A 60-year-old man visits your clinic 30 days after he was hospitalized for acute coronary syndrome (ACS) due to ST-elevation myocardial infarction (STEMI). The patient underwent percutaneous coronary intervention (PCI) with placement of a stent and received aspirin and a loading dose of ticagrelor for antiplatelet therapy. He was discharged on dual antiplatelet therapy (DAPT) consisting of daily aspirin and ticagrelor. He asks about the risk for bleeding associated with these medications. Should you recommend any changes?

Platelet inhibition during and after ACS to prevent recurrent ischemic events is a cornerstone of treatment for patients after a myocardial infarction (MI).² Current American College of Cardiology/American Heart Association and European Society of Cardiology guidelines recommend that patients with coronary artery disease who recently had an MI continue DAPT with aspirin and a P2Y12 blocker (clopidogrel, ticlopidine, ticagrelor, prasugrel, or cangrelor) for 12 months following ACS to reduce recurrent ischemia.^2-4

Studies have shown that using the newer P2Y12 inhibitors (prasugrel and ticagrelor) after PCI leads to a significant reduction in recurrent ischemic events, compared with clopidogrel.^5-7 These data prompted a guideline change recommending the use of the newer agents over clopidogrel for 12 months following PCI.² Follow-up studies show strong evidence for the use of the newer P2Y12 agents in the first month following PCI, but they also demonstrate an increased bleeding risk in the maintenance phase (from 30 days to 12 months post-PCI).^6,7 This increased risk is the basis for the study by Cuisset et al, which examined switching from a newer P2Y12 agent to clopidogrel after the initial 30-day period following PCI.

STUDY SUMMARY

Switched DAPT is superior

This open-label RCT (N = 646) evaluated changing DAPT from aspirin plus a newer P2Y12 blocker (prasugrel or ticagrelor) to a combination of aspirin and clopidogrel after the first month of DAPT post-ACS.¹ Prior to PCI, patients received a loading dose of ticagrelor (180 mg) or prasugrel (60 mg). Subsequently, all patients took aspirin (75 mg/d) and either prasugrel (10 mg/d) or ticagrelor (90 mg bid) for 1 month. After 30 days, participants who had no adverse events were randomly assigned in a 1:1 ratio to continue the aspirin and newer P2Y12 blocker regimen or switch to aspirin and clopidogrel (75 mg/d). In the following year, researchers examined the composite outcome of cardiovascular death, urgent revascularization, stroke, and major bleeding (defined by a Bleeding Academic Research Consortium [BARC] classification ≥ Type 2 at 1-year post-ACS).

Of the participants (average age, 60), 40% had a STEMI and 60% had a non-STEMI. Overall, 43% of patients were prescribed ticagrelor and 57% prasugrel. At 1 year, 86% of the switched-DAPT group and 75% of the unchanged-DAPT group were still taking their medication. The composite outcome at 1-year follow-up was lower in the switched group compared with the unchanged group (13.4% vs 26.3%; hazard ratio [HR], 0.48; 95% confidence interval [CI], 0.34-0.68; number needed to treat [NNT], 8).

Bleeding events (ranging from minimal to fatal) were lower in the switched group (9.3% vs 23.5%; HR, 0.39; 95% CI, 0.27-0.57; NNT, 7) and events identified as BARC ≥ Type 2 (defined as needing medical treatment) were also lower in this group (4% vs 14.9%; HR, 0.30, 95% CI, 0.18-0.50; NNT, 9). There were no significant differences in reported recurrent cardiovascular ischemic events (9.3% vs 11.5%; HR, 0.80, 95% CI, 0.50-1.29).

WHAT’S NEW

Less bleeding, no increase in ischemic events

Cardiology guidelines recommend the newer P2Y12 blockers as part of DAPT after ACS, but this trial showed switching to clopidogrel for DAPT after 30 days of treatment lowers bleeding events with no difference in recurrent ischemic events.^2-4

Continue to: CAVEATS

Less-than-ideal study methods

In this open-label and unblinded study, the investigators adjudicating critical events were blinded to the treatment allocation. However, patients could self-report minor bleeding and medication discontinuation for which no consultation was sought. In addition, the investigators used opaque envelopes—a less-than-ideal method—to conceal allocation at enrollment.

CHALLENGES TO IMPLEMENTATION

PCP may not change cardiologist’s ­prescription

Implementing this practice is facilitated by the comparatively lower cost of clopidogrel versus the newer P2Y12 blockers. However, after ACS and PCI treatment, cardiologists usually initiate antiplatelet therapy and may continue to manage patients after discharge. The primary care provider (PCP) may not be responsible for the DAPT switch initially; furthermore, ordering a switch may require coordination if the PCP is hesitant to change the cardiologist’s prescription. Lastly, guidelines currently recommend using the newer P2Y12 blockers for 12 months.² CR

ACKNOWLEDGEMENT

The PURLs Surveillance System was supported in part by Grant Number UL1RR024999 from the National Center For Research Resources, a Clinical Translational Science Award to the University of Chicago. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Center For Research Resources or the National Institutes of Health.

Copyright © 2019. The Family Physicians Inquiries Network. All rights reserved.

Reprinted with permission from the Family Physicians Inquiries Network and The Journal of Family Practice (2019;68[3]:162,164).

A 60-year-old man visits your clinic 30 days after he was hospitalized for acute coronary syndrome (ACS) due to ST-elevation myocardial infarction (STEMI). The patient underwent percutaneous coronary intervention (PCI) with placement of a stent and received aspirin and a loading dose of ticagrelor for antiplatelet therapy. He was discharged on dual antiplatelet therapy (DAPT) consisting of daily aspirin and ticagrelor. He asks about the risk for bleeding associated with these medications. Should you recommend any changes?

Platelet inhibition during and after ACS to prevent recurrent ischemic events is a cornerstone of treatment for patients after a myocardial infarction (MI).² Current American College of Cardiology/American Heart Association and European Society of Cardiology guidelines recommend that patients with coronary artery disease who recently had an MI continue DAPT with aspirin and a P2Y12 blocker (clopidogrel, ticlopidine, ticagrelor, prasugrel, or cangrelor) for 12 months following ACS to reduce recurrent ischemia.^2-4

Studies have shown that using the newer P2Y12 inhibitors (prasugrel and ticagrelor) after PCI leads to a significant reduction in recurrent ischemic events, compared with clopidogrel.^5-7 These data prompted a guideline change recommending the use of the newer agents over clopidogrel for 12 months following PCI.² Follow-up studies show strong evidence for the use of the newer P2Y12 agents in the first month following PCI, but they also demonstrate an increased bleeding risk in the maintenance phase (from 30 days to 12 months post-PCI).^6,7 This increased risk is the basis for the study by Cuisset et al, which examined switching from a newer P2Y12 agent to clopidogrel after the initial 30-day period following PCI.

STUDY SUMMARY

Switched DAPT is superior

This open-label RCT (N = 646) evaluated changing DAPT from aspirin plus a newer P2Y12 blocker (prasugrel or ticagrelor) to a combination of aspirin and clopidogrel after the first month of DAPT post-ACS.¹ Prior to PCI, patients received a loading dose of ticagrelor (180 mg) or prasugrel (60 mg). Subsequently, all patients took aspirin (75 mg/d) and either prasugrel (10 mg/d) or ticagrelor (90 mg bid) for 1 month. After 30 days, participants who had no adverse events were randomly assigned in a 1:1 ratio to continue the aspirin and newer P2Y12 blocker regimen or switch to aspirin and clopidogrel (75 mg/d). In the following year, researchers examined the composite outcome of cardiovascular death, urgent revascularization, stroke, and major bleeding (defined by a Bleeding Academic Research Consortium [BARC] classification ≥ Type 2 at 1-year post-ACS).

Of the participants (average age, 60), 40% had a STEMI and 60% had a non-STEMI. Overall, 43% of patients were prescribed ticagrelor and 57% prasugrel. At 1 year, 86% of the switched-DAPT group and 75% of the unchanged-DAPT group were still taking their medication. The composite outcome at 1-year follow-up was lower in the switched group compared with the unchanged group (13.4% vs 26.3%; hazard ratio [HR], 0.48; 95% confidence interval [CI], 0.34-0.68; number needed to treat [NNT], 8).

Bleeding events (ranging from minimal to fatal) were lower in the switched group (9.3% vs 23.5%; HR, 0.39; 95% CI, 0.27-0.57; NNT, 7) and events identified as BARC ≥ Type 2 (defined as needing medical treatment) were also lower in this group (4% vs 14.9%; HR, 0.30, 95% CI, 0.18-0.50; NNT, 9). There were no significant differences in reported recurrent cardiovascular ischemic events (9.3% vs 11.5%; HR, 0.80, 95% CI, 0.50-1.29).

WHAT’S NEW

Less bleeding, no increase in ischemic events

Cardiology guidelines recommend the newer P2Y12 blockers as part of DAPT after ACS, but this trial showed switching to clopidogrel for DAPT after 30 days of treatment lowers bleeding events with no difference in recurrent ischemic events.^2-4

Continue to: CAVEATS

Less-than-ideal study methods

In this open-label and unblinded study, the investigators adjudicating critical events were blinded to the treatment allocation. However, patients could self-report minor bleeding and medication discontinuation for which no consultation was sought. In addition, the investigators used opaque envelopes—a less-than-ideal method—to conceal allocation at enrollment.

CHALLENGES TO IMPLEMENTATION

PCP may not change cardiologist’s ­prescription

Implementing this practice is facilitated by the comparatively lower cost of clopidogrel versus the newer P2Y12 blockers. However, after ACS and PCI treatment, cardiologists usually initiate antiplatelet therapy and may continue to manage patients after discharge. The primary care provider (PCP) may not be responsible for the DAPT switch initially; furthermore, ordering a switch may require coordination if the PCP is hesitant to change the cardiologist’s prescription. Lastly, guidelines currently recommend using the newer P2Y12 blockers for 12 months.² CR

ACKNOWLEDGEMENT

The PURLs Surveillance System was supported in part by Grant Number UL1RR024999 from the National Center For Research Resources, a Clinical Translational Science Award to the University of Chicago. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Center For Research Resources or the National Institutes of Health.

Copyright © 2019. The Family Physicians Inquiries Network. All rights reserved.

Reprinted with permission from the Family Physicians Inquiries Network and The Journal of Family Practice (2019;68[3]:162,164).

A 60-year-old man visits your clinic 30 days after he was hospitalized for acute coronary syndrome (ACS) due to ST-elevation myocardial infarction (STEMI). The patient underwent percutaneous coronary intervention (PCI) with placement of a stent and received aspirin and a loading dose of ticagrelor for antiplatelet therapy. He was discharged on dual antiplatelet therapy (DAPT) consisting of daily aspirin and ticagrelor. He asks about the risk for bleeding associated with these medications. Should you recommend any changes?

Platelet inhibition during and after ACS to prevent recurrent ischemic events is a cornerstone of treatment for patients after a myocardial infarction (MI).² Current American College of Cardiology/American Heart Association and European Society of Cardiology guidelines recommend that patients with coronary artery disease who recently had an MI continue DAPT with aspirin and a P2Y12 blocker (clopidogrel, ticlopidine, ticagrelor, prasugrel, or cangrelor) for 12 months following ACS to reduce recurrent ischemia.^2-4

Studies have shown that using the newer P2Y12 inhibitors (prasugrel and ticagrelor) after PCI leads to a significant reduction in recurrent ischemic events, compared with clopidogrel.^5-7 These data prompted a guideline change recommending the use of the newer agents over clopidogrel for 12 months following PCI.² Follow-up studies show strong evidence for the use of the newer P2Y12 agents in the first month following PCI, but they also demonstrate an increased bleeding risk in the maintenance phase (from 30 days to 12 months post-PCI).^6,7 This increased risk is the basis for the study by Cuisset et al, which examined switching from a newer P2Y12 agent to clopidogrel after the initial 30-day period following PCI.

