Continued research over the past 25 years has led to steady progress in the management of nausea and vomiting among patients with cancer undergoing emetogenic chemotherapy, radiation therapy, or surgery. This review of antiemetic therapy discusses the evolution and improvement in treatment options available, the identification of risk factors for acute and delayed nausea and vomiting, and the development of alternative drug delivery systems and their impact on patient compliance and convenience.

Continued research over the past 25 years has led to steady progress in the management of nausea and vomiting among patients with cancer undergoing emetogenic chemotherapy, radiation therapy, or surgery. This review of antiemetic therapy discusses the evolution and improvement in treatment options available, the identification of risk factors for acute and delayed nausea and vomiting, and the development of alternative drug delivery systems and their impact on patient compliance and convenience.

Continued research over the past 25 years has led to steady progress in the management of nausea and vomiting among patients with cancer undergoing emetogenic chemotherapy, radiation therapy, or surgery. This review of antiemetic therapy discusses the evolution and improvement in treatment options available, the identification of risk factors for acute and delayed nausea and vomiting, and the development of alternative drug delivery systems and their impact on patient compliance and convenience.

AMANE KANEKO

Is it true that the Drug Enforcement Administration (DEA) is going to allow doctors to prescribe controlled drugs electronically?

Will I still be able to prescribe on my prescription pads, or is this big government forcing me to use a computer for prescriptions?

J. Hockenstein, DO

Des Moines, Iowa

Dr. Hospitalist responds: On March 31, the DEA published in the Federal Register an interim final rule regarding the “electronic prescription for controlled substances.” (View the entire rule at www.gpoaccess.gov/fr.) The DEA is seeking comment on the proposed rule for the next 60 days. Some of us might remember that the DEA proposed a similar rule for electronic prescribing in June 2008, but that rule did not meet the security requirements already in place at federal healthcare facilities.

Under the current system, providers can create prescriptions electronically, but the prescription has to be printed on paper. The new rule proposes a system of true electronic prescribing; data can be transmitted electronically from the hospital or doctor’s office to the pharmacy without the use of a printer or fax.

This proposed rule does not eliminate the traditional method of paper and pen for prescriptions but allows providers the voluntary option of prescribing controlled substances electronically. This proposed rule also allows pharmacies to receive, dispense, and archive these electronic prescriptions.

For those providers who choose to prescribe electronically, there will be specific requirements to prevent diversion and maintain privacy. Providers must utilize software that meets the rule’s specific requirements. For example, the software system will require a two-step process to authenticate the prescribing provider. These measures might include a password, a token, or the use of biometric identifier (e.g., fingerprint or handprint). For some of us, this might sound space-aged, but such biometric systems are commonplace in other industries. For example, I provided my fingerprint as part of the test center security system when I checked in for my American Board of Internal Medicine (ABIM) recertification examination.

There are several other issues with the proposed rule that one should consider. The new proposal does not affect the existing rule regarding emergency prescriptions. The current law allows physicians to prescribe a Schedule II controlled substance by telephone and the pharmacist to dispense this substance, provided that the amount being dispensed is limited to what is reasonably required during the emergency time period and that the provider provides a hard copy of the prescription to the pharmacist within seven days of the telephone prescription. Under the proposed rule, providers will still be able to prescribe Schedule II substances by telephone under emergency situations but will have the option of providing an electronic copy of the prescription, rather than a paper one, within seven days.

There are other components of the proposed rule that could change your practice. The rule clearly states that an electronic prescription cannot be changed after transmission and that any change to the content of the prescription will render it invalid. This might be important in a handful of situations. For example, if the provider electronically prescribes a brand-name drug, the pharmacist would not be able to make a generic substitution.

Another component of the proposed rule is that it precludes the printing of an electronic prescription, which already has been transmitted and precludes the electronic transmission of a prescription that already has been printed. This situation might arise if the electronic prescription did not transmit due to a computer problem. The provider would not be able to print or fax a copy of the electronic prescription.

The proposed rule has the potential to reduce medical errors, reduce prescription forgeries, and help providers and hospitals integrate their medical records. True electronic prescribing is long overdue. In the future, I envision hospitalists prescribing from their handheld devices.

The key to success, like any computerized system, will be the ability to keep the system running and continuously maintaining and upgrading security measures. For more information regarding electronic prescriptions for controlled substances, visit www.DEAdiversion.usdoj.gov. TH

AMANE KANEKO

Is it true that the Drug Enforcement Administration (DEA) is going to allow doctors to prescribe controlled drugs electronically?

Will I still be able to prescribe on my prescription pads, or is this big government forcing me to use a computer for prescriptions?

J. Hockenstein, DO

Des Moines, Iowa

Dr. Hospitalist responds: On March 31, the DEA published in the Federal Register an interim final rule regarding the “electronic prescription for controlled substances.” (View the entire rule at www.gpoaccess.gov/fr.) The DEA is seeking comment on the proposed rule for the next 60 days. Some of us might remember that the DEA proposed a similar rule for electronic prescribing in June 2008, but that rule did not meet the security requirements already in place at federal healthcare facilities.

Under the current system, providers can create prescriptions electronically, but the prescription has to be printed on paper. The new rule proposes a system of true electronic prescribing; data can be transmitted electronically from the hospital or doctor’s office to the pharmacy without the use of a printer or fax.

This proposed rule does not eliminate the traditional method of paper and pen for prescriptions but allows providers the voluntary option of prescribing controlled substances electronically. This proposed rule also allows pharmacies to receive, dispense, and archive these electronic prescriptions.

For those providers who choose to prescribe electronically, there will be specific requirements to prevent diversion and maintain privacy. Providers must utilize software that meets the rule’s specific requirements. For example, the software system will require a two-step process to authenticate the prescribing provider. These measures might include a password, a token, or the use of biometric identifier (e.g., fingerprint or handprint). For some of us, this might sound space-aged, but such biometric systems are commonplace in other industries. For example, I provided my fingerprint as part of the test center security system when I checked in for my American Board of Internal Medicine (ABIM) recertification examination.

There are several other issues with the proposed rule that one should consider. The new proposal does not affect the existing rule regarding emergency prescriptions. The current law allows physicians to prescribe a Schedule II controlled substance by telephone and the pharmacist to dispense this substance, provided that the amount being dispensed is limited to what is reasonably required during the emergency time period and that the provider provides a hard copy of the prescription to the pharmacist within seven days of the telephone prescription. Under the proposed rule, providers will still be able to prescribe Schedule II substances by telephone under emergency situations but will have the option of providing an electronic copy of the prescription, rather than a paper one, within seven days.

There are other components of the proposed rule that could change your practice. The rule clearly states that an electronic prescription cannot be changed after transmission and that any change to the content of the prescription will render it invalid. This might be important in a handful of situations. For example, if the provider electronically prescribes a brand-name drug, the pharmacist would not be able to make a generic substitution.

Another component of the proposed rule is that it precludes the printing of an electronic prescription, which already has been transmitted and precludes the electronic transmission of a prescription that already has been printed. This situation might arise if the electronic prescription did not transmit due to a computer problem. The provider would not be able to print or fax a copy of the electronic prescription.

The proposed rule has the potential to reduce medical errors, reduce prescription forgeries, and help providers and hospitals integrate their medical records. True electronic prescribing is long overdue. In the future, I envision hospitalists prescribing from their handheld devices.

The key to success, like any computerized system, will be the ability to keep the system running and continuously maintaining and upgrading security measures. For more information regarding electronic prescriptions for controlled substances, visit www.DEAdiversion.usdoj.gov. TH

AMANE KANEKO

Is it true that the Drug Enforcement Administration (DEA) is going to allow doctors to prescribe controlled drugs electronically?

Will I still be able to prescribe on my prescription pads, or is this big government forcing me to use a computer for prescriptions?

J. Hockenstein, DO

Des Moines, Iowa

Dr. Hospitalist responds: On March 31, the DEA published in the Federal Register an interim final rule regarding the “electronic prescription for controlled substances.” (View the entire rule at www.gpoaccess.gov/fr.) The DEA is seeking comment on the proposed rule for the next 60 days. Some of us might remember that the DEA proposed a similar rule for electronic prescribing in June 2008, but that rule did not meet the security requirements already in place at federal healthcare facilities.

Under the current system, providers can create prescriptions electronically, but the prescription has to be printed on paper. The new rule proposes a system of true electronic prescribing; data can be transmitted electronically from the hospital or doctor’s office to the pharmacy without the use of a printer or fax.

This proposed rule does not eliminate the traditional method of paper and pen for prescriptions but allows providers the voluntary option of prescribing controlled substances electronically. This proposed rule also allows pharmacies to receive, dispense, and archive these electronic prescriptions.

For those providers who choose to prescribe electronically, there will be specific requirements to prevent diversion and maintain privacy. Providers must utilize software that meets the rule’s specific requirements. For example, the software system will require a two-step process to authenticate the prescribing provider. These measures might include a password, a token, or the use of biometric identifier (e.g., fingerprint or handprint). For some of us, this might sound space-aged, but such biometric systems are commonplace in other industries. For example, I provided my fingerprint as part of the test center security system when I checked in for my American Board of Internal Medicine (ABIM) recertification examination.

There are several other issues with the proposed rule that one should consider. The new proposal does not affect the existing rule regarding emergency prescriptions. The current law allows physicians to prescribe a Schedule II controlled substance by telephone and the pharmacist to dispense this substance, provided that the amount being dispensed is limited to what is reasonably required during the emergency time period and that the provider provides a hard copy of the prescription to the pharmacist within seven days of the telephone prescription. Under the proposed rule, providers will still be able to prescribe Schedule II substances by telephone under emergency situations but will have the option of providing an electronic copy of the prescription, rather than a paper one, within seven days.

There are other components of the proposed rule that could change your practice. The rule clearly states that an electronic prescription cannot be changed after transmission and that any change to the content of the prescription will render it invalid. This might be important in a handful of situations. For example, if the provider electronically prescribes a brand-name drug, the pharmacist would not be able to make a generic substitution.

Another component of the proposed rule is that it precludes the printing of an electronic prescription, which already has been transmitted and precludes the electronic transmission of a prescription that already has been printed. This situation might arise if the electronic prescription did not transmit due to a computer problem. The provider would not be able to print or fax a copy of the electronic prescription.

The proposed rule has the potential to reduce medical errors, reduce prescription forgeries, and help providers and hospitals integrate their medical records. True electronic prescribing is long overdue. In the future, I envision hospitalists prescribing from their handheld devices.

The key to success, like any computerized system, will be the ability to keep the system running and continuously maintaining and upgrading security measures. For more information regarding electronic prescriptions for controlled substances, visit www.DEAdiversion.usdoj.gov. TH

LUX-Lung 3, an ongoing randomized, multicenter, open-label phase III trial, compares single-agent BIBW 2992 (afatinib) with standard pemetrexed/cisplatin chemotherapy as first-line treatment of stage IIIB/IV adenocarcinoma of the lung with epidermal growth factor receptor (EGFR)-activating mutations. BIBW 2992 is an investigational, orally administered irreversible EGFR-1 and human epidermal growth factor receptor-2 (HER2) tyrosine kinase inhibitor (TKI). The current trial (LUX-Lung 3) will randomize 330 patients in a 2:1 ratio to receive either BIBW 2992 or chemotherapy with pemetrexed/cisplatin. Patients will receive either BIBW 2992 at a starting dose of 40 mg once daily continuously or pemetrexed (500 mg/m² IV) and cisplatin (75 mg/m²) on day 1 of 21-day cycles. Patients will receive 6 cycles of chemotherapy unless unacceptable toxicity occurs. BIBW 2992 will be given continuously until disease progression occurs. The primary endpoint is progression-free survival (PFS). Secondary endpoints include objective response, disease control assessed using Response Evaluation Criteria in Solid Tumors (RECIST) criteria, and overall survival. Oncologists may obtain information on how to enroll patients from the National Institutes of Health’s Web site (www.clinicaltrials.gov/ct2/show/NCT00949650).

