How does your hospitalist group make decisions on important issues? There are many reasonable approaches. The best method will vary significantly depending on the group’s size and whether the doctors own their own private practice or are employees of a hospital or large multisite private hospitalist group.

Because many doctors are drawn to the profession in part seeking autonomy and independence, there is often a tension between their desire to make many decisions about business and practice operations independently and the need to set aside some personal interests in order for the group to function well. This can become apparent when the group reaches an agreement regarding a difficult issue for which there are different points of view.

Consider a hospitalist group made up of internists occasionally asked to admit teenagers younger than 17. There might be a variety of opinions about whether this is appropriate, but it will be best for everyone in the group to follow the same policy. If the majority decision is that it is reasonable to admit patients as long as they’re post-pubertal, everyone in the group should abide by this policy.

But when called by the emergency department about such a patient, a dissenting hospitalist might feel entitled to decline the admission despite the group’s decision. For this doctor, autonomy trumps cohesive group functioning.

The best approach to individual doctors not feeling bound by the group’s decisions is complex and will vary depending on the situation. But it can be mitigated by ensuring that the group has a clear governance structure and method for reaching controversial decisions.

Group Size Matters

A look at hospitalist groups of varying sizes illustrates the growing complexity of decision-making processes.

Small groups (eight or fewer individuals): Hospitalist groups nearly always start with a small number of doctors (often between one and three at the group’s inception) and find little need for a formal governance structure. They tend to make all important decisions based on consensus.

One risk of making decisions by consensus is that the group may be limited by the lowest common denominator. Even if most doctors in the group want to change something to avoid disadvantaging a doctor with a different point of view, the group may be held back and not make the change. In essence, the group can be ruled by the minority. This may not happen often, and as long as the group keeps this risk in mind it is usually fine to operate on consensus.

Medium-size groups (nine-14): A group this size probably needs to acknowledge that it will be unable to reach consensus on a number of issues and will need a voting system. It can be uncomfortable to jump from a culture of consensus to one of majority rule because the latter means there will be winners and losers. A clear set of rules or bylaws can increase the likelihood that those on the losing end of the issue will comply with the majority.

Large groups (more than 14): A large group usuallys face more complex decisions and has a wider range of opinions. Meetings may drag on as an issue is debated and all members have their say.

For this reason, large groups should consider forming a small executive committee consisting of the group’s leader and several representatives elected by a vote of the whole group. This can be a much more efficient way for the group to reach decisions. The executive committee researches issues and forms recommendations for the whole group. For some issues it might be reasonable for the executive committee’s decisions to be final. For others, the decisions of the executive committee might be presented to the whole group as a recommendation and put to a vote of all members.

It is important for a group of any size to have a clearly designated leader to oversee its operations and meetings and represent the group to external constituents. It’s critical that all groups have a culture of physician ownership even if they are contractual employees of another entity, such as the hospital.

It is best if the leader is not viewed as a boss others work for. That will lead to an employee—not an owner—mentality on the part of the others. 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 also on the faculty of 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.

How does your hospitalist group make decisions on important issues? There are many reasonable approaches. The best method will vary significantly depending on the group’s size and whether the doctors own their own private practice or are employees of a hospital or large multisite private hospitalist group.

Because many doctors are drawn to the profession in part seeking autonomy and independence, there is often a tension between their desire to make many decisions about business and practice operations independently and the need to set aside some personal interests in order for the group to function well. This can become apparent when the group reaches an agreement regarding a difficult issue for which there are different points of view.

Consider a hospitalist group made up of internists occasionally asked to admit teenagers younger than 17. There might be a variety of opinions about whether this is appropriate, but it will be best for everyone in the group to follow the same policy. If the majority decision is that it is reasonable to admit patients as long as they’re post-pubertal, everyone in the group should abide by this policy.

But when called by the emergency department about such a patient, a dissenting hospitalist might feel entitled to decline the admission despite the group’s decision. For this doctor, autonomy trumps cohesive group functioning.

The best approach to individual doctors not feeling bound by the group’s decisions is complex and will vary depending on the situation. But it can be mitigated by ensuring that the group has a clear governance structure and method for reaching controversial decisions.

Group Size Matters

A look at hospitalist groups of varying sizes illustrates the growing complexity of decision-making processes.

Small groups (eight or fewer individuals): Hospitalist groups nearly always start with a small number of doctors (often between one and three at the group’s inception) and find little need for a formal governance structure. They tend to make all important decisions based on consensus.

One risk of making decisions by consensus is that the group may be limited by the lowest common denominator. Even if most doctors in the group want to change something to avoid disadvantaging a doctor with a different point of view, the group may be held back and not make the change. In essence, the group can be ruled by the minority. This may not happen often, and as long as the group keeps this risk in mind it is usually fine to operate on consensus.

Medium-size groups (nine-14): A group this size probably needs to acknowledge that it will be unable to reach consensus on a number of issues and will need a voting system. It can be uncomfortable to jump from a culture of consensus to one of majority rule because the latter means there will be winners and losers. A clear set of rules or bylaws can increase the likelihood that those on the losing end of the issue will comply with the majority.

Large groups (more than 14): A large group usuallys face more complex decisions and has a wider range of opinions. Meetings may drag on as an issue is debated and all members have their say.

For this reason, large groups should consider forming a small executive committee consisting of the group’s leader and several representatives elected by a vote of the whole group. This can be a much more efficient way for the group to reach decisions. The executive committee researches issues and forms recommendations for the whole group. For some issues it might be reasonable for the executive committee’s decisions to be final. For others, the decisions of the executive committee might be presented to the whole group as a recommendation and put to a vote of all members.

It is important for a group of any size to have a clearly designated leader to oversee its operations and meetings and represent the group to external constituents. It’s critical that all groups have a culture of physician ownership even if they are contractual employees of another entity, such as the hospital.

It is best if the leader is not viewed as a boss others work for. That will lead to an employee—not an owner—mentality on the part of the others. 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 also on the faculty of 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.

How does your hospitalist group make decisions on important issues? There are many reasonable approaches. The best method will vary significantly depending on the group’s size and whether the doctors own their own private practice or are employees of a hospital or large multisite private hospitalist group.

Because many doctors are drawn to the profession in part seeking autonomy and independence, there is often a tension between their desire to make many decisions about business and practice operations independently and the need to set aside some personal interests in order for the group to function well. This can become apparent when the group reaches an agreement regarding a difficult issue for which there are different points of view.

Consider a hospitalist group made up of internists occasionally asked to admit teenagers younger than 17. There might be a variety of opinions about whether this is appropriate, but it will be best for everyone in the group to follow the same policy. If the majority decision is that it is reasonable to admit patients as long as they’re post-pubertal, everyone in the group should abide by this policy.

But when called by the emergency department about such a patient, a dissenting hospitalist might feel entitled to decline the admission despite the group’s decision. For this doctor, autonomy trumps cohesive group functioning.

The best approach to individual doctors not feeling bound by the group’s decisions is complex and will vary depending on the situation. But it can be mitigated by ensuring that the group has a clear governance structure and method for reaching controversial decisions.

Group Size Matters

A look at hospitalist groups of varying sizes illustrates the growing complexity of decision-making processes.

Small groups (eight or fewer individuals): Hospitalist groups nearly always start with a small number of doctors (often between one and three at the group’s inception) and find little need for a formal governance structure. They tend to make all important decisions based on consensus.

One risk of making decisions by consensus is that the group may be limited by the lowest common denominator. Even if most doctors in the group want to change something to avoid disadvantaging a doctor with a different point of view, the group may be held back and not make the change. In essence, the group can be ruled by the minority. This may not happen often, and as long as the group keeps this risk in mind it is usually fine to operate on consensus.

Medium-size groups (nine-14): A group this size probably needs to acknowledge that it will be unable to reach consensus on a number of issues and will need a voting system. It can be uncomfortable to jump from a culture of consensus to one of majority rule because the latter means there will be winners and losers. A clear set of rules or bylaws can increase the likelihood that those on the losing end of the issue will comply with the majority.

Large groups (more than 14): A large group usuallys face more complex decisions and has a wider range of opinions. Meetings may drag on as an issue is debated and all members have their say.

For this reason, large groups should consider forming a small executive committee consisting of the group’s leader and several representatives elected by a vote of the whole group. This can be a much more efficient way for the group to reach decisions. The executive committee researches issues and forms recommendations for the whole group. For some issues it might be reasonable for the executive committee’s decisions to be final. For others, the decisions of the executive committee might be presented to the whole group as a recommendation and put to a vote of all members.

It is important for a group of any size to have a clearly designated leader to oversee its operations and meetings and represent the group to external constituents. It’s critical that all groups have a culture of physician ownership even if they are contractual employees of another entity, such as the hospital.

It is best if the leader is not viewed as a boss others work for. That will lead to an employee—not an owner—mentality on the part of the others. 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 also on the faculty of 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.

Glass of wine in one hand and the Sept. 30 copy of Wine Spectator in the other, I intended to relax a bit—the future of hospital medicine not necessarily uppermost in my mind. But then I was struck by an article by Matt Kramer titled “10,000 hours.” In it he discusses the implications Daniel Levitin’s new book This Is Your Brain on Music: The Science of a Human Obsession (Dutton) may have for the field of wine tasting.

Levitin notes that “ten thousand hours of practice is required to achieve the level of mastery associated with being a world-class expert—in anything.” It turns out it doesn’t matter what you are trying to master.

“In study after study of composers, basketball players, fiction writers, ice skaters, concert pianists, chess players, master criminals, and what have you, this number comes up again and again,” he says. “No one has yet found a case in which true world-class expertise was accomplished in less time.” This is consistent with how we learn. “Learning requires the assimilation and consolidation of information in neural tissue,” writes Levitin. “The more experiences we have with something the stronger the memory/learning trace for the experience becomes.”

Ten thousand hours. Are you an expert in hospital medicine? Have you compiled the requisite 10,000 hours? The average hospitalist working approximately 200 shifts a year of 10 to 12 hours each would take four to five years to master the practice of hospital medicine. On the other hand, a provider spending 10 hours a week in the hospital would require 20 years to achieve the numeric equivalent of expert status.

While Levitin was discussing the impact of this calculation on music and Kramer on wine expertise, it struck me as applicable to one of the great debates surrounding hospital medicine. Early in the days of the hospitalist movement, many inside and outside the field opined as to whether hospitals should be the domain of hospitalists and clinics the domain of primary care doctors, without overlap. SHM and I proclaimed hospitals should be open to all providers, regardless of primary practice site.

Over time the argument has died down as the threat of a hospitalist takeover has given way to the realization that many primary care doctors prefer a practice without inpatient obligations.

Recently the American Board of Internal Medicine (ABIM) has decided to move forward with a Recognition of Focused Practice in hospital medicine (RFP-HM) certification. This designation will utilize the structure of the ABIM Maintenance of Certification (MOC) program. It will be available to those who have practiced hospital medicine at least three years, meet inpatient volume requirements, and successfully complete hospital medicine-specific Self-Evaluation Process (SEP) modules, Practice Improvement Modules (PIM) and a secure exam.

This has again raised concerns about the growth and direction of hospital medicine and the implications for internal medicine. Would this confer specialty status to hospitalists while leaving primary care doctors as the remaining generalists? Would this further fracture the field of internal medicine? Would this allow hospital-credentialing boards to preferentially allow only those with RFP-HM to practice within their walls, effectively outlawing the primary care doctor?

Having been a member of the task force that worked on RFP-HM, I can say emphatically that it is not intended to confer specialty status to hospitalists or exalt them above other general internists. Rather, it is meant to recognize that a practitioner has focused his or her practice in a manner that demonstrates greater proficiency in the practice of hospital medicine. While this denotes a presumably higher level of proficiency by RFP-HM providers, it does not mean those without it are not capable providers.

How then should we define who is a capable provider in the hospital setting? According to the Dreyfus Model of Skills Acquisition, as learners develop along the continuum from novice to beginner to competent to proficient to expert, their skills become more developed, letting them tackle more complex issues and tasks more efficiently.

For example, the novice knows that a patient with dyspnea might have pneumonia and orders a chest X-ray but little more. The competent provider realizes many other disease states can cause dyspnea and would assess for those as well, often getting bogged down in extraneous details. The proficient provider immediately focuses on the important details and determines pneumonia as the cause of the dyspnea, applying the proper treatment algorithms with a level of efficiency beyond that of the competent peer.

The expert intuitively diagnoses the pneumonia and prescribes the proper diagnostic and therapeutic evaluation. He does so while considering the patient’s immune status, the impact of the hospital’s antimicrobial resistance patterns, and the potential risks and benefits of short-course antimicrobial therapy—all through the prism of quality core measures, cost, and throughput.

In a healthcare system at best strained and by most evidence severely fractured, we can no longer accept competence as the determinant of a capable provider. Rather, we should use proficiency moving toward expertise as the measuring stick for caring for increasingly more complex patients.

The designation “hospitalist” or even RFP-HM should not determine if one is proficient to practice hospital medicine, just as the designation of primary care provider should not exclude one from practicing in the hospital. Certainly, there are practitioners able to seamlessly cross the inpatient/outpatient boundary without losing a step. However, I suspect the more likely scenario is expertise in one and at best proficiency in the other.

Levitin’s 10,000-hour threshold supports this assumption, as it would take at least 10 years to amass 10,000 hours in each practice setting. Most likely, development of expertise in one arena means mere competence in another. As exhibit A, I tremble at the thought of the mischief I would cause if I took my stethoscope to the primary care clinic.

Instead, the ethical standards of our profession should dictate that each provider determines if they meet this pursuit-of-expertise standard. Employers and credentialing boards need to raise the bar toward expertise, ensuring these thresholds are met.

In the end, hospital or clinic sites should be the domain of capable providers, regardless of their primary practice site. However, we need to recalibrate how we define a capable provider who is moving away from competence toward proficiency verging on expertise. Experience as a surrogate for expertise, more than primary practice setting or RFP-HM status, should be the major determinant for who cares for hospitalized patients. TH

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

Glass of wine in one hand and the Sept. 30 copy of Wine Spectator in the other, I intended to relax a bit—the future of hospital medicine not necessarily uppermost in my mind. But then I was struck by an article by Matt Kramer titled “10,000 hours.” In it he discusses the implications Daniel Levitin’s new book This Is Your Brain on Music: The Science of a Human Obsession (Dutton) may have for the field of wine tasting.

Levitin notes that “ten thousand hours of practice is required to achieve the level of mastery associated with being a world-class expert—in anything.” It turns out it doesn’t matter what you are trying to master.

“In study after study of composers, basketball players, fiction writers, ice skaters, concert pianists, chess players, master criminals, and what have you, this number comes up again and again,” he says. “No one has yet found a case in which true world-class expertise was accomplished in less time.” This is consistent with how we learn. “Learning requires the assimilation and consolidation of information in neural tissue,” writes Levitin. “The more experiences we have with something the stronger the memory/learning trace for the experience becomes.”

Ten thousand hours. Are you an expert in hospital medicine? Have you compiled the requisite 10,000 hours? The average hospitalist working approximately 200 shifts a year of 10 to 12 hours each would take four to five years to master the practice of hospital medicine. On the other hand, a provider spending 10 hours a week in the hospital would require 20 years to achieve the numeric equivalent of expert status.

While Levitin was discussing the impact of this calculation on music and Kramer on wine expertise, it struck me as applicable to one of the great debates surrounding hospital medicine. Early in the days of the hospitalist movement, many inside and outside the field opined as to whether hospitals should be the domain of hospitalists and clinics the domain of primary care doctors, without overlap. SHM and I proclaimed hospitals should be open to all providers, regardless of primary practice site.

Over time the argument has died down as the threat of a hospitalist takeover has given way to the realization that many primary care doctors prefer a practice without inpatient obligations.

Recently the American Board of Internal Medicine (ABIM) has decided to move forward with a Recognition of Focused Practice in hospital medicine (RFP-HM) certification. This designation will utilize the structure of the ABIM Maintenance of Certification (MOC) program. It will be available to those who have practiced hospital medicine at least three years, meet inpatient volume requirements, and successfully complete hospital medicine-specific Self-Evaluation Process (SEP) modules, Practice Improvement Modules (PIM) and a secure exam.

