Mark V. Williams, MD, FACP, FHM

Effective communication between patients and physicians improves a number of important outcomes including patient adherence to treatment,1‐3 quality of the medical history4 and clinical outcomes.1, 5, 6 Recognizing the importance of physician communication skills, the American Board of Medical Specialties, American Council for Graduate Medical Education and The Joint Commission all identify communication as a core competency for physicians.7‐9 For hospitalists and their patients, building a therapeutic partnership is challenged by the lack of a preexisting relationship and potential lack of patient history information, particularly psychosocial history.10 Other factors that complicate the relationships between hospitalists and their patients include acuity of illness, limited time course, and absence of or lack of input from patients' primary physicians.11

As a rapidly increasing percentage of hospitalized patients are cared for by hospitalists,12, 13 communication skills need to be directly assessed and addressed. As of 2006, at least 37% of all Medicare claims for inpatient evaluation and management services by general internists were attributed to hospitalists, and more than half of hospitalized Medicare patients are seen by hospitalists.14 Yet, a search of the MEDLINE database for articles published between 1965 and September 2009, querying hospitalist AND patient AND communication within the article title and abstract, yielded only 2 studies assessing hospitalist‐patient communication. A 1998 study15 compared patient‐reported communication problems with hospitalists versus continuity physicians involved with hospital care, and found that patients whose continuity physicians remained involved with care during the hospitalization were less likely to report communication problems than those patients who were cared for by a hospitalist alone. A 2004 study16 utilized chart documentation to compare the end‐of‐life care and communication provided by continuity physicians and hospitalists. Hospitalists were found to document end‐of‐life care discussions more often than continuity physicians, and were more likely to be present for these meetings, which may suggest improved end‐of‐life care. Neither of these hospitalist‐patient communication studies directly assessed patient perceptions of communication with hospitalists.

We undertook this study to explore patient perceptions of communication with hospitalists using the Communication Assessment Tool (CAT), a psychometrically validated instrument for patient assessment of physician communication skills.17 The CAT was initially field tested in outpatient offices, omitting the inpatient experience. A 2008 study18 successfully adapted the CAT tool for use in assessing emergency department (ED) teams. Given the importance of physician‐patient communication when patients are sickest and most vulnerable in the hospital setting, we sought to establish a baseline assessment of patient perceptions of communication with hospitalists in our group. Second, we compared results of our CAT implementation with published results examining communication in other physician groups.

Methods

Between September 2008 and August 2009 we performed a cross‐sectional study of patients admitted to the hospital medicine service at an urban, academic medical center with 873 beds. This busy service was responsible for 10,225 admissions in 2008. Patients of age 18 years or older and cared for by a hospitalist or teaching team led by a hospitalist were eligible to participate. Exclusion criteria included patient confusion, physiological instability, non‐English speaking, patient unable to communicate, or patient in isolation status. Interviews were conducted in the patient's private room with no other staff present.

Patient perception of communication with hospitalists was measured with the CAT.17 This 15‐item survey is written at a fourth grade reading level, and measures responses along a 5‐point scale (1 = poor, 2 = fair, 3 = good, 4 = very good, 5 = excellent). The CAT was originally field tested with a convenience sample of 38 physicians from various regions within the US, across 6 specialties (Dermatology, Family Medicine, Neurosurgery, Ophthalmology, Orthopedic Surgery, and Physical Medicine & Rehabilitation). Each physician's office recruited 25 patients to complete the CAT through a phone or Internet‐based system.

The 14 core items of the CAT, which focus on communication with the individual physician, were used in this study. The 15th item, The doctor's staff treated me with respect, was dropped as it does not reflect the inpatient setting. Results for each physician are reported as the percentage of excellent responses. This dichotomized scoring is consistent with the development study, where analysis with Andrich's rating scale model19, 20 indicated that excellent scores correspond to a yes response while poor through very good scores correspond to a no response. This method of reporting scores as a percentage of excellent responses was found to be more useful for summarizing physician scores than reporting mean scores, which are highly skewed towards positive performance.17

Interviews were conducted by trained research assistants during hospitalists' weekday shifts. Hospitalists were not told which patients would be recruited, but were aware that patients on the service were being interviewed to assess communication. A list of patient names, room numbers, dates of admission, and assigned hospitalists was obtained daily from the electronic medical record system. Patients were approached on the second or third day of the hospital admission, and only if they had been assigned to the same hospitalist for at least 2 consecutive days. After explaining the study to patients and receiving verbal consent, researchers verified that the patient recognized the hospitalist, providing a photo if necessary. Patients who were not confident of their hospitalist's identity were excluded.

The 14 core items of the CAT survey were read aloud to the patient, who was provided with a copy of the instrument's scale and asked to respond with a number or word description (1 = poor to 5 = excellent). Patients were allowed to skip any questions they did not wish to answer. At the conclusion of the survey, patients were asked if they had any further comments to add. Patient demographics as well as hospitalist service (general or teaching) and unit were recorded. Most interviews were completed in less than 5 minutes. Based on the recommendations of the original development and validation of the CAT,17 we collected 20 patient surveys for each hospitalist. For CAT items that the patients skipped, we did not impute values; rather the percentage of excellent responses was calculated based on the number of questions the patient answered. To examine basic psychometric characteristics, we assessed scale reliability and performed a factor analysis using the principal components method of extraction with Varimax rotation.

This project was determined exempt by the Northwestern University Institutional Review Board.

Results

We identified 1,137 patients as potentially eligible for the study. Figure 1 shows a flowchart of patient exclusion. Of note, 107 patients consenting to participate (13% overall) were unable to identify their hospitalist by name or photo. More specifically, 70 teaching service patients (25% of 275 eligible patients) were unable to identify their hospitalist, compared to 37 patients on general service (7% of 553 eligible patients); (z = 7.58, P < 0.001). Another 21 (3%) declined to participate because they had not talked enough with their doctor to render an assessment.

Figure 1

We analyzed 700 patient surveys (20 patients for each of 35 hospitalists; 62% of patients identified). Patient and hospitalist characteristics are presented in Table 1. The proportion of excellent ratings for each hospitalist ranged from 38.5% to 73.5% with an average of 59.1% excellent (standard deviation [SD] = 9.5). See Figure 2 for the distribution of hospitalist scores. For the group as a whole, highest ratings on individual CAT items were for treating the patient with respect (66% excellent), letting the patient talk without interruptions (66%), and talking in terms the patient can understand (64%). Lowest ratings were for involving the patient in decisions as much as he or she wanted (53%), encouraging the patient to ask questions (53%), and greeting the patient in a way that made him or her feel comfortable (55%). Table 2 contains a full ranking of individual item scores.

Figure 2

Overall scale reliability proved to be high (Cronbach's alpha = 0.97) in this sample. The factor analysis showed that scores for each of the 14 items load onto 1 factor. These results are consistent with the high reliability and single‐factor loading found in Makoul's original scale reliability and validity testing.17

The ad hoc comments made by patients at the conclusion of the CAT survey were categorized as positive or negative. Although many positive comments were made, they tended to be general in nature (eg, She is a great doctor). Negative comments were more explicit. A total of 110 patients (16%) made specific negative comments, which fell into 7 general domains: lack of information (35 comments), not enough time spent with the patient (27 comments), poor listening to the patient (24 comments), ineffective care delivery (7 comments), issues of care, concern, and respect (6 comments), ineffective communication with other staff (5 comments), and unclear role of physician (3 comments). Three patient comments were not related to these domains.

Patient age, race or gender did not correlate with CAT results. Hospitalist factors of age, race, gender, years of experience also were not associated with differences in ratings. However, race concordance between the patient and hospitalist was associated with improved CAT ratings. Patients of the same race as their hospitalist rated the hospitalist's communication significantly higher (M = 64.9%, SD = 39.1) than did patients who were of a different race than their hospitalist (M = 57.3%, SD = 40.3), P < 0.05. Gender concordance was not associated with improved CAT ratings. No score differences were found between patients cared for by a hospitalist on teaching service and direct care, and there were no differences between nursing units.

Discussion

To the best of our knowledge, this is the first study to explicitly measure patient perceptions of communication with hospitalists. The results yielded a wide distribution of scores for physicians within a single, large hospital medicine group. Comparing their own scores to those of peers may allow low‐scoring hospitalists to grasp the potential for improving their communication with patients. Our reliability testing matched the results of the original development study,17 indicating very high overall scale reliability. This suggests that the CAT could be streamlined by dropping some of the survey items. However we agree with Makoul et al.17 that it is best to keep the full set as it provides specific information for physicians without placing undue burden on patients (ie, the CAT takes only 1‐2 min to complete). Individual item scores for each of the 14 CAT items highlight specific communication tasks where intervention may be targeted for individual hospitalists and the group as a whole. It may be feasible to utilize CAT results as an individual report card for physicians. While program leaders should be aware that implementation of the CAT requires standardized data collection, it may be possible to build this into existing structures such as the discharge process.

