A few months ago SHM received an e-mail from SHM member Jennifer Bellino, MD, a hospitalist at William Backus Hospital in Norwich, Conn. She had gotten wind of a proposal flowing through the Public Health Committee at the Connecticut State Legislature that would mandate the frequency of communications between hospitalists and primary care physicians (PCPs). From her short e-mail SHM’s advocacy enterprise sprung into action.

Bill 5721 was being introduced to the Public Health Committee in the Connecticut Legislature, and it required the development of state regulations that would have governed the timing and frequency of communications between hospitalists and PCPs.

Laura Allendorf, SHM’s head of Governmental Affairs, engaged SHM’s Public Policy Committee to better understand the issues involved in this bill and to get a sense of whether this was a unique bill for Connecticut or whether it was being introduced in other state legislatures.

While the bill appeared to be isolated to Connecticut, the Public Policy Committee thought the issue was threatening enough to the practice of hospital medicine that local aggressive action was necessary.

Allendorf contacted the Connecticut State Medical Society and spoke to Ken Ferrucci, director of government relations, who was already aware of Bill 5721. The Connecticut State Medical Society (CSMS) was opposed to the bill as well, and Ferrucci proposed that SHM find a Connecticut hospitalist who could come to Hartford to speak against Bill 5721 at the Public Health Committee, which would hear testimony in just a few days.

Unfortunately, no one on the Public Policy Committee was from Connecticut. Fortunately, SHM was familiar with Bill Rifkin, MD, from Yale (New Haven) and Waterbury Hospital, who is active at SHM as a member of our Education Committee. Allendorf contacted Dr. Rifkin and explained the situation. He dropped everything on his calendar and changed his appointments and agreed to come to Hartford to fly the SHM banner and testify before the Public Health Committee.

Working together Allendorf, Eric Siegal, the Public Policy committee chair, and Dr. Rifkin crafted the testimony necessary to explain to the legislators just what hospital medicine is and what hospitalists do. In addition, they emphasized that hospitalists are working hard to be the experts in transitions of care and that mandates and regulations were not needed and, in fact, could be detrimental to the fundamental relationship between PCPs and hospitalists.

SHM then coordinated our approach with that of the Connecticut State Medical Society to create a unified front for maximum effectiveness. In the end Dr. Rifkin carried the day.

After Dr. Rifkin’s testimony, as well as testimony from the Connecticut State Medical Society, the bill died a quiet death. Eventually, a watered down amendment was made to another public health bill, which contained language that basically said hospitalists and PCPs should talk to each other. This amendment asked that the Quality of Care Advisory Committee, which advises the Department of Public Health, make recommendations to the department concerning best practices with respect to communications between a patient’s PCP and other providers involved in a patient’s care, including hospitalists and specialists.

Thanks to CSMS’ and SHM’s efforts, no regulations or mandates are currently planned in Connecticut.

It is unfortunate that some states, driven by a small vocal group of consumers or sometimes by just one legislator, can single out hospitalists for scrutiny and regulation. Dr. Rifkin found out how important and necessary it is to provide education to the involved legislators, as some professed knowing few of the details of the hospital medicine movement.

While you might be sitting in Texas or Minnesota or California and wondering what all of this has to do with you, know that a wildfire can start from a smoldering ember. SHM must vigilantly monitor the actions of local legislatures and regulators so that in their misunderstanding of hospital medicine or in their concerns for changes in the healthcare system they do not attempt to use the state or federal legislatures for their remedies.

Hospital medicine is new, and we are challenging the status quo. While we are driven by a goal of creating a more efficient healthcare system, driven by accountability and data, some will see the turbulence of change and attempt to rein this in. While some places have seen significant improvements, hospital medicine is still very much in its growth and evolutionary phase. This is the time to have the ability for flexibility and even experimentation in the best sense of the word. It is important not to be stifled by overregulation. At the same time, hospitalists need to be aware that we are no longer a boutique specialty off on the margins of healthcare. Hospital medicine is front and center at more than 2,000 hospitals and with 15,000 hospitalists nationwide too large to be ignored.

Expect more attempts to legislate how hospitalists practice. One SHM member’s e-mail brought the full strength of SHM to quash the wrong bill in Connecticut. We need your local eyes to let us know what is happening out in the real world. In the meantime SHM will work hard to develop the bench strength to be able to rise to your challenges. TH

Dr. Wellikson has been CEO of SHM since 2000.

A few months ago SHM received an e-mail from SHM member Jennifer Bellino, MD, a hospitalist at William Backus Hospital in Norwich, Conn. She had gotten wind of a proposal flowing through the Public Health Committee at the Connecticut State Legislature that would mandate the frequency of communications between hospitalists and primary care physicians (PCPs). From her short e-mail SHM’s advocacy enterprise sprung into action.

Bill 5721 was being introduced to the Public Health Committee in the Connecticut Legislature, and it required the development of state regulations that would have governed the timing and frequency of communications between hospitalists and PCPs.

Laura Allendorf, SHM’s head of Governmental Affairs, engaged SHM’s Public Policy Committee to better understand the issues involved in this bill and to get a sense of whether this was a unique bill for Connecticut or whether it was being introduced in other state legislatures.

While the bill appeared to be isolated to Connecticut, the Public Policy Committee thought the issue was threatening enough to the practice of hospital medicine that local aggressive action was necessary.

Allendorf contacted the Connecticut State Medical Society and spoke to Ken Ferrucci, director of government relations, who was already aware of Bill 5721. The Connecticut State Medical Society (CSMS) was opposed to the bill as well, and Ferrucci proposed that SHM find a Connecticut hospitalist who could come to Hartford to speak against Bill 5721 at the Public Health Committee, which would hear testimony in just a few days.

Unfortunately, no one on the Public Policy Committee was from Connecticut. Fortunately, SHM was familiar with Bill Rifkin, MD, from Yale (New Haven) and Waterbury Hospital, who is active at SHM as a member of our Education Committee. Allendorf contacted Dr. Rifkin and explained the situation. He dropped everything on his calendar and changed his appointments and agreed to come to Hartford to fly the SHM banner and testify before the Public Health Committee.

Working together Allendorf, Eric Siegal, the Public Policy committee chair, and Dr. Rifkin crafted the testimony necessary to explain to the legislators just what hospital medicine is and what hospitalists do. In addition, they emphasized that hospitalists are working hard to be the experts in transitions of care and that mandates and regulations were not needed and, in fact, could be detrimental to the fundamental relationship between PCPs and hospitalists.

SHM then coordinated our approach with that of the Connecticut State Medical Society to create a unified front for maximum effectiveness. In the end Dr. Rifkin carried the day.

After Dr. Rifkin’s testimony, as well as testimony from the Connecticut State Medical Society, the bill died a quiet death. Eventually, a watered down amendment was made to another public health bill, which contained language that basically said hospitalists and PCPs should talk to each other. This amendment asked that the Quality of Care Advisory Committee, which advises the Department of Public Health, make recommendations to the department concerning best practices with respect to communications between a patient’s PCP and other providers involved in a patient’s care, including hospitalists and specialists.

Thanks to CSMS’ and SHM’s efforts, no regulations or mandates are currently planned in Connecticut.

It is unfortunate that some states, driven by a small vocal group of consumers or sometimes by just one legislator, can single out hospitalists for scrutiny and regulation. Dr. Rifkin found out how important and necessary it is to provide education to the involved legislators, as some professed knowing few of the details of the hospital medicine movement.

While you might be sitting in Texas or Minnesota or California and wondering what all of this has to do with you, know that a wildfire can start from a smoldering ember. SHM must vigilantly monitor the actions of local legislatures and regulators so that in their misunderstanding of hospital medicine or in their concerns for changes in the healthcare system they do not attempt to use the state or federal legislatures for their remedies.

Hospital medicine is new, and we are challenging the status quo. While we are driven by a goal of creating a more efficient healthcare system, driven by accountability and data, some will see the turbulence of change and attempt to rein this in. While some places have seen significant improvements, hospital medicine is still very much in its growth and evolutionary phase. This is the time to have the ability for flexibility and even experimentation in the best sense of the word. It is important not to be stifled by overregulation. At the same time, hospitalists need to be aware that we are no longer a boutique specialty off on the margins of healthcare. Hospital medicine is front and center at more than 2,000 hospitals and with 15,000 hospitalists nationwide too large to be ignored.

Expect more attempts to legislate how hospitalists practice. One SHM member’s e-mail brought the full strength of SHM to quash the wrong bill in Connecticut. We need your local eyes to let us know what is happening out in the real world. In the meantime SHM will work hard to develop the bench strength to be able to rise to your challenges. TH

Dr. Wellikson has been CEO of SHM since 2000.

A few months ago SHM received an e-mail from SHM member Jennifer Bellino, MD, a hospitalist at William Backus Hospital in Norwich, Conn. She had gotten wind of a proposal flowing through the Public Health Committee at the Connecticut State Legislature that would mandate the frequency of communications between hospitalists and primary care physicians (PCPs). From her short e-mail SHM’s advocacy enterprise sprung into action.

Bill 5721 was being introduced to the Public Health Committee in the Connecticut Legislature, and it required the development of state regulations that would have governed the timing and frequency of communications between hospitalists and PCPs.

Laura Allendorf, SHM’s head of Governmental Affairs, engaged SHM’s Public Policy Committee to better understand the issues involved in this bill and to get a sense of whether this was a unique bill for Connecticut or whether it was being introduced in other state legislatures.

While the bill appeared to be isolated to Connecticut, the Public Policy Committee thought the issue was threatening enough to the practice of hospital medicine that local aggressive action was necessary.

Allendorf contacted the Connecticut State Medical Society and spoke to Ken Ferrucci, director of government relations, who was already aware of Bill 5721. The Connecticut State Medical Society (CSMS) was opposed to the bill as well, and Ferrucci proposed that SHM find a Connecticut hospitalist who could come to Hartford to speak against Bill 5721 at the Public Health Committee, which would hear testimony in just a few days.

Unfortunately, no one on the Public Policy Committee was from Connecticut. Fortunately, SHM was familiar with Bill Rifkin, MD, from Yale (New Haven) and Waterbury Hospital, who is active at SHM as a member of our Education Committee. Allendorf contacted Dr. Rifkin and explained the situation. He dropped everything on his calendar and changed his appointments and agreed to come to Hartford to fly the SHM banner and testify before the Public Health Committee.

Working together Allendorf, Eric Siegal, the Public Policy committee chair, and Dr. Rifkin crafted the testimony necessary to explain to the legislators just what hospital medicine is and what hospitalists do. In addition, they emphasized that hospitalists are working hard to be the experts in transitions of care and that mandates and regulations were not needed and, in fact, could be detrimental to the fundamental relationship between PCPs and hospitalists.

SHM then coordinated our approach with that of the Connecticut State Medical Society to create a unified front for maximum effectiveness. In the end Dr. Rifkin carried the day.

After Dr. Rifkin’s testimony, as well as testimony from the Connecticut State Medical Society, the bill died a quiet death. Eventually, a watered down amendment was made to another public health bill, which contained language that basically said hospitalists and PCPs should talk to each other. This amendment asked that the Quality of Care Advisory Committee, which advises the Department of Public Health, make recommendations to the department concerning best practices with respect to communications between a patient’s PCP and other providers involved in a patient’s care, including hospitalists and specialists.

Thanks to CSMS’ and SHM’s efforts, no regulations or mandates are currently planned in Connecticut.

It is unfortunate that some states, driven by a small vocal group of consumers or sometimes by just one legislator, can single out hospitalists for scrutiny and regulation. Dr. Rifkin found out how important and necessary it is to provide education to the involved legislators, as some professed knowing few of the details of the hospital medicine movement.

While you might be sitting in Texas or Minnesota or California and wondering what all of this has to do with you, know that a wildfire can start from a smoldering ember. SHM must vigilantly monitor the actions of local legislatures and regulators so that in their misunderstanding of hospital medicine or in their concerns for changes in the healthcare system they do not attempt to use the state or federal legislatures for their remedies.

Hospital medicine is new, and we are challenging the status quo. While we are driven by a goal of creating a more efficient healthcare system, driven by accountability and data, some will see the turbulence of change and attempt to rein this in. While some places have seen significant improvements, hospital medicine is still very much in its growth and evolutionary phase. This is the time to have the ability for flexibility and even experimentation in the best sense of the word. It is important not to be stifled by overregulation. At the same time, hospitalists need to be aware that we are no longer a boutique specialty off on the margins of healthcare. Hospital medicine is front and center at more than 2,000 hospitals and with 15,000 hospitalists nationwide too large to be ignored.

Expect more attempts to legislate how hospitalists practice. One SHM member’s e-mail brought the full strength of SHM to quash the wrong bill in Connecticut. We need your local eyes to let us know what is happening out in the real world. In the meantime SHM will work hard to develop the bench strength to be able to rise to your challenges. TH

Dr. Wellikson has been CEO of SHM since 2000.

The speed at which hospital medicine is growing is leaving many hospitalists in uncharted waters as they try to balance clinical practice and academic activities such as teaching, quality improvement, and research.

“Hospitalists often have great ideas but lack the resources to carry them out,” said Scott Flanders, MD, SHM president-elect, clinical associate professor of internal medicine, and director of the hospitalist program at the University of Michigan Health System, Ann Arbor.

Also, hospitalists do not always recognize the role of the subspecialist in diagnosing and treating complex patients—nor the advantages those specialists bring to designing and supporting clinical research. Given the nature of their education, specialists have a deeper understanding than hospitalists of the pathophysiologic concepts and scientific principles underlying important clinical questions, and are more likely to have had fellowship training that includes clinical research experience. They’re likely to be more adept at navigating outside bureaucracies to obtain grants for disease-based investigation.

All in all, specialist participation in hospital-based clinical research projects may improve project feasibility, increase the chances of obtaining money, and allow for wider dissemination of the results than if these projects had been undertaken by hospitalists alone.

“At large institutions, having hospitalists partner with clinical subspecialists could enhance patient enrollment and enhance funding opportunities, because subspecialists have a lot of credibility with funding agencies,” Dr. Flanders says.

Yet, clinical research programs performed by hospitalists and hospital medicine programs still are in an embryonic stage. In this month’s issue of the Journal of Hospital Medicine, he and his colleagues describe a new program for accelerating clinical and translational research by having hospitalists team with subspecialist physicians and other healthcare professionals to ask and answer novel research questions.

SHARP Solution

In the Specialist-Hospitalist Allied Research Program (SHARP), an academic hospitalist and an academic cardiologist serve as principle and co-principle investigators, respectively. Together, they direct a team of supporting personnel, including a hospitalist investigator, clinical research nurse, research associate, and clinical epidemiologist.

The program began in 2006, with the goal of facilitating multicenter, intervention-based clinical trials. Other aims include enhancing patient participation and supporting pilot projects that would generate enough data to attract money for more in-depth studies. The program is paid for three years by the department of internal medicine with revenues generated for the hospital medicine division.

Through SHARP, there will be “a pool of dollars to support a program and provide an infrastructure for a project,” Dr. Flanders says. “Otherwise, each new project would require a new team to find funding [and] perform data analysis.”

SHARP is, in part, an acknowledgment of the increasingly complex nature of clinical research, Dr. Flanders says. “Many big research projects involve more than one specialty, so there will always be a need to collaborate.”

In a sense, the program is an extension of what hospitalists do already. “Hospitalist work in general is often collaborative and team-based,” Dr. Flanders notes. “We frequently work with nurses and other hospital-based staff members.”

How it Works

A steering committee chaired by the two principle investigators and consisting of academic administrators from the University of Michigan will identify appropriate research projects, determine the best allocation of resources, and help the team overcome the bureaucratic hurdles that inevitably arise in any project that includes multiple departments and institutions.

The program has two opening projects. One is aimed at reducing the incidence of false-positive blood cultures. Right now, as many as half of all the blood cultures that test positive at the University of Michigan turn out to be contaminated. The SHARP team has started a randomized, controlled trial to compare the effects of several different skin antiseptics on the false-positive rate, and ultimately will test more than 12,000 blood culture sets. Other key outcomes will be the quantity of additional diagnostic testing generated by positive cultures, use of resources, and associated costs. Mortality and length of stay also will be examined as secondary outcomes.

The second study has been completed, and data analysis has begun. It examined the role of an inpatient clinical pharmacist in preventing medication errors related to hospital discharge among elderly patients.

“In our experience at the University of Michigan, patients frequently have medication-related adverse events after discharge because they do not understand what medications they should be taking, what they are used for, how to manage side effects, or whom to call with problems,” Dr. Flanders and his colleagues wrote. “In addition, predictable medication-related issues (such as ability to pay for a medicine or expected serum electrolyte changes with newly added medications) are not universally anticipated.”

The pharmacist divided his time between a non-resident hospitalist service and a resident general medicine service, focusing on high-risk patients older than 65. Those patients received pre-discharge counseling and post-discharge follow-up calls from the pharmacist within 72 hours and 30 days of leaving the hospital. The key outcomes include medication issues and actions taken by the pharmacist at or after discharge, as well as clinical outcomes such as emergency department visits, readmission rates, and healthcare-related costs.

So far, the biggest challenge faced by the hospitalists interested in SHARP simply has been finding enough hours in the day for it. One of the program’s goals is to generate grant money to hire supporting staff, but right now the doctors must participate on their own time. Nevertheless, says Dr. Flanders, the response to the program has been positive. “It facilitates the small, difficult steps [in funding and implementing research] along the way,” he says. “People have been pleasantly surprised that it works as well as it does.”TH

Norra MacReady is a medical writer based in California.

The speed at which hospital medicine is growing is leaving many hospitalists in uncharted waters as they try to balance clinical practice and academic activities such as teaching, quality improvement, and research.

“Hospitalists often have great ideas but lack the resources to carry them out,” said Scott Flanders, MD, SHM president-elect, clinical associate professor of internal medicine, and director of the hospitalist program at the University of Michigan Health System, Ann Arbor.

Also, hospitalists do not always recognize the role of the subspecialist in diagnosing and treating complex patients—nor the advantages those specialists bring to designing and supporting clinical research. Given the nature of their education, specialists have a deeper understanding than hospitalists of the pathophysiologic concepts and scientific principles underlying important clinical questions, and are more likely to have had fellowship training that includes clinical research experience. They’re likely to be more adept at navigating outside bureaucracies to obtain grants for disease-based investigation.

All in all, specialist participation in hospital-based clinical research projects may improve project feasibility, increase the chances of obtaining money, and allow for wider dissemination of the results than if these projects had been undertaken by hospitalists alone.

“At large institutions, having hospitalists partner with clinical subspecialists could enhance patient enrollment and enhance funding opportunities, because subspecialists have a lot of credibility with funding agencies,” Dr. Flanders says.

Yet, clinical research programs performed by hospitalists and hospital medicine programs still are in an embryonic stage. In this month’s issue of the Journal of Hospital Medicine, he and his colleagues describe a new program for accelerating clinical and translational research by having hospitalists team with subspecialist physicians and other healthcare professionals to ask and answer novel research questions.

SHARP Solution

In the Specialist-Hospitalist Allied Research Program (SHARP), an academic hospitalist and an academic cardiologist serve as principle and co-principle investigators, respectively. Together, they direct a team of supporting personnel, including a hospitalist investigator, clinical research nurse, research associate, and clinical epidemiologist.

The program began in 2006, with the goal of facilitating multicenter, intervention-based clinical trials. Other aims include enhancing patient participation and supporting pilot projects that would generate enough data to attract money for more in-depth studies. The program is paid for three years by the department of internal medicine with revenues generated for the hospital medicine division.

Through SHARP, there will be “a pool of dollars to support a program and provide an infrastructure for a project,” Dr. Flanders says. “Otherwise, each new project would require a new team to find funding [and] perform data analysis.”

SHARP is, in part, an acknowledgment of the increasingly complex nature of clinical research, Dr. Flanders says. “Many big research projects involve more than one specialty, so there will always be a need to collaborate.”

In a sense, the program is an extension of what hospitalists do already. “Hospitalist work in general is often collaborative and team-based,” Dr. Flanders notes. “We frequently work with nurses and other hospital-based staff members.”

How it Works

A steering committee chaired by the two principle investigators and consisting of academic administrators from the University of Michigan will identify appropriate research projects, determine the best allocation of resources, and help the team overcome the bureaucratic hurdles that inevitably arise in any project that includes multiple departments and institutions.

The program has two opening projects. One is aimed at reducing the incidence of false-positive blood cultures. Right now, as many as half of all the blood cultures that test positive at the University of Michigan turn out to be contaminated. The SHARP team has started a randomized, controlled trial to compare the effects of several different skin antiseptics on the false-positive rate, and ultimately will test more than 12,000 blood culture sets. Other key outcomes will be the quantity of additional diagnostic testing generated by positive cultures, use of resources, and associated costs. Mortality and length of stay also will be examined as secondary outcomes.

