Waseem Khaliq, MD, MPH

In 2014, there were more than 40,000 hospitalists in the United States, and approximately 20% were employed by academic medical centers.[1] Hospitalist physicians groups are committed to delivering excellent patient care. However, the published literature is limited with respect to defining optimal care in hospital medicine.

Patient satisfaction surveys, such as Press Ganey (PG)[2] and Hospital Consumer Assessment of Healthcare Providers and Systems,[3] are being used to assess patients' contentment with the quality of care they receive while hospitalized. The Society of Hospital Medicine, the largest professional medical society representing hospitalists, encourages the use of patient satisfaction surveys to measure hospitalist providers' quality of patient care.[4] There are, however, several problems with the current methods. First, the attribution to specific providers is questionable. Second, recall about the provider by the patients may be poor because surveys are sent to patients days after they return home. Third, the patients' recovery and health outcomes are likely to influence their assessment of the doctor. Finally, feedback is known to be most valuable and transformative when it is specific and given in real time. Thus, a tool that is able to provide feedback at the encounter level should be more helpful than a tool that offers assessment at the level of the admission, particularly when it can be also delivered immediately after the data are collected.

Comportment has been used to describe both the way a person behaves and also the way she carries herself (ie, her general manner).[5] Excellent comportment and communication can serve as the foundation for delivering patient‐centered care.[6, 7, 8] Patient centeredness has been shown to improve the patient experience and clinical outcomes, including compliance with therapeutic plans.[9, 10, 11] Respectful behavior, etiquette‐based medicine, and effective communication also lay the foundation upon which the therapeutic alliance between a doctor and patient can be built.

The goal of this study was to establish a metric that could comprehensively assess a hospitalist provider's comportment and communication skills during an encounter with a hospitalized patient.

METHODS

RESULTS

The average clinical experience of the 26 hospitalist physicians studied was 6 years (Table 1). Their mean age was 38 years, 13 (50%) were female, and 16 (62%) were of nonwhite race. Fourteen hospitalists (54%) worked at 1 of the nonacademic hospitals. In terms of clinical workload, most physicians (n = 17, 65%) devoted more than 70% of their time working in direct patient care. Mean time spent observing each physician was 280 minutes. During this time, the 26 physicians were observed for 181 separate clinical encounters; 54% of these patients were new encounters, patients who were not previously known to the physician. The average time each physician spent in a patient room was 10.8 minutes. Mean number of observed patient encounters per hospitalist was 7.

The distribution of HMCCOT scores was not statistically significantly different when analyzed by age, gender, race, amount of clinical experience, clinical workload of the hospitalist, hospital, time spent observing the hospitalist (all P > 0.05). The distribution of HMCCOT scores was statistically different in new patient encounters compared to follow‐ups (68.1% vs 39.7%, P 0.001). Encounters with patients that generated HMCCOT scores above versus below the mean were longer (13 minutes vs 8.7 minutes, P 0.001).

The mean HMCCOT score was 61 (standard deviation [SD] = 10.6), and it was normally distributed (Figure 1). Table 2 shows the data for the 23 behaviors that were objectively assessed as part of the HMCCOT for the 181 patient encounters. The most frequently observed behaviors were physicians washing hands after leaving the patient's room in 170 (94%) of the encounters and smiling (83%). The behaviors that were observed with the least regularity were using an empathic statement (26% of encounters), and employing teach‐back (13% of encounters). A common method of demonstrating interest in the patient as a person, seen in 41% of encounters, involved physicians asking about patients' personal histories and their interests.

Figure 1

The average composite PG scores for the physician sample was 38.95 (SD=39.64). A moderate correlation was found between the HMCCOT score and PG score (adjusted Pearson correlation: 0.45, P = 0.047).

DISCUSSION

In this study, we followed 26 hospitalist physicians during routine clinical care, and we focused intently on their communication and their comportment with patients at the bedside. Even among clinically respected hospitalists, the results reveal that there is wide variability in comportment and communication practices and behaviors at the bedside. The physicians' HMCCOT scores were associated with their PG scores. These findings suggest that improved bedside communication and comportment with patients might translate into enhanced patient satisfaction.

This is the first study that honed in on hospitalist communication and comportment. With validity evidence established for the HMCCOT, some may elect to more explicitly perform these behaviors themselves, and others may wish to watch other hospitalists to give them feedback that is tied to specific behaviors. Beginning with the basics, the hospitalists we studied introduced themselves to their patients at the initial encounter 78% of the time, less frequently than is done by primary care clinicians (89%) but more consistently than do emergency department providers (64%).[7] Other variables that stood out in the HMCCOT was that teach‐back was employed in only 13% of the encounters. Previous studies have shown that teach‐back corroborates patient comprehension and can be used to engage patients (and caregivers) in realistic goal setting and optimal health service utilization.[14] Further, patients who clearly understand their postdischarge plan are 30% less likely to be readmitted or visit the emergency department.[14] The data for our group have helped us to see areas of strengths, such as hand washing, where we are above compliance rates across hospitals in the United States,[15] as well as those matters that represent opportunities for improvement such as connecting more deeply with our patients.

Tackett et al. have looked at encounter length and its association with performance of etiquette‐based medicine behaviors.[7] Similar to their study, we found a positive correlation between spending more time with patients and higher HMCCOT scores. We also found that HMCCOT scores were higher when providers were caring for new patients. Patients' complaints about doctors often relate to feeling rushed, that their physicians did not listen to them, or that information was not conveyed in a clear manner.[16] Such challenges in physicianpatient communication are ubiquitous across clinical settings.[16] When successfully achieved, patient‐centered communication has been associated with improved clinical outcomes, including adherence to recommended treatment and better self‐management of chronic disease.[17, 18, 19, 20, 21, 22, 23, 24, 25, 26] Many of the components of the HMCCOT described in this article are at the heart of patient‐centered care.