This has again raised concerns about the growth and direction of hospital medicine and the implications for internal medicine. Would this confer specialty status to hospitalists while leaving primary care doctors as the remaining generalists? Would this further fracture the field of internal medicine? Would this allow hospital-credentialing boards to preferentially allow only those with RFP-HM to practice within their walls, effectively outlawing the primary care doctor?

Having been a member of the task force that worked on RFP-HM, I can say emphatically that it is not intended to confer specialty status to hospitalists or exalt them above other general internists. Rather, it is meant to recognize that a practitioner has focused his or her practice in a manner that demonstrates greater proficiency in the practice of hospital medicine. While this denotes a presumably higher level of proficiency by RFP-HM providers, it does not mean those without it are not capable providers.

How then should we define who is a capable provider in the hospital setting? According to the Dreyfus Model of Skills Acquisition, as learners develop along the continuum from novice to beginner to competent to proficient to expert, their skills become more developed, letting them tackle more complex issues and tasks more efficiently.

For example, the novice knows that a patient with dyspnea might have pneumonia and orders a chest X-ray but little more. The competent provider realizes many other disease states can cause dyspnea and would assess for those as well, often getting bogged down in extraneous details. The proficient provider immediately focuses on the important details and determines pneumonia as the cause of the dyspnea, applying the proper treatment algorithms with a level of efficiency beyond that of the competent peer.

The expert intuitively diagnoses the pneumonia and prescribes the proper diagnostic and therapeutic evaluation. He does so while considering the patient’s immune status, the impact of the hospital’s antimicrobial resistance patterns, and the potential risks and benefits of short-course antimicrobial therapy—all through the prism of quality core measures, cost, and throughput.

In a healthcare system at best strained and by most evidence severely fractured, we can no longer accept competence as the determinant of a capable provider. Rather, we should use proficiency moving toward expertise as the measuring stick for caring for increasingly more complex patients.

The designation “hospitalist” or even RFP-HM should not determine if one is proficient to practice hospital medicine, just as the designation of primary care provider should not exclude one from practicing in the hospital. Certainly, there are practitioners able to seamlessly cross the inpatient/outpatient boundary without losing a step. However, I suspect the more likely scenario is expertise in one and at best proficiency in the other.

Levitin’s 10,000-hour threshold supports this assumption, as it would take at least 10 years to amass 10,000 hours in each practice setting. Most likely, development of expertise in one arena means mere competence in another. As exhibit A, I tremble at the thought of the mischief I would cause if I took my stethoscope to the primary care clinic.

Instead, the ethical standards of our profession should dictate that each provider determines if they meet this pursuit-of-expertise standard. Employers and credentialing boards need to raise the bar toward expertise, ensuring these thresholds are met.

In the end, hospital or clinic sites should be the domain of capable providers, regardless of their primary practice site. However, we need to recalibrate how we define a capable provider who is moving away from competence toward proficiency verging on expertise. Experience as a surrogate for expertise, more than primary practice setting or RFP-HM status, should be the major determinant for who cares for hospitalized patients. TH

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

Glass of wine in one hand and the Sept. 30 copy of Wine Spectator in the other, I intended to relax a bit—the future of hospital medicine not necessarily uppermost in my mind. But then I was struck by an article by Matt Kramer titled “10,000 hours.” In it he discusses the implications Daniel Levitin’s new book This Is Your Brain on Music: The Science of a Human Obsession (Dutton) may have for the field of wine tasting.

Levitin notes that “ten thousand hours of practice is required to achieve the level of mastery associated with being a world-class expert—in anything.” It turns out it doesn’t matter what you are trying to master.

“In study after study of composers, basketball players, fiction writers, ice skaters, concert pianists, chess players, master criminals, and what have you, this number comes up again and again,” he says. “No one has yet found a case in which true world-class expertise was accomplished in less time.” This is consistent with how we learn. “Learning requires the assimilation and consolidation of information in neural tissue,” writes Levitin. “The more experiences we have with something the stronger the memory/learning trace for the experience becomes.”

Ten thousand hours. Are you an expert in hospital medicine? Have you compiled the requisite 10,000 hours? The average hospitalist working approximately 200 shifts a year of 10 to 12 hours each would take four to five years to master the practice of hospital medicine. On the other hand, a provider spending 10 hours a week in the hospital would require 20 years to achieve the numeric equivalent of expert status.

While Levitin was discussing the impact of this calculation on music and Kramer on wine expertise, it struck me as applicable to one of the great debates surrounding hospital medicine. Early in the days of the hospitalist movement, many inside and outside the field opined as to whether hospitals should be the domain of hospitalists and clinics the domain of primary care doctors, without overlap. SHM and I proclaimed hospitals should be open to all providers, regardless of primary practice site.

Over time the argument has died down as the threat of a hospitalist takeover has given way to the realization that many primary care doctors prefer a practice without inpatient obligations.

Recently the American Board of Internal Medicine (ABIM) has decided to move forward with a Recognition of Focused Practice in hospital medicine (RFP-HM) certification. This designation will utilize the structure of the ABIM Maintenance of Certification (MOC) program. It will be available to those who have practiced hospital medicine at least three years, meet inpatient volume requirements, and successfully complete hospital medicine-specific Self-Evaluation Process (SEP) modules, Practice Improvement Modules (PIM) and a secure exam.

This has again raised concerns about the growth and direction of hospital medicine and the implications for internal medicine. Would this confer specialty status to hospitalists while leaving primary care doctors as the remaining generalists? Would this further fracture the field of internal medicine? Would this allow hospital-credentialing boards to preferentially allow only those with RFP-HM to practice within their walls, effectively outlawing the primary care doctor?

Having been a member of the task force that worked on RFP-HM, I can say emphatically that it is not intended to confer specialty status to hospitalists or exalt them above other general internists. Rather, it is meant to recognize that a practitioner has focused his or her practice in a manner that demonstrates greater proficiency in the practice of hospital medicine. While this denotes a presumably higher level of proficiency by RFP-HM providers, it does not mean those without it are not capable providers.

How then should we define who is a capable provider in the hospital setting? According to the Dreyfus Model of Skills Acquisition, as learners develop along the continuum from novice to beginner to competent to proficient to expert, their skills become more developed, letting them tackle more complex issues and tasks more efficiently.

For example, the novice knows that a patient with dyspnea might have pneumonia and orders a chest X-ray but little more. The competent provider realizes many other disease states can cause dyspnea and would assess for those as well, often getting bogged down in extraneous details. The proficient provider immediately focuses on the important details and determines pneumonia as the cause of the dyspnea, applying the proper treatment algorithms with a level of efficiency beyond that of the competent peer.

The expert intuitively diagnoses the pneumonia and prescribes the proper diagnostic and therapeutic evaluation. He does so while considering the patient’s immune status, the impact of the hospital’s antimicrobial resistance patterns, and the potential risks and benefits of short-course antimicrobial therapy—all through the prism of quality core measures, cost, and throughput.

In a healthcare system at best strained and by most evidence severely fractured, we can no longer accept competence as the determinant of a capable provider. Rather, we should use proficiency moving toward expertise as the measuring stick for caring for increasingly more complex patients.

The designation “hospitalist” or even RFP-HM should not determine if one is proficient to practice hospital medicine, just as the designation of primary care provider should not exclude one from practicing in the hospital. Certainly, there are practitioners able to seamlessly cross the inpatient/outpatient boundary without losing a step. However, I suspect the more likely scenario is expertise in one and at best proficiency in the other.

Levitin’s 10,000-hour threshold supports this assumption, as it would take at least 10 years to amass 10,000 hours in each practice setting. Most likely, development of expertise in one arena means mere competence in another. As exhibit A, I tremble at the thought of the mischief I would cause if I took my stethoscope to the primary care clinic.

Instead, the ethical standards of our profession should dictate that each provider determines if they meet this pursuit-of-expertise standard. Employers and credentialing boards need to raise the bar toward expertise, ensuring these thresholds are met.

In the end, hospital or clinic sites should be the domain of capable providers, regardless of their primary practice site. However, we need to recalibrate how we define a capable provider who is moving away from competence toward proficiency verging on expertise. Experience as a surrogate for expertise, more than primary practice setting or RFP-HM status, should be the major determinant for who cares for hospitalized patients. TH

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

It’s hard to believe eight years have gone by since I came to SHM. More than that, it is strange to think of a world without hospitalists. Hospital medicine is part of the fabric of healthcare; there’s no longer a debate over whether hospitalists are good or bad. Now, the talk is about how hospitalists can help solve so many of the ills that vex our healthcare system.

This year has been an extraordinary year even by SHM standards. Witness our progress in the following areas.

ABIM Progress

In a landmark and revolutionary decision, the American Board of Internal Medicine (ABIM) recommended proceeding with a recognition of focused practice (RFP) in hospital medicine as an option in its maintenance of certification (MOC).

This is the culmination of a strategy SHM laid out three years ago. SHM is working with ABIM to continue to make the MOC process meaningful to hospitalists as the ABIM recommendations wend their way through the American Board of Medical Specialties. SHM continues to reach out to the pediatric and family medicine boards so the RFP can be available to all hospitalists.

JHM Listed

In its first year of publication, the Journal of Hospital Medicine (JHM) has been included in PubMed, the National Institutes of Health online archive of life science journals. JHM now resides among other established journals, fielding a marked increased in submissions for publication.

Quality

SHM received its third consecutive grant from the John A. Hartford Foundation, this one for $1.4 million over three years to develop interventions to improve care transitions for older adults at discharge.

As part of our work to improve quality for our nation’s seniors, SHM is developing discharge-planning tools and implementation strategies to limit the voltage drop in care at discharge. Hartford’s support means funders see that hospitalists, with SHM support, improve quality at their hospitals. SHM has become a leader in discharge planning tools and is helping set standards for transitions of care.

To help give hospitalists tools and resources to effect change on the front lines, SHM continues to develop online resource rooms and unique strategies such as mentored implementation.

We also have several hospitalist leaders on key panels at the National Quality Forum (NQF). The American Medical Association’s Physician Consortium on Practice Improvement has asked SHM to take the lead in forming a coalition for setting transitions-of-care measurements.

When the Institute for Healthcare Improvement needed a physician group to join the announcement of its 5 Million Lives Campaign, it reached out to SHM. President Rusty Holman took the stage to support the initiative, which intends to protect 5 million patients from incidents of medical harm over the next two years.

Further, the Joint Commission on Accreditation of Healthcare Organ­izations asked SHM to co-sponsor its medication reconciliation workgroup. Lastly, SHM continues to get significant visibility for hospitalists with our leadership of the deep-vein thrombosis awareness coalition of more than 35 organizations.

Annual Meeting

In May, SHM took over the Gaylord Texan in Dallas with professional meeting staging that rivaled older, larger organizations. With banners, Jumbotrons, and devices projecting the SHM logo, we transformed the Gaylord into a “hospitalist city.” We treated the nearly 1,200 attendees to three superlative speakers:

• David Brailer, MD, national coordinator for health information technology, United States Department of Health and Human Services;
• Jonathan Perlin, MD, former undersecretary for health at the Veterans Health Administration and now chief medical officer and senior vice president of quality for Hospital Corporation of America in Nashville; and
• Bob Wachter, MD, professor and chief of the division of hospital medicine at the University of California, San Francisco.

And, we had our largest poster session ever, with more than 200 submissions, and our largest exhibit hall. We plan to take it up a notch in San Diego in April.

Advocacy and Policy

Our presence in Washington, D.C., allows us to be active in Medicare payment reform. SHM leadership has met with senior staff at MedPAC, the organization that makes recommendations to the Centers for Medicare and Medicaid Services and Congress. MedPAC is interested in working with SHM as Medicare attempts to move away from paying for just visits and procedures and toward reimbursement strategies that drive performance and efficiency.

Current, Future Initiatives

In June, SHM forged a partnership with the Society of General Internal Medicine (SGIM) and the Association of Chiefs of General Internal Medicine to hold an academic summit to develop strategies for academic hospitalists to have a strong and sustainable career in teaching, training, and research in hospital medicine. When the Alliance for Academic Internal Medicine developed its proposal to redesign internal medicine training, SHM took the lead in crafting the hospitalist response.

In July, we joined the SGIM and American College of Physicians to hold a consensus conference on transitions of care. This coalition of more than 25 organizations produced a statement as the basis for future standards and measurements. Also in July, SHM worked with key leaders in emergency medicine and others to redefine the management and opportunities in observation units.

We held a multidisciplinary workforce summit in November to examine the challenges and solutions in growing hospital medicine from 20,000 to 40,000 or more physicians.

Diversity

While at times we may seem to focus more on internal-medicine-trained hospitalists, who make up more than 80% of the field, SHM continues to include hospitalists in family medicine and pediatrics, among other specialties. We also are home to nonphysician providers and physician assistants. We are working to support academic hospitalists, small groups, and multistate companies. In our toughest tightrope walk, SHM continues to be relevant and supportive of labor and management in hospital medicine.

Looking to 2008

The growth and influence of hospital medicine is relentless. Maybe 2008 is the year we will see hospitalists practicing in more than 3,000 hospitals or see the specialty grow to more than 25,000 hospitalists. One thing is for sure: SHM, with your suggestions, ideas, and energy, will be on the front lines with you, supporting and advocating a better healthcare system. TH

Dr. Wellikson is CEO of SHM.

It’s hard to believe eight years have gone by since I came to SHM. More than that, it is strange to think of a world without hospitalists. Hospital medicine is part of the fabric of healthcare; there’s no longer a debate over whether hospitalists are good or bad. Now, the talk is about how hospitalists can help solve so many of the ills that vex our healthcare system.

This year has been an extraordinary year even by SHM standards. Witness our progress in the following areas.

ABIM Progress

In a landmark and revolutionary decision, the American Board of Internal Medicine (ABIM) recommended proceeding with a recognition of focused practice (RFP) in hospital medicine as an option in its maintenance of certification (MOC).

This is the culmination of a strategy SHM laid out three years ago. SHM is working with ABIM to continue to make the MOC process meaningful to hospitalists as the ABIM recommendations wend their way through the American Board of Medical Specialties. SHM continues to reach out to the pediatric and family medicine boards so the RFP can be available to all hospitalists.

JHM Listed

In its first year of publication, the Journal of Hospital Medicine (JHM) has been included in PubMed, the National Institutes of Health online archive of life science journals. JHM now resides among other established journals, fielding a marked increased in submissions for publication.

Quality

SHM received its third consecutive grant from the John A. Hartford Foundation, this one for $1.4 million over three years to develop interventions to improve care transitions for older adults at discharge.

As part of our work to improve quality for our nation’s seniors, SHM is developing discharge-planning tools and implementation strategies to limit the voltage drop in care at discharge. Hartford’s support means funders see that hospitalists, with SHM support, improve quality at their hospitals. SHM has become a leader in discharge planning tools and is helping set standards for transitions of care.

To help give hospitalists tools and resources to effect change on the front lines, SHM continues to develop online resource rooms and unique strategies such as mentored implementation.

We also have several hospitalist leaders on key panels at the National Quality Forum (NQF). The American Medical Association’s Physician Consortium on Practice Improvement has asked SHM to take the lead in forming a coalition for setting transitions-of-care measurements.

When the Institute for Healthcare Improvement needed a physician group to join the announcement of its 5 Million Lives Campaign, it reached out to SHM. President Rusty Holman took the stage to support the initiative, which intends to protect 5 million patients from incidents of medical harm over the next two years.

Further, the Joint Commission on Accreditation of Healthcare Organ­izations asked SHM to co-sponsor its medication reconciliation workgroup. Lastly, SHM continues to get significant visibility for hospitalists with our leadership of the deep-vein thrombosis awareness coalition of more than 35 organizations.

