Hospice & Palliative Medicine

Dr. Sehgal

When it comes to communicating do-not-resuscitate (DNR) orders, hospitals rely on a bewildering array of paper documentation, electronic records, and colored wristbands that can easily be misinterpreted.

These are the findings reported in the November-December issue of the Journal of Hospital Medicine by Niraj Sehgal, MD, and Robert Wachter, MD. Dr. Wachter is associate chair of the department of medicine at the University of California, San Francisco. Dr. Sehgal is an assistant clinical professor of medicine at the school.

In a survey of 69 nursing executives representing hospitals in a consortium of academic medical centers, “More than 70% of respondents recalled situations when confusion around a DNR order led to problems in patient care,” the authors say.

Everyone has a “near-miss” story, says Dr. Sehgal.

In one budget-minded hospital where materials were recycled, someone forgot to remove a DNR sticker from a previous patient’s folder before the folder was assigned to someone else. Several nurses told of instances in which patients were resuscitated inappropriately because hospital staff members did not see DNR stickers in the patient’s chart, the patient was off the unit for a procedure without a complete chart, or the DNR order was buried under other materials.

Much of the problem stems from the lack of a standardized method for making a patient’s DNR wishes known, Dr. Sehgal explains.

For example, in 2004 Dr. Sehgal saw a newspaper report that BayCare Health hospitals, in and around Tampa, Fla., were covering yellow “Livestrong” bracelets issued by the Lance Armstrong Foundation and worn by some patients to support those living with cancer. BayCare uses yellow bracelets for DNR patients. Nearly 20% of Americans wear “Livestrong” bracelets, posing a challenge for any hospital that also uses yellow bracelets to indicate DNR.

The newspaper story was the impetus for this study, Dr. Sehgal recalls. “I saw that article and thought, ‘What a great metaphor for the need for standardization.’”

He and Dr. Wachter designed a brief survey and distributed it via an e-mail listserve to senior nursing staff members of the University HealthSystem Consortium, an alliance of 97 academic medical centers and their affiliated hospitals. Those institutions represent 90% of the nation’s nonprofit academic medical centers.

Of the 127 nursing executives who received survey announcements, 69 (54%) returned completed questionnaires. Of those, 39 (56%) reported that their hospitals documented patients’ DNR preferences only in the charts, while 11 (16%) used only electronic health records (EHRs). Seventeen (25%) augmented the paper charts or EHRs with color-coded wristbands in eight colors.

“We expected variability, but even so we were struck by how much variability existed in our findings,” Dr. Sehgal says.

Hospitals use wristbands in a rainbow of colors to convey many messages. Of the hospitals represented in this survey, 55% used them to warn of allergies, fall risks, and even same last names. The authors found “12 different indications were depicted by various colors, with variations in both the color choice for a given indication (e.g., red and yellow used for allergy wristbands at different hospitals) and across indications (e.g., red for allergy at one hospital and red for bleeding risk at another).”

Dr. Sehgal

A national, standardized system for conveying patients’ DNR wishes would seem logical, but no system is in place, Dr. Sehgal says. Hospitals cannot even agree on which method to use. While some use wristbands, others use notices or stickers incorporated into the chart. Still others use EHRs.

A few states, including Arizona, Pennsylvania, and Colorado have established statewide standards for using wristbands—but each state chose a different color. “I suspect that many physicians don’t know the meaning of many of the wristbands used in their hospitals, especially if those doctors rotate among different hospitals or hospital systems,” Dr. Sehgal says.

Developing a system for making a patient’s wishes known to hospital staff is one of two challenges reflected in this study, he adds. The second is to use what might be perfunctory questions about advance directives as an opening for a deeper discussion about the patient’s thoughts on end-of-life care. Right now, those questions are just another process measure hospitals must document. “It becomes just another box to check instead of a tool for opening a conversation about what the patient’s wishes are,” he says.

Hospitalists should embrace the opportunity to involve the patient, the patient’s family members, and the primary care provider in an ongoing discussion about the patient’s desires over the course of the hospital stay. “This can give patients a mechanism for thinking about what they’d want under certain circumstances,” Dr. Sehgal explains.

From this study’s findings emerge two take-home messages for hospitalists, he maintains. The first is to remember that “we in inpatient settings spend a lot of time taking care of patients, and we must be aware of what those patients’ wishes are with respect to DNR.” The second is to step back and take an even broader view by remaining alert to processes other than DNR that might benefit from a standardized approach. “Maybe we should think about that, particularly when there is the potential to significantly harm patients,” he says. TH

Norra MacReady is a medical writer based in California.

Dr. Sehgal

When it comes to communicating do-not-resuscitate (DNR) orders, hospitals rely on a bewildering array of paper documentation, electronic records, and colored wristbands that can easily be misinterpreted.

These are the findings reported in the November-December issue of the Journal of Hospital Medicine by Niraj Sehgal, MD, and Robert Wachter, MD. Dr. Wachter is associate chair of the department of medicine at the University of California, San Francisco. Dr. Sehgal is an assistant clinical professor of medicine at the school.

In a survey of 69 nursing executives representing hospitals in a consortium of academic medical centers, “More than 70% of respondents recalled situations when confusion around a DNR order led to problems in patient care,” the authors say.

Everyone has a “near-miss” story, says Dr. Sehgal.

In one budget-minded hospital where materials were recycled, someone forgot to remove a DNR sticker from a previous patient’s folder before the folder was assigned to someone else. Several nurses told of instances in which patients were resuscitated inappropriately because hospital staff members did not see DNR stickers in the patient’s chart, the patient was off the unit for a procedure without a complete chart, or the DNR order was buried under other materials.

Much of the problem stems from the lack of a standardized method for making a patient’s DNR wishes known, Dr. Sehgal explains.

For example, in 2004 Dr. Sehgal saw a newspaper report that BayCare Health hospitals, in and around Tampa, Fla., were covering yellow “Livestrong” bracelets issued by the Lance Armstrong Foundation and worn by some patients to support those living with cancer. BayCare uses yellow bracelets for DNR patients. Nearly 20% of Americans wear “Livestrong” bracelets, posing a challenge for any hospital that also uses yellow bracelets to indicate DNR.

The newspaper story was the impetus for this study, Dr. Sehgal recalls. “I saw that article and thought, ‘What a great metaphor for the need for standardization.’”

He and Dr. Wachter designed a brief survey and distributed it via an e-mail listserve to senior nursing staff members of the University HealthSystem Consortium, an alliance of 97 academic medical centers and their affiliated hospitals. Those institutions represent 90% of the nation’s nonprofit academic medical centers.

Of the 127 nursing executives who received survey announcements, 69 (54%) returned completed questionnaires. Of those, 39 (56%) reported that their hospitals documented patients’ DNR preferences only in the charts, while 11 (16%) used only electronic health records (EHRs). Seventeen (25%) augmented the paper charts or EHRs with color-coded wristbands in eight colors.

“We expected variability, but even so we were struck by how much variability existed in our findings,” Dr. Sehgal says.

Hospitals use wristbands in a rainbow of colors to convey many messages. Of the hospitals represented in this survey, 55% used them to warn of allergies, fall risks, and even same last names. The authors found “12 different indications were depicted by various colors, with variations in both the color choice for a given indication (e.g., red and yellow used for allergy wristbands at different hospitals) and across indications (e.g., red for allergy at one hospital and red for bleeding risk at another).”

Dr. Sehgal

A national, standardized system for conveying patients’ DNR wishes would seem logical, but no system is in place, Dr. Sehgal says. Hospitals cannot even agree on which method to use. While some use wristbands, others use notices or stickers incorporated into the chart. Still others use EHRs.

A few states, including Arizona, Pennsylvania, and Colorado have established statewide standards for using wristbands—but each state chose a different color. “I suspect that many physicians don’t know the meaning of many of the wristbands used in their hospitals, especially if those doctors rotate among different hospitals or hospital systems,” Dr. Sehgal says.

Developing a system for making a patient’s wishes known to hospital staff is one of two challenges reflected in this study, he adds. The second is to use what might be perfunctory questions about advance directives as an opening for a deeper discussion about the patient’s thoughts on end-of-life care. Right now, those questions are just another process measure hospitals must document. “It becomes just another box to check instead of a tool for opening a conversation about what the patient’s wishes are,” he says.

Hospitalists should embrace the opportunity to involve the patient, the patient’s family members, and the primary care provider in an ongoing discussion about the patient’s desires over the course of the hospital stay. “This can give patients a mechanism for thinking about what they’d want under certain circumstances,” Dr. Sehgal explains.

From this study’s findings emerge two take-home messages for hospitalists, he maintains. The first is to remember that “we in inpatient settings spend a lot of time taking care of patients, and we must be aware of what those patients’ wishes are with respect to DNR.” The second is to step back and take an even broader view by remaining alert to processes other than DNR that might benefit from a standardized approach. “Maybe we should think about that, particularly when there is the potential to significantly harm patients,” he says. TH

Norra MacReady is a medical writer based in California.

Dr. Sehgal

When it comes to communicating do-not-resuscitate (DNR) orders, hospitals rely on a bewildering array of paper documentation, electronic records, and colored wristbands that can easily be misinterpreted.

These are the findings reported in the November-December issue of the Journal of Hospital Medicine by Niraj Sehgal, MD, and Robert Wachter, MD. Dr. Wachter is associate chair of the department of medicine at the University of California, San Francisco. Dr. Sehgal is an assistant clinical professor of medicine at the school.

In a survey of 69 nursing executives representing hospitals in a consortium of academic medical centers, “More than 70% of respondents recalled situations when confusion around a DNR order led to problems in patient care,” the authors say.

Everyone has a “near-miss” story, says Dr. Sehgal.

In one budget-minded hospital where materials were recycled, someone forgot to remove a DNR sticker from a previous patient’s folder before the folder was assigned to someone else. Several nurses told of instances in which patients were resuscitated inappropriately because hospital staff members did not see DNR stickers in the patient’s chart, the patient was off the unit for a procedure without a complete chart, or the DNR order was buried under other materials.

Much of the problem stems from the lack of a standardized method for making a patient’s DNR wishes known, Dr. Sehgal explains.

For example, in 2004 Dr. Sehgal saw a newspaper report that BayCare Health hospitals, in and around Tampa, Fla., were covering yellow “Livestrong” bracelets issued by the Lance Armstrong Foundation and worn by some patients to support those living with cancer. BayCare uses yellow bracelets for DNR patients. Nearly 20% of Americans wear “Livestrong” bracelets, posing a challenge for any hospital that also uses yellow bracelets to indicate DNR.

The newspaper story was the impetus for this study, Dr. Sehgal recalls. “I saw that article and thought, ‘What a great metaphor for the need for standardization.’”

He and Dr. Wachter designed a brief survey and distributed it via an e-mail listserve to senior nursing staff members of the University HealthSystem Consortium, an alliance of 97 academic medical centers and their affiliated hospitals. Those institutions represent 90% of the nation’s nonprofit academic medical centers.

Of the 127 nursing executives who received survey announcements, 69 (54%) returned completed questionnaires. Of those, 39 (56%) reported that their hospitals documented patients’ DNR preferences only in the charts, while 11 (16%) used only electronic health records (EHRs). Seventeen (25%) augmented the paper charts or EHRs with color-coded wristbands in eight colors.

“We expected variability, but even so we were struck by how much variability existed in our findings,” Dr. Sehgal says.

Hospitals use wristbands in a rainbow of colors to convey many messages. Of the hospitals represented in this survey, 55% used them to warn of allergies, fall risks, and even same last names. The authors found “12 different indications were depicted by various colors, with variations in both the color choice for a given indication (e.g., red and yellow used for allergy wristbands at different hospitals) and across indications (e.g., red for allergy at one hospital and red for bleeding risk at another).”

Dr. Sehgal

A national, standardized system for conveying patients’ DNR wishes would seem logical, but no system is in place, Dr. Sehgal says. Hospitals cannot even agree on which method to use. While some use wristbands, others use notices or stickers incorporated into the chart. Still others use EHRs.

A few states, including Arizona, Pennsylvania, and Colorado have established statewide standards for using wristbands—but each state chose a different color. “I suspect that many physicians don’t know the meaning of many of the wristbands used in their hospitals, especially if those doctors rotate among different hospitals or hospital systems,” Dr. Sehgal says.

Developing a system for making a patient’s wishes known to hospital staff is one of two challenges reflected in this study, he adds. The second is to use what might be perfunctory questions about advance directives as an opening for a deeper discussion about the patient’s thoughts on end-of-life care. Right now, those questions are just another process measure hospitals must document. “It becomes just another box to check instead of a tool for opening a conversation about what the patient’s wishes are,” he says.

Hospitalists should embrace the opportunity to involve the patient, the patient’s family members, and the primary care provider in an ongoing discussion about the patient’s desires over the course of the hospital stay. “This can give patients a mechanism for thinking about what they’d want under certain circumstances,” Dr. Sehgal explains.

From this study’s findings emerge two take-home messages for hospitalists, he maintains. The first is to remember that “we in inpatient settings spend a lot of time taking care of patients, and we must be aware of what those patients’ wishes are with respect to DNR.” The second is to step back and take an even broader view by remaining alert to processes other than DNR that might benefit from a standardized approach. “Maybe we should think about that, particularly when there is the potential to significantly harm patients,” he says. TH

Norra MacReady is a medical writer based in California.

The July 26 New England Journal of Medicine contained several articles of interest for hospitalists: A trial of steroids for bronchiolitis, mortality associated with type B aortic dissections, cardiovascular outcomes in patients using rofecoxib, implications of our social networks on obesity, and a terrific review of methicillin-resistant Staph aureus in soft-tissue infections.

But all these were trumped in the media by Oscar the cat.1

National Public Radio, CNN, Fox, and the BBC all covered the story about the cantankerous cat that could predict death in a community nursing home’s third-floor dementia unit with Grim Reaper-like proficiency. The 2-year-old cat was adopted and raised from kittenhood by staff members at the Steere House Nursing and Rehabilitation Center in Providence, R.I.

Nursing staff began noticing that Oscar would curl up in bed next to patients who had only hours to live. Oscar was so adept at predicting death that the nursing staff began using his prophesies to alert family members of an impending demise. Oscar rounds daily, waiting for closed doors to open when necessary and employing somewhat less-sophisticated methods than his human colleagues—namely observing and sniffing. However, this “cat scan” appears to serve as an unprecedented augur, accurately predicting the death of 25 nursing home residents.

Why all the fuss about this predictive puss in boots? To be sure it’s an intriguing story. But why does the public care so much that Oscar the cat can now be found in Wikipedia—and why should the average hospitalist care about a prognosticating cat?

The answer lies in the medical profession’s dreadful lack of ability to predict patients’ survival at the end of life. Multiple studies have shown physicians are terrible at predicting survival, most often in an overly optimistic manner. A paper in the British Medical Journal examined the ability of 343 doctors to estimate the survival of 468 patients at the time of referral to hospice.2 Only 20% of physicians were able to accurately prognosticate the time of death to within 33% of the actual survival. While median survival was 24 days doctors, on average, predicted patients would live 5.3 times longer than they did. Interestingly, the longer the doctor knew the patient the more likely they were to predict wrongly.

Most seriously ill patients value prognostic information more than they do information about therapeutic options. It is a central determinant in how patients and families make end-of-life decisions. The fact that we seem to systematically provide overly optimistic predictions has several important downstream effects.

Unduly optimistic predictions likely delay referral to palliative care providers and hospice. Doctors generally believe patients should receive hospice care for several months before death. However, patients typically receive this care for less than a month and in many cases only a few hours. Our inability to realistically predict survival most likely plays into this discrepancy and negatively affects our patients’ quality of life.

Second, our consistently overestimated predictions likely translate into patients making inappropriate or counterproductive end-of-life decisions.

We’ve all experienced the patient who continues to push for obviously futile care despite our attempts to nudge them toward a palliative approach. Yet it’s easy to see why patients who believe they have six months to live would push for more aggressive treatments. If they knew they had six weeks to live, they might choose more palliative options.

Finally, hospitalists are increasingly under the gun to decrease length of stay (LOS) and contain costs. It is estimated that more than 25% of Medicare costs (approximately $88 billion a year) are associated with care in the last year of life, much of it in the hospital. While several studies have shown that early palliative care intervention reduces LOS and cost of care, overly optimistic predictions make it less likely these timely referrals will be made.

The development of the hospitalist model, with its fractured approach to care, might provide an opportunity to improve end-of-life prognostication. Having a strong, long-lasting relationship with a patient appears to be an important predictor of inaccurate prognosis. It isn’t hard to imagine that a provider with a long relationship with a patient might have a more difficult time acknowledging a patient’s poor outcome or unwittingly be less likely to squelch a patient’s hope with a poor prognosis.

We can take advantage of the inherent discontinuities of the hospitalist model as well as the severity and immediacy of the patient’s acute illness to not only proffer an end-of-life prediction but contextualize it for the patient. This, of course, needs to be done in a sensitive manner that recognizes our brief role in their care and, as such, is most often best managed in concert with the patient’s primary care provider.

The promise of the hospital medicine movement is that we can do it better and cheaper. This is a tall order indeed. While the hospitalist model has improved efficiency and quality, future improvements will require us to adopt and develop new efficiencies and better systems of care.

It is in this vein that I believe we can and should be able to improve end-of-life care. An early salvo in this front can be a dedicated and systematic push to improve end-of-life prognostication and its myriad downstream effects. This will require a conscientious effort, more formal education, and better predictive tools. As hospitalists, we are perfectly positioned to lead these efforts. The other alternative may be to adopt more cats into our multidisciplinary team. 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, Inpatient Clinical Services in the Department of Medicine, and the Hospitalist Training Program, and as associate program director of the Internal Medicine Residency Program.

References

1. Dosa DA. A day in the life of Oscar the cat. N Engl J Med. 2007;357(4):328-329.
2. Christakis NA, Lamont EB. Extent and determinants of error in doctors’ prognoses in terminally ill patients: prospective cohort study. BMJ. 2000;320:469-472.

The July 26 New England Journal of Medicine contained several articles of interest for hospitalists: A trial of steroids for bronchiolitis, mortality associated with type B aortic dissections, cardiovascular outcomes in patients using rofecoxib, implications of our social networks on obesity, and a terrific review of methicillin-resistant Staph aureus in soft-tissue infections.

But all these were trumped in the media by Oscar the cat.1

National Public Radio, CNN, Fox, and the BBC all covered the story about the cantankerous cat that could predict death in a community nursing home’s third-floor dementia unit with Grim Reaper-like proficiency. The 2-year-old cat was adopted and raised from kittenhood by staff members at the Steere House Nursing and Rehabilitation Center in Providence, R.I.

Nursing staff began noticing that Oscar would curl up in bed next to patients who had only hours to live. Oscar was so adept at predicting death that the nursing staff began using his prophesies to alert family members of an impending demise. Oscar rounds daily, waiting for closed doors to open when necessary and employing somewhat less-sophisticated methods than his human colleagues—namely observing and sniffing. However, this “cat scan” appears to serve as an unprecedented augur, accurately predicting the death of 25 nursing home residents.

Why all the fuss about this predictive puss in boots? To be sure it’s an intriguing story. But why does the public care so much that Oscar the cat can now be found in Wikipedia—and why should the average hospitalist care about a prognosticating cat?

The answer lies in the medical profession’s dreadful lack of ability to predict patients’ survival at the end of life. Multiple studies have shown physicians are terrible at predicting survival, most often in an overly optimistic manner. A paper in the British Medical Journal examined the ability of 343 doctors to estimate the survival of 468 patients at the time of referral to hospice.2 Only 20% of physicians were able to accurately prognosticate the time of death to within 33% of the actual survival. While median survival was 24 days doctors, on average, predicted patients would live 5.3 times longer than they did. Interestingly, the longer the doctor knew the patient the more likely they were to predict wrongly.

Most seriously ill patients value prognostic information more than they do information about therapeutic options. It is a central determinant in how patients and families make end-of-life decisions. The fact that we seem to systematically provide overly optimistic predictions has several important downstream effects.

Unduly optimistic predictions likely delay referral to palliative care providers and hospice. Doctors generally believe patients should receive hospice care for several months before death. However, patients typically receive this care for less than a month and in many cases only a few hours. Our inability to realistically predict survival most likely plays into this discrepancy and negatively affects our patients’ quality of life.

Second, our consistently overestimated predictions likely translate into patients making inappropriate or counterproductive end-of-life decisions.

We’ve all experienced the patient who continues to push for obviously futile care despite our attempts to nudge them toward a palliative approach. Yet it’s easy to see why patients who believe they have six months to live would push for more aggressive treatments. If they knew they had six weeks to live, they might choose more palliative options.

Finally, hospitalists are increasingly under the gun to decrease length of stay (LOS) and contain costs. It is estimated that more than 25% of Medicare costs (approximately $88 billion a year) are associated with care in the last year of life, much of it in the hospital. While several studies have shown that early palliative care intervention reduces LOS and cost of care, overly optimistic predictions make it less likely these timely referrals will be made.

The development of the hospitalist model, with its fractured approach to care, might provide an opportunity to improve end-of-life prognostication. Having a strong, long-lasting relationship with a patient appears to be an important predictor of inaccurate prognosis. It isn’t hard to imagine that a provider with a long relationship with a patient might have a more difficult time acknowledging a patient’s poor outcome or unwittingly be less likely to squelch a patient’s hope with a poor prognosis.

We can take advantage of the inherent discontinuities of the hospitalist model as well as the severity and immediacy of the patient’s acute illness to not only proffer an end-of-life prediction but contextualize it for the patient. This, of course, needs to be done in a sensitive manner that recognizes our brief role in their care and, as such, is most often best managed in concert with the patient’s primary care provider.

The promise of the hospital medicine movement is that we can do it better and cheaper. This is a tall order indeed. While the hospitalist model has improved efficiency and quality, future improvements will require us to adopt and develop new efficiencies and better systems of care.

It is in this vein that I believe we can and should be able to improve end-of-life care. An early salvo in this front can be a dedicated and systematic push to improve end-of-life prognostication and its myriad downstream effects. This will require a conscientious effort, more formal education, and better predictive tools. As hospitalists, we are perfectly positioned to lead these efforts. The other alternative may be to adopt more cats into our multidisciplinary team. 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, Inpatient Clinical Services in the Department of Medicine, and the Hospitalist Training Program, and as associate program director of the Internal Medicine Residency Program.

References

1. Dosa DA. A day in the life of Oscar the cat. N Engl J Med. 2007;357(4):328-329.
2. Christakis NA, Lamont EB. Extent and determinants of error in doctors’ prognoses in terminally ill patients: prospective cohort study. BMJ. 2000;320:469-472.

The July 26 New England Journal of Medicine contained several articles of interest for hospitalists: A trial of steroids for bronchiolitis, mortality associated with type B aortic dissections, cardiovascular outcomes in patients using rofecoxib, implications of our social networks on obesity, and a terrific review of methicillin-resistant Staph aureus in soft-tissue infections.

But all these were trumped in the media by Oscar the cat.1

National Public Radio, CNN, Fox, and the BBC all covered the story about the cantankerous cat that could predict death in a community nursing home’s third-floor dementia unit with Grim Reaper-like proficiency. The 2-year-old cat was adopted and raised from kittenhood by staff members at the Steere House Nursing and Rehabilitation Center in Providence, R.I.

Nursing staff began noticing that Oscar would curl up in bed next to patients who had only hours to live. Oscar was so adept at predicting death that the nursing staff began using his prophesies to alert family members of an impending demise. Oscar rounds daily, waiting for closed doors to open when necessary and employing somewhat less-sophisticated methods than his human colleagues—namely observing and sniffing. However, this “cat scan” appears to serve as an unprecedented augur, accurately predicting the death of 25 nursing home residents.

