WASHINGTON – Adenotonsillectomy reduced obstructive sleep apnea and bed-wetting in half of 35 children diagnosed with both conditions.

The study was limited by its small size, but the findings suggest that children with severe obstructive sleep apnea and nocturnal enuresis might benefit on both counts with adenotonsillectomy, said Dr. Prasad Thottam of Children’s Hospital of Michigan, Detroit.

The average age of the children studied was 8 years, 60% were male, and their average body mass index was 24 kg/m². Proper bladder function was documented in all of the children, and none had chronic conditions such as cerebral palsy, severe asthma, or morbid obesity. All experienced bed-wetting more than 3 nights per week. Any medications taken for nocturnal enuresis were discontinued for 1 month prior to surgery.

Four children had adenoidectomies, two had tonsillectomies, and 29 had adenotonsillectomies. After an average of 10 weeks post surgery, 51% of the children had reductions in bed-wetting, said Dr. Thottam. The reductions were most notable in children with a higher BMI and worse apnea characteristics on polysomnography.

Girls were five times more likely than were boys to have bed-wetting resolve after surgery. Children with prolonged stage 2 sleep were eight times more likely than were those with a normal duration of stage 2 sleep to have bed-wetting resolve.

In addition, when comparing the sleep architecture of the patients to established normal levels, an apnea-hypopnea index greater than 10 was associated with a higher rate of resolution of bed-wetting compared with the rest of the population.

The findings were presented at the annual meeting of the American Academy for Otolaryngology – Head and Neck Surgery Foundation. Dr. Thottam had no financial conflicts to disclose.

WASHINGTON – Adenotonsillectomy reduced obstructive sleep apnea and bed-wetting in half of 35 children diagnosed with both conditions.

The study was limited by its small size, but the findings suggest that children with severe obstructive sleep apnea and nocturnal enuresis might benefit on both counts with adenotonsillectomy, said Dr. Prasad Thottam of Children’s Hospital of Michigan, Detroit.

The average age of the children studied was 8 years, 60% were male, and their average body mass index was 24 kg/m². Proper bladder function was documented in all of the children, and none had chronic conditions such as cerebral palsy, severe asthma, or morbid obesity. All experienced bed-wetting more than 3 nights per week. Any medications taken for nocturnal enuresis were discontinued for 1 month prior to surgery.

Four children had adenoidectomies, two had tonsillectomies, and 29 had adenotonsillectomies. After an average of 10 weeks post surgery, 51% of the children had reductions in bed-wetting, said Dr. Thottam. The reductions were most notable in children with a higher BMI and worse apnea characteristics on polysomnography.

Girls were five times more likely than were boys to have bed-wetting resolve after surgery. Children with prolonged stage 2 sleep were eight times more likely than were those with a normal duration of stage 2 sleep to have bed-wetting resolve.

In addition, when comparing the sleep architecture of the patients to established normal levels, an apnea-hypopnea index greater than 10 was associated with a higher rate of resolution of bed-wetting compared with the rest of the population.

The findings were presented at the annual meeting of the American Academy for Otolaryngology – Head and Neck Surgery Foundation. Dr. Thottam had no financial conflicts to disclose.

WASHINGTON – Adenotonsillectomy reduced obstructive sleep apnea and bed-wetting in half of 35 children diagnosed with both conditions.

The study was limited by its small size, but the findings suggest that children with severe obstructive sleep apnea and nocturnal enuresis might benefit on both counts with adenotonsillectomy, said Dr. Prasad Thottam of Children’s Hospital of Michigan, Detroit.

The average age of the children studied was 8 years, 60% were male, and their average body mass index was 24 kg/m². Proper bladder function was documented in all of the children, and none had chronic conditions such as cerebral palsy, severe asthma, or morbid obesity. All experienced bed-wetting more than 3 nights per week. Any medications taken for nocturnal enuresis were discontinued for 1 month prior to surgery.

Four children had adenoidectomies, two had tonsillectomies, and 29 had adenotonsillectomies. After an average of 10 weeks post surgery, 51% of the children had reductions in bed-wetting, said Dr. Thottam. The reductions were most notable in children with a higher BMI and worse apnea characteristics on polysomnography.

Girls were five times more likely than were boys to have bed-wetting resolve after surgery. Children with prolonged stage 2 sleep were eight times more likely than were those with a normal duration of stage 2 sleep to have bed-wetting resolve.

In addition, when comparing the sleep architecture of the patients to established normal levels, an apnea-hypopnea index greater than 10 was associated with a higher rate of resolution of bed-wetting compared with the rest of the population.

The findings were presented at the annual meeting of the American Academy for Otolaryngology – Head and Neck Surgery Foundation. Dr. Thottam had no financial conflicts to disclose.

A concerted effort by SHM members has helped win some hospitalists an exemption to the Centers for Medicare & Medicaid Services' (CMS) final rule on Stage 2 compliance for meaningful use [PDF] of electronic health records (EHR).

The "hardship exception" frees hospitalists who round at nursing homes and other post-acute-care facilities from being subject to penalties for not being "meaningful users." SHM successfully argued that it isn't fair for HM clinicians working in such institutions be held accountable for records they can't fully control.

SHM Public Policy Committee member Kerry Weiner, MD, chief clinical officer of IPC: The Hospitalist Company Inc. of North Hollywood, Calif., says about 30% of hospitalists are involved in care delivery at nursing homes, skilled nursing facilities, or other post-acute-care settings. Those physicians need to be aware of how CMS views their job in relation to new regulations.

"Once the physician leaves the hospital, they're generally considered an outpatient doctor by CMS, even though leaving an acute-care facility and going into a step-down unit like a skilled nursing facility is not really going into a primary-care or outpatient practice," Dr. Weiner says. "There are a number of regulations coming down, and hospitalists have to be sensitive to the differences in reimbursement and accountability they'll be held to. Just because you're a hospitalist doesn't mean the government considers you a hospitalist for their regulations."

CMS initially proposed that "eligible professionals" (EPs) needed to meet three criteria to be granted a hardship exception: a lack of face-to-face or telemedicine interaction with patients, a lack of follow-up need with patients, and the "lack of control over the availability" of certified EHR technology. After SHM voiced concern, CMS agreed that EPs who practice at multiple locations can be granted the exception solely for lack of control over the availability of the technology. Dr. Weiner says that CMS' willingness to make changes before finalizing the rule shows the agency understands how difficult the new rules can be.

"CMS has realized they may not get it right the first time," he adds. "This is a dynamic process, and even if they do get it right exactly, it's only right for a particular moment. Medicine is transitioning and changing all the time."

A concerted effort by SHM members has helped win some hospitalists an exemption to the Centers for Medicare & Medicaid Services' (CMS) final rule on Stage 2 compliance for meaningful use [PDF] of electronic health records (EHR).

The "hardship exception" frees hospitalists who round at nursing homes and other post-acute-care facilities from being subject to penalties for not being "meaningful users." SHM successfully argued that it isn't fair for HM clinicians working in such institutions be held accountable for records they can't fully control.

SHM Public Policy Committee member Kerry Weiner, MD, chief clinical officer of IPC: The Hospitalist Company Inc. of North Hollywood, Calif., says about 30% of hospitalists are involved in care delivery at nursing homes, skilled nursing facilities, or other post-acute-care settings. Those physicians need to be aware of how CMS views their job in relation to new regulations.

"Once the physician leaves the hospital, they're generally considered an outpatient doctor by CMS, even though leaving an acute-care facility and going into a step-down unit like a skilled nursing facility is not really going into a primary-care or outpatient practice," Dr. Weiner says. "There are a number of regulations coming down, and hospitalists have to be sensitive to the differences in reimbursement and accountability they'll be held to. Just because you're a hospitalist doesn't mean the government considers you a hospitalist for their regulations."

CMS initially proposed that "eligible professionals" (EPs) needed to meet three criteria to be granted a hardship exception: a lack of face-to-face or telemedicine interaction with patients, a lack of follow-up need with patients, and the "lack of control over the availability" of certified EHR technology. After SHM voiced concern, CMS agreed that EPs who practice at multiple locations can be granted the exception solely for lack of control over the availability of the technology. Dr. Weiner says that CMS' willingness to make changes before finalizing the rule shows the agency understands how difficult the new rules can be.

"CMS has realized they may not get it right the first time," he adds. "This is a dynamic process, and even if they do get it right exactly, it's only right for a particular moment. Medicine is transitioning and changing all the time."

A concerted effort by SHM members has helped win some hospitalists an exemption to the Centers for Medicare & Medicaid Services' (CMS) final rule on Stage 2 compliance for meaningful use [PDF] of electronic health records (EHR).

The "hardship exception" frees hospitalists who round at nursing homes and other post-acute-care facilities from being subject to penalties for not being "meaningful users." SHM successfully argued that it isn't fair for HM clinicians working in such institutions be held accountable for records they can't fully control.

SHM Public Policy Committee member Kerry Weiner, MD, chief clinical officer of IPC: The Hospitalist Company Inc. of North Hollywood, Calif., says about 30% of hospitalists are involved in care delivery at nursing homes, skilled nursing facilities, or other post-acute-care settings. Those physicians need to be aware of how CMS views their job in relation to new regulations.

"Once the physician leaves the hospital, they're generally considered an outpatient doctor by CMS, even though leaving an acute-care facility and going into a step-down unit like a skilled nursing facility is not really going into a primary-care or outpatient practice," Dr. Weiner says. "There are a number of regulations coming down, and hospitalists have to be sensitive to the differences in reimbursement and accountability they'll be held to. Just because you're a hospitalist doesn't mean the government considers you a hospitalist for their regulations."

CMS initially proposed that "eligible professionals" (EPs) needed to meet three criteria to be granted a hardship exception: a lack of face-to-face or telemedicine interaction with patients, a lack of follow-up need with patients, and the "lack of control over the availability" of certified EHR technology. After SHM voiced concern, CMS agreed that EPs who practice at multiple locations can be granted the exception solely for lack of control over the availability of the technology. Dr. Weiner says that CMS' willingness to make changes before finalizing the rule shows the agency understands how difficult the new rules can be.

"CMS has realized they may not get it right the first time," he adds. "This is a dynamic process, and even if they do get it right exactly, it's only right for a particular moment. Medicine is transitioning and changing all the time."

Clinical question: What medication reconciliation practices are the most effective and beneficial to patients?

Background: Medication reconciliation identifies the most accurate medications a patient is taking which can limit adverse drug events. A wide variety of practices have been reported.

Study design: Systematic review of the literature.

Setting: Twenty-six controlled studies.

Synopsis: Using both MEDLINE and manual search, 26 studies of medication reconciliation practices were identified that met inclusion criteria. Studies were divided into pharmacist-related interventions, information technology interventions, and other. Reported interventions were found to successfully reduce medication discrepancies but the effects on adverse drug event reduction were inconsistent. The scarcity of rigorously designed studies does limit the ability to compare medication reconciliation strategies. Only 6 of the reviewed studies were considered good quality. Future studies will require more standardized methods and rigorous outcome measurements.

Bottom line: Current data regarding medication reconciliation is limited, but supports use of pharmacy staff and focusing efforts on patients at high risk for adverse drug events.

Citation:Mueller SK, Sponsler KC, Kripalani S, et al. Hospital-based medication reconciliation practices: a systematic review. Arch Intern Med. 2012;172(14):1057-1069.

Read more of our physician reviews of recent, HM-relevant literature.

Clinical question: What medication reconciliation practices are the most effective and beneficial to patients?

Background: Medication reconciliation identifies the most accurate medications a patient is taking which can limit adverse drug events. A wide variety of practices have been reported.

Study design: Systematic review of the literature.

Setting: Twenty-six controlled studies.

Synopsis: Using both MEDLINE and manual search, 26 studies of medication reconciliation practices were identified that met inclusion criteria. Studies were divided into pharmacist-related interventions, information technology interventions, and other. Reported interventions were found to successfully reduce medication discrepancies but the effects on adverse drug event reduction were inconsistent. The scarcity of rigorously designed studies does limit the ability to compare medication reconciliation strategies. Only 6 of the reviewed studies were considered good quality. Future studies will require more standardized methods and rigorous outcome measurements.