Interestingly, many patients could not recognize the hospitalist caring for them by name or photo. More than 1 in 10 patients (107 of 828; 13%) were unable to identify their hospitalist. This was more than 3 times as common on the teaching service, where the hospitalist is accompanied by house staff and the intern or resident is the primary physician for patient contact, compared to the service on which hospitalists directly take care of patients without residents. It is also troubling that another 3% of patients (21 of 828) stated they hadn't talked enough with their hospitalist to answer basic communication questions, when approached 2 or 3 days into the relationship. It may be telling that Greeted me in a way that made me feel comfortable was one of the lowest‐rated survey items. Hospitalists should recognize that patients, in addition to facing their own physical and emotional stressors, see many hospital staff members throughout the day; all of whom may be strangers to them. Thus it becomes vital for hospitalists to not only establish an initial rapport with the patient, but to reintroduce themselves each time they enter the room.

An examination of the ad hoc negative comments made by survey respondents reinforces and extends findings related to the CAT items, particularly about those areas of communication valued by patients. The majority of comments fell into categories of failing to give enough information (eg, Sometimes I was left confused when the doctor was ready to leave), not spending enough time with the patient (eg, He was just in and out), and not listening to the patient's own ideas (eg, When giving my history, she cut me off at some points when I had more to say). The information and time categories may directly relate to scores on the CAT items Gave me as much information as I wanted and Spent the right amount of time with me, which are among the lowest‐scoring items. Listening to the patient may reflect broader issues of considering the patient's own experience, questions, concerns and goals.

In this study, patient‐physician race concordance was associated with CAT ratings. Patients who were of the same race as their hospitalist rated the hospitalist higher compared to patients who were of a different race than their hospitalist. This effect is consistent with previous research describing higher patient ratings of communication and care when the patient and physician are of the same race or ethnicity.21

A number of factors limit interpretation of the results of this study. The data were collected at a single site, thus limiting generalizability to other hospitalist practice environments. We used a retrospective, patient assessment of hospitalist communication which may have inherent biases different from a study using direct researcher observation or recording of patient‐hospitalist interactions to assess communication. This methodology allowed us to examine the patient's own perceptions and expectations of communication, but certainly leaves room for selection bias in recruitment and recall bias. Patients were interviewed on the second or third day of their admission. This controlled the length of exposure to the hospitalist, but the course of treatment might vary considerably; at the time of interview, some patients may not yet have had a clear diagnosis and plan while others may have been ready for discharge. Future work should examine how stage of evaluation and management might affect patients' perception of communication with hospitalists. Severity of condition is another factor that may affect patients' ratings, and was not examined in this study.

When compared to physicians from the CAT development study's field test, this study sample of hospitalists scored much lower, 59.1% excellent vs. 76.3% (P < 0.001). A number of factors may account for some of these differences. The majority of patients in the original field test had multiple interactions with their physician, and rated their health status as good or very good. In contrast, hospitalized patients usually lack previous exposure to the hospitalist, and likely have poorer health status. Also, physicians in the original field test volunteered to participate, and patients completed the CAT survey through the Internet or phone response system, rather than through a face‐to‐face interview by trained research assistants. Another key difference is that field‐test patients answered the CAT within 1 day of their outpatient visit, while in this study patients were interviewed in the midst of their hospital admission and prior to completion of their hospital course. Finally, patients commonly choose their outpatient physician and can select someone else if dissatisfied with their communication skills, while hospitalized patients are assigned hospitalists based on availability. Thus, given this potential selection bias, outpatients could be expected to rate their personal physician higher.

Another possibility is that hospitalists are on average less skilled in patient communication than outpatient physicians. Given the transient nature of the inpatient relationship, hospitalists may not value developing rapport with patients, and may not make this a goal of patient care or seek extensive training in communication skills. In future research, evaluating hospitalists' training in and attitudes towards patient communication could be paired with communication assessment results.

Although it is beyond the scope of this study to assess precisely how these environmental and survey implementation factors may affect CAT summary scores, their importance is evident. Another hospital‐based implementation of the CAT tool, an evaluation of ED teams,18 utilized face‐to‐face interviews with trained research assistants. The study yielded results similar to our findings: the average percent excellent score for ED teams was 62.3%, vs. 58.2% percent excellent for our hospitalist group. Taken together, these study comparisons between the original field‐test, our hospitalist implementation, and the ED team implementation support the argument that factors of setting (inpatient vs. outpatient), mode of survey administration (face‐to‐face interview vs. self‐administration through phone or Internet), and shorter duration or course of patient‐physician interaction may be important considerations when implementing the CAT tool to assess physician communication skills, or attempting to set standards of minimally acceptable or desired scoring.

More work must be done to establish norms and/or minimally acceptable scores for hospitalists. Numerous factors of specialty, practice setting, survey implementation, patient variables, and even the expertise of who is setting the communication standards22 may strongly influence comparisons between physician groups, even within a single institution. Organizations seeking to establish norms or minimally acceptable scores for physician‐patient communication should be aware of these factors. As the original development study points out, standard‐setting studies could establish specialty‐specific and country‐specific norms as well as norms or standards for level‐of‐training (eg, medical students versus attending physicians).17

Conclusion

The previously validated CAT instrument appears to have reliable test characteristics and can be used to gauge patient perceptions of hospitalist communication skills. Comparative scores between physicians of different specialties and settings should be interpreted cautiously as there may be confounding variables. Within our single institution, comparative scores between hospitalists, along with an examination of the hospitalist's individual item scores, may offer useful feedback for efforts aimed at enhancing communication. Many hospitalists in this study may benefit from targeted training to improve patient communication skills, particularly in the areas of encouraging questions and involving patients in decision making. Future qualitative research in the context of hospital medicine could identify specific communication techniques used by highly‐rated physicians, with the goal of developing tools for targeted improvement and determining impact on outcomes.

Effective communication between patients and physicians improves a number of important outcomes including patient adherence to treatment,1‐3 quality of the medical history4 and clinical outcomes.1, 5, 6 Recognizing the importance of physician communication skills, the American Board of Medical Specialties, American Council for Graduate Medical Education and The Joint Commission all identify communication as a core competency for physicians.7‐9 For hospitalists and their patients, building a therapeutic partnership is challenged by the lack of a preexisting relationship and potential lack of patient history information, particularly psychosocial history.10 Other factors that complicate the relationships between hospitalists and their patients include acuity of illness, limited time course, and absence of or lack of input from patients' primary physicians.11

As a rapidly increasing percentage of hospitalized patients are cared for by hospitalists,12, 13 communication skills need to be directly assessed and addressed. As of 2006, at least 37% of all Medicare claims for inpatient evaluation and management services by general internists were attributed to hospitalists, and more than half of hospitalized Medicare patients are seen by hospitalists.14 Yet, a search of the MEDLINE database for articles published between 1965 and September 2009, querying hospitalist AND patient AND communication within the article title and abstract, yielded only 2 studies assessing hospitalist‐patient communication. A 1998 study15 compared patient‐reported communication problems with hospitalists versus continuity physicians involved with hospital care, and found that patients whose continuity physicians remained involved with care during the hospitalization were less likely to report communication problems than those patients who were cared for by a hospitalist alone. A 2004 study16 utilized chart documentation to compare the end‐of‐life care and communication provided by continuity physicians and hospitalists. Hospitalists were found to document end‐of‐life care discussions more often than continuity physicians, and were more likely to be present for these meetings, which may suggest improved end‐of‐life care. Neither of these hospitalist‐patient communication studies directly assessed patient perceptions of communication with hospitalists.

We undertook this study to explore patient perceptions of communication with hospitalists using the Communication Assessment Tool (CAT), a psychometrically validated instrument for patient assessment of physician communication skills.17 The CAT was initially field tested in outpatient offices, omitting the inpatient experience. A 2008 study18 successfully adapted the CAT tool for use in assessing emergency department (ED) teams. Given the importance of physician‐patient communication when patients are sickest and most vulnerable in the hospital setting, we sought to establish a baseline assessment of patient perceptions of communication with hospitalists in our group. Second, we compared results of our CAT implementation with published results examining communication in other physician groups.

Methods

Between September 2008 and August 2009 we performed a cross‐sectional study of patients admitted to the hospital medicine service at an urban, academic medical center with 873 beds. This busy service was responsible for 10,225 admissions in 2008. Patients of age 18 years or older and cared for by a hospitalist or teaching team led by a hospitalist were eligible to participate. Exclusion criteria included patient confusion, physiological instability, non‐English speaking, patient unable to communicate, or patient in isolation status. Interviews were conducted in the patient's private room with no other staff present.

