Richard Quinn

As a young student and resident, Joshua Allen-Dicker, MD, MPH, was stunned to see the flip side of medicine—miscommunication, disenfranchised patients, unnecessary testing, and, worst of all, medical errors. But then he saw a cast of doctors working against that tide and realized he wanted to be one of them.

“I was shocked at the existence of these problems but struck by the fervor of those physicians who worked to build systems that promoted safe and effective care,” Dr. Allen-Dicker says. “More often than not, these physicians were hospitalists. I was inspired to learn more about hospital medicine. I found that the core skills of the hospitalist—teamwork, problem-solving, communication, and leadership—were key areas that I wanted to develop.”

And so he has. Dr. Allen-Dicker recently joined the division of general medicine and primary care at Beth Israel Deaconess Medical Center in Boston. He’s also an instructor in medicine at Harvard Medical School and was previously in the division of hospital medicine at Icahn School of Medicine at Mount Sinai in New York City. He is a member of SHM’s Physicians in Training Committee, is on the faculty for HM15 in Washington, D.C., and is scheduled to speak as part of the new Young Hospitalists track.

Dr. Allen-Dicker, one of six new members of Team Hospitalist, The Hospitalist’s volunteer editorial advisory group, clearly loves his chosen profession. But as a young doctor in HM, a specialty that is itself often described as being in its adolescence, he admits there is one irksome question he hears a lot.

“I struggle with the question, ‘So what do you want to be when you grow up?’” he says. “Hospital medicine is a young field, and many patients, families, and occasionally some older physicians are not aware that [it] is a long-term career option. As hospitalists continue to demonstrate leadership in clinical care, academics, and education, this question will fade away.”

Question: What’s the best advice you ever received?

Answer: Just be yourself. People are exceptionally skilled at identifying when you’re not being authentic with them.

Q: What’s the worst advice you ever received?

A: Just be yourself. People rarely get things consistently right in healthcare without the right training. I say, “Be yourself, but practice first.”

Q: Did you have a mentor during training?

A: It wasn’t until I moved to New York City for my hospitalist position that I clearly saw how much I owed my residency mentors. I recognized that, with each interaction we have—with nurses, patients, families, other physicians—we make a decision about what kind of doctor we are going to be that day. For me, choosing to channel little parts of my mentors made my move to a new city less lonely and helped me to figure out how to be the doctor I wanted to be. ‘How would Tony answer that question? What would Anjala do right now?’ And if I didn’t know the answer, I acted as if there were someone who might want to channel me someday.

Q: Have you tried to mentor others?

A: There is a new generation of future hospitalists—students who never experienced a hospital without hospitalists and young physicians who have known they wanted a career in hospital medicine since beginning medical school. They are hungry for guidance and eager to be engaged. We are starting a hospital medicine interest group at my hospital to help create a formal pathway for those interested in hospital medicine mentorship. I am really excited about this project.

Q: What’s the biggest change you would like to see in HM?

A: I’m interested to see how hospital medicine engages students and trainees who are interested in hospital medicine. How we educate them, and how much we allow them to educate and change us, will be a defining issue as hospital medicine comes of age.

Q: What aspect of teaching in the 21st century is most difficult? And, what is most enjoyable?

A: As technology becomes increasingly integrated into healthcare and education, there are so many different modalities for engaging learners. Picking a topic and learning points is easy—picking how to teach it is the tough part! Seeing learners take knowledge you’ve imparted—whether it relates to management of renal failure, high-value care, or the patient experience—and put it into clinical practice is amazing.

Q: What is your biggest professional reward?

A: Remaining open to new ideas is a challenge and reward. It’s easy to get caught up in “this is the way we’ve always done this and thought about this.” For me, part of trying to become a better doctor means learning something new each day. I don’t always succeed, but it feels so good when I do.

Q: What SHM event has made the most lasting impression on you?

A: My first national HM conference as a PGY-2 resident. It was an amazing and energizing feeling to sit in the large plenary session with 3,000 hospitalists. I thought to myself, ‘This is a movement that is changing healthcare. I want in.’

Q: Where do you see yourself in 10 years?

A: One of the great things about hospital medicine is how flexible it can be as a career choice. Hospitalists can be residency program directors, hospital administrators, important academics, lauded teachers, and even the CMO of Medicare. None of those things are possible without first being a good clinical hospitalist, which is what I’m focusing on right now.

Q: What impact do you feel devices like smartphones and tablets have had on HM?

A: It’s amazing to see how much bottom-up innovation Apple and Google have inspired with their products. Without waiting for large, hospital-wide investments (e.g. electronic health records), physicians, start-ups, and patients are empowering themselves and changing healthcare. I would just recommend avoiding the mentality that every problem can be solved by buying patients/physicians/staff an iPad. Technology is not a substitute for well-designed healthcare delivery systems.

Richard Quinn is a freelance writer in New Jersey.

As a young student and resident, Joshua Allen-Dicker, MD, MPH, was stunned to see the flip side of medicine—miscommunication, disenfranchised patients, unnecessary testing, and, worst of all, medical errors. But then he saw a cast of doctors working against that tide and realized he wanted to be one of them.

“I was shocked at the existence of these problems but struck by the fervor of those physicians who worked to build systems that promoted safe and effective care,” Dr. Allen-Dicker says. “More often than not, these physicians were hospitalists. I was inspired to learn more about hospital medicine. I found that the core skills of the hospitalist—teamwork, problem-solving, communication, and leadership—were key areas that I wanted to develop.”

And so he has. Dr. Allen-Dicker recently joined the division of general medicine and primary care at Beth Israel Deaconess Medical Center in Boston. He’s also an instructor in medicine at Harvard Medical School and was previously in the division of hospital medicine at Icahn School of Medicine at Mount Sinai in New York City. He is a member of SHM’s Physicians in Training Committee, is on the faculty for HM15 in Washington, D.C., and is scheduled to speak as part of the new Young Hospitalists track.

Dr. Allen-Dicker, one of six new members of Team Hospitalist, The Hospitalist’s volunteer editorial advisory group, clearly loves his chosen profession. But as a young doctor in HM, a specialty that is itself often described as being in its adolescence, he admits there is one irksome question he hears a lot.

“I struggle with the question, ‘So what do you want to be when you grow up?’” he says. “Hospital medicine is a young field, and many patients, families, and occasionally some older physicians are not aware that [it] is a long-term career option. As hospitalists continue to demonstrate leadership in clinical care, academics, and education, this question will fade away.”

Question: What’s the best advice you ever received?

Answer: Just be yourself. People are exceptionally skilled at identifying when you’re not being authentic with them.

Q: What’s the worst advice you ever received?

A: Just be yourself. People rarely get things consistently right in healthcare without the right training. I say, “Be yourself, but practice first.”

Q: Did you have a mentor during training?

A: It wasn’t until I moved to New York City for my hospitalist position that I clearly saw how much I owed my residency mentors. I recognized that, with each interaction we have—with nurses, patients, families, other physicians—we make a decision about what kind of doctor we are going to be that day. For me, choosing to channel little parts of my mentors made my move to a new city less lonely and helped me to figure out how to be the doctor I wanted to be. ‘How would Tony answer that question? What would Anjala do right now?’ And if I didn’t know the answer, I acted as if there were someone who might want to channel me someday.

Q: Have you tried to mentor others?

A: There is a new generation of future hospitalists—students who never experienced a hospital without hospitalists and young physicians who have known they wanted a career in hospital medicine since beginning medical school. They are hungry for guidance and eager to be engaged. We are starting a hospital medicine interest group at my hospital to help create a formal pathway for those interested in hospital medicine mentorship. I am really excited about this project.

Q: What’s the biggest change you would like to see in HM?

A: I’m interested to see how hospital medicine engages students and trainees who are interested in hospital medicine. How we educate them, and how much we allow them to educate and change us, will be a defining issue as hospital medicine comes of age.

Q: What aspect of teaching in the 21st century is most difficult? And, what is most enjoyable?

A: As technology becomes increasingly integrated into healthcare and education, there are so many different modalities for engaging learners. Picking a topic and learning points is easy—picking how to teach it is the tough part! Seeing learners take knowledge you’ve imparted—whether it relates to management of renal failure, high-value care, or the patient experience—and put it into clinical practice is amazing.

