Among the newest fields in medicine, the specialty “hospitology” applies the precepts of the hospitality industry to the hospital environment.

Introduction

The hospitology industry celebrated its fifth birthday this year. The term was coined by health consumer advocate Katy Ericson and was actualized by the daughter of a hotel industry mogul, Marseilles Hyatt. Like their colleagues in other new specialties, including forensic proctology and cosmetic gynecology, “hospitologists” have organized and worked hard to define their specialty and are working toward board certification.

Scope of Practice

Hospitologists have expertise in making the “visitors” feel welcome in the hospital environment. (Hospitologists prefer to refer to patients as “visitors,” though they also use the term “customer.”) As the visitor arrives from admissions, the hospitologist is waiting at bedside. The hospitologist assures the visitor that all his needs will be met in his personalized care suite.

Subsequent to the greeting, the hospitologist assists in the selection of an appropriate gown, termed “hospital attire.” There are several modish alternatives from designers such as Yves Saint Levaquin, Pierre Cardiac, and Club Medicare.

Obtaining a history and completing a physical remain a necessary part of the hospitalization experience, and hospitologists know how to establish a peaceful rapport. Previous review of material excludes the need to spend time on such distractions as past medical history or medication list, though many patients wish to discuss these at excruciating length. If this is the case, the hospitologist is ready to sit quietly while the visitor reviews any or all details of medical encounters—tangential or otherwise.

Prior to a physical exam, the patient may opt for a massage or a nap, either of which can be arranged for an extra charge.

Physical exams by hospitologists are soothing and precise, though not strictly required. Studies show that the physical exam is of low sensitivity and specificity. Nonetheless, the use of a stethoscope is encouraged to create the sense of clinical competence that visitors prefer in care providers, though having the gadget draped around one’s neck is, in most cases, sufficient.

Admission orders are a true art form. Administer adequate narcotics, benzodiazepines, and an antidepressant to visitors—whether they truly need them or not. Gently encourage smokers to quit; however, if they choose not to, then a selection of fine brands should be available for purchase and delivery to the care suite. Most modern hospitology programs offer online ordering through the in-care suite entertainment system, which features a selection of cigarettes, alcohol, and other needed substances, for a small additional fee. The concierge may be of help as well.

When it comes to diagnostic testing, there is no provider more adept at meeting a visitor’s needs than a hospitologist. Whether the visitor desires a barium enema or a PET scan, the test will be arranged immediately. Lab work may also be ordered. Though it is often difficult to obtain blood without a phlebotomy and a needle, the hospitologist will at bedside to hold the visitor’s hand, and (if need be) can offer her own blood if the visitor cannot bear the thought of “getting stuck.” There is an extra fee for this service, however.

Hospitologists command the full range of therapeutic maneuvers including heavy water hydrotherapy, splenic massage, and isotope enemas.

At time of discharge the hospitologist will have the visitor ready to go—both medically and spiritually. If he has no ride or it’s just too rainy, discharge on an alternate night is always an option. Visitors are always welcomed back, even if it’s within 30 days and with the same diagnosis.

Hospitologist Metrics

Length of stay (LOS) is an important metric for any hospitologist. LOS less than eight days may be a measure of poor performance, though we frequently see a four-day, three-night weekend admission for the busy executive.

The 30-day readmission rate is also worth following, as a happy visitor will want to return to the healing environment.

Cost per admission is of no importance; hospitologists live to serve, and finances are just a distraction from our duties. Money is the root of all evil, and hospitologists are well rooted.

Hospitologists rely heavily on EBM—experience-based medicine. Statistics can lie, but a happy smiling patient remains the proof in the hospitologist’s pudding. (Multiple flavors are available; see the menu.)

Organized Medicine and Certification

Like all good practitioners of new specialties, the hospitologists of America are well represented. The original organization was called Hospitology Organization of Haversend, Ohio (HOHO), which merged with the Hospitologist Organization of Rybeck, N.Y., (HORNY), to form the American Clinical Hospitology Organization (ACHOO), Gesundheit.

The current CEO of ACHOO Gesundheit is Moe Larryundcurly. He has represented the organization for several years and has been acknowledged by his peers to be “outstanding,” though at the time, they were all “in” and “sitting.”

The move for Bored Certification is in the air for ACHOO Gesundheit. Every hospitology program wants to have certified hospitologists. The ABIM (American Bored of Internal Medicine) and the ACP (Association of Credentialed Persons) have generally been supportive of Bored Certification, despite distraction from rival groups, such as the Socialist Generic Inpatient Medicos and other nefarious organizations.

Criteria for Bored Certification includes the following: Being bored at committee meetings, providing room and board for me when I visit, and the ability to tolerate being bored stiff, to death, and to tears.

The Future

The future is bright for hospitologists. Changes in Medicare billing, support from the hotel industry, and association with other “ologists,” such as cosmetologists and herpetologists, will only make the group stronger. Major threats to the specialty include tort law, outcomes analysis, and my brother Seymour, the crooked shyster lawyer.

Next time you go to the hospital to be “healed,” ask for a hospitologist! TH

*Hospitologist in practice

Conflict of interest statement: Dr. Newman does not own 25% of common shares of Hospitologists Incorporated (HI), although his wife does.

Jamie Newman, MD, FACP, is the physician editor of The Hospitalist, consultant, Hospital Internal Medicine, and assistant professor of internal medicine and medical history, Mayo Clinic College of Medicine, Rochester, Minn.

Among the newest fields in medicine, the specialty “hospitology” applies the precepts of the hospitality industry to the hospital environment.

Introduction

The hospitology industry celebrated its fifth birthday this year. The term was coined by health consumer advocate Katy Ericson and was actualized by the daughter of a hotel industry mogul, Marseilles Hyatt. Like their colleagues in other new specialties, including forensic proctology and cosmetic gynecology, “hospitologists” have organized and worked hard to define their specialty and are working toward board certification.

Scope of Practice

Hospitologists have expertise in making the “visitors” feel welcome in the hospital environment. (Hospitologists prefer to refer to patients as “visitors,” though they also use the term “customer.”) As the visitor arrives from admissions, the hospitologist is waiting at bedside. The hospitologist assures the visitor that all his needs will be met in his personalized care suite.

Subsequent to the greeting, the hospitologist assists in the selection of an appropriate gown, termed “hospital attire.” There are several modish alternatives from designers such as Yves Saint Levaquin, Pierre Cardiac, and Club Medicare.

Obtaining a history and completing a physical remain a necessary part of the hospitalization experience, and hospitologists know how to establish a peaceful rapport. Previous review of material excludes the need to spend time on such distractions as past medical history or medication list, though many patients wish to discuss these at excruciating length. If this is the case, the hospitologist is ready to sit quietly while the visitor reviews any or all details of medical encounters—tangential or otherwise.

Prior to a physical exam, the patient may opt for a massage or a nap, either of which can be arranged for an extra charge.

Physical exams by hospitologists are soothing and precise, though not strictly required. Studies show that the physical exam is of low sensitivity and specificity. Nonetheless, the use of a stethoscope is encouraged to create the sense of clinical competence that visitors prefer in care providers, though having the gadget draped around one’s neck is, in most cases, sufficient.

Admission orders are a true art form. Administer adequate narcotics, benzodiazepines, and an antidepressant to visitors—whether they truly need them or not. Gently encourage smokers to quit; however, if they choose not to, then a selection of fine brands should be available for purchase and delivery to the care suite. Most modern hospitology programs offer online ordering through the in-care suite entertainment system, which features a selection of cigarettes, alcohol, and other needed substances, for a small additional fee. The concierge may be of help as well.

When it comes to diagnostic testing, there is no provider more adept at meeting a visitor’s needs than a hospitologist. Whether the visitor desires a barium enema or a PET scan, the test will be arranged immediately. Lab work may also be ordered. Though it is often difficult to obtain blood without a phlebotomy and a needle, the hospitologist will at bedside to hold the visitor’s hand, and (if need be) can offer her own blood if the visitor cannot bear the thought of “getting stuck.” There is an extra fee for this service, however.

Hospitologists command the full range of therapeutic maneuvers including heavy water hydrotherapy, splenic massage, and isotope enemas.

At time of discharge the hospitologist will have the visitor ready to go—both medically and spiritually. If he has no ride or it’s just too rainy, discharge on an alternate night is always an option. Visitors are always welcomed back, even if it’s within 30 days and with the same diagnosis.

Hospitologist Metrics

Length of stay (LOS) is an important metric for any hospitologist. LOS less than eight days may be a measure of poor performance, though we frequently see a four-day, three-night weekend admission for the busy executive.

The 30-day readmission rate is also worth following, as a happy visitor will want to return to the healing environment.

Cost per admission is of no importance; hospitologists live to serve, and finances are just a distraction from our duties. Money is the root of all evil, and hospitologists are well rooted.

Hospitologists rely heavily on EBM—experience-based medicine. Statistics can lie, but a happy smiling patient remains the proof in the hospitologist’s pudding. (Multiple flavors are available; see the menu.)

Organized Medicine and Certification

Like all good practitioners of new specialties, the hospitologists of America are well represented. The original organization was called Hospitology Organization of Haversend, Ohio (HOHO), which merged with the Hospitologist Organization of Rybeck, N.Y., (HORNY), to form the American Clinical Hospitology Organization (ACHOO), Gesundheit.

The current CEO of ACHOO Gesundheit is Moe Larryundcurly. He has represented the organization for several years and has been acknowledged by his peers to be “outstanding,” though at the time, they were all “in” and “sitting.”

The move for Bored Certification is in the air for ACHOO Gesundheit. Every hospitology program wants to have certified hospitologists. The ABIM (American Bored of Internal Medicine) and the ACP (Association of Credentialed Persons) have generally been supportive of Bored Certification, despite distraction from rival groups, such as the Socialist Generic Inpatient Medicos and other nefarious organizations.

Criteria for Bored Certification includes the following: Being bored at committee meetings, providing room and board for me when I visit, and the ability to tolerate being bored stiff, to death, and to tears.

The Future

The future is bright for hospitologists. Changes in Medicare billing, support from the hotel industry, and association with other “ologists,” such as cosmetologists and herpetologists, will only make the group stronger. Major threats to the specialty include tort law, outcomes analysis, and my brother Seymour, the crooked shyster lawyer.

Next time you go to the hospital to be “healed,” ask for a hospitologist! TH

*Hospitologist in practice

Conflict of interest statement: Dr. Newman does not own 25% of common shares of Hospitologists Incorporated (HI), although his wife does.

Jamie Newman, MD, FACP, is the physician editor of The Hospitalist, consultant, Hospital Internal Medicine, and assistant professor of internal medicine and medical history, Mayo Clinic College of Medicine, Rochester, Minn.

Among the newest fields in medicine, the specialty “hospitology” applies the precepts of the hospitality industry to the hospital environment.

Introduction

The hospitology industry celebrated its fifth birthday this year. The term was coined by health consumer advocate Katy Ericson and was actualized by the daughter of a hotel industry mogul, Marseilles Hyatt. Like their colleagues in other new specialties, including forensic proctology and cosmetic gynecology, “hospitologists” have organized and worked hard to define their specialty and are working toward board certification.

Scope of Practice

Hospitologists have expertise in making the “visitors” feel welcome in the hospital environment. (Hospitologists prefer to refer to patients as “visitors,” though they also use the term “customer.”) As the visitor arrives from admissions, the hospitologist is waiting at bedside. The hospitologist assures the visitor that all his needs will be met in his personalized care suite.

Subsequent to the greeting, the hospitologist assists in the selection of an appropriate gown, termed “hospital attire.” There are several modish alternatives from designers such as Yves Saint Levaquin, Pierre Cardiac, and Club Medicare.

Obtaining a history and completing a physical remain a necessary part of the hospitalization experience, and hospitologists know how to establish a peaceful rapport. Previous review of material excludes the need to spend time on such distractions as past medical history or medication list, though many patients wish to discuss these at excruciating length. If this is the case, the hospitologist is ready to sit quietly while the visitor reviews any or all details of medical encounters—tangential or otherwise.

Prior to a physical exam, the patient may opt for a massage or a nap, either of which can be arranged for an extra charge.

Physical exams by hospitologists are soothing and precise, though not strictly required. Studies show that the physical exam is of low sensitivity and specificity. Nonetheless, the use of a stethoscope is encouraged to create the sense of clinical competence that visitors prefer in care providers, though having the gadget draped around one’s neck is, in most cases, sufficient.

Admission orders are a true art form. Administer adequate narcotics, benzodiazepines, and an antidepressant to visitors—whether they truly need them or not. Gently encourage smokers to quit; however, if they choose not to, then a selection of fine brands should be available for purchase and delivery to the care suite. Most modern hospitology programs offer online ordering through the in-care suite entertainment system, which features a selection of cigarettes, alcohol, and other needed substances, for a small additional fee. The concierge may be of help as well.

When it comes to diagnostic testing, there is no provider more adept at meeting a visitor’s needs than a hospitologist. Whether the visitor desires a barium enema or a PET scan, the test will be arranged immediately. Lab work may also be ordered. Though it is often difficult to obtain blood without a phlebotomy and a needle, the hospitologist will at bedside to hold the visitor’s hand, and (if need be) can offer her own blood if the visitor cannot bear the thought of “getting stuck.” There is an extra fee for this service, however.

Hospitologists command the full range of therapeutic maneuvers including heavy water hydrotherapy, splenic massage, and isotope enemas.

At time of discharge the hospitologist will have the visitor ready to go—both medically and spiritually. If he has no ride or it’s just too rainy, discharge on an alternate night is always an option. Visitors are always welcomed back, even if it’s within 30 days and with the same diagnosis.

Hospitologist Metrics

Length of stay (LOS) is an important metric for any hospitologist. LOS less than eight days may be a measure of poor performance, though we frequently see a four-day, three-night weekend admission for the busy executive.

The 30-day readmission rate is also worth following, as a happy visitor will want to return to the healing environment.

Cost per admission is of no importance; hospitologists live to serve, and finances are just a distraction from our duties. Money is the root of all evil, and hospitologists are well rooted.

Hospitologists rely heavily on EBM—experience-based medicine. Statistics can lie, but a happy smiling patient remains the proof in the hospitologist’s pudding. (Multiple flavors are available; see the menu.)

Organized Medicine and Certification

Like all good practitioners of new specialties, the hospitologists of America are well represented. The original organization was called Hospitology Organization of Haversend, Ohio (HOHO), which merged with the Hospitologist Organization of Rybeck, N.Y., (HORNY), to form the American Clinical Hospitology Organization (ACHOO), Gesundheit.

The current CEO of ACHOO Gesundheit is Moe Larryundcurly. He has represented the organization for several years and has been acknowledged by his peers to be “outstanding,” though at the time, they were all “in” and “sitting.”

The move for Bored Certification is in the air for ACHOO Gesundheit. Every hospitology program wants to have certified hospitologists. The ABIM (American Bored of Internal Medicine) and the ACP (Association of Credentialed Persons) have generally been supportive of Bored Certification, despite distraction from rival groups, such as the Socialist Generic Inpatient Medicos and other nefarious organizations.

Criteria for Bored Certification includes the following: Being bored at committee meetings, providing room and board for me when I visit, and the ability to tolerate being bored stiff, to death, and to tears.

The Future

The future is bright for hospitologists. Changes in Medicare billing, support from the hotel industry, and association with other “ologists,” such as cosmetologists and herpetologists, will only make the group stronger. Major threats to the specialty include tort law, outcomes analysis, and my brother Seymour, the crooked shyster lawyer.

Next time you go to the hospital to be “healed,” ask for a hospitologist! TH

*Hospitologist in practice

Conflict of interest statement: Dr. Newman does not own 25% of common shares of Hospitologists Incorporated (HI), although his wife does.

Jamie Newman, MD, FACP, is the physician editor of The Hospitalist, consultant, Hospital Internal Medicine, and assistant professor of internal medicine and medical history, Mayo Clinic College of Medicine, Rochester, Minn.

Thirty years ago I was a medical resident at Duke University (Durham, N.C.). When I entered private practice there was very little time for family, much less outside activities. Little did I know that I would become a mountain climber with a desire to scale the world’s highest mountain: Mount Everest at 29,035 feet.

As the years passed I learned that to stay healthy and to meet all the demands that life seemed to dish out, I needed some balance. So I learned to play as hard I worked. I always loved to run and hike and eventually became a competitive distance runner. I ran marathons, including New York and Boston. I’ve also competed in ultra-marathons ranging from 100- to 50,000- mile distances. I completed two of three 100-mile races, running one in 23 hours. My favorite trail ultra-marathons are in the mountains of Colorado. My first 50-mile race was in the San Juan Mountains with elevations up to 12,000 feet.

My love of the mountains and endurance sports eventually led me to rock climbing, ice climbing, and alpine mountaineering. I’ve climbed multiple alpine and ice routes in Colorado. I have also climbed Mount Rainier (Washington state), and in the St. Elias, Chugach, and Alaskan ranges in Alaska, including expeditions to Denali and Moose’s Tooth.

In 2003 I got my first taste of the Himalayas while climbing Mount Ama Dablam—22,467 feet. Ama Dablam is a neighbor of Everest’s and one of the most stunning mountains in the entire Himalayan chain. I felt at home in the Himalayas and with the Sherpa people of the region. I knew I would return and attempt Mount Everest. I eventually teamed up with a Leadville, Colo.-based group of climbers who call themselves “Team No Limits.”

In the spring of 2004 I joined an Everest Expedition to the North—or Tibetan—side of Everest. I was only permitted to climb to the North Col at 23,000 feet. I performed a full polysomnography (sleep study) at 21,000 feet, comparing the sleep of Sherpas with that of Western climbers. This was valuable experience for my scheduled summit attempt in 2006. (Interestingly, our oxygen saturations were all in the high 60s at that height, and we were asymptomatic.)

Team No Limits worked hard in their preparation for the 2006 expedition. We planned to climb from the South—or Nepal—side of Everest, choosing the Hillary or South Col route. We were extremely fortunate in that we were able to contract with the legendary Apa Sherpa to be our sirdar, or head Sherpa guide. Apa held the world’s record for the most number of successful summit attempts on Everest: 15.

Our four-member team departed for the mountain in March 2006 with hopes for a summit bid in late April or early May. The first stop was in Katmandu, Nepal, and then a nine-day trek through the Himalayas to the Everest Base Camp. Shortly after arrival at base camp one of our team members became ill with altitude illness and subsequently had to descend to a lower altitude to recover. Little did we know that this would be the second deadliest season on Everest—second only to the 1996 climbing season.

On our climb the team was struck by tragedy. Early one morning several Team No Limits members were carrying loads through the dreaded Khumbu Ice Fall when a large ice avalanche came down, killing two of our Sherpas and injuring several others. Initially we were uncertain about continuing, but eventually we decided to continue the climb.

Dr. Rigsby (left) and a Sherpa guide. When this photo was taken, Dr. Rigsby was battling pulmonary edema on the Everest climb.

My expedition ended shortly after the Sherpas’ deaths. One cold, windy morning while climbing to the top of the icefall, I noticed something was wrong. My breathing became very labored, and every step took great effort. When I reached the Western Cwm close to Camp One I collapsed, unable to go farther. I knew I was in grave trouble and might not make it out alive. I had pulmonary edema, a condition I knew well from my hospital experience, but in a totally different setting.

Luckily, one of our Sherpas came upon me and assisted me to Camp One. It was a long night, but I survived with the assistance of my teammates and Sherpas. I was already on nifedipine for hypertension and as a prophylactic and acetazolamide (Diamox) and was hypotensive. I took a sildenafil (Viagra; this is not at all funny if you don’t regularly use Viagra), which improved my pulmonary volume status. Sildenafil citrate inhibits cGMP specific phosphodiesterase type-5 in smooth muscle, where it is responsible for degradation of cGMP; it increases cGMP within vascular smooth muscle cells resulting in relaxation and vasodilation, leading to the vasodilation of my pulmonary vascular bed. This was the only type of bed I was thinking about.

I was able to descend to Base Camp the next day and felt better as I went to a lower altitude. But I knew my climb was over. Another team member had a suspected heart condition and was later airlifted off the mountain by helicopter.

The rest of our team was eventually successful, however. The last man standing, Doug Tumminello, a lawyer from Denver, successfully summitted the mountain on May 22. Apa Sherpa also was successful, taking his world record from 15 to 16 summits.

Before returning home I trekked to the village of Thame, Nepal, the home of the deceased Sherpas. I wanted to pay my respects to their families and friends.

Being a hospitalist suits my lifestyle very well. Now I do a good job of working hard and playing hard. The ability to play hard has allowed me to work even harder and to keep my passion for medicine alive.

Now when I have a patient in pulmonary edema—whatever the cause—I have a greater understanding of the sensation and discomfort of dyspnea and the limitations of the human body. Despite not summitting, I would not have missed the ride for the world. I have no desire to climb Everest again, but hope to continue climbing for many years to come. TH

Dr. Rigsby, Everest climber and grandfather of eight, is a 55-year-old internal medicine physician. He is a practicing hospitalist at Memorial Hospital in Chattanooga, Tenn., and a consultant for Eagle Hospitalists in Atlanta.

Thirty years ago I was a medical resident at Duke University (Durham, N.C.). When I entered private practice there was very little time for family, much less outside activities. Little did I know that I would become a mountain climber with a desire to scale the world’s highest mountain: Mount Everest at 29,035 feet.

As the years passed I learned that to stay healthy and to meet all the demands that life seemed to dish out, I needed some balance. So I learned to play as hard I worked. I always loved to run and hike and eventually became a competitive distance runner. I ran marathons, including New York and Boston. I’ve also competed in ultra-marathons ranging from 100- to 50,000- mile distances. I completed two of three 100-mile races, running one in 23 hours. My favorite trail ultra-marathons are in the mountains of Colorado. My first 50-mile race was in the San Juan Mountains with elevations up to 12,000 feet.

My love of the mountains and endurance sports eventually led me to rock climbing, ice climbing, and alpine mountaineering. I’ve climbed multiple alpine and ice routes in Colorado. I have also climbed Mount Rainier (Washington state), and in the St. Elias, Chugach, and Alaskan ranges in Alaska, including expeditions to Denali and Moose’s Tooth.

In 2003 I got my first taste of the Himalayas while climbing Mount Ama Dablam—22,467 feet. Ama Dablam is a neighbor of Everest’s and one of the most stunning mountains in the entire Himalayan chain. I felt at home in the Himalayas and with the Sherpa people of the region. I knew I would return and attempt Mount Everest. I eventually teamed up with a Leadville, Colo.-based group of climbers who call themselves “Team No Limits.”

In the spring of 2004 I joined an Everest Expedition to the North—or Tibetan—side of Everest. I was only permitted to climb to the North Col at 23,000 feet. I performed a full polysomnography (sleep study) at 21,000 feet, comparing the sleep of Sherpas with that of Western climbers. This was valuable experience for my scheduled summit attempt in 2006. (Interestingly, our oxygen saturations were all in the high 60s at that height, and we were asymptomatic.)

Team No Limits worked hard in their preparation for the 2006 expedition. We planned to climb from the South—or Nepal—side of Everest, choosing the Hillary or South Col route. We were extremely fortunate in that we were able to contract with the legendary Apa Sherpa to be our sirdar, or head Sherpa guide. Apa held the world’s record for the most number of successful summit attempts on Everest: 15.

Our four-member team departed for the mountain in March 2006 with hopes for a summit bid in late April or early May. The first stop was in Katmandu, Nepal, and then a nine-day trek through the Himalayas to the Everest Base Camp. Shortly after arrival at base camp one of our team members became ill with altitude illness and subsequently had to descend to a lower altitude to recover. Little did we know that this would be the second deadliest season on Everest—second only to the 1996 climbing season.

On our climb the team was struck by tragedy. Early one morning several Team No Limits members were carrying loads through the dreaded Khumbu Ice Fall when a large ice avalanche came down, killing two of our Sherpas and injuring several others. Initially we were uncertain about continuing, but eventually we decided to continue the climb.

Dr. Rigsby (left) and a Sherpa guide. When this photo was taken, Dr. Rigsby was battling pulmonary edema on the Everest climb.

My expedition ended shortly after the Sherpas’ deaths. One cold, windy morning while climbing to the top of the icefall, I noticed something was wrong. My breathing became very labored, and every step took great effort. When I reached the Western Cwm close to Camp One I collapsed, unable to go farther. I knew I was in grave trouble and might not make it out alive. I had pulmonary edema, a condition I knew well from my hospital experience, but in a totally different setting.

Luckily, one of our Sherpas came upon me and assisted me to Camp One. It was a long night, but I survived with the assistance of my teammates and Sherpas. I was already on nifedipine for hypertension and as a prophylactic and acetazolamide (Diamox) and was hypotensive. I took a sildenafil (Viagra; this is not at all funny if you don’t regularly use Viagra), which improved my pulmonary volume status. Sildenafil citrate inhibits cGMP specific phosphodiesterase type-5 in smooth muscle, where it is responsible for degradation of cGMP; it increases cGMP within vascular smooth muscle cells resulting in relaxation and vasodilation, leading to the vasodilation of my pulmonary vascular bed. This was the only type of bed I was thinking about.

I was able to descend to Base Camp the next day and felt better as I went to a lower altitude. But I knew my climb was over. Another team member had a suspected heart condition and was later airlifted off the mountain by helicopter.

The rest of our team was eventually successful, however. The last man standing, Doug Tumminello, a lawyer from Denver, successfully summitted the mountain on May 22. Apa Sherpa also was successful, taking his world record from 15 to 16 summits.

Before returning home I trekked to the village of Thame, Nepal, the home of the deceased Sherpas. I wanted to pay my respects to their families and friends.

Being a hospitalist suits my lifestyle very well. Now I do a good job of working hard and playing hard. The ability to play hard has allowed me to work even harder and to keep my passion for medicine alive.

Now when I have a patient in pulmonary edema—whatever the cause—I have a greater understanding of the sensation and discomfort of dyspnea and the limitations of the human body. Despite not summitting, I would not have missed the ride for the world. I have no desire to climb Everest again, but hope to continue climbing for many years to come. TH

Dr. Rigsby, Everest climber and grandfather of eight, is a 55-year-old internal medicine physician. He is a practicing hospitalist at Memorial Hospital in Chattanooga, Tenn., and a consultant for Eagle Hospitalists in Atlanta.

Thirty years ago I was a medical resident at Duke University (Durham, N.C.). When I entered private practice there was very little time for family, much less outside activities. Little did I know that I would become a mountain climber with a desire to scale the world’s highest mountain: Mount Everest at 29,035 feet.

As the years passed I learned that to stay healthy and to meet all the demands that life seemed to dish out, I needed some balance. So I learned to play as hard I worked. I always loved to run and hike and eventually became a competitive distance runner. I ran marathons, including New York and Boston. I’ve also competed in ultra-marathons ranging from 100- to 50,000- mile distances. I completed two of three 100-mile races, running one in 23 hours. My favorite trail ultra-marathons are in the mountains of Colorado. My first 50-mile race was in the San Juan Mountains with elevations up to 12,000 feet.

My love of the mountains and endurance sports eventually led me to rock climbing, ice climbing, and alpine mountaineering. I’ve climbed multiple alpine and ice routes in Colorado. I have also climbed Mount Rainier (Washington state), and in the St. Elias, Chugach, and Alaskan ranges in Alaska, including expeditions to Denali and Moose’s Tooth.

In 2003 I got my first taste of the Himalayas while climbing Mount Ama Dablam—22,467 feet. Ama Dablam is a neighbor of Everest’s and one of the most stunning mountains in the entire Himalayan chain. I felt at home in the Himalayas and with the Sherpa people of the region. I knew I would return and attempt Mount Everest. I eventually teamed up with a Leadville, Colo.-based group of climbers who call themselves “Team No Limits.”

In the spring of 2004 I joined an Everest Expedition to the North—or Tibetan—side of Everest. I was only permitted to climb to the North Col at 23,000 feet. I performed a full polysomnography (sleep study) at 21,000 feet, comparing the sleep of Sherpas with that of Western climbers. This was valuable experience for my scheduled summit attempt in 2006. (Interestingly, our oxygen saturations were all in the high 60s at that height, and we were asymptomatic.)

Team No Limits worked hard in their preparation for the 2006 expedition. We planned to climb from the South—or Nepal—side of Everest, choosing the Hillary or South Col route. We were extremely fortunate in that we were able to contract with the legendary Apa Sherpa to be our sirdar, or head Sherpa guide. Apa held the world’s record for the most number of successful summit attempts on Everest: 15.

Our four-member team departed for the mountain in March 2006 with hopes for a summit bid in late April or early May. The first stop was in Katmandu, Nepal, and then a nine-day trek through the Himalayas to the Everest Base Camp. Shortly after arrival at base camp one of our team members became ill with altitude illness and subsequently had to descend to a lower altitude to recover. Little did we know that this would be the second deadliest season on Everest—second only to the 1996 climbing season.

On our climb the team was struck by tragedy. Early one morning several Team No Limits members were carrying loads through the dreaded Khumbu Ice Fall when a large ice avalanche came down, killing two of our Sherpas and injuring several others. Initially we were uncertain about continuing, but eventually we decided to continue the climb.

Dr. Rigsby (left) and a Sherpa guide. When this photo was taken, Dr. Rigsby was battling pulmonary edema on the Everest climb.

My expedition ended shortly after the Sherpas’ deaths. One cold, windy morning while climbing to the top of the icefall, I noticed something was wrong. My breathing became very labored, and every step took great effort. When I reached the Western Cwm close to Camp One I collapsed, unable to go farther. I knew I was in grave trouble and might not make it out alive. I had pulmonary edema, a condition I knew well from my hospital experience, but in a totally different setting.

