Because of ID patients’ decreased communication skills, polypharmacy is a significant risk; side effects of psychotropic agents may be mistakenly treated with additional agents. According to Janowsky and colleagues, the mean lowest effective dose of conventional antipsychotics such as haloperidol was 5.9 mg/day to maintain symptom suppression of maladaptive behavior, with relapse of symptoms occurring at a mean dose of 3.8 mg/day in an ID population.23 Atypical antipsychotics are now more widely used in adults with ID, and although they are less likely to cause extrapyramidal side effects, they can still lead to weight gain, sedation, increased lipid levels, and activation of diabetes mellitus. In one study, low dose risperidone (2 mg/day) reduced aberrant behavior by half in 57% of patients with ID. Increased appetite and weight gain were common side effects.26
Other agents such as benzodiazepines have been reported to have behavioral side effects as high as 13% when used in patients with ID; in one study, time to onset of side effects averaged 23 days.27 This may erroneously lead outpatient physicians to prescribe additional agents to counteract the behavioral side effects of the drugs that were initiated in the hospital. If you prescribe benzodiazepines then the patient’s side effects may be mitigated by using lower doses of lorazepam (3 mg/day or less). You may also consider naltrexone to treat patients with SIB. A review of 86 ID patients with SIB concluded that naltrexone was effective in reducing self-injury in 80% of subjects, with nearly half of the patients experiencing a 50% reduction in these types of behavior. The dose most studied was 50 mg.28
Palliative Care
Hospitalists should also be familiar with the palliative-care needs of patients with ID. A recent survey of directors providing services to older adults with ID identified the following as frequently cited obstacles to end-of-life care: availability of direct care staff, availability of nursing/medical staff, staff untrained in end-of-life care, anxiety about responding to families, and liability concerns.29
Because many patients with ID are unable to make medical decisions about their care, a surrogate (e.g., a family member, a judicially appointed guardian, or a court) must decide to initiate or maintain medical interventions. The prevailing standard that applies to surrogate decision-making in the ID population is identifying the patient’s best interests. The medical course chosen may not necessarily be the best option, but it should not be “antithetical to the patient’s interests as to constitute neglect or abuse.”30
A clinical scenario hospitalists may face in patients with profound ID that addresses this legal reasoning involves seeing a patient with respiratory distress in the ED who needs intubation and mechanical ventilation to have a chance at survival. Later, this patient is found to have metastatic cancer and is in significant pain and discomfort. Applying the best interests standard, the hospitalist may elect to intubate and treat the patient. Once the cancer is discovered, however, the physician does not insist that the patient undergo invasive treatment and, instead, focuses his/her efforts on providing palliative care.
Conclusion
As the number of patients with ID transitioning from pediatrics to medicine increases, hospitalists will be looked upon to develop a comprehensive approach to ensure their overall well-being. A systematic approach to caring for hospitalized adults is suggested in Table 2 (see p. 22). TH
Dr. Geskey is assistant professor, Pediatrics and Medicine, Penn State, Milton S. Hershey Medical Center, Penn State College of Medicine, Department of Pediatrics & Internal Medicine.
References
- Boyle CA, Decouflé P, Yeargin-Allsopp M. Prevalence and health impact of developmental disabilities in US children. Pediatrics. 1994;93(3):399-403.
- Janicki MP, Davidson PW, Henderson CM, et al. Health characteristics and health services utilization in older adults with intellectual disabilities living in community residences. J Intellect Disabil Res. 2002;46:287-298.
- Janicki MP, Dalton AJ, Henderson CM, et al. Mortality and morbidity among older adults with intellectual disability: health services considerations. Disabil Rehabil. 1999;21(5-6):284-294.
- van Karnebeek CD, Scheper FY, Abeling NG, et al. Etiology of mental retardation in children referred to a tertiary care center: a prospective study. Am J Ment Retard. 2005;110(4):253-267.
- Roizen NJ, Patterson D. Down’s syndrome. Lancet. 2003 Apr;361(9365):1281-1289. Comment in Lancet, 2003 Jul; 362(9365):1281-80-81.
- Samuels R, Chadwick DD. Predictors of asphyxiation risk in adults with intellectual disabilities and dysphagia. J Intellect Disabil Res. 2006 May;50(Pt 5):362-370.
- Rogers B, Stratton P, Msall M, et al. Long-term morbidity and management strategies of tracheal aspiration in adults with severe developmental disabilities. Am J Ment Retard. 1994 Jan:98(4):490-498.
- Kennedy M, McCombie L, Dawes P, et al. Nutritional support for patients with intellectual disability and nutrition/dysphagia disorders in community care. J Intellect Disabil Res. 1997 Oct;41(Pt 5):430-436.
- Gray DS, Kimmel D. Enteral tube feeding and pneumonia. Am J Ment Retard. 2006 Mar;111(2):113-120.
- Hassett JM, Sunby C, Flint LM. No elimination of aspiration pneumonia in neurologically disabled patients with feeding gastrostomy. Surg Gynecol Obstet. 1988 Nov;167(5):383-388.
- Böhmer CJM, Niezen-de Boer MC, Klinkenberg-Knol EC, et al. The prevalence of gastroesophageal reflux disease in institutionalized intellectually disabled individuals. Am J Gastroenterol. 1999;94(3):804-810.
- Bui HD, Dang CV, Chaney RH, et al. Does gastrostomy and fundoplication prevent aspiration pneumonia in mentally retarded persons? Am J Ment Retard. 1989 Jul;94(1):16-19.
- McDermott S, Moran R, Platt T, et al. Prevalence of epilepsy in adults with mental retardation and related disabilities in primary care. Am J Ment Retard. 2005 Jan;110(1):48-56.
- Forsgren L, Edvinsson SO, Nyström L, et al. Influence of epilepsy on mortality in mental retardation: an epidemiologic study. Epilepsia. 1996;37(19):956-963.
- Working group of the International Association of the Scientific Study of Intellectual Disability. Clinical guidelines for the management of epilepsy in adults with an intellectual disability. Seizure. 2001 Sep;10(6):401-409.
- Kelly K, Stephen LJ, Brodie MJ. Pharmacological outcomes in people with mental retardation and epilepsy. Epilepsy Behav. 2004 Feb;5(1):67-71.
- Sheth RD. Metabolic concerns associated with antiepileptic drugs. Neurology. 2004;63(Suppl 4):S24-29.
- Ryder KM, Williams J, Womack C, et al. Appendicular fractures: a significant problem among institutionalized adults with developmental disabilities. Am J Ment Retard. 2003 Sep;108(5):340-346.
- Jaffe JS, Timell AM, Elolia R, et al. Risk factors for low bone mineral density in individuals residing in a facility for the people with intellectual disability. J Intellect Disabil Res. 2005Jun;49(Pt 6):457-462.
- Vanlint S, Nugent N. Vitamin D and fractures in people with intellectual disability. J Intellect Disabil Res. 2006 Oct; 50(Pt 10):761-767.
- NIH Consensus Development Panel on Osteoporosis Prevention, Diagnosis, and Therapy. Osteoporosis prevention, diagnosis, and therapy. JAMA. 2001;285:785-795.
- Breau LM, Camfield CS, Symons FJ, et al. Relation between pain and self-injurious behavior in nonverbal children with severe cognitive impairments. J Pediatr. 2003 May;142(5):498-503.
