There are more than 20,000 practicing hospitalists in the United States, and yet from every corner of hospital medicine it seems everyone is looking for more hospitalists.

While SHM has been touting that there will be 30,000 hospitalists in the next five years, others are now calling for 40,000 and more. At the SHM Annual Meeting in Dallas in May, Bob Wachter, MD, predicted a specialty with as many as 50,000 hospitalists. What is driving this logarithmic growth in hospital medicine?

Initial studies by Jon Lurie, MD, of Dartmouth Medical School, Hanover, N.H., and others dating back to the late 1990s cited the need for “only” 20,000 hospitalists. Ten years later, those studies seem almost primitive.

Originally, hospitalists were perceived necessary to replace the inpatient work for a small percentage of family practitioners and general internists—mainly at larger hospitals. While there was initial resistance from primary care physicians (PCP) in the early years of hospital medicine, the rapid adoption of hospital medicine by most PCPs has driven our rapid growth. Now, hospital administrators are frequently besieged by their PCP base to “get us some hospitalists” rather than to block hospitalists from the medical staff. And this occurs at not only 500-bed hospitals but at many hospitals with fewer than 100 beds.

More recently hospitalists have been active in co-managing surgical patients, handling glycemic control, preventing DVT, and writing scrips for the antibiotics. This frees the surgeon to concentrate on operative and post-operative surgical aspects of the case. This division of labor allows specialists to use their unique talents, which can lead to better patient outcomes. Hospitalists frequently also staff a pre-admission clinic to evaluate elective surgical patients prior to admission to the hospital. Surgical co-management also is happening with orthopedics and neurosurgery at community hospitals and major academic medical centers.

The increasing role of hospitalists in what was traditionally subspecialty cases is further fueling the growth of hospital medicine. Hospitalists now admit more heart failure patients than cardiologists, manage more inpatient diabetic cases than endocrinologists, and have virtually replaced neurologists to manage inpatient stroke patients. Once again this allows specialists to focus their expertise as best they can, while hospitalists manage the aspects of these complex cases that fall under their purview.

Hospitalists also find themselves with an expanded role in the critical care arena, working with an inadequate supply of intensivists to help manage patients in extremis. And hospitalists are being called into the emergency department (ED), where they serve as in-house consultant, improve the movement of patients out of the ED, and take over some or all the responsibilities of managing the observation units.

Add to this clinical work the time hospitalists must spend on quality improvement, team building, systems changing, and education. The workload is expanding all the time as the hospitalist job description grows and grows.

With the prospect that almost every hospital is starting and growing its hospital medicine group (HMG)—therefore expanding the scope of hospital medicine—it is no wonder predictions of the need for 50,000 hospitalists are becoming credible.

And almost every hospital medicine company is growing. At this year’s SHM Annual Meeting in Dallas I talked to leaders from Emcare (Dallas), Cogent Healthcare (Irvine, Calif.), TeamHealth (Knoxville, Tenn.), Sound Inpatient Physicians (Tacoma, Wash.), Eagle Hospital Physicians (Atlanta), PrimeDoc (Asheville, N.C.), IPC–The Hospitalist Company (North Hollywood, Calif.), and other large employers of hospitalists. Every one of them saw their organizations adding HMGs, needing more hospitalists, and wondering where they will find them.

SHM has benefited by this recruitment feeding frenzy. Just look at the ads in this issue of The Hospitalist, surf SHM’s Online Career Center, or visit our meeting’s Exhibit Hall to see the tangible expression of the need to find more hospitalists. This cannot be solved by hospitalists jumping from one place to another. We need to find a way to attract a new wave of qualified hospitalists into our specialty.

Where will these new hospitalists come from?

Right now about 8% of internal medicine residency graduates enter hospital medicine. While this is a steady stream of new hospitalists, the flow is but a trickle and we need a rapid current. Is it time for hospital medicine to develop a more aggressive recruitment strategy geared to third-year medical students to pull them into hospital medicine with offers of a job or loan repayment?

In addition, some general internists move into hospital medicine each year, but this is a shrinking pool of potential new hospitalists. While 3% of hospitalists have been trained as family practitioners, there are no good statistics on how many family practitioner residents select hospital medicine as a career or how many family practitioners in practice come to hospital medicine. While the guess is that the pool of family practitioners presents an opportunity for future hospitalists, there are some concerns about how well today’s family practitioner residency training prepares young physicians to step right into the role of a hospitalist.

There are other sources for hospitalist physicians from overseas. Currently 25% of the U.S. physician workforce is made up of international medical graduates (IMGs).1 Further, 35% of internal medicine residents and fellows are graduates of medical schools outside the United States.2 SHM’s surveys indicate that approximately 26% of hospitalists are IMGs. That said, hiring physicians from outside the U.S. can present residency and visa issues that complicate employment. Will hospital medicine employers need to look abroad in the same way the U.S. has become a major importer of RNs and other health professionals?

Speaking of nonphysician providers, 5% of hospitalists are PAs and NPs, and this segment appears to be growing. Are there strategies that allow for increased use of nonphysicians in the hospital medicine workforce that can allow a group of hospitalists to be more productive and meet all their stretch goals?

While the question is clear—where will the next 20,000 to 30,000 hospitalists come from?—the answer is somewhat muddled. With this in mind, SHM will hold the National Summit on Hospital Medicine Workforce Issues in late 2007. This will be a practical work group made up of the key national leaders of hospital medicine employers along with key decision makers from medical schools, family practice, pediatrics, internal medicine residency programs, the nonphysician provider community, and others who can help set a direction to solve what is rapidly becoming a crisis in manpower. From this summit SHM hopes to have clear, actionable strategies to create an environment for continued growth and maturation of hospital medicine and deliver on the promise of better healthcare for the patients and the communities we serve. TH

Dr. Wellikson is the CEO of SHM.

References

1. Mullan F. The metrics of the physician brain drain. N Engl J Med. 2005 Oct 27;353(17):1810-1818.
2. Brotherton SE, Rockey PH, Etzel SI. US graduate medical education, 2004-2005: Trends in primary care specialties. JAMA. 2005 Sep 7;294(9):1075-1082.

There are more than 20,000 practicing hospitalists in the United States, and yet from every corner of hospital medicine it seems everyone is looking for more hospitalists.

While SHM has been touting that there will be 30,000 hospitalists in the next five years, others are now calling for 40,000 and more. At the SHM Annual Meeting in Dallas in May, Bob Wachter, MD, predicted a specialty with as many as 50,000 hospitalists. What is driving this logarithmic growth in hospital medicine?

Initial studies by Jon Lurie, MD, of Dartmouth Medical School, Hanover, N.H., and others dating back to the late 1990s cited the need for “only” 20,000 hospitalists. Ten years later, those studies seem almost primitive.

Originally, hospitalists were perceived necessary to replace the inpatient work for a small percentage of family practitioners and general internists—mainly at larger hospitals. While there was initial resistance from primary care physicians (PCP) in the early years of hospital medicine, the rapid adoption of hospital medicine by most PCPs has driven our rapid growth. Now, hospital administrators are frequently besieged by their PCP base to “get us some hospitalists” rather than to block hospitalists from the medical staff. And this occurs at not only 500-bed hospitals but at many hospitals with fewer than 100 beds.

More recently hospitalists have been active in co-managing surgical patients, handling glycemic control, preventing DVT, and writing scrips for the antibiotics. This frees the surgeon to concentrate on operative and post-operative surgical aspects of the case. This division of labor allows specialists to use their unique talents, which can lead to better patient outcomes. Hospitalists frequently also staff a pre-admission clinic to evaluate elective surgical patients prior to admission to the hospital. Surgical co-management also is happening with orthopedics and neurosurgery at community hospitals and major academic medical centers.

The increasing role of hospitalists in what was traditionally subspecialty cases is further fueling the growth of hospital medicine. Hospitalists now admit more heart failure patients than cardiologists, manage more inpatient diabetic cases than endocrinologists, and have virtually replaced neurologists to manage inpatient stroke patients. Once again this allows specialists to focus their expertise as best they can, while hospitalists manage the aspects of these complex cases that fall under their purview.

Hospitalists also find themselves with an expanded role in the critical care arena, working with an inadequate supply of intensivists to help manage patients in extremis. And hospitalists are being called into the emergency department (ED), where they serve as in-house consultant, improve the movement of patients out of the ED, and take over some or all the responsibilities of managing the observation units.

Add to this clinical work the time hospitalists must spend on quality improvement, team building, systems changing, and education. The workload is expanding all the time as the hospitalist job description grows and grows.

With the prospect that almost every hospital is starting and growing its hospital medicine group (HMG)—therefore expanding the scope of hospital medicine—it is no wonder predictions of the need for 50,000 hospitalists are becoming credible.

And almost every hospital medicine company is growing. At this year’s SHM Annual Meeting in Dallas I talked to leaders from Emcare (Dallas), Cogent Healthcare (Irvine, Calif.), TeamHealth (Knoxville, Tenn.), Sound Inpatient Physicians (Tacoma, Wash.), Eagle Hospital Physicians (Atlanta), PrimeDoc (Asheville, N.C.), IPC–The Hospitalist Company (North Hollywood, Calif.), and other large employers of hospitalists. Every one of them saw their organizations adding HMGs, needing more hospitalists, and wondering where they will find them.

SHM has benefited by this recruitment feeding frenzy. Just look at the ads in this issue of The Hospitalist, surf SHM’s Online Career Center, or visit our meeting’s Exhibit Hall to see the tangible expression of the need to find more hospitalists. This cannot be solved by hospitalists jumping from one place to another. We need to find a way to attract a new wave of qualified hospitalists into our specialty.

Where will these new hospitalists come from?

Right now about 8% of internal medicine residency graduates enter hospital medicine. While this is a steady stream of new hospitalists, the flow is but a trickle and we need a rapid current. Is it time for hospital medicine to develop a more aggressive recruitment strategy geared to third-year medical students to pull them into hospital medicine with offers of a job or loan repayment?

