Jeff Glasheen, MD, FHM

Silence.

Alone, I’m surrounded by strobes of memories—the baby monitor wresting us from sleep … muffled choking sounds … my wife holding our pale, stridorous 2-year-old … desperate attempts to clear his airway … the studied detachment of the 911 operator … paramedics … my wife running from the house without a jacket ... the fading ululations of the ambulance … silence.

I’m left in the bathroom, heart jack-hammering, holding a bloodied towel. Just 20 minutes earlier, I was cloaked in deep sleep. Now I’m shrouded with dread and cold sweat, my wife and son gone—leaving me to tend to our sleeping three-month-old daughter. The night ultimately ends well—perhaps comically, even—but not before being defined by three common cognitive errors.

History of Present Illness

It was a Monday night, and, after putting our kids down, my wife and I retired early to get a good night’s rest. An hour later, we awoke to gasping sounds from the monitor. My son, Grey, who was fine before bedtime, was panting and wheezing, unable to secure a full breath.

I immediately recalled that the night prior he had gagged on a dissolvable “gummy bear” vitamin. As he projected the appearance of someone who had aspirated something, we commenced manual sweeps of his mouth—feeling something in its deepest recesses. Gummy bear? Uvula? After numerous retching attempts to dislodge it, we moved on to Heimlich maneuvers. Nothing.

Just then, the paramedics showed up and took over, hearing this history of present illness.

Momentum Shift

An hour later, having secured a sitter for our sleeping infant, I showed up at the ED. Interestingly, the gummy-bear premise, nothing more than a harried utterance, had gathered the momentum of a boulder rolling downhill. The paramedics had relayed the possibility that our son might have aspirated a vitamin to the ED doctor, who relayed this certainty to the ear, nose, and throat doctor, who was actively scheduling operating-room time to bronchoscopically remove the offending foreign body.

It was all a bit like that childhood game of Telephone, in which the original message gets incrementally distorted with each telling, such that what starts as “Johnny told me he likes Lisa” turns into “Johnny crushed Lisa.”

My inner physician, elbowing the nervous parent aside, asked about the evidence for an aspiration. “The X-ray was negative, as was the exam, but the history suggests aspiration,” the ENT told me.

“What history?” I asked.

“That he has a history of ‘tonguing’ vitamins,” he said.

“Tonguing vitamins?” I responded, incredulously feeling the need to defend my child’s pill-swallowing honor. “Where did that story come from? We aren’t even sure we gave him a vitamin tonight.”

Nonetheless, the ENT was confident that “kids aspirate things all the time.”

Skeptical, I continued the debate. “But what if we hadn’t given that history? Would you still think of aspiration in this case?”

“Probably not, but then you did give us that history,” he replied. “So we need to bronch him.”

Culprit Revealed

Meanwhile, Grey was looking better with supplemental oxygen and a nebulizer’s worth of racemic epinephrine. His stridor took on more of a “barking seal” nature, and 30 minutes later, he developed a fever characteristic of croup. After a dose of steroids and another whiff of racemic epi, he was himself again, laughing the laugh of a wounded seal at the pulse oximeter, which backlit his big toe red. Comedy-club-level laughter replaced the look of death in the matter of an hour, as I was reminded of the resiliency of children. If only Mom and Dad could capture a bit of that.

Feeling a cocktail of relief and embarrassment—how could two physicians misdiagnose croup as an aspirated foreign body?—we readied ourselves for discharge. Just then, the ENT doctor came back in and told us the OR would be ready in a few hours. “But,” I inquired, “isn’t this just croup?”

“Most likely,” he replied, “but we can’t rule out aspiration without a bronchoscopy.”

It was then that I realized we (and our medical team) had fallen victim to some common heuristical errors. Heuristics are those little shortcuts in logic that we utilize to solve common problems. They are bred from years of experience and helpfully get us home every night in time for dinner. Without them, medicine would be a painstaking, Everlasting Gobstopper-like journey through endless differential diagnoses—in other words, your four-hour clerkship patient evaluations in medical school.

These shortcuts allow us to quickly recognize that a diaphoretic, 60-year-old man with diabetes, hyperlipidemia, and substernal chest pain has an acute coronary syndrome. We don’t spend hours thinking of Tietze’s syndrome, Boerhaave’s disease, and their ilk, because our mind quickly takes the shortcut to the right diagnosis. Although helpful, these shortcuts can cut both ways, occasionally resulting in thrombolytic therapy for an aortic dissection.

This is where Grey’s situation went wrong. My wife and I were victimized by the availability bias. This cognitive bias occurs when a recently encountered situation is given undue stature solely because of its proximity in time to the next event—i.e., it is “available.” So, because my son choked on a vitamin the night before, he must be choking on a vitamin the next night. (Even though we didn’t give him a vitamin and hours had passed since we put him to bed.) There is little connection between the two events, outside of the fact that aspiration is at the fore of your mind. This happens to us all the time. Think about the last presentation you attended about an obscure topic, only to amazingly find that the very next day, you had not one but two patients who surely required a workup for acute intermittent porphyria.

Common Practices

Anchoring bias is another common cognitive error in which we overly rely on one piece of information, the “anchor.” This was certainly in play during our ED visit. The mere mention of an aspirated foreign body was latched on to immediately. From there, tidbits of information that supported that diagnosis (something in the back of his throat on our exam, kids aspirate all the time) were kept, while the unsupporting evidence (negative X-ray and exam findings, fever, barking cough that awakes a kid at night) was jettisoned.

We fell prey to the momentum bias. This heuristical hiccup frequently wreaks cross-coverage havoc. You’ve seen this, I’m sure. Because the day team thought the renal failure was due to prerenal azotemia, the night team harmonizes, continuing to treat the patient’s bladder outlet obstruction with volume challenges. That is until someone—in my sphere, it’s usually the third-year medical student—asks if this could all be from the patient’s benign prostatic hyperplasia and medications.

After convincing our well-intentioned ENT colleague to call off the bronch, I was left with the important lesson that the ways in which our minds work, also well-intentioned, can cause us fits of trouble. I was left with the realization that the only way to mitigate the risk these cognitive shortcuts pose is to be constantly vigilant of their presence.

And, perhaps most importantly, I was left with an overstimulated 2-year-old high on the excitement of a hospital visit and large doses of adrenaline—a combination that left me desperately yearning for silence. TH

Dr. Glasheen is The Hospitalist’s physician editor.

Silence.

Alone, I’m surrounded by strobes of memories—the baby monitor wresting us from sleep … muffled choking sounds … my wife holding our pale, stridorous 2-year-old … desperate attempts to clear his airway … the studied detachment of the 911 operator … paramedics … my wife running from the house without a jacket ... the fading ululations of the ambulance … silence.

I’m left in the bathroom, heart jack-hammering, holding a bloodied towel. Just 20 minutes earlier, I was cloaked in deep sleep. Now I’m shrouded with dread and cold sweat, my wife and son gone—leaving me to tend to our sleeping three-month-old daughter. The night ultimately ends well—perhaps comically, even—but not before being defined by three common cognitive errors.

History of Present Illness

It was a Monday night, and, after putting our kids down, my wife and I retired early to get a good night’s rest. An hour later, we awoke to gasping sounds from the monitor. My son, Grey, who was fine before bedtime, was panting and wheezing, unable to secure a full breath.

I immediately recalled that the night prior he had gagged on a dissolvable “gummy bear” vitamin. As he projected the appearance of someone who had aspirated something, we commenced manual sweeps of his mouth—feeling something in its deepest recesses. Gummy bear? Uvula? After numerous retching attempts to dislodge it, we moved on to Heimlich maneuvers. Nothing.

Just then, the paramedics showed up and took over, hearing this history of present illness.

Momentum Shift

An hour later, having secured a sitter for our sleeping infant, I showed up at the ED. Interestingly, the gummy-bear premise, nothing more than a harried utterance, had gathered the momentum of a boulder rolling downhill. The paramedics had relayed the possibility that our son might have aspirated a vitamin to the ED doctor, who relayed this certainty to the ear, nose, and throat doctor, who was actively scheduling operating-room time to bronchoscopically remove the offending foreign body.

It was all a bit like that childhood game of Telephone, in which the original message gets incrementally distorted with each telling, such that what starts as “Johnny told me he likes Lisa” turns into “Johnny crushed Lisa.”

My inner physician, elbowing the nervous parent aside, asked about the evidence for an aspiration. “The X-ray was negative, as was the exam, but the history suggests aspiration,” the ENT told me.

“What history?” I asked.

“That he has a history of ‘tonguing’ vitamins,” he said.

“Tonguing vitamins?” I responded, incredulously feeling the need to defend my child’s pill-swallowing honor. “Where did that story come from? We aren’t even sure we gave him a vitamin tonight.”

Nonetheless, the ENT was confident that “kids aspirate things all the time.”

Skeptical, I continued the debate. “But what if we hadn’t given that history? Would you still think of aspiration in this case?”

“Probably not, but then you did give us that history,” he replied. “So we need to bronch him.”

Culprit Revealed

Meanwhile, Grey was looking better with supplemental oxygen and a nebulizer’s worth of racemic epinephrine. His stridor took on more of a “barking seal” nature, and 30 minutes later, he developed a fever characteristic of croup. After a dose of steroids and another whiff of racemic epi, he was himself again, laughing the laugh of a wounded seal at the pulse oximeter, which backlit his big toe red. Comedy-club-level laughter replaced the look of death in the matter of an hour, as I was reminded of the resiliency of children. If only Mom and Dad could capture a bit of that.

Feeling a cocktail of relief and embarrassment—how could two physicians misdiagnose croup as an aspirated foreign body?—we readied ourselves for discharge. Just then, the ENT doctor came back in and told us the OR would be ready in a few hours. “But,” I inquired, “isn’t this just croup?”

“Most likely,” he replied, “but we can’t rule out aspiration without a bronchoscopy.”

It was then that I realized we (and our medical team) had fallen victim to some common heuristical errors. Heuristics are those little shortcuts in logic that we utilize to solve common problems. They are bred from years of experience and helpfully get us home every night in time for dinner. Without them, medicine would be a painstaking, Everlasting Gobstopper-like journey through endless differential diagnoses—in other words, your four-hour clerkship patient evaluations in medical school.

These shortcuts allow us to quickly recognize that a diaphoretic, 60-year-old man with diabetes, hyperlipidemia, and substernal chest pain has an acute coronary syndrome. We don’t spend hours thinking of Tietze’s syndrome, Boerhaave’s disease, and their ilk, because our mind quickly takes the shortcut to the right diagnosis. Although helpful, these shortcuts can cut both ways, occasionally resulting in thrombolytic therapy for an aortic dissection.

This is where Grey’s situation went wrong. My wife and I were victimized by the availability bias. This cognitive bias occurs when a recently encountered situation is given undue stature solely because of its proximity in time to the next event—i.e., it is “available.” So, because my son choked on a vitamin the night before, he must be choking on a vitamin the next night. (Even though we didn’t give him a vitamin and hours had passed since we put him to bed.) There is little connection between the two events, outside of the fact that aspiration is at the fore of your mind. This happens to us all the time. Think about the last presentation you attended about an obscure topic, only to amazingly find that the very next day, you had not one but two patients who surely required a workup for acute intermittent porphyria.

Common Practices

Anchoring bias is another common cognitive error in which we overly rely on one piece of information, the “anchor.” This was certainly in play during our ED visit. The mere mention of an aspirated foreign body was latched on to immediately. From there, tidbits of information that supported that diagnosis (something in the back of his throat on our exam, kids aspirate all the time) were kept, while the unsupporting evidence (negative X-ray and exam findings, fever, barking cough that awakes a kid at night) was jettisoned.

We fell prey to the momentum bias. This heuristical hiccup frequently wreaks cross-coverage havoc. You’ve seen this, I’m sure. Because the day team thought the renal failure was due to prerenal azotemia, the night team harmonizes, continuing to treat the patient’s bladder outlet obstruction with volume challenges. That is until someone—in my sphere, it’s usually the third-year medical student—asks if this could all be from the patient’s benign prostatic hyperplasia and medications.

After convincing our well-intentioned ENT colleague to call off the bronch, I was left with the important lesson that the ways in which our minds work, also well-intentioned, can cause us fits of trouble. I was left with the realization that the only way to mitigate the risk these cognitive shortcuts pose is to be constantly vigilant of their presence.

And, perhaps most importantly, I was left with an overstimulated 2-year-old high on the excitement of a hospital visit and large doses of adrenaline—a combination that left me desperately yearning for silence. TH

Dr. Glasheen is The Hospitalist’s physician editor.

Silence.

Alone, I’m surrounded by strobes of memories—the baby monitor wresting us from sleep … muffled choking sounds … my wife holding our pale, stridorous 2-year-old … desperate attempts to clear his airway … the studied detachment of the 911 operator … paramedics … my wife running from the house without a jacket ... the fading ululations of the ambulance … silence.

I’m left in the bathroom, heart jack-hammering, holding a bloodied towel. Just 20 minutes earlier, I was cloaked in deep sleep. Now I’m shrouded with dread and cold sweat, my wife and son gone—leaving me to tend to our sleeping three-month-old daughter. The night ultimately ends well—perhaps comically, even—but not before being defined by three common cognitive errors.

History of Present Illness

It was a Monday night, and, after putting our kids down, my wife and I retired early to get a good night’s rest. An hour later, we awoke to gasping sounds from the monitor. My son, Grey, who was fine before bedtime, was panting and wheezing, unable to secure a full breath.

I immediately recalled that the night prior he had gagged on a dissolvable “gummy bear” vitamin. As he projected the appearance of someone who had aspirated something, we commenced manual sweeps of his mouth—feeling something in its deepest recesses. Gummy bear? Uvula? After numerous retching attempts to dislodge it, we moved on to Heimlich maneuvers. Nothing.

Just then, the paramedics showed up and took over, hearing this history of present illness.

Momentum Shift

An hour later, having secured a sitter for our sleeping infant, I showed up at the ED. Interestingly, the gummy-bear premise, nothing more than a harried utterance, had gathered the momentum of a boulder rolling downhill. The paramedics had relayed the possibility that our son might have aspirated a vitamin to the ED doctor, who relayed this certainty to the ear, nose, and throat doctor, who was actively scheduling operating-room time to bronchoscopically remove the offending foreign body.

It was all a bit like that childhood game of Telephone, in which the original message gets incrementally distorted with each telling, such that what starts as “Johnny told me he likes Lisa” turns into “Johnny crushed Lisa.”

My inner physician, elbowing the nervous parent aside, asked about the evidence for an aspiration. “The X-ray was negative, as was the exam, but the history suggests aspiration,” the ENT told me.

“What history?” I asked.

“That he has a history of ‘tonguing’ vitamins,” he said.

“Tonguing vitamins?” I responded, incredulously feeling the need to defend my child’s pill-swallowing honor. “Where did that story come from? We aren’t even sure we gave him a vitamin tonight.”

Nonetheless, the ENT was confident that “kids aspirate things all the time.”

Skeptical, I continued the debate. “But what if we hadn’t given that history? Would you still think of aspiration in this case?”

“Probably not, but then you did give us that history,” he replied. “So we need to bronch him.”

Culprit Revealed

Meanwhile, Grey was looking better with supplemental oxygen and a nebulizer’s worth of racemic epinephrine. His stridor took on more of a “barking seal” nature, and 30 minutes later, he developed a fever characteristic of croup. After a dose of steroids and another whiff of racemic epi, he was himself again, laughing the laugh of a wounded seal at the pulse oximeter, which backlit his big toe red. Comedy-club-level laughter replaced the look of death in the matter of an hour, as I was reminded of the resiliency of children. If only Mom and Dad could capture a bit of that.

Feeling a cocktail of relief and embarrassment—how could two physicians misdiagnose croup as an aspirated foreign body?—we readied ourselves for discharge. Just then, the ENT doctor came back in and told us the OR would be ready in a few hours. “But,” I inquired, “isn’t this just croup?”

“Most likely,” he replied, “but we can’t rule out aspiration without a bronchoscopy.”

It was then that I realized we (and our medical team) had fallen victim to some common heuristical errors. Heuristics are those little shortcuts in logic that we utilize to solve common problems. They are bred from years of experience and helpfully get us home every night in time for dinner. Without them, medicine would be a painstaking, Everlasting Gobstopper-like journey through endless differential diagnoses—in other words, your four-hour clerkship patient evaluations in medical school.

These shortcuts allow us to quickly recognize that a diaphoretic, 60-year-old man with diabetes, hyperlipidemia, and substernal chest pain has an acute coronary syndrome. We don’t spend hours thinking of Tietze’s syndrome, Boerhaave’s disease, and their ilk, because our mind quickly takes the shortcut to the right diagnosis. Although helpful, these shortcuts can cut both ways, occasionally resulting in thrombolytic therapy for an aortic dissection.

This is where Grey’s situation went wrong. My wife and I were victimized by the availability bias. This cognitive bias occurs when a recently encountered situation is given undue stature solely because of its proximity in time to the next event—i.e., it is “available.” So, because my son choked on a vitamin the night before, he must be choking on a vitamin the next night. (Even though we didn’t give him a vitamin and hours had passed since we put him to bed.) There is little connection between the two events, outside of the fact that aspiration is at the fore of your mind. This happens to us all the time. Think about the last presentation you attended about an obscure topic, only to amazingly find that the very next day, you had not one but two patients who surely required a workup for acute intermittent porphyria.

Common Practices

Anchoring bias is another common cognitive error in which we overly rely on one piece of information, the “anchor.” This was certainly in play during our ED visit. The mere mention of an aspirated foreign body was latched on to immediately. From there, tidbits of information that supported that diagnosis (something in the back of his throat on our exam, kids aspirate all the time) were kept, while the unsupporting evidence (negative X-ray and exam findings, fever, barking cough that awakes a kid at night) was jettisoned.

We fell prey to the momentum bias. This heuristical hiccup frequently wreaks cross-coverage havoc. You’ve seen this, I’m sure. Because the day team thought the renal failure was due to prerenal azotemia, the night team harmonizes, continuing to treat the patient’s bladder outlet obstruction with volume challenges. That is until someone—in my sphere, it’s usually the third-year medical student—asks if this could all be from the patient’s benign prostatic hyperplasia and medications.

After convincing our well-intentioned ENT colleague to call off the bronch, I was left with the important lesson that the ways in which our minds work, also well-intentioned, can cause us fits of trouble. I was left with the realization that the only way to mitigate the risk these cognitive shortcuts pose is to be constantly vigilant of their presence.

And, perhaps most importantly, I was left with an overstimulated 2-year-old high on the excitement of a hospital visit and large doses of adrenaline—a combination that left me desperately yearning for silence. TH

Dr. Glasheen is The Hospitalist’s physician editor.

O K, I’ll admit it: I like football. Call me a Neanderthal, but there is nothing quite like an afternoon with friends watching a tightly contested game of titans battling it out on the gridiron. Back in January, I enjoyed that glorious weekend in which the NFC and AFC crown their respective champions, each sending a team of combatants to the Super Bowl.

Fully enjoying the Sunday afternoon of ambrosia requires tons of preparation. Practically speaking, this means clearing my schedule of such clutter as child-rearing and housekeeping, along with dispatching my wife to the store minutes before my friends arrive to procure a second-chin’s worth of kettle chips and a potomaniac’s quantity of cheap beer. Then I settle into the butt-dented comfort of my overworked couch, where I’m surrounded by a rowdy pack of friends.

During hour three of the pre-game analysis, I can’t help but notice that my lovely wife, neither a fan of football or my friends spilling beer on her couch, has contracted a nasty case of the angry stink-eye, which she wields like a laser beam through my skull. I ponder the cost that all of this revelry, last-minute dispatching, and spilled beer will have on my marriage. Concluding that I indeed have at least three paws in the doghouse, I reflect on the facts that a) my wife is a saint; b) she reads this column—honey, read point “a” again; and c) Valentine’s Day is right around the corner.

Oh, well. The game must go on, and right now, it’s all about the NFL—hard-hitting, back-and-forth, in-your-face, smash-mouth action. Unbeatable. Unbeatable, that is, until you realize that a typical football game contains a lot of things, except for much actual football.

The Facts on Football

A recent Wall Street Journal analysis of NFL playoff games reported that the typical football game consists of many things, but not much real action. In fact, the average three-plus-hour telecast consists of just 10 minutes and 43 seconds of play. After subtracting about an hour of commercials, the rest of an average telecast consists of such things as players standing around (67 minutes), replays (17 minutes), and, of course, the all-important shots of cheerleaders—which is allotted, remarkably, only three seconds per game. Seems like more.

In percentage terms, the pie is doled out this way: standing around (58.5%), replays (14.5%), playing time (9.4%), coach shots (4.9%), sideline player shots (3.4%), referee shots (2.4%), crowd shots (0.9%), and other miscellany, such as footage of owners in their high-priced luxury suites (0.3%), the kicker warming up (0.2%), and, of course, cheerleaders (0.1%).

While this level of inaction has an enabling effect on convivial taunting, bet-brokering, and beer runs, it is, to be frank, a laughably low amount of action. How can an entire industry be built on such a level of inactivity? It’s a great question—one that induces a momentary chuckle until I consider how I spend much of my clinical days.

