The topic of comparative effectiveness research (CER) has recently gained prominence within the context of the national focus on health reform. This article provides a brief overview and history of CER, and discusses the implications of CER for hospitalists in each of four major career roles: research, clinical practice, education and training, and hospital leadership. Both medical journals and lay media have produced a flurry of articles recently on a variety of health reform subjects. One topic that has achieved prominence within this growing body of literature is comparative effectiveness research (CER). For many hospitalists, this particular brand of research may be unfamiliar. As discussions about CER priorities, the controversy surrounding CER, and even the definition of CER gain visibility, hospitalists may be left wondering, What exactly is CER and what does it mean for me?

Until recently no common definition for CER existed, and the very concept was identified only in relatively narrow policy and research circles. However, CER is not a new idea. Its ancestor is the notion of medical technology assessment (MTA), which garnered enthusiasm and support in the 1970s. In 1978, Congress established the National Center for Health Technology Assessment (which, over time, evolved into the Agency for Healthcare Research and Quality [AHRQ]), whose charge was to coordinate efforts within the government to assess the safety, efficacy, effectiveness, and cost‐effectiveness of medical technologies. The recognition of a need for technology assessment at that time is mirrored by the widespread interest in CER seen today. Part of the reason that MTA did not take hold is that then, as now, this type of evaluation is challenging and time consuming, requiring large, well‐designed effectiveness studies. These studies require rigorous methods, typically long‐term follow‐up, and acceptance via editors and the medical literature that effectiveness is as important as efficacy demonstrated in a randomized trial. With the spread of antiregulatory sentiment and the lack of an economic imperative to reduce costs, the national focus on technology assessment waned. The current economic crisis has refocused the government and private sector on the soaring cost of health care and the need to improve quality, and the stimulus package passed in February of 2009 placed CER once again in the forefront. The American Recovery and Reinvestment Act (ARRA) of 2009 allocated $1.1 billion for CER.1 On June 30, 2009, 2 reports delineating the strategy and priorities for CER were released. The report from the ARRA‐mandated Federal Coordinating Council (FCC) for CER includes a broad definition of CER and outlines a high‐level strategic framework for priorities and investments in CER.2 Simultaneously, the report from the Institute of Medicine (IOM) lists 100 priority research topics, and gives 10 general recommendations for the CER enterprise going forward.3

So what is CER and why is it important? How is it different from standard research that hospitalists use every day to inform their clinical decision‐making? Unfortunately, patients and providers confront medical decisions daily that are not evidence based. All too frequently it is unclear what therapeutic option works best for which patient under which circumstances. For example, what is the best inpatient diabetes management strategy for an African American woman with multiple medical problems? What is the best discharge process for an elderly man with heart disease in order to prevent readmission? CER seeks to fill the gaps in evidence needed by patients and clinicians in order to make appropriate medical decisions. It differs from standard efficacy research in that it compares interventions or management strategies in real world settings, allows identification of effectiveness in patient subgroups, and is more patient‐centered, focusing on the decisions confronting patients and their physicians. The following definition of CER was developed by the FCC for CER:

CER is the conduct and synthesis of research comparing the benefits and harms of different interventions and strategies to prevent, diagnose, treat and monitor health conditions in real world settings. The purpose of this research is to improve health outcomes by developing and disseminating evidence‐based information to patients, clinicians, and other decision‐makers, responding to their expressed needs about which interventions are most effective for which patients under specific circumstances.

• To provide this information, CER must assess a comprehensive array of health‐related outcomes for diverse patient populations and sub‐groups.

• Defined interventions compared may include medications, procedures, medical and assistive devices and technologies, diagnostic testing, behavioral change and delivery system strategies.

• This research necessitates the development, expansion and use of a variety of data sources and methods to assess comparative effectiveness and actively disseminate the results.

While CER is an evolving field requiring continued methodological development (such as enhancement of methods for practical, or pragmatic trials and complex analyses of large, linked databases), examples of rigorous comparative studies do exist. The Veterans Administration (VA) COURAGE trial compared optimal medical therapy (OMT) with or without percutaneous coronary intervention (PCI) for patients with stable coronary disease, finding that PCI did not reduce the risk of death or cardiovascular events compared to OMT alone.4 Another example is the Diabetes Prevention Program which compared placebo, metformin, and a lifestyle modification program to prevent or delay the onset of type 2 diabetes. This study famously showed that lifestyle modification was more effective than metformin or placebo in reducing the incidence of diabetes.5

CER holds the promise of significantly improving the health of Americans through the ability to target treatments and other interventions to individual patients. As noted by the FCC, CER can allow for the delivery of the right treatment to the right patient at the right time2 even as the field continues to evolve. To quote Fineberg and Hiatt6 in describing technology assessment in 1979, we cannot expect CER to lead to perfect decisions, but we can expect even imperfect methods to facilitate better informed decisions than would otherwise be possible.

CER has important implications for hospitalists in all roles and settings. As the field of hospital medicine has grown, hospitalists have increasingly assumed more responsibilities than just patient care. In academic and community hospitals, hospitalists take on leadership roles, particularly in quality improvement (QI) and patient safety, and educational roles in the training of housestaff, medical students, and physician extenders. The last several years have also seen a significant increase in hospitalists participating in research. The relevance of CER to each of these 4 major activities is described below and in the accompanying Table 1.

Hospitalists and Research

Many comparative effectiveness questions about clinical care, processes of care, and quality of care within the inpatient setting are in need of answers. Hospitalist researchers have the opportunity to make a significant impact on care by pursuing answers to questions that are unique to the field of hospital medicine. With the new availability of funds for CER, now is the time to address many of these questions head‐on. For example, there is a lack of evidence about best practices for a large number of inpatient acute conditions. What is the best strategy to manage acute hospital delirium in an elderly patient? What is the best approach to treating acute pain in an elderly woman on multiple medications? Overwhelmingly the patients that hospitalists care for are elderly and/or have multiple chronic conditions, including children with special health care needs. Many are from racial or ethnic minority backgrounds. These subgroups of patients have been historically under‐represented in clinical trials, yet represent exactly the priority populations that the Federal CER effort targets. The field of hospital medicine can be transformed with a substantial investment in research to address common inpatient clinical conditions in real world settings focused on the kinds of patients hospitalists actually care for.

One of the most vexing and frustrating care delivery issues for hospitalists, clinicians and researchers alike, is the discharge process. This problem received increased attention after a recent article highlighted the high rate of readmissions in the Medicare population.7 Research on the discharge process has grown substantially in recent years, and has become an area of intense focus and attention for hospitalists, nurses, researchers, hospital administrators and policymakers. Without question, hospitalists are uniquely poised to conduct research on this critically important topic, and CER is an ideal vehicle for moving this field forward. In collaboration with nurses, primary care physicians, pharmacists, case managers and others, hospitalists should take advantage of the Federal investment in studying care delivery systems interventions, and develop innovative methods and strategies for studying and improving this crucial transition in care. CER is also applicable to other care transitions, including the admission process, transitions within the hospital, and discharge to nursing facilities. Other examples of comparative effectiveness topics that hospitalist researchers are particularly suited for include comparing methods for implementing inpatient treatment protocols or clinical pathways, comparison of health information technology (IT) systems to reduce medical error, and QI approaches.

What are the methodologies that hospitalists should use to conduct CER? While randomized pragmatic real world trials are appealing, this method may not always be practical. Other methodologies are available for rigorous use, including cohort studies, comparative QI interventions, clustered and factorial design, systematic reviews, and analysis of registries, administrative claims, or other databases. Databases currently available for analysis on priority populations and subgroups are limited, and include the VA and Medicare databases. To address this need, one of the primary Federal investments in CER is for the enhancement and expansion of data infrastructure. Data infrastructure tools that are likely to be available to hospitalist researchers for CER include expanded longitudinal administrative claims databases with linkages to electronic health records (EHRs), expanded patient registries with linkages to other forms of data, and distributed data networks that are populated by EHRs in provider and practice settings. Hospitalist researchers should take advantage of these resources as they become available, as they have tremendous potential to inform decision‐making for providers and patients alike.

Hospitalists and Clinical Practice

As with all providers, hospitalists will be end‐users of CER evidence, and will have the responsibility of translating new knowledge into practice. This process will not be easy. How are hospitalists to reliably access and incorporate new comparative effectiveness information into their daily practice? How should they deal with some of the potential unintended consequences of CER, such as information overload or conflicting evidence? While hospitalists have a professional responsibility to search for and apply CER findings, the future development of CER‐based practice guidelines will encourage evidence translation. The development of a common platform for the dissemination of CER relevant to hospitalists would significantly enhance the uptake of new evidence by practicing hospitalists and other hospital‐based providers such as physician assistants or nurse practitioners. Medical societies such as the Society of Hospital Medicine and the American Academy of Pediatrics should consider developing committees for CER and leading coordinated educational efforts specifically focused on CER results through publications and presentations at local, regional, and national meetings. In addition, other dissemination tools for CER will soon emerge and existing tools will be enhanced, such as the Effective Health Care Program and Eisenberg Center housed at the AHRQ. The coming years will see an expansion of these and other dissemination efforts to both providers and patients, and hospitalists must be vigilant about accessing these resources and integrating comparative effectiveness evidence into practice. As Federal dissemination efforts to consumers spread, patients will increasingly expect physicians to discuss comparative effectiveness evidence in describing options for their individual health needs. Finally, a key lever for translating CER into practice will be payment models that place accountability for performance on physicians and hospitals, with a significant proportion of payment based on the delivery of high quality, efficient care.

Education and Training

Investment in the training and development of a skilled workforce to conduct CER is an important priority. Hospitalist researchers should take advantage of education and training programs to support the development of methodologies and skills for conducting CER that will become available. These programs will enable hospitalists to learn such skills as the use of the newly enhanced data infrastructure discussed above. The national investment in human and scientific capital for CER can promote the training of a corps of hospitalist researchers focused on this research which, in turn, could support the growth of the academic hospitalist field. Hospitalists who have responsibilities in medical education and residency training programs should take the lead in teaching CER concepts that are relevant to inpatient care. They will need to train the next generation of medical students and residents to read and understand comparative effectiveness literature and its application in clinical practice. Hospitalist educators are also best positioned to teach medical trainees comparative effectiveness evidence about inpatient QI methods and care processes.

Hospital Leadership

As front‐line providers and team leaders, hospitalists are well placed to direct the efforts within their hospitals to implement new CER evidence. For example, suppose new comparative effectiveness evidence about best practices for the discharge process for community‐dwelling older adults with multiple chronic conditions were to emerge. Hospitalists could lead efforts within their hospital to establish a multidisciplinary team to address this development, create standard protocols for implementing the new discharge process that align with their hospital's unique systems and organizational structure, advocate for necessary resources for the team to accomplish the goal of safely discharging these patients, ensure a method to track outcomes such as readmissions once the new discharge process is implemented, and provide data feedback to the team, hospital staff, and administrative leadership of the hospital. All of these activities should include a variety of disciplines working together, but as physician leaders, hospitalists can take the initiative to spearhead these endeavors. The inpatient setting is one that requires teamwork and coordination, and as team leaders, hospitalists can strongly influence the spread and adoption of CER results. Similarly, hospitalists are in a position to affect this dissemination and translation process by actively educating and empowering other clinicians and hospital staff within their local environment. Finally, as hospitalists increasingly take on leadership roles in QI departments and as chief medical officers within both community and university‐affiliated hospitals^8, they are in a unique position to lead efforts to implement CER‐based QI activities. These may range from the implementation of IT functions to reduce medical error to strategies to reduce hospital‐acquired infections or falls.

Conclusion

As a result of the stimulus funds directed towards CER, the coming years will see a vast increase in the generation of comparative effectiveness evidence and the application of that evidence into practice.9 The national CER endeavor is particularly germane to the field of hospital medicine, as uncertainty about best practices is common, and the patients hospitalists serve represent priority populations for CER investments. Hospitalists can play a central role in both generating CER and implementing its findings in settings in which patients are highly vulnerable, and existing information is insufficient. In addition to clinical questions, hospitalist researchers are particularly suited to answering important questions about quality of care and inpatient processes such as transitions of care and care coordination. Having evidence on the best practices for care transitions or strategies to reduce medical error, for example, could have a significant impact on patient outcomes, quality of life, and cost of care. However, none of this new evidence will be of any value if it is not used by front‐line providers.10 Practicing hospitalists should lead efforts within their hospital to disseminate new CER findings to their hospitalist and non‐hospitalist colleagues, and to leverage their position as hospital and team leaders to implement inpatient‐based CER findings. All of these combined efforts have the potential to significantly move the field of hospital medicine forward, with the end result being improved health and better outcomes for patients.

The topic of comparative effectiveness research (CER) has recently gained prominence within the context of the national focus on health reform. This article provides a brief overview and history of CER, and discusses the implications of CER for hospitalists in each of four major career roles: research, clinical practice, education and training, and hospital leadership. Both medical journals and lay media have produced a flurry of articles recently on a variety of health reform subjects. One topic that has achieved prominence within this growing body of literature is comparative effectiveness research (CER). For many hospitalists, this particular brand of research may be unfamiliar. As discussions about CER priorities, the controversy surrounding CER, and even the definition of CER gain visibility, hospitalists may be left wondering, What exactly is CER and what does it mean for me?

Until recently no common definition for CER existed, and the very concept was identified only in relatively narrow policy and research circles. However, CER is not a new idea. Its ancestor is the notion of medical technology assessment (MTA), which garnered enthusiasm and support in the 1970s. In 1978, Congress established the National Center for Health Technology Assessment (which, over time, evolved into the Agency for Healthcare Research and Quality [AHRQ]), whose charge was to coordinate efforts within the government to assess the safety, efficacy, effectiveness, and cost‐effectiveness of medical technologies. The recognition of a need for technology assessment at that time is mirrored by the widespread interest in CER seen today. Part of the reason that MTA did not take hold is that then, as now, this type of evaluation is challenging and time consuming, requiring large, well‐designed effectiveness studies. These studies require rigorous methods, typically long‐term follow‐up, and acceptance via editors and the medical literature that effectiveness is as important as efficacy demonstrated in a randomized trial. With the spread of antiregulatory sentiment and the lack of an economic imperative to reduce costs, the national focus on technology assessment waned. The current economic crisis has refocused the government and private sector on the soaring cost of health care and the need to improve quality, and the stimulus package passed in February of 2009 placed CER once again in the forefront. The American Recovery and Reinvestment Act (ARRA) of 2009 allocated $1.1 billion for CER.1 On June 30, 2009, 2 reports delineating the strategy and priorities for CER were released. The report from the ARRA‐mandated Federal Coordinating Council (FCC) for CER includes a broad definition of CER and outlines a high‐level strategic framework for priorities and investments in CER.2 Simultaneously, the report from the Institute of Medicine (IOM) lists 100 priority research topics, and gives 10 general recommendations for the CER enterprise going forward.3

So what is CER and why is it important? How is it different from standard research that hospitalists use every day to inform their clinical decision‐making? Unfortunately, patients and providers confront medical decisions daily that are not evidence based. All too frequently it is unclear what therapeutic option works best for which patient under which circumstances. For example, what is the best inpatient diabetes management strategy for an African American woman with multiple medical problems? What is the best discharge process for an elderly man with heart disease in order to prevent readmission? CER seeks to fill the gaps in evidence needed by patients and clinicians in order to make appropriate medical decisions. It differs from standard efficacy research in that it compares interventions or management strategies in real world settings, allows identification of effectiveness in patient subgroups, and is more patient‐centered, focusing on the decisions confronting patients and their physicians. The following definition of CER was developed by the FCC for CER:

CER is the conduct and synthesis of research comparing the benefits and harms of different interventions and strategies to prevent, diagnose, treat and monitor health conditions in real world settings. The purpose of this research is to improve health outcomes by developing and disseminating evidence‐based information to patients, clinicians, and other decision‐makers, responding to their expressed needs about which interventions are most effective for which patients under specific circumstances.

• To provide this information, CER must assess a comprehensive array of health‐related outcomes for diverse patient populations and sub‐groups.

• Defined interventions compared may include medications, procedures, medical and assistive devices and technologies, diagnostic testing, behavioral change and delivery system strategies.

• This research necessitates the development, expansion and use of a variety of data sources and methods to assess comparative effectiveness and actively disseminate the results.