Several limitations of the study should be considered. First, physicians may have behaved differently while they were being observed, which is known as the Hawthorne effect. We observed them for many hours and across multiple patient encounters, and the physicians were not aware of the specific types of data that we were collecting. These factors may have limited the biases along such lines. Second, there may be elements of optimal comportment and communication that were not captured by the HMCCOT. Hopefully, there are not big gaps, as we used multiple methods and an iterative process in the refinement of the HMCCOT metric. Third, one investigator did all of the observing, and it is possible that he might have missed certain behaviors. Through extensive pilot testing and comparisons with other raters, the observer became very skilled and facile with such data collection and the tool. Fourth, we did not survey the same patients that were cared for to compare their perspectives to the HMCCOT scores following the clinical encounters. For patient perspectives, we relied only on PG scores. Fifth, quality of care is a broad and multidimensional construct. The HMCCOT focuses exclusively on hospitalists' comportment and communication at the bedside; therefore, it does not comprehensively assess care quality. Sixth, with our goal to optimally validate the HMCCOT, we tested it on the top tier of hospitalists within each group. We may have observed different results had we randomly selected hospitalists from each hospital or had we conducted the study at hospitals in other geographic regions. Finally, all of the doctors observed worked at hospitals in the Mid‐Atlantic region. However, these five distinct hospitals each have their own cultures, and they are led by different administrators. We purposively chose to sample both academic as well as community settings.

In conclusion, this study reports on the development of a comportment and communication tool that was established and validated by following clinically excellent hospitalists at the bedside. Future studies are necessary to determine whether hospitalists of all levels of experience and clinical skill can improve when given data and feedback using the HMCCOT. Larger studies will then be needed to assess whether enhancing comportment and communication can truly improve patient satisfaction and clinical outcomes in the hospital.

Disclosures: Dr. Wright is a Miller‐Coulson Family Scholar and is supported through the Johns Hopkins Center for Innovative Medicine. Susrutha Kotwal, MD, and Waseem Khaliq, MD, contributed equally to this work. The authors report no conflicts of interest.

In 2014, there were more than 40,000 hospitalists in the United States, and approximately 20% were employed by academic medical centers.[1] Hospitalist physicians groups are committed to delivering excellent patient care. However, the published literature is limited with respect to defining optimal care in hospital medicine.

Patient satisfaction surveys, such as Press Ganey (PG)[2] and Hospital Consumer Assessment of Healthcare Providers and Systems,[3] are being used to assess patients' contentment with the quality of care they receive while hospitalized. The Society of Hospital Medicine, the largest professional medical society representing hospitalists, encourages the use of patient satisfaction surveys to measure hospitalist providers' quality of patient care.[4] There are, however, several problems with the current methods. First, the attribution to specific providers is questionable. Second, recall about the provider by the patients may be poor because surveys are sent to patients days after they return home. Third, the patients' recovery and health outcomes are likely to influence their assessment of the doctor. Finally, feedback is known to be most valuable and transformative when it is specific and given in real time. Thus, a tool that is able to provide feedback at the encounter level should be more helpful than a tool that offers assessment at the level of the admission, particularly when it can be also delivered immediately after the data are collected.

Comportment has been used to describe both the way a person behaves and also the way she carries herself (ie, her general manner).[5] Excellent comportment and communication can serve as the foundation for delivering patient‐centered care.[6, 7, 8] Patient centeredness has been shown to improve the patient experience and clinical outcomes, including compliance with therapeutic plans.[9, 10, 11] Respectful behavior, etiquette‐based medicine, and effective communication also lay the foundation upon which the therapeutic alliance between a doctor and patient can be built.

The goal of this study was to establish a metric that could comprehensively assess a hospitalist provider's comportment and communication skills during an encounter with a hospitalized patient.

METHODS

RESULTS

The average clinical experience of the 26 hospitalist physicians studied was 6 years (Table 1). Their mean age was 38 years, 13 (50%) were female, and 16 (62%) were of nonwhite race. Fourteen hospitalists (54%) worked at 1 of the nonacademic hospitals. In terms of clinical workload, most physicians (n = 17, 65%) devoted more than 70% of their time working in direct patient care. Mean time spent observing each physician was 280 minutes. During this time, the 26 physicians were observed for 181 separate clinical encounters; 54% of these patients were new encounters, patients who were not previously known to the physician. The average time each physician spent in a patient room was 10.8 minutes. Mean number of observed patient encounters per hospitalist was 7.

The distribution of HMCCOT scores was not statistically significantly different when analyzed by age, gender, race, amount of clinical experience, clinical workload of the hospitalist, hospital, time spent observing the hospitalist (all P > 0.05). The distribution of HMCCOT scores was statistically different in new patient encounters compared to follow‐ups (68.1% vs 39.7%, P 0.001). Encounters with patients that generated HMCCOT scores above versus below the mean were longer (13 minutes vs 8.7 minutes, P 0.001).

The mean HMCCOT score was 61 (standard deviation [SD] = 10.6), and it was normally distributed (Figure 1). Table 2 shows the data for the 23 behaviors that were objectively assessed as part of the HMCCOT for the 181 patient encounters. The most frequently observed behaviors were physicians washing hands after leaving the patient's room in 170 (94%) of the encounters and smiling (83%). The behaviors that were observed with the least regularity were using an empathic statement (26% of encounters), and employing teach‐back (13% of encounters). A common method of demonstrating interest in the patient as a person, seen in 41% of encounters, involved physicians asking about patients' personal histories and their interests.