In addition, some general internists move into hospital medicine each year, but this is a shrinking pool of potential new hospitalists. While 3% of hospitalists have been trained as family practitioners, there are no good statistics on how many family practitioner residents select hospital medicine as a career or how many family practitioners in practice come to hospital medicine. While the guess is that the pool of family practitioners presents an opportunity for future hospitalists, there are some concerns about how well today’s family practitioner residency training prepares young physicians to step right into the role of a hospitalist.

There are other sources for hospitalist physicians from overseas. Currently 25% of the U.S. physician workforce is made up of international medical graduates (IMGs).1 Further, 35% of internal medicine residents and fellows are graduates of medical schools outside the United States.2 SHM’s surveys indicate that approximately 26% of hospitalists are IMGs. That said, hiring physicians from outside the U.S. can present residency and visa issues that complicate employment. Will hospital medicine employers need to look abroad in the same way the U.S. has become a major importer of RNs and other health professionals?

Speaking of nonphysician providers, 5% of hospitalists are PAs and NPs, and this segment appears to be growing. Are there strategies that allow for increased use of nonphysicians in the hospital medicine workforce that can allow a group of hospitalists to be more productive and meet all their stretch goals?

While the question is clear—where will the next 20,000 to 30,000 hospitalists come from?—the answer is somewhat muddled. With this in mind, SHM will hold the National Summit on Hospital Medicine Workforce Issues in late 2007. This will be a practical work group made up of the key national leaders of hospital medicine employers along with key decision makers from medical schools, family practice, pediatrics, internal medicine residency programs, the nonphysician provider community, and others who can help set a direction to solve what is rapidly becoming a crisis in manpower. From this summit SHM hopes to have clear, actionable strategies to create an environment for continued growth and maturation of hospital medicine and deliver on the promise of better healthcare for the patients and the communities we serve. TH

Dr. Wellikson is the CEO of SHM.

References

1. Mullan F. The metrics of the physician brain drain. N Engl J Med. 2005 Oct 27;353(17):1810-1818.
2. Brotherton SE, Rockey PH, Etzel SI. US graduate medical education, 2004-2005: Trends in primary care specialties. JAMA. 2005 Sep 7;294(9):1075-1082.

There are more than 20,000 practicing hospitalists in the United States, and yet from every corner of hospital medicine it seems everyone is looking for more hospitalists.

While SHM has been touting that there will be 30,000 hospitalists in the next five years, others are now calling for 40,000 and more. At the SHM Annual Meeting in Dallas in May, Bob Wachter, MD, predicted a specialty with as many as 50,000 hospitalists. What is driving this logarithmic growth in hospital medicine?

Initial studies by Jon Lurie, MD, of Dartmouth Medical School, Hanover, N.H., and others dating back to the late 1990s cited the need for “only” 20,000 hospitalists. Ten years later, those studies seem almost primitive.

Originally, hospitalists were perceived necessary to replace the inpatient work for a small percentage of family practitioners and general internists—mainly at larger hospitals. While there was initial resistance from primary care physicians (PCP) in the early years of hospital medicine, the rapid adoption of hospital medicine by most PCPs has driven our rapid growth. Now, hospital administrators are frequently besieged by their PCP base to “get us some hospitalists” rather than to block hospitalists from the medical staff. And this occurs at not only 500-bed hospitals but at many hospitals with fewer than 100 beds.

More recently hospitalists have been active in co-managing surgical patients, handling glycemic control, preventing DVT, and writing scrips for the antibiotics. This frees the surgeon to concentrate on operative and post-operative surgical aspects of the case. This division of labor allows specialists to use their unique talents, which can lead to better patient outcomes. Hospitalists frequently also staff a pre-admission clinic to evaluate elective surgical patients prior to admission to the hospital. Surgical co-management also is happening with orthopedics and neurosurgery at community hospitals and major academic medical centers.

The increasing role of hospitalists in what was traditionally subspecialty cases is further fueling the growth of hospital medicine. Hospitalists now admit more heart failure patients than cardiologists, manage more inpatient diabetic cases than endocrinologists, and have virtually replaced neurologists to manage inpatient stroke patients. Once again this allows specialists to focus their expertise as best they can, while hospitalists manage the aspects of these complex cases that fall under their purview.

Hospitalists also find themselves with an expanded role in the critical care arena, working with an inadequate supply of intensivists to help manage patients in extremis. And hospitalists are being called into the emergency department (ED), where they serve as in-house consultant, improve the movement of patients out of the ED, and take over some or all the responsibilities of managing the observation units.

Add to this clinical work the time hospitalists must spend on quality improvement, team building, systems changing, and education. The workload is expanding all the time as the hospitalist job description grows and grows.

With the prospect that almost every hospital is starting and growing its hospital medicine group (HMG)—therefore expanding the scope of hospital medicine—it is no wonder predictions of the need for 50,000 hospitalists are becoming credible.

And almost every hospital medicine company is growing. At this year’s SHM Annual Meeting in Dallas I talked to leaders from Emcare (Dallas), Cogent Healthcare (Irvine, Calif.), TeamHealth (Knoxville, Tenn.), Sound Inpatient Physicians (Tacoma, Wash.), Eagle Hospital Physicians (Atlanta), PrimeDoc (Asheville, N.C.), IPC–The Hospitalist Company (North Hollywood, Calif.), and other large employers of hospitalists. Every one of them saw their organizations adding HMGs, needing more hospitalists, and wondering where they will find them.

SHM has benefited by this recruitment feeding frenzy. Just look at the ads in this issue of The Hospitalist, surf SHM’s Online Career Center, or visit our meeting’s Exhibit Hall to see the tangible expression of the need to find more hospitalists. This cannot be solved by hospitalists jumping from one place to another. We need to find a way to attract a new wave of qualified hospitalists into our specialty.

Where will these new hospitalists come from?

Right now about 8% of internal medicine residency graduates enter hospital medicine. While this is a steady stream of new hospitalists, the flow is but a trickle and we need a rapid current. Is it time for hospital medicine to develop a more aggressive recruitment strategy geared to third-year medical students to pull them into hospital medicine with offers of a job or loan repayment?

In addition, some general internists move into hospital medicine each year, but this is a shrinking pool of potential new hospitalists. While 3% of hospitalists have been trained as family practitioners, there are no good statistics on how many family practitioner residents select hospital medicine as a career or how many family practitioners in practice come to hospital medicine. While the guess is that the pool of family practitioners presents an opportunity for future hospitalists, there are some concerns about how well today’s family practitioner residency training prepares young physicians to step right into the role of a hospitalist.

There are other sources for hospitalist physicians from overseas. Currently 25% of the U.S. physician workforce is made up of international medical graduates (IMGs).1 Further, 35% of internal medicine residents and fellows are graduates of medical schools outside the United States.2 SHM’s surveys indicate that approximately 26% of hospitalists are IMGs. That said, hiring physicians from outside the U.S. can present residency and visa issues that complicate employment. Will hospital medicine employers need to look abroad in the same way the U.S. has become a major importer of RNs and other health professionals?

Speaking of nonphysician providers, 5% of hospitalists are PAs and NPs, and this segment appears to be growing. Are there strategies that allow for increased use of nonphysicians in the hospital medicine workforce that can allow a group of hospitalists to be more productive and meet all their stretch goals?

While the question is clear—where will the next 20,000 to 30,000 hospitalists come from?—the answer is somewhat muddled. With this in mind, SHM will hold the National Summit on Hospital Medicine Workforce Issues in late 2007. This will be a practical work group made up of the key national leaders of hospital medicine employers along with key decision makers from medical schools, family practice, pediatrics, internal medicine residency programs, the nonphysician provider community, and others who can help set a direction to solve what is rapidly becoming a crisis in manpower. From this summit SHM hopes to have clear, actionable strategies to create an environment for continued growth and maturation of hospital medicine and deliver on the promise of better healthcare for the patients and the communities we serve. TH

Dr. Wellikson is the CEO of SHM.

References

1. Mullan F. The metrics of the physician brain drain. N Engl J Med. 2005 Oct 27;353(17):1810-1818.
2. Brotherton SE, Rockey PH, Etzel SI. US graduate medical education, 2004-2005: Trends in primary care specialties. JAMA. 2005 Sep 7;294(9):1075-1082.

Jane Jerrard covered some potential career paths for academic hospitalists in her article “How to Navigate Hospital Medicine” (May 2007, p. 9). But I believe her account was incomplete. I would like to add detail to the opportunities in community-based and other programs.

Community-based medical groups offer a number of opportunities in hospitals or hospital systems. These include:

• Committee chairman. Most hospitals want interested, dedicated individuals to chair traditional medical staff committees. Hospitalists are well suited because our unique perspective lets us identify processes or products that can help many patients. Begin by serving on a committee, such as ethics, pharmacy and therapeutics, IRB, or departmental peer review. As you get comfortable, discuss potential chairmanships with the chief of staff or the vice president of medical affairs (VPMA). Don’t expect to advance if you don’t show up or don’t come prepared to committee meetings.
• Department chairperson. These positions are often elected and may allow one to serve on the credentials committee and the medical executive committee.
• Medical staff officers. Hospitalists often are elected to these key positions and gain access to administration and various committees.
• Project manager. Installing and using electronic medical records and devices calls for physician involvement in design and support. These are great chances to work on interesting projects and affect the tools you work with.
• Hospital administrative positions. Many hospitals have a VPMA or a chief medical officer (CMO), and some are developing the role of vice president of quality. These can be full- or part-time positions. You will be expected to help members of the medical staff implement change, and you should have experience and proven effectiveness in prior roles. Several predict that hospital COOs and CEOs of the future will be hospitalists.

Another path of opportunity is within your organization, depending on your employer. These roles may overlap with hospital positions:

• Group leader. Generally responsible for working on scheduling, recruitment, and organizational structure. The job may involve responsibility for one or more facilities.
• Compliance officer. Someone in the group must understand billing, coding, and proper use of rules and legislation.
• Quality and safety officer.
• Group president.

Hospitalists can also participate on committees that deal with such areas as pension plans, contracts, or other business.

Health insurance companies provide opportunities for individuals to practice part-time and serve as medical directors. They also have career paths for VPMAs and CMOs.

Also, many healthcare companies have been started and run by physicians. Invent something; start a company. The opportunities are endless.

