This is the first of a two-part series on care of the HIV/AIDS patient. Part 2 will address the public health and counseling aspects of HIV management, as well as the care of children with HIV.

It’s been a little more than a quarter-century since acquired immune deficiency syndrome (AIDS) was first identified. Since 1981, many facets of our understanding and management of HIV/AIDS have changed.

In some populations, HIV (when well-controlled) has been transformed to a chronic disease state, with few episodes of the AIDS-defining conditions (opportunistic infections, Kaposi’s sarcoma, wasting syndromes) seen in the early years of the epidemic. However, when treating underserved and indigent populations, hospitalists may still encounter the common symptoms of advanced disease in their HIV-positive patients.

What are the common presenting scenarios of HIV/AIDS seen by hospitalists in the current era of highly active antiretroviral therapy (HAART), and how does antiretroviral therapy affect hospitalists’ management of these patients? The Hospitalist recently interviewed HIV/AIDS specialists and practicing hospitalists to learn find out.

The Differential Diagnosis: Think Broadly

The Centers for Disease Control and Prevention estimates 1.04 million to 1.19 million people live with HIV/AIDS in the United States. The CDC also estimates approximately 40,000 people become infected with HIV each year.1

The conditions that bring HIV-positive patients to the hospital run the gamut. There is a broad range of presenting symptoms, noted Sigall K. Bell, MD, the Division of Infectious Diseases and General Medicine at Harvard Medical School and Beth Israel Deaconess Medical Center in Boston. “The differential diagnoses for patients who are HIV-infected—depending on their immunological status—can be dramatically expanded compared to HIV-negative patients,” says Dr. Bell. “For any given presenting symptom, one needs to think about whether the person’s HIV itself, an opportunistic infection secondary to the HIV, or HIV medication effects are playing into potential explanations for the presenting symptoms.”

Even the demographics of the hospital’s catchment area can be associated with patients’ problems. “The types of problems seen in hospitalized HIV-infected patients largely depends on the degree of access to care that people have,” says HIV and infectious disease specialist Harry Hollander, MD, program director for the University of California, San Francisco Internal Medicine Residency Program, and professor of Clinical Medicine at UCSF. In areas where care systems are not robust, explains Dr. Hollander, people admitted to the hospital will most likely have the same problems seen at the beginning of the epidemic.

If hospitalists are practicing in areas with highly developed systems of care and good penetration of care, people with HIV are just as likely to be admitted to the hospital with problems completely unrelated to their HIV status. In the pre-antiretroviral era, according to Dr. Hollander, hospital physicians typically saw three or four common types of presentations in these patients. “My biggest message these days,” he says, “is to think broadly about the problems these patients present with, and to generate parallel thinking about HIV-related causes as well as causes not related to HIV. Many patients with well-controlled HIV are more likely to wind up in the hospital because of other routine medical problems. If you only consider the HIV status, you may be missing other important, related and treatable conditions.”

Thomas Baudendistel, MD, who is associate residency program director at California Pacific Medical Center, a community-based hospital in San Francisco operated by Sutter Health, confirms that as HIV patients are getting healthier, “their immune systems are being kept intact [with CD4 counts in the normal range] for longer periods of time. We don’t see issues of HIV-related conditions in hospitalization as much as we did 20, 10, or even five years ago. The life-threatening opportunistic infections, although still there, have receded as cause for hospitalization. When an HIV patient gets admitted, it’s just as likely to be a noninfectious condition, such as lymphoma, or hematologic complications. Or, the patients may be old enough to have heart disease or COPD.”

Dr. Sabharwal

Other hospitalists practice in areas where the opposite is true. Aman D. Sabharwal, MD, is associate medical director, Inpatient and Hospitalist Services for Jackson Health Systems and practices primarily at Jackson Memorial Hospital, which serves a large indigent population in south Florida. While he agrees that some HIV patients are being well-managed because of advances in antiretroviral therapy, these are not the patients seen by hospitalists in his group.

“A majority of our HIV-positive patients come in for illnesses or opportunistic infections that are due to their HIV,” he says. “Most of these patients are either noncompliant with their medications or have low CD4 counts. Generally, the acute issue for which they are admitted is generally unrelated to the medication itself—it is probably due more so to the lack of medication.”

Dr. Bell

Dr. Baudendistel reports that he and fellow hospitalists at California Pacific Medical Center are also seeing more immune reconstitution illness, in which the reconstituted immune system exhibits an “overexuberant” reaction, causing unique presentations. For example, patients with low CD4 counts who have clinically silent infection with Mycobacterium Avium Complex, hepatitis B, or a variety of infectious agents may experience a significant boost in their CD4 count with antiretroviral therapy. The resurgent immune system can then mount a response to these previously quiescent pathogens, causing a flare-up of symptoms.

“If the primary site of occult disease is the lungs, a respiratory exacerbation will occur; if in the liver, as in the example of hepatitis B, a significant hepatitis can ensue,” says Dr. Baudendistel.

Call in Consultants: Keep a Low Threshold

As the management of HIV becomes more sophisticated, hospitalists should frequently consult infectious-disease and consulting pharmacy colleagues. “I think the hospitalist is very well-equipped to deal with the acute illnesses that these patients have,” notes Dr. Hollander. “Most hospitalists feel less comfortable with the details of managing the chronic medical regimen—particularly the antiretroviral drugs, which they don’t have an opportunity to prescribe, manage, and monitor over time.”

Dr. Baudendistel concurs: “As a hospitalist, what I face with these patients—especially if they come in with an illness unrelated to HIV—is trying to figure out how a drug I am thinking of prescribing for their heart disease or kidney failure will impact their HAART therapy. Is there going to be some hidden interaction that I’m not aware of because I don’t deal with those medications every day?”

It is precisely when weighing those questions about chronic therapy when hospitalists would be best served to quickly consider consulting either a primary physician or the appropriate consultant about the details of the medication regimen. “In most cases, you’re going to want to continue that regimen during hospitalization for other intercurrent problems,” he says.

When possible, it’s a good idea for the hospitalist to touch base with the primary HIV provider, says Dr. Bell. “There are sometimes subtleties to the care that are not necessarily transmitted in a faxed document or in information the patient brings to the hospital. Those subtleties—about doses of antiretroviral drugs or changes in regimen—can make big differences.”

Hospitalists should inform themselves of the potentially harmful effects of antiretroviral drugs, as well as the potential harm in stopping them. “It takes an awareness of knowing what the potential problems are to know when to utilize a consultant,” says Dr. Bell. “As doctors, we are appropriately aware of the power of medications, and it’s not uncommon when the clinical picture is unclear for physicians to think, ‘First do no harm—let me stop these medications.’ One has to be aware of the fact that stopping a medication doesn’t happen in a vacuum.”

Nuances of HAART Require Vigilance

“Highly active antiretroviral therapy has resulted in improved immunological status for many HIV-positive patients, but the therapy has also introduced several potential complications and consequences of which hospitalists should be aware,” says Dr. Bell. Most notable among those consequences: the effects of starting and stopping medications.

“It used to be,” says Dr. Baudendistel, “that we would say, ‘The patients are only going to be here in the hospital for a few days; let’s just stop their highly active HIV treatment.’ Now we know that is not a good idea, because stopping treatment can create resistant viruses.”

Dr. Bell explains one such example: Each of the classes of antiretroviral drugs has a different half-life. If a physician stops all antiretroviral therapy at the same time, the nucleoside/nucleotide reverse transcriptase inhibitor (NRTI) may wash out of the system more quickly than does the nonnucleoside reverse transcriptase inhibitor (NNRTI). The result will be NNRTI monotherapy, and drug resistance can occur quickly in that setting, says Dr. Bell. (Note: not all patients are on NNRTIs; some may be on protease inhibitors or fusion inhibitors, which all have potentially adverse events and drug-drug interactions.)

As another example, if a patient has co-infection with hepatitis B, stopping an NRTI with activity against hepatitis B (such as lamivudine or tenofovir), may cause hepatitis to flare up. Finally, several studies now suggest that the long-term consequences of starting and stopping therapy (structured treatment interruptions) are also detrimental.2

Hospitalists can incorporate into their diagnosis and treatment of these patients other management strategies beyond potential drug-drug interactions and consequences of incurring resistance when stopping antiretroviral medication. For instance:

Dr. Sabharwal

• Screen for other problems that may be attributable to long-term antiretroviral therapy, such as dyslipidemia, diabetes, and osteoporosis if the patient has adhered to HAART.3 Because mounting data suggest an increased incidence of cardiovascular disease, aggressive management of other underlying cardiovascular risk factors is an important part of care.
• Ensure electronic medication orders do not automatically default to inappropriate doses. For instance, ritonavir, a protease inhibitor, is most commonly used as a booster dose and not at full dose—but electronic pharmacy ordering systems may not reflect this current knowledge.
• Raise nursing and physician staff awareness to confirm that HAART doses are not missed (e.g., if a patient is off the floor for extended periods of time). Reconcile medication orders and the medication administration record to ensure all ordered medications are given. For example, if there is a delay in accessing one of the patient’s usual medications, it may be harmful to administer just the other two until the third is available. Alternative arrangements would be required.
• Consider orders allowing patients to use their own supply of medications if the hospital pharmacy is not able to supply the exact drug needed for their specific HAART regimen.

It is also advisable to ask HIV patients about their use of alternative therapies, says Dr. Hollander, because studies have shown that a substantial minority of people with HIV infection do, in fact, take alternative therapies.4 “We also know,” he says, “that some of these therapies cause adverse reactions and toxicities that you would not ordinarily consider, unless you had obtained that history.”

Education, Education, Education

Dr. Bell notes that there is wide variability in adherence to medication and follow-up clinic visits among those infected with HIV. “It’s important for hospitalists to emphasize links to care,” she says. “A hospital visit is an important time to emphasize education, and to make sure that those patients have the appropriate follow-up.”

The role of hospitalist as patient educator takes on more prominence in settings with a larger percentage of more indigent patients. “I think the key is education, education, education,” Dr. Sabharwal asserts.

He and hospitalists in his group make patient counseling a key component in their treatment, from the time they encounter patients until discharge. They emphasize that with today’s therapies, a 60-year-old HIV-positive patient may avoid hospitalization, while those who do not take their medications risk the severe sequelae of AIDS-defining conditions.

“It’s very important that physicians not be in a hurry to go from patient to patient,” he says. “A lot of times what’s lacking is for physicians to take the time to sit down with the patient and go over the severity of the disease in its later stages. We counsel patients every single time.”

Dr. Baudendistel’s counsel to fellow hospitalists is that although they may still be attuned to treating HIV complications, such as PCP or TB, HIV is now a chronic disease. And as such, “It’s not something that the casual generalist can manage independently,” he says. “When I was in training, I was very well-versed in managing HIV disease. With the initial drug treatments and the common opportunistic infections, treatment was pretty straightforward. But now I wouldn’t feel comfortable managing the HIV part of the illness on my own. HIV is a subspecialist disease now, and it is important to have a colleague with HIV expertise with whom they can consult.” TH

Gretchen Henkel is a frequent contributor to The Hospitalist.

References

1. CDC HIV/AIDS Fact Sheet, “A Glance at the HIV/AIDS Epidemic.” January 2007. Available online at http://www.cdc.gov/hiv. Last accessed April 2007.
2. Pai NP, Lawrence J, Reingold AL, et al. Structured treatment interruptions (STI) in chronic unsuppressed HIV infection in adults. Cochran Database Syst Rev. 2006 Jul 19;3:CD006148.
3. Agins BD, Alexander CS, Bartlett JG. Metabolic Complications of Antiretroviral Therapy. A Guide to Primary Care of People with HIV/AIDS, 2004 Ed. Available online at http://hab.hrsa.gov/tools/primarycareguide. Last accessed May 21, 2007.
4. Wutoh AK, Brown CM, Kumoji EK, et al. Antiretroviral adherence and use of alternative therapies among older HIV-infected adults. J Natl Med Assoc. 2001 Jul-Aug;93(7-8):243-250.

This is the first of a two-part series on care of the HIV/AIDS patient. Part 2 will address the public health and counseling aspects of HIV management, as well as the care of children with HIV.

It’s been a little more than a quarter-century since acquired immune deficiency syndrome (AIDS) was first identified. Since 1981, many facets of our understanding and management of HIV/AIDS have changed.

In some populations, HIV (when well-controlled) has been transformed to a chronic disease state, with few episodes of the AIDS-defining conditions (opportunistic infections, Kaposi’s sarcoma, wasting syndromes) seen in the early years of the epidemic. However, when treating underserved and indigent populations, hospitalists may still encounter the common symptoms of advanced disease in their HIV-positive patients.

What are the common presenting scenarios of HIV/AIDS seen by hospitalists in the current era of highly active antiretroviral therapy (HAART), and how does antiretroviral therapy affect hospitalists’ management of these patients? The Hospitalist recently interviewed HIV/AIDS specialists and practicing hospitalists to learn find out.

The Differential Diagnosis: Think Broadly

The Centers for Disease Control and Prevention estimates 1.04 million to 1.19 million people live with HIV/AIDS in the United States. The CDC also estimates approximately 40,000 people become infected with HIV each year.1

The conditions that bring HIV-positive patients to the hospital run the gamut. There is a broad range of presenting symptoms, noted Sigall K. Bell, MD, the Division of Infectious Diseases and General Medicine at Harvard Medical School and Beth Israel Deaconess Medical Center in Boston. “The differential diagnoses for patients who are HIV-infected—depending on their immunological status—can be dramatically expanded compared to HIV-negative patients,” says Dr. Bell. “For any given presenting symptom, one needs to think about whether the person’s HIV itself, an opportunistic infection secondary to the HIV, or HIV medication effects are playing into potential explanations for the presenting symptoms.”

Even the demographics of the hospital’s catchment area can be associated with patients’ problems. “The types of problems seen in hospitalized HIV-infected patients largely depends on the degree of access to care that people have,” says HIV and infectious disease specialist Harry Hollander, MD, program director for the University of California, San Francisco Internal Medicine Residency Program, and professor of Clinical Medicine at UCSF. In areas where care systems are not robust, explains Dr. Hollander, people admitted to the hospital will most likely have the same problems seen at the beginning of the epidemic.

If hospitalists are practicing in areas with highly developed systems of care and good penetration of care, people with HIV are just as likely to be admitted to the hospital with problems completely unrelated to their HIV status. In the pre-antiretroviral era, according to Dr. Hollander, hospital physicians typically saw three or four common types of presentations in these patients. “My biggest message these days,” he says, “is to think broadly about the problems these patients present with, and to generate parallel thinking about HIV-related causes as well as causes not related to HIV. Many patients with well-controlled HIV are more likely to wind up in the hospital because of other routine medical problems. If you only consider the HIV status, you may be missing other important, related and treatable conditions.”

Thomas Baudendistel, MD, who is associate residency program director at California Pacific Medical Center, a community-based hospital in San Francisco operated by Sutter Health, confirms that as HIV patients are getting healthier, “their immune systems are being kept intact [with CD4 counts in the normal range] for longer periods of time. We don’t see issues of HIV-related conditions in hospitalization as much as we did 20, 10, or even five years ago. The life-threatening opportunistic infections, although still there, have receded as cause for hospitalization. When an HIV patient gets admitted, it’s just as likely to be a noninfectious condition, such as lymphoma, or hematologic complications. Or, the patients may be old enough to have heart disease or COPD.”

Dr. Sabharwal

Other hospitalists practice in areas where the opposite is true. Aman D. Sabharwal, MD, is associate medical director, Inpatient and Hospitalist Services for Jackson Health Systems and practices primarily at Jackson Memorial Hospital, which serves a large indigent population in south Florida. While he agrees that some HIV patients are being well-managed because of advances in antiretroviral therapy, these are not the patients seen by hospitalists in his group.

“A majority of our HIV-positive patients come in for illnesses or opportunistic infections that are due to their HIV,” he says. “Most of these patients are either noncompliant with their medications or have low CD4 counts. Generally, the acute issue for which they are admitted is generally unrelated to the medication itself—it is probably due more so to the lack of medication.”

Dr. Bell

Dr. Baudendistel reports that he and fellow hospitalists at California Pacific Medical Center are also seeing more immune reconstitution illness, in which the reconstituted immune system exhibits an “overexuberant” reaction, causing unique presentations. For example, patients with low CD4 counts who have clinically silent infection with Mycobacterium Avium Complex, hepatitis B, or a variety of infectious agents may experience a significant boost in their CD4 count with antiretroviral therapy. The resurgent immune system can then mount a response to these previously quiescent pathogens, causing a flare-up of symptoms.

“If the primary site of occult disease is the lungs, a respiratory exacerbation will occur; if in the liver, as in the example of hepatitis B, a significant hepatitis can ensue,” says Dr. Baudendistel.

Call in Consultants: Keep a Low Threshold

As the management of HIV becomes more sophisticated, hospitalists should frequently consult infectious-disease and consulting pharmacy colleagues. “I think the hospitalist is very well-equipped to deal with the acute illnesses that these patients have,” notes Dr. Hollander. “Most hospitalists feel less comfortable with the details of managing the chronic medical regimen—particularly the antiretroviral drugs, which they don’t have an opportunity to prescribe, manage, and monitor over time.”

Dr. Baudendistel concurs: “As a hospitalist, what I face with these patients—especially if they come in with an illness unrelated to HIV—is trying to figure out how a drug I am thinking of prescribing for their heart disease or kidney failure will impact their HAART therapy. Is there going to be some hidden interaction that I’m not aware of because I don’t deal with those medications every day?”

It is precisely when weighing those questions about chronic therapy when hospitalists would be best served to quickly consider consulting either a primary physician or the appropriate consultant about the details of the medication regimen. “In most cases, you’re going to want to continue that regimen during hospitalization for other intercurrent problems,” he says.

When possible, it’s a good idea for the hospitalist to touch base with the primary HIV provider, says Dr. Bell. “There are sometimes subtleties to the care that are not necessarily transmitted in a faxed document or in information the patient brings to the hospital. Those subtleties—about doses of antiretroviral drugs or changes in regimen—can make big differences.”

Hospitalists should inform themselves of the potentially harmful effects of antiretroviral drugs, as well as the potential harm in stopping them. “It takes an awareness of knowing what the potential problems are to know when to utilize a consultant,” says Dr. Bell. “As doctors, we are appropriately aware of the power of medications, and it’s not uncommon when the clinical picture is unclear for physicians to think, ‘First do no harm—let me stop these medications.’ One has to be aware of the fact that stopping a medication doesn’t happen in a vacuum.”

Nuances of HAART Require Vigilance

“Highly active antiretroviral therapy has resulted in improved immunological status for many HIV-positive patients, but the therapy has also introduced several potential complications and consequences of which hospitalists should be aware,” says Dr. Bell. Most notable among those consequences: the effects of starting and stopping medications.

“It used to be,” says Dr. Baudendistel, “that we would say, ‘The patients are only going to be here in the hospital for a few days; let’s just stop their highly active HIV treatment.’ Now we know that is not a good idea, because stopping treatment can create resistant viruses.”

Dr. Bell explains one such example: Each of the classes of antiretroviral drugs has a different half-life. If a physician stops all antiretroviral therapy at the same time, the nucleoside/nucleotide reverse transcriptase inhibitor (NRTI) may wash out of the system more quickly than does the nonnucleoside reverse transcriptase inhibitor (NNRTI). The result will be NNRTI monotherapy, and drug resistance can occur quickly in that setting, says Dr. Bell. (Note: not all patients are on NNRTIs; some may be on protease inhibitors or fusion inhibitors, which all have potentially adverse events and drug-drug interactions.)

As another example, if a patient has co-infection with hepatitis B, stopping an NRTI with activity against hepatitis B (such as lamivudine or tenofovir), may cause hepatitis to flare up. Finally, several studies now suggest that the long-term consequences of starting and stopping therapy (structured treatment interruptions) are also detrimental.2

Hospitalists can incorporate into their diagnosis and treatment of these patients other management strategies beyond potential drug-drug interactions and consequences of incurring resistance when stopping antiretroviral medication. For instance:

Dr. Sabharwal

• Screen for other problems that may be attributable to long-term antiretroviral therapy, such as dyslipidemia, diabetes, and osteoporosis if the patient has adhered to HAART.3 Because mounting data suggest an increased incidence of cardiovascular disease, aggressive management of other underlying cardiovascular risk factors is an important part of care.
• Ensure electronic medication orders do not automatically default to inappropriate doses. For instance, ritonavir, a protease inhibitor, is most commonly used as a booster dose and not at full dose—but electronic pharmacy ordering systems may not reflect this current knowledge.
• Raise nursing and physician staff awareness to confirm that HAART doses are not missed (e.g., if a patient is off the floor for extended periods of time). Reconcile medication orders and the medication administration record to ensure all ordered medications are given. For example, if there is a delay in accessing one of the patient’s usual medications, it may be harmful to administer just the other two until the third is available. Alternative arrangements would be required.
• Consider orders allowing patients to use their own supply of medications if the hospital pharmacy is not able to supply the exact drug needed for their specific HAART regimen.

It is also advisable to ask HIV patients about their use of alternative therapies, says Dr. Hollander, because studies have shown that a substantial minority of people with HIV infection do, in fact, take alternative therapies.4 “We also know,” he says, “that some of these therapies cause adverse reactions and toxicities that you would not ordinarily consider, unless you had obtained that history.”

Education, Education, Education

Dr. Bell notes that there is wide variability in adherence to medication and follow-up clinic visits among those infected with HIV. “It’s important for hospitalists to emphasize links to care,” she says. “A hospital visit is an important time to emphasize education, and to make sure that those patients have the appropriate follow-up.”

The role of hospitalist as patient educator takes on more prominence in settings with a larger percentage of more indigent patients. “I think the key is education, education, education,” Dr. Sabharwal asserts.

He and hospitalists in his group make patient counseling a key component in their treatment, from the time they encounter patients until discharge. They emphasize that with today’s therapies, a 60-year-old HIV-positive patient may avoid hospitalization, while those who do not take their medications risk the severe sequelae of AIDS-defining conditions.

“It’s very important that physicians not be in a hurry to go from patient to patient,” he says. “A lot of times what’s lacking is for physicians to take the time to sit down with the patient and go over the severity of the disease in its later stages. We counsel patients every single time.”

