Gil Porat, MD

Many hospitalists face mysteries at work every day: a new admission’s enigmatic symptoms, inexplicable protocols for coding and other documentation—even the mystery of the missing chart.

One physician has created a much greater and more interesting mystery. Gil Porat, MD, a hospitalist with Colorado Springs Health Partners, just had his first novel, The Other Face of Murder, published by Alondra Press in April.

A Second Career

Dr. Porat worked on the novel steadily for years, starting during his residency. “I’ve been practicing medicine as a hospitalist for about five years now, so this novel has been a longer journey than medical school for me,” he admits.

His regular schedule, along with his dedication to writing, allowed him to finish the novel while working full time. “As a hospitalist, I work seven days on, seven days off, and that’s a terrific way to manage a second career,” explains Dr. Porat. “I spend my week off with my family—I have a wife and two boys—and on writing.”

Heavy Subject

The Other Face of Murder opens with a young physician stumbling across the corpse of his friend after hosting a dinner party. While it’s an entertaining mystery, the book also addresses deeper themes. As the physician investigates his friend’s untimely demise, he discovers not just “whodunit,” but ethical controversies behind the death.

“I did my residency in Oregon, which is the only state that has legalized physician-assisted suicide,” Dr. Porat notes. “The book discusses this, but it also discusses a lot of bioethical conundrums in medicine, including end-of-life care. It always disturbs physicians and staff to see a lot of suffering in end-of-life care; a big theme in the book is that we should be doing more palliative care [for these patients] and less intrusive care.”

Dr. Porat says he wrote the book for average mystery readers who may not be aware of these medical issues.

“My goal was to do more than just entertain; I wanted to teach some of the lessons that I’ve learned along the way,” he says. “Very little is heard in society regarding end-of-life issues. I hope this book will stimulate discussion about this in the general public.”

With his first published novel on the shelves, Dr. Porat has not taken a break. “I’m already working on a second book,” he says, “and that too will have a medical theme.” TH

Jane Jerrard is a medical writer based in Chicago.

Gil Porat, MD

Many hospitalists face mysteries at work every day: a new admission’s enigmatic symptoms, inexplicable protocols for coding and other documentation—even the mystery of the missing chart.

One physician has created a much greater and more interesting mystery. Gil Porat, MD, a hospitalist with Colorado Springs Health Partners, just had his first novel, The Other Face of Murder, published by Alondra Press in April.

A Second Career

Dr. Porat worked on the novel steadily for years, starting during his residency. “I’ve been practicing medicine as a hospitalist for about five years now, so this novel has been a longer journey than medical school for me,” he admits.

His regular schedule, along with his dedication to writing, allowed him to finish the novel while working full time. “As a hospitalist, I work seven days on, seven days off, and that’s a terrific way to manage a second career,” explains Dr. Porat. “I spend my week off with my family—I have a wife and two boys—and on writing.”

Heavy Subject

The Other Face of Murder opens with a young physician stumbling across the corpse of his friend after hosting a dinner party. While it’s an entertaining mystery, the book also addresses deeper themes. As the physician investigates his friend’s untimely demise, he discovers not just “whodunit,” but ethical controversies behind the death.

“I did my residency in Oregon, which is the only state that has legalized physician-assisted suicide,” Dr. Porat notes. “The book discusses this, but it also discusses a lot of bioethical conundrums in medicine, including end-of-life care. It always disturbs physicians and staff to see a lot of suffering in end-of-life care; a big theme in the book is that we should be doing more palliative care [for these patients] and less intrusive care.”

Dr. Porat says he wrote the book for average mystery readers who may not be aware of these medical issues.

“My goal was to do more than just entertain; I wanted to teach some of the lessons that I’ve learned along the way,” he says. “Very little is heard in society regarding end-of-life issues. I hope this book will stimulate discussion about this in the general public.”

With his first published novel on the shelves, Dr. Porat has not taken a break. “I’m already working on a second book,” he says, “and that too will have a medical theme.” TH

Jane Jerrard is a medical writer based in Chicago.

Gil Porat, MD

Many hospitalists face mysteries at work every day: a new admission’s enigmatic symptoms, inexplicable protocols for coding and other documentation—even the mystery of the missing chart.

One physician has created a much greater and more interesting mystery. Gil Porat, MD, a hospitalist with Colorado Springs Health Partners, just had his first novel, The Other Face of Murder, published by Alondra Press in April.

A Second Career

Dr. Porat worked on the novel steadily for years, starting during his residency. “I’ve been practicing medicine as a hospitalist for about five years now, so this novel has been a longer journey than medical school for me,” he admits.

His regular schedule, along with his dedication to writing, allowed him to finish the novel while working full time. “As a hospitalist, I work seven days on, seven days off, and that’s a terrific way to manage a second career,” explains Dr. Porat. “I spend my week off with my family—I have a wife and two boys—and on writing.”

Heavy Subject

The Other Face of Murder opens with a young physician stumbling across the corpse of his friend after hosting a dinner party. While it’s an entertaining mystery, the book also addresses deeper themes. As the physician investigates his friend’s untimely demise, he discovers not just “whodunit,” but ethical controversies behind the death.

“I did my residency in Oregon, which is the only state that has legalized physician-assisted suicide,” Dr. Porat notes. “The book discusses this, but it also discusses a lot of bioethical conundrums in medicine, including end-of-life care. It always disturbs physicians and staff to see a lot of suffering in end-of-life care; a big theme in the book is that we should be doing more palliative care [for these patients] and less intrusive care.”

Dr. Porat says he wrote the book for average mystery readers who may not be aware of these medical issues.

“My goal was to do more than just entertain; I wanted to teach some of the lessons that I’ve learned along the way,” he says. “Very little is heard in society regarding end-of-life issues. I hope this book will stimulate discussion about this in the general public.”

With his first published novel on the shelves, Dr. Porat has not taken a break. “I’m already working on a second book,” he says, “and that too will have a medical theme.” TH

Jane Jerrard is a medical writer based in Chicago.

There is an increasing debate in major academic medical centers across the county on where hospitalists fit in the organizational structure—and consequently what resources, prestige, and power they will have.

The movement of academic hospitalists toward autonomy may be inevitable. Community hospitalists are less affected by the separation issue, most agree, because a community hospital may have fewer hospitalists who relish remaining in general internal medicine divisions. Conversely, they may have their own division because they are not driven by research or teaching. Either structure seems to work well in a community setting.

Even those who want academic hospitalists to remain firmly ensconced in divisions of general internal medicine realize it may be a losing battle as hospitalist groups increase in size, depth, and importance. So they caution: “Not so fast.”

Hospitalists would be better off remaining in divisions of general internal medicine and “learning from the mistakes we’ve made over the last 25 years,” says Bob Centor, MD, professor and director of the division of general internal medicine at the University of Alabama at Birmingham and associate dean for the Huntsville Regional Medical campus.

While Dr. Centor acknowledges it’s not always wrong to have a separate division, he believes leadership in general medicine divisions can help hospitalists succeed in their careers and negotiate academic politics to better advance their interests.

Early Stirrings

The independence movement began about two years ago when some academic hospitalists formed separate divisions, frustrated by chairs of general internal medicine “who just didn’t get it,” says Dr. Centor.

Others have found support from division chiefs who worked to develop academic hospitalists and encouraged them to go out on their own.

Academic hospitalists at the University of California, San Francisco’s (UCSF) school of medicine became a separate division two years ago. The move was encouraged by its division of general internal medicine chief, according to Bob Wachter, MD, hospitalist division chief at UCSF who coined the term hospitalist. “After 10 years of growth, we had 38 academic hospitalists, 10 assistant professors, many faculty with impressive accomplishments, a robust research department and the support of the chief,” he says. “Clearly we were ready.”

Separation has become a hot topic as the numbers of hospitalist faculty reach critical mass in academic medical centers, with some hospitalists’ departments having larger faculties than any other specialty within the division.

While it may be time for hospitalists to separate in large medical centers, that may not be the case at smaller schools,” says Karen DeSalvo, MD, MPH, MSc, chief of general internal medicine and geriatrics, Tulane School of Medicine in New Orleans, and president-elect of the Association of Chiefs of General Internal Medicine. “For smaller medical schools, it just doesn’t make sense financially to have a separate division.”

A school’s culture also can be a barrier to separation, she points out. Tulane takes a multidisciplinary approach to teaching with faculty encouraged to work across traditional specialty areas. This is easier when hospitalists are in the same division, she says.

However, size is not the only requirement for divisions in medical schools. “The goals of divisions within the infrastructure of medical centers are clinical care, teaching, and research,” says SHM President-elect Scott A. Flanders, MD, associate professor of medicine at the University of Michigan, Ann Arbor. “While most hospitalist programs at major academic medical centers do a great job with clinical care and many have teaching success, very few have succeeded in developing robust research programs.” Until this happens, hospitalists should remain in divisions of general internal medicine and take advantage of their resources to develop research programs and faculty, he says.

Dr. Wachter agrees: “It’s not just size. It’s also scope and accomplishments and whether your leader is experienced enough and strong enough to go toe to toe with other division chiefs.”

Anticipate Demand

Dr. Flanders says the controversy has heated up as academic medical centers seek to recruit leaders for large hospitalist programs. “They dangle the division chief position as a tool to recruit from the small pool of experienced academic hospitalists who could head a program,” he says. Along with creating a division comes a package of incentives, such as tenure, investments in building the academic and research components, power, and prestige.

That was the case at Northwestern University’s Feinberg School of Medicine, which lured Mark Williams, MD, away from 18 years at Emory University to head a new division of hospital medicine. Dr. Williams, editor of the Journal of Hospital Medicine, believes it’s important for hospitalists to have a separate division so they are at the same level as the other academic specialties. “That’s why I came to Northwestern,” he says. “I think it’s essential that hospitalists have division status so they are present at the table when decisions are made about investments in research, coverage, teaching of residents, and particularly budgetary matters.”

However, Dr. DeSalvo points out that there are not enough experienced academic hospitalists to head divisions in all medical schools. “If we were to say tomorrow that all hospitalists should have their own divisions, there would not be enough experienced people to head all those divisions,” he stresses. “So if it’s going to happen, it will happen over time.” In the meantime, it’s important that schools mentor and train academic hospitalists who could be division chiefs, she says.

The issue has become a priority for SHM and the Society of General Internal Medicine (SGIM), which have created task forces to find ways to help academic hospitalists advance their careers without “isolating themselves as to site of care,” Dr. Centor says. “Hospitalists are complementary to outpatient physicians and vice versa. They have to talk to each other, and the general internal medicine division structure provides that.”

Fault Lines

Hospitalists and general internists have more in common and more reasons to stay together than to separate, according to Dr. Centor. “Internists and hospitalists both concentrate on taking care of the whole patient and see patients who have multiple diseases.” Their issues are the same: advancing their careers, creating knowledge, and developing better teaching methods, he says. “Exactly the same issues general internal medicine has been working on for the last 25 years,” he explains.

General internists worry hospitalists are dichotomizing internal medicine and their careers by separating. “If you have a division of inpatient medicine and a division of outpatient medicine, it becomes harder for hospitalists to switch to outpatient medicine when they burn out,” Dr. Centor says.

Dr. Williams says hospitalist burnout is a myth: “People keep bringing up hospitalist burnout as a threat. It’s not a problem. We have programs in which the original hospitalists have been practicing since 1988 and are still enjoying doing it.”

The question of where academic hospitalists, with so few older physicians in its ranks, will find mentors concerns those opposed to separate divisions. Dr. Williams says there is nothing preventing general internal medicine physicians from mentoring hospitalists whether or not they are in a separate division.

Dr. Wachter says strong division leaders help academic hospitalists find mentors among more experienced physicians in other divisions and even at other institutions.

Some general internists and hospitalists believe separation is an academic issue that doesn’t affect patient care. Dr. Williams disagrees. “Decisions on whether hospitalists are going to be the primary people delivering care to patients can affect budgetary, scheduling, and training issue, which ultimately affect patients,” he counters.

Academic turf wars, politics, and allocation of resources also play into the desire to keep hospitalists within divisions of general internal medicine. “Many chiefs don’t want them to separate because they see it as a reduction or fracturing of their division’s resources, both financial and human,” Dr. Flanders says.

Academic hospitalists who remain within divisions of general internal medicine need the support of those divisions. The SGIM task force recommended that divisions provide leadership to support hospitalists, build mentorships, create sustainable academic jobs, and value the education and quality improvement work of hospitalists, according to Dr. Flanders.

Many believe the independence of hospitalists is inevitable. “It’s where we are heading, and we will get there,” says Dr. Flanders.

Dr. Wachter says academic hospitalists are following the predictable “organizational rules of gravity. You start small and you build and you become more independent. Those who need parenting, over time, become adolescents and go to college and become independent. That’s just the nature of the beast,” he says. “It won’t happen at every place at the same minute, but I’ll be very surprised if 10 years from now, there aren’t very few academic hospitalists groups of any size that are not freestanding divisions.” TH

Barbara Dillard is a medical journalist based in Chicago.

There is an increasing debate in major academic medical centers across the county on where hospitalists fit in the organizational structure—and consequently what resources, prestige, and power they will have.

The movement of academic hospitalists toward autonomy may be inevitable. Community hospitalists are less affected by the separation issue, most agree, because a community hospital may have fewer hospitalists who relish remaining in general internal medicine divisions. Conversely, they may have their own division because they are not driven by research or teaching. Either structure seems to work well in a community setting.

Even those who want academic hospitalists to remain firmly ensconced in divisions of general internal medicine realize it may be a losing battle as hospitalist groups increase in size, depth, and importance. So they caution: “Not so fast.”

Hospitalists would be better off remaining in divisions of general internal medicine and “learning from the mistakes we’ve made over the last 25 years,” says Bob Centor, MD, professor and director of the division of general internal medicine at the University of Alabama at Birmingham and associate dean for the Huntsville Regional Medical campus.

While Dr. Centor acknowledges it’s not always wrong to have a separate division, he believes leadership in general medicine divisions can help hospitalists succeed in their careers and negotiate academic politics to better advance their interests.

Early Stirrings

The independence movement began about two years ago when some academic hospitalists formed separate divisions, frustrated by chairs of general internal medicine “who just didn’t get it,” says Dr. Centor.

Others have found support from division chiefs who worked to develop academic hospitalists and encouraged them to go out on their own.

Academic hospitalists at the University of California, San Francisco’s (UCSF) school of medicine became a separate division two years ago. The move was encouraged by its division of general internal medicine chief, according to Bob Wachter, MD, hospitalist division chief at UCSF who coined the term hospitalist. “After 10 years of growth, we had 38 academic hospitalists, 10 assistant professors, many faculty with impressive accomplishments, a robust research department and the support of the chief,” he says. “Clearly we were ready.”

Separation has become a hot topic as the numbers of hospitalist faculty reach critical mass in academic medical centers, with some hospitalists’ departments having larger faculties than any other specialty within the division.

While it may be time for hospitalists to separate in large medical centers, that may not be the case at smaller schools,” says Karen DeSalvo, MD, MPH, MSc, chief of general internal medicine and geriatrics, Tulane School of Medicine in New Orleans, and president-elect of the Association of Chiefs of General Internal Medicine. “For smaller medical schools, it just doesn’t make sense financially to have a separate division.”

A school’s culture also can be a barrier to separation, she points out. Tulane takes a multidisciplinary approach to teaching with faculty encouraged to work across traditional specialty areas. This is easier when hospitalists are in the same division, she says.

However, size is not the only requirement for divisions in medical schools. “The goals of divisions within the infrastructure of medical centers are clinical care, teaching, and research,” says SHM President-elect Scott A. Flanders, MD, associate professor of medicine at the University of Michigan, Ann Arbor. “While most hospitalist programs at major academic medical centers do a great job with clinical care and many have teaching success, very few have succeeded in developing robust research programs.” Until this happens, hospitalists should remain in divisions of general internal medicine and take advantage of their resources to develop research programs and faculty, he says.

Dr. Wachter agrees: “It’s not just size. It’s also scope and accomplishments and whether your leader is experienced enough and strong enough to go toe to toe with other division chiefs.”

Anticipate Demand

Dr. Flanders says the controversy has heated up as academic medical centers seek to recruit leaders for large hospitalist programs. “They dangle the division chief position as a tool to recruit from the small pool of experienced academic hospitalists who could head a program,” he says. Along with creating a division comes a package of incentives, such as tenure, investments in building the academic and research components, power, and prestige.

That was the case at Northwestern University’s Feinberg School of Medicine, which lured Mark Williams, MD, away from 18 years at Emory University to head a new division of hospital medicine. Dr. Williams, editor of the Journal of Hospital Medicine, believes it’s important for hospitalists to have a separate division so they are at the same level as the other academic specialties. “That’s why I came to Northwestern,” he says. “I think it’s essential that hospitalists have division status so they are present at the table when decisions are made about investments in research, coverage, teaching of residents, and particularly budgetary matters.”

However, Dr. DeSalvo points out that there are not enough experienced academic hospitalists to head divisions in all medical schools. “If we were to say tomorrow that all hospitalists should have their own divisions, there would not be enough experienced people to head all those divisions,” he stresses. “So if it’s going to happen, it will happen over time.” In the meantime, it’s important that schools mentor and train academic hospitalists who could be division chiefs, she says.

The issue has become a priority for SHM and the Society of General Internal Medicine (SGIM), which have created task forces to find ways to help academic hospitalists advance their careers without “isolating themselves as to site of care,” Dr. Centor says. “Hospitalists are complementary to outpatient physicians and vice versa. They have to talk to each other, and the general internal medicine division structure provides that.”

Fault Lines

Hospitalists and general internists have more in common and more reasons to stay together than to separate, according to Dr. Centor. “Internists and hospitalists both concentrate on taking care of the whole patient and see patients who have multiple diseases.” Their issues are the same: advancing their careers, creating knowledge, and developing better teaching methods, he says. “Exactly the same issues general internal medicine has been working on for the last 25 years,” he explains.

General internists worry hospitalists are dichotomizing internal medicine and their careers by separating. “If you have a division of inpatient medicine and a division of outpatient medicine, it becomes harder for hospitalists to switch to outpatient medicine when they burn out,” Dr. Centor says.

Dr. Williams says hospitalist burnout is a myth: “People keep bringing up hospitalist burnout as a threat. It’s not a problem. We have programs in which the original hospitalists have been practicing since 1988 and are still enjoying doing it.”

The question of where academic hospitalists, with so few older physicians in its ranks, will find mentors concerns those opposed to separate divisions. Dr. Williams says there is nothing preventing general internal medicine physicians from mentoring hospitalists whether or not they are in a separate division.

Dr. Wachter says strong division leaders help academic hospitalists find mentors among more experienced physicians in other divisions and even at other institutions.

Some general internists and hospitalists believe separation is an academic issue that doesn’t affect patient care. Dr. Williams disagrees. “Decisions on whether hospitalists are going to be the primary people delivering care to patients can affect budgetary, scheduling, and training issue, which ultimately affect patients,” he counters.

Academic turf wars, politics, and allocation of resources also play into the desire to keep hospitalists within divisions of general internal medicine. “Many chiefs don’t want them to separate because they see it as a reduction or fracturing of their division’s resources, both financial and human,” Dr. Flanders says.

Academic hospitalists who remain within divisions of general internal medicine need the support of those divisions. The SGIM task force recommended that divisions provide leadership to support hospitalists, build mentorships, create sustainable academic jobs, and value the education and quality improvement work of hospitalists, according to Dr. Flanders.

Many believe the independence of hospitalists is inevitable. “It’s where we are heading, and we will get there,” says Dr. Flanders.

Dr. Wachter says academic hospitalists are following the predictable “organizational rules of gravity. You start small and you build and you become more independent. Those who need parenting, over time, become adolescents and go to college and become independent. That’s just the nature of the beast,” he says. “It won’t happen at every place at the same minute, but I’ll be very surprised if 10 years from now, there aren’t very few academic hospitalists groups of any size that are not freestanding divisions.” TH

Barbara Dillard is a medical journalist based in Chicago.

There is an increasing debate in major academic medical centers across the county on where hospitalists fit in the organizational structure—and consequently what resources, prestige, and power they will have.

The movement of academic hospitalists toward autonomy may be inevitable. Community hospitalists are less affected by the separation issue, most agree, because a community hospital may have fewer hospitalists who relish remaining in general internal medicine divisions. Conversely, they may have their own division because they are not driven by research or teaching. Either structure seems to work well in a community setting.

Even those who want academic hospitalists to remain firmly ensconced in divisions of general internal medicine realize it may be a losing battle as hospitalist groups increase in size, depth, and importance. So they caution: “Not so fast.”

Hospitalists would be better off remaining in divisions of general internal medicine and “learning from the mistakes we’ve made over the last 25 years,” says Bob Centor, MD, professor and director of the division of general internal medicine at the University of Alabama at Birmingham and associate dean for the Huntsville Regional Medical campus.

While Dr. Centor acknowledges it’s not always wrong to have a separate division, he believes leadership in general medicine divisions can help hospitalists succeed in their careers and negotiate academic politics to better advance their interests.

Early Stirrings

The independence movement began about two years ago when some academic hospitalists formed separate divisions, frustrated by chairs of general internal medicine “who just didn’t get it,” says Dr. Centor.

Others have found support from division chiefs who worked to develop academic hospitalists and encouraged them to go out on their own.

Academic hospitalists at the University of California, San Francisco’s (UCSF) school of medicine became a separate division two years ago. The move was encouraged by its division of general internal medicine chief, according to Bob Wachter, MD, hospitalist division chief at UCSF who coined the term hospitalist. “After 10 years of growth, we had 38 academic hospitalists, 10 assistant professors, many faculty with impressive accomplishments, a robust research department and the support of the chief,” he says. “Clearly we were ready.”

Separation has become a hot topic as the numbers of hospitalist faculty reach critical mass in academic medical centers, with some hospitalists’ departments having larger faculties than any other specialty within the division.

While it may be time for hospitalists to separate in large medical centers, that may not be the case at smaller schools,” says Karen DeSalvo, MD, MPH, MSc, chief of general internal medicine and geriatrics, Tulane School of Medicine in New Orleans, and president-elect of the Association of Chiefs of General Internal Medicine. “For smaller medical schools, it just doesn’t make sense financially to have a separate division.”

A school’s culture also can be a barrier to separation, she points out. Tulane takes a multidisciplinary approach to teaching with faculty encouraged to work across traditional specialty areas. This is easier when hospitalists are in the same division, she says.

However, size is not the only requirement for divisions in medical schools. “The goals of divisions within the infrastructure of medical centers are clinical care, teaching, and research,” says SHM President-elect Scott A. Flanders, MD, associate professor of medicine at the University of Michigan, Ann Arbor. “While most hospitalist programs at major academic medical centers do a great job with clinical care and many have teaching success, very few have succeeded in developing robust research programs.” Until this happens, hospitalists should remain in divisions of general internal medicine and take advantage of their resources to develop research programs and faculty, he says.

Dr. Wachter agrees: “It’s not just size. It’s also scope and accomplishments and whether your leader is experienced enough and strong enough to go toe to toe with other division chiefs.”

Anticipate Demand

Dr. Flanders says the controversy has heated up as academic medical centers seek to recruit leaders for large hospitalist programs. “They dangle the division chief position as a tool to recruit from the small pool of experienced academic hospitalists who could head a program,” he says. Along with creating a division comes a package of incentives, such as tenure, investments in building the academic and research components, power, and prestige.

That was the case at Northwestern University’s Feinberg School of Medicine, which lured Mark Williams, MD, away from 18 years at Emory University to head a new division of hospital medicine. Dr. Williams, editor of the Journal of Hospital Medicine, believes it’s important for hospitalists to have a separate division so they are at the same level as the other academic specialties. “That’s why I came to Northwestern,” he says. “I think it’s essential that hospitalists have division status so they are present at the table when decisions are made about investments in research, coverage, teaching of residents, and particularly budgetary matters.”

However, Dr. DeSalvo points out that there are not enough experienced academic hospitalists to head divisions in all medical schools. “If we were to say tomorrow that all hospitalists should have their own divisions, there would not be enough experienced people to head all those divisions,” he stresses. “So if it’s going to happen, it will happen over time.” In the meantime, it’s important that schools mentor and train academic hospitalists who could be division chiefs, she says.

The issue has become a priority for SHM and the Society of General Internal Medicine (SGIM), which have created task forces to find ways to help academic hospitalists advance their careers without “isolating themselves as to site of care,” Dr. Centor says. “Hospitalists are complementary to outpatient physicians and vice versa. They have to talk to each other, and the general internal medicine division structure provides that.”

Fault Lines

Hospitalists and general internists have more in common and more reasons to stay together than to separate, according to Dr. Centor. “Internists and hospitalists both concentrate on taking care of the whole patient and see patients who have multiple diseases.” Their issues are the same: advancing their careers, creating knowledge, and developing better teaching methods, he says. “Exactly the same issues general internal medicine has been working on for the last 25 years,” he explains.

General internists worry hospitalists are dichotomizing internal medicine and their careers by separating. “If you have a division of inpatient medicine and a division of outpatient medicine, it becomes harder for hospitalists to switch to outpatient medicine when they burn out,” Dr. Centor says.