STUDY SUMMARY

Switched DAPT is superior

This open-label RCT (N = 646) evaluated changing DAPT from aspirin plus a newer P2Y12 blocker (prasugrel or ticagrelor) to a combination of aspirin and clopidogrel after the first month of DAPT post-ACS.¹ Prior to PCI, patients received a loading dose of ticagrelor (180 mg) or prasugrel (60 mg). Subsequently, all patients took aspirin (75 mg/d) and either prasugrel (10 mg/d) or ticagrelor (90 mg bid) for 1 month. After 30 days, participants who had no adverse events were randomly assigned in a 1:1 ratio to continue the aspirin and newer P2Y12 blocker regimen or switch to aspirin and clopidogrel (75 mg/d). In the following year, researchers examined the composite outcome of cardiovascular death, urgent revascularization, stroke, and major bleeding (defined by a Bleeding Academic Research Consortium [BARC] classification ≥ Type 2 at 1-year post-ACS).

Of the participants (average age, 60), 40% had a STEMI and 60% had a non-STEMI. Overall, 43% of patients were prescribed ticagrelor and 57% prasugrel. At 1 year, 86% of the switched-DAPT group and 75% of the unchanged-DAPT group were still taking their medication. The composite outcome at 1-year follow-up was lower in the switched group compared with the unchanged group (13.4% vs 26.3%; hazard ratio [HR], 0.48; 95% confidence interval [CI], 0.34-0.68; number needed to treat [NNT], 8).

Bleeding events (ranging from minimal to fatal) were lower in the switched group (9.3% vs 23.5%; HR, 0.39; 95% CI, 0.27-0.57; NNT, 7) and events identified as BARC ≥ Type 2 (defined as needing medical treatment) were also lower in this group (4% vs 14.9%; HR, 0.30, 95% CI, 0.18-0.50; NNT, 9). There were no significant differences in reported recurrent cardiovascular ischemic events (9.3% vs 11.5%; HR, 0.80, 95% CI, 0.50-1.29).

WHAT’S NEW

Less bleeding, no increase in ischemic events

Cardiology guidelines recommend the newer P2Y12 blockers as part of DAPT after ACS, but this trial showed switching to clopidogrel for DAPT after 30 days of treatment lowers bleeding events with no difference in recurrent ischemic events.^2-4

Continue to: CAVEATS

Less-than-ideal study methods

In this open-label and unblinded study, the investigators adjudicating critical events were blinded to the treatment allocation. However, patients could self-report minor bleeding and medication discontinuation for which no consultation was sought. In addition, the investigators used opaque envelopes—a less-than-ideal method—to conceal allocation at enrollment.

CHALLENGES TO IMPLEMENTATION

PCP may not change cardiologist’s ­prescription

Implementing this practice is facilitated by the comparatively lower cost of clopidogrel versus the newer P2Y12 blockers. However, after ACS and PCI treatment, cardiologists usually initiate antiplatelet therapy and may continue to manage patients after discharge. The primary care provider (PCP) may not be responsible for the DAPT switch initially; furthermore, ordering a switch may require coordination if the PCP is hesitant to change the cardiologist’s prescription. Lastly, guidelines currently recommend using the newer P2Y12 blockers for 12 months.² CR

ACKNOWLEDGEMENT

The PURLs Surveillance System was supported in part by Grant Number UL1RR024999 from the National Center For Research Resources, a Clinical Translational Science Award to the University of Chicago. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Center For Research Resources or the National Institutes of Health.

Copyright © 2019. The Family Physicians Inquiries Network. All rights reserved.

Reprinted with permission from the Family Physicians Inquiries Network and The Journal of Family Practice (2019;68[3]:162,164).

Benefits of adding chemotherapy to pelvic radiotherapy in localized high-risk endometrial cancer increase with follow-up, finds an updated analysis of the randomized PORTEC-3 trial.

The relative risk-benefit profile of chemoradiotherapy is uncertain, with some evidence suggesting it varies according to disease histology and stage, noted lead investigator Stephanie de Boer, MD, department of radiation oncology, Leiden (the Netherlands) University Medical Center, and coinvestigators.

PORTEC-3, a multicenter phase 3 trial, enrolled women who had undergone surgery for high-risk endometrial cancer: FIGO 2009 stage I, endometrioid grade 3 cancer with deep myometrial invasion, lymphovascular space invasion, or both; stage II or III disease; or stage I to III disease with serous or clear cell histology. In all, 660 women were evenly assigned to external-beam radiotherapy alone (48.6 Gy in 1.8-Gy fractions, on 5 days per week) or radiotherapy and chemotherapy (two cycles of cisplatin given during radiotherapy, followed by four cycles of carboplatin and paclitaxel).

A previous analysis, at a median follow-up of 60.2 months (5.0 years), showed a significant 5-year failure-free survival benefit of chemoradiotherapy over radiotherapy (hazard ratio [HR], 0.71; P = .022) but only a trend toward an overall survival benefit (Lancet Oncol. 2018;19[3]:295-309).

The updated analysis, now at a median follow-up of 72.6 months (6.1 years), was reported in Lancet Oncology and showed that chemoradiotherapy was still significantly superior to radiotherapy alone in terms of 5-year failure-free survival (76.5% vs. 69.1%; adjusted HR, 0.70; P = .016) but was now also significantly superior in terms of 5-year overall survival (81.4% vs. 76.1%; adjusted HR, 0.70; P = .034)

The 5-year probability of distant metastasis was lower with chemoradiotherapy than with radiotherapy alone (21.4% vs. 29.1%; HR, 0.74; P = .047). The two groups did not differ significantly with respect to isolated vaginal recurrence as first site (0.3% in each group) or isolated pelvic recurrence as first site (0.9% in each group).

Only a single patient, in the chemoradiotherapy group, experienced a grade 4 adverse event (ileus or obstruction). The chemoradiotherapy and radiotherapy-only groups were similar on the rate of grade 3 adverse events (8% vs. 5%; P = .24), the most common of which was hypertension. However, the former had a higher rate of grade 2 or worse adverse events (38% vs. 23%; P = .002), such as persistent sensory neuropathy (6% vs. 0%). None of the patients died from treatment-related causes.

“Combined adjuvant chemotherapy and radiotherapy should be discussed and recommended as a new standard of care, especially for women with stage III endometrial cancer or serous cancers, or both,” Dr. de Boer and coinvestigators maintained. “Shared decision making between doctors and their patients remains essential to weigh the costs and benefits for individual patients.

“Molecular analysis has the potential to improve risk stratification and should be used to identify subgroups that can derive the greatest benefit from chemotherapy and to select patients for targeted therapies; molecular studies on tissue samples donated by PORTEC-3 trial participants are ongoing,” they noted.

Dr. de Boer disclosed no competing interests in relation to the study. The study was supported in part by the Dutch Cancer Society, Cancer Research UK, National Health and Medical Research Council, Cancer Australia, the Italian Medicines Agency, and the Canadian Cancer Society Research Institute.

SOURCE: de Boer SM et al. Lancet Oncol. 2019 July 22. doi: 10.1016/S1470-2045(19)30395-X.

Benefits of adding chemotherapy to pelvic radiotherapy in localized high-risk endometrial cancer increase with follow-up, finds an updated analysis of the randomized PORTEC-3 trial.

The relative risk-benefit profile of chemoradiotherapy is uncertain, with some evidence suggesting it varies according to disease histology and stage, noted lead investigator Stephanie de Boer, MD, department of radiation oncology, Leiden (the Netherlands) University Medical Center, and coinvestigators.

PORTEC-3, a multicenter phase 3 trial, enrolled women who had undergone surgery for high-risk endometrial cancer: FIGO 2009 stage I, endometrioid grade 3 cancer with deep myometrial invasion, lymphovascular space invasion, or both; stage II or III disease; or stage I to III disease with serous or clear cell histology. In all, 660 women were evenly assigned to external-beam radiotherapy alone (48.6 Gy in 1.8-Gy fractions, on 5 days per week) or radiotherapy and chemotherapy (two cycles of cisplatin given during radiotherapy, followed by four cycles of carboplatin and paclitaxel).

A previous analysis, at a median follow-up of 60.2 months (5.0 years), showed a significant 5-year failure-free survival benefit of chemoradiotherapy over radiotherapy (hazard ratio [HR], 0.71; P = .022) but only a trend toward an overall survival benefit (Lancet Oncol. 2018;19[3]:295-309).

The updated analysis, now at a median follow-up of 72.6 months (6.1 years), was reported in Lancet Oncology and showed that chemoradiotherapy was still significantly superior to radiotherapy alone in terms of 5-year failure-free survival (76.5% vs. 69.1%; adjusted HR, 0.70; P = .016) but was now also significantly superior in terms of 5-year overall survival (81.4% vs. 76.1%; adjusted HR, 0.70; P = .034)

The 5-year probability of distant metastasis was lower with chemoradiotherapy than with radiotherapy alone (21.4% vs. 29.1%; HR, 0.74; P = .047). The two groups did not differ significantly with respect to isolated vaginal recurrence as first site (0.3% in each group) or isolated pelvic recurrence as first site (0.9% in each group).

Only a single patient, in the chemoradiotherapy group, experienced a grade 4 adverse event (ileus or obstruction). The chemoradiotherapy and radiotherapy-only groups were similar on the rate of grade 3 adverse events (8% vs. 5%; P = .24), the most common of which was hypertension. However, the former had a higher rate of grade 2 or worse adverse events (38% vs. 23%; P = .002), such as persistent sensory neuropathy (6% vs. 0%). None of the patients died from treatment-related causes.

“Combined adjuvant chemotherapy and radiotherapy should be discussed and recommended as a new standard of care, especially for women with stage III endometrial cancer or serous cancers, or both,” Dr. de Boer and coinvestigators maintained. “Shared decision making between doctors and their patients remains essential to weigh the costs and benefits for individual patients.

“Molecular analysis has the potential to improve risk stratification and should be used to identify subgroups that can derive the greatest benefit from chemotherapy and to select patients for targeted therapies; molecular studies on tissue samples donated by PORTEC-3 trial participants are ongoing,” they noted.

Dr. de Boer disclosed no competing interests in relation to the study. The study was supported in part by the Dutch Cancer Society, Cancer Research UK, National Health and Medical Research Council, Cancer Australia, the Italian Medicines Agency, and the Canadian Cancer Society Research Institute.

SOURCE: de Boer SM et al. Lancet Oncol. 2019 July 22. doi: 10.1016/S1470-2045(19)30395-X.

Benefits of adding chemotherapy to pelvic radiotherapy in localized high-risk endometrial cancer increase with follow-up, finds an updated analysis of the randomized PORTEC-3 trial.

The relative risk-benefit profile of chemoradiotherapy is uncertain, with some evidence suggesting it varies according to disease histology and stage, noted lead investigator Stephanie de Boer, MD, department of radiation oncology, Leiden (the Netherlands) University Medical Center, and coinvestigators.

PORTEC-3, a multicenter phase 3 trial, enrolled women who had undergone surgery for high-risk endometrial cancer: FIGO 2009 stage I, endometrioid grade 3 cancer with deep myometrial invasion, lymphovascular space invasion, or both; stage II or III disease; or stage I to III disease with serous or clear cell histology. In all, 660 women were evenly assigned to external-beam radiotherapy alone (48.6 Gy in 1.8-Gy fractions, on 5 days per week) or radiotherapy and chemotherapy (two cycles of cisplatin given during radiotherapy, followed by four cycles of carboplatin and paclitaxel).

A previous analysis, at a median follow-up of 60.2 months (5.0 years), showed a significant 5-year failure-free survival benefit of chemoradiotherapy over radiotherapy (hazard ratio [HR], 0.71; P = .022) but only a trend toward an overall survival benefit (Lancet Oncol. 2018;19[3]:295-309).

The updated analysis, now at a median follow-up of 72.6 months (6.1 years), was reported in Lancet Oncology and showed that chemoradiotherapy was still significantly superior to radiotherapy alone in terms of 5-year failure-free survival (76.5% vs. 69.1%; adjusted HR, 0.70; P = .016) but was now also significantly superior in terms of 5-year overall survival (81.4% vs. 76.1%; adjusted HR, 0.70; P = .034)

The 5-year probability of distant metastasis was lower with chemoradiotherapy than with radiotherapy alone (21.4% vs. 29.1%; HR, 0.74; P = .047). The two groups did not differ significantly with respect to isolated vaginal recurrence as first site (0.3% in each group) or isolated pelvic recurrence as first site (0.9% in each group).