Luckily, one of our Sherpas came upon me and assisted me to Camp One. It was a long night, but I survived with the assistance of my teammates and Sherpas. I was already on nifedipine for hypertension and as a prophylactic and acetazolamide (Diamox) and was hypotensive. I took a sildenafil (Viagra; this is not at all funny if you don’t regularly use Viagra), which improved my pulmonary volume status. Sildenafil citrate inhibits cGMP specific phosphodiesterase type-5 in smooth muscle, where it is responsible for degradation of cGMP; it increases cGMP within vascular smooth muscle cells resulting in relaxation and vasodilation, leading to the vasodilation of my pulmonary vascular bed. This was the only type of bed I was thinking about.

I was able to descend to Base Camp the next day and felt better as I went to a lower altitude. But I knew my climb was over. Another team member had a suspected heart condition and was later airlifted off the mountain by helicopter.

The rest of our team was eventually successful, however. The last man standing, Doug Tumminello, a lawyer from Denver, successfully summitted the mountain on May 22. Apa Sherpa also was successful, taking his world record from 15 to 16 summits.

Before returning home I trekked to the village of Thame, Nepal, the home of the deceased Sherpas. I wanted to pay my respects to their families and friends.

Being a hospitalist suits my lifestyle very well. Now I do a good job of working hard and playing hard. The ability to play hard has allowed me to work even harder and to keep my passion for medicine alive.

Now when I have a patient in pulmonary edema—whatever the cause—I have a greater understanding of the sensation and discomfort of dyspnea and the limitations of the human body. Despite not summitting, I would not have missed the ride for the world. I have no desire to climb Everest again, but hope to continue climbing for many years to come. TH

Dr. Rigsby, Everest climber and grandfather of eight, is a 55-year-old internal medicine physician. He is a practicing hospitalist at Memorial Hospital in Chattanooga, Tenn., and a consultant for Eagle Hospitalists in Atlanta.

Treat Atrial Flutter

Da Costa A, Thévenin J, Roche F, et al. Results from the Loire-Ardèche-Drôme-Isère-Puy-de-Dôme (LADIP) trial on atrial flutter, a multicentric prospective randomized study comparing amiodarone and radiofrequency ablation after the first episode of symptomatic atrial flutter. Circulation. 2006;114:1676-1681.

Radiofrequency ablation (RFA) has high success rates in atrial flutter, and American College of Cardiology/American Hospital Association guidelines classify a first episode of well-tolerated atrial flutter as a class IIa indication for RFA treatment. The LADIP trial compared RFA with the current practice of electroosmotic flow (EOF) cardioversion plus amiodarone after a first episode of symptomatic atrial flutter.

One hundred and four consecutive patients with a documented first episode of atrial flutter were enrolled over a period of 39 months. Excluded from the study were patients under the age of 70, those who had had previous antiarrythmic treatment for atrial flutter, those who had an amiodarone contraindication, patients with New York Heart Association class IV heart failure, and those who had a history of heart block. All 52 patients in group I received RFA by a standard method. Fifty-one of the 52 patients in group II underwent intracardiac stimulation, followed, if necessary, by external or internal cardioversion. All patients in group II received amiodarone as well as vitamin K antagonists.

The patients were followed up in the outpatient department at one, three, six, 12, and 18 months after randomization and at the end of the study. At each visit, arrhythmic or cardiovascular events were recorded, and a 12-lead ECG was obtained. Patients were fitted with a Holter monitor for seven days if they had recurring palpitations or symptoms. The primary outcome studied was recurrence of symptomatic atrial flutter and occurrence of atrial fibrillation.

After a mean follow-up of 13+/-6 months, atrial flutter recurred in two of the 52 (3.8%) patients in group I and 15 of 51 (29.5%) patients in group II (P<0.0001). In group I, one patient required a second, successful ablation. All the patients who recurred in group II were successfully treated using RFA. The occurrence of significant symptomatic atrial fibrillation was 8% in both groups at the end of the first year. By the end of the study, two patients in group I and one patient in group II were in chronic atrial fibrillation. When all the episodes of atrial fibrillation were counted (including those patients whose episodes lasted <10 minutes but were documented with an event monitor), the groups did not differ significantly.

No procedure-related complications occurred in group I. In the amiodarone group, however, two patients developed hypothyroidism, one developed hyperthyroidism, and two patients had symptomatic sick sinus syndrome. There were a total of 14 deaths during the course of the study (six patients in group I and eight patients in group II); none were related to the study protocol.

This study is the largest to date showing the superiority of RFA to cardioversion plus amiodarone after the first episode of symptomatic atrial flutter. The long-term risk of subsequent atrial fibrillation was found to be similar to that of the amiodarone-treatment group. Because the mean age of patients in this study was 78, however, these findings cannot necessarily be extrapolated to younger patient populations. Further, oral amiodarone was used initially in this study. It can be argued that IV amiodarone is far more efficacious than oral forms in the acute setting. Because RFA is an invasive procedure, it is user-dependent and may be unfeasible in different care settings. Also, RFA might not be as appropriate for many symptomatic patients with atrial flutter and hemodynamic instability. Nevertheless, this study presents hospital-based physicians with an additional consideration in the acute care setting for patients with a first episode of atrial flutter.

A Transitional Care Intervention Trial

Coleman EA, Parry C, Chalmers S, et al. The care transitions intervention: results of a randomized controlled trial. Arch Intern Med. 2006;166:1822-1828.

A growing body of evidence suggests that the quality of health management decreases when patients are transitioned across sites of care—particularly when they are not adequately prepared to self-manage their chronic disease, when they receive conflicting advice from various providers, or when they do not have access to their healthcare providers. Higher rates of medication errors and lack of appropriate follow up compromise patient safety during this vulnerable period. This is a particular problem for hospitalists, who introduce an additional discontinuity into the flow of patient care. Because patients and their caregivers are the only common thread moving across various sites of care, this study targeted them for an intervention designed to improve the quality of transitional care.

The study was done in collaboration with a not-for-profit capitated system in Colorado. To be eligible for the study, patients had to be over age 65 and admitted to one of the participating hospitals. Patients had to be community dwelling with no documented dementia and had to have one of eleven diagnoses selected to reflect a higher likelihood of long-term subacute care or anticoagulation, including stroke, congestive heart failure, COPD, diabetes, hip fracture, coronary artery disease, and pulmonary embolism. The intervention group comprised 379 patients, while the control group was made up of 371 patients.

The intervention model was built on four pillars derived from prior qualitative studies about care transitions:

1. Assistance with medication self-management;
2. A healthcare record owned and maintained by the patient;
3. Timely physician follow-up; and
4. A list of red flags indicative of clinical deterioration.

Intervention-group patients had access to a personal health record that included an active problem list, medications, allergies, and a list of red flags; in addition, these patients received a series of visits and telephone calls with a “transition coach,” an advanced care nurse who encouraged self-care by patients and their caregivers, facilitated communication between providers and patients, and assisted in medication review and reconciliation.

The primary outcome measure was the rate of nonelective rehospitalization at 30, 90, and 180 days after discharge from the index hospitalization. Ninety-five percent of the intervention patients and 94.9% of the control subjects were included in the analysis. Intervention patients had lower adjusted hospital readmission rates than controls at 30 (8.3% versus 11.9%) and 90 days (16.7% versus 22.5%), P=0.048 and 0.04 respectively. The result did not achieve significance at 180 days after discharge (P=0.28). Rehospitalization for the same diagnosis as the index diagnosis within 90 and 180 days of admission was 5.3% in the intervention group versus 9.8% in the control group (P=0.04) and 8.6% in the intervention group versus 13.9% (P=0.045) in the control group, respectively, but did not meet statistical significance within 30 days of readmission.

The concepts of a transition coach and a patient-maintained record are enticing, considering the amount of time hospitalists may invest in patient education and discharge planning processes. This study is different from prior studies in that it used transition coaches instead of healthcare professionals to assume the primary role in managing the post-hospitalization course, and it provided the caregiver and patient with tools that could be applied to future care transitions. The costs of intervention in this study were found to be about $74,310 for the transition coach and other related costs, compared with a semi-annual cost savings of $147,797.

The main drawbacks of the study were that the 180-day all-cause readmission rates did not achieve statistical significance, and even though the adjusted P values for all-cause 30- and 90-day readmission rates were reported to be significant, their 95% confidence interval for the odds ratio barely meets appropriate analytical criteria (OR 0.59 [0.35-1.00] and 0.64 [0.42-0.99]). Also disappointing was the fact that there was no difference in readmission rates at 30 days for the index diagnosis. Therefore, healthcare systems would likely hesitate to implement these interventions without more definitive data showing reductions in adverse outcomes and mortality rates.

Pleural Empyema in CAP Cases

Ahmed RA, Marrie TJ, Huang JQ. Thoracic empyema in patients with community-acquired pneumonia. Am J Med. 2006 Oct;119(10):877-883.

Pleural effusions complicate up to 44% of cases of community-acquired pneumonia (CAP). Of these cases, 10% develop complicated parapneumonic effusions. In the past, pleural empyema has been associated with poor outcomes and high mortality rate. Unfortunately, most of these studies were performed before the advent of newer antimicrobial agents and more modern diagnostic and therapeutic techniques.

This prospective, population-based study included all patients older than 17 who had been admitted with a diagnosis of CAP. Most of these patients were diagnosed and managed according to a “Pneumonia Critical Pathway.” Adherence to any aspect of the pathway by the admitting physician was completely voluntary.

Of 3,675 patients enrolled in the study, 47 (1.3%) were diagnosed with empyema by the attending physician—a number which correlates with previous studies. Of these, only 24 (0.7%) were ultimately classified as “definite empyema” by one or more of the following criteria:

1. Presence of microorganisms on Gram stain or culture of the pleural fluid;
2. Pleural fluid with a pH <7.2 plus radiographic evidence suggesting empyema; and
3. Frank pus in the pleural space at time of thoracoscopy.

The remaining 23 (0.6%) patients were classified as suspected empyema.

The study then compared the patients without empyema with patients with definite empyema. Patients with definite empyema were younger, more likely to have received antibiotics before admission, and more likely to have been admitted to the ICU. Further, these patients had a higher incidence of illicit drug use and frequently presented with a history of systemic symptoms, including fevers, chills, and pleuritic chest pain. Laboratory studies—aside from elevated WBC—were not useful in distinguishing between the two groups. Also, there were no significant features on chest radiographs to separate the two groups, although in patients with complex fluid collections, 19 of 22 patients (86%) with definite empyema had computed tomography (CT) scans suggesting the diagnosis.

Streptococcus milleri was the most common pathogen, isolated in 50% of patients with definite empyema. Patients with definite empyema were more likely to have invasive diagnostic procedures and had longer hospital stays (23.5 +/- 17 days) compared with their CAP counterparts (12.4 +/- 20.2 days, P=0.007).

Clinical and laboratory features remain nonspecific and should be used with caution when differentiating between empyema and complicated pleural effusions. Diagnostic pleural effusion aspiration is essential if infection is suspected. This study also points out the greater need of ICU support in definite empyema cases that suggest a greater severity of illness.

Interestingly, definite empyema had an in-hospital mortality rate of 4.2%, compared with 10% for CAP (P<0.05). Possible reasons for this result included the fact that 50% of the empyema cases were suspected at admission and thereby received earlier antibiotic treatment and more aggressive management than CAP cases.

Rapid Response Systems: A Call for Research

Devita MA, Bellomo R, Hillman K, et al. Findings of the first consensus conference on medical emergency teams. Crit Care Med. 2006 Sep;34(9):2463-2478.

The Institute for Healthcare Improvement has endorsed the concept of Rapid Response Teams (RRTs), and the 2005-2006 SHM survey indicated that 35% of responding hospitalist groups were involved with such systems. The field of in-house medical emergency teams suffers from a lack of quality research, however. Most of the existing data come from single-institution studies, and analysis is limited by a lack of standard definitions or processes. This consensus document addresses these issues and offers a “state of the literature” in RRTs, or—as the authors redefine them—rapid response systems, and attempts to frame the research agenda going forward.

The authors define an in-hospital medical emergency as a “mismatch between patient needs and resources available” and then proceed to outline the various types of responses that have been described, including medical emergency teams (METs), RRTs, and critical care outreach teams (CCO). According to the authors, a MET generally brings ICU capabilities, including procedures and medications, to the bedside, whereas an RRT is a “ramp-up” response, sometimes led by a nurse, that can rapidly assess and triage patients to a higher level of care. To be part of a complete RRS, any of these response options needs to have an adequate detection/triggering arm (“afferent”), a response arm (“efferent”), and administrative and QI components.

After establishing their suggestions for standardized nomenclature and the necessary components of a rapid response system (RRS), the authors review the literature and make several recommendations regarding areas for future research. In particular, they note that there is no data to demonstrate that one set of triggering criteria is superior to another to identify patients who will benefit from an RRS intervention; nor is there adequate literature on the relative effectiveness of the different types of responses. Finally, the authors make a formal recommendation that hospitals implement both afferent and efferent systems, although, interestingly, they do so based on evidence from single-center, historical-control trials and in spite of the lack of benefit seen in the only published multicenter randomized controlled trial (MERIT).

The authors also describe RRS as potentially inexpensive, but offer no data to support this claim. In fact, the prospect of dedicated 24-hour response personnel is probably more daunting for most institutions than the authors acknowledge. In any case, this is excellent reading for hospitalists, who will continue to be key players in the evolution of these systems, and the report is also accompanied by an outstanding bibliography.

Symptomatic Severe Carotid Stenosis: Endarterectomy Versus Stenting

Mas JL, Chatellier G, Beyssen B, et al. Endarterectomy versus stenting in patients with symptomatic severe carotid stenosis. N Engl J Med. 2006;355(16):1660-1671.

Two large, randomized, clinical trials have established endarterectomy as the standard treatment for severe symptomatic carotid artery stenosis. The new method of carotid stenting avoids the need for general anesthesia and may cost less than surgery, but it is unclear if stenting is as effective as or safer than endarterectomy.

The authors conducted a publicly funded, randomized controlled trial in 20 academic and 10 nonacademic centers in France to compare stenting with endarterectomy in patients with symptomatic carotid stenosis. Patients were eligible if they were 18 years of age or older, had had a hemispheric or retinal transient ischemic attack or a nondisabling stroke within 120 days of enrollment, and had a stenosis of 60% to 99% in the symptomatic carotid artery.

Patients were excluded if one of the following was present: a modified Rankin score of three or more (disabling stroke); nonatherosclerotic carotid disease; severe tandem lesions (stenosis of proximal common carotid artery or intracranial artery that was more severe than the cervical lesion); previous revascularization of the symptomatic stenosis; a history of bleeding disorder; uncontrolled hypertension or diabetes; unstable angina; contraindication to heparin, ticlopidine, or clopidogrel; life expectancy of less than two years; or percutaneous or surgical intervention within 30 days before or after the study procedure. The primary endpoint was the incidence of any stroke or death within 30 days after treatment.

The trial (EVA-3S) was stopped early, after the inclusion of 527 patients, for reasons of both safety and futility. The 30-day risk of any stroke or death was significantly higher after stenting (9.6%) than after endarterectomy (3.9%), resulting in a relative risk of 2.5 (95% CI, 1.2 to 5.1). The 30-day incidence of disabling stroke or death was 1.5% after endarterectomy (95% CI, 0.5 to 4.2) and 3.4% after stenting (95% CI, 1.7 to 6.7); the relative risk was 2.2 (95% CI, 0.7 to 7.2). At six months, the incidence of any stroke or death was 6.1% after endarterectomy and 11.7% after stenting (P=0.02). Cranial nerve injury was more common after endarterectomy than after stenting.

The practice of interventional physicians has expanded in the last few years to include placement of stents—not only in coronary arteries but also in carotid arteries and other vessels. As hospitalists, we must be aware of the latest research in this changing field to provide the best evidence-based advice to our patients.

Currently, the only use of carotid stenting that has been approved by the Food and Drug Administration (FDA) is in symptomatic patients with carotid artery stenosis of 70% or more who are at high surgical risk. This FDA approval is based on the results of the Stenting and Angioplasty with Protection in Patients at High Risk for Endarterectomy (SAPPHIRE) study, which included symptomatic patients with carotid artery stenosis exceeding 50% and asymptomatic patients, with stenosis exceeding 80%, who were at high surgical risk mainly due to severe coronary artery disease. The SAPPHIRE study showed that stenting was safer than endarterectomy mainly due to lower risk of myocardial infarction within 30 days after carotid stenting as compared with surgery. There was no significant difference in the rates of stroke or death between stenting and endarterectomy.

Why does the EVA-3S trial reported in NEJM show opposing results? The patients in the trial were different than the ones included in the SAPPHIRE study, and the periprocedural protocol was less strict. The patients in the EVA-3S trial were not at high surgical risk. Further, all patients in the EVA-3S trial had symptomatic carotid artery stenosis, whereas the majority of patients in the SAPPHIRE study were asymptomatic. Use of aspirin and clopidogrel or ticlopidine three days before carotid-artery stenting was only recommended in the EVA-3S trial but was required in the SAPPHIRE trial.

The ongoing Carotid Revascularization Endarterectomy versus Stenting Trial (CREST), funded by the National Institutes of Health, is enrolling patients with an average surgical risk similar to those in the EVA-3S study. The CREST study, which is expected to enroll 2,500 patients, may be able to provide a more definitive answer regarding the best treatment for symptomatic patients with high-grade carotid stenosis with an average surgical risk.

In the meantime, what should we recommend to our patients? For symptomatic patients with carotid artery stenosis of 70% or more, endarterectomy is superior to medical therapy alone. For asymptomatic patients with carotid artery stenosis exceeding 60%, endarterectomy is also superior to medical therapy alone, assuming a risk of perioperative stroke or death of less than 3%. Currently, the only accepted indication for stenting is in symptomatic patients with carotid artery stenosis exceeding 70% and a high surgical risk.

D-Dimer Testing to Risk Stratify VTE Patients

Palareti G, Cosmi B, Legnani C, et al. D-dimer testing to determine the duration of anticoagulation therapy. N Engl J Med. 2006;355:1780-1789.

D-dimer levels have been used to assist in diagnosing initial episodes of venous thromboembolism (VTE). Although not specific, D-dimer testing is very sensitive for VTE, giving it a high negative predictive value. Further, duplex ultrasound often remains abnormal after VTE, making the distinction between recurrent disease and old disease problematic when symptoms recur.

A recent study by Rathbun and colleagues investigated the use of D-dimer measurement in excluding recurrent VTE, finding that of former VTE patients presenting with symptoms, only 0.75% with a negative D-dimer level had recurrent VTE on ultrasound, compared to 6.0% with a positive test who had recurrent VTE. This study, conducted by Palareti and colleagues, tries to go a step further and assess whether D-dimer testing can be used to risk stratify VTE patients who are asymptomatic following treatment for an initial episode of VTE, as well as whether or not it can be used to determine the need to continue anticoagulation.

The PROLONG study was a multicenter prospective study of patients between 18 and 85 who had had their first episode of unprovoked, symptomatic VTE (including pulmonary embolism). Patients were enrolled in this study after completing treatment with vitamin K antagonists (VKA) for at least three months with a target INR (international normalized ratio) in the range of 2-3. Exclusion criteria included severe liver insufficiency, renal insufficiency with serum creatinine >2, or clear indications/contraindications for anticoagulation.

Six hundred twenty-four patients treated for VTE were enrolled in the study. All underwent compressive ultrasound in both legs to establish a baseline at the start of the study and were then instructed to stop anticoagulation. Follow-up occurred in one month, with another ultrasound to assess recurrence of VTE. Five patients were found to have VTE and were excluded. The remaining 619 patients were tested for D-dimer levels and were given thrombophilia tests. A further 11 patients were excluded due to antiphospholipid antibodies or antithrombin deficiency. Patients with factor V Leidin and G20210A mutation on the prothrombin gene were allowed to participate in the study.

Three hundred and eighty-five patients had normal D-dimer levels and were not placed on anticoagulation. The 223 patients with abnormal D-dimer levels were randomized to receive VKA (103 patients) or no treatment (120 patients). All patients were followed for minimum of 18 months. Of the 120 patients with abnormal D-dimer levels who were randomized to no treatment, 18 patients (15.0%) had recurrent VTE. Of the 103 patients with abnormal D-dimer levels who resumed anticoagulation, one had a major bleeding episode and two had recurrent VTE, for a composite result of 2.9%—a statistically significant difference (P<0.005). The group with normal D-dimer levels after initial treatment had 24 episodes of recurrent VTE (6.2%).

The study suggested that the patients with abnormal D-dimer levels who stopped anticoagulation had a statistically significant higher rate of recurrent VTE than those who continued anticoagulation. There was also a statistically significant difference in the recurrent VTE rate in the two groups who did not resume anticoagulation. Interestingly, while the absolute difference between the normal D-dimer group and the abnormal D-dimer group who resumed anticoagulation was evident (6.2% versus 2.9%), this did not reach statistical significance.

This study is promising; however, there are some caveats to take into account when trying to apply these results to current clinical practice. First, the trial was not blinded and only evaluated patients with the first unprovoked episode of VTE. It is unknown if these results will apply to secondary VTE. Older people in this study had a higher incidence of elevated D-dimer at enrollment. The authors utilized a qualitative assay for D-dimer to obtain uniform results across the multiple testing centers. Applying these results to centers that use quantitative measurements of D-dimer then becomes more difficult due to the variability inherent in the interpretation of these quantitative results. Because this study excluded patients with either severe liver disease or renal insufficiency (Cr >2.0), it remains unknown if the results are applicable to these populations.

Because D-dimer levels were only measured once at the time of the patients’ enrollment in the study, it is unknown if patients with normal levels of D-dimer might progress to abnormal D-dimer levels and, therefore, to a potentially higher risk of VTE. This question could be answered with serial testing of D-dimer levels. The study was not powered enough to detect relative risk of bleeding from anticoagulation alone. Thus, these results were taken as a composite with the VTE events.

This study argues that anticoagulation in VTE patients with abnormal D-dimer levels measured after a month of stopping a standard three-month course of anticoagulation should be continued. What is not clear is whether we should continue treating people with normal D-dimer levels. Although not statistically significant, the absolute rate of VTE of 6.2% in these patients was higher than the 2.9% rate in patients with high D-dimer levels who continued anticoagulation.

Early Administration of ACE Inhibitors in MI Patients

Borghi C, Bacchelli S, Degli Esposti D, et al. Effects of early angiotensin-converting enzyme inhibition in patients with non-ST-elevation acute anterior myocardial infarction. Am Heart J. 2006 Sep;152(3):470-477.

Angiotensin-converting enzyme inhibitors (ACEIs) have demonstrated efficacy in improving long-term survival, particularly in patients with ST-elevation MI (STEMI) with left ventricular dysfunction (LVD) and/or congestive heart failure (CHF). There is less information available from clinical trial data, however, regarding the early use of ACEIs with non-ST-elevation MI (NSTEMI) patients, who are believed to be at an overall lower risk of in-hospital morbidity and mortality than STEMI patients.

Researchers focused on the question of ACEI efficacy in NSTEMI in a post hoc analysis of the patients enrolled in the Survival of Myocardial Infarction Long-term Evaluation (SMILE) study. The original study enrolled 1,556 patients with anterior acute MI (AMI) who were admitted to 154 coronary care units in Italy. Participants were patients who presented with chest pain within 24 hours, who demonstrated electrocardiographic signs of anterior wall AMI, and who were not eligible for thrombolytic therapy or reperfusion. These patients did receive beta blockers, nitrates, analgesic agents, inotropic drugs, diuretic agents, and anticoagulation agents as deemed appropriate.

Exclusion criteria included cardiogenic shock, systolic blood pressure below 100 mm Hg, serum creatinine above 2.5 mg per deciliter, a history of CHF, prior treatment with ACEI, and contraindication to the use of ACEI. Patients were randomized to either placebo or the short-acting ACEI zofenopril, with a starting dose of 7.5 mg every 12 hours. The dose was progressively doubled until the final target dose of 30 mg twice a day was reached. Upon completion of a six-week double-blind period, the study medications were stopped, but the patients continued taking their other medications for approximately 48 additional weeks, at which time vital status was blindly obtained by questionnaire or from registry offices. The primary endpoints were the occurrence of death or CHF during the treatment period.

In this post hoc analysis, only the 526 patients with anterior MI were studied. The baseline characteristics of the placebo and zofenopril group were closely matched but were predominantly male. The primary endpoint of this analysis was the combined occurrence of death or severe CHF during the six weeks of treatment with zofenopril or placebo, both given in addition to conventional treatment. Secondary endpoints were the six-week occurrence of severe CHF, nonfatal MI or angina, and cumulative one-year mortality.

The findings of this analysis indicate a relative risk reduction (RRR) of 65% (95% CI 20%­80%, 2P=0.003) of a major cardiovascular event using zofenopril in the first 6 weeks of treatment. Cumulative incidence of combined death and CHF was significantly (P=0.017) greater in the placebo group than in the group of patients given zofenopril. In addition, occurrence of severe CHF was lower in the zofenopril group (RRR 84%, 95% CI 33%­97%), as was one-year mortality (RRR 43%, 95% CI 14%-57%, 2P=0.36). During the six weeks, there was a slightly lower usage of beta blockers in the zofenopril group, as well as lower usage of calcium channel blockers and diuretics in this same group at one year. Systolic blood pressure (SBP) and heart rate did not differ between the two groups.

The authors of this analysis concluded that early treatment for six weeks with zofenopril was effective in reducing death and severe CHF in non-thrombolysed anterior wall NSTEMI patients. The results were independent of SBP reduction, suggesting that zofenopril may have cardioprotective effects, preventing infarct expansion, left ventricular remodeling, and neurohormonal activation, which is involved in coronary vasoconstriction and endothelial dysfunction. Further, the relative risk reduction in composite endpoints of mortality and severe CHF exceeded that observed in the overall population in the SMILE trial (which included STEMI), drawing attention to a particular advantage of the early use of ACEI in NSTEMI patients.

Despite relevant findings, these results were derived from a post hoc analysis of the SMILE study, only including about one third of the original population. It is also a retrospective analysis, albeit recognizing the sparse availability of research in this area, thought to be related to the exclusion of such patients from most clinical trials. This analysis strongly highlights the beneficial effects of early administration ACE inhibition and should prompt prospective evaluation of these agents as first-line therapy in anterior wall NSTEMI. TH

Treat Atrial Flutter

Da Costa A, Thévenin J, Roche F, et al. Results from the Loire-Ardèche-Drôme-Isère-Puy-de-Dôme (LADIP) trial on atrial flutter, a multicentric prospective randomized study comparing amiodarone and radiofrequency ablation after the first episode of symptomatic atrial flutter. Circulation. 2006;114:1676-1681.

Radiofrequency ablation (RFA) has high success rates in atrial flutter, and American College of Cardiology/American Hospital Association guidelines classify a first episode of well-tolerated atrial flutter as a class IIa indication for RFA treatment. The LADIP trial compared RFA with the current practice of electroosmotic flow (EOF) cardioversion plus amiodarone after a first episode of symptomatic atrial flutter.

One hundred and four consecutive patients with a documented first episode of atrial flutter were enrolled over a period of 39 months. Excluded from the study were patients under the age of 70, those who had had previous antiarrythmic treatment for atrial flutter, those who had an amiodarone contraindication, patients with New York Heart Association class IV heart failure, and those who had a history of heart block. All 52 patients in group I received RFA by a standard method. Fifty-one of the 52 patients in group II underwent intracardiac stimulation, followed, if necessary, by external or internal cardioversion. All patients in group II received amiodarone as well as vitamin K antagonists.

The patients were followed up in the outpatient department at one, three, six, 12, and 18 months after randomization and at the end of the study. At each visit, arrhythmic or cardiovascular events were recorded, and a 12-lead ECG was obtained. Patients were fitted with a Holter monitor for seven days if they had recurring palpitations or symptoms. The primary outcome studied was recurrence of symptomatic atrial flutter and occurrence of atrial fibrillation.

After a mean follow-up of 13+/-6 months, atrial flutter recurred in two of the 52 (3.8%) patients in group I and 15 of 51 (29.5%) patients in group II (P<0.0001). In group I, one patient required a second, successful ablation. All the patients who recurred in group II were successfully treated using RFA. The occurrence of significant symptomatic atrial fibrillation was 8% in both groups at the end of the first year. By the end of the study, two patients in group I and one patient in group II were in chronic atrial fibrillation. When all the episodes of atrial fibrillation were counted (including those patients whose episodes lasted <10 minutes but were documented with an event monitor), the groups did not differ significantly.

No procedure-related complications occurred in group I. In the amiodarone group, however, two patients developed hypothyroidism, one developed hyperthyroidism, and two patients had symptomatic sick sinus syndrome. There were a total of 14 deaths during the course of the study (six patients in group I and eight patients in group II); none were related to the study protocol.

This study is the largest to date showing the superiority of RFA to cardioversion plus amiodarone after the first episode of symptomatic atrial flutter. The long-term risk of subsequent atrial fibrillation was found to be similar to that of the amiodarone-treatment group. Because the mean age of patients in this study was 78, however, these findings cannot necessarily be extrapolated to younger patient populations. Further, oral amiodarone was used initially in this study. It can be argued that IV amiodarone is far more efficacious than oral forms in the acute setting. Because RFA is an invasive procedure, it is user-dependent and may be unfeasible in different care settings. Also, RFA might not be as appropriate for many symptomatic patients with atrial flutter and hemodynamic instability. Nevertheless, this study presents hospital-based physicians with an additional consideration in the acute care setting for patients with a first episode of atrial flutter.

A Transitional Care Intervention Trial

Coleman EA, Parry C, Chalmers S, et al. The care transitions intervention: results of a randomized controlled trial. Arch Intern Med. 2006;166:1822-1828.

A growing body of evidence suggests that the quality of health management decreases when patients are transitioned across sites of care—particularly when they are not adequately prepared to self-manage their chronic disease, when they receive conflicting advice from various providers, or when they do not have access to their healthcare providers. Higher rates of medication errors and lack of appropriate follow up compromise patient safety during this vulnerable period. This is a particular problem for hospitalists, who introduce an additional discontinuity into the flow of patient care. Because patients and their caregivers are the only common thread moving across various sites of care, this study targeted them for an intervention designed to improve the quality of transitional care.