Dr. Williams says hospitalist burnout is a myth: “People keep bringing up hospitalist burnout as a threat. It’s not a problem. We have programs in which the original hospitalists have been practicing since 1988 and are still enjoying doing it.”

The question of where academic hospitalists, with so few older physicians in its ranks, will find mentors concerns those opposed to separate divisions. Dr. Williams says there is nothing preventing general internal medicine physicians from mentoring hospitalists whether or not they are in a separate division.

Dr. Wachter says strong division leaders help academic hospitalists find mentors among more experienced physicians in other divisions and even at other institutions.

Some general internists and hospitalists believe separation is an academic issue that doesn’t affect patient care. Dr. Williams disagrees. “Decisions on whether hospitalists are going to be the primary people delivering care to patients can affect budgetary, scheduling, and training issue, which ultimately affect patients,” he counters.

Academic turf wars, politics, and allocation of resources also play into the desire to keep hospitalists within divisions of general internal medicine. “Many chiefs don’t want them to separate because they see it as a reduction or fracturing of their division’s resources, both financial and human,” Dr. Flanders says.

Academic hospitalists who remain within divisions of general internal medicine need the support of those divisions. The SGIM task force recommended that divisions provide leadership to support hospitalists, build mentorships, create sustainable academic jobs, and value the education and quality improvement work of hospitalists, according to Dr. Flanders.

Many believe the independence of hospitalists is inevitable. “It’s where we are heading, and we will get there,” says Dr. Flanders.

Dr. Wachter says academic hospitalists are following the predictable “organizational rules of gravity. You start small and you build and you become more independent. Those who need parenting, over time, become adolescents and go to college and become independent. That’s just the nature of the beast,” he says. “It won’t happen at every place at the same minute, but I’ll be very surprised if 10 years from now, there aren’t very few academic hospitalists groups of any size that are not freestanding divisions.” TH

Barbara Dillard is a medical journalist based in Chicago.

What does being lean have to do with operating a hospital? Well, when you’re talking about the lean method known as the Toyota Production System, it just may be what puts hospitals back in the driver’s seat of their bottom lines.

Six years ago, few hospital administrators had ever heard the term. Today, what began as an experiment at Seattle’s Virginia Mason Medical Center is sweeping through cash-strapped hospitals across the country.

Originally envisioned by the Japanese automaker as a way of doing more with less, the much-copied management system is becoming the gold standard for U.S. hospitals. They are betting that going Toyota lean will streamline processes, increase employee satisfaction, improve their finances, and most importantly, enhance patient care.

What does being lean entail?

“At its core, lean is a process-improvement methodology and management improvement system,” says Mark Graban, a senior consultant with Ortho-Clinical Diagnostics’ ValuMetrix Services in Rochester, N.Y. Graban teaches the Toyota system to hospitals throughout the country. One of the system’s most basic tenets is respect for the work force. Another is that it does not assign blame. Instead, Graban explains, “Lean engages the work force to improve the work they are involved in—improving process and quality, and reducing delays for patients.”

Can Hospitalists Go Lean?

Hospitals have used lean to improve productivity in areas as diverse as inventory, testing, purchasing, and food service. What about their most critical function — patient care? Can lean help hospitalists to perform their jobs, too?

“Yes,” asserts Christopher Kim, MD, MBA, of the Departments of Internal Medicine and Pediatrics at the University of Michigan. Dr. Kim studied lean and applied it at his hospital in Ann Arbor. “To really do lean projects well, you need the buy-in of the physicians—the hospitalists. I believe hospitalists have a huge role in how successful lean projects can be. It behooves them to participate in these process improvement projects and take a lead role.”

Managers must sign on, as well.

“Lean gets managers out of their offices and into various departments to see what the problems are,” says Graban, whose book Lean Hospitals: Improving Quality, Patient Safety, and Employee Satisfaction is due out this summer. “Lean allows you to see it firsthand rather than relying on budget reports. We take executives to the nursing unit, and you see the light bulb go off. They say, ‘We need to help our employees provide care.’ ’’

Waste Not, Want Not

Lean solutions involve looking at processes, breaking them down into parts, and eliminating waste. Waste is an important concept in lean thinking, especially as it relates to time and motion.

“Lean is not necessarily about clinical care, but about reducing inefficiencies in processes needed for that care, by transforming waste into value,” explains Dr. Kim.

Waste, Graban asserts, “is any problem that pops up during the day that delays care.” Just ask a patient waiting for a doctor to write discharge orders or a nurse running around searching for missing supplies how much time is spent waiting.

“Up to 40% of time spent in hospitals is waste,” says Dr. Kim.

When lean strategy eliminates wasted time and motion that means efficiency, productivity, employee satisfaction, and patient satisfaction all increase. “That’s how hospitalists can use this—so much of what we do is about process,” Dr. Kim explains. “Once a clinical encounter is finished, much of what we do to achieve our goal of treating patients is really about those processes.” And processes are what lean seeks to optimize.

Hospitalist Brian Bossard, MD, director, Inpatient Associates, Lincoln, Neb., uses lean concepts to optimize his physicians’ patient loads. “We try to get each individual physician’s patient census close together—physically put the beds together to reduce the time the doctors are moving from one place to another,” he says. “It’s also much easier to communicate with nurses; [it’s] a significant savings in time and manpower.”

Lean Solutions

Max Langham, MD, chief of surgery at LeBonheur Children’s Medical Center in Memphis, Tenn., puts hospitals’ dilemmas about quality succinctly: “Most places want to be good and are working at getting better. It’s one thing to talk about it, but how do you do it?” His hospital chose Toyota lean, hiring Graban’s team to train the operating room (OR) staff.

Time-motion studies of the OR revealed a chaotic inventory system. Supplies were not systematically accounted for, resulting in either too much or inappropriate inventory. Sterilized surgical kits would be opened for one instrument, requiring resterilization of the rest. Establishing a master control inventory system and a master location for each supply made it easier to track them all in real time. First-year inventory savings were $243,828.

“Nurses know exactly where to go to get things now,” says Dr. Langham. “Lean’s focus was reducing waste and freeing up resources—and in a constrained environment that made a ton of sense.”

Recognizing what’s wrong with a process is the first step toward improving it, says Dr. Kim. He thinks hospitalists are uniquely qualified for the job. “They’re the ones who have the clear picture of the entire process for the patient,” he says. “They have the overview.”

One of the first processes Dr. Kim’s team examined was the turnaround time for placing PIC lines so patients could be discharged to home IV therapy. Applying lean methods reduced the average PIC wait time from 26 hours to 16, a reduction of 38%, with a concomitant savings in time, money, and patient satisfaction.

In radiation oncology, treatment for brain and bone metastases was streamlined from a three-visit procedure to a single hospital appointment by using lean methods. “The radiology workers at first did not like it,” says Dr. Kim. They feared job loss or increased workload, but soon found that lean is more about working smarter than harder. “Now they love it,” he says.

Success is not always assured. “We’ve had some areas of great success, some mediocre, and a few failures,” says Dr. Kim. The failures? “If too many departments and too many people are involved in one project, it tends to lead to failure,” he explains. “We are still on the upward phase of the learning curve.”

Lean is definitely not a set of cookie-cutter procedures. Each hospital has its own bottlenecks and waste points. Lean is a way of finding them and finding a customized correction for them.

“People used to work around obstacles,” Dr. Kim says. “Now we try to identify and eliminate them so people don’t have to work around them.”

At St. Joseph’s Mercy Hospital in Ypsilanti, Mich., inefficient ordering of diagnostic studies was a problem. “We have primarily used lean in test ordering and reporting,” says hospitalist Lakshmi Halasyamani, MD. “We decreased waiting times both for patients and for important diagnostic studies.” She thinks this can be of special value to hospitalists. “We benefit even more than others because we’re in the hospital all the time and ordering all the tests all the time,” she says.

Meanwhile, Mark Pool, MD, laboratory director of Riverside Medical Center in Kankakee, Ill., saw room for improvement in his lab. “Just walking through I saw a lot of redundant effort,” he explains. The results of his lean initiative were impressive. By getting a handle on inventory control, eliminating batching of tests, and standardizing procedures, Dr. Pool decreased test time considerably. That minimized backups in the emergency department. “Sitting in ED is like sitting in a taxi with the meter running,” he says. His department is able to turn the meter off. The lean project cost his hospital $300,000. The savings? “I don’t know, exactly,” he says. “But right off the bat with basic inventory control management, we saved $30,000 before we even blinked.” And he expects those savings to continue to add up.

Complacency is the Enemy

Any organization has its own long-term institutional culture. That culture also can lead to complacency, a “we’ve-always-done-it-this-way” attitude. That was the culture the Denver Health System wanted to change when it chose to go lean.

Eugene Chu, MD, director of the hospital medicine program at Denver Health, says his hospital’s lean program was initiated by Patricia Gabow, MD, the hospital’s CEO. “She had a vision that Denver Health and most healthcare systems were doing the same things for 20, 30, 40 years,” he says. “They had not changed anything. And she felt there was a lot to learn from outsiders, [like] how to manage operations and different products of the medical center.”

Dr. Gabow secured a grant from the Agency for Healthcare Research and Quality (AHRQ) to bring in a team of consultants to train hospital personnel as “black belts” in Toyota lean. Dr. Chu is one of them. “We have tried to improve patient flow and work flow,” he says. One project is to standardize the admissions procedure. “Before, house staff wrote things on crumpled pieces of paper and stored them in various places,” he recalls. Now, admissions are the responsibility of the hospitalists. No more chasing after a busy resident to get the pertinent facts out of his pocket. Admissions are transparent on Excel folders in hospital computers, for all staff to access.

Dr. Chu warns that Toyota lean doesn’t come easily or inexpensively. “To really do it right it is a significant investment. It is a set of tools and knowledge that you have to learn properly, and practice and develop,” he says, adding “Our black belts take 100 hours of training.”

Lean savings relating to billing procedures or food service can be easily measured. Savings related to actual patient care can be difficult to quantify. Dr. Chu says the hospital realized a $5 million net savings for all its lean projects. “It is just 1% of the operating budget, but it still helps,” he says.

Lean isn’t the only management system available. Julia Wright, MD, a hospitalist at the University of Wisconsin Hospital and Clinics in Madison, says her hospital is using a different approach to increase efficiency. “You need a system that can expedite care,” she says. “Lean is one way of doing it, but there are other models, too.”

Her hospital’s solution is a new IT system, with handheld computers into which physicians can enter and access data in real time. “Lean may not be IT-based, but it’s the same bottom line—a way of bringing care to the patient instead of bringing the patient to care,” she explains. That saves patients time. “When we look at patient satisfaction surveys, people get really frustrated with wait times. That’s what angers them,” she says.

As good as lean is, “I don’t think “lean” is [the be-all, end-all solution] to hospital efficiency and quality and safety,” Dr. Kim says. Other systems have come and gone as hospitals seek to rein in costs and improve care. “It’s not the model you choose,” Dr. Kim concludes. “It’s how you look at the model and decide to incorporate it into your hospital.” TH

Carol Berczuk is a medical journalist based in New York.

What does being lean have to do with operating a hospital? Well, when you’re talking about the lean method known as the Toyota Production System, it just may be what puts hospitals back in the driver’s seat of their bottom lines.

Six years ago, few hospital administrators had ever heard the term. Today, what began as an experiment at Seattle’s Virginia Mason Medical Center is sweeping through cash-strapped hospitals across the country.

Originally envisioned by the Japanese automaker as a way of doing more with less, the much-copied management system is becoming the gold standard for U.S. hospitals. They are betting that going Toyota lean will streamline processes, increase employee satisfaction, improve their finances, and most importantly, enhance patient care.

What does being lean entail?

“At its core, lean is a process-improvement methodology and management improvement system,” says Mark Graban, a senior consultant with Ortho-Clinical Diagnostics’ ValuMetrix Services in Rochester, N.Y. Graban teaches the Toyota system to hospitals throughout the country. One of the system’s most basic tenets is respect for the work force. Another is that it does not assign blame. Instead, Graban explains, “Lean engages the work force to improve the work they are involved in—improving process and quality, and reducing delays for patients.”

Can Hospitalists Go Lean?

Hospitals have used lean to improve productivity in areas as diverse as inventory, testing, purchasing, and food service. What about their most critical function — patient care? Can lean help hospitalists to perform their jobs, too?

“Yes,” asserts Christopher Kim, MD, MBA, of the Departments of Internal Medicine and Pediatrics at the University of Michigan. Dr. Kim studied lean and applied it at his hospital in Ann Arbor. “To really do lean projects well, you need the buy-in of the physicians—the hospitalists. I believe hospitalists have a huge role in how successful lean projects can be. It behooves them to participate in these process improvement projects and take a lead role.”

Managers must sign on, as well.

“Lean gets managers out of their offices and into various departments to see what the problems are,” says Graban, whose book Lean Hospitals: Improving Quality, Patient Safety, and Employee Satisfaction is due out this summer. “Lean allows you to see it firsthand rather than relying on budget reports. We take executives to the nursing unit, and you see the light bulb go off. They say, ‘We need to help our employees provide care.’ ’’

Waste Not, Want Not

Lean solutions involve looking at processes, breaking them down into parts, and eliminating waste. Waste is an important concept in lean thinking, especially as it relates to time and motion.

“Lean is not necessarily about clinical care, but about reducing inefficiencies in processes needed for that care, by transforming waste into value,” explains Dr. Kim.

Waste, Graban asserts, “is any problem that pops up during the day that delays care.” Just ask a patient waiting for a doctor to write discharge orders or a nurse running around searching for missing supplies how much time is spent waiting.

“Up to 40% of time spent in hospitals is waste,” says Dr. Kim.

When lean strategy eliminates wasted time and motion that means efficiency, productivity, employee satisfaction, and patient satisfaction all increase. “That’s how hospitalists can use this—so much of what we do is about process,” Dr. Kim explains. “Once a clinical encounter is finished, much of what we do to achieve our goal of treating patients is really about those processes.” And processes are what lean seeks to optimize.

Hospitalist Brian Bossard, MD, director, Inpatient Associates, Lincoln, Neb., uses lean concepts to optimize his physicians’ patient loads. “We try to get each individual physician’s patient census close together—physically put the beds together to reduce the time the doctors are moving from one place to another,” he says. “It’s also much easier to communicate with nurses; [it’s] a significant savings in time and manpower.”

Lean Solutions

Max Langham, MD, chief of surgery at LeBonheur Children’s Medical Center in Memphis, Tenn., puts hospitals’ dilemmas about quality succinctly: “Most places want to be good and are working at getting better. It’s one thing to talk about it, but how do you do it?” His hospital chose Toyota lean, hiring Graban’s team to train the operating room (OR) staff.

Time-motion studies of the OR revealed a chaotic inventory system. Supplies were not systematically accounted for, resulting in either too much or inappropriate inventory. Sterilized surgical kits would be opened for one instrument, requiring resterilization of the rest. Establishing a master control inventory system and a master location for each supply made it easier to track them all in real time. First-year inventory savings were $243,828.

“Nurses know exactly where to go to get things now,” says Dr. Langham. “Lean’s focus was reducing waste and freeing up resources—and in a constrained environment that made a ton of sense.”

Recognizing what’s wrong with a process is the first step toward improving it, says Dr. Kim. He thinks hospitalists are uniquely qualified for the job. “They’re the ones who have the clear picture of the entire process for the patient,” he says. “They have the overview.”

One of the first processes Dr. Kim’s team examined was the turnaround time for placing PIC lines so patients could be discharged to home IV therapy. Applying lean methods reduced the average PIC wait time from 26 hours to 16, a reduction of 38%, with a concomitant savings in time, money, and patient satisfaction.

In radiation oncology, treatment for brain and bone metastases was streamlined from a three-visit procedure to a single hospital appointment by using lean methods. “The radiology workers at first did not like it,” says Dr. Kim. They feared job loss or increased workload, but soon found that lean is more about working smarter than harder. “Now they love it,” he says.

Success is not always assured. “We’ve had some areas of great success, some mediocre, and a few failures,” says Dr. Kim. The failures? “If too many departments and too many people are involved in one project, it tends to lead to failure,” he explains. “We are still on the upward phase of the learning curve.”

Lean is definitely not a set of cookie-cutter procedures. Each hospital has its own bottlenecks and waste points. Lean is a way of finding them and finding a customized correction for them.

“People used to work around obstacles,” Dr. Kim says. “Now we try to identify and eliminate them so people don’t have to work around them.”

At St. Joseph’s Mercy Hospital in Ypsilanti, Mich., inefficient ordering of diagnostic studies was a problem. “We have primarily used lean in test ordering and reporting,” says hospitalist Lakshmi Halasyamani, MD. “We decreased waiting times both for patients and for important diagnostic studies.” She thinks this can be of special value to hospitalists. “We benefit even more than others because we’re in the hospital all the time and ordering all the tests all the time,” she says.

Meanwhile, Mark Pool, MD, laboratory director of Riverside Medical Center in Kankakee, Ill., saw room for improvement in his lab. “Just walking through I saw a lot of redundant effort,” he explains. The results of his lean initiative were impressive. By getting a handle on inventory control, eliminating batching of tests, and standardizing procedures, Dr. Pool decreased test time considerably. That minimized backups in the emergency department. “Sitting in ED is like sitting in a taxi with the meter running,” he says. His department is able to turn the meter off. The lean project cost his hospital $300,000. The savings? “I don’t know, exactly,” he says. “But right off the bat with basic inventory control management, we saved $30,000 before we even blinked.” And he expects those savings to continue to add up.

Complacency is the Enemy

Any organization has its own long-term institutional culture. That culture also can lead to complacency, a “we’ve-always-done-it-this-way” attitude. That was the culture the Denver Health System wanted to change when it chose to go lean.

Eugene Chu, MD, director of the hospital medicine program at Denver Health, says his hospital’s lean program was initiated by Patricia Gabow, MD, the hospital’s CEO. “She had a vision that Denver Health and most healthcare systems were doing the same things for 20, 30, 40 years,” he says. “They had not changed anything. And she felt there was a lot to learn from outsiders, [like] how to manage operations and different products of the medical center.”

Dr. Gabow secured a grant from the Agency for Healthcare Research and Quality (AHRQ) to bring in a team of consultants to train hospital personnel as “black belts” in Toyota lean. Dr. Chu is one of them. “We have tried to improve patient flow and work flow,” he says. One project is to standardize the admissions procedure. “Before, house staff wrote things on crumpled pieces of paper and stored them in various places,” he recalls. Now, admissions are the responsibility of the hospitalists. No more chasing after a busy resident to get the pertinent facts out of his pocket. Admissions are transparent on Excel folders in hospital computers, for all staff to access.

Dr. Chu warns that Toyota lean doesn’t come easily or inexpensively. “To really do it right it is a significant investment. It is a set of tools and knowledge that you have to learn properly, and practice and develop,” he says, adding “Our black belts take 100 hours of training.”

Lean savings relating to billing procedures or food service can be easily measured. Savings related to actual patient care can be difficult to quantify. Dr. Chu says the hospital realized a $5 million net savings for all its lean projects. “It is just 1% of the operating budget, but it still helps,” he says.

Lean isn’t the only management system available. Julia Wright, MD, a hospitalist at the University of Wisconsin Hospital and Clinics in Madison, says her hospital is using a different approach to increase efficiency. “You need a system that can expedite care,” she says. “Lean is one way of doing it, but there are other models, too.”

Her hospital’s solution is a new IT system, with handheld computers into which physicians can enter and access data in real time. “Lean may not be IT-based, but it’s the same bottom line—a way of bringing care to the patient instead of bringing the patient to care,” she explains. That saves patients time. “When we look at patient satisfaction surveys, people get really frustrated with wait times. That’s what angers them,” she says.

As good as lean is, “I don’t think “lean” is [the be-all, end-all solution] to hospital efficiency and quality and safety,” Dr. Kim says. Other systems have come and gone as hospitals seek to rein in costs and improve care. “It’s not the model you choose,” Dr. Kim concludes. “It’s how you look at the model and decide to incorporate it into your hospital.” TH

Carol Berczuk is a medical journalist based in New York.

What does being lean have to do with operating a hospital? Well, when you’re talking about the lean method known as the Toyota Production System, it just may be what puts hospitals back in the driver’s seat of their bottom lines.

Six years ago, few hospital administrators had ever heard the term. Today, what began as an experiment at Seattle’s Virginia Mason Medical Center is sweeping through cash-strapped hospitals across the country.

Originally envisioned by the Japanese automaker as a way of doing more with less, the much-copied management system is becoming the gold standard for U.S. hospitals. They are betting that going Toyota lean will streamline processes, increase employee satisfaction, improve their finances, and most importantly, enhance patient care.

What does being lean entail?

“At its core, lean is a process-improvement methodology and management improvement system,” says Mark Graban, a senior consultant with Ortho-Clinical Diagnostics’ ValuMetrix Services in Rochester, N.Y. Graban teaches the Toyota system to hospitals throughout the country. One of the system’s most basic tenets is respect for the work force. Another is that it does not assign blame. Instead, Graban explains, “Lean engages the work force to improve the work they are involved in—improving process and quality, and reducing delays for patients.”

Can Hospitalists Go Lean?

Hospitals have used lean to improve productivity in areas as diverse as inventory, testing, purchasing, and food service. What about their most critical function — patient care? Can lean help hospitalists to perform their jobs, too?

“Yes,” asserts Christopher Kim, MD, MBA, of the Departments of Internal Medicine and Pediatrics at the University of Michigan. Dr. Kim studied lean and applied it at his hospital in Ann Arbor. “To really do lean projects well, you need the buy-in of the physicians—the hospitalists. I believe hospitalists have a huge role in how successful lean projects can be. It behooves them to participate in these process improvement projects and take a lead role.”

Managers must sign on, as well.

“Lean gets managers out of their offices and into various departments to see what the problems are,” says Graban, whose book Lean Hospitals: Improving Quality, Patient Safety, and Employee Satisfaction is due out this summer. “Lean allows you to see it firsthand rather than relying on budget reports. We take executives to the nursing unit, and you see the light bulb go off. They say, ‘We need to help our employees provide care.’ ’’

Waste Not, Want Not

Lean solutions involve looking at processes, breaking them down into parts, and eliminating waste. Waste is an important concept in lean thinking, especially as it relates to time and motion.

“Lean is not necessarily about clinical care, but about reducing inefficiencies in processes needed for that care, by transforming waste into value,” explains Dr. Kim.

Waste, Graban asserts, “is any problem that pops up during the day that delays care.” Just ask a patient waiting for a doctor to write discharge orders or a nurse running around searching for missing supplies how much time is spent waiting.

“Up to 40% of time spent in hospitals is waste,” says Dr. Kim.

When lean strategy eliminates wasted time and motion that means efficiency, productivity, employee satisfaction, and patient satisfaction all increase. “That’s how hospitalists can use this—so much of what we do is about process,” Dr. Kim explains. “Once a clinical encounter is finished, much of what we do to achieve our goal of treating patients is really about those processes.” And processes are what lean seeks to optimize.

Hospitalist Brian Bossard, MD, director, Inpatient Associates, Lincoln, Neb., uses lean concepts to optimize his physicians’ patient loads. “We try to get each individual physician’s patient census close together—physically put the beds together to reduce the time the doctors are moving from one place to another,” he says. “It’s also much easier to communicate with nurses; [it’s] a significant savings in time and manpower.”

Lean Solutions

Max Langham, MD, chief of surgery at LeBonheur Children’s Medical Center in Memphis, Tenn., puts hospitals’ dilemmas about quality succinctly: “Most places want to be good and are working at getting better. It’s one thing to talk about it, but how do you do it?” His hospital chose Toyota lean, hiring Graban’s team to train the operating room (OR) staff.

Time-motion studies of the OR revealed a chaotic inventory system. Supplies were not systematically accounted for, resulting in either too much or inappropriate inventory. Sterilized surgical kits would be opened for one instrument, requiring resterilization of the rest. Establishing a master control inventory system and a master location for each supply made it easier to track them all in real time. First-year inventory savings were $243,828.

“Nurses know exactly where to go to get things now,” says Dr. Langham. “Lean’s focus was reducing waste and freeing up resources—and in a constrained environment that made a ton of sense.”

Recognizing what’s wrong with a process is the first step toward improving it, says Dr. Kim. He thinks hospitalists are uniquely qualified for the job. “They’re the ones who have the clear picture of the entire process for the patient,” he says. “They have the overview.”

One of the first processes Dr. Kim’s team examined was the turnaround time for placing PIC lines so patients could be discharged to home IV therapy. Applying lean methods reduced the average PIC wait time from 26 hours to 16, a reduction of 38%, with a concomitant savings in time, money, and patient satisfaction.

In radiation oncology, treatment for brain and bone metastases was streamlined from a three-visit procedure to a single hospital appointment by using lean methods. “The radiology workers at first did not like it,” says Dr. Kim. They feared job loss or increased workload, but soon found that lean is more about working smarter than harder. “Now they love it,” he says.

Success is not always assured. “We’ve had some areas of great success, some mediocre, and a few failures,” says Dr. Kim. The failures? “If too many departments and too many people are involved in one project, it tends to lead to failure,” he explains. “We are still on the upward phase of the learning curve.”

Lean is definitely not a set of cookie-cutter procedures. Each hospital has its own bottlenecks and waste points. Lean is a way of finding them and finding a customized correction for them.

