The clinical milieu of type 2 diabetes mellitus (T2DM) is undoubtedly one of the most challenging faced by family physicians. The association of T2DM with other chronic diseases, such as hypertension, dyslipidemia, cardiovascular disease, and obesity, speaks to the complex issues that must be addressed. Considering the complexity of these issues, it is important to recognize that, as a chronic disease, T2DM is largely self-managed and patients mostly control their own DM-related health outcomes. To assist patients with T2DM to successfully take on this responsibility, family physicians should raise and discuss the treatment options available to achieve agreed upon goals, and, in consultation with the patient, recommend treatment options that best address the patient’s clinical issues and meet the patient’s needs. These steps are important to help motivate the patient and promote long-term treatment adherence. Among the treatment options available for T2DM, the challenges of self-management are perhaps greatest with insulin.

Insulin is the most physiologic and effective glucose-lowering agent available, and is recommended as glucose-lowering therapy over the spectrum of T2DM.^1,2 Yet studies show that the initiation of insulin treatment is often delayed, sometimes for years, following loss of glycemic control with oral glucose-lowering agents.^3,4 Once initiated, adherence to insulin tends to be moderate at best.^5,6 It is crucial that family physicians address the issues that contribute to low levels of acceptance and adherence to insulin treatment. In addition, physicians need a firm understanding of how to initiate, modify, and intensify insulin therapy. The primary goal of this supplement is to provide the family physician with a detailed understanding of the current recommendations for, and advances in, insulin treatment.

This supplement includes three articles; the first of which is a historical review of the discovery of insulin. Also included in that article, by Michael Heile, MD, and Doron Schneider, MD, FACP, is a review of the evolution of insulin, including a comparison of the clinical pharmacology of human and analog insulins. The second article begins with a discussion of the conceptual strategies to address patient barriers that have a dramatic impact on the acceptance of, and self-management with, insulin. Building on that foundation, Luigi Meneghini, MD, MBA, and Timothy Reid, MD, present 4 case studies that detail how to assist patients in the implementation of these strategies when initiating or intensifying insulin therapy. The case studies also provide practical considerations with respect to dosing basal, basal-bolus, and premixed insulin. The third article examines advances in insulin, with a focus on the investigational agent, ultra–long-acting insulin degludec. Allen King, MD, provides a solid foundation of the clinical pharmacology of insulin degludec and the clinical experience to date regarding the use of insulin degludec in patients with type 1 DM or T2DM.

It is hoped that the information in this supplement will prove helpful for the practicing family physician in managing patients with this increasingly common disease and its associated clinical dilemmas.

The clinical milieu of type 2 diabetes mellitus (T2DM) is undoubtedly one of the most challenging faced by family physicians. The association of T2DM with other chronic diseases, such as hypertension, dyslipidemia, cardiovascular disease, and obesity, speaks to the complex issues that must be addressed. Considering the complexity of these issues, it is important to recognize that, as a chronic disease, T2DM is largely self-managed and patients mostly control their own DM-related health outcomes. To assist patients with T2DM to successfully take on this responsibility, family physicians should raise and discuss the treatment options available to achieve agreed upon goals, and, in consultation with the patient, recommend treatment options that best address the patient’s clinical issues and meet the patient’s needs. These steps are important to help motivate the patient and promote long-term treatment adherence. Among the treatment options available for T2DM, the challenges of self-management are perhaps greatest with insulin.

Insulin is the most physiologic and effective glucose-lowering agent available, and is recommended as glucose-lowering therapy over the spectrum of T2DM.^1,2 Yet studies show that the initiation of insulin treatment is often delayed, sometimes for years, following loss of glycemic control with oral glucose-lowering agents.^3,4 Once initiated, adherence to insulin tends to be moderate at best.^5,6 It is crucial that family physicians address the issues that contribute to low levels of acceptance and adherence to insulin treatment. In addition, physicians need a firm understanding of how to initiate, modify, and intensify insulin therapy. The primary goal of this supplement is to provide the family physician with a detailed understanding of the current recommendations for, and advances in, insulin treatment.

This supplement includes three articles; the first of which is a historical review of the discovery of insulin. Also included in that article, by Michael Heile, MD, and Doron Schneider, MD, FACP, is a review of the evolution of insulin, including a comparison of the clinical pharmacology of human and analog insulins. The second article begins with a discussion of the conceptual strategies to address patient barriers that have a dramatic impact on the acceptance of, and self-management with, insulin. Building on that foundation, Luigi Meneghini, MD, MBA, and Timothy Reid, MD, present 4 case studies that detail how to assist patients in the implementation of these strategies when initiating or intensifying insulin therapy. The case studies also provide practical considerations with respect to dosing basal, basal-bolus, and premixed insulin. The third article examines advances in insulin, with a focus on the investigational agent, ultra–long-acting insulin degludec. Allen King, MD, provides a solid foundation of the clinical pharmacology of insulin degludec and the clinical experience to date regarding the use of insulin degludec in patients with type 1 DM or T2DM.

It is hoped that the information in this supplement will prove helpful for the practicing family physician in managing patients with this increasingly common disease and its associated clinical dilemmas.

The clinical milieu of type 2 diabetes mellitus (T2DM) is undoubtedly one of the most challenging faced by family physicians. The association of T2DM with other chronic diseases, such as hypertension, dyslipidemia, cardiovascular disease, and obesity, speaks to the complex issues that must be addressed. Considering the complexity of these issues, it is important to recognize that, as a chronic disease, T2DM is largely self-managed and patients mostly control their own DM-related health outcomes. To assist patients with T2DM to successfully take on this responsibility, family physicians should raise and discuss the treatment options available to achieve agreed upon goals, and, in consultation with the patient, recommend treatment options that best address the patient’s clinical issues and meet the patient’s needs. These steps are important to help motivate the patient and promote long-term treatment adherence. Among the treatment options available for T2DM, the challenges of self-management are perhaps greatest with insulin.

Insulin is the most physiologic and effective glucose-lowering agent available, and is recommended as glucose-lowering therapy over the spectrum of T2DM.^1,2 Yet studies show that the initiation of insulin treatment is often delayed, sometimes for years, following loss of glycemic control with oral glucose-lowering agents.^3,4 Once initiated, adherence to insulin tends to be moderate at best.^5,6 It is crucial that family physicians address the issues that contribute to low levels of acceptance and adherence to insulin treatment. In addition, physicians need a firm understanding of how to initiate, modify, and intensify insulin therapy. The primary goal of this supplement is to provide the family physician with a detailed understanding of the current recommendations for, and advances in, insulin treatment.

This supplement includes three articles; the first of which is a historical review of the discovery of insulin. Also included in that article, by Michael Heile, MD, and Doron Schneider, MD, FACP, is a review of the evolution of insulin, including a comparison of the clinical pharmacology of human and analog insulins. The second article begins with a discussion of the conceptual strategies to address patient barriers that have a dramatic impact on the acceptance of, and self-management with, insulin. Building on that foundation, Luigi Meneghini, MD, MBA, and Timothy Reid, MD, present 4 case studies that detail how to assist patients in the implementation of these strategies when initiating or intensifying insulin therapy. The case studies also provide practical considerations with respect to dosing basal, basal-bolus, and premixed insulin. The third article examines advances in insulin, with a focus on the investigational agent, ultra–long-acting insulin degludec. Allen King, MD, provides a solid foundation of the clinical pharmacology of insulin degludec and the clinical experience to date regarding the use of insulin degludec in patients with type 1 DM or T2DM.

It is hoped that the information in this supplement will prove helpful for the practicing family physician in managing patients with this increasingly common disease and its associated clinical dilemmas.

The clinical milieu of type 2 diabetes mellitus (T2DM) is undoubtedly one of the most challenging faced by family physicians. The association of T2DM with other chronic diseases, such as hypertension, dyslipidemia, cardiovascular disease, and obesity, speaks to the complex issues that must be addressed. Considering the complexity of these issues, it is important to recognize that, as a chronic disease, T2DM is largely self-managed and patients mostly control their own DM-related health outcomes. To assist patients with T2DM to successfully take on this responsibility, family physicians should raise and discuss the treatment options available to achieve agreed upon goals, and, in consultation with the patient, recommend treatment options that best address the patient’s clinical issues and meet the patient’s needs. These steps are important to help motivate the patient and promote long-term treatment adherence. Among the treatment options available for T2DM, the challenges of self-management are perhaps greatest with insulin.

Insulin is the most physiologic and effective glucose-lowering agent available, and is recommended as glucose-lowering therapy over the spectrum of T2DM.^1,2 Yet studies show that the initiation of insulin treatment is often delayed, sometimes for years, following loss of glycemic control with oral glucose-lowering agents.^3,4 Once initiated, adherence to insulin tends to be moderate at best.^5,6 It is crucial that family physicians address the issues that contribute to low levels of acceptance and adherence to insulin treatment. In addition, physicians need a firm understanding of how to initiate, modify, and intensify insulin therapy. The primary goal of this supplement is to provide the family physician with a detailed understanding of the current recommendations for, and advances in, insulin treatment.

This supplement includes three articles; the first of which is a historical review of the discovery of insulin. Also included in that article, by Michael Heile, MD, and Doron Schneider, MD, FACP, is a review of the evolution of insulin, including a comparison of the clinical pharmacology of human and analog insulins. The second article begins with a discussion of the conceptual strategies to address patient barriers that have a dramatic impact on the acceptance of, and self-management with, insulin. Building on that foundation, Luigi Meneghini, MD, MBA, and Timothy Reid, MD, present 4 case studies that detail how to assist patients in the implementation of these strategies when initiating or intensifying insulin therapy. The case studies also provide practical considerations with respect to dosing basal, basal-bolus, and premixed insulin. The third article examines advances in insulin, with a focus on the investigational agent, ultra–long-acting insulin degludec. Allen King, MD, provides a solid foundation of the clinical pharmacology of insulin degludec and the clinical experience to date regarding the use of insulin degludec in patients with type 1 DM or T2DM.

It is hoped that the information in this supplement will prove helpful for the practicing family physician in managing patients with this increasingly common disease and its associated clinical dilemmas.

The clinical milieu of type 2 diabetes mellitus (T2DM) is undoubtedly one of the most challenging faced by family physicians. The association of T2DM with other chronic diseases, such as hypertension, dyslipidemia, cardiovascular disease, and obesity, speaks to the complex issues that must be addressed. Considering the complexity of these issues, it is important to recognize that, as a chronic disease, T2DM is largely self-managed and patients mostly control their own DM-related health outcomes. To assist patients with T2DM to successfully take on this responsibility, family physicians should raise and discuss the treatment options available to achieve agreed upon goals, and, in consultation with the patient, recommend treatment options that best address the patient’s clinical issues and meet the patient’s needs. These steps are important to help motivate the patient and promote long-term treatment adherence. Among the treatment options available for T2DM, the challenges of self-management are perhaps greatest with insulin.

Insulin is the most physiologic and effective glucose-lowering agent available, and is recommended as glucose-lowering therapy over the spectrum of T2DM.^1,2 Yet studies show that the initiation of insulin treatment is often delayed, sometimes for years, following loss of glycemic control with oral glucose-lowering agents.^3,4 Once initiated, adherence to insulin tends to be moderate at best.^5,6 It is crucial that family physicians address the issues that contribute to low levels of acceptance and adherence to insulin treatment. In addition, physicians need a firm understanding of how to initiate, modify, and intensify insulin therapy. The primary goal of this supplement is to provide the family physician with a detailed understanding of the current recommendations for, and advances in, insulin treatment.