Some other tips:

• Educate yourself. Take courses like the SHM Leadership Academy. Learn how to interact in a businesslike manner. Some on-the-job training is OK, but management and leadership are new fields that require new learning.
• Read. There are many great books on being an executive. Learn how to run a meeting, make an agenda, work with other professionals, and delegate.
• Ask for help. Find an individual or individuals with whom you can discuss ideas. Some of your best mentors will be managers in other fields.

Mary Jo Gorman, MD, MBA

Immediate Past President, SHM

Consequences of Locum Tenens Work

I feel one piece of advice in the Career Development section in the May issue of The Hospitalist (“How to Navigate Hospital Medicine,” p. 9) is not complete and may adversely affect a new hospitalist’s career.

The article recommends exploring locum tenens work. We have found two unintended consequences of such action. First, the locum companies usually have a buyout clause for the physician. Should he decide he likes a location and wishes to stay, the potential employer faces an additional cost in the $20,000-$30,000 range. It makes budgeting difficult. Also, there is usually a clause in the locum contract that this policy is in place for two years after leaving the locum company.

Second, frequent job changes lead to prolonged processing of credentials at hospitals as they verify good standing at all previous practice sites. This means delays that force a hospitalist company to look for more readily available docs. The physician may be unable to find hospitals in highly desirable areas.

The article was otherwise well balanced and timely.

George Block, MD

CMO, Galen Inpatient Physicians Medical Group

Emeryville, Calif.

Jane Jerrard covered some potential career paths for academic hospitalists in her article “How to Navigate Hospital Medicine” (May 2007, p. 9). But I believe her account was incomplete. I would like to add detail to the opportunities in community-based and other programs.

Community-based medical groups offer a number of opportunities in hospitals or hospital systems. These include:

• Committee chairman. Most hospitals want interested, dedicated individuals to chair traditional medical staff committees. Hospitalists are well suited because our unique perspective lets us identify processes or products that can help many patients. Begin by serving on a committee, such as ethics, pharmacy and therapeutics, IRB, or departmental peer review. As you get comfortable, discuss potential chairmanships with the chief of staff or the vice president of medical affairs (VPMA). Don’t expect to advance if you don’t show up or don’t come prepared to committee meetings.
• Department chairperson. These positions are often elected and may allow one to serve on the credentials committee and the medical executive committee.
• Medical staff officers. Hospitalists often are elected to these key positions and gain access to administration and various committees.
• Project manager. Installing and using electronic medical records and devices calls for physician involvement in design and support. These are great chances to work on interesting projects and affect the tools you work with.
• Hospital administrative positions. Many hospitals have a VPMA or a chief medical officer (CMO), and some are developing the role of vice president of quality. These can be full- or part-time positions. You will be expected to help members of the medical staff implement change, and you should have experience and proven effectiveness in prior roles. Several predict that hospital COOs and CEOs of the future will be hospitalists.

Another path of opportunity is within your organization, depending on your employer. These roles may overlap with hospital positions:

• Group leader. Generally responsible for working on scheduling, recruitment, and organizational structure. The job may involve responsibility for one or more facilities.
• Compliance officer. Someone in the group must understand billing, coding, and proper use of rules and legislation.
• Quality and safety officer.
• Group president.

Hospitalists can also participate on committees that deal with such areas as pension plans, contracts, or other business.

Health insurance companies provide opportunities for individuals to practice part-time and serve as medical directors. They also have career paths for VPMAs and CMOs.

Also, many healthcare companies have been started and run by physicians. Invent something; start a company. The opportunities are endless.

Some other tips:

• Educate yourself. Take courses like the SHM Leadership Academy. Learn how to interact in a businesslike manner. Some on-the-job training is OK, but management and leadership are new fields that require new learning.
• Read. There are many great books on being an executive. Learn how to run a meeting, make an agenda, work with other professionals, and delegate.
• Ask for help. Find an individual or individuals with whom you can discuss ideas. Some of your best mentors will be managers in other fields.

Mary Jo Gorman, MD, MBA

Immediate Past President, SHM

Consequences of Locum Tenens Work

I feel one piece of advice in the Career Development section in the May issue of The Hospitalist (“How to Navigate Hospital Medicine,” p. 9) is not complete and may adversely affect a new hospitalist’s career.

The article recommends exploring locum tenens work. We have found two unintended consequences of such action. First, the locum companies usually have a buyout clause for the physician. Should he decide he likes a location and wishes to stay, the potential employer faces an additional cost in the $20,000-$30,000 range. It makes budgeting difficult. Also, there is usually a clause in the locum contract that this policy is in place for two years after leaving the locum company.

Second, frequent job changes lead to prolonged processing of credentials at hospitals as they verify good standing at all previous practice sites. This means delays that force a hospitalist company to look for more readily available docs. The physician may be unable to find hospitals in highly desirable areas.

The article was otherwise well balanced and timely.

George Block, MD

CMO, Galen Inpatient Physicians Medical Group

Emeryville, Calif.

Jane Jerrard covered some potential career paths for academic hospitalists in her article “How to Navigate Hospital Medicine” (May 2007, p. 9). But I believe her account was incomplete. I would like to add detail to the opportunities in community-based and other programs.

Community-based medical groups offer a number of opportunities in hospitals or hospital systems. These include:

• Committee chairman. Most hospitals want interested, dedicated individuals to chair traditional medical staff committees. Hospitalists are well suited because our unique perspective lets us identify processes or products that can help many patients. Begin by serving on a committee, such as ethics, pharmacy and therapeutics, IRB, or departmental peer review. As you get comfortable, discuss potential chairmanships with the chief of staff or the vice president of medical affairs (VPMA). Don’t expect to advance if you don’t show up or don’t come prepared to committee meetings.
• Department chairperson. These positions are often elected and may allow one to serve on the credentials committee and the medical executive committee.
• Medical staff officers. Hospitalists often are elected to these key positions and gain access to administration and various committees.
• Project manager. Installing and using electronic medical records and devices calls for physician involvement in design and support. These are great chances to work on interesting projects and affect the tools you work with.
• Hospital administrative positions. Many hospitals have a VPMA or a chief medical officer (CMO), and some are developing the role of vice president of quality. These can be full- or part-time positions. You will be expected to help members of the medical staff implement change, and you should have experience and proven effectiveness in prior roles. Several predict that hospital COOs and CEOs of the future will be hospitalists.

Another path of opportunity is within your organization, depending on your employer. These roles may overlap with hospital positions:

• Group leader. Generally responsible for working on scheduling, recruitment, and organizational structure. The job may involve responsibility for one or more facilities.
• Compliance officer. Someone in the group must understand billing, coding, and proper use of rules and legislation.
• Quality and safety officer.
• Group president.

Hospitalists can also participate on committees that deal with such areas as pension plans, contracts, or other business.

Health insurance companies provide opportunities for individuals to practice part-time and serve as medical directors. They also have career paths for VPMAs and CMOs.

Also, many healthcare companies have been started and run by physicians. Invent something; start a company. The opportunities are endless.

Some other tips:

• Educate yourself. Take courses like the SHM Leadership Academy. Learn how to interact in a businesslike manner. Some on-the-job training is OK, but management and leadership are new fields that require new learning.
• Read. There are many great books on being an executive. Learn how to run a meeting, make an agenda, work with other professionals, and delegate.
• Ask for help. Find an individual or individuals with whom you can discuss ideas. Some of your best mentors will be managers in other fields.

Mary Jo Gorman, MD, MBA

Immediate Past President, SHM

Consequences of Locum Tenens Work

I feel one piece of advice in the Career Development section in the May issue of The Hospitalist (“How to Navigate Hospital Medicine,” p. 9) is not complete and may adversely affect a new hospitalist’s career.

The article recommends exploring locum tenens work. We have found two unintended consequences of such action. First, the locum companies usually have a buyout clause for the physician. Should he decide he likes a location and wishes to stay, the potential employer faces an additional cost in the $20,000-$30,000 range. It makes budgeting difficult. Also, there is usually a clause in the locum contract that this policy is in place for two years after leaving the locum company.

Second, frequent job changes lead to prolonged processing of credentials at hospitals as they verify good standing at all previous practice sites. This means delays that force a hospitalist company to look for more readily available docs. The physician may be unable to find hospitals in highly desirable areas.

The article was otherwise well balanced and timely.

George Block, MD

CMO, Galen Inpatient Physicians Medical Group

Emeryville, Calif.

On the last day of SHM’s Annual Meeting in May, attendees started their morning with an overview of three exciting projects in hospital medicine, with “Best of Research, Innovations and Clinical Vignettes in 2007.”

Boosting Hospitalists’ Research Efforts

Although hospital medicine programs in academic medical centers are growing rapidly, the role of hospitalist-researchers remains underdeveloped, said Scott A. Flanders, MD, clinical assistant professor, University of Michigan Health Systems, Ann Arbor, by way of introducing “Jumpstarting Hospitalist Clinical Research: The Specialist-Hospitalist Allied Research Program (SHARP).”

“The problem is that our clinical roles dominate over research,” he said. “Also, many hospitalists lack formal research training.” Hospitalists may also lack expertise in clinical areas and are less likely than specialists to become involved in the diagnosis, treatment, and follow-up of complex hospitalized patients. Specialists are also more likely to have access to extramural funding for disease-based clinical research.

For these reasons, Dr. Flanders and his colleagues implemented SHARP. Their purpose was to jumpstart inpatient-based clinical and translational research in academic medical centers by pairing specialists with hospitalists.

SHARP is designed to facilitate pilot projects and preliminary data collection, which can lead to funding. Ultimately, they hope to disseminate research activities to other institutions.

The SHARP infrastructure partners an academic hospitalist as principle investigator (PI) with an academic cardiologist serving as co-PI. The team also includes a hospitalist investigator, a research associate, a clinical epidemiologist, and other personnel as needed.

SHARP is overseen by the PI and co-PI along with an executive from the University of Michigan Health System, vice chair of the Department of Medicine, and the associate dean for Clinical and Translational Research. This oversight group meets semi-annually and facilitates project selection and program development. It also monitors all program metrics.