Why all the fuss about this predictive puss in boots? To be sure it’s an intriguing story. But why does the public care so much that Oscar the cat can now be found in Wikipedia—and why should the average hospitalist care about a prognosticating cat?

The answer lies in the medical profession’s dreadful lack of ability to predict patients’ survival at the end of life. Multiple studies have shown physicians are terrible at predicting survival, most often in an overly optimistic manner. A paper in the British Medical Journal examined the ability of 343 doctors to estimate the survival of 468 patients at the time of referral to hospice.2 Only 20% of physicians were able to accurately prognosticate the time of death to within 33% of the actual survival. While median survival was 24 days doctors, on average, predicted patients would live 5.3 times longer than they did. Interestingly, the longer the doctor knew the patient the more likely they were to predict wrongly.

Most seriously ill patients value prognostic information more than they do information about therapeutic options. It is a central determinant in how patients and families make end-of-life decisions. The fact that we seem to systematically provide overly optimistic predictions has several important downstream effects.

Unduly optimistic predictions likely delay referral to palliative care providers and hospice. Doctors generally believe patients should receive hospice care for several months before death. However, patients typically receive this care for less than a month and in many cases only a few hours. Our inability to realistically predict survival most likely plays into this discrepancy and negatively affects our patients’ quality of life.

Second, our consistently overestimated predictions likely translate into patients making inappropriate or counterproductive end-of-life decisions.

We’ve all experienced the patient who continues to push for obviously futile care despite our attempts to nudge them toward a palliative approach. Yet it’s easy to see why patients who believe they have six months to live would push for more aggressive treatments. If they knew they had six weeks to live, they might choose more palliative options.

Finally, hospitalists are increasingly under the gun to decrease length of stay (LOS) and contain costs. It is estimated that more than 25% of Medicare costs (approximately $88 billion a year) are associated with care in the last year of life, much of it in the hospital. While several studies have shown that early palliative care intervention reduces LOS and cost of care, overly optimistic predictions make it less likely these timely referrals will be made.

The development of the hospitalist model, with its fractured approach to care, might provide an opportunity to improve end-of-life prognostication. Having a strong, long-lasting relationship with a patient appears to be an important predictor of inaccurate prognosis. It isn’t hard to imagine that a provider with a long relationship with a patient might have a more difficult time acknowledging a patient’s poor outcome or unwittingly be less likely to squelch a patient’s hope with a poor prognosis.

We can take advantage of the inherent discontinuities of the hospitalist model as well as the severity and immediacy of the patient’s acute illness to not only proffer an end-of-life prediction but contextualize it for the patient. This, of course, needs to be done in a sensitive manner that recognizes our brief role in their care and, as such, is most often best managed in concert with the patient’s primary care provider.

The promise of the hospital medicine movement is that we can do it better and cheaper. This is a tall order indeed. While the hospitalist model has improved efficiency and quality, future improvements will require us to adopt and develop new efficiencies and better systems of care.

It is in this vein that I believe we can and should be able to improve end-of-life care. An early salvo in this front can be a dedicated and systematic push to improve end-of-life prognostication and its myriad downstream effects. This will require a conscientious effort, more formal education, and better predictive tools. As hospitalists, we are perfectly positioned to lead these efforts. The other alternative may be to adopt more cats into our multidisciplinary team. 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, Inpatient Clinical Services in the Department of Medicine, and the Hospitalist Training Program, and as associate program director of the Internal Medicine Residency Program.

References

1. Dosa DA. A day in the life of Oscar the cat. N Engl J Med. 2007;357(4):328-329.
2. Christakis NA, Lamont EB. Extent and determinants of error in doctors’ prognoses in terminally ill patients: prospective cohort study. BMJ. 2000;320:469-472.

As hospital-based palliative care programs continue to grow, palliative care specialists are eager to dispel misconceptions about their work.1 Quality palliative care management at the end of life is often mistakenly perceived as synonymous with adequate pain control, but controlling pain is just one of the facets of effectively moderating the intensity of patients’ and families’ suffering.

The cases narrated here illustrate some of the other common themes of good palliative care management at the end of life: aggressive symptom management, interdisciplinary teamwork, and attention to patients’ and families’ spiritual concerns. Active, respectful listening can help to identify and alleviate obstacles to a more humane end-of-life journey.

Time to Process the Big Picture

State-of-the-art medical therapy does not always address dying patients’ suffering, says Melissa Mahoney, MD, assistant professor of medicine at Emory University and co-director of the Palliative Care Consult Service at Emory Crawford Long Hospital in Atlanta. She experienced this firsthand with a request to consult with a 60-year-old woman who had been in and out of sub-acute rehabilitation facilities seeking pain relief for her spinal stenosis. During a recent rehab facility stay, she had become septic and was transferred to the hospital for dialysis and other treatments. When Dr. Mahoney met the patient, the woman had been saying that she wanted to die, and her family was supportive of her wishes.

During her first conversation with the patient, however, Dr. Mahoney was able to discern that when she said she wanted to die, the patient meant, “I’m in so much pain that I don’t want to live this way.” The first step for the palliative care team was to begin patient-controlled analgesia (PCA) with IV hydromorphone hydrochloride in an attempt to control her pain. The PCA worked—dramatically.

“The next day,” recalls Dr. Mahoney, “she was like a new person. She was able to cope with the idea of dialysis and was able to talk with her family and put things in perspective.”

The palliative care team followed the woman for months, as she continued a cycle of readmissions to both the sub-acute facility and the hospital. The difference from the previous scenario, however, was that the team could offer aggressive symptom management while encouraging the patient and her family to revisit quality of life issues. She eventually died in the hospital, but Dr. Mahoney believes that the palliative care team’s interventions and emphasis on communication helped the patient and her family to cope with the situation more effectively.

With pain under control, patients can begin to address such questions as What’s important to me now? How do I want to spend my days? Who would I want to speak for me if I can’t speak for myself? What are my end-of-life wishes?’

“None of those higher-level discussions can take place until someone can physically handle them,” emphasizes Dr. Mahoney. “The palliative care approach puts the focus back on the patient and on the family and away from the disease. It seeks to treat the person and hopefully ease suffering through the illness.”

Goals of Care Change with Time

Howard R. Epstein, MD, medical director, Care Management and Palliative Care at Regions Hospital in St. Paul, Minn., and a member of the SHM Palliative Care Task Force, notes that good palliative care incorporates ongoing discussions about patients’ and families’ goals of care. “Following diagnosis of a life-threatening illness, the initial goal might be ‘I want to be cured,’ ” he says. “But, if the disease progresses, then you need to have another discussion about goals of care. Hopefully, this is part of the process all along.”

Dr. Epstein participated in a particularly memorable case last fall, consulting with a patient who had metastatic renal cancer. Surgery had left him with an abdominal abscess, which surgeons were proposing to address with another procedure in order to prevent a potentially fatal infection. The palliative care team was called in to help Mr. A, who was only 50, decide on a care plan. During the care conference, says Dr. Epstein, Mr. A was alert and joking with his wife and indicated that he would rather go home with hospice care than undergo another surgery.

The team asked Mr. A about his goals. “He didn’t know how much time he had left,” recalls Dr. Epstein, “although he had a specific goal in mind: One of his four sons was getting married, and he wanted to be there for that. They were a very close-knit family.” Mr. A had been intensely engaged as a father all through his sons’ school years. They ranged in age from 19 to 30, and Mr. A was determined to remain close with them throughout his dying process.

The care team facilitated his return home with a PCA pump for pain and a link with a visiting hospice nurse and social worker. The case was followed by a reporter from the St. Paul Pioneer Press, and it was in those articles that Dr. Epstein learned more of Mr. A’s story. For instance, extended family members were pitching in to remodel the house; Mrs. A would have to sell it to cover her husband’s medical bills after he died. The engaged son later had to tell his father that his fiancée had canceled the wedding. Mr. A was able to allay his son’s guilt and fear about the canceled wedding and to be the kind of supportive father he had always been.

Because his goal of living until the wedding had changed, Mr. A was then able to focus on his other goal: having family with him as he died at home. And, indeed, Mr. A died a peaceful death a few weeks later surrounded by his whole family.

A Ship without a Captain

Pediatric hospitalists who handle palliative care recognize that, unlike adults’ end-of-life trajectories, which are usually a straight line, the trajectories of children with complex medical conditions tend to be more erratic between diagnosis and cure or death. As a result, their families spend a longer time relating to the medical system. The job of the palliative care team is to acknowledge the family’s experience and reframe that experience into a more egalitarian and satisfying one, including a comprehensive plan of care, says Margaret Hood, MD, senior pediatric hospitalist at MultiCare’s Mary Bridge Children’s Hospital in Tacoma, Wash. Thus, the interdisciplinary team at Mary Bridge meets with the family around a round table, where everyone’s input is given equal respect and weight.

Dr. Hood recalls one case that was brought to her attention by a social worker. Amy (not her real name) had been born prematurely and had endured many medical problems in her first four years. Then, at age four, she started walking and talking; by age seven, she was reading at the fifth grade level. From ages seven to 10, Amy had minor problems, but she began deteriorating at age 10, when it was found that she had mitochondrial disease. The family had taken her to many specialists without any resolution to her problem and had been charging medical treatments to their credit cards. The social worker was concerned that the family would be devastated by bankruptcy.

The palliative care team organized a care conference attended by Amy’s primary care physician, palliative care team members, and other specialists. Although the care conference resulted in small adjustments to her care plan—a change in medication and the addition of one diagnostic test—the true change came when Amy’s mother turned to Dr. Hood and said, “You know, I thought you’d given up on us.”

That’s when it occurred to Dr. Hood that families like these, visiting specialist after specialist for their child’s complex medical conditions, are “on ‘a ship without a captain.’ Whether or not their children have life-limiting illnesses, they need a captain of the ship to help them navigate their journey,” she says.

Amy’s mother had been under the impression that the physicians were telling her there was nothing else to hope for. “You don’t give up hope,” asserts Dr. Hood. “You just change what you’re hoping for.”

Amy died three months after the palliative care conference, but took a Make-A-Wish Foundation trip to Disneyland and celebrated Christmas at home with her family. Her last wish, after Christmas, was to avoid re-entering the hospital, and this was honored as well.

There May Be More Time to Live

Attention to nuances embedded in patients’ stated wishes can sometimes result in a reversal of expectations about end of life. Stephanie Grossman, MD, assistant professor of medicine and co-director of the Palliative Care Program for Emory University Hospital and Emory Crawford Long Hospital in Atlanta, was called by the hospitalist service last year to help facilitate transfer of a patient to hospice care.

In her 70s, the active woman had come to the hospital because a tumor mass was eroding through her breast tissue. The woman was avoiding treatment, including a biopsy, and appeared to be resolved to her fate. Based on her conversation with the emergency department (ED) attending, hospice was discussed and recommended; the patient was admitted primarily for IV antibiotics and care of her wound. In discussing goals of care with the patient, however, Dr. Grossman was able to elicit her reasons for refusing treatment. Ten years earlier, the patient had watched her daughter suffer with aggressive chemotherapy and radiation for her breast cancer. She told Dr. Grossman, “I’ve lived my life; I don’t want to go through all that.”

Knowing that breast cancer treatments have evolved in the past decade, Dr. Grossman asked the woman whether she would agree to a consultation with an oncologist to find out about less toxic treatment, including hormonal therapy. Subsequently, the patient decided to undergo a lumpectomy to increase her options. Dr. Grossman also prescribed a mild pain reliever for the woman, who had expressed fears about becoming addicted to pain medication (a common misperception in elderly patients). Upon discharge, the patient was feeling better physically, and she was optimistic about her future.

Despite the perceptions of the ED staff, the patient had not been hospice-appropriate. “No one had ever offered her the alternatives. In her mind, she saw chemotherapy as this terrible thing, and she just didn’t want to have that,” says Dr. Grossman. “So by listening to her we found out why she didn’t want chemotherapy, and we were able to encourage her to talk with the oncologist and the surgeon.”

I’m Afraid of What Comes after This Life

“Sometimes you find that patients and families are making decisions purely in a spiritual context,” notes Dr. Mahoney. “Until you know that, you can deliver clear and concise medical information and opinions and they won’t hear it. They may respect your opinion, but they will not take that into consideration when they’re making the decisions about themselves or a loved one because their spiritual belief system supersedes that factual information.”

Last year, Dr. Mahoney encountered a woman her late 50s with metastatic cancer. Her mother had died young of the same disease. The patient knew her disease was advanced and that she was facing the same thing her mother had faced. She, too, was leaving behind her daughters.

The patient, recalls Dr. Mahoney, had not filled out an advance directive and was having a difficult time talking with her family about her situation. It is Dr. Mahoney’s practice in such settings to ask people about their hopes and their fears, “because you can really gauge how someone sees their illness by asking those questions.”

The woman responded that she was very afraid of dying. “When I hear that answer, my next question is, ‘What do you fear? Do you fear that you might suffer?’ She said, ‘Oh no, no, I’m not afraid of that at all. Actually, I’ve sinned a lot in my life, and I’m afraid of what comes after this life.’ ”

Realizing that the woman was suffering spiritually, Dr. Mahoney called in her team’s chaplain to meet with the patient. During that meeting, the patient revealed to Chaplain Sandra Schaap that she had been the one to remove her mother from life support (her mother had not left an advance directive either). She was plagued by the fear of how she would be judged for that act. The chaplain was able to offer some comfort by sharing a benediction, which stated (among other things) that Christ would complete what we have left undone in this life.

“That conversation helped the patient see that she needed to complete her own advance directive so that her daughters wouldn’t go through the same thing that she had with her own mother,” says Dr. Mahoney.

Although Dr. Mahoney did not see the woman again, “I think we certainly set the framework for her and her family to be able to cope with what was coming. In the traditional medical model of disease treatment, I’m not sure that kind of detail would have come out. This woman would have left the hospital still carrying around that burden and [would have] had a very different life from that point,” she says.

Conclusion

“Every patient and family has a story of their illness and how it has impacted their lives,” Dr. Mahoney emphasizes. “Many times people are in the hospital for an acute problem, but they’ve suffered with an illness for years. There is a real opportunity to allow patients and families to tell their stories. People are often relieved when someone listens and can help put things in perspective. Palliative care specialists, by actively listening to patient and family concerns, can help relieve suffering on a physical, spiritual, and emotional level even when cure is not possible.” TH

In this issue Gretchen Henkel also writes about hospitalists who are overcommitted.

Reference

• Center to Advance Palliative Care. The case for hospital-based palliative care. Available at: www.capc.org/building-a-hospital-based-palliative-care-program/case/support-from-capc/capc_publications/making-the-case.pdf. Accessed on February 20, 2007.

As hospital-based palliative care programs continue to grow, palliative care specialists are eager to dispel misconceptions about their work.1 Quality palliative care management at the end of life is often mistakenly perceived as synonymous with adequate pain control, but controlling pain is just one of the facets of effectively moderating the intensity of patients’ and families’ suffering.

The cases narrated here illustrate some of the other common themes of good palliative care management at the end of life: aggressive symptom management, interdisciplinary teamwork, and attention to patients’ and families’ spiritual concerns. Active, respectful listening can help to identify and alleviate obstacles to a more humane end-of-life journey.

Time to Process the Big Picture

State-of-the-art medical therapy does not always address dying patients’ suffering, says Melissa Mahoney, MD, assistant professor of medicine at Emory University and co-director of the Palliative Care Consult Service at Emory Crawford Long Hospital in Atlanta. She experienced this firsthand with a request to consult with a 60-year-old woman who had been in and out of sub-acute rehabilitation facilities seeking pain relief for her spinal stenosis. During a recent rehab facility stay, she had become septic and was transferred to the hospital for dialysis and other treatments. When Dr. Mahoney met the patient, the woman had been saying that she wanted to die, and her family was supportive of her wishes.

During her first conversation with the patient, however, Dr. Mahoney was able to discern that when she said she wanted to die, the patient meant, “I’m in so much pain that I don’t want to live this way.” The first step for the palliative care team was to begin patient-controlled analgesia (PCA) with IV hydromorphone hydrochloride in an attempt to control her pain. The PCA worked—dramatically.

“The next day,” recalls Dr. Mahoney, “she was like a new person. She was able to cope with the idea of dialysis and was able to talk with her family and put things in perspective.”

The palliative care team followed the woman for months, as she continued a cycle of readmissions to both the sub-acute facility and the hospital. The difference from the previous scenario, however, was that the team could offer aggressive symptom management while encouraging the patient and her family to revisit quality of life issues. She eventually died in the hospital, but Dr. Mahoney believes that the palliative care team’s interventions and emphasis on communication helped the patient and her family to cope with the situation more effectively.

With pain under control, patients can begin to address such questions as What’s important to me now? How do I want to spend my days? Who would I want to speak for me if I can’t speak for myself? What are my end-of-life wishes?’

“None of those higher-level discussions can take place until someone can physically handle them,” emphasizes Dr. Mahoney. “The palliative care approach puts the focus back on the patient and on the family and away from the disease. It seeks to treat the person and hopefully ease suffering through the illness.”

Goals of Care Change with Time

Howard R. Epstein, MD, medical director, Care Management and Palliative Care at Regions Hospital in St. Paul, Minn., and a member of the SHM Palliative Care Task Force, notes that good palliative care incorporates ongoing discussions about patients’ and families’ goals of care. “Following diagnosis of a life-threatening illness, the initial goal might be ‘I want to be cured,’ ” he says. “But, if the disease progresses, then you need to have another discussion about goals of care. Hopefully, this is part of the process all along.”

Dr. Epstein participated in a particularly memorable case last fall, consulting with a patient who had metastatic renal cancer. Surgery had left him with an abdominal abscess, which surgeons were proposing to address with another procedure in order to prevent a potentially fatal infection. The palliative care team was called in to help Mr. A, who was only 50, decide on a care plan. During the care conference, says Dr. Epstein, Mr. A was alert and joking with his wife and indicated that he would rather go home with hospice care than undergo another surgery.

The team asked Mr. A about his goals. “He didn’t know how much time he had left,” recalls Dr. Epstein, “although he had a specific goal in mind: One of his four sons was getting married, and he wanted to be there for that. They were a very close-knit family.” Mr. A had been intensely engaged as a father all through his sons’ school years. They ranged in age from 19 to 30, and Mr. A was determined to remain close with them throughout his dying process.

The care team facilitated his return home with a PCA pump for pain and a link with a visiting hospice nurse and social worker. The case was followed by a reporter from the St. Paul Pioneer Press, and it was in those articles that Dr. Epstein learned more of Mr. A’s story. For instance, extended family members were pitching in to remodel the house; Mrs. A would have to sell it to cover her husband’s medical bills after he died. The engaged son later had to tell his father that his fiancée had canceled the wedding. Mr. A was able to allay his son’s guilt and fear about the canceled wedding and to be the kind of supportive father he had always been.

Because his goal of living until the wedding had changed, Mr. A was then able to focus on his other goal: having family with him as he died at home. And, indeed, Mr. A died a peaceful death a few weeks later surrounded by his whole family.

A Ship without a Captain

Pediatric hospitalists who handle palliative care recognize that, unlike adults’ end-of-life trajectories, which are usually a straight line, the trajectories of children with complex medical conditions tend to be more erratic between diagnosis and cure or death. As a result, their families spend a longer time relating to the medical system. The job of the palliative care team is to acknowledge the family’s experience and reframe that experience into a more egalitarian and satisfying one, including a comprehensive plan of care, says Margaret Hood, MD, senior pediatric hospitalist at MultiCare’s Mary Bridge Children’s Hospital in Tacoma, Wash. Thus, the interdisciplinary team at Mary Bridge meets with the family around a round table, where everyone’s input is given equal respect and weight.

Dr. Hood recalls one case that was brought to her attention by a social worker. Amy (not her real name) had been born prematurely and had endured many medical problems in her first four years. Then, at age four, she started walking and talking; by age seven, she was reading at the fifth grade level. From ages seven to 10, Amy had minor problems, but she began deteriorating at age 10, when it was found that she had mitochondrial disease. The family had taken her to many specialists without any resolution to her problem and had been charging medical treatments to their credit cards. The social worker was concerned that the family would be devastated by bankruptcy.

The palliative care team organized a care conference attended by Amy’s primary care physician, palliative care team members, and other specialists. Although the care conference resulted in small adjustments to her care plan—a change in medication and the addition of one diagnostic test—the true change came when Amy’s mother turned to Dr. Hood and said, “You know, I thought you’d given up on us.”

That’s when it occurred to Dr. Hood that families like these, visiting specialist after specialist for their child’s complex medical conditions, are “on ‘a ship without a captain.’ Whether or not their children have life-limiting illnesses, they need a captain of the ship to help them navigate their journey,” she says.

Amy’s mother had been under the impression that the physicians were telling her there was nothing else to hope for. “You don’t give up hope,” asserts Dr. Hood. “You just change what you’re hoping for.”

Amy died three months after the palliative care conference, but took a Make-A-Wish Foundation trip to Disneyland and celebrated Christmas at home with her family. Her last wish, after Christmas, was to avoid re-entering the hospital, and this was honored as well.

There May Be More Time to Live

Attention to nuances embedded in patients’ stated wishes can sometimes result in a reversal of expectations about end of life. Stephanie Grossman, MD, assistant professor of medicine and co-director of the Palliative Care Program for Emory University Hospital and Emory Crawford Long Hospital in Atlanta, was called by the hospitalist service last year to help facilitate transfer of a patient to hospice care.

In her 70s, the active woman had come to the hospital because a tumor mass was eroding through her breast tissue. The woman was avoiding treatment, including a biopsy, and appeared to be resolved to her fate. Based on her conversation with the emergency department (ED) attending, hospice was discussed and recommended; the patient was admitted primarily for IV antibiotics and care of her wound. In discussing goals of care with the patient, however, Dr. Grossman was able to elicit her reasons for refusing treatment. Ten years earlier, the patient had watched her daughter suffer with aggressive chemotherapy and radiation for her breast cancer. She told Dr. Grossman, “I’ve lived my life; I don’t want to go through all that.”

Knowing that breast cancer treatments have evolved in the past decade, Dr. Grossman asked the woman whether she would agree to a consultation with an oncologist to find out about less toxic treatment, including hormonal therapy. Subsequently, the patient decided to undergo a lumpectomy to increase her options. Dr. Grossman also prescribed a mild pain reliever for the woman, who had expressed fears about becoming addicted to pain medication (a common misperception in elderly patients). Upon discharge, the patient was feeling better physically, and she was optimistic about her future.

Despite the perceptions of the ED staff, the patient had not been hospice-appropriate. “No one had ever offered her the alternatives. In her mind, she saw chemotherapy as this terrible thing, and she just didn’t want to have that,” says Dr. Grossman. “So by listening to her we found out why she didn’t want chemotherapy, and we were able to encourage her to talk with the oncologist and the surgeon.”

I’m Afraid of What Comes after This Life

“Sometimes you find that patients and families are making decisions purely in a spiritual context,” notes Dr. Mahoney. “Until you know that, you can deliver clear and concise medical information and opinions and they won’t hear it. They may respect your opinion, but they will not take that into consideration when they’re making the decisions about themselves or a loved one because their spiritual belief system supersedes that factual information.”

Last year, Dr. Mahoney encountered a woman her late 50s with metastatic cancer. Her mother had died young of the same disease. The patient knew her disease was advanced and that she was facing the same thing her mother had faced. She, too, was leaving behind her daughters.

The patient, recalls Dr. Mahoney, had not filled out an advance directive and was having a difficult time talking with her family about her situation. It is Dr. Mahoney’s practice in such settings to ask people about their hopes and their fears, “because you can really gauge how someone sees their illness by asking those questions.”

