Syringomatous carcinoma (SC), considered by some to be a variant of microcystic adnexal carcinoma (MAC),1 is a rare malignant neoplasm of sweat gland origin. SC encompasses a range of neoplasms with different degrees of differentiation, and its nomenclature has varied over the years. SC also has been referred to as syringoid eccrine carcinoma,2 basal cell tumor with eccrine differentiation,3 malignant syringoma,4 and sclerosing sweat duct carcinoma.5 Its diagnosis has been a dilemma in a number of reported cases, probably due to the combination of its rarity and thus limited clinical and histopathologic information, microscopic similarities to other benign and malignant neoplasms, and characteristic histologic features that may only be apparent in surgical excisions containing deeper tissue. We report a case of SC that masqueraded as an epidermoid cyst in an unusually young patient.

Case Report
A 23-year-old Asian man, who was otherwise healthy, presented with an asymptomatic slowly enlarging nodule of one year's duration on the right medial eyebrow. Prior treatment with intralesional steroid injections resulted in minimal improvement. The patient had no personal or family history of skin cancers. Physical examination results demonstrated a well-demarcated, mobile, nontender subcutaneous nodule measuring 7 mm in diameter. The clinical presentation favored a diagnosis of an epidermal inclusion cyst, and the patient underwent surgical excision of the lesion. Results of the histopathologic examination revealed a neoplasm in the dermis consisting of bands and nests of pale staining basaloid cells extending between the collagen fibers (Figure 1). There were focal areas of ductal differentiation, scattered individual necrotic cells, moderate dermal fibrosis, and chronic inflammation with numerous eo-sinophils. Moderate nuclear atypia also was present (Figure 2). Perineural involvement was not seen. Results of immunohistochemical analysis revealed positive staining for high—and low—molecular-weight cytokeratins, as well as carcinoembryonic antigen (CEA)(Figure 3). There was scattered positivity with S-100 protein in occasional cells lining lumina and in dendritic cells (Figure 4). The histopathologic findings supported the diagnosis of SC. Because the neoplasm extended to the surgical margins of the specimen, repeat surgical excision with continuous microscopic control under the Mohs micrographic technique was performed to prevent local recurrence and spare normal tissue. At the 18-month follow-up visit, no local recurrence was seen.

Comment SC is a rare, malignant sweat gland neoplasm that usually occurs in the fourth and fifth decades of life.4-8 SC typically presents as a slow-growing, solitary, painless nodule or indurated plaque on the head or neck region.6-8 It has been frequently found on the upper and lower lips; however, it also has been reported to occur on the finger and breast.9,10 Predisposing factors for the development of SC are unclear11 but may include previous radiation to the face and history of receiving an organ transplant with immunosuppressive drug therapy.12-17 Histopathologically, SC is characterized by asymmetric and deep dermal invasion of tumor cells, perineural involvement, ductal formation, keratin-filled cysts, multiple nests of basaloid or squamous cells, and desmoplasia of the surrounding dermal stroma (Table 1).5,6 Some authors consider SC to be closely related to MAC but generally describe SC as more basaloid with larger tubules and a more sclerotic stroma than MAC.18-26 If histologic examination of SC is limited to the superficial dermis, SC demonstrates similarities to other neoplasms, including syringomas, trichoadenomas, trichoepitheliomas, basal cell carcinomas, or squamous cell carcinomas. In the reported cases in which SC was initially misdiagnosed as another benign or malignant neoplasm, many misdiagnoses were due to either a benign clinical appearance of the lesion or biopsy specimens that were too superficial to contain the deeper characteristic histologic features of SC.8,9,11,27-30

Immunohistochemical studies can facilitate the diagnosis of SC and differentiate it from other neoplasms. SC stains positively for CEA, S-100 protein, epithelial membrane antigen, cyto-keratin, and gross cystic disease fluid protein 15,31 all of which aid in the confirmation of a sweat gland neoplasm (Table 2).8,32,33,39 Positivity for CEA in the ductal lining cells and the luminal contents of tumor ducts confirms sweat gland differentiation.25,33,34 This ductal immunoreactivity to CEA appears to be one of the most reliable findings to differentiate SC and MAC from other adnexal tumors, especially desmoplastic trichoepithelioma, which may be one of the more challenging histo-pathologic differential diagnoses.35 In addition, epithelial membrane antigen positivity can be found in the areas showing glandular features.35 This can assist in distinguishing SC from a desmoplastic trichoepithelioma or sclerosing type basal cell carcinoma, both of which demonstrate negativity to epithelial membrane antigen.35 S-100 protein positivity in dendritic cells, as well as in some cords and ducts in SC, further verifies dendritic differentiation toward sweat gland structures and is useful as an adjunct in the confirmation of glandular differentiation.25,33,34,36

Without proper and timely diagnosis and management, SC can cause severe patient morbidity. Although SC rarely metastasizes and can have an indolent course, it can be locally de-structive and lead to potentially disfiguring outcomes.5-7 SC can invade deeply and infiltrate into the dermis, subcutaneous fat tissue, muscle, perichondrium, periosteum, and galea.8 Goto et al9 reported a case of an SC that was initially misdiagnosed as a basal cell carcinoma of the left middle finger. The deeper, characteristic features of SC were not recognized until after the affected finger required amputation due to erosion of the bone. Hoppenreijs et al11 described an aggressive case of an SC arising at a site of previously irradiated squamous cell carcinoma of the lower eyelid. Extensive involvement of the SC in the orbit led to the recommendation of an orbital exenter-ation; however, it was not performed because of the poor clinical condition of the patient. Treatments for SC have included wide local excision and Mohs micrographic surgery (MMS). SC treatment with wide local excision often resulted in incomplete excision of the neoplasm despite having taken an adequate margin around the clinically assessable tumor.5 Cases of SC treated with wide local excision had a recurrence rate of 47%.5 The positive surgical margins following wide local excision may be due to the deep infiltration of SC, which frequently exceeds the clinically predicted size of the tumor.5 Due to the close relationship of MAC and SC, we feel that MMS treatment of SC will reduce recurrences as it has for MAC. Currently, there is strong support for the treatment of MAC with MMS as a gold standard to ensure complete clearance of the neoplasm and to reduce the local recurrence rate.12,13,17,21,22,37,38 In a study of MAC by Chiller et al,37 the authors demonstrated a median 4-fold increase in defect size when they compared the clinically estimated pretreatment size of the lesion with the MMS-determined posttreatment size of the lesion. The authors therefore suggest that, similar to the MMS-treated lesions, the lesions completely treated with wide local excision also would produce a defect size that is at least 4 times greater than the predicted pretreatment size of the lesion. Because wide local excision relies on predicted margins of the lesion, which the authors have shown can be greatly underestimated, Chiller et al37 argue that the use of MMS, which does not rely on predicted margins, is a reasonable first-line therapeutic modality for effectively treating patients with MAC. Furthermore, MMS allows for the examination of the entire peripheral and deep margins of the lesion, which is critical when considering the deep infiltrative nature of MAC. The reported local recurrence rate of MAC treated with MMS is 0% to 5%,12,13,21,26,38 which is much lower than the reported local recurrence rate following treatment with wide local excision. This reduced recurrence rate found in MAC cases treated with MMS is probably due to the ability to confirm complete removal of the neoplasm with MMS. 

Conclusion To our knowledge, this case report describes the occurrence of SC, a rare sweat gland neoplasm, in the youngest reported patient and is only the second reported case of SC treated with MMS. Adequate sampling of tissue with an excisional biopsy allowed for appropriate evaluation with histologic and immunohistochemical studies to arrive at the diagnosis that could easily have been missed with a superficial biopsy. In our patient, histopathologic evaluation showed typical nests of basaloid cells, ductal differentiation, and ductal fibrosis seen in SC. However, perineural involvement that is particularly characteristic of SC was not present. This may portend a better prognosis for our patient whose tumor was completely excised after one stage of MMS and has not shown evidence of recurrence at the 18-month follow-up visit. MMS allowed for evaluation of the entire surgical margin and decreased risk of local recurrence resulting from an incomplete excision. In addition, it also allowed for sparing of normal tissue in a cosmetically sensitive area where SC commonly occurs. In summary, this case highlights the importance of including SC in the differential diagnosis of an enlarging cystic lesion in a younger patient and its successful treatment with MMS. 

Syringomatous carcinoma (SC), considered by some to be a variant of microcystic adnexal carcinoma (MAC),1 is a rare malignant neoplasm of sweat gland origin. SC encompasses a range of neoplasms with different degrees of differentiation, and its nomenclature has varied over the years. SC also has been referred to as syringoid eccrine carcinoma,2 basal cell tumor with eccrine differentiation,3 malignant syringoma,4 and sclerosing sweat duct carcinoma.5 Its diagnosis has been a dilemma in a number of reported cases, probably due to the combination of its rarity and thus limited clinical and histopathologic information, microscopic similarities to other benign and malignant neoplasms, and characteristic histologic features that may only be apparent in surgical excisions containing deeper tissue. We report a case of SC that masqueraded as an epidermoid cyst in an unusually young patient.

Case Report
A 23-year-old Asian man, who was otherwise healthy, presented with an asymptomatic slowly enlarging nodule of one year's duration on the right medial eyebrow. Prior treatment with intralesional steroid injections resulted in minimal improvement. The patient had no personal or family history of skin cancers. Physical examination results demonstrated a well-demarcated, mobile, nontender subcutaneous nodule measuring 7 mm in diameter. The clinical presentation favored a diagnosis of an epidermal inclusion cyst, and the patient underwent surgical excision of the lesion. Results of the histopathologic examination revealed a neoplasm in the dermis consisting of bands and nests of pale staining basaloid cells extending between the collagen fibers (Figure 1). There were focal areas of ductal differentiation, scattered individual necrotic cells, moderate dermal fibrosis, and chronic inflammation with numerous eo-sinophils. Moderate nuclear atypia also was present (Figure 2). Perineural involvement was not seen. Results of immunohistochemical analysis revealed positive staining for high—and low—molecular-weight cytokeratins, as well as carcinoembryonic antigen (CEA)(Figure 3). There was scattered positivity with S-100 protein in occasional cells lining lumina and in dendritic cells (Figure 4). The histopathologic findings supported the diagnosis of SC. Because the neoplasm extended to the surgical margins of the specimen, repeat surgical excision with continuous microscopic control under the Mohs micrographic technique was performed to prevent local recurrence and spare normal tissue. At the 18-month follow-up visit, no local recurrence was seen.

Comment SC is a rare, malignant sweat gland neoplasm that usually occurs in the fourth and fifth decades of life.4-8 SC typically presents as a slow-growing, solitary, painless nodule or indurated plaque on the head or neck region.6-8 It has been frequently found on the upper and lower lips; however, it also has been reported to occur on the finger and breast.9,10 Predisposing factors for the development of SC are unclear11 but may include previous radiation to the face and history of receiving an organ transplant with immunosuppressive drug therapy.12-17 Histopathologically, SC is characterized by asymmetric and deep dermal invasion of tumor cells, perineural involvement, ductal formation, keratin-filled cysts, multiple nests of basaloid or squamous cells, and desmoplasia of the surrounding dermal stroma (Table 1).5,6 Some authors consider SC to be closely related to MAC but generally describe SC as more basaloid with larger tubules and a more sclerotic stroma than MAC.18-26 If histologic examination of SC is limited to the superficial dermis, SC demonstrates similarities to other neoplasms, including syringomas, trichoadenomas, trichoepitheliomas, basal cell carcinomas, or squamous cell carcinomas. In the reported cases in which SC was initially misdiagnosed as another benign or malignant neoplasm, many misdiagnoses were due to either a benign clinical appearance of the lesion or biopsy specimens that were too superficial to contain the deeper characteristic histologic features of SC.8,9,11,27-30

Immunohistochemical studies can facilitate the diagnosis of SC and differentiate it from other neoplasms. SC stains positively for CEA, S-100 protein, epithelial membrane antigen, cyto-keratin, and gross cystic disease fluid protein 15,31 all of which aid in the confirmation of a sweat gland neoplasm (Table 2).8,32,33,39 Positivity for CEA in the ductal lining cells and the luminal contents of tumor ducts confirms sweat gland differentiation.25,33,34 This ductal immunoreactivity to CEA appears to be one of the most reliable findings to differentiate SC and MAC from other adnexal tumors, especially desmoplastic trichoepithelioma, which may be one of the more challenging histo-pathologic differential diagnoses.35 In addition, epithelial membrane antigen positivity can be found in the areas showing glandular features.35 This can assist in distinguishing SC from a desmoplastic trichoepithelioma or sclerosing type basal cell carcinoma, both of which demonstrate negativity to epithelial membrane antigen.35 S-100 protein positivity in dendritic cells, as well as in some cords and ducts in SC, further verifies dendritic differentiation toward sweat gland structures and is useful as an adjunct in the confirmation of glandular differentiation.25,33,34,36

Without proper and timely diagnosis and management, SC can cause severe patient morbidity. Although SC rarely metastasizes and can have an indolent course, it can be locally de-structive and lead to potentially disfiguring outcomes.5-7 SC can invade deeply and infiltrate into the dermis, subcutaneous fat tissue, muscle, perichondrium, periosteum, and galea.8 Goto et al9 reported a case of an SC that was initially misdiagnosed as a basal cell carcinoma of the left middle finger. The deeper, characteristic features of SC were not recognized until after the affected finger required amputation due to erosion of the bone. Hoppenreijs et al11 described an aggressive case of an SC arising at a site of previously irradiated squamous cell carcinoma of the lower eyelid. Extensive involvement of the SC in the orbit led to the recommendation of an orbital exenter-ation; however, it was not performed because of the poor clinical condition of the patient. Treatments for SC have included wide local excision and Mohs micrographic surgery (MMS). SC treatment with wide local excision often resulted in incomplete excision of the neoplasm despite having taken an adequate margin around the clinically assessable tumor.5 Cases of SC treated with wide local excision had a recurrence rate of 47%.5 The positive surgical margins following wide local excision may be due to the deep infiltration of SC, which frequently exceeds the clinically predicted size of the tumor.5 Due to the close relationship of MAC and SC, we feel that MMS treatment of SC will reduce recurrences as it has for MAC. Currently, there is strong support for the treatment of MAC with MMS as a gold standard to ensure complete clearance of the neoplasm and to reduce the local recurrence rate.12,13,17,21,22,37,38 In a study of MAC by Chiller et al,37 the authors demonstrated a median 4-fold increase in defect size when they compared the clinically estimated pretreatment size of the lesion with the MMS-determined posttreatment size of the lesion. The authors therefore suggest that, similar to the MMS-treated lesions, the lesions completely treated with wide local excision also would produce a defect size that is at least 4 times greater than the predicted pretreatment size of the lesion. Because wide local excision relies on predicted margins of the lesion, which the authors have shown can be greatly underestimated, Chiller et al37 argue that the use of MMS, which does not rely on predicted margins, is a reasonable first-line therapeutic modality for effectively treating patients with MAC. Furthermore, MMS allows for the examination of the entire peripheral and deep margins of the lesion, which is critical when considering the deep infiltrative nature of MAC. The reported local recurrence rate of MAC treated with MMS is 0% to 5%,12,13,21,26,38 which is much lower than the reported local recurrence rate following treatment with wide local excision. This reduced recurrence rate found in MAC cases treated with MMS is probably due to the ability to confirm complete removal of the neoplasm with MMS. 

