Affiliations
Department of Medicine, Denver Health
Given name(s)
Maria G.
Family name
Frank
Degrees
MD

Gender Disparities for Academic Hospitalists

Article Type
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Tue, 05/16/2017 - 23:12
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Gender disparities in leadership and scholarly productivity of academic hospitalists

Gender disparities still exist for women in academic medicine.[1, 2, 3, 4, 5, 6, 7, 8, 9] The most recent data from the Association of American Medical Colleges (AAMC) show that although gender disparities are decreasing, women are still under‐represented in the assistant, associate, and full‐professor ranks as well as in leadership positions.[1]

Some studies indicate that gender differences are less evident when examining younger cohorts.[1, 10, 11, 12, 13] Hospital medicine emerged around 1996, when the term hospitalist was first coined.[14] The gender distribution of academic hospitalists is likely nearly equal,[15, 16] and they are generally younger physicians.[15, 17, 18, 19, 20] Accordingly, we questioned whether gender disparities existed in academic hospital medicine (HM) and, if so, whether these disparities were greater than those that might exist in academic general internal medicine (GIM).

METHODS

This study consisted of both prospective and retrospective observation of data collected for academic adult hospitalists and general internists who practice in the United States. It was approved by the Colorado Multiple Institutional Review Board.

Gender distribution was assessed with respect to: (1) academic HM and GIM faculty, (2) leadership (ie, division or section heads), and (3) scholarly work (ie, speaking opportunities and publications). Data were collected between October 1, 2012 and August 31, 2014.

Gender Distribution of Faculty and Division/Section Heads

All US internal medicine residency programs were identified from the list of members or affiliates of the AAMC that were fully accredited by the Liaison Committee on Medical Education[21] using the Graduate Medical Education Directory.[22] We then determined the primary training hospital(s) affiliated with each program and selected those that were considered to be university hospitals and eliminated those that did not have divisions or sections of HM or GIM. We determined the gender of the respective division/section heads on the basis of the faculty member's first name (and often from accompanying photos) as well as from information obtained via Internet searches and, if necessary, contacted the individual institutions via email or phone call(s). We also determined the number and gender of all of the HM and GIM faculty members in a random sample of 25% of these hospitals from information on their respective websites.

Gender Distribution for Scholarly Productivity

We determined the gender and specialty of all speakers at the Society of Hospital Medicine and the Society of General Internal Medicine national conferences from 2006 to 2012. A list of speakers at each conference was obtained from conference pamphlets or agendas that were available via Internet searches or obtained directly from the organization. We also determined whether each presenter was a featured speaker (defined as one whose talk was unopposed by other sessions), plenary speaker (defined as such in the conference pamphlets), or if they spoke in a group format (also as indicated in the conference pamphlets). Because of the low number of featured and plenary speakers, these data were combined. Faculty labeled as additional faculty when presenting in a group format were excluded as were speakers at precourses, those presenting abstracts, and those participating in interest group sessions.

For authorship, a PubMed search was used to identify all articles published in the Journal of Hospital Medicine (JHM) and the Journal of General Internal Medicine (JGIM) from January 1, 2006 through December 31, 2012, and the gender and specialty of all the first and last authors were determined as described above. Specialty was determined from the division, section or department affiliation indicated for each author and by Internet searches. In some instances, it was necessary to contact the authors or their departments directly to verify their specialty. When articles had only 1 author, the author was considered a first author.

Duplicate records (eg, same author, same journal) and articles without an author were excluded, as were authors who did not have an MD, DO, or MBBS degree and those who were not affiliated with an institution in the United States. All manuscripts, with the exception of errata, were analyzed together as well as in 3 subgroups: original research, editorials, and others.

A second investigator corroborated data regarding gender and specialty for all speakers and authors to strengthen data integrity. On the rare occasion when discrepancies were found, a third investigator adjudicated the results.

Definitions

Physicians were defined as being hospitalists if they were listed as a member of a division or section of HM on their publications or if Internet searches indicated that they were a hospitalist or primarily worked on inpatient medical services. Physicians were considered to be general internists if they were listed as such on their publications and their specialty could be verified in Web‐based searches. If physicians appeared to have changing roles over time, we attempted to assign their specialty based upon their role at the time the article was published or the presentation was delivered. If necessary, phone calls and/or emails were also done to determine the physician's specialty.

Analysis

REDCap, a secure, Web‐based application for building and managing online surveys and databases, was used to collect and manage all study data.[23] All analyses were performed using SAS Enterprise Guide 4.3 (SAS Institute, Inc., Cary, NC). A [2] test was used to compare proportions of male versus female physicians, and data from hospitalists versus general internists. Because we performed multiple comparisons when analyzing presentations and publications, a Bonferroni adjustment was made such that a P<0.0125 for presentations and P<0.006 (within specialty) or P<0.0125 (between specialty) for the publication analyses were considered significant. P<0.05 was considered significant for all other comparisons.

RESULTS

Gender Distribution of Faculty

Eighteen HM and 20 GIM programs from university hospitals were randomly selected for review (see Supporting Figure 1 in the online version of this article). Seven of the HM programs and 1 of the GIM programs did not have a website, did not differentiate hospitalists from other faculty, or did not list their faculty on the website and were excluded from the analysis. In the remaining 11 HM programs and 19 GIM programs, women made up 277/568 (49%) and 555/1099 (51%) of the faculty, respectively (P=0.50).

Gender Distribution of Division/Section Heads

Eighty‐six of the programs were classified as university hospitals (see Supporting Figure 1 in the online version of this article), and in these, women led 11/69 (16%) of the HM divisions or sections and 28/80 (35%) of the GIM divisions (P=0.008).

Gender Distribution for Scholarly Productivity

Speaking Opportunities

A total of 1227 presentations were given at the 2 conferences from 2006 to 2012, with 1343 of the speakers meeting inclusion criteria (see Supporting Figure 2 in the online version of this article). Hospitalists accounted for 557 of the speakers, of which 146 (26%) were women. General internists accounted for 580 of the speakers, of which 291 (50%) were women (P<0.0001) (Table 1).

Gender Distribution for Presenters of Hospitalist and General Internists at National Conferences, 2006 to 2012
 Male, N (%)Female, N (%)
  • NOTE: *In‐specialty comparison, P0.0001. Between‐specialty comparison for conference data, P<0.0001.

Hospitalists  
All presentations411 (74)146 (26)*
Featured or plenary presentations49 (91)5 (9)*
General internists  
All presentations289 (50)291 (50)
Featured or plenary presentations27 (55)22 (45)

Of the 117 featured or plenary speakers, 54 were hospitalists and 5 (9%) of these were women. Of the 49 who were general internists, 22 (45%) were women (P<0.0001).

Authorship

The PubMed search identified a total of 3285 articles published in the JHM and the JGIM from 2006 to 2012, and 2172 first authors and 1869 last authors met inclusion criteria (see Supporting Figure 3 in the online version of this article). Hospitalists were listed as first or last authors on 464 and 305 articles, respectively, and of these, women were first authors on 153 (33%) and last authors on 63 (21%). General internists were listed as first or last authors on 895 and 769 articles, respectively, with women as first authors on 423 (47%) and last authors on 265 (34%). Compared with general internists, fewer women hospitalists were listed as either first or last authors (both P<0.0001) (Table 2).

Hospitalist and General Internal Medicine Authorship, 2006 to 2012
 First AuthorLast Author
Male, N (%)Female, N (%)Male, N (%)Female, N (%)
  • NOTE: *In‐specialty comparison, P<0.006. Between‐specialty comparison, P<0.0125.

Hospitalists    
All publications311 (67)153 (33)*242 (79)63 (21)*
Original investigations/brief reports124 (61)79 (39)*96 (76)30 (24)*
Editorials34 (77)10 (23)*18 (86)3 (14)*
Other153 (71)64 (29)*128 (81)30 (19)*
General internists    
All publications472 (53)423 (47)504 (66)265 (34)*
Original investigations/brief reports218 (46)261 (54)310 (65)170 (35)*
Editorial98 (68)46 (32)*43 (73)16 (27)*
Other156 (57)116 (43)151 (66)79 (34)*

Fewer women hospitalists were listed as first or last authors on all article types. For original research articles written by general internists, there was a trend for more women to be listed as first authors than men (261/479, 54%), but this difference was not statistically significant.

DISCUSSION

The important findings of this study are that, despite an equal gender distribution of academic HM and GIM faculty, fewer women were HM division/section chiefs, fewer women were speakers at the 2 selected national meetings, and fewer women were first or last authors of publications in 2 selected journals in comparison with general internists.

Previous studies have found that women lag behind their male counterparts with respect to academic productivity, leadership, and promotion.[1, 5, 7] Some studies suggest, however, that gender differences are reduced when younger cohorts are examined.[1, 10, 11, 12, 13] Surveys indicate that that the mean age of hospitalists is younger than most other specialties.[15, 19, 20, 24] The mean age of academic GIM physicians is unknown, but surveys of GIM (not differentiating academic from nonacademic) suggest that it is an older cohort than that of HM.[24] Despite hospitalists being a younger cohort, we found gender disparities in all areas investigated.

Our findings with respect to gender disparities in HM division or section leadership are consistent with the annual AAMC Women in US Academic Medicine and Science Benchmarking Report that found only 22% of all permanent division or section heads were women.[1]

Gender disparities with respect to authorship of medical publications have been previously noted,[3, 6, 15, 25] but to our knowledge, this is the first study to investigate the gender of authors who were hospitalists. Although we found a higher proportion of women hospitalists who were first or last authors than was observed by Jagsi and colleagues,[3] women hospitalists were still under‐represented with respect to this measure of academic productivity. Erren et al. reviewed 6 major journals from 2010 and 2011, and found that first authorship of original research by women ranged from 23.7% to 46.7%, and for last authorship from 18.3% to 28.8%.[25] Interestingly, we found no significant gender difference for first authors who were general internists, and there was a trend toward more women general internists being first authors than men for original research, reviews, and brief reports (data not shown).

Our study did not attempt to answer the question of why gender disparities persist, but many previous studies have explored this issue.[4, 8, 12, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42] Issues raised by others include the quantity of academic work (ie, publications and grants obtained), differences in hours worked and allocation of time, lack of mentorship, family responsibilities, discrimination, differences in career motivation, and levels of institutional support, to name a few.

The under‐representation of women hospitalists in leadership, authorship, and speaking opportunities may be consistent with gender‐related differences in research productivity. Fewer publications could lead to fewer national presentations, which could lead to fewer leadership opportunities. Our findings with respect to general internists are not consistent with this idea, however, as whereas women were under‐represented in GIM leadership positions, we found no disparities with respect to the gender of first authors or speakers at national meetings for general internists. The finding that hospitalists had gender disparities with respect to first authors and national speakers but general internists did not, argues against several hypotheses (ie, that women lack mentorship, have less career motivation, fewer career building opportunities).

One notable hypothesis, and perhaps one that is often discussed in the literature, is that women shoulder the majority of family responsibilities, and this may result in women having less time for their careers. Jolly and colleagues studied physician‐researchers and noted that women were more likely than men to have spouses or domestic partners who were fully employed, spent 8.5 more hours per week on domestic activities, and were more likely to take time off during disruptions of usual child care.[33] Carr and colleagues found that women with children (compared to men with children) had fewer publications, slower self‐perceived career progress, and lower career satisfaction, but having children had little effect on faculty aspirations and goals.[2] Kaplan et al., however, found that family responsibilities do not appear to account for sex differences in academic advancement.[4] Interestingly, in a study comparing physicians from Generation X to those of the Baby Boomer age, Generation X women reported working more than their male Generation X counterparts, and both had more of a focus on worklife balance than the older generation.[12]

The nature the of 2 specialties' work environment and job requirements could have also resulted in some of the differences seen. Primary care clinical work is typically conducted Monday through Friday, and hospitalist work frequently includes some weekend, evening, night, and holiday coverage. Although these are known differences, both specialties have also been noted to offer many advantages to women and men alike, including collaborative working environments and flexible work hours.[16]

Finally, finding disparity in leadership positions in both specialties supports the possibility that those responsible for hiring could have implicit gender biases. Under‐representation in entry‐level positions is also not a likely explanation for the differences we observed, because nearly an equal number of men and women graduate from medical school, pursue residency training in internal medicine, and become either academic hospitalists or general internists at university settings.[1, 15, 24] This hypothesis could, however, explain why disparities exist with respect to senior authorship and leadership positions, as typically, these individuals have been in practice longer and the current trends of improved gender equality have not always been the case.

Our study has a number of limitations. First, we only examined publications in 2 journals and presentations at 2 national conferences, although the journals and conferences selected are considered to be the major ones in the 2 specialties. Second, using Internet searches may have resulted in inaccurate gender and specialty assignment, but previous studies have used similar methodology.[3, 43] Additionally, we also attempted to contact individuals for direct confirmation when the information we obtained was not clear and had a second investigator independently verify the gender and specialty data. Third, we utilized division/department websites when available to determine the gender of HM divisions/sections. If not recently updated, these websites may not have reflected the most current leader of the unit, but this concern would seemingly pertain to both hospitalists and general internists. Fourth, we opted to only study faculty and division/section heads at university hospitals, as typically these institutions had GIM and hospitalist groups and also typically had websites. Because we only studied faculty and leadership at university hospitals, our data are not generalizable to all hospitalist and GIM groups. Finally, we excluded pediatric hospitalists, and thus, this study is representative of adult hospitalists only. Including pediatric hospitalists was out of the scope of this project.

Our study also had a number of strengths. To our knowledge, this is the first study to provide an estimate of the gender distribution in academic HM, of hospitalists as speakers at national meetings, as first and last authors, and of HM division or section heads, and is the first to compare these results with those observed for general internists. In addition, we examined 7 years of data from 2 of the major journals and national conferences for these specialties.

In summary, despite HM being a newer field with a younger cohort of physicians, we found that gender disparities exist for women with respect to authorship, national speaking opportunities, and division or section leadership. Identifying why these gender differences exist presents an important next step.

Disclosures: Nothing to report. Marisha Burden, MD and Maria G. Frank, MD are coprincipal authors.

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References
  1. Association of American Medical Colleges. Women in U.S. academic medicine and science: Statistics and benchmarking report. 2012. Available at: https://members.aamc.org/eweb/upload/Women%20in%20U%20S%20%20Academic%20Medicine%20Statistics%20and%20Benchmarking%20Report%202011-20123.pdf. Accessed September 1, 2014.
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  21. Association of American Medical Colleges. Women in U.S. Academic Medicine: Statistics and Benchmarking Report. 2009–2010. Available at: https://www.aamc.org/download/182674/data/gwims_stats_2009‐2010.pdf. Accessed September 1, 2014.
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  25. Erren TC, Gross JV, Shaw DM, Selle B. Representation of women as authors, reviewers, editors in chief, and editorial board members at 6 general medical journals in 2010 and 2011. JAMA Intern Med. 2014;174:633635.
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  30. Colletti LM, Mulholland MW, Sonnad SS. Perceived obstacles to career success for women in academic surgery. Arch Surg. 2000;135:972977.
  31. Frank E, McMurray JE, Linzer M, Elon L. Career satisfaction of US women physicians: results from the Women Physicians' Health Study. Society of General Internal Medicine Career Satisfaction Study Group. Arch Intern Med. 1999;159:14171426.
  32. Hoff TJ. Doing the same and earning less: male and female physicians in a new medical specialty. Inquiry. 2004;41:301315.
  33. Jolly S, Griffith KA, DeCastro R, Stewart A, Ubel P, Jagsi R. Gender differences in time spent on parenting and domestic responsibilities by high‐achieving young physician‐researchers. Ann Intern Med. 2014;160:344353.
  34. Levine RB, Lin F, Kern DE, Wright SM, Carrese J. Stories from early‐career women physicians who have left academic medicine: a qualitative study at a single institution. Acad Med. 2011;86:752758.
  35. Sasso AT, Richards MR, Chou CF, Gerber SE. The $16,819 pay gap for newly trained physicians: the unexplained trend of men earning more than women. Health Aff (Millwood). 2011;30:193201.
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Gender disparities still exist for women in academic medicine.[1, 2, 3, 4, 5, 6, 7, 8, 9] The most recent data from the Association of American Medical Colleges (AAMC) show that although gender disparities are decreasing, women are still under‐represented in the assistant, associate, and full‐professor ranks as well as in leadership positions.[1]

Some studies indicate that gender differences are less evident when examining younger cohorts.[1, 10, 11, 12, 13] Hospital medicine emerged around 1996, when the term hospitalist was first coined.[14] The gender distribution of academic hospitalists is likely nearly equal,[15, 16] and they are generally younger physicians.[15, 17, 18, 19, 20] Accordingly, we questioned whether gender disparities existed in academic hospital medicine (HM) and, if so, whether these disparities were greater than those that might exist in academic general internal medicine (GIM).

METHODS

This study consisted of both prospective and retrospective observation of data collected for academic adult hospitalists and general internists who practice in the United States. It was approved by the Colorado Multiple Institutional Review Board.

Gender distribution was assessed with respect to: (1) academic HM and GIM faculty, (2) leadership (ie, division or section heads), and (3) scholarly work (ie, speaking opportunities and publications). Data were collected between October 1, 2012 and August 31, 2014.

Gender Distribution of Faculty and Division/Section Heads

All US internal medicine residency programs were identified from the list of members or affiliates of the AAMC that were fully accredited by the Liaison Committee on Medical Education[21] using the Graduate Medical Education Directory.[22] We then determined the primary training hospital(s) affiliated with each program and selected those that were considered to be university hospitals and eliminated those that did not have divisions or sections of HM or GIM. We determined the gender of the respective division/section heads on the basis of the faculty member's first name (and often from accompanying photos) as well as from information obtained via Internet searches and, if necessary, contacted the individual institutions via email or phone call(s). We also determined the number and gender of all of the HM and GIM faculty members in a random sample of 25% of these hospitals from information on their respective websites.

Gender Distribution for Scholarly Productivity

We determined the gender and specialty of all speakers at the Society of Hospital Medicine and the Society of General Internal Medicine national conferences from 2006 to 2012. A list of speakers at each conference was obtained from conference pamphlets or agendas that were available via Internet searches or obtained directly from the organization. We also determined whether each presenter was a featured speaker (defined as one whose talk was unopposed by other sessions), plenary speaker (defined as such in the conference pamphlets), or if they spoke in a group format (also as indicated in the conference pamphlets). Because of the low number of featured and plenary speakers, these data were combined. Faculty labeled as additional faculty when presenting in a group format were excluded as were speakers at precourses, those presenting abstracts, and those participating in interest group sessions.

For authorship, a PubMed search was used to identify all articles published in the Journal of Hospital Medicine (JHM) and the Journal of General Internal Medicine (JGIM) from January 1, 2006 through December 31, 2012, and the gender and specialty of all the first and last authors were determined as described above. Specialty was determined from the division, section or department affiliation indicated for each author and by Internet searches. In some instances, it was necessary to contact the authors or their departments directly to verify their specialty. When articles had only 1 author, the author was considered a first author.

Duplicate records (eg, same author, same journal) and articles without an author were excluded, as were authors who did not have an MD, DO, or MBBS degree and those who were not affiliated with an institution in the United States. All manuscripts, with the exception of errata, were analyzed together as well as in 3 subgroups: original research, editorials, and others.

A second investigator corroborated data regarding gender and specialty for all speakers and authors to strengthen data integrity. On the rare occasion when discrepancies were found, a third investigator adjudicated the results.

Definitions

Physicians were defined as being hospitalists if they were listed as a member of a division or section of HM on their publications or if Internet searches indicated that they were a hospitalist or primarily worked on inpatient medical services. Physicians were considered to be general internists if they were listed as such on their publications and their specialty could be verified in Web‐based searches. If physicians appeared to have changing roles over time, we attempted to assign their specialty based upon their role at the time the article was published or the presentation was delivered. If necessary, phone calls and/or emails were also done to determine the physician's specialty.

Analysis

REDCap, a secure, Web‐based application for building and managing online surveys and databases, was used to collect and manage all study data.[23] All analyses were performed using SAS Enterprise Guide 4.3 (SAS Institute, Inc., Cary, NC). A [2] test was used to compare proportions of male versus female physicians, and data from hospitalists versus general internists. Because we performed multiple comparisons when analyzing presentations and publications, a Bonferroni adjustment was made such that a P<0.0125 for presentations and P<0.006 (within specialty) or P<0.0125 (between specialty) for the publication analyses were considered significant. P<0.05 was considered significant for all other comparisons.