Only a single patient, in the chemoradiotherapy group, experienced a grade 4 adverse event (ileus or obstruction). The chemoradiotherapy and radiotherapy-only groups were similar on the rate of grade 3 adverse events (8% vs. 5%; P = .24), the most common of which was hypertension. However, the former had a higher rate of grade 2 or worse adverse events (38% vs. 23%; P = .002), such as persistent sensory neuropathy (6% vs. 0%). None of the patients died from treatment-related causes.

“Combined adjuvant chemotherapy and radiotherapy should be discussed and recommended as a new standard of care, especially for women with stage III endometrial cancer or serous cancers, or both,” Dr. de Boer and coinvestigators maintained. “Shared decision making between doctors and their patients remains essential to weigh the costs and benefits for individual patients.

“Molecular analysis has the potential to improve risk stratification and should be used to identify subgroups that can derive the greatest benefit from chemotherapy and to select patients for targeted therapies; molecular studies on tissue samples donated by PORTEC-3 trial participants are ongoing,” they noted.

Dr. de Boer disclosed no competing interests in relation to the study. The study was supported in part by the Dutch Cancer Society, Cancer Research UK, National Health and Medical Research Council, Cancer Australia, the Italian Medicines Agency, and the Canadian Cancer Society Research Institute.

SOURCE: de Boer SM et al. Lancet Oncol. 2019 July 22. doi: 10.1016/S1470-2045(19)30395-X.

The general internist Elisabeth Poorman, MD, calls for institutions “to confront the size of the epidemic of [physician] depression and suicide head on,” while describing two exemplars at providing physicians with mental health support, in a recently published commentary.

“I want to call attention to the gap between what educators think and say is available, in terms of mental health support, and what trainees experience,” Dr. Poorman said in a statement on her piece in the Journal of Patient Safety and Risk Management. She shared the results of an anonymous depression survey of interns, which showed that 41.8% of participants screened positive for depression. Dr. Poorman also provided statistics on physician suicide, including that at least 66 residents killed themselves between 2000 and 2014, according to ACGME, and that another source estimated that 300-400 physician suicide deaths occur annually.

“When it comes to mental illness and suicide, we are all at risk, but we too often lacked compassion in the way we approach our colleagues. We have lacked the courage to fight the stigma that is killing us. We have not asked whether our unwillingness to reform medical training has eroded the empathy of generations of doctors. We have not done enough to fight medical boards that ask doctors about mental health diagnoses in the same way they ask if we have domestic violence charges,” wrote Dr. Poorman, who practices at a University of Washington neighborhood clinic in Kent.

“A focus on the occupational risks we face would shift us away from ‘wellness’ and ‘resilience,’ and place the onus on schools, training programs, and hospitals to do better for providers and patients,” continued Dr. Poorman, who serves on the editorial advisory board of Internal Medicine News.

She commended Oregon Health and Science University, Portland, and Stanford (Calif.) University’s divisions of general surgery for providing “rigorously confidential mental health support” through a wellness and suicide prevention program for residents and faculty, and a wellness program for residents “that emphasizes relationships, structural support, and psychological safety,” respectively. Dr. Poorman also applauded both for speaking openly about physician suicides.

[email protected]

SOURCE: Poorman E. J Patient Saf Risk Manag. 2019 Aug 5. doi: 10.1177/2516043519866993.

This article was updated 8/5/19.

The general internist Elisabeth Poorman, MD, calls for institutions “to confront the size of the epidemic of [physician] depression and suicide head on,” while describing two exemplars at providing physicians with mental health support, in a recently published commentary.

“I want to call attention to the gap between what educators think and say is available, in terms of mental health support, and what trainees experience,” Dr. Poorman said in a statement on her piece in the Journal of Patient Safety and Risk Management. She shared the results of an anonymous depression survey of interns, which showed that 41.8% of participants screened positive for depression. Dr. Poorman also provided statistics on physician suicide, including that at least 66 residents killed themselves between 2000 and 2014, according to ACGME, and that another source estimated that 300-400 physician suicide deaths occur annually.

“When it comes to mental illness and suicide, we are all at risk, but we too often lacked compassion in the way we approach our colleagues. We have lacked the courage to fight the stigma that is killing us. We have not asked whether our unwillingness to reform medical training has eroded the empathy of generations of doctors. We have not done enough to fight medical boards that ask doctors about mental health diagnoses in the same way they ask if we have domestic violence charges,” wrote Dr. Poorman, who practices at a University of Washington neighborhood clinic in Kent.

“A focus on the occupational risks we face would shift us away from ‘wellness’ and ‘resilience,’ and place the onus on schools, training programs, and hospitals to do better for providers and patients,” continued Dr. Poorman, who serves on the editorial advisory board of Internal Medicine News.

She commended Oregon Health and Science University, Portland, and Stanford (Calif.) University’s divisions of general surgery for providing “rigorously confidential mental health support” through a wellness and suicide prevention program for residents and faculty, and a wellness program for residents “that emphasizes relationships, structural support, and psychological safety,” respectively. Dr. Poorman also applauded both for speaking openly about physician suicides.

[email protected]

SOURCE: Poorman E. J Patient Saf Risk Manag. 2019 Aug 5. doi: 10.1177/2516043519866993.

This article was updated 8/5/19.

The general internist Elisabeth Poorman, MD, calls for institutions “to confront the size of the epidemic of [physician] depression and suicide head on,” while describing two exemplars at providing physicians with mental health support, in a recently published commentary.

“I want to call attention to the gap between what educators think and say is available, in terms of mental health support, and what trainees experience,” Dr. Poorman said in a statement on her piece in the Journal of Patient Safety and Risk Management. She shared the results of an anonymous depression survey of interns, which showed that 41.8% of participants screened positive for depression. Dr. Poorman also provided statistics on physician suicide, including that at least 66 residents killed themselves between 2000 and 2014, according to ACGME, and that another source estimated that 300-400 physician suicide deaths occur annually.

“When it comes to mental illness and suicide, we are all at risk, but we too often lacked compassion in the way we approach our colleagues. We have lacked the courage to fight the stigma that is killing us. We have not asked whether our unwillingness to reform medical training has eroded the empathy of generations of doctors. We have not done enough to fight medical boards that ask doctors about mental health diagnoses in the same way they ask if we have domestic violence charges,” wrote Dr. Poorman, who practices at a University of Washington neighborhood clinic in Kent.

“A focus on the occupational risks we face would shift us away from ‘wellness’ and ‘resilience,’ and place the onus on schools, training programs, and hospitals to do better for providers and patients,” continued Dr. Poorman, who serves on the editorial advisory board of Internal Medicine News.

She commended Oregon Health and Science University, Portland, and Stanford (Calif.) University’s divisions of general surgery for providing “rigorously confidential mental health support” through a wellness and suicide prevention program for residents and faculty, and a wellness program for residents “that emphasizes relationships, structural support, and psychological safety,” respectively. Dr. Poorman also applauded both for speaking openly about physician suicides.

[email protected]

SOURCE: Poorman E. J Patient Saf Risk Manag. 2019 Aug 5. doi: 10.1177/2516043519866993.

This article was updated 8/5/19.

This supplement to Neurology Reviews compiles MS-related news briefs from the 2019 annual meetings of the American Academy of Neurology, held in Philadelphia in early May, and the Consortium of Multiple Sclerosis Centers, held in Seattle in late May.  

View the supplement here.

This supplement to Neurology Reviews compiles MS-related news briefs from the 2019 annual meetings of the American Academy of Neurology, held in Philadelphia in early May, and the Consortium of Multiple Sclerosis Centers, held in Seattle in late May.  

View the supplement here.

This supplement to Neurology Reviews compiles MS-related news briefs from the 2019 annual meetings of the American Academy of Neurology, held in Philadelphia in early May, and the Consortium of Multiple Sclerosis Centers, held in Seattle in late May.  

View the supplement here.

Lori J. Heim, MD, FAAFP, a hospitalist in practice at Scotland Memorial Hospital in Laurinburg, N.C., for the past 10 years, recalls when she first decided to pursue hospital medicine as a career. As a family physician in private practice who admitted patients to the local hospital in Pinehurst, N.C., and even followed them into the ICU, she needed a more flexible schedule when she became president-elect of the American Academy of Family Physicians (AAFP).

“My local hospital told me they had a policy against hiring family physicians as hospitalists. They didn’t consider us qualified,” Dr. Heim said. “I was incredulous when I first heard that because I already had full admitting privileges at the hospital. It made no sense, since they allowed me to manage my patients in the ICU.”

Then an opportunity opened at Scotland Memorial, located an hour away. “That has been a fabulous experience for me,” she said. The transition was relatively easy, following more than 2 decades of office practice. Dr. Heim’s hospitalist group now includes eight full-time clinicians who have a mix of family medicine and internal medicine backgrounds.

“I’ve never felt anything other than collegial support here. We go to the ER to evaluate patients and decide whether to admit them, and we do a lot of medical procedures. I’m not practicing pediatrics currently, but I have no problem conducting a gynecological exam. I think my experience in family medicine and primary care has been an asset,” Dr. Heim said. “I’m not sure I would be a hospitalist today if I had not been elected president of AAFP, but it was fortuitous.”

Respect for HTFMs is growing

Hospitalists trained in family medicine (HTFM) are a small but important segment of this field and of the membership of the Society of Hospital Medicine. The board specialties of physicians who work in the hospital are not always broken out in existing databases, but HTFMs are believed to represent about 8% of SHM members, and somewhere around 10%-15% of the total hospitalist workforce. According to SHM’s 2018 State of Hospital Medicine Report, 65% of hospital medicine groups employed at least one family medicine–trained provider in their group.¹

SHM’s Special Interest Group (SIG) for HTFMs reports to the society’s Board of Directors. The American Academy of Family Medicine, with 131,400 members, also has a Member Interest Group (MIG) for HTFMs. When AAFP recently surveyed its members to identify their primary patient care practice location, only 4% named the hospital (not including the emergency department), while 3% said the hospital emergency department.²

Among 32,450 adult primary care-trained hospitalists surveyed for the June 2016 AAMC In Brief of the American Association of Medical Colleges, 81.9% of the hospitalists identified internal medicine as their specialty, while 5.2% identified themselves as family physicians.³ A 2014 Medical Group Management Association survey, which reported data for 4,200 hospitalists working in community hospitals, found that 82% were internal medicine trained, versus 10% in family medicine and 7% in pediatrics.

Family medicine hospitalists may be more common in rural areas or in small hospitals – where a clinician is often expected to wear more hats, said hospitalist David Goldstein, MD, FHM, assistant director of the family medicine residency program at Natividad Medical Center, Salinas, Calif., and cochair of SHM’s family medicine SIG. “In a smaller hospital, if there’s not sufficient volume to support full-time pediatric and adult hospital medicine services, a family medicine hospitalist might do both – and even help staff the ICU.”

A decade or so ago, much of the professional literature about the role of HTFMs suggested that some had experienced a lack of respect or of equal job opportunities, while others faced pay differentials.^3-5 Since then, the field of hospital medicine has come a long way toward recognizing their contributions, although there are still hurdles to overcome, mainly involving issues of credentialing, to allow HTFMs to play equal roles in the hospital, the ICU, or in residency training. The SHM 2018 State of Hospital Medicine Report reveals that HTFMs actually made slightly higher salaries on average than their internist colleagues, $301,833 versus $300,030.

Prior to the advent of hospital medicine, both family medicine and internal medicine physicians practiced in much the same way in their medical offices, and visited their patients in the hospital, said Claudia Geyer, MD, SFHM, system chief of hospital medicine at Central Maine Healthcare in Lewiston. She is trained and boarded in both family and internal medicine. “When hospital medicine launched, its heavy academic emphasis on internists led to underrecognition of the continued contributions of family medicine. Family physicians never left the hospital setting and – in certain locales – were the predominant hospitalists. We just waited for the recognition to catch up with the reality,” Dr. Geyer said.

“I don’t feel family medicine for hospitalists is nearly the stepchild of internal medicine that it was when I first started,” Dr. Heim said. “In my multihospital hospitalist group, I haven’t seen anything to suggest that they treat family medicine hospitalists as second class.” The demand for hospitalists is greater than internists can fill, while clearly the public is not concerned about these distinctions, she said.