Inactivity in the Workplace

A 2006 paper in the Journal of Hospital Medicine tackled the issue of hospitalist workflow.1 Researchers followed 10 academic hospitalists through various parts of a routine day, all the while measuring to the minute how they spent their time. What they found would be as astounding to hospital outsiders as the NFL data, should anyone ever find themselves so deep in the boredom pit to be watching a hospitalist make rounds.

Which made me wonder: What would Brett Favre, the Minnesota Vikings’ future Hall of Fame quarterback, think if he were watching me ply my trade? Which led me to further wonder how far afield Brett Favre’s life would have to be derailed for him to watch me round. Finally, it left me wondering why I don’t spend my time wondering about more productive things.

Anyway, if Brett were to watch one of us, this is what he’d see: The average hospitalist in this study spent only 18% of their time in direct-patient-care activities, including taking a patient history, examining a patient, and meeting with a patient’s family. Eighteen percent! Isn’t seeing patients why I became a doctor?

While it’s more time than Brett Favre spends slinging the pigskin, it’s still an astonishingly low amount of time actually working with patients. Then there’s the “indirect patient care” category (e.g., reviewing tests, writing notes, making orders), where we spend 69% of our day. This is our time in the huddle, so to speak: lots of planning, little action. Further, these academic hospitalists spent 4% of their time on personal activities (e.g., lunch, bathroom breaks), and 3% of their time in each of the following endeavors: professional development (learning, conferences), teaching, and traveling from floor to floor seeing patients.

Another revealing find was that the average hospitalist spent 6% of their time paging other physicians and 7% returning pages from others (the average hospitalist received 3.4 pages an hour). That’s 13% of the day spent on the phone, or waiting for a phone to ring. That’s about 1.5 hours of a typical 12-hour shift. Over the course of a year, that equates to about 300 hours of time (25 shifts) spent in the paging process. If we could find a way to totally remove the paging process from hospital communication, the average hospitalist could accomplish the same amount of work they do now, and take an additional 20-25 days off per year. Perhaps we should wear high-tech helmets—you know, the kind quarterbacks like Brett Favre use to communicate with his coaches on the sidelines.

Efficient Solutions

Before my hospitalists hit me up for wireless communication devices and an extra three weeks of vacation, understand that much of the paging downtime likely is used for multitasking. In fact, in the study, 21% of a hospitalist’s time was spent working on more than one endeavor. Still, my experience tells me that there is a lot of time lost in the paging vortex.

Furthermore, the 3% of time hospitalists spent walking to other floors, 5% spent on discharge paperwork, and 1% of time spent on routine clerical work (did the researchers inadvertently report 1% instead of 10%?) adds up to nearly a tenth of the day that is either wasted, could be automated, or could be completed by ancillary staff.

To be clear, this happens through no fault of individual hospitalists. Rather, it results from the inefficiency of hospital care systems. And if we endeavor to enhance the revenue, efficiency, and satisfaction of our providers, we need to re-engineer our systems to alter that vast expanse of time spent on inactivity and inefficiency. This means adopting new modes of communication, moving toward geographic rounds, and generally retooling our operational inefficiencies.

Short of that, we risk becoming as idle as the NFL—without the cheerleaders. TH

Dr. Glasheen is The Hospitalist’s physician editor.

Reference

1. O’Leary KJ, Liebovitz DM, Baker DW. How hospitalists spend their time: insights on efficiency and safety. J Hosp Med. 2006;1(2):88-93.

O K, I’ll admit it: I like football. Call me a Neanderthal, but there is nothing quite like an afternoon with friends watching a tightly contested game of titans battling it out on the gridiron. Back in January, I enjoyed that glorious weekend in which the NFC and AFC crown their respective champions, each sending a team of combatants to the Super Bowl.

Fully enjoying the Sunday afternoon of ambrosia requires tons of preparation. Practically speaking, this means clearing my schedule of such clutter as child-rearing and housekeeping, along with dispatching my wife to the store minutes before my friends arrive to procure a second-chin’s worth of kettle chips and a potomaniac’s quantity of cheap beer. Then I settle into the butt-dented comfort of my overworked couch, where I’m surrounded by a rowdy pack of friends.

During hour three of the pre-game analysis, I can’t help but notice that my lovely wife, neither a fan of football or my friends spilling beer on her couch, has contracted a nasty case of the angry stink-eye, which she wields like a laser beam through my skull. I ponder the cost that all of this revelry, last-minute dispatching, and spilled beer will have on my marriage. Concluding that I indeed have at least three paws in the doghouse, I reflect on the facts that a) my wife is a saint; b) she reads this column—honey, read point “a” again; and c) Valentine’s Day is right around the corner.

Oh, well. The game must go on, and right now, it’s all about the NFL—hard-hitting, back-and-forth, in-your-face, smash-mouth action. Unbeatable. Unbeatable, that is, until you realize that a typical football game contains a lot of things, except for much actual football.

The Facts on Football

A recent Wall Street Journal analysis of NFL playoff games reported that the typical football game consists of many things, but not much real action. In fact, the average three-plus-hour telecast consists of just 10 minutes and 43 seconds of play. After subtracting about an hour of commercials, the rest of an average telecast consists of such things as players standing around (67 minutes), replays (17 minutes), and, of course, the all-important shots of cheerleaders—which is allotted, remarkably, only three seconds per game. Seems like more.

In percentage terms, the pie is doled out this way: standing around (58.5%), replays (14.5%), playing time (9.4%), coach shots (4.9%), sideline player shots (3.4%), referee shots (2.4%), crowd shots (0.9%), and other miscellany, such as footage of owners in their high-priced luxury suites (0.3%), the kicker warming up (0.2%), and, of course, cheerleaders (0.1%).

While this level of inaction has an enabling effect on convivial taunting, bet-brokering, and beer runs, it is, to be frank, a laughably low amount of action. How can an entire industry be built on such a level of inactivity? It’s a great question—one that induces a momentary chuckle until I consider how I spend much of my clinical days.

Inactivity in the Workplace

A 2006 paper in the Journal of Hospital Medicine tackled the issue of hospitalist workflow.1 Researchers followed 10 academic hospitalists through various parts of a routine day, all the while measuring to the minute how they spent their time. What they found would be as astounding to hospital outsiders as the NFL data, should anyone ever find themselves so deep in the boredom pit to be watching a hospitalist make rounds.

Which made me wonder: What would Brett Favre, the Minnesota Vikings’ future Hall of Fame quarterback, think if he were watching me ply my trade? Which led me to further wonder how far afield Brett Favre’s life would have to be derailed for him to watch me round. Finally, it left me wondering why I don’t spend my time wondering about more productive things.

Anyway, if Brett were to watch one of us, this is what he’d see: The average hospitalist in this study spent only 18% of their time in direct-patient-care activities, including taking a patient history, examining a patient, and meeting with a patient’s family. Eighteen percent! Isn’t seeing patients why I became a doctor?

While it’s more time than Brett Favre spends slinging the pigskin, it’s still an astonishingly low amount of time actually working with patients. Then there’s the “indirect patient care” category (e.g., reviewing tests, writing notes, making orders), where we spend 69% of our day. This is our time in the huddle, so to speak: lots of planning, little action. Further, these academic hospitalists spent 4% of their time on personal activities (e.g., lunch, bathroom breaks), and 3% of their time in each of the following endeavors: professional development (learning, conferences), teaching, and traveling from floor to floor seeing patients.

Another revealing find was that the average hospitalist spent 6% of their time paging other physicians and 7% returning pages from others (the average hospitalist received 3.4 pages an hour). That’s 13% of the day spent on the phone, or waiting for a phone to ring. That’s about 1.5 hours of a typical 12-hour shift. Over the course of a year, that equates to about 300 hours of time (25 shifts) spent in the paging process. If we could find a way to totally remove the paging process from hospital communication, the average hospitalist could accomplish the same amount of work they do now, and take an additional 20-25 days off per year. Perhaps we should wear high-tech helmets—you know, the kind quarterbacks like Brett Favre use to communicate with his coaches on the sidelines.

Efficient Solutions

Before my hospitalists hit me up for wireless communication devices and an extra three weeks of vacation, understand that much of the paging downtime likely is used for multitasking. In fact, in the study, 21% of a hospitalist’s time was spent working on more than one endeavor. Still, my experience tells me that there is a lot of time lost in the paging vortex.

Furthermore, the 3% of time hospitalists spent walking to other floors, 5% spent on discharge paperwork, and 1% of time spent on routine clerical work (did the researchers inadvertently report 1% instead of 10%?) adds up to nearly a tenth of the day that is either wasted, could be automated, or could be completed by ancillary staff.

To be clear, this happens through no fault of individual hospitalists. Rather, it results from the inefficiency of hospital care systems. And if we endeavor to enhance the revenue, efficiency, and satisfaction of our providers, we need to re-engineer our systems to alter that vast expanse of time spent on inactivity and inefficiency. This means adopting new modes of communication, moving toward geographic rounds, and generally retooling our operational inefficiencies.

Short of that, we risk becoming as idle as the NFL—without the cheerleaders. TH

Dr. Glasheen is The Hospitalist’s physician editor.

Reference

1. O’Leary KJ, Liebovitz DM, Baker DW. How hospitalists spend their time: insights on efficiency and safety. J Hosp Med. 2006;1(2):88-93.

O K, I’ll admit it: I like football. Call me a Neanderthal, but there is nothing quite like an afternoon with friends watching a tightly contested game of titans battling it out on the gridiron. Back in January, I enjoyed that glorious weekend in which the NFC and AFC crown their respective champions, each sending a team of combatants to the Super Bowl.

Fully enjoying the Sunday afternoon of ambrosia requires tons of preparation. Practically speaking, this means clearing my schedule of such clutter as child-rearing and housekeeping, along with dispatching my wife to the store minutes before my friends arrive to procure a second-chin’s worth of kettle chips and a potomaniac’s quantity of cheap beer. Then I settle into the butt-dented comfort of my overworked couch, where I’m surrounded by a rowdy pack of friends.

During hour three of the pre-game analysis, I can’t help but notice that my lovely wife, neither a fan of football or my friends spilling beer on her couch, has contracted a nasty case of the angry stink-eye, which she wields like a laser beam through my skull. I ponder the cost that all of this revelry, last-minute dispatching, and spilled beer will have on my marriage. Concluding that I indeed have at least three paws in the doghouse, I reflect on the facts that a) my wife is a saint; b) she reads this column—honey, read point “a” again; and c) Valentine’s Day is right around the corner.

Oh, well. The game must go on, and right now, it’s all about the NFL—hard-hitting, back-and-forth, in-your-face, smash-mouth action. Unbeatable. Unbeatable, that is, until you realize that a typical football game contains a lot of things, except for much actual football.

The Facts on Football

A recent Wall Street Journal analysis of NFL playoff games reported that the typical football game consists of many things, but not much real action. In fact, the average three-plus-hour telecast consists of just 10 minutes and 43 seconds of play. After subtracting about an hour of commercials, the rest of an average telecast consists of such things as players standing around (67 minutes), replays (17 minutes), and, of course, the all-important shots of cheerleaders—which is allotted, remarkably, only three seconds per game. Seems like more.

In percentage terms, the pie is doled out this way: standing around (58.5%), replays (14.5%), playing time (9.4%), coach shots (4.9%), sideline player shots (3.4%), referee shots (2.4%), crowd shots (0.9%), and other miscellany, such as footage of owners in their high-priced luxury suites (0.3%), the kicker warming up (0.2%), and, of course, cheerleaders (0.1%).

While this level of inaction has an enabling effect on convivial taunting, bet-brokering, and beer runs, it is, to be frank, a laughably low amount of action. How can an entire industry be built on such a level of inactivity? It’s a great question—one that induces a momentary chuckle until I consider how I spend much of my clinical days.

Inactivity in the Workplace

A 2006 paper in the Journal of Hospital Medicine tackled the issue of hospitalist workflow.1 Researchers followed 10 academic hospitalists through various parts of a routine day, all the while measuring to the minute how they spent their time. What they found would be as astounding to hospital outsiders as the NFL data, should anyone ever find themselves so deep in the boredom pit to be watching a hospitalist make rounds.

Which made me wonder: What would Brett Favre, the Minnesota Vikings’ future Hall of Fame quarterback, think if he were watching me ply my trade? Which led me to further wonder how far afield Brett Favre’s life would have to be derailed for him to watch me round. Finally, it left me wondering why I don’t spend my time wondering about more productive things.

Anyway, if Brett were to watch one of us, this is what he’d see: The average hospitalist in this study spent only 18% of their time in direct-patient-care activities, including taking a patient history, examining a patient, and meeting with a patient’s family. Eighteen percent! Isn’t seeing patients why I became a doctor?

While it’s more time than Brett Favre spends slinging the pigskin, it’s still an astonishingly low amount of time actually working with patients. Then there’s the “indirect patient care” category (e.g., reviewing tests, writing notes, making orders), where we spend 69% of our day. This is our time in the huddle, so to speak: lots of planning, little action. Further, these academic hospitalists spent 4% of their time on personal activities (e.g., lunch, bathroom breaks), and 3% of their time in each of the following endeavors: professional development (learning, conferences), teaching, and traveling from floor to floor seeing patients.

Another revealing find was that the average hospitalist spent 6% of their time paging other physicians and 7% returning pages from others (the average hospitalist received 3.4 pages an hour). That’s 13% of the day spent on the phone, or waiting for a phone to ring. That’s about 1.5 hours of a typical 12-hour shift. Over the course of a year, that equates to about 300 hours of time (25 shifts) spent in the paging process. If we could find a way to totally remove the paging process from hospital communication, the average hospitalist could accomplish the same amount of work they do now, and take an additional 20-25 days off per year. Perhaps we should wear high-tech helmets—you know, the kind quarterbacks like Brett Favre use to communicate with his coaches on the sidelines.

Efficient Solutions

Before my hospitalists hit me up for wireless communication devices and an extra three weeks of vacation, understand that much of the paging downtime likely is used for multitasking. In fact, in the study, 21% of a hospitalist’s time was spent working on more than one endeavor. Still, my experience tells me that there is a lot of time lost in the paging vortex.

Furthermore, the 3% of time hospitalists spent walking to other floors, 5% spent on discharge paperwork, and 1% of time spent on routine clerical work (did the researchers inadvertently report 1% instead of 10%?) adds up to nearly a tenth of the day that is either wasted, could be automated, or could be completed by ancillary staff.

To be clear, this happens through no fault of individual hospitalists. Rather, it results from the inefficiency of hospital care systems. And if we endeavor to enhance the revenue, efficiency, and satisfaction of our providers, we need to re-engineer our systems to alter that vast expanse of time spent on inactivity and inefficiency. This means adopting new modes of communication, moving toward geographic rounds, and generally retooling our operational inefficiencies.

Short of that, we risk becoming as idle as the NFL—without the cheerleaders. TH

Dr. Glasheen is The Hospitalist’s physician editor.

Reference

1. O’Leary KJ, Liebovitz DM, Baker DW. How hospitalists spend their time: insights on efficiency and safety. J Hosp Med. 2006;1(2):88-93.

Jeff Glasheen, MD, FHM

Four eyes staring, boring through me, unblinking. Locked in a pose holding a hand-scrawled sign commanding their father to ♥♥GET WELL NOW♥♥, the photo of the 14-month-old twin girls was reproduced off a cheap color printer and taped to the window, backlit by the Christmas Eve morning sun. Both the sun and the daughters demanded my attention—the former a brilliant reminder of the glories of the day, the latter the sobering reality of a family rocked by illness.

Mr. Jasper, an otherwise healthy 36-year-old male who recently was diagnosed with a rare, life-threatening disease, would not be spending this holiday with his daughters. In fact, because of our hospital’s flu precautions, he hadn’t seen them in the six weeks he’d been an inpatient. In that time, one of his girls had learned to talk; the other had learned to walk. Mr. Jasper was a distant bystander. He was upset but understanding of his situation—even optimistic, remarkably. However, those girls’ eyes told a different story. What weeks ago shone as the cute countenances of toddlers—silly, carefree, cheerful—now articulated a different tone. “Let my father come home!” they beseeched.

Staring into those eyes on rounds that morning, I was haunted by a thought that had gnawed at my subconscious for weeks. It was likely, albeit not guaranteed, that we’d get Mr. Jasper home to his wife and daughters. However, it would be at a cost. Of course, there would be psychological costs, but I was more acutely concerned with the financial costs. Mr. Jasper, you see, is uninsured.

Healthcare Reform: Too Late for Many

Thousands of miles away, the U.S. Senate was, at that exact time, voting for legislation to greatly reform and expand the U.S. healthcare system. Passed along partisan lines, the bill now awaits reconciliation with the House of Representatives’ bill. From there, it will go before President Obama for signature into law. If passed, this legislation promises to give healthcare coverage to another 30 million Americans.

For Mr. Jasper, this new law will come too late.

It’ll also be too late for Mrs. Anderson, a middle-aged asthmatic now intubated in our ICU, wheezing against constricted bronchioles. Three days earlier, she was seen in the ED for worsening dyspnea, cough, and sputum production. Her symptoms resolved after a few courses of nebulized albuterol and IV steroids, and she was sent home with a prescription for prednisone and inhalers. Unable to afford to fill those prescriptions, her disease progressed, eventually strangling her breathing and tangling her in a healthcare system more willing to pay for the care of disease complications than disease prevention.

Face-to-Face with Catastrophe

Later that morning, I was asked by one of our ED physicians to see Mr. Reynolds and “persuade” him to be admitted to the hospital. Mr. Reynolds has insurance. In fact, of the 11 patients I saw that day, he was one of only three who did. One had Medicaid, the other Medicare.

Mr. Reynolds had a high-deductible, catastrophic-insurance policy. As such, he was wrestling with the decision of whether to come into the hospital to treat his severe cellulitis with IV antibiotics (our formal recommendation), or treat this at home with oral antibiotics. His face wore the torment of the trade-offs. The former surely would cost him his entire $5,000 deductible; the latter, perhaps his life, or at least a limb. As the erythema glared at me, I struggled to recollect a medical school lecture applicable to this situation.

My last patient of the day was Mr. Ramon. He, too, was uninsured. Felled by diabetic ketoacidosis, he was admitted and, as 19-year-olds are wont to do, rebounded quickly. New-onset diabetes, however, was the least of his concerns. With a girlfriend and young child at home, he had to get out of the hospital and return to his job as soon as possible: mouths to feed. Having seen his father lose limbs, kidneys, eyes, and ultimately his life to diabetes, he was motivated to do the right thing.

Unfortunately, motivation doesn’t pay for insulin. I wondered what would come of him in the next 30 years. Would he be able to care for his disease and live a long and prosperous life, or would this admission be just one in a long series of hospital stays?

Broken System

Every hospitalist is aware of these issues and could no doubt fill pages with similarly horrific stories of a healthcare system long broken. It’s remarkable how much of my time I spend trying to figure out a way to cobble together a passable (the notion of “gold standard” therapy long gone) therapeutic plan for my patients—the Walmart list of $4 drugs has taken white-coat prominence over my “Pocket Pharmacopoeia.”

This isn’t to say the U.S. healthcare system doesn’t do a lot of great things. It does, and that cannot be discounted. It’s also not to say that the bill before Congress is the answer. Still, the fact that medical costs limit many Americans from accessing needed care and have become the leading cause of bankruptcy in the U.S. should arouse concern in even the most ardent opponents of healthcare reform. Regardless of one’s political leanings and feelings about the current attempts at healthcare reform, it’s difficult to stand by and helplessly watch our patients struggle to maneuver within a system that so often seems to work against so many of them.

What’s easy to lose in the D.C. rhetoric and town-hall warfare is that every day, we delay healthcare reform results in undue patient suffering, both physical and financial. It is a system that is broken and needs, in the words of Mr. Jasper’s daughters, to “get well now.”

Before leaving to celebrate the holiday with my family, I was compelled to return to Mr. Jasper’s room. Unfortunately, the patient was off getting a treatment. But his daughters were still there, faces unchanged. Again, drawn to those eyes, I wondered what would become of this situation.

Would he make it home?

How would his family pay the bills?

What would this mean for his daughters’ future?

Would he and his family be forced to declare bankruptcy?

Would the family ever truly recover?

Staring at the picture in the window, I couldn’t help but think of my own children, also waiting for their father to come home from the hospital to celebrate the holidays.

As I turned to leave, my mind lost in thoughts of untimely illness, ill-fated outcomes, and financial devastation, I realized that in America today, nothing more than circumstances kept me from seeing my own children’s eyes staring back at me from that window. TH

Dr. Glasheen is associate professor of medicine at the University of Colorado Denver, where he serves as director of the Hospital Medicine Program and the Hospitalist Training Program, and as associate program director of the Internal Medicine Residency Program.

Jeff Glasheen, MD, FHM

Four eyes staring, boring through me, unblinking. Locked in a pose holding a hand-scrawled sign commanding their father to ♥♥GET WELL NOW♥♥, the photo of the 14-month-old twin girls was reproduced off a cheap color printer and taped to the window, backlit by the Christmas Eve morning sun. Both the sun and the daughters demanded my attention—the former a brilliant reminder of the glories of the day, the latter the sobering reality of a family rocked by illness.