RESULTS

Gender Distribution of Faculty

Eighteen HM and 20 GIM programs from university hospitals were randomly selected for review (see Supporting Figure 1 in the online version of this article). Seven of the HM programs and 1 of the GIM programs did not have a website, did not differentiate hospitalists from other faculty, or did not list their faculty on the website and were excluded from the analysis. In the remaining 11 HM programs and 19 GIM programs, women made up 277/568 (49%) and 555/1099 (51%) of the faculty, respectively (P=0.50).

Gender Distribution of Division/Section Heads

Eighty‐six of the programs were classified as university hospitals (see Supporting Figure 1 in the online version of this article), and in these, women led 11/69 (16%) of the HM divisions or sections and 28/80 (35%) of the GIM divisions (P=0.008).

Gender Distribution for Scholarly Productivity

Speaking Opportunities

A total of 1227 presentations were given at the 2 conferences from 2006 to 2012, with 1343 of the speakers meeting inclusion criteria (see Supporting Figure 2 in the online version of this article). Hospitalists accounted for 557 of the speakers, of which 146 (26%) were women. General internists accounted for 580 of the speakers, of which 291 (50%) were women (P<0.0001) (Table 1).

Gender Distribution for Presenters of Hospitalist and General Internists at National Conferences, 2006 to 2012
 Male, N (%)Female, N (%)
  • NOTE: *In‐specialty comparison, P0.0001. Between‐specialty comparison for conference data, P<0.0001.

Hospitalists  
All presentations411 (74)146 (26)*
Featured or plenary presentations49 (91)5 (9)*
General internists  
All presentations289 (50)291 (50)
Featured or plenary presentations27 (55)22 (45)

Of the 117 featured or plenary speakers, 54 were hospitalists and 5 (9%) of these were women. Of the 49 who were general internists, 22 (45%) were women (P<0.0001).

Authorship

The PubMed search identified a total of 3285 articles published in the JHM and the JGIM from 2006 to 2012, and 2172 first authors and 1869 last authors met inclusion criteria (see Supporting Figure 3 in the online version of this article). Hospitalists were listed as first or last authors on 464 and 305 articles, respectively, and of these, women were first authors on 153 (33%) and last authors on 63 (21%). General internists were listed as first or last authors on 895 and 769 articles, respectively, with women as first authors on 423 (47%) and last authors on 265 (34%). Compared with general internists, fewer women hospitalists were listed as either first or last authors (both P<0.0001) (Table 2).

Hospitalist and General Internal Medicine Authorship, 2006 to 2012
 First AuthorLast Author
Male, N (%)Female, N (%)Male, N (%)Female, N (%)
  • NOTE: *In‐specialty comparison, P<0.006. Between‐specialty comparison, P<0.0125.

Hospitalists    
All publications311 (67)153 (33)*242 (79)63 (21)*
Original investigations/brief reports124 (61)79 (39)*96 (76)30 (24)*
Editorials34 (77)10 (23)*18 (86)3 (14)*
Other153 (71)64 (29)*128 (81)30 (19)*
General internists    
All publications472 (53)423 (47)504 (66)265 (34)*
Original investigations/brief reports218 (46)261 (54)310 (65)170 (35)*
Editorial98 (68)46 (32)*43 (73)16 (27)*
Other156 (57)116 (43)151 (66)79 (34)*

Fewer women hospitalists were listed as first or last authors on all article types. For original research articles written by general internists, there was a trend for more women to be listed as first authors than men (261/479, 54%), but this difference was not statistically significant.

DISCUSSION

The important findings of this study are that, despite an equal gender distribution of academic HM and GIM faculty, fewer women were HM division/section chiefs, fewer women were speakers at the 2 selected national meetings, and fewer women were first or last authors of publications in 2 selected journals in comparison with general internists.

Previous studies have found that women lag behind their male counterparts with respect to academic productivity, leadership, and promotion.[1, 5, 7] Some studies suggest, however, that gender differences are reduced when younger cohorts are examined.[1, 10, 11, 12, 13] Surveys indicate that that the mean age of hospitalists is younger than most other specialties.[15, 19, 20, 24] The mean age of academic GIM physicians is unknown, but surveys of GIM (not differentiating academic from nonacademic) suggest that it is an older cohort than that of HM.[24] Despite hospitalists being a younger cohort, we found gender disparities in all areas investigated.

Our findings with respect to gender disparities in HM division or section leadership are consistent with the annual AAMC Women in US Academic Medicine and Science Benchmarking Report that found only 22% of all permanent division or section heads were women.[1]

Gender disparities with respect to authorship of medical publications have been previously noted,[3, 6, 15, 25] but to our knowledge, this is the first study to investigate the gender of authors who were hospitalists. Although we found a higher proportion of women hospitalists who were first or last authors than was observed by Jagsi and colleagues,[3] women hospitalists were still under‐represented with respect to this measure of academic productivity. Erren et al. reviewed 6 major journals from 2010 and 2011, and found that first authorship of original research by women ranged from 23.7% to 46.7%, and for last authorship from 18.3% to 28.8%.[25] Interestingly, we found no significant gender difference for first authors who were general internists, and there was a trend toward more women general internists being first authors than men for original research, reviews, and brief reports (data not shown).

Our study did not attempt to answer the question of why gender disparities persist, but many previous studies have explored this issue.[4, 8, 12, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42] Issues raised by others include the quantity of academic work (ie, publications and grants obtained), differences in hours worked and allocation of time, lack of mentorship, family responsibilities, discrimination, differences in career motivation, and levels of institutional support, to name a few.

The under‐representation of women hospitalists in leadership, authorship, and speaking opportunities may be consistent with gender‐related differences in research productivity. Fewer publications could lead to fewer national presentations, which could lead to fewer leadership opportunities. Our findings with respect to general internists are not consistent with this idea, however, as whereas women were under‐represented in GIM leadership positions, we found no disparities with respect to the gender of first authors or speakers at national meetings for general internists. The finding that hospitalists had gender disparities with respect to first authors and national speakers but general internists did not, argues against several hypotheses (ie, that women lack mentorship, have less career motivation, fewer career building opportunities).

One notable hypothesis, and perhaps one that is often discussed in the literature, is that women shoulder the majority of family responsibilities, and this may result in women having less time for their careers. Jolly and colleagues studied physician‐researchers and noted that women were more likely than men to have spouses or domestic partners who were fully employed, spent 8.5 more hours per week on domestic activities, and were more likely to take time off during disruptions of usual child care.[33] Carr and colleagues found that women with children (compared to men with children) had fewer publications, slower self‐perceived career progress, and lower career satisfaction, but having children had little effect on faculty aspirations and goals.[2] Kaplan et al., however, found that family responsibilities do not appear to account for sex differences in academic advancement.[4] Interestingly, in a study comparing physicians from Generation X to those of the Baby Boomer age, Generation X women reported working more than their male Generation X counterparts, and both had more of a focus on worklife balance than the older generation.[12]

The nature the of 2 specialties' work environment and job requirements could have also resulted in some of the differences seen. Primary care clinical work is typically conducted Monday through Friday, and hospitalist work frequently includes some weekend, evening, night, and holiday coverage. Although these are known differences, both specialties have also been noted to offer many advantages to women and men alike, including collaborative working environments and flexible work hours.[16]

Finally, finding disparity in leadership positions in both specialties supports the possibility that those responsible for hiring could have implicit gender biases. Under‐representation in entry‐level positions is also not a likely explanation for the differences we observed, because nearly an equal number of men and women graduate from medical school, pursue residency training in internal medicine, and become either academic hospitalists or general internists at university settings.[1, 15, 24] This hypothesis could, however, explain why disparities exist with respect to senior authorship and leadership positions, as typically, these individuals have been in practice longer and the current trends of improved gender equality have not always been the case.

Our study has a number of limitations. First, we only examined publications in 2 journals and presentations at 2 national conferences, although the journals and conferences selected are considered to be the major ones in the 2 specialties. Second, using Internet searches may have resulted in inaccurate gender and specialty assignment, but previous studies have used similar methodology.[3, 43] Additionally, we also attempted to contact individuals for direct confirmation when the information we obtained was not clear and had a second investigator independently verify the gender and specialty data. Third, we utilized division/department websites when available to determine the gender of HM divisions/sections. If not recently updated, these websites may not have reflected the most current leader of the unit, but this concern would seemingly pertain to both hospitalists and general internists. Fourth, we opted to only study faculty and division/section heads at university hospitals, as typically these institutions had GIM and hospitalist groups and also typically had websites. Because we only studied faculty and leadership at university hospitals, our data are not generalizable to all hospitalist and GIM groups. Finally, we excluded pediatric hospitalists, and thus, this study is representative of adult hospitalists only. Including pediatric hospitalists was out of the scope of this project.

Our study also had a number of strengths. To our knowledge, this is the first study to provide an estimate of the gender distribution in academic HM, of hospitalists as speakers at national meetings, as first and last authors, and of HM division or section heads, and is the first to compare these results with those observed for general internists. In addition, we examined 7 years of data from 2 of the major journals and national conferences for these specialties.

In summary, despite HM being a newer field with a younger cohort of physicians, we found that gender disparities exist for women with respect to authorship, national speaking opportunities, and division or section leadership. Identifying why these gender differences exist presents an important next step.

Disclosures: Nothing to report. Marisha Burden, MD and Maria G. Frank, MD are coprincipal authors.

Gender disparities still exist for women in academic medicine.[1, 2, 3, 4, 5, 6, 7, 8, 9] The most recent data from the Association of American Medical Colleges (AAMC) show that although gender disparities are decreasing, women are still under‐represented in the assistant, associate, and full‐professor ranks as well as in leadership positions.[1]

Some studies indicate that gender differences are less evident when examining younger cohorts.[1, 10, 11, 12, 13] Hospital medicine emerged around 1996, when the term hospitalist was first coined.[14] The gender distribution of academic hospitalists is likely nearly equal,[15, 16] and they are generally younger physicians.[15, 17, 18, 19, 20] Accordingly, we questioned whether gender disparities existed in academic hospital medicine (HM) and, if so, whether these disparities were greater than those that might exist in academic general internal medicine (GIM).

METHODS

This study consisted of both prospective and retrospective observation of data collected for academic adult hospitalists and general internists who practice in the United States. It was approved by the Colorado Multiple Institutional Review Board.

Gender distribution was assessed with respect to: (1) academic HM and GIM faculty, (2) leadership (ie, division or section heads), and (3) scholarly work (ie, speaking opportunities and publications). Data were collected between October 1, 2012 and August 31, 2014.

Gender Distribution of Faculty and Division/Section Heads

All US internal medicine residency programs were identified from the list of members or affiliates of the AAMC that were fully accredited by the Liaison Committee on Medical Education[21] using the Graduate Medical Education Directory.[22] We then determined the primary training hospital(s) affiliated with each program and selected those that were considered to be university hospitals and eliminated those that did not have divisions or sections of HM or GIM. We determined the gender of the respective division/section heads on the basis of the faculty member's first name (and often from accompanying photos) as well as from information obtained via Internet searches and, if necessary, contacted the individual institutions via email or phone call(s). We also determined the number and gender of all of the HM and GIM faculty members in a random sample of 25% of these hospitals from information on their respective websites.

Gender Distribution for Scholarly Productivity

We determined the gender and specialty of all speakers at the Society of Hospital Medicine and the Society of General Internal Medicine national conferences from 2006 to 2012. A list of speakers at each conference was obtained from conference pamphlets or agendas that were available via Internet searches or obtained directly from the organization. We also determined whether each presenter was a featured speaker (defined as one whose talk was unopposed by other sessions), plenary speaker (defined as such in the conference pamphlets), or if they spoke in a group format (also as indicated in the conference pamphlets). Because of the low number of featured and plenary speakers, these data were combined. Faculty labeled as additional faculty when presenting in a group format were excluded as were speakers at precourses, those presenting abstracts, and those participating in interest group sessions.

For authorship, a PubMed search was used to identify all articles published in the Journal of Hospital Medicine (JHM) and the Journal of General Internal Medicine (JGIM) from January 1, 2006 through December 31, 2012, and the gender and specialty of all the first and last authors were determined as described above. Specialty was determined from the division, section or department affiliation indicated for each author and by Internet searches. In some instances, it was necessary to contact the authors or their departments directly to verify their specialty. When articles had only 1 author, the author was considered a first author.

Duplicate records (eg, same author, same journal) and articles without an author were excluded, as were authors who did not have an MD, DO, or MBBS degree and those who were not affiliated with an institution in the United States. All manuscripts, with the exception of errata, were analyzed together as well as in 3 subgroups: original research, editorials, and others.

A second investigator corroborated data regarding gender and specialty for all speakers and authors to strengthen data integrity. On the rare occasion when discrepancies were found, a third investigator adjudicated the results.

Definitions

Physicians were defined as being hospitalists if they were listed as a member of a division or section of HM on their publications or if Internet searches indicated that they were a hospitalist or primarily worked on inpatient medical services. Physicians were considered to be general internists if they were listed as such on their publications and their specialty could be verified in Web‐based searches. If physicians appeared to have changing roles over time, we attempted to assign their specialty based upon their role at the time the article was published or the presentation was delivered. If necessary, phone calls and/or emails were also done to determine the physician's specialty.

Analysis

REDCap, a secure, Web‐based application for building and managing online surveys and databases, was used to collect and manage all study data.[23] All analyses were performed using SAS Enterprise Guide 4.3 (SAS Institute, Inc., Cary, NC). A [2] test was used to compare proportions of male versus female physicians, and data from hospitalists versus general internists. Because we performed multiple comparisons when analyzing presentations and publications, a Bonferroni adjustment was made such that a P<0.0125 for presentations and P<0.006 (within specialty) or P<0.0125 (between specialty) for the publication analyses were considered significant. P<0.05 was considered significant for all other comparisons.

RESULTS

Gender Distribution of Faculty

Eighteen HM and 20 GIM programs from university hospitals were randomly selected for review (see Supporting Figure 1 in the online version of this article). Seven of the HM programs and 1 of the GIM programs did not have a website, did not differentiate hospitalists from other faculty, or did not list their faculty on the website and were excluded from the analysis. In the remaining 11 HM programs and 19 GIM programs, women made up 277/568 (49%) and 555/1099 (51%) of the faculty, respectively (P=0.50).

Gender Distribution of Division/Section Heads

Eighty‐six of the programs were classified as university hospitals (see Supporting Figure 1 in the online version of this article), and in these, women led 11/69 (16%) of the HM divisions or sections and 28/80 (35%) of the GIM divisions (P=0.008).

Gender Distribution for Scholarly Productivity

Speaking Opportunities

A total of 1227 presentations were given at the 2 conferences from 2006 to 2012, with 1343 of the speakers meeting inclusion criteria (see Supporting Figure 2 in the online version of this article). Hospitalists accounted for 557 of the speakers, of which 146 (26%) were women. General internists accounted for 580 of the speakers, of which 291 (50%) were women (P<0.0001) (Table 1).

Gender Distribution for Presenters of Hospitalist and General Internists at National Conferences, 2006 to 2012
 Male, N (%)Female, N (%)
  • NOTE: *In‐specialty comparison, P0.0001. Between‐specialty comparison for conference data, P<0.0001.

Hospitalists  
All presentations411 (74)146 (26)*
Featured or plenary presentations49 (91)5 (9)*
General internists  
All presentations289 (50)291 (50)
Featured or plenary presentations27 (55)22 (45)

Of the 117 featured or plenary speakers, 54 were hospitalists and 5 (9%) of these were women. Of the 49 who were general internists, 22 (45%) were women (P<0.0001).

Authorship

The PubMed search identified a total of 3285 articles published in the JHM and the JGIM from 2006 to 2012, and 2172 first authors and 1869 last authors met inclusion criteria (see Supporting Figure 3 in the online version of this article). Hospitalists were listed as first or last authors on 464 and 305 articles, respectively, and of these, women were first authors on 153 (33%) and last authors on 63 (21%). General internists were listed as first or last authors on 895 and 769 articles, respectively, with women as first authors on 423 (47%) and last authors on 265 (34%). Compared with general internists, fewer women hospitalists were listed as either first or last authors (both P<0.0001) (Table 2).

Hospitalist and General Internal Medicine Authorship, 2006 to 2012
 First AuthorLast Author
Male, N (%)Female, N (%)Male, N (%)Female, N (%)
  • NOTE: *In‐specialty comparison, P<0.006. Between‐specialty comparison, P<0.0125.

Hospitalists    
All publications311 (67)153 (33)*242 (79)63 (21)*
Original investigations/brief reports124 (61)79 (39)*96 (76)30 (24)*
Editorials34 (77)10 (23)*18 (86)3 (14)*
Other153 (71)64 (29)*128 (81)30 (19)*
General internists    
All publications472 (53)423 (47)504 (66)265 (34)*
Original investigations/brief reports218 (46)261 (54)310 (65)170 (35)*
Editorial98 (68)46 (32)*43 (73)16 (27)*
Other156 (57)116 (43)151 (66)79 (34)*

Fewer women hospitalists were listed as first or last authors on all article types. For original research articles written by general internists, there was a trend for more women to be listed as first authors than men (261/479, 54%), but this difference was not statistically significant.

DISCUSSION

The important findings of this study are that, despite an equal gender distribution of academic HM and GIM faculty, fewer women were HM division/section chiefs, fewer women were speakers at the 2 selected national meetings, and fewer women were first or last authors of publications in 2 selected journals in comparison with general internists.

Previous studies have found that women lag behind their male counterparts with respect to academic productivity, leadership, and promotion.[1, 5, 7] Some studies suggest, however, that gender differences are reduced when younger cohorts are examined.[1, 10, 11, 12, 13] Surveys indicate that that the mean age of hospitalists is younger than most other specialties.[15, 19, 20, 24] The mean age of academic GIM physicians is unknown, but surveys of GIM (not differentiating academic from nonacademic) suggest that it is an older cohort than that of HM.[24] Despite hospitalists being a younger cohort, we found gender disparities in all areas investigated.

Our findings with respect to gender disparities in HM division or section leadership are consistent with the annual AAMC Women in US Academic Medicine and Science Benchmarking Report that found only 22% of all permanent division or section heads were women.[1]

Gender disparities with respect to authorship of medical publications have been previously noted,[3, 6, 15, 25] but to our knowledge, this is the first study to investigate the gender of authors who were hospitalists. Although we found a higher proportion of women hospitalists who were first or last authors than was observed by Jagsi and colleagues,[3] women hospitalists were still under‐represented with respect to this measure of academic productivity. Erren et al. reviewed 6 major journals from 2010 and 2011, and found that first authorship of original research by women ranged from 23.7% to 46.7%, and for last authorship from 18.3% to 28.8%.[25] Interestingly, we found no significant gender difference for first authors who were general internists, and there was a trend toward more women general internists being first authors than men for original research, reviews, and brief reports (data not shown).

Our study did not attempt to answer the question of why gender disparities persist, but many previous studies have explored this issue.[4, 8, 12, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42] Issues raised by others include the quantity of academic work (ie, publications and grants obtained), differences in hours worked and allocation of time, lack of mentorship, family responsibilities, discrimination, differences in career motivation, and levels of institutional support, to name a few.

The under‐representation of women hospitalists in leadership, authorship, and speaking opportunities may be consistent with gender‐related differences in research productivity. Fewer publications could lead to fewer national presentations, which could lead to fewer leadership opportunities. Our findings with respect to general internists are not consistent with this idea, however, as whereas women were under‐represented in GIM leadership positions, we found no disparities with respect to the gender of first authors or speakers at national meetings for general internists. The finding that hospitalists had gender disparities with respect to first authors and national speakers but general internists did not, argues against several hypotheses (ie, that women lack mentorship, have less career motivation, fewer career building opportunities).

