HM17

Presenters

Samir Shah, MD, MSCE

Session summary

Antibiotic stewardship is more than narrowing coverage once susceptibilities are available. It also means conversion of antibiotics to oral therapy when clinically appropriate.

Previously, many childhood infections were treated with IV therapy due to severity or concern that oral absorption delayed or limited response. Multiple studies have shown that early conversion is not only safe, but safer than prolonging IV therapy. At HM 17, we had the opportunity to hear from Samir Shah, MD, about the current literature that supports safe transitions to oral therapy, including the “when” and the “how.”

Terminology for conversion to oral therapy should not state that it is “step-down” therapy, but rather switch therapy or sequential therapy. This conversion reduces likelihood of treatment complications, reduces length of hospital stay, reduces nursing and pharmacy time, decreases discomfort for the patient, and reduces cost.

Antibiotics such as levofloxacin, clindamycin, ciprofloxacin, and metronidazole have excellent bioavailability when taken orally. Other commonly used IV medications such as ampicillin, ampicillin-sulbactam, and cefazolin can be substituted with amoxicillin, amoxicillin-clavulanate, and cephalexin, which have similar penetration characteristics.

In general, unless there are serious complications, such as endocarditis and meningitis, most patients should be switched to oral therapy as soon as clinically warranted to complete therapy. For example, the incidence of meningitis in patients less than 1 month of age with UTI is 1%-2% and the incidence of meningitis in those 1-2 months of age is 0.3%-0.5%. Therefore, these patients can be treated with oral therapy earlier in their course when meningitis is not suspected. The likelihood of endocarditis in a pediatric patient without a known heart lesion is very low, even in patients with repeat positive blood cultures, unlike our adult colleagues who have much higher incidence of endocarditis in bacteremic patients.

Further studies are emerging to help reduce total length of therapy for many bacterial infections. For example, good evidence now exists that skin and soft tissue infections can now be treated safely with 5-day courses.

Key takeaways for HM

• Transition to oral therapy earlier in the hospital course is justified and much safer than IV therapy.

• Conversion to oral antibiotic therapy reduces the likelihood of treatment complications, length of hospital stay, nursing time, pharmacy time, discomfort to the patient, and costs.

• Do not use the term “step-down” when referencing a transition to oral therapy.

• Oral therapy is effective in most bacterial infections in children except for meningitis and endocarditis.

• Levofloxacin, clindamycin, ciprofloxacin, and metronidazole have excellent bioavailability when taken orally and can be easily swapped for IV therapy.

Dr. Schwenk is a pediatric hospitalist at Norton Children’s Hospital and associate professor of pediatrics at the University of Louisville (Ky.), and a member of the Pediatrics Committee for SHM.

Presenters

Samir Shah, MD, MSCE

Session summary

Antibiotic stewardship is more than narrowing coverage once susceptibilities are available. It also means conversion of antibiotics to oral therapy when clinically appropriate.

Previously, many childhood infections were treated with IV therapy due to severity or concern that oral absorption delayed or limited response. Multiple studies have shown that early conversion is not only safe, but safer than prolonging IV therapy. At HM 17, we had the opportunity to hear from Samir Shah, MD, about the current literature that supports safe transitions to oral therapy, including the “when” and the “how.”

Terminology for conversion to oral therapy should not state that it is “step-down” therapy, but rather switch therapy or sequential therapy. This conversion reduces likelihood of treatment complications, reduces length of hospital stay, reduces nursing and pharmacy time, decreases discomfort for the patient, and reduces cost.

Antibiotics such as levofloxacin, clindamycin, ciprofloxacin, and metronidazole have excellent bioavailability when taken orally. Other commonly used IV medications such as ampicillin, ampicillin-sulbactam, and cefazolin can be substituted with amoxicillin, amoxicillin-clavulanate, and cephalexin, which have similar penetration characteristics.

In general, unless there are serious complications, such as endocarditis and meningitis, most patients should be switched to oral therapy as soon as clinically warranted to complete therapy. For example, the incidence of meningitis in patients less than 1 month of age with UTI is 1%-2% and the incidence of meningitis in those 1-2 months of age is 0.3%-0.5%. Therefore, these patients can be treated with oral therapy earlier in their course when meningitis is not suspected. The likelihood of endocarditis in a pediatric patient without a known heart lesion is very low, even in patients with repeat positive blood cultures, unlike our adult colleagues who have much higher incidence of endocarditis in bacteremic patients.

Further studies are emerging to help reduce total length of therapy for many bacterial infections. For example, good evidence now exists that skin and soft tissue infections can now be treated safely with 5-day courses.

Key takeaways for HM

• Transition to oral therapy earlier in the hospital course is justified and much safer than IV therapy.

• Conversion to oral antibiotic therapy reduces the likelihood of treatment complications, length of hospital stay, nursing time, pharmacy time, discomfort to the patient, and costs.

• Do not use the term “step-down” when referencing a transition to oral therapy.

• Oral therapy is effective in most bacterial infections in children except for meningitis and endocarditis.

• Levofloxacin, clindamycin, ciprofloxacin, and metronidazole have excellent bioavailability when taken orally and can be easily swapped for IV therapy.

Dr. Schwenk is a pediatric hospitalist at Norton Children’s Hospital and associate professor of pediatrics at the University of Louisville (Ky.), and a member of the Pediatrics Committee for SHM.

Presenters

Samir Shah, MD, MSCE

Session summary

Antibiotic stewardship is more than narrowing coverage once susceptibilities are available. It also means conversion of antibiotics to oral therapy when clinically appropriate.

Previously, many childhood infections were treated with IV therapy due to severity or concern that oral absorption delayed or limited response. Multiple studies have shown that early conversion is not only safe, but safer than prolonging IV therapy. At HM 17, we had the opportunity to hear from Samir Shah, MD, about the current literature that supports safe transitions to oral therapy, including the “when” and the “how.”

Terminology for conversion to oral therapy should not state that it is “step-down” therapy, but rather switch therapy or sequential therapy. This conversion reduces likelihood of treatment complications, reduces length of hospital stay, reduces nursing and pharmacy time, decreases discomfort for the patient, and reduces cost.

Antibiotics such as levofloxacin, clindamycin, ciprofloxacin, and metronidazole have excellent bioavailability when taken orally. Other commonly used IV medications such as ampicillin, ampicillin-sulbactam, and cefazolin can be substituted with amoxicillin, amoxicillin-clavulanate, and cephalexin, which have similar penetration characteristics.

In general, unless there are serious complications, such as endocarditis and meningitis, most patients should be switched to oral therapy as soon as clinically warranted to complete therapy. For example, the incidence of meningitis in patients less than 1 month of age with UTI is 1%-2% and the incidence of meningitis in those 1-2 months of age is 0.3%-0.5%. Therefore, these patients can be treated with oral therapy earlier in their course when meningitis is not suspected. The likelihood of endocarditis in a pediatric patient without a known heart lesion is very low, even in patients with repeat positive blood cultures, unlike our adult colleagues who have much higher incidence of endocarditis in bacteremic patients.

