Zahir Kanjee, MD, MPH

We read with interest the perspective of Drs Rodman and Warnock,¹ but disagree with the authors on several points. We find that the routine daily physical examination, often neglected or unappreciated amidst technological advances and new diagnostic testing, provides significant value to both hospitalist and patient in terms of diagnosis, treatment, patient-centered care, and maintaining the patient-doctor relationship.

First, the daily physical exam provides the practice that hospitalists need to develop and maintain necessary diagnostic finesse. We are taught fundamental physical exam maneuvers in medical school, but these skills often atrophy during residency and throughout our careers.² This leaves us, as practicing physicians, potentially worse at these competencies than when we were students. The daily physical exam, on the other hand, provides frequent and effective practice to keep up and build upon these skills. We gain in part from our repeated normal exams, which help us to skillfully recognize the rare abnormal finding; a hospitalist must likely feel hundreds of normal abdomens to reliably discover a furtive abdominal mass. Our exams also benefit from several forms of prompt and relevant feedback, including that which is provided by subspecialist consultants (like a cardiologist agreeing with your assessment of jugular venous pressure) and other diagnostic tests (like the echocardiogram without the valvulopathy thought to be detected at the bedside). The physical examination is best learned at the bedside, and the daily exam offers an unparalleled opportunity to do so. Such continual skill improvement is necessary for hospitalists to accurately apply data from the evidence-based physical diagnosis literature. Many studies of the utility of various physical exam findings³ involve maneuvers performed by experts; to truly apply their results to our generalist practice, we are required to push ourselves to obtain the diagnostic expertise of the specialist. The daily physical examination, being the most concrete way for hospitalists to do so, is therefore essential to practicing better evidence-based physical diagnosis.

Beyond these larger benefits of the daily physical examination on our own practice and skills, patients in our care benefit diagnostically from these exams as well. Time and again, we see an inadequate or incomplete physical exam leading to errors or adverse patient outcomes.^4,5 Even after completion of initial laboratory and imaging tests, laying of hands and stethoscope can lead to dramatic changes in inpatient diagnosis and management.⁶ The subsequent routine daily physical provides fresh opportunities to reexamine the evidence for or against our own working diagnoses and management plans. The adage that “you don’t know what you don’t know” is especially fitting here. We often do not know to look for and rule a disease process in or out if it is not on our initial differential on hospital day one or two; the daily physical exam allows us to be on the lookout for diagnoses we have not yet considered. The two of us have more than once made a serendipitous discovery of a new rash or other physical finding on hospital day three or four that helps suggest another, and ultimately correct, final diagnosis. Particularly in a setting in which so many inpatient diagnoses are wrong and can lead to patient harm,⁷ the daily physical examination provides an important check on our own diagnostic reasoning.

Even if we are right about the diagnosis, the daily exam also allows for timely recognition of complications from our management. Listening to each patient’s lungs every day, including those of patients with seemingly unrelated lower-extremity cellulitis, means we will more promptly notice when they retain fluid due to as yet unknown underlying heart failure. Those subtle bibasilar crackles not only become diagnostically useful, but also allow us the possibility of intervening and changing course even before the patient reports shortness of breath or the nurse notes hypoxemia on routine vital signs a day or two later. In an era when our treatment regimens are more complex, with frequent off-target results and side effects, the daily exam is a key screening tool for adverse outcomes in an increasingly ill population. Having a frequently updated and accurate baseline exam is also exceptionally important in the event of sudden neurologic deficits; an inpatient with new facial droop and left-arm weakness at 10 am has much better treatment options if their hospitalist has conducted a routine basic neurologic exam that morning and can confidently provide a time when they were “last known well.”

Finally, the daily physical examination is important to patient-centered care and potentially preventing physician burnout.⁸ Patients have more confidence in us when we conduct a thorough exam. The ritual of the physical exam is also an important contributor to the patient-doctor relationship, and a daily exam can help strengthen that bond each morning.⁹ Such benefits also extend to physicians. Hospitalists are spending less and less time at the bedside,¹⁰ a reality at least partially responsible for rising rates of burnout.¹¹ We all went into clinical medicine to take care of and connect with people. The daily physical examination offers valuable time to show our patients we care about them while also giving us the opportunity to spend time with them, rather than with the “iPatient” that can otherwise become our focus.¹² In this way, the daily physical examination can be immensely satisfying and may not only inoculate against burnout but also contribute to a stronger patient-doctor relationship.

For so many reasons, the daily physical exam is of great benefit to hospitalists looking to develop and maintain diagnostic skills, to our patients as we stay on the lookout for unexpected diagnoses and complications, and to the relationships we have with those for whom we care. It is a practice worth not only continuing but celebrating.

We read with interest the perspective of Drs Rodman and Warnock,¹ but disagree with the authors on several points. We find that the routine daily physical examination, often neglected or unappreciated amidst technological advances and new diagnostic testing, provides significant value to both hospitalist and patient in terms of diagnosis, treatment, patient-centered care, and maintaining the patient-doctor relationship.