One notable hypothesis, and perhaps one that is often discussed in the literature, is that women shoulder the majority of family responsibilities, and this may result in women having less time for their careers. Jolly and colleagues studied physician‐researchers and noted that women were more likely than men to have spouses or domestic partners who were fully employed, spent 8.5 more hours per week on domestic activities, and were more likely to take time off during disruptions of usual child care.[33] Carr and colleagues found that women with children (compared to men with children) had fewer publications, slower self‐perceived career progress, and lower career satisfaction, but having children had little effect on faculty aspirations and goals.[2] Kaplan et al., however, found that family responsibilities do not appear to account for sex differences in academic advancement.[4] Interestingly, in a study comparing physicians from Generation X to those of the Baby Boomer age, Generation X women reported working more than their male Generation X counterparts, and both had more of a focus on worklife balance than the older generation.[12]

The nature the of 2 specialties' work environment and job requirements could have also resulted in some of the differences seen. Primary care clinical work is typically conducted Monday through Friday, and hospitalist work frequently includes some weekend, evening, night, and holiday coverage. Although these are known differences, both specialties have also been noted to offer many advantages to women and men alike, including collaborative working environments and flexible work hours.[16]

Finally, finding disparity in leadership positions in both specialties supports the possibility that those responsible for hiring could have implicit gender biases. Under‐representation in entry‐level positions is also not a likely explanation for the differences we observed, because nearly an equal number of men and women graduate from medical school, pursue residency training in internal medicine, and become either academic hospitalists or general internists at university settings.[1, 15, 24] This hypothesis could, however, explain why disparities exist with respect to senior authorship and leadership positions, as typically, these individuals have been in practice longer and the current trends of improved gender equality have not always been the case.

Our study has a number of limitations. First, we only examined publications in 2 journals and presentations at 2 national conferences, although the journals and conferences selected are considered to be the major ones in the 2 specialties. Second, using Internet searches may have resulted in inaccurate gender and specialty assignment, but previous studies have used similar methodology.[3, 43] Additionally, we also attempted to contact individuals for direct confirmation when the information we obtained was not clear and had a second investigator independently verify the gender and specialty data. Third, we utilized division/department websites when available to determine the gender of HM divisions/sections. If not recently updated, these websites may not have reflected the most current leader of the unit, but this concern would seemingly pertain to both hospitalists and general internists. Fourth, we opted to only study faculty and division/section heads at university hospitals, as typically these institutions had GIM and hospitalist groups and also typically had websites. Because we only studied faculty and leadership at university hospitals, our data are not generalizable to all hospitalist and GIM groups. Finally, we excluded pediatric hospitalists, and thus, this study is representative of adult hospitalists only. Including pediatric hospitalists was out of the scope of this project.

Our study also had a number of strengths. To our knowledge, this is the first study to provide an estimate of the gender distribution in academic HM, of hospitalists as speakers at national meetings, as first and last authors, and of HM division or section heads, and is the first to compare these results with those observed for general internists. In addition, we examined 7 years of data from 2 of the major journals and national conferences for these specialties.

In summary, despite HM being a newer field with a younger cohort of physicians, we found that gender disparities exist for women with respect to authorship, national speaking opportunities, and division or section leadership. Identifying why these gender differences exist presents an important next step.

Disclosures: Nothing to report. Marisha Burden, MD and Maria G. Frank, MD are coprincipal authors.

References
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References
  1. Association of American Medical Colleges. Women in U.S. academic medicine and science: Statistics and benchmarking report. 2012. Available at: https://members.aamc.org/eweb/upload/Women%20in%20U%20S%20%20Academic%20Medicine%20Statistics%20and%20Benchmarking%20Report%202011-20123.pdf. Accessed September 1, 2014.
  2. Carr PL, Ash AS, Friedman RH, et al. Relation of family responsibilities and gender to the productivity and career satisfaction of medical faculty. Ann Intern Med. 1998;129:532538.
  3. Jagsi R, Guancial EA, Worobey CC, et al. The “gender gap” in authorship of academic medical literature—a 35‐year perspective. N Engl J Med. 2006;355:281287.
  4. Kaplan SH, Sullivan LM, Dukes KA, Phillips CF, Kelch RP, Schaller JG. Sex differences in academic advancement. Results of a national study of pediatricians. N Engl J Med. 1996;335:12821289.
  5. Nonnemaker L. Women physicians in academic medicine: new insights from cohort studies. N Engl J Med. 2000;342:399405.
  6. Reed DA, Enders F, Lindor R, McClees M, Lindor KD. Gender differences in academic productivity and leadership appointments of physicians throughout academic careers. Acad Med. 2011;86:4347.
  7. Tesch BJ, Wood HM, Helwig AL, Nattinger AB. Promotion of women physicians in academic medicine. Glass ceiling or sticky floor? JAMA. 1995;273:10221025.
  8. Ash AS, Carr PL, Goldstein R, Friedman RH. Compensation and advancement of women in academic medicine: is there equity? Ann Intern Med. 2004;141:205212.
  9. Borges NJ, Navarro AM, Grover AC. Women physicians: choosing a career in academic medicine. Acad Med. 2012;87:105114.
  10. Nickerson KG, Bennett NM, Estes D, Shea S. The status of women at one academic medical center. Breaking through the glass ceiling. JAMA. 1990;264:18131817.
  11. Wilkinson CJ, Linde HW. Status of women in academic anesthesiology. Anesthesiology. 1986;64:496500.
  12. Jovic E, Wallace JE, Lemaire J. The generation and gender shifts in medicine: an exploratory survey of internal medicine physicians. BMC Health Serv Res. 2006;6:55.
  13. Pew Research Center. On pay gap, millenial women near parity—for now. December 2013. Available at: http://www.pewsocialtrends.org/files/2013/12/gender-and-work_final.pdf. Published December 11, 2013. Accessed February 5, 2015.
  14. Wachter RM, Goldman L. The emerging role of "hospitalists" in the American health care system. N Engl J Med. 1996;335:514517.
  15. Reid MB, Misky GJ, Harrison RA, Sharpe B, Auerbach A, Glasheen JJ. Mentorship, productivity, and promotion among academic hospitalists. J Gen Intern Med. 2012;27:2327.
  16. Henkel G. The gender factor. The Hospitalist. Available at: http://www.the‐hospitalist.org/article/the‐gender‐factor. Published March 1, 2006. Accessed September 1, 2014.
  17. Association of American Medical Colleges. Analysis in brief: Supplemental information for estimating the number and characteristics of hospitalist physicians in the United States and their possible workforce implications. Available at: https://www.aamc.org/download/300686/data/aibvol12_no3-supplemental.pdf. Published August 2012. Accessed September 1, 2014.
  18. Harrison R, Hunter AJ, Sharpe B, Auerbach AD. Survey of US academic hospitalist leaders about mentorship and academic activities in hospitalist groups. J Hosp Med. 2011;6:59.
  19. State of Hospital Medicine: 2011 Report Based on 2010 Data. Medical Group Management Association and Society of Hospital Medicine. www.mgma.com, www.hospitalmedicine.org.
  20. Today's Hospitalist Survey. Compensation and Career Survey Results. 2013. Available at: http://www.todayshospitalist.com/index.php?b=salary_survey_results. Accessed January 11, 2015.
  21. Association of American Medical Colleges. Women in U.S. Academic Medicine: Statistics and Benchmarking Report. 2009–2010. Available at: https://www.aamc.org/download/182674/data/gwims_stats_2009‐2010.pdf. Accessed September 1, 2014.
  22. American Medical Association. Graduate Medical Education Directory 2012–2013. Chicago, IL: American Medical Association; 2012:182203.
  23. Harris PA, Taylor R, Thielke R, Payne J, Gonzalez N, Conde JG. Research electronic data capture (REDCap)—a metadata‐driven methodology and workflow process for providing translational research informatics support. J Biomed Inform. 2009;42:377381.
  24. Association of American Medical Colleges. 2012 Physician Specialty Data Book. Center for Workforce Studies. Available at: https://www.aamc.org/download/313228/data/2012physicianspecialtydatabook.pdf. Published November 2012. Accessed September 1, 2014.
  25. Erren TC, Gross JV, Shaw DM, Selle B. Representation of women as authors, reviewers, editors in chief, and editorial board members at 6 general medical journals in 2010 and 2011. JAMA Intern Med. 2014;174:633635.
  26. Barnett RC, Carr P, Boisnier AD, et al. Relationships of gender and career motivation to medical faculty members' production of academic publications. Acad Med. 1998;73:180186.
  27. Carr PL, Ash AS, Friedman RH, et al. Faculty perceptions of gender discrimination and sexual harassment in academic medicine. Ann Intern Med. 2000;132:889896.
  28. Buckley LM, Sanders K, Shih M, Hampton CL. Attitudes of clinical faculty about career progress, career success and recognition, and commitment to academic medicine. Results of a survey. Arch Intern Med. 2000;160:26252629.
  29. Carr PL, Szalacha L, Barnett R, Caswell C, Inui T. A "ton of feathers": gender discrimination in academic medical careers and how to manage it. J Womens Health (Larchmt). 2003;12:10091018.
  30. Colletti LM, Mulholland MW, Sonnad SS. Perceived obstacles to career success for women in academic surgery. Arch Surg. 2000;135:972977.
  31. Frank E, McMurray JE, Linzer M, Elon L. Career satisfaction of US women physicians: results from the Women Physicians' Health Study. Society of General Internal Medicine Career Satisfaction Study Group. Arch Intern Med. 1999;159:14171426.
  32. Hoff TJ. Doing the same and earning less: male and female physicians in a new medical specialty. Inquiry. 2004;41:301315.
  33. Jolly S, Griffith KA, DeCastro R, Stewart A, Ubel P, Jagsi R. Gender differences in time spent on parenting and domestic responsibilities by high‐achieving young physician‐researchers. Ann Intern Med. 2014;160:344353.
  34. Levine RB, Lin F, Kern DE, Wright SM, Carrese J. Stories from early‐career women physicians who have left academic medicine: a qualitative study at a single institution. Acad Med. 2011;86:752758.
  35. Sasso AT, Richards MR, Chou CF, Gerber SE. The $16,819 pay gap for newly trained physicians: the unexplained trend of men earning more than women. Health Aff (Millwood). 2011;30:193201.
  36. Pololi LH, Civian JT, Brennan RT, Dottolo AL, Krupat E. Experiencing the culture of academic medicine: gender matters, a national study. J Gen Intern Med. 2013;28:201207.
  37. Ryan L. Gender pay gaps in hospital medicine. The Hospitalist. Available at: http://www.the‐hospitalist.org/article/gender‐pay‐gaps‐in‐hospital‐medicine. Published February 29, 2012. Accessed September 1, 2014.
  38. Sambunjak D, Straus SE, Marusic A. Mentoring in academic medicine: a systematic review. JAMA. 2006;296:11031115.
  39. Shen H. Inequality quantified: mind the gender gap. Nature. 2013;495:2224.
  40. Wright AL, Schwindt LA, Bassford TL, et al. Gender differences in academic advancement: patterns, causes, and potential solutions in one US College of Medicine. Acad Med. 2003;78:500508.
  41. Yedidia MJ, Bickel J. Why aren't there more women leaders in academic medicine? The views of clinical department chairs. Acad Med. 2001;76:453465.
  42. Lloyd ME. Gender factors in reviewer recommendations for manuscript publication. J Appl Behav Anal. 1990;23:539543.
  43. Housri N, Cheung MC, Koniaris LG, Zimmers TA. Scientific impact of women in academic surgery. J Surg Res. 2008;148:1316.
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Address for correspondence and reprint requests: Marisha A. Burden, MD, Denver Health, 777 Bannock, MC 4000, Denver, CO 80204‐4507; Telephone: 303‐602‐5057; Fax: 303‐602‐5056; E‐mail: marisha.burden@dhha.org
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Study of Antimicrobial Scrubs

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Bacterial contamination of healthcare workers' uniforms: A randomized controlled trial of antimicrobial scrubs

Healthcare workers' (HCWs) attire becomes contaminated with bacterial pathogens during the course of the workday,[1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12] and Munoz‐Price et al.[13] recently demonstrated that finding bacterial pathogens on HCWs' white coats correlated with finding the same pathogens on their hands. Because of concern for an association between attire colonization and nosocomial infection, governmental agencies in England and Scotland banned HCWs from wearing white coats or long‐sleeve garments,[14, 15] despite evidence that such an approach does not reduce contamination.[12]

Newly developed antimicrobial textiles have been incorporated into HCW scrubs,[16, 17, 18, 19, 20] and commercial Web sites and product inserts report that these products can reduce bacterial contamination by 80.9% at 8 hours to greater than 99% under laboratory conditions depending on the product and microbe studied.[16, 17, 19] Because there are limited clinical data pertaining to the effectiveness of antimicrobial scrubs, we performed a prospective study designed to determine whether wearing these products reduced bacterial contamination of HCWs' scrubs or skin at the end of an 8‐hour workday.

METHODS

Design

The study was a prospective, unblinded, randomized, controlled trial that was approved by the Colorado Multiple Institutional Review Board and conducted at Denver Health, a university‐affiliated public safety net hospital. No protocol changes occurred during the study.

Participants

Participants included hospitalist physicians, internal medicine residents, physician assistants, nurse practitioners, and nurses who directly cared for patients hospitalized on internal medicine units between March 12, 2012 and August 28, 2012. Participants known to be pregnant or those who refused to participate in the study were excluded.

Intervention

Standard scrubs issued by the hospital were tested along with 2 different antimicrobial scrubs (scrub A and scrub B). Scrub A was made with a polyester microfiber material embedded with a proprietary antimicrobial chemical. Scrub B was a polyestercotton blend scrub that included 2 proprietary antimicrobial chemicals and silver embedded into the fabric. The standard scrub was made of a polyestercotton blend with no antimicrobial properties. All scrubs consisted of pants and a short‐sleeved shirt, with either a pocket at the left breast or lower front surface, and all were tested new prior to any washing or wear. Preliminary cultures were done on 2 scrubs in each group to assess the extent of preuse contamination. All providers were instructed not to wear white coats at any time during the day that they were wearing the scrubs. Providers were not told the type of scrub they received, but the antimicrobial scrubs had a different appearance and texture than the standard scrubs, so blinding was not possible.

Outcomes

The primary end point was the total bacterial colony count of samples obtained from the breast or lower front pocket, the sleeve cuff of the dominant hand, and the pant leg at the midthigh of the dominant leg on all scrubs after an 8‐hour workday. Secondary outcomes were the bacterial colony counts of cultures obtained from the volar surface of the wrists of the HCWs' dominant arm, and the colony counts of methicillin‐resistant Staphylococcus aureus (MRSA), vancomycin‐resistant enterococci (VRE), and resistant Gram‐negative bacteria on the 3 scrub types, all obtained after the 8‐hour workday.

Cultures were collected using a standardized RODAC imprint method[21] with BBL RODAC plates containing blood agar (Becton Dickinson, Sparks, MD). Cultures were incubated in ambient air at 35 to 37C for 18 to 22 hours. After incubation, visible colonies were counted using a dissecting microscope to a maximum of 200 colonies as recommended by the manufacturer. Colonies morphologically consistent with Staphylococcus species were subsequently tested for coagulase using a BactiStaph rapid latex agglutination test (Remel, Lenexa, KS). If positive, these colonies were subcultured to sheep blood agar (Remel) and BBL MRSA CHROMagar (Becton Dickinson) and incubated for an additional 18 to 24 hours. Characteristic growth on blood agar that also produced mauve‐colored colonies on CHROMagar was taken to indicate MRSA. Colonies morphologically suspicious for being VRE were identified and confirmed as VRE using a positive identification and susceptibility panel (Microscan; Siemens, Deerfield, IL). A negative combination panel (Microscan, Siemens) was also used to identify and confirm resistant Gram‐negative rods.

Each participant completed a survey that included questions that identified their occupation, whether they had had contact with patients who were known to be colonized or infected with MRSA, VRE, or resistant Gram‐negative rods during the testing period, and whether they experienced any adverse events that might relate to wearing the uniform.

Sample Size

We assumed that cultures taken from the sleeve of the control scrubs would have a mean ( standard deviation) colony count of 69 (67) based on data from our previous study.[12] Although the companies making the antimicrobial scrubs indicated that their respective products provided between 80.9% at 8 hours and >99% reduction in bacterial colony counts in laboratory settings, we assumed that a 70% decrease in colony count compared with standard scrubs could be clinically important. After adjusting for multiple comparisons and accounting for using nonparametric analyses with an unknown distribution, we estimated a need to recruit 35 subjects in each of 3 groups.

Randomization

The principal investigator and coinvestigators enrolled and consented participants. After obtaining consent, block randomization, stratified by occupation, occurred 1 day prior to the study using a computer‐generated table of random numbers.

Statistics

Data were collected and managed using REDCap (Research Electronic Data Capture; Vanderbilt UniversityThe Institute for Medicine and Public Health, Nashville, TN) electronic data capture tools hosted at Denver Health. REDCap is a secure Web‐based application designed to support data collection for research studies, providing: (1) an intuitive interface for validated data entry, (2) audit trails for tracking data manipulation and export procedures, (3) automated export procedures for seamless data downloads to common statistical packages, and (4) procedures for importing data from external sources.[22]

Colony counts were compared using a Kruskal‐Wallis 1‐way analysis of variance by ranks. Bonferroni's correction for multiple comparisons resulted in a P<0.01 as indicating statistical significance. Proportions were compared using [2] analysis. All data are presented as medians with interquartile range (IQR) or proportions.

RESULTS

We screened 118 HCWs for participation and randomized 109, 37 in the control and antimicrobial scrub group A, and 35 in antimicrobial scrub group B (during the course of the study we neglected to culture the pockets of 2 participants in the standard scrub group and 2 in antimicrobial scrub group A). Because our primary end point was total colony count from cultures taken from 3 sites, data from these 4 subjects could not be used, and all the data from these 4 subjects were excluded from the primary analysis; 4 additional subjects were subsequently recruited allowing us to meet our block enrollment target (Figure 1). The first and last participants were studied on March 12, 2012 and August 28, 2012, respectively. The trial ended once the defined number of participants was enrolled. The occupations of the 105 participants are summarized in Table 1.

Figure 1
Enrollment and randomization.
Demographics
 All Subjects, N=105Standard Scrub, n=35Antimicrobial Scrub A, n=35Antimicrobial Scrub B, n=35
Healthcare worker type, n (%)
Attending physician11 (10)5 (14)3 (9)3 (9)
Intern/resident51 (49)17 (49)16 (46)18 (51)
Midlevels6 (6)2 (6)2 (6)2 (6)
Nurse37 (35)11 (31)14 (40)12 (34)
Cared for colonized or infected patient with antibiotic resistant organism, n (%)55 (52)16 (46)20 (57)19 (54)
Number of colonized or infected patients cared for, n (%)
137 (67)10 (63)13 (65)14 (74)
211 (20)4 (25)6 (30)1 (5)
3 or more6 (11)2 (12)1 (5)3 (16)
Unknown1 (2)0 (0)0 (0)1 (5)

Colony counts of all scrubs cultured prior to use never exceeded 10 colonies. The median (IQR) total colony counts from all sites on the scrubs was 99 (66182) for standard scrubs, 137 (84289) for antimicrobial scrub type A, and 138 (62274) for antimicrobial scrub type B (P=0.36). We found no significant differences between the colony counts cultured from any of the individual sites among the 3 groups, regardless of occupation (Table 2). No significant difference was observed with respect to colony counts cultured from the wrist among the 3 study groups (Table 2). Comparisons between groups were planned a priori if a difference across all groups was found. Given the nonsignificant P values across all scrub groups, no further comparisons were made.

Colony Counts by Location and Occupation
 Total (From All Sites on Scrubs)PocketSleeve CuffThighWrist
  • NOTE: Data are presented as median (interquartile range).

All subjects, N=105     
Standard scrub99 (66182)41 (2070)20 (944)32 (2161)16 (540)
Antimicrobial scrub A137 (84289)65 (35117)33 (16124)41 (1586)23 (442)
Antimicrobial scrub B138 (62274)41 (2299)21 (941)40 (18107)15 (654)
P value0.360.170.070.570.92
Physicians and midlevels, n=68
Standard scrub115.5 (72.5173.5)44.5 (2270.5)27.5 (10.538.5)35 (2362.5)24.5 (755)
Antimicrobial scrub A210 (114289)86 (64120)39 (18129)49 (2486)24 (342)
Antimicrobial scrub B149 (68295)52 (26126)21 (1069)37 (18141)19 (872)
P value0.210.080.190.850.76
Nurses, n=37     
Standard scrub89 (31236)37 (1348)13 (552)28 (1342)9 (321)
Antimicrobial scrub A105 (43256)45.5 (2258)21.5 (1654)38.5 (1268)17 (643)
Antimicrobial scrub B91.5 (60174.5)27 (1340)16 (7.526)51 (2186.5)10 (3.543.5)
P value0.860.390.190.490.41

Fifty‐five participants (52%) reported caring for patients who were known to be colonized or infected with an antibiotic‐resistant organism, 16 (46%) randomized to wear standard scrubs, and 20 (57%) and 19 (54%) randomized to wear antimicrobial scrub A or B, respectively (P=0.61). Of these, however, antibiotic‐resistant organisms were only cultured from the scrubs of 2 providers (1 with 1 colony of MRSA from the breast pocket of antimicrobial scrub A, 1 with 1 colony of MRSA cultured from the pocket of antimicrobial scrub B [P=0.55]), and from the wrist of only 1 provider (a multiresistant Gram‐negative rod who wore antimicrobial scrub B).