Q: What is your biggest professional reward?

A: Remaining open to new ideas is a challenge and reward. It’s easy to get caught up in “this is the way we’ve always done this and thought about this.” For me, part of trying to become a better doctor means learning something new each day. I don’t always succeed, but it feels so good when I do.

Q: What SHM event has made the most lasting impression on you?

A: My first national HM conference as a PGY-2 resident. It was an amazing and energizing feeling to sit in the large plenary session with 3,000 hospitalists. I thought to myself, ‘This is a movement that is changing healthcare. I want in.’

Q: Where do you see yourself in 10 years?

A: One of the great things about hospital medicine is how flexible it can be as a career choice. Hospitalists can be residency program directors, hospital administrators, important academics, lauded teachers, and even the CMO of Medicare. None of those things are possible without first being a good clinical hospitalist, which is what I’m focusing on right now.

Q: What impact do you feel devices like smartphones and tablets have had on HM?

A: It’s amazing to see how much bottom-up innovation Apple and Google have inspired with their products. Without waiting for large, hospital-wide investments (e.g. electronic health records), physicians, start-ups, and patients are empowering themselves and changing healthcare. I would just recommend avoiding the mentality that every problem can be solved by buying patients/physicians/staff an iPad. Technology is not a substitute for well-designed healthcare delivery systems.

Richard Quinn is a freelance writer in New Jersey.

As a young student and resident, Joshua Allen-Dicker, MD, MPH, was stunned to see the flip side of medicine—miscommunication, disenfranchised patients, unnecessary testing, and, worst of all, medical errors. But then he saw a cast of doctors working against that tide and realized he wanted to be one of them.

“I was shocked at the existence of these problems but struck by the fervor of those physicians who worked to build systems that promoted safe and effective care,” Dr. Allen-Dicker says. “More often than not, these physicians were hospitalists. I was inspired to learn more about hospital medicine. I found that the core skills of the hospitalist—teamwork, problem-solving, communication, and leadership—were key areas that I wanted to develop.”

And so he has. Dr. Allen-Dicker recently joined the division of general medicine and primary care at Beth Israel Deaconess Medical Center in Boston. He’s also an instructor in medicine at Harvard Medical School and was previously in the division of hospital medicine at Icahn School of Medicine at Mount Sinai in New York City. He is a member of SHM’s Physicians in Training Committee, is on the faculty for HM15 in Washington, D.C., and is scheduled to speak as part of the new Young Hospitalists track.

Dr. Allen-Dicker, one of six new members of Team Hospitalist, The Hospitalist’s volunteer editorial advisory group, clearly loves his chosen profession. But as a young doctor in HM, a specialty that is itself often described as being in its adolescence, he admits there is one irksome question he hears a lot.

“I struggle with the question, ‘So what do you want to be when you grow up?’” he says. “Hospital medicine is a young field, and many patients, families, and occasionally some older physicians are not aware that [it] is a long-term career option. As hospitalists continue to demonstrate leadership in clinical care, academics, and education, this question will fade away.”

Question: What’s the best advice you ever received?

Answer: Just be yourself. People are exceptionally skilled at identifying when you’re not being authentic with them.

Q: What’s the worst advice you ever received?

A: Just be yourself. People rarely get things consistently right in healthcare without the right training. I say, “Be yourself, but practice first.”

Q: Did you have a mentor during training?

A: It wasn’t until I moved to New York City for my hospitalist position that I clearly saw how much I owed my residency mentors. I recognized that, with each interaction we have—with nurses, patients, families, other physicians—we make a decision about what kind of doctor we are going to be that day. For me, choosing to channel little parts of my mentors made my move to a new city less lonely and helped me to figure out how to be the doctor I wanted to be. ‘How would Tony answer that question? What would Anjala do right now?’ And if I didn’t know the answer, I acted as if there were someone who might want to channel me someday.

Q: Have you tried to mentor others?

A: There is a new generation of future hospitalists—students who never experienced a hospital without hospitalists and young physicians who have known they wanted a career in hospital medicine since beginning medical school. They are hungry for guidance and eager to be engaged. We are starting a hospital medicine interest group at my hospital to help create a formal pathway for those interested in hospital medicine mentorship. I am really excited about this project.

Q: What’s the biggest change you would like to see in HM?

A: I’m interested to see how hospital medicine engages students and trainees who are interested in hospital medicine. How we educate them, and how much we allow them to educate and change us, will be a defining issue as hospital medicine comes of age.

Q: What aspect of teaching in the 21st century is most difficult? And, what is most enjoyable?

A: As technology becomes increasingly integrated into healthcare and education, there are so many different modalities for engaging learners. Picking a topic and learning points is easy—picking how to teach it is the tough part! Seeing learners take knowledge you’ve imparted—whether it relates to management of renal failure, high-value care, or the patient experience—and put it into clinical practice is amazing.

Q: What is your biggest professional reward?

A: Remaining open to new ideas is a challenge and reward. It’s easy to get caught up in “this is the way we’ve always done this and thought about this.” For me, part of trying to become a better doctor means learning something new each day. I don’t always succeed, but it feels so good when I do.

Q: What SHM event has made the most lasting impression on you?

A: My first national HM conference as a PGY-2 resident. It was an amazing and energizing feeling to sit in the large plenary session with 3,000 hospitalists. I thought to myself, ‘This is a movement that is changing healthcare. I want in.’

Q: Where do you see yourself in 10 years?

A: One of the great things about hospital medicine is how flexible it can be as a career choice. Hospitalists can be residency program directors, hospital administrators, important academics, lauded teachers, and even the CMO of Medicare. None of those things are possible without first being a good clinical hospitalist, which is what I’m focusing on right now.

Q: What impact do you feel devices like smartphones and tablets have had on HM?

A: It’s amazing to see how much bottom-up innovation Apple and Google have inspired with their products. Without waiting for large, hospital-wide investments (e.g. electronic health records), physicians, start-ups, and patients are empowering themselves and changing healthcare. I would just recommend avoiding the mentality that every problem can be solved by buying patients/physicians/staff an iPad. Technology is not a substitute for well-designed healthcare delivery systems.

Richard Quinn is a freelance writer in New Jersey.

Sound Physicians' recent acquisition of Cogent Healthcare creates the largest hospitalist management group in the country, which may or may not be a good thing, one hospitalist expert notes.

The deal, which closed last month, creates a company with more than 1,750 hospitalists in 180 hospitals nationwide. Reuters estimated the sale price at more than $375 million.

"We certainly don't care so much about biggest," says Robert Bessler, MD, chief executive officer of Sound Physicians, which will be the merged firms' name moving forward. "We're focused on trying to be the practice of choice for docs and provider of choice for hospitals—and really focus on performance as a business model to drive results."

John Nelson, MD, MHM, a principal in Nelson Flores Hospital Medicine Consultants and regular columnist for The Hospitalist, says he believes the impact of the merger will vary by market.

"Hospitalists in competing groups could benefit, for example, by being seen as a more attractive alternative for candidates in the market to join a practice, and large companies may be able to invest in innovation that might benefit all of us," Dr. Nelson says in an email. "But for others, it may seem to make things worse, for example, by influencing the local market toward lower compensation or higher workload. It will be very market-dependent."

Dr. Bessler says he believes the merger "creates incredible synergy." For example, Cogent has The Intensivist Group, which operates full-service intensivist programs, and it can now potentially expand to hospitals where Sound hospitalists work.

Conversely, Sound’s post-acute-care program can be expanded to hospitals where Cogent has a presence.

Dr. Bessler understands that being the largest group can be seen as a good or a bad thing by industry watchers. "I think it leads to further innovation," he says. "It pools resources to do better things for hospital medicine, for hospitals, for patients, and for docs. And the reality is that even on a combined basis, we have less than 5% of the market. It's a massive market."

Visit our website for more information on mergers in hospital medicine.

Sound Physicians' recent acquisition of Cogent Healthcare creates the largest hospitalist management group in the country, which may or may not be a good thing, one hospitalist expert notes.

The deal, which closed last month, creates a company with more than 1,750 hospitalists in 180 hospitals nationwide. Reuters estimated the sale price at more than $375 million.