- Janowsky DS, Barnhill LJ, Shetty M, et al. Minimally effective doses of conventional antipsychotic medications used to treat aggression, self-injurious and destructive behaviors in mentally retarded adults. J Clin Psychopharmacol. 2005 Feb;25(1):19-25.
- Valdovinos MG, Schroeder SR, Kim G. Prevalence and correlates of psychotropic medication use among adults with developmental disabilities: 1970-2000. Int Rev Res Ment Retard. 2003;26:175-220.
- Szymanski L, King BH. Summary of the Practice Parameters for the Assessment and Treatment of Children, Adolescents, and Adults with Mental Retardation and Comorbid Mental Disorders. American Academy of Child and Adolescent Psychiatry. J Am Acad Child Adolesc Psychiatry. 1999;38:1606-1610.
- Hellings JA, Zarcone JR, Reese RM, et al. A crossover study of risperidone in children, adolescents and adults with mental retardation. J Autism Dev Disord. 2006;36(3):401-411.
- Kalachnik JE, Hanzel TE, Sevenich R, et al. Benzodiazepine behavioral side effects: review and implications for individuals with mental retardation. Am J Ment Retard. 2002 Sep;107(5):376-410.
- Symons FJ, Thompson A, Rodriguez MC. Self-injurious behavior and the efficacy of naltrexone treatment: a quantitative synthesis. Ment Retard Dev Disabil Res Rev. 2004;10(3):193-200.
- Botsford AL. Status of end of life care in organizations providing services for older people with a developmental disability. Am J Ment Retard. 2004;109(5):421-428.
- Cantor NL. The bane of surrogate decision-making defining the best interests of never-competent persons. J Leg Med. 2005 Jun;26(2):155-205.
Medical Student Evaluation of Hospitalist and Nonhospitalist Faculty
In 1996 Wachter and Goldman anticipated the emergence of hospitalists,1 physicians who are responsible for the care of hospitalized patients in place of their primary care physicians. The number of physicians who identify themselves as hospitalists has grown rapidly since 1996 and is currently estimated to be 10,00012,000, with the potential to reach as high as 30,000 in the next decade.2 This growth includes academic medical centers. In surveys of chairs of internal medicine and pediatric departments, 50% have hospitalists employed at their institutions.3, 4
Hospitalists in academic institutions are playing an increasingly prominent role in the medical education of both residents and medical students. The implications of adopting a hospitalist model on medical education has been discussed.57 Despite such concerns as fragmented continuity of care; decreased exposure to primary care physicians, subspecialists and physician‐scientists; reduced autonomy; and fewer educational opportunities to observe the natural histories of illnesses because of improved efficiency,57 the overall impact of hospitalists on medical and resident education has generally been favorable.818 Internal medicine residents have rated the teaching skills of hospitalists comparable to traditional academic physicians,8, 9 and believe the addition of hospitalists has contributed to an improved educational experience.10, 11, 14 In addition, a survey of third‐year medical students at a single academic teaching hospital concluded that hospitalists were able to provide at least as positive an educational experience during their inpatient medicine rotations as highly rated nonhospitalist teaching faculty.13
The role of hospitalists as educators in pediatrics has been studied much less. Pediatric resident satisfaction has improved in institutions that have used a hospitalist model.1618 In another study, hospitalists were rated by pediatric residents as more effective teachers than nonhospitalists.15 Because we are unaware of any study that has evaluated hospitalists in the education of medical students during their inpatient pediatric rotation, the purpose of our study was to compare hospitalist and nonhospitalist faculty on the educational experience of third‐year medical students during the inpatient portion of their pediatric clerkships at a single university children's hospital.
METHODS
Study Design
We conducted a retrospective study using evaluations of third‐year medical students comparing hospitalist and nonhospitalist faculty during the inpatient portions of their pediatrics clerkships at a single academic children's hospital over a 15‐month period (July 1999September 2000).
Setting and Sample
We conducted our study at Penn State Children's Hospital (PSCH), a 120‐bed tertiary‐care facility within the 504‐bed Hershey Medical Center, the main teaching hospital affiliated with the Penn State College of Medicine, Hershey, Pennsylvania. The pediatric hospitalist program commenced on July 1, 1999, and during the 15‐month study period the hospitalist staff consisted of 2 physicians who attended a total of 8 months, whereas the nonhospitalist staff consisted of 4 academic general pediatricians and 4 academic pediatric subspecialists who attended the remaining 7 months.
The inpatient clinical responsibilities of both groups of physicians during each month were similar. Both groups of physicians conducted daily rounds with a team that included a senior resident (postgraduate year 3), 2 to 4 interns (postgraduate year 1), 1 acting intern (fourth‐year medical student), and 2 to 4 third‐year medical students. This team was responsible for all admissions to the general pediatrics service, which averages 100 admissions per month. Both the hospitalists and nonhospitalists had outpatient responsibilities during the time they served as inpatient attendings.
During the 15‐month study period, 131 students completed their third‐year pediatrics clerkships. Students at the Penn State College of Medicine may complete their pediatrics clerkship at PSCH or at one of several alternative sites. Because of variability in the structure of the rotation from site to site, it was considered valid only to analyze evaluations completed by students who rotated at PSCH. Sixty‐seven students rotated at PSCH during the study period. Students spent 3 weeks of the 6‐week rotation on the inpatient general pediatrics service. The remaining 3 weeks occurred in multiple outpatient pediatric practice settings and in the newborn nursery. During the 3 weeks the students spent on the inpatient service they did not have outpatient clinic responsibilities, so they did not interact with either the hospitalists or nonhospitalists in the outpatient setting. At the end of the rotation, students were asked to rate the effectiveness of the faculty as teachers, pediatricians, and student advocates and overall on a 4‐point scale (1 = inadequate; 2 = adequate; 3 = very good; 4 = excellent). Students were also asked to evaluate 7 components of the clerkship on the same 4‐point scale (Table 1). Finally, students were asked to provide additional written comments in an unstructured format.
| Evaluation item | Hospitalist mean score (32 evaluations) | Nonhospitalist mean score (35 evaluations) | P value | No. of evaluations rated adequate or inadequate (%)b | |
|---|---|---|---|---|---|
| Hospitalist | Nonhospitalist | ||||
| |||||
| Effectiveness as teacherc | 3.87 | 2.91 | < .001a | 1 (2.9) | 13 (40.6) |
| Effectiveness as pediatriciand | 3.94 | 3.25 | < .001a | 0 (0.0) | 5 (15.6) |
| Effectiveness as student advocatee | 3.76 | 2.97 | < .001a | 2 (5.7) | 13 (40.6) |
| Overall evaluation | 3.93 | 3.06 | < .001a | 0 (0.0) | 10 (31.3) |
| Ward rounds | 3.15 | 2.58 | < .006a | 5 (15.6) | 12 (37.5) |
| Morning report | 3.16 | 3.14 | 0.923 | ||
| Sick newborn | 2.79 | 2.60 | 0.518 | ||
| Well newborn | 2.89 | 3.13 | 0.211 | ||
| Outpatient department clinics | 2.96 | 3.06 | 0.425 | ||
| Private physician's office | 2.97 | 3.01 | 0.794 | ||
| Noon conference | 3.03 | 3.13 | 0.512 | ||
After reviewing the literature concerning faculty evaluation forms and their components, an evaluation form was created for students to indicate their reactions to clerkship components. All the medical students' faculty evaluations were anonymous, and the faculty was not able to review student evaluations prior to assigning grades. Students were required to turn in an evaluation at the end of their rotations. The study was limited to 15 months, as the format of the evaluation form was changed after September 2000 and the general pediatrics service was in the process of transitioning to an exclusively hospitalist‐run service, thereby limiting the number of nonhospitalists available as a comparison group. Demographic characteristics of the hospitalist and nonhospitalist faculty were collected from a faculty database. The study was approved by the Penn State Milton S. Hershey Medical Center's Institutional Review Board.