While CER is an evolving field requiring continued methodological development (such as enhancement of methods for practical, or pragmatic trials and complex analyses of large, linked databases), examples of rigorous comparative studies do exist. The Veterans Administration (VA) COURAGE trial compared optimal medical therapy (OMT) with or without percutaneous coronary intervention (PCI) for patients with stable coronary disease, finding that PCI did not reduce the risk of death or cardiovascular events compared to OMT alone.4 Another example is the Diabetes Prevention Program which compared placebo, metformin, and a lifestyle modification program to prevent or delay the onset of type 2 diabetes. This study famously showed that lifestyle modification was more effective than metformin or placebo in reducing the incidence of diabetes.5

CER holds the promise of significantly improving the health of Americans through the ability to target treatments and other interventions to individual patients. As noted by the FCC, CER can allow for the delivery of the right treatment to the right patient at the right time2 even as the field continues to evolve. To quote Fineberg and Hiatt6 in describing technology assessment in 1979, we cannot expect CER to lead to perfect decisions, but we can expect even imperfect methods to facilitate better informed decisions than would otherwise be possible.

CER has important implications for hospitalists in all roles and settings. As the field of hospital medicine has grown, hospitalists have increasingly assumed more responsibilities than just patient care. In academic and community hospitals, hospitalists take on leadership roles, particularly in quality improvement (QI) and patient safety, and educational roles in the training of housestaff, medical students, and physician extenders. The last several years have also seen a significant increase in hospitalists participating in research. The relevance of CER to each of these 4 major activities is described below and in the accompanying Table 1.

Hospitalists and Research

Many comparative effectiveness questions about clinical care, processes of care, and quality of care within the inpatient setting are in need of answers. Hospitalist researchers have the opportunity to make a significant impact on care by pursuing answers to questions that are unique to the field of hospital medicine. With the new availability of funds for CER, now is the time to address many of these questions head‐on. For example, there is a lack of evidence about best practices for a large number of inpatient acute conditions. What is the best strategy to manage acute hospital delirium in an elderly patient? What is the best approach to treating acute pain in an elderly woman on multiple medications? Overwhelmingly the patients that hospitalists care for are elderly and/or have multiple chronic conditions, including children with special health care needs. Many are from racial or ethnic minority backgrounds. These subgroups of patients have been historically under‐represented in clinical trials, yet represent exactly the priority populations that the Federal CER effort targets. The field of hospital medicine can be transformed with a substantial investment in research to address common inpatient clinical conditions in real world settings focused on the kinds of patients hospitalists actually care for.

One of the most vexing and frustrating care delivery issues for hospitalists, clinicians and researchers alike, is the discharge process. This problem received increased attention after a recent article highlighted the high rate of readmissions in the Medicare population.7 Research on the discharge process has grown substantially in recent years, and has become an area of intense focus and attention for hospitalists, nurses, researchers, hospital administrators and policymakers. Without question, hospitalists are uniquely poised to conduct research on this critically important topic, and CER is an ideal vehicle for moving this field forward. In collaboration with nurses, primary care physicians, pharmacists, case managers and others, hospitalists should take advantage of the Federal investment in studying care delivery systems interventions, and develop innovative methods and strategies for studying and improving this crucial transition in care. CER is also applicable to other care transitions, including the admission process, transitions within the hospital, and discharge to nursing facilities. Other examples of comparative effectiveness topics that hospitalist researchers are particularly suited for include comparing methods for implementing inpatient treatment protocols or clinical pathways, comparison of health information technology (IT) systems to reduce medical error, and QI approaches.

What are the methodologies that hospitalists should use to conduct CER? While randomized pragmatic real world trials are appealing, this method may not always be practical. Other methodologies are available for rigorous use, including cohort studies, comparative QI interventions, clustered and factorial design, systematic reviews, and analysis of registries, administrative claims, or other databases. Databases currently available for analysis on priority populations and subgroups are limited, and include the VA and Medicare databases. To address this need, one of the primary Federal investments in CER is for the enhancement and expansion of data infrastructure. Data infrastructure tools that are likely to be available to hospitalist researchers for CER include expanded longitudinal administrative claims databases with linkages to electronic health records (EHRs), expanded patient registries with linkages to other forms of data, and distributed data networks that are populated by EHRs in provider and practice settings. Hospitalist researchers should take advantage of these resources as they become available, as they have tremendous potential to inform decision‐making for providers and patients alike.

Hospitalists and Clinical Practice

As with all providers, hospitalists will be end‐users of CER evidence, and will have the responsibility of translating new knowledge into practice. This process will not be easy. How are hospitalists to reliably access and incorporate new comparative effectiveness information into their daily practice? How should they deal with some of the potential unintended consequences of CER, such as information overload or conflicting evidence? While hospitalists have a professional responsibility to search for and apply CER findings, the future development of CER‐based practice guidelines will encourage evidence translation. The development of a common platform for the dissemination of CER relevant to hospitalists would significantly enhance the uptake of new evidence by practicing hospitalists and other hospital‐based providers such as physician assistants or nurse practitioners. Medical societies such as the Society of Hospital Medicine and the American Academy of Pediatrics should consider developing committees for CER and leading coordinated educational efforts specifically focused on CER results through publications and presentations at local, regional, and national meetings. In addition, other dissemination tools for CER will soon emerge and existing tools will be enhanced, such as the Effective Health Care Program and Eisenberg Center housed at the AHRQ. The coming years will see an expansion of these and other dissemination efforts to both providers and patients, and hospitalists must be vigilant about accessing these resources and integrating comparative effectiveness evidence into practice. As Federal dissemination efforts to consumers spread, patients will increasingly expect physicians to discuss comparative effectiveness evidence in describing options for their individual health needs. Finally, a key lever for translating CER into practice will be payment models that place accountability for performance on physicians and hospitals, with a significant proportion of payment based on the delivery of high quality, efficient care.

Education and Training

Investment in the training and development of a skilled workforce to conduct CER is an important priority. Hospitalist researchers should take advantage of education and training programs to support the development of methodologies and skills for conducting CER that will become available. These programs will enable hospitalists to learn such skills as the use of the newly enhanced data infrastructure discussed above. The national investment in human and scientific capital for CER can promote the training of a corps of hospitalist researchers focused on this research which, in turn, could support the growth of the academic hospitalist field. Hospitalists who have responsibilities in medical education and residency training programs should take the lead in teaching CER concepts that are relevant to inpatient care. They will need to train the next generation of medical students and residents to read and understand comparative effectiveness literature and its application in clinical practice. Hospitalist educators are also best positioned to teach medical trainees comparative effectiveness evidence about inpatient QI methods and care processes.

Hospital Leadership

As front‐line providers and team leaders, hospitalists are well placed to direct the efforts within their hospitals to implement new CER evidence. For example, suppose new comparative effectiveness evidence about best practices for the discharge process for community‐dwelling older adults with multiple chronic conditions were to emerge. Hospitalists could lead efforts within their hospital to establish a multidisciplinary team to address this development, create standard protocols for implementing the new discharge process that align with their hospital's unique systems and organizational structure, advocate for necessary resources for the team to accomplish the goal of safely discharging these patients, ensure a method to track outcomes such as readmissions once the new discharge process is implemented, and provide data feedback to the team, hospital staff, and administrative leadership of the hospital. All of these activities should include a variety of disciplines working together, but as physician leaders, hospitalists can take the initiative to spearhead these endeavors. The inpatient setting is one that requires teamwork and coordination, and as team leaders, hospitalists can strongly influence the spread and adoption of CER results. Similarly, hospitalists are in a position to affect this dissemination and translation process by actively educating and empowering other clinicians and hospital staff within their local environment. Finally, as hospitalists increasingly take on leadership roles in QI departments and as chief medical officers within both community and university‐affiliated hospitals^8, they are in a unique position to lead efforts to implement CER‐based QI activities. These may range from the implementation of IT functions to reduce medical error to strategies to reduce hospital‐acquired infections or falls.

Conclusion

As a result of the stimulus funds directed towards CER, the coming years will see a vast increase in the generation of comparative effectiveness evidence and the application of that evidence into practice.9 The national CER endeavor is particularly germane to the field of hospital medicine, as uncertainty about best practices is common, and the patients hospitalists serve represent priority populations for CER investments. Hospitalists can play a central role in both generating CER and implementing its findings in settings in which patients are highly vulnerable, and existing information is insufficient. In addition to clinical questions, hospitalist researchers are particularly suited to answering important questions about quality of care and inpatient processes such as transitions of care and care coordination. Having evidence on the best practices for care transitions or strategies to reduce medical error, for example, could have a significant impact on patient outcomes, quality of life, and cost of care. However, none of this new evidence will be of any value if it is not used by front‐line providers.10 Practicing hospitalists should lead efforts within their hospital to disseminate new CER findings to their hospitalist and non‐hospitalist colleagues, and to leverage their position as hospital and team leaders to implement inpatient‐based CER findings. All of these combined efforts have the potential to significantly move the field of hospital medicine forward, with the end result being improved health and better outcomes for patients.

The topic of comparative effectiveness research (CER) has recently gained prominence within the context of the national focus on health reform. This article provides a brief overview and history of CER, and discusses the implications of CER for hospitalists in each of four major career roles: research, clinical practice, education and training, and hospital leadership. Both medical journals and lay media have produced a flurry of articles recently on a variety of health reform subjects. One topic that has achieved prominence within this growing body of literature is comparative effectiveness research (CER). For many hospitalists, this particular brand of research may be unfamiliar. As discussions about CER priorities, the controversy surrounding CER, and even the definition of CER gain visibility, hospitalists may be left wondering, What exactly is CER and what does it mean for me?

Until recently no common definition for CER existed, and the very concept was identified only in relatively narrow policy and research circles. However, CER is not a new idea. Its ancestor is the notion of medical technology assessment (MTA), which garnered enthusiasm and support in the 1970s. In 1978, Congress established the National Center for Health Technology Assessment (which, over time, evolved into the Agency for Healthcare Research and Quality [AHRQ]), whose charge was to coordinate efforts within the government to assess the safety, efficacy, effectiveness, and cost‐effectiveness of medical technologies. The recognition of a need for technology assessment at that time is mirrored by the widespread interest in CER seen today. Part of the reason that MTA did not take hold is that then, as now, this type of evaluation is challenging and time consuming, requiring large, well‐designed effectiveness studies. These studies require rigorous methods, typically long‐term follow‐up, and acceptance via editors and the medical literature that effectiveness is as important as efficacy demonstrated in a randomized trial. With the spread of antiregulatory sentiment and the lack of an economic imperative to reduce costs, the national focus on technology assessment waned. The current economic crisis has refocused the government and private sector on the soaring cost of health care and the need to improve quality, and the stimulus package passed in February of 2009 placed CER once again in the forefront. The American Recovery and Reinvestment Act (ARRA) of 2009 allocated $1.1 billion for CER.1 On June 30, 2009, 2 reports delineating the strategy and priorities for CER were released. The report from the ARRA‐mandated Federal Coordinating Council (FCC) for CER includes a broad definition of CER and outlines a high‐level strategic framework for priorities and investments in CER.2 Simultaneously, the report from the Institute of Medicine (IOM) lists 100 priority research topics, and gives 10 general recommendations for the CER enterprise going forward.3

So what is CER and why is it important? How is it different from standard research that hospitalists use every day to inform their clinical decision‐making? Unfortunately, patients and providers confront medical decisions daily that are not evidence based. All too frequently it is unclear what therapeutic option works best for which patient under which circumstances. For example, what is the best inpatient diabetes management strategy for an African American woman with multiple medical problems? What is the best discharge process for an elderly man with heart disease in order to prevent readmission? CER seeks to fill the gaps in evidence needed by patients and clinicians in order to make appropriate medical decisions. It differs from standard efficacy research in that it compares interventions or management strategies in real world settings, allows identification of effectiveness in patient subgroups, and is more patient‐centered, focusing on the decisions confronting patients and their physicians. The following definition of CER was developed by the FCC for CER:

CER is the conduct and synthesis of research comparing the benefits and harms of different interventions and strategies to prevent, diagnose, treat and monitor health conditions in real world settings. The purpose of this research is to improve health outcomes by developing and disseminating evidence‐based information to patients, clinicians, and other decision‐makers, responding to their expressed needs about which interventions are most effective for which patients under specific circumstances.

• To provide this information, CER must assess a comprehensive array of health‐related outcomes for diverse patient populations and sub‐groups.

• Defined interventions compared may include medications, procedures, medical and assistive devices and technologies, diagnostic testing, behavioral change and delivery system strategies.

• This research necessitates the development, expansion and use of a variety of data sources and methods to assess comparative effectiveness and actively disseminate the results.

While CER is an evolving field requiring continued methodological development (such as enhancement of methods for practical, or pragmatic trials and complex analyses of large, linked databases), examples of rigorous comparative studies do exist. The Veterans Administration (VA) COURAGE trial compared optimal medical therapy (OMT) with or without percutaneous coronary intervention (PCI) for patients with stable coronary disease, finding that PCI did not reduce the risk of death or cardiovascular events compared to OMT alone.4 Another example is the Diabetes Prevention Program which compared placebo, metformin, and a lifestyle modification program to prevent or delay the onset of type 2 diabetes. This study famously showed that lifestyle modification was more effective than metformin or placebo in reducing the incidence of diabetes.5

CER holds the promise of significantly improving the health of Americans through the ability to target treatments and other interventions to individual patients. As noted by the FCC, CER can allow for the delivery of the right treatment to the right patient at the right time2 even as the field continues to evolve. To quote Fineberg and Hiatt6 in describing technology assessment in 1979, we cannot expect CER to lead to perfect decisions, but we can expect even imperfect methods to facilitate better informed decisions than would otherwise be possible.

CER has important implications for hospitalists in all roles and settings. As the field of hospital medicine has grown, hospitalists have increasingly assumed more responsibilities than just patient care. In academic and community hospitals, hospitalists take on leadership roles, particularly in quality improvement (QI) and patient safety, and educational roles in the training of housestaff, medical students, and physician extenders. The last several years have also seen a significant increase in hospitalists participating in research. The relevance of CER to each of these 4 major activities is described below and in the accompanying Table 1.

Hospitalists and Research

Many comparative effectiveness questions about clinical care, processes of care, and quality of care within the inpatient setting are in need of answers. Hospitalist researchers have the opportunity to make a significant impact on care by pursuing answers to questions that are unique to the field of hospital medicine. With the new availability of funds for CER, now is the time to address many of these questions head‐on. For example, there is a lack of evidence about best practices for a large number of inpatient acute conditions. What is the best strategy to manage acute hospital delirium in an elderly patient? What is the best approach to treating acute pain in an elderly woman on multiple medications? Overwhelmingly the patients that hospitalists care for are elderly and/or have multiple chronic conditions, including children with special health care needs. Many are from racial or ethnic minority backgrounds. These subgroups of patients have been historically under‐represented in clinical trials, yet represent exactly the priority populations that the Federal CER effort targets. The field of hospital medicine can be transformed with a substantial investment in research to address common inpatient clinical conditions in real world settings focused on the kinds of patients hospitalists actually care for.

One of the most vexing and frustrating care delivery issues for hospitalists, clinicians and researchers alike, is the discharge process. This problem received increased attention after a recent article highlighted the high rate of readmissions in the Medicare population.7 Research on the discharge process has grown substantially in recent years, and has become an area of intense focus and attention for hospitalists, nurses, researchers, hospital administrators and policymakers. Without question, hospitalists are uniquely poised to conduct research on this critically important topic, and CER is an ideal vehicle for moving this field forward. In collaboration with nurses, primary care physicians, pharmacists, case managers and others, hospitalists should take advantage of the Federal investment in studying care delivery systems interventions, and develop innovative methods and strategies for studying and improving this crucial transition in care. CER is also applicable to other care transitions, including the admission process, transitions within the hospital, and discharge to nursing facilities. Other examples of comparative effectiveness topics that hospitalist researchers are particularly suited for include comparing methods for implementing inpatient treatment protocols or clinical pathways, comparison of health information technology (IT) systems to reduce medical error, and QI approaches.

What are the methodologies that hospitalists should use to conduct CER? While randomized pragmatic real world trials are appealing, this method may not always be practical. Other methodologies are available for rigorous use, including cohort studies, comparative QI interventions, clustered and factorial design, systematic reviews, and analysis of registries, administrative claims, or other databases. Databases currently available for analysis on priority populations and subgroups are limited, and include the VA and Medicare databases. To address this need, one of the primary Federal investments in CER is for the enhancement and expansion of data infrastructure. Data infrastructure tools that are likely to be available to hospitalist researchers for CER include expanded longitudinal administrative claims databases with linkages to electronic health records (EHRs), expanded patient registries with linkages to other forms of data, and distributed data networks that are populated by EHRs in provider and practice settings. Hospitalist researchers should take advantage of these resources as they become available, as they have tremendous potential to inform decision‐making for providers and patients alike.