Annual Meeting

In May, SHM took over the Gaylord Texan in Dallas with professional meeting staging that rivaled older, larger organizations. With banners, Jumbotrons, and devices projecting the SHM logo, we transformed the Gaylord into a “hospitalist city.” We treated the nearly 1,200 attendees to three superlative speakers:

• David Brailer, MD, national coordinator for health information technology, United States Department of Health and Human Services;
• Jonathan Perlin, MD, former undersecretary for health at the Veterans Health Administration and now chief medical officer and senior vice president of quality for Hospital Corporation of America in Nashville; and
• Bob Wachter, MD, professor and chief of the division of hospital medicine at the University of California, San Francisco.

And, we had our largest poster session ever, with more than 200 submissions, and our largest exhibit hall. We plan to take it up a notch in San Diego in April.

Advocacy and Policy

Our presence in Washington, D.C., allows us to be active in Medicare payment reform. SHM leadership has met with senior staff at MedPAC, the organization that makes recommendations to the Centers for Medicare and Medicaid Services and Congress. MedPAC is interested in working with SHM as Medicare attempts to move away from paying for just visits and procedures and toward reimbursement strategies that drive performance and efficiency.

Current, Future Initiatives

In June, SHM forged a partnership with the Society of General Internal Medicine (SGIM) and the Association of Chiefs of General Internal Medicine to hold an academic summit to develop strategies for academic hospitalists to have a strong and sustainable career in teaching, training, and research in hospital medicine. When the Alliance for Academic Internal Medicine developed its proposal to redesign internal medicine training, SHM took the lead in crafting the hospitalist response.

In July, we joined the SGIM and American College of Physicians to hold a consensus conference on transitions of care. This coalition of more than 25 organizations produced a statement as the basis for future standards and measurements. Also in July, SHM worked with key leaders in emergency medicine and others to redefine the management and opportunities in observation units.

We held a multidisciplinary workforce summit in November to examine the challenges and solutions in growing hospital medicine from 20,000 to 40,000 or more physicians.

Diversity

While at times we may seem to focus more on internal-medicine-trained hospitalists, who make up more than 80% of the field, SHM continues to include hospitalists in family medicine and pediatrics, among other specialties. We also are home to nonphysician providers and physician assistants. We are working to support academic hospitalists, small groups, and multistate companies. In our toughest tightrope walk, SHM continues to be relevant and supportive of labor and management in hospital medicine.

Looking to 2008

The growth and influence of hospital medicine is relentless. Maybe 2008 is the year we will see hospitalists practicing in more than 3,000 hospitals or see the specialty grow to more than 25,000 hospitalists. One thing is for sure: SHM, with your suggestions, ideas, and energy, will be on the front lines with you, supporting and advocating a better healthcare system. TH

Dr. Wellikson is CEO of SHM.

It’s hard to believe eight years have gone by since I came to SHM. More than that, it is strange to think of a world without hospitalists. Hospital medicine is part of the fabric of healthcare; there’s no longer a debate over whether hospitalists are good or bad. Now, the talk is about how hospitalists can help solve so many of the ills that vex our healthcare system.

This year has been an extraordinary year even by SHM standards. Witness our progress in the following areas.

ABIM Progress

In a landmark and revolutionary decision, the American Board of Internal Medicine (ABIM) recommended proceeding with a recognition of focused practice (RFP) in hospital medicine as an option in its maintenance of certification (MOC).

This is the culmination of a strategy SHM laid out three years ago. SHM is working with ABIM to continue to make the MOC process meaningful to hospitalists as the ABIM recommendations wend their way through the American Board of Medical Specialties. SHM continues to reach out to the pediatric and family medicine boards so the RFP can be available to all hospitalists.

JHM Listed

In its first year of publication, the Journal of Hospital Medicine (JHM) has been included in PubMed, the National Institutes of Health online archive of life science journals. JHM now resides among other established journals, fielding a marked increased in submissions for publication.

Quality

SHM received its third consecutive grant from the John A. Hartford Foundation, this one for $1.4 million over three years to develop interventions to improve care transitions for older adults at discharge.

As part of our work to improve quality for our nation’s seniors, SHM is developing discharge-planning tools and implementation strategies to limit the voltage drop in care at discharge. Hartford’s support means funders see that hospitalists, with SHM support, improve quality at their hospitals. SHM has become a leader in discharge planning tools and is helping set standards for transitions of care.

To help give hospitalists tools and resources to effect change on the front lines, SHM continues to develop online resource rooms and unique strategies such as mentored implementation.

We also have several hospitalist leaders on key panels at the National Quality Forum (NQF). The American Medical Association’s Physician Consortium on Practice Improvement has asked SHM to take the lead in forming a coalition for setting transitions-of-care measurements.

When the Institute for Healthcare Improvement needed a physician group to join the announcement of its 5 Million Lives Campaign, it reached out to SHM. President Rusty Holman took the stage to support the initiative, which intends to protect 5 million patients from incidents of medical harm over the next two years.

Further, the Joint Commission on Accreditation of Healthcare Organ­izations asked SHM to co-sponsor its medication reconciliation workgroup. Lastly, SHM continues to get significant visibility for hospitalists with our leadership of the deep-vein thrombosis awareness coalition of more than 35 organizations.

Annual Meeting

In May, SHM took over the Gaylord Texan in Dallas with professional meeting staging that rivaled older, larger organizations. With banners, Jumbotrons, and devices projecting the SHM logo, we transformed the Gaylord into a “hospitalist city.” We treated the nearly 1,200 attendees to three superlative speakers:

• David Brailer, MD, national coordinator for health information technology, United States Department of Health and Human Services;
• Jonathan Perlin, MD, former undersecretary for health at the Veterans Health Administration and now chief medical officer and senior vice president of quality for Hospital Corporation of America in Nashville; and
• Bob Wachter, MD, professor and chief of the division of hospital medicine at the University of California, San Francisco.

And, we had our largest poster session ever, with more than 200 submissions, and our largest exhibit hall. We plan to take it up a notch in San Diego in April.

Advocacy and Policy

Our presence in Washington, D.C., allows us to be active in Medicare payment reform. SHM leadership has met with senior staff at MedPAC, the organization that makes recommendations to the Centers for Medicare and Medicaid Services and Congress. MedPAC is interested in working with SHM as Medicare attempts to move away from paying for just visits and procedures and toward reimbursement strategies that drive performance and efficiency.

Current, Future Initiatives

In June, SHM forged a partnership with the Society of General Internal Medicine (SGIM) and the Association of Chiefs of General Internal Medicine to hold an academic summit to develop strategies for academic hospitalists to have a strong and sustainable career in teaching, training, and research in hospital medicine. When the Alliance for Academic Internal Medicine developed its proposal to redesign internal medicine training, SHM took the lead in crafting the hospitalist response.

In July, we joined the SGIM and American College of Physicians to hold a consensus conference on transitions of care. This coalition of more than 25 organizations produced a statement as the basis for future standards and measurements. Also in July, SHM worked with key leaders in emergency medicine and others to redefine the management and opportunities in observation units.

We held a multidisciplinary workforce summit in November to examine the challenges and solutions in growing hospital medicine from 20,000 to 40,000 or more physicians.

Diversity

While at times we may seem to focus more on internal-medicine-trained hospitalists, who make up more than 80% of the field, SHM continues to include hospitalists in family medicine and pediatrics, among other specialties. We also are home to nonphysician providers and physician assistants. We are working to support academic hospitalists, small groups, and multistate companies. In our toughest tightrope walk, SHM continues to be relevant and supportive of labor and management in hospital medicine.

Looking to 2008

The growth and influence of hospital medicine is relentless. Maybe 2008 is the year we will see hospitalists practicing in more than 3,000 hospitals or see the specialty grow to more than 25,000 hospitalists. One thing is for sure: SHM, with your suggestions, ideas, and energy, will be on the front lines with you, supporting and advocating a better healthcare system. TH

Dr. Wellikson is CEO of SHM.

Charles Petit, MD, like many healthcare professionals, spends a good deal of time addressing the needs of the underprivileged. Since 2004, he has taken up the cause of the indigenous Miskito Indians of Puerto Lempira, Honduras. He is putting his own money into developing a modern clinic and international medicine program there.

But medicine isn’t his only mission. Dr. Petit, 56, a hospitalist at Palmetto Health Care’s Richland Memorial Hospital in Columbia, S.C., is also an Episcopal priest.

He joined Palmetto Health Senior Care as its first medical director in 1988 and reconnected with the group in 2004—not in his previous role as an office-based physician but as a hospitalist. In between those stints he pursued his ordination and medical missionary work in Africa and Latin America.

As a physician, Dr. Petit says he feels God’s presence at each patient’s bedside. Years ago he wondered how to handle that.

To deepen his connection between medicine and spirituality, he lived in a Christian intentional community in Indiana, Pa., from 1981 to 1988. Gradually, his views on medicine and spirituality crystallized.

“How does God do what he does?” Dr. Petit wondered. “Can medicine put Him to the test? I have seen that prayer works, including a patient miraculously healed of metastatic ovarian cancer. But God isn’t a vending machine. You don’t drop in a prayer and get a healing back.”

The Second Calling

Recognizing he needed something more to integrate medicine and spirituality, Dr. Petit sought a firmer grounding in religious studies.

He moved to Simpsonville, S.C., in 1995 and entered the Episcopal seminary, working as an emergency department doctor to pay the bills. Later, he earned a master’s of divinity from the University of the South in Sewanee, Tenn., in 2003.

His spiritual “internship” was a transitional deaconship from 2003 to 2005, under the Rev. Michael Flanagan, rector at Simpsonville’s Holy Cross Episcopal Church. Both had dual vocations—Flanagan was an engineer who sold electrical equipment for 10 years before ordination. Prior to meeting Dr. Petit, Flanagan was leery of the doctor’s ability to balance pastoral and medical duties.

“Would he be a doctor/priest?” Flanagan wondered. “A priest/doctor? His desire was to meld both and he did. Medicine and spirituality are both in his blood. He sees both as calls from God and connects medicine with spirituality into a holistic view of each person.” He says Dr. Petit “seems to know everything and sucks up knowledge, which he wants to share. He loves being the doctor and having the knowledge to fix the patient’s problem.”

While Dr. Petit keeps his hospitalist and priest roles mostly separate, working with elderly patients sometimes requires the skills of both disciplines. At Richland he wears a clerical collar on pastoral rounds. If a family or patient asks him to pray with them or discuss life’s ending, he does. He has conducted funerals for his own and colleagues’ patients.

“It’s a very powerful experience being both a priest and a doctor,” he says. “I grow so close to the patients and their families that it is natural for me to serve in both roles.”

Honduras Mission

As a seminarian, Dr. Petit took medical mission trips and briefly supported an African orphanage, looking for a cause to call his own. Until his first trip to Puerto Lempira, a village on the Miskito Coast of the Atlantic Ocean.

The abject poverty and medical needs of the Miskito Indians there pulled at him. Early on he enlisted the help of Ennis Whiddon, a builder and Holy Cross parishioner. Whiddon, who usually accompanies Dr. Petit to Puerto Lempira, says of his friend: “I knew him as [an emergency department] doctor first. Then I realized his extraordinary spiritual commitment. I went to Puerto Lempira on his first mission trip and I asked myself why anyone would want to be there, but I knew Chuck couldn’t bear not to be there. I also knew he wasn’t just going to give people two aspirins, come home and pray for them.”

Dr. Petit returns to Puerto Lempira three or four times a year with a team of doctors, seeing several hundred patients a day. During one two-week stint he dispensed $200,000 worth of medication he cadged from drug companies for $600 out of his pocket to rid the town’s youngsters of debilitating parasites.

Dr. Petit works with a Miskito nurse who runs their rudimentary clinic in his absence. He also uses hyperbaric medicine to treat divers whose crippling injuries result from diving deeply using pressurized oxygen tanks and rising too quickly to the surface.

“You wouldn’t believe the indescribably poor facilities we found there,” Whiddon says of the town’s clinic. “You wouldn’t have your dog treated there if you loved your dog.”

Last year Dr. Petit ratcheted up his commitment to Puerto Lempira, dreaming of building a permanent clinic there.

He decided to use his money to buy land to build a clinic, but got stonewalled by a stubborn local bureaucracy.

Then Andres Leone, a like-minded younger doctor who was part of the mission trip, stepped in with handy language and cultural skills. Leone who had attended medical school in Ecuador, is a Lutheran seminarian, and is completing a geriatric hospitalist fellowship at Palmetto Healthcare.

“We were in Puerto Lempira for two weeks and visited the mayor several times to buy land,” Dr. Leone explains. “He said the price was $600,000, which was ridiculous. In the town I overheard some conversations, which led to us meeting the 77-year-old daughter of missionaries. She sold us some of her land and even donated money to help build the clinic, which will be dedicated in her name.”

Thinking big, Dr. Petit is adding an apartment complete with air conditioning and a modern bathroom to the clinic’s blueprint, to attract residents in a to-be-formed international medicine program. As an assistant professor of family medicine at the University of South Carolina’s (USC) School of Medicine, he intends to oversee those residents.

Just back from Puerto Lempira, Dr. Petit finalized the clinic’s design, lined up local workers to figure out how to make concrete building blocks with native materials, and met with Anglican bishop the Right Rev. Lloyd E. Allen, bolstering support for the new clinic and the possibility of HIV outreach. Side by side with Honduran and Cuban doctors, Dr. Petit treated hundreds of Puerto Lempira’s villagers every day.

Back in the Hospital

Dr. Petit always wanted to be a doctor. Although his father suggested he become a hospital orderly, Dr. Petit knew being a physician was his calling, graduating from the University of West Virginia School of Medicine (Morgantown) family medicine program in 1978.

He enjoys hospital medicine as a holistic approach to caring for patients, consistent with his work early in his career.

An earlier 10-year stint as a hospitalist at HealthSouth Rehabilitation Hospital, also at USC, involved teaching residents and students rotating through the hospital, as well as a consultative service for neurosurgical patients at Richland. At Wheeling Hospital early in his career he became comfortable as a generalist, covering intensive care, assisting in surgery, and delivering many babies.

Being a hospitalist keeps that spirit alive. “It gives me the gift of time to spend with patients,” he says. “I try not to tie frail elderly patients down with IVs, Foley catheters, EKG monitors, worries that eating a leafy green vegetable will react badly with their Coumadin [warfarin], and polypharmacy.”

He discusses advanced directives, palliative care, and how the elderly in fragile condition can maintain as much freedom as possible. The hospital medicine group’s accommodating scheduling allows time for his parish duties and medical mission trips.

The group’s medical director, Victor Hirth, MD, describes Dr. Petit as a borderline workaholic who’s always looking for ways to make things better for the practice and patients. “The patients absolutely love him because he takes time to sit and talk to them,” says Dr. Hirth.

Dr. Petit also embraces new technologies. “Our [electronic medical record] makes working with my outpatient colleagues smooth and straightforward.” He relies on a personal digital device assistant for updates on clinical guidelines and optimal drug doses for elderly patients. Integrating a healer’s touch with new technology he says: “While medicine is a science, it’s still an art, a ministry, and a gift.”

What’s Next?

Back in South Carolina, Dr. Petit has picked up his hospitalist and pastoral responsibilities without missing a beat. He looks forward to building the palliative care consulting service and intends to launch a nonprofit corporation to receive donations to support the Puerto Lempira clinic’s construction.

He is planning more mission trips. He thrives on the work. Infused with boundless energy, he’s always looking for more to do.

“I love what I do,” he concludes. “If I felt much better they’d charge me an amusement tax.” TH

Marlene Piturro is a medical writer based in New York.

Charles Petit, MD, like many healthcare professionals, spends a good deal of time addressing the needs of the underprivileged. Since 2004, he has taken up the cause of the indigenous Miskito Indians of Puerto Lempira, Honduras. He is putting his own money into developing a modern clinic and international medicine program there.

But medicine isn’t his only mission. Dr. Petit, 56, a hospitalist at Palmetto Health Care’s Richland Memorial Hospital in Columbia, S.C., is also an Episcopal priest.

He joined Palmetto Health Senior Care as its first medical director in 1988 and reconnected with the group in 2004—not in his previous role as an office-based physician but as a hospitalist. In between those stints he pursued his ordination and medical missionary work in Africa and Latin America.

As a physician, Dr. Petit says he feels God’s presence at each patient’s bedside. Years ago he wondered how to handle that.

