A 48-year-old black man, on hemodialysis since August 2002, presented to his primary care provider (PCP) in July 2006 with excruciating leg pain. According to the patient, the leg pain had worsened during the previous six months and was so severe that he was barely able to walk without pain. He was a full-time night security guard and reported walking three to five miles each night.

The man was undergoing hemodialysis three times per week, necessitated by nephritic range proteinuria. He had a questionable history of diabetes but a known diagnosis of hypertension. Definitive diagnosis through kidney biopsy was not obtained because of the associated risk, the patient's obesity, and his aversion to the procedure. 

The patient had recently been hospitalized with shortness of breath and fluid overload. Intensive dialysis allowed a significant drop in his dialysis target weight. He was readmitted a few days later with chills, fever, cough, and shortness of breath. He was diagnosed with bilateral pulmonary emboli. The patient said his hypercoagulation work-up was negative, but he was started on warfarin before discharge.

On current presentation, he had swollen, tender legs and multiple excoriations over the calves, explained by the patient's admitted scratching. His skin was shiny and tight. He was still taking warfarin, with an international normalized ratio of 2.1. The patient denied shortness of breath, pruritus (any more than expected with renal disease), or increased fluid.

In addition to warfarin, he was taking esomeprazole 40 mg/d, extended-release metoprolol 25 mg bid, cinacalcet 90 mg/d, sevelamer 4,000 mg and lanthanum 5,000 mg before every meal, mometasone furoate as needed, hydroxyzine 25 mg every four hours as needed, miconazole powder applied to the feet as needed, and a daily prescription multivitamin complex.

Laboratory tests included normal findings (for a dialysis patient) on the complete blood count; blood urea nitrogen, 101 mg/dL (reference range, 7 to 20 mg/dL); serum creatinine, 16.6 mg/dL (0.8 to 1.4 mg/dL); Kt/V (a measure of adequacy of dialysis), 1.37 (acceptable); calcium, 9.6 mg/dL (8.2 to 10.2 mg/dL); serum phosphorus, 5.6 mg/dL (2.4 to 4.1 mg/dL); intact parathyroid hormone, 359 ng/L (10 to 65 ng/L).

The patient's PCP prescribed oxycodone for the pain and referred him to the vascular clinic for evaluation of his legs. A lower leg duplex scan with ankle/brachial indices performed on July 18 showed significant bilateral peripheral vascular disease. Subsequent magnetic resonance angiography (MRA) showed a questionable adrenal gland mass. Abdominal CT with and without contrast yielded negative results for the adrenal mass but showed a cyst in the right kidney. Although cysts are commonly found in dialysis patients, the vascular surgeon elected to evaluate the cyst with an MRI with gadolinium; the mass was found to be hemorrhagic.

Further vascular work-up continued, including MRI with gadolinium on September 26, 2006, which revealed two-vessel runoff in the right foot and three-vessel runoff in the left foot. According to the vascular consult, there was no area to bypass. The patient was sent back to his PCP. At this point, he was taking oxycodone four times per day and continuing to work full-time as a night security guard.

The patient was then sent to neurology for evaluation. By this time, the severity of his leg pain had increased 90%, with worsening swelling and persistent shininess (see figure). The neurologist was unable to obtain electromyograms due to the severity of the patient's pain and lower extremity swelling. No definitive diagnosis could be made.

About one year later, the man's attending nephrology group received copies of the work-up that the PCP sent to the dialysis center. It was apparent that neither the patient's PCP nor the vascular, radiology, or neurology consultants had seen the FDA warning released in June 2006¹ regarding the use of gadolinium in patients with renal disease. What had started out as a peripheral neuropathy (either renal or diabetic in etiology) was now a full-blown case of nephrogenic systemic fibrosis (NSF).

Open biopsy performed on October 29, 2007, confirmed the presence of gadolinium in the patient's epidermis. He became the first documented case of NSF in the Washington, DC area.

Discussion
In the late 1990s, several reports of an unknown sclerosing dermopathy in patients with chronic kidney disease began to emerge. In 2000, the new entity was named nephrogenic systemic fibrosis, with a disease course demonstrating systemic involvement that affected multiple organ systems and often resulted in severe joint limitations. A Web-based reporting system for this newly described disease, created by Shawn Cowper, MD, of Yale University,² made it possible to investigate associated epidemiologic factors.

Neither gender, race, nor age appeared relevant. However, all patients had renal disease—acute, chronic, or transient—and more than 90% of patients were dialysis dependent. Factors since recognized to confirm a diagnosis of NSF are severe renal impairment (ie, glomerular filtration rate [GFR] < 30 mL/min/1.73 m²),³ CD34+ dendritic cells found on deep biopsy,⁴ and the following clinical manifestations:

• Skin. Burning or itching, reddened or darkened patches; possible skin swelling, hardening, and/or tightening.

• Eyes. Yellow raised spots in the whites of the eyes.

• Bones, joints, muscles. Joint stiffness; limited range of motion in the arms, hands, legs, or feet; pain deep in the hip bone or ribs; and/or muscle weakness.³

Theories abounded on the cause of NSF. While the presence of renal disease is a requirement, dialysis did not seem to be.⁵ Ten percent of NSF cases are patients who have never been dialyzed, and thousands of dialysis patients never develop NSF. Neither was any temporal correlation to dialysis found: While some patients developed NSF soon after starting dialysis, many had been on dialysis for years before NSF occurred. No association was found between NSF and the type of dialysis (inpatient, outpatient, hemodialysis, or peritoneal dialysis), the filter, manufacturer, dialysate, technique, or dialysis unit.²

Authors of a retrospective study involving two large tissue repositories looked for cases of NSF before 1997, but none were found.⁶ If dialysis was not causing NSF, and the disease did not appear to have existed before 1997, what renal toxin had been introduced in the 1990s to explain it?

One early suspicion involved erythropoietin (EPO), used to treat anemia in patients with kidney disease. Skin changes had been reported in some patients after initiation of treatment with EPO, and the NSF patients received a significantly higher mean dose of EPO than controls received.⁷

Ninety percent of patients with NSF had fistula reconstruction or dialysis catheter placement, but these are common in renal disease patients.⁸ Forty-eight percent of patients had had liver or kidney transplants, and 12% had hypercoagulable states. Most patients with NSF had never received ACE inhibitors. Were the protective antifibrogenic properties of these agents missing?

Mystery Solved
In a triumph for the Internet and its capacity to disseminate information around the world, a breakthrough came in 2006 from a small town in Austria. Grobner⁹ described nine patients who had received gadodiamide (Omniscan™)–enhanced MRA, five of whom developed NSF. Upon release of this report, researchers reexamined the original cases and detected a clear correlation between gadolinium and NSF. Because the contrast dose given for MRA can be as much as three times that required for routine MRI, the absence of NSF cases before 1997 suddenly made sense.

In May 2006, researchers for the Danish Medicines Agency reported 13 cases of NSF in patients injected with gadodiamide.¹⁰ Within months, 28 biopsy-proven cases were reported in St. Louis, six in Texas, and 13 at the University of Wisconsin—all involving patients exposed to gadolinium.^11-13 It was apparent that NSF was iatrogenic and could be controlled.

What We Have Learned Since
In subsequent research, it has been found that more than 90% of reported cases of NSF occurred following exposure to gadodiamide—although gadodiamide accounts for only 15% of all gadolinium injections worldwide,¹⁴ and this number is decreasing as more cases are reported. The correlation between gadodiamide and NSF is so strong that its manufacturer, GE Healthcare, sent practitioners a letter in June 2006 warning of NSF as an adverse effect of gadolinium exposure.¹⁵ Two days later, the FDA issued an advisory on gadolinium-enhanced imaging procedures, recommending prompt hemodialysis after gadolinium exposure and reminding radiologists and nephrologists that gadolinium is not FDA approved for MRA.¹

Although the 44% incidence rate of NSF reported by Grobner⁹ has never been replicated, a retrospective review of all known NSF cases affirmed that more than 90% of patients had been exposed to gadolinium.¹⁴ Two 2007 reports published in the Journal of the American Academy of Dermatology demonstrated that gadolinium was detectable in the tissues of patients with NSF.^16,17

In Europe, in response to the May 2006 report from the Danish Medicines Agency,¹⁰ the European Society of Urogenital Radiology revised its guidelines with a directive that gadodiamide not be administered in any patients who had reduced kidney function or were undergoing dialysis.¹⁸ Shortly thereafter, the European Committee for Medicinal Products for Human Use issued a contraindication for gadodiamide use in patients with severe renal impairment and advised that these patients not be given gadolinium unless there was no other choice.¹⁹ A contraindication was also issued for gadodiamide use in patients with previous or anticipated liver transplantation.

The American College of Radiology guidelines published in 2007²⁰ stated that patients with any level of renal disease should not receive gadodiamide.

In March 2007, GE Healthcare published a paper on NSF, reiterating the safety of gadodiamide while acknowledging that 120 more cases had been reported to them ("usually associated with exposure at high doses").²¹ The FDA upholds an alert regarding use of all gadolinium-based contrast agents for patients with acute or chronic severe renal insufficiency,³ while stopping short of a ban on gadodiamide in such patients.

How Common Is NSF?
In a 2007 study conducted at the University of Wisconsin, Sadowski et al¹³ reported 13 cases of gadolinium-induced NSF, 11 involving patients with a GFR below 30 mL/min/1.73 m² but two with a GFR between 30 and 60 mL/min/1.73 m² (ie, with renal insufficiency, although the authors noted that renal insufficiency was acute in these two patients). The incidence of NSF was 4.6% among hospitalized patients with a GFR be-low 60 mL/min/1.73 m² who underwent gadolinium-enhanced MRI at the university hospital's radiology department. A reexamination of the charts of the patients with a GFR between 30 and 60 mL/min/1.73 m² revealed that these patients had levels below 30 mL/min/1.73 m² when their gadolinium exposure took place.

In an outpatient population–based calculation performed by Deo et al,²² a 2.4% chance of NSF was determined for each gadolinium exposure. Incidence of NSF was calculated at 4.3 cases per 1,000 patient-years in this population, making NSF as common as contrast-induced nephropathy. Nearly 5% of patients with NSF have an exceedingly rapid and fulminant disease course that may result in death. NSF, of itself, is not a cause of death but may contribute to death by restricting effective ventilation or by restricting mobility to the point of causing an accidental fall that may be further exacerbated by fractures and clotting complications. NSF survivors may experience disabling systemic symptoms. Full recovery occurs only in patients who recover renal function, either naturally or by kidney transplantation.⁴

Why Is NSF More Common With Gadodiamide?
As of June 2008, five gadolinium-based contrast agents were FDA approved for use with MRI (none with MRA)³: gadobenate (MultiHance^®), gadodiamide (Omniscan), gadopentetate (Magnevist^®), gadoteridol (ProHance^®), and gadoversetamide (Opti-MARK^®). More than 90% of NSF cases are associated with gadodiamide. Because this agent is the least stable thermodynamically, it may be more likely than the others to transmetallate.¹⁴ All gadolinium chelates are excreted by the kidney, and the decreased renal clearances associated with renal impairment may expose patients to prolonged gadolinium transmetallation, allowing the agent to accumulate in bone and other tissue.

Gadoterate (Dotarem^®), a cyclic gadolinium-based agent that is available in Europe but not the US, is considered more stable than other agents. It has been suggested that such agents may be safer choices for patients with decreased renal function.^14,19

Strategies to Prevent NSF
In the US and Europe, only a physician who has consulted with a radiologist can write an order for gadolinium use in a patient with a GFR below 30 mL/min/1.73 m².^18,20 European guidelines do not allow use of gadodiamide in such patients.

Although the actual population-based occurrence of NSF is low, the nature of the disease calls for an effort to limit vulnerable patients' exposure to gadolinium (see box). Outside of withholding imaging procedures, the only currently known strategies to reduce the incidence of NSF are to use a more stable, nonchelating gadolinium¹⁴ and to remove the gadolinium as soon as possible.^3,24

It has been recommended that patients with renal disease who are presently undergoing dialysis be dialyzed within two to three hours of gadolinium exposure, then again within 24 and 48 hours, provided it is clinically safe.^20,24 This has been shown to remove 99% of the gadolinium.²³

Since peritoneal dialysis clears gadolinium poorly, hemodialysis is recommended for peritoneal dialysis patients after gadolinium exposure, following the regimen outlined above.²⁰

No consensus has been reached regarding the patient with a GFR between 30 and 60 mL/min/1.73 m², nor for the patient with a lower GFR and no access for dialysis to be administered. Placement of a catheter for two days' dialysis incurs both surgical and renal risks for these patients.⁸

Patient Outcome
The only known cure for NSF is kidney transplantation, which is associated with a complete cure rate of 40%.^4,25 Nevertheless, while this manuscript was in preparation, the patient presented in this case study underwent kidney transplantation. On day 8 postsurgery, he was no longer taking oxycodone, his skin condition was clearing up, and he was feeling considerably better. His health care providers hope for further regression from his disease.

Conclusion
NSF is just one example of iatrogenic conditions that can occur in any hospital, office, or clinic. Health care providers cannot be too vigilant in keeping abreast of warnings from the FDA and other agencies. In this case, several clinicians overlooked a recent, urgent public health advisory, with significant consequences.

A 48-year-old black man, on hemodialysis since August 2002, presented to his primary care provider (PCP) in July 2006 with excruciating leg pain. According to the patient, the leg pain had worsened during the previous six months and was so severe that he was barely able to walk without pain. He was a full-time night security guard and reported walking three to five miles each night.

The man was undergoing hemodialysis three times per week, necessitated by nephritic range proteinuria. He had a questionable history of diabetes but a known diagnosis of hypertension. Definitive diagnosis through kidney biopsy was not obtained because of the associated risk, the patient's obesity, and his aversion to the procedure. 

The patient had recently been hospitalized with shortness of breath and fluid overload. Intensive dialysis allowed a significant drop in his dialysis target weight. He was readmitted a few days later with chills, fever, cough, and shortness of breath. He was diagnosed with bilateral pulmonary emboli. The patient said his hypercoagulation work-up was negative, but he was started on warfarin before discharge.

On current presentation, he had swollen, tender legs and multiple excoriations over the calves, explained by the patient's admitted scratching. His skin was shiny and tight. He was still taking warfarin, with an international normalized ratio of 2.1. The patient denied shortness of breath, pruritus (any more than expected with renal disease), or increased fluid.

In addition to warfarin, he was taking esomeprazole 40 mg/d, extended-release metoprolol 25 mg bid, cinacalcet 90 mg/d, sevelamer 4,000 mg and lanthanum 5,000 mg before every meal, mometasone furoate as needed, hydroxyzine 25 mg every four hours as needed, miconazole powder applied to the feet as needed, and a daily prescription multivitamin complex.

Laboratory tests included normal findings (for a dialysis patient) on the complete blood count; blood urea nitrogen, 101 mg/dL (reference range, 7 to 20 mg/dL); serum creatinine, 16.6 mg/dL (0.8 to 1.4 mg/dL); Kt/V (a measure of adequacy of dialysis), 1.37 (acceptable); calcium, 9.6 mg/dL (8.2 to 10.2 mg/dL); serum phosphorus, 5.6 mg/dL (2.4 to 4.1 mg/dL); intact parathyroid hormone, 359 ng/L (10 to 65 ng/L).

The patient's PCP prescribed oxycodone for the pain and referred him to the vascular clinic for evaluation of his legs. A lower leg duplex scan with ankle/brachial indices performed on July 18 showed significant bilateral peripheral vascular disease. Subsequent magnetic resonance angiography (MRA) showed a questionable adrenal gland mass. Abdominal CT with and without contrast yielded negative results for the adrenal mass but showed a cyst in the right kidney. Although cysts are commonly found in dialysis patients, the vascular surgeon elected to evaluate the cyst with an MRI with gadolinium; the mass was found to be hemorrhagic.

Further vascular work-up continued, including MRI with gadolinium on September 26, 2006, which revealed two-vessel runoff in the right foot and three-vessel runoff in the left foot. According to the vascular consult, there was no area to bypass. The patient was sent back to his PCP. At this point, he was taking oxycodone four times per day and continuing to work full-time as a night security guard.

The patient was then sent to neurology for evaluation. By this time, the severity of his leg pain had increased 90%, with worsening swelling and persistent shininess (see figure). The neurologist was unable to obtain electromyograms due to the severity of the patient's pain and lower extremity swelling. No definitive diagnosis could be made.

