Psychiatrist reveals patients’ information to another patient

Alameda County (CA) Superior Court

For several years 2 female patients were treated by the same psychiatrist. Jane Doe, age 56, read a breach of confidentiality report alleging sexual abuse filed by another patient of the psychiatrist. Jane Doe contacted the alleged victim, who informed her that the psychiatrist had disclosed information to her (the victim) regarding Jane Doe’s treatment, emotional problems, sexual preferences, and medication regimen.

Susan Doe, age 64, learned of the sexual abuse accusations against the psychiatrist in the same way and also contacted the alleged victim. She told Susan Doe that the psychiatrist had disclosed to her Susan Doe’s personal information regarding her dificult relationship with her daughter, depression, and instances when she stormed out of counseling sessions.

The patients brought separate claims, and their cases were later consolidated. The psychiatrist denied that he told the alleged sexual abuse victim details of the 2 patients’ treatments. The patients claimed that the victim could not have known their personal details unless the psychiatrist had told her.

• A jury returned a verdict in favor of the 2 patients. Jane Doe was awarded $225,000, and Susan Doe was awarded $47,000.

Dr. Grant’s observations

In the case of Jane Doe and Susan Doe, disclosing a patient’s personal information to another patient violates confidentiality. Patients must consent to the disclosure of information to third parties, and in this case these 2 patients apparently did not provide consent.

Medical practice—and particularly psychiatric practice—is based on the principle that communications between clinicians and patients are private. The Hippocratic oath states, “Whatever I see or hear in the lives of my patients, whether in connection with my professional practice or not, which ought not to be spoken of outside, I will keep secret, as considering all such things to be private.”¹

According to the American Psychiatric Association’s (APA) code of ethics, “Psychiatric records, including even the identification of a person as a patient, must be protected with extreme care. Confidentiality is essential to psychiatric treatment, in part because of the special nature of psychiatric therapy. A psychiatrist may release confidential information only with the patient’s authorization or under proper legal compulsion.”²

Doctor-patient confidentiality is rooted in the belief that potential disclosure of information communicated during psychiatric diagnosis and treatment would discourage patients from seeking medical and mental health care (Table)

Table

Underlying values of confidentiality

When to disclose

There are circumstances, however, that override the requirement to maintain confidentiality and do not need a patient’s consent. Examples include:³

Duty to protect third parties. In 1976 the California Supreme Court ruled in the landmark Tarasoff case⁴ that a psychiatrist has a duty to do what is reasonably necessary to protect third parties if a patient presents a serious risk of violence to another person. The specific applications of this principle are governed by other states’ laws, which have extended or limited this duty.⁵ Be familiar with the law in your jurisdiction before disclosing confidential information to third parties who may be at risk of violence.

The APA’s position on this exception is consistent with legal standards. Its code of ethics states, “When, in the clinical judgment of the treating psychiatrist, the risk of danger is deemed to be significant, the psychiatrist may reveal confidential information disclosed by the patient.”⁶

Emergency release of information. Psychiatrists can release confidential information during a medical emergency. Releasing the information must be in the patient’s best interests, and the patient’s inability to consent to the release should be the result of a potentially reversible condition that leads the clinician to question the patient’s capacity to consent.³

For example, if a patient in an emergency room is delirious because of ingesting an unknown substance and is unable to consent, a physician can call family members to ask about the patient’s medical problems. Notifying family that the patient is in the hospital could violate confidentiality, however.

Reporting abuse. All clinicians are obligated to report suspected child abuse or neglect. Some state laws also may require physicians to disclose abuse of vulnerable groups such as the elderly or the disabled and report to the local department of health diagnosis of communicable diseases such as HIV.³

Circle of confidentiality. Certain parties— including clinical staff on an inpatient unit or a psychiatrist supervising a resident— are considered to be within a circle of confidentiality.³ You do not need a patient’s consent to share clinical information with those within the circle of confidentiality. Do not release a patient’s information to parties who are not in the circle of confidentiality—such as family members, attorneys representing the patient, and law enforcement personnel—unless you’ve first obtained the patient’s consent.

Document the reasoning behind your decision to disclose your patient’s personal information without the patient’s consent. Show that you engaged in a reasonable clinical decision-making process.³ For example, record the risks and benefits of your decision and how you arrived at your conclusion.³

Other scenarios

Multidisciplinary teams. Members of a multidisciplinary treatment team—such as physicians, nurses, or social workers—should only receive confidential information that is relevant to the patient’s care. Other clinicians who are not involved in the case—although they may be seeing other patients on the same unit—should not have access to the patient’s confidential information. Discussions with these team members must be private so that others do not overhear confidential information.

Insurance companies generally are not party to the patient’s records unless the patient agrees to allow access by signing a release. If the patient’s refusal to allow disclosure results in the insurance company’s refusal to pay, then the patient is responsible for resolving the issue.⁷

Scientific publications and presentations. When you present a case report for a scientific publication or at a meeting, alter the patient’s biographical data so that someone who knows the patient would be unable to identify him or her based on the information in the case report. If the information is so specific that you cannot prevent patient identification, either do not publish the case or offer the patient the right to veto the manuscript’s distribution. If necessary, have the patient sign a consent form to allow publication or presentation of the case report.

Confidentiality violations

Breach of confidentiality may be intentional, such as disclosing a patient’s personal information to a third party as in this case, or unintentional, such as talking about a patient to a colleague and having someone overhear your discussion.⁸ Violating confidentiality may result in litigation for malpractice (negligence), invasion of privacy, or breach of contract, and ethical sanctions.⁸

Psychiatrist reveals patients’ information to another patient

Alameda County (CA) Superior Court

For several years 2 female patients were treated by the same psychiatrist. Jane Doe, age 56, read a breach of confidentiality report alleging sexual abuse filed by another patient of the psychiatrist. Jane Doe contacted the alleged victim, who informed her that the psychiatrist had disclosed information to her (the victim) regarding Jane Doe’s treatment, emotional problems, sexual preferences, and medication regimen.

Susan Doe, age 64, learned of the sexual abuse accusations against the psychiatrist in the same way and also contacted the alleged victim. She told Susan Doe that the psychiatrist had disclosed to her Susan Doe’s personal information regarding her dificult relationship with her daughter, depression, and instances when she stormed out of counseling sessions.

The patients brought separate claims, and their cases were later consolidated. The psychiatrist denied that he told the alleged sexual abuse victim details of the 2 patients’ treatments. The patients claimed that the victim could not have known their personal details unless the psychiatrist had told her.

• A jury returned a verdict in favor of the 2 patients. Jane Doe was awarded $225,000, and Susan Doe was awarded $47,000.

Dr. Grant’s observations

In the case of Jane Doe and Susan Doe, disclosing a patient’s personal information to another patient violates confidentiality. Patients must consent to the disclosure of information to third parties, and in this case these 2 patients apparently did not provide consent.

Medical practice—and particularly psychiatric practice—is based on the principle that communications between clinicians and patients are private. The Hippocratic oath states, “Whatever I see or hear in the lives of my patients, whether in connection with my professional practice or not, which ought not to be spoken of outside, I will keep secret, as considering all such things to be private.”¹

According to the American Psychiatric Association’s (APA) code of ethics, “Psychiatric records, including even the identification of a person as a patient, must be protected with extreme care. Confidentiality is essential to psychiatric treatment, in part because of the special nature of psychiatric therapy. A psychiatrist may release confidential information only with the patient’s authorization or under proper legal compulsion.”²

Doctor-patient confidentiality is rooted in the belief that potential disclosure of information communicated during psychiatric diagnosis and treatment would discourage patients from seeking medical and mental health care (Table)

Table

Underlying values of confidentiality

When to disclose

There are circumstances, however, that override the requirement to maintain confidentiality and do not need a patient’s consent. Examples include:³

Duty to protect third parties. In 1976 the California Supreme Court ruled in the landmark Tarasoff case⁴ that a psychiatrist has a duty to do what is reasonably necessary to protect third parties if a patient presents a serious risk of violence to another person. The specific applications of this principle are governed by other states’ laws, which have extended or limited this duty.⁵ Be familiar with the law in your jurisdiction before disclosing confidential information to third parties who may be at risk of violence.

The APA’s position on this exception is consistent with legal standards. Its code of ethics states, “When, in the clinical judgment of the treating psychiatrist, the risk of danger is deemed to be significant, the psychiatrist may reveal confidential information disclosed by the patient.”⁶

Emergency release of information. Psychiatrists can release confidential information during a medical emergency. Releasing the information must be in the patient’s best interests, and the patient’s inability to consent to the release should be the result of a potentially reversible condition that leads the clinician to question the patient’s capacity to consent.³

For example, if a patient in an emergency room is delirious because of ingesting an unknown substance and is unable to consent, a physician can call family members to ask about the patient’s medical problems. Notifying family that the patient is in the hospital could violate confidentiality, however.

Reporting abuse. All clinicians are obligated to report suspected child abuse or neglect. Some state laws also may require physicians to disclose abuse of vulnerable groups such as the elderly or the disabled and report to the local department of health diagnosis of communicable diseases such as HIV.³

Circle of confidentiality. Certain parties— including clinical staff on an inpatient unit or a psychiatrist supervising a resident— are considered to be within a circle of confidentiality.³ You do not need a patient’s consent to share clinical information with those within the circle of confidentiality. Do not release a patient’s information to parties who are not in the circle of confidentiality—such as family members, attorneys representing the patient, and law enforcement personnel—unless you’ve first obtained the patient’s consent.

Document the reasoning behind your decision to disclose your patient’s personal information without the patient’s consent. Show that you engaged in a reasonable clinical decision-making process.³ For example, record the risks and benefits of your decision and how you arrived at your conclusion.³

Other scenarios

Multidisciplinary teams. Members of a multidisciplinary treatment team—such as physicians, nurses, or social workers—should only receive confidential information that is relevant to the patient’s care. Other clinicians who are not involved in the case—although they may be seeing other patients on the same unit—should not have access to the patient’s confidential information. Discussions with these team members must be private so that others do not overhear confidential information.

Insurance companies generally are not party to the patient’s records unless the patient agrees to allow access by signing a release. If the patient’s refusal to allow disclosure results in the insurance company’s refusal to pay, then the patient is responsible for resolving the issue.⁷

Scientific publications and presentations. When you present a case report for a scientific publication or at a meeting, alter the patient’s biographical data so that someone who knows the patient would be unable to identify him or her based on the information in the case report. If the information is so specific that you cannot prevent patient identification, either do not publish the case or offer the patient the right to veto the manuscript’s distribution. If necessary, have the patient sign a consent form to allow publication or presentation of the case report.

Confidentiality violations

Breach of confidentiality may be intentional, such as disclosing a patient’s personal information to a third party as in this case, or unintentional, such as talking about a patient to a colleague and having someone overhear your discussion.⁸ Violating confidentiality may result in litigation for malpractice (negligence), invasion of privacy, or breach of contract, and ethical sanctions.⁸

Psychiatrist reveals patients’ information to another patient

Alameda County (CA) Superior Court

For several years 2 female patients were treated by the same psychiatrist. Jane Doe, age 56, read a breach of confidentiality report alleging sexual abuse filed by another patient of the psychiatrist. Jane Doe contacted the alleged victim, who informed her that the psychiatrist had disclosed information to her (the victim) regarding Jane Doe’s treatment, emotional problems, sexual preferences, and medication regimen.

Susan Doe, age 64, learned of the sexual abuse accusations against the psychiatrist in the same way and also contacted the alleged victim. She told Susan Doe that the psychiatrist had disclosed to her Susan Doe’s personal information regarding her dificult relationship with her daughter, depression, and instances when she stormed out of counseling sessions.

The patients brought separate claims, and their cases were later consolidated. The psychiatrist denied that he told the alleged sexual abuse victim details of the 2 patients’ treatments. The patients claimed that the victim could not have known their personal details unless the psychiatrist had told her.

• A jury returned a verdict in favor of the 2 patients. Jane Doe was awarded $225,000, and Susan Doe was awarded $47,000.

Dr. Grant’s observations

In the case of Jane Doe and Susan Doe, disclosing a patient’s personal information to another patient violates confidentiality. Patients must consent to the disclosure of information to third parties, and in this case these 2 patients apparently did not provide consent.

Medical practice—and particularly psychiatric practice—is based on the principle that communications between clinicians and patients are private. The Hippocratic oath states, “Whatever I see or hear in the lives of my patients, whether in connection with my professional practice or not, which ought not to be spoken of outside, I will keep secret, as considering all such things to be private.”¹

According to the American Psychiatric Association’s (APA) code of ethics, “Psychiatric records, including even the identification of a person as a patient, must be protected with extreme care. Confidentiality is essential to psychiatric treatment, in part because of the special nature of psychiatric therapy. A psychiatrist may release confidential information only with the patient’s authorization or under proper legal compulsion.”²

Doctor-patient confidentiality is rooted in the belief that potential disclosure of information communicated during psychiatric diagnosis and treatment would discourage patients from seeking medical and mental health care (Table)

Table

Underlying values of confidentiality

When to disclose

There are circumstances, however, that override the requirement to maintain confidentiality and do not need a patient’s consent. Examples include:³

Duty to protect third parties. In 1976 the California Supreme Court ruled in the landmark Tarasoff case⁴ that a psychiatrist has a duty to do what is reasonably necessary to protect third parties if a patient presents a serious risk of violence to another person. The specific applications of this principle are governed by other states’ laws, which have extended or limited this duty.⁵ Be familiar with the law in your jurisdiction before disclosing confidential information to third parties who may be at risk of violence.

The APA’s position on this exception is consistent with legal standards. Its code of ethics states, “When, in the clinical judgment of the treating psychiatrist, the risk of danger is deemed to be significant, the psychiatrist may reveal confidential information disclosed by the patient.”⁶

Emergency release of information. Psychiatrists can release confidential information during a medical emergency. Releasing the information must be in the patient’s best interests, and the patient’s inability to consent to the release should be the result of a potentially reversible condition that leads the clinician to question the patient’s capacity to consent.³

For example, if a patient in an emergency room is delirious because of ingesting an unknown substance and is unable to consent, a physician can call family members to ask about the patient’s medical problems. Notifying family that the patient is in the hospital could violate confidentiality, however.

Reporting abuse. All clinicians are obligated to report suspected child abuse or neglect. Some state laws also may require physicians to disclose abuse of vulnerable groups such as the elderly or the disabled and report to the local department of health diagnosis of communicable diseases such as HIV.³

Circle of confidentiality. Certain parties— including clinical staff on an inpatient unit or a psychiatrist supervising a resident— are considered to be within a circle of confidentiality.³ You do not need a patient’s consent to share clinical information with those within the circle of confidentiality. Do not release a patient’s information to parties who are not in the circle of confidentiality—such as family members, attorneys representing the patient, and law enforcement personnel—unless you’ve first obtained the patient’s consent.

Document the reasoning behind your decision to disclose your patient’s personal information without the patient’s consent. Show that you engaged in a reasonable clinical decision-making process.³ For example, record the risks and benefits of your decision and how you arrived at your conclusion.³

Other scenarios

Multidisciplinary teams. Members of a multidisciplinary treatment team—such as physicians, nurses, or social workers—should only receive confidential information that is relevant to the patient’s care. Other clinicians who are not involved in the case—although they may be seeing other patients on the same unit—should not have access to the patient’s confidential information. Discussions with these team members must be private so that others do not overhear confidential information.

Insurance companies generally are not party to the patient’s records unless the patient agrees to allow access by signing a release. If the patient’s refusal to allow disclosure results in the insurance company’s refusal to pay, then the patient is responsible for resolving the issue.⁷

Scientific publications and presentations. When you present a case report for a scientific publication or at a meeting, alter the patient’s biographical data so that someone who knows the patient would be unable to identify him or her based on the information in the case report. If the information is so specific that you cannot prevent patient identification, either do not publish the case or offer the patient the right to veto the manuscript’s distribution. If necessary, have the patient sign a consent form to allow publication or presentation of the case report.

Confidentiality violations

Breach of confidentiality may be intentional, such as disclosing a patient’s personal information to a third party as in this case, or unintentional, such as talking about a patient to a colleague and having someone overhear your discussion.⁸ Violating confidentiality may result in litigation for malpractice (negligence), invasion of privacy, or breach of contract, and ethical sanctions.⁸

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Question: I am working too hard and getting paid too little. Is there any easy to figure out if I am getting paid what I am worth?

Show Me the Money, Austin, Texas

Dr. Hospitalist responds: I suspect you may have already asked hospitalists you know about how much they make and compared schedules. Although this may be sadistically fun (alas, misery loves company), there are problems with this approach.

Your perspective is limited to friends and colleagues willing to share this information. Some people are reluctant to talk money, others have a tendency to embellish their productivity. I am not saying folks would intentionally lie to you (wink, nod), but who would tell you they feel overpaid and do not work hard?

What you need are objective data. You and a couple of colleagues could develop a survey, send it to every hospitalist you know, and hope they respond. But even if you did, how often could you muster the energy to do this to keep your data up to date?

Remember, you are doing this survey to demonstrate you are compensated appropriately for how much work you produce. Lucky for you, several organizations collect physician productivity and compensation data, including SHM and the Medical Group Management Association (MGMA). But there are differences in the data.

Some believe the MGMA data set may include information from primary care groups with inpatient rounders in addition to full-time hospitalists. Meanwhile, SHM data were last collected in November 2005. SHM collects updated information from hospitalists around the country. They will make those findings available at the next SHM annual meeting in San Diego in April 2008.

This will also be the first survey done since Medicare moved to the new 2007 relative value unit (RVU) values. Hospitalists who contribute to the survey can access the data for free. I suppose critics could argue that the approach taken by these groups is subject to bias because individuals could submit false data. This is all the more reason I would encourage you to submit data to the SHM survey. The larger the sample size, the more difficult it will be for any one individual’s data to warp the survey.

Speak Up

Question: I know hospitalists should communicate with primary care physicians (PCPs) about their patients, but I find it takes a lot of time for me to call their offices. Is there an easier way to do this? I am also not completely sure of when I should communicate. Any suggestions?

No Time to Talk, Atlanta

Dr. Hospitalist responds: Let me guess. Your “communication” with the PCP goes something like this: You pick up the telephone to call a patient’s PCP. After sitting on hold for what seems like eternity (your pager rings repeatedly during this time), a voice on the other end of line tells you that the doctor is in an exam room. “Do you want me to interrupt him?”

Do you say yes and run the risk of sitting on hold another five minutes? Or do you decide whatever you had to say really isn’t that important? But don’t you need that outpatient medication list? Do you really have to tell the PCP about the ongoing end of life discussions with the patient? What’s a hospitalist to do?

This method of communication may have worked when you were a resident in training, when your workload was capped and your attending physician had to make time for your calls. But try this as a hospitalist and you’ll quickly discover you don’t have enough hours each day.

When working out a relationship with a PCP, hospitalists should engage the PCP in a discussion about how they should communicate. For example, the hospitalist and PCP may agree that each time a patient presents for admission, the hospitalist will ask the hospitalist administrative assistant to fax the PCP office. A fax with admission diagnoses will not only serve as notification of admission but also as a request for information from the PCP.

As important as it is for the hospitalist to get his staff to fax the request in a timely manner, the PCP will have to do the same with his/her office staff. In such a system, the hospitalist and the PCP communicate about admissions via their administrative staff. If the PCP or hospitalist has further questions, the expectation may be that a page will be in order. But for the majority of admissions, that won’t be necessary.

I have seen hospitalists and PCPs handle routine communication in a variety of ways: phone calls, face-to-face discussion, e-mail, voicemail, discharge summaries/letters, fax notification of admission, pages. No single method works well with all groups all the time. To succeed, communication:

• Must be timely, easy to understand, and concise;
• Must be efficient for the communicator and the recipient, not labor intensive;
• Should occur at each transition in care; and
• Should meet privacy guidelines.

Communicators must understand the rules of engagement and share common expectations. Ideally, there should be a paper trail or other record.

Hiring is Work

Question: My group is having a hard time recruiting physicians. How can we do better?

Need Help, Richmond, Va.

Dr. Hospitalist responds: If it’s any consolation, you’re not alone. Look at the number of pages devoted to job ads in this issue of The Hospitalist and you’ll understand the high demand for hospitalists. There are about 20,000 hospitalists in the country, and many believe there is room for double that number. Advertising and hiring qualified staff is not a challenge unique to hospital medicine, but most hospitalists received no training on how to do it. Most hospitalists underestimate the time and resources it takes to recruit and hire staff.

Here are some hiring hints to help you and your hospitalist program maximize your success.

The first step is to create a job description. Before you can describe the job to prospective hospitalists, you need a clear understanding yourself. I would expect applicants to ask some of the following questions:

• Do your hospitalists to work days, nights or a combination of both?
• What about weekdays versus weekends?
• How does your group handle admissions versus daily rounding?
• Do your hospitalists provide consultative services?
• Are there teaching responsibilities?
• How many patients do you expect each hospitalists to see daily?

Based on your job description, how do you expect to compensate your hospitalists? Do your homework and find out what competitors are paying for similar job descriptions. While there are many reasons prospective hospitalists might accept an offer, salary is often not the only reason. What else is part of your compensation package? It might include some of the following:

• A retirement plan, like a 401k/ 403b or a pension;
• Paid parking;
• Continuing-education stipend;
• Productivity incentive;
• Access to health, life and/or disability insurance;
• Paid malpractice insurance; and
• Ownership/equity opportunity.

Once you create an attractive job description with a competitive compensation package, it’s time to get the word out. There are many options for reaching prospective candidates:

• Advertise in journals and online;
• Advertise at meetings;
• Tell friends, colleagues and nurses;
• Work with your hospital’s recruiter;
• Send targeted mailings; and
• Be seen at local hospitalist events.

Once you have an applicant interested, it’s time to close the deal. Qualified applicants are likely going to field offers from several groups. Why should the applicant accept your offer over another? Here are several incentives:

• Signing bonus;
• Relocation package;
• Loan forgiveness;
• Title for an administrative role; and
• Opportunity for advancement.

Don’t underestimate the effect of a simple phone call or e-mail to your candidate after the interview. I can’t emphasize how often I hear people say they joined a group because they felt as though they fit in well.

Hiring is a year-round group effort. The most important resource in any hospitalist program is staff. Recruitment, hiring, and retention should be a primary goal of any hospitalist medical director. TH

Question: I am working too hard and getting paid too little. Is there any easy to figure out if I am getting paid what I am worth?

Show Me the Money, Austin, Texas

Dr. Hospitalist responds: I suspect you may have already asked hospitalists you know about how much they make and compared schedules. Although this may be sadistically fun (alas, misery loves company), there are problems with this approach.

Your perspective is limited to friends and colleagues willing to share this information. Some people are reluctant to talk money, others have a tendency to embellish their productivity. I am not saying folks would intentionally lie to you (wink, nod), but who would tell you they feel overpaid and do not work hard?

What you need are objective data. You and a couple of colleagues could develop a survey, send it to every hospitalist you know, and hope they respond. But even if you did, how often could you muster the energy to do this to keep your data up to date?

Remember, you are doing this survey to demonstrate you are compensated appropriately for how much work you produce. Lucky for you, several organizations collect physician productivity and compensation data, including SHM and the Medical Group Management Association (MGMA). But there are differences in the data.

Some believe the MGMA data set may include information from primary care groups with inpatient rounders in addition to full-time hospitalists. Meanwhile, SHM data were last collected in November 2005. SHM collects updated information from hospitalists around the country. They will make those findings available at the next SHM annual meeting in San Diego in April 2008.

This will also be the first survey done since Medicare moved to the new 2007 relative value unit (RVU) values. Hospitalists who contribute to the survey can access the data for free. I suppose critics could argue that the approach taken by these groups is subject to bias because individuals could submit false data. This is all the more reason I would encourage you to submit data to the SHM survey. The larger the sample size, the more difficult it will be for any one individual’s data to warp the survey.

Speak Up

Question: I know hospitalists should communicate with primary care physicians (PCPs) about their patients, but I find it takes a lot of time for me to call their offices. Is there an easier way to do this? I am also not completely sure of when I should communicate. Any suggestions?

No Time to Talk, Atlanta

Dr. Hospitalist responds: Let me guess. Your “communication” with the PCP goes something like this: You pick up the telephone to call a patient’s PCP. After sitting on hold for what seems like eternity (your pager rings repeatedly during this time), a voice on the other end of line tells you that the doctor is in an exam room. “Do you want me to interrupt him?”

Do you say yes and run the risk of sitting on hold another five minutes? Or do you decide whatever you had to say really isn’t that important? But don’t you need that outpatient medication list? Do you really have to tell the PCP about the ongoing end of life discussions with the patient? What’s a hospitalist to do?

This method of communication may have worked when you were a resident in training, when your workload was capped and your attending physician had to make time for your calls. But try this as a hospitalist and you’ll quickly discover you don’t have enough hours each day.

When working out a relationship with a PCP, hospitalists should engage the PCP in a discussion about how they should communicate. For example, the hospitalist and PCP may agree that each time a patient presents for admission, the hospitalist will ask the hospitalist administrative assistant to fax the PCP office. A fax with admission diagnoses will not only serve as notification of admission but also as a request for information from the PCP.

As important as it is for the hospitalist to get his staff to fax the request in a timely manner, the PCP will have to do the same with his/her office staff. In such a system, the hospitalist and the PCP communicate about admissions via their administrative staff. If the PCP or hospitalist has further questions, the expectation may be that a page will be in order. But for the majority of admissions, that won’t be necessary.

I have seen hospitalists and PCPs handle routine communication in a variety of ways: phone calls, face-to-face discussion, e-mail, voicemail, discharge summaries/letters, fax notification of admission, pages. No single method works well with all groups all the time. To succeed, communication:

• Must be timely, easy to understand, and concise;
• Must be efficient for the communicator and the recipient, not labor intensive;
• Should occur at each transition in care; and
• Should meet privacy guidelines.

Communicators must understand the rules of engagement and share common expectations. Ideally, there should be a paper trail or other record.

Hiring is Work

Question: My group is having a hard time recruiting physicians. How can we do better?

Need Help, Richmond, Va.

Dr. Hospitalist responds: If it’s any consolation, you’re not alone. Look at the number of pages devoted to job ads in this issue of The Hospitalist and you’ll understand the high demand for hospitalists. There are about 20,000 hospitalists in the country, and many believe there is room for double that number. Advertising and hiring qualified staff is not a challenge unique to hospital medicine, but most hospitalists received no training on how to do it. Most hospitalists underestimate the time and resources it takes to recruit and hire staff.

Here are some hiring hints to help you and your hospitalist program maximize your success.

The first step is to create a job description. Before you can describe the job to prospective hospitalists, you need a clear understanding yourself. I would expect applicants to ask some of the following questions:

• Do your hospitalists to work days, nights or a combination of both?
• What about weekdays versus weekends?
• How does your group handle admissions versus daily rounding?
• Do your hospitalists provide consultative services?
• Are there teaching responsibilities?
• How many patients do you expect each hospitalists to see daily?

Based on your job description, how do you expect to compensate your hospitalists? Do your homework and find out what competitors are paying for similar job descriptions. While there are many reasons prospective hospitalists might accept an offer, salary is often not the only reason. What else is part of your compensation package? It might include some of the following:

• A retirement plan, like a 401k/ 403b or a pension;
• Paid parking;
• Continuing-education stipend;
• Productivity incentive;
• Access to health, life and/or disability insurance;
• Paid malpractice insurance; and
• Ownership/equity opportunity.

Once you create an attractive job description with a competitive compensation package, it’s time to get the word out. There are many options for reaching prospective candidates:

• Advertise in journals and online;
• Advertise at meetings;
• Tell friends, colleagues and nurses;
• Work with your hospital’s recruiter;
• Send targeted mailings; and
• Be seen at local hospitalist events.

Once you have an applicant interested, it’s time to close the deal. Qualified applicants are likely going to field offers from several groups. Why should the applicant accept your offer over another? Here are several incentives:

• Signing bonus;
• Relocation package;
• Loan forgiveness;
• Title for an administrative role; and
• Opportunity for advancement.

Don’t underestimate the effect of a simple phone call or e-mail to your candidate after the interview. I can’t emphasize how often I hear people say they joined a group because they felt as though they fit in well.

Hiring is a year-round group effort. The most important resource in any hospitalist program is staff. Recruitment, hiring, and retention should be a primary goal of any hospitalist medical director. TH

Question: I am working too hard and getting paid too little. Is there any easy to figure out if I am getting paid what I am worth?