The study was done in collaboration with a not-for-profit capitated system in Colorado. To be eligible for the study, patients had to be over age 65 and admitted to one of the participating hospitals. Patients had to be community dwelling with no documented dementia and had to have one of eleven diagnoses selected to reflect a higher likelihood of long-term subacute care or anticoagulation, including stroke, congestive heart failure, COPD, diabetes, hip fracture, coronary artery disease, and pulmonary embolism. The intervention group comprised 379 patients, while the control group was made up of 371 patients.

The intervention model was built on four pillars derived from prior qualitative studies about care transitions:

1. Assistance with medication self-management;
2. A healthcare record owned and maintained by the patient;
3. Timely physician follow-up; and
4. A list of red flags indicative of clinical deterioration.

Intervention-group patients had access to a personal health record that included an active problem list, medications, allergies, and a list of red flags; in addition, these patients received a series of visits and telephone calls with a “transition coach,” an advanced care nurse who encouraged self-care by patients and their caregivers, facilitated communication between providers and patients, and assisted in medication review and reconciliation.

The primary outcome measure was the rate of nonelective rehospitalization at 30, 90, and 180 days after discharge from the index hospitalization. Ninety-five percent of the intervention patients and 94.9% of the control subjects were included in the analysis. Intervention patients had lower adjusted hospital readmission rates than controls at 30 (8.3% versus 11.9%) and 90 days (16.7% versus 22.5%), P=0.048 and 0.04 respectively. The result did not achieve significance at 180 days after discharge (P=0.28). Rehospitalization for the same diagnosis as the index diagnosis within 90 and 180 days of admission was 5.3% in the intervention group versus 9.8% in the control group (P=0.04) and 8.6% in the intervention group versus 13.9% (P=0.045) in the control group, respectively, but did not meet statistical significance within 30 days of readmission.

The concepts of a transition coach and a patient-maintained record are enticing, considering the amount of time hospitalists may invest in patient education and discharge planning processes. This study is different from prior studies in that it used transition coaches instead of healthcare professionals to assume the primary role in managing the post-hospitalization course, and it provided the caregiver and patient with tools that could be applied to future care transitions. The costs of intervention in this study were found to be about $74,310 for the transition coach and other related costs, compared with a semi-annual cost savings of $147,797.

The main drawbacks of the study were that the 180-day all-cause readmission rates did not achieve statistical significance, and even though the adjusted P values for all-cause 30- and 90-day readmission rates were reported to be significant, their 95% confidence interval for the odds ratio barely meets appropriate analytical criteria (OR 0.59 [0.35-1.00] and 0.64 [0.42-0.99]). Also disappointing was the fact that there was no difference in readmission rates at 30 days for the index diagnosis. Therefore, healthcare systems would likely hesitate to implement these interventions without more definitive data showing reductions in adverse outcomes and mortality rates.

Pleural Empyema in CAP Cases

Ahmed RA, Marrie TJ, Huang JQ. Thoracic empyema in patients with community-acquired pneumonia. Am J Med. 2006 Oct;119(10):877-883.

Pleural effusions complicate up to 44% of cases of community-acquired pneumonia (CAP). Of these cases, 10% develop complicated parapneumonic effusions. In the past, pleural empyema has been associated with poor outcomes and high mortality rate. Unfortunately, most of these studies were performed before the advent of newer antimicrobial agents and more modern diagnostic and therapeutic techniques.

This prospective, population-based study included all patients older than 17 who had been admitted with a diagnosis of CAP. Most of these patients were diagnosed and managed according to a “Pneumonia Critical Pathway.” Adherence to any aspect of the pathway by the admitting physician was completely voluntary.

Of 3,675 patients enrolled in the study, 47 (1.3%) were diagnosed with empyema by the attending physician—a number which correlates with previous studies. Of these, only 24 (0.7%) were ultimately classified as “definite empyema” by one or more of the following criteria:

1. Presence of microorganisms on Gram stain or culture of the pleural fluid;
2. Pleural fluid with a pH <7.2 plus radiographic evidence suggesting empyema; and
3. Frank pus in the pleural space at time of thoracoscopy.

The remaining 23 (0.6%) patients were classified as suspected empyema.

The study then compared the patients without empyema with patients with definite empyema. Patients with definite empyema were younger, more likely to have received antibiotics before admission, and more likely to have been admitted to the ICU. Further, these patients had a higher incidence of illicit drug use and frequently presented with a history of systemic symptoms, including fevers, chills, and pleuritic chest pain. Laboratory studies—aside from elevated WBC—were not useful in distinguishing between the two groups. Also, there were no significant features on chest radiographs to separate the two groups, although in patients with complex fluid collections, 19 of 22 patients (86%) with definite empyema had computed tomography (CT) scans suggesting the diagnosis.

Streptococcus milleri was the most common pathogen, isolated in 50% of patients with definite empyema. Patients with definite empyema were more likely to have invasive diagnostic procedures and had longer hospital stays (23.5 +/- 17 days) compared with their CAP counterparts (12.4 +/- 20.2 days, P=0.007).

Clinical and laboratory features remain nonspecific and should be used with caution when differentiating between empyema and complicated pleural effusions. Diagnostic pleural effusion aspiration is essential if infection is suspected. This study also points out the greater need of ICU support in definite empyema cases that suggest a greater severity of illness.

Interestingly, definite empyema had an in-hospital mortality rate of 4.2%, compared with 10% for CAP (P<0.05). Possible reasons for this result included the fact that 50% of the empyema cases were suspected at admission and thereby received earlier antibiotic treatment and more aggressive management than CAP cases.

Rapid Response Systems: A Call for Research

Devita MA, Bellomo R, Hillman K, et al. Findings of the first consensus conference on medical emergency teams. Crit Care Med. 2006 Sep;34(9):2463-2478.

The Institute for Healthcare Improvement has endorsed the concept of Rapid Response Teams (RRTs), and the 2005-2006 SHM survey indicated that 35% of responding hospitalist groups were involved with such systems. The field of in-house medical emergency teams suffers from a lack of quality research, however. Most of the existing data come from single-institution studies, and analysis is limited by a lack of standard definitions or processes. This consensus document addresses these issues and offers a “state of the literature” in RRTs, or—as the authors redefine them—rapid response systems, and attempts to frame the research agenda going forward.

The authors define an in-hospital medical emergency as a “mismatch between patient needs and resources available” and then proceed to outline the various types of responses that have been described, including medical emergency teams (METs), RRTs, and critical care outreach teams (CCO). According to the authors, a MET generally brings ICU capabilities, including procedures and medications, to the bedside, whereas an RRT is a “ramp-up” response, sometimes led by a nurse, that can rapidly assess and triage patients to a higher level of care. To be part of a complete RRS, any of these response options needs to have an adequate detection/triggering arm (“afferent”), a response arm (“efferent”), and administrative and QI components.

After establishing their suggestions for standardized nomenclature and the necessary components of a rapid response system (RRS), the authors review the literature and make several recommendations regarding areas for future research. In particular, they note that there is no data to demonstrate that one set of triggering criteria is superior to another to identify patients who will benefit from an RRS intervention; nor is there adequate literature on the relative effectiveness of the different types of responses. Finally, the authors make a formal recommendation that hospitals implement both afferent and efferent systems, although, interestingly, they do so based on evidence from single-center, historical-control trials and in spite of the lack of benefit seen in the only published multicenter randomized controlled trial (MERIT).

The authors also describe RRS as potentially inexpensive, but offer no data to support this claim. In fact, the prospect of dedicated 24-hour response personnel is probably more daunting for most institutions than the authors acknowledge. In any case, this is excellent reading for hospitalists, who will continue to be key players in the evolution of these systems, and the report is also accompanied by an outstanding bibliography.

Symptomatic Severe Carotid Stenosis: Endarterectomy Versus Stenting

Mas JL, Chatellier G, Beyssen B, et al. Endarterectomy versus stenting in patients with symptomatic severe carotid stenosis. N Engl J Med. 2006;355(16):1660-1671.

Two large, randomized, clinical trials have established endarterectomy as the standard treatment for severe symptomatic carotid artery stenosis. The new method of carotid stenting avoids the need for general anesthesia and may cost less than surgery, but it is unclear if stenting is as effective as or safer than endarterectomy.

The authors conducted a publicly funded, randomized controlled trial in 20 academic and 10 nonacademic centers in France to compare stenting with endarterectomy in patients with symptomatic carotid stenosis. Patients were eligible if they were 18 years of age or older, had had a hemispheric or retinal transient ischemic attack or a nondisabling stroke within 120 days of enrollment, and had a stenosis of 60% to 99% in the symptomatic carotid artery.

Patients were excluded if one of the following was present: a modified Rankin score of three or more (disabling stroke); nonatherosclerotic carotid disease; severe tandem lesions (stenosis of proximal common carotid artery or intracranial artery that was more severe than the cervical lesion); previous revascularization of the symptomatic stenosis; a history of bleeding disorder; uncontrolled hypertension or diabetes; unstable angina; contraindication to heparin, ticlopidine, or clopidogrel; life expectancy of less than two years; or percutaneous or surgical intervention within 30 days before or after the study procedure. The primary endpoint was the incidence of any stroke or death within 30 days after treatment.

The trial (EVA-3S) was stopped early, after the inclusion of 527 patients, for reasons of both safety and futility. The 30-day risk of any stroke or death was significantly higher after stenting (9.6%) than after endarterectomy (3.9%), resulting in a relative risk of 2.5 (95% CI, 1.2 to 5.1). The 30-day incidence of disabling stroke or death was 1.5% after endarterectomy (95% CI, 0.5 to 4.2) and 3.4% after stenting (95% CI, 1.7 to 6.7); the relative risk was 2.2 (95% CI, 0.7 to 7.2). At six months, the incidence of any stroke or death was 6.1% after endarterectomy and 11.7% after stenting (P=0.02). Cranial nerve injury was more common after endarterectomy than after stenting.

The practice of interventional physicians has expanded in the last few years to include placement of stents—not only in coronary arteries but also in carotid arteries and other vessels. As hospitalists, we must be aware of the latest research in this changing field to provide the best evidence-based advice to our patients.

Currently, the only use of carotid stenting that has been approved by the Food and Drug Administration (FDA) is in symptomatic patients with carotid artery stenosis of 70% or more who are at high surgical risk. This FDA approval is based on the results of the Stenting and Angioplasty with Protection in Patients at High Risk for Endarterectomy (SAPPHIRE) study, which included symptomatic patients with carotid artery stenosis exceeding 50% and asymptomatic patients, with stenosis exceeding 80%, who were at high surgical risk mainly due to severe coronary artery disease. The SAPPHIRE study showed that stenting was safer than endarterectomy mainly due to lower risk of myocardial infarction within 30 days after carotid stenting as compared with surgery. There was no significant difference in the rates of stroke or death between stenting and endarterectomy.

Why does the EVA-3S trial reported in NEJM show opposing results? The patients in the trial were different than the ones included in the SAPPHIRE study, and the periprocedural protocol was less strict. The patients in the EVA-3S trial were not at high surgical risk. Further, all patients in the EVA-3S trial had symptomatic carotid artery stenosis, whereas the majority of patients in the SAPPHIRE study were asymptomatic. Use of aspirin and clopidogrel or ticlopidine three days before carotid-artery stenting was only recommended in the EVA-3S trial but was required in the SAPPHIRE trial.

The ongoing Carotid Revascularization Endarterectomy versus Stenting Trial (CREST), funded by the National Institutes of Health, is enrolling patients with an average surgical risk similar to those in the EVA-3S study. The CREST study, which is expected to enroll 2,500 patients, may be able to provide a more definitive answer regarding the best treatment for symptomatic patients with high-grade carotid stenosis with an average surgical risk.

In the meantime, what should we recommend to our patients? For symptomatic patients with carotid artery stenosis of 70% or more, endarterectomy is superior to medical therapy alone. For asymptomatic patients with carotid artery stenosis exceeding 60%, endarterectomy is also superior to medical therapy alone, assuming a risk of perioperative stroke or death of less than 3%. Currently, the only accepted indication for stenting is in symptomatic patients with carotid artery stenosis exceeding 70% and a high surgical risk.

D-Dimer Testing to Risk Stratify VTE Patients

Palareti G, Cosmi B, Legnani C, et al. D-dimer testing to determine the duration of anticoagulation therapy. N Engl J Med. 2006;355:1780-1789.

D-dimer levels have been used to assist in diagnosing initial episodes of venous thromboembolism (VTE). Although not specific, D-dimer testing is very sensitive for VTE, giving it a high negative predictive value. Further, duplex ultrasound often remains abnormal after VTE, making the distinction between recurrent disease and old disease problematic when symptoms recur.

A recent study by Rathbun and colleagues investigated the use of D-dimer measurement in excluding recurrent VTE, finding that of former VTE patients presenting with symptoms, only 0.75% with a negative D-dimer level had recurrent VTE on ultrasound, compared to 6.0% with a positive test who had recurrent VTE. This study, conducted by Palareti and colleagues, tries to go a step further and assess whether D-dimer testing can be used to risk stratify VTE patients who are asymptomatic following treatment for an initial episode of VTE, as well as whether or not it can be used to determine the need to continue anticoagulation.

The PROLONG study was a multicenter prospective study of patients between 18 and 85 who had had their first episode of unprovoked, symptomatic VTE (including pulmonary embolism). Patients were enrolled in this study after completing treatment with vitamin K antagonists (VKA) for at least three months with a target INR (international normalized ratio) in the range of 2-3. Exclusion criteria included severe liver insufficiency, renal insufficiency with serum creatinine >2, or clear indications/contraindications for anticoagulation.

Six hundred twenty-four patients treated for VTE were enrolled in the study. All underwent compressive ultrasound in both legs to establish a baseline at the start of the study and were then instructed to stop anticoagulation. Follow-up occurred in one month, with another ultrasound to assess recurrence of VTE. Five patients were found to have VTE and were excluded. The remaining 619 patients were tested for D-dimer levels and were given thrombophilia tests. A further 11 patients were excluded due to antiphospholipid antibodies or antithrombin deficiency. Patients with factor V Leidin and G20210A mutation on the prothrombin gene were allowed to participate in the study.

Three hundred and eighty-five patients had normal D-dimer levels and were not placed on anticoagulation. The 223 patients with abnormal D-dimer levels were randomized to receive VKA (103 patients) or no treatment (120 patients). All patients were followed for minimum of 18 months. Of the 120 patients with abnormal D-dimer levels who were randomized to no treatment, 18 patients (15.0%) had recurrent VTE. Of the 103 patients with abnormal D-dimer levels who resumed anticoagulation, one had a major bleeding episode and two had recurrent VTE, for a composite result of 2.9%—a statistically significant difference (P<0.005). The group with normal D-dimer levels after initial treatment had 24 episodes of recurrent VTE (6.2%).

The study suggested that the patients with abnormal D-dimer levels who stopped anticoagulation had a statistically significant higher rate of recurrent VTE than those who continued anticoagulation. There was also a statistically significant difference in the recurrent VTE rate in the two groups who did not resume anticoagulation. Interestingly, while the absolute difference between the normal D-dimer group and the abnormal D-dimer group who resumed anticoagulation was evident (6.2% versus 2.9%), this did not reach statistical significance.

This study is promising; however, there are some caveats to take into account when trying to apply these results to current clinical practice. First, the trial was not blinded and only evaluated patients with the first unprovoked episode of VTE. It is unknown if these results will apply to secondary VTE. Older people in this study had a higher incidence of elevated D-dimer at enrollment. The authors utilized a qualitative assay for D-dimer to obtain uniform results across the multiple testing centers. Applying these results to centers that use quantitative measurements of D-dimer then becomes more difficult due to the variability inherent in the interpretation of these quantitative results. Because this study excluded patients with either severe liver disease or renal insufficiency (Cr >2.0), it remains unknown if the results are applicable to these populations.

Because D-dimer levels were only measured once at the time of the patients’ enrollment in the study, it is unknown if patients with normal levels of D-dimer might progress to abnormal D-dimer levels and, therefore, to a potentially higher risk of VTE. This question could be answered with serial testing of D-dimer levels. The study was not powered enough to detect relative risk of bleeding from anticoagulation alone. Thus, these results were taken as a composite with the VTE events.

This study argues that anticoagulation in VTE patients with abnormal D-dimer levels measured after a month of stopping a standard three-month course of anticoagulation should be continued. What is not clear is whether we should continue treating people with normal D-dimer levels. Although not statistically significant, the absolute rate of VTE of 6.2% in these patients was higher than the 2.9% rate in patients with high D-dimer levels who continued anticoagulation.

Early Administration of ACE Inhibitors in MI Patients

Borghi C, Bacchelli S, Degli Esposti D, et al. Effects of early angiotensin-converting enzyme inhibition in patients with non-ST-elevation acute anterior myocardial infarction. Am Heart J. 2006 Sep;152(3):470-477.

Angiotensin-converting enzyme inhibitors (ACEIs) have demonstrated efficacy in improving long-term survival, particularly in patients with ST-elevation MI (STEMI) with left ventricular dysfunction (LVD) and/or congestive heart failure (CHF). There is less information available from clinical trial data, however, regarding the early use of ACEIs with non-ST-elevation MI (NSTEMI) patients, who are believed to be at an overall lower risk of in-hospital morbidity and mortality than STEMI patients.

Researchers focused on the question of ACEI efficacy in NSTEMI in a post hoc analysis of the patients enrolled in the Survival of Myocardial Infarction Long-term Evaluation (SMILE) study. The original study enrolled 1,556 patients with anterior acute MI (AMI) who were admitted to 154 coronary care units in Italy. Participants were patients who presented with chest pain within 24 hours, who demonstrated electrocardiographic signs of anterior wall AMI, and who were not eligible for thrombolytic therapy or reperfusion. These patients did receive beta blockers, nitrates, analgesic agents, inotropic drugs, diuretic agents, and anticoagulation agents as deemed appropriate.

Exclusion criteria included cardiogenic shock, systolic blood pressure below 100 mm Hg, serum creatinine above 2.5 mg per deciliter, a history of CHF, prior treatment with ACEI, and contraindication to the use of ACEI. Patients were randomized to either placebo or the short-acting ACEI zofenopril, with a starting dose of 7.5 mg every 12 hours. The dose was progressively doubled until the final target dose of 30 mg twice a day was reached. Upon completion of a six-week double-blind period, the study medications were stopped, but the patients continued taking their other medications for approximately 48 additional weeks, at which time vital status was blindly obtained by questionnaire or from registry offices. The primary endpoints were the occurrence of death or CHF during the treatment period.

In this post hoc analysis, only the 526 patients with anterior MI were studied. The baseline characteristics of the placebo and zofenopril group were closely matched but were predominantly male. The primary endpoint of this analysis was the combined occurrence of death or severe CHF during the six weeks of treatment with zofenopril or placebo, both given in addition to conventional treatment. Secondary endpoints were the six-week occurrence of severe CHF, nonfatal MI or angina, and cumulative one-year mortality.

The findings of this analysis indicate a relative risk reduction (RRR) of 65% (95% CI 20%­80%, 2P=0.003) of a major cardiovascular event using zofenopril in the first 6 weeks of treatment. Cumulative incidence of combined death and CHF was significantly (P=0.017) greater in the placebo group than in the group of patients given zofenopril. In addition, occurrence of severe CHF was lower in the zofenopril group (RRR 84%, 95% CI 33%­97%), as was one-year mortality (RRR 43%, 95% CI 14%-57%, 2P=0.36). During the six weeks, there was a slightly lower usage of beta blockers in the zofenopril group, as well as lower usage of calcium channel blockers and diuretics in this same group at one year. Systolic blood pressure (SBP) and heart rate did not differ between the two groups.

The authors of this analysis concluded that early treatment for six weeks with zofenopril was effective in reducing death and severe CHF in non-thrombolysed anterior wall NSTEMI patients. The results were independent of SBP reduction, suggesting that zofenopril may have cardioprotective effects, preventing infarct expansion, left ventricular remodeling, and neurohormonal activation, which is involved in coronary vasoconstriction and endothelial dysfunction. Further, the relative risk reduction in composite endpoints of mortality and severe CHF exceeded that observed in the overall population in the SMILE trial (which included STEMI), drawing attention to a particular advantage of the early use of ACEI in NSTEMI patients.

Despite relevant findings, these results were derived from a post hoc analysis of the SMILE study, only including about one third of the original population. It is also a retrospective analysis, albeit recognizing the sparse availability of research in this area, thought to be related to the exclusion of such patients from most clinical trials. This analysis strongly highlights the beneficial effects of early administration ACE inhibition and should prompt prospective evaluation of these agents as first-line therapy in anterior wall NSTEMI. TH

Treat Atrial Flutter

Da Costa A, Thévenin J, Roche F, et al. Results from the Loire-Ardèche-Drôme-Isère-Puy-de-Dôme (LADIP) trial on atrial flutter, a multicentric prospective randomized study comparing amiodarone and radiofrequency ablation after the first episode of symptomatic atrial flutter. Circulation. 2006;114:1676-1681.

Radiofrequency ablation (RFA) has high success rates in atrial flutter, and American College of Cardiology/American Hospital Association guidelines classify a first episode of well-tolerated atrial flutter as a class IIa indication for RFA treatment. The LADIP trial compared RFA with the current practice of electroosmotic flow (EOF) cardioversion plus amiodarone after a first episode of symptomatic atrial flutter.

One hundred and four consecutive patients with a documented first episode of atrial flutter were enrolled over a period of 39 months. Excluded from the study were patients under the age of 70, those who had had previous antiarrythmic treatment for atrial flutter, those who had an amiodarone contraindication, patients with New York Heart Association class IV heart failure, and those who had a history of heart block. All 52 patients in group I received RFA by a standard method. Fifty-one of the 52 patients in group II underwent intracardiac stimulation, followed, if necessary, by external or internal cardioversion. All patients in group II received amiodarone as well as vitamin K antagonists.

The patients were followed up in the outpatient department at one, three, six, 12, and 18 months after randomization and at the end of the study. At each visit, arrhythmic or cardiovascular events were recorded, and a 12-lead ECG was obtained. Patients were fitted with a Holter monitor for seven days if they had recurring palpitations or symptoms. The primary outcome studied was recurrence of symptomatic atrial flutter and occurrence of atrial fibrillation.

After a mean follow-up of 13+/-6 months, atrial flutter recurred in two of the 52 (3.8%) patients in group I and 15 of 51 (29.5%) patients in group II (P<0.0001). In group I, one patient required a second, successful ablation. All the patients who recurred in group II were successfully treated using RFA. The occurrence of significant symptomatic atrial fibrillation was 8% in both groups at the end of the first year. By the end of the study, two patients in group I and one patient in group II were in chronic atrial fibrillation. When all the episodes of atrial fibrillation were counted (including those patients whose episodes lasted <10 minutes but were documented with an event monitor), the groups did not differ significantly.

No procedure-related complications occurred in group I. In the amiodarone group, however, two patients developed hypothyroidism, one developed hyperthyroidism, and two patients had symptomatic sick sinus syndrome. There were a total of 14 deaths during the course of the study (six patients in group I and eight patients in group II); none were related to the study protocol.

This study is the largest to date showing the superiority of RFA to cardioversion plus amiodarone after the first episode of symptomatic atrial flutter. The long-term risk of subsequent atrial fibrillation was found to be similar to that of the amiodarone-treatment group. Because the mean age of patients in this study was 78, however, these findings cannot necessarily be extrapolated to younger patient populations. Further, oral amiodarone was used initially in this study. It can be argued that IV amiodarone is far more efficacious than oral forms in the acute setting. Because RFA is an invasive procedure, it is user-dependent and may be unfeasible in different care settings. Also, RFA might not be as appropriate for many symptomatic patients with atrial flutter and hemodynamic instability. Nevertheless, this study presents hospital-based physicians with an additional consideration in the acute care setting for patients with a first episode of atrial flutter.

A Transitional Care Intervention Trial

Coleman EA, Parry C, Chalmers S, et al. The care transitions intervention: results of a randomized controlled trial. Arch Intern Med. 2006;166:1822-1828.

A growing body of evidence suggests that the quality of health management decreases when patients are transitioned across sites of care—particularly when they are not adequately prepared to self-manage their chronic disease, when they receive conflicting advice from various providers, or when they do not have access to their healthcare providers. Higher rates of medication errors and lack of appropriate follow up compromise patient safety during this vulnerable period. This is a particular problem for hospitalists, who introduce an additional discontinuity into the flow of patient care. Because patients and their caregivers are the only common thread moving across various sites of care, this study targeted them for an intervention designed to improve the quality of transitional care.

The study was done in collaboration with a not-for-profit capitated system in Colorado. To be eligible for the study, patients had to be over age 65 and admitted to one of the participating hospitals. Patients had to be community dwelling with no documented dementia and had to have one of eleven diagnoses selected to reflect a higher likelihood of long-term subacute care or anticoagulation, including stroke, congestive heart failure, COPD, diabetes, hip fracture, coronary artery disease, and pulmonary embolism. The intervention group comprised 379 patients, while the control group was made up of 371 patients.

The intervention model was built on four pillars derived from prior qualitative studies about care transitions:

1. Assistance with medication self-management;
2. A healthcare record owned and maintained by the patient;
3. Timely physician follow-up; and
4. A list of red flags indicative of clinical deterioration.

Intervention-group patients had access to a personal health record that included an active problem list, medications, allergies, and a list of red flags; in addition, these patients received a series of visits and telephone calls with a “transition coach,” an advanced care nurse who encouraged self-care by patients and their caregivers, facilitated communication between providers and patients, and assisted in medication review and reconciliation.

The primary outcome measure was the rate of nonelective rehospitalization at 30, 90, and 180 days after discharge from the index hospitalization. Ninety-five percent of the intervention patients and 94.9% of the control subjects were included in the analysis. Intervention patients had lower adjusted hospital readmission rates than controls at 30 (8.3% versus 11.9%) and 90 days (16.7% versus 22.5%), P=0.048 and 0.04 respectively. The result did not achieve significance at 180 days after discharge (P=0.28). Rehospitalization for the same diagnosis as the index diagnosis within 90 and 180 days of admission was 5.3% in the intervention group versus 9.8% in the control group (P=0.04) and 8.6% in the intervention group versus 13.9% (P=0.045) in the control group, respectively, but did not meet statistical significance within 30 days of readmission.

The concepts of a transition coach and a patient-maintained record are enticing, considering the amount of time hospitalists may invest in patient education and discharge planning processes. This study is different from prior studies in that it used transition coaches instead of healthcare professionals to assume the primary role in managing the post-hospitalization course, and it provided the caregiver and patient with tools that could be applied to future care transitions. The costs of intervention in this study were found to be about $74,310 for the transition coach and other related costs, compared with a semi-annual cost savings of $147,797.

The main drawbacks of the study were that the 180-day all-cause readmission rates did not achieve statistical significance, and even though the adjusted P values for all-cause 30- and 90-day readmission rates were reported to be significant, their 95% confidence interval for the odds ratio barely meets appropriate analytical criteria (OR 0.59 [0.35-1.00] and 0.64 [0.42-0.99]). Also disappointing was the fact that there was no difference in readmission rates at 30 days for the index diagnosis. Therefore, healthcare systems would likely hesitate to implement these interventions without more definitive data showing reductions in adverse outcomes and mortality rates.

Pleural Empyema in CAP Cases

Ahmed RA, Marrie TJ, Huang JQ. Thoracic empyema in patients with community-acquired pneumonia. Am J Med. 2006 Oct;119(10):877-883.

Pleural effusions complicate up to 44% of cases of community-acquired pneumonia (CAP). Of these cases, 10% develop complicated parapneumonic effusions. In the past, pleural empyema has been associated with poor outcomes and high mortality rate. Unfortunately, most of these studies were performed before the advent of newer antimicrobial agents and more modern diagnostic and therapeutic techniques.

This prospective, population-based study included all patients older than 17 who had been admitted with a diagnosis of CAP. Most of these patients were diagnosed and managed according to a “Pneumonia Critical Pathway.” Adherence to any aspect of the pathway by the admitting physician was completely voluntary.

Of 3,675 patients enrolled in the study, 47 (1.3%) were diagnosed with empyema by the attending physician—a number which correlates with previous studies. Of these, only 24 (0.7%) were ultimately classified as “definite empyema” by one or more of the following criteria:

1. Presence of microorganisms on Gram stain or culture of the pleural fluid;
2. Pleural fluid with a pH <7.2 plus radiographic evidence suggesting empyema; and
3. Frank pus in the pleural space at time of thoracoscopy.

The remaining 23 (0.6%) patients were classified as suspected empyema.

The study then compared the patients without empyema with patients with definite empyema. Patients with definite empyema were younger, more likely to have received antibiotics before admission, and more likely to have been admitted to the ICU. Further, these patients had a higher incidence of illicit drug use and frequently presented with a history of systemic symptoms, including fevers, chills, and pleuritic chest pain. Laboratory studies—aside from elevated WBC—were not useful in distinguishing between the two groups. Also, there were no significant features on chest radiographs to separate the two groups, although in patients with complex fluid collections, 19 of 22 patients (86%) with definite empyema had computed tomography (CT) scans suggesting the diagnosis.

Streptococcus milleri was the most common pathogen, isolated in 50% of patients with definite empyema. Patients with definite empyema were more likely to have invasive diagnostic procedures and had longer hospital stays (23.5 +/- 17 days) compared with their CAP counterparts (12.4 +/- 20.2 days, P=0.007).

Clinical and laboratory features remain nonspecific and should be used with caution when differentiating between empyema and complicated pleural effusions. Diagnostic pleural effusion aspiration is essential if infection is suspected. This study also points out the greater need of ICU support in definite empyema cases that suggest a greater severity of illness.

Interestingly, definite empyema had an in-hospital mortality rate of 4.2%, compared with 10% for CAP (P<0.05). Possible reasons for this result included the fact that 50% of the empyema cases were suspected at admission and thereby received earlier antibiotic treatment and more aggressive management than CAP cases.

