Opinion

I first heard the term “discharge before noon” (DCBN) as a third-year medical student starting my internal medicine rotation. The basic idea made sense: Get patients out of the hospital early so rooms can be cleaned more quickly and new patients wouldn’t have to wait so long in the ED.

It quickly became apparent, however, that a lot of moving parts had to align perfectly for DCBN. Even if we prioritized rounding on dischargeable patients (starting 8-9 a.m. depending on the service/day), they still needed prescriptions filled, normal clothes to wear, and a way to get home, which wasn’t easy to coordinate while we were still trying to see all the other patients.

Fast forward through 5 years of residency/fellowship experience and DCBN seems even more unrealistic in hospitalized pediatric patients. As a simple example, discharge criteria for dehydration (one of the most common reasons for pediatric hospitalization) include demonstrating the ability to drink enough liquids to stay hydrated. Who’s going to force children to stay up all night sipping fluids (plus changing all those diapers or taking them to the bathroom)? If the child stays on intravenous fluids overnight, we have to monitor at least through breakfast, likely lunch, thus making DCBN nearly impossible.

In a January 2019 article in the Journal of Hospital Medicine, Hailey James, MHA, (@Haileyjms on Twitter) and her colleagues demonstrated an association between DCBN and decreased length of stay (LOS) for medical but not surgical pediatric discharges.¹ This made them question if DCBN is an appropriate metric for discharge efficiency, as well as workflow differences between services. Many hospitals, however, still try to push DCBN as a goal (see Destino et al in the same January 2019 issue of JHM²), which could potentially lead to people trying to game the system.

How does your institution try to make discharge processes more efficient? Is it actually possible to do everything more quickly without sacrificing quality or trainee education? Whether your patients are kids, adults, or both, there are likely many issues in common where we could all learn from each other.

We discussed this topic in #JHMChat on April 15 on Twitter. New to Twitter or not familiar with #JHMChat? Since October 2015, JHM has reviewed and discussed dozens of articles spanning a wide variety of topics related to caring for hospitalized patients. All are welcome to join, including medical students, residents, nurses, practicing hospitalists, and more. It’s a great opportunity to virtually meet and learn from others while earning free CME.

To participate in future chats, type #JHMChat in the search box on the top right corner of your Twitter homepage, click on the “Latest” tab at the top left to see the most recent tweets, and join the conversation (don’t forget the hashtag)!
 

Dr. Chen is a pediatric hospital medicine fellow at Rady Children’s Hospital, University of California, San Diego. She is one of the cofounders/moderators of #PHMFellowJC, serves as a fellow district representative for the American Academy of Pediatrics, and is an active #tweetiatrician at @DrJenChen4kids. This article appeared originally in SHM's official blog The Hospital Leader. Read more recent posts here.

References

1. James HJ et al. The Association of Discharge Before Noon and Length of Stay in Hospitalized Pediatric Patients. J Hosp Med. 2019;14(1):28-32. doi: 10.12788/jhm.3111.

2. Destino L et al. Improving Patient Flow: Analysis of an Initiative to Improve Early Discharge. J Hosp Med. 2019;14(1):22-7. doi: 10.12788/jhm.3133.

I first heard the term “discharge before noon” (DCBN) as a third-year medical student starting my internal medicine rotation. The basic idea made sense: Get patients out of the hospital early so rooms can be cleaned more quickly and new patients wouldn’t have to wait so long in the ED.

It quickly became apparent, however, that a lot of moving parts had to align perfectly for DCBN. Even if we prioritized rounding on dischargeable patients (starting 8-9 a.m. depending on the service/day), they still needed prescriptions filled, normal clothes to wear, and a way to get home, which wasn’t easy to coordinate while we were still trying to see all the other patients.

Fast forward through 5 years of residency/fellowship experience and DCBN seems even more unrealistic in hospitalized pediatric patients. As a simple example, discharge criteria for dehydration (one of the most common reasons for pediatric hospitalization) include demonstrating the ability to drink enough liquids to stay hydrated. Who’s going to force children to stay up all night sipping fluids (plus changing all those diapers or taking them to the bathroom)? If the child stays on intravenous fluids overnight, we have to monitor at least through breakfast, likely lunch, thus making DCBN nearly impossible.

In a January 2019 article in the Journal of Hospital Medicine, Hailey James, MHA, (@Haileyjms on Twitter) and her colleagues demonstrated an association between DCBN and decreased length of stay (LOS) for medical but not surgical pediatric discharges.¹ This made them question if DCBN is an appropriate metric for discharge efficiency, as well as workflow differences between services. Many hospitals, however, still try to push DCBN as a goal (see Destino et al in the same January 2019 issue of JHM²), which could potentially lead to people trying to game the system.

How does your institution try to make discharge processes more efficient? Is it actually possible to do everything more quickly without sacrificing quality or trainee education? Whether your patients are kids, adults, or both, there are likely many issues in common where we could all learn from each other.

We discussed this topic in #JHMChat on April 15 on Twitter. New to Twitter or not familiar with #JHMChat? Since October 2015, JHM has reviewed and discussed dozens of articles spanning a wide variety of topics related to caring for hospitalized patients. All are welcome to join, including medical students, residents, nurses, practicing hospitalists, and more. It’s a great opportunity to virtually meet and learn from others while earning free CME.

To participate in future chats, type #JHMChat in the search box on the top right corner of your Twitter homepage, click on the “Latest” tab at the top left to see the most recent tweets, and join the conversation (don’t forget the hashtag)!
 

Dr. Chen is a pediatric hospital medicine fellow at Rady Children’s Hospital, University of California, San Diego. She is one of the cofounders/moderators of #PHMFellowJC, serves as a fellow district representative for the American Academy of Pediatrics, and is an active #tweetiatrician at @DrJenChen4kids. This article appeared originally in SHM's official blog The Hospital Leader. Read more recent posts here.

References

1. James HJ et al. The Association of Discharge Before Noon and Length of Stay in Hospitalized Pediatric Patients. J Hosp Med. 2019;14(1):28-32. doi: 10.12788/jhm.3111.

2. Destino L et al. Improving Patient Flow: Analysis of an Initiative to Improve Early Discharge. J Hosp Med. 2019;14(1):22-7. doi: 10.12788/jhm.3133.

I first heard the term “discharge before noon” (DCBN) as a third-year medical student starting my internal medicine rotation. The basic idea made sense: Get patients out of the hospital early so rooms can be cleaned more quickly and new patients wouldn’t have to wait so long in the ED.

It quickly became apparent, however, that a lot of moving parts had to align perfectly for DCBN. Even if we prioritized rounding on dischargeable patients (starting 8-9 a.m. depending on the service/day), they still needed prescriptions filled, normal clothes to wear, and a way to get home, which wasn’t easy to coordinate while we were still trying to see all the other patients.

Fast forward through 5 years of residency/fellowship experience and DCBN seems even more unrealistic in hospitalized pediatric patients. As a simple example, discharge criteria for dehydration (one of the most common reasons for pediatric hospitalization) include demonstrating the ability to drink enough liquids to stay hydrated. Who’s going to force children to stay up all night sipping fluids (plus changing all those diapers or taking them to the bathroom)? If the child stays on intravenous fluids overnight, we have to monitor at least through breakfast, likely lunch, thus making DCBN nearly impossible.

In a January 2019 article in the Journal of Hospital Medicine, Hailey James, MHA, (@Haileyjms on Twitter) and her colleagues demonstrated an association between DCBN and decreased length of stay (LOS) for medical but not surgical pediatric discharges.¹ This made them question if DCBN is an appropriate metric for discharge efficiency, as well as workflow differences between services. Many hospitals, however, still try to push DCBN as a goal (see Destino et al in the same January 2019 issue of JHM²), which could potentially lead to people trying to game the system.

How does your institution try to make discharge processes more efficient? Is it actually possible to do everything more quickly without sacrificing quality or trainee education? Whether your patients are kids, adults, or both, there are likely many issues in common where we could all learn from each other.

We discussed this topic in #JHMChat on April 15 on Twitter. New to Twitter or not familiar with #JHMChat? Since October 2015, JHM has reviewed and discussed dozens of articles spanning a wide variety of topics related to caring for hospitalized patients. All are welcome to join, including medical students, residents, nurses, practicing hospitalists, and more. It’s a great opportunity to virtually meet and learn from others while earning free CME.

To participate in future chats, type #JHMChat in the search box on the top right corner of your Twitter homepage, click on the “Latest” tab at the top left to see the most recent tweets, and join the conversation (don’t forget the hashtag)!
 

Dr. Chen is a pediatric hospital medicine fellow at Rady Children’s Hospital, University of California, San Diego. She is one of the cofounders/moderators of #PHMFellowJC, serves as a fellow district representative for the American Academy of Pediatrics, and is an active #tweetiatrician at @DrJenChen4kids. This article appeared originally in SHM's official blog The Hospital Leader. Read more recent posts here.

References

1. James HJ et al. The Association of Discharge Before Noon and Length of Stay in Hospitalized Pediatric Patients. J Hosp Med. 2019;14(1):28-32. doi: 10.12788/jhm.3111.

2. Destino L et al. Improving Patient Flow: Analysis of an Initiative to Improve Early Discharge. J Hosp Med. 2019;14(1):22-7. doi: 10.12788/jhm.3133.

In this edition of “How I will treat my next patient,” I take a look at two recent trials in non–small cell lung cancer (NSCLC). One summarizes a late analysis of a previously published randomized trial in stage IV NSCLC with three or fewer sites of metastasis – oligometastatic disease. The other reviews deidentified patient data to discern whether immune-targeted treatment might be valuable in particular subsets of NSCLC patients with EGFR mutations.

Local consolidative therapy

Daniel R. Gomez, MD, and colleagues published an updated analysis of progression-free survival (PFS) and an initial analysis of overall survival (OS) data in a randomized phase 2 trial in oligometastatic NSCLC. As originally published, patients were randomized to local consolidative treatment (LCT) versus standard maintenance therapy or observation (MT/O). Patients were required to have responding or stable disease after first-line systemic therapy prior to randomization.

Among the 49 patients who received LCT, there was a clear benefit of LCT (PFS of 14.2 months vs. 4.4 months for MT/O; P = .022; and median OS 41.2 months vs. 17.0 months; P = .017). The OS benefit was seen despite allowing crossover to LCT for patients who demonstrated disease progression in the MT/O arm.
 

What this means in practice

These data are exciting and move clinical research forward – if not, at this time, clinical practice. They support the ongoing clinical trials in NSCLC (NRG LU002) and breast cancer (NRG BR002) investigating the role of LCT in the oligometastatic setting.

For patients who are not candidates for (or choose not to participate in) these important phase 2R/3 trials, I believe that LCT should be discussed with all of the caveats that the authors appropriately mention, from the small number of patients because of the premature closure of the trial, to heterogeneous systemic regimens, to the lack of clarity on whether newer systemic therapies are better.

Immune checkpoint blockade

Historically, EGFR-mutated NSCLCs have not derived comparable benefit to EGFR-wild type (WT) tumors from checkpoint inhibitors. For that reason, in EGFR-mutated tumors, guidelines from the National Comprehensive Cancer Network (NCCN) suggest immune-targeted treatment should be used only on clinical trials or after receipt of EGFR-targeted tyrosine kinase inhibitors and cytotoxic chemotherapy. Several recent studies (IMpower and ATLANTIC), however, have suggested that selected EGFR-mutated patients can benefit from immune-targeted treatment.

Katherine Hastings, PhD, of Yale University, New Haven, Conn., and associates found, in a multi-institution clinical-molecular data review, that among the 44 of 171 EGFR-mutated tumors with L858R mutations, benefit from checkpoint inhibitors was comparable to WT tumors with regard to overall response rate and OS, but not PFS. Additionally, tumors with the EGFR T790M mutation demonstrated similar benefit from checkpoint inhibitors as in WT tumors, L858R-mutated tumors (but not exon 19 deleted tumors) had high tumor mutation burden, and PD-L1 expression did not influence outcome from immunotherapy.
 

What this means in practice

I agree with the modesty of the authors’ conclusion that these findings should not change clinical practice but rather should encourage further research into which patients with EGFR-mutant disease might benefit from immune-targeted therapy. For now, outside of a clinical trial, in EGFR-mutated patients, I will follow NCCN guidelines, using immune-targeted therapy off-study only with attentiveness to the particular immunotherapy regimens that have shown promise in the literature – and later, not earlier.

Dr. Lyss has been a community-based medical oncologist and clinical researcher for more than 35 years, practicing in St. Louis. His clinical and research interests are in the prevention, diagnosis, and treatment of breast and lung cancers and in expanding access to clinical trials to medically underserved populations.

In this edition of “How I will treat my next patient,” I take a look at two recent trials in non–small cell lung cancer (NSCLC). One summarizes a late analysis of a previously published randomized trial in stage IV NSCLC with three or fewer sites of metastasis – oligometastatic disease. The other reviews deidentified patient data to discern whether immune-targeted treatment might be valuable in particular subsets of NSCLC patients with EGFR mutations.

Local consolidative therapy

Daniel R. Gomez, MD, and colleagues published an updated analysis of progression-free survival (PFS) and an initial analysis of overall survival (OS) data in a randomized phase 2 trial in oligometastatic NSCLC. As originally published, patients were randomized to local consolidative treatment (LCT) versus standard maintenance therapy or observation (MT/O). Patients were required to have responding or stable disease after first-line systemic therapy prior to randomization.