Dr. Baudendistel’s counsel to fellow hospitalists is that although they may still be attuned to treating HIV complications, such as PCP or TB, HIV is now a chronic disease. And as such, “It’s not something that the casual generalist can manage independently,” he says. “When I was in training, I was very well-versed in managing HIV disease. With the initial drug treatments and the common opportunistic infections, treatment was pretty straightforward. But now I wouldn’t feel comfortable managing the HIV part of the illness on my own. HIV is a subspecialist disease now, and it is important to have a colleague with HIV expertise with whom they can consult.” TH

Gretchen Henkel is a frequent contributor to The Hospitalist.

References

1. CDC HIV/AIDS Fact Sheet, “A Glance at the HIV/AIDS Epidemic.” January 2007. Available online at http://www.cdc.gov/hiv. Last accessed April 2007.
2. Pai NP, Lawrence J, Reingold AL, et al. Structured treatment interruptions (STI) in chronic unsuppressed HIV infection in adults. Cochran Database Syst Rev. 2006 Jul 19;3:CD006148.
3. Agins BD, Alexander CS, Bartlett JG. Metabolic Complications of Antiretroviral Therapy. A Guide to Primary Care of People with HIV/AIDS, 2004 Ed. Available online at http://hab.hrsa.gov/tools/primarycareguide. Last accessed May 21, 2007.
4. Wutoh AK, Brown CM, Kumoji EK, et al. Antiretroviral adherence and use of alternative therapies among older HIV-infected adults. J Natl Med Assoc. 2001 Jul-Aug;93(7-8):243-250.

This is the first of a two-part series on care of the HIV/AIDS patient. Part 2 will address the public health and counseling aspects of HIV management, as well as the care of children with HIV.

It’s been a little more than a quarter-century since acquired immune deficiency syndrome (AIDS) was first identified. Since 1981, many facets of our understanding and management of HIV/AIDS have changed.

In some populations, HIV (when well-controlled) has been transformed to a chronic disease state, with few episodes of the AIDS-defining conditions (opportunistic infections, Kaposi’s sarcoma, wasting syndromes) seen in the early years of the epidemic. However, when treating underserved and indigent populations, hospitalists may still encounter the common symptoms of advanced disease in their HIV-positive patients.

What are the common presenting scenarios of HIV/AIDS seen by hospitalists in the current era of highly active antiretroviral therapy (HAART), and how does antiretroviral therapy affect hospitalists’ management of these patients? The Hospitalist recently interviewed HIV/AIDS specialists and practicing hospitalists to learn find out.

The Differential Diagnosis: Think Broadly

The Centers for Disease Control and Prevention estimates 1.04 million to 1.19 million people live with HIV/AIDS in the United States. The CDC also estimates approximately 40,000 people become infected with HIV each year.1

The conditions that bring HIV-positive patients to the hospital run the gamut. There is a broad range of presenting symptoms, noted Sigall K. Bell, MD, the Division of Infectious Diseases and General Medicine at Harvard Medical School and Beth Israel Deaconess Medical Center in Boston. “The differential diagnoses for patients who are HIV-infected—depending on their immunological status—can be dramatically expanded compared to HIV-negative patients,” says Dr. Bell. “For any given presenting symptom, one needs to think about whether the person’s HIV itself, an opportunistic infection secondary to the HIV, or HIV medication effects are playing into potential explanations for the presenting symptoms.”

Even the demographics of the hospital’s catchment area can be associated with patients’ problems. “The types of problems seen in hospitalized HIV-infected patients largely depends on the degree of access to care that people have,” says HIV and infectious disease specialist Harry Hollander, MD, program director for the University of California, San Francisco Internal Medicine Residency Program, and professor of Clinical Medicine at UCSF. In areas where care systems are not robust, explains Dr. Hollander, people admitted to the hospital will most likely have the same problems seen at the beginning of the epidemic.

If hospitalists are practicing in areas with highly developed systems of care and good penetration of care, people with HIV are just as likely to be admitted to the hospital with problems completely unrelated to their HIV status. In the pre-antiretroviral era, according to Dr. Hollander, hospital physicians typically saw three or four common types of presentations in these patients. “My biggest message these days,” he says, “is to think broadly about the problems these patients present with, and to generate parallel thinking about HIV-related causes as well as causes not related to HIV. Many patients with well-controlled HIV are more likely to wind up in the hospital because of other routine medical problems. If you only consider the HIV status, you may be missing other important, related and treatable conditions.”

Thomas Baudendistel, MD, who is associate residency program director at California Pacific Medical Center, a community-based hospital in San Francisco operated by Sutter Health, confirms that as HIV patients are getting healthier, “their immune systems are being kept intact [with CD4 counts in the normal range] for longer periods of time. We don’t see issues of HIV-related conditions in hospitalization as much as we did 20, 10, or even five years ago. The life-threatening opportunistic infections, although still there, have receded as cause for hospitalization. When an HIV patient gets admitted, it’s just as likely to be a noninfectious condition, such as lymphoma, or hematologic complications. Or, the patients may be old enough to have heart disease or COPD.”

Dr. Sabharwal

Other hospitalists practice in areas where the opposite is true. Aman D. Sabharwal, MD, is associate medical director, Inpatient and Hospitalist Services for Jackson Health Systems and practices primarily at Jackson Memorial Hospital, which serves a large indigent population in south Florida. While he agrees that some HIV patients are being well-managed because of advances in antiretroviral therapy, these are not the patients seen by hospitalists in his group.

“A majority of our HIV-positive patients come in for illnesses or opportunistic infections that are due to their HIV,” he says. “Most of these patients are either noncompliant with their medications or have low CD4 counts. Generally, the acute issue for which they are admitted is generally unrelated to the medication itself—it is probably due more so to the lack of medication.”

Dr. Bell

Dr. Baudendistel reports that he and fellow hospitalists at California Pacific Medical Center are also seeing more immune reconstitution illness, in which the reconstituted immune system exhibits an “overexuberant” reaction, causing unique presentations. For example, patients with low CD4 counts who have clinically silent infection with Mycobacterium Avium Complex, hepatitis B, or a variety of infectious agents may experience a significant boost in their CD4 count with antiretroviral therapy. The resurgent immune system can then mount a response to these previously quiescent pathogens, causing a flare-up of symptoms.

“If the primary site of occult disease is the lungs, a respiratory exacerbation will occur; if in the liver, as in the example of hepatitis B, a significant hepatitis can ensue,” says Dr. Baudendistel.

Call in Consultants: Keep a Low Threshold

As the management of HIV becomes more sophisticated, hospitalists should frequently consult infectious-disease and consulting pharmacy colleagues. “I think the hospitalist is very well-equipped to deal with the acute illnesses that these patients have,” notes Dr. Hollander. “Most hospitalists feel less comfortable with the details of managing the chronic medical regimen—particularly the antiretroviral drugs, which they don’t have an opportunity to prescribe, manage, and monitor over time.”

Dr. Baudendistel concurs: “As a hospitalist, what I face with these patients—especially if they come in with an illness unrelated to HIV—is trying to figure out how a drug I am thinking of prescribing for their heart disease or kidney failure will impact their HAART therapy. Is there going to be some hidden interaction that I’m not aware of because I don’t deal with those medications every day?”

It is precisely when weighing those questions about chronic therapy when hospitalists would be best served to quickly consider consulting either a primary physician or the appropriate consultant about the details of the medication regimen. “In most cases, you’re going to want to continue that regimen during hospitalization for other intercurrent problems,” he says.

When possible, it’s a good idea for the hospitalist to touch base with the primary HIV provider, says Dr. Bell. “There are sometimes subtleties to the care that are not necessarily transmitted in a faxed document or in information the patient brings to the hospital. Those subtleties—about doses of antiretroviral drugs or changes in regimen—can make big differences.”

Hospitalists should inform themselves of the potentially harmful effects of antiretroviral drugs, as well as the potential harm in stopping them. “It takes an awareness of knowing what the potential problems are to know when to utilize a consultant,” says Dr. Bell. “As doctors, we are appropriately aware of the power of medications, and it’s not uncommon when the clinical picture is unclear for physicians to think, ‘First do no harm—let me stop these medications.’ One has to be aware of the fact that stopping a medication doesn’t happen in a vacuum.”

Nuances of HAART Require Vigilance

“Highly active antiretroviral therapy has resulted in improved immunological status for many HIV-positive patients, but the therapy has also introduced several potential complications and consequences of which hospitalists should be aware,” says Dr. Bell. Most notable among those consequences: the effects of starting and stopping medications.

“It used to be,” says Dr. Baudendistel, “that we would say, ‘The patients are only going to be here in the hospital for a few days; let’s just stop their highly active HIV treatment.’ Now we know that is not a good idea, because stopping treatment can create resistant viruses.”

Dr. Bell explains one such example: Each of the classes of antiretroviral drugs has a different half-life. If a physician stops all antiretroviral therapy at the same time, the nucleoside/nucleotide reverse transcriptase inhibitor (NRTI) may wash out of the system more quickly than does the nonnucleoside reverse transcriptase inhibitor (NNRTI). The result will be NNRTI monotherapy, and drug resistance can occur quickly in that setting, says Dr. Bell. (Note: not all patients are on NNRTIs; some may be on protease inhibitors or fusion inhibitors, which all have potentially adverse events and drug-drug interactions.)

As another example, if a patient has co-infection with hepatitis B, stopping an NRTI with activity against hepatitis B (such as lamivudine or tenofovir), may cause hepatitis to flare up. Finally, several studies now suggest that the long-term consequences of starting and stopping therapy (structured treatment interruptions) are also detrimental.2

Hospitalists can incorporate into their diagnosis and treatment of these patients other management strategies beyond potential drug-drug interactions and consequences of incurring resistance when stopping antiretroviral medication. For instance:

Dr. Sabharwal

• Screen for other problems that may be attributable to long-term antiretroviral therapy, such as dyslipidemia, diabetes, and osteoporosis if the patient has adhered to HAART.3 Because mounting data suggest an increased incidence of cardiovascular disease, aggressive management of other underlying cardiovascular risk factors is an important part of care.
• Ensure electronic medication orders do not automatically default to inappropriate doses. For instance, ritonavir, a protease inhibitor, is most commonly used as a booster dose and not at full dose—but electronic pharmacy ordering systems may not reflect this current knowledge.
• Raise nursing and physician staff awareness to confirm that HAART doses are not missed (e.g., if a patient is off the floor for extended periods of time). Reconcile medication orders and the medication administration record to ensure all ordered medications are given. For example, if there is a delay in accessing one of the patient’s usual medications, it may be harmful to administer just the other two until the third is available. Alternative arrangements would be required.
• Consider orders allowing patients to use their own supply of medications if the hospital pharmacy is not able to supply the exact drug needed for their specific HAART regimen.

It is also advisable to ask HIV patients about their use of alternative therapies, says Dr. Hollander, because studies have shown that a substantial minority of people with HIV infection do, in fact, take alternative therapies.4 “We also know,” he says, “that some of these therapies cause adverse reactions and toxicities that you would not ordinarily consider, unless you had obtained that history.”

Education, Education, Education

Dr. Bell notes that there is wide variability in adherence to medication and follow-up clinic visits among those infected with HIV. “It’s important for hospitalists to emphasize links to care,” she says. “A hospital visit is an important time to emphasize education, and to make sure that those patients have the appropriate follow-up.”

The role of hospitalist as patient educator takes on more prominence in settings with a larger percentage of more indigent patients. “I think the key is education, education, education,” Dr. Sabharwal asserts.

He and hospitalists in his group make patient counseling a key component in their treatment, from the time they encounter patients until discharge. They emphasize that with today’s therapies, a 60-year-old HIV-positive patient may avoid hospitalization, while those who do not take their medications risk the severe sequelae of AIDS-defining conditions.

“It’s very important that physicians not be in a hurry to go from patient to patient,” he says. “A lot of times what’s lacking is for physicians to take the time to sit down with the patient and go over the severity of the disease in its later stages. We counsel patients every single time.”

Dr. Baudendistel’s counsel to fellow hospitalists is that although they may still be attuned to treating HIV complications, such as PCP or TB, HIV is now a chronic disease. And as such, “It’s not something that the casual generalist can manage independently,” he says. “When I was in training, I was very well-versed in managing HIV disease. With the initial drug treatments and the common opportunistic infections, treatment was pretty straightforward. But now I wouldn’t feel comfortable managing the HIV part of the illness on my own. HIV is a subspecialist disease now, and it is important to have a colleague with HIV expertise with whom they can consult.” TH

Gretchen Henkel is a frequent contributor to The Hospitalist.

References

1. CDC HIV/AIDS Fact Sheet, “A Glance at the HIV/AIDS Epidemic.” January 2007. Available online at http://www.cdc.gov/hiv. Last accessed April 2007.
2. Pai NP, Lawrence J, Reingold AL, et al. Structured treatment interruptions (STI) in chronic unsuppressed HIV infection in adults. Cochran Database Syst Rev. 2006 Jul 19;3:CD006148.
3. Agins BD, Alexander CS, Bartlett JG. Metabolic Complications of Antiretroviral Therapy. A Guide to Primary Care of People with HIV/AIDS, 2004 Ed. Available online at http://hab.hrsa.gov/tools/primarycareguide. Last accessed May 21, 2007.
4. Wutoh AK, Brown CM, Kumoji EK, et al. Antiretroviral adherence and use of alternative therapies among older HIV-infected adults. J Natl Med Assoc. 2001 Jul-Aug;93(7-8):243-250.

Hospitalization can be risky business for geriatric patients. Americans 65 and older make up 13% of the population but account for 48% of inpatient days of care and 78% of hospital deaths. While in the hospital, patients 75 and older are at high risk for deconditioning and functional decline, medication errors, delirium, and falls.1,2

For geriatric patients not closely monitored, notes geriatrician Don Murphy, MD, co-principal of Senior Care of Colorado, a large primary care geriatrics group in Denver, going to the hospital can be like disappearing into a black hole.

As the U.S. population ages, hospitalists will be caring for an increasing number of geriatric patients. They will have to address patients’ acute medical conditions without compromising their functional status.

The Hospitalist asked several leading geriatricians to identify valuable tools and strategies for delivering comprehensive geriatric care in the hospital. Even in the absence of formal geriatric care units, they say, hospitalists are positioned for adopting the principles of quality geriatric care. Many of those principles align with the central mission of hospital medicine: promoting high-quality, patient-centered care, working as a team, and developing clear lines of communication between the hospitalist and the primary care teams.

A Survey of Interventions

“There’s no question that it’s becoming extraordinarily difficult to do good care,” says John Morley, MD, professor of medicine and chief of the Division of Geriatrics and Endocrinology at Saint Louis University Health Sciences Center in Missouri. “Taking care of an older person in the hospital is a team sport—the physician can’t do it alone.”

It’s clear the team approach is a crucial foundation for interventions that target at-risk geriatric patients, agrees Edgar Pierluissi, MD, associate clinical professor of medicine and medical director of the recently established ACE unit at San Francisco General Hospital. Reducing the incidence of delirium, for instance, cannot be accomplished simply by utilizing a geriatric consultation. Once established, acute confusion can be intractable. “The idea is to try to prevent delirium, and research has shown that single-person types of interventions in these massively impervious-to-change facilities don’t work,” he says.

Clinical trials have demonstrated that interventions, including interdisciplinary and collaborative teams, targeted patient-centered therapies, and comprehensive geriatric assessment can improve outcomes of hospitalization in geriatric patients. Four major interventions include:

• Acute Care for Elders (ACE) units based on interdisciplinary team rounds, discharge planning, and medical review in a prepared environment to foster patient self-care and improve function. Randomized clinical trials have shown ACE units can reduce the length of stay, the risk of nursing home admissions, and the use of physical restraints while improving providers’ satisfaction with patient care.3,4
• The Hospital Elder Life Program (HELP), led by a geriatrics resource nurse, is an intervention designed to reduce the incidence of delirium by adjusting environmental elements, such as dimming lights and keeping the floor quiet at night. HELP also introduces non-pharmacologic interventions, including massages and warm tea at night and promotes mobility and hydration during the day.
• Incidence of delirium is reduced and cost savings are realized using the HELP.5 (Visit http://elderlife.med.yale.edu/public for more information.)
• Geriatric Evaluation and Management (GEM) units also emphasize a multidisciplinary comprehensive approach using geriatrician-led teams. The intervention can reduce long-term costs, while improving physical functioning and general health domains in the SF-36.6
• Use of advanced practice nurses in comprehensive discharge planning interventions, including nursing home visits for older patients with risk factors for poor outcomes post-discharge, has been shown to reduce readmissions.7

Assessment Is the Bottom Line

Robert Palmer, MD, head of the Section of Geriatric Medicine and professor of medicine at Cleveland Clinic Lerner College of Medicine of Case Western Reserve University in Ohio, is known for his work with ACE units. He and his colleagues have tracked patients following discharge and have identified the highest priority issues that should be addressed to avoid deleterious geriatric syndromes in the hospital. Although he advocates what he calls a minimalist approach to conducting a geriatric assessment, Dr. Palmer underlines the idea that it must also be a deliberate and structured approach. Assessing and acting upon key indicators in four to five major domains, he notes, can make a big difference for patients’ hospital trajectories.8 Here are a few domains to consider:

1 Focus on activities of daily living (ADLs). Function and performance of ADLs can predict post-hospital outcome and help the physician prioritize elements of the patient’s trajectory and goals while in the hospital. “If a person was able to independently bathe, dress, toilet, walk, and transfer—from bed to chair, for instance—before the acute illness, then he or she should be able to get back to that point after the illness has been treated,” says Dr. Palmer. The ability to transfer independently is an important predictor of discharge status because if the patient requires assistance to transfer, he or she will need a different level of care upon discharge. The hospitalist should seek information —from the patient, family member or primary caregiver, or primary care physician—about the patient’s ADLs before he or she got sick. Again, recovery of ADLs may be possible if the patient was performing these independently before the acute episode.

2 Cognitive assessments are also key. Dr. Morley places assessment for delirium at the top of his list. Research shows that approximately one third of patients over 70 in the hospital will develop the condition. Delirium, or acute confusion, is also a predictor of decline in ADLs, notes Dr. Palmer. Dr. Morley recommends the use of the Confusion Assessment Method (CAM) because the Mini Mental State Exam can be time-consuming. (A CAM form is available free online as part of SHM’s “Clinical Toolbox for Geriatric Care.” Go to www.hospitalmedicine.org, click on “Resource Center” and then “Geriatric Special Interest Area” to find the Toolbox.) According to Dr. Palmer, the physician should also use common sense when initially examining the patient: Observe whether the patient is confused, distracted, or inappropriate in conversation. If so, the next step is to use the simple Digit Span test: Say a random set of four to five numbers, and ask the patient to repeat them. Inability to do this is consistent with delirium as a cause of cognitive impairment.

For assessing cognitive impairment, Dr. Morley prefers the St. Louis University Mental Status Exam (SLUMS) to the Mini Mental Status Exam. The SLUMS, developed in collaboration with the Department of Veterans Affairs (and available free online at: http://medschool.slu.edu/agingsuccessfully/pdfsurveys/slumsexam_05.pdf) successfully picks up even mild cognitive impairment, according to Dr. Morley. This is important information not just for the hospital trajectory but also for discharge planning: Inability to follow discharge instructions due to cognitive impairment could result in a readmission.

3 Malnutrition is associated with mortality. Dr. Morley uses the four questions of the Simplified Nutrition Assessment Questionnaire (SNAQ), which correlate well with future weight loss and poor outcomes.9

If the SNAQ is positive, the use of a lengthier questionnaire may be warranted. Dr. Palmer suggests that a review of the patient’s comprehensive metabolic panel to judge kidney and liver function and a bedside evaluation using the Subjective Global Assessment (SGA) can yield results just as usable as the more complex and time-consuming textbook nutritional assessments.

4 Mood and affect also play a role in patients’ outcomes. Research has shown that depressed patients have poor outcomes, so physicians should always assess for depression. While the Geriatric Depression Scale (see “Clinical Toolbox for Geriatric Care” on the SHM Web site) can help quantify the extent of the patient’s symptoms, simply asking the patient, “Are you depressed, sad, or blue?” can often elicit enough information about the patient’s psychological status to direct interventions.

5 Mobility is sometimes classified as a stand-alone domain. However, walking and balance may be included in the assessment of ADLs. A patient who can walk independently—even with a cane or a walker—has a good chance to return home, says Dr. Palmer. Requiring another person to help with walking most likely indicates the patient will need short-term rehabilitation in a skilled nursing facility before returning home.

6 Social and living situation are important. The physician must identify the extent and quality of the patient’s support network. If, for instance, a patient has mild dementia but has a network of 10 extended family members who act as caregivers, discharge to home may be possible. If the patient was admitted to the hospital from a nursing home, however, it is most likely he or she will return there.

Revisit Daily Goals

Dr. Palmer advises hospitalists to follow the geriatric assessment with a translation of the information into what he calls a functional trajectory for the patient’s hospital stay. This includes an estimate of the patient’s anticipated length of stay and the expected discharge site. Interventions and consultations from allied health providers will be keyed to the patient’s individualized needs and to the goals of the functional trajectory.

To head off problems, Dr. Palmer advocates consultations from allied health professionals early in the hospital trajectory. For instance, if the patient is having trouble transferring from bed to chair upon admission, a consult with physical therapy may be warranted immediately rather than right before discharge, as is usually the case.

“We should not be depending on physical therapists at the end of hospitalization, when patients are already deconditioned and can’t get out of bed and need to go to a nursing home,” he explains. “The ideal time to bring in the physical therapist or technician is when you’ve identified—on day one—that the patient needs assistance with transfers, so that you can preserve mobility and shorten hospital stay.”

In the same vein, knowing the patient’s living situation will allow involvement of the discharge planner from day one of the hospitalization to plan with the patient or family for the patient’s return to home or to an alternate site. If the patient has been on a complex drug regimen, involving the pharmacist to help straighten out medications can head off potential drug-drug interactions. (SHM’s Geriatric Toolbox also has a list of medications to avoid in geriatric patients.)

It is important to review the functional trajectory on a daily basis. Input from other members of the health team will be invaluable. “Each day you identify barriers to that successful plan of the outcome, and you take care of them one at a time,” says Dr. Palmer. “If the patient is not on track with that daily goal, the team goes back to the drawing board and asks, ‘What are we missing here?’ Then you do a reassessment of ADLs, nutrition, and cognition.”