Figure 1

The average composite PG scores for the physician sample was 38.95 (SD=39.64). A moderate correlation was found between the HMCCOT score and PG score (adjusted Pearson correlation: 0.45, P = 0.047).

DISCUSSION

In this study, we followed 26 hospitalist physicians during routine clinical care, and we focused intently on their communication and their comportment with patients at the bedside. Even among clinically respected hospitalists, the results reveal that there is wide variability in comportment and communication practices and behaviors at the bedside. The physicians' HMCCOT scores were associated with their PG scores. These findings suggest that improved bedside communication and comportment with patients might translate into enhanced patient satisfaction.

This is the first study that honed in on hospitalist communication and comportment. With validity evidence established for the HMCCOT, some may elect to more explicitly perform these behaviors themselves, and others may wish to watch other hospitalists to give them feedback that is tied to specific behaviors. Beginning with the basics, the hospitalists we studied introduced themselves to their patients at the initial encounter 78% of the time, less frequently than is done by primary care clinicians (89%) but more consistently than do emergency department providers (64%).[7] Other variables that stood out in the HMCCOT was that teach‐back was employed in only 13% of the encounters. Previous studies have shown that teach‐back corroborates patient comprehension and can be used to engage patients (and caregivers) in realistic goal setting and optimal health service utilization.[14] Further, patients who clearly understand their postdischarge plan are 30% less likely to be readmitted or visit the emergency department.[14] The data for our group have helped us to see areas of strengths, such as hand washing, where we are above compliance rates across hospitals in the United States,[15] as well as those matters that represent opportunities for improvement such as connecting more deeply with our patients.

Tackett et al. have looked at encounter length and its association with performance of etiquette‐based medicine behaviors.[7] Similar to their study, we found a positive correlation between spending more time with patients and higher HMCCOT scores. We also found that HMCCOT scores were higher when providers were caring for new patients. Patients' complaints about doctors often relate to feeling rushed, that their physicians did not listen to them, or that information was not conveyed in a clear manner.[16] Such challenges in physicianpatient communication are ubiquitous across clinical settings.[16] When successfully achieved, patient‐centered communication has been associated with improved clinical outcomes, including adherence to recommended treatment and better self‐management of chronic disease.[17, 18, 19, 20, 21, 22, 23, 24, 25, 26] Many of the components of the HMCCOT described in this article are at the heart of patient‐centered care.

Several limitations of the study should be considered. First, physicians may have behaved differently while they were being observed, which is known as the Hawthorne effect. We observed them for many hours and across multiple patient encounters, and the physicians were not aware of the specific types of data that we were collecting. These factors may have limited the biases along such lines. Second, there may be elements of optimal comportment and communication that were not captured by the HMCCOT. Hopefully, there are not big gaps, as we used multiple methods and an iterative process in the refinement of the HMCCOT metric. Third, one investigator did all of the observing, and it is possible that he might have missed certain behaviors. Through extensive pilot testing and comparisons with other raters, the observer became very skilled and facile with such data collection and the tool. Fourth, we did not survey the same patients that were cared for to compare their perspectives to the HMCCOT scores following the clinical encounters. For patient perspectives, we relied only on PG scores. Fifth, quality of care is a broad and multidimensional construct. The HMCCOT focuses exclusively on hospitalists' comportment and communication at the bedside; therefore, it does not comprehensively assess care quality. Sixth, with our goal to optimally validate the HMCCOT, we tested it on the top tier of hospitalists within each group. We may have observed different results had we randomly selected hospitalists from each hospital or had we conducted the study at hospitals in other geographic regions. Finally, all of the doctors observed worked at hospitals in the Mid‐Atlantic region. However, these five distinct hospitals each have their own cultures, and they are led by different administrators. We purposively chose to sample both academic as well as community settings.

In conclusion, this study reports on the development of a comportment and communication tool that was established and validated by following clinically excellent hospitalists at the bedside. Future studies are necessary to determine whether hospitalists of all levels of experience and clinical skill can improve when given data and feedback using the HMCCOT. Larger studies will then be needed to assess whether enhancing comportment and communication can truly improve patient satisfaction and clinical outcomes in the hospital.

Disclosures: Dr. Wright is a Miller‐Coulson Family Scholar and is supported through the Johns Hopkins Center for Innovative Medicine. Susrutha Kotwal, MD, and Waseem Khaliq, MD, contributed equally to this work. The authors report no conflicts of interest.

In 2014, there were more than 40,000 hospitalists in the United States, and approximately 20% were employed by academic medical centers.[1] Hospitalist physicians groups are committed to delivering excellent patient care. However, the published literature is limited with respect to defining optimal care in hospital medicine.

Patient satisfaction surveys, such as Press Ganey (PG)[2] and Hospital Consumer Assessment of Healthcare Providers and Systems,[3] are being used to assess patients' contentment with the quality of care they receive while hospitalized. The Society of Hospital Medicine, the largest professional medical society representing hospitalists, encourages the use of patient satisfaction surveys to measure hospitalist providers' quality of patient care.[4] There are, however, several problems with the current methods. First, the attribution to specific providers is questionable. Second, recall about the provider by the patients may be poor because surveys are sent to patients days after they return home. Third, the patients' recovery and health outcomes are likely to influence their assessment of the doctor. Finally, feedback is known to be most valuable and transformative when it is specific and given in real time. Thus, a tool that is able to provide feedback at the encounter level should be more helpful than a tool that offers assessment at the level of the admission, particularly when it can be also delivered immediately after the data are collected.

