Susan Kreimer

Sometimes those in helping roles could use some help, too. Caring for people who are suffering can cause a form of burnout known as “compassion fatigue.” After a while, it’s quite possible to become disillusioned and numb.

“Hospitalists can be affected as easily as any other physician in the hospital setting,” says Patricia Smith, founder of the Compassion Fatigue Awareness Project, the educational arm of Healthy Caregiving LLC in Mountain View, Calif. “This can be due to long hours, overload of patients, new procedures, and processes that are mandatory in healthcare reform, issues among hospital colleagues, poor leadership, and the types of violence and trauma they are experiencing, especially if a hospitalist is in the ED as a first responder.”

Compassion fatigue is a traumatic stress disorder marked by such symptoms as isolation, emotional outbursts, exaggerated sense of responsibility, chronic overeating, alcohol or drug abuse, recurring nightmares or flashbacks, sadness or apathy, and persistent physical ailments.

When signs of compassion fatigue appear to overwhelm a colleague, offer a shoulder to lean on and accept the legitimacy of the individual’s feelings. Health professionals often are “not valued for the caregiving work we do, and we are not validated for who we are,” Smith says. “To provide this level of support to each other is the best thing we can do.”

Healthcare workers who succumb to compassion fatigue often experience too much empathy and perform their jobs with unwavering devotion.

Self-neglect is common and makes them more susceptible to compassion fatigue, says Dennis Portnoy, a licensed psychotherapist in San Francisco and author of “Overextended and Undernourished: A Self-Care Guide for People in Helping Roles.”

Hospital-based educational sessions on compassion fatigue can be beneficial. “Helpers are often predisposed to being more attentive to the needs of others than they are at caring for their own needs,” he says. “Many helpers understand the importance of self-care intellectually, but this knowledge doesn’t lead to taking better care of themselves.”

Hospitalists might be reluctant to seek emotional support from colleagues, family, and friends. Support is essential in the prevention of and recovery from compassion fatigue. It’s also important to establish firm boundaries, Portnoy says. He suggests providers cultivate a healthy detachment from traumatic events while being empathetically engaged with people in distress.

To allow for detachment, job duties ideally should consist of more than direct patient care, says Katherine C. Chretien, MD, FACP, chief of the hospitalist section and clerkship director at Washington, D.C.’s Veterans Affairs Medical Center. As one of seven hospitalists in the group, she avoids scheduling anyone for longer than two consecutive weeks of attending on wards.

“At the end of one of those blocks, I am emotionally exhausted and need a break from that,” Dr. Chretien says. That’s when physicians should spend time on administrative and research tasks or quality improvement (QI) projects before resuming patient care.

Striking a balance between work and leisure also promotes resilience. “We have to care for ourselves first in order to care for others,” says Dr. Chretien, 38, founder and editor of the Mothers in Medicine blog, launched in 2008. She’s married to a physician, and they have three children, ages, 7, 5, and 2.

Listen to Dr. Chretien discuss the importance of fair schedules, work-life balance, and support systems

Dr. Chretien, who is an associate professor of medicine at George Washington University, recommends that hospitalists open up about their experiences—both good and bad—with peers. “We have regular meetings where we have an agenda to talk about our division issues,” she says. “But also, it’s an open forum to share whatever is on your mind.”

 

Despite the difficult challenges that arise, “there are moments when you’re so glad you’re a physician,” Dr. Chretien says. “You see the humanity in what we do.” TH

Susan Kreimer is a freelance writer in New York.

Sometimes those in helping roles could use some help, too. Caring for people who are suffering can cause a form of burnout known as “compassion fatigue.” After a while, it’s quite possible to become disillusioned and numb.

“Hospitalists can be affected as easily as any other physician in the hospital setting,” says Patricia Smith, founder of the Compassion Fatigue Awareness Project, the educational arm of Healthy Caregiving LLC in Mountain View, Calif. “This can be due to long hours, overload of patients, new procedures, and processes that are mandatory in healthcare reform, issues among hospital colleagues, poor leadership, and the types of violence and trauma they are experiencing, especially if a hospitalist is in the ED as a first responder.”

Compassion fatigue is a traumatic stress disorder marked by such symptoms as isolation, emotional outbursts, exaggerated sense of responsibility, chronic overeating, alcohol or drug abuse, recurring nightmares or flashbacks, sadness or apathy, and persistent physical ailments.

When signs of compassion fatigue appear to overwhelm a colleague, offer a shoulder to lean on and accept the legitimacy of the individual’s feelings. Health professionals often are “not valued for the caregiving work we do, and we are not validated for who we are,” Smith says. “To provide this level of support to each other is the best thing we can do.”

Healthcare workers who succumb to compassion fatigue often experience too much empathy and perform their jobs with unwavering devotion.

Self-neglect is common and makes them more susceptible to compassion fatigue, says Dennis Portnoy, a licensed psychotherapist in San Francisco and author of “Overextended and Undernourished: A Self-Care Guide for People in Helping Roles.”

Hospital-based educational sessions on compassion fatigue can be beneficial. “Helpers are often predisposed to being more attentive to the needs of others than they are at caring for their own needs,” he says. “Many helpers understand the importance of self-care intellectually, but this knowledge doesn’t lead to taking better care of themselves.”

Hospitalists might be reluctant to seek emotional support from colleagues, family, and friends. Support is essential in the prevention of and recovery from compassion fatigue. It’s also important to establish firm boundaries, Portnoy says. He suggests providers cultivate a healthy detachment from traumatic events while being empathetically engaged with people in distress.

To allow for detachment, job duties ideally should consist of more than direct patient care, says Katherine C. Chretien, MD, FACP, chief of the hospitalist section and clerkship director at Washington, D.C.’s Veterans Affairs Medical Center. As one of seven hospitalists in the group, she avoids scheduling anyone for longer than two consecutive weeks of attending on wards.

“At the end of one of those blocks, I am emotionally exhausted and need a break from that,” Dr. Chretien says. That’s when physicians should spend time on administrative and research tasks or quality improvement (QI) projects before resuming patient care.

Striking a balance between work and leisure also promotes resilience. “We have to care for ourselves first in order to care for others,” says Dr. Chretien, 38, founder and editor of the Mothers in Medicine blog, launched in 2008. She’s married to a physician, and they have three children, ages, 7, 5, and 2.

Listen to Dr. Chretien discuss the importance of fair schedules, work-life balance, and support systems

Dr. Chretien, who is an associate professor of medicine at George Washington University, recommends that hospitalists open up about their experiences—both good and bad—with peers. “We have regular meetings where we have an agenda to talk about our division issues,” she says. “But also, it’s an open forum to share whatever is on your mind.”

 

Despite the difficult challenges that arise, “there are moments when you’re so glad you’re a physician,” Dr. Chretien says. “You see the humanity in what we do.” TH

Susan Kreimer is a freelance writer in New York.

Sometimes those in helping roles could use some help, too. Caring for people who are suffering can cause a form of burnout known as “compassion fatigue.” After a while, it’s quite possible to become disillusioned and numb.

“Hospitalists can be affected as easily as any other physician in the hospital setting,” says Patricia Smith, founder of the Compassion Fatigue Awareness Project, the educational arm of Healthy Caregiving LLC in Mountain View, Calif. “This can be due to long hours, overload of patients, new procedures, and processes that are mandatory in healthcare reform, issues among hospital colleagues, poor leadership, and the types of violence and trauma they are experiencing, especially if a hospitalist is in the ED as a first responder.”

Compassion fatigue is a traumatic stress disorder marked by such symptoms as isolation, emotional outbursts, exaggerated sense of responsibility, chronic overeating, alcohol or drug abuse, recurring nightmares or flashbacks, sadness or apathy, and persistent physical ailments.

When signs of compassion fatigue appear to overwhelm a colleague, offer a shoulder to lean on and accept the legitimacy of the individual’s feelings. Health professionals often are “not valued for the caregiving work we do, and we are not validated for who we are,” Smith says. “To provide this level of support to each other is the best thing we can do.”

Healthcare workers who succumb to compassion fatigue often experience too much empathy and perform their jobs with unwavering devotion.

Self-neglect is common and makes them more susceptible to compassion fatigue, says Dennis Portnoy, a licensed psychotherapist in San Francisco and author of “Overextended and Undernourished: A Self-Care Guide for People in Helping Roles.”

Hospital-based educational sessions on compassion fatigue can be beneficial. “Helpers are often predisposed to being more attentive to the needs of others than they are at caring for their own needs,” he says. “Many helpers understand the importance of self-care intellectually, but this knowledge doesn’t lead to taking better care of themselves.”

Hospitalists might be reluctant to seek emotional support from colleagues, family, and friends. Support is essential in the prevention of and recovery from compassion fatigue. It’s also important to establish firm boundaries, Portnoy says. He suggests providers cultivate a healthy detachment from traumatic events while being empathetically engaged with people in distress.

To allow for detachment, job duties ideally should consist of more than direct patient care, says Katherine C. Chretien, MD, FACP, chief of the hospitalist section and clerkship director at Washington, D.C.’s Veterans Affairs Medical Center. As one of seven hospitalists in the group, she avoids scheduling anyone for longer than two consecutive weeks of attending on wards.

“At the end of one of those blocks, I am emotionally exhausted and need a break from that,” Dr. Chretien says. That’s when physicians should spend time on administrative and research tasks or quality improvement (QI) projects before resuming patient care.

Striking a balance between work and leisure also promotes resilience. “We have to care for ourselves first in order to care for others,” says Dr. Chretien, 38, founder and editor of the Mothers in Medicine blog, launched in 2008. She’s married to a physician, and they have three children, ages, 7, 5, and 2.

Listen to Dr. Chretien discuss the importance of fair schedules, work-life balance, and support systems

Dr. Chretien, who is an associate professor of medicine at George Washington University, recommends that hospitalists open up about their experiences—both good and bad—with peers. “We have regular meetings where we have an agenda to talk about our division issues,” she says. “But also, it’s an open forum to share whatever is on your mind.”

 

Despite the difficult challenges that arise, “there are moments when you’re so glad you’re a physician,” Dr. Chretien says. “You see the humanity in what we do.” TH

Susan Kreimer is a freelance writer in New York.

Click here to listen to Dr. Agarwal-Antal

Click here to listen to Dr. Agarwal-Antal

Click here to listen to Dr. Agarwal-Antal

Hospitalists sometimes come across skin problems in pediatric patients, and some of these issues fall outside the scope of their expertise.

“I find lesions incidentally that I recommend be referred to dermatologists for evaluation on an outpatient basis” more often than in inpatient dermatologic situations, says Logan Murray, MD, a pediatric hospitalist at the Barbara Bush Children’s Hospital at Maine Medical Center in Portland. “I recently managed a newborn with a 6 cm diameter brown patch in the lumbar area with fine, dark, vellus hair, which I suspect is a congenital giant melanocytic nevus,” he says. To properly evaluate the birthmark, he referred the patient’s parents to a dermatologist.

In these instances, it makes sense for a hospitalist to request that a dermatologist see the child and talk with the parents during hospitalization.

“We get many consults [that] are appropriate,” says Susan Bayliss, MD, a pediatric dermatologist at St. Louis Children’s Hospital. If a hospitalist can’t identify a particular skin issue and reassure parents, it’s time to call a dermatologist.

Distinguishing between acute and chronic dermatologic conditions is important. “The skin is often overlooked among hospitalists,” who are managing sicker patients nowadays, says Neera Agarwal-Antal, MD, head of the division of dermatology at Akron Children’s Hospital in Akron, Ohio.

One of the most dangerous and potentially fatal dermatologic emergencies is Stevens-Johnson syndrome, known in later stages as toxic epidermal necrolysis. Usually triggered by a drug-related reaction, the disease can cause large areas of skin to detach and lesions to develop in the mucous membranes. However, “the good news is most skin conditions are not acute or deadly,” Dr. Agarwal-Antal says.

Warts are very common and often can wait for examination in an outpatient setting. If an adolescent has significant acne, a hospitalist may ask gently, “Are you interested in doing something about your complexion?” To a patient who answers “yes,” a hospitalist could suggest over-the-counter benzoyl peroxide, says Dr. Bayliss, who is also professor of dermatology and pediatrics at Washington University School of Medicine in St. Louis.

“Pediatric dermatology is basically an outpatient specialty,” she adds. “Many kids have skin issues, but most of them do not need to be addressed by a hospitalist.” TH

Susan Kreimer is a freelance writer in New York.

Hospitalists sometimes come across skin problems in pediatric patients, and some of these issues fall outside the scope of their expertise.

“I find lesions incidentally that I recommend be referred to dermatologists for evaluation on an outpatient basis” more often than in inpatient dermatologic situations, says Logan Murray, MD, a pediatric hospitalist at the Barbara Bush Children’s Hospital at Maine Medical Center in Portland. “I recently managed a newborn with a 6 cm diameter brown patch in the lumbar area with fine, dark, vellus hair, which I suspect is a congenital giant melanocytic nevus,” he says. To properly evaluate the birthmark, he referred the patient’s parents to a dermatologist.

In these instances, it makes sense for a hospitalist to request that a dermatologist see the child and talk with the parents during hospitalization.

“We get many consults [that] are appropriate,” says Susan Bayliss, MD, a pediatric dermatologist at St. Louis Children’s Hospital. If a hospitalist can’t identify a particular skin issue and reassure parents, it’s time to call a dermatologist.

Distinguishing between acute and chronic dermatologic conditions is important. “The skin is often overlooked among hospitalists,” who are managing sicker patients nowadays, says Neera Agarwal-Antal, MD, head of the division of dermatology at Akron Children’s Hospital in Akron, Ohio.

One of the most dangerous and potentially fatal dermatologic emergencies is Stevens-Johnson syndrome, known in later stages as toxic epidermal necrolysis. Usually triggered by a drug-related reaction, the disease can cause large areas of skin to detach and lesions to develop in the mucous membranes. However, “the good news is most skin conditions are not acute or deadly,” Dr. Agarwal-Antal says.