To deepen his connection between medicine and spirituality, he lived in a Christian intentional community in Indiana, Pa., from 1981 to 1988. Gradually, his views on medicine and spirituality crystallized.

“How does God do what he does?” Dr. Petit wondered. “Can medicine put Him to the test? I have seen that prayer works, including a patient miraculously healed of metastatic ovarian cancer. But God isn’t a vending machine. You don’t drop in a prayer and get a healing back.”

The Second Calling

Recognizing he needed something more to integrate medicine and spirituality, Dr. Petit sought a firmer grounding in religious studies.

He moved to Simpsonville, S.C., in 1995 and entered the Episcopal seminary, working as an emergency department doctor to pay the bills. Later, he earned a master’s of divinity from the University of the South in Sewanee, Tenn., in 2003.

His spiritual “internship” was a transitional deaconship from 2003 to 2005, under the Rev. Michael Flanagan, rector at Simpsonville’s Holy Cross Episcopal Church. Both had dual vocations—Flanagan was an engineer who sold electrical equipment for 10 years before ordination. Prior to meeting Dr. Petit, Flanagan was leery of the doctor’s ability to balance pastoral and medical duties.

“Would he be a doctor/priest?” Flanagan wondered. “A priest/doctor? His desire was to meld both and he did. Medicine and spirituality are both in his blood. He sees both as calls from God and connects medicine with spirituality into a holistic view of each person.” He says Dr. Petit “seems to know everything and sucks up knowledge, which he wants to share. He loves being the doctor and having the knowledge to fix the patient’s problem.”

While Dr. Petit keeps his hospitalist and priest roles mostly separate, working with elderly patients sometimes requires the skills of both disciplines. At Richland he wears a clerical collar on pastoral rounds. If a family or patient asks him to pray with them or discuss life’s ending, he does. He has conducted funerals for his own and colleagues’ patients.

“It’s a very powerful experience being both a priest and a doctor,” he says. “I grow so close to the patients and their families that it is natural for me to serve in both roles.”

Honduras Mission

As a seminarian, Dr. Petit took medical mission trips and briefly supported an African orphanage, looking for a cause to call his own. Until his first trip to Puerto Lempira, a village on the Miskito Coast of the Atlantic Ocean.

The abject poverty and medical needs of the Miskito Indians there pulled at him. Early on he enlisted the help of Ennis Whiddon, a builder and Holy Cross parishioner. Whiddon, who usually accompanies Dr. Petit to Puerto Lempira, says of his friend: “I knew him as [an emergency department] doctor first. Then I realized his extraordinary spiritual commitment. I went to Puerto Lempira on his first mission trip and I asked myself why anyone would want to be there, but I knew Chuck couldn’t bear not to be there. I also knew he wasn’t just going to give people two aspirins, come home and pray for them.”

Dr. Petit returns to Puerto Lempira three or four times a year with a team of doctors, seeing several hundred patients a day. During one two-week stint he dispensed $200,000 worth of medication he cadged from drug companies for $600 out of his pocket to rid the town’s youngsters of debilitating parasites.

Dr. Petit works with a Miskito nurse who runs their rudimentary clinic in his absence. He also uses hyperbaric medicine to treat divers whose crippling injuries result from diving deeply using pressurized oxygen tanks and rising too quickly to the surface.

“You wouldn’t believe the indescribably poor facilities we found there,” Whiddon says of the town’s clinic. “You wouldn’t have your dog treated there if you loved your dog.”

Last year Dr. Petit ratcheted up his commitment to Puerto Lempira, dreaming of building a permanent clinic there.

He decided to use his money to buy land to build a clinic, but got stonewalled by a stubborn local bureaucracy.

Then Andres Leone, a like-minded younger doctor who was part of the mission trip, stepped in with handy language and cultural skills. Leone who had attended medical school in Ecuador, is a Lutheran seminarian, and is completing a geriatric hospitalist fellowship at Palmetto Healthcare.

“We were in Puerto Lempira for two weeks and visited the mayor several times to buy land,” Dr. Leone explains. “He said the price was $600,000, which was ridiculous. In the town I overheard some conversations, which led to us meeting the 77-year-old daughter of missionaries. She sold us some of her land and even donated money to help build the clinic, which will be dedicated in her name.”

Thinking big, Dr. Petit is adding an apartment complete with air conditioning and a modern bathroom to the clinic’s blueprint, to attract residents in a to-be-formed international medicine program. As an assistant professor of family medicine at the University of South Carolina’s (USC) School of Medicine, he intends to oversee those residents.

Just back from Puerto Lempira, Dr. Petit finalized the clinic’s design, lined up local workers to figure out how to make concrete building blocks with native materials, and met with Anglican bishop the Right Rev. Lloyd E. Allen, bolstering support for the new clinic and the possibility of HIV outreach. Side by side with Honduran and Cuban doctors, Dr. Petit treated hundreds of Puerto Lempira’s villagers every day.

Back in the Hospital

Dr. Petit always wanted to be a doctor. Although his father suggested he become a hospital orderly, Dr. Petit knew being a physician was his calling, graduating from the University of West Virginia School of Medicine (Morgantown) family medicine program in 1978.

He enjoys hospital medicine as a holistic approach to caring for patients, consistent with his work early in his career.

An earlier 10-year stint as a hospitalist at HealthSouth Rehabilitation Hospital, also at USC, involved teaching residents and students rotating through the hospital, as well as a consultative service for neurosurgical patients at Richland. At Wheeling Hospital early in his career he became comfortable as a generalist, covering intensive care, assisting in surgery, and delivering many babies.

Being a hospitalist keeps that spirit alive. “It gives me the gift of time to spend with patients,” he says. “I try not to tie frail elderly patients down with IVs, Foley catheters, EKG monitors, worries that eating a leafy green vegetable will react badly with their Coumadin [warfarin], and polypharmacy.”

He discusses advanced directives, palliative care, and how the elderly in fragile condition can maintain as much freedom as possible. The hospital medicine group’s accommodating scheduling allows time for his parish duties and medical mission trips.

The group’s medical director, Victor Hirth, MD, describes Dr. Petit as a borderline workaholic who’s always looking for ways to make things better for the practice and patients. “The patients absolutely love him because he takes time to sit and talk to them,” says Dr. Hirth.

Dr. Petit also embraces new technologies. “Our [electronic medical record] makes working with my outpatient colleagues smooth and straightforward.” He relies on a personal digital device assistant for updates on clinical guidelines and optimal drug doses for elderly patients. Integrating a healer’s touch with new technology he says: “While medicine is a science, it’s still an art, a ministry, and a gift.”

What’s Next?

Back in South Carolina, Dr. Petit has picked up his hospitalist and pastoral responsibilities without missing a beat. He looks forward to building the palliative care consulting service and intends to launch a nonprofit corporation to receive donations to support the Puerto Lempira clinic’s construction.

He is planning more mission trips. He thrives on the work. Infused with boundless energy, he’s always looking for more to do.

“I love what I do,” he concludes. “If I felt much better they’d charge me an amusement tax.” TH

Marlene Piturro is a medical writer based in New York.

Charles Petit, MD, like many healthcare professionals, spends a good deal of time addressing the needs of the underprivileged. Since 2004, he has taken up the cause of the indigenous Miskito Indians of Puerto Lempira, Honduras. He is putting his own money into developing a modern clinic and international medicine program there.

But medicine isn’t his only mission. Dr. Petit, 56, a hospitalist at Palmetto Health Care’s Richland Memorial Hospital in Columbia, S.C., is also an Episcopal priest.

He joined Palmetto Health Senior Care as its first medical director in 1988 and reconnected with the group in 2004—not in his previous role as an office-based physician but as a hospitalist. In between those stints he pursued his ordination and medical missionary work in Africa and Latin America.

As a physician, Dr. Petit says he feels God’s presence at each patient’s bedside. Years ago he wondered how to handle that.

To deepen his connection between medicine and spirituality, he lived in a Christian intentional community in Indiana, Pa., from 1981 to 1988. Gradually, his views on medicine and spirituality crystallized.

“How does God do what he does?” Dr. Petit wondered. “Can medicine put Him to the test? I have seen that prayer works, including a patient miraculously healed of metastatic ovarian cancer. But God isn’t a vending machine. You don’t drop in a prayer and get a healing back.”

The Second Calling

Recognizing he needed something more to integrate medicine and spirituality, Dr. Petit sought a firmer grounding in religious studies.

He moved to Simpsonville, S.C., in 1995 and entered the Episcopal seminary, working as an emergency department doctor to pay the bills. Later, he earned a master’s of divinity from the University of the South in Sewanee, Tenn., in 2003.

His spiritual “internship” was a transitional deaconship from 2003 to 2005, under the Rev. Michael Flanagan, rector at Simpsonville’s Holy Cross Episcopal Church. Both had dual vocations—Flanagan was an engineer who sold electrical equipment for 10 years before ordination. Prior to meeting Dr. Petit, Flanagan was leery of the doctor’s ability to balance pastoral and medical duties.

“Would he be a doctor/priest?” Flanagan wondered. “A priest/doctor? His desire was to meld both and he did. Medicine and spirituality are both in his blood. He sees both as calls from God and connects medicine with spirituality into a holistic view of each person.” He says Dr. Petit “seems to know everything and sucks up knowledge, which he wants to share. He loves being the doctor and having the knowledge to fix the patient’s problem.”

While Dr. Petit keeps his hospitalist and priest roles mostly separate, working with elderly patients sometimes requires the skills of both disciplines. At Richland he wears a clerical collar on pastoral rounds. If a family or patient asks him to pray with them or discuss life’s ending, he does. He has conducted funerals for his own and colleagues’ patients.

“It’s a very powerful experience being both a priest and a doctor,” he says. “I grow so close to the patients and their families that it is natural for me to serve in both roles.”

Honduras Mission

As a seminarian, Dr. Petit took medical mission trips and briefly supported an African orphanage, looking for a cause to call his own. Until his first trip to Puerto Lempira, a village on the Miskito Coast of the Atlantic Ocean.

The abject poverty and medical needs of the Miskito Indians there pulled at him. Early on he enlisted the help of Ennis Whiddon, a builder and Holy Cross parishioner. Whiddon, who usually accompanies Dr. Petit to Puerto Lempira, says of his friend: “I knew him as [an emergency department] doctor first. Then I realized his extraordinary spiritual commitment. I went to Puerto Lempira on his first mission trip and I asked myself why anyone would want to be there, but I knew Chuck couldn’t bear not to be there. I also knew he wasn’t just going to give people two aspirins, come home and pray for them.”

Dr. Petit returns to Puerto Lempira three or four times a year with a team of doctors, seeing several hundred patients a day. During one two-week stint he dispensed $200,000 worth of medication he cadged from drug companies for $600 out of his pocket to rid the town’s youngsters of debilitating parasites.

Dr. Petit works with a Miskito nurse who runs their rudimentary clinic in his absence. He also uses hyperbaric medicine to treat divers whose crippling injuries result from diving deeply using pressurized oxygen tanks and rising too quickly to the surface.

“You wouldn’t believe the indescribably poor facilities we found there,” Whiddon says of the town’s clinic. “You wouldn’t have your dog treated there if you loved your dog.”

Last year Dr. Petit ratcheted up his commitment to Puerto Lempira, dreaming of building a permanent clinic there.

He decided to use his money to buy land to build a clinic, but got stonewalled by a stubborn local bureaucracy.

Then Andres Leone, a like-minded younger doctor who was part of the mission trip, stepped in with handy language and cultural skills. Leone who had attended medical school in Ecuador, is a Lutheran seminarian, and is completing a geriatric hospitalist fellowship at Palmetto Healthcare.

“We were in Puerto Lempira for two weeks and visited the mayor several times to buy land,” Dr. Leone explains. “He said the price was $600,000, which was ridiculous. In the town I overheard some conversations, which led to us meeting the 77-year-old daughter of missionaries. She sold us some of her land and even donated money to help build the clinic, which will be dedicated in her name.”

Thinking big, Dr. Petit is adding an apartment complete with air conditioning and a modern bathroom to the clinic’s blueprint, to attract residents in a to-be-formed international medicine program. As an assistant professor of family medicine at the University of South Carolina’s (USC) School of Medicine, he intends to oversee those residents.

Just back from Puerto Lempira, Dr. Petit finalized the clinic’s design, lined up local workers to figure out how to make concrete building blocks with native materials, and met with Anglican bishop the Right Rev. Lloyd E. Allen, bolstering support for the new clinic and the possibility of HIV outreach. Side by side with Honduran and Cuban doctors, Dr. Petit treated hundreds of Puerto Lempira’s villagers every day.

Back in the Hospital

Dr. Petit always wanted to be a doctor. Although his father suggested he become a hospital orderly, Dr. Petit knew being a physician was his calling, graduating from the University of West Virginia School of Medicine (Morgantown) family medicine program in 1978.

He enjoys hospital medicine as a holistic approach to caring for patients, consistent with his work early in his career.

An earlier 10-year stint as a hospitalist at HealthSouth Rehabilitation Hospital, also at USC, involved teaching residents and students rotating through the hospital, as well as a consultative service for neurosurgical patients at Richland. At Wheeling Hospital early in his career he became comfortable as a generalist, covering intensive care, assisting in surgery, and delivering many babies.

Being a hospitalist keeps that spirit alive. “It gives me the gift of time to spend with patients,” he says. “I try not to tie frail elderly patients down with IVs, Foley catheters, EKG monitors, worries that eating a leafy green vegetable will react badly with their Coumadin [warfarin], and polypharmacy.”

He discusses advanced directives, palliative care, and how the elderly in fragile condition can maintain as much freedom as possible. The hospital medicine group’s accommodating scheduling allows time for his parish duties and medical mission trips.

The group’s medical director, Victor Hirth, MD, describes Dr. Petit as a borderline workaholic who’s always looking for ways to make things better for the practice and patients. “The patients absolutely love him because he takes time to sit and talk to them,” says Dr. Hirth.

Dr. Petit also embraces new technologies. “Our [electronic medical record] makes working with my outpatient colleagues smooth and straightforward.” He relies on a personal digital device assistant for updates on clinical guidelines and optimal drug doses for elderly patients. Integrating a healer’s touch with new technology he says: “While medicine is a science, it’s still an art, a ministry, and a gift.”

What’s Next?

Back in South Carolina, Dr. Petit has picked up his hospitalist and pastoral responsibilities without missing a beat. He looks forward to building the palliative care consulting service and intends to launch a nonprofit corporation to receive donations to support the Puerto Lempira clinic’s construction.

He is planning more mission trips. He thrives on the work. Infused with boundless energy, he’s always looking for more to do.

“I love what I do,” he concludes. “If I felt much better they’d charge me an amusement tax.” TH

Marlene Piturro is a medical writer based in New York.

Case

A 68-year-old cachectic female with a history of Alzheimer’s dementia presents with a slowly progressive decline in functional status. She is bed bound, minimally verbal, and has lost interest in eating.

Her problems with decreased oral intake started when her diet was changed to nectar-thickened liquids. This change was made after the patient was hospitalized multiple times for aspiration pneumonia and she underwent a fluoroscopic swallowing evaluation that revealed aspiration of thin liquids. The patient’s husband requests that a feeding tube be placed so his wife doesn’t “die of pneumonia or starve to death.”

Overview

As the U.S. population ages, hospitalists are seeing a steady increase in the average patient age and the prevalence of dementia. Alzheimer’s dementia affects an estimated 4 million to 5 million Americans; this number expected to triple by the year 2050.1

As patients with dementia near the end of life, they often fail to thrive, with less oral intake and more swallowing disorders leading to aspiration. This is when physicians and patient family members must decide whether a feeding tube should be placed.

Placement of a nasogastric or percutaneous endogastric gastrostomy (PEG) feeding tube has become a relatively common medical intervention instituted to maintain or improve a patient’s nutritional status. Prior to 1980, permanent gastric or postpyloric feeding tubes were placed surgically by laparotomy, but the advent of endoscopy and computed tomography (CT) guided procedures offers a simplified procedure requiring only mild sedation and local anesthesia.2

Many patients who suffer multiple bouts of aspiration pneumonia and fail a swallowing evaluation because of an irreversible process are offered a percutaneous feeding tube to maintain nutrition. A feeding tube is also seen as a way to supply nutrition at the end of life in patients no longer able or willing to take food orally.

