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

Case Report

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

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

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

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

Figure 1

Figure 2

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

Discussion

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

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

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

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

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

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

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

Case Report

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

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

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

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

Figure 1

Figure 2

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

Discussion

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

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

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

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

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

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

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

Case Report

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

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

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

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

Figure 1

Figure 2

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

Discussion

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

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

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

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

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

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

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

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

Practically, these vignettes and conferences serve three main purposes:

• 1

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

• 2

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

• 3

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

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

The Hospital Didn't Wait

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

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

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

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

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

I Told a Man Today That He Had Brain Cancer

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

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

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

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

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

Where is it? How big is it?

What now?

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

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

A Decimal Point Got Misplaced

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

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

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

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

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

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

Creating an Open Climate

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

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

Supervision and Modeling

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

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

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

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

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

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

Practically, these vignettes and conferences serve three main purposes:

• 1

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

• 2

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

• 3

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

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

The Hospital Didn't Wait

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

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

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

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

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

I Told a Man Today That He Had Brain Cancer

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

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

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

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

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

Where is it? How big is it?

What now?

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

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

A Decimal Point Got Misplaced

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

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

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

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

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

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

Creating an Open Climate

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

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

Supervision and Modeling

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

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

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

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

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

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

Practically, these vignettes and conferences serve three main purposes:

• 1

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

• 2

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

• 3

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

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

The Hospital Didn't Wait

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

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

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

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

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

I Told a Man Today That He Had Brain Cancer

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

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

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

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

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

Where is it? How big is it?

What now?

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

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

A Decimal Point Got Misplaced

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

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

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

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

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

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

Creating an Open Climate

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

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

Supervision and Modeling

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

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

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

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

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

Accreditation and Designation Statement

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

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

Educational Objectives

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

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

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

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

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

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

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

Instructions on Receiving Credit

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

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

Follow these steps to earn credit:

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

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

• Read the article in print or online format.

• Reflect on the article.

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

• Complete the required evaluation component of the activity.

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

Accreditation and Designation Statement

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

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

Educational Objectives

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

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

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

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

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

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

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

Instructions on Receiving Credit

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

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

Follow these steps to earn credit:

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

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

• Read the article in print or online format.

• Reflect on the article.

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

• Complete the required evaluation component of the activity.

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

Accreditation and Designation Statement

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

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

Educational Objectives

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

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

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

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

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

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

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

Instructions on Receiving Credit

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

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

Follow these steps to earn credit:

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

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

• Read the article in print or online format.

• Reflect on the article.

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

• Complete the required evaluation component of the activity.

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

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

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

Figure 1

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

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

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

Figure 1

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

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

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

Figure 1

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

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

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

Methods

Results

Discussion

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

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

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

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

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

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

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

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

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

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

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

Methods

Results

Discussion

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

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

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

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

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

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

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

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

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

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

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

Methods

Results

Discussion

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

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

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

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

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

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

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

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

Hospitalists have been suggested to offer rational and efficient medical care through specialized knowledge about inpatient care services.1 The goal that hospitalists will use care resources more efficiently presumes hospitalists' accurate knowledge about charges and costs.

Data regarding physicians' awareness of care charges and its impact upon care is limited. An international meta‐analysis of clinicians' awareness of pharmaceutical prices demonstrated poor accuracy of physicians' estimates of charges, but effects of increasing their knowledge remained unexamined.2 Continuous exposure to education and alerts about charges have been demonstrated to diminish physicians' unnecessary use of specific laboratory assays in a single teaching hospital, in a pediatric emergency department, and an outpatient primary care system; test use declined when physicians were alerted to test charges at the point‐of‐care without negative impact upon clinical outcomes; when the notices ceased, utilization climbed back towards baseline levels. Specific to inpatient care, a single‐center study evaluated the impact of price‐alerts upon laboratory and imaging use, but showed no effects.36

Applicability of these existing data for contemporary hospitalists are limited, and most data were collected before hospitalists developed as an organized focus of practice. A review of existing literature revealed no published data demonstrating hospitalists' higher expert awareness of charges generated by inpatient care. Published comparisons of the care expense generated by hospitalists' care versus that of general internists or academic teams have shown minimal and inconsistent effects.79 Those data showing reduced costs from hospitalists were associated with small length‐of‐stay reductions, rather than more expert resource utilization.7 We measured the accuracy and precision of hospitalist's estimates of charges associated with services commonly used in inpatient care.

Setting

Two community‐based private, academic‐affiliated hospitals operated by a not‐for‐profit health system in Washington State, comprising together 895 inpatient beds. The questionnaire instrument was approved by the governing Institutional Review Board (IRB).

