Rewards await in 2008 for meeting quality measures

Q. Our practice is considering reporting quality measures to Medicare in 2008. Except for those relating to stress incontinence, however, there do not seem to be many that apply to ObGyn practices. Is it worth our while to even try for the bonus reimbursements promised by the program?

A. A resounding “Yes!” It isn’t just Medicare that’s looking to reward medical practices for reporting quality measures: Many larger payers are also eyeing these data to ensure top-quality care for their beneficiaries.

In the July 2007 issue of OBG Management, I wrote an article about the Medicare Physician Quality Reporting Initiative (PQRI) program, which could have earned you as much as a 1.5% bonus at the end of that year (read this article). For 2008, there are many more quality measures for which you can qualify.

For example, there are now measures for screening, such as colon cancer screening and mammography. And more:

• New measure 113 allows you to note that you documented the result of a fecal occult blood test
  
• If you document, at the time of a problem visit, the result of a recent mammogram, you can report measure 112
  
• Measures 114 and 115 relate to inquiring about a patient’s tobacco use and then advising her to quit—activities customarily performed by ObGyns.
  

The list doesn’t stop there: New measures cover the use of electronic medical records, e-prescribing, and advising a patient to get the flu vaccine. And so on.

For details on how to participate in this program (and to see how easy it is to report measures), visit the Centers for Medicare & Medicaid Services (CMS) at www.cms.hhs.gov/PQRI/35_2008PQRI-Information.asp. Download “2008 PRQI Quality Measure Specifications.”

Reimbursement for repair of your surgical injury?

Q. If the bladder or bowel, or a ureter or blood vessel, is injured during surgery, what are the best coding options for handling repair?

A. The answer depends largely on 1) the policy of the particular payer and 2) when the injury is repaired.

When the injury occurs during the surgery and is repaired at that time, Medicare does not allow the surgeon who caused the injury to bill separately for repairing it. If another physician is called in to make the repair, however, he (she) is reimbursed for the work. According to Medicare’s General Correct Coding Policies for National Correct Coding Initiative Policy Manual for Medicare Services, “When a complication described by codes defining complications arises during an operative session…a separate service for treating the complication is not to be reported.”

A return to the operating room for a complication would be reimbursed, however; report this by adding a modifier -78 to the surgical code for the complication repair (for example, 49002 [re-opening of a recent laparotomy for hemorrhage exploration]).

Most private payers allow separate billing for repair of iatrogenic injury.

Rewards await in 2008 for meeting quality measures

Q. Our practice is considering reporting quality measures to Medicare in 2008. Except for those relating to stress incontinence, however, there do not seem to be many that apply to ObGyn practices. Is it worth our while to even try for the bonus reimbursements promised by the program?

A. A resounding “Yes!” It isn’t just Medicare that’s looking to reward medical practices for reporting quality measures: Many larger payers are also eyeing these data to ensure top-quality care for their beneficiaries.

In the July 2007 issue of OBG Management, I wrote an article about the Medicare Physician Quality Reporting Initiative (PQRI) program, which could have earned you as much as a 1.5% bonus at the end of that year (read this article). For 2008, there are many more quality measures for which you can qualify.

For example, there are now measures for screening, such as colon cancer screening and mammography. And more:

• New measure 113 allows you to note that you documented the result of a fecal occult blood test
  
• If you document, at the time of a problem visit, the result of a recent mammogram, you can report measure 112
  
• Measures 114 and 115 relate to inquiring about a patient’s tobacco use and then advising her to quit—activities customarily performed by ObGyns.
  

The list doesn’t stop there: New measures cover the use of electronic medical records, e-prescribing, and advising a patient to get the flu vaccine. And so on.

For details on how to participate in this program (and to see how easy it is to report measures), visit the Centers for Medicare & Medicaid Services (CMS) at www.cms.hhs.gov/PQRI/35_2008PQRI-Information.asp. Download “2008 PRQI Quality Measure Specifications.”

Reimbursement for repair of your surgical injury?

Q. If the bladder or bowel, or a ureter or blood vessel, is injured during surgery, what are the best coding options for handling repair?

A. The answer depends largely on 1) the policy of the particular payer and 2) when the injury is repaired.

When the injury occurs during the surgery and is repaired at that time, Medicare does not allow the surgeon who caused the injury to bill separately for repairing it. If another physician is called in to make the repair, however, he (she) is reimbursed for the work. According to Medicare’s General Correct Coding Policies for National Correct Coding Initiative Policy Manual for Medicare Services, “When a complication described by codes defining complications arises during an operative session…a separate service for treating the complication is not to be reported.”

A return to the operating room for a complication would be reimbursed, however; report this by adding a modifier -78 to the surgical code for the complication repair (for example, 49002 [re-opening of a recent laparotomy for hemorrhage exploration]).

Most private payers allow separate billing for repair of iatrogenic injury.

Rewards await in 2008 for meeting quality measures

Q. Our practice is considering reporting quality measures to Medicare in 2008. Except for those relating to stress incontinence, however, there do not seem to be many that apply to ObGyn practices. Is it worth our while to even try for the bonus reimbursements promised by the program?

A. A resounding “Yes!” It isn’t just Medicare that’s looking to reward medical practices for reporting quality measures: Many larger payers are also eyeing these data to ensure top-quality care for their beneficiaries.

In the July 2007 issue of OBG Management, I wrote an article about the Medicare Physician Quality Reporting Initiative (PQRI) program, which could have earned you as much as a 1.5% bonus at the end of that year (read this article). For 2008, there are many more quality measures for which you can qualify.

For example, there are now measures for screening, such as colon cancer screening and mammography. And more:

• New measure 113 allows you to note that you documented the result of a fecal occult blood test
  
• If you document, at the time of a problem visit, the result of a recent mammogram, you can report measure 112
  
• Measures 114 and 115 relate to inquiring about a patient’s tobacco use and then advising her to quit—activities customarily performed by ObGyns.
  

The list doesn’t stop there: New measures cover the use of electronic medical records, e-prescribing, and advising a patient to get the flu vaccine. And so on.

For details on how to participate in this program (and to see how easy it is to report measures), visit the Centers for Medicare & Medicaid Services (CMS) at www.cms.hhs.gov/PQRI/35_2008PQRI-Information.asp. Download “2008 PRQI Quality Measure Specifications.”

Reimbursement for repair of your surgical injury?

Q. If the bladder or bowel, or a ureter or blood vessel, is injured during surgery, what are the best coding options for handling repair?

A. The answer depends largely on 1) the policy of the particular payer and 2) when the injury is repaired.

When the injury occurs during the surgery and is repaired at that time, Medicare does not allow the surgeon who caused the injury to bill separately for repairing it. If another physician is called in to make the repair, however, he (she) is reimbursed for the work. According to Medicare’s General Correct Coding Policies for National Correct Coding Initiative Policy Manual for Medicare Services, “When a complication described by codes defining complications arises during an operative session…a separate service for treating the complication is not to be reported.”

A return to the operating room for a complication would be reimbursed, however; report this by adding a modifier -78 to the surgical code for the complication repair (for example, 49002 [re-opening of a recent laparotomy for hemorrhage exploration]).

Most private payers allow separate billing for repair of iatrogenic injury.

THE PATIENT. A 30-year-old police officer reports thoughts of suicide. He was under investigation for illegal work-related activities and feared he would have to report his coworkers’ involvement in these activities and lose his job.

CASE FACTS. The patient was voluntarily hospitalized for 4 days and received medication and inpatient psychotherapy. When he was discharged, a psychiatrist prescribed follow-up outpatient psychotherapy and antidepressant and antipsychotic medications. The next day, the officer fatally shot himself.

THE PATIENT’S FAMILY’S CLAIM. The psychiatrist did not adequately weigh the patient’s depression and stressors, including possibly losing his job, and did not properly assess suicidal ideation. Also, the patient’s mother claims she attended the discharge meeting with the psychiatrist and that her son expressed suicidal intentions at that time.

THE DOCTOR’S DEFENSE. The patient believed he could get another job if necessary and was no longer contemplating suicide. Also, he was a voluntary patient and could not be hospitalized any longer without consent.

Submit your verdict and find out how the court ruled at CurrentPsychiatry.com. Click on “Have more to say about this topic?” to comment.

THE PATIENT. A 30-year-old police officer reports thoughts of suicide. He was under investigation for illegal work-related activities and feared he would have to report his coworkers’ involvement in these activities and lose his job.

CASE FACTS. The patient was voluntarily hospitalized for 4 days and received medication and inpatient psychotherapy. When he was discharged, a psychiatrist prescribed follow-up outpatient psychotherapy and antidepressant and antipsychotic medications. The next day, the officer fatally shot himself.

THE PATIENT’S FAMILY’S CLAIM. The psychiatrist did not adequately weigh the patient’s depression and stressors, including possibly losing his job, and did not properly assess suicidal ideation. Also, the patient’s mother claims she attended the discharge meeting with the psychiatrist and that her son expressed suicidal intentions at that time.

THE DOCTOR’S DEFENSE. The patient believed he could get another job if necessary and was no longer contemplating suicide. Also, he was a voluntary patient and could not be hospitalized any longer without consent.

Submit your verdict and find out how the court ruled at CurrentPsychiatry.com. Click on “Have more to say about this topic?” to comment.

THE PATIENT. A 30-year-old police officer reports thoughts of suicide. He was under investigation for illegal work-related activities and feared he would have to report his coworkers’ involvement in these activities and lose his job.

CASE FACTS. The patient was voluntarily hospitalized for 4 days and received medication and inpatient psychotherapy. When he was discharged, a psychiatrist prescribed follow-up outpatient psychotherapy and antidepressant and antipsychotic medications. The next day, the officer fatally shot himself.

THE PATIENT’S FAMILY’S CLAIM. The psychiatrist did not adequately weigh the patient’s depression and stressors, including possibly losing his job, and did not properly assess suicidal ideation. Also, the patient’s mother claims she attended the discharge meeting with the psychiatrist and that her son expressed suicidal intentions at that time.

THE DOCTOR’S DEFENSE. The patient believed he could get another job if necessary and was no longer contemplating suicide. Also, he was a voluntary patient and could not be hospitalized any longer without consent.

Submit your verdict and find out how the court ruled at CurrentPsychiatry.com. Click on “Have more to say about this topic?” to comment.

Current Psychiatry’s malpractice column is evolving. Previously, “Malpractice Verdicts,” used case decisions to initiate discussions of clinical situations that can generate lawsuits. The verdicts remain as “Malpractice Minute”, but Current Psychiatry has invited me to contribute a new column, “Malpractice Rx,” that will solicit questions and address practicing clinicians’ concerns about malpractice risk.

To start this dialogue, I’ll begin with a question that often comes up in discussions with colleagues, and especially when I teach psychiatry residents: “What should I document?” In this article, we will review why proper documentation is essential. We’ll also look at some ideas that might make documentation easier, more efficient, and more satisfying.

Purposes of documentation

When I was in medical school, my professors said the primary reason for accurate charting was to communicate with the rest of the treatment team. This is still true. But in these sadder-but-wiser days, when I ask psychiatry residents “What is the purpose of documentation?” they always answer, “to create a legal record.”

Documentation plays many roles (Table 1). From the standpoint of preventing a malpractice judgment, the clinical record can accomplish 3 important things:

Lawsuit deterrence. Records are a key source—and often the only source—of information an attorney uses when deciding whether to file a lawsuit. An attorney won’t risk time and money on a malpractice case if the clinical record suggests that a psychiatrist was conscientious and met the standard of care.¹

Impression management. The patient’s chart is what plaintiffs’ and defendants’ experts use when forming their initial opinions about the quality of care delivered.

Credibility. Clinical records are the most believable source of information about what you observed, what you thought, what you did, why you did it, and when you did it. The adage “if it wasn’t written, it didn’t happen” is not always applicable,² but if an adverse event occurs, a defendant doctor’s verbal testimony about delivering good care will be more convincing when backed up by documentation created before the event.

Table 1

Purposes of medical record documentation

Communicate clinical information to current and future caregivers Remind you of what happened and what you did Justify care to third-party payers Inform professional standards review organizations Satisfy accrediting agencies Create a basis for defense in a malpractice action

Improving documentation

Because it is impossible to describe everything you see, hear, say, do, and think during clinical encounters with patients, you must make choices about what to include in the record. The components of good documentation depend on the clinical context, but the following general principles may avert some malpractice actions.

1 More is better. Psychiatric practice often requires you to be discreet about patients’ personal information. Within appropriate bounds, however, the more information the record contains about objective findings, patients’ statements, clinical judgments, and your decision making, the better the portrayal of competent care.

2 Record the time and date. When attorneys and experts try to reconstruct what happened before an adverse occurrence, knowing the exact time you saw the patient, recorded findings, wrote orders, followed up on lab tests, or discussed problems with others—including family and treatment team members—can make a big difference.

3 Sooner is better. The most credible charting is done during or just after a service is rendered. Charting completed after an adverse event is vulnerable to accusations of fabrication.

4 Describe your thinking. Most aspects of clinical medicine are far from certain. Documenting the reasoning behind your diagnosis and treatment selection—what you’ve ruled out, what still seems tentative, and what risks and benefits you’ve weighed—helps emphasize this reality.³ After something bad happens, people retrospectively regard the event as more probable than it really was.⁴ Documenting your uncertainty and ways of addressing it may help counter this “hindsight bias.” It also shows that you were thoughtful and took therapeutic steps prudently.

5 Collaborate with the patient. In some circumstances, it is appropriate to draft documents in a patient’s presence. Examples might include information sent to third-party payers or referrals to other clinicians. Noting that you’ve done this demonstrates the patient’s awareness and implicit concurrence. Also, collaborative documentation reinforces the “working together” aspects of a doctor-patient relationship and can be therapeutic.

 

⁵

6 Clarify capacity. Jurors may believe that all psychiatric patients are incompetent, and plaintiff’s attorneys sometimes try to create the impression that patients are completely controlled by weird whims and aberrant thoughts. To counter this, when appropriate indicate in the chart that the patient can handle responsibilities such as reporting side effects, seeking emergency attention, or notifying you about changes in thought or mood.^3,5

7 Manage appearance and content. Under Health Insurance Portability and Accountability Act (HIPAA) regulations, patients have the right to review their medical records.⁶ If a lawsuit occurs, the records might be read out loud in court. Documentation will make a better impression if it is clear, legible, and free of gratuitous comments.

8 Include quotations. Documenting verbatim statements from a patient, such as “I’ve never considered suicide,” can quickly convey key information that you considered when making a therapeutic decision.

Technical approaches

Table 2^7,8 lists several techniques and technologies that might improve documentation. For example, computer users can create templates or customize software to quickly produce thorough documentation for frequently encountered procedures or clinical events. Whether these approaches are useful and appropriate will depend on your work setting, but all aim to improve the speed and quality of clinical documentation.

Think creatively about improving documentation. Even if you’re never sued, better documentation helps you and your patients. For example, several years ago a colleague⁹ designed an emergency room form that allowed clinicians to complete in a few seconds a Brief Psychiatric Rating Scale on every patient we evaluated. This innovation shortened the time needed to document a systematic, comprehensive assessment and increased the quantity, quality, and reliability of information in patients’ records.

Table 2

Purposes of medical record documentation

Idea	Comment
Use speech recognition	You speak faster than you write. Transcription software
Software	accuracy has improved in the last few years.
Use handouts and	Patients often do not remember or understand much of what
medication instructions	doctors tell them,7,8 so handouts may be more useful than verbal instructions. Good handouts about medications are available on the Internet. Note in the chart that you gave the patient the document.
Seek anonymous	Documenting consultations shows you are prudent and
consultations with colleagues	a colleague agreed with your treatment.
Ask patients to rate their	This practice may improve your information gathering
own symptoms and progress	and help document what the patient told you.
Use standard rating scales	Rating scales can help you record more information in a scientifically validated format.
Use macros and templates	Macros can reduce time needed for documentation. Your memory isn’t perfect, but templates can help you include everything you need to cover.

Current Psychiatry’s malpractice column is evolving. Previously, “Malpractice Verdicts,” used case decisions to initiate discussions of clinical situations that can generate lawsuits. The verdicts remain as “Malpractice Minute”, but Current Psychiatry has invited me to contribute a new column, “Malpractice Rx,” that will solicit questions and address practicing clinicians’ concerns about malpractice risk.

To start this dialogue, I’ll begin with a question that often comes up in discussions with colleagues, and especially when I teach psychiatry residents: “What should I document?” In this article, we will review why proper documentation is essential. We’ll also look at some ideas that might make documentation easier, more efficient, and more satisfying.

Purposes of documentation

When I was in medical school, my professors said the primary reason for accurate charting was to communicate with the rest of the treatment team. This is still true. But in these sadder-but-wiser days, when I ask psychiatry residents “What is the purpose of documentation?” they always answer, “to create a legal record.”

Documentation plays many roles (Table 1). From the standpoint of preventing a malpractice judgment, the clinical record can accomplish 3 important things:

Lawsuit deterrence. Records are a key source—and often the only source—of information an attorney uses when deciding whether to file a lawsuit. An attorney won’t risk time and money on a malpractice case if the clinical record suggests that a psychiatrist was conscientious and met the standard of care.¹

Impression management. The patient’s chart is what plaintiffs’ and defendants’ experts use when forming their initial opinions about the quality of care delivered.

Credibility. Clinical records are the most believable source of information about what you observed, what you thought, what you did, why you did it, and when you did it. The adage “if it wasn’t written, it didn’t happen” is not always applicable,² but if an adverse event occurs, a defendant doctor’s verbal testimony about delivering good care will be more convincing when backed up by documentation created before the event.

Table 1

Purposes of medical record documentation

Communicate clinical information to current and future caregivers Remind you of what happened and what you did Justify care to third-party payers Inform professional standards review organizations Satisfy accrediting agencies Create a basis for defense in a malpractice action

Improving documentation

Because it is impossible to describe everything you see, hear, say, do, and think during clinical encounters with patients, you must make choices about what to include in the record. The components of good documentation depend on the clinical context, but the following general principles may avert some malpractice actions.