Further studies are emerging to help reduce total length of therapy for many bacterial infections. For example, good evidence now exists that skin and soft tissue infections can now be treated safely with 5-day courses.

Key takeaways for HM

• Transition to oral therapy earlier in the hospital course is justified and much safer than IV therapy.

• Conversion to oral antibiotic therapy reduces the likelihood of treatment complications, length of hospital stay, nursing time, pharmacy time, discomfort to the patient, and costs.

• Do not use the term “step-down” when referencing a transition to oral therapy.

• Oral therapy is effective in most bacterial infections in children except for meningitis and endocarditis.

• Levofloxacin, clindamycin, ciprofloxacin, and metronidazole have excellent bioavailability when taken orally and can be easily swapped for IV therapy.

Dr. Schwenk is a pediatric hospitalist at Norton Children’s Hospital and associate professor of pediatrics at the University of Louisville (Ky.), and a member of the Pediatrics Committee for SHM.

Presenters

Gaby Berger, MD; Aaron Hamilton, MD, FHM; Christopher Kim, MD, SFHM; Eduardo Margo, MD; Vikas Parekh, MD, FACP, SFHM; Anneliese Schleyer, MD, SFHM; Emily Wang, MD

Session Summary

This HM17 workshop brought together academic and community hospitalists to share effective strategies for improving hospital patient flow.

Key takeaways for HM

• Expedited discharge: Identify patients who can be safely discharged before noon. Consider creating standard work to ensure that key steps in discharge planning process, such as completion of medication reconciliation and discharge instructions and communication with patient and families and the interdisciplinary team, occur the day prior to discharge.
• Length of stay reduction strategies: Partner with utilization management to identify and develop a strategy to actively manage patients with long length of stay. Several institutions have set up committees to review such cases and address barriers, escalating requests for resources to executive leadership as needed.
• Facilitate transfers: Develop a standard process that is streamlined and patient-centered and includes established criteria for deciding whether interhospital transfers are appropriate.
• Short Stay Units: Some hospitals have had success with hospitalist-run short stay units as a strategy to decrease length of stay in observation patients. This strategy is most ideal for patients with a predictable length of stay. If you are thinking of starting an observation unit at your hospital, consider establishing criteria and protocols to expedite care.
• Hospitalist Quarterback: Given their broad perspective and clinical knowledge, hospitalists are uniquely positioned to help manage hospital, and even system-wide, capacity in real time. Some hospitals have successfully employed this strategy in some form to improve throughput. However, hospitalists need tools to help them electronically track incoming patients, integration with utilization management resources, and support from executive leadership to be successful.

Dr. Stella is a hospitalist in Denver and an editorial board member of The Hospitalist.

Presenters

Gaby Berger, MD; Aaron Hamilton, MD, FHM; Christopher Kim, MD, SFHM; Eduardo Margo, MD; Vikas Parekh, MD, FACP, SFHM; Anneliese Schleyer, MD, SFHM; Emily Wang, MD

Session Summary

This HM17 workshop brought together academic and community hospitalists to share effective strategies for improving hospital patient flow.

Key takeaways for HM

• Expedited discharge: Identify patients who can be safely discharged before noon. Consider creating standard work to ensure that key steps in discharge planning process, such as completion of medication reconciliation and discharge instructions and communication with patient and families and the interdisciplinary team, occur the day prior to discharge.
• Length of stay reduction strategies: Partner with utilization management to identify and develop a strategy to actively manage patients with long length of stay. Several institutions have set up committees to review such cases and address barriers, escalating requests for resources to executive leadership as needed.
• Facilitate transfers: Develop a standard process that is streamlined and patient-centered and includes established criteria for deciding whether interhospital transfers are appropriate.
• Short Stay Units: Some hospitals have had success with hospitalist-run short stay units as a strategy to decrease length of stay in observation patients. This strategy is most ideal for patients with a predictable length of stay. If you are thinking of starting an observation unit at your hospital, consider establishing criteria and protocols to expedite care.
• Hospitalist Quarterback: Given their broad perspective and clinical knowledge, hospitalists are uniquely positioned to help manage hospital, and even system-wide, capacity in real time. Some hospitals have successfully employed this strategy in some form to improve throughput. However, hospitalists need tools to help them electronically track incoming patients, integration with utilization management resources, and support from executive leadership to be successful.

Dr. Stella is a hospitalist in Denver and an editorial board member of The Hospitalist.

Presenters

Gaby Berger, MD; Aaron Hamilton, MD, FHM; Christopher Kim, MD, SFHM; Eduardo Margo, MD; Vikas Parekh, MD, FACP, SFHM; Anneliese Schleyer, MD, SFHM; Emily Wang, MD

Session Summary

This HM17 workshop brought together academic and community hospitalists to share effective strategies for improving hospital patient flow.

Key takeaways for HM

• Expedited discharge: Identify patients who can be safely discharged before noon. Consider creating standard work to ensure that key steps in discharge planning process, such as completion of medication reconciliation and discharge instructions and communication with patient and families and the interdisciplinary team, occur the day prior to discharge.
• Length of stay reduction strategies: Partner with utilization management to identify and develop a strategy to actively manage patients with long length of stay. Several institutions have set up committees to review such cases and address barriers, escalating requests for resources to executive leadership as needed.
• Facilitate transfers: Develop a standard process that is streamlined and patient-centered and includes established criteria for deciding whether interhospital transfers are appropriate.
• Short Stay Units: Some hospitals have had success with hospitalist-run short stay units as a strategy to decrease length of stay in observation patients. This strategy is most ideal for patients with a predictable length of stay. If you are thinking of starting an observation unit at your hospital, consider establishing criteria and protocols to expedite care.
• Hospitalist Quarterback: Given their broad perspective and clinical knowledge, hospitalists are uniquely positioned to help manage hospital, and even system-wide, capacity in real time. Some hospitals have successfully employed this strategy in some form to improve throughput. However, hospitalists need tools to help them electronically track incoming patients, integration with utilization management resources, and support from executive leadership to be successful.

Dr. Stella is a hospitalist in Denver and an editorial board member of The Hospitalist.

Presenter

Neal Birnbaum, MD

Session Summary

Dr. Birnbaum began with the differential diagnosis of acute monoarthritis, which is one of the more common reasons for inpatient rheumatology consultation and includes crystalline (e.g., gout), septic, autoimmune (psoriasis), traumatic, and hemorrhagic.

The synovial fluid will give an idea as to whether one is more likely than the other, he said. Normal synovial fluid is transparent, clear, has a low cell count, and is very viscous in nature. Noninflammatory etiologies (osteoarthritis) will have some cells but will largely be similar to normal synovial fluid. Inflammatory causes will have higher cell counts (2-10K WBC) but will have much lower viscosity. Septic joints will look pustular with very high cell counts (sometimes too high to be recorded) and will be positive on fluid culture (unless the patient has already received antimicrobial therapy). Hemorrhagic fluid will look like blood, and the history will give clues as to whether that is the case (recent trauma, history of hemophilia).