First, the daily physical exam provides the practice that hospitalists need to develop and maintain necessary diagnostic finesse. We are taught fundamental physical exam maneuvers in medical school, but these skills often atrophy during residency and throughout our careers.² This leaves us, as practicing physicians, potentially worse at these competencies than when we were students. The daily physical exam, on the other hand, provides frequent and effective practice to keep up and build upon these skills. We gain in part from our repeated normal exams, which help us to skillfully recognize the rare abnormal finding; a hospitalist must likely feel hundreds of normal abdomens to reliably discover a furtive abdominal mass. Our exams also benefit from several forms of prompt and relevant feedback, including that which is provided by subspecialist consultants (like a cardiologist agreeing with your assessment of jugular venous pressure) and other diagnostic tests (like the echocardiogram without the valvulopathy thought to be detected at the bedside). The physical examination is best learned at the bedside, and the daily exam offers an unparalleled opportunity to do so. Such continual skill improvement is necessary for hospitalists to accurately apply data from the evidence-based physical diagnosis literature. Many studies of the utility of various physical exam findings³ involve maneuvers performed by experts; to truly apply their results to our generalist practice, we are required to push ourselves to obtain the diagnostic expertise of the specialist. The daily physical examination, being the most concrete way for hospitalists to do so, is therefore essential to practicing better evidence-based physical diagnosis.

Beyond these larger benefits of the daily physical examination on our own practice and skills, patients in our care benefit diagnostically from these exams as well. Time and again, we see an inadequate or incomplete physical exam leading to errors or adverse patient outcomes.^4,5 Even after completion of initial laboratory and imaging tests, laying of hands and stethoscope can lead to dramatic changes in inpatient diagnosis and management.⁶ The subsequent routine daily physical provides fresh opportunities to reexamine the evidence for or against our own working diagnoses and management plans. The adage that “you don’t know what you don’t know” is especially fitting here. We often do not know to look for and rule a disease process in or out if it is not on our initial differential on hospital day one or two; the daily physical exam allows us to be on the lookout for diagnoses we have not yet considered. The two of us have more than once made a serendipitous discovery of a new rash or other physical finding on hospital day three or four that helps suggest another, and ultimately correct, final diagnosis. Particularly in a setting in which so many inpatient diagnoses are wrong and can lead to patient harm,⁷ the daily physical examination provides an important check on our own diagnostic reasoning.

Even if we are right about the diagnosis, the daily exam also allows for timely recognition of complications from our management. Listening to each patient’s lungs every day, including those of patients with seemingly unrelated lower-extremity cellulitis, means we will more promptly notice when they retain fluid due to as yet unknown underlying heart failure. Those subtle bibasilar crackles not only become diagnostically useful, but also allow us the possibility of intervening and changing course even before the patient reports shortness of breath or the nurse notes hypoxemia on routine vital signs a day or two later. In an era when our treatment regimens are more complex, with frequent off-target results and side effects, the daily exam is a key screening tool for adverse outcomes in an increasingly ill population. Having a frequently updated and accurate baseline exam is also exceptionally important in the event of sudden neurologic deficits; an inpatient with new facial droop and left-arm weakness at 10 am has much better treatment options if their hospitalist has conducted a routine basic neurologic exam that morning and can confidently provide a time when they were “last known well.”

Finally, the daily physical examination is important to patient-centered care and potentially preventing physician burnout.⁸ Patients have more confidence in us when we conduct a thorough exam. The ritual of the physical exam is also an important contributor to the patient-doctor relationship, and a daily exam can help strengthen that bond each morning.⁹ Such benefits also extend to physicians. Hospitalists are spending less and less time at the bedside,¹⁰ a reality at least partially responsible for rising rates of burnout.¹¹ We all went into clinical medicine to take care of and connect with people. The daily physical examination offers valuable time to show our patients we care about them while also giving us the opportunity to spend time with them, rather than with the “iPatient” that can otherwise become our focus.¹² In this way, the daily physical examination can be immensely satisfying and may not only inoculate against burnout but also contribute to a stronger patient-doctor relationship.

For so many reasons, the daily physical exam is of great benefit to hospitalists looking to develop and maintain diagnostic skills, to our patients as we stay on the lookout for unexpected diagnoses and complications, and to the relationships we have with those for whom we care. It is a practice worth not only continuing but celebrating.

We read with interest the perspective of Drs Rodman and Warnock,¹ but disagree with the authors on several points. We find that the routine daily physical examination, often neglected or unappreciated amidst technological advances and new diagnostic testing, provides significant value to both hospitalist and patient in terms of diagnosis, treatment, patient-centered care, and maintaining the patient-doctor relationship.

First, the daily physical exam provides the practice that hospitalists need to develop and maintain necessary diagnostic finesse. We are taught fundamental physical exam maneuvers in medical school, but these skills often atrophy during residency and throughout our careers.² This leaves us, as practicing physicians, potentially worse at these competencies than when we were students. The daily physical exam, on the other hand, provides frequent and effective practice to keep up and build upon these skills. We gain in part from our repeated normal exams, which help us to skillfully recognize the rare abnormal finding; a hospitalist must likely feel hundreds of normal abdomens to reliably discover a furtive abdominal mass. Our exams also benefit from several forms of prompt and relevant feedback, including that which is provided by subspecialist consultants (like a cardiologist agreeing with your assessment of jugular venous pressure) and other diagnostic tests (like the echocardiogram without the valvulopathy thought to be detected at the bedside). The physical examination is best learned at the bedside, and the daily exam offers an unparalleled opportunity to do so. Such continual skill improvement is necessary for hospitalists to accurately apply data from the evidence-based physical diagnosis literature. Many studies of the utility of various physical exam findings³ involve maneuvers performed by experts; to truly apply their results to our generalist practice, we are required to push ourselves to obtain the diagnostic expertise of the specialist. The daily physical examination, being the most concrete way for hospitalists to do so, is therefore essential to practicing better evidence-based physical diagnosis.