Comportment has been used to describe both the way a person behaves and also the way she carries herself (ie, her general manner).[5] Excellent comportment and communication can serve as the foundation for delivering patient‐centered care.[6, 7, 8] Patient centeredness has been shown to improve the patient experience and clinical outcomes, including compliance with therapeutic plans.[9, 10, 11] Respectful behavior, etiquette‐based medicine, and effective communication also lay the foundation upon which the therapeutic alliance between a doctor and patient can be built.

The goal of this study was to establish a metric that could comprehensively assess a hospitalist provider's comportment and communication skills during an encounter with a hospitalized patient.

METHODS

RESULTS

The average clinical experience of the 26 hospitalist physicians studied was 6 years (Table 1). Their mean age was 38 years, 13 (50%) were female, and 16 (62%) were of nonwhite race. Fourteen hospitalists (54%) worked at 1 of the nonacademic hospitals. In terms of clinical workload, most physicians (n = 17, 65%) devoted more than 70% of their time working in direct patient care. Mean time spent observing each physician was 280 minutes. During this time, the 26 physicians were observed for 181 separate clinical encounters; 54% of these patients were new encounters, patients who were not previously known to the physician. The average time each physician spent in a patient room was 10.8 minutes. Mean number of observed patient encounters per hospitalist was 7.

The distribution of HMCCOT scores was not statistically significantly different when analyzed by age, gender, race, amount of clinical experience, clinical workload of the hospitalist, hospital, time spent observing the hospitalist (all P > 0.05). The distribution of HMCCOT scores was statistically different in new patient encounters compared to follow‐ups (68.1% vs 39.7%, P 0.001). Encounters with patients that generated HMCCOT scores above versus below the mean were longer (13 minutes vs 8.7 minutes, P 0.001).

The mean HMCCOT score was 61 (standard deviation [SD] = 10.6), and it was normally distributed (Figure 1). Table 2 shows the data for the 23 behaviors that were objectively assessed as part of the HMCCOT for the 181 patient encounters. The most frequently observed behaviors were physicians washing hands after leaving the patient's room in 170 (94%) of the encounters and smiling (83%). The behaviors that were observed with the least regularity were using an empathic statement (26% of encounters), and employing teach‐back (13% of encounters). A common method of demonstrating interest in the patient as a person, seen in 41% of encounters, involved physicians asking about patients' personal histories and their interests.

Figure 1

The average composite PG scores for the physician sample was 38.95 (SD=39.64). A moderate correlation was found between the HMCCOT score and PG score (adjusted Pearson correlation: 0.45, P = 0.047).

DISCUSSION

In this study, we followed 26 hospitalist physicians during routine clinical care, and we focused intently on their communication and their comportment with patients at the bedside. Even among clinically respected hospitalists, the results reveal that there is wide variability in comportment and communication practices and behaviors at the bedside. The physicians' HMCCOT scores were associated with their PG scores. These findings suggest that improved bedside communication and comportment with patients might translate into enhanced patient satisfaction.

This is the first study that honed in on hospitalist communication and comportment. With validity evidence established for the HMCCOT, some may elect to more explicitly perform these behaviors themselves, and others may wish to watch other hospitalists to give them feedback that is tied to specific behaviors. Beginning with the basics, the hospitalists we studied introduced themselves to their patients at the initial encounter 78% of the time, less frequently than is done by primary care clinicians (89%) but more consistently than do emergency department providers (64%).[7] Other variables that stood out in the HMCCOT was that teach‐back was employed in only 13% of the encounters. Previous studies have shown that teach‐back corroborates patient comprehension and can be used to engage patients (and caregivers) in realistic goal setting and optimal health service utilization.[14] Further, patients who clearly understand their postdischarge plan are 30% less likely to be readmitted or visit the emergency department.[14] The data for our group have helped us to see areas of strengths, such as hand washing, where we are above compliance rates across hospitals in the United States,[15] as well as those matters that represent opportunities for improvement such as connecting more deeply with our patients.

Tackett et al. have looked at encounter length and its association with performance of etiquette‐based medicine behaviors.[7] Similar to their study, we found a positive correlation between spending more time with patients and higher HMCCOT scores. We also found that HMCCOT scores were higher when providers were caring for new patients. Patients' complaints about doctors often relate to feeling rushed, that their physicians did not listen to them, or that information was not conveyed in a clear manner.[16] Such challenges in physicianpatient communication are ubiquitous across clinical settings.[16] When successfully achieved, patient‐centered communication has been associated with improved clinical outcomes, including adherence to recommended treatment and better self‐management of chronic disease.[17, 18, 19, 20, 21, 22, 23, 24, 25, 26] Many of the components of the HMCCOT described in this article are at the heart of patient‐centered care.

Several limitations of the study should be considered. First, physicians may have behaved differently while they were being observed, which is known as the Hawthorne effect. We observed them for many hours and across multiple patient encounters, and the physicians were not aware of the specific types of data that we were collecting. These factors may have limited the biases along such lines. Second, there may be elements of optimal comportment and communication that were not captured by the HMCCOT. Hopefully, there are not big gaps, as we used multiple methods and an iterative process in the refinement of the HMCCOT metric. Third, one investigator did all of the observing, and it is possible that he might have missed certain behaviors. Through extensive pilot testing and comparisons with other raters, the observer became very skilled and facile with such data collection and the tool. Fourth, we did not survey the same patients that were cared for to compare their perspectives to the HMCCOT scores following the clinical encounters. For patient perspectives, we relied only on PG scores. Fifth, quality of care is a broad and multidimensional construct. The HMCCOT focuses exclusively on hospitalists' comportment and communication at the bedside; therefore, it does not comprehensively assess care quality. Sixth, with our goal to optimally validate the HMCCOT, we tested it on the top tier of hospitalists within each group. We may have observed different results had we randomly selected hospitalists from each hospital or had we conducted the study at hospitals in other geographic regions. Finally, all of the doctors observed worked at hospitals in the Mid‐Atlantic region. However, these five distinct hospitals each have their own cultures, and they are led by different administrators. We purposively chose to sample both academic as well as community settings.