Show Me the Money, Austin, Texas

Dr. Hospitalist responds: I suspect you may have already asked hospitalists you know about how much they make and compared schedules. Although this may be sadistically fun (alas, misery loves company), there are problems with this approach.

Your perspective is limited to friends and colleagues willing to share this information. Some people are reluctant to talk money, others have a tendency to embellish their productivity. I am not saying folks would intentionally lie to you (wink, nod), but who would tell you they feel overpaid and do not work hard?

What you need are objective data. You and a couple of colleagues could develop a survey, send it to every hospitalist you know, and hope they respond. But even if you did, how often could you muster the energy to do this to keep your data up to date?

Remember, you are doing this survey to demonstrate you are compensated appropriately for how much work you produce. Lucky for you, several organizations collect physician productivity and compensation data, including SHM and the Medical Group Management Association (MGMA). But there are differences in the data.

Some believe the MGMA data set may include information from primary care groups with inpatient rounders in addition to full-time hospitalists. Meanwhile, SHM data were last collected in November 2005. SHM collects updated information from hospitalists around the country. They will make those findings available at the next SHM annual meeting in San Diego in April 2008.

This will also be the first survey done since Medicare moved to the new 2007 relative value unit (RVU) values. Hospitalists who contribute to the survey can access the data for free. I suppose critics could argue that the approach taken by these groups is subject to bias because individuals could submit false data. This is all the more reason I would encourage you to submit data to the SHM survey. The larger the sample size, the more difficult it will be for any one individual’s data to warp the survey.

Speak Up

Question: I know hospitalists should communicate with primary care physicians (PCPs) about their patients, but I find it takes a lot of time for me to call their offices. Is there an easier way to do this? I am also not completely sure of when I should communicate. Any suggestions?

No Time to Talk, Atlanta

Dr. Hospitalist responds: Let me guess. Your “communication” with the PCP goes something like this: You pick up the telephone to call a patient’s PCP. After sitting on hold for what seems like eternity (your pager rings repeatedly during this time), a voice on the other end of line tells you that the doctor is in an exam room. “Do you want me to interrupt him?”

Do you say yes and run the risk of sitting on hold another five minutes? Or do you decide whatever you had to say really isn’t that important? But don’t you need that outpatient medication list? Do you really have to tell the PCP about the ongoing end of life discussions with the patient? What’s a hospitalist to do?

This method of communication may have worked when you were a resident in training, when your workload was capped and your attending physician had to make time for your calls. But try this as a hospitalist and you’ll quickly discover you don’t have enough hours each day.

When working out a relationship with a PCP, hospitalists should engage the PCP in a discussion about how they should communicate. For example, the hospitalist and PCP may agree that each time a patient presents for admission, the hospitalist will ask the hospitalist administrative assistant to fax the PCP office. A fax with admission diagnoses will not only serve as notification of admission but also as a request for information from the PCP.

As important as it is for the hospitalist to get his staff to fax the request in a timely manner, the PCP will have to do the same with his/her office staff. In such a system, the hospitalist and the PCP communicate about admissions via their administrative staff. If the PCP or hospitalist has further questions, the expectation may be that a page will be in order. But for the majority of admissions, that won’t be necessary.

I have seen hospitalists and PCPs handle routine communication in a variety of ways: phone calls, face-to-face discussion, e-mail, voicemail, discharge summaries/letters, fax notification of admission, pages. No single method works well with all groups all the time. To succeed, communication:

• Must be timely, easy to understand, and concise;
• Must be efficient for the communicator and the recipient, not labor intensive;
• Should occur at each transition in care; and
• Should meet privacy guidelines.

Communicators must understand the rules of engagement and share common expectations. Ideally, there should be a paper trail or other record.

Hiring is Work

Question: My group is having a hard time recruiting physicians. How can we do better?

Need Help, Richmond, Va.

Dr. Hospitalist responds: If it’s any consolation, you’re not alone. Look at the number of pages devoted to job ads in this issue of The Hospitalist and you’ll understand the high demand for hospitalists. There are about 20,000 hospitalists in the country, and many believe there is room for double that number. Advertising and hiring qualified staff is not a challenge unique to hospital medicine, but most hospitalists received no training on how to do it. Most hospitalists underestimate the time and resources it takes to recruit and hire staff.

Here are some hiring hints to help you and your hospitalist program maximize your success.

The first step is to create a job description. Before you can describe the job to prospective hospitalists, you need a clear understanding yourself. I would expect applicants to ask some of the following questions:

• Do your hospitalists to work days, nights or a combination of both?
• What about weekdays versus weekends?
• How does your group handle admissions versus daily rounding?
• Do your hospitalists provide consultative services?
• Are there teaching responsibilities?
• How many patients do you expect each hospitalists to see daily?

Based on your job description, how do you expect to compensate your hospitalists? Do your homework and find out what competitors are paying for similar job descriptions. While there are many reasons prospective hospitalists might accept an offer, salary is often not the only reason. What else is part of your compensation package? It might include some of the following:

• A retirement plan, like a 401k/ 403b or a pension;
• Paid parking;
• Continuing-education stipend;
• Productivity incentive;
• Access to health, life and/or disability insurance;
• Paid malpractice insurance; and
• Ownership/equity opportunity.

Once you create an attractive job description with a competitive compensation package, it’s time to get the word out. There are many options for reaching prospective candidates:

• Advertise in journals and online;
• Advertise at meetings;
• Tell friends, colleagues and nurses;
• Work with your hospital’s recruiter;
• Send targeted mailings; and
• Be seen at local hospitalist events.

Once you have an applicant interested, it’s time to close the deal. Qualified applicants are likely going to field offers from several groups. Why should the applicant accept your offer over another? Here are several incentives:

• Signing bonus;
• Relocation package;
• Loan forgiveness;
• Title for an administrative role; and
• Opportunity for advancement.

Don’t underestimate the effect of a simple phone call or e-mail to your candidate after the interview. I can’t emphasize how often I hear people say they joined a group because they felt as though they fit in well.

Hiring is a year-round group effort. The most important resource in any hospitalist program is staff. Recruitment, hiring, and retention should be a primary goal of any hospitalist medical director. TH

Many or most specialties in medicine are adopting a hospitalist model, at least to a limited extent. In fact, hospital care of adult medical patients wasn’t even the first place the idea was adopted.

In talking with people from hundreds of institutions it seems clear the idea appeared earlier and grew more quickly in pediatrics than adult medicine. And in the past 10 to 15 years, fields like obstetrics (“laborists”), psychiatry, gastroenterology, and many others have slowly begun to adopt the hospitalist model.

One of the most recent disciplines to join the parade is general surgery. And when comparing the forces in play for hospitalists in the early 1990s to the current situation for surgical hospitalists, I think we may be close to a surge in surgical hospitalists similar to what we’ve seen with medical hospitalists in the past 10 years.

When I say surgical hospitalists, I’m referring to surgeons with a nearly exclusive inpatient practice. Other terms such as surgicalist, acute care surgeon, and traumatologist overlap to some degree but have ambiguous meanings.

Generalizations

For some months I have contacted all the surgical hospitalist practices I can find to learn what forces led to their creation and how they are structured. Several common themes are emerging:

Prevalence: There are probably no more than 20 to 40 surgical hospitalist practices, but many institutions are considering the idea. This is similar to the situation for medical hospitalists in the early to mid-1990s.

Driver to start program: In every program I’ve found, the main impetus to start it was to address the burden of emergency department (ED) call for existing general surgeons. Like primary care, ED call is regarded as unattractive because it is unpredictable (lots of night and weekend work), usually has a poor payer mix, and many general surgeons have seen the “center of gravity” of their practice move away from the hospital toward an ambulatory surgery center over the past 10 years or so. Additionally, many general surgeons are increasingly uncomfortable caring for trauma patients because of recent changes in that field. (For an excellent discussion of the changing nature of general surgery and trauma care see “The Acute Care Surgeon” in The Hospitalist, May 2006, p. 25.)

Case volume: General surgery case volume tends to go up at a hospital that puts a surgical hospitalist program in place. When existing surgeons are relieved of ED call they increase their volume of (mostly elective) surgery. The availability of surgical hospitalists may mean fewer emergency cases presenting to the ED are referred elsewhere (which may happen when non-hospitalist surgeons are required to take ED call). These changes in case volume and the timing of the operations (e.g., volume of night surgeries may go up) may require adjustments to operating room staffing and scheduling. Presumably this increased volume would not occur in an area oversupplied with surgeons.

Economics: Like nearly all medical hospitalist programs, surgical hospitalist practices are not viable without financial support in addition to collected professional fees. In all cases I am aware of, this support comes from the sponsoring hospital.

While the cost may be similar to what the hospital might have paid for existing surgeons to take ED call, hospitals seem to be getting a better return on that investment with surgical hospitalists. A small group of surgical hospitalists can handle the increased volume and all ED calls, improving clinical and service quality. Some institutions report that surgical hospitalists are much more attentive to billing for nonoperative work than their predecessors.

Structure: Programs should have an outpatient clinic where the surgical hospitalists can provide post-operative follow-up. In most cases, each surgeon spends only half a day a week in the clinic.

Scope of practice: All surgical hospitalist practices take most or all ED general surgery calls. In some institutions, the surgical hospitalist also leads the trauma team. Other duties at a few institutions include things like managing a wound-care clinic and being on-call to place lines.

Opinion of other surgeons: Community private practice surgeons tend to support these programs, but most institutions limit or prohibit surgical hospitalists from accepting elective referrals. Community surgeons are still offered the option of remaining on the ED call schedule—as might be the case for surgeons new to the community. At least one institution reported that the presence of surgical hospitalists improved recruitment of non-hospitalist general surgeons. However, I am also aware of one program put into place largely at the insistence of the existing surgeons. Those same surgeons later insisted it be dissolved because they saw it as unwanted competition.

Staff needs: Surgical hospitalist practices nearly always require fewer doctors than a medical hospitalist practice in the same institution. This can lead to a tension between having the right number of surgical hospitalists for the case volume (often just one or two doctors) and enough to provide for a reasonable call schedule. Existing groups have adopted a number of strategies.

Groups with only two doctors often have each work seven on/seven off. The doctor on-call for that week takes all night call him/herself. In some practices that have a medical hospitalist in-house all night, it could be reasonable to have routine calls on the surgical patients (e.g., sleeping pills, laxatives, low urine output, fever) first paged to the medical hospitalist, who refers the call to the surgical hospitalist only as needed.

At least one practice has hired enough surgeons so the call burden on each is reasonable. This might be more staff than required for the patient volume: Four surgical hospitalists each work 12-hour shifts in a seven on/seven off schedule. During the seven consecutive night shifts (worked by each surgeon one week in four), patient volume is low.

Some practices hire community surgeons as moonlighters or consider using nurse practitioners or physician’s assistants as first responders at night.

Demographics: Surgical hospitalists are usually midcareer doctors, not surgeons who have recently completed their training. Many say they have gotten burned out with the stress of operating a private practice and prefer hospital work to office work.

Where Will It All Lead?

In every institution I have made contact with, the medical and surgical hospitalists have a good working relationship. Each is available to the other for consults, and they work together so frequently that they can begin to build a greater sense of teamwork. It is important that both groups jointly develop guidelines, such as who admits which type of patients.

If, like primary care doctors, general surgeons and a handful of other specialties with significant hospital volume (such as obstetrics and gastroenterology) move largely to a hospitalist model, U.S. healthcare will have made a remarkable transformation. In the span of my career we will have gone from a system of most doctors seeing patients in and out of the hospital to a division of physician labor such that most doctors practice almost exclusively in only one setting or the other.

I can see how this could be a good thing for patients and medical professionals, but that isn’t a given. For it to turn out we must preserve the elements of the earlier system that worked well and mitigate new problems and complexities. We will need well-designed research to show the economic and quality effects of the hospitalist model on non-primary care fields such as general surgery. We face growing challenges in ensuring excellent communication between inpatient and outpatient caregivers—something that doesn’t work ideally in all medical hospitalist practices.

Let Me Hear From You

I’d like to hear about any surgical hospitalist program you know of so I can add it to my database of information about such programs. And if you’re thinking about becoming a surgical hospitalist or you’re an institution thinking about starting such a practice, feel free to contact me so we can compare notes. I can be reached at (425) 467-3316, or by e-mail: john@jnelson.net. TH

Dr. Nelson has been a practicing hospitalist since 1988 and is co-founder and past president of SHM. He is a principal in Nelson/Flores Associates, a national hospitalist practice management-consulting firm. This column represents his views and is not intended to reflect an official position of SHM.

Many or most specialties in medicine are adopting a hospitalist model, at least to a limited extent. In fact, hospital care of adult medical patients wasn’t even the first place the idea was adopted.

In talking with people from hundreds of institutions it seems clear the idea appeared earlier and grew more quickly in pediatrics than adult medicine. And in the past 10 to 15 years, fields like obstetrics (“laborists”), psychiatry, gastroenterology, and many others have slowly begun to adopt the hospitalist model.

One of the most recent disciplines to join the parade is general surgery. And when comparing the forces in play for hospitalists in the early 1990s to the current situation for surgical hospitalists, I think we may be close to a surge in surgical hospitalists similar to what we’ve seen with medical hospitalists in the past 10 years.

When I say surgical hospitalists, I’m referring to surgeons with a nearly exclusive inpatient practice. Other terms such as surgicalist, acute care surgeon, and traumatologist overlap to some degree but have ambiguous meanings.

Generalizations

For some months I have contacted all the surgical hospitalist practices I can find to learn what forces led to their creation and how they are structured. Several common themes are emerging:

Prevalence: There are probably no more than 20 to 40 surgical hospitalist practices, but many institutions are considering the idea. This is similar to the situation for medical hospitalists in the early to mid-1990s.

Driver to start program: In every program I’ve found, the main impetus to start it was to address the burden of emergency department (ED) call for existing general surgeons. Like primary care, ED call is regarded as unattractive because it is unpredictable (lots of night and weekend work), usually has a poor payer mix, and many general surgeons have seen the “center of gravity” of their practice move away from the hospital toward an ambulatory surgery center over the past 10 years or so. Additionally, many general surgeons are increasingly uncomfortable caring for trauma patients because of recent changes in that field. (For an excellent discussion of the changing nature of general surgery and trauma care see “The Acute Care Surgeon” in The Hospitalist, May 2006, p. 25.)

Case volume: General surgery case volume tends to go up at a hospital that puts a surgical hospitalist program in place. When existing surgeons are relieved of ED call they increase their volume of (mostly elective) surgery. The availability of surgical hospitalists may mean fewer emergency cases presenting to the ED are referred elsewhere (which may happen when non-hospitalist surgeons are required to take ED call). These changes in case volume and the timing of the operations (e.g., volume of night surgeries may go up) may require adjustments to operating room staffing and scheduling. Presumably this increased volume would not occur in an area oversupplied with surgeons.

Economics: Like nearly all medical hospitalist programs, surgical hospitalist practices are not viable without financial support in addition to collected professional fees. In all cases I am aware of, this support comes from the sponsoring hospital.

While the cost may be similar to what the hospital might have paid for existing surgeons to take ED call, hospitals seem to be getting a better return on that investment with surgical hospitalists. A small group of surgical hospitalists can handle the increased volume and all ED calls, improving clinical and service quality. Some institutions report that surgical hospitalists are much more attentive to billing for nonoperative work than their predecessors.

Structure: Programs should have an outpatient clinic where the surgical hospitalists can provide post-operative follow-up. In most cases, each surgeon spends only half a day a week in the clinic.

Scope of practice: All surgical hospitalist practices take most or all ED general surgery calls. In some institutions, the surgical hospitalist also leads the trauma team. Other duties at a few institutions include things like managing a wound-care clinic and being on-call to place lines.

Opinion of other surgeons: Community private practice surgeons tend to support these programs, but most institutions limit or prohibit surgical hospitalists from accepting elective referrals. Community surgeons are still offered the option of remaining on the ED call schedule—as might be the case for surgeons new to the community. At least one institution reported that the presence of surgical hospitalists improved recruitment of non-hospitalist general surgeons. However, I am also aware of one program put into place largely at the insistence of the existing surgeons. Those same surgeons later insisted it be dissolved because they saw it as unwanted competition.

Staff needs: Surgical hospitalist practices nearly always require fewer doctors than a medical hospitalist practice in the same institution. This can lead to a tension between having the right number of surgical hospitalists for the case volume (often just one or two doctors) and enough to provide for a reasonable call schedule. Existing groups have adopted a number of strategies.

Groups with only two doctors often have each work seven on/seven off. The doctor on-call for that week takes all night call him/herself. In some practices that have a medical hospitalist in-house all night, it could be reasonable to have routine calls on the surgical patients (e.g., sleeping pills, laxatives, low urine output, fever) first paged to the medical hospitalist, who refers the call to the surgical hospitalist only as needed.

At least one practice has hired enough surgeons so the call burden on each is reasonable. This might be more staff than required for the patient volume: Four surgical hospitalists each work 12-hour shifts in a seven on/seven off schedule. During the seven consecutive night shifts (worked by each surgeon one week in four), patient volume is low.

Some practices hire community surgeons as moonlighters or consider using nurse practitioners or physician’s assistants as first responders at night.

Demographics: Surgical hospitalists are usually midcareer doctors, not surgeons who have recently completed their training. Many say they have gotten burned out with the stress of operating a private practice and prefer hospital work to office work.

Where Will It All Lead?

In every institution I have made contact with, the medical and surgical hospitalists have a good working relationship. Each is available to the other for consults, and they work together so frequently that they can begin to build a greater sense of teamwork. It is important that both groups jointly develop guidelines, such as who admits which type of patients.

If, like primary care doctors, general surgeons and a handful of other specialties with significant hospital volume (such as obstetrics and gastroenterology) move largely to a hospitalist model, U.S. healthcare will have made a remarkable transformation. In the span of my career we will have gone from a system of most doctors seeing patients in and out of the hospital to a division of physician labor such that most doctors practice almost exclusively in only one setting or the other.

I can see how this could be a good thing for patients and medical professionals, but that isn’t a given. For it to turn out we must preserve the elements of the earlier system that worked well and mitigate new problems and complexities. We will need well-designed research to show the economic and quality effects of the hospitalist model on non-primary care fields such as general surgery. We face growing challenges in ensuring excellent communication between inpatient and outpatient caregivers—something that doesn’t work ideally in all medical hospitalist practices.

Let Me Hear From You

I’d like to hear about any surgical hospitalist program you know of so I can add it to my database of information about such programs. And if you’re thinking about becoming a surgical hospitalist or you’re an institution thinking about starting such a practice, feel free to contact me so we can compare notes. I can be reached at (425) 467-3316, or by e-mail: john@jnelson.net. TH

Dr. Nelson has been a practicing hospitalist since 1988 and is co-founder and past president of SHM. He is a principal in Nelson/Flores Associates, a national hospitalist practice management-consulting firm. This column represents his views and is not intended to reflect an official position of SHM.

Many or most specialties in medicine are adopting a hospitalist model, at least to a limited extent. In fact, hospital care of adult medical patients wasn’t even the first place the idea was adopted.

In talking with people from hundreds of institutions it seems clear the idea appeared earlier and grew more quickly in pediatrics than adult medicine. And in the past 10 to 15 years, fields like obstetrics (“laborists”), psychiatry, gastroenterology, and many others have slowly begun to adopt the hospitalist model.

One of the most recent disciplines to join the parade is general surgery. And when comparing the forces in play for hospitalists in the early 1990s to the current situation for surgical hospitalists, I think we may be close to a surge in surgical hospitalists similar to what we’ve seen with medical hospitalists in the past 10 years.

When I say surgical hospitalists, I’m referring to surgeons with a nearly exclusive inpatient practice. Other terms such as surgicalist, acute care surgeon, and traumatologist overlap to some degree but have ambiguous meanings.

Generalizations

For some months I have contacted all the surgical hospitalist practices I can find to learn what forces led to their creation and how they are structured. Several common themes are emerging:

Prevalence: There are probably no more than 20 to 40 surgical hospitalist practices, but many institutions are considering the idea. This is similar to the situation for medical hospitalists in the early to mid-1990s.

Driver to start program: In every program I’ve found, the main impetus to start it was to address the burden of emergency department (ED) call for existing general surgeons. Like primary care, ED call is regarded as unattractive because it is unpredictable (lots of night and weekend work), usually has a poor payer mix, and many general surgeons have seen the “center of gravity” of their practice move away from the hospital toward an ambulatory surgery center over the past 10 years or so. Additionally, many general surgeons are increasingly uncomfortable caring for trauma patients because of recent changes in that field. (For an excellent discussion of the changing nature of general surgery and trauma care see “The Acute Care Surgeon” in The Hospitalist, May 2006, p. 25.)

Case volume: General surgery case volume tends to go up at a hospital that puts a surgical hospitalist program in place. When existing surgeons are relieved of ED call they increase their volume of (mostly elective) surgery. The availability of surgical hospitalists may mean fewer emergency cases presenting to the ED are referred elsewhere (which may happen when non-hospitalist surgeons are required to take ED call). These changes in case volume and the timing of the operations (e.g., volume of night surgeries may go up) may require adjustments to operating room staffing and scheduling. Presumably this increased volume would not occur in an area oversupplied with surgeons.

Economics: Like nearly all medical hospitalist programs, surgical hospitalist practices are not viable without financial support in addition to collected professional fees. In all cases I am aware of, this support comes from the sponsoring hospital.

While the cost may be similar to what the hospital might have paid for existing surgeons to take ED call, hospitals seem to be getting a better return on that investment with surgical hospitalists. A small group of surgical hospitalists can handle the increased volume and all ED calls, improving clinical and service quality. Some institutions report that surgical hospitalists are much more attentive to billing for nonoperative work than their predecessors.

Structure: Programs should have an outpatient clinic where the surgical hospitalists can provide post-operative follow-up. In most cases, each surgeon spends only half a day a week in the clinic.

Scope of practice: All surgical hospitalist practices take most or all ED general surgery calls. In some institutions, the surgical hospitalist also leads the trauma team. Other duties at a few institutions include things like managing a wound-care clinic and being on-call to place lines.

Opinion of other surgeons: Community private practice surgeons tend to support these programs, but most institutions limit or prohibit surgical hospitalists from accepting elective referrals. Community surgeons are still offered the option of remaining on the ED call schedule—as might be the case for surgeons new to the community. At least one institution reported that the presence of surgical hospitalists improved recruitment of non-hospitalist general surgeons. However, I am also aware of one program put into place largely at the insistence of the existing surgeons. Those same surgeons later insisted it be dissolved because they saw it as unwanted competition.

Staff needs: Surgical hospitalist practices nearly always require fewer doctors than a medical hospitalist practice in the same institution. This can lead to a tension between having the right number of surgical hospitalists for the case volume (often just one or two doctors) and enough to provide for a reasonable call schedule. Existing groups have adopted a number of strategies.

Groups with only two doctors often have each work seven on/seven off. The doctor on-call for that week takes all night call him/herself. In some practices that have a medical hospitalist in-house all night, it could be reasonable to have routine calls on the surgical patients (e.g., sleeping pills, laxatives, low urine output, fever) first paged to the medical hospitalist, who refers the call to the surgical hospitalist only as needed.

At least one practice has hired enough surgeons so the call burden on each is reasonable. This might be more staff than required for the patient volume: Four surgical hospitalists each work 12-hour shifts in a seven on/seven off schedule. During the seven consecutive night shifts (worked by each surgeon one week in four), patient volume is low.

Some practices hire community surgeons as moonlighters or consider using nurse practitioners or physician’s assistants as first responders at night.

Demographics: Surgical hospitalists are usually midcareer doctors, not surgeons who have recently completed their training. Many say they have gotten burned out with the stress of operating a private practice and prefer hospital work to office work.

Where Will It All Lead?

In every institution I have made contact with, the medical and surgical hospitalists have a good working relationship. Each is available to the other for consults, and they work together so frequently that they can begin to build a greater sense of teamwork. It is important that both groups jointly develop guidelines, such as who admits which type of patients.

If, like primary care doctors, general surgeons and a handful of other specialties with significant hospital volume (such as obstetrics and gastroenterology) move largely to a hospitalist model, U.S. healthcare will have made a remarkable transformation. In the span of my career we will have gone from a system of most doctors seeing patients in and out of the hospital to a division of physician labor such that most doctors practice almost exclusively in only one setting or the other.

I can see how this could be a good thing for patients and medical professionals, but that isn’t a given. For it to turn out we must preserve the elements of the earlier system that worked well and mitigate new problems and complexities. We will need well-designed research to show the economic and quality effects of the hospitalist model on non-primary care fields such as general surgery. We face growing challenges in ensuring excellent communication between inpatient and outpatient caregivers—something that doesn’t work ideally in all medical hospitalist practices.

Let Me Hear From You

I’d like to hear about any surgical hospitalist program you know of so I can add it to my database of information about such programs. And if you’re thinking about becoming a surgical hospitalist or you’re an institution thinking about starting such a practice, feel free to contact me so we can compare notes. I can be reached at (425) 467-3316, or by e-mail: john@jnelson.net. TH

Dr. Nelson has been a practicing hospitalist since 1988 and is co-founder and past president of SHM. He is a principal in Nelson/Flores Associates, a national hospitalist practice management-consulting firm. This column represents his views and is not intended to reflect an official position of SHM.

Author’s note: More than 1,500 passengers died in the Titanic, a disaster that resonates nearly a hundred years later. The equivalent of about 50 Titanics capsize annually in U.S. hospitals, nearly one every week (based on the Institute of Medicine’s estimate of 44,000-98,000 deaths per year from hospital adverse events). As hospitalists, it is our obligation to ensure the hull is solid, the crow’s nest properly manned, and the ship is turning in the right direction.

I’m the Rev. John Harper, and it’s April 10, 1912.

As I grasp my boarding pass I can’t contain my awe and excitement. Imagine me aboard the world’s most luxurious cruise liner heading to America. Granted, I’m booked in second class. But as everyone knows, second class on the Titanic outstrips first class on most liners these days. It should—for $66 this is an expensive way to travel. Still, it’s less than the cheapest first-class ticket of $125 and much less than a $4,500 booking in the millionaire’s suite. I could buy several houses for $4,500.

Walking along the gangway I recall hearing that this ship—the largest ever built—weighs nearly 47,000 tons and cost $7.5 million. Outside my cabin door I encounter a fellow passenger who exults over the ship’s amenities. The liner has a heated indoor swimming pool, four electric elevators, two libraries, a Turkish bath, a squash court and gymnasium, and ample room to move about. The White Star Line has thoughtfully limited the amount of lifeboats to 20 to preserve precious deck space for passengers.

I’m Jeff Glasheen, and it’s Sept. 15, 2007.

As my wife prepares to deliver our first child in the coming weeks, we visit the labor and delivery deck of the hospital.

It will be our first major interaction with the healthcare system as patients. It’s the largest healthcare system ever and costs nearly $2 trillion a year to operate. We have chosen a new hospital that features an amazing array of amenities, including a birthing center with private suites, in-room baths with oversize soaking tubs, an in-room sleeping area for family and friends, and a DVD player and flat-screen television. There are even Internet connections.

Room service is available 24 hours a day, and the staff is top-notch. I’m told some choose to stay in the VIP suites for an extra $1,000 a night. This restricted-access area offers 600-square-foot rooms with original art on the walls, luxury mattresses and 350-thread count linens, complimentary robes and slippers, and an office area supplied with newspapers, a printer, fax, voicemail, and teleconferencing capabilities. There is a family room as well as a private refrigerator, an assortment of beverages and a dedicated chef. Unfortunately the cost is too steep, so we’ll spend this voyage in second class. However, as everyone knows, second class on this vessel outstrips first class in most hospitals these days.

Midnight, April 14, 1912

Something has gone wrong; the ship just hiccupped a bit. From my cabin I clearly hear a grinding that could happen only when two large objects come into contact. It’s strange, but I assure my bunkmates there is nothing to worry about. The Titanic is unsinkable, built with every feasible safety feature. The ship’s hull is made of inch-thick steel and held together with nearly 3 million steel rivets. In the unlikely event the hull is breached, the ship contains 15 watertight bulkheads to contain the leakage. Further, 3,560 life vests, 48 life buoys, and the aforementioned 20 lifeboats (four more than required by British law) allay my concerns.

On the off chance something should go wrong, the ship is outfitted with the recently developed Marconi wireless telegraph capable of communicating with any ship or shore within 500 miles.