Beyond these larger benefits of the daily physical examination on our own practice and skills, patients in our care benefit diagnostically from these exams as well. Time and again, we see an inadequate or incomplete physical exam leading to errors or adverse patient outcomes.^4,5 Even after completion of initial laboratory and imaging tests, laying of hands and stethoscope can lead to dramatic changes in inpatient diagnosis and management.⁶ The subsequent routine daily physical provides fresh opportunities to reexamine the evidence for or against our own working diagnoses and management plans. The adage that “you don’t know what you don’t know” is especially fitting here. We often do not know to look for and rule a disease process in or out if it is not on our initial differential on hospital day one or two; the daily physical exam allows us to be on the lookout for diagnoses we have not yet considered. The two of us have more than once made a serendipitous discovery of a new rash or other physical finding on hospital day three or four that helps suggest another, and ultimately correct, final diagnosis. Particularly in a setting in which so many inpatient diagnoses are wrong and can lead to patient harm,⁷ the daily physical examination provides an important check on our own diagnostic reasoning.

Even if we are right about the diagnosis, the daily exam also allows for timely recognition of complications from our management. Listening to each patient’s lungs every day, including those of patients with seemingly unrelated lower-extremity cellulitis, means we will more promptly notice when they retain fluid due to as yet unknown underlying heart failure. Those subtle bibasilar crackles not only become diagnostically useful, but also allow us the possibility of intervening and changing course even before the patient reports shortness of breath or the nurse notes hypoxemia on routine vital signs a day or two later. In an era when our treatment regimens are more complex, with frequent off-target results and side effects, the daily exam is a key screening tool for adverse outcomes in an increasingly ill population. Having a frequently updated and accurate baseline exam is also exceptionally important in the event of sudden neurologic deficits; an inpatient with new facial droop and left-arm weakness at 10 am has much better treatment options if their hospitalist has conducted a routine basic neurologic exam that morning and can confidently provide a time when they were “last known well.”

Finally, the daily physical examination is important to patient-centered care and potentially preventing physician burnout.⁸ Patients have more confidence in us when we conduct a thorough exam. The ritual of the physical exam is also an important contributor to the patient-doctor relationship, and a daily exam can help strengthen that bond each morning.⁹ Such benefits also extend to physicians. Hospitalists are spending less and less time at the bedside,¹⁰ a reality at least partially responsible for rising rates of burnout.¹¹ We all went into clinical medicine to take care of and connect with people. The daily physical examination offers valuable time to show our patients we care about them while also giving us the opportunity to spend time with them, rather than with the “iPatient” that can otherwise become our focus.¹² In this way, the daily physical examination can be immensely satisfying and may not only inoculate against burnout but also contribute to a stronger patient-doctor relationship.

For so many reasons, the daily physical exam is of great benefit to hospitalists looking to develop and maintain diagnostic skills, to our patients as we stay on the lookout for unexpected diagnoses and complications, and to the relationships we have with those for whom we care. It is a practice worth not only continuing but celebrating.

“If your time to you is worth savin’

Then you better start swimmin’ or you’ll sink like a stone

For the times they are a-changin’...”

–Bob Dylan

The Accreditation Council for Graduate Medical Education requires residency programs to limit and track trainee work hours to reduce the risk of fatigue, burnout, and medical errors. These hours are documented most often by self-report, at the cost of additional administrative burden for trainees and programs, dubious accuracy, and potentially incentivizing misrepresentation.¹

Thus, the study by Soleimani and colleagues² in this issue is a welcome addition to the literature on duty-hours tracking. Using timestamp data from the electronic health record (EHR), the authors developed and collected validity evidence for an automated computerized algorithm to measure how much time trainees were spending on clinical work. The study was conducted at a large academic internal medicine residency program and tracked 203 trainees working 14,610 days. The authors compared their results to trainee self-report data. Though the approach centered on EHR access logs, it accommodated common scenarios of time away from the computer while at the hospital (eg, during patient rounds). Crucially, the algorithm included EHR access while at home. The absolute discrepancy between the algorithm and self-report averaged 1.38 hours per day. Notably, EHR work at home accounted for about an extra hour per day. When considering in-hospital work alone, the authors found 3% to 13% of trainees exceeding 80-hour workweek limits, but when adding out-of-hospital work, this percentage rose to 10% to 21%.

The authors used inventive methods to improve accuracy. They prespecified EHR functions that constituted active clinical work, classifying reading without editing notes or placing orders simply as “educational study,” which they excluded from duty hours. They ensured that time spent off-site was included and that logins from personal devices while in-hospital were not double-counted. Caveats to the study include the limited generalizability for institutions without the computational resources to replicate the model. The authors acknowledged the inherent flaw in using trainee self-report as the “gold standard,” and potentially some subset of the results could have been corroborated with time-motion observation studies.³ The decision to exclude passive medical record review at home as work arguably discounts the integral value that the “chart biopsy” has on direct patient care; it probably led to systematic underestimation of duty hours for junior and senior residents, who may be most likely to contribute in this way. Similarly, not counting time spent with patients at the end of the day after sign-out risks undercounting hours as well. Nonetheless, this study represents a rigorously designed and scalable approach to meeting regulatory requirements that can potentially lighten the administrative task load for trainees, improve reporting accuracy, and facilitate research comparing work hours to other variables of interest (eg, efficiency). The model can be generalized to other specialties and could document workload for staff physicians as well.

