Pornography. There can be few better hooks for readers than that. Just typing the word is a bit uncomfortable. As is, I imagine, reading it. But it’s effective, and likely why you’ve made it to word 37 of my column—34 words further than you usually get, I imagine.

“What about pornography?” you ask with bated breath. “What could pornography possibly have to do with hospital medicine?” your mind wonders. “Is this the column that (finally) gets Glasheen fired?” the ambulance chaser in you titillates.

By now, you’ve no doubt heard the famous Potter Stewart definition of pornography: “I know it when I see it.” That’s how the former U.S. Supreme Court justice described his threshold for recognizing pornography. It was made famous in a 1960s decision about whether a particular movie scene was protected by the 1st Amendment right to free speech or, indeed, a pornographic obscenity to be censured. Stewart, who clearly recognized the need to “define” pornography, also recognized the inherent challenges in doing so. The I-know-it-when-I-see-it benchmark is, of course, flawed, but I defy you to come up with a better definition.

Quality Is, of Course…

I was thinking about pornography (another discomforting phrase to type) recently—and Potter Stewart’s challenge in defining it, specifically—when I was asked about quality in healthcare. The query, which occurred during a several-hour, mind-numbing meeting (is there another type of several-hour meeting?), was “What is quality?” The question, laced with hostility and dripping with antagonism, was posed by a senior physician and directed pointedly at me. Indignantly, I cleared my throat, mentally stepping onto my pedestal to ceremoniously topple this academic egghead with my erudite response.

“Well, quality is, of course,” I confidently retorted, the “of course” added to demonstrate my moral superiority, “the ability to … uhhh, you see … ummmm, you know.” At which point I again cleared my throat not once, not twice, but a socially awkward three times before employing the timed-honored, full-body shock-twitch that signifies that you’ve just received an urgent vibrate page (faked, of course) and excused myself from the meeting, never to return.

The reality is that I struggle to define quality. Like Chief Justice Stewart, I think I know quality when I see it, but more precise definitions can be elusive.

And distracting.

It’s Not My Job

Just this morning, I read a news release from a respected physician group trumpeting the fact that their advocacy resulted in the federal government reducing the number of quality data-point requirements in their final rule for accountable-care organizations (ACOs) from 66 to 33. Trumpeting? Is this a good thing? Should we be supporting fewer quality measures? The article quoted a physician leader saying that the original reporting requirements were too burdensome. Too burdensome to whom? My guess is the recipients of our care, often referred to as our patients, wouldn’t categorize quality assurance as “too burdensome.”

I was at another meeting recently in which a respected colleague related her take on the physician role in improving quality. “I don’t think that’s a physician’s job. That’s what we have a quality department for,” she noted. “It’s just too expensive, time-consuming, and boring for physicians to do that kind of work.”

Too burdensome? Not a physician’s job to ensure the delivery of quality care? While I understand the sentiment (the need to have support staff collecting data, recognition of the huge infrastructure requirements, etc.), I can’t help but think that these types of responses are a large part of the struggle we are having with improving quality.

Then again, I would hazard that 0.0 percent of physicians would argue with the premise that we are obliged by the Hippocratic Oath, our moral compass, and our sense of professionalism to provide the best possible care to our patients. If we accept that we aren’t doing that—and we aren’t—then what is the disconnect? Why aren’t we seeking more quality data points? Why isn’t this “our job”?

Definitional Disconnect

Well, the truth is, it is our job. And we know it. The problem is that quality isn’t universally defined and the process of trying to define it often distracts us from the true task at hand—improving patient care.

Few of us would argue that a wrong-site surgery or anaphylaxis from administration of a medication known to have caused an allergy represents a suboptimal level of care. But more often than not, we see quality being measured and defined in less concrete, more obscure ways—ways that my eyes may not view as low-quality. These definitions are inherently flawed and breed contempt among providers who are told they aren’t passing muster in metrics they don’t see as “quality.”

So the real disconnect is definitional. Is quality defined by the Institute of Medicine characteristics of safe, effective, patient-centered, timely, efficient, and equitable care? Or is it the rates of underuse, overuse, and misuse of medical treatments and procedures? Or is it defined by individual quality metrics such as those captured by the Centers for Medicare & Medicaid Services (CMS)—you know, things like hospital fall rates, perioperative antibiotic usage, beta-blockers after MI, or whether a patient reported their bathroom as being clean?

Is 30% of the quality of care that we deliver referable to the patient experience (as measured by HCAHPS), as the new value-based purchasing program would have us believe? Is it hospital accreditation through the Joint Commission? Or physician certification through our parent boards? Is quality measured by a physician’s cognitive or technical skills, or where they went to school? Is it experience, medical knowledge, guideline usage?

We use such a mystifying array of metrics to define quality that it confuses the issue such that physicians who personally believe they are doing a good job can become disenfranchised. To a physician who provides clinically appropriate care around a surgical procedure or treatment of pneumonia, it can be demeaning and demoralizing to suggest that his or her patient did not receive “high quality” care because the bathroom wasn’t clean or the patient didn’t get a flu shot. Yet, this is the message we often send—a message that alienates many physicians, making them cynical about quality and disengaged in quality improvement. The result is that they seek fewer quality data points and defer the job of improving quality to someone else.

Make no mistake: Quality measures have an important role in our healthcare landscape. But to the degree that defining quality confuses, alienates, or disenfranchises providers, we should stop trying to define it. Quality is not a thing, a metric, or an outcome. It is not an elusive, unquantifiable creature that is achievable only by the elite. Quality is simply providing the best possible care. And quality improvement is simply closing the gap between the best possible care and actual care.

In this regard, we can learn a lot from Potter Stewart. We know quality when we see it. And we know what an absence of quality looks like.

Let’s close that gap by putting less energy into defining quality, and putting more energy into the tenacious pursuit of quality.

Dr. Glasheen is physician editor of The Hospitalist.

Pornography. There can be few better hooks for readers than that. Just typing the word is a bit uncomfortable. As is, I imagine, reading it. But it’s effective, and likely why you’ve made it to word 37 of my column—34 words further than you usually get, I imagine.

“What about pornography?” you ask with bated breath. “What could pornography possibly have to do with hospital medicine?” your mind wonders. “Is this the column that (finally) gets Glasheen fired?” the ambulance chaser in you titillates.

By now, you’ve no doubt heard the famous Potter Stewart definition of pornography: “I know it when I see it.” That’s how the former U.S. Supreme Court justice described his threshold for recognizing pornography. It was made famous in a 1960s decision about whether a particular movie scene was protected by the 1st Amendment right to free speech or, indeed, a pornographic obscenity to be censured. Stewart, who clearly recognized the need to “define” pornography, also recognized the inherent challenges in doing so. The I-know-it-when-I-see-it benchmark is, of course, flawed, but I defy you to come up with a better definition.

Quality Is, of Course…

I was thinking about pornography (another discomforting phrase to type) recently—and Potter Stewart’s challenge in defining it, specifically—when I was asked about quality in healthcare. The query, which occurred during a several-hour, mind-numbing meeting (is there another type of several-hour meeting?), was “What is quality?” The question, laced with hostility and dripping with antagonism, was posed by a senior physician and directed pointedly at me. Indignantly, I cleared my throat, mentally stepping onto my pedestal to ceremoniously topple this academic egghead with my erudite response.

“Well, quality is, of course,” I confidently retorted, the “of course” added to demonstrate my moral superiority, “the ability to … uhhh, you see … ummmm, you know.” At which point I again cleared my throat not once, not twice, but a socially awkward three times before employing the timed-honored, full-body shock-twitch that signifies that you’ve just received an urgent vibrate page (faked, of course) and excused myself from the meeting, never to return.

The reality is that I struggle to define quality. Like Chief Justice Stewart, I think I know quality when I see it, but more precise definitions can be elusive.

And distracting.