5 p.m., Sept. 17, 2007

As I write this column I consider that something could go wrong during our hospital stay. The Institute of Medicine reports that medications harm 1.5 million people annually (400,000 incidents occur in the hospital) and that nearly 100,000 die annually in adverse hospital events.

I assure myself there is nothing to worry about. The hospital of today is unsinkable, built with every feasible safety measure. Today’s hospitals require two patient identifiers, time-outs before procedures, read-backs, standardized abbreviations, rules for reporting of critical results, standardized approaches to hand-offs, awareness of look-alike/sound-alike medications, hand-hygiene guidelines, medication reconciliation, core measures, quality and patient safety committees—and, on the off chance that something should go wrong, requirements for communicating sentinel event reviews with regulatory agencies.

1:30 a.m., April 14, 1912

The scuttlebutt is that the Titanic has hit an iceberg, tearing open the hull, flooding the bulkheads, and overcoming the ship’s pumps. Apparently the crow’s nest spotted the iceberg only 30 seconds before the impact. The crew tried to change course immediately. But the unprecedented size and speed of the ship (there is a rumor that the captain may have been trying to set a new trans-Atlantic crossing record) made it impossible to avoid our destiny.

We are clearly sinking. As I anxiously pace the deck waiting for a spot on a lifeboat, I chat with a crew member who assures me help is coming. The ship’s band plays on deck, the music soothing in the night air.

1 p.m., Aug. 26, 2007

I’m about halfway through the Titanic exhibit at the local museum of nature and science. The display is designed to give you the experience of being a passenger aboard the RMS Titanic.

Prior to entering, visitors receive a boarding pass with information about one of the actual passengers. I am the Rev. John Harper, traveling to America with my young daughter to begin a series of revival meetings in Chicago. At the end of the tour I’ll view the passenger manifest to discover my outcome.

Reluctantly, I board the ship, anxiously awaiting my fate. I gaze upon thousands of trinkets and treasures rescued from the Titanic since its remains were discovered 2.5 miles below the ocean’s surface 900 miles off the coast of New York in 1985.

I marvel at dioramas of first- and third-class cabins with recovered china settings, uncorked and still-full bottles of champagne, toiletries, jewelry, and clothing.

One of the most fascinating pieces is a chunk of ice the size and shape of a small whale. The display represents the iceberg that doomed the Titanic and simulates the temperature of the water that fateful night. At approximately 28 degrees Fahrenheit, the average person would survive less than 15 minutes in the water. I was able to hold my hand on the ice only a few moments, quickly understanding the horrific way most passengers would die.

As I complete the tour and nervously approach the passenger manifest I am struck by how many lessons from the Titanic can be applied to modern medicine.

We operate in a system surrounded by perilous obstacles in a huge vessel that is slow to change course even in the face of extreme danger and poor outcomes.

We steam along at unparalleled speed embracing new, relatively untested technologies, procedures, and medications. Modern healthcare, like the Titanic, values building technologically advanced, well-adorned vessels rather than investing in the basic infrastructure to make it safer. We eschew quality for appearance.   

We spend money on heated indoor pools, squash courts, and Turkish baths rather than computerized provider order entry, bar code administration, and hand-off improvements. Despite all of this, our passengers trust the vessel is safe. They trust that we will protect them—that we have enough lifeboats.

The Rev. John Harper perished on April 14, 1912; unlike him, as I cross the threshold of the healthcare Titanic I am not filled with awe and excitement. I feel fear and dread. TH

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

Author’s note: More than 1,500 passengers died in the Titanic, a disaster that resonates nearly a hundred years later. The equivalent of about 50 Titanics capsize annually in U.S. hospitals, nearly one every week (based on the Institute of Medicine’s estimate of 44,000-98,000 deaths per year from hospital adverse events). As hospitalists, it is our obligation to ensure the hull is solid, the crow’s nest properly manned, and the ship is turning in the right direction.

I’m the Rev. John Harper, and it’s April 10, 1912.

As I grasp my boarding pass I can’t contain my awe and excitement. Imagine me aboard the world’s most luxurious cruise liner heading to America. Granted, I’m booked in second class. But as everyone knows, second class on the Titanic outstrips first class on most liners these days. It should—for $66 this is an expensive way to travel. Still, it’s less than the cheapest first-class ticket of $125 and much less than a $4,500 booking in the millionaire’s suite. I could buy several houses for $4,500.

Walking along the gangway I recall hearing that this ship—the largest ever built—weighs nearly 47,000 tons and cost $7.5 million. Outside my cabin door I encounter a fellow passenger who exults over the ship’s amenities. The liner has a heated indoor swimming pool, four electric elevators, two libraries, a Turkish bath, a squash court and gymnasium, and ample room to move about. The White Star Line has thoughtfully limited the amount of lifeboats to 20 to preserve precious deck space for passengers.

I’m Jeff Glasheen, and it’s Sept. 15, 2007.

As my wife prepares to deliver our first child in the coming weeks, we visit the labor and delivery deck of the hospital.

It will be our first major interaction with the healthcare system as patients. It’s the largest healthcare system ever and costs nearly $2 trillion a year to operate. We have chosen a new hospital that features an amazing array of amenities, including a birthing center with private suites, in-room baths with oversize soaking tubs, an in-room sleeping area for family and friends, and a DVD player and flat-screen television. There are even Internet connections.

Room service is available 24 hours a day, and the staff is top-notch. I’m told some choose to stay in the VIP suites for an extra $1,000 a night. This restricted-access area offers 600-square-foot rooms with original art on the walls, luxury mattresses and 350-thread count linens, complimentary robes and slippers, and an office area supplied with newspapers, a printer, fax, voicemail, and teleconferencing capabilities. There is a family room as well as a private refrigerator, an assortment of beverages and a dedicated chef. Unfortunately the cost is too steep, so we’ll spend this voyage in second class. However, as everyone knows, second class on this vessel outstrips first class in most hospitals these days.

Midnight, April 14, 1912

Something has gone wrong; the ship just hiccupped a bit. From my cabin I clearly hear a grinding that could happen only when two large objects come into contact. It’s strange, but I assure my bunkmates there is nothing to worry about. The Titanic is unsinkable, built with every feasible safety feature. The ship’s hull is made of inch-thick steel and held together with nearly 3 million steel rivets. In the unlikely event the hull is breached, the ship contains 15 watertight bulkheads to contain the leakage. Further, 3,560 life vests, 48 life buoys, and the aforementioned 20 lifeboats (four more than required by British law) allay my concerns.

On the off chance something should go wrong, the ship is outfitted with the recently developed Marconi wireless telegraph capable of communicating with any ship or shore within 500 miles.

5 p.m., Sept. 17, 2007

As I write this column I consider that something could go wrong during our hospital stay. The Institute of Medicine reports that medications harm 1.5 million people annually (400,000 incidents occur in the hospital) and that nearly 100,000 die annually in adverse hospital events.

I assure myself there is nothing to worry about. The hospital of today is unsinkable, built with every feasible safety measure. Today’s hospitals require two patient identifiers, time-outs before procedures, read-backs, standardized abbreviations, rules for reporting of critical results, standardized approaches to hand-offs, awareness of look-alike/sound-alike medications, hand-hygiene guidelines, medication reconciliation, core measures, quality and patient safety committees—and, on the off chance that something should go wrong, requirements for communicating sentinel event reviews with regulatory agencies.

1:30 a.m., April 14, 1912

The scuttlebutt is that the Titanic has hit an iceberg, tearing open the hull, flooding the bulkheads, and overcoming the ship’s pumps. Apparently the crow’s nest spotted the iceberg only 30 seconds before the impact. The crew tried to change course immediately. But the unprecedented size and speed of the ship (there is a rumor that the captain may have been trying to set a new trans-Atlantic crossing record) made it impossible to avoid our destiny.

We are clearly sinking. As I anxiously pace the deck waiting for a spot on a lifeboat, I chat with a crew member who assures me help is coming. The ship’s band plays on deck, the music soothing in the night air.

1 p.m., Aug. 26, 2007

I’m about halfway through the Titanic exhibit at the local museum of nature and science. The display is designed to give you the experience of being a passenger aboard the RMS Titanic.

Prior to entering, visitors receive a boarding pass with information about one of the actual passengers. I am the Rev. John Harper, traveling to America with my young daughter to begin a series of revival meetings in Chicago. At the end of the tour I’ll view the passenger manifest to discover my outcome.

Reluctantly, I board the ship, anxiously awaiting my fate. I gaze upon thousands of trinkets and treasures rescued from the Titanic since its remains were discovered 2.5 miles below the ocean’s surface 900 miles off the coast of New York in 1985.

I marvel at dioramas of first- and third-class cabins with recovered china settings, uncorked and still-full bottles of champagne, toiletries, jewelry, and clothing.

One of the most fascinating pieces is a chunk of ice the size and shape of a small whale. The display represents the iceberg that doomed the Titanic and simulates the temperature of the water that fateful night. At approximately 28 degrees Fahrenheit, the average person would survive less than 15 minutes in the water. I was able to hold my hand on the ice only a few moments, quickly understanding the horrific way most passengers would die.

As I complete the tour and nervously approach the passenger manifest I am struck by how many lessons from the Titanic can be applied to modern medicine.

We operate in a system surrounded by perilous obstacles in a huge vessel that is slow to change course even in the face of extreme danger and poor outcomes.

We steam along at unparalleled speed embracing new, relatively untested technologies, procedures, and medications. Modern healthcare, like the Titanic, values building technologically advanced, well-adorned vessels rather than investing in the basic infrastructure to make it safer. We eschew quality for appearance.   

We spend money on heated indoor pools, squash courts, and Turkish baths rather than computerized provider order entry, bar code administration, and hand-off improvements. Despite all of this, our passengers trust the vessel is safe. They trust that we will protect them—that we have enough lifeboats.

The Rev. John Harper perished on April 14, 1912; unlike him, as I cross the threshold of the healthcare Titanic I am not filled with awe and excitement. I feel fear and dread. TH

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

Author’s note: More than 1,500 passengers died in the Titanic, a disaster that resonates nearly a hundred years later. The equivalent of about 50 Titanics capsize annually in U.S. hospitals, nearly one every week (based on the Institute of Medicine’s estimate of 44,000-98,000 deaths per year from hospital adverse events). As hospitalists, it is our obligation to ensure the hull is solid, the crow’s nest properly manned, and the ship is turning in the right direction.

I’m the Rev. John Harper, and it’s April 10, 1912.

As I grasp my boarding pass I can’t contain my awe and excitement. Imagine me aboard the world’s most luxurious cruise liner heading to America. Granted, I’m booked in second class. But as everyone knows, second class on the Titanic outstrips first class on most liners these days. It should—for $66 this is an expensive way to travel. Still, it’s less than the cheapest first-class ticket of $125 and much less than a $4,500 booking in the millionaire’s suite. I could buy several houses for $4,500.

Walking along the gangway I recall hearing that this ship—the largest ever built—weighs nearly 47,000 tons and cost $7.5 million. Outside my cabin door I encounter a fellow passenger who exults over the ship’s amenities. The liner has a heated indoor swimming pool, four electric elevators, two libraries, a Turkish bath, a squash court and gymnasium, and ample room to move about. The White Star Line has thoughtfully limited the amount of lifeboats to 20 to preserve precious deck space for passengers.

I’m Jeff Glasheen, and it’s Sept. 15, 2007.

As my wife prepares to deliver our first child in the coming weeks, we visit the labor and delivery deck of the hospital.

It will be our first major interaction with the healthcare system as patients. It’s the largest healthcare system ever and costs nearly $2 trillion a year to operate. We have chosen a new hospital that features an amazing array of amenities, including a birthing center with private suites, in-room baths with oversize soaking tubs, an in-room sleeping area for family and friends, and a DVD player and flat-screen television. There are even Internet connections.

Room service is available 24 hours a day, and the staff is top-notch. I’m told some choose to stay in the VIP suites for an extra $1,000 a night. This restricted-access area offers 600-square-foot rooms with original art on the walls, luxury mattresses and 350-thread count linens, complimentary robes and slippers, and an office area supplied with newspapers, a printer, fax, voicemail, and teleconferencing capabilities. There is a family room as well as a private refrigerator, an assortment of beverages and a dedicated chef. Unfortunately the cost is too steep, so we’ll spend this voyage in second class. However, as everyone knows, second class on this vessel outstrips first class in most hospitals these days.

Midnight, April 14, 1912

Something has gone wrong; the ship just hiccupped a bit. From my cabin I clearly hear a grinding that could happen only when two large objects come into contact. It’s strange, but I assure my bunkmates there is nothing to worry about. The Titanic is unsinkable, built with every feasible safety feature. The ship’s hull is made of inch-thick steel and held together with nearly 3 million steel rivets. In the unlikely event the hull is breached, the ship contains 15 watertight bulkheads to contain the leakage. Further, 3,560 life vests, 48 life buoys, and the aforementioned 20 lifeboats (four more than required by British law) allay my concerns.

On the off chance something should go wrong, the ship is outfitted with the recently developed Marconi wireless telegraph capable of communicating with any ship or shore within 500 miles.

5 p.m., Sept. 17, 2007

As I write this column I consider that something could go wrong during our hospital stay. The Institute of Medicine reports that medications harm 1.5 million people annually (400,000 incidents occur in the hospital) and that nearly 100,000 die annually in adverse hospital events.

I assure myself there is nothing to worry about. The hospital of today is unsinkable, built with every feasible safety measure. Today’s hospitals require two patient identifiers, time-outs before procedures, read-backs, standardized abbreviations, rules for reporting of critical results, standardized approaches to hand-offs, awareness of look-alike/sound-alike medications, hand-hygiene guidelines, medication reconciliation, core measures, quality and patient safety committees—and, on the off chance that something should go wrong, requirements for communicating sentinel event reviews with regulatory agencies.

1:30 a.m., April 14, 1912

The scuttlebutt is that the Titanic has hit an iceberg, tearing open the hull, flooding the bulkheads, and overcoming the ship’s pumps. Apparently the crow’s nest spotted the iceberg only 30 seconds before the impact. The crew tried to change course immediately. But the unprecedented size and speed of the ship (there is a rumor that the captain may have been trying to set a new trans-Atlantic crossing record) made it impossible to avoid our destiny.

We are clearly sinking. As I anxiously pace the deck waiting for a spot on a lifeboat, I chat with a crew member who assures me help is coming. The ship’s band plays on deck, the music soothing in the night air.

1 p.m., Aug. 26, 2007

I’m about halfway through the Titanic exhibit at the local museum of nature and science. The display is designed to give you the experience of being a passenger aboard the RMS Titanic.

Prior to entering, visitors receive a boarding pass with information about one of the actual passengers. I am the Rev. John Harper, traveling to America with my young daughter to begin a series of revival meetings in Chicago. At the end of the tour I’ll view the passenger manifest to discover my outcome.

Reluctantly, I board the ship, anxiously awaiting my fate. I gaze upon thousands of trinkets and treasures rescued from the Titanic since its remains were discovered 2.5 miles below the ocean’s surface 900 miles off the coast of New York in 1985.

I marvel at dioramas of first- and third-class cabins with recovered china settings, uncorked and still-full bottles of champagne, toiletries, jewelry, and clothing.

One of the most fascinating pieces is a chunk of ice the size and shape of a small whale. The display represents the iceberg that doomed the Titanic and simulates the temperature of the water that fateful night. At approximately 28 degrees Fahrenheit, the average person would survive less than 15 minutes in the water. I was able to hold my hand on the ice only a few moments, quickly understanding the horrific way most passengers would die.

As I complete the tour and nervously approach the passenger manifest I am struck by how many lessons from the Titanic can be applied to modern medicine.

We operate in a system surrounded by perilous obstacles in a huge vessel that is slow to change course even in the face of extreme danger and poor outcomes.

We steam along at unparalleled speed embracing new, relatively untested technologies, procedures, and medications. Modern healthcare, like the Titanic, values building technologically advanced, well-adorned vessels rather than investing in the basic infrastructure to make it safer. We eschew quality for appearance.   

We spend money on heated indoor pools, squash courts, and Turkish baths rather than computerized provider order entry, bar code administration, and hand-off improvements. Despite all of this, our passengers trust the vessel is safe. They trust that we will protect them—that we have enough lifeboats.

The Rev. John Harper perished on April 14, 1912; unlike him, as I cross the threshold of the healthcare Titanic I am not filled with awe and excitement. I feel fear and dread. TH

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

The question that nearly stumped me came from the back of the room.

I was giving a presentation on the hospital medicine movement to 350 physicians with an organization interested in our rapidly developing specialty. The evolution of hospital medicine is a great story, and I relish telling it. My biggest problem is usually curbing my enthusiasm to fit the time allotted. As an old colleague once told me when I launched into an exhaustive explanation of a simple medical problem: “Rusty, don’t build the watch—just tell me the time!” For this talk, I behaved myself and had managed with 10 minutes to spare for questions.

Then came the question:

“With more than a third of hospitalists directly employed by the hospital I have concerns that the loyalty of the physician will be to the best interests of the institution instead of the patient, don’t you?”

  It was certainly thought provoking. The questioner was asking if the source of a physician’s paycheck trumped patient needs. For many hospitalists, our employer is technically not the patient, but the hospital. 

Some referring physicians, who put their patients in our care when they hospitalize them, wonder which master we serve. Can that hospitalist in charge of my patient resist the institutional pull to drive down length of stay (LOS) and curtail costs? Whose interests will that physician favor when there is a clash between what my patients might need and the hospital’s bottom line?

 I could have simply said: “No, I’m not concerned. Physicians should always act in the interest of their patients over that of the hospital.” But the real answer is far more complex—a synthesis of complementary interests that can appear mutually exclusive. 

How? While my response was somewhat less well organized than this column, I attempted to address the complexity of the question by including the profile of hospitalists’ employers, the obligations of the medical staff in any hospital, physician incentives, transparency of performance, checks and balances, and the general principle of managing polarities.

Let’s look at the scope of the issue. Who pays the hospitalist? A third are employed directly by hospitals, a fifth by academic medical centers, and nearly half by multispecialty or hospitalist-only medical groups. Two points emerge from the data. First, employment percentage by hospitals has remained stable, while academic centers and hospitalist-only groups have grown. Second, this employment model is not unique to hospitalists. These same types of practice groups and institutions employ physicians in other specialties, too.   

All physicians working in a hospital are members of the active medical staff and must uphold certain core responsibilities. Chief among these are the quality and safety of care, treatment, and services delivered at the institution. That duty applies whether they are solo practitioners or employees of a hospital or independent medical group. 

These core obligations are enforced by the organized medical staff through by-laws, rules, and regulations. Further, the medical staff is beholden to operate with the cooperation of hospital administration/management and hospital governance (i.e., the board) to support quality of care within the institution. 

These elements are intended to provide a structure for optimizing patient care. But they often collide with the real world in which we physicians operate—a world of competing interests we face daily. While a physician’s fiduciary responsibility is always to the patient, there are often other interests to consider. Who among us has not tried to balance the often conflicting opinions and agendas of the:

• Patient;
• Caregivers/family;
• Hospital;
• Primary care physician;
• Consulting specialists; and
• Insurers.

These conflicts are usually over methods rather than outcomes. If hospitals want to cut LOS, so do patients, who want to sleep in their own beds. Hospitals want to manage costly and scarce resources wisely; patients want judicious use of treatments and tests. Hospitals want to keep costs down; patients want to keep out-of-pocket expenses down.

Are the loyalties of doctors to their patients sometimes at odds? The honest answer is, “Sometimes, yes.” Sometimes hospitals make providing care more challenging. Incentives affect how doctors behave. If bonuses accrue to good infection control, infection rates fall. If bonuses are aligned with keeping costs down, costs likely go down. 

But such incentives play a role in how all doctors behave, not just hospitalists employed by a hospital. Self-employed physicians (hospitalists or otherwise) and members of a large medical practice group respond to incentives, as well.

One could argue these doctors might have a greater conflict of interest than hospital-based physicians. Think of the time pressures under which many physicians work, the complexity of the hospital environment, and the burden of paperwork. 

Solo private practitioners whose only source of revenue is professional service fees may be inclined to keep patients in the hospital longer because that generates higher fees. They may also have a secondary agenda: Drive higher patient satisfaction by keeping patients in the hospital until they feel completely well, “protecting” them from hospital administrators who want to “prematurely” discharge them.  

The real problem with incentives is aligning them with optimal care. 

Once we establish that incentives are important, that their ultimate goal is optimal care, the next step is to create transparent, explicit performance criteria. There should be no mystery concerning which behaviors and outcomes physicians are expected to achieve, including those involving quality and safety. Finally, incentives need good checks and balances. There must be a good measurement system for desired performance and a method for keeping tabs to mitigate or eliminate unintended consequences.

All physicians must simultaneously manage the interests of the patient and the interests of the healthcare system—especially the hospital. When these goals are met, patient and system benefit by maximally utilizing precious resources such as inpatient beds, diagnostic and treatment technologies, and drugs. These resources are not limitless and should never be used without a great deal of critical thinking and consideration of alternatives.

There will always be tension between optimizing resources and treatment. Balancing these interests is not a problem to be solved, but a polarity to manage. Polarities are unsolvable because neither pole alone is the right answer. Focusing on one pole to the neglect of the other undermines our efforts to optimize patient needs and propagate a sustainable hospital care system. These alternatives are ongoing and interdependent and must be managed together.

To achieve the right balance, we must establish measures to alert us when one pole “tips” over the other. While I believe physicians, in the face of conflict of interests, must do what is right for the patient, it is also our duty to find ways to balance the interests of all involved. This is the key to a more sustainable, reliable, satisfying healthcare system—and to fulfilling our promise to monitor and self-govern the quality and safety of care we deliver. TH

Dr. Holman is president of SHM. He can be reached at holman.russell@cogenthealthcare.com

The question that nearly stumped me came from the back of the room.

I was giving a presentation on the hospital medicine movement to 350 physicians with an organization interested in our rapidly developing specialty. The evolution of hospital medicine is a great story, and I relish telling it. My biggest problem is usually curbing my enthusiasm to fit the time allotted. As an old colleague once told me when I launched into an exhaustive explanation of a simple medical problem: “Rusty, don’t build the watch—just tell me the time!” For this talk, I behaved myself and had managed with 10 minutes to spare for questions.

Then came the question:

“With more than a third of hospitalists directly employed by the hospital I have concerns that the loyalty of the physician will be to the best interests of the institution instead of the patient, don’t you?”

  It was certainly thought provoking. The questioner was asking if the source of a physician’s paycheck trumped patient needs. For many hospitalists, our employer is technically not the patient, but the hospital. 

Some referring physicians, who put their patients in our care when they hospitalize them, wonder which master we serve. Can that hospitalist in charge of my patient resist the institutional pull to drive down length of stay (LOS) and curtail costs? Whose interests will that physician favor when there is a clash between what my patients might need and the hospital’s bottom line?

 I could have simply said: “No, I’m not concerned. Physicians should always act in the interest of their patients over that of the hospital.” But the real answer is far more complex—a synthesis of complementary interests that can appear mutually exclusive. 

How? While my response was somewhat less well organized than this column, I attempted to address the complexity of the question by including the profile of hospitalists’ employers, the obligations of the medical staff in any hospital, physician incentives, transparency of performance, checks and balances, and the general principle of managing polarities.

Let’s look at the scope of the issue. Who pays the hospitalist? A third are employed directly by hospitals, a fifth by academic medical centers, and nearly half by multispecialty or hospitalist-only medical groups. Two points emerge from the data. First, employment percentage by hospitals has remained stable, while academic centers and hospitalist-only groups have grown. Second, this employment model is not unique to hospitalists. These same types of practice groups and institutions employ physicians in other specialties, too.   

All physicians working in a hospital are members of the active medical staff and must uphold certain core responsibilities. Chief among these are the quality and safety of care, treatment, and services delivered at the institution. That duty applies whether they are solo practitioners or employees of a hospital or independent medical group. 

These core obligations are enforced by the organized medical staff through by-laws, rules, and regulations. Further, the medical staff is beholden to operate with the cooperation of hospital administration/management and hospital governance (i.e., the board) to support quality of care within the institution. 

These elements are intended to provide a structure for optimizing patient care. But they often collide with the real world in which we physicians operate—a world of competing interests we face daily. While a physician’s fiduciary responsibility is always to the patient, there are often other interests to consider. Who among us has not tried to balance the often conflicting opinions and agendas of the:

• Patient;
• Caregivers/family;
• Hospital;
• Primary care physician;
• Consulting specialists; and
• Insurers.

These conflicts are usually over methods rather than outcomes. If hospitals want to cut LOS, so do patients, who want to sleep in their own beds. Hospitals want to manage costly and scarce resources wisely; patients want judicious use of treatments and tests. Hospitals want to keep costs down; patients want to keep out-of-pocket expenses down.

Are the loyalties of doctors to their patients sometimes at odds? The honest answer is, “Sometimes, yes.” Sometimes hospitals make providing care more challenging. Incentives affect how doctors behave. If bonuses accrue to good infection control, infection rates fall. If bonuses are aligned with keeping costs down, costs likely go down. 

But such incentives play a role in how all doctors behave, not just hospitalists employed by a hospital. Self-employed physicians (hospitalists or otherwise) and members of a large medical practice group respond to incentives, as well.

One could argue these doctors might have a greater conflict of interest than hospital-based physicians. Think of the time pressures under which many physicians work, the complexity of the hospital environment, and the burden of paperwork. 

Solo private practitioners whose only source of revenue is professional service fees may be inclined to keep patients in the hospital longer because that generates higher fees. They may also have a secondary agenda: Drive higher patient satisfaction by keeping patients in the hospital until they feel completely well, “protecting” them from hospital administrators who want to “prematurely” discharge them.  

The real problem with incentives is aligning them with optimal care. 

Once we establish that incentives are important, that their ultimate goal is optimal care, the next step is to create transparent, explicit performance criteria. There should be no mystery concerning which behaviors and outcomes physicians are expected to achieve, including those involving quality and safety. Finally, incentives need good checks and balances. There must be a good measurement system for desired performance and a method for keeping tabs to mitigate or eliminate unintended consequences.

All physicians must simultaneously manage the interests of the patient and the interests of the healthcare system—especially the hospital. When these goals are met, patient and system benefit by maximally utilizing precious resources such as inpatient beds, diagnostic and treatment technologies, and drugs. These resources are not limitless and should never be used without a great deal of critical thinking and consideration of alternatives.

There will always be tension between optimizing resources and treatment. Balancing these interests is not a problem to be solved, but a polarity to manage. Polarities are unsolvable because neither pole alone is the right answer. Focusing on one pole to the neglect of the other undermines our efforts to optimize patient needs and propagate a sustainable hospital care system. These alternatives are ongoing and interdependent and must be managed together.

To achieve the right balance, we must establish measures to alert us when one pole “tips” over the other. While I believe physicians, in the face of conflict of interests, must do what is right for the patient, it is also our duty to find ways to balance the interests of all involved. This is the key to a more sustainable, reliable, satisfying healthcare system—and to fulfilling our promise to monitor and self-govern the quality and safety of care we deliver. TH

Dr. Holman is president of SHM. He can be reached at holman.russell@cogenthealthcare.com

The question that nearly stumped me came from the back of the room.

I was giving a presentation on the hospital medicine movement to 350 physicians with an organization interested in our rapidly developing specialty. The evolution of hospital medicine is a great story, and I relish telling it. My biggest problem is usually curbing my enthusiasm to fit the time allotted. As an old colleague once told me when I launched into an exhaustive explanation of a simple medical problem: “Rusty, don’t build the watch—just tell me the time!” For this talk, I behaved myself and had managed with 10 minutes to spare for questions.

Then came the question:

“With more than a third of hospitalists directly employed by the hospital I have concerns that the loyalty of the physician will be to the best interests of the institution instead of the patient, don’t you?”

  It was certainly thought provoking. The questioner was asking if the source of a physician’s paycheck trumped patient needs. For many hospitalists, our employer is technically not the patient, but the hospital. 

Some referring physicians, who put their patients in our care when they hospitalize them, wonder which master we serve. Can that hospitalist in charge of my patient resist the institutional pull to drive down length of stay (LOS) and curtail costs? Whose interests will that physician favor when there is a clash between what my patients might need and the hospital’s bottom line?

 I could have simply said: “No, I’m not concerned. Physicians should always act in the interest of their patients over that of the hospital.” But the real answer is far more complex—a synthesis of complementary interests that can appear mutually exclusive. 