In conclusion, this study reports on the development of a comportment and communication tool that was established and validated by following clinically excellent hospitalists at the bedside. Future studies are necessary to determine whether hospitalists of all levels of experience and clinical skill can improve when given data and feedback using the HMCCOT. Larger studies will then be needed to assess whether enhancing comportment and communication can truly improve patient satisfaction and clinical outcomes in the hospital.

Disclosures: Dr. Wright is a Miller‐Coulson Family Scholar and is supported through the Johns Hopkins Center for Innovative Medicine. Susrutha Kotwal, MD, and Waseem Khaliq, MD, contributed equally to this work. The authors report no conflicts of interest.

Testing for breast cancer is traditionally offered in outpatient settings, and screening mammography rates have plateaued since 2000.[1] Current data suggest that the mammography utilization gap by race has narrowed; however, disparity remains among low‐income, uninsured, and underinsured populations.[2, 3] The lowest compliance with screening mammography recommendations have been reported among women with low income (63.2%), uninsured (50.4%), and those without a usual source of healthcare (43.6%).[4] Although socioeconomic status, access to the healthcare system, and awareness about screening benefits can all influence women's willingness to have screening, the most common reason that women report for not having mammograms were that no one recommended the test.[5, 6] These findings support previous reports that physicians' recommendations about the need for screening mammography is an influential factor in determining women's decisions related to compliance.[7] Hence, the role of healthcare providers in all clinical care settings is pivotal in reducing mammography utilization disparities.

A recent study evaluating the breast cancer screening adherence among the hospitalized women aged 50 to 75 years noted that many (60%) were low income (annual household income <$20,000), 39% were nonadherent, and 35% were at high risk of developing breast cancer.[8] Further, a majority of these hospitalized women were amenable to inpatient screening mammography if due and offered during the hospital stay.[8] As a follow‐up, the purpose of the current study was to explore how hospitalists feel about getting involved in breast cancer screening and ordering screening mammograms for hospitalized women. We hypothesized that a greater proportion of hospitalists would order mammography for hospitalized women who were both overdue for screening and at high risk for developing breast cancer if they fundamentally believe that they have a role in breast cancer screening. This study also explored anticipated barriers that may be of concern to hospitalists when ordering inpatient screening mammography.

METHODS

RESULTS

Out of 106 study subjects willing to participate, 8 did not respond, yielding a response rate of 92%. The mean age of the study participants was 37.6 years, and 55% were female. Almost two‐thirds of study participants (59%) were faculty physicians at an academic hospital, and the average clinical experience as a hospitalist was 4.6 years. Study participants were diverse with respect to ethnicity, and only 30% reported having a family member with breast cancer (Table 1). Because breast cancer is a disease that affects primarily women, stratified analysis by gender showed that most of these characteristic were similar across genders, except fewer women were full time (76% vs 93%, P=0.04) and on the faculty (44% vs 77%, P=0.003).

Only 38% believed that hospitalists should be involved with breast cancer screening. The most commonly cited concern related to ordering an inpatient screening mammography was follow‐up of the results of the mammography, followed by the test may not be covered by patient's insurance. As shown in Table 2, these concerns were not perceived differently among providers who believed that hospitalists should be involved in breast cancer screening as compared to those who do not. Demographic variables from Table 1 failed to discern any significant associations related to believing that hospitalists should be involved with breast cancer screening or with concerns about the barriers to screening presented in Table 2 (data not shown). As shown in Table 2, overall, 32% hospitalists were willing to order a screening mammography during a hospital stay for the scenario of the woman at high risk for developing breast cancer (5‐year risk prediction using Gail model 2.1%) and 33% for the low‐risk scenario (5‐year risk prediction using Gail model 0.6%).

DISCUSSION

Our study suggests that most hospitalists do not believe that they should be involved in breast cancer screening for their hospitalized patients. This perspective was not influenced by either the physician gender, family history for breast cancer, or by the patient's level of risk for developing breast cancer. When patients are in the hospital, both the setting and the acute illness are known to promote reflection and consideration of self‐care.[10] With major healthcare system changes on the horizon and the passing of the Affordable Care Act, we are becoming teams of providers who are collectively responsible for optimal care delivery. It may be possible to increase breast cancer screening rates by educating our patients and offering inpatient screening mammography while they are in the hospital, particularly to those who are at high risk of developing breast cancer.

