Many primary care physicians welcome the introduction of hospital medicine for its potential to help normalize their schedules, reduce interruptions to their clinic work from hospitalized patients, and moderate after-hours on-call demands. Some have found hospital medicine itself such an attractive option for balancing their schedules between work and personal commitments that they have pursued it as a career.

Internist Doyle Detweiler, MD, started closing down his medical office practice in Newton, Kan., a small town 15 miles north of Wichita, in June of this year so he could become the first full-time hospitalist at 81-bed Newton Medical Center. Pulled between his office practice and the demands of visiting his patients at the hospital, Dr. Detweiler had seen his family life suffer, with limited quality time to spend with his daughters Lilly, 4, and Hannah, 18 months.

“The worst thing was that when I’d go to work, I’d kiss my little girls goodbye and they’d still be bed. When I’d come home and kiss them good night, they’d already be in bed,” he says. “My wife would never know even approximately when I’d be heading home. So it would be difficult for us to plan anything in the evenings.” He also spent a lot of time working on the weekends.

Dr. Detweiler still faces significant time demands in his new job—at least until a second hospitalist can be brought on board later this year. But the move has already produced dividends in terms of shorter and more predictable hours. Generally, he wraps up work shortly after 6 p.m., when the last post-operative case has been admitted, and he has been called back to the hospital only three times in two months for after-hours patient crises.

“One big advantage I can see—once we ultimately get the program rolling—is that I’ll know when I’ll be working and when I’m off and checked out,” he explains. “As a hospitalist, there still will be times when I’m really busy, but it will be easier to plan something like going out for dinner at 7 p.m.”

The Needs of Children—and Parents

The classic juggle of work and home life involves the care of young children, although that is only one of the competing personal demands on doctors’ time. As the proportion of women in medicine has grown, employers have been challenged to find ways to accommodate their staffs’ maternity leaves and child-care responsibilities, while working parents seek to accommodate their children’s swimming lessons, ball games, and ballet classes.

The generation that now dominates hospitalist ranks (average age 37, according to SHM’s “Biannual Survey of the Hospital Medicine Movement”) has little taste for the traditional image of the old-fashioned, male family doctor, essentially available to his patients 24/7. Lifestyle issues are important factors in their career choices.

Other working hospitalists want time to travel or to pursue outside interests. Their hours of work may be shorter and more predictable than for other physicians, but the pace can be intense, with life-and-death situations involving critically ill patients occurring every day. Many of today’s hospitalists also belong to the “sandwich generation,” juggling simultaneous caregiving responsibilities for children and aging parents.

Stacy Walton Goldsholl, MD, of Wilmington, N.C., president of the hospital medicine division of TeamHealth, and member of the SHM Board of Directors, faced an extreme version of these competing demands when starting her new managerial position on January 1, 2006. Pregnant with her second child, Richard, who was born in April, she was also caring for her 65-year-old father, who died of cancer in February.

“It was tough watching my dad, formerly a very robust person, truly the motivating force for my professional success, my moral compass, confidant, and advisor, as he got sicker,” says Dr. Goldsholl. “Some days I’d leave my two-year-old, Aiden, with my husband and go care for my dad, giving him his injection of Lovenox [enoxaparin] or replacing his PCA pump. My mom and I were his primary caregivers at home until we physically couldn’t handle it.”

At that point her father was admitted to a hospice inpatient facility, where she would sit by his bedside with a computer in her lap.

Dr. Goldsholl probably would have needed to take a leave of absence if she had been working as a hospitalist, but her new employers at TeamHealth gave her a lot of flexibility, limiting the number of strategic meetings she had to attend. In general, however, she believes hospitalist shift work is more accommodating to family demands than an administrative position. She returned from maternity leave full time on June 1 and now travels every week for her job; her mother, who lives nearby, fills in as her grandchildren’s nanny. But Dr. Goldsholl’s experience has sparked her interest in exploring sustainability issues for other hospitalists.

“TeamHealth’s leaders told me their turnover rate is about 5 percent for hospitalists, versus an industry average of 19 percent,” says Dr. Goldsholl. “I found that hard to believe, but when I interviewed some of our local medical directors, it turned out to be true. They were all extremely positive about their relationship with our operational infrastructure.

“There’s so much to do and so many opportunities out there, but it must be sustainable,” she continues. “In order to sustain a career, you must be fulfilled personally, which is directly related to your work/life balance.”

When she drilled down into the company’s data, trying to find out why TeamHealth is able to retain its doctors, she found that the hours they work average 7.3% less than the industry as a whole, while their compensation is comparable to others.1

For Daniel Dressler, MD, medical director of the Hospital Medicine Group at Emory Healthcare in Atlanta, Ga., hospital medicine can be a juggling act—as can his committee work for SHM—although he is able to conduct some business from home. “When we do the conference calls for SHM, half of the time I’m home taking care of our kids”—one-year-old twins—often with one of them in his lap.

Dr. Dressler and his wife had been building a new home and working closely with contractors and subcontractors when she discovered she was pregnant last year. The construction project experienced multiple delays. When interviewed in September, the Dresslers were living temporarily with his in-laws and hoping the house would be completed within another month. His wife, a physical therapist, was not working but was looking forward to returning to work.

Dr. Dressler estimates that he puts in a 60-hour workweek, including 30 hours of hospitalist shifts and the rest administrative, teaching, and education. “I don’t recommend building a new house and having kids at the same time,” he says. “Taking care of one-year-old twins is more difficult than anything I do at work. But we have a good time.”

He also tries to squeeze in a basketball game with the medical residents every weekend.

Dr. Dressler’s schedule demands reflect an additional wrinkle in terms of juggling work and family—especially in a relatively new field with huge growth opportunities and an emphasis on changing the healthcare system. Doctors must balance what is truly required to perform the job and satisfy their employers with what they do to satisfy their own standards and expectations, as well as take advantage of opportunities to advance their careers.

“There’s the balance of what’s reasonable for you at this point in your career. It’s a personal decision for everyone—[deciding] what is an adequate amount of time for each of the priorities in your life … what drives you, and what makes you happy in your life,” says Dr. Dressler. “The things that drive me include teaching and advancing the field, which means seizing opportunities to grow with this new and growing field, but hopefully not to the detriment of the rest of my life.”

A Family-Friendly Practice

Arpana Vidyarthi, MD, an academic hospitalist at the University of California-San Francisco (UCSF), has responsibilities for teaching residents and medical students and additional roles in hospital quality and safety. “It’s a somewhat different role than a shift hospitalist, with different stressors,” she says. “But there are many options out there, and one of the things that makes being a hospitalist attractive to me is the flexibility it offers.”

Dr. Vidyarthi’s husband also has a demanding job. She is able to do some of her own work at home with her two-year-old daughter, Anaiya, but estimates that her nanny puts in a 50-hour week. “I came to UCSF to do a hospitalist fellowship, and this is exactly what I want to do, with tremendous job satisfaction and a varied schedule. Yet I feel stretched all the time,” she says.

Dr. Vidyarthi credits her group practice at UCSF and its head, Robert Wachter, MD, for a supportive and family-friendly working environment. Colleague Adrienne Green, MD, agrees, adding that three of the group’s 24 physician members are pregnant at this time.

Dr. Green’s children are very interested in her work and have visited her at the hospital, which makes the work more real to them. “I’ll tell them about some of my patients who are really sick, and I’ll explain that the reason I’m going to work on the weekend is that I’m helping people get better and get out of the hospital,” says Dr. Green. “When I’m working on a Saturday and my son has a baseball game, I’ll tell him I’ll try to get to the game, but I can’t promise. But when we do have family time, we make it quality time.”

Dr. Wachter explains how he promotes a family-friendly work environment for hospitalists at UCSF: “My overarching management philosophy is that the quality of our program is equal to the quality of the people we’re able to recruit and retain. Thus, an environment that is professionally satisfying, collegiate, fun, and supportive of everyone’s personal and family goals is fundamental.”

Balancing life and work requires some give and take among the members of the group, who cover for each other when needed. It also takes a commitment to staffing in anticipation of predictable future needs for maternity leaves, sabbaticals and the like, rather than waiting for the actual need to arrive.

Making Good Career Choices

Lisa Kettering, MD, a member of SHM’s Board of Directors, has been a working hospitalist since 1998. Before that she worked in a traditional internal medicine practice. She also believes that hospital medicine offers more flexibility and opportunities for balance, with a full-time hospitalist position roughly comparable to the “part-time” private practice position she once held.