Hospitalists and Clinical Practice

As with all providers, hospitalists will be end‐users of CER evidence, and will have the responsibility of translating new knowledge into practice. This process will not be easy. How are hospitalists to reliably access and incorporate new comparative effectiveness information into their daily practice? How should they deal with some of the potential unintended consequences of CER, such as information overload or conflicting evidence? While hospitalists have a professional responsibility to search for and apply CER findings, the future development of CER‐based practice guidelines will encourage evidence translation. The development of a common platform for the dissemination of CER relevant to hospitalists would significantly enhance the uptake of new evidence by practicing hospitalists and other hospital‐based providers such as physician assistants or nurse practitioners. Medical societies such as the Society of Hospital Medicine and the American Academy of Pediatrics should consider developing committees for CER and leading coordinated educational efforts specifically focused on CER results through publications and presentations at local, regional, and national meetings. In addition, other dissemination tools for CER will soon emerge and existing tools will be enhanced, such as the Effective Health Care Program and Eisenberg Center housed at the AHRQ. The coming years will see an expansion of these and other dissemination efforts to both providers and patients, and hospitalists must be vigilant about accessing these resources and integrating comparative effectiveness evidence into practice. As Federal dissemination efforts to consumers spread, patients will increasingly expect physicians to discuss comparative effectiveness evidence in describing options for their individual health needs. Finally, a key lever for translating CER into practice will be payment models that place accountability for performance on physicians and hospitals, with a significant proportion of payment based on the delivery of high quality, efficient care.

Education and Training

Investment in the training and development of a skilled workforce to conduct CER is an important priority. Hospitalist researchers should take advantage of education and training programs to support the development of methodologies and skills for conducting CER that will become available. These programs will enable hospitalists to learn such skills as the use of the newly enhanced data infrastructure discussed above. The national investment in human and scientific capital for CER can promote the training of a corps of hospitalist researchers focused on this research which, in turn, could support the growth of the academic hospitalist field. Hospitalists who have responsibilities in medical education and residency training programs should take the lead in teaching CER concepts that are relevant to inpatient care. They will need to train the next generation of medical students and residents to read and understand comparative effectiveness literature and its application in clinical practice. Hospitalist educators are also best positioned to teach medical trainees comparative effectiveness evidence about inpatient QI methods and care processes.

Hospital Leadership

As front‐line providers and team leaders, hospitalists are well placed to direct the efforts within their hospitals to implement new CER evidence. For example, suppose new comparative effectiveness evidence about best practices for the discharge process for community‐dwelling older adults with multiple chronic conditions were to emerge. Hospitalists could lead efforts within their hospital to establish a multidisciplinary team to address this development, create standard protocols for implementing the new discharge process that align with their hospital's unique systems and organizational structure, advocate for necessary resources for the team to accomplish the goal of safely discharging these patients, ensure a method to track outcomes such as readmissions once the new discharge process is implemented, and provide data feedback to the team, hospital staff, and administrative leadership of the hospital. All of these activities should include a variety of disciplines working together, but as physician leaders, hospitalists can take the initiative to spearhead these endeavors. The inpatient setting is one that requires teamwork and coordination, and as team leaders, hospitalists can strongly influence the spread and adoption of CER results. Similarly, hospitalists are in a position to affect this dissemination and translation process by actively educating and empowering other clinicians and hospital staff within their local environment. Finally, as hospitalists increasingly take on leadership roles in QI departments and as chief medical officers within both community and university‐affiliated hospitals^8, they are in a unique position to lead efforts to implement CER‐based QI activities. These may range from the implementation of IT functions to reduce medical error to strategies to reduce hospital‐acquired infections or falls.

Conclusion

As a result of the stimulus funds directed towards CER, the coming years will see a vast increase in the generation of comparative effectiveness evidence and the application of that evidence into practice.9 The national CER endeavor is particularly germane to the field of hospital medicine, as uncertainty about best practices is common, and the patients hospitalists serve represent priority populations for CER investments. Hospitalists can play a central role in both generating CER and implementing its findings in settings in which patients are highly vulnerable, and existing information is insufficient. In addition to clinical questions, hospitalist researchers are particularly suited to answering important questions about quality of care and inpatient processes such as transitions of care and care coordination. Having evidence on the best practices for care transitions or strategies to reduce medical error, for example, could have a significant impact on patient outcomes, quality of life, and cost of care. However, none of this new evidence will be of any value if it is not used by front‐line providers.10 Practicing hospitalists should lead efforts within their hospital to disseminate new CER findings to their hospitalist and non‐hospitalist colleagues, and to leverage their position as hospital and team leaders to implement inpatient‐based CER findings. All of these combined efforts have the potential to significantly move the field of hospital medicine forward, with the end result being improved health and better outcomes for patients.

A 41‐year‐old woman with menorrhagia presented with dysphagia and fatigue. An examination revealed koilonychia (Figure 1), cheilosis, atrophic glossitis, and conjunctival pallor. The hemoglobin level was 4.3 g/dL, the mean corpuscular volume was 48.3, the iron level was 6 g/dL, and the ferritin level was undetectable (<1 ng/mL). A barium esophagram demonstrated probable esophageal webs (Figure 2). Esophageal webs were confirmed by upper endoscopy (Figure 3) and successfully dilated with a balloon dilator sequentially at 8, 9, and 10 mm. She was transfused, treated for menorrhagia, and given ferrous sulfate and ascorbic acid (to improve iron absorption).

Figure 1

Figure 2

Figure 3

Koilonychia (or spoon nails) is derived from the Greek word for hollow nails. Spoon nails are associated with iron deficiency, thyroid dysfunction, trauma, chronic solvent exposure, and nail‐patella syndrome, but they can be normal in infants.1 Patterson and Kelly independently described the triad of iron‐deficiency anemia, dysphagia, and upper esophageal webs in 1919 following Plummer's (1912) and Vinson's (1919) similar but less comprehensive descriptions of hysterical dysphagia.2 Plummer‐Vinson syndrome is rare, but precise prevalence data are unavailable.2 Whether iron deficiency truly causes esophageal webs is debated, but iron deficiency is thought to weaken esophageal musculature and cause epithelial cell atrophy.2 Autoimmunity and genetic predisposition are other putative causes. Dilation of esophageal webs is usually curative, although their association with an increased risk of upper alimentary cancers may justify surveillance endoscopy.3

A 41‐year‐old woman with menorrhagia presented with dysphagia and fatigue. An examination revealed koilonychia (Figure 1), cheilosis, atrophic glossitis, and conjunctival pallor. The hemoglobin level was 4.3 g/dL, the mean corpuscular volume was 48.3, the iron level was 6 g/dL, and the ferritin level was undetectable (<1 ng/mL). A barium esophagram demonstrated probable esophageal webs (Figure 2). Esophageal webs were confirmed by upper endoscopy (Figure 3) and successfully dilated with a balloon dilator sequentially at 8, 9, and 10 mm. She was transfused, treated for menorrhagia, and given ferrous sulfate and ascorbic acid (to improve iron absorption).

Figure 1

Figure 2

Figure 3

Koilonychia (or spoon nails) is derived from the Greek word for hollow nails. Spoon nails are associated with iron deficiency, thyroid dysfunction, trauma, chronic solvent exposure, and nail‐patella syndrome, but they can be normal in infants.1 Patterson and Kelly independently described the triad of iron‐deficiency anemia, dysphagia, and upper esophageal webs in 1919 following Plummer's (1912) and Vinson's (1919) similar but less comprehensive descriptions of hysterical dysphagia.2 Plummer‐Vinson syndrome is rare, but precise prevalence data are unavailable.2 Whether iron deficiency truly causes esophageal webs is debated, but iron deficiency is thought to weaken esophageal musculature and cause epithelial cell atrophy.2 Autoimmunity and genetic predisposition are other putative causes. Dilation of esophageal webs is usually curative, although their association with an increased risk of upper alimentary cancers may justify surveillance endoscopy.3

A 41‐year‐old woman with menorrhagia presented with dysphagia and fatigue. An examination revealed koilonychia (Figure 1), cheilosis, atrophic glossitis, and conjunctival pallor. The hemoglobin level was 4.3 g/dL, the mean corpuscular volume was 48.3, the iron level was 6 g/dL, and the ferritin level was undetectable (<1 ng/mL). A barium esophagram demonstrated probable esophageal webs (Figure 2). Esophageal webs were confirmed by upper endoscopy (Figure 3) and successfully dilated with a balloon dilator sequentially at 8, 9, and 10 mm. She was transfused, treated for menorrhagia, and given ferrous sulfate and ascorbic acid (to improve iron absorption).

Figure 1

Figure 2

Figure 3

Koilonychia (or spoon nails) is derived from the Greek word for hollow nails. Spoon nails are associated with iron deficiency, thyroid dysfunction, trauma, chronic solvent exposure, and nail‐patella syndrome, but they can be normal in infants.1 Patterson and Kelly independently described the triad of iron‐deficiency anemia, dysphagia, and upper esophageal webs in 1919 following Plummer's (1912) and Vinson's (1919) similar but less comprehensive descriptions of hysterical dysphagia.2 Plummer‐Vinson syndrome is rare, but precise prevalence data are unavailable.2 Whether iron deficiency truly causes esophageal webs is debated, but iron deficiency is thought to weaken esophageal musculature and cause epithelial cell atrophy.2 Autoimmunity and genetic predisposition are other putative causes. Dilation of esophageal webs is usually curative, although their association with an increased risk of upper alimentary cancers may justify surveillance endoscopy.3

Recurrent bacterial meningitis (RBM), particularly when caused by Streptococcus pneumoniae, warrants an aggressive and thorough evaluation to exclude transdural communication. We present an unusual case of RBM as a late manifestation of a traumatic head injury sustained 10 years prior and describe presentation, etiology, diagnosis, and treatment options for RBM.

Case Report

A middle‐aged woman with type 2 diabetes mellitus, hypertension, and a prior history of S. pneumoniae meningitis 1 year earlier, presented to an outside hospital with complaints of fever, headache, and change in mental status. Materials for basic laboratory tests and blood cultures were drawn in the Emergency Department; these showed diabetic ketoacidosis. Computed tomography (CT) scan of the head was negative and a lumbar puncture (LP) was attempted, but was unsuccessful. The patient was started on intravenous insulin drip, vancomycin, and ceftriaxone and was transported to our facility via Life‐Flight. She also developed acute respiratory failure requiring mechanical ventilation.

After arrival, the patient had a normal repeat CT scan of her head and a successful LP. Cerebrospinal fluid (CSF) revealed 9064 white blood cells (WBCs)/mm³ with 77% neutrophils and 9% lymphocytes, protein concentration of 275 mg/dL, and glucose of 93 mg/dL. CSF culture and Gram stain were negative, while 1 blood culture drawn at the outside hospital grew penicillin‐resistant S. pneumoniae (MIC 2 g/mL). WBC count was 9660/mm³ with 45% band forms. Bacterial meningitis was confirmed and the patient was continued on intravenous antibiotics and insulin drip. Additional laboratory studies revealed normal complement levels and a negative human immunodeficiency virus (HIV) 1 and HIV 2 antibody screen. The patient was extubated in 48 hours. and was treated with a total of 2 weeks of ceftriaxone and vancomycin for penicillin‐resistant S. pneumoniae meningitis.

The patient had an uneventful full recovery and was discharged from the hospital with neurosurgery follow‐up. The neurosurgeon ordered a CT scan of the facial bones, which revealed an irregular calcification in the right frontal sinus adjacent to the cribriform plate and thinning of the posterior wall of the sinus. Upon requestioning at a subsequent neurosurgical appointment, the patient recalled being an unrestrained passenger and striking her head against the windshield in a motor vehicle accident (MVA) approximately 10 years ago. Ever since the MVA, she noticed intermittent postnasal discharge while recumbent. However, she never sought a medical opinion and denied complaints of anterior rhinorrhea.

A CT cisternography confirmed the presence of CSF leakage with contrast accumulation via a defect in the right paramedian cribriform plate. Contrast opacification was seen in the fovea ethmoidalis extending into the right frontal sinus (Figure 1). The patient subsequently underwent transnasal endoscopic CSF leak repair (Figure 2). The postoperative cisternogram did not reveal the transdural communication. However a follow‐up cisternogram performed 3 months later demonstrated a recurrent CSF leak.

Figure 1

Figure 2

The patient was rehospitalized with grand‐mal seizures and a third episode of S. pneumoniae meningitis, this time with a penicillin‐sensitive strain. She was treated with a 2‐week course of ceftriaxone and also received heptavalent pneumococcal vaccine to supplement the 23‐valent pneumococcal vaccine. Two weeks after the hospital discharge, the patient underwent successful bifrontal transcranial repair. Currently, she has been disease‐free for 3 months and is followed closely by neurosurgery as an outpatient.

Discussion

After immune deficiency is ruled out, it is essential to evaluate for transdural communication between the subarachnoid space and the base of the skull resulting in a CSF leak as a cause for RBM. Meningitis secondary to a CSF leak is most commonly caused by S. pneumoniae, followed by Neisseria meningitidis and Haemophilus influenzae.1 Complement and immunoglobulin subclass defects may also predispose to RBM.2, 3

A recent case series by Adriani et al.4 suggested that as many as 77% of patients with RBM have an identifiable risk factor such as a remote head injury or CSF leakage. CSF rhinorrhea is most often secondary to trauma, occurring in approximately 1% to 3% of all blunt head injuries.2 Accidental falls, MVAs, altercations, and gunshot wounds are also commonly responsible.3 Nontraumatic CSF leaks are very rare but may be secondary to spontaneous, congenital, or iatrogenic etiologies.1, 3 Spontaneous CSF leaks could also occur due to violent sneezing or coughing.1, 3 Congenital defects include weakened preformed pathways, failure of germ layer closures, and bone imperfections.1, 3 Infrequently, CSF leak can be a complication of intracranial, otologic, nasal, or paranasal sinus surgeries.1, 3 Other rarer etiologies include intracranial tumors and hydrocephalus.1, 3

Bacterial meningitis due to traumatic CSF leak can present within 24 hours to as long as several decades after the development of the leak.2, 3 Along with the classic symptoms and signs of meningitis, including fever, headache, neck stiffness, change in sensorium, seizures, and vomiting, patients may also present with CSF rhinorrhea, CSF otorrhea, hearing impairment, or cranial injury residua.3, 5 It is important to note that CSF rhinorrhea and otorrhea are not always present in cases of chronic, posttraumatic CSF leaks.

The visualization of a fracture or bony dehiscence is very difficult but critical for identification and surgical repair. Frontal and ethmoid sinuses and cribriform plate are common fracture sites.1, 3, 5 CSF leakage may be from the anterior, middle, or posterior compartments, eventually ending in the nasal cavity.1, 3, 5 Various imaging modalities, including contrast cisternogram, high‐resolution CT, fluorescein nasal endoscopy, and magnetic resonance imaging (MRI) have been advocated for diagnosing the source of CSF leak with variable sensitivity and specificity.6 High‐resolution CT helps in identifying surgical anatomy and bony defects whereas contrast cisternography is confirmatory when the CSF leak is active.1, 6 Protein electrophoresis demonstrating 2 electrophoretically separate transferrin bands confirms CSF.7

In patients with persistent CSF rhinorrhea, there is a 19% overall risk of meningitis with an annual incidence of 0.3 meningitis episodes per year.8 The risk of meningitis is the greatest in the first year following the onset of a CSF leak.8 Generally, patients with posttraumatic CSF leak lasting more than 7 to 10 days need surgical repair to decrease their risk of bacterial meningitis.1, 3, 5 Endoscopic surgical correction with a success rate of 90% is an effective treatment for CSF leak and involves placement of a temporary lumbar drain in addition to endonasal duraplasty performed with the aid of microscope and/or nasoscope.9 Complicated anterior cranial base fractures are not as amenable to endoscopic repair and may require a combined intracranial extradural and intradural approach or a transcranial approach.10

Information on prophylactic antibiotics and vaccination is still evolving. Currently available evidence from randomized control trials does not support prophylactic antibiotic use in patients with basilar skull fracture with or without the evidence of CSF leakage.11 A meta‐analysis of 4 randomized controlled trials of patients with acute basilar skull fracture showed no significant difference between the antibiotic prophylaxis groups and control groups with respect to reduction of the frequency of meningitis, the need for surgical correction, meningitis‐related mortality, and all‐cause mortality.11 Direct invasion of the meninges by nasopharyngeal bacteria bypassing the circulating serum antibodies may limit the potential effectiveness of vaccination in preventing RBM.12 However, vaccination is generally recommended in patients with complement or immunoglobulin deficiency or after splenectomy.4

Recurrent bacterial meningitis (RBM), particularly when caused by Streptococcus pneumoniae, warrants an aggressive and thorough evaluation to exclude transdural communication. We present an unusual case of RBM as a late manifestation of a traumatic head injury sustained 10 years prior and describe presentation, etiology, diagnosis, and treatment options for RBM.

Case Report

A middle‐aged woman with type 2 diabetes mellitus, hypertension, and a prior history of S. pneumoniae meningitis 1 year earlier, presented to an outside hospital with complaints of fever, headache, and change in mental status. Materials for basic laboratory tests and blood cultures were drawn in the Emergency Department; these showed diabetic ketoacidosis. Computed tomography (CT) scan of the head was negative and a lumbar puncture (LP) was attempted, but was unsuccessful. The patient was started on intravenous insulin drip, vancomycin, and ceftriaxone and was transported to our facility via Life‐Flight. She also developed acute respiratory failure requiring mechanical ventilation.