Mr. Jasper, an otherwise healthy 36-year-old male who recently was diagnosed with a rare, life-threatening disease, would not be spending this holiday with his daughters. In fact, because of our hospital’s flu precautions, he hadn’t seen them in the six weeks he’d been an inpatient. In that time, one of his girls had learned to talk; the other had learned to walk. Mr. Jasper was a distant bystander. He was upset but understanding of his situation—even optimistic, remarkably. However, those girls’ eyes told a different story. What weeks ago shone as the cute countenances of toddlers—silly, carefree, cheerful—now articulated a different tone. “Let my father come home!” they beseeched.

Staring into those eyes on rounds that morning, I was haunted by a thought that had gnawed at my subconscious for weeks. It was likely, albeit not guaranteed, that we’d get Mr. Jasper home to his wife and daughters. However, it would be at a cost. Of course, there would be psychological costs, but I was more acutely concerned with the financial costs. Mr. Jasper, you see, is uninsured.

Healthcare Reform: Too Late for Many

Thousands of miles away, the U.S. Senate was, at that exact time, voting for legislation to greatly reform and expand the U.S. healthcare system. Passed along partisan lines, the bill now awaits reconciliation with the House of Representatives’ bill. From there, it will go before President Obama for signature into law. If passed, this legislation promises to give healthcare coverage to another 30 million Americans.

For Mr. Jasper, this new law will come too late.

It’ll also be too late for Mrs. Anderson, a middle-aged asthmatic now intubated in our ICU, wheezing against constricted bronchioles. Three days earlier, she was seen in the ED for worsening dyspnea, cough, and sputum production. Her symptoms resolved after a few courses of nebulized albuterol and IV steroids, and she was sent home with a prescription for prednisone and inhalers. Unable to afford to fill those prescriptions, her disease progressed, eventually strangling her breathing and tangling her in a healthcare system more willing to pay for the care of disease complications than disease prevention.

Face-to-Face with Catastrophe

Later that morning, I was asked by one of our ED physicians to see Mr. Reynolds and “persuade” him to be admitted to the hospital. Mr. Reynolds has insurance. In fact, of the 11 patients I saw that day, he was one of only three who did. One had Medicaid, the other Medicare.

Mr. Reynolds had a high-deductible, catastrophic-insurance policy. As such, he was wrestling with the decision of whether to come into the hospital to treat his severe cellulitis with IV antibiotics (our formal recommendation), or treat this at home with oral antibiotics. His face wore the torment of the trade-offs. The former surely would cost him his entire $5,000 deductible; the latter, perhaps his life, or at least a limb. As the erythema glared at me, I struggled to recollect a medical school lecture applicable to this situation.

My last patient of the day was Mr. Ramon. He, too, was uninsured. Felled by diabetic ketoacidosis, he was admitted and, as 19-year-olds are wont to do, rebounded quickly. New-onset diabetes, however, was the least of his concerns. With a girlfriend and young child at home, he had to get out of the hospital and return to his job as soon as possible: mouths to feed. Having seen his father lose limbs, kidneys, eyes, and ultimately his life to diabetes, he was motivated to do the right thing.

Unfortunately, motivation doesn’t pay for insulin. I wondered what would come of him in the next 30 years. Would he be able to care for his disease and live a long and prosperous life, or would this admission be just one in a long series of hospital stays?

Broken System

Every hospitalist is aware of these issues and could no doubt fill pages with similarly horrific stories of a healthcare system long broken. It’s remarkable how much of my time I spend trying to figure out a way to cobble together a passable (the notion of “gold standard” therapy long gone) therapeutic plan for my patients—the Walmart list of $4 drugs has taken white-coat prominence over my “Pocket Pharmacopoeia.”

This isn’t to say the U.S. healthcare system doesn’t do a lot of great things. It does, and that cannot be discounted. It’s also not to say that the bill before Congress is the answer. Still, the fact that medical costs limit many Americans from accessing needed care and have become the leading cause of bankruptcy in the U.S. should arouse concern in even the most ardent opponents of healthcare reform. Regardless of one’s political leanings and feelings about the current attempts at healthcare reform, it’s difficult to stand by and helplessly watch our patients struggle to maneuver within a system that so often seems to work against so many of them.

What’s easy to lose in the D.C. rhetoric and town-hall warfare is that every day, we delay healthcare reform results in undue patient suffering, both physical and financial. It is a system that is broken and needs, in the words of Mr. Jasper’s daughters, to “get well now.”

Before leaving to celebrate the holiday with my family, I was compelled to return to Mr. Jasper’s room. Unfortunately, the patient was off getting a treatment. But his daughters were still there, faces unchanged. Again, drawn to those eyes, I wondered what would become of this situation.

Would he make it home?

How would his family pay the bills?

What would this mean for his daughters’ future?

Would he and his family be forced to declare bankruptcy?

Would the family ever truly recover?

Staring at the picture in the window, I couldn’t help but think of my own children, also waiting for their father to come home from the hospital to celebrate the holidays.

As I turned to leave, my mind lost in thoughts of untimely illness, ill-fated outcomes, and financial devastation, I realized that in America today, nothing more than circumstances kept me from seeing my own children’s eyes staring back at me from that window. TH

Dr. Glasheen is associate professor of medicine at the University of Colorado Denver, where he serves as director of the Hospital Medicine Program and the Hospitalist Training Program, and as associate program director of the Internal Medicine Residency Program.

Jeff Glasheen, MD, FHM

Four eyes staring, boring through me, unblinking. Locked in a pose holding a hand-scrawled sign commanding their father to ♥♥GET WELL NOW♥♥, the photo of the 14-month-old twin girls was reproduced off a cheap color printer and taped to the window, backlit by the Christmas Eve morning sun. Both the sun and the daughters demanded my attention—the former a brilliant reminder of the glories of the day, the latter the sobering reality of a family rocked by illness.

Mr. Jasper, an otherwise healthy 36-year-old male who recently was diagnosed with a rare, life-threatening disease, would not be spending this holiday with his daughters. In fact, because of our hospital’s flu precautions, he hadn’t seen them in the six weeks he’d been an inpatient. In that time, one of his girls had learned to talk; the other had learned to walk. Mr. Jasper was a distant bystander. He was upset but understanding of his situation—even optimistic, remarkably. However, those girls’ eyes told a different story. What weeks ago shone as the cute countenances of toddlers—silly, carefree, cheerful—now articulated a different tone. “Let my father come home!” they beseeched.

Staring into those eyes on rounds that morning, I was haunted by a thought that had gnawed at my subconscious for weeks. It was likely, albeit not guaranteed, that we’d get Mr. Jasper home to his wife and daughters. However, it would be at a cost. Of course, there would be psychological costs, but I was more acutely concerned with the financial costs. Mr. Jasper, you see, is uninsured.

Healthcare Reform: Too Late for Many

Thousands of miles away, the U.S. Senate was, at that exact time, voting for legislation to greatly reform and expand the U.S. healthcare system. Passed along partisan lines, the bill now awaits reconciliation with the House of Representatives’ bill. From there, it will go before President Obama for signature into law. If passed, this legislation promises to give healthcare coverage to another 30 million Americans.

For Mr. Jasper, this new law will come too late.

It’ll also be too late for Mrs. Anderson, a middle-aged asthmatic now intubated in our ICU, wheezing against constricted bronchioles. Three days earlier, she was seen in the ED for worsening dyspnea, cough, and sputum production. Her symptoms resolved after a few courses of nebulized albuterol and IV steroids, and she was sent home with a prescription for prednisone and inhalers. Unable to afford to fill those prescriptions, her disease progressed, eventually strangling her breathing and tangling her in a healthcare system more willing to pay for the care of disease complications than disease prevention.

Face-to-Face with Catastrophe

Later that morning, I was asked by one of our ED physicians to see Mr. Reynolds and “persuade” him to be admitted to the hospital. Mr. Reynolds has insurance. In fact, of the 11 patients I saw that day, he was one of only three who did. One had Medicaid, the other Medicare.

Mr. Reynolds had a high-deductible, catastrophic-insurance policy. As such, he was wrestling with the decision of whether to come into the hospital to treat his severe cellulitis with IV antibiotics (our formal recommendation), or treat this at home with oral antibiotics. His face wore the torment of the trade-offs. The former surely would cost him his entire $5,000 deductible; the latter, perhaps his life, or at least a limb. As the erythema glared at me, I struggled to recollect a medical school lecture applicable to this situation.

My last patient of the day was Mr. Ramon. He, too, was uninsured. Felled by diabetic ketoacidosis, he was admitted and, as 19-year-olds are wont to do, rebounded quickly. New-onset diabetes, however, was the least of his concerns. With a girlfriend and young child at home, he had to get out of the hospital and return to his job as soon as possible: mouths to feed. Having seen his father lose limbs, kidneys, eyes, and ultimately his life to diabetes, he was motivated to do the right thing.

Unfortunately, motivation doesn’t pay for insulin. I wondered what would come of him in the next 30 years. Would he be able to care for his disease and live a long and prosperous life, or would this admission be just one in a long series of hospital stays?

Broken System

Every hospitalist is aware of these issues and could no doubt fill pages with similarly horrific stories of a healthcare system long broken. It’s remarkable how much of my time I spend trying to figure out a way to cobble together a passable (the notion of “gold standard” therapy long gone) therapeutic plan for my patients—the Walmart list of $4 drugs has taken white-coat prominence over my “Pocket Pharmacopoeia.”

This isn’t to say the U.S. healthcare system doesn’t do a lot of great things. It does, and that cannot be discounted. It’s also not to say that the bill before Congress is the answer. Still, the fact that medical costs limit many Americans from accessing needed care and have become the leading cause of bankruptcy in the U.S. should arouse concern in even the most ardent opponents of healthcare reform. Regardless of one’s political leanings and feelings about the current attempts at healthcare reform, it’s difficult to stand by and helplessly watch our patients struggle to maneuver within a system that so often seems to work against so many of them.

What’s easy to lose in the D.C. rhetoric and town-hall warfare is that every day, we delay healthcare reform results in undue patient suffering, both physical and financial. It is a system that is broken and needs, in the words of Mr. Jasper’s daughters, to “get well now.”

Before leaving to celebrate the holiday with my family, I was compelled to return to Mr. Jasper’s room. Unfortunately, the patient was off getting a treatment. But his daughters were still there, faces unchanged. Again, drawn to those eyes, I wondered what would become of this situation.

Would he make it home?

How would his family pay the bills?

What would this mean for his daughters’ future?

Would he and his family be forced to declare bankruptcy?

Would the family ever truly recover?

Staring at the picture in the window, I couldn’t help but think of my own children, also waiting for their father to come home from the hospital to celebrate the holidays.

As I turned to leave, my mind lost in thoughts of untimely illness, ill-fated outcomes, and financial devastation, I realized that in America today, nothing more than circumstances kept me from seeing my own children’s eyes staring back at me from that window. TH

Dr. Glasheen is associate professor of medicine at the University of Colorado Denver, where he serves as director of the Hospital Medicine Program and the Hospitalist Training Program, and as associate program director of the Internal Medicine Residency Program.

Is this really happening? That’s what I was thinking as my mind quickly ran a differential of the possible explanations for the 80 people before me, positioned erectly, hands audibly moving together and apart. This had never happened to me before. Was this some sort of group yoga stretch aimed at quelling DVT formation, perhaps a pre-determined signal alerting security to have me removed for hitting an unconscionable level of boredom, or, most likely, a synchronized form of mass exit (my talks are accustomed to a certain level of attrition)? Beyond these possibilities lies just one alternative: I actually was receiving a standing ovation.

First, let me dispense with one ever-important technicality. The ovation, coming at the close of the recent four-day Academic Hospitalist Academy held outside Atlanta, was more rightly intended for the efforts of the entire eight-member faculty than me alone. I just happened to be giving the closing session.

The fact of the matter is that as a faculty member for this program, which aimed to provide early-career development for junior academic hospitalists, I, too, was in awe at the tremendous, unparalleled work of the faculty: Drs. Brad Sharpe, Vikas Parekh, Andy Auerbach, Jeff Wiese, Shobi Chheda, Bob Centor, and Jen Myers.

Yet there I was, just moments after uttering a few closing comments, being showered with praise, each clap further pumping my chest fuller with pride. It was then, with a deflating wheeze, that I realized what was happening—they weren’t clapping for me, or even the rest of the faculty. It turns out the more obvious cause for their enthusiasm had been staring me in the face the whole time. Or, more to the point, the faces staring back at me were reflecting my numerous missteps that this course had ensured they’d never make. And that was very ovation-worthy.

Take-Home Points

Clapping excitedly at table No. 4 was a young first-year hospitalist from a major academic medical center. Looking at her, I could tell she would not, like I had, make the mistake of waiting too long to find a mentor. It wasn’t until my fourth year in academics that I found a mentor. That was four years of unproductive wandering, chasing dead ends, grabbing at wrong straws. So after multiple sessions covering the importance and means of finding mentors, as well as the role of mentees, it was clear that this young hospitalist would build her career foundation on more firm footing.

Applauding from table No. 7 was a second-year hospitalist from a community teaching hospital with aspirations of making a splash on the national hospitalist scene. Unlike my early fruitless attempts to get involved outside of my institution, the session on the importance of peer and national networking provided his quiver with several time-honored arrows that took me years to acquire.

The eyes of a hospitalist at table No. 8 foretold the story of a young faculty member who wouldn’t struggle with the process of promotion, as I had. After sitting through talks that lifted the veil on both the inner workings of an academic medical center and the mysteries by which said centers promote their members, she had a head start on ensuring her academic success.

Table No. 3 offered several hospitalists who wouldn’t make the errors I’ve made—repeatedly—with e-mail, phone conversations and running a meeting. A presentation on the basics of communications ensured that they wouldn’t send those irretrievable e-missives carrying unintentional messages or waste hours trying to cover in e-mail what would be better solved over the phone or in a face-to-face meeting.

A person at table one patted me on the shoulder, the glint in his eye signaling that the sessions on how to run a teaching team and be a more effective teacher at both the bedside and at the chalkboard would help him avoid the lower teaching scores that plagued my early academic years.

Focus on Fundamentals

I could go on, but the point is that while my fellow faculty and I reveled in the pleasure of a standing ovation, the truth is that the clapping had less to do with us or how we imparted information and more to do with the fact that we had shared with them the ingredients of their future success, something they actively longed for—a means to enhance their career success and satisfaction.

Mind you, none of these revelations were shocking; indeed, most are mundane and straightforward. However, the reality is that more often than not we just need help getting started—a little enzymatic push in the right direction. The fact that these needs were finally being met was evident in every heartfelt clap of the hands.

Lest you think these lessons are only important for us academic eggheads, I’d submit to you that the same, or at least similarly important, points are just as critical for young community hospitalists.

In fact, hospitalists and the field of HM are all very young; most of us are in desperate need of career guidance. And I’d go so far as to say the success of our field depends on meeting these needs as much or more than our ability to improve the quality of healthcare. The reality is that without sated, successful, career-oriented hospitalists, there can be no HM movement to improve the quality of care.

It’s tempting to feel that our residency training should prepare us for our jobs. However, the reality is that while residency prepares us reasonably well to practice clinic medicine, it does very little to prepare us for the wide-ranging rigors of medical practice. And while it’s easy to dismiss early-career development as touchy-feely nonsense, we do so at our own peril.

That message is written in the conflicts that abound within our HM groups and our hospitals, the burnout and low satisfaction that fuel our high turnover rate, and the unfulfilled careers that litter the HM landscape. It’s a message that threatens our beloved specialty—a message that all the clapping couldn’t drown out. TH

Dr. Glasheen is associate professor of medicine at the University of Colorado Denver, where he serves as director of the Hospital Medicine Program and the Hospitalist Training Program, and as associate program director of the Internal Medicine Residency Program.

Is this really happening? That’s what I was thinking as my mind quickly ran a differential of the possible explanations for the 80 people before me, positioned erectly, hands audibly moving together and apart. This had never happened to me before. Was this some sort of group yoga stretch aimed at quelling DVT formation, perhaps a pre-determined signal alerting security to have me removed for hitting an unconscionable level of boredom, or, most likely, a synchronized form of mass exit (my talks are accustomed to a certain level of attrition)? Beyond these possibilities lies just one alternative: I actually was receiving a standing ovation.

First, let me dispense with one ever-important technicality. The ovation, coming at the close of the recent four-day Academic Hospitalist Academy held outside Atlanta, was more rightly intended for the efforts of the entire eight-member faculty than me alone. I just happened to be giving the closing session.

The fact of the matter is that as a faculty member for this program, which aimed to provide early-career development for junior academic hospitalists, I, too, was in awe at the tremendous, unparalleled work of the faculty: Drs. Brad Sharpe, Vikas Parekh, Andy Auerbach, Jeff Wiese, Shobi Chheda, Bob Centor, and Jen Myers.

Yet there I was, just moments after uttering a few closing comments, being showered with praise, each clap further pumping my chest fuller with pride. It was then, with a deflating wheeze, that I realized what was happening—they weren’t clapping for me, or even the rest of the faculty. It turns out the more obvious cause for their enthusiasm had been staring me in the face the whole time. Or, more to the point, the faces staring back at me were reflecting my numerous missteps that this course had ensured they’d never make. And that was very ovation-worthy.

Take-Home Points

Clapping excitedly at table No. 4 was a young first-year hospitalist from a major academic medical center. Looking at her, I could tell she would not, like I had, make the mistake of waiting too long to find a mentor. It wasn’t until my fourth year in academics that I found a mentor. That was four years of unproductive wandering, chasing dead ends, grabbing at wrong straws. So after multiple sessions covering the importance and means of finding mentors, as well as the role of mentees, it was clear that this young hospitalist would build her career foundation on more firm footing.

Applauding from table No. 7 was a second-year hospitalist from a community teaching hospital with aspirations of making a splash on the national hospitalist scene. Unlike my early fruitless attempts to get involved outside of my institution, the session on the importance of peer and national networking provided his quiver with several time-honored arrows that took me years to acquire.

The eyes of a hospitalist at table No. 8 foretold the story of a young faculty member who wouldn’t struggle with the process of promotion, as I had. After sitting through talks that lifted the veil on both the inner workings of an academic medical center and the mysteries by which said centers promote their members, she had a head start on ensuring her academic success.

Table No. 3 offered several hospitalists who wouldn’t make the errors I’ve made—repeatedly—with e-mail, phone conversations and running a meeting. A presentation on the basics of communications ensured that they wouldn’t send those irretrievable e-missives carrying unintentional messages or waste hours trying to cover in e-mail what would be better solved over the phone or in a face-to-face meeting.

A person at table one patted me on the shoulder, the glint in his eye signaling that the sessions on how to run a teaching team and be a more effective teacher at both the bedside and at the chalkboard would help him avoid the lower teaching scores that plagued my early academic years.

Focus on Fundamentals

I could go on, but the point is that while my fellow faculty and I reveled in the pleasure of a standing ovation, the truth is that the clapping had less to do with us or how we imparted information and more to do with the fact that we had shared with them the ingredients of their future success, something they actively longed for—a means to enhance their career success and satisfaction.

Mind you, none of these revelations were shocking; indeed, most are mundane and straightforward. However, the reality is that more often than not we just need help getting started—a little enzymatic push in the right direction. The fact that these needs were finally being met was evident in every heartfelt clap of the hands.

Lest you think these lessons are only important for us academic eggheads, I’d submit to you that the same, or at least similarly important, points are just as critical for young community hospitalists.

In fact, hospitalists and the field of HM are all very young; most of us are in desperate need of career guidance. And I’d go so far as to say the success of our field depends on meeting these needs as much or more than our ability to improve the quality of healthcare. The reality is that without sated, successful, career-oriented hospitalists, there can be no HM movement to improve the quality of care.

It’s tempting to feel that our residency training should prepare us for our jobs. However, the reality is that while residency prepares us reasonably well to practice clinic medicine, it does very little to prepare us for the wide-ranging rigors of medical practice. And while it’s easy to dismiss early-career development as touchy-feely nonsense, we do so at our own peril.

That message is written in the conflicts that abound within our HM groups and our hospitals, the burnout and low satisfaction that fuel our high turnover rate, and the unfulfilled careers that litter the HM landscape. It’s a message that threatens our beloved specialty—a message that all the clapping couldn’t drown out. TH

Dr. Glasheen is associate professor of medicine at the University of Colorado Denver, where he serves as director of the Hospital Medicine Program and the Hospitalist Training Program, and as associate program director of the Internal Medicine Residency Program.

Is this really happening? That’s what I was thinking as my mind quickly ran a differential of the possible explanations for the 80 people before me, positioned erectly, hands audibly moving together and apart. This had never happened to me before. Was this some sort of group yoga stretch aimed at quelling DVT formation, perhaps a pre-determined signal alerting security to have me removed for hitting an unconscionable level of boredom, or, most likely, a synchronized form of mass exit (my talks are accustomed to a certain level of attrition)? Beyond these possibilities lies just one alternative: I actually was receiving a standing ovation.

First, let me dispense with one ever-important technicality. The ovation, coming at the close of the recent four-day Academic Hospitalist Academy held outside Atlanta, was more rightly intended for the efforts of the entire eight-member faculty than me alone. I just happened to be giving the closing session.