Statistics and Analysis
For all questions, a Wilcoxon rank sum test was used to evaluate whether the responses for nonhospitalists were different than those for hospitalists. Differences in response by group whose 2‐tailed P values were less than .05 were considered statistically significant. All analyses were performed using the SAS statistical software, version 8.2 (SAS Institute Inc., Cary, NC).
RESULTS
All 67 of the students who completed a pediatrics clerkship at PSCH returned evaluation forms, which were the data for further analysis. Thirty‐five students rotated with the hospitalist faculty, and 32 students rotated with the nonhospitalist faculty. There were no significant demographic differences between the hospitalist and nonhospitalist faculty in age, sex, academic rank, specialty, and years since completing training (Table 2). All the hospitalist faculty fulfilled the definition of a hospitalist,2 whereas none of the physicians in the nonhospitalist group did.
| Characteristic | Hospitalists (n = 2) | Nonhospitalists (n = 8) | P value |
|---|---|---|---|
| Age, mean (range) | 36.0 (3141) | 46.5 (3063) | 0.30 |
| Male/Female | 1/1 | 6/2 | 0.95 |
| Academic rank | |||
| Instructor | 0 | 1 | |
| Assistant professor | 2 | 3 | |
| Associate professor | 0 | 0 | 0.56 |
| Professor | 0 | 4 | |
| Specialty | |||
| General pediatrics | 1 | 4 | |
| Nephrology | 1 | 1 | |
| Genetics | 0 | 1 | 0.95 |
| Infectious ciseases | 0 | 1 | |
| Rheumatology | 0 | 1 | |
| Years since training, mean (range) | 4.0 (08) | 13.8 (030) | 0.43 |
The hospitalists were rated significantly higher than the nonhospitalist faculty in all 4 of the attending characteristics measured (Table 1): teaching effectiveness (3.87 vs. 2.91; P < .0001), effectiveness as a pediatrician (3.94 vs. 3.25; P < .001), student advocacy effectiveness (3.76 vs. 2.97; P < .0001), and overall evaluation (3.93 vs. 3.06; P < .001).
Analysis of specific aspects of the rotation showed the only feature that hospitalists were rated significantly higher on was quality of ward rounds (3.15 vs. 2.58, P < .006). There was no significant difference between the hospitalists and nonhospitalists on features that were not specifically part of the inpatient rotation, including various conferences, outpatient clinics, and newborn care (Table 1).
DISCUSSION
Our study demonstrates that pediatric hospitalists had a positive impact on the overall educational experience of third‐year medical students during the inpatient portions of their pediatrics clerkships. Hospitalists were rated more favorably than nonhospitalists as teachers, as pediatricians, as student advocates, and overall. Medical students also rated the value of ward rounds more favorably when hospitalists conducted them. In addition, higher percentages of nonhospitalists than hospitalists were rated as adequate or inadequate for the above items. When other aspects of the clerkship were analyzed, there were no statistically significant differences between the students who rotated with hospitalists and the students who rotated with nonhospitalists. This suggests that the higher scores for hospitalists were specifically related to their interactions with students, rather than with an overall more positive view of the rotation.
It has been suggested that forces promoting the use of hospitalists in adult medicine are even more persuasive in the pediatric population, as the difference in severity of illness between the inpatient and outpatient setting is greater, and the average pediatrician has less experience than the average internist in managing hospitalized patients.19 In a recent systematic review of the literature, Landrigan et al.20 reported that 6 of 7 studies demonstrated hospitalist systems had decreased hospital length of stay compared to systems in which a primary pediatrician served as the physician of record. This improved efficiency, if combined with the pressure to see more patients while trying to balance teaching and research demands, may have a negative impact on the quality of medical education.
Several factors may have contributed to the students' satisfaction with hospitalists. Studies have demonstrated that students rate clinical teachers more favorably with whom they have greater involvement.21 Hospitalists may be more likely to spend time on the inpatient wards given that is the primary site of their clinical activity. This increased presence may have contributed to more favorable evaluations for the hospitalist faculty, whereas the additional outpatient workload for nonhospitalist faculty may have reduced inpatient teaching opportunities, accounting for their lower teaching score. Included in the pediatrician category was the attribute of being a role model. In a study by Wright et al.,22 spending more than 25% of the time or 25 or more hours per week teaching and conducting rounds was independently associated with being considered an excellent role model. Again, the increased availability of the hospitalists on the inpatient wards may have led to more teaching opportunities, contributing to their higher score.
Our study had several limitations. First, it was a retrospective study conducted at a single institution with only 2 hospitalists. Although there were not statistical significant demographic differences between the 2 groups, this may simply reflect the small size of the sample in our study; therefore, the results may not be applicable to other academic institutions. Second, we retrospectively analyzed an evaluation form that had not been validated or specifically designed to compare 2 physician groups. Third, there were multiple statements in each category that students were asked to consider before scoring each attending on the parameters measured. Although hospitalists were rated higher in each category, there may have been individual characteristics within each category for which the nonhospitalist faculty performed better. Fourth, although hospitalists received higher average ratings than nonhospitalist faculty from third‐year medical students, it is important to emphasize this study measured students' attitudes and beliefs not specific educational outcomes. However, even though we cannot rule out the possibility that potentially confounding factors such as the personality of an attending physician influenced the results, prior studies have demonstrated that medical students make sophisticated judgments about teaching in the clinical setting.23, 24 It is unlikely that hospitalists at our institution were specifically selected to attend more months on a new inpatient service because they had a history of having more favorable teaching qualities because 1 of the 2 hospitalists had just finished residency training, and there were no significant demographic differences between the 2 groups. In a study examining trainee satisfaction in an internal medicine rotation 4 years after adoption of a hospitalist model, where nonhospitalist faculty attended based on their own interest and inpatient skill rather than as a requirement, Hauer et al.14 reported that trainees experienced more effective teaching and a more satisfying inpatient rotation when supervised by hospitalists. This suggests that hospitalists may possess or develop a specific inpatient knowledge base and teaching acumen over time that distinguishes them from nonhospitalists. There is evidence of accumulated experience leading to improved outcomes in the clinical setting for HIV infection,25 various surgical procedures,26 and hospitalist systems.27
In conclusion, this is the first study to evaluate the performance of hospitalists in the setting of a third‐year medical student pediatrics clerkship. Although third‐year medical students rate hospitalists at least as highly as nonhospitalist faculty, further studies are needed to reproduce this finding. In addition to the increased time spent on the wards with students and increased experience in caring for hospitalized patients, further studies should also examine the role that communication plays in clinical teaching. Also, the recent development of core competencies in hospital medicine28 may lead to the development of educational outcomes that can be objectively measured.