Rapid Response Systems: A Call for Research

Devita MA, Bellomo R, Hillman K, et al. Findings of the first consensus conference on medical emergency teams. Crit Care Med. 2006 Sep;34(9):2463-2478.

The Institute for Healthcare Improvement has endorsed the concept of Rapid Response Teams (RRTs), and the 2005-2006 SHM survey indicated that 35% of responding hospitalist groups were involved with such systems. The field of in-house medical emergency teams suffers from a lack of quality research, however. Most of the existing data come from single-institution studies, and analysis is limited by a lack of standard definitions or processes. This consensus document addresses these issues and offers a “state of the literature” in RRTs, or—as the authors redefine them—rapid response systems, and attempts to frame the research agenda going forward.

The authors define an in-hospital medical emergency as a “mismatch between patient needs and resources available” and then proceed to outline the various types of responses that have been described, including medical emergency teams (METs), RRTs, and critical care outreach teams (CCO). According to the authors, a MET generally brings ICU capabilities, including procedures and medications, to the bedside, whereas an RRT is a “ramp-up” response, sometimes led by a nurse, that can rapidly assess and triage patients to a higher level of care. To be part of a complete RRS, any of these response options needs to have an adequate detection/triggering arm (“afferent”), a response arm (“efferent”), and administrative and QI components.

After establishing their suggestions for standardized nomenclature and the necessary components of a rapid response system (RRS), the authors review the literature and make several recommendations regarding areas for future research. In particular, they note that there is no data to demonstrate that one set of triggering criteria is superior to another to identify patients who will benefit from an RRS intervention; nor is there adequate literature on the relative effectiveness of the different types of responses. Finally, the authors make a formal recommendation that hospitals implement both afferent and efferent systems, although, interestingly, they do so based on evidence from single-center, historical-control trials and in spite of the lack of benefit seen in the only published multicenter randomized controlled trial (MERIT).

The authors also describe RRS as potentially inexpensive, but offer no data to support this claim. In fact, the prospect of dedicated 24-hour response personnel is probably more daunting for most institutions than the authors acknowledge. In any case, this is excellent reading for hospitalists, who will continue to be key players in the evolution of these systems, and the report is also accompanied by an outstanding bibliography.

Symptomatic Severe Carotid Stenosis: Endarterectomy Versus Stenting

Mas JL, Chatellier G, Beyssen B, et al. Endarterectomy versus stenting in patients with symptomatic severe carotid stenosis. N Engl J Med. 2006;355(16):1660-1671.

Two large, randomized, clinical trials have established endarterectomy as the standard treatment for severe symptomatic carotid artery stenosis. The new method of carotid stenting avoids the need for general anesthesia and may cost less than surgery, but it is unclear if stenting is as effective as or safer than endarterectomy.

The authors conducted a publicly funded, randomized controlled trial in 20 academic and 10 nonacademic centers in France to compare stenting with endarterectomy in patients with symptomatic carotid stenosis. Patients were eligible if they were 18 years of age or older, had had a hemispheric or retinal transient ischemic attack or a nondisabling stroke within 120 days of enrollment, and had a stenosis of 60% to 99% in the symptomatic carotid artery.

Patients were excluded if one of the following was present: a modified Rankin score of three or more (disabling stroke); nonatherosclerotic carotid disease; severe tandem lesions (stenosis of proximal common carotid artery or intracranial artery that was more severe than the cervical lesion); previous revascularization of the symptomatic stenosis; a history of bleeding disorder; uncontrolled hypertension or diabetes; unstable angina; contraindication to heparin, ticlopidine, or clopidogrel; life expectancy of less than two years; or percutaneous or surgical intervention within 30 days before or after the study procedure. The primary endpoint was the incidence of any stroke or death within 30 days after treatment.

The trial (EVA-3S) was stopped early, after the inclusion of 527 patients, for reasons of both safety and futility. The 30-day risk of any stroke or death was significantly higher after stenting (9.6%) than after endarterectomy (3.9%), resulting in a relative risk of 2.5 (95% CI, 1.2 to 5.1). The 30-day incidence of disabling stroke or death was 1.5% after endarterectomy (95% CI, 0.5 to 4.2) and 3.4% after stenting (95% CI, 1.7 to 6.7); the relative risk was 2.2 (95% CI, 0.7 to 7.2). At six months, the incidence of any stroke or death was 6.1% after endarterectomy and 11.7% after stenting (P=0.02). Cranial nerve injury was more common after endarterectomy than after stenting.

The practice of interventional physicians has expanded in the last few years to include placement of stents—not only in coronary arteries but also in carotid arteries and other vessels. As hospitalists, we must be aware of the latest research in this changing field to provide the best evidence-based advice to our patients.

Currently, the only use of carotid stenting that has been approved by the Food and Drug Administration (FDA) is in symptomatic patients with carotid artery stenosis of 70% or more who are at high surgical risk. This FDA approval is based on the results of the Stenting and Angioplasty with Protection in Patients at High Risk for Endarterectomy (SAPPHIRE) study, which included symptomatic patients with carotid artery stenosis exceeding 50% and asymptomatic patients, with stenosis exceeding 80%, who were at high surgical risk mainly due to severe coronary artery disease. The SAPPHIRE study showed that stenting was safer than endarterectomy mainly due to lower risk of myocardial infarction within 30 days after carotid stenting as compared with surgery. There was no significant difference in the rates of stroke or death between stenting and endarterectomy.

Why does the EVA-3S trial reported in NEJM show opposing results? The patients in the trial were different than the ones included in the SAPPHIRE study, and the periprocedural protocol was less strict. The patients in the EVA-3S trial were not at high surgical risk. Further, all patients in the EVA-3S trial had symptomatic carotid artery stenosis, whereas the majority of patients in the SAPPHIRE study were asymptomatic. Use of aspirin and clopidogrel or ticlopidine three days before carotid-artery stenting was only recommended in the EVA-3S trial but was required in the SAPPHIRE trial.

The ongoing Carotid Revascularization Endarterectomy versus Stenting Trial (CREST), funded by the National Institutes of Health, is enrolling patients with an average surgical risk similar to those in the EVA-3S study. The CREST study, which is expected to enroll 2,500 patients, may be able to provide a more definitive answer regarding the best treatment for symptomatic patients with high-grade carotid stenosis with an average surgical risk.

In the meantime, what should we recommend to our patients? For symptomatic patients with carotid artery stenosis of 70% or more, endarterectomy is superior to medical therapy alone. For asymptomatic patients with carotid artery stenosis exceeding 60%, endarterectomy is also superior to medical therapy alone, assuming a risk of perioperative stroke or death of less than 3%. Currently, the only accepted indication for stenting is in symptomatic patients with carotid artery stenosis exceeding 70% and a high surgical risk.

D-Dimer Testing to Risk Stratify VTE Patients

Palareti G, Cosmi B, Legnani C, et al. D-dimer testing to determine the duration of anticoagulation therapy. N Engl J Med. 2006;355:1780-1789.

D-dimer levels have been used to assist in diagnosing initial episodes of venous thromboembolism (VTE). Although not specific, D-dimer testing is very sensitive for VTE, giving it a high negative predictive value. Further, duplex ultrasound often remains abnormal after VTE, making the distinction between recurrent disease and old disease problematic when symptoms recur.

A recent study by Rathbun and colleagues investigated the use of D-dimer measurement in excluding recurrent VTE, finding that of former VTE patients presenting with symptoms, only 0.75% with a negative D-dimer level had recurrent VTE on ultrasound, compared to 6.0% with a positive test who had recurrent VTE. This study, conducted by Palareti and colleagues, tries to go a step further and assess whether D-dimer testing can be used to risk stratify VTE patients who are asymptomatic following treatment for an initial episode of VTE, as well as whether or not it can be used to determine the need to continue anticoagulation.

The PROLONG study was a multicenter prospective study of patients between 18 and 85 who had had their first episode of unprovoked, symptomatic VTE (including pulmonary embolism). Patients were enrolled in this study after completing treatment with vitamin K antagonists (VKA) for at least three months with a target INR (international normalized ratio) in the range of 2-3. Exclusion criteria included severe liver insufficiency, renal insufficiency with serum creatinine >2, or clear indications/contraindications for anticoagulation.

Six hundred twenty-four patients treated for VTE were enrolled in the study. All underwent compressive ultrasound in both legs to establish a baseline at the start of the study and were then instructed to stop anticoagulation. Follow-up occurred in one month, with another ultrasound to assess recurrence of VTE. Five patients were found to have VTE and were excluded. The remaining 619 patients were tested for D-dimer levels and were given thrombophilia tests. A further 11 patients were excluded due to antiphospholipid antibodies or antithrombin deficiency. Patients with factor V Leidin and G20210A mutation on the prothrombin gene were allowed to participate in the study.

Three hundred and eighty-five patients had normal D-dimer levels and were not placed on anticoagulation. The 223 patients with abnormal D-dimer levels were randomized to receive VKA (103 patients) or no treatment (120 patients). All patients were followed for minimum of 18 months. Of the 120 patients with abnormal D-dimer levels who were randomized to no treatment, 18 patients (15.0%) had recurrent VTE. Of the 103 patients with abnormal D-dimer levels who resumed anticoagulation, one had a major bleeding episode and two had recurrent VTE, for a composite result of 2.9%—a statistically significant difference (P<0.005). The group with normal D-dimer levels after initial treatment had 24 episodes of recurrent VTE (6.2%).

The study suggested that the patients with abnormal D-dimer levels who stopped anticoagulation had a statistically significant higher rate of recurrent VTE than those who continued anticoagulation. There was also a statistically significant difference in the recurrent VTE rate in the two groups who did not resume anticoagulation. Interestingly, while the absolute difference between the normal D-dimer group and the abnormal D-dimer group who resumed anticoagulation was evident (6.2% versus 2.9%), this did not reach statistical significance.

This study is promising; however, there are some caveats to take into account when trying to apply these results to current clinical practice. First, the trial was not blinded and only evaluated patients with the first unprovoked episode of VTE. It is unknown if these results will apply to secondary VTE. Older people in this study had a higher incidence of elevated D-dimer at enrollment. The authors utilized a qualitative assay for D-dimer to obtain uniform results across the multiple testing centers. Applying these results to centers that use quantitative measurements of D-dimer then becomes more difficult due to the variability inherent in the interpretation of these quantitative results. Because this study excluded patients with either severe liver disease or renal insufficiency (Cr >2.0), it remains unknown if the results are applicable to these populations.

Because D-dimer levels were only measured once at the time of the patients’ enrollment in the study, it is unknown if patients with normal levels of D-dimer might progress to abnormal D-dimer levels and, therefore, to a potentially higher risk of VTE. This question could be answered with serial testing of D-dimer levels. The study was not powered enough to detect relative risk of bleeding from anticoagulation alone. Thus, these results were taken as a composite with the VTE events.

This study argues that anticoagulation in VTE patients with abnormal D-dimer levels measured after a month of stopping a standard three-month course of anticoagulation should be continued. What is not clear is whether we should continue treating people with normal D-dimer levels. Although not statistically significant, the absolute rate of VTE of 6.2% in these patients was higher than the 2.9% rate in patients with high D-dimer levels who continued anticoagulation.

Early Administration of ACE Inhibitors in MI Patients

Borghi C, Bacchelli S, Degli Esposti D, et al. Effects of early angiotensin-converting enzyme inhibition in patients with non-ST-elevation acute anterior myocardial infarction. Am Heart J. 2006 Sep;152(3):470-477.

Angiotensin-converting enzyme inhibitors (ACEIs) have demonstrated efficacy in improving long-term survival, particularly in patients with ST-elevation MI (STEMI) with left ventricular dysfunction (LVD) and/or congestive heart failure (CHF). There is less information available from clinical trial data, however, regarding the early use of ACEIs with non-ST-elevation MI (NSTEMI) patients, who are believed to be at an overall lower risk of in-hospital morbidity and mortality than STEMI patients.

Researchers focused on the question of ACEI efficacy in NSTEMI in a post hoc analysis of the patients enrolled in the Survival of Myocardial Infarction Long-term Evaluation (SMILE) study. The original study enrolled 1,556 patients with anterior acute MI (AMI) who were admitted to 154 coronary care units in Italy. Participants were patients who presented with chest pain within 24 hours, who demonstrated electrocardiographic signs of anterior wall AMI, and who were not eligible for thrombolytic therapy or reperfusion. These patients did receive beta blockers, nitrates, analgesic agents, inotropic drugs, diuretic agents, and anticoagulation agents as deemed appropriate.

Exclusion criteria included cardiogenic shock, systolic blood pressure below 100 mm Hg, serum creatinine above 2.5 mg per deciliter, a history of CHF, prior treatment with ACEI, and contraindication to the use of ACEI. Patients were randomized to either placebo or the short-acting ACEI zofenopril, with a starting dose of 7.5 mg every 12 hours. The dose was progressively doubled until the final target dose of 30 mg twice a day was reached. Upon completion of a six-week double-blind period, the study medications were stopped, but the patients continued taking their other medications for approximately 48 additional weeks, at which time vital status was blindly obtained by questionnaire or from registry offices. The primary endpoints were the occurrence of death or CHF during the treatment period.

In this post hoc analysis, only the 526 patients with anterior MI were studied. The baseline characteristics of the placebo and zofenopril group were closely matched but were predominantly male. The primary endpoint of this analysis was the combined occurrence of death or severe CHF during the six weeks of treatment with zofenopril or placebo, both given in addition to conventional treatment. Secondary endpoints were the six-week occurrence of severe CHF, nonfatal MI or angina, and cumulative one-year mortality.

The findings of this analysis indicate a relative risk reduction (RRR) of 65% (95% CI 20%­80%, 2P=0.003) of a major cardiovascular event using zofenopril in the first 6 weeks of treatment. Cumulative incidence of combined death and CHF was significantly (P=0.017) greater in the placebo group than in the group of patients given zofenopril. In addition, occurrence of severe CHF was lower in the zofenopril group (RRR 84%, 95% CI 33%­97%), as was one-year mortality (RRR 43%, 95% CI 14%-57%, 2P=0.36). During the six weeks, there was a slightly lower usage of beta blockers in the zofenopril group, as well as lower usage of calcium channel blockers and diuretics in this same group at one year. Systolic blood pressure (SBP) and heart rate did not differ between the two groups.

The authors of this analysis concluded that early treatment for six weeks with zofenopril was effective in reducing death and severe CHF in non-thrombolysed anterior wall NSTEMI patients. The results were independent of SBP reduction, suggesting that zofenopril may have cardioprotective effects, preventing infarct expansion, left ventricular remodeling, and neurohormonal activation, which is involved in coronary vasoconstriction and endothelial dysfunction. Further, the relative risk reduction in composite endpoints of mortality and severe CHF exceeded that observed in the overall population in the SMILE trial (which included STEMI), drawing attention to a particular advantage of the early use of ACEI in NSTEMI patients.

Despite relevant findings, these results were derived from a post hoc analysis of the SMILE study, only including about one third of the original population. It is also a retrospective analysis, albeit recognizing the sparse availability of research in this area, thought to be related to the exclusion of such patients from most clinical trials. This analysis strongly highlights the beneficial effects of early administration ACE inhibition and should prompt prospective evaluation of these agents as first-line therapy in anterior wall NSTEMI. TH

Patient history: The patient is a 53-year-old woman, 70 days status post-allogenic stem-cell transplantation for multiple myeloma. She presents with fever, mental status changes, and abdominal distension. Abdominal films are ordered.

Salient Findings

The patient has air within the wall of the bladder (see Figure 1 below, white arrow) and within the bladder lumen, diagnostic for emphysematous cystitis. On the lateral film the intravesicular air layers with a gravity dependent air-fluid level (see Figure 2 below, black arrow). The gas in the bladder wall is seen circumferentially. Because the lucency (air) remains in the dependent portions of the bladder, it must be in the bladder wall itself.

Patient population and disease history

Fifty to 80% of patients with emphysematous cystitis are diabetic. Other predisposing factors include immunosuppression, indwelling catheters, neutropenic bladders, female gender, and bladder outlet obstruction.

Most cases are caused by E. coli; less common pathogens are Enterobacter aerogenes and Klebsiella pneumoniae.

Management

Emphysematous infections are gas-forming infections of unknown mechanism. Common symptoms of emphysematous cystitis include abdominal pain, dysuria, and pneumaturia. Most patients with emphysematous cystitis (involvement of bladder only) respond well to systemic antibiotics, good bladder drainage, and excellent glycemic control.

On occasion, patients require cystectomy if unresponsive to medical management alone. Emphysematous pyelonephritis (involvement of renal parenchymal, intrarenal collecting system, and/or perinephric tissues), on the other hand, requires antibiotics along with surgical intervention. Percutaneous catheter placement is indicated for gas in the collecting system or renal parenchyma. Further extension of the gas or abscess formation may require surgical resection and/or total nephrectomy. Patients with emphysematous pyelonephritis should have a CT scan to define the extent of involvement.

Take-home points:

• Emphysematous cystitis is most common in diabetics;
• Pathogenesis is unclear at present;
• Emphysematous cystitis typically responds to IV antibiotics; and
• Emphysematous pyelonephritis requires systemic antibiotics and surgical intervention (percutaneous catheterization, resection of involved tissue, or total nephrectomy). CT can characterize the extent of tissue involvement and guide treatment. TH

Helena Summers is a radiology resident and Erik Summers is a hospitalist at the Mayo Clinic College of Medicine, Rochester, Minn.

References

1. Stamm WE; Harrison’s Textbook of Internal Medicine, 16th ed; 2005, McGraw-Hill. Chapter 269.
2. Huang JJ, Tseng CC. Emphysematous pyelonephritis: clinicoradiological classification, management, prognosis, and pathogenesis. Arch Intern Med. 2000;Mar 27;160(6):797-805.
3. Evanoff GV, Thompson CS, Foley R, Weinman EJ. Spectrum of gas within the kidney. Emphysematous pyelonephritis and emphysematous pyelitis. Am J Med. 1987 Jul;83(1):149-154.

Patient history: The patient is a 53-year-old woman, 70 days status post-allogenic stem-cell transplantation for multiple myeloma. She presents with fever, mental status changes, and abdominal distension. Abdominal films are ordered.

Salient Findings

The patient has air within the wall of the bladder (see Figure 1 below, white arrow) and within the bladder lumen, diagnostic for emphysematous cystitis. On the lateral film the intravesicular air layers with a gravity dependent air-fluid level (see Figure 2 below, black arrow). The gas in the bladder wall is seen circumferentially. Because the lucency (air) remains in the dependent portions of the bladder, it must be in the bladder wall itself.

Patient population and disease history

Fifty to 80% of patients with emphysematous cystitis are diabetic. Other predisposing factors include immunosuppression, indwelling catheters, neutropenic bladders, female gender, and bladder outlet obstruction.

Most cases are caused by E. coli; less common pathogens are Enterobacter aerogenes and Klebsiella pneumoniae.

Management

Emphysematous infections are gas-forming infections of unknown mechanism. Common symptoms of emphysematous cystitis include abdominal pain, dysuria, and pneumaturia. Most patients with emphysematous cystitis (involvement of bladder only) respond well to systemic antibiotics, good bladder drainage, and excellent glycemic control.

On occasion, patients require cystectomy if unresponsive to medical management alone. Emphysematous pyelonephritis (involvement of renal parenchymal, intrarenal collecting system, and/or perinephric tissues), on the other hand, requires antibiotics along with surgical intervention. Percutaneous catheter placement is indicated for gas in the collecting system or renal parenchyma. Further extension of the gas or abscess formation may require surgical resection and/or total nephrectomy. Patients with emphysematous pyelonephritis should have a CT scan to define the extent of involvement.

Take-home points:

• Emphysematous cystitis is most common in diabetics;
• Pathogenesis is unclear at present;
• Emphysematous cystitis typically responds to IV antibiotics; and
• Emphysematous pyelonephritis requires systemic antibiotics and surgical intervention (percutaneous catheterization, resection of involved tissue, or total nephrectomy). CT can characterize the extent of tissue involvement and guide treatment. TH

Helena Summers is a radiology resident and Erik Summers is a hospitalist at the Mayo Clinic College of Medicine, Rochester, Minn.

References

1. Stamm WE; Harrison’s Textbook of Internal Medicine, 16th ed; 2005, McGraw-Hill. Chapter 269.
2. Huang JJ, Tseng CC. Emphysematous pyelonephritis: clinicoradiological classification, management, prognosis, and pathogenesis. Arch Intern Med. 2000;Mar 27;160(6):797-805.
3. Evanoff GV, Thompson CS, Foley R, Weinman EJ. Spectrum of gas within the kidney. Emphysematous pyelonephritis and emphysematous pyelitis. Am J Med. 1987 Jul;83(1):149-154.

Patient history: The patient is a 53-year-old woman, 70 days status post-allogenic stem-cell transplantation for multiple myeloma. She presents with fever, mental status changes, and abdominal distension. Abdominal films are ordered.

Salient Findings

The patient has air within the wall of the bladder (see Figure 1 below, white arrow) and within the bladder lumen, diagnostic for emphysematous cystitis. On the lateral film the intravesicular air layers with a gravity dependent air-fluid level (see Figure 2 below, black arrow). The gas in the bladder wall is seen circumferentially. Because the lucency (air) remains in the dependent portions of the bladder, it must be in the bladder wall itself.

Patient population and disease history

Fifty to 80% of patients with emphysematous cystitis are diabetic. Other predisposing factors include immunosuppression, indwelling catheters, neutropenic bladders, female gender, and bladder outlet obstruction.

Most cases are caused by E. coli; less common pathogens are Enterobacter aerogenes and Klebsiella pneumoniae.

Management

Emphysematous infections are gas-forming infections of unknown mechanism. Common symptoms of emphysematous cystitis include abdominal pain, dysuria, and pneumaturia. Most patients with emphysematous cystitis (involvement of bladder only) respond well to systemic antibiotics, good bladder drainage, and excellent glycemic control.

On occasion, patients require cystectomy if unresponsive to medical management alone. Emphysematous pyelonephritis (involvement of renal parenchymal, intrarenal collecting system, and/or perinephric tissues), on the other hand, requires antibiotics along with surgical intervention. Percutaneous catheter placement is indicated for gas in the collecting system or renal parenchyma. Further extension of the gas or abscess formation may require surgical resection and/or total nephrectomy. Patients with emphysematous pyelonephritis should have a CT scan to define the extent of involvement.

Take-home points:

• Emphysematous cystitis is most common in diabetics;
• Pathogenesis is unclear at present;
• Emphysematous cystitis typically responds to IV antibiotics; and
• Emphysematous pyelonephritis requires systemic antibiotics and surgical intervention (percutaneous catheterization, resection of involved tissue, or total nephrectomy). CT can characterize the extent of tissue involvement and guide treatment. TH

Helena Summers is a radiology resident and Erik Summers is a hospitalist at the Mayo Clinic College of Medicine, Rochester, Minn.

References

1. Stamm WE; Harrison’s Textbook of Internal Medicine, 16th ed; 2005, McGraw-Hill. Chapter 269.
2. Huang JJ, Tseng CC. Emphysematous pyelonephritis: clinicoradiological classification, management, prognosis, and pathogenesis. Arch Intern Med. 2000;Mar 27;160(6):797-805.
3. Evanoff GV, Thompson CS, Foley R, Weinman EJ. Spectrum of gas within the kidney. Emphysematous pyelonephritis and emphysematous pyelitis. Am J Med. 1987 Jul;83(1):149-154.

You know them, you’ve received some, and so have your colleagues: those zinger questions—the tough questions your patients ask that momentarily throw you for a loop. Sometimes they’re simple, other times complex, and their psychological origin can be multifaceted. In any case, responding to zingers requires calm, diplomacy, and tact.

“How you respond to the inevitable zingers depends in large part upon your preparation,” writes Laura Sachs Hills in her Nov/Dec 2005 article in the Journal of Practice Management.1 That preparation, she suggests, is best established using staff training, group work, brainstorming, and role-play scenarios.

Both hospitalists and primary care physicians, writes Bernard Lo, MD, must be prepared for patients to ask difficult questions or make unsettling comments, even about the hospitalist system itself.2 Anticipating the nature of those comments or questions is likely to help the hospitalist respond in the moment.

“I don’t see these so much as zingers as challenging or uncomfortable questions or attempts by patients to assert some control,” says Steven Pantilat, MD, FACP, associate professor of clinical medicine in the Department of Medicine at the University of California, San Francisco, and past president of SHM.

Dr. Pantilat believes that the term “zinger” can imply they are used with malicious intent, yet, he comments, “I’m not sure they are, even if they are an attempt to exert control or challenge the physician. I suspect they arise from fear or other responses.” Below, some of the zingers Dr. Pantilat has dealt with.

How long have you been a doctor? “I’ve now been one long enough not to be flustered by this question, but many hospitalists are young and may be taken aback,” says Dr. Pantilat. “It’s a challenge to the doctor’s authority and expertise.”

Doc, you look so young is a related comment, believes Dr. Pantilat—one that can be interpreted as a compliment or a zinger. “My standard response is always, ‘I’m old enough to take that as a compliment,’ ” he says. “These days I really mean it.”

Vineet Aurora, MD, hospitalist at the University of Chicago Medical Center, says she is sometimes asked, “How old are you?”

“I think it happens to a lot of women who are or look young,” she says. “I usually just state my age, [which is] 32. Often they will say, ‘Oh you look much younger,’ and I take that as a compliment and laugh it off. I think most of the time our patients are just curious. It may also be related to height, and several of us speculate that shorter women may experience this more.”

Ian Jenkins, MD, a hospitalist at the University of California, San Diego, and an associate professor of clinical medicine, shares this zinger: You don't want to order this MRI for my back pain because it’s expensive, so why don’t you just admit it?

His response: “That’s right. We have a certain amount of money to take care of you and the rest of our patients and to do the best job possible. We can’t waste any of it on unnecessary tests or therapies, so you’ve gotten exactly what I would want if I had your back pain—a thorough history and physical exam.”

Here are some zingers from Vijay Rajput, MD, senior hospitalist at Cooper University Hospital, Camden, N.J., associate professor of medicine and program director, Internal Medicine Residency Program, University of Medicine and Dentistry, Robert Wood Johnson Medical School, Piscataway, N.J.º

What’s going on [with my condition]? “Sometimes when I say, ‘I don’t know,’ the patient comes back with, ‘How come you don’t know?’ I usually say, ‘Do you think that we need to know everything in medicine?’ ” says Dr. Rajput. “They usually say, ‘No, not necessarily, but I thought for my condition you might know.’ ”

Dr. Rajput continues, “Sometimes I tell them, ‘Medicine has advanced too fast … many times we [need] more updated knowledge, and sometimes we are not updated … . I would rather update the knowledge and do the right thing for you … than provide you with care with a half-knowledge.’ Most of the people will like and understand that answer.”

Dr. Rajput tells another anecdote: “One time I was rounding with the team on the floor and we all—students, residents, a pharmacy student, and myself—were Asian, [with] three of [us] … born here in the U.S. The patient asked, ‘How come there are too many foreign doctors in this country?’

“That was a zinger,” recalls Dr. Rajput, “and my team thought I [would] pass [on it], but I didn’t. I gave the patient a straight answer with a true explanation. It took a few minutes to explain it in detail.

“I asked him, ‘What is [your] perception?’ He did not have an answer. I explained to him that 25% of [the] doctors [in the U.S.] are not born in this country, and we have a constant need for more doctors. We have proper mechanisms [in place] so that these doctors are trained as well as in American schools and residencies before they start their practice. I also explained the relationships with Educational Commission for Foreign Medical Graduates (ECFMG), National Board of Medical Examiners (NBME), and Council for Graduate Medical Education (ACGME) and said that three out of four of us are U.S.-born and not ‘foreign’ doctors.”

David M. Grace, MD, of The Schumacher Group is a hospitalist practice director in Lafayette, La.; he remembers this zinger: If it’s OK with you, I’d like to stay today and go home tomorrow.

“At least once a week, I have a patient who just doesn’t feel up to going home at the appropriate time of discharge. My response always starts with ‘Why?’ All patients have the right to a safe and stable discharge from the hospital, and it’s important to ensure that no pertinent issues have been overlooked. Is their home support system not ready yet? Is payday tomorrow, and they can’t afford their medicines today? Are they just scared?

“Once I’m satisfied that no occult dangers exist, I sit and discuss the situation with the patient. I first remind them of our discussion … at admission; it’s the same discussion I have with every patient,” says Dr. Grace. “During the admission process, I outline what objectives need to be reached prior to discharge. I emphasize that the role of hospitalization is not to cure the patient but to ‘rectify the problems that require inpatient care’ and allow the convalescence to take place at home.

“Occasionally I have patients [with whom] my first-line strategy doesn’t work, and I move on to plan B. Plan B is where I quote statistics such as, ‘100,000 patients per year die in hospitals due to errors, and on average, each inpatient will have one medication error per day.’ Continuing to stay in the hospital beyond today will shift the risk/benefit ratio to a position where the patient would have additional risk but no additional medical benefit.

“Plan C is rarely used, but it’s in my arsenal,” he says. “I remind the patient that I’m responsible for doing what is medically appropriate, and I reiterate that I understand their concerns, but I cannot commit healthcare fraud by documenting that the patient is not stable for discharge when they are stable. I then shift the decision back to the patient by closing with, ‘We don’t force patients to leave or drag them out of the hospital; however, you need to check with your insurance carrier about whether they will cover the cost of a non-necessary additional hospital day.’ I inform them that the hospital will likely charge the additional day to the patient, and I don’t want to see them get an unexpected bill.”

Another of the zingers Dr. Grace has dealt with: I’m supposed to have test X done as an outpatient, but now that I’m here in the hospital, can we just do it now?

“On days where Lady Luck is shining on me, it’s a test we need to do as part of [the patient’s] acute work-up, and everything works out well. More often than not, it’s a test or procedure unrelated to the admitting diagnoses and one [that] is far more expensive to do as an inpatient, compared with an outpatient study.