“In private practice, you’re always coming back to phone calls and piles of charts,” says Dr. Kettering. “As a hospitalist, you take care of your business in real time, instead of always playing catch up.”

A year ago, Dr. Kettering assumed medical direction of a practice of nine hospitalists and three intensivists at Exempla-St. Joseph Hospital in Denver, Colo., a position that includes significant clinical duties and requires about 80 hours of her time per week.

“If my children [three sons age 21, 19, and 16] were not almost grown, I could not have accepted this position,” she says. “But this job is my passion. For me, the key to family balance has been a supportive spouse and lots of child care and other supports.”

Dr. Kettering’s sons were born just before or during her medical school and residency, so her long hours have always been part of the equation. “What I gave up [for this career] were aspects of a social life, such as dinners out with our friends and an opportunity to work on my tennis game” and similar hobbies, she says. She has continued to run, a time-efficient form of exercise and stress management. Now that her children are leaving home, there is more time to indulge a love of yoga and Pilates and to resume a more normal social life—although she doesn’t do much cooking.

Don’t be shy about getting help, Dr. Kettering advises. She engages a personal assistant eight hours a week to help with errands such as making travel arrangements, picking up groceries, taking the car in for servicing, or wrapping the birthday presents she buys. “Not that I couldn’t squeeze in a few errands on the way home from work, but it would just be more demands on my time,” she explains.

“I believe I am an optimist, but my advice to young doctors is this: Don’t believe you can do it all,” says Dr. Kettering. “You need to make careful, considered decisions along the way, understanding you do have control over your choices. But there’s no question that you’ll have to give up many things if you choose medicine as a career.”

The biggest recommendation Dr. Kettering offers for future hospitalists is to make career choices based on a passion for the work—not on the flexible hours. Then consider how to make the job work in terms of schedules and the other nuts and bolts of practice, being aware of the varied opportunities that exist.

Although hospital medicine is sometimes described as a young person’s game, Dr. Kettering believes that if it is practiced correctly, with a sustainable work schedule, it doesn’t have to lead to burnout or exhaustion. “My practice is [composed] exclusively of doctors who have chosen hospital medicine as a life’s work—not a stopgap between residency and fellowship,” she says. “We also have a wonderful group of physicians, and there has not been a time when somebody had a family emergency that somebody else didn’t step up to cover.” TH

Larry Beresford is a frequent contributor to The Hospitalist.

Reference

1. Compensation by Employment Model, Society of Hospital Medicine Benchmark Survey, 2003.

Many primary care physicians welcome the introduction of hospital medicine for its potential to help normalize their schedules, reduce interruptions to their clinic work from hospitalized patients, and moderate after-hours on-call demands. Some have found hospital medicine itself such an attractive option for balancing their schedules between work and personal commitments that they have pursued it as a career.

Internist Doyle Detweiler, MD, started closing down his medical office practice in Newton, Kan., a small town 15 miles north of Wichita, in June of this year so he could become the first full-time hospitalist at 81-bed Newton Medical Center. Pulled between his office practice and the demands of visiting his patients at the hospital, Dr. Detweiler had seen his family life suffer, with limited quality time to spend with his daughters Lilly, 4, and Hannah, 18 months.

“The worst thing was that when I’d go to work, I’d kiss my little girls goodbye and they’d still be bed. When I’d come home and kiss them good night, they’d already be in bed,” he says. “My wife would never know even approximately when I’d be heading home. So it would be difficult for us to plan anything in the evenings.” He also spent a lot of time working on the weekends.

Dr. Detweiler still faces significant time demands in his new job—at least until a second hospitalist can be brought on board later this year. But the move has already produced dividends in terms of shorter and more predictable hours. Generally, he wraps up work shortly after 6 p.m., when the last post-operative case has been admitted, and he has been called back to the hospital only three times in two months for after-hours patient crises.

“One big advantage I can see—once we ultimately get the program rolling—is that I’ll know when I’ll be working and when I’m off and checked out,” he explains. “As a hospitalist, there still will be times when I’m really busy, but it will be easier to plan something like going out for dinner at 7 p.m.”

The Needs of Children—and Parents

The classic juggle of work and home life involves the care of young children, although that is only one of the competing personal demands on doctors’ time. As the proportion of women in medicine has grown, employers have been challenged to find ways to accommodate their staffs’ maternity leaves and child-care responsibilities, while working parents seek to accommodate their children’s swimming lessons, ball games, and ballet classes.

The generation that now dominates hospitalist ranks (average age 37, according to SHM’s “Biannual Survey of the Hospital Medicine Movement”) has little taste for the traditional image of the old-fashioned, male family doctor, essentially available to his patients 24/7. Lifestyle issues are important factors in their career choices.

Other working hospitalists want time to travel or to pursue outside interests. Their hours of work may be shorter and more predictable than for other physicians, but the pace can be intense, with life-and-death situations involving critically ill patients occurring every day. Many of today’s hospitalists also belong to the “sandwich generation,” juggling simultaneous caregiving responsibilities for children and aging parents.

Stacy Walton Goldsholl, MD, of Wilmington, N.C., president of the hospital medicine division of TeamHealth, and member of the SHM Board of Directors, faced an extreme version of these competing demands when starting her new managerial position on January 1, 2006. Pregnant with her second child, Richard, who was born in April, she was also caring for her 65-year-old father, who died of cancer in February.

“It was tough watching my dad, formerly a very robust person, truly the motivating force for my professional success, my moral compass, confidant, and advisor, as he got sicker,” says Dr. Goldsholl. “Some days I’d leave my two-year-old, Aiden, with my husband and go care for my dad, giving him his injection of Lovenox [enoxaparin] or replacing his PCA pump. My mom and I were his primary caregivers at home until we physically couldn’t handle it.”

At that point her father was admitted to a hospice inpatient facility, where she would sit by his bedside with a computer in her lap.

Dr. Goldsholl probably would have needed to take a leave of absence if she had been working as a hospitalist, but her new employers at TeamHealth gave her a lot of flexibility, limiting the number of strategic meetings she had to attend. In general, however, she believes hospitalist shift work is more accommodating to family demands than an administrative position. She returned from maternity leave full time on June 1 and now travels every week for her job; her mother, who lives nearby, fills in as her grandchildren’s nanny. But Dr. Goldsholl’s experience has sparked her interest in exploring sustainability issues for other hospitalists.

“TeamHealth’s leaders told me their turnover rate is about 5 percent for hospitalists, versus an industry average of 19 percent,” says Dr. Goldsholl. “I found that hard to believe, but when I interviewed some of our local medical directors, it turned out to be true. They were all extremely positive about their relationship with our operational infrastructure.

“There’s so much to do and so many opportunities out there, but it must be sustainable,” she continues. “In order to sustain a career, you must be fulfilled personally, which is directly related to your work/life balance.”

When she drilled down into the company’s data, trying to find out why TeamHealth is able to retain its doctors, she found that the hours they work average 7.3% less than the industry as a whole, while their compensation is comparable to others.1

For Daniel Dressler, MD, medical director of the Hospital Medicine Group at Emory Healthcare in Atlanta, Ga., hospital medicine can be a juggling act—as can his committee work for SHM—although he is able to conduct some business from home. “When we do the conference calls for SHM, half of the time I’m home taking care of our kids”—one-year-old twins—often with one of them in his lap.

Dr. Dressler and his wife had been building a new home and working closely with contractors and subcontractors when she discovered she was pregnant last year. The construction project experienced multiple delays. When interviewed in September, the Dresslers were living temporarily with his in-laws and hoping the house would be completed within another month. His wife, a physical therapist, was not working but was looking forward to returning to work.

Dr. Dressler estimates that he puts in a 60-hour workweek, including 30 hours of hospitalist shifts and the rest administrative, teaching, and education. “I don’t recommend building a new house and having kids at the same time,” he says. “Taking care of one-year-old twins is more difficult than anything I do at work. But we have a good time.”

He also tries to squeeze in a basketball game with the medical residents every weekend.

Dr. Dressler’s schedule demands reflect an additional wrinkle in terms of juggling work and family—especially in a relatively new field with huge growth opportunities and an emphasis on changing the healthcare system. Doctors must balance what is truly required to perform the job and satisfy their employers with what they do to satisfy their own standards and expectations, as well as take advantage of opportunities to advance their careers.