After arrival, the patient had a normal repeat CT scan of her head and a successful LP. Cerebrospinal fluid (CSF) revealed 9064 white blood cells (WBCs)/mm³ with 77% neutrophils and 9% lymphocytes, protein concentration of 275 mg/dL, and glucose of 93 mg/dL. CSF culture and Gram stain were negative, while 1 blood culture drawn at the outside hospital grew penicillin‐resistant S. pneumoniae (MIC 2 g/mL). WBC count was 9660/mm³ with 45% band forms. Bacterial meningitis was confirmed and the patient was continued on intravenous antibiotics and insulin drip. Additional laboratory studies revealed normal complement levels and a negative human immunodeficiency virus (HIV) 1 and HIV 2 antibody screen. The patient was extubated in 48 hours. and was treated with a total of 2 weeks of ceftriaxone and vancomycin for penicillin‐resistant S. pneumoniae meningitis.

The patient had an uneventful full recovery and was discharged from the hospital with neurosurgery follow‐up. The neurosurgeon ordered a CT scan of the facial bones, which revealed an irregular calcification in the right frontal sinus adjacent to the cribriform plate and thinning of the posterior wall of the sinus. Upon requestioning at a subsequent neurosurgical appointment, the patient recalled being an unrestrained passenger and striking her head against the windshield in a motor vehicle accident (MVA) approximately 10 years ago. Ever since the MVA, she noticed intermittent postnasal discharge while recumbent. However, she never sought a medical opinion and denied complaints of anterior rhinorrhea.

A CT cisternography confirmed the presence of CSF leakage with contrast accumulation via a defect in the right paramedian cribriform plate. Contrast opacification was seen in the fovea ethmoidalis extending into the right frontal sinus (Figure 1). The patient subsequently underwent transnasal endoscopic CSF leak repair (Figure 2). The postoperative cisternogram did not reveal the transdural communication. However a follow‐up cisternogram performed 3 months later demonstrated a recurrent CSF leak.

Figure 1

Figure 2

The patient was rehospitalized with grand‐mal seizures and a third episode of S. pneumoniae meningitis, this time with a penicillin‐sensitive strain. She was treated with a 2‐week course of ceftriaxone and also received heptavalent pneumococcal vaccine to supplement the 23‐valent pneumococcal vaccine. Two weeks after the hospital discharge, the patient underwent successful bifrontal transcranial repair. Currently, she has been disease‐free for 3 months and is followed closely by neurosurgery as an outpatient.

Discussion

After immune deficiency is ruled out, it is essential to evaluate for transdural communication between the subarachnoid space and the base of the skull resulting in a CSF leak as a cause for RBM. Meningitis secondary to a CSF leak is most commonly caused by S. pneumoniae, followed by Neisseria meningitidis and Haemophilus influenzae.1 Complement and immunoglobulin subclass defects may also predispose to RBM.2, 3

A recent case series by Adriani et al.4 suggested that as many as 77% of patients with RBM have an identifiable risk factor such as a remote head injury or CSF leakage. CSF rhinorrhea is most often secondary to trauma, occurring in approximately 1% to 3% of all blunt head injuries.2 Accidental falls, MVAs, altercations, and gunshot wounds are also commonly responsible.3 Nontraumatic CSF leaks are very rare but may be secondary to spontaneous, congenital, or iatrogenic etiologies.1, 3 Spontaneous CSF leaks could also occur due to violent sneezing or coughing.1, 3 Congenital defects include weakened preformed pathways, failure of germ layer closures, and bone imperfections.1, 3 Infrequently, CSF leak can be a complication of intracranial, otologic, nasal, or paranasal sinus surgeries.1, 3 Other rarer etiologies include intracranial tumors and hydrocephalus.1, 3

Bacterial meningitis due to traumatic CSF leak can present within 24 hours to as long as several decades after the development of the leak.2, 3 Along with the classic symptoms and signs of meningitis, including fever, headache, neck stiffness, change in sensorium, seizures, and vomiting, patients may also present with CSF rhinorrhea, CSF otorrhea, hearing impairment, or cranial injury residua.3, 5 It is important to note that CSF rhinorrhea and otorrhea are not always present in cases of chronic, posttraumatic CSF leaks.

The visualization of a fracture or bony dehiscence is very difficult but critical for identification and surgical repair. Frontal and ethmoid sinuses and cribriform plate are common fracture sites.1, 3, 5 CSF leakage may be from the anterior, middle, or posterior compartments, eventually ending in the nasal cavity.1, 3, 5 Various imaging modalities, including contrast cisternogram, high‐resolution CT, fluorescein nasal endoscopy, and magnetic resonance imaging (MRI) have been advocated for diagnosing the source of CSF leak with variable sensitivity and specificity.6 High‐resolution CT helps in identifying surgical anatomy and bony defects whereas contrast cisternography is confirmatory when the CSF leak is active.1, 6 Protein electrophoresis demonstrating 2 electrophoretically separate transferrin bands confirms CSF.7

In patients with persistent CSF rhinorrhea, there is a 19% overall risk of meningitis with an annual incidence of 0.3 meningitis episodes per year.8 The risk of meningitis is the greatest in the first year following the onset of a CSF leak.8 Generally, patients with posttraumatic CSF leak lasting more than 7 to 10 days need surgical repair to decrease their risk of bacterial meningitis.1, 3, 5 Endoscopic surgical correction with a success rate of 90% is an effective treatment for CSF leak and involves placement of a temporary lumbar drain in addition to endonasal duraplasty performed with the aid of microscope and/or nasoscope.9 Complicated anterior cranial base fractures are not as amenable to endoscopic repair and may require a combined intracranial extradural and intradural approach or a transcranial approach.10

Information on prophylactic antibiotics and vaccination is still evolving. Currently available evidence from randomized control trials does not support prophylactic antibiotic use in patients with basilar skull fracture with or without the evidence of CSF leakage.11 A meta‐analysis of 4 randomized controlled trials of patients with acute basilar skull fracture showed no significant difference between the antibiotic prophylaxis groups and control groups with respect to reduction of the frequency of meningitis, the need for surgical correction, meningitis‐related mortality, and all‐cause mortality.11 Direct invasion of the meninges by nasopharyngeal bacteria bypassing the circulating serum antibodies may limit the potential effectiveness of vaccination in preventing RBM.12 However, vaccination is generally recommended in patients with complement or immunoglobulin deficiency or after splenectomy.4

Recurrent bacterial meningitis (RBM), particularly when caused by Streptococcus pneumoniae, warrants an aggressive and thorough evaluation to exclude transdural communication. We present an unusual case of RBM as a late manifestation of a traumatic head injury sustained 10 years prior and describe presentation, etiology, diagnosis, and treatment options for RBM.

Case Report

A middle‐aged woman with type 2 diabetes mellitus, hypertension, and a prior history of S. pneumoniae meningitis 1 year earlier, presented to an outside hospital with complaints of fever, headache, and change in mental status. Materials for basic laboratory tests and blood cultures were drawn in the Emergency Department; these showed diabetic ketoacidosis. Computed tomography (CT) scan of the head was negative and a lumbar puncture (LP) was attempted, but was unsuccessful. The patient was started on intravenous insulin drip, vancomycin, and ceftriaxone and was transported to our facility via Life‐Flight. She also developed acute respiratory failure requiring mechanical ventilation.

After arrival, the patient had a normal repeat CT scan of her head and a successful LP. Cerebrospinal fluid (CSF) revealed 9064 white blood cells (WBCs)/mm³ with 77% neutrophils and 9% lymphocytes, protein concentration of 275 mg/dL, and glucose of 93 mg/dL. CSF culture and Gram stain were negative, while 1 blood culture drawn at the outside hospital grew penicillin‐resistant S. pneumoniae (MIC 2 g/mL). WBC count was 9660/mm³ with 45% band forms. Bacterial meningitis was confirmed and the patient was continued on intravenous antibiotics and insulin drip. Additional laboratory studies revealed normal complement levels and a negative human immunodeficiency virus (HIV) 1 and HIV 2 antibody screen. The patient was extubated in 48 hours. and was treated with a total of 2 weeks of ceftriaxone and vancomycin for penicillin‐resistant S. pneumoniae meningitis.

The patient had an uneventful full recovery and was discharged from the hospital with neurosurgery follow‐up. The neurosurgeon ordered a CT scan of the facial bones, which revealed an irregular calcification in the right frontal sinus adjacent to the cribriform plate and thinning of the posterior wall of the sinus. Upon requestioning at a subsequent neurosurgical appointment, the patient recalled being an unrestrained passenger and striking her head against the windshield in a motor vehicle accident (MVA) approximately 10 years ago. Ever since the MVA, she noticed intermittent postnasal discharge while recumbent. However, she never sought a medical opinion and denied complaints of anterior rhinorrhea.

A CT cisternography confirmed the presence of CSF leakage with contrast accumulation via a defect in the right paramedian cribriform plate. Contrast opacification was seen in the fovea ethmoidalis extending into the right frontal sinus (Figure 1). The patient subsequently underwent transnasal endoscopic CSF leak repair (Figure 2). The postoperative cisternogram did not reveal the transdural communication. However a follow‐up cisternogram performed 3 months later demonstrated a recurrent CSF leak.

Figure 1

Figure 2

The patient was rehospitalized with grand‐mal seizures and a third episode of S. pneumoniae meningitis, this time with a penicillin‐sensitive strain. She was treated with a 2‐week course of ceftriaxone and also received heptavalent pneumococcal vaccine to supplement the 23‐valent pneumococcal vaccine. Two weeks after the hospital discharge, the patient underwent successful bifrontal transcranial repair. Currently, she has been disease‐free for 3 months and is followed closely by neurosurgery as an outpatient.

Discussion

After immune deficiency is ruled out, it is essential to evaluate for transdural communication between the subarachnoid space and the base of the skull resulting in a CSF leak as a cause for RBM. Meningitis secondary to a CSF leak is most commonly caused by S. pneumoniae, followed by Neisseria meningitidis and Haemophilus influenzae.1 Complement and immunoglobulin subclass defects may also predispose to RBM.2, 3

A recent case series by Adriani et al.4 suggested that as many as 77% of patients with RBM have an identifiable risk factor such as a remote head injury or CSF leakage. CSF rhinorrhea is most often secondary to trauma, occurring in approximately 1% to 3% of all blunt head injuries.2 Accidental falls, MVAs, altercations, and gunshot wounds are also commonly responsible.3 Nontraumatic CSF leaks are very rare but may be secondary to spontaneous, congenital, or iatrogenic etiologies.1, 3 Spontaneous CSF leaks could also occur due to violent sneezing or coughing.1, 3 Congenital defects include weakened preformed pathways, failure of germ layer closures, and bone imperfections.1, 3 Infrequently, CSF leak can be a complication of intracranial, otologic, nasal, or paranasal sinus surgeries.1, 3 Other rarer etiologies include intracranial tumors and hydrocephalus.1, 3

Bacterial meningitis due to traumatic CSF leak can present within 24 hours to as long as several decades after the development of the leak.2, 3 Along with the classic symptoms and signs of meningitis, including fever, headache, neck stiffness, change in sensorium, seizures, and vomiting, patients may also present with CSF rhinorrhea, CSF otorrhea, hearing impairment, or cranial injury residua.3, 5 It is important to note that CSF rhinorrhea and otorrhea are not always present in cases of chronic, posttraumatic CSF leaks.

The visualization of a fracture or bony dehiscence is very difficult but critical for identification and surgical repair. Frontal and ethmoid sinuses and cribriform plate are common fracture sites.1, 3, 5 CSF leakage may be from the anterior, middle, or posterior compartments, eventually ending in the nasal cavity.1, 3, 5 Various imaging modalities, including contrast cisternogram, high‐resolution CT, fluorescein nasal endoscopy, and magnetic resonance imaging (MRI) have been advocated for diagnosing the source of CSF leak with variable sensitivity and specificity.6 High‐resolution CT helps in identifying surgical anatomy and bony defects whereas contrast cisternography is confirmatory when the CSF leak is active.1, 6 Protein electrophoresis demonstrating 2 electrophoretically separate transferrin bands confirms CSF.7

In patients with persistent CSF rhinorrhea, there is a 19% overall risk of meningitis with an annual incidence of 0.3 meningitis episodes per year.8 The risk of meningitis is the greatest in the first year following the onset of a CSF leak.8 Generally, patients with posttraumatic CSF leak lasting more than 7 to 10 days need surgical repair to decrease their risk of bacterial meningitis.1, 3, 5 Endoscopic surgical correction with a success rate of 90% is an effective treatment for CSF leak and involves placement of a temporary lumbar drain in addition to endonasal duraplasty performed with the aid of microscope and/or nasoscope.9 Complicated anterior cranial base fractures are not as amenable to endoscopic repair and may require a combined intracranial extradural and intradural approach or a transcranial approach.10

Information on prophylactic antibiotics and vaccination is still evolving. Currently available evidence from randomized control trials does not support prophylactic antibiotic use in patients with basilar skull fracture with or without the evidence of CSF leakage.11 A meta‐analysis of 4 randomized controlled trials of patients with acute basilar skull fracture showed no significant difference between the antibiotic prophylaxis groups and control groups with respect to reduction of the frequency of meningitis, the need for surgical correction, meningitis‐related mortality, and all‐cause mortality.11 Direct invasion of the meninges by nasopharyngeal bacteria bypassing the circulating serum antibodies may limit the potential effectiveness of vaccination in preventing RBM.12 However, vaccination is generally recommended in patients with complement or immunoglobulin deficiency or after splenectomy.4

During their junior medicine rotation, our students are asked to post to Blackboard (an online student forum) an anonymous essay about an issue of professionalism or ethics, either inspiring or troubling. In many ways, these vignettes are like postcards, written by visitors describing foreign cultures and norms. They represent a way for the students to debrief, but also provide an opportunity for us, as faculty, to reflect upon the way we practice and teach medicine. Many postingslike postcards from exotic or historic placesare inspiring stories of residents and faculty extending themselves for their patients. Unfortunately, unlike typical postcards, there are also essays that are troubling or provoking and challenge us to consider how we could improve the professional and ethical environment on our teams.

In order to begin a learning process with our faculty and housestaff, we have presented a number of these anonymous essays at both faculty and housestaff Department of Medicine conferences as well as our monthly hospital Ethics conference. The goal of these conferences was to gather as a moral community to reflect on our students' experience and consider ways in which our day to day practice as attendings could be informed by what they tell us. In addition, the junior medicine site directors have a session each quarter with their junior students to review some of the most significant issues brought up by their essays.

Practically, these vignettes and conferences serve three main purposes:

• 1

  Raising Awareness: Many professional issues noted by our students occur under the radar. Attendings are often unaware of the issues of professionalism and/or ethics confronting our students and housestaff.

• 2

  Exploring Attitudes: Some attending may underemphasize the importance of specific issues of professionalism and/or ethics. Open discussions at faculty or resident conferences create opportunities for individuals to reflect upon their own reactions and for the group to create a norm.

• 3

  Sharing Skills: It is difficult to learn the practice of professionalism and ethics from a book. Skill in this area is gained primarily by experience. Conferences provide an excellent forum for seasoned physicians to share wisdom with less experienced physicians. In addition, important teaching points can be made: Students should not deliver bad news alone. Errors should be disclosed.

Following are 3 of the essays we presented, along with brief commentaries. At the end, we provide practical suggestions for individual attendings to improve the professional climate on their teams.

The Hospital Didn't Wait

Code. On 12, the surgical wards floor. Elise sprinted to the stairwell, dashed up to 12, and ran to the corner room as fast as she could. She could see the room before she got there. Instinctively, she started reviewing the steps she had memorized so many months ago. But when she finally arrived at the patient's bathroom, her thought process came to a jolting halt as she came upon the gruesome scene.

The 76‐year‐old patient had hanged himself with the cinching rope from his garment bag, and now dangled suspended from a high towel rack against the wall. Nurses from the floor started to file in, and without losing a beat Elise barked commands. Together they brought the man's body down to the floor, laid him on his back, and stripped off his hospital gown. Elise was in charge; deliberately but forcefully, she ordered a nurse to retrieve a defibrillator, and had another resident check for a pulse. There was none. Anesthesiology was here. Quickly and expertly, they shoved a plastic tube down his throat and began ventilation. The nurse placed on the electrodes between chest compressions then called to clear the body. Airway stepped back. The chest pumper stepped back. The body lurched forward as the defibrillator issued a long beep and discharged. Still no pulse. The cycle repeated.