“When possible, I’ll explain to the patient that the test they want may not be accurate in the setting of an acute illness, such as the test for lipid levels,” he says. “If the test doesn’t fit into that category, I’ll explain—depending on the request, such as one for an MRI or CT—that they may make it halfway through the test, and the test will need to be aborted because of an acutely sick patient who requires immediate intervention using that piece of equipment, which for the patient would mean that they may need to go through the procedure a second time, or possibly even a third.

“Failing that approach,” he continues, “I often make the insurance company the ‘bad one’ and inform them that their carrier may not pay for the test as an inpatient as it’s not related to their medical illness, and they should check to ensure that the bill won’t be passed on to them. Often the patient, who knows how much of a headache it can be to deal with their insurance company, will drop the request.” TH

Andrea Sattinger writes frequently for The Hospitalist.

References

1. Hills LS. How to answer the most common zinger questions. J Med Pract Manage. 2005 Nov-Dec;21(3):153-155.
2. Lo B. Ethical and policy implications of hospitalist systems. Am J Med. 2001;111:48-52.

You know them, you’ve received some, and so have your colleagues: those zinger questions—the tough questions your patients ask that momentarily throw you for a loop. Sometimes they’re simple, other times complex, and their psychological origin can be multifaceted. In any case, responding to zingers requires calm, diplomacy, and tact.

“How you respond to the inevitable zingers depends in large part upon your preparation,” writes Laura Sachs Hills in her Nov/Dec 2005 article in the Journal of Practice Management.1 That preparation, she suggests, is best established using staff training, group work, brainstorming, and role-play scenarios.

Both hospitalists and primary care physicians, writes Bernard Lo, MD, must be prepared for patients to ask difficult questions or make unsettling comments, even about the hospitalist system itself.2 Anticipating the nature of those comments or questions is likely to help the hospitalist respond in the moment.

“I don’t see these so much as zingers as challenging or uncomfortable questions or attempts by patients to assert some control,” says Steven Pantilat, MD, FACP, associate professor of clinical medicine in the Department of Medicine at the University of California, San Francisco, and past president of SHM.

Dr. Pantilat believes that the term “zinger” can imply they are used with malicious intent, yet, he comments, “I’m not sure they are, even if they are an attempt to exert control or challenge the physician. I suspect they arise from fear or other responses.” Below, some of the zingers Dr. Pantilat has dealt with.

How long have you been a doctor? “I’ve now been one long enough not to be flustered by this question, but many hospitalists are young and may be taken aback,” says Dr. Pantilat. “It’s a challenge to the doctor’s authority and expertise.”

Doc, you look so young is a related comment, believes Dr. Pantilat—one that can be interpreted as a compliment or a zinger. “My standard response is always, ‘I’m old enough to take that as a compliment,’ ” he says. “These days I really mean it.”

Vineet Aurora, MD, hospitalist at the University of Chicago Medical Center, says she is sometimes asked, “How old are you?”

“I think it happens to a lot of women who are or look young,” she says. “I usually just state my age, [which is] 32. Often they will say, ‘Oh you look much younger,’ and I take that as a compliment and laugh it off. I think most of the time our patients are just curious. It may also be related to height, and several of us speculate that shorter women may experience this more.”

Ian Jenkins, MD, a hospitalist at the University of California, San Diego, and an associate professor of clinical medicine, shares this zinger: You don't want to order this MRI for my back pain because it’s expensive, so why don’t you just admit it?

His response: “That’s right. We have a certain amount of money to take care of you and the rest of our patients and to do the best job possible. We can’t waste any of it on unnecessary tests or therapies, so you’ve gotten exactly what I would want if I had your back pain—a thorough history and physical exam.”

Here are some zingers from Vijay Rajput, MD, senior hospitalist at Cooper University Hospital, Camden, N.J., associate professor of medicine and program director, Internal Medicine Residency Program, University of Medicine and Dentistry, Robert Wood Johnson Medical School, Piscataway, N.J.º

What’s going on [with my condition]? “Sometimes when I say, ‘I don’t know,’ the patient comes back with, ‘How come you don’t know?’ I usually say, ‘Do you think that we need to know everything in medicine?’ ” says Dr. Rajput. “They usually say, ‘No, not necessarily, but I thought for my condition you might know.’ ”

Dr. Rajput continues, “Sometimes I tell them, ‘Medicine has advanced too fast … many times we [need] more updated knowledge, and sometimes we are not updated … . I would rather update the knowledge and do the right thing for you … than provide you with care with a half-knowledge.’ Most of the people will like and understand that answer.”

Dr. Rajput tells another anecdote: “One time I was rounding with the team on the floor and we all—students, residents, a pharmacy student, and myself—were Asian, [with] three of [us] … born here in the U.S. The patient asked, ‘How come there are too many foreign doctors in this country?’

“That was a zinger,” recalls Dr. Rajput, “and my team thought I [would] pass [on it], but I didn’t. I gave the patient a straight answer with a true explanation. It took a few minutes to explain it in detail.

“I asked him, ‘What is [your] perception?’ He did not have an answer. I explained to him that 25% of [the] doctors [in the U.S.] are not born in this country, and we have a constant need for more doctors. We have proper mechanisms [in place] so that these doctors are trained as well as in American schools and residencies before they start their practice. I also explained the relationships with Educational Commission for Foreign Medical Graduates (ECFMG), National Board of Medical Examiners (NBME), and Council for Graduate Medical Education (ACGME) and said that three out of four of us are U.S.-born and not ‘foreign’ doctors.”

David M. Grace, MD, of The Schumacher Group is a hospitalist practice director in Lafayette, La.; he remembers this zinger: If it’s OK with you, I’d like to stay today and go home tomorrow.

“At least once a week, I have a patient who just doesn’t feel up to going home at the appropriate time of discharge. My response always starts with ‘Why?’ All patients have the right to a safe and stable discharge from the hospital, and it’s important to ensure that no pertinent issues have been overlooked. Is their home support system not ready yet? Is payday tomorrow, and they can’t afford their medicines today? Are they just scared?

“Once I’m satisfied that no occult dangers exist, I sit and discuss the situation with the patient. I first remind them of our discussion … at admission; it’s the same discussion I have with every patient,” says Dr. Grace. “During the admission process, I outline what objectives need to be reached prior to discharge. I emphasize that the role of hospitalization is not to cure the patient but to ‘rectify the problems that require inpatient care’ and allow the convalescence to take place at home.

“Occasionally I have patients [with whom] my first-line strategy doesn’t work, and I move on to plan B. Plan B is where I quote statistics such as, ‘100,000 patients per year die in hospitals due to errors, and on average, each inpatient will have one medication error per day.’ Continuing to stay in the hospital beyond today will shift the risk/benefit ratio to a position where the patient would have additional risk but no additional medical benefit.

“Plan C is rarely used, but it’s in my arsenal,” he says. “I remind the patient that I’m responsible for doing what is medically appropriate, and I reiterate that I understand their concerns, but I cannot commit healthcare fraud by documenting that the patient is not stable for discharge when they are stable. I then shift the decision back to the patient by closing with, ‘We don’t force patients to leave or drag them out of the hospital; however, you need to check with your insurance carrier about whether they will cover the cost of a non-necessary additional hospital day.’ I inform them that the hospital will likely charge the additional day to the patient, and I don’t want to see them get an unexpected bill.”

Another of the zingers Dr. Grace has dealt with: I’m supposed to have test X done as an outpatient, but now that I’m here in the hospital, can we just do it now?

“On days where Lady Luck is shining on me, it’s a test we need to do as part of [the patient’s] acute work-up, and everything works out well. More often than not, it’s a test or procedure unrelated to the admitting diagnoses and one [that] is far more expensive to do as an inpatient, compared with an outpatient study.

“When possible, I’ll explain to the patient that the test they want may not be accurate in the setting of an acute illness, such as the test for lipid levels,” he says. “If the test doesn’t fit into that category, I’ll explain—depending on the request, such as one for an MRI or CT—that they may make it halfway through the test, and the test will need to be aborted because of an acutely sick patient who requires immediate intervention using that piece of equipment, which for the patient would mean that they may need to go through the procedure a second time, or possibly even a third.

“Failing that approach,” he continues, “I often make the insurance company the ‘bad one’ and inform them that their carrier may not pay for the test as an inpatient as it’s not related to their medical illness, and they should check to ensure that the bill won’t be passed on to them. Often the patient, who knows how much of a headache it can be to deal with their insurance company, will drop the request.” TH

Andrea Sattinger writes frequently for The Hospitalist.

References

1. Hills LS. How to answer the most common zinger questions. J Med Pract Manage. 2005 Nov-Dec;21(3):153-155.
2. Lo B. Ethical and policy implications of hospitalist systems. Am J Med. 2001;111:48-52.

You know them, you’ve received some, and so have your colleagues: those zinger questions—the tough questions your patients ask that momentarily throw you for a loop. Sometimes they’re simple, other times complex, and their psychological origin can be multifaceted. In any case, responding to zingers requires calm, diplomacy, and tact.

“How you respond to the inevitable zingers depends in large part upon your preparation,” writes Laura Sachs Hills in her Nov/Dec 2005 article in the Journal of Practice Management.1 That preparation, she suggests, is best established using staff training, group work, brainstorming, and role-play scenarios.

Both hospitalists and primary care physicians, writes Bernard Lo, MD, must be prepared for patients to ask difficult questions or make unsettling comments, even about the hospitalist system itself.2 Anticipating the nature of those comments or questions is likely to help the hospitalist respond in the moment.

“I don’t see these so much as zingers as challenging or uncomfortable questions or attempts by patients to assert some control,” says Steven Pantilat, MD, FACP, associate professor of clinical medicine in the Department of Medicine at the University of California, San Francisco, and past president of SHM.

Dr. Pantilat believes that the term “zinger” can imply they are used with malicious intent, yet, he comments, “I’m not sure they are, even if they are an attempt to exert control or challenge the physician. I suspect they arise from fear or other responses.” Below, some of the zingers Dr. Pantilat has dealt with.

How long have you been a doctor? “I’ve now been one long enough not to be flustered by this question, but many hospitalists are young and may be taken aback,” says Dr. Pantilat. “It’s a challenge to the doctor’s authority and expertise.”

Doc, you look so young is a related comment, believes Dr. Pantilat—one that can be interpreted as a compliment or a zinger. “My standard response is always, ‘I’m old enough to take that as a compliment,’ ” he says. “These days I really mean it.”

Vineet Aurora, MD, hospitalist at the University of Chicago Medical Center, says she is sometimes asked, “How old are you?”

“I think it happens to a lot of women who are or look young,” she says. “I usually just state my age, [which is] 32. Often they will say, ‘Oh you look much younger,’ and I take that as a compliment and laugh it off. I think most of the time our patients are just curious. It may also be related to height, and several of us speculate that shorter women may experience this more.”

Ian Jenkins, MD, a hospitalist at the University of California, San Diego, and an associate professor of clinical medicine, shares this zinger: You don't want to order this MRI for my back pain because it’s expensive, so why don’t you just admit it?

His response: “That’s right. We have a certain amount of money to take care of you and the rest of our patients and to do the best job possible. We can’t waste any of it on unnecessary tests or therapies, so you’ve gotten exactly what I would want if I had your back pain—a thorough history and physical exam.”

Here are some zingers from Vijay Rajput, MD, senior hospitalist at Cooper University Hospital, Camden, N.J., associate professor of medicine and program director, Internal Medicine Residency Program, University of Medicine and Dentistry, Robert Wood Johnson Medical School, Piscataway, N.J.º

What’s going on [with my condition]? “Sometimes when I say, ‘I don’t know,’ the patient comes back with, ‘How come you don’t know?’ I usually say, ‘Do you think that we need to know everything in medicine?’ ” says Dr. Rajput. “They usually say, ‘No, not necessarily, but I thought for my condition you might know.’ ”

Dr. Rajput continues, “Sometimes I tell them, ‘Medicine has advanced too fast … many times we [need] more updated knowledge, and sometimes we are not updated … . I would rather update the knowledge and do the right thing for you … than provide you with care with a half-knowledge.’ Most of the people will like and understand that answer.”

Dr. Rajput tells another anecdote: “One time I was rounding with the team on the floor and we all—students, residents, a pharmacy student, and myself—were Asian, [with] three of [us] … born here in the U.S. The patient asked, ‘How come there are too many foreign doctors in this country?’

“That was a zinger,” recalls Dr. Rajput, “and my team thought I [would] pass [on it], but I didn’t. I gave the patient a straight answer with a true explanation. It took a few minutes to explain it in detail.

“I asked him, ‘What is [your] perception?’ He did not have an answer. I explained to him that 25% of [the] doctors [in the U.S.] are not born in this country, and we have a constant need for more doctors. We have proper mechanisms [in place] so that these doctors are trained as well as in American schools and residencies before they start their practice. I also explained the relationships with Educational Commission for Foreign Medical Graduates (ECFMG), National Board of Medical Examiners (NBME), and Council for Graduate Medical Education (ACGME) and said that three out of four of us are U.S.-born and not ‘foreign’ doctors.”

David M. Grace, MD, of The Schumacher Group is a hospitalist practice director in Lafayette, La.; he remembers this zinger: If it’s OK with you, I’d like to stay today and go home tomorrow.

“At least once a week, I have a patient who just doesn’t feel up to going home at the appropriate time of discharge. My response always starts with ‘Why?’ All patients have the right to a safe and stable discharge from the hospital, and it’s important to ensure that no pertinent issues have been overlooked. Is their home support system not ready yet? Is payday tomorrow, and they can’t afford their medicines today? Are they just scared?

“Once I’m satisfied that no occult dangers exist, I sit and discuss the situation with the patient. I first remind them of our discussion … at admission; it’s the same discussion I have with every patient,” says Dr. Grace. “During the admission process, I outline what objectives need to be reached prior to discharge. I emphasize that the role of hospitalization is not to cure the patient but to ‘rectify the problems that require inpatient care’ and allow the convalescence to take place at home.

“Occasionally I have patients [with whom] my first-line strategy doesn’t work, and I move on to plan B. Plan B is where I quote statistics such as, ‘100,000 patients per year die in hospitals due to errors, and on average, each inpatient will have one medication error per day.’ Continuing to stay in the hospital beyond today will shift the risk/benefit ratio to a position where the patient would have additional risk but no additional medical benefit.

“Plan C is rarely used, but it’s in my arsenal,” he says. “I remind the patient that I’m responsible for doing what is medically appropriate, and I reiterate that I understand their concerns, but I cannot commit healthcare fraud by documenting that the patient is not stable for discharge when they are stable. I then shift the decision back to the patient by closing with, ‘We don’t force patients to leave or drag them out of the hospital; however, you need to check with your insurance carrier about whether they will cover the cost of a non-necessary additional hospital day.’ I inform them that the hospital will likely charge the additional day to the patient, and I don’t want to see them get an unexpected bill.”

Another of the zingers Dr. Grace has dealt with: I’m supposed to have test X done as an outpatient, but now that I’m here in the hospital, can we just do it now?

“On days where Lady Luck is shining on me, it’s a test we need to do as part of [the patient’s] acute work-up, and everything works out well. More often than not, it’s a test or procedure unrelated to the admitting diagnoses and one [that] is far more expensive to do as an inpatient, compared with an outpatient study.

“When possible, I’ll explain to the patient that the test they want may not be accurate in the setting of an acute illness, such as the test for lipid levels,” he says. “If the test doesn’t fit into that category, I’ll explain—depending on the request, such as one for an MRI or CT—that they may make it halfway through the test, and the test will need to be aborted because of an acutely sick patient who requires immediate intervention using that piece of equipment, which for the patient would mean that they may need to go through the procedure a second time, or possibly even a third.

“Failing that approach,” he continues, “I often make the insurance company the ‘bad one’ and inform them that their carrier may not pay for the test as an inpatient as it’s not related to their medical illness, and they should check to ensure that the bill won’t be passed on to them. Often the patient, who knows how much of a headache it can be to deal with their insurance company, will drop the request.” TH

Andrea Sattinger writes frequently for The Hospitalist.

References

1. Hills LS. How to answer the most common zinger questions. J Med Pract Manage. 2005 Nov-Dec;21(3):153-155.
2. Lo B. Ethical and policy implications of hospitalist systems. Am J Med. 2001;111:48-52.

As most of us are aware, medical education is a long-term endeavor. Medical schools provide students with the informational foundation and thinking skills necessary to be a doctor. Residency forges the knowledge into a usable skill set that builds the final product: a clinician. Like a hand-thrown pot being placed in the kiln to achieve the final step—that is, hardening with a lustrous glaze—newly graduated medical students take their place in residency programs to gain the experience necessary to practice medicine. It is a system that has worked for generations.

It has worked—but at a price. Many older physicians “put in their dues” at a cost of brutal working hours—often exceeding 120 hours per week—with no patient volume caps, no days off, and absolutely no regard for the resident’s home life or family. In recent years, changes have been made in residency programs to limit the hours worked per week and the number of patients a physician in training is expected to admit and cover; primarily, these changes have been imposed on institutions to address issues of patient safety. It may be time to take a fresh look at residency programs and develop creative work plans that accommodate the changing needs of physicians and twenty-first century medicine.1

What has changed? Everything. The patients changed, the doctors changed, our society changed, and the knowledge base changed; literally, nothing remained static. Increasing demand for patient participation in medical decision-making, increasing requirements for medical documentation, and increasing demand for proof of quality performance while concomitantly paring back the working hours permitted per resident have stressed a rigid system to its breaking point. Creative ideas, such as having residents admit to a single hospital floor, are new innovations to adapt quality teaching to the required 80-hour week.1

Additionally, in the past 25 to 30 years, medicine changed from a “man’s career” to a near gender-neutral profession. In 1970, about 7% of physicians were women. By 1980, women accounted for 11.6% of the workforce, and in 2004, women physicians comprised more than 26% of the total.2 With medical school matriculants numbering women and men at near parity—women have made up 45% to 49% of medical school classes since 1999—it is reasonable to assume that the percentage of women physicians will continue to rise annually.3 This process, the feminization of medicine, has created new needs and demands that have not traditionally been identified.4

As previously noted, medical education and training constitute a long-term process that extends into an individual’s later 20s and 30s. Deferred life issues such as marriage and children can wait only so long, and for women the biological clock imposes an earlier time frame than the one for men. Women often want to start a family before the end of their residency training. The traditional residency system was not designed to support multiple extended absences. In most residency programs—77% of programs in one study—maternity absences are handled by requiring the other residents to pick up the slack, an obviously less than happy arrangement.5,6 In the same survey, 83% of residency programs acknowledged that maternity leave had a significant effect on scheduling, despite the fact that 80% of programs had a maternity policy in place.5

It is time for innovative thinking for residency training. New plans must accommodate system needs as well as individual needs and must retain the teaching function necessary to develop the required clinical skills. This can be done, but it requires planning and flexibility. Most residency programs have a maternity policy.5 This policy defines the length of time allotted for maternity leave—free leave, or time off with no make-up requirement. Some programs, such as the one at the University of California at San Francisco, have incorporated a flexible option to accommodate longer absences using flexible make-up time.7

As early as 1989 the National Health Service in the United Kingdom proposed a part-time option in residency training to encourage women physicians to pursue careers in hospital medicine.8 In response to increasing numbers of women physicians, flexible part-time specialty training programs are now generally available in the United Kingdom.9

Developing a functional part-time residency option requires planning ahead and setting aside several residency slots to be paired as half-time equivalents. Training programs want upfront information; they want to have some idea of how many residents plan to start a family during residency years so that they can anticipate the numbers needed for clinical coverage. One would hope that open communication on this issue would not imply discrimination in hiring and that the information would be used to estimate the hiring needs of the program and to accommodate shared practices.

Obviously, some residents who anticipate using the part-time option may later choose not to have children at that time, while others who did not plan to do so may become pregnant. Because of this variability and the inherent concern of discrimination on the basis of the request, it is preferable for residency programs to build in half-time residency slots based on the need experienced in prior years. Once this program is viewed as a standard option, women with young children—or those who anticipate pregnancy during residency—may well request one of the part-time slots to accommodate their needs.

Flexible—part-time—residency programs have the downside of extending the length of training. Although most residents do not relish the idea of a longer residency, for individuals with family commitments this is a welcome option. The extended residency is a benefit if it allows completion of a training program that might otherwise be impossible.

Of women physicians with children in 1988, 22% had a child before finishing residency, and 54% had at least one child by the time they had completed a fellowship.10 I would guess that those percentages are significantly higher with newer data. All residency programs with young women physicians should anticipate pregnancy-leave time. Without a clear plan to cover the clinical workload during these absences, one can predict anger and resentment among the residents who are expected to cover the extra work.11 If the cross-coverage plan for maternity leave is haphazard and only created as the need arises, fellow residents tend to feel that the burden of work is allocated capriciously. If allowed to persist, the resulting frustration damages the program’s collegiality and may result in a view of women as a risk to the best function of the department.6 This consequence damages both the departmental image and the status of women in medicine.

Proactive departmental planning for maternity leave and potentially reduced work hours for women with small children in residency training should be a priority and should be well defined prior to the employment of new residents. Any plan needs to include options, including a brief, fixed maternity leave and a more extended leave with obligations for time payback or flexible extension of the residency with reduced work hours per week. A leave plan must also include the number of weeks a resident can be absent in a year, in two years, and for the duration of the residency, while still fulfilling requirements for board eligibility. Likewise, to ensure a fundamental knowledge base, rotations that must be successfully completed should be clearly enumerated as part of the policy. As a corollary, paternity policy should also be specifically delineated.

Even residents who don’t utilize the flexible option residency like the idea that it is available if needed and believe that having a policy in place is desirable.7 Maintaining a positive espirit de corps in a residency training program is vital to the smooth functioning of the program and also mentors residents on the benefits of collegiality for a lifetime of practice. Developing a well-thought-out and equitable plan for maternity, health, or family leave during residency training is as essential as figuring out how to teach medicine to residents in an 80-hour week—and it can be done. TH

Dr. Brezina is a hospitalist at Durham Regional Medical Hospital in Durham, N.C., and a member of the consulting clinical faculty at Duke University, Durham, N.C.

References

1. Croasdale M. Redesigning Residency: new models for internal medicine programs. American Medical News. October 23/30, 2006;Professional issues:10.
2. Smart DR. Table 1: Physicians by gender. In: Smart, DR. Physician Characteristics and Distribution in the U.S., 2006 Edition. American Medical Association; 2006.
3. AAMC: Data Warehouse: Applicant Matriculant File by sex, 1995-2006. Association of American Medical Colleges Web site. Available at: www.aamc.org/data/facts/2005/2005summary.htm. Last accessed November 29, 2006.
4. Levinson W, Lurie N. When most doctors are women: what lies ahead? Ann Intern Med. 2004 Sep 21;141(6):471-474.
5. Davis JL, Baillie S, Hodgson CS, et al. Maternity leave: existing policies in obstetrics and gynecology residency programs. Obstet Gynecol. 2001 Dec;98(6):1093-1098.
6. Tamburrino MB, Evans CL, Campbell NB, et al. Physician pregnancy: male and female colleagues’ attitudes. J Am Med Womens Assoc. 1992 May-Jun;47(3):82-84.
7. Kamei RK, Chen HC, Loeser H. Residency is not a race: our ten-year experience with a flexible schedule residency training option. Acad Med. 2004 May;79(5):447-452.
8. Warren VJ, Wakeford RE. ‘We’d like to have a family’—young women doctors’ opinions of maternity leave and part-time training. J R Soc Med. 1989 Sep;82(9):528-531.
9. Maingay J, Goldberg I. Flexible training opportunities in the European Union. Med Educ. 1998 Sep;32(5):543-548.
10. Sinal S, Weavil P, Camp MG. Survey of women physicians on issues relating to pregnancy during a medical career. J Med Educ. 1988 Jul;63(7):531-538.
11. Finch SJ. Pregnancy during residency: a literature review. Acad Med. 2003 Apr;78(4):418-428.

As most of us are aware, medical education is a long-term endeavor. Medical schools provide students with the informational foundation and thinking skills necessary to be a doctor. Residency forges the knowledge into a usable skill set that builds the final product: a clinician. Like a hand-thrown pot being placed in the kiln to achieve the final step—that is, hardening with a lustrous glaze—newly graduated medical students take their place in residency programs to gain the experience necessary to practice medicine. It is a system that has worked for generations.

It has worked—but at a price. Many older physicians “put in their dues” at a cost of brutal working hours—often exceeding 120 hours per week—with no patient volume caps, no days off, and absolutely no regard for the resident’s home life or family. In recent years, changes have been made in residency programs to limit the hours worked per week and the number of patients a physician in training is expected to admit and cover; primarily, these changes have been imposed on institutions to address issues of patient safety. It may be time to take a fresh look at residency programs and develop creative work plans that accommodate the changing needs of physicians and twenty-first century medicine.1

What has changed? Everything. The patients changed, the doctors changed, our society changed, and the knowledge base changed; literally, nothing remained static. Increasing demand for patient participation in medical decision-making, increasing requirements for medical documentation, and increasing demand for proof of quality performance while concomitantly paring back the working hours permitted per resident have stressed a rigid system to its breaking point. Creative ideas, such as having residents admit to a single hospital floor, are new innovations to adapt quality teaching to the required 80-hour week.1

Additionally, in the past 25 to 30 years, medicine changed from a “man’s career” to a near gender-neutral profession. In 1970, about 7% of physicians were women. By 1980, women accounted for 11.6% of the workforce, and in 2004, women physicians comprised more than 26% of the total.2 With medical school matriculants numbering women and men at near parity—women have made up 45% to 49% of medical school classes since 1999—it is reasonable to assume that the percentage of women physicians will continue to rise annually.3 This process, the feminization of medicine, has created new needs and demands that have not traditionally been identified.4

As previously noted, medical education and training constitute a long-term process that extends into an individual’s later 20s and 30s. Deferred life issues such as marriage and children can wait only so long, and for women the biological clock imposes an earlier time frame than the one for men. Women often want to start a family before the end of their residency training. The traditional residency system was not designed to support multiple extended absences. In most residency programs—77% of programs in one study—maternity absences are handled by requiring the other residents to pick up the slack, an obviously less than happy arrangement.5,6 In the same survey, 83% of residency programs acknowledged that maternity leave had a significant effect on scheduling, despite the fact that 80% of programs had a maternity policy in place.5

It is time for innovative thinking for residency training. New plans must accommodate system needs as well as individual needs and must retain the teaching function necessary to develop the required clinical skills. This can be done, but it requires planning and flexibility. Most residency programs have a maternity policy.5 This policy defines the length of time allotted for maternity leave—free leave, or time off with no make-up requirement. Some programs, such as the one at the University of California at San Francisco, have incorporated a flexible option to accommodate longer absences using flexible make-up time.7

As early as 1989 the National Health Service in the United Kingdom proposed a part-time option in residency training to encourage women physicians to pursue careers in hospital medicine.8 In response to increasing numbers of women physicians, flexible part-time specialty training programs are now generally available in the United Kingdom.9

Developing a functional part-time residency option requires planning ahead and setting aside several residency slots to be paired as half-time equivalents. Training programs want upfront information; they want to have some idea of how many residents plan to start a family during residency years so that they can anticipate the numbers needed for clinical coverage. One would hope that open communication on this issue would not imply discrimination in hiring and that the information would be used to estimate the hiring needs of the program and to accommodate shared practices.

Obviously, some residents who anticipate using the part-time option may later choose not to have children at that time, while others who did not plan to do so may become pregnant. Because of this variability and the inherent concern of discrimination on the basis of the request, it is preferable for residency programs to build in half-time residency slots based on the need experienced in prior years. Once this program is viewed as a standard option, women with young children—or those who anticipate pregnancy during residency—may well request one of the part-time slots to accommodate their needs.

Flexible—part-time—residency programs have the downside of extending the length of training. Although most residents do not relish the idea of a longer residency, for individuals with family commitments this is a welcome option. The extended residency is a benefit if it allows completion of a training program that might otherwise be impossible.

Of women physicians with children in 1988, 22% had a child before finishing residency, and 54% had at least one child by the time they had completed a fellowship.10 I would guess that those percentages are significantly higher with newer data. All residency programs with young women physicians should anticipate pregnancy-leave time. Without a clear plan to cover the clinical workload during these absences, one can predict anger and resentment among the residents who are expected to cover the extra work.11 If the cross-coverage plan for maternity leave is haphazard and only created as the need arises, fellow residents tend to feel that the burden of work is allocated capriciously. If allowed to persist, the resulting frustration damages the program’s collegiality and may result in a view of women as a risk to the best function of the department.6 This consequence damages both the departmental image and the status of women in medicine.

Proactive departmental planning for maternity leave and potentially reduced work hours for women with small children in residency training should be a priority and should be well defined prior to the employment of new residents. Any plan needs to include options, including a brief, fixed maternity leave and a more extended leave with obligations for time payback or flexible extension of the residency with reduced work hours per week. A leave plan must also include the number of weeks a resident can be absent in a year, in two years, and for the duration of the residency, while still fulfilling requirements for board eligibility. Likewise, to ensure a fundamental knowledge base, rotations that must be successfully completed should be clearly enumerated as part of the policy. As a corollary, paternity policy should also be specifically delineated.

Even residents who don’t utilize the flexible option residency like the idea that it is available if needed and believe that having a policy in place is desirable.7 Maintaining a positive espirit de corps in a residency training program is vital to the smooth functioning of the program and also mentors residents on the benefits of collegiality for a lifetime of practice. Developing a well-thought-out and equitable plan for maternity, health, or family leave during residency training is as essential as figuring out how to teach medicine to residents in an 80-hour week—and it can be done. TH

Dr. Brezina is a hospitalist at Durham Regional Medical Hospital in Durham, N.C., and a member of the consulting clinical faculty at Duke University, Durham, N.C.