Methods

A list of true charges for 14 services, procedures, tests, and physician charges commonly ordered by adult medicine hospitalists was acquired directly from the responsible departments of a multi‐hospital system operated by a single non‐profit entity using a unified chargemaster. Specifically, we acquired the charge that a hypothetical self‐paying patient would receive for each service, excluding any adjustments exercised by other payer sources. The list of charges was reported to the organization's financial officers for affirmation. Physician charges were standardized to geographically‐adjusted Medicare charges obtained directly from the American Medical Assocation's online Common Procedural Terminology tool.10 A cross‐section of hospitalists (n = 25) was surveyed from a private hospitalist group and an academically‐affiliated hospitalist service. Hospitalists included US and international medical graduates, new‐graduates from residency training and clinicians with a range of prior experiences in academic centers, government hospital systems, and private primary care. Respondents were asked to estimate to the nearest dollar the billing charge that a hypothetical self‐pay patient would receive for each care item. Direct data collection was arranged through the groups' medical directors and occurred in the hospitalist groups' regular business meetings. The design gathered no data on individual characteristics of respondents such as domestic or international education, sex, age, or time in practice, nor from which practice‐group a given respondent originated, to affirm to participants that their responses could not be used to imply performance measures or quality profiles.

Findings

Hospitalists tended to rank the expense of items in essentially the correct order, as reflected by the rough trend of rising estimates compared to true‐charges (Figure 1). Of note, we did not ask hospitalists to discern the different charges of 2 appropriate competing clinical choices, but asked for estimated prices of diverse services. The range of respondents' estimates about each item was broad. The mean‐value of hospitalists' estimates for each care item was less revealing than the range and diversity of estimates about each care item. Accuracy of hospitalists' estimates of charges was poor. Only 10.8% of hospitalists' estimates were within 10% of the actual unadjusted charge, 17.8% within 20% of that charge, and 24.8% were within a 30% margin of accuracy. Summary results are presented (Table 1). Pearson's r correlation value between the unadjusted charges and the estimates made by hospitalists was 0.548, a coefficient of determination equal to 0.300. Thus, the true charges list we obtained had only a low‐grade association with hospitalists' estimates (Figure 1). Hospitalists' estimates about the charges of relatively‐expensive items (abdominal computed tomography [CT]) overlapped with their estimates about the least‐expensive items (such as a urine culture ). Inter‐hospitalist agreement about charges associated with each care item was also low; estimates for each care item charge varied over logarithmic orders of magnitude.

Figure 1

Discussion

To date, hospitalist programs have shown little impact upon care costs when compared with other inpatient care staffing models. One limiting factor may be the opacity of medical care pricing. Patients have been demonstrated to have little access to knowledge of what care will cost them and complex barriers prevent them from gaining pricing information.11, 12 Hospitalists may be conjectured to serve as expert sources on the costs and values of medical care services on behalf of inpatients, but our observations suggest that hospitalists' actual knowledge of patient‐charges is lacking. The opacity of US medical prices to patients appears to extend to hospital‐care physicians as well. We observe that no widespread mechanism exists by which hospitalists would be well‐positioned to become informed about the actual charges their patients receive. Unadjusted chargemaster lists are generally restricted information, and would be difficult to access outside of participation in the charge‐notifications used in the existing studies cited above.

The inquiry was specifically limited to how closely hospitalists' estimates of the unadjusted charges for some commonly‐ordered items compare to the actual unadjusted chargemaster at their own institutions. We did not assess the hospitalists' perceptions about the accuracy of their estimates, nor the impact of specific hospitalist characteristics upon accuracy. Our sample's representation of the larger national population of hospital physicians is not established, but engenders no expectation that these clinicians' charge‐awareness is substantively different from that of hospitalists in most other institutions. It is not known what specific clinician or practice‐setting characteristics will direct charge‐awareness, or will influence the impact of charge‐awareness upon clinical practices.

The range of estimates different hospitalists made about the same care items in the same facilities was very broad, which argues that respondents did not estimate charges based upon a different knowledge base of which the investigators were unaware. This is important because our use of unadjusted charges to self‐pay patients as true prices is necessarily somewhat arbitrary. Chargemaster price may not reflect the institution's cost of performing the service, the different prices paid for a single service by different payer sources, nor reflect services' true value based upon outcomes. However, recognizing that these actual prices are somewhat artificial, the use of these prices suffices for the current inquiry, and does not negate our findings of hospitalists' low accuracy and low agreement. Also noteworthy, an unadjusted chargemaster can often represent the charges received by those uninsured US patients for whom payer‐source adjustment is inaccessible, and informs downstream accounting such as the value of unpaid care a hospital delivers annually.