About one year later, the man's attending nephrology group received copies of the work-up that the PCP sent to the dialysis center. It was apparent that neither the patient's PCP nor the vascular, radiology, or neurology consultants had seen the FDA warning released in June 2006¹ regarding the use of gadolinium in patients with renal disease. What had started out as a peripheral neuropathy (either renal or diabetic in etiology) was now a full-blown case of nephrogenic systemic fibrosis (NSF).

Open biopsy performed on October 29, 2007, confirmed the presence of gadolinium in the patient's epidermis. He became the first documented case of NSF in the Washington, DC area.

Discussion
In the late 1990s, several reports of an unknown sclerosing dermopathy in patients with chronic kidney disease began to emerge. In 2000, the new entity was named nephrogenic systemic fibrosis, with a disease course demonstrating systemic involvement that affected multiple organ systems and often resulted in severe joint limitations. A Web-based reporting system for this newly described disease, created by Shawn Cowper, MD, of Yale University,² made it possible to investigate associated epidemiologic factors.

Neither gender, race, nor age appeared relevant. However, all patients had renal disease—acute, chronic, or transient—and more than 90% of patients were dialysis dependent. Factors since recognized to confirm a diagnosis of NSF are severe renal impairment (ie, glomerular filtration rate [GFR] < 30 mL/min/1.73 m²),³ CD34+ dendritic cells found on deep biopsy,⁴ and the following clinical manifestations:

• Skin. Burning or itching, reddened or darkened patches; possible skin swelling, hardening, and/or tightening.

• Eyes. Yellow raised spots in the whites of the eyes.

• Bones, joints, muscles. Joint stiffness; limited range of motion in the arms, hands, legs, or feet; pain deep in the hip bone or ribs; and/or muscle weakness.³

Theories abounded on the cause of NSF. While the presence of renal disease is a requirement, dialysis did not seem to be.⁵ Ten percent of NSF cases are patients who have never been dialyzed, and thousands of dialysis patients never develop NSF. Neither was any temporal correlation to dialysis found: While some patients developed NSF soon after starting dialysis, many had been on dialysis for years before NSF occurred. No association was found between NSF and the type of dialysis (inpatient, outpatient, hemodialysis, or peritoneal dialysis), the filter, manufacturer, dialysate, technique, or dialysis unit.²

Authors of a retrospective study involving two large tissue repositories looked for cases of NSF before 1997, but none were found.⁶ If dialysis was not causing NSF, and the disease did not appear to have existed before 1997, what renal toxin had been introduced in the 1990s to explain it?

One early suspicion involved erythropoietin (EPO), used to treat anemia in patients with kidney disease. Skin changes had been reported in some patients after initiation of treatment with EPO, and the NSF patients received a significantly higher mean dose of EPO than controls received.⁷

Ninety percent of patients with NSF had fistula reconstruction or dialysis catheter placement, but these are common in renal disease patients.⁸ Forty-eight percent of patients had had liver or kidney transplants, and 12% had hypercoagulable states. Most patients with NSF had never received ACE inhibitors. Were the protective antifibrogenic properties of these agents missing?

Mystery Solved
In a triumph for the Internet and its capacity to disseminate information around the world, a breakthrough came in 2006 from a small town in Austria. Grobner⁹ described nine patients who had received gadodiamide (Omniscan™)–enhanced MRA, five of whom developed NSF. Upon release of this report, researchers reexamined the original cases and detected a clear correlation between gadolinium and NSF. Because the contrast dose given for MRA can be as much as three times that required for routine MRI, the absence of NSF cases before 1997 suddenly made sense.

In May 2006, researchers for the Danish Medicines Agency reported 13 cases of NSF in patients injected with gadodiamide.¹⁰ Within months, 28 biopsy-proven cases were reported in St. Louis, six in Texas, and 13 at the University of Wisconsin—all involving patients exposed to gadolinium.^11-13 It was apparent that NSF was iatrogenic and could be controlled.

What We Have Learned Since
In subsequent research, it has been found that more than 90% of reported cases of NSF occurred following exposure to gadodiamide—although gadodiamide accounts for only 15% of all gadolinium injections worldwide,¹⁴ and this number is decreasing as more cases are reported. The correlation between gadodiamide and NSF is so strong that its manufacturer, GE Healthcare, sent practitioners a letter in June 2006 warning of NSF as an adverse effect of gadolinium exposure.¹⁵ Two days later, the FDA issued an advisory on gadolinium-enhanced imaging procedures, recommending prompt hemodialysis after gadolinium exposure and reminding radiologists and nephrologists that gadolinium is not FDA approved for MRA.¹

Although the 44% incidence rate of NSF reported by Grobner⁹ has never been replicated, a retrospective review of all known NSF cases affirmed that more than 90% of patients had been exposed to gadolinium.¹⁴ Two 2007 reports published in the Journal of the American Academy of Dermatology demonstrated that gadolinium was detectable in the tissues of patients with NSF.^16,17

In Europe, in response to the May 2006 report from the Danish Medicines Agency,¹⁰ the European Society of Urogenital Radiology revised its guidelines with a directive that gadodiamide not be administered in any patients who had reduced kidney function or were undergoing dialysis.¹⁸ Shortly thereafter, the European Committee for Medicinal Products for Human Use issued a contraindication for gadodiamide use in patients with severe renal impairment and advised that these patients not be given gadolinium unless there was no other choice.¹⁹ A contraindication was also issued for gadodiamide use in patients with previous or anticipated liver transplantation.

The American College of Radiology guidelines published in 2007²⁰ stated that patients with any level of renal disease should not receive gadodiamide.

In March 2007, GE Healthcare published a paper on NSF, reiterating the safety of gadodiamide while acknowledging that 120 more cases had been reported to them ("usually associated with exposure at high doses").²¹ The FDA upholds an alert regarding use of all gadolinium-based contrast agents for patients with acute or chronic severe renal insufficiency,³ while stopping short of a ban on gadodiamide in such patients.

How Common Is NSF?
In a 2007 study conducted at the University of Wisconsin, Sadowski et al¹³ reported 13 cases of gadolinium-induced NSF, 11 involving patients with a GFR below 30 mL/min/1.73 m² but two with a GFR between 30 and 60 mL/min/1.73 m² (ie, with renal insufficiency, although the authors noted that renal insufficiency was acute in these two patients). The incidence of NSF was 4.6% among hospitalized patients with a GFR be-low 60 mL/min/1.73 m² who underwent gadolinium-enhanced MRI at the university hospital's radiology department. A reexamination of the charts of the patients with a GFR between 30 and 60 mL/min/1.73 m² revealed that these patients had levels below 30 mL/min/1.73 m² when their gadolinium exposure took place.

In an outpatient population–based calculation performed by Deo et al,²² a 2.4% chance of NSF was determined for each gadolinium exposure. Incidence of NSF was calculated at 4.3 cases per 1,000 patient-years in this population, making NSF as common as contrast-induced nephropathy. Nearly 5% of patients with NSF have an exceedingly rapid and fulminant disease course that may result in death. NSF, of itself, is not a cause of death but may contribute to death by restricting effective ventilation or by restricting mobility to the point of causing an accidental fall that may be further exacerbated by fractures and clotting complications. NSF survivors may experience disabling systemic symptoms. Full recovery occurs only in patients who recover renal function, either naturally or by kidney transplantation.⁴

Why Is NSF More Common With Gadodiamide?
As of June 2008, five gadolinium-based contrast agents were FDA approved for use with MRI (none with MRA)³: gadobenate (MultiHance^®), gadodiamide (Omniscan), gadopentetate (Magnevist^®), gadoteridol (ProHance^®), and gadoversetamide (Opti-MARK^®). More than 90% of NSF cases are associated with gadodiamide. Because this agent is the least stable thermodynamically, it may be more likely than the others to transmetallate.¹⁴ All gadolinium chelates are excreted by the kidney, and the decreased renal clearances associated with renal impairment may expose patients to prolonged gadolinium transmetallation, allowing the agent to accumulate in bone and other tissue.

Gadoterate (Dotarem^®), a cyclic gadolinium-based agent that is available in Europe but not the US, is considered more stable than other agents. It has been suggested that such agents may be safer choices for patients with decreased renal function.^14,19

Strategies to Prevent NSF
In the US and Europe, only a physician who has consulted with a radiologist can write an order for gadolinium use in a patient with a GFR below 30 mL/min/1.73 m².^18,20 European guidelines do not allow use of gadodiamide in such patients.

Although the actual population-based occurrence of NSF is low, the nature of the disease calls for an effort to limit vulnerable patients' exposure to gadolinium (see box). Outside of withholding imaging procedures, the only currently known strategies to reduce the incidence of NSF are to use a more stable, nonchelating gadolinium¹⁴ and to remove the gadolinium as soon as possible.^3,24

It has been recommended that patients with renal disease who are presently undergoing dialysis be dialyzed within two to three hours of gadolinium exposure, then again within 24 and 48 hours, provided it is clinically safe.^20,24 This has been shown to remove 99% of the gadolinium.²³

Since peritoneal dialysis clears gadolinium poorly, hemodialysis is recommended for peritoneal dialysis patients after gadolinium exposure, following the regimen outlined above.²⁰

No consensus has been reached regarding the patient with a GFR between 30 and 60 mL/min/1.73 m², nor for the patient with a lower GFR and no access for dialysis to be administered. Placement of a catheter for two days' dialysis incurs both surgical and renal risks for these patients.⁸

Patient Outcome
The only known cure for NSF is kidney transplantation, which is associated with a complete cure rate of 40%.^4,25 Nevertheless, while this manuscript was in preparation, the patient presented in this case study underwent kidney transplantation. On day 8 postsurgery, he was no longer taking oxycodone, his skin condition was clearing up, and he was feeling considerably better. His health care providers hope for further regression from his disease.

Conclusion
NSF is just one example of iatrogenic conditions that can occur in any hospital, office, or clinic. Health care providers cannot be too vigilant in keeping abreast of warnings from the FDA and other agencies. In this case, several clinicians overlooked a recent, urgent public health advisory, with significant consequences.

A 48-year-old black man, on hemodialysis since August 2002, presented to his primary care provider (PCP) in July 2006 with excruciating leg pain. According to the patient, the leg pain had worsened during the previous six months and was so severe that he was barely able to walk without pain. He was a full-time night security guard and reported walking three to five miles each night.

The man was undergoing hemodialysis three times per week, necessitated by nephritic range proteinuria. He had a questionable history of diabetes but a known diagnosis of hypertension. Definitive diagnosis through kidney biopsy was not obtained because of the associated risk, the patient's obesity, and his aversion to the procedure. 

The patient had recently been hospitalized with shortness of breath and fluid overload. Intensive dialysis allowed a significant drop in his dialysis target weight. He was readmitted a few days later with chills, fever, cough, and shortness of breath. He was diagnosed with bilateral pulmonary emboli. The patient said his hypercoagulation work-up was negative, but he was started on warfarin before discharge.

On current presentation, he had swollen, tender legs and multiple excoriations over the calves, explained by the patient's admitted scratching. His skin was shiny and tight. He was still taking warfarin, with an international normalized ratio of 2.1. The patient denied shortness of breath, pruritus (any more than expected with renal disease), or increased fluid.

In addition to warfarin, he was taking esomeprazole 40 mg/d, extended-release metoprolol 25 mg bid, cinacalcet 90 mg/d, sevelamer 4,000 mg and lanthanum 5,000 mg before every meal, mometasone furoate as needed, hydroxyzine 25 mg every four hours as needed, miconazole powder applied to the feet as needed, and a daily prescription multivitamin complex.

Laboratory tests included normal findings (for a dialysis patient) on the complete blood count; blood urea nitrogen, 101 mg/dL (reference range, 7 to 20 mg/dL); serum creatinine, 16.6 mg/dL (0.8 to 1.4 mg/dL); Kt/V (a measure of adequacy of dialysis), 1.37 (acceptable); calcium, 9.6 mg/dL (8.2 to 10.2 mg/dL); serum phosphorus, 5.6 mg/dL (2.4 to 4.1 mg/dL); intact parathyroid hormone, 359 ng/L (10 to 65 ng/L).

The patient's PCP prescribed oxycodone for the pain and referred him to the vascular clinic for evaluation of his legs. A lower leg duplex scan with ankle/brachial indices performed on July 18 showed significant bilateral peripheral vascular disease. Subsequent magnetic resonance angiography (MRA) showed a questionable adrenal gland mass. Abdominal CT with and without contrast yielded negative results for the adrenal mass but showed a cyst in the right kidney. Although cysts are commonly found in dialysis patients, the vascular surgeon elected to evaluate the cyst with an MRI with gadolinium; the mass was found to be hemorrhagic.

Further vascular work-up continued, including MRI with gadolinium on September 26, 2006, which revealed two-vessel runoff in the right foot and three-vessel runoff in the left foot. According to the vascular consult, there was no area to bypass. The patient was sent back to his PCP. At this point, he was taking oxycodone four times per day and continuing to work full-time as a night security guard.

The patient was then sent to neurology for evaluation. By this time, the severity of his leg pain had increased 90%, with worsening swelling and persistent shininess (see figure). The neurologist was unable to obtain electromyograms due to the severity of the patient's pain and lower extremity swelling. No definitive diagnosis could be made.

About one year later, the man's attending nephrology group received copies of the work-up that the PCP sent to the dialysis center. It was apparent that neither the patient's PCP nor the vascular, radiology, or neurology consultants had seen the FDA warning released in June 2006¹ regarding the use of gadolinium in patients with renal disease. What had started out as a peripheral neuropathy (either renal or diabetic in etiology) was now a full-blown case of nephrogenic systemic fibrosis (NSF).

Open biopsy performed on October 29, 2007, confirmed the presence of gadolinium in the patient's epidermis. He became the first documented case of NSF in the Washington, DC area.

Discussion
In the late 1990s, several reports of an unknown sclerosing dermopathy in patients with chronic kidney disease began to emerge. In 2000, the new entity was named nephrogenic systemic fibrosis, with a disease course demonstrating systemic involvement that affected multiple organ systems and often resulted in severe joint limitations. A Web-based reporting system for this newly described disease, created by Shawn Cowper, MD, of Yale University,² made it possible to investigate associated epidemiologic factors.

Neither gender, race, nor age appeared relevant. However, all patients had renal disease—acute, chronic, or transient—and more than 90% of patients were dialysis dependent. Factors since recognized to confirm a diagnosis of NSF are severe renal impairment (ie, glomerular filtration rate [GFR] < 30 mL/min/1.73 m²),³ CD34+ dendritic cells found on deep biopsy,⁴ and the following clinical manifestations:

• Skin. Burning or itching, reddened or darkened patches; possible skin swelling, hardening, and/or tightening.

• Eyes. Yellow raised spots in the whites of the eyes.

• Bones, joints, muscles. Joint stiffness; limited range of motion in the arms, hands, legs, or feet; pain deep in the hip bone or ribs; and/or muscle weakness.³

Theories abounded on the cause of NSF. While the presence of renal disease is a requirement, dialysis did not seem to be.⁵ Ten percent of NSF cases are patients who have never been dialyzed, and thousands of dialysis patients never develop NSF. Neither was any temporal correlation to dialysis found: While some patients developed NSF soon after starting dialysis, many had been on dialysis for years before NSF occurred. No association was found between NSF and the type of dialysis (inpatient, outpatient, hemodialysis, or peritoneal dialysis), the filter, manufacturer, dialysate, technique, or dialysis unit.²

Authors of a retrospective study involving two large tissue repositories looked for cases of NSF before 1997, but none were found.⁶ If dialysis was not causing NSF, and the disease did not appear to have existed before 1997, what renal toxin had been introduced in the 1990s to explain it?

One early suspicion involved erythropoietin (EPO), used to treat anemia in patients with kidney disease. Skin changes had been reported in some patients after initiation of treatment with EPO, and the NSF patients received a significantly higher mean dose of EPO than controls received.⁷

Ninety percent of patients with NSF had fistula reconstruction or dialysis catheter placement, but these are common in renal disease patients.⁸ Forty-eight percent of patients had had liver or kidney transplants, and 12% had hypercoagulable states. Most patients with NSF had never received ACE inhibitors. Were the protective antifibrogenic properties of these agents missing?