Finally, Elise called a stop. Time of death, 19:37. By now there were about 20 people crammed in the patient room, all of whom had a separate role during the code. Some stayed behind, while the rest left to return to their interrupted work. The medical student didn't know what to think as he returned to the team room. His jaw was sorehad he been clenching it the whole time?and as he brought his hand up to rub his face, he saw that his knuckles were bloody. Somehow he had scraped them during the code. As he logged back into the computer to finish off his evening notes, he knew that he wouldn't have time to reflect until hours later when he returned home. Codes happened all the time. There was still work to be done in the hospital, and the hospital didn't wait.

The room had already been assigned to a patient waiting in the Emergency Department downstairs. That patient would be here in a few minutes. The hospital didn't wait.

When we presented this case in our conferences, there was universal agreement that such a traumatic event merits, even demands, team debriefing and processing. But in the real life aftermath of this traumatic event, the take‐home message for the medical student was that the hospital didn't wait for such discussions. We know this is not unique to our institution. In a study of 32 medical students who were asked to reflect on their most memorable patient death,1 debriefing sessions were rare and many students felt inadequately supported. While experienced clinicians may be accustomed to seeing patients die, students are new to the culture of the hospital, and have not had the chance to develop the defense mechanisms necessary to cope with this sort of experience. Angoff2 writes, As medical educators, we ought to ask our students how they are coping with long hours, fatigue, illness, suffering, and death. We ought to model and commend compassion and react to the deep feelings of our students in the same way we would teach them to react to the deep feelings of their patients.

I Told a Man Today That He Had Brain Cancer

The resident, intern, and I were huddled together in our team room when the report came back on the computer. New 3.5 2.3 1.7 cm contrast‐enhancing lesion seen anterior to genu of corpus callosum. Concerning for metastatic focus vs. lymphoma. Advise follow‐up. It wasn't unexpected but we had nevertheless been hoping for better.

The three of us went into his room and I was waiting to see how my resident would deliver the bad news, but she didn't. She simply said that we were continuing to do imaging studies and that a neurology team would be in touch. There were probably several reasons why she didn't tell him: not enough time, not her responsibility, or maybe she was just uncomfortable with it. Whatever the case, we left the room with my patient still oblivious to the awful mass now tangled in his head.

If my resident was taking a pass on this conversation, I knew it fell to me he needed to hear it from his primary team. I came back after rounds alone, sat down next to his bed, and told him that his MRI results had come back, and that I had unfortunate news.

I told him that the images showed that his lung cancer had spread to his brain.

I paused to give him a chance to let it sink in. He turned away and looked up at the ceiling.

Where is it? How big is it?

What now?

Reflecting on this case, our audiences were disturbed that a student would attempt this difficult conversation alone, while recognizing that the student clearly felt a sense of responsibility and desire to help his patient by sharing important information. We talked about how students may erroneously pick up a message that the team member who has spent the most time with a patient is the most obvious choice to have difficult conversations. We also noted that, unfortunately, sometimes students are directly asked by their team to shoulder this responsibility on their own. In this painful account, there is no mention of preparation, supervision, or support for the student before or after the encounter. The student perceived (rightly or wrongly) that the team leaders lacked comfort or skill to deliver the bad news, and stepped in. It is possible that the attending lacked the skill and ability to model an interaction, but more likely the deficit was in awareness and attitude. It is unlikely the attending knew that the student had this conversation alone. One of the major reasons we present these vignettes is to make attendings and housestaff more aware of issues that occur under their radar so that they can take preventative action. However, once the resident or attending found out that the student had this conversation alone, the student should be pulled aside for a 1:1 discussion. At the end of the day, the student should know that it was inappropriate to attempt this conversation alone

Rosenbaum3 reviewed a number of strategies to teach the skill of delivering bad news, from lecture and small group discussions to role play and standardized patients. When asked, students cited role‐modeling as the best way to learn how to deliver bad news.4 Observation of a veteran clinician provides a firm foundation for learning; but that is not enough. Unfortunately, we know from the literature (and our student vignettes suggest) that students and residents are unprepared to carry out these conversations properly, either because of misguided attitudes, lack of experience, or inadequate training.57 We conceptualize engaging in difficult conversations as a procedure, demanding a skill set. Mere observation of an expert executing this procedure is only a beginning. With any other skill, from successful completion of a lumbar puncture to initiating cardiopulmonary resuscitation (CPR), a student would never conclude that knowing the patient the best sufficiently credentials the student to undertake these procedures. We maintain that a difficult conversationbe it breaking bad news, discussing end‐of‐life care preferences, code status discussions, or prognosisis a clinical intervention, like any other procedure in medicine. If performed with skill and caution, it can bring about a stronger therapeutic relationship and increased support for the patient; if performed clumsily, it can lead to unintended adverse outcomes, including misunderstanding, mistrust, anxiety, and anger.

A Decimal Point Got Misplaced

On palliative care, I had a 90 year‐old man with end stage lung CA that presented to the ED with increasing SOB. The resident decided that giving him some morphine would be a good solution but was worried that too much would push him over the edge. He was thin; his O2 sats weren't that good After some discussion it was decided that 2.5 mg should be the starting amount. Unfortunately, when the note was written a decimal point got misplaced and he got 25 mg as a first dose. He ended up very sedated for most of the day but his breathing was ok.

The mistake was not discussed with the patient or the patient's family. While it did not cause any lasting harm, I wondered if telling the patient/patient's family that an error had been made would have been more ethically sound.

When we presented this case in our conferences, there was little controversy about whether the error should have been disclosed. The discussion did provide reinforcement for doing a simple but difficult task. Our analysis is that the nondiscussion of this error reflects a deficit in attitude and possibly skill. The team was aware of the error, but the resident and attending did not take the opportunity to disclose an error. They should have. We do not know whether the attending or resident felt unprepared to discuss this or were simply unimpressed with the adverse event. We do get the sense that the student did not feel comfortable raising the issue with the team. As such, it was a missed opportunity to seek help from any number of hospital resources and find encouragement to take on difficult encounters.

Much has been written about apologies.810 Disclosing errors and apologizing is the ethical standard, and many of our institutions have made it policy. Yet in the moment, it is embarrassing, anxiety provoking, and our concern about litigation looms large. Learning to do the right thing begins, perhaps with lectures and standardized patients, but only when students see it modeled by our housestaff and faculty, does it take root for good.

Our housestaff are quite good at managing medical issues, but they may still need help in creating the appropriate environment for professional learning and growth. This is 1 of the most important contributions an attending can make. We have emphasized that faculty have an important role to play in the area of professional development, reinforcing the rudimentary information preclinical students are presented with in the classroom and processing experiences residents are exposed to on a regular basis. If the hospital doesn't wait, then it is the attending physician's job to create the space and time for trainees to think about what is happening and ask if it could have been done better.

A number of seasoned clinical teachers have written about ways to improve teaching on the wards.11 Below, we will add to that discussion by considering practical ways to enhance learning about professionalism and ethics (see Table 1). Note should be made that while we focus on specific behaviors and activities, underlying all is the importance of availability, presence, and intention. Like all good teaching, these activities require planning and effort.

Creating an Open Climate

The medical team, of which the attending, residents, and students are all a part, should not only be a unit that provides excellent medical care to its patients, but should also create a culture of continuous learning and improvement. As such, it is important to create a safe atmosphere where teachers are invested in the growth of their learners and learners feel free to question the prevailing logic and practice, including issues of professionalism and ethics. As Malcolm Gladwell12 describes in Outliers, Korean Air jets were crashing because subordinates were afraid to question their superiors. Once that culture changed, Korean Air safety improved dramatically. Similarly, breaking down some of the hierarchical barriers should improve the culture of a medical team. We typically make an effort to get to know our students and residents on a more personal basis: where they are from, who is in their family, what was their major, what are their interests outside of medicine, and what has been surprising to them in their training so far. Whether we set aside time when we first meet or e‐mail our questions before the first day, we aim for this to be 1 of the first team activities. We also share our own stories, making clear that the attending is part of the team, and not just an evaluating supervisor.

Vignette 1 describes the student's trauma of witnessing a code and the inability to process the event with anyone afterward. Failed resuscitation attempts are the most dramatic examples, but even expected deaths, nonfatal adverse events, and conflict between patients and providers may be traumatic for new trainees inexperienced with the reality of medicine. Attendings should be aware of these potentially traumatic events and make time to check in with the team members about how they are dealing with their emotions. Taking time on attending rounds, for example, allows the attending to not only model reflective practice and self‐care, but also elevates team support to a place traditionally reserved for discussions about diagnosis and treatment.

Supervision and Modeling

Vignettes 2 and 3 center around challenging communication tasks that require special training, including instruction, modeling, feedback, and practice. Unfortunately, as some of our student accounts document, many teaching opportunities are missed. As attendings, our duties include being aware of these opportunities, and being prepared to model competent patientor familydoctor interactions. Emphasizing the importance of the doctor‐patient relationship is in fact one of the key skills of an effective attending role model.13

When opportunities arise for any potentially difficult conversation, we make every effort to identify the issue, prebrief with the team about how to conduct the discussion, and either offer to model the conversation or be present to observe and provide feedback and debriefing afterwards. For example, by asking about all DNR discussions had with our patients, we gain insight into the skill level of our housestaff. As important, the housestaff understand that we believe that these conversations are vital to review during formal rounds, with the same attention we give to chest pain and electrocardiograms (ECGs).

Two key skills that develop with experience are the ability to know the limits of one's knowledge and to know when to ask for help. We try to be open about naming those limits and thinking about the other members of the larger healthcare team that may provide insight, skill, and expertise. We are used to doing this with medical questions (eg, asking the gastroenterology consult team to locate a source of bleeding). Asking our risk management, patient‐relations, or ethics services to assist with a difficult communication task or conflict with a family is no different, and often something the housestaff may not readily do.

We are grateful to our students and their postcards for the snapshots of our local medical culture. While we are gratified to read of excellent role modeling, we are also disappointed to read of situations which have left our students confused, demoralized and cynical. But if these exercises are to reach their full potential, they should tell us about where we would like to go, in addition to where we have been. We believe that our conferences have stimulated our faculty and housestaff to reflect on the professionalism lessons they are teaching. Reading the student postings has definitely affected our approach to teaching professionalism. They reinforce what every parent and educator knows: when it comes to teaching professionalism, communication and ethics, what matters most is the behavior of the teacher. Our words mean little if our actions do not live out what we espouse.

During their junior medicine rotation, our students are asked to post to Blackboard (an online student forum) an anonymous essay about an issue of professionalism or ethics, either inspiring or troubling. In many ways, these vignettes are like postcards, written by visitors describing foreign cultures and norms. They represent a way for the students to debrief, but also provide an opportunity for us, as faculty, to reflect upon the way we practice and teach medicine. Many postingslike postcards from exotic or historic placesare inspiring stories of residents and faculty extending themselves for their patients. Unfortunately, unlike typical postcards, there are also essays that are troubling or provoking and challenge us to consider how we could improve the professional and ethical environment on our teams.

In order to begin a learning process with our faculty and housestaff, we have presented a number of these anonymous essays at both faculty and housestaff Department of Medicine conferences as well as our monthly hospital Ethics conference. The goal of these conferences was to gather as a moral community to reflect on our students' experience and consider ways in which our day to day practice as attendings could be informed by what they tell us. In addition, the junior medicine site directors have a session each quarter with their junior students to review some of the most significant issues brought up by their essays.

Practically, these vignettes and conferences serve three main purposes:

• 1

  Raising Awareness: Many professional issues noted by our students occur under the radar. Attendings are often unaware of the issues of professionalism and/or ethics confronting our students and housestaff.

• 2

  Exploring Attitudes: Some attending may underemphasize the importance of specific issues of professionalism and/or ethics. Open discussions at faculty or resident conferences create opportunities for individuals to reflect upon their own reactions and for the group to create a norm.

• 3

  Sharing Skills: It is difficult to learn the practice of professionalism and ethics from a book. Skill in this area is gained primarily by experience. Conferences provide an excellent forum for seasoned physicians to share wisdom with less experienced physicians. In addition, important teaching points can be made: Students should not deliver bad news alone. Errors should be disclosed.

Following are 3 of the essays we presented, along with brief commentaries. At the end, we provide practical suggestions for individual attendings to improve the professional climate on their teams.

The Hospital Didn't Wait

Code. On 12, the surgical wards floor. Elise sprinted to the stairwell, dashed up to 12, and ran to the corner room as fast as she could. She could see the room before she got there. Instinctively, she started reviewing the steps she had memorized so many months ago. But when she finally arrived at the patient's bathroom, her thought process came to a jolting halt as she came upon the gruesome scene.

The 76‐year‐old patient had hanged himself with the cinching rope from his garment bag, and now dangled suspended from a high towel rack against the wall. Nurses from the floor started to file in, and without losing a beat Elise barked commands. Together they brought the man's body down to the floor, laid him on his back, and stripped off his hospital gown. Elise was in charge; deliberately but forcefully, she ordered a nurse to retrieve a defibrillator, and had another resident check for a pulse. There was none. Anesthesiology was here. Quickly and expertly, they shoved a plastic tube down his throat and began ventilation. The nurse placed on the electrodes between chest compressions then called to clear the body. Airway stepped back. The chest pumper stepped back. The body lurched forward as the defibrillator issued a long beep and discharged. Still no pulse. The cycle repeated.

Finally, Elise called a stop. Time of death, 19:37. By now there were about 20 people crammed in the patient room, all of whom had a separate role during the code. Some stayed behind, while the rest left to return to their interrupted work. The medical student didn't know what to think as he returned to the team room. His jaw was sorehad he been clenching it the whole time?and as he brought his hand up to rub his face, he saw that his knuckles were bloody. Somehow he had scraped them during the code. As he logged back into the computer to finish off his evening notes, he knew that he wouldn't have time to reflect until hours later when he returned home. Codes happened all the time. There was still work to be done in the hospital, and the hospital didn't wait.

The room had already been assigned to a patient waiting in the Emergency Department downstairs. That patient would be here in a few minutes. The hospital didn't wait.

When we presented this case in our conferences, there was universal agreement that such a traumatic event merits, even demands, team debriefing and processing. But in the real life aftermath of this traumatic event, the take‐home message for the medical student was that the hospital didn't wait for such discussions. We know this is not unique to our institution. In a study of 32 medical students who were asked to reflect on their most memorable patient death,1 debriefing sessions were rare and many students felt inadequately supported. While experienced clinicians may be accustomed to seeing patients die, students are new to the culture of the hospital, and have not had the chance to develop the defense mechanisms necessary to cope with this sort of experience. Angoff2 writes, As medical educators, we ought to ask our students how they are coping with long hours, fatigue, illness, suffering, and death. We ought to model and commend compassion and react to the deep feelings of our students in the same way we would teach them to react to the deep feelings of their patients.

I Told a Man Today That He Had Brain Cancer

The resident, intern, and I were huddled together in our team room when the report came back on the computer. New 3.5 2.3 1.7 cm contrast‐enhancing lesion seen anterior to genu of corpus callosum. Concerning for metastatic focus vs. lymphoma. Advise follow‐up. It wasn't unexpected but we had nevertheless been hoping for better.

The three of us went into his room and I was waiting to see how my resident would deliver the bad news, but she didn't. She simply said that we were continuing to do imaging studies and that a neurology team would be in touch. There were probably several reasons why she didn't tell him: not enough time, not her responsibility, or maybe she was just uncomfortable with it. Whatever the case, we left the room with my patient still oblivious to the awful mass now tangled in his head.

If my resident was taking a pass on this conversation, I knew it fell to me he needed to hear it from his primary team. I came back after rounds alone, sat down next to his bed, and told him that his MRI results had come back, and that I had unfortunate news.

I told him that the images showed that his lung cancer had spread to his brain.

I paused to give him a chance to let it sink in. He turned away and looked up at the ceiling.

Where is it? How big is it?

What now?