Hospitalists must also include the patient’s family members and primary caregivers as the patient moves toward discharge, asserts Dr. Morley. Clear, unambiguous written instructions must always be given to the patient or the primary caregiver when the patient leaves the hospital. (You can also find a discharge instruction sheet in SHM’s Toolbox.) If a patient appears to be facing the end of life, the hospitalist should schedule a conference with members of the primary care team, the hospitalist team, and all family stakeholders.

Transportable SKILLS

Some experts maintain that quality care for geriatric patients can be accomplished without a specialized geriatrics unit.

“I never conceived of the ACE intervention as being done exclusively on a unit,” says Dr. Palmer. “The idea was to develop the skills on a unit and then transport those skills to all units.” Although the protocols developed for ACE units are good for teaching, he says the team has been the key.

Dr. Morley agrees: “It’s not the physical part of the ACE unit that works. You must have team interactions. Finding a way to communicate between the different team members is absolutely key to good outcomes.”

Involving healthcare providers from different disciplines only enhances the care of geriatric patients. “Even though hospitalists may not have the depth of knowledge of geriatrics that a geriatrician has, they certainly have the knowledge of acute care medicine that we have, so they can manage the medical problems,” says Dr. Palmer. “What they need to do is think systematically, in a structured way, and to work collaboratively with key players. This only takes a few minutes each day, but more importantly, it saves time. You have fewer phone calls and fewer angry family members when you manage the care in a structured manner, working with a team of health professionals.”

Dr. Morley and his team have developed a form for their ACE unit that allows them to assess a patient’s status and goals in two to three minutes.

Dr. Pierluissi has experienced firsthand the benefits of working as a member of the interdisciplinary team. “Essentially,” he says, working in teams to treat the geriatric patient means there are “more heads in the game, more people trying to work in the patient’s best interest. You [the clinician] really do feel supported, and it makes your day more enjoyable and more productive.” TH

Gretchen Henkel is a medical journalist based in California.

Resources

1. Kozak LJ, Hall MJ, Owings MF. Hospitalization fact sheet. In: National Hospital Discharge Survey: 2000 Annual summary with detailed diagnosis and procedure data. Hyattsville, Maryland: National Center for Health Statistics. Vital Health Stat. 2002;13(153).
2. Covinsky KE, Palmer RM, Fortinsky RH, et al. Loss of independence in activities of daily living in older adults hospitalized with medical illnesses: increased vulnerability with age. J Am Geriatr Soc. 2003 Apr;51(4):451-458.
3. Landefeld CS, Palmer RM, Kresevic DM, et al. A randomized trial of care in a hospital medical unit especially designed to improve the functional outcomes of acutely ill older patients. N Engl J Med. 1995 May;332(20):1338-1344. Comments in: ACP J Club. 1995 Nov-Dec; 123(3):69 and N Engl J Med. 1995 May 18; 332(20):1376-1378.
4. Counsell SR, Holder CM, Liebenauer LL, et al. Effects of a multicomponent intervention on functional outcomes and process of care in hospitalized older patients: a randomized controlled trial of acute care for Elders (ACE) in a community hospital. J Am Geriatr Soc. 2000 Dec;48:1572-1581.
5. Inouye SK, Bogardus ST Jr, Charpentier PA, et al. A multicomponent intervention to prevent delirium in hospitalized older patients. N Engl J Med. 1999 Mar 4;340(9):669-676. Comments in: N Engl J Med. 1999 Jul 29; 341(5):369-370; author reply 370 and N Engl J Med. 1999 Mar 4; 340(9):720-721.
6. Cohen HJ, Feussner JR, Weinberger M, et al. A controlled trial of inpatient and outpatient geriatric evaluation and management. N Engl J Med. 2002 Mar 21;346(12):905-912. Comments in: Curr Surg. 2004 May-Jun;61(3):266-274; N Engl J Med. 2002 Aug 1;347(5):371-373; author reply 371-373 & N Engl J Med. 2002 Mar 21;346(12):874.
7. Naylor MD, Brooten DA, Campbell RL, et al. Transitional care of older adults hospitalized with heart failure: a randomized, controlled trial. J Am Geriatr Soc. 2004 May;52(5):675-684. Erratum in J Am Geriatr Soc. 2004 Jul; 52(7):1228. Comment in Evid Based Nurs. 2004 Oct;7(4):116.
8. Palmer RM. Acute hospital care of the elderly: making a difference. Caring for the Hospitalized Elderly [special supplement to The Hospitalist]. 2004. Available at: www.hospitalmedicine.org/AM/Template.cfm?Section=The_Hospitalist&Template=/CM/ContentDisplay.cfm&ContentFileID=1447. Last accessed March 14, 2007.
9. Wilson MM, Thomas DR, Rubenstein LZ, et al. Appetite assessment: simple appetite questionnaire predicts weight loss in community-dwelling adults and nursing home residents. Am J Clin Nutr. 2005 Nov;82(5):1074-1081.

Hospitalization can be risky business for geriatric patients. Americans 65 and older make up 13% of the population but account for 48% of inpatient days of care and 78% of hospital deaths. While in the hospital, patients 75 and older are at high risk for deconditioning and functional decline, medication errors, delirium, and falls.1,2

For geriatric patients not closely monitored, notes geriatrician Don Murphy, MD, co-principal of Senior Care of Colorado, a large primary care geriatrics group in Denver, going to the hospital can be like disappearing into a black hole.

As the U.S. population ages, hospitalists will be caring for an increasing number of geriatric patients. They will have to address patients’ acute medical conditions without compromising their functional status.

The Hospitalist asked several leading geriatricians to identify valuable tools and strategies for delivering comprehensive geriatric care in the hospital. Even in the absence of formal geriatric care units, they say, hospitalists are positioned for adopting the principles of quality geriatric care. Many of those principles align with the central mission of hospital medicine: promoting high-quality, patient-centered care, working as a team, and developing clear lines of communication between the hospitalist and the primary care teams.

A Survey of Interventions

“There’s no question that it’s becoming extraordinarily difficult to do good care,” says John Morley, MD, professor of medicine and chief of the Division of Geriatrics and Endocrinology at Saint Louis University Health Sciences Center in Missouri. “Taking care of an older person in the hospital is a team sport—the physician can’t do it alone.”

It’s clear the team approach is a crucial foundation for interventions that target at-risk geriatric patients, agrees Edgar Pierluissi, MD, associate clinical professor of medicine and medical director of the recently established ACE unit at San Francisco General Hospital. Reducing the incidence of delirium, for instance, cannot be accomplished simply by utilizing a geriatric consultation. Once established, acute confusion can be intractable. “The idea is to try to prevent delirium, and research has shown that single-person types of interventions in these massively impervious-to-change facilities don’t work,” he says.

Clinical trials have demonstrated that interventions, including interdisciplinary and collaborative teams, targeted patient-centered therapies, and comprehensive geriatric assessment can improve outcomes of hospitalization in geriatric patients. Four major interventions include:

• Acute Care for Elders (ACE) units based on interdisciplinary team rounds, discharge planning, and medical review in a prepared environment to foster patient self-care and improve function. Randomized clinical trials have shown ACE units can reduce the length of stay, the risk of nursing home admissions, and the use of physical restraints while improving providers’ satisfaction with patient care.3,4
• The Hospital Elder Life Program (HELP), led by a geriatrics resource nurse, is an intervention designed to reduce the incidence of delirium by adjusting environmental elements, such as dimming lights and keeping the floor quiet at night. HELP also introduces non-pharmacologic interventions, including massages and warm tea at night and promotes mobility and hydration during the day.
• Incidence of delirium is reduced and cost savings are realized using the HELP.5 (Visit http://elderlife.med.yale.edu/public for more information.)
• Geriatric Evaluation and Management (GEM) units also emphasize a multidisciplinary comprehensive approach using geriatrician-led teams. The intervention can reduce long-term costs, while improving physical functioning and general health domains in the SF-36.6
• Use of advanced practice nurses in comprehensive discharge planning interventions, including nursing home visits for older patients with risk factors for poor outcomes post-discharge, has been shown to reduce readmissions.7

Assessment Is the Bottom Line

Robert Palmer, MD, head of the Section of Geriatric Medicine and professor of medicine at Cleveland Clinic Lerner College of Medicine of Case Western Reserve University in Ohio, is known for his work with ACE units. He and his colleagues have tracked patients following discharge and have identified the highest priority issues that should be addressed to avoid deleterious geriatric syndromes in the hospital. Although he advocates what he calls a minimalist approach to conducting a geriatric assessment, Dr. Palmer underlines the idea that it must also be a deliberate and structured approach. Assessing and acting upon key indicators in four to five major domains, he notes, can make a big difference for patients’ hospital trajectories.8 Here are a few domains to consider:

1 Focus on activities of daily living (ADLs). Function and performance of ADLs can predict post-hospital outcome and help the physician prioritize elements of the patient’s trajectory and goals while in the hospital. “If a person was able to independently bathe, dress, toilet, walk, and transfer—from bed to chair, for instance—before the acute illness, then he or she should be able to get back to that point after the illness has been treated,” says Dr. Palmer. The ability to transfer independently is an important predictor of discharge status because if the patient requires assistance to transfer, he or she will need a different level of care upon discharge. The hospitalist should seek information —from the patient, family member or primary caregiver, or primary care physician—about the patient’s ADLs before he or she got sick. Again, recovery of ADLs may be possible if the patient was performing these independently before the acute episode.

2 Cognitive assessments are also key. Dr. Morley places assessment for delirium at the top of his list. Research shows that approximately one third of patients over 70 in the hospital will develop the condition. Delirium, or acute confusion, is also a predictor of decline in ADLs, notes Dr. Palmer. Dr. Morley recommends the use of the Confusion Assessment Method (CAM) because the Mini Mental State Exam can be time-consuming. (A CAM form is available free online as part of SHM’s “Clinical Toolbox for Geriatric Care.” Go to www.hospitalmedicine.org, click on “Resource Center” and then “Geriatric Special Interest Area” to find the Toolbox.) According to Dr. Palmer, the physician should also use common sense when initially examining the patient: Observe whether the patient is confused, distracted, or inappropriate in conversation. If so, the next step is to use the simple Digit Span test: Say a random set of four to five numbers, and ask the patient to repeat them. Inability to do this is consistent with delirium as a cause of cognitive impairment.

For assessing cognitive impairment, Dr. Morley prefers the St. Louis University Mental Status Exam (SLUMS) to the Mini Mental Status Exam. The SLUMS, developed in collaboration with the Department of Veterans Affairs (and available free online at: http://medschool.slu.edu/agingsuccessfully/pdfsurveys/slumsexam_05.pdf) successfully picks up even mild cognitive impairment, according to Dr. Morley. This is important information not just for the hospital trajectory but also for discharge planning: Inability to follow discharge instructions due to cognitive impairment could result in a readmission.

3 Malnutrition is associated with mortality. Dr. Morley uses the four questions of the Simplified Nutrition Assessment Questionnaire (SNAQ), which correlate well with future weight loss and poor outcomes.9

If the SNAQ is positive, the use of a lengthier questionnaire may be warranted. Dr. Palmer suggests that a review of the patient’s comprehensive metabolic panel to judge kidney and liver function and a bedside evaluation using the Subjective Global Assessment (SGA) can yield results just as usable as the more complex and time-consuming textbook nutritional assessments.

4 Mood and affect also play a role in patients’ outcomes. Research has shown that depressed patients have poor outcomes, so physicians should always assess for depression. While the Geriatric Depression Scale (see “Clinical Toolbox for Geriatric Care” on the SHM Web site) can help quantify the extent of the patient’s symptoms, simply asking the patient, “Are you depressed, sad, or blue?” can often elicit enough information about the patient’s psychological status to direct interventions.

5 Mobility is sometimes classified as a stand-alone domain. However, walking and balance may be included in the assessment of ADLs. A patient who can walk independently—even with a cane or a walker—has a good chance to return home, says Dr. Palmer. Requiring another person to help with walking most likely indicates the patient will need short-term rehabilitation in a skilled nursing facility before returning home.

6 Social and living situation are important. The physician must identify the extent and quality of the patient’s support network. If, for instance, a patient has mild dementia but has a network of 10 extended family members who act as caregivers, discharge to home may be possible. If the patient was admitted to the hospital from a nursing home, however, it is most likely he or she will return there.

Revisit Daily Goals

Dr. Palmer advises hospitalists to follow the geriatric assessment with a translation of the information into what he calls a functional trajectory for the patient’s hospital stay. This includes an estimate of the patient’s anticipated length of stay and the expected discharge site. Interventions and consultations from allied health providers will be keyed to the patient’s individualized needs and to the goals of the functional trajectory.

To head off problems, Dr. Palmer advocates consultations from allied health professionals early in the hospital trajectory. For instance, if the patient is having trouble transferring from bed to chair upon admission, a consult with physical therapy may be warranted immediately rather than right before discharge, as is usually the case.

“We should not be depending on physical therapists at the end of hospitalization, when patients are already deconditioned and can’t get out of bed and need to go to a nursing home,” he explains. “The ideal time to bring in the physical therapist or technician is when you’ve identified—on day one—that the patient needs assistance with transfers, so that you can preserve mobility and shorten hospital stay.”

In the same vein, knowing the patient’s living situation will allow involvement of the discharge planner from day one of the hospitalization to plan with the patient or family for the patient’s return to home or to an alternate site. If the patient has been on a complex drug regimen, involving the pharmacist to help straighten out medications can head off potential drug-drug interactions. (SHM’s Geriatric Toolbox also has a list of medications to avoid in geriatric patients.)

It is important to review the functional trajectory on a daily basis. Input from other members of the health team will be invaluable. “Each day you identify barriers to that successful plan of the outcome, and you take care of them one at a time,” says Dr. Palmer. “If the patient is not on track with that daily goal, the team goes back to the drawing board and asks, ‘What are we missing here?’ Then you do a reassessment of ADLs, nutrition, and cognition.”

Hospitalists must also include the patient’s family members and primary caregivers as the patient moves toward discharge, asserts Dr. Morley. Clear, unambiguous written instructions must always be given to the patient or the primary caregiver when the patient leaves the hospital. (You can also find a discharge instruction sheet in SHM’s Toolbox.) If a patient appears to be facing the end of life, the hospitalist should schedule a conference with members of the primary care team, the hospitalist team, and all family stakeholders.

Transportable SKILLS

Some experts maintain that quality care for geriatric patients can be accomplished without a specialized geriatrics unit.

“I never conceived of the ACE intervention as being done exclusively on a unit,” says Dr. Palmer. “The idea was to develop the skills on a unit and then transport those skills to all units.” Although the protocols developed for ACE units are good for teaching, he says the team has been the key.

Dr. Morley agrees: “It’s not the physical part of the ACE unit that works. You must have team interactions. Finding a way to communicate between the different team members is absolutely key to good outcomes.”

Involving healthcare providers from different disciplines only enhances the care of geriatric patients. “Even though hospitalists may not have the depth of knowledge of geriatrics that a geriatrician has, they certainly have the knowledge of acute care medicine that we have, so they can manage the medical problems,” says Dr. Palmer. “What they need to do is think systematically, in a structured way, and to work collaboratively with key players. This only takes a few minutes each day, but more importantly, it saves time. You have fewer phone calls and fewer angry family members when you manage the care in a structured manner, working with a team of health professionals.”

Dr. Morley and his team have developed a form for their ACE unit that allows them to assess a patient’s status and goals in two to three minutes.

Dr. Pierluissi has experienced firsthand the benefits of working as a member of the interdisciplinary team. “Essentially,” he says, working in teams to treat the geriatric patient means there are “more heads in the game, more people trying to work in the patient’s best interest. You [the clinician] really do feel supported, and it makes your day more enjoyable and more productive.” TH

Gretchen Henkel is a medical journalist based in California.

Resources

1. Kozak LJ, Hall MJ, Owings MF. Hospitalization fact sheet. In: National Hospital Discharge Survey: 2000 Annual summary with detailed diagnosis and procedure data. Hyattsville, Maryland: National Center for Health Statistics. Vital Health Stat. 2002;13(153).
2. Covinsky KE, Palmer RM, Fortinsky RH, et al. Loss of independence in activities of daily living in older adults hospitalized with medical illnesses: increased vulnerability with age. J Am Geriatr Soc. 2003 Apr;51(4):451-458.
3. Landefeld CS, Palmer RM, Kresevic DM, et al. A randomized trial of care in a hospital medical unit especially designed to improve the functional outcomes of acutely ill older patients. N Engl J Med. 1995 May;332(20):1338-1344. Comments in: ACP J Club. 1995 Nov-Dec; 123(3):69 and N Engl J Med. 1995 May 18; 332(20):1376-1378.
4. Counsell SR, Holder CM, Liebenauer LL, et al. Effects of a multicomponent intervention on functional outcomes and process of care in hospitalized older patients: a randomized controlled trial of acute care for Elders (ACE) in a community hospital. J Am Geriatr Soc. 2000 Dec;48:1572-1581.
5. Inouye SK, Bogardus ST Jr, Charpentier PA, et al. A multicomponent intervention to prevent delirium in hospitalized older patients. N Engl J Med. 1999 Mar 4;340(9):669-676. Comments in: N Engl J Med. 1999 Jul 29; 341(5):369-370; author reply 370 and N Engl J Med. 1999 Mar 4; 340(9):720-721.
6. Cohen HJ, Feussner JR, Weinberger M, et al. A controlled trial of inpatient and outpatient geriatric evaluation and management. N Engl J Med. 2002 Mar 21;346(12):905-912. Comments in: Curr Surg. 2004 May-Jun;61(3):266-274; N Engl J Med. 2002 Aug 1;347(5):371-373; author reply 371-373 & N Engl J Med. 2002 Mar 21;346(12):874.
7. Naylor MD, Brooten DA, Campbell RL, et al. Transitional care of older adults hospitalized with heart failure: a randomized, controlled trial. J Am Geriatr Soc. 2004 May;52(5):675-684. Erratum in J Am Geriatr Soc. 2004 Jul; 52(7):1228. Comment in Evid Based Nurs. 2004 Oct;7(4):116.
8. Palmer RM. Acute hospital care of the elderly: making a difference. Caring for the Hospitalized Elderly [special supplement to The Hospitalist]. 2004. Available at: www.hospitalmedicine.org/AM/Template.cfm?Section=The_Hospitalist&Template=/CM/ContentDisplay.cfm&ContentFileID=1447. Last accessed March 14, 2007.
9. Wilson MM, Thomas DR, Rubenstein LZ, et al. Appetite assessment: simple appetite questionnaire predicts weight loss in community-dwelling adults and nursing home residents. Am J Clin Nutr. 2005 Nov;82(5):1074-1081.

Hospitalization can be risky business for geriatric patients. Americans 65 and older make up 13% of the population but account for 48% of inpatient days of care and 78% of hospital deaths. While in the hospital, patients 75 and older are at high risk for deconditioning and functional decline, medication errors, delirium, and falls.1,2

For geriatric patients not closely monitored, notes geriatrician Don Murphy, MD, co-principal of Senior Care of Colorado, a large primary care geriatrics group in Denver, going to the hospital can be like disappearing into a black hole.

As the U.S. population ages, hospitalists will be caring for an increasing number of geriatric patients. They will have to address patients’ acute medical conditions without compromising their functional status.

The Hospitalist asked several leading geriatricians to identify valuable tools and strategies for delivering comprehensive geriatric care in the hospital. Even in the absence of formal geriatric care units, they say, hospitalists are positioned for adopting the principles of quality geriatric care. Many of those principles align with the central mission of hospital medicine: promoting high-quality, patient-centered care, working as a team, and developing clear lines of communication between the hospitalist and the primary care teams.

A Survey of Interventions

“There’s no question that it’s becoming extraordinarily difficult to do good care,” says John Morley, MD, professor of medicine and chief of the Division of Geriatrics and Endocrinology at Saint Louis University Health Sciences Center in Missouri. “Taking care of an older person in the hospital is a team sport—the physician can’t do it alone.”

It’s clear the team approach is a crucial foundation for interventions that target at-risk geriatric patients, agrees Edgar Pierluissi, MD, associate clinical professor of medicine and medical director of the recently established ACE unit at San Francisco General Hospital. Reducing the incidence of delirium, for instance, cannot be accomplished simply by utilizing a geriatric consultation. Once established, acute confusion can be intractable. “The idea is to try to prevent delirium, and research has shown that single-person types of interventions in these massively impervious-to-change facilities don’t work,” he says.

Clinical trials have demonstrated that interventions, including interdisciplinary and collaborative teams, targeted patient-centered therapies, and comprehensive geriatric assessment can improve outcomes of hospitalization in geriatric patients. Four major interventions include:

• Acute Care for Elders (ACE) units based on interdisciplinary team rounds, discharge planning, and medical review in a prepared environment to foster patient self-care and improve function. Randomized clinical trials have shown ACE units can reduce the length of stay, the risk of nursing home admissions, and the use of physical restraints while improving providers’ satisfaction with patient care.3,4
• The Hospital Elder Life Program (HELP), led by a geriatrics resource nurse, is an intervention designed to reduce the incidence of delirium by adjusting environmental elements, such as dimming lights and keeping the floor quiet at night. HELP also introduces non-pharmacologic interventions, including massages and warm tea at night and promotes mobility and hydration during the day.
• Incidence of delirium is reduced and cost savings are realized using the HELP.5 (Visit http://elderlife.med.yale.edu/public for more information.)
• Geriatric Evaluation and Management (GEM) units also emphasize a multidisciplinary comprehensive approach using geriatrician-led teams. The intervention can reduce long-term costs, while improving physical functioning and general health domains in the SF-36.6
• Use of advanced practice nurses in comprehensive discharge planning interventions, including nursing home visits for older patients with risk factors for poor outcomes post-discharge, has been shown to reduce readmissions.7

Assessment Is the Bottom Line

Robert Palmer, MD, head of the Section of Geriatric Medicine and professor of medicine at Cleveland Clinic Lerner College of Medicine of Case Western Reserve University in Ohio, is known for his work with ACE units. He and his colleagues have tracked patients following discharge and have identified the highest priority issues that should be addressed to avoid deleterious geriatric syndromes in the hospital. Although he advocates what he calls a minimalist approach to conducting a geriatric assessment, Dr. Palmer underlines the idea that it must also be a deliberate and structured approach. Assessing and acting upon key indicators in four to five major domains, he notes, can make a big difference for patients’ hospital trajectories.8 Here are a few domains to consider:

1 Focus on activities of daily living (ADLs). Function and performance of ADLs can predict post-hospital outcome and help the physician prioritize elements of the patient’s trajectory and goals while in the hospital. “If a person was able to independently bathe, dress, toilet, walk, and transfer—from bed to chair, for instance—before the acute illness, then he or she should be able to get back to that point after the illness has been treated,” says Dr. Palmer. The ability to transfer independently is an important predictor of discharge status because if the patient requires assistance to transfer, he or she will need a different level of care upon discharge. The hospitalist should seek information —from the patient, family member or primary caregiver, or primary care physician—about the patient’s ADLs before he or she got sick. Again, recovery of ADLs may be possible if the patient was performing these independently before the acute episode.