Among the 49 patients who received LCT, there was a clear benefit of LCT (PFS of 14.2 months vs. 4.4 months for MT/O; P = .022; and median OS 41.2 months vs. 17.0 months; P = .017). The OS benefit was seen despite allowing crossover to LCT for patients who demonstrated disease progression in the MT/O arm.
 

What this means in practice

These data are exciting and move clinical research forward – if not, at this time, clinical practice. They support the ongoing clinical trials in NSCLC (NRG LU002) and breast cancer (NRG BR002) investigating the role of LCT in the oligometastatic setting.

For patients who are not candidates for (or choose not to participate in) these important phase 2R/3 trials, I believe that LCT should be discussed with all of the caveats that the authors appropriately mention, from the small number of patients because of the premature closure of the trial, to heterogeneous systemic regimens, to the lack of clarity on whether newer systemic therapies are better.

Immune checkpoint blockade

Historically, EGFR-mutated NSCLCs have not derived comparable benefit to EGFR-wild type (WT) tumors from checkpoint inhibitors. For that reason, in EGFR-mutated tumors, guidelines from the National Comprehensive Cancer Network (NCCN) suggest immune-targeted treatment should be used only on clinical trials or after receipt of EGFR-targeted tyrosine kinase inhibitors and cytotoxic chemotherapy. Several recent studies (IMpower and ATLANTIC), however, have suggested that selected EGFR-mutated patients can benefit from immune-targeted treatment.

Katherine Hastings, PhD, of Yale University, New Haven, Conn., and associates found, in a multi-institution clinical-molecular data review, that among the 44 of 171 EGFR-mutated tumors with L858R mutations, benefit from checkpoint inhibitors was comparable to WT tumors with regard to overall response rate and OS, but not PFS. Additionally, tumors with the EGFR T790M mutation demonstrated similar benefit from checkpoint inhibitors as in WT tumors, L858R-mutated tumors (but not exon 19 deleted tumors) had high tumor mutation burden, and PD-L1 expression did not influence outcome from immunotherapy.
 

What this means in practice

I agree with the modesty of the authors’ conclusion that these findings should not change clinical practice but rather should encourage further research into which patients with EGFR-mutant disease might benefit from immune-targeted therapy. For now, outside of a clinical trial, in EGFR-mutated patients, I will follow NCCN guidelines, using immune-targeted therapy off-study only with attentiveness to the particular immunotherapy regimens that have shown promise in the literature – and later, not earlier.

Dr. Lyss has been a community-based medical oncologist and clinical researcher for more than 35 years, practicing in St. Louis. His clinical and research interests are in the prevention, diagnosis, and treatment of breast and lung cancers and in expanding access to clinical trials to medically underserved populations.

In this edition of “How I will treat my next patient,” I take a look at two recent trials in non–small cell lung cancer (NSCLC). One summarizes a late analysis of a previously published randomized trial in stage IV NSCLC with three or fewer sites of metastasis – oligometastatic disease. The other reviews deidentified patient data to discern whether immune-targeted treatment might be valuable in particular subsets of NSCLC patients with EGFR mutations.

Local consolidative therapy

Daniel R. Gomez, MD, and colleagues published an updated analysis of progression-free survival (PFS) and an initial analysis of overall survival (OS) data in a randomized phase 2 trial in oligometastatic NSCLC. As originally published, patients were randomized to local consolidative treatment (LCT) versus standard maintenance therapy or observation (MT/O). Patients were required to have responding or stable disease after first-line systemic therapy prior to randomization.

Among the 49 patients who received LCT, there was a clear benefit of LCT (PFS of 14.2 months vs. 4.4 months for MT/O; P = .022; and median OS 41.2 months vs. 17.0 months; P = .017). The OS benefit was seen despite allowing crossover to LCT for patients who demonstrated disease progression in the MT/O arm.
 

What this means in practice

These data are exciting and move clinical research forward – if not, at this time, clinical practice. They support the ongoing clinical trials in NSCLC (NRG LU002) and breast cancer (NRG BR002) investigating the role of LCT in the oligometastatic setting.

For patients who are not candidates for (or choose not to participate in) these important phase 2R/3 trials, I believe that LCT should be discussed with all of the caveats that the authors appropriately mention, from the small number of patients because of the premature closure of the trial, to heterogeneous systemic regimens, to the lack of clarity on whether newer systemic therapies are better.

Immune checkpoint blockade

Historically, EGFR-mutated NSCLCs have not derived comparable benefit to EGFR-wild type (WT) tumors from checkpoint inhibitors. For that reason, in EGFR-mutated tumors, guidelines from the National Comprehensive Cancer Network (NCCN) suggest immune-targeted treatment should be used only on clinical trials or after receipt of EGFR-targeted tyrosine kinase inhibitors and cytotoxic chemotherapy. Several recent studies (IMpower and ATLANTIC), however, have suggested that selected EGFR-mutated patients can benefit from immune-targeted treatment.

Katherine Hastings, PhD, of Yale University, New Haven, Conn., and associates found, in a multi-institution clinical-molecular data review, that among the 44 of 171 EGFR-mutated tumors with L858R mutations, benefit from checkpoint inhibitors was comparable to WT tumors with regard to overall response rate and OS, but not PFS. Additionally, tumors with the EGFR T790M mutation demonstrated similar benefit from checkpoint inhibitors as in WT tumors, L858R-mutated tumors (but not exon 19 deleted tumors) had high tumor mutation burden, and PD-L1 expression did not influence outcome from immunotherapy.
 

What this means in practice

I agree with the modesty of the authors’ conclusion that these findings should not change clinical practice but rather should encourage further research into which patients with EGFR-mutant disease might benefit from immune-targeted therapy. For now, outside of a clinical trial, in EGFR-mutated patients, I will follow NCCN guidelines, using immune-targeted therapy off-study only with attentiveness to the particular immunotherapy regimens that have shown promise in the literature – and later, not earlier.

Dr. Lyss has been a community-based medical oncologist and clinical researcher for more than 35 years, practicing in St. Louis. His clinical and research interests are in the prevention, diagnosis, and treatment of breast and lung cancers and in expanding access to clinical trials to medically underserved populations.

It was a slow week at my office. For whatever reason, almost no one called for an appointment. Roughly 80% of my office slots were empty.

As a result, I began to worry.

You’d think that after 20 years in practice I wouldn’t, but I still do. I wonder if someone has actually read my Yelp reviews (most of which aren’t particularly good), or that I’ve done something to upset my referral base, or that some scandal about me broke in the local news that I’m entirely unaware of.

rdegrie/iStock/Getty Images Plus

Of course, the reality is that business comes and goes in waves. It was also the week after local schools closed for summer, and people were fleeing for summer vacation. In Phoenix, the older population leaves town as it heats up, and our winter visitors from elsewhere went home last month. And, like any business, things go in cycles that often don’t have a rational explanation.

I reassure myself that plenty of weeks are crazy. Patients crammed into every nook and cranny of the schedule, more people needing to be worked in, a huge pile of test results to be reviewed and make decisions on, and a lot of phone calls to be returned.

Then I’ll wish for a quieter week. I’ve given up on finding a happy medium – it doesn’t seem to happen.

So I try to live with the quiet. Close up and go home a little early if there’s no one to see. Catch up on my sleep and reading. Do some online surveys for extra dollars. Throw away expired stuff in my drug sample cabinet.

Medicine is, in general, a pretty hectic job. I need to learn to accept the quiet times as a gift and enjoy them, because the crazy days always return.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

It was a slow week at my office. For whatever reason, almost no one called for an appointment. Roughly 80% of my office slots were empty.

As a result, I began to worry.

You’d think that after 20 years in practice I wouldn’t, but I still do. I wonder if someone has actually read my Yelp reviews (most of which aren’t particularly good), or that I’ve done something to upset my referral base, or that some scandal about me broke in the local news that I’m entirely unaware of.

rdegrie/iStock/Getty Images Plus

Of course, the reality is that business comes and goes in waves. It was also the week after local schools closed for summer, and people were fleeing for summer vacation. In Phoenix, the older population leaves town as it heats up, and our winter visitors from elsewhere went home last month. And, like any business, things go in cycles that often don’t have a rational explanation.

I reassure myself that plenty of weeks are crazy. Patients crammed into every nook and cranny of the schedule, more people needing to be worked in, a huge pile of test results to be reviewed and make decisions on, and a lot of phone calls to be returned.

Then I’ll wish for a quieter week. I’ve given up on finding a happy medium – it doesn’t seem to happen.

So I try to live with the quiet. Close up and go home a little early if there’s no one to see. Catch up on my sleep and reading. Do some online surveys for extra dollars. Throw away expired stuff in my drug sample cabinet.

Medicine is, in general, a pretty hectic job. I need to learn to accept the quiet times as a gift and enjoy them, because the crazy days always return.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

It was a slow week at my office. For whatever reason, almost no one called for an appointment. Roughly 80% of my office slots were empty.

As a result, I began to worry.

You’d think that after 20 years in practice I wouldn’t, but I still do. I wonder if someone has actually read my Yelp reviews (most of which aren’t particularly good), or that I’ve done something to upset my referral base, or that some scandal about me broke in the local news that I’m entirely unaware of.

rdegrie/iStock/Getty Images Plus

Of course, the reality is that business comes and goes in waves. It was also the week after local schools closed for summer, and people were fleeing for summer vacation. In Phoenix, the older population leaves town as it heats up, and our winter visitors from elsewhere went home last month. And, like any business, things go in cycles that often don’t have a rational explanation.

I reassure myself that plenty of weeks are crazy. Patients crammed into every nook and cranny of the schedule, more people needing to be worked in, a huge pile of test results to be reviewed and make decisions on, and a lot of phone calls to be returned.

Then I’ll wish for a quieter week. I’ve given up on finding a happy medium – it doesn’t seem to happen.

So I try to live with the quiet. Close up and go home a little early if there’s no one to see. Catch up on my sleep and reading. Do some online surveys for extra dollars. Throw away expired stuff in my drug sample cabinet.

Medicine is, in general, a pretty hectic job. I need to learn to accept the quiet times as a gift and enjoy them, because the crazy days always return.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

The fetal heart typically is examined during the routine 18-20 week obstetric ultrasound screening, and pregnancies with abnormalities on this routine scan are referred for detailed fetal echocardiography. Per multiple practice guidelines, patients deemed to be at high risk of congenital heart defects (CHDs) are referred for fetal echocardiography as well between 18 and 24 weeks’ gestation.

However, with technological advancements in ultrasound, it is possible for obstetricians to detect many major CHDs well before 16 weeks’ gestation. First-trimester fetal heart assessment – and early detection of CHDs – has numerous advantages: It enables early genetic testing, early decision making about continuation or termination of pregnancy, and earlier planning for appropriate management during and after pregnancy. Perioperative outcomes are improved.

At least 75% of CHDs occur in pregnancies with no identifiable maternal, familial, or fetal risk factors. It only seems fitting, therefore, that we check the structure of the fetal heart in all women at the time of their first-trimester screening and sonography at 11-14 weeks. In addition to a determination of fetal viability and gestational age, nuchal translucency measurement, and a check of basic anatomy, this early exam offers a great opportunity to screen for CHDs – the most common congenital anomaly, with an incidence of about 4-13 per 1,000 live births.
 

The value of early detection

Women who have diabetes, congenital defects, in vitro fertilization pregnancies, twin and multiple pregnancies, and certain medication and drug exposures are at high risk for their fetus having a CHD and should undergo fetal echocardiography. Lupus, Sjögren’s, and other medical disorders also are risk factors, as are abnormal biochemical test results.

During the last 10 years, the first-trimester fetal heart evaluation has been performed for all patients who come for a first-trimester screening scan at the University of Maryland’s fetal heart program, part of the Center for Advanced Fetal Care. Approximately 45% of indications for detailed first-trimester fetal heart evaluation have been driven by maternal history, and almost 40% by abnormal basic first-trimester ultrasound findings such as increased nuchal translucency, tricuspid regurgitation, abnormal ductus venosus blood flow, and other structural anomalies.

An estimated 50%-60% of serious cardiac malformations can be detected with a four-chamber heart view during routine first-trimester ultrasound. When the outflow tract relationship and three-vessel views also are examined in the first trimester – as is now recommended in guidelines for second-trimester protocols – an estimated 85%-95% of major CHDs can be detected. One should see the great arteries originating from the left and right sides and crisscrossing each other by a transabdominal scan, or by a transvaginal scan if the transabdominal approach fails to show these features of the fetal heart.

In fact, it is extremely important that we do early fetal heart evaluations in women who are obese, because the risk of having a fetus with CHD is increasingly being found to be higher in obese women, and because fetal heart assessment with transvaginal ultrasound is an option only in early gestation, when the fetal heart is within the depth of penetration of the vaginal probe. With advancing gestational age, a combined abdominal/transvaginal approach becomes increasingly difficult. Our study also demonstrated a dose-response relationship between maternal obesity and CHD risk.