Bottom line: Current data regarding medication reconciliation is limited, but supports use of pharmacy staff and focusing efforts on patients at high risk for adverse drug events.

Citation:Mueller SK, Sponsler KC, Kripalani S, et al. Hospital-based medication reconciliation practices: a systematic review. Arch Intern Med. 2012;172(14):1057-1069.

Read more of our physician reviews of recent, HM-relevant literature.

Clinical question: What medication reconciliation practices are the most effective and beneficial to patients?

Background: Medication reconciliation identifies the most accurate medications a patient is taking which can limit adverse drug events. A wide variety of practices have been reported.

Study design: Systematic review of the literature.

Setting: Twenty-six controlled studies.

Synopsis: Using both MEDLINE and manual search, 26 studies of medication reconciliation practices were identified that met inclusion criteria. Studies were divided into pharmacist-related interventions, information technology interventions, and other. Reported interventions were found to successfully reduce medication discrepancies but the effects on adverse drug event reduction were inconsistent. The scarcity of rigorously designed studies does limit the ability to compare medication reconciliation strategies. Only 6 of the reviewed studies were considered good quality. Future studies will require more standardized methods and rigorous outcome measurements.

Bottom line: Current data regarding medication reconciliation is limited, but supports use of pharmacy staff and focusing efforts on patients at high risk for adverse drug events.

Citation:Mueller SK, Sponsler KC, Kripalani S, et al. Hospital-based medication reconciliation practices: a systematic review. Arch Intern Med. 2012;172(14):1057-1069.

Read more of our physician reviews of recent, HM-relevant literature.

A concerted effort by SHM members has helped win some hospitalists an exemption to the Centers for Medicare & Medicaid Services' (CMS) final rule on Stage 2 compliance for meaningful use [PDF] of electronic health records (EHR).

The "hardship exception" frees hospitalists who round at nursing homes and other post-acute-care facilities from being subject to penalties for not being "meaningful users." SHM successfully argued that it isn't fair for HM clinicians working in such institutions be held accountable for records they can't fully control.

SHM Public Policy Committee member Kerry Weiner, MD, chief clinical officer of IPC: The Hospitalist Company Inc. of North Hollywood, Calif., says about 30% of hospitalists are involved in care delivery at nursing homes, skilled nursing facilities, or other post-acute-care settings. Those physicians need to be aware of how CMS views their job in relation to new regulations.

"Once the physician leaves the hospital, they're generally considered an outpatient doctor by CMS, even though leaving an acute-care facility and going into a step-down unit like a skilled nursing facility is not really going into a primary-care or outpatient practice," Dr. Weiner says. "There are a number of regulations coming down, and hospitalists have to be sensitive to the differences in reimbursement and accountability they'll be held to. Just because you're a hospitalist doesn't mean the government considers you a hospitalist for their regulations."

CMS initially proposed that "eligible professionals" (EPs) needed to meet three criteria to be granted a hardship exception: a lack of face-to-face or telemedicine interaction with patients, a lack of follow-up need with patients, and the "lack of control over the availability" of certified EHR technology. After SHM voiced concern, CMS agreed that EPs who practice at multiple locations can be granted the exception solely for lack of control over the availability of the technology. Dr. Weiner says that CMS' willingness to make changes before finalizing the rule shows the agency understands how difficult the new rules can be.

"CMS has realized they may not get it right the first time," he adds. "This is a dynamic process, and even if they do get it right exactly, it's only right for a particular moment. Medicine is transitioning and changing all the time."

A concerted effort by SHM members has helped win some hospitalists an exemption to the Centers for Medicare & Medicaid Services' (CMS) final rule on Stage 2 compliance for meaningful use [PDF] of electronic health records (EHR).

The "hardship exception" frees hospitalists who round at nursing homes and other post-acute-care facilities from being subject to penalties for not being "meaningful users." SHM successfully argued that it isn't fair for HM clinicians working in such institutions be held accountable for records they can't fully control.

SHM Public Policy Committee member Kerry Weiner, MD, chief clinical officer of IPC: The Hospitalist Company Inc. of North Hollywood, Calif., says about 30% of hospitalists are involved in care delivery at nursing homes, skilled nursing facilities, or other post-acute-care settings. Those physicians need to be aware of how CMS views their job in relation to new regulations.

"Once the physician leaves the hospital, they're generally considered an outpatient doctor by CMS, even though leaving an acute-care facility and going into a step-down unit like a skilled nursing facility is not really going into a primary-care or outpatient practice," Dr. Weiner says. "There are a number of regulations coming down, and hospitalists have to be sensitive to the differences in reimbursement and accountability they'll be held to. Just because you're a hospitalist doesn't mean the government considers you a hospitalist for their regulations."

CMS initially proposed that "eligible professionals" (EPs) needed to meet three criteria to be granted a hardship exception: a lack of face-to-face or telemedicine interaction with patients, a lack of follow-up need with patients, and the "lack of control over the availability" of certified EHR technology. After SHM voiced concern, CMS agreed that EPs who practice at multiple locations can be granted the exception solely for lack of control over the availability of the technology. Dr. Weiner says that CMS' willingness to make changes before finalizing the rule shows the agency understands how difficult the new rules can be.

"CMS has realized they may not get it right the first time," he adds. "This is a dynamic process, and even if they do get it right exactly, it's only right for a particular moment. Medicine is transitioning and changing all the time."

A concerted effort by SHM members has helped win some hospitalists an exemption to the Centers for Medicare & Medicaid Services' (CMS) final rule on Stage 2 compliance for meaningful use [PDF] of electronic health records (EHR).

The "hardship exception" frees hospitalists who round at nursing homes and other post-acute-care facilities from being subject to penalties for not being "meaningful users." SHM successfully argued that it isn't fair for HM clinicians working in such institutions be held accountable for records they can't fully control.

SHM Public Policy Committee member Kerry Weiner, MD, chief clinical officer of IPC: The Hospitalist Company Inc. of North Hollywood, Calif., says about 30% of hospitalists are involved in care delivery at nursing homes, skilled nursing facilities, or other post-acute-care settings. Those physicians need to be aware of how CMS views their job in relation to new regulations.

"Once the physician leaves the hospital, they're generally considered an outpatient doctor by CMS, even though leaving an acute-care facility and going into a step-down unit like a skilled nursing facility is not really going into a primary-care or outpatient practice," Dr. Weiner says. "There are a number of regulations coming down, and hospitalists have to be sensitive to the differences in reimbursement and accountability they'll be held to. Just because you're a hospitalist doesn't mean the government considers you a hospitalist for their regulations."

CMS initially proposed that "eligible professionals" (EPs) needed to meet three criteria to be granted a hardship exception: a lack of face-to-face or telemedicine interaction with patients, a lack of follow-up need with patients, and the "lack of control over the availability" of certified EHR technology. After SHM voiced concern, CMS agreed that EPs who practice at multiple locations can be granted the exception solely for lack of control over the availability of the technology. Dr. Weiner says that CMS' willingness to make changes before finalizing the rule shows the agency understands how difficult the new rules can be.

"CMS has realized they may not get it right the first time," he adds. "This is a dynamic process, and even if they do get it right exactly, it's only right for a particular moment. Medicine is transitioning and changing all the time."

Clinical question: What medication reconciliation practices are the most effective and beneficial to patients?

Background: Medication reconciliation identifies the most accurate medications a patient is taking which can limit adverse drug events. A wide variety of practices have been reported.

Study design: Systematic review of the literature.

Setting: Twenty-six controlled studies.

Synopsis: Using both MEDLINE and manual search, 26 studies of medication reconciliation practices were identified that met inclusion criteria. Studies were divided into pharmacist-related interventions, information technology interventions, and other. Reported interventions were found to successfully reduce medication discrepancies but the effects on adverse drug event reduction were inconsistent. The scarcity of rigorously designed studies does limit the ability to compare medication reconciliation strategies. Only 6 of the reviewed studies were considered good quality. Future studies will require more standardized methods and rigorous outcome measurements.

Bottom line: Current data regarding medication reconciliation is limited, but supports use of pharmacy staff and focusing efforts on patients at high risk for adverse drug events.

Citation:Mueller SK, Sponsler KC, Kripalani S, et al. Hospital-based medication reconciliation practices: a systematic review. Arch Intern Med. 2012;172(14):1057-1069.

Read more of our physician reviews of recent, HM-relevant literature.

Clinical question: What medication reconciliation practices are the most effective and beneficial to patients?

Background: Medication reconciliation identifies the most accurate medications a patient is taking which can limit adverse drug events. A wide variety of practices have been reported.

Study design: Systematic review of the literature.

Setting: Twenty-six controlled studies.

Synopsis: Using both MEDLINE and manual search, 26 studies of medication reconciliation practices were identified that met inclusion criteria. Studies were divided into pharmacist-related interventions, information technology interventions, and other. Reported interventions were found to successfully reduce medication discrepancies but the effects on adverse drug event reduction were inconsistent. The scarcity of rigorously designed studies does limit the ability to compare medication reconciliation strategies. Only 6 of the reviewed studies were considered good quality. Future studies will require more standardized methods and rigorous outcome measurements.

Bottom line: Current data regarding medication reconciliation is limited, but supports use of pharmacy staff and focusing efforts on patients at high risk for adverse drug events.

Citation:Mueller SK, Sponsler KC, Kripalani S, et al. Hospital-based medication reconciliation practices: a systematic review. Arch Intern Med. 2012;172(14):1057-1069.

Read more of our physician reviews of recent, HM-relevant literature.

Clinical question: What medication reconciliation practices are the most effective and beneficial to patients?

Background: Medication reconciliation identifies the most accurate medications a patient is taking which can limit adverse drug events. A wide variety of practices have been reported.

Study design: Systematic review of the literature.

Setting: Twenty-six controlled studies.

Synopsis: Using both MEDLINE and manual search, 26 studies of medication reconciliation practices were identified that met inclusion criteria. Studies were divided into pharmacist-related interventions, information technology interventions, and other. Reported interventions were found to successfully reduce medication discrepancies but the effects on adverse drug event reduction were inconsistent. The scarcity of rigorously designed studies does limit the ability to compare medication reconciliation strategies. Only 6 of the reviewed studies were considered good quality. Future studies will require more standardized methods and rigorous outcome measurements.

Bottom line: Current data regarding medication reconciliation is limited, but supports use of pharmacy staff and focusing efforts on patients at high risk for adverse drug events.

Citation:Mueller SK, Sponsler KC, Kripalani S, et al. Hospital-based medication reconciliation practices: a systematic review. Arch Intern Med. 2012;172(14):1057-1069.

Read more of our physician reviews of recent, HM-relevant literature.

"For every complex problem, there is an answer that is clear, simple, and wrong."

– H.L. Mencken

Every time I think about trying to solve the complex problems of surgical workforce, I am reminded of that great line from H.L. Mencken.

Some of our troubles began in 1975, when we tried to estimate the need for a surgical workforce. In the Report on the Manpower Subcommittee, written for the Study on Surgical Services for the United States, Dr. F.D. Moore called for moderating (that is, lowering) the output of surgical residents: "Better to have birth control, that is to say, control of the total residency programs, than abortion" (Ann. Surg. 1975;182:526-30). By that, he meant we should control the numbers coming in rather than have more failures by the American Board of Surgery. He was in favor of limiting output.

Similarly, COGME (Council of Graduate Medical Education) in 1992 also recommended fewer specialists and more primary care. In its Summary of the Third Report, Improving Access to Health Care Through Physician Workforce Reform: Directions for the 21st Century, COGME recommended reducing the number of physicians entering residency from 140% to 110% of the number of graduates of medical schools in the United States in 1993 and increasing the percentage of graduates who complete training and enter practice as generalists from the then-current level of 30% to 50%.

COGME was authorized by Congress in 1986 to provide an ongoing assessment of physician workforce trends, training issues, and financing policies, and to recommend appropriate federal and private sector efforts to address identified needs. Its authority was removed and it was disbanded in 2004 in part because its projections were wrong so many times that its recommendations had to be reversed.