It’s Not My Job

Just this morning, I read a news release from a respected physician group trumpeting the fact that their advocacy resulted in the federal government reducing the number of quality data-point requirements in their final rule for accountable-care organizations (ACOs) from 66 to 33. Trumpeting? Is this a good thing? Should we be supporting fewer quality measures? The article quoted a physician leader saying that the original reporting requirements were too burdensome. Too burdensome to whom? My guess is the recipients of our care, often referred to as our patients, wouldn’t categorize quality assurance as “too burdensome.”

I was at another meeting recently in which a respected colleague related her take on the physician role in improving quality. “I don’t think that’s a physician’s job. That’s what we have a quality department for,” she noted. “It’s just too expensive, time-consuming, and boring for physicians to do that kind of work.”

Too burdensome? Not a physician’s job to ensure the delivery of quality care? While I understand the sentiment (the need to have support staff collecting data, recognition of the huge infrastructure requirements, etc.), I can’t help but think that these types of responses are a large part of the struggle we are having with improving quality.

Then again, I would hazard that 0.0 percent of physicians would argue with the premise that we are obliged by the Hippocratic Oath, our moral compass, and our sense of professionalism to provide the best possible care to our patients. If we accept that we aren’t doing that—and we aren’t—then what is the disconnect? Why aren’t we seeking more quality data points? Why isn’t this “our job”?

Definitional Disconnect

Well, the truth is, it is our job. And we know it. The problem is that quality isn’t universally defined and the process of trying to define it often distracts us from the true task at hand—improving patient care.

Few of us would argue that a wrong-site surgery or anaphylaxis from administration of a medication known to have caused an allergy represents a suboptimal level of care. But more often than not, we see quality being measured and defined in less concrete, more obscure ways—ways that my eyes may not view as low-quality. These definitions are inherently flawed and breed contempt among providers who are told they aren’t passing muster in metrics they don’t see as “quality.”

So the real disconnect is definitional. Is quality defined by the Institute of Medicine characteristics of safe, effective, patient-centered, timely, efficient, and equitable care? Or is it the rates of underuse, overuse, and misuse of medical treatments and procedures? Or is it defined by individual quality metrics such as those captured by the Centers for Medicare & Medicaid Services (CMS)—you know, things like hospital fall rates, perioperative antibiotic usage, beta-blockers after MI, or whether a patient reported their bathroom as being clean?

Is 30% of the quality of care that we deliver referable to the patient experience (as measured by HCAHPS), as the new value-based purchasing program would have us believe? Is it hospital accreditation through the Joint Commission? Or physician certification through our parent boards? Is quality measured by a physician’s cognitive or technical skills, or where they went to school? Is it experience, medical knowledge, guideline usage?

We use such a mystifying array of metrics to define quality that it confuses the issue such that physicians who personally believe they are doing a good job can become disenfranchised. To a physician who provides clinically appropriate care around a surgical procedure or treatment of pneumonia, it can be demeaning and demoralizing to suggest that his or her patient did not receive “high quality” care because the bathroom wasn’t clean or the patient didn’t get a flu shot. Yet, this is the message we often send—a message that alienates many physicians, making them cynical about quality and disengaged in quality improvement. The result is that they seek fewer quality data points and defer the job of improving quality to someone else.

Make no mistake: Quality measures have an important role in our healthcare landscape. But to the degree that defining quality confuses, alienates, or disenfranchises providers, we should stop trying to define it. Quality is not a thing, a metric, or an outcome. It is not an elusive, unquantifiable creature that is achievable only by the elite. Quality is simply providing the best possible care. And quality improvement is simply closing the gap between the best possible care and actual care.

In this regard, we can learn a lot from Potter Stewart. We know quality when we see it. And we know what an absence of quality looks like.

Let’s close that gap by putting less energy into defining quality, and putting more energy into the tenacious pursuit of quality.

Dr. Glasheen is physician editor of The Hospitalist.

Pornography. There can be few better hooks for readers than that. Just typing the word is a bit uncomfortable. As is, I imagine, reading it. But it’s effective, and likely why you’ve made it to word 37 of my column—34 words further than you usually get, I imagine.

“What about pornography?” you ask with bated breath. “What could pornography possibly have to do with hospital medicine?” your mind wonders. “Is this the column that (finally) gets Glasheen fired?” the ambulance chaser in you titillates.

By now, you’ve no doubt heard the famous Potter Stewart definition of pornography: “I know it when I see it.” That’s how the former U.S. Supreme Court justice described his threshold for recognizing pornography. It was made famous in a 1960s decision about whether a particular movie scene was protected by the 1st Amendment right to free speech or, indeed, a pornographic obscenity to be censured. Stewart, who clearly recognized the need to “define” pornography, also recognized the inherent challenges in doing so. The I-know-it-when-I-see-it benchmark is, of course, flawed, but I defy you to come up with a better definition.

Quality Is, of Course…

I was thinking about pornography (another discomforting phrase to type) recently—and Potter Stewart’s challenge in defining it, specifically—when I was asked about quality in healthcare. The query, which occurred during a several-hour, mind-numbing meeting (is there another type of several-hour meeting?), was “What is quality?” The question, laced with hostility and dripping with antagonism, was posed by a senior physician and directed pointedly at me. Indignantly, I cleared my throat, mentally stepping onto my pedestal to ceremoniously topple this academic egghead with my erudite response.

“Well, quality is, of course,” I confidently retorted, the “of course” added to demonstrate my moral superiority, “the ability to … uhhh, you see … ummmm, you know.” At which point I again cleared my throat not once, not twice, but a socially awkward three times before employing the timed-honored, full-body shock-twitch that signifies that you’ve just received an urgent vibrate page (faked, of course) and excused myself from the meeting, never to return.

The reality is that I struggle to define quality. Like Chief Justice Stewart, I think I know quality when I see it, but more precise definitions can be elusive.

And distracting.

It’s Not My Job

Just this morning, I read a news release from a respected physician group trumpeting the fact that their advocacy resulted in the federal government reducing the number of quality data-point requirements in their final rule for accountable-care organizations (ACOs) from 66 to 33. Trumpeting? Is this a good thing? Should we be supporting fewer quality measures? The article quoted a physician leader saying that the original reporting requirements were too burdensome. Too burdensome to whom? My guess is the recipients of our care, often referred to as our patients, wouldn’t categorize quality assurance as “too burdensome.”

I was at another meeting recently in which a respected colleague related her take on the physician role in improving quality. “I don’t think that’s a physician’s job. That’s what we have a quality department for,” she noted. “It’s just too expensive, time-consuming, and boring for physicians to do that kind of work.”

Too burdensome? Not a physician’s job to ensure the delivery of quality care? While I understand the sentiment (the need to have support staff collecting data, recognition of the huge infrastructure requirements, etc.), I can’t help but think that these types of responses are a large part of the struggle we are having with improving quality.

Then again, I would hazard that 0.0 percent of physicians would argue with the premise that we are obliged by the Hippocratic Oath, our moral compass, and our sense of professionalism to provide the best possible care to our patients. If we accept that we aren’t doing that—and we aren’t—then what is the disconnect? Why aren’t we seeking more quality data points? Why isn’t this “our job”?

Definitional Disconnect

Well, the truth is, it is our job. And we know it. The problem is that quality isn’t universally defined and the process of trying to define it often distracts us from the true task at hand—improving patient care.

Few of us would argue that a wrong-site surgery or anaphylaxis from administration of a medication known to have caused an allergy represents a suboptimal level of care. But more often than not, we see quality being measured and defined in less concrete, more obscure ways—ways that my eyes may not view as low-quality. These definitions are inherently flawed and breed contempt among providers who are told they aren’t passing muster in metrics they don’t see as “quality.”

So the real disconnect is definitional. Is quality defined by the Institute of Medicine characteristics of safe, effective, patient-centered, timely, efficient, and equitable care? Or is it the rates of underuse, overuse, and misuse of medical treatments and procedures? Or is it defined by individual quality metrics such as those captured by the Centers for Medicare & Medicaid Services (CMS)—you know, things like hospital fall rates, perioperative antibiotic usage, beta-blockers after MI, or whether a patient reported their bathroom as being clean?