1 More is better. Psychiatric practice often requires you to be discreet about patients’ personal information. Within appropriate bounds, however, the more information the record contains about objective findings, patients’ statements, clinical judgments, and your decision making, the better the portrayal of competent care.

2 Record the time and date. When attorneys and experts try to reconstruct what happened before an adverse occurrence, knowing the exact time you saw the patient, recorded findings, wrote orders, followed up on lab tests, or discussed problems with others—including family and treatment team members—can make a big difference.

3 Sooner is better. The most credible charting is done during or just after a service is rendered. Charting completed after an adverse event is vulnerable to accusations of fabrication.

4 Describe your thinking. Most aspects of clinical medicine are far from certain. Documenting the reasoning behind your diagnosis and treatment selection—what you’ve ruled out, what still seems tentative, and what risks and benefits you’ve weighed—helps emphasize this reality.³ After something bad happens, people retrospectively regard the event as more probable than it really was.⁴ Documenting your uncertainty and ways of addressing it may help counter this “hindsight bias.” It also shows that you were thoughtful and took therapeutic steps prudently.

5 Collaborate with the patient. In some circumstances, it is appropriate to draft documents in a patient’s presence. Examples might include information sent to third-party payers or referrals to other clinicians. Noting that you’ve done this demonstrates the patient’s awareness and implicit concurrence. Also, collaborative documentation reinforces the “working together” aspects of a doctor-patient relationship and can be therapeutic.

 

⁵

6 Clarify capacity. Jurors may believe that all psychiatric patients are incompetent, and plaintiff’s attorneys sometimes try to create the impression that patients are completely controlled by weird whims and aberrant thoughts. To counter this, when appropriate indicate in the chart that the patient can handle responsibilities such as reporting side effects, seeking emergency attention, or notifying you about changes in thought or mood.^3,5

7 Manage appearance and content. Under Health Insurance Portability and Accountability Act (HIPAA) regulations, patients have the right to review their medical records.⁶ If a lawsuit occurs, the records might be read out loud in court. Documentation will make a better impression if it is clear, legible, and free of gratuitous comments.

8 Include quotations. Documenting verbatim statements from a patient, such as “I’ve never considered suicide,” can quickly convey key information that you considered when making a therapeutic decision.

Technical approaches

Table 2^7,8 lists several techniques and technologies that might improve documentation. For example, computer users can create templates or customize software to quickly produce thorough documentation for frequently encountered procedures or clinical events. Whether these approaches are useful and appropriate will depend on your work setting, but all aim to improve the speed and quality of clinical documentation.

Think creatively about improving documentation. Even if you’re never sued, better documentation helps you and your patients. For example, several years ago a colleague⁹ designed an emergency room form that allowed clinicians to complete in a few seconds a Brief Psychiatric Rating Scale on every patient we evaluated. This innovation shortened the time needed to document a systematic, comprehensive assessment and increased the quantity, quality, and reliability of information in patients’ records.

Table 2

Purposes of medical record documentation

Idea	Comment
Use speech recognition	You speak faster than you write. Transcription software
Software	accuracy has improved in the last few years.
Use handouts and	Patients often do not remember or understand much of what
medication instructions	doctors tell them,7,8 so handouts may be more useful than verbal instructions. Good handouts about medications are available on the Internet. Note in the chart that you gave the patient the document.
Seek anonymous	Documenting consultations shows you are prudent and
consultations with colleagues	a colleague agreed with your treatment.
Ask patients to rate their	This practice may improve your information gathering
own symptoms and progress	and help document what the patient told you.
Use standard rating scales	Rating scales can help you record more information in a scientifically validated format.
Use macros and templates	Macros can reduce time needed for documentation. Your memory isn’t perfect, but templates can help you include everything you need to cover.

Current Psychiatry’s malpractice column is evolving. Previously, “Malpractice Verdicts,” used case decisions to initiate discussions of clinical situations that can generate lawsuits. The verdicts remain as “Malpractice Minute”, but Current Psychiatry has invited me to contribute a new column, “Malpractice Rx,” that will solicit questions and address practicing clinicians’ concerns about malpractice risk.

To start this dialogue, I’ll begin with a question that often comes up in discussions with colleagues, and especially when I teach psychiatry residents: “What should I document?” In this article, we will review why proper documentation is essential. We’ll also look at some ideas that might make documentation easier, more efficient, and more satisfying.

Purposes of documentation

When I was in medical school, my professors said the primary reason for accurate charting was to communicate with the rest of the treatment team. This is still true. But in these sadder-but-wiser days, when I ask psychiatry residents “What is the purpose of documentation?” they always answer, “to create a legal record.”

Documentation plays many roles (Table 1). From the standpoint of preventing a malpractice judgment, the clinical record can accomplish 3 important things:

Lawsuit deterrence. Records are a key source—and often the only source—of information an attorney uses when deciding whether to file a lawsuit. An attorney won’t risk time and money on a malpractice case if the clinical record suggests that a psychiatrist was conscientious and met the standard of care.¹

Impression management. The patient’s chart is what plaintiffs’ and defendants’ experts use when forming their initial opinions about the quality of care delivered.

Credibility. Clinical records are the most believable source of information about what you observed, what you thought, what you did, why you did it, and when you did it. The adage “if it wasn’t written, it didn’t happen” is not always applicable,² but if an adverse event occurs, a defendant doctor’s verbal testimony about delivering good care will be more convincing when backed up by documentation created before the event.

Table 1

Purposes of medical record documentation

Communicate clinical information to current and future caregivers Remind you of what happened and what you did Justify care to third-party payers Inform professional standards review organizations Satisfy accrediting agencies Create a basis for defense in a malpractice action

Improving documentation

Because it is impossible to describe everything you see, hear, say, do, and think during clinical encounters with patients, you must make choices about what to include in the record. The components of good documentation depend on the clinical context, but the following general principles may avert some malpractice actions.

1 More is better. Psychiatric practice often requires you to be discreet about patients’ personal information. Within appropriate bounds, however, the more information the record contains about objective findings, patients’ statements, clinical judgments, and your decision making, the better the portrayal of competent care.

2 Record the time and date. When attorneys and experts try to reconstruct what happened before an adverse occurrence, knowing the exact time you saw the patient, recorded findings, wrote orders, followed up on lab tests, or discussed problems with others—including family and treatment team members—can make a big difference.

3 Sooner is better. The most credible charting is done during or just after a service is rendered. Charting completed after an adverse event is vulnerable to accusations of fabrication.

4 Describe your thinking. Most aspects of clinical medicine are far from certain. Documenting the reasoning behind your diagnosis and treatment selection—what you’ve ruled out, what still seems tentative, and what risks and benefits you’ve weighed—helps emphasize this reality.³ After something bad happens, people retrospectively regard the event as more probable than it really was.⁴ Documenting your uncertainty and ways of addressing it may help counter this “hindsight bias.” It also shows that you were thoughtful and took therapeutic steps prudently.

5 Collaborate with the patient. In some circumstances, it is appropriate to draft documents in a patient’s presence. Examples might include information sent to third-party payers or referrals to other clinicians. Noting that you’ve done this demonstrates the patient’s awareness and implicit concurrence. Also, collaborative documentation reinforces the “working together” aspects of a doctor-patient relationship and can be therapeutic.

 

⁵

6 Clarify capacity. Jurors may believe that all psychiatric patients are incompetent, and plaintiff’s attorneys sometimes try to create the impression that patients are completely controlled by weird whims and aberrant thoughts. To counter this, when appropriate indicate in the chart that the patient can handle responsibilities such as reporting side effects, seeking emergency attention, or notifying you about changes in thought or mood.^3,5

7 Manage appearance and content. Under Health Insurance Portability and Accountability Act (HIPAA) regulations, patients have the right to review their medical records.⁶ If a lawsuit occurs, the records might be read out loud in court. Documentation will make a better impression if it is clear, legible, and free of gratuitous comments.

8 Include quotations. Documenting verbatim statements from a patient, such as “I’ve never considered suicide,” can quickly convey key information that you considered when making a therapeutic decision.

Technical approaches

Table 2^7,8 lists several techniques and technologies that might improve documentation. For example, computer users can create templates or customize software to quickly produce thorough documentation for frequently encountered procedures or clinical events. Whether these approaches are useful and appropriate will depend on your work setting, but all aim to improve the speed and quality of clinical documentation.

Think creatively about improving documentation. Even if you’re never sued, better documentation helps you and your patients. For example, several years ago a colleague⁹ designed an emergency room form that allowed clinicians to complete in a few seconds a Brief Psychiatric Rating Scale on every patient we evaluated. This innovation shortened the time needed to document a systematic, comprehensive assessment and increased the quantity, quality, and reliability of information in patients’ records.

Table 2

Purposes of medical record documentation

Idea	Comment
Use speech recognition	You speak faster than you write. Transcription software
Software	accuracy has improved in the last few years.
Use handouts and	Patients often do not remember or understand much of what
medication instructions	doctors tell them,7,8 so handouts may be more useful than verbal instructions. Good handouts about medications are available on the Internet. Note in the chart that you gave the patient the document.
Seek anonymous	Documenting consultations shows you are prudent and
consultations with colleagues	a colleague agreed with your treatment.
Ask patients to rate their	This practice may improve your information gathering
own symptoms and progress	and help document what the patient told you.
Use standard rating scales	Rating scales can help you record more information in a scientifically validated format.
Use macros and templates	Macros can reduce time needed for documentation. Your memory isn’t perfect, but templates can help you include everything you need to cover.

 

 

SAN FRANCISCO – Hydrocephalus is an easy clue to potential Coccidioides immitis meningitis, but a subacute course of the disease can make it much more difficult to pin down the diagnosis, Dr. Parvin Azimi said at the annual meeting of the American Academy of Pediatrics.

She described two cases of chronic meningitis that illustrate different manifestations of C. immitis. The first patient, a 16-year-old African American boy, had a history of exposure to soil in endemic areas, the likely source of his fungal infection, said Dr. Azimi, director of infectious diseases at Children's Hospital and Research Center, Oakland, Calif. The patient presented with a 5-week history of headache, vomiting, and decreased energy, with no response to treatment with oral amoxicillin. He had a fever higher than 100° F with a stiff neck, flat affect, and lethargy.

A spinal tap showed that the cerebral spinal fluid (CSF) had a high protein level (148 mg/dL) and a low glucose level (15 mg/dL). The RBC count was 3/mcL and the WBC count was 380/mcL with 25% polymorphonuclear leukocytes (PMNs), 66% lymphocytes, and 9% monocytes. Gram stain and culture were negative for bacteria.

“Obviously, the spinal fluid findings look very much like TB,” so clinicians did a work-up for tuberculosis, she said. A purified protein derivative (PPD) skin test for tuberculosis produced no induration, although “that doesn't mean the patient doesn't have TB,” she acknowledged. Chest x-ray, cranial CT scan, and EEG were all normal.

The teenager had been traveling to Corpus Christi, Tex., where he collected insects and played with his pet tarantula and puppy during his visit. He sought help for his symptoms at a Texas hospital and was sent home to California with a diagnosis of viral meningitis.

The headaches and vomiting continued. A repeat spinal tap 3 weeks after the first one showed that the CSF protein level had increased (176 mg/dL) and the glucose level decreased (9 mg/dL). The RBC was 1/mcL and the WBC was 737/mcL with 33% PMNs, 51% lymphocytes, 15% monocytes, and 1% macrocytes.

Infectious disease consultants were called in at this point. They ordered fungal, parasitic, and acid-fast bacilli studies and started the patient on empiric therapy for presumed TB meningitis pending results of cultures. The CSF was negative for cryptococcal antigen and amebic trophozoites, ruling these out of the differential diagnosis, Dr. Azimi said. An HIV test was negative.

Finally, the CSF and sera were found to be reactive to C. immitis antibodies.

In the second case described by Dr. Azimi, a 19-month-old Filipino-Latino boy from Antioch, Calif., presented with a 6-month history of decreased activity, clinging behavior, and poor growth. In the past 6 days, he'd had lethargy, frequent falls, and difficulty walking. On physical exam, he was mildly feverish and irritable, and refused to stand or walk.

A head CT scan showed hydrocephalus “that was significant enough that it prompted surgeons to place a shunt quickly” to provide decompression, she said. Hydrocephalus is a well-known complication of Coccidioides meningitis.

The patient's CSF showed highly elevated protein (319 mg/dL) and low glucose (25 mg/dL). The RBC was 340/mcL and the WBC was 117/mcL with 65% lymphocytes and 4% PMNs, among other findings. CSF Gram stain and cultures were negative, as were a chest x-ray and PPD skin test for TB.

As in the first patient with subacute disease, this patient's CSF and sera were reactive for C. immitis antibodies.

Fewer than 1% of cases of Coccidioides infection become disseminated, but half of disseminated cases have CNS involvement, Dr. Azimi said. Oral fluconazole is the treatment of choice, continued for life. Stopping therapy risks a recurrence in 35% of cases.

 

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Fewer than 1% of cases become disseminated, but half of those cases have CNS involvement. DR. AZIMI

 

 

SAN FRANCISCO – Hydrocephalus is an easy clue to potential Coccidioides immitis meningitis, but a subacute course of the disease can make it much more difficult to pin down the diagnosis, Dr. Parvin Azimi said at the annual meeting of the American Academy of Pediatrics.

She described two cases of chronic meningitis that illustrate different manifestations of C. immitis. The first patient, a 16-year-old African American boy, had a history of exposure to soil in endemic areas, the likely source of his fungal infection, said Dr. Azimi, director of infectious diseases at Children's Hospital and Research Center, Oakland, Calif. The patient presented with a 5-week history of headache, vomiting, and decreased energy, with no response to treatment with oral amoxicillin. He had a fever higher than 100° F with a stiff neck, flat affect, and lethargy.

A spinal tap showed that the cerebral spinal fluid (CSF) had a high protein level (148 mg/dL) and a low glucose level (15 mg/dL). The RBC count was 3/mcL and the WBC count was 380/mcL with 25% polymorphonuclear leukocytes (PMNs), 66% lymphocytes, and 9% monocytes. Gram stain and culture were negative for bacteria.

“Obviously, the spinal fluid findings look very much like TB,” so clinicians did a work-up for tuberculosis, she said. A purified protein derivative (PPD) skin test for tuberculosis produced no induration, although “that doesn't mean the patient doesn't have TB,” she acknowledged. Chest x-ray, cranial CT scan, and EEG were all normal.

The teenager had been traveling to Corpus Christi, Tex., where he collected insects and played with his pet tarantula and puppy during his visit. He sought help for his symptoms at a Texas hospital and was sent home to California with a diagnosis of viral meningitis.

The headaches and vomiting continued. A repeat spinal tap 3 weeks after the first one showed that the CSF protein level had increased (176 mg/dL) and the glucose level decreased (9 mg/dL). The RBC was 1/mcL and the WBC was 737/mcL with 33% PMNs, 51% lymphocytes, 15% monocytes, and 1% macrocytes.

Infectious disease consultants were called in at this point. They ordered fungal, parasitic, and acid-fast bacilli studies and started the patient on empiric therapy for presumed TB meningitis pending results of cultures. The CSF was negative for cryptococcal antigen and amebic trophozoites, ruling these out of the differential diagnosis, Dr. Azimi said. An HIV test was negative.

Finally, the CSF and sera were found to be reactive to C. immitis antibodies.

In the second case described by Dr. Azimi, a 19-month-old Filipino-Latino boy from Antioch, Calif., presented with a 6-month history of decreased activity, clinging behavior, and poor growth. In the past 6 days, he'd had lethargy, frequent falls, and difficulty walking. On physical exam, he was mildly feverish and irritable, and refused to stand or walk.

A head CT scan showed hydrocephalus “that was significant enough that it prompted surgeons to place a shunt quickly” to provide decompression, she said. Hydrocephalus is a well-known complication of Coccidioides meningitis.

The patient's CSF showed highly elevated protein (319 mg/dL) and low glucose (25 mg/dL). The RBC was 340/mcL and the WBC was 117/mcL with 65% lymphocytes and 4% PMNs, among other findings. CSF Gram stain and cultures were negative, as were a chest x-ray and PPD skin test for TB.

As in the first patient with subacute disease, this patient's CSF and sera were reactive for C. immitis antibodies.

Fewer than 1% of cases of Coccidioides infection become disseminated, but half of disseminated cases have CNS involvement, Dr. Azimi said. Oral fluconazole is the treatment of choice, continued for life. Stopping therapy risks a recurrence in 35% of cases.

 

Document

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Fewer than 1% of cases become disseminated, but half of those cases have CNS involvement. DR. AZIMI

 

 

SAN FRANCISCO – Hydrocephalus is an easy clue to potential Coccidioides immitis meningitis, but a subacute course of the disease can make it much more difficult to pin down the diagnosis, Dr. Parvin Azimi said at the annual meeting of the American Academy of Pediatrics.

She described two cases of chronic meningitis that illustrate different manifestations of C. immitis. The first patient, a 16-year-old African American boy, had a history of exposure to soil in endemic areas, the likely source of his fungal infection, said Dr. Azimi, director of infectious diseases at Children's Hospital and Research Center, Oakland, Calif. The patient presented with a 5-week history of headache, vomiting, and decreased energy, with no response to treatment with oral amoxicillin. He had a fever higher than 100° F with a stiff neck, flat affect, and lethargy.

A spinal tap showed that the cerebral spinal fluid (CSF) had a high protein level (148 mg/dL) and a low glucose level (15 mg/dL). The RBC count was 3/mcL and the WBC count was 380/mcL with 25% polymorphonuclear leukocytes (PMNs), 66% lymphocytes, and 9% monocytes. Gram stain and culture were negative for bacteria.