“People used to work around obstacles,” Dr. Kim says. “Now we try to identify and eliminate them so people don’t have to work around them.”

At St. Joseph’s Mercy Hospital in Ypsilanti, Mich., inefficient ordering of diagnostic studies was a problem. “We have primarily used lean in test ordering and reporting,” says hospitalist Lakshmi Halasyamani, MD. “We decreased waiting times both for patients and for important diagnostic studies.” She thinks this can be of special value to hospitalists. “We benefit even more than others because we’re in the hospital all the time and ordering all the tests all the time,” she says.

Meanwhile, Mark Pool, MD, laboratory director of Riverside Medical Center in Kankakee, Ill., saw room for improvement in his lab. “Just walking through I saw a lot of redundant effort,” he explains. The results of his lean initiative were impressive. By getting a handle on inventory control, eliminating batching of tests, and standardizing procedures, Dr. Pool decreased test time considerably. That minimized backups in the emergency department. “Sitting in ED is like sitting in a taxi with the meter running,” he says. His department is able to turn the meter off. The lean project cost his hospital $300,000. The savings? “I don’t know, exactly,” he says. “But right off the bat with basic inventory control management, we saved $30,000 before we even blinked.” And he expects those savings to continue to add up.

Complacency is the Enemy

Any organization has its own long-term institutional culture. That culture also can lead to complacency, a “we’ve-always-done-it-this-way” attitude. That was the culture the Denver Health System wanted to change when it chose to go lean.

Eugene Chu, MD, director of the hospital medicine program at Denver Health, says his hospital’s lean program was initiated by Patricia Gabow, MD, the hospital’s CEO. “She had a vision that Denver Health and most healthcare systems were doing the same things for 20, 30, 40 years,” he says. “They had not changed anything. And she felt there was a lot to learn from outsiders, [like] how to manage operations and different products of the medical center.”

Dr. Gabow secured a grant from the Agency for Healthcare Research and Quality (AHRQ) to bring in a team of consultants to train hospital personnel as “black belts” in Toyota lean. Dr. Chu is one of them. “We have tried to improve patient flow and work flow,” he says. One project is to standardize the admissions procedure. “Before, house staff wrote things on crumpled pieces of paper and stored them in various places,” he recalls. Now, admissions are the responsibility of the hospitalists. No more chasing after a busy resident to get the pertinent facts out of his pocket. Admissions are transparent on Excel folders in hospital computers, for all staff to access.

Dr. Chu warns that Toyota lean doesn’t come easily or inexpensively. “To really do it right it is a significant investment. It is a set of tools and knowledge that you have to learn properly, and practice and develop,” he says, adding “Our black belts take 100 hours of training.”

Lean savings relating to billing procedures or food service can be easily measured. Savings related to actual patient care can be difficult to quantify. Dr. Chu says the hospital realized a $5 million net savings for all its lean projects. “It is just 1% of the operating budget, but it still helps,” he says.

Lean isn’t the only management system available. Julia Wright, MD, a hospitalist at the University of Wisconsin Hospital and Clinics in Madison, says her hospital is using a different approach to increase efficiency. “You need a system that can expedite care,” she says. “Lean is one way of doing it, but there are other models, too.”

Her hospital’s solution is a new IT system, with handheld computers into which physicians can enter and access data in real time. “Lean may not be IT-based, but it’s the same bottom line—a way of bringing care to the patient instead of bringing the patient to care,” she explains. That saves patients time. “When we look at patient satisfaction surveys, people get really frustrated with wait times. That’s what angers them,” she says.

As good as lean is, “I don’t think “lean” is [the be-all, end-all solution] to hospital efficiency and quality and safety,” Dr. Kim says. Other systems have come and gone as hospitals seek to rein in costs and improve care. “It’s not the model you choose,” Dr. Kim concludes. “It’s how you look at the model and decide to incorporate it into your hospital.” TH

Carol Berczuk is a medical journalist based in New York.

Clinical Privileges

Question: Is there a standard percentage of time for inpatient care that is used to define a hospitalist? (i.e., 25% of time in inpatient activities = expert in hospital medicine). Our hospitalist section is drafting a clinical privilege form, and I have been searching for a national standard.

Heather Toth, MD, Hospital Medicine, Department of Pediatrics, Department of Internal Medicine, Medical College of Wisconsin, Milwaukee

Dr. Hospitalist responds: You and others may be aware of a little secret in hospital medicine: hospitalists have been around in this country for decades.

Even though Drs. Robert Wachter and Lee Goldman coined the term “hospitalist” in the New England Journal of Medicine in 1996, hospitalists have been working our nation’s hospitals for a long, long time.

Don’t get me wrong—I am not diminishing their roles in establishing the field of hospital medicine. What I am saying is that hospitalists were around before 1996, but nobody had defined their role. and nobody knew what to call them.

Drs. Wachter and Goldman did not only name the profession, they also gave it credibility. Prior to the mid-’90s, I get the sense most medical professionals viewed hospitalists as second-rate doctors. These hospital doctors were doing the jobs most respectable doctors didn’t want to do or didn’t have to do.

Those jobs included caring for critically ill patients when other doctors were unavailable or didn’t have the time to see their patients. This could be at 2 p.m. or 2 a.m. in most hospitals. Drs. Wachter and Goldman were, and are, respected academic physicians. In their seminal article, they essentially called out these hospital doctors and lauded their roles in the hospital. Moreover, they anticipated growth in this field of medicine. In some ways, they were saying, “I’m OK and you’re OK. It’s OK to be a hospitalist.”

Well, the rest is history; whereas we had about 2,000 hospitalists in the mid-’90s, we now have an estimated 20,000 hospitalists in the country.

It seems nowadays, many doctors are calling themselves hospitalists. How many times have you heard a doctor say, “I was a hospitalist before the field existed?” I wonder whether we really had so many hospital doctors back then.

Or, is it an issue of how one defines “hospitalist”? Some doctors may be making claims about being a hospitalist because it is now acceptable to be a hospitalist. Whereas 15 years ago, hospitalists were looking in at the establishment; in some parts of the country, hospitalists have become the establishment.

My brother was a member of his high school basketball team, which was ranked No. 1 in the state. Ignore the fact that as a scrub he never came close to stepping onto the court during a game. He still made sure people knew he was a player on the championship team. Everyone wants to be part of a winner.

There may be other reasons to call oneself a hospitalist. Many view hospitalists as specialists in inpatient care. Before long, hospitals may grant privileges to hospitalists that they may not grant to other types of doctors. We have seen this before.

At one time, there was virtually no such thing as a “closed” ICU in hospitals.

Evidence suggested patients received better care when intensivists cared for ICU patients. Today, it is rare to find an academic medical center without a closed ICU, and many community hospitals have adopted a similar model.

Whether doctors are calling themselves “hospitalists” because it is the cool thing to do now or whether it is a matter of turf, you bring up a good question: “How much inpatient work does one have to do to be called a hospitalist?” Drs. Wachter and Goldman certainly didn’t specifically address this issue in their article, and neither has SHM.

SHM’s definition of a hospitalist is: “Hospitalists are 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.”

This definition of a hospitalist is about as good as any I have heard. It should be noted this definition makes no mention of training. One can be an internist, family physician, pediatrician, obstetrician, or general surgeon and be a hospitalist.

With this definition, it does mean, however, you can take care of patients one to two months out of the year and still be considered a “hospitalist” as long as your non-clinical work (teaching, research, and leadership roles) is related to hospital medicine.

I will caution you however as you draft your clinical privilege form that whether you are a hospitalist or not is a different issue than whether you are qualified or not to provide a specific type of clinical care.

Hospitalists are individuals with different knowledge bases and skills sets. You can work clinically as a hospitalist 12 months a year, but if you have never put in a central line, your hospital should not grant you privileges to put in central lines until you have demonstrated some minimal level of competency.

I suspect you are not alone. There are many doctors and institutions around the country that are or will be struggling with the same issues you are facing. TH

Clinical Privileges

Question: Is there a standard percentage of time for inpatient care that is used to define a hospitalist? (i.e., 25% of time in inpatient activities = expert in hospital medicine). Our hospitalist section is drafting a clinical privilege form, and I have been searching for a national standard.

Heather Toth, MD, Hospital Medicine, Department of Pediatrics, Department of Internal Medicine, Medical College of Wisconsin, Milwaukee

Dr. Hospitalist responds: You and others may be aware of a little secret in hospital medicine: hospitalists have been around in this country for decades.

Even though Drs. Robert Wachter and Lee Goldman coined the term “hospitalist” in the New England Journal of Medicine in 1996, hospitalists have been working our nation’s hospitals for a long, long time.

Don’t get me wrong—I am not diminishing their roles in establishing the field of hospital medicine. What I am saying is that hospitalists were around before 1996, but nobody had defined their role. and nobody knew what to call them.

Drs. Wachter and Goldman did not only name the profession, they also gave it credibility. Prior to the mid-’90s, I get the sense most medical professionals viewed hospitalists as second-rate doctors. These hospital doctors were doing the jobs most respectable doctors didn’t want to do or didn’t have to do.

Those jobs included caring for critically ill patients when other doctors were unavailable or didn’t have the time to see their patients. This could be at 2 p.m. or 2 a.m. in most hospitals. Drs. Wachter and Goldman were, and are, respected academic physicians. In their seminal article, they essentially called out these hospital doctors and lauded their roles in the hospital. Moreover, they anticipated growth in this field of medicine. In some ways, they were saying, “I’m OK and you’re OK. It’s OK to be a hospitalist.”

Well, the rest is history; whereas we had about 2,000 hospitalists in the mid-’90s, we now have an estimated 20,000 hospitalists in the country.

It seems nowadays, many doctors are calling themselves hospitalists. How many times have you heard a doctor say, “I was a hospitalist before the field existed?” I wonder whether we really had so many hospital doctors back then.

Or, is it an issue of how one defines “hospitalist”? Some doctors may be making claims about being a hospitalist because it is now acceptable to be a hospitalist. Whereas 15 years ago, hospitalists were looking in at the establishment; in some parts of the country, hospitalists have become the establishment.

My brother was a member of his high school basketball team, which was ranked No. 1 in the state. Ignore the fact that as a scrub he never came close to stepping onto the court during a game. He still made sure people knew he was a player on the championship team. Everyone wants to be part of a winner.

There may be other reasons to call oneself a hospitalist. Many view hospitalists as specialists in inpatient care. Before long, hospitals may grant privileges to hospitalists that they may not grant to other types of doctors. We have seen this before.

At one time, there was virtually no such thing as a “closed” ICU in hospitals.

Evidence suggested patients received better care when intensivists cared for ICU patients. Today, it is rare to find an academic medical center without a closed ICU, and many community hospitals have adopted a similar model.

Whether doctors are calling themselves “hospitalists” because it is the cool thing to do now or whether it is a matter of turf, you bring up a good question: “How much inpatient work does one have to do to be called a hospitalist?” Drs. Wachter and Goldman certainly didn’t specifically address this issue in their article, and neither has SHM.

SHM’s definition of a hospitalist is: “Hospitalists are 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.”

This definition of a hospitalist is about as good as any I have heard. It should be noted this definition makes no mention of training. One can be an internist, family physician, pediatrician, obstetrician, or general surgeon and be a hospitalist.

With this definition, it does mean, however, you can take care of patients one to two months out of the year and still be considered a “hospitalist” as long as your non-clinical work (teaching, research, and leadership roles) is related to hospital medicine.

I will caution you however as you draft your clinical privilege form that whether you are a hospitalist or not is a different issue than whether you are qualified or not to provide a specific type of clinical care.

Hospitalists are individuals with different knowledge bases and skills sets. You can work clinically as a hospitalist 12 months a year, but if you have never put in a central line, your hospital should not grant you privileges to put in central lines until you have demonstrated some minimal level of competency.

I suspect you are not alone. There are many doctors and institutions around the country that are or will be struggling with the same issues you are facing. TH

Clinical Privileges

Question: Is there a standard percentage of time for inpatient care that is used to define a hospitalist? (i.e., 25% of time in inpatient activities = expert in hospital medicine). Our hospitalist section is drafting a clinical privilege form, and I have been searching for a national standard.

Heather Toth, MD, Hospital Medicine, Department of Pediatrics, Department of Internal Medicine, Medical College of Wisconsin, Milwaukee

Dr. Hospitalist responds: You and others may be aware of a little secret in hospital medicine: hospitalists have been around in this country for decades.

Even though Drs. Robert Wachter and Lee Goldman coined the term “hospitalist” in the New England Journal of Medicine in 1996, hospitalists have been working our nation’s hospitals for a long, long time.

Don’t get me wrong—I am not diminishing their roles in establishing the field of hospital medicine. What I am saying is that hospitalists were around before 1996, but nobody had defined their role. and nobody knew what to call them.

Drs. Wachter and Goldman did not only name the profession, they also gave it credibility. Prior to the mid-’90s, I get the sense most medical professionals viewed hospitalists as second-rate doctors. These hospital doctors were doing the jobs most respectable doctors didn’t want to do or didn’t have to do.

Those jobs included caring for critically ill patients when other doctors were unavailable or didn’t have the time to see their patients. This could be at 2 p.m. or 2 a.m. in most hospitals. Drs. Wachter and Goldman were, and are, respected academic physicians. In their seminal article, they essentially called out these hospital doctors and lauded their roles in the hospital. Moreover, they anticipated growth in this field of medicine. In some ways, they were saying, “I’m OK and you’re OK. It’s OK to be a hospitalist.”

Well, the rest is history; whereas we had about 2,000 hospitalists in the mid-’90s, we now have an estimated 20,000 hospitalists in the country.

It seems nowadays, many doctors are calling themselves hospitalists. How many times have you heard a doctor say, “I was a hospitalist before the field existed?” I wonder whether we really had so many hospital doctors back then.

Or, is it an issue of how one defines “hospitalist”? Some doctors may be making claims about being a hospitalist because it is now acceptable to be a hospitalist. Whereas 15 years ago, hospitalists were looking in at the establishment; in some parts of the country, hospitalists have become the establishment.

My brother was a member of his high school basketball team, which was ranked No. 1 in the state. Ignore the fact that as a scrub he never came close to stepping onto the court during a game. He still made sure people knew he was a player on the championship team. Everyone wants to be part of a winner.

There may be other reasons to call oneself a hospitalist. Many view hospitalists as specialists in inpatient care. Before long, hospitals may grant privileges to hospitalists that they may not grant to other types of doctors. We have seen this before.

At one time, there was virtually no such thing as a “closed” ICU in hospitals.

Evidence suggested patients received better care when intensivists cared for ICU patients. Today, it is rare to find an academic medical center without a closed ICU, and many community hospitals have adopted a similar model.

Whether doctors are calling themselves “hospitalists” because it is the cool thing to do now or whether it is a matter of turf, you bring up a good question: “How much inpatient work does one have to do to be called a hospitalist?” Drs. Wachter and Goldman certainly didn’t specifically address this issue in their article, and neither has SHM.

SHM’s definition of a hospitalist is: “Hospitalists are 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.”

This definition of a hospitalist is about as good as any I have heard. It should be noted this definition makes no mention of training. One can be an internist, family physician, pediatrician, obstetrician, or general surgeon and be a hospitalist.

With this definition, it does mean, however, you can take care of patients one to two months out of the year and still be considered a “hospitalist” as long as your non-clinical work (teaching, research, and leadership roles) is related to hospital medicine.

I will caution you however as you draft your clinical privilege form that whether you are a hospitalist or not is a different issue than whether you are qualified or not to provide a specific type of clinical care.

Hospitalists are individuals with different knowledge bases and skills sets. You can work clinically as a hospitalist 12 months a year, but if you have never put in a central line, your hospital should not grant you privileges to put in central lines until you have demonstrated some minimal level of competency.

I suspect you are not alone. There are many doctors and institutions around the country that are or will be struggling with the same issues you are facing. TH

I eagerly await results from SHM’s survey of hospitalist productivity and compensation every two years. I’m most curious about whether a typical hospitalist has experienced an improvement in his/her “juice to squeeze ratio” (aka compensation per unit of work).

I was pleased to see in the recently released “Society of Hospital Medicine 2007-08 Survey: The Authoritative Source on the State of the Hospitalist Movement” that average hospitalist salaries increased the most for any two-year interval since we began surveying in 1997. If you haven’t seen the survey results, go to SHM’s Web site www.hospitalmedicine.org. Production remained flat, while compensation increased to an average of $188,500. (The survey showed an adjusted mean annual compensation of $193,300, and a median salary of $183,900. See complete survey for explanation regarding the adjusted mean, which refers to data for hospitalists who care for adult patients only.)

The 2008 survey has a couple of findings even more compelling than the gratifying improvement in compensation:

• 37% of HMG leaders did not know their annual expenses; and
• 35% of HMG leaders did not know their annual professional fee revenues.

Think about this for a minute. One-third of hospitalist group leaders don’t know enough about their own practice’s financial picture to know high-level details related to income and expenses. We only can presume an even larger portion of non-leader hospitalists don’t know these things about their practice.

These numbers are disconcerting, and they’re even a little worse than the numbers reported two years ago. How can this be?

Behind the Numbers

My first inclination is to look for reasons the data are misleading. Maybe some leaders chose to respond by indicating they don’t know these numbers, when in fact they do have the numbers but were just too busy to look them up and complete that part of the survey. So they might be better informed than the survey suggests, but just too busy to demonstrate it.

Or, some group leaders in large organizations, like Kaiser, may track and account for productivity and financial health in ways that differ from a typical practice. They may know a lot about their practice, but the metrics the survey asks for aren’t relevant to them.

Maybe the survey results are misleading and group leaders know a lot more about their practice financials than these numbers suggest. Well, maybe.

Unfortunately, in my consulting work up close and personal with hundreds of practices, I regularly meet group leaders who don’t see financial accountability as one of their duties. I think the survey numbers may be a reasonably accurate reflection of reality.

I typically ask group leaders things like what portion of their practice budget is funded by professional fee collections vs. payment from the hospital (or other “sponsoring organization”) and what the pro fee collection rate is. As in the survey, a large portion don’t know. They often say it’s up to someone else to keep track of those numbers and worry about the practice budget. I worry that a leader with such a hands-off approach to the practice budget can’t be very effective.

I also ask leaders things like what is their most important duty as group leader. “Making the schedule” is too often the disappointing answer. Clearly the schedule is a critical part of operating a practice, but in many practices it is reasonable, even optimal, to have a clerical person manage the schedule, or rotate responsibility for creating it among all members of the group. This frees some time the leader can spend on other activities like managing the group’s financial performance, among other things.

What Leaders Do

The ideal hospitalist practice leader’s job description will vary from place to place. It includes many things in addition to ensuring the schedule gets created. There are a handful of things that should probably be on every leader’s list. For my money, this leader should:

• Understand where the money comes from, where it goes, and what portion comes from professional fee collections vs. other sources. Also, to ensure all members of the group are updated on financial parameters regularly;
• Put in place mechanisms to ensure the hospitalists provide high-quality care to patients;
• Facilitate communication among hospitalists, hospital personnel, and medical staff to foster effective working relationships and facilitate problem-solving and conflict resolution;
• Proactively identify opportunities for the practice to enhance the service it provides to its constituents and the organization in general, and negotiating a reasonable balance between such opportunities and the practice’s resources and clinical expertise;
• Serve as a point of contact for referring primary care physicians;
• Representing the group when working and negotiating with the hospital administration; and
• Take an active role in recruitment while addressing behavior and performance issues within the practice.

Whether the leader handles these issues alone, delegates responsibility but still provides oversight, or forms a committee with other hospitalists, will vary from place to place. In every case, though, the leader should make sure these things are happening effectively.

Our field is young, and I think tends to attract people who want to avoid managing a complex practice. Perhaps it is no surprise some leaders may not be handling their job optimally. Fortunately, help is available.

Any group leader who wants to function more effectively can do several things. First, start talking to other practice leaders in your hospital. You could ask the lead doctor in another group what he/she regards as the most important components of their leadership role, and strategies that person used to become an effective leader.

Additionally, SHM has a highly regarded Leadership Academy designed to provide group leaders with the skills and resources required to successfully lead and manage a hospital medicine program now and in the future.

Each group leader should periodically step back from the day-to-day work to think about whether his/her time and energy is optimally allocated. Is the mix of clinical and administrative work reasonable? Does the leader devote time to activities (e.g., making the schedule) that could be handed off to others?

The standards used to differentiate between an effective and ineffective leader are hard to pin down and will vary a lot depending on the characteristics of a practice. Still, a comprehensive understanding of the practice’s budget and financial performance should probably be on everyone’s list. I hope the next SHM survey in late 2009 shows a lot more group leaders know things like their group’s annual expenses and revenues. We’ll see. 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.

I eagerly await results from SHM’s survey of hospitalist productivity and compensation every two years. I’m most curious about whether a typical hospitalist has experienced an improvement in his/her “juice to squeeze ratio” (aka compensation per unit of work).

I was pleased to see in the recently released “Society of Hospital Medicine 2007-08 Survey: The Authoritative Source on the State of the Hospitalist Movement” that average hospitalist salaries increased the most for any two-year interval since we began surveying in 1997. If you haven’t seen the survey results, go to SHM’s Web site www.hospitalmedicine.org. Production remained flat, while compensation increased to an average of $188,500. (The survey showed an adjusted mean annual compensation of $193,300, and a median salary of $183,900. See complete survey for explanation regarding the adjusted mean, which refers to data for hospitalists who care for adult patients only.)

The 2008 survey has a couple of findings even more compelling than the gratifying improvement in compensation:

• 37% of HMG leaders did not know their annual expenses; and
• 35% of HMG leaders did not know their annual professional fee revenues.

Think about this for a minute. One-third of hospitalist group leaders don’t know enough about their own practice’s financial picture to know high-level details related to income and expenses. We only can presume an even larger portion of non-leader hospitalists don’t know these things about their practice.

These numbers are disconcerting, and they’re even a little worse than the numbers reported two years ago. How can this be?

Behind the Numbers

My first inclination is to look for reasons the data are misleading. Maybe some leaders chose to respond by indicating they don’t know these numbers, when in fact they do have the numbers but were just too busy to look them up and complete that part of the survey. So they might be better informed than the survey suggests, but just too busy to demonstrate it.

Or, some group leaders in large organizations, like Kaiser, may track and account for productivity and financial health in ways that differ from a typical practice. They may know a lot about their practice, but the metrics the survey asks for aren’t relevant to them.

Maybe the survey results are misleading and group leaders know a lot more about their practice financials than these numbers suggest. Well, maybe.

Unfortunately, in my consulting work up close and personal with hundreds of practices, I regularly meet group leaders who don’t see financial accountability as one of their duties. I think the survey numbers may be a reasonably accurate reflection of reality.

I typically ask group leaders things like what portion of their practice budget is funded by professional fee collections vs. payment from the hospital (or other “sponsoring organization”) and what the pro fee collection rate is. As in the survey, a large portion don’t know. They often say it’s up to someone else to keep track of those numbers and worry about the practice budget. I worry that a leader with such a hands-off approach to the practice budget can’t be very effective.

I also ask leaders things like what is their most important duty as group leader. “Making the schedule” is too often the disappointing answer. Clearly the schedule is a critical part of operating a practice, but in many practices it is reasonable, even optimal, to have a clerical person manage the schedule, or rotate responsibility for creating it among all members of the group. This frees some time the leader can spend on other activities like managing the group’s financial performance, among other things.

What Leaders Do

The ideal hospitalist practice leader’s job description will vary from place to place. It includes many things in addition to ensuring the schedule gets created. There are a handful of things that should probably be on every leader’s list. For my money, this leader should:

• Understand where the money comes from, where it goes, and what portion comes from professional fee collections vs. other sources. Also, to ensure all members of the group are updated on financial parameters regularly;
• Put in place mechanisms to ensure the hospitalists provide high-quality care to patients;
• Facilitate communication among hospitalists, hospital personnel, and medical staff to foster effective working relationships and facilitate problem-solving and conflict resolution;
• Proactively identify opportunities for the practice to enhance the service it provides to its constituents and the organization in general, and negotiating a reasonable balance between such opportunities and the practice’s resources and clinical expertise;
• Serve as a point of contact for referring primary care physicians;
• Representing the group when working and negotiating with the hospital administration; and
• Take an active role in recruitment while addressing behavior and performance issues within the practice.

Whether the leader handles these issues alone, delegates responsibility but still provides oversight, or forms a committee with other hospitalists, will vary from place to place. In every case, though, the leader should make sure these things are happening effectively.

Our field is young, and I think tends to attract people who want to avoid managing a complex practice. Perhaps it is no surprise some leaders may not be handling their job optimally. Fortunately, help is available.

Any group leader who wants to function more effectively can do several things. First, start talking to other practice leaders in your hospital. You could ask the lead doctor in another group what he/she regards as the most important components of their leadership role, and strategies that person used to become an effective leader.

Additionally, SHM has a highly regarded Leadership Academy designed to provide group leaders with the skills and resources required to successfully lead and manage a hospital medicine program now and in the future.

Each group leader should periodically step back from the day-to-day work to think about whether his/her time and energy is optimally allocated. Is the mix of clinical and administrative work reasonable? Does the leader devote time to activities (e.g., making the schedule) that could be handed off to others?