Key takeaways for HM

• Know the differential diagnosis of acute monoarticular arthritis and how the synovial fluid will vary depending on the diagnosis.
• Gout can manifest in other joints besides the first toe. One can use allopurinol even in the acute setting. The goal is to attain a uric acid level of less than 6.0.
• Pseudogout should be considered in patients older than 70 years with acute arthritis. There is no allopurinol equivalent for chronic management.
• Positive ANAs are common, but they do not make the diagnosis of SLE (although a negative ANA generally does rule out SLE).
• SLE is a clinical diagnosis that requires multiple symptoms and findings to make the diagnosis. Please refer to the ACR classification criteria.
• Think of vasculitis in terms of small versus large vessel disease and think of the differential diagnosis as to the etiology (realizing that 33%-50% will end up being idiopathic).
• Chikungunya is mosquito-borne and associated with severe joint pains, headaches, and fevers but can also have joint swelling. While often acute, the symptoms can last for up to a year. Treatment is symptomatic management.
• Think of IgG4-related disease in patients with pancreatitis without the usual causes (alcohol, gallstones). Diagnosis is based on pathology and IgG4 levels. Treatment is with steroids and/or rituximab.

Dr. Kim is a hospitalist who works at Emory University Hospital in Atlanta and is an editorial board member of The Hospitalist.

Presenter

Neal Birnbaum, MD

Session Summary

Dr. Birnbaum began with the differential diagnosis of acute monoarthritis, which is one of the more common reasons for inpatient rheumatology consultation and includes crystalline (e.g., gout), septic, autoimmune (psoriasis), traumatic, and hemorrhagic.

The synovial fluid will give an idea as to whether one is more likely than the other, he said. Normal synovial fluid is transparent, clear, has a low cell count, and is very viscous in nature. Noninflammatory etiologies (osteoarthritis) will have some cells but will largely be similar to normal synovial fluid. Inflammatory causes will have higher cell counts (2-10K WBC) but will have much lower viscosity. Septic joints will look pustular with very high cell counts (sometimes too high to be recorded) and will be positive on fluid culture (unless the patient has already received antimicrobial therapy). Hemorrhagic fluid will look like blood, and the history will give clues as to whether that is the case (recent trauma, history of hemophilia).

Key takeaways for HM

• Know the differential diagnosis of acute monoarticular arthritis and how the synovial fluid will vary depending on the diagnosis.
• Gout can manifest in other joints besides the first toe. One can use allopurinol even in the acute setting. The goal is to attain a uric acid level of less than 6.0.
• Pseudogout should be considered in patients older than 70 years with acute arthritis. There is no allopurinol equivalent for chronic management.
• Positive ANAs are common, but they do not make the diagnosis of SLE (although a negative ANA generally does rule out SLE).
• SLE is a clinical diagnosis that requires multiple symptoms and findings to make the diagnosis. Please refer to the ACR classification criteria.
• Think of vasculitis in terms of small versus large vessel disease and think of the differential diagnosis as to the etiology (realizing that 33%-50% will end up being idiopathic).
• Chikungunya is mosquito-borne and associated with severe joint pains, headaches, and fevers but can also have joint swelling. While often acute, the symptoms can last for up to a year. Treatment is symptomatic management.
• Think of IgG4-related disease in patients with pancreatitis without the usual causes (alcohol, gallstones). Diagnosis is based on pathology and IgG4 levels. Treatment is with steroids and/or rituximab.

Dr. Kim is a hospitalist who works at Emory University Hospital in Atlanta and is an editorial board member of The Hospitalist.

Presenter

Neal Birnbaum, MD

Session Summary

Dr. Birnbaum began with the differential diagnosis of acute monoarthritis, which is one of the more common reasons for inpatient rheumatology consultation and includes crystalline (e.g., gout), septic, autoimmune (psoriasis), traumatic, and hemorrhagic.

The synovial fluid will give an idea as to whether one is more likely than the other, he said. Normal synovial fluid is transparent, clear, has a low cell count, and is very viscous in nature. Noninflammatory etiologies (osteoarthritis) will have some cells but will largely be similar to normal synovial fluid. Inflammatory causes will have higher cell counts (2-10K WBC) but will have much lower viscosity. Septic joints will look pustular with very high cell counts (sometimes too high to be recorded) and will be positive on fluid culture (unless the patient has already received antimicrobial therapy). Hemorrhagic fluid will look like blood, and the history will give clues as to whether that is the case (recent trauma, history of hemophilia).

Key takeaways for HM

• Know the differential diagnosis of acute monoarticular arthritis and how the synovial fluid will vary depending on the diagnosis.
• Gout can manifest in other joints besides the first toe. One can use allopurinol even in the acute setting. The goal is to attain a uric acid level of less than 6.0.
• Pseudogout should be considered in patients older than 70 years with acute arthritis. There is no allopurinol equivalent for chronic management.
• Positive ANAs are common, but they do not make the diagnosis of SLE (although a negative ANA generally does rule out SLE).
• SLE is a clinical diagnosis that requires multiple symptoms and findings to make the diagnosis. Please refer to the ACR classification criteria.
• Think of vasculitis in terms of small versus large vessel disease and think of the differential diagnosis as to the etiology (realizing that 33%-50% will end up being idiopathic).
• Chikungunya is mosquito-borne and associated with severe joint pains, headaches, and fevers but can also have joint swelling. While often acute, the symptoms can last for up to a year. Treatment is symptomatic management.
• Think of IgG4-related disease in patients with pancreatitis without the usual causes (alcohol, gallstones). Diagnosis is based on pathology and IgG4 levels. Treatment is with steroids and/or rituximab.

Dr. Kim is a hospitalist who works at Emory University Hospital in Atlanta and is an editorial board member of The Hospitalist.

Presenters

Tracy Cardin, ACNP, SFHM ; Emilie Thornhill, PA-C
 

Session summary

The Nurse Practitioner and Physician Assistant (NP/PA) special interest forum at HM17 drew more than 60 providers, including NPs, PAs, and physicians.

Emilie Thornhill, a certified PA and chair of the NP/PA Committee, and Tracy Cardin, SHM board member, updated the attendees regarding the work of the NP/PA committee over the last year. The committee has created a comprehensive “NP/PA Toolkit,” which was developed over the last 2 years in response to common inquiries about deployment and integration of NPs and PAs into Hospital Medicine practice groups.

• Benchmarking Surveys related to NP/PA burnout, including aspects of protected time, engagement, and workload; scheduling and deployment models; and NP/PA designation as faculty or staff.
• Increased utilization and engagement with HMX as a platform for sharing ideas and success stories to increase HM NP/PA visibility.
• Creation of a “Bizarre Bylaws Blog” to disseminate best practices and improve hospital bylaws through innovative storytelling of antiquated bylaws.
• Improved NP and PA participation and engagement with local chapters.

Key takeaways for HM

• An NP/PA Toolkit resource to be posted on the SHM website.
• The NP/PA committee will transition to a Special Interest Group over the next year.
• Hospital Medicine Exchange (HMX) engagement and participation are encouraged.
• An “Implementation and Optimization Project” to help improve workforce development is pending for the coming year.

Nicolas Houghton is an NP hospitalist in Cleveland and an editorial board member of The Hospitalist.