“Obviously, the spinal fluid findings look very much like TB,” so clinicians did a work-up for tuberculosis, she said. A purified protein derivative (PPD) skin test for tuberculosis produced no induration, although “that doesn't mean the patient doesn't have TB,” she acknowledged. Chest x-ray, cranial CT scan, and EEG were all normal.

The teenager had been traveling to Corpus Christi, Tex., where he collected insects and played with his pet tarantula and puppy during his visit. He sought help for his symptoms at a Texas hospital and was sent home to California with a diagnosis of viral meningitis.

The headaches and vomiting continued. A repeat spinal tap 3 weeks after the first one showed that the CSF protein level had increased (176 mg/dL) and the glucose level decreased (9 mg/dL). The RBC was 1/mcL and the WBC was 737/mcL with 33% PMNs, 51% lymphocytes, 15% monocytes, and 1% macrocytes.

Infectious disease consultants were called in at this point. They ordered fungal, parasitic, and acid-fast bacilli studies and started the patient on empiric therapy for presumed TB meningitis pending results of cultures. The CSF was negative for cryptococcal antigen and amebic trophozoites, ruling these out of the differential diagnosis, Dr. Azimi said. An HIV test was negative.

Finally, the CSF and sera were found to be reactive to C. immitis antibodies.

In the second case described by Dr. Azimi, a 19-month-old Filipino-Latino boy from Antioch, Calif., presented with a 6-month history of decreased activity, clinging behavior, and poor growth. In the past 6 days, he'd had lethargy, frequent falls, and difficulty walking. On physical exam, he was mildly feverish and irritable, and refused to stand or walk.

A head CT scan showed hydrocephalus “that was significant enough that it prompted surgeons to place a shunt quickly” to provide decompression, she said. Hydrocephalus is a well-known complication of Coccidioides meningitis.

The patient's CSF showed highly elevated protein (319 mg/dL) and low glucose (25 mg/dL). The RBC was 340/mcL and the WBC was 117/mcL with 65% lymphocytes and 4% PMNs, among other findings. CSF Gram stain and cultures were negative, as were a chest x-ray and PPD skin test for TB.

As in the first patient with subacute disease, this patient's CSF and sera were reactive for C. immitis antibodies.

Fewer than 1% of cases of Coccidioides infection become disseminated, but half of disseminated cases have CNS involvement, Dr. Azimi said. Oral fluconazole is the treatment of choice, continued for life. Stopping therapy risks a recurrence in 35% of cases.

 

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Fewer than 1% of cases become disseminated, but half of those cases have CNS involvement. DR. AZIMI

Docs Around the Clock

Our hospitalist group presently takes out-of-house call at night, but our hospital is pressuring us to move into the hospital 24/7. What should we do?

Afraid of the Dark,

Provo, Utah

Dr. Hospitalist responds: It can be a real challenge to find sufficient providers to staff the hospital nightly. But I encourage you to take this step. I believe there is a quality advantage to having hospitalists in house 24/7 versus having physicians on call at night from outside the hospital.

Hospitalized patients are no less likely to become acutely ill at night as during the day. From a quality perspective, it has never made sense to me why hospitals do not routinely have a physician in house 24/7. Many hospitals say they cannot afford to pay a physician to work in house at night because there are few opportunities to generate revenue. But in today’s environment, can you afford not to have a hospitalist in at night?

Hospitals without hospitalists in at night often encounter issues with patient throughput each morning. Nurses are waiting for physician orders, and physicians are scrambling to write admission notes on patients admitted overnight. This delays morning discharges and admissions, leading to other problems including overcrowding in the emergency department.

Hospitalized patients are now sicker than ever. Delays in evaluations can mean adverse outcomes. Just because the doctor is not in the hospital does not relieve them of any responsibility if a patient suffers an adverse outcome as a result of delay in care. Patients and payers are not only scrutinizing the care patients receive in the hospital but also paying based on performance. Can you and your hospital afford to not provide the timeliest care possible?

Right Night Solution?

Do you think it is better to have dedicated nocturnist(s) or have hospitalist staff members take turns working nights?

Sleepless in San Diego

Dr. Hospitalist responds: There are advantages and disadvantages of having a dedicated nocturnist versus having a rotation model with regular hospitalist staff members taking turns working nights in the hospital. If your hospital has different groups of nurses for days and nights, there may be an advantage to having nocturnists.

This model allows the doctors and nurses to work closely and develop a cohesive team. This would be more difficult if the doctor at night changes frequently. Using nocturnists to staff nights can also make daytime staffing easier or more difficult.

Consider this analogy. At the end of this baseball season, the New York Yankees faced the decision of whether or not to re-sign arguably the best player on the planet, Alex Rodriguez. With A-Rod’s high price tag ($30 million-plus annually), would the Yankees be better served taking this money and signing several players (because we assume no single player could match his talent)? What would happen if they signed A-Rod and he got hurt? Wouldn’t that leave a hole in the lineup the size of the Milky Way?

How different are nocturnists in today’s hospitalist workplace? Most hospitalist programs covet them. They can do things others can’t—work a large number of nights on the schedule. This means fewer or no nights for colleagues, which makes them happier. Nocturnists command a high salary, and if one leaves for your program for any reason, they leave a gaping hole in the schedule.

My advice is to hire a nocturnist but don’t rely solely on nocturnists to cover nights. Covering your night schedule with a mix of nocturnists and staff hospitalists will allow everyone to appreciate the nocturnist but won’t put you in the uncomfortable position of relying solely on nocturnists to keep your program running effectively.

 

Performance Anxiety

I just started working as a hospitalist. I was told that the federal government surveys patients about the care I provide in the hospital. Is this true?

Newbie in Fort Lauderdale

Dr. Hospitalist responds: I believe you are referring to the Consumer Assessment of Healthcare Providers and Systems (CAHPS) hospital survey. It is a standardized instrument designed to measure patients’ perspective of care in acute care hospitals.

Hospital participation is optional. Many hospitals survey patients about their perceptions of care after they leave the hospital. Press Ganey Associates works with hospitals nationwide to conduct the surveys. The Centers for Medicare and Medicaid Services (CMS) and the Joint Commission encourage hospitals to incorporate the CAHPS questions into any other surveys being performed. The survey has 27 questions that cover seven topic areas:

• Communication with doctors;
• Communication with nurses;
• Hospital staff responsiveness;
• Pain management;
• Communication about medicines;
• Hospital environment; and
• Discharge information.

Three questions ask about communication with doctors:

• How often did the doctors treat you with courtesy and respect?
• How often did doctors listen carefully to you?
• How often did doctors explain things so you could understand?

The survey will produce data that not only will “allow comparison between hospitals, it will create an incentive for hospitals to improve quality of care and to increase accountability by increasing transparency.” Data collection for the initial period from October 2006 to June 2007 will be publicly reported in March 2008 on the Hospital Compare Web site: www.hospitalcompare.hhs.gov. For additional information, go to www.hcaphsonline.org. TH

Docs Around the Clock

Our hospitalist group presently takes out-of-house call at night, but our hospital is pressuring us to move into the hospital 24/7. What should we do?

Afraid of the Dark,

Provo, Utah

Dr. Hospitalist responds: It can be a real challenge to find sufficient providers to staff the hospital nightly. But I encourage you to take this step. I believe there is a quality advantage to having hospitalists in house 24/7 versus having physicians on call at night from outside the hospital.

Hospitalized patients are no less likely to become acutely ill at night as during the day. From a quality perspective, it has never made sense to me why hospitals do not routinely have a physician in house 24/7. Many hospitals say they cannot afford to pay a physician to work in house at night because there are few opportunities to generate revenue. But in today’s environment, can you afford not to have a hospitalist in at night?

Hospitals without hospitalists in at night often encounter issues with patient throughput each morning. Nurses are waiting for physician orders, and physicians are scrambling to write admission notes on patients admitted overnight. This delays morning discharges and admissions, leading to other problems including overcrowding in the emergency department.

Hospitalized patients are now sicker than ever. Delays in evaluations can mean adverse outcomes. Just because the doctor is not in the hospital does not relieve them of any responsibility if a patient suffers an adverse outcome as a result of delay in care. Patients and payers are not only scrutinizing the care patients receive in the hospital but also paying based on performance. Can you and your hospital afford to not provide the timeliest care possible?

Right Night Solution?

Do you think it is better to have dedicated nocturnist(s) or have hospitalist staff members take turns working nights?

Sleepless in San Diego

Dr. Hospitalist responds: There are advantages and disadvantages of having a dedicated nocturnist versus having a rotation model with regular hospitalist staff members taking turns working nights in the hospital. If your hospital has different groups of nurses for days and nights, there may be an advantage to having nocturnists.

This model allows the doctors and nurses to work closely and develop a cohesive team. This would be more difficult if the doctor at night changes frequently. Using nocturnists to staff nights can also make daytime staffing easier or more difficult.

Consider this analogy. At the end of this baseball season, the New York Yankees faced the decision of whether or not to re-sign arguably the best player on the planet, Alex Rodriguez. With A-Rod’s high price tag ($30 million-plus annually), would the Yankees be better served taking this money and signing several players (because we assume no single player could match his talent)? What would happen if they signed A-Rod and he got hurt? Wouldn’t that leave a hole in the lineup the size of the Milky Way?

How different are nocturnists in today’s hospitalist workplace? Most hospitalist programs covet them. They can do things others can’t—work a large number of nights on the schedule. This means fewer or no nights for colleagues, which makes them happier. Nocturnists command a high salary, and if one leaves for your program for any reason, they leave a gaping hole in the schedule.

My advice is to hire a nocturnist but don’t rely solely on nocturnists to cover nights. Covering your night schedule with a mix of nocturnists and staff hospitalists will allow everyone to appreciate the nocturnist but won’t put you in the uncomfortable position of relying solely on nocturnists to keep your program running effectively.

 

Performance Anxiety

I just started working as a hospitalist. I was told that the federal government surveys patients about the care I provide in the hospital. Is this true?

Newbie in Fort Lauderdale

Dr. Hospitalist responds: I believe you are referring to the Consumer Assessment of Healthcare Providers and Systems (CAHPS) hospital survey. It is a standardized instrument designed to measure patients’ perspective of care in acute care hospitals.

Hospital participation is optional. Many hospitals survey patients about their perceptions of care after they leave the hospital. Press Ganey Associates works with hospitals nationwide to conduct the surveys. The Centers for Medicare and Medicaid Services (CMS) and the Joint Commission encourage hospitals to incorporate the CAHPS questions into any other surveys being performed. The survey has 27 questions that cover seven topic areas:

• Communication with doctors;
• Communication with nurses;
• Hospital staff responsiveness;
• Pain management;
• Communication about medicines;
• Hospital environment; and
• Discharge information.

Three questions ask about communication with doctors:

• How often did the doctors treat you with courtesy and respect?
• How often did doctors listen carefully to you?
• How often did doctors explain things so you could understand?

The survey will produce data that not only will “allow comparison between hospitals, it will create an incentive for hospitals to improve quality of care and to increase accountability by increasing transparency.” Data collection for the initial period from October 2006 to June 2007 will be publicly reported in March 2008 on the Hospital Compare Web site: www.hospitalcompare.hhs.gov. For additional information, go to www.hcaphsonline.org. TH

Docs Around the Clock

Our hospitalist group presently takes out-of-house call at night, but our hospital is pressuring us to move into the hospital 24/7. What should we do?

Afraid of the Dark,

Provo, Utah

Dr. Hospitalist responds: It can be a real challenge to find sufficient providers to staff the hospital nightly. But I encourage you to take this step. I believe there is a quality advantage to having hospitalists in house 24/7 versus having physicians on call at night from outside the hospital.

Hospitalized patients are no less likely to become acutely ill at night as during the day. From a quality perspective, it has never made sense to me why hospitals do not routinely have a physician in house 24/7. Many hospitals say they cannot afford to pay a physician to work in house at night because there are few opportunities to generate revenue. But in today’s environment, can you afford not to have a hospitalist in at night?

Hospitals without hospitalists in at night often encounter issues with patient throughput each morning. Nurses are waiting for physician orders, and physicians are scrambling to write admission notes on patients admitted overnight. This delays morning discharges and admissions, leading to other problems including overcrowding in the emergency department.

Hospitalized patients are now sicker than ever. Delays in evaluations can mean adverse outcomes. Just because the doctor is not in the hospital does not relieve them of any responsibility if a patient suffers an adverse outcome as a result of delay in care. Patients and payers are not only scrutinizing the care patients receive in the hospital but also paying based on performance. Can you and your hospital afford to not provide the timeliest care possible?

Right Night Solution?

Do you think it is better to have dedicated nocturnist(s) or have hospitalist staff members take turns working nights?

Sleepless in San Diego

Dr. Hospitalist responds: There are advantages and disadvantages of having a dedicated nocturnist versus having a rotation model with regular hospitalist staff members taking turns working nights in the hospital. If your hospital has different groups of nurses for days and nights, there may be an advantage to having nocturnists.

This model allows the doctors and nurses to work closely and develop a cohesive team. This would be more difficult if the doctor at night changes frequently. Using nocturnists to staff nights can also make daytime staffing easier or more difficult.

Consider this analogy. At the end of this baseball season, the New York Yankees faced the decision of whether or not to re-sign arguably the best player on the planet, Alex Rodriguez. With A-Rod’s high price tag ($30 million-plus annually), would the Yankees be better served taking this money and signing several players (because we assume no single player could match his talent)? What would happen if they signed A-Rod and he got hurt? Wouldn’t that leave a hole in the lineup the size of the Milky Way?

How different are nocturnists in today’s hospitalist workplace? Most hospitalist programs covet them. They can do things others can’t—work a large number of nights on the schedule. This means fewer or no nights for colleagues, which makes them happier. Nocturnists command a high salary, and if one leaves for your program for any reason, they leave a gaping hole in the schedule.

My advice is to hire a nocturnist but don’t rely solely on nocturnists to cover nights. Covering your night schedule with a mix of nocturnists and staff hospitalists will allow everyone to appreciate the nocturnist but won’t put you in the uncomfortable position of relying solely on nocturnists to keep your program running effectively.

 

Performance Anxiety

I just started working as a hospitalist. I was told that the federal government surveys patients about the care I provide in the hospital. Is this true?

Newbie in Fort Lauderdale

Dr. Hospitalist responds: I believe you are referring to the Consumer Assessment of Healthcare Providers and Systems (CAHPS) hospital survey. It is a standardized instrument designed to measure patients’ perspective of care in acute care hospitals.

Hospital participation is optional. Many hospitals survey patients about their perceptions of care after they leave the hospital. Press Ganey Associates works with hospitals nationwide to conduct the surveys. The Centers for Medicare and Medicaid Services (CMS) and the Joint Commission encourage hospitals to incorporate the CAHPS questions into any other surveys being performed. The survey has 27 questions that cover seven topic areas:

• Communication with doctors;
• Communication with nurses;
• Hospital staff responsiveness;
• Pain management;
• Communication about medicines;
• Hospital environment; and
• Discharge information.

Three questions ask about communication with doctors:

• How often did the doctors treat you with courtesy and respect?
• How often did doctors listen carefully to you?
• How often did doctors explain things so you could understand?

The survey will produce data that not only will “allow comparison between hospitals, it will create an incentive for hospitals to improve quality of care and to increase accountability by increasing transparency.” Data collection for the initial period from October 2006 to June 2007 will be publicly reported in March 2008 on the Hospital Compare Web site: www.hospitalcompare.hhs.gov. For additional information, go to www.hcaphsonline.org. TH

I enjoy hearing about the value hospitalists provide our healthcare system. These stories come from peer-reviewed research, magazine articles, local newspapers, and even the occasional blog. When I talk to hospitalists from around the country, they are often eager to tell of their success and how they made it happen.

Not as often, I also hear about problems that may be a result of the hospitalist model. I think any successful practice, and our field as a whole, must remain open to the weaknesses in the hospitalist model and work continuously to address them. Issues like disruptions in care and poor communication between hospitalists and outpatient providers get a reasonable amount of attention and seem to be on most groups’ radar screens. But there are some potential problems I don’t hear discussed often, and I’m not aware of any significant research that has been published or presented to analyze them. I’ll review two such potential problems here.

ED Throughput

Are hospitalists sometimes the cause of a bottleneck in the emergency department (ED)? Hospitalist practice is nearly always credited with improving throughput at a hospital, including in the ED. But many hospitalist practices could impede throughput by delaying patients from leaving the ED when there are multiple simultaneous admissions. Consider the following scenarios:

The pre-hospitalist era: It is 7:30 p.m. and the ED has four patients ready for hand-off to an admitting doctor. There are several primary care groups at the hospital, and each has a doctor on call. Of the four patients needing admission, two go to Dr. Emerson from group A, one goes to Dr. Lake from group B, and one to Dr. Palmer from group C. Because the on-call doctor for these groups is home, he/she provides admitting orders by phone and may or may not see the patient that night. Of course, waiting until the next day to see the patient can be risky. In many cases the ED would have admitting orders on all four patients quickly, say within 30 minutes, and can send the patients up to the floor as soon as the bed is ready.

The hospitalist era: Things can happen differently when hospitalists are at this hospital. All daytime hospitalists are typically signed out to a single night hospitalist (nocturnist) at 7:30 p.m. when the ED has four patients to admit. This solo nocturnist might show up almost immediately after being notified about the admissions by the ED doctor and promptly start seeing the first of the four admissions. But it might take him/her three or four hours or more to finish admitting all four patients. By that time there are probably additional admissions waiting. The ED might end up keeping each patient much longer than in the first scenario.

The difference in these two scenarios is the availability of several doctors to admit patients simultaneously in the pre-hospitalist era. These doctors may be replaced by a single hospitalist who admits patients one at a time.

A clear benefit of the hospitalist system described in this example is that patients are seen in person by the hospitalist at the time of admission, rather than admitted over the phone by the primary care physician (PCP) and perhaps not seen in person by the PCP until the next day. Yet this may come at a cost of creating a bottleneck that didn’t exist in the pre-hospitalist era.