Preexisting diabetes mellitus, which can occur in conjunction with obesity, has been found to increase the risk for all types of CHDs, especially conotruncal abnormalities. While the pathophysiology is not completely understood, elevated oxidative stress is believed to be the primary trigger.⁷
 

First-trimester echocardiography benefits

Patients referred to our fetal heart program for detailed first-trimester fetal heart evaluation – again, a significant number of whom have been found on standard 2-D ultrasound to have increased nuchal translucency thickness or other abnormalities – undergo a four-dimensional fetal echocardiographic technique that utilizes spatiotemporal image correlation and tomographic ultrasound imaging display (STIC-TUI echo) along with color Doppler. The heart is swept from top to bottom in about 10 seconds, and tomographic ultrasound imaging is used offline, after the patient leaves, to develop volume datasets that simultaneously display multiple cross-sectional images.

This method has been implemented into our routine scan at the first trimester as well, and all of our staff have been trained to perform it. Obtaining STIC-TUI by color Doppler allows us to assess all of the important landmarks of the cardiac anatomy in one picture.

Dr. Turan is associate professor of obstetrics, gynecology, and reproductive sciences, and director of the fetal heart program at the University of Maryland, Baltimore.
 

References

1. J Ultrasound Med. 2019 May;38(5):1269-77.

2. Prenat Diagn. 2005 Mar;25(3):253-60.

3. J Perinat Med. 2018 May 24;46(4):373-8.

4. Ultrasound Obstet Gynecol. 2015 Jun;45(6):631-8.

5. National Congenital Heart Disease Audit Report 2013-2016.

6. Pediatrics. 2015. doi: 10.1542/peds.2014-3783.

7. Echocardiography. 2018 Feb;35(2):244-57.

8. Ultrasound Obstet Gynecol. 2014 Nov;44(5):562-7.

The fetal heart typically is examined during the routine 18-20 week obstetric ultrasound screening, and pregnancies with abnormalities on this routine scan are referred for detailed fetal echocardiography. Per multiple practice guidelines, patients deemed to be at high risk of congenital heart defects (CHDs) are referred for fetal echocardiography as well between 18 and 24 weeks’ gestation.

However, with technological advancements in ultrasound, it is possible for obstetricians to detect many major CHDs well before 16 weeks’ gestation. First-trimester fetal heart assessment – and early detection of CHDs – has numerous advantages: It enables early genetic testing, early decision making about continuation or termination of pregnancy, and earlier planning for appropriate management during and after pregnancy. Perioperative outcomes are improved.

At least 75% of CHDs occur in pregnancies with no identifiable maternal, familial, or fetal risk factors. It only seems fitting, therefore, that we check the structure of the fetal heart in all women at the time of their first-trimester screening and sonography at 11-14 weeks. In addition to a determination of fetal viability and gestational age, nuchal translucency measurement, and a check of basic anatomy, this early exam offers a great opportunity to screen for CHDs – the most common congenital anomaly, with an incidence of about 4-13 per 1,000 live births.
 

The value of early detection

Women who have diabetes, congenital defects, in vitro fertilization pregnancies, twin and multiple pregnancies, and certain medication and drug exposures are at high risk for their fetus having a CHD and should undergo fetal echocardiography. Lupus, Sjögren’s, and other medical disorders also are risk factors, as are abnormal biochemical test results.

During the last 10 years, the first-trimester fetal heart evaluation has been performed for all patients who come for a first-trimester screening scan at the University of Maryland’s fetal heart program, part of the Center for Advanced Fetal Care. Approximately 45% of indications for detailed first-trimester fetal heart evaluation have been driven by maternal history, and almost 40% by abnormal basic first-trimester ultrasound findings such as increased nuchal translucency, tricuspid regurgitation, abnormal ductus venosus blood flow, and other structural anomalies.

An estimated 50%-60% of serious cardiac malformations can be detected with a four-chamber heart view during routine first-trimester ultrasound. When the outflow tract relationship and three-vessel views also are examined in the first trimester – as is now recommended in guidelines for second-trimester protocols – an estimated 85%-95% of major CHDs can be detected. One should see the great arteries originating from the left and right sides and crisscrossing each other by a transabdominal scan, or by a transvaginal scan if the transabdominal approach fails to show these features of the fetal heart.

In fact, it is extremely important that we do early fetal heart evaluations in women who are obese, because the risk of having a fetus with CHD is increasingly being found to be higher in obese women, and because fetal heart assessment with transvaginal ultrasound is an option only in early gestation, when the fetal heart is within the depth of penetration of the vaginal probe. With advancing gestational age, a combined abdominal/transvaginal approach becomes increasingly difficult. Our study also demonstrated a dose-response relationship between maternal obesity and CHD risk.

Preexisting diabetes mellitus, which can occur in conjunction with obesity, has been found to increase the risk for all types of CHDs, especially conotruncal abnormalities. While the pathophysiology is not completely understood, elevated oxidative stress is believed to be the primary trigger.⁷
 

First-trimester echocardiography benefits

Patients referred to our fetal heart program for detailed first-trimester fetal heart evaluation – again, a significant number of whom have been found on standard 2-D ultrasound to have increased nuchal translucency thickness or other abnormalities – undergo a four-dimensional fetal echocardiographic technique that utilizes spatiotemporal image correlation and tomographic ultrasound imaging display (STIC-TUI echo) along with color Doppler. The heart is swept from top to bottom in about 10 seconds, and tomographic ultrasound imaging is used offline, after the patient leaves, to develop volume datasets that simultaneously display multiple cross-sectional images.

This method has been implemented into our routine scan at the first trimester as well, and all of our staff have been trained to perform it. Obtaining STIC-TUI by color Doppler allows us to assess all of the important landmarks of the cardiac anatomy in one picture.

Dr. Turan is associate professor of obstetrics, gynecology, and reproductive sciences, and director of the fetal heart program at the University of Maryland, Baltimore.
 

References

1. J Ultrasound Med. 2019 May;38(5):1269-77.

2. Prenat Diagn. 2005 Mar;25(3):253-60.

3. J Perinat Med. 2018 May 24;46(4):373-8.

4. Ultrasound Obstet Gynecol. 2015 Jun;45(6):631-8.

5. National Congenital Heart Disease Audit Report 2013-2016.

6. Pediatrics. 2015. doi: 10.1542/peds.2014-3783.

7. Echocardiography. 2018 Feb;35(2):244-57.

8. Ultrasound Obstet Gynecol. 2014 Nov;44(5):562-7.

The fetal heart typically is examined during the routine 18-20 week obstetric ultrasound screening, and pregnancies with abnormalities on this routine scan are referred for detailed fetal echocardiography. Per multiple practice guidelines, patients deemed to be at high risk of congenital heart defects (CHDs) are referred for fetal echocardiography as well between 18 and 24 weeks’ gestation.

However, with technological advancements in ultrasound, it is possible for obstetricians to detect many major CHDs well before 16 weeks’ gestation. First-trimester fetal heart assessment – and early detection of CHDs – has numerous advantages: It enables early genetic testing, early decision making about continuation or termination of pregnancy, and earlier planning for appropriate management during and after pregnancy. Perioperative outcomes are improved.

At least 75% of CHDs occur in pregnancies with no identifiable maternal, familial, or fetal risk factors. It only seems fitting, therefore, that we check the structure of the fetal heart in all women at the time of their first-trimester screening and sonography at 11-14 weeks. In addition to a determination of fetal viability and gestational age, nuchal translucency measurement, and a check of basic anatomy, this early exam offers a great opportunity to screen for CHDs – the most common congenital anomaly, with an incidence of about 4-13 per 1,000 live births.
 

The value of early detection

Women who have diabetes, congenital defects, in vitro fertilization pregnancies, twin and multiple pregnancies, and certain medication and drug exposures are at high risk for their fetus having a CHD and should undergo fetal echocardiography. Lupus, Sjögren’s, and other medical disorders also are risk factors, as are abnormal biochemical test results.

During the last 10 years, the first-trimester fetal heart evaluation has been performed for all patients who come for a first-trimester screening scan at the University of Maryland’s fetal heart program, part of the Center for Advanced Fetal Care. Approximately 45% of indications for detailed first-trimester fetal heart evaluation have been driven by maternal history, and almost 40% by abnormal basic first-trimester ultrasound findings such as increased nuchal translucency, tricuspid regurgitation, abnormal ductus venosus blood flow, and other structural anomalies.

An estimated 50%-60% of serious cardiac malformations can be detected with a four-chamber heart view during routine first-trimester ultrasound. When the outflow tract relationship and three-vessel views also are examined in the first trimester – as is now recommended in guidelines for second-trimester protocols – an estimated 85%-95% of major CHDs can be detected. One should see the great arteries originating from the left and right sides and crisscrossing each other by a transabdominal scan, or by a transvaginal scan if the transabdominal approach fails to show these features of the fetal heart.

In fact, it is extremely important that we do early fetal heart evaluations in women who are obese, because the risk of having a fetus with CHD is increasingly being found to be higher in obese women, and because fetal heart assessment with transvaginal ultrasound is an option only in early gestation, when the fetal heart is within the depth of penetration of the vaginal probe. With advancing gestational age, a combined abdominal/transvaginal approach becomes increasingly difficult. Our study also demonstrated a dose-response relationship between maternal obesity and CHD risk.

Preexisting diabetes mellitus, which can occur in conjunction with obesity, has been found to increase the risk for all types of CHDs, especially conotruncal abnormalities. While the pathophysiology is not completely understood, elevated oxidative stress is believed to be the primary trigger.⁷
 

First-trimester echocardiography benefits

Patients referred to our fetal heart program for detailed first-trimester fetal heart evaluation – again, a significant number of whom have been found on standard 2-D ultrasound to have increased nuchal translucency thickness or other abnormalities – undergo a four-dimensional fetal echocardiographic technique that utilizes spatiotemporal image correlation and tomographic ultrasound imaging display (STIC-TUI echo) along with color Doppler. The heart is swept from top to bottom in about 10 seconds, and tomographic ultrasound imaging is used offline, after the patient leaves, to develop volume datasets that simultaneously display multiple cross-sectional images.

This method has been implemented into our routine scan at the first trimester as well, and all of our staff have been trained to perform it. Obtaining STIC-TUI by color Doppler allows us to assess all of the important landmarks of the cardiac anatomy in one picture.

Dr. Turan is associate professor of obstetrics, gynecology, and reproductive sciences, and director of the fetal heart program at the University of Maryland, Baltimore.
 

References

1. J Ultrasound Med. 2019 May;38(5):1269-77.

2. Prenat Diagn. 2005 Mar;25(3):253-60.

3. J Perinat Med. 2018 May 24;46(4):373-8.

4. Ultrasound Obstet Gynecol. 2015 Jun;45(6):631-8.

5. National Congenital Heart Disease Audit Report 2013-2016.

6. Pediatrics. 2015. doi: 10.1542/peds.2014-3783.

7. Echocardiography. 2018 Feb;35(2):244-57.

8. Ultrasound Obstet Gynecol. 2014 Nov;44(5):562-7.

Regardless of political or ideological views, detecting the embryonic heartbeat in the first trimester is a major milestone for a patient. Measured via ultrasound, normal beating of 90-110 bpm around 6 weeks’ gestation indicates a high probability of a successful pregnancy. Once the embryo becomes a fetus, around gestational weeks 8-9, a strong fetal heartbeat of 140-170 bpm should be detected. Finding a heartbeat is a reassuring sign. However, simply seeing and/or hearing the heart is not enough to ensure that the fetus will develop without problems.

Congenital heart defects (CHDs) are the most common birth defects worldwide and, although many CHDs can be mild forms, approximately 25% are severe forms requiring early detection and intervention.¹ In addition, CHDs in the fetus can cause miscarriage, stillbirth, and infant deaths.

A 2014 analysis of data from the Wisconsin Stillbirth Service Program revealed that approximately 9% of stillbirths after 20 weeks’ gestation and nearly 4% of miscarriages prior to 20 weeks were attributable to congenital heart defects.² An analysis of the Active Malformations Surveillance Program at Brigham and Women’s Hospital also revealed CHDs as a major cause of stillbirths.³ In addition, a retrospective study of the Metropolitan Atlanta Congenital Defects program showed that, although 1-year survival of infants with severe CHDs has improved over the last 4 decades, mortality remains high.¹

Because advances in medicine and surgical procedures have significantly reduced deaths attributable to CHDs, more women with a preexisting heart condition are becoming pregnant. Women who have a CHD, even if corrected, can experience pregnancy complications such as arrhythmias, thrombosis, and cardiac dysfunction. In addition, babies of women with CHDs have a higher risk of developing cardiac defects as well.

Therefore, it is critical that we closely monitor our patients – both the mother and her baby – to ensure that the fetal heart is present, functional, and developing normally. We have invited Dr. Shifa Turan, associate professor of obstetrics, gynecology, and reproductive sciences at the University of Maryland and director of the Fetal Heart Program at the University of Maryland Medical Center, both in Baltimore, to discuss the fetal heart. In this first section of a two-part series, Dr. Turan addresses how we can and should monitor fetal heart development.
 

Dr. Reece, who specializes in maternal-fetal medicine, is executive vice president for medical affairs at the University of Maryland, Baltimore, as well as the John Z. and Akiko K. Bowers Distinguished Professor and dean of the school of medicine. He is the medical editor of this column. He said he had no relevant financial disclosures. Contact him at obnews@mdedge.com.
 