References

1. Croasdale M. Redesigning Residency: new models for internal medicine programs. American Medical News. October 23/30, 2006;Professional issues:10.
2. Smart DR. Table 1: Physicians by gender. In: Smart, DR. Physician Characteristics and Distribution in the U.S., 2006 Edition. American Medical Association; 2006.
3. AAMC: Data Warehouse: Applicant Matriculant File by sex, 1995-2006. Association of American Medical Colleges Web site. Available at: www.aamc.org/data/facts/2005/2005summary.htm. Last accessed November 29, 2006.
4. Levinson W, Lurie N. When most doctors are women: what lies ahead? Ann Intern Med. 2004 Sep 21;141(6):471-474.
5. Davis JL, Baillie S, Hodgson CS, et al. Maternity leave: existing policies in obstetrics and gynecology residency programs. Obstet Gynecol. 2001 Dec;98(6):1093-1098.
6. Tamburrino MB, Evans CL, Campbell NB, et al. Physician pregnancy: male and female colleagues’ attitudes. J Am Med Womens Assoc. 1992 May-Jun;47(3):82-84.
7. Kamei RK, Chen HC, Loeser H. Residency is not a race: our ten-year experience with a flexible schedule residency training option. Acad Med. 2004 May;79(5):447-452.
8. Warren VJ, Wakeford RE. ‘We’d like to have a family’—young women doctors’ opinions of maternity leave and part-time training. J R Soc Med. 1989 Sep;82(9):528-531.
9. Maingay J, Goldberg I. Flexible training opportunities in the European Union. Med Educ. 1998 Sep;32(5):543-548.
10. Sinal S, Weavil P, Camp MG. Survey of women physicians on issues relating to pregnancy during a medical career. J Med Educ. 1988 Jul;63(7):531-538.
11. Finch SJ. Pregnancy during residency: a literature review. Acad Med. 2003 Apr;78(4):418-428.

As most of us are aware, medical education is a long-term endeavor. Medical schools provide students with the informational foundation and thinking skills necessary to be a doctor. Residency forges the knowledge into a usable skill set that builds the final product: a clinician. Like a hand-thrown pot being placed in the kiln to achieve the final step—that is, hardening with a lustrous glaze—newly graduated medical students take their place in residency programs to gain the experience necessary to practice medicine. It is a system that has worked for generations.

It has worked—but at a price. Many older physicians “put in their dues” at a cost of brutal working hours—often exceeding 120 hours per week—with no patient volume caps, no days off, and absolutely no regard for the resident’s home life or family. In recent years, changes have been made in residency programs to limit the hours worked per week and the number of patients a physician in training is expected to admit and cover; primarily, these changes have been imposed on institutions to address issues of patient safety. It may be time to take a fresh look at residency programs and develop creative work plans that accommodate the changing needs of physicians and twenty-first century medicine.1

What has changed? Everything. The patients changed, the doctors changed, our society changed, and the knowledge base changed; literally, nothing remained static. Increasing demand for patient participation in medical decision-making, increasing requirements for medical documentation, and increasing demand for proof of quality performance while concomitantly paring back the working hours permitted per resident have stressed a rigid system to its breaking point. Creative ideas, such as having residents admit to a single hospital floor, are new innovations to adapt quality teaching to the required 80-hour week.1

Additionally, in the past 25 to 30 years, medicine changed from a “man’s career” to a near gender-neutral profession. In 1970, about 7% of physicians were women. By 1980, women accounted for 11.6% of the workforce, and in 2004, women physicians comprised more than 26% of the total.2 With medical school matriculants numbering women and men at near parity—women have made up 45% to 49% of medical school classes since 1999—it is reasonable to assume that the percentage of women physicians will continue to rise annually.3 This process, the feminization of medicine, has created new needs and demands that have not traditionally been identified.4

As previously noted, medical education and training constitute a long-term process that extends into an individual’s later 20s and 30s. Deferred life issues such as marriage and children can wait only so long, and for women the biological clock imposes an earlier time frame than the one for men. Women often want to start a family before the end of their residency training. The traditional residency system was not designed to support multiple extended absences. In most residency programs—77% of programs in one study—maternity absences are handled by requiring the other residents to pick up the slack, an obviously less than happy arrangement.5,6 In the same survey, 83% of residency programs acknowledged that maternity leave had a significant effect on scheduling, despite the fact that 80% of programs had a maternity policy in place.5

It is time for innovative thinking for residency training. New plans must accommodate system needs as well as individual needs and must retain the teaching function necessary to develop the required clinical skills. This can be done, but it requires planning and flexibility. Most residency programs have a maternity policy.5 This policy defines the length of time allotted for maternity leave—free leave, or time off with no make-up requirement. Some programs, such as the one at the University of California at San Francisco, have incorporated a flexible option to accommodate longer absences using flexible make-up time.7

As early as 1989 the National Health Service in the United Kingdom proposed a part-time option in residency training to encourage women physicians to pursue careers in hospital medicine.8 In response to increasing numbers of women physicians, flexible part-time specialty training programs are now generally available in the United Kingdom.9

Developing a functional part-time residency option requires planning ahead and setting aside several residency slots to be paired as half-time equivalents. Training programs want upfront information; they want to have some idea of how many residents plan to start a family during residency years so that they can anticipate the numbers needed for clinical coverage. One would hope that open communication on this issue would not imply discrimination in hiring and that the information would be used to estimate the hiring needs of the program and to accommodate shared practices.

Obviously, some residents who anticipate using the part-time option may later choose not to have children at that time, while others who did not plan to do so may become pregnant. Because of this variability and the inherent concern of discrimination on the basis of the request, it is preferable for residency programs to build in half-time residency slots based on the need experienced in prior years. Once this program is viewed as a standard option, women with young children—or those who anticipate pregnancy during residency—may well request one of the part-time slots to accommodate their needs.

Flexible—part-time—residency programs have the downside of extending the length of training. Although most residents do not relish the idea of a longer residency, for individuals with family commitments this is a welcome option. The extended residency is a benefit if it allows completion of a training program that might otherwise be impossible.

Of women physicians with children in 1988, 22% had a child before finishing residency, and 54% had at least one child by the time they had completed a fellowship.10 I would guess that those percentages are significantly higher with newer data. All residency programs with young women physicians should anticipate pregnancy-leave time. Without a clear plan to cover the clinical workload during these absences, one can predict anger and resentment among the residents who are expected to cover the extra work.11 If the cross-coverage plan for maternity leave is haphazard and only created as the need arises, fellow residents tend to feel that the burden of work is allocated capriciously. If allowed to persist, the resulting frustration damages the program’s collegiality and may result in a view of women as a risk to the best function of the department.6 This consequence damages both the departmental image and the status of women in medicine.

Proactive departmental planning for maternity leave and potentially reduced work hours for women with small children in residency training should be a priority and should be well defined prior to the employment of new residents. Any plan needs to include options, including a brief, fixed maternity leave and a more extended leave with obligations for time payback or flexible extension of the residency with reduced work hours per week. A leave plan must also include the number of weeks a resident can be absent in a year, in two years, and for the duration of the residency, while still fulfilling requirements for board eligibility. Likewise, to ensure a fundamental knowledge base, rotations that must be successfully completed should be clearly enumerated as part of the policy. As a corollary, paternity policy should also be specifically delineated.

Even residents who don’t utilize the flexible option residency like the idea that it is available if needed and believe that having a policy in place is desirable.7 Maintaining a positive espirit de corps in a residency training program is vital to the smooth functioning of the program and also mentors residents on the benefits of collegiality for a lifetime of practice. Developing a well-thought-out and equitable plan for maternity, health, or family leave during residency training is as essential as figuring out how to teach medicine to residents in an 80-hour week—and it can be done. TH

Dr. Brezina is a hospitalist at Durham Regional Medical Hospital in Durham, N.C., and a member of the consulting clinical faculty at Duke University, Durham, N.C.

References

1. Croasdale M. Redesigning Residency: new models for internal medicine programs. American Medical News. October 23/30, 2006;Professional issues:10.
2. Smart DR. Table 1: Physicians by gender. In: Smart, DR. Physician Characteristics and Distribution in the U.S., 2006 Edition. American Medical Association; 2006.
3. AAMC: Data Warehouse: Applicant Matriculant File by sex, 1995-2006. Association of American Medical Colleges Web site. Available at: www.aamc.org/data/facts/2005/2005summary.htm. Last accessed November 29, 2006.
4. Levinson W, Lurie N. When most doctors are women: what lies ahead? Ann Intern Med. 2004 Sep 21;141(6):471-474.
5. Davis JL, Baillie S, Hodgson CS, et al. Maternity leave: existing policies in obstetrics and gynecology residency programs. Obstet Gynecol. 2001 Dec;98(6):1093-1098.
6. Tamburrino MB, Evans CL, Campbell NB, et al. Physician pregnancy: male and female colleagues’ attitudes. J Am Med Womens Assoc. 1992 May-Jun;47(3):82-84.
7. Kamei RK, Chen HC, Loeser H. Residency is not a race: our ten-year experience with a flexible schedule residency training option. Acad Med. 2004 May;79(5):447-452.
8. Warren VJ, Wakeford RE. ‘We’d like to have a family’—young women doctors’ opinions of maternity leave and part-time training. J R Soc Med. 1989 Sep;82(9):528-531.
9. Maingay J, Goldberg I. Flexible training opportunities in the European Union. Med Educ. 1998 Sep;32(5):543-548.
10. Sinal S, Weavil P, Camp MG. Survey of women physicians on issues relating to pregnancy during a medical career. J Med Educ. 1988 Jul;63(7):531-538.
11. Finch SJ. Pregnancy during residency: a literature review. Acad Med. 2003 Apr;78(4):418-428.

If you work at a teaching institution, an important part of your career track may be teaching residents the work of hospitalists. “Within academia, there are two major tracks: research[er] and clinical educator,” says Sanjay Saint, MD, MPH, hospitalist and professor of internal medicine at the Ann Arbor Veterans Affairs Medical Center and the University of Michigan Medical School, Ann Arbor. “We’re promoted based on our clinical work and on education evaluations; it’s helpful when we’re being reviewed if we’re seen as good teachers by our students.”

How are your teaching skills? How much thought and effort do you put into how you train your students? Do you take steps to improve your methods?

“Most of us have to work at being good teachers,” admits Dr. Saint. “We watch excellent teachers and learn as we go.” What follows is the advice of one excellent teacher.

Teachers: Champions for Hospital Medicine

Jeffrey Wiese, MD, FACP, is an SHM board member and associate professor of medicine at Tulane University Health Sciences Center in New Orleans, where he also serves as associate chairman of medicine, director of the Tulane Internal Medicine Residency Program, and associate director of student programs, internal medicine. “From an [SHM] board perspective, it’s been my agenda to better situate hospitalists as teachers,” he says.

One reason he’s committed to boosting the number of hospitalist-teachers is that Dr. Wiese believes the specialty is a perfect match for imparting knowledge. “Hospitalists are better instructors primarily because of their greater accessibility for supervision,” he says. “Because of the number of things they do and the consistent repetition with which they do them, they also have a better familiarity with what students need to know and how to do it.”

Another reason that hospitalists are excellent choices to train residents: “Hospitalists work at improving hospital systems and focus on quality of care,” says Dr. Wiese. “What better group of people to teach the systems of care and practice-based learning competencies?”

Coaching Versus Teaching

The basis of Dr. Wiese’s theory of teaching is that you should think and act as a coach—not a teacher. “A teacher is responsible for disseminating knowledge to his pupils; a coach is responsible for the performance of his pupils,” explains Dr. Wiese. “With a coach, the success of the job is contingent on the performance of the player—in this case, the student or resident.”

The coaching theory goes deeper than that distinction. “Components of coaching include [the following]: You have to teach the necessary skill, but you have to motivate the person to want to do it right, create a vision of how they’re going to do it, anticipate and prepare them for potential obstacles that might stand in the way of their performance, and provide feedback and evaluation when they do it,” says Dr. Wiese. “A football coach wouldn’t just tell you how to throw a ball. He would teach you the skill and then watch you do it, while providing feedback on your performance. He would tell you what the opposing team might do to oppose your performance of that skill and prepare you to overcome that opposition. And then he would instill a motivation such that you wanted to perform the skill well.”

Dr. Saint, who is familiar with Dr. Wiese’s theory, says, “I like the metaphor of coaching because a coach tries to make you better at what you’re learning. A coach may use techniques that make you uncomfortable at the time, but if you look back after a couple of years, you’ll be thankful that he pushed you.”

Another aspect of coaching that fits neatly into today’s clinical learning is the team aspect. “Medicine is no longer an individual event,” explains Dr. Wiese. “It’s a team activity, where the best patient care is provided by a team of healthcare professionals from doctors to nurses to physical therapists and others. Teaching the mentality of playing as part of a team will help residents perform better in this environment as they advance in their careers.”

Teaching in a “Vacum”

“I use the mnemonic VACUM [to describe coaching],” says Dr. Wiese. VACUM stands for:

• Visualization: To pique interest in a topic or procedure, start by asking students to visualize themselves using the skill. Repeatedly ask them how they think they will put the skill to use.
  

  
  

  “Get the person to picture herself with a patient,” urges Dr. Wiese. This step both hooks learners at the beginning of a session and helps teach them the skill.

• Anticipation: If you’re an experienced teacher and know your students well, you know where they will struggle in the learning process. “Think about the common pitfalls,” says Dr. Wiese. “Alert the student to where she will get confused or make mistakes and spend time preparing the student for how she can avoid the pitfall. For example, if you’re teaching them about putting in a central line, tell them, ‘You [might] not think about the patient’s bleeding risk prior to procedure. Make sure you know his INR [international normalized ratio] and platelet count prior to starting the procedure.’ ”
• Content: “This is where most teachers go awry,” warns Dr. Wiese. “Medical educators try to teach too much, and students try to learn too much. Not every detail in a topic needs to be discussed. It’s far better to sacrifice details to preserve time to ensure that students have mastered the fundamental concepts of a disease or skill. They can pick up the details later—focus on what they need to know.”
  

  
  

  How do you know what to focus on? “The guidelines of what students must learn during their internal medicine clerkship are voluminous,” says Dr. Wiese. “Find those that you think have utility in your practice or utility to the students. The best strategy is to stick to the fundamentals. With this strategy, they will walk away with the critical components that will empower them to pick up the details during subsequent teaching sessions.”

• Utility: “This goes with content,” says Dr. Wiese. “Teach them skills that they can utilize. Remember, utility varies from student to student. A student heading into a future career in orthopedics will find greater utility in learning about pre-operative care and management of atrial fibrillation than she will with a discourse on lupus.”
• Motivation: Motivation includes three subcategories. “Students or residents have to know that the coach is on their side,” says Dr. Wiese. One way to do this is to learn their names—and use them frequently. You should also use physical contact to show your support.

“Give a pat on the shoulder, or shake someone’s hand,” he advises. “If you’re in a classroom, move around the room. Show that you’re accessible.” Finally, find people’s hooks—that is, what interests them.

So how do you know you’ve become a good teacher? “The ultimate goal of coaching is successful student performance—not awards or approbation. The measure of your success is defined by seeing your students months or even years later, doing right by a patient because of what you taught them to do,” says Dr. Wiese. “Focus on that goal, and everything else will fall into place.” TH

Jane Jerrard regularly writes “Career Development.”

If you work at a teaching institution, an important part of your career track may be teaching residents the work of hospitalists. “Within academia, there are two major tracks: research[er] and clinical educator,” says Sanjay Saint, MD, MPH, hospitalist and professor of internal medicine at the Ann Arbor Veterans Affairs Medical Center and the University of Michigan Medical School, Ann Arbor. “We’re promoted based on our clinical work and on education evaluations; it’s helpful when we’re being reviewed if we’re seen as good teachers by our students.”

How are your teaching skills? How much thought and effort do you put into how you train your students? Do you take steps to improve your methods?

“Most of us have to work at being good teachers,” admits Dr. Saint. “We watch excellent teachers and learn as we go.” What follows is the advice of one excellent teacher.

Teachers: Champions for Hospital Medicine

Jeffrey Wiese, MD, FACP, is an SHM board member and associate professor of medicine at Tulane University Health Sciences Center in New Orleans, where he also serves as associate chairman of medicine, director of the Tulane Internal Medicine Residency Program, and associate director of student programs, internal medicine. “From an [SHM] board perspective, it’s been my agenda to better situate hospitalists as teachers,” he says.

One reason he’s committed to boosting the number of hospitalist-teachers is that Dr. Wiese believes the specialty is a perfect match for imparting knowledge. “Hospitalists are better instructors primarily because of their greater accessibility for supervision,” he says. “Because of the number of things they do and the consistent repetition with which they do them, they also have a better familiarity with what students need to know and how to do it.”

Another reason that hospitalists are excellent choices to train residents: “Hospitalists work at improving hospital systems and focus on quality of care,” says Dr. Wiese. “What better group of people to teach the systems of care and practice-based learning competencies?”

Coaching Versus Teaching

The basis of Dr. Wiese’s theory of teaching is that you should think and act as a coach—not a teacher. “A teacher is responsible for disseminating knowledge to his pupils; a coach is responsible for the performance of his pupils,” explains Dr. Wiese. “With a coach, the success of the job is contingent on the performance of the player—in this case, the student or resident.”

The coaching theory goes deeper than that distinction. “Components of coaching include [the following]: You have to teach the necessary skill, but you have to motivate the person to want to do it right, create a vision of how they’re going to do it, anticipate and prepare them for potential obstacles that might stand in the way of their performance, and provide feedback and evaluation when they do it,” says Dr. Wiese. “A football coach wouldn’t just tell you how to throw a ball. He would teach you the skill and then watch you do it, while providing feedback on your performance. He would tell you what the opposing team might do to oppose your performance of that skill and prepare you to overcome that opposition. And then he would instill a motivation such that you wanted to perform the skill well.”

Dr. Saint, who is familiar with Dr. Wiese’s theory, says, “I like the metaphor of coaching because a coach tries to make you better at what you’re learning. A coach may use techniques that make you uncomfortable at the time, but if you look back after a couple of years, you’ll be thankful that he pushed you.”

Another aspect of coaching that fits neatly into today’s clinical learning is the team aspect. “Medicine is no longer an individual event,” explains Dr. Wiese. “It’s a team activity, where the best patient care is provided by a team of healthcare professionals from doctors to nurses to physical therapists and others. Teaching the mentality of playing as part of a team will help residents perform better in this environment as they advance in their careers.”

Teaching in a “Vacum”

“I use the mnemonic VACUM [to describe coaching],” says Dr. Wiese. VACUM stands for:

• Visualization: To pique interest in a topic or procedure, start by asking students to visualize themselves using the skill. Repeatedly ask them how they think they will put the skill to use.
  

  
  

  “Get the person to picture herself with a patient,” urges Dr. Wiese. This step both hooks learners at the beginning of a session and helps teach them the skill.

• Anticipation: If you’re an experienced teacher and know your students well, you know where they will struggle in the learning process. “Think about the common pitfalls,” says Dr. Wiese. “Alert the student to where she will get confused or make mistakes and spend time preparing the student for how she can avoid the pitfall. For example, if you’re teaching them about putting in a central line, tell them, ‘You [might] not think about the patient’s bleeding risk prior to procedure. Make sure you know his INR [international normalized ratio] and platelet count prior to starting the procedure.’ ”
• Content: “This is where most teachers go awry,” warns Dr. Wiese. “Medical educators try to teach too much, and students try to learn too much. Not every detail in a topic needs to be discussed. It’s far better to sacrifice details to preserve time to ensure that students have mastered the fundamental concepts of a disease or skill. They can pick up the details later—focus on what they need to know.”
  

  
  

  How do you know what to focus on? “The guidelines of what students must learn during their internal medicine clerkship are voluminous,” says Dr. Wiese. “Find those that you think have utility in your practice or utility to the students. The best strategy is to stick to the fundamentals. With this strategy, they will walk away with the critical components that will empower them to pick up the details during subsequent teaching sessions.”

• Utility: “This goes with content,” says Dr. Wiese. “Teach them skills that they can utilize. Remember, utility varies from student to student. A student heading into a future career in orthopedics will find greater utility in learning about pre-operative care and management of atrial fibrillation than she will with a discourse on lupus.”
• Motivation: Motivation includes three subcategories. “Students or residents have to know that the coach is on their side,” says Dr. Wiese. One way to do this is to learn their names—and use them frequently. You should also use physical contact to show your support.

“Give a pat on the shoulder, or shake someone’s hand,” he advises. “If you’re in a classroom, move around the room. Show that you’re accessible.” Finally, find people’s hooks—that is, what interests them.

So how do you know you’ve become a good teacher? “The ultimate goal of coaching is successful student performance—not awards or approbation. The measure of your success is defined by seeing your students months or even years later, doing right by a patient because of what you taught them to do,” says Dr. Wiese. “Focus on that goal, and everything else will fall into place.” TH

Jane Jerrard regularly writes “Career Development.”

If you work at a teaching institution, an important part of your career track may be teaching residents the work of hospitalists. “Within academia, there are two major tracks: research[er] and clinical educator,” says Sanjay Saint, MD, MPH, hospitalist and professor of internal medicine at the Ann Arbor Veterans Affairs Medical Center and the University of Michigan Medical School, Ann Arbor. “We’re promoted based on our clinical work and on education evaluations; it’s helpful when we’re being reviewed if we’re seen as good teachers by our students.”

How are your teaching skills? How much thought and effort do you put into how you train your students? Do you take steps to improve your methods?

“Most of us have to work at being good teachers,” admits Dr. Saint. “We watch excellent teachers and learn as we go.” What follows is the advice of one excellent teacher.

Teachers: Champions for Hospital Medicine

Jeffrey Wiese, MD, FACP, is an SHM board member and associate professor of medicine at Tulane University Health Sciences Center in New Orleans, where he also serves as associate chairman of medicine, director of the Tulane Internal Medicine Residency Program, and associate director of student programs, internal medicine. “From an [SHM] board perspective, it’s been my agenda to better situate hospitalists as teachers,” he says.

One reason he’s committed to boosting the number of hospitalist-teachers is that Dr. Wiese believes the specialty is a perfect match for imparting knowledge. “Hospitalists are better instructors primarily because of their greater accessibility for supervision,” he says. “Because of the number of things they do and the consistent repetition with which they do them, they also have a better familiarity with what students need to know and how to do it.”

Another reason that hospitalists are excellent choices to train residents: “Hospitalists work at improving hospital systems and focus on quality of care,” says Dr. Wiese. “What better group of people to teach the systems of care and practice-based learning competencies?”

Coaching Versus Teaching

The basis of Dr. Wiese’s theory of teaching is that you should think and act as a coach—not a teacher. “A teacher is responsible for disseminating knowledge to his pupils; a coach is responsible for the performance of his pupils,” explains Dr. Wiese. “With a coach, the success of the job is contingent on the performance of the player—in this case, the student or resident.”

The coaching theory goes deeper than that distinction. “Components of coaching include [the following]: You have to teach the necessary skill, but you have to motivate the person to want to do it right, create a vision of how they’re going to do it, anticipate and prepare them for potential obstacles that might stand in the way of their performance, and provide feedback and evaluation when they do it,” says Dr. Wiese. “A football coach wouldn’t just tell you how to throw a ball. He would teach you the skill and then watch you do it, while providing feedback on your performance. He would tell you what the opposing team might do to oppose your performance of that skill and prepare you to overcome that opposition. And then he would instill a motivation such that you wanted to perform the skill well.”

Dr. Saint, who is familiar with Dr. Wiese’s theory, says, “I like the metaphor of coaching because a coach tries to make you better at what you’re learning. A coach may use techniques that make you uncomfortable at the time, but if you look back after a couple of years, you’ll be thankful that he pushed you.”

Another aspect of coaching that fits neatly into today’s clinical learning is the team aspect. “Medicine is no longer an individual event,” explains Dr. Wiese. “It’s a team activity, where the best patient care is provided by a team of healthcare professionals from doctors to nurses to physical therapists and others. Teaching the mentality of playing as part of a team will help residents perform better in this environment as they advance in their careers.”

Teaching in a “Vacum”

“I use the mnemonic VACUM [to describe coaching],” says Dr. Wiese. VACUM stands for:

• Visualization: To pique interest in a topic or procedure, start by asking students to visualize themselves using the skill. Repeatedly ask them how they think they will put the skill to use.
  

  
  

  “Get the person to picture herself with a patient,” urges Dr. Wiese. This step both hooks learners at the beginning of a session and helps teach them the skill.

• Anticipation: If you’re an experienced teacher and know your students well, you know where they will struggle in the learning process. “Think about the common pitfalls,” says Dr. Wiese. “Alert the student to where she will get confused or make mistakes and spend time preparing the student for how she can avoid the pitfall. For example, if you’re teaching them about putting in a central line, tell them, ‘You [might] not think about the patient’s bleeding risk prior to procedure. Make sure you know his INR [international normalized ratio] and platelet count prior to starting the procedure.’ ”
• Content: “This is where most teachers go awry,” warns Dr. Wiese. “Medical educators try to teach too much, and students try to learn too much. Not every detail in a topic needs to be discussed. It’s far better to sacrifice details to preserve time to ensure that students have mastered the fundamental concepts of a disease or skill. They can pick up the details later—focus on what they need to know.”
  

  
  

  How do you know what to focus on? “The guidelines of what students must learn during their internal medicine clerkship are voluminous,” says Dr. Wiese. “Find those that you think have utility in your practice or utility to the students. The best strategy is to stick to the fundamentals. With this strategy, they will walk away with the critical components that will empower them to pick up the details during subsequent teaching sessions.”

• Utility: “This goes with content,” says Dr. Wiese. “Teach them skills that they can utilize. Remember, utility varies from student to student. A student heading into a future career in orthopedics will find greater utility in learning about pre-operative care and management of atrial fibrillation than she will with a discourse on lupus.”
• Motivation: Motivation includes three subcategories. “Students or residents have to know that the coach is on their side,” says Dr. Wiese. One way to do this is to learn their names—and use them frequently. You should also use physical contact to show your support.

“Give a pat on the shoulder, or shake someone’s hand,” he advises. “If you’re in a classroom, move around the room. Show that you’re accessible.” Finally, find people’s hooks—that is, what interests them.

So how do you know you’ve become a good teacher? “The ultimate goal of coaching is successful student performance—not awards or approbation. The measure of your success is defined by seeing your students months or even years later, doing right by a patient because of what you taught them to do,” says Dr. Wiese. “Focus on that goal, and everything else will fall into place.” TH

Jane Jerrard regularly writes “Career Development.”

We’ve defended physicians involved in lawsuits for more than a decade. After representing dozens of physicians, nurses, and other healthcare professionals, we can say one thing for certain: No one likes to get sued.

Good physicians struggle with the litigation process. Even when their care has been absolutely appropriate, many doctors experience great anxiety when they are accused of having negligently injured a patient. Because they have trained so hard to gain their expertise, many of our clients have found that a lawsuit strikes at them personally as well as professionally. At the end of the day, lawsuits cause stress, take physicians away from their personal lives, and often lead to serious financial and professional consequences.

Therefore, one of the questions that we most often receive is, “How can a physician avoid lawsuits?”

Top 10 Ways to Stay Out of Litigation

1) Good documentation: Often, in a lawsuit, plaintiffs’ attorneys will tell the jury the old adage, “If it’s not in the record, it didn’t happen.” What everyone who has practiced medicine knows, however, is that many things don’t make it to the chart. Physicians don’t have the time to recount their conversations with patients verbatim. What we want to see in the chart are the following:

1. A description of the information provided by the patient that factored into your diagnoses or treatment decisions;
2. A description of the physical findings or laboratory results that factored into your diagnoses and treatment decisions;
3. A discussion of why you made a particular decision;
4. A discussion of the course of treatment you selected; and
5. A discussion of your anticipated follow-up.

Of these elements, we most often fail to see a discussion of why you made a particular decision, and this is a crucial piece of the record. As you know, physicians often have a broad range of treatment choices. Including information about why you selected a particular course of treatment—in light of the available data—makes the record more understandable to the jury. A good chart lays out more than just the physician’s actions. A good chart is so complete that another physician could assume care for the patient tomorrow, easily understanding both the course of treatment and why you chose it.

2) Good communication: In his book Blink, Malcolm Gladwell describes something defense lawyers have known for many years: That the quality of the care does not determine whether or not a physician gets sued. There are many instances in which a physician who makes a mistake that causes an injury manages to avoid litigation. There are also many instances in which a physician’s care is appropriate, but the patient sues the physician after a recognized complication. What makes the difference?

More often than not, the determining factor in whether or not a physician is sued is the patient’s perception of whether or not the physician cared about her. In situations in which patients leave the physician’s office believing that the physician listened carefully to their complaints, spent the time to explain the course of treatment, and genuinely cared about them as people, we don’t see as many lawsuits. If a physician explains why a complication occurred—not just that it occurred—and appears empathetic to the patient, she has less of a motivation to sue. Conversely, if the patient feels like the physician sees her as a commodity or didn’t take the time to understand her complaints, the risk of litigation goes up.

One of the most important aspects of good communication is adequate informed consent. Remember, informed consent is a dialogue—not a lecture. It requires physicians to discuss:

1. The substantial risks of the treatment;
2. The benefits of the treatment; and
3. The alternatives to the treatment. Sometimes it’s difficult to determine the substantial risks because a patient and a physician may view the magnitude of a particular risk differently. Our rule of thumb is that any risks associated with serious long-term sequelae, such as permanent impairment, must be discussed, even if the probability of the risk occurring is remote.

3) Good consultation: Many hospitalists do not have long-term relationships with their patients. After a course of hospital treatment, the patient will return to her regular physician. A common breakdown occurs when the consultation between the hospitalist and the regular physician is inadequate.

On the front end, the hospitalist who receives a patient should take the opportunity, if possible, to consult with the regular physician about any ongoing course of treatment. Unfortunately, patients are not always accurate medical historians and may not fully appreciate their conditions or courses of treatment. Consulting with the regular physician helps to eliminate the possibility that an important aspect of the patient’s history or condition is overlooked.