Merits of the study aside, the algorithm underscores troubling realities about the practice of medicine in the 21st century. Do we now equate clinical work with time on the computer? Is our contribution as physicians defined primarily by our presence at the keyboard, rather than the bedside?⁴ Future research facilitated by automated hours tracking is likely to further elucidate a connection between time spent in the EHR with burnout⁴ and job dissatisfaction, and the premise of this study is emblematic of the erosion of clinical work-life boundaries that began even before the pandemic.⁵ While the “times they are a-changin’,” in this respect, it may not be for the better.

“If your time to you is worth savin’

Then you better start swimmin’ or you’ll sink like a stone

For the times they are a-changin’...”

–Bob Dylan

The Accreditation Council for Graduate Medical Education requires residency programs to limit and track trainee work hours to reduce the risk of fatigue, burnout, and medical errors. These hours are documented most often by self-report, at the cost of additional administrative burden for trainees and programs, dubious accuracy, and potentially incentivizing misrepresentation.¹

Thus, the study by Soleimani and colleagues² in this issue is a welcome addition to the literature on duty-hours tracking. Using timestamp data from the electronic health record (EHR), the authors developed and collected validity evidence for an automated computerized algorithm to measure how much time trainees were spending on clinical work. The study was conducted at a large academic internal medicine residency program and tracked 203 trainees working 14,610 days. The authors compared their results to trainee self-report data. Though the approach centered on EHR access logs, it accommodated common scenarios of time away from the computer while at the hospital (eg, during patient rounds). Crucially, the algorithm included EHR access while at home. The absolute discrepancy between the algorithm and self-report averaged 1.38 hours per day. Notably, EHR work at home accounted for about an extra hour per day. When considering in-hospital work alone, the authors found 3% to 13% of trainees exceeding 80-hour workweek limits, but when adding out-of-hospital work, this percentage rose to 10% to 21%.

The authors used inventive methods to improve accuracy. They prespecified EHR functions that constituted active clinical work, classifying reading without editing notes or placing orders simply as “educational study,” which they excluded from duty hours. They ensured that time spent off-site was included and that logins from personal devices while in-hospital were not double-counted. Caveats to the study include the limited generalizability for institutions without the computational resources to replicate the model. The authors acknowledged the inherent flaw in using trainee self-report as the “gold standard,” and potentially some subset of the results could have been corroborated with time-motion observation studies.³ The decision to exclude passive medical record review at home as work arguably discounts the integral value that the “chart biopsy” has on direct patient care; it probably led to systematic underestimation of duty hours for junior and senior residents, who may be most likely to contribute in this way. Similarly, not counting time spent with patients at the end of the day after sign-out risks undercounting hours as well. Nonetheless, this study represents a rigorously designed and scalable approach to meeting regulatory requirements that can potentially lighten the administrative task load for trainees, improve reporting accuracy, and facilitate research comparing work hours to other variables of interest (eg, efficiency). The model can be generalized to other specialties and could document workload for staff physicians as well.

Merits of the study aside, the algorithm underscores troubling realities about the practice of medicine in the 21st century. Do we now equate clinical work with time on the computer? Is our contribution as physicians defined primarily by our presence at the keyboard, rather than the bedside?⁴ Future research facilitated by automated hours tracking is likely to further elucidate a connection between time spent in the EHR with burnout⁴ and job dissatisfaction, and the premise of this study is emblematic of the erosion of clinical work-life boundaries that began even before the pandemic.⁵ While the “times they are a-changin’,” in this respect, it may not be for the better.

“If your time to you is worth savin’

Then you better start swimmin’ or you’ll sink like a stone

For the times they are a-changin’...”

–Bob Dylan

The Accreditation Council for Graduate Medical Education requires residency programs to limit and track trainee work hours to reduce the risk of fatigue, burnout, and medical errors. These hours are documented most often by self-report, at the cost of additional administrative burden for trainees and programs, dubious accuracy, and potentially incentivizing misrepresentation.¹

Thus, the study by Soleimani and colleagues² in this issue is a welcome addition to the literature on duty-hours tracking. Using timestamp data from the electronic health record (EHR), the authors developed and collected validity evidence for an automated computerized algorithm to measure how much time trainees were spending on clinical work. The study was conducted at a large academic internal medicine residency program and tracked 203 trainees working 14,610 days. The authors compared their results to trainee self-report data. Though the approach centered on EHR access logs, it accommodated common scenarios of time away from the computer while at the hospital (eg, during patient rounds). Crucially, the algorithm included EHR access while at home. The absolute discrepancy between the algorithm and self-report averaged 1.38 hours per day. Notably, EHR work at home accounted for about an extra hour per day. When considering in-hospital work alone, the authors found 3% to 13% of trainees exceeding 80-hour workweek limits, but when adding out-of-hospital work, this percentage rose to 10% to 21%.