References

1. Pediatrics. 2013 May. doi: 10.1542/peds.2012-3435).

2. Am J Med Genet A. 2014 Mar. doi: 10.1002/ajmg.a.36366.

3. Birth Defects Res. 2018 Jan. 29. doi: 10.1002/bdr2.1097.

Regardless of political or ideological views, detecting the embryonic heartbeat in the first trimester is a major milestone for a patient. Measured via ultrasound, normal beating of 90-110 bpm around 6 weeks’ gestation indicates a high probability of a successful pregnancy. Once the embryo becomes a fetus, around gestational weeks 8-9, a strong fetal heartbeat of 140-170 bpm should be detected. Finding a heartbeat is a reassuring sign. However, simply seeing and/or hearing the heart is not enough to ensure that the fetus will develop without problems.

Congenital heart defects (CHDs) are the most common birth defects worldwide and, although many CHDs can be mild forms, approximately 25% are severe forms requiring early detection and intervention.¹ In addition, CHDs in the fetus can cause miscarriage, stillbirth, and infant deaths.

A 2014 analysis of data from the Wisconsin Stillbirth Service Program revealed that approximately 9% of stillbirths after 20 weeks’ gestation and nearly 4% of miscarriages prior to 20 weeks were attributable to congenital heart defects.² An analysis of the Active Malformations Surveillance Program at Brigham and Women’s Hospital also revealed CHDs as a major cause of stillbirths.³ In addition, a retrospective study of the Metropolitan Atlanta Congenital Defects program showed that, although 1-year survival of infants with severe CHDs has improved over the last 4 decades, mortality remains high.¹

Because advances in medicine and surgical procedures have significantly reduced deaths attributable to CHDs, more women with a preexisting heart condition are becoming pregnant. Women who have a CHD, even if corrected, can experience pregnancy complications such as arrhythmias, thrombosis, and cardiac dysfunction. In addition, babies of women with CHDs have a higher risk of developing cardiac defects as well.

Therefore, it is critical that we closely monitor our patients – both the mother and her baby – to ensure that the fetal heart is present, functional, and developing normally. We have invited Dr. Shifa Turan, associate professor of obstetrics, gynecology, and reproductive sciences at the University of Maryland and director of the Fetal Heart Program at the University of Maryland Medical Center, both in Baltimore, to discuss the fetal heart. In this first section of a two-part series, Dr. Turan addresses how we can and should monitor fetal heart development.
 

Dr. Reece, who specializes in maternal-fetal medicine, is executive vice president for medical affairs at the University of Maryland, Baltimore, as well as the John Z. and Akiko K. Bowers Distinguished Professor and dean of the school of medicine. He is the medical editor of this column. He said he had no relevant financial disclosures. Contact him at obnews@mdedge.com.
 

References

1. Pediatrics. 2013 May. doi: 10.1542/peds.2012-3435).

2. Am J Med Genet A. 2014 Mar. doi: 10.1002/ajmg.a.36366.

3. Birth Defects Res. 2018 Jan. 29. doi: 10.1002/bdr2.1097.

Regardless of political or ideological views, detecting the embryonic heartbeat in the first trimester is a major milestone for a patient. Measured via ultrasound, normal beating of 90-110 bpm around 6 weeks’ gestation indicates a high probability of a successful pregnancy. Once the embryo becomes a fetus, around gestational weeks 8-9, a strong fetal heartbeat of 140-170 bpm should be detected. Finding a heartbeat is a reassuring sign. However, simply seeing and/or hearing the heart is not enough to ensure that the fetus will develop without problems.

Congenital heart defects (CHDs) are the most common birth defects worldwide and, although many CHDs can be mild forms, approximately 25% are severe forms requiring early detection and intervention.¹ In addition, CHDs in the fetus can cause miscarriage, stillbirth, and infant deaths.

A 2014 analysis of data from the Wisconsin Stillbirth Service Program revealed that approximately 9% of stillbirths after 20 weeks’ gestation and nearly 4% of miscarriages prior to 20 weeks were attributable to congenital heart defects.² An analysis of the Active Malformations Surveillance Program at Brigham and Women’s Hospital also revealed CHDs as a major cause of stillbirths.³ In addition, a retrospective study of the Metropolitan Atlanta Congenital Defects program showed that, although 1-year survival of infants with severe CHDs has improved over the last 4 decades, mortality remains high.¹

Because advances in medicine and surgical procedures have significantly reduced deaths attributable to CHDs, more women with a preexisting heart condition are becoming pregnant. Women who have a CHD, even if corrected, can experience pregnancy complications such as arrhythmias, thrombosis, and cardiac dysfunction. In addition, babies of women with CHDs have a higher risk of developing cardiac defects as well.

Therefore, it is critical that we closely monitor our patients – both the mother and her baby – to ensure that the fetal heart is present, functional, and developing normally. We have invited Dr. Shifa Turan, associate professor of obstetrics, gynecology, and reproductive sciences at the University of Maryland and director of the Fetal Heart Program at the University of Maryland Medical Center, both in Baltimore, to discuss the fetal heart. In this first section of a two-part series, Dr. Turan addresses how we can and should monitor fetal heart development.
 

Dr. Reece, who specializes in maternal-fetal medicine, is executive vice president for medical affairs at the University of Maryland, Baltimore, as well as the John Z. and Akiko K. Bowers Distinguished Professor and dean of the school of medicine. He is the medical editor of this column. He said he had no relevant financial disclosures. Contact him at obnews@mdedge.com.
 

References

1. Pediatrics. 2013 May. doi: 10.1542/peds.2012-3435).

2. Am J Med Genet A. 2014 Mar. doi: 10.1002/ajmg.a.36366.

3. Birth Defects Res. 2018 Jan. 29. doi: 10.1002/bdr2.1097.

“No hassle” new manuscript submission process

Many authors have experienced the frustration of formatting a manuscript for submission to a medical journal. The process is time consuming and each journal has different requirements. This means that if you decide to submit your manuscript to one journal and later decide that another journal is a better fit, you may spend an hour (or several hours) reformatting to meet the new journal’s unique requirements.

To allow authors to spend more time on what matters to them, we’re pleased to introduce our “No Hassle” process for initial original research and brief report manuscript submissions to the Journal of Hospital Medicine. Our goal is to eliminate unnecessary and burdensome steps in the manuscript submission process. Thus, we have relaxed formatting requirements for initial manuscript submissions. Any conventional and readable manuscript format and reference style is acceptable.

Tables and figures can be embedded in the main document file or uploaded individually, depending on your preference. Funding and disclosures should be included on the title page but there is no need to submit completed disclosure or copyright forms unless we request a manuscript revision.
 

Timely decisions

We have all experienced the agony of waiting months on end for a journal to make a decision about our manuscript. The review process itself can take many months (or even longer). Furthermore, a manuscript may not be published for many more months (or even longer) following acceptance. At the Journal of Hospital Medicine, we commit to making timely decisions and publishing your accepted manuscript as fast as we can.

We currently reject approximately half of all original research and brief report manuscript submissions without formal peer review. We do this for two reasons. First, we want to ensure that we’re not overburdening our peer reviewers so we only ask them to review manuscripts that we are seriously considering for publication. Second, we want to ensure that we’re being respectful of our authors’ time. If we are unlikely to publish a manuscript based on lower priority scores assigned by me, as editor-in-chief, or other journal editors, we don’t want to subject your manuscript to a lengthy peer review, but would rather return the manuscript to you quickly for timely submission elsewhere.

Here are data that support our timely decision making:

• 1.3 days = our average time from manuscript submission to rejection without formal peer review (median, less than one day).
• 23 days = our average time from manuscript submission to first decision for manuscripts sent for peer review.

We also are working to improve our time to publication. Our goal is to publish accepted manuscripts within 120 days from initial submission to publication, and within 60 days from acceptance to publication.
 

Dissemination

Finally, little public knowledge is gleaned from medical research unless the study is published and widely read. The Journal of Hospital Medicine is at the leading edge of helping authors disseminate their work to a broader audience. Of course, we produce press releases and distribute those to many media outlets in partnership with the Society of Hospital Medicine. We also leverage social media to promote your article through tweets, visual abstracts, and, more recently, comics or graphic medicine abstracts. Some articles are even discussed on #JHMChat, our twitter-based journal club. This work is led by our exceptional Digital Media Editors, Dr. Vineet Arora (@FutureDocs), Dr. Charlie Wray (@WrayCharles), and Dr. Grace Farris (@gracefarris).

In summary, we are committed to making the Journal of Hospital Medicine even more author friendly. To that end, we’re making it easy for authors to submit their work, making timely disposition decisions, and facilitating dissemination of the work we publish.
 

Dr. Shah is chief metrics officer and director of the division of hospital medicine at Cincinnati Children’s Hospital Medical Center. He is the current editor-in-chief of the Journal of Hospital Medicine.

“No hassle” new manuscript submission process

Many authors have experienced the frustration of formatting a manuscript for submission to a medical journal. The process is time consuming and each journal has different requirements. This means that if you decide to submit your manuscript to one journal and later decide that another journal is a better fit, you may spend an hour (or several hours) reformatting to meet the new journal’s unique requirements.

To allow authors to spend more time on what matters to them, we’re pleased to introduce our “No Hassle” process for initial original research and brief report manuscript submissions to the Journal of Hospital Medicine. Our goal is to eliminate unnecessary and burdensome steps in the manuscript submission process. Thus, we have relaxed formatting requirements for initial manuscript submissions. Any conventional and readable manuscript format and reference style is acceptable.

Tables and figures can be embedded in the main document file or uploaded individually, depending on your preference. Funding and disclosures should be included on the title page but there is no need to submit completed disclosure or copyright forms unless we request a manuscript revision.
 

Timely decisions

We have all experienced the agony of waiting months on end for a journal to make a decision about our manuscript. The review process itself can take many months (or even longer). Furthermore, a manuscript may not be published for many more months (or even longer) following acceptance. At the Journal of Hospital Medicine, we commit to making timely decisions and publishing your accepted manuscript as fast as we can.

We currently reject approximately half of all original research and brief report manuscript submissions without formal peer review. We do this for two reasons. First, we want to ensure that we’re not overburdening our peer reviewers so we only ask them to review manuscripts that we are seriously considering for publication. Second, we want to ensure that we’re being respectful of our authors’ time. If we are unlikely to publish a manuscript based on lower priority scores assigned by me, as editor-in-chief, or other journal editors, we don’t want to subject your manuscript to a lengthy peer review, but would rather return the manuscript to you quickly for timely submission elsewhere.

Here are data that support our timely decision making:

• 1.3 days = our average time from manuscript submission to rejection without formal peer review (median, less than one day).
• 23 days = our average time from manuscript submission to first decision for manuscripts sent for peer review.

We also are working to improve our time to publication. Our goal is to publish accepted manuscripts within 120 days from initial submission to publication, and within 60 days from acceptance to publication.
 

Dissemination

Finally, little public knowledge is gleaned from medical research unless the study is published and widely read. The Journal of Hospital Medicine is at the leading edge of helping authors disseminate their work to a broader audience. Of course, we produce press releases and distribute those to many media outlets in partnership with the Society of Hospital Medicine. We also leverage social media to promote your article through tweets, visual abstracts, and, more recently, comics or graphic medicine abstracts. Some articles are even discussed on #JHMChat, our twitter-based journal club. This work is led by our exceptional Digital Media Editors, Dr. Vineet Arora (@FutureDocs), Dr. Charlie Wray (@WrayCharles), and Dr. Grace Farris (@gracefarris).

In summary, we are committed to making the Journal of Hospital Medicine even more author friendly. To that end, we’re making it easy for authors to submit their work, making timely disposition decisions, and facilitating dissemination of the work we publish.
 

Dr. Shah is chief metrics officer and director of the division of hospital medicine at Cincinnati Children’s Hospital Medical Center. He is the current editor-in-chief of the Journal of Hospital Medicine.

“No hassle” new manuscript submission process

Many authors have experienced the frustration of formatting a manuscript for submission to a medical journal. The process is time consuming and each journal has different requirements. This means that if you decide to submit your manuscript to one journal and later decide that another journal is a better fit, you may spend an hour (or several hours) reformatting to meet the new journal’s unique requirements.

To allow authors to spend more time on what matters to them, we’re pleased to introduce our “No Hassle” process for initial original research and brief report manuscript submissions to the Journal of Hospital Medicine. Our goal is to eliminate unnecessary and burdensome steps in the manuscript submission process. Thus, we have relaxed formatting requirements for initial manuscript submissions. Any conventional and readable manuscript format and reference style is acceptable.

Tables and figures can be embedded in the main document file or uploaded individually, depending on your preference. Funding and disclosures should be included on the title page but there is no need to submit completed disclosure or copyright forms unless we request a manuscript revision.
 

Timely decisions

We have all experienced the agony of waiting months on end for a journal to make a decision about our manuscript. The review process itself can take many months (or even longer). Furthermore, a manuscript may not be published for many more months (or even longer) following acceptance. At the Journal of Hospital Medicine, we commit to making timely decisions and publishing your accepted manuscript as fast as we can.

We currently reject approximately half of all original research and brief report manuscript submissions without formal peer review. We do this for two reasons. First, we want to ensure that we’re not overburdening our peer reviewers so we only ask them to review manuscripts that we are seriously considering for publication. Second, we want to ensure that we’re being respectful of our authors’ time. If we are unlikely to publish a manuscript based on lower priority scores assigned by me, as editor-in-chief, or other journal editors, we don’t want to subject your manuscript to a lengthy peer review, but would rather return the manuscript to you quickly for timely submission elsewhere.

Here are data that support our timely decision making:

• 1.3 days = our average time from manuscript submission to rejection without formal peer review (median, less than one day).
• 23 days = our average time from manuscript submission to first decision for manuscripts sent for peer review.