Whether clinicians are board certified in family medicine or internal medicine may be less important to their skills for practicing in the hospital than which residency program they completed, what emphasis it placed on working in the hospital or ICU, electives completed, and other past experience. “Some family medicine residencies offer more or less hospital experience,” Dr. Heim said.

Jasen Gundersen, MD, MBA, CPE, SFHM, president of acute and post-acute services for the national hospital services company TeamHealth, agreed that there has been dramatic improvement in the status of HTFMs. He is one, and still practices as a hospitalist at Boca Raton (Fla.) Regional Hospital when administrative responsibilities permit.

TeamHealth has long been open to family medicine doctors, Dr. Gundersen added, although some of the medical staff at hospitals that contract with TeamHealth have issues with it. “We will talk to them about it,” he said. “We hire hospitalists who can do the work, and we evaluate them based on their background and skill set, where they’ve practiced and for how long. We want people who are experienced and good at managing hospitalized patients. For new residency grads, we look at their electives and the focus of their training.”

What is home for HTFMs?

Where are HTFMs most likely to find their professional home? “That’s hard to answer,” said Patricia Seymour, MD, FHM, FAAFP, an academic hospitalist at the University of Massachusetts-Worcester. “In the last 4-5 years, SHM has worked very hard to create a space for HTFMs. AAFP has a hospital medicine track at their annual meeting, and that’s a good thing. But they also need to protect family physicians’ right to practice in any setting they choose. For those pursuing hospital medicine, there’s a different career trajectory, different CME needs, and different recertification needs.”

Dr. Seymour is the executive cochair of SHM’s family medicine SIG and serves as interim chief of a family medicine hospitalist group that provides inpatient training for a family practice residency, where up to a third of the 12 residents each year go on to pursue hospital medicine as a career. “We have the second-oldest family medicine–specific hospitalist group in the country, so our residency training has an emphasis on hospital medicine,” she explained.

“Because I’m a practicing hospitalist, the residents come to me seeking advice. I appreciate the training I received as a family physician in communication science, palliative care, geriatrics, family systems theory, and public health. I wouldn’t have done it any other way, and that’s how I counsel our students and residents,” she said. Others suggest that the generalist training and diverse experiences of family medicine can be a gift for a doctor who later chooses hospital medicine.

AAFP is a large umbrella organization and the majority of its members practice primary care, Dr. Heim said. “I don’t know the percentage of HTFMs who are members of AAFP. Some no doubt belong to both AAFP and SHM.” Even though both groups have recognized this important subset of their members who chose the field of hospital medicine and its status as a career track, it can be a stretch for family medicine to embrace hospitalists.

“It inherently goes against our training, which is to work in outpatient, inpatient, obstetric, pediatric, and adult settings,” Dr. Heim said. “It’s difficult to reconcile giving up a big part of what defined your training – that range of settings. I remember feeling like I should apologize to other family medicine doctors for choosing this path.”

Credentialing opportunities and barriers

For the diverse group of practicing HTFMs, credentialing and scope of practice represent their biggest current issues. A designation of Focused Practice in Hospital Medicine (FPHM) has been offered jointly since 2010 by the American Board of Family Medicine (ABFM) and the American Board of Internal Medicine (ABIM), although their specific requirements vary.

Eligible hospitalist candidates for the focused practice exam must have an unrestricted medical license, maintenance of current primary certification, and verification of three years of unsupervised hospital medicine practice experience. ABIM views FPHM not as a subspecialty, but as a variation of internal medicine certification, identifying diplomates who are board-certified in internal medicine with a hospital medicine specialization. They do not have to take the general internal medicine recertification exam if they qualify for FPHM.

ABFM-certified family physicians who work primarily in a hospital setting can take the same test for FPHM, with the same eligibility requirements. But ABFM does not consider focused practice a subspecialty, or the Certificate of Added Qualifications in Family Medicine as sufficient for board certification. That means family physicians also need to take its general board exam in order to maintain their ABFM board certification.

ABFM’s decision not to accept the focused practice designation as sufficient for boarding was disappointing to a lot of hospitalists, said Laura “Nell” Hodo, MD, FAAFP, chair of AAFP’s hospital medicine MIG, and a pediatric academic hospitalist at Icahn School of Medicine at Mount Sinai, New York. “Many family physicians practice hospital medicine exclusively and would prefer to take one boarding exam instead of two, and not have to do CME and board review in areas where we don’t practice anymore,” Dr. Hodo said, adding that she hopes that this decision could be revisited in the future.

A number of 1-year hospital medicine fellowships across the country provide additional training opportunities for both family practice and internal medicine residency graduates. These fellowships do not offer board certification or designated specialty credentialing for hospitalists and are not recognized by the American College of Graduate Medical Education (ACGME), which sets standards for residency and fellowship training. “But they reflect a need and an interest in optimizing the knowledge of hospital medicine and developing the specific skills needed to practice it well,” Dr. Geyer noted.

She directs a program for one to three fellows per year out of the Central Maine Family Medicine Residency program and Central Maine Medical Center in Lewiston, and is now recruiting her tenth class. At least 13 other hospital medicine fellowships, out of about 40 nationwide, are family medicine based. “We rely heavily on the Core Competencies in Hospital Medicine developed by SHM, which emphasize clinical conditions, medical procedures, and health care systems. Gaining fluency in the latter is really what makes hospital medicine unique,” Dr. Geyer said.

Often residency graduates seeking work in hospital medicine are insufficiently prepared for hospital billing and coding, enacting safe transitions of care, providing palliative care, and understanding how to impact their health care systems for quality improvement, patient safety and the like, she added.

Dr. Geyer said her fellowship does not mean just being a poorly paid hospitalist for a year. “The fellows are clearly trainees, getting the full benefit of our supervision and supplemental training focused on enhanced clinical and procedural exposure, but also on academics, quality improvement, leadership, and efficiency,” she said. “All of our fellows join SHM, go to the Annual Conference, propose case studies, do longitudinal quality or safety projects, and learn the other aspects of hospital medicine not well-taught in residency. We train them to be highly functional hospitalists right out of the gate.”

Until recently, another barrier for HTFMs was their ability to be on the faculty of internal medicine residency programs. Previous language from ACGME indicated that family medicine-trained physicians could not serve as faculty for these programs, Dr. Goldstein said. SHM has lobbied ACGME to change that rule, which could enable family medicine hospitalists who had achieved FPHM designation to be attendings and to teach internal medicine residents.
 

Needed in critical care – but not credentialed

One of the biggest frustrations for family medicine hospitalists is clarifying their role in the ICU. SHM’s Education Committee recently surveyed hospitalist members who practice in the ICU, finding that at least half felt obliged to practice beyond their scope, 90 percent occasionally perceived insufficient support from intensivists, and two-thirds reported moderate difficulty transferring patients to higher levels of intensive care.⁷ The respondents overwhelmingly indicated that they wanted more training and education in critical care medicine.

“I want to highlight the fact that in some settings family physicians are the sole providers of critical care,” Dr. Goldstein said. Meanwhile, the standards of the Leapfrog Group, a coalition of health care purchasers, call for ICUs to be staffed by physicians certified in critical care, even though there is a growing shortage of credentialed intensivists to treat an increasing number of older, sicker, critically ill patients.

Some internal medicine physicians don’t want to have anything to do with the ICU because of the medical and legal risks, said David Aymond, MD, a family physician and hospitalist at Byrd Regional Hospital in Leesville, La. “There’s a bunch of sick people in the ICU, and when some doctors like me started doing critical care, we realized we liked it. Depending on your locale, if you are doing hospital medicine, critically ill patients are going to fall in your lap,” he said. “But if you don’t have the skills, that could lead to poor outcomes and unnecessary transfers.”

Dr. Aymond started his career in family medicine. “When I got into residency, I saw how much critical care was needed in rural communities. I decided I would learn everything I could about it. I did a hospital medicine fellowship at the University of Alabama, which included considerable involvement in the ICU. When I went to Byrd Regional, a 60-bed facility with eight ICU beds, we did all of the critical care, and word started to spread in the community. My hospitalist partner and I are now on call 24/7 alternating weeks, doing the majority of the critical care and taking care of anything that goes on in an ICU at a larger center, although we often lack access to consultation services,” he explained.

“We needed to get the attention of the Society of Critical Care Medicine (SCCM) to communicate the scope of this problem. These doctors are doing critical care but there is no official medical training or recognition for them. So they’re legally out on a limb, even though often they are literally the only person available to do it,” Dr. Aymond said. “Certainly there’s a skills gap between HTFMs and board-certified intensivists, but some of that gap has to do with the volume of patients they have seen in the ICU and their comfort level,” he said.

SHM is pursuing initiatives to help address this gap, including collaborating with SCCM on developing a rigorous critical care training curriculum for internal medicine and family medicine hospitalists, with coursework drawn from existing sources, said Eric Siegal, MD, SFHM, a critical care physician in Milwaukee. “It doesn’t replace a 2-year critical care fellowship, but it will be a lot more than what’s currently out there for the nonintensivist who practices in the ICU.” SCCM has approved moving forward with the advanced training curriculum, he said.

Another priority is to try to create a pathway that could permit family medicine–trained hospitalists to apply for existing critical care fellowships, as internal medicine doctors are now able to do. SHM has lobbied ABFM to create a pathway to subspecialty certification in critical care medicine, similar to those that exist for internists and emergency physicians, Dr. Goldstein said, adding that ACGME, which controls access to fellowships, will be the next step. Dr. Aymond expects that there will be a lot of hoops to jump through.

“David Aymond is an exceptional hospitalist,” Dr. Siegal added. “He thinks and talks like an intensivist, but it took concerted and self-directed effort for him to get there. Family practitioners are a significant part of the rural critical care workforce, but their training generally does not adequately prepare them for this role – unless they have made a conscious effort to pursue additional training,” he said.

“My message to family practitioners is not that they’re not good enough to do this, but rather that they are being asked to do something they weren’t trained for. How can we help them do it well?”

References

1. Society of Hospital Medicine (SHM) Practice Analysis Committee. 2018 State of Hospital Medicine Report; Oct 2018.

2. American Academy of Family Physicians Member Census, Dec 31, 2017.

3. Jones KC et al. Hospitalists: A growing part of the primary care workforce. AAMC Analysis in Brief; June 2016; 16(5):1.

4. Berczuk C. Uniquely positioned. The Hospitalist; July 2009.

5. Iqbal Y. Family medicine hospitalists: Separate and unequal? Today’s Hospitalist; May 2007.

6. Kinnan JP. The family way. The Hospitalist; Nov 2007.

7. Sweigart JR et al. Characterizing hospitalist practice and perceptions of critical care delivery. J Hosp Med. 2018 Jan 1;13(1):6-12.

Lori J. Heim, MD, FAAFP, a hospitalist in practice at Scotland Memorial Hospital in Laurinburg, N.C., for the past 10 years, recalls when she first decided to pursue hospital medicine as a career. As a family physician in private practice who admitted patients to the local hospital in Pinehurst, N.C., and even followed them into the ICU, she needed a more flexible schedule when she became president-elect of the American Academy of Family Physicians (AAFP).

“My local hospital told me they had a policy against hiring family physicians as hospitalists. They didn’t consider us qualified,” Dr. Heim said. “I was incredulous when I first heard that because I already had full admitting privileges at the hospital. It made no sense, since they allowed me to manage my patients in the ICU.”

Then an opportunity opened at Scotland Memorial, located an hour away. “That has been a fabulous experience for me,” she said. The transition was relatively easy, following more than 2 decades of office practice. Dr. Heim’s hospitalist group now includes eight full-time clinicians who have a mix of family medicine and internal medicine backgrounds.

“I’ve never felt anything other than collegial support here. We go to the ER to evaluate patients and decide whether to admit them, and we do a lot of medical procedures. I’m not practicing pediatrics currently, but I have no problem conducting a gynecological exam. I think my experience in family medicine and primary care has been an asset,” Dr. Heim said. “I’m not sure I would be a hospitalist today if I had not been elected president of AAFP, but it was fortuitous.”