Reflecting on this case, our audiences were disturbed that a student would attempt this difficult conversation alone, while recognizing that the student clearly felt a sense of responsibility and desire to help his patient by sharing important information. We talked about how students may erroneously pick up a message that the team member who has spent the most time with a patient is the most obvious choice to have difficult conversations. We also noted that, unfortunately, sometimes students are directly asked by their team to shoulder this responsibility on their own. In this painful account, there is no mention of preparation, supervision, or support for the student before or after the encounter. The student perceived (rightly or wrongly) that the team leaders lacked comfort or skill to deliver the bad news, and stepped in. It is possible that the attending lacked the skill and ability to model an interaction, but more likely the deficit was in awareness and attitude. It is unlikely the attending knew that the student had this conversation alone. One of the major reasons we present these vignettes is to make attendings and housestaff more aware of issues that occur under their radar so that they can take preventative action. However, once the resident or attending found out that the student had this conversation alone, the student should be pulled aside for a 1:1 discussion. At the end of the day, the student should know that it was inappropriate to attempt this conversation alone

Rosenbaum3 reviewed a number of strategies to teach the skill of delivering bad news, from lecture and small group discussions to role play and standardized patients. When asked, students cited role‐modeling as the best way to learn how to deliver bad news.4 Observation of a veteran clinician provides a firm foundation for learning; but that is not enough. Unfortunately, we know from the literature (and our student vignettes suggest) that students and residents are unprepared to carry out these conversations properly, either because of misguided attitudes, lack of experience, or inadequate training.57 We conceptualize engaging in difficult conversations as a procedure, demanding a skill set. Mere observation of an expert executing this procedure is only a beginning. With any other skill, from successful completion of a lumbar puncture to initiating cardiopulmonary resuscitation (CPR), a student would never conclude that knowing the patient the best sufficiently credentials the student to undertake these procedures. We maintain that a difficult conversationbe it breaking bad news, discussing end‐of‐life care preferences, code status discussions, or prognosisis a clinical intervention, like any other procedure in medicine. If performed with skill and caution, it can bring about a stronger therapeutic relationship and increased support for the patient; if performed clumsily, it can lead to unintended adverse outcomes, including misunderstanding, mistrust, anxiety, and anger.

A Decimal Point Got Misplaced

On palliative care, I had a 90 year‐old man with end stage lung CA that presented to the ED with increasing SOB. The resident decided that giving him some morphine would be a good solution but was worried that too much would push him over the edge. He was thin; his O2 sats weren't that good After some discussion it was decided that 2.5 mg should be the starting amount. Unfortunately, when the note was written a decimal point got misplaced and he got 25 mg as a first dose. He ended up very sedated for most of the day but his breathing was ok.

The mistake was not discussed with the patient or the patient's family. While it did not cause any lasting harm, I wondered if telling the patient/patient's family that an error had been made would have been more ethically sound.

When we presented this case in our conferences, there was little controversy about whether the error should have been disclosed. The discussion did provide reinforcement for doing a simple but difficult task. Our analysis is that the nondiscussion of this error reflects a deficit in attitude and possibly skill. The team was aware of the error, but the resident and attending did not take the opportunity to disclose an error. They should have. We do not know whether the attending or resident felt unprepared to discuss this or were simply unimpressed with the adverse event. We do get the sense that the student did not feel comfortable raising the issue with the team. As such, it was a missed opportunity to seek help from any number of hospital resources and find encouragement to take on difficult encounters.

Much has been written about apologies.810 Disclosing errors and apologizing is the ethical standard, and many of our institutions have made it policy. Yet in the moment, it is embarrassing, anxiety provoking, and our concern about litigation looms large. Learning to do the right thing begins, perhaps with lectures and standardized patients, but only when students see it modeled by our housestaff and faculty, does it take root for good.

Our housestaff are quite good at managing medical issues, but they may still need help in creating the appropriate environment for professional learning and growth. This is 1 of the most important contributions an attending can make. We have emphasized that faculty have an important role to play in the area of professional development, reinforcing the rudimentary information preclinical students are presented with in the classroom and processing experiences residents are exposed to on a regular basis. If the hospital doesn't wait, then it is the attending physician's job to create the space and time for trainees to think about what is happening and ask if it could have been done better.

A number of seasoned clinical teachers have written about ways to improve teaching on the wards.11 Below, we will add to that discussion by considering practical ways to enhance learning about professionalism and ethics (see Table 1). Note should be made that while we focus on specific behaviors and activities, underlying all is the importance of availability, presence, and intention. Like all good teaching, these activities require planning and effort.

Creating an Open Climate

The medical team, of which the attending, residents, and students are all a part, should not only be a unit that provides excellent medical care to its patients, but should also create a culture of continuous learning and improvement. As such, it is important to create a safe atmosphere where teachers are invested in the growth of their learners and learners feel free to question the prevailing logic and practice, including issues of professionalism and ethics. As Malcolm Gladwell12 describes in Outliers, Korean Air jets were crashing because subordinates were afraid to question their superiors. Once that culture changed, Korean Air safety improved dramatically. Similarly, breaking down some of the hierarchical barriers should improve the culture of a medical team. We typically make an effort to get to know our students and residents on a more personal basis: where they are from, who is in their family, what was their major, what are their interests outside of medicine, and what has been surprising to them in their training so far. Whether we set aside time when we first meet or e‐mail our questions before the first day, we aim for this to be 1 of the first team activities. We also share our own stories, making clear that the attending is part of the team, and not just an evaluating supervisor.

Vignette 1 describes the student's trauma of witnessing a code and the inability to process the event with anyone afterward. Failed resuscitation attempts are the most dramatic examples, but even expected deaths, nonfatal adverse events, and conflict between patients and providers may be traumatic for new trainees inexperienced with the reality of medicine. Attendings should be aware of these potentially traumatic events and make time to check in with the team members about how they are dealing with their emotions. Taking time on attending rounds, for example, allows the attending to not only model reflective practice and self‐care, but also elevates team support to a place traditionally reserved for discussions about diagnosis and treatment.

Supervision and Modeling

Vignettes 2 and 3 center around challenging communication tasks that require special training, including instruction, modeling, feedback, and practice. Unfortunately, as some of our student accounts document, many teaching opportunities are missed. As attendings, our duties include being aware of these opportunities, and being prepared to model competent patientor familydoctor interactions. Emphasizing the importance of the doctor‐patient relationship is in fact one of the key skills of an effective attending role model.13

When opportunities arise for any potentially difficult conversation, we make every effort to identify the issue, prebrief with the team about how to conduct the discussion, and either offer to model the conversation or be present to observe and provide feedback and debriefing afterwards. For example, by asking about all DNR discussions had with our patients, we gain insight into the skill level of our housestaff. As important, the housestaff understand that we believe that these conversations are vital to review during formal rounds, with the same attention we give to chest pain and electrocardiograms (ECGs).

Two key skills that develop with experience are the ability to know the limits of one's knowledge and to know when to ask for help. We try to be open about naming those limits and thinking about the other members of the larger healthcare team that may provide insight, skill, and expertise. We are used to doing this with medical questions (eg, asking the gastroenterology consult team to locate a source of bleeding). Asking our risk management, patient‐relations, or ethics services to assist with a difficult communication task or conflict with a family is no different, and often something the housestaff may not readily do.

We are grateful to our students and their postcards for the snapshots of our local medical culture. While we are gratified to read of excellent role modeling, we are also disappointed to read of situations which have left our students confused, demoralized and cynical. But if these exercises are to reach their full potential, they should tell us about where we would like to go, in addition to where we have been. We believe that our conferences have stimulated our faculty and housestaff to reflect on the professionalism lessons they are teaching. Reading the student postings has definitely affected our approach to teaching professionalism. They reinforce what every parent and educator knows: when it comes to teaching professionalism, communication and ethics, what matters most is the behavior of the teacher. Our words mean little if our actions do not live out what we espouse.

During their junior medicine rotation, our students are asked to post to Blackboard (an online student forum) an anonymous essay about an issue of professionalism or ethics, either inspiring or troubling. In many ways, these vignettes are like postcards, written by visitors describing foreign cultures and norms. They represent a way for the students to debrief, but also provide an opportunity for us, as faculty, to reflect upon the way we practice and teach medicine. Many postingslike postcards from exotic or historic placesare inspiring stories of residents and faculty extending themselves for their patients. Unfortunately, unlike typical postcards, there are also essays that are troubling or provoking and challenge us to consider how we could improve the professional and ethical environment on our teams.

In order to begin a learning process with our faculty and housestaff, we have presented a number of these anonymous essays at both faculty and housestaff Department of Medicine conferences as well as our monthly hospital Ethics conference. The goal of these conferences was to gather as a moral community to reflect on our students' experience and consider ways in which our day to day practice as attendings could be informed by what they tell us. In addition, the junior medicine site directors have a session each quarter with their junior students to review some of the most significant issues brought up by their essays.

Practically, these vignettes and conferences serve three main purposes:

• 1

  Raising Awareness: Many professional issues noted by our students occur under the radar. Attendings are often unaware of the issues of professionalism and/or ethics confronting our students and housestaff.

• 2

  Exploring Attitudes: Some attending may underemphasize the importance of specific issues of professionalism and/or ethics. Open discussions at faculty or resident conferences create opportunities for individuals to reflect upon their own reactions and for the group to create a norm.

• 3

  Sharing Skills: It is difficult to learn the practice of professionalism and ethics from a book. Skill in this area is gained primarily by experience. Conferences provide an excellent forum for seasoned physicians to share wisdom with less experienced physicians. In addition, important teaching points can be made: Students should not deliver bad news alone. Errors should be disclosed.

Following are 3 of the essays we presented, along with brief commentaries. At the end, we provide practical suggestions for individual attendings to improve the professional climate on their teams.

The Hospital Didn't Wait

Code. On 12, the surgical wards floor. Elise sprinted to the stairwell, dashed up to 12, and ran to the corner room as fast as she could. She could see the room before she got there. Instinctively, she started reviewing the steps she had memorized so many months ago. But when she finally arrived at the patient's bathroom, her thought process came to a jolting halt as she came upon the gruesome scene.

The 76‐year‐old patient had hanged himself with the cinching rope from his garment bag, and now dangled suspended from a high towel rack against the wall. Nurses from the floor started to file in, and without losing a beat Elise barked commands. Together they brought the man's body down to the floor, laid him on his back, and stripped off his hospital gown. Elise was in charge; deliberately but forcefully, she ordered a nurse to retrieve a defibrillator, and had another resident check for a pulse. There was none. Anesthesiology was here. Quickly and expertly, they shoved a plastic tube down his throat and began ventilation. The nurse placed on the electrodes between chest compressions then called to clear the body. Airway stepped back. The chest pumper stepped back. The body lurched forward as the defibrillator issued a long beep and discharged. Still no pulse. The cycle repeated.

Finally, Elise called a stop. Time of death, 19:37. By now there were about 20 people crammed in the patient room, all of whom had a separate role during the code. Some stayed behind, while the rest left to return to their interrupted work. The medical student didn't know what to think as he returned to the team room. His jaw was sorehad he been clenching it the whole time?and as he brought his hand up to rub his face, he saw that his knuckles were bloody. Somehow he had scraped them during the code. As he logged back into the computer to finish off his evening notes, he knew that he wouldn't have time to reflect until hours later when he returned home. Codes happened all the time. There was still work to be done in the hospital, and the hospital didn't wait.

The room had already been assigned to a patient waiting in the Emergency Department downstairs. That patient would be here in a few minutes. The hospital didn't wait.

When we presented this case in our conferences, there was universal agreement that such a traumatic event merits, even demands, team debriefing and processing. But in the real life aftermath of this traumatic event, the take‐home message for the medical student was that the hospital didn't wait for such discussions. We know this is not unique to our institution. In a study of 32 medical students who were asked to reflect on their most memorable patient death,1 debriefing sessions were rare and many students felt inadequately supported. While experienced clinicians may be accustomed to seeing patients die, students are new to the culture of the hospital, and have not had the chance to develop the defense mechanisms necessary to cope with this sort of experience. Angoff2 writes, As medical educators, we ought to ask our students how they are coping with long hours, fatigue, illness, suffering, and death. We ought to model and commend compassion and react to the deep feelings of our students in the same way we would teach them to react to the deep feelings of their patients.

I Told a Man Today That He Had Brain Cancer

The resident, intern, and I were huddled together in our team room when the report came back on the computer. New 3.5 2.3 1.7 cm contrast‐enhancing lesion seen anterior to genu of corpus callosum. Concerning for metastatic focus vs. lymphoma. Advise follow‐up. It wasn't unexpected but we had nevertheless been hoping for better.

The three of us went into his room and I was waiting to see how my resident would deliver the bad news, but she didn't. She simply said that we were continuing to do imaging studies and that a neurology team would be in touch. There were probably several reasons why she didn't tell him: not enough time, not her responsibility, or maybe she was just uncomfortable with it. Whatever the case, we left the room with my patient still oblivious to the awful mass now tangled in his head.

If my resident was taking a pass on this conversation, I knew it fell to me he needed to hear it from his primary team. I came back after rounds alone, sat down next to his bed, and told him that his MRI results had come back, and that I had unfortunate news.

I told him that the images showed that his lung cancer had spread to his brain.

I paused to give him a chance to let it sink in. He turned away and looked up at the ceiling.

Where is it? How big is it?

What now?

Reflecting on this case, our audiences were disturbed that a student would attempt this difficult conversation alone, while recognizing that the student clearly felt a sense of responsibility and desire to help his patient by sharing important information. We talked about how students may erroneously pick up a message that the team member who has spent the most time with a patient is the most obvious choice to have difficult conversations. We also noted that, unfortunately, sometimes students are directly asked by their team to shoulder this responsibility on their own. In this painful account, there is no mention of preparation, supervision, or support for the student before or after the encounter. The student perceived (rightly or wrongly) that the team leaders lacked comfort or skill to deliver the bad news, and stepped in. It is possible that the attending lacked the skill and ability to model an interaction, but more likely the deficit was in awareness and attitude. It is unlikely the attending knew that the student had this conversation alone. One of the major reasons we present these vignettes is to make attendings and housestaff more aware of issues that occur under their radar so that they can take preventative action. However, once the resident or attending found out that the student had this conversation alone, the student should be pulled aside for a 1:1 discussion. At the end of the day, the student should know that it was inappropriate to attempt this conversation alone

Rosenbaum3 reviewed a number of strategies to teach the skill of delivering bad news, from lecture and small group discussions to role play and standardized patients. When asked, students cited role‐modeling as the best way to learn how to deliver bad news.4 Observation of a veteran clinician provides a firm foundation for learning; but that is not enough. Unfortunately, we know from the literature (and our student vignettes suggest) that students and residents are unprepared to carry out these conversations properly, either because of misguided attitudes, lack of experience, or inadequate training.57 We conceptualize engaging in difficult conversations as a procedure, demanding a skill set. Mere observation of an expert executing this procedure is only a beginning. With any other skill, from successful completion of a lumbar puncture to initiating cardiopulmonary resuscitation (CPR), a student would never conclude that knowing the patient the best sufficiently credentials the student to undertake these procedures. We maintain that a difficult conversationbe it breaking bad news, discussing end‐of‐life care preferences, code status discussions, or prognosisis a clinical intervention, like any other procedure in medicine. If performed with skill and caution, it can bring about a stronger therapeutic relationship and increased support for the patient; if performed clumsily, it can lead to unintended adverse outcomes, including misunderstanding, mistrust, anxiety, and anger.

A Decimal Point Got Misplaced

On palliative care, I had a 90 year‐old man with end stage lung CA that presented to the ED with increasing SOB. The resident decided that giving him some morphine would be a good solution but was worried that too much would push him over the edge. He was thin; his O2 sats weren't that good After some discussion it was decided that 2.5 mg should be the starting amount. Unfortunately, when the note was written a decimal point got misplaced and he got 25 mg as a first dose. He ended up very sedated for most of the day but his breathing was ok.

The mistake was not discussed with the patient or the patient's family. While it did not cause any lasting harm, I wondered if telling the patient/patient's family that an error had been made would have been more ethically sound.

When we presented this case in our conferences, there was little controversy about whether the error should have been disclosed. The discussion did provide reinforcement for doing a simple but difficult task. Our analysis is that the nondiscussion of this error reflects a deficit in attitude and possibly skill. The team was aware of the error, but the resident and attending did not take the opportunity to disclose an error. They should have. We do not know whether the attending or resident felt unprepared to discuss this or were simply unimpressed with the adverse event. We do get the sense that the student did not feel comfortable raising the issue with the team. As such, it was a missed opportunity to seek help from any number of hospital resources and find encouragement to take on difficult encounters.

Much has been written about apologies.810 Disclosing errors and apologizing is the ethical standard, and many of our institutions have made it policy. Yet in the moment, it is embarrassing, anxiety provoking, and our concern about litigation looms large. Learning to do the right thing begins, perhaps with lectures and standardized patients, but only when students see it modeled by our housestaff and faculty, does it take root for good.

Our housestaff are quite good at managing medical issues, but they may still need help in creating the appropriate environment for professional learning and growth. This is 1 of the most important contributions an attending can make. We have emphasized that faculty have an important role to play in the area of professional development, reinforcing the rudimentary information preclinical students are presented with in the classroom and processing experiences residents are exposed to on a regular basis. If the hospital doesn't wait, then it is the attending physician's job to create the space and time for trainees to think about what is happening and ask if it could have been done better.

A number of seasoned clinical teachers have written about ways to improve teaching on the wards.11 Below, we will add to that discussion by considering practical ways to enhance learning about professionalism and ethics (see Table 1). Note should be made that while we focus on specific behaviors and activities, underlying all is the importance of availability, presence, and intention. Like all good teaching, these activities require planning and effort.