Conclusion To our knowledge, this case report describes the occurrence of SC, a rare sweat gland neoplasm, in the youngest reported patient and is only the second reported case of SC treated with MMS. Adequate sampling of tissue with an excisional biopsy allowed for appropriate evaluation with histologic and immunohistochemical studies to arrive at the diagnosis that could easily have been missed with a superficial biopsy. In our patient, histopathologic evaluation showed typical nests of basaloid cells, ductal differentiation, and ductal fibrosis seen in SC. However, perineural involvement that is particularly characteristic of SC was not present. This may portend a better prognosis for our patient whose tumor was completely excised after one stage of MMS and has not shown evidence of recurrence at the 18-month follow-up visit. MMS allowed for evaluation of the entire surgical margin and decreased risk of local recurrence resulting from an incomplete excision. In addition, it also allowed for sparing of normal tissue in a cosmetically sensitive area where SC commonly occurs. In summary, this case highlights the importance of including SC in the differential diagnosis of an enlarging cystic lesion in a younger patient and its successful treatment with MMS. 

Syringomatous carcinoma (SC), considered by some to be a variant of microcystic adnexal carcinoma (MAC),1 is a rare malignant neoplasm of sweat gland origin. SC encompasses a range of neoplasms with different degrees of differentiation, and its nomenclature has varied over the years. SC also has been referred to as syringoid eccrine carcinoma,2 basal cell tumor with eccrine differentiation,3 malignant syringoma,4 and sclerosing sweat duct carcinoma.5 Its diagnosis has been a dilemma in a number of reported cases, probably due to the combination of its rarity and thus limited clinical and histopathologic information, microscopic similarities to other benign and malignant neoplasms, and characteristic histologic features that may only be apparent in surgical excisions containing deeper tissue. We report a case of SC that masqueraded as an epidermoid cyst in an unusually young patient.

Case Report
A 23-year-old Asian man, who was otherwise healthy, presented with an asymptomatic slowly enlarging nodule of one year's duration on the right medial eyebrow. Prior treatment with intralesional steroid injections resulted in minimal improvement. The patient had no personal or family history of skin cancers. Physical examination results demonstrated a well-demarcated, mobile, nontender subcutaneous nodule measuring 7 mm in diameter. The clinical presentation favored a diagnosis of an epidermal inclusion cyst, and the patient underwent surgical excision of the lesion. Results of the histopathologic examination revealed a neoplasm in the dermis consisting of bands and nests of pale staining basaloid cells extending between the collagen fibers (Figure 1). There were focal areas of ductal differentiation, scattered individual necrotic cells, moderate dermal fibrosis, and chronic inflammation with numerous eo-sinophils. Moderate nuclear atypia also was present (Figure 2). Perineural involvement was not seen. Results of immunohistochemical analysis revealed positive staining for high—and low—molecular-weight cytokeratins, as well as carcinoembryonic antigen (CEA)(Figure 3). There was scattered positivity with S-100 protein in occasional cells lining lumina and in dendritic cells (Figure 4). The histopathologic findings supported the diagnosis of SC. Because the neoplasm extended to the surgical margins of the specimen, repeat surgical excision with continuous microscopic control under the Mohs micrographic technique was performed to prevent local recurrence and spare normal tissue. At the 18-month follow-up visit, no local recurrence was seen.

Comment SC is a rare, malignant sweat gland neoplasm that usually occurs in the fourth and fifth decades of life.4-8 SC typically presents as a slow-growing, solitary, painless nodule or indurated plaque on the head or neck region.6-8 It has been frequently found on the upper and lower lips; however, it also has been reported to occur on the finger and breast.9,10 Predisposing factors for the development of SC are unclear11 but may include previous radiation to the face and history of receiving an organ transplant with immunosuppressive drug therapy.12-17 Histopathologically, SC is characterized by asymmetric and deep dermal invasion of tumor cells, perineural involvement, ductal formation, keratin-filled cysts, multiple nests of basaloid or squamous cells, and desmoplasia of the surrounding dermal stroma (Table 1).5,6 Some authors consider SC to be closely related to MAC but generally describe SC as more basaloid with larger tubules and a more sclerotic stroma than MAC.18-26 If histologic examination of SC is limited to the superficial dermis, SC demonstrates similarities to other neoplasms, including syringomas, trichoadenomas, trichoepitheliomas, basal cell carcinomas, or squamous cell carcinomas. In the reported cases in which SC was initially misdiagnosed as another benign or malignant neoplasm, many misdiagnoses were due to either a benign clinical appearance of the lesion or biopsy specimens that were too superficial to contain the deeper characteristic histologic features of SC.8,9,11,27-30

Immunohistochemical studies can facilitate the diagnosis of SC and differentiate it from other neoplasms. SC stains positively for CEA, S-100 protein, epithelial membrane antigen, cyto-keratin, and gross cystic disease fluid protein 15,31 all of which aid in the confirmation of a sweat gland neoplasm (Table 2).8,32,33,39 Positivity for CEA in the ductal lining cells and the luminal contents of tumor ducts confirms sweat gland differentiation.25,33,34 This ductal immunoreactivity to CEA appears to be one of the most reliable findings to differentiate SC and MAC from other adnexal tumors, especially desmoplastic trichoepithelioma, which may be one of the more challenging histo-pathologic differential diagnoses.35 In addition, epithelial membrane antigen positivity can be found in the areas showing glandular features.35 This can assist in distinguishing SC from a desmoplastic trichoepithelioma or sclerosing type basal cell carcinoma, both of which demonstrate negativity to epithelial membrane antigen.35 S-100 protein positivity in dendritic cells, as well as in some cords and ducts in SC, further verifies dendritic differentiation toward sweat gland structures and is useful as an adjunct in the confirmation of glandular differentiation.25,33,34,36

Without proper and timely diagnosis and management, SC can cause severe patient morbidity. Although SC rarely metastasizes and can have an indolent course, it can be locally de-structive and lead to potentially disfiguring outcomes.5-7 SC can invade deeply and infiltrate into the dermis, subcutaneous fat tissue, muscle, perichondrium, periosteum, and galea.8 Goto et al9 reported a case of an SC that was initially misdiagnosed as a basal cell carcinoma of the left middle finger. The deeper, characteristic features of SC were not recognized until after the affected finger required amputation due to erosion of the bone. Hoppenreijs et al11 described an aggressive case of an SC arising at a site of previously irradiated squamous cell carcinoma of the lower eyelid. Extensive involvement of the SC in the orbit led to the recommendation of an orbital exenter-ation; however, it was not performed because of the poor clinical condition of the patient. Treatments for SC have included wide local excision and Mohs micrographic surgery (MMS). SC treatment with wide local excision often resulted in incomplete excision of the neoplasm despite having taken an adequate margin around the clinically assessable tumor.5 Cases of SC treated with wide local excision had a recurrence rate of 47%.5 The positive surgical margins following wide local excision may be due to the deep infiltration of SC, which frequently exceeds the clinically predicted size of the tumor.5 Due to the close relationship of MAC and SC, we feel that MMS treatment of SC will reduce recurrences as it has for MAC. Currently, there is strong support for the treatment of MAC with MMS as a gold standard to ensure complete clearance of the neoplasm and to reduce the local recurrence rate.12,13,17,21,22,37,38 In a study of MAC by Chiller et al,37 the authors demonstrated a median 4-fold increase in defect size when they compared the clinically estimated pretreatment size of the lesion with the MMS-determined posttreatment size of the lesion. The authors therefore suggest that, similar to the MMS-treated lesions, the lesions completely treated with wide local excision also would produce a defect size that is at least 4 times greater than the predicted pretreatment size of the lesion. Because wide local excision relies on predicted margins of the lesion, which the authors have shown can be greatly underestimated, Chiller et al37 argue that the use of MMS, which does not rely on predicted margins, is a reasonable first-line therapeutic modality for effectively treating patients with MAC. Furthermore, MMS allows for the examination of the entire peripheral and deep margins of the lesion, which is critical when considering the deep infiltrative nature of MAC. The reported local recurrence rate of MAC treated with MMS is 0% to 5%,12,13,21,26,38 which is much lower than the reported local recurrence rate following treatment with wide local excision. This reduced recurrence rate found in MAC cases treated with MMS is probably due to the ability to confirm complete removal of the neoplasm with MMS. 

Conclusion To our knowledge, this case report describes the occurrence of SC, a rare sweat gland neoplasm, in the youngest reported patient and is only the second reported case of SC treated with MMS. Adequate sampling of tissue with an excisional biopsy allowed for appropriate evaluation with histologic and immunohistochemical studies to arrive at the diagnosis that could easily have been missed with a superficial biopsy. In our patient, histopathologic evaluation showed typical nests of basaloid cells, ductal differentiation, and ductal fibrosis seen in SC. However, perineural involvement that is particularly characteristic of SC was not present. This may portend a better prognosis for our patient whose tumor was completely excised after one stage of MMS and has not shown evidence of recurrence at the 18-month follow-up visit. MMS allowed for evaluation of the entire surgical margin and decreased risk of local recurrence resulting from an incomplete excision. In addition, it also allowed for sparing of normal tissue in a cosmetically sensitive area where SC commonly occurs. In summary, this case highlights the importance of including SC in the differential diagnosis of an enlarging cystic lesion in a younger patient and its successful treatment with MMS. 

Distinguishing the cause of a patient’s psychotic symptoms can be clinically challenging in a primary care practice. This case was submitted by Matthew Rosenberg, MD, who practices family medicine at Sacramento (CA) County Primary Care Clinic. This month’s consultant is Bezalel Dantz, MD.

How would you have advised Dr. Rosenberg?

Case: ‘you’re just gonna die’

I was seeing Mr. J, age 31, weekly to monitor abdominal complaints. For 3 weeks he experienced increasing epigastric pain, and he had been evaluated twice in the emergency room for this complaint. Plain films, ultrasound, CT, and an elevated lipase reading suggested an inconclusive diagnosis of pancreatitis.

During his second office visit, Mr. J also complained of “hearing voices.” Further questioning revealed that he had been hearing voices—often male—making degrading comments for several years. The voices have increased in frequency during his illness, and their negative comments include, “What do you have to live for?” and “You’re just gonna die.”

Mr. J blames the voices on distant drug use, claiming his parents “forced” him as a young teen to take hallucinogens. He often thinks he is being followed and does not trust others. He said both parents had mental illnesses but does not know the diagnoses or seriousness of their disorders.

His thoughts are well-organized with clear content. He shows no signs of depression or mania. He plays guitar in a band and appears to be a thoughtful and high-functioning individual.

I need help with the differential diagnosis and suggestions of possible treatment options.

Dr. Dantz’s consultation

The first step in evaluating psychosis is to determine whether it indicates a medical disorder, substanceinduced disorder, or primary psychiatric illness. The chronicity and nature of Mr. J’s psychotic symptoms (auditory hallucinations and paranoid delusions), his age, and a family history of psychiatric illness suggest a primary psychiatric disorder. The elevated lipase might explain his abdominal pain but is likely independent of his psychosis.

Medical workup. Conduct a comprehensive physical exam and medical and psychiatric history. Obtain collateral information from the family about the patient’s psychiatric symptoms, family history, recreational drug use, and stressors. Acute onset, age >40, comorbid medical conditions, lack of acute psychosocial stressors, and a negative personal or family psychiatric history suggest a medical cause (The skinny on one patient’s psychosis,” November 2005.) Also assess for use of alcohol, marijuana, hallucinogens, narcotics, stimulants, and inhalants. Until any drug has been stopped for at least 1 week, its contribution to psychosis may be unclear.

Table 1

Medical conditions that may present as psychosis

Lab testing. When signs or symptoms do not suggest an organic disease, laboratory tests have a low yield and are of questionable value.² In primary care practice, however, many psychotic patients complain of somatic symptoms. Given the devastating impact of psychotic illness, one can argue that even a yield <5% justifies a workup.

A urine toxicology screen is by far the most important lab test. CBC, comprehensive metabolic panel, thyroid function tests, erythrocyte sedimentation rate, and calcium level may reveal a medical cause. Consider HIV antibody and syphilis tests in at-risk individuals.

Findings on physical exam or abnormal lab results would guide further testing. Because of Mr. J’s GI and neurologic symptoms, a 24-hour urine test may be reasonable, particularly if he has had episodes of acute intermittent porphyria.

Neuroimaging. Consider a scan when psychosis is comorbid with:

• age >40
• neurologic complaints (such as headache, numbness, vertigo, seizures)
• focal neurologic findings (such as weakness, gait abnormality, clonus, or spasticity)
• confusion, cognitive deficit, history of malignancy
• head trauma
• immunocompromised state
• atypical psychotic symptoms (such as visual or olfactory hallucinations).

Psychiatric workup. If the history and physical exam reveal no organic basis, the next step is to determine the nature of this patient’s psychosis. The two most common psychiatric conditions associated with psychosis are:

• schizophrenic spectrum disorders (such as schizophreniform, schizophrenia and schizoaffective disorder)
• affective disorders (such as psychotic depression and bipolar disorder).

Distinguishing among these conditions can be challenging (Table 2) because patients rarely present with typical syndromes.

For example, a bipolar patient may present in a mixed state with both depressive and manic features. Psychosis in schizophrenia may be brief (<6 months in schizophreniform disorder) and may be characterized by manic-like grandiose delusions or negative symptoms (flat affect, poverty of speech) that mimic affective symptoms. Finally, some patients have both an affective disorder and schizophrenia, as in schizoaffective disorder.

For Mr. J, years of uninterrupted hallucinations, longstanding paranoid delusions, and absence of prominent affective symptoms suggest schizophrenia. His hallucinations are typical of those reported in schizophrenia. Voices giving a running commentary on a person’s thoughts and actions and derogatory comments are two of the most common auditory hallucinations.

Somatic concerns are also prominent in schizophrenia. Patients may describe symptoms in bizarre terms, such as “electric shocks in my head” or “there’s a fire in my spleen.”