“Every SHARP project developed is expected to apply for extramural support,” explained Dr. Flanders. SHARP projects and personnel are funded through these sources for pilot data and utilize revenue from the hospital medicine program.

To date, SHARP has resulted in a number of Internal Review Board-approved projects; a number of grants have been submitted, and some have been funded. In addition, peer-reviewed manuscripts have been submitted and accepted.

“Clinical research is underdeveloped at most academic hospitalist programs,” pronounced Dr. Flanders. “Partnering hospitalists with specialists can facilitate collaborative research and, in turn, identify the best way to care for inpatients. I encourage everyone to borrow this idea for their own institution.”

How Do Hospitalists Stack up?

In the short time hospitalists have been around, research has consistently shown that their addition has a positive or neutral effect on factors including length and cost of stay, patient mortality, and readmission rates. However, studies have been limited in scope—something Peter K. Lindenauer, MD, MSc, and his colleagues at Baystate Medical Center, Tufts University School of Medicine, Springfield, Mass., sought to correct in their own study, “Outcomes of Patients Treated by Hospitalists, General Internists and Family Physicians.”

The hospitalist-researchers wanted to compare outcomes for patients treated by three groups across a range of practice settings: hospitalists, non-hospitalist general internists, and family physicians.

The project they undertook was a retrospective cohort study that included patients admitted to 45 U.S. hospitals between September 2002 and July 2005. Patients were all at least 18 years old and had any of seven diagnoses: pneumonia, heart failure, chest pain, ischemic stroke, urinary tract infection, acute exacerbation of COPD, or acute myocardial infarction.

The total number of patients in the study was 76,926. Of these, 284 were cared for by a hospitalist, 993 by a general internist, and 971 by a family physician.

Dr. Lindenauer and his colleagues found that patients in all groups had similar patterns of comorbidities, although hospitalists were more likely to have patients who were covered by managed-care plans and not covered by traditional Medicare.

As for length of stay (LOS), patients cared for by hospitalists had an LOS 0.6 days shorter than internists and 0.4 days shorter than family physicians. Similarly, hospitalists’ patients had an adjusted cost per case approximately $404 less than that of general internists and on a par with family physicians.

The researchers found no significant differences in mortality or readmission rates among patients in the three physician groups.

Dr. Lindenauer wondered if the higher volume of patients seen by hospitalists would explain the differences in patient outcomes. However, when the researchers compared data for hospitalists with similar high-volume general internists and family physicians, they found similar differences in LOS and costs as they had found previously—suggesting other factors may be responsible for hospitalist effect.

Glycemic Control Issues

“Can we have our sugar-free cake and eat it too?” asked Greg Maynard, MD, MS, chief of the Division of Hospital Medicine, University of California, San Diego, when he presented his team’s project on inpatient glycemic control, “Effect of a Standardized Subcutaneous Insulin Order Set and an Insulin Management Protocol.”

“Inpatient diabetes and hyperglycemia is very common,” Dr. Maynard pointed out, “and poor control is associated with poor outcomes.” Although a standardized subcutaneous insulin order set (SQIO) is recommended, its impact is not yet proven.

Therefore, Dr. Maynard’s team set out to test the effectiveness of a standardized order set on adult inpatients in non-critical care wards with point-of-care glucose testing, in academic medical centers with more than 400 beds. Between November 2002 and October 2003, the group put together a baseline for insulin use patterns, glycemic control, and hypoglycemia. They then implemented a standardized SQIO set, which lasted for a year and a half, followed by a second intervention to monitor the incremental effect of an insulin management protocol.

In the first intervention, the researchers introduced basal, nutritional, and correction dose terminology to clinicians. They made a multiple correction dose scale available (based on total insulin dose required), discouraged sliding-scale-only regimens, instituted check-box simplicity, provided guidance for dosing, and incorporated hypoglycemia protocol. Order sets were produced in print first, then as computerized physician order entries.

The second stage, insulin management protocol, included a one-page algorithm, a glycemic target, a prompt for A1C, guidance on dosing including adjustments, and suggested regimens for patients who are eating, non-eating patients, and patients on enteral nutrition. This intervention was introduced with case-based teaching.

Within three months of implementing the SQIO, the use of sliding-scale-only regimens decreased as clinicians switched to regimens with some scheduled basal insulin.

The percentage of patients with a mean glucose lower than 180 mg a day was 62% at baseline and rose to 69% with the implementation of the SQIO. When the algorithm was used, it rose to 73%. The percentage of patient days with completely controlled glucose (between 60 and 180 mg/day) rose from 44% at baseline, to 48% with the SQIO, to 53% with the algorithm.

“But what about hypoglycemia?” asked Dr. Maynard. “The percentage of patient days with hypoglycemia decreased by 30% and 31%, respectively.” The addition of a standardized SQIO with an insulin management protocol improved glycemic control, reduced hypoglycemia, and changed insulin use patterns. TH

On the last day of SHM’s Annual Meeting in May, attendees started their morning with an overview of three exciting projects in hospital medicine, with “Best of Research, Innovations and Clinical Vignettes in 2007.”

Boosting Hospitalists’ Research Efforts

Although hospital medicine programs in academic medical centers are growing rapidly, the role of hospitalist-researchers remains underdeveloped, said Scott A. Flanders, MD, clinical assistant professor, University of Michigan Health Systems, Ann Arbor, by way of introducing “Jumpstarting Hospitalist Clinical Research: The Specialist-Hospitalist Allied Research Program (SHARP).”

“The problem is that our clinical roles dominate over research,” he said. “Also, many hospitalists lack formal research training.” Hospitalists may also lack expertise in clinical areas and are less likely than specialists to become involved in the diagnosis, treatment, and follow-up of complex hospitalized patients. Specialists are also more likely to have access to extramural funding for disease-based clinical research.

For these reasons, Dr. Flanders and his colleagues implemented SHARP. Their purpose was to jumpstart inpatient-based clinical and translational research in academic medical centers by pairing specialists with hospitalists.

SHARP is designed to facilitate pilot projects and preliminary data collection, which can lead to funding. Ultimately, they hope to disseminate research activities to other institutions.

The SHARP infrastructure partners an academic hospitalist as principle investigator (PI) with an academic cardiologist serving as co-PI. The team also includes a hospitalist investigator, a research associate, a clinical epidemiologist, and other personnel as needed.

SHARP is overseen by the PI and co-PI along with an executive from the University of Michigan Health System, vice chair of the Department of Medicine, and the associate dean for Clinical and Translational Research. This oversight group meets semi-annually and facilitates project selection and program development. It also monitors all program metrics.

“Every SHARP project developed is expected to apply for extramural support,” explained Dr. Flanders. SHARP projects and personnel are funded through these sources for pilot data and utilize revenue from the hospital medicine program.

To date, SHARP has resulted in a number of Internal Review Board-approved projects; a number of grants have been submitted, and some have been funded. In addition, peer-reviewed manuscripts have been submitted and accepted.

“Clinical research is underdeveloped at most academic hospitalist programs,” pronounced Dr. Flanders. “Partnering hospitalists with specialists can facilitate collaborative research and, in turn, identify the best way to care for inpatients. I encourage everyone to borrow this idea for their own institution.”

How Do Hospitalists Stack up?

In the short time hospitalists have been around, research has consistently shown that their addition has a positive or neutral effect on factors including length and cost of stay, patient mortality, and readmission rates. However, studies have been limited in scope—something Peter K. Lindenauer, MD, MSc, and his colleagues at Baystate Medical Center, Tufts University School of Medicine, Springfield, Mass., sought to correct in their own study, “Outcomes of Patients Treated by Hospitalists, General Internists and Family Physicians.”

The hospitalist-researchers wanted to compare outcomes for patients treated by three groups across a range of practice settings: hospitalists, non-hospitalist general internists, and family physicians.

The project they undertook was a retrospective cohort study that included patients admitted to 45 U.S. hospitals between September 2002 and July 2005. Patients were all at least 18 years old and had any of seven diagnoses: pneumonia, heart failure, chest pain, ischemic stroke, urinary tract infection, acute exacerbation of COPD, or acute myocardial infarction.

The total number of patients in the study was 76,926. Of these, 284 were cared for by a hospitalist, 993 by a general internist, and 971 by a family physician.

Dr. Lindenauer and his colleagues found that patients in all groups had similar patterns of comorbidities, although hospitalists were more likely to have patients who were covered by managed-care plans and not covered by traditional Medicare.

As for length of stay (LOS), patients cared for by hospitalists had an LOS 0.6 days shorter than internists and 0.4 days shorter than family physicians. Similarly, hospitalists’ patients had an adjusted cost per case approximately $404 less than that of general internists and on a par with family physicians.

The researchers found no significant differences in mortality or readmission rates among patients in the three physician groups.

Dr. Lindenauer wondered if the higher volume of patients seen by hospitalists would explain the differences in patient outcomes. However, when the researchers compared data for hospitalists with similar high-volume general internists and family physicians, they found similar differences in LOS and costs as they had found previously—suggesting other factors may be responsible for hospitalist effect.

Glycemic Control Issues

“Can we have our sugar-free cake and eat it too?” asked Greg Maynard, MD, MS, chief of the Division of Hospital Medicine, University of California, San Diego, when he presented his team’s project on inpatient glycemic control, “Effect of a Standardized Subcutaneous Insulin Order Set and an Insulin Management Protocol.”

“Inpatient diabetes and hyperglycemia is very common,” Dr. Maynard pointed out, “and poor control is associated with poor outcomes.” Although a standardized subcutaneous insulin order set (SQIO) is recommended, its impact is not yet proven.

Therefore, Dr. Maynard’s team set out to test the effectiveness of a standardized order set on adult inpatients in non-critical care wards with point-of-care glucose testing, in academic medical centers with more than 400 beds. Between November 2002 and October 2003, the group put together a baseline for insulin use patterns, glycemic control, and hypoglycemia. They then implemented a standardized SQIO set, which lasted for a year and a half, followed by a second intervention to monitor the incremental effect of an insulin management protocol.