The fact of the matter is that as a faculty member for this program, which aimed to provide early-career development for junior academic hospitalists, I, too, was in awe at the tremendous, unparalleled work of the faculty: Drs. Brad Sharpe, Vikas Parekh, Andy Auerbach, Jeff Wiese, Shobi Chheda, Bob Centor, and Jen Myers.

Yet there I was, just moments after uttering a few closing comments, being showered with praise, each clap further pumping my chest fuller with pride. It was then, with a deflating wheeze, that I realized what was happening—they weren’t clapping for me, or even the rest of the faculty. It turns out the more obvious cause for their enthusiasm had been staring me in the face the whole time. Or, more to the point, the faces staring back at me were reflecting my numerous missteps that this course had ensured they’d never make. And that was very ovation-worthy.

Take-Home Points

Clapping excitedly at table No. 4 was a young first-year hospitalist from a major academic medical center. Looking at her, I could tell she would not, like I had, make the mistake of waiting too long to find a mentor. It wasn’t until my fourth year in academics that I found a mentor. That was four years of unproductive wandering, chasing dead ends, grabbing at wrong straws. So after multiple sessions covering the importance and means of finding mentors, as well as the role of mentees, it was clear that this young hospitalist would build her career foundation on more firm footing.

Applauding from table No. 7 was a second-year hospitalist from a community teaching hospital with aspirations of making a splash on the national hospitalist scene. Unlike my early fruitless attempts to get involved outside of my institution, the session on the importance of peer and national networking provided his quiver with several time-honored arrows that took me years to acquire.

The eyes of a hospitalist at table No. 8 foretold the story of a young faculty member who wouldn’t struggle with the process of promotion, as I had. After sitting through talks that lifted the veil on both the inner workings of an academic medical center and the mysteries by which said centers promote their members, she had a head start on ensuring her academic success.

Table No. 3 offered several hospitalists who wouldn’t make the errors I’ve made—repeatedly—with e-mail, phone conversations and running a meeting. A presentation on the basics of communications ensured that they wouldn’t send those irretrievable e-missives carrying unintentional messages or waste hours trying to cover in e-mail what would be better solved over the phone or in a face-to-face meeting.

A person at table one patted me on the shoulder, the glint in his eye signaling that the sessions on how to run a teaching team and be a more effective teacher at both the bedside and at the chalkboard would help him avoid the lower teaching scores that plagued my early academic years.

Focus on Fundamentals

I could go on, but the point is that while my fellow faculty and I reveled in the pleasure of a standing ovation, the truth is that the clapping had less to do with us or how we imparted information and more to do with the fact that we had shared with them the ingredients of their future success, something they actively longed for—a means to enhance their career success and satisfaction.

Mind you, none of these revelations were shocking; indeed, most are mundane and straightforward. However, the reality is that more often than not we just need help getting started—a little enzymatic push in the right direction. The fact that these needs were finally being met was evident in every heartfelt clap of the hands.

Lest you think these lessons are only important for us academic eggheads, I’d submit to you that the same, or at least similarly important, points are just as critical for young community hospitalists.

In fact, hospitalists and the field of HM are all very young; most of us are in desperate need of career guidance. And I’d go so far as to say the success of our field depends on meeting these needs as much or more than our ability to improve the quality of healthcare. The reality is that without sated, successful, career-oriented hospitalists, there can be no HM movement to improve the quality of care.

It’s tempting to feel that our residency training should prepare us for our jobs. However, the reality is that while residency prepares us reasonably well to practice clinic medicine, it does very little to prepare us for the wide-ranging rigors of medical practice. And while it’s easy to dismiss early-career development as touchy-feely nonsense, we do so at our own peril.

That message is written in the conflicts that abound within our HM groups and our hospitals, the burnout and low satisfaction that fuel our high turnover rate, and the unfulfilled careers that litter the HM landscape. It’s a message that threatens our beloved specialty—a message that all the clapping couldn’t drown out. TH

Dr. Glasheen is associate professor of medicine at the University of Colorado Denver, where he serves as director of the Hospital Medicine Program and the Hospitalist Training Program, and as associate program director of the Internal Medicine Residency Program.

I had a baby. OK, that may not be entirely accurate: My wife, ever the stickler for details, likes to irritatingly point out that she had the baby and I just stood around, unearthing innovative means to get in the way while nervously asking inappropriate questions seemingly aimed only at annoying the hospital staff.

A baby was had, nonetheless.

And while that is remarkable, the really notable story is what happened during our hospital stay.

An Inauspicious Start

It’s hard to read a newspaper, view a television news program, or have a conversation in public without knowing the situation: The U.S. healthcare system is in shambles—nearly 50 million uninsured, 16% of GDP spent on healthcare, and a World Health Organization (WHO) overall ranking of 37th in the world based on multiple health indicators. And, of course, there’s the thorny data suggesting that as many as 98,000 patients die annually from hospital-induced medical errors.

As such, I was prepared and ever vigilant for this admission. This was my chance to see, from the patient’s perspective, this massive, impersonal, error-riddled, sputtering system. I would expose it for what it was, and take names.

We started our odyssey a bit early, as these things are wont to happen—two weeks early, in fact. A somewhat inauspicious start, some would say. Admittedly, that’s what my buddy grumbled as I called him 90 minutes before the first pitch of Game 4 of the National League Divisional Series to tell him he’d have to watch the Phillies play the Rockies without me.

The Death Trap Beckons

My wife went to check in while I parked the car. Well, sort of park the car. It turns out this unwelcoming beast known as “the hospital” actually employed valets to park my car. “Parking is the last thing you need to worry about right now,” the attendant said. I, however, saw through this ruse. Aaron—according to his nametag—is up to no good, or so I thought, counting the pennies in my ashtray.

After checking in, the first person my wife and I encountered was Jane, our nurse. She came in all bubbly, effusing that “things will go well and you’ll be with your new addition very soon.” All heart-warming encouragement and smiles aside, she actually appeared unaware of this death trap cavorting as a hospital—a jumbo jet’s worth of patients dying from medical errors every day is no laughing matter, missy. “I’ve got my eye on you,” I whispered conspiratorially to no one; a knowing smirk appeared as I took down her name.

Later, this Jane would interrupt my attempts to make my wife laugh through expertly executed 1980s dance moves. Jane implored her to just “let it out and cry for a few minutes—then you’ll feel better.” Somewhat embarrassingly, this automaton was so caught up in her own medical world that she misinterpreted my wife’s tears of laughter for tears of apprehension. Oh, how misguided these medical personnel can be. “Stick to the nursing and I’ll comfort my wife,” I thought to myself. My wife, meanwhile, was in the process of “letting it out,” after which she did indeed report feeling better. Oh, she’s good. If I didn’t know her so well, she would have led me to believe Nurse Jane’s advice was sage, caring, and spot-on. I wasn’t fooled; my wife’s a sucker for my dance moves.

Procedural Missteps: I’ll Be Outside

Next up: Steve, a second-year anesthesia resident intent on plunging a catheter into my wife’s spine for pain relief. Little did young Steve know that I was on to him and his attempts to give my wife Brown-Séquard syndrome. After all, procedures are a common source of hospital error. Under the guise of “informed consent,” he spouted the pros and cons of the procedure, all the while failing to mention the near certainty with which my wife would develop paralysis from a spinal hematoma.

Of course, I am no boob. I relentlessly exposed this neophyte with my knowing questions, finishing the undressing with a curt “there is no way you’re coming near my wife with that needle!” To which my wife, in her ever-tender way, ordered me to get the hell out of the room so she could get some (unprintable expletive) pain relief. See, this young doctor was getting to her as well.

Undeterred, I continued to prowl for medical errors. Knowing communication to be fertile ground for hospital slip-ups, I watched intently the handoff of care the day nurse, Jane, gave to the night nurse, Sarah. Surprisingly, Jane appeared to get it all right—at least that’s how it would appear to the untrained eye. She succinctly overviewed our history and course, documented the medications my wife received, gave the plan, and told her what to do if things didn’t follow that plan. Sarah repeated back the salient points as she reviewed the written chart and asked a few questions.

All good on the surface, but she spent so much time doting over my wife’s emotional needs that she failed to notice my discontent over the Rockies’ series-ending loss to the Phillies. I helpfully pointed out this blunder to her, at which time my wife rolled her eyes and asked, “Why can’t guys have babies?” Assuming my wife missed that class in medical school, I immediately began to overview basic reproductive physiology, at which point I was again asked to leave the room—this time by Nurse Sarah.

Waiting-Room Reflections

Not one to be satisfied with my victories, I stalked the halls looking for a less-than-15-second hand wash or an HIPAA violation. Seeing none, I pondered my wife’s fate at the hands of this massive, impersonal, error-riddled healthcare machine. I just couldn’t surmise a scenario in which she’d get out of there alive.

Just then, Susan, our obstetrician, came out to let me know that my daughter would soon be making her entrance. She informed me that it would be OK to film the procedure, if I liked. “But what about malpractice? Aren’t you worried about having this on film?” I asked. “Not a bit,” she replied. “What I’m worried about is your horsing around causing us both to miss this delivery.”

With that, we were back in the room, reunited in our common purpose. Moments later, I was the proud owner of a freshly minted baby girl.

Putting down the video camera, the state of the healthcare system finally came into focus. To be certain, we have our problems. But this wasn’t the massive, impersonal, sputtering system I was led to expect. Rather, I found it filled with caring, compassionate, highly skilled professionals with names like Aaron, Jane, Sarah, Steve, and Susan. Together, they had engineered a true miracle.

A miracle named Kaiya. TH

Dr. Glasheen is associate professor of medicine at the University of Colorado Denver, where he serves as director of the Hospital Medicine Program and the Hospitalist Training Program, and as associate program director of the Internal Medicine Residency Program.

I had a baby. OK, that may not be entirely accurate: My wife, ever the stickler for details, likes to irritatingly point out that she had the baby and I just stood around, unearthing innovative means to get in the way while nervously asking inappropriate questions seemingly aimed only at annoying the hospital staff.

A baby was had, nonetheless.

And while that is remarkable, the really notable story is what happened during our hospital stay.

An Inauspicious Start

It’s hard to read a newspaper, view a television news program, or have a conversation in public without knowing the situation: The U.S. healthcare system is in shambles—nearly 50 million uninsured, 16% of GDP spent on healthcare, and a World Health Organization (WHO) overall ranking of 37th in the world based on multiple health indicators. And, of course, there’s the thorny data suggesting that as many as 98,000 patients die annually from hospital-induced medical errors.

As such, I was prepared and ever vigilant for this admission. This was my chance to see, from the patient’s perspective, this massive, impersonal, error-riddled, sputtering system. I would expose it for what it was, and take names.

We started our odyssey a bit early, as these things are wont to happen—two weeks early, in fact. A somewhat inauspicious start, some would say. Admittedly, that’s what my buddy grumbled as I called him 90 minutes before the first pitch of Game 4 of the National League Divisional Series to tell him he’d have to watch the Phillies play the Rockies without me.

The Death Trap Beckons

My wife went to check in while I parked the car. Well, sort of park the car. It turns out this unwelcoming beast known as “the hospital” actually employed valets to park my car. “Parking is the last thing you need to worry about right now,” the attendant said. I, however, saw through this ruse. Aaron—according to his nametag—is up to no good, or so I thought, counting the pennies in my ashtray.

After checking in, the first person my wife and I encountered was Jane, our nurse. She came in all bubbly, effusing that “things will go well and you’ll be with your new addition very soon.” All heart-warming encouragement and smiles aside, she actually appeared unaware of this death trap cavorting as a hospital—a jumbo jet’s worth of patients dying from medical errors every day is no laughing matter, missy. “I’ve got my eye on you,” I whispered conspiratorially to no one; a knowing smirk appeared as I took down her name.

Later, this Jane would interrupt my attempts to make my wife laugh through expertly executed 1980s dance moves. Jane implored her to just “let it out and cry for a few minutes—then you’ll feel better.” Somewhat embarrassingly, this automaton was so caught up in her own medical world that she misinterpreted my wife’s tears of laughter for tears of apprehension. Oh, how misguided these medical personnel can be. “Stick to the nursing and I’ll comfort my wife,” I thought to myself. My wife, meanwhile, was in the process of “letting it out,” after which she did indeed report feeling better. Oh, she’s good. If I didn’t know her so well, she would have led me to believe Nurse Jane’s advice was sage, caring, and spot-on. I wasn’t fooled; my wife’s a sucker for my dance moves.

Procedural Missteps: I’ll Be Outside

Next up: Steve, a second-year anesthesia resident intent on plunging a catheter into my wife’s spine for pain relief. Little did young Steve know that I was on to him and his attempts to give my wife Brown-Séquard syndrome. After all, procedures are a common source of hospital error. Under the guise of “informed consent,” he spouted the pros and cons of the procedure, all the while failing to mention the near certainty with which my wife would develop paralysis from a spinal hematoma.

Of course, I am no boob. I relentlessly exposed this neophyte with my knowing questions, finishing the undressing with a curt “there is no way you’re coming near my wife with that needle!” To which my wife, in her ever-tender way, ordered me to get the hell out of the room so she could get some (unprintable expletive) pain relief. See, this young doctor was getting to her as well.

Undeterred, I continued to prowl for medical errors. Knowing communication to be fertile ground for hospital slip-ups, I watched intently the handoff of care the day nurse, Jane, gave to the night nurse, Sarah. Surprisingly, Jane appeared to get it all right—at least that’s how it would appear to the untrained eye. She succinctly overviewed our history and course, documented the medications my wife received, gave the plan, and told her what to do if things didn’t follow that plan. Sarah repeated back the salient points as she reviewed the written chart and asked a few questions.

All good on the surface, but she spent so much time doting over my wife’s emotional needs that she failed to notice my discontent over the Rockies’ series-ending loss to the Phillies. I helpfully pointed out this blunder to her, at which time my wife rolled her eyes and asked, “Why can’t guys have babies?” Assuming my wife missed that class in medical school, I immediately began to overview basic reproductive physiology, at which point I was again asked to leave the room—this time by Nurse Sarah.

Waiting-Room Reflections

Not one to be satisfied with my victories, I stalked the halls looking for a less-than-15-second hand wash or an HIPAA violation. Seeing none, I pondered my wife’s fate at the hands of this massive, impersonal, error-riddled healthcare machine. I just couldn’t surmise a scenario in which she’d get out of there alive.

Just then, Susan, our obstetrician, came out to let me know that my daughter would soon be making her entrance. She informed me that it would be OK to film the procedure, if I liked. “But what about malpractice? Aren’t you worried about having this on film?” I asked. “Not a bit,” she replied. “What I’m worried about is your horsing around causing us both to miss this delivery.”

With that, we were back in the room, reunited in our common purpose. Moments later, I was the proud owner of a freshly minted baby girl.

Putting down the video camera, the state of the healthcare system finally came into focus. To be certain, we have our problems. But this wasn’t the massive, impersonal, sputtering system I was led to expect. Rather, I found it filled with caring, compassionate, highly skilled professionals with names like Aaron, Jane, Sarah, Steve, and Susan. Together, they had engineered a true miracle.

A miracle named Kaiya. TH

Dr. Glasheen is associate professor of medicine at the University of Colorado Denver, where he serves as director of the Hospital Medicine Program and the Hospitalist Training Program, and as associate program director of the Internal Medicine Residency Program.

I had a baby. OK, that may not be entirely accurate: My wife, ever the stickler for details, likes to irritatingly point out that she had the baby and I just stood around, unearthing innovative means to get in the way while nervously asking inappropriate questions seemingly aimed only at annoying the hospital staff.

A baby was had, nonetheless.

And while that is remarkable, the really notable story is what happened during our hospital stay.

An Inauspicious Start

It’s hard to read a newspaper, view a television news program, or have a conversation in public without knowing the situation: The U.S. healthcare system is in shambles—nearly 50 million uninsured, 16% of GDP spent on healthcare, and a World Health Organization (WHO) overall ranking of 37th in the world based on multiple health indicators. And, of course, there’s the thorny data suggesting that as many as 98,000 patients die annually from hospital-induced medical errors.

As such, I was prepared and ever vigilant for this admission. This was my chance to see, from the patient’s perspective, this massive, impersonal, error-riddled, sputtering system. I would expose it for what it was, and take names.

We started our odyssey a bit early, as these things are wont to happen—two weeks early, in fact. A somewhat inauspicious start, some would say. Admittedly, that’s what my buddy grumbled as I called him 90 minutes before the first pitch of Game 4 of the National League Divisional Series to tell him he’d have to watch the Phillies play the Rockies without me.

The Death Trap Beckons

My wife went to check in while I parked the car. Well, sort of park the car. It turns out this unwelcoming beast known as “the hospital” actually employed valets to park my car. “Parking is the last thing you need to worry about right now,” the attendant said. I, however, saw through this ruse. Aaron—according to his nametag—is up to no good, or so I thought, counting the pennies in my ashtray.

After checking in, the first person my wife and I encountered was Jane, our nurse. She came in all bubbly, effusing that “things will go well and you’ll be with your new addition very soon.” All heart-warming encouragement and smiles aside, she actually appeared unaware of this death trap cavorting as a hospital—a jumbo jet’s worth of patients dying from medical errors every day is no laughing matter, missy. “I’ve got my eye on you,” I whispered conspiratorially to no one; a knowing smirk appeared as I took down her name.

Later, this Jane would interrupt my attempts to make my wife laugh through expertly executed 1980s dance moves. Jane implored her to just “let it out and cry for a few minutes—then you’ll feel better.” Somewhat embarrassingly, this automaton was so caught up in her own medical world that she misinterpreted my wife’s tears of laughter for tears of apprehension. Oh, how misguided these medical personnel can be. “Stick to the nursing and I’ll comfort my wife,” I thought to myself. My wife, meanwhile, was in the process of “letting it out,” after which she did indeed report feeling better. Oh, she’s good. If I didn’t know her so well, she would have led me to believe Nurse Jane’s advice was sage, caring, and spot-on. I wasn’t fooled; my wife’s a sucker for my dance moves.

Procedural Missteps: I’ll Be Outside

Next up: Steve, a second-year anesthesia resident intent on plunging a catheter into my wife’s spine for pain relief. Little did young Steve know that I was on to him and his attempts to give my wife Brown-Séquard syndrome. After all, procedures are a common source of hospital error. Under the guise of “informed consent,” he spouted the pros and cons of the procedure, all the while failing to mention the near certainty with which my wife would develop paralysis from a spinal hematoma.

Of course, I am no boob. I relentlessly exposed this neophyte with my knowing questions, finishing the undressing with a curt “there is no way you’re coming near my wife with that needle!” To which my wife, in her ever-tender way, ordered me to get the hell out of the room so she could get some (unprintable expletive) pain relief. See, this young doctor was getting to her as well.

Undeterred, I continued to prowl for medical errors. Knowing communication to be fertile ground for hospital slip-ups, I watched intently the handoff of care the day nurse, Jane, gave to the night nurse, Sarah. Surprisingly, Jane appeared to get it all right—at least that’s how it would appear to the untrained eye. She succinctly overviewed our history and course, documented the medications my wife received, gave the plan, and told her what to do if things didn’t follow that plan. Sarah repeated back the salient points as she reviewed the written chart and asked a few questions.

All good on the surface, but she spent so much time doting over my wife’s emotional needs that she failed to notice my discontent over the Rockies’ series-ending loss to the Phillies. I helpfully pointed out this blunder to her, at which time my wife rolled her eyes and asked, “Why can’t guys have babies?” Assuming my wife missed that class in medical school, I immediately began to overview basic reproductive physiology, at which point I was again asked to leave the room—this time by Nurse Sarah.

Waiting-Room Reflections

Not one to be satisfied with my victories, I stalked the halls looking for a less-than-15-second hand wash or an HIPAA violation. Seeing none, I pondered my wife’s fate at the hands of this massive, impersonal, error-riddled healthcare machine. I just couldn’t surmise a scenario in which she’d get out of there alive.

Just then, Susan, our obstetrician, came out to let me know that my daughter would soon be making her entrance. She informed me that it would be OK to film the procedure, if I liked. “But what about malpractice? Aren’t you worried about having this on film?” I asked. “Not a bit,” she replied. “What I’m worried about is your horsing around causing us both to miss this delivery.”

With that, we were back in the room, reunited in our common purpose. Moments later, I was the proud owner of a freshly minted baby girl.

Putting down the video camera, the state of the healthcare system finally came into focus. To be certain, we have our problems. But this wasn’t the massive, impersonal, sputtering system I was led to expect. Rather, I found it filled with caring, compassionate, highly skilled professionals with names like Aaron, Jane, Sarah, Steve, and Susan. Together, they had engineered a true miracle.

A miracle named Kaiya. TH

Dr. Glasheen is associate professor of medicine at the University of Colorado Denver, where he serves as director of the Hospital Medicine Program and the Hospitalist Training Program, and as associate program director of the Internal Medicine Residency Program.

“I don’t want to be rude or sarcastic,” he implored rudely and sarcastically, a pretentious smirk materializing, “but for hospital medicine to be considered a specialty, don’t you need to do something ‘special’?”