Download the Free Full Text in PDF Format 

LUX-Lung 3, an ongoing randomized, multicenter, open-label phase III trial, compares single-agent BIBW 2992 (afatinib) with standard pemetrexed/cisplatin chemotherapy as first-line treatment of stage IIIB/IV adenocarcinoma of the lung with epidermal growth factor receptor (EGFR)-activating mutations. BIBW 2992 is an investigational, orally administered irreversible EGFR-1 and human epidermal growth factor receptor-2 (HER2) tyrosine kinase inhibitor (TKI). The current trial (LUX-Lung 3) will randomize 330 patients in a 2:1 ratio to receive either BIBW 2992 or chemotherapy with pemetrexed/cisplatin. Patients will receive either BIBW 2992 at a starting dose of 40 mg once daily continuously or pemetrexed (500 mg/m² IV) and cisplatin (75 mg/m²) on day 1 of 21-day cycles. Patients will receive 6 cycles of chemotherapy unless unacceptable toxicity occurs. BIBW 2992 will be given continuously until disease progression occurs. The primary endpoint is progression-free survival (PFS). Secondary endpoints include objective response, disease control assessed using Response Evaluation Criteria in Solid Tumors (RECIST) criteria, and overall survival. Oncologists may obtain information on how to enroll patients from the National Institutes of Health’s Web site (www.clinicaltrials.gov/ct2/show/NCT00949650).

Download the Free Full Text in PDF Format 

LUX-Lung 3, an ongoing randomized, multicenter, open-label phase III trial, compares single-agent BIBW 2992 (afatinib) with standard pemetrexed/cisplatin chemotherapy as first-line treatment of stage IIIB/IV adenocarcinoma of the lung with epidermal growth factor receptor (EGFR)-activating mutations. BIBW 2992 is an investigational, orally administered irreversible EGFR-1 and human epidermal growth factor receptor-2 (HER2) tyrosine kinase inhibitor (TKI). The current trial (LUX-Lung 3) will randomize 330 patients in a 2:1 ratio to receive either BIBW 2992 or chemotherapy with pemetrexed/cisplatin. Patients will receive either BIBW 2992 at a starting dose of 40 mg once daily continuously or pemetrexed (500 mg/m² IV) and cisplatin (75 mg/m²) on day 1 of 21-day cycles. Patients will receive 6 cycles of chemotherapy unless unacceptable toxicity occurs. BIBW 2992 will be given continuously until disease progression occurs. The primary endpoint is progression-free survival (PFS). Secondary endpoints include objective response, disease control assessed using Response Evaluation Criteria in Solid Tumors (RECIST) criteria, and overall survival. Oncologists may obtain information on how to enroll patients from the National Institutes of Health’s Web site (www.clinicaltrials.gov/ct2/show/NCT00949650).

Download the Free Full Text in PDF Format 

It’s unfortunate that medical organizations such as SHM do not have the equivalent of a national championship or a Super Bowl. If there was, given what SHM has accomplished in the past 13 years, there is no question that SHM would have won it.

­­So as my first act as SHM president, I hereby declare the Society of Hospital Medicine the national champions of physician organizations.

With that out of the way, now comes the hard part: because the only thing harder than winning a championship is keeping it. For with success comes the temptation to rest. The struggle to achieve success is about outward comparisons. But having achieved success, the perspective of the champion must shift if it is to be sustained. For in the mind of the champion, the perspective is internal, and the measure of competition is about besting oneself. For a champion such as SHM, future success will be measured solely upon an internal inventory of what we do well . . . and what could be done better. Allow me to make this more tangible.

Continued Growth and Inclusion

Our membership continues to grow. And with 10,000 members, it would be easy to rest. But given that there are 30,000 hospitalists, it would be convenient to ignore the question we have to answer: “Where are the other 20,000?”

Would they not benefit from our attention to quality and patient safety? SHM, like no other organization, has built an infrastructure of empowerment, particularly with respect to advancing the goals of quality and patient safety. It is not merely a self-serving goal to recruit these 20,000 hospitalists to SHM; in your heart, you have to believe that their time with SHM would improve the care of their patients. I am confident that Brian Curtis, Manoj Matthews, and their respective Membership and Chapter Support committees will be instrumental as we work toward this goal.

As we grow, for our colleagues in pediatrics, family medicine, the nonphysician providers, and practice administrators, will we make the right decision to maintain the “big tent” that has defined SHM’s success? Quality is quality, regardless of specialty, and the principles of improving a healthcare system that is safe and patient-centered apply to us all.

But as we continue to grow, sustaining the big tent will become increasingly difficult to maintain. Even so, it must remain our priority. Erin Stucky, Bob Harrington, Jeannette Kalupa, Ajay Kharbanda, and their respective teams will be central in preserving this important goal.

At HM10, our annual meeting, attendance topped out at more than 2,500 participants, and the quality of the programming has never been stronger. But there are new challenges that come with this success. Can we sustain the intimacy—the personal attention—necessary for networking and collaboration as the annual meeting continues to grow? There are homogenous messages that do, and will continue to, speak to us all.

But heterogeneity persists in hospitalist systems, and the ability to network with other hospitalists around these unique issues has been an incredibly valuable service of the national meeting. Yet as the meeting grows, it will become increasingly difficult to network hospitalists with similar needs. Preserving the intimacy of the annual meeting, despite its growing size, must be our goal. Dan Dressler, Jeff Glasheen, Mike Pistoria, and the Annual Meeting Committee will be tasked with finding creative solutions to achieving this goal.

Technology = Solutions

At the heart of the solution to both challenges is Kendall Rogers and his Information Technology team. IT sustains meaningful communication in the face of growth, and I believe this to be a central solution. However, the tasks for our IT team are not merely internal. Our profession is at the very beginning of a sharp upward slope on the IT curve, and IT will play an increasing role in patient care.

Technology should be the servant of the people, not the other way around. The unanticipated consequence of more IT has been the temptation to depersonalize patient care in lieu of practicing medicine via computer. IT unquestionably makes healthcare more efficient, but it has the equal prospect of making it less patient-centered; no efficiency is worth that.

Our goal as a society must be to take a leadership role in ensuring that the efficiencies brought about by IT leverage more time to spend with our patients, and empower systems solutions that prevent medical errors. SHM must be positioned so that we have a meaningful voice in advocating for health IT solutions that enable the hospitalist to meet PQRI standards, and to empower the hospitalist to be a leader in the advocacy of appropriate IT solutions that advance, not deter, our mission of quality care. At no time should a computer screen replace the provider’s time at the bedside with the patient; we must be the leaders in preserving this central tenet of patient-centered care.

One Voice—Credible, Unified, Patient-Focused

Hospitalists have spent a decade trying to a get a voice in the legislative discussion. Now that we have a voice in the national healthcare conversation, we must speak with credibility. And the measure of our credibility will be grounded in fidelity to our core mission: preserving what is best for the patient. We cannot succumb, as so many other organizations have done, to merely advocating what is best for SHM. If we do, our time at the table will be short.

Finding the balance between what is best for hospitalists without compromising what is best for the patient will be our challenge. Eric Siegal, Pat Torcson, Kirk Matthews, and their respective Advocacy, Practice Analysis, and Performance and Standards committees will be at the heart of this solution. But through it all, we must not be afraid of confronting the tough issues. Whatever might come with value-based purchasing, bundling, or PQRI, we must have a voice in designing legislation that not only ensures the welfare of the hospitalized patient, but also the sustainability of the hospitalist who is central to that care.

For if we are who we say we are, one is synonymous with the other.

Quality Remains Job No. 1

Perhaps the biggest challenge facing us is heterogeneity. Thanks to SHM’s mentored implementation programs, there is an increasing number of high-performance hospitalist teams. But we are only as strong as our weakest link, and our success will be ignored in light of our weakness until we can ensure, from a quality perspective, homogeneity across all hospital groups. Tex Landis, Steve Deitelzweig, and their respective Practice Management and Practice Analysis committees will be central to finding this solution.

SHM’s biannual hospitalist survey has partnered with industry leader MGMA, and as such, we have gained great credibility in leveraging the results of the survey with the C-suite. But surveys are only as good as the questions that are asked, and SHM must continue its role in collaborating with MGMA to ensure that we are asking the right questions. We need to know what defines the highest-performing teams, and we must find creative solutions to bring every hospitalist team to that same standard of quality by adopting the best practices of our strongest groups.

But at the heart of it all is quality: SHM’s universal mandate is that hospitalists ensure safe, timely, efficient, equitable, and patient-centered care. The leadership of Vikas Parekh and the Education Committee, and Nasim Afsarmanesh, Andrew Dunn, Kevin O’Leary, Greg Maynard and their respective Quality committees, will be central to the advancement of this mandate.

But this mandate must not go unsupported. Each hospitalist group must not be tasked with reinventing the wheel with each QI project, and each hospitalist group must not suffer from the same mistakes. Imagine a day when SHM becomes the repository of QI projects, enabling one hospitalist group to search a database to find QI projects designed and executed by other groups of similar size and character. It is an ambitious goal, but it is a measure that will ensure that all hospitalists can prosper from the success of our colleagues. It will close the heterogeneity gap and ensure that in five years’ time, if there is a hospitalist who does not engage in QI, it is not because they didn’t know how.

Properly designed, such a database could enable hospitalists to create and complete the Practice Improvement Module (PIM) for the American Board of Internal Medicine’s Focused Practice in Hospital Medicine Maintenance of Certification, and empower hospitalists to meet PQRI requirements.

Train Generation Next

As we make all of these advances, we must not lose sight of the importance of a balance between “production” and “production capacity.” For SHM to be a true leader in hospital quality, we must become more than reactionary. Via “user-inspired research,” we must produce new knowledge that improves the practice of us all. And we must address the “hole in the boat.”

Despite our success in improving the understanding of quality with our current membership, I fear we are losing ground: Each year, 10,000 new practitioners leave their residency having been inadequately trained in the principles of quality and patient safety. To make meaningful changes in healthcare quality, we have to fulfill our call to become the stewards of this training, ensuring that the next generations of physicians will be more adept in the fundamentals of quality and patient safety than we were. Jeff Glasheen, David Meltzer, Lorenz DiFrancesco, Paul Grant, Greg Seymann, and the Academic, Research, Pipeline, and Early Career Hospitalists teams will be tasked with this important legacy.

And so we come to a defining moment in SHM’s history. Will SHM be a one-and-done champion? Or will it be defined as a legacy?

Less ambitious goals and visions are certainly more comfortable, but it is not the spirit that has brought us this far. I doubt that the legendary figures of hospital medicine—John Nelson, Win Whitcomb, Bob Wachter, Larry Wellikson, et al—dreamed of a day when SHM would be “OK.” I suspect even our success as an organization is not enough for them, and personally, it’s not enough for me, either.

So digest this as an ambitious strategy that only a champion would be brave enough to design. No team wins without coaching, but no team wins on coaching alone. It will take all of us to make meaningful execution of this strategy a reality. Yes, we are the champions. Now, let’s play like it. TH

Dr. Wiese is president of SHM.

It’s unfortunate that medical organizations such as SHM do not have the equivalent of a national championship or a Super Bowl. If there was, given what SHM has accomplished in the past 13 years, there is no question that SHM would have won it.

­­So as my first act as SHM president, I hereby declare the Society of Hospital Medicine the national champions of physician organizations.

With that out of the way, now comes the hard part: because the only thing harder than winning a championship is keeping it. For with success comes the temptation to rest. The struggle to achieve success is about outward comparisons. But having achieved success, the perspective of the champion must shift if it is to be sustained. For in the mind of the champion, the perspective is internal, and the measure of competition is about besting oneself. For a champion such as SHM, future success will be measured solely upon an internal inventory of what we do well . . . and what could be done better. Allow me to make this more tangible.

Continued Growth and Inclusion

Our membership continues to grow. And with 10,000 members, it would be easy to rest. But given that there are 30,000 hospitalists, it would be convenient to ignore the question we have to answer: “Where are the other 20,000?”

Would they not benefit from our attention to quality and patient safety? SHM, like no other organization, has built an infrastructure of empowerment, particularly with respect to advancing the goals of quality and patient safety. It is not merely a self-serving goal to recruit these 20,000 hospitalists to SHM; in your heart, you have to believe that their time with SHM would improve the care of their patients. I am confident that Brian Curtis, Manoj Matthews, and their respective Membership and Chapter Support committees will be instrumental as we work toward this goal.

As we grow, for our colleagues in pediatrics, family medicine, the nonphysician providers, and practice administrators, will we make the right decision to maintain the “big tent” that has defined SHM’s success? Quality is quality, regardless of specialty, and the principles of improving a healthcare system that is safe and patient-centered apply to us all.