Warts are very common and often can wait for examination in an outpatient setting. If an adolescent has significant acne, a hospitalist may ask gently, “Are you interested in doing something about your complexion?” To a patient who answers “yes,” a hospitalist could suggest over-the-counter benzoyl peroxide, says Dr. Bayliss, who is also professor of dermatology and pediatrics at Washington University School of Medicine in St. Louis.

“Pediatric dermatology is basically an outpatient specialty,” she adds. “Many kids have skin issues, but most of them do not need to be addressed by a hospitalist.” TH

Susan Kreimer is a freelance writer in New York.

Hospitalists sometimes come across skin problems in pediatric patients, and some of these issues fall outside the scope of their expertise.

“I find lesions incidentally that I recommend be referred to dermatologists for evaluation on an outpatient basis” more often than in inpatient dermatologic situations, says Logan Murray, MD, a pediatric hospitalist at the Barbara Bush Children’s Hospital at Maine Medical Center in Portland. “I recently managed a newborn with a 6 cm diameter brown patch in the lumbar area with fine, dark, vellus hair, which I suspect is a congenital giant melanocytic nevus,” he says. To properly evaluate the birthmark, he referred the patient’s parents to a dermatologist.

In these instances, it makes sense for a hospitalist to request that a dermatologist see the child and talk with the parents during hospitalization.

“We get many consults [that] are appropriate,” says Susan Bayliss, MD, a pediatric dermatologist at St. Louis Children’s Hospital. If a hospitalist can’t identify a particular skin issue and reassure parents, it’s time to call a dermatologist.

Distinguishing between acute and chronic dermatologic conditions is important. “The skin is often overlooked among hospitalists,” who are managing sicker patients nowadays, says Neera Agarwal-Antal, MD, head of the division of dermatology at Akron Children’s Hospital in Akron, Ohio.

One of the most dangerous and potentially fatal dermatologic emergencies is Stevens-Johnson syndrome, known in later stages as toxic epidermal necrolysis. Usually triggered by a drug-related reaction, the disease can cause large areas of skin to detach and lesions to develop in the mucous membranes. However, “the good news is most skin conditions are not acute or deadly,” Dr. Agarwal-Antal says.

Warts are very common and often can wait for examination in an outpatient setting. If an adolescent has significant acne, a hospitalist may ask gently, “Are you interested in doing something about your complexion?” To a patient who answers “yes,” a hospitalist could suggest over-the-counter benzoyl peroxide, says Dr. Bayliss, who is also professor of dermatology and pediatrics at Washington University School of Medicine in St. Louis.

“Pediatric dermatology is basically an outpatient specialty,” she adds. “Many kids have skin issues, but most of them do not need to be addressed by a hospitalist.” TH

Susan Kreimer is a freelance writer in New York.

Each day a patient spends on a ventilator increases pneumonia risk by about 1% (Am J Respir Crit Care Med. 2002;165[7]:867-903). Being unable to move or talk also might induce a sense of helplessness. As a result, many clinicians wean off a ventilator sooner rather than later.

A recent study (JAMA. 2013;309[7]:671-677) has found that unassisted breathing via a tracheostomy collar facilitates a quicker transition than breathing with pressure support after prolonged mechanical ventilation (>21 days). Investigators reported their findings at the Society of Critical Care Medicine’s 42nd Congress in January in San Juan, Puerto Rico.

On average, patients were able to successfully wean four days earlier with unassisted breathing versus pressure support—a significant difference, says lead investigator Amal Jubran, MD, section chief of pulmonary and critical-care medicine at the Edward Hines Jr. VA Hospital in Chicago. No major differences were reported in survival between the two groups at six-month and 12-month intervals after enrollment in the study.

“The faster pace of weaning in the tracheostomy collar group may be related to its effect on clinical decision-making,” says Dr. Jubran, a professor at Loyola University Chicago’s Stritch School of Medicine. “Observing a patient breathing through a tracheostomy collar provides the clinician with a clear view of the patient’s respiratory capabilities.”

In contrast, with pressure support, a clinician’s perception of weanability “is clouded because the patient is receiving ventilator assistance,” she says. “It is extremely difficult to distinguish between how much work the patient is doing and how much work the ventilator is doing.”

Amid this uncertainty, Dr. Jubran adds, clinicians are more likely to accelerate the weaning process in patients who unexpectedly respond well during a tracheostomy collar challenge than in those receiving a low level of pressure support.

In the study, less than 10% of 312 patients—most of whom were elderly—required reconnection to a ventilator after being weaned successfully. Weaning efforts should be restarted only after cardiopulmonary stability has been reached, she says.

Factoring into the equation are the measurements for blood pressure and respiratory rate and the amounts of oxygenation and sedation in patients on ventilators, says Paul Odenbach, MD, SHM, a hospitalist at Abbott Northwestern Hospital in Minneapolis.

“I look at them clinically overall,” he says. “The most important piece is eyeballing them from where they are in their disease trajectory.”

“Are they awake enough to be protecting their airway once they are extubated?” he adds. He has found that a stable airway is more easily achieved with a tracheostomy collar.

Managing heart failure, treating infections, and optimizing nutrition are crucial before weaning off ventilation, says geriatrician Joel Sender, MD, section chief of pulmonary medicine at St. Barnabas Hospital in Bronx, N.Y., and medical director of its Rehabilitation & Continuing Care Center.

“It is important to identify the best candidates for weaning and then apply the best methods,” says Dr. Sender. “Sadly, many patients are not good candidates, and only a portion are successfully weaned.” That’s why “there’s a great need to have a frank discussion with the family to answer their questions and to promote a realistic set of treatment goals.”

---

Susan Kreimer is a freelance writer based in New York.

Each day a patient spends on a ventilator increases pneumonia risk by about 1% (Am J Respir Crit Care Med. 2002;165[7]:867-903). Being unable to move or talk also might induce a sense of helplessness. As a result, many clinicians wean off a ventilator sooner rather than later.

A recent study (JAMA. 2013;309[7]:671-677) has found that unassisted breathing via a tracheostomy collar facilitates a quicker transition than breathing with pressure support after prolonged mechanical ventilation (>21 days). Investigators reported their findings at the Society of Critical Care Medicine’s 42nd Congress in January in San Juan, Puerto Rico.

On average, patients were able to successfully wean four days earlier with unassisted breathing versus pressure support—a significant difference, says lead investigator Amal Jubran, MD, section chief of pulmonary and critical-care medicine at the Edward Hines Jr. VA Hospital in Chicago. No major differences were reported in survival between the two groups at six-month and 12-month intervals after enrollment in the study.

“The faster pace of weaning in the tracheostomy collar group may be related to its effect on clinical decision-making,” says Dr. Jubran, a professor at Loyola University Chicago’s Stritch School of Medicine. “Observing a patient breathing through a tracheostomy collar provides the clinician with a clear view of the patient’s respiratory capabilities.”

In contrast, with pressure support, a clinician’s perception of weanability “is clouded because the patient is receiving ventilator assistance,” she says. “It is extremely difficult to distinguish between how much work the patient is doing and how much work the ventilator is doing.”

Amid this uncertainty, Dr. Jubran adds, clinicians are more likely to accelerate the weaning process in patients who unexpectedly respond well during a tracheostomy collar challenge than in those receiving a low level of pressure support.

In the study, less than 10% of 312 patients—most of whom were elderly—required reconnection to a ventilator after being weaned successfully. Weaning efforts should be restarted only after cardiopulmonary stability has been reached, she says.

Factoring into the equation are the measurements for blood pressure and respiratory rate and the amounts of oxygenation and sedation in patients on ventilators, says Paul Odenbach, MD, SHM, a hospitalist at Abbott Northwestern Hospital in Minneapolis.

“I look at them clinically overall,” he says. “The most important piece is eyeballing them from where they are in their disease trajectory.”

“Are they awake enough to be protecting their airway once they are extubated?” he adds. He has found that a stable airway is more easily achieved with a tracheostomy collar.

Managing heart failure, treating infections, and optimizing nutrition are crucial before weaning off ventilation, says geriatrician Joel Sender, MD, section chief of pulmonary medicine at St. Barnabas Hospital in Bronx, N.Y., and medical director of its Rehabilitation & Continuing Care Center.

“It is important to identify the best candidates for weaning and then apply the best methods,” says Dr. Sender. “Sadly, many patients are not good candidates, and only a portion are successfully weaned.” That’s why “there’s a great need to have a frank discussion with the family to answer their questions and to promote a realistic set of treatment goals.”

---

Susan Kreimer is a freelance writer based in New York.

Each day a patient spends on a ventilator increases pneumonia risk by about 1% (Am J Respir Crit Care Med. 2002;165[7]:867-903). Being unable to move or talk also might induce a sense of helplessness. As a result, many clinicians wean off a ventilator sooner rather than later.

A recent study (JAMA. 2013;309[7]:671-677) has found that unassisted breathing via a tracheostomy collar facilitates a quicker transition than breathing with pressure support after prolonged mechanical ventilation (>21 days). Investigators reported their findings at the Society of Critical Care Medicine’s 42nd Congress in January in San Juan, Puerto Rico.

On average, patients were able to successfully wean four days earlier with unassisted breathing versus pressure support—a significant difference, says lead investigator Amal Jubran, MD, section chief of pulmonary and critical-care medicine at the Edward Hines Jr. VA Hospital in Chicago. No major differences were reported in survival between the two groups at six-month and 12-month intervals after enrollment in the study.

“The faster pace of weaning in the tracheostomy collar group may be related to its effect on clinical decision-making,” says Dr. Jubran, a professor at Loyola University Chicago’s Stritch School of Medicine. “Observing a patient breathing through a tracheostomy collar provides the clinician with a clear view of the patient’s respiratory capabilities.”

In contrast, with pressure support, a clinician’s perception of weanability “is clouded because the patient is receiving ventilator assistance,” she says. “It is extremely difficult to distinguish between how much work the patient is doing and how much work the ventilator is doing.”

Amid this uncertainty, Dr. Jubran adds, clinicians are more likely to accelerate the weaning process in patients who unexpectedly respond well during a tracheostomy collar challenge than in those receiving a low level of pressure support.

In the study, less than 10% of 312 patients—most of whom were elderly—required reconnection to a ventilator after being weaned successfully. Weaning efforts should be restarted only after cardiopulmonary stability has been reached, she says.

Factoring into the equation are the measurements for blood pressure and respiratory rate and the amounts of oxygenation and sedation in patients on ventilators, says Paul Odenbach, MD, SHM, a hospitalist at Abbott Northwestern Hospital in Minneapolis.

“I look at them clinically overall,” he says. “The most important piece is eyeballing them from where they are in their disease trajectory.”

“Are they awake enough to be protecting their airway once they are extubated?” he adds. He has found that a stable airway is more easily achieved with a tracheostomy collar.

Managing heart failure, treating infections, and optimizing nutrition are crucial before weaning off ventilation, says geriatrician Joel Sender, MD, section chief of pulmonary medicine at St. Barnabas Hospital in Bronx, N.Y., and medical director of its Rehabilitation & Continuing Care Center.

“It is important to identify the best candidates for weaning and then apply the best methods,” says Dr. Sender. “Sadly, many patients are not good candidates, and only a portion are successfully weaned.” That’s why “there’s a great need to have a frank discussion with the family to answer their questions and to promote a realistic set of treatment goals.”

---

Susan Kreimer is a freelance writer based in New York.

A study is underway to assess the impact of a dermatologist’s consultation for patients admitted to the hospital with cellulitis.

Started last October, the randomized controlled trial is comparing patients overseen by internal-medicine hospitalists alone to those who are also evaluated by a dermatologist soon after admission to Massachusetts General Hospital in Boston. Daniela Kroshinsky, MD, MPH, the principal investigator, hypothesizes that hospital admission for cellulitis involving consultation with a dermatologist might decrease length of stay, readmission rates, incidence of pseudocellulitis, cost, and/or antibiotic usage.

“We did a similar study in the outpatient setting that demonstrated over 80 percent reduction in antibiotic use,” says Dr. Kroshinsky, the hospital’s director of pediatric dermatology and director of inpatient dermatology, education, and research.

Patients in the control group are instructed to follow hospitalists’ recommendations solely. This includes the timing and type of post-discharge appointments. As part of the standard of care, these patients can consult with a dermatologist if necessary or requested.

Patients randomized to the treatment group receive a consultation with a dermatologist, along with treatment recommendations. They also have a follow-up visit in a dermatology clinic after discharge. Both groups will be assessed for readmission or complications.

A study is underway to assess the impact of a dermatologist’s consultation for patients admitted to the hospital with cellulitis.

Started last October, the randomized controlled trial is comparing patients overseen by internal-medicine hospitalists alone to those who are also evaluated by a dermatologist soon after admission to Massachusetts General Hospital in Boston. Daniela Kroshinsky, MD, MPH, the principal investigator, hypothesizes that hospital admission for cellulitis involving consultation with a dermatologist might decrease length of stay, readmission rates, incidence of pseudocellulitis, cost, and/or antibiotic usage.

“We did a similar study in the outpatient setting that demonstrated over 80 percent reduction in antibiotic use,” says Dr. Kroshinsky, the hospital’s director of pediatric dermatology and director of inpatient dermatology, education, and research.

Patients in the control group are instructed to follow hospitalists’ recommendations solely. This includes the timing and type of post-discharge appointments. As part of the standard of care, these patients can consult with a dermatologist if necessary or requested.

Patients randomized to the treatment group receive a consultation with a dermatologist, along with treatment recommendations. They also have a follow-up visit in a dermatology clinic after discharge. Both groups will be assessed for readmission or complications.

A study is underway to assess the impact of a dermatologist’s consultation for patients admitted to the hospital with cellulitis.

Started last October, the randomized controlled trial is comparing patients overseen by internal-medicine hospitalists alone to those who are also evaluated by a dermatologist soon after admission to Massachusetts General Hospital in Boston. Daniela Kroshinsky, MD, MPH, the principal investigator, hypothesizes that hospital admission for cellulitis involving consultation with a dermatologist might decrease length of stay, readmission rates, incidence of pseudocellulitis, cost, and/or antibiotic usage.