Although it seems logical that a feeding tube might improve the outcomes of these clinical scenarios, limited literature exists on the topic because of the legal, ethical, emotional, and religious implications a large, randomized, placebo-controlled trial would entail.

Review of the Data

Placement of a PEG has become accepted as a relatively benign procedure, although it is associated with significant morbidity and mortality. Minor complications including pain, abdominal wall ulcers, wound infections, peristomal leakage, and tube displacement occur in approximately 10% of cases.3 Major complications including hemorrhage, bowel or liver perforation, or aspiration occur in 3% of cases.4

These numbers do not account for long-term complications including peristomal infections, leakage problems, or the use of physical restraints to avoid self-extubation.

click for large version

Aspiration Risk

A common indication for PEG placement is aspiration risk. PEG tubes are often placed in patients who fail swallowing evaluations in order to decrease their risk of aspiration and aspiration pneumonia.

True aspiration pneumonia is thought to originate from an inoculum of oral cavity or nasopharynx bacteria, which placement of a PEG tube would not prevent. Leibovitz, et al., showed that elderly patients with nasogastric or percutaneous feeding tubes are associated with colonization of the oropharynx with more pathogenic bacteria when compared with orally fed patients.5 Thus, the use of PEG tubes might put them at higher risk for pathogenic inoculation.

Aspiration pneumonia occurs in up to 50% of patients with feeding tubes. Studies have shown PEG tube placement decreases lower esophageal sphincter tone, potentially increasing regurgitation risk.6 It has also been shown that aspiration of gastric contents produces a pneumonitis with the resultant inflammatory response allowing for establishment of infection by smaller inoculums of or less virulent organisms.7

Small, randomized trials have shown no decrease in aspiration risk with post-pyloric versus gastric feeding tubes, nasogastric versus percutaneous feeding tubes, or continuous versus intermittent tube feeds.8 There have been no sizable randomized prospective trials to determine if feeding tube placement versus hand feeding patients with end-stage dementia alters aspiration pneumonia risk.

Pressure Ulcers

Patients with end-stage dementia often become bed bound as their disease progresses, and they commonly suffer from pressure ulcers. Pressure ulcers often coexist in patients with malnutrition, and it is well established that patients with biochemical markers of malnutrition are at higher risk for pressure ulcer formation.

Still, no studies show that improved nutrition prevents pressure ulcer formation. In a nursing home population of patients with dementia, a two-year follow-up study showed no significant improvement in pressure ulcer healing or decreased ulcer formation with nutrition by feeding tube.9 These studies are adjusted for independent risk factors for mortality and indication for PEG placement, but we can assume there are confounders that go into the decision for feeding tube placement that are not necessarily identifiable.

click for large version

Nutritional Status

Family members are often concerned that if the patient is unable to take food by mouth and no feeding tube is placed, then the patient will suffer from the discomfort of starvation and dehydration.

As a patient with a severe dementing illness enters the end stage of his/her clinical course, practitioners frequently make a plan with families to change the goals of care toward keeping the patient comfortable. Comfort is a difficult clinical parameter to measure, but studies in the hospice population of patients with end-stage cancer and AIDS report that the hunger and thirst are transient and improve with ice chips and mouth swabs.10

Despite the lack of evidence of PEG tubes prolonging survival in patients with dementia who are no longer able or willing to take in food orally, it is logical that withholding all hydration or nutritional support will hasten death despite the risks associated with feeding tubes. This is where the ethical argument arises regarding prolonging life of decreasing quality.

In certain medical and legal sectors, artificial nutrition, and hydration are considered a medical intervention. Therefore, the ideals of patient autonomy dictate that the patient’s proxy should decide whether or not the patient would have wanted the intervention after weighing the risks and benefits.

If hospitalists view artificial nutrition as a medical intervention, our moral obligation is to instruct patients and their families about these risks and benefits.

Often, the patient will not clinically improve with artificial nutrition. But we can maintain physiologic processes or at least slow their decline.

Emerging research indicates the standard of care in how we present this information is changing to include presentation of data instead of only using a patient’s suspected beliefs about quality of life.

A useful algorithm proposed by Rabeneck, et al., provides comprehensive guidelines for PEG placement in all patient populations based on the reason for PEG consideration.11

Back to the Case

Our patient is likely nearing the end of her life because of end-stage dementia. There is no evidence to suggest placement of a feeding tube would extend her life more than hand feeding.

We know feeding-tube placement could increase aspiration pneumonia risk and significant short- and long-term morbidity and mortality. We can keep her comfortable with small amounts of water, wetting her lips with swabs. If a feeding tube is placed, its use should be evaluated based on the patient’s clinical course. TH

Dr. Pell is an instructor of medicine in the Section of Hospital Medicine at the University of Colorado, Denver.

References

1. Gauderer MW, Ponsky JL, Izant RJ Jr. Gastrostomy without laparotomy: a percutaneous endoscopic technique. J Pediatr Surg. 1980;15(6):872-875.
2. Hebert LE, Beckett LA, Scherr PA, and Evans DA. Annual incidence of Alzheimer disease in the United States projected to the years 2000 through 2050. Alzheimer Dis Assoc Disord. 2001;15:169-173.
3. Grant MD, Rudberg MA, Brody JA. Gastrostomy placement and mortality among hospitalized Medicare beneficiaries. JAMA. 1998;279:1973-1976.
4. Finocchiaro C, Galletti R, Rovera G, et al. Percutaneous endoscopic gastrostomy: a long-term follow-up. Nutrition. 1997;13(6):520-523.
5. Leibovitz A, Plotnikov G, Habot B, et al. Pathogenic colonization of oral flora in frail elderly patients fed by nasogastric tube or percutaneous enterogastric tube. J Gerontol A Biol Sci Med. 2003;58(1):52-55.
6. McCann R. Lack of evidence about tube feeding: food for thought. JAMA. 1999;282(14):1380-1381.
7. Cameron JL, Caldini P, Toung J-K, et al. Aspiration pneumonia: physiologic data following experimental Aspiration. Surgery. 1972;72:238.
8. Loeb MB, Becker M, Eady A, et al. Interventions to prevent aspiration pneumonia in older adults: a systematic review. JAGS. 2003;51(7):1018-1022.
9. Mitchell SL, Kiely DK, Lipsitz LA. The risk factors and impact on survival of feeding tube placement in nursing home residents with severe cognitive impairment. Arch Intern Med. 1997;157:327-332.
10. McCann RM, Hall WJ, Groth-Junker A. Comfort care for terminally ill patients: the appropriate use of nutrition and hydration. JAMA. 1994;272:1263-1266.
11. Rabeneck L, McCullough LB. Ethically justified, clinically comprehensive guidelines for percutaneous endoscopic gastrostomy tube placement. Lancet. 1997;349(9050):496-498.

Case

A 68-year-old cachectic female with a history of Alzheimer’s dementia presents with a slowly progressive decline in functional status. She is bed bound, minimally verbal, and has lost interest in eating.

Her problems with decreased oral intake started when her diet was changed to nectar-thickened liquids. This change was made after the patient was hospitalized multiple times for aspiration pneumonia and she underwent a fluoroscopic swallowing evaluation that revealed aspiration of thin liquids. The patient’s husband requests that a feeding tube be placed so his wife doesn’t “die of pneumonia or starve to death.”

Overview

As the U.S. population ages, hospitalists are seeing a steady increase in the average patient age and the prevalence of dementia. Alzheimer’s dementia affects an estimated 4 million to 5 million Americans; this number expected to triple by the year 2050.1

As patients with dementia near the end of life, they often fail to thrive, with less oral intake and more swallowing disorders leading to aspiration. This is when physicians and patient family members must decide whether a feeding tube should be placed.

Placement of a nasogastric or percutaneous endogastric gastrostomy (PEG) feeding tube has become a relatively common medical intervention instituted to maintain or improve a patient’s nutritional status. Prior to 1980, permanent gastric or postpyloric feeding tubes were placed surgically by laparotomy, but the advent of endoscopy and computed tomography (CT) guided procedures offers a simplified procedure requiring only mild sedation and local anesthesia.2

Many patients who suffer multiple bouts of aspiration pneumonia and fail a swallowing evaluation because of an irreversible process are offered a percutaneous feeding tube to maintain nutrition. A feeding tube is also seen as a way to supply nutrition at the end of life in patients no longer able or willing to take food orally.

Although it seems logical that a feeding tube might improve the outcomes of these clinical scenarios, limited literature exists on the topic because of the legal, ethical, emotional, and religious implications a large, randomized, placebo-controlled trial would entail.

Review of the Data

Placement of a PEG has become accepted as a relatively benign procedure, although it is associated with significant morbidity and mortality. Minor complications including pain, abdominal wall ulcers, wound infections, peristomal leakage, and tube displacement occur in approximately 10% of cases.3 Major complications including hemorrhage, bowel or liver perforation, or aspiration occur in 3% of cases.4

These numbers do not account for long-term complications including peristomal infections, leakage problems, or the use of physical restraints to avoid self-extubation.

click for large version

Aspiration Risk

A common indication for PEG placement is aspiration risk. PEG tubes are often placed in patients who fail swallowing evaluations in order to decrease their risk of aspiration and aspiration pneumonia.

True aspiration pneumonia is thought to originate from an inoculum of oral cavity or nasopharynx bacteria, which placement of a PEG tube would not prevent. Leibovitz, et al., showed that elderly patients with nasogastric or percutaneous feeding tubes are associated with colonization of the oropharynx with more pathogenic bacteria when compared with orally fed patients.5 Thus, the use of PEG tubes might put them at higher risk for pathogenic inoculation.

Aspiration pneumonia occurs in up to 50% of patients with feeding tubes. Studies have shown PEG tube placement decreases lower esophageal sphincter tone, potentially increasing regurgitation risk.6 It has also been shown that aspiration of gastric contents produces a pneumonitis with the resultant inflammatory response allowing for establishment of infection by smaller inoculums of or less virulent organisms.7

Small, randomized trials have shown no decrease in aspiration risk with post-pyloric versus gastric feeding tubes, nasogastric versus percutaneous feeding tubes, or continuous versus intermittent tube feeds.8 There have been no sizable randomized prospective trials to determine if feeding tube placement versus hand feeding patients with end-stage dementia alters aspiration pneumonia risk.

Pressure Ulcers

Patients with end-stage dementia often become bed bound as their disease progresses, and they commonly suffer from pressure ulcers. Pressure ulcers often coexist in patients with malnutrition, and it is well established that patients with biochemical markers of malnutrition are at higher risk for pressure ulcer formation.

Still, no studies show that improved nutrition prevents pressure ulcer formation. In a nursing home population of patients with dementia, a two-year follow-up study showed no significant improvement in pressure ulcer healing or decreased ulcer formation with nutrition by feeding tube.9 These studies are adjusted for independent risk factors for mortality and indication for PEG placement, but we can assume there are confounders that go into the decision for feeding tube placement that are not necessarily identifiable.

click for large version

Nutritional Status

Family members are often concerned that if the patient is unable to take food by mouth and no feeding tube is placed, then the patient will suffer from the discomfort of starvation and dehydration.

As a patient with a severe dementing illness enters the end stage of his/her clinical course, practitioners frequently make a plan with families to change the goals of care toward keeping the patient comfortable. Comfort is a difficult clinical parameter to measure, but studies in the hospice population of patients with end-stage cancer and AIDS report that the hunger and thirst are transient and improve with ice chips and mouth swabs.10

Despite the lack of evidence of PEG tubes prolonging survival in patients with dementia who are no longer able or willing to take in food orally, it is logical that withholding all hydration or nutritional support will hasten death despite the risks associated with feeding tubes. This is where the ethical argument arises regarding prolonging life of decreasing quality.

In certain medical and legal sectors, artificial nutrition, and hydration are considered a medical intervention. Therefore, the ideals of patient autonomy dictate that the patient’s proxy should decide whether or not the patient would have wanted the intervention after weighing the risks and benefits.

If hospitalists view artificial nutrition as a medical intervention, our moral obligation is to instruct patients and their families about these risks and benefits.

Often, the patient will not clinically improve with artificial nutrition. But we can maintain physiologic processes or at least slow their decline.

Emerging research indicates the standard of care in how we present this information is changing to include presentation of data instead of only using a patient’s suspected beliefs about quality of life.

A useful algorithm proposed by Rabeneck, et al., provides comprehensive guidelines for PEG placement in all patient populations based on the reason for PEG consideration.11

Back to the Case

Our patient is likely nearing the end of her life because of end-stage dementia. There is no evidence to suggest placement of a feeding tube would extend her life more than hand feeding.

We know feeding-tube placement could increase aspiration pneumonia risk and significant short- and long-term morbidity and mortality. We can keep her comfortable with small amounts of water, wetting her lips with swabs. If a feeding tube is placed, its use should be evaluated based on the patient’s clinical course. TH

Dr. Pell is an instructor of medicine in the Section of Hospital Medicine at the University of Colorado, Denver.

References

1. Gauderer MW, Ponsky JL, Izant RJ Jr. Gastrostomy without laparotomy: a percutaneous endoscopic technique. J Pediatr Surg. 1980;15(6):872-875.
2. Hebert LE, Beckett LA, Scherr PA, and Evans DA. Annual incidence of Alzheimer disease in the United States projected to the years 2000 through 2050. Alzheimer Dis Assoc Disord. 2001;15:169-173.
3. Grant MD, Rudberg MA, Brody JA. Gastrostomy placement and mortality among hospitalized Medicare beneficiaries. JAMA. 1998;279:1973-1976.
4. Finocchiaro C, Galletti R, Rovera G, et al. Percutaneous endoscopic gastrostomy: a long-term follow-up. Nutrition. 1997;13(6):520-523.
5. Leibovitz A, Plotnikov G, Habot B, et al. Pathogenic colonization of oral flora in frail elderly patients fed by nasogastric tube or percutaneous enterogastric tube. J Gerontol A Biol Sci Med. 2003;58(1):52-55.
6. McCann R. Lack of evidence about tube feeding: food for thought. JAMA. 1999;282(14):1380-1381.
7. Cameron JL, Caldini P, Toung J-K, et al. Aspiration pneumonia: physiologic data following experimental Aspiration. Surgery. 1972;72:238.
8. Loeb MB, Becker M, Eady A, et al. Interventions to prevent aspiration pneumonia in older adults: a systematic review. JAGS. 2003;51(7):1018-1022.
9. Mitchell SL, Kiely DK, Lipsitz LA. The risk factors and impact on survival of feeding tube placement in nursing home residents with severe cognitive impairment. Arch Intern Med. 1997;157:327-332.
10. McCann RM, Hall WJ, Groth-Junker A. Comfort care for terminally ill patients: the appropriate use of nutrition and hydration. JAMA. 1994;272:1263-1266.
11. Rabeneck L, McCullough LB. Ethically justified, clinically comprehensive guidelines for percutaneous endoscopic gastrostomy tube placement. Lancet. 1997;349(9050):496-498.

Case

A 68-year-old cachectic female with a history of Alzheimer’s dementia presents with a slowly progressive decline in functional status. She is bed bound, minimally verbal, and has lost interest in eating.

Her problems with decreased oral intake started when her diet was changed to nectar-thickened liquids. This change was made after the patient was hospitalized multiple times for aspiration pneumonia and she underwent a fluoroscopic swallowing evaluation that revealed aspiration of thin liquids. The patient’s husband requests that a feeding tube be placed so his wife doesn’t “die of pneumonia or starve to death.”

Overview

As the U.S. population ages, hospitalists are seeing a steady increase in the average patient age and the prevalence of dementia. Alzheimer’s dementia affects an estimated 4 million to 5 million Americans; this number expected to triple by the year 2050.1

As patients with dementia near the end of life, they often fail to thrive, with less oral intake and more swallowing disorders leading to aspiration. This is when physicians and patient family members must decide whether a feeding tube should be placed.