But as we continue to grow, sustaining the big tent will become increasingly difficult to maintain. Even so, it must remain our priority. Erin Stucky, Bob Harrington, Jeannette Kalupa, Ajay Kharbanda, and their respective teams will be central in preserving this important goal.

At HM10, our annual meeting, attendance topped out at more than 2,500 participants, and the quality of the programming has never been stronger. But there are new challenges that come with this success. Can we sustain the intimacy—the personal attention—necessary for networking and collaboration as the annual meeting continues to grow? There are homogenous messages that do, and will continue to, speak to us all.

But heterogeneity persists in hospitalist systems, and the ability to network with other hospitalists around these unique issues has been an incredibly valuable service of the national meeting. Yet as the meeting grows, it will become increasingly difficult to network hospitalists with similar needs. Preserving the intimacy of the annual meeting, despite its growing size, must be our goal. Dan Dressler, Jeff Glasheen, Mike Pistoria, and the Annual Meeting Committee will be tasked with finding creative solutions to achieving this goal.

Technology = Solutions

At the heart of the solution to both challenges is Kendall Rogers and his Information Technology team. IT sustains meaningful communication in the face of growth, and I believe this to be a central solution. However, the tasks for our IT team are not merely internal. Our profession is at the very beginning of a sharp upward slope on the IT curve, and IT will play an increasing role in patient care.

Technology should be the servant of the people, not the other way around. The unanticipated consequence of more IT has been the temptation to depersonalize patient care in lieu of practicing medicine via computer. IT unquestionably makes healthcare more efficient, but it has the equal prospect of making it less patient-centered; no efficiency is worth that.

Our goal as a society must be to take a leadership role in ensuring that the efficiencies brought about by IT leverage more time to spend with our patients, and empower systems solutions that prevent medical errors. SHM must be positioned so that we have a meaningful voice in advocating for health IT solutions that enable the hospitalist to meet PQRI standards, and to empower the hospitalist to be a leader in the advocacy of appropriate IT solutions that advance, not deter, our mission of quality care. At no time should a computer screen replace the provider’s time at the bedside with the patient; we must be the leaders in preserving this central tenet of patient-centered care.

One Voice—Credible, Unified, Patient-Focused

Hospitalists have spent a decade trying to a get a voice in the legislative discussion. Now that we have a voice in the national healthcare conversation, we must speak with credibility. And the measure of our credibility will be grounded in fidelity to our core mission: preserving what is best for the patient. We cannot succumb, as so many other organizations have done, to merely advocating what is best for SHM. If we do, our time at the table will be short.

Finding the balance between what is best for hospitalists without compromising what is best for the patient will be our challenge. Eric Siegal, Pat Torcson, Kirk Matthews, and their respective Advocacy, Practice Analysis, and Performance and Standards committees will be at the heart of this solution. But through it all, we must not be afraid of confronting the tough issues. Whatever might come with value-based purchasing, bundling, or PQRI, we must have a voice in designing legislation that not only ensures the welfare of the hospitalized patient, but also the sustainability of the hospitalist who is central to that care.

For if we are who we say we are, one is synonymous with the other.

Quality Remains Job No. 1

Perhaps the biggest challenge facing us is heterogeneity. Thanks to SHM’s mentored implementation programs, there is an increasing number of high-performance hospitalist teams. But we are only as strong as our weakest link, and our success will be ignored in light of our weakness until we can ensure, from a quality perspective, homogeneity across all hospital groups. Tex Landis, Steve Deitelzweig, and their respective Practice Management and Practice Analysis committees will be central to finding this solution.

SHM’s biannual hospitalist survey has partnered with industry leader MGMA, and as such, we have gained great credibility in leveraging the results of the survey with the C-suite. But surveys are only as good as the questions that are asked, and SHM must continue its role in collaborating with MGMA to ensure that we are asking the right questions. We need to know what defines the highest-performing teams, and we must find creative solutions to bring every hospitalist team to that same standard of quality by adopting the best practices of our strongest groups.

But at the heart of it all is quality: SHM’s universal mandate is that hospitalists ensure safe, timely, efficient, equitable, and patient-centered care. The leadership of Vikas Parekh and the Education Committee, and Nasim Afsarmanesh, Andrew Dunn, Kevin O’Leary, Greg Maynard and their respective Quality committees, will be central to the advancement of this mandate.

But this mandate must not go unsupported. Each hospitalist group must not be tasked with reinventing the wheel with each QI project, and each hospitalist group must not suffer from the same mistakes. Imagine a day when SHM becomes the repository of QI projects, enabling one hospitalist group to search a database to find QI projects designed and executed by other groups of similar size and character. It is an ambitious goal, but it is a measure that will ensure that all hospitalists can prosper from the success of our colleagues. It will close the heterogeneity gap and ensure that in five years’ time, if there is a hospitalist who does not engage in QI, it is not because they didn’t know how.

Properly designed, such a database could enable hospitalists to create and complete the Practice Improvement Module (PIM) for the American Board of Internal Medicine’s Focused Practice in Hospital Medicine Maintenance of Certification, and empower hospitalists to meet PQRI requirements.

Train Generation Next

As we make all of these advances, we must not lose sight of the importance of a balance between “production” and “production capacity.” For SHM to be a true leader in hospital quality, we must become more than reactionary. Via “user-inspired research,” we must produce new knowledge that improves the practice of us all. And we must address the “hole in the boat.”

Despite our success in improving the understanding of quality with our current membership, I fear we are losing ground: Each year, 10,000 new practitioners leave their residency having been inadequately trained in the principles of quality and patient safety. To make meaningful changes in healthcare quality, we have to fulfill our call to become the stewards of this training, ensuring that the next generations of physicians will be more adept in the fundamentals of quality and patient safety than we were. Jeff Glasheen, David Meltzer, Lorenz DiFrancesco, Paul Grant, Greg Seymann, and the Academic, Research, Pipeline, and Early Career Hospitalists teams will be tasked with this important legacy.

And so we come to a defining moment in SHM’s history. Will SHM be a one-and-done champion? Or will it be defined as a legacy?

Less ambitious goals and visions are certainly more comfortable, but it is not the spirit that has brought us this far. I doubt that the legendary figures of hospital medicine—John Nelson, Win Whitcomb, Bob Wachter, Larry Wellikson, et al—dreamed of a day when SHM would be “OK.” I suspect even our success as an organization is not enough for them, and personally, it’s not enough for me, either.

So digest this as an ambitious strategy that only a champion would be brave enough to design. No team wins without coaching, but no team wins on coaching alone. It will take all of us to make meaningful execution of this strategy a reality. Yes, we are the champions. Now, let’s play like it. TH

Dr. Wiese is president of SHM.

It’s unfortunate that medical organizations such as SHM do not have the equivalent of a national championship or a Super Bowl. If there was, given what SHM has accomplished in the past 13 years, there is no question that SHM would have won it.

­­So as my first act as SHM president, I hereby declare the Society of Hospital Medicine the national champions of physician organizations.

With that out of the way, now comes the hard part: because the only thing harder than winning a championship is keeping it. For with success comes the temptation to rest. The struggle to achieve success is about outward comparisons. But having achieved success, the perspective of the champion must shift if it is to be sustained. For in the mind of the champion, the perspective is internal, and the measure of competition is about besting oneself. For a champion such as SHM, future success will be measured solely upon an internal inventory of what we do well . . . and what could be done better. Allow me to make this more tangible.

Continued Growth and Inclusion

Our membership continues to grow. And with 10,000 members, it would be easy to rest. But given that there are 30,000 hospitalists, it would be convenient to ignore the question we have to answer: “Where are the other 20,000?”

Would they not benefit from our attention to quality and patient safety? SHM, like no other organization, has built an infrastructure of empowerment, particularly with respect to advancing the goals of quality and patient safety. It is not merely a self-serving goal to recruit these 20,000 hospitalists to SHM; in your heart, you have to believe that their time with SHM would improve the care of their patients. I am confident that Brian Curtis, Manoj Matthews, and their respective Membership and Chapter Support committees will be instrumental as we work toward this goal.

As we grow, for our colleagues in pediatrics, family medicine, the nonphysician providers, and practice administrators, will we make the right decision to maintain the “big tent” that has defined SHM’s success? Quality is quality, regardless of specialty, and the principles of improving a healthcare system that is safe and patient-centered apply to us all.

But as we continue to grow, sustaining the big tent will become increasingly difficult to maintain. Even so, it must remain our priority. Erin Stucky, Bob Harrington, Jeannette Kalupa, Ajay Kharbanda, and their respective teams will be central in preserving this important goal.

At HM10, our annual meeting, attendance topped out at more than 2,500 participants, and the quality of the programming has never been stronger. But there are new challenges that come with this success. Can we sustain the intimacy—the personal attention—necessary for networking and collaboration as the annual meeting continues to grow? There are homogenous messages that do, and will continue to, speak to us all.

But heterogeneity persists in hospitalist systems, and the ability to network with other hospitalists around these unique issues has been an incredibly valuable service of the national meeting. Yet as the meeting grows, it will become increasingly difficult to network hospitalists with similar needs. Preserving the intimacy of the annual meeting, despite its growing size, must be our goal. Dan Dressler, Jeff Glasheen, Mike Pistoria, and the Annual Meeting Committee will be tasked with finding creative solutions to achieving this goal.

Technology = Solutions

At the heart of the solution to both challenges is Kendall Rogers and his Information Technology team. IT sustains meaningful communication in the face of growth, and I believe this to be a central solution. However, the tasks for our IT team are not merely internal. Our profession is at the very beginning of a sharp upward slope on the IT curve, and IT will play an increasing role in patient care.

Technology should be the servant of the people, not the other way around. The unanticipated consequence of more IT has been the temptation to depersonalize patient care in lieu of practicing medicine via computer. IT unquestionably makes healthcare more efficient, but it has the equal prospect of making it less patient-centered; no efficiency is worth that.

Our goal as a society must be to take a leadership role in ensuring that the efficiencies brought about by IT leverage more time to spend with our patients, and empower systems solutions that prevent medical errors. SHM must be positioned so that we have a meaningful voice in advocating for health IT solutions that enable the hospitalist to meet PQRI standards, and to empower the hospitalist to be a leader in the advocacy of appropriate IT solutions that advance, not deter, our mission of quality care. At no time should a computer screen replace the provider’s time at the bedside with the patient; we must be the leaders in preserving this central tenet of patient-centered care.

One Voice—Credible, Unified, Patient-Focused

Hospitalists have spent a decade trying to a get a voice in the legislative discussion. Now that we have a voice in the national healthcare conversation, we must speak with credibility. And the measure of our credibility will be grounded in fidelity to our core mission: preserving what is best for the patient. We cannot succumb, as so many other organizations have done, to merely advocating what is best for SHM. If we do, our time at the table will be short.

Finding the balance between what is best for hospitalists without compromising what is best for the patient will be our challenge. Eric Siegal, Pat Torcson, Kirk Matthews, and their respective Advocacy, Practice Analysis, and Performance and Standards committees will be at the heart of this solution. But through it all, we must not be afraid of confronting the tough issues. Whatever might come with value-based purchasing, bundling, or PQRI, we must have a voice in designing legislation that not only ensures the welfare of the hospitalized patient, but also the sustainability of the hospitalist who is central to that care.

For if we are who we say we are, one is synonymous with the other.

Quality Remains Job No. 1

Perhaps the biggest challenge facing us is heterogeneity. Thanks to SHM’s mentored implementation programs, there is an increasing number of high-performance hospitalist teams. But we are only as strong as our weakest link, and our success will be ignored in light of our weakness until we can ensure, from a quality perspective, homogeneity across all hospital groups. Tex Landis, Steve Deitelzweig, and their respective Practice Management and Practice Analysis committees will be central to finding this solution.

SHM’s biannual hospitalist survey has partnered with industry leader MGMA, and as such, we have gained great credibility in leveraging the results of the survey with the C-suite. But surveys are only as good as the questions that are asked, and SHM must continue its role in collaborating with MGMA to ensure that we are asking the right questions. We need to know what defines the highest-performing teams, and we must find creative solutions to bring every hospitalist team to that same standard of quality by adopting the best practices of our strongest groups.

But at the heart of it all is quality: SHM’s universal mandate is that hospitalists ensure safe, timely, efficient, equitable, and patient-centered care. The leadership of Vikas Parekh and the Education Committee, and Nasim Afsarmanesh, Andrew Dunn, Kevin O’Leary, Greg Maynard and their respective Quality committees, will be central to the advancement of this mandate.