"We certainly don't care so much about biggest," says Robert Bessler, MD, chief executive officer of Sound Physicians, which will be the merged firms' name moving forward. "We're focused on trying to be the practice of choice for docs and provider of choice for hospitals—and really focus on performance as a business model to drive results."

John Nelson, MD, MHM, a principal in Nelson Flores Hospital Medicine Consultants and regular columnist for The Hospitalist, says he believes the impact of the merger will vary by market.

"Hospitalists in competing groups could benefit, for example, by being seen as a more attractive alternative for candidates in the market to join a practice, and large companies may be able to invest in innovation that might benefit all of us," Dr. Nelson says in an email. "But for others, it may seem to make things worse, for example, by influencing the local market toward lower compensation or higher workload. It will be very market-dependent."

Dr. Bessler says he believes the merger "creates incredible synergy." For example, Cogent has The Intensivist Group, which operates full-service intensivist programs, and it can now potentially expand to hospitals where Sound hospitalists work.

Conversely, Sound’s post-acute-care program can be expanded to hospitals where Cogent has a presence.

Dr. Bessler understands that being the largest group can be seen as a good or a bad thing by industry watchers. "I think it leads to further innovation," he says. "It pools resources to do better things for hospital medicine, for hospitals, for patients, and for docs. And the reality is that even on a combined basis, we have less than 5% of the market. It's a massive market."

Visit our website for more information on mergers in hospital medicine.

Sound Physicians' recent acquisition of Cogent Healthcare creates the largest hospitalist management group in the country, which may or may not be a good thing, one hospitalist expert notes.

The deal, which closed last month, creates a company with more than 1,750 hospitalists in 180 hospitals nationwide. Reuters estimated the sale price at more than $375 million.

"We certainly don't care so much about biggest," says Robert Bessler, MD, chief executive officer of Sound Physicians, which will be the merged firms' name moving forward. "We're focused on trying to be the practice of choice for docs and provider of choice for hospitals—and really focus on performance as a business model to drive results."

John Nelson, MD, MHM, a principal in Nelson Flores Hospital Medicine Consultants and regular columnist for The Hospitalist, says he believes the impact of the merger will vary by market.

"Hospitalists in competing groups could benefit, for example, by being seen as a more attractive alternative for candidates in the market to join a practice, and large companies may be able to invest in innovation that might benefit all of us," Dr. Nelson says in an email. "But for others, it may seem to make things worse, for example, by influencing the local market toward lower compensation or higher workload. It will be very market-dependent."

Dr. Bessler says he believes the merger "creates incredible synergy." For example, Cogent has The Intensivist Group, which operates full-service intensivist programs, and it can now potentially expand to hospitals where Sound hospitalists work.

Conversely, Sound’s post-acute-care program can be expanded to hospitals where Cogent has a presence.

Dr. Bessler understands that being the largest group can be seen as a good or a bad thing by industry watchers. "I think it leads to further innovation," he says. "It pools resources to do better things for hospital medicine, for hospitals, for patients, and for docs. And the reality is that even on a combined basis, we have less than 5% of the market. It's a massive market."

Visit our website for more information on mergers in hospital medicine.

A group of hospitalists in Oregon have formed what is believed to be the first hospitalist union in the country—but it may not be the last.

Hospitalists at PeaceHealth Sacred Heart Medical Center locations in Springfield and Eugene, Ore., voted to form the union, dubbed Pacific Northwest Hospital Medicine Association, to have more say in patient care and working conditions there. Talk of unionizing started after hospitalists objected to a recommendation by a PeaceHealth consultant that their group's employment model be outsourced and run by a national management firm rather than remain hospital-owned.

"We really didn't have much of a say other than all quitting, which we didn't want to do because we like where we work," says hospitalist and union spokesperson David Schwartz, MD. "We started talking about unionizing."

The union is under the umbrella of the American Federation of Teachers, and likely is the first of its kind in the nation. The group started with 38 members, but 12 physicians who did not want to be managed under a national firm have left.

Now, the union is trying to persuade PeaceHealth to keep the group's management in-house. If not, the union will look to negotiate a contract with a national management firm chosen by its hospital administration.

A union of hospital physicians is uncommon. Healthcare workers often unionize but not individual specialists. Dr. Schwartz says he is curious to see whether other hospitalists who feel they want more of a say in their practice management will follow suit.

"The fact that we unionized seemed to galvanize a lot of the staff at the hospital," he says. "This might be a wave of the future. … Now people have a choice, which is interesting to watch."

Visit our website for more information on managing hospitalist groups.

A group of hospitalists in Oregon have formed what is believed to be the first hospitalist union in the country—but it may not be the last.

Hospitalists at PeaceHealth Sacred Heart Medical Center locations in Springfield and Eugene, Ore., voted to form the union, dubbed Pacific Northwest Hospital Medicine Association, to have more say in patient care and working conditions there. Talk of unionizing started after hospitalists objected to a recommendation by a PeaceHealth consultant that their group's employment model be outsourced and run by a national management firm rather than remain hospital-owned.

"We really didn't have much of a say other than all quitting, which we didn't want to do because we like where we work," says hospitalist and union spokesperson David Schwartz, MD. "We started talking about unionizing."

The union is under the umbrella of the American Federation of Teachers, and likely is the first of its kind in the nation. The group started with 38 members, but 12 physicians who did not want to be managed under a national firm have left.

Now, the union is trying to persuade PeaceHealth to keep the group's management in-house. If not, the union will look to negotiate a contract with a national management firm chosen by its hospital administration.

A union of hospital physicians is uncommon. Healthcare workers often unionize but not individual specialists. Dr. Schwartz says he is curious to see whether other hospitalists who feel they want more of a say in their practice management will follow suit.

"The fact that we unionized seemed to galvanize a lot of the staff at the hospital," he says. "This might be a wave of the future. … Now people have a choice, which is interesting to watch."

Visit our website for more information on managing hospitalist groups.

A group of hospitalists in Oregon have formed what is believed to be the first hospitalist union in the country—but it may not be the last.

Hospitalists at PeaceHealth Sacred Heart Medical Center locations in Springfield and Eugene, Ore., voted to form the union, dubbed Pacific Northwest Hospital Medicine Association, to have more say in patient care and working conditions there. Talk of unionizing started after hospitalists objected to a recommendation by a PeaceHealth consultant that their group's employment model be outsourced and run by a national management firm rather than remain hospital-owned.

"We really didn't have much of a say other than all quitting, which we didn't want to do because we like where we work," says hospitalist and union spokesperson David Schwartz, MD. "We started talking about unionizing."

The union is under the umbrella of the American Federation of Teachers, and likely is the first of its kind in the nation. The group started with 38 members, but 12 physicians who did not want to be managed under a national firm have left.

Now, the union is trying to persuade PeaceHealth to keep the group's management in-house. If not, the union will look to negotiate a contract with a national management firm chosen by its hospital administration.

A union of hospital physicians is uncommon. Healthcare workers often unionize but not individual specialists. Dr. Schwartz says he is curious to see whether other hospitalists who feel they want more of a say in their practice management will follow suit.

"The fact that we unionized seemed to galvanize a lot of the staff at the hospital," he says. "This might be a wave of the future. … Now people have a choice, which is interesting to watch."

Visit our website for more information on managing hospitalist groups.

Sometimes a physician’s choice of specialty is borne of one patient, one mentor, or one experience. And then sometimes there’s just a good feeling.

Put David Pressel, MD, PhD, FHM, in the latter category.

He simultaneously earned his medical degree and a doctorate in neuroscience from Washington University in Saint Louis in 1993. He did his internship and residency in pediatrics at St. Louis Children’s Hospital.

He hasn’t left HM since.

It was the “first temporary job out of training that I really liked and continued,” Dr. Pressel says.

Fast forward nearly 20 years and Dr. Pressel is one of six new members of Team Hospitalist, the volunteer editorial advisory board of The Hospitalist. Dr. Pressel is a pediatric hospitalist and inpatient medical director at Nemours/Alfred I. duPont Hospital for Children in Wilmington, Del. He has served as an associate professor of pediatrics at Jefferson Medical College in Philadelphia since 2008 and was an assistant professor at Temple University School of Medicine before that.

He was Nemours/Alfred I. duPont Hospital physician of the year in 2008 and recently won the Marcum Innovator of the Year Award for development of a hospital program to improve the care of patients experiencing a behavior emergency. He also has been an executive board member of SHM’s Philadelphia chapter for two years.