How? While my response was somewhat less well organized than this column, I attempted to address the complexity of the question by including the profile of hospitalists’ employers, the obligations of the medical staff in any hospital, physician incentives, transparency of performance, checks and balances, and the general principle of managing polarities.

Let’s look at the scope of the issue. Who pays the hospitalist? A third are employed directly by hospitals, a fifth by academic medical centers, and nearly half by multispecialty or hospitalist-only medical groups. Two points emerge from the data. First, employment percentage by hospitals has remained stable, while academic centers and hospitalist-only groups have grown. Second, this employment model is not unique to hospitalists. These same types of practice groups and institutions employ physicians in other specialties, too.   

All physicians working in a hospital are members of the active medical staff and must uphold certain core responsibilities. Chief among these are the quality and safety of care, treatment, and services delivered at the institution. That duty applies whether they are solo practitioners or employees of a hospital or independent medical group. 

These core obligations are enforced by the organized medical staff through by-laws, rules, and regulations. Further, the medical staff is beholden to operate with the cooperation of hospital administration/management and hospital governance (i.e., the board) to support quality of care within the institution. 

These elements are intended to provide a structure for optimizing patient care. But they often collide with the real world in which we physicians operate—a world of competing interests we face daily. While a physician’s fiduciary responsibility is always to the patient, there are often other interests to consider. Who among us has not tried to balance the often conflicting opinions and agendas of the:

• Patient;
• Caregivers/family;
• Hospital;
• Primary care physician;
• Consulting specialists; and
• Insurers.

These conflicts are usually over methods rather than outcomes. If hospitals want to cut LOS, so do patients, who want to sleep in their own beds. Hospitals want to manage costly and scarce resources wisely; patients want judicious use of treatments and tests. Hospitals want to keep costs down; patients want to keep out-of-pocket expenses down.

Are the loyalties of doctors to their patients sometimes at odds? The honest answer is, “Sometimes, yes.” Sometimes hospitals make providing care more challenging. Incentives affect how doctors behave. If bonuses accrue to good infection control, infection rates fall. If bonuses are aligned with keeping costs down, costs likely go down. 

But such incentives play a role in how all doctors behave, not just hospitalists employed by a hospital. Self-employed physicians (hospitalists or otherwise) and members of a large medical practice group respond to incentives, as well.

One could argue these doctors might have a greater conflict of interest than hospital-based physicians. Think of the time pressures under which many physicians work, the complexity of the hospital environment, and the burden of paperwork. 

Solo private practitioners whose only source of revenue is professional service fees may be inclined to keep patients in the hospital longer because that generates higher fees. They may also have a secondary agenda: Drive higher patient satisfaction by keeping patients in the hospital until they feel completely well, “protecting” them from hospital administrators who want to “prematurely” discharge them.  

The real problem with incentives is aligning them with optimal care. 

Once we establish that incentives are important, that their ultimate goal is optimal care, the next step is to create transparent, explicit performance criteria. There should be no mystery concerning which behaviors and outcomes physicians are expected to achieve, including those involving quality and safety. Finally, incentives need good checks and balances. There must be a good measurement system for desired performance and a method for keeping tabs to mitigate or eliminate unintended consequences.

All physicians must simultaneously manage the interests of the patient and the interests of the healthcare system—especially the hospital. When these goals are met, patient and system benefit by maximally utilizing precious resources such as inpatient beds, diagnostic and treatment technologies, and drugs. These resources are not limitless and should never be used without a great deal of critical thinking and consideration of alternatives.

There will always be tension between optimizing resources and treatment. Balancing these interests is not a problem to be solved, but a polarity to manage. Polarities are unsolvable because neither pole alone is the right answer. Focusing on one pole to the neglect of the other undermines our efforts to optimize patient needs and propagate a sustainable hospital care system. These alternatives are ongoing and interdependent and must be managed together.

To achieve the right balance, we must establish measures to alert us when one pole “tips” over the other. While I believe physicians, in the face of conflict of interests, must do what is right for the patient, it is also our duty to find ways to balance the interests of all involved. This is the key to a more sustainable, reliable, satisfying healthcare system—and to fulfilling our promise to monitor and self-govern the quality and safety of care we deliver. TH

Dr. Holman is president of SHM. He can be reached at holman.russell@cogenthealthcare.com

In addition to being expert in acute care clinical issues, hospitalists are knowledgeable in the ways and means of the hospital.

As teachers, hospitalists are ideally situated to improve house staff’s proficiency in areas such as evidence-based medicine, effective teamwork, communication, and quality improvement.1 These areas meld with hospitalist core competencies, writes David M. Pressel, MD, PhD, director of Inpatient Service and General Pediatrics at Alfred I. duPont Hospital for Children in Wilmington, Del.

What makes a great hospitalist a great teacher? “I don’t think there is anything special about a hospitalist [that would make him or her] a great teacher as opposed to another kind of physician,” Dr. Pressel says. “The only caveat to that is that presumably the hospitalist has specialized knowledge that they can impart similarly to [how] another doc can [impart information] in their specialized knowledge.”

Good teaching in all specialties has the same core features. But the key component a hospitalist would want to impart, he says, is that the hospitalist should maintain a holistic view of the patient.

In Dr. Pressel’s view, a great teacher loves what he does, has a sense of humor and makes learning fun or enjoyable, makes his lessons interactive, continually learns alongside his students, and knows his strengths and weaknesses.

“A great teacher has a sense of self-awareness as to what they do well and what they don’t do well,” he says. “Some people can be dynamic speakers for a mass audience and hold a lecture hall of 200 in thrall, but one on one, they’re not that strong. Others are the opposite. It is easy to teach people who are smart, dynamic, and interested; it is more challenging for someone who is a bit slower and [finds it] harder to get it.”

A good teacher also models for his trainees, especially in more delicate conversations, such as when giving bad news or asking patients and families to make difficult decisions.

“Residents should be watching you have those kinds of conversations,” says Howard Epstein, MD, a hospitalist and the medical director of the palliative care program at Regions Hospital, St. Paul, Minn. “[Rather than saying], ‘I’m just going to go have a family conference so why don’t you go take care of this, that, and the other thing,’ we should be saying, ‘This is really important. You need to come in and watch me do this now. This is just as important as putting in those discharge orders or putting in that central line.’ ”

Teach versus Coach

Jeffery G. Wiese, MD, associate professor of medicine at Tulane University in New Orleans, has thought a lot about what makes a great teacher and the differences between teaching information and teaching skills. To him it is the difference between teaching and coaching.

Dr. Wiese, who is on SHM’s board of directors, believes medical education is less about the dissemination of knowledge and more about how to apply that knowledge.

“Dissemination of knowledge is requisite but not sufficient,” says Dr. Wiese. “Clinical education is about performance because ultimately it doesn’t matter if the student knows a lot if he or she can’t put it in act for the benefit of their patient. And when you change that paradigm, then you move from being a good teacher to being a great coach.”

Dr. Wiese, who is also director of the Internal Medicine Residency Program and the chief of medicine at Tulane, presented a workshop at the SHM’s annual meeting in May, titled “Great Hospitalist to Great Teacher: Clinical Coaching.”

The five main points of the presentation are represented by the mnemonic VACUM: visualization, anticipation, choosing content that has utility, and motivation.

Visualization

Great teachers empower trainees to visualize how they will use the skill or knowledge for the benefit of the patient. The average lecture on hypotension, for example, disseminates the causes of hypotension and the treatment for each. The great coaching session, however, begins with getting the student to visualize using the skill. “Picture this: You are awakened from sleep on call to see a hypotensive patient,” Dr. Wiese says. “Do you see yourself in the room? Do you see the panic, the fear of those around you? Now visualize feeling the warmth of the patient’s extremities to exclude causes of low vascular resistance. Now imagine feeling the pulse to exclude bradycardia. Are you there? Now see yourself lowering the head of the bed and starting the IV to increase his preload.” The vision makes the content stick in the student’s memory.

Anticipation

“It’s not enough to teach a trainee how to do the skill,” says Dr. Wiese. “You have to anticipate where the trainee is going to get it confused and where the pitfalls are going to be in performing that skill down the road.”

This concept is analogous to that of someone giving directions to their house. Merely giving the student the destination (i.e., what they need to know) is not sufficient. Providing a heads up on where they might take a wrong turn ensures that they arrive at the destination.

In teaching hyperosmolar nonketotic coma (HONKC), for example, a great coach will begin with the warning: “Listen, this is where you could get confused. You might be tempted to ascribe a patient’s delirium to the osmotic effects of the high glucose, and while this can happen, it does not happen with a serum osmolarity of less than 340. You could forget that the cortisol surge that comes from infection is the leading cause of HONKC. Do you see yourself in the emergency department with that patient with HONKC? OK, when it happens, make sure you check the osmolarity; if it’s less than 340, do the lumbar puncture. Meningitis may just be the cause of the delirium and the infection that has caused the HONKC.”

Content With Utility

Teaching the oppressive details about a disease beyond what the student learns from textbooks probably does not have the same utility for them as learning the fundamental principles of how to diagnose, treat, and prognosticate a disease, says Dr. Wiese.

Although most hospitalists train in internal medicine, with a lesser number training in pediatrics or family practice, all hospitalist instructors are still responsible for all students—including those who may be headed for radiology or orthopedics, for instance.

“I can teach the medical content that is of utility to that student’s performance,” Dr. Wiese says, “and I still share responsibility for their performance as an orthopedic surgeon, particularly with respect to how they manage medical disease.” The important lesson is that utility is defined by the learner. “If my student has chosen a future career in orthopedics, the content of the lectures will shift away from high-end internal medicine topics and toward what I think the future orthopedist before me needs to know.”

Motivation

“Should we have to motivate students to be great physicians both professionally and in terms of patient care and knowledge competence?” asks Dr. Wiese. “At the end of the day, the answer should be no; everyone has responsibility for motivating themselves. But, like a great coach, it is still the coach’s responsibly to ensure that when the players are tired, when they’re hungry, when they’ve got other things on their mind, they will stay motivated to want to learn the skill—even before we begin to teach the skill.

“A big portion of that motivation comes from figuring out what their career goals are and helping to link the medical knowledge or the skill that you’re teaching to those hooks, those things that are going to be of interest to them.”

There are four key components to motivation, says Dr. Wiese.

“First, remember the student’s name and use it often,” he says. “Remember that they will not care what you know, until they know that you care. Second, be physical. Reach out with the handshake or pat on the shoulder when things get done correctly. Third, stay focused on their hooks: Couch all content in terms of how they will use it in their future careers, and focus your analogies on their personal interests. For example, if a student likes music, my teaching of heart murmurs is going to use analogies of the song writer and performer.”

Game Time

“The medical knowledge is analogous to the play that the team will run or the skill of throwing the ball, but [there are a lot of other factors that influence what’s needed for] the game-time scenario,” Dr. Wiese says. “It’s how you interact with the clock for the game, how you interact with the referees, how you interact with your team mates, how you interact against the defense.”

To teach in order to prepare your “players” for the realities of the challenge—or the challenges of reality, as the case may be—teachers need to do more than unwittingly repeat the methods used when they were students.

“A student who is learning about a disease from Harrison’s or Cecil’s [textbooks] can focus on all the details and knowledge they need to know,” says Dr. Wiese. “But the thing that they can’t get out of the book and that they really need from the hospitalist coach is all that game-time instruction.”

In other words, hospitalists must consider with their students how to integrate their knowledge into their interactions with the hospital system.

In this era of PDAs, wireless networking, and access to the Internet, hospitalists are way past the point of having to keep all their acquired information in their heads, Dr. Wiese says. “The issue now is how do you ask the right questions and then access that knowledge—and then more importantly, how do you take that knowledge and put it into the ‘play’ that is the patient?” And that is what a student can’t get out of a book, he says—and what they need to get from their coach.

Be an Agent for Change

Don’t automatically transfer the way you learned or the ways you were taught into how you teach your own students. “Learning and teaching are very different,” says Dr. Wiese. “Learning knowledge is focused on the details. Teaching is much more [about] how you put that knowledge into play.”

That kind of transference is easily recognizable in a situation where a student asks “Can you teach me something this afternoon?” and the hospitalist replies, “Well, let me go home tonight and prepare, and then I’ll teach you.”

“What they’re saying is, ‘Let me read up, make a list of facts—maybe worse, maybe put it in PowerPoint,’ ” says Dr. Wiese. “The student could have done that on his or her own.”

Because hospitalists are intimately familiar with the hospital system, they serve as agents of change, Dr. Wiese says.

“Hospitalists are the key group at the first level of being able to take a student or resident or fellow and say, ‘These are the patients, we’re on hospital wards, and let me show you how to put in action the knowledge and skills you have to make a success for your patients,’ ” he says.

Hospitalists know where the system doesn’t work. “The great hospitalist doesn’t [face a problem and think], ‘Oh, woe is me; I’m hopelessly at the whim of the system that is broken,” says Dr. Wiese. “A great hospitalist consistently looks at [the situation] and asks, ‘How can I improve this system?’ The only way that medical students and residents can move out of the helpless role where [they see themselves as] servants of the system is to have hospitalist teachers who have a perspective of themselves as owners and who take responsibility for improving the system. Nothing has to be the way that it is,” says Dr. Wiese. TH

Andrea Sattinger is a frequent contributor to The Hospitalist.

References

1. Pressel DM. Hospitalists in medical education: coming to an academic medical center near you. J Natl Med Assoc. 2006 Sep;98(9):1501-1504.

In addition to being expert in acute care clinical issues, hospitalists are knowledgeable in the ways and means of the hospital.

As teachers, hospitalists are ideally situated to improve house staff’s proficiency in areas such as evidence-based medicine, effective teamwork, communication, and quality improvement.1 These areas meld with hospitalist core competencies, writes David M. Pressel, MD, PhD, director of Inpatient Service and General Pediatrics at Alfred I. duPont Hospital for Children in Wilmington, Del.

What makes a great hospitalist a great teacher? “I don’t think there is anything special about a hospitalist [that would make him or her] a great teacher as opposed to another kind of physician,” Dr. Pressel says. “The only caveat to that is that presumably the hospitalist has specialized knowledge that they can impart similarly to [how] another doc can [impart information] in their specialized knowledge.”

Good teaching in all specialties has the same core features. But the key component a hospitalist would want to impart, he says, is that the hospitalist should maintain a holistic view of the patient.

In Dr. Pressel’s view, a great teacher loves what he does, has a sense of humor and makes learning fun or enjoyable, makes his lessons interactive, continually learns alongside his students, and knows his strengths and weaknesses.

“A great teacher has a sense of self-awareness as to what they do well and what they don’t do well,” he says. “Some people can be dynamic speakers for a mass audience and hold a lecture hall of 200 in thrall, but one on one, they’re not that strong. Others are the opposite. It is easy to teach people who are smart, dynamic, and interested; it is more challenging for someone who is a bit slower and [finds it] harder to get it.”

A good teacher also models for his trainees, especially in more delicate conversations, such as when giving bad news or asking patients and families to make difficult decisions.

“Residents should be watching you have those kinds of conversations,” says Howard Epstein, MD, a hospitalist and the medical director of the palliative care program at Regions Hospital, St. Paul, Minn. “[Rather than saying], ‘I’m just going to go have a family conference so why don’t you go take care of this, that, and the other thing,’ we should be saying, ‘This is really important. You need to come in and watch me do this now. This is just as important as putting in those discharge orders or putting in that central line.’ ”

Teach versus Coach

Jeffery G. Wiese, MD, associate professor of medicine at Tulane University in New Orleans, has thought a lot about what makes a great teacher and the differences between teaching information and teaching skills. To him it is the difference between teaching and coaching.

Dr. Wiese, who is on SHM’s board of directors, believes medical education is less about the dissemination of knowledge and more about how to apply that knowledge.

“Dissemination of knowledge is requisite but not sufficient,” says Dr. Wiese. “Clinical education is about performance because ultimately it doesn’t matter if the student knows a lot if he or she can’t put it in act for the benefit of their patient. And when you change that paradigm, then you move from being a good teacher to being a great coach.”

Dr. Wiese, who is also director of the Internal Medicine Residency Program and the chief of medicine at Tulane, presented a workshop at the SHM’s annual meeting in May, titled “Great Hospitalist to Great Teacher: Clinical Coaching.”

The five main points of the presentation are represented by the mnemonic VACUM: visualization, anticipation, choosing content that has utility, and motivation.

Visualization

Great teachers empower trainees to visualize how they will use the skill or knowledge for the benefit of the patient. The average lecture on hypotension, for example, disseminates the causes of hypotension and the treatment for each. The great coaching session, however, begins with getting the student to visualize using the skill. “Picture this: You are awakened from sleep on call to see a hypotensive patient,” Dr. Wiese says. “Do you see yourself in the room? Do you see the panic, the fear of those around you? Now visualize feeling the warmth of the patient’s extremities to exclude causes of low vascular resistance. Now imagine feeling the pulse to exclude bradycardia. Are you there? Now see yourself lowering the head of the bed and starting the IV to increase his preload.” The vision makes the content stick in the student’s memory.

Anticipation

“It’s not enough to teach a trainee how to do the skill,” says Dr. Wiese. “You have to anticipate where the trainee is going to get it confused and where the pitfalls are going to be in performing that skill down the road.”

This concept is analogous to that of someone giving directions to their house. Merely giving the student the destination (i.e., what they need to know) is not sufficient. Providing a heads up on where they might take a wrong turn ensures that they arrive at the destination.

In teaching hyperosmolar nonketotic coma (HONKC), for example, a great coach will begin with the warning: “Listen, this is where you could get confused. You might be tempted to ascribe a patient’s delirium to the osmotic effects of the high glucose, and while this can happen, it does not happen with a serum osmolarity of less than 340. You could forget that the cortisol surge that comes from infection is the leading cause of HONKC. Do you see yourself in the emergency department with that patient with HONKC? OK, when it happens, make sure you check the osmolarity; if it’s less than 340, do the lumbar puncture. Meningitis may just be the cause of the delirium and the infection that has caused the HONKC.”

Content With Utility

Teaching the oppressive details about a disease beyond what the student learns from textbooks probably does not have the same utility for them as learning the fundamental principles of how to diagnose, treat, and prognosticate a disease, says Dr. Wiese.

Although most hospitalists train in internal medicine, with a lesser number training in pediatrics or family practice, all hospitalist instructors are still responsible for all students—including those who may be headed for radiology or orthopedics, for instance.

“I can teach the medical content that is of utility to that student’s performance,” Dr. Wiese says, “and I still share responsibility for their performance as an orthopedic surgeon, particularly with respect to how they manage medical disease.” The important lesson is that utility is defined by the learner. “If my student has chosen a future career in orthopedics, the content of the lectures will shift away from high-end internal medicine topics and toward what I think the future orthopedist before me needs to know.”

Motivation

“Should we have to motivate students to be great physicians both professionally and in terms of patient care and knowledge competence?” asks Dr. Wiese. “At the end of the day, the answer should be no; everyone has responsibility for motivating themselves. But, like a great coach, it is still the coach’s responsibly to ensure that when the players are tired, when they’re hungry, when they’ve got other things on their mind, they will stay motivated to want to learn the skill—even before we begin to teach the skill.

“A big portion of that motivation comes from figuring out what their career goals are and helping to link the medical knowledge or the skill that you’re teaching to those hooks, those things that are going to be of interest to them.”

There are four key components to motivation, says Dr. Wiese.

“First, remember the student’s name and use it often,” he says. “Remember that they will not care what you know, until they know that you care. Second, be physical. Reach out with the handshake or pat on the shoulder when things get done correctly. Third, stay focused on their hooks: Couch all content in terms of how they will use it in their future careers, and focus your analogies on their personal interests. For example, if a student likes music, my teaching of heart murmurs is going to use analogies of the song writer and performer.”

Game Time

“The medical knowledge is analogous to the play that the team will run or the skill of throwing the ball, but [there are a lot of other factors that influence what’s needed for] the game-time scenario,” Dr. Wiese says. “It’s how you interact with the clock for the game, how you interact with the referees, how you interact with your team mates, how you interact against the defense.”

To teach in order to prepare your “players” for the realities of the challenge—or the challenges of reality, as the case may be—teachers need to do more than unwittingly repeat the methods used when they were students.

“A student who is learning about a disease from Harrison’s or Cecil’s [textbooks] can focus on all the details and knowledge they need to know,” says Dr. Wiese. “But the thing that they can’t get out of the book and that they really need from the hospitalist coach is all that game-time instruction.”

In other words, hospitalists must consider with their students how to integrate their knowledge into their interactions with the hospital system.

In this era of PDAs, wireless networking, and access to the Internet, hospitalists are way past the point of having to keep all their acquired information in their heads, Dr. Wiese says. “The issue now is how do you ask the right questions and then access that knowledge—and then more importantly, how do you take that knowledge and put it into the ‘play’ that is the patient?” And that is what a student can’t get out of a book, he says—and what they need to get from their coach.

Be an Agent for Change

Don’t automatically transfer the way you learned or the ways you were taught into how you teach your own students. “Learning and teaching are very different,” says Dr. Wiese. “Learning knowledge is focused on the details. Teaching is much more [about] how you put that knowledge into play.”

That kind of transference is easily recognizable in a situation where a student asks “Can you teach me something this afternoon?” and the hospitalist replies, “Well, let me go home tonight and prepare, and then I’ll teach you.”

“What they’re saying is, ‘Let me read up, make a list of facts—maybe worse, maybe put it in PowerPoint,’ ” says Dr. Wiese. “The student could have done that on his or her own.”

Because hospitalists are intimately familiar with the hospital system, they serve as agents of change, Dr. Wiese says.

“Hospitalists are the key group at the first level of being able to take a student or resident or fellow and say, ‘These are the patients, we’re on hospital wards, and let me show you how to put in action the knowledge and skills you have to make a success for your patients,’ ” he says.

Hospitalists know where the system doesn’t work. “The great hospitalist doesn’t [face a problem and think], ‘Oh, woe is me; I’m hopelessly at the whim of the system that is broken,” says Dr. Wiese. “A great hospitalist consistently looks at [the situation] and asks, ‘How can I improve this system?’ The only way that medical students and residents can move out of the helpless role where [they see themselves as] servants of the system is to have hospitalist teachers who have a perspective of themselves as owners and who take responsibility for improving the system. Nothing has to be the way that it is,” says Dr. Wiese. TH

Andrea Sattinger is a frequent contributor to The Hospitalist.

References

1. Pressel DM. Hospitalists in medical education: coming to an academic medical center near you. J Natl Med Assoc. 2006 Sep;98(9):1501-1504.

In addition to being expert in acute care clinical issues, hospitalists are knowledgeable in the ways and means of the hospital.

As teachers, hospitalists are ideally situated to improve house staff’s proficiency in areas such as evidence-based medicine, effective teamwork, communication, and quality improvement.1 These areas meld with hospitalist core competencies, writes David M. Pressel, MD, PhD, director of Inpatient Service and General Pediatrics at Alfred I. duPont Hospital for Children in Wilmington, Del.

What makes a great hospitalist a great teacher? “I don’t think there is anything special about a hospitalist [that would make him or her] a great teacher as opposed to another kind of physician,” Dr. Pressel says. “The only caveat to that is that presumably the hospitalist has specialized knowledge that they can impart similarly to [how] another doc can [impart information] in their specialized knowledge.”

Good teaching in all specialties has the same core features. But the key component a hospitalist would want to impart, he says, is that the hospitalist should maintain a holistic view of the patient.

In Dr. Pressel’s view, a great teacher loves what he does, has a sense of humor and makes learning fun or enjoyable, makes his lessons interactive, continually learns alongside his students, and knows his strengths and weaknesses.

“A great teacher has a sense of self-awareness as to what they do well and what they don’t do well,” he says. “Some people can be dynamic speakers for a mass audience and hold a lecture hall of 200 in thrall, but one on one, they’re not that strong. Others are the opposite. It is easy to teach people who are smart, dynamic, and interested; it is more challenging for someone who is a bit slower and [finds it] harder to get it.”

A good teacher also models for his trainees, especially in more delicate conversations, such as when giving bad news or asking patients and families to make difficult decisions.

“Residents should be watching you have those kinds of conversations,” says Howard Epstein, MD, a hospitalist and the medical director of the palliative care program at Regions Hospital, St. Paul, Minn. “[Rather than saying], ‘I’m just going to go have a family conference so why don’t you go take care of this, that, and the other thing,’ we should be saying, ‘This is really important. You need to come in and watch me do this now. This is just as important as putting in those discharge orders or putting in that central line.’ ”

Teach versus Coach

Jeffery G. Wiese, MD, associate professor of medicine at Tulane University in New Orleans, has thought a lot about what makes a great teacher and the differences between teaching information and teaching skills. To him it is the difference between teaching and coaching.

Dr. Wiese, who is on SHM’s board of directors, believes medical education is less about the dissemination of knowledge and more about how to apply that knowledge.

“Dissemination of knowledge is requisite but not sufficient,” says Dr. Wiese. “Clinical education is about performance because ultimately it doesn’t matter if the student knows a lot if he or she can’t put it in act for the benefit of their patient. And when you change that paradigm, then you move from being a good teacher to being a great coach.”

Dr. Wiese, who is also director of the Internal Medicine Residency Program and the chief of medicine at Tulane, presented a workshop at the SHM’s annual meeting in May, titled “Great Hospitalist to Great Teacher: Clinical Coaching.”

The five main points of the presentation are represented by the mnemonic VACUM: visualization, anticipation, choosing content that has utility, and motivation.

Visualization

Great teachers empower trainees to visualize how they will use the skill or knowledge for the benefit of the patient. The average lecture on hypotension, for example, disseminates the causes of hypotension and the treatment for each. The great coaching session, however, begins with getting the student to visualize using the skill. “Picture this: You are awakened from sleep on call to see a hypotensive patient,” Dr. Wiese says. “Do you see yourself in the room? Do you see the panic, the fear of those around you? Now visualize feeling the warmth of the patient’s extremities to exclude causes of low vascular resistance. Now imagine feeling the pulse to exclude bradycardia. Are you there? Now see yourself lowering the head of the bed and starting the IV to increase his preload.” The vision makes the content stick in the student’s memory.

Anticipation

“It’s not enough to teach a trainee how to do the skill,” says Dr. Wiese. “You have to anticipate where the trainee is going to get it confused and where the pitfalls are going to be in performing that skill down the road.”

This concept is analogous to that of someone giving directions to their house. Merely giving the student the destination (i.e., what they need to know) is not sufficient. Providing a heads up on where they might take a wrong turn ensures that they arrive at the destination.

In teaching hyperosmolar nonketotic coma (HONKC), for example, a great coach will begin with the warning: “Listen, this is where you could get confused. You might be tempted to ascribe a patient’s delirium to the osmotic effects of the high glucose, and while this can happen, it does not happen with a serum osmolarity of less than 340. You could forget that the cortisol surge that comes from infection is the leading cause of HONKC. Do you see yourself in the emergency department with that patient with HONKC? OK, when it happens, make sure you check the osmolarity; if it’s less than 340, do the lumbar puncture. Meningitis may just be the cause of the delirium and the infection that has caused the HONKC.”

Content With Utility

Teaching the oppressive details about a disease beyond what the student learns from textbooks probably does not have the same utility for them as learning the fundamental principles of how to diagnose, treat, and prognosticate a disease, says Dr. Wiese.

Although most hospitalists train in internal medicine, with a lesser number training in pediatrics or family practice, all hospitalist instructors are still responsible for all students—including those who may be headed for radiology or orthopedics, for instance.

“I can teach the medical content that is of utility to that student’s performance,” Dr. Wiese says, “and I still share responsibility for their performance as an orthopedic surgeon, particularly with respect to how they manage medical disease.” The important lesson is that utility is defined by the learner. “If my student has chosen a future career in orthopedics, the content of the lectures will shift away from high-end internal medicine topics and toward what I think the future orthopedist before me needs to know.”

Motivation

“Should we have to motivate students to be great physicians both professionally and in terms of patient care and knowledge competence?” asks Dr. Wiese. “At the end of the day, the answer should be no; everyone has responsibility for motivating themselves. But, like a great coach, it is still the coach’s responsibly to ensure that when the players are tired, when they’re hungry, when they’ve got other things on their mind, they will stay motivated to want to learn the skill—even before we begin to teach the skill.

“A big portion of that motivation comes from figuring out what their career goals are and helping to link the medical knowledge or the skill that you’re teaching to those hooks, those things that are going to be of interest to them.”