This supplement includes three articles; the first of which is a historical review of the discovery of insulin. Also included in that article, by Michael Heile, MD, and Doron Schneider, MD, FACP, is a review of the evolution of insulin, including a comparison of the clinical pharmacology of human and analog insulins. The second article begins with a discussion of the conceptual strategies to address patient barriers that have a dramatic impact on the acceptance of, and self-management with, insulin. Building on that foundation, Luigi Meneghini, MD, MBA, and Timothy Reid, MD, present 4 case studies that detail how to assist patients in the implementation of these strategies when initiating or intensifying insulin therapy. The case studies also provide practical considerations with respect to dosing basal, basal-bolus, and premixed insulin. The third article examines advances in insulin, with a focus on the investigational agent, ultra–long-acting insulin degludec. Allen King, MD, provides a solid foundation of the clinical pharmacology of insulin degludec and the clinical experience to date regarding the use of insulin degludec in patients with type 1 DM or T2DM.

It is hoped that the information in this supplement will prove helpful for the practicing family physician in managing patients with this increasingly common disease and its associated clinical dilemmas.

The clinical milieu of type 2 diabetes mellitus (T2DM) is undoubtedly one of the most challenging faced by family physicians. The association of T2DM with other chronic diseases, such as hypertension, dyslipidemia, cardiovascular disease, and obesity, speaks to the complex issues that must be addressed. Considering the complexity of these issues, it is important to recognize that, as a chronic disease, T2DM is largely self-managed and patients mostly control their own DM-related health outcomes. To assist patients with T2DM to successfully take on this responsibility, family physicians should raise and discuss the treatment options available to achieve agreed upon goals, and, in consultation with the patient, recommend treatment options that best address the patient’s clinical issues and meet the patient’s needs. These steps are important to help motivate the patient and promote long-term treatment adherence. Among the treatment options available for T2DM, the challenges of self-management are perhaps greatest with insulin.

Insulin is the most physiologic and effective glucose-lowering agent available, and is recommended as glucose-lowering therapy over the spectrum of T2DM.^1,2 Yet studies show that the initiation of insulin treatment is often delayed, sometimes for years, following loss of glycemic control with oral glucose-lowering agents.^3,4 Once initiated, adherence to insulin tends to be moderate at best.^5,6 It is crucial that family physicians address the issues that contribute to low levels of acceptance and adherence to insulin treatment. In addition, physicians need a firm understanding of how to initiate, modify, and intensify insulin therapy. The primary goal of this supplement is to provide the family physician with a detailed understanding of the current recommendations for, and advances in, insulin treatment.

This supplement includes three articles; the first of which is a historical review of the discovery of insulin. Also included in that article, by Michael Heile, MD, and Doron Schneider, MD, FACP, is a review of the evolution of insulin, including a comparison of the clinical pharmacology of human and analog insulins. The second article begins with a discussion of the conceptual strategies to address patient barriers that have a dramatic impact on the acceptance of, and self-management with, insulin. Building on that foundation, Luigi Meneghini, MD, MBA, and Timothy Reid, MD, present 4 case studies that detail how to assist patients in the implementation of these strategies when initiating or intensifying insulin therapy. The case studies also provide practical considerations with respect to dosing basal, basal-bolus, and premixed insulin. The third article examines advances in insulin, with a focus on the investigational agent, ultra–long-acting insulin degludec. Allen King, MD, provides a solid foundation of the clinical pharmacology of insulin degludec and the clinical experience to date regarding the use of insulin degludec in patients with type 1 DM or T2DM.

It is hoped that the information in this supplement will prove helpful for the practicing family physician in managing patients with this increasingly common disease and its associated clinical dilemmas.

A report from the Institute of Medicine in 2005¹ marked a watershed in the thinking about cancer patients and their long-term needs as survivors when it argued for oncology programs in the United States to address the unmet needs of cancer survivors at the community practice level. Cancer care in the United States has tended to focus on the more immediate aspects of the active treatment, limiting our long-term concerns for the patient’s well-being. Indeed, as a community oncologist in the early part of my career,² decades ago, I considered cancer patients “finished” with their cancer and back to “normal” soon after their last acute toxicity ended.² These days, our profession as well as patients and society as a whole have come to understand that the needs of cancer patients continue into well into survivorship, which can span years or even decades. These concerns should be addressed and accommodated through comprehensive, community-based survivorship programs.

*For a PDF of the full article, click on the link to the left of this introduction.

A report from the Institute of Medicine in 2005¹ marked a watershed in the thinking about cancer patients and their long-term needs as survivors when it argued for oncology programs in the United States to address the unmet needs of cancer survivors at the community practice level. Cancer care in the United States has tended to focus on the more immediate aspects of the active treatment, limiting our long-term concerns for the patient’s well-being. Indeed, as a community oncologist in the early part of my career,² decades ago, I considered cancer patients “finished” with their cancer and back to “normal” soon after their last acute toxicity ended.² These days, our profession as well as patients and society as a whole have come to understand that the needs of cancer patients continue into well into survivorship, which can span years or even decades. These concerns should be addressed and accommodated through comprehensive, community-based survivorship programs.

*For a PDF of the full article, click on the link to the left of this introduction.

A report from the Institute of Medicine in 2005¹ marked a watershed in the thinking about cancer patients and their long-term needs as survivors when it argued for oncology programs in the United States to address the unmet needs of cancer survivors at the community practice level. Cancer care in the United States has tended to focus on the more immediate aspects of the active treatment, limiting our long-term concerns for the patient’s well-being. Indeed, as a community oncologist in the early part of my career,² decades ago, I considered cancer patients “finished” with their cancer and back to “normal” soon after their last acute toxicity ended.² These days, our profession as well as patients and society as a whole have come to understand that the needs of cancer patients continue into well into survivorship, which can span years or even decades. These concerns should be addressed and accommodated through comprehensive, community-based survivorship programs.

*For a PDF of the full article, click on the link to the left of this introduction.

With related Commentary

Erwinia chrysanthemi, an asparaginase derived from the bacterium E chrysanthemi, was recently approved by the Food and Drug Administration as a component of multiagent chemotherapy in patients with acute lymphoblastic leukemia (ALL) who have developed hypersensitivity to Escherichia coli (E coli)-derived asparaginase and pegaspargase.¹ Hypersensitivity to E coli-derived asparaginase may occur in up to 30% of patients² with ALL, a common childhood cancer. Leukemic cells are not able to synthesize the amino acid asparagine, which is required for protein metabolism and survival, because of a lack of asparagine synthetase activity. Erwinia-derived asparaginase reduces circulating levels of asparagine by catalyzing the deamidation of asparagine to aspartic acid and ammonia. The reduction of circulating asparagine results in cytotoxicity specific for leukemic cells by depriving them of their source of the amino acid.

*For PDFs of the full report and accompanying Commentary, click on the links to the left of this introduction.

With related Commentary

Erwinia chrysanthemi, an asparaginase derived from the bacterium E chrysanthemi, was recently approved by the Food and Drug Administration as a component of multiagent chemotherapy in patients with acute lymphoblastic leukemia (ALL) who have developed hypersensitivity to Escherichia coli (E coli)-derived asparaginase and pegaspargase.¹ Hypersensitivity to E coli-derived asparaginase may occur in up to 30% of patients² with ALL, a common childhood cancer. Leukemic cells are not able to synthesize the amino acid asparagine, which is required for protein metabolism and survival, because of a lack of asparagine synthetase activity. Erwinia-derived asparaginase reduces circulating levels of asparagine by catalyzing the deamidation of asparagine to aspartic acid and ammonia. The reduction of circulating asparagine results in cytotoxicity specific for leukemic cells by depriving them of their source of the amino acid.

*For PDFs of the full report and accompanying Commentary, click on the links to the left of this introduction.

With related Commentary

Erwinia chrysanthemi, an asparaginase derived from the bacterium E chrysanthemi, was recently approved by the Food and Drug Administration as a component of multiagent chemotherapy in patients with acute lymphoblastic leukemia (ALL) who have developed hypersensitivity to Escherichia coli (E coli)-derived asparaginase and pegaspargase.¹ Hypersensitivity to E coli-derived asparaginase may occur in up to 30% of patients² with ALL, a common childhood cancer. Leukemic cells are not able to synthesize the amino acid asparagine, which is required for protein metabolism and survival, because of a lack of asparagine synthetase activity. Erwinia-derived asparaginase reduces circulating levels of asparagine by catalyzing the deamidation of asparagine to aspartic acid and ammonia. The reduction of circulating asparagine results in cytotoxicity specific for leukemic cells by depriving them of their source of the amino acid.

*For PDFs of the full report and accompanying Commentary, click on the links to the left of this introduction.

A supplement to Clinical Endocrinology News.
This supplement was sponsored by Amylin.

• Introduction
• Should Minimal Blood Glucose Variability Become the Gold Standard of Glycemic Control?
• Contributions of Fasting and Postprandial Plasma Glucose Increments to the Overall Diurnal Hyperglycemia of Type 2 Diabetic Patients
• Addition of Biphasic, Prandial, or Basal Insulin to Oral Therapy in Type 2 Diabetes
• Effects of Intensive Glucose Lowering in Type 2 Diabetes
• Pramlintide as an Adjunct to Insulin in Patients With Type 2 Diabetes in a Clinical Practice Setting Reduced A1C, Postprandial Glucose Excursions, and Weight
• Pramlintide as an Adjunct to Insulin Therapy Improves Long-Term Glycemic and Weight Control in Patients With Type 2 Diabetes: A 1-Year Randomized Controlled Trial
• Amylin Replacement with Primlintide as an Adjunct to Insulin Therapy Improves Long-Term Glycemic and Weight Control in Type 1 Diabetes Mellitus: A 1-Year, Randomized Controlled Trial
• Important Safety Information and SYMLIN Prescribing Information

Faculty/Faculty Disclosure

Steven V. Edelman, MD
Professor of Medicine, University of California, San Diego
Veterans Affairs Medical Center, San Diego, California
Founder and Director, Taking Control of Your Diabetes, 501(3)
Del Mar, California
Associate Clinical Professor of Medicine
Dr. Edelman is a consultant to and speaker for Amylin Pharmaceuticals, Inc., Eli Lilly and Company, Novo Nordisk A/S, and sanofi-aventis U.S., LLC.

Copyright © 2009 Elsevier Inc.

A supplement to Clinical Endocrinology News.
This supplement was sponsored by Amylin.

• Introduction
• Should Minimal Blood Glucose Variability Become the Gold Standard of Glycemic Control?
• Contributions of Fasting and Postprandial Plasma Glucose Increments to the Overall Diurnal Hyperglycemia of Type 2 Diabetic Patients
• Addition of Biphasic, Prandial, or Basal Insulin to Oral Therapy in Type 2 Diabetes
• Effects of Intensive Glucose Lowering in Type 2 Diabetes
• Pramlintide as an Adjunct to Insulin in Patients With Type 2 Diabetes in a Clinical Practice Setting Reduced A1C, Postprandial Glucose Excursions, and Weight
• Pramlintide as an Adjunct to Insulin Therapy Improves Long-Term Glycemic and Weight Control in Patients With Type 2 Diabetes: A 1-Year Randomized Controlled Trial
• Amylin Replacement with Primlintide as an Adjunct to Insulin Therapy Improves Long-Term Glycemic and Weight Control in Type 1 Diabetes Mellitus: A 1-Year, Randomized Controlled Trial
• Important Safety Information and SYMLIN Prescribing Information

Faculty/Faculty Disclosure

Steven V. Edelman, MD
Professor of Medicine, University of California, San Diego
Veterans Affairs Medical Center, San Diego, California
Founder and Director, Taking Control of Your Diabetes, 501(3)
Del Mar, California
Associate Clinical Professor of Medicine
Dr. Edelman is a consultant to and speaker for Amylin Pharmaceuticals, Inc., Eli Lilly and Company, Novo Nordisk A/S, and sanofi-aventis U.S., LLC.

Copyright © 2009 Elsevier Inc.

A supplement to Clinical Endocrinology News.
This supplement was sponsored by Amylin.