In the first intervention, the researchers introduced basal, nutritional, and correction dose terminology to clinicians. They made a multiple correction dose scale available (based on total insulin dose required), discouraged sliding-scale-only regimens, instituted check-box simplicity, provided guidance for dosing, and incorporated hypoglycemia protocol. Order sets were produced in print first, then as computerized physician order entries.

The second stage, insulin management protocol, included a one-page algorithm, a glycemic target, a prompt for A1C, guidance on dosing including adjustments, and suggested regimens for patients who are eating, non-eating patients, and patients on enteral nutrition. This intervention was introduced with case-based teaching.

Within three months of implementing the SQIO, the use of sliding-scale-only regimens decreased as clinicians switched to regimens with some scheduled basal insulin.

The percentage of patients with a mean glucose lower than 180 mg a day was 62% at baseline and rose to 69% with the implementation of the SQIO. When the algorithm was used, it rose to 73%. The percentage of patient days with completely controlled glucose (between 60 and 180 mg/day) rose from 44% at baseline, to 48% with the SQIO, to 53% with the algorithm.

“But what about hypoglycemia?” asked Dr. Maynard. “The percentage of patient days with hypoglycemia decreased by 30% and 31%, respectively.” The addition of a standardized SQIO with an insulin management protocol improved glycemic control, reduced hypoglycemia, and changed insulin use patterns. TH

On the last day of SHM’s Annual Meeting in May, attendees started their morning with an overview of three exciting projects in hospital medicine, with “Best of Research, Innovations and Clinical Vignettes in 2007.”

Boosting Hospitalists’ Research Efforts

Although hospital medicine programs in academic medical centers are growing rapidly, the role of hospitalist-researchers remains underdeveloped, said Scott A. Flanders, MD, clinical assistant professor, University of Michigan Health Systems, Ann Arbor, by way of introducing “Jumpstarting Hospitalist Clinical Research: The Specialist-Hospitalist Allied Research Program (SHARP).”

“The problem is that our clinical roles dominate over research,” he said. “Also, many hospitalists lack formal research training.” Hospitalists may also lack expertise in clinical areas and are less likely than specialists to become involved in the diagnosis, treatment, and follow-up of complex hospitalized patients. Specialists are also more likely to have access to extramural funding for disease-based clinical research.

For these reasons, Dr. Flanders and his colleagues implemented SHARP. Their purpose was to jumpstart inpatient-based clinical and translational research in academic medical centers by pairing specialists with hospitalists.

SHARP is designed to facilitate pilot projects and preliminary data collection, which can lead to funding. Ultimately, they hope to disseminate research activities to other institutions.

The SHARP infrastructure partners an academic hospitalist as principle investigator (PI) with an academic cardiologist serving as co-PI. The team also includes a hospitalist investigator, a research associate, a clinical epidemiologist, and other personnel as needed.

SHARP is overseen by the PI and co-PI along with an executive from the University of Michigan Health System, vice chair of the Department of Medicine, and the associate dean for Clinical and Translational Research. This oversight group meets semi-annually and facilitates project selection and program development. It also monitors all program metrics.

“Every SHARP project developed is expected to apply for extramural support,” explained Dr. Flanders. SHARP projects and personnel are funded through these sources for pilot data and utilize revenue from the hospital medicine program.

To date, SHARP has resulted in a number of Internal Review Board-approved projects; a number of grants have been submitted, and some have been funded. In addition, peer-reviewed manuscripts have been submitted and accepted.

“Clinical research is underdeveloped at most academic hospitalist programs,” pronounced Dr. Flanders. “Partnering hospitalists with specialists can facilitate collaborative research and, in turn, identify the best way to care for inpatients. I encourage everyone to borrow this idea for their own institution.”

How Do Hospitalists Stack up?

In the short time hospitalists have been around, research has consistently shown that their addition has a positive or neutral effect on factors including length and cost of stay, patient mortality, and readmission rates. However, studies have been limited in scope—something Peter K. Lindenauer, MD, MSc, and his colleagues at Baystate Medical Center, Tufts University School of Medicine, Springfield, Mass., sought to correct in their own study, “Outcomes of Patients Treated by Hospitalists, General Internists and Family Physicians.”

The hospitalist-researchers wanted to compare outcomes for patients treated by three groups across a range of practice settings: hospitalists, non-hospitalist general internists, and family physicians.

The project they undertook was a retrospective cohort study that included patients admitted to 45 U.S. hospitals between September 2002 and July 2005. Patients were all at least 18 years old and had any of seven diagnoses: pneumonia, heart failure, chest pain, ischemic stroke, urinary tract infection, acute exacerbation of COPD, or acute myocardial infarction.

The total number of patients in the study was 76,926. Of these, 284 were cared for by a hospitalist, 993 by a general internist, and 971 by a family physician.

Dr. Lindenauer and his colleagues found that patients in all groups had similar patterns of comorbidities, although hospitalists were more likely to have patients who were covered by managed-care plans and not covered by traditional Medicare.

As for length of stay (LOS), patients cared for by hospitalists had an LOS 0.6 days shorter than internists and 0.4 days shorter than family physicians. Similarly, hospitalists’ patients had an adjusted cost per case approximately $404 less than that of general internists and on a par with family physicians.

The researchers found no significant differences in mortality or readmission rates among patients in the three physician groups.

Dr. Lindenauer wondered if the higher volume of patients seen by hospitalists would explain the differences in patient outcomes. However, when the researchers compared data for hospitalists with similar high-volume general internists and family physicians, they found similar differences in LOS and costs as they had found previously—suggesting other factors may be responsible for hospitalist effect.

Glycemic Control Issues

“Can we have our sugar-free cake and eat it too?” asked Greg Maynard, MD, MS, chief of the Division of Hospital Medicine, University of California, San Diego, when he presented his team’s project on inpatient glycemic control, “Effect of a Standardized Subcutaneous Insulin Order Set and an Insulin Management Protocol.”

“Inpatient diabetes and hyperglycemia is very common,” Dr. Maynard pointed out, “and poor control is associated with poor outcomes.” Although a standardized subcutaneous insulin order set (SQIO) is recommended, its impact is not yet proven.

Therefore, Dr. Maynard’s team set out to test the effectiveness of a standardized order set on adult inpatients in non-critical care wards with point-of-care glucose testing, in academic medical centers with more than 400 beds. Between November 2002 and October 2003, the group put together a baseline for insulin use patterns, glycemic control, and hypoglycemia. They then implemented a standardized SQIO set, which lasted for a year and a half, followed by a second intervention to monitor the incremental effect of an insulin management protocol.

In the first intervention, the researchers introduced basal, nutritional, and correction dose terminology to clinicians. They made a multiple correction dose scale available (based on total insulin dose required), discouraged sliding-scale-only regimens, instituted check-box simplicity, provided guidance for dosing, and incorporated hypoglycemia protocol. Order sets were produced in print first, then as computerized physician order entries.

The second stage, insulin management protocol, included a one-page algorithm, a glycemic target, a prompt for A1C, guidance on dosing including adjustments, and suggested regimens for patients who are eating, non-eating patients, and patients on enteral nutrition. This intervention was introduced with case-based teaching.

Within three months of implementing the SQIO, the use of sliding-scale-only regimens decreased as clinicians switched to regimens with some scheduled basal insulin.

The percentage of patients with a mean glucose lower than 180 mg a day was 62% at baseline and rose to 69% with the implementation of the SQIO. When the algorithm was used, it rose to 73%. The percentage of patient days with completely controlled glucose (between 60 and 180 mg/day) rose from 44% at baseline, to 48% with the SQIO, to 53% with the algorithm.

“But what about hypoglycemia?” asked Dr. Maynard. “The percentage of patient days with hypoglycemia decreased by 30% and 31%, respectively.” The addition of a standardized SQIO with an insulin management protocol improved glycemic control, reduced hypoglycemia, and changed insulin use patterns. TH

Nobody thought it was possible. Could all indoor workplaces in Ireland—including pubs—be made smoke-free? Now, a law enacted in 2004 is seen as a triumph for public health policy worldwide.1

Smoking kills 438,000 people a year in the United States, and 8.6 million have a serious smoking-related illness.2 Research shows many outpatient physicians do not judge it worthwhile to talk with their patients about quitting smoking because they assume they will have no effect. The assumption is that even if patients quit, they will relapse.

Yet ample evidence suggests hospitalists can have a positive effect by intervening during a patient’s hospital visit.

Data also show that an individual will relapse an average of seven times before being able to take the step for the long term. Relapse is a part of the process, each time teaching an individual something about his or her motivation and behavior.

“Doctors who address smoking with patients can double or even triple the chances of their quitting,” says Shawn Ralston, MD, pediatric hospitalist at Presbyterian Hospital in Albuquerque, N.M. A few pointed questions and a show of compassion to the patient in the hospital could make a world of difference.

Golden Opportunity

Stephen Liu, MD, MPH, a hospitalist and an assistant program director at Dartmouth-Hitchcock Medical Center (DHMC) in Lebanon, N.H., has been interested in smoking-cessation interventions since his residency in DHMC’s Leadership Preventive Medicine Residency Program in 2003, where he worked on improving care for pneumonia patients. His efforts took off as a result of the Centers for Medicare and Medicaid Services (CMS) pay-for-performance measures, which made smoking-cessation counseling a key component of admission and discharge documentation for a number of disease states.

The approach used with adult patients at DHMC is the brainchild of Colleen Warren, a registered nurse on the medicine unit on which Dr. Liu worked.

“The more times that smokers hear the message [about quitting], the more likely they are to try to quit,” says Dr. Liu. “We capitalized on that [point when] we developed a tobacco treatment team in our hospital. The team, which includes two to five motivated nurses, social workers, or care managers in most units of the hospital, pursued training including an online tobacco treatment course through U Mass Medical Center.”

In January 2006, DHMC was awarded a grant from the New Hampshire Department of Health and Human Services to standardize the treatment of hospitalized smokers. This includes conducting tobacco screening, assessing a patient’s readiness to quit, providing brief counseling, documenting the status and stage of change into the electronic medical record, and referring the patient to community resources upon discharge. The funding allowed the institution to support Warren and Dr. Liu as they coordinated the team and its work. These efforts, including counseling, nicotine replacement therapy, and cessation medications, are also available free to DHMC employees.