Many individuals have criticized the recommendations that there are too many physicians and particularly surgeons in the country. Some of the most vocal critics, and some with the best actual data, are Dr. George Sheldon, Dr. Thomas Ricketts, and Dr. Richard Cooper.

I believe there is little question that we have a maldistribution of the surgical workforce, particularly in the rural setting, and we also have an absolute "undersupply" to address the nation’s surgical needs. What compounds this undersupply is the Balanced Budget Act of 1997, which put a ceiling on the number of residency slots paid for through Medicare.

In the current era of tighter Congressional fiscal control, I am not optimistic that the federal government will make available more money for graduate medical education. In fact, there is a continual threat that the current allocations for GME under Medicare will be reduced. Alternatives must be sought, and the one that comes to mind for most is an "all users fee" (actually a tax) that might include insurance carriers, hospitals, nursing homes, and so on.

Work by Dr. Atul Gawande and his colleagues indicates that the average American undergoes nine invasive procedures in a lifetime: three endoscopies, three outpatient procedures, and three inpatient procedures. I have already used up all of mine, so I am definitely looking for answers.

How can we pay for what we need, encourage young people to join the profession, attract students who are very lifestyle conscious, and keep the high standard and ethos we were brought up with? One of the consistent complaints surgical leaders hear from the men and women actually delivering surgical care is how poorly trained some graduates are when they become practicing surgeons. My friends in private practice say that this as one of our most serious workforce issues.

I recently had the opportunity to learn about a small group of surgical educators who are applying the "Ashley" rule, named after Stan Ashley when he was chairman of the American Board of Surgery. The Ashley rule gives flexibility to surgical trainees to "major" in certain subspecialties of surgery during their residency. Research being spearheaded by Dr. Mary Klingensmith, an ACS Fellow at Washington University in St. Louis, consists of a group of nine training programs across the country that will be used to study application of the Ashley rule. This self-appointed group has taken on the responsibility of trying to fix a least one part of the vast workforce issue we have through a new "innovation."

This is how the group describes innovation: "In this training paradigm, graduates will be able to spend additional months of training in their area of interest, will be able to spend this focused time sooner than traditional fellowship training allows, and will streamline and improve the experiences for all trainees in a single program as each will be afforded a more ‘customized’ training experience [including rural surgery]. As a result, graduates will finish training with additional clinical experience in their area of intended eventual practice; the likely effect of this has two primary outcomes: First, graduates will possess greater comfort with independent practice immediately following training, an issue that has been raised with some graduates of surgical programs since the advent of the duty hour restrictions; second, graduates will be better prepared to provide quality surgical care to their patients, with improved outcomes."

This new research is a refinement of the work many of us did as part of the American Surgical Association Blue Ribbon Committee on Surgical Education, which led to this recommendation: "There needs to be acceptance of the reality that most surgeons will confine the scope of their practices to meet definable goals. This should lead to earlier differentiation into goal-oriented specialty tracks" (Ann. Surg. 2005;241:1-8).

The new work may not solve all of the issues confronting surgical education in the United States, but it’s an important start by serious surgical educators. It will be interesting to watch and see how this work develops.

Dr. Zinner is an ACS Fellow and surgeon in chief at Brigham and Women’s Hospital in Boston.

"For every complex problem, there is an answer that is clear, simple, and wrong."

– H.L. Mencken

Every time I think about trying to solve the complex problems of surgical workforce, I am reminded of that great line from H.L. Mencken.

Some of our troubles began in 1975, when we tried to estimate the need for a surgical workforce. In the Report on the Manpower Subcommittee, written for the Study on Surgical Services for the United States, Dr. F.D. Moore called for moderating (that is, lowering) the output of surgical residents: "Better to have birth control, that is to say, control of the total residency programs, than abortion" (Ann. Surg. 1975;182:526-30). By that, he meant we should control the numbers coming in rather than have more failures by the American Board of Surgery. He was in favor of limiting output.

Similarly, COGME (Council of Graduate Medical Education) in 1992 also recommended fewer specialists and more primary care. In its Summary of the Third Report, Improving Access to Health Care Through Physician Workforce Reform: Directions for the 21st Century, COGME recommended reducing the number of physicians entering residency from 140% to 110% of the number of graduates of medical schools in the United States in 1993 and increasing the percentage of graduates who complete training and enter practice as generalists from the then-current level of 30% to 50%.

COGME was authorized by Congress in 1986 to provide an ongoing assessment of physician workforce trends, training issues, and financing policies, and to recommend appropriate federal and private sector efforts to address identified needs. Its authority was removed and it was disbanded in 2004 in part because its projections were wrong so many times that its recommendations had to be reversed.

Many individuals have criticized the recommendations that there are too many physicians and particularly surgeons in the country. Some of the most vocal critics, and some with the best actual data, are Dr. George Sheldon, Dr. Thomas Ricketts, and Dr. Richard Cooper.

I believe there is little question that we have a maldistribution of the surgical workforce, particularly in the rural setting, and we also have an absolute "undersupply" to address the nation’s surgical needs. What compounds this undersupply is the Balanced Budget Act of 1997, which put a ceiling on the number of residency slots paid for through Medicare.

In the current era of tighter Congressional fiscal control, I am not optimistic that the federal government will make available more money for graduate medical education. In fact, there is a continual threat that the current allocations for GME under Medicare will be reduced. Alternatives must be sought, and the one that comes to mind for most is an "all users fee" (actually a tax) that might include insurance carriers, hospitals, nursing homes, and so on.

Work by Dr. Atul Gawande and his colleagues indicates that the average American undergoes nine invasive procedures in a lifetime: three endoscopies, three outpatient procedures, and three inpatient procedures. I have already used up all of mine, so I am definitely looking for answers.

How can we pay for what we need, encourage young people to join the profession, attract students who are very lifestyle conscious, and keep the high standard and ethos we were brought up with? One of the consistent complaints surgical leaders hear from the men and women actually delivering surgical care is how poorly trained some graduates are when they become practicing surgeons. My friends in private practice say that this as one of our most serious workforce issues.

I recently had the opportunity to learn about a small group of surgical educators who are applying the "Ashley" rule, named after Stan Ashley when he was chairman of the American Board of Surgery. The Ashley rule gives flexibility to surgical trainees to "major" in certain subspecialties of surgery during their residency. Research being spearheaded by Dr. Mary Klingensmith, an ACS Fellow at Washington University in St. Louis, consists of a group of nine training programs across the country that will be used to study application of the Ashley rule. This self-appointed group has taken on the responsibility of trying to fix a least one part of the vast workforce issue we have through a new "innovation."

This is how the group describes innovation: "In this training paradigm, graduates will be able to spend additional months of training in their area of interest, will be able to spend this focused time sooner than traditional fellowship training allows, and will streamline and improve the experiences for all trainees in a single program as each will be afforded a more ‘customized’ training experience [including rural surgery]. As a result, graduates will finish training with additional clinical experience in their area of intended eventual practice; the likely effect of this has two primary outcomes: First, graduates will possess greater comfort with independent practice immediately following training, an issue that has been raised with some graduates of surgical programs since the advent of the duty hour restrictions; second, graduates will be better prepared to provide quality surgical care to their patients, with improved outcomes."

This new research is a refinement of the work many of us did as part of the American Surgical Association Blue Ribbon Committee on Surgical Education, which led to this recommendation: "There needs to be acceptance of the reality that most surgeons will confine the scope of their practices to meet definable goals. This should lead to earlier differentiation into goal-oriented specialty tracks" (Ann. Surg. 2005;241:1-8).

The new work may not solve all of the issues confronting surgical education in the United States, but it’s an important start by serious surgical educators. It will be interesting to watch and see how this work develops.

Dr. Zinner is an ACS Fellow and surgeon in chief at Brigham and Women’s Hospital in Boston.

"For every complex problem, there is an answer that is clear, simple, and wrong."

– H.L. Mencken

Every time I think about trying to solve the complex problems of surgical workforce, I am reminded of that great line from H.L. Mencken.

Some of our troubles began in 1975, when we tried to estimate the need for a surgical workforce. In the Report on the Manpower Subcommittee, written for the Study on Surgical Services for the United States, Dr. F.D. Moore called for moderating (that is, lowering) the output of surgical residents: "Better to have birth control, that is to say, control of the total residency programs, than abortion" (Ann. Surg. 1975;182:526-30). By that, he meant we should control the numbers coming in rather than have more failures by the American Board of Surgery. He was in favor of limiting output.

Similarly, COGME (Council of Graduate Medical Education) in 1992 also recommended fewer specialists and more primary care. In its Summary of the Third Report, Improving Access to Health Care Through Physician Workforce Reform: Directions for the 21st Century, COGME recommended reducing the number of physicians entering residency from 140% to 110% of the number of graduates of medical schools in the United States in 1993 and increasing the percentage of graduates who complete training and enter practice as generalists from the then-current level of 30% to 50%.

COGME was authorized by Congress in 1986 to provide an ongoing assessment of physician workforce trends, training issues, and financing policies, and to recommend appropriate federal and private sector efforts to address identified needs. Its authority was removed and it was disbanded in 2004 in part because its projections were wrong so many times that its recommendations had to be reversed.

Many individuals have criticized the recommendations that there are too many physicians and particularly surgeons in the country. Some of the most vocal critics, and some with the best actual data, are Dr. George Sheldon, Dr. Thomas Ricketts, and Dr. Richard Cooper.

I believe there is little question that we have a maldistribution of the surgical workforce, particularly in the rural setting, and we also have an absolute "undersupply" to address the nation’s surgical needs. What compounds this undersupply is the Balanced Budget Act of 1997, which put a ceiling on the number of residency slots paid for through Medicare.

In the current era of tighter Congressional fiscal control, I am not optimistic that the federal government will make available more money for graduate medical education. In fact, there is a continual threat that the current allocations for GME under Medicare will be reduced. Alternatives must be sought, and the one that comes to mind for most is an "all users fee" (actually a tax) that might include insurance carriers, hospitals, nursing homes, and so on.

Work by Dr. Atul Gawande and his colleagues indicates that the average American undergoes nine invasive procedures in a lifetime: three endoscopies, three outpatient procedures, and three inpatient procedures. I have already used up all of mine, so I am definitely looking for answers.

How can we pay for what we need, encourage young people to join the profession, attract students who are very lifestyle conscious, and keep the high standard and ethos we were brought up with? One of the consistent complaints surgical leaders hear from the men and women actually delivering surgical care is how poorly trained some graduates are when they become practicing surgeons. My friends in private practice say that this as one of our most serious workforce issues.

I recently had the opportunity to learn about a small group of surgical educators who are applying the "Ashley" rule, named after Stan Ashley when he was chairman of the American Board of Surgery. The Ashley rule gives flexibility to surgical trainees to "major" in certain subspecialties of surgery during their residency. Research being spearheaded by Dr. Mary Klingensmith, an ACS Fellow at Washington University in St. Louis, consists of a group of nine training programs across the country that will be used to study application of the Ashley rule. This self-appointed group has taken on the responsibility of trying to fix a least one part of the vast workforce issue we have through a new "innovation."

This is how the group describes innovation: "In this training paradigm, graduates will be able to spend additional months of training in their area of interest, will be able to spend this focused time sooner than traditional fellowship training allows, and will streamline and improve the experiences for all trainees in a single program as each will be afforded a more ‘customized’ training experience [including rural surgery]. As a result, graduates will finish training with additional clinical experience in their area of intended eventual practice; the likely effect of this has two primary outcomes: First, graduates will possess greater comfort with independent practice immediately following training, an issue that has been raised with some graduates of surgical programs since the advent of the duty hour restrictions; second, graduates will be better prepared to provide quality surgical care to their patients, with improved outcomes."

This new research is a refinement of the work many of us did as part of the American Surgical Association Blue Ribbon Committee on Surgical Education, which led to this recommendation: "There needs to be acceptance of the reality that most surgeons will confine the scope of their practices to meet definable goals. This should lead to earlier differentiation into goal-oriented specialty tracks" (Ann. Surg. 2005;241:1-8).

The new work may not solve all of the issues confronting surgical education in the United States, but it’s an important start by serious surgical educators. It will be interesting to watch and see how this work develops.