Physician recommendations for preventive health and screening have consistently been found to be among the strongest predictors of screening utilization.[11] This is the first study to our knowledge that has attempted to understand hospitalists' views and concerns about ordering screening tests to detect occult malignancy. Although addressing preventive care during a hospitalization may seem complex and difficult, helping these women understand their personal risk profile (eg, family history of breast cancer, use of estrogen, race, age, and genetic risk factors) may be what is needed for beginning to influence perspective that might ultimately translate into a willingness to undergo screening.[12, 13, 14] Such delivery of patient‐centered care is built on a foundation of shared decision‐making, which takes into account the patient's preferences, values, and wishes.[15]

Ordering screening mammography for hospitalized patients will require a deeper understanding of hospitalists' attitudes, because the way that these physicians feel about the tests utility will dramatically influence the way that this opportunity is presented to patients, and ultimately the patients' preference to have or forego testing. Our study results are consistent with another publication that highlighted incongruence between physicians' views and patients' preferences for screening practices.[8, 11] Concerns cited, such as interference with patient's acute care, deserve attention, because it may be possible to carry out the screening in ways and at times that do not interfere with treatment or prolong length of stay. Exploring this with a feasibility study will be necessary. Such an approach has been advocated by Trimble et al. for inpatient cervical cancer screening as an efficient strategy to target high‐risk, nonadherent women.[16]

The inpatient setting allows for the elimination of major barriers to screening (like transportation and remembering to get to screening appointments),[8] thereby actively facilitating this needed service. Costs associated with inpatient screening mammography may deter both hospitalists and patients from screening; however, some insurers and Medicare pay for the full cost of screening tests, irrespective of the clinical setting.[17] Further, as hospitals or accountable care organizations become responsible for total cost per beneficiary, screening costs will be preferable when compared with the expenses associated with later detection of pathology and caring for advanced disease states.

One might question whether the mortality benefit of screening mammography is comparable among hospitalized women (who are theoretically sicker and with shorter life expectancy) and those cared for in outpatient practices. Unfortunately, we do not yet know the answer to this question, because data for inpatient screening mammography are nonexistent, and currently this is not considered as a standard of care. However, one can expect the benefits to be similar, if not greater, when performed in the outpatient setting, if preliminary efforts are directed at those who are both nonadherent and at high risk for breast cancer. According to 1 study, increasing mammography utilization by 5% in our country would prevent 560 deaths from breast cancer each year.[18]

Several limitations of this study should be considered. First, this cross‐sectional study was conducted at hospitals associated with a single institution and the results may not be generalizable. Second, although physicians' concerns were explored in this study, we did not solicit input about the potential impact of prevention and screening on the nursing staff. Third, there may be concerns about the hypothetical nature of anchoring and possible framing effects with the 2 clinical scenarios. Finally, it is possible that the hospitalists' response may have been subject to social desirability bias. That said, the response to the key question Do you think hospitalists should be involved in breast cancer screening? do not support a socially desirable bias.

Given the current policy emphasis on reducing disparities in cancer screening, it may be reasonable to expand the role of all healthcare providers and healthcare facilities in screening high‐risk populations. Screening tests that may seem difficult to coordinate in hospitals currently may become easier as our hospitals evolve to become more patient centered. Future studies are needed to evaluate the feasibility and potential barriers to inpatient screening mammography.

Testing for breast cancer is traditionally offered in outpatient settings, and screening mammography rates have plateaued since 2000.[1] Current data suggest that the mammography utilization gap by race has narrowed; however, disparity remains among low‐income, uninsured, and underinsured populations.[2, 3] The lowest compliance with screening mammography recommendations have been reported among women with low income (63.2%), uninsured (50.4%), and those without a usual source of healthcare (43.6%).[4] Although socioeconomic status, access to the healthcare system, and awareness about screening benefits can all influence women's willingness to have screening, the most common reason that women report for not having mammograms were that no one recommended the test.[5, 6] These findings support previous reports that physicians' recommendations about the need for screening mammography is an influential factor in determining women's decisions related to compliance.[7] Hence, the role of healthcare providers in all clinical care settings is pivotal in reducing mammography utilization disparities.

A recent study evaluating the breast cancer screening adherence among the hospitalized women aged 50 to 75 years noted that many (60%) were low income (annual household income <$20,000), 39% were nonadherent, and 35% were at high risk of developing breast cancer.[8] Further, a majority of these hospitalized women were amenable to inpatient screening mammography if due and offered during the hospital stay.[8] As a follow‐up, the purpose of the current study was to explore how hospitalists feel about getting involved in breast cancer screening and ordering screening mammograms for hospitalized women. We hypothesized that a greater proportion of hospitalists would order mammography for hospitalized women who were both overdue for screening and at high risk for developing breast cancer if they fundamentally believe that they have a role in breast cancer screening. This study also explored anticipated barriers that may be of concern to hospitalists when ordering inpatient screening mammography.

METHODS

RESULTS

Out of 106 study subjects willing to participate, 8 did not respond, yielding a response rate of 92%. The mean age of the study participants was 37.6 years, and 55% were female. Almost two‐thirds of study participants (59%) were faculty physicians at an academic hospital, and the average clinical experience as a hospitalist was 4.6 years. Study participants were diverse with respect to ethnicity, and only 30% reported having a family member with breast cancer (Table 1). Because breast cancer is a disease that affects primarily women, stratified analysis by gender showed that most of these characteristic were similar across genders, except fewer women were full time (76% vs 93%, P=0.04) and on the faculty (44% vs 77%, P=0.003).

Only 38% believed that hospitalists should be involved with breast cancer screening. The most commonly cited concern related to ordering an inpatient screening mammography was follow‐up of the results of the mammography, followed by the test may not be covered by patient's insurance. As shown in Table 2, these concerns were not perceived differently among providers who believed that hospitalists should be involved in breast cancer screening as compared to those who do not. Demographic variables from Table 1 failed to discern any significant associations related to believing that hospitalists should be involved with breast cancer screening or with concerns about the barriers to screening presented in Table 2 (data not shown). As shown in Table 2, overall, 32% hospitalists were willing to order a screening mammography during a hospital stay for the scenario of the woman at high risk for developing breast cancer (5‐year risk prediction using Gail model 2.1%) and 33% for the low‐risk scenario (5‐year risk prediction using Gail model 0.6%).