Supporting evidence for a schizophrenia diagnosis would include a history of social isolation, lack of interest in work, and poor social interaction. Mr. J has a supportive partner, and we are told he appears to be high-functioning and active as a guitarist in a band. These factors might support an alternate diagnosis of affective psychosis. Finally, his past drug use and somatic symptoms raise the possibility of active substance abuse.

Table 2

Differential diagnosis of primary psychosis: Typical features

Suicide risk. Ask psychotic patients if they think about harming themselves. Lifetime risk of suicide in schizophrenia is 10% to 15%, and rates in bipolar disorder are higher. If patients deny suicidality, ask them why. Reassuring responses include religious prohibition, hopefulness about the future, concern about suicide’s effect on a loved one, fear of dying, or lack of means.

Candidates for emergent psychiatric consultation or hospitalization include patients with violent or homicidal thoughts and any patient who has attempted suicide, has a family history of suicide, has access to means, and lacks compelling reasons against suicide. Consider immediate psychiatric evaluation and admission of patients whose delusions or behaviors put them at risk for harm.

Abdominal pain workup. Although Mr. J’s abdominal pain may be functional, also seek an organic cause. His first-time disclosure of psychotic symptoms suggests that a serious medical stressor may be exacerbating a chronic psychiatric illness. Because the elevated lipase may indicate pancreatitis, consider an endoscopic or MRI examination of the pancreas and bile ducts. In consultation with a gastroenterologist, evaluate other causes such as peptic ulcer disease, ischemic bowel (perhaps as a result of cocaine use), inflammatory bowel disease, vasculitis, porphyria, and abdominal migraine.

Managing psychosis

Psychiatric consultation is strongly recommended for patients beginning therapy for psychotic disorders who have shown a particularly high risk for suicide. Uncontrolled symptoms, unanticipated psychiatric side effects, and the humiliation that results from the insight gained through treatment may contribute to this risk.

Assuming that Mr. J does not meet criteria for acute psychiatric hospitalization, the primary care clinician can stabilize the psychotic symptoms while awaiting psychiatric referral. Any atypical antipsychotic would be appropriate (Table 3).

Table 3

Starting an atypical antipsychotic* for primary psychosis

Patients who refuse treatment pose a quandary. If the patient is not acutely ill, try to establish an alliance over several visits rather than endangering the therapeutic relationship through confrontation or overzealous persuasion (Table 4).

Table 4

Strategies to build a therapeutic alliance with psychotic patients

Monitoring. The primary care physician’s role after the patient begins antipsychotic therapy is to:

• assess his or her symptoms (particularly suicidality) and adherence to psychiatric visits and treatment
• monitor for adverse effects from medications.

Atypical antipsychotics have been associated with weight gain, hyperglycemia, and hyperlipidemia. Check fasting glucose and lipids quarterly for the first year of antipsychotic therapy and annually thereafter.⁵ Watch for drug-drug interactions whenever a new medication is added. Monitor for abnormal movements, even though the risk of extrapyramidal symptoms and tardive dyskinesia is lower with atypical antipsychotics than with traditional agents.

For Mr. J’s psychiatric symptoms, I would:

• assess his willingness to start medication to reduce or eliminate the voices
• suggest he accept psychiatric referral
• assure him that I will remain involved in his care and continue to evaluate his abdominal symptoms.

I would also request permission to discuss his case with his partner and a family member to gather pertinent history and enlist their support for treatment. I would then start Mr. J on any drug listed in Table 3.

Distinguishing the cause of a patient’s psychotic symptoms can be clinically challenging in a primary care practice. This case was submitted by Matthew Rosenberg, MD, who practices family medicine at Sacramento (CA) County Primary Care Clinic. This month’s consultant is Bezalel Dantz, MD.

How would you have advised Dr. Rosenberg?

Case: ‘you’re just gonna die’

I was seeing Mr. J, age 31, weekly to monitor abdominal complaints. For 3 weeks he experienced increasing epigastric pain, and he had been evaluated twice in the emergency room for this complaint. Plain films, ultrasound, CT, and an elevated lipase reading suggested an inconclusive diagnosis of pancreatitis.

During his second office visit, Mr. J also complained of “hearing voices.” Further questioning revealed that he had been hearing voices—often male—making degrading comments for several years. The voices have increased in frequency during his illness, and their negative comments include, “What do you have to live for?” and “You’re just gonna die.”

Mr. J blames the voices on distant drug use, claiming his parents “forced” him as a young teen to take hallucinogens. He often thinks he is being followed and does not trust others. He said both parents had mental illnesses but does not know the diagnoses or seriousness of their disorders.

His thoughts are well-organized with clear content. He shows no signs of depression or mania. He plays guitar in a band and appears to be a thoughtful and high-functioning individual.

I need help with the differential diagnosis and suggestions of possible treatment options.

Dr. Dantz’s consultation

The first step in evaluating psychosis is to determine whether it indicates a medical disorder, substanceinduced disorder, or primary psychiatric illness. The chronicity and nature of Mr. J’s psychotic symptoms (auditory hallucinations and paranoid delusions), his age, and a family history of psychiatric illness suggest a primary psychiatric disorder. The elevated lipase might explain his abdominal pain but is likely independent of his psychosis.

Medical workup. Conduct a comprehensive physical exam and medical and psychiatric history. Obtain collateral information from the family about the patient’s psychiatric symptoms, family history, recreational drug use, and stressors. Acute onset, age >40, comorbid medical conditions, lack of acute psychosocial stressors, and a negative personal or family psychiatric history suggest a medical cause (The skinny on one patient’s psychosis,” November 2005.) Also assess for use of alcohol, marijuana, hallucinogens, narcotics, stimulants, and inhalants. Until any drug has been stopped for at least 1 week, its contribution to psychosis may be unclear.

Table 1

Medical conditions that may present as psychosis

Lab testing. When signs or symptoms do not suggest an organic disease, laboratory tests have a low yield and are of questionable value.² In primary care practice, however, many psychotic patients complain of somatic symptoms. Given the devastating impact of psychotic illness, one can argue that even a yield <5% justifies a workup.

A urine toxicology screen is by far the most important lab test. CBC, comprehensive metabolic panel, thyroid function tests, erythrocyte sedimentation rate, and calcium level may reveal a medical cause. Consider HIV antibody and syphilis tests in at-risk individuals.

Findings on physical exam or abnormal lab results would guide further testing. Because of Mr. J’s GI and neurologic symptoms, a 24-hour urine test may be reasonable, particularly if he has had episodes of acute intermittent porphyria.

Neuroimaging. Consider a scan when psychosis is comorbid with:

• age >40
• neurologic complaints (such as headache, numbness, vertigo, seizures)
• focal neurologic findings (such as weakness, gait abnormality, clonus, or spasticity)
• confusion, cognitive deficit, history of malignancy
• head trauma
• immunocompromised state
• atypical psychotic symptoms (such as visual or olfactory hallucinations).

Psychiatric workup. If the history and physical exam reveal no organic basis, the next step is to determine the nature of this patient’s psychosis. The two most common psychiatric conditions associated with psychosis are:

• schizophrenic spectrum disorders (such as schizophreniform, schizophrenia and schizoaffective disorder)
• affective disorders (such as psychotic depression and bipolar disorder).

Distinguishing among these conditions can be challenging (Table 2) because patients rarely present with typical syndromes.

For example, a bipolar patient may present in a mixed state with both depressive and manic features. Psychosis in schizophrenia may be brief (<6 months in schizophreniform disorder) and may be characterized by manic-like grandiose delusions or negative symptoms (flat affect, poverty of speech) that mimic affective symptoms. Finally, some patients have both an affective disorder and schizophrenia, as in schizoaffective disorder.

For Mr. J, years of uninterrupted hallucinations, longstanding paranoid delusions, and absence of prominent affective symptoms suggest schizophrenia. His hallucinations are typical of those reported in schizophrenia. Voices giving a running commentary on a person’s thoughts and actions and derogatory comments are two of the most common auditory hallucinations.

Somatic concerns are also prominent in schizophrenia. Patients may describe symptoms in bizarre terms, such as “electric shocks in my head” or “there’s a fire in my spleen.”

Supporting evidence for a schizophrenia diagnosis would include a history of social isolation, lack of interest in work, and poor social interaction. Mr. J has a supportive partner, and we are told he appears to be high-functioning and active as a guitarist in a band. These factors might support an alternate diagnosis of affective psychosis. Finally, his past drug use and somatic symptoms raise the possibility of active substance abuse.

Table 2

Differential diagnosis of primary psychosis: Typical features

Suicide risk. Ask psychotic patients if they think about harming themselves. Lifetime risk of suicide in schizophrenia is 10% to 15%, and rates in bipolar disorder are higher. If patients deny suicidality, ask them why. Reassuring responses include religious prohibition, hopefulness about the future, concern about suicide’s effect on a loved one, fear of dying, or lack of means.

Candidates for emergent psychiatric consultation or hospitalization include patients with violent or homicidal thoughts and any patient who has attempted suicide, has a family history of suicide, has access to means, and lacks compelling reasons against suicide. Consider immediate psychiatric evaluation and admission of patients whose delusions or behaviors put them at risk for harm.

Abdominal pain workup. Although Mr. J’s abdominal pain may be functional, also seek an organic cause. His first-time disclosure of psychotic symptoms suggests that a serious medical stressor may be exacerbating a chronic psychiatric illness. Because the elevated lipase may indicate pancreatitis, consider an endoscopic or MRI examination of the pancreas and bile ducts. In consultation with a gastroenterologist, evaluate other causes such as peptic ulcer disease, ischemic bowel (perhaps as a result of cocaine use), inflammatory bowel disease, vasculitis, porphyria, and abdominal migraine.

Managing psychosis

Psychiatric consultation is strongly recommended for patients beginning therapy for psychotic disorders who have shown a particularly high risk for suicide. Uncontrolled symptoms, unanticipated psychiatric side effects, and the humiliation that results from the insight gained through treatment may contribute to this risk.

Assuming that Mr. J does not meet criteria for acute psychiatric hospitalization, the primary care clinician can stabilize the psychotic symptoms while awaiting psychiatric referral. Any atypical antipsychotic would be appropriate (Table 3).

Table 3

Starting an atypical antipsychotic* for primary psychosis

Patients who refuse treatment pose a quandary. If the patient is not acutely ill, try to establish an alliance over several visits rather than endangering the therapeutic relationship through confrontation or overzealous persuasion (Table 4).

Table 4

Strategies to build a therapeutic alliance with psychotic patients

Monitoring. The primary care physician’s role after the patient begins antipsychotic therapy is to:

• assess his or her symptoms (particularly suicidality) and adherence to psychiatric visits and treatment
• monitor for adverse effects from medications.

Atypical antipsychotics have been associated with weight gain, hyperglycemia, and hyperlipidemia. Check fasting glucose and lipids quarterly for the first year of antipsychotic therapy and annually thereafter.⁵ Watch for drug-drug interactions whenever a new medication is added. Monitor for abnormal movements, even though the risk of extrapyramidal symptoms and tardive dyskinesia is lower with atypical antipsychotics than with traditional agents.

For Mr. J’s psychiatric symptoms, I would:

• assess his willingness to start medication to reduce or eliminate the voices
• suggest he accept psychiatric referral
• assure him that I will remain involved in his care and continue to evaluate his abdominal symptoms.

I would also request permission to discuss his case with his partner and a family member to gather pertinent history and enlist their support for treatment. I would then start Mr. J on any drug listed in Table 3.

Distinguishing the cause of a patient’s psychotic symptoms can be clinically challenging in a primary care practice. This case was submitted by Matthew Rosenberg, MD, who practices family medicine at Sacramento (CA) County Primary Care Clinic. This month’s consultant is Bezalel Dantz, MD.

How would you have advised Dr. Rosenberg?

Case: ‘you’re just gonna die’

I was seeing Mr. J, age 31, weekly to monitor abdominal complaints. For 3 weeks he experienced increasing epigastric pain, and he had been evaluated twice in the emergency room for this complaint. Plain films, ultrasound, CT, and an elevated lipase reading suggested an inconclusive diagnosis of pancreatitis.

During his second office visit, Mr. J also complained of “hearing voices.” Further questioning revealed that he had been hearing voices—often male—making degrading comments for several years. The voices have increased in frequency during his illness, and their negative comments include, “What do you have to live for?” and “You’re just gonna die.”

Mr. J blames the voices on distant drug use, claiming his parents “forced” him as a young teen to take hallucinogens. He often thinks he is being followed and does not trust others. He said both parents had mental illnesses but does not know the diagnoses or seriousness of their disorders.

His thoughts are well-organized with clear content. He shows no signs of depression or mania. He plays guitar in a band and appears to be a thoughtful and high-functioning individual.

I need help with the differential diagnosis and suggestions of possible treatment options.

Dr. Dantz’s consultation

The first step in evaluating psychosis is to determine whether it indicates a medical disorder, substanceinduced disorder, or primary psychiatric illness. The chronicity and nature of Mr. J’s psychotic symptoms (auditory hallucinations and paranoid delusions), his age, and a family history of psychiatric illness suggest a primary psychiatric disorder. The elevated lipase might explain his abdominal pain but is likely independent of his psychosis.

Medical workup. Conduct a comprehensive physical exam and medical and psychiatric history. Obtain collateral information from the family about the patient’s psychiatric symptoms, family history, recreational drug use, and stressors. Acute onset, age >40, comorbid medical conditions, lack of acute psychosocial stressors, and a negative personal or family psychiatric history suggest a medical cause (The skinny on one patient’s psychosis,” November 2005.) Also assess for use of alcohol, marijuana, hallucinogens, narcotics, stimulants, and inhalants. Until any drug has been stopped for at least 1 week, its contribution to psychosis may be unclear.

Table 1

Medical conditions that may present as psychosis

Lab testing. When signs or symptoms do not suggest an organic disease, laboratory tests have a low yield and are of questionable value.² In primary care practice, however, many psychotic patients complain of somatic symptoms. Given the devastating impact of psychotic illness, one can argue that even a yield <5% justifies a workup.

A urine toxicology screen is by far the most important lab test. CBC, comprehensive metabolic panel, thyroid function tests, erythrocyte sedimentation rate, and calcium level may reveal a medical cause. Consider HIV antibody and syphilis tests in at-risk individuals.

Findings on physical exam or abnormal lab results would guide further testing. Because of Mr. J’s GI and neurologic symptoms, a 24-hour urine test may be reasonable, particularly if he has had episodes of acute intermittent porphyria.