The woman responded that she was very afraid of dying. “When I hear that answer, my next question is, ‘What do you fear? Do you fear that you might suffer?’ She said, ‘Oh no, no, I’m not afraid of that at all. Actually, I’ve sinned a lot in my life, and I’m afraid of what comes after this life.’ ”

Realizing that the woman was suffering spiritually, Dr. Mahoney called in her team’s chaplain to meet with the patient. During that meeting, the patient revealed to Chaplain Sandra Schaap that she had been the one to remove her mother from life support (her mother had not left an advance directive either). She was plagued by the fear of how she would be judged for that act. The chaplain was able to offer some comfort by sharing a benediction, which stated (among other things) that Christ would complete what we have left undone in this life.

“That conversation helped the patient see that she needed to complete her own advance directive so that her daughters wouldn’t go through the same thing that she had with her own mother,” says Dr. Mahoney.

Although Dr. Mahoney did not see the woman again, “I think we certainly set the framework for her and her family to be able to cope with what was coming. In the traditional medical model of disease treatment, I’m not sure that kind of detail would have come out. This woman would have left the hospital still carrying around that burden and [would have] had a very different life from that point,” she says.

Conclusion

“Every patient and family has a story of their illness and how it has impacted their lives,” Dr. Mahoney emphasizes. “Many times people are in the hospital for an acute problem, but they’ve suffered with an illness for years. There is a real opportunity to allow patients and families to tell their stories. People are often relieved when someone listens and can help put things in perspective. Palliative care specialists, by actively listening to patient and family concerns, can help relieve suffering on a physical, spiritual, and emotional level even when cure is not possible.” TH

In this issue Gretchen Henkel also writes about hospitalists who are overcommitted.

Reference

• Center to Advance Palliative Care. The case for hospital-based palliative care. Available at: www.capc.org/building-a-hospital-based-palliative-care-program/case/support-from-capc/capc_publications/making-the-case.pdf. Accessed on February 20, 2007.

As hospital-based palliative care programs continue to grow, palliative care specialists are eager to dispel misconceptions about their work.1 Quality palliative care management at the end of life is often mistakenly perceived as synonymous with adequate pain control, but controlling pain is just one of the facets of effectively moderating the intensity of patients’ and families’ suffering.

The cases narrated here illustrate some of the other common themes of good palliative care management at the end of life: aggressive symptom management, interdisciplinary teamwork, and attention to patients’ and families’ spiritual concerns. Active, respectful listening can help to identify and alleviate obstacles to a more humane end-of-life journey.

Time to Process the Big Picture

State-of-the-art medical therapy does not always address dying patients’ suffering, says Melissa Mahoney, MD, assistant professor of medicine at Emory University and co-director of the Palliative Care Consult Service at Emory Crawford Long Hospital in Atlanta. She experienced this firsthand with a request to consult with a 60-year-old woman who had been in and out of sub-acute rehabilitation facilities seeking pain relief for her spinal stenosis. During a recent rehab facility stay, she had become septic and was transferred to the hospital for dialysis and other treatments. When Dr. Mahoney met the patient, the woman had been saying that she wanted to die, and her family was supportive of her wishes.

During her first conversation with the patient, however, Dr. Mahoney was able to discern that when she said she wanted to die, the patient meant, “I’m in so much pain that I don’t want to live this way.” The first step for the palliative care team was to begin patient-controlled analgesia (PCA) with IV hydromorphone hydrochloride in an attempt to control her pain. The PCA worked—dramatically.

“The next day,” recalls Dr. Mahoney, “she was like a new person. She was able to cope with the idea of dialysis and was able to talk with her family and put things in perspective.”

The palliative care team followed the woman for months, as she continued a cycle of readmissions to both the sub-acute facility and the hospital. The difference from the previous scenario, however, was that the team could offer aggressive symptom management while encouraging the patient and her family to revisit quality of life issues. She eventually died in the hospital, but Dr. Mahoney believes that the palliative care team’s interventions and emphasis on communication helped the patient and her family to cope with the situation more effectively.

With pain under control, patients can begin to address such questions as What’s important to me now? How do I want to spend my days? Who would I want to speak for me if I can’t speak for myself? What are my end-of-life wishes?’

“None of those higher-level discussions can take place until someone can physically handle them,” emphasizes Dr. Mahoney. “The palliative care approach puts the focus back on the patient and on the family and away from the disease. It seeks to treat the person and hopefully ease suffering through the illness.”

Goals of Care Change with Time

Howard R. Epstein, MD, medical director, Care Management and Palliative Care at Regions Hospital in St. Paul, Minn., and a member of the SHM Palliative Care Task Force, notes that good palliative care incorporates ongoing discussions about patients’ and families’ goals of care. “Following diagnosis of a life-threatening illness, the initial goal might be ‘I want to be cured,’ ” he says. “But, if the disease progresses, then you need to have another discussion about goals of care. Hopefully, this is part of the process all along.”

Dr. Epstein participated in a particularly memorable case last fall, consulting with a patient who had metastatic renal cancer. Surgery had left him with an abdominal abscess, which surgeons were proposing to address with another procedure in order to prevent a potentially fatal infection. The palliative care team was called in to help Mr. A, who was only 50, decide on a care plan. During the care conference, says Dr. Epstein, Mr. A was alert and joking with his wife and indicated that he would rather go home with hospice care than undergo another surgery.

The team asked Mr. A about his goals. “He didn’t know how much time he had left,” recalls Dr. Epstein, “although he had a specific goal in mind: One of his four sons was getting married, and he wanted to be there for that. They were a very close-knit family.” Mr. A had been intensely engaged as a father all through his sons’ school years. They ranged in age from 19 to 30, and Mr. A was determined to remain close with them throughout his dying process.

The care team facilitated his return home with a PCA pump for pain and a link with a visiting hospice nurse and social worker. The case was followed by a reporter from the St. Paul Pioneer Press, and it was in those articles that Dr. Epstein learned more of Mr. A’s story. For instance, extended family members were pitching in to remodel the house; Mrs. A would have to sell it to cover her husband’s medical bills after he died. The engaged son later had to tell his father that his fiancée had canceled the wedding. Mr. A was able to allay his son’s guilt and fear about the canceled wedding and to be the kind of supportive father he had always been.

Because his goal of living until the wedding had changed, Mr. A was then able to focus on his other goal: having family with him as he died at home. And, indeed, Mr. A died a peaceful death a few weeks later surrounded by his whole family.

A Ship without a Captain

Pediatric hospitalists who handle palliative care recognize that, unlike adults’ end-of-life trajectories, which are usually a straight line, the trajectories of children with complex medical conditions tend to be more erratic between diagnosis and cure or death. As a result, their families spend a longer time relating to the medical system. The job of the palliative care team is to acknowledge the family’s experience and reframe that experience into a more egalitarian and satisfying one, including a comprehensive plan of care, says Margaret Hood, MD, senior pediatric hospitalist at MultiCare’s Mary Bridge Children’s Hospital in Tacoma, Wash. Thus, the interdisciplinary team at Mary Bridge meets with the family around a round table, where everyone’s input is given equal respect and weight.

Dr. Hood recalls one case that was brought to her attention by a social worker. Amy (not her real name) had been born prematurely and had endured many medical problems in her first four years. Then, at age four, she started walking and talking; by age seven, she was reading at the fifth grade level. From ages seven to 10, Amy had minor problems, but she began deteriorating at age 10, when it was found that she had mitochondrial disease. The family had taken her to many specialists without any resolution to her problem and had been charging medical treatments to their credit cards. The social worker was concerned that the family would be devastated by bankruptcy.

The palliative care team organized a care conference attended by Amy’s primary care physician, palliative care team members, and other specialists. Although the care conference resulted in small adjustments to her care plan—a change in medication and the addition of one diagnostic test—the true change came when Amy’s mother turned to Dr. Hood and said, “You know, I thought you’d given up on us.”

That’s when it occurred to Dr. Hood that families like these, visiting specialist after specialist for their child’s complex medical conditions, are “on ‘a ship without a captain.’ Whether or not their children have life-limiting illnesses, they need a captain of the ship to help them navigate their journey,” she says.

Amy’s mother had been under the impression that the physicians were telling her there was nothing else to hope for. “You don’t give up hope,” asserts Dr. Hood. “You just change what you’re hoping for.”

Amy died three months after the palliative care conference, but took a Make-A-Wish Foundation trip to Disneyland and celebrated Christmas at home with her family. Her last wish, after Christmas, was to avoid re-entering the hospital, and this was honored as well.

There May Be More Time to Live

Attention to nuances embedded in patients’ stated wishes can sometimes result in a reversal of expectations about end of life. Stephanie Grossman, MD, assistant professor of medicine and co-director of the Palliative Care Program for Emory University Hospital and Emory Crawford Long Hospital in Atlanta, was called by the hospitalist service last year to help facilitate transfer of a patient to hospice care.

In her 70s, the active woman had come to the hospital because a tumor mass was eroding through her breast tissue. The woman was avoiding treatment, including a biopsy, and appeared to be resolved to her fate. Based on her conversation with the emergency department (ED) attending, hospice was discussed and recommended; the patient was admitted primarily for IV antibiotics and care of her wound. In discussing goals of care with the patient, however, Dr. Grossman was able to elicit her reasons for refusing treatment. Ten years earlier, the patient had watched her daughter suffer with aggressive chemotherapy and radiation for her breast cancer. She told Dr. Grossman, “I’ve lived my life; I don’t want to go through all that.”

Knowing that breast cancer treatments have evolved in the past decade, Dr. Grossman asked the woman whether she would agree to a consultation with an oncologist to find out about less toxic treatment, including hormonal therapy. Subsequently, the patient decided to undergo a lumpectomy to increase her options. Dr. Grossman also prescribed a mild pain reliever for the woman, who had expressed fears about becoming addicted to pain medication (a common misperception in elderly patients). Upon discharge, the patient was feeling better physically, and she was optimistic about her future.

Despite the perceptions of the ED staff, the patient had not been hospice-appropriate. “No one had ever offered her the alternatives. In her mind, she saw chemotherapy as this terrible thing, and she just didn’t want to have that,” says Dr. Grossman. “So by listening to her we found out why she didn’t want chemotherapy, and we were able to encourage her to talk with the oncologist and the surgeon.”

I’m Afraid of What Comes after This Life

“Sometimes you find that patients and families are making decisions purely in a spiritual context,” notes Dr. Mahoney. “Until you know that, you can deliver clear and concise medical information and opinions and they won’t hear it. They may respect your opinion, but they will not take that into consideration when they’re making the decisions about themselves or a loved one because their spiritual belief system supersedes that factual information.”

Last year, Dr. Mahoney encountered a woman her late 50s with metastatic cancer. Her mother had died young of the same disease. The patient knew her disease was advanced and that she was facing the same thing her mother had faced. She, too, was leaving behind her daughters.

The patient, recalls Dr. Mahoney, had not filled out an advance directive and was having a difficult time talking with her family about her situation. It is Dr. Mahoney’s practice in such settings to ask people about their hopes and their fears, “because you can really gauge how someone sees their illness by asking those questions.”

The woman responded that she was very afraid of dying. “When I hear that answer, my next question is, ‘What do you fear? Do you fear that you might suffer?’ She said, ‘Oh no, no, I’m not afraid of that at all. Actually, I’ve sinned a lot in my life, and I’m afraid of what comes after this life.’ ”

Realizing that the woman was suffering spiritually, Dr. Mahoney called in her team’s chaplain to meet with the patient. During that meeting, the patient revealed to Chaplain Sandra Schaap that she had been the one to remove her mother from life support (her mother had not left an advance directive either). She was plagued by the fear of how she would be judged for that act. The chaplain was able to offer some comfort by sharing a benediction, which stated (among other things) that Christ would complete what we have left undone in this life.

“That conversation helped the patient see that she needed to complete her own advance directive so that her daughters wouldn’t go through the same thing that she had with her own mother,” says Dr. Mahoney.

Although Dr. Mahoney did not see the woman again, “I think we certainly set the framework for her and her family to be able to cope with what was coming. In the traditional medical model of disease treatment, I’m not sure that kind of detail would have come out. This woman would have left the hospital still carrying around that burden and [would have] had a very different life from that point,” she says.

Conclusion

“Every patient and family has a story of their illness and how it has impacted their lives,” Dr. Mahoney emphasizes. “Many times people are in the hospital for an acute problem, but they’ve suffered with an illness for years. There is a real opportunity to allow patients and families to tell their stories. People are often relieved when someone listens and can help put things in perspective. Palliative care specialists, by actively listening to patient and family concerns, can help relieve suffering on a physical, spiritual, and emotional level even when cure is not possible.” TH

In this issue Gretchen Henkel also writes about hospitalists who are overcommitted.

Reference

• Center to Advance Palliative Care. The case for hospital-based palliative care. Available at: www.capc.org/building-a-hospital-based-palliative-care-program/case/support-from-capc/capc_publications/making-the-case.pdf. Accessed on February 20, 2007.

October 7, 2006, is World Hospice and Palliative Care Day. This day is dedicated to raising the visibility of palliative care within the global community and to providing opportunities to support hospice and palliative care in the form of a unified day of action.

According to official organizers, the event’s theme is “Access to care for all—highlighting the fact that everyone has a right to high-quality end-of-life care, but that more needs to be done to enable everyone to access it.” In creating World Hospice and Palliative Care Day 2006, the event’s organizers aim to raise awareness and understanding of the needs of those living with a terminal diagnosis, as well as the needs of their families. Other goals include calling attention to the need for increasing hospice and palliative care availability throughout the world and raising funds to be used in supporting these services.

Like the first World Hospice and Palliative Care Day, held in 2005, this event will be carried out in conjunction with Voices for Hospices, a global music effort that supports concerts held around the world to raise awareness of this important topic. The Voices for Hospices group is one of many supporters of this cause.

More than 1,000 events took place on World Hospice and Palliative Care Day 2005, and 74 countries supported the activities. Included in the 2005 event were a cycle rally in Nepal; art exhibitions in Australia, Hong Kong, and Austria; and palliative care conferences in Lithuania and Belarus. In addition, thousands of people from around the world signed a global petition calling for better quality care for people afflicted by terminal illness.

Hospitalists are asked frequently to lead and participate in initiatives meant to improve the identification and treatment of patients and families in need of palliative care. It is common knowledge that traditional medical training tends to focus on the efforts that must be made to cure and prevent illness. There are times when the first priority must be to look for a cure at all costs; however, it must be acknowledged that there are also times when the treatment of a patient’s symptoms should be looked upon as just as important. Conventional medical training frequently does not provide the tools needed to offer the best care for patients and their families when the latter goal becomes the higher priority.

This is why support of initiatives like World Hospice and Palliative Care Day can offer such value to the global community. Events like this one promote awareness of an important topic. For information and ideas on how to get involved in this or in future events, please consult www.worldday.org. Access the Web site’s “Get Involved” page for ideas on how to offer support. Suggested activities include campaigning, creating links and partnerships, and producing materials that will raise awareness.

On the “PR & Press” page of the Web site, in the “Key Messages 2006” section, the following question was posed: “What kinds of issues in general terms does World Hospice and Palliative Care Day hope to raise awareness of year on year?” One of the well-stated answers: “First and foremost we hope the Day helps to increase understanding of hospice and palliative care and how it supports those facing the end of life … . It’s not about ‘helping someone die’ but instead about helping someone to live as comfortably as possible with their illness. It’s about seeing them as [a] living person, not a dying patient. It’s supporting those closest to them and adding life to days, whether or not days can be added to lives.”

Smart Tools for QI Initiatives

SHM’s Quality Improvement Resource Rooms support hospitalists as QI leaders

The role and recognition of the hospitalist has evolved tremendously in the past 10 years, and hospitalists continue to be called upon to lead at their institutions, particularly in quality improvement initiatives. Based on their unique role within the hospital system (a job that requires interaction with many levels of hospital staff) hospitalists are clearly positioned to lead such efforts. As part of SHM’s dedication to promote the highest quality of care for the hospitalized patient, SHM’s Resource Rooms provide members and non-members alike access to information that will aid their knowledge in quality improvement around specific disease states. Currently, SHM provides four Resource Rooms: Venous Thromboembolism (VTE), Stroke, Antimicrobial Resistance (ABX), and Heart Failure. Two additional rooms, Geriatrics and Glycemic Control, will launch this fall.

Quality improvement for the patient will be successful if a systems-based multidisciplinary collaboration within the hospital is improved. Hospitalists are leading this challenging yet exciting opportunity to change the face of healthcare. It has been noted that medical school and residency training have failed to prepare the hospitalist for this leadership role. To this end, SHM provides users of the Resource Rooms with information describing how a specific disease state affects the population and explains why a hospitalist should act in initiating change, as well as what key knowledge, skills, and attitudes the hospitalist should possess. The user is offered information regarding didactic and bedside teaching, patient education, and opportunities for continuing medical education. These resources are useful for the novice as well as for the advanced hospitalist leader. Readers can also apply the concepts of these general mechanisms to any disease state they are seeking to improve at their institutions.

The QI workbook within each of the Resource Rooms is the most important feature and serves as a field guide to implementing a quality improvement program. The workbook includes the following aids:

• Essential first steps: garnering institutional support, assembling a team, developing team rules, and understanding the framework for improvement;
• Conducting an in-depth analysis of current processes and failures;
• Collecting data and devising metrics to assess the impact of your QI initiative;
• Moving from problems to solutions; and
• Continuing to improve: monitoring and learning from the process, as well as holding the gains and spreading your improvement

Other important resources that are common to all of the rooms and will aid in leading the QI efforts of the hospitalist are the educational features. Complex problems need multidisciplinary solutions. The “Improve” and “Educate” areas of the Resource Rooms include information that allow the hospitalist to teach and be taught. In the “Improve” section, a user can find QI Theory slide sets on the foundations of quality improvement initiatives and core measures on specific disease states.

Didactic sessions and teaching tools, as well as professional development, including core competencies and CME opportunities, are all present in the “Educate” feature of each room. For example, in the Heart Failure Resource Room, a didactic session slide set concerning the management of heart failure for hospitalized patients is provided. The slide set includes a heart failure overview that describes the epidemiology, etiologies, and objectives surrounding the management of acute congestive heart failure.

Evidence, improvement, and education tools designed to enhance inpatient outcomes can help the hospitalist develop and lead initiatives that can create a more cost-efficient approach to the treatment of hospitalized patients, while at the same time improving patient outcomes. SHM’s Quality Improvement Resource Rooms provide a compendium of resources to support the hospitalist who is embarking on this enormous task.

September Leadership Academy

New Level II a great success

The recently completed 4th SHM Leadership Academy was a true success in every sense of the word. The event was nearly a sellout, with 160 hospital medicine leaders arriving in Nashville, Tenn., in September to learn—from nationally respected leaders—tangible skills that they could take back to institute in their own practices.

The Leadership Academy Level I was designed to provide leaders in hospital medicine with the skills and resources required to lead and manage programs successfully both now and in the future. Small group sessions gave attendees a chance to interact with faculty and to share personal experiences from their own institutions. Nationally recognized speaker Jack Silversin, DMD, DrPH, presented his infamous broken squares activity, which kept the group energized and working together creatively to learn about effective communication. This course allowed attendees to evaluate personal leadership strengths and weaknesses and then apply them to everyday leadership and management challenges.

click for large version

click for large version

Another highlight was the self-evaluation session presented by David Javitch, PhD. His exercise gave everyone an opportunity to learn about their own personality traits and to practice working with extreme opposites, both in the workplace and in everyday life. Attendees continue to rave about the content of this meeting and are looking forward to enhancing their leadership skills by attending Level II courses, scheduled for fall 2007.

“No matter how many times I plan this course, I am amazed at the enthusiasm of the attendees and the new questions that they pose,” says Russell Holman, MD, SHM Leadership Academy course director.

Level II resulted from more than 300 Level I course evaluations that requested additional and ongoing leadership development activities. The Level II course focused on discussions about culture change, negotiation skills, and finance. Keynote speaker Leonard Marcus, PhD, defined the term “meta-leadership” in hospital medicine as a type of leadership that links individuals through their leader’s vision, creating enthusiastic followers.

The Level II course is a must have for those who want to expand upon leadership skills learned in Level I or for those who already have an MBA and want to improve upon leadership in clinical care. The skills discussed in this session are essential to effectively developing and implementing quality improvement programs, patient-safety initiatives, and other programs whose goal is to make system changes that improve patient care.

“The level of attendees participating in Level II was challenging,” says Dr. Holman. “It had us all—faculty and attendees alike—collaborating to answer questions from real-life experiences.”

The phrase “all work and no play” doesn’t describe any SHM meeting, and it certainly can’t be used in reference to the Leadership Academy. Attendees had an opportunity to network with fellow participants and exhibiting companies during the Monday night reception sponsored by Cogent Healthcare. Participants also had ample time to get out and experience some southern hospitality, while enjoying the spa, playing golf, touring on steamboats, dining, and shopping at the Gaylord Opryland Resort and Convention Center.

Leadership Academy Levels I and II were jam-packed with relevant materials and tools applicable to business and the real world. This is an outstanding opportunity for individuals just beginning their leadership journey and for those wanting to take their leadership skills to the next level.

Don’t miss out on the next opportunity to become a leader in hospital medicine. The next meeting will take place during the week of February 26–March 1, 2007, at the Gaylord Palms Resort and Convention Center in Orlando, Fla. Log on to www.hospitalmedicine.org or call (800) 843-3360 for more information.

October 7, 2006, is World Hospice and Palliative Care Day. This day is dedicated to raising the visibility of palliative care within the global community and to providing opportunities to support hospice and palliative care in the form of a unified day of action.

According to official organizers, the event’s theme is “Access to care for all—highlighting the fact that everyone has a right to high-quality end-of-life care, but that more needs to be done to enable everyone to access it.” In creating World Hospice and Palliative Care Day 2006, the event’s organizers aim to raise awareness and understanding of the needs of those living with a terminal diagnosis, as well as the needs of their families. Other goals include calling attention to the need for increasing hospice and palliative care availability throughout the world and raising funds to be used in supporting these services.

Like the first World Hospice and Palliative Care Day, held in 2005, this event will be carried out in conjunction with Voices for Hospices, a global music effort that supports concerts held around the world to raise awareness of this important topic. The Voices for Hospices group is one of many supporters of this cause.

More than 1,000 events took place on World Hospice and Palliative Care Day 2005, and 74 countries supported the activities. Included in the 2005 event were a cycle rally in Nepal; art exhibitions in Australia, Hong Kong, and Austria; and palliative care conferences in Lithuania and Belarus. In addition, thousands of people from around the world signed a global petition calling for better quality care for people afflicted by terminal illness.

Hospitalists are asked frequently to lead and participate in initiatives meant to improve the identification and treatment of patients and families in need of palliative care. It is common knowledge that traditional medical training tends to focus on the efforts that must be made to cure and prevent illness. There are times when the first priority must be to look for a cure at all costs; however, it must be acknowledged that there are also times when the treatment of a patient’s symptoms should be looked upon as just as important. Conventional medical training frequently does not provide the tools needed to offer the best care for patients and their families when the latter goal becomes the higher priority.

This is why support of initiatives like World Hospice and Palliative Care Day can offer such value to the global community. Events like this one promote awareness of an important topic. For information and ideas on how to get involved in this or in future events, please consult www.worldday.org. Access the Web site’s “Get Involved” page for ideas on how to offer support. Suggested activities include campaigning, creating links and partnerships, and producing materials that will raise awareness.