Dr. Zinner is an ACS Fellow and surgeon in chief at Brigham and Women’s Hospital in Boston.

Although the 2011-2012 influenza season was milder than usual and associated with fewer outpatient visits, lower hospitalization rates, and fewer pediatric deaths, practitioners should be aware that this virus is still the leading cause of vaccine-preventable deaths in children. Hopefully, practitioners are already providing influenza immunization utilizing the 2012-2013 vaccine, which contains the same influenza A (H1N1) antigen as the 2011-2012 seasonal vaccine but new influenza A (H3N2) and B antigens: These are A/California/7/2009 (H1N1)–like antigen, A/Victoria/361/2011(H3N2)–like antigen, and B/Wisconsin/1/2010–like antigen.

Here are the answers to some of the most common questions related to this year’s influenza season:

• How many doses are recommended this year for children between 6 months through 8 years of age?

For a child in this age group who had two or more doses of seasonal vaccine since July 1, 2010, or in whom you can document one dose of a pandemic H1N1–containing vaccine and at least two seasonal vaccines from any season, only one dose is needed. All others in this age group should receive two doses. As always, those 9 years of age and older receive one dose of vaccine.

• Given recent data that suggested a slight increased risk of a febrile seizure following trivalent inactivated vaccine (TIV) in children less than 4 years, have vaccine recommendations changed?

A suggestion of an increased risk for febrile seizures in young children after TIV was noted in the United States in 2010-2011. This followed enhanced monitoring after the observation in Australia in 2010 of an association with an increased risk of febrile seizures (greater than or equal to nine per 1,000 doses) that were related to a particular influenza vaccine. (Afluria vaccine is approved for use in those greater than age 5 years, but current recommendations from the American Academy of Pediatrics and the Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices (ACIP) state this vaccine should not be used in those less than 9 years of age. It could be considered for a high-risk patient between 5 through 8 years if no alternative TIV is available and after discussion of the seizure risk with parents.)

To further study this potential association, the CDC tracked more than 200,000 children in the United States who received TIV or PCV13 (Prevnar) vaccine at different visits or both together at the same visit. Rarely, a febrile seizure was noted in children less than 5 years who got TIV or PCV13 vaccine given at separate visits. Those 12- to 23-month-olds who received both at the same visit had a slightly increased risk for an uncomplicated febrile seizure in the 24 hours following vaccine receipt. This is the age group where febrile seizures peak in general and is equivalent to one excess seizure for every 2,000-3,000 vaccine doses. Based on this low risk and the uncomplicated course in such patients, coupled with the benefits of immunization, both the AAP and ACIP recommended no change in either the TIV or PCV13 vaccine policies. And remember that neither a prior febrile seizure history nor a preexisting seizure disorder is considered a contraindication for influenza vaccine.

• Who can get the intradermal formulation of influenza vaccine?

Fluzone Intradermal, which made its debut in the 2011-2012 season, is licensed for those 18-64 years of age, and is a preservative-free, trivalent inactivated influenza vaccine. It comes in a prefilled microinjection syringe, which for those who require TIV and are needle averse, may be preferred. Local reactions seen with intramuscular TIV (with the exception of pain), including redness, swelling, and itching at the site seem to be a bit more common with the intradermal product, but such reactions abate in 3-7 days. This vaccine could be utilized in an older adolescent who might opt for a vaccine that has a needle that is 90% shorter than the needle used for intramuscular injection of TIV.

• Is oseltamivir still the drug of choice to treat influenza?

Last year only 1.4% of strains were resistant to oseltamivir, and this year is expected to be the same. Treatment and prophylaxis dosing is the same as last year. The AAP and ACIP continue to emphasize early treatment for all children in high-risk groups who develop influenza, regardless of influenza immunization status. Treatment is also recommended for all who are ill enough to require hospitalization. For patients with influenzalike illness, the decision to treat should not be based on rapid antigen testing results. A negative test does not "rule out" influenza as commercially available tests are not sufficiently sensitive. You might want to check with your hospital to find out what other influenza testing is available in your locale.

• Which of my "egg-allergic" patients can receive influenza vaccine?

Decision making related to TIV depends on the type of prior reaction the patient had. Those with mild reactions, defined as hives alone, may receive TIV followed by a 30-minute observation period. Use the same vaccine for those who require a second dose, if at all possible. Consult an allergist for those with severe reactions including cardiovascular changes, respiratory and/or gastrointestinal tract symptoms, or reactions that required the use of epinephrine. An algorithm is available from the CDC that can be used to guide decision making in such cases.

Dr. Jackson is the chief of infectious diseases at Children’s Mercy Hospitals and Clinics in Kansas City, Mo., and professor of pediatrics at the University of Missouri–Kansas City. She said she has no relevant financial disclosures. E-mail her at [email protected].

Although the 2011-2012 influenza season was milder than usual and associated with fewer outpatient visits, lower hospitalization rates, and fewer pediatric deaths, practitioners should be aware that this virus is still the leading cause of vaccine-preventable deaths in children. Hopefully, practitioners are already providing influenza immunization utilizing the 2012-2013 vaccine, which contains the same influenza A (H1N1) antigen as the 2011-2012 seasonal vaccine but new influenza A (H3N2) and B antigens: These are A/California/7/2009 (H1N1)–like antigen, A/Victoria/361/2011(H3N2)–like antigen, and B/Wisconsin/1/2010–like antigen.

Here are the answers to some of the most common questions related to this year’s influenza season:

• How many doses are recommended this year for children between 6 months through 8 years of age?

For a child in this age group who had two or more doses of seasonal vaccine since July 1, 2010, or in whom you can document one dose of a pandemic H1N1–containing vaccine and at least two seasonal vaccines from any season, only one dose is needed. All others in this age group should receive two doses. As always, those 9 years of age and older receive one dose of vaccine.

• Given recent data that suggested a slight increased risk of a febrile seizure following trivalent inactivated vaccine (TIV) in children less than 4 years, have vaccine recommendations changed?

A suggestion of an increased risk for febrile seizures in young children after TIV was noted in the United States in 2010-2011. This followed enhanced monitoring after the observation in Australia in 2010 of an association with an increased risk of febrile seizures (greater than or equal to nine per 1,000 doses) that were related to a particular influenza vaccine. (Afluria vaccine is approved for use in those greater than age 5 years, but current recommendations from the American Academy of Pediatrics and the Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices (ACIP) state this vaccine should not be used in those less than 9 years of age. It could be considered for a high-risk patient between 5 through 8 years if no alternative TIV is available and after discussion of the seizure risk with parents.)

To further study this potential association, the CDC tracked more than 200,000 children in the United States who received TIV or PCV13 (Prevnar) vaccine at different visits or both together at the same visit. Rarely, a febrile seizure was noted in children less than 5 years who got TIV or PCV13 vaccine given at separate visits. Those 12- to 23-month-olds who received both at the same visit had a slightly increased risk for an uncomplicated febrile seizure in the 24 hours following vaccine receipt. This is the age group where febrile seizures peak in general and is equivalent to one excess seizure for every 2,000-3,000 vaccine doses. Based on this low risk and the uncomplicated course in such patients, coupled with the benefits of immunization, both the AAP and ACIP recommended no change in either the TIV or PCV13 vaccine policies. And remember that neither a prior febrile seizure history nor a preexisting seizure disorder is considered a contraindication for influenza vaccine.

• Who can get the intradermal formulation of influenza vaccine?

Fluzone Intradermal, which made its debut in the 2011-2012 season, is licensed for those 18-64 years of age, and is a preservative-free, trivalent inactivated influenza vaccine. It comes in a prefilled microinjection syringe, which for those who require TIV and are needle averse, may be preferred. Local reactions seen with intramuscular TIV (with the exception of pain), including redness, swelling, and itching at the site seem to be a bit more common with the intradermal product, but such reactions abate in 3-7 days. This vaccine could be utilized in an older adolescent who might opt for a vaccine that has a needle that is 90% shorter than the needle used for intramuscular injection of TIV.

• Is oseltamivir still the drug of choice to treat influenza?

Last year only 1.4% of strains were resistant to oseltamivir, and this year is expected to be the same. Treatment and prophylaxis dosing is the same as last year. The AAP and ACIP continue to emphasize early treatment for all children in high-risk groups who develop influenza, regardless of influenza immunization status. Treatment is also recommended for all who are ill enough to require hospitalization. For patients with influenzalike illness, the decision to treat should not be based on rapid antigen testing results. A negative test does not "rule out" influenza as commercially available tests are not sufficiently sensitive. You might want to check with your hospital to find out what other influenza testing is available in your locale.

• Which of my "egg-allergic" patients can receive influenza vaccine?

Decision making related to TIV depends on the type of prior reaction the patient had. Those with mild reactions, defined as hives alone, may receive TIV followed by a 30-minute observation period. Use the same vaccine for those who require a second dose, if at all possible. Consult an allergist for those with severe reactions including cardiovascular changes, respiratory and/or gastrointestinal tract symptoms, or reactions that required the use of epinephrine. An algorithm is available from the CDC that can be used to guide decision making in such cases.

Dr. Jackson is the chief of infectious diseases at Children’s Mercy Hospitals and Clinics in Kansas City, Mo., and professor of pediatrics at the University of Missouri–Kansas City. She said she has no relevant financial disclosures. E-mail her at [email protected].

Although the 2011-2012 influenza season was milder than usual and associated with fewer outpatient visits, lower hospitalization rates, and fewer pediatric deaths, practitioners should be aware that this virus is still the leading cause of vaccine-preventable deaths in children. Hopefully, practitioners are already providing influenza immunization utilizing the 2012-2013 vaccine, which contains the same influenza A (H1N1) antigen as the 2011-2012 seasonal vaccine but new influenza A (H3N2) and B antigens: These are A/California/7/2009 (H1N1)–like antigen, A/Victoria/361/2011(H3N2)–like antigen, and B/Wisconsin/1/2010–like antigen.

Here are the answers to some of the most common questions related to this year’s influenza season:

• How many doses are recommended this year for children between 6 months through 8 years of age?

For a child in this age group who had two or more doses of seasonal vaccine since July 1, 2010, or in whom you can document one dose of a pandemic H1N1–containing vaccine and at least two seasonal vaccines from any season, only one dose is needed. All others in this age group should receive two doses. As always, those 9 years of age and older receive one dose of vaccine.

• Given recent data that suggested a slight increased risk of a febrile seizure following trivalent inactivated vaccine (TIV) in children less than 4 years, have vaccine recommendations changed?

A suggestion of an increased risk for febrile seizures in young children after TIV was noted in the United States in 2010-2011. This followed enhanced monitoring after the observation in Australia in 2010 of an association with an increased risk of febrile seizures (greater than or equal to nine per 1,000 doses) that were related to a particular influenza vaccine. (Afluria vaccine is approved for use in those greater than age 5 years, but current recommendations from the American Academy of Pediatrics and the Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices (ACIP) state this vaccine should not be used in those less than 9 years of age. It could be considered for a high-risk patient between 5 through 8 years if no alternative TIV is available and after discussion of the seizure risk with parents.)

To further study this potential association, the CDC tracked more than 200,000 children in the United States who received TIV or PCV13 (Prevnar) vaccine at different visits or both together at the same visit. Rarely, a febrile seizure was noted in children less than 5 years who got TIV or PCV13 vaccine given at separate visits. Those 12- to 23-month-olds who received both at the same visit had a slightly increased risk for an uncomplicated febrile seizure in the 24 hours following vaccine receipt. This is the age group where febrile seizures peak in general and is equivalent to one excess seizure for every 2,000-3,000 vaccine doses. Based on this low risk and the uncomplicated course in such patients, coupled with the benefits of immunization, both the AAP and ACIP recommended no change in either the TIV or PCV13 vaccine policies. And remember that neither a prior febrile seizure history nor a preexisting seizure disorder is considered a contraindication for influenza vaccine.

• Who can get the intradermal formulation of influenza vaccine?