Is 30% of the quality of care that we deliver referable to the patient experience (as measured by HCAHPS), as the new value-based purchasing program would have us believe? Is it hospital accreditation through the Joint Commission? Or physician certification through our parent boards? Is quality measured by a physician’s cognitive or technical skills, or where they went to school? Is it experience, medical knowledge, guideline usage?

We use such a mystifying array of metrics to define quality that it confuses the issue such that physicians who personally believe they are doing a good job can become disenfranchised. To a physician who provides clinically appropriate care around a surgical procedure or treatment of pneumonia, it can be demeaning and demoralizing to suggest that his or her patient did not receive “high quality” care because the bathroom wasn’t clean or the patient didn’t get a flu shot. Yet, this is the message we often send—a message that alienates many physicians, making them cynical about quality and disengaged in quality improvement. The result is that they seek fewer quality data points and defer the job of improving quality to someone else.

Make no mistake: Quality measures have an important role in our healthcare landscape. But to the degree that defining quality confuses, alienates, or disenfranchises providers, we should stop trying to define it. Quality is not a thing, a metric, or an outcome. It is not an elusive, unquantifiable creature that is achievable only by the elite. Quality is simply providing the best possible care. And quality improvement is simply closing the gap between the best possible care and actual care.

In this regard, we can learn a lot from Potter Stewart. We know quality when we see it. And we know what an absence of quality looks like.

Let’s close that gap by putting less energy into defining quality, and putting more energy into the tenacious pursuit of quality.

Dr. Glasheen is physician editor of The Hospitalist.

I think 70% to 80% of U.S. hospitals now have a hospitalist practice. (Some have more than one hospitalist group operating within their walls.) I arrived at this estimate by relying on both my anecdotal experience and on the annual American Hospital Association survey, which in 2009 showed 58% of hospitals have hospitalists, with an ongoing rapid rate of adoption.

No regular reader of The Hospitalist should be surprised that most U.S. hospitals now have hospitalists, but some might be surprised that 20% to 30% don’t. There are about 5,800 hospitals in the U.S. (a ballpark figure), so that means about 1,100 to 1,800 don’t have hospitalists. What is unique about them?

For some hospitals, the answer is easy. For example, the U.S. has something like 450 psychiatric hospitals. They vary a lot, but many simply don’t accept patients with active medical problems, so these facilities would have little need for medical hospitalists.

Variations in how the term “hospitalist” is used probably account for some facilities reporting no hospitalists. For example, long-term acute-care hospitals (LTACs) might have dedicated inpatient providers but simply don’t call them hospitalists.

Even accounting for these things, there are still a lot of “med-surg” hospitals that say they don’t have hospitalists.

The Holdouts

My experience suggests the two most important reasons some hospitals have not yet developed a hospitalist practice are an oversupply of primary-care physicians (PCPs) and an attractive payor mix in the unassigned patient population. In fact, it is hard for me to imagine a hospital that enjoys both of these attributes ever being able to support hospitalists.

Although it isn’t a common problem, an excess of PCPs (or dearth of patients) removes the most universal and powerful stimulus to develop a hospitalist practice: the desire of PCPs to be relieved of hospital work. And in most cases, those PCPs can offset the loss of hospital work and its associated revenue, with more work in the office. This can mean a better lifestyle (e.g. no trips to the hospital on nights and weekends) and the same or higher income. But if there are too many PCPs in the community, they may be unwilling to give up the hospital work, as there might be no way to replace it in the office. End result: no hospitalists.

For the rare hospital that has an attractive ED-unassigned payor mix, PCPs are more likely to want to continue taking ED call and not support a proposal to develop a hospitalist practice. And access to the ED call roster can be important to new PCPs building a community practice. I have seen situations in which a hospital has addressed the poor reimbursement of unattached ED admissions by paying PCPs to provide that care. Even though that same hospital might want a hospitalist practice, the ED call payment it is providing to PCPs may create a barrier that can’t be overcome. Such a hospital will face the very difficult decision of terminating the payments for ED call and redirecting that money to a hospitalist practice—something that is likely to lead to a lot of frustration on the part of PCPs who depend on the pay-for-call arrangement. A common outcome: no hospitalists.

An occasional reason hospitals are late to the hospitalist party is one or two (rarely more than that) of its private PCPs have simply chosen to work heroic amounts, and in addition to office and hospital care of their private patients, they accept referrals from other PCPs. I have met a number of doctors like this. Some are terrific doctors who actively participate in hospital initiatives; many appear chronically tired and harried, and hospital staff express frustration that they do things like make rounds at 3 a.m., take hours to respond to urgent calls, refuse to use protocols, etc. But because they’ve responded to the PCPs’ desire to be relieved of hospital work, other doctors may rally to their support and prevent the hospital from moving forward with a hospitalist program.

Will Every Hospital Have Hospitalists Eventually?

It is really interesting to think about whether every hospital, outside narrow specialty hospitals, will have hospitalists in the future. I wonder what informed people in the 1970s and early 1980s were predicting for emergency medicine’s future. At that point it probably wasn’t clear that, in the future, dedicated ED doctors essentially would staff every ED in the country, but I think that is exactly what has happened. (I once worked with an approximately 100-bed rural hospital that didn’t have ED physicians until 1999. I wonder if they were the last adopter.)

I think hospitalists are critically important for nearly all med-surg hospitals; however, maybe there will always be a small number that either have PCPs continue to practice in the traditional model, working both outpatient and inpatient, or some other effective configuration that makes hospitalists less necessary. We’ll have to wait and see. But I’m pretty confident

that almost no institutions that have hospitalists will ever return to the pre-hospitalist model of care. It seems there is no going back.

For those hospitals without hospitalists currently who will at some future time have hospitalists, the right time for this to happen is dependent on a combination of local factors. It could be something like the departure (i.e. relocation or retirement) of some of the current doctors, or simply the arrival of someone who has a vision and energy to successfully navigate the obstacles to build one. TH

Dr. Nelson has been a practicing hospitalist since 1988 and is co-founder and past president of SHM. He is a principal in Nelson Flores Hospital Medicine Consultants, a national hospitalist practice management consulting firm (www.nelsonflores.com). He is also course co-director and faculty for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. This column represents his views and is not intended to reflect an official position of SHM.</p>

I think 70% to 80% of U.S. hospitals now have a hospitalist practice. (Some have more than one hospitalist group operating within their walls.) I arrived at this estimate by relying on both my anecdotal experience and on the annual American Hospital Association survey, which in 2009 showed 58% of hospitals have hospitalists, with an ongoing rapid rate of adoption.

No regular reader of The Hospitalist should be surprised that most U.S. hospitals now have hospitalists, but some might be surprised that 20% to 30% don’t. There are about 5,800 hospitals in the U.S. (a ballpark figure), so that means about 1,100 to 1,800 don’t have hospitalists. What is unique about them?

For some hospitals, the answer is easy. For example, the U.S. has something like 450 psychiatric hospitals. They vary a lot, but many simply don’t accept patients with active medical problems, so these facilities would have little need for medical hospitalists.

Variations in how the term “hospitalist” is used probably account for some facilities reporting no hospitalists. For example, long-term acute-care hospitals (LTACs) might have dedicated inpatient providers but simply don’t call them hospitalists.

Even accounting for these things, there are still a lot of “med-surg” hospitals that say they don’t have hospitalists.

The Holdouts

My experience suggests the two most important reasons some hospitals have not yet developed a hospitalist practice are an oversupply of primary-care physicians (PCPs) and an attractive payor mix in the unassigned patient population. In fact, it is hard for me to imagine a hospital that enjoys both of these attributes ever being able to support hospitalists.

Although it isn’t a common problem, an excess of PCPs (or dearth of patients) removes the most universal and powerful stimulus to develop a hospitalist practice: the desire of PCPs to be relieved of hospital work. And in most cases, those PCPs can offset the loss of hospital work and its associated revenue, with more work in the office. This can mean a better lifestyle (e.g. no trips to the hospital on nights and weekends) and the same or higher income. But if there are too many PCPs in the community, they may be unwilling to give up the hospital work, as there might be no way to replace it in the office. End result: no hospitalists.