There are four key components to motivation, says Dr. Wiese.

“First, remember the student’s name and use it often,” he says. “Remember that they will not care what you know, until they know that you care. Second, be physical. Reach out with the handshake or pat on the shoulder when things get done correctly. Third, stay focused on their hooks: Couch all content in terms of how they will use it in their future careers, and focus your analogies on their personal interests. For example, if a student likes music, my teaching of heart murmurs is going to use analogies of the song writer and performer.”

Game Time

“The medical knowledge is analogous to the play that the team will run or the skill of throwing the ball, but [there are a lot of other factors that influence what’s needed for] the game-time scenario,” Dr. Wiese says. “It’s how you interact with the clock for the game, how you interact with the referees, how you interact with your team mates, how you interact against the defense.”

To teach in order to prepare your “players” for the realities of the challenge—or the challenges of reality, as the case may be—teachers need to do more than unwittingly repeat the methods used when they were students.

“A student who is learning about a disease from Harrison’s or Cecil’s [textbooks] can focus on all the details and knowledge they need to know,” says Dr. Wiese. “But the thing that they can’t get out of the book and that they really need from the hospitalist coach is all that game-time instruction.”

In other words, hospitalists must consider with their students how to integrate their knowledge into their interactions with the hospital system.

In this era of PDAs, wireless networking, and access to the Internet, hospitalists are way past the point of having to keep all their acquired information in their heads, Dr. Wiese says. “The issue now is how do you ask the right questions and then access that knowledge—and then more importantly, how do you take that knowledge and put it into the ‘play’ that is the patient?” And that is what a student can’t get out of a book, he says—and what they need to get from their coach.

Be an Agent for Change

Don’t automatically transfer the way you learned or the ways you were taught into how you teach your own students. “Learning and teaching are very different,” says Dr. Wiese. “Learning knowledge is focused on the details. Teaching is much more [about] how you put that knowledge into play.”

That kind of transference is easily recognizable in a situation where a student asks “Can you teach me something this afternoon?” and the hospitalist replies, “Well, let me go home tonight and prepare, and then I’ll teach you.”

“What they’re saying is, ‘Let me read up, make a list of facts—maybe worse, maybe put it in PowerPoint,’ ” says Dr. Wiese. “The student could have done that on his or her own.”

Because hospitalists are intimately familiar with the hospital system, they serve as agents of change, Dr. Wiese says.

“Hospitalists are the key group at the first level of being able to take a student or resident or fellow and say, ‘These are the patients, we’re on hospital wards, and let me show you how to put in action the knowledge and skills you have to make a success for your patients,’ ” he says.

Hospitalists know where the system doesn’t work. “The great hospitalist doesn’t [face a problem and think], ‘Oh, woe is me; I’m hopelessly at the whim of the system that is broken,” says Dr. Wiese. “A great hospitalist consistently looks at [the situation] and asks, ‘How can I improve this system?’ The only way that medical students and residents can move out of the helpless role where [they see themselves as] servants of the system is to have hospitalist teachers who have a perspective of themselves as owners and who take responsibility for improving the system. Nothing has to be the way that it is,” says Dr. Wiese. TH

Andrea Sattinger is a frequent contributor to The Hospitalist.

References

1. Pressel DM. Hospitalists in medical education: coming to an academic medical center near you. J Natl Med Assoc. 2006 Sep;98(9):1501-1504.

Charles A. Crecelius, MD, of Saint Louis, has experienced best- and worst-case scenarios when his frail elderly patients have been admitted and discharged by local hospitalists.

Best case, he says: “My patient is admitted. I get a call. I’m told what is going on. I’m notified of meaningful changes, and at discharge, I get another call [from the hospitalist].”

But there are wide variations in hospitalist/nursing home relationships, notes Dr. Crecelius, a long-term care physician and president-elect of the American Medical Director’s Assoc­iation (AMDA).

This was brought home by the case of a patient with a well-documented history of dystonic reaction to toxic lithium levels. The patient was later misdiagnosed as having tardive dyskinesia, a movement disorder. Her much-needed medication was discontinued, and the hospital transferred the patient back to the nursing home in worse condition than before.

“We wasted an entire hospitalization,” Dr. Crecelius recalls ruefully.

The above scenario underscores the importance of a thorough transfer of information when elderly patients move from facility to facility. Interaction between hospitalists and nursing home staff will become increasingly important in light of the growing frail elderly population and the Joint Commission on Accreditation of Health Care Organization’s (JCAHO) push for improved discharge communications.1

By applying a customer service model and continually upgrading transfer documentation, hospital medicine groups can “keep the level of communication where it needs to be,” says Susan S. Cumming, MD, associate medical director of Marin Hospitalist Medical Group at Marin General Hospital in Greenbrae, Calif.

Running a Risk

Dan Osterweil, MD, CMD, is familiar with the hospitalist model through his medical training in Israel during the late 1970s and early 1980s. Hospitalists there routinely handled inpatient care.

Dr. Osterweil, a clinical professor of medicine/geriatric medicine at UCLA, research associate with the UCLA Borun Center for Gerontological Research, and former medical director of the Jewish Home for the Aging in Reseda, Calif., has the opportunity to observe hospitalists deal with nursing homes in his current capacity as a consultant for managed care corporations in Southern California.

“Hospitalists have an excellent understanding of acute care management,” he says. “They do a good on-site job of dealing with immediate problems of the individual, and they’re very efficient and very responsive. But while hospitalists are providing higher competency in the management of intra-hospital care, I think that those I’ve interfaced with fall short on the transitions of care, which is so critical with the nursing home patient.”

Dr. Osterweil recalls one patient who had in place do not resuscitate (DNR) and do not intubate (DNI) orders. But when he was hospitalized, the patient was intubated. “If [the hospitalist] had asked one question of the individual or the caregiver—‘What is the goal of care?’—they would have been able to plan a much smoother transition for that person back to the facility.”

At Lower Bucks Hospital in Bristol, Pa., where long-term care physician Daniel Haimowitz, MD, CMD serves as chairman of internal medicine and chairs the utilization committee, the surrounding community of physicians has responded in a mostly positive way to a new hospitalist program.

However, Dr. Haimowitz has concerns that transitioning admissions of nursing home patients to hospitalists can hinder continuity of care.

Different hospitalists work each shift, and unless the patient has been on the hospitalist service in the past, the admitting hospitalist may know nothing about the patient—and most probably has no relationship with the patient’s family (as the primary care physician would have).

“The family doctor has seen the patient for 20 or 30 years and knows what he or she wants,” Dr. Haimowitz says. “But this patient is brand new to the hospitalist. Unless the hospitalist is really good with communication and takes the extra step to call the physician at the nursing home, I think you run the real risk of duplicating workup or actually not doing what is in the best interest of the patient.”

“While demonstrating improved quality of care for the acutely ill hospitalized patient, hospital medicine has struggled with the fact that it inherently adds more patient hand-offs into the mix,” says Bryce Gartland, MD, medical director for care coordination and director of hospital medicine for Emory University Hospital in Atlanta. “We experience this internally, within our facility and externally when transferring patients into or out of the hospital.”

There is always a potential for what has been called the “voltage drop” when hand-offs occur, agrees Dr. Cumming, whether they’re between hospitalists in the same facility or from hospitalist back to the primary care provider. “We function in a healthcare system that is very individualized,” she says. “When you’re dealing with many different community hospitals that may not be part of the same system, it’s very hard to standardize [transfer processes].”

The standard of care for transferring patients from Marin General Hospital to subacute rehabilitation facilities or to skilled nursing facilities entails a detailed inter-facility transfer form. The form includes a thorough discharge summary, with a separate medication reconciliation form, photocopies of any relevant consultations, and a list of pending lab tests. In concert with the hospital’s case managers, Dr. Cumming and hospitalists on her team also make every effort to speak with patients’ receiving providers to relay a synopsis of what has occurred during their patients’ stay in the hospital.

Avoid Assumptions

Especially in the case of patients with dementia or severe illness prohibiting communication about their condition, a thorough transfer sheet or discharge summary—arriving with the patient or faxed in a timely manner—can help reduce errors and contribute to more seamless resumption of care at the next facility.

Without access to a patient’s history, the opportunity for errors increases. One of Dr. Crecelius’ pet peeves is seeing “history not obtainable” on the hospital’s patient transfer sheet. “A history is always obtainable,” Dr. Crecelius asserts. “You can call the nursing home, the family, or the patient’s physician. That phrase equals, ‘We didn’t bother to take the time.’ There is no such thing as ‘history not obtainable,’ and legally, that will not fly in a court of law.”

Missing or incomplete records necessitate communication between facilities. Dr. Crecelius has also found that hospitalists may not understand the nuances of medication prescription for the elderly—a situation that can be rectified with a phone call.

A case in point: Dr. Crecelius once prescribed theophylline for a bradycardic patient who refused a pacemaker but frequently lost consciousness when his pulse and blood pressure dropped. Although this was an obscure use of the drug, which is primarily a bronchodilator, “it worked to keep the patient’s pulse up so he was not passing out. When he went to the hospital, they stopped the drug, and it took forever to get him discharged. The patient came back to the nursing home in horrible shape. I assume the providers at the hospital thought I was crazy for prescribing theophylline to a frail old person!”

Dr. Crecelius’ prescription for avoiding the above scenario: “If you think the medicine is an odd choice, ask the prescriber why the patient is on it. We need to respect each other and get the information when there is a question.”

Cornerstones of Continuity

Medical directors have addressed continuity of care issues in their own ways. Whenever possible, Dr. Crecelius sees his patients in the hospital. He has also been working as a representative of the Missouri Association of Long-Term Care Physicians with a statewide transition planning committee. The committee is drafting new transfer forms for hospitals and post-acute care facilities.

The Asheville Hospitalist Group, PA has “gone to extraordinary lengths to address the issue of inter-facility transfers,” says Marc Westle, DO, FACP, president and managing partner for the large private group in N.C. His group has coordinated efforts with another group of hospitalists who specialize in managing patients in the Asheville area’s 20-plus nursing homes.

To facilitate transfers to a hospital, the nursing homes send paperwork (including history, physical, and medication records) with patients to the emergency department. When patients are ready for discharge, discharge summaries are dictated stat and faxed to the nursing home. Hospitalists discharging patients pre-order diagnostic tests that will be necessary when the patient returns to the nursing home by noting those tests on discharge orders. In addition, “The nursing home group has a list of all our beeper numbers for direct contact should a question arise,” says Dr. Westle.

Every patient transferred to another facility from Emory University Hospital in Atlanta is accompanied by a three-page transfer form, says Dr. Gartland. Included is a one-page summary of detailed nursing care; a second page listing hospitalization events, including pertinent consults, procedures, diagnoses, pending lab tests, and recommended follow-up; and a detailed medication sheet with discontinuation dates for such medication as antibiotics.

During his time as medical director at the Jewish Home for the Aging, Dr. Osterweil created what he calls his own “pseudo-hospitalist arrangement” to ensure continuity of care. He identified multiphysician groups comprising internists and nephrologists who, between them, could offer 24 hours on-call coverage.

When patients were transported to a local community hospital, Dr. Osterweil or his staff would call one of these physicians, who would take care of the patients when they were admitted to the floor. That arrangement is still in place.

“Any major decisions that are made, we are kept in the loop,” says Dr. Osterweil. “Twenty-four hours before readmission back to the skilled nursing facility, we receive a call letting us know the patient is coming back and his or her issues. The physician group executes a ‘stat’ dictated discharge summary, and the patient leaves the hospital with those orders. This ensures the continuity of care when the patient goes back to the nursing home or the board and care facility.”

Beef Up Communication

Dr. Crecelius concedes that certified medical directors (CMDs) are also often guilty of dropping the ball when it comes to communicating with inpatient provider colleagues.

Care of nursing home patients can be improved if hospitalists and medical directors of nursing homes talk directly on the phone, he says. “I met one wonderful hospitalist who actually showed up at the nursing home to see how the patients that he’d been sending out of the hospital were doing,’’ he recalls. “It was so nice to see the face behind the voice. You can’t get mad at a face!”

However, again demonstrating the range of practice techniques, another hospitalist group in Dr. Crecelius’ area does not do anything beyond faxing him the patient’s diagnosis. “Well, I knew the diagnosis, so that fax is not telling me anything,’’ he says. “And unfortunately, that is their idea of communication.”

The Marin Hospitalist Medical Group makes every effort to ensure communications with receiving facilities are timely and thorough. According to Dr. Cumming, the group has surveyed—and will continue to survey—its referring primary care physicians, whether office or facility-based, for feedback on their performance. Hospital case managers also relay feedback to the hospitalist group, she notes. “We’ve tried to use the customer service model across all the groups of physicians who transfer patients to us and to whom we transfer patients, to keep that level of communication where it needs to be,” she says. Some of the questions they ask of their facilities:

• Are we sending the information you need?
• Do you want to receive all documents with the patient when he or she is transferred, or just a small subset of documents?
• How do you want information delivered? Do you want forms, discharge summaries and other documents faxed to you? Would you prefer a phone call?
• What can we do better?

Dr. Haimowitz’s advice to hospitalists might parallel the advice he recently gave to local a hospital administrators who were considering starting an intensivist program. “If you’re going to do this right, you must have physicians who are sensitive to older patients and what they want,” he says. Quality of life, DNR orders, and goals of care take on subtle gradations when applied to the elderly, he emphasizes.

Absent the time to visit the area nursing homes, hospitalists can always at least call, Dr. Crecelius notes.

Just as a hospitalist or emergency department physician would contact the family to corroborate patient history, they should also call the nursing home. “Speaking with the nurse at the skilled nursing facility, you can access a wealth of information—and save time and effort,” he says.

Improve Transfers

Dr. Haimowitz believes communication—on a form or by phone—is essential. He sees even more opportunity for miscommunication between hospitals and nursing homes because of different recordkeeping systems.

Hospitals are moving increasingly to electronic health records, while nursing homes still rely on paper documentation. “How do you foster communication?” Dr. Haimowitz asks. “How do you get the right people on the same bus? The best transfer sheet in the world is no good if one, it’s not filled out, and two, if it’s not read.”

Disparate systems can be a barrier, but it does not mean you should not try to optimize communication within whatever system you have, says Dr. Cumming.

The Marin Hospitalist Medical Group is setting up a communication system to alert all primary care physicians of pending lab results so such tests do not fall through the cracks after patients are discharged.

In another initiative, the hospital will set up a system to note that any pneumonia or influenza vaccinations performed while the patient was hospitalized are communicated either to PCP or outside facility. The group is also working to urge all local nursing facilities to include records of patients’ recent vaccinations when they are transferred to the hospital.

It’s clear that effective transfers of elderly patients require a concerted effort by all involved. “If you perform a root cause analysis of [transfer] errors, most occur not because of any negligence, but because communication—written or verbal—was not handled as best as it could have been,” Dr. Gartland notes. “Oftentimes, we are just as frustrated as they [nursing facilities] are when patients return to the emergency room unable to communicate their medical conditions, wishes, and the like,” he says. As medical director of care coordination at Emory, he has worked to improve relationships with administrators and physicians in nursing facilities used most often by the hospital. “If people have a vested interest in a relationship, they are more likely to be diligent about the transfer of patients,” he asserts.

Above all, emphasizes Dr. Cumming, “it important to always solicit feedback from your primary care physician ‘clientele.’ They are your clients, much as your patients are, and your hospital is. We’re providing services to all these various groups. Quality patient care is the most important thing that we do, and part of that means that we have to have good transfer of information. Our group recognizes that we are far from perfect; we know we can always do better; and we always have to reassess to make sure that we’re on the right track.” TH

Gretchen Henkel is a frequent contributor to The Hospitalist.

Reference

1. Ouslander JG, Osterweil D, Morley J. Medical Care in the Nursing Home. 2nd ed. New York, New York: McGraw-Hill Publishers;1997.

Charles A. Crecelius, MD, of Saint Louis, has experienced best- and worst-case scenarios when his frail elderly patients have been admitted and discharged by local hospitalists.

Best case, he says: “My patient is admitted. I get a call. I’m told what is going on. I’m notified of meaningful changes, and at discharge, I get another call [from the hospitalist].”

But there are wide variations in hospitalist/nursing home relationships, notes Dr. Crecelius, a long-term care physician and president-elect of the American Medical Director’s Assoc­iation (AMDA).

This was brought home by the case of a patient with a well-documented history of dystonic reaction to toxic lithium levels. The patient was later misdiagnosed as having tardive dyskinesia, a movement disorder. Her much-needed medication was discontinued, and the hospital transferred the patient back to the nursing home in worse condition than before.

“We wasted an entire hospitalization,” Dr. Crecelius recalls ruefully.

The above scenario underscores the importance of a thorough transfer of information when elderly patients move from facility to facility. Interaction between hospitalists and nursing home staff will become increasingly important in light of the growing frail elderly population and the Joint Commission on Accreditation of Health Care Organization’s (JCAHO) push for improved discharge communications.1

By applying a customer service model and continually upgrading transfer documentation, hospital medicine groups can “keep the level of communication where it needs to be,” says Susan S. Cumming, MD, associate medical director of Marin Hospitalist Medical Group at Marin General Hospital in Greenbrae, Calif.

Running a Risk

Dan Osterweil, MD, CMD, is familiar with the hospitalist model through his medical training in Israel during the late 1970s and early 1980s. Hospitalists there routinely handled inpatient care.

Dr. Osterweil, a clinical professor of medicine/geriatric medicine at UCLA, research associate with the UCLA Borun Center for Gerontological Research, and former medical director of the Jewish Home for the Aging in Reseda, Calif., has the opportunity to observe hospitalists deal with nursing homes in his current capacity as a consultant for managed care corporations in Southern California.

“Hospitalists have an excellent understanding of acute care management,” he says. “They do a good on-site job of dealing with immediate problems of the individual, and they’re very efficient and very responsive. But while hospitalists are providing higher competency in the management of intra-hospital care, I think that those I’ve interfaced with fall short on the transitions of care, which is so critical with the nursing home patient.”

Dr. Osterweil recalls one patient who had in place do not resuscitate (DNR) and do not intubate (DNI) orders. But when he was hospitalized, the patient was intubated. “If [the hospitalist] had asked one question of the individual or the caregiver—‘What is the goal of care?’—they would have been able to plan a much smoother transition for that person back to the facility.”

At Lower Bucks Hospital in Bristol, Pa., where long-term care physician Daniel Haimowitz, MD, CMD serves as chairman of internal medicine and chairs the utilization committee, the surrounding community of physicians has responded in a mostly positive way to a new hospitalist program.

However, Dr. Haimowitz has concerns that transitioning admissions of nursing home patients to hospitalists can hinder continuity of care.

Different hospitalists work each shift, and unless the patient has been on the hospitalist service in the past, the admitting hospitalist may know nothing about the patient—and most probably has no relationship with the patient’s family (as the primary care physician would have).

“The family doctor has seen the patient for 20 or 30 years and knows what he or she wants,” Dr. Haimowitz says. “But this patient is brand new to the hospitalist. Unless the hospitalist is really good with communication and takes the extra step to call the physician at the nursing home, I think you run the real risk of duplicating workup or actually not doing what is in the best interest of the patient.”

“While demonstrating improved quality of care for the acutely ill hospitalized patient, hospital medicine has struggled with the fact that it inherently adds more patient hand-offs into the mix,” says Bryce Gartland, MD, medical director for care coordination and director of hospital medicine for Emory University Hospital in Atlanta. “We experience this internally, within our facility and externally when transferring patients into or out of the hospital.”

There is always a potential for what has been called the “voltage drop” when hand-offs occur, agrees Dr. Cumming, whether they’re between hospitalists in the same facility or from hospitalist back to the primary care provider. “We function in a healthcare system that is very individualized,” she says. “When you’re dealing with many different community hospitals that may not be part of the same system, it’s very hard to standardize [transfer processes].”

The standard of care for transferring patients from Marin General Hospital to subacute rehabilitation facilities or to skilled nursing facilities entails a detailed inter-facility transfer form. The form includes a thorough discharge summary, with a separate medication reconciliation form, photocopies of any relevant consultations, and a list of pending lab tests. In concert with the hospital’s case managers, Dr. Cumming and hospitalists on her team also make every effort to speak with patients’ receiving providers to relay a synopsis of what has occurred during their patients’ stay in the hospital.

Avoid Assumptions

Especially in the case of patients with dementia or severe illness prohibiting communication about their condition, a thorough transfer sheet or discharge summary—arriving with the patient or faxed in a timely manner—can help reduce errors and contribute to more seamless resumption of care at the next facility.

Without access to a patient’s history, the opportunity for errors increases. One of Dr. Crecelius’ pet peeves is seeing “history not obtainable” on the hospital’s patient transfer sheet. “A history is always obtainable,” Dr. Crecelius asserts. “You can call the nursing home, the family, or the patient’s physician. That phrase equals, ‘We didn’t bother to take the time.’ There is no such thing as ‘history not obtainable,’ and legally, that will not fly in a court of law.”

Missing or incomplete records necessitate communication between facilities. Dr. Crecelius has also found that hospitalists may not understand the nuances of medication prescription for the elderly—a situation that can be rectified with a phone call.

A case in point: Dr. Crecelius once prescribed theophylline for a bradycardic patient who refused a pacemaker but frequently lost consciousness when his pulse and blood pressure dropped. Although this was an obscure use of the drug, which is primarily a bronchodilator, “it worked to keep the patient’s pulse up so he was not passing out. When he went to the hospital, they stopped the drug, and it took forever to get him discharged. The patient came back to the nursing home in horrible shape. I assume the providers at the hospital thought I was crazy for prescribing theophylline to a frail old person!”

Dr. Crecelius’ prescription for avoiding the above scenario: “If you think the medicine is an odd choice, ask the prescriber why the patient is on it. We need to respect each other and get the information when there is a question.”

Cornerstones of Continuity

Medical directors have addressed continuity of care issues in their own ways. Whenever possible, Dr. Crecelius sees his patients in the hospital. He has also been working as a representative of the Missouri Association of Long-Term Care Physicians with a statewide transition planning committee. The committee is drafting new transfer forms for hospitals and post-acute care facilities.

The Asheville Hospitalist Group, PA has “gone to extraordinary lengths to address the issue of inter-facility transfers,” says Marc Westle, DO, FACP, president and managing partner for the large private group in N.C. His group has coordinated efforts with another group of hospitalists who specialize in managing patients in the Asheville area’s 20-plus nursing homes.

To facilitate transfers to a hospital, the nursing homes send paperwork (including history, physical, and medication records) with patients to the emergency department. When patients are ready for discharge, discharge summaries are dictated stat and faxed to the nursing home. Hospitalists discharging patients pre-order diagnostic tests that will be necessary when the patient returns to the nursing home by noting those tests on discharge orders. In addition, “The nursing home group has a list of all our beeper numbers for direct contact should a question arise,” says Dr. Westle.

Every patient transferred to another facility from Emory University Hospital in Atlanta is accompanied by a three-page transfer form, says Dr. Gartland. Included is a one-page summary of detailed nursing care; a second page listing hospitalization events, including pertinent consults, procedures, diagnoses, pending lab tests, and recommended follow-up; and a detailed medication sheet with discontinuation dates for such medication as antibiotics.

During his time as medical director at the Jewish Home for the Aging, Dr. Osterweil created what he calls his own “pseudo-hospitalist arrangement” to ensure continuity of care. He identified multiphysician groups comprising internists and nephrologists who, between them, could offer 24 hours on-call coverage.

When patients were transported to a local community hospital, Dr. Osterweil or his staff would call one of these physicians, who would take care of the patients when they were admitted to the floor. That arrangement is still in place.

“Any major decisions that are made, we are kept in the loop,” says Dr. Osterweil. “Twenty-four hours before readmission back to the skilled nursing facility, we receive a call letting us know the patient is coming back and his or her issues. The physician group executes a ‘stat’ dictated discharge summary, and the patient leaves the hospital with those orders. This ensures the continuity of care when the patient goes back to the nursing home or the board and care facility.”

Beef Up Communication

Dr. Crecelius concedes that certified medical directors (CMDs) are also often guilty of dropping the ball when it comes to communicating with inpatient provider colleagues.

Care of nursing home patients can be improved if hospitalists and medical directors of nursing homes talk directly on the phone, he says. “I met one wonderful hospitalist who actually showed up at the nursing home to see how the patients that he’d been sending out of the hospital were doing,’’ he recalls. “It was so nice to see the face behind the voice. You can’t get mad at a face!”

However, again demonstrating the range of practice techniques, another hospitalist group in Dr. Crecelius’ area does not do anything beyond faxing him the patient’s diagnosis. “Well, I knew the diagnosis, so that fax is not telling me anything,’’ he says. “And unfortunately, that is their idea of communication.”

The Marin Hospitalist Medical Group makes every effort to ensure communications with receiving facilities are timely and thorough. According to Dr. Cumming, the group has surveyed—and will continue to survey—its referring primary care physicians, whether office or facility-based, for feedback on their performance. Hospital case managers also relay feedback to the hospitalist group, she notes. “We’ve tried to use the customer service model across all the groups of physicians who transfer patients to us and to whom we transfer patients, to keep that level of communication where it needs to be,” she says. Some of the questions they ask of their facilities:

• Are we sending the information you need?
• Do you want to receive all documents with the patient when he or she is transferred, or just a small subset of documents?
• How do you want information delivered? Do you want forms, discharge summaries and other documents faxed to you? Would you prefer a phone call?
• What can we do better?

Dr. Haimowitz’s advice to hospitalists might parallel the advice he recently gave to local a hospital administrators who were considering starting an intensivist program. “If you’re going to do this right, you must have physicians who are sensitive to older patients and what they want,” he says. Quality of life, DNR orders, and goals of care take on subtle gradations when applied to the elderly, he emphasizes.

Absent the time to visit the area nursing homes, hospitalists can always at least call, Dr. Crecelius notes.

Just as a hospitalist or emergency department physician would contact the family to corroborate patient history, they should also call the nursing home. “Speaking with the nurse at the skilled nursing facility, you can access a wealth of information—and save time and effort,” he says.

Improve Transfers

Dr. Haimowitz believes communication—on a form or by phone—is essential. He sees even more opportunity for miscommunication between hospitals and nursing homes because of different recordkeeping systems.

Hospitals are moving increasingly to electronic health records, while nursing homes still rely on paper documentation. “How do you foster communication?” Dr. Haimowitz asks. “How do you get the right people on the same bus? The best transfer sheet in the world is no good if one, it’s not filled out, and two, if it’s not read.”

Disparate systems can be a barrier, but it does not mean you should not try to optimize communication within whatever system you have, says Dr. Cumming.

The Marin Hospitalist Medical Group is setting up a communication system to alert all primary care physicians of pending lab results so such tests do not fall through the cracks after patients are discharged.

In another initiative, the hospital will set up a system to note that any pneumonia or influenza vaccinations performed while the patient was hospitalized are communicated either to PCP or outside facility. The group is also working to urge all local nursing facilities to include records of patients’ recent vaccinations when they are transferred to the hospital.

It’s clear that effective transfers of elderly patients require a concerted effort by all involved. “If you perform a root cause analysis of [transfer] errors, most occur not because of any negligence, but because communication—written or verbal—was not handled as best as it could have been,” Dr. Gartland notes. “Oftentimes, we are just as frustrated as they [nursing facilities] are when patients return to the emergency room unable to communicate their medical conditions, wishes, and the like,” he says. As medical director of care coordination at Emory, he has worked to improve relationships with administrators and physicians in nursing facilities used most often by the hospital. “If people have a vested interest in a relationship, they are more likely to be diligent about the transfer of patients,” he asserts.

Above all, emphasizes Dr. Cumming, “it important to always solicit feedback from your primary care physician ‘clientele.’ They are your clients, much as your patients are, and your hospital is. We’re providing services to all these various groups. Quality patient care is the most important thing that we do, and part of that means that we have to have good transfer of information. Our group recognizes that we are far from perfect; we know we can always do better; and we always have to reassess to make sure that we’re on the right track.” TH

Gretchen Henkel is a frequent contributor to The Hospitalist.

Reference

1. Ouslander JG, Osterweil D, Morley J. Medical Care in the Nursing Home. 2nd ed. New York, New York: McGraw-Hill Publishers;1997.

Charles A. Crecelius, MD, of Saint Louis, has experienced best- and worst-case scenarios when his frail elderly patients have been admitted and discharged by local hospitalists.