Presenters

Tracy Cardin, ACNP, SFHM ; Emilie Thornhill, PA-C
 

Session summary

The Nurse Practitioner and Physician Assistant (NP/PA) special interest forum at HM17 drew more than 60 providers, including NPs, PAs, and physicians.

Emilie Thornhill, a certified PA and chair of the NP/PA Committee, and Tracy Cardin, SHM board member, updated the attendees regarding the work of the NP/PA committee over the last year. The committee has created a comprehensive “NP/PA Toolkit,” which was developed over the last 2 years in response to common inquiries about deployment and integration of NPs and PAs into Hospital Medicine practice groups.

• Benchmarking Surveys related to NP/PA burnout, including aspects of protected time, engagement, and workload; scheduling and deployment models; and NP/PA designation as faculty or staff.
• Increased utilization and engagement with HMX as a platform for sharing ideas and success stories to increase HM NP/PA visibility.
• Creation of a “Bizarre Bylaws Blog” to disseminate best practices and improve hospital bylaws through innovative storytelling of antiquated bylaws.
• Improved NP and PA participation and engagement with local chapters.

Key takeaways for HM

• An NP/PA Toolkit resource to be posted on the SHM website.
• The NP/PA committee will transition to a Special Interest Group over the next year.
• Hospital Medicine Exchange (HMX) engagement and participation are encouraged.
• An “Implementation and Optimization Project” to help improve workforce development is pending for the coming year.

Nicolas Houghton is an NP hospitalist in Cleveland and an editorial board member of The Hospitalist.

Presenters

Tracy Cardin, ACNP, SFHM ; Emilie Thornhill, PA-C
 

Session summary

The Nurse Practitioner and Physician Assistant (NP/PA) special interest forum at HM17 drew more than 60 providers, including NPs, PAs, and physicians.

Emilie Thornhill, a certified PA and chair of the NP/PA Committee, and Tracy Cardin, SHM board member, updated the attendees regarding the work of the NP/PA committee over the last year. The committee has created a comprehensive “NP/PA Toolkit,” which was developed over the last 2 years in response to common inquiries about deployment and integration of NPs and PAs into Hospital Medicine practice groups.

• Benchmarking Surveys related to NP/PA burnout, including aspects of protected time, engagement, and workload; scheduling and deployment models; and NP/PA designation as faculty or staff.
• Increased utilization and engagement with HMX as a platform for sharing ideas and success stories to increase HM NP/PA visibility.
• Creation of a “Bizarre Bylaws Blog” to disseminate best practices and improve hospital bylaws through innovative storytelling of antiquated bylaws.
• Improved NP and PA participation and engagement with local chapters.

Key takeaways for HM

• An NP/PA Toolkit resource to be posted on the SHM website.
• The NP/PA committee will transition to a Special Interest Group over the next year.
• Hospital Medicine Exchange (HMX) engagement and participation are encouraged.
• An “Implementation and Optimization Project” to help improve workforce development is pending for the coming year.

Nicolas Houghton is an NP hospitalist in Cleveland and an editorial board member of The Hospitalist.

Presenter

Timothy Kasprzak, MD, MBA
 

Session summary

“What imaging study should I order for this patient?” is a question that comes up frequently in the hospital. Dr. Kasprzak, the director of abdominopelvic and oncologic imaging at Case Western MetroHealth, Cleveland, offered some practical advice for inpatient clinicians during a rapid-fire session at HM17.

Key takeaways for HM

• Utilize appropriate use criteria (such as offered by the ACR) for choosing the most worthwhile imaging study.

• Give relevant clinical history in your order to help the radiologist narrow the differential (and to help prevent the “clinically correlate” phrase as much as possible).

• Consider the risk/benefit of contrast use for all patients getting CT or MRI studies.

• Avoid the use of inpatient PET scans, except for very specific indications (such as obscure infections).

Dr. Sehgal is a hospitalist at the South Texas Veterans Health Care System in San Antonio, an associate professor of medicine at University of Texas Health-San Antonio, and a an editorial board member of The Hospitalist.

Presenter

Timothy Kasprzak, MD, MBA
 

Session summary

“What imaging study should I order for this patient?” is a question that comes up frequently in the hospital. Dr. Kasprzak, the director of abdominopelvic and oncologic imaging at Case Western MetroHealth, Cleveland, offered some practical advice for inpatient clinicians during a rapid-fire session at HM17.

Key takeaways for HM

• Utilize appropriate use criteria (such as offered by the ACR) for choosing the most worthwhile imaging study.

• Give relevant clinical history in your order to help the radiologist narrow the differential (and to help prevent the “clinically correlate” phrase as much as possible).

• Consider the risk/benefit of contrast use for all patients getting CT or MRI studies.

• Avoid the use of inpatient PET scans, except for very specific indications (such as obscure infections).

Dr. Sehgal is a hospitalist at the South Texas Veterans Health Care System in San Antonio, an associate professor of medicine at University of Texas Health-San Antonio, and a an editorial board member of The Hospitalist.

Presenter

Timothy Kasprzak, MD, MBA
 

Session summary

“What imaging study should I order for this patient?” is a question that comes up frequently in the hospital. Dr. Kasprzak, the director of abdominopelvic and oncologic imaging at Case Western MetroHealth, Cleveland, offered some practical advice for inpatient clinicians during a rapid-fire session at HM17.

Key takeaways for HM

• Utilize appropriate use criteria (such as offered by the ACR) for choosing the most worthwhile imaging study.

• Give relevant clinical history in your order to help the radiologist narrow the differential (and to help prevent the “clinically correlate” phrase as much as possible).

• Consider the risk/benefit of contrast use for all patients getting CT or MRI studies.

• Avoid the use of inpatient PET scans, except for very specific indications (such as obscure infections).

Dr. Sehgal is a hospitalist at the South Texas Veterans Health Care System in San Antonio, an associate professor of medicine at University of Texas Health-San Antonio, and a an editorial board member of The Hospitalist.

Presenters

Shoshana J. Herzig, MD, MPH, and Hillary J. Mosher, MFA, MD, FHM

Summary

The growth in opiate prescribing and associated increases in adverse events has created unique challenges for hospitalists, including how best to assess pain and opiate use disorders and how to safely prescribe opiates during hospitalization and at discharge.

These challenges are compounded by patient and system factors and a paucity of evidence-based guidelines to help guide safe administration of opiates in hospitalized patients. This can mean frustration for hospitalists and harm for patients.