“We did a similar study in the outpatient setting that demonstrated over 80 percent reduction in antibiotic use,” says Dr. Kroshinsky, the hospital’s director of pediatric dermatology and director of inpatient dermatology, education, and research.

Patients in the control group are instructed to follow hospitalists’ recommendations solely. This includes the timing and type of post-discharge appointments. As part of the standard of care, these patients can consult with a dermatologist if necessary or requested.

Patients randomized to the treatment group receive a consultation with a dermatologist, along with treatment recommendations. They also have a follow-up visit in a dermatology clinic after discharge. Both groups will be assessed for readmission or complications.

Dr. Vinik

1. Maintain a broader range of differential diagnoses before ruling in or out something more concrete.
2. Attend dermatology lectures as part of primary care’s continuing medical education courses.
3. Review a good basic dermatology atlas from time to time.
4. Learn to correctly describe lesions to a dermatologist by phone.
5. Don’t assume that groin rashes are all fungal.
6. Don’t mistakenly associate a drug-related reaction with a medication given one to two days before the onset of a rash.
7. Consider involving a dermatologist to help manage open skin lesions, particularly if you’re unsure of the cause.
8. Prescribe an adequate quantity of topical corticosteroids for the duration of treatment.
9. Beware of painful or blistering rashes, especially if they involve the mucosa of the mouth, eyes, or genitals.
10. Watch out for zoster, widespread herpes, pemphigus, and pemphigoid.
11. Pay attention to itching in the wrists, genital region, and web spaces of fingers and toes.
12. Be mindful of the rapid onset of purpuric lesions on the skin.
13. Avoid consults for improving rashes and seborrheic keratosis, as well as nonurgent outpatient issues, such as psoriasis, rosacea, or a history of skin cancer.
14. Don’t prescribe combined betamethasone/clotrimazole, also known as Lotrisone, for chronic scaly hands, feet, or groin.
15. Encourage patients to follow up with a dermatologist on an outpatient basis.

Dermatologic diseases tend to receive little attention at most U.S. medical schools—typically only several days of lectures or a few weeks of clinical exposure.

“Not surprisingly, many general practitioners may feel unprepared to address hospitalized patients with challenging dermatologic findings,” says R. Samuel Hopkins, MD, assistant professor of dermatology and assistant residency program director at Oregon Health & Science University in Portland.

Few studies have examined the quality of inpatient dermatologic care. One study, a retrospective chart review at a Midwestern university hospital, found that the primary ward team submitted an accurate dermatologic diagnosis in only 23.9% of cases. Meanwhile, consultation with a dermatologist led to a change or addition to treatment in 77% of patients (Dermatol Online J. 2010;16(2):12).

“Given that medical schools may not be able to dedicate more time to managing dermatologic conditions, the burden of education may fall on post-graduate programs and continuing medical education to fill this gap,” Dr. Hopkins says. To further complicate matters, “it is difficult in many hospitals to obtain a dermatology consult on an inpatient, reflecting the limited access hospitalists often have to dermatologists.”

The most frequently encountered dermatologic conditions in the hospital setting are drug eruptions and skin infections. Dermatitis is the most misdiagnosed condition by nondermatologists in hospitals, says Russell Vinik, MD, co-director of the hospitalist group at the University of Utah Health Care in Salt Lake City.

The majority of skin issues don’t require a dermatologist’s input, but some do. “Clearly, there’s also the rash that we just don’t know what it is,” Dr. Vinik says. When in doubt, it’s best to err on the safe side and call the specialist.

Here’s how to assess whether to manage a dermatologic case yourself, or how to involve a dermatologist for appropriate diagnosis and treatment. In general, Dr. Hopkins says, “Whether one can handle a case on their own or not is a case-by-case decision by the hospitalist based on their comfort with their diagnosis and management.”

Maintain a broader range of differential diagnoses before ruling in or out something more concrete.

“Very often, patients with skin diseases are given a specific diagnosis without consideration of mimickers,” says Daniela Kroshinsky, MD, MPH, assistant professor of dermatology at Harvard Medical School in Boston.

“Cellulitis is a great example. People will come in with hot, red skin and be diagnosed with and treated for cellulitis but really have stasis dermatitis, Lyme [disease], gout, et cetera,” says Dr. Kroshinsky, who also is director of pediatric dermatology and director of inpatient dermatology, education, and research at Massachusetts General Hospital.

 

“The clinical picture of warm, red, tender skin can fit many conditions but is most often called cellulitis by nondermatologists,” she explains. “It’s not clear why, but I would suspect this is because cellulitis is one of the few dermatologic conditions taught in medical school, while the mimickers get less attention.”

 

Attend dermatology lectures as part of primary care’s continuing medical education courses.

This would increase your knowledge of skin conditions affecting hospitalized patients, Dr. Kroshinsky says. If there is a dermatologic consultant for your hospital, work closely with this specialist until you feel comfortable making diagnoses and incorporating treatment plans.

Similarly, if you are a resident who is interested in a career in hospital medicine, consider doing a rotation in dermatology.

Review a good basic dermatology atlas from time to time.

This keeps your mind open to differential diagnoses for a given situation that you may encounter in the hospital setting. A more comprehensive book or online reference can be helpful to peruse after seeing a patient with a particular rash, Dr. Kroshinsky says.

Learn to correctly describe lesions to a dermatologist by phone.

When a specialist isn’t available on site, the phone communication is vital to the specialist. This includes familiarizing yourself with some of the more life-threatening dermatologic problems, such as drug-induced hypersensitivity reactions. It will be easier to recognize when an urgent dermatologic consultation is required. Sometimes this is necessary when a patient doesn’t respond to treatment for a reasonable and presumed diagnosis—when one condition seems to mimic the symptoms of another, says Lindy Fox, MD, associate professor of clinical dermatology at the University of California at San Francisco and director of its hospital dermatology consultation service.

Don’t assume that groin rashes are all fungal.

In fact, there is a very large differential diagnosis for intertriginous eruptions, Dr. Fox says. Perform a KOH test (potassium hydroxide) and fungal cultures on intertriginous eruptions. If no fungus is identified or the patient is not responding appropriately to therapy, call for a dermatologic consultation.

 

Don’t mistakenly associate a drug-related reaction with a medication given one to two days before the onset of a rash.

It is typically seven to 10 days post-exposure that a drug eruption develops, Dr. Fox says. He suggests making a drug chart to highlight dates of medication administration. This helps pinpoint the most likely culprit based on timing and the probability that a certain drug may induce cutaneous eruptions. Correct identification of the type of drug eruption (e.g. simple drug eruption vs. hypersensitivity vs. potentially deadly Stevens-Johnson syndrome) is important.

Consider involving a dermatologist to help manage open skin lesions, particularly if you’re unsure of the cause.

There are many different causes of skin ulcers. Trauma, infections, and even malignancies can present as open wounds. Leg ulcers may be due to venous stasis, but they also can be caused by arterial insufficiency, vasculitis, and other conditions. A dermatologist might opt to perform a skin biopsy to help diagnose the lesion.

“Wound-care nurses can be very helpful in managing skin lesions, but they do not always have the experience needed to correctly diagnose the underlying problem,” says Kathryn Schwarzenberger, MD, professor of medicine at the University of Vermont College of Medicine in Burlington. “If you’re thinking of calling the wound-care nurse, think of calling the dermatologist first.”

Prescribe an adequate quantity of topical corticosteroids for the duration of treatment.

“It’s really important to provide enough medicine,” Dr. Schwarzenberger says. Typically, a patient will receive a small tube, apply the contents, and find that “it’s enough medicine to cover their body once. This doesn’t work if you intended to have the patient apply it all over for two weeks.”

 

It takes, on average, 30 g of a topical medication to cover the body once. With topical steroids, prescribing an insufficient quantity “dooms your therapy to failure.”

Allergic reactions from these medications are rare, and some insurance companies charge the same regardless of the size. Prescribing a small amount initially might incur an additional expense for the patient.

Beware of painful or blistering rashes, especially if they involve the mucosa of the mouth, eyes, or genitals.

“These symptoms can be associated with potentially deadly toxic epidermal necrolysis,” says Daniel Aires, MD, JD, director of the division of dermatology at the University of Kansas School of Medicine in Kansas City, Kan. “Consult dermatology immediately. The sooner treatment is begun, the better the odds of survival.”

If a rash involves the eye, call an ophthalmologist and a dermatologist. “Eyes are more likely than skin to develop chronic complications after resolution of an acute condition,” he says.

For a rash involving primarily the mouth, call an otolaryngologist, a dentist, or both, as well as a dermatologist. These specialists are more skilled in visualizing and treating oral conditions.

Watch out for zoster, widespread herpes, pemphigus, and pemphigoid.

These blistering conditions require urgent diagnosis and treatment, so a dermatologist’s expertise is needed quickly, Dr. Aires says. Even without the presence of blisters, a single region of the skin or “dermatome” gives pause for concern.

“This could be a sign of zoster, which is especially dangerous in immunosuppressed or otherwise debilitated patients,” he cautions. “Either perform a culture and begin treatment, or consult dermatology, or do both.”

Pay attention to itching in the wrists, genital region, and web spaces of fingers and toes.

This may be due to scabies infestation. “Scabies can spread rapidly throughout a hospital ward,” Dr. Aires says. What to do: Scrape for scabies, consider a trial of topical treatment, and consult a dermatologist if you’re unsure.

Be mindful of the rapid onset of purpuric lesionscon the skin.

They warrant suspicion of such conditions as vasculitis, hypercoaguable states, and disseminated angiotropic infections, says Dr. Hopkins of Oregon Health & Science University. “The shape and size of purpuric skin lesions help determine the etiology. A few characteristic examples include papular purpura and retiform purpura. Papular purpura [raised purpuric papules] may suggest vasculitis. Purpura that forms net-like patches is called retiform purpura and suggests a vaso-occlusive process, such as from a hypercoaguable state, embolic phenomena, or calciphylaxis.”

13 Avoid consults for improving rashes and seborrheic keratosis, as well as nonurgent outpatient issues, such as psoriasis, rosacea, or a history of skin cancer. These conditions “are more easily addressed in a clinic, as opposed to in a hospital, where the patient is lying in a bed feeling ill with IV tubes in place,” Dr. Aires says. “It also reflects respect for the dermatologist’s time. Inpatient dermatology can be pretty busy, so it’s preferable to consult primarily for urgent skin issues.” Consultations can be costly, too, and most patients would rather avoid additional medical bills.

Don’t prescribe combined betamethasone/clotrimazole, also known as Lotrisone, for chronic scaly hands, feet, or groin.

Although it is not harmful, “it is not usually a great choice for typical ‘dermatophyte’ fungal infections, such as athlete’s foot and ‘jock itch,’” Dr. Aires says. “Over-the-counter Lamisil is better, particularly following daily use of 10-minute soaks in 50-50 vinegar-water. Even for yeast infections, miconazole is better than clotrimazole.”

As for betamethasone, this “component is way too strong for the groin area and can cause atrophy or worse,” he says.

 

Encourage patients to follow up with a dermatologist on an outpatient basis.

By heeding this advice, patients are less likely to return to the ED for skin conditions that can be managed in an office, says Kirsten Flynn, MD, a dermatologist at Banner Health Center in Sun City West, Ariz. Inpatient admissions by dermatologists have been decreasing over the years. Most patients with skin diseases or cutaneous manifestations of systemic illnesses are admitted to hospitals by other physicians.

“Many dermatologists are happy to fit in urgent consults in their clinics. Drug eruptions are by far the most common consultation request,” says Dr. Flynn, who notes that high-dose IV steroids can cause complications, such as gastrointestinal bleeding, bowel perforation, opportunistic infections, and exacerbation of underlying diseases. “In most cases, removing the offending agent and providing supportive care is the best option.”

---

Susan Kreimer is a freelance writer in New York.

Dr. Vinik

1. Maintain a broader range of differential diagnoses before ruling in or out something more concrete.
2. Attend dermatology lectures as part of primary care’s continuing medical education courses.
3. Review a good basic dermatology atlas from time to time.
4. Learn to correctly describe lesions to a dermatologist by phone.
5. Don’t assume that groin rashes are all fungal.
6. Don’t mistakenly associate a drug-related reaction with a medication given one to two days before the onset of a rash.
7. Consider involving a dermatologist to help manage open skin lesions, particularly if you’re unsure of the cause.
8. Prescribe an adequate quantity of topical corticosteroids for the duration of treatment.
9. Beware of painful or blistering rashes, especially if they involve the mucosa of the mouth, eyes, or genitals.
10. Watch out for zoster, widespread herpes, pemphigus, and pemphigoid.
11. Pay attention to itching in the wrists, genital region, and web spaces of fingers and toes.
12. Be mindful of the rapid onset of purpuric lesions on the skin.
13. Avoid consults for improving rashes and seborrheic keratosis, as well as nonurgent outpatient issues, such as psoriasis, rosacea, or a history of skin cancer.
14. Don’t prescribe combined betamethasone/clotrimazole, also known as Lotrisone, for chronic scaly hands, feet, or groin.
15. Encourage patients to follow up with a dermatologist on an outpatient basis.

Dermatologic diseases tend to receive little attention at most U.S. medical schools—typically only several days of lectures or a few weeks of clinical exposure.

“Not surprisingly, many general practitioners may feel unprepared to address hospitalized patients with challenging dermatologic findings,” says R. Samuel Hopkins, MD, assistant professor of dermatology and assistant residency program director at Oregon Health & Science University in Portland.

Few studies have examined the quality of inpatient dermatologic care. One study, a retrospective chart review at a Midwestern university hospital, found that the primary ward team submitted an accurate dermatologic diagnosis in only 23.9% of cases. Meanwhile, consultation with a dermatologist led to a change or addition to treatment in 77% of patients (Dermatol Online J. 2010;16(2):12).

“Given that medical schools may not be able to dedicate more time to managing dermatologic conditions, the burden of education may fall on post-graduate programs and continuing medical education to fill this gap,” Dr. Hopkins says. To further complicate matters, “it is difficult in many hospitals to obtain a dermatology consult on an inpatient, reflecting the limited access hospitalists often have to dermatologists.”