Placement of a nasogastric or percutaneous endogastric gastrostomy (PEG) feeding tube has become a relatively common medical intervention instituted to maintain or improve a patient’s nutritional status. Prior to 1980, permanent gastric or postpyloric feeding tubes were placed surgically by laparotomy, but the advent of endoscopy and computed tomography (CT) guided procedures offers a simplified procedure requiring only mild sedation and local anesthesia.2

Many patients who suffer multiple bouts of aspiration pneumonia and fail a swallowing evaluation because of an irreversible process are offered a percutaneous feeding tube to maintain nutrition. A feeding tube is also seen as a way to supply nutrition at the end of life in patients no longer able or willing to take food orally.

Although it seems logical that a feeding tube might improve the outcomes of these clinical scenarios, limited literature exists on the topic because of the legal, ethical, emotional, and religious implications a large, randomized, placebo-controlled trial would entail.

Review of the Data

Placement of a PEG has become accepted as a relatively benign procedure, although it is associated with significant morbidity and mortality. Minor complications including pain, abdominal wall ulcers, wound infections, peristomal leakage, and tube displacement occur in approximately 10% of cases.3 Major complications including hemorrhage, bowel or liver perforation, or aspiration occur in 3% of cases.4

These numbers do not account for long-term complications including peristomal infections, leakage problems, or the use of physical restraints to avoid self-extubation.

click for large version

Aspiration Risk

A common indication for PEG placement is aspiration risk. PEG tubes are often placed in patients who fail swallowing evaluations in order to decrease their risk of aspiration and aspiration pneumonia.

True aspiration pneumonia is thought to originate from an inoculum of oral cavity or nasopharynx bacteria, which placement of a PEG tube would not prevent. Leibovitz, et al., showed that elderly patients with nasogastric or percutaneous feeding tubes are associated with colonization of the oropharynx with more pathogenic bacteria when compared with orally fed patients.5 Thus, the use of PEG tubes might put them at higher risk for pathogenic inoculation.

Aspiration pneumonia occurs in up to 50% of patients with feeding tubes. Studies have shown PEG tube placement decreases lower esophageal sphincter tone, potentially increasing regurgitation risk.6 It has also been shown that aspiration of gastric contents produces a pneumonitis with the resultant inflammatory response allowing for establishment of infection by smaller inoculums of or less virulent organisms.7

Small, randomized trials have shown no decrease in aspiration risk with post-pyloric versus gastric feeding tubes, nasogastric versus percutaneous feeding tubes, or continuous versus intermittent tube feeds.8 There have been no sizable randomized prospective trials to determine if feeding tube placement versus hand feeding patients with end-stage dementia alters aspiration pneumonia risk.

Pressure Ulcers

Patients with end-stage dementia often become bed bound as their disease progresses, and they commonly suffer from pressure ulcers. Pressure ulcers often coexist in patients with malnutrition, and it is well established that patients with biochemical markers of malnutrition are at higher risk for pressure ulcer formation.

Still, no studies show that improved nutrition prevents pressure ulcer formation. In a nursing home population of patients with dementia, a two-year follow-up study showed no significant improvement in pressure ulcer healing or decreased ulcer formation with nutrition by feeding tube.9 These studies are adjusted for independent risk factors for mortality and indication for PEG placement, but we can assume there are confounders that go into the decision for feeding tube placement that are not necessarily identifiable.

click for large version

Nutritional Status

Family members are often concerned that if the patient is unable to take food by mouth and no feeding tube is placed, then the patient will suffer from the discomfort of starvation and dehydration.

As a patient with a severe dementing illness enters the end stage of his/her clinical course, practitioners frequently make a plan with families to change the goals of care toward keeping the patient comfortable. Comfort is a difficult clinical parameter to measure, but studies in the hospice population of patients with end-stage cancer and AIDS report that the hunger and thirst are transient and improve with ice chips and mouth swabs.10

Despite the lack of evidence of PEG tubes prolonging survival in patients with dementia who are no longer able or willing to take in food orally, it is logical that withholding all hydration or nutritional support will hasten death despite the risks associated with feeding tubes. This is where the ethical argument arises regarding prolonging life of decreasing quality.

In certain medical and legal sectors, artificial nutrition, and hydration are considered a medical intervention. Therefore, the ideals of patient autonomy dictate that the patient’s proxy should decide whether or not the patient would have wanted the intervention after weighing the risks and benefits.

If hospitalists view artificial nutrition as a medical intervention, our moral obligation is to instruct patients and their families about these risks and benefits.

Often, the patient will not clinically improve with artificial nutrition. But we can maintain physiologic processes or at least slow their decline.

Emerging research indicates the standard of care in how we present this information is changing to include presentation of data instead of only using a patient’s suspected beliefs about quality of life.

A useful algorithm proposed by Rabeneck, et al., provides comprehensive guidelines for PEG placement in all patient populations based on the reason for PEG consideration.11

Back to the Case

Our patient is likely nearing the end of her life because of end-stage dementia. There is no evidence to suggest placement of a feeding tube would extend her life more than hand feeding.

We know feeding-tube placement could increase aspiration pneumonia risk and significant short- and long-term morbidity and mortality. We can keep her comfortable with small amounts of water, wetting her lips with swabs. If a feeding tube is placed, its use should be evaluated based on the patient’s clinical course. TH

Dr. Pell is an instructor of medicine in the Section of Hospital Medicine at the University of Colorado, Denver.

References

1. Gauderer MW, Ponsky JL, Izant RJ Jr. Gastrostomy without laparotomy: a percutaneous endoscopic technique. J Pediatr Surg. 1980;15(6):872-875.
2. Hebert LE, Beckett LA, Scherr PA, and Evans DA. Annual incidence of Alzheimer disease in the United States projected to the years 2000 through 2050. Alzheimer Dis Assoc Disord. 2001;15:169-173.
3. Grant MD, Rudberg MA, Brody JA. Gastrostomy placement and mortality among hospitalized Medicare beneficiaries. JAMA. 1998;279:1973-1976.
4. Finocchiaro C, Galletti R, Rovera G, et al. Percutaneous endoscopic gastrostomy: a long-term follow-up. Nutrition. 1997;13(6):520-523.
5. Leibovitz A, Plotnikov G, Habot B, et al. Pathogenic colonization of oral flora in frail elderly patients fed by nasogastric tube or percutaneous enterogastric tube. J Gerontol A Biol Sci Med. 2003;58(1):52-55.
6. McCann R. Lack of evidence about tube feeding: food for thought. JAMA. 1999;282(14):1380-1381.
7. Cameron JL, Caldini P, Toung J-K, et al. Aspiration pneumonia: physiologic data following experimental Aspiration. Surgery. 1972;72:238.
8. Loeb MB, Becker M, Eady A, et al. Interventions to prevent aspiration pneumonia in older adults: a systematic review. JAGS. 2003;51(7):1018-1022.
9. Mitchell SL, Kiely DK, Lipsitz LA. The risk factors and impact on survival of feeding tube placement in nursing home residents with severe cognitive impairment. Arch Intern Med. 1997;157:327-332.
10. McCann RM, Hall WJ, Groth-Junker A. Comfort care for terminally ill patients: the appropriate use of nutrition and hydration. JAMA. 1994;272:1263-1266.
11. Rabeneck L, McCullough LB. Ethically justified, clinically comprehensive guidelines for percutaneous endoscopic gastrostomy tube placement. Lancet. 1997;349(9050):496-498.

In the best interests of the patient. In accordance with the patient’s wishes. Preserving patient autonomy. These concepts are at the core of modern medical decision-making.

Traditionally medical decisions are made by hospitalists and communicated to patients. This approach has shifted to an emphasis on patient autonomy and input in decision-making.

But what about the patient unable to make decisions or provide input to the medical caregivers? How can the comatose or incompetent patient participate in his or her own care decisions? What happens when half of a team is no longer able to share team functions?

In these instances, hospitalists rely on surrogates. A surrogate is empowered not only to speak for but also to make legal decisions for a patient. The relationship becomes a triad of hospitalist, surrogate, and patient. This triad must include:

• A hospitalist who brings the same degree of trust, respect, and open communication to the new relationship;
• A surrogate who is an active participant rather than a passive spokesperson; and
• A patient whose interests are the primary goal.

Key Issues

The aging of the population and the increased prevalence of medical conditions causing cognitive impairment point up the need to take a closer look at the hospitalist-surrogate relationship. A study this year outlined four key issues:

• There are unique challenges for both parties in creating a hospitalist-surrogate relationship;
• The hospitalist and surrogate are dealing not only with each other but also with the decision-making role each will play in regard to the patient;
• The surrogate must understand that serving as a surrogate for a loved one is completely different from making decisions for oneself; and
• There may be more than one surrogate decision maker.1

The first challenge facing hospitalist and surrogate is establishing a foundation of trust, respect, and a treatment plan. Their perspectives play a critical role: The surrogate knows the patient as a lively, engaged, and interesting individual, while the hospitalist has seen the patient only in a nonresponsive, incapacitated state. Opening an immediate line of communication is the best way to assume their respective responsibilities.

Second, even after the hospitalist and surrogate develop an initial working relationship, they may still need to outline mutually satisfying ways to share decision-making with the patient. Both must balance their concern for the patient, their understanding of the patient’s status, and their perspectives of what the patient would want. With time pressures and the capabilities of modern technology, this mutual decision-making responsibility may seem daunting.

Third, surrogates may discover a conflict between their personal values and their patient’s. They may have to make a decision that reflects their patient’s wishes yet contradicts their own beliefs. Sometimes hospitalists can help the surrogate resolve this dilemma by suggesting consultations with other family members or professionals.

The fourth issue, multiple surrogates, may magnify the challenges but can also be an advantage. In most cases families, even those with members who have differing belief systems, tend to support each other during crises to reach a consensus in the patient’s best interests.

Tom Baudendistel, MD, a hospitalist at California Pacific Medical Center in San Francisco, says that although engaging in a dialogue with the multiple surrogates may reveal a family conflict, mistrust, or other issues, the problem is usually resolved. “One surrogate comes around after we make sure the one disagreeing sees in person what the patient is going through, the low quality of life,” says Dr. Baudendistel.

Howard Epstein, MD, medical director, Care Management and Palliative Care, Regions Hospital, St. Paul, Minn., suggests a different approach. “We ask the surrogate to imagine that if the patient could stand outside his or her body, hearing everything that is being said, what would he or she say?” says Dr. Epstein.

The Process

While these issues affect all hospitalists who work with surrogates, hospitalists often encounter additional circumstances that require special attention. These are not always problems but may be situations unique to the hospital setting or the hospitalist’s job.

The hospitalist’s first contact with a patient is often the patient’s admission to the hospital. The hospitalist is most often starting with a blank page with no background information. Gathering information quickly about an unknown patient is critical.

This duty often falls to hospitalists. Donald Krause, MD, medical director for quality assurance at St. Joseph Hospital in Bangor, Maine, and a hospitalist for 11 years, points out that “hospitalists take care of 90% of medical admissions and as part of this job arrange for surrogates if needed as well as anything else to help the patient.”

Beginning with the admission of a patient, the hospitalist may take on the responsibility of finding a surrogate.

Find a surrogate: When a patient is admitted, the hospitalist questions everyone connected to the patient about the existence of a surrogate or family spokesperson. If there is no information available, many hospitalists turn to other staff experts, such as social workers or chaplains, to seek people who know the patient.

Dr. Baudendistel says his medical center resuscitates “unbefriended” patients admitted to the emergency department to allow time to find a family member or surrogate. “Social workers then search the Internet, call shelters, and contact other hospitals and institutions to learn anything they can about the patient,” he says. If the search is unsuccessful, the hospitalist usually consults the institution’s ethics committee for additional suggestions.

Don C. Postema, PhD, ethics consultant for Regions Hospital, chair of the HealthPartners Ethics Committee, and ethicist-in-residence at Gillette Children’s Specialty HealthCare in St. Paul, Minn., proposes that an ethics committee look beyond the standard candidates in searching for a surrogate. “The legal relationship of a potential surrogate to the patient is secondary to what I consider to be the primary relationship, that is, the person who knows the patient best,” says Dr. Postema. “It could be the patient’s landlord or a neighbor who sees the patient on a regular basis.”

What about the patient whose family lives too far away to see the patient on a regular basis? Look into hiring a local geriatric case manager, Dr. Epstein advises.

There is one person who should not serve as a patient’s surrogate: the attending physician, whether a hospitalist or the primary caregiver. Erin Egan, MD, JD, assistant professor of hospital medicine, University of Colorado Hospitals, warns that a hospitalist acting as a surrogate has a conflict of interest. “Most states prohibit hospitalists from acting as surrogates,” Dr. Egan warns. “In some cases a doctor can presume consent for a short time before a surrogate is appointed in order to make an immediate medical decision. As a general rule, however, a clinician should never assume the surrogate’s role.”

Look for advance directives: Ideally, every patient’s file would contain an advance directive indicating a surrogate or a note that there is no surrogate.2 In addition, there should be a healthcare advance directive, also known as a healthcare power of attorney, that appoints a surrogate. It is often accompanied by a living will, an instruction sheet stipulating what treatment the patient wants if he or she is unable to speak or communicate. Unfortunately, many hospitalists cannot find these documents when they admit a patient.

In this case, the hospitalist must search. Most hospitals, nursing homes, or home healthcare agencies are required by the federal Patient Self-Determination Act (PSDA) to offer information about advance directives at the time of admission. This information states the patient’s healthcare decision-making rights under state law and the institution’s policy about adhering to advance directives. Contacting these agencies is a starting point.

Make difficult decisions: While some advance directives carry legal power, they often are not helpful to hospitalists or surrogates making end-of-life decisions. Because a medical crisis cannot always be predicted and treatment options change rapidly, a specific directive may not be as helpful as a written description of a patient’s beliefs, religious convictions, and cultural values. Equally valuable are notes about conversations among patients, family members, friends, and caregivers.3 This creates a picture of the patient’s feelings about quality of life, treatment preferences, and end-of-life outcomes.

The hospitalist’s role in this situation is to facilitate such discussions among all family and friends involved. The goal is to develop an accurate picture of the patient to make appropriate decisions. The hospitalist should explore the cultural values and religious beliefs of the patient, surrogate, family, and friends. “Different ethnic groups view medical care differently,” says Richard L. Heinrich, MD, medical director of Hospice of the Lakes, Bloomington, Minn. “Some religions believe that suffering in this life is rewarded in the next life, which makes a difference when making treatment decisions,” he says. “We must honor and work with cultural values unless in our view the individual is suffering needlessly.”

The hospitalist should be alert to the need for an interpreter and anything else that will promote a meaningful discussion. And, the hospitalist and the medical staff should be prepared to share as much medical information as is possible, including individual staff opinions, the rationale behind recommendations, and the pros and cons of each suggestion. The surrogate and family cannot make any meaningful contribution without all the pertinent information.

The goal should be a consensus about the patient’s best interests, how certain medical decisions will provide benefit or burden to the patient, and if the decision is what the patient would want. It’s especially critical to call a family conference to allow everyone the opportunity to discuss the patient’s concept of his or her death.

“Most people are afraid of getting caught in an end-of-life situation where they lose control,” says Dr. Postema. TH

Ann Kepler is a medical writer based in Chicago.

References

1. Torke AM, Alexander GC, Lantos J, et al. The physician-surrogate relationship. Arch Intern Med. 2007 Jun 11;167(11):1117-1121.
2. Wenger NS, Rosenfeld K. Quality indicators for end-of-life care in vulnerable elders. Ann Intern Med. 2001 Oct 16;135(8):677-685.
3. Bloche MG. Managing conflict at the end of life. N Engl J Med. 2005 Jun 9;352:2371-2373.

In the best interests of the patient. In accordance with the patient’s wishes. Preserving patient autonomy. These concepts are at the core of modern medical decision-making.

Traditionally medical decisions are made by hospitalists and communicated to patients. This approach has shifted to an emphasis on patient autonomy and input in decision-making.

But what about the patient unable to make decisions or provide input to the medical caregivers? How can the comatose or incompetent patient participate in his or her own care decisions? What happens when half of a team is no longer able to share team functions?