Acknowledgements
The authors thank David Mauger, PhD, from the Department of Health Evaluation Sciences at the Penn State College of Medicine for providing statistical analysis of the survey results.
- ,.The emerging role of “hospitalists” in the American health care system.N Engl J Med.1996;335:514–517.
- Society of Hospital Medicine. Frequently asked questions. Available at: http://www.hospitalmedicine.org/AM/Template.cfm?Section=FAQs75:S34–6.
- ,,,,,.Pediatric hospitalists in Canada and the United States: a survey of pediatric academic department chairs.Ambul Pediatr.2001;1:338–339.
- .The impact of hospitalists on medical education and the academic health system.Ann Intern Med.1999;130:364–367.
- ,.The role of hospitalists in medical education.Am J Med.1999;107:305–309.
- ,.Implications of the hospitalist model for medical students' education.Acad. Med.2001;76:324–330.
- ,,,,.Reorganizing an academic medical service: impact on cost, quality, patient satisfaction, and education.JAMA.1998;279:1560–1565.
- ,,, et al.Hospitalists as teachers: how do they compare to subspecialty and general medicine faculty.J Gen Intern Med.2004;19:8–15.
- ,,,,.Assessing the value of hospitalists to academic health centers: Brigham and Women's Hospital and Harvard Medical School.Am J Med.1999;106:134–137.
- ,,,,,.Resident satisfaction on an academic hospitalist service: time to teach.Am J Med.2002;112:597–601.
- ,,,,,,.The positive impact of initiation of hospitalist clinician educators: resource utilization and medical resident education.J Gen Intern Med.2004;19:293–301.
- ,,,.Medical student evaluation of the quality of hospitalist and nonhospitalist teaching faculty on inpatient medicine rotations.Acad Med.2004;79:78–82.
- ,,,,.Effects of hospitalist attending physicians on trainee satisfaction with teaching and with internal medicine rotations.Arch Intern Med.2004;164:1866–1871.
- ,,,,,.Effect of a pediatric hospitalist system on housestaff education and experience.Arch Pediatr Adolesc Med.2002;156:877–883.
- .Employing hospitalists to improve residents' inpatient learning.Acad Med.2001;76:556.
- ,,.Establishing a pediatric hospitalist program at an academic medical center.Clin Pediatr.2000;39:221–227.
- ,,,,,.Restructuring an academic pediatric inpatient service using concepts developed by hospitalists.Clin Pediatr.2001;40:653–660.
- ,.The hospitalist movement and its implications for the care of hospitalized children.Pediatrics.1999;103:473–477.
- ,,,.Pediatric hospitalists: a systematic review of the literature.Pediatrics.2006;117:1736–1744.
- ,,.Factors affecting ratings of clinical teachers by medical students and residents.J Med Educ.1987;62:1–7.
- ,,,,.Attributes of excellent attending‐physician role models.N Engl J Med.1998;339:1986–1993.
- ,.Evaluation of clinical instructors by third‐year medical students.Acad Med.1989;64:159–164.
- ,,.Clinical tutor evaluation: a 5‐year study by students on an in‐patient service and residents in an ambulatory care clinic.Med Educ.1993;27:48–53.
- ,,,,,.Physicians' experience with the acquired immunodeficiency syndrome as a factor in patients' survival.N Engl J Med.1996;334:701–706.
- ,,,.Hospital Volume, Physician Volume, and Patient Outcomes: Assessing the Evidence. Ann Arbor, MI: Health Administration Perspectives;1990.
- ,,, 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.
- ,,,,, eds.The core competencies in hospital medicine: a framework for curriculum development by the Society of Hospital Medicine.J Hosp Med.2006;1(S1):1–67.
In 1996 Wachter and Goldman anticipated the emergence of hospitalists,1 physicians who are responsible for the care of hospitalized patients in place of their primary care physicians. The number of physicians who identify themselves as hospitalists has grown rapidly since 1996 and is currently estimated to be 10,00012,000, with the potential to reach as high as 30,000 in the next decade.2 This growth includes academic medical centers. In surveys of chairs of internal medicine and pediatric departments, 50% have hospitalists employed at their institutions.3, 4
Hospitalists in academic institutions are playing an increasingly prominent role in the medical education of both residents and medical students. The implications of adopting a hospitalist model on medical education has been discussed.57 Despite such concerns as fragmented continuity of care; decreased exposure to primary care physicians, subspecialists and physician‐scientists; reduced autonomy; and fewer educational opportunities to observe the natural histories of illnesses because of improved efficiency,57 the overall impact of hospitalists on medical and resident education has generally been favorable.818 Internal medicine residents have rated the teaching skills of hospitalists comparable to traditional academic physicians,8, 9 and believe the addition of hospitalists has contributed to an improved educational experience.10, 11, 14 In addition, a survey of third‐year medical students at a single academic teaching hospital concluded that hospitalists were able to provide at least as positive an educational experience during their inpatient medicine rotations as highly rated nonhospitalist teaching faculty.13
The role of hospitalists as educators in pediatrics has been studied much less. Pediatric resident satisfaction has improved in institutions that have used a hospitalist model.1618 In another study, hospitalists were rated by pediatric residents as more effective teachers than nonhospitalists.15 Because we are unaware of any study that has evaluated hospitalists in the education of medical students during their inpatient pediatric rotation, the purpose of our study was to compare hospitalist and nonhospitalist faculty on the educational experience of third‐year medical students during the inpatient portion of their pediatric clerkships at a single university children's hospital.
METHODS
Study Design
We conducted a retrospective study using evaluations of third‐year medical students comparing hospitalist and nonhospitalist faculty during the inpatient portions of their pediatrics clerkships at a single academic children's hospital over a 15‐month period (July 1999September 2000).
Setting and Sample
We conducted our study at Penn State Children's Hospital (PSCH), a 120‐bed tertiary‐care facility within the 504‐bed Hershey Medical Center, the main teaching hospital affiliated with the Penn State College of Medicine, Hershey, Pennsylvania. The pediatric hospitalist program commenced on July 1, 1999, and during the 15‐month study period the hospitalist staff consisted of 2 physicians who attended a total of 8 months, whereas the nonhospitalist staff consisted of 4 academic general pediatricians and 4 academic pediatric subspecialists who attended the remaining 7 months.
The inpatient clinical responsibilities of both groups of physicians during each month were similar. Both groups of physicians conducted daily rounds with a team that included a senior resident (postgraduate year 3), 2 to 4 interns (postgraduate year 1), 1 acting intern (fourth‐year medical student), and 2 to 4 third‐year medical students. This team was responsible for all admissions to the general pediatrics service, which averages 100 admissions per month. Both the hospitalists and nonhospitalists had outpatient responsibilities during the time they served as inpatient attendings.
