AMSTERDAM – Video-assisted thoracoscopic surgery worked as well as open lobectomy for 5-year survival in early-stage lung cancer, based on a secondary analysis of nonrandomized patients who underwent surgery as part of a multicenter trial.

"These data demonstrate that VATS, when properly done, can achieve long-term survival that is similar to open lobectomy," Dr. Walter J. Scott said at the World Conference on Lung Cancer. He stressed that study included only patients with early-stage lung cancer that was either node negative or had nonhilar N1 disease, and hence the finding is specific for only these patients. Until now, questions existed about the oncologic efficacy of VATS, noted Dr. Scott, chief of the division of thoracic surgery at Fox Chase Cancer Center in Philadelphia.But "VATS lobectomy provides comparable oncologic outcomes" for this group of patients, he said.

His analysis used data collected from 964 lung cancer patients who participated in a multicenter study during 1999-2004 that compared two different strategies for lymph node assessment in early-stage lung cancer (Ann. Thorac. Surg. 2006;81:1013-20). Although most surgeons did not perform VATS during this time, a few surgeons did, and 5-year outcome results were available for 66 patients in the study underwent VATS. Five-year data also existed for 898 of the patients who underwent open lobectomy.

To adjust for baseline differences among the patients, Dr. Scott and his associates ran a propensity score analysis that took into account age, sex, performance status, tumor histology, location, and tumor size and invasion. The analysis excluded about a fifth of the open lobectomy patients because their propensity scores fell outside the range of the VATS patients, so the final survival comparison included 66 VATS and 686 open lobectomy patients.

With propensity adjustment, the results showed no significant differences between the VATS and open lobectomy patients in their 5-year rates of overall survival, disease-free survival, local disease-free survival, or freedom from new primary tumors (see table), Dr. Scott reported at the meeting, which was sponsored by the International Association for the Study of Lung Cancer.

Dr. Scott said that he is a shareholder in Biogen Idec, Celgene, and Johnson & Johnson.

AMSTERDAM – Video-assisted thoracoscopic surgery worked as well as open lobectomy for 5-year survival in early-stage lung cancer, based on a secondary analysis of nonrandomized patients who underwent surgery as part of a multicenter trial.

"These data demonstrate that VATS, when properly done, can achieve long-term survival that is similar to open lobectomy," Dr. Walter J. Scott said at the World Conference on Lung Cancer. He stressed that study included only patients with early-stage lung cancer that was either node negative or had nonhilar N1 disease, and hence the finding is specific for only these patients. Until now, questions existed about the oncologic efficacy of VATS, noted Dr. Scott, chief of the division of thoracic surgery at Fox Chase Cancer Center in Philadelphia.But "VATS lobectomy provides comparable oncologic outcomes" for this group of patients, he said.

His analysis used data collected from 964 lung cancer patients who participated in a multicenter study during 1999-2004 that compared two different strategies for lymph node assessment in early-stage lung cancer (Ann. Thorac. Surg. 2006;81:1013-20). Although most surgeons did not perform VATS during this time, a few surgeons did, and 5-year outcome results were available for 66 patients in the study underwent VATS. Five-year data also existed for 898 of the patients who underwent open lobectomy.

To adjust for baseline differences among the patients, Dr. Scott and his associates ran a propensity score analysis that took into account age, sex, performance status, tumor histology, location, and tumor size and invasion. The analysis excluded about a fifth of the open lobectomy patients because their propensity scores fell outside the range of the VATS patients, so the final survival comparison included 66 VATS and 686 open lobectomy patients.

With propensity adjustment, the results showed no significant differences between the VATS and open lobectomy patients in their 5-year rates of overall survival, disease-free survival, local disease-free survival, or freedom from new primary tumors (see table), Dr. Scott reported at the meeting, which was sponsored by the International Association for the Study of Lung Cancer.

Dr. Scott said that he is a shareholder in Biogen Idec, Celgene, and Johnson & Johnson.

AMSTERDAM – Video-assisted thoracoscopic surgery worked as well as open lobectomy for 5-year survival in early-stage lung cancer, based on a secondary analysis of nonrandomized patients who underwent surgery as part of a multicenter trial.

"These data demonstrate that VATS, when properly done, can achieve long-term survival that is similar to open lobectomy," Dr. Walter J. Scott said at the World Conference on Lung Cancer. He stressed that study included only patients with early-stage lung cancer that was either node negative or had nonhilar N1 disease, and hence the finding is specific for only these patients. Until now, questions existed about the oncologic efficacy of VATS, noted Dr. Scott, chief of the division of thoracic surgery at Fox Chase Cancer Center in Philadelphia.But "VATS lobectomy provides comparable oncologic outcomes" for this group of patients, he said.

His analysis used data collected from 964 lung cancer patients who participated in a multicenter study during 1999-2004 that compared two different strategies for lymph node assessment in early-stage lung cancer (Ann. Thorac. Surg. 2006;81:1013-20). Although most surgeons did not perform VATS during this time, a few surgeons did, and 5-year outcome results were available for 66 patients in the study underwent VATS. Five-year data also existed for 898 of the patients who underwent open lobectomy.

To adjust for baseline differences among the patients, Dr. Scott and his associates ran a propensity score analysis that took into account age, sex, performance status, tumor histology, location, and tumor size and invasion. The analysis excluded about a fifth of the open lobectomy patients because their propensity scores fell outside the range of the VATS patients, so the final survival comparison included 66 VATS and 686 open lobectomy patients.

With propensity adjustment, the results showed no significant differences between the VATS and open lobectomy patients in their 5-year rates of overall survival, disease-free survival, local disease-free survival, or freedom from new primary tumors (see table), Dr. Scott reported at the meeting, which was sponsored by the International Association for the Study of Lung Cancer.

Dr. Scott said that he is a shareholder in Biogen Idec, Celgene, and Johnson & Johnson.

John Krisa, MD, medical director of the hospitalist group at Albany Memorial Hospital in New York, pictures his HM group as an organic whole when he draws up the schedule. He tries to avoid a strict 50-50 parceling out of night and day shifts. The hospitalist group makes liberal use of per-diem hospitalists and moonlighters, and has a few nocturnists.

“The vast majority of the work at night is processing new admissions, so these tend to be single encounters. You want your full-time people there multiple consecutive days for continuity and to represent the face of your program,” he says.

But for the required, ’round-the-clock coverage, he and other group members are expected to pull their share of nights as well. “I was always more of a nighttime person, in terms of my body clock,” Dr. Krisa says, “but now that I have more daytime nonclinical duties [as regional site director for Cogent HMG], it’s been more of a challenge to juggle home responsibilities, night shifts, and multiple administrative meetings.”

There are some basic principles of sleep hygiene and lessons learned from industrial settings that are good to keep in mind, says Christopher P. Landrigan, MD, SFHM, MPH, associate professor of medicine and pediatrics at Harvard Medical School and director of the Sleep and Patient Safety Program at Brigham and Women’s Hospital in Boston. “It’s really incumbent upon hospitalist group leaders to recognize the hazards of scheduling people for too many nights in a row, which conveys a risk both to the patients and to the hospitalists themselves,” Dr. Landrigan says. “We know that if hospitalists are driving home after night shifts, particularly multiple night shifts, that they’re at risk for motor vehicle crashes and at risk of sticking themselves with needles and scalpels toward the tail end of their shifts. None of us want that.”

Dr. Landrigan advises hospitalist groups to be cognizant of the hazards and think about the schedule “proactively.”

John Krisa, MD, medical director of the hospitalist group at Albany Memorial Hospital in New York, pictures his HM group as an organic whole when he draws up the schedule. He tries to avoid a strict 50-50 parceling out of night and day shifts. The hospitalist group makes liberal use of per-diem hospitalists and moonlighters, and has a few nocturnists.

“The vast majority of the work at night is processing new admissions, so these tend to be single encounters. You want your full-time people there multiple consecutive days for continuity and to represent the face of your program,” he says.

But for the required, ’round-the-clock coverage, he and other group members are expected to pull their share of nights as well. “I was always more of a nighttime person, in terms of my body clock,” Dr. Krisa says, “but now that I have more daytime nonclinical duties [as regional site director for Cogent HMG], it’s been more of a challenge to juggle home responsibilities, night shifts, and multiple administrative meetings.”

There are some basic principles of sleep hygiene and lessons learned from industrial settings that are good to keep in mind, says Christopher P. Landrigan, MD, SFHM, MPH, associate professor of medicine and pediatrics at Harvard Medical School and director of the Sleep and Patient Safety Program at Brigham and Women’s Hospital in Boston. “It’s really incumbent upon hospitalist group leaders to recognize the hazards of scheduling people for too many nights in a row, which conveys a risk both to the patients and to the hospitalists themselves,” Dr. Landrigan says. “We know that if hospitalists are driving home after night shifts, particularly multiple night shifts, that they’re at risk for motor vehicle crashes and at risk of sticking themselves with needles and scalpels toward the tail end of their shifts. None of us want that.”

Dr. Landrigan advises hospitalist groups to be cognizant of the hazards and think about the schedule “proactively.”

John Krisa, MD, medical director of the hospitalist group at Albany Memorial Hospital in New York, pictures his HM group as an organic whole when he draws up the schedule. He tries to avoid a strict 50-50 parceling out of night and day shifts. The hospitalist group makes liberal use of per-diem hospitalists and moonlighters, and has a few nocturnists.

“The vast majority of the work at night is processing new admissions, so these tend to be single encounters. You want your full-time people there multiple consecutive days for continuity and to represent the face of your program,” he says.

But for the required, ’round-the-clock coverage, he and other group members are expected to pull their share of nights as well. “I was always more of a nighttime person, in terms of my body clock,” Dr. Krisa says, “but now that I have more daytime nonclinical duties [as regional site director for Cogent HMG], it’s been more of a challenge to juggle home responsibilities, night shifts, and multiple administrative meetings.”

There are some basic principles of sleep hygiene and lessons learned from industrial settings that are good to keep in mind, says Christopher P. Landrigan, MD, SFHM, MPH, associate professor of medicine and pediatrics at Harvard Medical School and director of the Sleep and Patient Safety Program at Brigham and Women’s Hospital in Boston. “It’s really incumbent upon hospitalist group leaders to recognize the hazards of scheduling people for too many nights in a row, which conveys a risk both to the patients and to the hospitalists themselves,” Dr. Landrigan says. “We know that if hospitalists are driving home after night shifts, particularly multiple night shifts, that they’re at risk for motor vehicle crashes and at risk of sticking themselves with needles and scalpels toward the tail end of their shifts. None of us want that.”

Dr. Landrigan advises hospitalist groups to be cognizant of the hazards and think about the schedule “proactively.”

Increased handoffs are often viewed as a byproduct of the growth in hospital medicine, with heightened scrutiny on the quality of communication that accompanies these transfers of care. As research suggests, though, finding and fixing the weak links can require persistence.

A study led by Siddhartha Singh, MD, MS, associate chief medical officer of Medical College Physicians, the adult practice for Medical College of Wisconsin in Milwaukee, compared a traditional, resident-based model of care to one involving a hospitalist-physician assistant team. Initially, his study found a 6% higher length of stay (LOS) for the hospitalist-physician assistant teams, with no differences in costs or readmission rates.1

But when the researchers pored over their results, they discovered that the increased LOS was limited to patients admitted overnight. Those patients, Dr. Singh says, were admitted by other providers—a night-float resident or faculty hospitalist—and then transferred to the hospitalist-physician assistant teams when they arrived in the morning. These “overflow patients” also were admitted only during busy periods, when limits on the number of admissions by house staff required other arrangements.

To make a direct comparison, Dr. Singh focused on a window from 11 a.m. to 4 p.m., when patients would have an equal probability of being admitted by a resident team or a hospitalist-physician assistant team. From a pool of about 3,000 admitted patients, the study found no significant difference in LOS, cost, readmission rates, or mortality. Instead of highlighting significant differences in models of care, then, Dr. Singh says, his study highlighted a potential weak link in the “treacherous” overnight-to-morning handoffs during busy periods that should be addressed.

“There have been a lot of studies implicating poor communication as a cause of patient-safety issues,” notes Sunil Kripalani, MD, MSc, FHM, chief of the section of hospital medicine and an associate professor of medicine at Vanderbilt University Medical Center in Nashville, Tenn. But fewer studies, he says, have shown how to effectively improve communication in a way that improves patient safety.

One focal point is the often incomplete and inadequate nature of discharge summaries. Several models are emerging on how to build a better discharge summary, Dr. Kripalani says, with researchers offering solid recommendations (as multiple presentations at SHM’s annual meeting suggest). The trick is ensuring that those plans can be implemented into practice on a consistent and timely basis.

Dr. Kripalani says at least one straightforward strategy might help improve handoffs, however: building time into the schedule for them, such as 15-minute overlaps between shifts.—BN

Increased handoffs are often viewed as a byproduct of the growth in hospital medicine, with heightened scrutiny on the quality of communication that accompanies these transfers of care. As research suggests, though, finding and fixing the weak links can require persistence.

A study led by Siddhartha Singh, MD, MS, associate chief medical officer of Medical College Physicians, the adult practice for Medical College of Wisconsin in Milwaukee, compared a traditional, resident-based model of care to one involving a hospitalist-physician assistant team. Initially, his study found a 6% higher length of stay (LOS) for the hospitalist-physician assistant teams, with no differences in costs or readmission rates.1

But when the researchers pored over their results, they discovered that the increased LOS was limited to patients admitted overnight. Those patients, Dr. Singh says, were admitted by other providers—a night-float resident or faculty hospitalist—and then transferred to the hospitalist-physician assistant teams when they arrived in the morning. These “overflow patients” also were admitted only during busy periods, when limits on the number of admissions by house staff required other arrangements.

To make a direct comparison, Dr. Singh focused on a window from 11 a.m. to 4 p.m., when patients would have an equal probability of being admitted by a resident team or a hospitalist-physician assistant team. From a pool of about 3,000 admitted patients, the study found no significant difference in LOS, cost, readmission rates, or mortality. Instead of highlighting significant differences in models of care, then, Dr. Singh says, his study highlighted a potential weak link in the “treacherous” overnight-to-morning handoffs during busy periods that should be addressed.

“There have been a lot of studies implicating poor communication as a cause of patient-safety issues,” notes Sunil Kripalani, MD, MSc, FHM, chief of the section of hospital medicine and an associate professor of medicine at Vanderbilt University Medical Center in Nashville, Tenn. But fewer studies, he says, have shown how to effectively improve communication in a way that improves patient safety.

One focal point is the often incomplete and inadequate nature of discharge summaries. Several models are emerging on how to build a better discharge summary, Dr. Kripalani says, with researchers offering solid recommendations (as multiple presentations at SHM’s annual meeting suggest). The trick is ensuring that those plans can be implemented into practice on a consistent and timely basis.

Dr. Kripalani says at least one straightforward strategy might help improve handoffs, however: building time into the schedule for them, such as 15-minute overlaps between shifts.—BN

Increased handoffs are often viewed as a byproduct of the growth in hospital medicine, with heightened scrutiny on the quality of communication that accompanies these transfers of care. As research suggests, though, finding and fixing the weak links can require persistence.

A study led by Siddhartha Singh, MD, MS, associate chief medical officer of Medical College Physicians, the adult practice for Medical College of Wisconsin in Milwaukee, compared a traditional, resident-based model of care to one involving a hospitalist-physician assistant team. Initially, his study found a 6% higher length of stay (LOS) for the hospitalist-physician assistant teams, with no differences in costs or readmission rates.1

But when the researchers pored over their results, they discovered that the increased LOS was limited to patients admitted overnight. Those patients, Dr. Singh says, were admitted by other providers—a night-float resident or faculty hospitalist—and then transferred to the hospitalist-physician assistant teams when they arrived in the morning. These “overflow patients” also were admitted only during busy periods, when limits on the number of admissions by house staff required other arrangements.

To make a direct comparison, Dr. Singh focused on a window from 11 a.m. to 4 p.m., when patients would have an equal probability of being admitted by a resident team or a hospitalist-physician assistant team. From a pool of about 3,000 admitted patients, the study found no significant difference in LOS, cost, readmission rates, or mortality. Instead of highlighting significant differences in models of care, then, Dr. Singh says, his study highlighted a potential weak link in the “treacherous” overnight-to-morning handoffs during busy periods that should be addressed.

“There have been a lot of studies implicating poor communication as a cause of patient-safety issues,” notes Sunil Kripalani, MD, MSc, FHM, chief of the section of hospital medicine and an associate professor of medicine at Vanderbilt University Medical Center in Nashville, Tenn. But fewer studies, he says, have shown how to effectively improve communication in a way that improves patient safety.

One focal point is the often incomplete and inadequate nature of discharge summaries. Several models are emerging on how to build a better discharge summary, Dr. Kripalani says, with researchers offering solid recommendations (as multiple presentations at SHM’s annual meeting suggest). The trick is ensuring that those plans can be implemented into practice on a consistent and timely basis.

Dr. Kripalani says at least one straightforward strategy might help improve handoffs, however: building time into the schedule for them, such as 15-minute overlaps between shifts.—BN

What’s up with the dress code in hospitals these days? Some of my colleagues wear white coats, some wear ties, some have short-sleeved shirts. Some even wear scrubs in the daytime, and they swear they are right as to “the most clinically appropriate attire.” Any thoughts?

Attirely Concerned in Los Angeles

Dr. Hospitalist responds:

There are a lot of suggestions out there regarding attire. The United Kingdom’s National Health Service is probably most famous for instituting a “bare below elbows” (BBE for short) dress code in 2007.

Although lots of studies have shown bacterial colonization on the items doctors wear or carry (e.g. pagers, pens, neckties, coats, scrubs), none of them truly show causality. The Journal of Hospital Medicine just published a study on scrubs versus white coats, which showed no real difference in contamination.¹

Even the BBE policy was meant to promote hand-washing more than anything else. On that point, there is little disagreement, as there is a substantial amount of data to show that good hand hygiene is a patient-care imperative. We all should spend more time thinking about “clean in/clean out” when it comes to patient rooms than deciding which article of clothing carries the fewest bacteria.

There is another issue at play here, though, and that is the question of how hospitalists are expected to dress. Certainly, there is some regional variation. I don’t think you’ll find that physicians at the Mayo Clinic in Rochester, Minn., are going to dress the same as physicians in San Diego or Hawaii.