The standards used to differentiate between an effective and ineffective leader are hard to pin down and will vary a lot depending on the characteristics of a practice. Still, a comprehensive understanding of the practice’s budget and financial performance should probably be on everyone’s list. I hope the next SHM survey in late 2009 shows a lot more group leaders know things like their group’s annual expenses and revenues. We’ll see. 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.

I eagerly await results from SHM’s survey of hospitalist productivity and compensation every two years. I’m most curious about whether a typical hospitalist has experienced an improvement in his/her “juice to squeeze ratio” (aka compensation per unit of work).

I was pleased to see in the recently released “Society of Hospital Medicine 2007-08 Survey: The Authoritative Source on the State of the Hospitalist Movement” that average hospitalist salaries increased the most for any two-year interval since we began surveying in 1997. If you haven’t seen the survey results, go to SHM’s Web site www.hospitalmedicine.org. Production remained flat, while compensation increased to an average of $188,500. (The survey showed an adjusted mean annual compensation of $193,300, and a median salary of $183,900. See complete survey for explanation regarding the adjusted mean, which refers to data for hospitalists who care for adult patients only.)

The 2008 survey has a couple of findings even more compelling than the gratifying improvement in compensation:

• 37% of HMG leaders did not know their annual expenses; and
• 35% of HMG leaders did not know their annual professional fee revenues.

Think about this for a minute. One-third of hospitalist group leaders don’t know enough about their own practice’s financial picture to know high-level details related to income and expenses. We only can presume an even larger portion of non-leader hospitalists don’t know these things about their practice.

These numbers are disconcerting, and they’re even a little worse than the numbers reported two years ago. How can this be?

Behind the Numbers

My first inclination is to look for reasons the data are misleading. Maybe some leaders chose to respond by indicating they don’t know these numbers, when in fact they do have the numbers but were just too busy to look them up and complete that part of the survey. So they might be better informed than the survey suggests, but just too busy to demonstrate it.

Or, some group leaders in large organizations, like Kaiser, may track and account for productivity and financial health in ways that differ from a typical practice. They may know a lot about their practice, but the metrics the survey asks for aren’t relevant to them.

Maybe the survey results are misleading and group leaders know a lot more about their practice financials than these numbers suggest. Well, maybe.

Unfortunately, in my consulting work up close and personal with hundreds of practices, I regularly meet group leaders who don’t see financial accountability as one of their duties. I think the survey numbers may be a reasonably accurate reflection of reality.

I typically ask group leaders things like what portion of their practice budget is funded by professional fee collections vs. payment from the hospital (or other “sponsoring organization”) and what the pro fee collection rate is. As in the survey, a large portion don’t know. They often say it’s up to someone else to keep track of those numbers and worry about the practice budget. I worry that a leader with such a hands-off approach to the practice budget can’t be very effective.

I also ask leaders things like what is their most important duty as group leader. “Making the schedule” is too often the disappointing answer. Clearly the schedule is a critical part of operating a practice, but in many practices it is reasonable, even optimal, to have a clerical person manage the schedule, or rotate responsibility for creating it among all members of the group. This frees some time the leader can spend on other activities like managing the group’s financial performance, among other things.

What Leaders Do

The ideal hospitalist practice leader’s job description will vary from place to place. It includes many things in addition to ensuring the schedule gets created. There are a handful of things that should probably be on every leader’s list. For my money, this leader should:

• Understand where the money comes from, where it goes, and what portion comes from professional fee collections vs. other sources. Also, to ensure all members of the group are updated on financial parameters regularly;
• Put in place mechanisms to ensure the hospitalists provide high-quality care to patients;
• Facilitate communication among hospitalists, hospital personnel, and medical staff to foster effective working relationships and facilitate problem-solving and conflict resolution;
• Proactively identify opportunities for the practice to enhance the service it provides to its constituents and the organization in general, and negotiating a reasonable balance between such opportunities and the practice’s resources and clinical expertise;
• Serve as a point of contact for referring primary care physicians;
• Representing the group when working and negotiating with the hospital administration; and
• Take an active role in recruitment while addressing behavior and performance issues within the practice.

Whether the leader handles these issues alone, delegates responsibility but still provides oversight, or forms a committee with other hospitalists, will vary from place to place. In every case, though, the leader should make sure these things are happening effectively.

Our field is young, and I think tends to attract people who want to avoid managing a complex practice. Perhaps it is no surprise some leaders may not be handling their job optimally. Fortunately, help is available.

Any group leader who wants to function more effectively can do several things. First, start talking to other practice leaders in your hospital. You could ask the lead doctor in another group what he/she regards as the most important components of their leadership role, and strategies that person used to become an effective leader.

Additionally, SHM has a highly regarded Leadership Academy designed to provide group leaders with the skills and resources required to successfully lead and manage a hospital medicine program now and in the future.

Each group leader should periodically step back from the day-to-day work to think about whether his/her time and energy is optimally allocated. Is the mix of clinical and administrative work reasonable? Does the leader devote time to activities (e.g., making the schedule) that could be handed off to others?

The standards used to differentiate between an effective and ineffective leader are hard to pin down and will vary a lot depending on the characteristics of a practice. Still, a comprehensive understanding of the practice’s budget and financial performance should probably be on everyone’s list. I hope the next SHM survey in late 2009 shows a lot more group leaders know things like their group’s annual expenses and revenues. We’ll see. 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.

Insanity is doing the same thing over and over again and expecting different results.—Albert Einstein

A hospitalist is defined as a provider whose primary professional focus is the general medical care of hospitalized patients.1

While this allows a concise, usable characterization of a hospitalist, it’s not the whole story. If it were, medical residents, nurses, and inpatient pharmacists all would be hospitalists.

Indeed, a traditional internist with a large hospital practice could reasonably deem him or herself a hospitalist. What defines what a hospitalist does, or should be doing—and how, if at all, is that different than what a traditional internist does in the hospital?

Education Deficiencies

Early data suggested a stark difference between outcomes attributed to hospitalists and general internists who rotated between the clinic and the hospital.

An early experience from the academic environment showed a hospitalist teaching model, when compared with a traditional teaching service, resulted in a 0.6-day length-of-stay (LOS) reduction and a cost savings of $700 per patient with no decrement in the quality of care, clinical outcomes, or satisfaction of provider, housestaff, or patient.2

Similar findings were revealed when community teaching and non-teaching hospitals transitioned to the hospitalist model.3-5 A 2002 review of 19 hospitalist studies revealed an average decreased LOS of 17% coupled with a 1% reduction in hospital costs per case.6

The year 2002 also saw, for the first time, published data that the hospitalist model could reduce in-hospital and 30-day mortality rates.7,8 Together with a 2004 paper showing reductions in minor post-operative complications with hospitalist comanagement of orthopedic patients, these studies suggested hospitalists’ care transcended mere cost savings, improving quality measures as well.9

More recently, however, Lindenauer, et al., found important but less robust differences between hospitalists and non-hospitalists.10 As compared with traditional internists, hospitalists reduced LOS 0.4 days and cost per patient by $268.

While these moderate reductions in LOS and cost versus traditional internists are statistically and clinically significant, they are less vigorous than previous findings. Despite some methodological concerns, this largest investigation—in terms of hospital sites (45), patients (76,926) and hospitalists (284)—revealed no demonstrable improvements in the quality outcomes measured.

Similarly, another recent publication found consultation, provided by medical subspecialists or hospitalists, did not improve glycemic control, rate of appropriate venous thromboembolism (VTE) prophylaxis or perioperative beta-blocker use compared with patients cared for by surgeons alone.11,12

While it is tempting to think hospitalists have re-engineered the systems of care to the point that any provider can fluently and adroitly care for patients, continued reports of less-than-optimal hospital outcomes do not support this hypothesis. More likely, the variance in the early and recent studies relates to the egress from the hospital of less capable or engaged non-hospitalist providers such that more recent findings reflect a comparator group that more closely approximates, in terms of clinical volume, hospitalists.

It’s time to reconsider how we document the merit of hospitalists. Continuing to benchmark hospitalists against non-hospitalists will not tell us if inpatient care is becoming safer, only how one group is doing compared with another. Nor will it necessarily lead to improvements in the quality of care.

To fulfill the promise of the hospitalist model, we need to ensure hospitalists are doing it better, not just better than an external comparator group. As such, it would be more valuable to evaluate hospitalists today versus those five years ago. If, as I suspect, there would be little difference in the clinical outcomes between a new hospitalist (or one in practice for three years) in 2003 and one in 2008 and we accept that hospitalist care has yet to achieve its pinnacle then we must adopt a new path. This will require redesigning the way we train hospitalists.

The ineffectiveness of our current training system is playing out in Dr. Lindenauer’s New England Journal of Medicine paper last year. He found hospitalist outcomes are only marginally better than their similarly trained traditional internist colleagues. To expect differences is to succumb to Albert Einstein’s definition of insanity. We simply cannot expect hospitalists to improve the quality of care with the same set of tools that didn’t allow our predecessors to do so.

Hospitalist-Focused Curricula

Several studies have evaluated the gap between internal medicine (IM) training and hospital medicine practice. A 2007 paper reported that nearly 30% of a community hospitalist practice consisted of areas of under emphasis in traditional IM training.13

These include consultative medicine (6.4% of practice) and the care of the patients with neurological (13.4%), orthopedic (6.4%), or general surgical (2.2%) issues. Additionally, nearly 50% of their practice consisted of patients older than 65, with the largest subset of patients ages 75-84.

Yet, most IM residency training programs do not adequately train housestaff to care for these types of patients and problems. Plauth, et al., documented areas of educational deficiencies by surveying several hundred IM-trained hospitalists about their preparedness to practice hospital medicine following residency training.14

The respondents reported feeling unprepared to care for the type and amount of neurology, geriatrics, palliative care and consultative and perioperative medicine they encountered.

Additionally, they were ill-equipped for the myriad quality improvement and systems and transitions-of-care issues they faced daily.

The “2005-2006 SHM Survey: State of the Hospital Medicine Movement” further highlighted the level of hospitalist non-clinical work, showing that 86% of hospitalist groups engage in quality improvement, 72% contribute practice guidelines, 54% work in utilization review, and 54% are involved in developing electronic medical records and provider order entry.15

For the hospitalist model to deliver outcomes superior to our traditional care model, we will need to create training programs that provide hospitalists with the skills current IM graduates do not possess.

Training programs must evolve to include the necessary clinical and non-clinical aspects of this new medical specialty. Hospitalists have populated the American healthcare landscape for more than a decade, yet very few training programs support innovation in the field of hospital medicine.

It is past time for IM educators, many of whom are hospitalists, to bridge this educational chasm through curricular reform. Short of this, the hospital medicine movement will achieve its pinnacle well short of its promise. TH

Dr. Glasheen is associate professor of medicine at the University of Colorado at 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.

References

1. Society of Hospital Medicine. General information about SHM. Available at: www.hospitalmedicine.org/Content/NavigationMenu/AboutSHM/GeneralInformation/General_Information.htm. Accessed April 25, 2008.
2. Wachter RB, Katz P, Showstack J, Bindman AB, Goldman L. Reorganizing an academic medical service. JAMA. 1998;279:1560-1565.
3. Diamond HS, Goldberg E, Janosky JE. The effect of full-time faculty hospitalists on the efficiency of care at a community teaching hospital. Ann Intern Med. 1998;129:197-203.
4. Freese RB. The Park Nicollet experience in establishing a hospitalist system. Ann Intern Med. 1999;130:350-354.
5. Craig DE, Hartka L, Likosky WH, Caplan WM, Litsky P, Smithey J. Implementation of a hospitalist system in a large health maintenance organization: The Kaiser Permanente experience. Ann Intern Med. 1999;130:355-359.
6. Wachter RM, Goldman L. The hospitalist movement 5 years later. JAMA. 2002;287:487-494.
7. Meltzer D, Manning W, Morrison J, et al. Effects of physician experience on costs and outcomes on an academic general medicine service: results of a trial of hospitalists. Ann Intern Med. 2002;137:866-874.
8. Auerbach AD, Wachter RM, Katz P, et al. Implementation of a voluntary hospitalist service at a community teaching hospital: Improved clinical efficiency and patient outcomes. Ann Intern Med. 2002;137:859-865.
9. Huddleston JM, Long KH, Naessens JM, et al. Medical and surgical comanagement after elective hip and knee arthroplasty. Ann Intern Med. 2004;141:28-38.
10. Lindenauer PK, Rothber MB, Pekow PS, Kenwood C, Benjamin EM, Auerbach AD. Outcomes of care by hospitalist, general internists, and family physicians. N Engl J Med. 2007;357:2589-600.
11. Dr Andrew Auerbach, personal communication, January 7, 2008.
12. Auerbach AD, Rasic MA, Sehgal N, Ide B, Stone B, Maselli J. Opportunity missed: medical consultation, resource use, and quality of care of patients undergoing major surgery. Arch Intern Med. 2007;167:2338-2344.
13. Glasheen JJ, Epstein KR, Siegal E, Kutner J, Prochazka AV. The spectrum of community-based hospitalist practice, a call to tailor internal medicine residency training. Arch Intern Med. 2007;167(7):727-728.
14. Plauth WH, Pantilat SZ, Wachter RM et al. Hospitalist’s perceptions of their residency training needs: Results of a national survey. Am J Med. 2001;111:247-254.
15. Society of Hospital Medicine. 2005-2006 SHM Survey: State of the Hospital Medicine Movement. Available at: http://dev.hospitalmedicine.org/AM/Template.cfm?Section=Survey&Template=/CM/ContentDisplay.cfm&ContentID=14352. Accessed April 28, 2008.

Insanity is doing the same thing over and over again and expecting different results.—Albert Einstein

A hospitalist is defined as a provider whose primary professional focus is the general medical care of hospitalized patients.1

While this allows a concise, usable characterization of a hospitalist, it’s not the whole story. If it were, medical residents, nurses, and inpatient pharmacists all would be hospitalists.

Indeed, a traditional internist with a large hospital practice could reasonably deem him or herself a hospitalist. What defines what a hospitalist does, or should be doing—and how, if at all, is that different than what a traditional internist does in the hospital?

Education Deficiencies

Early data suggested a stark difference between outcomes attributed to hospitalists and general internists who rotated between the clinic and the hospital.

An early experience from the academic environment showed a hospitalist teaching model, when compared with a traditional teaching service, resulted in a 0.6-day length-of-stay (LOS) reduction and a cost savings of $700 per patient with no decrement in the quality of care, clinical outcomes, or satisfaction of provider, housestaff, or patient.2

Similar findings were revealed when community teaching and non-teaching hospitals transitioned to the hospitalist model.3-5 A 2002 review of 19 hospitalist studies revealed an average decreased LOS of 17% coupled with a 1% reduction in hospital costs per case.6

The year 2002 also saw, for the first time, published data that the hospitalist model could reduce in-hospital and 30-day mortality rates.7,8 Together with a 2004 paper showing reductions in minor post-operative complications with hospitalist comanagement of orthopedic patients, these studies suggested hospitalists’ care transcended mere cost savings, improving quality measures as well.9

More recently, however, Lindenauer, et al., found important but less robust differences between hospitalists and non-hospitalists.10 As compared with traditional internists, hospitalists reduced LOS 0.4 days and cost per patient by $268.

While these moderate reductions in LOS and cost versus traditional internists are statistically and clinically significant, they are less vigorous than previous findings. Despite some methodological concerns, this largest investigation—in terms of hospital sites (45), patients (76,926) and hospitalists (284)—revealed no demonstrable improvements in the quality outcomes measured.

Similarly, another recent publication found consultation, provided by medical subspecialists or hospitalists, did not improve glycemic control, rate of appropriate venous thromboembolism (VTE) prophylaxis or perioperative beta-blocker use compared with patients cared for by surgeons alone.11,12

While it is tempting to think hospitalists have re-engineered the systems of care to the point that any provider can fluently and adroitly care for patients, continued reports of less-than-optimal hospital outcomes do not support this hypothesis. More likely, the variance in the early and recent studies relates to the egress from the hospital of less capable or engaged non-hospitalist providers such that more recent findings reflect a comparator group that more closely approximates, in terms of clinical volume, hospitalists.

It’s time to reconsider how we document the merit of hospitalists. Continuing to benchmark hospitalists against non-hospitalists will not tell us if inpatient care is becoming safer, only how one group is doing compared with another. Nor will it necessarily lead to improvements in the quality of care.

To fulfill the promise of the hospitalist model, we need to ensure hospitalists are doing it better, not just better than an external comparator group. As such, it would be more valuable to evaluate hospitalists today versus those five years ago. If, as I suspect, there would be little difference in the clinical outcomes between a new hospitalist (or one in practice for three years) in 2003 and one in 2008 and we accept that hospitalist care has yet to achieve its pinnacle then we must adopt a new path. This will require redesigning the way we train hospitalists.

The ineffectiveness of our current training system is playing out in Dr. Lindenauer’s New England Journal of Medicine paper last year. He found hospitalist outcomes are only marginally better than their similarly trained traditional internist colleagues. To expect differences is to succumb to Albert Einstein’s definition of insanity. We simply cannot expect hospitalists to improve the quality of care with the same set of tools that didn’t allow our predecessors to do so.

Hospitalist-Focused Curricula

Several studies have evaluated the gap between internal medicine (IM) training and hospital medicine practice. A 2007 paper reported that nearly 30% of a community hospitalist practice consisted of areas of under emphasis in traditional IM training.13

These include consultative medicine (6.4% of practice) and the care of the patients with neurological (13.4%), orthopedic (6.4%), or general surgical (2.2%) issues. Additionally, nearly 50% of their practice consisted of patients older than 65, with the largest subset of patients ages 75-84.

Yet, most IM residency training programs do not adequately train housestaff to care for these types of patients and problems. Plauth, et al., documented areas of educational deficiencies by surveying several hundred IM-trained hospitalists about their preparedness to practice hospital medicine following residency training.14

The respondents reported feeling unprepared to care for the type and amount of neurology, geriatrics, palliative care and consultative and perioperative medicine they encountered.

Additionally, they were ill-equipped for the myriad quality improvement and systems and transitions-of-care issues they faced daily.

The “2005-2006 SHM Survey: State of the Hospital Medicine Movement” further highlighted the level of hospitalist non-clinical work, showing that 86% of hospitalist groups engage in quality improvement, 72% contribute practice guidelines, 54% work in utilization review, and 54% are involved in developing electronic medical records and provider order entry.15

For the hospitalist model to deliver outcomes superior to our traditional care model, we will need to create training programs that provide hospitalists with the skills current IM graduates do not possess.

Training programs must evolve to include the necessary clinical and non-clinical aspects of this new medical specialty. Hospitalists have populated the American healthcare landscape for more than a decade, yet very few training programs support innovation in the field of hospital medicine.

It is past time for IM educators, many of whom are hospitalists, to bridge this educational chasm through curricular reform. Short of this, the hospital medicine movement will achieve its pinnacle well short of its promise. TH

Dr. Glasheen is associate professor of medicine at the University of Colorado at 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.

References

1. Society of Hospital Medicine. General information about SHM. Available at: www.hospitalmedicine.org/Content/NavigationMenu/AboutSHM/GeneralInformation/General_Information.htm. Accessed April 25, 2008.
2. Wachter RB, Katz P, Showstack J, Bindman AB, Goldman L. Reorganizing an academic medical service. JAMA. 1998;279:1560-1565.
3. Diamond HS, Goldberg E, Janosky JE. The effect of full-time faculty hospitalists on the efficiency of care at a community teaching hospital. Ann Intern Med. 1998;129:197-203.
4. Freese RB. The Park Nicollet experience in establishing a hospitalist system. Ann Intern Med. 1999;130:350-354.
5. Craig DE, Hartka L, Likosky WH, Caplan WM, Litsky P, Smithey J. Implementation of a hospitalist system in a large health maintenance organization: The Kaiser Permanente experience. Ann Intern Med. 1999;130:355-359.
6. Wachter RM, Goldman L. The hospitalist movement 5 years later. JAMA. 2002;287:487-494.
7. Meltzer D, Manning W, Morrison J, et al. Effects of physician experience on costs and outcomes on an academic general medicine service: results of a trial of hospitalists. Ann Intern Med. 2002;137:866-874.
8. Auerbach AD, Wachter RM, Katz P, et al. Implementation of a voluntary hospitalist service at a community teaching hospital: Improved clinical efficiency and patient outcomes. Ann Intern Med. 2002;137:859-865.
9. Huddleston JM, Long KH, Naessens JM, et al. Medical and surgical comanagement after elective hip and knee arthroplasty. Ann Intern Med. 2004;141:28-38.
10. Lindenauer PK, Rothber MB, Pekow PS, Kenwood C, Benjamin EM, Auerbach AD. Outcomes of care by hospitalist, general internists, and family physicians. N Engl J Med. 2007;357:2589-600.
11. Dr Andrew Auerbach, personal communication, January 7, 2008.
12. Auerbach AD, Rasic MA, Sehgal N, Ide B, Stone B, Maselli J. Opportunity missed: medical consultation, resource use, and quality of care of patients undergoing major surgery. Arch Intern Med. 2007;167:2338-2344.
13. Glasheen JJ, Epstein KR, Siegal E, Kutner J, Prochazka AV. The spectrum of community-based hospitalist practice, a call to tailor internal medicine residency training. Arch Intern Med. 2007;167(7):727-728.
14. Plauth WH, Pantilat SZ, Wachter RM et al. Hospitalist’s perceptions of their residency training needs: Results of a national survey. Am J Med. 2001;111:247-254.
15. Society of Hospital Medicine. 2005-2006 SHM Survey: State of the Hospital Medicine Movement. Available at: http://dev.hospitalmedicine.org/AM/Template.cfm?Section=Survey&Template=/CM/ContentDisplay.cfm&ContentID=14352. Accessed April 28, 2008.

Insanity is doing the same thing over and over again and expecting different results.—Albert Einstein

A hospitalist is defined as a provider whose primary professional focus is the general medical care of hospitalized patients.1

While this allows a concise, usable characterization of a hospitalist, it’s not the whole story. If it were, medical residents, nurses, and inpatient pharmacists all would be hospitalists.

Indeed, a traditional internist with a large hospital practice could reasonably deem him or herself a hospitalist. What defines what a hospitalist does, or should be doing—and how, if at all, is that different than what a traditional internist does in the hospital?

Education Deficiencies

Early data suggested a stark difference between outcomes attributed to hospitalists and general internists who rotated between the clinic and the hospital.

An early experience from the academic environment showed a hospitalist teaching model, when compared with a traditional teaching service, resulted in a 0.6-day length-of-stay (LOS) reduction and a cost savings of $700 per patient with no decrement in the quality of care, clinical outcomes, or satisfaction of provider, housestaff, or patient.2

Similar findings were revealed when community teaching and non-teaching hospitals transitioned to the hospitalist model.3-5 A 2002 review of 19 hospitalist studies revealed an average decreased LOS of 17% coupled with a 1% reduction in hospital costs per case.6

The year 2002 also saw, for the first time, published data that the hospitalist model could reduce in-hospital and 30-day mortality rates.7,8 Together with a 2004 paper showing reductions in minor post-operative complications with hospitalist comanagement of orthopedic patients, these studies suggested hospitalists’ care transcended mere cost savings, improving quality measures as well.9

More recently, however, Lindenauer, et al., found important but less robust differences between hospitalists and non-hospitalists.10 As compared with traditional internists, hospitalists reduced LOS 0.4 days and cost per patient by $268.

While these moderate reductions in LOS and cost versus traditional internists are statistically and clinically significant, they are less vigorous than previous findings. Despite some methodological concerns, this largest investigation—in terms of hospital sites (45), patients (76,926) and hospitalists (284)—revealed no demonstrable improvements in the quality outcomes measured.

Similarly, another recent publication found consultation, provided by medical subspecialists or hospitalists, did not improve glycemic control, rate of appropriate venous thromboembolism (VTE) prophylaxis or perioperative beta-blocker use compared with patients cared for by surgeons alone.11,12

While it is tempting to think hospitalists have re-engineered the systems of care to the point that any provider can fluently and adroitly care for patients, continued reports of less-than-optimal hospital outcomes do not support this hypothesis. More likely, the variance in the early and recent studies relates to the egress from the hospital of less capable or engaged non-hospitalist providers such that more recent findings reflect a comparator group that more closely approximates, in terms of clinical volume, hospitalists.

It’s time to reconsider how we document the merit of hospitalists. Continuing to benchmark hospitalists against non-hospitalists will not tell us if inpatient care is becoming safer, only how one group is doing compared with another. Nor will it necessarily lead to improvements in the quality of care.

To fulfill the promise of the hospitalist model, we need to ensure hospitalists are doing it better, not just better than an external comparator group. As such, it would be more valuable to evaluate hospitalists today versus those five years ago. If, as I suspect, there would be little difference in the clinical outcomes between a new hospitalist (or one in practice for three years) in 2003 and one in 2008 and we accept that hospitalist care has yet to achieve its pinnacle then we must adopt a new path. This will require redesigning the way we train hospitalists.