Adverse Events

Six subjects (5.7%) reported adverse events, all of whom were wearing antimicrobial scrubs (P=0.18). For participants wearing antimicrobial scrub A, 1 (3%) reported itchiness and 2 (6%) reported heaviness or poor breathability. For participants wearing antimicrobial scrub B, 1 (3%) reported redness, 1 (3%) reported itchiness, and 1 (3%) reported heaviness or poor breathability.

DISCUSSION

The important findings of this study are that we found no evidence indicating that either of the 2 antimicrobial scrubs tested reduced bacterial contamination or antibiotic‐resistant contamination on HCWs' scrubs or wrists compared with standard scrubs at the end of an 8‐hour workday, and that despite many HCWs being exposed to patients who were colonized or infected with antibiotic‐resistant bacteria, these organisms were only rarely cultured from their uniforms.

We found that HCWs in all 3 arms of the study had bacterial contamination on their scrubs and skin, consistent with previous studies showing that HCWs' uniforms are frequently contaminated with bacteria, including MRSA, VRE, and other pathogens.[1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12] We previously found that bacterial contamination of HCWs' uniforms occurs within hours of putting on newly laundered uniforms.[12]

Literature on the effectiveness of antimicrobial HCW uniforms when tested in clinical settings is limited. Bearman and colleagues[23] recently published the results of a study of 31 subjects who wore either standard or antimicrobial scrubs, crossing over every 4 weeks for 4 months, with random culturing done weekly at the beginning and end of a work shift. Scrubs were laundered an average of 1.5 times/week, but the timing of the laundering relative to when cultures were obtained was not reported. Very few isolates of MRSA, Gram‐negative rods, or VRE were found (only 3.9%, 0.4%, and 0.05% of the 2000 samples obtained, respectively), and no differences were observed with respect to the number of HCWs who had antibiotic‐resistant organisms cultured when they were wearing standard versus antimicrobial scrubs. Those who had MRSA cultured, however, had lower mean log colony counts when they were wearing the antimicrobial scrubs. The small number of samples with positive isolates, together with differences in the extent of before‐shift contamination among groups complicates interpreting these data. The authors concluded that a prospective trial was needed. We attempted to include the scrub studied by Bearman and colleagues[23] in our study, but the company had insufficient stock available at the time we tried to purchase the product.

Gross and colleagues[24] found no difference in the mean colony counts of cultures taken from silver‐impregnated versus standard scrubs in a pilot crossover study done with 10 HCWs (although there were trends toward higher colony counts when the subjects wore antimicrobial scrubs).

Antibiotic‐resistant bacteria were only cultured from 3 participants (2.9%) in our current study, compared to 16% of those randomized to wearing white coats in our previous study and 20% of those randomized to wearing standard scrubs.[12] This difference may be explained by several recent studies reporting that rates of MRSA infections in hospitals are decreasing.[25, 26] The rate of hospital‐acquired MRSA infection or colonization at our own institution decreased 80% from 2007 to 2012. At the times of our previous and current studies, providers were expected to wear gowns and gloves when caring for patients as per standard contact precautions. Rates of infection and colonization of VRE and resistant Gram‐negative rods have remained low at our hospital, and our data are consistent with the rates reported on HCWs' uniforms in other studies.[2, 5, 10]

Only 6 of our subjects reported adverse reactions, but all were wearing antimicrobial scrubs (P=0.18). Several of the participants described that the fabrics of the 2 antimicrobial scrubs were heavier and less breathable than the standard scrubs. We believe this difference is more likely to explain the adverse reactions reported than is any type of reaction to the specific chemicals in the fabrics.

Our study has several limitations. Because it was conducted on the general internal medicine units of a single university‐affiliated public hospital, the results may not generalize to other types of institutions or other inpatient services.

As we previously described,[12] the RODAC imprint method only samples a small area of HCWs' uniforms and thus does not represent total bacterial contamination.[21] We specifically cultured areas that are known to be highly contaminated (ie, sleeve cuffs and pockets). Although imprint methods have limitations (as do other methods for culturing clothing), they have been commonly utilized in studies assessing bacterial contamination of HCW clothing.[2, 3, 5]

Although some of the bacterial load we cultured could have come from the providers themselves, previous studies have shown that 80% to 90% of the resistant bacteria cultured from HCWs' attire come from other sources.[1, 2]

Because our sample size was calculated on the basis of being able to detect a difference of 70% in total bacterial colony count, our study was not large enough to exclude a lower level of effectiveness. However, we saw no trends suggesting the antimicrobial products might have a lower level of effectiveness.

We did not observe the hand‐washing practices of the participants, and accordingly, cannot confirm that these practices were the same in each of our 3 study groups. Intermittent, surreptitious monitoring of hand‐washing practices on our internal medicine units over the last several years has found compliance with hand hygiene recommendations varying from 70% to 90%.

Although the participants in our study were not explicitly told to which scrub they were randomized, the colors, appearances, and textures of the antimicrobial fabrics were different from the standard scrubs such that blinding was impossible. Participants wearing antimicrobial scrubs could have changed their hand hygiene practices (ie, less careful hand hygiene). Lack of blinding could also have led to over‐reporting of adverse events by the subjects randomized to wear the antimicrobial scrubs.

In an effort to treat all the scrubs in the same fashion, all were tested new, prior to being washed or previously worn. Studying the scrubs prior to washing or wearing could have increased the reports of adverse effects, as the fabrics could have been stiffer and more uncomfortable than they might have been at a later stage in their use.

Our study also has some strengths. Our participants included physicians, residents, nurses, nurse practitioners, and physician assistants. Accordingly, our results should be generalizable to most HCWs. We also confirmed that the scrubs that were tested were nearly sterile prior to use.

In conclusion, we found no evidence suggesting that either of 2 antimicrobial scrubs tested decreased bacterial contamination of HCWs' scrubs or skin after an 8‐hour workday compared to standard scrubs. We also found that, although HCWs are frequently exposed to patients harboring antibiotic‐resistant bacteria, these bacteria were only rarely cultured from HCWs' scrubs or skin.

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References
  1. Speers R, Shooter RA, Gaya H, Patel N. Contamination of nurses' uniforms with Staphylococcus aureus. Lancet. 1969;2:233235.
  2. Babb JR, Davies JG, Ayliffe GAJ. Contamination of protective clothing and nurses' uniforms in an isolation ward. J Hosp Infect. 1983;4:149157.
  3. Wong D, Nye K, Hollis P. Microbial flora on doctors' white coats. BMJ. 1991;303:16021604.
  4. Callaghan I. Bacterial contamination of nurses' uniforms: a study. Nursing Stand. 1998;13:3742.
  5. Loh W, Ng VV, Holton J. Bacterial flora on the white coats of medical students. J Hosp Infect. 2000;45:6568.
  6. Perry C, Marshall R, Jones E. Bacterial contamination of uniforms. J Hosp Infect. 2001;48:238241.
  7. Osawa K, Baba C, Ishimoto T, et al. Significance of methicillin‐resistant Staphylococcus aureus (MRSA) survey in a university teaching hospital. J Infect Chemother. 2003;9:172177.
  8. Boyce JM. Environmental contamination makes an important contribution to hospital infection. J Hosp Infect. 2007;65(suppl 2):5054.
  9. Snyder GM, Thom KA, Furuno JP, et al. Detection of methicillin‐resistant Staphylococcus aureus and vancomycin‐resistant enterococci on the gowns and gloves of healthcare workers. Infect Control Hosp Epidemiol. 2008;29:583589.
  10. Treakle AM, Thom KA, Furuno JP, Strauss SM, Harris AD, Perencevich EN. Bacterial contamination of health care workers' white coats. Am J Infect Control. 2009;37:101105.
  11. Wiener‐Well Y, Galuty M, Rudensky B, Schlesinger Y, Attias D, Yinon AM. Nursing and physician attire as possible source of nosocomial infections. Am J Infect Control. 2011;39:555559.
  12. Burden M, Cervantes L, Weed D, Keniston A, Price CS, Albert RK. Newly cleaned physician uniforms and infrequently washed white coats have similar rates of bacterial contamination after an 8‐hour workday: a randomized controlled trial. J Hosp Med. 2011;6:177182.
  13. Munoz‐Price LS, Arheart KL, Mills JP, et al. Associations between bacterial contamination of health care workers' hands and contamination of white coats and scrubs. Am J Infect Control. 2012;40:e245e248.
  14. Department of Health. Uniforms and workwear: an evidence base for developing local policy. National Health Service, 17 September 2007. Available at: http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/Publicationspolicyandguidance/DH_078433. Accessed January 29, 2010.
  15. Scottish Government Health Directorates. NHS Scotland dress code. Available at: http://www.sehd.scot.nhs.uk/mels/CEL2008_53.pdf. Accessed February 10, 2010.
  16. Bio Shield Tech Web site. Bio Gardz–unisex scrub top–antimicrobial treatment. Available at: http://www.bioshieldtech.com/Bio_Gardz_Unisex_Scrub_Top_Antimicrobial_Tre_p/sbt01‐r‐p.htm. Accessed January 9, 2013.
  17. Doc Froc Web site and informational packet. Available at: http://www.docfroc.com. Accessed July 22, 2011.
  18. Vestagen Web site and informational packet. Available at: http://www.vestagen.com. Accessed July 22, 2011.
  19. Under Scrub apparel Web site. Testing. Available at: http://underscrub.com/testing. Accessed March 21, 2013.
  20. MediThreads Web site. Microban FAQ's. Available at: http://medithreads.com/faq/microban‐faqs. Accessed March 21, 2013.
  21. Hacek DM, Trick WE, Collins SM, Noskin GA, Peterson LR. Comparison of the Rodac imprint method to selective enrichment broth for recovery of vancomycin‐resistant enterococci and drug‐resistant Enterobacteriaceae from environmental surfaces. J Clin Microbiol. 2000;38:46464648.
  22. Harris PA, Taylor R, Thielke R, Payne J, Gonzalez N, Conde JG. Research electronic data capture (REDCap)—a metadata‐driven methodology and workflow process for providing translational research informatics support. J Biomed Inform. 2009;42:377381.
  23. Bearman GM, Rosato A, Elam K, et al. A crossover trial of antimicrobial scrubs to reduce methicillin‐resistant Staphylococcus aureus burden on healthcare worker apparel. Infect Control Hosp Epidemiol. 2012;33:268275.
  24. Gross R, Hubner N, Assadian O, Jibson B, Kramer A. Pilot study on the microbial contamination of conventional vs. silver‐impregnated uniforms worn by ambulance personnel during one week of emergency medical service. GMS Krankenhhyg Interdiszip. 2010;5.pii: Doc09.
  25. Landrum ML, Neumann C, Cook C, et al. Epidemiology of Staphylococcus aureus blood and skin and soft tissue infections in the US military health system, 2005–2010. JAMA. 2012;308:5059.
  26. Kallen AJ, Mu Y, Bulens S, et al. Health care‐associated invasive MRSA infections, 2005–2008. JAMA. 2010;304:641648.
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Healthcare workers' (HCWs) attire becomes contaminated with bacterial pathogens during the course of the workday,[1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12] and Munoz‐Price et al.[13] recently demonstrated that finding bacterial pathogens on HCWs' white coats correlated with finding the same pathogens on their hands. Because of concern for an association between attire colonization and nosocomial infection, governmental agencies in England and Scotland banned HCWs from wearing white coats or long‐sleeve garments,[14, 15] despite evidence that such an approach does not reduce contamination.[12]

Newly developed antimicrobial textiles have been incorporated into HCW scrubs,[16, 17, 18, 19, 20] and commercial Web sites and product inserts report that these products can reduce bacterial contamination by 80.9% at 8 hours to greater than 99% under laboratory conditions depending on the product and microbe studied.[16, 17, 19] Because there are limited clinical data pertaining to the effectiveness of antimicrobial scrubs, we performed a prospective study designed to determine whether wearing these products reduced bacterial contamination of HCWs' scrubs or skin at the end of an 8‐hour workday.

METHODS

Design

The study was a prospective, unblinded, randomized, controlled trial that was approved by the Colorado Multiple Institutional Review Board and conducted at Denver Health, a university‐affiliated public safety net hospital. No protocol changes occurred during the study.

Participants

Participants included hospitalist physicians, internal medicine residents, physician assistants, nurse practitioners, and nurses who directly cared for patients hospitalized on internal medicine units between March 12, 2012 and August 28, 2012. Participants known to be pregnant or those who refused to participate in the study were excluded.

Intervention

Standard scrubs issued by the hospital were tested along with 2 different antimicrobial scrubs (scrub A and scrub B). Scrub A was made with a polyester microfiber material embedded with a proprietary antimicrobial chemical. Scrub B was a polyestercotton blend scrub that included 2 proprietary antimicrobial chemicals and silver embedded into the fabric. The standard scrub was made of a polyestercotton blend with no antimicrobial properties. All scrubs consisted of pants and a short‐sleeved shirt, with either a pocket at the left breast or lower front surface, and all were tested new prior to any washing or wear. Preliminary cultures were done on 2 scrubs in each group to assess the extent of preuse contamination. All providers were instructed not to wear white coats at any time during the day that they were wearing the scrubs. Providers were not told the type of scrub they received, but the antimicrobial scrubs had a different appearance and texture than the standard scrubs, so blinding was not possible.

Outcomes

The primary end point was the total bacterial colony count of samples obtained from the breast or lower front pocket, the sleeve cuff of the dominant hand, and the pant leg at the midthigh of the dominant leg on all scrubs after an 8‐hour workday. Secondary outcomes were the bacterial colony counts of cultures obtained from the volar surface of the wrists of the HCWs' dominant arm, and the colony counts of methicillin‐resistant Staphylococcus aureus (MRSA), vancomycin‐resistant enterococci (VRE), and resistant Gram‐negative bacteria on the 3 scrub types, all obtained after the 8‐hour workday.

Cultures were collected using a standardized RODAC imprint method[21] with BBL RODAC plates containing blood agar (Becton Dickinson, Sparks, MD). Cultures were incubated in ambient air at 35 to 37C for 18 to 22 hours. After incubation, visible colonies were counted using a dissecting microscope to a maximum of 200 colonies as recommended by the manufacturer. Colonies morphologically consistent with Staphylococcus species were subsequently tested for coagulase using a BactiStaph rapid latex agglutination test (Remel, Lenexa, KS). If positive, these colonies were subcultured to sheep blood agar (Remel) and BBL MRSA CHROMagar (Becton Dickinson) and incubated for an additional 18 to 24 hours. Characteristic growth on blood agar that also produced mauve‐colored colonies on CHROMagar was taken to indicate MRSA. Colonies morphologically suspicious for being VRE were identified and confirmed as VRE using a positive identification and susceptibility panel (Microscan; Siemens, Deerfield, IL). A negative combination panel (Microscan, Siemens) was also used to identify and confirm resistant Gram‐negative rods.

Each participant completed a survey that included questions that identified their occupation, whether they had had contact with patients who were known to be colonized or infected with MRSA, VRE, or resistant Gram‐negative rods during the testing period, and whether they experienced any adverse events that might relate to wearing the uniform.

Sample Size

We assumed that cultures taken from the sleeve of the control scrubs would have a mean ( standard deviation) colony count of 69 (67) based on data from our previous study.[12] Although the companies making the antimicrobial scrubs indicated that their respective products provided between 80.9% at 8 hours and >99% reduction in bacterial colony counts in laboratory settings, we assumed that a 70% decrease in colony count compared with standard scrubs could be clinically important. After adjusting for multiple comparisons and accounting for using nonparametric analyses with an unknown distribution, we estimated a need to recruit 35 subjects in each of 3 groups.

Randomization

The principal investigator and coinvestigators enrolled and consented participants. After obtaining consent, block randomization, stratified by occupation, occurred 1 day prior to the study using a computer‐generated table of random numbers.

Statistics

Data were collected and managed using REDCap (Research Electronic Data Capture; Vanderbilt UniversityThe Institute for Medicine and Public Health, Nashville, TN) electronic data capture tools hosted at Denver Health. REDCap is a secure Web‐based application designed to support data collection for research studies, providing: (1) an intuitive interface for validated data entry, (2) audit trails for tracking data manipulation and export procedures, (3) automated export procedures for seamless data downloads to common statistical packages, and (4) procedures for importing data from external sources.[22]

Colony counts were compared using a Kruskal‐Wallis 1‐way analysis of variance by ranks. Bonferroni's correction for multiple comparisons resulted in a P<0.01 as indicating statistical significance. Proportions were compared using [2] analysis. All data are presented as medians with interquartile range (IQR) or proportions.

RESULTS

We screened 118 HCWs for participation and randomized 109, 37 in the control and antimicrobial scrub group A, and 35 in antimicrobial scrub group B (during the course of the study we neglected to culture the pockets of 2 participants in the standard scrub group and 2 in antimicrobial scrub group A). Because our primary end point was total colony count from cultures taken from 3 sites, data from these 4 subjects could not be used, and all the data from these 4 subjects were excluded from the primary analysis; 4 additional subjects were subsequently recruited allowing us to meet our block enrollment target (Figure 1). The first and last participants were studied on March 12, 2012 and August 28, 2012, respectively. The trial ended once the defined number of participants was enrolled. The occupations of the 105 participants are summarized in Table 1.

Figure 1
Enrollment and randomization.
Demographics
 All Subjects, N=105Standard Scrub, n=35Antimicrobial Scrub A, n=35Antimicrobial Scrub B, n=35
Healthcare worker type, n (%)
Attending physician11 (10)5 (14)3 (9)3 (9)
Intern/resident51 (49)17 (49)16 (46)18 (51)
Midlevels6 (6)2 (6)2 (6)2 (6)
Nurse37 (35)11 (31)14 (40)12 (34)
Cared for colonized or infected patient with antibiotic resistant organism, n (%)55 (52)16 (46)20 (57)19 (54)
Number of colonized or infected patients cared for, n (%)
137 (67)10 (63)13 (65)14 (74)
211 (20)4 (25)6 (30)1 (5)
3 or more6 (11)2 (12)1 (5)3 (16)
Unknown1 (2)0 (0)0 (0)1 (5)

Colony counts of all scrubs cultured prior to use never exceeded 10 colonies. The median (IQR) total colony counts from all sites on the scrubs was 99 (66182) for standard scrubs, 137 (84289) for antimicrobial scrub type A, and 138 (62274) for antimicrobial scrub type B (P=0.36). We found no significant differences between the colony counts cultured from any of the individual sites among the 3 groups, regardless of occupation (Table 2). No significant difference was observed with respect to colony counts cultured from the wrist among the 3 study groups (Table 2). Comparisons between groups were planned a priori if a difference across all groups was found. Given the nonsignificant P values across all scrub groups, no further comparisons were made.

Colony Counts by Location and Occupation
 Total (From All Sites on Scrubs)PocketSleeve CuffThighWrist
  • NOTE: Data are presented as median (interquartile range).