“There’s the balance of what’s reasonable for you at this point in your career. It’s a personal decision for everyone—[deciding] what is an adequate amount of time for each of the priorities in your life … what drives you, and what makes you happy in your life,” says Dr. Dressler. “The things that drive me include teaching and advancing the field, which means seizing opportunities to grow with this new and growing field, but hopefully not to the detriment of the rest of my life.”

A Family-Friendly Practice

Arpana Vidyarthi, MD, an academic hospitalist at the University of California-San Francisco (UCSF), has responsibilities for teaching residents and medical students and additional roles in hospital quality and safety. “It’s a somewhat different role than a shift hospitalist, with different stressors,” she says. “But there are many options out there, and one of the things that makes being a hospitalist attractive to me is the flexibility it offers.”

Dr. Vidyarthi’s husband also has a demanding job. She is able to do some of her own work at home with her two-year-old daughter, Anaiya, but estimates that her nanny puts in a 50-hour week. “I came to UCSF to do a hospitalist fellowship, and this is exactly what I want to do, with tremendous job satisfaction and a varied schedule. Yet I feel stretched all the time,” she says.

Dr. Vidyarthi credits her group practice at UCSF and its head, Robert Wachter, MD, for a supportive and family-friendly working environment. Colleague Adrienne Green, MD, agrees, adding that three of the group’s 24 physician members are pregnant at this time.

Dr. Green’s children are very interested in her work and have visited her at the hospital, which makes the work more real to them. “I’ll tell them about some of my patients who are really sick, and I’ll explain that the reason I’m going to work on the weekend is that I’m helping people get better and get out of the hospital,” says Dr. Green. “When I’m working on a Saturday and my son has a baseball game, I’ll tell him I’ll try to get to the game, but I can’t promise. But when we do have family time, we make it quality time.”

Dr. Wachter explains how he promotes a family-friendly work environment for hospitalists at UCSF: “My overarching management philosophy is that the quality of our program is equal to the quality of the people we’re able to recruit and retain. Thus, an environment that is professionally satisfying, collegiate, fun, and supportive of everyone’s personal and family goals is fundamental.”

Balancing life and work requires some give and take among the members of the group, who cover for each other when needed. It also takes a commitment to staffing in anticipation of predictable future needs for maternity leaves, sabbaticals and the like, rather than waiting for the actual need to arrive.

Making Good Career Choices

Lisa Kettering, MD, a member of SHM’s Board of Directors, has been a working hospitalist since 1998. Before that she worked in a traditional internal medicine practice. She also believes that hospital medicine offers more flexibility and opportunities for balance, with a full-time hospitalist position roughly comparable to the “part-time” private practice position she once held.

“In private practice, you’re always coming back to phone calls and piles of charts,” says Dr. Kettering. “As a hospitalist, you take care of your business in real time, instead of always playing catch up.”

A year ago, Dr. Kettering assumed medical direction of a practice of nine hospitalists and three intensivists at Exempla-St. Joseph Hospital in Denver, Colo., a position that includes significant clinical duties and requires about 80 hours of her time per week.

“If my children [three sons age 21, 19, and 16] were not almost grown, I could not have accepted this position,” she says. “But this job is my passion. For me, the key to family balance has been a supportive spouse and lots of child care and other supports.”

Dr. Kettering’s sons were born just before or during her medical school and residency, so her long hours have always been part of the equation. “What I gave up [for this career] were aspects of a social life, such as dinners out with our friends and an opportunity to work on my tennis game” and similar hobbies, she says. She has continued to run, a time-efficient form of exercise and stress management. Now that her children are leaving home, there is more time to indulge a love of yoga and Pilates and to resume a more normal social life—although she doesn’t do much cooking.

Don’t be shy about getting help, Dr. Kettering advises. She engages a personal assistant eight hours a week to help with errands such as making travel arrangements, picking up groceries, taking the car in for servicing, or wrapping the birthday presents she buys. “Not that I couldn’t squeeze in a few errands on the way home from work, but it would just be more demands on my time,” she explains.

“I believe I am an optimist, but my advice to young doctors is this: Don’t believe you can do it all,” says Dr. Kettering. “You need to make careful, considered decisions along the way, understanding you do have control over your choices. But there’s no question that you’ll have to give up many things if you choose medicine as a career.”

The biggest recommendation Dr. Kettering offers for future hospitalists is to make career choices based on a passion for the work—not on the flexible hours. Then consider how to make the job work in terms of schedules and the other nuts and bolts of practice, being aware of the varied opportunities that exist.

Although hospital medicine is sometimes described as a young person’s game, Dr. Kettering believes that if it is practiced correctly, with a sustainable work schedule, it doesn’t have to lead to burnout or exhaustion. “My practice is [composed] exclusively of doctors who have chosen hospital medicine as a life’s work—not a stopgap between residency and fellowship,” she says. “We also have a wonderful group of physicians, and there has not been a time when somebody had a family emergency that somebody else didn’t step up to cover.” TH

Larry Beresford is a frequent contributor to The Hospitalist.

Reference

1. Compensation by Employment Model, Society of Hospital Medicine Benchmark Survey, 2003.

Many primary care physicians welcome the introduction of hospital medicine for its potential to help normalize their schedules, reduce interruptions to their clinic work from hospitalized patients, and moderate after-hours on-call demands. Some have found hospital medicine itself such an attractive option for balancing their schedules between work and personal commitments that they have pursued it as a career.

Internist Doyle Detweiler, MD, started closing down his medical office practice in Newton, Kan., a small town 15 miles north of Wichita, in June of this year so he could become the first full-time hospitalist at 81-bed Newton Medical Center. Pulled between his office practice and the demands of visiting his patients at the hospital, Dr. Detweiler had seen his family life suffer, with limited quality time to spend with his daughters Lilly, 4, and Hannah, 18 months.

“The worst thing was that when I’d go to work, I’d kiss my little girls goodbye and they’d still be bed. When I’d come home and kiss them good night, they’d already be in bed,” he says. “My wife would never know even approximately when I’d be heading home. So it would be difficult for us to plan anything in the evenings.” He also spent a lot of time working on the weekends.

Dr. Detweiler still faces significant time demands in his new job—at least until a second hospitalist can be brought on board later this year. But the move has already produced dividends in terms of shorter and more predictable hours. Generally, he wraps up work shortly after 6 p.m., when the last post-operative case has been admitted, and he has been called back to the hospital only three times in two months for after-hours patient crises.

“One big advantage I can see—once we ultimately get the program rolling—is that I’ll know when I’ll be working and when I’m off and checked out,” he explains. “As a hospitalist, there still will be times when I’m really busy, but it will be easier to plan something like going out for dinner at 7 p.m.”

The Needs of Children—and Parents

The classic juggle of work and home life involves the care of young children, although that is only one of the competing personal demands on doctors’ time. As the proportion of women in medicine has grown, employers have been challenged to find ways to accommodate their staffs’ maternity leaves and child-care responsibilities, while working parents seek to accommodate their children’s swimming lessons, ball games, and ballet classes.

The generation that now dominates hospitalist ranks (average age 37, according to SHM’s “Biannual Survey of the Hospital Medicine Movement”) has little taste for the traditional image of the old-fashioned, male family doctor, essentially available to his patients 24/7. Lifestyle issues are important factors in their career choices.

Other working hospitalists want time to travel or to pursue outside interests. Their hours of work may be shorter and more predictable than for other physicians, but the pace can be intense, with life-and-death situations involving critically ill patients occurring every day. Many of today’s hospitalists also belong to the “sandwich generation,” juggling simultaneous caregiving responsibilities for children and aging parents.

Stacy Walton Goldsholl, MD, of Wilmington, N.C., president of the hospital medicine division of TeamHealth, and member of the SHM Board of Directors, faced an extreme version of these competing demands when starting her new managerial position on January 1, 2006. Pregnant with her second child, Richard, who was born in April, she was also caring for her 65-year-old father, who died of cancer in February.

“It was tough watching my dad, formerly a very robust person, truly the motivating force for my professional success, my moral compass, confidant, and advisor, as he got sicker,” says Dr. Goldsholl. “Some days I’d leave my two-year-old, Aiden, with my husband and go care for my dad, giving him his injection of Lovenox [enoxaparin] or replacing his PCA pump. My mom and I were his primary caregivers at home until we physically couldn’t handle it.”

At that point her father was admitted to a hospice inpatient facility, where she would sit by his bedside with a computer in her lap.