But this mandate must not go unsupported. Each hospitalist group must not be tasked with reinventing the wheel with each QI project, and each hospitalist group must not suffer from the same mistakes. Imagine a day when SHM becomes the repository of QI projects, enabling one hospitalist group to search a database to find QI projects designed and executed by other groups of similar size and character. It is an ambitious goal, but it is a measure that will ensure that all hospitalists can prosper from the success of our colleagues. It will close the heterogeneity gap and ensure that in five years’ time, if there is a hospitalist who does not engage in QI, it is not because they didn’t know how.

Properly designed, such a database could enable hospitalists to create and complete the Practice Improvement Module (PIM) for the American Board of Internal Medicine’s Focused Practice in Hospital Medicine Maintenance of Certification, and empower hospitalists to meet PQRI requirements.

Train Generation Next

As we make all of these advances, we must not lose sight of the importance of a balance between “production” and “production capacity.” For SHM to be a true leader in hospital quality, we must become more than reactionary. Via “user-inspired research,” we must produce new knowledge that improves the practice of us all. And we must address the “hole in the boat.”

Despite our success in improving the understanding of quality with our current membership, I fear we are losing ground: Each year, 10,000 new practitioners leave their residency having been inadequately trained in the principles of quality and patient safety. To make meaningful changes in healthcare quality, we have to fulfill our call to become the stewards of this training, ensuring that the next generations of physicians will be more adept in the fundamentals of quality and patient safety than we were. Jeff Glasheen, David Meltzer, Lorenz DiFrancesco, Paul Grant, Greg Seymann, and the Academic, Research, Pipeline, and Early Career Hospitalists teams will be tasked with this important legacy.

And so we come to a defining moment in SHM’s history. Will SHM be a one-and-done champion? Or will it be defined as a legacy?

Less ambitious goals and visions are certainly more comfortable, but it is not the spirit that has brought us this far. I doubt that the legendary figures of hospital medicine—John Nelson, Win Whitcomb, Bob Wachter, Larry Wellikson, et al—dreamed of a day when SHM would be “OK.” I suspect even our success as an organization is not enough for them, and personally, it’s not enough for me, either.

So digest this as an ambitious strategy that only a champion would be brave enough to design. No team wins without coaching, but no team wins on coaching alone. It will take all of us to make meaningful execution of this strategy a reality. Yes, we are the champions. Now, let’s play like it. TH

Dr. Wiese is president of SHM.

In case you haven’t seen it, the latest national survey data on hospitalist production, compensation, and other metrics was released in June.

Just as the Masters golf tournament is promoted as “a tradition like no other,” the combined SHM-MGMA (Medical Group Management Association) survey is without peer. Prior to this year, MGMA and SHM conducted separate surveys annually and biannually, respectively. The organizations chose to do a combined survey to take advantage of MGMA’s size and expertise in survey work (they’ve been conducting an annual survey of every specialty in medicine for decades) as well as SHM’s database of hospitalists and knowledge of the issues unique to HM.

If you want the most reliable data, this is the source you should use. I freely acknowledge my potential conflict of interest, which stems from my history with SHM (as a cofounder of SHM, I feel like a proud parent eager to trumpet all its accomplishments), and my consulting partner, Leslie Flores, was in charge of the survey process and data analysis for SHM. You should consider other sources of hospitalist data that might be available to you, but unless you have an unusually robust local or regional survey, the SHM-MGMA data will be the most valuable.

It’s Just a Survey

This survey provides the best national data, but like all such surveys, it has limitations. First, survey respondents vary in their diligence and accuracy in reporting their own data. It is even likely that some might “sanitize” or adjust the data they report in an effort, usually misguided, to provide a more accurate picture of their practice or cover up what might be for them an embarrassing issue. There is a process in place to catch outlier and inconsistent data submitted by a practice, and such practices are questioned to ensure accurate reporting and clear up any confusion or errors. But even that process is imperfect. There isn’t a team of auditors sent to “look at the books” to independently verify the accuracy of the data reported by each practice; that would be too costly, time-consuming, and even intimidating or annoying to be practical. So keep in mind that there is clearly some unavoidable “noise” or contamination in the data.

People sometimes say “SHM [or MGMA] says that ‘X’ is the right number of encounters for a hospitalist in a year,” where X is a number taken from the survey. Don’t make this mistake. I think it is misleading to think of the survey as establishing optimal or “right” benchmarks for any metric.

In fact, I think of benchmarks being something other than just survey numbers; instead, they’re well-considered data points derived from research showing what is optimal. The average glycohemoglobin of diabetics in the U.S. isn’t a desirable benchmark or goal, but the glycohemoglobin shown by research to be associated with the lowest risk of diabetic complications is. Keep this in mind when thinking about the survey results. There are little or no robust and generalizable research data regarding hospitalist productivity and compensation targets associated with the best performance.

click for large version

Hospitalist Incomes Surge

Let’s look at one data point: mean salary. The data points in Figure 1 (left) are the average salary going back to the first year the SHM survey was conducted. Note that all historical data points are from the SHM survey only, and thus represent a different population of respondents than the 2010 SHM-MGMA data point. It is important to remember this when looking at any trended hospitalist data.

Perhaps most importantly, previous SHM survey numbers included a significant proportion of academic hospitalist practices, which were largely unrepresented in the new SHM-MGMA survey data because SHM and MGMA will be conducting a separate survey of academic hospitalist practices in the fall.

Since academic hospitalists tend to earn less—and have lower overall productivity—than hospitalists in other settings, their absence from this survey likely results in greater increases in average compensation and production than would otherwise have been the case.

Beginning in about 2001, MGMA began reporting hospitalist compensation, but I have left those numbers off of this figure. And since about 2002, SHM has separated data for hospitalists who care for adults versus those that care for children; when separate data were available, this figure shows the compensation for hospitalists who care for adults and excludes pediatric hospitalists.

Note that the compensation figures include all salary elements, including a “base” or fixed component, productivity component, quality bonus, etc. The numbers exclude such benefits as the cost of health insurance or matching retirement plan contributions.

Inflation and a trend of increased hospitalist productivity are two reasons that hospitalist compensation has been increasing, but neither explains more than a portion of the increase in salary. (According to computational-knowledge engine WolframAlpha.com, inflation in the U.S. averaged 2.3% per year from 1997 to 2002. I’ll talk more about trends in hospitalist productivity in a future column.) I think the principal reason for the rising trend in our pay is “market forces,” primarily demand for hospitalists that has exceeded the supply.

What the Future Holds

It is interesting to speculate whether the historical trend line will accurately predict future increases in salary. At some point, forces will have to “bend the curve” so that it climbs more slowly. It could look like a curve reaching asymptote.

It is anyone’s guess when that might start to happen, but there are two developments over the last couple of years that suggest it might be coming: In some markets, the demand for hospitalists has been met and new candidates can’t find positions, so salaries in those markets might start to level off. And, unlike a few years ago, hospitalists are now competing with nearly every other physician specialty to get financial support from their hospitals, so hospitalists might find their hospital has less money available for them.

But the really big—and unknown—variable that could increase or decrease future hospitalist salaries is the effect of any further national healthcare reform legislation. TH

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

In case you haven’t seen it, the latest national survey data on hospitalist production, compensation, and other metrics was released in June.

Just as the Masters golf tournament is promoted as “a tradition like no other,” the combined SHM-MGMA (Medical Group Management Association) survey is without peer. Prior to this year, MGMA and SHM conducted separate surveys annually and biannually, respectively. The organizations chose to do a combined survey to take advantage of MGMA’s size and expertise in survey work (they’ve been conducting an annual survey of every specialty in medicine for decades) as well as SHM’s database of hospitalists and knowledge of the issues unique to HM.

If you want the most reliable data, this is the source you should use. I freely acknowledge my potential conflict of interest, which stems from my history with SHM (as a cofounder of SHM, I feel like a proud parent eager to trumpet all its accomplishments), and my consulting partner, Leslie Flores, was in charge of the survey process and data analysis for SHM. You should consider other sources of hospitalist data that might be available to you, but unless you have an unusually robust local or regional survey, the SHM-MGMA data will be the most valuable.

It’s Just a Survey

This survey provides the best national data, but like all such surveys, it has limitations. First, survey respondents vary in their diligence and accuracy in reporting their own data. It is even likely that some might “sanitize” or adjust the data they report in an effort, usually misguided, to provide a more accurate picture of their practice or cover up what might be for them an embarrassing issue. There is a process in place to catch outlier and inconsistent data submitted by a practice, and such practices are questioned to ensure accurate reporting and clear up any confusion or errors. But even that process is imperfect. There isn’t a team of auditors sent to “look at the books” to independently verify the accuracy of the data reported by each practice; that would be too costly, time-consuming, and even intimidating or annoying to be practical. So keep in mind that there is clearly some unavoidable “noise” or contamination in the data.

People sometimes say “SHM [or MGMA] says that ‘X’ is the right number of encounters for a hospitalist in a year,” where X is a number taken from the survey. Don’t make this mistake. I think it is misleading to think of the survey as establishing optimal or “right” benchmarks for any metric.

In fact, I think of benchmarks being something other than just survey numbers; instead, they’re well-considered data points derived from research showing what is optimal. The average glycohemoglobin of diabetics in the U.S. isn’t a desirable benchmark or goal, but the glycohemoglobin shown by research to be associated with the lowest risk of diabetic complications is. Keep this in mind when thinking about the survey results. There are little or no robust and generalizable research data regarding hospitalist productivity and compensation targets associated with the best performance.

click for large version

Hospitalist Incomes Surge

Let’s look at one data point: mean salary. The data points in Figure 1 (left) are the average salary going back to the first year the SHM survey was conducted. Note that all historical data points are from the SHM survey only, and thus represent a different population of respondents than the 2010 SHM-MGMA data point. It is important to remember this when looking at any trended hospitalist data.

Perhaps most importantly, previous SHM survey numbers included a significant proportion of academic hospitalist practices, which were largely unrepresented in the new SHM-MGMA survey data because SHM and MGMA will be conducting a separate survey of academic hospitalist practices in the fall.

Since academic hospitalists tend to earn less—and have lower overall productivity—than hospitalists in other settings, their absence from this survey likely results in greater increases in average compensation and production than would otherwise have been the case.

Beginning in about 2001, MGMA began reporting hospitalist compensation, but I have left those numbers off of this figure. And since about 2002, SHM has separated data for hospitalists who care for adults versus those that care for children; when separate data were available, this figure shows the compensation for hospitalists who care for adults and excludes pediatric hospitalists.

Note that the compensation figures include all salary elements, including a “base” or fixed component, productivity component, quality bonus, etc. The numbers exclude such benefits as the cost of health insurance or matching retirement plan contributions.

Inflation and a trend of increased hospitalist productivity are two reasons that hospitalist compensation has been increasing, but neither explains more than a portion of the increase in salary. (According to computational-knowledge engine WolframAlpha.com, inflation in the U.S. averaged 2.3% per year from 1997 to 2002. I’ll talk more about trends in hospitalist productivity in a future column.) I think the principal reason for the rising trend in our pay is “market forces,” primarily demand for hospitalists that has exceeded the supply.

What the Future Holds

It is interesting to speculate whether the historical trend line will accurately predict future increases in salary. At some point, forces will have to “bend the curve” so that it climbs more slowly. It could look like a curve reaching asymptote.

It is anyone’s guess when that might start to happen, but there are two developments over the last couple of years that suggest it might be coming: In some markets, the demand for hospitalists has been met and new candidates can’t find positions, so salaries in those markets might start to level off. And, unlike a few years ago, hospitalists are now competing with nearly every other physician specialty to get financial support from their hospitals, so hospitalists might find their hospital has less money available for them.

But the really big—and unknown—variable that could increase or decrease future hospitalist salaries is the effect of any further national healthcare reform legislation. TH

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

In case you haven’t seen it, the latest national survey data on hospitalist production, compensation, and other metrics was released in June.

Just as the Masters golf tournament is promoted as “a tradition like no other,” the combined SHM-MGMA (Medical Group Management Association) survey is without peer. Prior to this year, MGMA and SHM conducted separate surveys annually and biannually, respectively. The organizations chose to do a combined survey to take advantage of MGMA’s size and expertise in survey work (they’ve been conducting an annual survey of every specialty in medicine for decades) as well as SHM’s database of hospitalists and knowledge of the issues unique to HM.