So, setting aside the cultural expectations for your region, I do think it’s a good idea for your group to agree on some standards. These policies might vary from white coats for everyone to scrubs after hours, or that blue jeans are OK only on weekends.

Why bother?

Well, for starters, a little consistency will promote the professionalism of your group, and it also sets some baseline expectations for everyone involved. Think about how many healthcare providers wander into a patient’s room during the day: You want to be readily identifiable as the treating physician. No, it’s not just how you dress (a voice, a name badge, and putting your name on the white board also count), but it is part of the picture.

As a hospitalist, not only are you a professional, but, by definition, you are going to meet patients with whom you have no prior relationship. Like it or not, perception matters, and when you need to quickly gain the trust of a patient (and a family) to make urgent clinical decisions, being dressed professionally will help. Looking like a slob won’t.

My advice? First, wash your hands where the patient can see you. If you have to use that gel 40 times a day, you might as well make a show of it. Two, dress professionally within the parameters that your group outlines.

Beyond that, I don’t think you need to autoclave your peripherals and go through a decontamination room just yet.

Reference

1. Burden M, Cervantes L, Weed D, Keniston A, Price CS, Albert RK. Newly cleaned physician uniforms and infrequently washed white coats have similar rates of bacterial contamination after an 8-hour workday: A randomized controlled trial. J Hosp Med. 2011;6(4):177-182.

What’s up with the dress code in hospitals these days? Some of my colleagues wear white coats, some wear ties, some have short-sleeved shirts. Some even wear scrubs in the daytime, and they swear they are right as to “the most clinically appropriate attire.” Any thoughts?

Attirely Concerned in Los Angeles

Dr. Hospitalist responds:

There are a lot of suggestions out there regarding attire. The United Kingdom’s National Health Service is probably most famous for instituting a “bare below elbows” (BBE for short) dress code in 2007.

Although lots of studies have shown bacterial colonization on the items doctors wear or carry (e.g. pagers, pens, neckties, coats, scrubs), none of them truly show causality. The Journal of Hospital Medicine just published a study on scrubs versus white coats, which showed no real difference in contamination.¹

Even the BBE policy was meant to promote hand-washing more than anything else. On that point, there is little disagreement, as there is a substantial amount of data to show that good hand hygiene is a patient-care imperative. We all should spend more time thinking about “clean in/clean out” when it comes to patient rooms than deciding which article of clothing carries the fewest bacteria.

There is another issue at play here, though, and that is the question of how hospitalists are expected to dress. Certainly, there is some regional variation. I don’t think you’ll find that physicians at the Mayo Clinic in Rochester, Minn., are going to dress the same as physicians in San Diego or Hawaii.

So, setting aside the cultural expectations for your region, I do think it’s a good idea for your group to agree on some standards. These policies might vary from white coats for everyone to scrubs after hours, or that blue jeans are OK only on weekends.

Why bother?

Well, for starters, a little consistency will promote the professionalism of your group, and it also sets some baseline expectations for everyone involved. Think about how many healthcare providers wander into a patient’s room during the day: You want to be readily identifiable as the treating physician. No, it’s not just how you dress (a voice, a name badge, and putting your name on the white board also count), but it is part of the picture.

As a hospitalist, not only are you a professional, but, by definition, you are going to meet patients with whom you have no prior relationship. Like it or not, perception matters, and when you need to quickly gain the trust of a patient (and a family) to make urgent clinical decisions, being dressed professionally will help. Looking like a slob won’t.

My advice? First, wash your hands where the patient can see you. If you have to use that gel 40 times a day, you might as well make a show of it. Two, dress professionally within the parameters that your group outlines.

Beyond that, I don’t think you need to autoclave your peripherals and go through a decontamination room just yet.

Reference

1. Burden M, Cervantes L, Weed D, Keniston A, Price CS, Albert RK. Newly cleaned physician uniforms and infrequently washed white coats have similar rates of bacterial contamination after an 8-hour workday: A randomized controlled trial. J Hosp Med. 2011;6(4):177-182.

What’s up with the dress code in hospitals these days? Some of my colleagues wear white coats, some wear ties, some have short-sleeved shirts. Some even wear scrubs in the daytime, and they swear they are right as to “the most clinically appropriate attire.” Any thoughts?

Attirely Concerned in Los Angeles

Dr. Hospitalist responds:

There are a lot of suggestions out there regarding attire. The United Kingdom’s National Health Service is probably most famous for instituting a “bare below elbows” (BBE for short) dress code in 2007.

Although lots of studies have shown bacterial colonization on the items doctors wear or carry (e.g. pagers, pens, neckties, coats, scrubs), none of them truly show causality. The Journal of Hospital Medicine just published a study on scrubs versus white coats, which showed no real difference in contamination.¹

Even the BBE policy was meant to promote hand-washing more than anything else. On that point, there is little disagreement, as there is a substantial amount of data to show that good hand hygiene is a patient-care imperative. We all should spend more time thinking about “clean in/clean out” when it comes to patient rooms than deciding which article of clothing carries the fewest bacteria.

There is another issue at play here, though, and that is the question of how hospitalists are expected to dress. Certainly, there is some regional variation. I don’t think you’ll find that physicians at the Mayo Clinic in Rochester, Minn., are going to dress the same as physicians in San Diego or Hawaii.

So, setting aside the cultural expectations for your region, I do think it’s a good idea for your group to agree on some standards. These policies might vary from white coats for everyone to scrubs after hours, or that blue jeans are OK only on weekends.

Why bother?

Well, for starters, a little consistency will promote the professionalism of your group, and it also sets some baseline expectations for everyone involved. Think about how many healthcare providers wander into a patient’s room during the day: You want to be readily identifiable as the treating physician. No, it’s not just how you dress (a voice, a name badge, and putting your name on the white board also count), but it is part of the picture.

As a hospitalist, not only are you a professional, but, by definition, you are going to meet patients with whom you have no prior relationship. Like it or not, perception matters, and when you need to quickly gain the trust of a patient (and a family) to make urgent clinical decisions, being dressed professionally will help. Looking like a slob won’t.

My advice? First, wash your hands where the patient can see you. If you have to use that gel 40 times a day, you might as well make a show of it. Two, dress professionally within the parameters that your group outlines.

Beyond that, I don’t think you need to autoclave your peripherals and go through a decontamination room just yet.

Reference

1. Burden M, Cervantes L, Weed D, Keniston A, Price CS, Albert RK. Newly cleaned physician uniforms and infrequently washed white coats have similar rates of bacterial contamination after an 8-hour workday: A randomized controlled trial. J Hosp Med. 2011;6(4):177-182.

Many hospitalist practices are started by “traditionalists”: primary-care physicians (PCPs) active in the outpatient and hospital settings. The practice typically grows due in large part to the leadership of the founders. Ultimately, the practice is made up of both the founders and a cadre of part- or full-time hospitalists who don’t work in the outpatient setting. And sometimes they have different incentives and ideas about how the practice should operate.

When these individuals disagree, which group should break the tie—the founding “hybrid” or “rotating” doctors who work part time on the hospitalist service or the doctors who work only as hospitalists?

This is a reasonably common issue for “medical” hospitalist groups, and in many cases is becoming an issue for groups in other specialties that adopt the hospitalist model, such as surgical hospitalists, laborists, etc.

A Common Scenario

Let me illustrate this issue with a composite of several former consulting clients. Let’s say this is a hospitalist practice that serves a 250-bed community hospital. One large private internal medicine group adopted a “rotating hospitalist” model there in the late 1990s. One of the internists provided the daytime hospital coverage for all the group’s patients one week out of every six. Their hospital volume grew quickly. They were asked to take on responsibility for admitting an increasing portion of the unassigned patients, provide care for patients referred by other PCPs who wanted to drop out of hospital work, and increasingly were asked to consult on patients admitted by surgeons.

When faced with this situation, many PCP groups decided to exit the hospital themselves and turn that work over to hospitalists. This group stuck it out. At first, the one doctor in the group covering the hospital each week kept up with the growing volume by simply working harder and longer every day. Eventually, the group sought financial help from the hospital to hire hospitalists who didn’t have outpatient responsibilities.

Years passed, and this PCP group transitioned to employment by the hospital, just like the full-time hospitalists. And by this time, the hospitalist practice was seen as distinct from the original PCP group. About 80% of the staffing was provided by hospitalists who didn’t work in the outpatient setting, the remainder by PCPs who essentially founded the practice. The PCPs chose to continue providing hospital care, both because they found it professionally satisfying and their compensation formula made it attractive for generating production in the hospital.

Tensions arose between the hospitalists and the “hybrids.” The hybrids refused to work night shifts and generally were unable to fill in for unplanned absences by the hospitalists. And because of the PCPs’ compensation formula, and possibly the work ethic of more senior doctors, they favored managing larger patient volumes and decreasing weekend staffing significantly to allow more weekends off in total for everyone. The hospitalists had other ideas about these things, and they were unhappy that the PCPs would have first say about when they could work hospital shifts, thereby decreasing the hospitalists’ scheduling flexibility.

The hospitalists were all within a few years of their residency training, and most of the PCPs were midcareer. This created a social divide, making it that much more difficult for the two groups to work through the issues. While the hybrid doctors saw the hospitalists as good clinicians, and vice versa, each group said: “The other guys are difficult to work with. They don’t understand what it is like for us.”

Need for Paradigm Shift

At many sites, the doctors and their administrative counterparts get stuck in a stalemate and have the same, unhappy conversations repeatedly. These conversations are really gripe sessions more than anything else.

I think the best solution is for everyone to acknowledge the valuable contribution of the hybrid doctors in founding and leading the hospitalist practice through years of growth, but also to begin seeing the hospitalist practice as being owned and governed primarily by the hospitalists who do most of the work. For most issues in which the two factions can’t agree, the hospitalists should have the tie-breaking vote.

While this approach reduces the autonomy of the hybrid doctors to make operational decisions, it doesn’t mean they have zero influence. In fact, the practice usually has a critical need for the hybrid doctors to continue providing some of the staffing. This usually means that the practice will need to ensure it puts together a package of compensation and available shifts on the schedule to ensure the hybrids want to remain active in the practice.

In most cases, all involved should ensure that those hybrid doctors who want to remain active in the hospital, and perform well in the hospitalist practice, should have the opportunity to do so indefinitely.

Compensation Methods for Hybrids

Even if the hybrids and hospitalists are able to harmoniously agree on things like work schedules, the hybrid doctors often have compensation schemes such that when working in the hospital, they have different financial incentives from the hospitalists. (I’m using “hybrid” to describe physicians who work in both inpatient and outpatient settings, usually more time in the office practice.) A common situation is that the production (i.e. wRVUs) generated in the hospital counts toward their office productivity. So the hybrids and the hospitalists will have different ideas about how hard they want to work.

The solution here is to divorce the office and hospital compensation schemes. There should be no connection between the compensation in the two settings, and both should be designed to ensure a competitive amount of money and performance incentives appropriate for that setting. Such methods usually mean that a day of work in the office will result in a different-sized paycheck than what comes with a day of work in the hospital.

Dr. Nelson has been a practicing hospitalist since 1988 and is cofounder and past president of SHM. He is a principal in Nelson Flores Hospital Medicine Consultants, a national hospitalist practice management consulting firm. He is course codirector 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.

Many hospitalist practices are started by “traditionalists”: primary-care physicians (PCPs) active in the outpatient and hospital settings. The practice typically grows due in large part to the leadership of the founders. Ultimately, the practice is made up of both the founders and a cadre of part- or full-time hospitalists who don’t work in the outpatient setting. And sometimes they have different incentives and ideas about how the practice should operate.

When these individuals disagree, which group should break the tie—the founding “hybrid” or “rotating” doctors who work part time on the hospitalist service or the doctors who work only as hospitalists?

This is a reasonably common issue for “medical” hospitalist groups, and in many cases is becoming an issue for groups in other specialties that adopt the hospitalist model, such as surgical hospitalists, laborists, etc.

A Common Scenario

Let me illustrate this issue with a composite of several former consulting clients. Let’s say this is a hospitalist practice that serves a 250-bed community hospital. One large private internal medicine group adopted a “rotating hospitalist” model there in the late 1990s. One of the internists provided the daytime hospital coverage for all the group’s patients one week out of every six. Their hospital volume grew quickly. They were asked to take on responsibility for admitting an increasing portion of the unassigned patients, provide care for patients referred by other PCPs who wanted to drop out of hospital work, and increasingly were asked to consult on patients admitted by surgeons.

When faced with this situation, many PCP groups decided to exit the hospital themselves and turn that work over to hospitalists. This group stuck it out. At first, the one doctor in the group covering the hospital each week kept up with the growing volume by simply working harder and longer every day. Eventually, the group sought financial help from the hospital to hire hospitalists who didn’t have outpatient responsibilities.

Years passed, and this PCP group transitioned to employment by the hospital, just like the full-time hospitalists. And by this time, the hospitalist practice was seen as distinct from the original PCP group. About 80% of the staffing was provided by hospitalists who didn’t work in the outpatient setting, the remainder by PCPs who essentially founded the practice. The PCPs chose to continue providing hospital care, both because they found it professionally satisfying and their compensation formula made it attractive for generating production in the hospital.

Tensions arose between the hospitalists and the “hybrids.” The hybrids refused to work night shifts and generally were unable to fill in for unplanned absences by the hospitalists. And because of the PCPs’ compensation formula, and possibly the work ethic of more senior doctors, they favored managing larger patient volumes and decreasing weekend staffing significantly to allow more weekends off in total for everyone. The hospitalists had other ideas about these things, and they were unhappy that the PCPs would have first say about when they could work hospital shifts, thereby decreasing the hospitalists’ scheduling flexibility.

The hospitalists were all within a few years of their residency training, and most of the PCPs were midcareer. This created a social divide, making it that much more difficult for the two groups to work through the issues. While the hybrid doctors saw the hospitalists as good clinicians, and vice versa, each group said: “The other guys are difficult to work with. They don’t understand what it is like for us.”

Need for Paradigm Shift

At many sites, the doctors and their administrative counterparts get stuck in a stalemate and have the same, unhappy conversations repeatedly. These conversations are really gripe sessions more than anything else.

I think the best solution is for everyone to acknowledge the valuable contribution of the hybrid doctors in founding and leading the hospitalist practice through years of growth, but also to begin seeing the hospitalist practice as being owned and governed primarily by the hospitalists who do most of the work. For most issues in which the two factions can’t agree, the hospitalists should have the tie-breaking vote.

While this approach reduces the autonomy of the hybrid doctors to make operational decisions, it doesn’t mean they have zero influence. In fact, the practice usually has a critical need for the hybrid doctors to continue providing some of the staffing. This usually means that the practice will need to ensure it puts together a package of compensation and available shifts on the schedule to ensure the hybrids want to remain active in the practice.

In most cases, all involved should ensure that those hybrid doctors who want to remain active in the hospital, and perform well in the hospitalist practice, should have the opportunity to do so indefinitely.

Compensation Methods for Hybrids

Even if the hybrids and hospitalists are able to harmoniously agree on things like work schedules, the hybrid doctors often have compensation schemes such that when working in the hospital, they have different financial incentives from the hospitalists. (I’m using “hybrid” to describe physicians who work in both inpatient and outpatient settings, usually more time in the office practice.) A common situation is that the production (i.e. wRVUs) generated in the hospital counts toward their office productivity. So the hybrids and the hospitalists will have different ideas about how hard they want to work.

The solution here is to divorce the office and hospital compensation schemes. There should be no connection between the compensation in the two settings, and both should be designed to ensure a competitive amount of money and performance incentives appropriate for that setting. Such methods usually mean that a day of work in the office will result in a different-sized paycheck than what comes with a day of work in the hospital.

Dr. Nelson has been a practicing hospitalist since 1988 and is cofounder and past president of SHM. He is a principal in Nelson Flores Hospital Medicine Consultants, a national hospitalist practice management consulting firm. He is course codirector 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.

Many hospitalist practices are started by “traditionalists”: primary-care physicians (PCPs) active in the outpatient and hospital settings. The practice typically grows due in large part to the leadership of the founders. Ultimately, the practice is made up of both the founders and a cadre of part- or full-time hospitalists who don’t work in the outpatient setting. And sometimes they have different incentives and ideas about how the practice should operate.

When these individuals disagree, which group should break the tie—the founding “hybrid” or “rotating” doctors who work part time on the hospitalist service or the doctors who work only as hospitalists?

This is a reasonably common issue for “medical” hospitalist groups, and in many cases is becoming an issue for groups in other specialties that adopt the hospitalist model, such as surgical hospitalists, laborists, etc.

A Common Scenario

Let me illustrate this issue with a composite of several former consulting clients. Let’s say this is a hospitalist practice that serves a 250-bed community hospital. One large private internal medicine group adopted a “rotating hospitalist” model there in the late 1990s. One of the internists provided the daytime hospital coverage for all the group’s patients one week out of every six. Their hospital volume grew quickly. They were asked to take on responsibility for admitting an increasing portion of the unassigned patients, provide care for patients referred by other PCPs who wanted to drop out of hospital work, and increasingly were asked to consult on patients admitted by surgeons.

When faced with this situation, many PCP groups decided to exit the hospital themselves and turn that work over to hospitalists. This group stuck it out. At first, the one doctor in the group covering the hospital each week kept up with the growing volume by simply working harder and longer every day. Eventually, the group sought financial help from the hospital to hire hospitalists who didn’t have outpatient responsibilities.

Years passed, and this PCP group transitioned to employment by the hospital, just like the full-time hospitalists. And by this time, the hospitalist practice was seen as distinct from the original PCP group. About 80% of the staffing was provided by hospitalists who didn’t work in the outpatient setting, the remainder by PCPs who essentially founded the practice. The PCPs chose to continue providing hospital care, both because they found it professionally satisfying and their compensation formula made it attractive for generating production in the hospital.

Tensions arose between the hospitalists and the “hybrids.” The hybrids refused to work night shifts and generally were unable to fill in for unplanned absences by the hospitalists. And because of the PCPs’ compensation formula, and possibly the work ethic of more senior doctors, they favored managing larger patient volumes and decreasing weekend staffing significantly to allow more weekends off in total for everyone. The hospitalists had other ideas about these things, and they were unhappy that the PCPs would have first say about when they could work hospital shifts, thereby decreasing the hospitalists’ scheduling flexibility.

The hospitalists were all within a few years of their residency training, and most of the PCPs were midcareer. This created a social divide, making it that much more difficult for the two groups to work through the issues. While the hybrid doctors saw the hospitalists as good clinicians, and vice versa, each group said: “The other guys are difficult to work with. They don’t understand what it is like for us.”