Fluzone Intradermal, which made its debut in the 2011-2012 season, is licensed for those 18-64 years of age, and is a preservative-free, trivalent inactivated influenza vaccine. It comes in a prefilled microinjection syringe, which for those who require TIV and are needle averse, may be preferred. Local reactions seen with intramuscular TIV (with the exception of pain), including redness, swelling, and itching at the site seem to be a bit more common with the intradermal product, but such reactions abate in 3-7 days. This vaccine could be utilized in an older adolescent who might opt for a vaccine that has a needle that is 90% shorter than the needle used for intramuscular injection of TIV.

• Is oseltamivir still the drug of choice to treat influenza?

Last year only 1.4% of strains were resistant to oseltamivir, and this year is expected to be the same. Treatment and prophylaxis dosing is the same as last year. The AAP and ACIP continue to emphasize early treatment for all children in high-risk groups who develop influenza, regardless of influenza immunization status. Treatment is also recommended for all who are ill enough to require hospitalization. For patients with influenzalike illness, the decision to treat should not be based on rapid antigen testing results. A negative test does not "rule out" influenza as commercially available tests are not sufficiently sensitive. You might want to check with your hospital to find out what other influenza testing is available in your locale.

• Which of my "egg-allergic" patients can receive influenza vaccine?

Decision making related to TIV depends on the type of prior reaction the patient had. Those with mild reactions, defined as hives alone, may receive TIV followed by a 30-minute observation period. Use the same vaccine for those who require a second dose, if at all possible. Consult an allergist for those with severe reactions including cardiovascular changes, respiratory and/or gastrointestinal tract symptoms, or reactions that required the use of epinephrine. An algorithm is available from the CDC that can be used to guide decision making in such cases.

Dr. Jackson is the chief of infectious diseases at Children’s Mercy Hospitals and Clinics in Kansas City, Mo., and professor of pediatrics at the University of Missouri–Kansas City. She said she has no relevant financial disclosures. E-mail her at [email protected].

A record number of hospitalists attended the combined biannual conference of the Chilean Society of Hospitalists and the Pan American Society of Hospitalists (PASHA) July 19-20 in Santiago, Chile. The meeting sold out with more than 250 attendees, and the energy of the South American hospitalist movement could be felt inside as hospitalists from across the Americas packed into the conference center.

It was the third such combined meeting, and hospitalists from Argentina, Colombia, the United States, and all parts of Chile were present. The first national meeting of hospitalists in Chile was held in 2008, and meetings have occurred every other year since 2008. PASHA was established in 2010 to unite hospitalists in South America and build collaborations with hospitalists in North America. PASHA’s past meetings were held in Brazil and Argentina, and organizers plan to continue it annually.

Hospitalists and subspecialists gathered to update their clinical knowledge and share ideas on patient safety, quality improvement (QI), and transitions of care.

“All of our countries have different challenges, but hospitalists everywhere are trying to do the same thing—provide quality healthcare as efficiently as possible. This central goal of hospitalists allows us to share ideas and learn from each other,” said Andres Aizman, MD, director of the division of hospital medicine at Pontificia Universidad Católica de Chile in Santiago.

Lectures were translated into multiple languages, including English, to engage not only local physicians, but also those from abroad.

“This has been an incredible experience,” said Dr. Eddie Greene, a nephrologist from the Mayo Clinic in Rochester, Minn., who presented a lecture on hypertensive crises. “Getting so many talented people from different backgrounds in the same place exchanging ideas on diverse topics has been an amazing experience. This is something special, and I hope to see it continue to grow.”

Two internists at Pontificia Universidad Católica de Chile founded its first HM division in 2004. The division has grown to include nine physicians, and there is a second, five-physician group of hospitalists at Universidad de Chile, a neighboring teaching hospital. The actual number of practicing hospitalists in Chile is hard to estimate because there are many hospital-based internists that have yet to be recognized as hospitalists; however, the most active academic hospitalists in the Chilean Society of Hospitalists are at the two universities.

One of the highlights of this year’s conference was a workshop on bedside applications of portable ultrasound for hospitalists. Lectures on procedural and diagnostic applications of portable ultrasound were presented to the general assembly, and a hands-on workshop with limited seating was sold out.

The workshop included brief lectures, simulation-based training, and scanning of live models.

“This meeting has enlightened me on so many topics and tools that I can easily use in my hospital,” said Ofelia Leiva, MD, a hospitalist from Curico, a city of 250,000 in southern Chile. “There are so many ways we can use ultrasound in the hospital. I’m grateful that I was able to attend.”

Nilam Soni, MD, of the University of Texas Health Science Center at San Antonio, spearheaded the ultrasound workshop in collaboration with Dr. Ricardo Franco from John H. Stroger Hospital in Chicago and Dr. Carolina Candotti from Penn State Hershey Medical Center.

Faculty from the Mayo Clinic, including Drs. Jamie Newman, Fernando Rivera, John Park, and Eddie Greene, attended the meeting for a second consecutive time. Their contributions made the event even more attractive to local hospitalists.

Although HM continues to grow in South America, barriers still exist. Each country has a different healthcare system, and the economic and political forces that drive these systems affect hospitalists and their patients. Certain metrics that are often used to gauge hospitalists’ impact in North America, such as length of stay, are less meaningful in Chile and other countries. Additionally, hospitalists’ ability to participate in conferences and exchange ideas is limited by distance and circumstance; the average hospitalist in Chile earns the equivalent of about $70,000 a year. Lastly, many hospitalists in South America aspire to develop research programs, but obtaining research training is challenging. Such opportunities are limited in South America, and physicians often encounter cost and immigration issues when they seek training abroad.

Despite the challenges, the enthusiasm to advance HM in South America and build international collaborations continues to grow. Hospitalists from different institutions in the U.S. have returned every year to participate in the conference. The opportunity to meet hospitalists from different countries, exchange ideas, and be part of the hospitalist movement abroad draws people back. The energy of the hospitalist movement is still alive.

Dr. Abbott and Dr. Rodriguez are adjunct professors and Dr. Aizman is an assistant professor in the department of internal medicine at Pontificia Universidad Católica de Chile School of Medicine in Santiago; Dr. Newman is an assistant professor in the division of hospital medicine at Mayo Clinic in Rochester, Minn.; and Dr. Soni is an assistant professor of medicine in the division of hospital medicine at the University of Texas Health Science Center at San Antonio.

A record number of hospitalists attended the combined biannual conference of the Chilean Society of Hospitalists and the Pan American Society of Hospitalists (PASHA) July 19-20 in Santiago, Chile. The meeting sold out with more than 250 attendees, and the energy of the South American hospitalist movement could be felt inside as hospitalists from across the Americas packed into the conference center.

It was the third such combined meeting, and hospitalists from Argentina, Colombia, the United States, and all parts of Chile were present. The first national meeting of hospitalists in Chile was held in 2008, and meetings have occurred every other year since 2008. PASHA was established in 2010 to unite hospitalists in South America and build collaborations with hospitalists in North America. PASHA’s past meetings were held in Brazil and Argentina, and organizers plan to continue it annually.

Hospitalists and subspecialists gathered to update their clinical knowledge and share ideas on patient safety, quality improvement (QI), and transitions of care.

“All of our countries have different challenges, but hospitalists everywhere are trying to do the same thing—provide quality healthcare as efficiently as possible. This central goal of hospitalists allows us to share ideas and learn from each other,” said Andres Aizman, MD, director of the division of hospital medicine at Pontificia Universidad Católica de Chile in Santiago.

Lectures were translated into multiple languages, including English, to engage not only local physicians, but also those from abroad.

“This has been an incredible experience,” said Dr. Eddie Greene, a nephrologist from the Mayo Clinic in Rochester, Minn., who presented a lecture on hypertensive crises. “Getting so many talented people from different backgrounds in the same place exchanging ideas on diverse topics has been an amazing experience. This is something special, and I hope to see it continue to grow.”

Two internists at Pontificia Universidad Católica de Chile founded its first HM division in 2004. The division has grown to include nine physicians, and there is a second, five-physician group of hospitalists at Universidad de Chile, a neighboring teaching hospital. The actual number of practicing hospitalists in Chile is hard to estimate because there are many hospital-based internists that have yet to be recognized as hospitalists; however, the most active academic hospitalists in the Chilean Society of Hospitalists are at the two universities.

One of the highlights of this year’s conference was a workshop on bedside applications of portable ultrasound for hospitalists. Lectures on procedural and diagnostic applications of portable ultrasound were presented to the general assembly, and a hands-on workshop with limited seating was sold out.

The workshop included brief lectures, simulation-based training, and scanning of live models.

“This meeting has enlightened me on so many topics and tools that I can easily use in my hospital,” said Ofelia Leiva, MD, a hospitalist from Curico, a city of 250,000 in southern Chile. “There are so many ways we can use ultrasound in the hospital. I’m grateful that I was able to attend.”

Nilam Soni, MD, of the University of Texas Health Science Center at San Antonio, spearheaded the ultrasound workshop in collaboration with Dr. Ricardo Franco from John H. Stroger Hospital in Chicago and Dr. Carolina Candotti from Penn State Hershey Medical Center.

Faculty from the Mayo Clinic, including Drs. Jamie Newman, Fernando Rivera, John Park, and Eddie Greene, attended the meeting for a second consecutive time. Their contributions made the event even more attractive to local hospitalists.

Although HM continues to grow in South America, barriers still exist. Each country has a different healthcare system, and the economic and political forces that drive these systems affect hospitalists and their patients. Certain metrics that are often used to gauge hospitalists’ impact in North America, such as length of stay, are less meaningful in Chile and other countries. Additionally, hospitalists’ ability to participate in conferences and exchange ideas is limited by distance and circumstance; the average hospitalist in Chile earns the equivalent of about $70,000 a year. Lastly, many hospitalists in South America aspire to develop research programs, but obtaining research training is challenging. Such opportunities are limited in South America, and physicians often encounter cost and immigration issues when they seek training abroad.

Despite the challenges, the enthusiasm to advance HM in South America and build international collaborations continues to grow. Hospitalists from different institutions in the U.S. have returned every year to participate in the conference. The opportunity to meet hospitalists from different countries, exchange ideas, and be part of the hospitalist movement abroad draws people back. The energy of the hospitalist movement is still alive.

Dr. Abbott and Dr. Rodriguez are adjunct professors and Dr. Aizman is an assistant professor in the department of internal medicine at Pontificia Universidad Católica de Chile School of Medicine in Santiago; Dr. Newman is an assistant professor in the division of hospital medicine at Mayo Clinic in Rochester, Minn.; and Dr. Soni is an assistant professor of medicine in the division of hospital medicine at the University of Texas Health Science Center at San Antonio.

A record number of hospitalists attended the combined biannual conference of the Chilean Society of Hospitalists and the Pan American Society of Hospitalists (PASHA) July 19-20 in Santiago, Chile. The meeting sold out with more than 250 attendees, and the energy of the South American hospitalist movement could be felt inside as hospitalists from across the Americas packed into the conference center.

It was the third such combined meeting, and hospitalists from Argentina, Colombia, the United States, and all parts of Chile were present. The first national meeting of hospitalists in Chile was held in 2008, and meetings have occurred every other year since 2008. PASHA was established in 2010 to unite hospitalists in South America and build collaborations with hospitalists in North America. PASHA’s past meetings were held in Brazil and Argentina, and organizers plan to continue it annually.

Hospitalists and subspecialists gathered to update their clinical knowledge and share ideas on patient safety, quality improvement (QI), and transitions of care.

“All of our countries have different challenges, but hospitalists everywhere are trying to do the same thing—provide quality healthcare as efficiently as possible. This central goal of hospitalists allows us to share ideas and learn from each other,” said Andres Aizman, MD, director of the division of hospital medicine at Pontificia Universidad Católica de Chile in Santiago.

Lectures were translated into multiple languages, including English, to engage not only local physicians, but also those from abroad.

“This has been an incredible experience,” said Dr. Eddie Greene, a nephrologist from the Mayo Clinic in Rochester, Minn., who presented a lecture on hypertensive crises. “Getting so many talented people from different backgrounds in the same place exchanging ideas on diverse topics has been an amazing experience. This is something special, and I hope to see it continue to grow.”