Creating an Open Climate

The medical team, of which the attending, residents, and students are all a part, should not only be a unit that provides excellent medical care to its patients, but should also create a culture of continuous learning and improvement. As such, it is important to create a safe atmosphere where teachers are invested in the growth of their learners and learners feel free to question the prevailing logic and practice, including issues of professionalism and ethics. As Malcolm Gladwell12 describes in Outliers, Korean Air jets were crashing because subordinates were afraid to question their superiors. Once that culture changed, Korean Air safety improved dramatically. Similarly, breaking down some of the hierarchical barriers should improve the culture of a medical team. We typically make an effort to get to know our students and residents on a more personal basis: where they are from, who is in their family, what was their major, what are their interests outside of medicine, and what has been surprising to them in their training so far. Whether we set aside time when we first meet or e‐mail our questions before the first day, we aim for this to be 1 of the first team activities. We also share our own stories, making clear that the attending is part of the team, and not just an evaluating supervisor.

Vignette 1 describes the student's trauma of witnessing a code and the inability to process the event with anyone afterward. Failed resuscitation attempts are the most dramatic examples, but even expected deaths, nonfatal adverse events, and conflict between patients and providers may be traumatic for new trainees inexperienced with the reality of medicine. Attendings should be aware of these potentially traumatic events and make time to check in with the team members about how they are dealing with their emotions. Taking time on attending rounds, for example, allows the attending to not only model reflective practice and self‐care, but also elevates team support to a place traditionally reserved for discussions about diagnosis and treatment.

Supervision and Modeling

Vignettes 2 and 3 center around challenging communication tasks that require special training, including instruction, modeling, feedback, and practice. Unfortunately, as some of our student accounts document, many teaching opportunities are missed. As attendings, our duties include being aware of these opportunities, and being prepared to model competent patientor familydoctor interactions. Emphasizing the importance of the doctor‐patient relationship is in fact one of the key skills of an effective attending role model.13

When opportunities arise for any potentially difficult conversation, we make every effort to identify the issue, prebrief with the team about how to conduct the discussion, and either offer to model the conversation or be present to observe and provide feedback and debriefing afterwards. For example, by asking about all DNR discussions had with our patients, we gain insight into the skill level of our housestaff. As important, the housestaff understand that we believe that these conversations are vital to review during formal rounds, with the same attention we give to chest pain and electrocardiograms (ECGs).

Two key skills that develop with experience are the ability to know the limits of one's knowledge and to know when to ask for help. We try to be open about naming those limits and thinking about the other members of the larger healthcare team that may provide insight, skill, and expertise. We are used to doing this with medical questions (eg, asking the gastroenterology consult team to locate a source of bleeding). Asking our risk management, patient‐relations, or ethics services to assist with a difficult communication task or conflict with a family is no different, and often something the housestaff may not readily do.

We are grateful to our students and their postcards for the snapshots of our local medical culture. While we are gratified to read of excellent role modeling, we are also disappointed to read of situations which have left our students confused, demoralized and cynical. But if these exercises are to reach their full potential, they should tell us about where we would like to go, in addition to where we have been. We believe that our conferences have stimulated our faculty and housestaff to reflect on the professionalism lessons they are teaching. Reading the student postings has definitely affected our approach to teaching professionalism. They reinforce what every parent and educator knows: when it comes to teaching professionalism, communication and ethics, what matters most is the behavior of the teacher. Our words mean little if our actions do not live out what we espouse.

If you wish to receive credit for this activity, which begins on the next page, please refer to the website: www.blackwellpublishing.com/cme.

Accreditation and Designation Statement

Blackwell Futura Media Services designates this educational activity for a 1 AMA PRA Category 1 Credit. Physicians should only claim credit commensurate with the extent of their participation in the activity.

Blackwell Futura Media Services is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

Educational Objectives

Continuous participation in the Journal of Hospital Medicine CME program will enable learners to be better able to:

• Interpret clinical guidelines and their applications for higher quality and more efficient care for all hospitalized patients.

• Describe the standard of care for common illnesses and conditions treated in the hospital; such as pneumonia, COPD exacerbation, acute coronary syndrome, HF exacerbation, glycemic control, venous thromboembolic disease, stroke, etc.

• Discuss evidence‐based recommendations involving transitions of care, including the hospital discharge process.

• Gain insights into the roles of hospitalists as medical educators, researchers, medical ethicists, palliative care providers, and hospital‐based geriatricians.

• Incorporate best practices for hospitalist administration, including quality improvement, patient safety, practice management, leadership, and demonstrating hospitalist value.

• Identify evidence‐based best practices and trends for both adult and pediatric hospital medicine.

Instructions on Receiving Credit

For information on applicability and acceptance of continuing medical education credit for this activity, please consult your professional licensing board.

This activity is designed to be completed within the time designated on the title page; physicians should claim only those credits that reflect the time actually spent in the activity. To successfully earn credit, participants must complete the activity during the valid credit period that is noted on the title page.

Follow these steps to earn credit:

• Log on to www.blackwellpublishing.com/cme.

• Read the target audience, learning objectives, and author disclosures.

• Read the article in print or online format.

• Reflect on the article.

• Access the CME Exam, and choose the best answer to each question.

• Complete the required evaluation component of the activity.

If you wish to receive credit for this activity, which begins on the next page, please refer to the website: www.blackwellpublishing.com/cme.

Accreditation and Designation Statement

Blackwell Futura Media Services designates this educational activity for a 1 AMA PRA Category 1 Credit. Physicians should only claim credit commensurate with the extent of their participation in the activity.

Blackwell Futura Media Services is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

Educational Objectives

Continuous participation in the Journal of Hospital Medicine CME program will enable learners to be better able to:

• Interpret clinical guidelines and their applications for higher quality and more efficient care for all hospitalized patients.

• Describe the standard of care for common illnesses and conditions treated in the hospital; such as pneumonia, COPD exacerbation, acute coronary syndrome, HF exacerbation, glycemic control, venous thromboembolic disease, stroke, etc.

• Discuss evidence‐based recommendations involving transitions of care, including the hospital discharge process.

• Gain insights into the roles of hospitalists as medical educators, researchers, medical ethicists, palliative care providers, and hospital‐based geriatricians.

• Incorporate best practices for hospitalist administration, including quality improvement, patient safety, practice management, leadership, and demonstrating hospitalist value.

• Identify evidence‐based best practices and trends for both adult and pediatric hospital medicine.

Instructions on Receiving Credit

For information on applicability and acceptance of continuing medical education credit for this activity, please consult your professional licensing board.

This activity is designed to be completed within the time designated on the title page; physicians should claim only those credits that reflect the time actually spent in the activity. To successfully earn credit, participants must complete the activity during the valid credit period that is noted on the title page.

Follow these steps to earn credit:

• Log on to www.blackwellpublishing.com/cme.

• Read the target audience, learning objectives, and author disclosures.

• Read the article in print or online format.

• Reflect on the article.

• Access the CME Exam, and choose the best answer to each question.

• Complete the required evaluation component of the activity.

If you wish to receive credit for this activity, which begins on the next page, please refer to the website: www.blackwellpublishing.com/cme.

Accreditation and Designation Statement

Blackwell Futura Media Services designates this educational activity for a 1 AMA PRA Category 1 Credit. Physicians should only claim credit commensurate with the extent of their participation in the activity.

Blackwell Futura Media Services is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

Educational Objectives

Continuous participation in the Journal of Hospital Medicine CME program will enable learners to be better able to:

• Interpret clinical guidelines and their applications for higher quality and more efficient care for all hospitalized patients.

• Describe the standard of care for common illnesses and conditions treated in the hospital; such as pneumonia, COPD exacerbation, acute coronary syndrome, HF exacerbation, glycemic control, venous thromboembolic disease, stroke, etc.

• Discuss evidence‐based recommendations involving transitions of care, including the hospital discharge process.

• Gain insights into the roles of hospitalists as medical educators, researchers, medical ethicists, palliative care providers, and hospital‐based geriatricians.

• Incorporate best practices for hospitalist administration, including quality improvement, patient safety, practice management, leadership, and demonstrating hospitalist value.

• Identify evidence‐based best practices and trends for both adult and pediatric hospital medicine.

Instructions on Receiving Credit

For information on applicability and acceptance of continuing medical education credit for this activity, please consult your professional licensing board.

This activity is designed to be completed within the time designated on the title page; physicians should claim only those credits that reflect the time actually spent in the activity. To successfully earn credit, participants must complete the activity during the valid credit period that is noted on the title page.

Follow these steps to earn credit:

• Log on to www.blackwellpublishing.com/cme.

• Read the target audience, learning objectives, and author disclosures.

• Read the article in print or online format.

• Reflect on the article.

• Access the CME Exam, and choose the best answer to each question.

• Complete the required evaluation component of the activity.

An 85‐year‐old male from rural southern New Jersey with history of innumerable tick bites over many years was admitted for fever of unknown origin. On hospital day 2, his hemoglobin dropped from 11.3 g/dL to 7.5 g/dL, with an associated elevated indirect bilirubin and lactate dehydrogenase. Blood smear showed numerous intracellular and extracellular trophozoites, with approximately 10% to 30% of red cells infected, consistent with severe babesiosis. Given his high parasitemia, new hypoxia, lethargy, and advanced age, treatment was initiated with intravenous antibiotics and red cell exchange transfusion.

Babesiosis should be considered on the differential diagnosis of hemolytic anemia in patients that live in or have traveled to endemic areas, especially with history of tick bites. The most common appearance on blood smear is round to oval rings with pale blue cytoplasm and a red‐staining nucleus (Fig. 1). Exoerythrocytic parasites or the pathognomonic Maltese Cross tetrad forms (not present in our patient's smear) help to differentiate from falciparum malaria.

The patient's parasite burden and clinical status markedly improved with treatment and he was discharged home. 0

Figure 1

An 85‐year‐old male from rural southern New Jersey with history of innumerable tick bites over many years was admitted for fever of unknown origin. On hospital day 2, his hemoglobin dropped from 11.3 g/dL to 7.5 g/dL, with an associated elevated indirect bilirubin and lactate dehydrogenase. Blood smear showed numerous intracellular and extracellular trophozoites, with approximately 10% to 30% of red cells infected, consistent with severe babesiosis. Given his high parasitemia, new hypoxia, lethargy, and advanced age, treatment was initiated with intravenous antibiotics and red cell exchange transfusion.

Babesiosis should be considered on the differential diagnosis of hemolytic anemia in patients that live in or have traveled to endemic areas, especially with history of tick bites. The most common appearance on blood smear is round to oval rings with pale blue cytoplasm and a red‐staining nucleus (Fig. 1). Exoerythrocytic parasites or the pathognomonic Maltese Cross tetrad forms (not present in our patient's smear) help to differentiate from falciparum malaria.

The patient's parasite burden and clinical status markedly improved with treatment and he was discharged home. 0

Figure 1

An 85‐year‐old male from rural southern New Jersey with history of innumerable tick bites over many years was admitted for fever of unknown origin. On hospital day 2, his hemoglobin dropped from 11.3 g/dL to 7.5 g/dL, with an associated elevated indirect bilirubin and lactate dehydrogenase. Blood smear showed numerous intracellular and extracellular trophozoites, with approximately 10% to 30% of red cells infected, consistent with severe babesiosis. Given his high parasitemia, new hypoxia, lethargy, and advanced age, treatment was initiated with intravenous antibiotics and red cell exchange transfusion.

Babesiosis should be considered on the differential diagnosis of hemolytic anemia in patients that live in or have traveled to endemic areas, especially with history of tick bites. The most common appearance on blood smear is round to oval rings with pale blue cytoplasm and a red‐staining nucleus (Fig. 1). Exoerythrocytic parasites or the pathognomonic Maltese Cross tetrad forms (not present in our patient's smear) help to differentiate from falciparum malaria.

The patient's parasite burden and clinical status markedly improved with treatment and he was discharged home. 0

Figure 1

It is well established that patients have difficulty understanding written health materials,1 medical terminology,2, 3 and other aspects of provider‐patient communication.4, 5 Such difficulties in communication can be magnified at transitions of care like hospital discharge.6 Patients often receive a large amount of information in a short period of time at discharge, and this information may be delivered in a way that is not straightforward or standardized.7, 8 When asked, patients commonly report a poor understanding of important self‐care instructions such as how to take medications upon returning home.9, 10 One study even showed that more than half of patients did not recall anyone providing instructions about how they should care for themselves after hospitalization.11 Poor medication management after hospital discharge contributes to adverse events,1215 inadequate disease control,16 and in the setting of cardiovascular disease, higher mortality.17, 18 Most adverse events after hospital discharge could be prevented or ameliorated through relatively simple means, including better communication among patients and providers.6, 1416, 1921 Greater attention to communication and care transitions could also reduce the number of unplanned rehospitalizations in the United States.22

Patients' health literacy is an important factor in effective health communication, yet little research has examined the role of health literacy in care transitions. Health literacy is defined as the extent to which an individual is able to obtain, process and understand basic health information and services needed to make appropriate health decisions.23, 24 Low health literacy is a prevalent problem in the United States, affecting approximately 40% of adults.25 Research has shown that low health literacy is associated with low self‐efficacy26 and less interaction in physician‐patient encounters,27 which in combination with physicians' use of complex medical language,28 may contribute to poor physician‐patient communication. Patients with low health literacy also have greater difficulty understanding prescription drug labels,29 limited knowledge of disease self‐management skills,30 a higher incidence of hospitalization,31 and higher mortality rates.3234

In order to elucidate the relationship between patient‐provider communication and health literacy in the hospital setting, we analyzed patients' ratings of their communication experience during their hospitalization. We report patients' perceptions of the clarity of communication and how this may vary by level of health literacy and other important patient characteristics.

Methods

Results

Discussion

We used a validated instrument, the IPC,40 to examine patients' ratings of the quality and clarity of hospital‐based communication. Overall, patients provided favorable ratings in many domains, including those pertaining to Responsiveness to patient concerns and Explanations of condition and prognosis. Clinicians' consideration of patients' desire and ability to comply with recommendations was rated least favorably overall. This represents an important area for improvement, particularly when considering the prevalence of nonadherence to medical therapy after hospital discharge, which may be as high as 50%.9, 42 Nonadherence after hospital discharge contributes to avoidable emergency department visits,43 hospital readmissions,44 and higher mortality.18, 45 The results of this study suggest that hospital physicians should give greater consideration to patients' preferences and problems that they may have in following the treatment recommendations.16 Future research will determine the extent to which this may enhance post‐discharge adherence.

Another important finding is that patients with inadequate health literacy rated hospital‐based communication less favorably than did patients with marginal or adequate literacy. In bivariate analyses, this effect was seen on several domains, including general clarity, Responsiveness to patient concerns, and explanations of processes of care. The latter 2 relationships persisted after adjustment for age, cognitive impairment, and educational attainment. To our knowledge, this is the first study which examines the effect of health literacy on patients' ratings of hospital‐based communication.

The majority of the literature on health communication and health literacy focuses on the outpatient setting.34, 46 However, the quality and clarity of patient‐provider communication in the hospital is also critically important. Ineffective communication in the hospital contributes to poor care transitions and post‐discharge complications. Patients commonly leave the hospital with a poor understanding of what transpired (eg, diagnoses, treatment provided, major test results) and inadequate knowledge about the self‐care activities that they must perform upon returning home (eg, medication management, physical activity, follow‐up appointments).911 Poor communication is often cited as the main underlying and remediable factor behind medical errors, adverse events, and the readmissions that commonly occur after hospital discharge.6, 16, 20 The results of this study provide complementary evidence, showing that patients often feel they have experienced suboptimal communication in the hospital setting. These findings highlight an opportunity for improvement in care transitions and patient safety, particularly among patients with inadequate health literacy.

In outpatient research that utilized the IPC, Schillinger et al.41 found that patients with inadequate functional health literacy reported significantly worse communication on the domains of general clarity, explanations of processes of care, and Explanations of condition and prognosis. Subsequent analyses by Sudore et al.47 demonstrated that patients with inadequate or marginal health literacy more often reported that physicians did not give them enough time to say what they thought was important, did not explain processes of care well, and did not ask about problems in following the recommended treatment (Table 3, IPC items 3, 12, and 26, respectively). Our findings were very similar. These relatively consistent results across studies and populations strengthen the conclusion that patients with inadequate health literacy feel their physicians do not communicate as effectively in these areas.

Importantly, the differences in patient responses by literacy category were driven by a few IPC items. These items pertained to physicians' use of medical terminology, the amount of time they gave patients to express their concerns, and how well they explained the patients' medical care. Training physicians to improve their communication skills in these specific areas may improve their ability to communicate effectively with patients who have limited literacy skills. Indeed, published recommendations on how to improve the clarity of verbal communication emphasize just a few major areas, including limiting the amount of medical terminology used, effectively encouraging patients to ask questions and express their concerns, and asking patients to teach‐back key points to make sure the physician has provided adequate explanation.4851 The present study provides some evidence for those recommendations, which for the most part, have been based on clinical experience and expert opinion.