In these instances, hospitalists rely on surrogates. A surrogate is empowered not only to speak for but also to make legal decisions for a patient. The relationship becomes a triad of hospitalist, surrogate, and patient. This triad must include:

• A hospitalist who brings the same degree of trust, respect, and open communication to the new relationship;
• A surrogate who is an active participant rather than a passive spokesperson; and
• A patient whose interests are the primary goal.

Key Issues

The aging of the population and the increased prevalence of medical conditions causing cognitive impairment point up the need to take a closer look at the hospitalist-surrogate relationship. A study this year outlined four key issues:

• There are unique challenges for both parties in creating a hospitalist-surrogate relationship;
• The hospitalist and surrogate are dealing not only with each other but also with the decision-making role each will play in regard to the patient;
• The surrogate must understand that serving as a surrogate for a loved one is completely different from making decisions for oneself; and
• There may be more than one surrogate decision maker.1

The first challenge facing hospitalist and surrogate is establishing a foundation of trust, respect, and a treatment plan. Their perspectives play a critical role: The surrogate knows the patient as a lively, engaged, and interesting individual, while the hospitalist has seen the patient only in a nonresponsive, incapacitated state. Opening an immediate line of communication is the best way to assume their respective responsibilities.

Second, even after the hospitalist and surrogate develop an initial working relationship, they may still need to outline mutually satisfying ways to share decision-making with the patient. Both must balance their concern for the patient, their understanding of the patient’s status, and their perspectives of what the patient would want. With time pressures and the capabilities of modern technology, this mutual decision-making responsibility may seem daunting.

Third, surrogates may discover a conflict between their personal values and their patient’s. They may have to make a decision that reflects their patient’s wishes yet contradicts their own beliefs. Sometimes hospitalists can help the surrogate resolve this dilemma by suggesting consultations with other family members or professionals.

The fourth issue, multiple surrogates, may magnify the challenges but can also be an advantage. In most cases families, even those with members who have differing belief systems, tend to support each other during crises to reach a consensus in the patient’s best interests.

Tom Baudendistel, MD, a hospitalist at California Pacific Medical Center in San Francisco, says that although engaging in a dialogue with the multiple surrogates may reveal a family conflict, mistrust, or other issues, the problem is usually resolved. “One surrogate comes around after we make sure the one disagreeing sees in person what the patient is going through, the low quality of life,” says Dr. Baudendistel.

Howard Epstein, MD, medical director, Care Management and Palliative Care, Regions Hospital, St. Paul, Minn., suggests a different approach. “We ask the surrogate to imagine that if the patient could stand outside his or her body, hearing everything that is being said, what would he or she say?” says Dr. Epstein.

The Process

While these issues affect all hospitalists who work with surrogates, hospitalists often encounter additional circumstances that require special attention. These are not always problems but may be situations unique to the hospital setting or the hospitalist’s job.

The hospitalist’s first contact with a patient is often the patient’s admission to the hospital. The hospitalist is most often starting with a blank page with no background information. Gathering information quickly about an unknown patient is critical.

This duty often falls to hospitalists. Donald Krause, MD, medical director for quality assurance at St. Joseph Hospital in Bangor, Maine, and a hospitalist for 11 years, points out that “hospitalists take care of 90% of medical admissions and as part of this job arrange for surrogates if needed as well as anything else to help the patient.”

Beginning with the admission of a patient, the hospitalist may take on the responsibility of finding a surrogate.

Find a surrogate: When a patient is admitted, the hospitalist questions everyone connected to the patient about the existence of a surrogate or family spokesperson. If there is no information available, many hospitalists turn to other staff experts, such as social workers or chaplains, to seek people who know the patient.

Dr. Baudendistel says his medical center resuscitates “unbefriended” patients admitted to the emergency department to allow time to find a family member or surrogate. “Social workers then search the Internet, call shelters, and contact other hospitals and institutions to learn anything they can about the patient,” he says. If the search is unsuccessful, the hospitalist usually consults the institution’s ethics committee for additional suggestions.

Don C. Postema, PhD, ethics consultant for Regions Hospital, chair of the HealthPartners Ethics Committee, and ethicist-in-residence at Gillette Children’s Specialty HealthCare in St. Paul, Minn., proposes that an ethics committee look beyond the standard candidates in searching for a surrogate. “The legal relationship of a potential surrogate to the patient is secondary to what I consider to be the primary relationship, that is, the person who knows the patient best,” says Dr. Postema. “It could be the patient’s landlord or a neighbor who sees the patient on a regular basis.”

What about the patient whose family lives too far away to see the patient on a regular basis? Look into hiring a local geriatric case manager, Dr. Epstein advises.

There is one person who should not serve as a patient’s surrogate: the attending physician, whether a hospitalist or the primary caregiver. Erin Egan, MD, JD, assistant professor of hospital medicine, University of Colorado Hospitals, warns that a hospitalist acting as a surrogate has a conflict of interest. “Most states prohibit hospitalists from acting as surrogates,” Dr. Egan warns. “In some cases a doctor can presume consent for a short time before a surrogate is appointed in order to make an immediate medical decision. As a general rule, however, a clinician should never assume the surrogate’s role.”

Look for advance directives: Ideally, every patient’s file would contain an advance directive indicating a surrogate or a note that there is no surrogate.2 In addition, there should be a healthcare advance directive, also known as a healthcare power of attorney, that appoints a surrogate. It is often accompanied by a living will, an instruction sheet stipulating what treatment the patient wants if he or she is unable to speak or communicate. Unfortunately, many hospitalists cannot find these documents when they admit a patient.

In this case, the hospitalist must search. Most hospitals, nursing homes, or home healthcare agencies are required by the federal Patient Self-Determination Act (PSDA) to offer information about advance directives at the time of admission. This information states the patient’s healthcare decision-making rights under state law and the institution’s policy about adhering to advance directives. Contacting these agencies is a starting point.

Make difficult decisions: While some advance directives carry legal power, they often are not helpful to hospitalists or surrogates making end-of-life decisions. Because a medical crisis cannot always be predicted and treatment options change rapidly, a specific directive may not be as helpful as a written description of a patient’s beliefs, religious convictions, and cultural values. Equally valuable are notes about conversations among patients, family members, friends, and caregivers.3 This creates a picture of the patient’s feelings about quality of life, treatment preferences, and end-of-life outcomes.

The hospitalist’s role in this situation is to facilitate such discussions among all family and friends involved. The goal is to develop an accurate picture of the patient to make appropriate decisions. The hospitalist should explore the cultural values and religious beliefs of the patient, surrogate, family, and friends. “Different ethnic groups view medical care differently,” says Richard L. Heinrich, MD, medical director of Hospice of the Lakes, Bloomington, Minn. “Some religions believe that suffering in this life is rewarded in the next life, which makes a difference when making treatment decisions,” he says. “We must honor and work with cultural values unless in our view the individual is suffering needlessly.”

The hospitalist should be alert to the need for an interpreter and anything else that will promote a meaningful discussion. And, the hospitalist and the medical staff should be prepared to share as much medical information as is possible, including individual staff opinions, the rationale behind recommendations, and the pros and cons of each suggestion. The surrogate and family cannot make any meaningful contribution without all the pertinent information.

The goal should be a consensus about the patient’s best interests, how certain medical decisions will provide benefit or burden to the patient, and if the decision is what the patient would want. It’s especially critical to call a family conference to allow everyone the opportunity to discuss the patient’s concept of his or her death.

“Most people are afraid of getting caught in an end-of-life situation where they lose control,” says Dr. Postema. TH

Ann Kepler is a medical writer based in Chicago.

References

1. Torke AM, Alexander GC, Lantos J, et al. The physician-surrogate relationship. Arch Intern Med. 2007 Jun 11;167(11):1117-1121.
2. Wenger NS, Rosenfeld K. Quality indicators for end-of-life care in vulnerable elders. Ann Intern Med. 2001 Oct 16;135(8):677-685.
3. Bloche MG. Managing conflict at the end of life. N Engl J Med. 2005 Jun 9;352:2371-2373.

In the best interests of the patient. In accordance with the patient’s wishes. Preserving patient autonomy. These concepts are at the core of modern medical decision-making.

Traditionally medical decisions are made by hospitalists and communicated to patients. This approach has shifted to an emphasis on patient autonomy and input in decision-making.

But what about the patient unable to make decisions or provide input to the medical caregivers? How can the comatose or incompetent patient participate in his or her own care decisions? What happens when half of a team is no longer able to share team functions?

In these instances, hospitalists rely on surrogates. A surrogate is empowered not only to speak for but also to make legal decisions for a patient. The relationship becomes a triad of hospitalist, surrogate, and patient. This triad must include:

• A hospitalist who brings the same degree of trust, respect, and open communication to the new relationship;
• A surrogate who is an active participant rather than a passive spokesperson; and
• A patient whose interests are the primary goal.

Key Issues

The aging of the population and the increased prevalence of medical conditions causing cognitive impairment point up the need to take a closer look at the hospitalist-surrogate relationship. A study this year outlined four key issues:

• There are unique challenges for both parties in creating a hospitalist-surrogate relationship;
• The hospitalist and surrogate are dealing not only with each other but also with the decision-making role each will play in regard to the patient;
• The surrogate must understand that serving as a surrogate for a loved one is completely different from making decisions for oneself; and
• There may be more than one surrogate decision maker.1

The first challenge facing hospitalist and surrogate is establishing a foundation of trust, respect, and a treatment plan. Their perspectives play a critical role: The surrogate knows the patient as a lively, engaged, and interesting individual, while the hospitalist has seen the patient only in a nonresponsive, incapacitated state. Opening an immediate line of communication is the best way to assume their respective responsibilities.

Second, even after the hospitalist and surrogate develop an initial working relationship, they may still need to outline mutually satisfying ways to share decision-making with the patient. Both must balance their concern for the patient, their understanding of the patient’s status, and their perspectives of what the patient would want. With time pressures and the capabilities of modern technology, this mutual decision-making responsibility may seem daunting.

Third, surrogates may discover a conflict between their personal values and their patient’s. They may have to make a decision that reflects their patient’s wishes yet contradicts their own beliefs. Sometimes hospitalists can help the surrogate resolve this dilemma by suggesting consultations with other family members or professionals.

The fourth issue, multiple surrogates, may magnify the challenges but can also be an advantage. In most cases families, even those with members who have differing belief systems, tend to support each other during crises to reach a consensus in the patient’s best interests.

Tom Baudendistel, MD, a hospitalist at California Pacific Medical Center in San Francisco, says that although engaging in a dialogue with the multiple surrogates may reveal a family conflict, mistrust, or other issues, the problem is usually resolved. “One surrogate comes around after we make sure the one disagreeing sees in person what the patient is going through, the low quality of life,” says Dr. Baudendistel.

Howard Epstein, MD, medical director, Care Management and Palliative Care, Regions Hospital, St. Paul, Minn., suggests a different approach. “We ask the surrogate to imagine that if the patient could stand outside his or her body, hearing everything that is being said, what would he or she say?” says Dr. Epstein.

The Process

While these issues affect all hospitalists who work with surrogates, hospitalists often encounter additional circumstances that require special attention. These are not always problems but may be situations unique to the hospital setting or the hospitalist’s job.

The hospitalist’s first contact with a patient is often the patient’s admission to the hospital. The hospitalist is most often starting with a blank page with no background information. Gathering information quickly about an unknown patient is critical.

This duty often falls to hospitalists. Donald Krause, MD, medical director for quality assurance at St. Joseph Hospital in Bangor, Maine, and a hospitalist for 11 years, points out that “hospitalists take care of 90% of medical admissions and as part of this job arrange for surrogates if needed as well as anything else to help the patient.”

Beginning with the admission of a patient, the hospitalist may take on the responsibility of finding a surrogate.

Find a surrogate: When a patient is admitted, the hospitalist questions everyone connected to the patient about the existence of a surrogate or family spokesperson. If there is no information available, many hospitalists turn to other staff experts, such as social workers or chaplains, to seek people who know the patient.

Dr. Baudendistel says his medical center resuscitates “unbefriended” patients admitted to the emergency department to allow time to find a family member or surrogate. “Social workers then search the Internet, call shelters, and contact other hospitals and institutions to learn anything they can about the patient,” he says. If the search is unsuccessful, the hospitalist usually consults the institution’s ethics committee for additional suggestions.

Don C. Postema, PhD, ethics consultant for Regions Hospital, chair of the HealthPartners Ethics Committee, and ethicist-in-residence at Gillette Children’s Specialty HealthCare in St. Paul, Minn., proposes that an ethics committee look beyond the standard candidates in searching for a surrogate. “The legal relationship of a potential surrogate to the patient is secondary to what I consider to be the primary relationship, that is, the person who knows the patient best,” says Dr. Postema. “It could be the patient’s landlord or a neighbor who sees the patient on a regular basis.”

What about the patient whose family lives too far away to see the patient on a regular basis? Look into hiring a local geriatric case manager, Dr. Epstein advises.

There is one person who should not serve as a patient’s surrogate: the attending physician, whether a hospitalist or the primary caregiver. Erin Egan, MD, JD, assistant professor of hospital medicine, University of Colorado Hospitals, warns that a hospitalist acting as a surrogate has a conflict of interest. “Most states prohibit hospitalists from acting as surrogates,” Dr. Egan warns. “In some cases a doctor can presume consent for a short time before a surrogate is appointed in order to make an immediate medical decision. As a general rule, however, a clinician should never assume the surrogate’s role.”

Look for advance directives: Ideally, every patient’s file would contain an advance directive indicating a surrogate or a note that there is no surrogate.2 In addition, there should be a healthcare advance directive, also known as a healthcare power of attorney, that appoints a surrogate. It is often accompanied by a living will, an instruction sheet stipulating what treatment the patient wants if he or she is unable to speak or communicate. Unfortunately, many hospitalists cannot find these documents when they admit a patient.

In this case, the hospitalist must search. Most hospitals, nursing homes, or home healthcare agencies are required by the federal Patient Self-Determination Act (PSDA) to offer information about advance directives at the time of admission. This information states the patient’s healthcare decision-making rights under state law and the institution’s policy about adhering to advance directives. Contacting these agencies is a starting point.

Make difficult decisions: While some advance directives carry legal power, they often are not helpful to hospitalists or surrogates making end-of-life decisions. Because a medical crisis cannot always be predicted and treatment options change rapidly, a specific directive may not be as helpful as a written description of a patient’s beliefs, religious convictions, and cultural values. Equally valuable are notes about conversations among patients, family members, friends, and caregivers.3 This creates a picture of the patient’s feelings about quality of life, treatment preferences, and end-of-life outcomes.

The hospitalist’s role in this situation is to facilitate such discussions among all family and friends involved. The goal is to develop an accurate picture of the patient to make appropriate decisions. The hospitalist should explore the cultural values and religious beliefs of the patient, surrogate, family, and friends. “Different ethnic groups view medical care differently,” says Richard L. Heinrich, MD, medical director of Hospice of the Lakes, Bloomington, Minn. “Some religions believe that suffering in this life is rewarded in the next life, which makes a difference when making treatment decisions,” he says. “We must honor and work with cultural values unless in our view the individual is suffering needlessly.”

The hospitalist should be alert to the need for an interpreter and anything else that will promote a meaningful discussion. And, the hospitalist and the medical staff should be prepared to share as much medical information as is possible, including individual staff opinions, the rationale behind recommendations, and the pros and cons of each suggestion. The surrogate and family cannot make any meaningful contribution without all the pertinent information.

The goal should be a consensus about the patient’s best interests, how certain medical decisions will provide benefit or burden to the patient, and if the decision is what the patient would want. It’s especially critical to call a family conference to allow everyone the opportunity to discuss the patient’s concept of his or her death.

“Most people are afraid of getting caught in an end-of-life situation where they lose control,” says Dr. Postema. TH

Ann Kepler is a medical writer based in Chicago.

References

1. Torke AM, Alexander GC, Lantos J, et al. The physician-surrogate relationship. Arch Intern Med. 2007 Jun 11;167(11):1117-1121.
2. Wenger NS, Rosenfeld K. Quality indicators for end-of-life care in vulnerable elders. Ann Intern Med. 2001 Oct 16;135(8):677-685.
3. Bloche MG. Managing conflict at the end of life. N Engl J Med. 2005 Jun 9;352:2371-2373.