Two internists at Pontificia Universidad Católica de Chile founded its first HM division in 2004. The division has grown to include nine physicians, and there is a second, five-physician group of hospitalists at Universidad de Chile, a neighboring teaching hospital. The actual number of practicing hospitalists in Chile is hard to estimate because there are many hospital-based internists that have yet to be recognized as hospitalists; however, the most active academic hospitalists in the Chilean Society of Hospitalists are at the two universities.

One of the highlights of this year’s conference was a workshop on bedside applications of portable ultrasound for hospitalists. Lectures on procedural and diagnostic applications of portable ultrasound were presented to the general assembly, and a hands-on workshop with limited seating was sold out.

The workshop included brief lectures, simulation-based training, and scanning of live models.

“This meeting has enlightened me on so many topics and tools that I can easily use in my hospital,” said Ofelia Leiva, MD, a hospitalist from Curico, a city of 250,000 in southern Chile. “There are so many ways we can use ultrasound in the hospital. I’m grateful that I was able to attend.”

Nilam Soni, MD, of the University of Texas Health Science Center at San Antonio, spearheaded the ultrasound workshop in collaboration with Dr. Ricardo Franco from John H. Stroger Hospital in Chicago and Dr. Carolina Candotti from Penn State Hershey Medical Center.

Faculty from the Mayo Clinic, including Drs. Jamie Newman, Fernando Rivera, John Park, and Eddie Greene, attended the meeting for a second consecutive time. Their contributions made the event even more attractive to local hospitalists.

Although HM continues to grow in South America, barriers still exist. Each country has a different healthcare system, and the economic and political forces that drive these systems affect hospitalists and their patients. Certain metrics that are often used to gauge hospitalists’ impact in North America, such as length of stay, are less meaningful in Chile and other countries. Additionally, hospitalists’ ability to participate in conferences and exchange ideas is limited by distance and circumstance; the average hospitalist in Chile earns the equivalent of about $70,000 a year. Lastly, many hospitalists in South America aspire to develop research programs, but obtaining research training is challenging. Such opportunities are limited in South America, and physicians often encounter cost and immigration issues when they seek training abroad.

Despite the challenges, the enthusiasm to advance HM in South America and build international collaborations continues to grow. Hospitalists from different institutions in the U.S. have returned every year to participate in the conference. The opportunity to meet hospitalists from different countries, exchange ideas, and be part of the hospitalist movement abroad draws people back. The energy of the hospitalist movement is still alive.

Dr. Abbott and Dr. Rodriguez are adjunct professors and Dr. Aizman is an assistant professor in the department of internal medicine at Pontificia Universidad Católica de Chile School of Medicine in Santiago; Dr. Newman is an assistant professor in the division of hospital medicine at Mayo Clinic in Rochester, Minn.; and Dr. Soni is an assistant professor of medicine in the division of hospital medicine at the University of Texas Health Science Center at San Antonio.

The long-simmering debate over whether and how hospitalists might help solve the worsening shortage of critical-care physicians is beginning to boil over.

In June, SHM and the Society of Critical Care Medicine (SCCM) issued a joint position paper proposing an expedited, one-year, critical-care fellowship for hospitalists with at least three years of clinical job experience, in lieu of the two-year fellowship now required for board certification.¹

“Bringing qualified hospitalists into the critical-care workforce through rigorous sanctioned and accredited one-year training programs,” the paper asserted, “will open a new intensivist training pipeline and potentially offer more critically ill patients the benefits of providers who are unequivocally qualified to care for them.”

The backlash was swift and sharp. In a strongly worded editorial response published in July, the American College of Chest Physicians (ACCP) and the American Association of Critical-Care Nurses (AACN) declared that one year of fellowship training is inadequate for HM physicians to achieve competence in critical-care medicine.² “No, the perfect should not be the enemy of the good in our efforts to craft solutions,” the editorial stated. “But the current imperfect SCCM/SHM proposal is an enemy of the existing good training processes already in place.”

HM leaders counter that the current strategies for bolstering the ranks of board-certified intensivists simply aren’t working, and that creative, outside-the-box thinking is required to solve the dilemma.

Dr. Siegal

“Hospitalists are rapidly becoming a dominant, if not the dominant, block of physicians who are providing critical care in the United States. You can decide, if you want, whether that’s good or bad, but that’s the reality,” says Eric Siegal, MD, SFHM, lead author of the SHM/SCCM position paper, director of critical-care medicine at Aurora St. Luke’s Medical Center in Milwaukee, and an SHM board member. Given the escalating shortage of intensivists, he says, he believes that concerned stakeholders can either try to help develop the skills and knowledge of those hospitalists already in the ICU or “hope that a whole bunch of hospitalists suddenly decide to abandon their practices and complete two-year medical

critical-care fellowships.”

Intensivist leaders say that less training will do nothing to improve patient outcomes. “The reality is that hospitalists are doing it. The question should be, ‘Are they doing it well or at the detriment of the patient?’” asks Michael Baumann, MD, MS, FCCP, professor of medicine in the division of pulmonary, critical-care, and sleep medicine at the University of Mississippi Medical Center in Jackson. “The patient is the one who loses if we have somebody pinch-hitting, which is really what we’re talking about here,” adds Dr. Baumann, lead author of the ACCP/AACN editorial.

Staffing Shortfall

Despite the heated rhetoric, interviews with leaders on both sides suggest an eagerness to move forward in trying to collectively solve a problem that has vexed the entire medical community.

In 2000, the Leapfrog Group, a Washington, D.C.-based consortium of major healthcare purchasers focused on improving the safety, quality, and value of care, recommended that all ICUs should be staffed with physicians certified in critical-care medicine.³ As part of its rationale, the group cited research suggesting that greater intensivist use can yield better patient outcomes.

But a seminal study published the same year hinted at just how difficult meeting Leapfrog’s ambitious goal might be. Based on the trajectory of supply and demand, the authors forecast a 22% shortfall in intensivist hours by 2020, and a 35% shortfall by 2030, mainly due to a surge in demand from an aging U.S. population.⁴ A follow-up report in 2006 estimated that 53% of the nation’s ICU units had no intensivist coverage at all, and that only 4% of adult ICUs were meeting the full Leapfrog standards of high-intensity ICU staffing, dedicated attending physician coverage during the day, and dedicated coverage by any physician at night.⁵

No one in their right mind will say one year [of fellowship training] is as good as two years. That would be folly. On the other hand, that’s not the question. The question is, “Can we structure training that is competency-focused, so that the majority of people who enter the training will achieve the necessary levels of competency within a year?”

—Timothy Buchman, PhD, MD, director, Emory University Center for Critical Care, Atlanta

Given the recent push for more outpatient treatment of less-critically-ill patients, many observers say the increased acuity of hospitalized patients—with more comorbidities—only exacerbates the mismatch between supply and demand. Making matters worse, providers are not evenly distributed throughout the country, with many smaller and rural hospitals already facing an acute shortage of intensivist services.

As a result, many hospitalists have been forced to step into the breach. According to SHM’s 2012 State of Hospital Medicine survey, 83.5% of responding nonacademic adult medicine groups said they routinely provide care for patients in an ICU setting, along with 27.9% of academic HM groups.

“So we have hospitalists who, either by choice or by default, care for patients who they may or may not be fully qualified to manage,” Dr. Siegal says. Practically speaking, he and his coauthors assert, the question of whether hospitalists should be in the ICU is now moot. The real question is how to ensure that those providers can deliver safe and effective care.

Experience vs. Training

Currently, internists who have completed fellowships in such specialties as pulmonary medicine, nephrology, and infectious disease can complete a one-year critical-care fellowship to obtain board certification. Experienced hospitalists have questioned the requirement that they instead complete a two-year fellowship, with no consideration given to the relevant clinical experience and maturity gained after years of hospitalist practice. In addition, they argue, it is logistically and financially unrealistic to expect a large cadre of experienced hospitalists to abandon their practices for two years to pursue critical-care training.

But Dr. Baumann says subpar internal-medicine residency requirements deserve much of the blame for offering inadequate training. “Critical care is a blend of critical thinking skills and procedural skills. Both of those are diminished tremendously in the current programs for internal medicine,” he says. “It’s really an indictment of our current training of internal-medicine residents now.”

SCCM, for its part, is sticking to its guns, albeit more quietly. When asked for comment, a spokesman issued a carefully worded statement that reads, “The paper reflects the society’s concerns regarding workforce shortages and the realities of today’s environment.”

The SHM/SCCM proposal makes sense provided that hospitalists are realistic about the types of patients they’ll see, says Timothy Buchman, PhD, MD, director of Emory University’s Center for Critical Care in Atlanta. “No one in their right mind will say one year is as good as two years. That would be folly,” he says. “On the other hand, that’s not the question. The question is, ‘Can we structure training that is competency-focused, so that the majority of people who enter the training will achieve the necessary levels of competency within a year?’”

Derek Angus, MD, chair of critical-care medicine at the University of Pittsburgh Medical Center and lead author of the 2000 study chronicling the intensivist shortfall, is more ambivalent. “Hospitalists and intensivists have to work hand in hand. In many ways, they are the two groups that run inpatient hospital medicine,” he says. In that respect, sorting out and streamlining training pathways might be a good idea.

“On the other hand, all of intensive-care training in the United States is a little thin in comparison to what goes on in many other countries,” Dr. Angus adds. “If anything, I would like to be seeing more vigorous training. So creating one more pathway that helps reinforce pretty light training feels like accreditation, in general, may be moving slightly in the wrong direction.”

Dr. Buchman and other observers view the debate as a difference in opinion among well-meaning people who are passionate about patient care. And they concede that no one knows yet who may be right.

“We do know that advanced training is required. We do know that it should be competency-focused,” Dr. Buchman says. “But what we don’t know is how long it’s really going to take to get to the competency levels that we believe are necessary to care for the patients.”

That point may provide one important opening for further discussions. Dr. Baumann agrees that the real issues are how to define critical-care competencies, how to measure them, and how to ensure that trainees prove their mettle as competent providers. “It really shouldn’t be time-based; it should be outcome-based,” he says.

The SHM/SCCM proposal, Dr. Siegal says, should be viewed as a conversation-starter. The true test will be whether everyone can reach an agreement on how to evaluate whether an ICU caregiver has attained the necessary knowledge, skills, and attitudes—and how relevant professional experience should factor into discussions over the length of training required for intensivist certification.

A Tiered Solution

The concept of tiered ICU care—already used in neonatal ICUs—might offer another opening for productive debate. “Can patients who are not that critically ill be managed by someone who hasn’t done that much critical-care training?” Dr. Angus asks. He believes it’s possible, provided patients are properly sorted and that hospitalists aren’t put in the uncomfortable position of managing medical conditions that they see only rarely. He has no problem, though, envisioning a tiered system in which fully trained intensivists spend most of their time managing the sickest patients, while other providers—including hospitalists—care for patients at intermediate risk.

Hospitalists have greeted the idea cautiously, noting that a two-tiered model might be difficult to define and standardize, and that it could present logistical challenges around transferring patients. However, Daniel D. Dressler, MD, MSc, SFHM, FACP, associate professor of internal medicine at Emory University School of Medicine and coauthor of the SHM/SCCM position paper, led a recent study that offers at least some support for a risk-based system.⁶

Overall, the study found no statistically significant difference in the length of stay or inpatient mortality rates for ICU patients cared for by hospitalist-led or intensivist-led teams. Among mechanically ventilated patients with intermediate illness severity, though, the study suggested that intensivist-led care resulted in a lower length of stay in both the hospital and ICU, as well as in a trend toward reduced inpatient mortality. “There may be some value in designing or developing a stratification system,” Dr. Dressler says, “but it definitely needs more study.”

In the meantime, Dr. Dressler says, more rapid solutions are needed. And although he says he understands and respects many of the doubts expressed about the SHM/SCCM proposal, he also believes some of the fear might be based on anecdotes about individual hospitalists who were deemed unlikely to thrive in an ICU environment. “For each person like that, we also know 10 or 20 people who might do really well” with just a year of additional training, says Dr. Dressler, a former SHM board member.