We also are working to improve our time to publication. Our goal is to publish accepted manuscripts within 120 days from initial submission to publication, and within 60 days from acceptance to publication.
 

Dissemination

Finally, little public knowledge is gleaned from medical research unless the study is published and widely read. The Journal of Hospital Medicine is at the leading edge of helping authors disseminate their work to a broader audience. Of course, we produce press releases and distribute those to many media outlets in partnership with the Society of Hospital Medicine. We also leverage social media to promote your article through tweets, visual abstracts, and, more recently, comics or graphic medicine abstracts. Some articles are even discussed on #JHMChat, our twitter-based journal club. This work is led by our exceptional Digital Media Editors, Dr. Vineet Arora (@FutureDocs), Dr. Charlie Wray (@WrayCharles), and Dr. Grace Farris (@gracefarris).

In summary, we are committed to making the Journal of Hospital Medicine even more author friendly. To that end, we’re making it easy for authors to submit their work, making timely disposition decisions, and facilitating dissemination of the work we publish.
 

Dr. Shah is chief metrics officer and director of the division of hospital medicine at Cincinnati Children’s Hospital Medical Center. He is the current editor-in-chief of the Journal of Hospital Medicine.

Amazon has opened a new health care frontier: Now Alexa can be used to transmit patient data. Using this new feature – which Amazon labeled as a “skill” – a company named Livongo will allow diabetes patients – which it calls “members” – to use the device to “query their last blood sugar reading, blood sugar measurement trends, and receive insights and Health Nudges that are personalized to them.”

Private equity and venture capital firms are in love with a legion of companies and startups touting the benefits of virtual doctors’ visits and telemedicine to revolutionize health care, investing almost $10 billion in 2018, a record for the sector. Without stepping into a gym or a clinic, a startup called Kinetxx will provide patients with virtual physical therapy, along with messaging and exercise logging. And Maven Clinic (which is not actually a physical place) offers online medical guidance and personal advice focusing on women’s health needs.

In April, at Fortune’s Brainstorm Health conference in San Diego, Bruce Broussard, CEO of health insurer Humana, said he believes technology will help patients receive help during medical crises, citing the benefits of home monitoring and the ability of doctors’ visits to be conducted by video conference.

But when I returned from Brainstorm Health, I was confronted by an alternative reality of virtual medicine: a $235 medical bill for a telehealth visit that resulted from one of my kids calling a longtime doctor’s office. It was for a five-minute phone call answering a question about a possible infection.

Virtual communications have streamlined life and transformed many of our relationships for the better. There is little need anymore to sit across the desk from a tax accountant or travel agent or to stand in a queue for a bank teller. And there is certainly room for disruptive digital innovation in our confusing and overpriced health care system.

But it remains an open question whether virtual medicine will prove a valuable, convenient adjunct to health care. Or, instead, will it be a way for the U.S. profit-driven health care system to make big bucks by outsourcing core duties – while providing a paler version of actual medical treatment?

After all, my doctors have long answered my questions and dispensed phone and email advice for free – as part of our doctor-patient relationship – though it didn’t have a cool branding moniker like telehealth. And my obstetrician’s office offered great support and advice through two difficult pregnancies – maybe they should have been paid for that valuable service. But $235 for a phone call (which works out to over $2,000 per hour)? Not even a corporate lawyer bills that.

Logic holds that some digital health tools have tremendous potential: A neurologist can view a patient by video to see if lopsided facial movements suggest a stroke. A patient with an irregular heart rhythm could send in digital tracings to see if a new prescription drug is working. But the tangible benefit of many other virtual services offered is less certain. Some people may like receiving feedback about their sleep from an Apple Watch, but I’m not sure that’s medicine.

And if virtual medicine is pursued in the name of business efficiency or just profit, it has enormous potential to make health care worse.

My doctor’s nurse is far better equipped to answer a question about my ongoing health problem than someone at a call center reading from a script. And, however thorough a virtual visit may be, it forsakes some of the diagnostic information that comes when you see and touch the patient.

A study published recently in Pediatrics found that children who had a telemedicine visit for an upper respiratory infection were far more likely to get an antibiotic than those who physically saw a doctor, suggesting overprescribing is at work. It makes sense: A doctor can’t use a stethoscope to listen to lungs or wiggle an otoscope into a kid’s ear by video. Similarly, a virtual physical therapist can’t feel the knots in muscle or notice a fleeting wince on a patient’s face via camera.

More important, perhaps, virtual medicine means losing the support that has long been a crucial part of the profession. There are programs to provide iPads to people in home hospice for resources about grief and chatbots that purport to treat depression. Maybe people at such challenging moments need – and deserve – human contact.

Of course, companies like those mentioned are expecting to be reimbursed for the remote monitoring and virtual advice they provide. Investors, in turn, get generous payback without having to employ so many actual doctors or other health professionals. Livongo, for instance, has raised a total of $235 million in funding over six rounds. And, as of 2018, Medicare announced it would allow such digital monitoring tools to “qualify for reimbursement,” if they are “clinically endorsed.” But, ultimately, will the well-being of patients or investors decide which tools are clinically endorsed?

So far, with its new so-called skill, Alexa will be able to perform a half-dozen health-related services. In addition to diabetes coaching, it can find the earliest urgent care appointment in a given area and check the status of a prescription drug delivery.

But it will not provide many things patients desperately want, which technology should be able to readily deliver, such as a reliable price estimate for an upcoming surgery, the infection rates at the local hospital, the location of the cheapest cholesterol test nearby. And if we’re trying to bring health care into the tech-enabled 21st century, how about starting with low-hanging fruit: Does any other sector still use paper bills and faxes?

Kaiser Health News is a nonprofit national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation that is not affiliated with Kaiser Permanente.

Amazon has opened a new health care frontier: Now Alexa can be used to transmit patient data. Using this new feature – which Amazon labeled as a “skill” – a company named Livongo will allow diabetes patients – which it calls “members” – to use the device to “query their last blood sugar reading, blood sugar measurement trends, and receive insights and Health Nudges that are personalized to them.”

Private equity and venture capital firms are in love with a legion of companies and startups touting the benefits of virtual doctors’ visits and telemedicine to revolutionize health care, investing almost $10 billion in 2018, a record for the sector. Without stepping into a gym or a clinic, a startup called Kinetxx will provide patients with virtual physical therapy, along with messaging and exercise logging. And Maven Clinic (which is not actually a physical place) offers online medical guidance and personal advice focusing on women’s health needs.

In April, at Fortune’s Brainstorm Health conference in San Diego, Bruce Broussard, CEO of health insurer Humana, said he believes technology will help patients receive help during medical crises, citing the benefits of home monitoring and the ability of doctors’ visits to be conducted by video conference.

But when I returned from Brainstorm Health, I was confronted by an alternative reality of virtual medicine: a $235 medical bill for a telehealth visit that resulted from one of my kids calling a longtime doctor’s office. It was for a five-minute phone call answering a question about a possible infection.

Virtual communications have streamlined life and transformed many of our relationships for the better. There is little need anymore to sit across the desk from a tax accountant or travel agent or to stand in a queue for a bank teller. And there is certainly room for disruptive digital innovation in our confusing and overpriced health care system.

But it remains an open question whether virtual medicine will prove a valuable, convenient adjunct to health care. Or, instead, will it be a way for the U.S. profit-driven health care system to make big bucks by outsourcing core duties – while providing a paler version of actual medical treatment?

After all, my doctors have long answered my questions and dispensed phone and email advice for free – as part of our doctor-patient relationship – though it didn’t have a cool branding moniker like telehealth. And my obstetrician’s office offered great support and advice through two difficult pregnancies – maybe they should have been paid for that valuable service. But $235 for a phone call (which works out to over $2,000 per hour)? Not even a corporate lawyer bills that.

Logic holds that some digital health tools have tremendous potential: A neurologist can view a patient by video to see if lopsided facial movements suggest a stroke. A patient with an irregular heart rhythm could send in digital tracings to see if a new prescription drug is working. But the tangible benefit of many other virtual services offered is less certain. Some people may like receiving feedback about their sleep from an Apple Watch, but I’m not sure that’s medicine.

And if virtual medicine is pursued in the name of business efficiency or just profit, it has enormous potential to make health care worse.

My doctor’s nurse is far better equipped to answer a question about my ongoing health problem than someone at a call center reading from a script. And, however thorough a virtual visit may be, it forsakes some of the diagnostic information that comes when you see and touch the patient.

A study published recently in Pediatrics found that children who had a telemedicine visit for an upper respiratory infection were far more likely to get an antibiotic than those who physically saw a doctor, suggesting overprescribing is at work. It makes sense: A doctor can’t use a stethoscope to listen to lungs or wiggle an otoscope into a kid’s ear by video. Similarly, a virtual physical therapist can’t feel the knots in muscle or notice a fleeting wince on a patient’s face via camera.

More important, perhaps, virtual medicine means losing the support that has long been a crucial part of the profession. There are programs to provide iPads to people in home hospice for resources about grief and chatbots that purport to treat depression. Maybe people at such challenging moments need – and deserve – human contact.

Of course, companies like those mentioned are expecting to be reimbursed for the remote monitoring and virtual advice they provide. Investors, in turn, get generous payback without having to employ so many actual doctors or other health professionals. Livongo, for instance, has raised a total of $235 million in funding over six rounds. And, as of 2018, Medicare announced it would allow such digital monitoring tools to “qualify for reimbursement,” if they are “clinically endorsed.” But, ultimately, will the well-being of patients or investors decide which tools are clinically endorsed?

So far, with its new so-called skill, Alexa will be able to perform a half-dozen health-related services. In addition to diabetes coaching, it can find the earliest urgent care appointment in a given area and check the status of a prescription drug delivery.

But it will not provide many things patients desperately want, which technology should be able to readily deliver, such as a reliable price estimate for an upcoming surgery, the infection rates at the local hospital, the location of the cheapest cholesterol test nearby. And if we’re trying to bring health care into the tech-enabled 21st century, how about starting with low-hanging fruit: Does any other sector still use paper bills and faxes?

Kaiser Health News is a nonprofit national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation that is not affiliated with Kaiser Permanente.

Amazon has opened a new health care frontier: Now Alexa can be used to transmit patient data. Using this new feature – which Amazon labeled as a “skill” – a company named Livongo will allow diabetes patients – which it calls “members” – to use the device to “query their last blood sugar reading, blood sugar measurement trends, and receive insights and Health Nudges that are personalized to them.”

Private equity and venture capital firms are in love with a legion of companies and startups touting the benefits of virtual doctors’ visits and telemedicine to revolutionize health care, investing almost $10 billion in 2018, a record for the sector. Without stepping into a gym or a clinic, a startup called Kinetxx will provide patients with virtual physical therapy, along with messaging and exercise logging. And Maven Clinic (which is not actually a physical place) offers online medical guidance and personal advice focusing on women’s health needs.

In April, at Fortune’s Brainstorm Health conference in San Diego, Bruce Broussard, CEO of health insurer Humana, said he believes technology will help patients receive help during medical crises, citing the benefits of home monitoring and the ability of doctors’ visits to be conducted by video conference.

But when I returned from Brainstorm Health, I was confronted by an alternative reality of virtual medicine: a $235 medical bill for a telehealth visit that resulted from one of my kids calling a longtime doctor’s office. It was for a five-minute phone call answering a question about a possible infection.

Virtual communications have streamlined life and transformed many of our relationships for the better. There is little need anymore to sit across the desk from a tax accountant or travel agent or to stand in a queue for a bank teller. And there is certainly room for disruptive digital innovation in our confusing and overpriced health care system.

But it remains an open question whether virtual medicine will prove a valuable, convenient adjunct to health care. Or, instead, will it be a way for the U.S. profit-driven health care system to make big bucks by outsourcing core duties – while providing a paler version of actual medical treatment?

After all, my doctors have long answered my questions and dispensed phone and email advice for free – as part of our doctor-patient relationship – though it didn’t have a cool branding moniker like telehealth. And my obstetrician’s office offered great support and advice through two difficult pregnancies – maybe they should have been paid for that valuable service. But $235 for a phone call (which works out to over $2,000 per hour)? Not even a corporate lawyer bills that.

Logic holds that some digital health tools have tremendous potential: A neurologist can view a patient by video to see if lopsided facial movements suggest a stroke. A patient with an irregular heart rhythm could send in digital tracings to see if a new prescription drug is working. But the tangible benefit of many other virtual services offered is less certain. Some people may like receiving feedback about their sleep from an Apple Watch, but I’m not sure that’s medicine.

And if virtual medicine is pursued in the name of business efficiency or just profit, it has enormous potential to make health care worse.

My doctor’s nurse is far better equipped to answer a question about my ongoing health problem than someone at a call center reading from a script. And, however thorough a virtual visit may be, it forsakes some of the diagnostic information that comes when you see and touch the patient.

A study published recently in Pediatrics found that children who had a telemedicine visit for an upper respiratory infection were far more likely to get an antibiotic than those who physically saw a doctor, suggesting overprescribing is at work. It makes sense: A doctor can’t use a stethoscope to listen to lungs or wiggle an otoscope into a kid’s ear by video. Similarly, a virtual physical therapist can’t feel the knots in muscle or notice a fleeting wince on a patient’s face via camera.

More important, perhaps, virtual medicine means losing the support that has long been a crucial part of the profession. There are programs to provide iPads to people in home hospice for resources about grief and chatbots that purport to treat depression. Maybe people at such challenging moments need – and deserve – human contact.