• Introduction
• Should Minimal Blood Glucose Variability Become the Gold Standard of Glycemic Control?
• Contributions of Fasting and Postprandial Plasma Glucose Increments to the Overall Diurnal Hyperglycemia of Type 2 Diabetic Patients
• Addition of Biphasic, Prandial, or Basal Insulin to Oral Therapy in Type 2 Diabetes
• Effects of Intensive Glucose Lowering in Type 2 Diabetes
• Pramlintide as an Adjunct to Insulin in Patients With Type 2 Diabetes in a Clinical Practice Setting Reduced A1C, Postprandial Glucose Excursions, and Weight
• Pramlintide as an Adjunct to Insulin Therapy Improves Long-Term Glycemic and Weight Control in Patients With Type 2 Diabetes: A 1-Year Randomized Controlled Trial
• Amylin Replacement with Primlintide as an Adjunct to Insulin Therapy Improves Long-Term Glycemic and Weight Control in Type 1 Diabetes Mellitus: A 1-Year, Randomized Controlled Trial
• Important Safety Information and SYMLIN Prescribing Information

Faculty/Faculty Disclosure

Steven V. Edelman, MD
Professor of Medicine, University of California, San Diego
Veterans Affairs Medical Center, San Diego, California
Founder and Director, Taking Control of Your Diabetes, 501(3)
Del Mar, California
Associate Clinical Professor of Medicine
Dr. Edelman is a consultant to and speaker for Amylin Pharmaceuticals, Inc., Eli Lilly and Company, Novo Nordisk A/S, and sanofi-aventis U.S., LLC.

Copyright © 2009 Elsevier Inc.

BOSTON – Children who present to the emergency department with the classic "seat-belt sign" may have intra-abdominal injuries that warrant further investigation, even when they do not exhibit abdominal pain or tenderness, reported investigators at the annual meeting of the Pediatric Academic Societies.

The seat-belt sign – a continuous area of erythema, ecchymosis, or contusion caused by seat-belt pressure during a vehicle collision or impact – was significantly associated with risk for any intra-abdominal injury, reported Dr. Angela Ellison, an emergency physician at the Children’s Hospital of Philadelphia.

One-third of children with the seat-belt sign did not have abdominal pain or tenderness, yet 10% of those who also had an abdominal CT scan were found to have an intra-abdominal injury.

"Children with seat-belt sign are at high risk of intra-abdominal injury, primarily gastrointestinal injury, and are more likely to undergo acute intervention for intra-abdominal injury," Dr. Ellison said, speaking on behalf of colleagues in the Pediatric Emergency Care Applied Research Network.

The investigators analyzed a subset of patients from a prospective multicenter study of children presenting to 20 emergency departments with blunt torso trauma. They identified 3,740 children younger than 18 years with blunt abdominal trauma from a motor vehicle collision, excluding those with injuries older than 24 hours, those with preexisting neurologic disorders, and those transferred with prior abdominal images.

To scan or not to scan was left to the discretion of the treating physician, and clinical data, including findings of the presence or absence of a seat-belt sign, were collected. Patients were followed with a telephone call at 1 week if they were discharged after treatment or with medical records if they were admitted.

The authors found that 585 children (16%) had the seat-belt sign, and 3,155 (84%) did not. In all, 443 patients with the sign (76%) had an abdominal CT, compared with 1,415 (45%) of those lacking the sign (P less than .001). In total, 50% of the study population had an abdominal CT.

Among the patients who underwent CT, 19% of those with the seat-belt sign had some form of intra-abdominal injury, compared with 11% of those who had CT scans but no seat-belt sign (relative risk [RR], 1.6; 95% confidence interval [CI], 1.3-2.1). Gastrointestinal injuries were the most common, occurring in 10% of the seat-belt sign patients and 1% of those with no sign (RR, 9.8; 95% CI, 5.5-17.4). There were no significant differences between the groups in rates of injury to the spleen, liver, kidney, or pancreas.

In multivariate analysis, they found that factors significantly associated with a risk for any intra-abdominal injury were the seat-belt sign (RR, 1.7; P less than .01), hypotension (RR, 2.6; P less than .01), Glasgow Coma Scale score less than 14 (RR, 2.2; P less than .01), decreased breath sounds (RR, 1.7; P = .03), abdominal tenderness (RR, 1.6; P less than .01), and evidence of thoracic trauma (RR, 1.4; P = .03).

Patients with the seat-belt sign were significantly more likely to undergo any acute intervention for intra-abdominal injury (RR, 4.5; 95% CI, 3.0-6.8), nothing-by-mouth orders and intravenous fluids for more than 2 nights (RR, 14.6; 95% CI, 7.1-29.9), laparotomy (RR, 9.5; 95% CI, 5.6-16.1), or blood transfusion (RR, 2.9; 95% CI, 1.6-5.1).

Of the 196 patients with the seat-belt sign but no abdominal pain or tenderness (34%), 103 had abdominal CT and, of this group, 11 (10.7%) had an intra-abdominal injury diagnosed. Of all 196 patients, 4 (2%) required an acute intervention for their injuries.

"Children with seat-belt sign and no abdominal pain or tenderness have a high risk of acute abdominal injury and a non-negligible risk of undergoing acute interventions for intra-abdominal injury. Therefore, we recommend that clinicians strongly consider additional evaluation in this subpopulation of patients," Dr. Ellison said.

The study was supported by the National Center for Injury Prevention and Control and the Health Resources and Services Administration. Dr. Ellison and coauthors reported having no conflicts of interest.

BOSTON – Children who present to the emergency department with the classic "seat-belt sign" may have intra-abdominal injuries that warrant further investigation, even when they do not exhibit abdominal pain or tenderness, reported investigators at the annual meeting of the Pediatric Academic Societies.

The seat-belt sign – a continuous area of erythema, ecchymosis, or contusion caused by seat-belt pressure during a vehicle collision or impact – was significantly associated with risk for any intra-abdominal injury, reported Dr. Angela Ellison, an emergency physician at the Children’s Hospital of Philadelphia.

One-third of children with the seat-belt sign did not have abdominal pain or tenderness, yet 10% of those who also had an abdominal CT scan were found to have an intra-abdominal injury.

"Children with seat-belt sign are at high risk of intra-abdominal injury, primarily gastrointestinal injury, and are more likely to undergo acute intervention for intra-abdominal injury," Dr. Ellison said, speaking on behalf of colleagues in the Pediatric Emergency Care Applied Research Network.

The investigators analyzed a subset of patients from a prospective multicenter study of children presenting to 20 emergency departments with blunt torso trauma. They identified 3,740 children younger than 18 years with blunt abdominal trauma from a motor vehicle collision, excluding those with injuries older than 24 hours, those with preexisting neurologic disorders, and those transferred with prior abdominal images.

To scan or not to scan was left to the discretion of the treating physician, and clinical data, including findings of the presence or absence of a seat-belt sign, were collected. Patients were followed with a telephone call at 1 week if they were discharged after treatment or with medical records if they were admitted.

The authors found that 585 children (16%) had the seat-belt sign, and 3,155 (84%) did not. In all, 443 patients with the sign (76%) had an abdominal CT, compared with 1,415 (45%) of those lacking the sign (P less than .001). In total, 50% of the study population had an abdominal CT.

Among the patients who underwent CT, 19% of those with the seat-belt sign had some form of intra-abdominal injury, compared with 11% of those who had CT scans but no seat-belt sign (relative risk [RR], 1.6; 95% confidence interval [CI], 1.3-2.1). Gastrointestinal injuries were the most common, occurring in 10% of the seat-belt sign patients and 1% of those with no sign (RR, 9.8; 95% CI, 5.5-17.4). There were no significant differences between the groups in rates of injury to the spleen, liver, kidney, or pancreas.

In multivariate analysis, they found that factors significantly associated with a risk for any intra-abdominal injury were the seat-belt sign (RR, 1.7; P less than .01), hypotension (RR, 2.6; P less than .01), Glasgow Coma Scale score less than 14 (RR, 2.2; P less than .01), decreased breath sounds (RR, 1.7; P = .03), abdominal tenderness (RR, 1.6; P less than .01), and evidence of thoracic trauma (RR, 1.4; P = .03).

Patients with the seat-belt sign were significantly more likely to undergo any acute intervention for intra-abdominal injury (RR, 4.5; 95% CI, 3.0-6.8), nothing-by-mouth orders and intravenous fluids for more than 2 nights (RR, 14.6; 95% CI, 7.1-29.9), laparotomy (RR, 9.5; 95% CI, 5.6-16.1), or blood transfusion (RR, 2.9; 95% CI, 1.6-5.1).

Of the 196 patients with the seat-belt sign but no abdominal pain or tenderness (34%), 103 had abdominal CT and, of this group, 11 (10.7%) had an intra-abdominal injury diagnosed. Of all 196 patients, 4 (2%) required an acute intervention for their injuries.

"Children with seat-belt sign and no abdominal pain or tenderness have a high risk of acute abdominal injury and a non-negligible risk of undergoing acute interventions for intra-abdominal injury. Therefore, we recommend that clinicians strongly consider additional evaluation in this subpopulation of patients," Dr. Ellison said.

The study was supported by the National Center for Injury Prevention and Control and the Health Resources and Services Administration. Dr. Ellison and coauthors reported having no conflicts of interest.

BOSTON – Children who present to the emergency department with the classic "seat-belt sign" may have intra-abdominal injuries that warrant further investigation, even when they do not exhibit abdominal pain or tenderness, reported investigators at the annual meeting of the Pediatric Academic Societies.

The seat-belt sign – a continuous area of erythema, ecchymosis, or contusion caused by seat-belt pressure during a vehicle collision or impact – was significantly associated with risk for any intra-abdominal injury, reported Dr. Angela Ellison, an emergency physician at the Children’s Hospital of Philadelphia.

One-third of children with the seat-belt sign did not have abdominal pain or tenderness, yet 10% of those who also had an abdominal CT scan were found to have an intra-abdominal injury.

"Children with seat-belt sign are at high risk of intra-abdominal injury, primarily gastrointestinal injury, and are more likely to undergo acute intervention for intra-abdominal injury," Dr. Ellison said, speaking on behalf of colleagues in the Pediatric Emergency Care Applied Research Network.

The investigators analyzed a subset of patients from a prospective multicenter study of children presenting to 20 emergency departments with blunt torso trauma. They identified 3,740 children younger than 18 years with blunt abdominal trauma from a motor vehicle collision, excluding those with injuries older than 24 hours, those with preexisting neurologic disorders, and those transferred with prior abdominal images.

To scan or not to scan was left to the discretion of the treating physician, and clinical data, including findings of the presence or absence of a seat-belt sign, were collected. Patients were followed with a telephone call at 1 week if they were discharged after treatment or with medical records if they were admitted.

The authors found that 585 children (16%) had the seat-belt sign, and 3,155 (84%) did not. In all, 443 patients with the sign (76%) had an abdominal CT, compared with 1,415 (45%) of those lacking the sign (P less than .001). In total, 50% of the study population had an abdominal CT.

Among the patients who underwent CT, 19% of those with the seat-belt sign had some form of intra-abdominal injury, compared with 11% of those who had CT scans but no seat-belt sign (relative risk [RR], 1.6; 95% confidence interval [CI], 1.3-2.1). Gastrointestinal injuries were the most common, occurring in 10% of the seat-belt sign patients and 1% of those with no sign (RR, 9.8; 95% CI, 5.5-17.4). There were no significant differences between the groups in rates of injury to the spleen, liver, kidney, or pancreas.

In multivariate analysis, they found that factors significantly associated with a risk for any intra-abdominal injury were the seat-belt sign (RR, 1.7; P less than .01), hypotension (RR, 2.6; P less than .01), Glasgow Coma Scale score less than 14 (RR, 2.2; P less than .01), decreased breath sounds (RR, 1.7; P = .03), abdominal tenderness (RR, 1.6; P less than .01), and evidence of thoracic trauma (RR, 1.4; P = .03).

Patients with the seat-belt sign were significantly more likely to undergo any acute intervention for intra-abdominal injury (RR, 4.5; 95% CI, 3.0-6.8), nothing-by-mouth orders and intravenous fluids for more than 2 nights (RR, 14.6; 95% CI, 7.1-29.9), laparotomy (RR, 9.5; 95% CI, 5.6-16.1), or blood transfusion (RR, 2.9; 95% CI, 1.6-5.1).