Dr. Goldsholl probably would have needed to take a leave of absence if she had been working as a hospitalist, but her new employers at TeamHealth gave her a lot of flexibility, limiting the number of strategic meetings she had to attend. In general, however, she believes hospitalist shift work is more accommodating to family demands than an administrative position. She returned from maternity leave full time on June 1 and now travels every week for her job; her mother, who lives nearby, fills in as her grandchildren’s nanny. But Dr. Goldsholl’s experience has sparked her interest in exploring sustainability issues for other hospitalists.

“TeamHealth’s leaders told me their turnover rate is about 5 percent for hospitalists, versus an industry average of 19 percent,” says Dr. Goldsholl. “I found that hard to believe, but when I interviewed some of our local medical directors, it turned out to be true. They were all extremely positive about their relationship with our operational infrastructure.

“There’s so much to do and so many opportunities out there, but it must be sustainable,” she continues. “In order to sustain a career, you must be fulfilled personally, which is directly related to your work/life balance.”

When she drilled down into the company’s data, trying to find out why TeamHealth is able to retain its doctors, she found that the hours they work average 7.3% less than the industry as a whole, while their compensation is comparable to others.1

For Daniel Dressler, MD, medical director of the Hospital Medicine Group at Emory Healthcare in Atlanta, Ga., hospital medicine can be a juggling act—as can his committee work for SHM—although he is able to conduct some business from home. “When we do the conference calls for SHM, half of the time I’m home taking care of our kids”—one-year-old twins—often with one of them in his lap.

Dr. Dressler and his wife had been building a new home and working closely with contractors and subcontractors when she discovered she was pregnant last year. The construction project experienced multiple delays. When interviewed in September, the Dresslers were living temporarily with his in-laws and hoping the house would be completed within another month. His wife, a physical therapist, was not working but was looking forward to returning to work.

Dr. Dressler estimates that he puts in a 60-hour workweek, including 30 hours of hospitalist shifts and the rest administrative, teaching, and education. “I don’t recommend building a new house and having kids at the same time,” he says. “Taking care of one-year-old twins is more difficult than anything I do at work. But we have a good time.”

He also tries to squeeze in a basketball game with the medical residents every weekend.

Dr. Dressler’s schedule demands reflect an additional wrinkle in terms of juggling work and family—especially in a relatively new field with huge growth opportunities and an emphasis on changing the healthcare system. Doctors must balance what is truly required to perform the job and satisfy their employers with what they do to satisfy their own standards and expectations, as well as take advantage of opportunities to advance their careers.

“There’s the balance of what’s reasonable for you at this point in your career. It’s a personal decision for everyone—[deciding] what is an adequate amount of time for each of the priorities in your life … what drives you, and what makes you happy in your life,” says Dr. Dressler. “The things that drive me include teaching and advancing the field, which means seizing opportunities to grow with this new and growing field, but hopefully not to the detriment of the rest of my life.”

A Family-Friendly Practice

Arpana Vidyarthi, MD, an academic hospitalist at the University of California-San Francisco (UCSF), has responsibilities for teaching residents and medical students and additional roles in hospital quality and safety. “It’s a somewhat different role than a shift hospitalist, with different stressors,” she says. “But there are many options out there, and one of the things that makes being a hospitalist attractive to me is the flexibility it offers.”

Dr. Vidyarthi’s husband also has a demanding job. She is able to do some of her own work at home with her two-year-old daughter, Anaiya, but estimates that her nanny puts in a 50-hour week. “I came to UCSF to do a hospitalist fellowship, and this is exactly what I want to do, with tremendous job satisfaction and a varied schedule. Yet I feel stretched all the time,” she says.

Dr. Vidyarthi credits her group practice at UCSF and its head, Robert Wachter, MD, for a supportive and family-friendly working environment. Colleague Adrienne Green, MD, agrees, adding that three of the group’s 24 physician members are pregnant at this time.

Dr. Green’s children are very interested in her work and have visited her at the hospital, which makes the work more real to them. “I’ll tell them about some of my patients who are really sick, and I’ll explain that the reason I’m going to work on the weekend is that I’m helping people get better and get out of the hospital,” says Dr. Green. “When I’m working on a Saturday and my son has a baseball game, I’ll tell him I’ll try to get to the game, but I can’t promise. But when we do have family time, we make it quality time.”

Dr. Wachter explains how he promotes a family-friendly work environment for hospitalists at UCSF: “My overarching management philosophy is that the quality of our program is equal to the quality of the people we’re able to recruit and retain. Thus, an environment that is professionally satisfying, collegiate, fun, and supportive of everyone’s personal and family goals is fundamental.”

Balancing life and work requires some give and take among the members of the group, who cover for each other when needed. It also takes a commitment to staffing in anticipation of predictable future needs for maternity leaves, sabbaticals and the like, rather than waiting for the actual need to arrive.

Making Good Career Choices

Lisa Kettering, MD, a member of SHM’s Board of Directors, has been a working hospitalist since 1998. Before that she worked in a traditional internal medicine practice. She also believes that hospital medicine offers more flexibility and opportunities for balance, with a full-time hospitalist position roughly comparable to the “part-time” private practice position she once held.

“In private practice, you’re always coming back to phone calls and piles of charts,” says Dr. Kettering. “As a hospitalist, you take care of your business in real time, instead of always playing catch up.”

A year ago, Dr. Kettering assumed medical direction of a practice of nine hospitalists and three intensivists at Exempla-St. Joseph Hospital in Denver, Colo., a position that includes significant clinical duties and requires about 80 hours of her time per week.

“If my children [three sons age 21, 19, and 16] were not almost grown, I could not have accepted this position,” she says. “But this job is my passion. For me, the key to family balance has been a supportive spouse and lots of child care and other supports.”

Dr. Kettering’s sons were born just before or during her medical school and residency, so her long hours have always been part of the equation. “What I gave up [for this career] were aspects of a social life, such as dinners out with our friends and an opportunity to work on my tennis game” and similar hobbies, she says. She has continued to run, a time-efficient form of exercise and stress management. Now that her children are leaving home, there is more time to indulge a love of yoga and Pilates and to resume a more normal social life—although she doesn’t do much cooking.

Don’t be shy about getting help, Dr. Kettering advises. She engages a personal assistant eight hours a week to help with errands such as making travel arrangements, picking up groceries, taking the car in for servicing, or wrapping the birthday presents she buys. “Not that I couldn’t squeeze in a few errands on the way home from work, but it would just be more demands on my time,” she explains.

“I believe I am an optimist, but my advice to young doctors is this: Don’t believe you can do it all,” says Dr. Kettering. “You need to make careful, considered decisions along the way, understanding you do have control over your choices. But there’s no question that you’ll have to give up many things if you choose medicine as a career.”

The biggest recommendation Dr. Kettering offers for future hospitalists is to make career choices based on a passion for the work—not on the flexible hours. Then consider how to make the job work in terms of schedules and the other nuts and bolts of practice, being aware of the varied opportunities that exist.

Although hospital medicine is sometimes described as a young person’s game, Dr. Kettering believes that if it is practiced correctly, with a sustainable work schedule, it doesn’t have to lead to burnout or exhaustion. “My practice is [composed] exclusively of doctors who have chosen hospital medicine as a life’s work—not a stopgap between residency and fellowship,” she says. “We also have a wonderful group of physicians, and there has not been a time when somebody had a family emergency that somebody else didn’t step up to cover.” TH

Larry Beresford is a frequent contributor to The Hospitalist.

Reference

1. Compensation by Employment Model, Society of Hospital Medicine Benchmark Survey, 2003.

Modern medicine … certainly as it should be practiced by hospitalists, is the most information-intensive activity that human beings ever engaged in,” says Kenneth W. Kizer, MD, MPH, CEO and chairman of the board of Medsphere Systems Corporation in Aliso Viejo, Calif.

He should know. From his first healthcare-related position in 1969 as a hospital orderly at Stanford University Hospital, he rose to become the Under Secretary for Health in the Department of Veterans Affairs (VA)—the CEO of the largest healthcare system in the nation. He is widely credited as being the chief architect and driving force behind the successful transformation of VA healthcare in the 1990s.

The VA’s 154 hospitals and 875 clinics, which serve 5.4 million patients, have been rated “best in class” by a number of independent groups since it implemented the changes in the 1990s.1 In a study conducted by the Rand Corporation, the VA scored higher compared with the U.S. private sector hospitals in every category except acute care, in which “the numbers ran neck and neck,” says Dr. Kizer. “Where the VA has done much better [than private sector hospitals] is in managing chronic disease and integrating prevention and health maintenance into the acute care program.”