He admits to having a lot of trepidation and uncertainty as a nascent physician but happily notes that those emotions subsided as he “became more competent and independent.”

Of course, the stresses of the job are still there today, but he can’t imagine a better job than being a pediatric hospitalist. Now, Dr. Pressel enjoys the variety of experiences that HM provides: interacting with patients and colleagues across the hospital, taking satisfaction from mentoring others, and networking at national meetings. In fact, he got his current job by chatting up a colleague at an SHM convention.

Question: Why did you choose a career in medicine?

Answer: Had an unbelievably positive experience with a physician during a personal illness. My degree of emotional concern was disproportionate to my physical issues—the doc I saw was perceptive and discussed them with me. It was an epiphany, and I decided to become a physician. Unfortunately, I don’t know her name and have no way of letting her know what a profound impact she had on my life.

Q: Did you have a mentor during training or early career? If so, who was the mentor and what were the most important lessons you learned from him/her?

A: Several. How to integrate work-life balance. Some folks I worked with seemed to be consumed by their career to the detriment of home life. I learned from one mentor to try to integrate one’s interests. I have tried to involve my family in my teaching—my wife and kids have role-played as model patients. My son is a co-author on a presentation regarding violent patients in which he plays a violent patient that workshop participants need to control and care for.

Q: What’s the biggest change you’ve seen in HM in your career?

A: Development as a full career rather than a temporary choice. I started as a hospitalist before the term was coined and initially was thinking I’d need to do a fellowship to have a successful career in academic medicine. This has not been the case.

Q: What’s the biggest change you would like to see in HM?

A: Board certification with salary increase.

Q: As a group leader, why is it important for you to continue seeing patients?

A: A boss who is disconnected from the front line is potentially dangerous.

Q: As a hospitalist, seeing most of your patients for the very first time, what aspect of patient care is most challenging?

A: The uncertainty of whether I’m making a mistake. Dealing with families with mental illness.

Q: What aspect of patient care is most rewarding?

A: Getting thanked.

Q: What aspect of teaching in the 21st century is most difficult? And, what is most enjoyable?

A: Same as 20th century except mobile technology, and the students are better. I am a late adopter of technology, having become reasonably successful and happy without these tools.

Q: Outside of patient care, tell me about your career interests.

A: Lots, including comanagement and violent patients. As above, agitated patients who become violent are encountered in hospital medicine. I’ve been bitten twice; other staff members have been injured by patients. There is limited training for staff in this area. By necessity, I have become expert and am expanding my skill and research interests in this area.

Richard Quinn is a freelance writer in New Jersey.

Sometimes a physician’s choice of specialty is borne of one patient, one mentor, or one experience. And then sometimes there’s just a good feeling.

Put David Pressel, MD, PhD, FHM, in the latter category.

He simultaneously earned his medical degree and a doctorate in neuroscience from Washington University in Saint Louis in 1993. He did his internship and residency in pediatrics at St. Louis Children’s Hospital.

He hasn’t left HM since.

It was the “first temporary job out of training that I really liked and continued,” Dr. Pressel says.

Fast forward nearly 20 years and Dr. Pressel is one of six new members of Team Hospitalist, the volunteer editorial advisory board of The Hospitalist. Dr. Pressel is a pediatric hospitalist and inpatient medical director at Nemours/Alfred I. duPont Hospital for Children in Wilmington, Del. He has served as an associate professor of pediatrics at Jefferson Medical College in Philadelphia since 2008 and was an assistant professor at Temple University School of Medicine before that.

He was Nemours/Alfred I. duPont Hospital physician of the year in 2008 and recently won the Marcum Innovator of the Year Award for development of a hospital program to improve the care of patients experiencing a behavior emergency. He also has been an executive board member of SHM’s Philadelphia chapter for two years.

He admits to having a lot of trepidation and uncertainty as a nascent physician but happily notes that those emotions subsided as he “became more competent and independent.”

Of course, the stresses of the job are still there today, but he can’t imagine a better job than being a pediatric hospitalist. Now, Dr. Pressel enjoys the variety of experiences that HM provides: interacting with patients and colleagues across the hospital, taking satisfaction from mentoring others, and networking at national meetings. In fact, he got his current job by chatting up a colleague at an SHM convention.

Question: Why did you choose a career in medicine?

Answer: Had an unbelievably positive experience with a physician during a personal illness. My degree of emotional concern was disproportionate to my physical issues—the doc I saw was perceptive and discussed them with me. It was an epiphany, and I decided to become a physician. Unfortunately, I don’t know her name and have no way of letting her know what a profound impact she had on my life.

Q: Did you have a mentor during training or early career? If so, who was the mentor and what were the most important lessons you learned from him/her?

A: Several. How to integrate work-life balance. Some folks I worked with seemed to be consumed by their career to the detriment of home life. I learned from one mentor to try to integrate one’s interests. I have tried to involve my family in my teaching—my wife and kids have role-played as model patients. My son is a co-author on a presentation regarding violent patients in which he plays a violent patient that workshop participants need to control and care for.

Q: What’s the biggest change you’ve seen in HM in your career?

A: Development as a full career rather than a temporary choice. I started as a hospitalist before the term was coined and initially was thinking I’d need to do a fellowship to have a successful career in academic medicine. This has not been the case.

Q: What’s the biggest change you would like to see in HM?

A: Board certification with salary increase.

Q: As a group leader, why is it important for you to continue seeing patients?

A: A boss who is disconnected from the front line is potentially dangerous.

Q: As a hospitalist, seeing most of your patients for the very first time, what aspect of patient care is most challenging?

A: The uncertainty of whether I’m making a mistake. Dealing with families with mental illness.

Q: What aspect of patient care is most rewarding?

A: Getting thanked.

Q: What aspect of teaching in the 21st century is most difficult? And, what is most enjoyable?

A: Same as 20th century except mobile technology, and the students are better. I am a late adopter of technology, having become reasonably successful and happy without these tools.

Q: Outside of patient care, tell me about your career interests.

A: Lots, including comanagement and violent patients. As above, agitated patients who become violent are encountered in hospital medicine. I’ve been bitten twice; other staff members have been injured by patients. There is limited training for staff in this area. By necessity, I have become expert and am expanding my skill and research interests in this area.

Richard Quinn is a freelance writer in New Jersey.

Sometimes a physician’s choice of specialty is borne of one patient, one mentor, or one experience. And then sometimes there’s just a good feeling.

Put David Pressel, MD, PhD, FHM, in the latter category.

He simultaneously earned his medical degree and a doctorate in neuroscience from Washington University in Saint Louis in 1993. He did his internship and residency in pediatrics at St. Louis Children’s Hospital.

He hasn’t left HM since.

It was the “first temporary job out of training that I really liked and continued,” Dr. Pressel says.

Fast forward nearly 20 years and Dr. Pressel is one of six new members of Team Hospitalist, the volunteer editorial advisory board of The Hospitalist. Dr. Pressel is a pediatric hospitalist and inpatient medical director at Nemours/Alfred I. duPont Hospital for Children in Wilmington, Del. He has served as an associate professor of pediatrics at Jefferson Medical College in Philadelphia since 2008 and was an assistant professor at Temple University School of Medicine before that.

He was Nemours/Alfred I. duPont Hospital physician of the year in 2008 and recently won the Marcum Innovator of the Year Award for development of a hospital program to improve the care of patients experiencing a behavior emergency. He also has been an executive board member of SHM’s Philadelphia chapter for two years.

He admits to having a lot of trepidation and uncertainty as a nascent physician but happily notes that those emotions subsided as he “became more competent and independent.”

Of course, the stresses of the job are still there today, but he can’t imagine a better job than being a pediatric hospitalist. Now, Dr. Pressel enjoys the variety of experiences that HM provides: interacting with patients and colleagues across the hospital, taking satisfaction from mentoring others, and networking at national meetings. In fact, he got his current job by chatting up a colleague at an SHM convention.

Question: Why did you choose a career in medicine?

Answer: Had an unbelievably positive experience with a physician during a personal illness. My degree of emotional concern was disproportionate to my physical issues—the doc I saw was perceptive and discussed them with me. It was an epiphany, and I decided to become a physician. Unfortunately, I don’t know her name and have no way of letting her know what a profound impact she had on my life.