DHMC is participating in the CMS demonstration project, in which the hospital publicly reports performance measures for several conditions on the CMS Web site. In addition, many more performance measures are publicly reported on the DHMC quality-measures Web site. Although the team initially targeted the intervention to performance measures related to pneumonia and heart failure hospitalizations, they decided to offer interventions to all patients admitted to the hospital. Of these patients, about 20% are smokers, Dr. Liu says.

Because financial support wasn’t available at first and staff time was voluntary, the work was more difficult. Data from a six-month pilot intervention on two inpatient floors at DHMC showed patient assessments increased from 2% to 85%. In addition, the percentage of eligible heart failure and pneumonia patients receiving smoking cessation advice or counseling prior to discharge has risen from 30% before 2005 to 80% to 90%.

“We have found that hospitalization is a golden opportunity to address smoking cessation in patients in that they become acutely aware of how the smoking has affected their health,” says Dr. Liu. Because patients frequently go without smoking for several days while hospitalized, they learn they can live without smoking and feel much better.

“The key for our kind of intervention is not only assessing it and addressing it while they are hospitalized, but making sure that we link them to resources after they leave,” Dr. Liu says. Those resources include telephone quit lines or local support groups and/or local cessation clinics.

Counseling patients can be personally and professionally fulfilling, says Dr. Liu. He recalls a 50-year-old man—a lifelong smoker—admitted for pancreatitis. The day he was discharged, he showed Dr. Liu a hospital-produced packet of information. The patient said he had been reading it during his stay, decided he was motivated to quit, and had called the quit line.

Dr. Liu and his team use what they call the five A’s:

• Ask (does the patient smoke and has he/she tried to quit?);
• Advise the patient to quit;
• Assess (if the patient is ready to try to quit);
• Assist (the patient in planning treatment and referrals); and
• Arrange for a follow-up visit.

As part of their counseling, DHMC team members ask patients whether they have used assistive medication, such as nicotine-replacement therapy, bupropion (Wellbutrin) or varenicline (Chantix), in their attempts. They find out what patients have and have not tried. Then they ask, “How can we as a hospital help so that you will not restart smoking when you get home?”

A slightly longer counseling session with a motivated patient means a provider can explore whether they know their triggers for smoking, such as stress, alcohol use, or being around other smokers, and help the patient develop a proactive plan for when they are re-exposed to triggers upon discharge.

Counseling Parents of Hospitalized Children

In Dr. Ralston’s case, her research and the research of others inspired her to begin counseling the parents of hospitalized children.3-4 She was conducting research on respiratory illness, specifically bronchiolitis—the most common reason children are hospitalized.

She noticed the vast majority of children had had secondary smoke exposure. The work of C. Andrew Aligne, MD, formerly in the department of general pediatrics at the University of Rochester (N.Y.) Medical Center, inspired her.5-6 His analyses of attributable risk data revealed that the major and preventable cause of death in children is secondary smoke from parents.

But the issue really crystallized for Dr. Ralston when she encountered the work of Jonathan Winickoff, MD, MPH, an assistant professor of pediatrics at Harvard Medical School and a researcher with the Massachusetts General Hospital Center for Child and Adolescent Health Policy in Boston.

“The AHRQ guidelines show a huge amount of literature that say hospitalization is a great time to address smoking in adults,” says Dr. Ralston. “The [quit rate in office patients] will move from 5% to 12% or 15%, depending on the message. But in hospitalized adults, the quit rate can rise to 25% or 27%. Dr. Winickoff said, ‘Why can’t hospitalization for children be a teachable moment for parents?’ ”7

Another researcher who inspired Dr. Ralston was William R. Miller, PhD, who created the motivational interviewing model. Motivational interviewing is used with individuals to elicit and examine the ambivalence surrounding their unhealthy behaviors. Dr. Miller, retiring this year from the University of New Mexico (Albuquerque), began his work in the area of alcohol abuse. He and his colleagues have increasingly used motivational interviewing in other areas of addiction.

Dr. Ralston says what she has learned from motivational interviewing—and how she counsels parents of hospitalized children differently because of it—primarily pertains to her willingness to talk to people about a difficult subject. Instead of bombarding parents with facts about how smoking is bad for their children—which they already believe but don’t want to talk about—she learned to focus on the parents’ needs instead of the effects on the child.

“And there is the issue of bringing it up when this is not technically your patient,” she says. But after fine-tuning and developing her technique, she now assumes a value-neutral, nonjudgmental, open-ended approach using motivational interviewing. “Eventually it becomes easy to do.”

When approaching a parent to offer help, says Dr. Ralston, “I will lead by acknowledging that the experience the parent is having is extremely stressful. Then, after addressing the primary illness of the child and what the plan is for that, I say, ‘I see [from our records] that you are smoking. Have you tried to quit? Are you interested in quitting now? What might I be able to do to help you?’ If there is an opening, then I’ll go into more extensive counseling.

“You don’t need all the data behind you. I use my expertise more to motivate pediatricians, not the parents.” Another tack she takes to motivate pediatricians to empathically address smoking is to ask them to think of something they do that they know is bad for them but that they continue to do.

Conclusion

“There have been some studies that have shown [disappointing] outcomes when we intervene with hospitalized patients, but I’m more optimistic,” says Dr. Liu. “I feel that as long as we can make a difference in some people’s lives and get them to quit after they leave the hospital, then it’s worth the effort.”

Look at what you are willing to do, advises Dr. Ralston. “If that is a brief message and then a referral to a quit line, that’s fabulous,” she says. “You still might double the quit rate.” Given the temporal nature of the hospitalist-patient relationship, there may be a good number of ways hospitalists could effect change by offering a few encouraging words. TH

Andrea Sattinger is a frequent contributor to The Hospitalist.

References

1. Koh HK, Joossens LX, Connolly GN. Making smoking history worldwide. N Engl J Med. 2007 Apr 12;356(15):1496-1498.
2. Centers for Disease Control and Prevention. Targeting Tobacco Use: The Nation’s Leading Cause of Preventable Death, 2007. Available at www.cdc.gov/Tobacco/basic_information/00_pdfs/AAGTobacco2007.pdf. Last accessed June 18, 2007.
3. Ralston S, Kellett N, Williams RL, et al. Practice-based assessment of tobacco usage in southwestern primary care patients: a Research Involving Outpatient Settings Network (RIOS Net) study. J Am Board Fam Med. 2007;20(2):174-180.
4. Ralston S, Mahshid R. The pediatric hospitalist and the smoking parent. Pediatric Research Day 2006. Available at http://hsc.unm.edu/pedsresearch/ORAL%20PRESENTATIONS.htm Albuquerque: Office of Research and Creative Endeavors, Department of Pediatrics, University of New Mexico Health Sciences Center; 2006. Last accessed June 18, 2007.
5. Aligne CA, Stoddard JJ. Tobacco and children. An economic evaluation of the medical effects of parental smoking. Arch Pediatr Adolesc Med. 1997 Jul;151(7):648-653. Erratum in: Arch Pediatr Adolesc Med 1997 Oct;151(10):988. Comment in: Arch Pediatr Adolesc Med. 1997 Dec;151(12):1269. Arch Pediatr Adolesc Med. 2000 Aug;154(8):850.
6. Leonard K, Mosquera M, Aligne CA. Pediatrics in the community: Taking a collective breath to help children who have asthma. Pediatr Rev. 2007;28:152-153.
7. Winickoff JP, Hillis VJ, Palfrey JS, et al. A smoking cessation intervention for parents of children who are hospitalized for respiratory illness: the stop tobacco outreach program. Pediatrics. 2003 Jan;111(1):140-145.

Nobody thought it was possible. Could all indoor workplaces in Ireland—including pubs—be made smoke-free? Now, a law enacted in 2004 is seen as a triumph for public health policy worldwide.1

Smoking kills 438,000 people a year in the United States, and 8.6 million have a serious smoking-related illness.2 Research shows many outpatient physicians do not judge it worthwhile to talk with their patients about quitting smoking because they assume they will have no effect. The assumption is that even if patients quit, they will relapse.

Yet ample evidence suggests hospitalists can have a positive effect by intervening during a patient’s hospital visit.

Data also show that an individual will relapse an average of seven times before being able to take the step for the long term. Relapse is a part of the process, each time teaching an individual something about his or her motivation and behavior.

“Doctors who address smoking with patients can double or even triple the chances of their quitting,” says Shawn Ralston, MD, pediatric hospitalist at Presbyterian Hospital in Albuquerque, N.M. A few pointed questions and a show of compassion to the patient in the hospital could make a world of difference.

Golden Opportunity

Stephen Liu, MD, MPH, a hospitalist and an assistant program director at Dartmouth-Hitchcock Medical Center (DHMC) in Lebanon, N.H., has been interested in smoking-cessation interventions since his residency in DHMC’s Leadership Preventive Medicine Residency Program in 2003, where he worked on improving care for pneumonia patients. His efforts took off as a result of the Centers for Medicare and Medicaid Services (CMS) pay-for-performance measures, which made smoking-cessation counseling a key component of admission and discharge documentation for a number of disease states.

The approach used with adult patients at DHMC is the brainchild of Colleen Warren, a registered nurse on the medicine unit on which Dr. Liu worked.

“The more times that smokers hear the message [about quitting], the more likely they are to try to quit,” says Dr. Liu. “We capitalized on that [point when] we developed a tobacco treatment team in our hospital. The team, which includes two to five motivated nurses, social workers, or care managers in most units of the hospital, pursued training including an online tobacco treatment course through U Mass Medical Center.”

In January 2006, DHMC was awarded a grant from the New Hampshire Department of Health and Human Services to standardize the treatment of hospitalized smokers. This includes conducting tobacco screening, assessing a patient’s readiness to quit, providing brief counseling, documenting the status and stage of change into the electronic medical record, and referring the patient to community resources upon discharge. The funding allowed the institution to support Warren and Dr. Liu as they coordinated the team and its work. These efforts, including counseling, nicotine replacement therapy, and cessation medications, are also available free to DHMC employees.