2 Cognitive assessments are also key. Dr. Morley places assessment for delirium at the top of his list. Research shows that approximately one third of patients over 70 in the hospital will develop the condition. Delirium, or acute confusion, is also a predictor of decline in ADLs, notes Dr. Palmer. Dr. Morley recommends the use of the Confusion Assessment Method (CAM) because the Mini Mental State Exam can be time-consuming. (A CAM form is available free online as part of SHM’s “Clinical Toolbox for Geriatric Care.” Go to www.hospitalmedicine.org, click on “Resource Center” and then “Geriatric Special Interest Area” to find the Toolbox.) According to Dr. Palmer, the physician should also use common sense when initially examining the patient: Observe whether the patient is confused, distracted, or inappropriate in conversation. If so, the next step is to use the simple Digit Span test: Say a random set of four to five numbers, and ask the patient to repeat them. Inability to do this is consistent with delirium as a cause of cognitive impairment.

For assessing cognitive impairment, Dr. Morley prefers the St. Louis University Mental Status Exam (SLUMS) to the Mini Mental Status Exam. The SLUMS, developed in collaboration with the Department of Veterans Affairs (and available free online at: http://medschool.slu.edu/agingsuccessfully/pdfsurveys/slumsexam_05.pdf) successfully picks up even mild cognitive impairment, according to Dr. Morley. This is important information not just for the hospital trajectory but also for discharge planning: Inability to follow discharge instructions due to cognitive impairment could result in a readmission.

3 Malnutrition is associated with mortality. Dr. Morley uses the four questions of the Simplified Nutrition Assessment Questionnaire (SNAQ), which correlate well with future weight loss and poor outcomes.9

If the SNAQ is positive, the use of a lengthier questionnaire may be warranted. Dr. Palmer suggests that a review of the patient’s comprehensive metabolic panel to judge kidney and liver function and a bedside evaluation using the Subjective Global Assessment (SGA) can yield results just as usable as the more complex and time-consuming textbook nutritional assessments.

4 Mood and affect also play a role in patients’ outcomes. Research has shown that depressed patients have poor outcomes, so physicians should always assess for depression. While the Geriatric Depression Scale (see “Clinical Toolbox for Geriatric Care” on the SHM Web site) can help quantify the extent of the patient’s symptoms, simply asking the patient, “Are you depressed, sad, or blue?” can often elicit enough information about the patient’s psychological status to direct interventions.

5 Mobility is sometimes classified as a stand-alone domain. However, walking and balance may be included in the assessment of ADLs. A patient who can walk independently—even with a cane or a walker—has a good chance to return home, says Dr. Palmer. Requiring another person to help with walking most likely indicates the patient will need short-term rehabilitation in a skilled nursing facility before returning home.

6 Social and living situation are important. The physician must identify the extent and quality of the patient’s support network. If, for instance, a patient has mild dementia but has a network of 10 extended family members who act as caregivers, discharge to home may be possible. If the patient was admitted to the hospital from a nursing home, however, it is most likely he or she will return there.

Revisit Daily Goals

Dr. Palmer advises hospitalists to follow the geriatric assessment with a translation of the information into what he calls a functional trajectory for the patient’s hospital stay. This includes an estimate of the patient’s anticipated length of stay and the expected discharge site. Interventions and consultations from allied health providers will be keyed to the patient’s individualized needs and to the goals of the functional trajectory.

To head off problems, Dr. Palmer advocates consultations from allied health professionals early in the hospital trajectory. For instance, if the patient is having trouble transferring from bed to chair upon admission, a consult with physical therapy may be warranted immediately rather than right before discharge, as is usually the case.

“We should not be depending on physical therapists at the end of hospitalization, when patients are already deconditioned and can’t get out of bed and need to go to a nursing home,” he explains. “The ideal time to bring in the physical therapist or technician is when you’ve identified—on day one—that the patient needs assistance with transfers, so that you can preserve mobility and shorten hospital stay.”

In the same vein, knowing the patient’s living situation will allow involvement of the discharge planner from day one of the hospitalization to plan with the patient or family for the patient’s return to home or to an alternate site. If the patient has been on a complex drug regimen, involving the pharmacist to help straighten out medications can head off potential drug-drug interactions. (SHM’s Geriatric Toolbox also has a list of medications to avoid in geriatric patients.)

It is important to review the functional trajectory on a daily basis. Input from other members of the health team will be invaluable. “Each day you identify barriers to that successful plan of the outcome, and you take care of them one at a time,” says Dr. Palmer. “If the patient is not on track with that daily goal, the team goes back to the drawing board and asks, ‘What are we missing here?’ Then you do a reassessment of ADLs, nutrition, and cognition.”

Hospitalists must also include the patient’s family members and primary caregivers as the patient moves toward discharge, asserts Dr. Morley. Clear, unambiguous written instructions must always be given to the patient or the primary caregiver when the patient leaves the hospital. (You can also find a discharge instruction sheet in SHM’s Toolbox.) If a patient appears to be facing the end of life, the hospitalist should schedule a conference with members of the primary care team, the hospitalist team, and all family stakeholders.

Transportable SKILLS

Some experts maintain that quality care for geriatric patients can be accomplished without a specialized geriatrics unit.

“I never conceived of the ACE intervention as being done exclusively on a unit,” says Dr. Palmer. “The idea was to develop the skills on a unit and then transport those skills to all units.” Although the protocols developed for ACE units are good for teaching, he says the team has been the key.

Dr. Morley agrees: “It’s not the physical part of the ACE unit that works. You must have team interactions. Finding a way to communicate between the different team members is absolutely key to good outcomes.”

Involving healthcare providers from different disciplines only enhances the care of geriatric patients. “Even though hospitalists may not have the depth of knowledge of geriatrics that a geriatrician has, they certainly have the knowledge of acute care medicine that we have, so they can manage the medical problems,” says Dr. Palmer. “What they need to do is think systematically, in a structured way, and to work collaboratively with key players. This only takes a few minutes each day, but more importantly, it saves time. You have fewer phone calls and fewer angry family members when you manage the care in a structured manner, working with a team of health professionals.”

Dr. Morley and his team have developed a form for their ACE unit that allows them to assess a patient’s status and goals in two to three minutes.

Dr. Pierluissi has experienced firsthand the benefits of working as a member of the interdisciplinary team. “Essentially,” he says, working in teams to treat the geriatric patient means there are “more heads in the game, more people trying to work in the patient’s best interest. You [the clinician] really do feel supported, and it makes your day more enjoyable and more productive.” TH

Gretchen Henkel is a medical journalist based in California.

Resources

1. Kozak LJ, Hall MJ, Owings MF. Hospitalization fact sheet. In: National Hospital Discharge Survey: 2000 Annual summary with detailed diagnosis and procedure data. Hyattsville, Maryland: National Center for Health Statistics. Vital Health Stat. 2002;13(153).
2. Covinsky KE, Palmer RM, Fortinsky RH, et al. Loss of independence in activities of daily living in older adults hospitalized with medical illnesses: increased vulnerability with age. J Am Geriatr Soc. 2003 Apr;51(4):451-458.
3. Landefeld CS, Palmer RM, Kresevic DM, et al. A randomized trial of care in a hospital medical unit especially designed to improve the functional outcomes of acutely ill older patients. N Engl J Med. 1995 May;332(20):1338-1344. Comments in: ACP J Club. 1995 Nov-Dec; 123(3):69 and N Engl J Med. 1995 May 18; 332(20):1376-1378.
4. Counsell SR, Holder CM, Liebenauer LL, et al. Effects of a multicomponent intervention on functional outcomes and process of care in hospitalized older patients: a randomized controlled trial of acute care for Elders (ACE) in a community hospital. J Am Geriatr Soc. 2000 Dec;48:1572-1581.
5. Inouye SK, Bogardus ST Jr, Charpentier PA, et al. A multicomponent intervention to prevent delirium in hospitalized older patients. N Engl J Med. 1999 Mar 4;340(9):669-676. Comments in: N Engl J Med. 1999 Jul 29; 341(5):369-370; author reply 370 and N Engl J Med. 1999 Mar 4; 340(9):720-721.
6. Cohen HJ, Feussner JR, Weinberger M, et al. A controlled trial of inpatient and outpatient geriatric evaluation and management. N Engl J Med. 2002 Mar 21;346(12):905-912. Comments in: Curr Surg. 2004 May-Jun;61(3):266-274; N Engl J Med. 2002 Aug 1;347(5):371-373; author reply 371-373 & N Engl J Med. 2002 Mar 21;346(12):874.
7. Naylor MD, Brooten DA, Campbell RL, et al. Transitional care of older adults hospitalized with heart failure: a randomized, controlled trial. J Am Geriatr Soc. 2004 May;52(5):675-684. Erratum in J Am Geriatr Soc. 2004 Jul; 52(7):1228. Comment in Evid Based Nurs. 2004 Oct;7(4):116.
8. Palmer RM. Acute hospital care of the elderly: making a difference. Caring for the Hospitalized Elderly [special supplement to The Hospitalist]. 2004. Available at: www.hospitalmedicine.org/AM/Template.cfm?Section=The_Hospitalist&Template=/CM/ContentDisplay.cfm&ContentFileID=1447. Last accessed March 14, 2007.
9. Wilson MM, Thomas DR, Rubenstein LZ, et al. Appetite assessment: simple appetite questionnaire predicts weight loss in community-dwelling adults and nursing home residents. Am J Clin Nutr. 2005 Nov;82(5):1074-1081.

The problem of falls among older adults has been recognized and studied for many years, including myriad analyses regarding assessment and prevention of falls in this population. The U.S. Census Bureau reported that there were 35.9 million people age 65 and over in the United States as of July 1, 2003. As this population increases, the specific issues pertaining to its members, including falls, must be addressed by hospitalists.

How Big Is the Problem?

The Center for Disease Control and Prevention’s (CDC) National Center for Injury Prevention and Control reports that:

• More than one-third of adults 65 and older fall each year in the United States;
• Falls are the leading cause of injury deaths for older adults;
• In 2003, about 1.8 million people 65 and older were treated in emergency departments for nonfatal falls, and about 460,000 of these patients were hospitalized;
• The rates of fall-related deaths among older adults rose significantly over the past decade;
• Many individuals who fall develop a fear of falling. That may cause them to limit activity, leading to reduced mobility and physical fitness and increasing their risk for additional falls; and
• In 2000, direct medical costs totaled $179 million for fatal falls and $19 billion for nonfatal fall injuries.1

One study exploring the relationship between the mechanism of fall and the pattern and severity of injury in geriatric patients compared with younger patients concluded that falls were the mechanism of injury in 48% of the older patients (those 65 and older) included in the study compared with 7% in the younger group. Further, 32% of falls in the older group resulted in serious injury, while this was true of only 4% of falls in the younger cohort.2

Risk Assessment

When an inpatient in an acute-care hospital falls, a number of negative outcomes can occur, including a longer hospital stay and higher rates of discharge to long-term care.

Falls are associated with higher levels of anxiety and depression and loss of confidence for the patient. They lead to increased costs for patients and hospitals. Feelings of anxiety and/or guilt among staff members may follow. Ultimately, a fall can result in complaints or even litigation from patients or their families.3

Traditional methods of fall risk evaluation may not be effective for assessing the risk of falling for a hospitalized patient, regardless of the reason the patient is hospitalized. The classic risk factors are generally well recognized among physicians and clinical staff and include:

• Age 65 and older;
• A history of falls;
• Cognitive impairment;
• Urinary/fecal incontinence/urgency;
• Balance problems, lower extremity weakness, arthritis;
• Vision problems;
• Use of more than four daily medications or use of psychotropics or narcotics; and
• ETOH.

Acute illness alone accounts for approximately 10% of falls in older adults.4 Many patients suffering or recovering from acute illness may go through a transient period of increased risk for falling that needs to be recognized by physicians and nursing staff.

The impact of pharmacology on a patient’s risk for falling is widely recognized. Patients who take four or more medications are generally considered to be at increased risk. Certain medications, including diuretics, anti-hypertensives, tricyclic antidepressants, sedatives, and hypoglycemics are known to increase an individual’s risk for falling. An October 2004 CDC-funded study by researchers at Johns Hopkins University (Baltimore) concluded that the short-term risk of single and recurring falls may triple within two days after a medication change.5 A patient hospitalized for an acute illness or injury is likely to have had a recent and significant change in the medications he or she is taking, thereby at least temporarily increasing that individual’s risk for falling.

The environmental hazards of the hospital room can’t be overlooked when assessing a patient’s risk for falling. The patient is in an unfamiliar setting—often with informal restraints in place, including IV tubing, feeding tubes, pulse oximeters, and catheters. These obstacles make it more difficult for the patient to maneuver and present opportunities for tripping.

All these things—individually or combined—can increase the chances of falling, even for a patient who at first glance doesn’t appear to be at risk.

Stephen Shaw, MD, medical director of Community Hospitalists in Cleveland, says that while falls assessment tools can be helpful, it would be difficult to outline a foolproof assessment form.

The physician must keep in mind the fact that falls prevention is multifactorial; it may be difficult to attribute the patient’s fall(s) to any single reason. “Any vigorous falls assessment program has to have a comprehensive approach,” he cautions. “Medications, attention to vision limitations, and his or her ability to feel in the dark in their surroundings all have to be taken into consideration.”

The Hospitalist’s Role

When a patient is admitted for injuries resulting from a fall or from an illness that may have been diagnosed as a result of a fall, consider acute conditions first. Also remember that falling is a symptom; understanding why the patient fell is the first step to prevention—both while the patient remains in the hospital and following discharge.

One of the first things the hospitalist must do to reduce patient falls effectively is to study risk assessment and prevention of geriatric falls. A study published in the Journal of Hospital Medicine in January/February 2006 (“Is There a Geriatrician in the House? Geriatric Care Approaches in Hospitalist Programs”) identifies the need for collaboration between hospitalists and geriatricians to better address the issues specific to hospitalized older adults. This collaboration combines the geriatrician’s expertise regarding the elderly patient’s unique needs and considerations with the hospitalist’s expertise regarding specific acute care situations.6

Heidi Wald, MD, MPH, assistant professor, Division of Health Care Policy and Research and General Internal Medicine at the University of Colorado in Denver and primary author of the Journal of Hospital Medicine study, says numerous things can be done to reduce the risk of inpatient falls, beginning with identifying patients at high risk for falling. This can be done by assessing the classic risk factors intrinsic to the patient, while keeping in mind the risk factors that could be mediated by the acute illness.

Risks created by the environment can be fairly easily addressed, according to Dr. Wald. Lower beds as far as they will go, with the wheels locked. Don’t use upper and lower bedrails simultaneously (this reduces the chance of a patient being caught between the two). Cut down on the use of restraints—both formal and informal.

Because many falls result from patients trying to get to the bathroom, Dr. Wald advises scheduled toileting, with the staff regularly assisting the patient to the bathroom. If a patient cannot ambulate to the restroom independently, ensure that a urinal or a bedpan is nearby and readily accessible to the patient.

Dr. Wald also advises utilizing the expertise and skills of those clinicians most familiar with the patient: the nursing staff. The nurses who have daily contact with the patient are in the best position to provide information regarding changes in the patient’s mental status, ability to ambulate, response to medications, compliance, and other factors that may increase the risk for a fall.

“The bottom line of any quality initiative will often fall to the nurses’ assessment,” says Dr. Shaw. “The front-line caregivers for fall assessments are our nurses.”

A Multidisciplinary Approach to Prevention

Drs. Wald and Shaw both stress the importance of a multidisciplinary approach to prevention of falls (both in hospital and following discharge). A patient who has already fallen—or one identified to be at risk for falling—can be offered a great deal of support and guidance pending discharge. And discharge planning can begin literally at admission.

It’s Dr. Shaw’s practice with at-risk patients to involve physical and occupational therapy (as well as social workers) in the patient’s care right from the beginning. Those individuals are then in a position not only to perform a thorough assessment of the patient but also to begin working on ways to reduce the patient’s risk following discharge. As Dr. Shaw points out, the hospitalist has access to resources the patient’s primary-care physician generally does not, and those resources should be utilized to full advantage.

Physical therapy can offer rehabilitative interventions, including transfer, gait, and balance training; strength and range-of-motion exercises; and habituation exercises for vestibular problems. Occupational therapy can offer the patient instruction on simplifying tasks and on performing everyday activities safely. Social workers can assist the patient with finding educational and assistive resources. All disciplines can be involved in home safety evaluations, patient and family education, and the procurement of assistive and adaptive equipment, such as ambulation devices, grab bars, handrails, raised toilet seats, and so on.

When all of these healthcare providers are involved in the patient’s care from the beginning and can coordinate discharge planning as a team, a more well-rounded and comprehensive plan for prevention of falls can be formulated. This team approach also offers a more accurate view of whether the patient is capable of returning home with or without help or if placement in a rehabilitation or long-term care facility may be more appropriate.

Involve the Patient

Once an at-risk patient has been identified, communicate that risk to everyone involved with the patient’s care, including the medical staff, the family, and the patient. “Patients have a certain degree of risk-taking behavior, and they won’t necessarily ask for help,” says Dr. Wald. “Part of that is that they’re not willing to admit that they need help.”

Patients need to be reminded that they are or have recently been sick—that’s why they’re in the hospital in the first place. She says patients and caregivers must be attuned to the fact that as patients begin to feel better and stronger and become more mobile, their risk for falling will go up before it starts to come down.

If a patient remains resistant to asking for or accepting assistance, Dr. Wald suggests finding out what the patient’s barriers are and trying to get around them. “Try to get people to admit that they have a problem,” she advises. “A lot of times, the barriers aren’t rational, so rationalizing isn’t always effective.”

She offers the example of a patient who resists the idea of using a walker. Sometimes simply demonstrating how much more quickly the patient can get around using the walker may do the trick.

Dr. Shaw adds that a certain level of sensitivity is required when approaching a patient who is in denial regarding his or her limitations. It may be necessary to ask a second physician or nurse to lend credibility by explaining to the patient again that he or she may have needs that didn’t exist previously. He cautions, however, that if his patient remains in denial about his or her limitations, he does not hesitate to engage the family. “If the patient is discharged home, it’s going to be the family who will be the policemen and watchdogs,” says Dr. Shaw.

After discharge, following up with the patient can make a big difference in patient compliance. The time following discharge to the home can be confusing for the patient, and he may be overwhelmed with changes in routines, medications, and activities. Dr. Shaw’s organization calls the patient three to four days post-discharge to verify that the patient understands the discharge instructions, to answer questions the patient may have, and to confirm that prescriptions have been filled and that follow-up appointments have been made with the primary-care physician. He notes that although this simple follow-up phone call takes little time and effort, it has improved patient satisfaction immensely.

Quality and Prevention Initiatives

The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) 2007 National Patient Safety Goals for hospitals includes the following goal: “Reduce the risk of patient harm resulting from falls” (Goal 9).

The requirement for this goal is the implementation of a fall reduction program, followed by evaluation of the effectiveness of the program. Drs. Wald and Shaw agree that, because of the nature of what they do, hospitalists are in an ideal position to spearhead the movement to assess the reasons a patient may have fallen and the risk for future falls—both in the hospital and following discharge—and to synthesize that data to create comprehensive falls prevention programs in their hospitals.

Because hospitalists are on-site 24 hours a day, seven days a week, they are usually first responders when a patient falls and can best evaluate the reasons for the fall and track outcomes. “We’re in an ideal position to create protocols for what to do once a patient does fall in the hospital and [to] evaluate the fall and the incident,” Dr. Wald says. “This is a great quality improvement project because the data are already being collected.”

Dr. Shaw concurs. “Hospitalists are the quality assessors that are in the trenches,” she says. “The hospitalists are really the clinicians most familiar with the strengths and weaknesses of any institution.” TH

Sheri Polley is a medical journalist based in Pennsylvania.

References

1. Centers for Disease Control and Prevention. Falls among older adults: an overview. CDC Web site. Available at: www.cdc.gov/ncipc/factsheets/adultfalls.htm. Last accessed March 13, 2007.
2. Sterling DA, O’Connor JA, Bonadies J. Geriatric falls: injury severity is high and disproportionate to mechanism. J Trauma. 2001 Jan;50(1):116-119.
3. Oliver D, Daly F, Martin FC, et al. Risk factors and risk assessment tools for falls in hospital in-patients: a systematic review. Age Ageing. 2004 Mar;33(2):122-130.
4. Nnodim JO, Alexander NB. Assessing falls in older adults: a comprehensive fall evaluation to reduce fall risk in older adults. Geriatrics. 2005 Oct;60(10):24-28.
5. Centers for Disease Control and Prevention. CDC fall prevention activities: research studies. CDC Web site. Available at: www.cdc.gov/ncipc/duip/FallsPreventionActivity.htm. Last accessed March 13, 2007.
6. Wald H, Huddleston J, Kramer A. Is there a geriatrician in the house? Geriatric care approaches in hospitalist programs. J Hosp Med. 2006 Jan;1(1):29-35.

The problem of falls among older adults has been recognized and studied for many years, including myriad analyses regarding assessment and prevention of falls in this population. The U.S. Census Bureau reported that there were 35.9 million people age 65 and over in the United States as of July 1, 2003. As this population increases, the specific issues pertaining to its members, including falls, must be addressed by hospitalists.

How Big Is the Problem?