Neuroimaging. Consider a scan when psychosis is comorbid with:

• age >40
• neurologic complaints (such as headache, numbness, vertigo, seizures)
• focal neurologic findings (such as weakness, gait abnormality, clonus, or spasticity)
• confusion, cognitive deficit, history of malignancy
• head trauma
• immunocompromised state
• atypical psychotic symptoms (such as visual or olfactory hallucinations).

Psychiatric workup. If the history and physical exam reveal no organic basis, the next step is to determine the nature of this patient’s psychosis. The two most common psychiatric conditions associated with psychosis are:

• schizophrenic spectrum disorders (such as schizophreniform, schizophrenia and schizoaffective disorder)
• affective disorders (such as psychotic depression and bipolar disorder).

Distinguishing among these conditions can be challenging (Table 2) because patients rarely present with typical syndromes.

For example, a bipolar patient may present in a mixed state with both depressive and manic features. Psychosis in schizophrenia may be brief (<6 months in schizophreniform disorder) and may be characterized by manic-like grandiose delusions or negative symptoms (flat affect, poverty of speech) that mimic affective symptoms. Finally, some patients have both an affective disorder and schizophrenia, as in schizoaffective disorder.

For Mr. J, years of uninterrupted hallucinations, longstanding paranoid delusions, and absence of prominent affective symptoms suggest schizophrenia. His hallucinations are typical of those reported in schizophrenia. Voices giving a running commentary on a person’s thoughts and actions and derogatory comments are two of the most common auditory hallucinations.

Somatic concerns are also prominent in schizophrenia. Patients may describe symptoms in bizarre terms, such as “electric shocks in my head” or “there’s a fire in my spleen.”

Supporting evidence for a schizophrenia diagnosis would include a history of social isolation, lack of interest in work, and poor social interaction. Mr. J has a supportive partner, and we are told he appears to be high-functioning and active as a guitarist in a band. These factors might support an alternate diagnosis of affective psychosis. Finally, his past drug use and somatic symptoms raise the possibility of active substance abuse.

Table 2

Differential diagnosis of primary psychosis: Typical features

Suicide risk. Ask psychotic patients if they think about harming themselves. Lifetime risk of suicide in schizophrenia is 10% to 15%, and rates in bipolar disorder are higher. If patients deny suicidality, ask them why. Reassuring responses include religious prohibition, hopefulness about the future, concern about suicide’s effect on a loved one, fear of dying, or lack of means.

Candidates for emergent psychiatric consultation or hospitalization include patients with violent or homicidal thoughts and any patient who has attempted suicide, has a family history of suicide, has access to means, and lacks compelling reasons against suicide. Consider immediate psychiatric evaluation and admission of patients whose delusions or behaviors put them at risk for harm.

Abdominal pain workup. Although Mr. J’s abdominal pain may be functional, also seek an organic cause. His first-time disclosure of psychotic symptoms suggests that a serious medical stressor may be exacerbating a chronic psychiatric illness. Because the elevated lipase may indicate pancreatitis, consider an endoscopic or MRI examination of the pancreas and bile ducts. In consultation with a gastroenterologist, evaluate other causes such as peptic ulcer disease, ischemic bowel (perhaps as a result of cocaine use), inflammatory bowel disease, vasculitis, porphyria, and abdominal migraine.

Managing psychosis

Psychiatric consultation is strongly recommended for patients beginning therapy for psychotic disorders who have shown a particularly high risk for suicide. Uncontrolled symptoms, unanticipated psychiatric side effects, and the humiliation that results from the insight gained through treatment may contribute to this risk.

Assuming that Mr. J does not meet criteria for acute psychiatric hospitalization, the primary care clinician can stabilize the psychotic symptoms while awaiting psychiatric referral. Any atypical antipsychotic would be appropriate (Table 3).

Table 3

Starting an atypical antipsychotic* for primary psychosis

Patients who refuse treatment pose a quandary. If the patient is not acutely ill, try to establish an alliance over several visits rather than endangering the therapeutic relationship through confrontation or overzealous persuasion (Table 4).

Table 4

Strategies to build a therapeutic alliance with psychotic patients

Monitoring. The primary care physician’s role after the patient begins antipsychotic therapy is to:

• assess his or her symptoms (particularly suicidality) and adherence to psychiatric visits and treatment
• monitor for adverse effects from medications.

Atypical antipsychotics have been associated with weight gain, hyperglycemia, and hyperlipidemia. Check fasting glucose and lipids quarterly for the first year of antipsychotic therapy and annually thereafter.⁵ Watch for drug-drug interactions whenever a new medication is added. Monitor for abnormal movements, even though the risk of extrapyramidal symptoms and tardive dyskinesia is lower with atypical antipsychotics than with traditional agents.

For Mr. J’s psychiatric symptoms, I would:

• assess his willingness to start medication to reduce or eliminate the voices
• suggest he accept psychiatric referral
• assure him that I will remain involved in his care and continue to evaluate his abdominal symptoms.

I would also request permission to discuss his case with his partner and a family member to gather pertinent history and enlist their support for treatment. I would then start Mr. J on any drug listed in Table 3.

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Internship is a stressful and life-altering experience. Demands from patients, consulting staff, and paperwork can dehumanize the new physician and make him or her feel like an automaton. The constant exigency of being an intern is further compounded by the increasing use of algorithms and computers. Guidelines for care have existed since the Hermetic books of Thoth in ancient Egypt, but strict “cookbook” medicine limits the intern’s decision-making and individuality. Pressure for electronic record-keeping and redundant documentation further reduce the new physician into not much more than a data entry-and-retrieval terminal. With the intern spending more time with patient records than actual patients, the physician-patient relationship invariably suffers as the intern becomes a small part of the machinery. Consequently, house-staff are constantly searching for a conceptual framework to better understand and cope with their unusual existence.

Isaac Asimov, the visionary science fiction writer and one-time biochemistry professor at Boston University School of Medicine, wrote an entire corpus of work around robots and the three “Laws of Robotics” starting in the 1940s.1 It seems the laws of robotics might also apply to interns as the Three Laws of “Internotics” (original text in parenthesis):

• First Law: An intern (robot) may not injure a patient (human being), or, through inaction, allow a patient (human being) to come to harm.
• Second Law: An intern (robot) must obey orders given it by attendings (human beings) except when such orders would conflict with the First Law.*
• Third Law: An intern (robot) must protect its own existence as long as such protection does not conflict with the First or Second Law.

Ten years after the creation of these laws, Asimov developed a “Zeroth” Law: An intern (robot) may not injure humanity, or through inaction, allow humanity to come to harm.

The First Law

Isolated interpretation of the First Law is the modus operandi of robots and interns. This law is a re-wording of the basic tenet of medicine: First do no harm, or primum non nocere as quoted from Hippocrates in Epidemics. On its surface, the First Law may seem easy for the intern to interpret and follow. However, when the patient’s own perception of benefit and harm deviates from the established norms in medicine, the intern is faced with dilemma of patient autonomy versus beneficence. This may not be a novel phenomenon in the modern consumer-based healthcare system, as Will Mayo, MD, from our own institution once said during a speech at Rush Medical College in 1910: “The best interest of the patient is the only interest to be considered.”

The Second Law

The Second Law explicitly states that the intern must follow the orders of the attending physician, but much rests in the intern’s additional obligation to reconcile obligatory recommendations with their own knowledge and patients’ idiosyncrasy. This may quickly become problematic for the intern, as few orders in modern medicine are considered absolutely risk-free.

The intern must undertake two levels of risk-benefit analysis: They must first determine what type of harm the patient faces in the setting of inaction—as spelled out by the First Law—if the attending’s orders were not carried out; he then must balance such hypothetical harm with the risks associated with the attendings orders of action. If such analysis were to favor inaction, to question the attending’s order is to challenge the attending’s own interpretation of the First Law and to risk the intern’s own existence (Third Law).

Therefore, the best solution for the intern is often to not question whether such order is necessary, but to do whatever possible to protect the patient. An example might be a consultant’s request for a CAT scan in a patient at high risk for contrast-induced nephropathy. In such a case, N-acetylcystein, adequate hydration or urine alkalinization may provide optimal protection against nephropathy. As such, the intern fulfills his or her obligations to the First and Second Laws without testing the limits imposed by the Third.

The Third Law

Much of the practice of—if not the principle of—internship is a violation of the Third Law. Excessive sleepiness and stressors may lead to medical errors, substance abuse, and traffic accidents.2 Work-hour restrictions may alleviate this condition, but can also erode the already limited patient-physician relationship. Further, certain attending physicians may denigrate the performance of the intern, leading to self doubt, lower self esteem, and mental anguish.

Similarly, interaction with certain patients may challenge the intern’s physical or mental well-being. As a result, the intern juxtaposes the new physician’s self-image of competency against the hierarchical stereotype of the rookie. The Third Law allows an opportunity for the intern to be associated with the proud heritage of the caduceus. However, as most interns soon learn, an intern can possibly best ensure his or her well-being and ascent to the next level when the Third Law is not cited as regularly as the first two laws.

The Zeroth Law

The Zeroth Law may be the most challenging law for both robots and interns. While robots and interns are both proficiently trained in serving individual humans, neither positronic programming nor medical education clearly establishes how this leads to the service of humanity.

If humanity is to be defined as the collection of individuals, principles in doctoring of the individual cannot be easily duplicated onto a population. This can be demonstrated through the continuously escalating medical expenditures in the setting of limited resources. For example, if a patient presents with “atypical” chest pain, a diligent medical graduate might order a set of laboratory studies and an electrocardiogram to rule out on-going myocardial infarction despite a low likelihood of abnormality. The slightest normal variation may then involve, by the First or Second Law, observation, stress testing, or cardiac catheterization.

Even though the current economic and legal systems allow for such shotgun approach of affordable technology, such application of the First Law onto humans as a collective will exhaust the population of its limited resources and utterly defy the Zeroth Law.

Alternatively, if humanity is to mean what constitutes each person’s individuality, argument involving maleficence and beneficence must give way to autonomy in the presentation, diagnosis, and treatment of disease, despite what the intern or attending physician perceive as benefits and harm. This obviously violates the First Law in the most fundamental level. However, different from the other laws, the Zeroth Law is not prefaced with the need to comply with the other Three Laws.

Interns can and often do feel dehumanized, whether from loss of decision-making role, from lack of sleep, or as a psychological tool of survival against the rigors of life and death in the hospital. Sometimes even a perfectly beneficent act violates the First Law at a later time and haunts the practitioners. Asimov himself received surgery-related transfusion with the best intention of his treating physicians and surgeons, yet he contracted transfusion-related HIV and died years later of AIDS complications.3

While the Three Laws create a framework of the intern’s existence, it can never create the ideal intern with both the competency of the attending and frailty of the patients. The Laws of Robotics—and Internotics—remind us that just as Asimov’s “Bicentennial man” wanted to transform from robot to human, we want our interns to finish their training more human, not less so.4,** TH

*This makes the assumption that most attendings are humans in the context of this discussion—a hypothesis only. **Dr. Hu was recently a medical intern for Dr. Newman. None of the original Three Laws were violated during the course of their relationship.

Jamie Newman, MD, FACP, is the physician editor of The Hospitalist, senior associate consultant, Hospital Internal Medicine, and assistant professor of internal medicine and medical history, Mayo Clinic College of Medicine at the Mayo Clinic College of Medicine, Rochester, Minn. Dr. Hu works in the Departments of Internal Medicine and Neurology, Mayo Clinic College of Medicine, Rochester, Minn.

References

1. Asimov, I. I, Robot. London: Grafton Books; 1968.
2. Barger LK, Cade BE, Ayas NT, et al. Extended work shifts and the risk of motor vehicle crashes among interns. N Engl J Med. 2005;352:125-134.
3. Asimov I, Asimov, JJ. Isaac Asimov: It’s Been a Good Life. New York: Prometheus; 2002.
4. Asimov, I. The Bicentennial Man and Other Stories. New York:Doubleday and Co; 1976.

Internship is a stressful and life-altering experience. Demands from patients, consulting staff, and paperwork can dehumanize the new physician and make him or her feel like an automaton. The constant exigency of being an intern is further compounded by the increasing use of algorithms and computers. Guidelines for care have existed since the Hermetic books of Thoth in ancient Egypt, but strict “cookbook” medicine limits the intern’s decision-making and individuality. Pressure for electronic record-keeping and redundant documentation further reduce the new physician into not much more than a data entry-and-retrieval terminal. With the intern spending more time with patient records than actual patients, the physician-patient relationship invariably suffers as the intern becomes a small part of the machinery. Consequently, house-staff are constantly searching for a conceptual framework to better understand and cope with their unusual existence.

Isaac Asimov, the visionary science fiction writer and one-time biochemistry professor at Boston University School of Medicine, wrote an entire corpus of work around robots and the three “Laws of Robotics” starting in the 1940s.1 It seems the laws of robotics might also apply to interns as the Three Laws of “Internotics” (original text in parenthesis):

• First Law: An intern (robot) may not injure a patient (human being), or, through inaction, allow a patient (human being) to come to harm.
• Second Law: An intern (robot) must obey orders given it by attendings (human beings) except when such orders would conflict with the First Law.*
• Third Law: An intern (robot) must protect its own existence as long as such protection does not conflict with the First or Second Law.

Ten years after the creation of these laws, Asimov developed a “Zeroth” Law: An intern (robot) may not injure humanity, or through inaction, allow humanity to come to harm.

The First Law

Isolated interpretation of the First Law is the modus operandi of robots and interns. This law is a re-wording of the basic tenet of medicine: First do no harm, or primum non nocere as quoted from Hippocrates in Epidemics. On its surface, the First Law may seem easy for the intern to interpret and follow. However, when the patient’s own perception of benefit and harm deviates from the established norms in medicine, the intern is faced with dilemma of patient autonomy versus beneficence. This may not be a novel phenomenon in the modern consumer-based healthcare system, as Will Mayo, MD, from our own institution once said during a speech at Rush Medical College in 1910: “The best interest of the patient is the only interest to be considered.”

The Second Law

The Second Law explicitly states that the intern must follow the orders of the attending physician, but much rests in the intern’s additional obligation to reconcile obligatory recommendations with their own knowledge and patients’ idiosyncrasy. This may quickly become problematic for the intern, as few orders in modern medicine are considered absolutely risk-free.

The intern must undertake two levels of risk-benefit analysis: They must first determine what type of harm the patient faces in the setting of inaction—as spelled out by the First Law—if the attending’s orders were not carried out; he then must balance such hypothetical harm with the risks associated with the attendings orders of action. If such analysis were to favor inaction, to question the attending’s order is to challenge the attending’s own interpretation of the First Law and to risk the intern’s own existence (Third Law).