The most immediate matter for examination among hospitalists is what effects increased charge‐awareness may exert upon clinical decisions and practice processes. It appears that the premise that hospitalists' exercise expert knowledge of costs is likely not valid; but it is unknown whether accurate charge‐awareness among hospitalists will improve cost‐reductions by hospitalists. In some payer‐arrangements, accurate charge‐awareness might engender reduced care quantity, rather than increased efficiency or quality. The impact of upgrading hospitalists' knowledge about the charges and costs they generate, and the most effective method to do so, is worthy of investigation; based upon this initial data we encourage and are undertaking a larger‐scale study and exploration of the effects of enhanced hospitalist charge‐awareness.

Conclusion

Hospitalists have low awareness of the charges associated with inpatient care. The opacity of hospital care pricing to patient populations extends also to hospitalist physicians. Hospitalists likely do not improve cost‐efficiency through expert knowledge of services' costs to patients. Education and reminder systems to apprise hospitalists of charges should be examined as possible tools to optimize the use of inpatient care resources.

Hospitalists have been suggested to offer rational and efficient medical care through specialized knowledge about inpatient care services.1 The goal that hospitalists will use care resources more efficiently presumes hospitalists' accurate knowledge about charges and costs.

Data regarding physicians' awareness of care charges and its impact upon care is limited. An international meta‐analysis of clinicians' awareness of pharmaceutical prices demonstrated poor accuracy of physicians' estimates of charges, but effects of increasing their knowledge remained unexamined.2 Continuous exposure to education and alerts about charges have been demonstrated to diminish physicians' unnecessary use of specific laboratory assays in a single teaching hospital, in a pediatric emergency department, and an outpatient primary care system; test use declined when physicians were alerted to test charges at the point‐of‐care without negative impact upon clinical outcomes; when the notices ceased, utilization climbed back towards baseline levels. Specific to inpatient care, a single‐center study evaluated the impact of price‐alerts upon laboratory and imaging use, but showed no effects.36

Applicability of these existing data for contemporary hospitalists are limited, and most data were collected before hospitalists developed as an organized focus of practice. A review of existing literature revealed no published data demonstrating hospitalists' higher expert awareness of charges generated by inpatient care. Published comparisons of the care expense generated by hospitalists' care versus that of general internists or academic teams have shown minimal and inconsistent effects.79 Those data showing reduced costs from hospitalists were associated with small length‐of‐stay reductions, rather than more expert resource utilization.7 We measured the accuracy and precision of hospitalist's estimates of charges associated with services commonly used in inpatient care.

Setting

Two community‐based private, academic‐affiliated hospitals operated by a not‐for‐profit health system in Washington State, comprising together 895 inpatient beds. The questionnaire instrument was approved by the governing Institutional Review Board (IRB).

Methods

A list of true charges for 14 services, procedures, tests, and physician charges commonly ordered by adult medicine hospitalists was acquired directly from the responsible departments of a multi‐hospital system operated by a single non‐profit entity using a unified chargemaster. Specifically, we acquired the charge that a hypothetical self‐paying patient would receive for each service, excluding any adjustments exercised by other payer sources. The list of charges was reported to the organization's financial officers for affirmation. Physician charges were standardized to geographically‐adjusted Medicare charges obtained directly from the American Medical Assocation's online Common Procedural Terminology tool.10 A cross‐section of hospitalists (n = 25) was surveyed from a private hospitalist group and an academically‐affiliated hospitalist service. Hospitalists included US and international medical graduates, new‐graduates from residency training and clinicians with a range of prior experiences in academic centers, government hospital systems, and private primary care. Respondents were asked to estimate to the nearest dollar the billing charge that a hypothetical self‐pay patient would receive for each care item. Direct data collection was arranged through the groups' medical directors and occurred in the hospitalist groups' regular business meetings. The design gathered no data on individual characteristics of respondents such as domestic or international education, sex, age, or time in practice, nor from which practice‐group a given respondent originated, to affirm to participants that their responses could not be used to imply performance measures or quality profiles.

Findings

Hospitalists tended to rank the expense of items in essentially the correct order, as reflected by the rough trend of rising estimates compared to true‐charges (Figure 1). Of note, we did not ask hospitalists to discern the different charges of 2 appropriate competing clinical choices, but asked for estimated prices of diverse services. The range of respondents' estimates about each item was broad. The mean‐value of hospitalists' estimates for each care item was less revealing than the range and diversity of estimates about each care item. Accuracy of hospitalists' estimates of charges was poor. Only 10.8% of hospitalists' estimates were within 10% of the actual unadjusted charge, 17.8% within 20% of that charge, and 24.8% were within a 30% margin of accuracy. Summary results are presented (Table 1). Pearson's r correlation value between the unadjusted charges and the estimates made by hospitalists was 0.548, a coefficient of determination equal to 0.300. Thus, the true charges list we obtained had only a low‐grade association with hospitalists' estimates (Figure 1). Hospitalists' estimates about the charges of relatively‐expensive items (abdominal computed tomography [CT]) overlapped with their estimates about the least‐expensive items (such as a urine culture ). Inter‐hospitalist agreement about charges associated with each care item was also low; estimates for each care item charge varied over logarithmic orders of magnitude.