Respect for HTFMs is growing

Hospitalists trained in family medicine (HTFM) are a small but important segment of this field and of the membership of the Society of Hospital Medicine. The board specialties of physicians who work in the hospital are not always broken out in existing databases, but HTFMs are believed to represent about 8% of SHM members, and somewhere around 10%-15% of the total hospitalist workforce. According to SHM’s 2018 State of Hospital Medicine Report, 65% of hospital medicine groups employed at least one family medicine–trained provider in their group.¹

SHM’s Special Interest Group (SIG) for HTFMs reports to the society’s Board of Directors. The American Academy of Family Medicine, with 131,400 members, also has a Member Interest Group (MIG) for HTFMs. When AAFP recently surveyed its members to identify their primary patient care practice location, only 4% named the hospital (not including the emergency department), while 3% said the hospital emergency department.²

Among 32,450 adult primary care-trained hospitalists surveyed for the June 2016 AAMC In Brief of the American Association of Medical Colleges, 81.9% of the hospitalists identified internal medicine as their specialty, while 5.2% identified themselves as family physicians.³ A 2014 Medical Group Management Association survey, which reported data for 4,200 hospitalists working in community hospitals, found that 82% were internal medicine trained, versus 10% in family medicine and 7% in pediatrics.

Family medicine hospitalists may be more common in rural areas or in small hospitals – where a clinician is often expected to wear more hats, said hospitalist David Goldstein, MD, FHM, assistant director of the family medicine residency program at Natividad Medical Center, Salinas, Calif., and cochair of SHM’s family medicine SIG. “In a smaller hospital, if there’s not sufficient volume to support full-time pediatric and adult hospital medicine services, a family medicine hospitalist might do both – and even help staff the ICU.”

A decade or so ago, much of the professional literature about the role of HTFMs suggested that some had experienced a lack of respect or of equal job opportunities, while others faced pay differentials.^3-5 Since then, the field of hospital medicine has come a long way toward recognizing their contributions, although there are still hurdles to overcome, mainly involving issues of credentialing, to allow HTFMs to play equal roles in the hospital, the ICU, or in residency training. The SHM 2018 State of Hospital Medicine Report reveals that HTFMs actually made slightly higher salaries on average than their internist colleagues, $301,833 versus $300,030.

Prior to the advent of hospital medicine, both family medicine and internal medicine physicians practiced in much the same way in their medical offices, and visited their patients in the hospital, said Claudia Geyer, MD, SFHM, system chief of hospital medicine at Central Maine Healthcare in Lewiston. She is trained and boarded in both family and internal medicine. “When hospital medicine launched, its heavy academic emphasis on internists led to underrecognition of the continued contributions of family medicine. Family physicians never left the hospital setting and – in certain locales – were the predominant hospitalists. We just waited for the recognition to catch up with the reality,” Dr. Geyer said.

“I don’t feel family medicine for hospitalists is nearly the stepchild of internal medicine that it was when I first started,” Dr. Heim said. “In my multihospital hospitalist group, I haven’t seen anything to suggest that they treat family medicine hospitalists as second class.” The demand for hospitalists is greater than internists can fill, while clearly the public is not concerned about these distinctions, she said.

Whether clinicians are board certified in family medicine or internal medicine may be less important to their skills for practicing in the hospital than which residency program they completed, what emphasis it placed on working in the hospital or ICU, electives completed, and other past experience. “Some family medicine residencies offer more or less hospital experience,” Dr. Heim said.

Jasen Gundersen, MD, MBA, CPE, SFHM, president of acute and post-acute services for the national hospital services company TeamHealth, agreed that there has been dramatic improvement in the status of HTFMs. He is one, and still practices as a hospitalist at Boca Raton (Fla.) Regional Hospital when administrative responsibilities permit.

TeamHealth has long been open to family medicine doctors, Dr. Gundersen added, although some of the medical staff at hospitals that contract with TeamHealth have issues with it. “We will talk to them about it,” he said. “We hire hospitalists who can do the work, and we evaluate them based on their background and skill set, where they’ve practiced and for how long. We want people who are experienced and good at managing hospitalized patients. For new residency grads, we look at their electives and the focus of their training.”

What is home for HTFMs?

Where are HTFMs most likely to find their professional home? “That’s hard to answer,” said Patricia Seymour, MD, FHM, FAAFP, an academic hospitalist at the University of Massachusetts-Worcester. “In the last 4-5 years, SHM has worked very hard to create a space for HTFMs. AAFP has a hospital medicine track at their annual meeting, and that’s a good thing. But they also need to protect family physicians’ right to practice in any setting they choose. For those pursuing hospital medicine, there’s a different career trajectory, different CME needs, and different recertification needs.”

Dr. Seymour is the executive cochair of SHM’s family medicine SIG and serves as interim chief of a family medicine hospitalist group that provides inpatient training for a family practice residency, where up to a third of the 12 residents each year go on to pursue hospital medicine as a career. “We have the second-oldest family medicine–specific hospitalist group in the country, so our residency training has an emphasis on hospital medicine,” she explained.

“Because I’m a practicing hospitalist, the residents come to me seeking advice. I appreciate the training I received as a family physician in communication science, palliative care, geriatrics, family systems theory, and public health. I wouldn’t have done it any other way, and that’s how I counsel our students and residents,” she said. Others suggest that the generalist training and diverse experiences of family medicine can be a gift for a doctor who later chooses hospital medicine.

AAFP is a large umbrella organization and the majority of its members practice primary care, Dr. Heim said. “I don’t know the percentage of HTFMs who are members of AAFP. Some no doubt belong to both AAFP and SHM.” Even though both groups have recognized this important subset of their members who chose the field of hospital medicine and its status as a career track, it can be a stretch for family medicine to embrace hospitalists.

“It inherently goes against our training, which is to work in outpatient, inpatient, obstetric, pediatric, and adult settings,” Dr. Heim said. “It’s difficult to reconcile giving up a big part of what defined your training – that range of settings. I remember feeling like I should apologize to other family medicine doctors for choosing this path.”

Credentialing opportunities and barriers

For the diverse group of practicing HTFMs, credentialing and scope of practice represent their biggest current issues. A designation of Focused Practice in Hospital Medicine (FPHM) has been offered jointly since 2010 by the American Board of Family Medicine (ABFM) and the American Board of Internal Medicine (ABIM), although their specific requirements vary.

Eligible hospitalist candidates for the focused practice exam must have an unrestricted medical license, maintenance of current primary certification, and verification of three years of unsupervised hospital medicine practice experience. ABIM views FPHM not as a subspecialty, but as a variation of internal medicine certification, identifying diplomates who are board-certified in internal medicine with a hospital medicine specialization. They do not have to take the general internal medicine recertification exam if they qualify for FPHM.

ABFM-certified family physicians who work primarily in a hospital setting can take the same test for FPHM, with the same eligibility requirements. But ABFM does not consider focused practice a subspecialty, or the Certificate of Added Qualifications in Family Medicine as sufficient for board certification. That means family physicians also need to take its general board exam in order to maintain their ABFM board certification.

ABFM’s decision not to accept the focused practice designation as sufficient for boarding was disappointing to a lot of hospitalists, said Laura “Nell” Hodo, MD, FAAFP, chair of AAFP’s hospital medicine MIG, and a pediatric academic hospitalist at Icahn School of Medicine at Mount Sinai, New York. “Many family physicians practice hospital medicine exclusively and would prefer to take one boarding exam instead of two, and not have to do CME and board review in areas where we don’t practice anymore,” Dr. Hodo said, adding that she hopes that this decision could be revisited in the future.

A number of 1-year hospital medicine fellowships across the country provide additional training opportunities for both family practice and internal medicine residency graduates. These fellowships do not offer board certification or designated specialty credentialing for hospitalists and are not recognized by the American College of Graduate Medical Education (ACGME), which sets standards for residency and fellowship training. “But they reflect a need and an interest in optimizing the knowledge of hospital medicine and developing the specific skills needed to practice it well,” Dr. Geyer noted.

She directs a program for one to three fellows per year out of the Central Maine Family Medicine Residency program and Central Maine Medical Center in Lewiston, and is now recruiting her tenth class. At least 13 other hospital medicine fellowships, out of about 40 nationwide, are family medicine based. “We rely heavily on the Core Competencies in Hospital Medicine developed by SHM, which emphasize clinical conditions, medical procedures, and health care systems. Gaining fluency in the latter is really what makes hospital medicine unique,” Dr. Geyer said.

Often residency graduates seeking work in hospital medicine are insufficiently prepared for hospital billing and coding, enacting safe transitions of care, providing palliative care, and understanding how to impact their health care systems for quality improvement, patient safety and the like, she added.

Dr. Geyer said her fellowship does not mean just being a poorly paid hospitalist for a year. “The fellows are clearly trainees, getting the full benefit of our supervision and supplemental training focused on enhanced clinical and procedural exposure, but also on academics, quality improvement, leadership, and efficiency,” she said. “All of our fellows join SHM, go to the Annual Conference, propose case studies, do longitudinal quality or safety projects, and learn the other aspects of hospital medicine not well-taught in residency. We train them to be highly functional hospitalists right out of the gate.”

Until recently, another barrier for HTFMs was their ability to be on the faculty of internal medicine residency programs. Previous language from ACGME indicated that family medicine-trained physicians could not serve as faculty for these programs, Dr. Goldstein said. SHM has lobbied ACGME to change that rule, which could enable family medicine hospitalists who had achieved FPHM designation to be attendings and to teach internal medicine residents.
 

Needed in critical care – but not credentialed

One of the biggest frustrations for family medicine hospitalists is clarifying their role in the ICU. SHM’s Education Committee recently surveyed hospitalist members who practice in the ICU, finding that at least half felt obliged to practice beyond their scope, 90 percent occasionally perceived insufficient support from intensivists, and two-thirds reported moderate difficulty transferring patients to higher levels of intensive care.⁷ The respondents overwhelmingly indicated that they wanted more training and education in critical care medicine.

“I want to highlight the fact that in some settings family physicians are the sole providers of critical care,” Dr. Goldstein said. Meanwhile, the standards of the Leapfrog Group, a coalition of health care purchasers, call for ICUs to be staffed by physicians certified in critical care, even though there is a growing shortage of credentialed intensivists to treat an increasing number of older, sicker, critically ill patients.

Some internal medicine physicians don’t want to have anything to do with the ICU because of the medical and legal risks, said David Aymond, MD, a family physician and hospitalist at Byrd Regional Hospital in Leesville, La. “There’s a bunch of sick people in the ICU, and when some doctors like me started doing critical care, we realized we liked it. Depending on your locale, if you are doing hospital medicine, critically ill patients are going to fall in your lap,” he said. “But if you don’t have the skills, that could lead to poor outcomes and unnecessary transfers.”

Dr. Aymond started his career in family medicine. “When I got into residency, I saw how much critical care was needed in rural communities. I decided I would learn everything I could about it. I did a hospital medicine fellowship at the University of Alabama, which included considerable involvement in the ICU. When I went to Byrd Regional, a 60-bed facility with eight ICU beds, we did all of the critical care, and word started to spread in the community. My hospitalist partner and I are now on call 24/7 alternating weeks, doing the majority of the critical care and taking care of anything that goes on in an ICU at a larger center, although we often lack access to consultation services,” he explained.

“We needed to get the attention of the Society of Critical Care Medicine (SCCM) to communicate the scope of this problem. These doctors are doing critical care but there is no official medical training or recognition for them. So they’re legally out on a limb, even though often they are literally the only person available to do it,” Dr. Aymond said. “Certainly there’s a skills gap between HTFMs and board-certified intensivists, but some of that gap has to do with the volume of patients they have seen in the ICU and their comfort level,” he said.

SHM is pursuing initiatives to help address this gap, including collaborating with SCCM on developing a rigorous critical care training curriculum for internal medicine and family medicine hospitalists, with coursework drawn from existing sources, said Eric Siegal, MD, SFHM, a critical care physician in Milwaukee. “It doesn’t replace a 2-year critical care fellowship, but it will be a lot more than what’s currently out there for the nonintensivist who practices in the ICU.” SCCM has approved moving forward with the advanced training curriculum, he said.