The most frequently encountered dermatologic conditions in the hospital setting are drug eruptions and skin infections. Dermatitis is the most misdiagnosed condition by nondermatologists in hospitals, says Russell Vinik, MD, co-director of the hospitalist group at the University of Utah Health Care in Salt Lake City.

The majority of skin issues don’t require a dermatologist’s input, but some do. “Clearly, there’s also the rash that we just don’t know what it is,” Dr. Vinik says. When in doubt, it’s best to err on the safe side and call the specialist.

Here’s how to assess whether to manage a dermatologic case yourself, or how to involve a dermatologist for appropriate diagnosis and treatment. In general, Dr. Hopkins says, “Whether one can handle a case on their own or not is a case-by-case decision by the hospitalist based on their comfort with their diagnosis and management.”

Maintain a broader range of differential diagnoses before ruling in or out something more concrete.

“Very often, patients with skin diseases are given a specific diagnosis without consideration of mimickers,” says Daniela Kroshinsky, MD, MPH, assistant professor of dermatology at Harvard Medical School in Boston.

“Cellulitis is a great example. People will come in with hot, red skin and be diagnosed with and treated for cellulitis but really have stasis dermatitis, Lyme [disease], gout, et cetera,” says Dr. Kroshinsky, who also is director of pediatric dermatology and director of inpatient dermatology, education, and research at Massachusetts General Hospital.

 

“The clinical picture of warm, red, tender skin can fit many conditions but is most often called cellulitis by nondermatologists,” she explains. “It’s not clear why, but I would suspect this is because cellulitis is one of the few dermatologic conditions taught in medical school, while the mimickers get less attention.”

 

Attend dermatology lectures as part of primary care’s continuing medical education courses.

This would increase your knowledge of skin conditions affecting hospitalized patients, Dr. Kroshinsky says. If there is a dermatologic consultant for your hospital, work closely with this specialist until you feel comfortable making diagnoses and incorporating treatment plans.

Similarly, if you are a resident who is interested in a career in hospital medicine, consider doing a rotation in dermatology.

Review a good basic dermatology atlas from time to time.

This keeps your mind open to differential diagnoses for a given situation that you may encounter in the hospital setting. A more comprehensive book or online reference can be helpful to peruse after seeing a patient with a particular rash, Dr. Kroshinsky says.

Learn to correctly describe lesions to a dermatologist by phone.

When a specialist isn’t available on site, the phone communication is vital to the specialist. This includes familiarizing yourself with some of the more life-threatening dermatologic problems, such as drug-induced hypersensitivity reactions. It will be easier to recognize when an urgent dermatologic consultation is required. Sometimes this is necessary when a patient doesn’t respond to treatment for a reasonable and presumed diagnosis—when one condition seems to mimic the symptoms of another, says Lindy Fox, MD, associate professor of clinical dermatology at the University of California at San Francisco and director of its hospital dermatology consultation service.

Don’t assume that groin rashes are all fungal.

In fact, there is a very large differential diagnosis for intertriginous eruptions, Dr. Fox says. Perform a KOH test (potassium hydroxide) and fungal cultures on intertriginous eruptions. If no fungus is identified or the patient is not responding appropriately to therapy, call for a dermatologic consultation.

 

Don’t mistakenly associate a drug-related reaction with a medication given one to two days before the onset of a rash.

It is typically seven to 10 days post-exposure that a drug eruption develops, Dr. Fox says. He suggests making a drug chart to highlight dates of medication administration. This helps pinpoint the most likely culprit based on timing and the probability that a certain drug may induce cutaneous eruptions. Correct identification of the type of drug eruption (e.g. simple drug eruption vs. hypersensitivity vs. potentially deadly Stevens-Johnson syndrome) is important.

Consider involving a dermatologist to help manage open skin lesions, particularly if you’re unsure of the cause.

There are many different causes of skin ulcers. Trauma, infections, and even malignancies can present as open wounds. Leg ulcers may be due to venous stasis, but they also can be caused by arterial insufficiency, vasculitis, and other conditions. A dermatologist might opt to perform a skin biopsy to help diagnose the lesion.

“Wound-care nurses can be very helpful in managing skin lesions, but they do not always have the experience needed to correctly diagnose the underlying problem,” says Kathryn Schwarzenberger, MD, professor of medicine at the University of Vermont College of Medicine in Burlington. “If you’re thinking of calling the wound-care nurse, think of calling the dermatologist first.”

Prescribe an adequate quantity of topical corticosteroids for the duration of treatment.

“It’s really important to provide enough medicine,” Dr. Schwarzenberger says. Typically, a patient will receive a small tube, apply the contents, and find that “it’s enough medicine to cover their body once. This doesn’t work if you intended to have the patient apply it all over for two weeks.”

 

It takes, on average, 30 g of a topical medication to cover the body once. With topical steroids, prescribing an insufficient quantity “dooms your therapy to failure.”

Allergic reactions from these medications are rare, and some insurance companies charge the same regardless of the size. Prescribing a small amount initially might incur an additional expense for the patient.

Beware of painful or blistering rashes, especially if they involve the mucosa of the mouth, eyes, or genitals.

“These symptoms can be associated with potentially deadly toxic epidermal necrolysis,” says Daniel Aires, MD, JD, director of the division of dermatology at the University of Kansas School of Medicine in Kansas City, Kan. “Consult dermatology immediately. The sooner treatment is begun, the better the odds of survival.”

If a rash involves the eye, call an ophthalmologist and a dermatologist. “Eyes are more likely than skin to develop chronic complications after resolution of an acute condition,” he says.

For a rash involving primarily the mouth, call an otolaryngologist, a dentist, or both, as well as a dermatologist. These specialists are more skilled in visualizing and treating oral conditions.

Watch out for zoster, widespread herpes, pemphigus, and pemphigoid.

These blistering conditions require urgent diagnosis and treatment, so a dermatologist’s expertise is needed quickly, Dr. Aires says. Even without the presence of blisters, a single region of the skin or “dermatome” gives pause for concern.

“This could be a sign of zoster, which is especially dangerous in immunosuppressed or otherwise debilitated patients,” he cautions. “Either perform a culture and begin treatment, or consult dermatology, or do both.”

Pay attention to itching in the wrists, genital region, and web spaces of fingers and toes.

This may be due to scabies infestation. “Scabies can spread rapidly throughout a hospital ward,” Dr. Aires says. What to do: Scrape for scabies, consider a trial of topical treatment, and consult a dermatologist if you’re unsure.

Be mindful of the rapid onset of purpuric lesionscon the skin.

They warrant suspicion of such conditions as vasculitis, hypercoaguable states, and disseminated angiotropic infections, says Dr. Hopkins of Oregon Health & Science University. “The shape and size of purpuric skin lesions help determine the etiology. A few characteristic examples include papular purpura and retiform purpura. Papular purpura [raised purpuric papules] may suggest vasculitis. Purpura that forms net-like patches is called retiform purpura and suggests a vaso-occlusive process, such as from a hypercoaguable state, embolic phenomena, or calciphylaxis.”

13 Avoid consults for improving rashes and seborrheic keratosis, as well as nonurgent outpatient issues, such as psoriasis, rosacea, or a history of skin cancer. These conditions “are more easily addressed in a clinic, as opposed to in a hospital, where the patient is lying in a bed feeling ill with IV tubes in place,” Dr. Aires says. “It also reflects respect for the dermatologist’s time. Inpatient dermatology can be pretty busy, so it’s preferable to consult primarily for urgent skin issues.” Consultations can be costly, too, and most patients would rather avoid additional medical bills.

Don’t prescribe combined betamethasone/clotrimazole, also known as Lotrisone, for chronic scaly hands, feet, or groin.

Although it is not harmful, “it is not usually a great choice for typical ‘dermatophyte’ fungal infections, such as athlete’s foot and ‘jock itch,’” Dr. Aires says. “Over-the-counter Lamisil is better, particularly following daily use of 10-minute soaks in 50-50 vinegar-water. Even for yeast infections, miconazole is better than clotrimazole.”

As for betamethasone, this “component is way too strong for the groin area and can cause atrophy or worse,” he says.

 

Encourage patients to follow up with a dermatologist on an outpatient basis.

By heeding this advice, patients are less likely to return to the ED for skin conditions that can be managed in an office, says Kirsten Flynn, MD, a dermatologist at Banner Health Center in Sun City West, Ariz. Inpatient admissions by dermatologists have been decreasing over the years. Most patients with skin diseases or cutaneous manifestations of systemic illnesses are admitted to hospitals by other physicians.

“Many dermatologists are happy to fit in urgent consults in their clinics. Drug eruptions are by far the most common consultation request,” says Dr. Flynn, who notes that high-dose IV steroids can cause complications, such as gastrointestinal bleeding, bowel perforation, opportunistic infections, and exacerbation of underlying diseases. “In most cases, removing the offending agent and providing supportive care is the best option.”

---

Susan Kreimer is a freelance writer in New York.

Dr. Vinik

1. Maintain a broader range of differential diagnoses before ruling in or out something more concrete.
2. Attend dermatology lectures as part of primary care’s continuing medical education courses.
3. Review a good basic dermatology atlas from time to time.
4. Learn to correctly describe lesions to a dermatologist by phone.
5. Don’t assume that groin rashes are all fungal.
6. Don’t mistakenly associate a drug-related reaction with a medication given one to two days before the onset of a rash.
7. Consider involving a dermatologist to help manage open skin lesions, particularly if you’re unsure of the cause.
8. Prescribe an adequate quantity of topical corticosteroids for the duration of treatment.
9. Beware of painful or blistering rashes, especially if they involve the mucosa of the mouth, eyes, or genitals.
10. Watch out for zoster, widespread herpes, pemphigus, and pemphigoid.
11. Pay attention to itching in the wrists, genital region, and web spaces of fingers and toes.
12. Be mindful of the rapid onset of purpuric lesions on the skin.
13. Avoid consults for improving rashes and seborrheic keratosis, as well as nonurgent outpatient issues, such as psoriasis, rosacea, or a history of skin cancer.
14. Don’t prescribe combined betamethasone/clotrimazole, also known as Lotrisone, for chronic scaly hands, feet, or groin.
15. Encourage patients to follow up with a dermatologist on an outpatient basis.

Dermatologic diseases tend to receive little attention at most U.S. medical schools—typically only several days of lectures or a few weeks of clinical exposure.

“Not surprisingly, many general practitioners may feel unprepared to address hospitalized patients with challenging dermatologic findings,” says R. Samuel Hopkins, MD, assistant professor of dermatology and assistant residency program director at Oregon Health & Science University in Portland.

Few studies have examined the quality of inpatient dermatologic care. One study, a retrospective chart review at a Midwestern university hospital, found that the primary ward team submitted an accurate dermatologic diagnosis in only 23.9% of cases. Meanwhile, consultation with a dermatologist led to a change or addition to treatment in 77% of patients (Dermatol Online J. 2010;16(2):12).

“Given that medical schools may not be able to dedicate more time to managing dermatologic conditions, the burden of education may fall on post-graduate programs and continuing medical education to fill this gap,” Dr. Hopkins says. To further complicate matters, “it is difficult in many hospitals to obtain a dermatology consult on an inpatient, reflecting the limited access hospitalists often have to dermatologists.”

The most frequently encountered dermatologic conditions in the hospital setting are drug eruptions and skin infections. Dermatitis is the most misdiagnosed condition by nondermatologists in hospitals, says Russell Vinik, MD, co-director of the hospitalist group at the University of Utah Health Care in Salt Lake City.

The majority of skin issues don’t require a dermatologist’s input, but some do. “Clearly, there’s also the rash that we just don’t know what it is,” Dr. Vinik says. When in doubt, it’s best to err on the safe side and call the specialist.

Here’s how to assess whether to manage a dermatologic case yourself, or how to involve a dermatologist for appropriate diagnosis and treatment. In general, Dr. Hopkins says, “Whether one can handle a case on their own or not is a case-by-case decision by the hospitalist based on their comfort with their diagnosis and management.”

Maintain a broader range of differential diagnoses before ruling in or out something more concrete.

“Very often, patients with skin diseases are given a specific diagnosis without consideration of mimickers,” says Daniela Kroshinsky, MD, MPH, assistant professor of dermatology at Harvard Medical School in Boston.

“Cellulitis is a great example. People will come in with hot, red skin and be diagnosed with and treated for cellulitis but really have stasis dermatitis, Lyme [disease], gout, et cetera,” says Dr. Kroshinsky, who also is director of pediatric dermatology and director of inpatient dermatology, education, and research at Massachusetts General Hospital.

 

“The clinical picture of warm, red, tender skin can fit many conditions but is most often called cellulitis by nondermatologists,” she explains. “It’s not clear why, but I would suspect this is because cellulitis is one of the few dermatologic conditions taught in medical school, while the mimickers get less attention.”

 

Attend dermatology lectures as part of primary care’s continuing medical education courses.

This would increase your knowledge of skin conditions affecting hospitalized patients, Dr. Kroshinsky says. If there is a dermatologic consultant for your hospital, work closely with this specialist until you feel comfortable making diagnoses and incorporating treatment plans.

Similarly, if you are a resident who is interested in a career in hospital medicine, consider doing a rotation in dermatology.

Review a good basic dermatology atlas from time to time.

This keeps your mind open to differential diagnoses for a given situation that you may encounter in the hospital setting. A more comprehensive book or online reference can be helpful to peruse after seeing a patient with a particular rash, Dr. Kroshinsky says.

Learn to correctly describe lesions to a dermatologist by phone.

When a specialist isn’t available on site, the phone communication is vital to the specialist. This includes familiarizing yourself with some of the more life-threatening dermatologic problems, such as drug-induced hypersensitivity reactions. It will be easier to recognize when an urgent dermatologic consultation is required. Sometimes this is necessary when a patient doesn’t respond to treatment for a reasonable and presumed diagnosis—when one condition seems to mimic the symptoms of another, says Lindy Fox, MD, associate professor of clinical dermatology at the University of California at San Francisco and director of its hospital dermatology consultation service.