All subjects, N=105     
Standard scrub99 (66182)41 (2070)20 (944)32 (2161)16 (540)
Antimicrobial scrub A137 (84289)65 (35117)33 (16124)41 (1586)23 (442)
Antimicrobial scrub B138 (62274)41 (2299)21 (941)40 (18107)15 (654)
P value0.360.170.070.570.92
Physicians and midlevels, n=68
Standard scrub115.5 (72.5173.5)44.5 (2270.5)27.5 (10.538.5)35 (2362.5)24.5 (755)
Antimicrobial scrub A210 (114289)86 (64120)39 (18129)49 (2486)24 (342)
Antimicrobial scrub B149 (68295)52 (26126)21 (1069)37 (18141)19 (872)
P value0.210.080.190.850.76
Nurses, n=37     
Standard scrub89 (31236)37 (1348)13 (552)28 (1342)9 (321)
Antimicrobial scrub A105 (43256)45.5 (2258)21.5 (1654)38.5 (1268)17 (643)
Antimicrobial scrub B91.5 (60174.5)27 (1340)16 (7.526)51 (2186.5)10 (3.543.5)
P value0.860.390.190.490.41

Fifty‐five participants (52%) reported caring for patients who were known to be colonized or infected with an antibiotic‐resistant organism, 16 (46%) randomized to wear standard scrubs, and 20 (57%) and 19 (54%) randomized to wear antimicrobial scrub A or B, respectively (P=0.61). Of these, however, antibiotic‐resistant organisms were only cultured from the scrubs of 2 providers (1 with 1 colony of MRSA from the breast pocket of antimicrobial scrub A, 1 with 1 colony of MRSA cultured from the pocket of antimicrobial scrub B [P=0.55]), and from the wrist of only 1 provider (a multiresistant Gram‐negative rod who wore antimicrobial scrub B).

Adverse Events

Six subjects (5.7%) reported adverse events, all of whom were wearing antimicrobial scrubs (P=0.18). For participants wearing antimicrobial scrub A, 1 (3%) reported itchiness and 2 (6%) reported heaviness or poor breathability. For participants wearing antimicrobial scrub B, 1 (3%) reported redness, 1 (3%) reported itchiness, and 1 (3%) reported heaviness or poor breathability.

DISCUSSION

The important findings of this study are that we found no evidence indicating that either of the 2 antimicrobial scrubs tested reduced bacterial contamination or antibiotic‐resistant contamination on HCWs' scrubs or wrists compared with standard scrubs at the end of an 8‐hour workday, and that despite many HCWs being exposed to patients who were colonized or infected with antibiotic‐resistant bacteria, these organisms were only rarely cultured from their uniforms.

We found that HCWs in all 3 arms of the study had bacterial contamination on their scrubs and skin, consistent with previous studies showing that HCWs' uniforms are frequently contaminated with bacteria, including MRSA, VRE, and other pathogens.[1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12] We previously found that bacterial contamination of HCWs' uniforms occurs within hours of putting on newly laundered uniforms.[12]

Literature on the effectiveness of antimicrobial HCW uniforms when tested in clinical settings is limited. Bearman and colleagues[23] recently published the results of a study of 31 subjects who wore either standard or antimicrobial scrubs, crossing over every 4 weeks for 4 months, with random culturing done weekly at the beginning and end of a work shift. Scrubs were laundered an average of 1.5 times/week, but the timing of the laundering relative to when cultures were obtained was not reported. Very few isolates of MRSA, Gram‐negative rods, or VRE were found (only 3.9%, 0.4%, and 0.05% of the 2000 samples obtained, respectively), and no differences were observed with respect to the number of HCWs who had antibiotic‐resistant organisms cultured when they were wearing standard versus antimicrobial scrubs. Those who had MRSA cultured, however, had lower mean log colony counts when they were wearing the antimicrobial scrubs. The small number of samples with positive isolates, together with differences in the extent of before‐shift contamination among groups complicates interpreting these data. The authors concluded that a prospective trial was needed. We attempted to include the scrub studied by Bearman and colleagues[23] in our study, but the company had insufficient stock available at the time we tried to purchase the product.

Gross and colleagues[24] found no difference in the mean colony counts of cultures taken from silver‐impregnated versus standard scrubs in a pilot crossover study done with 10 HCWs (although there were trends toward higher colony counts when the subjects wore antimicrobial scrubs).

Antibiotic‐resistant bacteria were only cultured from 3 participants (2.9%) in our current study, compared to 16% of those randomized to wearing white coats in our previous study and 20% of those randomized to wearing standard scrubs.[12] This difference may be explained by several recent studies reporting that rates of MRSA infections in hospitals are decreasing.[25, 26] The rate of hospital‐acquired MRSA infection or colonization at our own institution decreased 80% from 2007 to 2012. At the times of our previous and current studies, providers were expected to wear gowns and gloves when caring for patients as per standard contact precautions. Rates of infection and colonization of VRE and resistant Gram‐negative rods have remained low at our hospital, and our data are consistent with the rates reported on HCWs' uniforms in other studies.[2, 5, 10]

Only 6 of our subjects reported adverse reactions, but all were wearing antimicrobial scrubs (P=0.18). Several of the participants described that the fabrics of the 2 antimicrobial scrubs were heavier and less breathable than the standard scrubs. We believe this difference is more likely to explain the adverse reactions reported than is any type of reaction to the specific chemicals in the fabrics.

Our study has several limitations. Because it was conducted on the general internal medicine units of a single university‐affiliated public hospital, the results may not generalize to other types of institutions or other inpatient services.

As we previously described,[12] the RODAC imprint method only samples a small area of HCWs' uniforms and thus does not represent total bacterial contamination.[21] We specifically cultured areas that are known to be highly contaminated (ie, sleeve cuffs and pockets). Although imprint methods have limitations (as do other methods for culturing clothing), they have been commonly utilized in studies assessing bacterial contamination of HCW clothing.[2, 3, 5]

Although some of the bacterial load we cultured could have come from the providers themselves, previous studies have shown that 80% to 90% of the resistant bacteria cultured from HCWs' attire come from other sources.[1, 2]

Because our sample size was calculated on the basis of being able to detect a difference of 70% in total bacterial colony count, our study was not large enough to exclude a lower level of effectiveness. However, we saw no trends suggesting the antimicrobial products might have a lower level of effectiveness.

We did not observe the hand‐washing practices of the participants, and accordingly, cannot confirm that these practices were the same in each of our 3 study groups. Intermittent, surreptitious monitoring of hand‐washing practices on our internal medicine units over the last several years has found compliance with hand hygiene recommendations varying from 70% to 90%.

Although the participants in our study were not explicitly told to which scrub they were randomized, the colors, appearances, and textures of the antimicrobial fabrics were different from the standard scrubs such that blinding was impossible. Participants wearing antimicrobial scrubs could have changed their hand hygiene practices (ie, less careful hand hygiene). Lack of blinding could also have led to over‐reporting of adverse events by the subjects randomized to wear the antimicrobial scrubs.

In an effort to treat all the scrubs in the same fashion, all were tested new, prior to being washed or previously worn. Studying the scrubs prior to washing or wearing could have increased the reports of adverse effects, as the fabrics could have been stiffer and more uncomfortable than they might have been at a later stage in their use.

Our study also has some strengths. Our participants included physicians, residents, nurses, nurse practitioners, and physician assistants. Accordingly, our results should be generalizable to most HCWs. We also confirmed that the scrubs that were tested were nearly sterile prior to use.

In conclusion, we found no evidence suggesting that either of 2 antimicrobial scrubs tested decreased bacterial contamination of HCWs' scrubs or skin after an 8‐hour workday compared to standard scrubs. We also found that, although HCWs are frequently exposed to patients harboring antibiotic‐resistant bacteria, these bacteria were only rarely cultured from HCWs' scrubs or skin.

Healthcare workers' (HCWs) attire becomes contaminated with bacterial pathogens during the course of the workday,[1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12] and Munoz‐Price et al.[13] recently demonstrated that finding bacterial pathogens on HCWs' white coats correlated with finding the same pathogens on their hands. Because of concern for an association between attire colonization and nosocomial infection, governmental agencies in England and Scotland banned HCWs from wearing white coats or long‐sleeve garments,[14, 15] despite evidence that such an approach does not reduce contamination.[12]

Newly developed antimicrobial textiles have been incorporated into HCW scrubs,[16, 17, 18, 19, 20] and commercial Web sites and product inserts report that these products can reduce bacterial contamination by 80.9% at 8 hours to greater than 99% under laboratory conditions depending on the product and microbe studied.[16, 17, 19] Because there are limited clinical data pertaining to the effectiveness of antimicrobial scrubs, we performed a prospective study designed to determine whether wearing these products reduced bacterial contamination of HCWs' scrubs or skin at the end of an 8‐hour workday.

METHODS

Design

The study was a prospective, unblinded, randomized, controlled trial that was approved by the Colorado Multiple Institutional Review Board and conducted at Denver Health, a university‐affiliated public safety net hospital. No protocol changes occurred during the study.

Participants

Participants included hospitalist physicians, internal medicine residents, physician assistants, nurse practitioners, and nurses who directly cared for patients hospitalized on internal medicine units between March 12, 2012 and August 28, 2012. Participants known to be pregnant or those who refused to participate in the study were excluded.

Intervention

Standard scrubs issued by the hospital were tested along with 2 different antimicrobial scrubs (scrub A and scrub B). Scrub A was made with a polyester microfiber material embedded with a proprietary antimicrobial chemical. Scrub B was a polyestercotton blend scrub that included 2 proprietary antimicrobial chemicals and silver embedded into the fabric. The standard scrub was made of a polyestercotton blend with no antimicrobial properties. All scrubs consisted of pants and a short‐sleeved shirt, with either a pocket at the left breast or lower front surface, and all were tested new prior to any washing or wear. Preliminary cultures were done on 2 scrubs in each group to assess the extent of preuse contamination. All providers were instructed not to wear white coats at any time during the day that they were wearing the scrubs. Providers were not told the type of scrub they received, but the antimicrobial scrubs had a different appearance and texture than the standard scrubs, so blinding was not possible.

Outcomes

The primary end point was the total bacterial colony count of samples obtained from the breast or lower front pocket, the sleeve cuff of the dominant hand, and the pant leg at the midthigh of the dominant leg on all scrubs after an 8‐hour workday. Secondary outcomes were the bacterial colony counts of cultures obtained from the volar surface of the wrists of the HCWs' dominant arm, and the colony counts of methicillin‐resistant Staphylococcus aureus (MRSA), vancomycin‐resistant enterococci (VRE), and resistant Gram‐negative bacteria on the 3 scrub types, all obtained after the 8‐hour workday.

Cultures were collected using a standardized RODAC imprint method[21] with BBL RODAC plates containing blood agar (Becton Dickinson, Sparks, MD). Cultures were incubated in ambient air at 35 to 37C for 18 to 22 hours. After incubation, visible colonies were counted using a dissecting microscope to a maximum of 200 colonies as recommended by the manufacturer. Colonies morphologically consistent with Staphylococcus species were subsequently tested for coagulase using a BactiStaph rapid latex agglutination test (Remel, Lenexa, KS). If positive, these colonies were subcultured to sheep blood agar (Remel) and BBL MRSA CHROMagar (Becton Dickinson) and incubated for an additional 18 to 24 hours. Characteristic growth on blood agar that also produced mauve‐colored colonies on CHROMagar was taken to indicate MRSA. Colonies morphologically suspicious for being VRE were identified and confirmed as VRE using a positive identification and susceptibility panel (Microscan; Siemens, Deerfield, IL). A negative combination panel (Microscan, Siemens) was also used to identify and confirm resistant Gram‐negative rods.

Each participant completed a survey that included questions that identified their occupation, whether they had had contact with patients who were known to be colonized or infected with MRSA, VRE, or resistant Gram‐negative rods during the testing period, and whether they experienced any adverse events that might relate to wearing the uniform.

Sample Size

We assumed that cultures taken from the sleeve of the control scrubs would have a mean ( standard deviation) colony count of 69 (67) based on data from our previous study.[12] Although the companies making the antimicrobial scrubs indicated that their respective products provided between 80.9% at 8 hours and >99% reduction in bacterial colony counts in laboratory settings, we assumed that a 70% decrease in colony count compared with standard scrubs could be clinically important. After adjusting for multiple comparisons and accounting for using nonparametric analyses with an unknown distribution, we estimated a need to recruit 35 subjects in each of 3 groups.

Randomization

The principal investigator and coinvestigators enrolled and consented participants. After obtaining consent, block randomization, stratified by occupation, occurred 1 day prior to the study using a computer‐generated table of random numbers.

Statistics

Data were collected and managed using REDCap (Research Electronic Data Capture; Vanderbilt UniversityThe Institute for Medicine and Public Health, Nashville, TN) electronic data capture tools hosted at Denver Health. REDCap is a secure Web‐based application designed to support data collection for research studies, providing: (1) an intuitive interface for validated data entry, (2) audit trails for tracking data manipulation and export procedures, (3) automated export procedures for seamless data downloads to common statistical packages, and (4) procedures for importing data from external sources.[22]

Colony counts were compared using a Kruskal‐Wallis 1‐way analysis of variance by ranks. Bonferroni's correction for multiple comparisons resulted in a P<0.01 as indicating statistical significance. Proportions were compared using [2] analysis. All data are presented as medians with interquartile range (IQR) or proportions.

RESULTS

We screened 118 HCWs for participation and randomized 109, 37 in the control and antimicrobial scrub group A, and 35 in antimicrobial scrub group B (during the course of the study we neglected to culture the pockets of 2 participants in the standard scrub group and 2 in antimicrobial scrub group A). Because our primary end point was total colony count from cultures taken from 3 sites, data from these 4 subjects could not be used, and all the data from these 4 subjects were excluded from the primary analysis; 4 additional subjects were subsequently recruited allowing us to meet our block enrollment target (Figure 1). The first and last participants were studied on March 12, 2012 and August 28, 2012, respectively. The trial ended once the defined number of participants was enrolled. The occupations of the 105 participants are summarized in Table 1.

Figure 1
Enrollment and randomization.
Demographics
 All Subjects, N=105Standard Scrub, n=35Antimicrobial Scrub A, n=35Antimicrobial Scrub B, n=35
Healthcare worker type, n (%)
Attending physician11 (10)5 (14)3 (9)3 (9)
Intern/resident51 (49)17 (49)16 (46)18 (51)
Midlevels6 (6)2 (6)2 (6)2 (6)
Nurse37 (35)11 (31)14 (40)12 (34)
Cared for colonized or infected patient with antibiotic resistant organism, n (%)55 (52)16 (46)20 (57)19 (54)
Number of colonized or infected patients cared for, n (%)
137 (67)10 (63)13 (65)14 (74)
211 (20)4 (25)6 (30)1 (5)
3 or more6 (11)2 (12)1 (5)3 (16)
Unknown1 (2)0 (0)0 (0)1 (5)

Colony counts of all scrubs cultured prior to use never exceeded 10 colonies. The median (IQR) total colony counts from all sites on the scrubs was 99 (66182) for standard scrubs, 137 (84289) for antimicrobial scrub type A, and 138 (62274) for antimicrobial scrub type B (P=0.36). We found no significant differences between the colony counts cultured from any of the individual sites among the 3 groups, regardless of occupation (Table 2). No significant difference was observed with respect to colony counts cultured from the wrist among the 3 study groups (Table 2). Comparisons between groups were planned a priori if a difference across all groups was found. Given the nonsignificant P values across all scrub groups, no further comparisons were made.

Colony Counts by Location and Occupation
 Total (From All Sites on Scrubs)PocketSleeve CuffThighWrist
  • NOTE: Data are presented as median (interquartile range).

All subjects, N=105     
Standard scrub99 (66182)41 (2070)20 (944)32 (2161)16 (540)
Antimicrobial scrub A137 (84289)65 (35117)33 (16124)41 (1586)23 (442)
Antimicrobial scrub B138 (62274)41 (2299)21 (941)40 (18107)15 (654)
P value0.360.170.070.570.92
Physicians and midlevels, n=68
Standard scrub115.5 (72.5173.5)44.5 (2270.5)27.5 (10.538.5)35 (2362.5)24.5 (755)
Antimicrobial scrub A210 (114289)86 (64120)39 (18129)49 (2486)24 (342)
Antimicrobial scrub B149 (68295)52 (26126)21 (1069)37 (18141)19 (872)
P value0.210.080.190.850.76
Nurses, n=37     
Standard scrub89 (31236)37 (1348)13 (552)28 (1342)9 (321)
Antimicrobial scrub A105 (43256)45.5 (2258)21.5 (1654)38.5 (1268)17 (643)
Antimicrobial scrub B91.5 (60174.5)27 (1340)16 (7.526)51 (2186.5)10 (3.543.5)
P value0.860.390.190.490.41

Fifty‐five participants (52%) reported caring for patients who were known to be colonized or infected with an antibiotic‐resistant organism, 16 (46%) randomized to wear standard scrubs, and 20 (57%) and 19 (54%) randomized to wear antimicrobial scrub A or B, respectively (P=0.61). Of these, however, antibiotic‐resistant organisms were only cultured from the scrubs of 2 providers (1 with 1 colony of MRSA from the breast pocket of antimicrobial scrub A, 1 with 1 colony of MRSA cultured from the pocket of antimicrobial scrub B [P=0.55]), and from the wrist of only 1 provider (a multiresistant Gram‐negative rod who wore antimicrobial scrub B).

Adverse Events

Six subjects (5.7%) reported adverse events, all of whom were wearing antimicrobial scrubs (P=0.18). For participants wearing antimicrobial scrub A, 1 (3%) reported itchiness and 2 (6%) reported heaviness or poor breathability. For participants wearing antimicrobial scrub B, 1 (3%) reported redness, 1 (3%) reported itchiness, and 1 (3%) reported heaviness or poor breathability.

DISCUSSION

The important findings of this study are that we found no evidence indicating that either of the 2 antimicrobial scrubs tested reduced bacterial contamination or antibiotic‐resistant contamination on HCWs' scrubs or wrists compared with standard scrubs at the end of an 8‐hour workday, and that despite many HCWs being exposed to patients who were colonized or infected with antibiotic‐resistant bacteria, these organisms were only rarely cultured from their uniforms.

We found that HCWs in all 3 arms of the study had bacterial contamination on their scrubs and skin, consistent with previous studies showing that HCWs' uniforms are frequently contaminated with bacteria, including MRSA, VRE, and other pathogens.[1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12] We previously found that bacterial contamination of HCWs' uniforms occurs within hours of putting on newly laundered uniforms.[12]

Literature on the effectiveness of antimicrobial HCW uniforms when tested in clinical settings is limited. Bearman and colleagues[23] recently published the results of a study of 31 subjects who wore either standard or antimicrobial scrubs, crossing over every 4 weeks for 4 months, with random culturing done weekly at the beginning and end of a work shift. Scrubs were laundered an average of 1.5 times/week, but the timing of the laundering relative to when cultures were obtained was not reported. Very few isolates of MRSA, Gram‐negative rods, or VRE were found (only 3.9%, 0.4%, and 0.05% of the 2000 samples obtained, respectively), and no differences were observed with respect to the number of HCWs who had antibiotic‐resistant organisms cultured when they were wearing standard versus antimicrobial scrubs. Those who had MRSA cultured, however, had lower mean log colony counts when they were wearing the antimicrobial scrubs. The small number of samples with positive isolates, together with differences in the extent of before‐shift contamination among groups complicates interpreting these data. The authors concluded that a prospective trial was needed. We attempted to include the scrub studied by Bearman and colleagues[23] in our study, but the company had insufficient stock available at the time we tried to purchase the product.

Gross and colleagues[24] found no difference in the mean colony counts of cultures taken from silver‐impregnated versus standard scrubs in a pilot crossover study done with 10 HCWs (although there were trends toward higher colony counts when the subjects wore antimicrobial scrubs).

Antibiotic‐resistant bacteria were only cultured from 3 participants (2.9%) in our current study, compared to 16% of those randomized to wearing white coats in our previous study and 20% of those randomized to wearing standard scrubs.[12] This difference may be explained by several recent studies reporting that rates of MRSA infections in hospitals are decreasing.[25, 26] The rate of hospital‐acquired MRSA infection or colonization at our own institution decreased 80% from 2007 to 2012. At the times of our previous and current studies, providers were expected to wear gowns and gloves when caring for patients as per standard contact precautions. Rates of infection and colonization of VRE and resistant Gram‐negative rods have remained low at our hospital, and our data are consistent with the rates reported on HCWs' uniforms in other studies.[2, 5, 10]

Only 6 of our subjects reported adverse reactions, but all were wearing antimicrobial scrubs (P=0.18). Several of the participants described that the fabrics of the 2 antimicrobial scrubs were heavier and less breathable than the standard scrubs. We believe this difference is more likely to explain the adverse reactions reported than is any type of reaction to the specific chemicals in the fabrics.

Our study has several limitations. Because it was conducted on the general internal medicine units of a single university‐affiliated public hospital, the results may not generalize to other types of institutions or other inpatient services.