The ineffectiveness of our current training system is playing out in Dr. Lindenauer’s New England Journal of Medicine paper last year. He found hospitalist outcomes are only marginally better than their similarly trained traditional internist colleagues. To expect differences is to succumb to Albert Einstein’s definition of insanity. We simply cannot expect hospitalists to improve the quality of care with the same set of tools that didn’t allow our predecessors to do so.

Hospitalist-Focused Curricula

Several studies have evaluated the gap between internal medicine (IM) training and hospital medicine practice. A 2007 paper reported that nearly 30% of a community hospitalist practice consisted of areas of under emphasis in traditional IM training.13

These include consultative medicine (6.4% of practice) and the care of the patients with neurological (13.4%), orthopedic (6.4%), or general surgical (2.2%) issues. Additionally, nearly 50% of their practice consisted of patients older than 65, with the largest subset of patients ages 75-84.

Yet, most IM residency training programs do not adequately train housestaff to care for these types of patients and problems. Plauth, et al., documented areas of educational deficiencies by surveying several hundred IM-trained hospitalists about their preparedness to practice hospital medicine following residency training.14

The respondents reported feeling unprepared to care for the type and amount of neurology, geriatrics, palliative care and consultative and perioperative medicine they encountered.

Additionally, they were ill-equipped for the myriad quality improvement and systems and transitions-of-care issues they faced daily.

The “2005-2006 SHM Survey: State of the Hospital Medicine Movement” further highlighted the level of hospitalist non-clinical work, showing that 86% of hospitalist groups engage in quality improvement, 72% contribute practice guidelines, 54% work in utilization review, and 54% are involved in developing electronic medical records and provider order entry.15

For the hospitalist model to deliver outcomes superior to our traditional care model, we will need to create training programs that provide hospitalists with the skills current IM graduates do not possess.

Training programs must evolve to include the necessary clinical and non-clinical aspects of this new medical specialty. Hospitalists have populated the American healthcare landscape for more than a decade, yet very few training programs support innovation in the field of hospital medicine.

It is past time for IM educators, many of whom are hospitalists, to bridge this educational chasm through curricular reform. Short of this, the hospital medicine movement will achieve its pinnacle well short of its promise. TH

Dr. Glasheen is associate professor of medicine at the University of Colorado at 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.

References

1. Society of Hospital Medicine. General information about SHM. Available at: www.hospitalmedicine.org/Content/NavigationMenu/AboutSHM/GeneralInformation/General_Information.htm. Accessed April 25, 2008.
2. Wachter RB, Katz P, Showstack J, Bindman AB, Goldman L. Reorganizing an academic medical service. JAMA. 1998;279:1560-1565.
3. Diamond HS, Goldberg E, Janosky JE. The effect of full-time faculty hospitalists on the efficiency of care at a community teaching hospital. Ann Intern Med. 1998;129:197-203.
4. Freese RB. The Park Nicollet experience in establishing a hospitalist system. Ann Intern Med. 1999;130:350-354.
5. Craig DE, Hartka L, Likosky WH, Caplan WM, Litsky P, Smithey J. Implementation of a hospitalist system in a large health maintenance organization: The Kaiser Permanente experience. Ann Intern Med. 1999;130:355-359.
6. Wachter RM, Goldman L. The hospitalist movement 5 years later. JAMA. 2002;287:487-494.
7. Meltzer D, Manning W, Morrison J, et al. Effects of physician experience on costs and outcomes on an academic general medicine service: results of a trial of hospitalists. Ann Intern Med. 2002;137:866-874.
8. Auerbach AD, Wachter RM, Katz P, et al. Implementation of a voluntary hospitalist service at a community teaching hospital: Improved clinical efficiency and patient outcomes. Ann Intern Med. 2002;137:859-865.
9. Huddleston JM, Long KH, Naessens JM, et al. Medical and surgical comanagement after elective hip and knee arthroplasty. Ann Intern Med. 2004;141:28-38.
10. Lindenauer PK, Rothber MB, Pekow PS, Kenwood C, Benjamin EM, Auerbach AD. Outcomes of care by hospitalist, general internists, and family physicians. N Engl J Med. 2007;357:2589-600.
11. Dr Andrew Auerbach, personal communication, January 7, 2008.
12. Auerbach AD, Rasic MA, Sehgal N, Ide B, Stone B, Maselli J. Opportunity missed: medical consultation, resource use, and quality of care of patients undergoing major surgery. Arch Intern Med. 2007;167:2338-2344.
13. Glasheen JJ, Epstein KR, Siegal E, Kutner J, Prochazka AV. The spectrum of community-based hospitalist practice, a call to tailor internal medicine residency training. Arch Intern Med. 2007;167(7):727-728.
14. Plauth WH, Pantilat SZ, Wachter RM et al. Hospitalist’s perceptions of their residency training needs: Results of a national survey. Am J Med. 2001;111:247-254.
15. Society of Hospital Medicine. 2005-2006 SHM Survey: State of the Hospital Medicine Movement. Available at: http://dev.hospitalmedicine.org/AM/Template.cfm?Section=Survey&Template=/CM/ContentDisplay.cfm&ContentID=14352. Accessed April 28, 2008.

Change is in the air. Some pundits point to a new healthcare system; others point to something a little less dramatic on the edges. No matter how one views it, change definitely is afoot.

The last time I recall a similar feeling was 1993. There was a general feeling then among many in healthcare that a unique convergence of events might result in healthcare reform. Because of the similarities between 1993 and 2008, many people are naturally wondering whether the atmosphere is similar enough to again result in reform this time.

What do we know about healthcare in 2008 as opposed to 1993? Well, an even greater share of the United States economy is based on healthcare. The quality and patient-safety movement has arrived. There is a greater discussion about pay for performance. The effects of consumerism are being felt by all healthcare providers. There is evidence the United States does not have the best healthcare.1 There still are some physician shortages, and predictions of greater shortages, albeit in different areas then 1993. So, if anything, the burning platform for change appears brighter in 2008 than in 1993.

As I reflect on these facts and the differences between then and now, I think of the principles of change management.2,3 Establishing the burning platform or the sense of urgency is only the first step in change. It is a vital one, but if the next steps are not completed, hard-wired change does not occur.

The second tenet of change management is that you must pull together a guiding team. There must be a powerful group guiding the change—one with leadership skills, credibility, communications ability, authority, analytical skills, and sense of urgency.

This is the main difference between 1993 and 2008 and one that convinces me we are on the road to change in healthcare. For the biggest difference is you. In 1993, there were several hundred hospitalists in the United States. Now, there are approximately 20,000 and a robust professional society to help manage and lead the group.

You are the guiding team. Why? In many mature hospital medicine programs, hospitalists account for the majority of a hospital’s admissions. Add this to the fact that more than 30% of healthcare is spent on hospital care. The result is that hospitalists through their pens control a significant amount of the healthcare market. Hospitalists have the leadership, authority, and credibility to be the guiding team. And when I see the tremendous skills of hospitalists in guiding new programs and serving as medical staff leaders, I am convinced hospitalists are the nation’s guiding team in healthcare reform.

The third step in change management principles is deciding what to do. There must be a unified vision and strategy. I am not as confident this vision is fully formed yet and hence one of the reasons we won’t get change immediately. To create a unified vision and strategy, we need additional innovation in hospital care. Granted, hospital medicine is a relatively recent innovation; we are far from done developing the right care mode for hospitalized patients.

What is the area we need to innovate in the most? Our practices. While there is much innovation occurring in hospital medicine, we need to continue aggressively pursuing new methods of care delivery. Year after year at our annual meetings, we see tremendous evidence of innovation in the numerous abstracts presented. Still, we must try to take it up to a new level. The present way of doing things isn’t sustainable. We cannot completely care for patients by merely working harder in our current care-delivery model. Working differently or fundamentally redesigning our jobs will help us. It will help us see more patients and deliver greater quality, all while maintaining high degrees of personal and professional satisfaction.

Do not leave the innovation up to others. Each of us must continue to assess how we deliver care through a team model. We must evaluate how to better integrate with midlevel providers. We must lead in transitions of care and discharge planning. We need to re-examine the basic model of physician-patient care. We must make sure residency and post-residency training prepare hospitalists for all of this. Finally, we need to innovate on how hospital administrators and hospitalists work together to improve quality and patient safety.

Don’t forget to share those innovations with SHM. SHM is your conduit to change healthcare—and if you take things to the third step of change management, SHM easily can help you through the remaining steps. TH

Dr. Cawley is president of SHM.

References

1. Davis K, Schoen C, Schoenbaum SC, et al. Mirror, mirror on the wall: an international update on the comparative performance of American health care. Commonwealth Fund: May 2007.
2. Kotter J. Leading change. Boston: Harvard Business Press; 1996.
3. Kotter J, Rathgebar H. Our iceberg is melting: changing and succeeding under any condition. New York: St. Martin’s Press; 2005.

Change is in the air. Some pundits point to a new healthcare system; others point to something a little less dramatic on the edges. No matter how one views it, change definitely is afoot.

The last time I recall a similar feeling was 1993. There was a general feeling then among many in healthcare that a unique convergence of events might result in healthcare reform. Because of the similarities between 1993 and 2008, many people are naturally wondering whether the atmosphere is similar enough to again result in reform this time.

What do we know about healthcare in 2008 as opposed to 1993? Well, an even greater share of the United States economy is based on healthcare. The quality and patient-safety movement has arrived. There is a greater discussion about pay for performance. The effects of consumerism are being felt by all healthcare providers. There is evidence the United States does not have the best healthcare.1 There still are some physician shortages, and predictions of greater shortages, albeit in different areas then 1993. So, if anything, the burning platform for change appears brighter in 2008 than in 1993.

As I reflect on these facts and the differences between then and now, I think of the principles of change management.2,3 Establishing the burning platform or the sense of urgency is only the first step in change. It is a vital one, but if the next steps are not completed, hard-wired change does not occur.

The second tenet of change management is that you must pull together a guiding team. There must be a powerful group guiding the change—one with leadership skills, credibility, communications ability, authority, analytical skills, and sense of urgency.

This is the main difference between 1993 and 2008 and one that convinces me we are on the road to change in healthcare. For the biggest difference is you. In 1993, there were several hundred hospitalists in the United States. Now, there are approximately 20,000 and a robust professional society to help manage and lead the group.

You are the guiding team. Why? In many mature hospital medicine programs, hospitalists account for the majority of a hospital’s admissions. Add this to the fact that more than 30% of healthcare is spent on hospital care. The result is that hospitalists through their pens control a significant amount of the healthcare market. Hospitalists have the leadership, authority, and credibility to be the guiding team. And when I see the tremendous skills of hospitalists in guiding new programs and serving as medical staff leaders, I am convinced hospitalists are the nation’s guiding team in healthcare reform.

The third step in change management principles is deciding what to do. There must be a unified vision and strategy. I am not as confident this vision is fully formed yet and hence one of the reasons we won’t get change immediately. To create a unified vision and strategy, we need additional innovation in hospital care. Granted, hospital medicine is a relatively recent innovation; we are far from done developing the right care mode for hospitalized patients.

What is the area we need to innovate in the most? Our practices. While there is much innovation occurring in hospital medicine, we need to continue aggressively pursuing new methods of care delivery. Year after year at our annual meetings, we see tremendous evidence of innovation in the numerous abstracts presented. Still, we must try to take it up to a new level. The present way of doing things isn’t sustainable. We cannot completely care for patients by merely working harder in our current care-delivery model. Working differently or fundamentally redesigning our jobs will help us. It will help us see more patients and deliver greater quality, all while maintaining high degrees of personal and professional satisfaction.

Do not leave the innovation up to others. Each of us must continue to assess how we deliver care through a team model. We must evaluate how to better integrate with midlevel providers. We must lead in transitions of care and discharge planning. We need to re-examine the basic model of physician-patient care. We must make sure residency and post-residency training prepare hospitalists for all of this. Finally, we need to innovate on how hospital administrators and hospitalists work together to improve quality and patient safety.

Don’t forget to share those innovations with SHM. SHM is your conduit to change healthcare—and if you take things to the third step of change management, SHM easily can help you through the remaining steps. TH

Dr. Cawley is president of SHM.

References

1. Davis K, Schoen C, Schoenbaum SC, et al. Mirror, mirror on the wall: an international update on the comparative performance of American health care. Commonwealth Fund: May 2007.
2. Kotter J. Leading change. Boston: Harvard Business Press; 1996.
3. Kotter J, Rathgebar H. Our iceberg is melting: changing and succeeding under any condition. New York: St. Martin’s Press; 2005.

Change is in the air. Some pundits point to a new healthcare system; others point to something a little less dramatic on the edges. No matter how one views it, change definitely is afoot.

The last time I recall a similar feeling was 1993. There was a general feeling then among many in healthcare that a unique convergence of events might result in healthcare reform. Because of the similarities between 1993 and 2008, many people are naturally wondering whether the atmosphere is similar enough to again result in reform this time.

What do we know about healthcare in 2008 as opposed to 1993? Well, an even greater share of the United States economy is based on healthcare. The quality and patient-safety movement has arrived. There is a greater discussion about pay for performance. The effects of consumerism are being felt by all healthcare providers. There is evidence the United States does not have the best healthcare.1 There still are some physician shortages, and predictions of greater shortages, albeit in different areas then 1993. So, if anything, the burning platform for change appears brighter in 2008 than in 1993.

As I reflect on these facts and the differences between then and now, I think of the principles of change management.2,3 Establishing the burning platform or the sense of urgency is only the first step in change. It is a vital one, but if the next steps are not completed, hard-wired change does not occur.

The second tenet of change management is that you must pull together a guiding team. There must be a powerful group guiding the change—one with leadership skills, credibility, communications ability, authority, analytical skills, and sense of urgency.

This is the main difference between 1993 and 2008 and one that convinces me we are on the road to change in healthcare. For the biggest difference is you. In 1993, there were several hundred hospitalists in the United States. Now, there are approximately 20,000 and a robust professional society to help manage and lead the group.

You are the guiding team. Why? In many mature hospital medicine programs, hospitalists account for the majority of a hospital’s admissions. Add this to the fact that more than 30% of healthcare is spent on hospital care. The result is that hospitalists through their pens control a significant amount of the healthcare market. Hospitalists have the leadership, authority, and credibility to be the guiding team. And when I see the tremendous skills of hospitalists in guiding new programs and serving as medical staff leaders, I am convinced hospitalists are the nation’s guiding team in healthcare reform.

The third step in change management principles is deciding what to do. There must be a unified vision and strategy. I am not as confident this vision is fully formed yet and hence one of the reasons we won’t get change immediately. To create a unified vision and strategy, we need additional innovation in hospital care. Granted, hospital medicine is a relatively recent innovation; we are far from done developing the right care mode for hospitalized patients.

What is the area we need to innovate in the most? Our practices. While there is much innovation occurring in hospital medicine, we need to continue aggressively pursuing new methods of care delivery. Year after year at our annual meetings, we see tremendous evidence of innovation in the numerous abstracts presented. Still, we must try to take it up to a new level. The present way of doing things isn’t sustainable. We cannot completely care for patients by merely working harder in our current care-delivery model. Working differently or fundamentally redesigning our jobs will help us. It will help us see more patients and deliver greater quality, all while maintaining high degrees of personal and professional satisfaction.

Do not leave the innovation up to others. Each of us must continue to assess how we deliver care through a team model. We must evaluate how to better integrate with midlevel providers. We must lead in transitions of care and discharge planning. We need to re-examine the basic model of physician-patient care. We must make sure residency and post-residency training prepare hospitalists for all of this. Finally, we need to innovate on how hospital administrators and hospitalists work together to improve quality and patient safety.

Don’t forget to share those innovations with SHM. SHM is your conduit to change healthcare—and if you take things to the third step of change management, SHM easily can help you through the remaining steps. TH

Dr. Cawley is president of SHM.

References

1. Davis K, Schoen C, Schoenbaum SC, et al. Mirror, mirror on the wall: an international update on the comparative performance of American health care. Commonwealth Fund: May 2007.
2. Kotter J. Leading change. Boston: Harvard Business Press; 1996.
3. Kotter J, Rathgebar H. Our iceberg is melting: changing and succeeding under any condition. New York: St. Martin’s Press; 2005.

Case

A 56-year-old male with a 60-pack-a-year history of cigarette smoking is admitted to the telemetry unit with an initial assessment of acute coronary syndrome. Because there is a no-smoking policy in the hospital, he is willing to comply but is concerned about tobacco withdrawal symptoms.

Overview

As of 2006, approximately 20.8% of U.S. adults smoke cigarettes.1 Responsible for approximately 438,000 deaths annually, cigarette smoking is the most important preventable cause of death and disease in the U.S.2

Smoking cessation reduces the risk of tobacco-related diseases; the potential health benefits are numerous. This is most evident in the reduction of cardiovascular disease events upon tobacco abstinence.3 Yet, it remains a constant struggle for smokers to quit and stay abstinent.

The main barrier to quitting is nicotine addiction, which causes tolerance and physical dependence. Upon cessation of tobacco use, withdrawal symptoms, such as irritability, restlessness, impatience, and depression may occur within a few hours, peak within the first several days, and then wane during the next few months.

The crucial time frame to prevent relapse is the first week of cessation. For smokers to stay off cigarettes, they must break from routines, behaviors, or cues that trigger the urge to smoke.4

Among patients with acute myocardial infarction (AMI) in a study done by Van Spall, et al., 39% of them still smoked.5 Indeed, smoking is associated with 1.5 to three times increased relative risk of AMI, and hospitalists increasingly must manage cardiovascular disease patients’ tobacco dependence during their hospital stay.

Intervention strategies: Methods for smoking cessation need to target two aspects that support tobacco use—physical and psychological factors. High-intensity counseling and systematic behavioral intervention followed by sustained contact—in person or by phone up to one month after discharge—are effective behavioral interventions for sustained tobacco cessation.6 Pharmacotherapy also helps when added to high-intensity counseling of a hospitalized patient. It especially is beneficial for controlling withdrawal symptoms.

In addition, with policies prohibiting smoking in almost all U.S. hospitals, temporary tobacco abstinence promotes smoking cessation for hospitalized patients. Unfortunately, most hospitalized patients go back to smoking soon after discharge. Hospitalization may be the opportune time to help patients try to quit and avoid relapse.

Some hospitals feature inpatient smoking cessation programs in which nurse practitioners and counselors educate and counsel patients. It is highly recommended that a multidisciplinary team be involved in a tobacco cessation program catered to an individual patient’s needs. However, most hospitals have no such program. Nevertheless, the hospitalist can help a patient with brief or low-intensity tobacco cessation counseling, pharmacotherapy for nicotine withdrawal symptom control if clinically indicated, and follow-up upon discharge for relapse prevention.

Counseling: Smoking cessation counseling in the hospital after an AMI has been found to be associated with a relative risk reduction of mortality by 37% in one year. The hospitalist should give a two-minute cessation message as the first step. If tobacco cessation counselors or nurse practitioners are available, their additional counseling also may improve outcomes of smoking cessation therapies.7 However, if no established inpatient tobacco cessation program is available to the hospitalist, the following may be used to aid in physician counseling of the hospitalized cardiac patient:

The first step in treating tobacco dependence is to identify and assess tobacco use status.

Tobacco users willing to quit should be treated using the 5 A’s (Ask, Advise, Assess, Assist, and Arrange) (see Figure 1, p. 30). Tobacco users not willing to quit at the time of interaction should be treated using the 5 R’s for motivational intervention:

• Relevance (indicate why quitting is personally relevant);
• Risks (have patient identify potentially negative consequences of smoking);
• Rewards (have patient identify potential benefits of quitting smoking);
• Roadblocks (have patient identify potential barriers to smoking cessation and provide patient problem-solving techniques and pharmacotherapy to overcome the barriers); and
• Repetition (repeat motivational intervention to unmotivated patient each visit).

Further, former smokers who recently quit using tobacco should be given relapse prevention treatment.8 For the hospitalized smoker with acute cardiovascular disease, providing bedside counseling, enhancing self-coping behavior change, and arranging follow-up after discharge to maintain behavior change can help sustain tobacco abstinence.

Pharmacotherapy: The most important purpose of pharmacotherapy for smoking cessation is to reduce withdrawal symptoms and cigarette cravings. Public Health Service clinical guidelines for smoking cessation mention five first-line agents. These are sustained-release bupropion and four nicotine-replacement therapies (NRT): transdermal patch, gum, nasal spray, and vapor inhaler. Further, there are two second-line agents: clonidine and nortriptyline. Since the clinical guidelines’ release in 2000, the Food and Drug Administration has approved a fifth NRT product, the nicotine lozenge, in 2002, and a partial nicotine agonist, varenicline, in 2006 (see Table 1, right).9,10

Current guidelines recommend that NRT be used with caution in patients with unstable angina, serious arrhythmias, or an MI within the previous two weeks due to limited supportive data on the safety of use in these patients.11 The transdermal patch delivers nicotine at a slow and constant rate in contrast to the other forms of NRT and has been used safely in patients with stable coronary artery disease. However, the use of any NRT, including the patch, in acute cardiovascular disease is not advised due to the nicotine-mediated hemodynamic effects, such as increase heart rate and arterial vasoconstriction, which lead to increased myocardial workload.

click for large version

Sustained-release bupropion generally is well tolerated by hospitalized patients with cardiovascular disease, but there may be a delay in control of withdrawal symptoms. In addition, blood pressure must be monitored especially if combined with NRT as there have been anecdotal reports of increase in blood pressure with bupropion alone.12 Bupropion must be used cautiously in patients with recent MI. Other contraindications include history of seizure, conditions that potentially can increase risk for convulsions, and use of monoamine oxidase inhibitors (MAOI) within 14 days.

The new drug varenicline has not been studied in hospitalized patients or patients with acute coronary syndrome. However, since it does not have any important hemodynamic effects, it may be useful in this setting and in selected patients with close monitoring for mood changes since there have been anecdotal case reports of psychotic events in patients with underlying psychiatric disorders.13 Its routine use currently is not recommended.

Follow-up after discharge: Pharmacotherapy may be added for withdrawal control, as well as relapse prevention for the hospitalized patient who recently quit smoking. However, inclusion of intensive tobacco cessation counseling during the hospital stay is the most effective intervention given the setting and patient condition, and follow-up support up to at least one month after discharge has been found to be more effective in sustaining tobacco abstinence than pharmacotherapy alone. In order to maximize long-term quit rates among patients who recently abstained from smoking, the hospitalist should arrange access to ongoing outpatient post-discharge support and tobacco cessation treatment.

Back to the Case

After appropriate cardiac testing, the patient was found to have a non-cardiac etiology for his symptoms. From the start of his hospital stay, he was counseled by the hospitalist and started on sustained-release bupropion, but withdrawal symptoms and cravings persisted.

Prior to his discharge home, the patient wanted to discontinue bupropion and be provided an alternative. The patient was given a nicotine patch, and a follow-up appointment at the tobacco cessation clinic within one week of discharge from the hospital was arranged. The patient has been compliant with his quit-smoking treatment and has followed-up for continued tobacco cessation counseling. He hasn’t smoked cigarettes for a year. TH

Dr. Palisoc is a preventive medicine resident at the University of Colorado Denver. Dr. Prochazka works at the Denver VA and is a professor of medicine at the University of Colorado Denver.

References

click for large version

1. CDC. Cigarette Smoking Among Adults, United States, 2006. MMWR Morbidity Mortality Wkly Rep. 2007;56(44):1157-1161. Available at www.cdc.gov/mmwr/preview/mmwrhtml/mm5644a2.htm. Last accessed March 4, 2008.
2. CDC. Annual Smoking-Attributable Mortality, Years of Potential Life Lost, and Productivity, United States, 1997-2001. MMWR Morbidity Mortality Wkly Rep. 2005;54(25):625-628.
3. Thomson CC, Rigotti NA. Hospital- and clinic-based smoking cessation interventions for smokers with cardiovascular disease. Prog Cardiovasc Dis. 2003;45(6):459-479.
4. Rigotti NA. Treatment of tobacco use and dependence. N Engl J Med. 2002;346(7):506-512.
5. Van Spall HGC, Chong A, Tu JV. Inpatient smoking-cessation counseling and all-cause mortality in patients with acute myocardial infarction. Am Heart J. 2007;154(2):213-220.
6. Rigotti NA, Munafo MR, Stead LF. Interventions for smoking cessation in hospitalized patients. Cochrane Database Syst Rev. 2007;Issue 3.
7. Ludvig J, Miner B, and Eisenberg, MJ. Smoking cessation in patients with coronary artery disease. Am Heart J. 2005;149(4):565-572.
8. Fiore MC, Bailey WC, Cohen SJ, et al. Treating tobacco use and dependence: clinical practice guideline. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service 2000.
9. Rigotti NA, Thorndike AN, Regan S, et al. Bupropion for smokers hospitalized with acute cardiovascular disease. Am J Med. 2006;199:1080-1087.
10. Jorenby DE, Hays JT, Rigotti NA, et al. Efficacy of varenicline, an alpha4beta2 nicotinic acetylcholine receptor partial agonist, vs. placebo or sustained-release bupropion for smoking cessation: a randomized controlled trial. JAMA. 2006;296(1):56-63.
11. Joseph AM, Fu SS. Safety issues in pharmacotherapy for smoking in patients with cardiovascular disease. Prog Cardiovasc Dis. 2003;45(6):429-441.
12. FDA. Prescribing information of Zyban (bupropion hydrochloride) sustained release tablets. June 2007. Available at www.fda.gov/medwatch/safety/2007/ Aug_PI/Zyban_PI.pdf. Last accessed March 6, 2008.
13. FDA. Early Communication About an Ongoing Safety Review: Varenicline (marketed as Chantix). November 2007. Available at www.fda.gov/cder/drug/early_comm/varenicline.htm. Last accessed March 6, 2008.