Best case, he says: “My patient is admitted. I get a call. I’m told what is going on. I’m notified of meaningful changes, and at discharge, I get another call [from the hospitalist].”

But there are wide variations in hospitalist/nursing home relationships, notes Dr. Crecelius, a long-term care physician and president-elect of the American Medical Director’s Assoc­iation (AMDA).

This was brought home by the case of a patient with a well-documented history of dystonic reaction to toxic lithium levels. The patient was later misdiagnosed as having tardive dyskinesia, a movement disorder. Her much-needed medication was discontinued, and the hospital transferred the patient back to the nursing home in worse condition than before.

“We wasted an entire hospitalization,” Dr. Crecelius recalls ruefully.

The above scenario underscores the importance of a thorough transfer of information when elderly patients move from facility to facility. Interaction between hospitalists and nursing home staff will become increasingly important in light of the growing frail elderly population and the Joint Commission on Accreditation of Health Care Organization’s (JCAHO) push for improved discharge communications.1

By applying a customer service model and continually upgrading transfer documentation, hospital medicine groups can “keep the level of communication where it needs to be,” says Susan S. Cumming, MD, associate medical director of Marin Hospitalist Medical Group at Marin General Hospital in Greenbrae, Calif.

Running a Risk

Dan Osterweil, MD, CMD, is familiar with the hospitalist model through his medical training in Israel during the late 1970s and early 1980s. Hospitalists there routinely handled inpatient care.

Dr. Osterweil, a clinical professor of medicine/geriatric medicine at UCLA, research associate with the UCLA Borun Center for Gerontological Research, and former medical director of the Jewish Home for the Aging in Reseda, Calif., has the opportunity to observe hospitalists deal with nursing homes in his current capacity as a consultant for managed care corporations in Southern California.

“Hospitalists have an excellent understanding of acute care management,” he says. “They do a good on-site job of dealing with immediate problems of the individual, and they’re very efficient and very responsive. But while hospitalists are providing higher competency in the management of intra-hospital care, I think that those I’ve interfaced with fall short on the transitions of care, which is so critical with the nursing home patient.”

Dr. Osterweil recalls one patient who had in place do not resuscitate (DNR) and do not intubate (DNI) orders. But when he was hospitalized, the patient was intubated. “If [the hospitalist] had asked one question of the individual or the caregiver—‘What is the goal of care?’—they would have been able to plan a much smoother transition for that person back to the facility.”

At Lower Bucks Hospital in Bristol, Pa., where long-term care physician Daniel Haimowitz, MD, CMD serves as chairman of internal medicine and chairs the utilization committee, the surrounding community of physicians has responded in a mostly positive way to a new hospitalist program.

However, Dr. Haimowitz has concerns that transitioning admissions of nursing home patients to hospitalists can hinder continuity of care.

Different hospitalists work each shift, and unless the patient has been on the hospitalist service in the past, the admitting hospitalist may know nothing about the patient—and most probably has no relationship with the patient’s family (as the primary care physician would have).

“The family doctor has seen the patient for 20 or 30 years and knows what he or she wants,” Dr. Haimowitz says. “But this patient is brand new to the hospitalist. Unless the hospitalist is really good with communication and takes the extra step to call the physician at the nursing home, I think you run the real risk of duplicating workup or actually not doing what is in the best interest of the patient.”

“While demonstrating improved quality of care for the acutely ill hospitalized patient, hospital medicine has struggled with the fact that it inherently adds more patient hand-offs into the mix,” says Bryce Gartland, MD, medical director for care coordination and director of hospital medicine for Emory University Hospital in Atlanta. “We experience this internally, within our facility and externally when transferring patients into or out of the hospital.”

There is always a potential for what has been called the “voltage drop” when hand-offs occur, agrees Dr. Cumming, whether they’re between hospitalists in the same facility or from hospitalist back to the primary care provider. “We function in a healthcare system that is very individualized,” she says. “When you’re dealing with many different community hospitals that may not be part of the same system, it’s very hard to standardize [transfer processes].”

The standard of care for transferring patients from Marin General Hospital to subacute rehabilitation facilities or to skilled nursing facilities entails a detailed inter-facility transfer form. The form includes a thorough discharge summary, with a separate medication reconciliation form, photocopies of any relevant consultations, and a list of pending lab tests. In concert with the hospital’s case managers, Dr. Cumming and hospitalists on her team also make every effort to speak with patients’ receiving providers to relay a synopsis of what has occurred during their patients’ stay in the hospital.

Avoid Assumptions

Especially in the case of patients with dementia or severe illness prohibiting communication about their condition, a thorough transfer sheet or discharge summary—arriving with the patient or faxed in a timely manner—can help reduce errors and contribute to more seamless resumption of care at the next facility.

Without access to a patient’s history, the opportunity for errors increases. One of Dr. Crecelius’ pet peeves is seeing “history not obtainable” on the hospital’s patient transfer sheet. “A history is always obtainable,” Dr. Crecelius asserts. “You can call the nursing home, the family, or the patient’s physician. That phrase equals, ‘We didn’t bother to take the time.’ There is no such thing as ‘history not obtainable,’ and legally, that will not fly in a court of law.”

Missing or incomplete records necessitate communication between facilities. Dr. Crecelius has also found that hospitalists may not understand the nuances of medication prescription for the elderly—a situation that can be rectified with a phone call.

A case in point: Dr. Crecelius once prescribed theophylline for a bradycardic patient who refused a pacemaker but frequently lost consciousness when his pulse and blood pressure dropped. Although this was an obscure use of the drug, which is primarily a bronchodilator, “it worked to keep the patient’s pulse up so he was not passing out. When he went to the hospital, they stopped the drug, and it took forever to get him discharged. The patient came back to the nursing home in horrible shape. I assume the providers at the hospital thought I was crazy for prescribing theophylline to a frail old person!”

Dr. Crecelius’ prescription for avoiding the above scenario: “If you think the medicine is an odd choice, ask the prescriber why the patient is on it. We need to respect each other and get the information when there is a question.”

Cornerstones of Continuity

Medical directors have addressed continuity of care issues in their own ways. Whenever possible, Dr. Crecelius sees his patients in the hospital. He has also been working as a representative of the Missouri Association of Long-Term Care Physicians with a statewide transition planning committee. The committee is drafting new transfer forms for hospitals and post-acute care facilities.

The Asheville Hospitalist Group, PA has “gone to extraordinary lengths to address the issue of inter-facility transfers,” says Marc Westle, DO, FACP, president and managing partner for the large private group in N.C. His group has coordinated efforts with another group of hospitalists who specialize in managing patients in the Asheville area’s 20-plus nursing homes.

To facilitate transfers to a hospital, the nursing homes send paperwork (including history, physical, and medication records) with patients to the emergency department. When patients are ready for discharge, discharge summaries are dictated stat and faxed to the nursing home. Hospitalists discharging patients pre-order diagnostic tests that will be necessary when the patient returns to the nursing home by noting those tests on discharge orders. In addition, “The nursing home group has a list of all our beeper numbers for direct contact should a question arise,” says Dr. Westle.

Every patient transferred to another facility from Emory University Hospital in Atlanta is accompanied by a three-page transfer form, says Dr. Gartland. Included is a one-page summary of detailed nursing care; a second page listing hospitalization events, including pertinent consults, procedures, diagnoses, pending lab tests, and recommended follow-up; and a detailed medication sheet with discontinuation dates for such medication as antibiotics.

During his time as medical director at the Jewish Home for the Aging, Dr. Osterweil created what he calls his own “pseudo-hospitalist arrangement” to ensure continuity of care. He identified multiphysician groups comprising internists and nephrologists who, between them, could offer 24 hours on-call coverage.

When patients were transported to a local community hospital, Dr. Osterweil or his staff would call one of these physicians, who would take care of the patients when they were admitted to the floor. That arrangement is still in place.

“Any major decisions that are made, we are kept in the loop,” says Dr. Osterweil. “Twenty-four hours before readmission back to the skilled nursing facility, we receive a call letting us know the patient is coming back and his or her issues. The physician group executes a ‘stat’ dictated discharge summary, and the patient leaves the hospital with those orders. This ensures the continuity of care when the patient goes back to the nursing home or the board and care facility.”

Beef Up Communication

Dr. Crecelius concedes that certified medical directors (CMDs) are also often guilty of dropping the ball when it comes to communicating with inpatient provider colleagues.

Care of nursing home patients can be improved if hospitalists and medical directors of nursing homes talk directly on the phone, he says. “I met one wonderful hospitalist who actually showed up at the nursing home to see how the patients that he’d been sending out of the hospital were doing,’’ he recalls. “It was so nice to see the face behind the voice. You can’t get mad at a face!”

However, again demonstrating the range of practice techniques, another hospitalist group in Dr. Crecelius’ area does not do anything beyond faxing him the patient’s diagnosis. “Well, I knew the diagnosis, so that fax is not telling me anything,’’ he says. “And unfortunately, that is their idea of communication.”

The Marin Hospitalist Medical Group makes every effort to ensure communications with receiving facilities are timely and thorough. According to Dr. Cumming, the group has surveyed—and will continue to survey—its referring primary care physicians, whether office or facility-based, for feedback on their performance. Hospital case managers also relay feedback to the hospitalist group, she notes. “We’ve tried to use the customer service model across all the groups of physicians who transfer patients to us and to whom we transfer patients, to keep that level of communication where it needs to be,” she says. Some of the questions they ask of their facilities:

• Are we sending the information you need?
• Do you want to receive all documents with the patient when he or she is transferred, or just a small subset of documents?
• How do you want information delivered? Do you want forms, discharge summaries and other documents faxed to you? Would you prefer a phone call?
• What can we do better?

Dr. Haimowitz’s advice to hospitalists might parallel the advice he recently gave to local a hospital administrators who were considering starting an intensivist program. “If you’re going to do this right, you must have physicians who are sensitive to older patients and what they want,” he says. Quality of life, DNR orders, and goals of care take on subtle gradations when applied to the elderly, he emphasizes.

Absent the time to visit the area nursing homes, hospitalists can always at least call, Dr. Crecelius notes.

Just as a hospitalist or emergency department physician would contact the family to corroborate patient history, they should also call the nursing home. “Speaking with the nurse at the skilled nursing facility, you can access a wealth of information—and save time and effort,” he says.

Improve Transfers

Dr. Haimowitz believes communication—on a form or by phone—is essential. He sees even more opportunity for miscommunication between hospitals and nursing homes because of different recordkeeping systems.

Hospitals are moving increasingly to electronic health records, while nursing homes still rely on paper documentation. “How do you foster communication?” Dr. Haimowitz asks. “How do you get the right people on the same bus? The best transfer sheet in the world is no good if one, it’s not filled out, and two, if it’s not read.”

Disparate systems can be a barrier, but it does not mean you should not try to optimize communication within whatever system you have, says Dr. Cumming.

The Marin Hospitalist Medical Group is setting up a communication system to alert all primary care physicians of pending lab results so such tests do not fall through the cracks after patients are discharged.

In another initiative, the hospital will set up a system to note that any pneumonia or influenza vaccinations performed while the patient was hospitalized are communicated either to PCP or outside facility. The group is also working to urge all local nursing facilities to include records of patients’ recent vaccinations when they are transferred to the hospital.

It’s clear that effective transfers of elderly patients require a concerted effort by all involved. “If you perform a root cause analysis of [transfer] errors, most occur not because of any negligence, but because communication—written or verbal—was not handled as best as it could have been,” Dr. Gartland notes. “Oftentimes, we are just as frustrated as they [nursing facilities] are when patients return to the emergency room unable to communicate their medical conditions, wishes, and the like,” he says. As medical director of care coordination at Emory, he has worked to improve relationships with administrators and physicians in nursing facilities used most often by the hospital. “If people have a vested interest in a relationship, they are more likely to be diligent about the transfer of patients,” he asserts.

Above all, emphasizes Dr. Cumming, “it important to always solicit feedback from your primary care physician ‘clientele.’ They are your clients, much as your patients are, and your hospital is. We’re providing services to all these various groups. Quality patient care is the most important thing that we do, and part of that means that we have to have good transfer of information. Our group recognizes that we are far from perfect; we know we can always do better; and we always have to reassess to make sure that we’re on the right track.” TH

Gretchen Henkel is a frequent contributor to The Hospitalist.

Reference

1. Ouslander JG, Osterweil D, Morley J. Medical Care in the Nursing Home. 2nd ed. New York, New York: McGraw-Hill Publishers;1997.

Although the vast majority of physicians who practice hospital medicine in the United States are board certified in internal medicine, about 3% of hospitalists have their certification in family medicine.

How do differences in training, general outlook on the practice of medicine, or other factors affect their roles as hospitalists? Do practitioners of family medicine bring special skills to inpatient care? Why do they choose to become hospitalists instead of community-based family doctors? Does their certification in family practice give them a particular bond with the patient’s primary care doctor who may also be a family practitioner? How do they fit into the hospitalist picture, which is—at least in the U.S.—so dominated by internists?

To find out, we asked six hospitalists certified in family medicine:

• Jasen W. Gundersen, MD, division chief of hospital medicine, University of Massachusetts Memorial Medical Center, and assistant professor, UMass. ­Med­ical School, Worcester, Mass.
• Michael Kedansky, MD, lead hospitalist at the Kino Campus of University Physicians Healthcare Hospital in Tucson, Ariz., and clinical assistant professor of family and community medicine at the University of Arizona College of Medicine;
• Elizabeth Chmelik, MD, director of the Inpatient Medical Program at Scott and White University Medical Campus at Texas A&M University in Austin;
• Echo-Marie Enns, MD, a family practice hospitalist at the Peter Lougheed Center in Calgary, Alberta, Canada.
• Felix Aguirre, MD, vice president of medical affairs at IPC-the Hospitalist Company, San Antonio, Texas; and
• Jennifer Cameron, MD, a family medicine hospitalist with Central Texas Hospitalist who practices at St. David’s Hospital, Round Rock, Texas.

Drs. Gundersen, Kedansky, and Chmelik are members of SHM’s Family Practice Task Force.

Training And Decisions

Most of the experts we spoke with agree training influenced their decision to become hospitalists. They cite the diversity of cases in family practice residency (adult, pediatric, and obstetric/gynecologic), which they felt they would also find in hospital medicine.

Dr. Gundersen, chair of SHM’s Family Practice Task Force, suspects internists and family physicians probably share one motivator for opting into hospital medicine: the hospital environment. “Even in residency, I liked my time in the hospital,” Dr. Gundersen says. Echoing that sentiment, Dr. Kedansky says he missed hospital work when he was in community practice.

Family medicine is about people and relationships, says Dr. Chmelik. “You can get that same satisfaction on an inpatient basis,” she says. “I’ve always liked seeing the same patients from day to day. You get instant gratification.”

The higher levels of support and resources available in a hospital environment as opposed to those in a community-based practice appeal to Dr. Enns.

Dr. Gundersen adds that some physicians don’t like all the paperwork office practice entails; others favor the regulated hours of hospital practice. “People often evolve into it as they get more experience,” he says. “They feel that hospital medicine gives them a chance to really make a difference.”

Dr. Cameron agrees about the paperwork. “Out of residency, I became a primary care physician in Tucson,” she says. “When the local hospital group became unexpectedly short-handed, they asked me to fill in on weekends. Once I proved myself with my eagerness and team spirit, they asked me to join their group. The timing was just right: the office management, billings, paperwork, employee issues, and 24/7 schedule were just killing me, and I was ready to try something else.”

Dr. Aguirre says his hospitalist career grew out of his work with a primary care group. His primary aim was standardizing the care of the hospitalized patients in the group.

Whole-Patient View

What special skills do family medicine physicians bring to hospital medicine? The experts quickly pointed out that though training and backgrounds might differ somewhat between internists and family medicine hospitalists they view their respective skills as complementary.

“Family medicine physicians bring a wider breadth of general knowledge in more medical areas than a traditional internal medicine physician, but an internal medicine physician is expected to have a greater depth of knowledge in general adult medicine, which is the current mainstay of hospital medicine,” says Dr. Aguirre. But he suggests that the knowledge base tends to equalize with experience as internal medicine (IM) and family medicine hospitalists cover each other.

However, he also believes a family physician initially brings more knowledge and practical experience in gynecology, behavioral science, pediatric, orthopedic, and family medicine. “These experiences can be especially useful when crafting hospitalist programs to serve these specific target audiences and to help staff pediatric or IM/pediatric hospitalist programs as well,” he says.

Family medicine covers a lot of bases, these experts say. “Family medicine hospitalists have training in family dynamics, end-of-life issues, and family counseling,” says Dr. Chmelik. “These skills frequently come into play with hospitalized patients.” For Dr. Kedansky, family medicine residency training focuses on treating the whole patient “from birth to death.”

Dr. Gundersen knows how broad that role is. “We have the ability to treat adult, newborn, pediatric, and obstetric/gynecologic patients,” he says. “Some family medicine hospitalists even do labor management,” he says.

According to him, a family practice hospitalist gives a hospital special value because one hospitalist can take care of children as well as adults.

Community is important in the hospitalist-patient relationship. “Family practitioners learn how patients fit into the community,” says Dr. Enns. “We can picture patients in a home setting. This helps us in getting patients ready for discharge.”

The outpatient perspective gives family practitioners more foresight, says Dr. Cameron. Family practitioners “see possible roadblocks to a successful discharge to the home and are more willing to jump through the necessary hoops to ensure things go as planned once the patient is discharged,” she says. “As prior outpatient physicians, we know the frustration of having a patient just discharged from the hospital land in our clinic Monday morning with many issues unaddressed.”

Many family physicians had office practices before becoming hospitalists. “We understand how the continuum works,” says Dr. Kedansky.

Bond with Primary Docs

Does belonging to the same “fraternity”—family medicine—create a special relationship between a primary care doctor and a hospitalist with a similar background and training?

From the Canadian perspective, Dr. Enns thinks it may. She says resource constraints may apply to the primary care physician working in the community. “When I am treating a patient, I sometimes find a condition that is unrelated to the patient’s hospitalization,” she says. “I have better access to resources, so I might be able to accomplish a lot for my colleague. I’ll call and ask if the doctor would like me to run an appropriate test, for example. Usually the primary care doctor is extremely grateful for the help.”

In the U.S., Dr. Gundersen suggests that the specialty of neither the primary care doctor nor the hospitalist is particularly important. “Continuity of care is the critical thing,” he says. “The point is to have good communication and a smooth handoff back to the primary care doctor.”

Dr. Kedansky agrees on the necessity for good communication but feels a greater sense of connectivity with the primary care physician, partly because he has been one. “I also know many of the docs personally, so that helps,” he says.

For Drs. Aguirre and Cameron, having worked as a primary care physician helps them empathize with their concerns about continuity and quality of care.

“I have been in their shoes, so to speak,” says Dr. Cameron. “I know the frustrations they deal with daily.”

Some primary care doctors seem pleased the hospitalist shares their background, Dr. Chmelik notes, but she also emphasizes that continuity of care is much more important.

Everyone agreed that, in most cases, primary care doctors are grateful hospitalists are there to take over inpatient care, but Dr. Kedansky notes that some family physicians still want to do it all. “I give those docs credit if they want to maintain care of their patients when they’re in the hospital,” he says. “But most simply can’t keep up with it.”

Improved Training

Dr. Enns says that in Canada, family physicians have training in palliative care, but internists don’t. (They do in the U.S.)

“Family physicians have training in the broader aspects of patient care,” she says. “They view patients in terms of the goal to be achieved rather than the diagnosis.” However, she feels internists have superior training in differential diagnosis.

In her view, family physicians and internists learn skills they originally lacked as they evolve as hospitalists. “I know I’ve learned a lot about diagnosis since I’ve been a hospitalist,” she confesses. She feels that both groups—internists and family physicians—would benefit as hospitalists if they had cross-training in each other’s specialties.

More training on the business side would have been helpful, suggests Dr. Chmelik. “We learned how to be doctors,” she says, “but we also need to know how to function in a hospital setting.” She mentioned billing, length-of-stay protocols, and Joint Commission on Accreditation of Healthcare Organizations (JCAHO) rules as examples. She also would have liked more training in infection control.

Family practice physicians fear the specialty has been slower than internal medicine in developing a program that would offer credentialing for hospitalists.

The U.S. family medicine hospitalists worry that because they are such a small part of the hospitalist family their position will be further eroded unless they can offer a similar credential.

Further, all cited the urgency of expanding fellowships in hospital medicine as a means of training that could lead to credentialing.

It is unlikely any sort of joint credential will be developed, given that the certifying boards of family medicine and internal medicine are individual entities, they say.

In the Minority

Being a minority in the ranks of hospitalists has its disadvantages. Some family medicine hospitalists feel they have to struggle to achieve recognition. But all agreed there is no problem with colleagues.

“I manage a mixed group of internists and family physicians,” says Dr. Kedansky, “and there is no distinction.”

Patient respect is not at issue, either. The panelists say patients are curious about the term hospitalist but seem largely oblivious to any further distinction. If there is any preference for internist hospitalists—and not everyone agrees there is—it seems to be on the part of the people who hire hospitalists.

Some potential employers specify in their employment ads that an applicant be certified in internal medicine, but Dr. Kedansky suggests that because most hospitalists are internists, many hirers assume that is the standard. “The person’s skills are what’s important, not the specialty,” he says. “If the doctor wants the job, he should persist.” But Dr. Gundersen, who thinks there is bias in some cases, says he has found that some hirers will not even interview candidates with family physician boards. “This situation limits a family physician hospitalist’s ability to move around or even get a job in the first place,” he says.

Dr. Cameron knows whereof he speaks. “I had a few hospital groups and hospitals dismiss my [resume] without even talking to me despite my experience and stellar references,” she says of her frustrating year-and-a-half search for her present position.

Family physician hospitalists may have a bigger hurdle to overcome, acknowledges Dr. Chmelik. “We may have to prove more, but it is possible to earn recognition,” she believes. Dr. Aguirre concurs: “Respect is earned and not a predetermined right.”

In Canada there is no hiring issue because almost all hospitalists are family physicians, but Dr. Enns says her U.S. colleagues should “feel their own worth more. They add great value to the skills that internists bring.”

Outlook

Fewer doctors are opting to take the family medicine boards, but leaders are rising to the challenge to redefine and reassert the importance of the needs served by family physicians. At the same time, there is increasing demand for hospitalists.

According to Dr. Aguirre, demand may double—or go even higher—within the next 10 years.

“There are not enough internal medicine physicians, family medicine physicians, pediatric physicians, and physician extenders completing training or leaving private practice to become hospitalists in the near future to fill the oncoming void,” he warns.

Even if this situation proves true and hospitalist jobs are everywhere for the taking, it’s unclear whether that will rekindle interest in family practice as a path to becoming a hospitalist. But one thing seems certain: There will be credentialing processes for family physician and internist hospitalists.

Dr. Kedansky is concerned that family medicine is playing catch-up on this issue, and he wonders what effect credentialing will have. “Now it’s on the radar screen, though,” he says.

Dr. Cameron shares his concerns. She fears that if family physicians lack equal footing with internists as hospitalists, many rural and smaller hospitals will be without hospitalist coverage.

Early on, the medical community in Canada considered that the role of family medicine hospitalist might be a temporary one, taken to give family practice medicine time to regain strength, says Dr. Enns. “Now, there are no signs that it’s temporary,” she says. “It’s an effective method of patient care, and the community has embraced it. There are no more naysayers.”

Getting new physicians interested in the specialty is key, says Dr. Chmelik.

“Fellowships for further training are important,” she says. “We need to work with medical students too, show them there are options within the field. They want choices.”

Dr. Gundersen suggests that whether one is an internist or a family-physician hospitalist may not make much difference in years to come. “I think that in the future physicians will be classified on the basis of whether they are outpatient or inpatient doctors, rather than all these other designations,” he says. “It’s getting harder and harder to be both.” TH

Joen Kinnan is a frequent contributor to The Hospitalist.

Although the vast majority of physicians who practice hospital medicine in the United States are board certified in internal medicine, about 3% of hospitalists have their certification in family medicine.

How do differences in training, general outlook on the practice of medicine, or other factors affect their roles as hospitalists? Do practitioners of family medicine bring special skills to inpatient care? Why do they choose to become hospitalists instead of community-based family doctors? Does their certification in family practice give them a particular bond with the patient’s primary care doctor who may also be a family practitioner? How do they fit into the hospitalist picture, which is—at least in the U.S.—so dominated by internists?

To find out, we asked six hospitalists certified in family medicine:

• Jasen W. Gundersen, MD, division chief of hospital medicine, University of Massachusetts Memorial Medical Center, and assistant professor, UMass. ­Med­ical School, Worcester, Mass.
• Michael Kedansky, MD, lead hospitalist at the Kino Campus of University Physicians Healthcare Hospital in Tucson, Ariz., and clinical assistant professor of family and community medicine at the University of Arizona College of Medicine;
• Elizabeth Chmelik, MD, director of the Inpatient Medical Program at Scott and White University Medical Campus at Texas A&M University in Austin;
• Echo-Marie Enns, MD, a family practice hospitalist at the Peter Lougheed Center in Calgary, Alberta, Canada.
• Felix Aguirre, MD, vice president of medical affairs at IPC-the Hospitalist Company, San Antonio, Texas; and
• Jennifer Cameron, MD, a family medicine hospitalist with Central Texas Hospitalist who practices at St. David’s Hospital, Round Rock, Texas.

Drs. Gundersen, Kedansky, and Chmelik are members of SHM’s Family Practice Task Force.

Training And Decisions

Most of the experts we spoke with agree training influenced their decision to become hospitalists. They cite the diversity of cases in family practice residency (adult, pediatric, and obstetric/gynecologic), which they felt they would also find in hospital medicine.

Dr. Gundersen, chair of SHM’s Family Practice Task Force, suspects internists and family physicians probably share one motivator for opting into hospital medicine: the hospital environment. “Even in residency, I liked my time in the hospital,” Dr. Gundersen says. Echoing that sentiment, Dr. Kedansky says he missed hospital work when he was in community practice.

Family medicine is about people and relationships, says Dr. Chmelik. “You can get that same satisfaction on an inpatient basis,” she says. “I’ve always liked seeing the same patients from day to day. You get instant gratification.”

The higher levels of support and resources available in a hospital environment as opposed to those in a community-based practice appeal to Dr. Enns.

Dr. Gundersen adds that some physicians don’t like all the paperwork office practice entails; others favor the regulated hours of hospital practice. “People often evolve into it as they get more experience,” he says. “They feel that hospital medicine gives them a chance to really make a difference.”

Dr. Cameron agrees about the paperwork. “Out of residency, I became a primary care physician in Tucson,” she says. “When the local hospital group became unexpectedly short-handed, they asked me to fill in on weekends. Once I proved myself with my eagerness and team spirit, they asked me to join their group. The timing was just right: the office management, billings, paperwork, employee issues, and 24/7 schedule were just killing me, and I was ready to try something else.”

Dr. Aguirre says his hospitalist career grew out of his work with a primary care group. His primary aim was standardizing the care of the hospitalized patients in the group.

Whole-Patient View

What special skills do family medicine physicians bring to hospital medicine? The experts quickly pointed out that though training and backgrounds might differ somewhat between internists and family medicine hospitalists they view their respective skills as complementary.

“Family medicine physicians bring a wider breadth of general knowledge in more medical areas than a traditional internal medicine physician, but an internal medicine physician is expected to have a greater depth of knowledge in general adult medicine, which is the current mainstay of hospital medicine,” says Dr. Aguirre. But he suggests that the knowledge base tends to equalize with experience as internal medicine (IM) and family medicine hospitalists cover each other.

However, he also believes a family physician initially brings more knowledge and practical experience in gynecology, behavioral science, pediatric, orthopedic, and family medicine. “These experiences can be especially useful when crafting hospitalist programs to serve these specific target audiences and to help staff pediatric or IM/pediatric hospitalist programs as well,” he says.

Family medicine covers a lot of bases, these experts say. “Family medicine hospitalists have training in family dynamics, end-of-life issues, and family counseling,” says Dr. Chmelik. “These skills frequently come into play with hospitalized patients.” For Dr. Kedansky, family medicine residency training focuses on treating the whole patient “from birth to death.”

Dr. Gundersen knows how broad that role is. “We have the ability to treat adult, newborn, pediatric, and obstetric/gynecologic patients,” he says. “Some family medicine hospitalists even do labor management,” he says.

According to him, a family practice hospitalist gives a hospital special value because one hospitalist can take care of children as well as adults.