Need for Paradigm Shift

At many sites, the doctors and their administrative counterparts get stuck in a stalemate and have the same, unhappy conversations repeatedly. These conversations are really gripe sessions more than anything else.

I think the best solution is for everyone to acknowledge the valuable contribution of the hybrid doctors in founding and leading the hospitalist practice through years of growth, but also to begin seeing the hospitalist practice as being owned and governed primarily by the hospitalists who do most of the work. For most issues in which the two factions can’t agree, the hospitalists should have the tie-breaking vote.

While this approach reduces the autonomy of the hybrid doctors to make operational decisions, it doesn’t mean they have zero influence. In fact, the practice usually has a critical need for the hybrid doctors to continue providing some of the staffing. This usually means that the practice will need to ensure it puts together a package of compensation and available shifts on the schedule to ensure the hybrids want to remain active in the practice.

In most cases, all involved should ensure that those hybrid doctors who want to remain active in the hospital, and perform well in the hospitalist practice, should have the opportunity to do so indefinitely.

Compensation Methods for Hybrids

Even if the hybrids and hospitalists are able to harmoniously agree on things like work schedules, the hybrid doctors often have compensation schemes such that when working in the hospital, they have different financial incentives from the hospitalists. (I’m using “hybrid” to describe physicians who work in both inpatient and outpatient settings, usually more time in the office practice.) A common situation is that the production (i.e. wRVUs) generated in the hospital counts toward their office productivity. So the hybrids and the hospitalists will have different ideas about how hard they want to work.

The solution here is to divorce the office and hospital compensation schemes. There should be no connection between the compensation in the two settings, and both should be designed to ensure a competitive amount of money and performance incentives appropriate for that setting. Such methods usually mean that a day of work in the office will result in a different-sized paycheck than what comes with a day of work in the hospital.

Dr. Nelson has been a practicing hospitalist since 1988 and is cofounder and past president of SHM. He is a principal in Nelson Flores Hospital Medicine Consultants, a national hospitalist practice management consulting firm. He is course codirector 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.

Ah, 15 years. My, how time flies. August 1996 seems like yesterday. I had just moved to Denver. It was a hot summer. I still had hair, a normal BMI, and a social life. The world was gearing up for the Olympics in Atlanta; my adrenal glands were gearing up for the hypertrophying journey called internship. The films of ’96 seemed to portend ominously about my year ahead: Twister (a whirlwind ride?), Jerry Maguire (you complete me, internship?), Independence Day (apocalypse?), The Nutty Professor (research attendings on the wards?), Mission: Impossible (hmmm).

The Spice Girls were spreading girl power, this thing called the Internet was sort of catching on with 10 million (yes, that’s an “m,” not a “b”) users worldwide, and the dotcom era introduced us to eBay, which offered to sell your junk “online.”

In Scotland, Dolly the sheep was cloned and the world grappled with the ethical implications. In England, Diana and Charles divorced and cows became mad (coincidence?). Back home, Seinfeld, ER, and Friends teamed for “must-see” Thursday nights, the average car cost $16,000, and Federal Reserve Chairman Alan Greenspan wondered if the Dow Jones was overvalued at 6,400.

Oh, and on Aug. 15, the term “hospitalist” appeared in print for the first time, helping launch the fastest-growing medical specialty of all time.¹

Labor & Delivery

I remember as an intern seeing the article by Drs. Wachter and Goldman. I guess I didn’t get it, really. Was it that easy to create a new specialty? Just take something and add “ist” to the end? As interns, we excitedly begin to create new fields to describe our work: “dump-ologists,” “failure-to-thrive-ists,” “rectalists.” Much like Jamiroquai, however, our specialties never really caught on.

But HM did, and this month we celebrate 15 years. Now, I’ll recognize that its impossible to pin an exact date on the creation of a specialty, and in fact, hospitalists clearly existed prior to the term. But in terms of identifying a start date, Aug. 15, 1996, is as good as any.

The Early Days: Doing It

I don’t remember the day I became a hospitalist. It all sort of just flowed together. I finished residency, did a chief year where I taught, attended on the wards, and didn’t do any clinic, and then I took a job at the Denver VA, where I taught, attended on the wards, and didn’t do any clinic. It felt kind of all the same.

But from the outside, this was a significant transition point. Until this time, subspecialists or general internists, family medicine doctors, and pediatricians provided nearly all inpatient ward attending (and indeed, community inpatient care). I recall vividly the reaction of others; it was a mixture of amazement (you do what all year?), concern (you’ll burn out), apprehension (I won’t be able to care for my patients in the hospital), and enmity (you’ll destroy the fabric of internal medicine!).

And this was the point of the first few years: survival. These were the formative years. It was all about showing HM was a sustainable model that could enhance, not detract, from the system of care. And it had its very vocal critics, who saw it as a flash in the pan. They assumed it would go the way of the Tickle Me Elmo doll (a fad, for the record, that needed to die).

And this was the importance of the creation of the National Association of Inpatient Physicians (now SHM), HM textbooks, the development of hospitalist researchers, a national meeting, the creation of sustainable community hospitalist jobs, the growth of academic HM groups, and studies showing the model could indeed be implemented and wouldn’t negatively impact patient outcomes or outpatient provider satisfaction. These things legitimized the field, gave it legs, propelled it to the next phase.

The Next Phase: Doing it Cheaper

To be fair, HM is not all about the money. Even in the early days, it was recognized that at its pinnacle HM was about improving the patient experience—higher quality, safety, and satisfaction. That said, it was Medicare’s diagnosis-related group (DRG) that drove the model forward. To be clear, there were other factors that helped propel the HM movement: staffing issues, the rise in complexity of care, many PCPs and specialists willingly leaving the hospital. But in the end, the bottom line drove many hospital administrations to adopt the HM model.

Most hospital care is reimbursed via prospective payment, which means hospital reimbursement is, in a sense, determined upon admission. Every dollar of that DRG payment that isn’t spent is pocketed by the hospital as profit. As expected, specialists in hospital care were able to significantly reduce the length of hospital stay, costs of care, and, ultimately, save hospitals many dollars for each dollar of investment.

And to be clear, there was nothing unsavory about this. It wasn’t done through rationing care or reducing access, but rather through systematically reducing some of the estimated 30% waste in healthcare. This was shown in numerous studies, with a 2002 report estimating average savings at about 13% per patient cared for in the HM model.²

The Current Phase: Doing it Better

Pretty impressive, but mostly unsatisfying. Yes, as a group director that has negotiated for nearly a decade with hospital administrators, I’m well aware of the power of cost savings. Yet, I didn’t go into medicine to save money. I did so to help patients, enhance their experience, and improve outcomes. And indeed, there are data that hospitalists do this. Two 2002 papers showed that hospitalist groups could reduce readmission rates as well as inpatient and 30-day mortality.^3,4 A paper in 2004 showed that pairing hospitalists with orthopedic surgeons could reduce perioperative complications.⁵

Couple these studies with anecdotal experience and perusal of any issue of the Journal of Hospital Medicine, and its clear that hospitalists are fulfilling their promise of doing it better. But we have a long way to go. We must continue to innovative and create better, safer systems of care until we can be confident that not a single one of our patients is avoidably harmed by healthcare. That is the kind of care you’d want for your family member, for yourself.

Our Legacy, TBD

And here we are now, looking forward to the next 15 years. For many hospitalists, this will represent the twilight years of their careers. For others, it’ll be the formative years. What mark will we leave?

Clearly, the premium on patient safety and quality is increasing, morphing from word to deed as we speak. And hospitalists will find themselves in the middle of the fray. The healthcare reform alphabet soup calls for equal parts VBP and ACO, with a pinch of EHR, and a dash of PFP—boiled in a cost reduction. But more than ingredients, it requires a chef—someone to orchestrate the great change that is necessary in American healthcare.

Whether it’s leading inpatient safety, improving the quality of hospital care, bridging post-discharge transitions, or reducing readmissions, someone is required to tend these fires.

And I believe HM’s legacy will be forged in these flames of change. There is no single group as well positioned to impact the outcomes that matter most to healthcare reform now than hospitalists. In most hospitals, we will touch the majority of patients, control the spending of the majority of dollars, and be directly responsible for the majority of outcomes. This is an unfathomable position to be in for a specialty that is yet old enough to drive. Yet this is where we find ourselves.

Our legacy is being written. You are its author.

Dr. Glasheen is The Hospitalist’s physician editor.

References

1. Wachter RM, Goldman L. The emerging role of “hospitalists” in the American health care system. N Engl J Med. 1996;335:514-517.
2. Wachter RM, Goldman L. The hospitalist movement 5 years later. JAMA. 2002;287:487-494.
3. Auerbach AD, Wachter RM, Katz P, Showstack J, Baron RB, Goldman L. Implementation of a voluntary hospitalist service at a community teaching hospital: improved clinical efficiency and patient outcomes. Ann Intern Med. 2002;137:859-865.
4. Meltzer D, Manning WG, Morrison J, Shah MN, Jin L, Guth T, Levinson W. Effects of physician experience on costs and outcomes on an academic general medicine service: results of a trial of hospitalists. Ann Intern Med. 2002;137:866-874.
5. Huddleston JM, Long KH, Naessens JM, et. al. Medical and surgical comanagement after elective hip and knee arthroplasty: a randomized, controlled trial. Ann Intern Med. 2004;141:28-38.

Ah, 15 years. My, how time flies. August 1996 seems like yesterday. I had just moved to Denver. It was a hot summer. I still had hair, a normal BMI, and a social life. The world was gearing up for the Olympics in Atlanta; my adrenal glands were gearing up for the hypertrophying journey called internship. The films of ’96 seemed to portend ominously about my year ahead: Twister (a whirlwind ride?), Jerry Maguire (you complete me, internship?), Independence Day (apocalypse?), The Nutty Professor (research attendings on the wards?), Mission: Impossible (hmmm).

The Spice Girls were spreading girl power, this thing called the Internet was sort of catching on with 10 million (yes, that’s an “m,” not a “b”) users worldwide, and the dotcom era introduced us to eBay, which offered to sell your junk “online.”

In Scotland, Dolly the sheep was cloned and the world grappled with the ethical implications. In England, Diana and Charles divorced and cows became mad (coincidence?). Back home, Seinfeld, ER, and Friends teamed for “must-see” Thursday nights, the average car cost $16,000, and Federal Reserve Chairman Alan Greenspan wondered if the Dow Jones was overvalued at 6,400.

Oh, and on Aug. 15, the term “hospitalist” appeared in print for the first time, helping launch the fastest-growing medical specialty of all time.¹

Labor & Delivery

I remember as an intern seeing the article by Drs. Wachter and Goldman. I guess I didn’t get it, really. Was it that easy to create a new specialty? Just take something and add “ist” to the end? As interns, we excitedly begin to create new fields to describe our work: “dump-ologists,” “failure-to-thrive-ists,” “rectalists.” Much like Jamiroquai, however, our specialties never really caught on.

But HM did, and this month we celebrate 15 years. Now, I’ll recognize that its impossible to pin an exact date on the creation of a specialty, and in fact, hospitalists clearly existed prior to the term. But in terms of identifying a start date, Aug. 15, 1996, is as good as any.

The Early Days: Doing It

I don’t remember the day I became a hospitalist. It all sort of just flowed together. I finished residency, did a chief year where I taught, attended on the wards, and didn’t do any clinic, and then I took a job at the Denver VA, where I taught, attended on the wards, and didn’t do any clinic. It felt kind of all the same.

But from the outside, this was a significant transition point. Until this time, subspecialists or general internists, family medicine doctors, and pediatricians provided nearly all inpatient ward attending (and indeed, community inpatient care). I recall vividly the reaction of others; it was a mixture of amazement (you do what all year?), concern (you’ll burn out), apprehension (I won’t be able to care for my patients in the hospital), and enmity (you’ll destroy the fabric of internal medicine!).

And this was the point of the first few years: survival. These were the formative years. It was all about showing HM was a sustainable model that could enhance, not detract, from the system of care. And it had its very vocal critics, who saw it as a flash in the pan. They assumed it would go the way of the Tickle Me Elmo doll (a fad, for the record, that needed to die).

And this was the importance of the creation of the National Association of Inpatient Physicians (now SHM), HM textbooks, the development of hospitalist researchers, a national meeting, the creation of sustainable community hospitalist jobs, the growth of academic HM groups, and studies showing the model could indeed be implemented and wouldn’t negatively impact patient outcomes or outpatient provider satisfaction. These things legitimized the field, gave it legs, propelled it to the next phase.

The Next Phase: Doing it Cheaper

To be fair, HM is not all about the money. Even in the early days, it was recognized that at its pinnacle HM was about improving the patient experience—higher quality, safety, and satisfaction. That said, it was Medicare’s diagnosis-related group (DRG) that drove the model forward. To be clear, there were other factors that helped propel the HM movement: staffing issues, the rise in complexity of care, many PCPs and specialists willingly leaving the hospital. But in the end, the bottom line drove many hospital administrations to adopt the HM model.

Most hospital care is reimbursed via prospective payment, which means hospital reimbursement is, in a sense, determined upon admission. Every dollar of that DRG payment that isn’t spent is pocketed by the hospital as profit. As expected, specialists in hospital care were able to significantly reduce the length of hospital stay, costs of care, and, ultimately, save hospitals many dollars for each dollar of investment.

And to be clear, there was nothing unsavory about this. It wasn’t done through rationing care or reducing access, but rather through systematically reducing some of the estimated 30% waste in healthcare. This was shown in numerous studies, with a 2002 report estimating average savings at about 13% per patient cared for in the HM model.²

The Current Phase: Doing it Better

Pretty impressive, but mostly unsatisfying. Yes, as a group director that has negotiated for nearly a decade with hospital administrators, I’m well aware of the power of cost savings. Yet, I didn’t go into medicine to save money. I did so to help patients, enhance their experience, and improve outcomes. And indeed, there are data that hospitalists do this. Two 2002 papers showed that hospitalist groups could reduce readmission rates as well as inpatient and 30-day mortality.^3,4 A paper in 2004 showed that pairing hospitalists with orthopedic surgeons could reduce perioperative complications.⁵

Couple these studies with anecdotal experience and perusal of any issue of the Journal of Hospital Medicine, and its clear that hospitalists are fulfilling their promise of doing it better. But we have a long way to go. We must continue to innovative and create better, safer systems of care until we can be confident that not a single one of our patients is avoidably harmed by healthcare. That is the kind of care you’d want for your family member, for yourself.

Our Legacy, TBD

And here we are now, looking forward to the next 15 years. For many hospitalists, this will represent the twilight years of their careers. For others, it’ll be the formative years. What mark will we leave?

Clearly, the premium on patient safety and quality is increasing, morphing from word to deed as we speak. And hospitalists will find themselves in the middle of the fray. The healthcare reform alphabet soup calls for equal parts VBP and ACO, with a pinch of EHR, and a dash of PFP—boiled in a cost reduction. But more than ingredients, it requires a chef—someone to orchestrate the great change that is necessary in American healthcare.

Whether it’s leading inpatient safety, improving the quality of hospital care, bridging post-discharge transitions, or reducing readmissions, someone is required to tend these fires.

And I believe HM’s legacy will be forged in these flames of change. There is no single group as well positioned to impact the outcomes that matter most to healthcare reform now than hospitalists. In most hospitals, we will touch the majority of patients, control the spending of the majority of dollars, and be directly responsible for the majority of outcomes. This is an unfathomable position to be in for a specialty that is yet old enough to drive. Yet this is where we find ourselves.

Our legacy is being written. You are its author.

Dr. Glasheen is The Hospitalist’s physician editor.

References

1. Wachter RM, Goldman L. The emerging role of “hospitalists” in the American health care system. N Engl J Med. 1996;335:514-517.
2. Wachter RM, Goldman L. The hospitalist movement 5 years later. JAMA. 2002;287:487-494.
3. Auerbach AD, Wachter RM, Katz P, Showstack J, Baron RB, Goldman L. Implementation of a voluntary hospitalist service at a community teaching hospital: improved clinical efficiency and patient outcomes. Ann Intern Med. 2002;137:859-865.
4. Meltzer D, Manning WG, Morrison J, Shah MN, Jin L, Guth T, Levinson W. Effects of physician experience on costs and outcomes on an academic general medicine service: results of a trial of hospitalists. Ann Intern Med. 2002;137:866-874.
5. Huddleston JM, Long KH, Naessens JM, et. al. Medical and surgical comanagement after elective hip and knee arthroplasty: a randomized, controlled trial. Ann Intern Med. 2004;141:28-38.

Ah, 15 years. My, how time flies. August 1996 seems like yesterday. I had just moved to Denver. It was a hot summer. I still had hair, a normal BMI, and a social life. The world was gearing up for the Olympics in Atlanta; my adrenal glands were gearing up for the hypertrophying journey called internship. The films of ’96 seemed to portend ominously about my year ahead: Twister (a whirlwind ride?), Jerry Maguire (you complete me, internship?), Independence Day (apocalypse?), The Nutty Professor (research attendings on the wards?), Mission: Impossible (hmmm).

The Spice Girls were spreading girl power, this thing called the Internet was sort of catching on with 10 million (yes, that’s an “m,” not a “b”) users worldwide, and the dotcom era introduced us to eBay, which offered to sell your junk “online.”

In Scotland, Dolly the sheep was cloned and the world grappled with the ethical implications. In England, Diana and Charles divorced and cows became mad (coincidence?). Back home, Seinfeld, ER, and Friends teamed for “must-see” Thursday nights, the average car cost $16,000, and Federal Reserve Chairman Alan Greenspan wondered if the Dow Jones was overvalued at 6,400.

Oh, and on Aug. 15, the term “hospitalist” appeared in print for the first time, helping launch the fastest-growing medical specialty of all time.¹

Labor & Delivery

I remember as an intern seeing the article by Drs. Wachter and Goldman. I guess I didn’t get it, really. Was it that easy to create a new specialty? Just take something and add “ist” to the end? As interns, we excitedly begin to create new fields to describe our work: “dump-ologists,” “failure-to-thrive-ists,” “rectalists.” Much like Jamiroquai, however, our specialties never really caught on.

But HM did, and this month we celebrate 15 years. Now, I’ll recognize that its impossible to pin an exact date on the creation of a specialty, and in fact, hospitalists clearly existed prior to the term. But in terms of identifying a start date, Aug. 15, 1996, is as good as any.