Now that both sides clearly have the attention of the other, leaders say they hope the opening salvos give way to more temperate discussions about how to move more skilled providers to the front lines.

“Health professionals are a smart and clever lot,” says Mary Stahl, RN, MSN, ACNS-BC, CCNS-CMC, CCRN, immediate past president of AACN and a clinical nurse specialist at the Mid America Heart Institute at Saint Luke’s Hospital in Kansas City, Mo. “I’m confident we’ll develop an effective solution—maybe several—by focusing on the fundamental belief that patients’ needs must drive caregivers’ knowledge and skills.”

Bryn Nelson is a freelance medical writer in Seattle.

References

1. Siegal EM, Dressler DD, Dichter JR, Gorman MJ, Lipsett PA. Training a hospitalist workforce to address the intensivist shortage in American hospitals: a position paper from the Society of Hospital Medicine and the Society of Critical Care Medicine. J Hosp Med. 2012;7:359-364.
2. Baumann MH, Simpson SQ, Stahl M, et al. First, do no harm: less training ≠ quality care. Chest. 2012;142:5-7.
3. Milstein A, Galvin RS, Delbanco SF, et al. Improving the safety of health care: the Leapfrog initiative. Eff Clin Pract. 2000;3:313-316.
4. Angus DC, Kelley MA, Schmitz RJ, et al. Caring for the critically ill patient. Current and projected workforce requirements for care of the critically ill and patients with pulmonary disease: can we meet the requirements of an aging population? JAMA. 2000;284:2762-2770.
5. Angus DC, Shorr AF, White A, et al. Critical care delivery in the United States: distribution of services and compliance with Leapfrog recommendations. Crit Care Med. 2006;34:1016-1024.
6. Wise KR, Akopov VA, Williams BR Jr., Ido MS, Leeper KV, Dressler DD. Hospitalists and intensivists in the medical ICU: a prospective observational study comparing mortality and length of stay between two staffing models. J Hosp Med. 2012;7:183-189.

The long-simmering debate over whether and how hospitalists might help solve the worsening shortage of critical-care physicians is beginning to boil over.

In June, SHM and the Society of Critical Care Medicine (SCCM) issued a joint position paper proposing an expedited, one-year, critical-care fellowship for hospitalists with at least three years of clinical job experience, in lieu of the two-year fellowship now required for board certification.¹

“Bringing qualified hospitalists into the critical-care workforce through rigorous sanctioned and accredited one-year training programs,” the paper asserted, “will open a new intensivist training pipeline and potentially offer more critically ill patients the benefits of providers who are unequivocally qualified to care for them.”

The backlash was swift and sharp. In a strongly worded editorial response published in July, the American College of Chest Physicians (ACCP) and the American Association of Critical-Care Nurses (AACN) declared that one year of fellowship training is inadequate for HM physicians to achieve competence in critical-care medicine.² “No, the perfect should not be the enemy of the good in our efforts to craft solutions,” the editorial stated. “But the current imperfect SCCM/SHM proposal is an enemy of the existing good training processes already in place.”

HM leaders counter that the current strategies for bolstering the ranks of board-certified intensivists simply aren’t working, and that creative, outside-the-box thinking is required to solve the dilemma.

Dr. Siegal

“Hospitalists are rapidly becoming a dominant, if not the dominant, block of physicians who are providing critical care in the United States. You can decide, if you want, whether that’s good or bad, but that’s the reality,” says Eric Siegal, MD, SFHM, lead author of the SHM/SCCM position paper, director of critical-care medicine at Aurora St. Luke’s Medical Center in Milwaukee, and an SHM board member. Given the escalating shortage of intensivists, he says, he believes that concerned stakeholders can either try to help develop the skills and knowledge of those hospitalists already in the ICU or “hope that a whole bunch of hospitalists suddenly decide to abandon their practices and complete two-year medical

critical-care fellowships.”

Intensivist leaders say that less training will do nothing to improve patient outcomes. “The reality is that hospitalists are doing it. The question should be, ‘Are they doing it well or at the detriment of the patient?’” asks Michael Baumann, MD, MS, FCCP, professor of medicine in the division of pulmonary, critical-care, and sleep medicine at the University of Mississippi Medical Center in Jackson. “The patient is the one who loses if we have somebody pinch-hitting, which is really what we’re talking about here,” adds Dr. Baumann, lead author of the ACCP/AACN editorial.

Staffing Shortfall

Despite the heated rhetoric, interviews with leaders on both sides suggest an eagerness to move forward in trying to collectively solve a problem that has vexed the entire medical community.

In 2000, the Leapfrog Group, a Washington, D.C.-based consortium of major healthcare purchasers focused on improving the safety, quality, and value of care, recommended that all ICUs should be staffed with physicians certified in critical-care medicine.³ As part of its rationale, the group cited research suggesting that greater intensivist use can yield better patient outcomes.

But a seminal study published the same year hinted at just how difficult meeting Leapfrog’s ambitious goal might be. Based on the trajectory of supply and demand, the authors forecast a 22% shortfall in intensivist hours by 2020, and a 35% shortfall by 2030, mainly due to a surge in demand from an aging U.S. population.⁴ A follow-up report in 2006 estimated that 53% of the nation’s ICU units had no intensivist coverage at all, and that only 4% of adult ICUs were meeting the full Leapfrog standards of high-intensity ICU staffing, dedicated attending physician coverage during the day, and dedicated coverage by any physician at night.⁵

No one in their right mind will say one year [of fellowship training] is as good as two years. That would be folly. On the other hand, that’s not the question. The question is, “Can we structure training that is competency-focused, so that the majority of people who enter the training will achieve the necessary levels of competency within a year?”

—Timothy Buchman, PhD, MD, director, Emory University Center for Critical Care, Atlanta

Given the recent push for more outpatient treatment of less-critically-ill patients, many observers say the increased acuity of hospitalized patients—with more comorbidities—only exacerbates the mismatch between supply and demand. Making matters worse, providers are not evenly distributed throughout the country, with many smaller and rural hospitals already facing an acute shortage of intensivist services.

As a result, many hospitalists have been forced to step into the breach. According to SHM’s 2012 State of Hospital Medicine survey, 83.5% of responding nonacademic adult medicine groups said they routinely provide care for patients in an ICU setting, along with 27.9% of academic HM groups.

“So we have hospitalists who, either by choice or by default, care for patients who they may or may not be fully qualified to manage,” Dr. Siegal says. Practically speaking, he and his coauthors assert, the question of whether hospitalists should be in the ICU is now moot. The real question is how to ensure that those providers can deliver safe and effective care.

Experience vs. Training

Currently, internists who have completed fellowships in such specialties as pulmonary medicine, nephrology, and infectious disease can complete a one-year critical-care fellowship to obtain board certification. Experienced hospitalists have questioned the requirement that they instead complete a two-year fellowship, with no consideration given to the relevant clinical experience and maturity gained after years of hospitalist practice. In addition, they argue, it is logistically and financially unrealistic to expect a large cadre of experienced hospitalists to abandon their practices for two years to pursue critical-care training.

But Dr. Baumann says subpar internal-medicine residency requirements deserve much of the blame for offering inadequate training. “Critical care is a blend of critical thinking skills and procedural skills. Both of those are diminished tremendously in the current programs for internal medicine,” he says. “It’s really an indictment of our current training of internal-medicine residents now.”

SCCM, for its part, is sticking to its guns, albeit more quietly. When asked for comment, a spokesman issued a carefully worded statement that reads, “The paper reflects the society’s concerns regarding workforce shortages and the realities of today’s environment.”

The SHM/SCCM proposal makes sense provided that hospitalists are realistic about the types of patients they’ll see, says Timothy Buchman, PhD, MD, director of Emory University’s Center for Critical Care in Atlanta. “No one in their right mind will say one year is as good as two years. That would be folly,” he says. “On the other hand, that’s not the question. The question is, ‘Can we structure training that is competency-focused, so that the majority of people who enter the training will achieve the necessary levels of competency within a year?’”

Derek Angus, MD, chair of critical-care medicine at the University of Pittsburgh Medical Center and lead author of the 2000 study chronicling the intensivist shortfall, is more ambivalent. “Hospitalists and intensivists have to work hand in hand. In many ways, they are the two groups that run inpatient hospital medicine,” he says. In that respect, sorting out and streamlining training pathways might be a good idea.

“On the other hand, all of intensive-care training in the United States is a little thin in comparison to what goes on in many other countries,” Dr. Angus adds. “If anything, I would like to be seeing more vigorous training. So creating one more pathway that helps reinforce pretty light training feels like accreditation, in general, may be moving slightly in the wrong direction.”

Dr. Buchman and other observers view the debate as a difference in opinion among well-meaning people who are passionate about patient care. And they concede that no one knows yet who may be right.

“We do know that advanced training is required. We do know that it should be competency-focused,” Dr. Buchman says. “But what we don’t know is how long it’s really going to take to get to the competency levels that we believe are necessary to care for the patients.”

That point may provide one important opening for further discussions. Dr. Baumann agrees that the real issues are how to define critical-care competencies, how to measure them, and how to ensure that trainees prove their mettle as competent providers. “It really shouldn’t be time-based; it should be outcome-based,” he says.

The SHM/SCCM proposal, Dr. Siegal says, should be viewed as a conversation-starter. The true test will be whether everyone can reach an agreement on how to evaluate whether an ICU caregiver has attained the necessary knowledge, skills, and attitudes—and how relevant professional experience should factor into discussions over the length of training required for intensivist certification.

A Tiered Solution

The concept of tiered ICU care—already used in neonatal ICUs—might offer another opening for productive debate. “Can patients who are not that critically ill be managed by someone who hasn’t done that much critical-care training?” Dr. Angus asks. He believes it’s possible, provided patients are properly sorted and that hospitalists aren’t put in the uncomfortable position of managing medical conditions that they see only rarely. He has no problem, though, envisioning a tiered system in which fully trained intensivists spend most of their time managing the sickest patients, while other providers—including hospitalists—care for patients at intermediate risk.

Hospitalists have greeted the idea cautiously, noting that a two-tiered model might be difficult to define and standardize, and that it could present logistical challenges around transferring patients. However, Daniel D. Dressler, MD, MSc, SFHM, FACP, associate professor of internal medicine at Emory University School of Medicine and coauthor of the SHM/SCCM position paper, led a recent study that offers at least some support for a risk-based system.⁶

Overall, the study found no statistically significant difference in the length of stay or inpatient mortality rates for ICU patients cared for by hospitalist-led or intensivist-led teams. Among mechanically ventilated patients with intermediate illness severity, though, the study suggested that intensivist-led care resulted in a lower length of stay in both the hospital and ICU, as well as in a trend toward reduced inpatient mortality. “There may be some value in designing or developing a stratification system,” Dr. Dressler says, “but it definitely needs more study.”

In the meantime, Dr. Dressler says, more rapid solutions are needed. And although he says he understands and respects many of the doubts expressed about the SHM/SCCM proposal, he also believes some of the fear might be based on anecdotes about individual hospitalists who were deemed unlikely to thrive in an ICU environment. “For each person like that, we also know 10 or 20 people who might do really well” with just a year of additional training, says Dr. Dressler, a former SHM board member.

Now that both sides clearly have the attention of the other, leaders say they hope the opening salvos give way to more temperate discussions about how to move more skilled providers to the front lines.

“Health professionals are a smart and clever lot,” says Mary Stahl, RN, MSN, ACNS-BC, CCNS-CMC, CCRN, immediate past president of AACN and a clinical nurse specialist at the Mid America Heart Institute at Saint Luke’s Hospital in Kansas City, Mo. “I’m confident we’ll develop an effective solution—maybe several—by focusing on the fundamental belief that patients’ needs must drive caregivers’ knowledge and skills.”

Bryn Nelson is a freelance medical writer in Seattle.