Don’t assume that groin rashes are all fungal.

In fact, there is a very large differential diagnosis for intertriginous eruptions, Dr. Fox says. Perform a KOH test (potassium hydroxide) and fungal cultures on intertriginous eruptions. If no fungus is identified or the patient is not responding appropriately to therapy, call for a dermatologic consultation.

 

Don’t mistakenly associate a drug-related reaction with a medication given one to two days before the onset of a rash.

It is typically seven to 10 days post-exposure that a drug eruption develops, Dr. Fox says. He suggests making a drug chart to highlight dates of medication administration. This helps pinpoint the most likely culprit based on timing and the probability that a certain drug may induce cutaneous eruptions. Correct identification of the type of drug eruption (e.g. simple drug eruption vs. hypersensitivity vs. potentially deadly Stevens-Johnson syndrome) is important.

Consider involving a dermatologist to help manage open skin lesions, particularly if you’re unsure of the cause.

There are many different causes of skin ulcers. Trauma, infections, and even malignancies can present as open wounds. Leg ulcers may be due to venous stasis, but they also can be caused by arterial insufficiency, vasculitis, and other conditions. A dermatologist might opt to perform a skin biopsy to help diagnose the lesion.

“Wound-care nurses can be very helpful in managing skin lesions, but they do not always have the experience needed to correctly diagnose the underlying problem,” says Kathryn Schwarzenberger, MD, professor of medicine at the University of Vermont College of Medicine in Burlington. “If you’re thinking of calling the wound-care nurse, think of calling the dermatologist first.”

Prescribe an adequate quantity of topical corticosteroids for the duration of treatment.

“It’s really important to provide enough medicine,” Dr. Schwarzenberger says. Typically, a patient will receive a small tube, apply the contents, and find that “it’s enough medicine to cover their body once. This doesn’t work if you intended to have the patient apply it all over for two weeks.”

 

It takes, on average, 30 g of a topical medication to cover the body once. With topical steroids, prescribing an insufficient quantity “dooms your therapy to failure.”

Allergic reactions from these medications are rare, and some insurance companies charge the same regardless of the size. Prescribing a small amount initially might incur an additional expense for the patient.

Beware of painful or blistering rashes, especially if they involve the mucosa of the mouth, eyes, or genitals.

“These symptoms can be associated with potentially deadly toxic epidermal necrolysis,” says Daniel Aires, MD, JD, director of the division of dermatology at the University of Kansas School of Medicine in Kansas City, Kan. “Consult dermatology immediately. The sooner treatment is begun, the better the odds of survival.”

If a rash involves the eye, call an ophthalmologist and a dermatologist. “Eyes are more likely than skin to develop chronic complications after resolution of an acute condition,” he says.

For a rash involving primarily the mouth, call an otolaryngologist, a dentist, or both, as well as a dermatologist. These specialists are more skilled in visualizing and treating oral conditions.

Watch out for zoster, widespread herpes, pemphigus, and pemphigoid.

These blistering conditions require urgent diagnosis and treatment, so a dermatologist’s expertise is needed quickly, Dr. Aires says. Even without the presence of blisters, a single region of the skin or “dermatome” gives pause for concern.

“This could be a sign of zoster, which is especially dangerous in immunosuppressed or otherwise debilitated patients,” he cautions. “Either perform a culture and begin treatment, or consult dermatology, or do both.”

Pay attention to itching in the wrists, genital region, and web spaces of fingers and toes.

This may be due to scabies infestation. “Scabies can spread rapidly throughout a hospital ward,” Dr. Aires says. What to do: Scrape for scabies, consider a trial of topical treatment, and consult a dermatologist if you’re unsure.

Be mindful of the rapid onset of purpuric lesionscon the skin.

They warrant suspicion of such conditions as vasculitis, hypercoaguable states, and disseminated angiotropic infections, says Dr. Hopkins of Oregon Health & Science University. “The shape and size of purpuric skin lesions help determine the etiology. A few characteristic examples include papular purpura and retiform purpura. Papular purpura [raised purpuric papules] may suggest vasculitis. Purpura that forms net-like patches is called retiform purpura and suggests a vaso-occlusive process, such as from a hypercoaguable state, embolic phenomena, or calciphylaxis.”

13 Avoid consults for improving rashes and seborrheic keratosis, as well as nonurgent outpatient issues, such as psoriasis, rosacea, or a history of skin cancer. These conditions “are more easily addressed in a clinic, as opposed to in a hospital, where the patient is lying in a bed feeling ill with IV tubes in place,” Dr. Aires says. “It also reflects respect for the dermatologist’s time. Inpatient dermatology can be pretty busy, so it’s preferable to consult primarily for urgent skin issues.” Consultations can be costly, too, and most patients would rather avoid additional medical bills.

Don’t prescribe combined betamethasone/clotrimazole, also known as Lotrisone, for chronic scaly hands, feet, or groin.

Although it is not harmful, “it is not usually a great choice for typical ‘dermatophyte’ fungal infections, such as athlete’s foot and ‘jock itch,’” Dr. Aires says. “Over-the-counter Lamisil is better, particularly following daily use of 10-minute soaks in 50-50 vinegar-water. Even for yeast infections, miconazole is better than clotrimazole.”

As for betamethasone, this “component is way too strong for the groin area and can cause atrophy or worse,” he says.

 

Encourage patients to follow up with a dermatologist on an outpatient basis.

By heeding this advice, patients are less likely to return to the ED for skin conditions that can be managed in an office, says Kirsten Flynn, MD, a dermatologist at Banner Health Center in Sun City West, Ariz. Inpatient admissions by dermatologists have been decreasing over the years. Most patients with skin diseases or cutaneous manifestations of systemic illnesses are admitted to hospitals by other physicians.

“Many dermatologists are happy to fit in urgent consults in their clinics. Drug eruptions are by far the most common consultation request,” says Dr. Flynn, who notes that high-dose IV steroids can cause complications, such as gastrointestinal bleeding, bowel perforation, opportunistic infections, and exacerbation of underlying diseases. “In most cases, removing the offending agent and providing supportive care is the best option.”

---

Susan Kreimer is a freelance writer in New York.

Each day a patient spends on a ventilator increases pneumonia risk by about 1% (Am J Respir Crit Care Med. 2002;165[7]:867-903). Being unable to move or talk also might induce a sense of helplessness. As a result, many clinicians wean off a ventilator sooner rather than later.

A recent study (JAMA. 2013;309[7]:671-677) has found that unassisted breathing via a tracheostomy collar facilitates a quicker transition than breathing with pressure support after prolonged mechanical ventilation (>21 days). Investigators reported their findings at the Society of Critical Care Medicine’s 42nd Congress in January in San Juan, Puerto Rico.

On average, patients were able to successfully wean four days earlier with unassisted breathing versus pressure support—a significant difference, says lead investigator Amal Jubran, MD, section chief of pulmonary and critical-care medicine at the Edward Hines Jr. VA Hospital in Chicago. No major differences were reported in survival between the two groups at six-month and 12-month intervals after enrollment in the study.

“The faster pace of weaning in the tracheostomy collar group may be related to its effect on clinical decision-making,” says Dr. Jubran, a professor at Loyola University Chicago’s Stritch School of Medicine. “Observing a patient breathing through a tracheostomy collar provides the clinician with a clear view of the patient’s respiratory capabilities.”

In contrast, with pressure support, a clinician’s perception of weanability “is clouded because the patient is receiving ventilator assistance,” she says. “It is extremely difficult to distinguish between how much work the patient is doing and how much work the ventilator is doing.”

Amid this uncertainty, Dr. Jubran adds, clinicians are more likely to accelerate the weaning process in patients who unexpectedly respond well during a tracheostomy collar challenge than in those receiving a low level of pressure support.

In the study, less than 10% of 312 patients—most of whom were elderly—required reconnection to a ventilator after being weaned successfully. Weaning efforts should be restarted only after cardiopulmonary stability has been reached, she says.

Factoring into the equation are the measurements for blood pressure and respiratory rate and the amounts of oxygenation and sedation in patients on ventilators, says Paul Odenbach, MD, SHM, a hospitalist at Abbott Northwestern Hospital in Minneapolis.

“I look at them clinically overall,” he says. “The most important piece is eyeballing them from where they are in their disease trajectory.

Are they awake enough to be protecting their airway once they are extubated?” he adds. He has found that a stable airway is more easily achieved with a tracheostomy collar.

Listen to Dr. Odenbach explain what hospitalists should watch out for when weaning patients off mechanical ventilation, especially in critical-care situations.

 

Managing heart failure, treating infections, and optimizing nutrition are crucial before weaning off ventilation, says geriatrician Joel Sender, MD, section chief of pulmonary medicine at St. Barnabas Hospital in Bronx, N.Y., and medical director of its Rehabilitation & Continuing Care Center.

“It is important to identify the best candidates for weaning and then apply the best methods,” says Dr. Sender. “Sadly, many patients are not good candidates, and only a portion are successfully weaned.” That’s why “there’s a great need to have a frank discussion with the family to answer their questions and to promote a realistic set of treatment goals.” TH

Susan Kreimer is a freelance writer in New York.

 

 

Each day a patient spends on a ventilator increases pneumonia risk by about 1% (Am J Respir Crit Care Med. 2002;165[7]:867-903). Being unable to move or talk also might induce a sense of helplessness. As a result, many clinicians wean off a ventilator sooner rather than later.

A recent study (JAMA. 2013;309[7]:671-677) has found that unassisted breathing via a tracheostomy collar facilitates a quicker transition than breathing with pressure support after prolonged mechanical ventilation (>21 days). Investigators reported their findings at the Society of Critical Care Medicine’s 42nd Congress in January in San Juan, Puerto Rico.

On average, patients were able to successfully wean four days earlier with unassisted breathing versus pressure support—a significant difference, says lead investigator Amal Jubran, MD, section chief of pulmonary and critical-care medicine at the Edward Hines Jr. VA Hospital in Chicago. No major differences were reported in survival between the two groups at six-month and 12-month intervals after enrollment in the study.

“The faster pace of weaning in the tracheostomy collar group may be related to its effect on clinical decision-making,” says Dr. Jubran, a professor at Loyola University Chicago’s Stritch School of Medicine. “Observing a patient breathing through a tracheostomy collar provides the clinician with a clear view of the patient’s respiratory capabilities.”

In contrast, with pressure support, a clinician’s perception of weanability “is clouded because the patient is receiving ventilator assistance,” she says. “It is extremely difficult to distinguish between how much work the patient is doing and how much work the ventilator is doing.”

Amid this uncertainty, Dr. Jubran adds, clinicians are more likely to accelerate the weaning process in patients who unexpectedly respond well during a tracheostomy collar challenge than in those receiving a low level of pressure support.

In the study, less than 10% of 312 patients—most of whom were elderly—required reconnection to a ventilator after being weaned successfully. Weaning efforts should be restarted only after cardiopulmonary stability has been reached, she says.

Factoring into the equation are the measurements for blood pressure and respiratory rate and the amounts of oxygenation and sedation in patients on ventilators, says Paul Odenbach, MD, SHM, a hospitalist at Abbott Northwestern Hospital in Minneapolis.

“I look at them clinically overall,” he says. “The most important piece is eyeballing them from where they are in their disease trajectory.

Are they awake enough to be protecting their airway once they are extubated?” he adds. He has found that a stable airway is more easily achieved with a tracheostomy collar.

Listen to Dr. Odenbach explain what hospitalists should watch out for when weaning patients off mechanical ventilation, especially in critical-care situations.

 

Managing heart failure, treating infections, and optimizing nutrition are crucial before weaning off ventilation, says geriatrician Joel Sender, MD, section chief of pulmonary medicine at St. Barnabas Hospital in Bronx, N.Y., and medical director of its Rehabilitation & Continuing Care Center.

“It is important to identify the best candidates for weaning and then apply the best methods,” says Dr. Sender. “Sadly, many patients are not good candidates, and only a portion are successfully weaned.” That’s why “there’s a great need to have a frank discussion with the family to answer their questions and to promote a realistic set of treatment goals.” TH

Susan Kreimer is a freelance writer in New York.

 

 

Each day a patient spends on a ventilator increases pneumonia risk by about 1% (Am J Respir Crit Care Med. 2002;165[7]:867-903). Being unable to move or talk also might induce a sense of helplessness. As a result, many clinicians wean off a ventilator sooner rather than later.

A recent study (JAMA. 2013;309[7]:671-677) has found that unassisted breathing via a tracheostomy collar facilitates a quicker transition than breathing with pressure support after prolonged mechanical ventilation (>21 days). Investigators reported their findings at the Society of Critical Care Medicine’s 42nd Congress in January in San Juan, Puerto Rico.

On average, patients were able to successfully wean four days earlier with unassisted breathing versus pressure support—a significant difference, says lead investigator Amal Jubran, MD, section chief of pulmonary and critical-care medicine at the Edward Hines Jr. VA Hospital in Chicago. No major differences were reported in survival between the two groups at six-month and 12-month intervals after enrollment in the study.

“The faster pace of weaning in the tracheostomy collar group may be related to its effect on clinical decision-making,” says Dr. Jubran, a professor at Loyola University Chicago’s Stritch School of Medicine. “Observing a patient breathing through a tracheostomy collar provides the clinician with a clear view of the patient’s respiratory capabilities.”

In contrast, with pressure support, a clinician’s perception of weanability “is clouded because the patient is receiving ventilator assistance,” she says. “It is extremely difficult to distinguish between how much work the patient is doing and how much work the ventilator is doing.”

Amid this uncertainty, Dr. Jubran adds, clinicians are more likely to accelerate the weaning process in patients who unexpectedly respond well during a tracheostomy collar challenge than in those receiving a low level of pressure support.

In the study, less than 10% of 312 patients—most of whom were elderly—required reconnection to a ventilator after being weaned successfully. Weaning efforts should be restarted only after cardiopulmonary stability has been reached, she says.