The authors used inventive methods to improve accuracy. They prespecified EHR functions that constituted active clinical work, classifying reading without editing notes or placing orders simply as “educational study,” which they excluded from duty hours. They ensured that time spent off-site was included and that logins from personal devices while in-hospital were not double-counted. Caveats to the study include the limited generalizability for institutions without the computational resources to replicate the model. The authors acknowledged the inherent flaw in using trainee self-report as the “gold standard,” and potentially some subset of the results could have been corroborated with time-motion observation studies.³ The decision to exclude passive medical record review at home as work arguably discounts the integral value that the “chart biopsy” has on direct patient care; it probably led to systematic underestimation of duty hours for junior and senior residents, who may be most likely to contribute in this way. Similarly, not counting time spent with patients at the end of the day after sign-out risks undercounting hours as well. Nonetheless, this study represents a rigorously designed and scalable approach to meeting regulatory requirements that can potentially lighten the administrative task load for trainees, improve reporting accuracy, and facilitate research comparing work hours to other variables of interest (eg, efficiency). The model can be generalized to other specialties and could document workload for staff physicians as well.

Merits of the study aside, the algorithm underscores troubling realities about the practice of medicine in the 21st century. Do we now equate clinical work with time on the computer? Is our contribution as physicians defined primarily by our presence at the keyboard, rather than the bedside?⁴ Future research facilitated by automated hours tracking is likely to further elucidate a connection between time spent in the EHR with burnout⁴ and job dissatisfaction, and the premise of this study is emblematic of the erosion of clinical work-life boundaries that began even before the pandemic.⁵ While the “times they are a-changin’,” in this respect, it may not be for the better.

Siloed, adj.:

Kept in isolation in a way that hinders communication and cooperation . . .

—Merriam-Webster’s Dictionary

Humans naturally separate into groups, and the medical field is no exception. Being a member of a likeminded group, such as one’s specialty, can improve self-esteem and provide social organization: it feels good to identify with people we admire. Through culture, these specialty-based groups implicitly and explicitly guide and encourage positive attributes or behaviors like a hospitalist’s thoroughness or an emergency medicine physician’s steady management of unstable patients. Our specialties also provide support and understanding in challenging times. 

Despite these positive aspects, such divisions can negatively affect interprofessional relationships when our specialties become siloed. A potential side-effect of building up ourselves and our own groups is that we can implicitly put others down. For example, a hospitalist who spends extra time on the phone regularly updating each patient’s family will appropriately take pride in their practice, but over time this can also lead to an unreasonable assumption that physicians in other departments with different routines are not as committed to outstanding communication.

These rigid separations facilitate the fundamental attribution error, the tendency to ascribe a problem or disagreement to a colleague’s substandard character or ability. Imagine that the aforementioned hospitalist’s phone call delays a response to an admission page from the emergency room. The emergency medicine physician, who is waiting to sign out the admission while simultaneously managing many sick and complex patients, could assume the hospitalist is being disrespectful, rather than also working hard to provide the best care. Our siloed specialty identities can lead us to imagine the worst in each other and exacerbate intergroup conflict.¹

Silos in medicine also adversely affect patients. Poor communication and lack of information-sharing across disciplines can lead to medical error² and stifle dissemination of safer practices.³ Further, the unintentional disparaging of other medical specialties undermines the confidence our patients have in all of us; a patient within earshot of the hospitalist expressing annoyance at the “impatient” emergency medicine physician who “won’t stop paging,” or the emergency medicine physician complaining about the hospitalist who “refuses to call back,” will lose trust in each of their providers. 

We suggest three steps to reduce the negative impact of specialty silos in medicine: 

1. Get to know each other personally. Friendly conversation during work hours and social interaction outside the hospital can inoculate against interspecialty conflict by putting a human face on our colleagues. The resultant relationships make it easier to work together and see things from another’s perspective. 
2. Emphasize our shared affiliations.⁴ The greater the salience of a mutual identity as “healthcare providers,” the more likely we are to recognize each other’s unique contributions and question the stereotypes we imagine about one another. 
3. Consider projects across specialties. Interdepartmental data-sharing and joint meetings, including educational conferences, can facilitate situational awareness, synergy, and efficient problem-solving. 

Our medical specialties will continue to group together. While these groups can be a source of strength and meaning, silos can interfere with professional alliances and effective patient care. Mitigating the harmful effects of silos can benefit all of us and our patients.

Authors’ note: This article was previously published using the term “tribalism,” which we have since learned is derogatory to Indigenous Americans and others. We apologize for any harm. We have retracted and republished the article without this language. We appreciate readers teaching us how to choose better words so all people feel respected and valued.

Siloed, adj.:

Kept in isolation in a way that hinders communication and cooperation . . .

—Merriam-Webster’s Dictionary

Humans naturally separate into groups, and the medical field is no exception. Being a member of a likeminded group, such as one’s specialty, can improve self-esteem and provide social organization: it feels good to identify with people we admire. Through culture, these specialty-based groups implicitly and explicitly guide and encourage positive attributes or behaviors like a hospitalist’s thoroughness or an emergency medicine physician’s steady management of unstable patients. Our specialties also provide support and understanding in challenging times. 

Despite these positive aspects, such divisions can negatively affect interprofessional relationships when our specialties become siloed. A potential side-effect of building up ourselves and our own groups is that we can implicitly put others down. For example, a hospitalist who spends extra time on the phone regularly updating each patient’s family will appropriately take pride in their practice, but over time this can also lead to an unreasonable assumption that physicians in other departments with different routines are not as committed to outstanding communication.