Another priority is to try to create a pathway that could permit family medicine–trained hospitalists to apply for existing critical care fellowships, as internal medicine doctors are now able to do. SHM has lobbied ABFM to create a pathway to subspecialty certification in critical care medicine, similar to those that exist for internists and emergency physicians, Dr. Goldstein said, adding that ACGME, which controls access to fellowships, will be the next step. Dr. Aymond expects that there will be a lot of hoops to jump through.

“David Aymond is an exceptional hospitalist,” Dr. Siegal added. “He thinks and talks like an intensivist, but it took concerted and self-directed effort for him to get there. Family practitioners are a significant part of the rural critical care workforce, but their training generally does not adequately prepare them for this role – unless they have made a conscious effort to pursue additional training,” he said.

“My message to family practitioners is not that they’re not good enough to do this, but rather that they are being asked to do something they weren’t trained for. How can we help them do it well?”

References

1. Society of Hospital Medicine (SHM) Practice Analysis Committee. 2018 State of Hospital Medicine Report; Oct 2018.

2. American Academy of Family Physicians Member Census, Dec 31, 2017.

3. Jones KC et al. Hospitalists: A growing part of the primary care workforce. AAMC Analysis in Brief; June 2016; 16(5):1.

4. Berczuk C. Uniquely positioned. The Hospitalist; July 2009.

5. Iqbal Y. Family medicine hospitalists: Separate and unequal? Today’s Hospitalist; May 2007.

6. Kinnan JP. The family way. The Hospitalist; Nov 2007.

7. Sweigart JR et al. Characterizing hospitalist practice and perceptions of critical care delivery. J Hosp Med. 2018 Jan 1;13(1):6-12.

Lori J. Heim, MD, FAAFP, a hospitalist in practice at Scotland Memorial Hospital in Laurinburg, N.C., for the past 10 years, recalls when she first decided to pursue hospital medicine as a career. As a family physician in private practice who admitted patients to the local hospital in Pinehurst, N.C., and even followed them into the ICU, she needed a more flexible schedule when she became president-elect of the American Academy of Family Physicians (AAFP).

“My local hospital told me they had a policy against hiring family physicians as hospitalists. They didn’t consider us qualified,” Dr. Heim said. “I was incredulous when I first heard that because I already had full admitting privileges at the hospital. It made no sense, since they allowed me to manage my patients in the ICU.”

Then an opportunity opened at Scotland Memorial, located an hour away. “That has been a fabulous experience for me,” she said. The transition was relatively easy, following more than 2 decades of office practice. Dr. Heim’s hospitalist group now includes eight full-time clinicians who have a mix of family medicine and internal medicine backgrounds.

“I’ve never felt anything other than collegial support here. We go to the ER to evaluate patients and decide whether to admit them, and we do a lot of medical procedures. I’m not practicing pediatrics currently, but I have no problem conducting a gynecological exam. I think my experience in family medicine and primary care has been an asset,” Dr. Heim said. “I’m not sure I would be a hospitalist today if I had not been elected president of AAFP, but it was fortuitous.”

Respect for HTFMs is growing

Hospitalists trained in family medicine (HTFM) are a small but important segment of this field and of the membership of the Society of Hospital Medicine. The board specialties of physicians who work in the hospital are not always broken out in existing databases, but HTFMs are believed to represent about 8% of SHM members, and somewhere around 10%-15% of the total hospitalist workforce. According to SHM’s 2018 State of Hospital Medicine Report, 65% of hospital medicine groups employed at least one family medicine–trained provider in their group.¹

SHM’s Special Interest Group (SIG) for HTFMs reports to the society’s Board of Directors. The American Academy of Family Medicine, with 131,400 members, also has a Member Interest Group (MIG) for HTFMs. When AAFP recently surveyed its members to identify their primary patient care practice location, only 4% named the hospital (not including the emergency department), while 3% said the hospital emergency department.²

Among 32,450 adult primary care-trained hospitalists surveyed for the June 2016 AAMC In Brief of the American Association of Medical Colleges, 81.9% of the hospitalists identified internal medicine as their specialty, while 5.2% identified themselves as family physicians.³ A 2014 Medical Group Management Association survey, which reported data for 4,200 hospitalists working in community hospitals, found that 82% were internal medicine trained, versus 10% in family medicine and 7% in pediatrics.

Family medicine hospitalists may be more common in rural areas or in small hospitals – where a clinician is often expected to wear more hats, said hospitalist David Goldstein, MD, FHM, assistant director of the family medicine residency program at Natividad Medical Center, Salinas, Calif., and cochair of SHM’s family medicine SIG. “In a smaller hospital, if there’s not sufficient volume to support full-time pediatric and adult hospital medicine services, a family medicine hospitalist might do both – and even help staff the ICU.”

A decade or so ago, much of the professional literature about the role of HTFMs suggested that some had experienced a lack of respect or of equal job opportunities, while others faced pay differentials.^3-5 Since then, the field of hospital medicine has come a long way toward recognizing their contributions, although there are still hurdles to overcome, mainly involving issues of credentialing, to allow HTFMs to play equal roles in the hospital, the ICU, or in residency training. The SHM 2018 State of Hospital Medicine Report reveals that HTFMs actually made slightly higher salaries on average than their internist colleagues, $301,833 versus $300,030.

Prior to the advent of hospital medicine, both family medicine and internal medicine physicians practiced in much the same way in their medical offices, and visited their patients in the hospital, said Claudia Geyer, MD, SFHM, system chief of hospital medicine at Central Maine Healthcare in Lewiston. She is trained and boarded in both family and internal medicine. “When hospital medicine launched, its heavy academic emphasis on internists led to underrecognition of the continued contributions of family medicine. Family physicians never left the hospital setting and – in certain locales – were the predominant hospitalists. We just waited for the recognition to catch up with the reality,” Dr. Geyer said.

“I don’t feel family medicine for hospitalists is nearly the stepchild of internal medicine that it was when I first started,” Dr. Heim said. “In my multihospital hospitalist group, I haven’t seen anything to suggest that they treat family medicine hospitalists as second class.” The demand for hospitalists is greater than internists can fill, while clearly the public is not concerned about these distinctions, she said.

Whether clinicians are board certified in family medicine or internal medicine may be less important to their skills for practicing in the hospital than which residency program they completed, what emphasis it placed on working in the hospital or ICU, electives completed, and other past experience. “Some family medicine residencies offer more or less hospital experience,” Dr. Heim said.

Jasen Gundersen, MD, MBA, CPE, SFHM, president of acute and post-acute services for the national hospital services company TeamHealth, agreed that there has been dramatic improvement in the status of HTFMs. He is one, and still practices as a hospitalist at Boca Raton (Fla.) Regional Hospital when administrative responsibilities permit.

TeamHealth has long been open to family medicine doctors, Dr. Gundersen added, although some of the medical staff at hospitals that contract with TeamHealth have issues with it. “We will talk to them about it,” he said. “We hire hospitalists who can do the work, and we evaluate them based on their background and skill set, where they’ve practiced and for how long. We want people who are experienced and good at managing hospitalized patients. For new residency grads, we look at their electives and the focus of their training.”

What is home for HTFMs?

Where are HTFMs most likely to find their professional home? “That’s hard to answer,” said Patricia Seymour, MD, FHM, FAAFP, an academic hospitalist at the University of Massachusetts-Worcester. “In the last 4-5 years, SHM has worked very hard to create a space for HTFMs. AAFP has a hospital medicine track at their annual meeting, and that’s a good thing. But they also need to protect family physicians’ right to practice in any setting they choose. For those pursuing hospital medicine, there’s a different career trajectory, different CME needs, and different recertification needs.”

Dr. Seymour is the executive cochair of SHM’s family medicine SIG and serves as interim chief of a family medicine hospitalist group that provides inpatient training for a family practice residency, where up to a third of the 12 residents each year go on to pursue hospital medicine as a career. “We have the second-oldest family medicine–specific hospitalist group in the country, so our residency training has an emphasis on hospital medicine,” she explained.

“Because I’m a practicing hospitalist, the residents come to me seeking advice. I appreciate the training I received as a family physician in communication science, palliative care, geriatrics, family systems theory, and public health. I wouldn’t have done it any other way, and that’s how I counsel our students and residents,” she said. Others suggest that the generalist training and diverse experiences of family medicine can be a gift for a doctor who later chooses hospital medicine.

AAFP is a large umbrella organization and the majority of its members practice primary care, Dr. Heim said. “I don’t know the percentage of HTFMs who are members of AAFP. Some no doubt belong to both AAFP and SHM.” Even though both groups have recognized this important subset of their members who chose the field of hospital medicine and its status as a career track, it can be a stretch for family medicine to embrace hospitalists.

“It inherently goes against our training, which is to work in outpatient, inpatient, obstetric, pediatric, and adult settings,” Dr. Heim said. “It’s difficult to reconcile giving up a big part of what defined your training – that range of settings. I remember feeling like I should apologize to other family medicine doctors for choosing this path.”

Credentialing opportunities and barriers

For the diverse group of practicing HTFMs, credentialing and scope of practice represent their biggest current issues. A designation of Focused Practice in Hospital Medicine (FPHM) has been offered jointly since 2010 by the American Board of Family Medicine (ABFM) and the American Board of Internal Medicine (ABIM), although their specific requirements vary.

Eligible hospitalist candidates for the focused practice exam must have an unrestricted medical license, maintenance of current primary certification, and verification of three years of unsupervised hospital medicine practice experience. ABIM views FPHM not as a subspecialty, but as a variation of internal medicine certification, identifying diplomates who are board-certified in internal medicine with a hospital medicine specialization. They do not have to take the general internal medicine recertification exam if they qualify for FPHM.

ABFM-certified family physicians who work primarily in a hospital setting can take the same test for FPHM, with the same eligibility requirements. But ABFM does not consider focused practice a subspecialty, or the Certificate of Added Qualifications in Family Medicine as sufficient for board certification. That means family physicians also need to take its general board exam in order to maintain their ABFM board certification.

ABFM’s decision not to accept the focused practice designation as sufficient for boarding was disappointing to a lot of hospitalists, said Laura “Nell” Hodo, MD, FAAFP, chair of AAFP’s hospital medicine MIG, and a pediatric academic hospitalist at Icahn School of Medicine at Mount Sinai, New York. “Many family physicians practice hospital medicine exclusively and would prefer to take one boarding exam instead of two, and not have to do CME and board review in areas where we don’t practice anymore,” Dr. Hodo said, adding that she hopes that this decision could be revisited in the future.

A number of 1-year hospital medicine fellowships across the country provide additional training opportunities for both family practice and internal medicine residency graduates. These fellowships do not offer board certification or designated specialty credentialing for hospitalists and are not recognized by the American College of Graduate Medical Education (ACGME), which sets standards for residency and fellowship training. “But they reflect a need and an interest in optimizing the knowledge of hospital medicine and developing the specific skills needed to practice it well,” Dr. Geyer noted.

She directs a program for one to three fellows per year out of the Central Maine Family Medicine Residency program and Central Maine Medical Center in Lewiston, and is now recruiting her tenth class. At least 13 other hospital medicine fellowships, out of about 40 nationwide, are family medicine based. “We rely heavily on the Core Competencies in Hospital Medicine developed by SHM, which emphasize clinical conditions, medical procedures, and health care systems. Gaining fluency in the latter is really what makes hospital medicine unique,” Dr. Geyer said.

Often residency graduates seeking work in hospital medicine are insufficiently prepared for hospital billing and coding, enacting safe transitions of care, providing palliative care, and understanding how to impact their health care systems for quality improvement, patient safety and the like, she added.

Dr. Geyer said her fellowship does not mean just being a poorly paid hospitalist for a year. “The fellows are clearly trainees, getting the full benefit of our supervision and supplemental training focused on enhanced clinical and procedural exposure, but also on academics, quality improvement, leadership, and efficiency,” she said. “All of our fellows join SHM, go to the Annual Conference, propose case studies, do longitudinal quality or safety projects, and learn the other aspects of hospital medicine not well-taught in residency. We train them to be highly functional hospitalists right out of the gate.”