Factoring into the equation are the measurements for blood pressure and respiratory rate and the amounts of oxygenation and sedation in patients on ventilators, says Paul Odenbach, MD, SHM, a hospitalist at Abbott Northwestern Hospital in Minneapolis.

“I look at them clinically overall,” he says. “The most important piece is eyeballing them from where they are in their disease trajectory.

Are they awake enough to be protecting their airway once they are extubated?” he adds. He has found that a stable airway is more easily achieved with a tracheostomy collar.

Listen to Dr. Odenbach explain what hospitalists should watch out for when weaning patients off mechanical ventilation, especially in critical-care situations.

 

Managing heart failure, treating infections, and optimizing nutrition are crucial before weaning off ventilation, says geriatrician Joel Sender, MD, section chief of pulmonary medicine at St. Barnabas Hospital in Bronx, N.Y., and medical director of its Rehabilitation & Continuing Care Center.

“It is important to identify the best candidates for weaning and then apply the best methods,” says Dr. Sender. “Sadly, many patients are not good candidates, and only a portion are successfully weaned.” That’s why “there’s a great need to have a frank discussion with the family to answer their questions and to promote a realistic set of treatment goals.” TH

Susan Kreimer is a freelance writer in New York.

 

 

20 Things At A Glance

1. Acknowledge that collaboration between health professionals is important, even when schedules are hectic and reimbursement doesn’t cover these discussions.
2. Secure patient consent before consulting a psychiatrist.
3. Present the psychiatrist’s anticipated insight as a benefit to the patient.
4. Ask the patient if it’s all right to discuss their health status and needs with family members.
5. Recognize that psychiatric illness is real, not imaginary.
6. Realize that not all sadness constitutes depression.
7. Don’t gloss over the possibility of delirium.
8. Take the time to really listen.
9. Always remain conscious of alcohol and substance abuse.
10. Monitor patients’ vital signs for autonomic instability.
11. Avoid arguments and power struggles with difficult or demanding patients.
12. Adapt your vocabulary to the patient’s and family’s level of understanding.
13. Be mindful of your nonverbal cues.
14. Always take suicide risk seriously.
15. Beware of patients who exhibit attention-seeking behavior, which can have a negative impact on the healthcare team and the care provided to the patient.
16. Consider the possibility of a factitious disorder when there is a lack of objective evidence for pathology to explain a patient’s symptoms despite extensive evaluation.
17. Choose an intravenous psychiatric medication when a patient with severe and persistent mental illness should avoid oral medication for a procedure.
18. Listen to your instincts.
19. Arrange for post-discharge follow-up with a primary-care physician or psychiatrist.
20. Extend genuine compassion to your patients.

Patients can be hospitalized with chest pain, a kidney infection, pneumonia, or myriad other medical conditions. Hospital stays on occasion upend a patient’s mental state, with upcoming tests, surgery, or other procedures triggering anxiety or other conditions.

That doesn’t mean these patients have psychiatric or psychological problems, but some of them might. Hospitalists walk a fine line in deciding when to consult a psychiatrist in certain cases.

“A common mistake, when it comes to psychiatry, for hospitalists is to either think they know too much or they know too little,” says Philip R. Muskin, MD, professor of clinical psychiatry at Columbia University College of Physicians & Surgeons in New York City. “Sometimes they’re too quick to call a psychiatrist, and sometimes they’re too slow to call a specialist because they don’t think it’s a psychiatric problem.”

The Hospitalist asked more than half a dozen specialists in psychiatry and hospital medicine to shed light on when to seek additional expertise—and how to inform patients about your request to do so. “If I say, ‘You need to see a psychiatrist,’ it carries some stigma,” says Dr. Muskin, who is the chief of consultation for liaison psychiatry at New York-Presbyterian Medical Center’s Columbia campus. “We have to be sensitive to that.”

So how can you more comfortably approach psychiatric or psychological issues in the hospital setting?

1. Acknowledge that collaboration between health professionals is important, even when schedules are hectic and reimbursement doesn’t cover these discussions.

“Because of the overwhelming comorbidity between psychiatric illness and medical illness, it’s important to have some communication between the emergency room, caregiver, the hospitalist, and the psychiatrist,” says Ken Duckworth, MD, medical director of the National Alliance on Mental Illness (NAMI) and an assistant clinical professor of psychiatry at Harvard Medical School in Boston. “We know that people with mental health vulnerabilities consume a much higher amount of medical services. That’s a well-known phenomenon.”

2. Secure patient consent before consulting a psychiatrist.

“You need the patient’s permission,” Dr. Duckworth says. “That’s an important piece of the equation.” There are exceptions in emergencies, and the laws pertaining to this vary by state. Verbal consent may suffice if written authorization is already on file. If a patient declines, a hospitalist has to respect those wishes.

 

3. Present the psychiatrist’s anticipated insight as a benefit to the patient.

Physicians sometimes are uncomfortable informing their patients that they’re asking for a psychiatric consultation. They fear a bad reaction, such as “You think I’m crazy?” The consultation will be more useful if the patient is open and accepting of the process. For example, tell your patient at the outset: “I’d really like you to talk to one of my colleagues, whom I trust a great deal. He/she is an expert in the overlapping area between the body and the brain. I need their help so that I can take better care of you,’” says Linda L.M. Worley, MD, FAPM, professor of psychiatry and obstetrics and gynecology at the University of Arkansas for Medical Sciences in Little Rock.

4. Ask the patient if it’s all right to discuss their health status and needs with family members.

Get to know their names. Identify the medical expert in the family and be certain to involve them in overall discussions and the decision-making process, Dr. Worley says.

5. Recognize that psychiatric illness is real, not imaginary.

The illness “should be placed in exactly the same arena as other medical problems,” Dr. Muskin says. Patients with psychiatric conditions are “not weak. They’re not dumb. It’s not all in their head.” Their mental health “deserves the same attention as their heart, stomach, or kidneys.”

6. Realize that not all sadness constitutes depression.

“There are many reasons why people cry or feel down, and most are not psychiatric illnesses. Depression is often overdiagnosed, leading to wasted time and inappropriate medications,” says Robert Boland, MD, professor of psychiatry and human behavior at Brown University’s Warren Alpert School of Medicine in Providence, R.I. “Unfortunately, the opposite is also true. Depression is often missed in the hospital.”

So how does a hospitalist reconcile those extremes? First, consider depression in any patient who is predisposed, then rely on a consistent way of working it up. The Diagnostic and Statistical Manual of Mental Disorders (DSM, http://www.dsm5.org) offers a conservative approach, so you usually can’t go wrong by following it.

7. Don’t gloss over the possibility of delirium.

It is probably the most frequently missed diagnosis in the general hospital. “We usually recognize it when patients are agitated, but most patients aren’t,” Dr. Boland says. “If anything, they are hypoactive or change throughout the day. When a patient seems confused, we want to find a cause, but that cause isn’t always obvious.”

These situations are particularly true in fragile patients (e.g. the very old or those with dementia). Sometimes medical problems that seem very minor can “push them over the edge,” he adds. When you do expect dementia, the main treatments revolve around medically stabilizing the patient, and psychiatric medications are a minor part of the management, if at all.

8. Take the time to really listen.

Patients’ biggest complaint is that physicians don’t listen. “The best doctors in any specialty know how to communicate with patients,” Dr. Boland says. “It doesn’t take longer—in fact, good communication usually saves time. But it does take attention and focus to let the patient try and explain what is going on with them. It always pays off in the end.”

9. Always remain conscious of alcohol and substance abuse.

Although it might not be the reason patients are hospitalized, it is one of the more common underlying causes. When this is the case, don’t be nihilistic. Many patients improve with treatment, and some get better simply because a physician explained how damaging substance abuse can be to their health, Dr. Boland says.

 

For those in complete remission from a past addiction to alcohol, benzodiazepines, opiates, or a combination thereof, beware that prescribing certain medications puts them at substantially increased risk for relapse. Use alternative treatments whenever possible; if clinically indicated, be certain that these patients have a safety net to prevent relapse. Patients with severe pain need effective relief.

“If a patient has been exposed to significant dosages of pain medications in the past, their neurotransmitters will have physically adapted,” says Dr. Worley, president-elect of the Academy of Psychosomatic Medicine. “They will require higher doses than normal for effective pain relief.”

10. Monitor patients’ vital signs for autonomic instability.

“Patients in withdrawal from physiologically addictive medications may have forgotten to tell you that they were taking these medications,” Dr. Worley says. “Abrupt discontinuation can cause incapacitating anxiety and life-threatening delirium.”

11. Avoid arguments and power struggles with difficult or demanding patients.

Put on your thick skin. Don’t take insults or slights personally. And resist the urge to flee or counterattack. Instead, Dr. Worley suggests hospitalists stay calm and focused on providing the best medical care that they can. “Chronically noncompliant patients can be excruciatingly frustrating to care for when they don’t follow through on what they are repeatedly advised to do, but lecturing more vigorously at them won’t help,” she says. “It only makes them shut down more and feel more helpless and you more exhausted. Shift to more of a listening mode and inquire about what they hope to accomplish by coming to you for help.”

12. Adapt your vocabulary to the patient’s and family’s level of understanding.

After your explanation, ask them, “Do me a favor and explain back to me in your words what I said. I want to be sure I got across what I wanted to say.” Then ask whether they have any questions. Also know that all too often patients are so anxious and upset that they are “emotionally flooded” and unable to hear much of what you communicated. You can save a lot of time if they understand you in the first place.

13. Be mindful of your nonverbal cues.

A majority of communication is nonverbal, and your facial expressions, gestures, and body posture speak volumes to patients and family members. “The innocent tilt of a chin upwards while peering through bifocals can be misperceived as arrogance,” Dr. Worley says. “The thoughtful furled brow of contemplation may be misconstrued as irritability or disapproval.”

14. Always take suicide risk seriously.

It’s better to call a psychiatrist unnecessarily than to overlook a patient at risk for suicide. Benzodiazepines, alcohol, or a combination of the two might reduce inhibition and increase the likelihood of a suicide attempt. Be sure to assess suicidal ideation, intent, and lethality of suicide attempt.

“Hopelessness about the future correlates with completed suicide,” says Gregory Ruhnke, MD, assistant professor in the section of hospital medicine at the University of Chicago Pritzker School of Medicine. “Additionally, it is helpful to ask about the four H’s: Hate, humiliation, hostility, handguns.”

15. Beware of patients who exhibit attention-seeking behavior, which can have a negative impact on the healthcare team and the care provided to the patient.

“The patient may become angry and engage in splitting, whereby he or she emphatically expresses the view that certain caregivers are all good or all bad. This may reflect such [a] patient’s desire to divide the caregivers into opposing factions. It’s a maladaptive way of coping,” says Marie Tobin, MD, associate professor of psychiatry and consult-liaison psychiatrist at the Pritzker School of Medicine. This can be very time-consuming, and it can breed hostility among colleagues. “Communication between caregivers is really important in creating a unified treatment plan that is coherently presented to the patient in a single voice.”

 

Fortunately, she says, “even though these situations can arise, they are the exception rather than the rule.”

16. Consider the possibility of a factitious disorder when there is a lack of objective evidence for pathology to explain a patient’s symptoms despite extensive evaluation.

For example, Dr. Ruhnke says, if a patient complains of hemoptysis and hematochezia with negative endoscopies, talk to the nurse about the patient’s diet, and be suspicious if it includes only red foods and liquids. The most common symptoms among patients who come to medical attention because of factitious disorders are diarrhea, fever of unknown origin, gastrointestinal bleeding, hematuria, seizures, and hypoglycemia.

17. Choose an intravenous psychiatric medication when a patient with severe and persistent mental illness should avoid oral medication for a procedure.

A patient with schizophrenia or bipolar disorder could experience a severe psychiatric episode without psychiatric medication. An appropriate alternative, perhaps administered intravenously if necessary, “can make all the difference in the world,” says Christopher Dobbelstein, MD, assistant professor of psychiatry at the University of Pittsburgh School of Medicine.

18. Listen to your instincts.

Medical teams can handle many psychiatric issues. Straightforward delirium is a good example. The bigger question, which takes experience and confidence, is to recognize when a line has been crossed. “The decision to consult psychiatry is not formulaic,” Dr. Dobbelstein says.

Sometimes a patient is acting strangely, and the team can’t explain why a psychiatrist could offer sound advice. “That’s when they should trust their instincts and consult us,” he says, “because the patient likely does have something more complex going on.”

19. Arrange for post-discharge follow-up with a primary-care physician or psychiatrist.

Sometimes psychiatric medications are started without good oversight. Suicide risk is highest during the weeks following an inpatient psychiatric admission, so a patient should see an outpatient mental health provider within seven days after hospital discharge, says NAMI’s Dr. Duckworth.

20. Extend genuine compassion to your patients.

“This is the secret to achieving a lifelong rewarding career in medicine,” Dr. Worley says, “and is the most important ingredient in positive outcomes.”

---

Susan Kreimer is a freelance writer in New York.

20 Things At A Glance

1. Acknowledge that collaboration between health professionals is important, even when schedules are hectic and reimbursement doesn’t cover these discussions.
2. Secure patient consent before consulting a psychiatrist.
3. Present the psychiatrist’s anticipated insight as a benefit to the patient.
4. Ask the patient if it’s all right to discuss their health status and needs with family members.
5. Recognize that psychiatric illness is real, not imaginary.
6. Realize that not all sadness constitutes depression.
7. Don’t gloss over the possibility of delirium.
8. Take the time to really listen.
9. Always remain conscious of alcohol and substance abuse.
10. Monitor patients’ vital signs for autonomic instability.
11. Avoid arguments and power struggles with difficult or demanding patients.
12. Adapt your vocabulary to the patient’s and family’s level of understanding.
13. Be mindful of your nonverbal cues.
14. Always take suicide risk seriously.
15. Beware of patients who exhibit attention-seeking behavior, which can have a negative impact on the healthcare team and the care provided to the patient.
16. Consider the possibility of a factitious disorder when there is a lack of objective evidence for pathology to explain a patient’s symptoms despite extensive evaluation.
17. Choose an intravenous psychiatric medication when a patient with severe and persistent mental illness should avoid oral medication for a procedure.
18. Listen to your instincts.
19. Arrange for post-discharge follow-up with a primary-care physician or psychiatrist.
20. Extend genuine compassion to your patients.