Community is important in the hospitalist-patient relationship. “Family practitioners learn how patients fit into the community,” says Dr. Enns. “We can picture patients in a home setting. This helps us in getting patients ready for discharge.”

The outpatient perspective gives family practitioners more foresight, says Dr. Cameron. Family practitioners “see possible roadblocks to a successful discharge to the home and are more willing to jump through the necessary hoops to ensure things go as planned once the patient is discharged,” she says. “As prior outpatient physicians, we know the frustration of having a patient just discharged from the hospital land in our clinic Monday morning with many issues unaddressed.”

Many family physicians had office practices before becoming hospitalists. “We understand how the continuum works,” says Dr. Kedansky.

Bond with Primary Docs

Does belonging to the same “fraternity”—family medicine—create a special relationship between a primary care doctor and a hospitalist with a similar background and training?

From the Canadian perspective, Dr. Enns thinks it may. She says resource constraints may apply to the primary care physician working in the community. “When I am treating a patient, I sometimes find a condition that is unrelated to the patient’s hospitalization,” she says. “I have better access to resources, so I might be able to accomplish a lot for my colleague. I’ll call and ask if the doctor would like me to run an appropriate test, for example. Usually the primary care doctor is extremely grateful for the help.”

In the U.S., Dr. Gundersen suggests that the specialty of neither the primary care doctor nor the hospitalist is particularly important. “Continuity of care is the critical thing,” he says. “The point is to have good communication and a smooth handoff back to the primary care doctor.”

Dr. Kedansky agrees on the necessity for good communication but feels a greater sense of connectivity with the primary care physician, partly because he has been one. “I also know many of the docs personally, so that helps,” he says.

For Drs. Aguirre and Cameron, having worked as a primary care physician helps them empathize with their concerns about continuity and quality of care.

“I have been in their shoes, so to speak,” says Dr. Cameron. “I know the frustrations they deal with daily.”

Some primary care doctors seem pleased the hospitalist shares their background, Dr. Chmelik notes, but she also emphasizes that continuity of care is much more important.

Everyone agreed that, in most cases, primary care doctors are grateful hospitalists are there to take over inpatient care, but Dr. Kedansky notes that some family physicians still want to do it all. “I give those docs credit if they want to maintain care of their patients when they’re in the hospital,” he says. “But most simply can’t keep up with it.”

Improved Training

Dr. Enns says that in Canada, family physicians have training in palliative care, but internists don’t. (They do in the U.S.)

“Family physicians have training in the broader aspects of patient care,” she says. “They view patients in terms of the goal to be achieved rather than the diagnosis.” However, she feels internists have superior training in differential diagnosis.

In her view, family physicians and internists learn skills they originally lacked as they evolve as hospitalists. “I know I’ve learned a lot about diagnosis since I’ve been a hospitalist,” she confesses. She feels that both groups—internists and family physicians—would benefit as hospitalists if they had cross-training in each other’s specialties.

More training on the business side would have been helpful, suggests Dr. Chmelik. “We learned how to be doctors,” she says, “but we also need to know how to function in a hospital setting.” She mentioned billing, length-of-stay protocols, and Joint Commission on Accreditation of Healthcare Organizations (JCAHO) rules as examples. She also would have liked more training in infection control.

Family practice physicians fear the specialty has been slower than internal medicine in developing a program that would offer credentialing for hospitalists.

The U.S. family medicine hospitalists worry that because they are such a small part of the hospitalist family their position will be further eroded unless they can offer a similar credential.

Further, all cited the urgency of expanding fellowships in hospital medicine as a means of training that could lead to credentialing.

It is unlikely any sort of joint credential will be developed, given that the certifying boards of family medicine and internal medicine are individual entities, they say.

In the Minority

Being a minority in the ranks of hospitalists has its disadvantages. Some family medicine hospitalists feel they have to struggle to achieve recognition. But all agreed there is no problem with colleagues.

“I manage a mixed group of internists and family physicians,” says Dr. Kedansky, “and there is no distinction.”

Patient respect is not at issue, either. The panelists say patients are curious about the term hospitalist but seem largely oblivious to any further distinction. If there is any preference for internist hospitalists—and not everyone agrees there is—it seems to be on the part of the people who hire hospitalists.

Some potential employers specify in their employment ads that an applicant be certified in internal medicine, but Dr. Kedansky suggests that because most hospitalists are internists, many hirers assume that is the standard. “The person’s skills are what’s important, not the specialty,” he says. “If the doctor wants the job, he should persist.” But Dr. Gundersen, who thinks there is bias in some cases, says he has found that some hirers will not even interview candidates with family physician boards. “This situation limits a family physician hospitalist’s ability to move around or even get a job in the first place,” he says.

Dr. Cameron knows whereof he speaks. “I had a few hospital groups and hospitals dismiss my [resume] without even talking to me despite my experience and stellar references,” she says of her frustrating year-and-a-half search for her present position.

Family physician hospitalists may have a bigger hurdle to overcome, acknowledges Dr. Chmelik. “We may have to prove more, but it is possible to earn recognition,” she believes. Dr. Aguirre concurs: “Respect is earned and not a predetermined right.”

In Canada there is no hiring issue because almost all hospitalists are family physicians, but Dr. Enns says her U.S. colleagues should “feel their own worth more. They add great value to the skills that internists bring.”

Outlook

Fewer doctors are opting to take the family medicine boards, but leaders are rising to the challenge to redefine and reassert the importance of the needs served by family physicians. At the same time, there is increasing demand for hospitalists.

According to Dr. Aguirre, demand may double—or go even higher—within the next 10 years.

“There are not enough internal medicine physicians, family medicine physicians, pediatric physicians, and physician extenders completing training or leaving private practice to become hospitalists in the near future to fill the oncoming void,” he warns.

Even if this situation proves true and hospitalist jobs are everywhere for the taking, it’s unclear whether that will rekindle interest in family practice as a path to becoming a hospitalist. But one thing seems certain: There will be credentialing processes for family physician and internist hospitalists.

Dr. Kedansky is concerned that family medicine is playing catch-up on this issue, and he wonders what effect credentialing will have. “Now it’s on the radar screen, though,” he says.

Dr. Cameron shares his concerns. She fears that if family physicians lack equal footing with internists as hospitalists, many rural and smaller hospitals will be without hospitalist coverage.

Early on, the medical community in Canada considered that the role of family medicine hospitalist might be a temporary one, taken to give family practice medicine time to regain strength, says Dr. Enns. “Now, there are no signs that it’s temporary,” she says. “It’s an effective method of patient care, and the community has embraced it. There are no more naysayers.”

Getting new physicians interested in the specialty is key, says Dr. Chmelik.

“Fellowships for further training are important,” she says. “We need to work with medical students too, show them there are options within the field. They want choices.”

Dr. Gundersen suggests that whether one is an internist or a family-physician hospitalist may not make much difference in years to come. “I think that in the future physicians will be classified on the basis of whether they are outpatient or inpatient doctors, rather than all these other designations,” he says. “It’s getting harder and harder to be both.” TH

Joen Kinnan is a frequent contributor to The Hospitalist.

Although the vast majority of physicians who practice hospital medicine in the United States are board certified in internal medicine, about 3% of hospitalists have their certification in family medicine.

How do differences in training, general outlook on the practice of medicine, or other factors affect their roles as hospitalists? Do practitioners of family medicine bring special skills to inpatient care? Why do they choose to become hospitalists instead of community-based family doctors? Does their certification in family practice give them a particular bond with the patient’s primary care doctor who may also be a family practitioner? How do they fit into the hospitalist picture, which is—at least in the U.S.—so dominated by internists?

To find out, we asked six hospitalists certified in family medicine:

• Jasen W. Gundersen, MD, division chief of hospital medicine, University of Massachusetts Memorial Medical Center, and assistant professor, UMass. ­Med­ical School, Worcester, Mass.
• Michael Kedansky, MD, lead hospitalist at the Kino Campus of University Physicians Healthcare Hospital in Tucson, Ariz., and clinical assistant professor of family and community medicine at the University of Arizona College of Medicine;
• Elizabeth Chmelik, MD, director of the Inpatient Medical Program at Scott and White University Medical Campus at Texas A&M University in Austin;
• Echo-Marie Enns, MD, a family practice hospitalist at the Peter Lougheed Center in Calgary, Alberta, Canada.
• Felix Aguirre, MD, vice president of medical affairs at IPC-the Hospitalist Company, San Antonio, Texas; and
• Jennifer Cameron, MD, a family medicine hospitalist with Central Texas Hospitalist who practices at St. David’s Hospital, Round Rock, Texas.

Drs. Gundersen, Kedansky, and Chmelik are members of SHM’s Family Practice Task Force.

Training And Decisions

Most of the experts we spoke with agree training influenced their decision to become hospitalists. They cite the diversity of cases in family practice residency (adult, pediatric, and obstetric/gynecologic), which they felt they would also find in hospital medicine.

Dr. Gundersen, chair of SHM’s Family Practice Task Force, suspects internists and family physicians probably share one motivator for opting into hospital medicine: the hospital environment. “Even in residency, I liked my time in the hospital,” Dr. Gundersen says. Echoing that sentiment, Dr. Kedansky says he missed hospital work when he was in community practice.

Family medicine is about people and relationships, says Dr. Chmelik. “You can get that same satisfaction on an inpatient basis,” she says. “I’ve always liked seeing the same patients from day to day. You get instant gratification.”

The higher levels of support and resources available in a hospital environment as opposed to those in a community-based practice appeal to Dr. Enns.

Dr. Gundersen adds that some physicians don’t like all the paperwork office practice entails; others favor the regulated hours of hospital practice. “People often evolve into it as they get more experience,” he says. “They feel that hospital medicine gives them a chance to really make a difference.”

Dr. Cameron agrees about the paperwork. “Out of residency, I became a primary care physician in Tucson,” she says. “When the local hospital group became unexpectedly short-handed, they asked me to fill in on weekends. Once I proved myself with my eagerness and team spirit, they asked me to join their group. The timing was just right: the office management, billings, paperwork, employee issues, and 24/7 schedule were just killing me, and I was ready to try something else.”

Dr. Aguirre says his hospitalist career grew out of his work with a primary care group. His primary aim was standardizing the care of the hospitalized patients in the group.

Whole-Patient View

What special skills do family medicine physicians bring to hospital medicine? The experts quickly pointed out that though training and backgrounds might differ somewhat between internists and family medicine hospitalists they view their respective skills as complementary.

“Family medicine physicians bring a wider breadth of general knowledge in more medical areas than a traditional internal medicine physician, but an internal medicine physician is expected to have a greater depth of knowledge in general adult medicine, which is the current mainstay of hospital medicine,” says Dr. Aguirre. But he suggests that the knowledge base tends to equalize with experience as internal medicine (IM) and family medicine hospitalists cover each other.

However, he also believes a family physician initially brings more knowledge and practical experience in gynecology, behavioral science, pediatric, orthopedic, and family medicine. “These experiences can be especially useful when crafting hospitalist programs to serve these specific target audiences and to help staff pediatric or IM/pediatric hospitalist programs as well,” he says.

Family medicine covers a lot of bases, these experts say. “Family medicine hospitalists have training in family dynamics, end-of-life issues, and family counseling,” says Dr. Chmelik. “These skills frequently come into play with hospitalized patients.” For Dr. Kedansky, family medicine residency training focuses on treating the whole patient “from birth to death.”

Dr. Gundersen knows how broad that role is. “We have the ability to treat adult, newborn, pediatric, and obstetric/gynecologic patients,” he says. “Some family medicine hospitalists even do labor management,” he says.

According to him, a family practice hospitalist gives a hospital special value because one hospitalist can take care of children as well as adults.

Community is important in the hospitalist-patient relationship. “Family practitioners learn how patients fit into the community,” says Dr. Enns. “We can picture patients in a home setting. This helps us in getting patients ready for discharge.”

The outpatient perspective gives family practitioners more foresight, says Dr. Cameron. Family practitioners “see possible roadblocks to a successful discharge to the home and are more willing to jump through the necessary hoops to ensure things go as planned once the patient is discharged,” she says. “As prior outpatient physicians, we know the frustration of having a patient just discharged from the hospital land in our clinic Monday morning with many issues unaddressed.”

Many family physicians had office practices before becoming hospitalists. “We understand how the continuum works,” says Dr. Kedansky.

Bond with Primary Docs

Does belonging to the same “fraternity”—family medicine—create a special relationship between a primary care doctor and a hospitalist with a similar background and training?

From the Canadian perspective, Dr. Enns thinks it may. She says resource constraints may apply to the primary care physician working in the community. “When I am treating a patient, I sometimes find a condition that is unrelated to the patient’s hospitalization,” she says. “I have better access to resources, so I might be able to accomplish a lot for my colleague. I’ll call and ask if the doctor would like me to run an appropriate test, for example. Usually the primary care doctor is extremely grateful for the help.”

In the U.S., Dr. Gundersen suggests that the specialty of neither the primary care doctor nor the hospitalist is particularly important. “Continuity of care is the critical thing,” he says. “The point is to have good communication and a smooth handoff back to the primary care doctor.”

Dr. Kedansky agrees on the necessity for good communication but feels a greater sense of connectivity with the primary care physician, partly because he has been one. “I also know many of the docs personally, so that helps,” he says.

For Drs. Aguirre and Cameron, having worked as a primary care physician helps them empathize with their concerns about continuity and quality of care.

“I have been in their shoes, so to speak,” says Dr. Cameron. “I know the frustrations they deal with daily.”

Some primary care doctors seem pleased the hospitalist shares their background, Dr. Chmelik notes, but she also emphasizes that continuity of care is much more important.

Everyone agreed that, in most cases, primary care doctors are grateful hospitalists are there to take over inpatient care, but Dr. Kedansky notes that some family physicians still want to do it all. “I give those docs credit if they want to maintain care of their patients when they’re in the hospital,” he says. “But most simply can’t keep up with it.”

Improved Training

Dr. Enns says that in Canada, family physicians have training in palliative care, but internists don’t. (They do in the U.S.)

“Family physicians have training in the broader aspects of patient care,” she says. “They view patients in terms of the goal to be achieved rather than the diagnosis.” However, she feels internists have superior training in differential diagnosis.

In her view, family physicians and internists learn skills they originally lacked as they evolve as hospitalists. “I know I’ve learned a lot about diagnosis since I’ve been a hospitalist,” she confesses. She feels that both groups—internists and family physicians—would benefit as hospitalists if they had cross-training in each other’s specialties.

More training on the business side would have been helpful, suggests Dr. Chmelik. “We learned how to be doctors,” she says, “but we also need to know how to function in a hospital setting.” She mentioned billing, length-of-stay protocols, and Joint Commission on Accreditation of Healthcare Organizations (JCAHO) rules as examples. She also would have liked more training in infection control.

Family practice physicians fear the specialty has been slower than internal medicine in developing a program that would offer credentialing for hospitalists.

The U.S. family medicine hospitalists worry that because they are such a small part of the hospitalist family their position will be further eroded unless they can offer a similar credential.

Further, all cited the urgency of expanding fellowships in hospital medicine as a means of training that could lead to credentialing.

It is unlikely any sort of joint credential will be developed, given that the certifying boards of family medicine and internal medicine are individual entities, they say.

In the Minority

Being a minority in the ranks of hospitalists has its disadvantages. Some family medicine hospitalists feel they have to struggle to achieve recognition. But all agreed there is no problem with colleagues.

“I manage a mixed group of internists and family physicians,” says Dr. Kedansky, “and there is no distinction.”

Patient respect is not at issue, either. The panelists say patients are curious about the term hospitalist but seem largely oblivious to any further distinction. If there is any preference for internist hospitalists—and not everyone agrees there is—it seems to be on the part of the people who hire hospitalists.

Some potential employers specify in their employment ads that an applicant be certified in internal medicine, but Dr. Kedansky suggests that because most hospitalists are internists, many hirers assume that is the standard. “The person’s skills are what’s important, not the specialty,” he says. “If the doctor wants the job, he should persist.” But Dr. Gundersen, who thinks there is bias in some cases, says he has found that some hirers will not even interview candidates with family physician boards. “This situation limits a family physician hospitalist’s ability to move around or even get a job in the first place,” he says.

Dr. Cameron knows whereof he speaks. “I had a few hospital groups and hospitals dismiss my [resume] without even talking to me despite my experience and stellar references,” she says of her frustrating year-and-a-half search for her present position.

Family physician hospitalists may have a bigger hurdle to overcome, acknowledges Dr. Chmelik. “We may have to prove more, but it is possible to earn recognition,” she believes. Dr. Aguirre concurs: “Respect is earned and not a predetermined right.”

In Canada there is no hiring issue because almost all hospitalists are family physicians, but Dr. Enns says her U.S. colleagues should “feel their own worth more. They add great value to the skills that internists bring.”

Outlook

Fewer doctors are opting to take the family medicine boards, but leaders are rising to the challenge to redefine and reassert the importance of the needs served by family physicians. At the same time, there is increasing demand for hospitalists.

According to Dr. Aguirre, demand may double—or go even higher—within the next 10 years.

“There are not enough internal medicine physicians, family medicine physicians, pediatric physicians, and physician extenders completing training or leaving private practice to become hospitalists in the near future to fill the oncoming void,” he warns.

Even if this situation proves true and hospitalist jobs are everywhere for the taking, it’s unclear whether that will rekindle interest in family practice as a path to becoming a hospitalist. But one thing seems certain: There will be credentialing processes for family physician and internist hospitalists.

Dr. Kedansky is concerned that family medicine is playing catch-up on this issue, and he wonders what effect credentialing will have. “Now it’s on the radar screen, though,” he says.

Dr. Cameron shares his concerns. She fears that if family physicians lack equal footing with internists as hospitalists, many rural and smaller hospitals will be without hospitalist coverage.

Early on, the medical community in Canada considered that the role of family medicine hospitalist might be a temporary one, taken to give family practice medicine time to regain strength, says Dr. Enns. “Now, there are no signs that it’s temporary,” she says. “It’s an effective method of patient care, and the community has embraced it. There are no more naysayers.”

Getting new physicians interested in the specialty is key, says Dr. Chmelik.

“Fellowships for further training are important,” she says. “We need to work with medical students too, show them there are options within the field. They want choices.”

Dr. Gundersen suggests that whether one is an internist or a family-physician hospitalist may not make much difference in years to come. “I think that in the future physicians will be classified on the basis of whether they are outpatient or inpatient doctors, rather than all these other designations,” he says. “It’s getting harder and harder to be both.” TH

Joen Kinnan is a frequent contributor to The Hospitalist.

Case

A 62-year-old obese woman with type 2 diabetes, hypertension, and a pack-a-day smoking habit presents to the emergency department for acute onset of left-side arm and leg weakness and sensory loss on awakening.

She reports taking a baby aspirin daily to “prevent heart attacks.” Her electrocardiogram demonstrates a left bundle branch block and frequent premature atrial contractions. She recovers partially but has residual mild hemiparesis. A duplex carotid ultrasound shows 80% stenosis of the right internal carotid artery.

Overview

In the United States each year approximately 700,000 cerebrovascular accidents (CVA) constitute the largest cause of age-adjusted morbidity of any illness.1 About 200,000 of these strokes are recurrent events.

CVA is the third-leading cause of death. Hospitalists increasingly are responsible for the inpatient care of patients with acute CVA. Atheroembolism from carotid atherosclerosis is the suspected cause for about one in five ischemic strokes.2

The link between carotid stenosis and stroke has been recognized for many years. The first carotid endarterectomy (CEA) was reported more than 50 years ago.3

This targeted review covers the natural history of symptomatic carotid stenosis, the key efficacy trials of CEA and carotid angioplasty and stenting (CAS) among symptomatic patients, and pitfalls for properly diagnosing the severity of carotid stenosis. The medical therapy of carotid stenosis and the secondary prevention of CVA were recently reviewed in The Hospitalist (October 2007, p. 34).

Natural History

The presence or absence of referable neurological symptoms is pivotal to understanding the near-term risk for recurrent CVA related to carotid stenosis. In the absence of symptoms, the risk for future CVA is essentially constant over years.

However, once symptoms occur, the risk for a second event accelerates substantially. Among patients with newly symptomatic carotid stenosis, the risk for another transient ischemic attack (TIA) or stroke within the following 24 months is 26%.4 This risk peaks within the first month or two following the index event, underscoring the time-dependent nature of carotid evaluation and intervention.

Guidelines from the American Heart Association and the American College of Cardiology on the management of ischemic stroke assign early carotid intervention, defined as within two weeks from the index event, a Class 2 indication.5 Hospitalists must rapidly identify the severity of carotid stenosis and make timely referrals to meet this recommended therapeutic window.

Carotid Endarterectomy

CEA is perhaps the best-studied surgical procedure, with multiple well-conducted prospective randomized trials demonstrating its efficacy. The procedure had been performed for hundreds of thousands of patients prior to this data being published in the early 1990s. The North American Symptomatic Carotid Endarterectomy Trial (NASCET) was the landmark study demonstrating the efficacy of intervention. The trial of patients with symptomatic carotid stenosis was stopped early for patients with severe stenosis, defined as 70% to 99% narrowing by conventional angiography. At two years, the rate of ipsilateral stroke or post-operative death in patients with severe stenosis decreased from 26% in the medical arm to 9% in the CEA arm [an absolute risk reduction of 17% and number needed to treat of six (p<0.001)].

Rarely has any medical or surgical procedure had such a robust effect over so short an interval for such an important outcome. Patients with less severe stenosis were followed out to five years, with the final results showing benefit among patients with moderate stenosis (50% to 69%).6 The Veterans Affairs Cooperative Trial 309 and the European Carotid Stenosis Trial (ECST) were combined with NASCET in a pooled analysis of more than 6,000 patients and about 35,000 patient-years of follow-up.7-9

Among patients with 70% or greater stenosis, CEA reduced the absolute five-year risk of ipsilateral ischemic stroke and any operative stroke or death by 16% (95% confidence interval 11.2% to 20.8%). The benefit was less pronounced among patients with 50% to 69% stenosis, in whom CEA conferred a 4.6% (95% confidence interval 0.6% to 8.6%) absolute five-year risk reduction.

The medical aspect of these trials required only the use of aspirin. Intensive lipid control and tight glycemic and blood pressure control would probably reduce the rate of events. The 30-day operative risk was consistently less than 6% across these trials, with the benefit seen by two years among patients with 70% to 99% stenosis and by five years among patients with 50% to 69% stenosis.

Referring hospitalists should know the operative event rates of the surgeons to whom they are referring. Hospitalists should also refer those patients whose anticipated life expectancy is at least two years for patients with 70% to 99% stenosis and at least five years for patients with 50% to 69% stenosis.

Figures 1 and 2. ACCUnet Distal Embolic Protection Device, Before and After Carotid Angioplasty and Stenting

Figures 1 and 2. ACCUnet Distal Embolic Protection Device, Before and After Carotid Angioplasty and Stenting

Carotid Angioplasty and Stenting

CAS is increasingly used as an alternative to CEA among selected patients. Two procedural developments have improved the safety of percutaneous carotid revascularization.

First, distal embolic protection filters deployed prior to angioplasty collect debris associated with the mechanical intervention and limit the risk of peri-procedural stroke. (See Figures 1 and 2, p. 36.)

Second, the use of self-expanding stents has improved long-term patency over balloon-expanding stents, which can be damaged by neck movement and external pressure.

The Stenting and Angioplasty with [distal embolic] Protection in Patients at High Risk for Endarterectomy trial demonstrated the noninferiority of CAS versus CEA among high-risk patients.10 Inclusion criteria were symptomatic carotid stenosis of greater than 50% or asymptomatic stenosis greater than 80%. Patients had to have one of several high-risk features to be included. (See Table 1, above)

The cumulative incidence of post-operative stroke, myocardial infarction, death, and ipsilateral stroke within one year after the procedure was 20.1% in the CEA arm and 12.2% in the CAS arm (p=0.004 for noninferiority and p=0.053 for superiority). The rate of post-procedural cranial nerve injury was substantially lower (zero) in the CEA arm.

However, among those patients with symptomatic carotid stenosis, the cumulative incidence of the primary endpoint was 16.8% in the CAS arm and 16.5% in the CEA arm. Based upon this trial, CAS has equivalent one-year outcomes versus CEA in a high-risk population.

click for large version

The Carotid and Vertebral Artery Transluminal Angioplasty Study trial was the first large prospective trial comparing CEA and CAS among symptomatic patients with severe carotid stenosis (mean 86.4% stenosis).11 At 30 days, the rate of death or disabling stroke was 6.4% with CAS and 5.9% with CEA, which were not significantly different in this trial of about 500 patients.

The trial was begun in 1994, with a large portion of angioplasty performed without stents or distal embolic protection. There were fewer local complications but higher rates of restenosis in the CAS arm. The authors noted “no substantial difference in the rate of ipsilateral stroke … up to three years after randomization” but cautioned that the confidence intervals were wide.

Two recently published trials of CAS versus CEA in lower-risk populations do not support the overall safety of CAS among symptomatic patients. The Stent-Protected Angioplasty versus Carotid Endarterectomy trial randomized 1,200 average-risk patients with symptomatic carotid stenosis of 50% or greater by angiography or 70% of greater by ultrasound to either CAS or CEA.12

The trial design stipulated that both surgeons and percutaneous interventionalists perform at least 25 procedures prior to inclusion in the study and that independent quality committees review these procedures. The use of distal embolic protection devices was left to the discretion of the operators. The 30-day rate of death or ipsilateral ischemic stroke was 6.34% in the CEA arm and 6.84% in the CAS arm (p=0.09 for noninferiority).

The investigators concluded that CAS is not non-inferior to CEA (i.e., that CAS is inferior). The Endarterectomy versus Angioplasty in Patients with Symptomatic Severe Carotid Stenosis trial randomized 527 patients with symptomatic carotid stenosis of 70% or greater by angiography or magnetic resonance angiography (MRA) to either CAS or CEA within two weeks of the index event.13

This trial design also stipulated that surgeons had performed at least 25 CEAs in the prior year. Percutaneous interventionalists did not have similar numeric procedure requirements, although the investigators provided for tutoring of less experienced operators. The trial was stopped prematurely due to futility (in terms of noninferiority) and harm within the CAS arm.

The 30-day cumulative incidence of death or any stroke was 3.9% in the CEA arm and 9.6% in the CAS arm (p=0.01 for superiority of CEA). The trial was powered to detect only large differences among low- and high-volume operators. Nearly 10% of patients did not have distal embolic protection devices used during their CAS procedures. Ongoing trials will further define the role of CAS versus CEA in the interventional treatment of carotid stenosis.

Accurate Diagnosis

Different trials used different criteria for defining the percent stenosis of the diseased carotid arterial segment. These differences were based primarily on the mode of testing (i.e., conventional angiography versus ultrasound), and on what portion of the carotid artery was used as the reference or baseline segment to calculate the percent stenosis.

A meta-analysis of various non-invasive modes of testing for carotid stenosis concluded that duplex ultrasound had a pooled sensitivity and specificity of 86% and 87%, respectively, to distinguish 70% to 99% stenosis from less than 70% stenosis.14 MRA had a pooled sensitivity and specificity of 95% and 90%, respectively.

The authors selected trials comparing these non-invasive methods with the gold standard of digital subtraction angiography. Using ultrasonography to first identify patients with at least 50% stenosis, followed by MRA or conventional angiography to more accurately confirm the degree of stenosis has been shown to be cost-effective.15

Back to the Case

For the patient in the vignette, the positive ultrasonography should lead to an MRA or conventional angiography to more precisely determine the percent stenosis. Current guidelines would suggest referring the patient for CEA to be completed within the next two weeks to treat a 50% or greater stenosis. That’s provided the surgeons have an operative morbidity and mortality rate less than 6% and her life expectancy is at least five years. If the patient had high-risk features as listed in Table 1 (left), referral for CAS in the hands of an experienced operator would be an alternative. TH

Dr. Anderson is an assistant professor of medicine at the University of Colorado, Denver, and an associate program director of the internal medicine residency program.