Differences between a VA facility and one in the private sector are mostly “cosmetic and in the financing,” says Dr. Kizer. “The VA takes care of a particular patient population—veterans of military service—but it is a civilian practice that happens to be run by the federal government.”

According to a July 17, 2006, article in BusinessWeek, “The Best Medical Care in the U.S.,” the VA system provides about two-thirds of the care protocols recommended by organizations such as the Agency for Healthcare Research and Quality, compared with 50% provided in private sector hospitals.1 Also, as many as 8% of the prescriptions filled in private sector hospitals contain errors, but the VA’s prescription-related accuracy is greater than 99.997%. In addition, the VA spends an average of $5,000 per patient compared with the national average of $6,300.

Dr. Kizer’s focus on quality improvement at the VA should not be surprising in view of his long-time focus on improving the quality of healthcare. In his mind, an essential element in improving the quality of American healthcare is the widespread adoption of electronic health records (EHR).

When he arrived at his post at the VA in 1994, Dr. Kizer was pleasantly surprised to find advanced automated information management in place. The VA had been working on developing an EHR since 1978. As part Kizer’s transformation of the VA, all of the VA’s information systems were integrated, and VistA (an acronym for Veterans Health Information Systems and Technology Architecture) was launched in 1997. VistA is often the first thing that VA-affiliated hospitalists mention when they are asked what distinguishes VA hospitals from non-VA hospitals.

Key Features and Benefits of the VA

Sanjay Saint, MD, knows a great deal about academically affiliated VAs. He was a resident (July 1993-June 1995) and then chief medical resident at the San Francisco VA (June 1995-June 1996), an affiliate of the University of California at San Francisco. He was also a fellow at the University of Washington-affiliated Seattle VA (July 1996-June 1998), and for more than eight years he has been on the faculty at the University of Michigan as a professor of internal medicine (1998-2006). Dr. Saint is currently a hospitalist at the University of Michigan-affiliated Ann Arbor VA Hospital. He was also recently the acting chief of medicine there for six months (Dec. 2005-May 2006) while the permanent chief was on sabbatical.

The instant availability of the EHR system is a key benefit of practicing in a VA hospital, says Dr. Saint. “It involves not only being able to get up-to-date, relevant patient information at our VA but also the information obtained if the patient has been seen at other VAs.”

“One of the reasons why [the VA’s EHR] is so good is that it is fully integrated,” says Dr. Kizer. “Everything was made to fit together to begin with—in contrast to essentially all commercial products, which have been melded together from pieces that come from a variety of origins. Being fully integrated certainly increases the speed and efficiency of operations. The second reason why VistA is so good is that it was developed by clinicians for clinicians … .”

A key feature operating as part of the EHR is the focus on computer-based provider order entry (CPOE). CPOE can help physicians make correct clinical decisions, says Dr. Saint. He cites the example of a pilot test he and co-workers conducted at the Seattle VA: After 72 hours of urinary catheterization in a patient, an alert reminded physicians to remove the catheter. From that simple type of quality improvement experiment, the data revealed that those patients for whom the reminder had been used had a significantly reduced rate of infection compared with those for whom it had not.

One particularly good, but perhaps underutilized, aspect of the computerized system is the use of care protocols or models that can be used across the VA, says Peter Kaboli, MD, MS, hospitalist at the Iowa City VA Hospital, an affiliate of the University of Iowa. “And we could probably … have more available electronically [that] could be modified for the local care environment,” he says, adding that insulin protocols come to mind first.

Another key EHR feature is an extensive adverse event reporting system, including registering near misses. About 96% of prescriptions and physician orders are entered with the system; in private sector hospitals, the rough estimate is 8%. There is also a bar-coding system for verification of medications and identification of patients. The VA “has done a great job of changing the culture to foster systems-based care and to address errors and adverse patient outcomes straightforward[ly] and deal with them up front.”

Another distinguishing feature of the VA, says Dr. Saint, is its heavy investment in quality improvement and health services research (HSR). The VA has large repositories of administrative and clinical data for performing research with hospitalized patients. Dr. Saint also points out that a lot of the academic centers benefit from having a VA as an affiliate. “The house staff, medical students, and physicians often will be at the VA [and can] see the state-of-the-art electronic medical records and CPOE system and inquire, ‘Why can’t we have that at the university hospital?’ ”

Discharge: Seamless Transition

Dr. Kaboli can point to another advantage for hospital medicine in the VA: a concerted interest in developing hospitalists. Two-thirds of VA medical centers (VAMCs) use hospitalists, and two-thirds of inpatients are cared for by hospitalists. In total, approximately 400 hospitalists are employed by the VA, making it the largest single employer of hospitalists in the United States. Within two years, 75% of VAMCs will use hospitalists.2

Dr. Kaboli has also become well versed on the advantages of the VA’s EHR in the area of patient discharge. The greatest benefit to hospitalists of having a fully integrated medical record with CPOE and all inpatient and outpatient notes available in all the VA facilities across the country, he says, “is the almost seamless transition of these records both from the clinic side to the hospital and from the hospital back to the clinic.”

One “great luxury” of having that integrated system, Dr. Kaboli adds, is that a hospitalist can hand patients their discharge summaries and advise them to pass the information on in the next doctor’s visit. “Even though you’re going to send it via e-mail, [in a] fax, or by mail, you have that as another option to translate that information to other docs,” he explains. Hospitalists can also “alert other providers by making them co-signers to notes so that when it comes into their inbox, they know that a patient was discharged, and they get the discharge summary immediately.”

There is no connection electronically with non-VA providers, however, which is the same situation that exists in any other non-VA healthcare system. “We know [that] a fairly large percentage of veterans receive care, both within and outside the VA, who are what we call co-managed,” says Dr. Kaboli. “If a patient doesn’t live near a VA hospital or clinic, he may have to travel an hour or two, so that person might as well have a local doctor. Without that [EHR system], if [the patient is] speaking to a primary care physician in a local community, [that physician is] up against the same challenges as [someone who works] outside the VA.”

Get on the EHR Bandwagon

“The federal government has a crucial leadership role in promoting a national health information infrastructure,” said Dr. Kizer in his June 17, 2004 testimony to Congress. When asked about that statement, Dr. Saint (who is also director of the VA/University of Michigan Patient Safety Enhancement Program) has one piece of advice for his hospitalist colleagues. “You don’t want perfect to become the enemy of the very good,” he says. “Rather than waiting until there is a national technology information infrastructure, which may be years—if not decades—away, you can at least advocate for change in your own hospital.”

Use the VA as a model, he says. “You don’t have to use the exact same system, but at least you can point to some of the quality advantages that electronic medical records and CPOE can provide. You can also point out some of the advantages that investment in quality improvement and health services research can bring to an organization and say, ‘We can adapt—not necessarily adopt—what the VA has done.’ ”

How can hospitalists best do that? Many publications in the peer-reviewed literature address the quality improvement focus of the VA. There is also a VA Web site that discusses the focus on HSR and development (www1. va.gov/health). A VA-sponsored national health services research and development (HSR&D) meeting, at which investigators from all over the country present their latest findings, is held annually in Washington, D.C., usually in February.

For the young hospitalist who wants to pursue additional training, Dr. Saint says, there are VA-funded fellowships, HSR&D, a quality scholars program, and other career development opportunities within the VA that promote leadership roles both in and outside the VA.

Dr. Kaboli suggests identifying networks of hospitalists within and outside of your own healthcare system that you can work with and learn from. Hospitalists can also collaborate in developing protocols that incorporate local modifications. Also, he suggests, “there are a lot of questions that come up in the day-to-day care of patients. If you have colleagues as interested as you are, as hospitalists, in the quality of care for hospitalized medical patients, you can tap into that passion. The SHM listservs are a great way to connect; one for VA hospitalists has just been organized.

Anyone interested in the OpenVista Electronic Health Record, Medsphere’s commercial product (which, Dr. Kizer says, “is VistA at the core” and is being marketed to hospitals and large clinics) can learn more at www.medsphere.com.

Dr. Kizer says hospitalists will need to understand the needs of future healthcare and help prepare for and welcome it. “For example, performance measurement is an absolute part of the future of healthcare,” he says. “I think, by and large, hospitalists understand that better and are more accepting of that than certainly most docs in private practice.”