As I spun my internal Rolodex of responses for a setting-appropriate rebuttal, he exchanged knowing glances with the group of grizzled subspecialist academics surrounding him. The crowd, sensing its young prey was cornered, looked on with pitch-forked stares. The prey, sweaty-palmed and tachycardic, made a valiant yet ultimately futile attempt to stave off the questioner.

This exchange came during the question-and-answer portion of a medical grand rounds presentation that I made as a visiting professor at a major academic medical center many years ago. I was asked to talk about the growing specialty of HM, then a relatively new concept to the starched white coats in the academic ivory tower. To be fair, my interpretation of this interaction might be tainted by transference of an early-career inferiority complex. The inquiry had more than a kernel of legitimacy. Is HM really anything special? That query has lived with me for years in the form of a running internal discussion I’ve had with that questioner’s visage.

A Hospitalist is Born

I distinctly remember the day I became a hospitalist. Unlike for most of you, it wasn’t the day I began practicing as a hospitalist. Rather, it was about two years after I started, when my boss dropped off a brochure to join the National Association of Inpatient Physicians (NAIP). “You should probably join this group, whatever it is,” my nonhospitalist boss said dismissively. I nodded my head approvingly, my face contorting into a deferential and admiring look that indicated appreciation for the boss’s all-knowing greatness (note to my hospitalist group: Read that last sentence again). Moments later, I accessed this group’s Web page and found that the position I’d really been filling, what we called “attending on the medical wards 10 months a year,” was called a “hospitalist.”

OK, I had a name.

But was I special?

Growing Up and Finding Our ‘Disease’

Over the ensuing years, NAIP became SHM, HM textbooks were written, national and local CME meetings sprouted up, and a newsmagazine (this one) and medical journal for hospitalists (Journal of Hospital Medicine) were born.

“That’s terrific,” my imaginary grand rounds visage patronizes, “but a specialty needs more than a few people. It needs a critical mass of providers.”

By the beginning of this decade, the number of hospitalists had surpassed the number of practitioners in such time-honored specialties as geriatrics, critical care, and infectious diseases. By 2005, estimates had hospitalists trumping the number of cardiology and emergency medicine doctors. It is likely that the next decade will see the field mushroom to as many as 50,000, even 70,000, providers.

“But you don’t ‘own’ a disease,” exclaims the organ-centric visage. “You can’t be a specialty without ‘owning’ something.”

About five years ago, SHM decided to embrace VTE as a “hospitalist disease.” For sure, we treat the vast majority of pulmonary embolisms and DVTs, and we are best positioned to prevent the hospital-acquired variants. This, along with the realization that hospitalists care for the vast majority of myocardial infarctions, pneumonia, and stroke cases, provided us several diseases to “own,” or at least share with our subspecialist colleagues. The past decade has seen hospitalists take—and eventually run with—the QI and patient-safety baton. These are not diseases per se, but efforts poised to define the next generation of U.S. healthcare.

Research Agenda

“Let’s be clear,” my visage chides grumpily. “Owning a disease means more than caring for patients with it. You have to build a research agenda and advance the science of that field.”

HM now counts numerous primary research-based training fellowships and hospitalist researchers. The result is a growing cadre of research-funded hospitalists establishing careers in QI, patient safety, and comparative-effectiveness work around inpatient disease states. Additionally, SHM recently decided to begin funding early-career researchers to bolster the ranks of hospitalist researchers.

Training: The Next Frontier

“That’s cute,” the visage condescends, “but come on—you just can’t be a specialty without training programs. How can you be special if anyone coming out of residency training can do what you do?”

This is a question that has preoccupied me for years. Is there really something that hospitalists do that the typical graduating resident isn’t trained to do? The answer is clear to anyone who has reviewed the published literature—or practiced HM.1,2 Necessity dictates that hospitalists become experts in the perioperative management of surgical patients, provide the bulk of care for acute stroke and many neurosurgical patients, be front-line palliative-care providers, and grant a level of medical consultation that is infrequently stressed in residency training.

Moreover, hospitalists require a strong understanding of healthcare finance, transitions of care, and leadership and communication skills that are underemphasized in most training programs. On top of that, we are tasked with improving hospital efficiency, stewarding hospital resources, and tackling the myriad patient safety and QI initiatives being foisted upon American hospitals. Traditional residency training falls short in most of these categories. Educators are taking note, quickly adapting their HM-focused programs.3

“All right, maybe you’re right there, but you can’t be a specialty without certification. Period, end of story,” my friend, now exasperated, states.

Specialty Status

Enter the recently announced American Board of Internal Medicine’s (ABIM) Recognition of Focused Practice (RFP) in Hospital Medicine program. Although the full details have yet to be released, the RFP in HM will utilize the ABIM’s maintenance of certification (MOC) process that all internists are required to partake in at least every 10 years after their initial certification. Certification in HM will most likely include successful completion of four baseline requirements, starting with the ability to document that an applicant has truly focused their practice on inpatient medicine.

Next, diplomates will have to apply their QI skills to HM-based PIMs, or practice improvement modules. Additionally, diplomates will have to complete hospitalist-specific Self-Evaluation Program (SEPs) modules in medical knowledge. And, of course, there will be a secure examination written specifically for hospitalists that is focused on inpatient medicine (see “A-Plus Achievement,” p. 1).

So, as I reminisce fondly with my imaginary visage, it is with the clarity that the next time I give medical grand rounds, I will do so as an unquestioned specialist. TH

Dr. Glasheen is associate professor of medicine at the University of Colorado Denver, where he serves as director of the Hospital Medicine Program and the Hospitalist Training Program, and as associate program director of the Internal Medicine Residency Program.

References

1. Plauth WH III, Pantilat SZ, Wachter RM, Fenton CL. Hospitalists’ perceptions of their residency training needs: results of a national survey. Am J Med. 2001;111(3):247-254.
2. Glasheen JJ, Epstein KR, Siegal E, Kutner J, Prochazka AV. The spectrum of community-based hospitalist practice: a call to tailor internal medicine residency training. Arch Intern Med. 2007;167(7): 727-728.
3. Glasheen JJ, Siegal EM, Epstein K, Kutner, J, Prochazka AV. Fulfilling the promise of hospital medicine: Tailoring internal medicine training to address hospitalists’ needs. J Gen Intern Med. 2008;23(7): 1110-1115.

“I don’t want to be rude or sarcastic,” he implored rudely and sarcastically, a pretentious smirk materializing, “but for hospital medicine to be considered a specialty, don’t you need to do something ‘special’?”

As I spun my internal Rolodex of responses for a setting-appropriate rebuttal, he exchanged knowing glances with the group of grizzled subspecialist academics surrounding him. The crowd, sensing its young prey was cornered, looked on with pitch-forked stares. The prey, sweaty-palmed and tachycardic, made a valiant yet ultimately futile attempt to stave off the questioner.

This exchange came during the question-and-answer portion of a medical grand rounds presentation that I made as a visiting professor at a major academic medical center many years ago. I was asked to talk about the growing specialty of HM, then a relatively new concept to the starched white coats in the academic ivory tower. To be fair, my interpretation of this interaction might be tainted by transference of an early-career inferiority complex. The inquiry had more than a kernel of legitimacy. Is HM really anything special? That query has lived with me for years in the form of a running internal discussion I’ve had with that questioner’s visage.

A Hospitalist is Born

I distinctly remember the day I became a hospitalist. Unlike for most of you, it wasn’t the day I began practicing as a hospitalist. Rather, it was about two years after I started, when my boss dropped off a brochure to join the National Association of Inpatient Physicians (NAIP). “You should probably join this group, whatever it is,” my nonhospitalist boss said dismissively. I nodded my head approvingly, my face contorting into a deferential and admiring look that indicated appreciation for the boss’s all-knowing greatness (note to my hospitalist group: Read that last sentence again). Moments later, I accessed this group’s Web page and found that the position I’d really been filling, what we called “attending on the medical wards 10 months a year,” was called a “hospitalist.”

OK, I had a name.

But was I special?

Growing Up and Finding Our ‘Disease’

Over the ensuing years, NAIP became SHM, HM textbooks were written, national and local CME meetings sprouted up, and a newsmagazine (this one) and medical journal for hospitalists (Journal of Hospital Medicine) were born.

“That’s terrific,” my imaginary grand rounds visage patronizes, “but a specialty needs more than a few people. It needs a critical mass of providers.”

By the beginning of this decade, the number of hospitalists had surpassed the number of practitioners in such time-honored specialties as geriatrics, critical care, and infectious diseases. By 2005, estimates had hospitalists trumping the number of cardiology and emergency medicine doctors. It is likely that the next decade will see the field mushroom to as many as 50,000, even 70,000, providers.

“But you don’t ‘own’ a disease,” exclaims the organ-centric visage. “You can’t be a specialty without ‘owning’ something.”

About five years ago, SHM decided to embrace VTE as a “hospitalist disease.” For sure, we treat the vast majority of pulmonary embolisms and DVTs, and we are best positioned to prevent the hospital-acquired variants. This, along with the realization that hospitalists care for the vast majority of myocardial infarctions, pneumonia, and stroke cases, provided us several diseases to “own,” or at least share with our subspecialist colleagues. The past decade has seen hospitalists take—and eventually run with—the QI and patient-safety baton. These are not diseases per se, but efforts poised to define the next generation of U.S. healthcare.

Research Agenda

“Let’s be clear,” my visage chides grumpily. “Owning a disease means more than caring for patients with it. You have to build a research agenda and advance the science of that field.”

HM now counts numerous primary research-based training fellowships and hospitalist researchers. The result is a growing cadre of research-funded hospitalists establishing careers in QI, patient safety, and comparative-effectiveness work around inpatient disease states. Additionally, SHM recently decided to begin funding early-career researchers to bolster the ranks of hospitalist researchers.

Training: The Next Frontier

“That’s cute,” the visage condescends, “but come on—you just can’t be a specialty without training programs. How can you be special if anyone coming out of residency training can do what you do?”

This is a question that has preoccupied me for years. Is there really something that hospitalists do that the typical graduating resident isn’t trained to do? The answer is clear to anyone who has reviewed the published literature—or practiced HM.1,2 Necessity dictates that hospitalists become experts in the perioperative management of surgical patients, provide the bulk of care for acute stroke and many neurosurgical patients, be front-line palliative-care providers, and grant a level of medical consultation that is infrequently stressed in residency training.

Moreover, hospitalists require a strong understanding of healthcare finance, transitions of care, and leadership and communication skills that are underemphasized in most training programs. On top of that, we are tasked with improving hospital efficiency, stewarding hospital resources, and tackling the myriad patient safety and QI initiatives being foisted upon American hospitals. Traditional residency training falls short in most of these categories. Educators are taking note, quickly adapting their HM-focused programs.3

“All right, maybe you’re right there, but you can’t be a specialty without certification. Period, end of story,” my friend, now exasperated, states.

Specialty Status

Enter the recently announced American Board of Internal Medicine’s (ABIM) Recognition of Focused Practice (RFP) in Hospital Medicine program. Although the full details have yet to be released, the RFP in HM will utilize the ABIM’s maintenance of certification (MOC) process that all internists are required to partake in at least every 10 years after their initial certification. Certification in HM will most likely include successful completion of four baseline requirements, starting with the ability to document that an applicant has truly focused their practice on inpatient medicine.

Next, diplomates will have to apply their QI skills to HM-based PIMs, or practice improvement modules. Additionally, diplomates will have to complete hospitalist-specific Self-Evaluation Program (SEPs) modules in medical knowledge. And, of course, there will be a secure examination written specifically for hospitalists that is focused on inpatient medicine (see “A-Plus Achievement,” p. 1).

So, as I reminisce fondly with my imaginary visage, it is with the clarity that the next time I give medical grand rounds, I will do so as an unquestioned specialist. TH

Dr. Glasheen is associate professor of medicine at the University of Colorado Denver, where he serves as director of the Hospital Medicine Program and the Hospitalist Training Program, and as associate program director of the Internal Medicine Residency Program.

References

1. Plauth WH III, Pantilat SZ, Wachter RM, Fenton CL. Hospitalists’ perceptions of their residency training needs: results of a national survey. Am J Med. 2001;111(3):247-254.
2. Glasheen JJ, Epstein KR, Siegal E, Kutner J, Prochazka AV. The spectrum of community-based hospitalist practice: a call to tailor internal medicine residency training. Arch Intern Med. 2007;167(7): 727-728.
3. Glasheen JJ, Siegal EM, Epstein K, Kutner, J, Prochazka AV. Fulfilling the promise of hospital medicine: Tailoring internal medicine training to address hospitalists’ needs. J Gen Intern Med. 2008;23(7): 1110-1115.

“I don’t want to be rude or sarcastic,” he implored rudely and sarcastically, a pretentious smirk materializing, “but for hospital medicine to be considered a specialty, don’t you need to do something ‘special’?”

As I spun my internal Rolodex of responses for a setting-appropriate rebuttal, he exchanged knowing glances with the group of grizzled subspecialist academics surrounding him. The crowd, sensing its young prey was cornered, looked on with pitch-forked stares. The prey, sweaty-palmed and tachycardic, made a valiant yet ultimately futile attempt to stave off the questioner.

This exchange came during the question-and-answer portion of a medical grand rounds presentation that I made as a visiting professor at a major academic medical center many years ago. I was asked to talk about the growing specialty of HM, then a relatively new concept to the starched white coats in the academic ivory tower. To be fair, my interpretation of this interaction might be tainted by transference of an early-career inferiority complex. The inquiry had more than a kernel of legitimacy. Is HM really anything special? That query has lived with me for years in the form of a running internal discussion I’ve had with that questioner’s visage.

A Hospitalist is Born

I distinctly remember the day I became a hospitalist. Unlike for most of you, it wasn’t the day I began practicing as a hospitalist. Rather, it was about two years after I started, when my boss dropped off a brochure to join the National Association of Inpatient Physicians (NAIP). “You should probably join this group, whatever it is,” my nonhospitalist boss said dismissively. I nodded my head approvingly, my face contorting into a deferential and admiring look that indicated appreciation for the boss’s all-knowing greatness (note to my hospitalist group: Read that last sentence again). Moments later, I accessed this group’s Web page and found that the position I’d really been filling, what we called “attending on the medical wards 10 months a year,” was called a “hospitalist.”

OK, I had a name.

But was I special?

Growing Up and Finding Our ‘Disease’

Over the ensuing years, NAIP became SHM, HM textbooks were written, national and local CME meetings sprouted up, and a newsmagazine (this one) and medical journal for hospitalists (Journal of Hospital Medicine) were born.

“That’s terrific,” my imaginary grand rounds visage patronizes, “but a specialty needs more than a few people. It needs a critical mass of providers.”

By the beginning of this decade, the number of hospitalists had surpassed the number of practitioners in such time-honored specialties as geriatrics, critical care, and infectious diseases. By 2005, estimates had hospitalists trumping the number of cardiology and emergency medicine doctors. It is likely that the next decade will see the field mushroom to as many as 50,000, even 70,000, providers.

“But you don’t ‘own’ a disease,” exclaims the organ-centric visage. “You can’t be a specialty without ‘owning’ something.”

About five years ago, SHM decided to embrace VTE as a “hospitalist disease.” For sure, we treat the vast majority of pulmonary embolisms and DVTs, and we are best positioned to prevent the hospital-acquired variants. This, along with the realization that hospitalists care for the vast majority of myocardial infarctions, pneumonia, and stroke cases, provided us several diseases to “own,” or at least share with our subspecialist colleagues. The past decade has seen hospitalists take—and eventually run with—the QI and patient-safety baton. These are not diseases per se, but efforts poised to define the next generation of U.S. healthcare.

Research Agenda

“Let’s be clear,” my visage chides grumpily. “Owning a disease means more than caring for patients with it. You have to build a research agenda and advance the science of that field.”

HM now counts numerous primary research-based training fellowships and hospitalist researchers. The result is a growing cadre of research-funded hospitalists establishing careers in QI, patient safety, and comparative-effectiveness work around inpatient disease states. Additionally, SHM recently decided to begin funding early-career researchers to bolster the ranks of hospitalist researchers.

Training: The Next Frontier

“That’s cute,” the visage condescends, “but come on—you just can’t be a specialty without training programs. How can you be special if anyone coming out of residency training can do what you do?”

This is a question that has preoccupied me for years. Is there really something that hospitalists do that the typical graduating resident isn’t trained to do? The answer is clear to anyone who has reviewed the published literature—or practiced HM.1,2 Necessity dictates that hospitalists become experts in the perioperative management of surgical patients, provide the bulk of care for acute stroke and many neurosurgical patients, be front-line palliative-care providers, and grant a level of medical consultation that is infrequently stressed in residency training.

Moreover, hospitalists require a strong understanding of healthcare finance, transitions of care, and leadership and communication skills that are underemphasized in most training programs. On top of that, we are tasked with improving hospital efficiency, stewarding hospital resources, and tackling the myriad patient safety and QI initiatives being foisted upon American hospitals. Traditional residency training falls short in most of these categories. Educators are taking note, quickly adapting their HM-focused programs.3

“All right, maybe you’re right there, but you can’t be a specialty without certification. Period, end of story,” my friend, now exasperated, states.

Specialty Status

Enter the recently announced American Board of Internal Medicine’s (ABIM) Recognition of Focused Practice (RFP) in Hospital Medicine program. Although the full details have yet to be released, the RFP in HM will utilize the ABIM’s maintenance of certification (MOC) process that all internists are required to partake in at least every 10 years after their initial certification. Certification in HM will most likely include successful completion of four baseline requirements, starting with the ability to document that an applicant has truly focused their practice on inpatient medicine.

Next, diplomates will have to apply their QI skills to HM-based PIMs, or practice improvement modules. Additionally, diplomates will have to complete hospitalist-specific Self-Evaluation Program (SEPs) modules in medical knowledge. And, of course, there will be a secure examination written specifically for hospitalists that is focused on inpatient medicine (see “A-Plus Achievement,” p. 1).

So, as I reminisce fondly with my imaginary visage, it is with the clarity that the next time I give medical grand rounds, I will do so as an unquestioned specialist. TH

Dr. Glasheen is associate professor of medicine at the University of Colorado Denver, where he serves as director of the Hospital Medicine Program and the Hospitalist Training Program, and as associate program director of the Internal Medicine Residency Program.

References

1. Plauth WH III, Pantilat SZ, Wachter RM, Fenton CL. Hospitalists’ perceptions of their residency training needs: results of a national survey. Am J Med. 2001;111(3):247-254.
2. Glasheen JJ, Epstein KR, Siegal E, Kutner J, Prochazka AV. The spectrum of community-based hospitalist practice: a call to tailor internal medicine residency training. Arch Intern Med. 2007;167(7): 727-728.
3. Glasheen JJ, Siegal EM, Epstein K, Kutner, J, Prochazka AV. Fulfilling the promise of hospital medicine: Tailoring internal medicine training to address hospitalists’ needs. J Gen Intern Med. 2008;23(7): 1110-1115.

Apocalypse, pestilence, death. As I head back to work after a late-summer vacation, those words are on the tip of my tongue. Now before your mind drifts too far afield, this is not a synopsis of the time spent with family, or even my in-laws—although some have used similar words to describe my mother’s cooking. Rather, these are the descriptors of my vacation reading.

Summer Reading

I started the week relaxing contentedly with Cormac McCarthy’s “The Road.” I chose this book in part because I noticed that it soon will be released as a movie, but mostly because it had won the dustiest-book-in-my-office-reading-pile award. This tale of a young boy and his father traversing a post-apocalyptic America was shocking and surreal. I couldn’t help but interchange images of my 2-year-old son, Greyson, and me out on that road fighting for our existence. In my personal fictional account, I continuously, and heroically, MacGyver my way across a burned-out and treacherous landscape with death-defying adeptness—all the while Grey unknowingly totters, drooling and muttering in tow.

HULTON ARCHIVE/GETTYIMAGES

Reality, of course, would paint us in substantially different roles, with mine involving the lion’s share of muttering and drooling, leaving Grey wishing the apocalyptic dealer had dealt him his mother instead.

Next up, “The Last Town on Earth,” by Thomas Mullen. I don’t recall how this book got into my reading pile, but I’m glad it did. The story is set in the fictional city of Commonwealth in 1918. The small, isolated mill town makes the drastic decision to stanch the tide of Spanish flu by cutting itself off from civilization through a self-imposed quarantine.

It is here, on p. 98, that I was sidetracked by a family member’s question—“Do you think this swine flu will be as bad as the Spanish flu?” I was asked shortly after being inquired about my reading choice. “Of course not,” I replied knowingly, moments before realizing I didn’t know. In fact, I didn’t have the faintest idea—not because it’s tough to divine the future, but because I realized I had little more than a passing knowledge of the famous flu that raked the world early last century. And with that, I was off on my final vacation reading session—a quest to slake my thirst for influenza knowledge.

Flu Pandemic

The Spanish flu pandemic of 1918-1920 was the first of three to hit in the 20th century. It took its name not from its site of origin (debated but generally felt to be the U.S., Kansas specifically), but rather from the fact that Spain, a neutral country in World War I, had the most uncensored lines of communication, so the most credible news of the disease came from that country. This provided the false impression that Spain was the only—or at least most dramatically—affected country. Like today’s swine flu, the Spanish flu was an H1N1 influenza. To sate your inner microbiologist, this means the virus exhibits the first of 16 subtypes of hemagglutinin (H) and nine subtypes of neuraminidase (N). Generally, only H1, H2, H3, and N1 and N2 affect humans, and tend to cause mild disease in otherwise healthy populations, killing the immunocompromised, the very young, and the very old. This typically results in a case-fatality rate of about 0.1% and 250,000 to 500,000 deaths worldwide annually.