Of the 196 patients with the seat-belt sign but no abdominal pain or tenderness (34%), 103 had abdominal CT and, of this group, 11 (10.7%) had an intra-abdominal injury diagnosed. Of all 196 patients, 4 (2%) required an acute intervention for their injuries.

"Children with seat-belt sign and no abdominal pain or tenderness have a high risk of acute abdominal injury and a non-negligible risk of undergoing acute interventions for intra-abdominal injury. Therefore, we recommend that clinicians strongly consider additional evaluation in this subpopulation of patients," Dr. Ellison said.

The study was supported by the National Center for Injury Prevention and Control and the Health Resources and Services Administration. Dr. Ellison and coauthors reported having no conflicts of interest.

A Case Studies Compendium supplement to Clinical Endocrinology News. This supplement was sponsored by Daiichi Sankyo, Inc.

• Background
• Current Visit
• Laboratory Results
• Clinical Discussion
• Endocrinologist Consultation
• New Treatment Regimen With Add-On Therapy
• Conclusions

Case 2 Topics

• Background
• Current Visit: Exam Findings
• Current Treatment Regimen
• Health History
• Laboratory Results
• Clinical Discussion
• Cardiologist Visit
• Three Months After Visiting the Cardiologist
• Add-On Therapy With Welchol for Patients With T2DM and CHD
• Treatment Goals for Alice
• Conclusions

Faculty/Faculty Disclosures

Yehuda Handelsman, MD, FACP, FACE
Medical Director
Metabolic Institute of America
Chair and Program Director
7th World Congress on InsulinResistance
Chair, International Committeefor Insulin Resistance
18372 Clark Street, Suite 212
Tarzana, CA 91356
E-mail:[email protected]
Web Site:www.TheMetabolicCenter.com
Dr Handelsman is a consultant for Bristol-Myers Squibb

Company, Daiichi Sankyo, Inc., GlaxoSmithKline, Medtronic, Merck, Tethys,

and Xoma; he has received clinical research grant funding from Daiichi Sankyo, Inc., GlaxoSmithKline, Novo Nordisk, and Takeda; and he ison the speakers bureau for AstraZeneca, Bristol-Myers Squibb, Daiichi Sankyo, Inc., GlaxoSmithKline, Merck, and Novartis. He also serves on the advisory board for CLINICAL ENDOCRINOLOGY NEWS.

Peter H. Jones, MD, FACP
Co-Director, Lipid Metabolism
and Atherosclerosis Clinic
Medical Director, Weight
Management Center
The Methodist Hospital
Associate Professor of Medicine
Section of Atherosclerosis andLipid Research
Baylor College of Medicine
Houston, TX 77030
E-mail: [email protected]
Dr Jones has disclosed that he has received support in the form of consulting agreements from Abbott Laboratories, AstraZeneca Pharmaceuticals LP, Daiichi Sankyo, Inc., and Merck.

Copyright © 2010 Elsevier Inc.

To view the supplement, click the image above.

A Case Studies Compendium supplement to Clinical Endocrinology News. This supplement was sponsored by Daiichi Sankyo, Inc.

• Background
• Current Visit
• Laboratory Results
• Clinical Discussion
• Endocrinologist Consultation
• New Treatment Regimen With Add-On Therapy
• Conclusions

Case 2 Topics

• Background
• Current Visit: Exam Findings
• Current Treatment Regimen
• Health History
• Laboratory Results
• Clinical Discussion
• Cardiologist Visit
• Three Months After Visiting the Cardiologist
• Add-On Therapy With Welchol for Patients With T2DM and CHD
• Treatment Goals for Alice
• Conclusions

Faculty/Faculty Disclosures

Yehuda Handelsman, MD, FACP, FACE
Medical Director
Metabolic Institute of America
Chair and Program Director
7th World Congress on InsulinResistance
Chair, International Committeefor Insulin Resistance
18372 Clark Street, Suite 212
Tarzana, CA 91356
E-mail:[email protected]
Web Site:www.TheMetabolicCenter.com
Dr Handelsman is a consultant for Bristol-Myers Squibb

Company, Daiichi Sankyo, Inc., GlaxoSmithKline, Medtronic, Merck, Tethys,

and Xoma; he has received clinical research grant funding from Daiichi Sankyo, Inc., GlaxoSmithKline, Novo Nordisk, and Takeda; and he ison the speakers bureau for AstraZeneca, Bristol-Myers Squibb, Daiichi Sankyo, Inc., GlaxoSmithKline, Merck, and Novartis. He also serves on the advisory board for CLINICAL ENDOCRINOLOGY NEWS.

Peter H. Jones, MD, FACP
Co-Director, Lipid Metabolism
and Atherosclerosis Clinic
Medical Director, Weight
Management Center
The Methodist Hospital
Associate Professor of Medicine
Section of Atherosclerosis andLipid Research
Baylor College of Medicine
Houston, TX 77030
E-mail: [email protected]
Dr Jones has disclosed that he has received support in the form of consulting agreements from Abbott Laboratories, AstraZeneca Pharmaceuticals LP, Daiichi Sankyo, Inc., and Merck.

Copyright © 2010 Elsevier Inc.

To view the supplement, click the image above.

A Case Studies Compendium supplement to Clinical Endocrinology News. This supplement was sponsored by Daiichi Sankyo, Inc.

• Background
• Current Visit
• Laboratory Results
• Clinical Discussion
• Endocrinologist Consultation
• New Treatment Regimen With Add-On Therapy
• Conclusions

Case 2 Topics

• Background
• Current Visit: Exam Findings
• Current Treatment Regimen
• Health History
• Laboratory Results
• Clinical Discussion
• Cardiologist Visit
• Three Months After Visiting the Cardiologist
• Add-On Therapy With Welchol for Patients With T2DM and CHD
• Treatment Goals for Alice
• Conclusions

Faculty/Faculty Disclosures

Yehuda Handelsman, MD, FACP, FACE
Medical Director
Metabolic Institute of America
Chair and Program Director
7th World Congress on InsulinResistance
Chair, International Committeefor Insulin Resistance
18372 Clark Street, Suite 212
Tarzana, CA 91356
E-mail:[email protected]
Web Site:www.TheMetabolicCenter.com
Dr Handelsman is a consultant for Bristol-Myers Squibb

Company, Daiichi Sankyo, Inc., GlaxoSmithKline, Medtronic, Merck, Tethys,

and Xoma; he has received clinical research grant funding from Daiichi Sankyo, Inc., GlaxoSmithKline, Novo Nordisk, and Takeda; and he ison the speakers bureau for AstraZeneca, Bristol-Myers Squibb, Daiichi Sankyo, Inc., GlaxoSmithKline, Merck, and Novartis. He also serves on the advisory board for CLINICAL ENDOCRINOLOGY NEWS.

Peter H. Jones, MD, FACP
Co-Director, Lipid Metabolism
and Atherosclerosis Clinic
Medical Director, Weight
Management Center
The Methodist Hospital
Associate Professor of Medicine
Section of Atherosclerosis andLipid Research
Baylor College of Medicine
Houston, TX 77030
E-mail: [email protected]
Dr Jones has disclosed that he has received support in the form of consulting agreements from Abbott Laboratories, AstraZeneca Pharmaceuticals LP, Daiichi Sankyo, Inc., and Merck.

Copyright © 2010 Elsevier Inc.

To view the supplement, click the image above.

A Journal Scan supplement to Clinical Endocrinology News. This supplement was sponsored by Daiichi Sankyo, Inc.

• Introduction
• Results of the Glucose-Lowering Effect of WelChol Study (GLOWS): A Randomized, Double-Blind, Placebo-Controlled Pilot Study Evaluating the Effect of Colesevelam Hydrochloride on Glycemic Control in Subjects with Type 2 Diabetes
• Efficacy and Safety of Colesevelam in Patients With Type 2 Diabetes Mellitus and Inadequate Glycemic Control Receiving Insulin-Based Therapy
• Colesevelam HCl Improves Glycemic Control and Reduces LDL Cholesterol in Patients With Inadequately Controlled Type 2 Diabetes on Sulfonylurea-Based Therapy
• Colesevelam Hydrochloride Therapy in Patients With Type 2 Diabetes Mellitus Treated With Metformin: Glucose and Lipid Effects

Faculty/Faculty Disclosures

Endocrinologist:
Harold E. Bays, MD, FACP, FACE
Medical Director/President
Louisville Metabolic and
Atherosclerosis Research Center
Louisville, Kentucky
Dr Bays has research grants, consultant fees, and speaker fees with Abbott Laboratories, Aegerion Pharmaceuticals, Akros Pharma Inc, Amarin, Amgen Inc., Amylin Pharmaceuticals, Inc., Arena Pharmaceuticals, Inc., Arete Therapeutics Inc., AstraZeneca, Bristol-Myers Squibb, Boehringer Ingelheim Corporation, Cargill, Inc., Daiichi Sankyo, Inc., Eli Lilly and Company, Essentialis, Inc., GlaxoSmithKline plc, Hoffmann-La Roche Inc., Home Access Health Corporation, InteKrin Therapeutics Inc., Isis Pharmaceuticals, Inc., Johnson & Johnson Services, Inc., Merck & Co., Inc.,Merck/Schering-Plough Pharmaceuticals, Metabolex, Inc., Neuromed Pharmaceuticals Ltd., NicOx, Novo Nordisk A/S, Orexigen Therapeutics, Inc., Pfizer Inc., Purdue Pharma L.P., sanofi-aventis US LLC, Sciele Pharma, Inc., Surface Logix, Inc., Takeda Pharmaceutical Company Limited, and VIVUS Inc.

Cardiologist:
Peter H. Jones, MD
Associate Professor of Medicine
Baylor College of Medicine
Houston, Texas
Dr Jones has consulting agreements with Abbott Laboratories, AstraZeneca, Daiichi Sankyo, Inc., and Merck/Schering-Plough Pharmaceuticals.

Copyright © 2010 Elsevier Inc.

To view the supplement, click the image above.

A Journal Scan supplement to Clinical Endocrinology News. This supplement was sponsored by Daiichi Sankyo, Inc.

• Introduction
• Results of the Glucose-Lowering Effect of WelChol Study (GLOWS): A Randomized, Double-Blind, Placebo-Controlled Pilot Study Evaluating the Effect of Colesevelam Hydrochloride on Glycemic Control in Subjects with Type 2 Diabetes
• Efficacy and Safety of Colesevelam in Patients With Type 2 Diabetes Mellitus and Inadequate Glycemic Control Receiving Insulin-Based Therapy
• Colesevelam HCl Improves Glycemic Control and Reduces LDL Cholesterol in Patients With Inadequately Controlled Type 2 Diabetes on Sulfonylurea-Based Therapy
• Colesevelam Hydrochloride Therapy in Patients With Type 2 Diabetes Mellitus Treated With Metformin: Glucose and Lipid Effects

Faculty/Faculty Disclosures

Endocrinologist:
Harold E. Bays, MD, FACP, FACE
Medical Director/President
Louisville Metabolic and
Atherosclerosis Research Center
Louisville, Kentucky
Dr Bays has research grants, consultant fees, and speaker fees with Abbott Laboratories, Aegerion Pharmaceuticals, Akros Pharma Inc, Amarin, Amgen Inc., Amylin Pharmaceuticals, Inc., Arena Pharmaceuticals, Inc., Arete Therapeutics Inc., AstraZeneca, Bristol-Myers Squibb, Boehringer Ingelheim Corporation, Cargill, Inc., Daiichi Sankyo, Inc., Eli Lilly and Company, Essentialis, Inc., GlaxoSmithKline plc, Hoffmann-La Roche Inc., Home Access Health Corporation, InteKrin Therapeutics Inc., Isis Pharmaceuticals, Inc., Johnson & Johnson Services, Inc., Merck & Co., Inc.,Merck/Schering-Plough Pharmaceuticals, Metabolex, Inc., Neuromed Pharmaceuticals Ltd., NicOx, Novo Nordisk A/S, Orexigen Therapeutics, Inc., Pfizer Inc., Purdue Pharma L.P., sanofi-aventis US LLC, Sciele Pharma, Inc., Surface Logix, Inc., Takeda Pharmaceutical Company Limited, and VIVUS Inc.