The second study has been completed, and data analysis has begun. It examined the role of an inpatient clinical pharmacist in preventing medication errors related to hospital discharge among elderly patients.

“In our experience at the University of Michigan, patients frequently have medication-related adverse events after discharge because they do not understand what medications they should be taking, what they are used for, how to manage side effects, or whom to call with problems,” Dr. Flanders and his colleagues wrote. “In addition, predictable medication-related issues (such as ability to pay for a medicine or expected serum electrolyte changes with newly added medications) are not universally anticipated.”

The pharmacist divided his time between a non-resident hospitalist service and a resident general medicine service, focusing on high-risk patients older than 65. Those patients received pre-discharge counseling and post-discharge follow-up calls from the pharmacist within 72 hours and 30 days of leaving the hospital. The key outcomes include medication issues and actions taken by the pharmacist at or after discharge, as well as clinical outcomes such as emergency department visits, readmission rates, and healthcare-related costs.

So far, the biggest challenge faced by the hospitalists interested in SHARP simply has been finding enough hours in the day for it. One of the program’s goals is to generate grant money to hire supporting staff, but right now the doctors must participate on their own time. Nevertheless, says Dr. Flanders, the response to the program has been positive. “It facilitates the small, difficult steps [in funding and implementing research] along the way,” he says. “People have been pleasantly surprised that it works as well as it does.”TH

Norra MacReady is a medical writer based in California.

The speed at which hospital medicine is growing is leaving many hospitalists in uncharted waters as they try to balance clinical practice and academic activities such as teaching, quality improvement, and research.

“Hospitalists often have great ideas but lack the resources to carry them out,” said Scott Flanders, MD, SHM president-elect, clinical associate professor of internal medicine, and director of the hospitalist program at the University of Michigan Health System, Ann Arbor.

Also, hospitalists do not always recognize the role of the subspecialist in diagnosing and treating complex patients—nor the advantages those specialists bring to designing and supporting clinical research. Given the nature of their education, specialists have a deeper understanding than hospitalists of the pathophysiologic concepts and scientific principles underlying important clinical questions, and are more likely to have had fellowship training that includes clinical research experience. They’re likely to be more adept at navigating outside bureaucracies to obtain grants for disease-based investigation.

All in all, specialist participation in hospital-based clinical research projects may improve project feasibility, increase the chances of obtaining money, and allow for wider dissemination of the results than if these projects had been undertaken by hospitalists alone.

“At large institutions, having hospitalists partner with clinical subspecialists could enhance patient enrollment and enhance funding opportunities, because subspecialists have a lot of credibility with funding agencies,” Dr. Flanders says.

Yet, clinical research programs performed by hospitalists and hospital medicine programs still are in an embryonic stage. In this month’s issue of the Journal of Hospital Medicine, he and his colleagues describe a new program for accelerating clinical and translational research by having hospitalists team with subspecialist physicians and other healthcare professionals to ask and answer novel research questions.

SHARP Solution

In the Specialist-Hospitalist Allied Research Program (SHARP), an academic hospitalist and an academic cardiologist serve as principle and co-principle investigators, respectively. Together, they direct a team of supporting personnel, including a hospitalist investigator, clinical research nurse, research associate, and clinical epidemiologist.

The program began in 2006, with the goal of facilitating multicenter, intervention-based clinical trials. Other aims include enhancing patient participation and supporting pilot projects that would generate enough data to attract money for more in-depth studies. The program is paid for three years by the department of internal medicine with revenues generated for the hospital medicine division.

Through SHARP, there will be “a pool of dollars to support a program and provide an infrastructure for a project,” Dr. Flanders says. “Otherwise, each new project would require a new team to find funding [and] perform data analysis.”

SHARP is, in part, an acknowledgment of the increasingly complex nature of clinical research, Dr. Flanders says. “Many big research projects involve more than one specialty, so there will always be a need to collaborate.”

In a sense, the program is an extension of what hospitalists do already. “Hospitalist work in general is often collaborative and team-based,” Dr. Flanders notes. “We frequently work with nurses and other hospital-based staff members.”

How it Works

A steering committee chaired by the two principle investigators and consisting of academic administrators from the University of Michigan will identify appropriate research projects, determine the best allocation of resources, and help the team overcome the bureaucratic hurdles that inevitably arise in any project that includes multiple departments and institutions.

The program has two opening projects. One is aimed at reducing the incidence of false-positive blood cultures. Right now, as many as half of all the blood cultures that test positive at the University of Michigan turn out to be contaminated. The SHARP team has started a randomized, controlled trial to compare the effects of several different skin antiseptics on the false-positive rate, and ultimately will test more than 12,000 blood culture sets. Other key outcomes will be the quantity of additional diagnostic testing generated by positive cultures, use of resources, and associated costs. Mortality and length of stay also will be examined as secondary outcomes.

The second study has been completed, and data analysis has begun. It examined the role of an inpatient clinical pharmacist in preventing medication errors related to hospital discharge among elderly patients.

“In our experience at the University of Michigan, patients frequently have medication-related adverse events after discharge because they do not understand what medications they should be taking, what they are used for, how to manage side effects, or whom to call with problems,” Dr. Flanders and his colleagues wrote. “In addition, predictable medication-related issues (such as ability to pay for a medicine or expected serum electrolyte changes with newly added medications) are not universally anticipated.”

The pharmacist divided his time between a non-resident hospitalist service and a resident general medicine service, focusing on high-risk patients older than 65. Those patients received pre-discharge counseling and post-discharge follow-up calls from the pharmacist within 72 hours and 30 days of leaving the hospital. The key outcomes include medication issues and actions taken by the pharmacist at or after discharge, as well as clinical outcomes such as emergency department visits, readmission rates, and healthcare-related costs.

So far, the biggest challenge faced by the hospitalists interested in SHARP simply has been finding enough hours in the day for it. One of the program’s goals is to generate grant money to hire supporting staff, but right now the doctors must participate on their own time. Nevertheless, says Dr. Flanders, the response to the program has been positive. “It facilitates the small, difficult steps [in funding and implementing research] along the way,” he says. “People have been pleasantly surprised that it works as well as it does.”TH

Norra MacReady is a medical writer based in California.

Literature at a Glance

A guide to this month’s studies.

• Survival of in-hospital cardiac arrest decreases during nights and weekends.
• C-reactive protein levels predict severity and complications in community-acquired pneumonia.
• Adherence to current guidelines improves outcome in treatment of prosthetic joint infection.
• Sodium phosphate bowel prep use is associated with a decline in GFR.
• Minimally interrupted cardiac resuscitation improves survival.
• Lower aPTT increases risk for future VTE.
• Warfarin combined with antiplatelet therapy increases hemorrhage rate.
• Creatinine rise during MI hospitalization is associated with long-term risk of death and ESRD.
• Communication improves patient adherence to beta-blockers after MI.

Does Time of Day Affect Survival of Cardiac Arrest Patients?

Background: In-hospital cardiac arrest is a major public health problem. Small studies have demonstrated survival after cardiac arrest is worse at night as compared with all other times. Multiple hypothesis are proffered for this decreased survival, including less effective detection and treatment of the warning signs of impending arrest during the night hours.

Study design: Prospective registry.

Setting: 507 hospitals participating through the National Registry of Cardiopulmonary Resuscitation.

Synopsis: 86,748 consecutive, inpatient cardiac arrests were reported from Jan. 1, 2000, through Feb. 1, 2007, including 58,593 cases during day/evening hours and 28,155 cases during night hours.

Rates of survival to discharge (14.7 % vs. 19.8%), survival at 24 hours (28.9% vs. 35.4%), and favorable neurological outcomes (11.0% vs. 15.2%) were substantially lower during the night compared with day/evening (all p values < 0.001). The first documented rhythm at night was more frequently asystole as opposed to ventricular fibrillation during the day/evening. There also was a higher survival rate with cardiac arrests during day/evening hours occurring on weekdays compared with weekends (odds ratio [OR] 1.15). There was no difference in survival rates between weekdays or weekends among cardiac arrests occurring during the night hours.

Bottom line: Survival rates for in-hospital cardiac arrest are lower during nights and weekends, which may relate to differential physician and hospital staffing patterns during these hours.

Citation: Peberdy MA, Ornato JP, Larkin GL et al. Survival from in-hospital cardiac arrest during nights and weekends. JAMA 2008;299:785-792.

Can CRP Identify Risk in CAP Patients?

Background: Small initial studies suggest an elevated C-reactive protein (CRP) is relatively nonspecific but may have a role in predicting disease severity in community-acquired pneumonia (CAP).

Study design: Prospective study.

Setting: Large academic center in the United Kingdom.

Synopsis: In this study of 570 patients over a two-year time period, all patients presenting to the hospital with a diagnosis of CAP and the absence of exclusion criteria were evaluated. CRP was measured on admission and repeated on day four of hospitalization.

Low CRP levels (less than 100 mg/L) were independently associated with a reduced risk of 30-day mortality (OR 0.18; p=0.03), need for invasive ventilation and/or inotropic support (OR 0.21; p=0.002), and complicated pneumonia (OR 0.05; p=0.003). In addition, the failure of CRP to fall by 50% or more at day four of hospitalization was associated with an increased risk of 30-day mortality (OR 24.5; p<0.0001), need for mechanical ventilation and/or inotropic support (OR 7.1; p<0.0001), and complicated pneumonia (OR 15.4; p<0.0001).

Patients with chronic lung disease, immunosuppression, active malignancy or hospital-acquired pneumonia were excluded from the study and the conclusions cannot be extrapolated to these higher risk populations.

Bottom line: C-reactive protein is an independent marker of severity in CAP, and low levels can be used as an adjunct to clinical judgment to help identify patients who may be safely discharged from the hospital.

Citation: Chalmers JD, Singanayagam A, Hill AT. C-reactive protein is an independent predictor of severity in community-acquired pneumonia. Am J of Med. 2008;121:219-225.

Do Aggressive Surgical Intervention and Antimicrobial Treatment Improve Outcomes in Patients Suffering PJI?

Background: Prosthetic joint infection (PJI) is a severe complication, causing significant morbidity and healthcare costs. A recent article put forth up to date guidelines for the management of PJI. The purpose of this current study was to evaluate the external clinical validity of these treatment recommendations.

Study design: Retrospective cohort analysis.

Setting: 1,000-bed tertiary care center in Switzerland.

Synopsis: 68 consecutive episodes of PJI from January 1995 through December 2004 were reviewed. Patients with polymicrobial infections and with treatment failures prior to referral to this center were included.

The success rate for treatment of PJI was highest (67%) when the surgical strategy met current recommendations and antimicrobial treatment was adequate or partially adequate. The preferred surgical strategy was a two-stage exchange. The risk of treatment failure was higher for PJI treated with a surgical strategy other than that recommended (hazard ratio [HR] 2.34, p=0.01) and for PJIs treated with antibiotics not corresponding to recommendations (HR 3.45, p=0.002).

This study was limited by its small sample size and retrospective nature. Patients were not randomized, and cure rates for PJI were significantly lower than in prior published studies.

Bottom line: Treatment of PJI in higher risk populations in accordance with currently recommended surgical and antimicrobial treatment recommendations is associated with better outcomes and cure rates.

Citation: Betsch BY, Eggli S, Siebenrock KA, Tauber MG, Muhlemann K. Treatment of joint prosthesis infection in accordance with current recommendations improves outcome. Clin Infect Dis. 2008;46:1221-1226.

Do Oral Sodium Phosphate Drugs in Large Bowel Prep for Endoscopy Worsen Renal Function?

Background: Proper bowel preparation is essential for adequate colonoscopy and flexible sigmoidoscopy. Oral agents that are most commonly used for bowel preparation are sodium phosphate drugs, polyethylglycol and magnesium citrate. Sodium phosphate drugs are often preferred because of the decreased amount of fluid necessary for bowel preparation.

Study design: Retrospective study.

Setting: Scott and White Clinic, Temple, Texas.

Synopsis: Researchers compared 286 patients receiving an oral sodium phosphate solution for colonoscopy bowel preparation with 125 patients with similar comorbidities who received a non-sodium phosphate solution for bowel preparation. All patients had normal baseline creatinine levels.

The baseline, six-month, and one-year glomerular filtration rates (GFR) were compared between the two groups. GFR declined from 79 to 73 to 71 ml/min/1.73 m2 in the study group vs. 76 to 74 to 74 ml/min/1.73 m2 in the control group for the baseline, six-month, and one-year time periods, respectively.

This is an observational study and thus limited by its non-randomized nature. Sodium phosphate has a black-box warning in stage four and five chronic kidney disease because of its deleterious effect on renal function and the potential for inducing electrolyte abnormalities. Given the findings of this study and the availability of other effective preps alternative regimens should be considered for colonic preparation.

Bottom line: Oral sodium phosphate drugs may cause an acute and chronic decline in renal function as measured by the GFR.

Citation: Khurana A, McLean L, Atkinson S, Foulks C. The effect of oral sodium phosphate drug products on renal function in adults is undergoing bowel endoscopy. Arch Intern Med. 2008; 168(6):593-597.

Does MICR Improve Survival-to-hospital Discharge vs. Traditional CPR and ACLS in Cardiac Arrest Outside the Hospital?

Background: Minimally interrupted cardiac resuscitation (MICR), also known as cardiocerebral resuscitation, is hypothesized to increase survival compared with traditional CPR and advanced cardiac life support (ACLS) in out-of-hospital cardiac arrest. In MICR, 200 “pre-shock” chest compressions (100 compressions/minute) are initially given. The rhythm is then analyzed, with a single shock given if indicated.

Study design: Prospective study.

Setting: Two cities in Arizona.

Synopsis: Using data in the Save Heart in Arizona Registry and Education (SHARE) program, outcomes of 218 individuals with cardiac arrest receiving traditional CPR/ACLS were compared to 668 individuals after MICR training was instituted in the same two metropolitan cities. Survival-to-hospital discharge increased from 1.8% (4/218) before MICR training to 5.4% (36/668) after MICR training. The authors then compared the outcomes of 1,799 individuals with cardiac arrest resuscitated by emergency medical services (EMS) who did not receive training in MICR to 661 individuals who received MICR training over the same period. Survival-to-hospital discharge was 9.1% (60/601) in the patients cared from by EMS that received MICR training versus 3.8% (69/1730) in their non-MICR trained colleagues.

This study is limited by its observational nature and lack of randomization. Surprisingly, more individuals were intubated in the MICR groups. For hospitalists, the results could have a dramatic affect on cardiac arrest survival and lead to future changes to CPR/ACLS protocols.

Bottom line: MICR has a significant impact on survival in out-of-hospital cardiac arrest as compared with traditional CPR and ACLS.

Citation: Bobrow B, Clark L, Ewy G, et al. Minimally interrupted cardiac resuscitation by emergency medical services for out-of-hospital cardiac arrest. JAMA. 2008;299(10):1158-1165.

Does Lower aPTT Increase Future VTE Independent of Other Pro-coagulant Factors?

Background: Certain factors, such as obesity, D-dimer levels, and factor V Leiden gene mutations, increase the risk of future venous thromboembolism (VTE) events. This study sought to determine whether lower baseline levels of activated partial thromboplastin time aPTT also increase this risk.

Study design: Prospective multicenter cohort study.

Setting: Longitudinal Investigation of Thromboembolism Etiology research study (Atherosclerosis Risk in Communities portion) in four U.S. communities.

Synopsis: 13,880 individuals with baseline aPTT measurements were followed for 13 years for future VTE events. Of those, 260 developed a VTE of which 111 were described as idiopathic. Individuals in the lowest two quartiles of aPTT compared with the highest fourth quartile had a 2.4-fold and 1.9-fold increase in the risk of VTE, respectively. A lower aPTT further increased the risk of VTE when associated with obesity, elevated D-dimer level, and particularly factor V Leiden.

This study was limited by the relatively small number of VTE events. It also did not clarify whether aPTT measurements in high-risk groups such as those with positive family history of VTE were useful for predicting risk of future VTE. For hospitalists, patients with a lower initial aPTT may warrant more aggressive inpatient DVT prophylaxis.

Bottom line: aPTT below the median level increases the risk of future VTE events, especially if associated with obesity, elevated D-dimer levels, and/or factor V Leiden.

Citation: Zakai NA, Ohira T, White R, Folsom A, Cushman M. Activated partial thromboplastin time and risk of future venous thromboembolism. Am J of Med. 2008;121:231-238.

What Bleeding Outcomes are Associated with Using Warfarin with Antiplatelet Agents?

Background: Despite a high prevalence of combining antiplatelet and warfarin therapy, the timing, safety, and efficacy of this strategy remain controversial.

Study design: Retrospective cohort study.

Setting: Kaiser Permanente Colorado.

Synopsis: Using a pharmacy database, the authors identified 2,560 patients receiving warfarin alone (monotherapy cohort) and 1,623 patients receiving warfarin combined with antiplatelet agents (combination therapy cohort).

In the combination therapy cohort, aspirin was the most common antiplatelet agent (37%) followed by clopidogrel (13%) and dipyridamole (2%). During a six-month period, the combination therapy cohort had a 4.2% risk of hemorrhage and a 2.0% risk of major hemorrhage. Warfarin monotherapy was associated with a 2% risk of hemorrhage and 0.9% risk of major hemorrhage.

At baseline, the combination therapy patients were twice as likely to have diabetes or congestive heart failure and four times as likely to have coronary artery disease. In both cohorts, the most common reason for warfarin therapy was atrial fibrillation.

Since this was a retrospective investigation, hospitalists should be careful about drawing conclusions from this study alone, but are reminded to discuss risks carefully and engage in shared decision-making with patients when using combined warfarin and antiplatelet therapy.

Bottom line: Warfarin use in combination with antiplatelet therapy is associated with more than double the risk of bleeding compared with warfarin monotherapy.

Citation: Johnson SG, Rogers K, Delate T, Witt DM. Outcomes associated with combined antiplatelet and anticoagulant therapy. Chest. 2008;133:948-954.

Does a Rise in Serum Creatinine Affect Post-hospitalization Mortality and ESRD in Elderly MI Patients?

Background: Previous studies found an association between small changes in serum creatinine during hospitalization and short-term mortality. Data has shown patients experiencing a rise in creatinine at the time of CABG have increased in-hospital and long-term follow-up mortality.

Study design: Retrospective cohort study

Setting: Nationwide Medicare database of acute MI hospitalizations.

Synopsis: The authors reviewed outcomes data for 87,094 patients hospitalized for acute myocardial infarction (MI) from 1994-1995 with follow-up data through 2004. Patients were classified into groups with no rise in creatinine during hospitalization and those with rises of 0.1 mg/dL, 0.2 mg/dL, 0.3-0.5 mg/dL, and 0.6-3 mg/dL.

Compared with patients with no rise in creatinine, a rise of 0.1 mg/dL was associated with an adjusted hazard ratio of 1.45 for end-stage renal disease (ESRD) and 1.14 for post-hospitalization death during long-term follow-up. An incremental increase in poor outcomes was seen with more dramatic increases in creatinine, with patients in the group with a 0.6-3 mg/dL rise in creatinine having an adjusted hazard ratio of 3.26 for ESRD and 1.39 for post-hospitalization death. Among patients with a creatinine rise, the absolute risk of mortality (15% annually) was greater than that of ESRD (0.3% annually).

Hospitalists should note limitations of this retrospective study, including its restriction to hospitalized elderly patients.

Bottom line: Even small rises in serum creatinine during acute hospitalization for MI are associated with long-term risk for death and ESRD in elderly patients.

Citation: Newsome BB, Warnock DG, McClellan WM, et al. Long-term risk of mortality and end-stage renal disease among the elderly after small increases in serum creatinine level during hospitalization for acute myocardial infarction. Arch Intern Med. 2008;168(6):609-616.

Does Direct-to-patient Communication Improve Adherence to Beta-blocker Therapy Following an MI?

Background: The joint American Heart Association and American College of Cardiology guidelines have specific treatment recommendations regarding care of a patient post-myocardial infarction (MI). A key component of this regimen is beta-blocker therapy. Beta-blockers routinely are prescribed at hospital discharge following MI; however, patient adherence has been shown to decline substantially over time.

Study design: Cluster randomized control trial.

Setting: Four health maintenance organizations in Boston, Minneapolis, Atlanta, and Portland, Ore.

Synopsis: 836 post-MI patients were given a beta-blocker prescription upon discharge from the hospital. The intervention group received two mailed communications. The first was a personalized, simply worded letter from a health plan physician-administrator, followed two months later by a similar letter with a brochure. Mailers were low cost and easily replicable; they addressed the importance of these medications, the risks of non-adherence, and adverse effects.

The primary outcome measure was beta-blocker adherence. Medication adherence was analyzed as a continuous measure and as a monthly proportion of days covered (PDC) of 80% or greater. Across all months of follow-up, a mean of 64.8% of intervention patients had a PDC of more than 80% compared with 58.5% of control group patients (number needed to treat=16). The intervention group was 17% more likely to have a PDC of 80% or greater over the entire post-intervention period.