Mystery Solved
In a triumph for the Internet and its capacity to disseminate information around the world, a breakthrough came in 2006 from a small town in Austria. Grobner⁹ described nine patients who had received gadodiamide (Omniscan™)–enhanced MRA, five of whom developed NSF. Upon release of this report, researchers reexamined the original cases and detected a clear correlation between gadolinium and NSF. Because the contrast dose given for MRA can be as much as three times that required for routine MRI, the absence of NSF cases before 1997 suddenly made sense.

In May 2006, researchers for the Danish Medicines Agency reported 13 cases of NSF in patients injected with gadodiamide.¹⁰ Within months, 28 biopsy-proven cases were reported in St. Louis, six in Texas, and 13 at the University of Wisconsin—all involving patients exposed to gadolinium.^11-13 It was apparent that NSF was iatrogenic and could be controlled.

What We Have Learned Since
In subsequent research, it has been found that more than 90% of reported cases of NSF occurred following exposure to gadodiamide—although gadodiamide accounts for only 15% of all gadolinium injections worldwide,¹⁴ and this number is decreasing as more cases are reported. The correlation between gadodiamide and NSF is so strong that its manufacturer, GE Healthcare, sent practitioners a letter in June 2006 warning of NSF as an adverse effect of gadolinium exposure.¹⁵ Two days later, the FDA issued an advisory on gadolinium-enhanced imaging procedures, recommending prompt hemodialysis after gadolinium exposure and reminding radiologists and nephrologists that gadolinium is not FDA approved for MRA.¹

Although the 44% incidence rate of NSF reported by Grobner⁹ has never been replicated, a retrospective review of all known NSF cases affirmed that more than 90% of patients had been exposed to gadolinium.¹⁴ Two 2007 reports published in the Journal of the American Academy of Dermatology demonstrated that gadolinium was detectable in the tissues of patients with NSF.^16,17

In Europe, in response to the May 2006 report from the Danish Medicines Agency,¹⁰ the European Society of Urogenital Radiology revised its guidelines with a directive that gadodiamide not be administered in any patients who had reduced kidney function or were undergoing dialysis.¹⁸ Shortly thereafter, the European Committee for Medicinal Products for Human Use issued a contraindication for gadodiamide use in patients with severe renal impairment and advised that these patients not be given gadolinium unless there was no other choice.¹⁹ A contraindication was also issued for gadodiamide use in patients with previous or anticipated liver transplantation.

The American College of Radiology guidelines published in 2007²⁰ stated that patients with any level of renal disease should not receive gadodiamide.

In March 2007, GE Healthcare published a paper on NSF, reiterating the safety of gadodiamide while acknowledging that 120 more cases had been reported to them ("usually associated with exposure at high doses").²¹ The FDA upholds an alert regarding use of all gadolinium-based contrast agents for patients with acute or chronic severe renal insufficiency,³ while stopping short of a ban on gadodiamide in such patients.

How Common Is NSF?
In a 2007 study conducted at the University of Wisconsin, Sadowski et al¹³ reported 13 cases of gadolinium-induced NSF, 11 involving patients with a GFR below 30 mL/min/1.73 m² but two with a GFR between 30 and 60 mL/min/1.73 m² (ie, with renal insufficiency, although the authors noted that renal insufficiency was acute in these two patients). The incidence of NSF was 4.6% among hospitalized patients with a GFR be-low 60 mL/min/1.73 m² who underwent gadolinium-enhanced MRI at the university hospital's radiology department. A reexamination of the charts of the patients with a GFR between 30 and 60 mL/min/1.73 m² revealed that these patients had levels below 30 mL/min/1.73 m² when their gadolinium exposure took place.

In an outpatient population–based calculation performed by Deo et al,²² a 2.4% chance of NSF was determined for each gadolinium exposure. Incidence of NSF was calculated at 4.3 cases per 1,000 patient-years in this population, making NSF as common as contrast-induced nephropathy. Nearly 5% of patients with NSF have an exceedingly rapid and fulminant disease course that may result in death. NSF, of itself, is not a cause of death but may contribute to death by restricting effective ventilation or by restricting mobility to the point of causing an accidental fall that may be further exacerbated by fractures and clotting complications. NSF survivors may experience disabling systemic symptoms. Full recovery occurs only in patients who recover renal function, either naturally or by kidney transplantation.⁴

Why Is NSF More Common With Gadodiamide?
As of June 2008, five gadolinium-based contrast agents were FDA approved for use with MRI (none with MRA)³: gadobenate (MultiHance^®), gadodiamide (Omniscan), gadopentetate (Magnevist^®), gadoteridol (ProHance^®), and gadoversetamide (Opti-MARK^®). More than 90% of NSF cases are associated with gadodiamide. Because this agent is the least stable thermodynamically, it may be more likely than the others to transmetallate.¹⁴ All gadolinium chelates are excreted by the kidney, and the decreased renal clearances associated with renal impairment may expose patients to prolonged gadolinium transmetallation, allowing the agent to accumulate in bone and other tissue.

Gadoterate (Dotarem^®), a cyclic gadolinium-based agent that is available in Europe but not the US, is considered more stable than other agents. It has been suggested that such agents may be safer choices for patients with decreased renal function.^14,19

Strategies to Prevent NSF
In the US and Europe, only a physician who has consulted with a radiologist can write an order for gadolinium use in a patient with a GFR below 30 mL/min/1.73 m².^18,20 European guidelines do not allow use of gadodiamide in such patients.

Although the actual population-based occurrence of NSF is low, the nature of the disease calls for an effort to limit vulnerable patients' exposure to gadolinium (see box). Outside of withholding imaging procedures, the only currently known strategies to reduce the incidence of NSF are to use a more stable, nonchelating gadolinium¹⁴ and to remove the gadolinium as soon as possible.^3,24

It has been recommended that patients with renal disease who are presently undergoing dialysis be dialyzed within two to three hours of gadolinium exposure, then again within 24 and 48 hours, provided it is clinically safe.^20,24 This has been shown to remove 99% of the gadolinium.²³

Since peritoneal dialysis clears gadolinium poorly, hemodialysis is recommended for peritoneal dialysis patients after gadolinium exposure, following the regimen outlined above.²⁰

No consensus has been reached regarding the patient with a GFR between 30 and 60 mL/min/1.73 m², nor for the patient with a lower GFR and no access for dialysis to be administered. Placement of a catheter for two days' dialysis incurs both surgical and renal risks for these patients.⁸

Patient Outcome
The only known cure for NSF is kidney transplantation, which is associated with a complete cure rate of 40%.^4,25 Nevertheless, while this manuscript was in preparation, the patient presented in this case study underwent kidney transplantation. On day 8 postsurgery, he was no longer taking oxycodone, his skin condition was clearing up, and he was feeling considerably better. His health care providers hope for further regression from his disease.

Conclusion
NSF is just one example of iatrogenic conditions that can occur in any hospital, office, or clinic. Health care providers cannot be too vigilant in keeping abreast of warnings from the FDA and other agencies. In this case, several clinicians overlooked a recent, urgent public health advisory, with significant consequences.

Did the medication cause a young girl's mood disorder?

THE PATIENT. A young girl was prescribed paroxetine after complaining of stomachaches and headaches.

CASE FACTS. The patient saw many healthcare providers and received several different medications until a psychiatrist diagnosed the girl with bipolar disorder with psychotic features, prescribed numerous medications, and hospitalized the patient. The girl was released then readmitted to another hospital, where a different psychiatrist tapered several medications and left her on low doses of clonazepam and topiramate. The patient improved and returned home. Later she stopped taking her medications, became psychotic, and was rehospitalized. The patient was then tapered off all medications and her condition returned to normal.

THE PATIENT’S CLAIM. She was not bipolar and had a substance-induced mood disorder caused by the medications she had been prescribed.

THE PSYCHIATRISTS’ DEFENSE. The patient was bipolar.

Submit your verdict and find out how the court ruled. To offer additional feedback, use the ‘Enter comments’ field above.

Did the medication cause a young girl's mood disorder?

THE PATIENT. A young girl was prescribed paroxetine after complaining of stomachaches and headaches.

CASE FACTS. The patient saw many healthcare providers and received several different medications until a psychiatrist diagnosed the girl with bipolar disorder with psychotic features, prescribed numerous medications, and hospitalized the patient. The girl was released then readmitted to another hospital, where a different psychiatrist tapered several medications and left her on low doses of clonazepam and topiramate. The patient improved and returned home. Later she stopped taking her medications, became psychotic, and was rehospitalized. The patient was then tapered off all medications and her condition returned to normal.

THE PATIENT’S CLAIM. She was not bipolar and had a substance-induced mood disorder caused by the medications she had been prescribed.

THE PSYCHIATRISTS’ DEFENSE. The patient was bipolar.

Submit your verdict and find out how the court ruled. To offer additional feedback, use the ‘Enter comments’ field above.

Did the medication cause a young girl's mood disorder?

THE PATIENT. A young girl was prescribed paroxetine after complaining of stomachaches and headaches.

CASE FACTS. The patient saw many healthcare providers and received several different medications until a psychiatrist diagnosed the girl with bipolar disorder with psychotic features, prescribed numerous medications, and hospitalized the patient. The girl was released then readmitted to another hospital, where a different psychiatrist tapered several medications and left her on low doses of clonazepam and topiramate. The patient improved and returned home. Later she stopped taking her medications, became psychotic, and was rehospitalized. The patient was then tapered off all medications and her condition returned to normal.

THE PATIENT’S CLAIM. She was not bipolar and had a substance-induced mood disorder caused by the medications she had been prescribed.

THE PSYCHIATRISTS’ DEFENSE. The patient was bipolar.

Submit your verdict and find out how the court ruled. To offer additional feedback, use the ‘Enter comments’ field above.

MARCH 2008

Coffee and conception—what’s your counsel?

A woman drinks 4 cups of caffeinated coffee daily but reports no other source of caffeine, which means that she consumes about 500 mg of caffeine a day. She tells you that she’s concerned about the impact of caffeine on a future pregnancy.

What would you say to this patient about her consumption of caffeine when she begins to try to conceive and, later, while she is pregnant?

APRIL 2008

Failed weight loss: Take the next step

Your patient is a 27-year-old woman who has a body mass index of 41 and polycystic ovary syndrome. Her medications are an estrogen–progestin oral contraceptive and metformin, 1,500 mg/day.

She has tried to lose weight many times, without lasting success. She has consulted with nutritionists, personal trainers, and endocrinologists. The next step is yours:

MARCH 2008

Coffee and conception—what’s your counsel?

A woman drinks 4 cups of caffeinated coffee daily but reports no other source of caffeine, which means that she consumes about 500 mg of caffeine a day. She tells you that she’s concerned about the impact of caffeine on a future pregnancy.

What would you say to this patient about her consumption of caffeine when she begins to try to conceive and, later, while she is pregnant?

APRIL 2008

Failed weight loss: Take the next step

Your patient is a 27-year-old woman who has a body mass index of 41 and polycystic ovary syndrome. Her medications are an estrogen–progestin oral contraceptive and metformin, 1,500 mg/day.

She has tried to lose weight many times, without lasting success. She has consulted with nutritionists, personal trainers, and endocrinologists. The next step is yours:

MARCH 2008

Coffee and conception—what’s your counsel?

A woman drinks 4 cups of caffeinated coffee daily but reports no other source of caffeine, which means that she consumes about 500 mg of caffeine a day. She tells you that she’s concerned about the impact of caffeine on a future pregnancy.

What would you say to this patient about her consumption of caffeine when she begins to try to conceive and, later, while she is pregnant?

APRIL 2008

Failed weight loss: Take the next step

Your patient is a 27-year-old woman who has a body mass index of 41 and polycystic ovary syndrome. Her medications are an estrogen–progestin oral contraceptive and metformin, 1,500 mg/day.

She has tried to lose weight many times, without lasting success. She has consulted with nutritionists, personal trainers, and endocrinologists. The next step is yours:

Could a patient’s violent act have been prevented?

A man under outpatient care of the state’s regional behavioral health authority was diagnosed with schizophrenia, paranoid type. He killed his developmentally disabled niece, age 26. The niece’s family claimed the death could have been prevented if the man was civilly committed or heavily medicated. Was the behavioral health authority liable?

⋥ LIABLE: 11% ⋥ NOT LIABLE: 89%

What did the court decide?

The mother was found to be 39% at fault, the patient 11% at fault, and the behavioral health authority 50% at fault for the woman’s death and paid half of the verdict amount to the parents. A $101,740 verdict was returned for the niece’s mother and a $100,625 verdict was returned for the father.

Could a patient’s violent act have been prevented?

A man under outpatient care of the state’s regional behavioral health authority was diagnosed with schizophrenia, paranoid type. He killed his developmentally disabled niece, age 26. The niece’s family claimed the death could have been prevented if the man was civilly committed or heavily medicated. Was the behavioral health authority liable?

⋥ LIABLE: 11% ⋥ NOT LIABLE: 89%

What did the court decide?

The mother was found to be 39% at fault, the patient 11% at fault, and the behavioral health authority 50% at fault for the woman’s death and paid half of the verdict amount to the parents. A $101,740 verdict was returned for the niece’s mother and a $100,625 verdict was returned for the father.

Could a patient’s violent act have been prevented?

A man under outpatient care of the state’s regional behavioral health authority was diagnosed with schizophrenia, paranoid type. He killed his developmentally disabled niece, age 26. The niece’s family claimed the death could have been prevented if the man was civilly committed or heavily medicated. Was the behavioral health authority liable?

⋥ LIABLE: 11% ⋥ NOT LIABLE: 89%

What did the court decide?

The mother was found to be 39% at fault, the patient 11% at fault, and the behavioral health authority 50% at fault for the woman’s death and paid half of the verdict amount to the parents. A $101,740 verdict was returned for the niece’s mother and a $100,625 verdict was returned for the father.

Dear Dr. Mossman:

I treat children and adolescents in an acute inpatient setting. Sometimes a child of divorced parents—call him “Johnny”—is admitted to the hospital by one parent—for example the mother—but she doesn’t inform the father. Although the parents have joint custody, Mom doesn’t want me to contact Dad.

I tell Mom that I’d like to get clinical information and consent from Dad, but she refuses, saying, “This will make me look bad, and my ex-husband will try to take emergency custody of Johnny.” My hospital’s legal department says consent from both parents isn’t needed.

These scenarios always leave me feeling upset and confused. I’d appreciate clarification on how to handle these matters.—Submitted by “Dr. K”

Knowing the correct legal answer to a question often doesn’t supply the best clinical solution for your patient. Dr. K received a legally sound response from hospital administrators: a parent who has legal custody may authorize medical treatment for a minor child without first asking or informing the other parent. But Dr. K feels unsatisfied because the hospital didn’t provide what Dr. K sought: a clinically sound answer.

This article reviews custody arrangements and the legal rights they give divorced parents. Also, we will discuss the mother’s concerns and explain why—despite her fears—notifying and involving Johnny’s father can be important, even when it’s not legally required.

Custody and urgent treatment

A minor—defined in most states as a person younger than age 18—legally cannot give consent for medical care except in limited circumstances, such as contraceptive care.^1,2 When a minor undergoes psychiatric hospitalization, physicians usually must obtain consent from the minor’s legal custodian.

Married parents both have legal custody of their children. They also have equal rights to spend time with their children and make major decisions about their welfare, such as authorizing medical care. When parents divorce, these rights must be reassigned in a court-approved divorce decree. Table 1 explains some key terms used to describe custody arrangements after divorce.^2,3

Several decades ago, children—especially those younger age 10—usually remained with their mothers, who received sole legal custody; fathers typically had visitation privileges.⁴ Now, however, most states’ statutes presume that divorced mothers and fathers will have joint legal custody.³

Joint legal custody lets both parents retain their individual legal authority to make decisions on behalf of minor children, although the children may spend most of their time in the physical custody of 1 parent. This means that when urgent medical care is needed—such as a psychiatric hospitalization—1 parent’s consent is sufficient legal authorization for treatment.^1,2

What if a child’s parent claims to have legal custody, but the doctor isn’t sure? A doctor who in good faith relies on a parent’s statement can properly provide urgent treatment without delving into custody arrangements.² In many states, noncustodial parents may authorize treatment in urgent situations—and even some nonurgent ones—if they happen to have physical control of the child when care is needed, such as during a visit.¹

Table 1

Child custody: Key legal terms

Nonurgent treatment

After receiving urgent treatment, psychiatric patients typically need continuing, nonurgent care. Dr. K’s inquiry may be anticipating this scenario. In general, parents with joint custody have an equal right to authorize nonurgent care for their children, and Johnny’s treatment could proceed with only Mom’s consent.¹ However, if Dr. K knows or has reason to think that Johnny’s father would refuse to give consent for ongoing, nonurgent psychiatric care, providing treatment over the father’s objection may be legally questionable. Under some joint legal custody agreements, both parents need to give consent for medical care and receive clinical information about their children.²

Moreover, trying to treat Johnny in the face of Dad’s explicit objection may be clinically unwise. Unfortunately, many couples’ conflicts are not resolved by divorce, and children can become pawns in ongoing postmarital battles. Such situations can exacerbate children’s emotional problems, which is the opposite of what Dr. K hopes to do for Johnny.