 

Think about whether this is a common problem in your practice. Several strategies might help minimize this bottleneck. The most common approach in a practice of more than about 10 hospitalists is to ensure that there is more than one hospitalist available to admit patients until 10 or 11 p.m. when admission volume typically subsides. This has led some groups to develop an evening “swing shift” from late afternoon until about 10 or 11 p.m.

Large groups may decide to dedicate one hospitalist entirely to the ED from sometime in the morning (e.g., 11 a.m.) until near midnight. This person is available to respond quickly to ED admissions and consult with ED doctors regarding management and disposition of borderline cases. While ED staff are usually thrilled to have a hospitalist for the day, that hospitalist often will need to get help from other hospitalists when several patients must be admitted at the same time. And hospitalist-patient continuity suffers because the patient will nearly always need to be handed off to a different hospitalist for follow-up visits.

Marginal Admissions

Do hospitalists increase the number of marginal or potentially avoidable admissions?

The pre-hospitalist era: The ED physician sees a patient of Dr. Bernstein’s at 1 a.m. and is having trouble deciding whether admission is the best approach. The ED doctor gets Dr. Bernstein or his on-call partner, Dr. Copeland, on the phone and learns this patient is well known to the practice and can be seen in the outpatient office early the next morning. Admission is unnecessary.

The hospitalist era: The ED physician sees the same patient at 1 a.m. Because there is a reasonable chance admission is the best approach, he decides to call the hospitalist first rather than the patient’s PCP. Neither the ED doctor nor the hospitalist knows the patient well, and they are unaware outpatient follow-up with the PCP next morning is an option. After all, most PCPs are already “booked up” and probably unable to work someone in on such short notice. And, it’s tough to be sure the PCP would have all the relevant records regarding the data gathered and decisions made during the ED visit. So the hospitalist and ED doctor agree the best approach is to admit this patient to observation status, when in the pre-hospitalist era the patient might have been safely discharged from the ED for outpatient follow-up.

I fear this is a reasonably common scenario for many hospitalist practices. And yet these marginal admissions are often discharged the next day, lowering the overall length of stay (LOS) for hospitalist patients. By admitting marginal patients, some of whom might have been safely discharged from the ED in the pre-hospitalist era, a hospitalist practice can improve its overall LOS. The hospitalists might be patting themselves on the back for such good performance on LOS by admitting patients who could be discharged.

These two problems are difficult to quantify. If you’re confident these aren’t an issue for your practice, you deserve lots of credit. But I think most practices should think carefully about both issues and work to minimize how often they occur. 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.” This column represents his views and is not intended to reflect an official position of SHM.

I enjoy hearing about the value hospitalists provide our healthcare system. These stories come from peer-reviewed research, magazine articles, local newspapers, and even the occasional blog. When I talk to hospitalists from around the country, they are often eager to tell of their success and how they made it happen.

Not as often, I also hear about problems that may be a result of the hospitalist model. I think any successful practice, and our field as a whole, must remain open to the weaknesses in the hospitalist model and work continuously to address them. Issues like disruptions in care and poor communication between hospitalists and outpatient providers get a reasonable amount of attention and seem to be on most groups’ radar screens. But there are some potential problems I don’t hear discussed often, and I’m not aware of any significant research that has been published or presented to analyze them. I’ll review two such potential problems here.

ED Throughput

Are hospitalists sometimes the cause of a bottleneck in the emergency department (ED)? Hospitalist practice is nearly always credited with improving throughput at a hospital, including in the ED. But many hospitalist practices could impede throughput by delaying patients from leaving the ED when there are multiple simultaneous admissions. Consider the following scenarios:

The pre-hospitalist era: It is 7:30 p.m. and the ED has four patients ready for hand-off to an admitting doctor. There are several primary care groups at the hospital, and each has a doctor on call. Of the four patients needing admission, two go to Dr. Emerson from group A, one goes to Dr. Lake from group B, and one to Dr. Palmer from group C. Because the on-call doctor for these groups is home, he/she provides admitting orders by phone and may or may not see the patient that night. Of course, waiting until the next day to see the patient can be risky. In many cases the ED would have admitting orders on all four patients quickly, say within 30 minutes, and can send the patients up to the floor as soon as the bed is ready.

The hospitalist era: Things can happen differently when hospitalists are at this hospital. All daytime hospitalists are typically signed out to a single night hospitalist (nocturnist) at 7:30 p.m. when the ED has four patients to admit. This solo nocturnist might show up almost immediately after being notified about the admissions by the ED doctor and promptly start seeing the first of the four admissions. But it might take him/her three or four hours or more to finish admitting all four patients. By that time there are probably additional admissions waiting. The ED might end up keeping each patient much longer than in the first scenario.

The difference in these two scenarios is the availability of several doctors to admit patients simultaneously in the pre-hospitalist era. These doctors may be replaced by a single hospitalist who admits patients one at a time.

A clear benefit of the hospitalist system described in this example is that patients are seen in person by the hospitalist at the time of admission, rather than admitted over the phone by the primary care physician (PCP) and perhaps not seen in person by the PCP until the next day. Yet this may come at a cost of creating a bottleneck that didn’t exist in the pre-hospitalist era.

 

Think about whether this is a common problem in your practice. Several strategies might help minimize this bottleneck. The most common approach in a practice of more than about 10 hospitalists is to ensure that there is more than one hospitalist available to admit patients until 10 or 11 p.m. when admission volume typically subsides. This has led some groups to develop an evening “swing shift” from late afternoon until about 10 or 11 p.m.

Large groups may decide to dedicate one hospitalist entirely to the ED from sometime in the morning (e.g., 11 a.m.) until near midnight. This person is available to respond quickly to ED admissions and consult with ED doctors regarding management and disposition of borderline cases. While ED staff are usually thrilled to have a hospitalist for the day, that hospitalist often will need to get help from other hospitalists when several patients must be admitted at the same time. And hospitalist-patient continuity suffers because the patient will nearly always need to be handed off to a different hospitalist for follow-up visits.

Marginal Admissions

Do hospitalists increase the number of marginal or potentially avoidable admissions?

The pre-hospitalist era: The ED physician sees a patient of Dr. Bernstein’s at 1 a.m. and is having trouble deciding whether admission is the best approach. The ED doctor gets Dr. Bernstein or his on-call partner, Dr. Copeland, on the phone and learns this patient is well known to the practice and can be seen in the outpatient office early the next morning. Admission is unnecessary.

The hospitalist era: The ED physician sees the same patient at 1 a.m. Because there is a reasonable chance admission is the best approach, he decides to call the hospitalist first rather than the patient’s PCP. Neither the ED doctor nor the hospitalist knows the patient well, and they are unaware outpatient follow-up with the PCP next morning is an option. After all, most PCPs are already “booked up” and probably unable to work someone in on such short notice. And, it’s tough to be sure the PCP would have all the relevant records regarding the data gathered and decisions made during the ED visit. So the hospitalist and ED doctor agree the best approach is to admit this patient to observation status, when in the pre-hospitalist era the patient might have been safely discharged from the ED for outpatient follow-up.

I fear this is a reasonably common scenario for many hospitalist practices. And yet these marginal admissions are often discharged the next day, lowering the overall length of stay (LOS) for hospitalist patients. By admitting marginal patients, some of whom might have been safely discharged from the ED in the pre-hospitalist era, a hospitalist practice can improve its overall LOS. The hospitalists might be patting themselves on the back for such good performance on LOS by admitting patients who could be discharged.

These two problems are difficult to quantify. If you’re confident these aren’t an issue for your practice, you deserve lots of credit. But I think most practices should think carefully about both issues and work to minimize how often they occur. 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.” This column represents his views and is not intended to reflect an official position of SHM.

I enjoy hearing about the value hospitalists provide our healthcare system. These stories come from peer-reviewed research, magazine articles, local newspapers, and even the occasional blog. When I talk to hospitalists from around the country, they are often eager to tell of their success and how they made it happen.

Not as often, I also hear about problems that may be a result of the hospitalist model. I think any successful practice, and our field as a whole, must remain open to the weaknesses in the hospitalist model and work continuously to address them. Issues like disruptions in care and poor communication between hospitalists and outpatient providers get a reasonable amount of attention and seem to be on most groups’ radar screens. But there are some potential problems I don’t hear discussed often, and I’m not aware of any significant research that has been published or presented to analyze them. I’ll review two such potential problems here.

ED Throughput

Are hospitalists sometimes the cause of a bottleneck in the emergency department (ED)? Hospitalist practice is nearly always credited with improving throughput at a hospital, including in the ED. But many hospitalist practices could impede throughput by delaying patients from leaving the ED when there are multiple simultaneous admissions. Consider the following scenarios:

The pre-hospitalist era: It is 7:30 p.m. and the ED has four patients ready for hand-off to an admitting doctor. There are several primary care groups at the hospital, and each has a doctor on call. Of the four patients needing admission, two go to Dr. Emerson from group A, one goes to Dr. Lake from group B, and one to Dr. Palmer from group C. Because the on-call doctor for these groups is home, he/she provides admitting orders by phone and may or may not see the patient that night. Of course, waiting until the next day to see the patient can be risky. In many cases the ED would have admitting orders on all four patients quickly, say within 30 minutes, and can send the patients up to the floor as soon as the bed is ready.

The hospitalist era: Things can happen differently when hospitalists are at this hospital. All daytime hospitalists are typically signed out to a single night hospitalist (nocturnist) at 7:30 p.m. when the ED has four patients to admit. This solo nocturnist might show up almost immediately after being notified about the admissions by the ED doctor and promptly start seeing the first of the four admissions. But it might take him/her three or four hours or more to finish admitting all four patients. By that time there are probably additional admissions waiting. The ED might end up keeping each patient much longer than in the first scenario.

The difference in these two scenarios is the availability of several doctors to admit patients simultaneously in the pre-hospitalist era. These doctors may be replaced by a single hospitalist who admits patients one at a time.

A clear benefit of the hospitalist system described in this example is that patients are seen in person by the hospitalist at the time of admission, rather than admitted over the phone by the primary care physician (PCP) and perhaps not seen in person by the PCP until the next day. Yet this may come at a cost of creating a bottleneck that didn’t exist in the pre-hospitalist era.

 

Think about whether this is a common problem in your practice. Several strategies might help minimize this bottleneck. The most common approach in a practice of more than about 10 hospitalists is to ensure that there is more than one hospitalist available to admit patients until 10 or 11 p.m. when admission volume typically subsides. This has led some groups to develop an evening “swing shift” from late afternoon until about 10 or 11 p.m.

Large groups may decide to dedicate one hospitalist entirely to the ED from sometime in the morning (e.g., 11 a.m.) until near midnight. This person is available to respond quickly to ED admissions and consult with ED doctors regarding management and disposition of borderline cases. While ED staff are usually thrilled to have a hospitalist for the day, that hospitalist often will need to get help from other hospitalists when several patients must be admitted at the same time. And hospitalist-patient continuity suffers because the patient will nearly always need to be handed off to a different hospitalist for follow-up visits.

Marginal Admissions

Do hospitalists increase the number of marginal or potentially avoidable admissions?

The pre-hospitalist era: The ED physician sees a patient of Dr. Bernstein’s at 1 a.m. and is having trouble deciding whether admission is the best approach. The ED doctor gets Dr. Bernstein or his on-call partner, Dr. Copeland, on the phone and learns this patient is well known to the practice and can be seen in the outpatient office early the next morning. Admission is unnecessary.

The hospitalist era: The ED physician sees the same patient at 1 a.m. Because there is a reasonable chance admission is the best approach, he decides to call the hospitalist first rather than the patient’s PCP. Neither the ED doctor nor the hospitalist knows the patient well, and they are unaware outpatient follow-up with the PCP next morning is an option. After all, most PCPs are already “booked up” and probably unable to work someone in on such short notice. And, it’s tough to be sure the PCP would have all the relevant records regarding the data gathered and decisions made during the ED visit. So the hospitalist and ED doctor agree the best approach is to admit this patient to observation status, when in the pre-hospitalist era the patient might have been safely discharged from the ED for outpatient follow-up.

I fear this is a reasonably common scenario for many hospitalist practices. And yet these marginal admissions are often discharged the next day, lowering the overall length of stay (LOS) for hospitalist patients. By admitting marginal patients, some of whom might have been safely discharged from the ED in the pre-hospitalist era, a hospitalist practice can improve its overall LOS. The hospitalists might be patting themselves on the back for such good performance on LOS by admitting patients who could be discharged.

These two problems are difficult to quantify. If you’re confident these aren’t an issue for your practice, you deserve lots of credit. But I think most practices should think carefully about both issues and work to minimize how often they occur. 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.” This column represents his views and is not intended to reflect an official position of SHM.

With shirt buttons bulging and my panniculus spilling like the top of an oversized muffin over my belt—which was essentially a tourniquet strangling my lower extremities—I examined my options.

After hours of grazing through the snack food pyramid and consuming significant portions of a dinosaur-size turkey, an acromegalic dollop of dressing, a bog of cranberries, and a field of mashed potatoes, I was faced with the proposition of shoveling in another 500 calories cleverly disguised as a heaping slice of pumpkin pie.

The intensity of the situation was palpable. My in-laws sat mouths agape, stunned by the amount and rate at which I forked thousands of calories into my gullet. They fidgeted as I stared with steely, miotic pupils and furrowed, sweat-beaded brow at my prospective ingestion.

The tension heightened as my lower two shirt buttons gave up the cause, careening across the table and striking, respectively, a deserted bowl of creamed corn and the forehead of a comatose relative who had long ago lost interest in watching my acute food intoxication. As my cousins brokered bets over the likelihood of my impending demise, I sat and deliberated, fork hovering over my sugary prey.

click for large version

Source: CDCclick for large version

Obesity Epidemic

As healthcare practitioners, we are well aware of the dangers of obesity, yet seem paralyzed to make change. However, hospitalists are perfectly positioned to help patients resolve to lose their weight.

A body mass index (BMI) of 30 or more indicates obesity; its slimmer overweight cousin weighs in with a BMI of 25-29.

Overweight or obese people are at increased risk of osteoarthritis, dyslipidemia, obstructive sleep apnea, hypertension, coronary artery disease, stroke, cancer, and diabetes. Obesity accounts for 300,000 excess deaths per year in the U.S., along with about 10% of all healthcare expenditures, according to the Centers for Disease Control and Prevention (CDC). It affects all ages, races, and professions—including physicians. It is perhaps the most significant health issue facing our nation.

Despite this awareness, we keep getting bigger. In the past 20 years we have seen an epic swelling of American waistlines. In 1990 the CDC reported that among adult residents, 10 states had a prevalence rate of obesity less than 10%, and no states had a rate more than 15% (see Fig. 1, above). By 2006, no state had a prevalence of obesity less than 10%, while only four states clocked in with a rate less than 20%. A whopping 22 states found at least 25% of their inhabitants obese. Since 2005 we’ve become so big the CDC had to create a new category for states with more than 30% of their residents being obese. When the BMI cutoff is dropped to 25 or more, 66% meet of U.S. adults meet this definition for being overweight or obese.

Recent CDC data reveal a glimmer of hope. There was no statistically significant increase in the prevalence of obesity in 2005-2006, compared with 2003-2004. In the earlier time period, 31.1% of men and 33.2% of women were obese, compared with 33.3% of men and 35.3% of women in the most recent time period.

Still, one of every three U.S. adults is obese. That’s 100 million Americans. More than 50% of non-Hispanic black and Mexican-American women age 40-59 are obese. Sixty-one percent of non-Hispanic black women older than 60 are obese.

A complex mix of components, including environment and genetics, determines weight gain. The rapid rate of weight gain in recent years is unlikely to be explained by genetics alone—the population’s genetic composition cannot change that quickly. Thus the bulk of the recent increase in obesity is likely related to cultural and environmental determinants. A 2007 paper by Christakis, et al., found that social networks play a large role in the spread of obesity.1 The study followed 12,067 people for more than 30 years. Those with a friend, sibling, or spouse who became obese over that period were 57%, 40%, and 37% more likely, respectively, to become obese. The authors hypothesize that obesity may become less stigmatized and more tolerable for those surrounded by obese associates. Another theory is that peer groups tend to adopt similar behaviors, such as smoking, eating fast food, and inactivity.

 

The average person gains about one to two pounds a year.2 When distilled to its simplest form, weight gain occurs anytime calories in exceed calories out—that is, a positive energy balance or gap.

The six weeks from Thanksgiving to New Year’s is an especially vulnerable time for weight gain. In a 2000 study of 195 subjects, the average person gained about one pound during the holiday season. When these subjects were followed up with six months later, there was no statistically significant loss of peri-holiday weight gain. This holiday pound may seem trivial (and keep in mind these subjects gained weight despite being closely watched in a weight-gain study). But this weight appears hard to shed and results in much of the weight gained during adulthood.

However, unlike my Thanksgiving gorging, the hallmark of obesity is the small but frequent positive energy gaps, that is, days of 50 to 100 calories of intake greater than use. Over the course of the year, these small daily caloric gaps are anabolically transformed into pounds.

Resolve to Lose

By now, like me, many of you may have added a holiday pound or two. This may be in addition to a nefarious pound or two added throughout the rest of the year. As you ponder scribing your annual resolutions, consider making weight loss a top priority for your patients and yourself, if appropriate.

Unfortunately no magic bullet will turn your New Year’s resolution into reality, just hard work. The key is to tilt the energy balance toward weight loss by reducing caloric intake and increasing activity. Fortunately this can be done in non-Draconian ways. Just as weight gain can snowball from small daily caloric overdoses, it can be removed the same way. Instead of setting or recommending insurmountable goals to your patients—like reducing intake to 1,000 calories a day or adhering to a triathletic training regimen—the CDC suggests a simpler, more sustainable approach to shedding those pounds, namely tipping your energy balance to a negative 150 calories per day.