For the rare hospital that has an attractive ED-unassigned payor mix, PCPs are more likely to want to continue taking ED call and not support a proposal to develop a hospitalist practice. And access to the ED call roster can be important to new PCPs building a community practice. I have seen situations in which a hospital has addressed the poor reimbursement of unattached ED admissions by paying PCPs to provide that care. Even though that same hospital might want a hospitalist practice, the ED call payment it is providing to PCPs may create a barrier that can’t be overcome. Such a hospital will face the very difficult decision of terminating the payments for ED call and redirecting that money to a hospitalist practice—something that is likely to lead to a lot of frustration on the part of PCPs who depend on the pay-for-call arrangement. A common outcome: no hospitalists.

An occasional reason hospitals are late to the hospitalist party is one or two (rarely more than that) of its private PCPs have simply chosen to work heroic amounts, and in addition to office and hospital care of their private patients, they accept referrals from other PCPs. I have met a number of doctors like this. Some are terrific doctors who actively participate in hospital initiatives; many appear chronically tired and harried, and hospital staff express frustration that they do things like make rounds at 3 a.m., take hours to respond to urgent calls, refuse to use protocols, etc. But because they’ve responded to the PCPs’ desire to be relieved of hospital work, other doctors may rally to their support and prevent the hospital from moving forward with a hospitalist program.

Will Every Hospital Have Hospitalists Eventually?

It is really interesting to think about whether every hospital, outside narrow specialty hospitals, will have hospitalists in the future. I wonder what informed people in the 1970s and early 1980s were predicting for emergency medicine’s future. At that point it probably wasn’t clear that, in the future, dedicated ED doctors essentially would staff every ED in the country, but I think that is exactly what has happened. (I once worked with an approximately 100-bed rural hospital that didn’t have ED physicians until 1999. I wonder if they were the last adopter.)

I think hospitalists are critically important for nearly all med-surg hospitals; however, maybe there will always be a small number that either have PCPs continue to practice in the traditional model, working both outpatient and inpatient, or some other effective configuration that makes hospitalists less necessary. We’ll have to wait and see. But I’m pretty confident

that almost no institutions that have hospitalists will ever return to the pre-hospitalist model of care. It seems there is no going back.

For those hospitals without hospitalists currently who will at some future time have hospitalists, the right time for this to happen is dependent on a combination of local factors. It could be something like the departure (i.e. relocation or retirement) of some of the current doctors, or simply the arrival of someone who has a vision and energy to successfully navigate the obstacles to build one. TH

Dr. Nelson has been a practicing hospitalist since 1988 and is co-founder and past president of SHM. He is a principal in Nelson Flores Hospital Medicine Consultants, a national hospitalist practice management consulting firm (www.nelsonflores.com). He is also course co-director and faculty for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. This column represents his views and is not intended to reflect an official position of SHM.</p>

I think 70% to 80% of U.S. hospitals now have a hospitalist practice. (Some have more than one hospitalist group operating within their walls.) I arrived at this estimate by relying on both my anecdotal experience and on the annual American Hospital Association survey, which in 2009 showed 58% of hospitals have hospitalists, with an ongoing rapid rate of adoption.

No regular reader of The Hospitalist should be surprised that most U.S. hospitals now have hospitalists, but some might be surprised that 20% to 30% don’t. There are about 5,800 hospitals in the U.S. (a ballpark figure), so that means about 1,100 to 1,800 don’t have hospitalists. What is unique about them?

For some hospitals, the answer is easy. For example, the U.S. has something like 450 psychiatric hospitals. They vary a lot, but many simply don’t accept patients with active medical problems, so these facilities would have little need for medical hospitalists.

Variations in how the term “hospitalist” is used probably account for some facilities reporting no hospitalists. For example, long-term acute-care hospitals (LTACs) might have dedicated inpatient providers but simply don’t call them hospitalists.

Even accounting for these things, there are still a lot of “med-surg” hospitals that say they don’t have hospitalists.

The Holdouts

My experience suggests the two most important reasons some hospitals have not yet developed a hospitalist practice are an oversupply of primary-care physicians (PCPs) and an attractive payor mix in the unassigned patient population. In fact, it is hard for me to imagine a hospital that enjoys both of these attributes ever being able to support hospitalists.

Although it isn’t a common problem, an excess of PCPs (or dearth of patients) removes the most universal and powerful stimulus to develop a hospitalist practice: the desire of PCPs to be relieved of hospital work. And in most cases, those PCPs can offset the loss of hospital work and its associated revenue, with more work in the office. This can mean a better lifestyle (e.g. no trips to the hospital on nights and weekends) and the same or higher income. But if there are too many PCPs in the community, they may be unwilling to give up the hospital work, as there might be no way to replace it in the office. End result: no hospitalists.

For the rare hospital that has an attractive ED-unassigned payor mix, PCPs are more likely to want to continue taking ED call and not support a proposal to develop a hospitalist practice. And access to the ED call roster can be important to new PCPs building a community practice. I have seen situations in which a hospital has addressed the poor reimbursement of unattached ED admissions by paying PCPs to provide that care. Even though that same hospital might want a hospitalist practice, the ED call payment it is providing to PCPs may create a barrier that can’t be overcome. Such a hospital will face the very difficult decision of terminating the payments for ED call and redirecting that money to a hospitalist practice—something that is likely to lead to a lot of frustration on the part of PCPs who depend on the pay-for-call arrangement. A common outcome: no hospitalists.

An occasional reason hospitals are late to the hospitalist party is one or two (rarely more than that) of its private PCPs have simply chosen to work heroic amounts, and in addition to office and hospital care of their private patients, they accept referrals from other PCPs. I have met a number of doctors like this. Some are terrific doctors who actively participate in hospital initiatives; many appear chronically tired and harried, and hospital staff express frustration that they do things like make rounds at 3 a.m., take hours to respond to urgent calls, refuse to use protocols, etc. But because they’ve responded to the PCPs’ desire to be relieved of hospital work, other doctors may rally to their support and prevent the hospital from moving forward with a hospitalist program.

Will Every Hospital Have Hospitalists Eventually?

It is really interesting to think about whether every hospital, outside narrow specialty hospitals, will have hospitalists in the future. I wonder what informed people in the 1970s and early 1980s were predicting for emergency medicine’s future. At that point it probably wasn’t clear that, in the future, dedicated ED doctors essentially would staff every ED in the country, but I think that is exactly what has happened. (I once worked with an approximately 100-bed rural hospital that didn’t have ED physicians until 1999. I wonder if they were the last adopter.)

I think hospitalists are critically important for nearly all med-surg hospitals; however, maybe there will always be a small number that either have PCPs continue to practice in the traditional model, working both outpatient and inpatient, or some other effective configuration that makes hospitalists less necessary. We’ll have to wait and see. But I’m pretty confident

that almost no institutions that have hospitalists will ever return to the pre-hospitalist model of care. It seems there is no going back.

For those hospitals without hospitalists currently who will at some future time have hospitalists, the right time for this to happen is dependent on a combination of local factors. It could be something like the departure (i.e. relocation or retirement) of some of the current doctors, or simply the arrival of someone who has a vision and energy to successfully navigate the obstacles to build one. TH

Dr. Nelson has been a practicing hospitalist since 1988 and is co-founder and past president of SHM. He is a principal in Nelson Flores Hospital Medicine Consultants, a national hospitalist practice management consulting firm (www.nelsonflores.com). He is also course co-director and faculty for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. This column represents his views and is not intended to reflect an official position of SHM.</p>

Dr. Sali, the resident, asks his attending: Dr. Biba, are you saying that you can tell if a patient has marital problems in the first 5 minutes of an interview?

Dr. Biba: Yes. In fact, Jill Hooley says that you just need to ask one question of a patient: "How critical is your spouse of you?"

Dr. Sali: Okay, so I asked Jeanie "the Critical Question" at our first meeting. She said yes. Now what?