Therefore, the best solution for the intern is often to not question whether such order is necessary, but to do whatever possible to protect the patient. An example might be a consultant’s request for a CAT scan in a patient at high risk for contrast-induced nephropathy. In such a case, N-acetylcystein, adequate hydration or urine alkalinization may provide optimal protection against nephropathy. As such, the intern fulfills his or her obligations to the First and Second Laws without testing the limits imposed by the Third.

The Third Law

Much of the practice of—if not the principle of—internship is a violation of the Third Law. Excessive sleepiness and stressors may lead to medical errors, substance abuse, and traffic accidents.2 Work-hour restrictions may alleviate this condition, but can also erode the already limited patient-physician relationship. Further, certain attending physicians may denigrate the performance of the intern, leading to self doubt, lower self esteem, and mental anguish.

Similarly, interaction with certain patients may challenge the intern’s physical or mental well-being. As a result, the intern juxtaposes the new physician’s self-image of competency against the hierarchical stereotype of the rookie. The Third Law allows an opportunity for the intern to be associated with the proud heritage of the caduceus. However, as most interns soon learn, an intern can possibly best ensure his or her well-being and ascent to the next level when the Third Law is not cited as regularly as the first two laws.

The Zeroth Law

The Zeroth Law may be the most challenging law for both robots and interns. While robots and interns are both proficiently trained in serving individual humans, neither positronic programming nor medical education clearly establishes how this leads to the service of humanity.

If humanity is to be defined as the collection of individuals, principles in doctoring of the individual cannot be easily duplicated onto a population. This can be demonstrated through the continuously escalating medical expenditures in the setting of limited resources. For example, if a patient presents with “atypical” chest pain, a diligent medical graduate might order a set of laboratory studies and an electrocardiogram to rule out on-going myocardial infarction despite a low likelihood of abnormality. The slightest normal variation may then involve, by the First or Second Law, observation, stress testing, or cardiac catheterization.

Even though the current economic and legal systems allow for such shotgun approach of affordable technology, such application of the First Law onto humans as a collective will exhaust the population of its limited resources and utterly defy the Zeroth Law.

Alternatively, if humanity is to mean what constitutes each person’s individuality, argument involving maleficence and beneficence must give way to autonomy in the presentation, diagnosis, and treatment of disease, despite what the intern or attending physician perceive as benefits and harm. This obviously violates the First Law in the most fundamental level. However, different from the other laws, the Zeroth Law is not prefaced with the need to comply with the other Three Laws.

Interns can and often do feel dehumanized, whether from loss of decision-making role, from lack of sleep, or as a psychological tool of survival against the rigors of life and death in the hospital. Sometimes even a perfectly beneficent act violates the First Law at a later time and haunts the practitioners. Asimov himself received surgery-related transfusion with the best intention of his treating physicians and surgeons, yet he contracted transfusion-related HIV and died years later of AIDS complications.3

While the Three Laws create a framework of the intern’s existence, it can never create the ideal intern with both the competency of the attending and frailty of the patients. The Laws of Robotics—and Internotics—remind us that just as Asimov’s “Bicentennial man” wanted to transform from robot to human, we want our interns to finish their training more human, not less so.4,** TH

*This makes the assumption that most attendings are humans in the context of this discussion—a hypothesis only. **Dr. Hu was recently a medical intern for Dr. Newman. None of the original Three Laws were violated during the course of their relationship.

Jamie Newman, MD, FACP, is the physician editor of The Hospitalist, senior associate consultant, Hospital Internal Medicine, and assistant professor of internal medicine and medical history, Mayo Clinic College of Medicine at the Mayo Clinic College of Medicine, Rochester, Minn. Dr. Hu works in the Departments of Internal Medicine and Neurology, Mayo Clinic College of Medicine, Rochester, Minn.

References

1. Asimov, I. I, Robot. London: Grafton Books; 1968.
2. Barger LK, Cade BE, Ayas NT, et al. Extended work shifts and the risk of motor vehicle crashes among interns. N Engl J Med. 2005;352:125-134.
3. Asimov I, Asimov, JJ. Isaac Asimov: It’s Been a Good Life. New York: Prometheus; 2002.
4. Asimov, I. The Bicentennial Man and Other Stories. New York:Doubleday and Co; 1976.

Internship is a stressful and life-altering experience. Demands from patients, consulting staff, and paperwork can dehumanize the new physician and make him or her feel like an automaton. The constant exigency of being an intern is further compounded by the increasing use of algorithms and computers. Guidelines for care have existed since the Hermetic books of Thoth in ancient Egypt, but strict “cookbook” medicine limits the intern’s decision-making and individuality. Pressure for electronic record-keeping and redundant documentation further reduce the new physician into not much more than a data entry-and-retrieval terminal. With the intern spending more time with patient records than actual patients, the physician-patient relationship invariably suffers as the intern becomes a small part of the machinery. Consequently, house-staff are constantly searching for a conceptual framework to better understand and cope with their unusual existence.

Isaac Asimov, the visionary science fiction writer and one-time biochemistry professor at Boston University School of Medicine, wrote an entire corpus of work around robots and the three “Laws of Robotics” starting in the 1940s.1 It seems the laws of robotics might also apply to interns as the Three Laws of “Internotics” (original text in parenthesis):

• First Law: An intern (robot) may not injure a patient (human being), or, through inaction, allow a patient (human being) to come to harm.
• Second Law: An intern (robot) must obey orders given it by attendings (human beings) except when such orders would conflict with the First Law.*
• Third Law: An intern (robot) must protect its own existence as long as such protection does not conflict with the First or Second Law.

Ten years after the creation of these laws, Asimov developed a “Zeroth” Law: An intern (robot) may not injure humanity, or through inaction, allow humanity to come to harm.

The First Law

Isolated interpretation of the First Law is the modus operandi of robots and interns. This law is a re-wording of the basic tenet of medicine: First do no harm, or primum non nocere as quoted from Hippocrates in Epidemics. On its surface, the First Law may seem easy for the intern to interpret and follow. However, when the patient’s own perception of benefit and harm deviates from the established norms in medicine, the intern is faced with dilemma of patient autonomy versus beneficence. This may not be a novel phenomenon in the modern consumer-based healthcare system, as Will Mayo, MD, from our own institution once said during a speech at Rush Medical College in 1910: “The best interest of the patient is the only interest to be considered.”

The Second Law

The Second Law explicitly states that the intern must follow the orders of the attending physician, but much rests in the intern’s additional obligation to reconcile obligatory recommendations with their own knowledge and patients’ idiosyncrasy. This may quickly become problematic for the intern, as few orders in modern medicine are considered absolutely risk-free.

The intern must undertake two levels of risk-benefit analysis: They must first determine what type of harm the patient faces in the setting of inaction—as spelled out by the First Law—if the attending’s orders were not carried out; he then must balance such hypothetical harm with the risks associated with the attendings orders of action. If such analysis were to favor inaction, to question the attending’s order is to challenge the attending’s own interpretation of the First Law and to risk the intern’s own existence (Third Law).

Therefore, the best solution for the intern is often to not question whether such order is necessary, but to do whatever possible to protect the patient. An example might be a consultant’s request for a CAT scan in a patient at high risk for contrast-induced nephropathy. In such a case, N-acetylcystein, adequate hydration or urine alkalinization may provide optimal protection against nephropathy. As such, the intern fulfills his or her obligations to the First and Second Laws without testing the limits imposed by the Third.

The Third Law

Much of the practice of—if not the principle of—internship is a violation of the Third Law. Excessive sleepiness and stressors may lead to medical errors, substance abuse, and traffic accidents.2 Work-hour restrictions may alleviate this condition, but can also erode the already limited patient-physician relationship. Further, certain attending physicians may denigrate the performance of the intern, leading to self doubt, lower self esteem, and mental anguish.

Similarly, interaction with certain patients may challenge the intern’s physical or mental well-being. As a result, the intern juxtaposes the new physician’s self-image of competency against the hierarchical stereotype of the rookie. The Third Law allows an opportunity for the intern to be associated with the proud heritage of the caduceus. However, as most interns soon learn, an intern can possibly best ensure his or her well-being and ascent to the next level when the Third Law is not cited as regularly as the first two laws.

The Zeroth Law

The Zeroth Law may be the most challenging law for both robots and interns. While robots and interns are both proficiently trained in serving individual humans, neither positronic programming nor medical education clearly establishes how this leads to the service of humanity.

If humanity is to be defined as the collection of individuals, principles in doctoring of the individual cannot be easily duplicated onto a population. This can be demonstrated through the continuously escalating medical expenditures in the setting of limited resources. For example, if a patient presents with “atypical” chest pain, a diligent medical graduate might order a set of laboratory studies and an electrocardiogram to rule out on-going myocardial infarction despite a low likelihood of abnormality. The slightest normal variation may then involve, by the First or Second Law, observation, stress testing, or cardiac catheterization.

Even though the current economic and legal systems allow for such shotgun approach of affordable technology, such application of the First Law onto humans as a collective will exhaust the population of its limited resources and utterly defy the Zeroth Law.

Alternatively, if humanity is to mean what constitutes each person’s individuality, argument involving maleficence and beneficence must give way to autonomy in the presentation, diagnosis, and treatment of disease, despite what the intern or attending physician perceive as benefits and harm. This obviously violates the First Law in the most fundamental level. However, different from the other laws, the Zeroth Law is not prefaced with the need to comply with the other Three Laws.

Interns can and often do feel dehumanized, whether from loss of decision-making role, from lack of sleep, or as a psychological tool of survival against the rigors of life and death in the hospital. Sometimes even a perfectly beneficent act violates the First Law at a later time and haunts the practitioners. Asimov himself received surgery-related transfusion with the best intention of his treating physicians and surgeons, yet he contracted transfusion-related HIV and died years later of AIDS complications.3

While the Three Laws create a framework of the intern’s existence, it can never create the ideal intern with both the competency of the attending and frailty of the patients. The Laws of Robotics—and Internotics—remind us that just as Asimov’s “Bicentennial man” wanted to transform from robot to human, we want our interns to finish their training more human, not less so.4,** TH

*This makes the assumption that most attendings are humans in the context of this discussion—a hypothesis only. **Dr. Hu was recently a medical intern for Dr. Newman. None of the original Three Laws were violated during the course of their relationship.

Jamie Newman, MD, FACP, is the physician editor of The Hospitalist, senior associate consultant, Hospital Internal Medicine, and assistant professor of internal medicine and medical history, Mayo Clinic College of Medicine at the Mayo Clinic College of Medicine, Rochester, Minn. Dr. Hu works in the Departments of Internal Medicine and Neurology, Mayo Clinic College of Medicine, Rochester, Minn.

References

1. Asimov, I. I, Robot. London: Grafton Books; 1968.
2. Barger LK, Cade BE, Ayas NT, et al. Extended work shifts and the risk of motor vehicle crashes among interns. N Engl J Med. 2005;352:125-134.
3. Asimov I, Asimov, JJ. Isaac Asimov: It’s Been a Good Life. New York: Prometheus; 2002.
4. Asimov, I. The Bicentennial Man and Other Stories. New York:Doubleday and Co; 1976.

Community Teaching

Halasyamani L, Valenstein P, Friedlander M. et al. A comparison of two hospitalist models with traditional care in a community teaching hospital. Am J Med. 2005;118:536-543.

Background: A growing body of literature has demonstrated the effects of hospitalists on reducing inpatient length of stay and cost of care, with some literature showing a decreased in-hospital and 30-day mortality. However, most prior studies were conducted in academic medical centers or health maintenance organizations where one group of hospitalists, employed by the institution within which they worked, was compared with traditional primary care physicians. Direct comparisons between different hospitalist models practicing within a single institution have not been published. As a result, the impact of different hospitalist characteristics, including employment status and reimbursement incentives, on inpatient resource utilization and patient care outcomes is unknown.

Methods: Halasyamani and colleagues conducted a retrospective cohort study of 10,595 patients in a tertiary care community-based teaching hospital in which private hospitalists, academic hospitalists, and community physicians all practice. They measured risk-adjusted length of stay, variable costs, 30-day readmission rates, and in-hospital and 30-day mortality for patients treated by each of these three groups, controlling for potentially confounding variables. Community physicians belonged to 21 rounding groups, most of which were private or solo. Two of the community physicians groups were hospital-owned practices reimbursed by a relative value unit system. The private hospitalist group was self-employed with no financial relationship to the hospital and worked an average of 40 weeks per year. Community physicians and private hospitalists worked Monday-Friday and covered weekends or holidays about 25% of the time. Academic hospitalists worked with internal medicine residents and students on a teaching service. They were employed by the hospital using a relative value unit system. They worked an average of 14 weeks per year as an inpatient attending in half-month rotations, which included weekend coverage.

Results: There was a 20% reduction (-0.72 days absolute difference) in length of stay on the academic hospitalist service (P<0.0001) and 8% (-0.28 days absolute difference) on the private hospitalist service (P=0.049) compared with community physicians. Case-mix adjusted relative total costs were 10% less ($173 absolute difference) on the academic (P<0.0001) and 6% less ($109 absolute difference) on the private hospitalist services (P=0.02) compared with community physicians. There were no differences in 30-day readmission, in-hospital and 30-day mortality between the three groups.

Discussion: This study is the first to look at the effects of two separate hospitalist models on resource utilization and patient outcomes within the same institution. Although both the academic and private hospitalist groups demonstrated improved resource utilization as compared with the community physicians, the magnitude of benefit was much greater for the academic hospitalist group.

As the authors point out, one major difference between the two groups was employment status, with the academic hospitalists employed directly by the hospital and the private hospitalists receiving all payment directly from payers. Previous studies have also focused on hospitalists, which were employed by the institution at which they worked, raising the question of whether alignment of employee and employer incentives is an important factor affecting resource utilization outcomes.

Results of this study highlight the need for more studies which seek to clarify specific physician-level, group-level, and organization-level characteristics of hospitalists that result in improved resource utilization and patient care outcomes.

The Last Few Hours

Bailey FA, Burgio KL, Woodby LL, et al. Improving the processes of hospital care during the last hours of life. Arch Int Med. 2005;165(15):1722-1727.

Background: End-of-life care in the acute care inpatient setting is often not initiated until very late in the dying process and may be related to inadequate early recognition of dying patients as well as difficulty transitioning from disease-modifying treatments to palliative measures. Additional barriers exist, including lack of familiarity of hospital staff with initiation and implementation of hospice care. Education about end-of-life care and introduction of a physician-led palliative care team available for consultation within acute care hospitals may help promote better recognition of the dying patient by staff and allow for a “good death.”