Patients can be hospitalized with chest pain, a kidney infection, pneumonia, or myriad other medical conditions. Hospital stays on occasion upend a patient’s mental state, with upcoming tests, surgery, or other procedures triggering anxiety or other conditions.

That doesn’t mean these patients have psychiatric or psychological problems, but some of them might. Hospitalists walk a fine line in deciding when to consult a psychiatrist in certain cases.

“A common mistake, when it comes to psychiatry, for hospitalists is to either think they know too much or they know too little,” says Philip R. Muskin, MD, professor of clinical psychiatry at Columbia University College of Physicians & Surgeons in New York City. “Sometimes they’re too quick to call a psychiatrist, and sometimes they’re too slow to call a specialist because they don’t think it’s a psychiatric problem.”

The Hospitalist asked more than half a dozen specialists in psychiatry and hospital medicine to shed light on when to seek additional expertise—and how to inform patients about your request to do so. “If I say, ‘You need to see a psychiatrist,’ it carries some stigma,” says Dr. Muskin, who is the chief of consultation for liaison psychiatry at New York-Presbyterian Medical Center’s Columbia campus. “We have to be sensitive to that.”

So how can you more comfortably approach psychiatric or psychological issues in the hospital setting?

1. Acknowledge that collaboration between health professionals is important, even when schedules are hectic and reimbursement doesn’t cover these discussions.

“Because of the overwhelming comorbidity between psychiatric illness and medical illness, it’s important to have some communication between the emergency room, caregiver, the hospitalist, and the psychiatrist,” says Ken Duckworth, MD, medical director of the National Alliance on Mental Illness (NAMI) and an assistant clinical professor of psychiatry at Harvard Medical School in Boston. “We know that people with mental health vulnerabilities consume a much higher amount of medical services. That’s a well-known phenomenon.”

2. Secure patient consent before consulting a psychiatrist.

“You need the patient’s permission,” Dr. Duckworth says. “That’s an important piece of the equation.” There are exceptions in emergencies, and the laws pertaining to this vary by state. Verbal consent may suffice if written authorization is already on file. If a patient declines, a hospitalist has to respect those wishes.

 

3. Present the psychiatrist’s anticipated insight as a benefit to the patient.

Physicians sometimes are uncomfortable informing their patients that they’re asking for a psychiatric consultation. They fear a bad reaction, such as “You think I’m crazy?” The consultation will be more useful if the patient is open and accepting of the process. For example, tell your patient at the outset: “I’d really like you to talk to one of my colleagues, whom I trust a great deal. He/she is an expert in the overlapping area between the body and the brain. I need their help so that I can take better care of you,’” says Linda L.M. Worley, MD, FAPM, professor of psychiatry and obstetrics and gynecology at the University of Arkansas for Medical Sciences in Little Rock.

4. Ask the patient if it’s all right to discuss their health status and needs with family members.

Get to know their names. Identify the medical expert in the family and be certain to involve them in overall discussions and the decision-making process, Dr. Worley says.

5. Recognize that psychiatric illness is real, not imaginary.

The illness “should be placed in exactly the same arena as other medical problems,” Dr. Muskin says. Patients with psychiatric conditions are “not weak. They’re not dumb. It’s not all in their head.” Their mental health “deserves the same attention as their heart, stomach, or kidneys.”

6. Realize that not all sadness constitutes depression.

“There are many reasons why people cry or feel down, and most are not psychiatric illnesses. Depression is often overdiagnosed, leading to wasted time and inappropriate medications,” says Robert Boland, MD, professor of psychiatry and human behavior at Brown University’s Warren Alpert School of Medicine in Providence, R.I. “Unfortunately, the opposite is also true. Depression is often missed in the hospital.”

So how does a hospitalist reconcile those extremes? First, consider depression in any patient who is predisposed, then rely on a consistent way of working it up. The Diagnostic and Statistical Manual of Mental Disorders (DSM, http://www.dsm5.org) offers a conservative approach, so you usually can’t go wrong by following it.

7. Don’t gloss over the possibility of delirium.

It is probably the most frequently missed diagnosis in the general hospital. “We usually recognize it when patients are agitated, but most patients aren’t,” Dr. Boland says. “If anything, they are hypoactive or change throughout the day. When a patient seems confused, we want to find a cause, but that cause isn’t always obvious.”

These situations are particularly true in fragile patients (e.g. the very old or those with dementia). Sometimes medical problems that seem very minor can “push them over the edge,” he adds. When you do expect dementia, the main treatments revolve around medically stabilizing the patient, and psychiatric medications are a minor part of the management, if at all.

8. Take the time to really listen.

Patients’ biggest complaint is that physicians don’t listen. “The best doctors in any specialty know how to communicate with patients,” Dr. Boland says. “It doesn’t take longer—in fact, good communication usually saves time. But it does take attention and focus to let the patient try and explain what is going on with them. It always pays off in the end.”

9. Always remain conscious of alcohol and substance abuse.

Although it might not be the reason patients are hospitalized, it is one of the more common underlying causes. When this is the case, don’t be nihilistic. Many patients improve with treatment, and some get better simply because a physician explained how damaging substance abuse can be to their health, Dr. Boland says.

 

For those in complete remission from a past addiction to alcohol, benzodiazepines, opiates, or a combination thereof, beware that prescribing certain medications puts them at substantially increased risk for relapse. Use alternative treatments whenever possible; if clinically indicated, be certain that these patients have a safety net to prevent relapse. Patients with severe pain need effective relief.

“If a patient has been exposed to significant dosages of pain medications in the past, their neurotransmitters will have physically adapted,” says Dr. Worley, president-elect of the Academy of Psychosomatic Medicine. “They will require higher doses than normal for effective pain relief.”

10. Monitor patients’ vital signs for autonomic instability.

“Patients in withdrawal from physiologically addictive medications may have forgotten to tell you that they were taking these medications,” Dr. Worley says. “Abrupt discontinuation can cause incapacitating anxiety and life-threatening delirium.”

11. Avoid arguments and power struggles with difficult or demanding patients.

Put on your thick skin. Don’t take insults or slights personally. And resist the urge to flee or counterattack. Instead, Dr. Worley suggests hospitalists stay calm and focused on providing the best medical care that they can. “Chronically noncompliant patients can be excruciatingly frustrating to care for when they don’t follow through on what they are repeatedly advised to do, but lecturing more vigorously at them won’t help,” she says. “It only makes them shut down more and feel more helpless and you more exhausted. Shift to more of a listening mode and inquire about what they hope to accomplish by coming to you for help.”

12. Adapt your vocabulary to the patient’s and family’s level of understanding.

After your explanation, ask them, “Do me a favor and explain back to me in your words what I said. I want to be sure I got across what I wanted to say.” Then ask whether they have any questions. Also know that all too often patients are so anxious and upset that they are “emotionally flooded” and unable to hear much of what you communicated. You can save a lot of time if they understand you in the first place.

13. Be mindful of your nonverbal cues.

A majority of communication is nonverbal, and your facial expressions, gestures, and body posture speak volumes to patients and family members. “The innocent tilt of a chin upwards while peering through bifocals can be misperceived as arrogance,” Dr. Worley says. “The thoughtful furled brow of contemplation may be misconstrued as irritability or disapproval.”

14. Always take suicide risk seriously.

It’s better to call a psychiatrist unnecessarily than to overlook a patient at risk for suicide. Benzodiazepines, alcohol, or a combination of the two might reduce inhibition and increase the likelihood of a suicide attempt. Be sure to assess suicidal ideation, intent, and lethality of suicide attempt.

“Hopelessness about the future correlates with completed suicide,” says Gregory Ruhnke, MD, assistant professor in the section of hospital medicine at the University of Chicago Pritzker School of Medicine. “Additionally, it is helpful to ask about the four H’s: Hate, humiliation, hostility, handguns.”

15. Beware of patients who exhibit attention-seeking behavior, which can have a negative impact on the healthcare team and the care provided to the patient.

“The patient may become angry and engage in splitting, whereby he or she emphatically expresses the view that certain caregivers are all good or all bad. This may reflect such [a] patient’s desire to divide the caregivers into opposing factions. It’s a maladaptive way of coping,” says Marie Tobin, MD, associate professor of psychiatry and consult-liaison psychiatrist at the Pritzker School of Medicine. This can be very time-consuming, and it can breed hostility among colleagues. “Communication between caregivers is really important in creating a unified treatment plan that is coherently presented to the patient in a single voice.”

 

Fortunately, she says, “even though these situations can arise, they are the exception rather than the rule.”

16. Consider the possibility of a factitious disorder when there is a lack of objective evidence for pathology to explain a patient’s symptoms despite extensive evaluation.

For example, Dr. Ruhnke says, if a patient complains of hemoptysis and hematochezia with negative endoscopies, talk to the nurse about the patient’s diet, and be suspicious if it includes only red foods and liquids. The most common symptoms among patients who come to medical attention because of factitious disorders are diarrhea, fever of unknown origin, gastrointestinal bleeding, hematuria, seizures, and hypoglycemia.

17. Choose an intravenous psychiatric medication when a patient with severe and persistent mental illness should avoid oral medication for a procedure.

A patient with schizophrenia or bipolar disorder could experience a severe psychiatric episode without psychiatric medication. An appropriate alternative, perhaps administered intravenously if necessary, “can make all the difference in the world,” says Christopher Dobbelstein, MD, assistant professor of psychiatry at the University of Pittsburgh School of Medicine.

18. Listen to your instincts.

Medical teams can handle many psychiatric issues. Straightforward delirium is a good example. The bigger question, which takes experience and confidence, is to recognize when a line has been crossed. “The decision to consult psychiatry is not formulaic,” Dr. Dobbelstein says.

Sometimes a patient is acting strangely, and the team can’t explain why a psychiatrist could offer sound advice. “That’s when they should trust their instincts and consult us,” he says, “because the patient likely does have something more complex going on.”

19. Arrange for post-discharge follow-up with a primary-care physician or psychiatrist.

Sometimes psychiatric medications are started without good oversight. Suicide risk is highest during the weeks following an inpatient psychiatric admission, so a patient should see an outpatient mental health provider within seven days after hospital discharge, says NAMI’s Dr. Duckworth.

20. Extend genuine compassion to your patients.

“This is the secret to achieving a lifelong rewarding career in medicine,” Dr. Worley says, “and is the most important ingredient in positive outcomes.”

---

Susan Kreimer is a freelance writer in New York.

20 Things At A Glance

1. Acknowledge that collaboration between health professionals is important, even when schedules are hectic and reimbursement doesn’t cover these discussions.
2. Secure patient consent before consulting a psychiatrist.
3. Present the psychiatrist’s anticipated insight as a benefit to the patient.
4. Ask the patient if it’s all right to discuss their health status and needs with family members.
5. Recognize that psychiatric illness is real, not imaginary.
6. Realize that not all sadness constitutes depression.
7. Don’t gloss over the possibility of delirium.
8. Take the time to really listen.
9. Always remain conscious of alcohol and substance abuse.
10. Monitor patients’ vital signs for autonomic instability.
11. Avoid arguments and power struggles with difficult or demanding patients.
12. Adapt your vocabulary to the patient’s and family’s level of understanding.
13. Be mindful of your nonverbal cues.
14. Always take suicide risk seriously.
15. Beware of patients who exhibit attention-seeking behavior, which can have a negative impact on the healthcare team and the care provided to the patient.
16. Consider the possibility of a factitious disorder when there is a lack of objective evidence for pathology to explain a patient’s symptoms despite extensive evaluation.
17. Choose an intravenous psychiatric medication when a patient with severe and persistent mental illness should avoid oral medication for a procedure.
18. Listen to your instincts.
19. Arrange for post-discharge follow-up with a primary-care physician or psychiatrist.
20. Extend genuine compassion to your patients.

Patients can be hospitalized with chest pain, a kidney infection, pneumonia, or myriad other medical conditions. Hospital stays on occasion upend a patient’s mental state, with upcoming tests, surgery, or other procedures triggering anxiety or other conditions.

That doesn’t mean these patients have psychiatric or psychological problems, but some of them might. Hospitalists walk a fine line in deciding when to consult a psychiatrist in certain cases.

“A common mistake, when it comes to psychiatry, for hospitalists is to either think they know too much or they know too little,” says Philip R. Muskin, MD, professor of clinical psychiatry at Columbia University College of Physicians & Surgeons in New York City. “Sometimes they’re too quick to call a psychiatrist, and sometimes they’re too slow to call a specialist because they don’t think it’s a psychiatric problem.”

The Hospitalist asked more than half a dozen specialists in psychiatry and hospital medicine to shed light on when to seek additional expertise—and how to inform patients about your request to do so. “If I say, ‘You need to see a psychiatrist,’ it carries some stigma,” says Dr. Muskin, who is the chief of consultation for liaison psychiatry at New York-Presbyterian Medical Center’s Columbia campus. “We have to be sensitive to that.”

So how can you more comfortably approach psychiatric or psychological issues in the hospital setting?

1. Acknowledge that collaboration between health professionals is important, even when schedules are hectic and reimbursement doesn’t cover these discussions.

“Because of the overwhelming comorbidity between psychiatric illness and medical illness, it’s important to have some communication between the emergency room, caregiver, the hospitalist, and the psychiatrist,” says Ken Duckworth, MD, medical director of the National Alliance on Mental Illness (NAMI) and an assistant clinical professor of psychiatry at Harvard Medical School in Boston. “We know that people with mental health vulnerabilities consume a much higher amount of medical services. That’s a well-known phenomenon.”

2. Secure patient consent before consulting a psychiatrist.

“You need the patient’s permission,” Dr. Duckworth says. “That’s an important piece of the equation.” There are exceptions in emergencies, and the laws pertaining to this vary by state. Verbal consent may suffice if written authorization is already on file. If a patient declines, a hospitalist has to respect those wishes.