Figure 1

Discussion

To date, hospitalist programs have shown little impact upon care costs when compared with other inpatient care staffing models. One limiting factor may be the opacity of medical care pricing. Patients have been demonstrated to have little access to knowledge of what care will cost them and complex barriers prevent them from gaining pricing information.11, 12 Hospitalists may be conjectured to serve as expert sources on the costs and values of medical care services on behalf of inpatients, but our observations suggest that hospitalists' actual knowledge of patient‐charges is lacking. The opacity of US medical prices to patients appears to extend to hospital‐care physicians as well. We observe that no widespread mechanism exists by which hospitalists would be well‐positioned to become informed about the actual charges their patients receive. Unadjusted chargemaster lists are generally restricted information, and would be difficult to access outside of participation in the charge‐notifications used in the existing studies cited above.

The inquiry was specifically limited to how closely hospitalists' estimates of the unadjusted charges for some commonly‐ordered items compare to the actual unadjusted chargemaster at their own institutions. We did not assess the hospitalists' perceptions about the accuracy of their estimates, nor the impact of specific hospitalist characteristics upon accuracy. Our sample's representation of the larger national population of hospital physicians is not established, but engenders no expectation that these clinicians' charge‐awareness is substantively different from that of hospitalists in most other institutions. It is not known what specific clinician or practice‐setting characteristics will direct charge‐awareness, or will influence the impact of charge‐awareness upon clinical practices.

The range of estimates different hospitalists made about the same care items in the same facilities was very broad, which argues that respondents did not estimate charges based upon a different knowledge base of which the investigators were unaware. This is important because our use of unadjusted charges to self‐pay patients as true prices is necessarily somewhat arbitrary. Chargemaster price may not reflect the institution's cost of performing the service, the different prices paid for a single service by different payer sources, nor reflect services' true value based upon outcomes. However, recognizing that these actual prices are somewhat artificial, the use of these prices suffices for the current inquiry, and does not negate our findings of hospitalists' low accuracy and low agreement. Also noteworthy, an unadjusted chargemaster can often represent the charges received by those uninsured US patients for whom payer‐source adjustment is inaccessible, and informs downstream accounting such as the value of unpaid care a hospital delivers annually.

The most immediate matter for examination among hospitalists is what effects increased charge‐awareness may exert upon clinical decisions and practice processes. It appears that the premise that hospitalists' exercise expert knowledge of costs is likely not valid; but it is unknown whether accurate charge‐awareness among hospitalists will improve cost‐reductions by hospitalists. In some payer‐arrangements, accurate charge‐awareness might engender reduced care quantity, rather than increased efficiency or quality. The impact of upgrading hospitalists' knowledge about the charges and costs they generate, and the most effective method to do so, is worthy of investigation; based upon this initial data we encourage and are undertaking a larger‐scale study and exploration of the effects of enhanced hospitalist charge‐awareness.

Conclusion

Hospitalists have low awareness of the charges associated with inpatient care. The opacity of hospital care pricing to patient populations extends also to hospitalist physicians. Hospitalists likely do not improve cost‐efficiency through expert knowledge of services' costs to patients. Education and reminder systems to apprise hospitalists of charges should be examined as possible tools to optimize the use of inpatient care resources.

Hospitalists have been suggested to offer rational and efficient medical care through specialized knowledge about inpatient care services.1 The goal that hospitalists will use care resources more efficiently presumes hospitalists' accurate knowledge about charges and costs.

Data regarding physicians' awareness of care charges and its impact upon care is limited. An international meta‐analysis of clinicians' awareness of pharmaceutical prices demonstrated poor accuracy of physicians' estimates of charges, but effects of increasing their knowledge remained unexamined.2 Continuous exposure to education and alerts about charges have been demonstrated to diminish physicians' unnecessary use of specific laboratory assays in a single teaching hospital, in a pediatric emergency department, and an outpatient primary care system; test use declined when physicians were alerted to test charges at the point‐of‐care without negative impact upon clinical outcomes; when the notices ceased, utilization climbed back towards baseline levels. Specific to inpatient care, a single‐center study evaluated the impact of price‐alerts upon laboratory and imaging use, but showed no effects.36

Applicability of these existing data for contemporary hospitalists are limited, and most data were collected before hospitalists developed as an organized focus of practice. A review of existing literature revealed no published data demonstrating hospitalists' higher expert awareness of charges generated by inpatient care. Published comparisons of the care expense generated by hospitalists' care versus that of general internists or academic teams have shown minimal and inconsistent effects.79 Those data showing reduced costs from hospitalists were associated with small length‐of‐stay reductions, rather than more expert resource utilization.7 We measured the accuracy and precision of hospitalist's estimates of charges associated with services commonly used in inpatient care.