The Early Days: Doing It

I don’t remember the day I became a hospitalist. It all sort of just flowed together. I finished residency, did a chief year where I taught, attended on the wards, and didn’t do any clinic, and then I took a job at the Denver VA, where I taught, attended on the wards, and didn’t do any clinic. It felt kind of all the same.

But from the outside, this was a significant transition point. Until this time, subspecialists or general internists, family medicine doctors, and pediatricians provided nearly all inpatient ward attending (and indeed, community inpatient care). I recall vividly the reaction of others; it was a mixture of amazement (you do what all year?), concern (you’ll burn out), apprehension (I won’t be able to care for my patients in the hospital), and enmity (you’ll destroy the fabric of internal medicine!).

And this was the point of the first few years: survival. These were the formative years. It was all about showing HM was a sustainable model that could enhance, not detract, from the system of care. And it had its very vocal critics, who saw it as a flash in the pan. They assumed it would go the way of the Tickle Me Elmo doll (a fad, for the record, that needed to die).

And this was the importance of the creation of the National Association of Inpatient Physicians (now SHM), HM textbooks, the development of hospitalist researchers, a national meeting, the creation of sustainable community hospitalist jobs, the growth of academic HM groups, and studies showing the model could indeed be implemented and wouldn’t negatively impact patient outcomes or outpatient provider satisfaction. These things legitimized the field, gave it legs, propelled it to the next phase.

The Next Phase: Doing it Cheaper

To be fair, HM is not all about the money. Even in the early days, it was recognized that at its pinnacle HM was about improving the patient experience—higher quality, safety, and satisfaction. That said, it was Medicare’s diagnosis-related group (DRG) that drove the model forward. To be clear, there were other factors that helped propel the HM movement: staffing issues, the rise in complexity of care, many PCPs and specialists willingly leaving the hospital. But in the end, the bottom line drove many hospital administrations to adopt the HM model.

Most hospital care is reimbursed via prospective payment, which means hospital reimbursement is, in a sense, determined upon admission. Every dollar of that DRG payment that isn’t spent is pocketed by the hospital as profit. As expected, specialists in hospital care were able to significantly reduce the length of hospital stay, costs of care, and, ultimately, save hospitals many dollars for each dollar of investment.

And to be clear, there was nothing unsavory about this. It wasn’t done through rationing care or reducing access, but rather through systematically reducing some of the estimated 30% waste in healthcare. This was shown in numerous studies, with a 2002 report estimating average savings at about 13% per patient cared for in the HM model.²

The Current Phase: Doing it Better

Pretty impressive, but mostly unsatisfying. Yes, as a group director that has negotiated for nearly a decade with hospital administrators, I’m well aware of the power of cost savings. Yet, I didn’t go into medicine to save money. I did so to help patients, enhance their experience, and improve outcomes. And indeed, there are data that hospitalists do this. Two 2002 papers showed that hospitalist groups could reduce readmission rates as well as inpatient and 30-day mortality.^3,4 A paper in 2004 showed that pairing hospitalists with orthopedic surgeons could reduce perioperative complications.⁵

Couple these studies with anecdotal experience and perusal of any issue of the Journal of Hospital Medicine, and its clear that hospitalists are fulfilling their promise of doing it better. But we have a long way to go. We must continue to innovative and create better, safer systems of care until we can be confident that not a single one of our patients is avoidably harmed by healthcare. That is the kind of care you’d want for your family member, for yourself.

Our Legacy, TBD

And here we are now, looking forward to the next 15 years. For many hospitalists, this will represent the twilight years of their careers. For others, it’ll be the formative years. What mark will we leave?

Clearly, the premium on patient safety and quality is increasing, morphing from word to deed as we speak. And hospitalists will find themselves in the middle of the fray. The healthcare reform alphabet soup calls for equal parts VBP and ACO, with a pinch of EHR, and a dash of PFP—boiled in a cost reduction. But more than ingredients, it requires a chef—someone to orchestrate the great change that is necessary in American healthcare.

Whether it’s leading inpatient safety, improving the quality of hospital care, bridging post-discharge transitions, or reducing readmissions, someone is required to tend these fires.

And I believe HM’s legacy will be forged in these flames of change. There is no single group as well positioned to impact the outcomes that matter most to healthcare reform now than hospitalists. In most hospitals, we will touch the majority of patients, control the spending of the majority of dollars, and be directly responsible for the majority of outcomes. This is an unfathomable position to be in for a specialty that is yet old enough to drive. Yet this is where we find ourselves.

Our legacy is being written. You are its author.

Dr. Glasheen is The Hospitalist’s physician editor.

References

1. Wachter RM, Goldman L. The emerging role of “hospitalists” in the American health care system. N Engl J Med. 1996;335:514-517.
2. Wachter RM, Goldman L. The hospitalist movement 5 years later. JAMA. 2002;287:487-494.
3. Auerbach AD, Wachter RM, Katz P, Showstack J, Baron RB, Goldman L. Implementation of a voluntary hospitalist service at a community teaching hospital: improved clinical efficiency and patient outcomes. Ann Intern Med. 2002;137:859-865.
4. Meltzer D, Manning WG, Morrison J, Shah MN, Jin L, Guth T, Levinson W. Effects of physician experience on costs and outcomes on an academic general medicine service: results of a trial of hospitalists. Ann Intern Med. 2002;137:866-874.
5. Huddleston JM, Long KH, Naessens JM, et. al. Medical and surgical comanagement after elective hip and knee arthroplasty: a randomized, controlled trial. Ann Intern Med. 2004;141:28-38.

For those of you who were kind enough to catch my column in last month’s issue of The Hospitalist (see “What Is Your Value,” p. 56), you spent a few minutes reading my thoughts on the value of hospitalists. I mentioned the fact that the U.S. is moving rapidly toward a value-based system of purchasing healthcare, and that all healthcare providers, including hospitalists, increasingly will be judged on the value of care they deliver to their patients and the healthcare system. (Remember, value=quality/cost.)

Hospitalists, like all other healthcare providers, can increase their “value” by improving the quality of care they provide and decreasing the cost of healthcare delivery. Seems simple enough, right? Take better care of patients and do so while minimizing unnecessary costs. (If you have figured out how to do this, I want to learn from you!)

As a doctor and as the leader of the hospitalist group at Beth Israel Deaconess Medical Center in Boston, I have given this topic considerable thought. How do I become a “high value” provider? How do I help my hospitalist colleagues become “high value” hospitalists? Another persistent thought that has crossed my mind is: “How do I know that I am not already a high-value hospitalist?”

Maybe all of my hospitalist colleagues at Beth Israel Deaconess Medical Center are high-value providers. Seems fair enough, right? Maybe each of us is providing “high quality” care and doing so while minimizing unnecessary costs.

I mean, who really wants to think of themselves as low-quality doctors spending a considerable amount of unnecessary resources?

Like many of you, it became evident to me that the first step to improving quality and/or decreasing cost is to define “quality” and “cost.”

The First Step

Although it might seem difficult for the individual hospitalist to know the cost of a patient’s hospitalization, such information is available, and your hospital administrator might be willing to share such information with you and your group. But when it comes to quality of care, I think most patients would expect that doctors should understand the definition of “high-quality care.”

So, what is the definition of “high-quality care?” Try asking this question of patients and doctors, and you are likely to get very different answers. Not surprised? Try asking this question just to doctors, and you are likely to get some different answers. (For fun, you could try this exercise with your hospitalist colleagues; I have.)

Honestly, none of us should be alarmed if a group of doctors cannot easily define “high-quality care.” Not being able to do so does not mean these are “bad” doctors. While it may not be easy to define high-quality care, I suspect most of us recognize it when we see it.

The process of defining the quality of care involves capturing the essence of what we see. For example, can we agree that prescribing aspirin for patients with acute coronary syndrome is optimal care? If so, it stands to reason that a patient with acute coronary syndrome who did not receive aspirin received suboptimal care.

This is how a group of hospitalists can go about creating a quality standard. If you are a hospitalist or HM group leader who is interested in improving the quality of care you and your colleagues are providing to your patients, defining a quality standard is the critical first step to process improvement. Do not limit yourself to clinical processes. Although clinical processes are important, so are communication and documentation processes.

For example, most of us, as hospitalists, believe that communication with outpatient providers is important to the provision of high-quality inpatient care. How often do your hospitalists communicate with patients’ primary-care providers? Is this a quality standard for your hospitalist group? What about the documentation of a patient’s code status at the time of admission or documentation of a patient’s functional status in the discharge summary?

If you believe these are important, your group should include these as quality standards. You should be measuring them and reporting the results to individual providers.

Start with Definition

At this point, some of us might be tempted to get ahead of ourselves and worry about what standards we can or cannot measure, but I urge you to complete this first step of defining “high-quality care” before worrying about anything else. (In other words, don’t start running before you can walk.)

Another suggestion: Please don’t try to do too much all at once. Nobody is going to argue that patients with acute coronary syndrome should not receive aspirin. Reaching consensus on other quality standards might not be as easy. But do not get bogged down trying to create too many quality standards all at once. Start with a few and get yourself and your colleagues accustomed to the process.

Remember, when it comes to doctors, we have centuries of history of not knowing exactly what we are doing. I hope it won’t take centuries to fix this problem, but I also know we are not going to fix this in a few days or weeks. Small victories along the way are important if we hope to succeed.

Once you and your hospitalist colleagues arrive at a mutually agreed upon quality standard, the next step is performance measurement. I honestly believe performance measurement is easy when we spend the time understanding and agreeing to the most appropriate quality standards for our hospitalist groups.

I am interested in learning about your efforts to define the quality standards for your hospitalist group. Feel free to email me at [email protected].

Dr. Li is president of SHM.

For those of you who were kind enough to catch my column in last month’s issue of The Hospitalist (see “What Is Your Value,” p. 56), you spent a few minutes reading my thoughts on the value of hospitalists. I mentioned the fact that the U.S. is moving rapidly toward a value-based system of purchasing healthcare, and that all healthcare providers, including hospitalists, increasingly will be judged on the value of care they deliver to their patients and the healthcare system. (Remember, value=quality/cost.)

Hospitalists, like all other healthcare providers, can increase their “value” by improving the quality of care they provide and decreasing the cost of healthcare delivery. Seems simple enough, right? Take better care of patients and do so while minimizing unnecessary costs. (If you have figured out how to do this, I want to learn from you!)

As a doctor and as the leader of the hospitalist group at Beth Israel Deaconess Medical Center in Boston, I have given this topic considerable thought. How do I become a “high value” provider? How do I help my hospitalist colleagues become “high value” hospitalists? Another persistent thought that has crossed my mind is: “How do I know that I am not already a high-value hospitalist?”

Maybe all of my hospitalist colleagues at Beth Israel Deaconess Medical Center are high-value providers. Seems fair enough, right? Maybe each of us is providing “high quality” care and doing so while minimizing unnecessary costs.

I mean, who really wants to think of themselves as low-quality doctors spending a considerable amount of unnecessary resources?

Like many of you, it became evident to me that the first step to improving quality and/or decreasing cost is to define “quality” and “cost.”

The First Step

Although it might seem difficult for the individual hospitalist to know the cost of a patient’s hospitalization, such information is available, and your hospital administrator might be willing to share such information with you and your group. But when it comes to quality of care, I think most patients would expect that doctors should understand the definition of “high-quality care.”

So, what is the definition of “high-quality care?” Try asking this question of patients and doctors, and you are likely to get very different answers. Not surprised? Try asking this question just to doctors, and you are likely to get some different answers. (For fun, you could try this exercise with your hospitalist colleagues; I have.)

Honestly, none of us should be alarmed if a group of doctors cannot easily define “high-quality care.” Not being able to do so does not mean these are “bad” doctors. While it may not be easy to define high-quality care, I suspect most of us recognize it when we see it.

The process of defining the quality of care involves capturing the essence of what we see. For example, can we agree that prescribing aspirin for patients with acute coronary syndrome is optimal care? If so, it stands to reason that a patient with acute coronary syndrome who did not receive aspirin received suboptimal care.

This is how a group of hospitalists can go about creating a quality standard. If you are a hospitalist or HM group leader who is interested in improving the quality of care you and your colleagues are providing to your patients, defining a quality standard is the critical first step to process improvement. Do not limit yourself to clinical processes. Although clinical processes are important, so are communication and documentation processes.

For example, most of us, as hospitalists, believe that communication with outpatient providers is important to the provision of high-quality inpatient care. How often do your hospitalists communicate with patients’ primary-care providers? Is this a quality standard for your hospitalist group? What about the documentation of a patient’s code status at the time of admission or documentation of a patient’s functional status in the discharge summary?

If you believe these are important, your group should include these as quality standards. You should be measuring them and reporting the results to individual providers.

Start with Definition

At this point, some of us might be tempted to get ahead of ourselves and worry about what standards we can or cannot measure, but I urge you to complete this first step of defining “high-quality care” before worrying about anything else. (In other words, don’t start running before you can walk.)

Another suggestion: Please don’t try to do too much all at once. Nobody is going to argue that patients with acute coronary syndrome should not receive aspirin. Reaching consensus on other quality standards might not be as easy. But do not get bogged down trying to create too many quality standards all at once. Start with a few and get yourself and your colleagues accustomed to the process.

Remember, when it comes to doctors, we have centuries of history of not knowing exactly what we are doing. I hope it won’t take centuries to fix this problem, but I also know we are not going to fix this in a few days or weeks. Small victories along the way are important if we hope to succeed.

Once you and your hospitalist colleagues arrive at a mutually agreed upon quality standard, the next step is performance measurement. I honestly believe performance measurement is easy when we spend the time understanding and agreeing to the most appropriate quality standards for our hospitalist groups.

I am interested in learning about your efforts to define the quality standards for your hospitalist group. Feel free to email me at [email protected].

Dr. Li is president of SHM.

For those of you who were kind enough to catch my column in last month’s issue of The Hospitalist (see “What Is Your Value,” p. 56), you spent a few minutes reading my thoughts on the value of hospitalists. I mentioned the fact that the U.S. is moving rapidly toward a value-based system of purchasing healthcare, and that all healthcare providers, including hospitalists, increasingly will be judged on the value of care they deliver to their patients and the healthcare system. (Remember, value=quality/cost.)

Hospitalists, like all other healthcare providers, can increase their “value” by improving the quality of care they provide and decreasing the cost of healthcare delivery. Seems simple enough, right? Take better care of patients and do so while minimizing unnecessary costs. (If you have figured out how to do this, I want to learn from you!)

As a doctor and as the leader of the hospitalist group at Beth Israel Deaconess Medical Center in Boston, I have given this topic considerable thought. How do I become a “high value” provider? How do I help my hospitalist colleagues become “high value” hospitalists? Another persistent thought that has crossed my mind is: “How do I know that I am not already a high-value hospitalist?”

Maybe all of my hospitalist colleagues at Beth Israel Deaconess Medical Center are high-value providers. Seems fair enough, right? Maybe each of us is providing “high quality” care and doing so while minimizing unnecessary costs.

I mean, who really wants to think of themselves as low-quality doctors spending a considerable amount of unnecessary resources?

Like many of you, it became evident to me that the first step to improving quality and/or decreasing cost is to define “quality” and “cost.”

The First Step

Although it might seem difficult for the individual hospitalist to know the cost of a patient’s hospitalization, such information is available, and your hospital administrator might be willing to share such information with you and your group. But when it comes to quality of care, I think most patients would expect that doctors should understand the definition of “high-quality care.”

So, what is the definition of “high-quality care?” Try asking this question of patients and doctors, and you are likely to get very different answers. Not surprised? Try asking this question just to doctors, and you are likely to get some different answers. (For fun, you could try this exercise with your hospitalist colleagues; I have.)

Honestly, none of us should be alarmed if a group of doctors cannot easily define “high-quality care.” Not being able to do so does not mean these are “bad” doctors. While it may not be easy to define high-quality care, I suspect most of us recognize it when we see it.

The process of defining the quality of care involves capturing the essence of what we see. For example, can we agree that prescribing aspirin for patients with acute coronary syndrome is optimal care? If so, it stands to reason that a patient with acute coronary syndrome who did not receive aspirin received suboptimal care.

This is how a group of hospitalists can go about creating a quality standard. If you are a hospitalist or HM group leader who is interested in improving the quality of care you and your colleagues are providing to your patients, defining a quality standard is the critical first step to process improvement. Do not limit yourself to clinical processes. Although clinical processes are important, so are communication and documentation processes.

For example, most of us, as hospitalists, believe that communication with outpatient providers is important to the provision of high-quality inpatient care. How often do your hospitalists communicate with patients’ primary-care providers? Is this a quality standard for your hospitalist group? What about the documentation of a patient’s code status at the time of admission or documentation of a patient’s functional status in the discharge summary?

If you believe these are important, your group should include these as quality standards. You should be measuring them and reporting the results to individual providers.

Start with Definition

At this point, some of us might be tempted to get ahead of ourselves and worry about what standards we can or cannot measure, but I urge you to complete this first step of defining “high-quality care” before worrying about anything else. (In other words, don’t start running before you can walk.)

Another suggestion: Please don’t try to do too much all at once. Nobody is going to argue that patients with acute coronary syndrome should not receive aspirin. Reaching consensus on other quality standards might not be as easy. But do not get bogged down trying to create too many quality standards all at once. Start with a few and get yourself and your colleagues accustomed to the process.

Remember, when it comes to doctors, we have centuries of history of not knowing exactly what we are doing. I hope it won’t take centuries to fix this problem, but I also know we are not going to fix this in a few days or weeks. Small victories along the way are important if we hope to succeed.

Once you and your hospitalist colleagues arrive at a mutually agreed upon quality standard, the next step is performance measurement. I honestly believe performance measurement is easy when we spend the time understanding and agreeing to the most appropriate quality standards for our hospitalist groups.

I am interested in learning about your efforts to define the quality standards for your hospitalist group. Feel free to email me at [email protected].

Dr. Li is president of SHM.

In his June 3 blog post at CIO.com, Tom Kaneshige asks: “Can the iPad cure what ails us?” He goes on to describe new applications for iPads in Texas hospitals, including the remote monitoring of patients’ EKGs by nurses roaming the hospital.

“The big revolution in tablet computing for hospitalists, which has been right around the corner for the past decade, hasn’t quite arrived yet,” says Russ Cucina, MD, MS, hospitalist and medical director of information technology at the University of California San Francisco Medical Center. “But I think we’re getting close, even though I’m not convinced that the iPad will be the vehicle.”