Key takeaways for HM

• When assessing patients’ pain, it is crucial to differentiate between acute and chronic pain (or both) and whether it is nociceptive or neuropathic. Misclassification of pain contributes to inappropriate exposure and escalation of opiate therapy during hospitalization.
• Always consider nonopioid analgesics such as NSAIDs first and pair them with opiates. Studies in a variety of conditions have demonstrated that these are equally, if not more, effective, even for severe pain, such as with renal colic. Reserve opiates for moderate to severe pain.
• Always assess whether the benefits of initiating or continuing opioid therapy outweigh the risks for individual patients. There is no validated tool to predict risk for adverse events and/or opioid abuse disorder but a careful review of patient history can identify established risk factors (such as a history of mental illness or substance abuse disorders, renal impairment, or other comorbidities). In addition, nearly all states now have Prescription Drug Monitoring Programs, and hospitalists should consult these routinely when prescribing opiates.
• Always clearly discuss expectations and risks of opioid therapy, including the potential for development of opioid use disorders with hospitalized patients prior to initiation. Emphasize pain reduction rather than elimination and focus on functional goals such as improved mobility. Also, set expectations for stepping down treatment up front.
• Use the lowest effective dose of immediate-release opioids (preferably oral route) for shortest duration possible. Long acting opiates are associated with increased risk of adverse events, and their initiation should generally be avoided in hospitalized patients with noncancer pain.
• Minimize risk by avoiding concurrent administration of other medications with sedative properties, especially benzodiazepines, which have been found to significantly increase the risk of adverse events, including overdose.
• Recognize that chronic opioid use often begins with treatment of acute pain during hospitalization. Adopt best practice for discharge, including prescribing shorter courses whenever possible, discussing initiation, and changes or modifications in opiate therapy with patients’ primary care provider, and ensure timely postdischarge follow-up. Also consider coprescription of naloxone at discharge for higher risk patients.

Dr. Stella is a hospitalist in Denver and an editorial board member of The Hospitalist.

Presenters

Shoshana J. Herzig, MD, MPH, and Hillary J. Mosher, MFA, MD, FHM

Summary

The growth in opiate prescribing and associated increases in adverse events has created unique challenges for hospitalists, including how best to assess pain and opiate use disorders and how to safely prescribe opiates during hospitalization and at discharge.

These challenges are compounded by patient and system factors and a paucity of evidence-based guidelines to help guide safe administration of opiates in hospitalized patients. This can mean frustration for hospitalists and harm for patients.

Key takeaways for HM

• When assessing patients’ pain, it is crucial to differentiate between acute and chronic pain (or both) and whether it is nociceptive or neuropathic. Misclassification of pain contributes to inappropriate exposure and escalation of opiate therapy during hospitalization.
• Always consider nonopioid analgesics such as NSAIDs first and pair them with opiates. Studies in a variety of conditions have demonstrated that these are equally, if not more, effective, even for severe pain, such as with renal colic. Reserve opiates for moderate to severe pain.
• Always assess whether the benefits of initiating or continuing opioid therapy outweigh the risks for individual patients. There is no validated tool to predict risk for adverse events and/or opioid abuse disorder but a careful review of patient history can identify established risk factors (such as a history of mental illness or substance abuse disorders, renal impairment, or other comorbidities). In addition, nearly all states now have Prescription Drug Monitoring Programs, and hospitalists should consult these routinely when prescribing opiates.
• Always clearly discuss expectations and risks of opioid therapy, including the potential for development of opioid use disorders with hospitalized patients prior to initiation. Emphasize pain reduction rather than elimination and focus on functional goals such as improved mobility. Also, set expectations for stepping down treatment up front.
• Use the lowest effective dose of immediate-release opioids (preferably oral route) for shortest duration possible. Long acting opiates are associated with increased risk of adverse events, and their initiation should generally be avoided in hospitalized patients with noncancer pain.
• Minimize risk by avoiding concurrent administration of other medications with sedative properties, especially benzodiazepines, which have been found to significantly increase the risk of adverse events, including overdose.
• Recognize that chronic opioid use often begins with treatment of acute pain during hospitalization. Adopt best practice for discharge, including prescribing shorter courses whenever possible, discussing initiation, and changes or modifications in opiate therapy with patients’ primary care provider, and ensure timely postdischarge follow-up. Also consider coprescription of naloxone at discharge for higher risk patients.

Dr. Stella is a hospitalist in Denver and an editorial board member of The Hospitalist.

Presenters

Shoshana J. Herzig, MD, MPH, and Hillary J. Mosher, MFA, MD, FHM

Summary

The growth in opiate prescribing and associated increases in adverse events has created unique challenges for hospitalists, including how best to assess pain and opiate use disorders and how to safely prescribe opiates during hospitalization and at discharge.

These challenges are compounded by patient and system factors and a paucity of evidence-based guidelines to help guide safe administration of opiates in hospitalized patients. This can mean frustration for hospitalists and harm for patients.

Key takeaways for HM

• When assessing patients’ pain, it is crucial to differentiate between acute and chronic pain (or both) and whether it is nociceptive or neuropathic. Misclassification of pain contributes to inappropriate exposure and escalation of opiate therapy during hospitalization.
• Always consider nonopioid analgesics such as NSAIDs first and pair them with opiates. Studies in a variety of conditions have demonstrated that these are equally, if not more, effective, even for severe pain, such as with renal colic. Reserve opiates for moderate to severe pain.
• Always assess whether the benefits of initiating or continuing opioid therapy outweigh the risks for individual patients. There is no validated tool to predict risk for adverse events and/or opioid abuse disorder but a careful review of patient history can identify established risk factors (such as a history of mental illness or substance abuse disorders, renal impairment, or other comorbidities). In addition, nearly all states now have Prescription Drug Monitoring Programs, and hospitalists should consult these routinely when prescribing opiates.
• Always clearly discuss expectations and risks of opioid therapy, including the potential for development of opioid use disorders with hospitalized patients prior to initiation. Emphasize pain reduction rather than elimination and focus on functional goals such as improved mobility. Also, set expectations for stepping down treatment up front.
• Use the lowest effective dose of immediate-release opioids (preferably oral route) for shortest duration possible. Long acting opiates are associated with increased risk of adverse events, and their initiation should generally be avoided in hospitalized patients with noncancer pain.
• Minimize risk by avoiding concurrent administration of other medications with sedative properties, especially benzodiazepines, which have been found to significantly increase the risk of adverse events, including overdose.
• Recognize that chronic opioid use often begins with treatment of acute pain during hospitalization. Adopt best practice for discharge, including prescribing shorter courses whenever possible, discussing initiation, and changes or modifications in opiate therapy with patients’ primary care provider, and ensure timely postdischarge follow-up. Also consider coprescription of naloxone at discharge for higher risk patients.

Dr. Stella is a hospitalist in Denver and an editorial board member of The Hospitalist.

LAS VEGAS – Alla Zilbering, MD, sat at attention for hours during HM17, jotting notes like a scribe about the myriad of federal rules that are pretty rapidly pushing hospitalists and health care as a whole away from fee-for-service payments to a world where doctors are paid for quality.

So, why did she do it? Why all that time on policy, instead of practice?

Because Dr. Zilbering felt compelled to get more involved. As a lead hospitalist at Cigna-HealthSpring, a Medicare Advantage program in Philadelphia, she’s already part of initiatives to improve transitions of care and reduce readmissions.

However, she said she wants to do more. “I’m feeling like, unless you actually address the policy, you can’t get that far in terms of what you can physically do with a patient.”

HM17 was the meeting for her, then. SHM, this year, unveiled its first Health Policy Mini Track, dedicated to updating attendees on the implementation of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), the Bundled Payments for Care Improvement initiative, and a host of other federal programs. Hospitalists were updated on a litany of advocacy efforts, including observation status, interoperability of electronic health records systems, and the recent launch of the first hospitalist billing code.