Until recently, another barrier for HTFMs was their ability to be on the faculty of internal medicine residency programs. Previous language from ACGME indicated that family medicine-trained physicians could not serve as faculty for these programs, Dr. Goldstein said. SHM has lobbied ACGME to change that rule, which could enable family medicine hospitalists who had achieved FPHM designation to be attendings and to teach internal medicine residents.
 

Needed in critical care – but not credentialed

One of the biggest frustrations for family medicine hospitalists is clarifying their role in the ICU. SHM’s Education Committee recently surveyed hospitalist members who practice in the ICU, finding that at least half felt obliged to practice beyond their scope, 90 percent occasionally perceived insufficient support from intensivists, and two-thirds reported moderate difficulty transferring patients to higher levels of intensive care.⁷ The respondents overwhelmingly indicated that they wanted more training and education in critical care medicine.

“I want to highlight the fact that in some settings family physicians are the sole providers of critical care,” Dr. Goldstein said. Meanwhile, the standards of the Leapfrog Group, a coalition of health care purchasers, call for ICUs to be staffed by physicians certified in critical care, even though there is a growing shortage of credentialed intensivists to treat an increasing number of older, sicker, critically ill patients.

Some internal medicine physicians don’t want to have anything to do with the ICU because of the medical and legal risks, said David Aymond, MD, a family physician and hospitalist at Byrd Regional Hospital in Leesville, La. “There’s a bunch of sick people in the ICU, and when some doctors like me started doing critical care, we realized we liked it. Depending on your locale, if you are doing hospital medicine, critically ill patients are going to fall in your lap,” he said. “But if you don’t have the skills, that could lead to poor outcomes and unnecessary transfers.”

Dr. Aymond started his career in family medicine. “When I got into residency, I saw how much critical care was needed in rural communities. I decided I would learn everything I could about it. I did a hospital medicine fellowship at the University of Alabama, which included considerable involvement in the ICU. When I went to Byrd Regional, a 60-bed facility with eight ICU beds, we did all of the critical care, and word started to spread in the community. My hospitalist partner and I are now on call 24/7 alternating weeks, doing the majority of the critical care and taking care of anything that goes on in an ICU at a larger center, although we often lack access to consultation services,” he explained.

“We needed to get the attention of the Society of Critical Care Medicine (SCCM) to communicate the scope of this problem. These doctors are doing critical care but there is no official medical training or recognition for them. So they’re legally out on a limb, even though often they are literally the only person available to do it,” Dr. Aymond said. “Certainly there’s a skills gap between HTFMs and board-certified intensivists, but some of that gap has to do with the volume of patients they have seen in the ICU and their comfort level,” he said.

SHM is pursuing initiatives to help address this gap, including collaborating with SCCM on developing a rigorous critical care training curriculum for internal medicine and family medicine hospitalists, with coursework drawn from existing sources, said Eric Siegal, MD, SFHM, a critical care physician in Milwaukee. “It doesn’t replace a 2-year critical care fellowship, but it will be a lot more than what’s currently out there for the nonintensivist who practices in the ICU.” SCCM has approved moving forward with the advanced training curriculum, he said.

Another priority is to try to create a pathway that could permit family medicine–trained hospitalists to apply for existing critical care fellowships, as internal medicine doctors are now able to do. SHM has lobbied ABFM to create a pathway to subspecialty certification in critical care medicine, similar to those that exist for internists and emergency physicians, Dr. Goldstein said, adding that ACGME, which controls access to fellowships, will be the next step. Dr. Aymond expects that there will be a lot of hoops to jump through.

“David Aymond is an exceptional hospitalist,” Dr. Siegal added. “He thinks and talks like an intensivist, but it took concerted and self-directed effort for him to get there. Family practitioners are a significant part of the rural critical care workforce, but their training generally does not adequately prepare them for this role – unless they have made a conscious effort to pursue additional training,” he said.

“My message to family practitioners is not that they’re not good enough to do this, but rather that they are being asked to do something they weren’t trained for. How can we help them do it well?”

References

1. Society of Hospital Medicine (SHM) Practice Analysis Committee. 2018 State of Hospital Medicine Report; Oct 2018.

2. American Academy of Family Physicians Member Census, Dec 31, 2017.

3. Jones KC et al. Hospitalists: A growing part of the primary care workforce. AAMC Analysis in Brief; June 2016; 16(5):1.

4. Berczuk C. Uniquely positioned. The Hospitalist; July 2009.

5. Iqbal Y. Family medicine hospitalists: Separate and unequal? Today’s Hospitalist; May 2007.

6. Kinnan JP. The family way. The Hospitalist; Nov 2007.

7. Sweigart JR et al. Characterizing hospitalist practice and perceptions of critical care delivery. J Hosp Med. 2018 Jan 1;13(1):6-12.

Slightly less than half of directors at National Cancer Institute–designated cancer centers received payments from industry in 2017, according to recent analysis of the Centers for Medicare & Medicaid Services Open Payments database.

That number is lower than in 2014, but approximately one-fourth of National Cancer Institute (NCI) directors received payments of $5,000 or more that were not related to research, David Carr, MD, of the University of California in San Diego, and H. Gilbert Welch, MD, MPH, of Thetford, Vt., reported in a research letter in JAMA Internal Medicine.

Although cancer care is shaped by public funding through centers under NCI, “[c]ancer care is also shaped by industry, because developing new cancer therapeutics represents a major market opportunity,” Dr. Carr and Dr. Welch said. “Industry payments to academic physicians risk blurring the line between innovation and the evaluation of new therapies.”

In their research letter, Dr. Carr and Dr. Welch examined research- and non–research-based payments made to 53 physician cancer center directors between 2015 and 2017. In 2016, 44 of 53 directors held their current positions, while 41 of 53 directors held their position in 2015.

Analysis from 2017 showed $4.42 million in total industry payments were distributed to the directors, consisting of $1.89 million in research-based payments and $2.53 million in nonresearch payments across 22 directors. There were 27 directors (51%) who did not receive any payments from industry.

The authors found 19 directors (36%) received payments of $5,000 or more, while 12 of 53 directors (23%) received nonresearch payments of $5,000 or more. The largest payment received in 2017 for research was $863,000. Two directors received industry payments at $50,000 or higher that significantly exceeded payments other directors received, and one director received $2.27 million for “compensation for services other than consulting, including serving as faculty or a speaker at a venue other than a continuing education program.”

The NCI currently defines any remuneration above $5,000 to be of “significant financial interest.”

“Our findings raise the question of whether industry payments to the directors of publicly supported institutions, such as NCI-designated cancer centers, serve the public interest,” Dr. Carr and Dr. Welch noted. “Policy makers—and the public—should consider whether such payments should be allowed, limited (e.g., to less than $5,000 a year), or eliminated.”

The authors reported no conflicts of interest.

SOURCE: Carr D, et al. JAMA Intern Med. 2019 Aug 5. doi: 10.1001/jamainternmed.2019.3098.

Slightly less than half of directors at National Cancer Institute–designated cancer centers received payments from industry in 2017, according to recent analysis of the Centers for Medicare & Medicaid Services Open Payments database.

That number is lower than in 2014, but approximately one-fourth of National Cancer Institute (NCI) directors received payments of $5,000 or more that were not related to research, David Carr, MD, of the University of California in San Diego, and H. Gilbert Welch, MD, MPH, of Thetford, Vt., reported in a research letter in JAMA Internal Medicine.

Although cancer care is shaped by public funding through centers under NCI, “[c]ancer care is also shaped by industry, because developing new cancer therapeutics represents a major market opportunity,” Dr. Carr and Dr. Welch said. “Industry payments to academic physicians risk blurring the line between innovation and the evaluation of new therapies.”

In their research letter, Dr. Carr and Dr. Welch examined research- and non–research-based payments made to 53 physician cancer center directors between 2015 and 2017. In 2016, 44 of 53 directors held their current positions, while 41 of 53 directors held their position in 2015.

Analysis from 2017 showed $4.42 million in total industry payments were distributed to the directors, consisting of $1.89 million in research-based payments and $2.53 million in nonresearch payments across 22 directors. There were 27 directors (51%) who did not receive any payments from industry.

The authors found 19 directors (36%) received payments of $5,000 or more, while 12 of 53 directors (23%) received nonresearch payments of $5,000 or more. The largest payment received in 2017 for research was $863,000. Two directors received industry payments at $50,000 or higher that significantly exceeded payments other directors received, and one director received $2.27 million for “compensation for services other than consulting, including serving as faculty or a speaker at a venue other than a continuing education program.”

The NCI currently defines any remuneration above $5,000 to be of “significant financial interest.”

“Our findings raise the question of whether industry payments to the directors of publicly supported institutions, such as NCI-designated cancer centers, serve the public interest,” Dr. Carr and Dr. Welch noted. “Policy makers—and the public—should consider whether such payments should be allowed, limited (e.g., to less than $5,000 a year), or eliminated.”

The authors reported no conflicts of interest.

SOURCE: Carr D, et al. JAMA Intern Med. 2019 Aug 5. doi: 10.1001/jamainternmed.2019.3098.

Slightly less than half of directors at National Cancer Institute–designated cancer centers received payments from industry in 2017, according to recent analysis of the Centers for Medicare & Medicaid Services Open Payments database.

That number is lower than in 2014, but approximately one-fourth of National Cancer Institute (NCI) directors received payments of $5,000 or more that were not related to research, David Carr, MD, of the University of California in San Diego, and H. Gilbert Welch, MD, MPH, of Thetford, Vt., reported in a research letter in JAMA Internal Medicine.

Although cancer care is shaped by public funding through centers under NCI, “[c]ancer care is also shaped by industry, because developing new cancer therapeutics represents a major market opportunity,” Dr. Carr and Dr. Welch said. “Industry payments to academic physicians risk blurring the line between innovation and the evaluation of new therapies.”

In their research letter, Dr. Carr and Dr. Welch examined research- and non–research-based payments made to 53 physician cancer center directors between 2015 and 2017. In 2016, 44 of 53 directors held their current positions, while 41 of 53 directors held their position in 2015.

Analysis from 2017 showed $4.42 million in total industry payments were distributed to the directors, consisting of $1.89 million in research-based payments and $2.53 million in nonresearch payments across 22 directors. There were 27 directors (51%) who did not receive any payments from industry.

The authors found 19 directors (36%) received payments of $5,000 or more, while 12 of 53 directors (23%) received nonresearch payments of $5,000 or more. The largest payment received in 2017 for research was $863,000. Two directors received industry payments at $50,000 or higher that significantly exceeded payments other directors received, and one director received $2.27 million for “compensation for services other than consulting, including serving as faculty or a speaker at a venue other than a continuing education program.”

The NCI currently defines any remuneration above $5,000 to be of “significant financial interest.”

“Our findings raise the question of whether industry payments to the directors of publicly supported institutions, such as NCI-designated cancer centers, serve the public interest,” Dr. Carr and Dr. Welch noted. “Policy makers—and the public—should consider whether such payments should be allowed, limited (e.g., to less than $5,000 a year), or eliminated.”

The authors reported no conflicts of interest.

SOURCE: Carr D, et al. JAMA Intern Med. 2019 Aug 5. doi: 10.1001/jamainternmed.2019.3098.

The Society for Vascular Surgery seeks proposals for invited sessions for the 2020 Vascular Annual Meeting, to be held June 17 to 20 in Toronto, Ontario, Canada. Scientific sessions will be June 18 to 20 and exhibits will be open June 18 to 19. Proposals should include the session's educational benefit, a short outline of the program topic, session goals and target audience, among other information. Obtain the information/submission form here. Email completed forms to [email protected].

The Society for Vascular Surgery seeks proposals for invited sessions for the 2020 Vascular Annual Meeting, to be held June 17 to 20 in Toronto, Ontario, Canada. Scientific sessions will be June 18 to 20 and exhibits will be open June 18 to 19. Proposals should include the session's educational benefit, a short outline of the program topic, session goals and target audience, among other information. Obtain the information/submission form here. Email completed forms to [email protected].

The Society for Vascular Surgery seeks proposals for invited sessions for the 2020 Vascular Annual Meeting, to be held June 17 to 20 in Toronto, Ontario, Canada. Scientific sessions will be June 18 to 20 and exhibits will be open June 18 to 19. Proposals should include the session's educational benefit, a short outline of the program topic, session goals and target audience, among other information. Obtain the information/submission form here. Email completed forms to [email protected].