Case

A 56-year-old male with a 60-pack-a-year history of cigarette smoking is admitted to the telemetry unit with an initial assessment of acute coronary syndrome. Because there is a no-smoking policy in the hospital, he is willing to comply but is concerned about tobacco withdrawal symptoms.

Overview

As of 2006, approximately 20.8% of U.S. adults smoke cigarettes.1 Responsible for approximately 438,000 deaths annually, cigarette smoking is the most important preventable cause of death and disease in the U.S.2

Smoking cessation reduces the risk of tobacco-related diseases; the potential health benefits are numerous. This is most evident in the reduction of cardiovascular disease events upon tobacco abstinence.3 Yet, it remains a constant struggle for smokers to quit and stay abstinent.

The main barrier to quitting is nicotine addiction, which causes tolerance and physical dependence. Upon cessation of tobacco use, withdrawal symptoms, such as irritability, restlessness, impatience, and depression may occur within a few hours, peak within the first several days, and then wane during the next few months.

The crucial time frame to prevent relapse is the first week of cessation. For smokers to stay off cigarettes, they must break from routines, behaviors, or cues that trigger the urge to smoke.4

Among patients with acute myocardial infarction (AMI) in a study done by Van Spall, et al., 39% of them still smoked.5 Indeed, smoking is associated with 1.5 to three times increased relative risk of AMI, and hospitalists increasingly must manage cardiovascular disease patients’ tobacco dependence during their hospital stay.

Intervention strategies: Methods for smoking cessation need to target two aspects that support tobacco use—physical and psychological factors. High-intensity counseling and systematic behavioral intervention followed by sustained contact—in person or by phone up to one month after discharge—are effective behavioral interventions for sustained tobacco cessation.6 Pharmacotherapy also helps when added to high-intensity counseling of a hospitalized patient. It especially is beneficial for controlling withdrawal symptoms.

In addition, with policies prohibiting smoking in almost all U.S. hospitals, temporary tobacco abstinence promotes smoking cessation for hospitalized patients. Unfortunately, most hospitalized patients go back to smoking soon after discharge. Hospitalization may be the opportune time to help patients try to quit and avoid relapse.

Some hospitals feature inpatient smoking cessation programs in which nurse practitioners and counselors educate and counsel patients. It is highly recommended that a multidisciplinary team be involved in a tobacco cessation program catered to an individual patient’s needs. However, most hospitals have no such program. Nevertheless, the hospitalist can help a patient with brief or low-intensity tobacco cessation counseling, pharmacotherapy for nicotine withdrawal symptom control if clinically indicated, and follow-up upon discharge for relapse prevention.

Counseling: Smoking cessation counseling in the hospital after an AMI has been found to be associated with a relative risk reduction of mortality by 37% in one year. The hospitalist should give a two-minute cessation message as the first step. If tobacco cessation counselors or nurse practitioners are available, their additional counseling also may improve outcomes of smoking cessation therapies.7 However, if no established inpatient tobacco cessation program is available to the hospitalist, the following may be used to aid in physician counseling of the hospitalized cardiac patient:

The first step in treating tobacco dependence is to identify and assess tobacco use status.

Tobacco users willing to quit should be treated using the 5 A’s (Ask, Advise, Assess, Assist, and Arrange) (see Figure 1, p. 30). Tobacco users not willing to quit at the time of interaction should be treated using the 5 R’s for motivational intervention:

• Relevance (indicate why quitting is personally relevant);
• Risks (have patient identify potentially negative consequences of smoking);
• Rewards (have patient identify potential benefits of quitting smoking);
• Roadblocks (have patient identify potential barriers to smoking cessation and provide patient problem-solving techniques and pharmacotherapy to overcome the barriers); and
• Repetition (repeat motivational intervention to unmotivated patient each visit).

Further, former smokers who recently quit using tobacco should be given relapse prevention treatment.8 For the hospitalized smoker with acute cardiovascular disease, providing bedside counseling, enhancing self-coping behavior change, and arranging follow-up after discharge to maintain behavior change can help sustain tobacco abstinence.

Pharmacotherapy: The most important purpose of pharmacotherapy for smoking cessation is to reduce withdrawal symptoms and cigarette cravings. Public Health Service clinical guidelines for smoking cessation mention five first-line agents. These are sustained-release bupropion and four nicotine-replacement therapies (NRT): transdermal patch, gum, nasal spray, and vapor inhaler. Further, there are two second-line agents: clonidine and nortriptyline. Since the clinical guidelines’ release in 2000, the Food and Drug Administration has approved a fifth NRT product, the nicotine lozenge, in 2002, and a partial nicotine agonist, varenicline, in 2006 (see Table 1, right).9,10

Current guidelines recommend that NRT be used with caution in patients with unstable angina, serious arrhythmias, or an MI within the previous two weeks due to limited supportive data on the safety of use in these patients.11 The transdermal patch delivers nicotine at a slow and constant rate in contrast to the other forms of NRT and has been used safely in patients with stable coronary artery disease. However, the use of any NRT, including the patch, in acute cardiovascular disease is not advised due to the nicotine-mediated hemodynamic effects, such as increase heart rate and arterial vasoconstriction, which lead to increased myocardial workload.

click for large version

Sustained-release bupropion generally is well tolerated by hospitalized patients with cardiovascular disease, but there may be a delay in control of withdrawal symptoms. In addition, blood pressure must be monitored especially if combined with NRT as there have been anecdotal reports of increase in blood pressure with bupropion alone.12 Bupropion must be used cautiously in patients with recent MI. Other contraindications include history of seizure, conditions that potentially can increase risk for convulsions, and use of monoamine oxidase inhibitors (MAOI) within 14 days.

The new drug varenicline has not been studied in hospitalized patients or patients with acute coronary syndrome. However, since it does not have any important hemodynamic effects, it may be useful in this setting and in selected patients with close monitoring for mood changes since there have been anecdotal case reports of psychotic events in patients with underlying psychiatric disorders.13 Its routine use currently is not recommended.

Follow-up after discharge: Pharmacotherapy may be added for withdrawal control, as well as relapse prevention for the hospitalized patient who recently quit smoking. However, inclusion of intensive tobacco cessation counseling during the hospital stay is the most effective intervention given the setting and patient condition, and follow-up support up to at least one month after discharge has been found to be more effective in sustaining tobacco abstinence than pharmacotherapy alone. In order to maximize long-term quit rates among patients who recently abstained from smoking, the hospitalist should arrange access to ongoing outpatient post-discharge support and tobacco cessation treatment.

Back to the Case

After appropriate cardiac testing, the patient was found to have a non-cardiac etiology for his symptoms. From the start of his hospital stay, he was counseled by the hospitalist and started on sustained-release bupropion, but withdrawal symptoms and cravings persisted.

Prior to his discharge home, the patient wanted to discontinue bupropion and be provided an alternative. The patient was given a nicotine patch, and a follow-up appointment at the tobacco cessation clinic within one week of discharge from the hospital was arranged. The patient has been compliant with his quit-smoking treatment and has followed-up for continued tobacco cessation counseling. He hasn’t smoked cigarettes for a year. TH

Dr. Palisoc is a preventive medicine resident at the University of Colorado Denver. Dr. Prochazka works at the Denver VA and is a professor of medicine at the University of Colorado Denver.

References

click for large version

1. CDC. Cigarette Smoking Among Adults, United States, 2006. MMWR Morbidity Mortality Wkly Rep. 2007;56(44):1157-1161. Available at www.cdc.gov/mmwr/preview/mmwrhtml/mm5644a2.htm. Last accessed March 4, 2008.
2. CDC. Annual Smoking-Attributable Mortality, Years of Potential Life Lost, and Productivity, United States, 1997-2001. MMWR Morbidity Mortality Wkly Rep. 2005;54(25):625-628.
3. Thomson CC, Rigotti NA. Hospital- and clinic-based smoking cessation interventions for smokers with cardiovascular disease. Prog Cardiovasc Dis. 2003;45(6):459-479.
4. Rigotti NA. Treatment of tobacco use and dependence. N Engl J Med. 2002;346(7):506-512.
5. Van Spall HGC, Chong A, Tu JV. Inpatient smoking-cessation counseling and all-cause mortality in patients with acute myocardial infarction. Am Heart J. 2007;154(2):213-220.
6. Rigotti NA, Munafo MR, Stead LF. Interventions for smoking cessation in hospitalized patients. Cochrane Database Syst Rev. 2007;Issue 3.
7. Ludvig J, Miner B, and Eisenberg, MJ. Smoking cessation in patients with coronary artery disease. Am Heart J. 2005;149(4):565-572.
8. Fiore MC, Bailey WC, Cohen SJ, et al. Treating tobacco use and dependence: clinical practice guideline. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service 2000.
9. Rigotti NA, Thorndike AN, Regan S, et al. Bupropion for smokers hospitalized with acute cardiovascular disease. Am J Med. 2006;199:1080-1087.
10. Jorenby DE, Hays JT, Rigotti NA, et al. Efficacy of varenicline, an alpha4beta2 nicotinic acetylcholine receptor partial agonist, vs. placebo or sustained-release bupropion for smoking cessation: a randomized controlled trial. JAMA. 2006;296(1):56-63.
11. Joseph AM, Fu SS. Safety issues in pharmacotherapy for smoking in patients with cardiovascular disease. Prog Cardiovasc Dis. 2003;45(6):429-441.
12. FDA. Prescribing information of Zyban (bupropion hydrochloride) sustained release tablets. June 2007. Available at www.fda.gov/medwatch/safety/2007/ Aug_PI/Zyban_PI.pdf. Last accessed March 6, 2008.
13. FDA. Early Communication About an Ongoing Safety Review: Varenicline (marketed as Chantix). November 2007. Available at www.fda.gov/cder/drug/early_comm/varenicline.htm. Last accessed March 6, 2008.

Case

A 56-year-old male with a 60-pack-a-year history of cigarette smoking is admitted to the telemetry unit with an initial assessment of acute coronary syndrome. Because there is a no-smoking policy in the hospital, he is willing to comply but is concerned about tobacco withdrawal symptoms.

Overview

As of 2006, approximately 20.8% of U.S. adults smoke cigarettes.1 Responsible for approximately 438,000 deaths annually, cigarette smoking is the most important preventable cause of death and disease in the U.S.2

Smoking cessation reduces the risk of tobacco-related diseases; the potential health benefits are numerous. This is most evident in the reduction of cardiovascular disease events upon tobacco abstinence.3 Yet, it remains a constant struggle for smokers to quit and stay abstinent.

The main barrier to quitting is nicotine addiction, which causes tolerance and physical dependence. Upon cessation of tobacco use, withdrawal symptoms, such as irritability, restlessness, impatience, and depression may occur within a few hours, peak within the first several days, and then wane during the next few months.

The crucial time frame to prevent relapse is the first week of cessation. For smokers to stay off cigarettes, they must break from routines, behaviors, or cues that trigger the urge to smoke.4

Among patients with acute myocardial infarction (AMI) in a study done by Van Spall, et al., 39% of them still smoked.5 Indeed, smoking is associated with 1.5 to three times increased relative risk of AMI, and hospitalists increasingly must manage cardiovascular disease patients’ tobacco dependence during their hospital stay.

Intervention strategies: Methods for smoking cessation need to target two aspects that support tobacco use—physical and psychological factors. High-intensity counseling and systematic behavioral intervention followed by sustained contact—in person or by phone up to one month after discharge—are effective behavioral interventions for sustained tobacco cessation.6 Pharmacotherapy also helps when added to high-intensity counseling of a hospitalized patient. It especially is beneficial for controlling withdrawal symptoms.

In addition, with policies prohibiting smoking in almost all U.S. hospitals, temporary tobacco abstinence promotes smoking cessation for hospitalized patients. Unfortunately, most hospitalized patients go back to smoking soon after discharge. Hospitalization may be the opportune time to help patients try to quit and avoid relapse.

Some hospitals feature inpatient smoking cessation programs in which nurse practitioners and counselors educate and counsel patients. It is highly recommended that a multidisciplinary team be involved in a tobacco cessation program catered to an individual patient’s needs. However, most hospitals have no such program. Nevertheless, the hospitalist can help a patient with brief or low-intensity tobacco cessation counseling, pharmacotherapy for nicotine withdrawal symptom control if clinically indicated, and follow-up upon discharge for relapse prevention.

Counseling: Smoking cessation counseling in the hospital after an AMI has been found to be associated with a relative risk reduction of mortality by 37% in one year. The hospitalist should give a two-minute cessation message as the first step. If tobacco cessation counselors or nurse practitioners are available, their additional counseling also may improve outcomes of smoking cessation therapies.7 However, if no established inpatient tobacco cessation program is available to the hospitalist, the following may be used to aid in physician counseling of the hospitalized cardiac patient:

The first step in treating tobacco dependence is to identify and assess tobacco use status.

Tobacco users willing to quit should be treated using the 5 A’s (Ask, Advise, Assess, Assist, and Arrange) (see Figure 1, p. 30). Tobacco users not willing to quit at the time of interaction should be treated using the 5 R’s for motivational intervention:

• Relevance (indicate why quitting is personally relevant);
• Risks (have patient identify potentially negative consequences of smoking);
• Rewards (have patient identify potential benefits of quitting smoking);
• Roadblocks (have patient identify potential barriers to smoking cessation and provide patient problem-solving techniques and pharmacotherapy to overcome the barriers); and
• Repetition (repeat motivational intervention to unmotivated patient each visit).

Further, former smokers who recently quit using tobacco should be given relapse prevention treatment.8 For the hospitalized smoker with acute cardiovascular disease, providing bedside counseling, enhancing self-coping behavior change, and arranging follow-up after discharge to maintain behavior change can help sustain tobacco abstinence.

Pharmacotherapy: The most important purpose of pharmacotherapy for smoking cessation is to reduce withdrawal symptoms and cigarette cravings. Public Health Service clinical guidelines for smoking cessation mention five first-line agents. These are sustained-release bupropion and four nicotine-replacement therapies (NRT): transdermal patch, gum, nasal spray, and vapor inhaler. Further, there are two second-line agents: clonidine and nortriptyline. Since the clinical guidelines’ release in 2000, the Food and Drug Administration has approved a fifth NRT product, the nicotine lozenge, in 2002, and a partial nicotine agonist, varenicline, in 2006 (see Table 1, right).9,10

Current guidelines recommend that NRT be used with caution in patients with unstable angina, serious arrhythmias, or an MI within the previous two weeks due to limited supportive data on the safety of use in these patients.11 The transdermal patch delivers nicotine at a slow and constant rate in contrast to the other forms of NRT and has been used safely in patients with stable coronary artery disease. However, the use of any NRT, including the patch, in acute cardiovascular disease is not advised due to the nicotine-mediated hemodynamic effects, such as increase heart rate and arterial vasoconstriction, which lead to increased myocardial workload.

click for large version

Sustained-release bupropion generally is well tolerated by hospitalized patients with cardiovascular disease, but there may be a delay in control of withdrawal symptoms. In addition, blood pressure must be monitored especially if combined with NRT as there have been anecdotal reports of increase in blood pressure with bupropion alone.12 Bupropion must be used cautiously in patients with recent MI. Other contraindications include history of seizure, conditions that potentially can increase risk for convulsions, and use of monoamine oxidase inhibitors (MAOI) within 14 days.

The new drug varenicline has not been studied in hospitalized patients or patients with acute coronary syndrome. However, since it does not have any important hemodynamic effects, it may be useful in this setting and in selected patients with close monitoring for mood changes since there have been anecdotal case reports of psychotic events in patients with underlying psychiatric disorders.13 Its routine use currently is not recommended.

Follow-up after discharge: Pharmacotherapy may be added for withdrawal control, as well as relapse prevention for the hospitalized patient who recently quit smoking. However, inclusion of intensive tobacco cessation counseling during the hospital stay is the most effective intervention given the setting and patient condition, and follow-up support up to at least one month after discharge has been found to be more effective in sustaining tobacco abstinence than pharmacotherapy alone. In order to maximize long-term quit rates among patients who recently abstained from smoking, the hospitalist should arrange access to ongoing outpatient post-discharge support and tobacco cessation treatment.

Back to the Case

After appropriate cardiac testing, the patient was found to have a non-cardiac etiology for his symptoms. From the start of his hospital stay, he was counseled by the hospitalist and started on sustained-release bupropion, but withdrawal symptoms and cravings persisted.

Prior to his discharge home, the patient wanted to discontinue bupropion and be provided an alternative. The patient was given a nicotine patch, and a follow-up appointment at the tobacco cessation clinic within one week of discharge from the hospital was arranged. The patient has been compliant with his quit-smoking treatment and has followed-up for continued tobacco cessation counseling. He hasn’t smoked cigarettes for a year. TH

Dr. Palisoc is a preventive medicine resident at the University of Colorado Denver. Dr. Prochazka works at the Denver VA and is a professor of medicine at the University of Colorado Denver.

References

click for large version

1. CDC. Cigarette Smoking Among Adults, United States, 2006. MMWR Morbidity Mortality Wkly Rep. 2007;56(44):1157-1161. Available at www.cdc.gov/mmwr/preview/mmwrhtml/mm5644a2.htm. Last accessed March 4, 2008.
2. CDC. Annual Smoking-Attributable Mortality, Years of Potential Life Lost, and Productivity, United States, 1997-2001. MMWR Morbidity Mortality Wkly Rep. 2005;54(25):625-628.
3. Thomson CC, Rigotti NA. Hospital- and clinic-based smoking cessation interventions for smokers with cardiovascular disease. Prog Cardiovasc Dis. 2003;45(6):459-479.
4. Rigotti NA. Treatment of tobacco use and dependence. N Engl J Med. 2002;346(7):506-512.
5. Van Spall HGC, Chong A, Tu JV. Inpatient smoking-cessation counseling and all-cause mortality in patients with acute myocardial infarction. Am Heart J. 2007;154(2):213-220.
6. Rigotti NA, Munafo MR, Stead LF. Interventions for smoking cessation in hospitalized patients. Cochrane Database Syst Rev. 2007;Issue 3.
7. Ludvig J, Miner B, and Eisenberg, MJ. Smoking cessation in patients with coronary artery disease. Am Heart J. 2005;149(4):565-572.
8. Fiore MC, Bailey WC, Cohen SJ, et al. Treating tobacco use and dependence: clinical practice guideline. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service 2000.
9. Rigotti NA, Thorndike AN, Regan S, et al. Bupropion for smokers hospitalized with acute cardiovascular disease. Am J Med. 2006;199:1080-1087.
10. Jorenby DE, Hays JT, Rigotti NA, et al. Efficacy of varenicline, an alpha4beta2 nicotinic acetylcholine receptor partial agonist, vs. placebo or sustained-release bupropion for smoking cessation: a randomized controlled trial. JAMA. 2006;296(1):56-63.
11. Joseph AM, Fu SS. Safety issues in pharmacotherapy for smoking in patients with cardiovascular disease. Prog Cardiovasc Dis. 2003;45(6):429-441.
12. FDA. Prescribing information of Zyban (bupropion hydrochloride) sustained release tablets. June 2007. Available at www.fda.gov/medwatch/safety/2007/ Aug_PI/Zyban_PI.pdf. Last accessed March 6, 2008.
13. FDA. Early Communication About an Ongoing Safety Review: Varenicline (marketed as Chantix). November 2007. Available at www.fda.gov/cder/drug/early_comm/varenicline.htm. Last accessed March 6, 2008.

The iPhone may be the latest “it” gadget, but a flurry of recent innovation has given portable ultrasound devices a healthy buzz within the biomedical community.

Beyond the gee-whiz factor, though, a growing number of studies demonstrate the everyday value of putting portable units in the hands of hospitalists.

“The big news has been the tiny portable scanner,” says Stephen Smith, a biomedical engineer at Duke University, in North Carolina, and a pioneer in ultrasound technology. Siemens recently introduced a hand-held device called the Acuson P10, which weighs 1.6 pounds, retails for $9,499 and can fit within a hospitalist’s coat pocket. Not to be outdone, GE has announced plans to introduce an ultrasound unit no bigger than an iPod.

Smith and his collaborators have taken the technology one step farther. They incorporate electrocardial leads on the unit’s transducer face to permit electrocardiograms and a microphone to let hospitalists use the ultrasound like a stethoscope.

Eric Isaacs, MD, a clinical professor of medicine at San Francisco General Hospital, says he routinely uses ultrasound for vascular access “to ensure the safety of procedures that we previously performed either blind or by anatomical landmarks.” Beyond improving the accuracy of placing central and peripheral lines, he says, “the reason we are using ultrasound more now is that the machine is so portable. The radiologists are no longer in the hospital 24 hours a day, and so by necessity we are using the tools that were previously only accessible from 9 to 5.”

Range of Uses

Dr. Wiese

Among the reports recognizing ultrasound’s value, he cited a 2003 study in the British Medical Journal affirming the technology’s superiority to relying on physical landmarks in gaining central venous access, resulting in a lower technical failure rate, reduced complications, and faster access.1 Dr. Issacs says ultrasound also has helped guide procedures such as thorancentesis and paracentesis, other applications once confined to radiology. “It’s something that’s allowing me to do at the bedside what I would otherwise have to wait several hours for,” he says.

For heart patients, he says, a hospitalist can bring ultrasound to the bedside during a cardiac arrest to inspect cardiac motion and fluid, and monitor the patient’s hydration status by examining the size of the inferior vena cava. Internists likewise could examine the size of a patient’s aorta to look for signs of an aneurism, especially for a patient experiencing abdominal pain in the middle of the night. “Quite frankly, it seems like the only limit to ultrasound use is imagination,” Dr. Isaacs says.

Robert Rodriguez, MD, a clinical professor of medicine and emergency medicine at San Francisco General Hospital, says he uses ultrasound on 25% of the patients he sees on an in-patient basis. His biggest use, he says, is for placing central lines—though that could soon change.

“I work with a population that has a very high percentage of injection drug abuse, in whom it’s very difficult to find even a peripheral vein,” he says. At least once a day, he uses ultrasound to locate the brachial vein for such peripheral lines, circumventing the need for a central line through the subclavian vein and the risk of a pneumothorax. “In the past, we would have to put in a central line for just about anything,” he says. “And now we can put in a peripheral line that saves them the risk.”

Another benefit, he says, is in breeding better patient interactions—for example, with gallstones. “You can say to the patient: ‘This is the gallbladder, these are the stones in the gallbladder, this is what’s causing the pain,’” he says. “I think patients appreciate being able to see that firsthand. I think they also appreciate that it’s going to lessen their likelihood of having a complication.”

At the University of Chicago Medical Center, cardiologist Kirk Spencer, MD, says ultrasound procedures still are performed mainly by sonographers and cardiologists. He hopes to change that with a slew of studies demonstrating the feasibility of putting portable ultrasound in the hands of internists.

In one study, hospitalized patients indicated for echocardiography received an echocardiogram, while all others were examined with ultrasound. “We found a significant number of cardio pathologies,” Dr. Spencer says. The findings, he says, were independent of specific medical complaints, such as endocrinology or orthopedic problems.2 “If you were sick enough to get in the hospital, there was a chance that you had a significant cardiac problem that needed to be addressed,” he says.

The study that most excites Dr. Spencer was presented at the 2007 IEEE International Ultrasonics Symposium in October.2 It looked at using ultrasound before releasing a cardiac patient. “One of the biggest problems, one of the most common diagnoses is congestive heart failure,” he says, with a six-month readmission rate of 30% to 40%. Giving ultrasound devices to internists allowed them to look at the amount of fluid around the heart of each cardiac patient.

“The patients who got readmitted all had more fluid detected by ultrasound,” Dr. Spencer says. “So we can do that and say, ‘Hey, you need to stay in the hospital two more days. But if that prevents you from coming back in six months, then that’s a good thing.’”

In patients diagnosed with congestive heart failure, he and his collaborators found, the mean fluid volume was higher for those who were later readmitted. Dr. Spencer plans to pick a reasonable cut-off value and prospectively test whether delaying the release of patients whose fluid levels exceed that value can cut readmission rates.

Most of the battery-operated units used by the medical center weigh between 6 to 10 pounds and cost between $12,000 and $20,000, he says. The devices, about twice the thickness of an iBook, can easily be carried on a shoulder strap. Echocardiogram machines, by contrast, weigh about 300 pounds, must be plugged in and retail for about $250,000.

Concerns, Obstacles

Dr. Spencer cautioned that ultrasound shouldn’t replace echocardiograms or other tools. “So no one is proposing that this would replace a full exam,” he says. “What we’re hoping is that this would detect things that have gone missing or would help ask very specific questions at the bedside.” His studies suggest the approach works well as long as the questions are simple: “Is there fluid or not? Is the heart good or bad?’ But not: ‘Is there an infection?’”