These interventions were studied in a prepaid integrated care delivery system—limiting generalization to other insurance types. Nevertheless, finding ways to improve patient compliance and decrease recurrent cardiac events is liking to result in cost saving to any healthcare plan.

Bottom line: A low-cost direct-to-patient communication effort can have a positive effect on beta-blocker adherence following MI.

Citation: Smith DH, Kramer JM, Perrin N, et al. A randomized trial of direct-to-patient communication to enhance adherence to beta-blocker therapy following myocardial infarction. Arch Intern Med. 2008;168(5):477-483. TH

Literature at a Glance

A guide to this month’s studies.

• Survival of in-hospital cardiac arrest decreases during nights and weekends.
• C-reactive protein levels predict severity and complications in community-acquired pneumonia.
• Adherence to current guidelines improves outcome in treatment of prosthetic joint infection.
• Sodium phosphate bowel prep use is associated with a decline in GFR.
• Minimally interrupted cardiac resuscitation improves survival.
• Lower aPTT increases risk for future VTE.
• Warfarin combined with antiplatelet therapy increases hemorrhage rate.
• Creatinine rise during MI hospitalization is associated with long-term risk of death and ESRD.
• Communication improves patient adherence to beta-blockers after MI.

Does Time of Day Affect Survival of Cardiac Arrest Patients?

Background: In-hospital cardiac arrest is a major public health problem. Small studies have demonstrated survival after cardiac arrest is worse at night as compared with all other times. Multiple hypothesis are proffered for this decreased survival, including less effective detection and treatment of the warning signs of impending arrest during the night hours.

Study design: Prospective registry.

Setting: 507 hospitals participating through the National Registry of Cardiopulmonary Resuscitation.

Synopsis: 86,748 consecutive, inpatient cardiac arrests were reported from Jan. 1, 2000, through Feb. 1, 2007, including 58,593 cases during day/evening hours and 28,155 cases during night hours.

Rates of survival to discharge (14.7 % vs. 19.8%), survival at 24 hours (28.9% vs. 35.4%), and favorable neurological outcomes (11.0% vs. 15.2%) were substantially lower during the night compared with day/evening (all p values < 0.001). The first documented rhythm at night was more frequently asystole as opposed to ventricular fibrillation during the day/evening. There also was a higher survival rate with cardiac arrests during day/evening hours occurring on weekdays compared with weekends (odds ratio [OR] 1.15). There was no difference in survival rates between weekdays or weekends among cardiac arrests occurring during the night hours.

Bottom line: Survival rates for in-hospital cardiac arrest are lower during nights and weekends, which may relate to differential physician and hospital staffing patterns during these hours.

Citation: Peberdy MA, Ornato JP, Larkin GL et al. Survival from in-hospital cardiac arrest during nights and weekends. JAMA 2008;299:785-792.

Can CRP Identify Risk in CAP Patients?

Background: Small initial studies suggest an elevated C-reactive protein (CRP) is relatively nonspecific but may have a role in predicting disease severity in community-acquired pneumonia (CAP).

Study design: Prospective study.

Setting: Large academic center in the United Kingdom.

Synopsis: In this study of 570 patients over a two-year time period, all patients presenting to the hospital with a diagnosis of CAP and the absence of exclusion criteria were evaluated. CRP was measured on admission and repeated on day four of hospitalization.

Low CRP levels (less than 100 mg/L) were independently associated with a reduced risk of 30-day mortality (OR 0.18; p=0.03), need for invasive ventilation and/or inotropic support (OR 0.21; p=0.002), and complicated pneumonia (OR 0.05; p=0.003). In addition, the failure of CRP to fall by 50% or more at day four of hospitalization was associated with an increased risk of 30-day mortality (OR 24.5; p<0.0001), need for mechanical ventilation and/or inotropic support (OR 7.1; p<0.0001), and complicated pneumonia (OR 15.4; p<0.0001).

Patients with chronic lung disease, immunosuppression, active malignancy or hospital-acquired pneumonia were excluded from the study and the conclusions cannot be extrapolated to these higher risk populations.

Bottom line: C-reactive protein is an independent marker of severity in CAP, and low levels can be used as an adjunct to clinical judgment to help identify patients who may be safely discharged from the hospital.

Citation: Chalmers JD, Singanayagam A, Hill AT. C-reactive protein is an independent predictor of severity in community-acquired pneumonia. Am J of Med. 2008;121:219-225.

Do Aggressive Surgical Intervention and Antimicrobial Treatment Improve Outcomes in Patients Suffering PJI?

Background: Prosthetic joint infection (PJI) is a severe complication, causing significant morbidity and healthcare costs. A recent article put forth up to date guidelines for the management of PJI. The purpose of this current study was to evaluate the external clinical validity of these treatment recommendations.

Study design: Retrospective cohort analysis.

Setting: 1,000-bed tertiary care center in Switzerland.

Synopsis: 68 consecutive episodes of PJI from January 1995 through December 2004 were reviewed. Patients with polymicrobial infections and with treatment failures prior to referral to this center were included.

The success rate for treatment of PJI was highest (67%) when the surgical strategy met current recommendations and antimicrobial treatment was adequate or partially adequate. The preferred surgical strategy was a two-stage exchange. The risk of treatment failure was higher for PJI treated with a surgical strategy other than that recommended (hazard ratio [HR] 2.34, p=0.01) and for PJIs treated with antibiotics not corresponding to recommendations (HR 3.45, p=0.002).

This study was limited by its small sample size and retrospective nature. Patients were not randomized, and cure rates for PJI were significantly lower than in prior published studies.

Bottom line: Treatment of PJI in higher risk populations in accordance with currently recommended surgical and antimicrobial treatment recommendations is associated with better outcomes and cure rates.

Citation: Betsch BY, Eggli S, Siebenrock KA, Tauber MG, Muhlemann K. Treatment of joint prosthesis infection in accordance with current recommendations improves outcome. Clin Infect Dis. 2008;46:1221-1226.

Do Oral Sodium Phosphate Drugs in Large Bowel Prep for Endoscopy Worsen Renal Function?

Background: Proper bowel preparation is essential for adequate colonoscopy and flexible sigmoidoscopy. Oral agents that are most commonly used for bowel preparation are sodium phosphate drugs, polyethylglycol and magnesium citrate. Sodium phosphate drugs are often preferred because of the decreased amount of fluid necessary for bowel preparation.

Study design: Retrospective study.

Setting: Scott and White Clinic, Temple, Texas.

Synopsis: Researchers compared 286 patients receiving an oral sodium phosphate solution for colonoscopy bowel preparation with 125 patients with similar comorbidities who received a non-sodium phosphate solution for bowel preparation. All patients had normal baseline creatinine levels.

The baseline, six-month, and one-year glomerular filtration rates (GFR) were compared between the two groups. GFR declined from 79 to 73 to 71 ml/min/1.73 m2 in the study group vs. 76 to 74 to 74 ml/min/1.73 m2 in the control group for the baseline, six-month, and one-year time periods, respectively.

This is an observational study and thus limited by its non-randomized nature. Sodium phosphate has a black-box warning in stage four and five chronic kidney disease because of its deleterious effect on renal function and the potential for inducing electrolyte abnormalities. Given the findings of this study and the availability of other effective preps alternative regimens should be considered for colonic preparation.

Bottom line: Oral sodium phosphate drugs may cause an acute and chronic decline in renal function as measured by the GFR.

Citation: Khurana A, McLean L, Atkinson S, Foulks C. The effect of oral sodium phosphate drug products on renal function in adults is undergoing bowel endoscopy. Arch Intern Med. 2008; 168(6):593-597.

Does MICR Improve Survival-to-hospital Discharge vs. Traditional CPR and ACLS in Cardiac Arrest Outside the Hospital?

Background: Minimally interrupted cardiac resuscitation (MICR), also known as cardiocerebral resuscitation, is hypothesized to increase survival compared with traditional CPR and advanced cardiac life support (ACLS) in out-of-hospital cardiac arrest. In MICR, 200 “pre-shock” chest compressions (100 compressions/minute) are initially given. The rhythm is then analyzed, with a single shock given if indicated.

Study design: Prospective study.

Setting: Two cities in Arizona.

Synopsis: Using data in the Save Heart in Arizona Registry and Education (SHARE) program, outcomes of 218 individuals with cardiac arrest receiving traditional CPR/ACLS were compared to 668 individuals after MICR training was instituted in the same two metropolitan cities. Survival-to-hospital discharge increased from 1.8% (4/218) before MICR training to 5.4% (36/668) after MICR training. The authors then compared the outcomes of 1,799 individuals with cardiac arrest resuscitated by emergency medical services (EMS) who did not receive training in MICR to 661 individuals who received MICR training over the same period. Survival-to-hospital discharge was 9.1% (60/601) in the patients cared from by EMS that received MICR training versus 3.8% (69/1730) in their non-MICR trained colleagues.

This study is limited by its observational nature and lack of randomization. Surprisingly, more individuals were intubated in the MICR groups. For hospitalists, the results could have a dramatic affect on cardiac arrest survival and lead to future changes to CPR/ACLS protocols.

Bottom line: MICR has a significant impact on survival in out-of-hospital cardiac arrest as compared with traditional CPR and ACLS.

Citation: Bobrow B, Clark L, Ewy G, et al. Minimally interrupted cardiac resuscitation by emergency medical services for out-of-hospital cardiac arrest. JAMA. 2008;299(10):1158-1165.

Does Lower aPTT Increase Future VTE Independent of Other Pro-coagulant Factors?

Background: Certain factors, such as obesity, D-dimer levels, and factor V Leiden gene mutations, increase the risk of future venous thromboembolism (VTE) events. This study sought to determine whether lower baseline levels of activated partial thromboplastin time aPTT also increase this risk.

Study design: Prospective multicenter cohort study.

Setting: Longitudinal Investigation of Thromboembolism Etiology research study (Atherosclerosis Risk in Communities portion) in four U.S. communities.

Synopsis: 13,880 individuals with baseline aPTT measurements were followed for 13 years for future VTE events. Of those, 260 developed a VTE of which 111 were described as idiopathic. Individuals in the lowest two quartiles of aPTT compared with the highest fourth quartile had a 2.4-fold and 1.9-fold increase in the risk of VTE, respectively. A lower aPTT further increased the risk of VTE when associated with obesity, elevated D-dimer level, and particularly factor V Leiden.

This study was limited by the relatively small number of VTE events. It also did not clarify whether aPTT measurements in high-risk groups such as those with positive family history of VTE were useful for predicting risk of future VTE. For hospitalists, patients with a lower initial aPTT may warrant more aggressive inpatient DVT prophylaxis.

Bottom line: aPTT below the median level increases the risk of future VTE events, especially if associated with obesity, elevated D-dimer levels, and/or factor V Leiden.

Citation: Zakai NA, Ohira T, White R, Folsom A, Cushman M. Activated partial thromboplastin time and risk of future venous thromboembolism. Am J of Med. 2008;121:231-238.

What Bleeding Outcomes are Associated with Using Warfarin with Antiplatelet Agents?

Background: Despite a high prevalence of combining antiplatelet and warfarin therapy, the timing, safety, and efficacy of this strategy remain controversial.

Study design: Retrospective cohort study.

Setting: Kaiser Permanente Colorado.

Synopsis: Using a pharmacy database, the authors identified 2,560 patients receiving warfarin alone (monotherapy cohort) and 1,623 patients receiving warfarin combined with antiplatelet agents (combination therapy cohort).

In the combination therapy cohort, aspirin was the most common antiplatelet agent (37%) followed by clopidogrel (13%) and dipyridamole (2%). During a six-month period, the combination therapy cohort had a 4.2% risk of hemorrhage and a 2.0% risk of major hemorrhage. Warfarin monotherapy was associated with a 2% risk of hemorrhage and 0.9% risk of major hemorrhage.

At baseline, the combination therapy patients were twice as likely to have diabetes or congestive heart failure and four times as likely to have coronary artery disease. In both cohorts, the most common reason for warfarin therapy was atrial fibrillation.

Since this was a retrospective investigation, hospitalists should be careful about drawing conclusions from this study alone, but are reminded to discuss risks carefully and engage in shared decision-making with patients when using combined warfarin and antiplatelet therapy.

Bottom line: Warfarin use in combination with antiplatelet therapy is associated with more than double the risk of bleeding compared with warfarin monotherapy.

Citation: Johnson SG, Rogers K, Delate T, Witt DM. Outcomes associated with combined antiplatelet and anticoagulant therapy. Chest. 2008;133:948-954.

Does a Rise in Serum Creatinine Affect Post-hospitalization Mortality and ESRD in Elderly MI Patients?

Background: Previous studies found an association between small changes in serum creatinine during hospitalization and short-term mortality. Data has shown patients experiencing a rise in creatinine at the time of CABG have increased in-hospital and long-term follow-up mortality.

Study design: Retrospective cohort study

Setting: Nationwide Medicare database of acute MI hospitalizations.

Synopsis: The authors reviewed outcomes data for 87,094 patients hospitalized for acute myocardial infarction (MI) from 1994-1995 with follow-up data through 2004. Patients were classified into groups with no rise in creatinine during hospitalization and those with rises of 0.1 mg/dL, 0.2 mg/dL, 0.3-0.5 mg/dL, and 0.6-3 mg/dL.

Compared with patients with no rise in creatinine, a rise of 0.1 mg/dL was associated with an adjusted hazard ratio of 1.45 for end-stage renal disease (ESRD) and 1.14 for post-hospitalization death during long-term follow-up. An incremental increase in poor outcomes was seen with more dramatic increases in creatinine, with patients in the group with a 0.6-3 mg/dL rise in creatinine having an adjusted hazard ratio of 3.26 for ESRD and 1.39 for post-hospitalization death. Among patients with a creatinine rise, the absolute risk of mortality (15% annually) was greater than that of ESRD (0.3% annually).

Hospitalists should note limitations of this retrospective study, including its restriction to hospitalized elderly patients.

Bottom line: Even small rises in serum creatinine during acute hospitalization for MI are associated with long-term risk for death and ESRD in elderly patients.

Citation: Newsome BB, Warnock DG, McClellan WM, et al. Long-term risk of mortality and end-stage renal disease among the elderly after small increases in serum creatinine level during hospitalization for acute myocardial infarction. Arch Intern Med. 2008;168(6):609-616.

Does Direct-to-patient Communication Improve Adherence to Beta-blocker Therapy Following an MI?

Background: The joint American Heart Association and American College of Cardiology guidelines have specific treatment recommendations regarding care of a patient post-myocardial infarction (MI). A key component of this regimen is beta-blocker therapy. Beta-blockers routinely are prescribed at hospital discharge following MI; however, patient adherence has been shown to decline substantially over time.

Study design: Cluster randomized control trial.

Setting: Four health maintenance organizations in Boston, Minneapolis, Atlanta, and Portland, Ore.

Synopsis: 836 post-MI patients were given a beta-blocker prescription upon discharge from the hospital. The intervention group received two mailed communications. The first was a personalized, simply worded letter from a health plan physician-administrator, followed two months later by a similar letter with a brochure. Mailers were low cost and easily replicable; they addressed the importance of these medications, the risks of non-adherence, and adverse effects.

The primary outcome measure was beta-blocker adherence. Medication adherence was analyzed as a continuous measure and as a monthly proportion of days covered (PDC) of 80% or greater. Across all months of follow-up, a mean of 64.8% of intervention patients had a PDC of more than 80% compared with 58.5% of control group patients (number needed to treat=16). The intervention group was 17% more likely to have a PDC of 80% or greater over the entire post-intervention period.

These interventions were studied in a prepaid integrated care delivery system—limiting generalization to other insurance types. Nevertheless, finding ways to improve patient compliance and decrease recurrent cardiac events is liking to result in cost saving to any healthcare plan.

Bottom line: A low-cost direct-to-patient communication effort can have a positive effect on beta-blocker adherence following MI.

Citation: Smith DH, Kramer JM, Perrin N, et al. A randomized trial of direct-to-patient communication to enhance adherence to beta-blocker therapy following myocardial infarction. Arch Intern Med. 2008;168(5):477-483. TH

Literature at a Glance

A guide to this month’s studies.

• Survival of in-hospital cardiac arrest decreases during nights and weekends.
• C-reactive protein levels predict severity and complications in community-acquired pneumonia.
• Adherence to current guidelines improves outcome in treatment of prosthetic joint infection.
• Sodium phosphate bowel prep use is associated with a decline in GFR.
• Minimally interrupted cardiac resuscitation improves survival.
• Lower aPTT increases risk for future VTE.
• Warfarin combined with antiplatelet therapy increases hemorrhage rate.
• Creatinine rise during MI hospitalization is associated with long-term risk of death and ESRD.
• Communication improves patient adherence to beta-blockers after MI.

Does Time of Day Affect Survival of Cardiac Arrest Patients?

Background: In-hospital cardiac arrest is a major public health problem. Small studies have demonstrated survival after cardiac arrest is worse at night as compared with all other times. Multiple hypothesis are proffered for this decreased survival, including less effective detection and treatment of the warning signs of impending arrest during the night hours.

Study design: Prospective registry.

Setting: 507 hospitals participating through the National Registry of Cardiopulmonary Resuscitation.

Synopsis: 86,748 consecutive, inpatient cardiac arrests were reported from Jan. 1, 2000, through Feb. 1, 2007, including 58,593 cases during day/evening hours and 28,155 cases during night hours.

Rates of survival to discharge (14.7 % vs. 19.8%), survival at 24 hours (28.9% vs. 35.4%), and favorable neurological outcomes (11.0% vs. 15.2%) were substantially lower during the night compared with day/evening (all p values < 0.001). The first documented rhythm at night was more frequently asystole as opposed to ventricular fibrillation during the day/evening. There also was a higher survival rate with cardiac arrests during day/evening hours occurring on weekdays compared with weekends (odds ratio [OR] 1.15). There was no difference in survival rates between weekdays or weekends among cardiac arrests occurring during the night hours.

Bottom line: Survival rates for in-hospital cardiac arrest are lower during nights and weekends, which may relate to differential physician and hospital staffing patterns during these hours.

Citation: Peberdy MA, Ornato JP, Larkin GL et al. Survival from in-hospital cardiac arrest during nights and weekends. JAMA 2008;299:785-792.

Can CRP Identify Risk in CAP Patients?

Background: Small initial studies suggest an elevated C-reactive protein (CRP) is relatively nonspecific but may have a role in predicting disease severity in community-acquired pneumonia (CAP).

Study design: Prospective study.

Setting: Large academic center in the United Kingdom.

Synopsis: In this study of 570 patients over a two-year time period, all patients presenting to the hospital with a diagnosis of CAP and the absence of exclusion criteria were evaluated. CRP was measured on admission and repeated on day four of hospitalization.

Low CRP levels (less than 100 mg/L) were independently associated with a reduced risk of 30-day mortality (OR 0.18; p=0.03), need for invasive ventilation and/or inotropic support (OR 0.21; p=0.002), and complicated pneumonia (OR 0.05; p=0.003). In addition, the failure of CRP to fall by 50% or more at day four of hospitalization was associated with an increased risk of 30-day mortality (OR 24.5; p<0.0001), need for mechanical ventilation and/or inotropic support (OR 7.1; p<0.0001), and complicated pneumonia (OR 15.4; p<0.0001).

Patients with chronic lung disease, immunosuppression, active malignancy or hospital-acquired pneumonia were excluded from the study and the conclusions cannot be extrapolated to these higher risk populations.

Bottom line: C-reactive protein is an independent marker of severity in CAP, and low levels can be used as an adjunct to clinical judgment to help identify patients who may be safely discharged from the hospital.

Citation: Chalmers JD, Singanayagam A, Hill AT. C-reactive protein is an independent predictor of severity in community-acquired pneumonia. Am J of Med. 2008;121:219-225.

Do Aggressive Surgical Intervention and Antimicrobial Treatment Improve Outcomes in Patients Suffering PJI?

Background: Prosthetic joint infection (PJI) is a severe complication, causing significant morbidity and healthcare costs. A recent article put forth up to date guidelines for the management of PJI. The purpose of this current study was to evaluate the external clinical validity of these treatment recommendations.

Study design: Retrospective cohort analysis.

Setting: 1,000-bed tertiary care center in Switzerland.

Synopsis: 68 consecutive episodes of PJI from January 1995 through December 2004 were reviewed. Patients with polymicrobial infections and with treatment failures prior to referral to this center were included.

The success rate for treatment of PJI was highest (67%) when the surgical strategy met current recommendations and antimicrobial treatment was adequate or partially adequate. The preferred surgical strategy was a two-stage exchange. The risk of treatment failure was higher for PJI treated with a surgical strategy other than that recommended (hazard ratio [HR] 2.34, p=0.01) and for PJIs treated with antibiotics not corresponding to recommendations (HR 3.45, p=0.002).

This study was limited by its small sample size and retrospective nature. Patients were not randomized, and cure rates for PJI were significantly lower than in prior published studies.