 

3. Present the psychiatrist’s anticipated insight as a benefit to the patient.

Physicians sometimes are uncomfortable informing their patients that they’re asking for a psychiatric consultation. They fear a bad reaction, such as “You think I’m crazy?” The consultation will be more useful if the patient is open and accepting of the process. For example, tell your patient at the outset: “I’d really like you to talk to one of my colleagues, whom I trust a great deal. He/she is an expert in the overlapping area between the body and the brain. I need their help so that I can take better care of you,’” says Linda L.M. Worley, MD, FAPM, professor of psychiatry and obstetrics and gynecology at the University of Arkansas for Medical Sciences in Little Rock.

4. Ask the patient if it’s all right to discuss their health status and needs with family members.

Get to know their names. Identify the medical expert in the family and be certain to involve them in overall discussions and the decision-making process, Dr. Worley says.

5. Recognize that psychiatric illness is real, not imaginary.

The illness “should be placed in exactly the same arena as other medical problems,” Dr. Muskin says. Patients with psychiatric conditions are “not weak. They’re not dumb. It’s not all in their head.” Their mental health “deserves the same attention as their heart, stomach, or kidneys.”

6. Realize that not all sadness constitutes depression.

“There are many reasons why people cry or feel down, and most are not psychiatric illnesses. Depression is often overdiagnosed, leading to wasted time and inappropriate medications,” says Robert Boland, MD, professor of psychiatry and human behavior at Brown University’s Warren Alpert School of Medicine in Providence, R.I. “Unfortunately, the opposite is also true. Depression is often missed in the hospital.”

So how does a hospitalist reconcile those extremes? First, consider depression in any patient who is predisposed, then rely on a consistent way of working it up. The Diagnostic and Statistical Manual of Mental Disorders (DSM, http://www.dsm5.org) offers a conservative approach, so you usually can’t go wrong by following it.

7. Don’t gloss over the possibility of delirium.

It is probably the most frequently missed diagnosis in the general hospital. “We usually recognize it when patients are agitated, but most patients aren’t,” Dr. Boland says. “If anything, they are hypoactive or change throughout the day. When a patient seems confused, we want to find a cause, but that cause isn’t always obvious.”

These situations are particularly true in fragile patients (e.g. the very old or those with dementia). Sometimes medical problems that seem very minor can “push them over the edge,” he adds. When you do expect dementia, the main treatments revolve around medically stabilizing the patient, and psychiatric medications are a minor part of the management, if at all.

8. Take the time to really listen.

Patients’ biggest complaint is that physicians don’t listen. “The best doctors in any specialty know how to communicate with patients,” Dr. Boland says. “It doesn’t take longer—in fact, good communication usually saves time. But it does take attention and focus to let the patient try and explain what is going on with them. It always pays off in the end.”

9. Always remain conscious of alcohol and substance abuse.

Although it might not be the reason patients are hospitalized, it is one of the more common underlying causes. When this is the case, don’t be nihilistic. Many patients improve with treatment, and some get better simply because a physician explained how damaging substance abuse can be to their health, Dr. Boland says.

 

For those in complete remission from a past addiction to alcohol, benzodiazepines, opiates, or a combination thereof, beware that prescribing certain medications puts them at substantially increased risk for relapse. Use alternative treatments whenever possible; if clinically indicated, be certain that these patients have a safety net to prevent relapse. Patients with severe pain need effective relief.

“If a patient has been exposed to significant dosages of pain medications in the past, their neurotransmitters will have physically adapted,” says Dr. Worley, president-elect of the Academy of Psychosomatic Medicine. “They will require higher doses than normal for effective pain relief.”

10. Monitor patients’ vital signs for autonomic instability.

“Patients in withdrawal from physiologically addictive medications may have forgotten to tell you that they were taking these medications,” Dr. Worley says. “Abrupt discontinuation can cause incapacitating anxiety and life-threatening delirium.”

11. Avoid arguments and power struggles with difficult or demanding patients.

Put on your thick skin. Don’t take insults or slights personally. And resist the urge to flee or counterattack. Instead, Dr. Worley suggests hospitalists stay calm and focused on providing the best medical care that they can. “Chronically noncompliant patients can be excruciatingly frustrating to care for when they don’t follow through on what they are repeatedly advised to do, but lecturing more vigorously at them won’t help,” she says. “It only makes them shut down more and feel more helpless and you more exhausted. Shift to more of a listening mode and inquire about what they hope to accomplish by coming to you for help.”

12. Adapt your vocabulary to the patient’s and family’s level of understanding.

After your explanation, ask them, “Do me a favor and explain back to me in your words what I said. I want to be sure I got across what I wanted to say.” Then ask whether they have any questions. Also know that all too often patients are so anxious and upset that they are “emotionally flooded” and unable to hear much of what you communicated. You can save a lot of time if they understand you in the first place.

13. Be mindful of your nonverbal cues.

A majority of communication is nonverbal, and your facial expressions, gestures, and body posture speak volumes to patients and family members. “The innocent tilt of a chin upwards while peering through bifocals can be misperceived as arrogance,” Dr. Worley says. “The thoughtful furled brow of contemplation may be misconstrued as irritability or disapproval.”

14. Always take suicide risk seriously.

It’s better to call a psychiatrist unnecessarily than to overlook a patient at risk for suicide. Benzodiazepines, alcohol, or a combination of the two might reduce inhibition and increase the likelihood of a suicide attempt. Be sure to assess suicidal ideation, intent, and lethality of suicide attempt.

“Hopelessness about the future correlates with completed suicide,” says Gregory Ruhnke, MD, assistant professor in the section of hospital medicine at the University of Chicago Pritzker School of Medicine. “Additionally, it is helpful to ask about the four H’s: Hate, humiliation, hostility, handguns.”

15. Beware of patients who exhibit attention-seeking behavior, which can have a negative impact on the healthcare team and the care provided to the patient.

“The patient may become angry and engage in splitting, whereby he or she emphatically expresses the view that certain caregivers are all good or all bad. This may reflect such [a] patient’s desire to divide the caregivers into opposing factions. It’s a maladaptive way of coping,” says Marie Tobin, MD, associate professor of psychiatry and consult-liaison psychiatrist at the Pritzker School of Medicine. This can be very time-consuming, and it can breed hostility among colleagues. “Communication between caregivers is really important in creating a unified treatment plan that is coherently presented to the patient in a single voice.”

 

Fortunately, she says, “even though these situations can arise, they are the exception rather than the rule.”

16. Consider the possibility of a factitious disorder when there is a lack of objective evidence for pathology to explain a patient’s symptoms despite extensive evaluation.

For example, Dr. Ruhnke says, if a patient complains of hemoptysis and hematochezia with negative endoscopies, talk to the nurse about the patient’s diet, and be suspicious if it includes only red foods and liquids. The most common symptoms among patients who come to medical attention because of factitious disorders are diarrhea, fever of unknown origin, gastrointestinal bleeding, hematuria, seizures, and hypoglycemia.

17. Choose an intravenous psychiatric medication when a patient with severe and persistent mental illness should avoid oral medication for a procedure.

A patient with schizophrenia or bipolar disorder could experience a severe psychiatric episode without psychiatric medication. An appropriate alternative, perhaps administered intravenously if necessary, “can make all the difference in the world,” says Christopher Dobbelstein, MD, assistant professor of psychiatry at the University of Pittsburgh School of Medicine.

18. Listen to your instincts.

Medical teams can handle many psychiatric issues. Straightforward delirium is a good example. The bigger question, which takes experience and confidence, is to recognize when a line has been crossed. “The decision to consult psychiatry is not formulaic,” Dr. Dobbelstein says.

Sometimes a patient is acting strangely, and the team can’t explain why a psychiatrist could offer sound advice. “That’s when they should trust their instincts and consult us,” he says, “because the patient likely does have something more complex going on.”

19. Arrange for post-discharge follow-up with a primary-care physician or psychiatrist.

Sometimes psychiatric medications are started without good oversight. Suicide risk is highest during the weeks following an inpatient psychiatric admission, so a patient should see an outpatient mental health provider within seven days after hospital discharge, says NAMI’s Dr. Duckworth.

20. Extend genuine compassion to your patients.

“This is the secret to achieving a lifelong rewarding career in medicine,” Dr. Worley says, “and is the most important ingredient in positive outcomes.”

---

Susan Kreimer is a freelance writer in New York.

Among the challenging psychiatric conditions hospitalists encounter are factitious disorders in which patients fabricate symptoms to draw attention, elicit empathy, and intentionally take on a sick role.

For example, at the University of Chicago, a patient in her 30s complained of blood in her urine, stool, and vomit. The staff performed an extensive evaluation, including laboratory analyses and upper and lower gastrointestinal endoscopies, but they found no source of the alleged bleeding, says Gregory Ruhnke, MD, MS, MPH, assistant professor in the section of hospital medicine at the university’s Pritzker School of Medicine.

After lengthy discussions with several nurses and direct observation, caregivers became suspicious, in part, because the patient was ordering predominantly red food and drinks, such as Jell-O and cranberry juice. She emptied them into a basin and claimed to have vomited blood, Dr. Ruhnke says. Lab results confirmed the absence of any blood.

In this instance, the patient’s objective was “to stay in the hospital,” says Marie Tobin, MD, associate professor of psychiatry and consult-liaison psychiatrist at the University of Chicago. “That’s the goal—to be taken care of as a patient.”

The staff later learned that the patient had engaged in similar tactics at other hospitals. When physicians wanted to obtain medical records from those facilities, the patient declined to grant permission.

“We do have to respect the patient’s confidentiality,” Dr. Tobin says. “If they refuse, we really can’t [obtain their records].”

Aside from previous records, “room searches can help confirm suspicions,” Dr. Ruhnke says. Security personnel should conduct a room search when necessary. This preserves the patient’s therapeutic rapport with healthcare providers. A search could uncover knives or needles, which a patient could use to inflict harm. More important, room searches can resolve inconsistencies and help hospitalists avoid ordering unjustified tests and procedures.

“It’s not a pleasant situation, but it is for safety,” Dr. Tobin says of investigations.

“These are people who can be at high risk to themselves.” TH

Susan Kreimer is a freelance writer in New York.

 

Among the challenging psychiatric conditions hospitalists encounter are factitious disorders in which patients fabricate symptoms to draw attention, elicit empathy, and intentionally take on a sick role.

For example, at the University of Chicago, a patient in her 30s complained of blood in her urine, stool, and vomit. The staff performed an extensive evaluation, including laboratory analyses and upper and lower gastrointestinal endoscopies, but they found no source of the alleged bleeding, says Gregory Ruhnke, MD, MS, MPH, assistant professor in the section of hospital medicine at the university’s Pritzker School of Medicine.

After lengthy discussions with several nurses and direct observation, caregivers became suspicious, in part, because the patient was ordering predominantly red food and drinks, such as Jell-O and cranberry juice. She emptied them into a basin and claimed to have vomited blood, Dr. Ruhnke says. Lab results confirmed the absence of any blood.

In this instance, the patient’s objective was “to stay in the hospital,” says Marie Tobin, MD, associate professor of psychiatry and consult-liaison psychiatrist at the University of Chicago. “That’s the goal—to be taken care of as a patient.”

The staff later learned that the patient had engaged in similar tactics at other hospitals. When physicians wanted to obtain medical records from those facilities, the patient declined to grant permission.

“We do have to respect the patient’s confidentiality,” Dr. Tobin says. “If they refuse, we really can’t [obtain their records].”

Aside from previous records, “room searches can help confirm suspicions,” Dr. Ruhnke says. Security personnel should conduct a room search when necessary. This preserves the patient’s therapeutic rapport with healthcare providers. A search could uncover knives or needles, which a patient could use to inflict harm. More important, room searches can resolve inconsistencies and help hospitalists avoid ordering unjustified tests and procedures.

“It’s not a pleasant situation, but it is for safety,” Dr. Tobin says of investigations.

“These are people who can be at high risk to themselves.” TH

Susan Kreimer is a freelance writer in New York.

 

Among the challenging psychiatric conditions hospitalists encounter are factitious disorders in which patients fabricate symptoms to draw attention, elicit empathy, and intentionally take on a sick role.

For example, at the University of Chicago, a patient in her 30s complained of blood in her urine, stool, and vomit. The staff performed an extensive evaluation, including laboratory analyses and upper and lower gastrointestinal endoscopies, but they found no source of the alleged bleeding, says Gregory Ruhnke, MD, MS, MPH, assistant professor in the section of hospital medicine at the university’s Pritzker School of Medicine.

After lengthy discussions with several nurses and direct observation, caregivers became suspicious, in part, because the patient was ordering predominantly red food and drinks, such as Jell-O and cranberry juice. She emptied them into a basin and claimed to have vomited blood, Dr. Ruhnke says. Lab results confirmed the absence of any blood.

In this instance, the patient’s objective was “to stay in the hospital,” says Marie Tobin, MD, associate professor of psychiatry and consult-liaison psychiatrist at the University of Chicago. “That’s the goal—to be taken care of as a patient.”

The staff later learned that the patient had engaged in similar tactics at other hospitals. When physicians wanted to obtain medical records from those facilities, the patient declined to grant permission.

“We do have to respect the patient’s confidentiality,” Dr. Tobin says. “If they refuse, we really can’t [obtain their records].”

Aside from previous records, “room searches can help confirm suspicions,” Dr. Ruhnke says. Security personnel should conduct a room search when necessary. This preserves the patient’s therapeutic rapport with healthcare providers. A search could uncover knives or needles, which a patient could use to inflict harm. More important, room searches can resolve inconsistencies and help hospitalists avoid ordering unjustified tests and procedures.

“It’s not a pleasant situation, but it is for safety,” Dr. Tobin says of investigations.

“These are people who can be at high risk to themselves.” TH

Susan Kreimer is a freelance writer in New York.

 

Click here to listen to Dr. Duckworth

Click here to listen to Dr. Duckworth

Click here to listen to Dr. Duckworth