Beyond cardiology and the emergency room, Dr. Spencer says ultrasound has obvious imaging uses in the ICU. The dichotomy, he says, is that imaging intensive care patients can be especially difficult due to their edema, wounds, and lack of mobility. “That area has not blossomed as well as it could have,” he says.

Even so, the burgeoning number of applications for ultrasound “really has huge potential for good,” says Harvey Nisenbaum, MD, an associate professor of radiology at the University of Pennsylvania School of Medicine and president-elect of the American Institute of Ultrasound in Medicine (AIUM). “But the problem is that it’s an art form in the sense that it’s not automated.” No two ultrasound images will be identical, for example, because each depends upon the probe’s precise location. The key, Dr. Nisenbaum says, is proper training under agreed-upon guidelines, followed by continuing education and the maintenance of a hospitalist’s competency.

The AIUM, Nisenbaum says, is working to develop standard credentialing criteria for a range of ultrasound applications to help unify what has been a patchwork approach. Another limitation, he says, has been the lack of Food and Drug Administration (FDA) approval for ultrasound contrast agents Optison and Definity for noncardiac applications. Several deaths have been linked to the use of the intravenous agents in the sickest patients.

The institute is working with the FDA on trying to get the reagents approved for broader use, as they are in other countries. Nisenbaum cautioned the process likely will take a while. Once approved, getting a reimbursement code established for insurance purposes could take even longer.

A further obstacle, according to Dr. Spencer, is the lack of resolution surrounding medical legal issues. “Are we going to agree that this is like a physical examination?” he asks. “It’s unclear whether the medical legal community is going to accept that with ultrasound,” he says.

For cardiology applications, at least, he wonders if the push for reimbursement is such a good thing. “General internists are under incredible pressure [for billing],” he says. “They’re in a really tough spot, and so there would be enormous pressure to get reimbursed for every ultrasound.” As it is, he says, Medicare is targeting echocardiogram as an overutilized reimbursement item. “I hope the reason we’re using this is because we’re examining the patients anyway and this would allow us to find things that we might have missed,” he says. “It’s a better way of examining people, not a new technique for generating revenues. I think that would be a disaster.”

Dr. Wiese

Jeffrey Wiese, MD, SHM board member and associate dean of graduate medical education at Tulane University School of Medicine’s Section of General Internal Medicine and Geriatrics in New Orleans, began putting ultrasound in the hands of his hospitalists and residents in 2007. It’s the “100% right thing to do,” he advises hospitalist groups. “It can be a meaningful way of improving safety. I hope that everyody would move that way.”

Dr. Wiese says residents began using ultrasound more and more for extra visualization during procedures.

“The reason we got into this was straightaway safety, independent of [Centers for Medicare and Medicaid Services] codes and billing—particularly regarding thoracentesis and internal lines,’’ he says. His hospitalists use SonaSite’s MicroMaxx system, “which was a key piece in the way of being able to bill. For all CMT just like endoscopy and bronchoscopy, you have to provide images of the procedure to prove you did it. With the MicroMaxx machine, it allows you to insert a USB and pull down images, take them to a print machine, print them out, and put them in a chart.”

Dr. Wiese touts the sheer amount of what hospitalists can use ultrasound for. “You can do echoes and abdominal ultrasound—not at the level of the radiology room or the cardiology lab, but you can get a quick look,” he says.

Should other hospitalist programs go in the same direction? “From a quality perspective there’s no question you go down that road,” Dr. Wiese asserts. “You do the math: How much does one pneumothorax cost? That’s especially true if [a] pneuothorax finds its way to CMS. One pneuomothorax that you prevent probably pays for your [$20,000-$30,000] machine. That’s even before you get into issues of billing for the use of it, which I think is a secondary way of funding the purchase.”

Forging Ahead

In the meantime, researchers are focusing on ever-diverse applications and smaller units.

At the Mayo Clinic in Jacksonville, Fla., director of regional anesthesia Steven Clendenen, MD, has pioneered the use of ultrasound for guiding nerve blocks.3 The imaging has “totally revolutionized” how the hospital manages pain, he says. As yet, the device still is cart-based, though he expects its size to shrink considerably. “You remember the first calculators, how big they were, and now look at them,” he says.

Beyond working toward miniaturized ultrasound units, Duke’s Smith has been developing real-time three-dimensional angiograms of blood vessels in the brain, a potential boon for stroke diagnoses.4 Another project may bring hospital-based ultrasound full circle: a device that produces a 3-D stereo-image, “like in the IMAX theater,” he says.5 Smith and his colleagues have modified a commercial scanner, “so the target comes out of the screen at you.” Among the many potential uses, expectant parents could see a 3-D stereo view of the developing fetus—something not even the iPhone can offer. TH

Bryn Nelson is a science journalist based in New York.

References

1. Hind, D, Calvert, N, McWilliams, R, Davidson, A, Paisley, S, Beverley, C, Thomas, S. Ultrasonic locating devices for central venous cannulation: meta-analysis. Br Med J. 2003;327(7411):361.
2. Fedson, S, Neithardt, G, Thomas, P, et al. Unsuspected clinically important findings detected with a small portable ultrasound device in patients admitted to a general medicine service. J Am Soc Echocardiogr. 2003;16(9):901-905.
3. Feinglass NG, Clendenen SR, Torp KD, Wang RD, Castello R, Greengrass RA. Real-time three-dimensional ultrasound for continuous popliteal blockade: a case report and image description. Anesth Analg. 2007;105(1):272-274.
4. Smith SW, Chu K, Idriss SF, Ivancevich NM, Light ED, Wolf PD. Feasibility Study: Real time 3D ultrasound imaging of the brain. Ultras Med Biol. 2004;30:1365-1371.
5. Noble JR, Fronheiser MP, Smith SW. Real-time Stereo 3D Ultrasound. Ultrason Imaging. 2006;28:245-254.

The iPhone may be the latest “it” gadget, but a flurry of recent innovation has given portable ultrasound devices a healthy buzz within the biomedical community.

Beyond the gee-whiz factor, though, a growing number of studies demonstrate the everyday value of putting portable units in the hands of hospitalists.

“The big news has been the tiny portable scanner,” says Stephen Smith, a biomedical engineer at Duke University, in North Carolina, and a pioneer in ultrasound technology. Siemens recently introduced a hand-held device called the Acuson P10, which weighs 1.6 pounds, retails for $9,499 and can fit within a hospitalist’s coat pocket. Not to be outdone, GE has announced plans to introduce an ultrasound unit no bigger than an iPod.

Smith and his collaborators have taken the technology one step farther. They incorporate electrocardial leads on the unit’s transducer face to permit electrocardiograms and a microphone to let hospitalists use the ultrasound like a stethoscope.

Eric Isaacs, MD, a clinical professor of medicine at San Francisco General Hospital, says he routinely uses ultrasound for vascular access “to ensure the safety of procedures that we previously performed either blind or by anatomical landmarks.” Beyond improving the accuracy of placing central and peripheral lines, he says, “the reason we are using ultrasound more now is that the machine is so portable. The radiologists are no longer in the hospital 24 hours a day, and so by necessity we are using the tools that were previously only accessible from 9 to 5.”

Range of Uses

Dr. Wiese

Among the reports recognizing ultrasound’s value, he cited a 2003 study in the British Medical Journal affirming the technology’s superiority to relying on physical landmarks in gaining central venous access, resulting in a lower technical failure rate, reduced complications, and faster access.1 Dr. Issacs says ultrasound also has helped guide procedures such as thorancentesis and paracentesis, other applications once confined to radiology. “It’s something that’s allowing me to do at the bedside what I would otherwise have to wait several hours for,” he says.

For heart patients, he says, a hospitalist can bring ultrasound to the bedside during a cardiac arrest to inspect cardiac motion and fluid, and monitor the patient’s hydration status by examining the size of the inferior vena cava. Internists likewise could examine the size of a patient’s aorta to look for signs of an aneurism, especially for a patient experiencing abdominal pain in the middle of the night. “Quite frankly, it seems like the only limit to ultrasound use is imagination,” Dr. Isaacs says.

Robert Rodriguez, MD, a clinical professor of medicine and emergency medicine at San Francisco General Hospital, says he uses ultrasound on 25% of the patients he sees on an in-patient basis. His biggest use, he says, is for placing central lines—though that could soon change.

“I work with a population that has a very high percentage of injection drug abuse, in whom it’s very difficult to find even a peripheral vein,” he says. At least once a day, he uses ultrasound to locate the brachial vein for such peripheral lines, circumventing the need for a central line through the subclavian vein and the risk of a pneumothorax. “In the past, we would have to put in a central line for just about anything,” he says. “And now we can put in a peripheral line that saves them the risk.”

Another benefit, he says, is in breeding better patient interactions—for example, with gallstones. “You can say to the patient: ‘This is the gallbladder, these are the stones in the gallbladder, this is what’s causing the pain,’” he says. “I think patients appreciate being able to see that firsthand. I think they also appreciate that it’s going to lessen their likelihood of having a complication.”

At the University of Chicago Medical Center, cardiologist Kirk Spencer, MD, says ultrasound procedures still are performed mainly by sonographers and cardiologists. He hopes to change that with a slew of studies demonstrating the feasibility of putting portable ultrasound in the hands of internists.

In one study, hospitalized patients indicated for echocardiography received an echocardiogram, while all others were examined with ultrasound. “We found a significant number of cardio pathologies,” Dr. Spencer says. The findings, he says, were independent of specific medical complaints, such as endocrinology or orthopedic problems.2 “If you were sick enough to get in the hospital, there was a chance that you had a significant cardiac problem that needed to be addressed,” he says.

The study that most excites Dr. Spencer was presented at the 2007 IEEE International Ultrasonics Symposium in October.2 It looked at using ultrasound before releasing a cardiac patient. “One of the biggest problems, one of the most common diagnoses is congestive heart failure,” he says, with a six-month readmission rate of 30% to 40%. Giving ultrasound devices to internists allowed them to look at the amount of fluid around the heart of each cardiac patient.

“The patients who got readmitted all had more fluid detected by ultrasound,” Dr. Spencer says. “So we can do that and say, ‘Hey, you need to stay in the hospital two more days. But if that prevents you from coming back in six months, then that’s a good thing.’”

In patients diagnosed with congestive heart failure, he and his collaborators found, the mean fluid volume was higher for those who were later readmitted. Dr. Spencer plans to pick a reasonable cut-off value and prospectively test whether delaying the release of patients whose fluid levels exceed that value can cut readmission rates.

Most of the battery-operated units used by the medical center weigh between 6 to 10 pounds and cost between $12,000 and $20,000, he says. The devices, about twice the thickness of an iBook, can easily be carried on a shoulder strap. Echocardiogram machines, by contrast, weigh about 300 pounds, must be plugged in and retail for about $250,000.

Concerns, Obstacles

Dr. Spencer cautioned that ultrasound shouldn’t replace echocardiograms or other tools. “So no one is proposing that this would replace a full exam,” he says. “What we’re hoping is that this would detect things that have gone missing or would help ask very specific questions at the bedside.” His studies suggest the approach works well as long as the questions are simple: “Is there fluid or not? Is the heart good or bad?’ But not: ‘Is there an infection?’”

Beyond cardiology and the emergency room, Dr. Spencer says ultrasound has obvious imaging uses in the ICU. The dichotomy, he says, is that imaging intensive care patients can be especially difficult due to their edema, wounds, and lack of mobility. “That area has not blossomed as well as it could have,” he says.

Even so, the burgeoning number of applications for ultrasound “really has huge potential for good,” says Harvey Nisenbaum, MD, an associate professor of radiology at the University of Pennsylvania School of Medicine and president-elect of the American Institute of Ultrasound in Medicine (AIUM). “But the problem is that it’s an art form in the sense that it’s not automated.” No two ultrasound images will be identical, for example, because each depends upon the probe’s precise location. The key, Dr. Nisenbaum says, is proper training under agreed-upon guidelines, followed by continuing education and the maintenance of a hospitalist’s competency.

The AIUM, Nisenbaum says, is working to develop standard credentialing criteria for a range of ultrasound applications to help unify what has been a patchwork approach. Another limitation, he says, has been the lack of Food and Drug Administration (FDA) approval for ultrasound contrast agents Optison and Definity for noncardiac applications. Several deaths have been linked to the use of the intravenous agents in the sickest patients.

The institute is working with the FDA on trying to get the reagents approved for broader use, as they are in other countries. Nisenbaum cautioned the process likely will take a while. Once approved, getting a reimbursement code established for insurance purposes could take even longer.

A further obstacle, according to Dr. Spencer, is the lack of resolution surrounding medical legal issues. “Are we going to agree that this is like a physical examination?” he asks. “It’s unclear whether the medical legal community is going to accept that with ultrasound,” he says.

For cardiology applications, at least, he wonders if the push for reimbursement is such a good thing. “General internists are under incredible pressure [for billing],” he says. “They’re in a really tough spot, and so there would be enormous pressure to get reimbursed for every ultrasound.” As it is, he says, Medicare is targeting echocardiogram as an overutilized reimbursement item. “I hope the reason we’re using this is because we’re examining the patients anyway and this would allow us to find things that we might have missed,” he says. “It’s a better way of examining people, not a new technique for generating revenues. I think that would be a disaster.”

Dr. Wiese

Jeffrey Wiese, MD, SHM board member and associate dean of graduate medical education at Tulane University School of Medicine’s Section of General Internal Medicine and Geriatrics in New Orleans, began putting ultrasound in the hands of his hospitalists and residents in 2007. It’s the “100% right thing to do,” he advises hospitalist groups. “It can be a meaningful way of improving safety. I hope that everyody would move that way.”

Dr. Wiese says residents began using ultrasound more and more for extra visualization during procedures.

“The reason we got into this was straightaway safety, independent of [Centers for Medicare and Medicaid Services] codes and billing—particularly regarding thoracentesis and internal lines,’’ he says. His hospitalists use SonaSite’s MicroMaxx system, “which was a key piece in the way of being able to bill. For all CMT just like endoscopy and bronchoscopy, you have to provide images of the procedure to prove you did it. With the MicroMaxx machine, it allows you to insert a USB and pull down images, take them to a print machine, print them out, and put them in a chart.”

Dr. Wiese touts the sheer amount of what hospitalists can use ultrasound for. “You can do echoes and abdominal ultrasound—not at the level of the radiology room or the cardiology lab, but you can get a quick look,” he says.

Should other hospitalist programs go in the same direction? “From a quality perspective there’s no question you go down that road,” Dr. Wiese asserts. “You do the math: How much does one pneumothorax cost? That’s especially true if [a] pneuothorax finds its way to CMS. One pneuomothorax that you prevent probably pays for your [$20,000-$30,000] machine. That’s even before you get into issues of billing for the use of it, which I think is a secondary way of funding the purchase.”

Forging Ahead

In the meantime, researchers are focusing on ever-diverse applications and smaller units.

At the Mayo Clinic in Jacksonville, Fla., director of regional anesthesia Steven Clendenen, MD, has pioneered the use of ultrasound for guiding nerve blocks.3 The imaging has “totally revolutionized” how the hospital manages pain, he says. As yet, the device still is cart-based, though he expects its size to shrink considerably. “You remember the first calculators, how big they were, and now look at them,” he says.

Beyond working toward miniaturized ultrasound units, Duke’s Smith has been developing real-time three-dimensional angiograms of blood vessels in the brain, a potential boon for stroke diagnoses.4 Another project may bring hospital-based ultrasound full circle: a device that produces a 3-D stereo-image, “like in the IMAX theater,” he says.5 Smith and his colleagues have modified a commercial scanner, “so the target comes out of the screen at you.” Among the many potential uses, expectant parents could see a 3-D stereo view of the developing fetus—something not even the iPhone can offer. TH

Bryn Nelson is a science journalist based in New York.

References

1. Hind, D, Calvert, N, McWilliams, R, Davidson, A, Paisley, S, Beverley, C, Thomas, S. Ultrasonic locating devices for central venous cannulation: meta-analysis. Br Med J. 2003;327(7411):361.
2. Fedson, S, Neithardt, G, Thomas, P, et al. Unsuspected clinically important findings detected with a small portable ultrasound device in patients admitted to a general medicine service. J Am Soc Echocardiogr. 2003;16(9):901-905.
3. Feinglass NG, Clendenen SR, Torp KD, Wang RD, Castello R, Greengrass RA. Real-time three-dimensional ultrasound for continuous popliteal blockade: a case report and image description. Anesth Analg. 2007;105(1):272-274.
4. Smith SW, Chu K, Idriss SF, Ivancevich NM, Light ED, Wolf PD. Feasibility Study: Real time 3D ultrasound imaging of the brain. Ultras Med Biol. 2004;30:1365-1371.
5. Noble JR, Fronheiser MP, Smith SW. Real-time Stereo 3D Ultrasound. Ultrason Imaging. 2006;28:245-254.

The iPhone may be the latest “it” gadget, but a flurry of recent innovation has given portable ultrasound devices a healthy buzz within the biomedical community.

Beyond the gee-whiz factor, though, a growing number of studies demonstrate the everyday value of putting portable units in the hands of hospitalists.

“The big news has been the tiny portable scanner,” says Stephen Smith, a biomedical engineer at Duke University, in North Carolina, and a pioneer in ultrasound technology. Siemens recently introduced a hand-held device called the Acuson P10, which weighs 1.6 pounds, retails for $9,499 and can fit within a hospitalist’s coat pocket. Not to be outdone, GE has announced plans to introduce an ultrasound unit no bigger than an iPod.

Smith and his collaborators have taken the technology one step farther. They incorporate electrocardial leads on the unit’s transducer face to permit electrocardiograms and a microphone to let hospitalists use the ultrasound like a stethoscope.

Eric Isaacs, MD, a clinical professor of medicine at San Francisco General Hospital, says he routinely uses ultrasound for vascular access “to ensure the safety of procedures that we previously performed either blind or by anatomical landmarks.” Beyond improving the accuracy of placing central and peripheral lines, he says, “the reason we are using ultrasound more now is that the machine is so portable. The radiologists are no longer in the hospital 24 hours a day, and so by necessity we are using the tools that were previously only accessible from 9 to 5.”

Range of Uses

Dr. Wiese

Among the reports recognizing ultrasound’s value, he cited a 2003 study in the British Medical Journal affirming the technology’s superiority to relying on physical landmarks in gaining central venous access, resulting in a lower technical failure rate, reduced complications, and faster access.1 Dr. Issacs says ultrasound also has helped guide procedures such as thorancentesis and paracentesis, other applications once confined to radiology. “It’s something that’s allowing me to do at the bedside what I would otherwise have to wait several hours for,” he says.

For heart patients, he says, a hospitalist can bring ultrasound to the bedside during a cardiac arrest to inspect cardiac motion and fluid, and monitor the patient’s hydration status by examining the size of the inferior vena cava. Internists likewise could examine the size of a patient’s aorta to look for signs of an aneurism, especially for a patient experiencing abdominal pain in the middle of the night. “Quite frankly, it seems like the only limit to ultrasound use is imagination,” Dr. Isaacs says.

Robert Rodriguez, MD, a clinical professor of medicine and emergency medicine at San Francisco General Hospital, says he uses ultrasound on 25% of the patients he sees on an in-patient basis. His biggest use, he says, is for placing central lines—though that could soon change.

“I work with a population that has a very high percentage of injection drug abuse, in whom it’s very difficult to find even a peripheral vein,” he says. At least once a day, he uses ultrasound to locate the brachial vein for such peripheral lines, circumventing the need for a central line through the subclavian vein and the risk of a pneumothorax. “In the past, we would have to put in a central line for just about anything,” he says. “And now we can put in a peripheral line that saves them the risk.”

Another benefit, he says, is in breeding better patient interactions—for example, with gallstones. “You can say to the patient: ‘This is the gallbladder, these are the stones in the gallbladder, this is what’s causing the pain,’” he says. “I think patients appreciate being able to see that firsthand. I think they also appreciate that it’s going to lessen their likelihood of having a complication.”

At the University of Chicago Medical Center, cardiologist Kirk Spencer, MD, says ultrasound procedures still are performed mainly by sonographers and cardiologists. He hopes to change that with a slew of studies demonstrating the feasibility of putting portable ultrasound in the hands of internists.

In one study, hospitalized patients indicated for echocardiography received an echocardiogram, while all others were examined with ultrasound. “We found a significant number of cardio pathologies,” Dr. Spencer says. The findings, he says, were independent of specific medical complaints, such as endocrinology or orthopedic problems.2 “If you were sick enough to get in the hospital, there was a chance that you had a significant cardiac problem that needed to be addressed,” he says.

The study that most excites Dr. Spencer was presented at the 2007 IEEE International Ultrasonics Symposium in October.2 It looked at using ultrasound before releasing a cardiac patient. “One of the biggest problems, one of the most common diagnoses is congestive heart failure,” he says, with a six-month readmission rate of 30% to 40%. Giving ultrasound devices to internists allowed them to look at the amount of fluid around the heart of each cardiac patient.

“The patients who got readmitted all had more fluid detected by ultrasound,” Dr. Spencer says. “So we can do that and say, ‘Hey, you need to stay in the hospital two more days. But if that prevents you from coming back in six months, then that’s a good thing.’”

In patients diagnosed with congestive heart failure, he and his collaborators found, the mean fluid volume was higher for those who were later readmitted. Dr. Spencer plans to pick a reasonable cut-off value and prospectively test whether delaying the release of patients whose fluid levels exceed that value can cut readmission rates.

Most of the battery-operated units used by the medical center weigh between 6 to 10 pounds and cost between $12,000 and $20,000, he says. The devices, about twice the thickness of an iBook, can easily be carried on a shoulder strap. Echocardiogram machines, by contrast, weigh about 300 pounds, must be plugged in and retail for about $250,000.

Concerns, Obstacles

Dr. Spencer cautioned that ultrasound shouldn’t replace echocardiograms or other tools. “So no one is proposing that this would replace a full exam,” he says. “What we’re hoping is that this would detect things that have gone missing or would help ask very specific questions at the bedside.” His studies suggest the approach works well as long as the questions are simple: “Is there fluid or not? Is the heart good or bad?’ But not: ‘Is there an infection?’”

Beyond cardiology and the emergency room, Dr. Spencer says ultrasound has obvious imaging uses in the ICU. The dichotomy, he says, is that imaging intensive care patients can be especially difficult due to their edema, wounds, and lack of mobility. “That area has not blossomed as well as it could have,” he says.

Even so, the burgeoning number of applications for ultrasound “really has huge potential for good,” says Harvey Nisenbaum, MD, an associate professor of radiology at the University of Pennsylvania School of Medicine and president-elect of the American Institute of Ultrasound in Medicine (AIUM). “But the problem is that it’s an art form in the sense that it’s not automated.” No two ultrasound images will be identical, for example, because each depends upon the probe’s precise location. The key, Dr. Nisenbaum says, is proper training under agreed-upon guidelines, followed by continuing education and the maintenance of a hospitalist’s competency.

The AIUM, Nisenbaum says, is working to develop standard credentialing criteria for a range of ultrasound applications to help unify what has been a patchwork approach. Another limitation, he says, has been the lack of Food and Drug Administration (FDA) approval for ultrasound contrast agents Optison and Definity for noncardiac applications. Several deaths have been linked to the use of the intravenous agents in the sickest patients.

The institute is working with the FDA on trying to get the reagents approved for broader use, as they are in other countries. Nisenbaum cautioned the process likely will take a while. Once approved, getting a reimbursement code established for insurance purposes could take even longer.

A further obstacle, according to Dr. Spencer, is the lack of resolution surrounding medical legal issues. “Are we going to agree that this is like a physical examination?” he asks. “It’s unclear whether the medical legal community is going to accept that with ultrasound,” he says.

For cardiology applications, at least, he wonders if the push for reimbursement is such a good thing. “General internists are under incredible pressure [for billing],” he says. “They’re in a really tough spot, and so there would be enormous pressure to get reimbursed for every ultrasound.” As it is, he says, Medicare is targeting echocardiogram as an overutilized reimbursement item. “I hope the reason we’re using this is because we’re examining the patients anyway and this would allow us to find things that we might have missed,” he says. “It’s a better way of examining people, not a new technique for generating revenues. I think that would be a disaster.”

Dr. Wiese

Jeffrey Wiese, MD, SHM board member and associate dean of graduate medical education at Tulane University School of Medicine’s Section of General Internal Medicine and Geriatrics in New Orleans, began putting ultrasound in the hands of his hospitalists and residents in 2007. It’s the “100% right thing to do,” he advises hospitalist groups. “It can be a meaningful way of improving safety. I hope that everyody would move that way.”

Dr. Wiese says residents began using ultrasound more and more for extra visualization during procedures.

“The reason we got into this was straightaway safety, independent of [Centers for Medicare and Medicaid Services] codes and billing—particularly regarding thoracentesis and internal lines,’’ he says. His hospitalists use SonaSite’s MicroMaxx system, “which was a key piece in the way of being able to bill. For all CMT just like endoscopy and bronchoscopy, you have to provide images of the procedure to prove you did it. With the MicroMaxx machine, it allows you to insert a USB and pull down images, take them to a print machine, print them out, and put them in a chart.”

Dr. Wiese touts the sheer amount of what hospitalists can use ultrasound for. “You can do echoes and abdominal ultrasound—not at the level of the radiology room or the cardiology lab, but you can get a quick look,” he says.