On the “PR & Press” page of the Web site, in the “Key Messages 2006” section, the following question was posed: “What kinds of issues in general terms does World Hospice and Palliative Care Day hope to raise awareness of year on year?” One of the well-stated answers: “First and foremost we hope the Day helps to increase understanding of hospice and palliative care and how it supports those facing the end of life … . It’s not about ‘helping someone die’ but instead about helping someone to live as comfortably as possible with their illness. It’s about seeing them as [a] living person, not a dying patient. It’s supporting those closest to them and adding life to days, whether or not days can be added to lives.”

Smart Tools for QI Initiatives

SHM’s Quality Improvement Resource Rooms support hospitalists as QI leaders

The role and recognition of the hospitalist has evolved tremendously in the past 10 years, and hospitalists continue to be called upon to lead at their institutions, particularly in quality improvement initiatives. Based on their unique role within the hospital system (a job that requires interaction with many levels of hospital staff) hospitalists are clearly positioned to lead such efforts. As part of SHM’s dedication to promote the highest quality of care for the hospitalized patient, SHM’s Resource Rooms provide members and non-members alike access to information that will aid their knowledge in quality improvement around specific disease states. Currently, SHM provides four Resource Rooms: Venous Thromboembolism (VTE), Stroke, Antimicrobial Resistance (ABX), and Heart Failure. Two additional rooms, Geriatrics and Glycemic Control, will launch this fall.

Quality improvement for the patient will be successful if a systems-based multidisciplinary collaboration within the hospital is improved. Hospitalists are leading this challenging yet exciting opportunity to change the face of healthcare. It has been noted that medical school and residency training have failed to prepare the hospitalist for this leadership role. To this end, SHM provides users of the Resource Rooms with information describing how a specific disease state affects the population and explains why a hospitalist should act in initiating change, as well as what key knowledge, skills, and attitudes the hospitalist should possess. The user is offered information regarding didactic and bedside teaching, patient education, and opportunities for continuing medical education. These resources are useful for the novice as well as for the advanced hospitalist leader. Readers can also apply the concepts of these general mechanisms to any disease state they are seeking to improve at their institutions.

The QI workbook within each of the Resource Rooms is the most important feature and serves as a field guide to implementing a quality improvement program. The workbook includes the following aids:

• Essential first steps: garnering institutional support, assembling a team, developing team rules, and understanding the framework for improvement;
• Conducting an in-depth analysis of current processes and failures;
• Collecting data and devising metrics to assess the impact of your QI initiative;
• Moving from problems to solutions; and
• Continuing to improve: monitoring and learning from the process, as well as holding the gains and spreading your improvement

Other important resources that are common to all of the rooms and will aid in leading the QI efforts of the hospitalist are the educational features. Complex problems need multidisciplinary solutions. The “Improve” and “Educate” areas of the Resource Rooms include information that allow the hospitalist to teach and be taught. In the “Improve” section, a user can find QI Theory slide sets on the foundations of quality improvement initiatives and core measures on specific disease states.

Didactic sessions and teaching tools, as well as professional development, including core competencies and CME opportunities, are all present in the “Educate” feature of each room. For example, in the Heart Failure Resource Room, a didactic session slide set concerning the management of heart failure for hospitalized patients is provided. The slide set includes a heart failure overview that describes the epidemiology, etiologies, and objectives surrounding the management of acute congestive heart failure.

Evidence, improvement, and education tools designed to enhance inpatient outcomes can help the hospitalist develop and lead initiatives that can create a more cost-efficient approach to the treatment of hospitalized patients, while at the same time improving patient outcomes. SHM’s Quality Improvement Resource Rooms provide a compendium of resources to support the hospitalist who is embarking on this enormous task.

September Leadership Academy

New Level II a great success

The recently completed 4th SHM Leadership Academy was a true success in every sense of the word. The event was nearly a sellout, with 160 hospital medicine leaders arriving in Nashville, Tenn., in September to learn—from nationally respected leaders—tangible skills that they could take back to institute in their own practices.

The Leadership Academy Level I was designed to provide leaders in hospital medicine with the skills and resources required to lead and manage programs successfully both now and in the future. Small group sessions gave attendees a chance to interact with faculty and to share personal experiences from their own institutions. Nationally recognized speaker Jack Silversin, DMD, DrPH, presented his infamous broken squares activity, which kept the group energized and working together creatively to learn about effective communication. This course allowed attendees to evaluate personal leadership strengths and weaknesses and then apply them to everyday leadership and management challenges.

click for large version

click for large version

Another highlight was the self-evaluation session presented by David Javitch, PhD. His exercise gave everyone an opportunity to learn about their own personality traits and to practice working with extreme opposites, both in the workplace and in everyday life. Attendees continue to rave about the content of this meeting and are looking forward to enhancing their leadership skills by attending Level II courses, scheduled for fall 2007.

“No matter how many times I plan this course, I am amazed at the enthusiasm of the attendees and the new questions that they pose,” says Russell Holman, MD, SHM Leadership Academy course director.

Level II resulted from more than 300 Level I course evaluations that requested additional and ongoing leadership development activities. The Level II course focused on discussions about culture change, negotiation skills, and finance. Keynote speaker Leonard Marcus, PhD, defined the term “meta-leadership” in hospital medicine as a type of leadership that links individuals through their leader’s vision, creating enthusiastic followers.

The Level II course is a must have for those who want to expand upon leadership skills learned in Level I or for those who already have an MBA and want to improve upon leadership in clinical care. The skills discussed in this session are essential to effectively developing and implementing quality improvement programs, patient-safety initiatives, and other programs whose goal is to make system changes that improve patient care.

“The level of attendees participating in Level II was challenging,” says Dr. Holman. “It had us all—faculty and attendees alike—collaborating to answer questions from real-life experiences.”

The phrase “all work and no play” doesn’t describe any SHM meeting, and it certainly can’t be used in reference to the Leadership Academy. Attendees had an opportunity to network with fellow participants and exhibiting companies during the Monday night reception sponsored by Cogent Healthcare. Participants also had ample time to get out and experience some southern hospitality, while enjoying the spa, playing golf, touring on steamboats, dining, and shopping at the Gaylord Opryland Resort and Convention Center.

Leadership Academy Levels I and II were jam-packed with relevant materials and tools applicable to business and the real world. This is an outstanding opportunity for individuals just beginning their leadership journey and for those wanting to take their leadership skills to the next level.

Don’t miss out on the next opportunity to become a leader in hospital medicine. The next meeting will take place during the week of February 26–March 1, 2007, at the Gaylord Palms Resort and Convention Center in Orlando, Fla. Log on to www.hospitalmedicine.org or call (800) 843-3360 for more information.

October 7, 2006, is World Hospice and Palliative Care Day. This day is dedicated to raising the visibility of palliative care within the global community and to providing opportunities to support hospice and palliative care in the form of a unified day of action.

According to official organizers, the event’s theme is “Access to care for all—highlighting the fact that everyone has a right to high-quality end-of-life care, but that more needs to be done to enable everyone to access it.” In creating World Hospice and Palliative Care Day 2006, the event’s organizers aim to raise awareness and understanding of the needs of those living with a terminal diagnosis, as well as the needs of their families. Other goals include calling attention to the need for increasing hospice and palliative care availability throughout the world and raising funds to be used in supporting these services.

Like the first World Hospice and Palliative Care Day, held in 2005, this event will be carried out in conjunction with Voices for Hospices, a global music effort that supports concerts held around the world to raise awareness of this important topic. The Voices for Hospices group is one of many supporters of this cause.

More than 1,000 events took place on World Hospice and Palliative Care Day 2005, and 74 countries supported the activities. Included in the 2005 event were a cycle rally in Nepal; art exhibitions in Australia, Hong Kong, and Austria; and palliative care conferences in Lithuania and Belarus. In addition, thousands of people from around the world signed a global petition calling for better quality care for people afflicted by terminal illness.

Hospitalists are asked frequently to lead and participate in initiatives meant to improve the identification and treatment of patients and families in need of palliative care. It is common knowledge that traditional medical training tends to focus on the efforts that must be made to cure and prevent illness. There are times when the first priority must be to look for a cure at all costs; however, it must be acknowledged that there are also times when the treatment of a patient’s symptoms should be looked upon as just as important. Conventional medical training frequently does not provide the tools needed to offer the best care for patients and their families when the latter goal becomes the higher priority.

This is why support of initiatives like World Hospice and Palliative Care Day can offer such value to the global community. Events like this one promote awareness of an important topic. For information and ideas on how to get involved in this or in future events, please consult www.worldday.org. Access the Web site’s “Get Involved” page for ideas on how to offer support. Suggested activities include campaigning, creating links and partnerships, and producing materials that will raise awareness.

On the “PR & Press” page of the Web site, in the “Key Messages 2006” section, the following question was posed: “What kinds of issues in general terms does World Hospice and Palliative Care Day hope to raise awareness of year on year?” One of the well-stated answers: “First and foremost we hope the Day helps to increase understanding of hospice and palliative care and how it supports those facing the end of life … . It’s not about ‘helping someone die’ but instead about helping someone to live as comfortably as possible with their illness. It’s about seeing them as [a] living person, not a dying patient. It’s supporting those closest to them and adding life to days, whether or not days can be added to lives.”

Smart Tools for QI Initiatives

SHM’s Quality Improvement Resource Rooms support hospitalists as QI leaders

The role and recognition of the hospitalist has evolved tremendously in the past 10 years, and hospitalists continue to be called upon to lead at their institutions, particularly in quality improvement initiatives. Based on their unique role within the hospital system (a job that requires interaction with many levels of hospital staff) hospitalists are clearly positioned to lead such efforts. As part of SHM’s dedication to promote the highest quality of care for the hospitalized patient, SHM’s Resource Rooms provide members and non-members alike access to information that will aid their knowledge in quality improvement around specific disease states. Currently, SHM provides four Resource Rooms: Venous Thromboembolism (VTE), Stroke, Antimicrobial Resistance (ABX), and Heart Failure. Two additional rooms, Geriatrics and Glycemic Control, will launch this fall.

Quality improvement for the patient will be successful if a systems-based multidisciplinary collaboration within the hospital is improved. Hospitalists are leading this challenging yet exciting opportunity to change the face of healthcare. It has been noted that medical school and residency training have failed to prepare the hospitalist for this leadership role. To this end, SHM provides users of the Resource Rooms with information describing how a specific disease state affects the population and explains why a hospitalist should act in initiating change, as well as what key knowledge, skills, and attitudes the hospitalist should possess. The user is offered information regarding didactic and bedside teaching, patient education, and opportunities for continuing medical education. These resources are useful for the novice as well as for the advanced hospitalist leader. Readers can also apply the concepts of these general mechanisms to any disease state they are seeking to improve at their institutions.

The QI workbook within each of the Resource Rooms is the most important feature and serves as a field guide to implementing a quality improvement program. The workbook includes the following aids:

• Essential first steps: garnering institutional support, assembling a team, developing team rules, and understanding the framework for improvement;
• Conducting an in-depth analysis of current processes and failures;
• Collecting data and devising metrics to assess the impact of your QI initiative;
• Moving from problems to solutions; and
• Continuing to improve: monitoring and learning from the process, as well as holding the gains and spreading your improvement

Other important resources that are common to all of the rooms and will aid in leading the QI efforts of the hospitalist are the educational features. Complex problems need multidisciplinary solutions. The “Improve” and “Educate” areas of the Resource Rooms include information that allow the hospitalist to teach and be taught. In the “Improve” section, a user can find QI Theory slide sets on the foundations of quality improvement initiatives and core measures on specific disease states.

Didactic sessions and teaching tools, as well as professional development, including core competencies and CME opportunities, are all present in the “Educate” feature of each room. For example, in the Heart Failure Resource Room, a didactic session slide set concerning the management of heart failure for hospitalized patients is provided. The slide set includes a heart failure overview that describes the epidemiology, etiologies, and objectives surrounding the management of acute congestive heart failure.

Evidence, improvement, and education tools designed to enhance inpatient outcomes can help the hospitalist develop and lead initiatives that can create a more cost-efficient approach to the treatment of hospitalized patients, while at the same time improving patient outcomes. SHM’s Quality Improvement Resource Rooms provide a compendium of resources to support the hospitalist who is embarking on this enormous task.

September Leadership Academy

New Level II a great success

The recently completed 4th SHM Leadership Academy was a true success in every sense of the word. The event was nearly a sellout, with 160 hospital medicine leaders arriving in Nashville, Tenn., in September to learn—from nationally respected leaders—tangible skills that they could take back to institute in their own practices.

The Leadership Academy Level I was designed to provide leaders in hospital medicine with the skills and resources required to lead and manage programs successfully both now and in the future. Small group sessions gave attendees a chance to interact with faculty and to share personal experiences from their own institutions. Nationally recognized speaker Jack Silversin, DMD, DrPH, presented his infamous broken squares activity, which kept the group energized and working together creatively to learn about effective communication. This course allowed attendees to evaluate personal leadership strengths and weaknesses and then apply them to everyday leadership and management challenges.

click for large version

click for large version

Another highlight was the self-evaluation session presented by David Javitch, PhD. His exercise gave everyone an opportunity to learn about their own personality traits and to practice working with extreme opposites, both in the workplace and in everyday life. Attendees continue to rave about the content of this meeting and are looking forward to enhancing their leadership skills by attending Level II courses, scheduled for fall 2007.

“No matter how many times I plan this course, I am amazed at the enthusiasm of the attendees and the new questions that they pose,” says Russell Holman, MD, SHM Leadership Academy course director.

Level II resulted from more than 300 Level I course evaluations that requested additional and ongoing leadership development activities. The Level II course focused on discussions about culture change, negotiation skills, and finance. Keynote speaker Leonard Marcus, PhD, defined the term “meta-leadership” in hospital medicine as a type of leadership that links individuals through their leader’s vision, creating enthusiastic followers.

The Level II course is a must have for those who want to expand upon leadership skills learned in Level I or for those who already have an MBA and want to improve upon leadership in clinical care. The skills discussed in this session are essential to effectively developing and implementing quality improvement programs, patient-safety initiatives, and other programs whose goal is to make system changes that improve patient care.

“The level of attendees participating in Level II was challenging,” says Dr. Holman. “It had us all—faculty and attendees alike—collaborating to answer questions from real-life experiences.”

The phrase “all work and no play” doesn’t describe any SHM meeting, and it certainly can’t be used in reference to the Leadership Academy. Attendees had an opportunity to network with fellow participants and exhibiting companies during the Monday night reception sponsored by Cogent Healthcare. Participants also had ample time to get out and experience some southern hospitality, while enjoying the spa, playing golf, touring on steamboats, dining, and shopping at the Gaylord Opryland Resort and Convention Center.

Leadership Academy Levels I and II were jam-packed with relevant materials and tools applicable to business and the real world. This is an outstanding opportunity for individuals just beginning their leadership journey and for those wanting to take their leadership skills to the next level.

Don’t miss out on the next opportunity to become a leader in hospital medicine. The next meeting will take place during the week of February 26–March 1, 2007, at the Gaylord Palms Resort and Convention Center in Orlando, Fla. Log on to www.hospitalmedicine.org or call (800) 843-3360 for more information.

Hospital-based palliative care programs are gaining traction in the United States as studies show their efficacy in decreasing length of stay and improved quality of patient care.1,2 According to the American Hospital Association, 22% of all U.S. hospitals now have such programs.3 These programs—with their emphasis on coordinated, team-delivered care and communication—seem tailor-made for the expertise of hospitalists who are increasingly taking the lead to establish them at their institutions.

Through the SHM Web site (www.hospitalmedicine.org) and the Center to Advance Palliative Care (www.capc.org) ample resources exist for developing program infrastructure and acquiring on-site training (see www.capc.org/palliative-care-leadershipinitiative/overview).

There are unwritten protocols, however, that can make or break a palliative care service. Hospitalists involved with palliative care often find themselves relating to oncologists because many patients who have palliative care needs are undergoing inpatient curative treatments (such as brachytherapy) or are actively dying. Palliative care experts interviewed for this article agreed that in order to encourage referrals from their oncology colleagues, hospitalists must be attentive to oncologists’ concerns and to consultation etiquette.

“Palliative care has been something that oncologists traditionally think they do pretty well,” says David H. Lawson, MD, section chief, Medical Oncology at Emory Clinic. “I think there will be a lot of variability between oncologists about what they see as their province and what they see as open for someone else.”

Assessing Oncologists’ Needs

During the organizational phase of a hospital-based palliative care service, it is advisable to meet with oncologists one-on-one, believes Charles F. von Gunten, MD, PhD, medical director of the Palliative Care Consultation Service at the University of California, San Diego, and director of the Center for Palliative Studies at San Diego Hospice and Palliative Care. “All consult services are fundamentally about providing advice to the managing physician when requested, about what is requested, and nothing else.”

He recommends that hospitalists involved in development of a hospital-based palliative care service find out how key oncologists at their hospital perceive the needs in the area of palliative care. “This may not match what the hospitalist thinks the oncologist needs, but that’s immaterial,” he cautions.

This advice squares with that of Steve Pantilat, MD, immediate past-president of SHM, and his team at the University of California, San Francisco. The palliative care service at UCSF is one of six Palliative Care Leadership Centers nationwide, so designated during an initiative launched two years ago by the Center to Advance Palliative Care. (The Robert Wood Johnson Foundation underwrites training activities at the six centers.) The issue in establishing palliative care services, says Dr. Pantilat, is “figuring out what would attract oncologists about such a program. What issues are most salient to them? Instead of saying, ‘I have a new service; would you please use it?’ You have to come in and say, ‘We’re thinking of starting this new service; how can we be of help to you?’ ”

Dr. Lawson agrees with Dr. von Gunten and Dr. Pantilat that hospitalists must develop communication with oncologists early during the start-up phase of a palliative care service. Hospitalists who offer palliative care services should also take time to familiarize themselves with patients’ treatment plans.

“I think there is going to be a learning curve for palliative care specialists,” says Dr. Lawson. “Part of that learning is to get some sense of how oncologists make decisions about whether to give chemo[therapy] or not. Oftentimes, there are pressures that might not be obvious.”

For instance, it may appear to a palliative care consultant that a certain patient should not undergo chemotherapy, but in fact the patient or the family may demand it.

Stephanie Grossman, MD, assistant professor of medicine and co-director of the Palliative Care Program for Emory University Hospital and Emory Crawford Long Hospital in Atlanta, says the majority of consults she does are with oncology patients. She has found that attending Monday morning sign-out meetings with Emory oncologists has not only increased referrals to the palliative care service, but has added to her understanding of oncologists’ decision-making processes.

“When I go to weekly meetings, I hear the full spectrum of what they are doing. I see how oncologists work and how they decide about treatments,” she says. “It’s been a really good experience because I never would have seen this from the hospitalist viewpoint.”

Emory’s palliative care program was launched in November 2005 and has grown so quickly that they already need additional staff.

The Primary Client

The “key message” for a hospitalist when asked to do a palliative care consult is to remember that the client of a consultation service is the referring physician, points out geriatrician Diane E. Meier, MD, director of the Center to Advance Palliative Care and the director of the Hertzberg Palliative Care Institute at Mount Sinai School of Medicine in New York City. “As a geriatrician, if I call in an infectious disease consultant, I’m calling that physician to help me make decisions about my patient—not for that person to take over the care of my patient or to undermine my relationship to that patient. This is basic consultation etiquette, but physicians are often not taught in medical school or residency the difference between a primary care responsibility and a consultation responsibility.”

“The biggest mistake that people make in putting together palliative care services,” concurs Dr. von Gunten, “is thinking that the patient is the client. That isn’t true. It is the person requesting the consultation—meaning, the referring physician or the managing service. The patient is the secondary beneficiary.

“The language we use—‘my patient’—is fundamental to the practice of American medicine,” explains Dr. von Gunten. You have to respect that. If you go to someone’s home, you don’t redecorate it because you don’t like their taste. You do not comment on their choice of draperies or their choice of food. The same applies to medical consultations.” (See “Consult Etiquette for Palliative Care Services,” p. 33.)

Oncologists generally feel “very possessive” about their patients, adds Dr. von Gunten. Even though oncologists are technically also consultants (to the patient’s primary care physician), the pattern in American medicine is that oncologists treating patients acquire the status of a primary care physician. “So,” he says, “you treat them with that kind of respect, which means that you ask permission before you do things, and you don’t disparage what they are doing—either to their faces or to their patients or to other bystanders like nurses.”

Dr. Lawson agrees that oncologists often have a strong personal bond with their patients. “These personal feelings are often reciprocated by the patients and families,” he says. “Accepting another person [the hospitalist as palliative care consultant] into the equation can be difficult at times, even more so while the patient is still in the hospital and the oncologist is still around.”

The palliative care program at Emory is consult-driven. “The doctor has to agree to us getting involved, so I don’t get into territorial issues,” says Dr. Grossman. “When I do get involved with patients, the oncologists welcome me taking care of them and realize the benefit of what I’m doing. They see that my approach is collaborative.”

Dr. Grossman has been able to offer services to oncologists whose patients are receiving chemotherapy and experiencing significant symptoms, such as pain. When hospitalists on the hospital medicine service consult her about cancer patients, she calls the primary oncologist to familiarize herself with the patient’s background and to check if other treatments are available.

Strengths of Hospitalists

Palliative care should be distinguished from hospice or end-of-life care, although it can be concurrent. Palliative care needs—ranging from symptom management to alleviating psychological suffering—can exist at any point along the cancer care trajectory, notes Dr. von Gunten, who was a co-developer with Dr. Pantilat and others of the California Hospital Initiative in Palliative Services program to assist hospitals to develop palliative services.4

Hospitalists, says Dr. von Gunten, already possess some of the baseline skills needed to deliver palliative care: They’re based in the hospital and so have the opportunity to interact with patients and their families; they are experienced in hospital-based management of patients; they are experienced in teamwork with other providers also based in the hospital. The ability to be available to patients and physicians 24/7 is a real advantage in symptom management, says Dr. Lawson.

Because hospitalists by definition care for people who are not their primary care patients, the sophistication and sensitivity about working with one’s colleagues “is already inculcated,” observes Dr. Meier. In addition, “hospitalists understand that their responsibility to and relationship with the patient is only one piece of being a good doctor. Ensuring good care for a patient means very high level and high intensity communications with everyone involved in that patient’s care: all the other specialists, the primary care physician, and the floor team—the social workers, nurses, certified nursing assistants, dietary staff, and rehab and physiatry staff. Unless everyone is reading from the same page, the patient’s care will not be good. Very often, it’s the hospitalist or palliative care consultant who is at the center of the wheel, making sure that all the spokes are getting the same message,” she says.

Busy oncologists may call upon Dr. Grossman’s service to conduct family meetings about care plans. “Patients are very loyal to their oncologists, and they want their oncologists to be supportive of their decisions,” she notes. “I always explain to patients that my consultation was requested or supported by their oncologist. I am not there to cause more barriers; I’m there to have everybody on board and to understand where the patient is. We call everybody in—the social worker, the nurse, chaplaincy staff—because our approach is interdisciplinary and these are the essential members of our team.”

Dr. Grossman believes that hospitalists’ training in teamwork and communications are key to providing a good experience for oncology patients and their families. She is board certified in palliative care, which allows her to bring additional expertise to symptom support, including situations where she can help the dying process be as peaceful as possible—for both patient and family.

The issues important in palliative care—availability to patients, families, and referring physicians, ability to work in teams, and quality of care—dovetail with the primary goals of hospital medicine. Hospitalists’ palliative care services can thrive when they forge strong foundational relationships with their referring colleagues. TH

Gretchen Henkel regularly contributes to The Hospitalist.