The Center for Disease Control and Prevention’s (CDC) National Center for Injury Prevention and Control reports that:

• More than one-third of adults 65 and older fall each year in the United States;
• Falls are the leading cause of injury deaths for older adults;
• In 2003, about 1.8 million people 65 and older were treated in emergency departments for nonfatal falls, and about 460,000 of these patients were hospitalized;
• The rates of fall-related deaths among older adults rose significantly over the past decade;
• Many individuals who fall develop a fear of falling. That may cause them to limit activity, leading to reduced mobility and physical fitness and increasing their risk for additional falls; and
• In 2000, direct medical costs totaled $179 million for fatal falls and $19 billion for nonfatal fall injuries.1

One study exploring the relationship between the mechanism of fall and the pattern and severity of injury in geriatric patients compared with younger patients concluded that falls were the mechanism of injury in 48% of the older patients (those 65 and older) included in the study compared with 7% in the younger group. Further, 32% of falls in the older group resulted in serious injury, while this was true of only 4% of falls in the younger cohort.2

Risk Assessment

When an inpatient in an acute-care hospital falls, a number of negative outcomes can occur, including a longer hospital stay and higher rates of discharge to long-term care.

Falls are associated with higher levels of anxiety and depression and loss of confidence for the patient. They lead to increased costs for patients and hospitals. Feelings of anxiety and/or guilt among staff members may follow. Ultimately, a fall can result in complaints or even litigation from patients or their families.3

Traditional methods of fall risk evaluation may not be effective for assessing the risk of falling for a hospitalized patient, regardless of the reason the patient is hospitalized. The classic risk factors are generally well recognized among physicians and clinical staff and include:

• Age 65 and older;
• A history of falls;
• Cognitive impairment;
• Urinary/fecal incontinence/urgency;
• Balance problems, lower extremity weakness, arthritis;
• Vision problems;
• Use of more than four daily medications or use of psychotropics or narcotics; and
• ETOH.

Acute illness alone accounts for approximately 10% of falls in older adults.4 Many patients suffering or recovering from acute illness may go through a transient period of increased risk for falling that needs to be recognized by physicians and nursing staff.

The impact of pharmacology on a patient’s risk for falling is widely recognized. Patients who take four or more medications are generally considered to be at increased risk. Certain medications, including diuretics, anti-hypertensives, tricyclic antidepressants, sedatives, and hypoglycemics are known to increase an individual’s risk for falling. An October 2004 CDC-funded study by researchers at Johns Hopkins University (Baltimore) concluded that the short-term risk of single and recurring falls may triple within two days after a medication change.5 A patient hospitalized for an acute illness or injury is likely to have had a recent and significant change in the medications he or she is taking, thereby at least temporarily increasing that individual’s risk for falling.

The environmental hazards of the hospital room can’t be overlooked when assessing a patient’s risk for falling. The patient is in an unfamiliar setting—often with informal restraints in place, including IV tubing, feeding tubes, pulse oximeters, and catheters. These obstacles make it more difficult for the patient to maneuver and present opportunities for tripping.

All these things—individually or combined—can increase the chances of falling, even for a patient who at first glance doesn’t appear to be at risk.

Stephen Shaw, MD, medical director of Community Hospitalists in Cleveland, says that while falls assessment tools can be helpful, it would be difficult to outline a foolproof assessment form.

The physician must keep in mind the fact that falls prevention is multifactorial; it may be difficult to attribute the patient’s fall(s) to any single reason. “Any vigorous falls assessment program has to have a comprehensive approach,” he cautions. “Medications, attention to vision limitations, and his or her ability to feel in the dark in their surroundings all have to be taken into consideration.”

The Hospitalist’s Role

When a patient is admitted for injuries resulting from a fall or from an illness that may have been diagnosed as a result of a fall, consider acute conditions first. Also remember that falling is a symptom; understanding why the patient fell is the first step to prevention—both while the patient remains in the hospital and following discharge.

One of the first things the hospitalist must do to reduce patient falls effectively is to study risk assessment and prevention of geriatric falls. A study published in the Journal of Hospital Medicine in January/February 2006 (“Is There a Geriatrician in the House? Geriatric Care Approaches in Hospitalist Programs”) identifies the need for collaboration between hospitalists and geriatricians to better address the issues specific to hospitalized older adults. This collaboration combines the geriatrician’s expertise regarding the elderly patient’s unique needs and considerations with the hospitalist’s expertise regarding specific acute care situations.6

Heidi Wald, MD, MPH, assistant professor, Division of Health Care Policy and Research and General Internal Medicine at the University of Colorado in Denver and primary author of the Journal of Hospital Medicine study, says numerous things can be done to reduce the risk of inpatient falls, beginning with identifying patients at high risk for falling. This can be done by assessing the classic risk factors intrinsic to the patient, while keeping in mind the risk factors that could be mediated by the acute illness.

Risks created by the environment can be fairly easily addressed, according to Dr. Wald. Lower beds as far as they will go, with the wheels locked. Don’t use upper and lower bedrails simultaneously (this reduces the chance of a patient being caught between the two). Cut down on the use of restraints—both formal and informal.

Because many falls result from patients trying to get to the bathroom, Dr. Wald advises scheduled toileting, with the staff regularly assisting the patient to the bathroom. If a patient cannot ambulate to the restroom independently, ensure that a urinal or a bedpan is nearby and readily accessible to the patient.

Dr. Wald also advises utilizing the expertise and skills of those clinicians most familiar with the patient: the nursing staff. The nurses who have daily contact with the patient are in the best position to provide information regarding changes in the patient’s mental status, ability to ambulate, response to medications, compliance, and other factors that may increase the risk for a fall.

“The bottom line of any quality initiative will often fall to the nurses’ assessment,” says Dr. Shaw. “The front-line caregivers for fall assessments are our nurses.”

A Multidisciplinary Approach to Prevention

Drs. Wald and Shaw both stress the importance of a multidisciplinary approach to prevention of falls (both in hospital and following discharge). A patient who has already fallen—or one identified to be at risk for falling—can be offered a great deal of support and guidance pending discharge. And discharge planning can begin literally at admission.

It’s Dr. Shaw’s practice with at-risk patients to involve physical and occupational therapy (as well as social workers) in the patient’s care right from the beginning. Those individuals are then in a position not only to perform a thorough assessment of the patient but also to begin working on ways to reduce the patient’s risk following discharge. As Dr. Shaw points out, the hospitalist has access to resources the patient’s primary-care physician generally does not, and those resources should be utilized to full advantage.

Physical therapy can offer rehabilitative interventions, including transfer, gait, and balance training; strength and range-of-motion exercises; and habituation exercises for vestibular problems. Occupational therapy can offer the patient instruction on simplifying tasks and on performing everyday activities safely. Social workers can assist the patient with finding educational and assistive resources. All disciplines can be involved in home safety evaluations, patient and family education, and the procurement of assistive and adaptive equipment, such as ambulation devices, grab bars, handrails, raised toilet seats, and so on.

When all of these healthcare providers are involved in the patient’s care from the beginning and can coordinate discharge planning as a team, a more well-rounded and comprehensive plan for prevention of falls can be formulated. This team approach also offers a more accurate view of whether the patient is capable of returning home with or without help or if placement in a rehabilitation or long-term care facility may be more appropriate.

Involve the Patient

Once an at-risk patient has been identified, communicate that risk to everyone involved with the patient’s care, including the medical staff, the family, and the patient. “Patients have a certain degree of risk-taking behavior, and they won’t necessarily ask for help,” says Dr. Wald. “Part of that is that they’re not willing to admit that they need help.”

Patients need to be reminded that they are or have recently been sick—that’s why they’re in the hospital in the first place. She says patients and caregivers must be attuned to the fact that as patients begin to feel better and stronger and become more mobile, their risk for falling will go up before it starts to come down.

If a patient remains resistant to asking for or accepting assistance, Dr. Wald suggests finding out what the patient’s barriers are and trying to get around them. “Try to get people to admit that they have a problem,” she advises. “A lot of times, the barriers aren’t rational, so rationalizing isn’t always effective.”

She offers the example of a patient who resists the idea of using a walker. Sometimes simply demonstrating how much more quickly the patient can get around using the walker may do the trick.

Dr. Shaw adds that a certain level of sensitivity is required when approaching a patient who is in denial regarding his or her limitations. It may be necessary to ask a second physician or nurse to lend credibility by explaining to the patient again that he or she may have needs that didn’t exist previously. He cautions, however, that if his patient remains in denial about his or her limitations, he does not hesitate to engage the family. “If the patient is discharged home, it’s going to be the family who will be the policemen and watchdogs,” says Dr. Shaw.

After discharge, following up with the patient can make a big difference in patient compliance. The time following discharge to the home can be confusing for the patient, and he may be overwhelmed with changes in routines, medications, and activities. Dr. Shaw’s organization calls the patient three to four days post-discharge to verify that the patient understands the discharge instructions, to answer questions the patient may have, and to confirm that prescriptions have been filled and that follow-up appointments have been made with the primary-care physician. He notes that although this simple follow-up phone call takes little time and effort, it has improved patient satisfaction immensely.

Quality and Prevention Initiatives

The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) 2007 National Patient Safety Goals for hospitals includes the following goal: “Reduce the risk of patient harm resulting from falls” (Goal 9).

The requirement for this goal is the implementation of a fall reduction program, followed by evaluation of the effectiveness of the program. Drs. Wald and Shaw agree that, because of the nature of what they do, hospitalists are in an ideal position to spearhead the movement to assess the reasons a patient may have fallen and the risk for future falls—both in the hospital and following discharge—and to synthesize that data to create comprehensive falls prevention programs in their hospitals.

Because hospitalists are on-site 24 hours a day, seven days a week, they are usually first responders when a patient falls and can best evaluate the reasons for the fall and track outcomes. “We’re in an ideal position to create protocols for what to do once a patient does fall in the hospital and [to] evaluate the fall and the incident,” Dr. Wald says. “This is a great quality improvement project because the data are already being collected.”

Dr. Shaw concurs. “Hospitalists are the quality assessors that are in the trenches,” she says. “The hospitalists are really the clinicians most familiar with the strengths and weaknesses of any institution.” TH

Sheri Polley is a medical journalist based in Pennsylvania.

References

1. Centers for Disease Control and Prevention. Falls among older adults: an overview. CDC Web site. Available at: www.cdc.gov/ncipc/factsheets/adultfalls.htm. Last accessed March 13, 2007.
2. Sterling DA, O’Connor JA, Bonadies J. Geriatric falls: injury severity is high and disproportionate to mechanism. J Trauma. 2001 Jan;50(1):116-119.
3. Oliver D, Daly F, Martin FC, et al. Risk factors and risk assessment tools for falls in hospital in-patients: a systematic review. Age Ageing. 2004 Mar;33(2):122-130.
4. Nnodim JO, Alexander NB. Assessing falls in older adults: a comprehensive fall evaluation to reduce fall risk in older adults. Geriatrics. 2005 Oct;60(10):24-28.
5. Centers for Disease Control and Prevention. CDC fall prevention activities: research studies. CDC Web site. Available at: www.cdc.gov/ncipc/duip/FallsPreventionActivity.htm. Last accessed March 13, 2007.
6. Wald H, Huddleston J, Kramer A. Is there a geriatrician in the house? Geriatric care approaches in hospitalist programs. J Hosp Med. 2006 Jan;1(1):29-35.

The problem of falls among older adults has been recognized and studied for many years, including myriad analyses regarding assessment and prevention of falls in this population. The U.S. Census Bureau reported that there were 35.9 million people age 65 and over in the United States as of July 1, 2003. As this population increases, the specific issues pertaining to its members, including falls, must be addressed by hospitalists.

How Big Is the Problem?

The Center for Disease Control and Prevention’s (CDC) National Center for Injury Prevention and Control reports that:

• More than one-third of adults 65 and older fall each year in the United States;
• Falls are the leading cause of injury deaths for older adults;
• In 2003, about 1.8 million people 65 and older were treated in emergency departments for nonfatal falls, and about 460,000 of these patients were hospitalized;
• The rates of fall-related deaths among older adults rose significantly over the past decade;
• Many individuals who fall develop a fear of falling. That may cause them to limit activity, leading to reduced mobility and physical fitness and increasing their risk for additional falls; and
• In 2000, direct medical costs totaled $179 million for fatal falls and $19 billion for nonfatal fall injuries.1

One study exploring the relationship between the mechanism of fall and the pattern and severity of injury in geriatric patients compared with younger patients concluded that falls were the mechanism of injury in 48% of the older patients (those 65 and older) included in the study compared with 7% in the younger group. Further, 32% of falls in the older group resulted in serious injury, while this was true of only 4% of falls in the younger cohort.2

Risk Assessment

When an inpatient in an acute-care hospital falls, a number of negative outcomes can occur, including a longer hospital stay and higher rates of discharge to long-term care.

Falls are associated with higher levels of anxiety and depression and loss of confidence for the patient. They lead to increased costs for patients and hospitals. Feelings of anxiety and/or guilt among staff members may follow. Ultimately, a fall can result in complaints or even litigation from patients or their families.3

Traditional methods of fall risk evaluation may not be effective for assessing the risk of falling for a hospitalized patient, regardless of the reason the patient is hospitalized. The classic risk factors are generally well recognized among physicians and clinical staff and include:

• Age 65 and older;
• A history of falls;
• Cognitive impairment;
• Urinary/fecal incontinence/urgency;
• Balance problems, lower extremity weakness, arthritis;
• Vision problems;
• Use of more than four daily medications or use of psychotropics or narcotics; and
• ETOH.

Acute illness alone accounts for approximately 10% of falls in older adults.4 Many patients suffering or recovering from acute illness may go through a transient period of increased risk for falling that needs to be recognized by physicians and nursing staff.

The impact of pharmacology on a patient’s risk for falling is widely recognized. Patients who take four or more medications are generally considered to be at increased risk. Certain medications, including diuretics, anti-hypertensives, tricyclic antidepressants, sedatives, and hypoglycemics are known to increase an individual’s risk for falling. An October 2004 CDC-funded study by researchers at Johns Hopkins University (Baltimore) concluded that the short-term risk of single and recurring falls may triple within two days after a medication change.5 A patient hospitalized for an acute illness or injury is likely to have had a recent and significant change in the medications he or she is taking, thereby at least temporarily increasing that individual’s risk for falling.

The environmental hazards of the hospital room can’t be overlooked when assessing a patient’s risk for falling. The patient is in an unfamiliar setting—often with informal restraints in place, including IV tubing, feeding tubes, pulse oximeters, and catheters. These obstacles make it more difficult for the patient to maneuver and present opportunities for tripping.

All these things—individually or combined—can increase the chances of falling, even for a patient who at first glance doesn’t appear to be at risk.

Stephen Shaw, MD, medical director of Community Hospitalists in Cleveland, says that while falls assessment tools can be helpful, it would be difficult to outline a foolproof assessment form.

The physician must keep in mind the fact that falls prevention is multifactorial; it may be difficult to attribute the patient’s fall(s) to any single reason. “Any vigorous falls assessment program has to have a comprehensive approach,” he cautions. “Medications, attention to vision limitations, and his or her ability to feel in the dark in their surroundings all have to be taken into consideration.”

The Hospitalist’s Role

When a patient is admitted for injuries resulting from a fall or from an illness that may have been diagnosed as a result of a fall, consider acute conditions first. Also remember that falling is a symptom; understanding why the patient fell is the first step to prevention—both while the patient remains in the hospital and following discharge.

One of the first things the hospitalist must do to reduce patient falls effectively is to study risk assessment and prevention of geriatric falls. A study published in the Journal of Hospital Medicine in January/February 2006 (“Is There a Geriatrician in the House? Geriatric Care Approaches in Hospitalist Programs”) identifies the need for collaboration between hospitalists and geriatricians to better address the issues specific to hospitalized older adults. This collaboration combines the geriatrician’s expertise regarding the elderly patient’s unique needs and considerations with the hospitalist’s expertise regarding specific acute care situations.6

Heidi Wald, MD, MPH, assistant professor, Division of Health Care Policy and Research and General Internal Medicine at the University of Colorado in Denver and primary author of the Journal of Hospital Medicine study, says numerous things can be done to reduce the risk of inpatient falls, beginning with identifying patients at high risk for falling. This can be done by assessing the classic risk factors intrinsic to the patient, while keeping in mind the risk factors that could be mediated by the acute illness.

Risks created by the environment can be fairly easily addressed, according to Dr. Wald. Lower beds as far as they will go, with the wheels locked. Don’t use upper and lower bedrails simultaneously (this reduces the chance of a patient being caught between the two). Cut down on the use of restraints—both formal and informal.

Because many falls result from patients trying to get to the bathroom, Dr. Wald advises scheduled toileting, with the staff regularly assisting the patient to the bathroom. If a patient cannot ambulate to the restroom independently, ensure that a urinal or a bedpan is nearby and readily accessible to the patient.

Dr. Wald also advises utilizing the expertise and skills of those clinicians most familiar with the patient: the nursing staff. The nurses who have daily contact with the patient are in the best position to provide information regarding changes in the patient’s mental status, ability to ambulate, response to medications, compliance, and other factors that may increase the risk for a fall.

“The bottom line of any quality initiative will often fall to the nurses’ assessment,” says Dr. Shaw. “The front-line caregivers for fall assessments are our nurses.”

A Multidisciplinary Approach to Prevention

Drs. Wald and Shaw both stress the importance of a multidisciplinary approach to prevention of falls (both in hospital and following discharge). A patient who has already fallen—or one identified to be at risk for falling—can be offered a great deal of support and guidance pending discharge. And discharge planning can begin literally at admission.

It’s Dr. Shaw’s practice with at-risk patients to involve physical and occupational therapy (as well as social workers) in the patient’s care right from the beginning. Those individuals are then in a position not only to perform a thorough assessment of the patient but also to begin working on ways to reduce the patient’s risk following discharge. As Dr. Shaw points out, the hospitalist has access to resources the patient’s primary-care physician generally does not, and those resources should be utilized to full advantage.

Physical therapy can offer rehabilitative interventions, including transfer, gait, and balance training; strength and range-of-motion exercises; and habituation exercises for vestibular problems. Occupational therapy can offer the patient instruction on simplifying tasks and on performing everyday activities safely. Social workers can assist the patient with finding educational and assistive resources. All disciplines can be involved in home safety evaluations, patient and family education, and the procurement of assistive and adaptive equipment, such as ambulation devices, grab bars, handrails, raised toilet seats, and so on.

When all of these healthcare providers are involved in the patient’s care from the beginning and can coordinate discharge planning as a team, a more well-rounded and comprehensive plan for prevention of falls can be formulated. This team approach also offers a more accurate view of whether the patient is capable of returning home with or without help or if placement in a rehabilitation or long-term care facility may be more appropriate.

Involve the Patient

Once an at-risk patient has been identified, communicate that risk to everyone involved with the patient’s care, including the medical staff, the family, and the patient. “Patients have a certain degree of risk-taking behavior, and they won’t necessarily ask for help,” says Dr. Wald. “Part of that is that they’re not willing to admit that they need help.”

Patients need to be reminded that they are or have recently been sick—that’s why they’re in the hospital in the first place. She says patients and caregivers must be attuned to the fact that as patients begin to feel better and stronger and become more mobile, their risk for falling will go up before it starts to come down.

If a patient remains resistant to asking for or accepting assistance, Dr. Wald suggests finding out what the patient’s barriers are and trying to get around them. “Try to get people to admit that they have a problem,” she advises. “A lot of times, the barriers aren’t rational, so rationalizing isn’t always effective.”

She offers the example of a patient who resists the idea of using a walker. Sometimes simply demonstrating how much more quickly the patient can get around using the walker may do the trick.

Dr. Shaw adds that a certain level of sensitivity is required when approaching a patient who is in denial regarding his or her limitations. It may be necessary to ask a second physician or nurse to lend credibility by explaining to the patient again that he or she may have needs that didn’t exist previously. He cautions, however, that if his patient remains in denial about his or her limitations, he does not hesitate to engage the family. “If the patient is discharged home, it’s going to be the family who will be the policemen and watchdogs,” says Dr. Shaw.

After discharge, following up with the patient can make a big difference in patient compliance. The time following discharge to the home can be confusing for the patient, and he may be overwhelmed with changes in routines, medications, and activities. Dr. Shaw’s organization calls the patient three to four days post-discharge to verify that the patient understands the discharge instructions, to answer questions the patient may have, and to confirm that prescriptions have been filled and that follow-up appointments have been made with the primary-care physician. He notes that although this simple follow-up phone call takes little time and effort, it has improved patient satisfaction immensely.

Quality and Prevention Initiatives

The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) 2007 National Patient Safety Goals for hospitals includes the following goal: “Reduce the risk of patient harm resulting from falls” (Goal 9).

The requirement for this goal is the implementation of a fall reduction program, followed by evaluation of the effectiveness of the program. Drs. Wald and Shaw agree that, because of the nature of what they do, hospitalists are in an ideal position to spearhead the movement to assess the reasons a patient may have fallen and the risk for future falls—both in the hospital and following discharge—and to synthesize that data to create comprehensive falls prevention programs in their hospitals.

Because hospitalists are on-site 24 hours a day, seven days a week, they are usually first responders when a patient falls and can best evaluate the reasons for the fall and track outcomes. “We’re in an ideal position to create protocols for what to do once a patient does fall in the hospital and [to] evaluate the fall and the incident,” Dr. Wald says. “This is a great quality improvement project because the data are already being collected.”

Dr. Shaw concurs. “Hospitalists are the quality assessors that are in the trenches,” she says. “The hospitalists are really the clinicians most familiar with the strengths and weaknesses of any institution.” TH

Sheri Polley is a medical journalist based in Pennsylvania.

References

1. Centers for Disease Control and Prevention. Falls among older adults: an overview. CDC Web site. Available at: www.cdc.gov/ncipc/factsheets/adultfalls.htm. Last accessed March 13, 2007.
2. Sterling DA, O’Connor JA, Bonadies J. Geriatric falls: injury severity is high and disproportionate to mechanism. J Trauma. 2001 Jan;50(1):116-119.
3. Oliver D, Daly F, Martin FC, et al. Risk factors and risk assessment tools for falls in hospital in-patients: a systematic review. Age Ageing. 2004 Mar;33(2):122-130.
4. Nnodim JO, Alexander NB. Assessing falls in older adults: a comprehensive fall evaluation to reduce fall risk in older adults. Geriatrics. 2005 Oct;60(10):24-28.
5. Centers for Disease Control and Prevention. CDC fall prevention activities: research studies. CDC Web site. Available at: www.cdc.gov/ncipc/duip/FallsPreventionActivity.htm. Last accessed March 13, 2007.
6. Wald H, Huddleston J, Kramer A. Is there a geriatrician in the house? Geriatric care approaches in hospitalist programs. J Hosp Med. 2006 Jan;1(1):29-35.