Q: Did you have a mentor during training or early career? If so, who was the mentor and what were the most important lessons you learned from him/her?

A: Several. How to integrate work-life balance. Some folks I worked with seemed to be consumed by their career to the detriment of home life. I learned from one mentor to try to integrate one’s interests. I have tried to involve my family in my teaching—my wife and kids have role-played as model patients. My son is a co-author on a presentation regarding violent patients in which he plays a violent patient that workshop participants need to control and care for.

Q: What’s the biggest change you’ve seen in HM in your career?

A: Development as a full career rather than a temporary choice. I started as a hospitalist before the term was coined and initially was thinking I’d need to do a fellowship to have a successful career in academic medicine. This has not been the case.

Q: What’s the biggest change you would like to see in HM?

A: Board certification with salary increase.

Q: As a group leader, why is it important for you to continue seeing patients?

A: A boss who is disconnected from the front line is potentially dangerous.

Q: As a hospitalist, seeing most of your patients for the very first time, what aspect of patient care is most challenging?

A: The uncertainty of whether I’m making a mistake. Dealing with families with mental illness.

Q: What aspect of patient care is most rewarding?

A: Getting thanked.

Q: What aspect of teaching in the 21st century is most difficult? And, what is most enjoyable?

A: Same as 20th century except mobile technology, and the students are better. I am a late adopter of technology, having become reasonably successful and happy without these tools.

Q: Outside of patient care, tell me about your career interests.

A: Lots, including comanagement and violent patients. As above, agitated patients who become violent are encountered in hospital medicine. I’ve been bitten twice; other staff members have been injured by patients. There is limited training for staff in this area. By necessity, I have become expert and am expanding my skill and research interests in this area.

Richard Quinn is a freelance writer in New Jersey.

Hospitalists have taken positions in every corner of healthcare: the C-suite, hospital administration, and even nominee for U.S. surgeon general.

Now, add county coroner to the list.

This month, hospitalist Adam Duckett, MD, was elected coroner for Cayuga County, N.Y., whose county seat of Auburn is about 30 miles west of Syracuse. Dr. Duckett, who had never run for public office, is a hospitalist at Auburn Community Hospital and serves as a board member for Hospice of the Finger Lakes.

The Hospitalist spoke with him about his new post, which might make him the only hospitalist/coroner in the country.

Question: HM is a time-consuming job. Why take time out for public service?

Answer: I believe everyone owes a debt of service to their community, and I felt that this was one that I would enjoy.

Q: What skills from HM apply to your new position?

A: The majority of unattended deaths in our county are related to long-standing medical illness. Because of this, I feel that in order to understand how somebody may have died, you must first know how they lived. I believe my role as a hospitalist enables me to review medical records and determine if the medical history provides enough information to determine a cause of death.

Q: What skills from your hospice care experience apply?

A: My role as a hospitalist has given me valuable insight in helping families cope with the loss of a loved one by providing explanations as to why somebody might have passed. It’s very important for a family to understand why a loved one died before they can accept it, and it’s very rewarding to help families through this process.

Get involved in public policy via SHM's advocacy home page. TH

Visit our website for more information about community involvement.

Hospitalists have taken positions in every corner of healthcare: the C-suite, hospital administration, and even nominee for U.S. surgeon general.

Now, add county coroner to the list.

This month, hospitalist Adam Duckett, MD, was elected coroner for Cayuga County, N.Y., whose county seat of Auburn is about 30 miles west of Syracuse. Dr. Duckett, who had never run for public office, is a hospitalist at Auburn Community Hospital and serves as a board member for Hospice of the Finger Lakes.

The Hospitalist spoke with him about his new post, which might make him the only hospitalist/coroner in the country.

Question: HM is a time-consuming job. Why take time out for public service?

Answer: I believe everyone owes a debt of service to their community, and I felt that this was one that I would enjoy.

Q: What skills from HM apply to your new position?

A: The majority of unattended deaths in our county are related to long-standing medical illness. Because of this, I feel that in order to understand how somebody may have died, you must first know how they lived. I believe my role as a hospitalist enables me to review medical records and determine if the medical history provides enough information to determine a cause of death.

Q: What skills from your hospice care experience apply?

A: My role as a hospitalist has given me valuable insight in helping families cope with the loss of a loved one by providing explanations as to why somebody might have passed. It’s very important for a family to understand why a loved one died before they can accept it, and it’s very rewarding to help families through this process.

Get involved in public policy via SHM's advocacy home page. TH

Visit our website for more information about community involvement.

Hospitalists have taken positions in every corner of healthcare: the C-suite, hospital administration, and even nominee for U.S. surgeon general.

Now, add county coroner to the list.

This month, hospitalist Adam Duckett, MD, was elected coroner for Cayuga County, N.Y., whose county seat of Auburn is about 30 miles west of Syracuse. Dr. Duckett, who had never run for public office, is a hospitalist at Auburn Community Hospital and serves as a board member for Hospice of the Finger Lakes.

The Hospitalist spoke with him about his new post, which might make him the only hospitalist/coroner in the country.

Question: HM is a time-consuming job. Why take time out for public service?

Answer: I believe everyone owes a debt of service to their community, and I felt that this was one that I would enjoy.

Q: What skills from HM apply to your new position?

A: The majority of unattended deaths in our county are related to long-standing medical illness. Because of this, I feel that in order to understand how somebody may have died, you must first know how they lived. I believe my role as a hospitalist enables me to review medical records and determine if the medical history provides enough information to determine a cause of death.

Q: What skills from your hospice care experience apply?

A: My role as a hospitalist has given me valuable insight in helping families cope with the loss of a loved one by providing explanations as to why somebody might have passed. It’s very important for a family to understand why a loved one died before they can accept it, and it’s very rewarding to help families through this process.

Get involved in public policy via SHM's advocacy home page. TH

Visit our website for more information about community involvement.

A new study on transitions of care gives hospitalists a view from the other side.

Published recently online in the Journal of Hospital Medicine, the authors surveyed 22 primary-care physician leaders in California-based post-discharge clinics and asked them about ways to improve care transitions.

Physicians' responses focused on several areas that need work, most notably aligned financial incentives, regulations to standardize interoperability among electronic health records (EHR) and data sharing, and more opportunities for professional networking, the authors note.

Although the qualitative study takes a broad view of the healthcare system, its lead author says hospitalists should view "systems change" as a long-term goal achievable via incremental improvements that can start now.

"National policy change is needed to move the needle for the whole health system," says hospitalist Oanh Kieu Nguyen, MD, MAS, of the University of Texas Southwestern Medical Center in Dallas. "But locally, you can innovate within these domains and start to make changes to improve practice settings more immediately. National policy to align financial incentives and improve EHR interoperability will be key to helping local changes take hold and spread across systems. Otherwise, there will continue to be a lot of variability and fragmentation around care transitions on a national level."

Dr. Nguyen, who has practiced as both a hospitalist and PCP, says that because policies and studies on post-discharge care transitions primarily have focused on the hospital perspective, it is important to gain an understanding of the primary-care point of view.

"As a hospitalist, it's really easy to get caught up in just wanting to get patients teed up and sent home. Once they're out, we think they're no longer really our problem," Dr. Nguyen adds. "It's easy to forget that primary care is an important part of the other side of the equation. The way our healthcare system is designed doesn't really give physicians an incentive to look at the whole picture of a patient across all the environments they're in."

Many hospitalists are sharing their challenges and successes in care transitions through HMX. Join the conversation now.

Visit our website for more information on transitions of care.

A new study on transitions of care gives hospitalists a view from the other side.

Published recently online in the Journal of Hospital Medicine, the authors surveyed 22 primary-care physician leaders in California-based post-discharge clinics and asked them about ways to improve care transitions.

Physicians' responses focused on several areas that need work, most notably aligned financial incentives, regulations to standardize interoperability among electronic health records (EHR) and data sharing, and more opportunities for professional networking, the authors note.

Although the qualitative study takes a broad view of the healthcare system, its lead author says hospitalists should view "systems change" as a long-term goal achievable via incremental improvements that can start now.