A net negative energy balance of 150 calories per day will at worst stabilize your weight (depending on your current energy balance) and at best net five to 10 pounds of weight loss per year. For most this can result from something as simple as switching your daily Coke to a Diet Coke. Even more ground can be gained by reducing portion size. The super-sizing of the American menu over the past 20 years is one of the prime drivers of the obesity epidemic (see Table 1, p. 64). Consider cutting back in small ways. For example, continue to enjoy that gourmet chocolate chip cookie but downsize it to a smaller version and reduce your intake by 150 to 200 calories.

As important as reducing caloric intake is the need for activity. Adding moderate amounts of exercise five days a week can burn an additional 150 calories per day, reducing overall weight by another five to 10 pounds in a year. This can include things like walking for 30 minutes, swimming for 20 minutes, or biking for 15 minutes. More adventurous (dancing for 30 minutes), parental (pushing a stroller for 30 minutes), agricultural (gardening for 30 minutes), or chore-oriented (shoveling 15 minutes) options also help.

Much to the dismay of my cousin Mike, who bet that I’d eat at least half the piece of Thanksgiving pie, I put down my fork. After packing away a winter’s worth of calories I was feeling diaphoretic and pathetic. I wobbled away from the table and began charting my course to redemption. It would begin the next day with an apple instead of a bagel, an extra hour at the gym—and a trip to the cleaners to get those buttons replaced. TH

 

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

Editor’s note: The author’s driver license claims a weight of 165 pounds. Physical evidence, as well as his wife’s report, paints a substantially different picture.

References

1. Christakis NA, Fowler JH. The spread of obesity in a large social network over 32 years. N Engl J Med. 2007;357:370-379.
2. Yanovksi JA, Yanovski SZ, Sovik KN, et al. A prospective study of holiday weight gain. N Engl J Med. 2000;342:861-867.

With shirt buttons bulging and my panniculus spilling like the top of an oversized muffin over my belt—which was essentially a tourniquet strangling my lower extremities—I examined my options.

After hours of grazing through the snack food pyramid and consuming significant portions of a dinosaur-size turkey, an acromegalic dollop of dressing, a bog of cranberries, and a field of mashed potatoes, I was faced with the proposition of shoveling in another 500 calories cleverly disguised as a heaping slice of pumpkin pie.

The intensity of the situation was palpable. My in-laws sat mouths agape, stunned by the amount and rate at which I forked thousands of calories into my gullet. They fidgeted as I stared with steely, miotic pupils and furrowed, sweat-beaded brow at my prospective ingestion.

The tension heightened as my lower two shirt buttons gave up the cause, careening across the table and striking, respectively, a deserted bowl of creamed corn and the forehead of a comatose relative who had long ago lost interest in watching my acute food intoxication. As my cousins brokered bets over the likelihood of my impending demise, I sat and deliberated, fork hovering over my sugary prey.

click for large version

Source: CDCclick for large version

Obesity Epidemic

As healthcare practitioners, we are well aware of the dangers of obesity, yet seem paralyzed to make change. However, hospitalists are perfectly positioned to help patients resolve to lose their weight.

A body mass index (BMI) of 30 or more indicates obesity; its slimmer overweight cousin weighs in with a BMI of 25-29.

Overweight or obese people are at increased risk of osteoarthritis, dyslipidemia, obstructive sleep apnea, hypertension, coronary artery disease, stroke, cancer, and diabetes. Obesity accounts for 300,000 excess deaths per year in the U.S., along with about 10% of all healthcare expenditures, according to the Centers for Disease Control and Prevention (CDC). It affects all ages, races, and professions—including physicians. It is perhaps the most significant health issue facing our nation.

Despite this awareness, we keep getting bigger. In the past 20 years we have seen an epic swelling of American waistlines. In 1990 the CDC reported that among adult residents, 10 states had a prevalence rate of obesity less than 10%, and no states had a rate more than 15% (see Fig. 1, above). By 2006, no state had a prevalence of obesity less than 10%, while only four states clocked in with a rate less than 20%. A whopping 22 states found at least 25% of their inhabitants obese. Since 2005 we’ve become so big the CDC had to create a new category for states with more than 30% of their residents being obese. When the BMI cutoff is dropped to 25 or more, 66% meet of U.S. adults meet this definition for being overweight or obese.

Recent CDC data reveal a glimmer of hope. There was no statistically significant increase in the prevalence of obesity in 2005-2006, compared with 2003-2004. In the earlier time period, 31.1% of men and 33.2% of women were obese, compared with 33.3% of men and 35.3% of women in the most recent time period.

Still, one of every three U.S. adults is obese. That’s 100 million Americans. More than 50% of non-Hispanic black and Mexican-American women age 40-59 are obese. Sixty-one percent of non-Hispanic black women older than 60 are obese.

A complex mix of components, including environment and genetics, determines weight gain. The rapid rate of weight gain in recent years is unlikely to be explained by genetics alone—the population’s genetic composition cannot change that quickly. Thus the bulk of the recent increase in obesity is likely related to cultural and environmental determinants. A 2007 paper by Christakis, et al., found that social networks play a large role in the spread of obesity.1 The study followed 12,067 people for more than 30 years. Those with a friend, sibling, or spouse who became obese over that period were 57%, 40%, and 37% more likely, respectively, to become obese. The authors hypothesize that obesity may become less stigmatized and more tolerable for those surrounded by obese associates. Another theory is that peer groups tend to adopt similar behaviors, such as smoking, eating fast food, and inactivity.

 

The average person gains about one to two pounds a year.2 When distilled to its simplest form, weight gain occurs anytime calories in exceed calories out—that is, a positive energy balance or gap.

The six weeks from Thanksgiving to New Year’s is an especially vulnerable time for weight gain. In a 2000 study of 195 subjects, the average person gained about one pound during the holiday season. When these subjects were followed up with six months later, there was no statistically significant loss of peri-holiday weight gain. This holiday pound may seem trivial (and keep in mind these subjects gained weight despite being closely watched in a weight-gain study). But this weight appears hard to shed and results in much of the weight gained during adulthood.

However, unlike my Thanksgiving gorging, the hallmark of obesity is the small but frequent positive energy gaps, that is, days of 50 to 100 calories of intake greater than use. Over the course of the year, these small daily caloric gaps are anabolically transformed into pounds.

Resolve to Lose

By now, like me, many of you may have added a holiday pound or two. This may be in addition to a nefarious pound or two added throughout the rest of the year. As you ponder scribing your annual resolutions, consider making weight loss a top priority for your patients and yourself, if appropriate.

Unfortunately no magic bullet will turn your New Year’s resolution into reality, just hard work. The key is to tilt the energy balance toward weight loss by reducing caloric intake and increasing activity. Fortunately this can be done in non-Draconian ways. Just as weight gain can snowball from small daily caloric overdoses, it can be removed the same way. Instead of setting or recommending insurmountable goals to your patients—like reducing intake to 1,000 calories a day or adhering to a triathletic training regimen—the CDC suggests a simpler, more sustainable approach to shedding those pounds, namely tipping your energy balance to a negative 150 calories per day.

A net negative energy balance of 150 calories per day will at worst stabilize your weight (depending on your current energy balance) and at best net five to 10 pounds of weight loss per year. For most this can result from something as simple as switching your daily Coke to a Diet Coke. Even more ground can be gained by reducing portion size. The super-sizing of the American menu over the past 20 years is one of the prime drivers of the obesity epidemic (see Table 1, p. 64). Consider cutting back in small ways. For example, continue to enjoy that gourmet chocolate chip cookie but downsize it to a smaller version and reduce your intake by 150 to 200 calories.

As important as reducing caloric intake is the need for activity. Adding moderate amounts of exercise five days a week can burn an additional 150 calories per day, reducing overall weight by another five to 10 pounds in a year. This can include things like walking for 30 minutes, swimming for 20 minutes, or biking for 15 minutes. More adventurous (dancing for 30 minutes), parental (pushing a stroller for 30 minutes), agricultural (gardening for 30 minutes), or chore-oriented (shoveling 15 minutes) options also help.

Much to the dismay of my cousin Mike, who bet that I’d eat at least half the piece of Thanksgiving pie, I put down my fork. After packing away a winter’s worth of calories I was feeling diaphoretic and pathetic. I wobbled away from the table and began charting my course to redemption. It would begin the next day with an apple instead of a bagel, an extra hour at the gym—and a trip to the cleaners to get those buttons replaced. TH

 

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

Editor’s note: The author’s driver license claims a weight of 165 pounds. Physical evidence, as well as his wife’s report, paints a substantially different picture.

References

1. Christakis NA, Fowler JH. The spread of obesity in a large social network over 32 years. N Engl J Med. 2007;357:370-379.
2. Yanovksi JA, Yanovski SZ, Sovik KN, et al. A prospective study of holiday weight gain. N Engl J Med. 2000;342:861-867.

With shirt buttons bulging and my panniculus spilling like the top of an oversized muffin over my belt—which was essentially a tourniquet strangling my lower extremities—I examined my options.

After hours of grazing through the snack food pyramid and consuming significant portions of a dinosaur-size turkey, an acromegalic dollop of dressing, a bog of cranberries, and a field of mashed potatoes, I was faced with the proposition of shoveling in another 500 calories cleverly disguised as a heaping slice of pumpkin pie.

The intensity of the situation was palpable. My in-laws sat mouths agape, stunned by the amount and rate at which I forked thousands of calories into my gullet. They fidgeted as I stared with steely, miotic pupils and furrowed, sweat-beaded brow at my prospective ingestion.

The tension heightened as my lower two shirt buttons gave up the cause, careening across the table and striking, respectively, a deserted bowl of creamed corn and the forehead of a comatose relative who had long ago lost interest in watching my acute food intoxication. As my cousins brokered bets over the likelihood of my impending demise, I sat and deliberated, fork hovering over my sugary prey.

click for large version

Source: CDCclick for large version

Obesity Epidemic

As healthcare practitioners, we are well aware of the dangers of obesity, yet seem paralyzed to make change. However, hospitalists are perfectly positioned to help patients resolve to lose their weight.

A body mass index (BMI) of 30 or more indicates obesity; its slimmer overweight cousin weighs in with a BMI of 25-29.

Overweight or obese people are at increased risk of osteoarthritis, dyslipidemia, obstructive sleep apnea, hypertension, coronary artery disease, stroke, cancer, and diabetes. Obesity accounts for 300,000 excess deaths per year in the U.S., along with about 10% of all healthcare expenditures, according to the Centers for Disease Control and Prevention (CDC). It affects all ages, races, and professions—including physicians. It is perhaps the most significant health issue facing our nation.

Despite this awareness, we keep getting bigger. In the past 20 years we have seen an epic swelling of American waistlines. In 1990 the CDC reported that among adult residents, 10 states had a prevalence rate of obesity less than 10%, and no states had a rate more than 15% (see Fig. 1, above). By 2006, no state had a prevalence of obesity less than 10%, while only four states clocked in with a rate less than 20%. A whopping 22 states found at least 25% of their inhabitants obese. Since 2005 we’ve become so big the CDC had to create a new category for states with more than 30% of their residents being obese. When the BMI cutoff is dropped to 25 or more, 66% meet of U.S. adults meet this definition for being overweight or obese.

Recent CDC data reveal a glimmer of hope. There was no statistically significant increase in the prevalence of obesity in 2005-2006, compared with 2003-2004. In the earlier time period, 31.1% of men and 33.2% of women were obese, compared with 33.3% of men and 35.3% of women in the most recent time period.

Still, one of every three U.S. adults is obese. That’s 100 million Americans. More than 50% of non-Hispanic black and Mexican-American women age 40-59 are obese. Sixty-one percent of non-Hispanic black women older than 60 are obese.

A complex mix of components, including environment and genetics, determines weight gain. The rapid rate of weight gain in recent years is unlikely to be explained by genetics alone—the population’s genetic composition cannot change that quickly. Thus the bulk of the recent increase in obesity is likely related to cultural and environmental determinants. A 2007 paper by Christakis, et al., found that social networks play a large role in the spread of obesity.1 The study followed 12,067 people for more than 30 years. Those with a friend, sibling, or spouse who became obese over that period were 57%, 40%, and 37% more likely, respectively, to become obese. The authors hypothesize that obesity may become less stigmatized and more tolerable for those surrounded by obese associates. Another theory is that peer groups tend to adopt similar behaviors, such as smoking, eating fast food, and inactivity.

 

The average person gains about one to two pounds a year.2 When distilled to its simplest form, weight gain occurs anytime calories in exceed calories out—that is, a positive energy balance or gap.

The six weeks from Thanksgiving to New Year’s is an especially vulnerable time for weight gain. In a 2000 study of 195 subjects, the average person gained about one pound during the holiday season. When these subjects were followed up with six months later, there was no statistically significant loss of peri-holiday weight gain. This holiday pound may seem trivial (and keep in mind these subjects gained weight despite being closely watched in a weight-gain study). But this weight appears hard to shed and results in much of the weight gained during adulthood.

However, unlike my Thanksgiving gorging, the hallmark of obesity is the small but frequent positive energy gaps, that is, days of 50 to 100 calories of intake greater than use. Over the course of the year, these small daily caloric gaps are anabolically transformed into pounds.

Resolve to Lose

By now, like me, many of you may have added a holiday pound or two. This may be in addition to a nefarious pound or two added throughout the rest of the year. As you ponder scribing your annual resolutions, consider making weight loss a top priority for your patients and yourself, if appropriate.

Unfortunately no magic bullet will turn your New Year’s resolution into reality, just hard work. The key is to tilt the energy balance toward weight loss by reducing caloric intake and increasing activity. Fortunately this can be done in non-Draconian ways. Just as weight gain can snowball from small daily caloric overdoses, it can be removed the same way. Instead of setting or recommending insurmountable goals to your patients—like reducing intake to 1,000 calories a day or adhering to a triathletic training regimen—the CDC suggests a simpler, more sustainable approach to shedding those pounds, namely tipping your energy balance to a negative 150 calories per day.

A net negative energy balance of 150 calories per day will at worst stabilize your weight (depending on your current energy balance) and at best net five to 10 pounds of weight loss per year. For most this can result from something as simple as switching your daily Coke to a Diet Coke. Even more ground can be gained by reducing portion size. The super-sizing of the American menu over the past 20 years is one of the prime drivers of the obesity epidemic (see Table 1, p. 64). Consider cutting back in small ways. For example, continue to enjoy that gourmet chocolate chip cookie but downsize it to a smaller version and reduce your intake by 150 to 200 calories.

As important as reducing caloric intake is the need for activity. Adding moderate amounts of exercise five days a week can burn an additional 150 calories per day, reducing overall weight by another five to 10 pounds in a year. This can include things like walking for 30 minutes, swimming for 20 minutes, or biking for 15 minutes. More adventurous (dancing for 30 minutes), parental (pushing a stroller for 30 minutes), agricultural (gardening for 30 minutes), or chore-oriented (shoveling 15 minutes) options also help.

Much to the dismay of my cousin Mike, who bet that I’d eat at least half the piece of Thanksgiving pie, I put down my fork. After packing away a winter’s worth of calories I was feeling diaphoretic and pathetic. I wobbled away from the table and began charting my course to redemption. It would begin the next day with an apple instead of a bagel, an extra hour at the gym—and a trip to the cleaners to get those buttons replaced. TH

 

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

Editor’s note: The author’s driver license claims a weight of 165 pounds. Physical evidence, as well as his wife’s report, paints a substantially different picture.

References

1. Christakis NA, Fowler JH. The spread of obesity in a large social network over 32 years. N Engl J Med. 2007;357:370-379.
2. Yanovksi JA, Yanovski SZ, Sovik KN, et al. A prospective study of holiday weight gain. N Engl J Med. 2000;342:861-867.

It’s a refrain I have heard too many times in too many places: “Don’t do it.”

You have probably heard it, too—that plaintive cry from some practicing physicians trying to discourage young people from entering a career in medicine. I understand why so many doctors seem so pessimistic about medicine’s future. They’re grappling with a healthcare industry that struggles with overwhelming complexity. They face unrelenting cost pressures, misaligned incentives and policies, massive shortfalls in quality and service, fragmented systems, and disunity among peers.

I understand the pessimism, but I cannot agree with it. At the midpoint of my term as SHM president, I reflect upon the strengths that distinguish our specialty and our society from the general malaise of the broader healthcare industry. These strengths compel me to redouble my resolve to deliver on the promise of hospital medicine.

What is that promise? Hospitalists are poised to lead the way toward a better healthcare system in two critical ways. They are situated to help advance quality control and they are uniquely situated to promote medicine as a team effort, a shared vision with the hospital.

Now, quality control and teamwork are not in the standard curriculum. Medical school training focuses on disease. But in the real world of the hospital, quality control and the teamwork it takes to ensure it are vital issues. This is where hospitalists must prove themselves. This is where our special skills align with the priorities of hospital CEOs nationwide. We must advance the quality agenda and engage other physicians in a shared vision with the hospital.

These factors set us apart from other specialties and allow us to lead from the core of our strength. We lead:

• Through quality rather than narrow professional self-interests;
• While valuing the team over the individual; and
• With openness and inclusiveness to all medical personnel involved patient care, from pharmacists to nurses, to nonphysician providers, to management.

This is our great promise—but only if we exercise it. As the brilliant author and scientist Johann Wolfgang von Goethe cautioned 200 years ago: “Knowing is not enough. We must apply.”

Honesty requires physicians to admit there is sometimes a gap between what we know and what we apply. Many quality metrics measure our performance. For example, we know we must get aspirin to a heart attack victim quickly. But the clinical strides that dictate the care patients ought to get must be moved into the operational area, where optimal care is sometimes lacking.

We next need to work out the systems to ensure that care, turning best practices into routine practice. Hospitalists are in the vanguard on that front, just as other specialties have been on the cutting edge of academic medicine. Our specialty will always need to weigh in on the development and vetting of quality and safety metrics related to hospital care.

We are also poised to advance the implementation and application of systems that drive improvement in those metrics.