What can Dr. K do?

Address a parent’s fears. Few parents are at their levelheaded best when their children need psychiatric hospitalization. To help Mom and Johnny, Dr. K can point out these things:

• Many states, such as Ohio,⁵ give Dad the right to learn about Johnny’s treatment and access to treatment records.
• Sooner or later, Dad will find out about the hospitalization. The next time Johnny visits his father, he’ll probably tell Dad what happened. In a few weeks, Dad may receive insurance paperwork or a bill from the hospital.
• Dad may be far more upset and prone to retaliate if he finds out later and is excluded from Johnny’s treatment than if he is notified immediately and gets to participate in his son’s care.
• Realistically, Dad cannot take Johnny away because Mom has arranged for appropriate medical care. If hospitalization is indicated, Mom’s failure to get treatment for Johnny could be grounds for Dad to claim she’s an unfit parent.

Why both parents are needed

Johnny’s hospital care probably will benefit from Dad’s involvement for several reasons (Table 2).

More information. Child and adolescent psychiatrists agree that in most clinical situations it helps to obtain information from as many sources as possible.^6-9 Johnny’s father might have crucial information relevant to diagnosis or treatment, such as family history details that Mom doesn’t know.

Debiasing. If Johnny spends time living with both parents, Dr. K should know how often symptoms appear in both environments. Dad’s perspective may be vital, but when postdivorce relationships are strained, what parents convey about each other can be biased. Getting information directly from both parents will give Dr. K a more realistic picture of the child’s environment and psychosocial stressors.⁷

Treatment planning. After a psychiatric hospitalization, both parents should be aware of Johnny’s diagnosis and treatment. Johnny may need careful supervision for recurrence of symptoms, such as suicidal or homicidal ideation, that can have life-threatening implications.

Medication management. If Johnny is taking medication, he’ll need to receive it regularly. Missing medication when Johnny is with Dad would reduce effectiveness and in some cases could be dangerous. Both parents also should know about possible side effects so they can provide good monitoring.

Psychotherapy. Often, family therapy is an important element of a child’s recovery and will achieve optimum results only if all family members participate. Also, children need consistency. If a behavioral plan is part of Johnny’s treatment, Mom and Dad will need to agree on the rules and implement them consistently at both homes.

Table 2

Why both parents’ input is valuable

Work with parents

When one divorced parent is reluctant to inform the other about their child’s hospitalization, you can respond empathically to fears and concerns. Despite mental health professionals’ best efforts, psychiatric illness still generates feelings of stigma and shame. Divorced parents often feel guilty about the stress the divorce has brought to their children, and they may consciously or unconsciously blame themselves for their child’s illness. In the midst of an ongoing custody dispute, the parent initiating a psychiatric hospitalization may feel especially vulnerable and reluctant to inform the other parent about what’s happening.

Being attuned to these issues will help you address and normalize a parent’s fears. Parents should know that a court could support their seeking treatment for their children’s illness, and they could be contributing to medical neglect if they do not seek this treatment.

In rare instances, not informing the other parent may be the best clinical decision. In situations involving child abuse or extreme domestic violence, a parent’s learning about the hospitalization could create safety issues. In most instances, however, both Mom and Dad will see their child soon after hospitalization, so one parent cannot hope to conceal a hospitalization for very long. Involving both parents from the outset usually will give the child and his family the best shot at a positive outcome.

Dear Dr. Mossman:

I treat children and adolescents in an acute inpatient setting. Sometimes a child of divorced parents—call him “Johnny”—is admitted to the hospital by one parent—for example the mother—but she doesn’t inform the father. Although the parents have joint custody, Mom doesn’t want me to contact Dad.

I tell Mom that I’d like to get clinical information and consent from Dad, but she refuses, saying, “This will make me look bad, and my ex-husband will try to take emergency custody of Johnny.” My hospital’s legal department says consent from both parents isn’t needed.

These scenarios always leave me feeling upset and confused. I’d appreciate clarification on how to handle these matters.—Submitted by “Dr. K”

Knowing the correct legal answer to a question often doesn’t supply the best clinical solution for your patient. Dr. K received a legally sound response from hospital administrators: a parent who has legal custody may authorize medical treatment for a minor child without first asking or informing the other parent. But Dr. K feels unsatisfied because the hospital didn’t provide what Dr. K sought: a clinically sound answer.

This article reviews custody arrangements and the legal rights they give divorced parents. Also, we will discuss the mother’s concerns and explain why—despite her fears—notifying and involving Johnny’s father can be important, even when it’s not legally required.

Custody and urgent treatment

A minor—defined in most states as a person younger than age 18—legally cannot give consent for medical care except in limited circumstances, such as contraceptive care.^1,2 When a minor undergoes psychiatric hospitalization, physicians usually must obtain consent from the minor’s legal custodian.

Married parents both have legal custody of their children. They also have equal rights to spend time with their children and make major decisions about their welfare, such as authorizing medical care. When parents divorce, these rights must be reassigned in a court-approved divorce decree. Table 1 explains some key terms used to describe custody arrangements after divorce.^2,3

Several decades ago, children—especially those younger age 10—usually remained with their mothers, who received sole legal custody; fathers typically had visitation privileges.⁴ Now, however, most states’ statutes presume that divorced mothers and fathers will have joint legal custody.³

Joint legal custody lets both parents retain their individual legal authority to make decisions on behalf of minor children, although the children may spend most of their time in the physical custody of 1 parent. This means that when urgent medical care is needed—such as a psychiatric hospitalization—1 parent’s consent is sufficient legal authorization for treatment.^1,2

What if a child’s parent claims to have legal custody, but the doctor isn’t sure? A doctor who in good faith relies on a parent’s statement can properly provide urgent treatment without delving into custody arrangements.² In many states, noncustodial parents may authorize treatment in urgent situations—and even some nonurgent ones—if they happen to have physical control of the child when care is needed, such as during a visit.¹

Table 1

Child custody: Key legal terms

Nonurgent treatment

After receiving urgent treatment, psychiatric patients typically need continuing, nonurgent care. Dr. K’s inquiry may be anticipating this scenario. In general, parents with joint custody have an equal right to authorize nonurgent care for their children, and Johnny’s treatment could proceed with only Mom’s consent.¹ However, if Dr. K knows or has reason to think that Johnny’s father would refuse to give consent for ongoing, nonurgent psychiatric care, providing treatment over the father’s objection may be legally questionable. Under some joint legal custody agreements, both parents need to give consent for medical care and receive clinical information about their children.²

Moreover, trying to treat Johnny in the face of Dad’s explicit objection may be clinically unwise. Unfortunately, many couples’ conflicts are not resolved by divorce, and children can become pawns in ongoing postmarital battles. Such situations can exacerbate children’s emotional problems, which is the opposite of what Dr. K hopes to do for Johnny.

What can Dr. K do?

Address a parent’s fears. Few parents are at their levelheaded best when their children need psychiatric hospitalization. To help Mom and Johnny, Dr. K can point out these things:

• Many states, such as Ohio,⁵ give Dad the right to learn about Johnny’s treatment and access to treatment records.
• Sooner or later, Dad will find out about the hospitalization. The next time Johnny visits his father, he’ll probably tell Dad what happened. In a few weeks, Dad may receive insurance paperwork or a bill from the hospital.
• Dad may be far more upset and prone to retaliate if he finds out later and is excluded from Johnny’s treatment than if he is notified immediately and gets to participate in his son’s care.
• Realistically, Dad cannot take Johnny away because Mom has arranged for appropriate medical care. If hospitalization is indicated, Mom’s failure to get treatment for Johnny could be grounds for Dad to claim she’s an unfit parent.

Why both parents are needed

Johnny’s hospital care probably will benefit from Dad’s involvement for several reasons (Table 2).

More information. Child and adolescent psychiatrists agree that in most clinical situations it helps to obtain information from as many sources as possible.^6-9 Johnny’s father might have crucial information relevant to diagnosis or treatment, such as family history details that Mom doesn’t know.

Debiasing. If Johnny spends time living with both parents, Dr. K should know how often symptoms appear in both environments. Dad’s perspective may be vital, but when postdivorce relationships are strained, what parents convey about each other can be biased. Getting information directly from both parents will give Dr. K a more realistic picture of the child’s environment and psychosocial stressors.⁷

Treatment planning. After a psychiatric hospitalization, both parents should be aware of Johnny’s diagnosis and treatment. Johnny may need careful supervision for recurrence of symptoms, such as suicidal or homicidal ideation, that can have life-threatening implications.

Medication management. If Johnny is taking medication, he’ll need to receive it regularly. Missing medication when Johnny is with Dad would reduce effectiveness and in some cases could be dangerous. Both parents also should know about possible side effects so they can provide good monitoring.

Psychotherapy. Often, family therapy is an important element of a child’s recovery and will achieve optimum results only if all family members participate. Also, children need consistency. If a behavioral plan is part of Johnny’s treatment, Mom and Dad will need to agree on the rules and implement them consistently at both homes.

Table 2

Why both parents’ input is valuable

Work with parents

When one divorced parent is reluctant to inform the other about their child’s hospitalization, you can respond empathically to fears and concerns. Despite mental health professionals’ best efforts, psychiatric illness still generates feelings of stigma and shame. Divorced parents often feel guilty about the stress the divorce has brought to their children, and they may consciously or unconsciously blame themselves for their child’s illness. In the midst of an ongoing custody dispute, the parent initiating a psychiatric hospitalization may feel especially vulnerable and reluctant to inform the other parent about what’s happening.

Being attuned to these issues will help you address and normalize a parent’s fears. Parents should know that a court could support their seeking treatment for their children’s illness, and they could be contributing to medical neglect if they do not seek this treatment.

In rare instances, not informing the other parent may be the best clinical decision. In situations involving child abuse or extreme domestic violence, a parent’s learning about the hospitalization could create safety issues. In most instances, however, both Mom and Dad will see their child soon after hospitalization, so one parent cannot hope to conceal a hospitalization for very long. Involving both parents from the outset usually will give the child and his family the best shot at a positive outcome.

Dear Dr. Mossman:

I treat children and adolescents in an acute inpatient setting. Sometimes a child of divorced parents—call him “Johnny”—is admitted to the hospital by one parent—for example the mother—but she doesn’t inform the father. Although the parents have joint custody, Mom doesn’t want me to contact Dad.

I tell Mom that I’d like to get clinical information and consent from Dad, but she refuses, saying, “This will make me look bad, and my ex-husband will try to take emergency custody of Johnny.” My hospital’s legal department says consent from both parents isn’t needed.

These scenarios always leave me feeling upset and confused. I’d appreciate clarification on how to handle these matters.—Submitted by “Dr. K”

Knowing the correct legal answer to a question often doesn’t supply the best clinical solution for your patient. Dr. K received a legally sound response from hospital administrators: a parent who has legal custody may authorize medical treatment for a minor child without first asking or informing the other parent. But Dr. K feels unsatisfied because the hospital didn’t provide what Dr. K sought: a clinically sound answer.

This article reviews custody arrangements and the legal rights they give divorced parents. Also, we will discuss the mother’s concerns and explain why—despite her fears—notifying and involving Johnny’s father can be important, even when it’s not legally required.

Custody and urgent treatment

A minor—defined in most states as a person younger than age 18—legally cannot give consent for medical care except in limited circumstances, such as contraceptive care.^1,2 When a minor undergoes psychiatric hospitalization, physicians usually must obtain consent from the minor’s legal custodian.

Married parents both have legal custody of their children. They also have equal rights to spend time with their children and make major decisions about their welfare, such as authorizing medical care. When parents divorce, these rights must be reassigned in a court-approved divorce decree. Table 1 explains some key terms used to describe custody arrangements after divorce.^2,3

Several decades ago, children—especially those younger age 10—usually remained with their mothers, who received sole legal custody; fathers typically had visitation privileges.⁴ Now, however, most states’ statutes presume that divorced mothers and fathers will have joint legal custody.³

Joint legal custody lets both parents retain their individual legal authority to make decisions on behalf of minor children, although the children may spend most of their time in the physical custody of 1 parent. This means that when urgent medical care is needed—such as a psychiatric hospitalization—1 parent’s consent is sufficient legal authorization for treatment.^1,2

What if a child’s parent claims to have legal custody, but the doctor isn’t sure? A doctor who in good faith relies on a parent’s statement can properly provide urgent treatment without delving into custody arrangements.² In many states, noncustodial parents may authorize treatment in urgent situations—and even some nonurgent ones—if they happen to have physical control of the child when care is needed, such as during a visit.¹

Table 1

Child custody: Key legal terms

Nonurgent treatment

After receiving urgent treatment, psychiatric patients typically need continuing, nonurgent care. Dr. K’s inquiry may be anticipating this scenario. In general, parents with joint custody have an equal right to authorize nonurgent care for their children, and Johnny’s treatment could proceed with only Mom’s consent.¹ However, if Dr. K knows or has reason to think that Johnny’s father would refuse to give consent for ongoing, nonurgent psychiatric care, providing treatment over the father’s objection may be legally questionable. Under some joint legal custody agreements, both parents need to give consent for medical care and receive clinical information about their children.²

Moreover, trying to treat Johnny in the face of Dad’s explicit objection may be clinically unwise. Unfortunately, many couples’ conflicts are not resolved by divorce, and children can become pawns in ongoing postmarital battles. Such situations can exacerbate children’s emotional problems, which is the opposite of what Dr. K hopes to do for Johnny.

What can Dr. K do?

Address a parent’s fears. Few parents are at their levelheaded best when their children need psychiatric hospitalization. To help Mom and Johnny, Dr. K can point out these things:

• Many states, such as Ohio,⁵ give Dad the right to learn about Johnny’s treatment and access to treatment records.
• Sooner or later, Dad will find out about the hospitalization. The next time Johnny visits his father, he’ll probably tell Dad what happened. In a few weeks, Dad may receive insurance paperwork or a bill from the hospital.
• Dad may be far more upset and prone to retaliate if he finds out later and is excluded from Johnny’s treatment than if he is notified immediately and gets to participate in his son’s care.
• Realistically, Dad cannot take Johnny away because Mom has arranged for appropriate medical care. If hospitalization is indicated, Mom’s failure to get treatment for Johnny could be grounds for Dad to claim she’s an unfit parent.

Why both parents are needed

Johnny’s hospital care probably will benefit from Dad’s involvement for several reasons (Table 2).

More information. Child and adolescent psychiatrists agree that in most clinical situations it helps to obtain information from as many sources as possible.^6-9 Johnny’s father might have crucial information relevant to diagnosis or treatment, such as family history details that Mom doesn’t know.

Debiasing. If Johnny spends time living with both parents, Dr. K should know how often symptoms appear in both environments. Dad’s perspective may be vital, but when postdivorce relationships are strained, what parents convey about each other can be biased. Getting information directly from both parents will give Dr. K a more realistic picture of the child’s environment and psychosocial stressors.⁷

Treatment planning. After a psychiatric hospitalization, both parents should be aware of Johnny’s diagnosis and treatment. Johnny may need careful supervision for recurrence of symptoms, such as suicidal or homicidal ideation, that can have life-threatening implications.

Medication management. If Johnny is taking medication, he’ll need to receive it regularly. Missing medication when Johnny is with Dad would reduce effectiveness and in some cases could be dangerous. Both parents also should know about possible side effects so they can provide good monitoring.

Psychotherapy. Often, family therapy is an important element of a child’s recovery and will achieve optimum results only if all family members participate. Also, children need consistency. If a behavioral plan is part of Johnny’s treatment, Mom and Dad will need to agree on the rules and implement them consistently at both homes.