Methods: A single hospital within the Veterans Affairs (VA) medical system (Birmingham, Ala., VA Medical Center) was chosen as a pilot center for initiation of a physician-led Inpatient Comfort Care Program (ICCP). The study was framed as a “before-after intervention trial” and analyzed all inpatient deaths identified by the Computerized Patient Recognition System during a six-month period before and substantially after the introduction of the ICCP. A structured chart abstraction tool was used and data was obtained from the last seven days of hospitalization analyzing variables associated with recognition of the dying patient and initiation of palliative care. Education of hospital staff on both hospice care and case identification was initiated during the intervention phase of the study. Additionally, a flexible comfort care order set was introduced.

Results: Two hundred and three veterans were identified (98% men, average age 68) and no significant differences in clinical characteristics were noted between the two groups, pre-intervention and post-intervention. Post-intervention, 59.3% of patients had formal palliative care consultation. Significant findings (P<0.01) following implementation of ICCP were increased documentation of end-of-life symptoms, increased documentation of care plans, increased utilization of opioids (57.1% to 87.2%), increased initiation of do-not-resuscitate orders (61.9% to 85.1%) with a concurrent decrease in cardiopulmonary resuscitation at death (34.4% to 15.4%), and a surprising increase in restraint use (6.0% to 22.6%).

Discussion: Data on hospice care patients indicate that 10% to 30% die in an acute care hospital, identifying a need for increased education and training in palliative medicine. This study demonstrates the positive outcomes of implementation of an inpatient palliative care service both for heightened awareness of identifying the dying patient as well as initiation of end-of-life care. The increased use of opioid medications is an important marker given that many patients experience pain and dyspnea at the end of life. This study is limited by its single site and further validation at other centers implementing similar protocols and assessing similar outcomes is needed. While this intervention had important clinical benefits, additional studies examining the cost implications of this system would be helpful.

Education alone has not been shown to be entirely effective in creating change. This single-site implementation of a palliative care consultation service successfully integrated an education program with on-site consultants. Distributing pocket cards with clinical findings identifying the dying patient aided in recognition of those patients and pre-printed order sets facilitated initiation of end-of-life care. The intervention initiated is possible for many medical centers and promotes an environment allowing for a “good death” for dying patients.

Computers, Doctors, and Errors

Koppel R, Metlay JP, Cohen A, et al. Role of computerized physician order entry systems in facilitating medication errors. JAMA. 2005;293(10):1197-1203

For physicians, computerized physician order entry (CPOE) has become an important topic of discussion as many hospitals and health systems embark on the complex and lengthy process of implementing new enterprise clinical systems. Though there are undoubtedly benefits to such systems, practicing clinicians are apt to remain skeptical of the grandiose pictures the more vocal advocates of CPOE may paint. This is not to say that the promises of CPOE are empty; to the contrary, there have been substantial successes, notably in the realm of medication error prevention.

At the same time, CPOE is a mixture of complex technologies that interface in complicated ways with the culture of clinical medicine. The view that medical informatics is a technical problem that has been solved long ago is simplistic and naïve. The article by Koppel, et al, has two important implications: 1) It is critical to look at clinical information systems in the social milieu in which it functions, and 2) there are often unintended consequences that may not beneficial.

This article examines a widely used, commercial CPOE system in use at the University of Pennsylvania (Philadelphia) using both quantitative and qualitative methods. The researchers conducted focus groups and expert interviews in addition to field observations of physicians (house officers and attendings), nurses, and pharmacists in order to identify themes relating to work with the order entry system. This work helped to guide the creation of a survey instrument subsequently used to survey house staff about working conditions and sources of error and stress. There was an 85%-90% response rate that primarily included house staff who ordered more than nine medication orders per month.

Researchers found two broad categories of errors that were fostered in this environment. The first category, which they termed “information errors” were generated by fragmentation of data and the failure to integrate the hospitals various systems both electronic and paper. Examples of this type of error include antibiotic renewal failures. A common way this failure would occur is that renewal reminder stickers would be placed in the patients’ charts, but the house staff would overlook these because medication orders occurred electronically. Another example is assumed dose errors, where house staff would assume that the default dose displayed was the recommended starting dose, when in fact this was the smallest dose unit available. Physicians were assuming decision support was available when it was not.

The second type of error, human-machine interface flaws, occurred when machine rules did not correspond to work behaviors. An example of this is when patients were listed alphabetically rather than by service, making it easy to select the wrong patient. In another instance, many screens (up to 20) were required to view all of a patient’s medications, making it difficult to choose a correct medication for editing.

This study has been criticized by industry advocates for focusing on an older set of technologies or because a number of these issues related to training or “user factors.” At the other extreme, this study has been cited as a cautionary tale about the risks of CPOE. Both types of criticism miss the point. This study demonstrates that CPOE and the social environment in which it sits is a complex entity and that careful design, proper support, and maintenance are critical ingredients to the success of an incredibly complex but vital new component of hospital medicine.

Point-of-Care HIV Testing in Inpatients

Lubelchek R, Kroc K, Hota B, et al. The role of rapid vs conventional human immunodeficiency virus testing for inpatients: effects on quality of care. Arch Intern Med. 2005;165:1956-1960.

Despite advances in treatment, infection with HIV and AIDS remains a public health problem in the United States. According to the CDC the rate of new diagnosis of HIV infection has remained steady from 2000 to 2003 at about 20 per 100,000 people. (Centers for Disease Control and Prevention. Diagnosis of HIV/AIDS–32 states, 2009-2003. MMWR Morb Mortal Wkly Rep. 2004;53:1106-1110). Currently, about 850,000 to 950,000 people are believed to be living with HIV infection, and it is estimated that 180,000 to 280,000 are unaware of their diagnosis. (Fleming P, Byers RH, Sweeney PA, et al., HIV prevalence in the United States, 2000 [Abstract 11]. Presented at the Ninth Conference on Retroviruses and Opportunistic Infections, Seattle; February 24–28, 2002). These patients are not only at risk for disease progression, but can undermine efforts at disease prevention if they continue to engage in unsafe activities. Thus, increasing awareness of HIV status is an important aspect of disease prevention.

HIV testing remains a challenge. Conventional testing with enzyme immunoassay (EIA) and confirmatory Western blot requires patient follow-up for results, which approximately 25% of patients in various outpatient testing sites fail to do. (Centers for Disease Control and Prevention. Update: HIV counseling and testing using rapid tests, United States, 1995. MMWR Morb Mortal Wkly Rep. 1998;47:211-215). Given the difficulties inherent in the transition of care from the inpatient to outpatient setting, conventional testing in the inpatient setting presents additional barriers to appropriate notification. As various point-of-care HIV tests have been developed for commercial use, the possibility of rapid HIV testing presents an opportunity to reduce notification failure and improve patient care. While not replacing traditional testing, the CDC has endorsed rapid HIV testing as a means to initiate therapy and provide counseling with a particular focus on preventing further disease transmission. In this retrospective study, Lubelchek and colleagues present the effects of a rapid HIV test utilized in the emergency department on various inpatient quality of care measures for those patients who received a positive rapid HIV test later confirmed by Western blot as compared with those patients who were diagnosed after admission by traditional diagnostic methods. This study took place in the context of CDC-funded study of the use of OraQuick (OraSure Technologies, Bethlehem, Pa.) rapid HIV testing in the emergency department at Cook County Hospital in Chicago.

The manufacturer claims the product has a sensitivity of 99.6% and a specificity of 100% as compared with conventional testing. (OraQuick rapid HIV-1 antibody test summary of safety and effectiveness. November 7, 2002. Accessed October 1, 2005, at www.fda.gov/cber/pma/P010047.htm). In the initial study, two of the three emergency department’s treatment pods were equipped to provide HIV screening utilizing the point-of-care technology to consenting patients. Patients in the third pod could be referred to rapid testing based on symptoms or risk factors. All patients who received the rapid test also submitted specimens for conventional EIA and confirmatory Western blot testing. All positive rapid HIV tests were confirmed by Western blot.

In this study, patients who were not known to be infected and were subsequently admitted on non-obstetric or surgical services over 17 months from 2003 to 2004 and confirmed to be HIV positive by Western blot were identified utilizing administrative records. Where possible, charts were reviewed to confirm no prior diagnosis of HIV. Patients who received rapid HIV testing were compared with those who only received conventional testing. Endpoints included time to primary inpatient care service awareness of HIV diagnosis, time to admission or transfer to the inpatient HIV service, time to empiric treatment of diagnosis of opportunistic infection, length of stay, discharge with appropriate prophylactic medications, discharge with patient knowledge of HIV diagnosis, and initial engagement in outpatient care. Length of stay was adjusted by multivariate regression on co-morbid diagnoses (congestive heart failure, end-stage renal disease, cirrhosis, chronic obstructive pulmonary disease, and diabetes), opportunistic infections, ICU admission, need for mechanical ventilation, and CD4 count.

A total of 103 patients were identified with complete chart review completed on 86 of them. All patients except one were admitted through the emergency department. Forty-eight patients were diagnosed initially with the rapid HIV test with 58% of these specifically referred for testing by the emergency department physician, and 55 were diagnosed with conventional testing. Overall, 78% were male, 62% African American, and 20% Hispanic. The two groups were comparable in terms of age, sex, ethnicity, history of substance abuse, HIV risk factors, psychiatric diagnoses, homelessness, CD4 count, presence of opportunistic infections, mechanical ventilation, and co-morbidities. However, conventionally tested patients were more likely to require an ICU stay (31% vs. 10%, P=.01).

Patients in the rapid test group were more quickly documented in the chart as having HIV (.8 vs. 6.4 days, p<.001), placed on an HIV service sooner (1.4 versus 6.9 days, P<.001), initiated outpatient follow-up sooner (21.5 versus 49.5 days, p=.05), and had less unawareness of their HIV status (0 vs. 16%, P=.002). There was no significant difference between the two groups in time from admission to empiric treatment or diagnosis of an opportunistic infection. Patients who received the rapid test did have a lower length of stay (6.4 versus 13.2 days, P<.001). Although much of this difference was due to higher number of ICU stays in the conventional group, in multivariate analysis conventional testing still increased length of stay significantly, OR 5.4 days (2.5, 8.3).

This study suggests that patients who are tested with rapid HIV testing can lead to more efficient inpatient treatment of the complications of HIV, improved patient awareness of HIV status, and quicker outpatient follow-up. These findings have ramifications not just to the inpatient management of patients with HIV but to general public health efforts to reduce the spread of HIV infection.

Nevertheless, these results must be interpreted with caution. They reflect the experience of one institution situated in an area with a high prevalence of HIV. Some degree of selection bias is suggested by the higher presence of ICU admissions in the conventional testing group. The multivariate analysis attempted to control for confounding factors, but the possibility remains that other unrecognized factors may have influenced results. The authors do note that an analysis of patients in the rapid test group stratified by whether the test was performed for screening or by referral of the physician did not demonstrate a statistically significant difference in length of stay. This finding provides further support that the sicker patients which triggered the rapid test had shorter lengths of stay on account of the rapid test and not simply because they were sicker.

As recognized by the authors, physicians in routine practice rely on surrogate markers of HIV infection, most notably a patient’s CD4 count, and thus it is not surprising that the rapid test did not affect time to empiric treatment or diagnosis of opportunistic infection. If treatment did not differ, then explaining the longer length of stay remains an unexplained puzzle. The fact that the two groups were equally matched socially and psychiatrically leaves open the possibility that it was actual knowledge of the HIV test result—and not its effect on treatment—that drove the longer length of stay.

One possibility not suggested by the authors is that definitive knowledge of HIV status helped to mobilize patient discharge. If there were legitimate concerns of follow-up, physicians may have delayed discharge in order to receive HIV test results. Alternatively, some patients may have resisted discharge until receiving test results and the development of a more concrete plan. It would be interesting to know if the time to follow-up for the two groups would be the same if the 16% who did not know their HIV status at discharge were excluded. This suggests that knowledge of HIV status drives follow-up time and would lend some support to the notion that patient discharge was delayed for test results and clarification of the follow-up treatment plan.

Even putting aside the difference in length of stay, the difference of rapid testing on improved knowledge of HIV status and quicker follow-up is likely real and meaningful. Although this study was not designed to assess the impact of this knowledge on patient behavior, immediate knowledge of HIV status during hospitalization may translate to decreased transmission as patients alter their behavior and lends further credibility to the utility of rapid HIV testing in conjunction with conventional methods in the management of inpatients. TH

Community Teaching

Halasyamani L, Valenstein P, Friedlander M. et al. A comparison of two hospitalist models with traditional care in a community teaching hospital. Am J Med. 2005;118:536-543.

Background: A growing body of literature has demonstrated the effects of hospitalists on reducing inpatient length of stay and cost of care, with some literature showing a decreased in-hospital and 30-day mortality. However, most prior studies were conducted in academic medical centers or health maintenance organizations where one group of hospitalists, employed by the institution within which they worked, was compared with traditional primary care physicians. Direct comparisons between different hospitalist models practicing within a single institution have not been published. As a result, the impact of different hospitalist characteristics, including employment status and reimbursement incentives, on inpatient resource utilization and patient care outcomes is unknown.

Methods: Halasyamani and colleagues conducted a retrospective cohort study of 10,595 patients in a tertiary care community-based teaching hospital in which private hospitalists, academic hospitalists, and community physicians all practice. They measured risk-adjusted length of stay, variable costs, 30-day readmission rates, and in-hospital and 30-day mortality for patients treated by each of these three groups, controlling for potentially confounding variables. Community physicians belonged to 21 rounding groups, most of which were private or solo. Two of the community physicians groups were hospital-owned practices reimbursed by a relative value unit system. The private hospitalist group was self-employed with no financial relationship to the hospital and worked an average of 40 weeks per year. Community physicians and private hospitalists worked Monday-Friday and covered weekends or holidays about 25% of the time. Academic hospitalists worked with internal medicine residents and students on a teaching service. They were employed by the hospital using a relative value unit system. They worked an average of 14 weeks per year as an inpatient attending in half-month rotations, which included weekend coverage.

Results: There was a 20% reduction (-0.72 days absolute difference) in length of stay on the academic hospitalist service (P<0.0001) and 8% (-0.28 days absolute difference) on the private hospitalist service (P=0.049) compared with community physicians. Case-mix adjusted relative total costs were 10% less ($173 absolute difference) on the academic (P<0.0001) and 6% less ($109 absolute difference) on the private hospitalist services (P=0.02) compared with community physicians. There were no differences in 30-day readmission, in-hospital and 30-day mortality between the three groups.

Discussion: This study is the first to look at the effects of two separate hospitalist models on resource utilization and patient outcomes within the same institution. Although both the academic and private hospitalist groups demonstrated improved resource utilization as compared with the community physicians, the magnitude of benefit was much greater for the academic hospitalist group.