These rigid separations facilitate the fundamental attribution error, the tendency to ascribe a problem or disagreement to a colleague’s substandard character or ability. Imagine that the aforementioned hospitalist’s phone call delays a response to an admission page from the emergency room. The emergency medicine physician, who is waiting to sign out the admission while simultaneously managing many sick and complex patients, could assume the hospitalist is being disrespectful, rather than also working hard to provide the best care. Our siloed specialty identities can lead us to imagine the worst in each other and exacerbate intergroup conflict.¹

Silos in medicine also adversely affect patients. Poor communication and lack of information-sharing across disciplines can lead to medical error² and stifle dissemination of safer practices.³ Further, the unintentional disparaging of other medical specialties undermines the confidence our patients have in all of us; a patient within earshot of the hospitalist expressing annoyance at the “impatient” emergency medicine physician who “won’t stop paging,” or the emergency medicine physician complaining about the hospitalist who “refuses to call back,” will lose trust in each of their providers. 

We suggest three steps to reduce the negative impact of specialty silos in medicine: 

1. Get to know each other personally. Friendly conversation during work hours and social interaction outside the hospital can inoculate against interspecialty conflict by putting a human face on our colleagues. The resultant relationships make it easier to work together and see things from another’s perspective. 
2. Emphasize our shared affiliations.⁴ The greater the salience of a mutual identity as “healthcare providers,” the more likely we are to recognize each other’s unique contributions and question the stereotypes we imagine about one another. 
3. Consider projects across specialties. Interdepartmental data-sharing and joint meetings, including educational conferences, can facilitate situational awareness, synergy, and efficient problem-solving. 

Our medical specialties will continue to group together. While these groups can be a source of strength and meaning, silos can interfere with professional alliances and effective patient care. Mitigating the harmful effects of silos can benefit all of us and our patients.

Authors’ note: This article was previously published using the term “tribalism,” which we have since learned is derogatory to Indigenous Americans and others. We apologize for any harm. We have retracted and republished the article without this language. We appreciate readers teaching us how to choose better words so all people feel respected and valued.

Siloed, adj.:

Kept in isolation in a way that hinders communication and cooperation . . .

—Merriam-Webster’s Dictionary

Humans naturally separate into groups, and the medical field is no exception. Being a member of a likeminded group, such as one’s specialty, can improve self-esteem and provide social organization: it feels good to identify with people we admire. Through culture, these specialty-based groups implicitly and explicitly guide and encourage positive attributes or behaviors like a hospitalist’s thoroughness or an emergency medicine physician’s steady management of unstable patients. Our specialties also provide support and understanding in challenging times. 

Despite these positive aspects, such divisions can negatively affect interprofessional relationships when our specialties become siloed. A potential side-effect of building up ourselves and our own groups is that we can implicitly put others down. For example, a hospitalist who spends extra time on the phone regularly updating each patient’s family will appropriately take pride in their practice, but over time this can also lead to an unreasonable assumption that physicians in other departments with different routines are not as committed to outstanding communication.

These rigid separations facilitate the fundamental attribution error, the tendency to ascribe a problem or disagreement to a colleague’s substandard character or ability. Imagine that the aforementioned hospitalist’s phone call delays a response to an admission page from the emergency room. The emergency medicine physician, who is waiting to sign out the admission while simultaneously managing many sick and complex patients, could assume the hospitalist is being disrespectful, rather than also working hard to provide the best care. Our siloed specialty identities can lead us to imagine the worst in each other and exacerbate intergroup conflict.¹

Silos in medicine also adversely affect patients. Poor communication and lack of information-sharing across disciplines can lead to medical error² and stifle dissemination of safer practices.³ Further, the unintentional disparaging of other medical specialties undermines the confidence our patients have in all of us; a patient within earshot of the hospitalist expressing annoyance at the “impatient” emergency medicine physician who “won’t stop paging,” or the emergency medicine physician complaining about the hospitalist who “refuses to call back,” will lose trust in each of their providers. 

We suggest three steps to reduce the negative impact of specialty silos in medicine: 

1. Get to know each other personally. Friendly conversation during work hours and social interaction outside the hospital can inoculate against interspecialty conflict by putting a human face on our colleagues. The resultant relationships make it easier to work together and see things from another’s perspective. 
2. Emphasize our shared affiliations.⁴ The greater the salience of a mutual identity as “healthcare providers,” the more likely we are to recognize each other’s unique contributions and question the stereotypes we imagine about one another. 
3. Consider projects across specialties. Interdepartmental data-sharing and joint meetings, including educational conferences, can facilitate situational awareness, synergy, and efficient problem-solving. 

Our medical specialties will continue to group together. While these groups can be a source of strength and meaning, silos can interfere with professional alliances and effective patient care. Mitigating the harmful effects of silos can benefit all of us and our patients.

Authors’ note: This article was previously published using the term “tribalism,” which we have since learned is derogatory to Indigenous Americans and others. We apologize for any harm. We have retracted and republished the article without this language. We appreciate readers teaching us how to choose better words so all people feel respected and valued.

Clinical question: Is rivaroxaban as effective and safe as warfarin immediately following minor acute ischemic stroke from atrial fibrillation?