One of the hallmarks of such a technological revolution will be to free up hospitalists and other workers from computer work stations, where they are increasingly removed from face-to-face interactions. “Something gets lost in the name of efficiency,” Dr. Cucina says.

Hurdles to the tablet revolution include:

• Short battery life and the lack of rechargeable batteries. “Doctors need to be on the floor longer than eight hours,” Dr. Cucina says.
• Interacting with a tablet using thumbs and a touchscreen is fundamentally different from using a laptop, and applications should recognize the differences.
• Wireless access to secure electronic health records (EHR) throughout the hospital. “This is more of a cost issue than a technical problem,” Dr. Cucina explains. “It’s also incumbent upon us as physicians to develop good security practices with our tablets.”
• The skills to use the screen in the presence of others—in other words, What is the proper etiquette in front of care team members, patients, their families, etc.?

Hospitalists Look to Partner with New Quality Institute

Don’t be surprised if HM eventually gets a piece of the new Armstrong Institute for Patient Safety and Quality at Johns Hopkins University School of Medicine in Baltimore.

The center, funded through a $10 million gift from Johns Hopkins Medicine board of trustees chairman C. Michael Armstrong, will become the umbrella arm in charge of reducing preventable harm and improving healthcare quality.

Eric Howell, MD, SFHM, associate professor of medicine at Johns Hopkins University and director of Johns Hopkins Bayview Medical Center’s HM division, already sees that as hospitalist turf and could easily see HM partnering with the new institute. Dr. Howell, who already has reached out to the institute’s head, checklist guru Peter Pronovost, MD, PhD, wrote in an email to The Hospitalist: “Hospitalists at Hopkins have a long tradition of exactly this type of work.”

Dr. Howell points to recent HM-driven research and initiatives to reduce “red alerts,” the term for ambulance diversions in the ICU, and streamlining the admission process to allow outpatient doctors to bypass the ED for patients for whom hospitalist admission is needed. At Howard County General Hospital, a suburb about 15 miles southwest of Baltimore, the HM group is running all rapid response team (RRT) events.

“In short,” Dr. Howell writes, “the Armstrong Institute will find hospitalists to be a willing partner.”

Hospitalists Must Prepare for Primary-Care Shortfalls

The Milwaukee-based American Society for Quality (ASQ) recently surveyed healthcare quality professionals about anticipated shortages of primary-care physicians (PCPs) and other medical staff, particularly as more Americans gain health insurance under the Accountable Care Act and Medicare). The trend is real, says Joseph Fortuna, MD, chair of ASQ’s Health Care Division, and hospitalists will face challenges in discharging patients who lack a defined PCP.

Survey respondents highlighted some strategies for dealing with the primary-care shortage, including the EHR for improving efficiency, teamwork, and checklists. Dr. Fortuna suggests HM groups:

• Work with PCPs and federally qualified health centers to enhance integrated relationships and improve handoffs. Local public health departments will be important collaborators.
• Define quality not just clinically, but also in terms of financial, operational, and cultural domains, using techniques of change management, root cause analysis, and other quality tools.
• Be involved in patient-centered medical homes as “catalysts, coordinators, and facilitators.”

HM Group Redesigns Workflow to Comply with ACGME Rules and Improve Continuity

As academic HM groups react to the new Accreditation Council for Graduation Medical Education (ACGME) guidelines on how long residents can work, they might want to keep the Toyota Production System (TPS) in mind.

Diana Mancini, MD, a hospitalist at Denver Health Medical Center and associate program director of the University of Colorado Internal Medicine Residency, presented data in the Research, Innovations, and Clinical Vignettes competition at HM11 that showed how the use of continuous workflow and standardized tasks—hallmarks of TPS—helped redesign the medicine ward system to both comply with the ACGME rules and improve continuity of care.

The project replaced the traditional call system, and its corresponding floats and moonlighters, with a shift system comprised of two teams of six interns and three residents. At night, one intern worked a “continuity shift.” Using administrative data, Dr. Mancini and colleagues projected that 89% of patients admitted on a continuity shift would be discharged by the end of that intern’s five consecutive shifts. And, by dividing admissions among two teams, the “bolus” effect was halved, she says.

“The continuity shift is crucial for both the patient safety/continuity and educational content/value for the housestaff,” Dr. Mancini wrote in an email. “With the new work hours coming ... the hours would have to be adjusted … but the continuity could most certainly be maintained.”

Feds Delay Deadline for Stage 2 “Meaningful Use” Application Process

If your HM group is among the first cohort that reaches Stage 1 attestation this year for meaningful use of electronic health records (EHR), you may get more time to reach Stage 2. The federal Health Information Technology (HIT) policy committee has voted for a 12-month delay in implementing the criteria for that second stage, agreeing with those who say the current deadline of October 2013 “poses a nearly insurmountable timing challenge.”

The HIT is pushing to delay the deadline until 2014, which would mean providers have three years to verify that they have met Stage 1 meaningful use requirements, according to Government HealthIT. A cadre of medical trade groups, led by the AMA, is now pushing the Department of Health and Human Services to adopt the new timeline.

The ultimate decision rests with the Centers for Medicaid & Medicare Services (CMS).

By the numbers

Number of months without a central-line-associated bloodstream infection (BSI) on the eight-bed ICU at Beaufort Memorial Hospital, a 197-bed community hospital in Beaufort, S.C.

The hospital, which had a higher rate of BSIs than the national average in 2005, created a team to reduce its BSIs, led by infection-prevention specialist Beverly Yoder, RN, and involving hospitalists. Beaufort joined the Institute for Healthcare Improvement’s 100K Lives Campaign and the South Carolina Hospital Association’s Stop BSI Project.

The team implemented a central-line “bundle” of quality practices, then simplified the bundle and incorporated it into its EHR. The unit celebrated its 30-month achievement with a luncheon in June.

For information, contact critical-care director Diane Razo, RN, MSN, PCCN, at [email protected]. (For more information about central-line infection prevention, visit SHM's Resource Room (www.hospitalmedicine.org/resource)

In his June 3 blog post at CIO.com, Tom Kaneshige asks: “Can the iPad cure what ails us?” He goes on to describe new applications for iPads in Texas hospitals, including the remote monitoring of patients’ EKGs by nurses roaming the hospital.

“The big revolution in tablet computing for hospitalists, which has been right around the corner for the past decade, hasn’t quite arrived yet,” says Russ Cucina, MD, MS, hospitalist and medical director of information technology at the University of California San Francisco Medical Center. “But I think we’re getting close, even though I’m not convinced that the iPad will be the vehicle.”

One of the hallmarks of such a technological revolution will be to free up hospitalists and other workers from computer work stations, where they are increasingly removed from face-to-face interactions. “Something gets lost in the name of efficiency,” Dr. Cucina says.

Hurdles to the tablet revolution include:

• Short battery life and the lack of rechargeable batteries. “Doctors need to be on the floor longer than eight hours,” Dr. Cucina says.
• Interacting with a tablet using thumbs and a touchscreen is fundamentally different from using a laptop, and applications should recognize the differences.
• Wireless access to secure electronic health records (EHR) throughout the hospital. “This is more of a cost issue than a technical problem,” Dr. Cucina explains. “It’s also incumbent upon us as physicians to develop good security practices with our tablets.”
• The skills to use the screen in the presence of others—in other words, What is the proper etiquette in front of care team members, patients, their families, etc.?

Hospitalists Look to Partner with New Quality Institute

Don’t be surprised if HM eventually gets a piece of the new Armstrong Institute for Patient Safety and Quality at Johns Hopkins University School of Medicine in Baltimore.

The center, funded through a $10 million gift from Johns Hopkins Medicine board of trustees chairman C. Michael Armstrong, will become the umbrella arm in charge of reducing preventable harm and improving healthcare quality.

Eric Howell, MD, SFHM, associate professor of medicine at Johns Hopkins University and director of Johns Hopkins Bayview Medical Center’s HM division, already sees that as hospitalist turf and could easily see HM partnering with the new institute. Dr. Howell, who already has reached out to the institute’s head, checklist guru Peter Pronovost, MD, PhD, wrote in an email to The Hospitalist: “Hospitalists at Hopkins have a long tradition of exactly this type of work.”

Dr. Howell points to recent HM-driven research and initiatives to reduce “red alerts,” the term for ambulance diversions in the ICU, and streamlining the admission process to allow outpatient doctors to bypass the ED for patients for whom hospitalist admission is needed. At Howard County General Hospital, a suburb about 15 miles southwest of Baltimore, the HM group is running all rapid response team (RRT) events.

“In short,” Dr. Howell writes, “the Armstrong Institute will find hospitalists to be a willing partner.”

Hospitalists Must Prepare for Primary-Care Shortfalls

The Milwaukee-based American Society for Quality (ASQ) recently surveyed healthcare quality professionals about anticipated shortages of primary-care physicians (PCPs) and other medical staff, particularly as more Americans gain health insurance under the Accountable Care Act and Medicare). The trend is real, says Joseph Fortuna, MD, chair of ASQ’s Health Care Division, and hospitalists will face challenges in discharging patients who lack a defined PCP.

Survey respondents highlighted some strategies for dealing with the primary-care shortage, including the EHR for improving efficiency, teamwork, and checklists. Dr. Fortuna suggests HM groups:

• Work with PCPs and federally qualified health centers to enhance integrated relationships and improve handoffs. Local public health departments will be important collaborators.
• Define quality not just clinically, but also in terms of financial, operational, and cultural domains, using techniques of change management, root cause analysis, and other quality tools.
• Be involved in patient-centered medical homes as “catalysts, coordinators, and facilitators.”

HM Group Redesigns Workflow to Comply with ACGME Rules and Improve Continuity

As academic HM groups react to the new Accreditation Council for Graduation Medical Education (ACGME) guidelines on how long residents can work, they might want to keep the Toyota Production System (TPS) in mind.

Diana Mancini, MD, a hospitalist at Denver Health Medical Center and associate program director of the University of Colorado Internal Medicine Residency, presented data in the Research, Innovations, and Clinical Vignettes competition at HM11 that showed how the use of continuous workflow and standardized tasks—hallmarks of TPS—helped redesign the medicine ward system to both comply with the ACGME rules and improve continuity of care.

The project replaced the traditional call system, and its corresponding floats and moonlighters, with a shift system comprised of two teams of six interns and three residents. At night, one intern worked a “continuity shift.” Using administrative data, Dr. Mancini and colleagues projected that 89% of patients admitted on a continuity shift would be discharged by the end of that intern’s five consecutive shifts. And, by dividing admissions among two teams, the “bolus” effect was halved, she says.

“The continuity shift is crucial for both the patient safety/continuity and educational content/value for the housestaff,” Dr. Mancini wrote in an email. “With the new work hours coming ... the hours would have to be adjusted … but the continuity could most certainly be maintained.”

Feds Delay Deadline for Stage 2 “Meaningful Use” Application Process

If your HM group is among the first cohort that reaches Stage 1 attestation this year for meaningful use of electronic health records (EHR), you may get more time to reach Stage 2. The federal Health Information Technology (HIT) policy committee has voted for a 12-month delay in implementing the criteria for that second stage, agreeing with those who say the current deadline of October 2013 “poses a nearly insurmountable timing challenge.”

The HIT is pushing to delay the deadline until 2014, which would mean providers have three years to verify that they have met Stage 1 meaningful use requirements, according to Government HealthIT. A cadre of medical trade groups, led by the AMA, is now pushing the Department of Health and Human Services to adopt the new timeline.

The ultimate decision rests with the Centers for Medicaid & Medicare Services (CMS).

By the numbers

Number of months without a central-line-associated bloodstream infection (BSI) on the eight-bed ICU at Beaufort Memorial Hospital, a 197-bed community hospital in Beaufort, S.C.

The hospital, which had a higher rate of BSIs than the national average in 2005, created a team to reduce its BSIs, led by infection-prevention specialist Beverly Yoder, RN, and involving hospitalists. Beaufort joined the Institute for Healthcare Improvement’s 100K Lives Campaign and the South Carolina Hospital Association’s Stop BSI Project.

The team implemented a central-line “bundle” of quality practices, then simplified the bundle and incorporated it into its EHR. The unit celebrated its 30-month achievement with a luncheon in June.

For information, contact critical-care director Diane Razo, RN, MSN, PCCN, at [email protected]. (For more information about central-line infection prevention, visit SHM's Resource Room (www.hospitalmedicine.org/resource)

In his June 3 blog post at CIO.com, Tom Kaneshige asks: “Can the iPad cure what ails us?” He goes on to describe new applications for iPads in Texas hospitals, including the remote monitoring of patients’ EKGs by nurses roaming the hospital.

“The big revolution in tablet computing for hospitalists, which has been right around the corner for the past decade, hasn’t quite arrived yet,” says Russ Cucina, MD, MS, hospitalist and medical director of information technology at the University of California San Francisco Medical Center. “But I think we’re getting close, even though I’m not convinced that the iPad will be the vehicle.”

One of the hallmarks of such a technological revolution will be to free up hospitalists and other workers from computer work stations, where they are increasingly removed from face-to-face interactions. “Something gets lost in the name of efficiency,” Dr. Cucina says.

Hurdles to the tablet revolution include:

• Short battery life and the lack of rechargeable batteries. “Doctors need to be on the floor longer than eight hours,” Dr. Cucina says.
• Interacting with a tablet using thumbs and a touchscreen is fundamentally different from using a laptop, and applications should recognize the differences.
• Wireless access to secure electronic health records (EHR) throughout the hospital. “This is more of a cost issue than a technical problem,” Dr. Cucina explains. “It’s also incumbent upon us as physicians to develop good security practices with our tablets.”
• The skills to use the screen in the presence of others—in other words, What is the proper etiquette in front of care team members, patients, their families, etc.?

Hospitalists Look to Partner with New Quality Institute

Don’t be surprised if HM eventually gets a piece of the new Armstrong Institute for Patient Safety and Quality at Johns Hopkins University School of Medicine in Baltimore.

The center, funded through a $10 million gift from Johns Hopkins Medicine board of trustees chairman C. Michael Armstrong, will become the umbrella arm in charge of reducing preventable harm and improving healthcare quality.

Eric Howell, MD, SFHM, associate professor of medicine at Johns Hopkins University and director of Johns Hopkins Bayview Medical Center’s HM division, already sees that as hospitalist turf and could easily see HM partnering with the new institute. Dr. Howell, who already has reached out to the institute’s head, checklist guru Peter Pronovost, MD, PhD, wrote in an email to The Hospitalist: “Hospitalists at Hopkins have a long tradition of exactly this type of work.”

Dr. Howell points to recent HM-driven research and initiatives to reduce “red alerts,” the term for ambulance diversions in the ICU, and streamlining the admission process to allow outpatient doctors to bypass the ED for patients for whom hospitalist admission is needed. At Howard County General Hospital, a suburb about 15 miles southwest of Baltimore, the HM group is running all rapid response team (RRT) events.

“In short,” Dr. Howell writes, “the Armstrong Institute will find hospitalists to be a willing partner.”

Hospitalists Must Prepare for Primary-Care Shortfalls

The Milwaukee-based American Society for Quality (ASQ) recently surveyed healthcare quality professionals about anticipated shortages of primary-care physicians (PCPs) and other medical staff, particularly as more Americans gain health insurance under the Accountable Care Act and Medicare). The trend is real, says Joseph Fortuna, MD, chair of ASQ’s Health Care Division, and hospitalists will face challenges in discharging patients who lack a defined PCP.

Survey respondents highlighted some strategies for dealing with the primary-care shortage, including the EHR for improving efficiency, teamwork, and checklists. Dr. Fortuna suggests HM groups:

• Work with PCPs and federally qualified health centers to enhance integrated relationships and improve handoffs. Local public health departments will be important collaborators.
• Define quality not just clinically, but also in terms of financial, operational, and cultural domains, using techniques of change management, root cause analysis, and other quality tools.
• Be involved in patient-centered medical homes as “catalysts, coordinators, and facilitators.”

HM Group Redesigns Workflow to Comply with ACGME Rules and Improve Continuity

As academic HM groups react to the new Accreditation Council for Graduation Medical Education (ACGME) guidelines on how long residents can work, they might want to keep the Toyota Production System (TPS) in mind.

Diana Mancini, MD, a hospitalist at Denver Health Medical Center and associate program director of the University of Colorado Internal Medicine Residency, presented data in the Research, Innovations, and Clinical Vignettes competition at HM11 that showed how the use of continuous workflow and standardized tasks—hallmarks of TPS—helped redesign the medicine ward system to both comply with the ACGME rules and improve continuity of care.

The project replaced the traditional call system, and its corresponding floats and moonlighters, with a shift system comprised of two teams of six interns and three residents. At night, one intern worked a “continuity shift.” Using administrative data, Dr. Mancini and colleagues projected that 89% of patients admitted on a continuity shift would be discharged by the end of that intern’s five consecutive shifts. And, by dividing admissions among two teams, the “bolus” effect was halved, she says.

“The continuity shift is crucial for both the patient safety/continuity and educational content/value for the housestaff,” Dr. Mancini wrote in an email. “With the new work hours coming ... the hours would have to be adjusted … but the continuity could most certainly be maintained.”

Feds Delay Deadline for Stage 2 “Meaningful Use” Application Process

If your HM group is among the first cohort that reaches Stage 1 attestation this year for meaningful use of electronic health records (EHR), you may get more time to reach Stage 2. The federal Health Information Technology (HIT) policy committee has voted for a 12-month delay in implementing the criteria for that second stage, agreeing with those who say the current deadline of October 2013 “poses a nearly insurmountable timing challenge.”

The HIT is pushing to delay the deadline until 2014, which would mean providers have three years to verify that they have met Stage 1 meaningful use requirements, according to Government HealthIT. A cadre of medical trade groups, led by the AMA, is now pushing the Department of Health and Human Services to adopt the new timeline.

The ultimate decision rests with the Centers for Medicaid & Medicare Services (CMS).

By the numbers

Number of months without a central-line-associated bloodstream infection (BSI) on the eight-bed ICU at Beaufort Memorial Hospital, a 197-bed community hospital in Beaufort, S.C.

The hospital, which had a higher rate of BSIs than the national average in 2005, created a team to reduce its BSIs, led by infection-prevention specialist Beverly Yoder, RN, and involving hospitalists. Beaufort joined the Institute for Healthcare Improvement’s 100K Lives Campaign and the South Carolina Hospital Association’s Stop BSI Project.