As the authors point out, one major difference between the two groups was employment status, with the academic hospitalists employed directly by the hospital and the private hospitalists receiving all payment directly from payers. Previous studies have also focused on hospitalists, which were employed by the institution at which they worked, raising the question of whether alignment of employee and employer incentives is an important factor affecting resource utilization outcomes.

Results of this study highlight the need for more studies which seek to clarify specific physician-level, group-level, and organization-level characteristics of hospitalists that result in improved resource utilization and patient care outcomes.

The Last Few Hours

Bailey FA, Burgio KL, Woodby LL, et al. Improving the processes of hospital care during the last hours of life. Arch Int Med. 2005;165(15):1722-1727.

Background: End-of-life care in the acute care inpatient setting is often not initiated until very late in the dying process and may be related to inadequate early recognition of dying patients as well as difficulty transitioning from disease-modifying treatments to palliative measures. Additional barriers exist, including lack of familiarity of hospital staff with initiation and implementation of hospice care. Education about end-of-life care and introduction of a physician-led palliative care team available for consultation within acute care hospitals may help promote better recognition of the dying patient by staff and allow for a “good death.”

Methods: A single hospital within the Veterans Affairs (VA) medical system (Birmingham, Ala., VA Medical Center) was chosen as a pilot center for initiation of a physician-led Inpatient Comfort Care Program (ICCP). The study was framed as a “before-after intervention trial” and analyzed all inpatient deaths identified by the Computerized Patient Recognition System during a six-month period before and substantially after the introduction of the ICCP. A structured chart abstraction tool was used and data was obtained from the last seven days of hospitalization analyzing variables associated with recognition of the dying patient and initiation of palliative care. Education of hospital staff on both hospice care and case identification was initiated during the intervention phase of the study. Additionally, a flexible comfort care order set was introduced.

Results: Two hundred and three veterans were identified (98% men, average age 68) and no significant differences in clinical characteristics were noted between the two groups, pre-intervention and post-intervention. Post-intervention, 59.3% of patients had formal palliative care consultation. Significant findings (P<0.01) following implementation of ICCP were increased documentation of end-of-life symptoms, increased documentation of care plans, increased utilization of opioids (57.1% to 87.2%), increased initiation of do-not-resuscitate orders (61.9% to 85.1%) with a concurrent decrease in cardiopulmonary resuscitation at death (34.4% to 15.4%), and a surprising increase in restraint use (6.0% to 22.6%).

Discussion: Data on hospice care patients indicate that 10% to 30% die in an acute care hospital, identifying a need for increased education and training in palliative medicine. This study demonstrates the positive outcomes of implementation of an inpatient palliative care service both for heightened awareness of identifying the dying patient as well as initiation of end-of-life care. The increased use of opioid medications is an important marker given that many patients experience pain and dyspnea at the end of life. This study is limited by its single site and further validation at other centers implementing similar protocols and assessing similar outcomes is needed. While this intervention had important clinical benefits, additional studies examining the cost implications of this system would be helpful.

Education alone has not been shown to be entirely effective in creating change. This single-site implementation of a palliative care consultation service successfully integrated an education program with on-site consultants. Distributing pocket cards with clinical findings identifying the dying patient aided in recognition of those patients and pre-printed order sets facilitated initiation of end-of-life care. The intervention initiated is possible for many medical centers and promotes an environment allowing for a “good death” for dying patients.

Computers, Doctors, and Errors

Koppel R, Metlay JP, Cohen A, et al. Role of computerized physician order entry systems in facilitating medication errors. JAMA. 2005;293(10):1197-1203

For physicians, computerized physician order entry (CPOE) has become an important topic of discussion as many hospitals and health systems embark on the complex and lengthy process of implementing new enterprise clinical systems. Though there are undoubtedly benefits to such systems, practicing clinicians are apt to remain skeptical of the grandiose pictures the more vocal advocates of CPOE may paint. This is not to say that the promises of CPOE are empty; to the contrary, there have been substantial successes, notably in the realm of medication error prevention.

At the same time, CPOE is a mixture of complex technologies that interface in complicated ways with the culture of clinical medicine. The view that medical informatics is a technical problem that has been solved long ago is simplistic and naïve. The article by Koppel, et al, has two important implications: 1) It is critical to look at clinical information systems in the social milieu in which it functions, and 2) there are often unintended consequences that may not beneficial.

This article examines a widely used, commercial CPOE system in use at the University of Pennsylvania (Philadelphia) using both quantitative and qualitative methods. The researchers conducted focus groups and expert interviews in addition to field observations of physicians (house officers and attendings), nurses, and pharmacists in order to identify themes relating to work with the order entry system. This work helped to guide the creation of a survey instrument subsequently used to survey house staff about working conditions and sources of error and stress. There was an 85%-90% response rate that primarily included house staff who ordered more than nine medication orders per month.

Researchers found two broad categories of errors that were fostered in this environment. The first category, which they termed “information errors” were generated by fragmentation of data and the failure to integrate the hospitals various systems both electronic and paper. Examples of this type of error include antibiotic renewal failures. A common way this failure would occur is that renewal reminder stickers would be placed in the patients’ charts, but the house staff would overlook these because medication orders occurred electronically. Another example is assumed dose errors, where house staff would assume that the default dose displayed was the recommended starting dose, when in fact this was the smallest dose unit available. Physicians were assuming decision support was available when it was not.

The second type of error, human-machine interface flaws, occurred when machine rules did not correspond to work behaviors. An example of this is when patients were listed alphabetically rather than by service, making it easy to select the wrong patient. In another instance, many screens (up to 20) were required to view all of a patient’s medications, making it difficult to choose a correct medication for editing.

This study has been criticized by industry advocates for focusing on an older set of technologies or because a number of these issues related to training or “user factors.” At the other extreme, this study has been cited as a cautionary tale about the risks of CPOE. Both types of criticism miss the point. This study demonstrates that CPOE and the social environment in which it sits is a complex entity and that careful design, proper support, and maintenance are critical ingredients to the success of an incredibly complex but vital new component of hospital medicine.

Point-of-Care HIV Testing in Inpatients

Lubelchek R, Kroc K, Hota B, et al. The role of rapid vs conventional human immunodeficiency virus testing for inpatients: effects on quality of care. Arch Intern Med. 2005;165:1956-1960.

Despite advances in treatment, infection with HIV and AIDS remains a public health problem in the United States. According to the CDC the rate of new diagnosis of HIV infection has remained steady from 2000 to 2003 at about 20 per 100,000 people. (Centers for Disease Control and Prevention. Diagnosis of HIV/AIDS–32 states, 2009-2003. MMWR Morb Mortal Wkly Rep. 2004;53:1106-1110). Currently, about 850,000 to 950,000 people are believed to be living with HIV infection, and it is estimated that 180,000 to 280,000 are unaware of their diagnosis. (Fleming P, Byers RH, Sweeney PA, et al., HIV prevalence in the United States, 2000 [Abstract 11]. Presented at the Ninth Conference on Retroviruses and Opportunistic Infections, Seattle; February 24–28, 2002). These patients are not only at risk for disease progression, but can undermine efforts at disease prevention if they continue to engage in unsafe activities. Thus, increasing awareness of HIV status is an important aspect of disease prevention.

HIV testing remains a challenge. Conventional testing with enzyme immunoassay (EIA) and confirmatory Western blot requires patient follow-up for results, which approximately 25% of patients in various outpatient testing sites fail to do. (Centers for Disease Control and Prevention. Update: HIV counseling and testing using rapid tests, United States, 1995. MMWR Morb Mortal Wkly Rep. 1998;47:211-215). Given the difficulties inherent in the transition of care from the inpatient to outpatient setting, conventional testing in the inpatient setting presents additional barriers to appropriate notification. As various point-of-care HIV tests have been developed for commercial use, the possibility of rapid HIV testing presents an opportunity to reduce notification failure and improve patient care. While not replacing traditional testing, the CDC has endorsed rapid HIV testing as a means to initiate therapy and provide counseling with a particular focus on preventing further disease transmission. In this retrospective study, Lubelchek and colleagues present the effects of a rapid HIV test utilized in the emergency department on various inpatient quality of care measures for those patients who received a positive rapid HIV test later confirmed by Western blot as compared with those patients who were diagnosed after admission by traditional diagnostic methods. This study took place in the context of CDC-funded study of the use of OraQuick (OraSure Technologies, Bethlehem, Pa.) rapid HIV testing in the emergency department at Cook County Hospital in Chicago.

The manufacturer claims the product has a sensitivity of 99.6% and a specificity of 100% as compared with conventional testing. (OraQuick rapid HIV-1 antibody test summary of safety and effectiveness. November 7, 2002. Accessed October 1, 2005, at www.fda.gov/cber/pma/P010047.htm). In the initial study, two of the three emergency department’s treatment pods were equipped to provide HIV screening utilizing the point-of-care technology to consenting patients. Patients in the third pod could be referred to rapid testing based on symptoms or risk factors. All patients who received the rapid test also submitted specimens for conventional EIA and confirmatory Western blot testing. All positive rapid HIV tests were confirmed by Western blot.

In this study, patients who were not known to be infected and were subsequently admitted on non-obstetric or surgical services over 17 months from 2003 to 2004 and confirmed to be HIV positive by Western blot were identified utilizing administrative records. Where possible, charts were reviewed to confirm no prior diagnosis of HIV. Patients who received rapid HIV testing were compared with those who only received conventional testing. Endpoints included time to primary inpatient care service awareness of HIV diagnosis, time to admission or transfer to the inpatient HIV service, time to empiric treatment of diagnosis of opportunistic infection, length of stay, discharge with appropriate prophylactic medications, discharge with patient knowledge of HIV diagnosis, and initial engagement in outpatient care. Length of stay was adjusted by multivariate regression on co-morbid diagnoses (congestive heart failure, end-stage renal disease, cirrhosis, chronic obstructive pulmonary disease, and diabetes), opportunistic infections, ICU admission, need for mechanical ventilation, and CD4 count.

A total of 103 patients were identified with complete chart review completed on 86 of them. All patients except one were admitted through the emergency department. Forty-eight patients were diagnosed initially with the rapid HIV test with 58% of these specifically referred for testing by the emergency department physician, and 55 were diagnosed with conventional testing. Overall, 78% were male, 62% African American, and 20% Hispanic. The two groups were comparable in terms of age, sex, ethnicity, history of substance abuse, HIV risk factors, psychiatric diagnoses, homelessness, CD4 count, presence of opportunistic infections, mechanical ventilation, and co-morbidities. However, conventionally tested patients were more likely to require an ICU stay (31% vs. 10%, P=.01).

Patients in the rapid test group were more quickly documented in the chart as having HIV (.8 vs. 6.4 days, p<.001), placed on an HIV service sooner (1.4 versus 6.9 days, P<.001), initiated outpatient follow-up sooner (21.5 versus 49.5 days, p=.05), and had less unawareness of their HIV status (0 vs. 16%, P=.002). There was no significant difference between the two groups in time from admission to empiric treatment or diagnosis of an opportunistic infection. Patients who received the rapid test did have a lower length of stay (6.4 versus 13.2 days, P<.001). Although much of this difference was due to higher number of ICU stays in the conventional group, in multivariate analysis conventional testing still increased length of stay significantly, OR 5.4 days (2.5, 8.3).

This study suggests that patients who are tested with rapid HIV testing can lead to more efficient inpatient treatment of the complications of HIV, improved patient awareness of HIV status, and quicker outpatient follow-up. These findings have ramifications not just to the inpatient management of patients with HIV but to general public health efforts to reduce the spread of HIV infection.

Nevertheless, these results must be interpreted with caution. They reflect the experience of one institution situated in an area with a high prevalence of HIV. Some degree of selection bias is suggested by the higher presence of ICU admissions in the conventional testing group. The multivariate analysis attempted to control for confounding factors, but the possibility remains that other unrecognized factors may have influenced results. The authors do note that an analysis of patients in the rapid test group stratified by whether the test was performed for screening or by referral of the physician did not demonstrate a statistically significant difference in length of stay. This finding provides further support that the sicker patients which triggered the rapid test had shorter lengths of stay on account of the rapid test and not simply because they were sicker.

As recognized by the authors, physicians in routine practice rely on surrogate markers of HIV infection, most notably a patient’s CD4 count, and thus it is not surprising that the rapid test did not affect time to empiric treatment or diagnosis of opportunistic infection. If treatment did not differ, then explaining the longer length of stay remains an unexplained puzzle. The fact that the two groups were equally matched socially and psychiatrically leaves open the possibility that it was actual knowledge of the HIV test result—and not its effect on treatment—that drove the longer length of stay.

One possibility not suggested by the authors is that definitive knowledge of HIV status helped to mobilize patient discharge. If there were legitimate concerns of follow-up, physicians may have delayed discharge in order to receive HIV test results. Alternatively, some patients may have resisted discharge until receiving test results and the development of a more concrete plan. It would be interesting to know if the time to follow-up for the two groups would be the same if the 16% who did not know their HIV status at discharge were excluded. This suggests that knowledge of HIV status drives follow-up time and would lend some support to the notion that patient discharge was delayed for test results and clarification of the follow-up treatment plan.

Even putting aside the difference in length of stay, the difference of rapid testing on improved knowledge of HIV status and quicker follow-up is likely real and meaningful. Although this study was not designed to assess the impact of this knowledge on patient behavior, immediate knowledge of HIV status during hospitalization may translate to decreased transmission as patients alter their behavior and lends further credibility to the utility of rapid HIV testing in conjunction with conventional methods in the management of inpatients. TH

Community Teaching

Halasyamani L, Valenstein P, Friedlander M. et al. A comparison of two hospitalist models with traditional care in a community teaching hospital. Am J Med. 2005;118:536-543.

Background: A growing body of literature has demonstrated the effects of hospitalists on reducing inpatient length of stay and cost of care, with some literature showing a decreased in-hospital and 30-day mortality. However, most prior studies were conducted in academic medical centers or health maintenance organizations where one group of hospitalists, employed by the institution within which they worked, was compared with traditional primary care physicians. Direct comparisons between different hospitalist models practicing within a single institution have not been published. As a result, the impact of different hospitalist characteristics, including employment status and reimbursement incentives, on inpatient resource utilization and patient care outcomes is unknown.

Methods: Halasyamani and colleagues conducted a retrospective cohort study of 10,595 patients in a tertiary care community-based teaching hospital in which private hospitalists, academic hospitalists, and community physicians all practice. They measured risk-adjusted length of stay, variable costs, 30-day readmission rates, and in-hospital and 30-day mortality for patients treated by each of these three groups, controlling for potentially confounding variables. Community physicians belonged to 21 rounding groups, most of which were private or solo. Two of the community physicians groups were hospital-owned practices reimbursed by a relative value unit system. The private hospitalist group was self-employed with no financial relationship to the hospital and worked an average of 40 weeks per year. Community physicians and private hospitalists worked Monday-Friday and covered weekends or holidays about 25% of the time. Academic hospitalists worked with internal medicine residents and students on a teaching service. They were employed by the hospital using a relative value unit system. They worked an average of 14 weeks per year as an inpatient attending in half-month rotations, which included weekend coverage.