Setting

Two community‐based private, academic‐affiliated hospitals operated by a not‐for‐profit health system in Washington State, comprising together 895 inpatient beds. The questionnaire instrument was approved by the governing Institutional Review Board (IRB).

Methods

A list of true charges for 14 services, procedures, tests, and physician charges commonly ordered by adult medicine hospitalists was acquired directly from the responsible departments of a multi‐hospital system operated by a single non‐profit entity using a unified chargemaster. Specifically, we acquired the charge that a hypothetical self‐paying patient would receive for each service, excluding any adjustments exercised by other payer sources. The list of charges was reported to the organization's financial officers for affirmation. Physician charges were standardized to geographically‐adjusted Medicare charges obtained directly from the American Medical Assocation's online Common Procedural Terminology tool.10 A cross‐section of hospitalists (n = 25) was surveyed from a private hospitalist group and an academically‐affiliated hospitalist service. Hospitalists included US and international medical graduates, new‐graduates from residency training and clinicians with a range of prior experiences in academic centers, government hospital systems, and private primary care. Respondents were asked to estimate to the nearest dollar the billing charge that a hypothetical self‐pay patient would receive for each care item. Direct data collection was arranged through the groups' medical directors and occurred in the hospitalist groups' regular business meetings. The design gathered no data on individual characteristics of respondents such as domestic or international education, sex, age, or time in practice, nor from which practice‐group a given respondent originated, to affirm to participants that their responses could not be used to imply performance measures or quality profiles.

Findings

Hospitalists tended to rank the expense of items in essentially the correct order, as reflected by the rough trend of rising estimates compared to true‐charges (Figure 1). Of note, we did not ask hospitalists to discern the different charges of 2 appropriate competing clinical choices, but asked for estimated prices of diverse services. The range of respondents' estimates about each item was broad. The mean‐value of hospitalists' estimates for each care item was less revealing than the range and diversity of estimates about each care item. Accuracy of hospitalists' estimates of charges was poor. Only 10.8% of hospitalists' estimates were within 10% of the actual unadjusted charge, 17.8% within 20% of that charge, and 24.8% were within a 30% margin of accuracy. Summary results are presented (Table 1). Pearson's r correlation value between the unadjusted charges and the estimates made by hospitalists was 0.548, a coefficient of determination equal to 0.300. Thus, the true charges list we obtained had only a low‐grade association with hospitalists' estimates (Figure 1). Hospitalists' estimates about the charges of relatively‐expensive items (abdominal computed tomography [CT]) overlapped with their estimates about the least‐expensive items (such as a urine culture ). Inter‐hospitalist agreement about charges associated with each care item was also low; estimates for each care item charge varied over logarithmic orders of magnitude.

Figure 1

Discussion

To date, hospitalist programs have shown little impact upon care costs when compared with other inpatient care staffing models. One limiting factor may be the opacity of medical care pricing. Patients have been demonstrated to have little access to knowledge of what care will cost them and complex barriers prevent them from gaining pricing information.11, 12 Hospitalists may be conjectured to serve as expert sources on the costs and values of medical care services on behalf of inpatients, but our observations suggest that hospitalists' actual knowledge of patient‐charges is lacking. The opacity of US medical prices to patients appears to extend to hospital‐care physicians as well. We observe that no widespread mechanism exists by which hospitalists would be well‐positioned to become informed about the actual charges their patients receive. Unadjusted chargemaster lists are generally restricted information, and would be difficult to access outside of participation in the charge‐notifications used in the existing studies cited above.

The inquiry was specifically limited to how closely hospitalists' estimates of the unadjusted charges for some commonly‐ordered items compare to the actual unadjusted chargemaster at their own institutions. We did not assess the hospitalists' perceptions about the accuracy of their estimates, nor the impact of specific hospitalist characteristics upon accuracy. Our sample's representation of the larger national population of hospital physicians is not established, but engenders no expectation that these clinicians' charge‐awareness is substantively different from that of hospitalists in most other institutions. It is not known what specific clinician or practice‐setting characteristics will direct charge‐awareness, or will influence the impact of charge‐awareness upon clinical practices.

The range of estimates different hospitalists made about the same care items in the same facilities was very broad, which argues that respondents did not estimate charges based upon a different knowledge base of which the investigators were unaware. This is important because our use of unadjusted charges to self‐pay patients as true prices is necessarily somewhat arbitrary. Chargemaster price may not reflect the institution's cost of performing the service, the different prices paid for a single service by different payer sources, nor reflect services' true value based upon outcomes. However, recognizing that these actual prices are somewhat artificial, the use of these prices suffices for the current inquiry, and does not negate our findings of hospitalists' low accuracy and low agreement. Also noteworthy, an unadjusted chargemaster can often represent the charges received by those uninsured US patients for whom payer‐source adjustment is inaccessible, and informs downstream accounting such as the value of unpaid care a hospital delivers annually.