If you want the most reliable data, this is the source you should use. I freely acknowledge my potential conflict of interest, which stems from my history with SHM (as a cofounder of SHM, I feel like a proud parent eager to trumpet all its accomplishments), and my consulting partner, Leslie Flores, was in charge of the survey process and data analysis for SHM. You should consider other sources of hospitalist data that might be available to you, but unless you have an unusually robust local or regional survey, the SHM-MGMA data will be the most valuable.

It’s Just a Survey

This survey provides the best national data, but like all such surveys, it has limitations. First, survey respondents vary in their diligence and accuracy in reporting their own data. It is even likely that some might “sanitize” or adjust the data they report in an effort, usually misguided, to provide a more accurate picture of their practice or cover up what might be for them an embarrassing issue. There is a process in place to catch outlier and inconsistent data submitted by a practice, and such practices are questioned to ensure accurate reporting and clear up any confusion or errors. But even that process is imperfect. There isn’t a team of auditors sent to “look at the books” to independently verify the accuracy of the data reported by each practice; that would be too costly, time-consuming, and even intimidating or annoying to be practical. So keep in mind that there is clearly some unavoidable “noise” or contamination in the data.

People sometimes say “SHM [or MGMA] says that ‘X’ is the right number of encounters for a hospitalist in a year,” where X is a number taken from the survey. Don’t make this mistake. I think it is misleading to think of the survey as establishing optimal or “right” benchmarks for any metric.

In fact, I think of benchmarks being something other than just survey numbers; instead, they’re well-considered data points derived from research showing what is optimal. The average glycohemoglobin of diabetics in the U.S. isn’t a desirable benchmark or goal, but the glycohemoglobin shown by research to be associated with the lowest risk of diabetic complications is. Keep this in mind when thinking about the survey results. There are little or no robust and generalizable research data regarding hospitalist productivity and compensation targets associated with the best performance.

click for large version

Hospitalist Incomes Surge

Let’s look at one data point: mean salary. The data points in Figure 1 (left) are the average salary going back to the first year the SHM survey was conducted. Note that all historical data points are from the SHM survey only, and thus represent a different population of respondents than the 2010 SHM-MGMA data point. It is important to remember this when looking at any trended hospitalist data.

Perhaps most importantly, previous SHM survey numbers included a significant proportion of academic hospitalist practices, which were largely unrepresented in the new SHM-MGMA survey data because SHM and MGMA will be conducting a separate survey of academic hospitalist practices in the fall.

Since academic hospitalists tend to earn less—and have lower overall productivity—than hospitalists in other settings, their absence from this survey likely results in greater increases in average compensation and production than would otherwise have been the case.

Beginning in about 2001, MGMA began reporting hospitalist compensation, but I have left those numbers off of this figure. And since about 2002, SHM has separated data for hospitalists who care for adults versus those that care for children; when separate data were available, this figure shows the compensation for hospitalists who care for adults and excludes pediatric hospitalists.

Note that the compensation figures include all salary elements, including a “base” or fixed component, productivity component, quality bonus, etc. The numbers exclude such benefits as the cost of health insurance or matching retirement plan contributions.

Inflation and a trend of increased hospitalist productivity are two reasons that hospitalist compensation has been increasing, but neither explains more than a portion of the increase in salary. (According to computational-knowledge engine WolframAlpha.com, inflation in the U.S. averaged 2.3% per year from 1997 to 2002. I’ll talk more about trends in hospitalist productivity in a future column.) I think the principal reason for the rising trend in our pay is “market forces,” primarily demand for hospitalists that has exceeded the supply.

What the Future Holds

It is interesting to speculate whether the historical trend line will accurately predict future increases in salary. At some point, forces will have to “bend the curve” so that it climbs more slowly. It could look like a curve reaching asymptote.

It is anyone’s guess when that might start to happen, but there are two developments over the last couple of years that suggest it might be coming: In some markets, the demand for hospitalists has been met and new candidates can’t find positions, so salaries in those markets might start to level off. And, unlike a few years ago, hospitalists are now competing with nearly every other physician specialty to get financial support from their hospitals, so hospitalists might find their hospital has less money available for them.

But the really big—and unknown—variable that could increase or decrease future hospitalist salaries is the effect of any further national healthcare reform legislation. TH

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

Registration for the Focused Practice in Hospital Medicine (FPHM) Maintenance of Certification (MOC) through the American Board of Internal Medicine (ABIM) opened March 15. Since then, hundreds of board-certified IM physicians have registered to complete their MOC through the FPHM. For those of you who haven’t gone through MOC yet, it is required every 10 years in order to maintain your board certification.

As a member of the committee tasked with helping ABIM develop the FPHM, as well as write the FPHM examination, I’m frequently asked questions about this process, especially since FPHM was featured on the May 2010 cover of this magazine. Some of the questions stem from the perplexity associated with this significant change to the MOC process. Others arise from misinformation and apprehension, and could rightly be called urban legends. Here is a sample of those questions, with their respective veracity.

Does This Certification Mean I’ll No Longer be an Internist?

No. I clearly remember the day I found out I passed the ABIM certification exam; it represented the culmination of years of work, the pinnacle. All those long hours of study, late-night admissions, and exam preparation had finally paid off. I was a board-certified internist! I cherish my board certification and hold it out as recognition of my mastery of the field of IM. As such, I certainly understand the concern that entering the FPHM will somehow result in “losing” IM certification. However, this just isn’t true.

First, all diplomates—ABIM terminology for those enrolled in the board (re)certification process—in the FPHM are certified as internists. This is simply, as the name suggests, recognition of focused practice in HM—the core certification is still in IM. We are still internists—just internists who have focused our practice to hospital care. The formal board designation will read: ABIM Board Certified in Internal Medicine with a Focused Practice in Hospital Medicine.

Will Hospital Credentialing Boards Recognize This Certification?

Yes. The FPHM is certification in IM by the ABIM. This carries the same weight and meaning as the regular IM MOC. All credentialing boards that recognize the ABIM MOC in IM will recognize the FPHM.

Is the FPHM MOC More Rigorous Than the Regular IM MOC?

Yes, and it was intentional. It is recognized that hospitalists do things that make them “special” by acquiring and refining skills learned experientially outside of a supervised training program. Thus, one can attain FPHM board designation only after three years of practice as a hospitalist. The problem is that this is largely unsupervised time (unlike a fellowship), so the threshold to ensure we have achieved a level of competency has to be established through the MOC process.

As such, the bar for the MOC for FPHM has been set higher. The upshot is that to maintain designation of FPHM, hospitalists are required to achieve 60 self-evaluation points every three years, compared with 100 points every 10 years for IM MOC. Forty of those 60 points must come in the form of Practice Improvement Modules, or PIMs. While more rigorous, it only makes sense that a group committed to the improvement of healthcare quality would commit to higher levels of quality assurance.

Will the FPHM Confer Subspecialty Status to Hospitalists?

No. This is where there has been the greatest deal of controversy surrounding the FPHM program. FPHM is not a subspecialty certification. Rather, it is MOC for IM physicians who focus their practice in the hospital setting. The American Board of Medical Specialties (ABMS), the group that oversees the ABIM, is very clear that only training-based subspecialties can be deemed board-certified subspecialties.

Still, the new FPHM will differentiate hospitalists from nonhospitalists. To me, this is semantics, and the recognition that comes with the FPHM is enough to recognize what I do as “special.”

Will the Examination for the FPHM Reflect What I Do?

Yes. I’ve had several colleagues tell me they’ve heard that the examination will contain elements not found on the standard MOC test. This is true, but it also is the major benefit of the new test. As reported on the ABIM website, the FPHM MOC exam will consist of roughly 45% inpatient medicine, 15% consultative and comanagement work, 15% transitions and ambulatory medicine, 15% patient safety/quality improvement, 5% epidemiology, and 5% ethics and end-of-life care. In this respect, it better reflects what most of us spend most of our time doing—inpatient care, consultative medicine, and transitions of care. Those three areas comprise nearly 75% of the examination. The one area that is new is the focus on patient safety and quality. However, for a field built on the promise of improving the quality, safety, and efficiency of healthcare, this is a welcome change.

Will I Be Able to Prepare for the FPHM Exam?

Yes. Because the FPHM utilizes a different exam than the standard IM MOC, some physicians are concerned that they there are no avenues for preparation, but this is not true. While the exam will weigh various portions of the test differently (e.g., less ambulatory and more inpatient content), the inpatient content will be similar to what is currently on the standard MOC test. After all, heart failure, cellulitis, and pulmonary embolism are the same, regardless of the test it shows up on.

The difference is that there will be more of it—a good thing for the practicing hospitalist. Many of the standard IM test preparation options will help you prepare for the FPHM exam. The ABIM also offers HM knowledge modules as part of the enrollment fee, which, while not meant to be preparation for the exam, can help you identify gaps in your knowledge. The blueprint for the exam is on the ABIM website and can give you clues to areas in which to prepare.

It is true that there will be patient safety and QI content on the HM test, which might not be available for study in typical board review books. However, much of this is the kind of information hospitalists live every day, such as handoffs, transitions of care, and infection control.

Should I Fear the Change?

Humans are intrinsically wired to dislike change. It’s that old saw about choosing the devil we know rather than the devil we don’t. My guess is that much of the concern around the new process stems from this human sentiment—it’s just easier to not do the FPHM and go down the standard IM MOC route. We must avoid this temptation.

The FPHM is a key step in solidifying HM’s status in the healthcare milieu. It gives us credibility in a way no other designation can. It also allows those of us who are serious about an HM career to differentiate ourselves from those who masquerade as hospitalists. And, most importantly, it allows us to demonstrate to our patients our sincere commitment to improving the quality of the inpatient systems that envelop them at their sickest moments.

For that reason alone, I’m enrolling in the FPHM MOC. TH

Dr. Glasheen is physician editor of The Hospitalist.

Registration for the Focused Practice in Hospital Medicine (FPHM) Maintenance of Certification (MOC) through the American Board of Internal Medicine (ABIM) opened March 15. Since then, hundreds of board-certified IM physicians have registered to complete their MOC through the FPHM. For those of you who haven’t gone through MOC yet, it is required every 10 years in order to maintain your board certification.

As a member of the committee tasked with helping ABIM develop the FPHM, as well as write the FPHM examination, I’m frequently asked questions about this process, especially since FPHM was featured on the May 2010 cover of this magazine. Some of the questions stem from the perplexity associated with this significant change to the MOC process. Others arise from misinformation and apprehension, and could rightly be called urban legends. Here is a sample of those questions, with their respective veracity.

Does This Certification Mean I’ll No Longer be an Internist?

No. I clearly remember the day I found out I passed the ABIM certification exam; it represented the culmination of years of work, the pinnacle. All those long hours of study, late-night admissions, and exam preparation had finally paid off. I was a board-certified internist! I cherish my board certification and hold it out as recognition of my mastery of the field of IM. As such, I certainly understand the concern that entering the FPHM will somehow result in “losing” IM certification. However, this just isn’t true.

First, all diplomates—ABIM terminology for those enrolled in the board (re)certification process—in the FPHM are certified as internists. This is simply, as the name suggests, recognition of focused practice in HM—the core certification is still in IM. We are still internists—just internists who have focused our practice to hospital care. The formal board designation will read: ABIM Board Certified in Internal Medicine with a Focused Practice in Hospital Medicine.

Will Hospital Credentialing Boards Recognize This Certification?

Yes. The FPHM is certification in IM by the ABIM. This carries the same weight and meaning as the regular IM MOC. All credentialing boards that recognize the ABIM MOC in IM will recognize the FPHM.

Is the FPHM MOC More Rigorous Than the Regular IM MOC?

Yes, and it was intentional. It is recognized that hospitalists do things that make them “special” by acquiring and refining skills learned experientially outside of a supervised training program. Thus, one can attain FPHM board designation only after three years of practice as a hospitalist. The problem is that this is largely unsupervised time (unlike a fellowship), so the threshold to ensure we have achieved a level of competency has to be established through the MOC process.

As such, the bar for the MOC for FPHM has been set higher. The upshot is that to maintain designation of FPHM, hospitalists are required to achieve 60 self-evaluation points every three years, compared with 100 points every 10 years for IM MOC. Forty of those 60 points must come in the form of Practice Improvement Modules, or PIMs. While more rigorous, it only makes sense that a group committed to the improvement of healthcare quality would commit to higher levels of quality assurance.