Dr. Biba: Now you bring in the husband and try to understand what is going on.

A week later:

Dr. Sali: So I met with Jeanie and her husband. He started right in with "So what’s wrong with my wife?" When I explained about depression, he said "What do you mean she’s depressed? She’s never said that before! Jeanie, why are you saying this stuff? Don’t you want to go to work?"

Dr. Biba: Wow, that sounds bad. What did you do then?

Dr. Sali: I explained some more about depression, all its symptoms and signs. I asked the husband to listen and said that we needed to work together to help Jeanie. Then he said, "That’s how her mother was!" He completely changed! He still was a bit agitated but he was okay and said, "So, let’s get this illness treated!" I am not sure I trust his quick change, but at least he has some idea of what needs to be done.

Dr. Biba: What did you tell him he needs to do?

Dr. Sali: I didn’t know what to tell him. I gave him a handout about depression and families that I found on the Internet. Can you meet with them and me next week?

High criticalness in families is often tied to a lack of understanding about illness. In the scenario described above, the patient’s husband thought he was being a good husband by standing tough with his wife. His intentions were good, but he did not understand the extent to which depression impairs energy and motivation.

High criticalness is a component of the concept of expressed emotion (EE), a robust research construct in family psychiatry. High levels of EE are found in patient-family interactions when patients relapse sooner and more frequently. EE was first described with schizophrenia, but high EE is associated with early relapse in many other psychiatric and medical illnesses (Arch. Gen. Psychiatry 1998;55:547-52).

EE consists of three components: criticalness, overt hostility, and emotional overinvolvement. It originally was measured with the 2-hour Camberwell Family Interview ("Expressed Emotion in Families." New York: Guilford Press, 1985). But shorter tools now exist, such as the critical question conceptualized by Jill Hooley, D.Phil., and the Five-Minute Speech Sample (FMSS). The FMSS consists of asking a family member to speak freely about the patient’s character and their relationships, without disturbance from the interviewer, for 5 minutes (Psychiatry Res. 1986;17:203-12).

Dr. Hooley measured marital distress and patients’ perceptions of criticism from spouses in hospitalized patients with major depression. EE and marital distress predicted the same relapse rates at 9 months. However, a patient’s response to the question, "How critical is your spouse of you?" accounted for more of the variance in relapse rates than did EE and marital distress combined (J. Abnorm. Psychol. 1989;98:229-35).

The good news is that EE is reduced with psychoeducational family interventions. In addition, many interventions that reduce EE are evidence based, and are effective across many illnesses and cultures. For example, a recent study of a family work intervention in Catalonia, Spain, found improvements in the clinical status as well as global and social functioning of patients with schizophrenia (Int. J. Soc. Psychiatry 2011 Aug. 1 [doi:10.1177/00207640114155]).

Dr. Julian Leff, one of the social psychiatrists who delineated EE, is still hard at work reducing EE, this time in the auditory hallucination of patients with schizophrenia in a new therapy called Avatar Therapy for people with persistent auditory hallucinations (Department of Psychiatry Grand Rounds, University of Colorado at Denver, Oct. 19, 2011).

Dr. Sali, the resident, asks his attending: Dr. Biba, are you saying that you can tell if a patient has marital problems in the first 5 minutes of an interview?

Dr. Biba: Yes. In fact, Jill Hooley says that you just need to ask one question of a patient: "How critical is your spouse of you?"

Dr. Sali: Okay, so I asked Jeanie "the Critical Question" at our first meeting. She said yes. Now what?

Dr. Biba: Now you bring in the husband and try to understand what is going on.

A week later:

Dr. Sali: So I met with Jeanie and her husband. He started right in with "So what’s wrong with my wife?" When I explained about depression, he said "What do you mean she’s depressed? She’s never said that before! Jeanie, why are you saying this stuff? Don’t you want to go to work?"

Dr. Biba: Wow, that sounds bad. What did you do then?

Dr. Sali: I explained some more about depression, all its symptoms and signs. I asked the husband to listen and said that we needed to work together to help Jeanie. Then he said, "That’s how her mother was!" He completely changed! He still was a bit agitated but he was okay and said, "So, let’s get this illness treated!" I am not sure I trust his quick change, but at least he has some idea of what needs to be done.

Dr. Biba: What did you tell him he needs to do?

Dr. Sali: I didn’t know what to tell him. I gave him a handout about depression and families that I found on the Internet. Can you meet with them and me next week?

High criticalness in families is often tied to a lack of understanding about illness. In the scenario described above, the patient’s husband thought he was being a good husband by standing tough with his wife. His intentions were good, but he did not understand the extent to which depression impairs energy and motivation.

High criticalness is a component of the concept of expressed emotion (EE), a robust research construct in family psychiatry. High levels of EE are found in patient-family interactions when patients relapse sooner and more frequently. EE was first described with schizophrenia, but high EE is associated with early relapse in many other psychiatric and medical illnesses (Arch. Gen. Psychiatry 1998;55:547-52).

EE consists of three components: criticalness, overt hostility, and emotional overinvolvement. It originally was measured with the 2-hour Camberwell Family Interview ("Expressed Emotion in Families." New York: Guilford Press, 1985). But shorter tools now exist, such as the critical question conceptualized by Jill Hooley, D.Phil., and the Five-Minute Speech Sample (FMSS). The FMSS consists of asking a family member to speak freely about the patient’s character and their relationships, without disturbance from the interviewer, for 5 minutes (Psychiatry Res. 1986;17:203-12).

Dr. Hooley measured marital distress and patients’ perceptions of criticism from spouses in hospitalized patients with major depression. EE and marital distress predicted the same relapse rates at 9 months. However, a patient’s response to the question, "How critical is your spouse of you?" accounted for more of the variance in relapse rates than did EE and marital distress combined (J. Abnorm. Psychol. 1989;98:229-35).

The good news is that EE is reduced with psychoeducational family interventions. In addition, many interventions that reduce EE are evidence based, and are effective across many illnesses and cultures. For example, a recent study of a family work intervention in Catalonia, Spain, found improvements in the clinical status as well as global and social functioning of patients with schizophrenia (Int. J. Soc. Psychiatry 2011 Aug. 1 [doi:10.1177/00207640114155]).

Dr. Julian Leff, one of the social psychiatrists who delineated EE, is still hard at work reducing EE, this time in the auditory hallucination of patients with schizophrenia in a new therapy called Avatar Therapy for people with persistent auditory hallucinations (Department of Psychiatry Grand Rounds, University of Colorado at Denver, Oct. 19, 2011).

Dr. Sali, the resident, asks his attending: Dr. Biba, are you saying that you can tell if a patient has marital problems in the first 5 minutes of an interview?

Dr. Biba: Yes. In fact, Jill Hooley says that you just need to ask one question of a patient: "How critical is your spouse of you?"

Dr. Sali: Okay, so I asked Jeanie "the Critical Question" at our first meeting. She said yes. Now what?

Dr. Biba: Now you bring in the husband and try to understand what is going on.

A week later:

Dr. Sali: So I met with Jeanie and her husband. He started right in with "So what’s wrong with my wife?" When I explained about depression, he said "What do you mean she’s depressed? She’s never said that before! Jeanie, why are you saying this stuff? Don’t you want to go to work?"

Dr. Biba: Wow, that sounds bad. What did you do then?

Dr. Sali: I explained some more about depression, all its symptoms and signs. I asked the husband to listen and said that we needed to work together to help Jeanie. Then he said, "That’s how her mother was!" He completely changed! He still was a bit agitated but he was okay and said, "So, let’s get this illness treated!" I am not sure I trust his quick change, but at least he has some idea of what needs to be done.

Dr. Biba: What did you tell him he needs to do?

Dr. Sali: I didn’t know what to tell him. I gave him a handout about depression and families that I found on the Internet. Can you meet with them and me next week?

High criticalness in families is often tied to a lack of understanding about illness. In the scenario described above, the patient’s husband thought he was being a good husband by standing tough with his wife. His intentions were good, but he did not understand the extent to which depression impairs energy and motivation.