Cardiologist:
Peter H. Jones, MD
Associate Professor of Medicine
Baylor College of Medicine
Houston, Texas
Dr Jones has consulting agreements with Abbott Laboratories, AstraZeneca, Daiichi Sankyo, Inc., and Merck/Schering-Plough Pharmaceuticals.

Copyright © 2010 Elsevier Inc.

To view the supplement, click the image above.

A Journal Scan supplement to Clinical Endocrinology News. This supplement was sponsored by Daiichi Sankyo, Inc.

• Introduction
• Results of the Glucose-Lowering Effect of WelChol Study (GLOWS): A Randomized, Double-Blind, Placebo-Controlled Pilot Study Evaluating the Effect of Colesevelam Hydrochloride on Glycemic Control in Subjects with Type 2 Diabetes
• Efficacy and Safety of Colesevelam in Patients With Type 2 Diabetes Mellitus and Inadequate Glycemic Control Receiving Insulin-Based Therapy
• Colesevelam HCl Improves Glycemic Control and Reduces LDL Cholesterol in Patients With Inadequately Controlled Type 2 Diabetes on Sulfonylurea-Based Therapy
• Colesevelam Hydrochloride Therapy in Patients With Type 2 Diabetes Mellitus Treated With Metformin: Glucose and Lipid Effects

Faculty/Faculty Disclosures

Endocrinologist:
Harold E. Bays, MD, FACP, FACE
Medical Director/President
Louisville Metabolic and
Atherosclerosis Research Center
Louisville, Kentucky
Dr Bays has research grants, consultant fees, and speaker fees with Abbott Laboratories, Aegerion Pharmaceuticals, Akros Pharma Inc, Amarin, Amgen Inc., Amylin Pharmaceuticals, Inc., Arena Pharmaceuticals, Inc., Arete Therapeutics Inc., AstraZeneca, Bristol-Myers Squibb, Boehringer Ingelheim Corporation, Cargill, Inc., Daiichi Sankyo, Inc., Eli Lilly and Company, Essentialis, Inc., GlaxoSmithKline plc, Hoffmann-La Roche Inc., Home Access Health Corporation, InteKrin Therapeutics Inc., Isis Pharmaceuticals, Inc., Johnson & Johnson Services, Inc., Merck & Co., Inc.,Merck/Schering-Plough Pharmaceuticals, Metabolex, Inc., Neuromed Pharmaceuticals Ltd., NicOx, Novo Nordisk A/S, Orexigen Therapeutics, Inc., Pfizer Inc., Purdue Pharma L.P., sanofi-aventis US LLC, Sciele Pharma, Inc., Surface Logix, Inc., Takeda Pharmaceutical Company Limited, and VIVUS Inc.

Cardiologist:
Peter H. Jones, MD
Associate Professor of Medicine
Baylor College of Medicine
Houston, Texas
Dr Jones has consulting agreements with Abbott Laboratories, AstraZeneca, Daiichi Sankyo, Inc., and Merck/Schering-Plough Pharmaceuticals.

Copyright © 2010 Elsevier Inc.

To view the supplement, click the image above.

A supplement to Clinical Endocrinology News. This supplement was sponsored by Daiichi Sankyo, Inc.

• Background
• Current Visit
• Laboratory Results
• Clinical Discussion
• Endocrinologist Consultation
• New Treatment Regimen With Add-On Therapy
• Conclusions

Faculty

Yehuda Handelsman, MD, FACP, FACE
Medical Director, Metabolic Institute of America
Chair and Program Director, 7th World Congress on Insulin Resistance Chair, International Committee for Insulin Resistance
18372 Clark Street, Suite 212
Tarzana, CA 91356
E-mail:[email protected]
Web site:www.TheMetabolicCenter.com
Dr Handelsman is a consultant for Bristol-Myers Squibb Company, Daiichi Sankyo, Inc., GlaxoSmithKline, Medtronic, Merck, Xoma, and Tethys;he has received clinical research grant funding from Takeda, Daiichi Sankyo Inc., GlaxoSmithKline, and Novo Nordisk; and he is on the speakers bureau for AstraZeneca, Bristol-Myers Squibb, Daiichi Sankyo Inc., GlaxoSmithKline, Merck, and Novartis. He also serves on the advisory board for CLINICAL ENDOCRINOLOGY NEWS.

Copyright © 2010 Elsevier Inc.

To view the supplement, click the image above.

A supplement to Clinical Endocrinology News. This supplement was sponsored by Daiichi Sankyo, Inc.

• Background
• Current Visit
• Laboratory Results
• Clinical Discussion
• Endocrinologist Consultation
• New Treatment Regimen With Add-On Therapy
• Conclusions

Faculty

Yehuda Handelsman, MD, FACP, FACE
Medical Director, Metabolic Institute of America
Chair and Program Director, 7th World Congress on Insulin Resistance Chair, International Committee for Insulin Resistance
18372 Clark Street, Suite 212
Tarzana, CA 91356
E-mail:[email protected]
Web site:www.TheMetabolicCenter.com
Dr Handelsman is a consultant for Bristol-Myers Squibb Company, Daiichi Sankyo, Inc., GlaxoSmithKline, Medtronic, Merck, Xoma, and Tethys;he has received clinical research grant funding from Takeda, Daiichi Sankyo Inc., GlaxoSmithKline, and Novo Nordisk; and he is on the speakers bureau for AstraZeneca, Bristol-Myers Squibb, Daiichi Sankyo Inc., GlaxoSmithKline, Merck, and Novartis. He also serves on the advisory board for CLINICAL ENDOCRINOLOGY NEWS.

Copyright © 2010 Elsevier Inc.

To view the supplement, click the image above.

A supplement to Clinical Endocrinology News. This supplement was sponsored by Daiichi Sankyo, Inc.

• Background
• Current Visit
• Laboratory Results
• Clinical Discussion
• Endocrinologist Consultation
• New Treatment Regimen With Add-On Therapy
• Conclusions

Faculty

Yehuda Handelsman, MD, FACP, FACE
Medical Director, Metabolic Institute of America
Chair and Program Director, 7th World Congress on Insulin Resistance Chair, International Committee for Insulin Resistance
18372 Clark Street, Suite 212
Tarzana, CA 91356
E-mail:[email protected]
Web site:www.TheMetabolicCenter.com
Dr Handelsman is a consultant for Bristol-Myers Squibb Company, Daiichi Sankyo, Inc., GlaxoSmithKline, Medtronic, Merck, Xoma, and Tethys;he has received clinical research grant funding from Takeda, Daiichi Sankyo Inc., GlaxoSmithKline, and Novo Nordisk; and he is on the speakers bureau for AstraZeneca, Bristol-Myers Squibb, Daiichi Sankyo Inc., GlaxoSmithKline, Merck, and Novartis. He also serves on the advisory board for CLINICAL ENDOCRINOLOGY NEWS.

Copyright © 2010 Elsevier Inc.

To view the supplement, click the image above.

When recounting her HM career, Janet Nagamine, RN, MD, SFHM, often tells people she went from being the chief of everything to the chief of nothing, by choice. She can remember the whirlwind of being a quality-improvement (QI) chief, patient safety officer, risk management team member, and new mother who felt more married to her beeper than to her husband.

“I felt incredibly stressed and pulled in so many different directions,” says Dr. Nagamine, a hospitalist at Kaiser Permanente Medical Center in Santa Clara, Calif., and an SHM board member. “What really concerned me was that I was starting to feel that I wasn’t doing anything well, that I was dropping balls here and there.”

A revelation came to Dr. Nagamine at a time-management workshop. The speaker asked participants to list the three most important things in their lives, then add up the hours spent doing them.

“There was obviously a disconnect when I looked at the actual waking hours I spent with my family,” says Dr. Nagamine, who placed family at the top of her list. “That’s where I made the decision that I could always come back to doing these leadership things at a later time.”

Now pursuing an MBA, she intends to return to leadership positions to focus on QI, patient safety, and hospitalist work-life issues—for both women and men.

“Work-life balance is a key anchor for us,” says Dr. Nagamine, who helped organize a “Women in Hospital Medicine” session at HM12 last month in San Diego. “Whether you’re male or female, work-life [balance] is a challenge. We need to do better on that.”

In today’s era of ever-increasing healthcare demands, the future of hospitalist practice rests, in no small part, on the work-life satisfaction of its physicians. Recent studies suggest hospitalists are experiencing more stress and burnout now than in the past, a phenomenon HM groups would be wise to address by offering more flexible work options and workload support, regardless of gender, experts say. But individual hospitalists can mitigate strain and dissatisfaction by assessing their life and goals, and developing a work-life balance that is right for them.

“Work-life balance is really not something that is ‘a nice thing to have,’” says Iris Grimm, creator of the Atlanta-based Balanced Physician program, which helps physicians meet work, life, and leadership challenges. “It is a necessity for them if they want to sustain a long-term career.”

Defining Balance

So what causes tension between work and life outside of work? The list is long and growing.

“We still define the ideal worker as someone who starts to work in early adulthood and works full time, full force, for 40 years straight, available for overtime as needed,” says Joan Williams, distinguished professor of law, founding director of the Center of WorkLife Law at the University of California’s Hastings College of the Law in San Francisco, and author of “Unbending Gender: Why Family and Work Conflict and What To Do About It.” “That basically describes a man married to a homemaker, and that’s not who the work force is.”

In general, workplaces—including those in the hospital work environment—have been slow to adjust to the changing work force, Williams says. In time, friction arises, which leads to dissatisfied workers.

Work-life balance is when a person can rise above the conflict and align their responsibilities with their values and priorities, says Maria Bailey, founder and CEO of BlueSuitMom.com, a Pompano Beach, Fla.-based company that provides work-life balance information for professional working mothers and their employers.

“It is being satisfied with one’s entire life, with the work side as well as with the personal side,” Grimm says.

It makes sense to take care of your people. First, it’s the right thing to do. Second, it’s financially and fiscally a good move. It’s not just work-life balance for the sake of work-life balance; it’s critically important to your operations and your overall success in delivering good care.

—Janet Nagamine, RN, MD, SFHM, Kaiser Permanente Medical Center, Santa Clara, Calif., SHM board member

Young physicians of both genders view work-life balance as essential, and are willing to risk career advancement to achieve it, according to a 2006 survey of U.S. doctors under age 50 conducted by the Association of American Medical Colleges and the American Medical Association.¹ When asked to rate factors that are very important to a desirable position, 71% identified work-life balance. Two out of 3 young physicians said they were not interested in working longer hours for more money—a sharp contrast from previous generations.

“It started in the 1990s, but I think in the early 2000s was when the medical world began to take a much more honest appraisal of the long-term impact of an unbalanced life and what that meant for physicians,” says Erin Stucky Fisher, MD, MHM, medical director for quality at Rady Children’s Hospital San Diego, associate program director for the University of California at San Diego Pediatric Residency Program, and an SHM board member.

Dr. Nagamine agrees the tide has shifted in terms of physician attitudes toward work hours, compensation, and personal time. “Now that we have work-hour rules in residency, the doctors coming out don’t buy that you have to be on 24/7, 365 days a year,” she says.

The Survey Says...

Recent research on hospitalist work-life satisfaction indicates that while hospitalists generally are satisfied with their job and specialty, burnout rates appear higher than the 13% previously reported in 2001.²

Earlier this year, a study in the Journal of General Internal Medicine found that 29.9% of respondents to a national survey of hospitalists reported job burnout symptoms.³ Hospitalists surveyed also reported low satisfaction with personal time (28.3%), autonomy (17.4%), organizational climate (10.7%), and organizational fairness (31.2%). The results are somewhat alarming to longtime hospitalists, in that hospitalist work models might be less flexible and less sustainable than originally thought.