During the 15‐month study period, 131 students completed their third‐year pediatrics clerkships. Students at the Penn State College of Medicine may complete their pediatrics clerkship at PSCH or at one of several alternative sites. Because of variability in the structure of the rotation from site to site, it was considered valid only to analyze evaluations completed by students who rotated at PSCH. Sixty‐seven students rotated at PSCH during the study period. Students spent 3 weeks of the 6‐week rotation on the inpatient general pediatrics service. The remaining 3 weeks occurred in multiple outpatient pediatric practice settings and in the newborn nursery. During the 3 weeks the students spent on the inpatient service they did not have outpatient clinic responsibilities, so they did not interact with either the hospitalists or nonhospitalists in the outpatient setting. At the end of the rotation, students were asked to rate the effectiveness of the faculty as teachers, pediatricians, and student advocates and overall on a 4‐point scale (1 = inadequate; 2 = adequate; 3 = very good; 4 = excellent). Students were also asked to evaluate 7 components of the clerkship on the same 4‐point scale (Table 1). Finally, students were asked to provide additional written comments in an unstructured format.
| Evaluation item | Hospitalist mean score (32 evaluations) | Nonhospitalist mean score (35 evaluations) | P value | No. of evaluations rated adequate or inadequate (%)b | |
|---|---|---|---|---|---|
| Hospitalist | Nonhospitalist | ||||
| |||||
| Effectiveness as teacherc | 3.87 | 2.91 | < .001a | 1 (2.9) | 13 (40.6) |
| Effectiveness as pediatriciand | 3.94 | 3.25 | < .001a | 0 (0.0) | 5 (15.6) |
| Effectiveness as student advocatee | 3.76 | 2.97 | < .001a | 2 (5.7) | 13 (40.6) |
| Overall evaluation | 3.93 | 3.06 | < .001a | 0 (0.0) | 10 (31.3) |
| Ward rounds | 3.15 | 2.58 | < .006a | 5 (15.6) | 12 (37.5) |
| Morning report | 3.16 | 3.14 | 0.923 | ||
| Sick newborn | 2.79 | 2.60 | 0.518 | ||
| Well newborn | 2.89 | 3.13 | 0.211 | ||
| Outpatient department clinics | 2.96 | 3.06 | 0.425 | ||
| Private physician's office | 2.97 | 3.01 | 0.794 | ||
| Noon conference | 3.03 | 3.13 | 0.512 | ||
After reviewing the literature concerning faculty evaluation forms and their components, an evaluation form was created for students to indicate their reactions to clerkship components. All the medical students' faculty evaluations were anonymous, and the faculty was not able to review student evaluations prior to assigning grades. Students were required to turn in an evaluation at the end of their rotations. The study was limited to 15 months, as the format of the evaluation form was changed after September 2000 and the general pediatrics service was in the process of transitioning to an exclusively hospitalist‐run service, thereby limiting the number of nonhospitalists available as a comparison group. Demographic characteristics of the hospitalist and nonhospitalist faculty were collected from a faculty database. The study was approved by the Penn State Milton S. Hershey Medical Center's Institutional Review Board.
Statistics and Analysis
For all questions, a Wilcoxon rank sum test was used to evaluate whether the responses for nonhospitalists were different than those for hospitalists. Differences in response by group whose 2‐tailed P values were less than .05 were considered statistically significant. All analyses were performed using the SAS statistical software, version 8.2 (SAS Institute Inc., Cary, NC).
RESULTS
All 67 of the students who completed a pediatrics clerkship at PSCH returned evaluation forms, which were the data for further analysis. Thirty‐five students rotated with the hospitalist faculty, and 32 students rotated with the nonhospitalist faculty. There were no significant demographic differences between the hospitalist and nonhospitalist faculty in age, sex, academic rank, specialty, and years since completing training (Table 2). All the hospitalist faculty fulfilled the definition of a hospitalist,2 whereas none of the physicians in the nonhospitalist group did.
| Characteristic | Hospitalists (n = 2) | Nonhospitalists (n = 8) | P value |
|---|---|---|---|
| Age, mean (range) | 36.0 (3141) | 46.5 (3063) | 0.30 |
| Male/Female | 1/1 | 6/2 | 0.95 |
| Academic rank | |||
| Instructor | 0 | 1 | |
| Assistant professor | 2 | 3 | |
| Associate professor | 0 | 0 | 0.56 |
| Professor | 0 | 4 | |
| Specialty | |||
| General pediatrics | 1 | 4 | |
| Nephrology | 1 | 1 | |
| Genetics | 0 | 1 | 0.95 |
| Infectious ciseases | 0 | 1 | |
| Rheumatology | 0 | 1 | |
| Years since training, mean (range) | 4.0 (08) | 13.8 (030) | 0.43 |
The hospitalists were rated significantly higher than the nonhospitalist faculty in all 4 of the attending characteristics measured (Table 1): teaching effectiveness (3.87 vs. 2.91; P < .0001), effectiveness as a pediatrician (3.94 vs. 3.25; P < .001), student advocacy effectiveness (3.76 vs. 2.97; P < .0001), and overall evaluation (3.93 vs. 3.06; P < .001).
Analysis of specific aspects of the rotation showed the only feature that hospitalists were rated significantly higher on was quality of ward rounds (3.15 vs. 2.58, P < .006). There was no significant difference between the hospitalists and nonhospitalists on features that were not specifically part of the inpatient rotation, including various conferences, outpatient clinics, and newborn care (Table 1).
DISCUSSION
Our study demonstrates that pediatric hospitalists had a positive impact on the overall educational experience of third‐year medical students during the inpatient portions of their pediatrics clerkships. Hospitalists were rated more favorably than nonhospitalists as teachers, as pediatricians, as student advocates, and overall. Medical students also rated the value of ward rounds more favorably when hospitalists conducted them. In addition, higher percentages of nonhospitalists than hospitalists were rated as adequate or inadequate for the above items. When other aspects of the clerkship were analyzed, there were no statistically significant differences between the students who rotated with hospitalists and the students who rotated with nonhospitalists. This suggests that the higher scores for hospitalists were specifically related to their interactions with students, rather than with an overall more positive view of the rotation.
It has been suggested that forces promoting the use of hospitalists in adult medicine are even more persuasive in the pediatric population, as the difference in severity of illness between the inpatient and outpatient setting is greater, and the average pediatrician has less experience than the average internist in managing hospitalized patients.19 In a recent systematic review of the literature, Landrigan et al.20 reported that 6 of 7 studies demonstrated hospitalist systems had decreased hospital length of stay compared to systems in which a primary pediatrician served as the physician of record. This improved efficiency, if combined with the pressure to see more patients while trying to balance teaching and research demands, may have a negative impact on the quality of medical education.
Several factors may have contributed to the students' satisfaction with hospitalists. Studies have demonstrated that students rate clinical teachers more favorably with whom they have greater involvement.21 Hospitalists may be more likely to spend time on the inpatient wards given that is the primary site of their clinical activity. This increased presence may have contributed to more favorable evaluations for the hospitalist faculty, whereas the additional outpatient workload for nonhospitalist faculty may have reduced inpatient teaching opportunities, accounting for their lower teaching score. Included in the pediatrician category was the attribute of being a role model. In a study by Wright et al.,22 spending more than 25% of the time or 25 or more hours per week teaching and conducting rounds was independently associated with being considered an excellent role model. Again, the increased availability of the hospitalists on the inpatient wards may have led to more teaching opportunities, contributing to their higher score.