The team implemented a central-line “bundle” of quality practices, then simplified the bundle and incorporated it into its EHR. The unit celebrated its 30-month achievement with a luncheon in June.

For information, contact critical-care director Diane Razo, RN, MSN, PCCN, at [email protected]. (For more information about central-line infection prevention, visit SHM's Resource Room (www.hospitalmedicine.org/resource)

Case

A 79-year-old male with coronary artery disease, hypertension, non-insulin-dependent mellitus, moderate dementia, and chronic renal insufficiency is admitted after a fall evaluation. He is widowed and lives in an assisted living facility. He’s accompanied by his niece, is alert, and oriented to person. He thinks he is in a clinic and is unable to state the year, but the remainder of the examination is unremarkable. His labs are notable for potassium of 6.3 mmol/L, BUN of 78 mg/dL, and Cr of 3.7 mg/dL. The niece reports that the patient is not fond of medical care, thus the most recent labs are from two years ago (and indicate a BUN of 39 and Cr of 2.8, with an upward trend over the past decade). You discuss possible long-term need for dialysis with the patient and niece, and the patient clearly states "no." However, he also states that it is 1988. How do you determine if he has the capacity to make decisions?

Overview

Hospitalists are familiar with the doctrine of informed consent—describing a disease, treatment options, associated risks and benefits, potential for complications, and alternatives, including no treatment. Not only must the patient be informed, and the decision free from any coercion, but the patient also must have capacity to make the decision.

Hospitalists often care for patients in whom decision-making capacity comes into question. This includes populations with depression, psychosis, dementia, stroke, severe personality disorders, developmental delay, comatose patients, as well as those with impaired attentional capacity (e.g. acute pain) or general debility (e.g. metastatic cancer).^1,2

ave for the comatose patient, whether the patient has capacity might not be obvious. However, addressing the components of capacity (communication, understanding, appreciation, and rationalization) by using a validated clinical tool, such as the MacCAT-T, or more simply by systematically applying those four components to the clinical scenario under consideration, hospitalists can make this determination.

Review of the Literature

It is important to differentiate capacity from competency. Competency is a global assessment and a legal determination made by a judge in court. Capacity, on the other hand, is a functional assessment regarding a particular decision. Capacity is not static, and it can be performed by any clinician familiar with the patient. A hospitalist often is well positioned to make a capacity determination given established rapport with the patient and familiarity with the details of the case.

To make this determination, a hospitalist needs to know how to assess capacity. Although capacity usually is defined by state law and varies by jurisdiction, clinicians generally can assume it includes one or more of the four key components:

• Communication. The patient needs to be able to express a treatment choice, and this decision needs to be stable enough for the treatment to be implemented. Changing one’s decision in itself would not bring a patient’s capacity into question, so long as the patient was able to explain the rationale behind the switch. Frequent changes back and forth in the decision-making, however, could be indicative of an underlying psychiatric disorder or extreme indecision, which could bring capacity into question.
• Understanding. The patient needs to recall conversations about treatment, to make the link between causal relationships, and to process probabilities for outcomes. Problems with memory, attention span, and intelligence can affect one’s understanding.
• Appreciation. The patient should be able to identify the illness, treatment options, and likely outcomes as things that will affect him or her directly. A lack of appreciation usually stems from a denial based on intelligence (lack of a capability to understand) or emotion, or a delusion that the patient is not affected by this situation the same way and will have a different outcome.
• Rationalization or reasoning. The patient needs to be able to weigh the risks and benefits of the treatment options presented to come to a conclusion in keeping with their goals and best interests, as defined by their personal set of values. This often is affected in psychosis, depression, anxiety, phobias, delirium, and dementia.³

Several clinical capacity tools have been developed to assess these components:

Clinical tools.

The Mini-Mental Status Examination (MMSE) is a bedside test of a patient’s cognitive function, with scores ranging from 0 to 30.⁴ Although it wasn’t developed for assessing decision-making capacity, it has been compared with expert evaluation for assessment of capacity; the test performs reasonably well, particularly with high and low scores. Specifically, a MMSE >24 has a negative likelihood ratio (LR) of 0.05 for lack of capacity, while a MMSE <16 has a positive LR of 15.⁵ Scores from 17 to 23 do not correlate well with capacity, and further testing would be necessary. It is easy to administer, requires no formal training, and is familiar to most hospitalists. However, it does not address any specific aspects of informed consent, such as understanding or choice, and has not been validated in patients with mental illness.

The MacArthur Competence Assessment Tools for Treatment (MacCAT-T) is regarded as the gold standard for capacity assessment aids. It utilizes hospital chart review followed by a semi-structured interview to address clinical issues relevant to the patient being assessed; it takes 15 to 20 minutes to complete.⁶ The test provides scores in each of the four domains (choice, understanding, appreciation, and reasoning) of capacity. It has been validated in patients with dementia, schizophrenia, and depression. Limiting its clinical applicability is the fact that the MacCAT-T requires training to administer and interpret the results, though this is a relatively brief process.

The Capacity to Consent to Treatment Instrument (CCTI) uses hypothetical clinical vignettes in a structured interview to assess capacity across all four domains. The tool was developed and validated in patients with dementia and Parkinson’s disease, and takes 20 to 25 minutes to complete.⁷ A potential limitation is the CCTI’s use of vignettes as opposed to a patient-specific discussion, which could lead to different patient answers and a false assessment of the patient’s capacity.

The Hopemont Capacity Assessment Interview (HCAI) utilizes hypothetical vignettes in a semi-structured interview format to assess understanding, appreciation, choice, and likely reasoning.^8,9 Similar to CCTI, HCAI is not modified for individual patients. Rather, it uses clinical vignettes to gauge a patient’s ability to make decisions. The test takes 30 to 60 minutes to administer and performs less well in assessing appreciation and reasoning than the MacCAT-T and CCTI.¹⁰

It is not necessary to perform a formal assessment of capacity on every inpatient. For most, there is no reasonable concern for impaired capacity, obviating the need for formal testing. Likewise, in patients who clearly lack capacity, such as those with end-stage dementia or established guardians, formal reassessment usually is not required. Formal testing is most useful in situations in which capacity is unclear, disagreement amongst surrogate decision-makers exists, or judicial involvement is anticipated.

The MacCAT-T has been validated in the broadest population and is probably the most clinically useful tool currently available. The MMSE is an attractive alternative because of its widespread use and familiarity; however, it is imprecise with scores from 17 to 23, limiting its applicability.

click for large version

At a minimum, familiarity with the core legal standards of capacity (communication of choice, understanding, appreciation, and reasoning) will improve a hospitalist’s ability to identify patients who lack capacity. Understanding and applying the defined markers most often provides a sufficient capacity evaluation in itself. As capacity is not static, the decision usually requires more than one assessment.

Equally, deciding that a patient lacks capacity is not an end in itself, and the underlying cause should be addressed. Certain factors, such as infection, medication, time of day, and relationship with the clinician doing the assessment, can affect a patient’s capacity. These should be addressed through treatment, education, and social support whenever possible in order to optimize a patient’s performance during the capacity evaluation. If the decision can be delayed until a time when the patient can regain capacity, this should be done in order to maximize the patient’s autonomy.¹¹

Risk-related standards of capacity.

Although some question the notion, given our desire to facilitate management beneficial to the patient, the general consensus is that we have a lower threshold for capacity for consent to treatments that are low-risk and high-benefit.^12,13 We would then have a somewhat higher threshold for capacity to refuse that same treatment. Stemming from a desire to protect patients from harm, we have a relatively higher threshold for capacity to make decisions regarding high-risk, low-benefit treatments. For the remainder of cases (low risk/low benefit; high risk/high benefit), as well as treatments that significantly impact a patient’s lifestyle (e.g. dialysis, amputation), we have a low capacity to let patients decide for themselves.^11,14

Other considerations.

Clinicians should be thorough in documenting details in coming to a capacity determination, both as a means to formalize the thought process running through the four determinants of capacity, and in order to document for future reference. Cases in which it could be reasonable to call a consultant for those familiar with the assessment basics include:

• Cases in which a determination of lack of capacity could adversely affect the hospitalist’s relationship with the patient;
• Cases in which the hospitalist lacks the time to properly perform the evaluation;
• Particularly difficult or high-stakes cases (e.g. cases that might involve legal proceedings); and
• Cases in which significant mental illness affects a patient’s capacity.¹¹

Early involvement of potential surrogate decision-makers is wise for patients in whom capacity is questioned, both for obtaining collateral history as well as initiating dialogue as to the patient’s wishes. When a patient is found to lack capacity, resources to utilize to help make a treatment decision include existing advance directives and substitute decision-makers, such as durable power of attorneys (DPOAs) and family members. In those rare cases in which clinicians are unable to reach a consensus about a patient’s capacity, an ethics consult should be considered.

click for large version

Back to the Case.

Following the patient’s declaration that dialysis is not something he is interested in, his niece reports that he is a minimalist when it comes to interventions, and that he had similarly refused a cardiac catheterization in the 1990s. You review with the patient and niece that dialysis would be a procedure to replace his failing kidney function, and that failure to pursue this would ultimately be life-threatening and likely result in death, especially in regard to electrolyte abnormalities and his lack of any other terminal illness.

The consulting nephrologist reviews their recommendations with the patient and niece as well, and the patient consistently refuses. Having clearly communicated his choice, you ask the patient if he understands the situation. He says, "My kidneys are failing. That’s how I got the high potassium." You ask him what that means. "They aren’t going to function on their own much longer," he says. "I could die from it."

You confirm his ideas, and ask him why he doesn’t want dialysis. "I don’t want dialysis because I don’t want to spend my life hooked up to machines three times a week," the patient explains. "I just want to let things run their natural course." The niece says her uncle wouldn’t have wanted dialysis even if it were 10 years ago, so she’s not surprised he is refusing now.

Following this discussion, you feel comfortable that the patient has capacity to make this decision. Having documented this discussion, you discharge him to a subacute rehabilitation facility.

Bottom Line.

In cases in which capacity is in question, a hospitalist’s case-by-case review of the four components of capacity—communicating a choice, understanding, appreciation, and rationalization and reasoning—is warranted to help determine whether a patient has capacity. In cases in which a second opinion is warranted, psychiatry, geriatrics, or ethics consults could be utilized.

Drs. Dastidar and Odden are hospitalists at the University of Michigan in Ann Arbor.

References

1. Buchanan A, Brock DW. Deciding for others. Milbank Q. 1986;64(Suppl. 2):17-94.
2. Guidelines for assessing the decision-making capacities of potential research subjects with cognitive impairment. American Psychiatric Association. Am J Psychiatry. 1998;155(11):1649-50.
3. Appelbaum PS, Grisso T. Assessing patients’ capacities to consent to treatment. N Engl J Med. 1988;319(25):1635-1638.
4. Folstein MF, Folstein SE, McHugh PR. “Mini-mental state”. A practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res. 1975;12:189-198.
5. Etchells E, Darzins P, Silberfeld M, et al. Assessment of patient capacity to consent to treatment. J Gen Intern Med. 1999;14:27-34.
6. Grisso T, Appelbaum PS, Hill-Fotouhi C. The MacCAT-T: a clinical tool to assess patients’ capacities to make treatment decisions. Psychiatr Serv. 1997;48:1415- 1419.
7. Marson DC, Ingram KK, Cody HA, Harrell LE. Assessing the competency of patients with Alzheimer’s disease under different legal standards. A prototype instrument. Arch Neurol. 1995;52:949-954.
8. Edelstein B. Hopemont Capacity Assessment Interview Manual and Scoring Guide. 1999: Morgantown, W.V.: West Virginia University.
9. Pruchno RA, Smyer MA, Rose MS, Hartman-Stein PE, Henderson-Laribee DL. Competence of long-term care residents to participate in decisions about their medical care: a brief, objective assessment. Gerontologist. 1995;35:622-629.
10. Moye J, Karel M, Azar AR, Gurrera R. Capacity to consent to treatment: empirical comparison of three instruments in older adults with and without dementia. Gerontologist. 2004;44:166-175.
11. Grisso T, Appelbaum PS. Assessing competence to consent to treatment: a guide for physicians and other health professionals. 1998; New York: Oxford University Press, 211.
12. Cale GS. Risk-related standards of competence: continuing the debate over risk-related standards of competence. Bioethics. 1999;13(2):131-148.
13. Checkland D. On risk and decisional capacity. J Med Philos. 2001;26(1):35-59.
14. Wilks I. The debate over risk-related standards of competence. Bioethics. 1997;11(5):413-426.
15. Ganzini L, Volicer L, Nelson WA, Fox E, Derse AR. Ten myths about decision-making capacity. J Am Med Dir Assoc. 2004;5(4):263-267.

Acknowledgements:The authors would like to thank Dr. Jeff Rohde for reviewing a copy of the manuscript, and Dr. Amy Rosinski for providing direction from the psychiatry standpoint

Case

A 79-year-old male with coronary artery disease, hypertension, non-insulin-dependent mellitus, moderate dementia, and chronic renal insufficiency is admitted after a fall evaluation. He is widowed and lives in an assisted living facility. He’s accompanied by his niece, is alert, and oriented to person. He thinks he is in a clinic and is unable to state the year, but the remainder of the examination is unremarkable. His labs are notable for potassium of 6.3 mmol/L, BUN of 78 mg/dL, and Cr of 3.7 mg/dL. The niece reports that the patient is not fond of medical care, thus the most recent labs are from two years ago (and indicate a BUN of 39 and Cr of 2.8, with an upward trend over the past decade). You discuss possible long-term need for dialysis with the patient and niece, and the patient clearly states "no." However, he also states that it is 1988. How do you determine if he has the capacity to make decisions?

Overview

Hospitalists are familiar with the doctrine of informed consent—describing a disease, treatment options, associated risks and benefits, potential for complications, and alternatives, including no treatment. Not only must the patient be informed, and the decision free from any coercion, but the patient also must have capacity to make the decision.

Hospitalists often care for patients in whom decision-making capacity comes into question. This includes populations with depression, psychosis, dementia, stroke, severe personality disorders, developmental delay, comatose patients, as well as those with impaired attentional capacity (e.g. acute pain) or general debility (e.g. metastatic cancer).^1,2

ave for the comatose patient, whether the patient has capacity might not be obvious. However, addressing the components of capacity (communication, understanding, appreciation, and rationalization) by using a validated clinical tool, such as the MacCAT-T, or more simply by systematically applying those four components to the clinical scenario under consideration, hospitalists can make this determination.

Review of the Literature

It is important to differentiate capacity from competency. Competency is a global assessment and a legal determination made by a judge in court. Capacity, on the other hand, is a functional assessment regarding a particular decision. Capacity is not static, and it can be performed by any clinician familiar with the patient. A hospitalist often is well positioned to make a capacity determination given established rapport with the patient and familiarity with the details of the case.

To make this determination, a hospitalist needs to know how to assess capacity. Although capacity usually is defined by state law and varies by jurisdiction, clinicians generally can assume it includes one or more of the four key components:

• Communication. The patient needs to be able to express a treatment choice, and this decision needs to be stable enough for the treatment to be implemented. Changing one’s decision in itself would not bring a patient’s capacity into question, so long as the patient was able to explain the rationale behind the switch. Frequent changes back and forth in the decision-making, however, could be indicative of an underlying psychiatric disorder or extreme indecision, which could bring capacity into question.
• Understanding. The patient needs to recall conversations about treatment, to make the link between causal relationships, and to process probabilities for outcomes. Problems with memory, attention span, and intelligence can affect one’s understanding.
• Appreciation. The patient should be able to identify the illness, treatment options, and likely outcomes as things that will affect him or her directly. A lack of appreciation usually stems from a denial based on intelligence (lack of a capability to understand) or emotion, or a delusion that the patient is not affected by this situation the same way and will have a different outcome.
• Rationalization or reasoning. The patient needs to be able to weigh the risks and benefits of the treatment options presented to come to a conclusion in keeping with their goals and best interests, as defined by their personal set of values. This often is affected in psychosis, depression, anxiety, phobias, delirium, and dementia.³

Several clinical capacity tools have been developed to assess these components:

Clinical tools.

The Mini-Mental Status Examination (MMSE) is a bedside test of a patient’s cognitive function, with scores ranging from 0 to 30.⁴ Although it wasn’t developed for assessing decision-making capacity, it has been compared with expert evaluation for assessment of capacity; the test performs reasonably well, particularly with high and low scores. Specifically, a MMSE >24 has a negative likelihood ratio (LR) of 0.05 for lack of capacity, while a MMSE <16 has a positive LR of 15.⁵ Scores from 17 to 23 do not correlate well with capacity, and further testing would be necessary. It is easy to administer, requires no formal training, and is familiar to most hospitalists. However, it does not address any specific aspects of informed consent, such as understanding or choice, and has not been validated in patients with mental illness.

The MacArthur Competence Assessment Tools for Treatment (MacCAT-T) is regarded as the gold standard for capacity assessment aids. It utilizes hospital chart review followed by a semi-structured interview to address clinical issues relevant to the patient being assessed; it takes 15 to 20 minutes to complete.⁶ The test provides scores in each of the four domains (choice, understanding, appreciation, and reasoning) of capacity. It has been validated in patients with dementia, schizophrenia, and depression. Limiting its clinical applicability is the fact that the MacCAT-T requires training to administer and interpret the results, though this is a relatively brief process.

The Capacity to Consent to Treatment Instrument (CCTI) uses hypothetical clinical vignettes in a structured interview to assess capacity across all four domains. The tool was developed and validated in patients with dementia and Parkinson’s disease, and takes 20 to 25 minutes to complete.⁷ A potential limitation is the CCTI’s use of vignettes as opposed to a patient-specific discussion, which could lead to different patient answers and a false assessment of the patient’s capacity.

The Hopemont Capacity Assessment Interview (HCAI) utilizes hypothetical vignettes in a semi-structured interview format to assess understanding, appreciation, choice, and likely reasoning.^8,9 Similar to CCTI, HCAI is not modified for individual patients. Rather, it uses clinical vignettes to gauge a patient’s ability to make decisions. The test takes 30 to 60 minutes to administer and performs less well in assessing appreciation and reasoning than the MacCAT-T and CCTI.¹⁰

It is not necessary to perform a formal assessment of capacity on every inpatient. For most, there is no reasonable concern for impaired capacity, obviating the need for formal testing. Likewise, in patients who clearly lack capacity, such as those with end-stage dementia or established guardians, formal reassessment usually is not required. Formal testing is most useful in situations in which capacity is unclear, disagreement amongst surrogate decision-makers exists, or judicial involvement is anticipated.