High criticalness is a component of the concept of expressed emotion (EE), a robust research construct in family psychiatry. High levels of EE are found in patient-family interactions when patients relapse sooner and more frequently. EE was first described with schizophrenia, but high EE is associated with early relapse in many other psychiatric and medical illnesses (Arch. Gen. Psychiatry 1998;55:547-52).

EE consists of three components: criticalness, overt hostility, and emotional overinvolvement. It originally was measured with the 2-hour Camberwell Family Interview ("Expressed Emotion in Families." New York: Guilford Press, 1985). But shorter tools now exist, such as the critical question conceptualized by Jill Hooley, D.Phil., and the Five-Minute Speech Sample (FMSS). The FMSS consists of asking a family member to speak freely about the patient’s character and their relationships, without disturbance from the interviewer, for 5 minutes (Psychiatry Res. 1986;17:203-12).

Dr. Hooley measured marital distress and patients’ perceptions of criticism from spouses in hospitalized patients with major depression. EE and marital distress predicted the same relapse rates at 9 months. However, a patient’s response to the question, "How critical is your spouse of you?" accounted for more of the variance in relapse rates than did EE and marital distress combined (J. Abnorm. Psychol. 1989;98:229-35).

The good news is that EE is reduced with psychoeducational family interventions. In addition, many interventions that reduce EE are evidence based, and are effective across many illnesses and cultures. For example, a recent study of a family work intervention in Catalonia, Spain, found improvements in the clinical status as well as global and social functioning of patients with schizophrenia (Int. J. Soc. Psychiatry 2011 Aug. 1 [doi:10.1177/00207640114155]).

Dr. Julian Leff, one of the social psychiatrists who delineated EE, is still hard at work reducing EE, this time in the auditory hallucination of patients with schizophrenia in a new therapy called Avatar Therapy for people with persistent auditory hallucinations (Department of Psychiatry Grand Rounds, University of Colorado at Denver, Oct. 19, 2011).

When you first observe or suspect an infant has hypotonia, you face a decision whether the condition is benign and likely to resolve over time vs. a more serious condition with an important neurologic basis.

You will be in a position to make that call in many cases in your practice. Related observations include spontaneous movement during a physical examination; basic laboratory testing; and any relevant family history of genetic-based disease. These can go a long way to guide your diagnosis. Any abnormality in growth, feeding patterns, or respiration also provides important clinical clues.

Pediatricians, depending on their experience, can determine when a "wait and watch" approach is appropriate. For example, benign hypotonia is more likely when there are no major delays in growth or motor milestones, no signs of abnormal respiration, and parents report normal feeding patterns.

Since we cannot test the strength of a 7- or 8-month-old infant by asking them to offer resistance with their arms and legs, it’s useful to observe the amount and quality of their spontaneous movements. Watch their head control when you pull the infant to sit from a supine position. Does the head lag behind at all? How vigorously does the infant kick or grasp? These signs can help examiners compare impressions of degree of weakness, if there is any, in hypotonic infants.

Parents may be unaware of any low muscle tone, so it’s important to include hypotonia on your physical examination checklist.

Ask parents about the strength of the infant during diaper or clothing changes. Often parents have a good sense of the amount of force their child displays, and it can be reassuring to make these observations in the examination room as well.

An infant with a benign form of congenital hypotonia will move her arms and legs frequently: batting, roving, and sometimes synchronous movements come and go depending on level of alertness. In contrast, an infant with hypotonia caused by a neurologic disease, such as spinal muscle atrophy, will move much less frequently and the initiation of the movement(s) is slower.

In some cases, the degree or cause of hypotonia may not be clear, and the question becomes what to do with that uncertainty. A creatine phosphokinase (CPK) assay, the most common initial laboratory test to assess low muscle tone, can be helpful, although a normal result doesn’t rule out muscle or nerve disease.

In addition, check the baby’s respiratory rate and listen for any stridor or other signs of obstruction in her breathing. Noisy breathing can suggest upper respiratory muscle involvement, in which case further work-up is warranted. How’s the head growth over time?

Testing deep tendon reflexes can be tricky. While the presence of reflexes is reassuring, absence suggests a peripheral nerve problem or anterior horn cell disease.

Ask parents about the baby’s typical feeding pattern. An infant that seems to take a long time to feed and/or has an interrupted pattern of feeding should raise your clinical suspicion about an important neurologic cause for their hypotonia.

Family history can be an independent risk factor for a more serious, inherited neurologic etiology. Many of the causes of hypotonia are genetic, and specialist input will be appropriate if you uncover relevant family history. Inquire about any first-degree relative or others with an inherited neurologic condition that could underlie the infant’s hypotonia. In some cases, a non-neurologic inherited disease such as Marfan syndrome can cause hypotonia as well.

Specialist input is indicated if you suspect a genetic basis for the hypotonia, even if the infant passes the other important elements of your evaluation (for example, normal milestones, eating, and breathing).

These patients are a pretty diverse group, and there are many infants with hypotonia who will ultimately do well. If you are unsure, it’s definitely worth tracking these patients a little closer using history and physical examination checklists. Check in with a specialist if you continue to be unsure as you move forward.

Dr. Bingham is a pediatric neurologist at Fletcher Allen Health Care and associate professor of neurology at the University of Vermont in Burlington. Dr. Bingham said he had no relevant financial disclosures. 

When you first observe or suspect an infant has hypotonia, you face a decision whether the condition is benign and likely to resolve over time vs. a more serious condition with an important neurologic basis.

You will be in a position to make that call in many cases in your practice. Related observations include spontaneous movement during a physical examination; basic laboratory testing; and any relevant family history of genetic-based disease. These can go a long way to guide your diagnosis. Any abnormality in growth, feeding patterns, or respiration also provides important clinical clues.

Pediatricians, depending on their experience, can determine when a "wait and watch" approach is appropriate. For example, benign hypotonia is more likely when there are no major delays in growth or motor milestones, no signs of abnormal respiration, and parents report normal feeding patterns.

Since we cannot test the strength of a 7- or 8-month-old infant by asking them to offer resistance with their arms and legs, it’s useful to observe the amount and quality of their spontaneous movements. Watch their head control when you pull the infant to sit from a supine position. Does the head lag behind at all? How vigorously does the infant kick or grasp? These signs can help examiners compare impressions of degree of weakness, if there is any, in hypotonic infants.

Parents may be unaware of any low muscle tone, so it’s important to include hypotonia on your physical examination checklist.

Ask parents about the strength of the infant during diaper or clothing changes. Often parents have a good sense of the amount of force their child displays, and it can be reassuring to make these observations in the examination room as well.

An infant with a benign form of congenital hypotonia will move her arms and legs frequently: batting, roving, and sometimes synchronous movements come and go depending on level of alertness. In contrast, an infant with hypotonia caused by a neurologic disease, such as spinal muscle atrophy, will move much less frequently and the initiation of the movement(s) is slower.

In some cases, the degree or cause of hypotonia may not be clear, and the question becomes what to do with that uncertainty. A creatine phosphokinase (CPK) assay, the most common initial laboratory test to assess low muscle tone, can be helpful, although a normal result doesn’t rule out muscle or nerve disease.

In addition, check the baby’s respiratory rate and listen for any stridor or other signs of obstruction in her breathing. Noisy breathing can suggest upper respiratory muscle involvement, in which case further work-up is warranted. How’s the head growth over time?

Testing deep tendon reflexes can be tricky. While the presence of reflexes is reassuring, absence suggests a peripheral nerve problem or anterior horn cell disease.

Ask parents about the baby’s typical feeding pattern. An infant that seems to take a long time to feed and/or has an interrupted pattern of feeding should raise your clinical suspicion about an important neurologic cause for their hypotonia.

Family history can be an independent risk factor for a more serious, inherited neurologic etiology. Many of the causes of hypotonia are genetic, and specialist input will be appropriate if you uncover relevant family history. Inquire about any first-degree relative or others with an inherited neurologic condition that could underlie the infant’s hypotonia. In some cases, a non-neurologic inherited disease such as Marfan syndrome can cause hypotonia as well.