Bottom line: Treatment of PJI in higher risk populations in accordance with currently recommended surgical and antimicrobial treatment recommendations is associated with better outcomes and cure rates.

Citation: Betsch BY, Eggli S, Siebenrock KA, Tauber MG, Muhlemann K. Treatment of joint prosthesis infection in accordance with current recommendations improves outcome. Clin Infect Dis. 2008;46:1221-1226.

Do Oral Sodium Phosphate Drugs in Large Bowel Prep for Endoscopy Worsen Renal Function?

Background: Proper bowel preparation is essential for adequate colonoscopy and flexible sigmoidoscopy. Oral agents that are most commonly used for bowel preparation are sodium phosphate drugs, polyethylglycol and magnesium citrate. Sodium phosphate drugs are often preferred because of the decreased amount of fluid necessary for bowel preparation.

Study design: Retrospective study.

Setting: Scott and White Clinic, Temple, Texas.

Synopsis: Researchers compared 286 patients receiving an oral sodium phosphate solution for colonoscopy bowel preparation with 125 patients with similar comorbidities who received a non-sodium phosphate solution for bowel preparation. All patients had normal baseline creatinine levels.

The baseline, six-month, and one-year glomerular filtration rates (GFR) were compared between the two groups. GFR declined from 79 to 73 to 71 ml/min/1.73 m2 in the study group vs. 76 to 74 to 74 ml/min/1.73 m2 in the control group for the baseline, six-month, and one-year time periods, respectively.

This is an observational study and thus limited by its non-randomized nature. Sodium phosphate has a black-box warning in stage four and five chronic kidney disease because of its deleterious effect on renal function and the potential for inducing electrolyte abnormalities. Given the findings of this study and the availability of other effective preps alternative regimens should be considered for colonic preparation.

Bottom line: Oral sodium phosphate drugs may cause an acute and chronic decline in renal function as measured by the GFR.

Citation: Khurana A, McLean L, Atkinson S, Foulks C. The effect of oral sodium phosphate drug products on renal function in adults is undergoing bowel endoscopy. Arch Intern Med. 2008; 168(6):593-597.

Does MICR Improve Survival-to-hospital Discharge vs. Traditional CPR and ACLS in Cardiac Arrest Outside the Hospital?

Background: Minimally interrupted cardiac resuscitation (MICR), also known as cardiocerebral resuscitation, is hypothesized to increase survival compared with traditional CPR and advanced cardiac life support (ACLS) in out-of-hospital cardiac arrest. In MICR, 200 “pre-shock” chest compressions (100 compressions/minute) are initially given. The rhythm is then analyzed, with a single shock given if indicated.

Study design: Prospective study.

Setting: Two cities in Arizona.

Synopsis: Using data in the Save Heart in Arizona Registry and Education (SHARE) program, outcomes of 218 individuals with cardiac arrest receiving traditional CPR/ACLS were compared to 668 individuals after MICR training was instituted in the same two metropolitan cities. Survival-to-hospital discharge increased from 1.8% (4/218) before MICR training to 5.4% (36/668) after MICR training. The authors then compared the outcomes of 1,799 individuals with cardiac arrest resuscitated by emergency medical services (EMS) who did not receive training in MICR to 661 individuals who received MICR training over the same period. Survival-to-hospital discharge was 9.1% (60/601) in the patients cared from by EMS that received MICR training versus 3.8% (69/1730) in their non-MICR trained colleagues.

This study is limited by its observational nature and lack of randomization. Surprisingly, more individuals were intubated in the MICR groups. For hospitalists, the results could have a dramatic affect on cardiac arrest survival and lead to future changes to CPR/ACLS protocols.

Bottom line: MICR has a significant impact on survival in out-of-hospital cardiac arrest as compared with traditional CPR and ACLS.

Citation: Bobrow B, Clark L, Ewy G, et al. Minimally interrupted cardiac resuscitation by emergency medical services for out-of-hospital cardiac arrest. JAMA. 2008;299(10):1158-1165.

Does Lower aPTT Increase Future VTE Independent of Other Pro-coagulant Factors?

Background: Certain factors, such as obesity, D-dimer levels, and factor V Leiden gene mutations, increase the risk of future venous thromboembolism (VTE) events. This study sought to determine whether lower baseline levels of activated partial thromboplastin time aPTT also increase this risk.

Study design: Prospective multicenter cohort study.

Setting: Longitudinal Investigation of Thromboembolism Etiology research study (Atherosclerosis Risk in Communities portion) in four U.S. communities.

Synopsis: 13,880 individuals with baseline aPTT measurements were followed for 13 years for future VTE events. Of those, 260 developed a VTE of which 111 were described as idiopathic. Individuals in the lowest two quartiles of aPTT compared with the highest fourth quartile had a 2.4-fold and 1.9-fold increase in the risk of VTE, respectively. A lower aPTT further increased the risk of VTE when associated with obesity, elevated D-dimer level, and particularly factor V Leiden.

This study was limited by the relatively small number of VTE events. It also did not clarify whether aPTT measurements in high-risk groups such as those with positive family history of VTE were useful for predicting risk of future VTE. For hospitalists, patients with a lower initial aPTT may warrant more aggressive inpatient DVT prophylaxis.

Bottom line: aPTT below the median level increases the risk of future VTE events, especially if associated with obesity, elevated D-dimer levels, and/or factor V Leiden.

Citation: Zakai NA, Ohira T, White R, Folsom A, Cushman M. Activated partial thromboplastin time and risk of future venous thromboembolism. Am J of Med. 2008;121:231-238.

What Bleeding Outcomes are Associated with Using Warfarin with Antiplatelet Agents?

Background: Despite a high prevalence of combining antiplatelet and warfarin therapy, the timing, safety, and efficacy of this strategy remain controversial.

Study design: Retrospective cohort study.

Setting: Kaiser Permanente Colorado.

Synopsis: Using a pharmacy database, the authors identified 2,560 patients receiving warfarin alone (monotherapy cohort) and 1,623 patients receiving warfarin combined with antiplatelet agents (combination therapy cohort).

In the combination therapy cohort, aspirin was the most common antiplatelet agent (37%) followed by clopidogrel (13%) and dipyridamole (2%). During a six-month period, the combination therapy cohort had a 4.2% risk of hemorrhage and a 2.0% risk of major hemorrhage. Warfarin monotherapy was associated with a 2% risk of hemorrhage and 0.9% risk of major hemorrhage.

At baseline, the combination therapy patients were twice as likely to have diabetes or congestive heart failure and four times as likely to have coronary artery disease. In both cohorts, the most common reason for warfarin therapy was atrial fibrillation.

Since this was a retrospective investigation, hospitalists should be careful about drawing conclusions from this study alone, but are reminded to discuss risks carefully and engage in shared decision-making with patients when using combined warfarin and antiplatelet therapy.

Bottom line: Warfarin use in combination with antiplatelet therapy is associated with more than double the risk of bleeding compared with warfarin monotherapy.

Citation: Johnson SG, Rogers K, Delate T, Witt DM. Outcomes associated with combined antiplatelet and anticoagulant therapy. Chest. 2008;133:948-954.

Does a Rise in Serum Creatinine Affect Post-hospitalization Mortality and ESRD in Elderly MI Patients?

Background: Previous studies found an association between small changes in serum creatinine during hospitalization and short-term mortality. Data has shown patients experiencing a rise in creatinine at the time of CABG have increased in-hospital and long-term follow-up mortality.

Study design: Retrospective cohort study

Setting: Nationwide Medicare database of acute MI hospitalizations.

Synopsis: The authors reviewed outcomes data for 87,094 patients hospitalized for acute myocardial infarction (MI) from 1994-1995 with follow-up data through 2004. Patients were classified into groups with no rise in creatinine during hospitalization and those with rises of 0.1 mg/dL, 0.2 mg/dL, 0.3-0.5 mg/dL, and 0.6-3 mg/dL.

Compared with patients with no rise in creatinine, a rise of 0.1 mg/dL was associated with an adjusted hazard ratio of 1.45 for end-stage renal disease (ESRD) and 1.14 for post-hospitalization death during long-term follow-up. An incremental increase in poor outcomes was seen with more dramatic increases in creatinine, with patients in the group with a 0.6-3 mg/dL rise in creatinine having an adjusted hazard ratio of 3.26 for ESRD and 1.39 for post-hospitalization death. Among patients with a creatinine rise, the absolute risk of mortality (15% annually) was greater than that of ESRD (0.3% annually).

Hospitalists should note limitations of this retrospective study, including its restriction to hospitalized elderly patients.

Bottom line: Even small rises in serum creatinine during acute hospitalization for MI are associated with long-term risk for death and ESRD in elderly patients.

Citation: Newsome BB, Warnock DG, McClellan WM, et al. Long-term risk of mortality and end-stage renal disease among the elderly after small increases in serum creatinine level during hospitalization for acute myocardial infarction. Arch Intern Med. 2008;168(6):609-616.

Does Direct-to-patient Communication Improve Adherence to Beta-blocker Therapy Following an MI?

Background: The joint American Heart Association and American College of Cardiology guidelines have specific treatment recommendations regarding care of a patient post-myocardial infarction (MI). A key component of this regimen is beta-blocker therapy. Beta-blockers routinely are prescribed at hospital discharge following MI; however, patient adherence has been shown to decline substantially over time.

Study design: Cluster randomized control trial.

Setting: Four health maintenance organizations in Boston, Minneapolis, Atlanta, and Portland, Ore.

Synopsis: 836 post-MI patients were given a beta-blocker prescription upon discharge from the hospital. The intervention group received two mailed communications. The first was a personalized, simply worded letter from a health plan physician-administrator, followed two months later by a similar letter with a brochure. Mailers were low cost and easily replicable; they addressed the importance of these medications, the risks of non-adherence, and adverse effects.

The primary outcome measure was beta-blocker adherence. Medication adherence was analyzed as a continuous measure and as a monthly proportion of days covered (PDC) of 80% or greater. Across all months of follow-up, a mean of 64.8% of intervention patients had a PDC of more than 80% compared with 58.5% of control group patients (number needed to treat=16). The intervention group was 17% more likely to have a PDC of 80% or greater over the entire post-intervention period.

These interventions were studied in a prepaid integrated care delivery system—limiting generalization to other insurance types. Nevertheless, finding ways to improve patient compliance and decrease recurrent cardiac events is liking to result in cost saving to any healthcare plan.

Bottom line: A low-cost direct-to-patient communication effort can have a positive effect on beta-blocker adherence following MI.

Citation: Smith DH, Kramer JM, Perrin N, et al. A randomized trial of direct-to-patient communication to enhance adherence to beta-blocker therapy following myocardial infarction. Arch Intern Med. 2008;168(5):477-483. TH

Dear John Q. Hospitalist,

Recently, a pair of college students in our office presented an impressive summary of Web 2.0, including Facebook.com and LinkedIn.com, to the rest of the SHM staff.

As I listened to their presentation and heard the energy in their voices, I couldn’t help but think about my initial experience and excitement with the World Wide Web. Instead of doing homework, I spent many late nights searching the Internet looking for more information to help me create my first Web page. After countless hours of coding and debugging, as well as throwing the keyboard a time or two, I published my Web page and became a part of the Internet. I was hooked.

After listening to these students I was inspired to check out LinkedIn.com and create my own LinkedIn profile. While I did not stay up until the very early morning sending invites or completing every part of my profile, I found connections to old colleagues, college friends, high school buddies, and family members. Today, I eagerly await the flood of e-mail from people accepting me as a friend in their network, some of them members of SHM. I am hooked again.

Seeing SHM members on LinkedIn got me thinking about how SHM might use social networking technology. I think there is an opportunity here to create an interactive resource that will empower hospitalists to find other hospitalists, make connections, and build their own networks. I’m interested in getting your perspective. Do you think our members will use this type of an online resource?

Many social networking sites on the Internet grew out of individuals in an academic setting trying to find ways to connect with each other. I would imagine many of our student and resident members already are using social networking sites. Do you think this is the case? If so, what features and functions of a social networking tool do you think are most important? Is that different from a third-year resident, or a hospitalist who has been practicing hospital medicine for a number of years?

Johnson

I know I have thrown a bunch of questions at you, so let me share with you some ideas and maybe we can begin a dialogue that will help SHM find ways in which we can leverage social networking and other Web 2.0 tools.

One of the tasks in creating a LinkedIn account is selecting the college or institution you attended and the years in which you attended. Immediately after setting up my account I was able to see the names of other alumni who attended my university during my four years and invite old friends to join my network. I can envision a scenario where an SHM member indicates which medical school he or she attended and is able to see a list of other colleagues who attended at the same time.

For the general member, someone who hasn’t attended a meeting, participated in a committee, or been more actively engaged in SHM, an online network might be a first step to increased involvement with SHM. Members could use this site to connect with other hospitalists in their area and share their interests and experience with others.

Along the way, they might learn about an SHM initiative they are interested in and connect with another hospitalist who working on this project and begin to have a dialogue. Throughout time, this person builds their network and establishes new connections. When it’s time to register for next year’s SHM Annual Meeting in Chicago, they already know a few faces in the crowd—and maybe a couple of them have become friends.

These are just a couple of ways I think SHM and our members might benefit from social networking. I am confident there are many, many more ways this technology can help our members and the hospital medicine community. What do you think? I would love to hear your thoughts and ideas. E-mail me at sjohnson@hospitalmedicine.org. TH

Dear John Q. Hospitalist,

Recently, a pair of college students in our office presented an impressive summary of Web 2.0, including Facebook.com and LinkedIn.com, to the rest of the SHM staff.

As I listened to their presentation and heard the energy in their voices, I couldn’t help but think about my initial experience and excitement with the World Wide Web. Instead of doing homework, I spent many late nights searching the Internet looking for more information to help me create my first Web page. After countless hours of coding and debugging, as well as throwing the keyboard a time or two, I published my Web page and became a part of the Internet. I was hooked.

After listening to these students I was inspired to check out LinkedIn.com and create my own LinkedIn profile. While I did not stay up until the very early morning sending invites or completing every part of my profile, I found connections to old colleagues, college friends, high school buddies, and family members. Today, I eagerly await the flood of e-mail from people accepting me as a friend in their network, some of them members of SHM. I am hooked again.

Seeing SHM members on LinkedIn got me thinking about how SHM might use social networking technology. I think there is an opportunity here to create an interactive resource that will empower hospitalists to find other hospitalists, make connections, and build their own networks. I’m interested in getting your perspective. Do you think our members will use this type of an online resource?

Many social networking sites on the Internet grew out of individuals in an academic setting trying to find ways to connect with each other. I would imagine many of our student and resident members already are using social networking sites. Do you think this is the case? If so, what features and functions of a social networking tool do you think are most important? Is that different from a third-year resident, or a hospitalist who has been practicing hospital medicine for a number of years?

Johnson

I know I have thrown a bunch of questions at you, so let me share with you some ideas and maybe we can begin a dialogue that will help SHM find ways in which we can leverage social networking and other Web 2.0 tools.

One of the tasks in creating a LinkedIn account is selecting the college or institution you attended and the years in which you attended. Immediately after setting up my account I was able to see the names of other alumni who attended my university during my four years and invite old friends to join my network. I can envision a scenario where an SHM member indicates which medical school he or she attended and is able to see a list of other colleagues who attended at the same time.

For the general member, someone who hasn’t attended a meeting, participated in a committee, or been more actively engaged in SHM, an online network might be a first step to increased involvement with SHM. Members could use this site to connect with other hospitalists in their area and share their interests and experience with others.

Along the way, they might learn about an SHM initiative they are interested in and connect with another hospitalist who working on this project and begin to have a dialogue. Throughout time, this person builds their network and establishes new connections. When it’s time to register for next year’s SHM Annual Meeting in Chicago, they already know a few faces in the crowd—and maybe a couple of them have become friends.

These are just a couple of ways I think SHM and our members might benefit from social networking. I am confident there are many, many more ways this technology can help our members and the hospital medicine community. What do you think? I would love to hear your thoughts and ideas. E-mail me at sjohnson@hospitalmedicine.org. TH

Dear John Q. Hospitalist,

Recently, a pair of college students in our office presented an impressive summary of Web 2.0, including Facebook.com and LinkedIn.com, to the rest of the SHM staff.

As I listened to their presentation and heard the energy in their voices, I couldn’t help but think about my initial experience and excitement with the World Wide Web. Instead of doing homework, I spent many late nights searching the Internet looking for more information to help me create my first Web page. After countless hours of coding and debugging, as well as throwing the keyboard a time or two, I published my Web page and became a part of the Internet. I was hooked.

After listening to these students I was inspired to check out LinkedIn.com and create my own LinkedIn profile. While I did not stay up until the very early morning sending invites or completing every part of my profile, I found connections to old colleagues, college friends, high school buddies, and family members. Today, I eagerly await the flood of e-mail from people accepting me as a friend in their network, some of them members of SHM. I am hooked again.

Seeing SHM members on LinkedIn got me thinking about how SHM might use social networking technology. I think there is an opportunity here to create an interactive resource that will empower hospitalists to find other hospitalists, make connections, and build their own networks. I’m interested in getting your perspective. Do you think our members will use this type of an online resource?

Many social networking sites on the Internet grew out of individuals in an academic setting trying to find ways to connect with each other. I would imagine many of our student and resident members already are using social networking sites. Do you think this is the case? If so, what features and functions of a social networking tool do you think are most important? Is that different from a third-year resident, or a hospitalist who has been practicing hospital medicine for a number of years?

Johnson

I know I have thrown a bunch of questions at you, so let me share with you some ideas and maybe we can begin a dialogue that will help SHM find ways in which we can leverage social networking and other Web 2.0 tools.

One of the tasks in creating a LinkedIn account is selecting the college or institution you attended and the years in which you attended. Immediately after setting up my account I was able to see the names of other alumni who attended my university during my four years and invite old friends to join my network. I can envision a scenario where an SHM member indicates which medical school he or she attended and is able to see a list of other colleagues who attended at the same time.

For the general member, someone who hasn’t attended a meeting, participated in a committee, or been more actively engaged in SHM, an online network might be a first step to increased involvement with SHM. Members could use this site to connect with other hospitalists in their area and share their interests and experience with others.

Along the way, they might learn about an SHM initiative they are interested in and connect with another hospitalist who working on this project and begin to have a dialogue. Throughout time, this person builds their network and establishes new connections. When it’s time to register for next year’s SHM Annual Meeting in Chicago, they already know a few faces in the crowd—and maybe a couple of them have become friends.

These are just a couple of ways I think SHM and our members might benefit from social networking. I am confident there are many, many more ways this technology can help our members and the hospital medicine community. What do you think? I would love to hear your thoughts and ideas. E-mail me at sjohnson@hospitalmedicine.org. TH

One of the best things about working in the membership department is seeing the passion and commitment our members have for the success of our specialty. You also get to hear about what is needed to elevate our field to the next level.

Throughout the past 10 years, hospitalists have been asking for a unique designation that clearly identifies those physicians whose career is committed to hospital medicine. SHM wants you to know that we have heard you and have responded to this need by creating a Fellowship in Hospital Medicine (FHM) program.

Hospitalists who earn their FHM designation will have a demonstrated commitment to hospital medicine, systems change, and quality improvement principals. There will be three designations available, each with increasingly more challenging selection criteria:

• Fellow in Hospital Medicine (FHM);
• Senior Fellow in Hospital Medicine (SFHM); and
• Master in Hospital Medicine (MHM).

Application requirements include:

• Five years as a practicing hospitalist;
• Demonstration of competencies tied to the SHM Core Competencies in Hospital Medicine, including systems improvement, quality initiatives, and clinical excellence; and
• Endorsement by two active SHM members.

Applications for Fellow in Hospital Medicine will be available this fall, and the first class will be inducted at Hospital Medicine 2009 in Chicago.

One of the best things about working in the membership department is seeing the passion and commitment our members have for the success of our specialty. You also get to hear about what is needed to elevate our field to the next level.

Throughout the past 10 years, hospitalists have been asking for a unique designation that clearly identifies those physicians whose career is committed to hospital medicine. SHM wants you to know that we have heard you and have responded to this need by creating a Fellowship in Hospital Medicine (FHM) program.

Hospitalists who earn their FHM designation will have a demonstrated commitment to hospital medicine, systems change, and quality improvement principals. There will be three designations available, each with increasingly more challenging selection criteria:

• Fellow in Hospital Medicine (FHM);
• Senior Fellow in Hospital Medicine (SFHM); and
• Master in Hospital Medicine (MHM).

Application requirements include:

• Five years as a practicing hospitalist;
• Demonstration of competencies tied to the SHM Core Competencies in Hospital Medicine, including systems improvement, quality initiatives, and clinical excellence; and
• Endorsement by two active SHM members.

Applications for Fellow in Hospital Medicine will be available this fall, and the first class will be inducted at Hospital Medicine 2009 in Chicago.