As we previously described,[12] the RODAC imprint method only samples a small area of HCWs' uniforms and thus does not represent total bacterial contamination.[21] We specifically cultured areas that are known to be highly contaminated (ie, sleeve cuffs and pockets). Although imprint methods have limitations (as do other methods for culturing clothing), they have been commonly utilized in studies assessing bacterial contamination of HCW clothing.[2, 3, 5]

Although some of the bacterial load we cultured could have come from the providers themselves, previous studies have shown that 80% to 90% of the resistant bacteria cultured from HCWs' attire come from other sources.[1, 2]

Because our sample size was calculated on the basis of being able to detect a difference of 70% in total bacterial colony count, our study was not large enough to exclude a lower level of effectiveness. However, we saw no trends suggesting the antimicrobial products might have a lower level of effectiveness.

We did not observe the hand‐washing practices of the participants, and accordingly, cannot confirm that these practices were the same in each of our 3 study groups. Intermittent, surreptitious monitoring of hand‐washing practices on our internal medicine units over the last several years has found compliance with hand hygiene recommendations varying from 70% to 90%.

Although the participants in our study were not explicitly told to which scrub they were randomized, the colors, appearances, and textures of the antimicrobial fabrics were different from the standard scrubs such that blinding was impossible. Participants wearing antimicrobial scrubs could have changed their hand hygiene practices (ie, less careful hand hygiene). Lack of blinding could also have led to over‐reporting of adverse events by the subjects randomized to wear the antimicrobial scrubs.

In an effort to treat all the scrubs in the same fashion, all were tested new, prior to being washed or previously worn. Studying the scrubs prior to washing or wearing could have increased the reports of adverse effects, as the fabrics could have been stiffer and more uncomfortable than they might have been at a later stage in their use.

Our study also has some strengths. Our participants included physicians, residents, nurses, nurse practitioners, and physician assistants. Accordingly, our results should be generalizable to most HCWs. We also confirmed that the scrubs that were tested were nearly sterile prior to use.

In conclusion, we found no evidence suggesting that either of 2 antimicrobial scrubs tested decreased bacterial contamination of HCWs' scrubs or skin after an 8‐hour workday compared to standard scrubs. We also found that, although HCWs are frequently exposed to patients harboring antibiotic‐resistant bacteria, these bacteria were only rarely cultured from HCWs' scrubs or skin.

References
  1. Speers R, Shooter RA, Gaya H, Patel N. Contamination of nurses' uniforms with Staphylococcus aureus. Lancet. 1969;2:233235.
  2. Babb JR, Davies JG, Ayliffe GAJ. Contamination of protective clothing and nurses' uniforms in an isolation ward. J Hosp Infect. 1983;4:149157.
  3. Wong D, Nye K, Hollis P. Microbial flora on doctors' white coats. BMJ. 1991;303:16021604.
  4. Callaghan I. Bacterial contamination of nurses' uniforms: a study. Nursing Stand. 1998;13:3742.
  5. Loh W, Ng VV, Holton J. Bacterial flora on the white coats of medical students. J Hosp Infect. 2000;45:6568.
  6. Perry C, Marshall R, Jones E. Bacterial contamination of uniforms. J Hosp Infect. 2001;48:238241.
  7. Osawa K, Baba C, Ishimoto T, et al. Significance of methicillin‐resistant Staphylococcus aureus (MRSA) survey in a university teaching hospital. J Infect Chemother. 2003;9:172177.
  8. Boyce JM. Environmental contamination makes an important contribution to hospital infection. J Hosp Infect. 2007;65(suppl 2):5054.
  9. Snyder GM, Thom KA, Furuno JP, et al. Detection of methicillin‐resistant Staphylococcus aureus and vancomycin‐resistant enterococci on the gowns and gloves of healthcare workers. Infect Control Hosp Epidemiol. 2008;29:583589.
  10. Treakle AM, Thom KA, Furuno JP, Strauss SM, Harris AD, Perencevich EN. Bacterial contamination of health care workers' white coats. Am J Infect Control. 2009;37:101105.
  11. Wiener‐Well Y, Galuty M, Rudensky B, Schlesinger Y, Attias D, Yinon AM. Nursing and physician attire as possible source of nosocomial infections. Am J Infect Control. 2011;39:555559.
  12. Burden M, Cervantes L, Weed D, Keniston A, Price CS, Albert RK. Newly cleaned physician uniforms and infrequently washed white coats have similar rates of bacterial contamination after an 8‐hour workday: a randomized controlled trial. J Hosp Med. 2011;6:177182.
  13. Munoz‐Price LS, Arheart KL, Mills JP, et al. Associations between bacterial contamination of health care workers' hands and contamination of white coats and scrubs. Am J Infect Control. 2012;40:e245e248.
  14. Department of Health. Uniforms and workwear: an evidence base for developing local policy. National Health Service, 17 September 2007. Available at: http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/Publicationspolicyandguidance/DH_078433. Accessed January 29, 2010.
  15. Scottish Government Health Directorates. NHS Scotland dress code. Available at: http://www.sehd.scot.nhs.uk/mels/CEL2008_53.pdf. Accessed February 10, 2010.
  16. Bio Shield Tech Web site. Bio Gardz–unisex scrub top–antimicrobial treatment. Available at: http://www.bioshieldtech.com/Bio_Gardz_Unisex_Scrub_Top_Antimicrobial_Tre_p/sbt01‐r‐p.htm. Accessed January 9, 2013.
  17. Doc Froc Web site and informational packet. Available at: http://www.docfroc.com. Accessed July 22, 2011.
  18. Vestagen Web site and informational packet. Available at: http://www.vestagen.com. Accessed July 22, 2011.
  19. Under Scrub apparel Web site. Testing. Available at: http://underscrub.com/testing. Accessed March 21, 2013.
  20. MediThreads Web site. Microban FAQ's. Available at: http://medithreads.com/faq/microban‐faqs. Accessed March 21, 2013.
  21. Hacek DM, Trick WE, Collins SM, Noskin GA, Peterson LR. Comparison of the Rodac imprint method to selective enrichment broth for recovery of vancomycin‐resistant enterococci and drug‐resistant Enterobacteriaceae from environmental surfaces. J Clin Microbiol. 2000;38:46464648.
  22. Harris PA, Taylor R, Thielke R, Payne J, Gonzalez N, Conde JG. Research electronic data capture (REDCap)—a metadata‐driven methodology and workflow process for providing translational research informatics support. J Biomed Inform. 2009;42:377381.
  23. Bearman GM, Rosato A, Elam K, et al. A crossover trial of antimicrobial scrubs to reduce methicillin‐resistant Staphylococcus aureus burden on healthcare worker apparel. Infect Control Hosp Epidemiol. 2012;33:268275.
  24. Gross R, Hubner N, Assadian O, Jibson B, Kramer A. Pilot study on the microbial contamination of conventional vs. silver‐impregnated uniforms worn by ambulance personnel during one week of emergency medical service. GMS Krankenhhyg Interdiszip. 2010;5.pii: Doc09.
  25. Landrum ML, Neumann C, Cook C, et al. Epidemiology of Staphylococcus aureus blood and skin and soft tissue infections in the US military health system, 2005–2010. JAMA. 2012;308:5059.
  26. Kallen AJ, Mu Y, Bulens S, et al. Health care‐associated invasive MRSA infections, 2005–2008. JAMA. 2010;304:641648.
References
  1. Speers R, Shooter RA, Gaya H, Patel N. Contamination of nurses' uniforms with Staphylococcus aureus. Lancet. 1969;2:233235.
  2. Babb JR, Davies JG, Ayliffe GAJ. Contamination of protective clothing and nurses' uniforms in an isolation ward. J Hosp Infect. 1983;4:149157.
  3. Wong D, Nye K, Hollis P. Microbial flora on doctors' white coats. BMJ. 1991;303:16021604.
  4. Callaghan I. Bacterial contamination of nurses' uniforms: a study. Nursing Stand. 1998;13:3742.
  5. Loh W, Ng VV, Holton J. Bacterial flora on the white coats of medical students. J Hosp Infect. 2000;45:6568.
  6. Perry C, Marshall R, Jones E. Bacterial contamination of uniforms. J Hosp Infect. 2001;48:238241.
  7. Osawa K, Baba C, Ishimoto T, et al. Significance of methicillin‐resistant Staphylococcus aureus (MRSA) survey in a university teaching hospital. J Infect Chemother. 2003;9:172177.
  8. Boyce JM. Environmental contamination makes an important contribution to hospital infection. J Hosp Infect. 2007;65(suppl 2):5054.
  9. Snyder GM, Thom KA, Furuno JP, et al. Detection of methicillin‐resistant Staphylococcus aureus and vancomycin‐resistant enterococci on the gowns and gloves of healthcare workers. Infect Control Hosp Epidemiol. 2008;29:583589.
  10. Treakle AM, Thom KA, Furuno JP, Strauss SM, Harris AD, Perencevich EN. Bacterial contamination of health care workers' white coats. Am J Infect Control. 2009;37:101105.
  11. Wiener‐Well Y, Galuty M, Rudensky B, Schlesinger Y, Attias D, Yinon AM. Nursing and physician attire as possible source of nosocomial infections. Am J Infect Control. 2011;39:555559.
  12. Burden M, Cervantes L, Weed D, Keniston A, Price CS, Albert RK. Newly cleaned physician uniforms and infrequently washed white coats have similar rates of bacterial contamination after an 8‐hour workday: a randomized controlled trial. J Hosp Med. 2011;6:177182.
  13. Munoz‐Price LS, Arheart KL, Mills JP, et al. Associations between bacterial contamination of health care workers' hands and contamination of white coats and scrubs. Am J Infect Control. 2012;40:e245e248.
  14. Department of Health. Uniforms and workwear: an evidence base for developing local policy. National Health Service, 17 September 2007. Available at: http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/Publicationspolicyandguidance/DH_078433. Accessed January 29, 2010.
  15. Scottish Government Health Directorates. NHS Scotland dress code. Available at: http://www.sehd.scot.nhs.uk/mels/CEL2008_53.pdf. Accessed February 10, 2010.
  16. Bio Shield Tech Web site. Bio Gardz–unisex scrub top–antimicrobial treatment. Available at: http://www.bioshieldtech.com/Bio_Gardz_Unisex_Scrub_Top_Antimicrobial_Tre_p/sbt01‐r‐p.htm. Accessed January 9, 2013.
  17. Doc Froc Web site and informational packet. Available at: http://www.docfroc.com. Accessed July 22, 2011.
  18. Vestagen Web site and informational packet. Available at: http://www.vestagen.com. Accessed July 22, 2011.
  19. Under Scrub apparel Web site. Testing. Available at: http://underscrub.com/testing. Accessed March 21, 2013.
  20. MediThreads Web site. Microban FAQ's. Available at: http://medithreads.com/faq/microban‐faqs. Accessed March 21, 2013.
  21. Hacek DM, Trick WE, Collins SM, Noskin GA, Peterson LR. Comparison of the Rodac imprint method to selective enrichment broth for recovery of vancomycin‐resistant enterococci and drug‐resistant Enterobacteriaceae from environmental surfaces. J Clin Microbiol. 2000;38:46464648.
  22. Harris PA, Taylor R, Thielke R, Payne J, Gonzalez N, Conde JG. Research electronic data capture (REDCap)—a metadata‐driven methodology and workflow process for providing translational research informatics support. J Biomed Inform. 2009;42:377381.
  23. Bearman GM, Rosato A, Elam K, et al. A crossover trial of antimicrobial scrubs to reduce methicillin‐resistant Staphylococcus aureus burden on healthcare worker apparel. Infect Control Hosp Epidemiol. 2012;33:268275.
  24. Gross R, Hubner N, Assadian O, Jibson B, Kramer A. Pilot study on the microbial contamination of conventional vs. silver‐impregnated uniforms worn by ambulance personnel during one week of emergency medical service. GMS Krankenhhyg Interdiszip. 2010;5.pii: Doc09.
  25. Landrum ML, Neumann C, Cook C, et al. Epidemiology of Staphylococcus aureus blood and skin and soft tissue infections in the US military health system, 2005–2010. JAMA. 2012;308:5059.
  26. Kallen AJ, Mu Y, Bulens S, et al. Health care‐associated invasive MRSA infections, 2005–2008. JAMA. 2010;304:641648.
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Address for correspondence and reprint requests: Marisha A. Burden, MD, Denver Health, 777 Bannock, MC 4000, Denver, CO 80204‐4507; Telephone: 303‐602‐5057; Fax: 303‐602‐5056; E‐mail: marisha.burden@dhha.org
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Curbside vs Formal Consultation

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Prospective comparison of curbside versus formal consultations

A curbside consultation is an informal process whereby a consultant is asked to provide information or advice about a patient's care without doing a formal assessment of the patient.14 Curbside consultations are common in the practice of medicine2, 3, 5 and are frequently requested by physicians caring for hospitalized patients. Several surveys have documented the quantity of curbside consultations requested of various subspecialties, the types of questions asked, the time it takes to respond, and physicians' perceptions about the quality of the information exchanged.111 While curbside consultations have a number of advantages, physicians' perceptions are that the information conveyed may be inaccurate or incomplete and that the advice offered may be erroneous.13, 5, 10, 12, 13

Cartmill and White14 performed a random audit of 10% of the telephone referrals they received for neurosurgical consultation over a 1‐year period and noted discrepancies between the Glascow Coma Scores reported during the telephone referrals and those noted in the medical records, but the frequency of these discrepancies was not reported. To our knowledge, no studies have compared the quality of the information provided in curbside consultations with that obtained in formal consultations that included direct face‐to‐face patient evaluations and primary data collection, and whether the advice provided in curbside and formal consultations on the same patient differed.

We performed a prospective cohort study to compare the information received by hospitalists during curbside consultations on hospitalized patients, with that obtained from formal consultations done the same day on the same patients, by different hospitalists who were unaware of any details regarding the curbside consultation. We also compared the advice provided by the 2 hospitalists following their curbside and formal consultations. Our hypotheses were that the information received during curbside consultations was frequently inaccurate or incomplete, that the recommendations made after the formal consultation would frequently differ from those made in the curbside consultation, and that these differences would have important implications on patient care.

METHODS

This was a quality improvement study conducted at Denver Health, a 500‐bed university‐affiliated urban safety net hospital from January 10, 2011 to January 9, 2012. The study design was a prospective cohort that included all curbside consultations on hospitalized patients received between 7 AM and 3 PM, on intermittently selected weekdays, by the Internal Medicine Consultation Service that was staffed by 18 hospitalists. Data were collected intermittently based upon hospitalist availability and was done to limit potential alterations in the consulting practices of the providers requesting consultations.

Consultations were defined as being curbside when the consulting provider asked for advice, suggestions, or opinions about a patient's care but did not ask the hospitalist to see the patient.15, 15 Consultations pertaining to administrative issues (eg, whether a patient should be admitted to an intensive care bed as opposed to an acute care floor bed) or on patients who were already being followed by a hospitalist were excluded.

The hospitalist receiving the curbside consultation was allowed to ask questions as they normally would, but could not verify the accuracy of the information received (eg, could not review any portion of the patient's medical record, such as notes or lab data). A standardized data collection sheet was used to record the service and level of training of the requesting provider, the medical issue(s) of concern, all clinical data offered by the provider, the number of questions asked by the hospitalist of the provider, and whether, on the basis of the information provided, the hospitalist felt that the question(s) being asked was (were) of sufficient complexity that a formal consultation should occur. The hospitalist then offered advice based upon the information given during the curbside consultation.

After completing the curbside consultation, the hospitalist requested verbal permission from the requesting provider to perform a formal consultation. If the request was approved, the hospitalist performing the curbside consultation contacted a different hospitalist who performed the formal consultation within the next few hours. The only information given to the second hospitalist was the patient's identifiers and the clinical question(s) being asked. The formal consultation included a complete face‐to‐face history and physical examination, a review of the patient's medical record, documentation of the provider's findings, and recommendations for care.

Upon completion of the formal consultation, the hospitalists who performed the curbside and the formal consultations met to review the advice each gave to the requesting provider and the information on which this advice was based. The 2 hospitalists jointly determined the following: (a) whether the information received during the curbside consultation was correct and complete, (b) whether the advice provided in the formal consultation differed from that provided in the curbside consultation, (c) whether the advice provided in the formal consultation dealt with issues other than one(s) leading to the curbside consultation, (d) whether differences in the recommendations given in the curbside versus the formal consultation changed patient management in a meaningful way, and (e) whether the curbside consultation alone was felt to be sufficient.

Information obtained by the hospitalist performing the formal consultation that was different from, or not included in, the information recorded during the curbside consultation was considered to be incorrect or incomplete, respectively. A change in management was defined as an alteration in the direction or type of care that the patient would have received as a result of the advice being given. A pulmonary and critical care physician, with >35 years of experience in inpatient medicine, reviewed the information provided in the curbside and formal consultations, and independently assessed whether the curbside consultation alone would have been sufficient and whether the formal consultation changed management.

Curbside consultations were neither solicited nor discouraged during the course of the study. The provider requesting the curbside consultation was not informed or debriefed about the study in an attempt to avoid affecting future consultation practices from that provider or service.

Associations were sought between the frequency of inaccurate or incomplete data and the requesting service and provider, the consultative category and medical issue, the number of questions asked by the hospitalist during the curbside consultation, and whether the hospitalist doing the curbside consultation thought that formal consultation was needed. A chi‐square test was used to analyze all associations. A P value of <0.05 was considered significant. All analyses were performed using SAS Enterprise Guide 4.3 (SAS Institute, Inc, Cary, NC) software. The study was approved by the Colorado Multiple Institutional Review Board.

RESULTS

Fifty curbside consultations were requested on a total of 215 study days. The requesting service declined formal consultation in 3 instances, leaving 47 curbside consultations that had a formal consultation. Curbside consultations came from a variety of services and providers, and addressed a variety of issues and concerns (Table 1).

Characteristics of Curbside Consultations (N = 47)
 Curbside Consultations, N (%)
 47 (100)
  • Consultations could be listed in more than one category; accordingly, the totals exceed 100%.

Requesting service 
Psychiatry21 (45)
Emergency Department9 (19)
Obstetrics/Gynecology5 (11)
Neurology4 (8)
Other (Orthopedics, Anesthesia, General Surgery, Neurosurgery, and Interventional Radiology)8 (17)
Requesting provider 
Resident25 (53)
Intern8 (17)
Attending9 (19)
Other5 (11)
Consultative issue* 
Diagnosis10 (21)
Treatment29 (62)
Evaluation20 (43)
Discharge13 (28)
Lab interpretation4 (9)
Medical concern* 
Cardiac27 (57)
Endocrine17 (36)
Infectious disease9 (19)
Pulmonary8 (17)
Gastroenterology6 (13)
Fluid and electrolyte6 (13)
Others23 (49)

The hospitalists asked 0 to 2 questions during 8/47 (17%) of the curbside consultations, 3 to 5 questions during 26/47 (55%) consultations, and more than 5 questions during 13/47 (28%). Based on the information received during the curbside consultations, the hospitalists thought that the curbside consultations were insufficient for 18/47 (38%) of patients. In all instances, the opinions of the 2 hospitalists concurred with respect to this conclusion, and the independent reviewer agreed with this assessment in 17 of these 18 (94%).

The advice rendered in the formal consultations differed from that provided in 26/47 (55%) of the curbside consultations, and the formal consultation was thought to have changed management for 28/47 (60%) of patients (Table 2). The independent reviewer thought that the advice provided in the formal consultations changed management in 29/47 (62%) of the cases, and in 24/28 cases (86%) where the hospitalist felt that the formal consult changed management.

Curbside Consultation Assessment
 Curbside Consultations, N (%)
 TotalAccurate and CompleteInaccurate or Incomplete
47 (100)23 (49)24 (51)
  • P < 0.001

  • P < 0.0001.