These days you’re just as likely to find Jeffrey Krebs, MD, FACP, in front of a camera as behind a stethoscope. And his patients are as likely to see him in a movie theater as they are by their hospital beds.

That’s because the San Diego hospitalist has a schedule that allows him to build an acting career without giving up the patient care he loves. But don’t expect to see him playing a physician. The youthful-looking 46-year-old doesn’t match Hollywood’s “Marcus Welby, MD” image. He’s usually only considered for resident or intern roles despite almost two decades of experience working in medicine. “I’ve been a physician for more than 17 years, and yet I don’t look like a doctor, casting directors tell me,” he says.

From Dabbling to Passion

Dr. Krebs has been dabbling in acting since he was a resident, but it wasn’t until he became a hospitalist last year that made his acting passion a priority. He first became interested in acting in 1989 while he interned at Cedars-Sinai Medical Center in Los Angeles. Frequent contact with celebrity patients led to the offer of a role as an extra in the movie “Heart Condition,” (1990) a comedy starring Denzel Washington and Bob Hoskins.

“I thought it would be fun,” Dr. Krebs says. “Because they were filming in a restaurant a couple of miles from the hospital, it was convenient.”

The day he spent on the set in his non-speaking role taught him how things are done in Hollywood. Even though his efforts ended up on the cutting-room floor, the experience sparked a passion for acting that has grown stronger every year.

After completing his internal medicine residency in Los Angeles in 1989, Dr. Krebs moved to San Diego to become a primary care physician at Kaiser Permanente San Diego Medical Center. He found an acting teacher who held classes in San Diego on Sundays and began developing his craft.

Despite the demands of his work as a busy primary care physician, Dr. Krebs has racked up an impressive list of film and TV credits through the years. He was cast as a softball attendant in the martial arts film “3 Ninjas: High Noon at Mega Mountain,” (1998) the last of the “tween” movie “3 Ninjas” series. He played Agent Hans in “The English Job” (2006), a food critic in “Single White Female 2: The Psycho” (2005), a computer programmer in “Form 3254-A” (2005), and a young doctor in “True Vinyl” (2000), a romantic musical movie.

He has also performed in local theater, appearing in “Intrusion,” “Hypocrisy,” “Prelude to a Kiss,” “Apres Opera,” and “Ignoto’s Farewell” in San Diego, where he was often recognized by patients and colleagues.

Time for a Change

But the last-minute demands of an actor have conflicted frequently with his responsibilities as a physician. “I would be cast in a film and then not hear from the casting director for months,” Dr. Krebs explains. “Then the travel department could call one day and tell me I had to be on the out-of-town set in three days. There were times when I had to turn down a role because I won’t put my patients’ health on hold to do a film. I began to realize that if I really wanted to make a go of my acting, I needed to make some changes in my life.”

An opportunity presented itself last year when Kaiser Permanente in San Diego created two nocturnist positions for hospitalists. When Dr. Krebs heard about the positions, he quickly applied. “I thought that was perfect because all the auditions and filming happen during the day, and I could attend them if I worked at night,” he explains.

Dr. Krebs and another physician work 12-hour shifts beginning at 6 p.m. three times a week. For Dr. Krebs it’s Sunday through Tuesday nights. When his shift ends Wednesday morning, he drives the 125 miles from San Diego to his apartment in Los Angeles, catches some sleep, then assumes the role of Hollywood actor.

From Wednesday through Saturday, you might find him auditioning, taking acting classes, filming on location, doing the behind-the-scenes business of an aspiring actor, or attending a Hollywood party to network. On Sunday afternoon, he returns to the hospital in San Diego to begin another round of night shifts.

“Sometimes I can put in a 31-hour day if I have an audition in Los Angeles on Wednesday afternoon after my shift in San Diego Tuesday night,” he says. “Then I’ll be running on adrenaline, but it’s worth it.”

Balanced from the Beginning

A Southern California native, Dr. Krebs grew up near Disneyland, where he played clarinet during the bicentennial parade there in 1976. He knew he wanted to be a doctor when he was 7 years old. His grandfather was an optometrist, and Dr. Krebs spent many of his school holidays talking happily to his grandfather’s office patients.

Dr. Krebs graduated with honors from the University of California at Davis and received a medical degree from the University of California, San Diego, School of Medicine. He has been honored by Kaiser Permanente Medical Group with its Distinguished Service Award, its Everyday Hero Award, and its Primary Care Leadership Recognition Award.

Dr. Krebs says being a physician and an actor creates the perfect balance between his right and left brains: “The analytical side of my brain is satisfied by medicine, and my creative side is satisfied by being able to immerse myself in acting on my days off. It’s a perfect balance for me.”

Patients benefit from this balance, Dr. Krebs believes, because he brings to his job the increased empathy he’s developed as an actor. “My acting has absolutely enhanced my relationships with patients,” he says. “Acting requires developing intense listening skills. I’ve become a much better listener. Acting also requires you to focus on what the other person is saying, and that has helped me really focus on what patients tell me.”

Conversely, being a physician has helped him with his acting.

“Physicians are trained observers. Medicine has helped me become a better observer of people’s mannerisms and what they say about their character,” he explains. “And that training in observation makes me better able to relate to other actors.”

Two different careers also fulfill two different aspects of his personality.

“I’m a bit of a ham, although I don’t ham it up in my acting,” admits Dr. Krebs. “I like being noticed. In acting, it’s all about me, so I’m on the receiving end. But when I’m a physician, it’s never about me; it’s about the patient. So I’m the giver. I like that because it balances my life.”

Dr. Krebs played Dolph Lundgren’s brother, Jeff, in “Missionary Man.”

Win-Win Situation

Dr. Krebs isn’t the only one satisfied with his nocturnist position. It’s also “a win, win, win situation for the hospital,” says Ted Geer, MD, chief of internal medicine at Kaiser Permanente San Diego Medical Center.

“Administratively it’s great because there aren’t as many shifts that have to be covered by other physicians,” Dr. Geer explains. “It’s win-win for patients and the emergency room because we have more physicians who are up all night to help.”

While many hospitalists use their off hours to pursue hobbies, it’s unusual for them to have another profession. “It’s a credit to him that he’s able to have a second career,” says Dr. Geer.

Dr. Krebs is a well-respected clinician and a good internist, according to Dr. Geer. “His skills as an internist make him fit into this role very well,” says Dr. Geer. “He takes very good care of his patients.”

Overlapping Worlds

Dr. Krebs says his medical colleagues get a kick out of his acting career. “Many of their children own the “3 Ninjas” movie. They tell me they have spotted me in the film while watching it with their kids,” he says.

Actors are surprised when they find out about his medical career. Although Dr. Krebs doesn’t volunteer the information that he’s a physician, he’ll tell others in the film industry when asked. “I want to keep my two worlds separate, but I am proud of who I am and what I do as a physician.”

Sometimes those two worlds overlap. When Dr. Krebs was cast in “True Vinyl,” “The casting director asked me what I did in my off hours and, when I said I was a physician, he said, ‘OK, so you’re the doctor in the film.’ ”

For that movie, Dr. Krebs also served as the medical consultant, ensuring the medical scenes were accurate.

Even though he enjoyed the experience, Dr. Krebs doesn’t want to pursue more medical consultant opportunities; acting is his passion. “When I’m on the set, I’m an actor and that’s what I want to be,” he says.

Can Do

It takes a focused, high-energy person to succeed as a physician and an actor. Dr. Krebs keeps his stamina high by making his health a priority. He exercises almost every day, eats right, and surrounds himself with positive people. “I have always been a high-energy person; I’m never depressed and always look at the positive side of any situation,” he says.

He credits his parents with instilling in him an optimistic view of life. “They told us we could be anybody and do anything we wanted,” he recalls. “When I was told that I couldn’t compete at a high level in figure skating and go to medical school, I thought, ‘My parents said I could do anything I wanted and I want to do this,’ so I did.”

It may have been his figure-skating background that gave Dr. Krebs the fearlessness required of a successful actor, according to his manager, Fritz Friedman.

“He’s willing to take chances,” notes Friedman. “It’s a fearsome thing to take those leaps in skating that seem so effortless. The risk he takes, as all actors do, is that he will look foolish. But actors don’t care. They try and hope their bodies will listen to their brains.”

Friedman says Dr. Krebs’ acting style is dramatic and intense: “I think he has capabilities of comedic roles but they haven’t been offered to him yet,” he says. “I think, given the right opportunity, he’d be terrific at that. Jeff has a very strong on-screen presence. When he’s on screen, people focus on him. He’s charismatic.”

And That’s Not All He Does …

In his free time, Dr. Krebs loves to cook, travel, and take photographs. He entertains his friends with a meal made from scratch at least once a month and has hired chefs from local restaurants to teach him advanced cooking techniques. In October, he’s going to Tuscany to indulge all three passions with Italian culinary classes, travel, and photography.

With two careers and many interests, Dr. Krebs sometimes finds it hard to get enough sleep. Although he would like to take singing lessons and French classes, that’s more than he can handle right now. “Sleep has to be a priority so I can continue to make good medical decisions,” he says. And he admits that getting his laundry done “is one of my biggest challenges in life.”

Dr. Krebs recently focused his acting career on film and television, giving up theater. “Acting in plays is harder—if not impossible—with my new life as a nocturnist,” he says. Theater requires months of rehearsals, held in the daytime during the week. But choosing film was an easy choice. “I like watching myself on film so that I can learn from it,” he says.

Dr. Krebs says his favorite roles have been “any in which I can learn something new or develop a new aspect of myself.” In a film to be released this spring, “Half Past Dead II: Justified,” he plays an inmate at a maximum-security prison. “That was a stretch because I had to tap into my inner serial killer. Sometimes the roles that I play are in conflict with who I am,” he explains. “You learn that everyone has every possibility inside of them, and you have to tap into that.”

He does this by developing the back story, which in this case meant creating a character who had done something bad enough to be in Alcatraz. The film’s director called Dr. Krebs recently to praise his efforts.

In March, Dr. Krebs was in Dallas filming “Missionary Man,” starring Dolph Lundgren. It is a Western-style movie involving “revenge and redemption at the end of a gun barrel.” In the film, Dr. Krebs plays Lundgren’s brother; the character’s name was changed to Jeff. “Imagine having a character named after me,” Dr. Krebs exclaims.

The Perfect Combination

What would happen if Dr. Krebs landed a major film role or a long-term television series? Would he give up medicine to become star of the next “ER” or “Grey’s Anatomy”? Not if it meant giving up his medical career, he says.

“It would be very difficult for me to give up medicine completely because I really love being a physician,” Dr. Krebs admits. “I might take a leave for a month or two if a big film opportunity came along. But right now I’m happy with the roles I’m getting that allow me to continue my medical career.”

Dr. Krebs says he could not have been the kind of actor he is and practice the kind of medicine he wants to practice without being a hospitalist, and he’s grateful for the opportunity.

“I’m so happy the hospitalist movement has taken off in the last several years,” he says. “My life is much, much better since I became a hospitalist. I feel like I have it all.” TH

Barbara Dillard is a medical journalist based in Chicago.

These days you’re just as likely to find Jeffrey Krebs, MD, FACP, in front of a camera as behind a stethoscope. And his patients are as likely to see him in a movie theater as they are by their hospital beds.

That’s because the San Diego hospitalist has a schedule that allows him to build an acting career without giving up the patient care he loves. But don’t expect to see him playing a physician. The youthful-looking 46-year-old doesn’t match Hollywood’s “Marcus Welby, MD” image. He’s usually only considered for resident or intern roles despite almost two decades of experience working in medicine. “I’ve been a physician for more than 17 years, and yet I don’t look like a doctor, casting directors tell me,” he says.

From Dabbling to Passion

Dr. Krebs has been dabbling in acting since he was a resident, but it wasn’t until he became a hospitalist last year that made his acting passion a priority. He first became interested in acting in 1989 while he interned at Cedars-Sinai Medical Center in Los Angeles. Frequent contact with celebrity patients led to the offer of a role as an extra in the movie “Heart Condition,” (1990) a comedy starring Denzel Washington and Bob Hoskins.

“I thought it would be fun,” Dr. Krebs says. “Because they were filming in a restaurant a couple of miles from the hospital, it was convenient.”

The day he spent on the set in his non-speaking role taught him how things are done in Hollywood. Even though his efforts ended up on the cutting-room floor, the experience sparked a passion for acting that has grown stronger every year.

After completing his internal medicine residency in Los Angeles in 1989, Dr. Krebs moved to San Diego to become a primary care physician at Kaiser Permanente San Diego Medical Center. He found an acting teacher who held classes in San Diego on Sundays and began developing his craft.

Despite the demands of his work as a busy primary care physician, Dr. Krebs has racked up an impressive list of film and TV credits through the years. He was cast as a softball attendant in the martial arts film “3 Ninjas: High Noon at Mega Mountain,” (1998) the last of the “tween” movie “3 Ninjas” series. He played Agent Hans in “The English Job” (2006), a food critic in “Single White Female 2: The Psycho” (2005), a computer programmer in “Form 3254-A” (2005), and a young doctor in “True Vinyl” (2000), a romantic musical movie.

He has also performed in local theater, appearing in “Intrusion,” “Hypocrisy,” “Prelude to a Kiss,” “Apres Opera,” and “Ignoto’s Farewell” in San Diego, where he was often recognized by patients and colleagues.

Time for a Change

But the last-minute demands of an actor have conflicted frequently with his responsibilities as a physician. “I would be cast in a film and then not hear from the casting director for months,” Dr. Krebs explains. “Then the travel department could call one day and tell me I had to be on the out-of-town set in three days. There were times when I had to turn down a role because I won’t put my patients’ health on hold to do a film. I began to realize that if I really wanted to make a go of my acting, I needed to make some changes in my life.”

An opportunity presented itself last year when Kaiser Permanente in San Diego created two nocturnist positions for hospitalists. When Dr. Krebs heard about the positions, he quickly applied. “I thought that was perfect because all the auditions and filming happen during the day, and I could attend them if I worked at night,” he explains.

Dr. Krebs and another physician work 12-hour shifts beginning at 6 p.m. three times a week. For Dr. Krebs it’s Sunday through Tuesday nights. When his shift ends Wednesday morning, he drives the 125 miles from San Diego to his apartment in Los Angeles, catches some sleep, then assumes the role of Hollywood actor.

From Wednesday through Saturday, you might find him auditioning, taking acting classes, filming on location, doing the behind-the-scenes business of an aspiring actor, or attending a Hollywood party to network. On Sunday afternoon, he returns to the hospital in San Diego to begin another round of night shifts.

“Sometimes I can put in a 31-hour day if I have an audition in Los Angeles on Wednesday afternoon after my shift in San Diego Tuesday night,” he says. “Then I’ll be running on adrenaline, but it’s worth it.”

Balanced from the Beginning

A Southern California native, Dr. Krebs grew up near Disneyland, where he played clarinet during the bicentennial parade there in 1976. He knew he wanted to be a doctor when he was 7 years old. His grandfather was an optometrist, and Dr. Krebs spent many of his school holidays talking happily to his grandfather’s office patients.

Dr. Krebs graduated with honors from the University of California at Davis and received a medical degree from the University of California, San Diego, School of Medicine. He has been honored by Kaiser Permanente Medical Group with its Distinguished Service Award, its Everyday Hero Award, and its Primary Care Leadership Recognition Award.

Dr. Krebs says being a physician and an actor creates the perfect balance between his right and left brains: “The analytical side of my brain is satisfied by medicine, and my creative side is satisfied by being able to immerse myself in acting on my days off. It’s a perfect balance for me.”

Patients benefit from this balance, Dr. Krebs believes, because he brings to his job the increased empathy he’s developed as an actor. “My acting has absolutely enhanced my relationships with patients,” he says. “Acting requires developing intense listening skills. I’ve become a much better listener. Acting also requires you to focus on what the other person is saying, and that has helped me really focus on what patients tell me.”

Conversely, being a physician has helped him with his acting.

“Physicians are trained observers. Medicine has helped me become a better observer of people’s mannerisms and what they say about their character,” he explains. “And that training in observation makes me better able to relate to other actors.”

Two different careers also fulfill two different aspects of his personality.

“I’m a bit of a ham, although I don’t ham it up in my acting,” admits Dr. Krebs. “I like being noticed. In acting, it’s all about me, so I’m on the receiving end. But when I’m a physician, it’s never about me; it’s about the patient. So I’m the giver. I like that because it balances my life.”

Dr. Krebs played Dolph Lundgren’s brother, Jeff, in “Missionary Man.”

Win-Win Situation

Dr. Krebs isn’t the only one satisfied with his nocturnist position. It’s also “a win, win, win situation for the hospital,” says Ted Geer, MD, chief of internal medicine at Kaiser Permanente San Diego Medical Center.

“Administratively it’s great because there aren’t as many shifts that have to be covered by other physicians,” Dr. Geer explains. “It’s win-win for patients and the emergency room because we have more physicians who are up all night to help.”

While many hospitalists use their off hours to pursue hobbies, it’s unusual for them to have another profession. “It’s a credit to him that he’s able to have a second career,” says Dr. Geer.

Dr. Krebs is a well-respected clinician and a good internist, according to Dr. Geer. “His skills as an internist make him fit into this role very well,” says Dr. Geer. “He takes very good care of his patients.”

Overlapping Worlds

Dr. Krebs says his medical colleagues get a kick out of his acting career. “Many of their children own the “3 Ninjas” movie. They tell me they have spotted me in the film while watching it with their kids,” he says.

Actors are surprised when they find out about his medical career. Although Dr. Krebs doesn’t volunteer the information that he’s a physician, he’ll tell others in the film industry when asked. “I want to keep my two worlds separate, but I am proud of who I am and what I do as a physician.”

Sometimes those two worlds overlap. When Dr. Krebs was cast in “True Vinyl,” “The casting director asked me what I did in my off hours and, when I said I was a physician, he said, ‘OK, so you’re the doctor in the film.’ ”

For that movie, Dr. Krebs also served as the medical consultant, ensuring the medical scenes were accurate.

Even though he enjoyed the experience, Dr. Krebs doesn’t want to pursue more medical consultant opportunities; acting is his passion. “When I’m on the set, I’m an actor and that’s what I want to be,” he says.

Can Do

It takes a focused, high-energy person to succeed as a physician and an actor. Dr. Krebs keeps his stamina high by making his health a priority. He exercises almost every day, eats right, and surrounds himself with positive people. “I have always been a high-energy person; I’m never depressed and always look at the positive side of any situation,” he says.

He credits his parents with instilling in him an optimistic view of life. “They told us we could be anybody and do anything we wanted,” he recalls. “When I was told that I couldn’t compete at a high level in figure skating and go to medical school, I thought, ‘My parents said I could do anything I wanted and I want to do this,’ so I did.”

It may have been his figure-skating background that gave Dr. Krebs the fearlessness required of a successful actor, according to his manager, Fritz Friedman.

“He’s willing to take chances,” notes Friedman. “It’s a fearsome thing to take those leaps in skating that seem so effortless. The risk he takes, as all actors do, is that he will look foolish. But actors don’t care. They try and hope their bodies will listen to their brains.”

Friedman says Dr. Krebs’ acting style is dramatic and intense: “I think he has capabilities of comedic roles but they haven’t been offered to him yet,” he says. “I think, given the right opportunity, he’d be terrific at that. Jeff has a very strong on-screen presence. When he’s on screen, people focus on him. He’s charismatic.”

And That’s Not All He Does …

In his free time, Dr. Krebs loves to cook, travel, and take photographs. He entertains his friends with a meal made from scratch at least once a month and has hired chefs from local restaurants to teach him advanced cooking techniques. In October, he’s going to Tuscany to indulge all three passions with Italian culinary classes, travel, and photography.

With two careers and many interests, Dr. Krebs sometimes finds it hard to get enough sleep. Although he would like to take singing lessons and French classes, that’s more than he can handle right now. “Sleep has to be a priority so I can continue to make good medical decisions,” he says. And he admits that getting his laundry done “is one of my biggest challenges in life.”

Dr. Krebs recently focused his acting career on film and television, giving up theater. “Acting in plays is harder—if not impossible—with my new life as a nocturnist,” he says. Theater requires months of rehearsals, held in the daytime during the week. But choosing film was an easy choice. “I like watching myself on film so that I can learn from it,” he says.

Dr. Krebs says his favorite roles have been “any in which I can learn something new or develop a new aspect of myself.” In a film to be released this spring, “Half Past Dead II: Justified,” he plays an inmate at a maximum-security prison. “That was a stretch because I had to tap into my inner serial killer. Sometimes the roles that I play are in conflict with who I am,” he explains. “You learn that everyone has every possibility inside of them, and you have to tap into that.”

He does this by developing the back story, which in this case meant creating a character who had done something bad enough to be in Alcatraz. The film’s director called Dr. Krebs recently to praise his efforts.

In March, Dr. Krebs was in Dallas filming “Missionary Man,” starring Dolph Lundgren. It is a Western-style movie involving “revenge and redemption at the end of a gun barrel.” In the film, Dr. Krebs plays Lundgren’s brother; the character’s name was changed to Jeff. “Imagine having a character named after me,” Dr. Krebs exclaims.

The Perfect Combination

What would happen if Dr. Krebs landed a major film role or a long-term television series? Would he give up medicine to become star of the next “ER” or “Grey’s Anatomy”? Not if it meant giving up his medical career, he says.

“It would be very difficult for me to give up medicine completely because I really love being a physician,” Dr. Krebs admits. “I might take a leave for a month or two if a big film opportunity came along. But right now I’m happy with the roles I’m getting that allow me to continue my medical career.”

Dr. Krebs says he could not have been the kind of actor he is and practice the kind of medicine he wants to practice without being a hospitalist, and he’s grateful for the opportunity.

“I’m so happy the hospitalist movement has taken off in the last several years,” he says. “My life is much, much better since I became a hospitalist. I feel like I have it all.” TH

Barbara Dillard is a medical journalist based in Chicago.

These days you’re just as likely to find Jeffrey Krebs, MD, FACP, in front of a camera as behind a stethoscope. And his patients are as likely to see him in a movie theater as they are by their hospital beds.

That’s because the San Diego hospitalist has a schedule that allows him to build an acting career without giving up the patient care he loves. But don’t expect to see him playing a physician. The youthful-looking 46-year-old doesn’t match Hollywood’s “Marcus Welby, MD” image. He’s usually only considered for resident or intern roles despite almost two decades of experience working in medicine. “I’ve been a physician for more than 17 years, and yet I don’t look like a doctor, casting directors tell me,” he says.