One of the best things about working in the membership department is seeing the passion and commitment our members have for the success of our specialty. You also get to hear about what is needed to elevate our field to the next level.

Throughout the past 10 years, hospitalists have been asking for a unique designation that clearly identifies those physicians whose career is committed to hospital medicine. SHM wants you to know that we have heard you and have responded to this need by creating a Fellowship in Hospital Medicine (FHM) program.

Hospitalists who earn their FHM designation will have a demonstrated commitment to hospital medicine, systems change, and quality improvement principals. There will be three designations available, each with increasingly more challenging selection criteria:

• Fellow in Hospital Medicine (FHM);
• Senior Fellow in Hospital Medicine (SFHM); and
• Master in Hospital Medicine (MHM).

Application requirements include:

• Five years as a practicing hospitalist;
• Demonstration of competencies tied to the SHM Core Competencies in Hospital Medicine, including systems improvement, quality initiatives, and clinical excellence; and
• Endorsement by two active SHM members.

Applications for Fellow in Hospital Medicine will be available this fall, and the first class will be inducted at Hospital Medicine 2009 in Chicago.

Supplement Editor:
Brian F. Mandell, MD, PhD

Contents

Despite its treatability, gout remains a problem: Confessions of a goutophile
Brian F. Mandell, MD, PhD

The pathogenesis of gout
H. Ralph Schumacher, Jr, MD

Clinical manifestations of hyperuricemia and gout
Brian F. Mandell, MD, PhD

Epidemiology of gout
Arthur L. Weaver, MD, MS

The role of hyperuricemia and gout in kidney and cardiovascular disease
N. Lawrence Edwards, MD

The gout diagnosis
Robin K. Dore, MD

The practical management of gout
H. Ralph Schumacher, Jr, MD, and Lan X. Chen, MD, PhD

Supplement Editor:
Brian F. Mandell, MD, PhD

Contents

Despite its treatability, gout remains a problem: Confessions of a goutophile
Brian F. Mandell, MD, PhD

The pathogenesis of gout
H. Ralph Schumacher, Jr, MD

Clinical manifestations of hyperuricemia and gout
Brian F. Mandell, MD, PhD

Epidemiology of gout
Arthur L. Weaver, MD, MS

The role of hyperuricemia and gout in kidney and cardiovascular disease
N. Lawrence Edwards, MD

The gout diagnosis
Robin K. Dore, MD

The practical management of gout
H. Ralph Schumacher, Jr, MD, and Lan X. Chen, MD, PhD

Supplement Editor:
Brian F. Mandell, MD, PhD

Contents

Despite its treatability, gout remains a problem: Confessions of a goutophile
Brian F. Mandell, MD, PhD

The pathogenesis of gout
H. Ralph Schumacher, Jr, MD

Clinical manifestations of hyperuricemia and gout
Brian F. Mandell, MD, PhD

Epidemiology of gout
Arthur L. Weaver, MD, MS

The role of hyperuricemia and gout in kidney and cardiovascular disease
N. Lawrence Edwards, MD

The gout diagnosis
Robin K. Dore, MD

The practical management of gout
H. Ralph Schumacher, Jr, MD, and Lan X. Chen, MD, PhD

Budnitz

Somebody oughta fix that. I’m sure you’ve heard that phrase from friends or relatives lamenting their recent visit to a hospital.

My grandmother will use just about any opportunity to inform me that hospitals make people sicker. I’ve tried to explain that her perspective is skewed. After all, a lot of her friends were pretty sick before they entered the hospital. But “it’s that place” she vows. “They oughta change it.” Fortunately for me, my grandmother still hasn’t figured out what I do professionally, so I’m not considered part of “they.” I let her rant to my husband, since he has the letters MD after his name.

The truth, as you know, is many hospital medicine physicians and their teams are working their tails off trying to improve inpatient care. Much like my grandmother, hospital administrators haven’t identified who the “they” (change agents) are or what exactly the “it” (practices and systems that lead to suboptimal care) is that needs to be changed. It often is unclear how quality improvement initiatives affect the bottom line or which initiatives will ultimately improve outcomes. Today, a considerable amount of improvement efforts depend on the good will and perseverance of a few champions working with minimal institutional support.

The Hospital Quality and Patient Safety Committee (HQPSC) and SHM leadership recently convened a summit to define a vision for the optimal hospital stay and determine how to best train and support hospitalists as leaders and change agents.

The HQPSC and summit participants concluded SHM is, and should be, a national leader in quality improvement efforts including aspects of education, clinical care, and political advocacy for the hospital setting. To that end, the following strategy recently was submitted by the HQPSC and approved by the SHM Board of Directors to promote development of local, regional, and national infrastructures that support quality and patient safety:

Advance a national quality agenda for hospitals and hospitalists.

• Create a task force reporting to the HQPSC that partners with stakeholders to define the “ideal hospital stay” and promote quality improvement;
• Inform federal accrediting and policy-making groups about the effect of current quality measures and changes required to better support the “ideal hospital stay”;
• Advocate for the alignment of reimbursement practices that reward providers and institutions that demonstrate value and translate these practices into improved quality and patient safety;
• Establish an Acute Care Collaborative (ACC) comprising national organizations representing nurses, pharmacists, case managers, social workers, and other allied medical professionals. The ACC might be expanded to include other key physician groups (e.g., emergency physicians, geriatricians, intensivists); and
• Determine what other key national organizations are doing in quality improvement (QI) and look for opportunities for SHM to partner in these efforts.

Develop educational programs and technical support tools for all practicing hospitalists (entry level to QI leaders) engaged in quality improvement efforts.

• Delineate entry-level and advanced quality improvement offerings. Develop offerings specifically for advanced level participants;
• Expand mentored implementation programs to accommodate more participants and assess the need for other types of programs that provide longitudinal support or coaching;
• Expand current offerings, including resource rooms, mentored implementation, and expert training sessions, to other disease states, system processes, and special populations with attention to coordinating this with SHM’s The Core Competencies in Hospital Medicine: A Framework for Curriculum Development;
• Assess the need for new instructional modalities to reach a broader audience (e.g., Web based self-study modules); and
• Promote QI training in medical school, residency, and fellowship programs. Promote systems-based practice and QI throughout the continuum of education. This would include programs that engage medical students, residents, and fellows as well as the development of performance improvement modules (PIMs) for the American Board of Internal Medicine.

Improves the perceived value of implementing and sustaining QI efforts, and hospitalist leadership of those efforts.

• Advocate directly to the C-suites of hospitals to facilitate alignment of incentives that support hospitalists leading quality initiatives;
• Conduct a survey to quantify resources needed for hospitalists to successfully lead quality initiatives and develop safety programs. Develop a white paper based on survey results and distribute it to the C-suite;
• Encourage QI research that creates evidence and outcomes that can influence C-suites to commit adequate resources to QI activities;
• Explore opportunities to use existing local and national infrastructures to promote a more proactive and evidence-based approach to quality and safety rather than reactive and compliance-oriented quality projects; and
• Create a monthly column in The Hospitalist spotlighting QI efforts and assign staff to recruit submissions of “improvement stories” for the Web site.

Evaluate effectiveness of SHM’s current QI resources, educational offerings. SHM needs to assess its current offerings to understand and improve their effectiveness. Process and impact data are needed to obtain external money to create or sustain QI offerings.

• Create robust evaluations and collect better data to assess use and impact of resource rooms, quality precourses, and other SHM offerings.

Promote and support hospitalists as quality improvement experts. Contribute to the “new science” of quality improvement.

• Partner with the Research Committee to define and publish key areas in need of future research related to quality improvement. Advocate to granting agencies to put out RFPs that will help define the ideal hospital stay and support SHM’s research agenda;
• Partner with federal agencies to assess the value of current performance measures and facilitate development of more reliable and meaningful measures;
• Develop trainings for hospitalists on the methods and science of quality improvement research;
• Partner with the Research Committee to develop a research network; and
• Seek money to support demonstration projects that support our quality agenda.

Another goal, to promote development and adoption of health information technology and decision support tools that advance quality and patient safety, recently was discussed by the HQPSC and will be integrated into the next stage of planning.

Next Steps

SHM has an impressive history of working with its members to develop and implement quality initiatives. Our programs have helped reduce rates of venous thromboembolisms, improve glycemic control, and improve the discharge process. Our highly praised online resource rooms provide free tutorials in QI and implementation guides for specific interventions.

More than 250 healthcare professionals have completed our QI pre-course and more than one thousand hospitalists have completed our leadership programs. This momentum, combined with the acceleration of national interest in quality and patient safety, brings an unprecedented opportunity for SHM to advance hospital medicine, promote the highest quality care for our patients, and position hospitalists to be leaders in transforming hospital care.

During the next year, HQPSC will be translating this strategy into specific activities. SHM staff, HQPSC, and other members are developing additional training programs and technical tools.

If you are interested in becoming more involved in SHM’s quality initiatives, please contact me at tbudnitz@hospitalmedicine.org.

If you have a QI success story to share, please consider submission to the Improvement Stories section of the online Resource Rooms or The Hospitalist.

I thank all of you who are part of the “they” who are working tirelessly with SHM to fix “it.” Together we can move mountains, or something more impervious like healthcare systems and performance measures.

Budnitz

Somebody oughta fix that. I’m sure you’ve heard that phrase from friends or relatives lamenting their recent visit to a hospital.

My grandmother will use just about any opportunity to inform me that hospitals make people sicker. I’ve tried to explain that her perspective is skewed. After all, a lot of her friends were pretty sick before they entered the hospital. But “it’s that place” she vows. “They oughta change it.” Fortunately for me, my grandmother still hasn’t figured out what I do professionally, so I’m not considered part of “they.” I let her rant to my husband, since he has the letters MD after his name.

The truth, as you know, is many hospital medicine physicians and their teams are working their tails off trying to improve inpatient care. Much like my grandmother, hospital administrators haven’t identified who the “they” (change agents) are or what exactly the “it” (practices and systems that lead to suboptimal care) is that needs to be changed. It often is unclear how quality improvement initiatives affect the bottom line or which initiatives will ultimately improve outcomes. Today, a considerable amount of improvement efforts depend on the good will and perseverance of a few champions working with minimal institutional support.

The Hospital Quality and Patient Safety Committee (HQPSC) and SHM leadership recently convened a summit to define a vision for the optimal hospital stay and determine how to best train and support hospitalists as leaders and change agents.

The HQPSC and summit participants concluded SHM is, and should be, a national leader in quality improvement efforts including aspects of education, clinical care, and political advocacy for the hospital setting. To that end, the following strategy recently was submitted by the HQPSC and approved by the SHM Board of Directors to promote development of local, regional, and national infrastructures that support quality and patient safety:

Advance a national quality agenda for hospitals and hospitalists.

• Create a task force reporting to the HQPSC that partners with stakeholders to define the “ideal hospital stay” and promote quality improvement;
• Inform federal accrediting and policy-making groups about the effect of current quality measures and changes required to better support the “ideal hospital stay”;
• Advocate for the alignment of reimbursement practices that reward providers and institutions that demonstrate value and translate these practices into improved quality and patient safety;
• Establish an Acute Care Collaborative (ACC) comprising national organizations representing nurses, pharmacists, case managers, social workers, and other allied medical professionals. The ACC might be expanded to include other key physician groups (e.g., emergency physicians, geriatricians, intensivists); and
• Determine what other key national organizations are doing in quality improvement (QI) and look for opportunities for SHM to partner in these efforts.

Develop educational programs and technical support tools for all practicing hospitalists (entry level to QI leaders) engaged in quality improvement efforts.

• Delineate entry-level and advanced quality improvement offerings. Develop offerings specifically for advanced level participants;
• Expand mentored implementation programs to accommodate more participants and assess the need for other types of programs that provide longitudinal support or coaching;
• Expand current offerings, including resource rooms, mentored implementation, and expert training sessions, to other disease states, system processes, and special populations with attention to coordinating this with SHM’s The Core Competencies in Hospital Medicine: A Framework for Curriculum Development;
• Assess the need for new instructional modalities to reach a broader audience (e.g., Web based self-study modules); and
• Promote QI training in medical school, residency, and fellowship programs. Promote systems-based practice and QI throughout the continuum of education. This would include programs that engage medical students, residents, and fellows as well as the development of performance improvement modules (PIMs) for the American Board of Internal Medicine.

Improves the perceived value of implementing and sustaining QI efforts, and hospitalist leadership of those efforts.

• Advocate directly to the C-suites of hospitals to facilitate alignment of incentives that support hospitalists leading quality initiatives;
• Conduct a survey to quantify resources needed for hospitalists to successfully lead quality initiatives and develop safety programs. Develop a white paper based on survey results and distribute it to the C-suite;
• Encourage QI research that creates evidence and outcomes that can influence C-suites to commit adequate resources to QI activities;
• Explore opportunities to use existing local and national infrastructures to promote a more proactive and evidence-based approach to quality and safety rather than reactive and compliance-oriented quality projects; and
• Create a monthly column in The Hospitalist spotlighting QI efforts and assign staff to recruit submissions of “improvement stories” for the Web site.

Evaluate effectiveness of SHM’s current QI resources, educational offerings. SHM needs to assess its current offerings to understand and improve their effectiveness. Process and impact data are needed to obtain external money to create or sustain QI offerings.

• Create robust evaluations and collect better data to assess use and impact of resource rooms, quality precourses, and other SHM offerings.

Promote and support hospitalists as quality improvement experts. Contribute to the “new science” of quality improvement.

• Partner with the Research Committee to define and publish key areas in need of future research related to quality improvement. Advocate to granting agencies to put out RFPs that will help define the ideal hospital stay and support SHM’s research agenda;
• Partner with federal agencies to assess the value of current performance measures and facilitate development of more reliable and meaningful measures;
• Develop trainings for hospitalists on the methods and science of quality improvement research;
• Partner with the Research Committee to develop a research network; and
• Seek money to support demonstration projects that support our quality agenda.

Another goal, to promote development and adoption of health information technology and decision support tools that advance quality and patient safety, recently was discussed by the HQPSC and will be integrated into the next stage of planning.

Next Steps

SHM has an impressive history of working with its members to develop and implement quality initiatives. Our programs have helped reduce rates of venous thromboembolisms, improve glycemic control, and improve the discharge process. Our highly praised online resource rooms provide free tutorials in QI and implementation guides for specific interventions.

More than 250 healthcare professionals have completed our QI pre-course and more than one thousand hospitalists have completed our leadership programs. This momentum, combined with the acceleration of national interest in quality and patient safety, brings an unprecedented opportunity for SHM to advance hospital medicine, promote the highest quality care for our patients, and position hospitalists to be leaders in transforming hospital care.

During the next year, HQPSC will be translating this strategy into specific activities. SHM staff, HQPSC, and other members are developing additional training programs and technical tools.

If you are interested in becoming more involved in SHM’s quality initiatives, please contact me at tbudnitz@hospitalmedicine.org.

If you have a QI success story to share, please consider submission to the Improvement Stories section of the online Resource Rooms or The Hospitalist.

I thank all of you who are part of the “they” who are working tirelessly with SHM to fix “it.” Together we can move mountains, or something more impervious like healthcare systems and performance measures.

Budnitz

Somebody oughta fix that. I’m sure you’ve heard that phrase from friends or relatives lamenting their recent visit to a hospital.

My grandmother will use just about any opportunity to inform me that hospitals make people sicker. I’ve tried to explain that her perspective is skewed. After all, a lot of her friends were pretty sick before they entered the hospital. But “it’s that place” she vows. “They oughta change it.” Fortunately for me, my grandmother still hasn’t figured out what I do professionally, so I’m not considered part of “they.” I let her rant to my husband, since he has the letters MD after his name.

The truth, as you know, is many hospital medicine physicians and their teams are working their tails off trying to improve inpatient care. Much like my grandmother, hospital administrators haven’t identified who the “they” (change agents) are or what exactly the “it” (practices and systems that lead to suboptimal care) is that needs to be changed. It often is unclear how quality improvement initiatives affect the bottom line or which initiatives will ultimately improve outcomes. Today, a considerable amount of improvement efforts depend on the good will and perseverance of a few champions working with minimal institutional support.

The Hospital Quality and Patient Safety Committee (HQPSC) and SHM leadership recently convened a summit to define a vision for the optimal hospital stay and determine how to best train and support hospitalists as leaders and change agents.

The HQPSC and summit participants concluded SHM is, and should be, a national leader in quality improvement efforts including aspects of education, clinical care, and political advocacy for the hospital setting. To that end, the following strategy recently was submitted by the HQPSC and approved by the SHM Board of Directors to promote development of local, regional, and national infrastructures that support quality and patient safety:

Advance a national quality agenda for hospitals and hospitalists.

• Create a task force reporting to the HQPSC that partners with stakeholders to define the “ideal hospital stay” and promote quality improvement;
• Inform federal accrediting and policy-making groups about the effect of current quality measures and changes required to better support the “ideal hospital stay”;
• Advocate for the alignment of reimbursement practices that reward providers and institutions that demonstrate value and translate these practices into improved quality and patient safety;
• Establish an Acute Care Collaborative (ACC) comprising national organizations representing nurses, pharmacists, case managers, social workers, and other allied medical professionals. The ACC might be expanded to include other key physician groups (e.g., emergency physicians, geriatricians, intensivists); and
• Determine what other key national organizations are doing in quality improvement (QI) and look for opportunities for SHM to partner in these efforts.

Develop educational programs and technical support tools for all practicing hospitalists (entry level to QI leaders) engaged in quality improvement efforts.

• Delineate entry-level and advanced quality improvement offerings. Develop offerings specifically for advanced level participants;
• Expand mentored implementation programs to accommodate more participants and assess the need for other types of programs that provide longitudinal support or coaching;
• Expand current offerings, including resource rooms, mentored implementation, and expert training sessions, to other disease states, system processes, and special populations with attention to coordinating this with SHM’s The Core Competencies in Hospital Medicine: A Framework for Curriculum Development;
• Assess the need for new instructional modalities to reach a broader audience (e.g., Web based self-study modules); and
• Promote QI training in medical school, residency, and fellowship programs. Promote systems-based practice and QI throughout the continuum of education. This would include programs that engage medical students, residents, and fellows as well as the development of performance improvement modules (PIMs) for the American Board of Internal Medicine.

Improves the perceived value of implementing and sustaining QI efforts, and hospitalist leadership of those efforts.

• Advocate directly to the C-suites of hospitals to facilitate alignment of incentives that support hospitalists leading quality initiatives;
• Conduct a survey to quantify resources needed for hospitalists to successfully lead quality initiatives and develop safety programs. Develop a white paper based on survey results and distribute it to the C-suite;
• Encourage QI research that creates evidence and outcomes that can influence C-suites to commit adequate resources to QI activities;
• Explore opportunities to use existing local and national infrastructures to promote a more proactive and evidence-based approach to quality and safety rather than reactive and compliance-oriented quality projects; and
• Create a monthly column in The Hospitalist spotlighting QI efforts and assign staff to recruit submissions of “improvement stories” for the Web site.

Evaluate effectiveness of SHM’s current QI resources, educational offerings. SHM needs to assess its current offerings to understand and improve their effectiveness. Process and impact data are needed to obtain external money to create or sustain QI offerings.

• Create robust evaluations and collect better data to assess use and impact of resource rooms, quality precourses, and other SHM offerings.

Promote and support hospitalists as quality improvement experts. Contribute to the “new science” of quality improvement.

• Partner with the Research Committee to define and publish key areas in need of future research related to quality improvement. Advocate to granting agencies to put out RFPs that will help define the ideal hospital stay and support SHM’s research agenda;
• Partner with federal agencies to assess the value of current performance measures and facilitate development of more reliable and meaningful measures;
• Develop trainings for hospitalists on the methods and science of quality improvement research;
• Partner with the Research Committee to develop a research network; and
• Seek money to support demonstration projects that support our quality agenda.

Another goal, to promote development and adoption of health information technology and decision support tools that advance quality and patient safety, recently was discussed by the HQPSC and will be integrated into the next stage of planning.

Next Steps

SHM has an impressive history of working with its members to develop and implement quality initiatives. Our programs have helped reduce rates of venous thromboembolisms, improve glycemic control, and improve the discharge process. Our highly praised online resource rooms provide free tutorials in QI and implementation guides for specific interventions.

More than 250 healthcare professionals have completed our QI pre-course and more than one thousand hospitalists have completed our leadership programs. This momentum, combined with the acceleration of national interest in quality and patient safety, brings an unprecedented opportunity for SHM to advance hospital medicine, promote the highest quality care for our patients, and position hospitalists to be leaders in transforming hospital care.

During the next year, HQPSC will be translating this strategy into specific activities. SHM staff, HQPSC, and other members are developing additional training programs and technical tools.

If you are interested in becoming more involved in SHM’s quality initiatives, please contact me at tbudnitz@hospitalmedicine.org.

If you have a QI success story to share, please consider submission to the Improvement Stories section of the online Resource Rooms or The Hospitalist.