Of course, companies like those mentioned are expecting to be reimbursed for the remote monitoring and virtual advice they provide. Investors, in turn, get generous payback without having to employ so many actual doctors or other health professionals. Livongo, for instance, has raised a total of $235 million in funding over six rounds. And, as of 2018, Medicare announced it would allow such digital monitoring tools to “qualify for reimbursement,” if they are “clinically endorsed.” But, ultimately, will the well-being of patients or investors decide which tools are clinically endorsed?

So far, with its new so-called skill, Alexa will be able to perform a half-dozen health-related services. In addition to diabetes coaching, it can find the earliest urgent care appointment in a given area and check the status of a prescription drug delivery.

But it will not provide many things patients desperately want, which technology should be able to readily deliver, such as a reliable price estimate for an upcoming surgery, the infection rates at the local hospital, the location of the cheapest cholesterol test nearby. And if we’re trying to bring health care into the tech-enabled 21st century, how about starting with low-hanging fruit: Does any other sector still use paper bills and faxes?

Kaiser Health News is a nonprofit national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation that is not affiliated with Kaiser Permanente.

“There is a house in New Orleans. They call the Rising Sun. And it’s been the ruin of many a poor boy. And, God, I know I’m one.”

The 1960s rock band the Animals will tell you a tale to convince you to get vaccinated. Don’t believe me? Follow along.

The first hints of the song “House of the Rising Sun” rolled out of the hills of Appalachia.

Somewhere in the Golden Triangle, far away from New Orleans, where Virginia, Kentucky, and Tennessee rise in quiet desolation, a warning song about a tailor and a drunk emerged. Sometime around the Civil War, a hint of a tune began. Over the next century, it evolved, until it became cemented in rock culture 50 years ago by The Animals, existing as the version played most commonly today.

In the mid-19th century, medicine shows rambled through the South, stopping in places like Noetown or Daisy. The small towns would empty out for the day to see the entertainers, singers, and jugglers perform. Hundreds gathered in the hot summer day, the entertainment solely a pretext for the traveling doctors to sell their wares, the snake oil, and cure-alls, as well as various patent medicines.

These were isolated towns, with no deliveries, few visitors, and the railroad yet to arrive. Frequently, the only news from outside came from these caravans of entertainers and con men who swept into town. They were like Professor Marvel from The Wizard of Oz, or a current-day Dr. Oz, luring the crowd with false advertising, selling colored water, and then disappearing before you realized you were duped. Today, traveling doctors of the same ilk convince parents to not vaccinate their children, tell them to visit stem cell centers that claim false cures, and offer them a shiny object with one hand while taking their cash with the other.

Yet, there was a positive development in the wake of these patent medicine shows: the entertainment lingered. New songs traveled the same journeys as these medicine shows – new earworms that would then be warbled in the local bars, while doing chores around the barn, or simply during walks on the Appalachian trails.

In 1937, Alan Lomax arrived in Noetown, Ky., with a microphone and an acetate record and recorded the voice of 16-year-old Georgia Turner singing “House of the Rising Sun.” She didn’t know where she heard that song, but most likely picked it up at the medicine show.

One of those singers was Clarence Ashley, who would croon about the Rising Sun Blues. He sang with Doc Cloud and Doc Hauer, who offered tonics for whatever ailed you. Perhaps Georgia Turner heard the song in the early 1900s as well. Her 1937 version contains the lyrics most closely related to the Animals’ tune.

Lomax spent the 1940s gathering songs around the Appalachian South. He put these songs into a songbook and spread them throughout the country. He would also return to New York City and gather in a room with legendary folk singers. They would hear these new lyrics, new sounds, and make them their own.

In that room would be Lead Belly, Pete Seeger, Woody Guthrie, and Josh White, the fathers of folk music. The music Lomax pulled out of the mountains in small towns would become new again in the guitars and harmonicas of the Greenwich Village singers and musicians. Pete Seeger performed with the Weavers, named because they would weave songs from the past into new versions.

“House of the Rising Sun” was woven into the folk music landscape, evolving and growing. Josh White is credited with changing the song from a major key into the minor key we know today. Bob Dylan sang a version. And then in 1964, Eric Burdon and The Animals released their version, which became the standard. An arpeggio guitar opening, the rhythm sped up, a louder sound, and that minor key provides an emotional wallop for this warning song.

Numerous covers followed, including a beautiful version of “Amazing Grace”, sung to the tune of “House of the Rising Sun” by the Blind Boys of Alabama.

The song endures for its melody as well as for its lyrics. This was a warning song, a universal song, “not to do what I have done.” The small towns in Kentucky may have heard of the sinful ways of New Orleans and would spread the message with these songs to avoid the brothels, the drink, and the broken marriages that would reverberate with visits to the Crescent City.

“House of the Rising Sun” is one of the most covered songs, traveling wide and far, no longer with the need for a medicine show. It was a pivotal moment in rock ‘n roll, turning folk music into rock music. The Animals became huge because of this song, and their version became the standard on which all subsequent covers based their version. It made Bob Dylan’s older version seem quaint.

The song has been in my head for a while now. My wife is hoping writing about it will keep it from being played in our household any more. There are various reasons it has been resonating with me, including the following:

• It traces the origins of folk music and the importance of people like Lomax and Guthrie to collect and save Americana.
• The magic of musical evolution – a reminder of how art is built on the work of those who came before, each version with its unique personality.
• The release of “House of the Rising Sun” was a seminal, transformative moment when folk became rock music.
• The lasting power of warning songs.
• The hucksters that enabled this song to be kept alive.

That last one has really stuck with me. The medicine shows are an important part of American history. For instance, Coca-Cola started as one of those patent medicines; it was one of the many concoctions of the Atlanta pharmacist John Stith Pemberton, sold to treat all that ails us. Dr. Pepper, too, was a medicine in a sugary bottle – another that often contained alcohol or cocaine. Society wants a cure-all, and the marketing and selling done during these medicine shows offered placebos.

The hucksters exist in various forms today, selling detoxifications, magic diet cures, psychic powers of healing, or convincing parents that their kids don’t need vaccines. We need a warning song that goes viral to keep our children safe. We are blessed to be in a world without smallpox, almost rid of polio, and we have the knowledge and opportunity to rid the world of other preventable illnesses. Measles was declared eliminated in the United States in 2000; now, outbreaks emerge in every news cycle.

The CDC admits they have not been targeting misinformation well. How can we spread the science, the truth, the message faster than the lies? Better marketing? The answer may be through stories and narratives and song, with the backing of good science. “House of the Rising Sun” is a warning song. Maybe we need more. We need that deep history, that long trail to remind us of the world before vaccines, when everyone knew someone, either in their own household or next door, who succumbed to one of the childhood illnesses.

Let the “House of the Rising Sun” play on. Create a new version, and let that message reverberate, too.

Tell your children; they need to be vaccinated.
 

Dr. Messler is a hospitalist at Morton Plant Hospitalist group in Clearwater, Fla. He previously chaired SHM’s Quality and Patient Safety Committee and has been active in several SHM mentoring programs, most recently with Project BOOST and Glycemic Control. This article appeared originally in SHM's official blog The Hospital Leader. Read more recent posts here.

“There is a house in New Orleans. They call the Rising Sun. And it’s been the ruin of many a poor boy. And, God, I know I’m one.”

The 1960s rock band the Animals will tell you a tale to convince you to get vaccinated. Don’t believe me? Follow along.

The first hints of the song “House of the Rising Sun” rolled out of the hills of Appalachia.

Somewhere in the Golden Triangle, far away from New Orleans, where Virginia, Kentucky, and Tennessee rise in quiet desolation, a warning song about a tailor and a drunk emerged. Sometime around the Civil War, a hint of a tune began. Over the next century, it evolved, until it became cemented in rock culture 50 years ago by The Animals, existing as the version played most commonly today.

In the mid-19th century, medicine shows rambled through the South, stopping in places like Noetown or Daisy. The small towns would empty out for the day to see the entertainers, singers, and jugglers perform. Hundreds gathered in the hot summer day, the entertainment solely a pretext for the traveling doctors to sell their wares, the snake oil, and cure-alls, as well as various patent medicines.

These were isolated towns, with no deliveries, few visitors, and the railroad yet to arrive. Frequently, the only news from outside came from these caravans of entertainers and con men who swept into town. They were like Professor Marvel from The Wizard of Oz, or a current-day Dr. Oz, luring the crowd with false advertising, selling colored water, and then disappearing before you realized you were duped. Today, traveling doctors of the same ilk convince parents to not vaccinate their children, tell them to visit stem cell centers that claim false cures, and offer them a shiny object with one hand while taking their cash with the other.

Yet, there was a positive development in the wake of these patent medicine shows: the entertainment lingered. New songs traveled the same journeys as these medicine shows – new earworms that would then be warbled in the local bars, while doing chores around the barn, or simply during walks on the Appalachian trails.

In 1937, Alan Lomax arrived in Noetown, Ky., with a microphone and an acetate record and recorded the voice of 16-year-old Georgia Turner singing “House of the Rising Sun.” She didn’t know where she heard that song, but most likely picked it up at the medicine show.

One of those singers was Clarence Ashley, who would croon about the Rising Sun Blues. He sang with Doc Cloud and Doc Hauer, who offered tonics for whatever ailed you. Perhaps Georgia Turner heard the song in the early 1900s as well. Her 1937 version contains the lyrics most closely related to the Animals’ tune.

Lomax spent the 1940s gathering songs around the Appalachian South. He put these songs into a songbook and spread them throughout the country. He would also return to New York City and gather in a room with legendary folk singers. They would hear these new lyrics, new sounds, and make them their own.

In that room would be Lead Belly, Pete Seeger, Woody Guthrie, and Josh White, the fathers of folk music. The music Lomax pulled out of the mountains in small towns would become new again in the guitars and harmonicas of the Greenwich Village singers and musicians. Pete Seeger performed with the Weavers, named because they would weave songs from the past into new versions.

“House of the Rising Sun” was woven into the folk music landscape, evolving and growing. Josh White is credited with changing the song from a major key into the minor key we know today. Bob Dylan sang a version. And then in 1964, Eric Burdon and The Animals released their version, which became the standard. An arpeggio guitar opening, the rhythm sped up, a louder sound, and that minor key provides an emotional wallop for this warning song.

Numerous covers followed, including a beautiful version of “Amazing Grace”, sung to the tune of “House of the Rising Sun” by the Blind Boys of Alabama.

The song endures for its melody as well as for its lyrics. This was a warning song, a universal song, “not to do what I have done.” The small towns in Kentucky may have heard of the sinful ways of New Orleans and would spread the message with these songs to avoid the brothels, the drink, and the broken marriages that would reverberate with visits to the Crescent City.

“House of the Rising Sun” is one of the most covered songs, traveling wide and far, no longer with the need for a medicine show. It was a pivotal moment in rock ‘n roll, turning folk music into rock music. The Animals became huge because of this song, and their version became the standard on which all subsequent covers based their version. It made Bob Dylan’s older version seem quaint.

The song has been in my head for a while now. My wife is hoping writing about it will keep it from being played in our household any more. There are various reasons it has been resonating with me, including the following:

• It traces the origins of folk music and the importance of people like Lomax and Guthrie to collect and save Americana.
• The magic of musical evolution – a reminder of how art is built on the work of those who came before, each version with its unique personality.
• The release of “House of the Rising Sun” was a seminal, transformative moment when folk became rock music.
• The lasting power of warning songs.
• The hucksters that enabled this song to be kept alive.

That last one has really stuck with me. The medicine shows are an important part of American history. For instance, Coca-Cola started as one of those patent medicines; it was one of the many concoctions of the Atlanta pharmacist John Stith Pemberton, sold to treat all that ails us. Dr. Pepper, too, was a medicine in a sugary bottle – another that often contained alcohol or cocaine. Society wants a cure-all, and the marketing and selling done during these medicine shows offered placebos.

The hucksters exist in various forms today, selling detoxifications, magic diet cures, psychic powers of healing, or convincing parents that their kids don’t need vaccines. We need a warning song that goes viral to keep our children safe. We are blessed to be in a world without smallpox, almost rid of polio, and we have the knowledge and opportunity to rid the world of other preventable illnesses. Measles was declared eliminated in the United States in 2000; now, outbreaks emerge in every news cycle.

The CDC admits they have not been targeting misinformation well. How can we spread the science, the truth, the message faster than the lies? Better marketing? The answer may be through stories and narratives and song, with the backing of good science. “House of the Rising Sun” is a warning song. Maybe we need more. We need that deep history, that long trail to remind us of the world before vaccines, when everyone knew someone, either in their own household or next door, who succumbed to one of the childhood illnesses.

Let the “House of the Rising Sun” play on. Create a new version, and let that message reverberate, too.

Tell your children; they need to be vaccinated.
 

Dr. Messler is a hospitalist at Morton Plant Hospitalist group in Clearwater, Fla. He previously chaired SHM’s Quality and Patient Safety Committee and has been active in several SHM mentoring programs, most recently with Project BOOST and Glycemic Control. This article appeared originally in SHM's official blog The Hospital Leader. Read more recent posts here.

“There is a house in New Orleans. They call the Rising Sun. And it’s been the ruin of many a poor boy. And, God, I know I’m one.”