References

1. Selwyn PA, Rivard M, Kappell D, et al. Palliative care for AIDS at a large urban teaching hospital: program description and preliminary outcomes. J Palliat Med. 2003 Jun;6(3):461-474.
2. Ryan A, Carter J, Lucas J, Berger J. You need not make the journey alone: overcoming impediments to providing palliative care in a public urban teaching hospital. Am J Hosp Palliat Care. 2002 May-June;19(3):171-180.
3. The Case for Hospital-Based Palliative Care, published by the Center to Advance Palliative Care. Available online at: www.capc.org/building-a-hospital-based-palliative-care-program/case/support-from-capc/capc_publications/making-the-case.pdf. Last accessed March 22, 2006.
4. Pantilat SZ, Rabow MW, Citko J, et al. Evaluating the California Hospital Initiative in Palliative Services. Arch Intern Med. 2006 Jan 23;166(2):227-230.

Hospital-based palliative care programs are gaining traction in the United States as studies show their efficacy in decreasing length of stay and improved quality of patient care.1,2 According to the American Hospital Association, 22% of all U.S. hospitals now have such programs.3 These programs—with their emphasis on coordinated, team-delivered care and communication—seem tailor-made for the expertise of hospitalists who are increasingly taking the lead to establish them at their institutions.

Through the SHM Web site (www.hospitalmedicine.org) and the Center to Advance Palliative Care (www.capc.org) ample resources exist for developing program infrastructure and acquiring on-site training (see www.capc.org/palliative-care-leadershipinitiative/overview).

There are unwritten protocols, however, that can make or break a palliative care service. Hospitalists involved with palliative care often find themselves relating to oncologists because many patients who have palliative care needs are undergoing inpatient curative treatments (such as brachytherapy) or are actively dying. Palliative care experts interviewed for this article agreed that in order to encourage referrals from their oncology colleagues, hospitalists must be attentive to oncologists’ concerns and to consultation etiquette.

“Palliative care has been something that oncologists traditionally think they do pretty well,” says David H. Lawson, MD, section chief, Medical Oncology at Emory Clinic. “I think there will be a lot of variability between oncologists about what they see as their province and what they see as open for someone else.”

Assessing Oncologists’ Needs

During the organizational phase of a hospital-based palliative care service, it is advisable to meet with oncologists one-on-one, believes Charles F. von Gunten, MD, PhD, medical director of the Palliative Care Consultation Service at the University of California, San Diego, and director of the Center for Palliative Studies at San Diego Hospice and Palliative Care. “All consult services are fundamentally about providing advice to the managing physician when requested, about what is requested, and nothing else.”

He recommends that hospitalists involved in development of a hospital-based palliative care service find out how key oncologists at their hospital perceive the needs in the area of palliative care. “This may not match what the hospitalist thinks the oncologist needs, but that’s immaterial,” he cautions.

This advice squares with that of Steve Pantilat, MD, immediate past-president of SHM, and his team at the University of California, San Francisco. The palliative care service at UCSF is one of six Palliative Care Leadership Centers nationwide, so designated during an initiative launched two years ago by the Center to Advance Palliative Care. (The Robert Wood Johnson Foundation underwrites training activities at the six centers.) The issue in establishing palliative care services, says Dr. Pantilat, is “figuring out what would attract oncologists about such a program. What issues are most salient to them? Instead of saying, ‘I have a new service; would you please use it?’ You have to come in and say, ‘We’re thinking of starting this new service; how can we be of help to you?’ ”

Dr. Lawson agrees with Dr. von Gunten and Dr. Pantilat that hospitalists must develop communication with oncologists early during the start-up phase of a palliative care service. Hospitalists who offer palliative care services should also take time to familiarize themselves with patients’ treatment plans.

“I think there is going to be a learning curve for palliative care specialists,” says Dr. Lawson. “Part of that learning is to get some sense of how oncologists make decisions about whether to give chemo[therapy] or not. Oftentimes, there are pressures that might not be obvious.”

For instance, it may appear to a palliative care consultant that a certain patient should not undergo chemotherapy, but in fact the patient or the family may demand it.

Stephanie Grossman, MD, assistant professor of medicine and co-director of the Palliative Care Program for Emory University Hospital and Emory Crawford Long Hospital in Atlanta, says the majority of consults she does are with oncology patients. She has found that attending Monday morning sign-out meetings with Emory oncologists has not only increased referrals to the palliative care service, but has added to her understanding of oncologists’ decision-making processes.

“When I go to weekly meetings, I hear the full spectrum of what they are doing. I see how oncologists work and how they decide about treatments,” she says. “It’s been a really good experience because I never would have seen this from the hospitalist viewpoint.”

Emory’s palliative care program was launched in November 2005 and has grown so quickly that they already need additional staff.

The Primary Client

The “key message” for a hospitalist when asked to do a palliative care consult is to remember that the client of a consultation service is the referring physician, points out geriatrician Diane E. Meier, MD, director of the Center to Advance Palliative Care and the director of the Hertzberg Palliative Care Institute at Mount Sinai School of Medicine in New York City. “As a geriatrician, if I call in an infectious disease consultant, I’m calling that physician to help me make decisions about my patient—not for that person to take over the care of my patient or to undermine my relationship to that patient. This is basic consultation etiquette, but physicians are often not taught in medical school or residency the difference between a primary care responsibility and a consultation responsibility.”

“The biggest mistake that people make in putting together palliative care services,” concurs Dr. von Gunten, “is thinking that the patient is the client. That isn’t true. It is the person requesting the consultation—meaning, the referring physician or the managing service. The patient is the secondary beneficiary.

“The language we use—‘my patient’—is fundamental to the practice of American medicine,” explains Dr. von Gunten. You have to respect that. If you go to someone’s home, you don’t redecorate it because you don’t like their taste. You do not comment on their choice of draperies or their choice of food. The same applies to medical consultations.” (See “Consult Etiquette for Palliative Care Services,” p. 33.)

Oncologists generally feel “very possessive” about their patients, adds Dr. von Gunten. Even though oncologists are technically also consultants (to the patient’s primary care physician), the pattern in American medicine is that oncologists treating patients acquire the status of a primary care physician. “So,” he says, “you treat them with that kind of respect, which means that you ask permission before you do things, and you don’t disparage what they are doing—either to their faces or to their patients or to other bystanders like nurses.”

Dr. Lawson agrees that oncologists often have a strong personal bond with their patients. “These personal feelings are often reciprocated by the patients and families,” he says. “Accepting another person [the hospitalist as palliative care consultant] into the equation can be difficult at times, even more so while the patient is still in the hospital and the oncologist is still around.”

The palliative care program at Emory is consult-driven. “The doctor has to agree to us getting involved, so I don’t get into territorial issues,” says Dr. Grossman. “When I do get involved with patients, the oncologists welcome me taking care of them and realize the benefit of what I’m doing. They see that my approach is collaborative.”

Dr. Grossman has been able to offer services to oncologists whose patients are receiving chemotherapy and experiencing significant symptoms, such as pain. When hospitalists on the hospital medicine service consult her about cancer patients, she calls the primary oncologist to familiarize herself with the patient’s background and to check if other treatments are available.

Strengths of Hospitalists

Palliative care should be distinguished from hospice or end-of-life care, although it can be concurrent. Palliative care needs—ranging from symptom management to alleviating psychological suffering—can exist at any point along the cancer care trajectory, notes Dr. von Gunten, who was a co-developer with Dr. Pantilat and others of the California Hospital Initiative in Palliative Services program to assist hospitals to develop palliative services.4

Hospitalists, says Dr. von Gunten, already possess some of the baseline skills needed to deliver palliative care: They’re based in the hospital and so have the opportunity to interact with patients and their families; they are experienced in hospital-based management of patients; they are experienced in teamwork with other providers also based in the hospital. The ability to be available to patients and physicians 24/7 is a real advantage in symptom management, says Dr. Lawson.

Because hospitalists by definition care for people who are not their primary care patients, the sophistication and sensitivity about working with one’s colleagues “is already inculcated,” observes Dr. Meier. In addition, “hospitalists understand that their responsibility to and relationship with the patient is only one piece of being a good doctor. Ensuring good care for a patient means very high level and high intensity communications with everyone involved in that patient’s care: all the other specialists, the primary care physician, and the floor team—the social workers, nurses, certified nursing assistants, dietary staff, and rehab and physiatry staff. Unless everyone is reading from the same page, the patient’s care will not be good. Very often, it’s the hospitalist or palliative care consultant who is at the center of the wheel, making sure that all the spokes are getting the same message,” she says.

Busy oncologists may call upon Dr. Grossman’s service to conduct family meetings about care plans. “Patients are very loyal to their oncologists, and they want their oncologists to be supportive of their decisions,” she notes. “I always explain to patients that my consultation was requested or supported by their oncologist. I am not there to cause more barriers; I’m there to have everybody on board and to understand where the patient is. We call everybody in—the social worker, the nurse, chaplaincy staff—because our approach is interdisciplinary and these are the essential members of our team.”

Dr. Grossman believes that hospitalists’ training in teamwork and communications are key to providing a good experience for oncology patients and their families. She is board certified in palliative care, which allows her to bring additional expertise to symptom support, including situations where she can help the dying process be as peaceful as possible—for both patient and family.

The issues important in palliative care—availability to patients, families, and referring physicians, ability to work in teams, and quality of care—dovetail with the primary goals of hospital medicine. Hospitalists’ palliative care services can thrive when they forge strong foundational relationships with their referring colleagues. TH

Gretchen Henkel regularly contributes to The Hospitalist.

References

1. Selwyn PA, Rivard M, Kappell D, et al. Palliative care for AIDS at a large urban teaching hospital: program description and preliminary outcomes. J Palliat Med. 2003 Jun;6(3):461-474.
2. Ryan A, Carter J, Lucas J, Berger J. You need not make the journey alone: overcoming impediments to providing palliative care in a public urban teaching hospital. Am J Hosp Palliat Care. 2002 May-June;19(3):171-180.
3. The Case for Hospital-Based Palliative Care, published by the Center to Advance Palliative Care. Available online at: www.capc.org/building-a-hospital-based-palliative-care-program/case/support-from-capc/capc_publications/making-the-case.pdf. Last accessed March 22, 2006.
4. Pantilat SZ, Rabow MW, Citko J, et al. Evaluating the California Hospital Initiative in Palliative Services. Arch Intern Med. 2006 Jan 23;166(2):227-230.

Hospital-based palliative care programs are gaining traction in the United States as studies show their efficacy in decreasing length of stay and improved quality of patient care.1,2 According to the American Hospital Association, 22% of all U.S. hospitals now have such programs.3 These programs—with their emphasis on coordinated, team-delivered care and communication—seem tailor-made for the expertise of hospitalists who are increasingly taking the lead to establish them at their institutions.

Through the SHM Web site (www.hospitalmedicine.org) and the Center to Advance Palliative Care (www.capc.org) ample resources exist for developing program infrastructure and acquiring on-site training (see www.capc.org/palliative-care-leadershipinitiative/overview).

There are unwritten protocols, however, that can make or break a palliative care service. Hospitalists involved with palliative care often find themselves relating to oncologists because many patients who have palliative care needs are undergoing inpatient curative treatments (such as brachytherapy) or are actively dying. Palliative care experts interviewed for this article agreed that in order to encourage referrals from their oncology colleagues, hospitalists must be attentive to oncologists’ concerns and to consultation etiquette.

“Palliative care has been something that oncologists traditionally think they do pretty well,” says David H. Lawson, MD, section chief, Medical Oncology at Emory Clinic. “I think there will be a lot of variability between oncologists about what they see as their province and what they see as open for someone else.”

Assessing Oncologists’ Needs

During the organizational phase of a hospital-based palliative care service, it is advisable to meet with oncologists one-on-one, believes Charles F. von Gunten, MD, PhD, medical director of the Palliative Care Consultation Service at the University of California, San Diego, and director of the Center for Palliative Studies at San Diego Hospice and Palliative Care. “All consult services are fundamentally about providing advice to the managing physician when requested, about what is requested, and nothing else.”

He recommends that hospitalists involved in development of a hospital-based palliative care service find out how key oncologists at their hospital perceive the needs in the area of palliative care. “This may not match what the hospitalist thinks the oncologist needs, but that’s immaterial,” he cautions.

This advice squares with that of Steve Pantilat, MD, immediate past-president of SHM, and his team at the University of California, San Francisco. The palliative care service at UCSF is one of six Palliative Care Leadership Centers nationwide, so designated during an initiative launched two years ago by the Center to Advance Palliative Care. (The Robert Wood Johnson Foundation underwrites training activities at the six centers.) The issue in establishing palliative care services, says Dr. Pantilat, is “figuring out what would attract oncologists about such a program. What issues are most salient to them? Instead of saying, ‘I have a new service; would you please use it?’ You have to come in and say, ‘We’re thinking of starting this new service; how can we be of help to you?’ ”

Dr. Lawson agrees with Dr. von Gunten and Dr. Pantilat that hospitalists must develop communication with oncologists early during the start-up phase of a palliative care service. Hospitalists who offer palliative care services should also take time to familiarize themselves with patients’ treatment plans.

“I think there is going to be a learning curve for palliative care specialists,” says Dr. Lawson. “Part of that learning is to get some sense of how oncologists make decisions about whether to give chemo[therapy] or not. Oftentimes, there are pressures that might not be obvious.”

For instance, it may appear to a palliative care consultant that a certain patient should not undergo chemotherapy, but in fact the patient or the family may demand it.

Stephanie Grossman, MD, assistant professor of medicine and co-director of the Palliative Care Program for Emory University Hospital and Emory Crawford Long Hospital in Atlanta, says the majority of consults she does are with oncology patients. She has found that attending Monday morning sign-out meetings with Emory oncologists has not only increased referrals to the palliative care service, but has added to her understanding of oncologists’ decision-making processes.

“When I go to weekly meetings, I hear the full spectrum of what they are doing. I see how oncologists work and how they decide about treatments,” she says. “It’s been a really good experience because I never would have seen this from the hospitalist viewpoint.”

Emory’s palliative care program was launched in November 2005 and has grown so quickly that they already need additional staff.

The Primary Client

The “key message” for a hospitalist when asked to do a palliative care consult is to remember that the client of a consultation service is the referring physician, points out geriatrician Diane E. Meier, MD, director of the Center to Advance Palliative Care and the director of the Hertzberg Palliative Care Institute at Mount Sinai School of Medicine in New York City. “As a geriatrician, if I call in an infectious disease consultant, I’m calling that physician to help me make decisions about my patient—not for that person to take over the care of my patient or to undermine my relationship to that patient. This is basic consultation etiquette, but physicians are often not taught in medical school or residency the difference between a primary care responsibility and a consultation responsibility.”

“The biggest mistake that people make in putting together palliative care services,” concurs Dr. von Gunten, “is thinking that the patient is the client. That isn’t true. It is the person requesting the consultation—meaning, the referring physician or the managing service. The patient is the secondary beneficiary.

“The language we use—‘my patient’—is fundamental to the practice of American medicine,” explains Dr. von Gunten. You have to respect that. If you go to someone’s home, you don’t redecorate it because you don’t like their taste. You do not comment on their choice of draperies or their choice of food. The same applies to medical consultations.” (See “Consult Etiquette for Palliative Care Services,” p. 33.)

Oncologists generally feel “very possessive” about their patients, adds Dr. von Gunten. Even though oncologists are technically also consultants (to the patient’s primary care physician), the pattern in American medicine is that oncologists treating patients acquire the status of a primary care physician. “So,” he says, “you treat them with that kind of respect, which means that you ask permission before you do things, and you don’t disparage what they are doing—either to their faces or to their patients or to other bystanders like nurses.”

Dr. Lawson agrees that oncologists often have a strong personal bond with their patients. “These personal feelings are often reciprocated by the patients and families,” he says. “Accepting another person [the hospitalist as palliative care consultant] into the equation can be difficult at times, even more so while the patient is still in the hospital and the oncologist is still around.”

The palliative care program at Emory is consult-driven. “The doctor has to agree to us getting involved, so I don’t get into territorial issues,” says Dr. Grossman. “When I do get involved with patients, the oncologists welcome me taking care of them and realize the benefit of what I’m doing. They see that my approach is collaborative.”

Dr. Grossman has been able to offer services to oncologists whose patients are receiving chemotherapy and experiencing significant symptoms, such as pain. When hospitalists on the hospital medicine service consult her about cancer patients, she calls the primary oncologist to familiarize herself with the patient’s background and to check if other treatments are available.

Strengths of Hospitalists

Palliative care should be distinguished from hospice or end-of-life care, although it can be concurrent. Palliative care needs—ranging from symptom management to alleviating psychological suffering—can exist at any point along the cancer care trajectory, notes Dr. von Gunten, who was a co-developer with Dr. Pantilat and others of the California Hospital Initiative in Palliative Services program to assist hospitals to develop palliative services.4

Hospitalists, says Dr. von Gunten, already possess some of the baseline skills needed to deliver palliative care: They’re based in the hospital and so have the opportunity to interact with patients and their families; they are experienced in hospital-based management of patients; they are experienced in teamwork with other providers also based in the hospital. The ability to be available to patients and physicians 24/7 is a real advantage in symptom management, says Dr. Lawson.

Because hospitalists by definition care for people who are not their primary care patients, the sophistication and sensitivity about working with one’s colleagues “is already inculcated,” observes Dr. Meier. In addition, “hospitalists understand that their responsibility to and relationship with the patient is only one piece of being a good doctor. Ensuring good care for a patient means very high level and high intensity communications with everyone involved in that patient’s care: all the other specialists, the primary care physician, and the floor team—the social workers, nurses, certified nursing assistants, dietary staff, and rehab and physiatry staff. Unless everyone is reading from the same page, the patient’s care will not be good. Very often, it’s the hospitalist or palliative care consultant who is at the center of the wheel, making sure that all the spokes are getting the same message,” she says.

Busy oncologists may call upon Dr. Grossman’s service to conduct family meetings about care plans. “Patients are very loyal to their oncologists, and they want their oncologists to be supportive of their decisions,” she notes. “I always explain to patients that my consultation was requested or supported by their oncologist. I am not there to cause more barriers; I’m there to have everybody on board and to understand where the patient is. We call everybody in—the social worker, the nurse, chaplaincy staff—because our approach is interdisciplinary and these are the essential members of our team.”

Dr. Grossman believes that hospitalists’ training in teamwork and communications are key to providing a good experience for oncology patients and their families. She is board certified in palliative care, which allows her to bring additional expertise to symptom support, including situations where she can help the dying process be as peaceful as possible—for both patient and family.

The issues important in palliative care—availability to patients, families, and referring physicians, ability to work in teams, and quality of care—dovetail with the primary goals of hospital medicine. Hospitalists’ palliative care services can thrive when they forge strong foundational relationships with their referring colleagues. TH

Gretchen Henkel regularly contributes to The Hospitalist.

References

1. Selwyn PA, Rivard M, Kappell D, et al. Palliative care for AIDS at a large urban teaching hospital: program description and preliminary outcomes. J Palliat Med. 2003 Jun;6(3):461-474.
2. Ryan A, Carter J, Lucas J, Berger J. You need not make the journey alone: overcoming impediments to providing palliative care in a public urban teaching hospital. Am J Hosp Palliat Care. 2002 May-June;19(3):171-180.
3. The Case for Hospital-Based Palliative Care, published by the Center to Advance Palliative Care. Available online at: www.capc.org/building-a-hospital-based-palliative-care-program/case/support-from-capc/capc_publications/making-the-case.pdf. Last accessed March 22, 2006.
4. Pantilat SZ, Rabow MW, Citko J, et al. Evaluating the California Hospital Initiative in Palliative Services. Arch Intern Med. 2006 Jan 23;166(2):227-230.

Hospitalists lead, coordinate, and participate in initiatives to improve the identification and treatment of patients and families in need of palliative care. Yet we often lack the knowledge and skills necessary to provide outstanding palliative care; we may also lack the comfort level we need to take care of patients at that stage of illness.

Steve Pantilat, MD, SHM president and member of the SHM Education Committee, established the Palliative Care Task Force to identify and create opportunities to improve palliative care in the field of hospital medicine. The Palliative Care Task Force had its inaugural meeting in August. Led by founder Dr. Pantilat and Chad Whelan, MD, Palliative Care Task Force chair, the task force established the following goals:

1. Promote palliative care as an important skill and activity for hospital medicine physicians and providers;
2. Identify and create palliative-care-focused educational activities for hospital medicine physicians and other key stakeholders within hospital medicine;
3. Advocate for the creation and or support of hospital-based palliative care services;
4. Promote the use of best practices in palliative care; and
5. Develop a core community of hospital medicine physicians dedicated to improving our understanding of palliative care.

Our current task force membership is small but energetic. We actively recruit members, particularly nonphysicians and non-SHM members. Palliative care is a multidisciplinary field, and we hope the Palliative Care Task Force membership will reflect this diversity. Potential areas of growth include pharmacists, nurses, social workers, spiritual care providers, and nonhospitalist physicians. We are also looking for a pediatrician with an interest in palliative care to represent the pediatric interests among SHM members.

Since the first meeting in August our members have been developing a plan to achieve our identified goals. While the plan is still early in its development, we have designed a multimodal approach that will rely on traditional CME meetings, print media, as well as electronic media.

The task force’s short-term goals include promoting best practices in palliative care via SHM communication vehicles. For example, we plan to propose a series of articles for the forthcoming Journal of Hospital Medicine to highlight key issues in palliative care.

The 2006 SHM Annual Meeting will feature two workshops with a palliative care focus. One workshop will discuss how to build the case for a palliative care service; the other will address issues in pain management for hospitalized patients. We will learn from the 2006 experience as we look toward the 2007 SHM Annual Meeting in Texas. An electronic CME module is also under development.

Finally, we are planning an electronic compendium of resources and tools for practicing high-quality palliative care. Although the format has not been finalized, the concept is to provide resources that will make caring for palliative care patients as easy as possible.

While we are pleased with the progress of the task force to date, there is still much to do. Hospital medicine physicians can and should serve as leaders to improve palliative care. Traditional medical training focuses our efforts and thoughts of curing and preventing. We’ve all felt the exhilaration of making a life-saving diagnosis on the young, otherwise healthy patient; however, just as there are times to look for a cure at all costs, there are also times when we must treat our patients’ symptoms at all costs.

Often traditional medical training doesn’t provide us with the tools we need to best care for our patients and their families when palliative care goals become the priority. We hope this task force will raise the visibility of palliative care within SHM and provide the opportunities and tools needed for us, as hospital medicine providers, to offer the best palliative care possible to our patients. If successful, we’ll feel the deep personal satisfaction and self-reward of helping a patient and their family transition from hopes of a cure to comfort in the knowledge that their symptoms and needs will be cared for.

Interested in joining the task force or participating in a related work group? Contact Chad Whelan at cwhelan@medicine.bsd.uchicago.edu.

The Stroke Resource Room

SHM’s Web site features stroke information on call

Online resource rooms comprise an innovative venue within the SHM Web site to focus on essential topics from the forthcoming core curriculum. Specifically, the Web-based resource rooms organize expert opinions, evidence-based literature, clinical tools and guidelines, and recommendations about essential topics in hospital medicine. Initial areas of development include the DVT and stroke resource rooms, with ongoing efforts in other areas including geriatrics, antimicrobial resistance, congestive heart failure, and glycemic control. These interactive rooms help connect hospitalists to information, content experts, and each other.

The Stroke Imperative

Stroke is the third leading cause of death in the United States and a common admission diagnosis. Cerebrovascular disease is a field of great complexity and rapid advance. There is great pressure on the practicing hospitalist to have both a base knowledge of the approach to the patient with stroke as well as an understanding of current best practice.

Traditional internal medicine residencies may not fully prepare one for hospitalist practice. Many patients seen by hospitalists have diagnoses that were managed by internal medicine subspecialties in the past. Most hospitalists feel comfortable managing straightforward gastrointestinal bleeds, myocardial infarctions, and renal failure without consultation. Neurologic cases are somewhat different.