References

1. Rosamond W, Flegal K, Friday G, et al. Heart disease and stroke statistics-2007 update: a report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation. 2007;115:e69-e171.
2. White H, Boden-Albala B, Wang C, et al. Ischemic stroke subtype incidence among whites, blacks, and Hispanics: the Northern Manhattan Study. Circulation. 2005;111(10):1327-1331.
3. Eastcott HH, Pickering GW, Rob CG. Recon­struction of internal carotid artery in a patient with intermittent attacks of hemiplegia. Lancet. 1954;267(6846):994-996.
4. Beneficial effect of carotid endarterectomy in symptomatic patients with high-grade carotid stenosis: North American Symptomatic Carotid Endarterectomy Trial Collaborators. N Engl J Med. 1991; 325(7):445-453.
5. Sacco RL, Adams R, Albers G, et al. American Heart Association/American Stroke Association Council on Stroke; Council on Cardiovascular Radiology and Intervention; American Academy of Neurology. Guidelines for prevention of stroke in patients with ischemic stroke or transient ischemic attack: a statement for healthcare professionals from the American Heart Association/American Stroke Association Council on Stroke: co-sponsored by the Council on Cardiovascular Radiology and Intervention. Circulation. 2006;113:e409-e449.
6. North American Symptomatic Carotid Endarterectomy Trialists’ Collaborative Group. The final results of the NASCET trial. N Engl J Med. 1998;339:1415-1425.
7. Mayberg MR, Wilson E, Yatsu F, et al. Carotid endarterectomy and prevention of cerebral ischemia in symptomatic carotid stenosis. JAMA. 1991;266:3289-3294.
8. European Carotid Surgery Trialists’ Investigators. Randomised trial of endarterectomy for recently symptomatic carotid stenosis: final results of the MRC European Carotid Surgery Trial (ECST). Lancet. 1998;351:1379-1387.
9. Rothwell P, Eliasziw M, Gutnikov A, et al. Analysis of pooled data from the randomised controlled trials of endarterectomy for symptomatic carotid stenosis. Lancet. 2003;361(9352):107-116.
10. Yadav JS, Wholey MH, Kuntz, et al. Protected carotid-artery stenting versus endarterectomy in high-risk patients. N Engl J Med. 2004;351(15):1493-1501.
11. Endovascular versus surgical treatment in patients with carotid stenosis in the Carotid and Vertebral Artery Transluminal Angioplasty Study (CAVATAS): a randomised trial. Lancet. 2001;357:1729-1737.
12. SPACE Collaborative Group. 30-day results from the SPACE trial of stent-protected angioplasty versus carotid endarterectomy in symptomatic patients: a randomised noninferiority trial. Lancet. 2006;368:1239-1247.
13. Mas J, Chatellier G, Beyssen B, et al. EVA-3S Investigators. Endarterectomy versus stenting in patients with symptomatic severe carotid stenosis. N Engl J Med. 2006;355:1660-1671.
14. Nederkoorn PJ, van der Graaf Y, Hunink MG. Duplex ultrasound and magnetic resonance angiography compared with digital subtraction angiography in carotid artery stenosis: a systematic review. Stroke. 2003;34:1324-1332.
15. U-King-Im JM, Hollingworth W, Trivedi RA, et al. Cost-effectiveness of diagnostic strategies prior to carotid endarterectomy. Ann Neurol. 2005;58(4):506-515.

Case

A 62-year-old obese woman with type 2 diabetes, hypertension, and a pack-a-day smoking habit presents to the emergency department for acute onset of left-side arm and leg weakness and sensory loss on awakening.

She reports taking a baby aspirin daily to “prevent heart attacks.” Her electrocardiogram demonstrates a left bundle branch block and frequent premature atrial contractions. She recovers partially but has residual mild hemiparesis. A duplex carotid ultrasound shows 80% stenosis of the right internal carotid artery.

Overview

In the United States each year approximately 700,000 cerebrovascular accidents (CVA) constitute the largest cause of age-adjusted morbidity of any illness.1 About 200,000 of these strokes are recurrent events.

CVA is the third-leading cause of death. Hospitalists increasingly are responsible for the inpatient care of patients with acute CVA. Atheroembolism from carotid atherosclerosis is the suspected cause for about one in five ischemic strokes.2

The link between carotid stenosis and stroke has been recognized for many years. The first carotid endarterectomy (CEA) was reported more than 50 years ago.3

This targeted review covers the natural history of symptomatic carotid stenosis, the key efficacy trials of CEA and carotid angioplasty and stenting (CAS) among symptomatic patients, and pitfalls for properly diagnosing the severity of carotid stenosis. The medical therapy of carotid stenosis and the secondary prevention of CVA were recently reviewed in The Hospitalist (October 2007, p. 34).

Natural History

The presence or absence of referable neurological symptoms is pivotal to understanding the near-term risk for recurrent CVA related to carotid stenosis. In the absence of symptoms, the risk for future CVA is essentially constant over years.

However, once symptoms occur, the risk for a second event accelerates substantially. Among patients with newly symptomatic carotid stenosis, the risk for another transient ischemic attack (TIA) or stroke within the following 24 months is 26%.4 This risk peaks within the first month or two following the index event, underscoring the time-dependent nature of carotid evaluation and intervention.

Guidelines from the American Heart Association and the American College of Cardiology on the management of ischemic stroke assign early carotid intervention, defined as within two weeks from the index event, a Class 2 indication.5 Hospitalists must rapidly identify the severity of carotid stenosis and make timely referrals to meet this recommended therapeutic window.

Carotid Endarterectomy

CEA is perhaps the best-studied surgical procedure, with multiple well-conducted prospective randomized trials demonstrating its efficacy. The procedure had been performed for hundreds of thousands of patients prior to this data being published in the early 1990s. The North American Symptomatic Carotid Endarterectomy Trial (NASCET) was the landmark study demonstrating the efficacy of intervention. The trial of patients with symptomatic carotid stenosis was stopped early for patients with severe stenosis, defined as 70% to 99% narrowing by conventional angiography. At two years, the rate of ipsilateral stroke or post-operative death in patients with severe stenosis decreased from 26% in the medical arm to 9% in the CEA arm [an absolute risk reduction of 17% and number needed to treat of six (p<0.001)].

Rarely has any medical or surgical procedure had such a robust effect over so short an interval for such an important outcome. Patients with less severe stenosis were followed out to five years, with the final results showing benefit among patients with moderate stenosis (50% to 69%).6 The Veterans Affairs Cooperative Trial 309 and the European Carotid Stenosis Trial (ECST) were combined with NASCET in a pooled analysis of more than 6,000 patients and about 35,000 patient-years of follow-up.7-9

Among patients with 70% or greater stenosis, CEA reduced the absolute five-year risk of ipsilateral ischemic stroke and any operative stroke or death by 16% (95% confidence interval 11.2% to 20.8%). The benefit was less pronounced among patients with 50% to 69% stenosis, in whom CEA conferred a 4.6% (95% confidence interval 0.6% to 8.6%) absolute five-year risk reduction.

The medical aspect of these trials required only the use of aspirin. Intensive lipid control and tight glycemic and blood pressure control would probably reduce the rate of events. The 30-day operative risk was consistently less than 6% across these trials, with the benefit seen by two years among patients with 70% to 99% stenosis and by five years among patients with 50% to 69% stenosis.

Referring hospitalists should know the operative event rates of the surgeons to whom they are referring. Hospitalists should also refer those patients whose anticipated life expectancy is at least two years for patients with 70% to 99% stenosis and at least five years for patients with 50% to 69% stenosis.

Figures 1 and 2. ACCUnet Distal Embolic Protection Device, Before and After Carotid Angioplasty and Stenting

Figures 1 and 2. ACCUnet Distal Embolic Protection Device, Before and After Carotid Angioplasty and Stenting

Carotid Angioplasty and Stenting

CAS is increasingly used as an alternative to CEA among selected patients. Two procedural developments have improved the safety of percutaneous carotid revascularization.

First, distal embolic protection filters deployed prior to angioplasty collect debris associated with the mechanical intervention and limit the risk of peri-procedural stroke. (See Figures 1 and 2, p. 36.)

Second, the use of self-expanding stents has improved long-term patency over balloon-expanding stents, which can be damaged by neck movement and external pressure.

The Stenting and Angioplasty with [distal embolic] Protection in Patients at High Risk for Endarterectomy trial demonstrated the noninferiority of CAS versus CEA among high-risk patients.10 Inclusion criteria were symptomatic carotid stenosis of greater than 50% or asymptomatic stenosis greater than 80%. Patients had to have one of several high-risk features to be included. (See Table 1, above)

The cumulative incidence of post-operative stroke, myocardial infarction, death, and ipsilateral stroke within one year after the procedure was 20.1% in the CEA arm and 12.2% in the CAS arm (p=0.004 for noninferiority and p=0.053 for superiority). The rate of post-procedural cranial nerve injury was substantially lower (zero) in the CEA arm.

However, among those patients with symptomatic carotid stenosis, the cumulative incidence of the primary endpoint was 16.8% in the CAS arm and 16.5% in the CEA arm. Based upon this trial, CAS has equivalent one-year outcomes versus CEA in a high-risk population.

click for large version

The Carotid and Vertebral Artery Transluminal Angioplasty Study trial was the first large prospective trial comparing CEA and CAS among symptomatic patients with severe carotid stenosis (mean 86.4% stenosis).11 At 30 days, the rate of death or disabling stroke was 6.4% with CAS and 5.9% with CEA, which were not significantly different in this trial of about 500 patients.

The trial was begun in 1994, with a large portion of angioplasty performed without stents or distal embolic protection. There were fewer local complications but higher rates of restenosis in the CAS arm. The authors noted “no substantial difference in the rate of ipsilateral stroke … up to three years after randomization” but cautioned that the confidence intervals were wide.

Two recently published trials of CAS versus CEA in lower-risk populations do not support the overall safety of CAS among symptomatic patients. The Stent-Protected Angioplasty versus Carotid Endarterectomy trial randomized 1,200 average-risk patients with symptomatic carotid stenosis of 50% or greater by angiography or 70% of greater by ultrasound to either CAS or CEA.12

The trial design stipulated that both surgeons and percutaneous interventionalists perform at least 25 procedures prior to inclusion in the study and that independent quality committees review these procedures. The use of distal embolic protection devices was left to the discretion of the operators. The 30-day rate of death or ipsilateral ischemic stroke was 6.34% in the CEA arm and 6.84% in the CAS arm (p=0.09 for noninferiority).

The investigators concluded that CAS is not non-inferior to CEA (i.e., that CAS is inferior). The Endarterectomy versus Angioplasty in Patients with Symptomatic Severe Carotid Stenosis trial randomized 527 patients with symptomatic carotid stenosis of 70% or greater by angiography or magnetic resonance angiography (MRA) to either CAS or CEA within two weeks of the index event.13

This trial design also stipulated that surgeons had performed at least 25 CEAs in the prior year. Percutaneous interventionalists did not have similar numeric procedure requirements, although the investigators provided for tutoring of less experienced operators. The trial was stopped prematurely due to futility (in terms of noninferiority) and harm within the CAS arm.

The 30-day cumulative incidence of death or any stroke was 3.9% in the CEA arm and 9.6% in the CAS arm (p=0.01 for superiority of CEA). The trial was powered to detect only large differences among low- and high-volume operators. Nearly 10% of patients did not have distal embolic protection devices used during their CAS procedures. Ongoing trials will further define the role of CAS versus CEA in the interventional treatment of carotid stenosis.

Accurate Diagnosis

Different trials used different criteria for defining the percent stenosis of the diseased carotid arterial segment. These differences were based primarily on the mode of testing (i.e., conventional angiography versus ultrasound), and on what portion of the carotid artery was used as the reference or baseline segment to calculate the percent stenosis.

A meta-analysis of various non-invasive modes of testing for carotid stenosis concluded that duplex ultrasound had a pooled sensitivity and specificity of 86% and 87%, respectively, to distinguish 70% to 99% stenosis from less than 70% stenosis.14 MRA had a pooled sensitivity and specificity of 95% and 90%, respectively.

The authors selected trials comparing these non-invasive methods with the gold standard of digital subtraction angiography. Using ultrasonography to first identify patients with at least 50% stenosis, followed by MRA or conventional angiography to more accurately confirm the degree of stenosis has been shown to be cost-effective.15

Back to the Case

For the patient in the vignette, the positive ultrasonography should lead to an MRA or conventional angiography to more precisely determine the percent stenosis. Current guidelines would suggest referring the patient for CEA to be completed within the next two weeks to treat a 50% or greater stenosis. That’s provided the surgeons have an operative morbidity and mortality rate less than 6% and her life expectancy is at least five years. If the patient had high-risk features as listed in Table 1 (left), referral for CAS in the hands of an experienced operator would be an alternative. TH

Dr. Anderson is an assistant professor of medicine at the University of Colorado, Denver, and an associate program director of the internal medicine residency program.

References

1. Rosamond W, Flegal K, Friday G, et al. Heart disease and stroke statistics-2007 update: a report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation. 2007;115:e69-e171.
2. White H, Boden-Albala B, Wang C, et al. Ischemic stroke subtype incidence among whites, blacks, and Hispanics: the Northern Manhattan Study. Circulation. 2005;111(10):1327-1331.
3. Eastcott HH, Pickering GW, Rob CG. Recon­struction of internal carotid artery in a patient with intermittent attacks of hemiplegia. Lancet. 1954;267(6846):994-996.
4. Beneficial effect of carotid endarterectomy in symptomatic patients with high-grade carotid stenosis: North American Symptomatic Carotid Endarterectomy Trial Collaborators. N Engl J Med. 1991; 325(7):445-453.
5. Sacco RL, Adams R, Albers G, et al. American Heart Association/American Stroke Association Council on Stroke; Council on Cardiovascular Radiology and Intervention; American Academy of Neurology. Guidelines for prevention of stroke in patients with ischemic stroke or transient ischemic attack: a statement for healthcare professionals from the American Heart Association/American Stroke Association Council on Stroke: co-sponsored by the Council on Cardiovascular Radiology and Intervention. Circulation. 2006;113:e409-e449.
6. North American Symptomatic Carotid Endarterectomy Trialists’ Collaborative Group. The final results of the NASCET trial. N Engl J Med. 1998;339:1415-1425.
7. Mayberg MR, Wilson E, Yatsu F, et al. Carotid endarterectomy and prevention of cerebral ischemia in symptomatic carotid stenosis. JAMA. 1991;266:3289-3294.
8. European Carotid Surgery Trialists’ Investigators. Randomised trial of endarterectomy for recently symptomatic carotid stenosis: final results of the MRC European Carotid Surgery Trial (ECST). Lancet. 1998;351:1379-1387.
9. Rothwell P, Eliasziw M, Gutnikov A, et al. Analysis of pooled data from the randomised controlled trials of endarterectomy for symptomatic carotid stenosis. Lancet. 2003;361(9352):107-116.
10. Yadav JS, Wholey MH, Kuntz, et al. Protected carotid-artery stenting versus endarterectomy in high-risk patients. N Engl J Med. 2004;351(15):1493-1501.
11. Endovascular versus surgical treatment in patients with carotid stenosis in the Carotid and Vertebral Artery Transluminal Angioplasty Study (CAVATAS): a randomised trial. Lancet. 2001;357:1729-1737.
12. SPACE Collaborative Group. 30-day results from the SPACE trial of stent-protected angioplasty versus carotid endarterectomy in symptomatic patients: a randomised noninferiority trial. Lancet. 2006;368:1239-1247.
13. Mas J, Chatellier G, Beyssen B, et al. EVA-3S Investigators. Endarterectomy versus stenting in patients with symptomatic severe carotid stenosis. N Engl J Med. 2006;355:1660-1671.
14. Nederkoorn PJ, van der Graaf Y, Hunink MG. Duplex ultrasound and magnetic resonance angiography compared with digital subtraction angiography in carotid artery stenosis: a systematic review. Stroke. 2003;34:1324-1332.
15. U-King-Im JM, Hollingworth W, Trivedi RA, et al. Cost-effectiveness of diagnostic strategies prior to carotid endarterectomy. Ann Neurol. 2005;58(4):506-515.

Case

A 62-year-old obese woman with type 2 diabetes, hypertension, and a pack-a-day smoking habit presents to the emergency department for acute onset of left-side arm and leg weakness and sensory loss on awakening.

She reports taking a baby aspirin daily to “prevent heart attacks.” Her electrocardiogram demonstrates a left bundle branch block and frequent premature atrial contractions. She recovers partially but has residual mild hemiparesis. A duplex carotid ultrasound shows 80% stenosis of the right internal carotid artery.

Overview

In the United States each year approximately 700,000 cerebrovascular accidents (CVA) constitute the largest cause of age-adjusted morbidity of any illness.1 About 200,000 of these strokes are recurrent events.

CVA is the third-leading cause of death. Hospitalists increasingly are responsible for the inpatient care of patients with acute CVA. Atheroembolism from carotid atherosclerosis is the suspected cause for about one in five ischemic strokes.2

The link between carotid stenosis and stroke has been recognized for many years. The first carotid endarterectomy (CEA) was reported more than 50 years ago.3

This targeted review covers the natural history of symptomatic carotid stenosis, the key efficacy trials of CEA and carotid angioplasty and stenting (CAS) among symptomatic patients, and pitfalls for properly diagnosing the severity of carotid stenosis. The medical therapy of carotid stenosis and the secondary prevention of CVA were recently reviewed in The Hospitalist (October 2007, p. 34).

Natural History

The presence or absence of referable neurological symptoms is pivotal to understanding the near-term risk for recurrent CVA related to carotid stenosis. In the absence of symptoms, the risk for future CVA is essentially constant over years.

However, once symptoms occur, the risk for a second event accelerates substantially. Among patients with newly symptomatic carotid stenosis, the risk for another transient ischemic attack (TIA) or stroke within the following 24 months is 26%.4 This risk peaks within the first month or two following the index event, underscoring the time-dependent nature of carotid evaluation and intervention.

Guidelines from the American Heart Association and the American College of Cardiology on the management of ischemic stroke assign early carotid intervention, defined as within two weeks from the index event, a Class 2 indication.5 Hospitalists must rapidly identify the severity of carotid stenosis and make timely referrals to meet this recommended therapeutic window.

Carotid Endarterectomy

CEA is perhaps the best-studied surgical procedure, with multiple well-conducted prospective randomized trials demonstrating its efficacy. The procedure had been performed for hundreds of thousands of patients prior to this data being published in the early 1990s. The North American Symptomatic Carotid Endarterectomy Trial (NASCET) was the landmark study demonstrating the efficacy of intervention. The trial of patients with symptomatic carotid stenosis was stopped early for patients with severe stenosis, defined as 70% to 99% narrowing by conventional angiography. At two years, the rate of ipsilateral stroke or post-operative death in patients with severe stenosis decreased from 26% in the medical arm to 9% in the CEA arm [an absolute risk reduction of 17% and number needed to treat of six (p<0.001)].

Rarely has any medical or surgical procedure had such a robust effect over so short an interval for such an important outcome. Patients with less severe stenosis were followed out to five years, with the final results showing benefit among patients with moderate stenosis (50% to 69%).6 The Veterans Affairs Cooperative Trial 309 and the European Carotid Stenosis Trial (ECST) were combined with NASCET in a pooled analysis of more than 6,000 patients and about 35,000 patient-years of follow-up.7-9

Among patients with 70% or greater stenosis, CEA reduced the absolute five-year risk of ipsilateral ischemic stroke and any operative stroke or death by 16% (95% confidence interval 11.2% to 20.8%). The benefit was less pronounced among patients with 50% to 69% stenosis, in whom CEA conferred a 4.6% (95% confidence interval 0.6% to 8.6%) absolute five-year risk reduction.

The medical aspect of these trials required only the use of aspirin. Intensive lipid control and tight glycemic and blood pressure control would probably reduce the rate of events. The 30-day operative risk was consistently less than 6% across these trials, with the benefit seen by two years among patients with 70% to 99% stenosis and by five years among patients with 50% to 69% stenosis.

Referring hospitalists should know the operative event rates of the surgeons to whom they are referring. Hospitalists should also refer those patients whose anticipated life expectancy is at least two years for patients with 70% to 99% stenosis and at least five years for patients with 50% to 69% stenosis.

Figures 1 and 2. ACCUnet Distal Embolic Protection Device, Before and After Carotid Angioplasty and Stenting

Figures 1 and 2. ACCUnet Distal Embolic Protection Device, Before and After Carotid Angioplasty and Stenting

Carotid Angioplasty and Stenting

CAS is increasingly used as an alternative to CEA among selected patients. Two procedural developments have improved the safety of percutaneous carotid revascularization.

First, distal embolic protection filters deployed prior to angioplasty collect debris associated with the mechanical intervention and limit the risk of peri-procedural stroke. (See Figures 1 and 2, p. 36.)

Second, the use of self-expanding stents has improved long-term patency over balloon-expanding stents, which can be damaged by neck movement and external pressure.

The Stenting and Angioplasty with [distal embolic] Protection in Patients at High Risk for Endarterectomy trial demonstrated the noninferiority of CAS versus CEA among high-risk patients.10 Inclusion criteria were symptomatic carotid stenosis of greater than 50% or asymptomatic stenosis greater than 80%. Patients had to have one of several high-risk features to be included. (See Table 1, above)

The cumulative incidence of post-operative stroke, myocardial infarction, death, and ipsilateral stroke within one year after the procedure was 20.1% in the CEA arm and 12.2% in the CAS arm (p=0.004 for noninferiority and p=0.053 for superiority). The rate of post-procedural cranial nerve injury was substantially lower (zero) in the CEA arm.

However, among those patients with symptomatic carotid stenosis, the cumulative incidence of the primary endpoint was 16.8% in the CAS arm and 16.5% in the CEA arm. Based upon this trial, CAS has equivalent one-year outcomes versus CEA in a high-risk population.

click for large version

The Carotid and Vertebral Artery Transluminal Angioplasty Study trial was the first large prospective trial comparing CEA and CAS among symptomatic patients with severe carotid stenosis (mean 86.4% stenosis).11 At 30 days, the rate of death or disabling stroke was 6.4% with CAS and 5.9% with CEA, which were not significantly different in this trial of about 500 patients.

The trial was begun in 1994, with a large portion of angioplasty performed without stents or distal embolic protection. There were fewer local complications but higher rates of restenosis in the CAS arm. The authors noted “no substantial difference in the rate of ipsilateral stroke … up to three years after randomization” but cautioned that the confidence intervals were wide.

Two recently published trials of CAS versus CEA in lower-risk populations do not support the overall safety of CAS among symptomatic patients. The Stent-Protected Angioplasty versus Carotid Endarterectomy trial randomized 1,200 average-risk patients with symptomatic carotid stenosis of 50% or greater by angiography or 70% of greater by ultrasound to either CAS or CEA.12

The trial design stipulated that both surgeons and percutaneous interventionalists perform at least 25 procedures prior to inclusion in the study and that independent quality committees review these procedures. The use of distal embolic protection devices was left to the discretion of the operators. The 30-day rate of death or ipsilateral ischemic stroke was 6.34% in the CEA arm and 6.84% in the CAS arm (p=0.09 for noninferiority).

The investigators concluded that CAS is not non-inferior to CEA (i.e., that CAS is inferior). The Endarterectomy versus Angioplasty in Patients with Symptomatic Severe Carotid Stenosis trial randomized 527 patients with symptomatic carotid stenosis of 70% or greater by angiography or magnetic resonance angiography (MRA) to either CAS or CEA within two weeks of the index event.13

This trial design also stipulated that surgeons had performed at least 25 CEAs in the prior year. Percutaneous interventionalists did not have similar numeric procedure requirements, although the investigators provided for tutoring of less experienced operators. The trial was stopped prematurely due to futility (in terms of noninferiority) and harm within the CAS arm.

The 30-day cumulative incidence of death or any stroke was 3.9% in the CEA arm and 9.6% in the CAS arm (p=0.01 for superiority of CEA). The trial was powered to detect only large differences among low- and high-volume operators. Nearly 10% of patients did not have distal embolic protection devices used during their CAS procedures. Ongoing trials will further define the role of CAS versus CEA in the interventional treatment of carotid stenosis.

Accurate Diagnosis

Different trials used different criteria for defining the percent stenosis of the diseased carotid arterial segment. These differences were based primarily on the mode of testing (i.e., conventional angiography versus ultrasound), and on what portion of the carotid artery was used as the reference or baseline segment to calculate the percent stenosis.

A meta-analysis of various non-invasive modes of testing for carotid stenosis concluded that duplex ultrasound had a pooled sensitivity and specificity of 86% and 87%, respectively, to distinguish 70% to 99% stenosis from less than 70% stenosis.14 MRA had a pooled sensitivity and specificity of 95% and 90%, respectively.

The authors selected trials comparing these non-invasive methods with the gold standard of digital subtraction angiography. Using ultrasonography to first identify patients with at least 50% stenosis, followed by MRA or conventional angiography to more accurately confirm the degree of stenosis has been shown to be cost-effective.15

Back to the Case

For the patient in the vignette, the positive ultrasonography should lead to an MRA or conventional angiography to more precisely determine the percent stenosis. Current guidelines would suggest referring the patient for CEA to be completed within the next two weeks to treat a 50% or greater stenosis. That’s provided the surgeons have an operative morbidity and mortality rate less than 6% and her life expectancy is at least five years. If the patient had high-risk features as listed in Table 1 (left), referral for CAS in the hands of an experienced operator would be an alternative. TH

Dr. Anderson is an assistant professor of medicine at the University of Colorado, Denver, and an associate program director of the internal medicine residency program.

References

1. Rosamond W, Flegal K, Friday G, et al. Heart disease and stroke statistics-2007 update: a report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation. 2007;115:e69-e171.
2. White H, Boden-Albala B, Wang C, et al. Ischemic stroke subtype incidence among whites, blacks, and Hispanics: the Northern Manhattan Study. Circulation. 2005;111(10):1327-1331.
3. Eastcott HH, Pickering GW, Rob CG. Recon­struction of internal carotid artery in a patient with intermittent attacks of hemiplegia. Lancet. 1954;267(6846):994-996.
4. Beneficial effect of carotid endarterectomy in symptomatic patients with high-grade carotid stenosis: North American Symptomatic Carotid Endarterectomy Trial Collaborators. N Engl J Med. 1991; 325(7):445-453.
5. Sacco RL, Adams R, Albers G, et al. American Heart Association/American Stroke Association Council on Stroke; Council on Cardiovascular Radiology and Intervention; American Academy of Neurology. Guidelines for prevention of stroke in patients with ischemic stroke or transient ischemic attack: a statement for healthcare professionals from the American Heart Association/American Stroke Association Council on Stroke: co-sponsored by the Council on Cardiovascular Radiology and Intervention. Circulation. 2006;113:e409-e449.
6. North American Symptomatic Carotid Endarterectomy Trialists’ Collaborative Group. The final results of the NASCET trial. N Engl J Med. 1998;339:1415-1425.
7. Mayberg MR, Wilson E, Yatsu F, et al. Carotid endarterectomy and prevention of cerebral ischemia in symptomatic carotid stenosis. JAMA. 1991;266:3289-3294.
8. European Carotid Surgery Trialists’ Investigators. Randomised trial of endarterectomy for recently symptomatic carotid stenosis: final results of the MRC European Carotid Surgery Trial (ECST). Lancet. 1998;351:1379-1387.
9. Rothwell P, Eliasziw M, Gutnikov A, et al. Analysis of pooled data from the randomised controlled trials of endarterectomy for symptomatic carotid stenosis. Lancet. 2003;361(9352):107-116.
10. Yadav JS, Wholey MH, Kuntz, et al. Protected carotid-artery stenting versus endarterectomy in high-risk patients. N Engl J Med. 2004;351(15):1493-1501.
11. Endovascular versus surgical treatment in patients with carotid stenosis in the Carotid and Vertebral Artery Transluminal Angioplasty Study (CAVATAS): a randomised trial. Lancet. 2001;357:1729-1737.
12. SPACE Collaborative Group. 30-day results from the SPACE trial of stent-protected angioplasty versus carotid endarterectomy in symptomatic patients: a randomised noninferiority trial. Lancet. 2006;368:1239-1247.
13. Mas J, Chatellier G, Beyssen B, et al. EVA-3S Investigators. Endarterectomy versus stenting in patients with symptomatic severe carotid stenosis. N Engl J Med. 2006;355:1660-1671.
14. Nederkoorn PJ, van der Graaf Y, Hunink MG. Duplex ultrasound and magnetic resonance angiography compared with digital subtraction angiography in carotid artery stenosis: a systematic review. Stroke. 2003;34:1324-1332.
15. U-King-Im JM, Hollingworth W, Trivedi RA, et al. Cost-effectiveness of diagnostic strategies prior to carotid endarterectomy. Ann Neurol. 2005;58(4):506-515.