The most immediate matter for examination among hospitalists is what effects increased charge‐awareness may exert upon clinical decisions and practice processes. It appears that the premise that hospitalists' exercise expert knowledge of costs is likely not valid; but it is unknown whether accurate charge‐awareness among hospitalists will improve cost‐reductions by hospitalists. In some payer‐arrangements, accurate charge‐awareness might engender reduced care quantity, rather than increased efficiency or quality. The impact of upgrading hospitalists' knowledge about the charges and costs they generate, and the most effective method to do so, is worthy of investigation; based upon this initial data we encourage and are undertaking a larger‐scale study and exploration of the effects of enhanced hospitalist charge‐awareness.

Conclusion

Hospitalists have low awareness of the charges associated with inpatient care. The opacity of hospital care pricing to patient populations extends also to hospitalist physicians. Hospitalists likely do not improve cost‐efficiency through expert knowledge of services' costs to patients. Education and reminder systems to apprise hospitalists of charges should be examined as possible tools to optimize the use of inpatient care resources.

The demand for physician talent is intensifying as the US healthcare system confronts an unprecedented confluence of demographic pressures. Not only will 78 million retiring baby‐boomers require significant healthcare resources, but tens of thousands of practicing physicians will themselves reach retirement age within the next decade.1 At the same time, factors like the large increase in the percentage of female physicians (who are more likely to work part time), the growth of nonpractice opportunities for MDs, and generational demands for greater worklife balance are creating a major supply‐demand mismatch within the physician workforce.2 In this demographic atmosphere, the ability to recruit and retain physician leaders confers tremendous value to healthcare enterprisesboth public and private. Recruiting and retaining strategies already weigh heavily in the most palpable shortage areas, like primary care, but the system faces widespread unmet demand for a variety of specialist and generalist practitioners.36

This article does not address the public policy implications of the upcoming physician shortage, recognition of which will lead to the largest increase in new medical school slots in decades.7 Rather, we set out to illustrate how successful nonmedical businesses are embracing a thoughtful, systematic approach to retaining talent, based on the philosophy that keeping and engaging valued employees is more efficient than recruiting and orienting replacements. We posit that the innovations used by progressive companies could apply to recruitment and retention challenges confronting medicine.

How Industry Approaches the Talent Vacuum: Talent Facilitation

Leaders outside of medicine have long acknowledged that changing demographics and a global economy are driving unprecedented employee turnover.8 In confronting a talent vacuum, forward‐thinking managers have prioritized retaining key talent (rather than hiring anew) in planning for the future.9, 10 Doing so begins with attempts to understand the relationship between workers and the workplace, with a particular emphasis on appreciating workers' priorities. Indeed, new executive positions with titles like Chief Learning Officer and Chief Experience Officer are appearing as companies realize a need for focused expertise beyond traditional human resource departments. These companies understand that offering higher salaries is not the only retention strategyand often not even the most effective one.

The Four Actions of Talent Facilitation

The talent facilitation process centers on four actions: attract, engage, develop, and retain. None of these actions can stand alone, and all should be present, to some degree, at all stages of a worker's tenure. To attract or engage an employee or practice partner is not a 1‐time hook, but a constant and dynamic process.

Importantly, the concepts addressed here are not specific to 1 type of corporate system, size, or management level. Although the early business focus had been on upper‐level and executive talent within large corporate settings, there is an increasing recognition that a dedicated talent strategy is useful wherever recruiting and retaining talented people is important (and where is it not?).

The ideas presented here may seem most applicable to leaders of large physician corporations, hospital‐owned physician groups, or large integrated healthcare systems (such as Kaiser) that employ physicians. However, we also believe that the ideas apply across‐the‐board in medicine, including entities such as small, private, physician‐owned groups. We argue that regardless of the exact practice structure, a limited pool of resources must be dedicated to the attraction and retention of talented partners or employees, or to the cost of replacing those people if they pursue other opportunities (or the cost of inefficient and disengaged physicians). While an integrated health system may have the resources and scale to hire a Chief Experience Officer, we do not anticipate that a 5‐partner private practice would. Rather, we point to examples to illustrate the talent facilitation paradigm as a tool to systematically frame the allocation of those resources. Undoubtedly, the specific shape of a thoughtful talent facilitation effort will vary when applied in a large urban academic medical center vs. an integrated healthcare system vs. a small physician private practice, but the basic principles remain the same.