He believes hospitalists “can help promote that understanding among their peers and their hospitals and keep moving things forward as opposed to resisting it.” This is just one aspect of the “openness and transparency that we want to see in so many areas,” says Dr. Kizer, and hospitalists can be “pushing for the tools to make it happen. The hospitalists, I would think, should be leading the charge for electronic health records.”

Now and Tomorrow

Dr. Kizer, who is one of nine experts on veterans’ issues named to the newly formed Commission on the Future for America’s Veterans and is board certified in six medical specialties, also has a personal view on the work of hospital medicine. Recently, his wife was hospitalized in the ICU at the University of California at Davis Medical Center for a number of months, and Dr. Kizer says that a succession of hospitalists have served as her principal providers. It’s given him a more intimate view of what matters, beyond strictly clinical care, to patients and their families.

“By and large, I’ve always supported the hospitalist notion,” he says, “because it … supports my view [that] keeping up to date on all the science and technology and running an office practice [at the same time] is just more than you can reasonably expect anyone to do.” What he has especially noticed now, as a family caregiver visiting a hospital, “is that there is tremendous variability in how much [hospitalists] communicate with the patient and his or her family and how they view the episode of care within the context of the family and their community.”

Dr. Kizer, who has studied communications for a long time and in myriad ways, notes that a lot of the hospitalists he has met during this recent experience “think they’re communicating, but they often don’t take the time to determine if they are actually connecting with the family or addressing the issues that are important to the patient and family.”

In the same vein, he agrees that the better the electronic communication systems of a healthcare system—including proficiency in identifying medical errors—the more minutes can be freed up for a physician to pull up a chair and talk with a patient. “It is also a powerful tool to educate and to help inform,” he says. “For example, when [a hospitalist] can just quickly graph out where the patient’s blood pressure … or blood sugars or … creatinine has been, you can use the display of data to quickly educate the patient and/or the family about what has happened and where you need to go. One picture can save you 10 minutes of explaining.”

Conclusion

The VA has taken a lead in addressing the issues that have been brought up over the years by organizations such as the Institute of Medicine and the Institute for Healthcare Improvement. Their integrated electronic health records system can serve as a model for non-VA hospitals. Until there is a national integration of computerized technology, hospitalists can become advocates for improving their own hospital technology systems. “Electronic health records and hospitalists should go hand in glove,” concludes Dr. Kizer. “It’s potentially a great marriage of technology and the human element.” TH

Andrea Sattinger is a regular contributor to The Hospitalist.

References

1. Arnst C. The best medical care in the U.S.: How Veterans Affairs transformed itself—and what it means for the rest of us. BusinessWeek online. July 17, 2006. Available at www.businessweek.com/magazine/content/06_29/b3993061.htm?chan=top+news_top+news. Last accessed October 20, 2006.
2. Kaboli PJ, Barrett T, Vazirani S, et al. Growth of hospitalists in the Veterans Administration (VA) healthcare system: 1997-2005. Hosp Med. Abstract. 2006;1(S2):1-30.
3. Lurie JD, Merrens EJ, Lee J, et al. An approach to hospital quality improvement. Med Clin North Am. 2002 Jul;86(4):825-845.

A Hospitalist Revolutionizes UCSD’s Online Clinical Systems

Josh Lee, MD, is a hospitalist. But Dr. Lee is also a computer geek, and the combination has served him and patient care well.

As medical director of Information Services at the University of California at San Diego (UCSD), Dr. Lee has oversight over all online clinical systems, and that is no small task. With Dr. Lee’s guidance, UCSD is now a leader in the medical informatics movement. With the exception of physician documentation, the system has comprehensive electronic records; that is, some physicians still prefer to “wet-sign” their notes. Lab results at UCSD are 100% electronic, as is order entry for adult inpatients. “We have now completed what we call the entire order life cycle: physician orders, direct integrations through our pharmacy, pharmacy validation, and bar-coded administration at bedside,” he says.

As opposed to the VA’s homegrown EHR, UCSD did what many healthcare systems do: They bought an off-the-shelf product—this one was Invision from Siemens—but UCSD calls their product PCIS, for Patient Care Information Services.

“A lot of people are able to do cool stuff [with medical informatics],” says Dr. Lee, “but they have done it with a proprietary product, so it’s different than VA, where they are using something they have total control over.”

He says many people are now focused on order entry, “but I think the newest area of research and integration [involves the question], how do we communicate key clinical issues and follow-up for discharge?” (See Figure 1, above.) At UCSD Medical Center, these screens can be printed and the pages given directly to the patient upon discharge.) “We have leveraged our electronic system to ensure that, at the moment of discharge, not only is the patient informed about [his or her] care, but it is clear to anybody on our side, or from the side of the receiving physician, what is supposed to happen next.”

As any hospitalist knows, there can be a huge “voltage drop” in this area, as Robert Wachter, MD, professor and associate chairman at UCSF’s Department of Medicine, San Francisco, refers to it. Dr. Wachter is

And the great advantages of the VA’s electronic products are not available to the “99% of American hospitalists who don’t practice in closed systems,” says Dr. Lee.

Because most hospitalists don’t have that advantage, careful and complete discharge communications are imperative. That’s why UCSD built screens that can accommodate the specific information patients need, he says. “It’s different from the classic discharge summary, which is usually a lengthy, unwieldy, dictated document that is mostly [composed] after the patient leaves the hospital. This is done in real time … and these print-outs are immediately available for the patient.”

Before Dr. Lee came to UCSD, he worked with Drs. Jon Lurie, Mark Splaine, and Ed Merrens, all members of the general internal medicine division at Dartmouth-Hitchcock Medical Center in Hanover, N.H.3 As part of the team’s exploration of quality improvement and medical informatics, they particularly looked at how to adapt products to be workflow sensitive.

And one of the most important things Dr. Lee says he would tell his counterparts at other institutions is “to ensure that computerized solutions for safety and documentation are appropriately matched to the work flow.” He thinks that when these initiatives fail it is often due to an underappreciation of the impact that these changes and enhancements have on actual provision of care. “Do those things that are [the] most highly successful, leverage moments that you’re going to do anyway, but then automate it, make it safer, make it more comprehensive,” he says. “That’s my challenge to my colleagues.”—AS

Modern medicine … certainly as it should be practiced by hospitalists, is the most information-intensive activity that human beings ever engaged in,” says Kenneth W. Kizer, MD, MPH, CEO and chairman of the board of Medsphere Systems Corporation in Aliso Viejo, Calif.

He should know. From his first healthcare-related position in 1969 as a hospital orderly at Stanford University Hospital, he rose to become the Under Secretary for Health in the Department of Veterans Affairs (VA)—the CEO of the largest healthcare system in the nation. He is widely credited as being the chief architect and driving force behind the successful transformation of VA healthcare in the 1990s.

The VA’s 154 hospitals and 875 clinics, which serve 5.4 million patients, have been rated “best in class” by a number of independent groups since it implemented the changes in the 1990s.1 In a study conducted by the Rand Corporation, the VA scored higher compared with the U.S. private sector hospitals in every category except acute care, in which “the numbers ran neck and neck,” says Dr. Kizer. “Where the VA has done much better [than private sector hospitals] is in managing chronic disease and integrating prevention and health maintenance into the acute care program.”

Differences between a VA facility and one in the private sector are mostly “cosmetic and in the financing,” says Dr. Kizer. “The VA takes care of a particular patient population—veterans of military service—but it is a civilian practice that happens to be run by the federal government.”

According to a July 17, 2006, article in BusinessWeek, “The Best Medical Care in the U.S.,” the VA system provides about two-thirds of the care protocols recommended by organizations such as the Agency for Healthcare Research and Quality, compared with 50% provided in private sector hospitals.1 Also, as many as 8% of the prescriptions filled in private sector hospitals contain errors, but the VA’s prescription-related accuracy is greater than 99.997%. In addition, the VA spends an average of $5,000 per patient compared with the national average of $6,300.

Dr. Kizer’s focus on quality improvement at the VA should not be surprising in view of his long-time focus on improving the quality of healthcare. In his mind, an essential element in improving the quality of American healthcare is the widespread adoption of electronic health records (EHR).

When he arrived at his post at the VA in 1994, Dr. Kizer was pleasantly surprised to find advanced automated information management in place. The VA had been working on developing an EHR since 1978. As part Kizer’s transformation of the VA, all of the VA’s information systems were integrated, and VistA (an acronym for Veterans Health Information Systems and Technology Architecture) was launched in 1997. VistA is often the first thing that VA-affiliated hospitalists mention when they are asked what distinguishes VA hospitals from non-VA hospitals.