Patient perception of communication with hospitalists was measured with the CAT.17 This 15‐item survey is written at a fourth grade reading level, and measures responses along a 5‐point scale (1 = poor, 2 = fair, 3 = good, 4 = very good, 5 = excellent). The CAT was originally field tested with a convenience sample of 38 physicians from various regions within the US, across 6 specialties (Dermatology, Family Medicine, Neurosurgery, Ophthalmology, Orthopedic Surgery, and Physical Medicine & Rehabilitation). Each physician's office recruited 25 patients to complete the CAT through a phone or Internet‐based system.

The 14 core items of the CAT, which focus on communication with the individual physician, were used in this study. The 15th item, The doctor's staff treated me with respect, was dropped as it does not reflect the inpatient setting. Results for each physician are reported as the percentage of excellent responses. This dichotomized scoring is consistent with the development study, where analysis with Andrich's rating scale model19, 20 indicated that excellent scores correspond to a yes response while poor through very good scores correspond to a no response. This method of reporting scores as a percentage of excellent responses was found to be more useful for summarizing physician scores than reporting mean scores, which are highly skewed towards positive performance.17

Interviews were conducted by trained research assistants during hospitalists' weekday shifts. Hospitalists were not told which patients would be recruited, but were aware that patients on the service were being interviewed to assess communication. A list of patient names, room numbers, dates of admission, and assigned hospitalists was obtained daily from the electronic medical record system. Patients were approached on the second or third day of the hospital admission, and only if they had been assigned to the same hospitalist for at least 2 consecutive days. After explaining the study to patients and receiving verbal consent, researchers verified that the patient recognized the hospitalist, providing a photo if necessary. Patients who were not confident of their hospitalist's identity were excluded.

The 14 core items of the CAT survey were read aloud to the patient, who was provided with a copy of the instrument's scale and asked to respond with a number or word description (1 = poor to 5 = excellent). Patients were allowed to skip any questions they did not wish to answer. At the conclusion of the survey, patients were asked if they had any further comments to add. Patient demographics as well as hospitalist service (general or teaching) and unit were recorded. Most interviews were completed in less than 5 minutes. Based on the recommendations of the original development and validation of the CAT,17 we collected 20 patient surveys for each hospitalist. For CAT items that the patients skipped, we did not impute values; rather the percentage of excellent responses was calculated based on the number of questions the patient answered. To examine basic psychometric characteristics, we assessed scale reliability and performed a factor analysis using the principal components method of extraction with Varimax rotation.

This project was determined exempt by the Northwestern University Institutional Review Board.

Results

We identified 1,137 patients as potentially eligible for the study. Figure 1 shows a flowchart of patient exclusion. Of note, 107 patients consenting to participate (13% overall) were unable to identify their hospitalist by name or photo. More specifically, 70 teaching service patients (25% of 275 eligible patients) were unable to identify their hospitalist, compared to 37 patients on general service (7% of 553 eligible patients); (z = 7.58, P < 0.001). Another 21 (3%) declined to participate because they had not talked enough with their doctor to render an assessment.

Figure 1

We analyzed 700 patient surveys (20 patients for each of 35 hospitalists; 62% of patients identified). Patient and hospitalist characteristics are presented in Table 1. The proportion of excellent ratings for each hospitalist ranged from 38.5% to 73.5% with an average of 59.1% excellent (standard deviation [SD] = 9.5). See Figure 2 for the distribution of hospitalist scores. For the group as a whole, highest ratings on individual CAT items were for treating the patient with respect (66% excellent), letting the patient talk without interruptions (66%), and talking in terms the patient can understand (64%). Lowest ratings were for involving the patient in decisions as much as he or she wanted (53%), encouraging the patient to ask questions (53%), and greeting the patient in a way that made him or her feel comfortable (55%). Table 2 contains a full ranking of individual item scores.

Figure 2

Overall scale reliability proved to be high (Cronbach's alpha = 0.97) in this sample. The factor analysis showed that scores for each of the 14 items load onto 1 factor. These results are consistent with the high reliability and single‐factor loading found in Makoul's original scale reliability and validity testing.17

The ad hoc comments made by patients at the conclusion of the CAT survey were categorized as positive or negative. Although many positive comments were made, they tended to be general in nature (eg, She is a great doctor). Negative comments were more explicit. A total of 110 patients (16%) made specific negative comments, which fell into 7 general domains: lack of information (35 comments), not enough time spent with the patient (27 comments), poor listening to the patient (24 comments), ineffective care delivery (7 comments), issues of care, concern, and respect (6 comments), ineffective communication with other staff (5 comments), and unclear role of physician (3 comments). Three patient comments were not related to these domains.

Patient age, race or gender did not correlate with CAT results. Hospitalist factors of age, race, gender, years of experience also were not associated with differences in ratings. However, race concordance between the patient and hospitalist was associated with improved CAT ratings. Patients of the same race as their hospitalist rated the hospitalist's communication significantly higher (M = 64.9%, SD = 39.1) than did patients who were of a different race than their hospitalist (M = 57.3%, SD = 40.3), P < 0.05. Gender concordance was not associated with improved CAT ratings. No score differences were found between patients cared for by a hospitalist on teaching service and direct care, and there were no differences between nursing units.

Discussion

To the best of our knowledge, this is the first study to explicitly measure patient perceptions of communication with hospitalists. The results yielded a wide distribution of scores for physicians within a single, large hospital medicine group. Comparing their own scores to those of peers may allow low‐scoring hospitalists to grasp the potential for improving their communication with patients. Our reliability testing matched the results of the original development study,17 indicating very high overall scale reliability. This suggests that the CAT could be streamlined by dropping some of the survey items. However we agree with Makoul et al.17 that it is best to keep the full set as it provides specific information for physicians without placing undue burden on patients (ie, the CAT takes only 1‐2 min to complete). Individual item scores for each of the 14 CAT items highlight specific communication tasks where intervention may be targeted for individual hospitalists and the group as a whole. It may be feasible to utilize CAT results as an individual report card for physicians. While program leaders should be aware that implementation of the CAT requires standardized data collection, it may be possible to build this into existing structures such as the discharge process.

Interestingly, many patients could not recognize the hospitalist caring for them by name or photo. More than 1 in 10 patients (107 of 828; 13%) were unable to identify their hospitalist. This was more than 3 times as common on the teaching service, where the hospitalist is accompanied by house staff and the intern or resident is the primary physician for patient contact, compared to the service on which hospitalists directly take care of patients without residents. It is also troubling that another 3% of patients (21 of 828) stated they hadn't talked enough with their hospitalist to answer basic communication questions, when approached 2 or 3 days into the relationship. It may be telling that Greeted me in a way that made me feel comfortable was one of the lowest‐rated survey items. Hospitalists should recognize that patients, in addition to facing their own physical and emotional stressors, see many hospital staff members throughout the day; all of whom may be strangers to them. Thus it becomes vital for hospitalists to not only establish an initial rapport with the patient, but to reintroduce themselves each time they enter the room.

An examination of the ad hoc negative comments made by survey respondents reinforces and extends findings related to the CAT items, particularly about those areas of communication valued by patients. The majority of comments fell into categories of failing to give enough information (eg, Sometimes I was left confused when the doctor was ready to leave), not spending enough time with the patient (eg, He was just in and out), and not listening to the patient's own ideas (eg, When giving my history, she cut me off at some points when I had more to say). The information and time categories may directly relate to scores on the CAT items Gave me as much information as I wanted and Spent the right amount of time with me, which are among the lowest‐scoring items. Listening to the patient may reflect broader issues of considering the patient's own experience, questions, concerns and goals.

In this study, patient‐physician race concordance was associated with CAT ratings. Patients who were of the same race as their hospitalist rated the hospitalist higher compared to patients who were of a different race than their hospitalist. This effect is consistent with previous research describing higher patient ratings of communication and care when the patient and physician are of the same race or ethnicity.21

A number of factors limit interpretation of the results of this study. The data were collected at a single site, thus limiting generalizability to other hospitalist practice environments. We used a retrospective, patient assessment of hospitalist communication which may have inherent biases different from a study using direct researcher observation or recording of patient‐hospitalist interactions to assess communication. This methodology allowed us to examine the patient's own perceptions and expectations of communication, but certainly leaves room for selection bias in recruitment and recall bias. Patients were interviewed on the second or third day of their admission. This controlled the length of exposure to the hospitalist, but the course of treatment might vary considerably; at the time of interview, some patients may not yet have had a clear diagnosis and plan while others may have been ready for discharge. Future work should examine how stage of evaluation and management might affect patients' perception of communication with hospitalists. Severity of condition is another factor that may affect patients' ratings, and was not examined in this study.

When compared to physicians from the CAT development study's field test, this study sample of hospitalists scored much lower, 59.1% excellent vs. 76.3% (P < 0.001). A number of factors may account for some of these differences. The majority of patients in the original field test had multiple interactions with their physician, and rated their health status as good or very good. In contrast, hospitalized patients usually lack previous exposure to the hospitalist, and likely have poorer health status. Also, physicians in the original field test volunteered to participate, and patients completed the CAT survey through the Internet or phone response system, rather than through a face‐to‐face interview by trained research assistants. Another key difference is that field‐test patients answered the CAT within 1 day of their outpatient visit, while in this study patients were interviewed in the midst of their hospital admission and prior to completion of their hospital course. Finally, patients commonly choose their outpatient physician and can select someone else if dissatisfied with their communication skills, while hospitalized patients are assigned hospitalists based on availability. Thus, given this potential selection bias, outpatients could be expected to rate their personal physician higher.