Table 2

Why both parents’ input is valuable

Work with parents

When one divorced parent is reluctant to inform the other about their child’s hospitalization, you can respond empathically to fears and concerns. Despite mental health professionals’ best efforts, psychiatric illness still generates feelings of stigma and shame. Divorced parents often feel guilty about the stress the divorce has brought to their children, and they may consciously or unconsciously blame themselves for their child’s illness. In the midst of an ongoing custody dispute, the parent initiating a psychiatric hospitalization may feel especially vulnerable and reluctant to inform the other parent about what’s happening.

Being attuned to these issues will help you address and normalize a parent’s fears. Parents should know that a court could support their seeking treatment for their children’s illness, and they could be contributing to medical neglect if they do not seek this treatment.

In rare instances, not informing the other parent may be the best clinical decision. In situations involving child abuse or extreme domestic violence, a parent’s learning about the hospitalization could create safety issues. In most instances, however, both Mom and Dad will see their child soon after hospitalization, so one parent cannot hope to conceal a hospitalization for very long. Involving both parents from the outset usually will give the child and his family the best shot at a positive outcome.

As the healthcare system struggles with the definition of quality and the implementation of patient-centered care, renewed attention is being given to patient satisfaction.

Now, this performance measure has moved from the hospital’s marketing department into the C-suite, where senior administrators at some hospitals have patient satisfaction scores tied to their compensation.

Pressure is being applied to nudge key hospital care providers, including hospitalists, to keep their patients happy while giving them the care they deserve.

With the recent publishing of the Hospital Consumer Assessment of Healthcare providers and Systems (HCAHPS) scorecards for each hospital on the Hospital Compare Web site (www.hospitalcompare.hhs.gov), patients can see and compare local hospitals.

Because hospitalists are managing an ever-increasing portion of the hospital census, we can count on being right in the middle of all this. Coupled with the fact that 40% of hospitalists are directly employed by their hospital and a significant portion of other hospitalist groups have contracts with hospitals tied to quality improvement, we can expect a lot of pressure to not only improve patient satisfaction, but to make the “numbers” look better.

What Survey Measures

An important starting point for hospitalists and especially their leaders, who will be engaged in conversations with the C-suite about patient satisfaction data, is to better understand what the data indicate.

First, you need to know that the patient questionnaires were designed by several large vendors, the largest being Press Ganey.

While it is possible to segment the patients by those treated by a hospitalist and those not, the questions were not meant to describe, define, or compare the performance of different physicians. Remember, non-hospitalists for this purpose includes not only internists, but also surgeons, obstetricians, and other specialists.

Some questions on the survey about physicians include:

• During this hospital stay, how often did doctors treat you with respect? (never, sometimes, usually, always);
• During this hospital stay, how often did doctors explain things in a way you could understand? and
• During this hospital stay, how often did doctors listen carefully to you?

Other questions that might pertain to care directed by hospitalists but also relate to the entire care team include:

• How often was your pain controlled?
• Before giving you a new medicine, how often did staff tell you what it was for? and
• Before giving you a new medicine, how often did staff describe possible side effects in a way you could understand?

While you might aggregate all the replies specifically about the doctors’ performance and grade all the doctors separately, the all-important questions to the C-suite are the last two sections:

• How do patients rate the hospital? and
• Would patients recommend the hospital to friends and family?

Patients Are Different

It is important to understand the unique characteristics of the patients admitted and managed by hospitalists and to understand how these patients may respond differently to the standard patient satisfaction surveys than others in the patient population.

More often than not, hospitalists admit patients who are acutely ill, presenting through the emergency department (ED) with medical problems. Some studies have estimated that more than 70% of hospitalists’ patients come through the ED, while for the rest of the staff it is closer to 30% to 40%.

It is well known that patients admitted electively are more satisfied than those with an acute illness who come through the ED. In addition, patients admitted for medical problems have lower satisfaction ratings than those admitted for general surgery, subspecialty surgery, or obstetrics.

Therefore, if your hospital administration has pulled together statistics that purport to compare patient satisfaction for your hospitalist group versus all other admissions, you need to make sure that comparisons are made to a similar population, i.e., acutely ill patients admitted through the ED with medical diagnoses. The survey companies should be able to produce just such a comparison.

It is equally as important to make sure you focus on the total experience at the hospital and not just the questions specifically concerning only the doctors. Since hospitalists not only do front-line, face-to-face patient care, but also work with the team and attempt to improve the system to provide better overall quality, make sure to focus on questions like “How do patients rate the hospital?” and “Would patients recommend the hospital to friends and family?”

The other consideration is to understand how close the top quartile is to the bottom quartile, when comparisons are made with this data. In many of these surveys the patients are giving ratings on a scale of one to four, with many of the responses at three or four. Therefore, the top score might be a 3.6 and the bottom score average 3.2. It is important to understand if you are just minor adjustments away from being in a good range or if you are either so far above or below the standard of care that a real situation exists.

HM’s Role

Does the hospitalist model lead to better patient satisfaction? Like most things in hospital medicine, the answer is yes, no, and maybe. There are certain aspects of hospital medicine that should lead to happier patients:

• Present and easily available;
• Expert in hospital care;
• Improved coordination of care by specialists;
• Availability for multiple visits if patient condition changes;
• Availability to visit with loved-ones at their convenience; and
• Rapid response to nurse’s concerns.

There are aspects of getting your care from a hospitalist that may initially make the patient more concerned:

• They may be unfamiliar with the hospitalist and the hospitalist model;
• The hospitalist may demonstrate little or no knowledge of the patient’s history;
• The referring physician may not introduce the patient to the hospitalist; and
• The hospitalist may not explain the relationship with the referring physician.

How to Be Proactive

With all we have to do every day (and the list seems to get longer by the minute), it is easy to get perplexed by having to be responsible for the patients’ satisfaction with their hospital experience. That being said, hospitalists perform well when we step up to the plate and take action in these ways:

• Proactively meet with the person in the C-suite who oversees the patient satisfaction survey process or relates to the hospitalist group (e.g., vice president of medical affairs or chief medical officer) to better understand the survey results;
• Make sure if the data are being used to compare hospitalist care with non-hospitalist care that the comparison group of patients is equivalent (i.e., acutely ill medical patients admitted through the ED, not surgical or obstetrical patients);
• Make sure to focus not only on the “doctor-related” questions, but on patients’ overall satisfaction with the hospital; and
• Offer to help the C-suite improve patient satisfaction, but don’t attempt to “own” this performance measure for the entire hospital. Hospitalists can be helpful, but this is broader than any one group of physicians.

Further, make improving patient satisfaction a core goal for your group. Some strategies that may work include:

• Have a script for each patient encounter (“Hi, I’m Dr. Smith, I take care of Dr. Jones’ patients in the hospital. The way we communicate about your care is … The advantages to our partnership are …”);
• Hand out a brochure with your group’s hospitalists’ pictures, answers to frequently asked questions, and how to contact the hospitalist; and
• Sit down and shut up (i.e., patients will perceive you are taking time with them and listening if you are seated and let them speak without interruption).

Hospitals have been doing patient surveys for some time now. The Centers for Medicare and Medicaid Services and other payers are placing more emphasis on this quality measure. Now that the results easily are available to the public, major newspapers and broadcast media are calling attention to patient perspectives on their hospital care.

Once hospitalist groups understand the data, there is an opportunity to partner with their hospitals to better understand how our patients see their hospital care and allow for hospitalists to have an appropriate role in working with the other health professionals to improve patients’ experience with their care. TH

Dr. Wellikson is the CEO of SHM.

Note to readers: I would like to acknowledge SHM co-founder Win Whitcomb, MD, and SHM Senior Vice President Joe Miller for their assistance with this column.

As the healthcare system struggles with the definition of quality and the implementation of patient-centered care, renewed attention is being given to patient satisfaction.

Now, this performance measure has moved from the hospital’s marketing department into the C-suite, where senior administrators at some hospitals have patient satisfaction scores tied to their compensation.

Pressure is being applied to nudge key hospital care providers, including hospitalists, to keep their patients happy while giving them the care they deserve.

With the recent publishing of the Hospital Consumer Assessment of Healthcare providers and Systems (HCAHPS) scorecards for each hospital on the Hospital Compare Web site (www.hospitalcompare.hhs.gov), patients can see and compare local hospitals.

Because hospitalists are managing an ever-increasing portion of the hospital census, we can count on being right in the middle of all this. Coupled with the fact that 40% of hospitalists are directly employed by their hospital and a significant portion of other hospitalist groups have contracts with hospitals tied to quality improvement, we can expect a lot of pressure to not only improve patient satisfaction, but to make the “numbers” look better.

What Survey Measures

An important starting point for hospitalists and especially their leaders, who will be engaged in conversations with the C-suite about patient satisfaction data, is to better understand what the data indicate.

First, you need to know that the patient questionnaires were designed by several large vendors, the largest being Press Ganey.

While it is possible to segment the patients by those treated by a hospitalist and those not, the questions were not meant to describe, define, or compare the performance of different physicians. Remember, non-hospitalists for this purpose includes not only internists, but also surgeons, obstetricians, and other specialists.

Some questions on the survey about physicians include:

• During this hospital stay, how often did doctors treat you with respect? (never, sometimes, usually, always);
• During this hospital stay, how often did doctors explain things in a way you could understand? and
• During this hospital stay, how often did doctors listen carefully to you?

Other questions that might pertain to care directed by hospitalists but also relate to the entire care team include:

• How often was your pain controlled?
• Before giving you a new medicine, how often did staff tell you what it was for? and
• Before giving you a new medicine, how often did staff describe possible side effects in a way you could understand?

While you might aggregate all the replies specifically about the doctors’ performance and grade all the doctors separately, the all-important questions to the C-suite are the last two sections:

• How do patients rate the hospital? and
• Would patients recommend the hospital to friends and family?

Patients Are Different

It is important to understand the unique characteristics of the patients admitted and managed by hospitalists and to understand how these patients may respond differently to the standard patient satisfaction surveys than others in the patient population.

More often than not, hospitalists admit patients who are acutely ill, presenting through the emergency department (ED) with medical problems. Some studies have estimated that more than 70% of hospitalists’ patients come through the ED, while for the rest of the staff it is closer to 30% to 40%.

It is well known that patients admitted electively are more satisfied than those with an acute illness who come through the ED. In addition, patients admitted for medical problems have lower satisfaction ratings than those admitted for general surgery, subspecialty surgery, or obstetrics.

Therefore, if your hospital administration has pulled together statistics that purport to compare patient satisfaction for your hospitalist group versus all other admissions, you need to make sure that comparisons are made to a similar population, i.e., acutely ill patients admitted through the ED with medical diagnoses. The survey companies should be able to produce just such a comparison.

It is equally as important to make sure you focus on the total experience at the hospital and not just the questions specifically concerning only the doctors. Since hospitalists not only do front-line, face-to-face patient care, but also work with the team and attempt to improve the system to provide better overall quality, make sure to focus on questions like “How do patients rate the hospital?” and “Would patients recommend the hospital to friends and family?”

The other consideration is to understand how close the top quartile is to the bottom quartile, when comparisons are made with this data. In many of these surveys the patients are giving ratings on a scale of one to four, with many of the responses at three or four. Therefore, the top score might be a 3.6 and the bottom score average 3.2. It is important to understand if you are just minor adjustments away from being in a good range or if you are either so far above or below the standard of care that a real situation exists.

HM’s Role

Does the hospitalist model lead to better patient satisfaction? Like most things in hospital medicine, the answer is yes, no, and maybe. There are certain aspects of hospital medicine that should lead to happier patients:

• Present and easily available;
• Expert in hospital care;
• Improved coordination of care by specialists;
• Availability for multiple visits if patient condition changes;
• Availability to visit with loved-ones at their convenience; and
• Rapid response to nurse’s concerns.

There are aspects of getting your care from a hospitalist that may initially make the patient more concerned:

• They may be unfamiliar with the hospitalist and the hospitalist model;
• The hospitalist may demonstrate little or no knowledge of the patient’s history;
• The referring physician may not introduce the patient to the hospitalist; and
• The hospitalist may not explain the relationship with the referring physician.

How to Be Proactive

With all we have to do every day (and the list seems to get longer by the minute), it is easy to get perplexed by having to be responsible for the patients’ satisfaction with their hospital experience. That being said, hospitalists perform well when we step up to the plate and take action in these ways:

• Proactively meet with the person in the C-suite who oversees the patient satisfaction survey process or relates to the hospitalist group (e.g., vice president of medical affairs or chief medical officer) to better understand the survey results;
• Make sure if the data are being used to compare hospitalist care with non-hospitalist care that the comparison group of patients is equivalent (i.e., acutely ill medical patients admitted through the ED, not surgical or obstetrical patients);
• Make sure to focus not only on the “doctor-related” questions, but on patients’ overall satisfaction with the hospital; and
• Offer to help the C-suite improve patient satisfaction, but don’t attempt to “own” this performance measure for the entire hospital. Hospitalists can be helpful, but this is broader than any one group of physicians.

Further, make improving patient satisfaction a core goal for your group. Some strategies that may work include:

• Have a script for each patient encounter (“Hi, I’m Dr. Smith, I take care of Dr. Jones’ patients in the hospital. The way we communicate about your care is … The advantages to our partnership are …”);
• Hand out a brochure with your group’s hospitalists’ pictures, answers to frequently asked questions, and how to contact the hospitalist; and
• Sit down and shut up (i.e., patients will perceive you are taking time with them and listening if you are seated and let them speak without interruption).

Hospitals have been doing patient surveys for some time now. The Centers for Medicare and Medicaid Services and other payers are placing more emphasis on this quality measure. Now that the results easily are available to the public, major newspapers and broadcast media are calling attention to patient perspectives on their hospital care.

Once hospitalist groups understand the data, there is an opportunity to partner with their hospitals to better understand how our patients see their hospital care and allow for hospitalists to have an appropriate role in working with the other health professionals to improve patients’ experience with their care. TH

Dr. Wellikson is the CEO of SHM.

Note to readers: I would like to acknowledge SHM co-founder Win Whitcomb, MD, and SHM Senior Vice President Joe Miller for their assistance with this column.

As the healthcare system struggles with the definition of quality and the implementation of patient-centered care, renewed attention is being given to patient satisfaction.

Now, this performance measure has moved from the hospital’s marketing department into the C-suite, where senior administrators at some hospitals have patient satisfaction scores tied to their compensation.

Pressure is being applied to nudge key hospital care providers, including hospitalists, to keep their patients happy while giving them the care they deserve.

With the recent publishing of the Hospital Consumer Assessment of Healthcare providers and Systems (HCAHPS) scorecards for each hospital on the Hospital Compare Web site (www.hospitalcompare.hhs.gov), patients can see and compare local hospitals.

Because hospitalists are managing an ever-increasing portion of the hospital census, we can count on being right in the middle of all this. Coupled with the fact that 40% of hospitalists are directly employed by their hospital and a significant portion of other hospitalist groups have contracts with hospitals tied to quality improvement, we can expect a lot of pressure to not only improve patient satisfaction, but to make the “numbers” look better.

What Survey Measures

An important starting point for hospitalists and especially their leaders, who will be engaged in conversations with the C-suite about patient satisfaction data, is to better understand what the data indicate.

First, you need to know that the patient questionnaires were designed by several large vendors, the largest being Press Ganey.

While it is possible to segment the patients by those treated by a hospitalist and those not, the questions were not meant to describe, define, or compare the performance of different physicians. Remember, non-hospitalists for this purpose includes not only internists, but also surgeons, obstetricians, and other specialists.

Some questions on the survey about physicians include:

• During this hospital stay, how often did doctors treat you with respect? (never, sometimes, usually, always);
• During this hospital stay, how often did doctors explain things in a way you could understand? and
• During this hospital stay, how often did doctors listen carefully to you?

Other questions that might pertain to care directed by hospitalists but also relate to the entire care team include:

• How often was your pain controlled?
• Before giving you a new medicine, how often did staff tell you what it was for? and
• Before giving you a new medicine, how often did staff describe possible side effects in a way you could understand?

While you might aggregate all the replies specifically about the doctors’ performance and grade all the doctors separately, the all-important questions to the C-suite are the last two sections:

• How do patients rate the hospital? and
• Would patients recommend the hospital to friends and family?

Patients Are Different

It is important to understand the unique characteristics of the patients admitted and managed by hospitalists and to understand how these patients may respond differently to the standard patient satisfaction surveys than others in the patient population.