I thank all of you who are part of the “they” who are working tirelessly with SHM to fix “it.” Together we can move mountains, or something more impervious like healthcare systems and performance measures.

The rapidly expanding field of hospital medicine has spurred a growing number of textbooks devoted to the specialty. Textbooks by some of the specialty’s leading voices are available to those keen on honing their knowledge.

Ranging in scope from practice management issues to clinical synopses, titles include:

• “Hospitalists: A Guide to Building and Sustaining a Successful Program” by SHM founders John Nelson, MD, and Win Whitcomb, MD, and Joe Miller, SHM’s executive adviser to the CEO. (Health Administration Press, 2007, $72);
• “Comprehensive Hospital Medicine,” by Mark Williams, MD, chief, division of hospital medicine, Feinberg School of Medicine, Chicago (Elsevier, 2007, $109);
• “Hospital Medicine Secrets,” by The Hospitalist physician editor Jeff Glasheen, MD (Mosby/Elsevier, 2007, $39);
• “Understanding Patient Safety” by Robert Wachter, MD, chief of the Division of Hospital Medicine, and chief of the Medical Service at the University of California, at San Francisco Medical Center, and author of “Wachter’s World,” a blog featured on The Hospitalist Web site (McGraw-Hill, 2007, $35);
• “Hospital Medicine: Just the Facts,” by Sylvia McKean, MD, director, hospitalist service, Brigham and Women’s Hospital, Boston (McGraw-Hill, 2008, $50);
• “First Exposure. Internal Medicine: Hospital Medicine” by Charles Griffith, MD, inpatient internal medicine clerkship director, and Andrew R. Hoellein, MD, outpatient internal medicine clerkship director, Department of Internal Medicine, University of Kentucky, Lexington (McGraw-Hill, 2007, $34); and
• “Tools and Strategies for an Effective Hospitalist Program” by Jeffrey R. Dichter, MD, and Kenneth G. Simone, MD (HCPro, 2008, $299).

SHM’s book

SHM’s offering in the arena reinforces the ideas of “the critical need for leadership of HMGs and the need to create an ownership mentality for hospitalists within an HMG,” Miller says. “The book is filled with examples, tools, and checklists” and has sold approximately 500 copies so far.

The newest text, just off the press in May, is Dr. McKean’s. “This book provides concise, templated information designed to save the clinician valuable time,” she says. It also has a variety of uses, including exam review, clinical reference, point-of-care lookup, [and] quick updates in hospital medicine for those attending on the wards. It covers vital information on issues in administration and management.”

Dr. Wachter wrote his text “because I didn’t see any book for those seeking to learn the key clinical, organizational, and systems issues in patient safety,” he says. “I tried to write it in a lively and accessible style and fill it with illustrative cases and analyses, as well as up-to-date tables, graphics, references, and tools. My goal was to introduce the patient safety field to physicians—particularly hospitalists—nurses, pharmacists, and hospital administrators, as well as to trainees in these fields. [I hope it’s a] go-to book for experienced clinicians and nonclinicians alike.”

Already in its second printing, Dr. Wachter estimates it has sold between 7,500 and 10,000 copies. He plans to update the book every two years and is working on producing some Web-based learning modules. TH

The rapidly expanding field of hospital medicine has spurred a growing number of textbooks devoted to the specialty. Textbooks by some of the specialty’s leading voices are available to those keen on honing their knowledge.

Ranging in scope from practice management issues to clinical synopses, titles include:

• “Hospitalists: A Guide to Building and Sustaining a Successful Program” by SHM founders John Nelson, MD, and Win Whitcomb, MD, and Joe Miller, SHM’s executive adviser to the CEO. (Health Administration Press, 2007, $72);
• “Comprehensive Hospital Medicine,” by Mark Williams, MD, chief, division of hospital medicine, Feinberg School of Medicine, Chicago (Elsevier, 2007, $109);
• “Hospital Medicine Secrets,” by The Hospitalist physician editor Jeff Glasheen, MD (Mosby/Elsevier, 2007, $39);
• “Understanding Patient Safety” by Robert Wachter, MD, chief of the Division of Hospital Medicine, and chief of the Medical Service at the University of California, at San Francisco Medical Center, and author of “Wachter’s World,” a blog featured on The Hospitalist Web site (McGraw-Hill, 2007, $35);
• “Hospital Medicine: Just the Facts,” by Sylvia McKean, MD, director, hospitalist service, Brigham and Women’s Hospital, Boston (McGraw-Hill, 2008, $50);
• “First Exposure. Internal Medicine: Hospital Medicine” by Charles Griffith, MD, inpatient internal medicine clerkship director, and Andrew R. Hoellein, MD, outpatient internal medicine clerkship director, Department of Internal Medicine, University of Kentucky, Lexington (McGraw-Hill, 2007, $34); and
• “Tools and Strategies for an Effective Hospitalist Program” by Jeffrey R. Dichter, MD, and Kenneth G. Simone, MD (HCPro, 2008, $299).

SHM’s book

SHM’s offering in the arena reinforces the ideas of “the critical need for leadership of HMGs and the need to create an ownership mentality for hospitalists within an HMG,” Miller says. “The book is filled with examples, tools, and checklists” and has sold approximately 500 copies so far.

The newest text, just off the press in May, is Dr. McKean’s. “This book provides concise, templated information designed to save the clinician valuable time,” she says. It also has a variety of uses, including exam review, clinical reference, point-of-care lookup, [and] quick updates in hospital medicine for those attending on the wards. It covers vital information on issues in administration and management.”

Dr. Wachter wrote his text “because I didn’t see any book for those seeking to learn the key clinical, organizational, and systems issues in patient safety,” he says. “I tried to write it in a lively and accessible style and fill it with illustrative cases and analyses, as well as up-to-date tables, graphics, references, and tools. My goal was to introduce the patient safety field to physicians—particularly hospitalists—nurses, pharmacists, and hospital administrators, as well as to trainees in these fields. [I hope it’s a] go-to book for experienced clinicians and nonclinicians alike.”

Already in its second printing, Dr. Wachter estimates it has sold between 7,500 and 10,000 copies. He plans to update the book every two years and is working on producing some Web-based learning modules. TH

The rapidly expanding field of hospital medicine has spurred a growing number of textbooks devoted to the specialty. Textbooks by some of the specialty’s leading voices are available to those keen on honing their knowledge.

Ranging in scope from practice management issues to clinical synopses, titles include:

• “Hospitalists: A Guide to Building and Sustaining a Successful Program” by SHM founders John Nelson, MD, and Win Whitcomb, MD, and Joe Miller, SHM’s executive adviser to the CEO. (Health Administration Press, 2007, $72);
• “Comprehensive Hospital Medicine,” by Mark Williams, MD, chief, division of hospital medicine, Feinberg School of Medicine, Chicago (Elsevier, 2007, $109);
• “Hospital Medicine Secrets,” by The Hospitalist physician editor Jeff Glasheen, MD (Mosby/Elsevier, 2007, $39);
• “Understanding Patient Safety” by Robert Wachter, MD, chief of the Division of Hospital Medicine, and chief of the Medical Service at the University of California, at San Francisco Medical Center, and author of “Wachter’s World,” a blog featured on The Hospitalist Web site (McGraw-Hill, 2007, $35);
• “Hospital Medicine: Just the Facts,” by Sylvia McKean, MD, director, hospitalist service, Brigham and Women’s Hospital, Boston (McGraw-Hill, 2008, $50);
• “First Exposure. Internal Medicine: Hospital Medicine” by Charles Griffith, MD, inpatient internal medicine clerkship director, and Andrew R. Hoellein, MD, outpatient internal medicine clerkship director, Department of Internal Medicine, University of Kentucky, Lexington (McGraw-Hill, 2007, $34); and
• “Tools and Strategies for an Effective Hospitalist Program” by Jeffrey R. Dichter, MD, and Kenneth G. Simone, MD (HCPro, 2008, $299).

SHM’s book

SHM’s offering in the arena reinforces the ideas of “the critical need for leadership of HMGs and the need to create an ownership mentality for hospitalists within an HMG,” Miller says. “The book is filled with examples, tools, and checklists” and has sold approximately 500 copies so far.

The newest text, just off the press in May, is Dr. McKean’s. “This book provides concise, templated information designed to save the clinician valuable time,” she says. It also has a variety of uses, including exam review, clinical reference, point-of-care lookup, [and] quick updates in hospital medicine for those attending on the wards. It covers vital information on issues in administration and management.”

Dr. Wachter wrote his text “because I didn’t see any book for those seeking to learn the key clinical, organizational, and systems issues in patient safety,” he says. “I tried to write it in a lively and accessible style and fill it with illustrative cases and analyses, as well as up-to-date tables, graphics, references, and tools. My goal was to introduce the patient safety field to physicians—particularly hospitalists—nurses, pharmacists, and hospital administrators, as well as to trainees in these fields. [I hope it’s a] go-to book for experienced clinicians and nonclinicians alike.”

Already in its second printing, Dr. Wachter estimates it has sold between 7,500 and 10,000 copies. He plans to update the book every two years and is working on producing some Web-based learning modules. TH

It used to be so simple. The relationship between doctors and hospitals was a straightforward quid pro quo.

Hospitals granted privileges to physicians to admit and treat their patients, and the physicians returned the favor by assuming unpaid responsibilities like taking call, providing care to uninsured or emergency patients, and serving on administrative committees.

The hospital was like a friendly club whose members exchanged benefits for duties—a win-win situation. No more.

“You used to be part of a fraternity,” explains Win Whitcomb, MD, director of performance improvement at Mercy Medical Center in Springfield, Mass., and a co-founder of SHM. “There were social rewards. There was opportunity for collegial interchange.”

Economic pressure has taken that all away. “The pace of care has greatly intensified, and the financial reward system has deteriorated significantly,” Dr. Whitcomb continues. “We treat larger numbers of uninsured patients with chronic unmanaged illnesses that require intervention. The reward system for physicians to take call and fulfill their obligation to the hospital no longer matches the responsibility.”

To illustrate the change, Dr. Whitcomb offers an example: “We have some days of the month where the call roster for general surgeries has vacancies. A month ago we had to send a patient to another hospital for an appendectomy.”

It is not an isolated instance. “Every hospital is struggling with the fact that many physicians don’t view unassigned call as a part of membership on the staff; they want to be paid for it,” says SHM President Patrick Cawley, MD, executive medical director of the Medical University of South Carolina (MUSC). And extra “pay” for services that used to be rendered gratis is one thing today’s strapped hospitals can little afford.

Committee staffing is another area undergoing change. Attending physicians are simply declining the duty. Neal Axon, MD, a hospitalist and assistant professor of medicine and pediatrics at MUSC, has seen the transformation firsthand. At one hospital his service covered, he saw the following: “At the first staff meeting there were 50 people; there was food, liquor. It was social and attendance was mandatory. You had to make three or four meetings a year to be on medical staff at this hospital.” But then, he says, attendance waned, and in the last year “dropped off precipitously.”

The old ways don’t work so what will replace them? “The point is that both physicians and hospitals need to put something on the table to collaborate,” Dr. Cawley says. “Many are saying that the hospital-physician relationship needs to change, but everyone is still feeling their way through it. What does it mean?”

SHM’s CEO Larry Wellikson, MD, sees a layered structure ahead. “Clearly the system is evolving into three kinds of physicians who use the hospital,” he says. “We are not advocating for it—just saying what it is. This is what is evolving, and hospital staffs need to see this is coming.” His three kinds of physicians are categorized by their relationship to the hospital.

The home team: “The first group is those physicians who work only at the hospital,” he says. “Their professional life is with the hospital as an institution: hospitalists, ER doctors, critical care physicians, and sometimes the anesthesiologists and radiologists. The hospital is the location of their work and provides the tools to do their job. If the hospital works well, they can do their job well. If hospital is dysfunctional, they can’t work well.”

He describes their relationship to the hospital with an anecdote: “When I was regular physician who came to the hospital just to see my patient, if they couldn’t find the chart I would scream and yell about that one patient.” Every physician faced with a missing chart thinks of it as an individual problem. “But now as a hospitalist, I try to fix the system, because all my patients are affected,” he says. “Hospitalists are on the inside trying to make it work.”

Important visitors: The second group, whom Dr. Wellikson calls important visitors, has a totally different relationship with the hospital. These are the cardiologists, orthopedic surgeons, and other medical specialties. “They are very important,” he says. “But they use the hospital intermittently and are not as tightly connected to it.”

Even so, they desire a high-quality hospital for their patients and will be willing to help set performance standards to achieve it. But their interest may not extend to patients who are not their own. “If the hospital says you have to also take care of free patients, they may choose not to,” Dr. Wellikson notes. “In fact, sometimes they have their own outpatient centers,” making them direct competitors as their competing practices sap revenue from money-making patients and procedures—all the while sending the sickest and costliest patients to the hospital.

Office-based physicians: The last of Dr. Wellikson’s groups is office-based physicians. These are the doctors who once made daily morning and evening rounds of their hospitalized patients but are now infrequently found at the bedside. “They are the physicians who don’t come to the hospital anymore: primary care physicians, endocrinologists, rheumatologists, neurologists, physicians who do all their surgery as outpatient procedures,” Dr. Wellikson explains.

This upheaval is due to tectonic shifts in both medical economics and lifestyle preferences. “Because the reimbursement for care has gone down, physicians have to see more patients to make the same amount of money,” explains Dr. Wellikson. Turning their hospitalized patients over to hospitalists allows office-based physicians to maximize their income and optimize their time.

“It increases satisfaction, limits the hours you spend in the hospital, and puts some boundaries on your work day,” Dr. Cawley says.

“Doctors want more a predictable lifestyle,” Dr. Whitcomb says. In fact, their absence is already a fait accompli in many community hospitals.

As Dr. Axon succinctly puts it: “The primary care doc has left the building.”

Dr. Cawley believes the new system is a relief to many office-based physicians. “Some do miss going to the hospital and seeing other physicians to network with them. Some miss taking care of their acute in-care patients. But I think most are relieved to not have to go to hospital. They say, ‘No, things are better this way.’”

With so many other physicians withdrawing from hospitals to their offices and clinics, Dr. Wellikson believes hospitalists will become increasingly crucial to the institution’s operation and governance. “Now the home team is going to be more active; how you staff, how you make the hospital more efficient,” he says. “The inside physicians will be much more interactive. That’s why hospital medicine has grown so rapidly.”

The explosive expansion of hospital medicine as a specialty is a direct result of the need to increase efficiency and quality standards in this new hospital atmosphere.

In addition, good home teams create a milieu in which other physicians—the important visitors (cardiologists, surgeons, orthopedists)—will want to work. “My job (as a hospitalist) is to create an environment where you can come in and do your surgery,” Dr. Wellikson points out.

The home team offers something else too: medical expertise. Providing post-operative care is not cost-effective for many surgeons. “The surgical specialists are not paid to manage medical issues,” Dr. Cawley says. “It takes time and if somebody else can manage it, that’s great.” That somebody is often a hospitalist. “There is a quality-control aspect as well,” he adds. “With hospitalists focusing on medical issues, the result is better patient care.”

Melding these groups of physicians with disparate interests and responsibilities is the next challenge for hospital leadership. It is a challenge fraught with potential pitfalls. As Dr. Wellikson explains, “The biggest obstacle is that physicians don’t do change very well.”

Administrators will turn to their institution’s hospitalists (both hospital-employed and contracted) to effect these changes and ensure overall standards and efficiency.

“I think hospitalists are in a position to bridge the gap between administrators and medical staff,” says David Yu, MD, medical director of hospitalist services at Decatur Memorial Hospital in Illinois. “I think that’s why there will be more and more hospitalists in leadership positions. That’s why hospitalists are unique: they have their feet in both worlds.”

Dr. Wellikson believes the home team will step up to the plate and take over many of the leadership duties of the new hospital.

Kenneth Patrick, MD, the ICU director of Chestnut Hill Hospital in Philadelphia, sounds a more cautionary note. Dr. Patrick, a trained hospitalist and intensivist, believes the demise of the old “hospital privilege” model is dissolving ties between physicians and their workplace. “I think younger physicians will be much more transient and more concerned with their position, work hours, and pay,” he says.

He sees a young workforce—whether hospital or office-based—as more disengaged than physicians used to be. “They will meet hospital standards, but not be actively involved in developing them,” he believes. That will be left to a small group of hospital-based physicians “who will voluntarily come forward because it is their civic responsibility. It would be nice if more physicians would work on committees, but they look at them like jury duty and they don’t want to serve.”

Dr. Patrick

“The question everyone asks is ‘What’s in it for me?’” Dr. Yu says. He notes a common sticking point: the requirement for increased documentation, which often means more work for doctors. “I think administrators are going to be in shock if they think practitioners are going to line up and say, ‘Well that’s great for the hospital.’”

The key to cooperation, says Dr. Yu, is the linking of changes to mutual benefit and patient welfare: “The administrators have to communicate that in the long run everyone will gain and it will ultimately lead to better patient care. You have to share your vision, inspire, motivate, and develop a culture of providing quality care. It’s easier said than done, but it’s the essence of medical care.”

What about patients? How do they react when a group of strangers takes over their hospital care rather than the primary care physician they often have gotten to know and trust for years? “Wanting your doctor present is counterbalanced by not having your doctor in the house,” Dr. Axon says. “Now you can see a physician anytime during the day.” And most patients are glad for the tradeoff. Dr. Yu has found the same dynamic with his patients at Decatur Memorial Hospital. “I can just count on one hand patients who were not happy the primary care physician wasn’t there,” he says. “Patients are more concerned with having their problems solved than with who is solving them.” And he makes sure his hospitalist staff never undermines the office based physicians. “We always say we are not better physicians, we are just more available.”

While they may have left the hospital, office-based physicians still will be a large presence in it by advocating for their patients. “If my whole currency is, ‘Do I have hospital privileges?’ then all my decisions are based on that,” Dr. Wellikson says.

Armed with the power of their patient referrals, office-based physicians will be able to demand that hospitals show proof of performance—thus becoming their patients’ ombudsmen. “I’m your shopper for the best healthcare, so the hospital has to step up to the plate and make sure it gets the business,” Dr. Wellikson explains. “They want standards because their patients need the best treatment, and they will have a choice of which hospital to put their patients into. If I now have a choice of three hospitals, I am looking to see that you are the Lexus of healthcare for my patients.”

Looking out for their patients’ interests is not the only way office-based physicians will continue to affect hospitals. As in-patient revenue declines, hospitals must look to the outpatient side to make up the difference. “The hospital is lucky if they break even on the inpatient side; they get the vast majority of money on the outpatient side: testing and procedures that private attendings are sending to the hospital,” Dr. Yu says.

He cautions against alienating those private practitioners by forcing change that is not mutually beneficial. “If you alienate them, you might lose money because they can send their patients to a different institution,” he warns. “These are the same doctors that never admit patients but do order the outpatient ultrasounds, blood tests, and therapies that are all money makers for the hospital. Why would you want to alienate these physicians?”

Dr. Patrick agrees: office-based physicians and hospitalists need each other. “I have to work with the primaries,” he says. “They are my source of referrals.”

There is another group that hospitals must learn to court, according to Dr. Axon: its own hospitalists. “I think you will see more innovative solutions to problems of recruiting hospital-based physicians to perform these functions,” he says. “For that to happen, the doctors will need to get more out of it. Many hospitalist groups are in a quandary; they are expected to do all these extra things, but pay is closely liked to clinical production and the number of patients they see. Those incentives will have to be aligned.”

All of which increases the reliance on—and importance of—those physicians who do work in the hospital—the home team. As Dr. Yu puts it: “I think the hospitalist model, whether you like or hate it, is the wave of the future.” TH

Carol Berczuk is a journalist based in New York.

It used to be so simple. The relationship between doctors and hospitals was a straightforward quid pro quo.

Hospitals granted privileges to physicians to admit and treat their patients, and the physicians returned the favor by assuming unpaid responsibilities like taking call, providing care to uninsured or emergency patients, and serving on administrative committees.

The hospital was like a friendly club whose members exchanged benefits for duties—a win-win situation. No more.

“You used to be part of a fraternity,” explains Win Whitcomb, MD, director of performance improvement at Mercy Medical Center in Springfield, Mass., and a co-founder of SHM. “There were social rewards. There was opportunity for collegial interchange.”

Economic pressure has taken that all away. “The pace of care has greatly intensified, and the financial reward system has deteriorated significantly,” Dr. Whitcomb continues. “We treat larger numbers of uninsured patients with chronic unmanaged illnesses that require intervention. The reward system for physicians to take call and fulfill their obligation to the hospital no longer matches the responsibility.”

To illustrate the change, Dr. Whitcomb offers an example: “We have some days of the month where the call roster for general surgeries has vacancies. A month ago we had to send a patient to another hospital for an appendectomy.”