Two of the meeting’s three keynote speakers were Washington veterans who confirmed that, while nightly news reports may suggest that health care reforms contained in the Affordable Care Act are constantly in flux, the trajectory toward paying for higher quality care at lower costs shows no signs of abating.

LAS VEGAS – Alla Zilbering, MD, sat at attention for hours during HM17, jotting notes like a scribe about the myriad of federal rules that are pretty rapidly pushing hospitalists and health care as a whole away from fee-for-service payments to a world where doctors are paid for quality.

So, why did she do it? Why all that time on policy, instead of practice?

Because Dr. Zilbering felt compelled to get more involved. As a lead hospitalist at Cigna-HealthSpring, a Medicare Advantage program in Philadelphia, she’s already part of initiatives to improve transitions of care and reduce readmissions.

However, she said she wants to do more. “I’m feeling like, unless you actually address the policy, you can’t get that far in terms of what you can physically do with a patient.”

HM17 was the meeting for her, then. SHM, this year, unveiled its first Health Policy Mini Track, dedicated to updating attendees on the implementation of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), the Bundled Payments for Care Improvement initiative, and a host of other federal programs. Hospitalists were updated on a litany of advocacy efforts, including observation status, interoperability of electronic health records systems, and the recent launch of the first hospitalist billing code.

Two of the meeting’s three keynote speakers were Washington veterans who confirmed that, while nightly news reports may suggest that health care reforms contained in the Affordable Care Act are constantly in flux, the trajectory toward paying for higher quality care at lower costs shows no signs of abating.

LAS VEGAS – Alla Zilbering, MD, sat at attention for hours during HM17, jotting notes like a scribe about the myriad of federal rules that are pretty rapidly pushing hospitalists and health care as a whole away from fee-for-service payments to a world where doctors are paid for quality.

So, why did she do it? Why all that time on policy, instead of practice?

Because Dr. Zilbering felt compelled to get more involved. As a lead hospitalist at Cigna-HealthSpring, a Medicare Advantage program in Philadelphia, she’s already part of initiatives to improve transitions of care and reduce readmissions.

However, she said she wants to do more. “I’m feeling like, unless you actually address the policy, you can’t get that far in terms of what you can physically do with a patient.”

HM17 was the meeting for her, then. SHM, this year, unveiled its first Health Policy Mini Track, dedicated to updating attendees on the implementation of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), the Bundled Payments for Care Improvement initiative, and a host of other federal programs. Hospitalists were updated on a litany of advocacy efforts, including observation status, interoperability of electronic health records systems, and the recent launch of the first hospitalist billing code.

Two of the meeting’s three keynote speakers were Washington veterans who confirmed that, while nightly news reports may suggest that health care reforms contained in the Affordable Care Act are constantly in flux, the trajectory toward paying for higher quality care at lower costs shows no signs of abating.

LAS VEGAS – Babatunde Akinsete, MD, took a new job about 18 months ago as a lead hospitalist within Adventist Health System of Florida. The role has the expected leadership responsibilities, but those folks he’s now partly supervising are the same ones who used to be his peers.

The same people he spent time “in the trenches” with, complaining about the problems they saw – issues that are now partly his job to help fix.

“It’s tough,” Dr. Akinsete said at the annual meeting of the Society of Hospital Medicine. “How do you motivate people?”

Welcome to managing a practice, circa 2017. The day-to-day doings of an HM group – recruiting, retention, compensation, scheduling and more – are the backbone of the specialty. And SHM’s annual meeting makes the topics a principal point, from a dedicated precourse to dozens of presentations to networking opportunities introducing experienced leaders to nascent ones.

The subject is more relevant than ever these days as the maturing specialty now has three generations of hospitalists practicing side by side, including those who founded the society and laid the groundwork for the specialty some 20 years ago and those who will now infuse it with new blood for the next 20 years, said Jerome Siy, MD, SFHM, an HM17 faculty member and chair of SHM’s Practice Management Committee.

“We’re heading into a cycle of a lot of change,” he said. “Being able to manage change is going to be pretty key.”

The first step in building or bettering a “healthy practice” is building a “culture of ownership,” Dr. Siy said.

“You must have the right culture first if you’re going to tackle any of these issues, whether it’s things like schedules to finances to negotiations,” he added. “Second is this openness and innovation to think outside the box and to allow yourself to hear things that might not work for you. Be open to it because whether you hear something that doesn’t work or not, it may inspire you to figure out … what is the key element you were missing before.”

That’s what Liza Rodriguez Jimenez, MD, is taking away from the meeting. She is moving into a codirector position for her medical group at St. Luke’s in Boise, Idaho. A crash course in alternative-payment models, full-time equivalents (FTEs), relative value units (RVUs) and scheduling was an eye-opener for her.

But to Dr. Siy’s point, it wasn’t the specific examples of how other people do what they do that intrigued Dr. Rodriguez Jimenez. It was more so that people just did it differently.

“It’s just helpful to know that there are other choices,” Dr. Rodriguez Jimenez said. “In other words, why do we do 7 on, 7 off? I don’t know. We just do. If you don’t know that you don’t know, then how do you know to change it? You get exposed to so much stuff here now that you can theoretically go back and say, ‘why do we do 7 on, 7 off? … And then let the group say we want 5 on, 10 off, 4 on, 3 off. Whatever people decide.”

Nasim Afsar, MD, SFHM, chief quality officer of the department of medicine at UCLA Health in Los Angeles, said that idea of just framing the question differently is a big deal, and a leadership skill in and of itself. For example, say a hospital medicine group’s leaders are trying to discuss whether the practice should continue its comanagement focus.

“If you frame a decision as, ‘We are going to lose this comanagement,’ there’s just something, like a gut feeling, you don’t want to lose stuff,” she said. “As opposed to, if you say, ‘Gosh, think about the gains. That we will have all this free time that we now have where we can develop other aspects of our hospital medicine group.’ So when you frame the same exact thing in terms of loss, it becomes so much more difficult for us to actually let go of that.”

Leadership is more than just framing, of course. Dr. Afsar and former SHM president Eric Howell, MD, MHM, said that leadership traits include using standardized processes to make decisions, as well as getting group members involved in those decisions when necessary and using feedback and motivation properly.

But, at day’s end, practice management is managing the needs of your practice.

For Abdul-Hady Kheder, MD, of Hamilton Hospitalists LLC in Central New Jersey, the meeting opened his eyes to techniques he could use to deal with lower reimbursement figures and less patients.

“What can help my situation will be increasing the volume of the practice,” he said. “Right now, we admit 30%-40% of the patients admitted into the hospital. National average is 60%-90% of total hospital admissions. I think that most probably will balance my financial dilemma.”

For Rodney Hollis, practice administrator for Eskenazi Health of Indianapolis, the meeting was a way to glean tips on improving his practice. One nugget he’s excited about: pairing an experienced hospitalist with a new hire for a year. As a nonclinical administrator, Hollis said he views his role as helping clinicians work on the things they are best at, while he handle the rest.