Results from an email survey published in 2011 showed that 67% of academic hospitalists reported high levels of stress, and 23% described some level of burnout.⁴ Additionally, 57% of the respondents had 20% or less of protected time for scholarly activity—a disconnect between career goals and actual work that could lead to career dissatisfaction. More than half of the academic hospitalists surveyed, however, did express high or somewhat high satisfaction with personal and family time, and control over work schedules.

“Hospital medicine is still a new field, and people are trying to find the right balance in the work,” says Rebecca Harrison, MD, associate professor of medicine and section chief of the division of hospital medicine at Oregon Health & Science University in Portland. “I think we’re in a very critical time now where we have to look at scheduling, patient load, fulfillment factors. A physician’s sense of commitment, happiness, and enjoyment in their work is going to be much higher if you pay attention to the things they want to pursue.”

What Women Really Want

Female physicians are far less able to control their work environments than men, says Mark Linzer, MD. He helped design and conduct the Society of General Internal Medicine’s Physician Work Life Study, which found that aside from less work control, the female doctors surveyed said they faced a more difficult patient mix, more time pressure in patient examinations, and a 60% greater chance of burnout compared with their male counterparts.⁵

“One of those factors, we think, is what has been called ‘gendered expectations for listening,’” says Dr. Linzer, division director for general internal medicine at Hennepin County Medical Center in Minneapolis and professor of medicine at the University of Minnesota. Patients prefer female doctors because they believe women are better listeners than men, he explains. But listening takes time, and female physicians generally aren’t afforded more time for patient visits than male physicians are.

“This is an issue I see many times with female physicians, with hospitalists in particular,” Grimm says. “They just can’t seem to stay in the time frame that has been given to them for their patients. They think that the more time they spend with their patients, the more the patients appreciate them and feel like they are heard.”

Another factor is extra work outside the office. “If you measure the total number of work hours performed, including work and home, it is considerably higher for women,” Dr. Linzer says.

Even if a working woman has help at home or a spouse who works part time or stays at home, she never really relinquishes responsibility of the home, Bailey says.

“A woman carries social pressures that she needs to—even if she has a career—carry out the role of a traditional wife and mother,” she says.

Regardless of whether they have a spouse and children, women generally feel a responsibility to care for their loved ones’ needs, whether it’s an aging parent, an ailing sibling, or a friend facing a difficult situation, says Jennifer Owens, director of the Working Mother Research Institute in New York City. One thing working in female physicians’ favor, however, is they are less likely to lose their careers due to work-family conflicts than are women in such high-skill professions as finance or law, because part-time work is readily available for female doctors, Williams says.

“The number of hours that women work has been increasing. So there’s incredible stress on women,” says Owens. “Just to have the support that you’re not stigmatized for dialing back and not working a 60-hour-plus work week means a lot.”

The Flip Side

Men also have partners, families, children, and outside interests. Therefore, if hospitalist groups are going to create flexible work opportunities, they have to market them and make them available to everyone, regardless of gender, Dr. Fisher says.

The key work-life balance battle today, Williams says, centers around male workers and the stereotypes surrounding masculinity. Increasing numbers of young men want to participate in the day-to-day caregiving of their children. Most workplaces, however, have been slow to adjust.

“Women have the cultural room to make workplace adjustments to ease work-family conflict, and men often don’t,” Williams says. “The ideas of masculinity are closely intertwined with the idea of being a provider. So if a man leaves work to care for his child or ailing mother, people not only think of him as a poor worker, they often think of him as less of a man. The stereotypes that hit people who make their caregiving responsibilities salient on the job are extremely hostile and even more powerful for men than for women.”

Similarly, if male physicians want to structure their schedules around personal interests or take extended time off to pursue a life passion, they often are viewed unfavorably because the culture of medicine for years has been complete dedication to patients and career over personal needs, Dr. Harrison says.

“For example, a single person or someone who doesn’t have a family might want to go climbing the Himalayas and take three months off. Or perhaps a staff member wants to go part time in order to go back to school for an MBA,” Dr. Nagamine says. “We’re not prepared to deal with those types of requests.”

Stop the Churn

HM groups around the country—big and small, academic and community—deal with work-life balance issues on a regular basis. Some have solved the issue; many have not. Too many hospitalist groups are stuck in a churn cycle: hire hospitalist, fail to meet their needs, see them leave after a year or two, repeat.

“When you see people churning their staff, especially when they’re losing good ones, it’s a financial and human capital drain,” Dr. Nagamine says. “Think about the care that’s being delivered within the system, what’s happening to the other members in the group, the return on investment for keeping your staff happy. We argue over pennies sometimes, but we don’t calculate these types of losses of personnel.”

Dr. Nagamine says hospitalist groups should approach work-life balance not just on a day-to-day or week-to-week basis, but also in terms of extended leave for child or elder care, travel, volunteer work, professional development, etc.

Compensation and workload are used to recruit and retain hospitalists. But recent research suggests that leaders might find more nuanced approaches to improving their hospitalists’ overall satisfaction.⁶ For example, leaders of local community-based hospitalist groups might find their hospitalists tolerant of heavier workloads, provided they are financially rewarded and given autonomy over their work. And rather than using higher salaries to be competitive, leaders of academic programs might find it more effective to provide their hospitalists with time and training to pursue scholarly work.

“Physicians and faculty are the most valuable commodities for moving the work forward,” Dr. Harrison says, “and good leaders pay attention to this data.”

HM groups should think about surveying their employees to find out where problems exist, Bailey says. Once you determine what work-life benefits and/or flexible employment opportunities will work, train supervisors to manage workplace flexibility, then hold them accountable for executing the policies, Owens says.

“It makes sense to take care of your people,” Dr. Nagamine says. “First, it’s the right thing to do. Second, it’s financially and fiscally a good move. It’s not just work-life balance for the sake of work-life balance; it’s critically important to your operations and your overall success in delivering good care.”

Lisa Ryan is a freelance writer in New Jersey.

Take Ownership of Your Time Off

The only way to fully achieve work-life balance is if you’re trying to achieve balance, according to experts in physician career satisfaction. In other words, work-life balance starts with you. Here are six steps you can take to improve your balancing act:

Define balance. Draw a picture of what you look like when your life is in balance, Bailey says. Or write a description in a journal. The goal is to determine what balance means for you at this point in your life, Grimm says.

Conduct a personal assessment. Look at every area of your life to assess what’s working and what’s not working, Owens says. Where things aren’t working, identify what you would have to add or subtract from your life to make improvements, says Grimm.

Eliminate stressors. Pinpoint your primary stressors and work to resolve or mitigate them, Grimm says. If it’s new software at work, find ways to master the technology. If it’s lack of spousal support, practice effective communication and teamwork.

Maximize energy. Create a workplace with the least amount of friction by investing energy in areas where you can make a positive impact, Grimm says. Don’t waste time or effort on things that cannot be changed.

Practice self-care. To be effective at caring for loved ones and patients, you have to care for yourself, Dr. Harrison says. Self-care can include protecting time with friends and family, taking short breaks during the workday, exercising, and getting regular sleep and meals. Hospitalists also should schedule vacations.

Consider job fit. Read recent research on the job characteristics of hospitalist practice models.6 If you’re someone who’s less concerned about workload but want to be paid well and have more autonomy, a local, community-based hospitalist group might be right for you. Academic HM might fit better if you’re willing to sacrifice some compensation for a variety of activities beyond direct clinical care.

—Lisa Ryan

References

1. Kirch DG, Salsberg E. The physician workforce challenge: response of the academic community. Ann Surg. 2007;246(4):535-540.
2. Hoff TH, Whitcomb WF, Williams K, Nelson JR, Cheesman RA. Characteristics and work experiences of hospitalists in the United States. Arch Intern Med. 2001;161(6):851-8.
3. Hinami K, Whelan CT, Wolosin RJ, Miller JA, Wetterneck TB. Worklife and satisfaction of hospitalists: toward flourishing careers. J Gen Intern Med. 2012;27(1):28-36.
4. Glasheen JJ, Misky GJ, Reid MB, Harrison RA, Sharpe B, Auerbach A. Career satisfaction and burnout in academic hospital medicine. Arch Intern Med. 2011;171(8):782-785.
5. McMurray JE, Linzer M, Konrad TR, Douglas J, Shugerman R, Nelson K. The work lives of women physicians results from the physician work life study. The SGIM Career Satisfaction Study Group. J Gen Intern Med. 2000;15(6):372-380.
6. Hinami K, Whelan CT, Miller JA, Wolosin RJ, Wetterneck TB. Job characteristics, satisfaction, and burnout across hospitalist practice models. Journal of Hospital Medicine website. Available at: http://onlinelibrary.wiley.com/doi/10.1002/jhm.1907/full. Accessed March 21, 2012.

When recounting her HM career, Janet Nagamine, RN, MD, SFHM, often tells people she went from being the chief of everything to the chief of nothing, by choice. She can remember the whirlwind of being a quality-improvement (QI) chief, patient safety officer, risk management team member, and new mother who felt more married to her beeper than to her husband.

“I felt incredibly stressed and pulled in so many different directions,” says Dr. Nagamine, a hospitalist at Kaiser Permanente Medical Center in Santa Clara, Calif., and an SHM board member. “What really concerned me was that I was starting to feel that I wasn’t doing anything well, that I was dropping balls here and there.”

A revelation came to Dr. Nagamine at a time-management workshop. The speaker asked participants to list the three most important things in their lives, then add up the hours spent doing them.

“There was obviously a disconnect when I looked at the actual waking hours I spent with my family,” says Dr. Nagamine, who placed family at the top of her list. “That’s where I made the decision that I could always come back to doing these leadership things at a later time.”

Now pursuing an MBA, she intends to return to leadership positions to focus on QI, patient safety, and hospitalist work-life issues—for both women and men.

“Work-life balance is a key anchor for us,” says Dr. Nagamine, who helped organize a “Women in Hospital Medicine” session at HM12 last month in San Diego. “Whether you’re male or female, work-life [balance] is a challenge. We need to do better on that.”

In today’s era of ever-increasing healthcare demands, the future of hospitalist practice rests, in no small part, on the work-life satisfaction of its physicians. Recent studies suggest hospitalists are experiencing more stress and burnout now than in the past, a phenomenon HM groups would be wise to address by offering more flexible work options and workload support, regardless of gender, experts say. But individual hospitalists can mitigate strain and dissatisfaction by assessing their life and goals, and developing a work-life balance that is right for them.

“Work-life balance is really not something that is ‘a nice thing to have,’” says Iris Grimm, creator of the Atlanta-based Balanced Physician program, which helps physicians meet work, life, and leadership challenges. “It is a necessity for them if they want to sustain a long-term career.”

Defining Balance

So what causes tension between work and life outside of work? The list is long and growing.

“We still define the ideal worker as someone who starts to work in early adulthood and works full time, full force, for 40 years straight, available for overtime as needed,” says Joan Williams, distinguished professor of law, founding director of the Center of WorkLife Law at the University of California’s Hastings College of the Law in San Francisco, and author of “Unbending Gender: Why Family and Work Conflict and What To Do About It.” “That basically describes a man married to a homemaker, and that’s not who the work force is.”

In general, workplaces—including those in the hospital work environment—have been slow to adjust to the changing work force, Williams says. In time, friction arises, which leads to dissatisfied workers.

Work-life balance is when a person can rise above the conflict and align their responsibilities with their values and priorities, says Maria Bailey, founder and CEO of BlueSuitMom.com, a Pompano Beach, Fla.-based company that provides work-life balance information for professional working mothers and their employers.

“It is being satisfied with one’s entire life, with the work side as well as with the personal side,” Grimm says.

It makes sense to take care of your people. First, it’s the right thing to do. Second, it’s financially and fiscally a good move. It’s not just work-life balance for the sake of work-life balance; it’s critically important to your operations and your overall success in delivering good care.