It is not an isolated instance. “Every hospital is struggling with the fact that many physicians don’t view unassigned call as a part of membership on the staff; they want to be paid for it,” says SHM President Patrick Cawley, MD, executive medical director of the Medical University of South Carolina (MUSC). And extra “pay” for services that used to be rendered gratis is one thing today’s strapped hospitals can little afford.

Committee staffing is another area undergoing change. Attending physicians are simply declining the duty. Neal Axon, MD, a hospitalist and assistant professor of medicine and pediatrics at MUSC, has seen the transformation firsthand. At one hospital his service covered, he saw the following: “At the first staff meeting there were 50 people; there was food, liquor. It was social and attendance was mandatory. You had to make three or four meetings a year to be on medical staff at this hospital.” But then, he says, attendance waned, and in the last year “dropped off precipitously.”

The old ways don’t work so what will replace them? “The point is that both physicians and hospitals need to put something on the table to collaborate,” Dr. Cawley says. “Many are saying that the hospital-physician relationship needs to change, but everyone is still feeling their way through it. What does it mean?”

SHM’s CEO Larry Wellikson, MD, sees a layered structure ahead. “Clearly the system is evolving into three kinds of physicians who use the hospital,” he says. “We are not advocating for it—just saying what it is. This is what is evolving, and hospital staffs need to see this is coming.” His three kinds of physicians are categorized by their relationship to the hospital.

The home team: “The first group is those physicians who work only at the hospital,” he says. “Their professional life is with the hospital as an institution: hospitalists, ER doctors, critical care physicians, and sometimes the anesthesiologists and radiologists. The hospital is the location of their work and provides the tools to do their job. If the hospital works well, they can do their job well. If hospital is dysfunctional, they can’t work well.”

He describes their relationship to the hospital with an anecdote: “When I was regular physician who came to the hospital just to see my patient, if they couldn’t find the chart I would scream and yell about that one patient.” Every physician faced with a missing chart thinks of it as an individual problem. “But now as a hospitalist, I try to fix the system, because all my patients are affected,” he says. “Hospitalists are on the inside trying to make it work.”

Important visitors: The second group, whom Dr. Wellikson calls important visitors, has a totally different relationship with the hospital. These are the cardiologists, orthopedic surgeons, and other medical specialties. “They are very important,” he says. “But they use the hospital intermittently and are not as tightly connected to it.”

Even so, they desire a high-quality hospital for their patients and will be willing to help set performance standards to achieve it. But their interest may not extend to patients who are not their own. “If the hospital says you have to also take care of free patients, they may choose not to,” Dr. Wellikson notes. “In fact, sometimes they have their own outpatient centers,” making them direct competitors as their competing practices sap revenue from money-making patients and procedures—all the while sending the sickest and costliest patients to the hospital.

Office-based physicians: The last of Dr. Wellikson’s groups is office-based physicians. These are the doctors who once made daily morning and evening rounds of their hospitalized patients but are now infrequently found at the bedside. “They are the physicians who don’t come to the hospital anymore: primary care physicians, endocrinologists, rheumatologists, neurologists, physicians who do all their surgery as outpatient procedures,” Dr. Wellikson explains.

This upheaval is due to tectonic shifts in both medical economics and lifestyle preferences. “Because the reimbursement for care has gone down, physicians have to see more patients to make the same amount of money,” explains Dr. Wellikson. Turning their hospitalized patients over to hospitalists allows office-based physicians to maximize their income and optimize their time.

“It increases satisfaction, limits the hours you spend in the hospital, and puts some boundaries on your work day,” Dr. Cawley says.

“Doctors want more a predictable lifestyle,” Dr. Whitcomb says. In fact, their absence is already a fait accompli in many community hospitals.

As Dr. Axon succinctly puts it: “The primary care doc has left the building.”

Dr. Cawley believes the new system is a relief to many office-based physicians. “Some do miss going to the hospital and seeing other physicians to network with them. Some miss taking care of their acute in-care patients. But I think most are relieved to not have to go to hospital. They say, ‘No, things are better this way.’”

With so many other physicians withdrawing from hospitals to their offices and clinics, Dr. Wellikson believes hospitalists will become increasingly crucial to the institution’s operation and governance. “Now the home team is going to be more active; how you staff, how you make the hospital more efficient,” he says. “The inside physicians will be much more interactive. That’s why hospital medicine has grown so rapidly.”

The explosive expansion of hospital medicine as a specialty is a direct result of the need to increase efficiency and quality standards in this new hospital atmosphere.

In addition, good home teams create a milieu in which other physicians—the important visitors (cardiologists, surgeons, orthopedists)—will want to work. “My job (as a hospitalist) is to create an environment where you can come in and do your surgery,” Dr. Wellikson points out.

The home team offers something else too: medical expertise. Providing post-operative care is not cost-effective for many surgeons. “The surgical specialists are not paid to manage medical issues,” Dr. Cawley says. “It takes time and if somebody else can manage it, that’s great.” That somebody is often a hospitalist. “There is a quality-control aspect as well,” he adds. “With hospitalists focusing on medical issues, the result is better patient care.”

Melding these groups of physicians with disparate interests and responsibilities is the next challenge for hospital leadership. It is a challenge fraught with potential pitfalls. As Dr. Wellikson explains, “The biggest obstacle is that physicians don’t do change very well.”

Administrators will turn to their institution’s hospitalists (both hospital-employed and contracted) to effect these changes and ensure overall standards and efficiency.

“I think hospitalists are in a position to bridge the gap between administrators and medical staff,” says David Yu, MD, medical director of hospitalist services at Decatur Memorial Hospital in Illinois. “I think that’s why there will be more and more hospitalists in leadership positions. That’s why hospitalists are unique: they have their feet in both worlds.”

Dr. Wellikson believes the home team will step up to the plate and take over many of the leadership duties of the new hospital.

Kenneth Patrick, MD, the ICU director of Chestnut Hill Hospital in Philadelphia, sounds a more cautionary note. Dr. Patrick, a trained hospitalist and intensivist, believes the demise of the old “hospital privilege” model is dissolving ties between physicians and their workplace. “I think younger physicians will be much more transient and more concerned with their position, work hours, and pay,” he says.

He sees a young workforce—whether hospital or office-based—as more disengaged than physicians used to be. “They will meet hospital standards, but not be actively involved in developing them,” he believes. That will be left to a small group of hospital-based physicians “who will voluntarily come forward because it is their civic responsibility. It would be nice if more physicians would work on committees, but they look at them like jury duty and they don’t want to serve.”

Dr. Patrick

“The question everyone asks is ‘What’s in it for me?’” Dr. Yu says. He notes a common sticking point: the requirement for increased documentation, which often means more work for doctors. “I think administrators are going to be in shock if they think practitioners are going to line up and say, ‘Well that’s great for the hospital.’”

The key to cooperation, says Dr. Yu, is the linking of changes to mutual benefit and patient welfare: “The administrators have to communicate that in the long run everyone will gain and it will ultimately lead to better patient care. You have to share your vision, inspire, motivate, and develop a culture of providing quality care. It’s easier said than done, but it’s the essence of medical care.”

What about patients? How do they react when a group of strangers takes over their hospital care rather than the primary care physician they often have gotten to know and trust for years? “Wanting your doctor present is counterbalanced by not having your doctor in the house,” Dr. Axon says. “Now you can see a physician anytime during the day.” And most patients are glad for the tradeoff. Dr. Yu has found the same dynamic with his patients at Decatur Memorial Hospital. “I can just count on one hand patients who were not happy the primary care physician wasn’t there,” he says. “Patients are more concerned with having their problems solved than with who is solving them.” And he makes sure his hospitalist staff never undermines the office based physicians. “We always say we are not better physicians, we are just more available.”

While they may have left the hospital, office-based physicians still will be a large presence in it by advocating for their patients. “If my whole currency is, ‘Do I have hospital privileges?’ then all my decisions are based on that,” Dr. Wellikson says.

Armed with the power of their patient referrals, office-based physicians will be able to demand that hospitals show proof of performance—thus becoming their patients’ ombudsmen. “I’m your shopper for the best healthcare, so the hospital has to step up to the plate and make sure it gets the business,” Dr. Wellikson explains. “They want standards because their patients need the best treatment, and they will have a choice of which hospital to put their patients into. If I now have a choice of three hospitals, I am looking to see that you are the Lexus of healthcare for my patients.”

Looking out for their patients’ interests is not the only way office-based physicians will continue to affect hospitals. As in-patient revenue declines, hospitals must look to the outpatient side to make up the difference. “The hospital is lucky if they break even on the inpatient side; they get the vast majority of money on the outpatient side: testing and procedures that private attendings are sending to the hospital,” Dr. Yu says.

He cautions against alienating those private practitioners by forcing change that is not mutually beneficial. “If you alienate them, you might lose money because they can send their patients to a different institution,” he warns. “These are the same doctors that never admit patients but do order the outpatient ultrasounds, blood tests, and therapies that are all money makers for the hospital. Why would you want to alienate these physicians?”

Dr. Patrick agrees: office-based physicians and hospitalists need each other. “I have to work with the primaries,” he says. “They are my source of referrals.”

There is another group that hospitals must learn to court, according to Dr. Axon: its own hospitalists. “I think you will see more innovative solutions to problems of recruiting hospital-based physicians to perform these functions,” he says. “For that to happen, the doctors will need to get more out of it. Many hospitalist groups are in a quandary; they are expected to do all these extra things, but pay is closely liked to clinical production and the number of patients they see. Those incentives will have to be aligned.”

All of which increases the reliance on—and importance of—those physicians who do work in the hospital—the home team. As Dr. Yu puts it: “I think the hospitalist model, whether you like or hate it, is the wave of the future.” TH

Carol Berczuk is a journalist based in New York.

It used to be so simple. The relationship between doctors and hospitals was a straightforward quid pro quo.

Hospitals granted privileges to physicians to admit and treat their patients, and the physicians returned the favor by assuming unpaid responsibilities like taking call, providing care to uninsured or emergency patients, and serving on administrative committees.

The hospital was like a friendly club whose members exchanged benefits for duties—a win-win situation. No more.

“You used to be part of a fraternity,” explains Win Whitcomb, MD, director of performance improvement at Mercy Medical Center in Springfield, Mass., and a co-founder of SHM. “There were social rewards. There was opportunity for collegial interchange.”

Economic pressure has taken that all away. “The pace of care has greatly intensified, and the financial reward system has deteriorated significantly,” Dr. Whitcomb continues. “We treat larger numbers of uninsured patients with chronic unmanaged illnesses that require intervention. The reward system for physicians to take call and fulfill their obligation to the hospital no longer matches the responsibility.”

To illustrate the change, Dr. Whitcomb offers an example: “We have some days of the month where the call roster for general surgeries has vacancies. A month ago we had to send a patient to another hospital for an appendectomy.”

It is not an isolated instance. “Every hospital is struggling with the fact that many physicians don’t view unassigned call as a part of membership on the staff; they want to be paid for it,” says SHM President Patrick Cawley, MD, executive medical director of the Medical University of South Carolina (MUSC). And extra “pay” for services that used to be rendered gratis is one thing today’s strapped hospitals can little afford.

Committee staffing is another area undergoing change. Attending physicians are simply declining the duty. Neal Axon, MD, a hospitalist and assistant professor of medicine and pediatrics at MUSC, has seen the transformation firsthand. At one hospital his service covered, he saw the following: “At the first staff meeting there were 50 people; there was food, liquor. It was social and attendance was mandatory. You had to make three or four meetings a year to be on medical staff at this hospital.” But then, he says, attendance waned, and in the last year “dropped off precipitously.”

The old ways don’t work so what will replace them? “The point is that both physicians and hospitals need to put something on the table to collaborate,” Dr. Cawley says. “Many are saying that the hospital-physician relationship needs to change, but everyone is still feeling their way through it. What does it mean?”

SHM’s CEO Larry Wellikson, MD, sees a layered structure ahead. “Clearly the system is evolving into three kinds of physicians who use the hospital,” he says. “We are not advocating for it—just saying what it is. This is what is evolving, and hospital staffs need to see this is coming.” His three kinds of physicians are categorized by their relationship to the hospital.

The home team: “The first group is those physicians who work only at the hospital,” he says. “Their professional life is with the hospital as an institution: hospitalists, ER doctors, critical care physicians, and sometimes the anesthesiologists and radiologists. The hospital is the location of their work and provides the tools to do their job. If the hospital works well, they can do their job well. If hospital is dysfunctional, they can’t work well.”

He describes their relationship to the hospital with an anecdote: “When I was regular physician who came to the hospital just to see my patient, if they couldn’t find the chart I would scream and yell about that one patient.” Every physician faced with a missing chart thinks of it as an individual problem. “But now as a hospitalist, I try to fix the system, because all my patients are affected,” he says. “Hospitalists are on the inside trying to make it work.”

Important visitors: The second group, whom Dr. Wellikson calls important visitors, has a totally different relationship with the hospital. These are the cardiologists, orthopedic surgeons, and other medical specialties. “They are very important,” he says. “But they use the hospital intermittently and are not as tightly connected to it.”

Even so, they desire a high-quality hospital for their patients and will be willing to help set performance standards to achieve it. But their interest may not extend to patients who are not their own. “If the hospital says you have to also take care of free patients, they may choose not to,” Dr. Wellikson notes. “In fact, sometimes they have their own outpatient centers,” making them direct competitors as their competing practices sap revenue from money-making patients and procedures—all the while sending the sickest and costliest patients to the hospital.

Office-based physicians: The last of Dr. Wellikson’s groups is office-based physicians. These are the doctors who once made daily morning and evening rounds of their hospitalized patients but are now infrequently found at the bedside. “They are the physicians who don’t come to the hospital anymore: primary care physicians, endocrinologists, rheumatologists, neurologists, physicians who do all their surgery as outpatient procedures,” Dr. Wellikson explains.

This upheaval is due to tectonic shifts in both medical economics and lifestyle preferences. “Because the reimbursement for care has gone down, physicians have to see more patients to make the same amount of money,” explains Dr. Wellikson. Turning their hospitalized patients over to hospitalists allows office-based physicians to maximize their income and optimize their time.

“It increases satisfaction, limits the hours you spend in the hospital, and puts some boundaries on your work day,” Dr. Cawley says.

“Doctors want more a predictable lifestyle,” Dr. Whitcomb says. In fact, their absence is already a fait accompli in many community hospitals.

As Dr. Axon succinctly puts it: “The primary care doc has left the building.”

Dr. Cawley believes the new system is a relief to many office-based physicians. “Some do miss going to the hospital and seeing other physicians to network with them. Some miss taking care of their acute in-care patients. But I think most are relieved to not have to go to hospital. They say, ‘No, things are better this way.’”

With so many other physicians withdrawing from hospitals to their offices and clinics, Dr. Wellikson believes hospitalists will become increasingly crucial to the institution’s operation and governance. “Now the home team is going to be more active; how you staff, how you make the hospital more efficient,” he says. “The inside physicians will be much more interactive. That’s why hospital medicine has grown so rapidly.”

The explosive expansion of hospital medicine as a specialty is a direct result of the need to increase efficiency and quality standards in this new hospital atmosphere.

In addition, good home teams create a milieu in which other physicians—the important visitors (cardiologists, surgeons, orthopedists)—will want to work. “My job (as a hospitalist) is to create an environment where you can come in and do your surgery,” Dr. Wellikson points out.

The home team offers something else too: medical expertise. Providing post-operative care is not cost-effective for many surgeons. “The surgical specialists are not paid to manage medical issues,” Dr. Cawley says. “It takes time and if somebody else can manage it, that’s great.” That somebody is often a hospitalist. “There is a quality-control aspect as well,” he adds. “With hospitalists focusing on medical issues, the result is better patient care.”

Melding these groups of physicians with disparate interests and responsibilities is the next challenge for hospital leadership. It is a challenge fraught with potential pitfalls. As Dr. Wellikson explains, “The biggest obstacle is that physicians don’t do change very well.”

Administrators will turn to their institution’s hospitalists (both hospital-employed and contracted) to effect these changes and ensure overall standards and efficiency.

“I think hospitalists are in a position to bridge the gap between administrators and medical staff,” says David Yu, MD, medical director of hospitalist services at Decatur Memorial Hospital in Illinois. “I think that’s why there will be more and more hospitalists in leadership positions. That’s why hospitalists are unique: they have their feet in both worlds.”

Dr. Wellikson believes the home team will step up to the plate and take over many of the leadership duties of the new hospital.

Kenneth Patrick, MD, the ICU director of Chestnut Hill Hospital in Philadelphia, sounds a more cautionary note. Dr. Patrick, a trained hospitalist and intensivist, believes the demise of the old “hospital privilege” model is dissolving ties between physicians and their workplace. “I think younger physicians will be much more transient and more concerned with their position, work hours, and pay,” he says.

He sees a young workforce—whether hospital or office-based—as more disengaged than physicians used to be. “They will meet hospital standards, but not be actively involved in developing them,” he believes. That will be left to a small group of hospital-based physicians “who will voluntarily come forward because it is their civic responsibility. It would be nice if more physicians would work on committees, but they look at them like jury duty and they don’t want to serve.”

Dr. Patrick

“The question everyone asks is ‘What’s in it for me?’” Dr. Yu says. He notes a common sticking point: the requirement for increased documentation, which often means more work for doctors. “I think administrators are going to be in shock if they think practitioners are going to line up and say, ‘Well that’s great for the hospital.’”

The key to cooperation, says Dr. Yu, is the linking of changes to mutual benefit and patient welfare: “The administrators have to communicate that in the long run everyone will gain and it will ultimately lead to better patient care. You have to share your vision, inspire, motivate, and develop a culture of providing quality care. It’s easier said than done, but it’s the essence of medical care.”

What about patients? How do they react when a group of strangers takes over their hospital care rather than the primary care physician they often have gotten to know and trust for years? “Wanting your doctor present is counterbalanced by not having your doctor in the house,” Dr. Axon says. “Now you can see a physician anytime during the day.” And most patients are glad for the tradeoff. Dr. Yu has found the same dynamic with his patients at Decatur Memorial Hospital. “I can just count on one hand patients who were not happy the primary care physician wasn’t there,” he says. “Patients are more concerned with having their problems solved than with who is solving them.” And he makes sure his hospitalist staff never undermines the office based physicians. “We always say we are not better physicians, we are just more available.”

While they may have left the hospital, office-based physicians still will be a large presence in it by advocating for their patients. “If my whole currency is, ‘Do I have hospital privileges?’ then all my decisions are based on that,” Dr. Wellikson says.

Armed with the power of their patient referrals, office-based physicians will be able to demand that hospitals show proof of performance—thus becoming their patients’ ombudsmen. “I’m your shopper for the best healthcare, so the hospital has to step up to the plate and make sure it gets the business,” Dr. Wellikson explains. “They want standards because their patients need the best treatment, and they will have a choice of which hospital to put their patients into. If I now have a choice of three hospitals, I am looking to see that you are the Lexus of healthcare for my patients.”

Looking out for their patients’ interests is not the only way office-based physicians will continue to affect hospitals. As in-patient revenue declines, hospitals must look to the outpatient side to make up the difference. “The hospital is lucky if they break even on the inpatient side; they get the vast majority of money on the outpatient side: testing and procedures that private attendings are sending to the hospital,” Dr. Yu says.

He cautions against alienating those private practitioners by forcing change that is not mutually beneficial. “If you alienate them, you might lose money because they can send their patients to a different institution,” he warns. “These are the same doctors that never admit patients but do order the outpatient ultrasounds, blood tests, and therapies that are all money makers for the hospital. Why would you want to alienate these physicians?”

Dr. Patrick agrees: office-based physicians and hospitalists need each other. “I have to work with the primaries,” he says. “They are my source of referrals.”

There is another group that hospitals must learn to court, according to Dr. Axon: its own hospitalists. “I think you will see more innovative solutions to problems of recruiting hospital-based physicians to perform these functions,” he says. “For that to happen, the doctors will need to get more out of it. Many hospitalist groups are in a quandary; they are expected to do all these extra things, but pay is closely liked to clinical production and the number of patients they see. Those incentives will have to be aligned.”

All of which increases the reliance on—and importance of—those physicians who do work in the hospital—the home team. As Dr. Yu puts it: “I think the hospitalist model, whether you like or hate it, is the wave of the future.” TH

Carol Berczuk is a journalist based in New York.

Hospitalist Nhi Lan Pham, MD, accepted a signing/starting bonus to relocate to Texas after finishing her residency in internal medicine in the Detroit area in 2007. The accompanying relocation expenses helped Dr. Pham begin her career near her family in Austin, and the flexible work schedule she negotiated allowed her to spend time with her family.

Another hospitalist willing to relocate for the right job used the relocation budget to his advantage. Moving to take the right job cost $2,000. The employer had budgeted $5,000 for relocation expenses, and the physician was able to arrange to have the $3,000 difference added to his signing bonus.