Most medicine residents have rotated on a neurology service, but that limited experience is frequently insufficient in preparing physicians for their future experience as hospitalists. While neurology residencies include one year of internal medicine, the two diverge dramatically afterward. Practitioners of both internal medicine and neurology frequently feel that they speak a different language from one another.

Particularly in the community setting, hospitalists manage the bulk of neurology patients either with or without neurologic consultation. The reasons for this are varied, including poor inpatient reimbursement for neurologists and a tradition of nonaggressive approaches to stroke care.1

The Opportunity

Realizing the need to provide direct access to important information about inpatient stroke management, SHM convened a stroke advisory board, including general hospitalists, a neurologist, and members of the education committee. SHM and Boehringer-Ingelheim provided funding for the resource room through educational funds and an unrestricted grant, respectively.

There is great pressure on the practicing hospitalist to have both a base knowledge of the approach to the patient with stroke as well as an understanding of current best practice.

Stroke Resource Room Content

The Stroke Resource Room is patterned after the template of the DVT Resource Room; the idea being that a standardized format will allow easy navigation and maximal utility. David Likosky, MD, served as content editor, Sandeep Sachdeva, MD, as quality editor, Alpesh Amin, MD as education editor, and Jason Stein, MD, as managing editor.

The rooms are structured to facilitate access to specific types of information. Whether one is looking for the details of a certain study, slide sets to help teach residents, or for input on how to approach a difficult patient, that resource should be readily available. The main sections of the room are summarized below.

The “Awareness” area on the main page of the Stroke Resource Room defines the effects of stroke as well as the hospitalists’ scope of practice.

A separate debate is ongoing within neurology about who should be responsible for the inpatient management of stroke. Interestingly, much of this is about whether general neurologists or vascular/stroke neurologists should primarily manage these patients. One such article referred to the brain as “… the Rolls Royce of the human body” going on to ask, “Would you want your Rolls Royce to be serviced by any ordinary mechanic, who takes care of all kinds of automobiles?”2 Many hospitalists find this argument less than compelling given how difficult it can be in many communities to get a neurologist much less a “vascular neurologist” to see an inpatient.

The “Evidence” section consists of two main parts with the goal of providing a one-stop shop for stroke care literature. The first is a set of links to articles reviewed by the ACP journal club. The second is a concise list of landmark trials, such as the Heparin Acute Embolic Stroke HAEST) trial, which compared low molecular weight heparin versus aspirin in patients with acute stroke and atrial fibrillation.3 These articles help answer questions that come up commonly in clinical practice.

The Experience link capitalizes on the Internet’s ability to disseminate information. There are a limited number of protocols and order sets for ischemic and hemorrhagic stroke available. One can download these and, perhaps more importantly, submit one’s own—including comments on what about that particular tool has been valuable.

Finally, the “Ask the Expert” section features an interactive venue for interacting with a panel of neurologists and neurocritical care physicians. This section answers the more common and more difficult clinical questions in a shared forum. Supportive evidence is cited, with the knowledge that much of stroke care remains in the realm of standard of practice.

The “Improve” section reflects the other roles of hospitalists, such as hospital leader. The three current links include a PowerPoint primer on quality improvement. In addition, there are links to the “Get with the Guidelines” program from the American Stroke Association. This is a continuous quality improvement program focusing on care team protocols and outcome measurement. The final linked site is to the criteria for the disease specific accreditation program from JCAHO. This national effort may drive where patients receive their care for certain conditions.

The “Educate” section caters to multiple audiences. The academic hospitalist may find the “Teaching Pearls” section helpful, as well as the slide sets from the International Stroke Conference and StrokeSTOP, which is aimed at medical students. The patient education links contain a wealth of quality information. The “Professional Development” subsection contains sources for audio lectures with slide sets as well as case presentations and NIH stroke scale training—all with free CME hours. A chapter on stroke from the SHM’s forthcoming core competencies is included as well.

Moving Forward

One of the advantages of an Internet-based resource is the ability to be easily modified. A progressively more robust database will be developed over time as questions are answered in the “Ask the Expert” section and as participants share their stroke care protocols.

The Stroke Resource Room is an excellent forum to improve clinical care and form the basis for future SHM workshops, lectures, and to review articles. By building our collective knowledge, we will be limited only by the energy we put into the adding to and using available information and our desire to apply that energy to patient care.

References

1. Likosky DJ, Amin AN. Who will care for our hospitalized patients? Stroke. 2005;36(6): 1113-1114.
2. Caplan L. Stroke is best managed by neurologists. Stroke. 2003;34(11):2763.
3. Berge E, Abdelnoor M, Nakstad PH, et al. Low molecular-weight heparin versus aspirin in patients with acute ischaemic stroke and atrial fibrillation: a double-blind randomized study. HAEST Study Group. Lancet. 2000;355(9211):1205-1210.

Secure the Future

Encourage trainees to consider lifelong careers in hospital medicine

By Vineet Arora, MD, MA, and Margaret C. Fang, MD, MPH, co-chairs of SHM’s Young Physicians Section

Interest in hospital medicine is booming, and it is estimated that the number of hospitalists in the United States is estimated will exceed the number of cardiologists in the near future. Yet, many graduating residents view hospital medicine as a temporary job where they can take time off and work before going on to a subspecialty fellowship. Others perceive hospitalists as “super-residents” susceptible to burnout, and therefore do not consider hospital medicine a sustainable career option. These perceptions may contribute to a high turnover of hospitalists and compromise the accumulation of enough inpatient experience to accomplish many of the benefits associated with the use of hospitalists, including shorter lengths of stay and comparable—if not better—quality of care.

To ensure recruitment and retention of the best and brightest trainees, it’s important to consider ways to educate and encourage them to consider a career in hospital medicine as a rewarding lifelong career. Below, we discuss strategies to encourage trainees to pursue a lifelong career in hospital medicine.

Showcase Your Clinical Work

First, consider your everyday practice an excellent way to showcase the often-exciting world of inpatient medicine. Preclinical students often cherish any opportunity to interact with patients. Inviting first- or second-year medical students to accompany you on rounds is an excellent opportunity to teach clinical medicine and physical exam skills, and a good way to influence their career choice early in their medical career.

If you’re in an academic medical center, accessing preclinical students is as easy as approaching students in an internal medicine interest group or volunteering as a preceptor for a physical diagnosis course for preclinical students. In fact, hospitalists are often acknowledged as some of the best teachers and are highly accessible because of their inpatient duties.

Community-based hospitalists also can provide valuable career advice and opportunities, particularly in exposing students to real-life career experiences often not covered through traditional medical school training. One way for a community-based hospitalist to become involved is to host preclinical students over the summer by contacting a local medical school dean’s office and volunteering as a summer preceptor for interested preclinical students. Your alma mater may be particularly responsive. Or, contact interest groups in internal medicine, family medicine, or pediatrics through the state or local leaders of the American College of Physicians, the American Academy of Family Physicians, and the American Academy of Pediatrics.

Explain Your Nonclinical Work

It’s important to explain your nonclinical roles to residency trainees. Hospitalists increasingly take on numerous administrative, educational, and leadership roles and responsibilities. Whether you are leading a quality improvement effort, interfacing with hospital operations, or running a medical student clerkship, it is crucial that physicians-in-training understand the diverse opportunities within hospital medicine to achieve a healthy work-life balance and avoid clinical burnout.

If you are involved with quality improvement projects at your institution, enlist the help of an interested resident or student. Because student rotations are frequent, their prior experience may be scant and their time limited. So make sure the projects have definite goals and are easily accomplished. Ensure that the projects provide reasonable educational value and experience within a finite time. Lay out explicit goals at the beginning of the project, ask for frequent updates, and then recap the experience and any concrete accomplishments to provide structure and expectations for the process.

For example, the University of California at San Francisco Hospitalist Group is spearheading an educational initiative in which residents learn about both the theory and practice of quality improvement through choosing a project and working with a mentor to design, implement, and measure the results of a quality improvement initiative.

Share Your Passion

In addition to showcasing your clinical and nonclinical activities, share your passion about hospital medicine. Reflect on the reasons you entered hospital medicine, as well as your thoughts on the pros and cons of the field. Perhaps you were drawn to hospital medicine because of a desire to take care of acutely ill patients, or to work on improving the quality of a medical system, or because of a more controllable work schedule with competitive compensation.

In some cases, it may have been a particular interest in medical ethics, palliative care, geriatrics, or perioperative care. Sharing your enthusiasm is the best way to cultivate reciprocal interest. Medical students and residents closely observe your attitudes toward your career, your job satisfaction, and your work-life balance. In addition to mentoring those already entering a medical career, there are endless opportunities to outreach to younger students, including those in high school and college. Many local schools and community organizations offer mentorship programs to area students. Engaging in an informal discussion about your career at a social or community event with younger students can be incredibly rewarding. Younger students often lack realistic career experiences and access to career-specific role models on which to base informed decisions. Although they may express an interest in science or medicine, they may not know how long the training process is or the importance of good grades.

Take a moment to inquire about career interests and explain what a hospitalist is; this can be invaluable in promoting understanding and cultivating interest into the field. More structured interactions with hospitalists can also prepare students for successful entry into the medical field. The University of Chicago Hospitalists, for example, host high-achieving Chicago public school juniors in a summer clinical and research enrichment program in hospital-based medicine called TEACH Research.

Offer Advice and Assistance

Finding your first job can be a nerve-racking situation. Sharing your advice on the process with trainees is always appreciated. For instance, they are interested in hearing how you decided to become a hospitalist and what you did to secure your position.

Offer to meet with them and review their career interests, goals, and curriculum vitae. If you hear of job openings and opportunities, inform the community of trainees by contacting program directors or chief residents at residency programs. Many residency program directors showcase available opportunities in their house-staff office or direct such opportunities to interested residents. Some residency programs invite community-based physicians to give residents insight on securing their first job. This process is particularly foreign to medical trainees who have never had to negotiate such things as benefit packages, compensation, or call schedule. Your candid thoughts on what to expect and how to approach the process are invaluable.

Again, approaching the residency program where you trained is a good starting point. Alternatively, you can locate a nearby residency through the Fellowship and Residency Electronic Interactive Database database offered by the American Medical Association (www.ama-assn.org/vapp/freida/srch/).

Finally, if you know any trainees interested in hospital medicine,encourage them to attend the SHM’s local or national meetings. The annual meeting is an excellent place for medical trainees to hear the latest research and innovations, learn about advanced training and job opportunities, network, and connect with mentors through the Mentorship Breakfast. For the last two years, the Young Physicians Section has organized a Forum for Early Career Hospitalists where we addressed different career paths in hospital medicine and conducted research during training. Continued growth in our field depends on promoting hospital medicine as a vital, sustainable career.

Busy Summer for HQPS

The Health Quality and Patient Safety Committee (HQPS) has developed an array of initiatives to support SHM members in the development, implementation, and evaluation of quality and system improvements at their institutions. Educational programming, tools, and resources are being developed for four specific content areas including prevention of VTE, improving the discharge process, glycemic control, and improving outcomes for hospitalized heart failure patients.

HQPS members and Course Directors Greg Maynard, MD, and Tosha Wetterneck, MD, are developing a quality precourse for the 2006 SHM Annual Meeting. The educational goal for the precourse will be to enable hospitalists to become leaders in quality and safety through the effective implementation of evidence-based, high reliability interventions. Precourse participants will actively participate in small groups to apply techniques for designing, implementing, and evaluating quality improvement projects to address a specific improvement need in one of four areas: heart failure care, glycemic control, and preventing VTE in the hospital or the discharge process. Registration for this precourse will begin in November and space will be limited. Plan to register early.

In June, HQPS convened a multidisciplinary, multiagency Heart Failure Advisory Board to guide the development of a clinical guidelines implementation toolkit (CGIT), resource room, and CME modules related to implementing best practices for care of patients with heart-failure. The advisory board has representatives from several organizations and allied health professions, including the American College of Cardiology, American Medical Directors Association, American Hospital Association, Case Managers Society of America, American Association of Heart Failure Nurses, American Society of Health-System Pharmacists, American Association of Critical Care Nurses, National Association of Social Workers and the Heart Failure Society of America. Currently, the advisory board is completing a needs assessment and will begin development on the CGIT, resource room and CME modules next month.

In July, in collaboration with the Education Committee and SHM staff, HQPS launched the SHM VTE Resource Room (www.hospitalmedicine.org/AM/Template.cfm?Section=Quality_Improvement_Resource_Rooms1&Template=/CM/HTMLDisplay.cfm&ContentID=6312). The resource room provides users with a workbook, or step-wise process to assess the need for VTE prevention, advocate for local improvements, and implement and evaluate a VTE prevention program. The resource room also provides a useful review of the literature, an “Ask the Expert” forum, slide sets, and bedside teaching tools.

In August, the SHM Executive Committee approved the SHM Discharge Planning Checklist developed by HQPS under the direction of Dennis Manning, MD. This discharge planning checklist and a white paper on guidance for its implementation will be available to members in the near future.

Interested in learning more about these initiatives or becoming involved in an HQPS workgroup? Contact Lakshmi Halasyamani, MD, HQPS chair, at HalasyaL@trinity-health.org.

Hartford Grants Awarded

SHM presents Hartford Foundation grant funds to hospitalists for QI demo project

By Kathleen K. Frampton, RN, MPH

Shm remains committed to expanding its efforts to improve inpatient care for older patients. The John A. Hartford Foundation has generously awarded approximately $370,000 to SHM in support of its focus on the geriatric population. This funding will assist SHM in its endeavors related to educational programs and products, hospitalist leadership training, and quality improvement projects. In light of this, SHM allocated a portion of these Hartford grant funds to study a critical aspect of elderly patient care, safety-care transitions.

A competitive request for the proposal (RFP) process was conducted to solicit interest from healthcare institutional providers and SHM members willing to serve as the principle investigator in their work setting. The RFP delineated the requirements for a hospital to serve as a designated study site to implement a discharge planning intervention from hospital-based care to community-based care for elderly patients and to evaluate the facilitating factors, barriers to implementation and outcomes associated with the new approach.

All research proposals submitted by hospitals were evaluated and scored against established criteria. Qualifying hospital finalists were reviewed by a panel consisting of members of three standing SHM Committees: Education, Hospital Quality and Patient Safety, and Research and Executive. In July 2005, this panel selected three hospitals to receive funding for this initiative: Johns Hopkins-Bayview, Baltimore, Md.; Northeast Medical Center, Concord, N.C.; and Geisinger Health System, Danville, Penn.

Johns Hopkins-Bayview (coordinating site): A 355-bed community-based facility located in southeast Baltimore with academic affiliations and approximately 25% of patients over age 65. The hospitalist service consists of nine physicians, five physician assistants, and three nurse practitioners.

Northeast Medical Center: A 457-bed, private, nonprofit community-based facility located in the Charlotte Region with a residency training program and 36% of patients over age 65. The hospitalist service consists of 16 physicians and 24/7 intensivist coverage.

Geisinger Health System: A 366-bed facility and Level 1 Trauma Center, private, nonprofit community based system located in north central Pennsylvania with a residency training program and 70% of patients over age 65. The hospitalist service is staffed by 15 physicians (10 full-time employees).

The QI Demonstration Project will run for 18 months and, according to Tina Budnitz, MPH, SHM senior advisor for planning and development, the study “represents new territory for both SHM and other professional societies … . We have moved beyond developing a best practice to use in the clinical setting to how you can actually change the system so that best practices can be successfully implemented … . It is the intention of SHM to focus on safe practice interventions that can be generalized to other settings.”

Budnitz also explained that near completion of the project SHM plans to convene the advisory board, grantee project teams, representatives of the Hartford Foundation, and the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) to review the data from the demonstration project and design a larger scale quality improvement program.

“Our grantees will work with the SHM Advisory Board to develop a comprehensive toolkit, which will document the lessons learned during the implementation process and any other resources that facilitate adaptation and/or adoption of these safe practice interventions,” explains Budnitz.

Care Transitions in the Treatment of the Elderly

According to the Institute of Medicine (IOM), the healthcare system is poorly organized to meet its current challenges. The delivery of care is often overly complex and uncoordinated, requiring steps and patient hand-offs that slow care and decrease rather than improve patient safety.

An IOM seminal report published in 2001, Crossing the Quality Chasm: A New Health System for the 21st Century, emphasizes that cumbersome processes waste resources, leave unaccountable voids in coverage, lead to loss of information, and fail to build on the strengths of all professionals involved to ensure that care is appropriate, timely, and safe. Right before and after discharge, there often is no one clearly in charge of the transition whom the patient may contact for guidance. Patients are often instructed to contact their primary care provider for follow-up issues or questions, whether or not the primary care provider had been involved in the hospitalization.

A recent study supported by the Agency for Healthcare Research and Quality (AHRQ) showed that high-risk patient targeting, better communications, and better coordination of care and follow-up could potentially prevent some readmissions when transitioning patients from hospital to home.

In 2002, the American Geriatric Society (AGS) issued a Position Statement, Improving the Quality of Transitional Care for Persons with Complex Care Needs, which stressed that both the “sending” and “receiving” health professionals bear responsibility and accountability in this phase. Successful transitions require that there be both a uniform plan of care and procedure for communicating the following:

1. An accessible medical record that contains a current problem list;
2. A medication regimen;
3. A list of allergies;
4. Advance directives;
5. Baseline physical and cognitive function; and
6. Contact information for all professional and informal care providers.

Also, input must be solicited from informal care providers who are involved in the execution of the plan of care. The AGS recommends the use of a “coordinating” health professional who oversees both the sending and receiving aspects of the transition. This professional should be skilled in the identification of health status, assessment and management of multiple chronic conditions, managing medications, and collaboration with members of the interdisciplinary team and caregivers.

The QI Demonstration Project

According to SHM Immediate Past-President Jeanne Huddleston, MD, SHM has structured this demonstration project so that the three study sites in the Hartford Grant Group will implement identical clinical tools while they employ unique processes and procedures at each of the individual sites.

“The what needs to be in common across sites, but the how and who in the implementation will be individually tailored to each specific hospital environment,” she explains.

This is a real strength of the study because standardized interventions can be studied in varied and representative test environments. Dr. Huddleston also stresses that, “SHM envisions its role in quality management to be in the actual implementation realm—rather than in the development of new clinical guidelines. SHM seeks to know whether hospitalists [use] the same tools at different sites and understand their impact at each site.”

The patient care domains selected as a focus for the safe practice implementation tools for the care transition process are:

1. Communications;
2. Medication reconciliation; and
3. Functional status.

Communication tools will be developed for primary care physicians, patients, and their support systems so that important clinical information is transmitted during the discharge process. The implementation tools designed for medication reconciliation will be employed by physicians, care managers, or pharmacists in the hospital. Transmitting the medication regimen is widely recognized as an error-prone element of care. These specific implementation tools will include a method to review and verify any dose/frequency changes of medications that the patient was taking upon admission, as well as those that were added or discontinued during the inpatient episode. Because patient functional status is a critical issue in discharge planning, detailed tools will also be created to standardize content for risk assessment and evaluation of the types of assistance needed for patients to resume activities of daily living.

The demonstration project will also utilize specific metrics to measure patient outcomes as well as the effect that these safe practices have on the discharge and care transition processes. The three study sites will measure referring physician satisfaction with the adequacy of post-hospitalization follow-up information, the accuracy of medication reconciliation, readmission rates, and patient understanding of their treatment plan and medication regimen.

QI Requires Expert Change Management

Hospitalists recognize that the challenge of patient safety is linked to the challenge of organizational change. Patient safety initiatives can succeed only to the extent to which healthcare organizations recognize the need for and develop the means to implement the organizational changes. According to the AHRQ, systemwide improvements in patient safety are possible only if there are coordinated changes in multiple components—clinical procedures, attitudes and behaviors of care providers, incentive systems, coordination structures and processes, patterns of interactions among care providers, and organizational culture.

Senior leadership must play an active role in establishing patient safety as a priority, and staff involved directly in providing care must actively participate in implementing change. The likelihood of successful implementation of even simple change requires multiple tactics or many bullets directed at the same target. Additionally, it is critical to redesign the roles of healthcare workers at the point of care to accommodate the necessary changes and to retrain them to fulfill these roles.

Hospitalists Prepare to Lead

Identifying the facilitating factors and barriers to improvement is essential to effect change because it helps ensure success. It’s also crucial to match the patient safety goals with the change strategies and tactics. Otherwise, mismatches can lead to unintended consequences that will hinder continuous improvements such as employee skepticism, frustration of safety champions, and mislearning or unnecessary ”workarounds“ by staff.

SHM sees this QI Demonstration Project as critical to assisting institutions in the design, implementation, and evaluation of QI programs and systemwide interventions with effectiveness and value. These findings should equip hospitalists with vital tools necessary to provide essential leadership in meeting their institution’s quality and patient safety goals. TH

Writer Kathleen Frampton is based in Columbia, Md

Hospitalists lead, coordinate, and participate in initiatives to improve the identification and treatment of patients and families in need of palliative care. Yet we often lack the knowledge and skills necessary to provide outstanding palliative care; we may also lack the comfort level we need to take care of patients at that stage of illness.

Steve Pantilat, MD, SHM president and member of the SHM Education Committee, established the Palliative Care Task Force to identify and create opportunities to improve palliative care in the field of hospital medicine. The Palliative Care Task Force had its inaugural meeting in August. Led by founder Dr. Pantilat and Chad Whelan, MD, Palliative Care Task Force chair, the task force established the following goals:

1. Promote palliative care as an important skill and activity for hospital medicine physicians and providers;
2. Identify and create palliative-care-focused educational activities for hospital medicine physicians and other key stakeholders within hospital medicine;
3. Advocate for the creation and or support of hospital-based palliative care services;
4. Promote the use of best practices in palliative care; and
5. Develop a core community of hospital medicine physicians dedicated to improving our understanding of palliative care.

Our current task force membership is small but energetic. We actively recruit members, particularly nonphysicians and non-SHM members. Palliative care is a multidisciplinary field, and we hope the Palliative Care Task Force membership will reflect this diversity. Potential areas of growth include pharmacists, nurses, social workers, spiritual care providers, and nonhospitalist physicians. We are also looking for a pediatrician with an interest in palliative care to represent the pediatric interests among SHM members.

Since the first meeting in August our members have been developing a plan to achieve our identified goals. While the plan is still early in its development, we have designed a multimodal approach that will rely on traditional CME meetings, print media, as well as electronic media.

The task force’s short-term goals include promoting best practices in palliative care via SHM communication vehicles. For example, we plan to propose a series of articles for the forthcoming Journal of Hospital Medicine to highlight key issues in palliative care.

The 2006 SHM Annual Meeting will feature two workshops with a palliative care focus. One workshop will discuss how to build the case for a palliative care service; the other will address issues in pain management for hospitalized patients. We will learn from the 2006 experience as we look toward the 2007 SHM Annual Meeting in Texas. An electronic CME module is also under development.

Finally, we are planning an electronic compendium of resources and tools for practicing high-quality palliative care. Although the format has not been finalized, the concept is to provide resources that will make caring for palliative care patients as easy as possible.

While we are pleased with the progress of the task force to date, there is still much to do. Hospital medicine physicians can and should serve as leaders to improve palliative care. Traditional medical training focuses our efforts and thoughts of curing and preventing. We’ve all felt the exhilaration of making a life-saving diagnosis on the young, otherwise healthy patient; however, just as there are times to look for a cure at all costs, there are also times when we must treat our patients’ symptoms at all costs.

Often traditional medical training doesn’t provide us with the tools we need to best care for our patients and their families when palliative care goals become the priority. We hope this task force will raise the visibility of palliative care within SHM and provide the opportunities and tools needed for us, as hospital medicine providers, to offer the best palliative care possible to our patients. If successful, we’ll feel the deep personal satisfaction and self-reward of helping a patient and their family transition from hopes of a cure to comfort in the knowledge that their symptoms and needs will be cared for.