More often than not, hospitalists admit patients who are acutely ill, presenting through the emergency department (ED) with medical problems. Some studies have estimated that more than 70% of hospitalists’ patients come through the ED, while for the rest of the staff it is closer to 30% to 40%.

It is well known that patients admitted electively are more satisfied than those with an acute illness who come through the ED. In addition, patients admitted for medical problems have lower satisfaction ratings than those admitted for general surgery, subspecialty surgery, or obstetrics.

Therefore, if your hospital administration has pulled together statistics that purport to compare patient satisfaction for your hospitalist group versus all other admissions, you need to make sure that comparisons are made to a similar population, i.e., acutely ill patients admitted through the ED with medical diagnoses. The survey companies should be able to produce just such a comparison.

It is equally as important to make sure you focus on the total experience at the hospital and not just the questions specifically concerning only the doctors. Since hospitalists not only do front-line, face-to-face patient care, but also work with the team and attempt to improve the system to provide better overall quality, make sure to focus on questions like “How do patients rate the hospital?” and “Would patients recommend the hospital to friends and family?”

The other consideration is to understand how close the top quartile is to the bottom quartile, when comparisons are made with this data. In many of these surveys the patients are giving ratings on a scale of one to four, with many of the responses at three or four. Therefore, the top score might be a 3.6 and the bottom score average 3.2. It is important to understand if you are just minor adjustments away from being in a good range or if you are either so far above or below the standard of care that a real situation exists.

HM’s Role

Does the hospitalist model lead to better patient satisfaction? Like most things in hospital medicine, the answer is yes, no, and maybe. There are certain aspects of hospital medicine that should lead to happier patients:

• Present and easily available;
• Expert in hospital care;
• Improved coordination of care by specialists;
• Availability for multiple visits if patient condition changes;
• Availability to visit with loved-ones at their convenience; and
• Rapid response to nurse’s concerns.

There are aspects of getting your care from a hospitalist that may initially make the patient more concerned:

• They may be unfamiliar with the hospitalist and the hospitalist model;
• The hospitalist may demonstrate little or no knowledge of the patient’s history;
• The referring physician may not introduce the patient to the hospitalist; and
• The hospitalist may not explain the relationship with the referring physician.

How to Be Proactive

With all we have to do every day (and the list seems to get longer by the minute), it is easy to get perplexed by having to be responsible for the patients’ satisfaction with their hospital experience. That being said, hospitalists perform well when we step up to the plate and take action in these ways:

• Proactively meet with the person in the C-suite who oversees the patient satisfaction survey process or relates to the hospitalist group (e.g., vice president of medical affairs or chief medical officer) to better understand the survey results;
• Make sure if the data are being used to compare hospitalist care with non-hospitalist care that the comparison group of patients is equivalent (i.e., acutely ill medical patients admitted through the ED, not surgical or obstetrical patients);
• Make sure to focus not only on the “doctor-related” questions, but on patients’ overall satisfaction with the hospital; and
• Offer to help the C-suite improve patient satisfaction, but don’t attempt to “own” this performance measure for the entire hospital. Hospitalists can be helpful, but this is broader than any one group of physicians.

Further, make improving patient satisfaction a core goal for your group. Some strategies that may work include:

• Have a script for each patient encounter (“Hi, I’m Dr. Smith, I take care of Dr. Jones’ patients in the hospital. The way we communicate about your care is … The advantages to our partnership are …”);
• Hand out a brochure with your group’s hospitalists’ pictures, answers to frequently asked questions, and how to contact the hospitalist; and
• Sit down and shut up (i.e., patients will perceive you are taking time with them and listening if you are seated and let them speak without interruption).

Hospitals have been doing patient surveys for some time now. The Centers for Medicare and Medicaid Services and other payers are placing more emphasis on this quality measure. Now that the results easily are available to the public, major newspapers and broadcast media are calling attention to patient perspectives on their hospital care.

Once hospitalist groups understand the data, there is an opportunity to partner with their hospitals to better understand how our patients see their hospital care and allow for hospitalists to have an appropriate role in working with the other health professionals to improve patients’ experience with their care. TH

Dr. Wellikson is the CEO of SHM.

Note to readers: I would like to acknowledge SHM co-founder Win Whitcomb, MD, and SHM Senior Vice President Joe Miller for their assistance with this column.

Maternity Maneuvers

How do most hospitalist groups manage maternity leave? I recently took six weeks for maternity leave. My colleagues worked my shifts, and I have virtually paid them all back. To do so I often would end up working 18 to 20 days consecutively and numerous weekends. This was not ideal on many levels. I most likely will not [receive a] bonus this year as well. Is there a better way?

New Mom in Midwest

Dr. Hospitalist responds: Congratulations on the birth of your child. As you recognize, becoming a parent is a wonderful experience but also can be stressful. It is not easy to balance the competing demands of family and work.

Medical leave is not unique to hospitalists—but with the average age of hospitalists being 37, it is commonplace to have hospitalist staff start families at this stage of their lives. In fact, as a hospitalist director, it would be foolish for me not to expect and plan for maternity and paternity leaves.

Medical leaves often are stressful for hospitalist programs because of the need to find replacement staff to fill the work schedule. There is no “best” way to cover the schedule during medical leaves. One thing is certain: Not offering medical leave is not only unrealistic, it may be against the law.

Hospitalist directors and those contemplating medical leave from work should familiarize themselves with the federal government’s Family Medical Leave Act (FMLA). Of course, I’m not an attorney; anyone who is looking for accurate advice concerning FMLA and other legal matters should consult a lawyer.

Briefly stated, the FMLA requires that “covered employers must grant an eligible employee up to a total of 12 work weeks of unpaid leave during any 12-month period for one or more of the following reasons:

• Birth and care of the newborn child of the employee;
• Placement with the employee of a son or daughter for adoption or foster care;
• To care for an immediate family member (spouse, child, or parent) with a serious health condition; or
• To take medical leave when the employee is unable to work because of a serious health condition.

It is important to know that the FMLA strictly defines eligibility criteria. For example, a covered employer is one who “employs 50 or more employees for each working day during each of 20 or more calendar work weeks in the current or preceding calendar year.” There also are strict criteria that define whether one is an eligible employee. It is important to note that FMLA does not guarantee paid time off—it only requires unpaid leave. You can find additional information about the FMLA online at the government’s Web site: www.dol.gov/esa/whd/fmla.

Peer Pressure

I am an attorney who often represents physicians in hospital peer-review matters. I represent a hospitalist whom the medical staff has recommended be terminated. Two internists have been appointed to the peer-review committee; one has an office-based practice, and the other is a cardiologist. Neither is a hospitalist.

I am trying to convince the medical staff that there should be a hospitalist on the peer-review committee because I believe what a hospitalist does each day is fundamentally different in scope and patient mix than the other two internists. My argument will be much stronger if it is the case that a hospitalist’s practice is now its own medical specialty.

Can you point me to any information or articles that support my belief that hospital practice is now a separate specialty?

Anxious Attorney

Dr. Hospitalist responds: Is a hospitalist practice sufficiently different than that of an office-based internist or cardiologist, so much so that peer-review activities would necessitate at a minimum some involvement of other hospitalists? To answer this question, I think we need to understand the definition of a hospitalist.

I recently heard a doctor describe himself as a hospitalist despite working clinically in the hospital only one month annually. Is he correct in defining himself as a hospitalist? If so, how would we distinguish him from primary care doctors who spend one-twelfth of their work life caring for hospitalized patients?

SHM defines hospitalists as “physicians whose primary professional focus is the general medical care of hospitalized patients. Their activities include patient care, teaching, research, and leadership related to hospital medicine.” Based on this definition, the doctor who spends one month annually caring for inpatients could be a hospitalist if the remainder of his work involved teaching, research, and leadership related to hospital medicine.

In your example, you cite two physicians on the peer-review committee: an office based internist and a cardiologist. Is it reasonable to consider their work similar to or different from that of a hospitalist? In the case of the internist, I think the key point is the fact you described him as office-based. That suggests to me his primary professional focus does not involve hospitalized patients.

One could argue that since both the hospitalist and the office-based internist were trained in internal medicine and both have American Board of Internal Medicine certification, they should be considered peers. I would point out that one’s specialty training has nothing to do with the definition of a hospitalist.

Although the majority of hospitalists in this country are internists, many others are family physicians and pediatricians. Some have subspecialty training, some don’t. Even obstetricians and surgeons are defining themselves as hospitalists.

With all that in mind, would we consider the cardiologist a hospitalist? Again, I think it would depend on the nature of the cardiologist practice. If this cardiologist has a primarily outpatient practice, that would be quite different from a hospitalist practice.

What if this cardiologist’s practice primarily is inpatient? I think it is reasonable to think about the scope of these physicians’ practices. Assuming the cardiologist practice is limited to the care of patients with primary cardiac issues, this would be a much narrower scope than that of most hospitalists.

It also is important to consider the training of the hospitalist. Take geriatrics hospitalists, for instance. The scope of their practice may be quite similar to that of a geriatrician who spends the majority of time caring for hospitalized patients.

Does the hospitalist have additional cardiology training? Does the focus of discussion at peer-review committee involve care of patients with primarily cardiac needs? The issue of which physicians should serve on peer-review committees when evaluating hospitalists is a complicated one that demands further scrutiny. TH

Maternity Maneuvers

How do most hospitalist groups manage maternity leave? I recently took six weeks for maternity leave. My colleagues worked my shifts, and I have virtually paid them all back. To do so I often would end up working 18 to 20 days consecutively and numerous weekends. This was not ideal on many levels. I most likely will not [receive a] bonus this year as well. Is there a better way?

New Mom in Midwest

Dr. Hospitalist responds: Congratulations on the birth of your child. As you recognize, becoming a parent is a wonderful experience but also can be stressful. It is not easy to balance the competing demands of family and work.

Medical leave is not unique to hospitalists—but with the average age of hospitalists being 37, it is commonplace to have hospitalist staff start families at this stage of their lives. In fact, as a hospitalist director, it would be foolish for me not to expect and plan for maternity and paternity leaves.

Medical leaves often are stressful for hospitalist programs because of the need to find replacement staff to fill the work schedule. There is no “best” way to cover the schedule during medical leaves. One thing is certain: Not offering medical leave is not only unrealistic, it may be against the law.

Hospitalist directors and those contemplating medical leave from work should familiarize themselves with the federal government’s Family Medical Leave Act (FMLA). Of course, I’m not an attorney; anyone who is looking for accurate advice concerning FMLA and other legal matters should consult a lawyer.

Briefly stated, the FMLA requires that “covered employers must grant an eligible employee up to a total of 12 work weeks of unpaid leave during any 12-month period for one or more of the following reasons:

• Birth and care of the newborn child of the employee;
• Placement with the employee of a son or daughter for adoption or foster care;
• To care for an immediate family member (spouse, child, or parent) with a serious health condition; or
• To take medical leave when the employee is unable to work because of a serious health condition.

It is important to know that the FMLA strictly defines eligibility criteria. For example, a covered employer is one who “employs 50 or more employees for each working day during each of 20 or more calendar work weeks in the current or preceding calendar year.” There also are strict criteria that define whether one is an eligible employee. It is important to note that FMLA does not guarantee paid time off—it only requires unpaid leave. You can find additional information about the FMLA online at the government’s Web site: www.dol.gov/esa/whd/fmla.

Peer Pressure

I am an attorney who often represents physicians in hospital peer-review matters. I represent a hospitalist whom the medical staff has recommended be terminated. Two internists have been appointed to the peer-review committee; one has an office-based practice, and the other is a cardiologist. Neither is a hospitalist.

I am trying to convince the medical staff that there should be a hospitalist on the peer-review committee because I believe what a hospitalist does each day is fundamentally different in scope and patient mix than the other two internists. My argument will be much stronger if it is the case that a hospitalist’s practice is now its own medical specialty.

Can you point me to any information or articles that support my belief that hospital practice is now a separate specialty?

Anxious Attorney

Dr. Hospitalist responds: Is a hospitalist practice sufficiently different than that of an office-based internist or cardiologist, so much so that peer-review activities would necessitate at a minimum some involvement of other hospitalists? To answer this question, I think we need to understand the definition of a hospitalist.

I recently heard a doctor describe himself as a hospitalist despite working clinically in the hospital only one month annually. Is he correct in defining himself as a hospitalist? If so, how would we distinguish him from primary care doctors who spend one-twelfth of their work life caring for hospitalized patients?

SHM defines hospitalists as “physicians whose primary professional focus is the general medical care of hospitalized patients. Their activities include patient care, teaching, research, and leadership related to hospital medicine.” Based on this definition, the doctor who spends one month annually caring for inpatients could be a hospitalist if the remainder of his work involved teaching, research, and leadership related to hospital medicine.

In your example, you cite two physicians on the peer-review committee: an office based internist and a cardiologist. Is it reasonable to consider their work similar to or different from that of a hospitalist? In the case of the internist, I think the key point is the fact you described him as office-based. That suggests to me his primary professional focus does not involve hospitalized patients.

One could argue that since both the hospitalist and the office-based internist were trained in internal medicine and both have American Board of Internal Medicine certification, they should be considered peers. I would point out that one’s specialty training has nothing to do with the definition of a hospitalist.

Although the majority of hospitalists in this country are internists, many others are family physicians and pediatricians. Some have subspecialty training, some don’t. Even obstetricians and surgeons are defining themselves as hospitalists.

With all that in mind, would we consider the cardiologist a hospitalist? Again, I think it would depend on the nature of the cardiologist practice. If this cardiologist has a primarily outpatient practice, that would be quite different from a hospitalist practice.

What if this cardiologist’s practice primarily is inpatient? I think it is reasonable to think about the scope of these physicians’ practices. Assuming the cardiologist practice is limited to the care of patients with primary cardiac issues, this would be a much narrower scope than that of most hospitalists.

It also is important to consider the training of the hospitalist. Take geriatrics hospitalists, for instance. The scope of their practice may be quite similar to that of a geriatrician who spends the majority of time caring for hospitalized patients.

Does the hospitalist have additional cardiology training? Does the focus of discussion at peer-review committee involve care of patients with primarily cardiac needs? The issue of which physicians should serve on peer-review committees when evaluating hospitalists is a complicated one that demands further scrutiny. TH

Maternity Maneuvers

How do most hospitalist groups manage maternity leave? I recently took six weeks for maternity leave. My colleagues worked my shifts, and I have virtually paid them all back. To do so I often would end up working 18 to 20 days consecutively and numerous weekends. This was not ideal on many levels. I most likely will not [receive a] bonus this year as well. Is there a better way?

New Mom in Midwest

Dr. Hospitalist responds: Congratulations on the birth of your child. As you recognize, becoming a parent is a wonderful experience but also can be stressful. It is not easy to balance the competing demands of family and work.

Medical leave is not unique to hospitalists—but with the average age of hospitalists being 37, it is commonplace to have hospitalist staff start families at this stage of their lives. In fact, as a hospitalist director, it would be foolish for me not to expect and plan for maternity and paternity leaves.

Medical leaves often are stressful for hospitalist programs because of the need to find replacement staff to fill the work schedule. There is no “best” way to cover the schedule during medical leaves. One thing is certain: Not offering medical leave is not only unrealistic, it may be against the law.

Hospitalist directors and those contemplating medical leave from work should familiarize themselves with the federal government’s Family Medical Leave Act (FMLA). Of course, I’m not an attorney; anyone who is looking for accurate advice concerning FMLA and other legal matters should consult a lawyer.

Briefly stated, the FMLA requires that “covered employers must grant an eligible employee up to a total of 12 work weeks of unpaid leave during any 12-month period for one or more of the following reasons:

• Birth and care of the newborn child of the employee;
• Placement with the employee of a son or daughter for adoption or foster care;
• To care for an immediate family member (spouse, child, or parent) with a serious health condition; or
• To take medical leave when the employee is unable to work because of a serious health condition.

It is important to know that the FMLA strictly defines eligibility criteria. For example, a covered employer is one who “employs 50 or more employees for each working day during each of 20 or more calendar work weeks in the current or preceding calendar year.” There also are strict criteria that define whether one is an eligible employee. It is important to note that FMLA does not guarantee paid time off—it only requires unpaid leave. You can find additional information about the FMLA online at the government’s Web site: www.dol.gov/esa/whd/fmla.