Yet another physician, already established as a hospitalist in an underserved area of his state, was attracted to a new position. However, his original acceptance of a loan repayment from the state as an inducement to work in the underserved region precluded his applying for the new position. His arrangement with the state did not prevent his approaching the new hospital to see what might be possible. It was a wise move; the new hospital agreed to increase the hospitalist’s signing bonus by enough to reimburse the state for the loan repayment.

One foreign-born physician secured a commitment from his recruiter that his employer would sponsor him and his family for green cards. Another candidate agreed to a reduced starting salary in return for help in securing a visa.

With a projected need for 30,000 hospitalists by 2010, hospitalists find themselves in the driver’s seat when it comes to weighing offers. Incentives are increasingly enticing as hospitalist recruiters nationwide struggle to lure top talent.

Incentives, Perks

What does this mean in practical terms? It means not only rising salaries but also incentives and extra perks to attract candidates to this fast-growing specialty.

Financial benefits are widespread, including signing and performance bonuses. Many hospitalists can plan on a guaranteed income. Employers may agree to pay off student loans or reimburse tuition. Malpractice insurance and tail coverage are commonly covered. Some employers also allow part-time or temporary employment to give a new hospitalist an opportunity to decide about the future or to accommodate a personal schedule.

“There is often a laundry list of incentives from which to choose, as well as more of a cafeteria plan that a doctor and employer can customize to meet specific needs,” according to Mark Dotson, MD, senior director of recruitment at Brentwood, Tenn.-based Cogent Healthcare. Cogent is a recruiting firm dedicated to building and managing hospitalist programs.

By far, the most appealing incentives are flexibility of scheduling and workload that allow physicians to coordinate their work schedule with their lifestyle. In fact, Dan Polk, MD, chief of the division of hospital-based medicine at Children’s Memorial Hospital in Chicago, considers flexible scheduling the basis of his plan to retain staff and build job satisfaction.

“We support lifestyle choices and respect life situations,” Dr. Polk says. “We foster the idea of joining a great team, and we make the environment attractive enough to encourage people to stay. We try to work within the team to cover those who need help, such as maternity or family leave, and we compensate for extra time at a different rate. We embrace people who want to work part time or share a job. Our goals are to support people and to make them want to get up in the morning to come to work.”

Part of the attractiveness of schedule flexibility is fewer weekend and night hours. In addition, employers may allow hospitalists to limit their caseload. Some hospitalists, for example, request a cap of 15 to 18 patients a day.

While retaining experienced, motivated staff is a goal of hospitals, lower caseloads mean “more doctors to do the work if doctors work fewer hours,” says Rusty Holman, MD, Cogent’s chief operating officer and SHM’s immediate past president. To meet that need, hospitals are turning to community-based physicians, fellows, and residents to work weekends and evenings. This, in turn, offers the perk of part-time work for those who want more personal time in their schedule.

The demand for nocturnists also is growing (The Hospitalist, January 2008, p. 22). Nocturnists work at night and on weekends and usually work shorter hours. These physicians prefer this schedule so they can have their days free for family or other pursuits. They also enjoy higher compensation, fewer workdays per month, and lower productivity expectations.

In addition to the having the options of part-time hours, temporary work, or job sharing, hospitalists also can negotiate other schedule perks. Some request and receive a two-week-on, two-week-off schedule. Many ask about the shift model, which demands nothing beyond the full eight or 12 hours of work. Still other applicants find a swing shift fits their lifestyle. There are even short-term choices: the hospitalist program at the University of California at Irvine offers recent residents the opportunity to work for one year while deciding about their career. With scheduling choices as part of an incentive package, many hospitalists achieve Dr. Polk’s goal of being eager to come to work each morning.

Physicians are not the only beneficiaries of these perks. Cogent, for example, recruits physician assistants and nurse practitioners when forming hospitalist groups. These employees also enjoy incentives, including tuition for continuing education and the same schedule flexibility as hospitalists.

Seller’s Market

Hospital medicine faces a shortage of qualified applicants. The need for hospitalists far surpasses the supply of physicians, who are in the enviable position of sifting through incentives and perks when selecting a hospitalist job.

This has become a national concern, according to Vikas Parekh, MD, assistant director of the hospitalist program and assistant professor of medicine at the University of Michigan Health Center in Ann Arbor. “We’re not seeing a pool of applicants because top residents are not pursuing hospitalist careers,” Dr. Parekh says.

Alpesh Amin, MD, MBA, a member of SHM’s Board of Directors, concurs but also points out that the number of hospitalist jobs is growing. “The need for a few hundred hospitalists 10 years ago has grown to 20,000 to 30,000 today, thus creating a need much greater than the supply,” says Dr. Amin, professor and chief, general internal medicine, executive director and founder of the hospitalist program at the University of California Irvine.

Why the shortage? First, fewer physicians are choosing to practice general medicine, either as an internist, family practitioner, or hospitalist. A recent study found fewer medical students were planning to concentrate on internal and family medicine, and that those who did planned to go into a subspecialty later.1 Dr. Parekh attributes this to a combination of reasons. “Most internal medicine residents are subspecialty oriented and may have decided their specialty early on,” Dr. Parekh says. “They may choose a subspecialty for financial reasons or prestige,” he continues, “but they may also be unclear about what a hospitalist career really is.”

Second, hospitalist programs have begun to expand from large metropolitan regions to smaller and rural areas. The result is an even greater demand for hospitalists.

Meet the Need

“There are no saturated markets within hospital medicine,” Dr. Holman says. “That is, most groups are always actively recruiting. [Cogent develops] full hospitalist programs, including recruiting, employing, managing, and training for new and existing hospitalist groups.”

Who is being recruited? Many recruiters approach residents who have not chosen a subspecialty to offer a staff position after they finish the residency. Although a recruiting firm may not offer financial aid during the residency, an employer may provide some sort of stipend if the candidate commits to remain on staff for a specified time after residency. “Recruit and retain” is the operative phrase in these cases.

Recruiters also are approaching generalists just entering the market to point out the advantages of avoiding the startup costs of establishing an outpatient practice. Further, many hospitalists are emerging from the ranks of solo practitioners interested in the financial and personal advantages of belonging to hospitalist groups. Not only does that eliminate the practice overhead (including the burden of regulatory compliance), but it also may offer additional administrative and academic opportunities. As Dr. Amin says, “There are more MD-MBA combos out there.”

Are incentives the answer to the shortage? Perhaps for now. With time, hospital medicine’s built-in perks may end the shortage and the need for added incentives. TH

Ann Kepler is a medical writer based in Chicago.

Reference

1. Croasdale M. Primary care doctors in demand; signing bonuses and higher pay for some. American Medical News. June 19, 2006. Available at www.ama-assn.org/amednews/site/free/prl10619.htm. Last accessed March 19, 2008.

Hospitalist Nhi Lan Pham, MD, accepted a signing/starting bonus to relocate to Texas after finishing her residency in internal medicine in the Detroit area in 2007. The accompanying relocation expenses helped Dr. Pham begin her career near her family in Austin, and the flexible work schedule she negotiated allowed her to spend time with her family.

Another hospitalist willing to relocate for the right job used the relocation budget to his advantage. Moving to take the right job cost $2,000. The employer had budgeted $5,000 for relocation expenses, and the physician was able to arrange to have the $3,000 difference added to his signing bonus.

Yet another physician, already established as a hospitalist in an underserved area of his state, was attracted to a new position. However, his original acceptance of a loan repayment from the state as an inducement to work in the underserved region precluded his applying for the new position. His arrangement with the state did not prevent his approaching the new hospital to see what might be possible. It was a wise move; the new hospital agreed to increase the hospitalist’s signing bonus by enough to reimburse the state for the loan repayment.

One foreign-born physician secured a commitment from his recruiter that his employer would sponsor him and his family for green cards. Another candidate agreed to a reduced starting salary in return for help in securing a visa.

With a projected need for 30,000 hospitalists by 2010, hospitalists find themselves in the driver’s seat when it comes to weighing offers. Incentives are increasingly enticing as hospitalist recruiters nationwide struggle to lure top talent.

Incentives, Perks

What does this mean in practical terms? It means not only rising salaries but also incentives and extra perks to attract candidates to this fast-growing specialty.

Financial benefits are widespread, including signing and performance bonuses. Many hospitalists can plan on a guaranteed income. Employers may agree to pay off student loans or reimburse tuition. Malpractice insurance and tail coverage are commonly covered. Some employers also allow part-time or temporary employment to give a new hospitalist an opportunity to decide about the future or to accommodate a personal schedule.

“There is often a laundry list of incentives from which to choose, as well as more of a cafeteria plan that a doctor and employer can customize to meet specific needs,” according to Mark Dotson, MD, senior director of recruitment at Brentwood, Tenn.-based Cogent Healthcare. Cogent is a recruiting firm dedicated to building and managing hospitalist programs.

By far, the most appealing incentives are flexibility of scheduling and workload that allow physicians to coordinate their work schedule with their lifestyle. In fact, Dan Polk, MD, chief of the division of hospital-based medicine at Children’s Memorial Hospital in Chicago, considers flexible scheduling the basis of his plan to retain staff and build job satisfaction.

“We support lifestyle choices and respect life situations,” Dr. Polk says. “We foster the idea of joining a great team, and we make the environment attractive enough to encourage people to stay. We try to work within the team to cover those who need help, such as maternity or family leave, and we compensate for extra time at a different rate. We embrace people who want to work part time or share a job. Our goals are to support people and to make them want to get up in the morning to come to work.”

Part of the attractiveness of schedule flexibility is fewer weekend and night hours. In addition, employers may allow hospitalists to limit their caseload. Some hospitalists, for example, request a cap of 15 to 18 patients a day.

While retaining experienced, motivated staff is a goal of hospitals, lower caseloads mean “more doctors to do the work if doctors work fewer hours,” says Rusty Holman, MD, Cogent’s chief operating officer and SHM’s immediate past president. To meet that need, hospitals are turning to community-based physicians, fellows, and residents to work weekends and evenings. This, in turn, offers the perk of part-time work for those who want more personal time in their schedule.

The demand for nocturnists also is growing (The Hospitalist, January 2008, p. 22). Nocturnists work at night and on weekends and usually work shorter hours. These physicians prefer this schedule so they can have their days free for family or other pursuits. They also enjoy higher compensation, fewer workdays per month, and lower productivity expectations.

In addition to the having the options of part-time hours, temporary work, or job sharing, hospitalists also can negotiate other schedule perks. Some request and receive a two-week-on, two-week-off schedule. Many ask about the shift model, which demands nothing beyond the full eight or 12 hours of work. Still other applicants find a swing shift fits their lifestyle. There are even short-term choices: the hospitalist program at the University of California at Irvine offers recent residents the opportunity to work for one year while deciding about their career. With scheduling choices as part of an incentive package, many hospitalists achieve Dr. Polk’s goal of being eager to come to work each morning.

Physicians are not the only beneficiaries of these perks. Cogent, for example, recruits physician assistants and nurse practitioners when forming hospitalist groups. These employees also enjoy incentives, including tuition for continuing education and the same schedule flexibility as hospitalists.

Seller’s Market

Hospital medicine faces a shortage of qualified applicants. The need for hospitalists far surpasses the supply of physicians, who are in the enviable position of sifting through incentives and perks when selecting a hospitalist job.

This has become a national concern, according to Vikas Parekh, MD, assistant director of the hospitalist program and assistant professor of medicine at the University of Michigan Health Center in Ann Arbor. “We’re not seeing a pool of applicants because top residents are not pursuing hospitalist careers,” Dr. Parekh says.

Alpesh Amin, MD, MBA, a member of SHM’s Board of Directors, concurs but also points out that the number of hospitalist jobs is growing. “The need for a few hundred hospitalists 10 years ago has grown to 20,000 to 30,000 today, thus creating a need much greater than the supply,” says Dr. Amin, professor and chief, general internal medicine, executive director and founder of the hospitalist program at the University of California Irvine.

Why the shortage? First, fewer physicians are choosing to practice general medicine, either as an internist, family practitioner, or hospitalist. A recent study found fewer medical students were planning to concentrate on internal and family medicine, and that those who did planned to go into a subspecialty later.1 Dr. Parekh attributes this to a combination of reasons. “Most internal medicine residents are subspecialty oriented and may have decided their specialty early on,” Dr. Parekh says. “They may choose a subspecialty for financial reasons or prestige,” he continues, “but they may also be unclear about what a hospitalist career really is.”

Second, hospitalist programs have begun to expand from large metropolitan regions to smaller and rural areas. The result is an even greater demand for hospitalists.

Meet the Need

“There are no saturated markets within hospital medicine,” Dr. Holman says. “That is, most groups are always actively recruiting. [Cogent develops] full hospitalist programs, including recruiting, employing, managing, and training for new and existing hospitalist groups.”

Who is being recruited? Many recruiters approach residents who have not chosen a subspecialty to offer a staff position after they finish the residency. Although a recruiting firm may not offer financial aid during the residency, an employer may provide some sort of stipend if the candidate commits to remain on staff for a specified time after residency. “Recruit and retain” is the operative phrase in these cases.

Recruiters also are approaching generalists just entering the market to point out the advantages of avoiding the startup costs of establishing an outpatient practice. Further, many hospitalists are emerging from the ranks of solo practitioners interested in the financial and personal advantages of belonging to hospitalist groups. Not only does that eliminate the practice overhead (including the burden of regulatory compliance), but it also may offer additional administrative and academic opportunities. As Dr. Amin says, “There are more MD-MBA combos out there.”

Are incentives the answer to the shortage? Perhaps for now. With time, hospital medicine’s built-in perks may end the shortage and the need for added incentives. TH

Ann Kepler is a medical writer based in Chicago.

Reference

1. Croasdale M. Primary care doctors in demand; signing bonuses and higher pay for some. American Medical News. June 19, 2006. Available at www.ama-assn.org/amednews/site/free/prl10619.htm. Last accessed March 19, 2008.

Hospitalist Nhi Lan Pham, MD, accepted a signing/starting bonus to relocate to Texas after finishing her residency in internal medicine in the Detroit area in 2007. The accompanying relocation expenses helped Dr. Pham begin her career near her family in Austin, and the flexible work schedule she negotiated allowed her to spend time with her family.

Another hospitalist willing to relocate for the right job used the relocation budget to his advantage. Moving to take the right job cost $2,000. The employer had budgeted $5,000 for relocation expenses, and the physician was able to arrange to have the $3,000 difference added to his signing bonus.

Yet another physician, already established as a hospitalist in an underserved area of his state, was attracted to a new position. However, his original acceptance of a loan repayment from the state as an inducement to work in the underserved region precluded his applying for the new position. His arrangement with the state did not prevent his approaching the new hospital to see what might be possible. It was a wise move; the new hospital agreed to increase the hospitalist’s signing bonus by enough to reimburse the state for the loan repayment.

One foreign-born physician secured a commitment from his recruiter that his employer would sponsor him and his family for green cards. Another candidate agreed to a reduced starting salary in return for help in securing a visa.

With a projected need for 30,000 hospitalists by 2010, hospitalists find themselves in the driver’s seat when it comes to weighing offers. Incentives are increasingly enticing as hospitalist recruiters nationwide struggle to lure top talent.

Incentives, Perks

What does this mean in practical terms? It means not only rising salaries but also incentives and extra perks to attract candidates to this fast-growing specialty.

Financial benefits are widespread, including signing and performance bonuses. Many hospitalists can plan on a guaranteed income. Employers may agree to pay off student loans or reimburse tuition. Malpractice insurance and tail coverage are commonly covered. Some employers also allow part-time or temporary employment to give a new hospitalist an opportunity to decide about the future or to accommodate a personal schedule.

“There is often a laundry list of incentives from which to choose, as well as more of a cafeteria plan that a doctor and employer can customize to meet specific needs,” according to Mark Dotson, MD, senior director of recruitment at Brentwood, Tenn.-based Cogent Healthcare. Cogent is a recruiting firm dedicated to building and managing hospitalist programs.

By far, the most appealing incentives are flexibility of scheduling and workload that allow physicians to coordinate their work schedule with their lifestyle. In fact, Dan Polk, MD, chief of the division of hospital-based medicine at Children’s Memorial Hospital in Chicago, considers flexible scheduling the basis of his plan to retain staff and build job satisfaction.

“We support lifestyle choices and respect life situations,” Dr. Polk says. “We foster the idea of joining a great team, and we make the environment attractive enough to encourage people to stay. We try to work within the team to cover those who need help, such as maternity or family leave, and we compensate for extra time at a different rate. We embrace people who want to work part time or share a job. Our goals are to support people and to make them want to get up in the morning to come to work.”

Part of the attractiveness of schedule flexibility is fewer weekend and night hours. In addition, employers may allow hospitalists to limit their caseload. Some hospitalists, for example, request a cap of 15 to 18 patients a day.

While retaining experienced, motivated staff is a goal of hospitals, lower caseloads mean “more doctors to do the work if doctors work fewer hours,” says Rusty Holman, MD, Cogent’s chief operating officer and SHM’s immediate past president. To meet that need, hospitals are turning to community-based physicians, fellows, and residents to work weekends and evenings. This, in turn, offers the perk of part-time work for those who want more personal time in their schedule.

The demand for nocturnists also is growing (The Hospitalist, January 2008, p. 22). Nocturnists work at night and on weekends and usually work shorter hours. These physicians prefer this schedule so they can have their days free for family or other pursuits. They also enjoy higher compensation, fewer workdays per month, and lower productivity expectations.

In addition to the having the options of part-time hours, temporary work, or job sharing, hospitalists also can negotiate other schedule perks. Some request and receive a two-week-on, two-week-off schedule. Many ask about the shift model, which demands nothing beyond the full eight or 12 hours of work. Still other applicants find a swing shift fits their lifestyle. There are even short-term choices: the hospitalist program at the University of California at Irvine offers recent residents the opportunity to work for one year while deciding about their career. With scheduling choices as part of an incentive package, many hospitalists achieve Dr. Polk’s goal of being eager to come to work each morning.

Physicians are not the only beneficiaries of these perks. Cogent, for example, recruits physician assistants and nurse practitioners when forming hospitalist groups. These employees also enjoy incentives, including tuition for continuing education and the same schedule flexibility as hospitalists.

Seller’s Market

Hospital medicine faces a shortage of qualified applicants. The need for hospitalists far surpasses the supply of physicians, who are in the enviable position of sifting through incentives and perks when selecting a hospitalist job.

This has become a national concern, according to Vikas Parekh, MD, assistant director of the hospitalist program and assistant professor of medicine at the University of Michigan Health Center in Ann Arbor. “We’re not seeing a pool of applicants because top residents are not pursuing hospitalist careers,” Dr. Parekh says.

Alpesh Amin, MD, MBA, a member of SHM’s Board of Directors, concurs but also points out that the number of hospitalist jobs is growing. “The need for a few hundred hospitalists 10 years ago has grown to 20,000 to 30,000 today, thus creating a need much greater than the supply,” says Dr. Amin, professor and chief, general internal medicine, executive director and founder of the hospitalist program at the University of California Irvine.

Why the shortage? First, fewer physicians are choosing to practice general medicine, either as an internist, family practitioner, or hospitalist. A recent study found fewer medical students were planning to concentrate on internal and family medicine, and that those who did planned to go into a subspecialty later.1 Dr. Parekh attributes this to a combination of reasons. “Most internal medicine residents are subspecialty oriented and may have decided their specialty early on,” Dr. Parekh says. “They may choose a subspecialty for financial reasons or prestige,” he continues, “but they may also be unclear about what a hospitalist career really is.”

Second, hospitalist programs have begun to expand from large metropolitan regions to smaller and rural areas. The result is an even greater demand for hospitalists.

Meet the Need

“There are no saturated markets within hospital medicine,” Dr. Holman says. “That is, most groups are always actively recruiting. [Cogent develops] full hospitalist programs, including recruiting, employing, managing, and training for new and existing hospitalist groups.”

Who is being recruited? Many recruiters approach residents who have not chosen a subspecialty to offer a staff position after they finish the residency. Although a recruiting firm may not offer financial aid during the residency, an employer may provide some sort of stipend if the candidate commits to remain on staff for a specified time after residency. “Recruit and retain” is the operative phrase in these cases.

Recruiters also are approaching generalists just entering the market to point out the advantages of avoiding the startup costs of establishing an outpatient practice. Further, many hospitalists are emerging from the ranks of solo practitioners interested in the financial and personal advantages of belonging to hospitalist groups. Not only does that eliminate the practice overhead (including the burden of regulatory compliance), but it also may offer additional administrative and academic opportunities. As Dr. Amin says, “There are more MD-MBA combos out there.”

Are incentives the answer to the shortage? Perhaps for now. With time, hospital medicine’s built-in perks may end the shortage and the need for added incentives. TH

Ann Kepler is a medical writer based in Chicago.

Reference

1. Croasdale M. Primary care doctors in demand; signing bonuses and higher pay for some. American Medical News. June 19, 2006. Available at www.ama-assn.org/amednews/site/free/prl10619.htm. Last accessed March 19, 2008.