The 1960s rock band the Animals will tell you a tale to convince you to get vaccinated. Don’t believe me? Follow along.

The first hints of the song “House of the Rising Sun” rolled out of the hills of Appalachia.

Somewhere in the Golden Triangle, far away from New Orleans, where Virginia, Kentucky, and Tennessee rise in quiet desolation, a warning song about a tailor and a drunk emerged. Sometime around the Civil War, a hint of a tune began. Over the next century, it evolved, until it became cemented in rock culture 50 years ago by The Animals, existing as the version played most commonly today.

In the mid-19th century, medicine shows rambled through the South, stopping in places like Noetown or Daisy. The small towns would empty out for the day to see the entertainers, singers, and jugglers perform. Hundreds gathered in the hot summer day, the entertainment solely a pretext for the traveling doctors to sell their wares, the snake oil, and cure-alls, as well as various patent medicines.

These were isolated towns, with no deliveries, few visitors, and the railroad yet to arrive. Frequently, the only news from outside came from these caravans of entertainers and con men who swept into town. They were like Professor Marvel from The Wizard of Oz, or a current-day Dr. Oz, luring the crowd with false advertising, selling colored water, and then disappearing before you realized you were duped. Today, traveling doctors of the same ilk convince parents to not vaccinate their children, tell them to visit stem cell centers that claim false cures, and offer them a shiny object with one hand while taking their cash with the other.

Yet, there was a positive development in the wake of these patent medicine shows: the entertainment lingered. New songs traveled the same journeys as these medicine shows – new earworms that would then be warbled in the local bars, while doing chores around the barn, or simply during walks on the Appalachian trails.

In 1937, Alan Lomax arrived in Noetown, Ky., with a microphone and an acetate record and recorded the voice of 16-year-old Georgia Turner singing “House of the Rising Sun.” She didn’t know where she heard that song, but most likely picked it up at the medicine show.

One of those singers was Clarence Ashley, who would croon about the Rising Sun Blues. He sang with Doc Cloud and Doc Hauer, who offered tonics for whatever ailed you. Perhaps Georgia Turner heard the song in the early 1900s as well. Her 1937 version contains the lyrics most closely related to the Animals’ tune.

Lomax spent the 1940s gathering songs around the Appalachian South. He put these songs into a songbook and spread them throughout the country. He would also return to New York City and gather in a room with legendary folk singers. They would hear these new lyrics, new sounds, and make them their own.

In that room would be Lead Belly, Pete Seeger, Woody Guthrie, and Josh White, the fathers of folk music. The music Lomax pulled out of the mountains in small towns would become new again in the guitars and harmonicas of the Greenwich Village singers and musicians. Pete Seeger performed with the Weavers, named because they would weave songs from the past into new versions.

“House of the Rising Sun” was woven into the folk music landscape, evolving and growing. Josh White is credited with changing the song from a major key into the minor key we know today. Bob Dylan sang a version. And then in 1964, Eric Burdon and The Animals released their version, which became the standard. An arpeggio guitar opening, the rhythm sped up, a louder sound, and that minor key provides an emotional wallop for this warning song.

Numerous covers followed, including a beautiful version of “Amazing Grace”, sung to the tune of “House of the Rising Sun” by the Blind Boys of Alabama.

The song endures for its melody as well as for its lyrics. This was a warning song, a universal song, “not to do what I have done.” The small towns in Kentucky may have heard of the sinful ways of New Orleans and would spread the message with these songs to avoid the brothels, the drink, and the broken marriages that would reverberate with visits to the Crescent City.

“House of the Rising Sun” is one of the most covered songs, traveling wide and far, no longer with the need for a medicine show. It was a pivotal moment in rock ‘n roll, turning folk music into rock music. The Animals became huge because of this song, and their version became the standard on which all subsequent covers based their version. It made Bob Dylan’s older version seem quaint.

The song has been in my head for a while now. My wife is hoping writing about it will keep it from being played in our household any more. There are various reasons it has been resonating with me, including the following:

• It traces the origins of folk music and the importance of people like Lomax and Guthrie to collect and save Americana.
• The magic of musical evolution – a reminder of how art is built on the work of those who came before, each version with its unique personality.
• The release of “House of the Rising Sun” was a seminal, transformative moment when folk became rock music.
• The lasting power of warning songs.
• The hucksters that enabled this song to be kept alive.

That last one has really stuck with me. The medicine shows are an important part of American history. For instance, Coca-Cola started as one of those patent medicines; it was one of the many concoctions of the Atlanta pharmacist John Stith Pemberton, sold to treat all that ails us. Dr. Pepper, too, was a medicine in a sugary bottle – another that often contained alcohol or cocaine. Society wants a cure-all, and the marketing and selling done during these medicine shows offered placebos.

The hucksters exist in various forms today, selling detoxifications, magic diet cures, psychic powers of healing, or convincing parents that their kids don’t need vaccines. We need a warning song that goes viral to keep our children safe. We are blessed to be in a world without smallpox, almost rid of polio, and we have the knowledge and opportunity to rid the world of other preventable illnesses. Measles was declared eliminated in the United States in 2000; now, outbreaks emerge in every news cycle.

The CDC admits they have not been targeting misinformation well. How can we spread the science, the truth, the message faster than the lies? Better marketing? The answer may be through stories and narratives and song, with the backing of good science. “House of the Rising Sun” is a warning song. Maybe we need more. We need that deep history, that long trail to remind us of the world before vaccines, when everyone knew someone, either in their own household or next door, who succumbed to one of the childhood illnesses.

Let the “House of the Rising Sun” play on. Create a new version, and let that message reverberate, too.

Tell your children; they need to be vaccinated.
 

Dr. Messler is a hospitalist at Morton Plant Hospitalist group in Clearwater, Fla. He previously chaired SHM’s Quality and Patient Safety Committee and has been active in several SHM mentoring programs, most recently with Project BOOST and Glycemic Control. This article appeared originally in SHM's official blog The Hospital Leader. Read more recent posts here.

When you have a few spare minutes on your lunch break, walk by the grade school playground in your neighborhood. Even at a quick glance you will notice that almost all the children are in motion – running, chasing, or being chased. Don’t linger too long or make repeat visits because unfortunately your presence may raise suspicions about your motives. But, even on your brief visit, you will also notice that there are a few children who are sitting down either chatting with a classmate or playing by themselves. If despite my caution you returned several days in a row, you would have noticed that the sedentary outliers tend to be the same children.

©Jupiterimages/Thinkstock.com

Some of the children playing alone simply may be shy loners or socially inept. But I’ve always suspected that there are some people who come in the world genetically predisposed to being sedentary. You can try to make the environment more enticing and stimulating, but the children predestined to be inactive will choose to sit and watch. Not surprisingly, most of those less active children are predestined to be overweight and obese.

At least as young children we seem to be driven to be active, and it is the few outliers who are sedentary. A recent investigation from the department of health and kinesiology at Texas A&M University at College Station is beginning to shed some light on when in our evolutionary history the urge to be active was incorporated into our genome (PLOS ONE. 2019 Apr 29. doi: 10.1371/journal.pone.0216155). The researchers found that snippets of DNA already known to be associated with levels of activity emerged in our ancestors before we were Homo sapiens about 500,000 years ago. This finding surprised the investigators who had suspected that this incorporation of a gene sequence driving activity was more likely to have occurred ten thousand years ago when subsistence farming and its physical demands first appeared.

The authors now postulate that the drive to be active coincided as pre–Homo sapiens grew larger and moved from a treed landscape into the open savanna (“To Move Is to Thrive. It’s in Our Genes” by Gretchen Reynolds. The New York Times, May 15, 2019). As J. Timothy Lightfoot, the senior investigator, observed, “If you were lazy then, you did not survive.”

So if the drive to be active is so deeply buried in our genome why have we slipped so easily into a species in which being sedentary is the norm? Our observation of a playground in contact motion is probably evidence that those snippets of DNA still are buried in our genome. However, it is abundantly clear that in North America one doesn’t need to be active to survive, at least in the sense of being reproductively fit. It only takes a few us who must be physically active to grow and build things that we in the sedentary majority can buy or trade for.

There are some of us who have inherited some DNA snippets that drive us to be active post early childhood. My father walked two or three times a day until a few months before his death at 92, and not because someone told him it do it for his health. Like him, I just feel better if I have spent a couple of hours being active every day.

The challenge for us as pediatricians is to help families create environments that foster continued activity by discouraging sedentary entertainments and modeling active lifestyles. For example, simple things like choosing a spot at the periphery of the parking lot instead of close to the store. Choosing stairs instead of the elevator. Of course, anything you will be doing is artificial because the truth is we don’t need to be active to survive even though the urge to move is deeply rooted in our genes.
 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at pdnews@mdedge.com.

When you have a few spare minutes on your lunch break, walk by the grade school playground in your neighborhood. Even at a quick glance you will notice that almost all the children are in motion – running, chasing, or being chased. Don’t linger too long or make repeat visits because unfortunately your presence may raise suspicions about your motives. But, even on your brief visit, you will also notice that there are a few children who are sitting down either chatting with a classmate or playing by themselves. If despite my caution you returned several days in a row, you would have noticed that the sedentary outliers tend to be the same children.

©Jupiterimages/Thinkstock.com

Some of the children playing alone simply may be shy loners or socially inept. But I’ve always suspected that there are some people who come in the world genetically predisposed to being sedentary. You can try to make the environment more enticing and stimulating, but the children predestined to be inactive will choose to sit and watch. Not surprisingly, most of those less active children are predestined to be overweight and obese.

At least as young children we seem to be driven to be active, and it is the few outliers who are sedentary. A recent investigation from the department of health and kinesiology at Texas A&M University at College Station is beginning to shed some light on when in our evolutionary history the urge to be active was incorporated into our genome (PLOS ONE. 2019 Apr 29. doi: 10.1371/journal.pone.0216155). The researchers found that snippets of DNA already known to be associated with levels of activity emerged in our ancestors before we were Homo sapiens about 500,000 years ago. This finding surprised the investigators who had suspected that this incorporation of a gene sequence driving activity was more likely to have occurred ten thousand years ago when subsistence farming and its physical demands first appeared.

The authors now postulate that the drive to be active coincided as pre–Homo sapiens grew larger and moved from a treed landscape into the open savanna (“To Move Is to Thrive. It’s in Our Genes” by Gretchen Reynolds. The New York Times, May 15, 2019). As J. Timothy Lightfoot, the senior investigator, observed, “If you were lazy then, you did not survive.”

So if the drive to be active is so deeply buried in our genome why have we slipped so easily into a species in which being sedentary is the norm? Our observation of a playground in contact motion is probably evidence that those snippets of DNA still are buried in our genome. However, it is abundantly clear that in North America one doesn’t need to be active to survive, at least in the sense of being reproductively fit. It only takes a few us who must be physically active to grow and build things that we in the sedentary majority can buy or trade for.

There are some of us who have inherited some DNA snippets that drive us to be active post early childhood. My father walked two or three times a day until a few months before his death at 92, and not because someone told him it do it for his health. Like him, I just feel better if I have spent a couple of hours being active every day.

The challenge for us as pediatricians is to help families create environments that foster continued activity by discouraging sedentary entertainments and modeling active lifestyles. For example, simple things like choosing a spot at the periphery of the parking lot instead of close to the store. Choosing stairs instead of the elevator. Of course, anything you will be doing is artificial because the truth is we don’t need to be active to survive even though the urge to move is deeply rooted in our genes.
 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at pdnews@mdedge.com.

When you have a few spare minutes on your lunch break, walk by the grade school playground in your neighborhood. Even at a quick glance you will notice that almost all the children are in motion – running, chasing, or being chased. Don’t linger too long or make repeat visits because unfortunately your presence may raise suspicions about your motives. But, even on your brief visit, you will also notice that there are a few children who are sitting down either chatting with a classmate or playing by themselves. If despite my caution you returned several days in a row, you would have noticed that the sedentary outliers tend to be the same children.

©Jupiterimages/Thinkstock.com

Some of the children playing alone simply may be shy loners or socially inept. But I’ve always suspected that there are some people who come in the world genetically predisposed to being sedentary. You can try to make the environment more enticing and stimulating, but the children predestined to be inactive will choose to sit and watch. Not surprisingly, most of those less active children are predestined to be overweight and obese.

At least as young children we seem to be driven to be active, and it is the few outliers who are sedentary. A recent investigation from the department of health and kinesiology at Texas A&M University at College Station is beginning to shed some light on when in our evolutionary history the urge to be active was incorporated into our genome (PLOS ONE. 2019 Apr 29. doi: 10.1371/journal.pone.0216155). The researchers found that snippets of DNA already known to be associated with levels of activity emerged in our ancestors before we were Homo sapiens about 500,000 years ago. This finding surprised the investigators who had suspected that this incorporation of a gene sequence driving activity was more likely to have occurred ten thousand years ago when subsistence farming and its physical demands first appeared.

The authors now postulate that the drive to be active coincided as pre–Homo sapiens grew larger and moved from a treed landscape into the open savanna (“To Move Is to Thrive. It’s in Our Genes” by Gretchen Reynolds. The New York Times, May 15, 2019). As J. Timothy Lightfoot, the senior investigator, observed, “If you were lazy then, you did not survive.”

So if the drive to be active is so deeply buried in our genome why have we slipped so easily into a species in which being sedentary is the norm? Our observation of a playground in contact motion is probably evidence that those snippets of DNA still are buried in our genome. However, it is abundantly clear that in North America one doesn’t need to be active to survive, at least in the sense of being reproductively fit. It only takes a few us who must be physically active to grow and build things that we in the sedentary majority can buy or trade for.