Specialist input is indicated if you suspect a genetic basis for the hypotonia, even if the infant passes the other important elements of your evaluation (for example, normal milestones, eating, and breathing).

These patients are a pretty diverse group, and there are many infants with hypotonia who will ultimately do well. If you are unsure, it’s definitely worth tracking these patients a little closer using history and physical examination checklists. Check in with a specialist if you continue to be unsure as you move forward.

Dr. Bingham is a pediatric neurologist at Fletcher Allen Health Care and associate professor of neurology at the University of Vermont in Burlington. Dr. Bingham said he had no relevant financial disclosures. 

When you first observe or suspect an infant has hypotonia, you face a decision whether the condition is benign and likely to resolve over time vs. a more serious condition with an important neurologic basis.

You will be in a position to make that call in many cases in your practice. Related observations include spontaneous movement during a physical examination; basic laboratory testing; and any relevant family history of genetic-based disease. These can go a long way to guide your diagnosis. Any abnormality in growth, feeding patterns, or respiration also provides important clinical clues.

Pediatricians, depending on their experience, can determine when a "wait and watch" approach is appropriate. For example, benign hypotonia is more likely when there are no major delays in growth or motor milestones, no signs of abnormal respiration, and parents report normal feeding patterns.

Since we cannot test the strength of a 7- or 8-month-old infant by asking them to offer resistance with their arms and legs, it’s useful to observe the amount and quality of their spontaneous movements. Watch their head control when you pull the infant to sit from a supine position. Does the head lag behind at all? How vigorously does the infant kick or grasp? These signs can help examiners compare impressions of degree of weakness, if there is any, in hypotonic infants.

Parents may be unaware of any low muscle tone, so it’s important to include hypotonia on your physical examination checklist.

Ask parents about the strength of the infant during diaper or clothing changes. Often parents have a good sense of the amount of force their child displays, and it can be reassuring to make these observations in the examination room as well.

An infant with a benign form of congenital hypotonia will move her arms and legs frequently: batting, roving, and sometimes synchronous movements come and go depending on level of alertness. In contrast, an infant with hypotonia caused by a neurologic disease, such as spinal muscle atrophy, will move much less frequently and the initiation of the movement(s) is slower.

In some cases, the degree or cause of hypotonia may not be clear, and the question becomes what to do with that uncertainty. A creatine phosphokinase (CPK) assay, the most common initial laboratory test to assess low muscle tone, can be helpful, although a normal result doesn’t rule out muscle or nerve disease.

In addition, check the baby’s respiratory rate and listen for any stridor or other signs of obstruction in her breathing. Noisy breathing can suggest upper respiratory muscle involvement, in which case further work-up is warranted. How’s the head growth over time?

Testing deep tendon reflexes can be tricky. While the presence of reflexes is reassuring, absence suggests a peripheral nerve problem or anterior horn cell disease.

Ask parents about the baby’s typical feeding pattern. An infant that seems to take a long time to feed and/or has an interrupted pattern of feeding should raise your clinical suspicion about an important neurologic cause for their hypotonia.

Family history can be an independent risk factor for a more serious, inherited neurologic etiology. Many of the causes of hypotonia are genetic, and specialist input will be appropriate if you uncover relevant family history. Inquire about any first-degree relative or others with an inherited neurologic condition that could underlie the infant’s hypotonia. In some cases, a non-neurologic inherited disease such as Marfan syndrome can cause hypotonia as well.

Specialist input is indicated if you suspect a genetic basis for the hypotonia, even if the infant passes the other important elements of your evaluation (for example, normal milestones, eating, and breathing).

These patients are a pretty diverse group, and there are many infants with hypotonia who will ultimately do well. If you are unsure, it’s definitely worth tracking these patients a little closer using history and physical examination checklists. Check in with a specialist if you continue to be unsure as you move forward.

Dr. Bingham is a pediatric neurologist at Fletcher Allen Health Care and associate professor of neurology at the University of Vermont in Burlington. Dr. Bingham said he had no relevant financial disclosures. 

PARIS – Elderly patients with multiple myeloma and severe comorbid disease are more than twice as likely to die as were those with no comorbidities, data from a single-center, retrospective study show.

Mild or moderate comorbidities did not appear to influence overall survival significantly in the 179-patient study. The hazard ratio (HR) for death in patients with severe comorbidity vs. none was 2.36 (P = .01), which was associated with a median overall survival of 15.1 months.

Median overall survival was 43.1 months for those with no comorbidities and 31.5 and 35 months, respectively, in those with mild (HR, 1.38; P = .26) or moderate (HR, 1.5; P = .19) comorbidities.

"The severity of comorbidities is associated with poorer survival in older adults with multiple myeloma," said lead author Dr. Tanya M. Wildes of Washington University in St. Louis.

Nevertheless, comorbidities are not currently incorporated into any staging systems for the disease, Dr. Wildes observed in an interview at the annual meeting of the International Society of Geriatric Oncology.

The research is part of a wider project that is looking at the value of performing a geriatric assessment to help predict which elderly patients with hematological malignancies may be able to undergo standard cancer treatment, or require additional monitoring for adverse events, or more supportive care.

"The severity of comorbidities is associated with poorer survival in older adults with multiple myeloma."

In the current study, Dr. Wildes and her colleagues identified all patients who were diagnosed and treated for multiple myeloma at Barnes-Jewish Hospital, St. Louis, between January 2000 and March 2010. Demographic, clinical, and survival data were obtained, with concomitant conditions graded using the Adult Comorbidity Evaluation (ACE) 27 index as none, mild, moderate, or severe.

The primary end point of the study was overall survival, the duration of which was calculated from the date of diagnosis until the time of last follow-up.

The median age of patients at baseline was 69 years (range, 65-91 years). There was a similar percentage of men (48.4%) and women (51.4%), and 75% of the population was white. Most of the remainder were black (23.5%).

According to the ACE-27 index, 41.3% of patients had mild, 24.6% had moderate, and 15.6% had severe comorbidities. The remaining 18.5% had no comorbidities.

"The challenge with multiple myeloma is that some of the comorbidities may be disease related as opposed to patient’s underlying comorbidities," Dr. Wildes noted. That would require reviewing the patients’ medical records, which was not done in the current evaluation of this data set but is something that the researchers plan on looking at next.

"These are hypothesis-generating data at the moment," Dr. Wildes said. Further study, to evaluate the impact of comorbidities on survival in multiple myeloma and their influence on patients’ tolerance of therapy and treatment decisions, is needed.

"On average, three comorbidities can be expected in a patient [aged] 65 years and older," said Dr. Lazzaro Repetto of the Istituto Nazionale di Riposo e Cura per Anziani at the Istituto di Ricovero e Cura a Carattere Scientifico in Rome.

Speaking at separate session during the meeting, Dr. Repetto said common comorbidities in elderly cancer patients included cardiovascular disease, renal insufficiency, diabetes, dementia, depression, anemia, osteoporosis, arthritis and arthrosis, and chronic obstructive pulmonary disease. All of these may have an impact on survival.

Indeed, other research presented by a Danish team showed that colorectal and lung cancers in particular were associated with a high number of comorbidities when compared with the general elderly population. A high comorbidity burden was also linked to reduced overall survival, but only in those with lung cancer, reported Dr. Trine Lembrecht Jørgensen of Odense (Denmark) University Hospital and associates.

The presence of comorbidities can alter treatment decisions, influencing the type of treatment offered, said Dr. Repetto. However, although assessing comorbid disease is important, it should always be part of a wider geriatric assessment, he advised. This should include measures of cognition, emotional and physical functioning, medication use, socioeconomic and social support factors, and the patient’s wishes.

"Using the geriatric assessment we can personalize treatment, and optimize the balance between benefit and risk of our decisions," Dr. Repetto suggested.