On the back end, when the regular physician resumes care of the patient, he should be able to reinforce the course of hospital care and provide an additional layer of education about why the hospitalist made certain treatment decisions. Of course, the regular physician can serve in this role only if the hospitalist has taken the opportunity to inform the regular physician about the course of care.

4) Accurate representations: We are seeing more cases in which physicians are being sued for alleged misrepresentations to patients.

For example, each of you has probably seen an ad in which a Lasik provider advertises that the procedure is “20/20 or it’s free.” A patient may be able to allege that this advertisement is a guarantee that the procedure will result in 20/20 vision, but no medical provider should guarantee a successful outcome. Each human body reacts differently to treatment, and there is no physician who has not seen an unexpected outcome. Providing patients with unrealistic expectations about their outcomes can lead to lawsuits, even if a physician has obtained a signed informed consent detailing the risks involved.

The situation is even worse when the physician misrepresents his experience. We have defended cases in which physicians have told patients that they had performed a procedure hundreds of times, when that representation was not accurate. One of the greatest assets available to physicians in litigation is their advanced training and professional experience, but that asset becomes worthless if a physician gives the jury a reason to doubt his credibility. Once the jury believes that a physician has misrepresented his experience, he loses the ability to credibly explain his treatment decisions.

5) HMO-directed medicine: It’s no secret that many patients are dissatisfied with their managed care plans. In the abstract, patients understand that rising healthcare costs have caused insurers to limit care, but they are unwilling to view their own situations objectively. They believe that they are entitled to unlimited medical resources. When the HMO tells patients “no,” they have a tendency to transfer their frustrations to their physicians.

The coverage provided by the HMO is a contractual matter between the patient and the insurer. At the end of the day, the treating physician does not control the patient’s eligibility for certain types of care. What the treating physician cannot overlook, however, is that the physician-patient relationship is a personal one that exists independently of the insurance relationship. The standards of professional care require a physician to inform patients of all treatment options—even if the physician believes that the HMO is unlikely to authorize some of them. Ultimately, even if the cost of a treatment option would be prohibitive, a physician must remember that the patient has a right to be informed and to make her own decisions. Physicians should also be receptive to advocating on a patient’s behalf about the reasonableness or necessity of care.

6) Attend to the patient: Few things are harder to explain to a jury than a physician’s failure to personally attend to a patient. The reality is that physicians may receive information over the telephone or through an intermediary’s relay, and they often have to use these means of communication. The risk is that a physician will miss a detail that he would have seen if he had personally examined the patient.

Err on the side of caution. If your differential diagnosis includes a potentially serious condition and your ability to rule out that condition might be influenced by physical findings, arrange to see the patient in person. If the situation does not allow for a face-to-face appointment, instruct the patient to seek medical care through an emergency department or another provider.

Having been there, we can say that there is nothing more difficult for a physician than to have to admit, at deposition, “I wish I had seen the patient personally.”

7) Adequate discharge instructions: Another reality of modern medical practice is that patients often leave the hospital before their course of healing is complete. Patients may leave the hospital shortly after surgery or while still affected by an illness. Even when the treatment in the hospital has been appropriate, we regularly see cases arising from the physician’s discharge instructions. Patients allege that they did not receive enough information to allow them to recognize the onset of potentially serious complications. To prevent confusion, discharge instructions should address all areas of potential concern, including pain, wound care, and signs of infection. The instructions should also include information regarding whom to contact if questions arise and should instruct the patient to return if she experiences a change in condition.

8) Be prepared to deal with misinformation: Technology is wonderful. This morning, we typed the term “diabetes mellitus” into the Google search engine. It returned more than 7.3 million references. Within 30 seconds, we located the “final cure for diabetes,” which was compounded from banana, bitter melon, licorice extract, and cayenne pepper (among other things). While this might cure diabetes, we have our doubts; however, we will leave the debate to more scientific minds.

The problem is that sick people often become desperate people—particularly when fighting diseases like cancer, AIDS, and Alzheimer’s. They are likely to be vulnerable to misinformation and might be inclined to pursue courses of action that could actually harm them. Physicians must realize that they will regularly deal with patients who have unrealistic expectations of the medical system. The only way physicians can combat misinformation is by providing better information. Physicians need to be prepared to educate patients who have unsuccessfully tried to educate themselves. Part of that education can be verbal, but physicians should consider directing patients to reliable resources that they can explore after leaving the hospital.

Patients are also bombarded by advertisements for prescription medications, all of which are designed to persuade them to take an active role in requesting particular prescriptions. The problem is that the physician is responsible for selecting an appropriate medication. Physicians have to be able to explain why an advertised medication may not be the best choice under the circumstances, no matter what the TV commercial said.

9) Take responsibility: Everyone makes mistakes. No physician is perfect, nor is it fair to expect perfection from those who deal with the intricate machinery of the human body. A culture of fear, however, has caused many physicians to believe that they should not admit their mistakes. Our experience shows that recognizing and responding to mistakes is a far better course of action than trying to pretend they didn’t exist.

Taking responsibility doesn’t mean admitting that you were negligent. It does mean acknowledging a complication when it occurs and assisting the patient in minimizing the consequences. Sometimes this will result in transferring the patient to another physician. At other times, the physician may have to pay to correct the mistake. Many medical malpractice insurance carriers now have programs targeted at promptly recognizing and reacting to unexpected outcomes. These insurers realize that the best time to correct a bad situation is within hours or days of its occurrence. Enlist the help of your insurer or hospital risk manager. If patients feel like their physicians are trying to minimize a situation, hoping mistakenly that it will go away, it becomes much more difficult to avoid litigation.

10) Don’t compromise your integrity: Physicians are professionals. Whether it’s fair or not, jurors hold physicians to a higher standard of conduct. They expect more of doctors. They expect doctors to “do the right thing.” Consequently, jurors tend to punish physicians who place their personal interests above their patients’ interests. Federal law already prohibits physicians from engaging in many forms of self-dealing, such as investing in certain businesses or receiving kickbacks for medical care. But there are many lawful forms of conduct that might cause a jury to question why a physician chose a particular course of action.

Recent medical literature demonstrates that pharmaceutical manufacturers direct 90% of an estimated $21 billion annual marketing budget at physicians, including the sponsorship of an estimated 300,000 annual education events. This amounts to approximately $13,000 per physician annually. Because of concerns that even small inducements might have an unwanted effect upon physician independence, the Stanford Medical Center recently announced a new policy prohibiting physicians from accepting free drug samples or even small gifts from pharmaceutical sales representatives. Prominent newspapers have been running stories about the “free lunches” physicians receive.

We’re not suggesting that physicians spurn pharmaceutical sales representatives or that they avoid legal business opportunities. We caution you, however, that smart plaintiffs’ attorneys are sensitive to any indications that a physician has allowed his interests to influence a patient’s treatment. Don’t put yourself in a position where a jury could reasonably question whether or not you had your patient’s best interests in mind.

Unfortunately, even if a physician observes all of these precautions, a patient still might file a lawsuit. If you sense a real potential for litigation, contact your insurance company and provide notice of a potential claim. This will help ensure that your insurance coverage is available if a lawsuit is filed. It also allows the insurance company to retain an attorney to assist you. The next time we write, we’ll provide our top tips for winning a lawsuit once it occurs. TH

Patrick O’Rourke is the managing associate university counsel for the University of Colorado’s litigation office. Kari M. Hershey, JD, practices health law in Colorado.

We’ve defended physicians involved in lawsuits for more than a decade. After representing dozens of physicians, nurses, and other healthcare professionals, we can say one thing for certain: No one likes to get sued.

Good physicians struggle with the litigation process. Even when their care has been absolutely appropriate, many doctors experience great anxiety when they are accused of having negligently injured a patient. Because they have trained so hard to gain their expertise, many of our clients have found that a lawsuit strikes at them personally as well as professionally. At the end of the day, lawsuits cause stress, take physicians away from their personal lives, and often lead to serious financial and professional consequences.

Therefore, one of the questions that we most often receive is, “How can a physician avoid lawsuits?”

Top 10 Ways to Stay Out of Litigation

1) Good documentation: Often, in a lawsuit, plaintiffs’ attorneys will tell the jury the old adage, “If it’s not in the record, it didn’t happen.” What everyone who has practiced medicine knows, however, is that many things don’t make it to the chart. Physicians don’t have the time to recount their conversations with patients verbatim. What we want to see in the chart are the following:

1. A description of the information provided by the patient that factored into your diagnoses or treatment decisions;
2. A description of the physical findings or laboratory results that factored into your diagnoses and treatment decisions;
3. A discussion of why you made a particular decision;
4. A discussion of the course of treatment you selected; and
5. A discussion of your anticipated follow-up.

Of these elements, we most often fail to see a discussion of why you made a particular decision, and this is a crucial piece of the record. As you know, physicians often have a broad range of treatment choices. Including information about why you selected a particular course of treatment—in light of the available data—makes the record more understandable to the jury. A good chart lays out more than just the physician’s actions. A good chart is so complete that another physician could assume care for the patient tomorrow, easily understanding both the course of treatment and why you chose it.

2) Good communication: In his book Blink, Malcolm Gladwell describes something defense lawyers have known for many years: That the quality of the care does not determine whether or not a physician gets sued. There are many instances in which a physician who makes a mistake that causes an injury manages to avoid litigation. There are also many instances in which a physician’s care is appropriate, but the patient sues the physician after a recognized complication. What makes the difference?

More often than not, the determining factor in whether or not a physician is sued is the patient’s perception of whether or not the physician cared about her. In situations in which patients leave the physician’s office believing that the physician listened carefully to their complaints, spent the time to explain the course of treatment, and genuinely cared about them as people, we don’t see as many lawsuits. If a physician explains why a complication occurred—not just that it occurred—and appears empathetic to the patient, she has less of a motivation to sue. Conversely, if the patient feels like the physician sees her as a commodity or didn’t take the time to understand her complaints, the risk of litigation goes up.

One of the most important aspects of good communication is adequate informed consent. Remember, informed consent is a dialogue—not a lecture. It requires physicians to discuss:

1. The substantial risks of the treatment;
2. The benefits of the treatment; and
3. The alternatives to the treatment. Sometimes it’s difficult to determine the substantial risks because a patient and a physician may view the magnitude of a particular risk differently. Our rule of thumb is that any risks associated with serious long-term sequelae, such as permanent impairment, must be discussed, even if the probability of the risk occurring is remote.

3) Good consultation: Many hospitalists do not have long-term relationships with their patients. After a course of hospital treatment, the patient will return to her regular physician. A common breakdown occurs when the consultation between the hospitalist and the regular physician is inadequate.

On the front end, the hospitalist who receives a patient should take the opportunity, if possible, to consult with the regular physician about any ongoing course of treatment. Unfortunately, patients are not always accurate medical historians and may not fully appreciate their conditions or courses of treatment. Consulting with the regular physician helps to eliminate the possibility that an important aspect of the patient’s history or condition is overlooked.

On the back end, when the regular physician resumes care of the patient, he should be able to reinforce the course of hospital care and provide an additional layer of education about why the hospitalist made certain treatment decisions. Of course, the regular physician can serve in this role only if the hospitalist has taken the opportunity to inform the regular physician about the course of care.

4) Accurate representations: We are seeing more cases in which physicians are being sued for alleged misrepresentations to patients.

For example, each of you has probably seen an ad in which a Lasik provider advertises that the procedure is “20/20 or it’s free.” A patient may be able to allege that this advertisement is a guarantee that the procedure will result in 20/20 vision, but no medical provider should guarantee a successful outcome. Each human body reacts differently to treatment, and there is no physician who has not seen an unexpected outcome. Providing patients with unrealistic expectations about their outcomes can lead to lawsuits, even if a physician has obtained a signed informed consent detailing the risks involved.

The situation is even worse when the physician misrepresents his experience. We have defended cases in which physicians have told patients that they had performed a procedure hundreds of times, when that representation was not accurate. One of the greatest assets available to physicians in litigation is their advanced training and professional experience, but that asset becomes worthless if a physician gives the jury a reason to doubt his credibility. Once the jury believes that a physician has misrepresented his experience, he loses the ability to credibly explain his treatment decisions.

5) HMO-directed medicine: It’s no secret that many patients are dissatisfied with their managed care plans. In the abstract, patients understand that rising healthcare costs have caused insurers to limit care, but they are unwilling to view their own situations objectively. They believe that they are entitled to unlimited medical resources. When the HMO tells patients “no,” they have a tendency to transfer their frustrations to their physicians.

The coverage provided by the HMO is a contractual matter between the patient and the insurer. At the end of the day, the treating physician does not control the patient’s eligibility for certain types of care. What the treating physician cannot overlook, however, is that the physician-patient relationship is a personal one that exists independently of the insurance relationship. The standards of professional care require a physician to inform patients of all treatment options—even if the physician believes that the HMO is unlikely to authorize some of them. Ultimately, even if the cost of a treatment option would be prohibitive, a physician must remember that the patient has a right to be informed and to make her own decisions. Physicians should also be receptive to advocating on a patient’s behalf about the reasonableness or necessity of care.

6) Attend to the patient: Few things are harder to explain to a jury than a physician’s failure to personally attend to a patient. The reality is that physicians may receive information over the telephone or through an intermediary’s relay, and they often have to use these means of communication. The risk is that a physician will miss a detail that he would have seen if he had personally examined the patient.

Err on the side of caution. If your differential diagnosis includes a potentially serious condition and your ability to rule out that condition might be influenced by physical findings, arrange to see the patient in person. If the situation does not allow for a face-to-face appointment, instruct the patient to seek medical care through an emergency department or another provider.

Having been there, we can say that there is nothing more difficult for a physician than to have to admit, at deposition, “I wish I had seen the patient personally.”

7) Adequate discharge instructions: Another reality of modern medical practice is that patients often leave the hospital before their course of healing is complete. Patients may leave the hospital shortly after surgery or while still affected by an illness. Even when the treatment in the hospital has been appropriate, we regularly see cases arising from the physician’s discharge instructions. Patients allege that they did not receive enough information to allow them to recognize the onset of potentially serious complications. To prevent confusion, discharge instructions should address all areas of potential concern, including pain, wound care, and signs of infection. The instructions should also include information regarding whom to contact if questions arise and should instruct the patient to return if she experiences a change in condition.

8) Be prepared to deal with misinformation: Technology is wonderful. This morning, we typed the term “diabetes mellitus” into the Google search engine. It returned more than 7.3 million references. Within 30 seconds, we located the “final cure for diabetes,” which was compounded from banana, bitter melon, licorice extract, and cayenne pepper (among other things). While this might cure diabetes, we have our doubts; however, we will leave the debate to more scientific minds.

The problem is that sick people often become desperate people—particularly when fighting diseases like cancer, AIDS, and Alzheimer’s. They are likely to be vulnerable to misinformation and might be inclined to pursue courses of action that could actually harm them. Physicians must realize that they will regularly deal with patients who have unrealistic expectations of the medical system. The only way physicians can combat misinformation is by providing better information. Physicians need to be prepared to educate patients who have unsuccessfully tried to educate themselves. Part of that education can be verbal, but physicians should consider directing patients to reliable resources that they can explore after leaving the hospital.

Patients are also bombarded by advertisements for prescription medications, all of which are designed to persuade them to take an active role in requesting particular prescriptions. The problem is that the physician is responsible for selecting an appropriate medication. Physicians have to be able to explain why an advertised medication may not be the best choice under the circumstances, no matter what the TV commercial said.

9) Take responsibility: Everyone makes mistakes. No physician is perfect, nor is it fair to expect perfection from those who deal with the intricate machinery of the human body. A culture of fear, however, has caused many physicians to believe that they should not admit their mistakes. Our experience shows that recognizing and responding to mistakes is a far better course of action than trying to pretend they didn’t exist.

Taking responsibility doesn’t mean admitting that you were negligent. It does mean acknowledging a complication when it occurs and assisting the patient in minimizing the consequences. Sometimes this will result in transferring the patient to another physician. At other times, the physician may have to pay to correct the mistake. Many medical malpractice insurance carriers now have programs targeted at promptly recognizing and reacting to unexpected outcomes. These insurers realize that the best time to correct a bad situation is within hours or days of its occurrence. Enlist the help of your insurer or hospital risk manager. If patients feel like their physicians are trying to minimize a situation, hoping mistakenly that it will go away, it becomes much more difficult to avoid litigation.

10) Don’t compromise your integrity: Physicians are professionals. Whether it’s fair or not, jurors hold physicians to a higher standard of conduct. They expect more of doctors. They expect doctors to “do the right thing.” Consequently, jurors tend to punish physicians who place their personal interests above their patients’ interests. Federal law already prohibits physicians from engaging in many forms of self-dealing, such as investing in certain businesses or receiving kickbacks for medical care. But there are many lawful forms of conduct that might cause a jury to question why a physician chose a particular course of action.

Recent medical literature demonstrates that pharmaceutical manufacturers direct 90% of an estimated $21 billion annual marketing budget at physicians, including the sponsorship of an estimated 300,000 annual education events. This amounts to approximately $13,000 per physician annually. Because of concerns that even small inducements might have an unwanted effect upon physician independence, the Stanford Medical Center recently announced a new policy prohibiting physicians from accepting free drug samples or even small gifts from pharmaceutical sales representatives. Prominent newspapers have been running stories about the “free lunches” physicians receive.

We’re not suggesting that physicians spurn pharmaceutical sales representatives or that they avoid legal business opportunities. We caution you, however, that smart plaintiffs’ attorneys are sensitive to any indications that a physician has allowed his interests to influence a patient’s treatment. Don’t put yourself in a position where a jury could reasonably question whether or not you had your patient’s best interests in mind.

Unfortunately, even if a physician observes all of these precautions, a patient still might file a lawsuit. If you sense a real potential for litigation, contact your insurance company and provide notice of a potential claim. This will help ensure that your insurance coverage is available if a lawsuit is filed. It also allows the insurance company to retain an attorney to assist you. The next time we write, we’ll provide our top tips for winning a lawsuit once it occurs. TH

Patrick O’Rourke is the managing associate university counsel for the University of Colorado’s litigation office. Kari M. Hershey, JD, practices health law in Colorado.

We’ve defended physicians involved in lawsuits for more than a decade. After representing dozens of physicians, nurses, and other healthcare professionals, we can say one thing for certain: No one likes to get sued.

Good physicians struggle with the litigation process. Even when their care has been absolutely appropriate, many doctors experience great anxiety when they are accused of having negligently injured a patient. Because they have trained so hard to gain their expertise, many of our clients have found that a lawsuit strikes at them personally as well as professionally. At the end of the day, lawsuits cause stress, take physicians away from their personal lives, and often lead to serious financial and professional consequences.

Therefore, one of the questions that we most often receive is, “How can a physician avoid lawsuits?”

Top 10 Ways to Stay Out of Litigation

1) Good documentation: Often, in a lawsuit, plaintiffs’ attorneys will tell the jury the old adage, “If it’s not in the record, it didn’t happen.” What everyone who has practiced medicine knows, however, is that many things don’t make it to the chart. Physicians don’t have the time to recount their conversations with patients verbatim. What we want to see in the chart are the following:

1. A description of the information provided by the patient that factored into your diagnoses or treatment decisions;
2. A description of the physical findings or laboratory results that factored into your diagnoses and treatment decisions;
3. A discussion of why you made a particular decision;
4. A discussion of the course of treatment you selected; and
5. A discussion of your anticipated follow-up.

Of these elements, we most often fail to see a discussion of why you made a particular decision, and this is a crucial piece of the record. As you know, physicians often have a broad range of treatment choices. Including information about why you selected a particular course of treatment—in light of the available data—makes the record more understandable to the jury. A good chart lays out more than just the physician’s actions. A good chart is so complete that another physician could assume care for the patient tomorrow, easily understanding both the course of treatment and why you chose it.

2) Good communication: In his book Blink, Malcolm Gladwell describes something defense lawyers have known for many years: That the quality of the care does not determine whether or not a physician gets sued. There are many instances in which a physician who makes a mistake that causes an injury manages to avoid litigation. There are also many instances in which a physician’s care is appropriate, but the patient sues the physician after a recognized complication. What makes the difference?

More often than not, the determining factor in whether or not a physician is sued is the patient’s perception of whether or not the physician cared about her. In situations in which patients leave the physician’s office believing that the physician listened carefully to their complaints, spent the time to explain the course of treatment, and genuinely cared about them as people, we don’t see as many lawsuits. If a physician explains why a complication occurred—not just that it occurred—and appears empathetic to the patient, she has less of a motivation to sue. Conversely, if the patient feels like the physician sees her as a commodity or didn’t take the time to understand her complaints, the risk of litigation goes up.

One of the most important aspects of good communication is adequate informed consent. Remember, informed consent is a dialogue—not a lecture. It requires physicians to discuss:

1. The substantial risks of the treatment;
2. The benefits of the treatment; and
3. The alternatives to the treatment. Sometimes it’s difficult to determine the substantial risks because a patient and a physician may view the magnitude of a particular risk differently. Our rule of thumb is that any risks associated with serious long-term sequelae, such as permanent impairment, must be discussed, even if the probability of the risk occurring is remote.

3) Good consultation: Many hospitalists do not have long-term relationships with their patients. After a course of hospital treatment, the patient will return to her regular physician. A common breakdown occurs when the consultation between the hospitalist and the regular physician is inadequate.

On the front end, the hospitalist who receives a patient should take the opportunity, if possible, to consult with the regular physician about any ongoing course of treatment. Unfortunately, patients are not always accurate medical historians and may not fully appreciate their conditions or courses of treatment. Consulting with the regular physician helps to eliminate the possibility that an important aspect of the patient’s history or condition is overlooked.

On the back end, when the regular physician resumes care of the patient, he should be able to reinforce the course of hospital care and provide an additional layer of education about why the hospitalist made certain treatment decisions. Of course, the regular physician can serve in this role only if the hospitalist has taken the opportunity to inform the regular physician about the course of care.

4) Accurate representations: We are seeing more cases in which physicians are being sued for alleged misrepresentations to patients.

For example, each of you has probably seen an ad in which a Lasik provider advertises that the procedure is “20/20 or it’s free.” A patient may be able to allege that this advertisement is a guarantee that the procedure will result in 20/20 vision, but no medical provider should guarantee a successful outcome. Each human body reacts differently to treatment, and there is no physician who has not seen an unexpected outcome. Providing patients with unrealistic expectations about their outcomes can lead to lawsuits, even if a physician has obtained a signed informed consent detailing the risks involved.

The situation is even worse when the physician misrepresents his experience. We have defended cases in which physicians have told patients that they had performed a procedure hundreds of times, when that representation was not accurate. One of the greatest assets available to physicians in litigation is their advanced training and professional experience, but that asset becomes worthless if a physician gives the jury a reason to doubt his credibility. Once the jury believes that a physician has misrepresented his experience, he loses the ability to credibly explain his treatment decisions.

5) HMO-directed medicine: It’s no secret that many patients are dissatisfied with their managed care plans. In the abstract, patients understand that rising healthcare costs have caused insurers to limit care, but they are unwilling to view their own situations objectively. They believe that they are entitled to unlimited medical resources. When the HMO tells patients “no,” they have a tendency to transfer their frustrations to their physicians.

The coverage provided by the HMO is a contractual matter between the patient and the insurer. At the end of the day, the treating physician does not control the patient’s eligibility for certain types of care. What the treating physician cannot overlook, however, is that the physician-patient relationship is a personal one that exists independently of the insurance relationship. The standards of professional care require a physician to inform patients of all treatment options—even if the physician believes that the HMO is unlikely to authorize some of them. Ultimately, even if the cost of a treatment option would be prohibitive, a physician must remember that the patient has a right to be informed and to make her own decisions. Physicians should also be receptive to advocating on a patient’s behalf about the reasonableness or necessity of care.

6) Attend to the patient: Few things are harder to explain to a jury than a physician’s failure to personally attend to a patient. The reality is that physicians may receive information over the telephone or through an intermediary’s relay, and they often have to use these means of communication. The risk is that a physician will miss a detail that he would have seen if he had personally examined the patient.

Err on the side of caution. If your differential diagnosis includes a potentially serious condition and your ability to rule out that condition might be influenced by physical findings, arrange to see the patient in person. If the situation does not allow for a face-to-face appointment, instruct the patient to seek medical care through an emergency department or another provider.

Having been there, we can say that there is nothing more difficult for a physician than to have to admit, at deposition, “I wish I had seen the patient personally.”

7) Adequate discharge instructions: Another reality of modern medical practice is that patients often leave the hospital before their course of healing is complete. Patients may leave the hospital shortly after surgery or while still affected by an illness. Even when the treatment in the hospital has been appropriate, we regularly see cases arising from the physician’s discharge instructions. Patients allege that they did not receive enough information to allow them to recognize the onset of potentially serious complications. To prevent confusion, discharge instructions should address all areas of potential concern, including pain, wound care, and signs of infection. The instructions should also include information regarding whom to contact if questions arise and should instruct the patient to return if she experiences a change in condition.

8) Be prepared to deal with misinformation: Technology is wonderful. This morning, we typed the term “diabetes mellitus” into the Google search engine. It returned more than 7.3 million references. Within 30 seconds, we located the “final cure for diabetes,” which was compounded from banana, bitter melon, licorice extract, and cayenne pepper (among other things). While this might cure diabetes, we have our doubts; however, we will leave the debate to more scientific minds.

The problem is that sick people often become desperate people—particularly when fighting diseases like cancer, AIDS, and Alzheimer’s. They are likely to be vulnerable to misinformation and might be inclined to pursue courses of action that could actually harm them. Physicians must realize that they will regularly deal with patients who have unrealistic expectations of the medical system. The only way physicians can combat misinformation is by providing better information. Physicians need to be prepared to educate patients who have unsuccessfully tried to educate themselves. Part of that education can be verbal, but physicians should consider directing patients to reliable resources that they can explore after leaving the hospital.

Patients are also bombarded by advertisements for prescription medications, all of which are designed to persuade them to take an active role in requesting particular prescriptions. The problem is that the physician is responsible for selecting an appropriate medication. Physicians have to be able to explain why an advertised medication may not be the best choice under the circumstances, no matter what the TV commercial said.

9) Take responsibility: Everyone makes mistakes. No physician is perfect, nor is it fair to expect perfection from those who deal with the intricate machinery of the human body. A culture of fear, however, has caused many physicians to believe that they should not admit their mistakes. Our experience shows that recognizing and responding to mistakes is a far better course of action than trying to pretend they didn’t exist.

Taking responsibility doesn’t mean admitting that you were negligent. It does mean acknowledging a complication when it occurs and assisting the patient in minimizing the consequences. Sometimes this will result in transferring the patient to another physician. At other times, the physician may have to pay to correct the mistake. Many medical malpractice insurance carriers now have programs targeted at promptly recognizing and reacting to unexpected outcomes. These insurers realize that the best time to correct a bad situation is within hours or days of its occurrence. Enlist the help of your insurer or hospital risk manager. If patients feel like their physicians are trying to minimize a situation, hoping mistakenly that it will go away, it becomes much more difficult to avoid litigation.

10) Don’t compromise your integrity: Physicians are professionals. Whether it’s fair or not, jurors hold physicians to a higher standard of conduct. They expect more of doctors. They expect doctors to “do the right thing.” Consequently, jurors tend to punish physicians who place their personal interests above their patients’ interests. Federal law already prohibits physicians from engaging in many forms of self-dealing, such as investing in certain businesses or receiving kickbacks for medical care. But there are many lawful forms of conduct that might cause a jury to question why a physician chose a particular course of action.

Recent medical literature demonstrates that pharmaceutical manufacturers direct 90% of an estimated $21 billion annual marketing budget at physicians, including the sponsorship of an estimated 300,000 annual education events. This amounts to approximately $13,000 per physician annually. Because of concerns that even small inducements might have an unwanted effect upon physician independence, the Stanford Medical Center recently announced a new policy prohibiting physicians from accepting free drug samples or even small gifts from pharmaceutical sales representatives. Prominent newspapers have been running stories about the “free lunches” physicians receive.

We’re not suggesting that physicians spurn pharmaceutical sales representatives or that they avoid legal business opportunities. We caution you, however, that smart plaintiffs’ attorneys are sensitive to any indications that a physician has allowed his interests to influence a patient’s treatment. Don’t put yourself in a position where a jury could reasonably question whether or not you had your patient’s best interests in mind.

Unfortunately, even if a physician observes all of these precautions, a patient still might file a lawsuit. If you sense a real potential for litigation, contact your insurance company and provide notice of a potential claim. This will help ensure that your insurance coverage is available if a lawsuit is filed. It also allows the insurance company to retain an attorney to assist you. The next time we write, we’ll provide our top tips for winning a lawsuit once it occurs. TH

Patrick O’Rourke is the managing associate university counsel for the University of Colorado’s litigation office. Kari M. Hershey, JD, practices health law in Colorado.

I definitely think there may be some biases on the part of hospitalists,” says Ashish Boghani, MD, chief of the hospitalist service at Highland Hospital, Rochester, N.Y. As a young physician, he noticed some bias in his own thoughts and behaviors.

“But as I got more and more experienced,” he says, “if I was told by another provider that someone was a difficult patient, I left that outside the door. When I go into a patient’s room the first time, I start fresh—no matter what I read on the chart or heard from any staff or colleagues. … And it usually turns out that once you approach it like that … the situation turns out differently.”

In other words, if a physician doesn’t approach a patient with the bias of someone else’s interpretation, that patient will not necessarily be perceived as difficult. What about a physician’s own biases?

Personal Biases

“A lot of a hospitalists’ interactions with patients are colored by our own experiences,” says Bilal Ahmed, MD, associate program director for the residency program and associate professor of clinical medicine, University of Rochester School of Medicine. For example, “when physicians see a patient who has COPD or cancer and is smoking,” he says, “there may be this thought at the back of their minds that this is something they brought upon themselves. [In that case] the empathy that you feel for that person may go down just a notch, which is a very human response.”