All who attended the 2019 Vascular Annual Meeting can now review sessions they attended, as well as “attend” those that they missed. Those who weren’t at VAM can now experience all they missed. Slides and audio presentations of nearly every session are included in the now available VAM on Demand. The cost for one year of access is $199 for VAM attendees and $499 for non-attendees. Those who purchased VAM on Demand before the meeting ended can visit this site to gain access by logging in with their SVS credentials.

All who attended the 2019 Vascular Annual Meeting can now review sessions they attended, as well as “attend” those that they missed. Those who weren’t at VAM can now experience all they missed. Slides and audio presentations of nearly every session are included in the now available VAM on Demand. The cost for one year of access is $199 for VAM attendees and $499 for non-attendees. Those who purchased VAM on Demand before the meeting ended can visit this site to gain access by logging in with their SVS credentials.

All who attended the 2019 Vascular Annual Meeting can now review sessions they attended, as well as “attend” those that they missed. Those who weren’t at VAM can now experience all they missed. Slides and audio presentations of nearly every session are included in the now available VAM on Demand. The cost for one year of access is $199 for VAM attendees and $499 for non-attendees. Those who purchased VAM on Demand before the meeting ended can visit this site to gain access by logging in with their SVS credentials.

Around once a month I go to the cemetery to visit my Dad. Although this was difficult 6 years ago when I started, it’s become easier thanks to that great healer, time.

germi_p/Thinkstock

His grave is a short distance from the parking spot, so I have to walk past a number of others to get there. As a result you see these change over time.

A few times in the last several years I’ve noticed a new grave marker that, to my surprise, has the name of one of my (former) patients on it. Granted, a lot of my practice is the above-75 crowd, and they wouldn’t be coming to me if they didn’t have health issues.

But still, it jolts me a bit when it happens. I may not have thought about them for a while, but suddenly I see the marker and realize why that person hadn’t been in recently. I can usually picture them, too, and remember something they may have said that concerned me or just made me laugh.

Obviously, regardless of age we all end up there, and I certainly don’t consider this a personal medical failing on my part. It’s the nature of life on Earth, no matter how good a job we do as physicians.

But it still surprises me. If it was a patient I have fond memories of, I’ll often stop and say a few words to them, too. To date no one has answered, but I suspect there’s something therapeutic for me in doing so. The cemetery is generally peaceful, and certainly not a place where I feel rushed.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

Around once a month I go to the cemetery to visit my Dad. Although this was difficult 6 years ago when I started, it’s become easier thanks to that great healer, time.

germi_p/Thinkstock

His grave is a short distance from the parking spot, so I have to walk past a number of others to get there. As a result you see these change over time.

A few times in the last several years I’ve noticed a new grave marker that, to my surprise, has the name of one of my (former) patients on it. Granted, a lot of my practice is the above-75 crowd, and they wouldn’t be coming to me if they didn’t have health issues.

But still, it jolts me a bit when it happens. I may not have thought about them for a while, but suddenly I see the marker and realize why that person hadn’t been in recently. I can usually picture them, too, and remember something they may have said that concerned me or just made me laugh.

Obviously, regardless of age we all end up there, and I certainly don’t consider this a personal medical failing on my part. It’s the nature of life on Earth, no matter how good a job we do as physicians.

But it still surprises me. If it was a patient I have fond memories of, I’ll often stop and say a few words to them, too. To date no one has answered, but I suspect there’s something therapeutic for me in doing so. The cemetery is generally peaceful, and certainly not a place where I feel rushed.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

Around once a month I go to the cemetery to visit my Dad. Although this was difficult 6 years ago when I started, it’s become easier thanks to that great healer, time.

germi_p/Thinkstock

His grave is a short distance from the parking spot, so I have to walk past a number of others to get there. As a result you see these change over time.

A few times in the last several years I’ve noticed a new grave marker that, to my surprise, has the name of one of my (former) patients on it. Granted, a lot of my practice is the above-75 crowd, and they wouldn’t be coming to me if they didn’t have health issues.

But still, it jolts me a bit when it happens. I may not have thought about them for a while, but suddenly I see the marker and realize why that person hadn’t been in recently. I can usually picture them, too, and remember something they may have said that concerned me or just made me laugh.

Obviously, regardless of age we all end up there, and I certainly don’t consider this a personal medical failing on my part. It’s the nature of life on Earth, no matter how good a job we do as physicians.

But it still surprises me. If it was a patient I have fond memories of, I’ll often stop and say a few words to them, too. To date no one has answered, but I suspect there’s something therapeutic for me in doing so. The cemetery is generally peaceful, and certainly not a place where I feel rushed.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

During Operations Iraqi and Enduring Freedom, everything from old uniforms to plastic, aerosol cans, electronic equipment, human waste, tires, and batteries were thrown into open pits, often doused with jet fuel, and set on fire.

Many deployed soldiers were exposed to smoke from these open-air burn pits, putting them at risk for cancer, neurologic effects, reproductive effects, respiratory toxicity, and cardiovascular toxicity. Veterans who were close to burn pits have reported eye irritation, itching, rashes, and respiratory problems, such as bronchitis, asthma, and emphysema.

In May 2019, the VA redesignated the Airborne Hazards Center of Excellence (AHCE), established in 2013, as the Airborne Hazards and Burn Pits Center of Excellence (AHBPCE). The redesignation was a consequence of the Helping Veterans Exposed to Burn Pits Act, which stemmed from an 18-month bipartisan effort to prevent burn pits from becoming “the Agent Orange of this generation of soldiers.” Senator Amy Klobuchar (D-MN), who cosponsored the legislation with Thom Tillis (R-NC) said, “After the Vietnam War, it took the US government years to recognize that there was a link between Agent Orange and its devastating health effects on our soldiers. … [W]e can’t make that same tragic mistake again by failing to identify the devastating health effects associated with burn pits.”

The AHCE was responsible for assessing veterans’ cardiopulmonary function, military/ nonmilitary exposures, and health-related symptoms for those with airborne hazard concerns. The AHBPCE will specialize in clinical and transitional research, focusing on expanding understanding of health outcomes and treatments for burn pit–related issues.

VA providers can consult with the AHBPCE about assessment and treatment. When appropriate, veterans may be invited for a comprehensive, multiday health evaluation from a specialized team. The examination includes state-of-the-art assessments of lung function and exercise capacity. The findings are used to develop recommendations, which are shared with the veteran and referring provider for follow-up care. The findings also are used by researchers at the center and throughout the VA to develop research questions to investigate and potentially improve clinical practice.

Veterans (including those who receive VA-authorized care in the community) with complex clinical presentations who are unable to be diagnosed locally may be referred for consultation or examination.

AHBPCE, which is located at the New Jersey War Related Illness and Injury Study Center (WRIISC), also provides the AHBPCE-WRIISC Airborne hazards Registry (AWARE) program, designed for veterans who complete the Airborne Hazards and Open Burn Pit Registry online questionnaire, report chronic respiratory symptoms, and meet other eligibility criteria. AHBPCE’s mandate also includes analyzing registry data to monitor the VA’s overall clinical response to exposure concerns.

During Operations Iraqi and Enduring Freedom, everything from old uniforms to plastic, aerosol cans, electronic equipment, human waste, tires, and batteries were thrown into open pits, often doused with jet fuel, and set on fire.

Many deployed soldiers were exposed to smoke from these open-air burn pits, putting them at risk for cancer, neurologic effects, reproductive effects, respiratory toxicity, and cardiovascular toxicity. Veterans who were close to burn pits have reported eye irritation, itching, rashes, and respiratory problems, such as bronchitis, asthma, and emphysema.

In May 2019, the VA redesignated the Airborne Hazards Center of Excellence (AHCE), established in 2013, as the Airborne Hazards and Burn Pits Center of Excellence (AHBPCE). The redesignation was a consequence of the Helping Veterans Exposed to Burn Pits Act, which stemmed from an 18-month bipartisan effort to prevent burn pits from becoming “the Agent Orange of this generation of soldiers.” Senator Amy Klobuchar (D-MN), who cosponsored the legislation with Thom Tillis (R-NC) said, “After the Vietnam War, it took the US government years to recognize that there was a link between Agent Orange and its devastating health effects on our soldiers. … [W]e can’t make that same tragic mistake again by failing to identify the devastating health effects associated with burn pits.”

The AHCE was responsible for assessing veterans’ cardiopulmonary function, military/ nonmilitary exposures, and health-related symptoms for those with airborne hazard concerns. The AHBPCE will specialize in clinical and transitional research, focusing on expanding understanding of health outcomes and treatments for burn pit–related issues.

VA providers can consult with the AHBPCE about assessment and treatment. When appropriate, veterans may be invited for a comprehensive, multiday health evaluation from a specialized team. The examination includes state-of-the-art assessments of lung function and exercise capacity. The findings are used to develop recommendations, which are shared with the veteran and referring provider for follow-up care. The findings also are used by researchers at the center and throughout the VA to develop research questions to investigate and potentially improve clinical practice.

Veterans (including those who receive VA-authorized care in the community) with complex clinical presentations who are unable to be diagnosed locally may be referred for consultation or examination.

AHBPCE, which is located at the New Jersey War Related Illness and Injury Study Center (WRIISC), also provides the AHBPCE-WRIISC Airborne hazards Registry (AWARE) program, designed for veterans who complete the Airborne Hazards and Open Burn Pit Registry online questionnaire, report chronic respiratory symptoms, and meet other eligibility criteria. AHBPCE’s mandate also includes analyzing registry data to monitor the VA’s overall clinical response to exposure concerns.

During Operations Iraqi and Enduring Freedom, everything from old uniforms to plastic, aerosol cans, electronic equipment, human waste, tires, and batteries were thrown into open pits, often doused with jet fuel, and set on fire.

Many deployed soldiers were exposed to smoke from these open-air burn pits, putting them at risk for cancer, neurologic effects, reproductive effects, respiratory toxicity, and cardiovascular toxicity. Veterans who were close to burn pits have reported eye irritation, itching, rashes, and respiratory problems, such as bronchitis, asthma, and emphysema.

In May 2019, the VA redesignated the Airborne Hazards Center of Excellence (AHCE), established in 2013, as the Airborne Hazards and Burn Pits Center of Excellence (AHBPCE). The redesignation was a consequence of the Helping Veterans Exposed to Burn Pits Act, which stemmed from an 18-month bipartisan effort to prevent burn pits from becoming “the Agent Orange of this generation of soldiers.” Senator Amy Klobuchar (D-MN), who cosponsored the legislation with Thom Tillis (R-NC) said, “After the Vietnam War, it took the US government years to recognize that there was a link between Agent Orange and its devastating health effects on our soldiers. … [W]e can’t make that same tragic mistake again by failing to identify the devastating health effects associated with burn pits.”

The AHCE was responsible for assessing veterans’ cardiopulmonary function, military/ nonmilitary exposures, and health-related symptoms for those with airborne hazard concerns. The AHBPCE will specialize in clinical and transitional research, focusing on expanding understanding of health outcomes and treatments for burn pit–related issues.

VA providers can consult with the AHBPCE about assessment and treatment. When appropriate, veterans may be invited for a comprehensive, multiday health evaluation from a specialized team. The examination includes state-of-the-art assessments of lung function and exercise capacity. The findings are used to develop recommendations, which are shared with the veteran and referring provider for follow-up care. The findings also are used by researchers at the center and throughout the VA to develop research questions to investigate and potentially improve clinical practice.

Veterans (including those who receive VA-authorized care in the community) with complex clinical presentations who are unable to be diagnosed locally may be referred for consultation or examination.

AHBPCE, which is located at the New Jersey War Related Illness and Injury Study Center (WRIISC), also provides the AHBPCE-WRIISC Airborne hazards Registry (AWARE) program, designed for veterans who complete the Airborne Hazards and Open Burn Pit Registry online questionnaire, report chronic respiratory symptoms, and meet other eligibility criteria. AHBPCE’s mandate also includes analyzing registry data to monitor the VA’s overall clinical response to exposure concerns.