"National policy change is needed to move the needle for the whole health system," says hospitalist Oanh Kieu Nguyen, MD, MAS, of the University of Texas Southwestern Medical Center in Dallas. "But locally, you can innovate within these domains and start to make changes to improve practice settings more immediately. National policy to align financial incentives and improve EHR interoperability will be key to helping local changes take hold and spread across systems. Otherwise, there will continue to be a lot of variability and fragmentation around care transitions on a national level."

Dr. Nguyen, who has practiced as both a hospitalist and PCP, says that because policies and studies on post-discharge care transitions primarily have focused on the hospital perspective, it is important to gain an understanding of the primary-care point of view.

"As a hospitalist, it's really easy to get caught up in just wanting to get patients teed up and sent home. Once they're out, we think they're no longer really our problem," Dr. Nguyen adds. "It's easy to forget that primary care is an important part of the other side of the equation. The way our healthcare system is designed doesn't really give physicians an incentive to look at the whole picture of a patient across all the environments they're in."

Many hospitalists are sharing their challenges and successes in care transitions through HMX. Join the conversation now.

Visit our website for more information on transitions of care.

A new study on transitions of care gives hospitalists a view from the other side.

Published recently online in the Journal of Hospital Medicine, the authors surveyed 22 primary-care physician leaders in California-based post-discharge clinics and asked them about ways to improve care transitions.

Physicians' responses focused on several areas that need work, most notably aligned financial incentives, regulations to standardize interoperability among electronic health records (EHR) and data sharing, and more opportunities for professional networking, the authors note.

Although the qualitative study takes a broad view of the healthcare system, its lead author says hospitalists should view "systems change" as a long-term goal achievable via incremental improvements that can start now.

"National policy change is needed to move the needle for the whole health system," says hospitalist Oanh Kieu Nguyen, MD, MAS, of the University of Texas Southwestern Medical Center in Dallas. "But locally, you can innovate within these domains and start to make changes to improve practice settings more immediately. National policy to align financial incentives and improve EHR interoperability will be key to helping local changes take hold and spread across systems. Otherwise, there will continue to be a lot of variability and fragmentation around care transitions on a national level."

Dr. Nguyen, who has practiced as both a hospitalist and PCP, says that because policies and studies on post-discharge care transitions primarily have focused on the hospital perspective, it is important to gain an understanding of the primary-care point of view.

"As a hospitalist, it's really easy to get caught up in just wanting to get patients teed up and sent home. Once they're out, we think they're no longer really our problem," Dr. Nguyen adds. "It's easy to forget that primary care is an important part of the other side of the equation. The way our healthcare system is designed doesn't really give physicians an incentive to look at the whole picture of a patient across all the environments they're in."

Many hospitalists are sharing their challenges and successes in care transitions through HMX. Join the conversation now.

Visit our website for more information on transitions of care.

Clinical question: Does understanding the expected clinical course of advanced dementia influence end-of-life decisions by proxy decision-makers?

Background: Advanced dementia is a leading cause of death in the United States, but the clinical course of advanced dementia has not been described in a rigorous, prospective manner. The lack of information might cause risk to be underestimated, and patients might receive suboptimal palliative care.

Study design: Multicenter prospective cohort study.

Setting: Twenty-two nursing homes in a single U.S. city.

Synopsis: The survey examined 323 nursing home residents with advanced dementia. The patients were clinically assessed at baseline and quarterly for 18 months through chart reviews, nursing interviews, and physical examinations. Additionally, their proxies were surveyed regarding their understanding of the subjects’ prognoses.

During the survey period, 41.1% of patients developed pneumonia, 52.6% of patients experienced a febrile episode, and 85.8% of patients developed an eating problem; cumulative all-cause mortality was 54.8%. Adjusted for age, sex, and disease duration, the six-month mortality rate for subjects who had pneumonia was 46.7%; a febrile episode, 44.5%; and an eating problem, 38.6%.

Distressing symptoms, including dyspnea (46.0%) and pain (39.1%), were common. In the last three months of life, 40.7% of subjects underwent at least one burdensome intervention (defined as hospitalization, ED visit, parenteral therapy, or tube feeding).

Subjects whose proxies reported an understanding of the poor prognosis and expected clinical complications of advanced dementia underwent significantly fewer burdensome interventions (adjusted odds ratio 0.12).

Bottom line: Advanced dementia is associated with frequent complications, including infections and eating problems, with high six-month mortality and significant associated morbidity. Patients whose healthcare proxies have a good understanding of the expected clinical course and prognosis receive less-aggressive end-of-life care.

Citation: Mitchell SL, Teno JM, Kiely DK, et al. The clinical course of advanced dementia. N Engl J Med. 2009;361(16):1529-1538. TH

Clinical question: Does understanding the expected clinical course of advanced dementia influence end-of-life decisions by proxy decision-makers?

Background: Advanced dementia is a leading cause of death in the United States, but the clinical course of advanced dementia has not been described in a rigorous, prospective manner. The lack of information might cause risk to be underestimated, and patients might receive suboptimal palliative care.

Study design: Multicenter prospective cohort study.

Setting: Twenty-two nursing homes in a single U.S. city.

Synopsis: The survey examined 323 nursing home residents with advanced dementia. The patients were clinically assessed at baseline and quarterly for 18 months through chart reviews, nursing interviews, and physical examinations. Additionally, their proxies were surveyed regarding their understanding of the subjects’ prognoses.

During the survey period, 41.1% of patients developed pneumonia, 52.6% of patients experienced a febrile episode, and 85.8% of patients developed an eating problem; cumulative all-cause mortality was 54.8%. Adjusted for age, sex, and disease duration, the six-month mortality rate for subjects who had pneumonia was 46.7%; a febrile episode, 44.5%; and an eating problem, 38.6%.

Distressing symptoms, including dyspnea (46.0%) and pain (39.1%), were common. In the last three months of life, 40.7% of subjects underwent at least one burdensome intervention (defined as hospitalization, ED visit, parenteral therapy, or tube feeding).

Subjects whose proxies reported an understanding of the poor prognosis and expected clinical complications of advanced dementia underwent significantly fewer burdensome interventions (adjusted odds ratio 0.12).

Bottom line: Advanced dementia is associated with frequent complications, including infections and eating problems, with high six-month mortality and significant associated morbidity. Patients whose healthcare proxies have a good understanding of the expected clinical course and prognosis receive less-aggressive end-of-life care.

Citation: Mitchell SL, Teno JM, Kiely DK, et al. The clinical course of advanced dementia. N Engl J Med. 2009;361(16):1529-1538. TH

Clinical question: Does understanding the expected clinical course of advanced dementia influence end-of-life decisions by proxy decision-makers?

Background: Advanced dementia is a leading cause of death in the United States, but the clinical course of advanced dementia has not been described in a rigorous, prospective manner. The lack of information might cause risk to be underestimated, and patients might receive suboptimal palliative care.

Study design: Multicenter prospective cohort study.

Setting: Twenty-two nursing homes in a single U.S. city.

Synopsis: The survey examined 323 nursing home residents with advanced dementia. The patients were clinically assessed at baseline and quarterly for 18 months through chart reviews, nursing interviews, and physical examinations. Additionally, their proxies were surveyed regarding their understanding of the subjects’ prognoses.

During the survey period, 41.1% of patients developed pneumonia, 52.6% of patients experienced a febrile episode, and 85.8% of patients developed an eating problem; cumulative all-cause mortality was 54.8%. Adjusted for age, sex, and disease duration, the six-month mortality rate for subjects who had pneumonia was 46.7%; a febrile episode, 44.5%; and an eating problem, 38.6%.

Distressing symptoms, including dyspnea (46.0%) and pain (39.1%), were common. In the last three months of life, 40.7% of subjects underwent at least one burdensome intervention (defined as hospitalization, ED visit, parenteral therapy, or tube feeding).

Subjects whose proxies reported an understanding of the poor prognosis and expected clinical complications of advanced dementia underwent significantly fewer burdensome interventions (adjusted odds ratio 0.12).

Bottom line: Advanced dementia is associated with frequent complications, including infections and eating problems, with high six-month mortality and significant associated morbidity. Patients whose healthcare proxies have a good understanding of the expected clinical course and prognosis receive less-aggressive end-of-life care.