Another possibility is that hospitalists are on average less skilled in patient communication than outpatient physicians. Given the transient nature of the inpatient relationship, hospitalists may not value developing rapport with patients, and may not make this a goal of patient care or seek extensive training in communication skills. In future research, evaluating hospitalists' training in and attitudes towards patient communication could be paired with communication assessment results.

Although it is beyond the scope of this study to assess precisely how these environmental and survey implementation factors may affect CAT summary scores, their importance is evident. Another hospital‐based implementation of the CAT tool, an evaluation of ED teams,18 utilized face‐to‐face interviews with trained research assistants. The study yielded results similar to our findings: the average percent excellent score for ED teams was 62.3%, vs. 58.2% percent excellent for our hospitalist group. Taken together, these study comparisons between the original field‐test, our hospitalist implementation, and the ED team implementation support the argument that factors of setting (inpatient vs. outpatient), mode of survey administration (face‐to‐face interview vs. self‐administration through phone or Internet), and shorter duration or course of patient‐physician interaction may be important considerations when implementing the CAT tool to assess physician communication skills, or attempting to set standards of minimally acceptable or desired scoring.

More work must be done to establish norms and/or minimally acceptable scores for hospitalists. Numerous factors of specialty, practice setting, survey implementation, patient variables, and even the expertise of who is setting the communication standards22 may strongly influence comparisons between physician groups, even within a single institution. Organizations seeking to establish norms or minimally acceptable scores for physician‐patient communication should be aware of these factors. As the original development study points out, standard‐setting studies could establish specialty‐specific and country‐specific norms as well as norms or standards for level‐of‐training (eg, medical students versus attending physicians).17

Conclusion

The previously validated CAT instrument appears to have reliable test characteristics and can be used to gauge patient perceptions of hospitalist communication skills. Comparative scores between physicians of different specialties and settings should be interpreted cautiously as there may be confounding variables. Within our single institution, comparative scores between hospitalists, along with an examination of the hospitalist's individual item scores, may offer useful feedback for efforts aimed at enhancing communication. Many hospitalists in this study may benefit from targeted training to improve patient communication skills, particularly in the areas of encouraging questions and involving patients in decision making. Future qualitative research in the context of hospital medicine could identify specific communication techniques used by highly‐rated physicians, with the goal of developing tools for targeted improvement and determining impact on outcomes.

Effective communication between patients and physicians improves a number of important outcomes including patient adherence to treatment,1‐3 quality of the medical history4 and clinical outcomes.1, 5, 6 Recognizing the importance of physician communication skills, the American Board of Medical Specialties, American Council for Graduate Medical Education and The Joint Commission all identify communication as a core competency for physicians.7‐9 For hospitalists and their patients, building a therapeutic partnership is challenged by the lack of a preexisting relationship and potential lack of patient history information, particularly psychosocial history.10 Other factors that complicate the relationships between hospitalists and their patients include acuity of illness, limited time course, and absence of or lack of input from patients' primary physicians.11

As a rapidly increasing percentage of hospitalized patients are cared for by hospitalists,12, 13 communication skills need to be directly assessed and addressed. As of 2006, at least 37% of all Medicare claims for inpatient evaluation and management services by general internists were attributed to hospitalists, and more than half of hospitalized Medicare patients are seen by hospitalists.14 Yet, a search of the MEDLINE database for articles published between 1965 and September 2009, querying hospitalist AND patient AND communication within the article title and abstract, yielded only 2 studies assessing hospitalist‐patient communication. A 1998 study15 compared patient‐reported communication problems with hospitalists versus continuity physicians involved with hospital care, and found that patients whose continuity physicians remained involved with care during the hospitalization were less likely to report communication problems than those patients who were cared for by a hospitalist alone. A 2004 study16 utilized chart documentation to compare the end‐of‐life care and communication provided by continuity physicians and hospitalists. Hospitalists were found to document end‐of‐life care discussions more often than continuity physicians, and were more likely to be present for these meetings, which may suggest improved end‐of‐life care. Neither of these hospitalist‐patient communication studies directly assessed patient perceptions of communication with hospitalists.

We undertook this study to explore patient perceptions of communication with hospitalists using the Communication Assessment Tool (CAT), a psychometrically validated instrument for patient assessment of physician communication skills.17 The CAT was initially field tested in outpatient offices, omitting the inpatient experience. A 2008 study18 successfully adapted the CAT tool for use in assessing emergency department (ED) teams. Given the importance of physician‐patient communication when patients are sickest and most vulnerable in the hospital setting, we sought to establish a baseline assessment of patient perceptions of communication with hospitalists in our group. Second, we compared results of our CAT implementation with published results examining communication in other physician groups.

Methods

Between September 2008 and August 2009 we performed a cross‐sectional study of patients admitted to the hospital medicine service at an urban, academic medical center with 873 beds. This busy service was responsible for 10,225 admissions in 2008. Patients of age 18 years or older and cared for by a hospitalist or teaching team led by a hospitalist were eligible to participate. Exclusion criteria included patient confusion, physiological instability, non‐English speaking, patient unable to communicate, or patient in isolation status. Interviews were conducted in the patient's private room with no other staff present.

Patient perception of communication with hospitalists was measured with the CAT.17 This 15‐item survey is written at a fourth grade reading level, and measures responses along a 5‐point scale (1 = poor, 2 = fair, 3 = good, 4 = very good, 5 = excellent). The CAT was originally field tested with a convenience sample of 38 physicians from various regions within the US, across 6 specialties (Dermatology, Family Medicine, Neurosurgery, Ophthalmology, Orthopedic Surgery, and Physical Medicine & Rehabilitation). Each physician's office recruited 25 patients to complete the CAT through a phone or Internet‐based system.

The 14 core items of the CAT, which focus on communication with the individual physician, were used in this study. The 15th item, The doctor's staff treated me with respect, was dropped as it does not reflect the inpatient setting. Results for each physician are reported as the percentage of excellent responses. This dichotomized scoring is consistent with the development study, where analysis with Andrich's rating scale model19, 20 indicated that excellent scores correspond to a yes response while poor through very good scores correspond to a no response. This method of reporting scores as a percentage of excellent responses was found to be more useful for summarizing physician scores than reporting mean scores, which are highly skewed towards positive performance.17

Interviews were conducted by trained research assistants during hospitalists' weekday shifts. Hospitalists were not told which patients would be recruited, but were aware that patients on the service were being interviewed to assess communication. A list of patient names, room numbers, dates of admission, and assigned hospitalists was obtained daily from the electronic medical record system. Patients were approached on the second or third day of the hospital admission, and only if they had been assigned to the same hospitalist for at least 2 consecutive days. After explaining the study to patients and receiving verbal consent, researchers verified that the patient recognized the hospitalist, providing a photo if necessary. Patients who were not confident of their hospitalist's identity were excluded.

The 14 core items of the CAT survey were read aloud to the patient, who was provided with a copy of the instrument's scale and asked to respond with a number or word description (1 = poor to 5 = excellent). Patients were allowed to skip any questions they did not wish to answer. At the conclusion of the survey, patients were asked if they had any further comments to add. Patient demographics as well as hospitalist service (general or teaching) and unit were recorded. Most interviews were completed in less than 5 minutes. Based on the recommendations of the original development and validation of the CAT,17 we collected 20 patient surveys for each hospitalist. For CAT items that the patients skipped, we did not impute values; rather the percentage of excellent responses was calculated based on the number of questions the patient answered. To examine basic psychometric characteristics, we assessed scale reliability and performed a factor analysis using the principal components method of extraction with Varimax rotation.

This project was determined exempt by the Northwestern University Institutional Review Board.

Results

We identified 1,137 patients as potentially eligible for the study. Figure 1 shows a flowchart of patient exclusion. Of note, 107 patients consenting to participate (13% overall) were unable to identify their hospitalist by name or photo. More specifically, 70 teaching service patients (25% of 275 eligible patients) were unable to identify their hospitalist, compared to 37 patients on general service (7% of 553 eligible patients); (z = 7.58, P < 0.001). Another 21 (3%) declined to participate because they had not talked enough with their doctor to render an assessment.