Dr. Wildes’ research was supported by a grant from the U.S. National Cancer Institute. Dr. Wildes and Dr. Repetto had no conflicts of interest.

PARIS – Elderly patients with multiple myeloma and severe comorbid disease are more than twice as likely to die as were those with no comorbidities, data from a single-center, retrospective study show.

Mild or moderate comorbidities did not appear to influence overall survival significantly in the 179-patient study. The hazard ratio (HR) for death in patients with severe comorbidity vs. none was 2.36 (P = .01), which was associated with a median overall survival of 15.1 months.

Median overall survival was 43.1 months for those with no comorbidities and 31.5 and 35 months, respectively, in those with mild (HR, 1.38; P = .26) or moderate (HR, 1.5; P = .19) comorbidities.

"The severity of comorbidities is associated with poorer survival in older adults with multiple myeloma," said lead author Dr. Tanya M. Wildes of Washington University in St. Louis.

Nevertheless, comorbidities are not currently incorporated into any staging systems for the disease, Dr. Wildes observed in an interview at the annual meeting of the International Society of Geriatric Oncology.

The research is part of a wider project that is looking at the value of performing a geriatric assessment to help predict which elderly patients with hematological malignancies may be able to undergo standard cancer treatment, or require additional monitoring for adverse events, or more supportive care.

"The severity of comorbidities is associated with poorer survival in older adults with multiple myeloma."

In the current study, Dr. Wildes and her colleagues identified all patients who were diagnosed and treated for multiple myeloma at Barnes-Jewish Hospital, St. Louis, between January 2000 and March 2010. Demographic, clinical, and survival data were obtained, with concomitant conditions graded using the Adult Comorbidity Evaluation (ACE) 27 index as none, mild, moderate, or severe.

The primary end point of the study was overall survival, the duration of which was calculated from the date of diagnosis until the time of last follow-up.

The median age of patients at baseline was 69 years (range, 65-91 years). There was a similar percentage of men (48.4%) and women (51.4%), and 75% of the population was white. Most of the remainder were black (23.5%).

According to the ACE-27 index, 41.3% of patients had mild, 24.6% had moderate, and 15.6% had severe comorbidities. The remaining 18.5% had no comorbidities.

"The challenge with multiple myeloma is that some of the comorbidities may be disease related as opposed to patient’s underlying comorbidities," Dr. Wildes noted. That would require reviewing the patients’ medical records, which was not done in the current evaluation of this data set but is something that the researchers plan on looking at next.

"These are hypothesis-generating data at the moment," Dr. Wildes said. Further study, to evaluate the impact of comorbidities on survival in multiple myeloma and their influence on patients’ tolerance of therapy and treatment decisions, is needed.

"On average, three comorbidities can be expected in a patient [aged] 65 years and older," said Dr. Lazzaro Repetto of the Istituto Nazionale di Riposo e Cura per Anziani at the Istituto di Ricovero e Cura a Carattere Scientifico in Rome.

Speaking at separate session during the meeting, Dr. Repetto said common comorbidities in elderly cancer patients included cardiovascular disease, renal insufficiency, diabetes, dementia, depression, anemia, osteoporosis, arthritis and arthrosis, and chronic obstructive pulmonary disease. All of these may have an impact on survival.

Indeed, other research presented by a Danish team showed that colorectal and lung cancers in particular were associated with a high number of comorbidities when compared with the general elderly population. A high comorbidity burden was also linked to reduced overall survival, but only in those with lung cancer, reported Dr. Trine Lembrecht Jørgensen of Odense (Denmark) University Hospital and associates.

The presence of comorbidities can alter treatment decisions, influencing the type of treatment offered, said Dr. Repetto. However, although assessing comorbid disease is important, it should always be part of a wider geriatric assessment, he advised. This should include measures of cognition, emotional and physical functioning, medication use, socioeconomic and social support factors, and the patient’s wishes.

"Using the geriatric assessment we can personalize treatment, and optimize the balance between benefit and risk of our decisions," Dr. Repetto suggested.

Dr. Wildes’ research was supported by a grant from the U.S. National Cancer Institute. Dr. Wildes and Dr. Repetto had no conflicts of interest.

PARIS – Elderly patients with multiple myeloma and severe comorbid disease are more than twice as likely to die as were those with no comorbidities, data from a single-center, retrospective study show.

Mild or moderate comorbidities did not appear to influence overall survival significantly in the 179-patient study. The hazard ratio (HR) for death in patients with severe comorbidity vs. none was 2.36 (P = .01), which was associated with a median overall survival of 15.1 months.

Median overall survival was 43.1 months for those with no comorbidities and 31.5 and 35 months, respectively, in those with mild (HR, 1.38; P = .26) or moderate (HR, 1.5; P = .19) comorbidities.

"The severity of comorbidities is associated with poorer survival in older adults with multiple myeloma," said lead author Dr. Tanya M. Wildes of Washington University in St. Louis.

Nevertheless, comorbidities are not currently incorporated into any staging systems for the disease, Dr. Wildes observed in an interview at the annual meeting of the International Society of Geriatric Oncology.

The research is part of a wider project that is looking at the value of performing a geriatric assessment to help predict which elderly patients with hematological malignancies may be able to undergo standard cancer treatment, or require additional monitoring for adverse events, or more supportive care.

"The severity of comorbidities is associated with poorer survival in older adults with multiple myeloma."

In the current study, Dr. Wildes and her colleagues identified all patients who were diagnosed and treated for multiple myeloma at Barnes-Jewish Hospital, St. Louis, between January 2000 and March 2010. Demographic, clinical, and survival data were obtained, with concomitant conditions graded using the Adult Comorbidity Evaluation (ACE) 27 index as none, mild, moderate, or severe.

The primary end point of the study was overall survival, the duration of which was calculated from the date of diagnosis until the time of last follow-up.

The median age of patients at baseline was 69 years (range, 65-91 years). There was a similar percentage of men (48.4%) and women (51.4%), and 75% of the population was white. Most of the remainder were black (23.5%).

According to the ACE-27 index, 41.3% of patients had mild, 24.6% had moderate, and 15.6% had severe comorbidities. The remaining 18.5% had no comorbidities.

"The challenge with multiple myeloma is that some of the comorbidities may be disease related as opposed to patient’s underlying comorbidities," Dr. Wildes noted. That would require reviewing the patients’ medical records, which was not done in the current evaluation of this data set but is something that the researchers plan on looking at next.

"These are hypothesis-generating data at the moment," Dr. Wildes said. Further study, to evaluate the impact of comorbidities on survival in multiple myeloma and their influence on patients’ tolerance of therapy and treatment decisions, is needed.

"On average, three comorbidities can be expected in a patient [aged] 65 years and older," said Dr. Lazzaro Repetto of the Istituto Nazionale di Riposo e Cura per Anziani at the Istituto di Ricovero e Cura a Carattere Scientifico in Rome.

Speaking at separate session during the meeting, Dr. Repetto said common comorbidities in elderly cancer patients included cardiovascular disease, renal insufficiency, diabetes, dementia, depression, anemia, osteoporosis, arthritis and arthrosis, and chronic obstructive pulmonary disease. All of these may have an impact on survival.

Indeed, other research presented by a Danish team showed that colorectal and lung cancers in particular were associated with a high number of comorbidities when compared with the general elderly population. A high comorbidity burden was also linked to reduced overall survival, but only in those with lung cancer, reported Dr. Trine Lembrecht Jørgensen of Odense (Denmark) University Hospital and associates.

The presence of comorbidities can alter treatment decisions, influencing the type of treatment offered, said Dr. Repetto. However, although assessing comorbid disease is important, it should always be part of a wider geriatric assessment, he advised. This should include measures of cognition, emotional and physical functioning, medication use, socioeconomic and social support factors, and the patient’s wishes.

"Using the geriatric assessment we can personalize treatment, and optimize the balance between benefit and risk of our decisions," Dr. Repetto suggested.

Dr. Wildes’ research was supported by a grant from the U.S. National Cancer Institute. Dr. Wildes and Dr. Repetto had no conflicts of interest.

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