Key Features and Benefits of the VA

Sanjay Saint, MD, knows a great deal about academically affiliated VAs. He was a resident (July 1993-June 1995) and then chief medical resident at the San Francisco VA (June 1995-June 1996), an affiliate of the University of California at San Francisco. He was also a fellow at the University of Washington-affiliated Seattle VA (July 1996-June 1998), and for more than eight years he has been on the faculty at the University of Michigan as a professor of internal medicine (1998-2006). Dr. Saint is currently a hospitalist at the University of Michigan-affiliated Ann Arbor VA Hospital. He was also recently the acting chief of medicine there for six months (Dec. 2005-May 2006) while the permanent chief was on sabbatical.

The instant availability of the EHR system is a key benefit of practicing in a VA hospital, says Dr. Saint. “It involves not only being able to get up-to-date, relevant patient information at our VA but also the information obtained if the patient has been seen at other VAs.”

“One of the reasons why [the VA’s EHR] is so good is that it is fully integrated,” says Dr. Kizer. “Everything was made to fit together to begin with—in contrast to essentially all commercial products, which have been melded together from pieces that come from a variety of origins. Being fully integrated certainly increases the speed and efficiency of operations. The second reason why VistA is so good is that it was developed by clinicians for clinicians … .”

A key feature operating as part of the EHR is the focus on computer-based provider order entry (CPOE). CPOE can help physicians make correct clinical decisions, says Dr. Saint. He cites the example of a pilot test he and co-workers conducted at the Seattle VA: After 72 hours of urinary catheterization in a patient, an alert reminded physicians to remove the catheter. From that simple type of quality improvement experiment, the data revealed that those patients for whom the reminder had been used had a significantly reduced rate of infection compared with those for whom it had not.

One particularly good, but perhaps underutilized, aspect of the computerized system is the use of care protocols or models that can be used across the VA, says Peter Kaboli, MD, MS, hospitalist at the Iowa City VA Hospital, an affiliate of the University of Iowa. “And we could probably … have more available electronically [that] could be modified for the local care environment,” he says, adding that insulin protocols come to mind first.

Another key EHR feature is an extensive adverse event reporting system, including registering near misses. About 96% of prescriptions and physician orders are entered with the system; in private sector hospitals, the rough estimate is 8%. There is also a bar-coding system for verification of medications and identification of patients. The VA “has done a great job of changing the culture to foster systems-based care and to address errors and adverse patient outcomes straightforward[ly] and deal with them up front.”

Another distinguishing feature of the VA, says Dr. Saint, is its heavy investment in quality improvement and health services research (HSR). The VA has large repositories of administrative and clinical data for performing research with hospitalized patients. Dr. Saint also points out that a lot of the academic centers benefit from having a VA as an affiliate. “The house staff, medical students, and physicians often will be at the VA [and can] see the state-of-the-art electronic medical records and CPOE system and inquire, ‘Why can’t we have that at the university hospital?’ ”

Discharge: Seamless Transition

Dr. Kaboli can point to another advantage for hospital medicine in the VA: a concerted interest in developing hospitalists. Two-thirds of VA medical centers (VAMCs) use hospitalists, and two-thirds of inpatients are cared for by hospitalists. In total, approximately 400 hospitalists are employed by the VA, making it the largest single employer of hospitalists in the United States. Within two years, 75% of VAMCs will use hospitalists.2

Dr. Kaboli has also become well versed on the advantages of the VA’s EHR in the area of patient discharge. The greatest benefit to hospitalists of having a fully integrated medical record with CPOE and all inpatient and outpatient notes available in all the VA facilities across the country, he says, “is the almost seamless transition of these records both from the clinic side to the hospital and from the hospital back to the clinic.”

One “great luxury” of having that integrated system, Dr. Kaboli adds, is that a hospitalist can hand patients their discharge summaries and advise them to pass the information on in the next doctor’s visit. “Even though you’re going to send it via e-mail, [in a] fax, or by mail, you have that as another option to translate that information to other docs,” he explains. Hospitalists can also “alert other providers by making them co-signers to notes so that when it comes into their inbox, they know that a patient was discharged, and they get the discharge summary immediately.”

There is no connection electronically with non-VA providers, however, which is the same situation that exists in any other non-VA healthcare system. “We know [that] a fairly large percentage of veterans receive care, both within and outside the VA, who are what we call co-managed,” says Dr. Kaboli. “If a patient doesn’t live near a VA hospital or clinic, he may have to travel an hour or two, so that person might as well have a local doctor. Without that [EHR system], if [the patient is] speaking to a primary care physician in a local community, [that physician is] up against the same challenges as [someone who works] outside the VA.”

Get on the EHR Bandwagon

“The federal government has a crucial leadership role in promoting a national health information infrastructure,” said Dr. Kizer in his June 17, 2004 testimony to Congress. When asked about that statement, Dr. Saint (who is also director of the VA/University of Michigan Patient Safety Enhancement Program) has one piece of advice for his hospitalist colleagues. “You don’t want perfect to become the enemy of the very good,” he says. “Rather than waiting until there is a national technology information infrastructure, which may be years—if not decades—away, you can at least advocate for change in your own hospital.”

Use the VA as a model, he says. “You don’t have to use the exact same system, but at least you can point to some of the quality advantages that electronic medical records and CPOE can provide. You can also point out some of the advantages that investment in quality improvement and health services research can bring to an organization and say, ‘We can adapt—not necessarily adopt—what the VA has done.’ ”

How can hospitalists best do that? Many publications in the peer-reviewed literature address the quality improvement focus of the VA. There is also a VA Web site that discusses the focus on HSR and development (www1. va.gov/health). A VA-sponsored national health services research and development (HSR&D) meeting, at which investigators from all over the country present their latest findings, is held annually in Washington, D.C., usually in February.

For the young hospitalist who wants to pursue additional training, Dr. Saint says, there are VA-funded fellowships, HSR&D, a quality scholars program, and other career development opportunities within the VA that promote leadership roles both in and outside the VA.

Dr. Kaboli suggests identifying networks of hospitalists within and outside of your own healthcare system that you can work with and learn from. Hospitalists can also collaborate in developing protocols that incorporate local modifications. Also, he suggests, “there are a lot of questions that come up in the day-to-day care of patients. If you have colleagues as interested as you are, as hospitalists, in the quality of care for hospitalized medical patients, you can tap into that passion. The SHM listservs are a great way to connect; one for VA hospitalists has just been organized.

Anyone interested in the OpenVista Electronic Health Record, Medsphere’s commercial product (which, Dr. Kizer says, “is VistA at the core” and is being marketed to hospitals and large clinics) can learn more at www.medsphere.com.

Dr. Kizer says hospitalists will need to understand the needs of future healthcare and help prepare for and welcome it. “For example, performance measurement is an absolute part of the future of healthcare,” he says. “I think, by and large, hospitalists understand that better and are more accepting of that than certainly most docs in private practice.”

He believes hospitalists “can help promote that understanding among their peers and their hospitals and keep moving things forward as opposed to resisting it.” This is just one aspect of the “openness and transparency that we want to see in so many areas,” says Dr. Kizer, and hospitalists can be “pushing for the tools to make it happen. The hospitalists, I would think, should be leading the charge for electronic health records.”

Now and Tomorrow

Dr. Kizer, who is one of nine experts on veterans’ issues named to the newly formed Commission on the Future for America’s Veterans and is board certified in six medical specialties, also has a personal view on the work of hospital medicine. Recently, his wife was hospitalized in the ICU at the University of California at Davis Medical Center for a number of months, and Dr. Kizer says that a succession of hospitalists have served as her principal providers. It’s given him a more intimate view of what matters, beyond strictly clinical care, to patients and their families.

“By and large, I’ve always supported the hospitalist notion,” he says, “because it … supports my view [that] keeping up to date on all the science and technology and running an office practice [at the same time] is just more than you can reasonably expect anyone to do.” What he has especially noticed now, as a family caregiver visiting a hospital, “is that there is tremendous variability in how much [hospitalists] communicate with the patient and his or her family and how they view the episode of care within the context of the family and their community.”

Dr. Kizer, who has studied communications for a long time and in myriad ways, notes that a lot of the hospitalists he has met during this recent experience “think they’re communicating, but they often don’t take the time to determine if they are actually connecting with the family or addressing the issues that are important to the patient and family.”