Attract

Increasingly, companies approach talented prospects with dedicated marketing campaigns to convey the value of a work environment.11 Silicon Valley employee lounges with free massages and foosball tables are the iconic example of attraction, but the concept runs deeper. Today's workers seek access to state‐of‐the‐art ideas and technology and often want to be part of a larger vision. Many seek opportunities to integrate their own professional and personal aspirations into a particular job description.

Hospital executives have long recognized the importance of attracting physicians to their facility (after all, the physicians draw patients and thus generate revenue). The traditional approach has surrounded perks, from comfortable doctor's lounges to the latest in surgical technology. But, the stakes seem greater now than before, and successful talent facilitation strategies are going beyond the tried and true.

Clearly, physicians seek financially stable practice settings with historical success. But they may also seek evidence of a defined strategic plan focused on more than mere profitability. Physicians may gravitate to practice environments that endorse progressive movements like the No One Dies Alone campaign.12 Similarly, recognition of movements beyond healthcarea commitment to Leadership in Energy and Environmental Design (LEED) (Green Building Rating System; US Green Building Council [USGBC]; http://www.usgbc.org) designation,13 for examplemay help attract talented staff physicians or enhance a hospital system's ability to facilitate partnerships with desirable physician groups. Within small private practices, this may take the form of a collaborative dedication to physician wellness and burnout prevention, or in a shared commitment to some form of local or international service.

The current recruitment campaign of California's prison healthcare system offers an unlikely source of inspiration. The prison system was placed in receivership to address a shortage of competent physician staff and other inadequacies. A central feature of the campaign is an attractive starting salary and good benefits. But, the campaign does not rely on money alone. For example, the campaign's website (http://changingprisonhealthcare.org) promises that prison physicians will create the standard for correctional healthcare and join an historic effort to make a difference in people's lives (Figure 1). The campaign thus rebrands what might be seen as an unpalatable job into a legitimate and noble career option. Of course, the long‐term success of the campaign will rely on a genuine commitment to the campaign's ideals. But the point is this: if a prison system can deploy innovative attraction strategies, so can healthcare leaders at all levels.

Figure 1

Lessons From Industry

Doctors frequently assume that the challenges and obstacles confronted in healthcare are unique to medicine. But, for every phrase like When I started practice, I decided how long office visits were, not the insurance company, or Young doctors just don't want to work as hard, there is a parallel utterance in the greater business world. Luckily, there are now examples of the healthcare world learning lessons from business. For example, innovators in medical quality improvement found value in the experience of other industries.20 Airlines and automakers have long honed systems for error prevention and possess expertise that may curb errors in the hospital.2123

We suspect that the ideas and practice of talent facilitation have already made their way into some medical settings. A Google search reveals multiple opportunities for hospital‐based talent managers, and websites advertise the availability of talent consultants ready to lend their expertise to the medical world. In the arena of academic medicine, the University of California, San Francisco (UCSF) Division of Hospital Medicine put some of the ideas of talent facilitation into practice over the past year, in part in response to an increasingly competitive market for academic hospitalists.24 Leaders introduced a formal faculty development program that links junior faculty with mentors and facilitates early and frequent feedback across hierarchical boundaries.25 These more intentional mentoring efforts were accompanied by a seminar series aimed at the needs of new faculty members, a research incubator program, divisional grand rounds, and other web‐based and in‐person forums for sharing best practices and innovations. Less formal social events have also been promoted. Importantly, these sweeping strategies seek to encompass the needs of both teaching and nonteaching hospitalists within UCSF.26

Clearly, an academic hospitalist group with 45 faculty physicians has unique characteristics that inform the specifics of its talent facilitation strategy. The interventions discussed above are meant to represent examples of the types of strategies that may be utilized by physician groups once a decision is made to focus on talent management. Undoubtedly, the shape of such efforts will vary in diverse practice settings, but physician leaders have much to gain through further exploration of where these core principles already exist within medicine and where they may be more effectively deployed. By examining how multinational businesses are systematically applying the concepts of talent facilitation to address a global talent shortage, the doctoring profession might again take an outside hint to help inform its future.

The demand for physician talent is intensifying as the US healthcare system confronts an unprecedented confluence of demographic pressures. Not only will 78 million retiring baby‐boomers require significant healthcare resources, but tens of thousands of practicing physicians will themselves reach retirement age within the next decade.1 At the same time, factors like the large increase in the percentage of female physicians (who are more likely to work part time), the growth of nonpractice opportunities for MDs, and generational demands for greater worklife balance are creating a major supply‐demand mismatch within the physician workforce.2 In this demographic atmosphere, the ability to recruit and retain physician leaders confers tremendous value to healthcare enterprisesboth public and private. Recruiting and retaining strategies already weigh heavily in the most palpable shortage areas, like primary care, but the system faces widespread unmet demand for a variety of specialist and generalist practitioners.36

This article does not address the public policy implications of the upcoming physician shortage, recognition of which will lead to the largest increase in new medical school slots in decades.7 Rather, we set out to illustrate how successful nonmedical businesses are embracing a thoughtful, systematic approach to retaining talent, based on the philosophy that keeping and engaging valued employees is more efficient than recruiting and orienting replacements. We posit that the innovations used by progressive companies could apply to recruitment and retention challenges confronting medicine.