Dr. Ahmed often discusses remaining nonjudgmental with his residents. “But it is not that easy to always practice it, so it kind of creeps back in,” he says.

In particular, biases against obese patients are common and have been shown to affect a physician’s practice style. Research published in 2005 demonstrated that with regard to obese patients, poorer physical health, a lower level of education, and a lower income level were significantly associated with the doctor spending more time on technical tasks during primary care medical encounters, rather than engaging in educational interactions with these patients that encouraged health.1, 2

In a study of 62 severely overweight and 29 normal weight adolescents, satisfaction with affective aspects of the patient-physician relationship was negatively correlated with body mass index score.3 And although these were studies involving primary care, a physician’s specialty is irrelevant when it comes to these very human responses, says Howard Beckman, MD, clinical professor of internal medicine and family medicine at the University of Rochester School of Medicine and Dentistry.

In the once- or twice-monthly conversations Dr. Ahmed holds with his residents about the topic of obesity, “we look at the social, cultural, genetic, metabolic, and other components so we can understand that it is not just that the person is eating a lot,” he explains. “It’s multifactorial, and [there is] a complex set of facts that leads a person to be where they are.”

What’s Behind Bias?

“The areas where we judge other people may be just the areas where we are doing these things ourselves,” says Dr. Beckman. “Part of why we are the way we are with certain patients is that we fear that we may be like that person, and we want to blame them to let ourselves off the hook.”

Many types of patients may trigger an individual physician’s dislike or aversion, including passive patients, patients who smoke, overweight patients, depressed patients, patients who abuse various substances, non-adherent patients, whiny patients, passive-aggressive patients, and elderly patients.

“The movement in medicine is for insightful reflection about what the physician brings into the room,” says Dr. Beckman.

When he comes across a patient he does not like, Dr. Beckman asks, “This is someone I could not like, but do I want to not like them?” At that point, he is ready to make a conscious decision either to change his attitude or behavior or to seek a solution that protects patient care.

Insightfulness into the physician’s own history and family of origin is a cornerstone of the work being done by a number of physicians at the University of Rochester, including Dr. Beckman, an expert in physician-patient communication and the medical director for the Rochester Individual Practice Association (RIPA). For instance, was the hospitalist’s mother overly passive or his father an alcoholic?

Dr. Beckman addressed bias recently when he rewrote a chapter on difficult patients for a new edition of a behavioral medicine textbook.4 “One belief is that there are difficult patients; there is something about them that’s difficult,” says Dr. Beckman. “And in some cases that may be true. But what [investigators have now] recognized is that people who are difficult for one doctor [may] not [be] difficult for another doctor. And so it would appear that the variable is not the patient, but rather it’s the doctor.”

When this phenomenon was examined to a greater extent, “they tended to find that the type of person that the doctor doesn’t like, they’ve often seen before … usually in their family,” he explains.

Is Reflection the Answer?

Dr. Beckman believes it is the obligation of medical schools to help practitioners understand their own strengths and weaknesses, including their biases. He and a number of colleagues have just received a grant to study teaching the practice of such mindfulness to physicians. The study will investigate whether that education will ultimately affect a doctor’s cost of care. Essentially, Dr. Beckman says, it comes down to a question: Does knowing more about yourself change the way you practice?

At Strong Memorial Hospital in Rochester, N.Y., where Andrew Rudmann, MD, is chief of a hospital medicine division that includes 17 faculty members and 40 midlevel practitioners, physicians have not formally discussed having negative feelings toward their patients. But, “I think hospitalists would do well to reflect on their feelings about these issues,” says Dr. Rudmann, who is also associate director of the internal medicine residency program at Strong.

Reflection on what physicians bring to their medical encounters should take into account what Dr. Beckman calls “the three big pieces” of how humans work together in a medical encounter: “What is happening to the patient before the doctor walks into room, what is happening to the doctor before he walks into the room, and what happens in the room.” TH

Andrea Sattinger also writes about “vintage bugs” in this issue.

References

1. Bertakis KD, Azari R. The impact of obesity on primary care visits. Obes Res. 2005 Sep;13(9):1615-1623.
2. Robinson BE, Gjerdingen DK, Houge DR. Obesity: a move from traditional to more patient-oriented management. J Am Board Fam Pract. 1995 Mar-Apr;8(2):99-108.
3. Cohen ML, Tanofsky-Kraff M, Young-Hyman D, et al. Weight and its relationship to adolescent perceptions of their providers (WRAP): a qualitative and quantitative assessment of teen weight-related preferences and concerns. J Adolesc Health. 2005;37:163.
4. Beckman H. Difficult Patients. In: Feldman MD, Christensen JF, eds. Behavioral Medicine in Primary Care: A Practical Guide. New York: McGraw-Hill Medical; 2003:23-32.

I definitely think there may be some biases on the part of hospitalists,” says Ashish Boghani, MD, chief of the hospitalist service at Highland Hospital, Rochester, N.Y. As a young physician, he noticed some bias in his own thoughts and behaviors.

“But as I got more and more experienced,” he says, “if I was told by another provider that someone was a difficult patient, I left that outside the door. When I go into a patient’s room the first time, I start fresh—no matter what I read on the chart or heard from any staff or colleagues. … And it usually turns out that once you approach it like that … the situation turns out differently.”

In other words, if a physician doesn’t approach a patient with the bias of someone else’s interpretation, that patient will not necessarily be perceived as difficult. What about a physician’s own biases?

Personal Biases

“A lot of a hospitalists’ interactions with patients are colored by our own experiences,” says Bilal Ahmed, MD, associate program director for the residency program and associate professor of clinical medicine, University of Rochester School of Medicine. For example, “when physicians see a patient who has COPD or cancer and is smoking,” he says, “there may be this thought at the back of their minds that this is something they brought upon themselves. [In that case] the empathy that you feel for that person may go down just a notch, which is a very human response.”

Dr. Ahmed often discusses remaining nonjudgmental with his residents. “But it is not that easy to always practice it, so it kind of creeps back in,” he says.

In particular, biases against obese patients are common and have been shown to affect a physician’s practice style. Research published in 2005 demonstrated that with regard to obese patients, poorer physical health, a lower level of education, and a lower income level were significantly associated with the doctor spending more time on technical tasks during primary care medical encounters, rather than engaging in educational interactions with these patients that encouraged health.1, 2

In a study of 62 severely overweight and 29 normal weight adolescents, satisfaction with affective aspects of the patient-physician relationship was negatively correlated with body mass index score.3 And although these were studies involving primary care, a physician’s specialty is irrelevant when it comes to these very human responses, says Howard Beckman, MD, clinical professor of internal medicine and family medicine at the University of Rochester School of Medicine and Dentistry.

In the once- or twice-monthly conversations Dr. Ahmed holds with his residents about the topic of obesity, “we look at the social, cultural, genetic, metabolic, and other components so we can understand that it is not just that the person is eating a lot,” he explains. “It’s multifactorial, and [there is] a complex set of facts that leads a person to be where they are.”

What’s Behind Bias?

“The areas where we judge other people may be just the areas where we are doing these things ourselves,” says Dr. Beckman. “Part of why we are the way we are with certain patients is that we fear that we may be like that person, and we want to blame them to let ourselves off the hook.”

Many types of patients may trigger an individual physician’s dislike or aversion, including passive patients, patients who smoke, overweight patients, depressed patients, patients who abuse various substances, non-adherent patients, whiny patients, passive-aggressive patients, and elderly patients.

“The movement in medicine is for insightful reflection about what the physician brings into the room,” says Dr. Beckman.

When he comes across a patient he does not like, Dr. Beckman asks, “This is someone I could not like, but do I want to not like them?” At that point, he is ready to make a conscious decision either to change his attitude or behavior or to seek a solution that protects patient care.

Insightfulness into the physician’s own history and family of origin is a cornerstone of the work being done by a number of physicians at the University of Rochester, including Dr. Beckman, an expert in physician-patient communication and the medical director for the Rochester Individual Practice Association (RIPA). For instance, was the hospitalist’s mother overly passive or his father an alcoholic?

Dr. Beckman addressed bias recently when he rewrote a chapter on difficult patients for a new edition of a behavioral medicine textbook.4 “One belief is that there are difficult patients; there is something about them that’s difficult,” says Dr. Beckman. “And in some cases that may be true. But what [investigators have now] recognized is that people who are difficult for one doctor [may] not [be] difficult for another doctor. And so it would appear that the variable is not the patient, but rather it’s the doctor.”

When this phenomenon was examined to a greater extent, “they tended to find that the type of person that the doctor doesn’t like, they’ve often seen before … usually in their family,” he explains.

Is Reflection the Answer?

Dr. Beckman believes it is the obligation of medical schools to help practitioners understand their own strengths and weaknesses, including their biases. He and a number of colleagues have just received a grant to study teaching the practice of such mindfulness to physicians. The study will investigate whether that education will ultimately affect a doctor’s cost of care. Essentially, Dr. Beckman says, it comes down to a question: Does knowing more about yourself change the way you practice?

At Strong Memorial Hospital in Rochester, N.Y., where Andrew Rudmann, MD, is chief of a hospital medicine division that includes 17 faculty members and 40 midlevel practitioners, physicians have not formally discussed having negative feelings toward their patients. But, “I think hospitalists would do well to reflect on their feelings about these issues,” says Dr. Rudmann, who is also associate director of the internal medicine residency program at Strong.

Reflection on what physicians bring to their medical encounters should take into account what Dr. Beckman calls “the three big pieces” of how humans work together in a medical encounter: “What is happening to the patient before the doctor walks into room, what is happening to the doctor before he walks into the room, and what happens in the room.” TH

Andrea Sattinger also writes about “vintage bugs” in this issue.

References

1. Bertakis KD, Azari R. The impact of obesity on primary care visits. Obes Res. 2005 Sep;13(9):1615-1623.
2. Robinson BE, Gjerdingen DK, Houge DR. Obesity: a move from traditional to more patient-oriented management. J Am Board Fam Pract. 1995 Mar-Apr;8(2):99-108.
3. Cohen ML, Tanofsky-Kraff M, Young-Hyman D, et al. Weight and its relationship to adolescent perceptions of their providers (WRAP): a qualitative and quantitative assessment of teen weight-related preferences and concerns. J Adolesc Health. 2005;37:163.
4. Beckman H. Difficult Patients. In: Feldman MD, Christensen JF, eds. Behavioral Medicine in Primary Care: A Practical Guide. New York: McGraw-Hill Medical; 2003:23-32.

I definitely think there may be some biases on the part of hospitalists,” says Ashish Boghani, MD, chief of the hospitalist service at Highland Hospital, Rochester, N.Y. As a young physician, he noticed some bias in his own thoughts and behaviors.

“But as I got more and more experienced,” he says, “if I was told by another provider that someone was a difficult patient, I left that outside the door. When I go into a patient’s room the first time, I start fresh—no matter what I read on the chart or heard from any staff or colleagues. … And it usually turns out that once you approach it like that … the situation turns out differently.”

In other words, if a physician doesn’t approach a patient with the bias of someone else’s interpretation, that patient will not necessarily be perceived as difficult. What about a physician’s own biases?

Personal Biases

“A lot of a hospitalists’ interactions with patients are colored by our own experiences,” says Bilal Ahmed, MD, associate program director for the residency program and associate professor of clinical medicine, University of Rochester School of Medicine. For example, “when physicians see a patient who has COPD or cancer and is smoking,” he says, “there may be this thought at the back of their minds that this is something they brought upon themselves. [In that case] the empathy that you feel for that person may go down just a notch, which is a very human response.”

Dr. Ahmed often discusses remaining nonjudgmental with his residents. “But it is not that easy to always practice it, so it kind of creeps back in,” he says.

In particular, biases against obese patients are common and have been shown to affect a physician’s practice style. Research published in 2005 demonstrated that with regard to obese patients, poorer physical health, a lower level of education, and a lower income level were significantly associated with the doctor spending more time on technical tasks during primary care medical encounters, rather than engaging in educational interactions with these patients that encouraged health.1, 2

In a study of 62 severely overweight and 29 normal weight adolescents, satisfaction with affective aspects of the patient-physician relationship was negatively correlated with body mass index score.3 And although these were studies involving primary care, a physician’s specialty is irrelevant when it comes to these very human responses, says Howard Beckman, MD, clinical professor of internal medicine and family medicine at the University of Rochester School of Medicine and Dentistry.

In the once- or twice-monthly conversations Dr. Ahmed holds with his residents about the topic of obesity, “we look at the social, cultural, genetic, metabolic, and other components so we can understand that it is not just that the person is eating a lot,” he explains. “It’s multifactorial, and [there is] a complex set of facts that leads a person to be where they are.”

What’s Behind Bias?

“The areas where we judge other people may be just the areas where we are doing these things ourselves,” says Dr. Beckman. “Part of why we are the way we are with certain patients is that we fear that we may be like that person, and we want to blame them to let ourselves off the hook.”

Many types of patients may trigger an individual physician’s dislike or aversion, including passive patients, patients who smoke, overweight patients, depressed patients, patients who abuse various substances, non-adherent patients, whiny patients, passive-aggressive patients, and elderly patients.

“The movement in medicine is for insightful reflection about what the physician brings into the room,” says Dr. Beckman.

When he comes across a patient he does not like, Dr. Beckman asks, “This is someone I could not like, but do I want to not like them?” At that point, he is ready to make a conscious decision either to change his attitude or behavior or to seek a solution that protects patient care.

Insightfulness into the physician’s own history and family of origin is a cornerstone of the work being done by a number of physicians at the University of Rochester, including Dr. Beckman, an expert in physician-patient communication and the medical director for the Rochester Individual Practice Association (RIPA). For instance, was the hospitalist’s mother overly passive or his father an alcoholic?

Dr. Beckman addressed bias recently when he rewrote a chapter on difficult patients for a new edition of a behavioral medicine textbook.4 “One belief is that there are difficult patients; there is something about them that’s difficult,” says Dr. Beckman. “And in some cases that may be true. But what [investigators have now] recognized is that people who are difficult for one doctor [may] not [be] difficult for another doctor. And so it would appear that the variable is not the patient, but rather it’s the doctor.”

When this phenomenon was examined to a greater extent, “they tended to find that the type of person that the doctor doesn’t like, they’ve often seen before … usually in their family,” he explains.

Is Reflection the Answer?

Dr. Beckman believes it is the obligation of medical schools to help practitioners understand their own strengths and weaknesses, including their biases. He and a number of colleagues have just received a grant to study teaching the practice of such mindfulness to physicians. The study will investigate whether that education will ultimately affect a doctor’s cost of care. Essentially, Dr. Beckman says, it comes down to a question: Does knowing more about yourself change the way you practice?

At Strong Memorial Hospital in Rochester, N.Y., where Andrew Rudmann, MD, is chief of a hospital medicine division that includes 17 faculty members and 40 midlevel practitioners, physicians have not formally discussed having negative feelings toward their patients. But, “I think hospitalists would do well to reflect on their feelings about these issues,” says Dr. Rudmann, who is also associate director of the internal medicine residency program at Strong.

Reflection on what physicians bring to their medical encounters should take into account what Dr. Beckman calls “the three big pieces” of how humans work together in a medical encounter: “What is happening to the patient before the doctor walks into room, what is happening to the doctor before he walks into the room, and what happens in the room.” TH

Andrea Sattinger also writes about “vintage bugs” in this issue.

References

1. Bertakis KD, Azari R. The impact of obesity on primary care visits. Obes Res. 2005 Sep;13(9):1615-1623.
2. Robinson BE, Gjerdingen DK, Houge DR. Obesity: a move from traditional to more patient-oriented management. J Am Board Fam Pract. 1995 Mar-Apr;8(2):99-108.
3. Cohen ML, Tanofsky-Kraff M, Young-Hyman D, et al. Weight and its relationship to adolescent perceptions of their providers (WRAP): a qualitative and quantitative assessment of teen weight-related preferences and concerns. J Adolesc Health. 2005;37:163.
4. Beckman H. Difficult Patients. In: Feldman MD, Christensen JF, eds. Behavioral Medicine in Primary Care: A Practical Guide. New York: McGraw-Hill Medical; 2003:23-32.

One of the many trends in healthcare today is a move toward making specific quality and pricing information available to the public.

“When you’re buying a car, you can easily compare quality, features, and prices to make an educated guess,” points out Eric Siegal, MD, regional medical director, Cogent Healthcare, Madison, Wis., and chair of SHM’s Public Policy Committee. “In contrast, healthcare is completely opaque. People choose a doctor or a hospital—sometimes for a surgery that’s life threatening—by word of mouth or [based on] proximity. How do you make it possible to choose based on quality of care and on price?”

Known as healthcare transparency, this trend is driven by multiple sources. “The [CMS] Hospital Compare initiative was a first step in this, as were the Leapfrog initiative and the IHI [Institute for Health Improvement] Collaborative,” says Dr. Siegal. “In fact, the government is a little late to the game, but they’re quickly closing the gap.”

Mandate from the President

On August 22, 2006, President George W. Bush signed an executive order requiring key federal agencies to collect information about the quality and cost of the healthcare they provide and to share that data with each another—and with beneficiaries. Agencies included in the order are the Department of Health and Human Services (HHS), the Department of Defense (DoD), the Department of Veterans Affairs (VA), and the Office of Personnel Management (OPM).

The executive order directs these four agencies to work with the private sector and other government agencies to develop programs to measure quality of care. They were required by Jan. 1, 2007, to identify practices that promote high quality care and to compile information on the prices they pay for common services available to their members. Ultimately, the executive order calls for combining that data in a comprehensive source on providers’ quality and prices; this information will then be available to consumers.

President Bush has said that his order sends a message to healthcare providers that “in order to do business with the federal government, you’ve got to show us your prices.” The new requirements for transparency will affect healthcare providers across the country because treating about one-quarter of Americans covered by health insurance entails “doing business with the federal government.” That one-quarter includes Medicare beneficiaries, health insurance beneficiaries at the DoD and the VA, and federal employees. (The order clearly states that the directive does not apply to state-administered or -funded programs.)

House Legislation: Make Prices Public

Comprehensive pricing transparency may also be required on a state level. On Sept. 13, 2006, Representative Michael Burgess (R-Texas) introduced the Health Care Price Transparency Act of 2006 in the House. This American Hospital Association (AHA)-supported legislation would require states to publicly report hospital charges for specific inpatient and outpatient services and would require insurers to give patients, on request, an estimate of their expected out-of-pocket expenses.

The bill would also require the Agency for Healthcare Research and Quality to study what type of healthcare price information consumers would find useful and how that information could be made available in a timely, understandable form.

Thirty-two states already require hospitals to report pricing information, and six more are voluntarily doing so, but this legislation would likely change the information that hospitals and other providers are gathering and providing.

At press time, the legislation had been referred to the House Subcommittee on Health.

How Transparency Will Roll Out

While the House legislation is in limbo, the executive order will have an immediate effect on healthcare, starting this year. The quality measures to be included in reporting will be developed from private and government sources, including local providers, employers, and health plans and insurers.

After the data are gathered and the information technology (IT) infrastructure is set up, consumers will be able to access specific information on pricing and quality of services performed by doctors, hospitals, and other healthcare providers. This information may be available through a variety of sources, including insurance companies, employers, and Medicare-sponsored Web sites.

One of the keys to success will be in the collaboration among the agencies involved. “There’s a keen understanding among the major players that if everyone does their own thing, we’ll have chaos,” says Dr. Siegal. “There has to be a significant degree of harmonization [among] physician measures, hospital measures, inpatient measures, and outpatient measures.”

Where Hospitalists Fit in

Will healthcare transparency affect hospitalists? “It’s already impacting hospitalists,” says Dr. Siegal. “Not on pricing, but on quality reporting. The good news is that hospitalists may be the single best-prepared group of physicians [for transparency] because we’re already doing it. The question will be, as it becomes more pervasive, will it be done in a way that is thoughtful, measured, and practical?”

Hospitals are likely to look to their hospitalists to ensure that their quality measurements are competitive. Dr. Siegal explains, “Hospitals looking to improve quality will be most effective in getting results from the physicians whose financial incentives are aligned with theirs.”

However, additional—or more public—quality indicators will not necessarily create a huge source of income for hospital medicine. “The low-hanging fruit won’t be the patients that hospitalists see; it will be elective surgical cases,” predicts Dr. Siegal. “Those are cleanly defined procedures, with bundled payments and predictable outcomes, where a hospital can understand what happens and what’s included. Then they can say, ‘Why do we charge 20% more for a total elective hip [surgery] than the hospital down the road?’ ”

As transparency is rolled out in U.S. hospitals and healthcare systems, hospitalists will look good. “Hospitalists already live in a quality reporting world, more so than other doctors,” says Dr. Siegal. TH

Jane Jerrard writes “Public Policy” for The Hospitalist.

One of the many trends in healthcare today is a move toward making specific quality and pricing information available to the public.

“When you’re buying a car, you can easily compare quality, features, and prices to make an educated guess,” points out Eric Siegal, MD, regional medical director, Cogent Healthcare, Madison, Wis., and chair of SHM’s Public Policy Committee. “In contrast, healthcare is completely opaque. People choose a doctor or a hospital—sometimes for a surgery that’s life threatening—by word of mouth or [based on] proximity. How do you make it possible to choose based on quality of care and on price?”

Known as healthcare transparency, this trend is driven by multiple sources. “The [CMS] Hospital Compare initiative was a first step in this, as were the Leapfrog initiative and the IHI [Institute for Health Improvement] Collaborative,” says Dr. Siegal. “In fact, the government is a little late to the game, but they’re quickly closing the gap.”

Mandate from the President

On August 22, 2006, President George W. Bush signed an executive order requiring key federal agencies to collect information about the quality and cost of the healthcare they provide and to share that data with each another—and with beneficiaries. Agencies included in the order are the Department of Health and Human Services (HHS), the Department of Defense (DoD), the Department of Veterans Affairs (VA), and the Office of Personnel Management (OPM).

The executive order directs these four agencies to work with the private sector and other government agencies to develop programs to measure quality of care. They were required by Jan. 1, 2007, to identify practices that promote high quality care and to compile information on the prices they pay for common services available to their members. Ultimately, the executive order calls for combining that data in a comprehensive source on providers’ quality and prices; this information will then be available to consumers.

President Bush has said that his order sends a message to healthcare providers that “in order to do business with the federal government, you’ve got to show us your prices.” The new requirements for transparency will affect healthcare providers across the country because treating about one-quarter of Americans covered by health insurance entails “doing business with the federal government.” That one-quarter includes Medicare beneficiaries, health insurance beneficiaries at the DoD and the VA, and federal employees. (The order clearly states that the directive does not apply to state-administered or -funded programs.)

House Legislation: Make Prices Public

Comprehensive pricing transparency may also be required on a state level. On Sept. 13, 2006, Representative Michael Burgess (R-Texas) introduced the Health Care Price Transparency Act of 2006 in the House. This American Hospital Association (AHA)-supported legislation would require states to publicly report hospital charges for specific inpatient and outpatient services and would require insurers to give patients, on request, an estimate of their expected out-of-pocket expenses.

The bill would also require the Agency for Healthcare Research and Quality to study what type of healthcare price information consumers would find useful and how that information could be made available in a timely, understandable form.

Thirty-two states already require hospitals to report pricing information, and six more are voluntarily doing so, but this legislation would likely change the information that hospitals and other providers are gathering and providing.

At press time, the legislation had been referred to the House Subcommittee on Health.

How Transparency Will Roll Out

While the House legislation is in limbo, the executive order will have an immediate effect on healthcare, starting this year. The quality measures to be included in reporting will be developed from private and government sources, including local providers, employers, and health plans and insurers.

After the data are gathered and the information technology (IT) infrastructure is set up, consumers will be able to access specific information on pricing and quality of services performed by doctors, hospitals, and other healthcare providers. This information may be available through a variety of sources, including insurance companies, employers, and Medicare-sponsored Web sites.

One of the keys to success will be in the collaboration among the agencies involved. “There’s a keen understanding among the major players that if everyone does their own thing, we’ll have chaos,” says Dr. Siegal. “There has to be a significant degree of harmonization [among] physician measures, hospital measures, inpatient measures, and outpatient measures.”

Where Hospitalists Fit in

Will healthcare transparency affect hospitalists? “It’s already impacting hospitalists,” says Dr. Siegal. “Not on pricing, but on quality reporting. The good news is that hospitalists may be the single best-prepared group of physicians [for transparency] because we’re already doing it. The question will be, as it becomes more pervasive, will it be done in a way that is thoughtful, measured, and practical?”

Hospitals are likely to look to their hospitalists to ensure that their quality measurements are competitive. Dr. Siegal explains, “Hospitals looking to improve quality will be most effective in getting results from the physicians whose financial incentives are aligned with theirs.”

However, additional—or more public—quality indicators will not necessarily create a huge source of income for hospital medicine. “The low-hanging fruit won’t be the patients that hospitalists see; it will be elective surgical cases,” predicts Dr. Siegal. “Those are cleanly defined procedures, with bundled payments and predictable outcomes, where a hospital can understand what happens and what’s included. Then they can say, ‘Why do we charge 20% more for a total elective hip [surgery] than the hospital down the road?’ ”

As transparency is rolled out in U.S. hospitals and healthcare systems, hospitalists will look good. “Hospitalists already live in a quality reporting world, more so than other doctors,” says Dr. Siegal. TH

Jane Jerrard writes “Public Policy” for The Hospitalist.

One of the many trends in healthcare today is a move toward making specific quality and pricing information available to the public.

“When you’re buying a car, you can easily compare quality, features, and prices to make an educated guess,” points out Eric Siegal, MD, regional medical director, Cogent Healthcare, Madison, Wis., and chair of SHM’s Public Policy Committee. “In contrast, healthcare is completely opaque. People choose a doctor or a hospital—sometimes for a surgery that’s life threatening—by word of mouth or [based on] proximity. How do you make it possible to choose based on quality of care and on price?”

Known as healthcare transparency, this trend is driven by multiple sources. “The [CMS] Hospital Compare initiative was a first step in this, as were the Leapfrog initiative and the IHI [Institute for Health Improvement] Collaborative,” says Dr. Siegal. “In fact, the government is a little late to the game, but they’re quickly closing the gap.”

Mandate from the President

On August 22, 2006, President George W. Bush signed an executive order requiring key federal agencies to collect information about the quality and cost of the healthcare they provide and to share that data with each another—and with beneficiaries. Agencies included in the order are the Department of Health and Human Services (HHS), the Department of Defense (DoD), the Department of Veterans Affairs (VA), and the Office of Personnel Management (OPM).

The executive order directs these four agencies to work with the private sector and other government agencies to develop programs to measure quality of care. They were required by Jan. 1, 2007, to identify practices that promote high quality care and to compile information on the prices they pay for common services available to their members. Ultimately, the executive order calls for combining that data in a comprehensive source on providers’ quality and prices; this information will then be available to consumers.

President Bush has said that his order sends a message to healthcare providers that “in order to do business with the federal government, you’ve got to show us your prices.” The new requirements for transparency will affect healthcare providers across the country because treating about one-quarter of Americans covered by health insurance entails “doing business with the federal government.” That one-quarter includes Medicare beneficiaries, health insurance beneficiaries at the DoD and the VA, and federal employees. (The order clearly states that the directive does not apply to state-administered or -funded programs.)

House Legislation: Make Prices Public

Comprehensive pricing transparency may also be required on a state level. On Sept. 13, 2006, Representative Michael Burgess (R-Texas) introduced the Health Care Price Transparency Act of 2006 in the House. This American Hospital Association (AHA)-supported legislation would require states to publicly report hospital charges for specific inpatient and outpatient services and would require insurers to give patients, on request, an estimate of their expected out-of-pocket expenses.

The bill would also require the Agency for Healthcare Research and Quality to study what type of healthcare price information consumers would find useful and how that information could be made available in a timely, understandable form.

Thirty-two states already require hospitals to report pricing information, and six more are voluntarily doing so, but this legislation would likely change the information that hospitals and other providers are gathering and providing.

At press time, the legislation had been referred to the House Subcommittee on Health.

How Transparency Will Roll Out

While the House legislation is in limbo, the executive order will have an immediate effect on healthcare, starting this year. The quality measures to be included in reporting will be developed from private and government sources, including local providers, employers, and health plans and insurers.

After the data are gathered and the information technology (IT) infrastructure is set up, consumers will be able to access specific information on pricing and quality of services performed by doctors, hospitals, and other healthcare providers. This information may be available through a variety of sources, including insurance companies, employers, and Medicare-sponsored Web sites.

One of the keys to success will be in the collaboration among the agencies involved. “There’s a keen understanding among the major players that if everyone does their own thing, we’ll have chaos,” says Dr. Siegal. “There has to be a significant degree of harmonization [among] physician measures, hospital measures, inpatient measures, and outpatient measures.”

Where Hospitalists Fit in

Will healthcare transparency affect hospitalists? “It’s already impacting hospitalists,” says Dr. Siegal. “Not on pricing, but on quality reporting. The good news is that hospitalists may be the single best-prepared group of physicians [for transparency] because we’re already doing it. The question will be, as it becomes more pervasive, will it be done in a way that is thoughtful, measured, and practical?”

Hospitals are likely to look to their hospitalists to ensure that their quality measurements are competitive. Dr. Siegal explains, “Hospitals looking to improve quality will be most effective in getting results from the physicians whose financial incentives are aligned with theirs.”

However, additional—or more public—quality indicators will not necessarily create a huge source of income for hospital medicine. “The low-hanging fruit won’t be the patients that hospitalists see; it will be elective surgical cases,” predicts Dr. Siegal. “Those are cleanly defined procedures, with bundled payments and predictable outcomes, where a hospital can understand what happens and what’s included. Then they can say, ‘Why do we charge 20% more for a total elective hip [surgery] than the hospital down the road?’ ”

As transparency is rolled out in U.S. hospitals and healthcare systems, hospitalists will look good. “Hospitalists already live in a quality reporting world, more so than other doctors,” says Dr. Siegal. TH

Jane Jerrard writes “Public Policy” for The Hospitalist.