—Janet Nagamine, RN, MD, SFHM, Kaiser Permanente Medical Center, Santa Clara, Calif., SHM board member

Young physicians of both genders view work-life balance as essential, and are willing to risk career advancement to achieve it, according to a 2006 survey of U.S. doctors under age 50 conducted by the Association of American Medical Colleges and the American Medical Association.¹ When asked to rate factors that are very important to a desirable position, 71% identified work-life balance. Two out of 3 young physicians said they were not interested in working longer hours for more money—a sharp contrast from previous generations.

“It started in the 1990s, but I think in the early 2000s was when the medical world began to take a much more honest appraisal of the long-term impact of an unbalanced life and what that meant for physicians,” says Erin Stucky Fisher, MD, MHM, medical director for quality at Rady Children’s Hospital San Diego, associate program director for the University of California at San Diego Pediatric Residency Program, and an SHM board member.

Dr. Nagamine agrees the tide has shifted in terms of physician attitudes toward work hours, compensation, and personal time. “Now that we have work-hour rules in residency, the doctors coming out don’t buy that you have to be on 24/7, 365 days a year,” she says.

The Survey Says...

Recent research on hospitalist work-life satisfaction indicates that while hospitalists generally are satisfied with their job and specialty, burnout rates appear higher than the 13% previously reported in 2001.²

Earlier this year, a study in the Journal of General Internal Medicine found that 29.9% of respondents to a national survey of hospitalists reported job burnout symptoms.³ Hospitalists surveyed also reported low satisfaction with personal time (28.3%), autonomy (17.4%), organizational climate (10.7%), and organizational fairness (31.2%). The results are somewhat alarming to longtime hospitalists, in that hospitalist work models might be less flexible and less sustainable than originally thought.

Results from an email survey published in 2011 showed that 67% of academic hospitalists reported high levels of stress, and 23% described some level of burnout.⁴ Additionally, 57% of the respondents had 20% or less of protected time for scholarly activity—a disconnect between career goals and actual work that could lead to career dissatisfaction. More than half of the academic hospitalists surveyed, however, did express high or somewhat high satisfaction with personal and family time, and control over work schedules.

“Hospital medicine is still a new field, and people are trying to find the right balance in the work,” says Rebecca Harrison, MD, associate professor of medicine and section chief of the division of hospital medicine at Oregon Health & Science University in Portland. “I think we’re in a very critical time now where we have to look at scheduling, patient load, fulfillment factors. A physician’s sense of commitment, happiness, and enjoyment in their work is going to be much higher if you pay attention to the things they want to pursue.”

What Women Really Want

Female physicians are far less able to control their work environments than men, says Mark Linzer, MD. He helped design and conduct the Society of General Internal Medicine’s Physician Work Life Study, which found that aside from less work control, the female doctors surveyed said they faced a more difficult patient mix, more time pressure in patient examinations, and a 60% greater chance of burnout compared with their male counterparts.⁵

“One of those factors, we think, is what has been called ‘gendered expectations for listening,’” says Dr. Linzer, division director for general internal medicine at Hennepin County Medical Center in Minneapolis and professor of medicine at the University of Minnesota. Patients prefer female doctors because they believe women are better listeners than men, he explains. But listening takes time, and female physicians generally aren’t afforded more time for patient visits than male physicians are.

“This is an issue I see many times with female physicians, with hospitalists in particular,” Grimm says. “They just can’t seem to stay in the time frame that has been given to them for their patients. They think that the more time they spend with their patients, the more the patients appreciate them and feel like they are heard.”

Another factor is extra work outside the office. “If you measure the total number of work hours performed, including work and home, it is considerably higher for women,” Dr. Linzer says.

Even if a working woman has help at home or a spouse who works part time or stays at home, she never really relinquishes responsibility of the home, Bailey says.

“A woman carries social pressures that she needs to—even if she has a career—carry out the role of a traditional wife and mother,” she says.

Regardless of whether they have a spouse and children, women generally feel a responsibility to care for their loved ones’ needs, whether it’s an aging parent, an ailing sibling, or a friend facing a difficult situation, says Jennifer Owens, director of the Working Mother Research Institute in New York City. One thing working in female physicians’ favor, however, is they are less likely to lose their careers due to work-family conflicts than are women in such high-skill professions as finance or law, because part-time work is readily available for female doctors, Williams says.

“The number of hours that women work has been increasing. So there’s incredible stress on women,” says Owens. “Just to have the support that you’re not stigmatized for dialing back and not working a 60-hour-plus work week means a lot.”

The Flip Side

Men also have partners, families, children, and outside interests. Therefore, if hospitalist groups are going to create flexible work opportunities, they have to market them and make them available to everyone, regardless of gender, Dr. Fisher says.

The key work-life balance battle today, Williams says, centers around male workers and the stereotypes surrounding masculinity. Increasing numbers of young men want to participate in the day-to-day caregiving of their children. Most workplaces, however, have been slow to adjust.

“Women have the cultural room to make workplace adjustments to ease work-family conflict, and men often don’t,” Williams says. “The ideas of masculinity are closely intertwined with the idea of being a provider. So if a man leaves work to care for his child or ailing mother, people not only think of him as a poor worker, they often think of him as less of a man. The stereotypes that hit people who make their caregiving responsibilities salient on the job are extremely hostile and even more powerful for men than for women.”

Similarly, if male physicians want to structure their schedules around personal interests or take extended time off to pursue a life passion, they often are viewed unfavorably because the culture of medicine for years has been complete dedication to patients and career over personal needs, Dr. Harrison says.

“For example, a single person or someone who doesn’t have a family might want to go climbing the Himalayas and take three months off. Or perhaps a staff member wants to go part time in order to go back to school for an MBA,” Dr. Nagamine says. “We’re not prepared to deal with those types of requests.”

Stop the Churn

HM groups around the country—big and small, academic and community—deal with work-life balance issues on a regular basis. Some have solved the issue; many have not. Too many hospitalist groups are stuck in a churn cycle: hire hospitalist, fail to meet their needs, see them leave after a year or two, repeat.

“When you see people churning their staff, especially when they’re losing good ones, it’s a financial and human capital drain,” Dr. Nagamine says. “Think about the care that’s being delivered within the system, what’s happening to the other members in the group, the return on investment for keeping your staff happy. We argue over pennies sometimes, but we don’t calculate these types of losses of personnel.”

Dr. Nagamine says hospitalist groups should approach work-life balance not just on a day-to-day or week-to-week basis, but also in terms of extended leave for child or elder care, travel, volunteer work, professional development, etc.

Compensation and workload are used to recruit and retain hospitalists. But recent research suggests that leaders might find more nuanced approaches to improving their hospitalists’ overall satisfaction.⁶ For example, leaders of local community-based hospitalist groups might find their hospitalists tolerant of heavier workloads, provided they are financially rewarded and given autonomy over their work. And rather than using higher salaries to be competitive, leaders of academic programs might find it more effective to provide their hospitalists with time and training to pursue scholarly work.

“Physicians and faculty are the most valuable commodities for moving the work forward,” Dr. Harrison says, “and good leaders pay attention to this data.”

HM groups should think about surveying their employees to find out where problems exist, Bailey says. Once you determine what work-life benefits and/or flexible employment opportunities will work, train supervisors to manage workplace flexibility, then hold them accountable for executing the policies, Owens says.

“It makes sense to take care of your people,” Dr. Nagamine says. “First, it’s the right thing to do. Second, it’s financially and fiscally a good move. It’s not just work-life balance for the sake of work-life balance; it’s critically important to your operations and your overall success in delivering good care.”

Lisa Ryan is a freelance writer in New Jersey.

Take Ownership of Your Time Off

The only way to fully achieve work-life balance is if you’re trying to achieve balance, according to experts in physician career satisfaction. In other words, work-life balance starts with you. Here are six steps you can take to improve your balancing act:

Define balance. Draw a picture of what you look like when your life is in balance, Bailey says. Or write a description in a journal. The goal is to determine what balance means for you at this point in your life, Grimm says.

Conduct a personal assessment. Look at every area of your life to assess what’s working and what’s not working, Owens says. Where things aren’t working, identify what you would have to add or subtract from your life to make improvements, says Grimm.

Eliminate stressors. Pinpoint your primary stressors and work to resolve or mitigate them, Grimm says. If it’s new software at work, find ways to master the technology. If it’s lack of spousal support, practice effective communication and teamwork.

Maximize energy. Create a workplace with the least amount of friction by investing energy in areas where you can make a positive impact, Grimm says. Don’t waste time or effort on things that cannot be changed.

Practice self-care. To be effective at caring for loved ones and patients, you have to care for yourself, Dr. Harrison says. Self-care can include protecting time with friends and family, taking short breaks during the workday, exercising, and getting regular sleep and meals. Hospitalists also should schedule vacations.

Consider job fit. Read recent research on the job characteristics of hospitalist practice models.6 If you’re someone who’s less concerned about workload but want to be paid well and have more autonomy, a local, community-based hospitalist group might be right for you. Academic HM might fit better if you’re willing to sacrifice some compensation for a variety of activities beyond direct clinical care.

—Lisa Ryan

References

1. Kirch DG, Salsberg E. The physician workforce challenge: response of the academic community. Ann Surg. 2007;246(4):535-540.
2. Hoff TH, Whitcomb WF, Williams K, Nelson JR, Cheesman RA. Characteristics and work experiences of hospitalists in the United States. Arch Intern Med. 2001;161(6):851-8.
3. Hinami K, Whelan CT, Wolosin RJ, Miller JA, Wetterneck TB. Worklife and satisfaction of hospitalists: toward flourishing careers. J Gen Intern Med. 2012;27(1):28-36.
4. Glasheen JJ, Misky GJ, Reid MB, Harrison RA, Sharpe B, Auerbach A. Career satisfaction and burnout in academic hospital medicine. Arch Intern Med. 2011;171(8):782-785.
5. McMurray JE, Linzer M, Konrad TR, Douglas J, Shugerman R, Nelson K. The work lives of women physicians results from the physician work life study. The SGIM Career Satisfaction Study Group. J Gen Intern Med. 2000;15(6):372-380.
6. Hinami K, Whelan CT, Miller JA, Wolosin RJ, Wetterneck TB. Job characteristics, satisfaction, and burnout across hospitalist practice models. Journal of Hospital Medicine website. Available at: http://onlinelibrary.wiley.com/doi/10.1002/jhm.1907/full. Accessed March 21, 2012.

When recounting her HM career, Janet Nagamine, RN, MD, SFHM, often tells people she went from being the chief of everything to the chief of nothing, by choice. She can remember the whirlwind of being a quality-improvement (QI) chief, patient safety officer, risk management team member, and new mother who felt more married to her beeper than to her husband.

“I felt incredibly stressed and pulled in so many different directions,” says Dr. Nagamine, a hospitalist at Kaiser Permanente Medical Center in Santa Clara, Calif., and an SHM board member. “What really concerned me was that I was starting to feel that I wasn’t doing anything well, that I was dropping balls here and there.”

A revelation came to Dr. Nagamine at a time-management workshop. The speaker asked participants to list the three most important things in their lives, then add up the hours spent doing them.

“There was obviously a disconnect when I looked at the actual waking hours I spent with my family,” says Dr. Nagamine, who placed family at the top of her list. “That’s where I made the decision that I could always come back to doing these leadership things at a later time.”

Now pursuing an MBA, she intends to return to leadership positions to focus on QI, patient safety, and hospitalist work-life issues—for both women and men.

“Work-life balance is a key anchor for us,” says Dr. Nagamine, who helped organize a “Women in Hospital Medicine” session at HM12 last month in San Diego. “Whether you’re male or female, work-life [balance] is a challenge. We need to do better on that.”

In today’s era of ever-increasing healthcare demands, the future of hospitalist practice rests, in no small part, on the work-life satisfaction of its physicians. Recent studies suggest hospitalists are experiencing more stress and burnout now than in the past, a phenomenon HM groups would be wise to address by offering more flexible work options and workload support, regardless of gender, experts say. But individual hospitalists can mitigate strain and dissatisfaction by assessing their life and goals, and developing a work-life balance that is right for them.