References

1. Siegal EM, Dressler DD, Dichter JR, Gorman MJ, Lipsett PA. Training a hospitalist workforce to address the intensivist shortage in American hospitals: a position paper from the Society of Hospital Medicine and the Society of Critical Care Medicine. J Hosp Med. 2012;7:359-364.
2. Baumann MH, Simpson SQ, Stahl M, et al. First, do no harm: less training ≠ quality care. Chest. 2012;142:5-7.
3. Milstein A, Galvin RS, Delbanco SF, et al. Improving the safety of health care: the Leapfrog initiative. Eff Clin Pract. 2000;3:313-316.
4. Angus DC, Kelley MA, Schmitz RJ, et al. Caring for the critically ill patient. Current and projected workforce requirements for care of the critically ill and patients with pulmonary disease: can we meet the requirements of an aging population? JAMA. 2000;284:2762-2770.
5. Angus DC, Shorr AF, White A, et al. Critical care delivery in the United States: distribution of services and compliance with Leapfrog recommendations. Crit Care Med. 2006;34:1016-1024.
6. Wise KR, Akopov VA, Williams BR Jr., Ido MS, Leeper KV, Dressler DD. Hospitalists and intensivists in the medical ICU: a prospective observational study comparing mortality and length of stay between two staffing models. J Hosp Med. 2012;7:183-189.

The long-simmering debate over whether and how hospitalists might help solve the worsening shortage of critical-care physicians is beginning to boil over.

In June, SHM and the Society of Critical Care Medicine (SCCM) issued a joint position paper proposing an expedited, one-year, critical-care fellowship for hospitalists with at least three years of clinical job experience, in lieu of the two-year fellowship now required for board certification.¹

“Bringing qualified hospitalists into the critical-care workforce through rigorous sanctioned and accredited one-year training programs,” the paper asserted, “will open a new intensivist training pipeline and potentially offer more critically ill patients the benefits of providers who are unequivocally qualified to care for them.”

The backlash was swift and sharp. In a strongly worded editorial response published in July, the American College of Chest Physicians (ACCP) and the American Association of Critical-Care Nurses (AACN) declared that one year of fellowship training is inadequate for HM physicians to achieve competence in critical-care medicine.² “No, the perfect should not be the enemy of the good in our efforts to craft solutions,” the editorial stated. “But the current imperfect SCCM/SHM proposal is an enemy of the existing good training processes already in place.”

HM leaders counter that the current strategies for bolstering the ranks of board-certified intensivists simply aren’t working, and that creative, outside-the-box thinking is required to solve the dilemma.

Dr. Siegal

“Hospitalists are rapidly becoming a dominant, if not the dominant, block of physicians who are providing critical care in the United States. You can decide, if you want, whether that’s good or bad, but that’s the reality,” says Eric Siegal, MD, SFHM, lead author of the SHM/SCCM position paper, director of critical-care medicine at Aurora St. Luke’s Medical Center in Milwaukee, and an SHM board member. Given the escalating shortage of intensivists, he says, he believes that concerned stakeholders can either try to help develop the skills and knowledge of those hospitalists already in the ICU or “hope that a whole bunch of hospitalists suddenly decide to abandon their practices and complete two-year medical

critical-care fellowships.”

Intensivist leaders say that less training will do nothing to improve patient outcomes. “The reality is that hospitalists are doing it. The question should be, ‘Are they doing it well or at the detriment of the patient?’” asks Michael Baumann, MD, MS, FCCP, professor of medicine in the division of pulmonary, critical-care, and sleep medicine at the University of Mississippi Medical Center in Jackson. “The patient is the one who loses if we have somebody pinch-hitting, which is really what we’re talking about here,” adds Dr. Baumann, lead author of the ACCP/AACN editorial.

Staffing Shortfall

Despite the heated rhetoric, interviews with leaders on both sides suggest an eagerness to move forward in trying to collectively solve a problem that has vexed the entire medical community.

In 2000, the Leapfrog Group, a Washington, D.C.-based consortium of major healthcare purchasers focused on improving the safety, quality, and value of care, recommended that all ICUs should be staffed with physicians certified in critical-care medicine.³ As part of its rationale, the group cited research suggesting that greater intensivist use can yield better patient outcomes.

But a seminal study published the same year hinted at just how difficult meeting Leapfrog’s ambitious goal might be. Based on the trajectory of supply and demand, the authors forecast a 22% shortfall in intensivist hours by 2020, and a 35% shortfall by 2030, mainly due to a surge in demand from an aging U.S. population.⁴ A follow-up report in 2006 estimated that 53% of the nation’s ICU units had no intensivist coverage at all, and that only 4% of adult ICUs were meeting the full Leapfrog standards of high-intensity ICU staffing, dedicated attending physician coverage during the day, and dedicated coverage by any physician at night.⁵

No one in their right mind will say one year [of fellowship training] is as good as two years. That would be folly. On the other hand, that’s not the question. The question is, “Can we structure training that is competency-focused, so that the majority of people who enter the training will achieve the necessary levels of competency within a year?”

—Timothy Buchman, PhD, MD, director, Emory University Center for Critical Care, Atlanta

Given the recent push for more outpatient treatment of less-critically-ill patients, many observers say the increased acuity of hospitalized patients—with more comorbidities—only exacerbates the mismatch between supply and demand. Making matters worse, providers are not evenly distributed throughout the country, with many smaller and rural hospitals already facing an acute shortage of intensivist services.

As a result, many hospitalists have been forced to step into the breach. According to SHM’s 2012 State of Hospital Medicine survey, 83.5% of responding nonacademic adult medicine groups said they routinely provide care for patients in an ICU setting, along with 27.9% of academic HM groups.

“So we have hospitalists who, either by choice or by default, care for patients who they may or may not be fully qualified to manage,” Dr. Siegal says. Practically speaking, he and his coauthors assert, the question of whether hospitalists should be in the ICU is now moot. The real question is how to ensure that those providers can deliver safe and effective care.

Experience vs. Training

Currently, internists who have completed fellowships in such specialties as pulmonary medicine, nephrology, and infectious disease can complete a one-year critical-care fellowship to obtain board certification. Experienced hospitalists have questioned the requirement that they instead complete a two-year fellowship, with no consideration given to the relevant clinical experience and maturity gained after years of hospitalist practice. In addition, they argue, it is logistically and financially unrealistic to expect a large cadre of experienced hospitalists to abandon their practices for two years to pursue critical-care training.

But Dr. Baumann says subpar internal-medicine residency requirements deserve much of the blame for offering inadequate training. “Critical care is a blend of critical thinking skills and procedural skills. Both of those are diminished tremendously in the current programs for internal medicine,” he says. “It’s really an indictment of our current training of internal-medicine residents now.”

SCCM, for its part, is sticking to its guns, albeit more quietly. When asked for comment, a spokesman issued a carefully worded statement that reads, “The paper reflects the society’s concerns regarding workforce shortages and the realities of today’s environment.”

The SHM/SCCM proposal makes sense provided that hospitalists are realistic about the types of patients they’ll see, says Timothy Buchman, PhD, MD, director of Emory University’s Center for Critical Care in Atlanta. “No one in their right mind will say one year is as good as two years. That would be folly,” he says. “On the other hand, that’s not the question. The question is, ‘Can we structure training that is competency-focused, so that the majority of people who enter the training will achieve the necessary levels of competency within a year?’”

Derek Angus, MD, chair of critical-care medicine at the University of Pittsburgh Medical Center and lead author of the 2000 study chronicling the intensivist shortfall, is more ambivalent. “Hospitalists and intensivists have to work hand in hand. In many ways, they are the two groups that run inpatient hospital medicine,” he says. In that respect, sorting out and streamlining training pathways might be a good idea.

“On the other hand, all of intensive-care training in the United States is a little thin in comparison to what goes on in many other countries,” Dr. Angus adds. “If anything, I would like to be seeing more vigorous training. So creating one more pathway that helps reinforce pretty light training feels like accreditation, in general, may be moving slightly in the wrong direction.”

Dr. Buchman and other observers view the debate as a difference in opinion among well-meaning people who are passionate about patient care. And they concede that no one knows yet who may be right.

“We do know that advanced training is required. We do know that it should be competency-focused,” Dr. Buchman says. “But what we don’t know is how long it’s really going to take to get to the competency levels that we believe are necessary to care for the patients.”

That point may provide one important opening for further discussions. Dr. Baumann agrees that the real issues are how to define critical-care competencies, how to measure them, and how to ensure that trainees prove their mettle as competent providers. “It really shouldn’t be time-based; it should be outcome-based,” he says.

The SHM/SCCM proposal, Dr. Siegal says, should be viewed as a conversation-starter. The true test will be whether everyone can reach an agreement on how to evaluate whether an ICU caregiver has attained the necessary knowledge, skills, and attitudes—and how relevant professional experience should factor into discussions over the length of training required for intensivist certification.

A Tiered Solution

The concept of tiered ICU care—already used in neonatal ICUs—might offer another opening for productive debate. “Can patients who are not that critically ill be managed by someone who hasn’t done that much critical-care training?” Dr. Angus asks. He believes it’s possible, provided patients are properly sorted and that hospitalists aren’t put in the uncomfortable position of managing medical conditions that they see only rarely. He has no problem, though, envisioning a tiered system in which fully trained intensivists spend most of their time managing the sickest patients, while other providers—including hospitalists—care for patients at intermediate risk.

Hospitalists have greeted the idea cautiously, noting that a two-tiered model might be difficult to define and standardize, and that it could present logistical challenges around transferring patients. However, Daniel D. Dressler, MD, MSc, SFHM, FACP, associate professor of internal medicine at Emory University School of Medicine and coauthor of the SHM/SCCM position paper, led a recent study that offers at least some support for a risk-based system.⁶

Overall, the study found no statistically significant difference in the length of stay or inpatient mortality rates for ICU patients cared for by hospitalist-led or intensivist-led teams. Among mechanically ventilated patients with intermediate illness severity, though, the study suggested that intensivist-led care resulted in a lower length of stay in both the hospital and ICU, as well as in a trend toward reduced inpatient mortality. “There may be some value in designing or developing a stratification system,” Dr. Dressler says, “but it definitely needs more study.”

In the meantime, Dr. Dressler says, more rapid solutions are needed. And although he says he understands and respects many of the doubts expressed about the SHM/SCCM proposal, he also believes some of the fear might be based on anecdotes about individual hospitalists who were deemed unlikely to thrive in an ICU environment. “For each person like that, we also know 10 or 20 people who might do really well” with just a year of additional training, says Dr. Dressler, a former SHM board member.

Now that both sides clearly have the attention of the other, leaders say they hope the opening salvos give way to more temperate discussions about how to move more skilled providers to the front lines.

“Health professionals are a smart and clever lot,” says Mary Stahl, RN, MSN, ACNS-BC, CCNS-CMC, CCRN, immediate past president of AACN and a clinical nurse specialist at the Mid America Heart Institute at Saint Luke’s Hospital in Kansas City, Mo. “I’m confident we’ll develop an effective solution—maybe several—by focusing on the fundamental belief that patients’ needs must drive caregivers’ knowledge and skills.”

Bryn Nelson is a freelance medical writer in Seattle.

References

1. Siegal EM, Dressler DD, Dichter JR, Gorman MJ, Lipsett PA. Training a hospitalist workforce to address the intensivist shortage in American hospitals: a position paper from the Society of Hospital Medicine and the Society of Critical Care Medicine. J Hosp Med. 2012;7:359-364.
2. Baumann MH, Simpson SQ, Stahl M, et al. First, do no harm: less training ≠ quality care. Chest. 2012;142:5-7.
3. Milstein A, Galvin RS, Delbanco SF, et al. Improving the safety of health care: the Leapfrog initiative. Eff Clin Pract. 2000;3:313-316.
4. Angus DC, Kelley MA, Schmitz RJ, et al. Caring for the critically ill patient. Current and projected workforce requirements for care of the critically ill and patients with pulmonary disease: can we meet the requirements of an aging population? JAMA. 2000;284:2762-2770.
5. Angus DC, Shorr AF, White A, et al. Critical care delivery in the United States: distribution of services and compliance with Leapfrog recommendations. Crit Care Med. 2006;34:1016-1024.
6. Wise KR, Akopov VA, Williams BR Jr., Ido MS, Leeper KV, Dressler DD. Hospitalists and intensivists in the medical ICU: a prospective observational study comparing mortality and length of stay between two staffing models. J Hosp Med. 2012;7:183-189.