Advice in formal consultation differed from advice in curbside consultation26 (55)7 (30)19 (79)*
Formal consultation changed management28 (60)6 (26)22 (92)
Minor change18 (64)6 (100)12 (55)
Major change10 (36)0 (0)10 (45)
Curbside consultation insufficient18 (38)2 (9)16 (67)

Information was felt to be inaccurate or incomplete in 24/47 (51%) of the curbside consultations (13/47 inaccurate, 16/47 incomplete, 5/47 both inaccurate and incomplete), and when inaccurate or incomplete information was obtained, the advice given in the formal consultations more commonly differed from that provided in the curbside consultation (19/24, 79% vs 7/23, 30%; P < 0.001), and was more commonly felt to change management (22/24, 92% vs 6/23, 26%; P < 0.0001) (Table 2). No association was found between whether the curbside consultation contained complete or accurate information and the consulting service from which the curbside originated, the consulting provider, the consultative aspect(s) or medical issue(s) addressed, the number of questions asked by the hospitalist during the curbside consultation, nor whether the hospitalists felt that a formal consultation was needed.

DISCUSSION

The important findings of this study are that (a) the recommendations made by hospitalists in curbside versus formal consultations on the same patient frequently differ, (b) these differences frequently result in changes in clinical management, (c) the information presented in curbside consultations by providers is frequently inaccurate or incomplete, regardless of the providers specialty or seniority, (d) when inaccurate or incomplete information is received, the recommendations made in curbside and formal consultations differ more frequently, and (e) we found no way to predict whether the information provided in a curbside consultation was likely to be inaccurate or incomplete.

Our hospitalists thought that 38% of the curbside consultations they received should have had formal consultations. Manian and McKinsey7 reported that as many as 53% of questions asked of infectious disease consultants were thought to be too complex to be addressed in an informal consultation. Others, however, report that only 11%33% of curbside consultations were thought to require formal consultation.1, 9, 10, 16 Our hospitalists asked 3 or more questions of the consulting providers in more than 80% of the curbside consultations, suggesting that the curbside consultations we received might have had a higher complexity than those seen by others.

Our finding that information provided in curbside consultation was frequently inaccurate or incomplete is consistent with a number of previous studies reporting physicians' perceptions of the accuracy of curbside consultations.2, 3 Hospital medicine is not likely to be the only discipline affected by inaccurate curbside consultation practices, as surveys of specialists in infectious disease, gynecology, and neurosurgery report that practitioners in these disciplines have similar concerns.1, 10, 14 In a survey returned by 34 physicians, Myers1 found that 50% thought the information exchanged during curbside consultations was inaccurate, leading him to conclude that inaccuracies presented during curbside consultations required further study.

We found no way of predicting whether curbside consultations were likely to include inaccurate or incomplete information. This observation is consistent with the results of Bergus et al16 who found that the frequency of curbside consultations being converted to formal consultations was independent of the training status of the consulting physician, and with the data of Myers1 who found no way of predicting the likelihood that a curbside consultation should be converted to a formal consultation.

We found that formal consultations resulted in management changes more often than differences in recommendations (ie, 60% vs 55%, respectively). This small difference occurred because, on occasion, the formal consultations found issues to address other than the one(s) for which the curbside consultation was requested. In the majority of these instances, the management changes were minor and the curbside consultation was still felt to be sufficient.

In some instances, the advice given after the curbside and the formal consultations differed to only a minor extent (eg, varying recommendations for oral diabetes management). In other instances, however, the advice differed substantially (eg, change in antibiotic management in a septic patient with a multidrug resistant organism, when the original curbside question was for when to order a follow‐up chest roentgenogram for hypoxia; see Supporting Information, Appendix, in the online version of this article). In 26 patients (55%), formal consultation resulted in different medications being started or stopped, additional tests being performed, or different decisions being made about admission versus discharge.

Our study has a number of strengths. First, while a number of reports document that physicians' perceptions are that curbside consultations frequently contain errors,2, 3, 5, 12 to our knowledge this is the first study that prospectively compared the information collected and advice given in curbside versus formal consultation. Second, while this study was conducted as a quality improvement project, thereby requiring us to conclude that the results are not generalizable, the data presented were collected by 18 different hospitalists, reducing the potential of bias from an individual provider's knowledge base or practice. Third, there was excellent agreement between the independent reviewer and the 2 hospitalists who performed the curbside and formal consultations regarding whether a curbside consultation would have been sufficient, and whether the formal consultation changed patient management. Fourth, the study was conducted over a 1‐year period, which should have reduced potential bias arising from the increasing experience of residents requesting consultations as their training progressed.

Our study has several limitations. First, the number of curbside consultations we received during the study period (50 over 215 days) was lower than anticipated, and lower than the rates of consultation reported by others.1, 7, 9 This likely relates to the fact that, prior to beginning the study, Denver Health hospitalists already provided mandatory consultations for several surgical services (thereby reducing the number of curbside consultations received from these services), because curbside consultations received during evenings, nights, and weekends were not included in the study for reasons of convenience, and because we excluded all administrative curbside consultations. Our hospitalist service also provides consultative services 24 hours a day, thereby reducing the number of consultations received during daytime hours. Second, the frequency with which curbside consultations included inaccurate or incomplete information might be higher than what occurs in other hospitals, as Denver Health is an urban, university‐affiliated public hospital and the patients encountered may be more complex and trainees may be less adept at recognizing the information that would facilitate accurate curbside consultations (although we found no difference in the frequency with which inaccurate or incomplete information was provided as a function of the seniority of the requesting physician). Third, the disparity between curbside and formal consultations that we observed could have been biased by the Hawthorne effect. We attempted to address this by not providing the hospitalists who did the formal consultation with any information collected by the hospitalist involved with the curbside consultation, and by comparing the conclusions reached by the hospitalists performing the curbside and formal consultations with those of a third party reviewer. Fourth, while we found no association between the frequency of curbside consultations in which information was inaccurate or incomplete and the consulting service, there could be a selection bias of the consulting service requesting the curbside consultations as a result of the mandatory consultations already provided by our hospitalists. Finally, our study was not designed or adequately powered to determine why curbside consultations frequently have inaccurate or incomplete information.

In summary, we found that the information provided to hospitalists during a curbside consultation was often inaccurate and incomplete, and that these problems with information exchange adversely affected the accuracy of the resulting recommendations. While there are a number of advantages to curbside consultations,1, 3, 7, 10, 12, 13 our findings indicate that the risk associated with this practice is substantial.

Acknowledgements

Disclosure: Nothing to report.

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References
  1. Myers JP.Curbside consultation in infectious diseases: a prospective study.J Infect Dis.1984;150:797802.
  2. Keating NL,Zaslavsky AM,Ayanian JZ.Physicians' experiences and beliefs regarding informal consultation.JAMA.1998;280:900904.
  3. Kuo D,Gifford DR,Stein MD.Curbside consultation practices and attitudes among primary care physicians and medical subspecialists.JAMA.1998;280:905909.
  4. Grace C,Alston WK,Ramundo M,Polish L,Kirkpatrick B,Huston C.The complexity, relative value, and financial worth of curbside consultations in an academic infectious diseases unit.Clin Infect Dis.2010;51:651655.
  5. Manian FA,Janssen DA.Curbside consultations. A closer look at a common practice.JAMA.1996;275:145147.
  6. Weinberg AD,Ullian L,Richards WD,Cooper P.Informal advice‐ and information‐seeking between physicians.J Med Educ.1981;56;174180.
  7. Manian FA,McKinsey DS.A prospective study of 2,092 “curbside” questions asked of two infectious disease consultants in private practice in the midwest.Clin Infect Dis.1996;22:303307.
  8. Findling JW,Shaker JL,Brickner RC,Riordan PR,Aron DC.Curbside consultation in endocrine practice: a prospective observational study.Endocrinologist.1996;6:328331.
  9. Pearson SD,Moreno R,Trnka Y.Informal consultations provided to general internists by the gastroenterology department of an HMO.J Gen Intern Med.1998;13:435438.
  10. Muntz HG.“Curbside” consultations in gynecologic oncology: a closer look at a common practice.Gynecol Oncol.1999;74:456459.
  11. Leblebicioglu H,Akbulut A,Ulusoy S, et al.Informal consultations in infectious diseases and clinical microbiology practice.Clin Microbiol Infect.2003;9:724726.
  12. Golub RM.Curbside consultations and the viaduct effect.JAMA.1998;280:929930.
  13. Borowsky SJ.What do we really need to know about consultation and referral?J Gen Intern Med.1998;13:497498.
  14. Cartmill M,White BD.Telephone advice for neurosurgical referrals. Who assumes duty of care?Br J Neurosurg.2001;15:453455.
  15. Olick RS,Bergus GR.Malpractice liability for informal consultations.Fam Med.2003;35:476481.
  16. Bergus GR,Randall CS,Sinift SD,Rosenthal DM.Does the structure of clinical questions affect the outcome of curbside consultations with specialty colleagues?Arch Fam Med.2000;9:541547.
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A curbside consultation is an informal process whereby a consultant is asked to provide information or advice about a patient's care without doing a formal assessment of the patient.14 Curbside consultations are common in the practice of medicine2, 3, 5 and are frequently requested by physicians caring for hospitalized patients. Several surveys have documented the quantity of curbside consultations requested of various subspecialties, the types of questions asked, the time it takes to respond, and physicians' perceptions about the quality of the information exchanged.111 While curbside consultations have a number of advantages, physicians' perceptions are that the information conveyed may be inaccurate or incomplete and that the advice offered may be erroneous.13, 5, 10, 12, 13

Cartmill and White14 performed a random audit of 10% of the telephone referrals they received for neurosurgical consultation over a 1‐year period and noted discrepancies between the Glascow Coma Scores reported during the telephone referrals and those noted in the medical records, but the frequency of these discrepancies was not reported. To our knowledge, no studies have compared the quality of the information provided in curbside consultations with that obtained in formal consultations that included direct face‐to‐face patient evaluations and primary data collection, and whether the advice provided in curbside and formal consultations on the same patient differed.

We performed a prospective cohort study to compare the information received by hospitalists during curbside consultations on hospitalized patients, with that obtained from formal consultations done the same day on the same patients, by different hospitalists who were unaware of any details regarding the curbside consultation. We also compared the advice provided by the 2 hospitalists following their curbside and formal consultations. Our hypotheses were that the information received during curbside consultations was frequently inaccurate or incomplete, that the recommendations made after the formal consultation would frequently differ from those made in the curbside consultation, and that these differences would have important implications on patient care.

METHODS

This was a quality improvement study conducted at Denver Health, a 500‐bed university‐affiliated urban safety net hospital from January 10, 2011 to January 9, 2012. The study design was a prospective cohort that included all curbside consultations on hospitalized patients received between 7 AM and 3 PM, on intermittently selected weekdays, by the Internal Medicine Consultation Service that was staffed by 18 hospitalists. Data were collected intermittently based upon hospitalist availability and was done to limit potential alterations in the consulting practices of the providers requesting consultations.

Consultations were defined as being curbside when the consulting provider asked for advice, suggestions, or opinions about a patient's care but did not ask the hospitalist to see the patient.15, 15 Consultations pertaining to administrative issues (eg, whether a patient should be admitted to an intensive care bed as opposed to an acute care floor bed) or on patients who were already being followed by a hospitalist were excluded.

The hospitalist receiving the curbside consultation was allowed to ask questions as they normally would, but could not verify the accuracy of the information received (eg, could not review any portion of the patient's medical record, such as notes or lab data). A standardized data collection sheet was used to record the service and level of training of the requesting provider, the medical issue(s) of concern, all clinical data offered by the provider, the number of questions asked by the hospitalist of the provider, and whether, on the basis of the information provided, the hospitalist felt that the question(s) being asked was (were) of sufficient complexity that a formal consultation should occur. The hospitalist then offered advice based upon the information given during the curbside consultation.

After completing the curbside consultation, the hospitalist requested verbal permission from the requesting provider to perform a formal consultation. If the request was approved, the hospitalist performing the curbside consultation contacted a different hospitalist who performed the formal consultation within the next few hours. The only information given to the second hospitalist was the patient's identifiers and the clinical question(s) being asked. The formal consultation included a complete face‐to‐face history and physical examination, a review of the patient's medical record, documentation of the provider's findings, and recommendations for care.

Upon completion of the formal consultation, the hospitalists who performed the curbside and the formal consultations met to review the advice each gave to the requesting provider and the information on which this advice was based. The 2 hospitalists jointly determined the following: (a) whether the information received during the curbside consultation was correct and complete, (b) whether the advice provided in the formal consultation differed from that provided in the curbside consultation, (c) whether the advice provided in the formal consultation dealt with issues other than one(s) leading to the curbside consultation, (d) whether differences in the recommendations given in the curbside versus the formal consultation changed patient management in a meaningful way, and (e) whether the curbside consultation alone was felt to be sufficient.

Information obtained by the hospitalist performing the formal consultation that was different from, or not included in, the information recorded during the curbside consultation was considered to be incorrect or incomplete, respectively. A change in management was defined as an alteration in the direction or type of care that the patient would have received as a result of the advice being given. A pulmonary and critical care physician, with >35 years of experience in inpatient medicine, reviewed the information provided in the curbside and formal consultations, and independently assessed whether the curbside consultation alone would have been sufficient and whether the formal consultation changed management.

Curbside consultations were neither solicited nor discouraged during the course of the study. The provider requesting the curbside consultation was not informed or debriefed about the study in an attempt to avoid affecting future consultation practices from that provider or service.

Associations were sought between the frequency of inaccurate or incomplete data and the requesting service and provider, the consultative category and medical issue, the number of questions asked by the hospitalist during the curbside consultation, and whether the hospitalist doing the curbside consultation thought that formal consultation was needed. A chi‐square test was used to analyze all associations. A P value of <0.05 was considered significant. All analyses were performed using SAS Enterprise Guide 4.3 (SAS Institute, Inc, Cary, NC) software. The study was approved by the Colorado Multiple Institutional Review Board.

RESULTS

Fifty curbside consultations were requested on a total of 215 study days. The requesting service declined formal consultation in 3 instances, leaving 47 curbside consultations that had a formal consultation. Curbside consultations came from a variety of services and providers, and addressed a variety of issues and concerns (Table 1).

Characteristics of Curbside Consultations (N = 47)
 Curbside Consultations, N (%)
 47 (100)
  • Consultations could be listed in more than one category; accordingly, the totals exceed 100%.

Requesting service 
Psychiatry21 (45)
Emergency Department9 (19)
Obstetrics/Gynecology5 (11)
Neurology4 (8)
Other (Orthopedics, Anesthesia, General Surgery, Neurosurgery, and Interventional Radiology)8 (17)
Requesting provider 
Resident25 (53)
Intern8 (17)
Attending9 (19)
Other5 (11)
Consultative issue* 
Diagnosis10 (21)
Treatment29 (62)
Evaluation20 (43)
Discharge13 (28)
Lab interpretation4 (9)
Medical concern* 
Cardiac27 (57)
Endocrine17 (36)
Infectious disease9 (19)
Pulmonary8 (17)
Gastroenterology6 (13)
Fluid and electrolyte6 (13)
Others23 (49)

The hospitalists asked 0 to 2 questions during 8/47 (17%) of the curbside consultations, 3 to 5 questions during 26/47 (55%) consultations, and more than 5 questions during 13/47 (28%). Based on the information received during the curbside consultations, the hospitalists thought that the curbside consultations were insufficient for 18/47 (38%) of patients. In all instances, the opinions of the 2 hospitalists concurred with respect to this conclusion, and the independent reviewer agreed with this assessment in 17 of these 18 (94%).

The advice rendered in the formal consultations differed from that provided in 26/47 (55%) of the curbside consultations, and the formal consultation was thought to have changed management for 28/47 (60%) of patients (Table 2). The independent reviewer thought that the advice provided in the formal consultations changed management in 29/47 (62%) of the cases, and in 24/28 cases (86%) where the hospitalist felt that the formal consult changed management.

Curbside Consultation Assessment
 Curbside Consultations, N (%)
 TotalAccurate and CompleteInaccurate or Incomplete
47 (100)23 (49)24 (51)
  • P < 0.001

  • P < 0.0001.

Advice in formal consultation differed from advice in curbside consultation26 (55)7 (30)19 (79)*
Formal consultation changed management28 (60)6 (26)22 (92)
Minor change18 (64)6 (100)12 (55)
Major change10 (36)0 (0)10 (45)
Curbside consultation insufficient18 (38)2 (9)16 (67)

Information was felt to be inaccurate or incomplete in 24/47 (51%) of the curbside consultations (13/47 inaccurate, 16/47 incomplete, 5/47 both inaccurate and incomplete), and when inaccurate or incomplete information was obtained, the advice given in the formal consultations more commonly differed from that provided in the curbside consultation (19/24, 79% vs 7/23, 30%; P < 0.001), and was more commonly felt to change management (22/24, 92% vs 6/23, 26%; P < 0.0001) (Table 2). No association was found between whether the curbside consultation contained complete or accurate information and the consulting service from which the curbside originated, the consulting provider, the consultative aspect(s) or medical issue(s) addressed, the number of questions asked by the hospitalist during the curbside consultation, nor whether the hospitalists felt that a formal consultation was needed.

DISCUSSION

The important findings of this study are that (a) the recommendations made by hospitalists in curbside versus formal consultations on the same patient frequently differ, (b) these differences frequently result in changes in clinical management, (c) the information presented in curbside consultations by providers is frequently inaccurate or incomplete, regardless of the providers specialty or seniority, (d) when inaccurate or incomplete information is received, the recommendations made in curbside and formal consultations differ more frequently, and (e) we found no way to predict whether the information provided in a curbside consultation was likely to be inaccurate or incomplete.

Our hospitalists thought that 38% of the curbside consultations they received should have had formal consultations. Manian and McKinsey7 reported that as many as 53% of questions asked of infectious disease consultants were thought to be too complex to be addressed in an informal consultation. Others, however, report that only 11%33% of curbside consultations were thought to require formal consultation.1, 9, 10, 16 Our hospitalists asked 3 or more questions of the consulting providers in more than 80% of the curbside consultations, suggesting that the curbside consultations we received might have had a higher complexity than those seen by others.

Our finding that information provided in curbside consultation was frequently inaccurate or incomplete is consistent with a number of previous studies reporting physicians' perceptions of the accuracy of curbside consultations.2, 3 Hospital medicine is not likely to be the only discipline affected by inaccurate curbside consultation practices, as surveys of specialists in infectious disease, gynecology, and neurosurgery report that practitioners in these disciplines have similar concerns.1, 10, 14 In a survey returned by 34 physicians, Myers1 found that 50% thought the information exchanged during curbside consultations was inaccurate, leading him to conclude that inaccuracies presented during curbside consultations required further study.

We found no way of predicting whether curbside consultations were likely to include inaccurate or incomplete information. This observation is consistent with the results of Bergus et al16 who found that the frequency of curbside consultations being converted to formal consultations was independent of the training status of the consulting physician, and with the data of Myers1 who found no way of predicting the likelihood that a curbside consultation should be converted to a formal consultation.

We found that formal consultations resulted in management changes more often than differences in recommendations (ie, 60% vs 55%, respectively). This small difference occurred because, on occasion, the formal consultations found issues to address other than the one(s) for which the curbside consultation was requested. In the majority of these instances, the management changes were minor and the curbside consultation was still felt to be sufficient.

In some instances, the advice given after the curbside and the formal consultations differed to only a minor extent (eg, varying recommendations for oral diabetes management). In other instances, however, the advice differed substantially (eg, change in antibiotic management in a septic patient with a multidrug resistant organism, when the original curbside question was for when to order a follow‐up chest roentgenogram for hypoxia; see Supporting Information, Appendix, in the online version of this article). In 26 patients (55%), formal consultation resulted in different medications being started or stopped, additional tests being performed, or different decisions being made about admission versus discharge.

Our study has a number of strengths. First, while a number of reports document that physicians' perceptions are that curbside consultations frequently contain errors,2, 3, 5, 12 to our knowledge this is the first study that prospectively compared the information collected and advice given in curbside versus formal consultation. Second, while this study was conducted as a quality improvement project, thereby requiring us to conclude that the results are not generalizable, the data presented were collected by 18 different hospitalists, reducing the potential of bias from an individual provider's knowledge base or practice. Third, there was excellent agreement between the independent reviewer and the 2 hospitalists who performed the curbside and formal consultations regarding whether a curbside consultation would have been sufficient, and whether the formal consultation changed patient management. Fourth, the study was conducted over a 1‐year period, which should have reduced potential bias arising from the increasing experience of residents requesting consultations as their training progressed.