The Spanish flu, however, was different. For reasons that are not entirely clear, the Spanish flu struck in two waves. The first wave, in the spring of 1918, induced typical flu-like illness with generally mild outcomes, except for the immunocompromised. The second wave was unusual for two reasons. First, it began in the late summer of 1918, rather than the typical winter pattern seen in North America. Second, it was much more deadly, inducing what has been termed a cytokine storm. This immunological avalanche produced more severe disease in the immunopotent young, healthy populations—resulting in its unprecedented mortality in this cohort. In fact, upward of 99% of all Spanish flu deaths were in people younger than 65.

In the end, the pandemic left a broad swath of destruction in its wake. It is estimated that 500 million people—one-third of the world’s population at the time—were infected. The mortality rate was 10% to 20%, resulting in 50 million to 100 million deaths. Put another way, the Spanish flu killed 5% of humanity.

It did so rapidly. Nearly 1 million people died per week in the first 25 weeks of the second wave. To put it in perspective, it took HIV 25 years to reach that number. Thus, historians have termed the Spanish flu “the greatest medical holocaust in history.”

And then as quickly as it commenced, it abated. For example, in Philadelphia, there were about 5,000 flu deaths in one week in October 1918, yet a month later, the virus had nearly disappeared from the city. It’s not clear why this happened, but prevailing theories postulate that either the medical community got better at managing its mortal complications (e.g., bacterial pneumonia), or the bug itself mutated to a less virulent strain.

Is the Swine Flu our Spanish Flu?

On June 11, 2009, the World Health Organization (WHO) declared that the current H1N1 flu virus had reached pandemic status. This novel H1N1 serotype appears to be a direct descendent of the Spanish H1N1 subtype, but the new strain also combines genetic material culled from swine and birds reassorted in a manner that results in limited innate human defenses. And like the Spanish variant, it appears this new strain is hitting earlier in the year than usual and disproportionately affecting the young, with about two-thirds of U.S. deaths coming in the 25- to 64-year-old demographic.

So can we expect hundreds of millions of deaths from swine flu? Probably not. The WHO has been cautious to note that the upgrade to pandemic status was based on the rapidity and ease of spread, not the lethality of the virus. Furthermore, the Centers for Disease Control and Prevention (CDC)—which publishes a wonderful weekly update called FluView (www.cdc.gov/flu/weekly/)—notes that while the number of doctor’s visits for influenza-like illnesses through mid-August is unusually high, the rates of hospitalizations and proportion of deaths attributed to pneumonia and influenza are low and within normal limits for this time of year. Further, the virus continues in its original form, meaning it has not mutated, become more resistant to antiviral drugs, or been altered from the viruses selected for the 2009 vaccine.

So while we certainly must brace for the worst, I feel comfortable in the answer I provided my family member. I also am confident that Grey won’t be quarantined or left to roam the barren Earth anytime soon. TH

Dr. Glasheen is associate professor of medicine at the University of Colorado Denver, where he serves as director of the Hospital Medicine Program and the Hospitalist Training Program, and as associate program director of the Internal Medicine Residency Program.

Apocalypse, pestilence, death. As I head back to work after a late-summer vacation, those words are on the tip of my tongue. Now before your mind drifts too far afield, this is not a synopsis of the time spent with family, or even my in-laws—although some have used similar words to describe my mother’s cooking. Rather, these are the descriptors of my vacation reading.

Summer Reading

I started the week relaxing contentedly with Cormac McCarthy’s “The Road.” I chose this book in part because I noticed that it soon will be released as a movie, but mostly because it had won the dustiest-book-in-my-office-reading-pile award. This tale of a young boy and his father traversing a post-apocalyptic America was shocking and surreal. I couldn’t help but interchange images of my 2-year-old son, Greyson, and me out on that road fighting for our existence. In my personal fictional account, I continuously, and heroically, MacGyver my way across a burned-out and treacherous landscape with death-defying adeptness—all the while Grey unknowingly totters, drooling and muttering in tow.

HULTON ARCHIVE/GETTYIMAGES

Reality, of course, would paint us in substantially different roles, with mine involving the lion’s share of muttering and drooling, leaving Grey wishing the apocalyptic dealer had dealt him his mother instead.

Next up, “The Last Town on Earth,” by Thomas Mullen. I don’t recall how this book got into my reading pile, but I’m glad it did. The story is set in the fictional city of Commonwealth in 1918. The small, isolated mill town makes the drastic decision to stanch the tide of Spanish flu by cutting itself off from civilization through a self-imposed quarantine.

It is here, on p. 98, that I was sidetracked by a family member’s question—“Do you think this swine flu will be as bad as the Spanish flu?” I was asked shortly after being inquired about my reading choice. “Of course not,” I replied knowingly, moments before realizing I didn’t know. In fact, I didn’t have the faintest idea—not because it’s tough to divine the future, but because I realized I had little more than a passing knowledge of the famous flu that raked the world early last century. And with that, I was off on my final vacation reading session—a quest to slake my thirst for influenza knowledge.

Flu Pandemic

The Spanish flu pandemic of 1918-1920 was the first of three to hit in the 20th century. It took its name not from its site of origin (debated but generally felt to be the U.S., Kansas specifically), but rather from the fact that Spain, a neutral country in World War I, had the most uncensored lines of communication, so the most credible news of the disease came from that country. This provided the false impression that Spain was the only—or at least most dramatically—affected country. Like today’s swine flu, the Spanish flu was an H1N1 influenza. To sate your inner microbiologist, this means the virus exhibits the first of 16 subtypes of hemagglutinin (H) and nine subtypes of neuraminidase (N). Generally, only H1, H2, H3, and N1 and N2 affect humans, and tend to cause mild disease in otherwise healthy populations, killing the immunocompromised, the very young, and the very old. This typically results in a case-fatality rate of about 0.1% and 250,000 to 500,000 deaths worldwide annually.

The Spanish flu, however, was different. For reasons that are not entirely clear, the Spanish flu struck in two waves. The first wave, in the spring of 1918, induced typical flu-like illness with generally mild outcomes, except for the immunocompromised. The second wave was unusual for two reasons. First, it began in the late summer of 1918, rather than the typical winter pattern seen in North America. Second, it was much more deadly, inducing what has been termed a cytokine storm. This immunological avalanche produced more severe disease in the immunopotent young, healthy populations—resulting in its unprecedented mortality in this cohort. In fact, upward of 99% of all Spanish flu deaths were in people younger than 65.

In the end, the pandemic left a broad swath of destruction in its wake. It is estimated that 500 million people—one-third of the world’s population at the time—were infected. The mortality rate was 10% to 20%, resulting in 50 million to 100 million deaths. Put another way, the Spanish flu killed 5% of humanity.

It did so rapidly. Nearly 1 million people died per week in the first 25 weeks of the second wave. To put it in perspective, it took HIV 25 years to reach that number. Thus, historians have termed the Spanish flu “the greatest medical holocaust in history.”

And then as quickly as it commenced, it abated. For example, in Philadelphia, there were about 5,000 flu deaths in one week in October 1918, yet a month later, the virus had nearly disappeared from the city. It’s not clear why this happened, but prevailing theories postulate that either the medical community got better at managing its mortal complications (e.g., bacterial pneumonia), or the bug itself mutated to a less virulent strain.

Is the Swine Flu our Spanish Flu?

On June 11, 2009, the World Health Organization (WHO) declared that the current H1N1 flu virus had reached pandemic status. This novel H1N1 serotype appears to be a direct descendent of the Spanish H1N1 subtype, but the new strain also combines genetic material culled from swine and birds reassorted in a manner that results in limited innate human defenses. And like the Spanish variant, it appears this new strain is hitting earlier in the year than usual and disproportionately affecting the young, with about two-thirds of U.S. deaths coming in the 25- to 64-year-old demographic.

So can we expect hundreds of millions of deaths from swine flu? Probably not. The WHO has been cautious to note that the upgrade to pandemic status was based on the rapidity and ease of spread, not the lethality of the virus. Furthermore, the Centers for Disease Control and Prevention (CDC)—which publishes a wonderful weekly update called FluView (www.cdc.gov/flu/weekly/)—notes that while the number of doctor’s visits for influenza-like illnesses through mid-August is unusually high, the rates of hospitalizations and proportion of deaths attributed to pneumonia and influenza are low and within normal limits for this time of year. Further, the virus continues in its original form, meaning it has not mutated, become more resistant to antiviral drugs, or been altered from the viruses selected for the 2009 vaccine.

So while we certainly must brace for the worst, I feel comfortable in the answer I provided my family member. I also am confident that Grey won’t be quarantined or left to roam the barren Earth anytime soon. TH

Dr. Glasheen is associate professor of medicine at the University of Colorado Denver, where he serves as director of the Hospital Medicine Program and the Hospitalist Training Program, and as associate program director of the Internal Medicine Residency Program.

Apocalypse, pestilence, death. As I head back to work after a late-summer vacation, those words are on the tip of my tongue. Now before your mind drifts too far afield, this is not a synopsis of the time spent with family, or even my in-laws—although some have used similar words to describe my mother’s cooking. Rather, these are the descriptors of my vacation reading.

Summer Reading

I started the week relaxing contentedly with Cormac McCarthy’s “The Road.” I chose this book in part because I noticed that it soon will be released as a movie, but mostly because it had won the dustiest-book-in-my-office-reading-pile award. This tale of a young boy and his father traversing a post-apocalyptic America was shocking and surreal. I couldn’t help but interchange images of my 2-year-old son, Greyson, and me out on that road fighting for our existence. In my personal fictional account, I continuously, and heroically, MacGyver my way across a burned-out and treacherous landscape with death-defying adeptness—all the while Grey unknowingly totters, drooling and muttering in tow.

HULTON ARCHIVE/GETTYIMAGES

Reality, of course, would paint us in substantially different roles, with mine involving the lion’s share of muttering and drooling, leaving Grey wishing the apocalyptic dealer had dealt him his mother instead.

Next up, “The Last Town on Earth,” by Thomas Mullen. I don’t recall how this book got into my reading pile, but I’m glad it did. The story is set in the fictional city of Commonwealth in 1918. The small, isolated mill town makes the drastic decision to stanch the tide of Spanish flu by cutting itself off from civilization through a self-imposed quarantine.

It is here, on p. 98, that I was sidetracked by a family member’s question—“Do you think this swine flu will be as bad as the Spanish flu?” I was asked shortly after being inquired about my reading choice. “Of course not,” I replied knowingly, moments before realizing I didn’t know. In fact, I didn’t have the faintest idea—not because it’s tough to divine the future, but because I realized I had little more than a passing knowledge of the famous flu that raked the world early last century. And with that, I was off on my final vacation reading session—a quest to slake my thirst for influenza knowledge.

Flu Pandemic

The Spanish flu pandemic of 1918-1920 was the first of three to hit in the 20th century. It took its name not from its site of origin (debated but generally felt to be the U.S., Kansas specifically), but rather from the fact that Spain, a neutral country in World War I, had the most uncensored lines of communication, so the most credible news of the disease came from that country. This provided the false impression that Spain was the only—or at least most dramatically—affected country. Like today’s swine flu, the Spanish flu was an H1N1 influenza. To sate your inner microbiologist, this means the virus exhibits the first of 16 subtypes of hemagglutinin (H) and nine subtypes of neuraminidase (N). Generally, only H1, H2, H3, and N1 and N2 affect humans, and tend to cause mild disease in otherwise healthy populations, killing the immunocompromised, the very young, and the very old. This typically results in a case-fatality rate of about 0.1% and 250,000 to 500,000 deaths worldwide annually.

The Spanish flu, however, was different. For reasons that are not entirely clear, the Spanish flu struck in two waves. The first wave, in the spring of 1918, induced typical flu-like illness with generally mild outcomes, except for the immunocompromised. The second wave was unusual for two reasons. First, it began in the late summer of 1918, rather than the typical winter pattern seen in North America. Second, it was much more deadly, inducing what has been termed a cytokine storm. This immunological avalanche produced more severe disease in the immunopotent young, healthy populations—resulting in its unprecedented mortality in this cohort. In fact, upward of 99% of all Spanish flu deaths were in people younger than 65.

In the end, the pandemic left a broad swath of destruction in its wake. It is estimated that 500 million people—one-third of the world’s population at the time—were infected. The mortality rate was 10% to 20%, resulting in 50 million to 100 million deaths. Put another way, the Spanish flu killed 5% of humanity.

It did so rapidly. Nearly 1 million people died per week in the first 25 weeks of the second wave. To put it in perspective, it took HIV 25 years to reach that number. Thus, historians have termed the Spanish flu “the greatest medical holocaust in history.”

And then as quickly as it commenced, it abated. For example, in Philadelphia, there were about 5,000 flu deaths in one week in October 1918, yet a month later, the virus had nearly disappeared from the city. It’s not clear why this happened, but prevailing theories postulate that either the medical community got better at managing its mortal complications (e.g., bacterial pneumonia), or the bug itself mutated to a less virulent strain.

Is the Swine Flu our Spanish Flu?

On June 11, 2009, the World Health Organization (WHO) declared that the current H1N1 flu virus had reached pandemic status. This novel H1N1 serotype appears to be a direct descendent of the Spanish H1N1 subtype, but the new strain also combines genetic material culled from swine and birds reassorted in a manner that results in limited innate human defenses. And like the Spanish variant, it appears this new strain is hitting earlier in the year than usual and disproportionately affecting the young, with about two-thirds of U.S. deaths coming in the 25- to 64-year-old demographic.

So can we expect hundreds of millions of deaths from swine flu? Probably not. The WHO has been cautious to note that the upgrade to pandemic status was based on the rapidity and ease of spread, not the lethality of the virus. Furthermore, the Centers for Disease Control and Prevention (CDC)—which publishes a wonderful weekly update called FluView (www.cdc.gov/flu/weekly/)—notes that while the number of doctor’s visits for influenza-like illnesses through mid-August is unusually high, the rates of hospitalizations and proportion of deaths attributed to pneumonia and influenza are low and within normal limits for this time of year. Further, the virus continues in its original form, meaning it has not mutated, become more resistant to antiviral drugs, or been altered from the viruses selected for the 2009 vaccine.

So while we certainly must brace for the worst, I feel comfortable in the answer I provided my family member. I also am confident that Grey won’t be quarantined or left to roam the barren Earth anytime soon. TH

Dr. Glasheen is associate professor of medicine at the University of Colorado Denver, where he serves as director of the Hospital Medicine Program and the Hospitalist Training Program, and as associate program director of the Internal Medicine Residency Program.

Irecently bought an Apple computer. This is newsworthy because I am a lifelong PC user, and because I suffer from a genetic inability to adopt new technologies. In fact, I’m so old-school that only the graceless act of brandishing my credit card kept me from being unceremoniously escorted out of the store by Apple “specialists” for scaring off iPod-yearning tweens. Even then I wasn’t allowed to linger post-purchase.

After racing home, I eagerly slipped the 24 inches of iMac splendor out of its slick, mod-ish packaging and set it up on my desk. Thoughts of newfound cachet danced in my head as I peeled off my black “dad” socks and Tevas. It was clear to me that, as advertised, this sleek beauty was going to transform me from a doddering old Luddite into one of those trendy hipsters so keyed into the pulse of society. And it promised to be easier … and better.

What followed reminded me that the gospel of technology could sometimes preach a false god. It took but a few keystrokes to find myself grappling with a new operating system—it looked like Windows but felt like closed doors. Things that I can do effortlessly on my PC—navigate through files, open Web browsers, access my Outlook account, PowerPoint—seemed to take extra steps, new steps, or unknown steps.

Eventually, I was able figure most of this out, but in the end I was left with the very un-sating realization that the Mac wasn’t really any better than my PC. It was cooler, that’s for sure—even my wife took a renewed interest in me. However, after that cool factor quickly chilled, I was left with the queasy feeling that I had just dropped thousands of dollars on a machine that didn’t really function any better than my old machine. And in some cases, it functioned worse.

Fool’s Gold?

Like my new iMac, electronic health records (EHR) are touted as the technological savior of healthcare—if you invest in the rhetoric coming out of Washington. As our legislators struggle to figure out ways to shoehorn 50 million more Americans into the “insured” category, stave off the growing epidemic of medical errors, and improve the general quality of care, digitizing our health records is a commonly noted panacea. And EHR, it’s promised, somehow will do all of this while conveniently reducing the skyrocketing costs of healthcare.

My hospital is on the verge of siphoning tens of millions of dollars of government stimulus funding and hospital capital into the purchase of a major EHR upgrade. This system aims to seamlessly integrate our inpatient and outpatient billing, documentation, lab, and ordering systems into one neatly packaged, computer-driven solution. I’m left wondering if my iMac experience is an augur of how this will play out on a grand stage.

In the spirit of full disclosure, I fully support automating healthcare as much as possible and sit on numerous committees at my institution charged with doing just that. Further, I believe it will be a salve to many of our efficiency, quality, and patient safety issues. However, I worry that in solving some problems, these new technological cure-alls will simply introduce other, unanticipated problems.

Several years ago, my hospital introduced several systems and technological applications aimed at improving quality, safety, and efficiency. One of these is called “rounds reports.” These very handy, printable documents are a terrific idea and a great example of simplified workflow. The doctor simply prints out a one-page summary of the patient’s 24-hour vital signs, medications, and labs, and uses that as the template for their daily note.

As promised, it’s a time-saver. The problem is that this new technology harbors insidious flaws that prey on the frailties of human nature by introducing new portals for error. For example, the report makes it simple to not reconcile medications daily. The time-honored and time-intensive manner of writing all the meds on a progress note is indeed cumbersome, but it has the added effect of forcing the provider to think about each medication—the utility, the dosage, the effects of the failing kidney on the dosage. Automation of this process removes this small but critical safety check. Sure, diligent providers can overcome this by paying close attention to the printout, but human nature dictates that we don’t always do it. In fact, we employed automation to save this type of time in the first place.

The rounds report also helpfully displays the vital signs and blood sugars for the past 24 hours, reducing the time the harried hospitalist has to spend looking these up and writing them down. However, the report doesn’t print out every vital sign and blood-sugar level; it provides a range. Again, it is possible to access these individual levels, but the post-EHR provider, lured by simplification, often doesn’t take the extra step to go to the separate program to gather these numbers. This shortcut enhances efficiency at the expense of having complete data, a scenario that can breed bad outcomes.

More Efficient Doesn’t Mean Better

Then there is the catch-22 of electronic imaging reports. It is impressive how quickly a chest X-ray gets read and reported electronically in my hospital. The downside, of course, is that today’s techno-doc can rely on the written report without reviewing the actual image. We’ve again, in not reviewing the films personally, removed an important safety check.

The point is that while mechanization offers great potential, it is easy to overlook the downside. Many physicians are not as tech-savvy as their kids and likely will struggle with these newfangled devices. For them, this will not simplify their workflow, but rather it will bog them down. These gizmos also are extremely expensive, and many small clinics and rural hospitals will struggle to afford these upgrades, even with taxpayer support. And let’s not overlook the myriad unforeseen hiccups these new systems will breed.

None of this is to say we shouldn’t embrace our “Jetsons”-like future. In fact, I’d counter that we must, and now is the opportune time. Still, I get nervous when I read stories of the endless EHR potential that omit or gloss over the probable limitations. The key will be to adopt these systems in ways that augment their strengths while mitigating their weaknesses. This must include achieving the delicate balance of usability, efficiency, and safety.

Otherwise, we might find that the technological apple will keep the doctors away. TH

Dr. Glasheen is associate professor of medicine at the University of Colorado Denver, where he serves as director of the Hospital Medicine Program and the Hospitalist Training Program, and as associate program director of the Internal Medicine Residency Program.

Irecently bought an Apple computer. This is newsworthy because I am a lifelong PC user, and because I suffer from a genetic inability to adopt new technologies. In fact, I’m so old-school that only the graceless act of brandishing my credit card kept me from being unceremoniously escorted out of the store by Apple “specialists” for scaring off iPod-yearning tweens. Even then I wasn’t allowed to linger post-purchase.

After racing home, I eagerly slipped the 24 inches of iMac splendor out of its slick, mod-ish packaging and set it up on my desk. Thoughts of newfound cachet danced in my head as I peeled off my black “dad” socks and Tevas. It was clear to me that, as advertised, this sleek beauty was going to transform me from a doddering old Luddite into one of those trendy hipsters so keyed into the pulse of society. And it promised to be easier … and better.

What followed reminded me that the gospel of technology could sometimes preach a false god. It took but a few keystrokes to find myself grappling with a new operating system—it looked like Windows but felt like closed doors. Things that I can do effortlessly on my PC—navigate through files, open Web browsers, access my Outlook account, PowerPoint—seemed to take extra steps, new steps, or unknown steps.