The MacCAT-T has been validated in the broadest population and is probably the most clinically useful tool currently available. The MMSE is an attractive alternative because of its widespread use and familiarity; however, it is imprecise with scores from 17 to 23, limiting its applicability.

click for large version

At a minimum, familiarity with the core legal standards of capacity (communication of choice, understanding, appreciation, and reasoning) will improve a hospitalist’s ability to identify patients who lack capacity. Understanding and applying the defined markers most often provides a sufficient capacity evaluation in itself. As capacity is not static, the decision usually requires more than one assessment.

Equally, deciding that a patient lacks capacity is not an end in itself, and the underlying cause should be addressed. Certain factors, such as infection, medication, time of day, and relationship with the clinician doing the assessment, can affect a patient’s capacity. These should be addressed through treatment, education, and social support whenever possible in order to optimize a patient’s performance during the capacity evaluation. If the decision can be delayed until a time when the patient can regain capacity, this should be done in order to maximize the patient’s autonomy.¹¹

Risk-related standards of capacity.

Although some question the notion, given our desire to facilitate management beneficial to the patient, the general consensus is that we have a lower threshold for capacity for consent to treatments that are low-risk and high-benefit.^12,13 We would then have a somewhat higher threshold for capacity to refuse that same treatment. Stemming from a desire to protect patients from harm, we have a relatively higher threshold for capacity to make decisions regarding high-risk, low-benefit treatments. For the remainder of cases (low risk/low benefit; high risk/high benefit), as well as treatments that significantly impact a patient’s lifestyle (e.g. dialysis, amputation), we have a low capacity to let patients decide for themselves.^11,14

Other considerations.

Clinicians should be thorough in documenting details in coming to a capacity determination, both as a means to formalize the thought process running through the four determinants of capacity, and in order to document for future reference. Cases in which it could be reasonable to call a consultant for those familiar with the assessment basics include:

• Cases in which a determination of lack of capacity could adversely affect the hospitalist’s relationship with the patient;
• Cases in which the hospitalist lacks the time to properly perform the evaluation;
• Particularly difficult or high-stakes cases (e.g. cases that might involve legal proceedings); and
• Cases in which significant mental illness affects a patient’s capacity.¹¹

Early involvement of potential surrogate decision-makers is wise for patients in whom capacity is questioned, both for obtaining collateral history as well as initiating dialogue as to the patient’s wishes. When a patient is found to lack capacity, resources to utilize to help make a treatment decision include existing advance directives and substitute decision-makers, such as durable power of attorneys (DPOAs) and family members. In those rare cases in which clinicians are unable to reach a consensus about a patient’s capacity, an ethics consult should be considered.

click for large version

Back to the Case.

Following the patient’s declaration that dialysis is not something he is interested in, his niece reports that he is a minimalist when it comes to interventions, and that he had similarly refused a cardiac catheterization in the 1990s. You review with the patient and niece that dialysis would be a procedure to replace his failing kidney function, and that failure to pursue this would ultimately be life-threatening and likely result in death, especially in regard to electrolyte abnormalities and his lack of any other terminal illness.

The consulting nephrologist reviews their recommendations with the patient and niece as well, and the patient consistently refuses. Having clearly communicated his choice, you ask the patient if he understands the situation. He says, "My kidneys are failing. That’s how I got the high potassium." You ask him what that means. "They aren’t going to function on their own much longer," he says. "I could die from it."

You confirm his ideas, and ask him why he doesn’t want dialysis. "I don’t want dialysis because I don’t want to spend my life hooked up to machines three times a week," the patient explains. "I just want to let things run their natural course." The niece says her uncle wouldn’t have wanted dialysis even if it were 10 years ago, so she’s not surprised he is refusing now.

Following this discussion, you feel comfortable that the patient has capacity to make this decision. Having documented this discussion, you discharge him to a subacute rehabilitation facility.

Bottom Line.

In cases in which capacity is in question, a hospitalist’s case-by-case review of the four components of capacity—communicating a choice, understanding, appreciation, and rationalization and reasoning—is warranted to help determine whether a patient has capacity. In cases in which a second opinion is warranted, psychiatry, geriatrics, or ethics consults could be utilized.

Drs. Dastidar and Odden are hospitalists at the University of Michigan in Ann Arbor.

References

1. Buchanan A, Brock DW. Deciding for others. Milbank Q. 1986;64(Suppl. 2):17-94.
2. Guidelines for assessing the decision-making capacities of potential research subjects with cognitive impairment. American Psychiatric Association. Am J Psychiatry. 1998;155(11):1649-50.
3. Appelbaum PS, Grisso T. Assessing patients’ capacities to consent to treatment. N Engl J Med. 1988;319(25):1635-1638.
4. Folstein MF, Folstein SE, McHugh PR. “Mini-mental state”. A practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res. 1975;12:189-198.
5. Etchells E, Darzins P, Silberfeld M, et al. Assessment of patient capacity to consent to treatment. J Gen Intern Med. 1999;14:27-34.
6. Grisso T, Appelbaum PS, Hill-Fotouhi C. The MacCAT-T: a clinical tool to assess patients’ capacities to make treatment decisions. Psychiatr Serv. 1997;48:1415- 1419.
7. Marson DC, Ingram KK, Cody HA, Harrell LE. Assessing the competency of patients with Alzheimer’s disease under different legal standards. A prototype instrument. Arch Neurol. 1995;52:949-954.
8. Edelstein B. Hopemont Capacity Assessment Interview Manual and Scoring Guide. 1999: Morgantown, W.V.: West Virginia University.
9. Pruchno RA, Smyer MA, Rose MS, Hartman-Stein PE, Henderson-Laribee DL. Competence of long-term care residents to participate in decisions about their medical care: a brief, objective assessment. Gerontologist. 1995;35:622-629.
10. Moye J, Karel M, Azar AR, Gurrera R. Capacity to consent to treatment: empirical comparison of three instruments in older adults with and without dementia. Gerontologist. 2004;44:166-175.
11. Grisso T, Appelbaum PS. Assessing competence to consent to treatment: a guide for physicians and other health professionals. 1998; New York: Oxford University Press, 211.
12. Cale GS. Risk-related standards of competence: continuing the debate over risk-related standards of competence. Bioethics. 1999;13(2):131-148.
13. Checkland D. On risk and decisional capacity. J Med Philos. 2001;26(1):35-59.
14. Wilks I. The debate over risk-related standards of competence. Bioethics. 1997;11(5):413-426.
15. Ganzini L, Volicer L, Nelson WA, Fox E, Derse AR. Ten myths about decision-making capacity. J Am Med Dir Assoc. 2004;5(4):263-267.

Acknowledgements:The authors would like to thank Dr. Jeff Rohde for reviewing a copy of the manuscript, and Dr. Amy Rosinski for providing direction from the psychiatry standpoint

Case

A 79-year-old male with coronary artery disease, hypertension, non-insulin-dependent mellitus, moderate dementia, and chronic renal insufficiency is admitted after a fall evaluation. He is widowed and lives in an assisted living facility. He’s accompanied by his niece, is alert, and oriented to person. He thinks he is in a clinic and is unable to state the year, but the remainder of the examination is unremarkable. His labs are notable for potassium of 6.3 mmol/L, BUN of 78 mg/dL, and Cr of 3.7 mg/dL. The niece reports that the patient is not fond of medical care, thus the most recent labs are from two years ago (and indicate a BUN of 39 and Cr of 2.8, with an upward trend over the past decade). You discuss possible long-term need for dialysis with the patient and niece, and the patient clearly states "no." However, he also states that it is 1988. How do you determine if he has the capacity to make decisions?

Overview

Hospitalists are familiar with the doctrine of informed consent—describing a disease, treatment options, associated risks and benefits, potential for complications, and alternatives, including no treatment. Not only must the patient be informed, and the decision free from any coercion, but the patient also must have capacity to make the decision.

Hospitalists often care for patients in whom decision-making capacity comes into question. This includes populations with depression, psychosis, dementia, stroke, severe personality disorders, developmental delay, comatose patients, as well as those with impaired attentional capacity (e.g. acute pain) or general debility (e.g. metastatic cancer).^1,2

ave for the comatose patient, whether the patient has capacity might not be obvious. However, addressing the components of capacity (communication, understanding, appreciation, and rationalization) by using a validated clinical tool, such as the MacCAT-T, or more simply by systematically applying those four components to the clinical scenario under consideration, hospitalists can make this determination.

Review of the Literature

It is important to differentiate capacity from competency. Competency is a global assessment and a legal determination made by a judge in court. Capacity, on the other hand, is a functional assessment regarding a particular decision. Capacity is not static, and it can be performed by any clinician familiar with the patient. A hospitalist often is well positioned to make a capacity determination given established rapport with the patient and familiarity with the details of the case.

To make this determination, a hospitalist needs to know how to assess capacity. Although capacity usually is defined by state law and varies by jurisdiction, clinicians generally can assume it includes one or more of the four key components:

• Communication. The patient needs to be able to express a treatment choice, and this decision needs to be stable enough for the treatment to be implemented. Changing one’s decision in itself would not bring a patient’s capacity into question, so long as the patient was able to explain the rationale behind the switch. Frequent changes back and forth in the decision-making, however, could be indicative of an underlying psychiatric disorder or extreme indecision, which could bring capacity into question.
• Understanding. The patient needs to recall conversations about treatment, to make the link between causal relationships, and to process probabilities for outcomes. Problems with memory, attention span, and intelligence can affect one’s understanding.
• Appreciation. The patient should be able to identify the illness, treatment options, and likely outcomes as things that will affect him or her directly. A lack of appreciation usually stems from a denial based on intelligence (lack of a capability to understand) or emotion, or a delusion that the patient is not affected by this situation the same way and will have a different outcome.
• Rationalization or reasoning. The patient needs to be able to weigh the risks and benefits of the treatment options presented to come to a conclusion in keeping with their goals and best interests, as defined by their personal set of values. This often is affected in psychosis, depression, anxiety, phobias, delirium, and dementia.³

Several clinical capacity tools have been developed to assess these components:

Clinical tools.

The Mini-Mental Status Examination (MMSE) is a bedside test of a patient’s cognitive function, with scores ranging from 0 to 30.⁴ Although it wasn’t developed for assessing decision-making capacity, it has been compared with expert evaluation for assessment of capacity; the test performs reasonably well, particularly with high and low scores. Specifically, a MMSE >24 has a negative likelihood ratio (LR) of 0.05 for lack of capacity, while a MMSE <16 has a positive LR of 15.⁵ Scores from 17 to 23 do not correlate well with capacity, and further testing would be necessary. It is easy to administer, requires no formal training, and is familiar to most hospitalists. However, it does not address any specific aspects of informed consent, such as understanding or choice, and has not been validated in patients with mental illness.

The MacArthur Competence Assessment Tools for Treatment (MacCAT-T) is regarded as the gold standard for capacity assessment aids. It utilizes hospital chart review followed by a semi-structured interview to address clinical issues relevant to the patient being assessed; it takes 15 to 20 minutes to complete.⁶ The test provides scores in each of the four domains (choice, understanding, appreciation, and reasoning) of capacity. It has been validated in patients with dementia, schizophrenia, and depression. Limiting its clinical applicability is the fact that the MacCAT-T requires training to administer and interpret the results, though this is a relatively brief process.

The Capacity to Consent to Treatment Instrument (CCTI) uses hypothetical clinical vignettes in a structured interview to assess capacity across all four domains. The tool was developed and validated in patients with dementia and Parkinson’s disease, and takes 20 to 25 minutes to complete.⁷ A potential limitation is the CCTI’s use of vignettes as opposed to a patient-specific discussion, which could lead to different patient answers and a false assessment of the patient’s capacity.

The Hopemont Capacity Assessment Interview (HCAI) utilizes hypothetical vignettes in a semi-structured interview format to assess understanding, appreciation, choice, and likely reasoning.^8,9 Similar to CCTI, HCAI is not modified for individual patients. Rather, it uses clinical vignettes to gauge a patient’s ability to make decisions. The test takes 30 to 60 minutes to administer and performs less well in assessing appreciation and reasoning than the MacCAT-T and CCTI.¹⁰

It is not necessary to perform a formal assessment of capacity on every inpatient. For most, there is no reasonable concern for impaired capacity, obviating the need for formal testing. Likewise, in patients who clearly lack capacity, such as those with end-stage dementia or established guardians, formal reassessment usually is not required. Formal testing is most useful in situations in which capacity is unclear, disagreement amongst surrogate decision-makers exists, or judicial involvement is anticipated.

The MacCAT-T has been validated in the broadest population and is probably the most clinically useful tool currently available. The MMSE is an attractive alternative because of its widespread use and familiarity; however, it is imprecise with scores from 17 to 23, limiting its applicability.

click for large version

At a minimum, familiarity with the core legal standards of capacity (communication of choice, understanding, appreciation, and reasoning) will improve a hospitalist’s ability to identify patients who lack capacity. Understanding and applying the defined markers most often provides a sufficient capacity evaluation in itself. As capacity is not static, the decision usually requires more than one assessment.

Equally, deciding that a patient lacks capacity is not an end in itself, and the underlying cause should be addressed. Certain factors, such as infection, medication, time of day, and relationship with the clinician doing the assessment, can affect a patient’s capacity. These should be addressed through treatment, education, and social support whenever possible in order to optimize a patient’s performance during the capacity evaluation. If the decision can be delayed until a time when the patient can regain capacity, this should be done in order to maximize the patient’s autonomy.¹¹

Risk-related standards of capacity.

Although some question the notion, given our desire to facilitate management beneficial to the patient, the general consensus is that we have a lower threshold for capacity for consent to treatments that are low-risk and high-benefit.^12,13 We would then have a somewhat higher threshold for capacity to refuse that same treatment. Stemming from a desire to protect patients from harm, we have a relatively higher threshold for capacity to make decisions regarding high-risk, low-benefit treatments. For the remainder of cases (low risk/low benefit; high risk/high benefit), as well as treatments that significantly impact a patient’s lifestyle (e.g. dialysis, amputation), we have a low capacity to let patients decide for themselves.^11,14

Other considerations.

Clinicians should be thorough in documenting details in coming to a capacity determination, both as a means to formalize the thought process running through the four determinants of capacity, and in order to document for future reference. Cases in which it could be reasonable to call a consultant for those familiar with the assessment basics include:

• Cases in which a determination of lack of capacity could adversely affect the hospitalist’s relationship with the patient;
• Cases in which the hospitalist lacks the time to properly perform the evaluation;
• Particularly difficult or high-stakes cases (e.g. cases that might involve legal proceedings); and
• Cases in which significant mental illness affects a patient’s capacity.¹¹

Early involvement of potential surrogate decision-makers is wise for patients in whom capacity is questioned, both for obtaining collateral history as well as initiating dialogue as to the patient’s wishes. When a patient is found to lack capacity, resources to utilize to help make a treatment decision include existing advance directives and substitute decision-makers, such as durable power of attorneys (DPOAs) and family members. In those rare cases in which clinicians are unable to reach a consensus about a patient’s capacity, an ethics consult should be considered.

click for large version

Back to the Case.

Following the patient’s declaration that dialysis is not something he is interested in, his niece reports that he is a minimalist when it comes to interventions, and that he had similarly refused a cardiac catheterization in the 1990s. You review with the patient and niece that dialysis would be a procedure to replace his failing kidney function, and that failure to pursue this would ultimately be life-threatening and likely result in death, especially in regard to electrolyte abnormalities and his lack of any other terminal illness.

The consulting nephrologist reviews their recommendations with the patient and niece as well, and the patient consistently refuses. Having clearly communicated his choice, you ask the patient if he understands the situation. He says, "My kidneys are failing. That’s how I got the high potassium." You ask him what that means. "They aren’t going to function on their own much longer," he says. "I could die from it."

You confirm his ideas, and ask him why he doesn’t want dialysis. "I don’t want dialysis because I don’t want to spend my life hooked up to machines three times a week," the patient explains. "I just want to let things run their natural course." The niece says her uncle wouldn’t have wanted dialysis even if it were 10 years ago, so she’s not surprised he is refusing now.

Following this discussion, you feel comfortable that the patient has capacity to make this decision. Having documented this discussion, you discharge him to a subacute rehabilitation facility.

Bottom Line.

In cases in which capacity is in question, a hospitalist’s case-by-case review of the four components of capacity—communicating a choice, understanding, appreciation, and rationalization and reasoning—is warranted to help determine whether a patient has capacity. In cases in which a second opinion is warranted, psychiatry, geriatrics, or ethics consults could be utilized.

Drs. Dastidar and Odden are hospitalists at the University of Michigan in Ann Arbor.

References

1. Buchanan A, Brock DW. Deciding for others. Milbank Q. 1986;64(Suppl. 2):17-94.
2. Guidelines for assessing the decision-making capacities of potential research subjects with cognitive impairment. American Psychiatric Association. Am J Psychiatry. 1998;155(11):1649-50.
3. Appelbaum PS, Grisso T. Assessing patients’ capacities to consent to treatment. N Engl J Med. 1988;319(25):1635-1638.
4. Folstein MF, Folstein SE, McHugh PR. “Mini-mental state”. A practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res. 1975;12:189-198.
5. Etchells E, Darzins P, Silberfeld M, et al. Assessment of patient capacity to consent to treatment. J Gen Intern Med. 1999;14:27-34.
6. Grisso T, Appelbaum PS, Hill-Fotouhi C. The MacCAT-T: a clinical tool to assess patients’ capacities to make treatment decisions. Psychiatr Serv. 1997;48:1415- 1419.
7. Marson DC, Ingram KK, Cody HA, Harrell LE. Assessing the competency of patients with Alzheimer’s disease under different legal standards. A prototype instrument. Arch Neurol. 1995;52:949-954.
8. Edelstein B. Hopemont Capacity Assessment Interview Manual and Scoring Guide. 1999: Morgantown, W.V.: West Virginia University.
9. Pruchno RA, Smyer MA, Rose MS, Hartman-Stein PE, Henderson-Laribee DL. Competence of long-term care residents to participate in decisions about their medical care: a brief, objective assessment. Gerontologist. 1995;35:622-629.
10. Moye J, Karel M, Azar AR, Gurrera R. Capacity to consent to treatment: empirical comparison of three instruments in older adults with and without dementia. Gerontologist. 2004;44:166-175.
11. Grisso T, Appelbaum PS. Assessing competence to consent to treatment: a guide for physicians and other health professionals. 1998; New York: Oxford University Press, 211.
12. Cale GS. Risk-related standards of competence: continuing the debate over risk-related standards of competence. Bioethics. 1999;13(2):131-148.
13. Checkland D. On risk and decisional capacity. J Med Philos. 2001;26(1):35-59.
14. Wilks I. The debate over risk-related standards of competence. Bioethics. 1997;11(5):413-426.
15. Ganzini L, Volicer L, Nelson WA, Fox E, Derse AR. Ten myths about decision-making capacity. J Am Med Dir Assoc. 2004;5(4):263-267.