Results: There was a 20% reduction (-0.72 days absolute difference) in length of stay on the academic hospitalist service (P<0.0001) and 8% (-0.28 days absolute difference) on the private hospitalist service (P=0.049) compared with community physicians. Case-mix adjusted relative total costs were 10% less ($173 absolute difference) on the academic (P<0.0001) and 6% less ($109 absolute difference) on the private hospitalist services (P=0.02) compared with community physicians. There were no differences in 30-day readmission, in-hospital and 30-day mortality between the three groups.

Discussion: This study is the first to look at the effects of two separate hospitalist models on resource utilization and patient outcomes within the same institution. Although both the academic and private hospitalist groups demonstrated improved resource utilization as compared with the community physicians, the magnitude of benefit was much greater for the academic hospitalist group.

As the authors point out, one major difference between the two groups was employment status, with the academic hospitalists employed directly by the hospital and the private hospitalists receiving all payment directly from payers. Previous studies have also focused on hospitalists, which were employed by the institution at which they worked, raising the question of whether alignment of employee and employer incentives is an important factor affecting resource utilization outcomes.

Results of this study highlight the need for more studies which seek to clarify specific physician-level, group-level, and organization-level characteristics of hospitalists that result in improved resource utilization and patient care outcomes.

The Last Few Hours

Bailey FA, Burgio KL, Woodby LL, et al. Improving the processes of hospital care during the last hours of life. Arch Int Med. 2005;165(15):1722-1727.

Background: End-of-life care in the acute care inpatient setting is often not initiated until very late in the dying process and may be related to inadequate early recognition of dying patients as well as difficulty transitioning from disease-modifying treatments to palliative measures. Additional barriers exist, including lack of familiarity of hospital staff with initiation and implementation of hospice care. Education about end-of-life care and introduction of a physician-led palliative care team available for consultation within acute care hospitals may help promote better recognition of the dying patient by staff and allow for a “good death.”

Methods: A single hospital within the Veterans Affairs (VA) medical system (Birmingham, Ala., VA Medical Center) was chosen as a pilot center for initiation of a physician-led Inpatient Comfort Care Program (ICCP). The study was framed as a “before-after intervention trial” and analyzed all inpatient deaths identified by the Computerized Patient Recognition System during a six-month period before and substantially after the introduction of the ICCP. A structured chart abstraction tool was used and data was obtained from the last seven days of hospitalization analyzing variables associated with recognition of the dying patient and initiation of palliative care. Education of hospital staff on both hospice care and case identification was initiated during the intervention phase of the study. Additionally, a flexible comfort care order set was introduced.

Results: Two hundred and three veterans were identified (98% men, average age 68) and no significant differences in clinical characteristics were noted between the two groups, pre-intervention and post-intervention. Post-intervention, 59.3% of patients had formal palliative care consultation. Significant findings (P<0.01) following implementation of ICCP were increased documentation of end-of-life symptoms, increased documentation of care plans, increased utilization of opioids (57.1% to 87.2%), increased initiation of do-not-resuscitate orders (61.9% to 85.1%) with a concurrent decrease in cardiopulmonary resuscitation at death (34.4% to 15.4%), and a surprising increase in restraint use (6.0% to 22.6%).

Discussion: Data on hospice care patients indicate that 10% to 30% die in an acute care hospital, identifying a need for increased education and training in palliative medicine. This study demonstrates the positive outcomes of implementation of an inpatient palliative care service both for heightened awareness of identifying the dying patient as well as initiation of end-of-life care. The increased use of opioid medications is an important marker given that many patients experience pain and dyspnea at the end of life. This study is limited by its single site and further validation at other centers implementing similar protocols and assessing similar outcomes is needed. While this intervention had important clinical benefits, additional studies examining the cost implications of this system would be helpful.

Education alone has not been shown to be entirely effective in creating change. This single-site implementation of a palliative care consultation service successfully integrated an education program with on-site consultants. Distributing pocket cards with clinical findings identifying the dying patient aided in recognition of those patients and pre-printed order sets facilitated initiation of end-of-life care. The intervention initiated is possible for many medical centers and promotes an environment allowing for a “good death” for dying patients.

Computers, Doctors, and Errors

Koppel R, Metlay JP, Cohen A, et al. Role of computerized physician order entry systems in facilitating medication errors. JAMA. 2005;293(10):1197-1203

For physicians, computerized physician order entry (CPOE) has become an important topic of discussion as many hospitals and health systems embark on the complex and lengthy process of implementing new enterprise clinical systems. Though there are undoubtedly benefits to such systems, practicing clinicians are apt to remain skeptical of the grandiose pictures the more vocal advocates of CPOE may paint. This is not to say that the promises of CPOE are empty; to the contrary, there have been substantial successes, notably in the realm of medication error prevention.

At the same time, CPOE is a mixture of complex technologies that interface in complicated ways with the culture of clinical medicine. The view that medical informatics is a technical problem that has been solved long ago is simplistic and naïve. The article by Koppel, et al, has two important implications: 1) It is critical to look at clinical information systems in the social milieu in which it functions, and 2) there are often unintended consequences that may not beneficial.

This article examines a widely used, commercial CPOE system in use at the University of Pennsylvania (Philadelphia) using both quantitative and qualitative methods. The researchers conducted focus groups and expert interviews in addition to field observations of physicians (house officers and attendings), nurses, and pharmacists in order to identify themes relating to work with the order entry system. This work helped to guide the creation of a survey instrument subsequently used to survey house staff about working conditions and sources of error and stress. There was an 85%-90% response rate that primarily included house staff who ordered more than nine medication orders per month.

Researchers found two broad categories of errors that were fostered in this environment. The first category, which they termed “information errors” were generated by fragmentation of data and the failure to integrate the hospitals various systems both electronic and paper. Examples of this type of error include antibiotic renewal failures. A common way this failure would occur is that renewal reminder stickers would be placed in the patients’ charts, but the house staff would overlook these because medication orders occurred electronically. Another example is assumed dose errors, where house staff would assume that the default dose displayed was the recommended starting dose, when in fact this was the smallest dose unit available. Physicians were assuming decision support was available when it was not.

The second type of error, human-machine interface flaws, occurred when machine rules did not correspond to work behaviors. An example of this is when patients were listed alphabetically rather than by service, making it easy to select the wrong patient. In another instance, many screens (up to 20) were required to view all of a patient’s medications, making it difficult to choose a correct medication for editing.

This study has been criticized by industry advocates for focusing on an older set of technologies or because a number of these issues related to training or “user factors.” At the other extreme, this study has been cited as a cautionary tale about the risks of CPOE. Both types of criticism miss the point. This study demonstrates that CPOE and the social environment in which it sits is a complex entity and that careful design, proper support, and maintenance are critical ingredients to the success of an incredibly complex but vital new component of hospital medicine.

Point-of-Care HIV Testing in Inpatients

Lubelchek R, Kroc K, Hota B, et al. The role of rapid vs conventional human immunodeficiency virus testing for inpatients: effects on quality of care. Arch Intern Med. 2005;165:1956-1960.

Despite advances in treatment, infection with HIV and AIDS remains a public health problem in the United States. According to the CDC the rate of new diagnosis of HIV infection has remained steady from 2000 to 2003 at about 20 per 100,000 people. (Centers for Disease Control and Prevention. Diagnosis of HIV/AIDS–32 states, 2009-2003. MMWR Morb Mortal Wkly Rep. 2004;53:1106-1110). Currently, about 850,000 to 950,000 people are believed to be living with HIV infection, and it is estimated that 180,000 to 280,000 are unaware of their diagnosis. (Fleming P, Byers RH, Sweeney PA, et al., HIV prevalence in the United States, 2000 [Abstract 11]. Presented at the Ninth Conference on Retroviruses and Opportunistic Infections, Seattle; February 24–28, 2002). These patients are not only at risk for disease progression, but can undermine efforts at disease prevention if they continue to engage in unsafe activities. Thus, increasing awareness of HIV status is an important aspect of disease prevention.

HIV testing remains a challenge. Conventional testing with enzyme immunoassay (EIA) and confirmatory Western blot requires patient follow-up for results, which approximately 25% of patients in various outpatient testing sites fail to do. (Centers for Disease Control and Prevention. Update: HIV counseling and testing using rapid tests, United States, 1995. MMWR Morb Mortal Wkly Rep. 1998;47:211-215). Given the difficulties inherent in the transition of care from the inpatient to outpatient setting, conventional testing in the inpatient setting presents additional barriers to appropriate notification. As various point-of-care HIV tests have been developed for commercial use, the possibility of rapid HIV testing presents an opportunity to reduce notification failure and improve patient care. While not replacing traditional testing, the CDC has endorsed rapid HIV testing as a means to initiate therapy and provide counseling with a particular focus on preventing further disease transmission. In this retrospective study, Lubelchek and colleagues present the effects of a rapid HIV test utilized in the emergency department on various inpatient quality of care measures for those patients who received a positive rapid HIV test later confirmed by Western blot as compared with those patients who were diagnosed after admission by traditional diagnostic methods. This study took place in the context of CDC-funded study of the use of OraQuick (OraSure Technologies, Bethlehem, Pa.) rapid HIV testing in the emergency department at Cook County Hospital in Chicago.

The manufacturer claims the product has a sensitivity of 99.6% and a specificity of 100% as compared with conventional testing. (OraQuick rapid HIV-1 antibody test summary of safety and effectiveness. November 7, 2002. Accessed October 1, 2005, at www.fda.gov/cber/pma/P010047.htm). In the initial study, two of the three emergency department’s treatment pods were equipped to provide HIV screening utilizing the point-of-care technology to consenting patients. Patients in the third pod could be referred to rapid testing based on symptoms or risk factors. All patients who received the rapid test also submitted specimens for conventional EIA and confirmatory Western blot testing. All positive rapid HIV tests were confirmed by Western blot.

In this study, patients who were not known to be infected and were subsequently admitted on non-obstetric or surgical services over 17 months from 2003 to 2004 and confirmed to be HIV positive by Western blot were identified utilizing administrative records. Where possible, charts were reviewed to confirm no prior diagnosis of HIV. Patients who received rapid HIV testing were compared with those who only received conventional testing. Endpoints included time to primary inpatient care service awareness of HIV diagnosis, time to admission or transfer to the inpatient HIV service, time to empiric treatment of diagnosis of opportunistic infection, length of stay, discharge with appropriate prophylactic medications, discharge with patient knowledge of HIV diagnosis, and initial engagement in outpatient care. Length of stay was adjusted by multivariate regression on co-morbid diagnoses (congestive heart failure, end-stage renal disease, cirrhosis, chronic obstructive pulmonary disease, and diabetes), opportunistic infections, ICU admission, need for mechanical ventilation, and CD4 count.

A total of 103 patients were identified with complete chart review completed on 86 of them. All patients except one were admitted through the emergency department. Forty-eight patients were diagnosed initially with the rapid HIV test with 58% of these specifically referred for testing by the emergency department physician, and 55 were diagnosed with conventional testing. Overall, 78% were male, 62% African American, and 20% Hispanic. The two groups were comparable in terms of age, sex, ethnicity, history of substance abuse, HIV risk factors, psychiatric diagnoses, homelessness, CD4 count, presence of opportunistic infections, mechanical ventilation, and co-morbidities. However, conventionally tested patients were more likely to require an ICU stay (31% vs. 10%, P=.01).

Patients in the rapid test group were more quickly documented in the chart as having HIV (.8 vs. 6.4 days, p<.001), placed on an HIV service sooner (1.4 versus 6.9 days, P<.001), initiated outpatient follow-up sooner (21.5 versus 49.5 days, p=.05), and had less unawareness of their HIV status (0 vs. 16%, P=.002). There was no significant difference between the two groups in time from admission to empiric treatment or diagnosis of an opportunistic infection. Patients who received the rapid test did have a lower length of stay (6.4 versus 13.2 days, P<.001). Although much of this difference was due to higher number of ICU stays in the conventional group, in multivariate analysis conventional testing still increased length of stay significantly, OR 5.4 days (2.5, 8.3).

This study suggests that patients who are tested with rapid HIV testing can lead to more efficient inpatient treatment of the complications of HIV, improved patient awareness of HIV status, and quicker outpatient follow-up. These findings have ramifications not just to the inpatient management of patients with HIV but to general public health efforts to reduce the spread of HIV infection.

Nevertheless, these results must be interpreted with caution. They reflect the experience of one institution situated in an area with a high prevalence of HIV. Some degree of selection bias is suggested by the higher presence of ICU admissions in the conventional testing group. The multivariate analysis attempted to control for confounding factors, but the possibility remains that other unrecognized factors may have influenced results. The authors do note that an analysis of patients in the rapid test group stratified by whether the test was performed for screening or by referral of the physician did not demonstrate a statistically significant difference in length of stay. This finding provides further support that the sicker patients which triggered the rapid test had shorter lengths of stay on account of the rapid test and not simply because they were sicker.

As recognized by the authors, physicians in routine practice rely on surrogate markers of HIV infection, most notably a patient’s CD4 count, and thus it is not surprising that the rapid test did not affect time to empiric treatment or diagnosis of opportunistic infection. If treatment did not differ, then explaining the longer length of stay remains an unexplained puzzle. The fact that the two groups were equally matched socially and psychiatrically leaves open the possibility that it was actual knowledge of the HIV test result—and not its effect on treatment—that drove the longer length of stay.

One possibility not suggested by the authors is that definitive knowledge of HIV status helped to mobilize patient discharge. If there were legitimate concerns of follow-up, physicians may have delayed discharge in order to receive HIV test results. Alternatively, some patients may have resisted discharge until receiving test results and the development of a more concrete plan. It would be interesting to know if the time to follow-up for the two groups would be the same if the 16% who did not know their HIV status at discharge were excluded. This suggests that knowledge of HIV status drives follow-up time and would lend some support to the notion that patient discharge was delayed for test results and clarification of the follow-up treatment plan.

Even putting aside the difference in length of stay, the difference of rapid testing on improved knowledge of HIV status and quicker follow-up is likely real and meaningful. Although this study was not designed to assess the impact of this knowledge on patient behavior, immediate knowledge of HIV status during hospitalization may translate to decreased transmission as patients alter their behavior and lends further credibility to the utility of rapid HIV testing in conjunction with conventional methods in the management of inpatients. TH