“The more clinical time that the clinical directors can spend, that’s more advantageous to the group,” Hollis said. “Allowing the nonclinical activities to be done by an administrator helps. We want more responsibility and if there’s something that our clinical is doing that I can do, why not have me do it?”

For Dr. Rodriguez Jimenez, open-ended questions like that one are among the most “insightful” takeaways from the meeting.

“There is no right or wrong way, so maybe we’ve been doing it this way ‘just because,’ ” she said. “Now we need to look at it and say, ‘Can we do it a different way? Can we adapt it? Can we change it?’”

She’s starting to sound like a practice manager already.

LAS VEGAS – Babatunde Akinsete, MD, took a new job about 18 months ago as a lead hospitalist within Adventist Health System of Florida. The role has the expected leadership responsibilities, but those folks he’s now partly supervising are the same ones who used to be his peers.

The same people he spent time “in the trenches” with, complaining about the problems they saw – issues that are now partly his job to help fix.

“It’s tough,” Dr. Akinsete said at the annual meeting of the Society of Hospital Medicine. “How do you motivate people?”

Welcome to managing a practice, circa 2017. The day-to-day doings of an HM group – recruiting, retention, compensation, scheduling and more – are the backbone of the specialty. And SHM’s annual meeting makes the topics a principal point, from a dedicated precourse to dozens of presentations to networking opportunities introducing experienced leaders to nascent ones.

The subject is more relevant than ever these days as the maturing specialty now has three generations of hospitalists practicing side by side, including those who founded the society and laid the groundwork for the specialty some 20 years ago and those who will now infuse it with new blood for the next 20 years, said Jerome Siy, MD, SFHM, an HM17 faculty member and chair of SHM’s Practice Management Committee.

“We’re heading into a cycle of a lot of change,” he said. “Being able to manage change is going to be pretty key.”

The first step in building or bettering a “healthy practice” is building a “culture of ownership,” Dr. Siy said.

“You must have the right culture first if you’re going to tackle any of these issues, whether it’s things like schedules to finances to negotiations,” he added. “Second is this openness and innovation to think outside the box and to allow yourself to hear things that might not work for you. Be open to it because whether you hear something that doesn’t work or not, it may inspire you to figure out … what is the key element you were missing before.”

That’s what Liza Rodriguez Jimenez, MD, is taking away from the meeting. She is moving into a codirector position for her medical group at St. Luke’s in Boise, Idaho. A crash course in alternative-payment models, full-time equivalents (FTEs), relative value units (RVUs) and scheduling was an eye-opener for her.

But to Dr. Siy’s point, it wasn’t the specific examples of how other people do what they do that intrigued Dr. Rodriguez Jimenez. It was more so that people just did it differently.

“It’s just helpful to know that there are other choices,” Dr. Rodriguez Jimenez said. “In other words, why do we do 7 on, 7 off? I don’t know. We just do. If you don’t know that you don’t know, then how do you know to change it? You get exposed to so much stuff here now that you can theoretically go back and say, ‘why do we do 7 on, 7 off? … And then let the group say we want 5 on, 10 off, 4 on, 3 off. Whatever people decide.”

Nasim Afsar, MD, SFHM, chief quality officer of the department of medicine at UCLA Health in Los Angeles, said that idea of just framing the question differently is a big deal, and a leadership skill in and of itself. For example, say a hospital medicine group’s leaders are trying to discuss whether the practice should continue its comanagement focus.

“If you frame a decision as, ‘We are going to lose this comanagement,’ there’s just something, like a gut feeling, you don’t want to lose stuff,” she said. “As opposed to, if you say, ‘Gosh, think about the gains. That we will have all this free time that we now have where we can develop other aspects of our hospital medicine group.’ So when you frame the same exact thing in terms of loss, it becomes so much more difficult for us to actually let go of that.”

Leadership is more than just framing, of course. Dr. Afsar and former SHM president Eric Howell, MD, MHM, said that leadership traits include using standardized processes to make decisions, as well as getting group members involved in those decisions when necessary and using feedback and motivation properly.

But, at day’s end, practice management is managing the needs of your practice.

For Abdul-Hady Kheder, MD, of Hamilton Hospitalists LLC in Central New Jersey, the meeting opened his eyes to techniques he could use to deal with lower reimbursement figures and less patients.

“What can help my situation will be increasing the volume of the practice,” he said. “Right now, we admit 30%-40% of the patients admitted into the hospital. National average is 60%-90% of total hospital admissions. I think that most probably will balance my financial dilemma.”

For Rodney Hollis, practice administrator for Eskenazi Health of Indianapolis, the meeting was a way to glean tips on improving his practice. One nugget he’s excited about: pairing an experienced hospitalist with a new hire for a year. As a nonclinical administrator, Hollis said he views his role as helping clinicians work on the things they are best at, while he handle the rest.

“The more clinical time that the clinical directors can spend, that’s more advantageous to the group,” Hollis said. “Allowing the nonclinical activities to be done by an administrator helps. We want more responsibility and if there’s something that our clinical is doing that I can do, why not have me do it?”

For Dr. Rodriguez Jimenez, open-ended questions like that one are among the most “insightful” takeaways from the meeting.

“There is no right or wrong way, so maybe we’ve been doing it this way ‘just because,’ ” she said. “Now we need to look at it and say, ‘Can we do it a different way? Can we adapt it? Can we change it?’”

She’s starting to sound like a practice manager already.

LAS VEGAS – Babatunde Akinsete, MD, took a new job about 18 months ago as a lead hospitalist within Adventist Health System of Florida. The role has the expected leadership responsibilities, but those folks he’s now partly supervising are the same ones who used to be his peers.

The same people he spent time “in the trenches” with, complaining about the problems they saw – issues that are now partly his job to help fix.

“It’s tough,” Dr. Akinsete said at the annual meeting of the Society of Hospital Medicine. “How do you motivate people?”

Welcome to managing a practice, circa 2017. The day-to-day doings of an HM group – recruiting, retention, compensation, scheduling and more – are the backbone of the specialty. And SHM’s annual meeting makes the topics a principal point, from a dedicated precourse to dozens of presentations to networking opportunities introducing experienced leaders to nascent ones.

The subject is more relevant than ever these days as the maturing specialty now has three generations of hospitalists practicing side by side, including those who founded the society and laid the groundwork for the specialty some 20 years ago and those who will now infuse it with new blood for the next 20 years, said Jerome Siy, MD, SFHM, an HM17 faculty member and chair of SHM’s Practice Management Committee.

“We’re heading into a cycle of a lot of change,” he said. “Being able to manage change is going to be pretty key.”

The first step in building or bettering a “healthy practice” is building a “culture of ownership,” Dr. Siy said.

“You must have the right culture first if you’re going to tackle any of these issues, whether it’s things like schedules to finances to negotiations,” he added. “Second is this openness and innovation to think outside the box and to allow yourself to hear things that might not work for you. Be open to it because whether you hear something that doesn’t work or not, it may inspire you to figure out … what is the key element you were missing before.”