Figure 1

We analyzed 700 patient surveys (20 patients for each of 35 hospitalists; 62% of patients identified). Patient and hospitalist characteristics are presented in Table 1. The proportion of excellent ratings for each hospitalist ranged from 38.5% to 73.5% with an average of 59.1% excellent (standard deviation [SD] = 9.5). See Figure 2 for the distribution of hospitalist scores. For the group as a whole, highest ratings on individual CAT items were for treating the patient with respect (66% excellent), letting the patient talk without interruptions (66%), and talking in terms the patient can understand (64%). Lowest ratings were for involving the patient in decisions as much as he or she wanted (53%), encouraging the patient to ask questions (53%), and greeting the patient in a way that made him or her feel comfortable (55%). Table 2 contains a full ranking of individual item scores.

Figure 2

Overall scale reliability proved to be high (Cronbach's alpha = 0.97) in this sample. The factor analysis showed that scores for each of the 14 items load onto 1 factor. These results are consistent with the high reliability and single‐factor loading found in Makoul's original scale reliability and validity testing.17

The ad hoc comments made by patients at the conclusion of the CAT survey were categorized as positive or negative. Although many positive comments were made, they tended to be general in nature (eg, She is a great doctor). Negative comments were more explicit. A total of 110 patients (16%) made specific negative comments, which fell into 7 general domains: lack of information (35 comments), not enough time spent with the patient (27 comments), poor listening to the patient (24 comments), ineffective care delivery (7 comments), issues of care, concern, and respect (6 comments), ineffective communication with other staff (5 comments), and unclear role of physician (3 comments). Three patient comments were not related to these domains.

Patient age, race or gender did not correlate with CAT results. Hospitalist factors of age, race, gender, years of experience also were not associated with differences in ratings. However, race concordance between the patient and hospitalist was associated with improved CAT ratings. Patients of the same race as their hospitalist rated the hospitalist's communication significantly higher (M = 64.9%, SD = 39.1) than did patients who were of a different race than their hospitalist (M = 57.3%, SD = 40.3), P < 0.05. Gender concordance was not associated with improved CAT ratings. No score differences were found between patients cared for by a hospitalist on teaching service and direct care, and there were no differences between nursing units.

Discussion

To the best of our knowledge, this is the first study to explicitly measure patient perceptions of communication with hospitalists. The results yielded a wide distribution of scores for physicians within a single, large hospital medicine group. Comparing their own scores to those of peers may allow low‐scoring hospitalists to grasp the potential for improving their communication with patients. Our reliability testing matched the results of the original development study,17 indicating very high overall scale reliability. This suggests that the CAT could be streamlined by dropping some of the survey items. However we agree with Makoul et al.17 that it is best to keep the full set as it provides specific information for physicians without placing undue burden on patients (ie, the CAT takes only 1‐2 min to complete). Individual item scores for each of the 14 CAT items highlight specific communication tasks where intervention may be targeted for individual hospitalists and the group as a whole. It may be feasible to utilize CAT results as an individual report card for physicians. While program leaders should be aware that implementation of the CAT requires standardized data collection, it may be possible to build this into existing structures such as the discharge process.

Interestingly, many patients could not recognize the hospitalist caring for them by name or photo. More than 1 in 10 patients (107 of 828; 13%) were unable to identify their hospitalist. This was more than 3 times as common on the teaching service, where the hospitalist is accompanied by house staff and the intern or resident is the primary physician for patient contact, compared to the service on which hospitalists directly take care of patients without residents. It is also troubling that another 3% of patients (21 of 828) stated they hadn't talked enough with their hospitalist to answer basic communication questions, when approached 2 or 3 days into the relationship. It may be telling that Greeted me in a way that made me feel comfortable was one of the lowest‐rated survey items. Hospitalists should recognize that patients, in addition to facing their own physical and emotional stressors, see many hospital staff members throughout the day; all of whom may be strangers to them. Thus it becomes vital for hospitalists to not only establish an initial rapport with the patient, but to reintroduce themselves each time they enter the room.

An examination of the ad hoc negative comments made by survey respondents reinforces and extends findings related to the CAT items, particularly about those areas of communication valued by patients. The majority of comments fell into categories of failing to give enough information (eg, Sometimes I was left confused when the doctor was ready to leave), not spending enough time with the patient (eg, He was just in and out), and not listening to the patient's own ideas (eg, When giving my history, she cut me off at some points when I had more to say). The information and time categories may directly relate to scores on the CAT items Gave me as much information as I wanted and Spent the right amount of time with me, which are among the lowest‐scoring items. Listening to the patient may reflect broader issues of considering the patient's own experience, questions, concerns and goals.

In this study, patient‐physician race concordance was associated with CAT ratings. Patients who were of the same race as their hospitalist rated the hospitalist higher compared to patients who were of a different race than their hospitalist. This effect is consistent with previous research describing higher patient ratings of communication and care when the patient and physician are of the same race or ethnicity.21

A number of factors limit interpretation of the results of this study. The data were collected at a single site, thus limiting generalizability to other hospitalist practice environments. We used a retrospective, patient assessment of hospitalist communication which may have inherent biases different from a study using direct researcher observation or recording of patient‐hospitalist interactions to assess communication. This methodology allowed us to examine the patient's own perceptions and expectations of communication, but certainly leaves room for selection bias in recruitment and recall bias. Patients were interviewed on the second or third day of their admission. This controlled the length of exposure to the hospitalist, but the course of treatment might vary considerably; at the time of interview, some patients may not yet have had a clear diagnosis and plan while others may have been ready for discharge. Future work should examine how stage of evaluation and management might affect patients' perception of communication with hospitalists. Severity of condition is another factor that may affect patients' ratings, and was not examined in this study.

When compared to physicians from the CAT development study's field test, this study sample of hospitalists scored much lower, 59.1% excellent vs. 76.3% (P < 0.001). A number of factors may account for some of these differences. The majority of patients in the original field test had multiple interactions with their physician, and rated their health status as good or very good. In contrast, hospitalized patients usually lack previous exposure to the hospitalist, and likely have poorer health status. Also, physicians in the original field test volunteered to participate, and patients completed the CAT survey through the Internet or phone response system, rather than through a face‐to‐face interview by trained research assistants. Another key difference is that field‐test patients answered the CAT within 1 day of their outpatient visit, while in this study patients were interviewed in the midst of their hospital admission and prior to completion of their hospital course. Finally, patients commonly choose their outpatient physician and can select someone else if dissatisfied with their communication skills, while hospitalized patients are assigned hospitalists based on availability. Thus, given this potential selection bias, outpatients could be expected to rate their personal physician higher.

Another possibility is that hospitalists are on average less skilled in patient communication than outpatient physicians. Given the transient nature of the inpatient relationship, hospitalists may not value developing rapport with patients, and may not make this a goal of patient care or seek extensive training in communication skills. In future research, evaluating hospitalists' training in and attitudes towards patient communication could be paired with communication assessment results.

Although it is beyond the scope of this study to assess precisely how these environmental and survey implementation factors may affect CAT summary scores, their importance is evident. Another hospital‐based implementation of the CAT tool, an evaluation of ED teams,18 utilized face‐to‐face interviews with trained research assistants. The study yielded results similar to our findings: the average percent excellent score for ED teams was 62.3%, vs. 58.2% percent excellent for our hospitalist group. Taken together, these study comparisons between the original field‐test, our hospitalist implementation, and the ED team implementation support the argument that factors of setting (inpatient vs. outpatient), mode of survey administration (face‐to‐face interview vs. self‐administration through phone or Internet), and shorter duration or course of patient‐physician interaction may be important considerations when implementing the CAT tool to assess physician communication skills, or attempting to set standards of minimally acceptable or desired scoring.

More work must be done to establish norms and/or minimally acceptable scores for hospitalists. Numerous factors of specialty, practice setting, survey implementation, patient variables, and even the expertise of who is setting the communication standards22 may strongly influence comparisons between physician groups, even within a single institution. Organizations seeking to establish norms or minimally acceptable scores for physician‐patient communication should be aware of these factors. As the original development study points out, standard‐setting studies could establish specialty‐specific and country‐specific norms as well as norms or standards for level‐of‐training (eg, medical students versus attending physicians).17

Conclusion

The previously validated CAT instrument appears to have reliable test characteristics and can be used to gauge patient perceptions of hospitalist communication skills. Comparative scores between physicians of different specialties and settings should be interpreted cautiously as there may be confounding variables. Within our single institution, comparative scores between hospitalists, along with an examination of the hospitalist's individual item scores, may offer useful feedback for efforts aimed at enhancing communication. Many hospitalists in this study may benefit from targeted training to improve patient communication skills, particularly in the areas of encouraging questions and involving patients in decision making. Future qualitative research in the context of hospital medicine could identify specific communication techniques used by highly‐rated physicians, with the goal of developing tools for targeted improvement and determining impact on outcomes.

If you wish to receive credit for this activity, which begins on the next page, please refer to the website: www. blackwellpublishing.com/cme.

Accreditation and Designation Statement

Blackwell Futura Media Services designates this educational activity for a 1 AMA PRA Category 1 Credit. Physicians should only claim credit commensurate with the extent of their participation in the activity.