There are some of us who have inherited some DNA snippets that drive us to be active post early childhood. My father walked two or three times a day until a few months before his death at 92, and not because someone told him it do it for his health. Like him, I just feel better if I have spent a couple of hours being active every day.

The challenge for us as pediatricians is to help families create environments that foster continued activity by discouraging sedentary entertainments and modeling active lifestyles. For example, simple things like choosing a spot at the periphery of the parking lot instead of close to the store. Choosing stairs instead of the elevator. Of course, anything you will be doing is artificial because the truth is we don’t need to be active to survive even though the urge to move is deeply rooted in our genes.
 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at pdnews@mdedge.com.

In April 2017, the Centers for Medicare and Medicaid Services implemented the new physician specialty code C6, specifically for hospitalists. There has been a lot of confusion about what this means and some uncertainty about why clinicians should bother to use it.

Some folks thought initially that it was a new CPT code they could use to bill hospitalist services, which might recognize the increased intensity of services hospitalists often provide to their hospitalized patients compared to many traditional internal medicine and family medicine primary care physicians. Others thought it was a code that was added to the HCFA 1500 billing form somewhere to designate that the service was provided by a hospitalist.

Neither is true. The C6 physician specialty code is one of a large number of such codes used by physicians to designate their primary physician specialty when they enroll with Medicare via the PECOS online enrollment system. It describes the unique type of medicine practiced by the enrolling physician and is used by the CMS both for claims processing purposes and for “programmatic” purposes (whatever that means).

It doesn’t change how your claim is processed or how much you get paid. So why bother going through the laborious process of re-credentialing with CMS via PECOS just to change your specialty code? Well, I believe there are several ways in which the C6 specialty code provides value – both to you and to the specialty of hospital medicine.

Reduce concurrent care denials

First, it distinguishes you from a general internal medicine or general family medicine practitioner by recognizing “hospitalist” as a distinct specialty. This can be valuable from a financial perspective because it may reduce the risk that claims for your services might be denied due to “concurrent care” by another provider in the same specialty on the same calendar day.

And it’s not just a general internist or family medicine physician that you might run into concurrent care trouble with. I’ve seen situations where doctors completed critical care or cardiology fellowships but never got around to re-credentialing with Medicare in their new specialty, so their claims still showed up with an “internal medicine” physician specialty code, resulting in denied “concurrent care” claims for either the hospitalist or the specialist.

While Medicare may still see unnecessary overlap between services provided by you and an internal medicine or family physician to the same patient on the same calendar day, you can make a better argument that your services were unique and complementary to (not duplicative of) the services of others if you are credentialed as a hospitalist.

Ensure “apples to apples” comparisons

A second reason to re-credential as a hospitalist is to ensure that when the CMS looks at the services you are providing and the CPT codes you are selecting, it is comparing you to an appropriate peer group for compliance purposes.

The mix of CPT codes reported by hospitalists in the SHM State of Hospital Medicine Survey has historically tilted toward higher-level care than has the mix of CPT codes reported by the CMS for internal medicine or family medicine physicians. But last year when Medicare released the utilization of evaluation and management services by specialty for calendar year 2017, CPT utilization was shown separately for hospitalists for the first time!

The volume of services reported for physicians credentialed as hospitalists was very small relative to the volume of inpatient services provided by internal medicine and family medicine physicians, but the distribution of inpatient admission, subsequent visit, and discharge codes for hospitalists closely mirrored those reported by SHM in its 2018 State of Hospital Medicine Report (see graphic).

If you’re going to be targeted in a RAC audit for the high proportion of 99233s you bill, you want to be sure the CMS is looking at your performance compared to those who are truly your peers, caring for patients of the same type and complexity.

Improve CMS data used for research purposes

Finally, the ability of academic hospitalists and other health services researchers to utilize Medicare claims data to better understand the care provided by hospitalists and its impact on the overall health care system will be significantly enhanced by a more robust presence of physicians who have identified themselves as hospitalists in the PECOS credentialing system.

We care for the majority of patients in most hospitals these days, yet “hospitalists” billed only 2,009,869 inpatient subsequent visits (CPT codes 99231, 99232, and 99233) in 2017 compared to 25,903,829 billed by internal medicine physicians and 4,678,111 billed by family medicine physicians. And regardless of what you think about using claims data as a proxy for health care services and quality, it’s undeniably the best data set we currently have.

So, let’s work together to build a bigger, better database of hospitalist information at the CMS. I urge you to go to your credentialing folks today and find out how you can work with them to get yourself re-credentialed in PECOS using the C6 “hospitalist” physician specialty.
 

Ms. Flores is a partner at Nelson Flores Hospital Medicine Consultants, La Quinta, Calif. She serves on SHM’s Practice Analysis and Annual Meeting Committees, and helps to coordinate SHM’s bi-annual State of Hospital Medicine Survey. This article appeared originally in SHM's official blog The Hospital Leader. Read more recent posts here.

In April 2017, the Centers for Medicare and Medicaid Services implemented the new physician specialty code C6, specifically for hospitalists. There has been a lot of confusion about what this means and some uncertainty about why clinicians should bother to use it.

Some folks thought initially that it was a new CPT code they could use to bill hospitalist services, which might recognize the increased intensity of services hospitalists often provide to their hospitalized patients compared to many traditional internal medicine and family medicine primary care physicians. Others thought it was a code that was added to the HCFA 1500 billing form somewhere to designate that the service was provided by a hospitalist.

Neither is true. The C6 physician specialty code is one of a large number of such codes used by physicians to designate their primary physician specialty when they enroll with Medicare via the PECOS online enrollment system. It describes the unique type of medicine practiced by the enrolling physician and is used by the CMS both for claims processing purposes and for “programmatic” purposes (whatever that means).

It doesn’t change how your claim is processed or how much you get paid. So why bother going through the laborious process of re-credentialing with CMS via PECOS just to change your specialty code? Well, I believe there are several ways in which the C6 specialty code provides value – both to you and to the specialty of hospital medicine.

Reduce concurrent care denials

First, it distinguishes you from a general internal medicine or general family medicine practitioner by recognizing “hospitalist” as a distinct specialty. This can be valuable from a financial perspective because it may reduce the risk that claims for your services might be denied due to “concurrent care” by another provider in the same specialty on the same calendar day.

And it’s not just a general internist or family medicine physician that you might run into concurrent care trouble with. I’ve seen situations where doctors completed critical care or cardiology fellowships but never got around to re-credentialing with Medicare in their new specialty, so their claims still showed up with an “internal medicine” physician specialty code, resulting in denied “concurrent care” claims for either the hospitalist or the specialist.

While Medicare may still see unnecessary overlap between services provided by you and an internal medicine or family physician to the same patient on the same calendar day, you can make a better argument that your services were unique and complementary to (not duplicative of) the services of others if you are credentialed as a hospitalist.

Ensure “apples to apples” comparisons

A second reason to re-credential as a hospitalist is to ensure that when the CMS looks at the services you are providing and the CPT codes you are selecting, it is comparing you to an appropriate peer group for compliance purposes.

The mix of CPT codes reported by hospitalists in the SHM State of Hospital Medicine Survey has historically tilted toward higher-level care than has the mix of CPT codes reported by the CMS for internal medicine or family medicine physicians. But last year when Medicare released the utilization of evaluation and management services by specialty for calendar year 2017, CPT utilization was shown separately for hospitalists for the first time!

The volume of services reported for physicians credentialed as hospitalists was very small relative to the volume of inpatient services provided by internal medicine and family medicine physicians, but the distribution of inpatient admission, subsequent visit, and discharge codes for hospitalists closely mirrored those reported by SHM in its 2018 State of Hospital Medicine Report (see graphic).

If you’re going to be targeted in a RAC audit for the high proportion of 99233s you bill, you want to be sure the CMS is looking at your performance compared to those who are truly your peers, caring for patients of the same type and complexity.

Improve CMS data used for research purposes

Finally, the ability of academic hospitalists and other health services researchers to utilize Medicare claims data to better understand the care provided by hospitalists and its impact on the overall health care system will be significantly enhanced by a more robust presence of physicians who have identified themselves as hospitalists in the PECOS credentialing system.

We care for the majority of patients in most hospitals these days, yet “hospitalists” billed only 2,009,869 inpatient subsequent visits (CPT codes 99231, 99232, and 99233) in 2017 compared to 25,903,829 billed by internal medicine physicians and 4,678,111 billed by family medicine physicians. And regardless of what you think about using claims data as a proxy for health care services and quality, it’s undeniably the best data set we currently have.

So, let’s work together to build a bigger, better database of hospitalist information at the CMS. I urge you to go to your credentialing folks today and find out how you can work with them to get yourself re-credentialed in PECOS using the C6 “hospitalist” physician specialty.
 

Ms. Flores is a partner at Nelson Flores Hospital Medicine Consultants, La Quinta, Calif. She serves on SHM’s Practice Analysis and Annual Meeting Committees, and helps to coordinate SHM’s bi-annual State of Hospital Medicine Survey. This article appeared originally in SHM's official blog The Hospital Leader. Read more recent posts here.

In April 2017, the Centers for Medicare and Medicaid Services implemented the new physician specialty code C6, specifically for hospitalists. There has been a lot of confusion about what this means and some uncertainty about why clinicians should bother to use it.

Some folks thought initially that it was a new CPT code they could use to bill hospitalist services, which might recognize the increased intensity of services hospitalists often provide to their hospitalized patients compared to many traditional internal medicine and family medicine primary care physicians. Others thought it was a code that was added to the HCFA 1500 billing form somewhere to designate that the service was provided by a hospitalist.

Neither is true. The C6 physician specialty code is one of a large number of such codes used by physicians to designate their primary physician specialty when they enroll with Medicare via the PECOS online enrollment system. It describes the unique type of medicine practiced by the enrolling physician and is used by the CMS both for claims processing purposes and for “programmatic” purposes (whatever that means).

It doesn’t change how your claim is processed or how much you get paid. So why bother going through the laborious process of re-credentialing with CMS via PECOS just to change your specialty code? Well, I believe there are several ways in which the C6 specialty code provides value – both to you and to the specialty of hospital medicine.

Reduce concurrent care denials

First, it distinguishes you from a general internal medicine or general family medicine practitioner by recognizing “hospitalist” as a distinct specialty. This can be valuable from a financial perspective because it may reduce the risk that claims for your services might be denied due to “concurrent care” by another provider in the same specialty on the same calendar day.

And it’s not just a general internist or family medicine physician that you might run into concurrent care trouble with. I’ve seen situations where doctors completed critical care or cardiology fellowships but never got around to re-credentialing with Medicare in their new specialty, so their claims still showed up with an “internal medicine” physician specialty code, resulting in denied “concurrent care” claims for either the hospitalist or the specialist.

While Medicare may still see unnecessary overlap between services provided by you and an internal medicine or family physician to the same patient on the same calendar day, you can make a better argument that your services were unique and complementary to (not duplicative of) the services of others if you are credentialed as a hospitalist.

Ensure “apples to apples” comparisons

A second reason to re-credential as a hospitalist is to ensure that when the CMS looks at the services you are providing and the CPT codes you are selecting, it is comparing you to an appropriate peer group for compliance purposes.

The mix of CPT codes reported by hospitalists in the SHM State of Hospital Medicine Survey has historically tilted toward higher-level care than has the mix of CPT codes reported by the CMS for internal medicine or family medicine physicians. But last year when Medicare released the utilization of evaluation and management services by specialty for calendar year 2017, CPT utilization was shown separately for hospitalists for the first time!

The volume of services reported for physicians credentialed as hospitalists was very small relative to the volume of inpatient services provided by internal medicine and family medicine physicians, but the distribution of inpatient admission, subsequent visit, and discharge codes for hospitalists closely mirrored those reported by SHM in its 2018 State of Hospital Medicine Report (see graphic).

If you’re going to be targeted in a RAC audit for the high proportion of 99233s you bill, you want to be sure the CMS is looking at your performance compared to those who are truly your peers, caring for patients of the same type and complexity.

Improve CMS data used for research purposes

Finally, the ability of academic hospitalists and other health services researchers to utilize Medicare claims data to better understand the care provided by hospitalists and its impact on the overall health care system will be significantly enhanced by a more robust presence of physicians who have identified themselves as hospitalists in the PECOS credentialing system.

We care for the majority of patients in most hospitals these days, yet “hospitalists” billed only 2,009,869 inpatient subsequent visits (CPT codes 99231, 99232, and 99233) in 2017 compared to 25,903,829 billed by internal medicine physicians and 4,678,111 billed by family medicine physicians. And regardless of what you think about using claims data as a proxy for health care services and quality, it’s undeniably the best data set we currently have.

So, let’s work together to build a bigger, better database of hospitalist information at the CMS. I urge you to go to your credentialing folks today and find out how you can work with them to get yourself re-credentialed in PECOS using the C6 “hospitalist” physician specialty.
 

Ms. Flores is a partner at Nelson Flores Hospital Medicine Consultants, La Quinta, Calif. She serves on SHM’s Practice Analysis and Annual Meeting Committees, and helps to coordinate SHM’s bi-annual State of Hospital Medicine Survey. This article appeared originally in SHM's official blog The Hospital Leader. Read more recent posts here.