Ours is a young specialty—the average hospitalist is 37, the leadership 41. While we have accomplished much in our 10 years of existence, there is much more to do. Hospitalists must meet the extraordinarily high expectations of hospitals and the other physicians who work in them. We must help manage emergency patients, surgical patients, and the in-hospital patient census of primary care physicians.

But there is a shortage of physicians in our specialty because demand is so great. It’s hard to sustain our growth as a specialty and work on quality control at the same time.

 

We are in the financial crosshairs, as well. Administrators want to see value—that is, money saved. But the fact that we see and manage patients does not generate savings per se because insurance companies do not allow reimbursement as such for our services. “Prove your value,” they say. “Show us the money.” That translates into driving down length of stay, cutting nursing expenses, and reducing pharmacy costs though better quality control and more coordinated care.

But administrators also know that to accomplish these goals and bring other physicians on board, their best ally is the hospitalist.

Our patients demand more of us, too. In “Zen and the Art of Physician Autonomy Maintenance” in Annals of Internal Medicine in 2003, author Jim Reinertsen clearly stated the public’s perspective. “You claim that your profession is based on science … now show us that you can use all the science you know, for our benefit,” he writes. He asks us to “join together—as a profession—with our colleagues, in venues large and small to decide on and apply the best science.”

It is the least we can do as physicians. But in practice, working together to apply the best science is difficult.

All of which brings me to my final point: SHM’s commitment to our members. In October, SHM sponsored two summits, the first on healthcare quality, the second on leadership development. Two themes emerged. First, it takes an unwavering commitment to teamwork to accomplish anything of substance. Second, the educational needs of our workforce are tremendous. SHM’s focus on acquiring skills and applying knowledge are the society’s greatest accomplishment and greatest ongoing opportunity. To that end, we are working on four fronts.

First, we are developing alliances with other like-minded organizations such as the Case Management Association of America, the American Nursing Association, the American Hospital Association, and the Institute for Healthcare Improvement. Through these alliances we hope to foster the teams that will improve the monitoring of parameters of hospital care, and the care itself.

Second, we are committed to creating the tools to equip hospitalists to make the changes that will lead to improvements in the front lines of hospital medicine. We have taken several such steps. SHM has developed a discharge checklist for physicians to use before sending patients home or to other facilities. The checklist, somewhat like those used by pilots, ensures nothing is forgotten or overlooked upon discharge. We believe it will become an invaluable tool.

SHM has also added Resource Rooms to our Web site (www.hospitalmedicine.org). Here, our members can look up and download information on disease states like heart failure or venous thromboembolism.

Third, SHM is funding a group of quality-control mentors available to visit hospitals. These mentors will evaluate and advise on quality-control programs at SHM’s expense.

Finally, SHM wants to train its next generation of leaders. Quality control is a never-ending quest; it can always be better. That is what we at SHM strive for. That is what we owe our patients.

All these tools have one goal: Make quality easy. With so many other pressures of physicians and hospital staff, making it easy is also the key to making it work.

“Knowing is not enough,” Goethe said. “We must apply.” I say: “Willing is not enough. We must do.” TH

Dr. Holman is president of SHM.

It’s a refrain I have heard too many times in too many places: “Don’t do it.”

You have probably heard it, too—that plaintive cry from some practicing physicians trying to discourage young people from entering a career in medicine. I understand why so many doctors seem so pessimistic about medicine’s future. They’re grappling with a healthcare industry that struggles with overwhelming complexity. They face unrelenting cost pressures, misaligned incentives and policies, massive shortfalls in quality and service, fragmented systems, and disunity among peers.

I understand the pessimism, but I cannot agree with it. At the midpoint of my term as SHM president, I reflect upon the strengths that distinguish our specialty and our society from the general malaise of the broader healthcare industry. These strengths compel me to redouble my resolve to deliver on the promise of hospital medicine.

What is that promise? Hospitalists are poised to lead the way toward a better healthcare system in two critical ways. They are situated to help advance quality control and they are uniquely situated to promote medicine as a team effort, a shared vision with the hospital.

Now, quality control and teamwork are not in the standard curriculum. Medical school training focuses on disease. But in the real world of the hospital, quality control and the teamwork it takes to ensure it are vital issues. This is where hospitalists must prove themselves. This is where our special skills align with the priorities of hospital CEOs nationwide. We must advance the quality agenda and engage other physicians in a shared vision with the hospital.

These factors set us apart from other specialties and allow us to lead from the core of our strength. We lead:

• Through quality rather than narrow professional self-interests;
• While valuing the team over the individual; and
• With openness and inclusiveness to all medical personnel involved patient care, from pharmacists to nurses, to nonphysician providers, to management.

This is our great promise—but only if we exercise it. As the brilliant author and scientist Johann Wolfgang von Goethe cautioned 200 years ago: “Knowing is not enough. We must apply.”

Honesty requires physicians to admit there is sometimes a gap between what we know and what we apply. Many quality metrics measure our performance. For example, we know we must get aspirin to a heart attack victim quickly. But the clinical strides that dictate the care patients ought to get must be moved into the operational area, where optimal care is sometimes lacking.

We next need to work out the systems to ensure that care, turning best practices into routine practice. Hospitalists are in the vanguard on that front, just as other specialties have been on the cutting edge of academic medicine. Our specialty will always need to weigh in on the development and vetting of quality and safety metrics related to hospital care.

We are also poised to advance the implementation and application of systems that drive improvement in those metrics.

Ours is a young specialty—the average hospitalist is 37, the leadership 41. While we have accomplished much in our 10 years of existence, there is much more to do. Hospitalists must meet the extraordinarily high expectations of hospitals and the other physicians who work in them. We must help manage emergency patients, surgical patients, and the in-hospital patient census of primary care physicians.

But there is a shortage of physicians in our specialty because demand is so great. It’s hard to sustain our growth as a specialty and work on quality control at the same time.

 

We are in the financial crosshairs, as well. Administrators want to see value—that is, money saved. But the fact that we see and manage patients does not generate savings per se because insurance companies do not allow reimbursement as such for our services. “Prove your value,” they say. “Show us the money.” That translates into driving down length of stay, cutting nursing expenses, and reducing pharmacy costs though better quality control and more coordinated care.

But administrators also know that to accomplish these goals and bring other physicians on board, their best ally is the hospitalist.

Our patients demand more of us, too. In “Zen and the Art of Physician Autonomy Maintenance” in Annals of Internal Medicine in 2003, author Jim Reinertsen clearly stated the public’s perspective. “You claim that your profession is based on science … now show us that you can use all the science you know, for our benefit,” he writes. He asks us to “join together—as a profession—with our colleagues, in venues large and small to decide on and apply the best science.”

It is the least we can do as physicians. But in practice, working together to apply the best science is difficult.

All of which brings me to my final point: SHM’s commitment to our members. In October, SHM sponsored two summits, the first on healthcare quality, the second on leadership development. Two themes emerged. First, it takes an unwavering commitment to teamwork to accomplish anything of substance. Second, the educational needs of our workforce are tremendous. SHM’s focus on acquiring skills and applying knowledge are the society’s greatest accomplishment and greatest ongoing opportunity. To that end, we are working on four fronts.

First, we are developing alliances with other like-minded organizations such as the Case Management Association of America, the American Nursing Association, the American Hospital Association, and the Institute for Healthcare Improvement. Through these alliances we hope to foster the teams that will improve the monitoring of parameters of hospital care, and the care itself.

Second, we are committed to creating the tools to equip hospitalists to make the changes that will lead to improvements in the front lines of hospital medicine. We have taken several such steps. SHM has developed a discharge checklist for physicians to use before sending patients home or to other facilities. The checklist, somewhat like those used by pilots, ensures nothing is forgotten or overlooked upon discharge. We believe it will become an invaluable tool.

SHM has also added Resource Rooms to our Web site (www.hospitalmedicine.org). Here, our members can look up and download information on disease states like heart failure or venous thromboembolism.

Third, SHM is funding a group of quality-control mentors available to visit hospitals. These mentors will evaluate and advise on quality-control programs at SHM’s expense.

Finally, SHM wants to train its next generation of leaders. Quality control is a never-ending quest; it can always be better. That is what we at SHM strive for. That is what we owe our patients.

All these tools have one goal: Make quality easy. With so many other pressures of physicians and hospital staff, making it easy is also the key to making it work.

“Knowing is not enough,” Goethe said. “We must apply.” I say: “Willing is not enough. We must do.” TH

Dr. Holman is president of SHM.

It’s a refrain I have heard too many times in too many places: “Don’t do it.”

You have probably heard it, too—that plaintive cry from some practicing physicians trying to discourage young people from entering a career in medicine. I understand why so many doctors seem so pessimistic about medicine’s future. They’re grappling with a healthcare industry that struggles with overwhelming complexity. They face unrelenting cost pressures, misaligned incentives and policies, massive shortfalls in quality and service, fragmented systems, and disunity among peers.

I understand the pessimism, but I cannot agree with it. At the midpoint of my term as SHM president, I reflect upon the strengths that distinguish our specialty and our society from the general malaise of the broader healthcare industry. These strengths compel me to redouble my resolve to deliver on the promise of hospital medicine.

What is that promise? Hospitalists are poised to lead the way toward a better healthcare system in two critical ways. They are situated to help advance quality control and they are uniquely situated to promote medicine as a team effort, a shared vision with the hospital.

Now, quality control and teamwork are not in the standard curriculum. Medical school training focuses on disease. But in the real world of the hospital, quality control and the teamwork it takes to ensure it are vital issues. This is where hospitalists must prove themselves. This is where our special skills align with the priorities of hospital CEOs nationwide. We must advance the quality agenda and engage other physicians in a shared vision with the hospital.

These factors set us apart from other specialties and allow us to lead from the core of our strength. We lead:

• Through quality rather than narrow professional self-interests;
• While valuing the team over the individual; and
• With openness and inclusiveness to all medical personnel involved patient care, from pharmacists to nurses, to nonphysician providers, to management.

This is our great promise—but only if we exercise it. As the brilliant author and scientist Johann Wolfgang von Goethe cautioned 200 years ago: “Knowing is not enough. We must apply.”

Honesty requires physicians to admit there is sometimes a gap between what we know and what we apply. Many quality metrics measure our performance. For example, we know we must get aspirin to a heart attack victim quickly. But the clinical strides that dictate the care patients ought to get must be moved into the operational area, where optimal care is sometimes lacking.

We next need to work out the systems to ensure that care, turning best practices into routine practice. Hospitalists are in the vanguard on that front, just as other specialties have been on the cutting edge of academic medicine. Our specialty will always need to weigh in on the development and vetting of quality and safety metrics related to hospital care.

We are also poised to advance the implementation and application of systems that drive improvement in those metrics.

Ours is a young specialty—the average hospitalist is 37, the leadership 41. While we have accomplished much in our 10 years of existence, there is much more to do. Hospitalists must meet the extraordinarily high expectations of hospitals and the other physicians who work in them. We must help manage emergency patients, surgical patients, and the in-hospital patient census of primary care physicians.

But there is a shortage of physicians in our specialty because demand is so great. It’s hard to sustain our growth as a specialty and work on quality control at the same time.

 

We are in the financial crosshairs, as well. Administrators want to see value—that is, money saved. But the fact that we see and manage patients does not generate savings per se because insurance companies do not allow reimbursement as such for our services. “Prove your value,” they say. “Show us the money.” That translates into driving down length of stay, cutting nursing expenses, and reducing pharmacy costs though better quality control and more coordinated care.

But administrators also know that to accomplish these goals and bring other physicians on board, their best ally is the hospitalist.

Our patients demand more of us, too. In “Zen and the Art of Physician Autonomy Maintenance” in Annals of Internal Medicine in 2003, author Jim Reinertsen clearly stated the public’s perspective. “You claim that your profession is based on science … now show us that you can use all the science you know, for our benefit,” he writes. He asks us to “join together—as a profession—with our colleagues, in venues large and small to decide on and apply the best science.”

It is the least we can do as physicians. But in practice, working together to apply the best science is difficult.

All of which brings me to my final point: SHM’s commitment to our members. In October, SHM sponsored two summits, the first on healthcare quality, the second on leadership development. Two themes emerged. First, it takes an unwavering commitment to teamwork to accomplish anything of substance. Second, the educational needs of our workforce are tremendous. SHM’s focus on acquiring skills and applying knowledge are the society’s greatest accomplishment and greatest ongoing opportunity. To that end, we are working on four fronts.

First, we are developing alliances with other like-minded organizations such as the Case Management Association of America, the American Nursing Association, the American Hospital Association, and the Institute for Healthcare Improvement. Through these alliances we hope to foster the teams that will improve the monitoring of parameters of hospital care, and the care itself.

Second, we are committed to creating the tools to equip hospitalists to make the changes that will lead to improvements in the front lines of hospital medicine. We have taken several such steps. SHM has developed a discharge checklist for physicians to use before sending patients home or to other facilities. The checklist, somewhat like those used by pilots, ensures nothing is forgotten or overlooked upon discharge. We believe it will become an invaluable tool.

SHM has also added Resource Rooms to our Web site (www.hospitalmedicine.org). Here, our members can look up and download information on disease states like heart failure or venous thromboembolism.

Third, SHM is funding a group of quality-control mentors available to visit hospitals. These mentors will evaluate and advise on quality-control programs at SHM’s expense.

Finally, SHM wants to train its next generation of leaders. Quality control is a never-ending quest; it can always be better. That is what we at SHM strive for. That is what we owe our patients.

All these tools have one goal: Make quality easy. With so many other pressures of physicians and hospital staff, making it easy is also the key to making it work.

“Knowing is not enough,” Goethe said. “We must apply.” I say: “Willing is not enough. We must do.” TH

Dr. Holman is president of SHM.

Twenty years before the term “hospitalist” was coined, and not long after serving as a battlefield surgeon in Vietnam, Tracy Spencer III, MD, selected a path few—if any—had chosen before.

Fresh from his combat experience, he became chief resident at the University of Colorado School of Medicine in Denver in 1975. He dreaded clinic hours but enjoyed the hospital. The flash, dash, and adrenaline of battlefield medicine were still in his blood; he wanted challenges.

“I didn’t want an outpatient practice with the overhead of an office,” says Dr. Spencer, 63, “I wanted to do internal medicine in a hospital setting. I had tons of energy to deal with the unassigned patients who came in the ER, and [I liked] the idea of being a hospital-based physician.”

He began searching for the right setting for his skills and temperament. Eventually, the third-generation physician made a bold leap—he started a hospital-based internal medicine practice in Everett, Wash.

Grass-roots Campaign

In 1976, Dr. Spencer knocked on lots of doors and convinced scores of Everett’s primary care physicians that his caring for their hospitalized patients would free them to build their practices. Although many of those physicians thought it bizarre that Dr. Spencer had no outpatients, they readily turned over their inpatients to him.

“I believe he was one of the first, if not the first, hospitalist in the state of Washington, and perhaps the country,” says John Cramer, MD, MBA, an intern at the University of Colorado 1974-1975 when Dr. Spencer was chief resident. Their relationship has endured more than three decades—with a twist. Now the former intern, who joined Dr. Spencer as a hospitalist in 1979, supervises his former boss in the growing 32-physician hospitalist group at Providence Everett Medical Center.

“Tracy is a member of the team, dispensing wisdom to the younger docs,” says Dr. Cramer. “I have never seen him happier professionally than he is now.”

Early Influence

Dr. Spencer’s medical training and early experiences shed light on how he came to be an inpatient physician two decades before hospitalist medicine formally emerged.

Theodore Woodward, MD, nominated for a Nobel Prize in 1948 for his work on typhus and typhoid, was Dr. Spencer’s professor at the University of Maryland, Baltimore. He impressed Dr. Woodward with “an old-fashioned, knowledge-based, and holistic approach to patients.”

Later, Thomas Petty, MD, an eminent pulmonologist who headed a respiratory team at the University of Colorado Medical Center and became chairman of the National Lung Educational Program, introduced the young physician to a team-based approach to hospital care. During his 1968-1969 internship at the University of Colorado under Dr. Petty, Dr. Spencer found he enjoyed working on a hospital team and the discipline of the hospital hierarchy.

After graduating from medical school, Dr. Spencer was drafted in 1970 by the Marines and was sent to Dà Nang, Vietnam. As a regimental doctor, he worked alone—and didn’t like it. “There was no collegiality for field combat docs,” he recalls. “There were ship-based specialists who didn’t even talk to us. The most serious cases we triaged were [taken] to the ship, and I didn’t see them again. I was dissatisfied and felt that the doctors in the field deserved more respect.”

Maurice Ramirez, DO, an emergency physician and federal medical officer with the Department of Homeland Security, suggests the military’s command structure may have influenced Dr. Spencer more than he realizes. “Before hospitalist medicine, physicians were like British aristocrats in their fiefdoms, ordering their lessers about,” explains Dr. Ramirez. “[The] hospitalist movement has changed all that.”

 

Turning Point

Dr. Spencer returned from his tour of duty and began his chief resident stint at the University of Colorado in 1975.

That year, Boyd Bigelow, MD, “a maverick with a plane” by Dr. Spencer’s account, hired him to admit and manage patients at Denver’s St. Anthony’s Central Hospital, which had no house staff. “To compete with big hospitals, we’d fly referrals into Stapleton [Air Force Base],” Dr. Spencer says. Dr. Bigelow became medical director of Flight for Life, the first civilian airborne emergency medical service, which has flown more than 65,000 patients to critical care facilities. He would swoop down from the sky through Colorado’s whirling snow, delivering patients to Dr. Spencer.

In 1976 Dr. Spencer took stock of his career and recognized he wanted to be a hospital-based physician. He contacted John Hoidal, MD, from his University of Colorado days, expecting to buddy up, move both of their families to Everett, and cover inpatients at two hospitals 24/7. But Dr. Hoidal chose not to go.

“It would have been easier if the two of us had started the hospitalist practice together, but it wasn’t right for him,” says Dr. Spencer. “I saw that I could do it on my own. I had energy to burn and ambition to succeed.”