Our study had several limitations. First, it was a retrospective study conducted at a single institution with only 2 hospitalists. Although there were not statistical significant demographic differences between the 2 groups, this may simply reflect the small size of the sample in our study; therefore, the results may not be applicable to other academic institutions. Second, we retrospectively analyzed an evaluation form that had not been validated or specifically designed to compare 2 physician groups. Third, there were multiple statements in each category that students were asked to consider before scoring each attending on the parameters measured. Although hospitalists were rated higher in each category, there may have been individual characteristics within each category for which the nonhospitalist faculty performed better. Fourth, although hospitalists received higher average ratings than nonhospitalist faculty from third‐year medical students, it is important to emphasize this study measured students' attitudes and beliefs not specific educational outcomes. However, even though we cannot rule out the possibility that potentially confounding factors such as the personality of an attending physician influenced the results, prior studies have demonstrated that medical students make sophisticated judgments about teaching in the clinical setting.23, 24 It is unlikely that hospitalists at our institution were specifically selected to attend more months on a new inpatient service because they had a history of having more favorable teaching qualities because 1 of the 2 hospitalists had just finished residency training, and there were no significant demographic differences between the 2 groups. In a study examining trainee satisfaction in an internal medicine rotation 4 years after adoption of a hospitalist model, where nonhospitalist faculty attended based on their own interest and inpatient skill rather than as a requirement, Hauer et al.14 reported that trainees experienced more effective teaching and a more satisfying inpatient rotation when supervised by hospitalists. This suggests that hospitalists may possess or develop a specific inpatient knowledge base and teaching acumen over time that distinguishes them from nonhospitalists. There is evidence of accumulated experience leading to improved outcomes in the clinical setting for HIV infection,25 various surgical procedures,26 and hospitalist systems.27
In conclusion, this is the first study to evaluate the performance of hospitalists in the setting of a third‐year medical student pediatrics clerkship. Although third‐year medical students rate hospitalists at least as highly as nonhospitalist faculty, further studies are needed to reproduce this finding. In addition to the increased time spent on the wards with students and increased experience in caring for hospitalized patients, further studies should also examine the role that communication plays in clinical teaching. Also, the recent development of core competencies in hospital medicine28 may lead to the development of educational outcomes that can be objectively measured.
Acknowledgements
The authors thank David Mauger, PhD, from the Department of Health Evaluation Sciences at the Penn State College of Medicine for providing statistical analysis of the survey results.
In 1996 Wachter and Goldman anticipated the emergence of hospitalists,1 physicians who are responsible for the care of hospitalized patients in place of their primary care physicians. The number of physicians who identify themselves as hospitalists has grown rapidly since 1996 and is currently estimated to be 10,00012,000, with the potential to reach as high as 30,000 in the next decade.2 This growth includes academic medical centers. In surveys of chairs of internal medicine and pediatric departments, 50% have hospitalists employed at their institutions.3, 4
Hospitalists in academic institutions are playing an increasingly prominent role in the medical education of both residents and medical students. The implications of adopting a hospitalist model on medical education has been discussed.57 Despite such concerns as fragmented continuity of care; decreased exposure to primary care physicians, subspecialists and physician‐scientists; reduced autonomy; and fewer educational opportunities to observe the natural histories of illnesses because of improved efficiency,57 the overall impact of hospitalists on medical and resident education has generally been favorable.818 Internal medicine residents have rated the teaching skills of hospitalists comparable to traditional academic physicians,8, 9 and believe the addition of hospitalists has contributed to an improved educational experience.10, 11, 14 In addition, a survey of third‐year medical students at a single academic teaching hospital concluded that hospitalists were able to provide at least as positive an educational experience during their inpatient medicine rotations as highly rated nonhospitalist teaching faculty.13
The role of hospitalists as educators in pediatrics has been studied much less. Pediatric resident satisfaction has improved in institutions that have used a hospitalist model.1618 In another study, hospitalists were rated by pediatric residents as more effective teachers than nonhospitalists.15 Because we are unaware of any study that has evaluated hospitalists in the education of medical students during their inpatient pediatric rotation, the purpose of our study was to compare hospitalist and nonhospitalist faculty on the educational experience of third‐year medical students during the inpatient portion of their pediatric clerkships at a single university children's hospital.
METHODS
Study Design
We conducted a retrospective study using evaluations of third‐year medical students comparing hospitalist and nonhospitalist faculty during the inpatient portions of their pediatrics clerkships at a single academic children's hospital over a 15‐month period (July 1999September 2000).
Setting and Sample
We conducted our study at Penn State Children's Hospital (PSCH), a 120‐bed tertiary‐care facility within the 504‐bed Hershey Medical Center, the main teaching hospital affiliated with the Penn State College of Medicine, Hershey, Pennsylvania. The pediatric hospitalist program commenced on July 1, 1999, and during the 15‐month study period the hospitalist staff consisted of 2 physicians who attended a total of 8 months, whereas the nonhospitalist staff consisted of 4 academic general pediatricians and 4 academic pediatric subspecialists who attended the remaining 7 months.
The inpatient clinical responsibilities of both groups of physicians during each month were similar. Both groups of physicians conducted daily rounds with a team that included a senior resident (postgraduate year 3), 2 to 4 interns (postgraduate year 1), 1 acting intern (fourth‐year medical student), and 2 to 4 third‐year medical students. This team was responsible for all admissions to the general pediatrics service, which averages 100 admissions per month. Both the hospitalists and nonhospitalists had outpatient responsibilities during the time they served as inpatient attendings.
During the 15‐month study period, 131 students completed their third‐year pediatrics clerkships. Students at the Penn State College of Medicine may complete their pediatrics clerkship at PSCH or at one of several alternative sites. Because of variability in the structure of the rotation from site to site, it was considered valid only to analyze evaluations completed by students who rotated at PSCH. Sixty‐seven students rotated at PSCH during the study period. Students spent 3 weeks of the 6‐week rotation on the inpatient general pediatrics service. The remaining 3 weeks occurred in multiple outpatient pediatric practice settings and in the newborn nursery. During the 3 weeks the students spent on the inpatient service they did not have outpatient clinic responsibilities, so they did not interact with either the hospitalists or nonhospitalists in the outpatient setting. At the end of the rotation, students were asked to rate the effectiveness of the faculty as teachers, pediatricians, and student advocates and overall on a 4‐point scale (1 = inadequate; 2 = adequate; 3 = very good; 4 = excellent). Students were also asked to evaluate 7 components of the clerkship on the same 4‐point scale (Table 1). Finally, students were asked to provide additional written comments in an unstructured format.
| Evaluation item | Hospitalist mean score (32 evaluations) | Nonhospitalist mean score (35 evaluations) | P value | No. of evaluations rated adequate or inadequate (%)b | |
|---|---|---|---|---|---|
| Hospitalist | Nonhospitalist | ||||
| |||||
| Effectiveness as teacherc | 3.87 | 2.91 | < .001a | 1 (2.9) | 13 (40.6) |
| Effectiveness as pediatriciand | 3.94 | 3.25 | < .001a | 0 (0.0) | 5 (15.6) |
| Effectiveness as student advocatee | 3.76 | 2.97 | < .001a | 2 (5.7) | 13 (40.6) |
| Overall evaluation | 3.93 | 3.06 | < .001a | 0 (0.0) | 10 (31.3) |
| Ward rounds | 3.15 | 2.58 | < .006a | 5 (15.6) | 12 (37.5) |
| Morning report | 3.16 | 3.14 | 0.923 | ||
| Sick newborn | 2.79 | 2.60 | 0.518 | ||
| Well newborn | 2.89 | 3.13 | 0.211 | ||
| Outpatient department clinics | 2.96 | 3.06 | 0.425 | ||
| Private physician's office | 2.97 | 3.01 | 0.794 | ||
| Noon conference | 3.03 | 3.13 | 0.512 | ||
After reviewing the literature concerning faculty evaluation forms and their components, an evaluation form was created for students to indicate their reactions to clerkship components. All the medical students' faculty evaluations were anonymous, and the faculty was not able to review student evaluations prior to assigning grades. Students were required to turn in an evaluation at the end of their rotations. The study was limited to 15 months, as the format of the evaluation form was changed after September 2000 and the general pediatrics service was in the process of transitioning to an exclusively hospitalist‐run service, thereby limiting the number of nonhospitalists available as a comparison group. Demographic characteristics of the hospitalist and nonhospitalist faculty were collected from a faculty database. The study was approved by the Penn State Milton S. Hershey Medical Center's Institutional Review Board.