Eventually, I was able figure most of this out, but in the end I was left with the very un-sating realization that the Mac wasn’t really any better than my PC. It was cooler, that’s for sure—even my wife took a renewed interest in me. However, after that cool factor quickly chilled, I was left with the queasy feeling that I had just dropped thousands of dollars on a machine that didn’t really function any better than my old machine. And in some cases, it functioned worse.

Fool’s Gold?

Like my new iMac, electronic health records (EHR) are touted as the technological savior of healthcare—if you invest in the rhetoric coming out of Washington. As our legislators struggle to figure out ways to shoehorn 50 million more Americans into the “insured” category, stave off the growing epidemic of medical errors, and improve the general quality of care, digitizing our health records is a commonly noted panacea. And EHR, it’s promised, somehow will do all of this while conveniently reducing the skyrocketing costs of healthcare.

My hospital is on the verge of siphoning tens of millions of dollars of government stimulus funding and hospital capital into the purchase of a major EHR upgrade. This system aims to seamlessly integrate our inpatient and outpatient billing, documentation, lab, and ordering systems into one neatly packaged, computer-driven solution. I’m left wondering if my iMac experience is an augur of how this will play out on a grand stage.

In the spirit of full disclosure, I fully support automating healthcare as much as possible and sit on numerous committees at my institution charged with doing just that. Further, I believe it will be a salve to many of our efficiency, quality, and patient safety issues. However, I worry that in solving some problems, these new technological cure-alls will simply introduce other, unanticipated problems.

Several years ago, my hospital introduced several systems and technological applications aimed at improving quality, safety, and efficiency. One of these is called “rounds reports.” These very handy, printable documents are a terrific idea and a great example of simplified workflow. The doctor simply prints out a one-page summary of the patient’s 24-hour vital signs, medications, and labs, and uses that as the template for their daily note.

As promised, it’s a time-saver. The problem is that this new technology harbors insidious flaws that prey on the frailties of human nature by introducing new portals for error. For example, the report makes it simple to not reconcile medications daily. The time-honored and time-intensive manner of writing all the meds on a progress note is indeed cumbersome, but it has the added effect of forcing the provider to think about each medication—the utility, the dosage, the effects of the failing kidney on the dosage. Automation of this process removes this small but critical safety check. Sure, diligent providers can overcome this by paying close attention to the printout, but human nature dictates that we don’t always do it. In fact, we employed automation to save this type of time in the first place.

The rounds report also helpfully displays the vital signs and blood sugars for the past 24 hours, reducing the time the harried hospitalist has to spend looking these up and writing them down. However, the report doesn’t print out every vital sign and blood-sugar level; it provides a range. Again, it is possible to access these individual levels, but the post-EHR provider, lured by simplification, often doesn’t take the extra step to go to the separate program to gather these numbers. This shortcut enhances efficiency at the expense of having complete data, a scenario that can breed bad outcomes.

More Efficient Doesn’t Mean Better

Then there is the catch-22 of electronic imaging reports. It is impressive how quickly a chest X-ray gets read and reported electronically in my hospital. The downside, of course, is that today’s techno-doc can rely on the written report without reviewing the actual image. We’ve again, in not reviewing the films personally, removed an important safety check.

The point is that while mechanization offers great potential, it is easy to overlook the downside. Many physicians are not as tech-savvy as their kids and likely will struggle with these newfangled devices. For them, this will not simplify their workflow, but rather it will bog them down. These gizmos also are extremely expensive, and many small clinics and rural hospitals will struggle to afford these upgrades, even with taxpayer support. And let’s not overlook the myriad unforeseen hiccups these new systems will breed.

None of this is to say we shouldn’t embrace our “Jetsons”-like future. In fact, I’d counter that we must, and now is the opportune time. Still, I get nervous when I read stories of the endless EHR potential that omit or gloss over the probable limitations. The key will be to adopt these systems in ways that augment their strengths while mitigating their weaknesses. This must include achieving the delicate balance of usability, efficiency, and safety.

Otherwise, we might find that the technological apple will keep the doctors away. TH

Dr. Glasheen is associate professor of medicine at the University of Colorado Denver, where he serves as director of the Hospital Medicine Program and the Hospitalist Training Program, and as associate program director of the Internal Medicine Residency Program.

Irecently bought an Apple computer. This is newsworthy because I am a lifelong PC user, and because I suffer from a genetic inability to adopt new technologies. In fact, I’m so old-school that only the graceless act of brandishing my credit card kept me from being unceremoniously escorted out of the store by Apple “specialists” for scaring off iPod-yearning tweens. Even then I wasn’t allowed to linger post-purchase.

After racing home, I eagerly slipped the 24 inches of iMac splendor out of its slick, mod-ish packaging and set it up on my desk. Thoughts of newfound cachet danced in my head as I peeled off my black “dad” socks and Tevas. It was clear to me that, as advertised, this sleek beauty was going to transform me from a doddering old Luddite into one of those trendy hipsters so keyed into the pulse of society. And it promised to be easier … and better.

What followed reminded me that the gospel of technology could sometimes preach a false god. It took but a few keystrokes to find myself grappling with a new operating system—it looked like Windows but felt like closed doors. Things that I can do effortlessly on my PC—navigate through files, open Web browsers, access my Outlook account, PowerPoint—seemed to take extra steps, new steps, or unknown steps.

Eventually, I was able figure most of this out, but in the end I was left with the very un-sating realization that the Mac wasn’t really any better than my PC. It was cooler, that’s for sure—even my wife took a renewed interest in me. However, after that cool factor quickly chilled, I was left with the queasy feeling that I had just dropped thousands of dollars on a machine that didn’t really function any better than my old machine. And in some cases, it functioned worse.

Fool’s Gold?

Like my new iMac, electronic health records (EHR) are touted as the technological savior of healthcare—if you invest in the rhetoric coming out of Washington. As our legislators struggle to figure out ways to shoehorn 50 million more Americans into the “insured” category, stave off the growing epidemic of medical errors, and improve the general quality of care, digitizing our health records is a commonly noted panacea. And EHR, it’s promised, somehow will do all of this while conveniently reducing the skyrocketing costs of healthcare.

My hospital is on the verge of siphoning tens of millions of dollars of government stimulus funding and hospital capital into the purchase of a major EHR upgrade. This system aims to seamlessly integrate our inpatient and outpatient billing, documentation, lab, and ordering systems into one neatly packaged, computer-driven solution. I’m left wondering if my iMac experience is an augur of how this will play out on a grand stage.

In the spirit of full disclosure, I fully support automating healthcare as much as possible and sit on numerous committees at my institution charged with doing just that. Further, I believe it will be a salve to many of our efficiency, quality, and patient safety issues. However, I worry that in solving some problems, these new technological cure-alls will simply introduce other, unanticipated problems.

Several years ago, my hospital introduced several systems and technological applications aimed at improving quality, safety, and efficiency. One of these is called “rounds reports.” These very handy, printable documents are a terrific idea and a great example of simplified workflow. The doctor simply prints out a one-page summary of the patient’s 24-hour vital signs, medications, and labs, and uses that as the template for their daily note.

As promised, it’s a time-saver. The problem is that this new technology harbors insidious flaws that prey on the frailties of human nature by introducing new portals for error. For example, the report makes it simple to not reconcile medications daily. The time-honored and time-intensive manner of writing all the meds on a progress note is indeed cumbersome, but it has the added effect of forcing the provider to think about each medication—the utility, the dosage, the effects of the failing kidney on the dosage. Automation of this process removes this small but critical safety check. Sure, diligent providers can overcome this by paying close attention to the printout, but human nature dictates that we don’t always do it. In fact, we employed automation to save this type of time in the first place.

The rounds report also helpfully displays the vital signs and blood sugars for the past 24 hours, reducing the time the harried hospitalist has to spend looking these up and writing them down. However, the report doesn’t print out every vital sign and blood-sugar level; it provides a range. Again, it is possible to access these individual levels, but the post-EHR provider, lured by simplification, often doesn’t take the extra step to go to the separate program to gather these numbers. This shortcut enhances efficiency at the expense of having complete data, a scenario that can breed bad outcomes.

More Efficient Doesn’t Mean Better

Then there is the catch-22 of electronic imaging reports. It is impressive how quickly a chest X-ray gets read and reported electronically in my hospital. The downside, of course, is that today’s techno-doc can rely on the written report without reviewing the actual image. We’ve again, in not reviewing the films personally, removed an important safety check.

The point is that while mechanization offers great potential, it is easy to overlook the downside. Many physicians are not as tech-savvy as their kids and likely will struggle with these newfangled devices. For them, this will not simplify their workflow, but rather it will bog them down. These gizmos also are extremely expensive, and many small clinics and rural hospitals will struggle to afford these upgrades, even with taxpayer support. And let’s not overlook the myriad unforeseen hiccups these new systems will breed.

None of this is to say we shouldn’t embrace our “Jetsons”-like future. In fact, I’d counter that we must, and now is the opportune time. Still, I get nervous when I read stories of the endless EHR potential that omit or gloss over the probable limitations. The key will be to adopt these systems in ways that augment their strengths while mitigating their weaknesses. This must include achieving the delicate balance of usability, efficiency, and safety.

Otherwise, we might find that the technological apple will keep the doctors away. TH

Dr. Glasheen is associate professor of medicine at the University of Colorado Denver, where he serves as director of the Hospital Medicine Program and the Hospitalist Training Program, and as associate program director of the Internal Medicine Residency Program.

Lying in bed, I’m jarred by what can only be an anvil dropping heavily upon my chest. Wakefulness reveals a more canine, cranium-like object. Staring deep into cataract-smudged eyes, I ponder the question that has occupied my mind for nearly two weeks: What would Hogan want?

My Dog Has Cancer

More accurately, he has a tumor—or, I guess, what appears to be a tumor on his chest X-ray. It was discovered, incidentally, on a liver ultrasound that was being done for abnormal liver function test results. That study revealed nothing wrong with his liver, but led to a follow-up radiograph showing a 4.9-cm, right-lower-lobe lung mass. Also uncovered in this process was a tangle of complex emotions, turmoil, and uncertainty surrounding my first personal foray into end-of-life decision-making.

Hogan, my now-presumed-cancer-ridden, 10-year-old Weimaraner, came into my life permanently when he was all of 8 weeks old. I first met him during a visit to the breeder when his litter was only three days old. Over the successive weeks, I visited him often, anxious for the day I’d be able to take my new companion home.

I picked up Hogan on Fourth of July weekend during my chief year of residency—sort of a gift for completing my grueling training. He was the first dog I raised, trained, and cared for by myself. And while we had our share of eaten walls, destroyed comforters, and chewed bits of Jeep Cherokee, this was no “Marley & Me” relationship. We were more like roommates, best friends. We hiked, camped, and went everywhere together—either an idyllic boy-and-his-dog relationship or a sad, pitifully lonely, soul-in-need-of-a-girlfriend existence, depending on your point of view, I suppose.

In the end, the two viewpoints melded as Hogan eventually brought my wife and I together, a story that shall not be printed in these pages.

Through the years, Hogan bore witness to many personal and family milestones. My chief residency, my first grand rounds (his constant audience during my preparation brought him unparalleled expertise in canine zoonoses), my first house, our marriage, a horribly flailing attempt to recapture the magic of my first dog through a second Weim named Grady (definitely “Marley & Me” mixed with a healthy dose of “Dumb & Dumber”), and the birth of our first child.

It was during this time that Hogan began a long journey toward today. He became a little long in the tooth, droopy in the belly, and slow on the trail. His limitless energy and boundless passion for chasing tennis balls gave way to such leisurely pursuits as park pooping and command disobedience. His fluid, sinew-laced limbs became arthritic shells of their former selves, betraying the youthful grace that still echoed inside of him. I distinctly recall the first time Grady beat him to a tennis ball, a moment that clearly represented a passing of the baton—a crestfallen 6-year-old canine eclipsed by the 2-year-old whippersnapper. The youngster sprinted back, bursting with a mouthful of tennis ball and pride. The elder took a decidedly more tortuous and tortured route back—a carriage of nonchalance that failed in its attempt to convey the message that “chasing tennis balls is stupid.”

On the advice of our veterinarian, we stopped throwing Frisbees at Hogan at age 8, out of concern that an awkward jump might result in a paralytic shift in his progressively stenosing spine. While Hogan is otherwise healthy, his hips and forepaws are riddled with osteoarthritis, his eyes carry the cottony haze of cataracts, and his abdomen and skin are home to lumpy lipomas. So, on the advent of his 10th birthday, we are asked to decide how many resources, how much physical distress, how much intervention we afford to an older, sleep-most-of-the-day arthritic dog.

This scenario is complicated by the idiosyncrasies and mores of veterinary medicine. Unlike human medicine, which is replete with tomes of data steeped in decades of experience, our veterinarian counterparts often are left with gaping treatment holes and inadequately studied interventions. This is not a knock against the profession. In fact, I have had nothing short of fantastic experiences with the veterinary professionals with whom I’ve interacted. Rather, there just aren’t prospective, randomized, controlled trials to inform whether intervention will enhance Hogan’s quantity and quality of life.

Then there are the economic realities of the situation. As one who has rarely been ill and always been insured, I was staggered by the cost of medicine for the uninsured. Two-hundred-dollar antibiotics, $500 ultrasounds, $1,500 CT scans, and up to $10,000 operative and surgical ICU stays would have invoked, “you’re joking, right?” exclamations from me prior to this experience. Now they are just another variable that complicates this already emotionally complex discussion—the variable that makes you feel hollow inside for considering it, foolhardy for not.

Questions Abound

What price would I pay to have another few years with my best friend? What if it’s only a year, six months? Would the money be better spent funding my child’s 529 account? What if this is a benign process and intervention is for naught? What if this tumor is metastatic and intervention is futile? Should we spend the extra money on an upfront staging CT scan that has much lower sensitivity than those we routinely utilize?

If we intervene, should we attempt a costly, CT-guided biopsy to rule in malignant disease, or go straight to lobectomy? What if the surgery negatively alters his quality of life? What if he dies on the table? What do I know about the surgical outcomes of the two centers I’m considering? Should we attempt an open or laparoscopic approach to this tumor?

Can we achieve a cure? If we do, what does that mean for a dog in the twilight years of his life? Should we just let the disease progress to its natural endpoint?

What Would Hogan Want?

These are the questions that haunt me. As I stare into Hogan’s eyes, a portal to my companion’s soul, I am tormented by the cauldron of emotions, the indecision bred by incomplete information and the guilt that comes from knowing that Hogan unconditionally trusts that I will do what is right for him.

Will I? My eyes continue to ask Hogan what he would want until finally the answer becomes obvious.

Hogan wants his breakfast. TH

Dr. Glasheen is associate professor of medicine and director of the hospital medicine group and hospitalist training program at the University of Colorado at Denver.

Lying in bed, I’m jarred by what can only be an anvil dropping heavily upon my chest. Wakefulness reveals a more canine, cranium-like object. Staring deep into cataract-smudged eyes, I ponder the question that has occupied my mind for nearly two weeks: What would Hogan want?

My Dog Has Cancer

More accurately, he has a tumor—or, I guess, what appears to be a tumor on his chest X-ray. It was discovered, incidentally, on a liver ultrasound that was being done for abnormal liver function test results. That study revealed nothing wrong with his liver, but led to a follow-up radiograph showing a 4.9-cm, right-lower-lobe lung mass. Also uncovered in this process was a tangle of complex emotions, turmoil, and uncertainty surrounding my first personal foray into end-of-life decision-making.

Hogan, my now-presumed-cancer-ridden, 10-year-old Weimaraner, came into my life permanently when he was all of 8 weeks old. I first met him during a visit to the breeder when his litter was only three days old. Over the successive weeks, I visited him often, anxious for the day I’d be able to take my new companion home.

I picked up Hogan on Fourth of July weekend during my chief year of residency—sort of a gift for completing my grueling training. He was the first dog I raised, trained, and cared for by myself. And while we had our share of eaten walls, destroyed comforters, and chewed bits of Jeep Cherokee, this was no “Marley & Me” relationship. We were more like roommates, best friends. We hiked, camped, and went everywhere together—either an idyllic boy-and-his-dog relationship or a sad, pitifully lonely, soul-in-need-of-a-girlfriend existence, depending on your point of view, I suppose.

In the end, the two viewpoints melded as Hogan eventually brought my wife and I together, a story that shall not be printed in these pages.

Through the years, Hogan bore witness to many personal and family milestones. My chief residency, my first grand rounds (his constant audience during my preparation brought him unparalleled expertise in canine zoonoses), my first house, our marriage, a horribly flailing attempt to recapture the magic of my first dog through a second Weim named Grady (definitely “Marley & Me” mixed with a healthy dose of “Dumb & Dumber”), and the birth of our first child.

It was during this time that Hogan began a long journey toward today. He became a little long in the tooth, droopy in the belly, and slow on the trail. His limitless energy and boundless passion for chasing tennis balls gave way to such leisurely pursuits as park pooping and command disobedience. His fluid, sinew-laced limbs became arthritic shells of their former selves, betraying the youthful grace that still echoed inside of him. I distinctly recall the first time Grady beat him to a tennis ball, a moment that clearly represented a passing of the baton—a crestfallen 6-year-old canine eclipsed by the 2-year-old whippersnapper. The youngster sprinted back, bursting with a mouthful of tennis ball and pride. The elder took a decidedly more tortuous and tortured route back—a carriage of nonchalance that failed in its attempt to convey the message that “chasing tennis balls is stupid.”

On the advice of our veterinarian, we stopped throwing Frisbees at Hogan at age 8, out of concern that an awkward jump might result in a paralytic shift in his progressively stenosing spine. While Hogan is otherwise healthy, his hips and forepaws are riddled with osteoarthritis, his eyes carry the cottony haze of cataracts, and his abdomen and skin are home to lumpy lipomas. So, on the advent of his 10th birthday, we are asked to decide how many resources, how much physical distress, how much intervention we afford to an older, sleep-most-of-the-day arthritic dog.

This scenario is complicated by the idiosyncrasies and mores of veterinary medicine. Unlike human medicine, which is replete with tomes of data steeped in decades of experience, our veterinarian counterparts often are left with gaping treatment holes and inadequately studied interventions. This is not a knock against the profession. In fact, I have had nothing short of fantastic experiences with the veterinary professionals with whom I’ve interacted. Rather, there just aren’t prospective, randomized, controlled trials to inform whether intervention will enhance Hogan’s quantity and quality of life.

Then there are the economic realities of the situation. As one who has rarely been ill and always been insured, I was staggered by the cost of medicine for the uninsured. Two-hundred-dollar antibiotics, $500 ultrasounds, $1,500 CT scans, and up to $10,000 operative and surgical ICU stays would have invoked, “you’re joking, right?” exclamations from me prior to this experience. Now they are just another variable that complicates this already emotionally complex discussion—the variable that makes you feel hollow inside for considering it, foolhardy for not.

Questions Abound

What price would I pay to have another few years with my best friend? What if it’s only a year, six months? Would the money be better spent funding my child’s 529 account? What if this is a benign process and intervention is for naught? What if this tumor is metastatic and intervention is futile? Should we spend the extra money on an upfront staging CT scan that has much lower sensitivity than those we routinely utilize?

If we intervene, should we attempt a costly, CT-guided biopsy to rule in malignant disease, or go straight to lobectomy? What if the surgery negatively alters his quality of life? What if he dies on the table? What do I know about the surgical outcomes of the two centers I’m considering? Should we attempt an open or laparoscopic approach to this tumor?

Can we achieve a cure? If we do, what does that mean for a dog in the twilight years of his life? Should we just let the disease progress to its natural endpoint?

What Would Hogan Want?

These are the questions that haunt me. As I stare into Hogan’s eyes, a portal to my companion’s soul, I am tormented by the cauldron of emotions, the indecision bred by incomplete information and the guilt that comes from knowing that Hogan unconditionally trusts that I will do what is right for him.

Will I? My eyes continue to ask Hogan what he would want until finally the answer becomes obvious.

Hogan wants his breakfast. TH

Dr. Glasheen is associate professor of medicine and director of the hospital medicine group and hospitalist training program at the University of Colorado at Denver.

Lying in bed, I’m jarred by what can only be an anvil dropping heavily upon my chest. Wakefulness reveals a more canine, cranium-like object. Staring deep into cataract-smudged eyes, I ponder the question that has occupied my mind for nearly two weeks: What would Hogan want?

My Dog Has Cancer

More accurately, he has a tumor—or, I guess, what appears to be a tumor on his chest X-ray. It was discovered, incidentally, on a liver ultrasound that was being done for abnormal liver function test results. That study revealed nothing wrong with his liver, but led to a follow-up radiograph showing a 4.9-cm, right-lower-lobe lung mass. Also uncovered in this process was a tangle of complex emotions, turmoil, and uncertainty surrounding my first personal foray into end-of-life decision-making.

Hogan, my now-presumed-cancer-ridden, 10-year-old Weimaraner, came into my life permanently when he was all of 8 weeks old. I first met him during a visit to the breeder when his litter was only three days old. Over the successive weeks, I visited him often, anxious for the day I’d be able to take my new companion home.