Acknowledgements:The authors would like to thank Dr. Jeff Rohde for reviewing a copy of the manuscript, and Dr. Amy Rosinski for providing direction from the psychiatry standpoint

The reviews are in, and most healthcare provider groups are finding little to their liking in the proposed rules for the Centers for Medicare & Medicaid Services’ (CMS) voluntary Accountable Care Organization (ACO) program. Organizations like SHM have publically supported the concept of an ACO, but details in the 128 pages of proposed rules released March 31 apparently were not what they had in mind. The problem, as many provider groups detailed in a flurry of letters sent before the June 6 deadline for comments, is too much stick and not enough carrot.

The Patient Protection and Affordable Care Act of 2010, which authorized the program, stipulates that any Medicare savings deriving from ACOs must be divided between CMS and participating organizations. Organizations can choose between two financial models: One track allows participants to retain 60% of overall savings but also requires them to assume financial risk from the start; a second track delays any risk until the third year and offers 50% savings. In exchange, ACOs must achieve an average savings of 2% per patient, as well as meet or beat thresholds for 65 measures of quality.

Organizational Uproar

Critics contend that the recommended rules are so onerous and bureaucratic that the program is likely to attract few takers. In its comment letter, SHM expressed an opinion shared by many: "Although the ACO concept holds much promise, the proposed rule as written presents many barriers to successful ACO development and operations. Establishing an ACO will require an enormous upfront investment from participating providers, but the proposed rule does not allow for enough flexibility to ensure a reasonable return on investment." (Read SHM’s response letter at www.hospital medicine.org/advocacy.)

The American College of Physicians similarly warned that the proposed rules set the bar too high for many would-be participants. "The required administrative, infrastructure, service delivery, and financial resources and the need to accept risk will effectively limit participation to those few large entities already organized under an ACO-like structure; that already have ready access to capital, substantial infrastructure development, and experience operating under an integrative service/payment model (e.g. Medicare Advantage)," the ACP wrote in its response letter (www.acponline.org/run ning_practice/aco/acp_comments.pdf).

The tone was markedly different in letters from consumer and advocacy groups, including one by the Campaign for Better Care, signed by more than 40 organizations (www.national­partnership.org). "Overall we believe you are moving in the right direction with the proposed rule, and we applaud your commitment to ensuring ACOs deliver truly patient-centered care," the letter stated. Acknowledging the negative feedback, the letter continued, "While some are concerned about asking too much of ACOs, we cannot expect genuine transformation to be easy, and we know that these new models must be held to standards that ensure they deliver on the promise of better care, better health, and lower cost."

Accountability Gap

Michael W. Painter, JD, MD, senior program officer at the Robert Wood Johnson Foundation in Princeton, N.J., helped research and write the foundation’s own comment letter, which he says tried to bridge the divide between provider and patient groups.

"We did get behind the notion of ratcheting up the accountability for quality and cost, including the risk, as soon as it makes sense to do it," he says. "Not dragging our feet, recognizing that we have to do it rapidly, but it has to be balanced by being reasonable to help move from where we are."

Given the mandate for change, Dr. Painter says, the negative tone of many letters from provider organizations shouldn’t be surprising. "What we’re asking the hospital, the health professionals, to do is to change fairly radically and embrace this accountability. So as you just walk through the door of this conversation, it’s not surprising that they would balk," he says. "Nobody wants to take on all of this new responsibility. It’s no fault of theirs; they’ve just been following the rules of the road of the current system and the payment schemes to try to be successful in that environment."

Success, of course, depends on financial stability, and Dr. Painter says the worry that participating ACOs could open themselves up to financial risk too soon is "absolutely a legitimate concern." CMS, he says, should give providers clear guidance and assistance, as well as assurance that the regulations won’t change on them once they’ve enrolled.

So far, at least, CMS has not swayed some of the very institutions that government officials have lauded as examples of how ACOs should be run. In June, the Mayo Clinic in Rochester, Minn., announced that it would not participate. As reported by the Minneapolis Star Tribune, clinic officials said the proposed regulations clashed with Mayo’s existing Medicare operations. One of the clinic’s chief complaints is the proposed requirement that patients be added to oversight boards charged with assessing performance, something that Mayo argues is unnecessary to deliver patient-centered care. Antitrust rules represent another major concern for Mayo and others that argue their dominant position as healthcare providers in rural communities could run afoul of the regulations.

Cleveland Clinic likewise blasted the proposed ACO rules in a letter. "Rather than providing a broad framework that focuses on results as the key criteria of success, the Proposed Rule is replete with (1) prescriptive requirements that have little to do with outcomes, and (2) many detailed governance and reporting requirements that create significant administrative burdens," stated Delos Cosgrove, MD, the clinic’s CEO and president.

Furthermore, Cosgrove’s letter concluded that the shared-savings component "is structured in such a way that creates real uncertainty about whether applicants will be able to achieve success."

The American Medical Group Association went so far as to include in its letter the results of a member survey, which showed 93% would not enroll under the current ACO rules.

No Turning Back

Dr. Painter says the pushback is to be expected. Although the country has no choice but to move toward more accountability, he says, it’s impossible for the first attempt at a proposed rule to be the "magic bullet" that gets it exactly right. "One, this is a radical departure, and two, when you get into the nitty-gritty of the proposed rule and people crunch the numbers, if it’s not going to work for them or it’s simply not enticing enough for them, they [CMS] need to go back to the table and make it that way," he says.

Organizations like the American Medical Association have been particularly vocal about asking CMS to delay issuing its final rule, slated for January. So far, Dr. Painter says, CMS officials have indicated that the timeline will proceed according to schedule, though he notes that providers have raised plenty of valid concerns that should be addressed.

"Would I be surprised if there’s a delay? No. This is a big deal," he says.

Along with some expected rule changes, he says the newly formed Center for Medicare and Medicaid Innovation could play a key role in offering assistance and developing alternative ACO models and pilot programs.

Regardless of whether the voluntary CMS program ultimately pleases both providers and patients, though, one thing seems certain: The accountable-care concept is here to stay.

Bryn Nelson is a freelance medical writer based in Seattle

The reviews are in, and most healthcare provider groups are finding little to their liking in the proposed rules for the Centers for Medicare & Medicaid Services’ (CMS) voluntary Accountable Care Organization (ACO) program. Organizations like SHM have publically supported the concept of an ACO, but details in the 128 pages of proposed rules released March 31 apparently were not what they had in mind. The problem, as many provider groups detailed in a flurry of letters sent before the June 6 deadline for comments, is too much stick and not enough carrot.

The Patient Protection and Affordable Care Act of 2010, which authorized the program, stipulates that any Medicare savings deriving from ACOs must be divided between CMS and participating organizations. Organizations can choose between two financial models: One track allows participants to retain 60% of overall savings but also requires them to assume financial risk from the start; a second track delays any risk until the third year and offers 50% savings. In exchange, ACOs must achieve an average savings of 2% per patient, as well as meet or beat thresholds for 65 measures of quality.

Organizational Uproar

Critics contend that the recommended rules are so onerous and bureaucratic that the program is likely to attract few takers. In its comment letter, SHM expressed an opinion shared by many: "Although the ACO concept holds much promise, the proposed rule as written presents many barriers to successful ACO development and operations. Establishing an ACO will require an enormous upfront investment from participating providers, but the proposed rule does not allow for enough flexibility to ensure a reasonable return on investment." (Read SHM’s response letter at www.hospital medicine.org/advocacy.)

The American College of Physicians similarly warned that the proposed rules set the bar too high for many would-be participants. "The required administrative, infrastructure, service delivery, and financial resources and the need to accept risk will effectively limit participation to those few large entities already organized under an ACO-like structure; that already have ready access to capital, substantial infrastructure development, and experience operating under an integrative service/payment model (e.g. Medicare Advantage)," the ACP wrote in its response letter (www.acponline.org/run ning_practice/aco/acp_comments.pdf).

The tone was markedly different in letters from consumer and advocacy groups, including one by the Campaign for Better Care, signed by more than 40 organizations (www.national­partnership.org). "Overall we believe you are moving in the right direction with the proposed rule, and we applaud your commitment to ensuring ACOs deliver truly patient-centered care," the letter stated. Acknowledging the negative feedback, the letter continued, "While some are concerned about asking too much of ACOs, we cannot expect genuine transformation to be easy, and we know that these new models must be held to standards that ensure they deliver on the promise of better care, better health, and lower cost."

Accountability Gap

Michael W. Painter, JD, MD, senior program officer at the Robert Wood Johnson Foundation in Princeton, N.J., helped research and write the foundation’s own comment letter, which he says tried to bridge the divide between provider and patient groups.

"We did get behind the notion of ratcheting up the accountability for quality and cost, including the risk, as soon as it makes sense to do it," he says. "Not dragging our feet, recognizing that we have to do it rapidly, but it has to be balanced by being reasonable to help move from where we are."

Given the mandate for change, Dr. Painter says, the negative tone of many letters from provider organizations shouldn’t be surprising. "What we’re asking the hospital, the health professionals, to do is to change fairly radically and embrace this accountability. So as you just walk through the door of this conversation, it’s not surprising that they would balk," he says. "Nobody wants to take on all of this new responsibility. It’s no fault of theirs; they’ve just been following the rules of the road of the current system and the payment schemes to try to be successful in that environment."

Success, of course, depends on financial stability, and Dr. Painter says the worry that participating ACOs could open themselves up to financial risk too soon is "absolutely a legitimate concern." CMS, he says, should give providers clear guidance and assistance, as well as assurance that the regulations won’t change on them once they’ve enrolled.

So far, at least, CMS has not swayed some of the very institutions that government officials have lauded as examples of how ACOs should be run. In June, the Mayo Clinic in Rochester, Minn., announced that it would not participate. As reported by the Minneapolis Star Tribune, clinic officials said the proposed regulations clashed with Mayo’s existing Medicare operations. One of the clinic’s chief complaints is the proposed requirement that patients be added to oversight boards charged with assessing performance, something that Mayo argues is unnecessary to deliver patient-centered care. Antitrust rules represent another major concern for Mayo and others that argue their dominant position as healthcare providers in rural communities could run afoul of the regulations.

Cleveland Clinic likewise blasted the proposed ACO rules in a letter. "Rather than providing a broad framework that focuses on results as the key criteria of success, the Proposed Rule is replete with (1) prescriptive requirements that have little to do with outcomes, and (2) many detailed governance and reporting requirements that create significant administrative burdens," stated Delos Cosgrove, MD, the clinic’s CEO and president.

Furthermore, Cosgrove’s letter concluded that the shared-savings component "is structured in such a way that creates real uncertainty about whether applicants will be able to achieve success."

The American Medical Group Association went so far as to include in its letter the results of a member survey, which showed 93% would not enroll under the current ACO rules.

No Turning Back

Dr. Painter says the pushback is to be expected. Although the country has no choice but to move toward more accountability, he says, it’s impossible for the first attempt at a proposed rule to be the "magic bullet" that gets it exactly right. "One, this is a radical departure, and two, when you get into the nitty-gritty of the proposed rule and people crunch the numbers, if it’s not going to work for them or it’s simply not enticing enough for them, they [CMS] need to go back to the table and make it that way," he says.

Organizations like the American Medical Association have been particularly vocal about asking CMS to delay issuing its final rule, slated for January. So far, Dr. Painter says, CMS officials have indicated that the timeline will proceed according to schedule, though he notes that providers have raised plenty of valid concerns that should be addressed.

"Would I be surprised if there’s a delay? No. This is a big deal," he says.

Along with some expected rule changes, he says the newly formed Center for Medicare and Medicaid Innovation could play a key role in offering assistance and developing alternative ACO models and pilot programs.

Regardless of whether the voluntary CMS program ultimately pleases both providers and patients, though, one thing seems certain: The accountable-care concept is here to stay.

Bryn Nelson is a freelance medical writer based in Seattle

The reviews are in, and most healthcare provider groups are finding little to their liking in the proposed rules for the Centers for Medicare & Medicaid Services’ (CMS) voluntary Accountable Care Organization (ACO) program. Organizations like SHM have publically supported the concept of an ACO, but details in the 128 pages of proposed rules released March 31 apparently were not what they had in mind. The problem, as many provider groups detailed in a flurry of letters sent before the June 6 deadline for comments, is too much stick and not enough carrot.

The Patient Protection and Affordable Care Act of 2010, which authorized the program, stipulates that any Medicare savings deriving from ACOs must be divided between CMS and participating organizations. Organizations can choose between two financial models: One track allows participants to retain 60% of overall savings but also requires them to assume financial risk from the start; a second track delays any risk until the third year and offers 50% savings. In exchange, ACOs must achieve an average savings of 2% per patient, as well as meet or beat thresholds for 65 measures of quality.

Organizational Uproar

Critics contend that the recommended rules are so onerous and bureaucratic that the program is likely to attract few takers. In its comment letter, SHM expressed an opinion shared by many: "Although the ACO concept holds much promise, the proposed rule as written presents many barriers to successful ACO development and operations. Establishing an ACO will require an enormous upfront investment from participating providers, but the proposed rule does not allow for enough flexibility to ensure a reasonable return on investment." (Read SHM’s response letter at www.hospital medicine.org/advocacy.)

The American College of Physicians similarly warned that the proposed rules set the bar too high for many would-be participants. "The required administrative, infrastructure, service delivery, and financial resources and the need to accept risk will effectively limit participation to those few large entities already organized under an ACO-like structure; that already have ready access to capital, substantial infrastructure development, and experience operating under an integrative service/payment model (e.g. Medicare Advantage)," the ACP wrote in its response letter (www.acponline.org/run ning_practice/aco/acp_comments.pdf).

The tone was markedly different in letters from consumer and advocacy groups, including one by the Campaign for Better Care, signed by more than 40 organizations (www.national­partnership.org). "Overall we believe you are moving in the right direction with the proposed rule, and we applaud your commitment to ensuring ACOs deliver truly patient-centered care," the letter stated. Acknowledging the negative feedback, the letter continued, "While some are concerned about asking too much of ACOs, we cannot expect genuine transformation to be easy, and we know that these new models must be held to standards that ensure they deliver on the promise of better care, better health, and lower cost."

Accountability Gap

Michael W. Painter, JD, MD, senior program officer at the Robert Wood Johnson Foundation in Princeton, N.J., helped research and write the foundation’s own comment letter, which he says tried to bridge the divide between provider and patient groups.

"We did get behind the notion of ratcheting up the accountability for quality and cost, including the risk, as soon as it makes sense to do it," he says. "Not dragging our feet, recognizing that we have to do it rapidly, but it has to be balanced by being reasonable to help move from where we are."

Given the mandate for change, Dr. Painter says, the negative tone of many letters from provider organizations shouldn’t be surprising. "What we’re asking the hospital, the health professionals, to do is to change fairly radically and embrace this accountability. So as you just walk through the door of this conversation, it’s not surprising that they would balk," he says. "Nobody wants to take on all of this new responsibility. It’s no fault of theirs; they’ve just been following the rules of the road of the current system and the payment schemes to try to be successful in that environment."

Success, of course, depends on financial stability, and Dr. Painter says the worry that participating ACOs could open themselves up to financial risk too soon is "absolutely a legitimate concern." CMS, he says, should give providers clear guidance and assistance, as well as assurance that the regulations won’t change on them once they’ve enrolled.

So far, at least, CMS has not swayed some of the very institutions that government officials have lauded as examples of how ACOs should be run. In June, the Mayo Clinic in Rochester, Minn., announced that it would not participate. As reported by the Minneapolis Star Tribune, clinic officials said the proposed regulations clashed with Mayo’s existing Medicare operations. One of the clinic’s chief complaints is the proposed requirement that patients be added to oversight boards charged with assessing performance, something that Mayo argues is unnecessary to deliver patient-centered care. Antitrust rules represent another major concern for Mayo and others that argue their dominant position as healthcare providers in rural communities could run afoul of the regulations.

Cleveland Clinic likewise blasted the proposed ACO rules in a letter. "Rather than providing a broad framework that focuses on results as the key criteria of success, the Proposed Rule is replete with (1) prescriptive requirements that have little to do with outcomes, and (2) many detailed governance and reporting requirements that create significant administrative burdens," stated Delos Cosgrove, MD, the clinic’s CEO and president.

Furthermore, Cosgrove’s letter concluded that the shared-savings component "is structured in such a way that creates real uncertainty about whether applicants will be able to achieve success."

The American Medical Group Association went so far as to include in its letter the results of a member survey, which showed 93% would not enroll under the current ACO rules.

No Turning Back

Dr. Painter says the pushback is to be expected. Although the country has no choice but to move toward more accountability, he says, it’s impossible for the first attempt at a proposed rule to be the "magic bullet" that gets it exactly right. "One, this is a radical departure, and two, when you get into the nitty-gritty of the proposed rule and people crunch the numbers, if it’s not going to work for them or it’s simply not enticing enough for them, they [CMS] need to go back to the table and make it that way," he says.

Organizations like the American Medical Association have been particularly vocal about asking CMS to delay issuing its final rule, slated for January. So far, Dr. Painter says, CMS officials have indicated that the timeline will proceed according to schedule, though he notes that providers have raised plenty of valid concerns that should be addressed.

"Would I be surprised if there’s a delay? No. This is a big deal," he says.

Along with some expected rule changes, he says the newly formed Center for Medicare and Medicaid Innovation could play a key role in offering assistance and developing alternative ACO models and pilot programs.

Regardless of whether the voluntary CMS program ultimately pleases both providers and patients, though, one thing seems certain: The accountable-care concept is here to stay.

Bryn Nelson is a freelance medical writer based in Seattle