From Dabbling to Passion

Dr. Krebs has been dabbling in acting since he was a resident, but it wasn’t until he became a hospitalist last year that made his acting passion a priority. He first became interested in acting in 1989 while he interned at Cedars-Sinai Medical Center in Los Angeles. Frequent contact with celebrity patients led to the offer of a role as an extra in the movie “Heart Condition,” (1990) a comedy starring Denzel Washington and Bob Hoskins.

“I thought it would be fun,” Dr. Krebs says. “Because they were filming in a restaurant a couple of miles from the hospital, it was convenient.”

The day he spent on the set in his non-speaking role taught him how things are done in Hollywood. Even though his efforts ended up on the cutting-room floor, the experience sparked a passion for acting that has grown stronger every year.

After completing his internal medicine residency in Los Angeles in 1989, Dr. Krebs moved to San Diego to become a primary care physician at Kaiser Permanente San Diego Medical Center. He found an acting teacher who held classes in San Diego on Sundays and began developing his craft.

Despite the demands of his work as a busy primary care physician, Dr. Krebs has racked up an impressive list of film and TV credits through the years. He was cast as a softball attendant in the martial arts film “3 Ninjas: High Noon at Mega Mountain,” (1998) the last of the “tween” movie “3 Ninjas” series. He played Agent Hans in “The English Job” (2006), a food critic in “Single White Female 2: The Psycho” (2005), a computer programmer in “Form 3254-A” (2005), and a young doctor in “True Vinyl” (2000), a romantic musical movie.

He has also performed in local theater, appearing in “Intrusion,” “Hypocrisy,” “Prelude to a Kiss,” “Apres Opera,” and “Ignoto’s Farewell” in San Diego, where he was often recognized by patients and colleagues.

Time for a Change

But the last-minute demands of an actor have conflicted frequently with his responsibilities as a physician. “I would be cast in a film and then not hear from the casting director for months,” Dr. Krebs explains. “Then the travel department could call one day and tell me I had to be on the out-of-town set in three days. There were times when I had to turn down a role because I won’t put my patients’ health on hold to do a film. I began to realize that if I really wanted to make a go of my acting, I needed to make some changes in my life.”

An opportunity presented itself last year when Kaiser Permanente in San Diego created two nocturnist positions for hospitalists. When Dr. Krebs heard about the positions, he quickly applied. “I thought that was perfect because all the auditions and filming happen during the day, and I could attend them if I worked at night,” he explains.

Dr. Krebs and another physician work 12-hour shifts beginning at 6 p.m. three times a week. For Dr. Krebs it’s Sunday through Tuesday nights. When his shift ends Wednesday morning, he drives the 125 miles from San Diego to his apartment in Los Angeles, catches some sleep, then assumes the role of Hollywood actor.

From Wednesday through Saturday, you might find him auditioning, taking acting classes, filming on location, doing the behind-the-scenes business of an aspiring actor, or attending a Hollywood party to network. On Sunday afternoon, he returns to the hospital in San Diego to begin another round of night shifts.

“Sometimes I can put in a 31-hour day if I have an audition in Los Angeles on Wednesday afternoon after my shift in San Diego Tuesday night,” he says. “Then I’ll be running on adrenaline, but it’s worth it.”

Balanced from the Beginning

A Southern California native, Dr. Krebs grew up near Disneyland, where he played clarinet during the bicentennial parade there in 1976. He knew he wanted to be a doctor when he was 7 years old. His grandfather was an optometrist, and Dr. Krebs spent many of his school holidays talking happily to his grandfather’s office patients.

Dr. Krebs graduated with honors from the University of California at Davis and received a medical degree from the University of California, San Diego, School of Medicine. He has been honored by Kaiser Permanente Medical Group with its Distinguished Service Award, its Everyday Hero Award, and its Primary Care Leadership Recognition Award.

Dr. Krebs says being a physician and an actor creates the perfect balance between his right and left brains: “The analytical side of my brain is satisfied by medicine, and my creative side is satisfied by being able to immerse myself in acting on my days off. It’s a perfect balance for me.”

Patients benefit from this balance, Dr. Krebs believes, because he brings to his job the increased empathy he’s developed as an actor. “My acting has absolutely enhanced my relationships with patients,” he says. “Acting requires developing intense listening skills. I’ve become a much better listener. Acting also requires you to focus on what the other person is saying, and that has helped me really focus on what patients tell me.”

Conversely, being a physician has helped him with his acting.

“Physicians are trained observers. Medicine has helped me become a better observer of people’s mannerisms and what they say about their character,” he explains. “And that training in observation makes me better able to relate to other actors.”

Two different careers also fulfill two different aspects of his personality.

“I’m a bit of a ham, although I don’t ham it up in my acting,” admits Dr. Krebs. “I like being noticed. In acting, it’s all about me, so I’m on the receiving end. But when I’m a physician, it’s never about me; it’s about the patient. So I’m the giver. I like that because it balances my life.”

Dr. Krebs played Dolph Lundgren’s brother, Jeff, in “Missionary Man.”

Win-Win Situation

Dr. Krebs isn’t the only one satisfied with his nocturnist position. It’s also “a win, win, win situation for the hospital,” says Ted Geer, MD, chief of internal medicine at Kaiser Permanente San Diego Medical Center.

“Administratively it’s great because there aren’t as many shifts that have to be covered by other physicians,” Dr. Geer explains. “It’s win-win for patients and the emergency room because we have more physicians who are up all night to help.”

While many hospitalists use their off hours to pursue hobbies, it’s unusual for them to have another profession. “It’s a credit to him that he’s able to have a second career,” says Dr. Geer.

Dr. Krebs is a well-respected clinician and a good internist, according to Dr. Geer. “His skills as an internist make him fit into this role very well,” says Dr. Geer. “He takes very good care of his patients.”

Overlapping Worlds

Dr. Krebs says his medical colleagues get a kick out of his acting career. “Many of their children own the “3 Ninjas” movie. They tell me they have spotted me in the film while watching it with their kids,” he says.

Actors are surprised when they find out about his medical career. Although Dr. Krebs doesn’t volunteer the information that he’s a physician, he’ll tell others in the film industry when asked. “I want to keep my two worlds separate, but I am proud of who I am and what I do as a physician.”

Sometimes those two worlds overlap. When Dr. Krebs was cast in “True Vinyl,” “The casting director asked me what I did in my off hours and, when I said I was a physician, he said, ‘OK, so you’re the doctor in the film.’ ”

For that movie, Dr. Krebs also served as the medical consultant, ensuring the medical scenes were accurate.

Even though he enjoyed the experience, Dr. Krebs doesn’t want to pursue more medical consultant opportunities; acting is his passion. “When I’m on the set, I’m an actor and that’s what I want to be,” he says.

Can Do

It takes a focused, high-energy person to succeed as a physician and an actor. Dr. Krebs keeps his stamina high by making his health a priority. He exercises almost every day, eats right, and surrounds himself with positive people. “I have always been a high-energy person; I’m never depressed and always look at the positive side of any situation,” he says.

He credits his parents with instilling in him an optimistic view of life. “They told us we could be anybody and do anything we wanted,” he recalls. “When I was told that I couldn’t compete at a high level in figure skating and go to medical school, I thought, ‘My parents said I could do anything I wanted and I want to do this,’ so I did.”

It may have been his figure-skating background that gave Dr. Krebs the fearlessness required of a successful actor, according to his manager, Fritz Friedman.

“He’s willing to take chances,” notes Friedman. “It’s a fearsome thing to take those leaps in skating that seem so effortless. The risk he takes, as all actors do, is that he will look foolish. But actors don’t care. They try and hope their bodies will listen to their brains.”

Friedman says Dr. Krebs’ acting style is dramatic and intense: “I think he has capabilities of comedic roles but they haven’t been offered to him yet,” he says. “I think, given the right opportunity, he’d be terrific at that. Jeff has a very strong on-screen presence. When he’s on screen, people focus on him. He’s charismatic.”

And That’s Not All He Does …

In his free time, Dr. Krebs loves to cook, travel, and take photographs. He entertains his friends with a meal made from scratch at least once a month and has hired chefs from local restaurants to teach him advanced cooking techniques. In October, he’s going to Tuscany to indulge all three passions with Italian culinary classes, travel, and photography.

With two careers and many interests, Dr. Krebs sometimes finds it hard to get enough sleep. Although he would like to take singing lessons and French classes, that’s more than he can handle right now. “Sleep has to be a priority so I can continue to make good medical decisions,” he says. And he admits that getting his laundry done “is one of my biggest challenges in life.”

Dr. Krebs recently focused his acting career on film and television, giving up theater. “Acting in plays is harder—if not impossible—with my new life as a nocturnist,” he says. Theater requires months of rehearsals, held in the daytime during the week. But choosing film was an easy choice. “I like watching myself on film so that I can learn from it,” he says.

Dr. Krebs says his favorite roles have been “any in which I can learn something new or develop a new aspect of myself.” In a film to be released this spring, “Half Past Dead II: Justified,” he plays an inmate at a maximum-security prison. “That was a stretch because I had to tap into my inner serial killer. Sometimes the roles that I play are in conflict with who I am,” he explains. “You learn that everyone has every possibility inside of them, and you have to tap into that.”

He does this by developing the back story, which in this case meant creating a character who had done something bad enough to be in Alcatraz. The film’s director called Dr. Krebs recently to praise his efforts.

In March, Dr. Krebs was in Dallas filming “Missionary Man,” starring Dolph Lundgren. It is a Western-style movie involving “revenge and redemption at the end of a gun barrel.” In the film, Dr. Krebs plays Lundgren’s brother; the character’s name was changed to Jeff. “Imagine having a character named after me,” Dr. Krebs exclaims.

The Perfect Combination

What would happen if Dr. Krebs landed a major film role or a long-term television series? Would he give up medicine to become star of the next “ER” or “Grey’s Anatomy”? Not if it meant giving up his medical career, he says.

“It would be very difficult for me to give up medicine completely because I really love being a physician,” Dr. Krebs admits. “I might take a leave for a month or two if a big film opportunity came along. But right now I’m happy with the roles I’m getting that allow me to continue my medical career.”

Dr. Krebs says he could not have been the kind of actor he is and practice the kind of medicine he wants to practice without being a hospitalist, and he’s grateful for the opportunity.

“I’m so happy the hospitalist movement has taken off in the last several years,” he says. “My life is much, much better since I became a hospitalist. I feel like I have it all.” TH

Barbara Dillard is a medical journalist based in Chicago.

Whether obligatory or voluntary, service on committees is a reality for most hospitalists. “The 2005-2006 SHM Survey: State of the Hospital Medicine Movement” found that, for 92% of respondents, committee participation topped the list of non-clinical activities.1 Hospital medicine group leaders, consultants, and administrators interviewed for this article say time-pressed hospitalists must become more effective committee participants.

Civic Duty or Career Advancement?

Because of growing presence at the hospital and their knowledge of hospital operations, hospitalists are a logical choice for committee assignments. These can range from committees dedicated to care delivery (e.g., pharmacy and therapeutics) to the hospital board’s governance committees.

“Hospitalists, with their perspective of hospital operations and clinical care, could be a great part of broadening the perspective of the board, informing their decision-making and helping them to formulate policies,” says John Combes, MD, president of the Center for Healthcare Governance in Chicago, a subsidiary committee of the American Hospital Association.

Mark V. Williams, MD, professor of medicine and director, Emory Hospital Medicine Unit in Atlanta, and editor in chief of the Journal of Hospital Medicine, does not consider committee participation optional.

“I strongly encourage—if not almost require—all of the hospitalists in our group to be involved in at least one committee,” says Dr. Williams. “My belief is that hospitalists are integral to the functioning of the hospital, and as part of their responsibility, they need to be actively involved in committee work to move projects forward.”

Leslie Flores, MHA, co-principal of Nelson/Flores Associates, LLC, agrees. “It’s in the hospitalists’ best interest to be involved in committees,” she says. “Hospitalists are often in the best position to see what needs to be fixed, and they have the potential to have a significant impact on how effectively their hospital operates, which can make their own jobs easier.”

Further, she points out, “If the hospital, which is financially supporting them, is more successful and effective, there’s likely to be less financial pressure on their practice.”

Hospitalists’ perceptions about committee participation can be influenced by each hospitalist’s employment model. If one is working directly for the hospital and giving 110% to that employer, being asked to volunteer additional time to serve on a committee might be viewed as a burden. On the other hand, an independent hospital medicine group (HMG) contracting with the hospital to deliver services may view committee participation as an avenue for ensuring the group’s success. Whatever the employment model, and whatever the career goals of individual hospitalists, it often pays to target one’s participation in committees.

Make Participation Count

Hospitalists will be playing more key roles in medical staff leadership, according to William D. Atchley Jr., MD, medical director of the Division of Hospital Medicine for Sentara Medical Group in Hampton, Va. His concern is that hospitalists will be asked to serve on more than one or two committees. He advises younger hospitalists to notify the president of the medical staff of which committees they would be interested in working on. Dr. Atchley is also a member of the SHM Board of Directors.

“It could be peer review, performance improvement, or ad hoc committees focused on developing evidence-based order sets, improving through-put or disaster preparedness,” says Dr. Atchley. Whatever the pick, “it should be something that they’re going to find enjoyable and that they feel will advance their stature within the hospital.”

To be an effective member of a hospital board committee, a hospitalist must represent the greater interests of all stakeholders—not just his or her own self-interest, cautions Dr. Combes. However, “as physicians become more stressed and production-oriented, giving up clinical time to participate in governance activities becomes more and more difficult,” he concedes. Hospitalists should choose committee assignments based on their interests and expertise.

Dr. Williams encourages hospitalists in his group to pick one committee—preferably one focused on care delivery (quality improvement, pharmacy and therapeutics, utilization review) and take an active role. “Then, over time, I encourage them to try to chair committees to obtain leadership experience,” he says.

Taking on too many extracurricular committee tasks can be counterproductive. To avoid this, Flores advises younger hospitalists to ask themselves the following:

• What will my committee participation do to support the goals of the committee and the organization?
• By participating in this committee, can I expand my own knowledge or understanding of the culture and politics of the organization?
• Can I become more comfortable interacting on an organizational level?
• Can I network and get to know people I wouldn’t otherwise encounter, who can be helpful to me personally?

In addition, Dr. Atchley believes rotating committee assignments is also beneficial, especially for the younger hospitalist. In his tenure as a hospitalist, Dr. Atchley has served as chairman of the Department of Medicine’s credentials and quality assurance committees, and as vice president of the medical staff. Each committee furnishes hospitalists with a different perspective about how the hospital functions.

“I think hospitalists should understand the medical staff bylaws and procedures,” says Dr. Atchley. “Each hospital medicine staff has this governance structure, and I have found it beneficial in resolving conflicts about patient care and interaction between physicians.”

Mary A. Dallas, MD, has seen the committee situation from both sides of the fence. She is medical information officer for Presbyterian Healthcare Services, an integrated healthcare delivery network in Albuquerque, N.M., but served as medical director of Presbyterian’s hospitalist group for five years before that.

“Hospitalists have a vested interest in making sure their work area is protected, so they need to plant some people in strategic places for the governance and medical staff,” says Dr. Dallas. “In order to be effective in the governance of the hospital, you have to be part of that medical substructure and get involved.”

For instance, as medical director, she sat on the hospital’s credential committee and found it allowed her to keep tabs on new HMG hires going through the credentialing process. “This [the hospital] is your work environment,” she explains. “You are here day in and day out, and you should shape that environment, have a say in policies and rules, so that you can make your job more successful and make patient care better.”

The Quandary over Compensation

Many hospitalists feel frustrated when committee obligations impinge on clinical duties. Is compensation the answer for filling committee slots? Opinions are mixed.

Dr. Williams says he is “a little uncomfortable with the concept of people getting paid every time they attend a committee meeting. For hospitalists who receive funding from the hospital to support their programs, it’s important for the leader [of the HMG] to ensure that they’re collaborating with hospital administration. The hospital has the expectation that, as part of our salary structure, we will be members of committees. That needs to be part of the job.”

Dr. Dallas agrees: “Regardless of whether you’re getting paid or not, this is your work environment. I think it’s very important to be involved, so that your voice is heard and so that you can help make the [hospital] structure better.”

Compensating physicians for their time does communicate that their time is valued and respected, says Dr. Combes, but payment does not necessarily guarantee a high level of committee members’ engagement. In addition, he says, if physicians are being compensated directly by the hospital for serving on committees, “this can threaten the perception of their objectivity, in terms of bringing an independent perspective to the board.” A better solution might be for the hospital medicine group to build its own compensation structure for non-clinical work so members retain independence when voicing opinions to the hospital board.

Dr. Atchley admits it’s sometimes a struggle to find people willing to serve on medical staff committees. He advocates compensation for those duties on a per-meeting or hourly basis. His hospital meets attendance requirements by giving credit to doctors who participate on selected medical staff committees.

Through her consulting assignments, Flores has observed that in some organizations where hospitalists are paid based on productivity, committee participation can be assigned a relative value unit so hospitalists are compensated on the same basis as for clinical work.

Flores concurs with Drs. Dallas and Williams: “In most organizations, a certain minimum level of participation in medical staff activities is expected of all staff members. I think that hospitalists should expect to do that to the same degree as other medical staff members, on a voluntary basis.

“If hospitalists truly want to impact how the medical staff and the hospital operate, and to be considered for high-level leadership positions, then their best way of becoming known and respected in the medical community is by participating on committees.” TH

Gretchen Henkel writes frequently for The Hospitalist.

Reference

1. SHM’s “2005-2006 Survey: State of the Hospital Medicine Movement, 2006.” Available online at www.hospitalmedicine.org Last accessed April 5, 2007.

Whether obligatory or voluntary, service on committees is a reality for most hospitalists. “The 2005-2006 SHM Survey: State of the Hospital Medicine Movement” found that, for 92% of respondents, committee participation topped the list of non-clinical activities.1 Hospital medicine group leaders, consultants, and administrators interviewed for this article say time-pressed hospitalists must become more effective committee participants.

Civic Duty or Career Advancement?

Because of growing presence at the hospital and their knowledge of hospital operations, hospitalists are a logical choice for committee assignments. These can range from committees dedicated to care delivery (e.g., pharmacy and therapeutics) to the hospital board’s governance committees.

“Hospitalists, with their perspective of hospital operations and clinical care, could be a great part of broadening the perspective of the board, informing their decision-making and helping them to formulate policies,” says John Combes, MD, president of the Center for Healthcare Governance in Chicago, a subsidiary committee of the American Hospital Association.

Mark V. Williams, MD, professor of medicine and director, Emory Hospital Medicine Unit in Atlanta, and editor in chief of the Journal of Hospital Medicine, does not consider committee participation optional.

“I strongly encourage—if not almost require—all of the hospitalists in our group to be involved in at least one committee,” says Dr. Williams. “My belief is that hospitalists are integral to the functioning of the hospital, and as part of their responsibility, they need to be actively involved in committee work to move projects forward.”

Leslie Flores, MHA, co-principal of Nelson/Flores Associates, LLC, agrees. “It’s in the hospitalists’ best interest to be involved in committees,” she says. “Hospitalists are often in the best position to see what needs to be fixed, and they have the potential to have a significant impact on how effectively their hospital operates, which can make their own jobs easier.”

Further, she points out, “If the hospital, which is financially supporting them, is more successful and effective, there’s likely to be less financial pressure on their practice.”

Hospitalists’ perceptions about committee participation can be influenced by each hospitalist’s employment model. If one is working directly for the hospital and giving 110% to that employer, being asked to volunteer additional time to serve on a committee might be viewed as a burden. On the other hand, an independent hospital medicine group (HMG) contracting with the hospital to deliver services may view committee participation as an avenue for ensuring the group’s success. Whatever the employment model, and whatever the career goals of individual hospitalists, it often pays to target one’s participation in committees.

Make Participation Count

Hospitalists will be playing more key roles in medical staff leadership, according to William D. Atchley Jr., MD, medical director of the Division of Hospital Medicine for Sentara Medical Group in Hampton, Va. His concern is that hospitalists will be asked to serve on more than one or two committees. He advises younger hospitalists to notify the president of the medical staff of which committees they would be interested in working on. Dr. Atchley is also a member of the SHM Board of Directors.

“It could be peer review, performance improvement, or ad hoc committees focused on developing evidence-based order sets, improving through-put or disaster preparedness,” says Dr. Atchley. Whatever the pick, “it should be something that they’re going to find enjoyable and that they feel will advance their stature within the hospital.”

To be an effective member of a hospital board committee, a hospitalist must represent the greater interests of all stakeholders—not just his or her own self-interest, cautions Dr. Combes. However, “as physicians become more stressed and production-oriented, giving up clinical time to participate in governance activities becomes more and more difficult,” he concedes. Hospitalists should choose committee assignments based on their interests and expertise.

Dr. Williams encourages hospitalists in his group to pick one committee—preferably one focused on care delivery (quality improvement, pharmacy and therapeutics, utilization review) and take an active role. “Then, over time, I encourage them to try to chair committees to obtain leadership experience,” he says.

Taking on too many extracurricular committee tasks can be counterproductive. To avoid this, Flores advises younger hospitalists to ask themselves the following:

• What will my committee participation do to support the goals of the committee and the organization?
• By participating in this committee, can I expand my own knowledge or understanding of the culture and politics of the organization?
• Can I become more comfortable interacting on an organizational level?
• Can I network and get to know people I wouldn’t otherwise encounter, who can be helpful to me personally?

In addition, Dr. Atchley believes rotating committee assignments is also beneficial, especially for the younger hospitalist. In his tenure as a hospitalist, Dr. Atchley has served as chairman of the Department of Medicine’s credentials and quality assurance committees, and as vice president of the medical staff. Each committee furnishes hospitalists with a different perspective about how the hospital functions.

“I think hospitalists should understand the medical staff bylaws and procedures,” says Dr. Atchley. “Each hospital medicine staff has this governance structure, and I have found it beneficial in resolving conflicts about patient care and interaction between physicians.”

Mary A. Dallas, MD, has seen the committee situation from both sides of the fence. She is medical information officer for Presbyterian Healthcare Services, an integrated healthcare delivery network in Albuquerque, N.M., but served as medical director of Presbyterian’s hospitalist group for five years before that.