Will the FPHM Confer Subspecialty Status to Hospitalists?

No. This is where there has been the greatest deal of controversy surrounding the FPHM program. FPHM is not a subspecialty certification. Rather, it is MOC for IM physicians who focus their practice in the hospital setting. The American Board of Medical Specialties (ABMS), the group that oversees the ABIM, is very clear that only training-based subspecialties can be deemed board-certified subspecialties.

Still, the new FPHM will differentiate hospitalists from nonhospitalists. To me, this is semantics, and the recognition that comes with the FPHM is enough to recognize what I do as “special.”

Will the Examination for the FPHM Reflect What I Do?

Yes. I’ve had several colleagues tell me they’ve heard that the examination will contain elements not found on the standard MOC test. This is true, but it also is the major benefit of the new test. As reported on the ABIM website, the FPHM MOC exam will consist of roughly 45% inpatient medicine, 15% consultative and comanagement work, 15% transitions and ambulatory medicine, 15% patient safety/quality improvement, 5% epidemiology, and 5% ethics and end-of-life care. In this respect, it better reflects what most of us spend most of our time doing—inpatient care, consultative medicine, and transitions of care. Those three areas comprise nearly 75% of the examination. The one area that is new is the focus on patient safety and quality. However, for a field built on the promise of improving the quality, safety, and efficiency of healthcare, this is a welcome change.

Will I Be Able to Prepare for the FPHM Exam?

Yes. Because the FPHM utilizes a different exam than the standard IM MOC, some physicians are concerned that they there are no avenues for preparation, but this is not true. While the exam will weigh various portions of the test differently (e.g., less ambulatory and more inpatient content), the inpatient content will be similar to what is currently on the standard MOC test. After all, heart failure, cellulitis, and pulmonary embolism are the same, regardless of the test it shows up on.

The difference is that there will be more of it—a good thing for the practicing hospitalist. Many of the standard IM test preparation options will help you prepare for the FPHM exam. The ABIM also offers HM knowledge modules as part of the enrollment fee, which, while not meant to be preparation for the exam, can help you identify gaps in your knowledge. The blueprint for the exam is on the ABIM website and can give you clues to areas in which to prepare.

It is true that there will be patient safety and QI content on the HM test, which might not be available for study in typical board review books. However, much of this is the kind of information hospitalists live every day, such as handoffs, transitions of care, and infection control.

Should I Fear the Change?

Humans are intrinsically wired to dislike change. It’s that old saw about choosing the devil we know rather than the devil we don’t. My guess is that much of the concern around the new process stems from this human sentiment—it’s just easier to not do the FPHM and go down the standard IM MOC route. We must avoid this temptation.

The FPHM is a key step in solidifying HM’s status in the healthcare milieu. It gives us credibility in a way no other designation can. It also allows those of us who are serious about an HM career to differentiate ourselves from those who masquerade as hospitalists. And, most importantly, it allows us to demonstrate to our patients our sincere commitment to improving the quality of the inpatient systems that envelop them at their sickest moments.

For that reason alone, I’m enrolling in the FPHM MOC. TH

Dr. Glasheen is physician editor of The Hospitalist.

Registration for the Focused Practice in Hospital Medicine (FPHM) Maintenance of Certification (MOC) through the American Board of Internal Medicine (ABIM) opened March 15. Since then, hundreds of board-certified IM physicians have registered to complete their MOC through the FPHM. For those of you who haven’t gone through MOC yet, it is required every 10 years in order to maintain your board certification.

As a member of the committee tasked with helping ABIM develop the FPHM, as well as write the FPHM examination, I’m frequently asked questions about this process, especially since FPHM was featured on the May 2010 cover of this magazine. Some of the questions stem from the perplexity associated with this significant change to the MOC process. Others arise from misinformation and apprehension, and could rightly be called urban legends. Here is a sample of those questions, with their respective veracity.

Does This Certification Mean I’ll No Longer be an Internist?

No. I clearly remember the day I found out I passed the ABIM certification exam; it represented the culmination of years of work, the pinnacle. All those long hours of study, late-night admissions, and exam preparation had finally paid off. I was a board-certified internist! I cherish my board certification and hold it out as recognition of my mastery of the field of IM. As such, I certainly understand the concern that entering the FPHM will somehow result in “losing” IM certification. However, this just isn’t true.

First, all diplomates—ABIM terminology for those enrolled in the board (re)certification process—in the FPHM are certified as internists. This is simply, as the name suggests, recognition of focused practice in HM—the core certification is still in IM. We are still internists—just internists who have focused our practice to hospital care. The formal board designation will read: ABIM Board Certified in Internal Medicine with a Focused Practice in Hospital Medicine.

Will Hospital Credentialing Boards Recognize This Certification?

Yes. The FPHM is certification in IM by the ABIM. This carries the same weight and meaning as the regular IM MOC. All credentialing boards that recognize the ABIM MOC in IM will recognize the FPHM.

Is the FPHM MOC More Rigorous Than the Regular IM MOC?

Yes, and it was intentional. It is recognized that hospitalists do things that make them “special” by acquiring and refining skills learned experientially outside of a supervised training program. Thus, one can attain FPHM board designation only after three years of practice as a hospitalist. The problem is that this is largely unsupervised time (unlike a fellowship), so the threshold to ensure we have achieved a level of competency has to be established through the MOC process.

As such, the bar for the MOC for FPHM has been set higher. The upshot is that to maintain designation of FPHM, hospitalists are required to achieve 60 self-evaluation points every three years, compared with 100 points every 10 years for IM MOC. Forty of those 60 points must come in the form of Practice Improvement Modules, or PIMs. While more rigorous, it only makes sense that a group committed to the improvement of healthcare quality would commit to higher levels of quality assurance.

Will the FPHM Confer Subspecialty Status to Hospitalists?

No. This is where there has been the greatest deal of controversy surrounding the FPHM program. FPHM is not a subspecialty certification. Rather, it is MOC for IM physicians who focus their practice in the hospital setting. The American Board of Medical Specialties (ABMS), the group that oversees the ABIM, is very clear that only training-based subspecialties can be deemed board-certified subspecialties.

Still, the new FPHM will differentiate hospitalists from nonhospitalists. To me, this is semantics, and the recognition that comes with the FPHM is enough to recognize what I do as “special.”

Will the Examination for the FPHM Reflect What I Do?

Yes. I’ve had several colleagues tell me they’ve heard that the examination will contain elements not found on the standard MOC test. This is true, but it also is the major benefit of the new test. As reported on the ABIM website, the FPHM MOC exam will consist of roughly 45% inpatient medicine, 15% consultative and comanagement work, 15% transitions and ambulatory medicine, 15% patient safety/quality improvement, 5% epidemiology, and 5% ethics and end-of-life care. In this respect, it better reflects what most of us spend most of our time doing—inpatient care, consultative medicine, and transitions of care. Those three areas comprise nearly 75% of the examination. The one area that is new is the focus on patient safety and quality. However, for a field built on the promise of improving the quality, safety, and efficiency of healthcare, this is a welcome change.

Will I Be Able to Prepare for the FPHM Exam?

Yes. Because the FPHM utilizes a different exam than the standard IM MOC, some physicians are concerned that they there are no avenues for preparation, but this is not true. While the exam will weigh various portions of the test differently (e.g., less ambulatory and more inpatient content), the inpatient content will be similar to what is currently on the standard MOC test. After all, heart failure, cellulitis, and pulmonary embolism are the same, regardless of the test it shows up on.

The difference is that there will be more of it—a good thing for the practicing hospitalist. Many of the standard IM test preparation options will help you prepare for the FPHM exam. The ABIM also offers HM knowledge modules as part of the enrollment fee, which, while not meant to be preparation for the exam, can help you identify gaps in your knowledge. The blueprint for the exam is on the ABIM website and can give you clues to areas in which to prepare.

It is true that there will be patient safety and QI content on the HM test, which might not be available for study in typical board review books. However, much of this is the kind of information hospitalists live every day, such as handoffs, transitions of care, and infection control.

Should I Fear the Change?

Humans are intrinsically wired to dislike change. It’s that old saw about choosing the devil we know rather than the devil we don’t. My guess is that much of the concern around the new process stems from this human sentiment—it’s just easier to not do the FPHM and go down the standard IM MOC route. We must avoid this temptation.

The FPHM is a key step in solidifying HM’s status in the healthcare milieu. It gives us credibility in a way no other designation can. It also allows those of us who are serious about an HM career to differentiate ourselves from those who masquerade as hospitalists. And, most importantly, it allows us to demonstrate to our patients our sincere commitment to improving the quality of the inpatient systems that envelop them at their sickest moments.

For that reason alone, I’m enrolling in the FPHM MOC. TH

Dr. Glasheen is physician editor of The Hospitalist.

Click here to listen to Dr. Vidyarthi

Click here to listen to Dr. Dalal

Click here to listen to Dr. Kripalani

Click here to listen to Dr. Vidyarthi

Click here to listen to Dr. Dalal

Click here to listen to Dr. Kripalani

Click here to listen to Dr. Vidyarthi

Click here to listen to Dr. Dalal

Click here to listen to Dr. Kripalani

Few medical students receive formal training in how to perform patient handoffs effectively and efficiently, says Vineet Arora, MD, FHM, who chairs an SHM task force on improving handoffs. Most pick it up on the job, but Dr. Arora and her colleagues at the University of Chicago—where she is associate director of the internal-medicine residency program—and at the University of Michigan have been exploring ways to improve the process through education.¹ Handoffs and care transitions are a major focus for hospital quality-improvement (QI) efforts nationally.

Dr. Arora’s group created an “observed simulation handoff experience” for medical students and residents, “offering an air of authenticity to the experience without the high-risk environment of learning on live patients,” she explains. Students who have completed an interactive training session perform the simulation at a computer station. They are provided with two types of information: static data about the mock patient—including such information as diagnosis, primary-care physician, and code status from a history and physical report—and video clips offering “a virtual, real-time barrage of constant updates” about the patient’s changing clinical status.

“They are given some time to extract and synthesize the important data for a handoff, and then they go in and perform the handoff in person to a ‘standardized receiver,’ ” Dr. Arora explains. The receiver is a resident or other clinician familiar both with the case and how the handoff should go, and who then provides a standardized evaluation, grade, and feedback.

“The goal is to teach students the triggers that need to be incorporated into an effective handoff,” Dr. Arora says. Her group also reviewed concepts of good handoffs from the medical literature and worked with a psychology expert in human communication.

“How do you teach people to give good handoffs? We don’t know all of the answers, but we think you have to start somewhere,” she says. “Technology can be a great facilitator to make handoffs go better. It’s not a perfect substitute for face-to-face, interactive handoffs, but it can dramatically inform care transitions.”

Larry Beresford is a freelance writer based in Oakland, Calif.

Few medical students receive formal training in how to perform patient handoffs effectively and efficiently, says Vineet Arora, MD, FHM, who chairs an SHM task force on improving handoffs. Most pick it up on the job, but Dr. Arora and her colleagues at the University of Chicago—where she is associate director of the internal-medicine residency program—and at the University of Michigan have been exploring ways to improve the process through education.¹ Handoffs and care transitions are a major focus for hospital quality-improvement (QI) efforts nationally.

Dr. Arora’s group created an “observed simulation handoff experience” for medical students and residents, “offering an air of authenticity to the experience without the high-risk environment of learning on live patients,” she explains. Students who have completed an interactive training session perform the simulation at a computer station. They are provided with two types of information: static data about the mock patient—including such information as diagnosis, primary-care physician, and code status from a history and physical report—and video clips offering “a virtual, real-time barrage of constant updates” about the patient’s changing clinical status.

“They are given some time to extract and synthesize the important data for a handoff, and then they go in and perform the handoff in person to a ‘standardized receiver,’ ” Dr. Arora explains. The receiver is a resident or other clinician familiar both with the case and how the handoff should go, and who then provides a standardized evaluation, grade, and feedback.

“The goal is to teach students the triggers that need to be incorporated into an effective handoff,” Dr. Arora says. Her group also reviewed concepts of good handoffs from the medical literature and worked with a psychology expert in human communication.