Statistics and Analysis
For all questions, a Wilcoxon rank sum test was used to evaluate whether the responses for nonhospitalists were different than those for hospitalists. Differences in response by group whose 2‐tailed P values were less than .05 were considered statistically significant. All analyses were performed using the SAS statistical software, version 8.2 (SAS Institute Inc., Cary, NC).
RESULTS
All 67 of the students who completed a pediatrics clerkship at PSCH returned evaluation forms, which were the data for further analysis. Thirty‐five students rotated with the hospitalist faculty, and 32 students rotated with the nonhospitalist faculty. There were no significant demographic differences between the hospitalist and nonhospitalist faculty in age, sex, academic rank, specialty, and years since completing training (Table 2). All the hospitalist faculty fulfilled the definition of a hospitalist,2 whereas none of the physicians in the nonhospitalist group did.
| Characteristic | Hospitalists (n = 2) | Nonhospitalists (n = 8) | P value |
|---|---|---|---|
| Age, mean (range) | 36.0 (3141) | 46.5 (3063) | 0.30 |
| Male/Female | 1/1 | 6/2 | 0.95 |
| Academic rank | |||
| Instructor | 0 | 1 | |
| Assistant professor | 2 | 3 | |
| Associate professor | 0 | 0 | 0.56 |
| Professor | 0 | 4 | |
| Specialty | |||
| General pediatrics | 1 | 4 | |
| Nephrology | 1 | 1 | |
| Genetics | 0 | 1 | 0.95 |
| Infectious ciseases | 0 | 1 | |
| Rheumatology | 0 | 1 | |
| Years since training, mean (range) | 4.0 (08) | 13.8 (030) | 0.43 |
The hospitalists were rated significantly higher than the nonhospitalist faculty in all 4 of the attending characteristics measured (Table 1): teaching effectiveness (3.87 vs. 2.91; P < .0001), effectiveness as a pediatrician (3.94 vs. 3.25; P < .001), student advocacy effectiveness (3.76 vs. 2.97; P < .0001), and overall evaluation (3.93 vs. 3.06; P < .001).
Analysis of specific aspects of the rotation showed the only feature that hospitalists were rated significantly higher on was quality of ward rounds (3.15 vs. 2.58, P < .006). There was no significant difference between the hospitalists and nonhospitalists on features that were not specifically part of the inpatient rotation, including various conferences, outpatient clinics, and newborn care (Table 1).
DISCUSSION
Our study demonstrates that pediatric hospitalists had a positive impact on the overall educational experience of third‐year medical students during the inpatient portions of their pediatrics clerkships. Hospitalists were rated more favorably than nonhospitalists as teachers, as pediatricians, as student advocates, and overall. Medical students also rated the value of ward rounds more favorably when hospitalists conducted them. In addition, higher percentages of nonhospitalists than hospitalists were rated as adequate or inadequate for the above items. When other aspects of the clerkship were analyzed, there were no statistically significant differences between the students who rotated with hospitalists and the students who rotated with nonhospitalists. This suggests that the higher scores for hospitalists were specifically related to their interactions with students, rather than with an overall more positive view of the rotation.
It has been suggested that forces promoting the use of hospitalists in adult medicine are even more persuasive in the pediatric population, as the difference in severity of illness between the inpatient and outpatient setting is greater, and the average pediatrician has less experience than the average internist in managing hospitalized patients.19 In a recent systematic review of the literature, Landrigan et al.20 reported that 6 of 7 studies demonstrated hospitalist systems had decreased hospital length of stay compared to systems in which a primary pediatrician served as the physician of record. This improved efficiency, if combined with the pressure to see more patients while trying to balance teaching and research demands, may have a negative impact on the quality of medical education.
Several factors may have contributed to the students' satisfaction with hospitalists. Studies have demonstrated that students rate clinical teachers more favorably with whom they have greater involvement.21 Hospitalists may be more likely to spend time on the inpatient wards given that is the primary site of their clinical activity. This increased presence may have contributed to more favorable evaluations for the hospitalist faculty, whereas the additional outpatient workload for nonhospitalist faculty may have reduced inpatient teaching opportunities, accounting for their lower teaching score. Included in the pediatrician category was the attribute of being a role model. In a study by Wright et al.,22 spending more than 25% of the time or 25 or more hours per week teaching and conducting rounds was independently associated with being considered an excellent role model. Again, the increased availability of the hospitalists on the inpatient wards may have led to more teaching opportunities, contributing to their higher score.
Our study had several limitations. First, it was a retrospective study conducted at a single institution with only 2 hospitalists. Although there were not statistical significant demographic differences between the 2 groups, this may simply reflect the small size of the sample in our study; therefore, the results may not be applicable to other academic institutions. Second, we retrospectively analyzed an evaluation form that had not been validated or specifically designed to compare 2 physician groups. Third, there were multiple statements in each category that students were asked to consider before scoring each attending on the parameters measured. Although hospitalists were rated higher in each category, there may have been individual characteristics within each category for which the nonhospitalist faculty performed better. Fourth, although hospitalists received higher average ratings than nonhospitalist faculty from third‐year medical students, it is important to emphasize this study measured students' attitudes and beliefs not specific educational outcomes. However, even though we cannot rule out the possibility that potentially confounding factors such as the personality of an attending physician influenced the results, prior studies have demonstrated that medical students make sophisticated judgments about teaching in the clinical setting.23, 24 It is unlikely that hospitalists at our institution were specifically selected to attend more months on a new inpatient service because they had a history of having more favorable teaching qualities because 1 of the 2 hospitalists had just finished residency training, and there were no significant demographic differences between the 2 groups. In a study examining trainee satisfaction in an internal medicine rotation 4 years after adoption of a hospitalist model, where nonhospitalist faculty attended based on their own interest and inpatient skill rather than as a requirement, Hauer et al.14 reported that trainees experienced more effective teaching and a more satisfying inpatient rotation when supervised by hospitalists. This suggests that hospitalists may possess or develop a specific inpatient knowledge base and teaching acumen over time that distinguishes them from nonhospitalists. There is evidence of accumulated experience leading to improved outcomes in the clinical setting for HIV infection,25 various surgical procedures,26 and hospitalist systems.27
In conclusion, this is the first study to evaluate the performance of hospitalists in the setting of a third‐year medical student pediatrics clerkship. Although third‐year medical students rate hospitalists at least as highly as nonhospitalist faculty, further studies are needed to reproduce this finding. In addition to the increased time spent on the wards with students and increased experience in caring for hospitalized patients, further studies should also examine the role that communication plays in clinical teaching. Also, the recent development of core competencies in hospital medicine28 may lead to the development of educational outcomes that can be objectively measured.