Blackwell Futura Media Services is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

Educational Objectives

Continuous participation in the Journal of Hospital Medicine CME program will enable learners to be better able to:

• Interpret clinical guidelines and their applications for higher quality and more efficient care for all hospitalized patients.

• Describe the standard of care for common illnesses and conditions treated in the hospital; such as pneumonia, COPD exacerbation, acute coronary syndrome, HF exacerbation, glycemic control, venous thromboembolic disease, stroke, etc.

• Discuss evidence‐based recommendations involving transitions of care, including the hospital discharge process.

• Gain insights into the roles of hospitalists as medical educators, researchers, medical ethicists, palliative care providers, and hospital‐based geriatricians.

• Incorporate best practices for hospitalist administration, including quality improvement, patient safety, practice management, leadership, and demonstrating hospitalist value.

• Identify evidence‐based best practices and trends for both adult and pediatric hospital medicine.

Instructions on Receiving Credit

For information on applicability and acceptance of continuing medical education credit for this activity, please consult your professional licensing board.

This activity is designed to be completed within the time designated on the title page; physicians should claim only those credits that reflect the time actually spent in the activity. To successfully earn credit, participants must complete the activity during the valid credit period that is noted on the title page.

Follow these steps to earn credit:

• Log on to www.blackwellpublishing.com/cme.

• Read the target audience, learning objectives, and author disclosures.

• Read the article in print or online format.

• Reflect on the article.

• Access the CME Exam, and choose the best answer to each question.

• Complete the required evaluation component of the activity.

If you wish to receive credit for this activity, which begins on the next page, please refer to the website: www. blackwellpublishing.com/cme.

Accreditation and Designation Statement

Blackwell Futura Media Services designates this educational activity for a 1 AMA PRA Category 1 Credit. Physicians should only claim credit commensurate with the extent of their participation in the activity.

Blackwell Futura Media Services is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

Educational Objectives

Continuous participation in the Journal of Hospital Medicine CME program will enable learners to be better able to:

• Interpret clinical guidelines and their applications for higher quality and more efficient care for all hospitalized patients.

• Describe the standard of care for common illnesses and conditions treated in the hospital; such as pneumonia, COPD exacerbation, acute coronary syndrome, HF exacerbation, glycemic control, venous thromboembolic disease, stroke, etc.

• Discuss evidence‐based recommendations involving transitions of care, including the hospital discharge process.

• Gain insights into the roles of hospitalists as medical educators, researchers, medical ethicists, palliative care providers, and hospital‐based geriatricians.

• Incorporate best practices for hospitalist administration, including quality improvement, patient safety, practice management, leadership, and demonstrating hospitalist value.

• Identify evidence‐based best practices and trends for both adult and pediatric hospital medicine.

Instructions on Receiving Credit

For information on applicability and acceptance of continuing medical education credit for this activity, please consult your professional licensing board.

This activity is designed to be completed within the time designated on the title page; physicians should claim only those credits that reflect the time actually spent in the activity. To successfully earn credit, participants must complete the activity during the valid credit period that is noted on the title page.

Follow these steps to earn credit:

• Log on to www.blackwellpublishing.com/cme.

• Read the target audience, learning objectives, and author disclosures.

• Read the article in print or online format.

• Reflect on the article.

• Access the CME Exam, and choose the best answer to each question.

• Complete the required evaluation component of the activity.

If you wish to receive credit for this activity, which begins on the next page, please refer to the website: www. blackwellpublishing.com/cme.

Accreditation and Designation Statement

Blackwell Futura Media Services designates this educational activity for a 1 AMA PRA Category 1 Credit. Physicians should only claim credit commensurate with the extent of their participation in the activity.

Blackwell Futura Media Services is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

Educational Objectives

Continuous participation in the Journal of Hospital Medicine CME program will enable learners to be better able to:

• Interpret clinical guidelines and their applications for higher quality and more efficient care for all hospitalized patients.

• Describe the standard of care for common illnesses and conditions treated in the hospital; such as pneumonia, COPD exacerbation, acute coronary syndrome, HF exacerbation, glycemic control, venous thromboembolic disease, stroke, etc.

• Discuss evidence‐based recommendations involving transitions of care, including the hospital discharge process.

• Gain insights into the roles of hospitalists as medical educators, researchers, medical ethicists, palliative care providers, and hospital‐based geriatricians.

• Incorporate best practices for hospitalist administration, including quality improvement, patient safety, practice management, leadership, and demonstrating hospitalist value.

• Identify evidence‐based best practices and trends for both adult and pediatric hospital medicine.

Instructions on Receiving Credit

For information on applicability and acceptance of continuing medical education credit for this activity, please consult your professional licensing board.

This activity is designed to be completed within the time designated on the title page; physicians should claim only those credits that reflect the time actually spent in the activity. To successfully earn credit, participants must complete the activity during the valid credit period that is noted on the title page.

Follow these steps to earn credit:

• Log on to www.blackwellpublishing.com/cme.

• Read the target audience, learning objectives, and author disclosures.

• Read the article in print or online format.

• Reflect on the article.

• Access the CME Exam, and choose the best answer to each question.

• Complete the required evaluation component of the activity.

Hospital readmissions are common, costly in both economic and human terms, and often preventable. This perfect storm of attributes has placed hospital readmissions at the center of discourse among payers, providers, and policy makers, which is leading to innovations in care delivery. Evolving efforts to enhance discharge communication, to improve care coordination and accountability, and to meaningfully involve primary care, show promise of reducing readmissions.14 These pockets of success demonstrate that improving care transitions can increase quality of care while decreasing costs.

Within the hospital, it is now clear that the discharge process typically requires the same intensity of effort as admission. The hospitalist guides an interdisciplinary team, including nurses, pharmacists, case managers, and social workers, through a checklist of discharge tasks. Some tasks require substantial hospitalist involvement and expertise, such as medication reconciliationa detail‐oriented, time‐consuming process. Other tasks can be accomplished by team members, overseen by the hospitalist, such as scheduling timely follow‐up appointments, coordinating outpatient services, and assembling educational materials. Taken as a whole, significant time and effort must be devoted by the inpatient team to address the complex landscape of a patient's medical and psychosocial needs.

That of course, is only half of the equation, as patient care must be transferred to an equally invested outpatient team led by a primary care provider (PCP). Several influential medical societies have endorsed the medical home (a multidisciplinary care team led by a PCP) as the primary agent to coordinate patient care across settings.5 Indeed, promptly reconnecting with their PCP and primary care team after discharge can have profound meaning for patients, who may otherwise be unsupported with their postdischarge clinical needs. In this issue of the Journal of Hospital Medicine, 4 important articles provide evidence in support of an outpatient partner to actively assume patient care responsibility after hospital discharge.

van Walraven et al.6 conducted an elegant study to evaluate the impact of postdischarge PCP visits on readmissions. Following more than 5000 patients for nearly 6 months, they demonstrated that increased PCP follow‐up was significantly and independently associated with a decreased risk of hospital readmission. This confirms the positive impact that a primary care connection can have on postdischarge care. This study also highlights some challenges: 18% of the original cohort were excluded from the final analyses because they had only 1 or no PCP visit in the 6 months following discharge, indicating inadequate postdischarge follow‐up for a substantial sub‐group. Misky et al.7 similarly established that patients with timely PCP follow‐up (within one month of discharge) were 10 times less likely to be readmitted for the same condition as their index admission. These are also encouraging findings for those patients with PCP follow‐up. Yet among patients in their study, PCP follow‐up was even less common, with only 49% of patients having appointments within one month. Future studies should consider how more intensive outreach strategies might engage difficult‐to‐reach patients and communities.

PCP follow‐up may be beneficial because discharged patients often have ongoing issues that need to be addressed. Arora et al.8 surveyed inner city patients and their PCPs 2 weeks after hospital discharge to assess whether patients experienced any problems in the postdischarge period, and whether PCPs were aware of their patients' hospitalization. Nearly half of all patients recounted 1 or more postdischarge problems. The likelihood of reporting such a problem was twice as common among those patients whose PCP was unaware of their hospitalization. Again, this is strong validation of the importance of PCP involvement in posthospital care, but equally concerning is their finding that fully 3 in 10 PCPs were unaware of their patient's hospitalization.

Finally, Mitchell et al.9 further refine our understanding of risk factors for readmission. In an ethnically diverse inner city population, they screened 738 inpatients for depression. Among the 238 (32%) patients who screened positive, there was a marked 73% increase in hospital utilization (emergency department [ED] visits and readmissions) within 30 days of discharge.9 This confirms previous research that depression is a risk factor for rehospitalization.10 Depression, however, is amenable to treatment and receiving care through one's primary care practice can potentially mitigate how depression negatively affects patients' medication adherence, self‐care behavior, and ultimately readmission rates.