DISCUSSION

Our study suggests that most hospitalists do not believe that they should be involved in breast cancer screening for their hospitalized patients. This perspective was not influenced by either the physician gender, family history for breast cancer, or by the patient's level of risk for developing breast cancer. When patients are in the hospital, both the setting and the acute illness are known to promote reflection and consideration of self‐care.[10] With major healthcare system changes on the horizon and the passing of the Affordable Care Act, we are becoming teams of providers who are collectively responsible for optimal care delivery. It may be possible to increase breast cancer screening rates by educating our patients and offering inpatient screening mammography while they are in the hospital, particularly to those who are at high risk of developing breast cancer.

Physician recommendations for preventive health and screening have consistently been found to be among the strongest predictors of screening utilization.[11] This is the first study to our knowledge that has attempted to understand hospitalists' views and concerns about ordering screening tests to detect occult malignancy. Although addressing preventive care during a hospitalization may seem complex and difficult, helping these women understand their personal risk profile (eg, family history of breast cancer, use of estrogen, race, age, and genetic risk factors) may be what is needed for beginning to influence perspective that might ultimately translate into a willingness to undergo screening.[12, 13, 14] Such delivery of patient‐centered care is built on a foundation of shared decision‐making, which takes into account the patient's preferences, values, and wishes.[15]

Ordering screening mammography for hospitalized patients will require a deeper understanding of hospitalists' attitudes, because the way that these physicians feel about the tests utility will dramatically influence the way that this opportunity is presented to patients, and ultimately the patients' preference to have or forego testing. Our study results are consistent with another publication that highlighted incongruence between physicians' views and patients' preferences for screening practices.[8, 11] Concerns cited, such as interference with patient's acute care, deserve attention, because it may be possible to carry out the screening in ways and at times that do not interfere with treatment or prolong length of stay. Exploring this with a feasibility study will be necessary. Such an approach has been advocated by Trimble et al. for inpatient cervical cancer screening as an efficient strategy to target high‐risk, nonadherent women.[16]

The inpatient setting allows for the elimination of major barriers to screening (like transportation and remembering to get to screening appointments),[8] thereby actively facilitating this needed service. Costs associated with inpatient screening mammography may deter both hospitalists and patients from screening; however, some insurers and Medicare pay for the full cost of screening tests, irrespective of the clinical setting.[17] Further, as hospitals or accountable care organizations become responsible for total cost per beneficiary, screening costs will be preferable when compared with the expenses associated with later detection of pathology and caring for advanced disease states.

One might question whether the mortality benefit of screening mammography is comparable among hospitalized women (who are theoretically sicker and with shorter life expectancy) and those cared for in outpatient practices. Unfortunately, we do not yet know the answer to this question, because data for inpatient screening mammography are nonexistent, and currently this is not considered as a standard of care. However, one can expect the benefits to be similar, if not greater, when performed in the outpatient setting, if preliminary efforts are directed at those who are both nonadherent and at high risk for breast cancer. According to 1 study, increasing mammography utilization by 5% in our country would prevent 560 deaths from breast cancer each year.[18]

Several limitations of this study should be considered. First, this cross‐sectional study was conducted at hospitals associated with a single institution and the results may not be generalizable. Second, although physicians' concerns were explored in this study, we did not solicit input about the potential impact of prevention and screening on the nursing staff. Third, there may be concerns about the hypothetical nature of anchoring and possible framing effects with the 2 clinical scenarios. Finally, it is possible that the hospitalists' response may have been subject to social desirability bias. That said, the response to the key question Do you think hospitalists should be involved in breast cancer screening? do not support a socially desirable bias.

Given the current policy emphasis on reducing disparities in cancer screening, it may be reasonable to expand the role of all healthcare providers and healthcare facilities in screening high‐risk populations. Screening tests that may seem difficult to coordinate in hospitals currently may become easier as our hospitals evolve to become more patient centered. Future studies are needed to evaluate the feasibility and potential barriers to inpatient screening mammography.

Testing for breast cancer is traditionally offered in outpatient settings, and screening mammography rates have plateaued since 2000.[1] Current data suggest that the mammography utilization gap by race has narrowed; however, disparity remains among low‐income, uninsured, and underinsured populations.[2, 3] The lowest compliance with screening mammography recommendations have been reported among women with low income (63.2%), uninsured (50.4%), and those without a usual source of healthcare (43.6%).[4] Although socioeconomic status, access to the healthcare system, and awareness about screening benefits can all influence women's willingness to have screening, the most common reason that women report for not having mammograms were that no one recommended the test.[5, 6] These findings support previous reports that physicians' recommendations about the need for screening mammography is an influential factor in determining women's decisions related to compliance.[7] Hence, the role of healthcare providers in all clinical care settings is pivotal in reducing mammography utilization disparities.

A recent study evaluating the breast cancer screening adherence among the hospitalized women aged 50 to 75 years noted that many (60%) were low income (annual household income <$20,000), 39% were nonadherent, and 35% were at high risk of developing breast cancer.[8] Further, a majority of these hospitalized women were amenable to inpatient screening mammography if due and offered during the hospital stay.[8] As a follow‐up, the purpose of the current study was to explore how hospitalists feel about getting involved in breast cancer screening and ordering screening mammograms for hospitalized women. We hypothesized that a greater proportion of hospitalists would order mammography for hospitalized women who were both overdue for screening and at high risk for developing breast cancer if they fundamentally believe that they have a role in breast cancer screening. This study also explored anticipated barriers that may be of concern to hospitalists when ordering inpatient screening mammography.