I picked up Hogan on Fourth of July weekend during my chief year of residency—sort of a gift for completing my grueling training. He was the first dog I raised, trained, and cared for by myself. And while we had our share of eaten walls, destroyed comforters, and chewed bits of Jeep Cherokee, this was no “Marley & Me” relationship. We were more like roommates, best friends. We hiked, camped, and went everywhere together—either an idyllic boy-and-his-dog relationship or a sad, pitifully lonely, soul-in-need-of-a-girlfriend existence, depending on your point of view, I suppose.

In the end, the two viewpoints melded as Hogan eventually brought my wife and I together, a story that shall not be printed in these pages.

Through the years, Hogan bore witness to many personal and family milestones. My chief residency, my first grand rounds (his constant audience during my preparation brought him unparalleled expertise in canine zoonoses), my first house, our marriage, a horribly flailing attempt to recapture the magic of my first dog through a second Weim named Grady (definitely “Marley & Me” mixed with a healthy dose of “Dumb & Dumber”), and the birth of our first child.

It was during this time that Hogan began a long journey toward today. He became a little long in the tooth, droopy in the belly, and slow on the trail. His limitless energy and boundless passion for chasing tennis balls gave way to such leisurely pursuits as park pooping and command disobedience. His fluid, sinew-laced limbs became arthritic shells of their former selves, betraying the youthful grace that still echoed inside of him. I distinctly recall the first time Grady beat him to a tennis ball, a moment that clearly represented a passing of the baton—a crestfallen 6-year-old canine eclipsed by the 2-year-old whippersnapper. The youngster sprinted back, bursting with a mouthful of tennis ball and pride. The elder took a decidedly more tortuous and tortured route back—a carriage of nonchalance that failed in its attempt to convey the message that “chasing tennis balls is stupid.”

On the advice of our veterinarian, we stopped throwing Frisbees at Hogan at age 8, out of concern that an awkward jump might result in a paralytic shift in his progressively stenosing spine. While Hogan is otherwise healthy, his hips and forepaws are riddled with osteoarthritis, his eyes carry the cottony haze of cataracts, and his abdomen and skin are home to lumpy lipomas. So, on the advent of his 10th birthday, we are asked to decide how many resources, how much physical distress, how much intervention we afford to an older, sleep-most-of-the-day arthritic dog.

This scenario is complicated by the idiosyncrasies and mores of veterinary medicine. Unlike human medicine, which is replete with tomes of data steeped in decades of experience, our veterinarian counterparts often are left with gaping treatment holes and inadequately studied interventions. This is not a knock against the profession. In fact, I have had nothing short of fantastic experiences with the veterinary professionals with whom I’ve interacted. Rather, there just aren’t prospective, randomized, controlled trials to inform whether intervention will enhance Hogan’s quantity and quality of life.

Then there are the economic realities of the situation. As one who has rarely been ill and always been insured, I was staggered by the cost of medicine for the uninsured. Two-hundred-dollar antibiotics, $500 ultrasounds, $1,500 CT scans, and up to $10,000 operative and surgical ICU stays would have invoked, “you’re joking, right?” exclamations from me prior to this experience. Now they are just another variable that complicates this already emotionally complex discussion—the variable that makes you feel hollow inside for considering it, foolhardy for not.

Questions Abound

What price would I pay to have another few years with my best friend? What if it’s only a year, six months? Would the money be better spent funding my child’s 529 account? What if this is a benign process and intervention is for naught? What if this tumor is metastatic and intervention is futile? Should we spend the extra money on an upfront staging CT scan that has much lower sensitivity than those we routinely utilize?

If we intervene, should we attempt a costly, CT-guided biopsy to rule in malignant disease, or go straight to lobectomy? What if the surgery negatively alters his quality of life? What if he dies on the table? What do I know about the surgical outcomes of the two centers I’m considering? Should we attempt an open or laparoscopic approach to this tumor?

Can we achieve a cure? If we do, what does that mean for a dog in the twilight years of his life? Should we just let the disease progress to its natural endpoint?

What Would Hogan Want?

These are the questions that haunt me. As I stare into Hogan’s eyes, a portal to my companion’s soul, I am tormented by the cauldron of emotions, the indecision bred by incomplete information and the guilt that comes from knowing that Hogan unconditionally trusts that I will do what is right for him.

Will I? My eyes continue to ask Hogan what he would want until finally the answer becomes obvious.

Hogan wants his breakfast. TH

Dr. Glasheen is associate professor of medicine and director of the hospital medicine group and hospitalist training program at the University of Colorado at Denver.

A specialty without a disease: It was a major hangup for the field of hospital medicine in the early days. We’d hurdled many of the traditional barriers to specialty status—research fellowships, textbooks, an active society, a growing body of research, and thousands of practitioners focusing their practice on the hospital setting. However, despite several examples of site-defined specialties like emergency and critical-care medicine, cynics clung to the time-honored need for a specialty to own an organ, or at least a disease.

Early SHM efforts made a strong push to make VTE our disease—both its treatment and, more importantly, its prevention. It was a laudable effort, one that has saved many thousands of lives and limbs. It made sense for hospitalists to tackle VTE; it’s an incapacitating disease that affects many, is largely preventable, and had no strong inpatient advocate. While hematologists were the obvious “owner” of this disease, they were neither available nor able to redesign the inpatient systems of care necessary to thwart this illness. Hospitalists, invested in this issue by consequence of direct care of many at-risk patients and through commitment to improving hospital systems, came to own VTE prevention.

The Next Frontier: Stroke

It is time hospitalists apply this experience to the management of an even more incapacitating, largely preventable disease looking for an inpatient steward: stroke. A stroke occurs in the U.S. every 40 seconds, with disabling sequelae that often are avoidable with rapid detection and treatment. This is especially true when we are given the clarion call of a transient ischemic attack (TIA). The problem is that most American hospitals are not kingpins of efficiency—the key ingredient of the processes necessary to improve stroke outcomes. Furthermore, while our neurologic colleagues are the obvious group to lead the deployment of stroke QI programs, there just aren’t enough of them to do so.

Hospitalists provide a significant amount of neurologic care. One study notes that TIA and stroke were among the most commonly cared-for diseases by hospitalists.1 This places us in a prime position to take the lead and own this disease in collaboration with our neurology colleagues. Just as with reliable VTE prevention, the key to effective stroke care requires effective systems engineering in conjunction with disease-specific expertise.

Rapid Care for Acute Medical Crisis

EDs are equipped with stroke pathways to efficiently evaluate, triage, scan, and intervene for patients who present with stroke symptoms. While most hospitals have a long way to go to perfect these systems, some hospitals—mostly in large, urban centers—have achieved the appropriate level of ED efficiency. These hospitals are recognized by The Joint Commission accreditation as stroke centers. As a result, patients who present to these hospitals with stroke symptoms often receive thrombolytics—a disease- and life-altering therapy—within the appropriate, but very limited, time window for benefit.

But what happens if that same patient develops those same signs and symptoms in the hospital? Will they get the same level of efficient evaluation, triage, scanning, and intervention that occurs in the ED? This is more than an academic question. Fifteen percent of all strokes are heralded by transient neurologic deficits, so many of the estimated 300,000 annual TIA patients are admitted to the hospital. What’s the reason for the admission? To facilitate the diagnostic workup, monitor for stroke symptoms and apply timely interventions should this occur.

But are we equipped to provide this kind of timely care in the hospital?

Case Study

Let’s take a 70-year-old diabetic male who presents with 45 minutes of aphasia and right-side arm weakness that resolve prior to presentation to the ED. If the patient is hypertensive on admission, the ABCD tool would suggest that he has a risk of stroke that approximates 20% in 90 days.2 Importantly, nearly half of that risk is in the first 48 hours. In other words, he has about a 10% risk of having a stroke in the next two days. Thus, we rightly admit him for monitoring in order to react quickly to any new signs and symptoms.

The problem is that most hospitals don’t have a system to efficiently manage patients who develop new stroke symptoms in the hospital. Does your hospital have an inpatient stroke pathway? That is, for a patient who has stroke onset while already in the hospital:

• Are the nurses aware of stroke signs and symptoms?
• Do nurses have a phone number to call to initiate an evaluation?
• Is there a team with stroke expertise immediately available to respond to those calls?
• Is there a priority path to get the patient promptly transported to the CT scanner for brain imaging with immediate radiology interpretation?
• How fast can thrombolytics be delivered, and is there an inpatient neurologist available 24/7 to assist?

The goal is 25 minutes from first recognition of symptoms to CT scan, and 60 minutes to complete evaluation and commencement of treatment. What percentage of your inpatient units could meet that goal? Could they do it any day of the week, at any time of the day or night?

ED systems had to be developed and implemented to ensure that appropriate candidates receive thrombolytic therapy in a timely manner. If those systems are not in place outside your hospital’s ED, then inpatient stroke cases are likely to miss the window of opportunity for thrombolytics. Ironically, they might have been better off going home and coming to the ED with any new symptoms. As a hospitalist, that is a sobering thought.

Hospitalist Ownership

It takes more than hospitalists being on-site to improve stroke outcomes. Processes need to be sharpened, roles defined, and outcomes monitored and acted upon to further sharpen the process. All of this plays to the strengths of hospitalists and should be undertaken with the vigor afforded to VTE prevention. This will take recognition that there’s a problem with the system, a dedication of resources, and a commitment to relentlessly work to improve and streamline the processes of stroke care.

In other words, it takes ownership. TH

Dr. Glasheen is associate professor of medicine and director of the hospital medicine group and hospitalist training program at the University of Colorado Denver. Ethan Cumbler, MD, contributed to this article. Dr. Cumbler is assistant professor of medicine at UC Denver and a member of the university’s Hospital Stroke Council.

This column represents the opinions of the author and is not intended to reflect an official position of SHM.

References

1. Glasheen JJ, Epstein KR, Siegal E, Kutner J, Prochazka AV. The spectrum of community-based hospitalist practice: a call to tailor internal medicine residency training. Arch Intern Med. 2007;167(7):727-728.
2. Johnston SC, Rothwell PM, Nguyen-Huynh MN, et al. Validation and refinement of scores to predict very early stroke risk after transient ischaemic attack. Lancet. 2007;369(9558):283-292.

A specialty without a disease: It was a major hangup for the field of hospital medicine in the early days. We’d hurdled many of the traditional barriers to specialty status—research fellowships, textbooks, an active society, a growing body of research, and thousands of practitioners focusing their practice on the hospital setting. However, despite several examples of site-defined specialties like emergency and critical-care medicine, cynics clung to the time-honored need for a specialty to own an organ, or at least a disease.

Early SHM efforts made a strong push to make VTE our disease—both its treatment and, more importantly, its prevention. It was a laudable effort, one that has saved many thousands of lives and limbs. It made sense for hospitalists to tackle VTE; it’s an incapacitating disease that affects many, is largely preventable, and had no strong inpatient advocate. While hematologists were the obvious “owner” of this disease, they were neither available nor able to redesign the inpatient systems of care necessary to thwart this illness. Hospitalists, invested in this issue by consequence of direct care of many at-risk patients and through commitment to improving hospital systems, came to own VTE prevention.

The Next Frontier: Stroke

It is time hospitalists apply this experience to the management of an even more incapacitating, largely preventable disease looking for an inpatient steward: stroke. A stroke occurs in the U.S. every 40 seconds, with disabling sequelae that often are avoidable with rapid detection and treatment. This is especially true when we are given the clarion call of a transient ischemic attack (TIA). The problem is that most American hospitals are not kingpins of efficiency—the key ingredient of the processes necessary to improve stroke outcomes. Furthermore, while our neurologic colleagues are the obvious group to lead the deployment of stroke QI programs, there just aren’t enough of them to do so.

Hospitalists provide a significant amount of neurologic care. One study notes that TIA and stroke were among the most commonly cared-for diseases by hospitalists.1 This places us in a prime position to take the lead and own this disease in collaboration with our neurology colleagues. Just as with reliable VTE prevention, the key to effective stroke care requires effective systems engineering in conjunction with disease-specific expertise.

Rapid Care for Acute Medical Crisis

EDs are equipped with stroke pathways to efficiently evaluate, triage, scan, and intervene for patients who present with stroke symptoms. While most hospitals have a long way to go to perfect these systems, some hospitals—mostly in large, urban centers—have achieved the appropriate level of ED efficiency. These hospitals are recognized by The Joint Commission accreditation as stroke centers. As a result, patients who present to these hospitals with stroke symptoms often receive thrombolytics—a disease- and life-altering therapy—within the appropriate, but very limited, time window for benefit.

But what happens if that same patient develops those same signs and symptoms in the hospital? Will they get the same level of efficient evaluation, triage, scanning, and intervention that occurs in the ED? This is more than an academic question. Fifteen percent of all strokes are heralded by transient neurologic deficits, so many of the estimated 300,000 annual TIA patients are admitted to the hospital. What’s the reason for the admission? To facilitate the diagnostic workup, monitor for stroke symptoms and apply timely interventions should this occur.

But are we equipped to provide this kind of timely care in the hospital?

Case Study

Let’s take a 70-year-old diabetic male who presents with 45 minutes of aphasia and right-side arm weakness that resolve prior to presentation to the ED. If the patient is hypertensive on admission, the ABCD tool would suggest that he has a risk of stroke that approximates 20% in 90 days.2 Importantly, nearly half of that risk is in the first 48 hours. In other words, he has about a 10% risk of having a stroke in the next two days. Thus, we rightly admit him for monitoring in order to react quickly to any new signs and symptoms.

The problem is that most hospitals don’t have a system to efficiently manage patients who develop new stroke symptoms in the hospital. Does your hospital have an inpatient stroke pathway? That is, for a patient who has stroke onset while already in the hospital:

• Are the nurses aware of stroke signs and symptoms?
• Do nurses have a phone number to call to initiate an evaluation?
• Is there a team with stroke expertise immediately available to respond to those calls?
• Is there a priority path to get the patient promptly transported to the CT scanner for brain imaging with immediate radiology interpretation?
• How fast can thrombolytics be delivered, and is there an inpatient neurologist available 24/7 to assist?

The goal is 25 minutes from first recognition of symptoms to CT scan, and 60 minutes to complete evaluation and commencement of treatment. What percentage of your inpatient units could meet that goal? Could they do it any day of the week, at any time of the day or night?

ED systems had to be developed and implemented to ensure that appropriate candidates receive thrombolytic therapy in a timely manner. If those systems are not in place outside your hospital’s ED, then inpatient stroke cases are likely to miss the window of opportunity for thrombolytics. Ironically, they might have been better off going home and coming to the ED with any new symptoms. As a hospitalist, that is a sobering thought.

Hospitalist Ownership

It takes more than hospitalists being on-site to improve stroke outcomes. Processes need to be sharpened, roles defined, and outcomes monitored and acted upon to further sharpen the process. All of this plays to the strengths of hospitalists and should be undertaken with the vigor afforded to VTE prevention. This will take recognition that there’s a problem with the system, a dedication of resources, and a commitment to relentlessly work to improve and streamline the processes of stroke care.

In other words, it takes ownership. TH

Dr. Glasheen is associate professor of medicine and director of the hospital medicine group and hospitalist training program at the University of Colorado Denver. Ethan Cumbler, MD, contributed to this article. Dr. Cumbler is assistant professor of medicine at UC Denver and a member of the university’s Hospital Stroke Council.

This column represents the opinions of the author and is not intended to reflect an official position of SHM.

References

1. Glasheen JJ, Epstein KR, Siegal E, Kutner J, Prochazka AV. The spectrum of community-based hospitalist practice: a call to tailor internal medicine residency training. Arch Intern Med. 2007;167(7):727-728.
2. Johnston SC, Rothwell PM, Nguyen-Huynh MN, et al. Validation and refinement of scores to predict very early stroke risk after transient ischaemic attack. Lancet. 2007;369(9558):283-292.

A specialty without a disease: It was a major hangup for the field of hospital medicine in the early days. We’d hurdled many of the traditional barriers to specialty status—research fellowships, textbooks, an active society, a growing body of research, and thousands of practitioners focusing their practice on the hospital setting. However, despite several examples of site-defined specialties like emergency and critical-care medicine, cynics clung to the time-honored need for a specialty to own an organ, or at least a disease.

Early SHM efforts made a strong push to make VTE our disease—both its treatment and, more importantly, its prevention. It was a laudable effort, one that has saved many thousands of lives and limbs. It made sense for hospitalists to tackle VTE; it’s an incapacitating disease that affects many, is largely preventable, and had no strong inpatient advocate. While hematologists were the obvious “owner” of this disease, they were neither available nor able to redesign the inpatient systems of care necessary to thwart this illness. Hospitalists, invested in this issue by consequence of direct care of many at-risk patients and through commitment to improving hospital systems, came to own VTE prevention.

The Next Frontier: Stroke

It is time hospitalists apply this experience to the management of an even more incapacitating, largely preventable disease looking for an inpatient steward: stroke. A stroke occurs in the U.S. every 40 seconds, with disabling sequelae that often are avoidable with rapid detection and treatment. This is especially true when we are given the clarion call of a transient ischemic attack (TIA). The problem is that most American hospitals are not kingpins of efficiency—the key ingredient of the processes necessary to improve stroke outcomes. Furthermore, while our neurologic colleagues are the obvious group to lead the deployment of stroke QI programs, there just aren’t enough of them to do so.

Hospitalists provide a significant amount of neurologic care. One study notes that TIA and stroke were among the most commonly cared-for diseases by hospitalists.1 This places us in a prime position to take the lead and own this disease in collaboration with our neurology colleagues. Just as with reliable VTE prevention, the key to effective stroke care requires effective systems engineering in conjunction with disease-specific expertise.

Rapid Care for Acute Medical Crisis

EDs are equipped with stroke pathways to efficiently evaluate, triage, scan, and intervene for patients who present with stroke symptoms. While most hospitals have a long way to go to perfect these systems, some hospitals—mostly in large, urban centers—have achieved the appropriate level of ED efficiency. These hospitals are recognized by The Joint Commission accreditation as stroke centers. As a result, patients who present to these hospitals with stroke symptoms often receive thrombolytics—a disease- and life-altering therapy—within the appropriate, but very limited, time window for benefit.

But what happens if that same patient develops those same signs and symptoms in the hospital? Will they get the same level of efficient evaluation, triage, scanning, and intervention that occurs in the ED? This is more than an academic question. Fifteen percent of all strokes are heralded by transient neurologic deficits, so many of the estimated 300,000 annual TIA patients are admitted to the hospital. What’s the reason for the admission? To facilitate the diagnostic workup, monitor for stroke symptoms and apply timely interventions should this occur.

But are we equipped to provide this kind of timely care in the hospital?

Case Study

Let’s take a 70-year-old diabetic male who presents with 45 minutes of aphasia and right-side arm weakness that resolve prior to presentation to the ED. If the patient is hypertensive on admission, the ABCD tool would suggest that he has a risk of stroke that approximates 20% in 90 days.2 Importantly, nearly half of that risk is in the first 48 hours. In other words, he has about a 10% risk of having a stroke in the next two days. Thus, we rightly admit him for monitoring in order to react quickly to any new signs and symptoms.

The problem is that most hospitals don’t have a system to efficiently manage patients who develop new stroke symptoms in the hospital. Does your hospital have an inpatient stroke pathway? That is, for a patient who has stroke onset while already in the hospital:

• Are the nurses aware of stroke signs and symptoms?
• Do nurses have a phone number to call to initiate an evaluation?
• Is there a team with stroke expertise immediately available to respond to those calls?
• Is there a priority path to get the patient promptly transported to the CT scanner for brain imaging with immediate radiology interpretation?
• How fast can thrombolytics be delivered, and is there an inpatient neurologist available 24/7 to assist?

The goal is 25 minutes from first recognition of symptoms to CT scan, and 60 minutes to complete evaluation and commencement of treatment. What percentage of your inpatient units could meet that goal? Could they do it any day of the week, at any time of the day or night?

ED systems had to be developed and implemented to ensure that appropriate candidates receive thrombolytic therapy in a timely manner. If those systems are not in place outside your hospital’s ED, then inpatient stroke cases are likely to miss the window of opportunity for thrombolytics. Ironically, they might have been better off going home and coming to the ED with any new symptoms. As a hospitalist, that is a sobering thought.

Hospitalist Ownership

It takes more than hospitalists being on-site to improve stroke outcomes. Processes need to be sharpened, roles defined, and outcomes monitored and acted upon to further sharpen the process. All of this plays to the strengths of hospitalists and should be undertaken with the vigor afforded to VTE prevention. This will take recognition that there’s a problem with the system, a dedication of resources, and a commitment to relentlessly work to improve and streamline the processes of stroke care.

In other words, it takes ownership. TH

Dr. Glasheen is associate professor of medicine and director of the hospital medicine group and hospitalist training program at the University of Colorado Denver. Ethan Cumbler, MD, contributed to this article. Dr. Cumbler is assistant professor of medicine at UC Denver and a member of the university’s Hospital Stroke Council.

This column represents the opinions of the author and is not intended to reflect an official position of SHM.

References

1. Glasheen JJ, Epstein KR, Siegal E, Kutner J, Prochazka AV. The spectrum of community-based hospitalist practice: a call to tailor internal medicine residency training. Arch Intern Med. 2007;167(7):727-728.
2. Johnston SC, Rothwell PM, Nguyen-Huynh MN, et al. Validation and refinement of scores to predict very early stroke risk after transient ischaemic attack. Lancet. 2007;369(9558):283-292.