Collectively, these 4 articles give us reason to experience both despair and hope. It is discouraging that large numbers of patients do not have timely encounters with their PCP after discharge, confirming previous findings,11 and that too often PCPs are unaware of their patients' hospitalizations. In any other industry this sort of inefficiency and poor customer service would put a company out of business; that it persists in medicine is embarrassing. Because our medical system is not sufficiently incentivized by quality outcomes, such poor practices continue to be tolerated, and our patients suffer the consequences.

But we are also shown a way forward, with accumulating evidence complimenting existing studies that a primary care connection can improve the quality of postdischarge care and decrease readmissions.1214 Recognizing this central role of primary care, however, forces us to acknowledge the diminishing availability of primary care nationwide; in many inner city and rural locations, accessible primary care is largely nonexistent. This shortage must be corrected to attain needed access and to advance health care reform.

Postdischarge PCP involvement is particularly essential with shorter hospital stays, as patients will predictably have complex postdischarge needs as they complete their recuperation at home. Indeed, Arora et al.8 indicate that posthospitalization problems may be more the rule than the exception, and that specific types of problems can be foreseen. Most commonly reported were challenges obtaining follow‐up appointments, difficulties managing or obtaining medications, feeling unprepared for discharge, having unanswered questions, or needing an urgent reevaluation. While well organized predischarge efforts help to prepare patients, even the most perfect discharge process cannot anticipate all possible pitfalls. Fortunately, most postdischarge problems can be effectively handled by those who often know the patient best, the patient's primary care team. The outpatient team is ideally situated to assist patients with the logistics of accessing the care system, to provide ongoing education, and to help with such basic needs as transportation and social support. It makes sense that such personalized outreach can prevent small problems from blossoming into more serious issues that might ultimately require rehospitalization.

Upon discharge, patients and families are also often expected to assume new self‐care responsibilities, to implement new dietary restrictions, to use new medications, and to monitor and respond to new and evolving symptoms. Gaining the knowledge, the confidence, and the experience to adopt new behaviors is critical to successful postdischarge self‐care. Adult learning theory informs us that education is an ongoing process. Mastering new material occurs with repetition, over time, and under different circumstances. An ancient Chinese proverb encapsulates the key aspects of learning:

• I hear and I forget;

• I see and I remember;

• I do and I understand.

Thus, a single didactic discharge session in the hospital is unlikely to provide patients with sufficient depth of understanding that one attains through experiential learning. Hospital‐based discharge teaching is further compromised in the setting of patient fatigue, anxiety and illness: it is not surprising that patients comprehend and retain only 50% of the medical information discussed with their physicians.15

While teach back has been effectively used to ensure that information is registered when initially presented, it does not ensure that information has been internalized in such a way that it can be utilized hours or days later. Instead, it is the active engagement with the primary care team that provides opportunities for ongoing learning, personalized to the educational needs of each patient. With nurses, dieticians, pharmacists, and medical educators playing a central guiding role, patients can receive appropriately tailored instruction, as well as opportunities to practically apply their new knowledge.

The evolving partnership among hospitals, hospitalists, and primary care holds great promise to reduce avoidable readmissions, and the Patient Protection and Affordable Care Act of 2010 will provide financial incentives to support this partnership. Health care reform aims to adjust hospital payments based on rates of preventable Medicare readmissions; bundling payments (paying for episodes of illness based on outcomes) and accountable care organizations (ACOs) will ideally foster seamless care coordination.16 Nurturing and developing this collaboration between the inpatient and outpatient care teams will be essential as we seek to provide patients the safest transition possible from the hospital to home.

Hospital readmissions are common, costly in both economic and human terms, and often preventable. This perfect storm of attributes has placed hospital readmissions at the center of discourse among payers, providers, and policy makers, which is leading to innovations in care delivery. Evolving efforts to enhance discharge communication, to improve care coordination and accountability, and to meaningfully involve primary care, show promise of reducing readmissions.14 These pockets of success demonstrate that improving care transitions can increase quality of care while decreasing costs.

Within the hospital, it is now clear that the discharge process typically requires the same intensity of effort as admission. The hospitalist guides an interdisciplinary team, including nurses, pharmacists, case managers, and social workers, through a checklist of discharge tasks. Some tasks require substantial hospitalist involvement and expertise, such as medication reconciliationa detail‐oriented, time‐consuming process. Other tasks can be accomplished by team members, overseen by the hospitalist, such as scheduling timely follow‐up appointments, coordinating outpatient services, and assembling educational materials. Taken as a whole, significant time and effort must be devoted by the inpatient team to address the complex landscape of a patient's medical and psychosocial needs.

That of course, is only half of the equation, as patient care must be transferred to an equally invested outpatient team led by a primary care provider (PCP). Several influential medical societies have endorsed the medical home (a multidisciplinary care team led by a PCP) as the primary agent to coordinate patient care across settings.5 Indeed, promptly reconnecting with their PCP and primary care team after discharge can have profound meaning for patients, who may otherwise be unsupported with their postdischarge clinical needs. In this issue of the Journal of Hospital Medicine, 4 important articles provide evidence in support of an outpatient partner to actively assume patient care responsibility after hospital discharge.

van Walraven et al.6 conducted an elegant study to evaluate the impact of postdischarge PCP visits on readmissions. Following more than 5000 patients for nearly 6 months, they demonstrated that increased PCP follow‐up was significantly and independently associated with a decreased risk of hospital readmission. This confirms the positive impact that a primary care connection can have on postdischarge care. This study also highlights some challenges: 18% of the original cohort were excluded from the final analyses because they had only 1 or no PCP visit in the 6 months following discharge, indicating inadequate postdischarge follow‐up for a substantial sub‐group. Misky et al.7 similarly established that patients with timely PCP follow‐up (within one month of discharge) were 10 times less likely to be readmitted for the same condition as their index admission. These are also encouraging findings for those patients with PCP follow‐up. Yet among patients in their study, PCP follow‐up was even less common, with only 49% of patients having appointments within one month. Future studies should consider how more intensive outreach strategies might engage difficult‐to‐reach patients and communities.

PCP follow‐up may be beneficial because discharged patients often have ongoing issues that need to be addressed. Arora et al.8 surveyed inner city patients and their PCPs 2 weeks after hospital discharge to assess whether patients experienced any problems in the postdischarge period, and whether PCPs were aware of their patients' hospitalization. Nearly half of all patients recounted 1 or more postdischarge problems. The likelihood of reporting such a problem was twice as common among those patients whose PCP was unaware of their hospitalization. Again, this is strong validation of the importance of PCP involvement in posthospital care, but equally concerning is their finding that fully 3 in 10 PCPs were unaware of their patient's hospitalization.

Finally, Mitchell et al.9 further refine our understanding of risk factors for readmission. In an ethnically diverse inner city population, they screened 738 inpatients for depression. Among the 238 (32%) patients who screened positive, there was a marked 73% increase in hospital utilization (emergency department [ED] visits and readmissions) within 30 days of discharge.9 This confirms previous research that depression is a risk factor for rehospitalization.10 Depression, however, is amenable to treatment and receiving care through one's primary care practice can potentially mitigate how depression negatively affects patients' medication adherence, self‐care behavior, and ultimately readmission rates.

Collectively, these 4 articles give us reason to experience both despair and hope. It is discouraging that large numbers of patients do not have timely encounters with their PCP after discharge, confirming previous findings,11 and that too often PCPs are unaware of their patients' hospitalizations. In any other industry this sort of inefficiency and poor customer service would put a company out of business; that it persists in medicine is embarrassing. Because our medical system is not sufficiently incentivized by quality outcomes, such poor practices continue to be tolerated, and our patients suffer the consequences.

But we are also shown a way forward, with accumulating evidence complimenting existing studies that a primary care connection can improve the quality of postdischarge care and decrease readmissions.1214 Recognizing this central role of primary care, however, forces us to acknowledge the diminishing availability of primary care nationwide; in many inner city and rural locations, accessible primary care is largely nonexistent. This shortage must be corrected to attain needed access and to advance health care reform.

Postdischarge PCP involvement is particularly essential with shorter hospital stays, as patients will predictably have complex postdischarge needs as they complete their recuperation at home. Indeed, Arora et al.8 indicate that posthospitalization problems may be more the rule than the exception, and that specific types of problems can be foreseen. Most commonly reported were challenges obtaining follow‐up appointments, difficulties managing or obtaining medications, feeling unprepared for discharge, having unanswered questions, or needing an urgent reevaluation. While well organized predischarge efforts help to prepare patients, even the most perfect discharge process cannot anticipate all possible pitfalls. Fortunately, most postdischarge problems can be effectively handled by those who often know the patient best, the patient's primary care team. The outpatient team is ideally situated to assist patients with the logistics of accessing the care system, to provide ongoing education, and to help with such basic needs as transportation and social support. It makes sense that such personalized outreach can prevent small problems from blossoming into more serious issues that might ultimately require rehospitalization.