“How do you teach people to give good handoffs? We don’t know all of the answers, but we think you have to start somewhere,” she says. “Technology can be a great facilitator to make handoffs go better. It’s not a perfect substitute for face-to-face, interactive handoffs, but it can dramatically inform care transitions.”

Larry Beresford is a freelance writer based in Oakland, Calif.

Few medical students receive formal training in how to perform patient handoffs effectively and efficiently, says Vineet Arora, MD, FHM, who chairs an SHM task force on improving handoffs. Most pick it up on the job, but Dr. Arora and her colleagues at the University of Chicago—where she is associate director of the internal-medicine residency program—and at the University of Michigan have been exploring ways to improve the process through education.¹ Handoffs and care transitions are a major focus for hospital quality-improvement (QI) efforts nationally.

Dr. Arora’s group created an “observed simulation handoff experience” for medical students and residents, “offering an air of authenticity to the experience without the high-risk environment of learning on live patients,” she explains. Students who have completed an interactive training session perform the simulation at a computer station. They are provided with two types of information: static data about the mock patient—including such information as diagnosis, primary-care physician, and code status from a history and physical report—and video clips offering “a virtual, real-time barrage of constant updates” about the patient’s changing clinical status.

“They are given some time to extract and synthesize the important data for a handoff, and then they go in and perform the handoff in person to a ‘standardized receiver,’ ” Dr. Arora explains. The receiver is a resident or other clinician familiar both with the case and how the handoff should go, and who then provides a standardized evaluation, grade, and feedback.

“The goal is to teach students the triggers that need to be incorporated into an effective handoff,” Dr. Arora says. Her group also reviewed concepts of good handoffs from the medical literature and worked with a psychology expert in human communication.

“How do you teach people to give good handoffs? We don’t know all of the answers, but we think you have to start somewhere,” she says. “Technology can be a great facilitator to make handoffs go better. It’s not a perfect substitute for face-to-face, interactive handoffs, but it can dramatically inform care transitions.”

Larry Beresford is a freelance writer based in Oakland, Calif.

Supplement Editor:
Marc S. Penn, MD, PhD

Contents

Introduction: Heart-brain medicine: Update 2009
Marc S. Penn, MD, PhD, and Earl E. Bakken, MD (HonC), DSc (3 Hon), DHL (2 Hon)

Depression and Heart Disease

Depression and heart failure: An overview of what we know and don't know
Marc A. Silver, MD

The American Heart Association science advisory on depression and coronary heart disease: An exploration of the issues raised
J. Thomas Bigger, MD, and Alexander H. Glassman, MD

Depression and cardiovascular disease: Selected findings, controversies, and clinical implications from 2009
Karina W. Davidson, PhD, and Maya Rom Korin, PhD

Pioneer Lecture

Recovery of consciousness after severe brain injury: The role of arousal regulation mechanisms and some speculation on the heart-brain interface
Nicholas D. Schiff, MD

Heart-Brain Medicine Publications: The Year in Review

Neuroscience and heart-brain medicine: The year in review
David S. Goldstein, MD, PhD

Pathophysiologic mechanisms linking impaired cardiovascular health and neurologic dysfunction: The year in review
Ki E. Park, MD, and Carl J. Pepine, MD

Biomedical engineering in heart-brain medicine: A review
Peter G. Katona, ScD

Novel Findings in Heart-Brain Medicine

Sudden death in epilepsy, surgery, and seizure outcomes: The interface between heart and brain
Lara Jehi, MD

Biofeedback in the Treatment of Disease

Biofeedback in the treatment of heart failure
Michael G. McKee, PhD, and Christine S. Moravec, PhD

Biofeedback in the treatment of epilepsy
M. Barry Sterman, PhD

The effects of biofeedback in diabetes and essential hypertension
Angele McGrady, PhD, MEd, LPCC

Biofeedback in headache: An overview of approaches and evidence
Frank Andrasik, PhD

Device-Based Therapies

Use of deep brain stimulation in treatment-resistant depression
Donald A. Malone, Jr, MD

Poster Abstracts

Abstract 1: Potential role of the cardiac protease corin in energy metabolism
Jingjing Jiang, Yujie Cui, Wei Wang, and Qingyu Wu

Abstract 2: Anxiety and type D personality in ICD patients: Impact of shocks
Mina K. Chung, MD; Melanie Panko, RN; Tina Gupta; Scott Bea, PhD; Karen Broer, PhD; Diana Bauer; Denise Kosty-Sweeney, RN; Betty Ching, RN; Suzanne Pedersen, PhD; Sam Sears, PhD; and Leo Pozuelo, MD

Abstract 3: Microglia activation and neuroprotection during CNS preconditioning
Walid Jalabi, Ranjan Dutta, Yongming Jin, Gerson Criste, Xinghua Yin, Grahame J. Kidd, and Bruce D. Trapp

Abstract 4: Brain MRI correlates of atrial fibrillation
Stephen E. Jones, MD, PhD; Thomas Callahan, MD; Kamal Chémali, MD; Michael Phillips, MD; David Van Wagoner, PhD; and Walid Saliba, MD

Abstract 5: Identification and characterization of autonomic dysfunction in migraineurs with and without auras: Phase I
Mark Stillman, MD

Abstract 6: Sudden unexpected death in epilepsy: Finding the missing cardiac links
Lara Jehi, MD; Kanjana Unnongswe, MD; Thomas Callahan, MD; Liang Li, PhD; and Imad Najm, MD

Abstract 7: Cardiomyopathy after subarachnoid hemorrhage is mediated by neutrophils
J. Javier Provencio, Shari Moore, and Saksith Smithason

Abstract 8: Mindfulness, yoga, and cardiovascular disease
Didier Allexandre, Emily Fox, Mladen Golubic, Tom Morledge, and Joan E.B. Fox

Abstract 9: Multidisciplinary research in biofeedback
Christine S. Moravec, PhD; Michael G. McKee, PhD; James B. Young, MD; Betul Hatipoglu, MD; Leopoldo Pozuelo, MD; Leslie Cho, MD; Gordon Blackburn, MD; Francois Bethoux, MD; Mary Rensel, MD; Katherine Hoercher, RN; J. Javier Provencio, MD; and Marc S. Penn, MD

Abstract 10: Complex regional pain syndrome (CRPS I): A systemic disease of the autonomic nervous system
Kamal Chemali, MD; Robert Shields, MD; Lan Zhou, MD, PhD; Salim Hayek, MD, PhD; and Thomas Chelimsky, MD

Abstract 11: Biofeedback in the treatment of heart failure
Dana L. Frank, BA; Lamees Khorshid, PsyD; Jerome Kiffer, MA; Christine S. Moravec, PhD; and Michael G. McKee, PhD

Abstract 12: Change in depressive symptom status predicts health-related quality of life in patients with heart failure
Rebecca L. Dekker, MSN, RN, PhD candidate; Terry A. Lennie, PhD, RN; Nancy Albert, PhD, CCNS; Barbara Riegel, DNSc, RN; Misook L. Chung, PhD, RN; Seongkum Heo, PhD, RN; Eun Kyeung Song, PhD, RN; Jia-Rong Wu, PhD, RN; and Debra K. Moser, DNSc, RN

Abstract 13: Entropy of EKG time series distinguishes epileptic from nonepileptic patients
Rebecca O’Dwyer, Ulrich Zurcher, Brian Vyhnalek, Miron Kaufman, and Richard Burgess

Abstract 14: Evaluation of cardiac autonomic balance in major depression treated with different antidepressant therapies: A study with heart rate variability measures
K. Udupa, K.R. Kishore, J. Thirthalli, B.N. Gangadhar, T.R. Raju, and T.N. Sathyaprabha

Abstract 15: Proinflammatory status in major depression: Effects of escitalopram
John Piletz, PhD; Angelos Halaris, MD; Erin Tobin, MS; Edwin Meresh, MD; Jawed Fareed, PhD; Omer Iqbal, MD; Debra Hoppenstead, PhD; and James Sinacore, PhD

Abstract 16: Heart rate variability in depression: Effect of escitalopram
Angelos Halaris, MD; John Piletz, PhD; Erin Tobin, MA; Edwin Meresh, MD; James Sinacore, PhD; and Christopher Lowden

Abstract 17: Effects of omega-3/6 dietary ratio variation after a myocardial infarction in a rat model
Guy Rousseau, Isabelle Rondeau, Sandrine Picard, Thierno Madjou Bah, Louis Roy, and Roger Godbout

Abstract 18: The effects of tai chi on the heart and the brain
Qian Luo, Xi Cheng, and Xi Zha

Abstract 19: A randomized controlled trial of the effect of hostility reduction on cardiac autonomic regulation
Richard P. Sloan, PhD; Peter A. Shapiro, MD; Ethan E. Gorenstein, PhD; Felice A. Tager, PhD; Catherine E. Monk, PhD; Paula S. McKinley, PhD; Michael M. Myers, PhD; Emilia Bagiella, PhD; Ivy Chen, MST; Richard Steinman, BA; and J. Thomas Bigger, Jr., MD

Supplement Editor:
Marc S. Penn, MD, PhD

Contents

Introduction: Heart-brain medicine: Update 2009
Marc S. Penn, MD, PhD, and Earl E. Bakken, MD (HonC), DSc (3 Hon), DHL (2 Hon)

Depression and Heart Disease

Depression and heart failure: An overview of what we know and don't know
Marc A. Silver, MD

The American Heart Association science advisory on depression and coronary heart disease: An exploration of the issues raised
J. Thomas Bigger, MD, and Alexander H. Glassman, MD

Depression and cardiovascular disease: Selected findings, controversies, and clinical implications from 2009
Karina W. Davidson, PhD, and Maya Rom Korin, PhD

Pioneer Lecture

Recovery of consciousness after severe brain injury: The role of arousal regulation mechanisms and some speculation on the heart-brain interface
Nicholas D. Schiff, MD

Heart-Brain Medicine Publications: The Year in Review

Neuroscience and heart-brain medicine: The year in review
David S. Goldstein, MD, PhD

Pathophysiologic mechanisms linking impaired cardiovascular health and neurologic dysfunction: The year in review
Ki E. Park, MD, and Carl J. Pepine, MD

Biomedical engineering in heart-brain medicine: A review
Peter G. Katona, ScD

Novel Findings in Heart-Brain Medicine

Sudden death in epilepsy, surgery, and seizure outcomes: The interface between heart and brain
Lara Jehi, MD

Biofeedback in the Treatment of Disease

Biofeedback in the treatment of heart failure
Michael G. McKee, PhD, and Christine S. Moravec, PhD

Biofeedback in the treatment of epilepsy
M. Barry Sterman, PhD

The effects of biofeedback in diabetes and essential hypertension
Angele McGrady, PhD, MEd, LPCC

Biofeedback in headache: An overview of approaches and evidence
Frank Andrasik, PhD

Device-Based Therapies

Use of deep brain stimulation in treatment-resistant depression
Donald A. Malone, Jr, MD

Poster Abstracts

Abstract 1: Potential role of the cardiac protease corin in energy metabolism
Jingjing Jiang, Yujie Cui, Wei Wang, and Qingyu Wu

Abstract 2: Anxiety and type D personality in ICD patients: Impact of shocks
Mina K. Chung, MD; Melanie Panko, RN; Tina Gupta; Scott Bea, PhD; Karen Broer, PhD; Diana Bauer; Denise Kosty-Sweeney, RN; Betty Ching, RN; Suzanne Pedersen, PhD; Sam Sears, PhD; and Leo Pozuelo, MD

Abstract 3: Microglia activation and neuroprotection during CNS preconditioning
Walid Jalabi, Ranjan Dutta, Yongming Jin, Gerson Criste, Xinghua Yin, Grahame J. Kidd, and Bruce D. Trapp

Abstract 4: Brain MRI correlates of atrial fibrillation
Stephen E. Jones, MD, PhD; Thomas Callahan, MD; Kamal Chémali, MD; Michael Phillips, MD; David Van Wagoner, PhD; and Walid Saliba, MD

Abstract 5: Identification and characterization of autonomic dysfunction in migraineurs with and without auras: Phase I
Mark Stillman, MD

Abstract 6: Sudden unexpected death in epilepsy: Finding the missing cardiac links
Lara Jehi, MD; Kanjana Unnongswe, MD; Thomas Callahan, MD; Liang Li, PhD; and Imad Najm, MD

Abstract 7: Cardiomyopathy after subarachnoid hemorrhage is mediated by neutrophils
J. Javier Provencio, Shari Moore, and Saksith Smithason