In the first part of this two-part series, we examined the implications of international medical graduates (IMGs) in hospital medicine groups (November 2007, p. 1). Part 2 features stories from hospitalist IMGs as they establish themselves as professionals in their communities.

December 2005 was a tough time for Charles Onunkwo, MD, and his wife. He had been working since July 1 as a hospitalist with St. Clare’s Hospital in Wausau, a small town in central Wisconsin, and had just received alarming news. His H1-B visa transfer, filed by his immigration attorney, had been denied.

His wife’s application to change from a visitor visa to an H-4 (dependent of an H1-B visa holder) was also denied. As a result, his wife was considered “unlawfully present” in the country. Dr. Onunkwo was now “out of status,” because the Naturalization and Immigration Service (INS) did not recognize St. Clare’s as exempt from caps on the annual number of H1-B visas granted. The couple was faced with a mandatory return trip to their native Nigeria, and no guarantee that the U.S. Consulate in Lagos would grant them permission to return to the United States to work as physicians.

“It was a bad time for us,” he recalls.

Charles Onunkwo, MD, hospitalist, St. Clare’s Hospital, Wausau, Wis.

Barriers and Adjustments

The obstacles faced by IMGs in obtaining visas and eventual permanent employment status have been well documented.1 For the Onunkwos, the story had a good outcome: a new immigration attorney hired by St. Clare’s was able to establish the hospital as a “cap-exempt” organization. Intervention by the staff of Rep. David R. Obey, D-Wis., allowed them to secure new H-1B visas and a return to this country.

Dr. Onunkwo and the other hospitalist IMGs attest that immigration hurdles constitute their biggest challenges.

There can be other barriers as well. Mark Dotson, senior recruiter for Cogent Healthcare in Nashville, Tenn., has encountered resistance toward IMG candidates from hospital administrators in some communities. Concerns usually relate to candidates’ ability to communicate effectively and demonstrate appropriate bedside manner. “There are also some misperceptions about some residency programs that can hinder an international medical graduate,” he says. In addition, some communities “want the doctors to reflect the makeup of the local community.” That means in a community that is 95% Caucasian, hospital administrators may be reluctant to hire a physician of color.

Dotson says attention to communication skills should be the primary goal of IMGs, and that buy-in from hospital administrators or leaders of hospital medicine groups is critical for smooth transitions. “I think some of the best physicians we have out there are doctors who are international medical graduates who see this as their life calling,” he says. “And, I think that even people in the general population understand that IMGs are extremely intelligent, and that they work extremely hard.”

As the following stories affirm, communities in remote or medically underserved areas are often welcoming of physicians who offer much-needed primary care.

Dr. Fajardo and his wife, Beverly

A Long Journey

In 1997, Emmanuel Fajardo, MD, medical director of the hospitalist program at St. Dominic-Jackson Memorial Hospital in Jackson, Miss., found himself “between the devil and the deep blue sea.” He had just been offered a chief residency position at the Meharry Medical College Affiliated Hospitals Internal Medicine residency program and was torn between accepting that job and a J-1 waiver offer in Shubuta, Miss., a federally designated Medically Underserved Area (MUSA).

He had been waiting a full year for the J-1 visa waiver, which allows IMGs to remain in the U.S. in exchange for five years of service in an MUSA. But, he also liked teaching and was attracted to the opportunity to pass on a legacy to the junior residents and incoming interns. He elected to proceed with the waiver because it offered the opportunity to “stay here in the States and to be able to practice medicine for good.”

Born in the Philippines, Dr. Fajardo says his family was wary about his locating to a remote area in Mississippi—but he wasn’t. “When I make a decision, I go for it 100%,” he says. “In everything I do I always do my best and leave the rest to God. I was very fortunate to find out that the community was very involved in and engaged with my waiver.

“Also, to my surprise, I didn’t feel discriminated against at all. They made me feel like I’m a part of the family. There is a strong sense of community here, indeed. The only problem then was, of course, being in a small town, that whatever you do, everybody knows about it.”

Although Dr. Onunkwo moved to Wausau, Wis., a small town in a predominantly white area, he says it was not difficult for him to adjust to life there. Part of the reason, he says, is that his first overseas experience was in Ireland, where he obtained a diploma in tropical medical at the Royal College of Surgeons in Dublin and practiced in a small village nearby. In addition, he and his wife were together in Wausau. “It was probably easier for both of us because we had each other,” he says.

And then there were their great neighbors, says Dr. Onunkwo. ”They made the transition seamless,” he says. “We have formed lifelong relationships with some of our neighbors in Wausau.” The strength of those relationships became apparent on Christmas Day 2005. “They really don’t know what they have done for us,” Dr. Onunkwo recalls warmly. “When we were going through our travails, they knew something was wrong, but we didn’t tell them exactly what we were going through. They made our day for us, because they just rang our bell and here they had the three-course Christmas dinner for us.”

Dr. Patel

Prove Yourself

Dr. Onunkwo has been aware of misperceptions about his professional competency. “Depending on what part of the country you find yourself in, you need to continually prove yourself,” he says. “There is this perception, maybe due to the accent or the way you express yourself. It’s unspoken, but it’s there and you don’t need to be a rocket scientist to observe that. You need to prove that you’re good to be able to survive.”

This is easier for some than others.

“I cannot say I have experienced any barriers in that respect,” reports Gunter Kurrle, MD, lead physician with the WellStar Kennestone Hospitalist Group in Atlanta. “I’m European, like most Americans with European background, so it has not been my personal experience to encounter prejudice.” Dr. Kurrle’s journey to his present post as lead hospitalist is also atypical compared with most IMGs who come to the U.S. He initially took his foreign medical graduate examination in the late 1980s, just before the United States Medical Licensing Examination was initiated. He then returned to Germany for five years of additional training after his residency in this country. He came back to the U.S. for personal reasons (his wife is a U.S. citizen and was starting her residency training here) and found that entering hospital medicine was “a better fit than trying to start a practice on my own.”

Hemant Patel, MD, president of the American Association of Physicians of Indian Origin (AAIP), based in Oak Brook, Ill., believes discrimination toward foreign-born physicians has been greatly reduced since the early 1980s, when he entered the country. AAPI, with membership of 45,000, was founded in 1982 to offer support to IMGs from India. Physicians of Indian origin constitute the largest group of IMGs.2

“At that time, it was very difficult to obtain residency slots due to competition, and we had a lot more physicians to occupy those slots,” says Dr. Patel.

Dr. Fajardo believes the inclination to discriminate is inherent in everyone: “It’s latent, but if you give them the reason to discriminate against you, then it will manifest.” With regards to the physician-patient relationship, Dr. Fajardo reports that initially, on rare occasions, he encountered resistance from patients who were reluctant to trust their care to him because of his name (“I can’t pronounce it—are you a terrorist?”) or his looks (“You look too young to be a doctor—are you sure you can take care of me?”).

“At the end of the day, it’s very fulfilling when you hear them say, ‘Thanks a lot, doc, for getting me better,’’ says Dr. Fajardo. “I believe that it isn’t where you come from that matters; it’s what you can do.” Overall, he says, the realities of the medical profession are that “the outcome of what we do speaks for itself, and that’s what matters most.”

Dr. Onunkwo is philosophical about the initial skepticism he sometimes senses from patients and other colleagues. “I understand that people are wary of the unknown, and I think it’s just natural,” he says. “Usually, what happens in my situation is that I feel the skepticism, but I don’t do anything about it. I still treat the person with the respect that they deserve and ultimately, I just let my work do the talking. Everybody gets the same level of respect and attention that they need and nine times out of 10, before patients are done with their hospital stay, their attitudes toward me have changed.” TH

Gretchen Henkel is a frequent contributor to The Hospitalist.

References

1. Leon LR Jr, Villar H, Leon CR, et al. The journey of a foreign-trained physician to a United States residency. J Am Coll Surg. 2007 Mar;204(3):486-494.
2. Hart LG, Skillman SM, Fordyce M, et al. International medical graduate physicians in the United States: changes since 1981. Health Aff. 2007 Jul/Aug;26(4):1159-1169.

In the first part of this two-part series, we examined the implications of international medical graduates (IMGs) in hospital medicine groups (November 2007, p. 1). Part 2 features stories from hospitalist IMGs as they establish themselves as professionals in their communities.

December 2005 was a tough time for Charles Onunkwo, MD, and his wife. He had been working since July 1 as a hospitalist with St. Clare’s Hospital in Wausau, a small town in central Wisconsin, and had just received alarming news. His H1-B visa transfer, filed by his immigration attorney, had been denied.

His wife’s application to change from a visitor visa to an H-4 (dependent of an H1-B visa holder) was also denied. As a result, his wife was considered “unlawfully present” in the country. Dr. Onunkwo was now “out of status,” because the Naturalization and Immigration Service (INS) did not recognize St. Clare’s as exempt from caps on the annual number of H1-B visas granted. The couple was faced with a mandatory return trip to their native Nigeria, and no guarantee that the U.S. Consulate in Lagos would grant them permission to return to the United States to work as physicians.

“It was a bad time for us,” he recalls.

Charles Onunkwo, MD, hospitalist, St. Clare’s Hospital, Wausau, Wis.

Barriers and Adjustments

The obstacles faced by IMGs in obtaining visas and eventual permanent employment status have been well documented.1 For the Onunkwos, the story had a good outcome: a new immigration attorney hired by St. Clare’s was able to establish the hospital as a “cap-exempt” organization. Intervention by the staff of Rep. David R. Obey, D-Wis., allowed them to secure new H-1B visas and a return to this country.

Dr. Onunkwo and the other hospitalist IMGs attest that immigration hurdles constitute their biggest challenges.

There can be other barriers as well. Mark Dotson, senior recruiter for Cogent Healthcare in Nashville, Tenn., has encountered resistance toward IMG candidates from hospital administrators in some communities. Concerns usually relate to candidates’ ability to communicate effectively and demonstrate appropriate bedside manner. “There are also some misperceptions about some residency programs that can hinder an international medical graduate,” he says. In addition, some communities “want the doctors to reflect the makeup of the local community.” That means in a community that is 95% Caucasian, hospital administrators may be reluctant to hire a physician of color.

Dotson says attention to communication skills should be the primary goal of IMGs, and that buy-in from hospital administrators or leaders of hospital medicine groups is critical for smooth transitions. “I think some of the best physicians we have out there are doctors who are international medical graduates who see this as their life calling,” he says. “And, I think that even people in the general population understand that IMGs are extremely intelligent, and that they work extremely hard.”

As the following stories affirm, communities in remote or medically underserved areas are often welcoming of physicians who offer much-needed primary care.

Dr. Fajardo and his wife, Beverly

A Long Journey

In 1997, Emmanuel Fajardo, MD, medical director of the hospitalist program at St. Dominic-Jackson Memorial Hospital in Jackson, Miss., found himself “between the devil and the deep blue sea.” He had just been offered a chief residency position at the Meharry Medical College Affiliated Hospitals Internal Medicine residency program and was torn between accepting that job and a J-1 waiver offer in Shubuta, Miss., a federally designated Medically Underserved Area (MUSA).

He had been waiting a full year for the J-1 visa waiver, which allows IMGs to remain in the U.S. in exchange for five years of service in an MUSA. But, he also liked teaching and was attracted to the opportunity to pass on a legacy to the junior residents and incoming interns. He elected to proceed with the waiver because it offered the opportunity to “stay here in the States and to be able to practice medicine for good.”

Born in the Philippines, Dr. Fajardo says his family was wary about his locating to a remote area in Mississippi—but he wasn’t. “When I make a decision, I go for it 100%,” he says. “In everything I do I always do my best and leave the rest to God. I was very fortunate to find out that the community was very involved in and engaged with my waiver.

“Also, to my surprise, I didn’t feel discriminated against at all. They made me feel like I’m a part of the family. There is a strong sense of community here, indeed. The only problem then was, of course, being in a small town, that whatever you do, everybody knows about it.”

Although Dr. Onunkwo moved to Wausau, Wis., a small town in a predominantly white area, he says it was not difficult for him to adjust to life there. Part of the reason, he says, is that his first overseas experience was in Ireland, where he obtained a diploma in tropical medical at the Royal College of Surgeons in Dublin and practiced in a small village nearby. In addition, he and his wife were together in Wausau. “It was probably easier for both of us because we had each other,” he says.

And then there were their great neighbors, says Dr. Onunkwo. ”They made the transition seamless,” he says. “We have formed lifelong relationships with some of our neighbors in Wausau.” The strength of those relationships became apparent on Christmas Day 2005. “They really don’t know what they have done for us,” Dr. Onunkwo recalls warmly. “When we were going through our travails, they knew something was wrong, but we didn’t tell them exactly what we were going through. They made our day for us, because they just rang our bell and here they had the three-course Christmas dinner for us.”

Dr. Patel

Prove Yourself

Dr. Onunkwo has been aware of misperceptions about his professional competency. “Depending on what part of the country you find yourself in, you need to continually prove yourself,” he says. “There is this perception, maybe due to the accent or the way you express yourself. It’s unspoken, but it’s there and you don’t need to be a rocket scientist to observe that. You need to prove that you’re good to be able to survive.”

This is easier for some than others.

“I cannot say I have experienced any barriers in that respect,” reports Gunter Kurrle, MD, lead physician with the WellStar Kennestone Hospitalist Group in Atlanta. “I’m European, like most Americans with European background, so it has not been my personal experience to encounter prejudice.” Dr. Kurrle’s journey to his present post as lead hospitalist is also atypical compared with most IMGs who come to the U.S. He initially took his foreign medical graduate examination in the late 1980s, just before the United States Medical Licensing Examination was initiated. He then returned to Germany for five years of additional training after his residency in this country. He came back to the U.S. for personal reasons (his wife is a U.S. citizen and was starting her residency training here) and found that entering hospital medicine was “a better fit than trying to start a practice on my own.”

Hemant Patel, MD, president of the American Association of Physicians of Indian Origin (AAIP), based in Oak Brook, Ill., believes discrimination toward foreign-born physicians has been greatly reduced since the early 1980s, when he entered the country. AAPI, with membership of 45,000, was founded in 1982 to offer support to IMGs from India. Physicians of Indian origin constitute the largest group of IMGs.2

“At that time, it was very difficult to obtain residency slots due to competition, and we had a lot more physicians to occupy those slots,” says Dr. Patel.

Dr. Fajardo believes the inclination to discriminate is inherent in everyone: “It’s latent, but if you give them the reason to discriminate against you, then it will manifest.” With regards to the physician-patient relationship, Dr. Fajardo reports that initially, on rare occasions, he encountered resistance from patients who were reluctant to trust their care to him because of his name (“I can’t pronounce it—are you a terrorist?”) or his looks (“You look too young to be a doctor—are you sure you can take care of me?”).

“At the end of the day, it’s very fulfilling when you hear them say, ‘Thanks a lot, doc, for getting me better,’’ says Dr. Fajardo. “I believe that it isn’t where you come from that matters; it’s what you can do.” Overall, he says, the realities of the medical profession are that “the outcome of what we do speaks for itself, and that’s what matters most.”

Dr. Onunkwo is philosophical about the initial skepticism he sometimes senses from patients and other colleagues. “I understand that people are wary of the unknown, and I think it’s just natural,” he says. “Usually, what happens in my situation is that I feel the skepticism, but I don’t do anything about it. I still treat the person with the respect that they deserve and ultimately, I just let my work do the talking. Everybody gets the same level of respect and attention that they need and nine times out of 10, before patients are done with their hospital stay, their attitudes toward me have changed.” TH

Gretchen Henkel is a frequent contributor to The Hospitalist.

References

1. Leon LR Jr, Villar H, Leon CR, et al. The journey of a foreign-trained physician to a United States residency. J Am Coll Surg. 2007 Mar;204(3):486-494.
2. Hart LG, Skillman SM, Fordyce M, et al. International medical graduate physicians in the United States: changes since 1981. Health Aff. 2007 Jul/Aug;26(4):1159-1169.