“Work-life balance is really not something that is ‘a nice thing to have,’” says Iris Grimm, creator of the Atlanta-based Balanced Physician program, which helps physicians meet work, life, and leadership challenges. “It is a necessity for them if they want to sustain a long-term career.”

Defining Balance

So what causes tension between work and life outside of work? The list is long and growing.

“We still define the ideal worker as someone who starts to work in early adulthood and works full time, full force, for 40 years straight, available for overtime as needed,” says Joan Williams, distinguished professor of law, founding director of the Center of WorkLife Law at the University of California’s Hastings College of the Law in San Francisco, and author of “Unbending Gender: Why Family and Work Conflict and What To Do About It.” “That basically describes a man married to a homemaker, and that’s not who the work force is.”

In general, workplaces—including those in the hospital work environment—have been slow to adjust to the changing work force, Williams says. In time, friction arises, which leads to dissatisfied workers.

Work-life balance is when a person can rise above the conflict and align their responsibilities with their values and priorities, says Maria Bailey, founder and CEO of BlueSuitMom.com, a Pompano Beach, Fla.-based company that provides work-life balance information for professional working mothers and their employers.

“It is being satisfied with one’s entire life, with the work side as well as with the personal side,” Grimm says.

It makes sense to take care of your people. First, it’s the right thing to do. Second, it’s financially and fiscally a good move. It’s not just work-life balance for the sake of work-life balance; it’s critically important to your operations and your overall success in delivering good care.

—Janet Nagamine, RN, MD, SFHM, Kaiser Permanente Medical Center, Santa Clara, Calif., SHM board member

Young physicians of both genders view work-life balance as essential, and are willing to risk career advancement to achieve it, according to a 2006 survey of U.S. doctors under age 50 conducted by the Association of American Medical Colleges and the American Medical Association.¹ When asked to rate factors that are very important to a desirable position, 71% identified work-life balance. Two out of 3 young physicians said they were not interested in working longer hours for more money—a sharp contrast from previous generations.

“It started in the 1990s, but I think in the early 2000s was when the medical world began to take a much more honest appraisal of the long-term impact of an unbalanced life and what that meant for physicians,” says Erin Stucky Fisher, MD, MHM, medical director for quality at Rady Children’s Hospital San Diego, associate program director for the University of California at San Diego Pediatric Residency Program, and an SHM board member.

Dr. Nagamine agrees the tide has shifted in terms of physician attitudes toward work hours, compensation, and personal time. “Now that we have work-hour rules in residency, the doctors coming out don’t buy that you have to be on 24/7, 365 days a year,” she says.

The Survey Says...

Recent research on hospitalist work-life satisfaction indicates that while hospitalists generally are satisfied with their job and specialty, burnout rates appear higher than the 13% previously reported in 2001.²

Earlier this year, a study in the Journal of General Internal Medicine found that 29.9% of respondents to a national survey of hospitalists reported job burnout symptoms.³ Hospitalists surveyed also reported low satisfaction with personal time (28.3%), autonomy (17.4%), organizational climate (10.7%), and organizational fairness (31.2%). The results are somewhat alarming to longtime hospitalists, in that hospitalist work models might be less flexible and less sustainable than originally thought.

Results from an email survey published in 2011 showed that 67% of academic hospitalists reported high levels of stress, and 23% described some level of burnout.⁴ Additionally, 57% of the respondents had 20% or less of protected time for scholarly activity—a disconnect between career goals and actual work that could lead to career dissatisfaction. More than half of the academic hospitalists surveyed, however, did express high or somewhat high satisfaction with personal and family time, and control over work schedules.

“Hospital medicine is still a new field, and people are trying to find the right balance in the work,” says Rebecca Harrison, MD, associate professor of medicine and section chief of the division of hospital medicine at Oregon Health & Science University in Portland. “I think we’re in a very critical time now where we have to look at scheduling, patient load, fulfillment factors. A physician’s sense of commitment, happiness, and enjoyment in their work is going to be much higher if you pay attention to the things they want to pursue.”

What Women Really Want

Female physicians are far less able to control their work environments than men, says Mark Linzer, MD. He helped design and conduct the Society of General Internal Medicine’s Physician Work Life Study, which found that aside from less work control, the female doctors surveyed said they faced a more difficult patient mix, more time pressure in patient examinations, and a 60% greater chance of burnout compared with their male counterparts.⁵

“One of those factors, we think, is what has been called ‘gendered expectations for listening,’” says Dr. Linzer, division director for general internal medicine at Hennepin County Medical Center in Minneapolis and professor of medicine at the University of Minnesota. Patients prefer female doctors because they believe women are better listeners than men, he explains. But listening takes time, and female physicians generally aren’t afforded more time for patient visits than male physicians are.

“This is an issue I see many times with female physicians, with hospitalists in particular,” Grimm says. “They just can’t seem to stay in the time frame that has been given to them for their patients. They think that the more time they spend with their patients, the more the patients appreciate them and feel like they are heard.”

Another factor is extra work outside the office. “If you measure the total number of work hours performed, including work and home, it is considerably higher for women,” Dr. Linzer says.

Even if a working woman has help at home or a spouse who works part time or stays at home, she never really relinquishes responsibility of the home, Bailey says.

“A woman carries social pressures that she needs to—even if she has a career—carry out the role of a traditional wife and mother,” she says.

Regardless of whether they have a spouse and children, women generally feel a responsibility to care for their loved ones’ needs, whether it’s an aging parent, an ailing sibling, or a friend facing a difficult situation, says Jennifer Owens, director of the Working Mother Research Institute in New York City. One thing working in female physicians’ favor, however, is they are less likely to lose their careers due to work-family conflicts than are women in such high-skill professions as finance or law, because part-time work is readily available for female doctors, Williams says.

“The number of hours that women work has been increasing. So there’s incredible stress on women,” says Owens. “Just to have the support that you’re not stigmatized for dialing back and not working a 60-hour-plus work week means a lot.”

The Flip Side

Men also have partners, families, children, and outside interests. Therefore, if hospitalist groups are going to create flexible work opportunities, they have to market them and make them available to everyone, regardless of gender, Dr. Fisher says.

The key work-life balance battle today, Williams says, centers around male workers and the stereotypes surrounding masculinity. Increasing numbers of young men want to participate in the day-to-day caregiving of their children. Most workplaces, however, have been slow to adjust.

“Women have the cultural room to make workplace adjustments to ease work-family conflict, and men often don’t,” Williams says. “The ideas of masculinity are closely intertwined with the idea of being a provider. So if a man leaves work to care for his child or ailing mother, people not only think of him as a poor worker, they often think of him as less of a man. The stereotypes that hit people who make their caregiving responsibilities salient on the job are extremely hostile and even more powerful for men than for women.”

Similarly, if male physicians want to structure their schedules around personal interests or take extended time off to pursue a life passion, they often are viewed unfavorably because the culture of medicine for years has been complete dedication to patients and career over personal needs, Dr. Harrison says.

“For example, a single person or someone who doesn’t have a family might want to go climbing the Himalayas and take three months off. Or perhaps a staff member wants to go part time in order to go back to school for an MBA,” Dr. Nagamine says. “We’re not prepared to deal with those types of requests.”

Stop the Churn

HM groups around the country—big and small, academic and community—deal with work-life balance issues on a regular basis. Some have solved the issue; many have not. Too many hospitalist groups are stuck in a churn cycle: hire hospitalist, fail to meet their needs, see them leave after a year or two, repeat.

“When you see people churning their staff, especially when they’re losing good ones, it’s a financial and human capital drain,” Dr. Nagamine says. “Think about the care that’s being delivered within the system, what’s happening to the other members in the group, the return on investment for keeping your staff happy. We argue over pennies sometimes, but we don’t calculate these types of losses of personnel.”

Dr. Nagamine says hospitalist groups should approach work-life balance not just on a day-to-day or week-to-week basis, but also in terms of extended leave for child or elder care, travel, volunteer work, professional development, etc.

Compensation and workload are used to recruit and retain hospitalists. But recent research suggests that leaders might find more nuanced approaches to improving their hospitalists’ overall satisfaction.⁶ For example, leaders of local community-based hospitalist groups might find their hospitalists tolerant of heavier workloads, provided they are financially rewarded and given autonomy over their work. And rather than using higher salaries to be competitive, leaders of academic programs might find it more effective to provide their hospitalists with time and training to pursue scholarly work.

“Physicians and faculty are the most valuable commodities for moving the work forward,” Dr. Harrison says, “and good leaders pay attention to this data.”

HM groups should think about surveying their employees to find out where problems exist, Bailey says. Once you determine what work-life benefits and/or flexible employment opportunities will work, train supervisors to manage workplace flexibility, then hold them accountable for executing the policies, Owens says.

“It makes sense to take care of your people,” Dr. Nagamine says. “First, it’s the right thing to do. Second, it’s financially and fiscally a good move. It’s not just work-life balance for the sake of work-life balance; it’s critically important to your operations and your overall success in delivering good care.”

Lisa Ryan is a freelance writer in New Jersey.

Take Ownership of Your Time Off

The only way to fully achieve work-life balance is if you’re trying to achieve balance, according to experts in physician career satisfaction. In other words, work-life balance starts with you. Here are six steps you can take to improve your balancing act:

Define balance. Draw a picture of what you look like when your life is in balance, Bailey says. Or write a description in a journal. The goal is to determine what balance means for you at this point in your life, Grimm says.

Conduct a personal assessment. Look at every area of your life to assess what’s working and what’s not working, Owens says. Where things aren’t working, identify what you would have to add or subtract from your life to make improvements, says Grimm.

Eliminate stressors. Pinpoint your primary stressors and work to resolve or mitigate them, Grimm says. If it’s new software at work, find ways to master the technology. If it’s lack of spousal support, practice effective communication and teamwork.

Maximize energy. Create a workplace with the least amount of friction by investing energy in areas where you can make a positive impact, Grimm says. Don’t waste time or effort on things that cannot be changed.

Practice self-care. To be effective at caring for loved ones and patients, you have to care for yourself, Dr. Harrison says. Self-care can include protecting time with friends and family, taking short breaks during the workday, exercising, and getting regular sleep and meals. Hospitalists also should schedule vacations.

Consider job fit. Read recent research on the job characteristics of hospitalist practice models.6 If you’re someone who’s less concerned about workload but want to be paid well and have more autonomy, a local, community-based hospitalist group might be right for you. Academic HM might fit better if you’re willing to sacrifice some compensation for a variety of activities beyond direct clinical care.

—Lisa Ryan

References

1. Kirch DG, Salsberg E. The physician workforce challenge: response of the academic community. Ann Surg. 2007;246(4):535-540.
2. Hoff TH, Whitcomb WF, Williams K, Nelson JR, Cheesman RA. Characteristics and work experiences of hospitalists in the United States. Arch Intern Med. 2001;161(6):851-8.
3. Hinami K, Whelan CT, Wolosin RJ, Miller JA, Wetterneck TB. Worklife and satisfaction of hospitalists: toward flourishing careers. J Gen Intern Med. 2012;27(1):28-36.
4. Glasheen JJ, Misky GJ, Reid MB, Harrison RA, Sharpe B, Auerbach A. Career satisfaction and burnout in academic hospital medicine. Arch Intern Med. 2011;171(8):782-785.
5. McMurray JE, Linzer M, Konrad TR, Douglas J, Shugerman R, Nelson K. The work lives of women physicians results from the physician work life study. The SGIM Career Satisfaction Study Group. J Gen Intern Med. 2000;15(6):372-380.
6. Hinami K, Whelan CT, Miller JA, Wolosin RJ, Wetterneck TB. Job characteristics, satisfaction, and burnout across hospitalist practice models. Journal of Hospital Medicine website. Available at: http://onlinelibrary.wiley.com/doi/10.1002/jhm.1907/full. Accessed March 21, 2012.