Citation: Mitchell SL, Teno JM, Kiely DK, et al. The clinical course of advanced dementia. N Engl J Med. 2009;361(16):1529-1538. TH

Clinical question: When added to oral diabetic agents, which insulin regimen (biphasic, prandial or basal) best achieves glycemic control in patients with Type 2 diabetes?

Background: Most patients with Type 2 diabetes mellitus (DM2) require insulin when oral agents provide suboptimal glycemic control. Little is known about which insulin regimen is most effective.

Study design: Three-year, open-label, multicenter trial.

Setting: Fifty-eight clinical centers in the United Kingdom and Ireland.

Synopsis: The authors randomized 708 insulin-naïve DM2 patients (median age 62 years) with HgbA1c 7% to 10% on maximum-dose metformin or sulfonylurea to one of three regimens: biphasic insulin twice daily; prandial insulin three times daily; or basal insulin once daily. Outcomes were HgbA1c, hypoglycemia rates, and weight gain. Sulfonylureas were replaced by another insulin if glycemic control was unacceptable.

The patients were mostly Caucasian and overweight. At three years of followup, median HgbA1c was similar in all groups (7.1% biphasic, 6.8% prandial, 6.9% basal); however, more patients who received prandial or basal insulin achieved HgbA1c less than 6.5% (45% and 43%, respectively) than in the biphasic group (32%).

Hypoglycemia was significantly less frequent in the basal insulin group (1.7 per patient per year versus 3.0 and 5.5 with biphasic and prandial, respectively). Patients gained weight in all groups; the greatest gain was with prandial insulin. At three years, there were no significant between-group differences in blood pressure, cholesterol, albuminuria, or quality of life.

Bottom line: Adding insulin to oral diabetic regimens improves glycemic control. Basal or prandial insulin regimens achieve glycemic targets more frequently than biphasic dosing.

Citation: Holman RR, Farmer AJ, Davies MJ, et al. Three-year efficacy of complex insulin regimens in type 2 diabetes. N Engl J Med. 2009;361(18):1736-1747.

Clinical question: When added to oral diabetic agents, which insulin regimen (biphasic, prandial or basal) best achieves glycemic control in patients with Type 2 diabetes?

Background: Most patients with Type 2 diabetes mellitus (DM2) require insulin when oral agents provide suboptimal glycemic control. Little is known about which insulin regimen is most effective.

Study design: Three-year, open-label, multicenter trial.

Setting: Fifty-eight clinical centers in the United Kingdom and Ireland.

Synopsis: The authors randomized 708 insulin-naïve DM2 patients (median age 62 years) with HgbA1c 7% to 10% on maximum-dose metformin or sulfonylurea to one of three regimens: biphasic insulin twice daily; prandial insulin three times daily; or basal insulin once daily. Outcomes were HgbA1c, hypoglycemia rates, and weight gain. Sulfonylureas were replaced by another insulin if glycemic control was unacceptable.

The patients were mostly Caucasian and overweight. At three years of followup, median HgbA1c was similar in all groups (7.1% biphasic, 6.8% prandial, 6.9% basal); however, more patients who received prandial or basal insulin achieved HgbA1c less than 6.5% (45% and 43%, respectively) than in the biphasic group (32%).

Hypoglycemia was significantly less frequent in the basal insulin group (1.7 per patient per year versus 3.0 and 5.5 with biphasic and prandial, respectively). Patients gained weight in all groups; the greatest gain was with prandial insulin. At three years, there were no significant between-group differences in blood pressure, cholesterol, albuminuria, or quality of life.

Bottom line: Adding insulin to oral diabetic regimens improves glycemic control. Basal or prandial insulin regimens achieve glycemic targets more frequently than biphasic dosing.

Citation: Holman RR, Farmer AJ, Davies MJ, et al. Three-year efficacy of complex insulin regimens in type 2 diabetes. N Engl J Med. 2009;361(18):1736-1747.

Clinical question: When added to oral diabetic agents, which insulin regimen (biphasic, prandial or basal) best achieves glycemic control in patients with Type 2 diabetes?

Background: Most patients with Type 2 diabetes mellitus (DM2) require insulin when oral agents provide suboptimal glycemic control. Little is known about which insulin regimen is most effective.

Study design: Three-year, open-label, multicenter trial.

Setting: Fifty-eight clinical centers in the United Kingdom and Ireland.

Synopsis: The authors randomized 708 insulin-naïve DM2 patients (median age 62 years) with HgbA1c 7% to 10% on maximum-dose metformin or sulfonylurea to one of three regimens: biphasic insulin twice daily; prandial insulin three times daily; or basal insulin once daily. Outcomes were HgbA1c, hypoglycemia rates, and weight gain. Sulfonylureas were replaced by another insulin if glycemic control was unacceptable.

The patients were mostly Caucasian and overweight. At three years of followup, median HgbA1c was similar in all groups (7.1% biphasic, 6.8% prandial, 6.9% basal); however, more patients who received prandial or basal insulin achieved HgbA1c less than 6.5% (45% and 43%, respectively) than in the biphasic group (32%).

Hypoglycemia was significantly less frequent in the basal insulin group (1.7 per patient per year versus 3.0 and 5.5 with biphasic and prandial, respectively). Patients gained weight in all groups; the greatest gain was with prandial insulin. At three years, there were no significant between-group differences in blood pressure, cholesterol, albuminuria, or quality of life.

Bottom line: Adding insulin to oral diabetic regimens improves glycemic control. Basal or prandial insulin regimens achieve glycemic targets more frequently than biphasic dosing.

Citation: Holman RR, Farmer AJ, Davies MJ, et al. Three-year efficacy of complex insulin regimens in type 2 diabetes. N Engl J Med. 2009;361(18):1736-1747.

Clinical question: Is functional status in the elderly maintained over time after initiating long-term dialysis?

Background: Quality-of-life maintenance often is used as a goal when initiating long-term dialysis in elderly patients with end-stage renal disease. More elderly patients are being offered long-term dialysis treatment. Little is known about the functional status of elderly patients on long-term dialysis.

Study design: Retrospective cohort study.

Setting: U.S. nursing homes.

Synopsis: By cross-linking data from two population-based administrative datasets, this study identified 3,702 nursing home patients (mean 73.4 years) who had started long-term dialysis and whose functional status had been assessed. Activities of daily living assessments before and at three-month intervals after dialysis initiation were compared to see if functional status was maintained.

Within three months of starting dialysis, 61% of patients had a decline in functional status or had died. By one year, only 1 in 8 patients had maintained their pre-dialysis functional status.

Decline in functional status cannot be attributed solely to dialysis because study patients were not compared to patients with chronic kidney disease who were not dialyzed. In addition, these results might not apply to all elderly patients on dialysis, as the functional status of elderly nursing home patients might differ significantly from those living at home.

Bottom line: Functional status is not maintained in most elderly nursing home patients in the first 12 months after long-term dialysis is initiated. Elderly patients considering dialysis treatment should be aware that dialysis might not help maintain functional status and quality of life.

Citation: Kurella Tamura MK, Covinsky KE, Chertow GM, Yaffe C, Landefeld CS, McCulloch CE. Functional status of elderly adults before and after initiation of dialysis. N Engl J Med. 2009;361(16):1539-1547.

Clinical question: Is functional status in the elderly maintained over time after initiating long-term dialysis?

Background: Quality-of-life maintenance often is used as a goal when initiating long-term dialysis in elderly patients with end-stage renal disease. More elderly patients are being offered long-term dialysis treatment. Little is known about the functional status of elderly patients on long-term dialysis.

Study design: Retrospective cohort study.

Setting: U.S. nursing homes.

Synopsis: By cross-linking data from two population-based administrative datasets, this study identified 3,702 nursing home patients (mean 73.4 years) who had started long-term dialysis and whose functional status had been assessed. Activities of daily living assessments before and at three-month intervals after dialysis initiation were compared to see if functional status was maintained.

Within three months of starting dialysis, 61% of patients had a decline in functional status or had died. By one year, only 1 in 8 patients had maintained their pre-dialysis functional status.

Decline in functional status cannot be attributed solely to dialysis because study patients were not compared to patients with chronic kidney disease who were not dialyzed. In addition, these results might not apply to all elderly patients on dialysis, as the functional status of elderly nursing home patients might differ significantly from those living at home.