DHMC is participating in the CMS demonstration project, in which the hospital publicly reports performance measures for several conditions on the CMS Web site. In addition, many more performance measures are publicly reported on the DHMC quality-measures Web site. Although the team initially targeted the intervention to performance measures related to pneumonia and heart failure hospitalizations, they decided to offer interventions to all patients admitted to the hospital. Of these patients, about 20% are smokers, Dr. Liu says.

Because financial support wasn’t available at first and staff time was voluntary, the work was more difficult. Data from a six-month pilot intervention on two inpatient floors at DHMC showed patient assessments increased from 2% to 85%. In addition, the percentage of eligible heart failure and pneumonia patients receiving smoking cessation advice or counseling prior to discharge has risen from 30% before 2005 to 80% to 90%.

“We have found that hospitalization is a golden opportunity to address smoking cessation in patients in that they become acutely aware of how the smoking has affected their health,” says Dr. Liu. Because patients frequently go without smoking for several days while hospitalized, they learn they can live without smoking and feel much better.

“The key for our kind of intervention is not only assessing it and addressing it while they are hospitalized, but making sure that we link them to resources after they leave,” Dr. Liu says. Those resources include telephone quit lines or local support groups and/or local cessation clinics.

Counseling patients can be personally and professionally fulfilling, says Dr. Liu. He recalls a 50-year-old man—a lifelong smoker—admitted for pancreatitis. The day he was discharged, he showed Dr. Liu a hospital-produced packet of information. The patient said he had been reading it during his stay, decided he was motivated to quit, and had called the quit line.

Dr. Liu and his team use what they call the five A’s:

• Ask (does the patient smoke and has he/she tried to quit?);
• Advise the patient to quit;
• Assess (if the patient is ready to try to quit);
• Assist (the patient in planning treatment and referrals); and
• Arrange for a follow-up visit.

As part of their counseling, DHMC team members ask patients whether they have used assistive medication, such as nicotine-replacement therapy, bupropion (Wellbutrin) or varenicline (Chantix), in their attempts. They find out what patients have and have not tried. Then they ask, “How can we as a hospital help so that you will not restart smoking when you get home?”

A slightly longer counseling session with a motivated patient means a provider can explore whether they know their triggers for smoking, such as stress, alcohol use, or being around other smokers, and help the patient develop a proactive plan for when they are re-exposed to triggers upon discharge.

Counseling Parents of Hospitalized Children

In Dr. Ralston’s case, her research and the research of others inspired her to begin counseling the parents of hospitalized children.3-4 She was conducting research on respiratory illness, specifically bronchiolitis—the most common reason children are hospitalized.

She noticed the vast majority of children had had secondary smoke exposure. The work of C. Andrew Aligne, MD, formerly in the department of general pediatrics at the University of Rochester (N.Y.) Medical Center, inspired her.5-6 His analyses of attributable risk data revealed that the major and preventable cause of death in children is secondary smoke from parents.

But the issue really crystallized for Dr. Ralston when she encountered the work of Jonathan Winickoff, MD, MPH, an assistant professor of pediatrics at Harvard Medical School and a researcher with the Massachusetts General Hospital Center for Child and Adolescent Health Policy in Boston.

“The AHRQ guidelines show a huge amount of literature that say hospitalization is a great time to address smoking in adults,” says Dr. Ralston. “The [quit rate in office patients] will move from 5% to 12% or 15%, depending on the message. But in hospitalized adults, the quit rate can rise to 25% or 27%. Dr. Winickoff said, ‘Why can’t hospitalization for children be a teachable moment for parents?’ ”7

Another researcher who inspired Dr. Ralston was William R. Miller, PhD, who created the motivational interviewing model. Motivational interviewing is used with individuals to elicit and examine the ambivalence surrounding their unhealthy behaviors. Dr. Miller, retiring this year from the University of New Mexico (Albuquerque), began his work in the area of alcohol abuse. He and his colleagues have increasingly used motivational interviewing in other areas of addiction.

Dr. Ralston says what she has learned from motivational interviewing—and how she counsels parents of hospitalized children differently because of it—primarily pertains to her willingness to talk to people about a difficult subject. Instead of bombarding parents with facts about how smoking is bad for their children—which they already believe but don’t want to talk about—she learned to focus on the parents’ needs instead of the effects on the child.

“And there is the issue of bringing it up when this is not technically your patient,” she says. But after fine-tuning and developing her technique, she now assumes a value-neutral, nonjudgmental, open-ended approach using motivational interviewing. “Eventually it becomes easy to do.”

When approaching a parent to offer help, says Dr. Ralston, “I will lead by acknowledging that the experience the parent is having is extremely stressful. Then, after addressing the primary illness of the child and what the plan is for that, I say, ‘I see [from our records] that you are smoking. Have you tried to quit? Are you interested in quitting now? What might I be able to do to help you?’ If there is an opening, then I’ll go into more extensive counseling.

“You don’t need all the data behind you. I use my expertise more to motivate pediatricians, not the parents.” Another tack she takes to motivate pediatricians to empathically address smoking is to ask them to think of something they do that they know is bad for them but that they continue to do.

Conclusion

“There have been some studies that have shown [disappointing] outcomes when we intervene with hospitalized patients, but I’m more optimistic,” says Dr. Liu. “I feel that as long as we can make a difference in some people’s lives and get them to quit after they leave the hospital, then it’s worth the effort.”

Look at what you are willing to do, advises Dr. Ralston. “If that is a brief message and then a referral to a quit line, that’s fabulous,” she says. “You still might double the quit rate.” Given the temporal nature of the hospitalist-patient relationship, there may be a good number of ways hospitalists could effect change by offering a few encouraging words. TH

Andrea Sattinger is a frequent contributor to The Hospitalist.

References

1. Koh HK, Joossens LX, Connolly GN. Making smoking history worldwide. N Engl J Med. 2007 Apr 12;356(15):1496-1498.
2. Centers for Disease Control and Prevention. Targeting Tobacco Use: The Nation’s Leading Cause of Preventable Death, 2007. Available at www.cdc.gov/Tobacco/basic_information/00_pdfs/AAGTobacco2007.pdf. Last accessed June 18, 2007.
3. Ralston S, Kellett N, Williams RL, et al. Practice-based assessment of tobacco usage in southwestern primary care patients: a Research Involving Outpatient Settings Network (RIOS Net) study. J Am Board Fam Med. 2007;20(2):174-180.
4. Ralston S, Mahshid R. The pediatric hospitalist and the smoking parent. Pediatric Research Day 2006. Available at http://hsc.unm.edu/pedsresearch/ORAL%20PRESENTATIONS.htm Albuquerque: Office of Research and Creative Endeavors, Department of Pediatrics, University of New Mexico Health Sciences Center; 2006. Last accessed June 18, 2007.
5. Aligne CA, Stoddard JJ. Tobacco and children. An economic evaluation of the medical effects of parental smoking. Arch Pediatr Adolesc Med. 1997 Jul;151(7):648-653. Erratum in: Arch Pediatr Adolesc Med 1997 Oct;151(10):988. Comment in: Arch Pediatr Adolesc Med. 1997 Dec;151(12):1269. Arch Pediatr Adolesc Med. 2000 Aug;154(8):850.
6. Leonard K, Mosquera M, Aligne CA. Pediatrics in the community: Taking a collective breath to help children who have asthma. Pediatr Rev. 2007;28:152-153.
7. Winickoff JP, Hillis VJ, Palfrey JS, et al. A smoking cessation intervention for parents of children who are hospitalized for respiratory illness: the stop tobacco outreach program. Pediatrics. 2003 Jan;111(1):140-145.

Nobody thought it was possible. Could all indoor workplaces in Ireland—including pubs—be made smoke-free? Now, a law enacted in 2004 is seen as a triumph for public health policy worldwide.1

Smoking kills 438,000 people a year in the United States, and 8.6 million have a serious smoking-related illness.2 Research shows many outpatient physicians do not judge it worthwhile to talk with their patients about quitting smoking because they assume they will have no effect. The assumption is that even if patients quit, they will relapse.

Yet ample evidence suggests hospitalists can have a positive effect by intervening during a patient’s hospital visit.

Data also show that an individual will relapse an average of seven times before being able to take the step for the long term. Relapse is a part of the process, each time teaching an individual something about his or her motivation and behavior.

“Doctors who address smoking with patients can double or even triple the chances of their quitting,” says Shawn Ralston, MD, pediatric hospitalist at Presbyterian Hospital in Albuquerque, N.M. A few pointed questions and a show of compassion to the patient in the hospital could make a world of difference.

Golden Opportunity

Stephen Liu, MD, MPH, a hospitalist and an assistant program director at Dartmouth-Hitchcock Medical Center (DHMC) in Lebanon, N.H., has been interested in smoking-cessation interventions since his residency in DHMC’s Leadership Preventive Medicine Residency Program in 2003, where he worked on improving care for pneumonia patients. His efforts took off as a result of the Centers for Medicare and Medicaid Services (CMS) pay-for-performance measures, which made smoking-cessation counseling a key component of admission and discharge documentation for a number of disease states.

The approach used with adult patients at DHMC is the brainchild of Colleen Warren, a registered nurse on the medicine unit on which Dr. Liu worked.

“The more times that smokers hear the message [about quitting], the more likely they are to try to quit,” says Dr. Liu. “We capitalized on that [point when] we developed a tobacco treatment team in our hospital. The team, which includes two to five motivated nurses, social workers, or care managers in most units of the hospital, pursued training including an online tobacco treatment course through U Mass Medical Center.”

In January 2006, DHMC was awarded a grant from the New Hampshire Department of Health and Human Services to standardize the treatment of hospitalized smokers. This includes conducting tobacco screening, assessing a patient’s readiness to quit, providing brief counseling, documenting the status and stage of change into the electronic medical record, and referring the patient to community resources upon discharge. The funding allowed the institution to support Warren and Dr. Liu as they coordinated the team and its work. These efforts, including counseling, nicotine replacement therapy, and cessation medications, are also available free to DHMC employees.