There remains a need for professional education about health literacy and techniques to improve communication with patients who may have limited literacy skills. Many experts advocate clear verbal communication with all patients, so‐called Universal Precautions.52 Although 10 years have passed since the American Medical Association (AMA) called for more work in this area,53 few curricula have been described in the literature.48, 5456 The extent to which health literacy curricula have been implemented in medical schools and other professional schools is unknown. The impact of such training on the communication skills of health care providers and patient outcomes is also unclear.

The strengths of this study include a relatively good response rate and use of a validated measure to grade the quality of physician‐patient communication. This measure, the IPC, has been used previously in the context of health literacy.41 Nevertheless, certain limitations should be acknowledged. First, the study was performed at a single teaching hospital, where patients had a high prevalence of inadequate health literacy. The findings may not generalize to other institutions that serve a different patient population or to nonacademic programs. Second, communication was assessed by patient report, rather than by recording patient‐provider discussions for rating by independent observers. While patient report is inherently more subjective, patients' own perceptions about the effectiveness of health communication are arguably more important than those of independent raters, and thus, the data source may not represent a true limitation. Third, patient responses were obtained approximately 2 weeks after hospital discharge, and accordingly, they are subject to recall bias, which may be greater among those with cognitive impairment. Finally, patients were directed to rate the communication of the overall group of physicians who took care of them in the hospital. Given the academic setting, patients typically received care from a team that included medical students, interns, a resident, and an attending physician. We were not able to determine whether patients' ratings were influenced by a specific member of the team, nor how ratings may have been influenced by certain characteristics of that team member (eg, year of training, prior communication skills training, race or gender concordance, etc).

In summary, by surveying patients soon after an acute care hospitalization, we determined that certain areas held room for improvement, such as consideration of patients' desire and ability to comply with treatment recommendations. Patients with inadequate health literacy reported lower quality physician‐patient communication on several domains. They expressed particular concern about physicians' use of medical terminology, not getting enough time to express their concerns, and not receiving clear enough explanations about the medical care. Efforts are needed to improve physicians' communication skills in these areas. Such training should be evaluated to determine if it has a beneficial effect on physician communication skills and patient outcomes.

It is well established that patients have difficulty understanding written health materials,1 medical terminology,2, 3 and other aspects of provider‐patient communication.4, 5 Such difficulties in communication can be magnified at transitions of care like hospital discharge.6 Patients often receive a large amount of information in a short period of time at discharge, and this information may be delivered in a way that is not straightforward or standardized.7, 8 When asked, patients commonly report a poor understanding of important self‐care instructions such as how to take medications upon returning home.9, 10 One study even showed that more than half of patients did not recall anyone providing instructions about how they should care for themselves after hospitalization.11 Poor medication management after hospital discharge contributes to adverse events,1215 inadequate disease control,16 and in the setting of cardiovascular disease, higher mortality.17, 18 Most adverse events after hospital discharge could be prevented or ameliorated through relatively simple means, including better communication among patients and providers.6, 1416, 1921 Greater attention to communication and care transitions could also reduce the number of unplanned rehospitalizations in the United States.22

Patients' health literacy is an important factor in effective health communication, yet little research has examined the role of health literacy in care transitions. Health literacy is defined as the extent to which an individual is able to obtain, process and understand basic health information and services needed to make appropriate health decisions.23, 24 Low health literacy is a prevalent problem in the United States, affecting approximately 40% of adults.25 Research has shown that low health literacy is associated with low self‐efficacy26 and less interaction in physician‐patient encounters,27 which in combination with physicians' use of complex medical language,28 may contribute to poor physician‐patient communication. Patients with low health literacy also have greater difficulty understanding prescription drug labels,29 limited knowledge of disease self‐management skills,30 a higher incidence of hospitalization,31 and higher mortality rates.3234

In order to elucidate the relationship between patient‐provider communication and health literacy in the hospital setting, we analyzed patients' ratings of their communication experience during their hospitalization. We report patients' perceptions of the clarity of communication and how this may vary by level of health literacy and other important patient characteristics.

Methods

Results

Discussion

We used a validated instrument, the IPC,40 to examine patients' ratings of the quality and clarity of hospital‐based communication. Overall, patients provided favorable ratings in many domains, including those pertaining to Responsiveness to patient concerns and Explanations of condition and prognosis. Clinicians' consideration of patients' desire and ability to comply with recommendations was rated least favorably overall. This represents an important area for improvement, particularly when considering the prevalence of nonadherence to medical therapy after hospital discharge, which may be as high as 50%.9, 42 Nonadherence after hospital discharge contributes to avoidable emergency department visits,43 hospital readmissions,44 and higher mortality.18, 45 The results of this study suggest that hospital physicians should give greater consideration to patients' preferences and problems that they may have in following the treatment recommendations.16 Future research will determine the extent to which this may enhance post‐discharge adherence.

Another important finding is that patients with inadequate health literacy rated hospital‐based communication less favorably than did patients with marginal or adequate literacy. In bivariate analyses, this effect was seen on several domains, including general clarity, Responsiveness to patient concerns, and explanations of processes of care. The latter 2 relationships persisted after adjustment for age, cognitive impairment, and educational attainment. To our knowledge, this is the first study which examines the effect of health literacy on patients' ratings of hospital‐based communication.

The majority of the literature on health communication and health literacy focuses on the outpatient setting.34, 46 However, the quality and clarity of patient‐provider communication in the hospital is also critically important. Ineffective communication in the hospital contributes to poor care transitions and post‐discharge complications. Patients commonly leave the hospital with a poor understanding of what transpired (eg, diagnoses, treatment provided, major test results) and inadequate knowledge about the self‐care activities that they must perform upon returning home (eg, medication management, physical activity, follow‐up appointments).911 Poor communication is often cited as the main underlying and remediable factor behind medical errors, adverse events, and the readmissions that commonly occur after hospital discharge.6, 16, 20 The results of this study provide complementary evidence, showing that patients often feel they have experienced suboptimal communication in the hospital setting. These findings highlight an opportunity for improvement in care transitions and patient safety, particularly among patients with inadequate health literacy.

In outpatient research that utilized the IPC, Schillinger et al.41 found that patients with inadequate functional health literacy reported significantly worse communication on the domains of general clarity, explanations of processes of care, and Explanations of condition and prognosis. Subsequent analyses by Sudore et al.47 demonstrated that patients with inadequate or marginal health literacy more often reported that physicians did not give them enough time to say what they thought was important, did not explain processes of care well, and did not ask about problems in following the recommended treatment (Table 3, IPC items 3, 12, and 26, respectively). Our findings were very similar. These relatively consistent results across studies and populations strengthen the conclusion that patients with inadequate health literacy feel their physicians do not communicate as effectively in these areas.

Importantly, the differences in patient responses by literacy category were driven by a few IPC items. These items pertained to physicians' use of medical terminology, the amount of time they gave patients to express their concerns, and how well they explained the patients' medical care. Training physicians to improve their communication skills in these specific areas may improve their ability to communicate effectively with patients who have limited literacy skills. Indeed, published recommendations on how to improve the clarity of verbal communication emphasize just a few major areas, including limiting the amount of medical terminology used, effectively encouraging patients to ask questions and express their concerns, and asking patients to teach‐back key points to make sure the physician has provided adequate explanation.4851 The present study provides some evidence for those recommendations, which for the most part, have been based on clinical experience and expert opinion.

There remains a need for professional education about health literacy and techniques to improve communication with patients who may have limited literacy skills. Many experts advocate clear verbal communication with all patients, so‐called Universal Precautions.52 Although 10 years have passed since the American Medical Association (AMA) called for more work in this area,53 few curricula have been described in the literature.48, 5456 The extent to which health literacy curricula have been implemented in medical schools and other professional schools is unknown. The impact of such training on the communication skills of health care providers and patient outcomes is also unclear.

The strengths of this study include a relatively good response rate and use of a validated measure to grade the quality of physician‐patient communication. This measure, the IPC, has been used previously in the context of health literacy.41 Nevertheless, certain limitations should be acknowledged. First, the study was performed at a single teaching hospital, where patients had a high prevalence of inadequate health literacy. The findings may not generalize to other institutions that serve a different patient population or to nonacademic programs. Second, communication was assessed by patient report, rather than by recording patient‐provider discussions for rating by independent observers. While patient report is inherently more subjective, patients' own perceptions about the effectiveness of health communication are arguably more important than those of independent raters, and thus, the data source may not represent a true limitation. Third, patient responses were obtained approximately 2 weeks after hospital discharge, and accordingly, they are subject to recall bias, which may be greater among those with cognitive impairment. Finally, patients were directed to rate the communication of the overall group of physicians who took care of them in the hospital. Given the academic setting, patients typically received care from a team that included medical students, interns, a resident, and an attending physician. We were not able to determine whether patients' ratings were influenced by a specific member of the team, nor how ratings may have been influenced by certain characteristics of that team member (eg, year of training, prior communication skills training, race or gender concordance, etc).

In summary, by surveying patients soon after an acute care hospitalization, we determined that certain areas held room for improvement, such as consideration of patients' desire and ability to comply with treatment recommendations. Patients with inadequate health literacy reported lower quality physician‐patient communication on several domains. They expressed particular concern about physicians' use of medical terminology, not getting enough time to express their concerns, and not receiving clear enough explanations about the medical care. Efforts are needed to improve physicians' communication skills in these areas. Such training should be evaluated to determine if it has a beneficial effect on physician communication skills and patient outcomes.

It is well established that patients have difficulty understanding written health materials,1 medical terminology,2, 3 and other aspects of provider‐patient communication.4, 5 Such difficulties in communication can be magnified at transitions of care like hospital discharge.6 Patients often receive a large amount of information in a short period of time at discharge, and this information may be delivered in a way that is not straightforward or standardized.7, 8 When asked, patients commonly report a poor understanding of important self‐care instructions such as how to take medications upon returning home.9, 10 One study even showed that more than half of patients did not recall anyone providing instructions about how they should care for themselves after hospitalization.11 Poor medication management after hospital discharge contributes to adverse events,1215 inadequate disease control,16 and in the setting of cardiovascular disease, higher mortality.17, 18 Most adverse events after hospital discharge could be prevented or ameliorated through relatively simple means, including better communication among patients and providers.6, 1416, 1921 Greater attention to communication and care transitions could also reduce the number of unplanned rehospitalizations in the United States.22

Patients' health literacy is an important factor in effective health communication, yet little research has examined the role of health literacy in care transitions. Health literacy is defined as the extent to which an individual is able to obtain, process and understand basic health information and services needed to make appropriate health decisions.23, 24 Low health literacy is a prevalent problem in the United States, affecting approximately 40% of adults.25 Research has shown that low health literacy is associated with low self‐efficacy26 and less interaction in physician‐patient encounters,27 which in combination with physicians' use of complex medical language,28 may contribute to poor physician‐patient communication. Patients with low health literacy also have greater difficulty understanding prescription drug labels,29 limited knowledge of disease self‐management skills,30 a higher incidence of hospitalization,31 and higher mortality rates.3234

In order to elucidate the relationship between patient‐provider communication and health literacy in the hospital setting, we analyzed patients' ratings of their communication experience during their hospitalization. We report patients' perceptions of the clarity of communication and how this may vary by level of health literacy and other important patient characteristics.

Methods

Results

Discussion

We used a validated instrument, the IPC,40 to examine patients' ratings of the quality and clarity of hospital‐based communication. Overall, patients provided favorable ratings in many domains, including those pertaining to Responsiveness to patient concerns and Explanations of condition and prognosis. Clinicians' consideration of patients' desire and ability to comply with recommendations was rated least favorably overall. This represents an important area for improvement, particularly when considering the prevalence of nonadherence to medical therapy after hospital discharge, which may be as high as 50%.9, 42 Nonadherence after hospital discharge contributes to avoidable emergency department visits,43 hospital readmissions,44 and higher mortality.18, 45 The results of this study suggest that hospital physicians should give greater consideration to patients' preferences and problems that they may have in following the treatment recommendations.16 Future research will determine the extent to which this may enhance post‐discharge adherence.

Another important finding is that patients with inadequate health literacy rated hospital‐based communication less favorably than did patients with marginal or adequate literacy. In bivariate analyses, this effect was seen on several domains, including general clarity, Responsiveness to patient concerns, and explanations of processes of care. The latter 2 relationships persisted after adjustment for age, cognitive impairment, and educational attainment. To our knowledge, this is the first study which examines the effect of health literacy on patients' ratings of hospital‐based communication.

The majority of the literature on health communication and health literacy focuses on the outpatient setting.34, 46 However, the quality and clarity of patient‐provider communication in the hospital is also critically important. Ineffective communication in the hospital contributes to poor care transitions and post‐discharge complications. Patients commonly leave the hospital with a poor understanding of what transpired (eg, diagnoses, treatment provided, major test results) and inadequate knowledge about the self‐care activities that they must perform upon returning home (eg, medication management, physical activity, follow‐up appointments).911 Poor communication is often cited as the main underlying and remediable factor behind medical errors, adverse events, and the readmissions that commonly occur after hospital discharge.6, 16, 20 The results of this study provide complementary evidence, showing that patients often feel they have experienced suboptimal communication in the hospital setting. These findings highlight an opportunity for improvement in care transitions and patient safety, particularly among patients with inadequate health literacy.

In outpatient research that utilized the IPC, Schillinger et al.41 found that patients with inadequate functional health literacy reported significantly worse communication on the domains of general clarity, explanations of processes of care, and Explanations of condition and prognosis. Subsequent analyses by Sudore et al.47 demonstrated that patients with inadequate or marginal health literacy more often reported that physicians did not give them enough time to say what they thought was important, did not explain processes of care well, and did not ask about problems in following the recommended treatment (Table 3, IPC items 3, 12, and 26, respectively). Our findings were very similar. These relatively consistent results across studies and populations strengthen the conclusion that patients with inadequate health literacy feel their physicians do not communicate as effectively in these areas.

Importantly, the differences in patient responses by literacy category were driven by a few IPC items. These items pertained to physicians' use of medical terminology, the amount of time they gave patients to express their concerns, and how well they explained the patients' medical care. Training physicians to improve their communication skills in these specific areas may improve their ability to communicate effectively with patients who have limited literacy skills. Indeed, published recommendations on how to improve the clarity of verbal communication emphasize just a few major areas, including limiting the amount of medical terminology used, effectively encouraging patients to ask questions and express their concerns, and asking patients to teach‐back key points to make sure the physician has provided adequate explanation.4851 The present study provides some evidence for those recommendations, which for the most part, have been based on clinical experience and expert opinion.

There remains a need for professional education about health literacy and techniques to improve communication with patients who may have limited literacy skills. Many experts advocate clear verbal communication with all patients, so‐called Universal Precautions.52 Although 10 years have passed since the American Medical Association (AMA) called for more work in this area,53 few curricula have been described in the literature.48, 5456 The extent to which health literacy curricula have been implemented in medical schools and other professional schools is unknown. The impact of such training on the communication skills of health care providers and patient outcomes is also unclear.

The strengths of this study include a relatively good response rate and use of a validated measure to grade the quality of physician‐patient communication. This measure, the IPC, has been used previously in the context of health literacy.41 Nevertheless, certain limitations should be acknowledged. First, the study was performed at a single teaching hospital, where patients had a high prevalence of inadequate health literacy. The findings may not generalize to other institutions that serve a different patient population or to nonacademic programs. Second, communication was assessed by patient report, rather than by recording patient‐provider discussions for rating by independent observers. While patient report is inherently more subjective, patients' own perceptions about the effectiveness of health communication are arguably more important than those of independent raters, and thus, the data source may not represent a true limitation. Third, patient responses were obtained approximately 2 weeks after hospital discharge, and accordingly, they are subject to recall bias, which may be greater among those with cognitive impairment. Finally, patients were directed to rate the communication of the overall group of physicians who took care of them in the hospital. Given the academic setting, patients typically received care from a team that included medical students, interns, a resident, and an attending physician. We were not able to determine whether patients' ratings were influenced by a specific member of the team, nor how ratings may have been influenced by certain characteristics of that team member (eg, year of training, prior communication skills training, race or gender concordance, etc).

In summary, by surveying patients soon after an acute care hospitalization, we determined that certain areas held room for improvement, such as consideration of patients' desire and ability to comply with treatment recommendations. Patients with inadequate health literacy reported lower quality physician‐patient communication on several domains. They expressed particular concern about physicians' use of medical terminology, not getting enough time to express their concerns, and not receiving clear enough explanations about the medical care. Efforts are needed to improve physicians' communication skills in these areas. Such training should be evaluated to determine if it has a beneficial effect on physician communication skills and patient outcomes.