“Hospitalists have a vested interest in making sure their work area is protected, so they need to plant some people in strategic places for the governance and medical staff,” says Dr. Dallas. “In order to be effective in the governance of the hospital, you have to be part of that medical substructure and get involved.”

For instance, as medical director, she sat on the hospital’s credential committee and found it allowed her to keep tabs on new HMG hires going through the credentialing process. “This [the hospital] is your work environment,” she explains. “You are here day in and day out, and you should shape that environment, have a say in policies and rules, so that you can make your job more successful and make patient care better.”

The Quandary over Compensation

Many hospitalists feel frustrated when committee obligations impinge on clinical duties. Is compensation the answer for filling committee slots? Opinions are mixed.

Dr. Williams says he is “a little uncomfortable with the concept of people getting paid every time they attend a committee meeting. For hospitalists who receive funding from the hospital to support their programs, it’s important for the leader [of the HMG] to ensure that they’re collaborating with hospital administration. The hospital has the expectation that, as part of our salary structure, we will be members of committees. That needs to be part of the job.”

Dr. Dallas agrees: “Regardless of whether you’re getting paid or not, this is your work environment. I think it’s very important to be involved, so that your voice is heard and so that you can help make the [hospital] structure better.”

Compensating physicians for their time does communicate that their time is valued and respected, says Dr. Combes, but payment does not necessarily guarantee a high level of committee members’ engagement. In addition, he says, if physicians are being compensated directly by the hospital for serving on committees, “this can threaten the perception of their objectivity, in terms of bringing an independent perspective to the board.” A better solution might be for the hospital medicine group to build its own compensation structure for non-clinical work so members retain independence when voicing opinions to the hospital board.

Dr. Atchley admits it’s sometimes a struggle to find people willing to serve on medical staff committees. He advocates compensation for those duties on a per-meeting or hourly basis. His hospital meets attendance requirements by giving credit to doctors who participate on selected medical staff committees.

Through her consulting assignments, Flores has observed that in some organizations where hospitalists are paid based on productivity, committee participation can be assigned a relative value unit so hospitalists are compensated on the same basis as for clinical work.

Flores concurs with Drs. Dallas and Williams: “In most organizations, a certain minimum level of participation in medical staff activities is expected of all staff members. I think that hospitalists should expect to do that to the same degree as other medical staff members, on a voluntary basis.

“If hospitalists truly want to impact how the medical staff and the hospital operate, and to be considered for high-level leadership positions, then their best way of becoming known and respected in the medical community is by participating on committees.” TH

Gretchen Henkel writes frequently for The Hospitalist.

Reference

1. SHM’s “2005-2006 Survey: State of the Hospital Medicine Movement, 2006.” Available online at www.hospitalmedicine.org Last accessed April 5, 2007.

Whether obligatory or voluntary, service on committees is a reality for most hospitalists. “The 2005-2006 SHM Survey: State of the Hospital Medicine Movement” found that, for 92% of respondents, committee participation topped the list of non-clinical activities.1 Hospital medicine group leaders, consultants, and administrators interviewed for this article say time-pressed hospitalists must become more effective committee participants.

Civic Duty or Career Advancement?

Because of growing presence at the hospital and their knowledge of hospital operations, hospitalists are a logical choice for committee assignments. These can range from committees dedicated to care delivery (e.g., pharmacy and therapeutics) to the hospital board’s governance committees.

“Hospitalists, with their perspective of hospital operations and clinical care, could be a great part of broadening the perspective of the board, informing their decision-making and helping them to formulate policies,” says John Combes, MD, president of the Center for Healthcare Governance in Chicago, a subsidiary committee of the American Hospital Association.

Mark V. Williams, MD, professor of medicine and director, Emory Hospital Medicine Unit in Atlanta, and editor in chief of the Journal of Hospital Medicine, does not consider committee participation optional.

“I strongly encourage—if not almost require—all of the hospitalists in our group to be involved in at least one committee,” says Dr. Williams. “My belief is that hospitalists are integral to the functioning of the hospital, and as part of their responsibility, they need to be actively involved in committee work to move projects forward.”

Leslie Flores, MHA, co-principal of Nelson/Flores Associates, LLC, agrees. “It’s in the hospitalists’ best interest to be involved in committees,” she says. “Hospitalists are often in the best position to see what needs to be fixed, and they have the potential to have a significant impact on how effectively their hospital operates, which can make their own jobs easier.”

Further, she points out, “If the hospital, which is financially supporting them, is more successful and effective, there’s likely to be less financial pressure on their practice.”

Hospitalists’ perceptions about committee participation can be influenced by each hospitalist’s employment model. If one is working directly for the hospital and giving 110% to that employer, being asked to volunteer additional time to serve on a committee might be viewed as a burden. On the other hand, an independent hospital medicine group (HMG) contracting with the hospital to deliver services may view committee participation as an avenue for ensuring the group’s success. Whatever the employment model, and whatever the career goals of individual hospitalists, it often pays to target one’s participation in committees.

Make Participation Count

Hospitalists will be playing more key roles in medical staff leadership, according to William D. Atchley Jr., MD, medical director of the Division of Hospital Medicine for Sentara Medical Group in Hampton, Va. His concern is that hospitalists will be asked to serve on more than one or two committees. He advises younger hospitalists to notify the president of the medical staff of which committees they would be interested in working on. Dr. Atchley is also a member of the SHM Board of Directors.

“It could be peer review, performance improvement, or ad hoc committees focused on developing evidence-based order sets, improving through-put or disaster preparedness,” says Dr. Atchley. Whatever the pick, “it should be something that they’re going to find enjoyable and that they feel will advance their stature within the hospital.”

To be an effective member of a hospital board committee, a hospitalist must represent the greater interests of all stakeholders—not just his or her own self-interest, cautions Dr. Combes. However, “as physicians become more stressed and production-oriented, giving up clinical time to participate in governance activities becomes more and more difficult,” he concedes. Hospitalists should choose committee assignments based on their interests and expertise.

Dr. Williams encourages hospitalists in his group to pick one committee—preferably one focused on care delivery (quality improvement, pharmacy and therapeutics, utilization review) and take an active role. “Then, over time, I encourage them to try to chair committees to obtain leadership experience,” he says.

Taking on too many extracurricular committee tasks can be counterproductive. To avoid this, Flores advises younger hospitalists to ask themselves the following:

• What will my committee participation do to support the goals of the committee and the organization?
• By participating in this committee, can I expand my own knowledge or understanding of the culture and politics of the organization?
• Can I become more comfortable interacting on an organizational level?
• Can I network and get to know people I wouldn’t otherwise encounter, who can be helpful to me personally?

In addition, Dr. Atchley believes rotating committee assignments is also beneficial, especially for the younger hospitalist. In his tenure as a hospitalist, Dr. Atchley has served as chairman of the Department of Medicine’s credentials and quality assurance committees, and as vice president of the medical staff. Each committee furnishes hospitalists with a different perspective about how the hospital functions.

“I think hospitalists should understand the medical staff bylaws and procedures,” says Dr. Atchley. “Each hospital medicine staff has this governance structure, and I have found it beneficial in resolving conflicts about patient care and interaction between physicians.”

Mary A. Dallas, MD, has seen the committee situation from both sides of the fence. She is medical information officer for Presbyterian Healthcare Services, an integrated healthcare delivery network in Albuquerque, N.M., but served as medical director of Presbyterian’s hospitalist group for five years before that.

“Hospitalists have a vested interest in making sure their work area is protected, so they need to plant some people in strategic places for the governance and medical staff,” says Dr. Dallas. “In order to be effective in the governance of the hospital, you have to be part of that medical substructure and get involved.”

For instance, as medical director, she sat on the hospital’s credential committee and found it allowed her to keep tabs on new HMG hires going through the credentialing process. “This [the hospital] is your work environment,” she explains. “You are here day in and day out, and you should shape that environment, have a say in policies and rules, so that you can make your job more successful and make patient care better.”

The Quandary over Compensation

Many hospitalists feel frustrated when committee obligations impinge on clinical duties. Is compensation the answer for filling committee slots? Opinions are mixed.

Dr. Williams says he is “a little uncomfortable with the concept of people getting paid every time they attend a committee meeting. For hospitalists who receive funding from the hospital to support their programs, it’s important for the leader [of the HMG] to ensure that they’re collaborating with hospital administration. The hospital has the expectation that, as part of our salary structure, we will be members of committees. That needs to be part of the job.”

Dr. Dallas agrees: “Regardless of whether you’re getting paid or not, this is your work environment. I think it’s very important to be involved, so that your voice is heard and so that you can help make the [hospital] structure better.”

Compensating physicians for their time does communicate that their time is valued and respected, says Dr. Combes, but payment does not necessarily guarantee a high level of committee members’ engagement. In addition, he says, if physicians are being compensated directly by the hospital for serving on committees, “this can threaten the perception of their objectivity, in terms of bringing an independent perspective to the board.” A better solution might be for the hospital medicine group to build its own compensation structure for non-clinical work so members retain independence when voicing opinions to the hospital board.

Dr. Atchley admits it’s sometimes a struggle to find people willing to serve on medical staff committees. He advocates compensation for those duties on a per-meeting or hourly basis. His hospital meets attendance requirements by giving credit to doctors who participate on selected medical staff committees.

Through her consulting assignments, Flores has observed that in some organizations where hospitalists are paid based on productivity, committee participation can be assigned a relative value unit so hospitalists are compensated on the same basis as for clinical work.

Flores concurs with Drs. Dallas and Williams: “In most organizations, a certain minimum level of participation in medical staff activities is expected of all staff members. I think that hospitalists should expect to do that to the same degree as other medical staff members, on a voluntary basis.

“If hospitalists truly want to impact how the medical staff and the hospital operate, and to be considered for high-level leadership positions, then their best way of becoming known and respected in the medical community is by participating on committees.” TH

Gretchen Henkel writes frequently for The Hospitalist.

Reference

1. SHM’s “2005-2006 Survey: State of the Hospital Medicine Movement, 2006.” Available online at www.hospitalmedicine.org Last accessed April 5, 2007.

This is the second in a series on the four pillars of career satisfaction. Part 1 appeared on p. 14 in the June issue of The Hospitalist.

How can hospitalists work long days often packed from beginning to end and still remain happy with their jobs? One answer can be found in “A Challenge for a New Specialty: A White Paper on Hospitalist Career Satisfaction” (available online at www.hospitalmedicine.org), a comprehensive document by SHM’s Career Satisfaction Task Force (CSTF). This white paper can be used by hospitalists and hospital medicine practices as a toolkit for improving job satisfaction. It outlines the four pillars of career satisfaction.

The Second Pillar: Workload/Schedule

The workload/schedule pillar refers to the type, volume, and intensity of a hospitalist’s work as well as time pressures, variability of work, and number of interruptions. A hospitalist schedule must take all these factors into consideration.

CSTF Co-Chairperson Winthrop Whitcomb, MD, Mercy Medical Center, Springfield, Mass., maintains that this pillar is supported by the other three—autonomy/control, reward/recognition, and community/environment—but most closely with reward/recognition.

“There needs to be a reward system in place no matter what the workload,” says Dr. Whitcomb. “You can’t really talk about workload without addressing rewards. It’s human nature that in order to work hard, you need to be rewarded in some meaningful way.”

But many people—not just physicians but workers from all fields—may have separate concerns about heavy workload and just rewards.

An Example of Workload Issues

You probably know from your own experience as a hospitalist how workload can affect career satisfaction. Here is a fictional example of a hospitalist struggling with an increased patient load:

The director of my community-based hospital medicine program has mandated that each hospitalist see 15 to 20 patients each weekday, and 20 to 30 patients a day over weekends. I know this workload is too heavy to allow good quality of care. Under the pressure of seeing my quota of patients, I’m afraid I might make a mistake or miss something.

“There are physicians out there who can and do handle this type of workload, and they do it happily and well,” Dr. Whitcomb points out. “But this is only true if there is an appropriate reward system in place, and there clearly needs to be a good support system in order to provide quality of care” under this example.

CSTF says this individual should take the following steps:

Step 1: Go on a fact-finding mission. Find out whether hospitalist workload, responsibilities, and schedule at this facility are the norm. “[The hospitalist] should get an idea of what’s happening at other hospital medicine groups; he should understand the national picture,” says Dr. Whitcomb. “He might then realize that hospitalists in his group are only working 187 days a year, and that over a course of a year they’re not really working any harder than others who work more days,” says Dr. Whitcomb. “This might get him thinking a little bit differently about the workload.”

Step 2: Undertake organizational strategies. A hospitalist can find out how he or she has a voice in workload issues.“Figure out how hospitalists are represented in the structure of the group,” advises Dr. Whitcomb. “If a director is mandating how much [hospitalists] work, there has to be some mechanism for the physicians to be able to provide feedback. This often takes the shape of a compensation committee; this group is not just about compensation but about budget and sustainability for both the hospital and the hospitalists.” Physician representation—having a say in workload and schedule—is important to maintain a good balance within a hospital medicine program.

Step 3: Consider recommendations to ease workload. “You can try to change the workload through justifying adding staff or through putting systems in place that allow you to see more patients,” says Dr. Whitcomb. But what if the hospitalist considers or takes these steps and still finds his patient load to be unsustainable long term? “In terms of feeling like you’re not able to provide safe care,” says Dr. Whitcomb, “once you’ve suggested changes to the leadership and no changes are made, this may become a deal-breaker.”

Workload Leans on Other Pillars

The interesting thing about the workload/schedule pillar of job satisfaction is that, if you are unhappy with your workload, the other three pillars can sustain you and make you generally satisfied.

Dr. Whitcomb points to a 2002 article published in the Journal of Health and Social Behavior.1 The study examined a national survey of hospitalists and found that job burnout and intent to remain in the career are more meaningfully associated with favorable “community” relations than with negative experiences such as reduced autonomy.

“Workload is not a predictor of burnout as long as the other three pillars are intact,” summarizes Dr. Whitcomb.

Jane Jerrard has written for The Hospitalist since 2005.

Reference

1. Hoff T, Whitcomb WF, Nelson JR. Thriving and surviving in a new medical career: the case of hospitalist physicians. J Health Social Behav. 2002 Mar;43(1):72-91

This is the second in a series on the four pillars of career satisfaction. Part 1 appeared on p. 14 in the June issue of The Hospitalist.

How can hospitalists work long days often packed from beginning to end and still remain happy with their jobs? One answer can be found in “A Challenge for a New Specialty: A White Paper on Hospitalist Career Satisfaction” (available online at www.hospitalmedicine.org), a comprehensive document by SHM’s Career Satisfaction Task Force (CSTF). This white paper can be used by hospitalists and hospital medicine practices as a toolkit for improving job satisfaction. It outlines the four pillars of career satisfaction.

The Second Pillar: Workload/Schedule

The workload/schedule pillar refers to the type, volume, and intensity of a hospitalist’s work as well as time pressures, variability of work, and number of interruptions. A hospitalist schedule must take all these factors into consideration.

CSTF Co-Chairperson Winthrop Whitcomb, MD, Mercy Medical Center, Springfield, Mass., maintains that this pillar is supported by the other three—autonomy/control, reward/recognition, and community/environment—but most closely with reward/recognition.

“There needs to be a reward system in place no matter what the workload,” says Dr. Whitcomb. “You can’t really talk about workload without addressing rewards. It’s human nature that in order to work hard, you need to be rewarded in some meaningful way.”

But many people—not just physicians but workers from all fields—may have separate concerns about heavy workload and just rewards.

An Example of Workload Issues

You probably know from your own experience as a hospitalist how workload can affect career satisfaction. Here is a fictional example of a hospitalist struggling with an increased patient load:

The director of my community-based hospital medicine program has mandated that each hospitalist see 15 to 20 patients each weekday, and 20 to 30 patients a day over weekends. I know this workload is too heavy to allow good quality of care. Under the pressure of seeing my quota of patients, I’m afraid I might make a mistake or miss something.

“There are physicians out there who can and do handle this type of workload, and they do it happily and well,” Dr. Whitcomb points out. “But this is only true if there is an appropriate reward system in place, and there clearly needs to be a good support system in order to provide quality of care” under this example.

CSTF says this individual should take the following steps:

Step 1: Go on a fact-finding mission. Find out whether hospitalist workload, responsibilities, and schedule at this facility are the norm. “[The hospitalist] should get an idea of what’s happening at other hospital medicine groups; he should understand the national picture,” says Dr. Whitcomb. “He might then realize that hospitalists in his group are only working 187 days a year, and that over a course of a year they’re not really working any harder than others who work more days,” says Dr. Whitcomb. “This might get him thinking a little bit differently about the workload.”

Step 2: Undertake organizational strategies. A hospitalist can find out how he or she has a voice in workload issues.“Figure out how hospitalists are represented in the structure of the group,” advises Dr. Whitcomb. “If a director is mandating how much [hospitalists] work, there has to be some mechanism for the physicians to be able to provide feedback. This often takes the shape of a compensation committee; this group is not just about compensation but about budget and sustainability for both the hospital and the hospitalists.” Physician representation—having a say in workload and schedule—is important to maintain a good balance within a hospital medicine program.

Step 3: Consider recommendations to ease workload. “You can try to change the workload through justifying adding staff or through putting systems in place that allow you to see more patients,” says Dr. Whitcomb. But what if the hospitalist considers or takes these steps and still finds his patient load to be unsustainable long term? “In terms of feeling like you’re not able to provide safe care,” says Dr. Whitcomb, “once you’ve suggested changes to the leadership and no changes are made, this may become a deal-breaker.”

Workload Leans on Other Pillars

The interesting thing about the workload/schedule pillar of job satisfaction is that, if you are unhappy with your workload, the other three pillars can sustain you and make you generally satisfied.

Dr. Whitcomb points to a 2002 article published in the Journal of Health and Social Behavior.1 The study examined a national survey of hospitalists and found that job burnout and intent to remain in the career are more meaningfully associated with favorable “community” relations than with negative experiences such as reduced autonomy.

“Workload is not a predictor of burnout as long as the other three pillars are intact,” summarizes Dr. Whitcomb.

Jane Jerrard has written for The Hospitalist since 2005.

Reference

1. Hoff T, Whitcomb WF, Nelson JR. Thriving and surviving in a new medical career: the case of hospitalist physicians. J Health Social Behav. 2002 Mar;43(1):72-91

This is the second in a series on the four pillars of career satisfaction. Part 1 appeared on p. 14 in the June issue of The Hospitalist.

How can hospitalists work long days often packed from beginning to end and still remain happy with their jobs? One answer can be found in “A Challenge for a New Specialty: A White Paper on Hospitalist Career Satisfaction” (available online at www.hospitalmedicine.org), a comprehensive document by SHM’s Career Satisfaction Task Force (CSTF). This white paper can be used by hospitalists and hospital medicine practices as a toolkit for improving job satisfaction. It outlines the four pillars of career satisfaction.

The Second Pillar: Workload/Schedule

The workload/schedule pillar refers to the type, volume, and intensity of a hospitalist’s work as well as time pressures, variability of work, and number of interruptions. A hospitalist schedule must take all these factors into consideration.

CSTF Co-Chairperson Winthrop Whitcomb, MD, Mercy Medical Center, Springfield, Mass., maintains that this pillar is supported by the other three—autonomy/control, reward/recognition, and community/environment—but most closely with reward/recognition.

“There needs to be a reward system in place no matter what the workload,” says Dr. Whitcomb. “You can’t really talk about workload without addressing rewards. It’s human nature that in order to work hard, you need to be rewarded in some meaningful way.”

But many people—not just physicians but workers from all fields—may have separate concerns about heavy workload and just rewards.

An Example of Workload Issues

You probably know from your own experience as a hospitalist how workload can affect career satisfaction. Here is a fictional example of a hospitalist struggling with an increased patient load:

The director of my community-based hospital medicine program has mandated that each hospitalist see 15 to 20 patients each weekday, and 20 to 30 patients a day over weekends. I know this workload is too heavy to allow good quality of care. Under the pressure of seeing my quota of patients, I’m afraid I might make a mistake or miss something.

“There are physicians out there who can and do handle this type of workload, and they do it happily and well,” Dr. Whitcomb points out. “But this is only true if there is an appropriate reward system in place, and there clearly needs to be a good support system in order to provide quality of care” under this example.

CSTF says this individual should take the following steps:

Step 1: Go on a fact-finding mission. Find out whether hospitalist workload, responsibilities, and schedule at this facility are the norm. “[The hospitalist] should get an idea of what’s happening at other hospital medicine groups; he should understand the national picture,” says Dr. Whitcomb. “He might then realize that hospitalists in his group are only working 187 days a year, and that over a course of a year they’re not really working any harder than others who work more days,” says Dr. Whitcomb. “This might get him thinking a little bit differently about the workload.”

Step 2: Undertake organizational strategies. A hospitalist can find out how he or she has a voice in workload issues.“Figure out how hospitalists are represented in the structure of the group,” advises Dr. Whitcomb. “If a director is mandating how much [hospitalists] work, there has to be some mechanism for the physicians to be able to provide feedback. This often takes the shape of a compensation committee; this group is not just about compensation but about budget and sustainability for both the hospital and the hospitalists.” Physician representation—having a say in workload and schedule—is important to maintain a good balance within a hospital medicine program.

Step 3: Consider recommendations to ease workload. “You can try to change the workload through justifying adding staff or through putting systems in place that allow you to see more patients,” says Dr. Whitcomb. But what if the hospitalist considers or takes these steps and still finds his patient load to be unsustainable long term? “In terms of feeling like you’re not able to provide safe care,” says Dr. Whitcomb, “once you’ve suggested changes to the leadership and no changes are made, this may become a deal-breaker.”

Workload Leans on Other Pillars

The interesting thing about the workload/schedule pillar of job satisfaction is that, if you are unhappy with your workload, the other three pillars can sustain you and make you generally satisfied.

Dr. Whitcomb points to a 2002 article published in the Journal of Health and Social Behavior.1 The study examined a national survey of hospitalists and found that job burnout and intent to remain in the career are more meaningfully associated with favorable “community” relations than with negative experiences such as reduced autonomy.

“Workload is not a predictor of burnout as long as the other three pillars are intact,” summarizes Dr. Whitcomb.

Jane Jerrard has written for The Hospitalist since 2005.

Reference

1. Hoff T, Whitcomb WF, Nelson JR. Thriving and surviving in a new medical career: the case of hospitalist physicians. J Health Social Behav. 2002 Mar;43(1):72-91