How Industry Approaches the Talent Vacuum: Talent Facilitation

Leaders outside of medicine have long acknowledged that changing demographics and a global economy are driving unprecedented employee turnover.8 In confronting a talent vacuum, forward‐thinking managers have prioritized retaining key talent (rather than hiring anew) in planning for the future.9, 10 Doing so begins with attempts to understand the relationship between workers and the workplace, with a particular emphasis on appreciating workers' priorities. Indeed, new executive positions with titles like Chief Learning Officer and Chief Experience Officer are appearing as companies realize a need for focused expertise beyond traditional human resource departments. These companies understand that offering higher salaries is not the only retention strategyand often not even the most effective one.

The Four Actions of Talent Facilitation

The talent facilitation process centers on four actions: attract, engage, develop, and retain. None of these actions can stand alone, and all should be present, to some degree, at all stages of a worker's tenure. To attract or engage an employee or practice partner is not a 1‐time hook, but a constant and dynamic process.

Importantly, the concepts addressed here are not specific to 1 type of corporate system, size, or management level. Although the early business focus had been on upper‐level and executive talent within large corporate settings, there is an increasing recognition that a dedicated talent strategy is useful wherever recruiting and retaining talented people is important (and where is it not?).

The ideas presented here may seem most applicable to leaders of large physician corporations, hospital‐owned physician groups, or large integrated healthcare systems (such as Kaiser) that employ physicians. However, we also believe that the ideas apply across‐the‐board in medicine, including entities such as small, private, physician‐owned groups. We argue that regardless of the exact practice structure, a limited pool of resources must be dedicated to the attraction and retention of talented partners or employees, or to the cost of replacing those people if they pursue other opportunities (or the cost of inefficient and disengaged physicians). While an integrated health system may have the resources and scale to hire a Chief Experience Officer, we do not anticipate that a 5‐partner private practice would. Rather, we point to examples to illustrate the talent facilitation paradigm as a tool to systematically frame the allocation of those resources. Undoubtedly, the specific shape of a thoughtful talent facilitation effort will vary when applied in a large urban academic medical center vs. an integrated healthcare system vs. a small physician private practice, but the basic principles remain the same.

Attract

Increasingly, companies approach talented prospects with dedicated marketing campaigns to convey the value of a work environment.11 Silicon Valley employee lounges with free massages and foosball tables are the iconic example of attraction, but the concept runs deeper. Today's workers seek access to state‐of‐the‐art ideas and technology and often want to be part of a larger vision. Many seek opportunities to integrate their own professional and personal aspirations into a particular job description.

Hospital executives have long recognized the importance of attracting physicians to their facility (after all, the physicians draw patients and thus generate revenue). The traditional approach has surrounded perks, from comfortable doctor's lounges to the latest in surgical technology. But, the stakes seem greater now than before, and successful talent facilitation strategies are going beyond the tried and true.

Clearly, physicians seek financially stable practice settings with historical success. But they may also seek evidence of a defined strategic plan focused on more than mere profitability. Physicians may gravitate to practice environments that endorse progressive movements like the No One Dies Alone campaign.12 Similarly, recognition of movements beyond healthcarea commitment to Leadership in Energy and Environmental Design (LEED) (Green Building Rating System; US Green Building Council [USGBC]; http://www.usgbc.org) designation,13 for examplemay help attract talented staff physicians or enhance a hospital system's ability to facilitate partnerships with desirable physician groups. Within small private practices, this may take the form of a collaborative dedication to physician wellness and burnout prevention, or in a shared commitment to some form of local or international service.

The current recruitment campaign of California's prison healthcare system offers an unlikely source of inspiration. The prison system was placed in receivership to address a shortage of competent physician staff and other inadequacies. A central feature of the campaign is an attractive starting salary and good benefits. But, the campaign does not rely on money alone. For example, the campaign's website (http://changingprisonhealthcare.org) promises that prison physicians will create the standard for correctional healthcare and join an historic effort to make a difference in people's lives (Figure 1). The campaign thus rebrands what might be seen as an unpalatable job into a legitimate and noble career option. Of course, the long‐term success of the campaign will rely on a genuine commitment to the campaign's ideals. But the point is this: if a prison system can deploy innovative attraction strategies, so can healthcare leaders at all levels.

Figure 1