Undaunted, he soldiered on to Everett.

“It is an absolutely gorgeous place to live,” he says. “When we arrived I found Everett loaded with GPs in their busy offices, and I had the expertise they needed to manage their inpatients. I hooked them with my three A’s: availability, affability, and ability.”

Everett Hospital hired him to provide 24/7 coverage for respiratory care, the intensive care unit, medical/surgical consults, and overall inpatient management. He worked solo for more than a year and grew exhausted. He hired a second physician in 1977, then Dr. Cramer in 1979.

Also in 1977, Dr. Spencer forged what has become a 30-year professional relationship with Eric Larson, MD, MPH, executive director of the Center for Health Studies Group in Everett.

“In 1977 I was chief resident at Providence General [which merged with Everett Hospital to become Providence Everett Medical Center in 1994],” Dr. Larson says. “Tracy introduced himself as a hospitalist and said he took care of patients in the hospital for GPs. It seemed like an interesting solo practice model.”

What struck Dr. Larson at the time was the contrast between the commotion of a teaching hospital with medical students, interns, residents, and attendings “tripping all over each other” and Dr. Spencer’s approach.

“He embodied the principle of keeping things simple and was organized and methodical in his approach to patients,” Dr. Larson says. “He was superb in pulmonary medicine and the ICU.”

Challenging Times

The hospitalist practice and Everett’s medical community kept growing through the early ’80s, with specialists joining general practitioners in using Dr. Spencer’s group for consults and co-management. Then came managed care in the mid-’80s, and the hospitalists’ gains seemed threatened. “Managed care’s tight controls and preauthorizes of inpatient services were terribly frustrating,” says Dr. Larson. Dr. Spencer found himself competing for managed-care contracts rather than seeing patients.

By the time managed care loosened its grip in the 1990s and the hospitalist movement was officially launched, there were new challenges and frustrations. Dr. Spencer felt worn out administrating rather than doctoring. Dr. Larson felt something else: futility. “One of the hardest things about being a hospitalist is dealing with the futility of treating old people with multiple co-morbidities who shouldn’t even be in a hospital,” explains Dr. Larson. “Hospitals are now so protocolized. Once a patient gets in the hospital he’s almost on automatic.”

 

Frustrated and tired 25 years after becoming the first hospitalist, Dr. Spencer retired in April 2001. Then he realized he wasn’t finished with medicine. Six months later he joined the hospitalist cadre led by his former intern, Dr. Cramer, at the Everett Clinic, a multispecialty group with 250 physicians and 65 midlevel providers.

Putting 30 years of hospitalist experience to work, Dr. Spencer recruits young hospitalists, teaches best practices, and continues to build relationships with general practitioners and specialists. From his unique vantage point, he sees hospital medicine as a maturing discipline gone mainstream.

“There’s still so much to do,” he says. He plans to explore a variety of hospitalist growth areas, such as efficient use of diagnostic testing, higher intensity medicine with patients of markedly higher acuity, step-down cardiac telemetry, more involvement with ICUs, and managing complex patients living with multiple co-morbidities.

But Dr. Ramirez says that with all he’s already accomplished, Dr. Spencer has earned a place of note: “I hope that hospitalists recognize he was three decades and six generations of physicians ahead of his time.” TH

Marlene Piturro is a medical writer based in New York.

Twenty years before the term “hospitalist” was coined, and not long after serving as a battlefield surgeon in Vietnam, Tracy Spencer III, MD, selected a path few—if any—had chosen before.

Fresh from his combat experience, he became chief resident at the University of Colorado School of Medicine in Denver in 1975. He dreaded clinic hours but enjoyed the hospital. The flash, dash, and adrenaline of battlefield medicine were still in his blood; he wanted challenges.

“I didn’t want an outpatient practice with the overhead of an office,” says Dr. Spencer, 63, “I wanted to do internal medicine in a hospital setting. I had tons of energy to deal with the unassigned patients who came in the ER, and [I liked] the idea of being a hospital-based physician.”

He began searching for the right setting for his skills and temperament. Eventually, the third-generation physician made a bold leap—he started a hospital-based internal medicine practice in Everett, Wash.

Grass-roots Campaign

In 1976, Dr. Spencer knocked on lots of doors and convinced scores of Everett’s primary care physicians that his caring for their hospitalized patients would free them to build their practices. Although many of those physicians thought it bizarre that Dr. Spencer had no outpatients, they readily turned over their inpatients to him.

“I believe he was one of the first, if not the first, hospitalist in the state of Washington, and perhaps the country,” says John Cramer, MD, MBA, an intern at the University of Colorado 1974-1975 when Dr. Spencer was chief resident. Their relationship has endured more than three decades—with a twist. Now the former intern, who joined Dr. Spencer as a hospitalist in 1979, supervises his former boss in the growing 32-physician hospitalist group at Providence Everett Medical Center.

“Tracy is a member of the team, dispensing wisdom to the younger docs,” says Dr. Cramer. “I have never seen him happier professionally than he is now.”

Early Influence

Dr. Spencer’s medical training and early experiences shed light on how he came to be an inpatient physician two decades before hospitalist medicine formally emerged.

Theodore Woodward, MD, nominated for a Nobel Prize in 1948 for his work on typhus and typhoid, was Dr. Spencer’s professor at the University of Maryland, Baltimore. He impressed Dr. Woodward with “an old-fashioned, knowledge-based, and holistic approach to patients.”

Later, Thomas Petty, MD, an eminent pulmonologist who headed a respiratory team at the University of Colorado Medical Center and became chairman of the National Lung Educational Program, introduced the young physician to a team-based approach to hospital care. During his 1968-1969 internship at the University of Colorado under Dr. Petty, Dr. Spencer found he enjoyed working on a hospital team and the discipline of the hospital hierarchy.

After graduating from medical school, Dr. Spencer was drafted in 1970 by the Marines and was sent to Dà Nang, Vietnam. As a regimental doctor, he worked alone—and didn’t like it. “There was no collegiality for field combat docs,” he recalls. “There were ship-based specialists who didn’t even talk to us. The most serious cases we triaged were [taken] to the ship, and I didn’t see them again. I was dissatisfied and felt that the doctors in the field deserved more respect.”

Maurice Ramirez, DO, an emergency physician and federal medical officer with the Department of Homeland Security, suggests the military’s command structure may have influenced Dr. Spencer more than he realizes. “Before hospitalist medicine, physicians were like British aristocrats in their fiefdoms, ordering their lessers about,” explains Dr. Ramirez. “[The] hospitalist movement has changed all that.”

 

Turning Point

Dr. Spencer returned from his tour of duty and began his chief resident stint at the University of Colorado in 1975.

That year, Boyd Bigelow, MD, “a maverick with a plane” by Dr. Spencer’s account, hired him to admit and manage patients at Denver’s St. Anthony’s Central Hospital, which had no house staff. “To compete with big hospitals, we’d fly referrals into Stapleton [Air Force Base],” Dr. Spencer says. Dr. Bigelow became medical director of Flight for Life, the first civilian airborne emergency medical service, which has flown more than 65,000 patients to critical care facilities. He would swoop down from the sky through Colorado’s whirling snow, delivering patients to Dr. Spencer.

In 1976 Dr. Spencer took stock of his career and recognized he wanted to be a hospital-based physician. He contacted John Hoidal, MD, from his University of Colorado days, expecting to buddy up, move both of their families to Everett, and cover inpatients at two hospitals 24/7. But Dr. Hoidal chose not to go.

“It would have been easier if the two of us had started the hospitalist practice together, but it wasn’t right for him,” says Dr. Spencer. “I saw that I could do it on my own. I had energy to burn and ambition to succeed.”

Undaunted, he soldiered on to Everett.

“It is an absolutely gorgeous place to live,” he says. “When we arrived I found Everett loaded with GPs in their busy offices, and I had the expertise they needed to manage their inpatients. I hooked them with my three A’s: availability, affability, and ability.”

Everett Hospital hired him to provide 24/7 coverage for respiratory care, the intensive care unit, medical/surgical consults, and overall inpatient management. He worked solo for more than a year and grew exhausted. He hired a second physician in 1977, then Dr. Cramer in 1979.

Also in 1977, Dr. Spencer forged what has become a 30-year professional relationship with Eric Larson, MD, MPH, executive director of the Center for Health Studies Group in Everett.

“In 1977 I was chief resident at Providence General [which merged with Everett Hospital to become Providence Everett Medical Center in 1994],” Dr. Larson says. “Tracy introduced himself as a hospitalist and said he took care of patients in the hospital for GPs. It seemed like an interesting solo practice model.”

What struck Dr. Larson at the time was the contrast between the commotion of a teaching hospital with medical students, interns, residents, and attendings “tripping all over each other” and Dr. Spencer’s approach.

“He embodied the principle of keeping things simple and was organized and methodical in his approach to patients,” Dr. Larson says. “He was superb in pulmonary medicine and the ICU.”

Challenging Times

The hospitalist practice and Everett’s medical community kept growing through the early ’80s, with specialists joining general practitioners in using Dr. Spencer’s group for consults and co-management. Then came managed care in the mid-’80s, and the hospitalists’ gains seemed threatened. “Managed care’s tight controls and preauthorizes of inpatient services were terribly frustrating,” says Dr. Larson. Dr. Spencer found himself competing for managed-care contracts rather than seeing patients.

By the time managed care loosened its grip in the 1990s and the hospitalist movement was officially launched, there were new challenges and frustrations. Dr. Spencer felt worn out administrating rather than doctoring. Dr. Larson felt something else: futility. “One of the hardest things about being a hospitalist is dealing with the futility of treating old people with multiple co-morbidities who shouldn’t even be in a hospital,” explains Dr. Larson. “Hospitals are now so protocolized. Once a patient gets in the hospital he’s almost on automatic.”

 

Frustrated and tired 25 years after becoming the first hospitalist, Dr. Spencer retired in April 2001. Then he realized he wasn’t finished with medicine. Six months later he joined the hospitalist cadre led by his former intern, Dr. Cramer, at the Everett Clinic, a multispecialty group with 250 physicians and 65 midlevel providers.

Putting 30 years of hospitalist experience to work, Dr. Spencer recruits young hospitalists, teaches best practices, and continues to build relationships with general practitioners and specialists. From his unique vantage point, he sees hospital medicine as a maturing discipline gone mainstream.

“There’s still so much to do,” he says. He plans to explore a variety of hospitalist growth areas, such as efficient use of diagnostic testing, higher intensity medicine with patients of markedly higher acuity, step-down cardiac telemetry, more involvement with ICUs, and managing complex patients living with multiple co-morbidities.

But Dr. Ramirez says that with all he’s already accomplished, Dr. Spencer has earned a place of note: “I hope that hospitalists recognize he was three decades and six generations of physicians ahead of his time.” TH

Marlene Piturro is a medical writer based in New York.

Twenty years before the term “hospitalist” was coined, and not long after serving as a battlefield surgeon in Vietnam, Tracy Spencer III, MD, selected a path few—if any—had chosen before.

Fresh from his combat experience, he became chief resident at the University of Colorado School of Medicine in Denver in 1975. He dreaded clinic hours but enjoyed the hospital. The flash, dash, and adrenaline of battlefield medicine were still in his blood; he wanted challenges.

“I didn’t want an outpatient practice with the overhead of an office,” says Dr. Spencer, 63, “I wanted to do internal medicine in a hospital setting. I had tons of energy to deal with the unassigned patients who came in the ER, and [I liked] the idea of being a hospital-based physician.”

He began searching for the right setting for his skills and temperament. Eventually, the third-generation physician made a bold leap—he started a hospital-based internal medicine practice in Everett, Wash.

Grass-roots Campaign

In 1976, Dr. Spencer knocked on lots of doors and convinced scores of Everett’s primary care physicians that his caring for their hospitalized patients would free them to build their practices. Although many of those physicians thought it bizarre that Dr. Spencer had no outpatients, they readily turned over their inpatients to him.

“I believe he was one of the first, if not the first, hospitalist in the state of Washington, and perhaps the country,” says John Cramer, MD, MBA, an intern at the University of Colorado 1974-1975 when Dr. Spencer was chief resident. Their relationship has endured more than three decades—with a twist. Now the former intern, who joined Dr. Spencer as a hospitalist in 1979, supervises his former boss in the growing 32-physician hospitalist group at Providence Everett Medical Center.

“Tracy is a member of the team, dispensing wisdom to the younger docs,” says Dr. Cramer. “I have never seen him happier professionally than he is now.”

Early Influence

Dr. Spencer’s medical training and early experiences shed light on how he came to be an inpatient physician two decades before hospitalist medicine formally emerged.

Theodore Woodward, MD, nominated for a Nobel Prize in 1948 for his work on typhus and typhoid, was Dr. Spencer’s professor at the University of Maryland, Baltimore. He impressed Dr. Woodward with “an old-fashioned, knowledge-based, and holistic approach to patients.”

Later, Thomas Petty, MD, an eminent pulmonologist who headed a respiratory team at the University of Colorado Medical Center and became chairman of the National Lung Educational Program, introduced the young physician to a team-based approach to hospital care. During his 1968-1969 internship at the University of Colorado under Dr. Petty, Dr. Spencer found he enjoyed working on a hospital team and the discipline of the hospital hierarchy.

After graduating from medical school, Dr. Spencer was drafted in 1970 by the Marines and was sent to Dà Nang, Vietnam. As a regimental doctor, he worked alone—and didn’t like it. “There was no collegiality for field combat docs,” he recalls. “There were ship-based specialists who didn’t even talk to us. The most serious cases we triaged were [taken] to the ship, and I didn’t see them again. I was dissatisfied and felt that the doctors in the field deserved more respect.”

Maurice Ramirez, DO, an emergency physician and federal medical officer with the Department of Homeland Security, suggests the military’s command structure may have influenced Dr. Spencer more than he realizes. “Before hospitalist medicine, physicians were like British aristocrats in their fiefdoms, ordering their lessers about,” explains Dr. Ramirez. “[The] hospitalist movement has changed all that.”

 

Turning Point

Dr. Spencer returned from his tour of duty and began his chief resident stint at the University of Colorado in 1975.

That year, Boyd Bigelow, MD, “a maverick with a plane” by Dr. Spencer’s account, hired him to admit and manage patients at Denver’s St. Anthony’s Central Hospital, which had no house staff. “To compete with big hospitals, we’d fly referrals into Stapleton [Air Force Base],” Dr. Spencer says. Dr. Bigelow became medical director of Flight for Life, the first civilian airborne emergency medical service, which has flown more than 65,000 patients to critical care facilities. He would swoop down from the sky through Colorado’s whirling snow, delivering patients to Dr. Spencer.

In 1976 Dr. Spencer took stock of his career and recognized he wanted to be a hospital-based physician. He contacted John Hoidal, MD, from his University of Colorado days, expecting to buddy up, move both of their families to Everett, and cover inpatients at two hospitals 24/7. But Dr. Hoidal chose not to go.

“It would have been easier if the two of us had started the hospitalist practice together, but it wasn’t right for him,” says Dr. Spencer. “I saw that I could do it on my own. I had energy to burn and ambition to succeed.”

Undaunted, he soldiered on to Everett.

“It is an absolutely gorgeous place to live,” he says. “When we arrived I found Everett loaded with GPs in their busy offices, and I had the expertise they needed to manage their inpatients. I hooked them with my three A’s: availability, affability, and ability.”

Everett Hospital hired him to provide 24/7 coverage for respiratory care, the intensive care unit, medical/surgical consults, and overall inpatient management. He worked solo for more than a year and grew exhausted. He hired a second physician in 1977, then Dr. Cramer in 1979.

Also in 1977, Dr. Spencer forged what has become a 30-year professional relationship with Eric Larson, MD, MPH, executive director of the Center for Health Studies Group in Everett.

“In 1977 I was chief resident at Providence General [which merged with Everett Hospital to become Providence Everett Medical Center in 1994],” Dr. Larson says. “Tracy introduced himself as a hospitalist and said he took care of patients in the hospital for GPs. It seemed like an interesting solo practice model.”

What struck Dr. Larson at the time was the contrast between the commotion of a teaching hospital with medical students, interns, residents, and attendings “tripping all over each other” and Dr. Spencer’s approach.

“He embodied the principle of keeping things simple and was organized and methodical in his approach to patients,” Dr. Larson says. “He was superb in pulmonary medicine and the ICU.”

Challenging Times

The hospitalist practice and Everett’s medical community kept growing through the early ’80s, with specialists joining general practitioners in using Dr. Spencer’s group for consults and co-management. Then came managed care in the mid-’80s, and the hospitalists’ gains seemed threatened. “Managed care’s tight controls and preauthorizes of inpatient services were terribly frustrating,” says Dr. Larson. Dr. Spencer found himself competing for managed-care contracts rather than seeing patients.

By the time managed care loosened its grip in the 1990s and the hospitalist movement was officially launched, there were new challenges and frustrations. Dr. Spencer felt worn out administrating rather than doctoring. Dr. Larson felt something else: futility. “One of the hardest things about being a hospitalist is dealing with the futility of treating old people with multiple co-morbidities who shouldn’t even be in a hospital,” explains Dr. Larson. “Hospitals are now so protocolized. Once a patient gets in the hospital he’s almost on automatic.”

 

Frustrated and tired 25 years after becoming the first hospitalist, Dr. Spencer retired in April 2001. Then he realized he wasn’t finished with medicine. Six months later he joined the hospitalist cadre led by his former intern, Dr. Cramer, at the Everett Clinic, a multispecialty group with 250 physicians and 65 midlevel providers.

Putting 30 years of hospitalist experience to work, Dr. Spencer recruits young hospitalists, teaches best practices, and continues to build relationships with general practitioners and specialists. From his unique vantage point, he sees hospital medicine as a maturing discipline gone mainstream.