Interested in joining the task force or participating in a related work group? Contact Chad Whelan at cwhelan@medicine.bsd.uchicago.edu.

The Stroke Resource Room

SHM’s Web site features stroke information on call

Online resource rooms comprise an innovative venue within the SHM Web site to focus on essential topics from the forthcoming core curriculum. Specifically, the Web-based resource rooms organize expert opinions, evidence-based literature, clinical tools and guidelines, and recommendations about essential topics in hospital medicine. Initial areas of development include the DVT and stroke resource rooms, with ongoing efforts in other areas including geriatrics, antimicrobial resistance, congestive heart failure, and glycemic control. These interactive rooms help connect hospitalists to information, content experts, and each other.

The Stroke Imperative

Stroke is the third leading cause of death in the United States and a common admission diagnosis. Cerebrovascular disease is a field of great complexity and rapid advance. There is great pressure on the practicing hospitalist to have both a base knowledge of the approach to the patient with stroke as well as an understanding of current best practice.

Traditional internal medicine residencies may not fully prepare one for hospitalist practice. Many patients seen by hospitalists have diagnoses that were managed by internal medicine subspecialties in the past. Most hospitalists feel comfortable managing straightforward gastrointestinal bleeds, myocardial infarctions, and renal failure without consultation. Neurologic cases are somewhat different.

Most medicine residents have rotated on a neurology service, but that limited experience is frequently insufficient in preparing physicians for their future experience as hospitalists. While neurology residencies include one year of internal medicine, the two diverge dramatically afterward. Practitioners of both internal medicine and neurology frequently feel that they speak a different language from one another.

Particularly in the community setting, hospitalists manage the bulk of neurology patients either with or without neurologic consultation. The reasons for this are varied, including poor inpatient reimbursement for neurologists and a tradition of nonaggressive approaches to stroke care.1

The Opportunity

Realizing the need to provide direct access to important information about inpatient stroke management, SHM convened a stroke advisory board, including general hospitalists, a neurologist, and members of the education committee. SHM and Boehringer-Ingelheim provided funding for the resource room through educational funds and an unrestricted grant, respectively.

There is great pressure on the practicing hospitalist to have both a base knowledge of the approach to the patient with stroke as well as an understanding of current best practice.

Stroke Resource Room Content

The Stroke Resource Room is patterned after the template of the DVT Resource Room; the idea being that a standardized format will allow easy navigation and maximal utility. David Likosky, MD, served as content editor, Sandeep Sachdeva, MD, as quality editor, Alpesh Amin, MD as education editor, and Jason Stein, MD, as managing editor.

The rooms are structured to facilitate access to specific types of information. Whether one is looking for the details of a certain study, slide sets to help teach residents, or for input on how to approach a difficult patient, that resource should be readily available. The main sections of the room are summarized below.

The “Awareness” area on the main page of the Stroke Resource Room defines the effects of stroke as well as the hospitalists’ scope of practice.

A separate debate is ongoing within neurology about who should be responsible for the inpatient management of stroke. Interestingly, much of this is about whether general neurologists or vascular/stroke neurologists should primarily manage these patients. One such article referred to the brain as “… the Rolls Royce of the human body” going on to ask, “Would you want your Rolls Royce to be serviced by any ordinary mechanic, who takes care of all kinds of automobiles?”2 Many hospitalists find this argument less than compelling given how difficult it can be in many communities to get a neurologist much less a “vascular neurologist” to see an inpatient.

The “Evidence” section consists of two main parts with the goal of providing a one-stop shop for stroke care literature. The first is a set of links to articles reviewed by the ACP journal club. The second is a concise list of landmark trials, such as the Heparin Acute Embolic Stroke HAEST) trial, which compared low molecular weight heparin versus aspirin in patients with acute stroke and atrial fibrillation.3 These articles help answer questions that come up commonly in clinical practice.

The Experience link capitalizes on the Internet’s ability to disseminate information. There are a limited number of protocols and order sets for ischemic and hemorrhagic stroke available. One can download these and, perhaps more importantly, submit one’s own—including comments on what about that particular tool has been valuable.

Finally, the “Ask the Expert” section features an interactive venue for interacting with a panel of neurologists and neurocritical care physicians. This section answers the more common and more difficult clinical questions in a shared forum. Supportive evidence is cited, with the knowledge that much of stroke care remains in the realm of standard of practice.

The “Improve” section reflects the other roles of hospitalists, such as hospital leader. The three current links include a PowerPoint primer on quality improvement. In addition, there are links to the “Get with the Guidelines” program from the American Stroke Association. This is a continuous quality improvement program focusing on care team protocols and outcome measurement. The final linked site is to the criteria for the disease specific accreditation program from JCAHO. This national effort may drive where patients receive their care for certain conditions.

The “Educate” section caters to multiple audiences. The academic hospitalist may find the “Teaching Pearls” section helpful, as well as the slide sets from the International Stroke Conference and StrokeSTOP, which is aimed at medical students. The patient education links contain a wealth of quality information. The “Professional Development” subsection contains sources for audio lectures with slide sets as well as case presentations and NIH stroke scale training—all with free CME hours. A chapter on stroke from the SHM’s forthcoming core competencies is included as well.

Moving Forward

One of the advantages of an Internet-based resource is the ability to be easily modified. A progressively more robust database will be developed over time as questions are answered in the “Ask the Expert” section and as participants share their stroke care protocols.

The Stroke Resource Room is an excellent forum to improve clinical care and form the basis for future SHM workshops, lectures, and to review articles. By building our collective knowledge, we will be limited only by the energy we put into the adding to and using available information and our desire to apply that energy to patient care.

References

1. Likosky DJ, Amin AN. Who will care for our hospitalized patients? Stroke. 2005;36(6): 1113-1114.
2. Caplan L. Stroke is best managed by neurologists. Stroke. 2003;34(11):2763.
3. Berge E, Abdelnoor M, Nakstad PH, et al. Low molecular-weight heparin versus aspirin in patients with acute ischaemic stroke and atrial fibrillation: a double-blind randomized study. HAEST Study Group. Lancet. 2000;355(9211):1205-1210.

Secure the Future

Encourage trainees to consider lifelong careers in hospital medicine

By Vineet Arora, MD, MA, and Margaret C. Fang, MD, MPH, co-chairs of SHM’s Young Physicians Section

Interest in hospital medicine is booming, and it is estimated that the number of hospitalists in the United States is estimated will exceed the number of cardiologists in the near future. Yet, many graduating residents view hospital medicine as a temporary job where they can take time off and work before going on to a subspecialty fellowship. Others perceive hospitalists as “super-residents” susceptible to burnout, and therefore do not consider hospital medicine a sustainable career option. These perceptions may contribute to a high turnover of hospitalists and compromise the accumulation of enough inpatient experience to accomplish many of the benefits associated with the use of hospitalists, including shorter lengths of stay and comparable—if not better—quality of care.

To ensure recruitment and retention of the best and brightest trainees, it’s important to consider ways to educate and encourage them to consider a career in hospital medicine as a rewarding lifelong career. Below, we discuss strategies to encourage trainees to pursue a lifelong career in hospital medicine.

Showcase Your Clinical Work

First, consider your everyday practice an excellent way to showcase the often-exciting world of inpatient medicine. Preclinical students often cherish any opportunity to interact with patients. Inviting first- or second-year medical students to accompany you on rounds is an excellent opportunity to teach clinical medicine and physical exam skills, and a good way to influence their career choice early in their medical career.

If you’re in an academic medical center, accessing preclinical students is as easy as approaching students in an internal medicine interest group or volunteering as a preceptor for a physical diagnosis course for preclinical students. In fact, hospitalists are often acknowledged as some of the best teachers and are highly accessible because of their inpatient duties.

Community-based hospitalists also can provide valuable career advice and opportunities, particularly in exposing students to real-life career experiences often not covered through traditional medical school training. One way for a community-based hospitalist to become involved is to host preclinical students over the summer by contacting a local medical school dean’s office and volunteering as a summer preceptor for interested preclinical students. Your alma mater may be particularly responsive. Or, contact interest groups in internal medicine, family medicine, or pediatrics through the state or local leaders of the American College of Physicians, the American Academy of Family Physicians, and the American Academy of Pediatrics.

Explain Your Nonclinical Work

It’s important to explain your nonclinical roles to residency trainees. Hospitalists increasingly take on numerous administrative, educational, and leadership roles and responsibilities. Whether you are leading a quality improvement effort, interfacing with hospital operations, or running a medical student clerkship, it is crucial that physicians-in-training understand the diverse opportunities within hospital medicine to achieve a healthy work-life balance and avoid clinical burnout.

If you are involved with quality improvement projects at your institution, enlist the help of an interested resident or student. Because student rotations are frequent, their prior experience may be scant and their time limited. So make sure the projects have definite goals and are easily accomplished. Ensure that the projects provide reasonable educational value and experience within a finite time. Lay out explicit goals at the beginning of the project, ask for frequent updates, and then recap the experience and any concrete accomplishments to provide structure and expectations for the process.

For example, the University of California at San Francisco Hospitalist Group is spearheading an educational initiative in which residents learn about both the theory and practice of quality improvement through choosing a project and working with a mentor to design, implement, and measure the results of a quality improvement initiative.

Share Your Passion

In addition to showcasing your clinical and nonclinical activities, share your passion about hospital medicine. Reflect on the reasons you entered hospital medicine, as well as your thoughts on the pros and cons of the field. Perhaps you were drawn to hospital medicine because of a desire to take care of acutely ill patients, or to work on improving the quality of a medical system, or because of a more controllable work schedule with competitive compensation.

In some cases, it may have been a particular interest in medical ethics, palliative care, geriatrics, or perioperative care. Sharing your enthusiasm is the best way to cultivate reciprocal interest. Medical students and residents closely observe your attitudes toward your career, your job satisfaction, and your work-life balance. In addition to mentoring those already entering a medical career, there are endless opportunities to outreach to younger students, including those in high school and college. Many local schools and community organizations offer mentorship programs to area students. Engaging in an informal discussion about your career at a social or community event with younger students can be incredibly rewarding. Younger students often lack realistic career experiences and access to career-specific role models on which to base informed decisions. Although they may express an interest in science or medicine, they may not know how long the training process is or the importance of good grades.

Take a moment to inquire about career interests and explain what a hospitalist is; this can be invaluable in promoting understanding and cultivating interest into the field. More structured interactions with hospitalists can also prepare students for successful entry into the medical field. The University of Chicago Hospitalists, for example, host high-achieving Chicago public school juniors in a summer clinical and research enrichment program in hospital-based medicine called TEACH Research.

Offer Advice and Assistance

Finding your first job can be a nerve-racking situation. Sharing your advice on the process with trainees is always appreciated. For instance, they are interested in hearing how you decided to become a hospitalist and what you did to secure your position.

Offer to meet with them and review their career interests, goals, and curriculum vitae. If you hear of job openings and opportunities, inform the community of trainees by contacting program directors or chief residents at residency programs. Many residency program directors showcase available opportunities in their house-staff office or direct such opportunities to interested residents. Some residency programs invite community-based physicians to give residents insight on securing their first job. This process is particularly foreign to medical trainees who have never had to negotiate such things as benefit packages, compensation, or call schedule. Your candid thoughts on what to expect and how to approach the process are invaluable.

Again, approaching the residency program where you trained is a good starting point. Alternatively, you can locate a nearby residency through the Fellowship and Residency Electronic Interactive Database database offered by the American Medical Association (www.ama-assn.org/vapp/freida/srch/).

Finally, if you know any trainees interested in hospital medicine,encourage them to attend the SHM’s local or national meetings. The annual meeting is an excellent place for medical trainees to hear the latest research and innovations, learn about advanced training and job opportunities, network, and connect with mentors through the Mentorship Breakfast. For the last two years, the Young Physicians Section has organized a Forum for Early Career Hospitalists where we addressed different career paths in hospital medicine and conducted research during training. Continued growth in our field depends on promoting hospital medicine as a vital, sustainable career.

Busy Summer for HQPS

The Health Quality and Patient Safety Committee (HQPS) has developed an array of initiatives to support SHM members in the development, implementation, and evaluation of quality and system improvements at their institutions. Educational programming, tools, and resources are being developed for four specific content areas including prevention of VTE, improving the discharge process, glycemic control, and improving outcomes for hospitalized heart failure patients.

HQPS members and Course Directors Greg Maynard, MD, and Tosha Wetterneck, MD, are developing a quality precourse for the 2006 SHM Annual Meeting. The educational goal for the precourse will be to enable hospitalists to become leaders in quality and safety through the effective implementation of evidence-based, high reliability interventions. Precourse participants will actively participate in small groups to apply techniques for designing, implementing, and evaluating quality improvement projects to address a specific improvement need in one of four areas: heart failure care, glycemic control, and preventing VTE in the hospital or the discharge process. Registration for this precourse will begin in November and space will be limited. Plan to register early.

In June, HQPS convened a multidisciplinary, multiagency Heart Failure Advisory Board to guide the development of a clinical guidelines implementation toolkit (CGIT), resource room, and CME modules related to implementing best practices for care of patients with heart-failure. The advisory board has representatives from several organizations and allied health professions, including the American College of Cardiology, American Medical Directors Association, American Hospital Association, Case Managers Society of America, American Association of Heart Failure Nurses, American Society of Health-System Pharmacists, American Association of Critical Care Nurses, National Association of Social Workers and the Heart Failure Society of America. Currently, the advisory board is completing a needs assessment and will begin development on the CGIT, resource room and CME modules next month.

In July, in collaboration with the Education Committee and SHM staff, HQPS launched the SHM VTE Resource Room (www.hospitalmedicine.org/AM/Template.cfm?Section=Quality_Improvement_Resource_Rooms1&Template=/CM/HTMLDisplay.cfm&ContentID=6312). The resource room provides users with a workbook, or step-wise process to assess the need for VTE prevention, advocate for local improvements, and implement and evaluate a VTE prevention program. The resource room also provides a useful review of the literature, an “Ask the Expert” forum, slide sets, and bedside teaching tools.

In August, the SHM Executive Committee approved the SHM Discharge Planning Checklist developed by HQPS under the direction of Dennis Manning, MD. This discharge planning checklist and a white paper on guidance for its implementation will be available to members in the near future.

Interested in learning more about these initiatives or becoming involved in an HQPS workgroup? Contact Lakshmi Halasyamani, MD, HQPS chair, at HalasyaL@trinity-health.org.

Hartford Grants Awarded

SHM presents Hartford Foundation grant funds to hospitalists for QI demo project

By Kathleen K. Frampton, RN, MPH

Shm remains committed to expanding its efforts to improve inpatient care for older patients. The John A. Hartford Foundation has generously awarded approximately $370,000 to SHM in support of its focus on the geriatric population. This funding will assist SHM in its endeavors related to educational programs and products, hospitalist leadership training, and quality improvement projects. In light of this, SHM allocated a portion of these Hartford grant funds to study a critical aspect of elderly patient care, safety-care transitions.

A competitive request for the proposal (RFP) process was conducted to solicit interest from healthcare institutional providers and SHM members willing to serve as the principle investigator in their work setting. The RFP delineated the requirements for a hospital to serve as a designated study site to implement a discharge planning intervention from hospital-based care to community-based care for elderly patients and to evaluate the facilitating factors, barriers to implementation and outcomes associated with the new approach.

All research proposals submitted by hospitals were evaluated and scored against established criteria. Qualifying hospital finalists were reviewed by a panel consisting of members of three standing SHM Committees: Education, Hospital Quality and Patient Safety, and Research and Executive. In July 2005, this panel selected three hospitals to receive funding for this initiative: Johns Hopkins-Bayview, Baltimore, Md.; Northeast Medical Center, Concord, N.C.; and Geisinger Health System, Danville, Penn.

Johns Hopkins-Bayview (coordinating site): A 355-bed community-based facility located in southeast Baltimore with academic affiliations and approximately 25% of patients over age 65. The hospitalist service consists of nine physicians, five physician assistants, and three nurse practitioners.

Northeast Medical Center: A 457-bed, private, nonprofit community-based facility located in the Charlotte Region with a residency training program and 36% of patients over age 65. The hospitalist service consists of 16 physicians and 24/7 intensivist coverage.

Geisinger Health System: A 366-bed facility and Level 1 Trauma Center, private, nonprofit community based system located in north central Pennsylvania with a residency training program and 70% of patients over age 65. The hospitalist service is staffed by 15 physicians (10 full-time employees).

The QI Demonstration Project will run for 18 months and, according to Tina Budnitz, MPH, SHM senior advisor for planning and development, the study “represents new territory for both SHM and other professional societies … . We have moved beyond developing a best practice to use in the clinical setting to how you can actually change the system so that best practices can be successfully implemented … . It is the intention of SHM to focus on safe practice interventions that can be generalized to other settings.”

Budnitz also explained that near completion of the project SHM plans to convene the advisory board, grantee project teams, representatives of the Hartford Foundation, and the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) to review the data from the demonstration project and design a larger scale quality improvement program.

“Our grantees will work with the SHM Advisory Board to develop a comprehensive toolkit, which will document the lessons learned during the implementation process and any other resources that facilitate adaptation and/or adoption of these safe practice interventions,” explains Budnitz.

Care Transitions in the Treatment of the Elderly

According to the Institute of Medicine (IOM), the healthcare system is poorly organized to meet its current challenges. The delivery of care is often overly complex and uncoordinated, requiring steps and patient hand-offs that slow care and decrease rather than improve patient safety.

An IOM seminal report published in 2001, Crossing the Quality Chasm: A New Health System for the 21st Century, emphasizes that cumbersome processes waste resources, leave unaccountable voids in coverage, lead to loss of information, and fail to build on the strengths of all professionals involved to ensure that care is appropriate, timely, and safe. Right before and after discharge, there often is no one clearly in charge of the transition whom the patient may contact for guidance. Patients are often instructed to contact their primary care provider for follow-up issues or questions, whether or not the primary care provider had been involved in the hospitalization.

A recent study supported by the Agency for Healthcare Research and Quality (AHRQ) showed that high-risk patient targeting, better communications, and better coordination of care and follow-up could potentially prevent some readmissions when transitioning patients from hospital to home.

In 2002, the American Geriatric Society (AGS) issued a Position Statement, Improving the Quality of Transitional Care for Persons with Complex Care Needs, which stressed that both the “sending” and “receiving” health professionals bear responsibility and accountability in this phase. Successful transitions require that there be both a uniform plan of care and procedure for communicating the following:

1. An accessible medical record that contains a current problem list;
2. A medication regimen;
3. A list of allergies;
4. Advance directives;
5. Baseline physical and cognitive function; and
6. Contact information for all professional and informal care providers.

Also, input must be solicited from informal care providers who are involved in the execution of the plan of care. The AGS recommends the use of a “coordinating” health professional who oversees both the sending and receiving aspects of the transition. This professional should be skilled in the identification of health status, assessment and management of multiple chronic conditions, managing medications, and collaboration with members of the interdisciplinary team and caregivers.

The QI Demonstration Project

According to SHM Immediate Past-President Jeanne Huddleston, MD, SHM has structured this demonstration project so that the three study sites in the Hartford Grant Group will implement identical clinical tools while they employ unique processes and procedures at each of the individual sites.

“The what needs to be in common across sites, but the how and who in the implementation will be individually tailored to each specific hospital environment,” she explains.

This is a real strength of the study because standardized interventions can be studied in varied and representative test environments. Dr. Huddleston also stresses that, “SHM envisions its role in quality management to be in the actual implementation realm—rather than in the development of new clinical guidelines. SHM seeks to know whether hospitalists [use] the same tools at different sites and understand their impact at each site.”

The patient care domains selected as a focus for the safe practice implementation tools for the care transition process are:

1. Communications;
2. Medication reconciliation; and
3. Functional status.

Communication tools will be developed for primary care physicians, patients, and their support systems so that important clinical information is transmitted during the discharge process. The implementation tools designed for medication reconciliation will be employed by physicians, care managers, or pharmacists in the hospital. Transmitting the medication regimen is widely recognized as an error-prone element of care. These specific implementation tools will include a method to review and verify any dose/frequency changes of medications that the patient was taking upon admission, as well as those that were added or discontinued during the inpatient episode. Because patient functional status is a critical issue in discharge planning, detailed tools will also be created to standardize content for risk assessment and evaluation of the types of assistance needed for patients to resume activities of daily living.

The demonstration project will also utilize specific metrics to measure patient outcomes as well as the effect that these safe practices have on the discharge and care transition processes. The three study sites will measure referring physician satisfaction with the adequacy of post-hospitalization follow-up information, the accuracy of medication reconciliation, readmission rates, and patient understanding of their treatment plan and medication regimen.

QI Requires Expert Change Management

Hospitalists recognize that the challenge of patient safety is linked to the challenge of organizational change. Patient safety initiatives can succeed only to the extent to which healthcare organizations recognize the need for and develop the means to implement the organizational changes. According to the AHRQ, systemwide improvements in patient safety are possible only if there are coordinated changes in multiple components—clinical procedures, attitudes and behaviors of care providers, incentive systems, coordination structures and processes, patterns of interactions among care providers, and organizational culture.

Senior leadership must play an active role in establishing patient safety as a priority, and staff involved directly in providing care must actively participate in implementing change. The likelihood of successful implementation of even simple change requires multiple tactics or many bullets directed at the same target. Additionally, it is critical to redesign the roles of healthcare workers at the point of care to accommodate the necessary changes and to retrain them to fulfill these roles.

Hospitalists Prepare to Lead

Identifying the facilitating factors and barriers to improvement is essential to effect change because it helps ensure success. It’s also crucial to match the patient safety goals with the change strategies and tactics. Otherwise, mismatches can lead to unintended consequences that will hinder continuous improvements such as employee skepticism, frustration of safety champions, and mislearning or unnecessary ”workarounds“ by staff.

SHM sees this QI Demonstration Project as critical to assisting institutions in the design, implementation, and evaluation of QI programs and systemwide interventions with effectiveness and value. These findings should equip hospitalists with vital tools necessary to provide essential leadership in meeting their institution’s quality and patient safety goals. TH

Writer Kathleen Frampton is based in Columbia, Md

Hospitalists lead, coordinate, and participate in initiatives to improve the identification and treatment of patients and families in need of palliative care. Yet we often lack the knowledge and skills necessary to provide outstanding palliative care; we may also lack the comfort level we need to take care of patients at that stage of illness.

Steve Pantilat, MD, SHM president and member of the SHM Education Committee, established the Palliative Care Task Force to identify and create opportunities to improve palliative care in the field of hospital medicine. The Palliative Care Task Force had its inaugural meeting in August. Led by founder Dr. Pantilat and Chad Whelan, MD, Palliative Care Task Force chair, the task force established the following goals:

1. Promote palliative care as an important skill and activity for hospital medicine physicians and providers;
2. Identify and create palliative-care-focused educational activities for hospital medicine physicians and other key stakeholders within hospital medicine;
3. Advocate for the creation and or support of hospital-based palliative care services;
4. Promote the use of best practices in palliative care; and
5. Develop a core community of hospital medicine physicians dedicated to improving our understanding of palliative care.

Our current task force membership is small but energetic. We actively recruit members, particularly nonphysicians and non-SHM members. Palliative care is a multidisciplinary field, and we hope the Palliative Care Task Force membership will reflect this diversity. Potential areas of growth include pharmacists, nurses, social workers, spiritual care providers, and nonhospitalist physicians. We are also looking for a pediatrician with an interest in palliative care to represent the pediatric interests among SHM members.