Bottom line: Functional status is not maintained in most elderly nursing home patients in the first 12 months after long-term dialysis is initiated. Elderly patients considering dialysis treatment should be aware that dialysis might not help maintain functional status and quality of life.

Citation: Kurella Tamura MK, Covinsky KE, Chertow GM, Yaffe C, Landefeld CS, McCulloch CE. Functional status of elderly adults before and after initiation of dialysis. N Engl J Med. 2009;361(16):1539-1547.

Clinical question: Is functional status in the elderly maintained over time after initiating long-term dialysis?

Background: Quality-of-life maintenance often is used as a goal when initiating long-term dialysis in elderly patients with end-stage renal disease. More elderly patients are being offered long-term dialysis treatment. Little is known about the functional status of elderly patients on long-term dialysis.

Study design: Retrospective cohort study.

Setting: U.S. nursing homes.

Synopsis: By cross-linking data from two population-based administrative datasets, this study identified 3,702 nursing home patients (mean 73.4 years) who had started long-term dialysis and whose functional status had been assessed. Activities of daily living assessments before and at three-month intervals after dialysis initiation were compared to see if functional status was maintained.

Within three months of starting dialysis, 61% of patients had a decline in functional status or had died. By one year, only 1 in 8 patients had maintained their pre-dialysis functional status.

Decline in functional status cannot be attributed solely to dialysis because study patients were not compared to patients with chronic kidney disease who were not dialyzed. In addition, these results might not apply to all elderly patients on dialysis, as the functional status of elderly nursing home patients might differ significantly from those living at home.

Bottom line: Functional status is not maintained in most elderly nursing home patients in the first 12 months after long-term dialysis is initiated. Elderly patients considering dialysis treatment should be aware that dialysis might not help maintain functional status and quality of life.

Citation: Kurella Tamura MK, Covinsky KE, Chertow GM, Yaffe C, Landefeld CS, McCulloch CE. Functional status of elderly adults before and after initiation of dialysis. N Engl J Med. 2009;361(16):1539-1547.

Clinical question: Does long-term inhaled corticosteroid therapy, with and without long-acting beta-agonists, decrease airway inflammation and improve lung function in patients with moderate to severe chronic obstructive pulmonary disease (COPD)?

Background: Guideline-recommended treatment of COPD with inhaled corticosteroids and long-acting beta-agonists improves symptoms and exacerbation rates; little is known about the impact of these therapies on inflammation and long-term lung function.

Study design: Randomized, double-blind, placebo-controlled trial.

Setting: Two university medical centers in the Netherlands.

Synopsis: One hundred one steroid-naïve patients, ages 45 to 75 who were current or former smokers with moderate to severe COPD, were randomized to one of four regimens: 1) fluticasone for six months, then placebo for 24 months; 2) fluticasone for 30 months; 3) fluticasone and salmeterol for 30 months; or 4) placebo for 30 months. The primary outcome was inflammatory cell counts in bronchial biopsies/induced sputum. Secondary outcomes included postbronchodilator spirometry, methacholine hyperresponsiveness, and self-reported symptoms and health status. Patients with asthma were excluded.

Short-term fluticasone therapy decreased inflammation and improved forced expiratory volume in one second (FEV1). Long-term therapy also decreased the rate of FEV1 decline, reduced dyspnea, and improved health status. Discontinuation of therapy at six months led to inflammation relapse with worsened symptoms and increased rate of FEV1 decline. The addition of long-acting beta-agonists did not provide additional anti-inflammatory benefits, but it did improve FEV1 and dyspnea at six months.

Additional studies are needed to further define clinical outcomes and assess the cost benefit of these therapies.

Bottom line: Inhaled corticosteroids decrease inflammation in steroid-naïve patients with moderate to severe COPD and might decrease the rate of lung function decline. Long-acting beta-agonists do not offer additional anti-inflammatory benefit.

Citation: Lapperre TS, Snoeck-Stroband JB, Gosman MM, et al. Effect of fluticasone with and without salmeterol on pulmonary outcomes in chronic obstructive pulmonary disease: a randomized trial. Ann Intern Med. 2009;151(8):517-527.

Clinical question: Does long-term inhaled corticosteroid therapy, with and without long-acting beta-agonists, decrease airway inflammation and improve lung function in patients with moderate to severe chronic obstructive pulmonary disease (COPD)?

Background: Guideline-recommended treatment of COPD with inhaled corticosteroids and long-acting beta-agonists improves symptoms and exacerbation rates; little is known about the impact of these therapies on inflammation and long-term lung function.

Study design: Randomized, double-blind, placebo-controlled trial.

Setting: Two university medical centers in the Netherlands.

Synopsis: One hundred one steroid-naïve patients, ages 45 to 75 who were current or former smokers with moderate to severe COPD, were randomized to one of four regimens: 1) fluticasone for six months, then placebo for 24 months; 2) fluticasone for 30 months; 3) fluticasone and salmeterol for 30 months; or 4) placebo for 30 months. The primary outcome was inflammatory cell counts in bronchial biopsies/induced sputum. Secondary outcomes included postbronchodilator spirometry, methacholine hyperresponsiveness, and self-reported symptoms and health status. Patients with asthma were excluded.

Short-term fluticasone therapy decreased inflammation and improved forced expiratory volume in one second (FEV1). Long-term therapy also decreased the rate of FEV1 decline, reduced dyspnea, and improved health status. Discontinuation of therapy at six months led to inflammation relapse with worsened symptoms and increased rate of FEV1 decline. The addition of long-acting beta-agonists did not provide additional anti-inflammatory benefits, but it did improve FEV1 and dyspnea at six months.

Additional studies are needed to further define clinical outcomes and assess the cost benefit of these therapies.

Bottom line: Inhaled corticosteroids decrease inflammation in steroid-naïve patients with moderate to severe COPD and might decrease the rate of lung function decline. Long-acting beta-agonists do not offer additional anti-inflammatory benefit.

Citation: Lapperre TS, Snoeck-Stroband JB, Gosman MM, et al. Effect of fluticasone with and without salmeterol on pulmonary outcomes in chronic obstructive pulmonary disease: a randomized trial. Ann Intern Med. 2009;151(8):517-527.

Clinical question: Does long-term inhaled corticosteroid therapy, with and without long-acting beta-agonists, decrease airway inflammation and improve lung function in patients with moderate to severe chronic obstructive pulmonary disease (COPD)?

Background: Guideline-recommended treatment of COPD with inhaled corticosteroids and long-acting beta-agonists improves symptoms and exacerbation rates; little is known about the impact of these therapies on inflammation and long-term lung function.

Study design: Randomized, double-blind, placebo-controlled trial.

Setting: Two university medical centers in the Netherlands.

Synopsis: One hundred one steroid-naïve patients, ages 45 to 75 who were current or former smokers with moderate to severe COPD, were randomized to one of four regimens: 1) fluticasone for six months, then placebo for 24 months; 2) fluticasone for 30 months; 3) fluticasone and salmeterol for 30 months; or 4) placebo for 30 months. The primary outcome was inflammatory cell counts in bronchial biopsies/induced sputum. Secondary outcomes included postbronchodilator spirometry, methacholine hyperresponsiveness, and self-reported symptoms and health status. Patients with asthma were excluded.

Short-term fluticasone therapy decreased inflammation and improved forced expiratory volume in one second (FEV1). Long-term therapy also decreased the rate of FEV1 decline, reduced dyspnea, and improved health status. Discontinuation of therapy at six months led to inflammation relapse with worsened symptoms and increased rate of FEV1 decline. The addition of long-acting beta-agonists did not provide additional anti-inflammatory benefits, but it did improve FEV1 and dyspnea at six months.

Additional studies are needed to further define clinical outcomes and assess the cost benefit of these therapies.

Bottom line: Inhaled corticosteroids decrease inflammation in steroid-naïve patients with moderate to severe COPD and might decrease the rate of lung function decline. Long-acting beta-agonists do not offer additional anti-inflammatory benefit.

Citation: Lapperre TS, Snoeck-Stroband JB, Gosman MM, et al. Effect of fluticasone with and without salmeterol on pulmonary outcomes in chronic obstructive pulmonary disease: a randomized trial. Ann Intern Med. 2009;151(8):517-527.