Background: There is uncertainty regarding the best approach to anticoagulation acutely after ischemic stroke secondary to atrial fibrillation. To reduce the risk of intracranial hemorrhage, many physicians start aspirin immediately and delay initiating warfarin until days to weeks later. With their more predictable and rapid anticoagulant effect with potentially lower risk of intracranial hemorrhage, direct oral anticoagulants such as rivaroxaban are an attractive possible alternative to warfarin in the acute setting.

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Study design: Multicenter, randomized, open-label superiority trial with blinded outcome assessment.

Setting: Fourteen academic hospitals in South Korea.

Synopsis: One hundred eighty-three patients with mild acute (within 5 days) ischemic stroke secondary to nonvalvular atrial fibrillation were randomized to immediately initiate either rivaroxaban or warfarin. The primary outcome (composite of new ischemic lesion or new intracranial hemorrhage on MRI at 4 weeks) occurred at similar frequency between groups (49.5% versus 54.5%, P = .49). Rates of adverse events were comparable in each group. Median hospitalization length was shorter in those randomized to rivaroxaban (4.0 versus 6.0 days, P less than .001). Limitations include a radiographic primary outcome that captured many asymptomatic lesions, homogenous study population, and lack of a delayed anticoagulation group.

Bottom line: In patients with mild acute stroke from nonvalvular atrial fibrillation, rivaroxaban and warfarin demonstrated comparable efficacy and safety. More study is needed to determine the optimal anticoagulation strategy in acute stroke.

Citation: Hong K-S et al. Rivaroxaban vs. warfarin sodium in the ultra-early period after atrial fibrillation-related mild ischemic stroke: A randomized clinical trial. JAMA Neurol. 2017; 74(10):1206-15.

Dr. Kanjee is a hospitalist, Beth Israel Deaconess Medical Center, and instructor in medicine, Harvard Medical School, Boston.

Clinical question: Is rivaroxaban as effective and safe as warfarin immediately following minor acute ischemic stroke from atrial fibrillation?

Background: There is uncertainty regarding the best approach to anticoagulation acutely after ischemic stroke secondary to atrial fibrillation. To reduce the risk of intracranial hemorrhage, many physicians start aspirin immediately and delay initiating warfarin until days to weeks later. With their more predictable and rapid anticoagulant effect with potentially lower risk of intracranial hemorrhage, direct oral anticoagulants such as rivaroxaban are an attractive possible alternative to warfarin in the acute setting.

inthelit_web.jpg

Study design: Multicenter, randomized, open-label superiority trial with blinded outcome assessment.

Setting: Fourteen academic hospitals in South Korea.

Synopsis: One hundred eighty-three patients with mild acute (within 5 days) ischemic stroke secondary to nonvalvular atrial fibrillation were randomized to immediately initiate either rivaroxaban or warfarin. The primary outcome (composite of new ischemic lesion or new intracranial hemorrhage on MRI at 4 weeks) occurred at similar frequency between groups (49.5% versus 54.5%, P = .49). Rates of adverse events were comparable in each group. Median hospitalization length was shorter in those randomized to rivaroxaban (4.0 versus 6.0 days, P less than .001). Limitations include a radiographic primary outcome that captured many asymptomatic lesions, homogenous study population, and lack of a delayed anticoagulation group.

Bottom line: In patients with mild acute stroke from nonvalvular atrial fibrillation, rivaroxaban and warfarin demonstrated comparable efficacy and safety. More study is needed to determine the optimal anticoagulation strategy in acute stroke.

Citation: Hong K-S et al. Rivaroxaban vs. warfarin sodium in the ultra-early period after atrial fibrillation-related mild ischemic stroke: A randomized clinical trial. JAMA Neurol. 2017; 74(10):1206-15.

Dr. Kanjee is a hospitalist, Beth Israel Deaconess Medical Center, and instructor in medicine, Harvard Medical School, Boston.

Clinical question: Is rivaroxaban as effective and safe as warfarin immediately following minor acute ischemic stroke from atrial fibrillation?

Background: There is uncertainty regarding the best approach to anticoagulation acutely after ischemic stroke secondary to atrial fibrillation. To reduce the risk of intracranial hemorrhage, many physicians start aspirin immediately and delay initiating warfarin until days to weeks later. With their more predictable and rapid anticoagulant effect with potentially lower risk of intracranial hemorrhage, direct oral anticoagulants such as rivaroxaban are an attractive possible alternative to warfarin in the acute setting.

inthelit_web.jpg

Study design: Multicenter, randomized, open-label superiority trial with blinded outcome assessment.

Setting: Fourteen academic hospitals in South Korea.

Synopsis: One hundred eighty-three patients with mild acute (within 5 days) ischemic stroke secondary to nonvalvular atrial fibrillation were randomized to immediately initiate either rivaroxaban or warfarin. The primary outcome (composite of new ischemic lesion or new intracranial hemorrhage on MRI at 4 weeks) occurred at similar frequency between groups (49.5% versus 54.5%, P = .49). Rates of adverse events were comparable in each group. Median hospitalization length was shorter in those randomized to rivaroxaban (4.0 versus 6.0 days, P less than .001). Limitations include a radiographic primary outcome that captured many asymptomatic lesions, homogenous study population, and lack of a delayed anticoagulation group.

Bottom line: In patients with mild acute stroke from nonvalvular atrial fibrillation, rivaroxaban and warfarin demonstrated comparable efficacy and safety. More study is needed to determine the optimal anticoagulation strategy in acute stroke.