DHMC is participating in the CMS demonstration project, in which the hospital publicly reports performance measures for several conditions on the CMS Web site. In addition, many more performance measures are publicly reported on the DHMC quality-measures Web site. Although the team initially targeted the intervention to performance measures related to pneumonia and heart failure hospitalizations, they decided to offer interventions to all patients admitted to the hospital. Of these patients, about 20% are smokers, Dr. Liu says.

Because financial support wasn’t available at first and staff time was voluntary, the work was more difficult. Data from a six-month pilot intervention on two inpatient floors at DHMC showed patient assessments increased from 2% to 85%. In addition, the percentage of eligible heart failure and pneumonia patients receiving smoking cessation advice or counseling prior to discharge has risen from 30% before 2005 to 80% to 90%.

“We have found that hospitalization is a golden opportunity to address smoking cessation in patients in that they become acutely aware of how the smoking has affected their health,” says Dr. Liu. Because patients frequently go without smoking for several days while hospitalized, they learn they can live without smoking and feel much better.

“The key for our kind of intervention is not only assessing it and addressing it while they are hospitalized, but making sure that we link them to resources after they leave,” Dr. Liu says. Those resources include telephone quit lines or local support groups and/or local cessation clinics.

Counseling patients can be personally and professionally fulfilling, says Dr. Liu. He recalls a 50-year-old man—a lifelong smoker—admitted for pancreatitis. The day he was discharged, he showed Dr. Liu a hospital-produced packet of information. The patient said he had been reading it during his stay, decided he was motivated to quit, and had called the quit line.

Dr. Liu and his team use what they call the five A’s:

• Ask (does the patient smoke and has he/she tried to quit?);
• Advise the patient to quit;
• Assess (if the patient is ready to try to quit);
• Assist (the patient in planning treatment and referrals); and
• Arrange for a follow-up visit.

As part of their counseling, DHMC team members ask patients whether they have used assistive medication, such as nicotine-replacement therapy, bupropion (Wellbutrin) or varenicline (Chantix), in their attempts. They find out what patients have and have not tried. Then they ask, “How can we as a hospital help so that you will not restart smoking when you get home?”

A slightly longer counseling session with a motivated patient means a provider can explore whether they know their triggers for smoking, such as stress, alcohol use, or being around other smokers, and help the patient develop a proactive plan for when they are re-exposed to triggers upon discharge.

Counseling Parents of Hospitalized Children

In Dr. Ralston’s case, her research and the research of others inspired her to begin counseling the parents of hospitalized children.3-4 She was conducting research on respiratory illness, specifically bronchiolitis—the most common reason children are hospitalized.

She noticed the vast majority of children had had secondary smoke exposure. The work of C. Andrew Aligne, MD, formerly in the department of general pediatrics at the University of Rochester (N.Y.) Medical Center, inspired her.5-6 His analyses of attributable risk data revealed that the major and preventable cause of death in children is secondary smoke from parents.

But the issue really crystallized for Dr. Ralston when she encountered the work of Jonathan Winickoff, MD, MPH, an assistant professor of pediatrics at Harvard Medical School and a researcher with the Massachusetts General Hospital Center for Child and Adolescent Health Policy in Boston.

“The AHRQ guidelines show a huge amount of literature that say hospitalization is a great time to address smoking in adults,” says Dr. Ralston. “The [quit rate in office patients] will move from 5% to 12% or 15%, depending on the message. But in hospitalized adults, the quit rate can rise to 25% or 27%. Dr. Winickoff said, ‘Why can’t hospitalization for children be a teachable moment for parents?’ ”7

Another researcher who inspired Dr. Ralston was William R. Miller, PhD, who created the motivational interviewing model. Motivational interviewing is used with individuals to elicit and examine the ambivalence surrounding their unhealthy behaviors. Dr. Miller, retiring this year from the University of New Mexico (Albuquerque), began his work in the area of alcohol abuse. He and his colleagues have increasingly used motivational interviewing in other areas of addiction.

Dr. Ralston says what she has learned from motivational interviewing—and how she counsels parents of hospitalized children differently because of it—primarily pertains to her willingness to talk to people about a difficult subject. Instead of bombarding parents with facts about how smoking is bad for their children—which they already believe but don’t want to talk about—she learned to focus on the parents’ needs instead of the effects on the child.

“And there is the issue of bringing it up when this is not technically your patient,” she says. But after fine-tuning and developing her technique, she now assumes a value-neutral, nonjudgmental, open-ended approach using motivational interviewing. “Eventually it becomes easy to do.”

When approaching a parent to offer help, says Dr. Ralston, “I will lead by acknowledging that the experience the parent is having is extremely stressful. Then, after addressing the primary illness of the child and what the plan is for that, I say, ‘I see [from our records] that you are smoking. Have you tried to quit? Are you interested in quitting now? What might I be able to do to help you?’ If there is an opening, then I’ll go into more extensive counseling.

“You don’t need all the data behind you. I use my expertise more to motivate pediatricians, not the parents.” Another tack she takes to motivate pediatricians to empathically address smoking is to ask them to think of something they do that they know is bad for them but that they continue to do.

Conclusion

“There have been some studies that have shown [disappointing] outcomes when we intervene with hospitalized patients, but I’m more optimistic,” says Dr. Liu. “I feel that as long as we can make a difference in some people’s lives and get them to quit after they leave the hospital, then it’s worth the effort.”

Look at what you are willing to do, advises Dr. Ralston. “If that is a brief message and then a referral to a quit line, that’s fabulous,” she says. “You still might double the quit rate.” Given the temporal nature of the hospitalist-patient relationship, there may be a good number of ways hospitalists could effect change by offering a few encouraging words. TH

Andrea Sattinger is a frequent contributor to The Hospitalist.

References

1. Koh HK, Joossens LX, Connolly GN. Making smoking history worldwide. N Engl J Med. 2007 Apr 12;356(15):1496-1498.
2. Centers for Disease Control and Prevention. Targeting Tobacco Use: The Nation’s Leading Cause of Preventable Death, 2007. Available at www.cdc.gov/Tobacco/basic_information/00_pdfs/AAGTobacco2007.pdf. Last accessed June 18, 2007.
3. Ralston S, Kellett N, Williams RL, et al. Practice-based assessment of tobacco usage in southwestern primary care patients: a Research Involving Outpatient Settings Network (RIOS Net) study. J Am Board Fam Med. 2007;20(2):174-180.
4. Ralston S, Mahshid R. The pediatric hospitalist and the smoking parent. Pediatric Research Day 2006. Available at http://hsc.unm.edu/pedsresearch/ORAL%20PRESENTATIONS.htm Albuquerque: Office of Research and Creative Endeavors, Department of Pediatrics, University of New Mexico Health Sciences Center; 2006. Last accessed June 18, 2007.
5. Aligne CA, Stoddard JJ. Tobacco and children. An economic evaluation of the medical effects of parental smoking. Arch Pediatr Adolesc Med. 1997 Jul;151(7):648-653. Erratum in: Arch Pediatr Adolesc Med 1997 Oct;151(10):988. Comment in: Arch Pediatr Adolesc Med. 1997 Dec;151(12):1269. Arch Pediatr Adolesc Med. 2000 Aug;154(8):850.
6. Leonard K, Mosquera M, Aligne CA. Pediatrics in the community: Taking a collective breath to help children who have asthma. Pediatr Rev. 2007;28:152-153.
7. Winickoff JP, Hillis VJ, Palfrey JS, et al. A smoking cessation intervention for parents of children who are hospitalized for respiratory illness: the stop tobacco outreach program. Pediatrics. 2003 Jan;111(1):140-145.

Supplement Editors:
Susan J. Rehm, MD, and Alpesh N. Amin, MD, MBA

Contents

Infections in hospitalized patients: What is happening and who can help?
Alpesh N. Amin, MD, MBA, and Susan J. Rehm, MD

Impact of community-acquired methicillin-resistant Staphylococcus aureus in the hospital setting
Thomas M. File, Jr., MD

Emerging issues in the management of infections caused by multidrug-resistant gram-negative bacteria
Louis B. Rice, MD

Complicated skin and soft-tissue infections: Diagnostic approach and empiric treatment options
James I. Merlino, MD, and Mark A. Malangoni, MD

Empiric treatment options in the management of complicated intra-abdominal infections
John A. Weigelt, MD

Antibacterial treatment strategies in hospitalized patients: What role for pharmacoeconomics?
Morton P. Goldman, PharmD, BCPS, and Radhika Nair, PhD

Supplement Editors:
Susan J. Rehm, MD, and Alpesh N. Amin, MD, MBA

Contents

Infections in hospitalized patients: What is happening and who can help?
Alpesh N. Amin, MD, MBA, and Susan J. Rehm, MD

Impact of community-acquired methicillin-resistant Staphylococcus aureus in the hospital setting
Thomas M. File, Jr., MD

Emerging issues in the management of infections caused by multidrug-resistant gram-negative bacteria
Louis B. Rice, MD

Complicated skin and soft-tissue infections: Diagnostic approach and empiric treatment options
James I. Merlino, MD, and Mark A. Malangoni, MD

Empiric treatment options in the management of complicated intra-abdominal infections
John A. Weigelt, MD

Antibacterial treatment strategies in hospitalized patients: What role for pharmacoeconomics?
Morton P. Goldman, PharmD, BCPS, and Radhika Nair, PhD

Supplement Editors:
Susan J. Rehm, MD, and Alpesh N. Amin, MD, MBA

Contents

Infections in hospitalized patients: What is happening and who can help?
Alpesh N. Amin, MD, MBA, and Susan J. Rehm, MD

Impact of community-acquired methicillin-resistant Staphylococcus aureus in the hospital setting
Thomas M. File, Jr., MD

Emerging issues in the management of infections caused by multidrug-resistant gram-negative bacteria
Louis B. Rice, MD

Complicated skin and soft-tissue infections: Diagnostic approach and empiric treatment options
James I. Merlino, MD, and Mark A. Malangoni, MD

Empiric treatment options in the management of complicated intra-abdominal infections
John A. Weigelt, MD

Antibacterial treatment strategies in hospitalized patients: What role for pharmacoeconomics?
Morton P. Goldman, PharmD, BCPS, and Radhika Nair, PhD