Peer Pressure

I am an attorney who often represents physicians in hospital peer-review matters. I represent a hospitalist whom the medical staff has recommended be terminated. Two internists have been appointed to the peer-review committee; one has an office-based practice, and the other is a cardiologist. Neither is a hospitalist.

I am trying to convince the medical staff that there should be a hospitalist on the peer-review committee because I believe what a hospitalist does each day is fundamentally different in scope and patient mix than the other two internists. My argument will be much stronger if it is the case that a hospitalist’s practice is now its own medical specialty.

Can you point me to any information or articles that support my belief that hospital practice is now a separate specialty?

Anxious Attorney

Dr. Hospitalist responds: Is a hospitalist practice sufficiently different than that of an office-based internist or cardiologist, so much so that peer-review activities would necessitate at a minimum some involvement of other hospitalists? To answer this question, I think we need to understand the definition of a hospitalist.

I recently heard a doctor describe himself as a hospitalist despite working clinically in the hospital only one month annually. Is he correct in defining himself as a hospitalist? If so, how would we distinguish him from primary care doctors who spend one-twelfth of their work life caring for hospitalized patients?

SHM defines hospitalists as “physicians whose primary professional focus is the general medical care of hospitalized patients. Their activities include patient care, teaching, research, and leadership related to hospital medicine.” Based on this definition, the doctor who spends one month annually caring for inpatients could be a hospitalist if the remainder of his work involved teaching, research, and leadership related to hospital medicine.

In your example, you cite two physicians on the peer-review committee: an office based internist and a cardiologist. Is it reasonable to consider their work similar to or different from that of a hospitalist? In the case of the internist, I think the key point is the fact you described him as office-based. That suggests to me his primary professional focus does not involve hospitalized patients.

One could argue that since both the hospitalist and the office-based internist were trained in internal medicine and both have American Board of Internal Medicine certification, they should be considered peers. I would point out that one’s specialty training has nothing to do with the definition of a hospitalist.

Although the majority of hospitalists in this country are internists, many others are family physicians and pediatricians. Some have subspecialty training, some don’t. Even obstetricians and surgeons are defining themselves as hospitalists.

With all that in mind, would we consider the cardiologist a hospitalist? Again, I think it would depend on the nature of the cardiologist practice. If this cardiologist has a primarily outpatient practice, that would be quite different from a hospitalist practice.

What if this cardiologist’s practice primarily is inpatient? I think it is reasonable to think about the scope of these physicians’ practices. Assuming the cardiologist practice is limited to the care of patients with primary cardiac issues, this would be a much narrower scope than that of most hospitalists.

It also is important to consider the training of the hospitalist. Take geriatrics hospitalists, for instance. The scope of their practice may be quite similar to that of a geriatrician who spends the majority of time caring for hospitalized patients.

Does the hospitalist have additional cardiology training? Does the focus of discussion at peer-review committee involve care of patients with primarily cardiac needs? The issue of which physicians should serve on peer-review committees when evaluating hospitalists is a complicated one that demands further scrutiny. TH

At the 2008 SHM Annual Meeting in San Diego, I had the pleasure of serving as moderator for a panel commenting on the opportunities and challenges faced by hospitalists. I’m not sure how well our predictions will withstand the test of time, but two things came up that I’ll discuss here:

1) Nearly every group is recruiting, and many seem to think the hospitalist shortage will last throughout the careers of those in practice today.

2) Nearly all hospitalist groups are looking for more doctors. I asked the approximately 1,600 in attendance how many are recruiting for more hospitalists. Nearly every hand in the room shot up. It was impressive; one friend (Bob Reynolds) told me he was sitting in the back and could feel a breeze in the room from all the hands being raised. Only about three hands went up when I asked how many thought their staffing was adequate.

Bear in mind that based on the show of hands nearly every group in the country is recruiting. Many groups are looking to add three to six hospitalists this year alone. This is on top of the average group growing about 20% to 25% the past two years, based on my study of data from the “Society of Hospital Medicine 2007-08 Survey: The Authoritative Source on the State of the Hospitalist Movement.” The survey showed the number of FTE doctors in the average hospitalist group grew from a median six to eight hospitalists (the average went from eight to 9.7).

Source: “Society of Hospital Medicine 2007-08 Survey: The Authoritative Source on the State of the Hospitalist Movement.”click for large version

Hospital medicine is the fastest-growing field in the history of American medicine, and it looks like the demand for hospitalists may be increasing even faster than the supply.

I was tempted to ask for a show of hands from doctors at the meeting who were looking for a hospitalist position, but feared it could disrupt the whole conference as those seeking new doctors pounced on the potential candidates in a piranha-like feeding frenzy. So there is good news for anyone interested in joining a hospitalist group: You should have a lot of choices. If you’re recruiting, you’d better get to work to make sure you have really good plan. Let me offer a few ideas.

Never stop recruiting. Dr. Greg Mappin, VPMA at Self Regional Hospital in Greenwood, S.C., told me his philosophy is to “recruit forever, and hire when necessary.” I agree.

You should build and maintain a robust candidate pipeline by ensuring your practice maintains a high level of visibility before your best source of new doctors. The best source for most groups is the closest residency training program, though other nearby hospitalist or outpatient practices might be a secondary source of new manpower.

I suggest you engage residents by hosting a dinner near their hospital once or twice a year and inviting all second- and third-year residents to attend regardless of their interest in becoming hospitalists. You might do this even in years you may not need to add hospitalists to ensure your dinner becomes a regular event for them and to ensure they’re very familiar with your program. Some hospitals develop night and weekend moonlighting programs that employ nearby residents, which increases the chance some will join the practice upon completion of their training.

Ensure all hospitalists—especially the group leader—actively participate in recruiting. Your hospital or medical group’s physician recruiter can be a terrific asset. He/she can provide advice regarding how to find candidates, arranging interviews, etc. Yet, it is critical for the hospitalist group leader to actively communicate with every candidate, including responding to every inquiry within a day or so.

Too many group leaders make a big mistake by waiting many days to respond to new inquiries, or letting the recruiter handle all communication in advance of an interview. During the interview, be sure the candidate spends time with many of the current group members and provides contact information for every group member in case the candidate would like to call any who weren’t available on the interview day. Consider providing the candidate with a copy of the group schedule, any orientation documents you have, and other such printed materials to review after the visit.

Recruit specifically for short-term members of your practice. Despite concerns about turnover, I think it is reasonable to actively pursue candidates who may have as little as two years to work in your practice. For example, they may plan to move to another town (e.g., when their spouse finishes training) or start fellowship training. In my experience, at least half of new doctors who plan to be a hospitalist for only a year or two will choose to stay on long term.

If you want your classified ad to stand out, think about writing one that specifically targets short-term hospitalists. It could say something like: “Do you have only two years to work as a hospitalist? Then this is the place for you.” You even could add benefits, such as tuition to attend conferences that would be of value for the doctor regardless of their future specialty or practice setting. If you desperately need additional doctors, get creative in recruiting those who plan to stay with you for only a couple years. I’m confident some will end up staying long term.

Continue “recruiting” the doctors in your practice. For a number of reasons, hospitalist turnover may be higher than most other specialties. So it is particularly important to take steps to minimize it. SHM’s white paper on hospitalist career satisfaction (“A Challenge for a New Specialty: A White Paper on Hospitalist Career Satisfaction”) offers observations and valuable suggestions for any practice. Find it under the “Publications” link on SHM’s Web site, www. hospitalmedicine.org.

No End to Shortage

Now back to that panel discussion at SHM’s Annual Meeting in April. I asked the panelists what things would be like if in 10 years the demand for hospitalists decreased, and the supply finally caught up with and ultimately exceeded demand.

I thought this could be a provocative question that would lead to a discussion about how much of our current situation, such as recent increases in hospital financial support provided per hospitalist, are due to the current hospitalist shortage. Will hospitals decrease their support if there is ever an excess of hospitalists?

No one was buying it. Everyone was convinced that despite the incredible growth in numbers of doctors practicing as hospitalists, the demand for hospitalists will continue to grow even faster than the supply. Panelist Ron Greeno, MD, FCCP, chief medical officer of Cogent Healthcare in Irvine, Calif., thought this hospitalist shortage would continue throughout our lifetime. I’m not sure how long Ron thinks he (or I) will live, but that’s a pretty bold prediction.

It looks like the current intense recruiting environment is here to stay for a long time. Every practice should be thinking about how best to manage it. TH

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

At the 2008 SHM Annual Meeting in San Diego, I had the pleasure of serving as moderator for a panel commenting on the opportunities and challenges faced by hospitalists. I’m not sure how well our predictions will withstand the test of time, but two things came up that I’ll discuss here:

1) Nearly every group is recruiting, and many seem to think the hospitalist shortage will last throughout the careers of those in practice today.

2) Nearly all hospitalist groups are looking for more doctors. I asked the approximately 1,600 in attendance how many are recruiting for more hospitalists. Nearly every hand in the room shot up. It was impressive; one friend (Bob Reynolds) told me he was sitting in the back and could feel a breeze in the room from all the hands being raised. Only about three hands went up when I asked how many thought their staffing was adequate.

Bear in mind that based on the show of hands nearly every group in the country is recruiting. Many groups are looking to add three to six hospitalists this year alone. This is on top of the average group growing about 20% to 25% the past two years, based on my study of data from the “Society of Hospital Medicine 2007-08 Survey: The Authoritative Source on the State of the Hospitalist Movement.” The survey showed the number of FTE doctors in the average hospitalist group grew from a median six to eight hospitalists (the average went from eight to 9.7).

Source: “Society of Hospital Medicine 2007-08 Survey: The Authoritative Source on the State of the Hospitalist Movement.”click for large version

Hospital medicine is the fastest-growing field in the history of American medicine, and it looks like the demand for hospitalists may be increasing even faster than the supply.

I was tempted to ask for a show of hands from doctors at the meeting who were looking for a hospitalist position, but feared it could disrupt the whole conference as those seeking new doctors pounced on the potential candidates in a piranha-like feeding frenzy. So there is good news for anyone interested in joining a hospitalist group: You should have a lot of choices. If you’re recruiting, you’d better get to work to make sure you have really good plan. Let me offer a few ideas.

Never stop recruiting. Dr. Greg Mappin, VPMA at Self Regional Hospital in Greenwood, S.C., told me his philosophy is to “recruit forever, and hire when necessary.” I agree.

You should build and maintain a robust candidate pipeline by ensuring your practice maintains a high level of visibility before your best source of new doctors. The best source for most groups is the closest residency training program, though other nearby hospitalist or outpatient practices might be a secondary source of new manpower.

I suggest you engage residents by hosting a dinner near their hospital once or twice a year and inviting all second- and third-year residents to attend regardless of their interest in becoming hospitalists. You might do this even in years you may not need to add hospitalists to ensure your dinner becomes a regular event for them and to ensure they’re very familiar with your program. Some hospitals develop night and weekend moonlighting programs that employ nearby residents, which increases the chance some will join the practice upon completion of their training.

Ensure all hospitalists—especially the group leader—actively participate in recruiting. Your hospital or medical group’s physician recruiter can be a terrific asset. He/she can provide advice regarding how to find candidates, arranging interviews, etc. Yet, it is critical for the hospitalist group leader to actively communicate with every candidate, including responding to every inquiry within a day or so.

Too many group leaders make a big mistake by waiting many days to respond to new inquiries, or letting the recruiter handle all communication in advance of an interview. During the interview, be sure the candidate spends time with many of the current group members and provides contact information for every group member in case the candidate would like to call any who weren’t available on the interview day. Consider providing the candidate with a copy of the group schedule, any orientation documents you have, and other such printed materials to review after the visit.

Recruit specifically for short-term members of your practice. Despite concerns about turnover, I think it is reasonable to actively pursue candidates who may have as little as two years to work in your practice. For example, they may plan to move to another town (e.g., when their spouse finishes training) or start fellowship training. In my experience, at least half of new doctors who plan to be a hospitalist for only a year or two will choose to stay on long term.

If you want your classified ad to stand out, think about writing one that specifically targets short-term hospitalists. It could say something like: “Do you have only two years to work as a hospitalist? Then this is the place for you.” You even could add benefits, such as tuition to attend conferences that would be of value for the doctor regardless of their future specialty or practice setting. If you desperately need additional doctors, get creative in recruiting those who plan to stay with you for only a couple years. I’m confident some will end up staying long term.

Continue “recruiting” the doctors in your practice. For a number of reasons, hospitalist turnover may be higher than most other specialties. So it is particularly important to take steps to minimize it. SHM’s white paper on hospitalist career satisfaction (“A Challenge for a New Specialty: A White Paper on Hospitalist Career Satisfaction”) offers observations and valuable suggestions for any practice. Find it under the “Publications” link on SHM’s Web site, www. hospitalmedicine.org.

No End to Shortage

Now back to that panel discussion at SHM’s Annual Meeting in April. I asked the panelists what things would be like if in 10 years the demand for hospitalists decreased, and the supply finally caught up with and ultimately exceeded demand.

I thought this could be a provocative question that would lead to a discussion about how much of our current situation, such as recent increases in hospital financial support provided per hospitalist, are due to the current hospitalist shortage. Will hospitals decrease their support if there is ever an excess of hospitalists?

No one was buying it. Everyone was convinced that despite the incredible growth in numbers of doctors practicing as hospitalists, the demand for hospitalists will continue to grow even faster than the supply. Panelist Ron Greeno, MD, FCCP, chief medical officer of Cogent Healthcare in Irvine, Calif., thought this hospitalist shortage would continue throughout our lifetime. I’m not sure how long Ron thinks he (or I) will live, but that’s a pretty bold prediction.

It looks like the current intense recruiting environment is here to stay for a long time. Every practice should be thinking about how best to manage it. TH

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

At the 2008 SHM Annual Meeting in San Diego, I had the pleasure of serving as moderator for a panel commenting on the opportunities and challenges faced by hospitalists. I’m not sure how well our predictions will withstand the test of time, but two things came up that I’ll discuss here:

1) Nearly every group is recruiting, and many seem to think the hospitalist shortage will last throughout the careers of those in practice today.

2) Nearly all hospitalist groups are looking for more doctors. I asked the approximately 1,600 in attendance how many are recruiting for more hospitalists. Nearly every hand in the room shot up. It was impressive; one friend (Bob Reynolds) told me he was sitting in the back and could feel a breeze in the room from all the hands being raised. Only about three hands went up when I asked how many thought their staffing was adequate.

Bear in mind that based on the show of hands nearly every group in the country is recruiting. Many groups are looking to add three to six hospitalists this year alone. This is on top of the average group growing about 20% to 25% the past two years, based on my study of data from the “Society of Hospital Medicine 2007-08 Survey: The Authoritative Source on the State of the Hospitalist Movement.” The survey showed the number of FTE doctors in the average hospitalist group grew from a median six to eight hospitalists (the average went from eight to 9.7).

Source: “Society of Hospital Medicine 2007-08 Survey: The Authoritative Source on the State of the Hospitalist Movement.”click for large version

Hospital medicine is the fastest-growing field in the history of American medicine, and it looks like the demand for hospitalists may be increasing even faster than the supply.

I was tempted to ask for a show of hands from doctors at the meeting who were looking for a hospitalist position, but feared it could disrupt the whole conference as those seeking new doctors pounced on the potential candidates in a piranha-like feeding frenzy. So there is good news for anyone interested in joining a hospitalist group: You should have a lot of choices. If you’re recruiting, you’d better get to work to make sure you have really good plan. Let me offer a few ideas.

Never stop recruiting. Dr. Greg Mappin, VPMA at Self Regional Hospital in Greenwood, S.C., told me his philosophy is to “recruit forever, and hire when necessary.” I agree.

You should build and maintain a robust candidate pipeline by ensuring your practice maintains a high level of visibility before your best source of new doctors. The best source for most groups is the closest residency training program, though other nearby hospitalist or outpatient practices might be a secondary source of new manpower.

I suggest you engage residents by hosting a dinner near their hospital once or twice a year and inviting all second- and third-year residents to attend regardless of their interest in becoming hospitalists. You might do this even in years you may not need to add hospitalists to ensure your dinner becomes a regular event for them and to ensure they’re very familiar with your program. Some hospitals develop night and weekend moonlighting programs that employ nearby residents, which increases the chance some will join the practice upon completion of their training.