That’s what Liza Rodriguez Jimenez, MD, is taking away from the meeting. She is moving into a codirector position for her medical group at St. Luke’s in Boise, Idaho. A crash course in alternative-payment models, full-time equivalents (FTEs), relative value units (RVUs) and scheduling was an eye-opener for her.

But to Dr. Siy’s point, it wasn’t the specific examples of how other people do what they do that intrigued Dr. Rodriguez Jimenez. It was more so that people just did it differently.

“It’s just helpful to know that there are other choices,” Dr. Rodriguez Jimenez said. “In other words, why do we do 7 on, 7 off? I don’t know. We just do. If you don’t know that you don’t know, then how do you know to change it? You get exposed to so much stuff here now that you can theoretically go back and say, ‘why do we do 7 on, 7 off? … And then let the group say we want 5 on, 10 off, 4 on, 3 off. Whatever people decide.”

Nasim Afsar, MD, SFHM, chief quality officer of the department of medicine at UCLA Health in Los Angeles, said that idea of just framing the question differently is a big deal, and a leadership skill in and of itself. For example, say a hospital medicine group’s leaders are trying to discuss whether the practice should continue its comanagement focus.

“If you frame a decision as, ‘We are going to lose this comanagement,’ there’s just something, like a gut feeling, you don’t want to lose stuff,” she said. “As opposed to, if you say, ‘Gosh, think about the gains. That we will have all this free time that we now have where we can develop other aspects of our hospital medicine group.’ So when you frame the same exact thing in terms of loss, it becomes so much more difficult for us to actually let go of that.”

Leadership is more than just framing, of course. Dr. Afsar and former SHM president Eric Howell, MD, MHM, said that leadership traits include using standardized processes to make decisions, as well as getting group members involved in those decisions when necessary and using feedback and motivation properly.

But, at day’s end, practice management is managing the needs of your practice.

For Abdul-Hady Kheder, MD, of Hamilton Hospitalists LLC in Central New Jersey, the meeting opened his eyes to techniques he could use to deal with lower reimbursement figures and less patients.

“What can help my situation will be increasing the volume of the practice,” he said. “Right now, we admit 30%-40% of the patients admitted into the hospital. National average is 60%-90% of total hospital admissions. I think that most probably will balance my financial dilemma.”

For Rodney Hollis, practice administrator for Eskenazi Health of Indianapolis, the meeting was a way to glean tips on improving his practice. One nugget he’s excited about: pairing an experienced hospitalist with a new hire for a year. As a nonclinical administrator, Hollis said he views his role as helping clinicians work on the things they are best at, while he handle the rest.

“The more clinical time that the clinical directors can spend, that’s more advantageous to the group,” Hollis said. “Allowing the nonclinical activities to be done by an administrator helps. We want more responsibility and if there’s something that our clinical is doing that I can do, why not have me do it?”

For Dr. Rodriguez Jimenez, open-ended questions like that one are among the most “insightful” takeaways from the meeting.

“There is no right or wrong way, so maybe we’ve been doing it this way ‘just because,’ ” she said. “Now we need to look at it and say, ‘Can we do it a different way? Can we adapt it? Can we change it?’”

She’s starting to sound like a practice manager already.

Presenter

Ethan Cumbler, MD, FACP, FHM

Session summary

This session was designed to give learners a different paradigm in thinking about the structure and organization of presentations, for a more dynamic and engaging lecture.

Memorable teaching points are tied to a narrative with emotional impact. One study of surgery residents immediately after finishing grand rounds found that learners only remember approximately 10% of the material embedded in a lecture. Therefore, the focus of the lecture should not necessarily be to include a comprehensive amount of information, but to make the major points as “sticky” as possible.

Key takeaways for HM

• Consider the stand-up comedy concept of the “call-back.” Start with a concept, and then return to this concept in different forms through the presentation. One can return to another variation of this for a surprise at the end. One can make a key point memorable by using a theme with multiple variations.
• Think about structure in order to draw listeners into a talk and keep them invested (organizational framework centered around a patient); create a “hook”; think about slides visually, not from a content perspective (that’s what handouts are for); keep the tempo, timing, and volume dynamic; use body language and presence to engage the room.
• If one would like to learn more, consider reading the book Presentation Zen; watch TED talks; practice multiple times to hone various aspects of the talk; give the talk multiple times for iterative improvement; always ask for feedback and try to change at least one thing from one talk to another to continuously improve.

Dr. Kim is a hospitalist who works at Emory University Hospital in Atlanta, and is an editorial board member of The Hospitalist.

Presenter

Ethan Cumbler, MD, FACP, FHM

Session summary

This session was designed to give learners a different paradigm in thinking about the structure and organization of presentations, for a more dynamic and engaging lecture.

Memorable teaching points are tied to a narrative with emotional impact. One study of surgery residents immediately after finishing grand rounds found that learners only remember approximately 10% of the material embedded in a lecture. Therefore, the focus of the lecture should not necessarily be to include a comprehensive amount of information, but to make the major points as “sticky” as possible.

Key takeaways for HM

• Consider the stand-up comedy concept of the “call-back.” Start with a concept, and then return to this concept in different forms through the presentation. One can return to another variation of this for a surprise at the end. One can make a key point memorable by using a theme with multiple variations.
• Think about structure in order to draw listeners into a talk and keep them invested (organizational framework centered around a patient); create a “hook”; think about slides visually, not from a content perspective (that’s what handouts are for); keep the tempo, timing, and volume dynamic; use body language and presence to engage the room.
• If one would like to learn more, consider reading the book Presentation Zen; watch TED talks; practice multiple times to hone various aspects of the talk; give the talk multiple times for iterative improvement; always ask for feedback and try to change at least one thing from one talk to another to continuously improve.

Dr. Kim is a hospitalist who works at Emory University Hospital in Atlanta, and is an editorial board member of The Hospitalist.

Presenter

Ethan Cumbler, MD, FACP, FHM

Session summary

This session was designed to give learners a different paradigm in thinking about the structure and organization of presentations, for a more dynamic and engaging lecture.

Memorable teaching points are tied to a narrative with emotional impact. One study of surgery residents immediately after finishing grand rounds found that learners only remember approximately 10% of the material embedded in a lecture. Therefore, the focus of the lecture should not necessarily be to include a comprehensive amount of information, but to make the major points as “sticky” as possible.

Key takeaways for HM

• Consider the stand-up comedy concept of the “call-back.” Start with a concept, and then return to this concept in different forms through the presentation. One can return to another variation of this for a surprise at the end. One can make a key point memorable by using a theme with multiple variations.
• Think about structure in order to draw listeners into a talk and keep them invested (organizational framework centered around a patient); create a “hook”; think about slides visually, not from a content perspective (that’s what handouts are for); keep the tempo, timing, and volume dynamic; use body language and presence to engage the room.
• If one would like to learn more, consider reading the book Presentation Zen; watch TED talks; practice multiple times to hone various aspects of the talk; give the talk multiple times for iterative improvement; always ask for feedback and try to change at least one thing from one talk to another to continuously improve.

Dr. Kim is a hospitalist who works at Emory University Hospital in Atlanta, and is an editorial board member of The Hospitalist.