Since the first meeting in August our members have been developing a plan to achieve our identified goals. While the plan is still early in its development, we have designed a multimodal approach that will rely on traditional CME meetings, print media, as well as electronic media.

The task force’s short-term goals include promoting best practices in palliative care via SHM communication vehicles. For example, we plan to propose a series of articles for the forthcoming Journal of Hospital Medicine to highlight key issues in palliative care.

The 2006 SHM Annual Meeting will feature two workshops with a palliative care focus. One workshop will discuss how to build the case for a palliative care service; the other will address issues in pain management for hospitalized patients. We will learn from the 2006 experience as we look toward the 2007 SHM Annual Meeting in Texas. An electronic CME module is also under development.

Finally, we are planning an electronic compendium of resources and tools for practicing high-quality palliative care. Although the format has not been finalized, the concept is to provide resources that will make caring for palliative care patients as easy as possible.

While we are pleased with the progress of the task force to date, there is still much to do. Hospital medicine physicians can and should serve as leaders to improve palliative care. Traditional medical training focuses our efforts and thoughts of curing and preventing. We’ve all felt the exhilaration of making a life-saving diagnosis on the young, otherwise healthy patient; however, just as there are times to look for a cure at all costs, there are also times when we must treat our patients’ symptoms at all costs.

Often traditional medical training doesn’t provide us with the tools we need to best care for our patients and their families when palliative care goals become the priority. We hope this task force will raise the visibility of palliative care within SHM and provide the opportunities and tools needed for us, as hospital medicine providers, to offer the best palliative care possible to our patients. If successful, we’ll feel the deep personal satisfaction and self-reward of helping a patient and their family transition from hopes of a cure to comfort in the knowledge that their symptoms and needs will be cared for.

Interested in joining the task force or participating in a related work group? Contact Chad Whelan at cwhelan@medicine.bsd.uchicago.edu.

The Stroke Resource Room

SHM’s Web site features stroke information on call

Online resource rooms comprise an innovative venue within the SHM Web site to focus on essential topics from the forthcoming core curriculum. Specifically, the Web-based resource rooms organize expert opinions, evidence-based literature, clinical tools and guidelines, and recommendations about essential topics in hospital medicine. Initial areas of development include the DVT and stroke resource rooms, with ongoing efforts in other areas including geriatrics, antimicrobial resistance, congestive heart failure, and glycemic control. These interactive rooms help connect hospitalists to information, content experts, and each other.

The Stroke Imperative

Stroke is the third leading cause of death in the United States and a common admission diagnosis. Cerebrovascular disease is a field of great complexity and rapid advance. There is great pressure on the practicing hospitalist to have both a base knowledge of the approach to the patient with stroke as well as an understanding of current best practice.

Traditional internal medicine residencies may not fully prepare one for hospitalist practice. Many patients seen by hospitalists have diagnoses that were managed by internal medicine subspecialties in the past. Most hospitalists feel comfortable managing straightforward gastrointestinal bleeds, myocardial infarctions, and renal failure without consultation. Neurologic cases are somewhat different.

Most medicine residents have rotated on a neurology service, but that limited experience is frequently insufficient in preparing physicians for their future experience as hospitalists. While neurology residencies include one year of internal medicine, the two diverge dramatically afterward. Practitioners of both internal medicine and neurology frequently feel that they speak a different language from one another.

Particularly in the community setting, hospitalists manage the bulk of neurology patients either with or without neurologic consultation. The reasons for this are varied, including poor inpatient reimbursement for neurologists and a tradition of nonaggressive approaches to stroke care.1

The Opportunity

Realizing the need to provide direct access to important information about inpatient stroke management, SHM convened a stroke advisory board, including general hospitalists, a neurologist, and members of the education committee. SHM and Boehringer-Ingelheim provided funding for the resource room through educational funds and an unrestricted grant, respectively.

There is great pressure on the practicing hospitalist to have both a base knowledge of the approach to the patient with stroke as well as an understanding of current best practice.

Stroke Resource Room Content

The Stroke Resource Room is patterned after the template of the DVT Resource Room; the idea being that a standardized format will allow easy navigation and maximal utility. David Likosky, MD, served as content editor, Sandeep Sachdeva, MD, as quality editor, Alpesh Amin, MD as education editor, and Jason Stein, MD, as managing editor.

The rooms are structured to facilitate access to specific types of information. Whether one is looking for the details of a certain study, slide sets to help teach residents, or for input on how to approach a difficult patient, that resource should be readily available. The main sections of the room are summarized below.

The “Awareness” area on the main page of the Stroke Resource Room defines the effects of stroke as well as the hospitalists’ scope of practice.

A separate debate is ongoing within neurology about who should be responsible for the inpatient management of stroke. Interestingly, much of this is about whether general neurologists or vascular/stroke neurologists should primarily manage these patients. One such article referred to the brain as “… the Rolls Royce of the human body” going on to ask, “Would you want your Rolls Royce to be serviced by any ordinary mechanic, who takes care of all kinds of automobiles?”2 Many hospitalists find this argument less than compelling given how difficult it can be in many communities to get a neurologist much less a “vascular neurologist” to see an inpatient.

The “Evidence” section consists of two main parts with the goal of providing a one-stop shop for stroke care literature. The first is a set of links to articles reviewed by the ACP journal club. The second is a concise list of landmark trials, such as the Heparin Acute Embolic Stroke HAEST) trial, which compared low molecular weight heparin versus aspirin in patients with acute stroke and atrial fibrillation.3 These articles help answer questions that come up commonly in clinical practice.

The Experience link capitalizes on the Internet’s ability to disseminate information. There are a limited number of protocols and order sets for ischemic and hemorrhagic stroke available. One can download these and, perhaps more importantly, submit one’s own—including comments on what about that particular tool has been valuable.

Finally, the “Ask the Expert” section features an interactive venue for interacting with a panel of neurologists and neurocritical care physicians. This section answers the more common and more difficult clinical questions in a shared forum. Supportive evidence is cited, with the knowledge that much of stroke care remains in the realm of standard of practice.

The “Improve” section reflects the other roles of hospitalists, such as hospital leader. The three current links include a PowerPoint primer on quality improvement. In addition, there are links to the “Get with the Guidelines” program from the American Stroke Association. This is a continuous quality improvement program focusing on care team protocols and outcome measurement. The final linked site is to the criteria for the disease specific accreditation program from JCAHO. This national effort may drive where patients receive their care for certain conditions.

The “Educate” section caters to multiple audiences. The academic hospitalist may find the “Teaching Pearls” section helpful, as well as the slide sets from the International Stroke Conference and StrokeSTOP, which is aimed at medical students. The patient education links contain a wealth of quality information. The “Professional Development” subsection contains sources for audio lectures with slide sets as well as case presentations and NIH stroke scale training—all with free CME hours. A chapter on stroke from the SHM’s forthcoming core competencies is included as well.

Moving Forward

One of the advantages of an Internet-based resource is the ability to be easily modified. A progressively more robust database will be developed over time as questions are answered in the “Ask the Expert” section and as participants share their stroke care protocols.

The Stroke Resource Room is an excellent forum to improve clinical care and form the basis for future SHM workshops, lectures, and to review articles. By building our collective knowledge, we will be limited only by the energy we put into the adding to and using available information and our desire to apply that energy to patient care.

References

1. Likosky DJ, Amin AN. Who will care for our hospitalized patients? Stroke. 2005;36(6): 1113-1114.
2. Caplan L. Stroke is best managed by neurologists. Stroke. 2003;34(11):2763.
3. Berge E, Abdelnoor M, Nakstad PH, et al. Low molecular-weight heparin versus aspirin in patients with acute ischaemic stroke and atrial fibrillation: a double-blind randomized study. HAEST Study Group. Lancet. 2000;355(9211):1205-1210.

Secure the Future

Encourage trainees to consider lifelong careers in hospital medicine

By Vineet Arora, MD, MA, and Margaret C. Fang, MD, MPH, co-chairs of SHM’s Young Physicians Section

Interest in hospital medicine is booming, and it is estimated that the number of hospitalists in the United States is estimated will exceed the number of cardiologists in the near future. Yet, many graduating residents view hospital medicine as a temporary job where they can take time off and work before going on to a subspecialty fellowship. Others perceive hospitalists as “super-residents” susceptible to burnout, and therefore do not consider hospital medicine a sustainable career option. These perceptions may contribute to a high turnover of hospitalists and compromise the accumulation of enough inpatient experience to accomplish many of the benefits associated with the use of hospitalists, including shorter lengths of stay and comparable—if not better—quality of care.

To ensure recruitment and retention of the best and brightest trainees, it’s important to consider ways to educate and encourage them to consider a career in hospital medicine as a rewarding lifelong career. Below, we discuss strategies to encourage trainees to pursue a lifelong career in hospital medicine.

Showcase Your Clinical Work

First, consider your everyday practice an excellent way to showcase the often-exciting world of inpatient medicine. Preclinical students often cherish any opportunity to interact with patients. Inviting first- or second-year medical students to accompany you on rounds is an excellent opportunity to teach clinical medicine and physical exam skills, and a good way to influence their career choice early in their medical career.

If you’re in an academic medical center, accessing preclinical students is as easy as approaching students in an internal medicine interest group or volunteering as a preceptor for a physical diagnosis course for preclinical students. In fact, hospitalists are often acknowledged as some of the best teachers and are highly accessible because of their inpatient duties.

Community-based hospitalists also can provide valuable career advice and opportunities, particularly in exposing students to real-life career experiences often not covered through traditional medical school training. One way for a community-based hospitalist to become involved is to host preclinical students over the summer by contacting a local medical school dean’s office and volunteering as a summer preceptor for interested preclinical students. Your alma mater may be particularly responsive. Or, contact interest groups in internal medicine, family medicine, or pediatrics through the state or local leaders of the American College of Physicians, the American Academy of Family Physicians, and the American Academy of Pediatrics.

Explain Your Nonclinical Work

It’s important to explain your nonclinical roles to residency trainees. Hospitalists increasingly take on numerous administrative, educational, and leadership roles and responsibilities. Whether you are leading a quality improvement effort, interfacing with hospital operations, or running a medical student clerkship, it is crucial that physicians-in-training understand the diverse opportunities within hospital medicine to achieve a healthy work-life balance and avoid clinical burnout.

If you are involved with quality improvement projects at your institution, enlist the help of an interested resident or student. Because student rotations are frequent, their prior experience may be scant and their time limited. So make sure the projects have definite goals and are easily accomplished. Ensure that the projects provide reasonable educational value and experience within a finite time. Lay out explicit goals at the beginning of the project, ask for frequent updates, and then recap the experience and any concrete accomplishments to provide structure and expectations for the process.

For example, the University of California at San Francisco Hospitalist Group is spearheading an educational initiative in which residents learn about both the theory and practice of quality improvement through choosing a project and working with a mentor to design, implement, and measure the results of a quality improvement initiative.

Share Your Passion

In addition to showcasing your clinical and nonclinical activities, share your passion about hospital medicine. Reflect on the reasons you entered hospital medicine, as well as your thoughts on the pros and cons of the field. Perhaps you were drawn to hospital medicine because of a desire to take care of acutely ill patients, or to work on improving the quality of a medical system, or because of a more controllable work schedule with competitive compensation.

In some cases, it may have been a particular interest in medical ethics, palliative care, geriatrics, or perioperative care. Sharing your enthusiasm is the best way to cultivate reciprocal interest. Medical students and residents closely observe your attitudes toward your career, your job satisfaction, and your work-life balance. In addition to mentoring those already entering a medical career, there are endless opportunities to outreach to younger students, including those in high school and college. Many local schools and community organizations offer mentorship programs to area students. Engaging in an informal discussion about your career at a social or community event with younger students can be incredibly rewarding. Younger students often lack realistic career experiences and access to career-specific role models on which to base informed decisions. Although they may express an interest in science or medicine, they may not know how long the training process is or the importance of good grades.

Take a moment to inquire about career interests and explain what a hospitalist is; this can be invaluable in promoting understanding and cultivating interest into the field. More structured interactions with hospitalists can also prepare students for successful entry into the medical field. The University of Chicago Hospitalists, for example, host high-achieving Chicago public school juniors in a summer clinical and research enrichment program in hospital-based medicine called TEACH Research.

Offer Advice and Assistance

Finding your first job can be a nerve-racking situation. Sharing your advice on the process with trainees is always appreciated. For instance, they are interested in hearing how you decided to become a hospitalist and what you did to secure your position.

Offer to meet with them and review their career interests, goals, and curriculum vitae. If you hear of job openings and opportunities, inform the community of trainees by contacting program directors or chief residents at residency programs. Many residency program directors showcase available opportunities in their house-staff office or direct such opportunities to interested residents. Some residency programs invite community-based physicians to give residents insight on securing their first job. This process is particularly foreign to medical trainees who have never had to negotiate such things as benefit packages, compensation, or call schedule. Your candid thoughts on what to expect and how to approach the process are invaluable.

Again, approaching the residency program where you trained is a good starting point. Alternatively, you can locate a nearby residency through the Fellowship and Residency Electronic Interactive Database database offered by the American Medical Association (www.ama-assn.org/vapp/freida/srch/).

Finally, if you know any trainees interested in hospital medicine,encourage them to attend the SHM’s local or national meetings. The annual meeting is an excellent place for medical trainees to hear the latest research and innovations, learn about advanced training and job opportunities, network, and connect with mentors through the Mentorship Breakfast. For the last two years, the Young Physicians Section has organized a Forum for Early Career Hospitalists where we addressed different career paths in hospital medicine and conducted research during training. Continued growth in our field depends on promoting hospital medicine as a vital, sustainable career.

Busy Summer for HQPS

The Health Quality and Patient Safety Committee (HQPS) has developed an array of initiatives to support SHM members in the development, implementation, and evaluation of quality and system improvements at their institutions. Educational programming, tools, and resources are being developed for four specific content areas including prevention of VTE, improving the discharge process, glycemic control, and improving outcomes for hospitalized heart failure patients.

HQPS members and Course Directors Greg Maynard, MD, and Tosha Wetterneck, MD, are developing a quality precourse for the 2006 SHM Annual Meeting. The educational goal for the precourse will be to enable hospitalists to become leaders in quality and safety through the effective implementation of evidence-based, high reliability interventions. Precourse participants will actively participate in small groups to apply techniques for designing, implementing, and evaluating quality improvement projects to address a specific improvement need in one of four areas: heart failure care, glycemic control, and preventing VTE in the hospital or the discharge process. Registration for this precourse will begin in November and space will be limited. Plan to register early.

In June, HQPS convened a multidisciplinary, multiagency Heart Failure Advisory Board to guide the development of a clinical guidelines implementation toolkit (CGIT), resource room, and CME modules related to implementing best practices for care of patients with heart-failure. The advisory board has representatives from several organizations and allied health professions, including the American College of Cardiology, American Medical Directors Association, American Hospital Association, Case Managers Society of America, American Association of Heart Failure Nurses, American Society of Health-System Pharmacists, American Association of Critical Care Nurses, National Association of Social Workers and the Heart Failure Society of America. Currently, the advisory board is completing a needs assessment and will begin development on the CGIT, resource room and CME modules next month.

In July, in collaboration with the Education Committee and SHM staff, HQPS launched the SHM VTE Resource Room (www.hospitalmedicine.org/AM/Template.cfm?Section=Quality_Improvement_Resource_Rooms1&Template=/CM/HTMLDisplay.cfm&ContentID=6312). The resource room provides users with a workbook, or step-wise process to assess the need for VTE prevention, advocate for local improvements, and implement and evaluate a VTE prevention program. The resource room also provides a useful review of the literature, an “Ask the Expert” forum, slide sets, and bedside teaching tools.

In August, the SHM Executive Committee approved the SHM Discharge Planning Checklist developed by HQPS under the direction of Dennis Manning, MD. This discharge planning checklist and a white paper on guidance for its implementation will be available to members in the near future.

Interested in learning more about these initiatives or becoming involved in an HQPS workgroup? Contact Lakshmi Halasyamani, MD, HQPS chair, at HalasyaL@trinity-health.org.

Hartford Grants Awarded

SHM presents Hartford Foundation grant funds to hospitalists for QI demo project

By Kathleen K. Frampton, RN, MPH

Shm remains committed to expanding its efforts to improve inpatient care for older patients. The John A. Hartford Foundation has generously awarded approximately $370,000 to SHM in support of its focus on the geriatric population. This funding will assist SHM in its endeavors related to educational programs and products, hospitalist leadership training, and quality improvement projects. In light of this, SHM allocated a portion of these Hartford grant funds to study a critical aspect of elderly patient care, safety-care transitions.

A competitive request for the proposal (RFP) process was conducted to solicit interest from healthcare institutional providers and SHM members willing to serve as the principle investigator in their work setting. The RFP delineated the requirements for a hospital to serve as a designated study site to implement a discharge planning intervention from hospital-based care to community-based care for elderly patients and to evaluate the facilitating factors, barriers to implementation and outcomes associated with the new approach.

All research proposals submitted by hospitals were evaluated and scored against established criteria. Qualifying hospital finalists were reviewed by a panel consisting of members of three standing SHM Committees: Education, Hospital Quality and Patient Safety, and Research and Executive. In July 2005, this panel selected three hospitals to receive funding for this initiative: Johns Hopkins-Bayview, Baltimore, Md.; Northeast Medical Center, Concord, N.C.; and Geisinger Health System, Danville, Penn.

Johns Hopkins-Bayview (coordinating site): A 355-bed community-based facility located in southeast Baltimore with academic affiliations and approximately 25% of patients over age 65. The hospitalist service consists of nine physicians, five physician assistants, and three nurse practitioners.

Northeast Medical Center: A 457-bed, private, nonprofit community-based facility located in the Charlotte Region with a residency training program and 36% of patients over age 65. The hospitalist service consists of 16 physicians and 24/7 intensivist coverage.

Geisinger Health System: A 366-bed facility and Level 1 Trauma Center, private, nonprofit community based system located in north central Pennsylvania with a residency training program and 70% of patients over age 65. The hospitalist service is staffed by 15 physicians (10 full-time employees).

The QI Demonstration Project will run for 18 months and, according to Tina Budnitz, MPH, SHM senior advisor for planning and development, the study “represents new territory for both SHM and other professional societies … . We have moved beyond developing a best practice to use in the clinical setting to how you can actually change the system so that best practices can be successfully implemented … . It is the intention of SHM to focus on safe practice interventions that can be generalized to other settings.”

Budnitz also explained that near completion of the project SHM plans to convene the advisory board, grantee project teams, representatives of the Hartford Foundation, and the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) to review the data from the demonstration project and design a larger scale quality improvement program.

“Our grantees will work with the SHM Advisory Board to develop a comprehensive toolkit, which will document the lessons learned during the implementation process and any other resources that facilitate adaptation and/or adoption of these safe practice interventions,” explains Budnitz.

Care Transitions in the Treatment of the Elderly

According to the Institute of Medicine (IOM), the healthcare system is poorly organized to meet its current challenges. The delivery of care is often overly complex and uncoordinated, requiring steps and patient hand-offs that slow care and decrease rather than improve patient safety.

An IOM seminal report published in 2001, Crossing the Quality Chasm: A New Health System for the 21st Century, emphasizes that cumbersome processes waste resources, leave unaccountable voids in coverage, lead to loss of information, and fail to build on the strengths of all professionals involved to ensure that care is appropriate, timely, and safe. Right before and after discharge, there often is no one clearly in charge of the transition whom the patient may contact for guidance. Patients are often instructed to contact their primary care provider for follow-up issues or questions, whether or not the primary care provider had been involved in the hospitalization.

A recent study supported by the Agency for Healthcare Research and Quality (AHRQ) showed that high-risk patient targeting, better communications, and better coordination of care and follow-up could potentially prevent some readmissions when transitioning patients from hospital to home.

In 2002, the American Geriatric Society (AGS) issued a Position Statement, Improving the Quality of Transitional Care for Persons with Complex Care Needs, which stressed that both the “sending” and “receiving” health professionals bear responsibility and accountability in this phase. Successful transitions require that there be both a uniform plan of care and procedure for communicating the following:

1. An accessible medical record that contains a current problem list;
2. A medication regimen;
3. A list of allergies;
4. Advance directives;
5. Baseline physical and cognitive function; and
6. Contact information for all professional and informal care providers.

Also, input must be solicited from informal care providers who are involved in the execution of the plan of care. The AGS recommends the use of a “coordinating” health professional who oversees both the sending and receiving aspects of the transition. This professional should be skilled in the identification of health status, assessment and management of multiple chronic conditions, managing medications, and collaboration with members of the interdisciplinary team and caregivers.

The QI Demonstration Project

According to SHM Immediate Past-President Jeanne Huddleston, MD, SHM has structured this demonstration project so that the three study sites in the Hartford Grant Group will implement identical clinical tools while they employ unique processes and procedures at each of the individual sites.

“The what needs to be in common across sites, but the how and who in the implementation will be individually tailored to each specific hospital environment,” she explains.

This is a real strength of the study because standardized interventions can be studied in varied and representative test environments. Dr. Huddleston also stresses that, “SHM envisions its role in quality management to be in the actual implementation realm—rather than in the development of new clinical guidelines. SHM seeks to know whether hospitalists [use] the same tools at different sites and understand their impact at each site.”

The patient care domains selected as a focus for the safe practice implementation tools for the care transition process are:

1. Communications;
2. Medication reconciliation; and
3. Functional status.

Communication tools will be developed for primary care physicians, patients, and their support systems so that important clinical information is transmitted during the discharge process. The implementation tools designed for medication reconciliation will be employed by physicians, care managers, or pharmacists in the hospital. Transmitting the medication regimen is widely recognized as an error-prone element of care. These specific implementation tools will include a method to review and verify any dose/frequency changes of medications that the patient was taking upon admission, as well as those that were added or discontinued during the inpatient episode. Because patient functional status is a critical issue in discharge planning, detailed tools will also be created to standardize content for risk assessment and evaluation of the types of assistance needed for patients to resume activities of daily living.

The demonstration project will also utilize specific metrics to measure patient outcomes as well as the effect that these safe practices have on the discharge and care transition processes. The three study sites will measure referring physician satisfaction with the adequacy of post-hospitalization follow-up information, the accuracy of medication reconciliation, readmission rates, and patient understanding of their treatment plan and medication regimen.

QI Requires Expert Change Management

Hospitalists recognize that the challenge of patient safety is linked to the challenge of organizational change. Patient safety initiatives can succeed only to the extent to which healthcare organizations recognize the need for and develop the means to implement the organizational changes. According to the AHRQ, systemwide improvements in patient safety are possible only if there are coordinated changes in multiple components—clinical procedures, attitudes and behaviors of care providers, incentive systems, coordination structures and processes, patterns of interactions among care providers, and organizational culture.

Senior leadership must play an active role in establishing patient safety as a priority, and staff involved directly in providing care must actively participate in implementing change. The likelihood of successful implementation of even simple change requires multiple tactics or many bullets directed at the same target. Additionally, it is critical to redesign the roles of healthcare workers at the point of care to accommodate the necessary changes and to retrain them to fulfill these roles.

Hospitalists Prepare to Lead

Identifying the facilitating factors and barriers to improvement is essential to effect change because it helps ensure success. It’s also crucial to match the patient safety goals with the change strategies and tactics. Otherwise, mismatches can lead to unintended consequences that will hinder continuous improvements such as employee skepticism, frustration of safety champions, and mislearning or unnecessary ”workarounds“ by staff.

SHM sees this QI Demonstration Project as critical to assisting institutions in the design, implementation, and evaluation of QI programs and systemwide interventions with effectiveness and value. These findings should equip hospitalists with vital tools necessary to provide essential leadership in meeting their institution’s quality and patient safety goals. TH

Writer Kathleen Frampton is based in Columbia, Md