“There’s still so much to do,” he says. He plans to explore a variety of hospitalist growth areas, such as efficient use of diagnostic testing, higher intensity medicine with patients of markedly higher acuity, step-down cardiac telemetry, more involvement with ICUs, and managing complex patients living with multiple co-morbidities.

But Dr. Ramirez says that with all he’s already accomplished, Dr. Spencer has earned a place of note: “I hope that hospitalists recognize he was three decades and six generations of physicians ahead of his time.” TH

Marlene Piturro is a medical writer based in New York.

Were you born at “the Beth?” Generations are proud to have entered the world at Newark Beth Israel Medical Center, a 673-bed teaching hospital that offers comprehensive healthcare to its communities and is a major referral and treatment center for patients throughout the northern New Jersey metropolitan area.

The lively history of Newark Beth Israel Medical Center, an affiliate of the Saint Barnabas Health Care System, is typical of the histories of the voluntary nonprofit Jewish hospitals in the United States from the mid-19th to mid-20th centuries.

The Need for Healthcare

At the turn of the 20th century, Newark, N.J. was a city filled with tanneries, breweries, varnish factories, fine silver manufacturers, and inventors who hoped to emulate its most famous resident—Thomas Edison.

City officials struggled to overcome the myriad industrial accidents, sanitation problems, and epidemics of diphtheria, typhus, and smallpox that had made Newark the nation’s unhealthiest city.

With population exceeding 100,000 in the 1890 census, Newark would endure one of the first outbreaks of polio in 1916. Because of its proximity to Fort Dix, the city was an epicenter of the 1918 influenza pandemic.

On Oct. 22, 1900, Newark residents first learned of the possibility of a Jewish hospital when newsboys held up copies of the Newark Evening News and shouted, “There’s Trouble in the Beth Israel Hospital Association!” When the men of the association voted to open a storefront dispensary, the women broke away, renaming themselves the Daughters of Israel and purchasing a crumbling mansion that opened as a 28-bed hospital on Aug. 31, 1902. For six years, the dispensary and hospital operated separate facilities. They merged their services in 1908, when a 110-bed, four-story facility opened on the site of the old mansion.

Expression of Assimilation

“They come to the United States, eager to breathe the air of freedom, anxious to repay the country for this blessing that she offers,” said Reform Rabbi Solomon Foster at the dedication ceremony Jan. 30, 1908. For the Eastern European Jews who passed through Ellis Island from 1880 to 1920, the founding of a Jewish hospital became their expression of becoming Americans.

In Newark, more than 87 Jewish societies, workmen’s lodges, and synagogues provided funds for the hospital. The 1908 opening was celebrated with a massive parade through the immigrant neighborhood, where tenements were festooned with American flag bunting.

The Beth practiced a nonsectarian policy in hospital admissions, the extension of hospital privileges to doctors, and the hiring of hospital staff. “While this hospital will be mainly supported by Jews, it will open its doors just as wide as they can swing to receive all who may desire to enter, and his religious sentiments shall be carefully safeguarded,” the policy stated. Kosher meals were available upon request, and Christmas decorations were displayed to cheer patients.

Community-based Care

In 1924, a new, modern image of the hospital appeared on billboards and newspapers: Miss Beth, who launched a campaign for a new hospital with the question: “Is your heart with the hospital?”

The third hospital—a 350-bed yellow-brick tower with a Spanish tile roof—rose nearly 200 feet from its foundation like a sentinel beckoning its community. The new hospital opened in 1928, relocated from the city center to the southern tip of the city north of Lake Weequahic.

 

The Jewish community followed its hospital to settle in the surrounding streets, transforming it into a vibrant Jewish neighborhood celebrated by Philip Roth in his many novels about Newark.

The Beth was committed to providing training and research opportunities to doctors—Jewish and non-Jewish—who were denied privileges at other hospitals early in the 20th century.

The commitment to providing high-caliber training was evident in its accreditation from the American College of Surgeons in 1919 and the AMA Council approval for the internships in 1921.

By 1930, the laboratory, physical therapy, social work, and dietary departments were offering technical training programs. During World War II, it was designated as one of 1,000 depots that stored penicillin.

During the Great Depression, despite financial difficulties that nearly bankrupted the hospital, the Beth maintained an animal house for research. It was at the Beth that the Rh factor was identified as the cause of erythroblastosis fetalis.

A Laboratory Research Foundation was created to provide funding for research projects and support publication of a hospital journal. The journal published the earliest research results of the Beth Cardiopulmonary Laboratory, which became a leading center for the development of the pacemaker.

In the mid-1960s, as the Newark Jewish community resettled in the outlying New Jersey suburbs, hospital leaders decided to remain on Lyons Avenue and expand into a regional medical center.

Like other industrial cities, Newark suffered through a turbulent decade, requiring the hospital to redefine itself in its mission to serve its neighborhood and waves of immigrants settling into the region.

Federal grant programs and loans from the Prudential Life Insurance Corp. enabled the phased construction of a fourth hospital complex next to the old hospital, providing inpatient and ambulatory care services.

In 1996, Newark Beth Israel Hospital and Medical Center became an affiliate of Barnabas Health Care—New Jersey’s largest integrated healthcare system.

The Beth Today

These days, Newark Beth Israel Hospital and Medical Center is a major teaching affiliate of the Mount Sinai School of Medicine in New York City, the New York College of Osteopathic Medicine in Old Westbury, N.Y, and St. George’s University School of Medicine in Grenada.

The Beth’s division of cardiology continues pioneering work on therapeutic cardiac services and offers the most comprehensive robotic surgical center in the state.

And, honoring a 75-year-old tradition, the center still holds the outreach health screening and health fairs program begun by the Maternity Guild as a citywide public health initiative.

At its inception, the “Born at the Beth” program meant every baby born in the hospital was eligible to join a Babies’ Alumni Club. The $1 annual dues paid on their behalf entitled them to attend an annual babies’ health fair at which they enjoyed Dixie cups of ice cream and free examinations from the hospital staff. Now, the hospital offers the Born at the Beth Wall of Recognition to pay tribute to all those who greeted life within the hospital’s walls.

The Star of David remains at the front entrance, an enduring symbol of the hospital’s heritage. And the hospital’s creed—first displayed in 1928—still asserts the commitment of its staff: “The value of the human touch as a power for healing is never lost sight of at Beth Israel.” TH

The Krauts are coauthors of “Covenant of Care: Newark Beth Israel Hospital and the Jewish Hospital in America.”

Were you born at “the Beth?” Generations are proud to have entered the world at Newark Beth Israel Medical Center, a 673-bed teaching hospital that offers comprehensive healthcare to its communities and is a major referral and treatment center for patients throughout the northern New Jersey metropolitan area.

The lively history of Newark Beth Israel Medical Center, an affiliate of the Saint Barnabas Health Care System, is typical of the histories of the voluntary nonprofit Jewish hospitals in the United States from the mid-19th to mid-20th centuries.

The Need for Healthcare

At the turn of the 20th century, Newark, N.J. was a city filled with tanneries, breweries, varnish factories, fine silver manufacturers, and inventors who hoped to emulate its most famous resident—Thomas Edison.

City officials struggled to overcome the myriad industrial accidents, sanitation problems, and epidemics of diphtheria, typhus, and smallpox that had made Newark the nation’s unhealthiest city.

With population exceeding 100,000 in the 1890 census, Newark would endure one of the first outbreaks of polio in 1916. Because of its proximity to Fort Dix, the city was an epicenter of the 1918 influenza pandemic.

On Oct. 22, 1900, Newark residents first learned of the possibility of a Jewish hospital when newsboys held up copies of the Newark Evening News and shouted, “There’s Trouble in the Beth Israel Hospital Association!” When the men of the association voted to open a storefront dispensary, the women broke away, renaming themselves the Daughters of Israel and purchasing a crumbling mansion that opened as a 28-bed hospital on Aug. 31, 1902. For six years, the dispensary and hospital operated separate facilities. They merged their services in 1908, when a 110-bed, four-story facility opened on the site of the old mansion.

Expression of Assimilation

“They come to the United States, eager to breathe the air of freedom, anxious to repay the country for this blessing that she offers,” said Reform Rabbi Solomon Foster at the dedication ceremony Jan. 30, 1908. For the Eastern European Jews who passed through Ellis Island from 1880 to 1920, the founding of a Jewish hospital became their expression of becoming Americans.

In Newark, more than 87 Jewish societies, workmen’s lodges, and synagogues provided funds for the hospital. The 1908 opening was celebrated with a massive parade through the immigrant neighborhood, where tenements were festooned with American flag bunting.

The Beth practiced a nonsectarian policy in hospital admissions, the extension of hospital privileges to doctors, and the hiring of hospital staff. “While this hospital will be mainly supported by Jews, it will open its doors just as wide as they can swing to receive all who may desire to enter, and his religious sentiments shall be carefully safeguarded,” the policy stated. Kosher meals were available upon request, and Christmas decorations were displayed to cheer patients.

Community-based Care

In 1924, a new, modern image of the hospital appeared on billboards and newspapers: Miss Beth, who launched a campaign for a new hospital with the question: “Is your heart with the hospital?”

The third hospital—a 350-bed yellow-brick tower with a Spanish tile roof—rose nearly 200 feet from its foundation like a sentinel beckoning its community. The new hospital opened in 1928, relocated from the city center to the southern tip of the city north of Lake Weequahic.

 

The Jewish community followed its hospital to settle in the surrounding streets, transforming it into a vibrant Jewish neighborhood celebrated by Philip Roth in his many novels about Newark.

The Beth was committed to providing training and research opportunities to doctors—Jewish and non-Jewish—who were denied privileges at other hospitals early in the 20th century.

The commitment to providing high-caliber training was evident in its accreditation from the American College of Surgeons in 1919 and the AMA Council approval for the internships in 1921.

By 1930, the laboratory, physical therapy, social work, and dietary departments were offering technical training programs. During World War II, it was designated as one of 1,000 depots that stored penicillin.

During the Great Depression, despite financial difficulties that nearly bankrupted the hospital, the Beth maintained an animal house for research. It was at the Beth that the Rh factor was identified as the cause of erythroblastosis fetalis.

A Laboratory Research Foundation was created to provide funding for research projects and support publication of a hospital journal. The journal published the earliest research results of the Beth Cardiopulmonary Laboratory, which became a leading center for the development of the pacemaker.

In the mid-1960s, as the Newark Jewish community resettled in the outlying New Jersey suburbs, hospital leaders decided to remain on Lyons Avenue and expand into a regional medical center.

Like other industrial cities, Newark suffered through a turbulent decade, requiring the hospital to redefine itself in its mission to serve its neighborhood and waves of immigrants settling into the region.

Federal grant programs and loans from the Prudential Life Insurance Corp. enabled the phased construction of a fourth hospital complex next to the old hospital, providing inpatient and ambulatory care services.

In 1996, Newark Beth Israel Hospital and Medical Center became an affiliate of Barnabas Health Care—New Jersey’s largest integrated healthcare system.

The Beth Today

These days, Newark Beth Israel Hospital and Medical Center is a major teaching affiliate of the Mount Sinai School of Medicine in New York City, the New York College of Osteopathic Medicine in Old Westbury, N.Y, and St. George’s University School of Medicine in Grenada.

The Beth’s division of cardiology continues pioneering work on therapeutic cardiac services and offers the most comprehensive robotic surgical center in the state.

And, honoring a 75-year-old tradition, the center still holds the outreach health screening and health fairs program begun by the Maternity Guild as a citywide public health initiative.

At its inception, the “Born at the Beth” program meant every baby born in the hospital was eligible to join a Babies’ Alumni Club. The $1 annual dues paid on their behalf entitled them to attend an annual babies’ health fair at which they enjoyed Dixie cups of ice cream and free examinations from the hospital staff. Now, the hospital offers the Born at the Beth Wall of Recognition to pay tribute to all those who greeted life within the hospital’s walls.

The Star of David remains at the front entrance, an enduring symbol of the hospital’s heritage. And the hospital’s creed—first displayed in 1928—still asserts the commitment of its staff: “The value of the human touch as a power for healing is never lost sight of at Beth Israel.” TH

The Krauts are coauthors of “Covenant of Care: Newark Beth Israel Hospital and the Jewish Hospital in America.”

Were you born at “the Beth?” Generations are proud to have entered the world at Newark Beth Israel Medical Center, a 673-bed teaching hospital that offers comprehensive healthcare to its communities and is a major referral and treatment center for patients throughout the northern New Jersey metropolitan area.

The lively history of Newark Beth Israel Medical Center, an affiliate of the Saint Barnabas Health Care System, is typical of the histories of the voluntary nonprofit Jewish hospitals in the United States from the mid-19th to mid-20th centuries.

The Need for Healthcare

At the turn of the 20th century, Newark, N.J. was a city filled with tanneries, breweries, varnish factories, fine silver manufacturers, and inventors who hoped to emulate its most famous resident—Thomas Edison.

City officials struggled to overcome the myriad industrial accidents, sanitation problems, and epidemics of diphtheria, typhus, and smallpox that had made Newark the nation’s unhealthiest city.

With population exceeding 100,000 in the 1890 census, Newark would endure one of the first outbreaks of polio in 1916. Because of its proximity to Fort Dix, the city was an epicenter of the 1918 influenza pandemic.

On Oct. 22, 1900, Newark residents first learned of the possibility of a Jewish hospital when newsboys held up copies of the Newark Evening News and shouted, “There’s Trouble in the Beth Israel Hospital Association!” When the men of the association voted to open a storefront dispensary, the women broke away, renaming themselves the Daughters of Israel and purchasing a crumbling mansion that opened as a 28-bed hospital on Aug. 31, 1902. For six years, the dispensary and hospital operated separate facilities. They merged their services in 1908, when a 110-bed, four-story facility opened on the site of the old mansion.

Expression of Assimilation

“They come to the United States, eager to breathe the air of freedom, anxious to repay the country for this blessing that she offers,” said Reform Rabbi Solomon Foster at the dedication ceremony Jan. 30, 1908. For the Eastern European Jews who passed through Ellis Island from 1880 to 1920, the founding of a Jewish hospital became their expression of becoming Americans.

In Newark, more than 87 Jewish societies, workmen’s lodges, and synagogues provided funds for the hospital. The 1908 opening was celebrated with a massive parade through the immigrant neighborhood, where tenements were festooned with American flag bunting.

The Beth practiced a nonsectarian policy in hospital admissions, the extension of hospital privileges to doctors, and the hiring of hospital staff. “While this hospital will be mainly supported by Jews, it will open its doors just as wide as they can swing to receive all who may desire to enter, and his religious sentiments shall be carefully safeguarded,” the policy stated. Kosher meals were available upon request, and Christmas decorations were displayed to cheer patients.

Community-based Care

In 1924, a new, modern image of the hospital appeared on billboards and newspapers: Miss Beth, who launched a campaign for a new hospital with the question: “Is your heart with the hospital?”

The third hospital—a 350-bed yellow-brick tower with a Spanish tile roof—rose nearly 200 feet from its foundation like a sentinel beckoning its community. The new hospital opened in 1928, relocated from the city center to the southern tip of the city north of Lake Weequahic.

 

The Jewish community followed its hospital to settle in the surrounding streets, transforming it into a vibrant Jewish neighborhood celebrated by Philip Roth in his many novels about Newark.

The Beth was committed to providing training and research opportunities to doctors—Jewish and non-Jewish—who were denied privileges at other hospitals early in the 20th century.

The commitment to providing high-caliber training was evident in its accreditation from the American College of Surgeons in 1919 and the AMA Council approval for the internships in 1921.

By 1930, the laboratory, physical therapy, social work, and dietary departments were offering technical training programs. During World War II, it was designated as one of 1,000 depots that stored penicillin.

During the Great Depression, despite financial difficulties that nearly bankrupted the hospital, the Beth maintained an animal house for research. It was at the Beth that the Rh factor was identified as the cause of erythroblastosis fetalis.

A Laboratory Research Foundation was created to provide funding for research projects and support publication of a hospital journal. The journal published the earliest research results of the Beth Cardiopulmonary Laboratory, which became a leading center for the development of the pacemaker.

In the mid-1960s, as the Newark Jewish community resettled in the outlying New Jersey suburbs, hospital leaders decided to remain on Lyons Avenue and expand into a regional medical center.

Like other industrial cities, Newark suffered through a turbulent decade, requiring the hospital to redefine itself in its mission to serve its neighborhood and waves of immigrants settling into the region.

Federal grant programs and loans from the Prudential Life Insurance Corp. enabled the phased construction of a fourth hospital complex next to the old hospital, providing inpatient and ambulatory care services.

In 1996, Newark Beth Israel Hospital and Medical Center became an affiliate of Barnabas Health Care—New Jersey’s largest integrated healthcare system.

The Beth Today

These days, Newark Beth Israel Hospital and Medical Center is a major teaching affiliate of the Mount Sinai School of Medicine in New York City, the New York College of Osteopathic Medicine in Old Westbury, N.Y, and St. George’s University School of Medicine in Grenada.

The Beth’s division of cardiology continues pioneering work on therapeutic cardiac services and offers the most comprehensive robotic surgical center in the state.

And, honoring a 75-year-old tradition, the center still holds the outreach health screening and health fairs program begun by the Maternity Guild as a citywide public health initiative.

At its inception, the “Born at the Beth” program meant every baby born in the hospital was eligible to join a Babies’ Alumni Club. The $1 annual dues paid on their behalf entitled them to attend an annual babies’ health fair at which they enjoyed Dixie cups of ice cream and free examinations from the hospital staff. Now, the hospital offers the Born at the Beth Wall of Recognition to pay tribute to all those who greeted life within the hospital’s walls.

The Star of David remains at the front entrance, an enduring symbol of the hospital’s heritage. And the hospital’s creed—first displayed in 1928—still asserts the commitment of its staff: “The value of the human touch as a power for healing is never lost sight of at Beth Israel.” TH

The Krauts are coauthors of “Covenant of Care: Newark Beth Israel Hospital and the Jewish Hospital in America.”