Ensure all hospitalists—especially the group leader—actively participate in recruiting. Your hospital or medical group’s physician recruiter can be a terrific asset. He/she can provide advice regarding how to find candidates, arranging interviews, etc. Yet, it is critical for the hospitalist group leader to actively communicate with every candidate, including responding to every inquiry within a day or so.

Too many group leaders make a big mistake by waiting many days to respond to new inquiries, or letting the recruiter handle all communication in advance of an interview. During the interview, be sure the candidate spends time with many of the current group members and provides contact information for every group member in case the candidate would like to call any who weren’t available on the interview day. Consider providing the candidate with a copy of the group schedule, any orientation documents you have, and other such printed materials to review after the visit.

Recruit specifically for short-term members of your practice. Despite concerns about turnover, I think it is reasonable to actively pursue candidates who may have as little as two years to work in your practice. For example, they may plan to move to another town (e.g., when their spouse finishes training) or start fellowship training. In my experience, at least half of new doctors who plan to be a hospitalist for only a year or two will choose to stay on long term.

If you want your classified ad to stand out, think about writing one that specifically targets short-term hospitalists. It could say something like: “Do you have only two years to work as a hospitalist? Then this is the place for you.” You even could add benefits, such as tuition to attend conferences that would be of value for the doctor regardless of their future specialty or practice setting. If you desperately need additional doctors, get creative in recruiting those who plan to stay with you for only a couple years. I’m confident some will end up staying long term.

Continue “recruiting” the doctors in your practice. For a number of reasons, hospitalist turnover may be higher than most other specialties. So it is particularly important to take steps to minimize it. SHM’s white paper on hospitalist career satisfaction (“A Challenge for a New Specialty: A White Paper on Hospitalist Career Satisfaction”) offers observations and valuable suggestions for any practice. Find it under the “Publications” link on SHM’s Web site, www. hospitalmedicine.org.

No End to Shortage

Now back to that panel discussion at SHM’s Annual Meeting in April. I asked the panelists what things would be like if in 10 years the demand for hospitalists decreased, and the supply finally caught up with and ultimately exceeded demand.

I thought this could be a provocative question that would lead to a discussion about how much of our current situation, such as recent increases in hospital financial support provided per hospitalist, are due to the current hospitalist shortage. Will hospitals decrease their support if there is ever an excess of hospitalists?

No one was buying it. Everyone was convinced that despite the incredible growth in numbers of doctors practicing as hospitalists, the demand for hospitalists will continue to grow even faster than the supply. Panelist Ron Greeno, MD, FCCP, chief medical officer of Cogent Healthcare in Irvine, Calif., thought this hospitalist shortage would continue throughout our lifetime. I’m not sure how long Ron thinks he (or I) will live, but that’s a pretty bold prediction.

It looks like the current intense recruiting environment is here to stay for a long time. Every practice should be thinking about how best to manage it. TH

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

A sea of pimples and drooling yawns. That’s what was staring, glassy-eyed back at me.

More realistically they were staring through me—through space, actually—to 50 minutes into the future. The look inhabited the hinterlands between boredom and loathing. A less-trained eye would mistake their tranquil countenances as anticipatory rapture. However, years of educating medical students and residents taught me that this was the look of those residing serenely in their own world, eons away from the classroom.

Then the ring of the first-period bell jolted me from my thoughts.

It was 7:45 a.m., and I found myself back at my hometown high school—jettisoned 20 years back in time. Months earlier I had agreed to teach a health and biology class as a visiting teacher as part of a career-planning program. I was instructed to teach them about what I do in my professional life. At the time I foolishly imagined a cohort of eagerly engrossed students hanging on my every word. What I found was more in line with a pack of sedated sloths sleepily hanging from the tedium tree.

My folly became even more obvious when I introduced my title slide: “The Epidemic of Medical Error.”

What was I thinking trying to teach 14-year-old kids about patient safety and medical error? Months before the talk I had agreed to this topic only after the principal assured me this would be of great interest to high school freshman and sophomores. It wasn’t until the week before the talk that the unease set in.

Could I really interest hormone-raged pubescent teenagers in the intricacies of hospital patient safety? My wife, ever helpful, was instrumental in triggering this epiphany. She noted that 14-year-olds are really only interested in … well, nothing. The prospect of engaging them in the complexities of hospital healthcare seemed about as likely as getting a trout excited over a fish fry.

Engaged they were not; in fact, some narcoleptic kid in the back had already engaged REM sleep. I was only four minutes into this and I was already foundering miserably. I had become that teacher. You know the one. He is so exceptionally mind-numbing that you wonder if he was brought in as some sort of social experiment testing the currently known limits of boredom.

Then someone had an, er, gastric accident.

The ensuing hilarity made it difficult to pinpoint the exact source or even if this was a true gastroenterological event or its ever-comical cousin, the armpit version. Now, I’m young enough to remember the comic genius of well-timed and executed classroom flatus. As such I understood that this was clearly intended as a territorial marking. The natives had spoken; there was an enemy among them.

As the clock metamorphosed into one of those melting Dali timepieces, we commenced discussion of three cases. The first involved a man who had the wrong leg amputated. The second reviewed the case of young women who suffered devastating consequences after an ICU medication was dropped off her medication list upon transfer to a medical ward team. The final case involved a patient with a myocardial infarction who did not receive aspirin upon admission to the hospital.

An interesting thing happened after I presented the first case. They were interested. It seems cutting off the wrong leg resonates with high school students. Moreover they were aghast that these types of medical errors were occurring. They were shocked that such smart people could make such dumb mistakes. Mr. Narcolepsy slid out of stage 1 sleep long enough to sarcastically note that even he knew that heart attack patients should get aspirin.

I asked them how they thought we could avoid these mistakes. A girl in the front wondered if we couldn’t just ask the patient which leg they wanted cut off. I noted that patients are anesthetized when we meet them for the surgery. She then proffered that perhaps we could ask them while they were awake and then mark the correct leg with a marker prior to going into the operating room.

Regarding the ICU transfer patient who had a medication drop off her med list, a quiet kid in the front asked, “Why don’t you just compare the list of medications used in the ICU to those outside of the ICU?” Another suggested that the two different teams of doctors could sit down and discuss the patient’s medications to be sure nothing was left off.

They wondered if we could avoid forgetting important medications—such as was done with the aspirin for the MI patient—by making a list of the things every patient with a heart attack would need. For example, didn’t they need an EKG, some lab tests, and some medications? Wouldn’t it be best to just have this list so that we didn’t have to remember all these things?

Unwittingly, these teen-agers—none old enough to shave—had just in their own words recited some of the key tenets of the patient safety movement:

• Active communication with the patient prior to surgery;
• Time out prior to surgery to ensure correct patient and surgery;
• Marking the site of surgery;
• Improved communication around patient handoffs;
• Medication reconciliation at every transfer of care; and
• Use of protocols to ensure best practices.

I was floored. In 30 minutes, a group of teenagers had developed a list of hospital safety measures that it has taken modern medicine generations to grasp.

The amount of medical errors has risen in step with the complexity of the medical care we provide. However, this does not mean that the causes of these medical errors are complex. Rather, most errors result from simple mistakes and systems issues. In fact, as I was taught on that fateful spring morning, I learned everything I need to know about patient safety in high school. TH

Dr. Glasheen is associate professor of medicine at the University of Colorado, Denver, where he serves as director of the Hospital Medicine Program and the Hospitalist Training Program, and as associate program director of the Internal Medicine Residency Program.

A sea of pimples and drooling yawns. That’s what was staring, glassy-eyed back at me.

More realistically they were staring through me—through space, actually—to 50 minutes into the future. The look inhabited the hinterlands between boredom and loathing. A less-trained eye would mistake their tranquil countenances as anticipatory rapture. However, years of educating medical students and residents taught me that this was the look of those residing serenely in their own world, eons away from the classroom.

Then the ring of the first-period bell jolted me from my thoughts.

It was 7:45 a.m., and I found myself back at my hometown high school—jettisoned 20 years back in time. Months earlier I had agreed to teach a health and biology class as a visiting teacher as part of a career-planning program. I was instructed to teach them about what I do in my professional life. At the time I foolishly imagined a cohort of eagerly engrossed students hanging on my every word. What I found was more in line with a pack of sedated sloths sleepily hanging from the tedium tree.

My folly became even more obvious when I introduced my title slide: “The Epidemic of Medical Error.”

What was I thinking trying to teach 14-year-old kids about patient safety and medical error? Months before the talk I had agreed to this topic only after the principal assured me this would be of great interest to high school freshman and sophomores. It wasn’t until the week before the talk that the unease set in.

Could I really interest hormone-raged pubescent teenagers in the intricacies of hospital patient safety? My wife, ever helpful, was instrumental in triggering this epiphany. She noted that 14-year-olds are really only interested in … well, nothing. The prospect of engaging them in the complexities of hospital healthcare seemed about as likely as getting a trout excited over a fish fry.

Engaged they were not; in fact, some narcoleptic kid in the back had already engaged REM sleep. I was only four minutes into this and I was already foundering miserably. I had become that teacher. You know the one. He is so exceptionally mind-numbing that you wonder if he was brought in as some sort of social experiment testing the currently known limits of boredom.

Then someone had an, er, gastric accident.

The ensuing hilarity made it difficult to pinpoint the exact source or even if this was a true gastroenterological event or its ever-comical cousin, the armpit version. Now, I’m young enough to remember the comic genius of well-timed and executed classroom flatus. As such I understood that this was clearly intended as a territorial marking. The natives had spoken; there was an enemy among them.

As the clock metamorphosed into one of those melting Dali timepieces, we commenced discussion of three cases. The first involved a man who had the wrong leg amputated. The second reviewed the case of young women who suffered devastating consequences after an ICU medication was dropped off her medication list upon transfer to a medical ward team. The final case involved a patient with a myocardial infarction who did not receive aspirin upon admission to the hospital.

An interesting thing happened after I presented the first case. They were interested. It seems cutting off the wrong leg resonates with high school students. Moreover they were aghast that these types of medical errors were occurring. They were shocked that such smart people could make such dumb mistakes. Mr. Narcolepsy slid out of stage 1 sleep long enough to sarcastically note that even he knew that heart attack patients should get aspirin.

I asked them how they thought we could avoid these mistakes. A girl in the front wondered if we couldn’t just ask the patient which leg they wanted cut off. I noted that patients are anesthetized when we meet them for the surgery. She then proffered that perhaps we could ask them while they were awake and then mark the correct leg with a marker prior to going into the operating room.

Regarding the ICU transfer patient who had a medication drop off her med list, a quiet kid in the front asked, “Why don’t you just compare the list of medications used in the ICU to those outside of the ICU?” Another suggested that the two different teams of doctors could sit down and discuss the patient’s medications to be sure nothing was left off.

They wondered if we could avoid forgetting important medications—such as was done with the aspirin for the MI patient—by making a list of the things every patient with a heart attack would need. For example, didn’t they need an EKG, some lab tests, and some medications? Wouldn’t it be best to just have this list so that we didn’t have to remember all these things?

Unwittingly, these teen-agers—none old enough to shave—had just in their own words recited some of the key tenets of the patient safety movement:

• Active communication with the patient prior to surgery;
• Time out prior to surgery to ensure correct patient and surgery;
• Marking the site of surgery;
• Improved communication around patient handoffs;
• Medication reconciliation at every transfer of care; and
• Use of protocols to ensure best practices.

I was floored. In 30 minutes, a group of teenagers had developed a list of hospital safety measures that it has taken modern medicine generations to grasp.

The amount of medical errors has risen in step with the complexity of the medical care we provide. However, this does not mean that the causes of these medical errors are complex. Rather, most errors result from simple mistakes and systems issues. In fact, as I was taught on that fateful spring morning, I learned everything I need to know about patient safety in high school. TH

Dr. Glasheen is associate professor of medicine at the University of Colorado, Denver, where he serves as director of the Hospital Medicine Program and the Hospitalist Training Program, and as associate program director of the Internal Medicine Residency Program.

A sea of pimples and drooling yawns. That’s what was staring, glassy-eyed back at me.

More realistically they were staring through me—through space, actually—to 50 minutes into the future. The look inhabited the hinterlands between boredom and loathing. A less-trained eye would mistake their tranquil countenances as anticipatory rapture. However, years of educating medical students and residents taught me that this was the look of those residing serenely in their own world, eons away from the classroom.

Then the ring of the first-period bell jolted me from my thoughts.

It was 7:45 a.m., and I found myself back at my hometown high school—jettisoned 20 years back in time. Months earlier I had agreed to teach a health and biology class as a visiting teacher as part of a career-planning program. I was instructed to teach them about what I do in my professional life. At the time I foolishly imagined a cohort of eagerly engrossed students hanging on my every word. What I found was more in line with a pack of sedated sloths sleepily hanging from the tedium tree.

My folly became even more obvious when I introduced my title slide: “The Epidemic of Medical Error.”

What was I thinking trying to teach 14-year-old kids about patient safety and medical error? Months before the talk I had agreed to this topic only after the principal assured me this would be of great interest to high school freshman and sophomores. It wasn’t until the week before the talk that the unease set in.

Could I really interest hormone-raged pubescent teenagers in the intricacies of hospital patient safety? My wife, ever helpful, was instrumental in triggering this epiphany. She noted that 14-year-olds are really only interested in … well, nothing. The prospect of engaging them in the complexities of hospital healthcare seemed about as likely as getting a trout excited over a fish fry.

Engaged they were not; in fact, some narcoleptic kid in the back had already engaged REM sleep. I was only four minutes into this and I was already foundering miserably. I had become that teacher. You know the one. He is so exceptionally mind-numbing that you wonder if he was brought in as some sort of social experiment testing the currently known limits of boredom.

Then someone had an, er, gastric accident.

The ensuing hilarity made it difficult to pinpoint the exact source or even if this was a true gastroenterological event or its ever-comical cousin, the armpit version. Now, I’m young enough to remember the comic genius of well-timed and executed classroom flatus. As such I understood that this was clearly intended as a territorial marking. The natives had spoken; there was an enemy among them.

As the clock metamorphosed into one of those melting Dali timepieces, we commenced discussion of three cases. The first involved a man who had the wrong leg amputated. The second reviewed the case of young women who suffered devastating consequences after an ICU medication was dropped off her medication list upon transfer to a medical ward team. The final case involved a patient with a myocardial infarction who did not receive aspirin upon admission to the hospital.

An interesting thing happened after I presented the first case. They were interested. It seems cutting off the wrong leg resonates with high school students. Moreover they were aghast that these types of medical errors were occurring. They were shocked that such smart people could make such dumb mistakes. Mr. Narcolepsy slid out of stage 1 sleep long enough to sarcastically note that even he knew that heart attack patients should get aspirin.

I asked them how they thought we could avoid these mistakes. A girl in the front wondered if we couldn’t just ask the patient which leg they wanted cut off. I noted that patients are anesthetized when we meet them for the surgery. She then proffered that perhaps we could ask them while they were awake and then mark the correct leg with a marker prior to going into the operating room.

Regarding the ICU transfer patient who had a medication drop off her med list, a quiet kid in the front asked, “Why don’t you just compare the list of medications used in the ICU to those outside of the ICU?” Another suggested that the two different teams of doctors could sit down and discuss the patient’s medications to be sure nothing was left off.

They wondered if we could avoid forgetting important medications—such as was done with the aspirin for the MI patient—by making a list of the things every patient with a heart attack would need. For example, didn’t they need an EKG, some lab tests, and some medications? Wouldn’t it be best to just have this list so that we didn’t have to remember all these things?

Unwittingly, these teen-agers—none old enough to shave—had just in their own words recited some of the key tenets of the patient safety movement:

• Active communication with the patient prior to surgery;
• Time out prior to surgery to ensure correct patient and surgery;
• Marking the site of surgery;
• Improved communication around patient handoffs;
• Medication reconciliation at every transfer of care; and
• Use of protocols to ensure best practices.

I was floored. In 30 minutes, a group of teenagers had developed a list of hospital safety measures that it has taken modern medicine generations to grasp.

The amount of medical errors has risen in step with the complexity of the medical care we provide. However, this does not mean that the causes of these medical errors are complex. Rather, most errors result from simple mistakes and systems issues. In fact, as I was taught on that fateful spring morning, I learned everything I need to know about patient safety in high school. TH

Dr. Glasheen is associate professor of medicine at the University of Colorado, Denver, where he serves as director of the Hospital Medicine Program and the Hospitalist Training Program, and as associate program director of the Internal Medicine Residency Program.