Our study has several limitations. First, the number of curbside consultations we received during the study period (50 over 215 days) was lower than anticipated, and lower than the rates of consultation reported by others.1, 7, 9 This likely relates to the fact that, prior to beginning the study, Denver Health hospitalists already provided mandatory consultations for several surgical services (thereby reducing the number of curbside consultations received from these services), because curbside consultations received during evenings, nights, and weekends were not included in the study for reasons of convenience, and because we excluded all administrative curbside consultations. Our hospitalist service also provides consultative services 24 hours a day, thereby reducing the number of consultations received during daytime hours. Second, the frequency with which curbside consultations included inaccurate or incomplete information might be higher than what occurs in other hospitals, as Denver Health is an urban, university‐affiliated public hospital and the patients encountered may be more complex and trainees may be less adept at recognizing the information that would facilitate accurate curbside consultations (although we found no difference in the frequency with which inaccurate or incomplete information was provided as a function of the seniority of the requesting physician). Third, the disparity between curbside and formal consultations that we observed could have been biased by the Hawthorne effect. We attempted to address this by not providing the hospitalists who did the formal consultation with any information collected by the hospitalist involved with the curbside consultation, and by comparing the conclusions reached by the hospitalists performing the curbside and formal consultations with those of a third party reviewer. Fourth, while we found no association between the frequency of curbside consultations in which information was inaccurate or incomplete and the consulting service, there could be a selection bias of the consulting service requesting the curbside consultations as a result of the mandatory consultations already provided by our hospitalists. Finally, our study was not designed or adequately powered to determine why curbside consultations frequently have inaccurate or incomplete information.

In summary, we found that the information provided to hospitalists during a curbside consultation was often inaccurate and incomplete, and that these problems with information exchange adversely affected the accuracy of the resulting recommendations. While there are a number of advantages to curbside consultations,1, 3, 7, 10, 12, 13 our findings indicate that the risk associated with this practice is substantial.

Acknowledgements

Disclosure: Nothing to report.

A curbside consultation is an informal process whereby a consultant is asked to provide information or advice about a patient's care without doing a formal assessment of the patient.14 Curbside consultations are common in the practice of medicine2, 3, 5 and are frequently requested by physicians caring for hospitalized patients. Several surveys have documented the quantity of curbside consultations requested of various subspecialties, the types of questions asked, the time it takes to respond, and physicians' perceptions about the quality of the information exchanged.111 While curbside consultations have a number of advantages, physicians' perceptions are that the information conveyed may be inaccurate or incomplete and that the advice offered may be erroneous.13, 5, 10, 12, 13

Cartmill and White14 performed a random audit of 10% of the telephone referrals they received for neurosurgical consultation over a 1‐year period and noted discrepancies between the Glascow Coma Scores reported during the telephone referrals and those noted in the medical records, but the frequency of these discrepancies was not reported. To our knowledge, no studies have compared the quality of the information provided in curbside consultations with that obtained in formal consultations that included direct face‐to‐face patient evaluations and primary data collection, and whether the advice provided in curbside and formal consultations on the same patient differed.

We performed a prospective cohort study to compare the information received by hospitalists during curbside consultations on hospitalized patients, with that obtained from formal consultations done the same day on the same patients, by different hospitalists who were unaware of any details regarding the curbside consultation. We also compared the advice provided by the 2 hospitalists following their curbside and formal consultations. Our hypotheses were that the information received during curbside consultations was frequently inaccurate or incomplete, that the recommendations made after the formal consultation would frequently differ from those made in the curbside consultation, and that these differences would have important implications on patient care.

METHODS

This was a quality improvement study conducted at Denver Health, a 500‐bed university‐affiliated urban safety net hospital from January 10, 2011 to January 9, 2012. The study design was a prospective cohort that included all curbside consultations on hospitalized patients received between 7 AM and 3 PM, on intermittently selected weekdays, by the Internal Medicine Consultation Service that was staffed by 18 hospitalists. Data were collected intermittently based upon hospitalist availability and was done to limit potential alterations in the consulting practices of the providers requesting consultations.

Consultations were defined as being curbside when the consulting provider asked for advice, suggestions, or opinions about a patient's care but did not ask the hospitalist to see the patient.15, 15 Consultations pertaining to administrative issues (eg, whether a patient should be admitted to an intensive care bed as opposed to an acute care floor bed) or on patients who were already being followed by a hospitalist were excluded.

The hospitalist receiving the curbside consultation was allowed to ask questions as they normally would, but could not verify the accuracy of the information received (eg, could not review any portion of the patient's medical record, such as notes or lab data). A standardized data collection sheet was used to record the service and level of training of the requesting provider, the medical issue(s) of concern, all clinical data offered by the provider, the number of questions asked by the hospitalist of the provider, and whether, on the basis of the information provided, the hospitalist felt that the question(s) being asked was (were) of sufficient complexity that a formal consultation should occur. The hospitalist then offered advice based upon the information given during the curbside consultation.

After completing the curbside consultation, the hospitalist requested verbal permission from the requesting provider to perform a formal consultation. If the request was approved, the hospitalist performing the curbside consultation contacted a different hospitalist who performed the formal consultation within the next few hours. The only information given to the second hospitalist was the patient's identifiers and the clinical question(s) being asked. The formal consultation included a complete face‐to‐face history and physical examination, a review of the patient's medical record, documentation of the provider's findings, and recommendations for care.

Upon completion of the formal consultation, the hospitalists who performed the curbside and the formal consultations met to review the advice each gave to the requesting provider and the information on which this advice was based. The 2 hospitalists jointly determined the following: (a) whether the information received during the curbside consultation was correct and complete, (b) whether the advice provided in the formal consultation differed from that provided in the curbside consultation, (c) whether the advice provided in the formal consultation dealt with issues other than one(s) leading to the curbside consultation, (d) whether differences in the recommendations given in the curbside versus the formal consultation changed patient management in a meaningful way, and (e) whether the curbside consultation alone was felt to be sufficient.

Information obtained by the hospitalist performing the formal consultation that was different from, or not included in, the information recorded during the curbside consultation was considered to be incorrect or incomplete, respectively. A change in management was defined as an alteration in the direction or type of care that the patient would have received as a result of the advice being given. A pulmonary and critical care physician, with >35 years of experience in inpatient medicine, reviewed the information provided in the curbside and formal consultations, and independently assessed whether the curbside consultation alone would have been sufficient and whether the formal consultation changed management.

Curbside consultations were neither solicited nor discouraged during the course of the study. The provider requesting the curbside consultation was not informed or debriefed about the study in an attempt to avoid affecting future consultation practices from that provider or service.

Associations were sought between the frequency of inaccurate or incomplete data and the requesting service and provider, the consultative category and medical issue, the number of questions asked by the hospitalist during the curbside consultation, and whether the hospitalist doing the curbside consultation thought that formal consultation was needed. A chi‐square test was used to analyze all associations. A P value of <0.05 was considered significant. All analyses were performed using SAS Enterprise Guide 4.3 (SAS Institute, Inc, Cary, NC) software. The study was approved by the Colorado Multiple Institutional Review Board.

RESULTS

Fifty curbside consultations were requested on a total of 215 study days. The requesting service declined formal consultation in 3 instances, leaving 47 curbside consultations that had a formal consultation. Curbside consultations came from a variety of services and providers, and addressed a variety of issues and concerns (Table 1).

Characteristics of Curbside Consultations (N = 47)
 Curbside Consultations, N (%)
 47 (100)
  • Consultations could be listed in more than one category; accordingly, the totals exceed 100%.

Requesting service 
Psychiatry21 (45)
Emergency Department9 (19)
Obstetrics/Gynecology5 (11)
Neurology4 (8)
Other (Orthopedics, Anesthesia, General Surgery, Neurosurgery, and Interventional Radiology)8 (17)
Requesting provider 
Resident25 (53)
Intern8 (17)
Attending9 (19)
Other5 (11)
Consultative issue* 
Diagnosis10 (21)
Treatment29 (62)
Evaluation20 (43)
Discharge13 (28)
Lab interpretation4 (9)
Medical concern* 
Cardiac27 (57)
Endocrine17 (36)
Infectious disease9 (19)
Pulmonary8 (17)
Gastroenterology6 (13)
Fluid and electrolyte6 (13)
Others23 (49)

The hospitalists asked 0 to 2 questions during 8/47 (17%) of the curbside consultations, 3 to 5 questions during 26/47 (55%) consultations, and more than 5 questions during 13/47 (28%). Based on the information received during the curbside consultations, the hospitalists thought that the curbside consultations were insufficient for 18/47 (38%) of patients. In all instances, the opinions of the 2 hospitalists concurred with respect to this conclusion, and the independent reviewer agreed with this assessment in 17 of these 18 (94%).

The advice rendered in the formal consultations differed from that provided in 26/47 (55%) of the curbside consultations, and the formal consultation was thought to have changed management for 28/47 (60%) of patients (Table 2). The independent reviewer thought that the advice provided in the formal consultations changed management in 29/47 (62%) of the cases, and in 24/28 cases (86%) where the hospitalist felt that the formal consult changed management.

Curbside Consultation Assessment
 Curbside Consultations, N (%)
 TotalAccurate and CompleteInaccurate or Incomplete
47 (100)23 (49)24 (51)
  • P < 0.001

  • P < 0.0001.

Advice in formal consultation differed from advice in curbside consultation26 (55)7 (30)19 (79)*
Formal consultation changed management28 (60)6 (26)22 (92)
Minor change18 (64)6 (100)12 (55)
Major change10 (36)0 (0)10 (45)
Curbside consultation insufficient18 (38)2 (9)16 (67)

Information was felt to be inaccurate or incomplete in 24/47 (51%) of the curbside consultations (13/47 inaccurate, 16/47 incomplete, 5/47 both inaccurate and incomplete), and when inaccurate or incomplete information was obtained, the advice given in the formal consultations more commonly differed from that provided in the curbside consultation (19/24, 79% vs 7/23, 30%; P < 0.001), and was more commonly felt to change management (22/24, 92% vs 6/23, 26%; P < 0.0001) (Table 2). No association was found between whether the curbside consultation contained complete or accurate information and the consulting service from which the curbside originated, the consulting provider, the consultative aspect(s) or medical issue(s) addressed, the number of questions asked by the hospitalist during the curbside consultation, nor whether the hospitalists felt that a formal consultation was needed.

DISCUSSION

The important findings of this study are that (a) the recommendations made by hospitalists in curbside versus formal consultations on the same patient frequently differ, (b) these differences frequently result in changes in clinical management, (c) the information presented in curbside consultations by providers is frequently inaccurate or incomplete, regardless of the providers specialty or seniority, (d) when inaccurate or incomplete information is received, the recommendations made in curbside and formal consultations differ more frequently, and (e) we found no way to predict whether the information provided in a curbside consultation was likely to be inaccurate or incomplete.

Our hospitalists thought that 38% of the curbside consultations they received should have had formal consultations. Manian and McKinsey7 reported that as many as 53% of questions asked of infectious disease consultants were thought to be too complex to be addressed in an informal consultation. Others, however, report that only 11%33% of curbside consultations were thought to require formal consultation.1, 9, 10, 16 Our hospitalists asked 3 or more questions of the consulting providers in more than 80% of the curbside consultations, suggesting that the curbside consultations we received might have had a higher complexity than those seen by others.

Our finding that information provided in curbside consultation was frequently inaccurate or incomplete is consistent with a number of previous studies reporting physicians' perceptions of the accuracy of curbside consultations.2, 3 Hospital medicine is not likely to be the only discipline affected by inaccurate curbside consultation practices, as surveys of specialists in infectious disease, gynecology, and neurosurgery report that practitioners in these disciplines have similar concerns.1, 10, 14 In a survey returned by 34 physicians, Myers1 found that 50% thought the information exchanged during curbside consultations was inaccurate, leading him to conclude that inaccuracies presented during curbside consultations required further study.

We found no way of predicting whether curbside consultations were likely to include inaccurate or incomplete information. This observation is consistent with the results of Bergus et al16 who found that the frequency of curbside consultations being converted to formal consultations was independent of the training status of the consulting physician, and with the data of Myers1 who found no way of predicting the likelihood that a curbside consultation should be converted to a formal consultation.

We found that formal consultations resulted in management changes more often than differences in recommendations (ie, 60% vs 55%, respectively). This small difference occurred because, on occasion, the formal consultations found issues to address other than the one(s) for which the curbside consultation was requested. In the majority of these instances, the management changes were minor and the curbside consultation was still felt to be sufficient.

In some instances, the advice given after the curbside and the formal consultations differed to only a minor extent (eg, varying recommendations for oral diabetes management). In other instances, however, the advice differed substantially (eg, change in antibiotic management in a septic patient with a multidrug resistant organism, when the original curbside question was for when to order a follow‐up chest roentgenogram for hypoxia; see Supporting Information, Appendix, in the online version of this article). In 26 patients (55%), formal consultation resulted in different medications being started or stopped, additional tests being performed, or different decisions being made about admission versus discharge.

Our study has a number of strengths. First, while a number of reports document that physicians' perceptions are that curbside consultations frequently contain errors,2, 3, 5, 12 to our knowledge this is the first study that prospectively compared the information collected and advice given in curbside versus formal consultation. Second, while this study was conducted as a quality improvement project, thereby requiring us to conclude that the results are not generalizable, the data presented were collected by 18 different hospitalists, reducing the potential of bias from an individual provider's knowledge base or practice. Third, there was excellent agreement between the independent reviewer and the 2 hospitalists who performed the curbside and formal consultations regarding whether a curbside consultation would have been sufficient, and whether the formal consultation changed patient management. Fourth, the study was conducted over a 1‐year period, which should have reduced potential bias arising from the increasing experience of residents requesting consultations as their training progressed.

Our study has several limitations. First, the number of curbside consultations we received during the study period (50 over 215 days) was lower than anticipated, and lower than the rates of consultation reported by others.1, 7, 9 This likely relates to the fact that, prior to beginning the study, Denver Health hospitalists already provided mandatory consultations for several surgical services (thereby reducing the number of curbside consultations received from these services), because curbside consultations received during evenings, nights, and weekends were not included in the study for reasons of convenience, and because we excluded all administrative curbside consultations. Our hospitalist service also provides consultative services 24 hours a day, thereby reducing the number of consultations received during daytime hours. Second, the frequency with which curbside consultations included inaccurate or incomplete information might be higher than what occurs in other hospitals, as Denver Health is an urban, university‐affiliated public hospital and the patients encountered may be more complex and trainees may be less adept at recognizing the information that would facilitate accurate curbside consultations (although we found no difference in the frequency with which inaccurate or incomplete information was provided as a function of the seniority of the requesting physician). Third, the disparity between curbside and formal consultations that we observed could have been biased by the Hawthorne effect. We attempted to address this by not providing the hospitalists who did the formal consultation with any information collected by the hospitalist involved with the curbside consultation, and by comparing the conclusions reached by the hospitalists performing the curbside and formal consultations with those of a third party reviewer. Fourth, while we found no association between the frequency of curbside consultations in which information was inaccurate or incomplete and the consulting service, there could be a selection bias of the consulting service requesting the curbside consultations as a result of the mandatory consultations already provided by our hospitalists. Finally, our study was not designed or adequately powered to determine why curbside consultations frequently have inaccurate or incomplete information.

In summary, we found that the information provided to hospitalists during a curbside consultation was often inaccurate and incomplete, and that these problems with information exchange adversely affected the accuracy of the resulting recommendations. While there are a number of advantages to curbside consultations,1, 3, 7, 10, 12, 13 our findings indicate that the risk associated with this practice is substantial.

Acknowledgements

Disclosure: Nothing to report.

References
  1. Myers JP.Curbside consultation in infectious diseases: a prospective study.J Infect Dis.1984;150:797802.
  2. Keating NL,Zaslavsky AM,Ayanian JZ.Physicians' experiences and beliefs regarding informal consultation.JAMA.1998;280:900904.
  3. Kuo D,Gifford DR,Stein MD.Curbside consultation practices and attitudes among primary care physicians and medical subspecialists.JAMA.1998;280:905909.
  4. Grace C,Alston WK,Ramundo M,Polish L,Kirkpatrick B,Huston C.The complexity, relative value, and financial worth of curbside consultations in an academic infectious diseases unit.Clin Infect Dis.2010;51:651655.
  5. Manian FA,Janssen DA.Curbside consultations. A closer look at a common practice.JAMA.1996;275:145147.
  6. Weinberg AD,Ullian L,Richards WD,Cooper P.Informal advice‐ and information‐seeking between physicians.J Med Educ.1981;56;174180.
  7. Manian FA,McKinsey DS.A prospective study of 2,092 “curbside” questions asked of two infectious disease consultants in private practice in the midwest.Clin Infect Dis.1996;22:303307.
  8. Findling JW,Shaker JL,Brickner RC,Riordan PR,Aron DC.Curbside consultation in endocrine practice: a prospective observational study.Endocrinologist.1996;6:328331.
  9. Pearson SD,Moreno R,Trnka Y.Informal consultations provided to general internists by the gastroenterology department of an HMO.J Gen Intern Med.1998;13:435438.
  10. Muntz HG.“Curbside” consultations in gynecologic oncology: a closer look at a common practice.Gynecol Oncol.1999;74:456459.
  11. Leblebicioglu H,Akbulut A,Ulusoy S, et al.Informal consultations in infectious diseases and clinical microbiology practice.Clin Microbiol Infect.2003;9:724726.
  12. Golub RM.Curbside consultations and the viaduct effect.JAMA.1998;280:929930.
  13. Borowsky SJ.What do we really need to know about consultation and referral?J Gen Intern Med.1998;13:497498.
  14. Cartmill M,White BD.Telephone advice for neurosurgical referrals. Who assumes duty of care?Br J Neurosurg.2001;15:453455.
  15. Olick RS,Bergus GR.Malpractice liability for informal consultations.Fam Med.2003;35:476481.
  16. Bergus GR,Randall CS,Sinift SD,Rosenthal DM.Does the structure of clinical questions affect the outcome of curbside consultations with specialty colleagues?Arch Fam Med.2000;9:541547.
References
  1. Myers JP.Curbside consultation in infectious diseases: a prospective study.J Infect Dis.1984;150:797802.
  2. Keating NL,Zaslavsky AM,Ayanian JZ.Physicians' experiences and beliefs regarding informal consultation.JAMA.1998;280:900904.
  3. Kuo D,Gifford DR,Stein MD.Curbside consultation practices and attitudes among primary care physicians and medical subspecialists.JAMA.1998;280:905909.
  4. Grace C,Alston WK,Ramundo M,Polish L,Kirkpatrick B,Huston C.The complexity, relative value, and financial worth of curbside consultations in an academic infectious diseases unit.Clin Infect Dis.2010;51:651655.
  5. Manian FA,Janssen DA.Curbside consultations. A closer look at a common practice.JAMA.1996;275:145147.
  6. Weinberg AD,Ullian L,Richards WD,Cooper P.Informal advice‐ and information‐seeking between physicians.J Med Educ.1981;56;174180.
  7. Manian FA,McKinsey DS.A prospective study of 2,092 “curbside” questions asked of two infectious disease consultants in private practice in the midwest.Clin Infect Dis.1996;22:303307.
  8. Findling JW,Shaker JL,Brickner RC,Riordan PR,Aron DC.Curbside consultation in endocrine practice: a prospective observational study.Endocrinologist.1996;6:328331.
  9. Pearson SD,Moreno R,Trnka Y.Informal consultations provided to general internists by the gastroenterology department of an HMO.J Gen Intern Med.1998;13:435438.
  10. Muntz HG.“Curbside” consultations in gynecologic oncology: a closer look at a common practice.Gynecol Oncol.1999;74:456459.
  11. Leblebicioglu H,Akbulut A,Ulusoy S, et al.Informal consultations in infectious diseases and clinical microbiology practice.Clin Microbiol Infect.2003;9:724726.
  12. Golub RM.Curbside consultations and the viaduct effect.JAMA.1998;280:929930.
  13. Borowsky SJ.What do we really need to know about consultation and referral?J Gen Intern Med.1998;13:497498.
  14. Cartmill M,White BD.Telephone advice for neurosurgical referrals. Who assumes duty of care?Br J Neurosurg.2001;15:453455.
  15. Olick RS,Bergus GR.Malpractice liability for informal consultations.Fam Med.2003;35:476481.
  16. Bergus GR,Randall CS,Sinift SD,Rosenthal DM.Does the structure of clinical questions affect the outcome of curbside consultations with specialty colleagues?Arch Fam Med.2000;9:541547.
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