METHODS

RESULTS

Out of 106 study subjects willing to participate, 8 did not respond, yielding a response rate of 92%. The mean age of the study participants was 37.6 years, and 55% were female. Almost two‐thirds of study participants (59%) were faculty physicians at an academic hospital, and the average clinical experience as a hospitalist was 4.6 years. Study participants were diverse with respect to ethnicity, and only 30% reported having a family member with breast cancer (Table 1). Because breast cancer is a disease that affects primarily women, stratified analysis by gender showed that most of these characteristic were similar across genders, except fewer women were full time (76% vs 93%, P=0.04) and on the faculty (44% vs 77%, P=0.003).

Only 38% believed that hospitalists should be involved with breast cancer screening. The most commonly cited concern related to ordering an inpatient screening mammography was follow‐up of the results of the mammography, followed by the test may not be covered by patient's insurance. As shown in Table 2, these concerns were not perceived differently among providers who believed that hospitalists should be involved in breast cancer screening as compared to those who do not. Demographic variables from Table 1 failed to discern any significant associations related to believing that hospitalists should be involved with breast cancer screening or with concerns about the barriers to screening presented in Table 2 (data not shown). As shown in Table 2, overall, 32% hospitalists were willing to order a screening mammography during a hospital stay for the scenario of the woman at high risk for developing breast cancer (5‐year risk prediction using Gail model 2.1%) and 33% for the low‐risk scenario (5‐year risk prediction using Gail model 0.6%).

DISCUSSION

Our study suggests that most hospitalists do not believe that they should be involved in breast cancer screening for their hospitalized patients. This perspective was not influenced by either the physician gender, family history for breast cancer, or by the patient's level of risk for developing breast cancer. When patients are in the hospital, both the setting and the acute illness are known to promote reflection and consideration of self‐care.[10] With major healthcare system changes on the horizon and the passing of the Affordable Care Act, we are becoming teams of providers who are collectively responsible for optimal care delivery. It may be possible to increase breast cancer screening rates by educating our patients and offering inpatient screening mammography while they are in the hospital, particularly to those who are at high risk of developing breast cancer.

Physician recommendations for preventive health and screening have consistently been found to be among the strongest predictors of screening utilization.[11] This is the first study to our knowledge that has attempted to understand hospitalists' views and concerns about ordering screening tests to detect occult malignancy. Although addressing preventive care during a hospitalization may seem complex and difficult, helping these women understand their personal risk profile (eg, family history of breast cancer, use of estrogen, race, age, and genetic risk factors) may be what is needed for beginning to influence perspective that might ultimately translate into a willingness to undergo screening.[12, 13, 14] Such delivery of patient‐centered care is built on a foundation of shared decision‐making, which takes into account the patient's preferences, values, and wishes.[15]

Ordering screening mammography for hospitalized patients will require a deeper understanding of hospitalists' attitudes, because the way that these physicians feel about the tests utility will dramatically influence the way that this opportunity is presented to patients, and ultimately the patients' preference to have or forego testing. Our study results are consistent with another publication that highlighted incongruence between physicians' views and patients' preferences for screening practices.[8, 11] Concerns cited, such as interference with patient's acute care, deserve attention, because it may be possible to carry out the screening in ways and at times that do not interfere with treatment or prolong length of stay. Exploring this with a feasibility study will be necessary. Such an approach has been advocated by Trimble et al. for inpatient cervical cancer screening as an efficient strategy to target high‐risk, nonadherent women.[16]

The inpatient setting allows for the elimination of major barriers to screening (like transportation and remembering to get to screening appointments),[8] thereby actively facilitating this needed service. Costs associated with inpatient screening mammography may deter both hospitalists and patients from screening; however, some insurers and Medicare pay for the full cost of screening tests, irrespective of the clinical setting.[17] Further, as hospitals or accountable care organizations become responsible for total cost per beneficiary, screening costs will be preferable when compared with the expenses associated with later detection of pathology and caring for advanced disease states.

One might question whether the mortality benefit of screening mammography is comparable among hospitalized women (who are theoretically sicker and with shorter life expectancy) and those cared for in outpatient practices. Unfortunately, we do not yet know the answer to this question, because data for inpatient screening mammography are nonexistent, and currently this is not considered as a standard of care. However, one can expect the benefits to be similar, if not greater, when performed in the outpatient setting, if preliminary efforts are directed at those who are both nonadherent and at high risk for breast cancer. According to 1 study, increasing mammography utilization by 5% in our country would prevent 560 deaths from breast cancer each year.[18]

Several limitations of this study should be considered. First, this cross‐sectional study was conducted at hospitals associated with a single institution and the results may not be generalizable. Second, although physicians' concerns were explored in this study, we did not solicit input about the potential impact of prevention and screening on the nursing staff. Third, there may be concerns about the hypothetical nature of anchoring and possible framing effects with the 2 clinical scenarios. Finally, it is possible that the hospitalists' response may have been subject to social desirability bias. That said, the response to the key question Do you think hospitalists should be involved in breast cancer screening? do not support a socially desirable bias.

Given the current policy emphasis on reducing disparities in cancer screening, it may be reasonable to expand the role of all healthcare providers and healthcare facilities in screening high‐risk populations. Screening tests that may seem difficult to coordinate in hospitals currently may become easier as our hospitals evolve to become more patient centered. Future studies are needed to evaluate the feasibility and potential barriers to inpatient screening mammography.