Acknowledgements
The authors thank David Mauger, PhD, from the Department of Health Evaluation Sciences at the Penn State College of Medicine for providing statistical analysis of the survey results.
- ,.The emerging role of “hospitalists” in the American health care system.N Engl J Med.1996;335:514–517.
- Society of Hospital Medicine. Frequently asked questions. Available at: http://www.hospitalmedicine.org/AM/Template.cfm?Section=FAQs75:S34–6.
- ,,,,,.Pediatric hospitalists in Canada and the United States: a survey of pediatric academic department chairs.Ambul Pediatr.2001;1:338–339.
- .The impact of hospitalists on medical education and the academic health system.Ann Intern Med.1999;130:364–367.
- ,.The role of hospitalists in medical education.Am J Med.1999;107:305–309.
- ,.Implications of the hospitalist model for medical students' education.Acad. Med.2001;76:324–330.
- ,,,,.Reorganizing an academic medical service: impact on cost, quality, patient satisfaction, and education.JAMA.1998;279:1560–1565.
- ,,, et al.Hospitalists as teachers: how do they compare to subspecialty and general medicine faculty.J Gen Intern Med.2004;19:8–15.
- ,,,,.Assessing the value of hospitalists to academic health centers: Brigham and Women's Hospital and Harvard Medical School.Am J Med.1999;106:134–137.
- ,,,,,.Resident satisfaction on an academic hospitalist service: time to teach.Am J Med.2002;112:597–601.
- ,,,,,,.The positive impact of initiation of hospitalist clinician educators: resource utilization and medical resident education.J Gen Intern Med.2004;19:293–301.
- ,,,.Medical student evaluation of the quality of hospitalist and nonhospitalist teaching faculty on inpatient medicine rotations.Acad Med.2004;79:78–82.
- ,,,,.Effects of hospitalist attending physicians on trainee satisfaction with teaching and with internal medicine rotations.Arch Intern Med.2004;164:1866–1871.
- ,,,,,.Effect of a pediatric hospitalist system on housestaff education and experience.Arch Pediatr Adolesc Med.2002;156:877–883.
- .Employing hospitalists to improve residents' inpatient learning.Acad Med.2001;76:556.
- ,,.Establishing a pediatric hospitalist program at an academic medical center.Clin Pediatr.2000;39:221–227.
- ,,,,,.Restructuring an academic pediatric inpatient service using concepts developed by hospitalists.Clin Pediatr.2001;40:653–660.
- ,.The hospitalist movement and its implications for the care of hospitalized children.Pediatrics.1999;103:473–477.
- ,,,.Pediatric hospitalists: a systematic review of the literature.Pediatrics.2006;117:1736–1744.
- ,,.Factors affecting ratings of clinical teachers by medical students and residents.J Med Educ.1987;62:1–7.
- ,,,,.Attributes of excellent attending‐physician role models.N Engl J Med.1998;339:1986–1993.
- ,.Evaluation of clinical instructors by third‐year medical students.Acad Med.1989;64:159–164.
- ,,.Clinical tutor evaluation: a 5‐year study by students on an in‐patient service and residents in an ambulatory care clinic.Med Educ.1993;27:48–53.
- ,,,,,.Physicians' experience with the acquired immunodeficiency syndrome as a factor in patients' survival.N Engl J Med.1996;334:701–706.
- ,,,.Hospital Volume, Physician Volume, and Patient Outcomes: Assessing the Evidence. Ann Arbor, MI: Health Administration Perspectives;1990.
- ,,, 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.
- ,,,,, eds.The core competencies in hospital medicine: a framework for curriculum development by the Society of Hospital Medicine.J Hosp Med.2006;1(S1):1–67.
- ,.The emerging role of “hospitalists” in the American health care system.N Engl J Med.1996;335:514–517.
- Society of Hospital Medicine. Frequently asked questions. Available at: http://www.hospitalmedicine.org/AM/Template.cfm?Section=FAQs75:S34–6.
- ,,,,,.Pediatric hospitalists in Canada and the United States: a survey of pediatric academic department chairs.Ambul Pediatr.2001;1:338–339.
- .The impact of hospitalists on medical education and the academic health system.Ann Intern Med.1999;130:364–367.
- ,.The role of hospitalists in medical education.Am J Med.1999;107:305–309.
- ,.Implications of the hospitalist model for medical students' education.Acad. Med.2001;76:324–330.
- ,,,,.Reorganizing an academic medical service: impact on cost, quality, patient satisfaction, and education.JAMA.1998;279:1560–1565.
- ,,, et al.Hospitalists as teachers: how do they compare to subspecialty and general medicine faculty.J Gen Intern Med.2004;19:8–15.
- ,,,,.Assessing the value of hospitalists to academic health centers: Brigham and Women's Hospital and Harvard Medical School.Am J Med.1999;106:134–137.
- ,,,,,.Resident satisfaction on an academic hospitalist service: time to teach.Am J Med.2002;112:597–601.
- ,,,,,,.The positive impact of initiation of hospitalist clinician educators: resource utilization and medical resident education.J Gen Intern Med.2004;19:293–301.
- ,,,.Medical student evaluation of the quality of hospitalist and nonhospitalist teaching faculty on inpatient medicine rotations.Acad Med.2004;79:78–82.
- ,,,,.Effects of hospitalist attending physicians on trainee satisfaction with teaching and with internal medicine rotations.Arch Intern Med.2004;164:1866–1871.
- ,,,,,.Effect of a pediatric hospitalist system on housestaff education and experience.Arch Pediatr Adolesc Med.2002;156:877–883.
- .Employing hospitalists to improve residents' inpatient learning.Acad Med.2001;76:556.
- ,,.Establishing a pediatric hospitalist program at an academic medical center.Clin Pediatr.2000;39:221–227.
- ,,,,,.Restructuring an academic pediatric inpatient service using concepts developed by hospitalists.Clin Pediatr.2001;40:653–660.
- ,.The hospitalist movement and its implications for the care of hospitalized children.Pediatrics.1999;103:473–477.
- ,,,.Pediatric hospitalists: a systematic review of the literature.Pediatrics.2006;117:1736–1744.
- ,,.Factors affecting ratings of clinical teachers by medical students and residents.J Med Educ.1987;62:1–7.
- ,,,,.Attributes of excellent attending‐physician role models.N Engl J Med.1998;339:1986–1993.
- ,.Evaluation of clinical instructors by third‐year medical students.Acad Med.1989;64:159–164.
- ,,.Clinical tutor evaluation: a 5‐year study by students on an in‐patient service and residents in an ambulatory care clinic.Med Educ.1993;27:48–53.
- ,,,,,.Physicians' experience with the acquired immunodeficiency syndrome as a factor in patients' survival.N Engl J Med.1996;334:701–706.
- ,,,.Hospital Volume, Physician Volume, and Patient Outcomes: Assessing the Evidence. Ann Arbor, MI: Health Administration Perspectives;1990.
- ,,, 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.
- ,,,,, eds.The core competencies in hospital medicine: a framework for curriculum development by the Society of Hospital Medicine.J Hosp Med.2006;1(S1):1–67.
Copyright © 2007 Society of Hospital Medicine