Citation: Hong K-S et al. Rivaroxaban vs. warfarin sodium in the ultra-early period after atrial fibrillation-related mild ischemic stroke: A randomized clinical trial. JAMA Neurol. 2017; 74(10):1206-15.

Dr. Kanjee is a hospitalist, Beth Israel Deaconess Medical Center, and instructor in medicine, Harvard Medical School, Boston.

Clinical question: What effect does hospitalist empathy have on patient anxiety, ratings of physician communication, and duration of encounter?

Background: Physician empathy is associated with better patient-reported and medical outcomes in a number of settings. The effects of hospitalist empathy have been less well studied.

Study design: Observational study of audio recordings of hospitalist admission encounters.

Setting: General medical service at two urban hospitals within an academic medical center from August 2008 to March 2009.

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Synopsis: Admission encounters (76 patients, 27 hospitalists) were recorded. Researchers detected negative emotional expressions from patients and characterized resultant physician replies as either empathic (“focuses toward further expression of emotion”), neutral (“focuses neither toward nor away from emotion”), or nonempathic (“focuses away from emotion”). Through use of regression models, response frequency was compared with change in pre/post-encounter patient anxiety, patient ratings of physician communication, and duration of encounter. Every additional empathic response was associated with a small decrease in anxiety, better ratings of physician communication, and no change in encounter duration. Nonempathic responses were associated with worse communication ratings. Limitations of the study include its observational nature, small sample size, exclusion of non–English-speaking patients, absence of data on nonverbal communication, and exclusively urban academic setting.

Bottom line: Empathic hospitalist responses during admission encounters are associated with reductions in patient anxiety and better ratings of physician communication without increases in encounter duration.

Citation: Weiss R et al. Associations of physician empathy with patient anxiety and ratings of communication in hospital admission encounters. J Hosp Med. 2017;12(10):805-10.
 

Dr. Kanjee is a hospitalist, Beth Israel Deaconess Medical Center, and instructor in medicine, Harvard Medical School, Boston.

Clinical question: What effect does hospitalist empathy have on patient anxiety, ratings of physician communication, and duration of encounter?

Background: Physician empathy is associated with better patient-reported and medical outcomes in a number of settings. The effects of hospitalist empathy have been less well studied.

Study design: Observational study of audio recordings of hospitalist admission encounters.

Setting: General medical service at two urban hospitals within an academic medical center from August 2008 to March 2009.

Kanjee_Zahir_BOSTON_web.jpg

Synopsis: Admission encounters (76 patients, 27 hospitalists) were recorded. Researchers detected negative emotional expressions from patients and characterized resultant physician replies as either empathic (“focuses toward further expression of emotion”), neutral (“focuses neither toward nor away from emotion”), or nonempathic (“focuses away from emotion”). Through use of regression models, response frequency was compared with change in pre/post-encounter patient anxiety, patient ratings of physician communication, and duration of encounter. Every additional empathic response was associated with a small decrease in anxiety, better ratings of physician communication, and no change in encounter duration. Nonempathic responses were associated with worse communication ratings. Limitations of the study include its observational nature, small sample size, exclusion of non–English-speaking patients, absence of data on nonverbal communication, and exclusively urban academic setting.

Bottom line: Empathic hospitalist responses during admission encounters are associated with reductions in patient anxiety and better ratings of physician communication without increases in encounter duration.

Citation: Weiss R et al. Associations of physician empathy with patient anxiety and ratings of communication in hospital admission encounters. J Hosp Med. 2017;12(10):805-10.
 

Dr. Kanjee is a hospitalist, Beth Israel Deaconess Medical Center, and instructor in medicine, Harvard Medical School, Boston.

Clinical question: What effect does hospitalist empathy have on patient anxiety, ratings of physician communication, and duration of encounter?

Background: Physician empathy is associated with better patient-reported and medical outcomes in a number of settings. The effects of hospitalist empathy have been less well studied.

Study design: Observational study of audio recordings of hospitalist admission encounters.

Setting: General medical service at two urban hospitals within an academic medical center from August 2008 to March 2009.

Kanjee_Zahir_BOSTON_web.jpg

Synopsis: Admission encounters (76 patients, 27 hospitalists) were recorded. Researchers detected negative emotional expressions from patients and characterized resultant physician replies as either empathic (“focuses toward further expression of emotion”), neutral (“focuses neither toward nor away from emotion”), or nonempathic (“focuses away from emotion”). Through use of regression models, response frequency was compared with change in pre/post-encounter patient anxiety, patient ratings of physician communication, and duration of encounter. Every additional empathic response was associated with a small decrease in anxiety, better ratings of physician communication, and no change in encounter duration. Nonempathic responses were associated with worse communication ratings. Limitations of the study include its observational nature, small sample size, exclusion of non–English-speaking patients, absence of data on nonverbal communication, and exclusively urban academic setting.

Bottom line: Empathic hospitalist responses during admission encounters are associated with reductions in patient anxiety and better ratings of physician communication without increases in encounter duration.

Citation: Weiss R et al. Associations of physician empathy with patient anxiety and ratings of communication in hospital admission encounters. J Hosp Med. 2017;12(10):805-10.
 

Dr. Kanjee is a hospitalist, Beth Israel Deaconess Medical Center, and instructor in medicine, Harvard Medical School, Boston.