Upon discharge, patients and families are also often expected to assume new self‐care responsibilities, to implement new dietary restrictions, to use new medications, and to monitor and respond to new and evolving symptoms. Gaining the knowledge, the confidence, and the experience to adopt new behaviors is critical to successful postdischarge self‐care. Adult learning theory informs us that education is an ongoing process. Mastering new material occurs with repetition, over time, and under different circumstances. An ancient Chinese proverb encapsulates the key aspects of learning:

• I hear and I forget;

• I see and I remember;

• I do and I understand.

Thus, a single didactic discharge session in the hospital is unlikely to provide patients with sufficient depth of understanding that one attains through experiential learning. Hospital‐based discharge teaching is further compromised in the setting of patient fatigue, anxiety and illness: it is not surprising that patients comprehend and retain only 50% of the medical information discussed with their physicians.15

While teach back has been effectively used to ensure that information is registered when initially presented, it does not ensure that information has been internalized in such a way that it can be utilized hours or days later. Instead, it is the active engagement with the primary care team that provides opportunities for ongoing learning, personalized to the educational needs of each patient. With nurses, dieticians, pharmacists, and medical educators playing a central guiding role, patients can receive appropriately tailored instruction, as well as opportunities to practically apply their new knowledge.

The evolving partnership among hospitals, hospitalists, and primary care holds great promise to reduce avoidable readmissions, and the Patient Protection and Affordable Care Act of 2010 will provide financial incentives to support this partnership. Health care reform aims to adjust hospital payments based on rates of preventable Medicare readmissions; bundling payments (paying for episodes of illness based on outcomes) and accountable care organizations (ACOs) will ideally foster seamless care coordination.16 Nurturing and developing this collaboration between the inpatient and outpatient care teams will be essential as we seek to provide patients the safest transition possible from the hospital to home.

Hospital readmissions are common, costly in both economic and human terms, and often preventable. This perfect storm of attributes has placed hospital readmissions at the center of discourse among payers, providers, and policy makers, which is leading to innovations in care delivery. Evolving efforts to enhance discharge communication, to improve care coordination and accountability, and to meaningfully involve primary care, show promise of reducing readmissions.14 These pockets of success demonstrate that improving care transitions can increase quality of care while decreasing costs.

Within the hospital, it is now clear that the discharge process typically requires the same intensity of effort as admission. The hospitalist guides an interdisciplinary team, including nurses, pharmacists, case managers, and social workers, through a checklist of discharge tasks. Some tasks require substantial hospitalist involvement and expertise, such as medication reconciliationa detail‐oriented, time‐consuming process. Other tasks can be accomplished by team members, overseen by the hospitalist, such as scheduling timely follow‐up appointments, coordinating outpatient services, and assembling educational materials. Taken as a whole, significant time and effort must be devoted by the inpatient team to address the complex landscape of a patient's medical and psychosocial needs.

That of course, is only half of the equation, as patient care must be transferred to an equally invested outpatient team led by a primary care provider (PCP). Several influential medical societies have endorsed the medical home (a multidisciplinary care team led by a PCP) as the primary agent to coordinate patient care across settings.5 Indeed, promptly reconnecting with their PCP and primary care team after discharge can have profound meaning for patients, who may otherwise be unsupported with their postdischarge clinical needs. In this issue of the Journal of Hospital Medicine, 4 important articles provide evidence in support of an outpatient partner to actively assume patient care responsibility after hospital discharge.

van Walraven et al.6 conducted an elegant study to evaluate the impact of postdischarge PCP visits on readmissions. Following more than 5000 patients for nearly 6 months, they demonstrated that increased PCP follow‐up was significantly and independently associated with a decreased risk of hospital readmission. This confirms the positive impact that a primary care connection can have on postdischarge care. This study also highlights some challenges: 18% of the original cohort were excluded from the final analyses because they had only 1 or no PCP visit in the 6 months following discharge, indicating inadequate postdischarge follow‐up for a substantial sub‐group. Misky et al.7 similarly established that patients with timely PCP follow‐up (within one month of discharge) were 10 times less likely to be readmitted for the same condition as their index admission. These are also encouraging findings for those patients with PCP follow‐up. Yet among patients in their study, PCP follow‐up was even less common, with only 49% of patients having appointments within one month. Future studies should consider how more intensive outreach strategies might engage difficult‐to‐reach patients and communities.

PCP follow‐up may be beneficial because discharged patients often have ongoing issues that need to be addressed. Arora et al.8 surveyed inner city patients and their PCPs 2 weeks after hospital discharge to assess whether patients experienced any problems in the postdischarge period, and whether PCPs were aware of their patients' hospitalization. Nearly half of all patients recounted 1 or more postdischarge problems. The likelihood of reporting such a problem was twice as common among those patients whose PCP was unaware of their hospitalization. Again, this is strong validation of the importance of PCP involvement in posthospital care, but equally concerning is their finding that fully 3 in 10 PCPs were unaware of their patient's hospitalization.

Finally, Mitchell et al.9 further refine our understanding of risk factors for readmission. In an ethnically diverse inner city population, they screened 738 inpatients for depression. Among the 238 (32%) patients who screened positive, there was a marked 73% increase in hospital utilization (emergency department [ED] visits and readmissions) within 30 days of discharge.9 This confirms previous research that depression is a risk factor for rehospitalization.10 Depression, however, is amenable to treatment and receiving care through one's primary care practice can potentially mitigate how depression negatively affects patients' medication adherence, self‐care behavior, and ultimately readmission rates.

Collectively, these 4 articles give us reason to experience both despair and hope. It is discouraging that large numbers of patients do not have timely encounters with their PCP after discharge, confirming previous findings,11 and that too often PCPs are unaware of their patients' hospitalizations. In any other industry this sort of inefficiency and poor customer service would put a company out of business; that it persists in medicine is embarrassing. Because our medical system is not sufficiently incentivized by quality outcomes, such poor practices continue to be tolerated, and our patients suffer the consequences.

But we are also shown a way forward, with accumulating evidence complimenting existing studies that a primary care connection can improve the quality of postdischarge care and decrease readmissions.1214 Recognizing this central role of primary care, however, forces us to acknowledge the diminishing availability of primary care nationwide; in many inner city and rural locations, accessible primary care is largely nonexistent. This shortage must be corrected to attain needed access and to advance health care reform.

Postdischarge PCP involvement is particularly essential with shorter hospital stays, as patients will predictably have complex postdischarge needs as they complete their recuperation at home. Indeed, Arora et al.8 indicate that posthospitalization problems may be more the rule than the exception, and that specific types of problems can be foreseen. Most commonly reported were challenges obtaining follow‐up appointments, difficulties managing or obtaining medications, feeling unprepared for discharge, having unanswered questions, or needing an urgent reevaluation. While well organized predischarge efforts help to prepare patients, even the most perfect discharge process cannot anticipate all possible pitfalls. Fortunately, most postdischarge problems can be effectively handled by those who often know the patient best, the patient's primary care team. The outpatient team is ideally situated to assist patients with the logistics of accessing the care system, to provide ongoing education, and to help with such basic needs as transportation and social support. It makes sense that such personalized outreach can prevent small problems from blossoming into more serious issues that might ultimately require rehospitalization.

Upon discharge, patients and families are also often expected to assume new self‐care responsibilities, to implement new dietary restrictions, to use new medications, and to monitor and respond to new and evolving symptoms. Gaining the knowledge, the confidence, and the experience to adopt new behaviors is critical to successful postdischarge self‐care. Adult learning theory informs us that education is an ongoing process. Mastering new material occurs with repetition, over time, and under different circumstances. An ancient Chinese proverb encapsulates the key aspects of learning:

• I hear and I forget;

• I see and I remember;

• I do and I understand.

Thus, a single didactic discharge session in the hospital is unlikely to provide patients with sufficient depth of understanding that one attains through experiential learning. Hospital‐based discharge teaching is further compromised in the setting of patient fatigue, anxiety and illness: it is not surprising that patients comprehend and retain only 50% of the medical information discussed with their physicians.15

While teach back has been effectively used to ensure that information is registered when initially presented, it does not ensure that information has been internalized in such a way that it can be utilized hours or days later. Instead, it is the active engagement with the primary care team that provides opportunities for ongoing learning, personalized to the educational needs of each patient. With nurses, dieticians, pharmacists, and medical educators playing a central guiding role, patients can receive appropriately tailored instruction, as well as opportunities to practically apply their new knowledge.

The evolving partnership among hospitals, hospitalists, and primary care holds great promise to reduce avoidable readmissions, and the Patient Protection and Affordable Care Act of 2010 will provide financial incentives to support this partnership. Health care reform aims to adjust hospital payments based on rates of preventable Medicare readmissions; bundling payments (paying for episodes of illness based on outcomes) and accountable care organizations (ACOs) will ideally foster seamless care coordination.16 Nurturing and developing this collaboration between the inpatient and outpatient care teams will be essential as we seek to provide patients the safest transition possible from the hospital to home.