Should other hospitalist programs go in the same direction? “From a quality perspective there’s no question you go down that road,” Dr. Wiese asserts. “You do the math: How much does one pneumothorax cost? That’s especially true if [a] pneuothorax finds its way to CMS. One pneuomothorax that you prevent probably pays for your [$20,000-$30,000] machine. That’s even before you get into issues of billing for the use of it, which I think is a secondary way of funding the purchase.”

Forging Ahead

In the meantime, researchers are focusing on ever-diverse applications and smaller units.

At the Mayo Clinic in Jacksonville, Fla., director of regional anesthesia Steven Clendenen, MD, has pioneered the use of ultrasound for guiding nerve blocks.3 The imaging has “totally revolutionized” how the hospital manages pain, he says. As yet, the device still is cart-based, though he expects its size to shrink considerably. “You remember the first calculators, how big they were, and now look at them,” he says.

Beyond working toward miniaturized ultrasound units, Duke’s Smith has been developing real-time three-dimensional angiograms of blood vessels in the brain, a potential boon for stroke diagnoses.4 Another project may bring hospital-based ultrasound full circle: a device that produces a 3-D stereo-image, “like in the IMAX theater,” he says.5 Smith and his colleagues have modified a commercial scanner, “so the target comes out of the screen at you.” Among the many potential uses, expectant parents could see a 3-D stereo view of the developing fetus—something not even the iPhone can offer. TH

Bryn Nelson is a science journalist based in New York.

References

1. Hind, D, Calvert, N, McWilliams, R, Davidson, A, Paisley, S, Beverley, C, Thomas, S. Ultrasonic locating devices for central venous cannulation: meta-analysis. Br Med J. 2003;327(7411):361.
2. Fedson, S, Neithardt, G, Thomas, P, et al. Unsuspected clinically important findings detected with a small portable ultrasound device in patients admitted to a general medicine service. J Am Soc Echocardiogr. 2003;16(9):901-905.
3. Feinglass NG, Clendenen SR, Torp KD, Wang RD, Castello R, Greengrass RA. Real-time three-dimensional ultrasound for continuous popliteal blockade: a case report and image description. Anesth Analg. 2007;105(1):272-274.
4. Smith SW, Chu K, Idriss SF, Ivancevich NM, Light ED, Wolf PD. Feasibility Study: Real time 3D ultrasound imaging of the brain. Ultras Med Biol. 2004;30:1365-1371.
5. Noble JR, Fronheiser MP, Smith SW. Real-time Stereo 3D Ultrasound. Ultrason Imaging. 2006;28:245-254.

With hospitals facing increasing pressure to improve safety based on measurements, hospitalists need to build a key role in improving quality by developing safety scorecards, say leading hospital medicine experts.

A framework for designing scorecards was recently suggested by researchers at Johns Hopkins University in Baltimore in an article published by the Journal of the American Medical Association.1 The commentary suggests a framework to help healthcare organizations develop safety scorecards, evaluate their validity, and understand measures appropriate to present as rates.

Their framework is intended to build scorecards that monitor progress in improving patient safety over time or relative to a benchmark. The authors urged organizations to think of safety on a continuum and look for improvements, rather than regard practices as either safe or unsafe. They also stated that their term “safety scorecard” acknowledges an overlap between quality and safety.

To build their framework, the researchers adapted elements of the “Users’ Guide to the Medical Literature: A Manual for Evidence-Based Clinical Practice,” to address three key questions:

• Is the measure important?
• Is the measure valid? and
• Can the measure be used to improve safety in healthcare organizations?

The resulting worksheet to evaluate a scorecard guides hospitals through questions aimed at determining whether their institution meets the three criteria.

Initial Reaction

“This worksheet would be very important to follow, a good step forward in efforts to improve quality because its questions make clear where a group might be falling down in developing a scorecard,” says hospitalist Brian Bossard, MD, director of Inpatient Physician Associates at BryanLGH Medical Center in Lincoln, Neb. Dr. Bossard, who is also the medical staff quality designee, says he believes large national hospitalist groups should be involved in planning scorecards as part of a multidisciplinary team.

Other experts also tout hospitalists’ importance in the vanguard of creating these vital instruments.

“Hospitalists should be on or chairing safety committees, and there should be investments in training them in these areas,” says Eric Kupersmith, MD, division head of hospital medicine and assistant professor of medicine for the Cooper Health System, University of Medicine and Dentistry of New Jersey Robert Wood Johnson Medical School in Newark. “Because we are frontline physicians experiencing what is happening with patients and orchestrating as well as delivering care, we should provide feedback.”

Dr. Kupersmith, who is on his facility’s patient safety committee and has participated in a root-cause analysis of hand-offs as well as worked on medical reconciliation and pneumonia core measure performance improvement, says SHM “should help take the lead in bringing together specialists, administrators, and nurses with hospitalists who should have a major impact in designing a scorecard as a society.”

As hospitalists mature as clinicians, they become system- and process-oriented, says Dr. Kupersmith. As a result, “We should be part of re-engineering efforts because of our experience bringing people together,” he says. “We’re in a good position to analyze the process.”

Use with Care

There is also value in hospitalists’ anecdotal experiences, Dr. Kupersmith says, but “there needs to be a filter between anecdotes and a facility’s leadership to ensure that the information provided is broadly important. Decisions shouldn’t be made on anecdotes, but creative ideas can come from them.”

Randy Ferrance, DC, MD, and chief of the medical staff at Riverside Tappahannock Hospital in Tappahan-nock, Va., regards anecdotal information in much the same light. “It should be seen as guidelines, not rules,” he cautions. “There is still an art to medicine even though it is clearly science. Sometimes the best available evidence may be anecdotal. It’s not hard data, but it can be valuable.”

Dr. Ferrance at one time chaired his hospital’s quality improvement committee; the panel now reports to him. He believes hospitalists are fortunate that “we became a specialty after evidence-based medicine really came to the forefront. We are fortunate to have the backing of much hard data.”

Still, he acknowledges the difficulty of establishing proof that an action affects patient outcome. “It’s hard, but what we can do is look at what might help result in things like decreased morbidity, length of stays and complications, and a faster return to a patient’s normal functions. Then we might see influence on patient outcomes.”

Beyond Core Measures

Richard Rohr, MD, vice president for medical affairs at Cortland Regional Medical Center in New York, works extensively on quality improvements. He urges hospitalists and institutions to go beyond required measures.

“A lot of what we’re doing now is imposed by government, insurers or the Joint Commission,” says Dr. Rohr. “In day-to-day work, we should look for areas to go beyond what is required.”

He believes hospitalists should look at specific issues underlying the Johns Hopkins framework’s three core questions.

For example, within the first core question “Is the measure important?” he suggests hospitalists consider what their facility’s priorities are. “There are thousands of things that could address safety,” he says. “Hospitalists should look at how a measure fits in to their organization’s priorities. At an institution known for cardiac care, look at safety measures in cardiology.”

He also suggests looking at a facility’s potential problem areas to help determine if a measure is important. “I worked at a facility that had a rule that Coumadin had to be ordered one day at a time,” says Dr. Rohr. “Since patient use of the medication was closely monitored, there were very few patients with serious bleeding.”

The point, he says, is that hospitalists should “make sure the safety process they’re interested in truly addresses a true problem and is not already in place. Try to add something of value.”

Hospitalists are in a good position to do this, he says, because of their day-to-day perspective on patients. “Hospitalists should start by looking at what their organization has addressed and what’s causing patient problems day to day and then set priorities,” he advises.

Institutional Support

Of critical importance also, Dr. Rohr says, is to see what their organization can support before deciding what safety measure to explore.

“Is it feasible to collect data to use this measure?” he asks. “That’s partly dependent on where your facility is in using electronic medical records. Does the benefit of researching and implementing outweigh the cost? You may have to spend some staff time to decide what is worthwhile.”

The last task may be easier for hospitalists working at more academic hospitals, he says, which is also an important part of trying to answer the Johns Hopkins framework’s second question: “Is the measure valid?”

It’s often hard to answer that one, Dr. Rohr acknowledges. “Research has at times shown that a process may show statistically significant improvement, but it does not show up clinically,” he says. “Aspirin and beta-blockers for heart patients, for example, has a statistically significant difference—but it is small.”

Most hospitalists try to see patients and do this kind of work on the side, he concedes: “They should do some research, but value what they see when treating patients. You have a good sense of what has helped patients.”

Dr. Wright

Julia Wright, MD, associate professor of medicine at the University of Wisconsin School of Medicine and Public Health and medical director for hospital medicine at the University of Wisconsin Hospital in Madison, agrees.

“The expertise of our specialty is that we deliver care that is not just clinical, asking, ‘Did I meet the guidelines?’’’ she says. “We’re with patients. We should help determine how quality and safety models are addressing how care is delivered.”

She also believes hospitalists should work closely with hospital administrators on these issues. “Hospitalists have an intrinsic sense of value in delivering care,” she notes. “We are unique in that we can combine consideration of hospital goals with knowledge of care at patient levels. This provides great value to the institutions.”

Culture of Safety

While he agrees with the importance of involving hospitalists deeply in safety efforts, Dr. Kupersmith believes institutions should strive to create a culture that focuses on safety and looks at all its processes in that light.

“You shouldn’t just track hard outcomes,” he suggests. “Track the outcomes of your processes. This gives an overall sense of safety awareness in all personnel. If you focus on the process and culture, you might find a significant change in outcomes.” This also helps address the difficulty of finding data on outcomes, he says.

He agrees with the researchers’ view that safety is on a continuum, and he thinks acknowledging that can help establish an institutional culture around safety. “There is always going to be patient danger,” he says. “You want to get to a point where it is minimized because of an awareness of actions. That focus on safety will lead to less danger.”

As a result, he believes quality improvement strategies must address culture. “You need to provide education for all on safety and provide oversight and monitoring with expectations that can be tracked,” he says. “You need to create this mandate and speak in the quality language from the top. Then you start to have people bring in information that affects outcomes.” TH

Karla Feuer is a journalist based in New York.

Reference

1. Pronovost PJ, Berenholtz SM, Needham DM. A framework for health care organizations to develop and evaluate a safety scorecard. JAMA. 2007;298(17):2063-2065.

With hospitals facing increasing pressure to improve safety based on measurements, hospitalists need to build a key role in improving quality by developing safety scorecards, say leading hospital medicine experts.

A framework for designing scorecards was recently suggested by researchers at Johns Hopkins University in Baltimore in an article published by the Journal of the American Medical Association.1 The commentary suggests a framework to help healthcare organizations develop safety scorecards, evaluate their validity, and understand measures appropriate to present as rates.

Their framework is intended to build scorecards that monitor progress in improving patient safety over time or relative to a benchmark. The authors urged organizations to think of safety on a continuum and look for improvements, rather than regard practices as either safe or unsafe. They also stated that their term “safety scorecard” acknowledges an overlap between quality and safety.

To build their framework, the researchers adapted elements of the “Users’ Guide to the Medical Literature: A Manual for Evidence-Based Clinical Practice,” to address three key questions:

• Is the measure important?
• Is the measure valid? and
• Can the measure be used to improve safety in healthcare organizations?

The resulting worksheet to evaluate a scorecard guides hospitals through questions aimed at determining whether their institution meets the three criteria.

Initial Reaction

“This worksheet would be very important to follow, a good step forward in efforts to improve quality because its questions make clear where a group might be falling down in developing a scorecard,” says hospitalist Brian Bossard, MD, director of Inpatient Physician Associates at BryanLGH Medical Center in Lincoln, Neb. Dr. Bossard, who is also the medical staff quality designee, says he believes large national hospitalist groups should be involved in planning scorecards as part of a multidisciplinary team.

Other experts also tout hospitalists’ importance in the vanguard of creating these vital instruments.

“Hospitalists should be on or chairing safety committees, and there should be investments in training them in these areas,” says Eric Kupersmith, MD, division head of hospital medicine and assistant professor of medicine for the Cooper Health System, University of Medicine and Dentistry of New Jersey Robert Wood Johnson Medical School in Newark. “Because we are frontline physicians experiencing what is happening with patients and orchestrating as well as delivering care, we should provide feedback.”

Dr. Kupersmith, who is on his facility’s patient safety committee and has participated in a root-cause analysis of hand-offs as well as worked on medical reconciliation and pneumonia core measure performance improvement, says SHM “should help take the lead in bringing together specialists, administrators, and nurses with hospitalists who should have a major impact in designing a scorecard as a society.”

As hospitalists mature as clinicians, they become system- and process-oriented, says Dr. Kupersmith. As a result, “We should be part of re-engineering efforts because of our experience bringing people together,” he says. “We’re in a good position to analyze the process.”

Use with Care

There is also value in hospitalists’ anecdotal experiences, Dr. Kupersmith says, but “there needs to be a filter between anecdotes and a facility’s leadership to ensure that the information provided is broadly important. Decisions shouldn’t be made on anecdotes, but creative ideas can come from them.”

Randy Ferrance, DC, MD, and chief of the medical staff at Riverside Tappahannock Hospital in Tappahan-nock, Va., regards anecdotal information in much the same light. “It should be seen as guidelines, not rules,” he cautions. “There is still an art to medicine even though it is clearly science. Sometimes the best available evidence may be anecdotal. It’s not hard data, but it can be valuable.”

Dr. Ferrance at one time chaired his hospital’s quality improvement committee; the panel now reports to him. He believes hospitalists are fortunate that “we became a specialty after evidence-based medicine really came to the forefront. We are fortunate to have the backing of much hard data.”

Still, he acknowledges the difficulty of establishing proof that an action affects patient outcome. “It’s hard, but what we can do is look at what might help result in things like decreased morbidity, length of stays and complications, and a faster return to a patient’s normal functions. Then we might see influence on patient outcomes.”

Beyond Core Measures

Richard Rohr, MD, vice president for medical affairs at Cortland Regional Medical Center in New York, works extensively on quality improvements. He urges hospitalists and institutions to go beyond required measures.

“A lot of what we’re doing now is imposed by government, insurers or the Joint Commission,” says Dr. Rohr. “In day-to-day work, we should look for areas to go beyond what is required.”

He believes hospitalists should look at specific issues underlying the Johns Hopkins framework’s three core questions.

For example, within the first core question “Is the measure important?” he suggests hospitalists consider what their facility’s priorities are. “There are thousands of things that could address safety,” he says. “Hospitalists should look at how a measure fits in to their organization’s priorities. At an institution known for cardiac care, look at safety measures in cardiology.”

He also suggests looking at a facility’s potential problem areas to help determine if a measure is important. “I worked at a facility that had a rule that Coumadin had to be ordered one day at a time,” says Dr. Rohr. “Since patient use of the medication was closely monitored, there were very few patients with serious bleeding.”

The point, he says, is that hospitalists should “make sure the safety process they’re interested in truly addresses a true problem and is not already in place. Try to add something of value.”

Hospitalists are in a good position to do this, he says, because of their day-to-day perspective on patients. “Hospitalists should start by looking at what their organization has addressed and what’s causing patient problems day to day and then set priorities,” he advises.

Institutional Support

Of critical importance also, Dr. Rohr says, is to see what their organization can support before deciding what safety measure to explore.

“Is it feasible to collect data to use this measure?” he asks. “That’s partly dependent on where your facility is in using electronic medical records. Does the benefit of researching and implementing outweigh the cost? You may have to spend some staff time to decide what is worthwhile.”

The last task may be easier for hospitalists working at more academic hospitals, he says, which is also an important part of trying to answer the Johns Hopkins framework’s second question: “Is the measure valid?”

It’s often hard to answer that one, Dr. Rohr acknowledges. “Research has at times shown that a process may show statistically significant improvement, but it does not show up clinically,” he says. “Aspirin and beta-blockers for heart patients, for example, has a statistically significant difference—but it is small.”

Most hospitalists try to see patients and do this kind of work on the side, he concedes: “They should do some research, but value what they see when treating patients. You have a good sense of what has helped patients.”

Dr. Wright

Julia Wright, MD, associate professor of medicine at the University of Wisconsin School of Medicine and Public Health and medical director for hospital medicine at the University of Wisconsin Hospital in Madison, agrees.

“The expertise of our specialty is that we deliver care that is not just clinical, asking, ‘Did I meet the guidelines?’’’ she says. “We’re with patients. We should help determine how quality and safety models are addressing how care is delivered.”

She also believes hospitalists should work closely with hospital administrators on these issues. “Hospitalists have an intrinsic sense of value in delivering care,” she notes. “We are unique in that we can combine consideration of hospital goals with knowledge of care at patient levels. This provides great value to the institutions.”

Culture of Safety

While he agrees with the importance of involving hospitalists deeply in safety efforts, Dr. Kupersmith believes institutions should strive to create a culture that focuses on safety and looks at all its processes in that light.

“You shouldn’t just track hard outcomes,” he suggests. “Track the outcomes of your processes. This gives an overall sense of safety awareness in all personnel. If you focus on the process and culture, you might find a significant change in outcomes.” This also helps address the difficulty of finding data on outcomes, he says.

He agrees with the researchers’ view that safety is on a continuum, and he thinks acknowledging that can help establish an institutional culture around safety. “There is always going to be patient danger,” he says. “You want to get to a point where it is minimized because of an awareness of actions. That focus on safety will lead to less danger.”

As a result, he believes quality improvement strategies must address culture. “You need to provide education for all on safety and provide oversight and monitoring with expectations that can be tracked,” he says. “You need to create this mandate and speak in the quality language from the top. Then you start to have people bring in information that affects outcomes.” TH

Karla Feuer is a journalist based in New York.

Reference

1. Pronovost PJ, Berenholtz SM, Needham DM. A framework for health care organizations to develop and evaluate a safety scorecard. JAMA. 2007;298(17):2063-2065.

With hospitals facing increasing pressure to improve safety based on measurements, hospitalists need to build a key role in improving quality by developing safety scorecards, say leading hospital medicine experts.

A framework for designing scorecards was recently suggested by researchers at Johns Hopkins University in Baltimore in an article published by the Journal of the American Medical Association.1 The commentary suggests a framework to help healthcare organizations develop safety scorecards, evaluate their validity, and understand measures appropriate to present as rates.

Their framework is intended to build scorecards that monitor progress in improving patient safety over time or relative to a benchmark. The authors urged organizations to think of safety on a continuum and look for improvements, rather than regard practices as either safe or unsafe. They also stated that their term “safety scorecard” acknowledges an overlap between quality and safety.

To build their framework, the researchers adapted elements of the “Users’ Guide to the Medical Literature: A Manual for Evidence-Based Clinical Practice,” to address three key questions:

• Is the measure important?
• Is the measure valid? and
• Can the measure be used to improve safety in healthcare organizations?

The resulting worksheet to evaluate a scorecard guides hospitals through questions aimed at determining whether their institution meets the three criteria.

Initial Reaction

“This worksheet would be very important to follow, a good step forward in efforts to improve quality because its questions make clear where a group might be falling down in developing a scorecard,” says hospitalist Brian Bossard, MD, director of Inpatient Physician Associates at BryanLGH Medical Center in Lincoln, Neb. Dr. Bossard, who is also the medical staff quality designee, says he believes large national hospitalist groups should be involved in planning scorecards as part of a multidisciplinary team.

Other experts also tout hospitalists’ importance in the vanguard of creating these vital instruments.

“Hospitalists should be on or chairing safety committees, and there should be investments in training them in these areas,” says Eric Kupersmith, MD, division head of hospital medicine and assistant professor of medicine for the Cooper Health System, University of Medicine and Dentistry of New Jersey Robert Wood Johnson Medical School in Newark. “Because we are frontline physicians experiencing what is happening with patients and orchestrating as well as delivering care, we should provide feedback.”

Dr. Kupersmith, who is on his facility’s patient safety committee and has participated in a root-cause analysis of hand-offs as well as worked on medical reconciliation and pneumonia core measure performance improvement, says SHM “should help take the lead in bringing together specialists, administrators, and nurses with hospitalists who should have a major impact in designing a scorecard as a society.”

As hospitalists mature as clinicians, they become system- and process-oriented, says Dr. Kupersmith. As a result, “We should be part of re-engineering efforts because of our experience bringing people together,” he says. “We’re in a good position to analyze the process.”

Use with Care

There is also value in hospitalists’ anecdotal experiences, Dr. Kupersmith says, but “there needs to be a filter between anecdotes and a facility’s leadership to ensure that the information provided is broadly important. Decisions shouldn’t be made on anecdotes, but creative ideas can come from them.”

Randy Ferrance, DC, MD, and chief of the medical staff at Riverside Tappahannock Hospital in Tappahan-nock, Va., regards anecdotal information in much the same light. “It should be seen as guidelines, not rules,” he cautions. “There is still an art to medicine even though it is clearly science. Sometimes the best available evidence may be anecdotal. It’s not hard data, but it can be valuable.”

Dr. Ferrance at one time chaired his hospital’s quality improvement committee; the panel now reports to him. He believes hospitalists are fortunate that “we became a specialty after evidence-based medicine really came to the forefront. We are fortunate to have the backing of much hard data.”

Still, he acknowledges the difficulty of establishing proof that an action affects patient outcome. “It’s hard, but what we can do is look at what might help result in things like decreased morbidity, length of stays and complications, and a faster return to a patient’s normal functions. Then we might see influence on patient outcomes.”

Beyond Core Measures

Richard Rohr, MD, vice president for medical affairs at Cortland Regional Medical Center in New York, works extensively on quality improvements. He urges hospitalists and institutions to go beyond required measures.

“A lot of what we’re doing now is imposed by government, insurers or the Joint Commission,” says Dr. Rohr. “In day-to-day work, we should look for areas to go beyond what is required.”

He believes hospitalists should look at specific issues underlying the Johns Hopkins framework’s three core questions.

For example, within the first core question “Is the measure important?” he suggests hospitalists consider what their facility’s priorities are. “There are thousands of things that could address safety,” he says. “Hospitalists should look at how a measure fits in to their organization’s priorities. At an institution known for cardiac care, look at safety measures in cardiology.”

He also suggests looking at a facility’s potential problem areas to help determine if a measure is important. “I worked at a facility that had a rule that Coumadin had to be ordered one day at a time,” says Dr. Rohr. “Since patient use of the medication was closely monitored, there were very few patients with serious bleeding.”

The point, he says, is that hospitalists should “make sure the safety process they’re interested in truly addresses a true problem and is not already in place. Try to add something of value.”

Hospitalists are in a good position to do this, he says, because of their day-to-day perspective on patients. “Hospitalists should start by looking at what their organization has addressed and what’s causing patient problems day to day and then set priorities,” he advises.

Institutional Support

Of critical importance also, Dr. Rohr says, is to see what their organization can support before deciding what safety measure to explore.

“Is it feasible to collect data to use this measure?” he asks. “That’s partly dependent on where your facility is in using electronic medical records. Does the benefit of researching and implementing outweigh the cost? You may have to spend some staff time to decide what is worthwhile.”

The last task may be easier for hospitalists working at more academic hospitals, he says, which is also an important part of trying to answer the Johns Hopkins framework’s second question: “Is the measure valid?”

It’s often hard to answer that one, Dr. Rohr acknowledges. “Research has at times shown that a process may show statistically significant improvement, but it does not show up clinically,” he says. “Aspirin and beta-blockers for heart patients, for example, has a statistically significant difference—but it is small.”

Most hospitalists try to see patients and do this kind of work on the side, he concedes: “They should do some research, but value what they see when treating patients. You have a good sense of what has helped patients.”

Dr. Wright

Julia Wright, MD, associate professor of medicine at the University of Wisconsin School of Medicine and Public Health and medical director for hospital medicine at the University of Wisconsin Hospital in Madison, agrees.

“The expertise of our specialty is that we deliver care that is not just clinical, asking, ‘Did I meet the guidelines?’’’ she says. “We’re with patients. We should help determine how quality and safety models are addressing how care is delivered.”

She also believes hospitalists should work closely with hospital administrators on these issues. “Hospitalists have an intrinsic sense of value in delivering care,” she notes. “We are unique in that we can combine consideration of hospital goals with knowledge of care at patient levels. This provides great value to the institutions.”

Culture of Safety

While he agrees with the importance of involving hospitalists deeply in safety efforts, Dr. Kupersmith believes institutions should strive to create a culture that focuses on safety and looks at all its processes in that light.

“You shouldn’t just track hard outcomes,” he suggests. “Track the outcomes of your processes. This gives an overall sense of safety awareness in all personnel. If you focus on the process and culture, you might find a significant change in outcomes.” This also helps address the difficulty of finding data on outcomes, he says.

He agrees with the researchers’ view that safety is on a continuum, and he thinks acknowledging that can help establish an institutional culture around safety. “There is always going to be patient danger,” he says. “You want to get to a point where it is minimized because of an awareness of actions. That focus on safety will lead to less danger.”

As a result, he believes quality improvement strategies must address culture. “You need to provide education for all on safety and provide oversight and monitoring with expectations that can be tracked,” he says. “You need to create this mandate and speak in the quality language from the top. Then you start to have people bring in information that affects outcomes.” TH

Karla Feuer is a journalist based in New York.

Reference

1. Pronovost PJ, Berenholtz SM, Needham DM. A framework for health care organizations to develop and evaluate a safety scorecard. JAMA. 2007;298(17):2063-2065.