Abstract 8: Mindfulness, yoga, and cardiovascular disease
Didier Allexandre, Emily Fox, Mladen Golubic, Tom Morledge, and Joan E.B. Fox

Abstract 9: Multidisciplinary research in biofeedback
Christine S. Moravec, PhD; Michael G. McKee, PhD; James B. Young, MD; Betul Hatipoglu, MD; Leopoldo Pozuelo, MD; Leslie Cho, MD; Gordon Blackburn, MD; Francois Bethoux, MD; Mary Rensel, MD; Katherine Hoercher, RN; J. Javier Provencio, MD; and Marc S. Penn, MD

Abstract 10: Complex regional pain syndrome (CRPS I): A systemic disease of the autonomic nervous system
Kamal Chemali, MD; Robert Shields, MD; Lan Zhou, MD, PhD; Salim Hayek, MD, PhD; and Thomas Chelimsky, MD

Abstract 11: Biofeedback in the treatment of heart failure
Dana L. Frank, BA; Lamees Khorshid, PsyD; Jerome Kiffer, MA; Christine S. Moravec, PhD; and Michael G. McKee, PhD

Abstract 12: Change in depressive symptom status predicts health-related quality of life in patients with heart failure
Rebecca L. Dekker, MSN, RN, PhD candidate; Terry A. Lennie, PhD, RN; Nancy Albert, PhD, CCNS; Barbara Riegel, DNSc, RN; Misook L. Chung, PhD, RN; Seongkum Heo, PhD, RN; Eun Kyeung Song, PhD, RN; Jia-Rong Wu, PhD, RN; and Debra K. Moser, DNSc, RN

Abstract 13: Entropy of EKG time series distinguishes epileptic from nonepileptic patients
Rebecca O’Dwyer, Ulrich Zurcher, Brian Vyhnalek, Miron Kaufman, and Richard Burgess

Abstract 14: Evaluation of cardiac autonomic balance in major depression treated with different antidepressant therapies: A study with heart rate variability measures
K. Udupa, K.R. Kishore, J. Thirthalli, B.N. Gangadhar, T.R. Raju, and T.N. Sathyaprabha

Abstract 15: Proinflammatory status in major depression: Effects of escitalopram
John Piletz, PhD; Angelos Halaris, MD; Erin Tobin, MS; Edwin Meresh, MD; Jawed Fareed, PhD; Omer Iqbal, MD; Debra Hoppenstead, PhD; and James Sinacore, PhD

Abstract 16: Heart rate variability in depression: Effect of escitalopram
Angelos Halaris, MD; John Piletz, PhD; Erin Tobin, MA; Edwin Meresh, MD; James Sinacore, PhD; and Christopher Lowden

Abstract 17: Effects of omega-3/6 dietary ratio variation after a myocardial infarction in a rat model
Guy Rousseau, Isabelle Rondeau, Sandrine Picard, Thierno Madjou Bah, Louis Roy, and Roger Godbout

Abstract 18: The effects of tai chi on the heart and the brain
Qian Luo, Xi Cheng, and Xi Zha

Abstract 19: A randomized controlled trial of the effect of hostility reduction on cardiac autonomic regulation
Richard P. Sloan, PhD; Peter A. Shapiro, MD; Ethan E. Gorenstein, PhD; Felice A. Tager, PhD; Catherine E. Monk, PhD; Paula S. McKinley, PhD; Michael M. Myers, PhD; Emilia Bagiella, PhD; Ivy Chen, MST; Richard Steinman, BA; and J. Thomas Bigger, Jr., MD

Supplement Editor:
Marc S. Penn, MD, PhD

Contents

Introduction: Heart-brain medicine: Update 2009
Marc S. Penn, MD, PhD, and Earl E. Bakken, MD (HonC), DSc (3 Hon), DHL (2 Hon)

Depression and Heart Disease

Depression and heart failure: An overview of what we know and don't know
Marc A. Silver, MD

The American Heart Association science advisory on depression and coronary heart disease: An exploration of the issues raised
J. Thomas Bigger, MD, and Alexander H. Glassman, MD

Depression and cardiovascular disease: Selected findings, controversies, and clinical implications from 2009
Karina W. Davidson, PhD, and Maya Rom Korin, PhD

Pioneer Lecture

Recovery of consciousness after severe brain injury: The role of arousal regulation mechanisms and some speculation on the heart-brain interface
Nicholas D. Schiff, MD

Heart-Brain Medicine Publications: The Year in Review

Neuroscience and heart-brain medicine: The year in review
David S. Goldstein, MD, PhD

Pathophysiologic mechanisms linking impaired cardiovascular health and neurologic dysfunction: The year in review
Ki E. Park, MD, and Carl J. Pepine, MD

Biomedical engineering in heart-brain medicine: A review
Peter G. Katona, ScD

Novel Findings in Heart-Brain Medicine

Sudden death in epilepsy, surgery, and seizure outcomes: The interface between heart and brain
Lara Jehi, MD

Biofeedback in the Treatment of Disease

Biofeedback in the treatment of heart failure
Michael G. McKee, PhD, and Christine S. Moravec, PhD

Biofeedback in the treatment of epilepsy
M. Barry Sterman, PhD

The effects of biofeedback in diabetes and essential hypertension
Angele McGrady, PhD, MEd, LPCC

Biofeedback in headache: An overview of approaches and evidence
Frank Andrasik, PhD

Device-Based Therapies

Use of deep brain stimulation in treatment-resistant depression
Donald A. Malone, Jr, MD

Poster Abstracts

Abstract 1: Potential role of the cardiac protease corin in energy metabolism
Jingjing Jiang, Yujie Cui, Wei Wang, and Qingyu Wu

Abstract 2: Anxiety and type D personality in ICD patients: Impact of shocks
Mina K. Chung, MD; Melanie Panko, RN; Tina Gupta; Scott Bea, PhD; Karen Broer, PhD; Diana Bauer; Denise Kosty-Sweeney, RN; Betty Ching, RN; Suzanne Pedersen, PhD; Sam Sears, PhD; and Leo Pozuelo, MD

Abstract 3: Microglia activation and neuroprotection during CNS preconditioning
Walid Jalabi, Ranjan Dutta, Yongming Jin, Gerson Criste, Xinghua Yin, Grahame J. Kidd, and Bruce D. Trapp

Abstract 4: Brain MRI correlates of atrial fibrillation
Stephen E. Jones, MD, PhD; Thomas Callahan, MD; Kamal Chémali, MD; Michael Phillips, MD; David Van Wagoner, PhD; and Walid Saliba, MD

Abstract 5: Identification and characterization of autonomic dysfunction in migraineurs with and without auras: Phase I
Mark Stillman, MD

Abstract 6: Sudden unexpected death in epilepsy: Finding the missing cardiac links
Lara Jehi, MD; Kanjana Unnongswe, MD; Thomas Callahan, MD; Liang Li, PhD; and Imad Najm, MD

Abstract 7: Cardiomyopathy after subarachnoid hemorrhage is mediated by neutrophils
J. Javier Provencio, Shari Moore, and Saksith Smithason

Abstract 8: Mindfulness, yoga, and cardiovascular disease
Didier Allexandre, Emily Fox, Mladen Golubic, Tom Morledge, and Joan E.B. Fox

Abstract 9: Multidisciplinary research in biofeedback
Christine S. Moravec, PhD; Michael G. McKee, PhD; James B. Young, MD; Betul Hatipoglu, MD; Leopoldo Pozuelo, MD; Leslie Cho, MD; Gordon Blackburn, MD; Francois Bethoux, MD; Mary Rensel, MD; Katherine Hoercher, RN; J. Javier Provencio, MD; and Marc S. Penn, MD

Abstract 10: Complex regional pain syndrome (CRPS I): A systemic disease of the autonomic nervous system
Kamal Chemali, MD; Robert Shields, MD; Lan Zhou, MD, PhD; Salim Hayek, MD, PhD; and Thomas Chelimsky, MD

Abstract 11: Biofeedback in the treatment of heart failure
Dana L. Frank, BA; Lamees Khorshid, PsyD; Jerome Kiffer, MA; Christine S. Moravec, PhD; and Michael G. McKee, PhD

Abstract 12: Change in depressive symptom status predicts health-related quality of life in patients with heart failure
Rebecca L. Dekker, MSN, RN, PhD candidate; Terry A. Lennie, PhD, RN; Nancy Albert, PhD, CCNS; Barbara Riegel, DNSc, RN; Misook L. Chung, PhD, RN; Seongkum Heo, PhD, RN; Eun Kyeung Song, PhD, RN; Jia-Rong Wu, PhD, RN; and Debra K. Moser, DNSc, RN

Abstract 13: Entropy of EKG time series distinguishes epileptic from nonepileptic patients
Rebecca O’Dwyer, Ulrich Zurcher, Brian Vyhnalek, Miron Kaufman, and Richard Burgess

Abstract 14: Evaluation of cardiac autonomic balance in major depression treated with different antidepressant therapies: A study with heart rate variability measures
K. Udupa, K.R. Kishore, J. Thirthalli, B.N. Gangadhar, T.R. Raju, and T.N. Sathyaprabha

Abstract 15: Proinflammatory status in major depression: Effects of escitalopram
John Piletz, PhD; Angelos Halaris, MD; Erin Tobin, MS; Edwin Meresh, MD; Jawed Fareed, PhD; Omer Iqbal, MD; Debra Hoppenstead, PhD; and James Sinacore, PhD

Abstract 16: Heart rate variability in depression: Effect of escitalopram
Angelos Halaris, MD; John Piletz, PhD; Erin Tobin, MA; Edwin Meresh, MD; James Sinacore, PhD; and Christopher Lowden

Abstract 17: Effects of omega-3/6 dietary ratio variation after a myocardial infarction in a rat model
Guy Rousseau, Isabelle Rondeau, Sandrine Picard, Thierno Madjou Bah, Louis Roy, and Roger Godbout

Abstract 18: The effects of tai chi on the heart and the brain
Qian Luo, Xi Cheng, and Xi Zha

Abstract 19: A randomized controlled trial of the effect of hostility reduction on cardiac autonomic regulation
Richard P. Sloan, PhD; Peter A. Shapiro, MD; Ethan E. Gorenstein, PhD; Felice A. Tager, PhD; Catherine E. Monk, PhD; Paula S. McKinley, PhD; Michael M. Myers, PhD; Emilia Bagiella, PhD; Ivy Chen, MST; Richard Steinman, BA; and J. Thomas Bigger, Jr., MD

Hypogonadism is a highly prevalent condition that is under-diagnosed and under-treated despite available effective therapies. Low levels of testosterone result in losses of lean body mass and bone mass, decreases in libido and sexual function and is associated with insulin resistance, metabolic syndrome, diabetes, and other chronic comorbid conditions. It is important for physicians to be aware of how testosterone levels can be related to these conditions, which are seen in primary care practices on a daily basis.

This CME supplement discusses the definition, epidemiology and key signs and symptoms of late-onset hypogonadism, the role of lab measurements, factors to consider in selecting patients for testosterone replacement therapy, and how to identify the best treatment strategy for each patient.

Hypogonadism is a highly prevalent condition that is under-diagnosed and under-treated despite available effective therapies. Low levels of testosterone result in losses of lean body mass and bone mass, decreases in libido and sexual function and is associated with insulin resistance, metabolic syndrome, diabetes, and other chronic comorbid conditions. It is important for physicians to be aware of how testosterone levels can be related to these conditions, which are seen in primary care practices on a daily basis.

This CME supplement discusses the definition, epidemiology and key signs and symptoms of late-onset hypogonadism, the role of lab measurements, factors to consider in selecting patients for testosterone replacement therapy, and how to identify the best treatment strategy for each patient.

Hypogonadism is a highly prevalent condition that is under-diagnosed and under-treated despite available effective therapies. Low levels of testosterone result in losses of lean body mass and bone mass, decreases in libido and sexual function and is associated with insulin resistance, metabolic syndrome, diabetes, and other chronic comorbid conditions. It is important for physicians to be aware of how testosterone levels can be related to these conditions, which are seen in primary care practices on a daily basis.

This CME supplement discusses the definition, epidemiology and key signs and symptoms of late-onset hypogonadism, the role of lab measurements, factors to consider in selecting patients for testosterone replacement therapy, and how to identify the best treatment strategy for each patient.