In the same vein, he agrees that the better the electronic communication systems of a healthcare system—including proficiency in identifying medical errors—the more minutes can be freed up for a physician to pull up a chair and talk with a patient. “It is also a powerful tool to educate and to help inform,” he says. “For example, when [a hospitalist] can just quickly graph out where the patient’s blood pressure … or blood sugars or … creatinine has been, you can use the display of data to quickly educate the patient and/or the family about what has happened and where you need to go. One picture can save you 10 minutes of explaining.”

Conclusion

The VA has taken a lead in addressing the issues that have been brought up over the years by organizations such as the Institute of Medicine and the Institute for Healthcare Improvement. Their integrated electronic health records system can serve as a model for non-VA hospitals. Until there is a national integration of computerized technology, hospitalists can become advocates for improving their own hospital technology systems. “Electronic health records and hospitalists should go hand in glove,” concludes Dr. Kizer. “It’s potentially a great marriage of technology and the human element.” TH

Andrea Sattinger is a regular contributor to The Hospitalist.

References

1. Arnst C. The best medical care in the U.S.: How Veterans Affairs transformed itself—and what it means for the rest of us. BusinessWeek online. July 17, 2006. Available at www.businessweek.com/magazine/content/06_29/b3993061.htm?chan=top+news_top+news. Last accessed October 20, 2006.
2. Kaboli PJ, Barrett T, Vazirani S, et al. Growth of hospitalists in the Veterans Administration (VA) healthcare system: 1997-2005. Hosp Med. Abstract. 2006;1(S2):1-30.
3. Lurie JD, Merrens EJ, Lee J, et al. An approach to hospital quality improvement. Med Clin North Am. 2002 Jul;86(4):825-845.

A Hospitalist Revolutionizes UCSD’s Online Clinical Systems

Josh Lee, MD, is a hospitalist. But Dr. Lee is also a computer geek, and the combination has served him and patient care well.

As medical director of Information Services at the University of California at San Diego (UCSD), Dr. Lee has oversight over all online clinical systems, and that is no small task. With Dr. Lee’s guidance, UCSD is now a leader in the medical informatics movement. With the exception of physician documentation, the system has comprehensive electronic records; that is, some physicians still prefer to “wet-sign” their notes. Lab results at UCSD are 100% electronic, as is order entry for adult inpatients. “We have now completed what we call the entire order life cycle: physician orders, direct integrations through our pharmacy, pharmacy validation, and bar-coded administration at bedside,” he says.

As opposed to the VA’s homegrown EHR, UCSD did what many healthcare systems do: They bought an off-the-shelf product—this one was Invision from Siemens—but UCSD calls their product PCIS, for Patient Care Information Services.

“A lot of people are able to do cool stuff [with medical informatics],” says Dr. Lee, “but they have done it with a proprietary product, so it’s different than VA, where they are using something they have total control over.”

He says many people are now focused on order entry, “but I think the newest area of research and integration [involves the question], how do we communicate key clinical issues and follow-up for discharge?” (See Figure 1, above.) At UCSD Medical Center, these screens can be printed and the pages given directly to the patient upon discharge.) “We have leveraged our electronic system to ensure that, at the moment of discharge, not only is the patient informed about [his or her] care, but it is clear to anybody on our side, or from the side of the receiving physician, what is supposed to happen next.”

As any hospitalist knows, there can be a huge “voltage drop” in this area, as Robert Wachter, MD, professor and associate chairman at UCSF’s Department of Medicine, San Francisco, refers to it. Dr. Wachter is

And the great advantages of the VA’s electronic products are not available to the “99% of American hospitalists who don’t practice in closed systems,” says Dr. Lee.

Because most hospitalists don’t have that advantage, careful and complete discharge communications are imperative. That’s why UCSD built screens that can accommodate the specific information patients need, he says. “It’s different from the classic discharge summary, which is usually a lengthy, unwieldy, dictated document that is mostly [composed] after the patient leaves the hospital. This is done in real time … and these print-outs are immediately available for the patient.”

Before Dr. Lee came to UCSD, he worked with Drs. Jon Lurie, Mark Splaine, and Ed Merrens, all members of the general internal medicine division at Dartmouth-Hitchcock Medical Center in Hanover, N.H.3 As part of the team’s exploration of quality improvement and medical informatics, they particularly looked at how to adapt products to be workflow sensitive.

And one of the most important things Dr. Lee says he would tell his counterparts at other institutions is “to ensure that computerized solutions for safety and documentation are appropriately matched to the work flow.” He thinks that when these initiatives fail it is often due to an underappreciation of the impact that these changes and enhancements have on actual provision of care. “Do those things that are [the] most highly successful, leverage moments that you’re going to do anyway, but then automate it, make it safer, make it more comprehensive,” he says. “That’s my challenge to my colleagues.”—AS

Modern medicine … certainly as it should be practiced by hospitalists, is the most information-intensive activity that human beings ever engaged in,” says Kenneth W. Kizer, MD, MPH, CEO and chairman of the board of Medsphere Systems Corporation in Aliso Viejo, Calif.

He should know. From his first healthcare-related position in 1969 as a hospital orderly at Stanford University Hospital, he rose to become the Under Secretary for Health in the Department of Veterans Affairs (VA)—the CEO of the largest healthcare system in the nation. He is widely credited as being the chief architect and driving force behind the successful transformation of VA healthcare in the 1990s.

The VA’s 154 hospitals and 875 clinics, which serve 5.4 million patients, have been rated “best in class” by a number of independent groups since it implemented the changes in the 1990s.1 In a study conducted by the Rand Corporation, the VA scored higher compared with the U.S. private sector hospitals in every category except acute care, in which “the numbers ran neck and neck,” says Dr. Kizer. “Where the VA has done much better [than private sector hospitals] is in managing chronic disease and integrating prevention and health maintenance into the acute care program.”

Differences between a VA facility and one in the private sector are mostly “cosmetic and in the financing,” says Dr. Kizer. “The VA takes care of a particular patient population—veterans of military service—but it is a civilian practice that happens to be run by the federal government.”

According to a July 17, 2006, article in BusinessWeek, “The Best Medical Care in the U.S.,” the VA system provides about two-thirds of the care protocols recommended by organizations such as the Agency for Healthcare Research and Quality, compared with 50% provided in private sector hospitals.1 Also, as many as 8% of the prescriptions filled in private sector hospitals contain errors, but the VA’s prescription-related accuracy is greater than 99.997%. In addition, the VA spends an average of $5,000 per patient compared with the national average of $6,300.

Dr. Kizer’s focus on quality improvement at the VA should not be surprising in view of his long-time focus on improving the quality of healthcare. In his mind, an essential element in improving the quality of American healthcare is the widespread adoption of electronic health records (EHR).

When he arrived at his post at the VA in 1994, Dr. Kizer was pleasantly surprised to find advanced automated information management in place. The VA had been working on developing an EHR since 1978. As part Kizer’s transformation of the VA, all of the VA’s information systems were integrated, and VistA (an acronym for Veterans Health Information Systems and Technology Architecture) was launched in 1997. VistA is often the first thing that VA-affiliated hospitalists mention when they are asked what distinguishes VA hospitals from non-VA hospitals.

Key Features and Benefits of the VA

Sanjay Saint, MD, knows a great deal about academically affiliated VAs. He was a resident (July 1993-June 1995) and then chief medical resident at the San Francisco VA (June 1995-June 1996), an affiliate of the University of California at San Francisco. He was also a fellow at the University of Washington-affiliated Seattle VA (July 1996-June 1998), and for more than eight years he has been on the faculty at the University of Michigan as a professor of internal medicine (1998-2006). Dr. Saint is currently a hospitalist at the University of Michigan-affiliated Ann Arbor VA Hospital. He was also recently the acting chief of medicine there for six months (Dec. 2005-May 2006) while the permanent chief was on sabbatical.

The instant availability of the EHR system is a key benefit of practicing in a VA hospital, says Dr. Saint. “It involves not only being able to get up-to-date, relevant patient information at our VA but also the information obtained if the patient has been seen at other VAs.”

“One of the reasons why [the VA’s EHR] is so good is that it is fully integrated,” says Dr. Kizer. “Everything was made to fit together to begin with—in contrast to essentially all commercial products, which have been melded together from pieces that come from a variety of origins. Being fully integrated certainly increases the speed and efficiency of operations. The second reason why VistA is so good is that it was developed by clinicians for clinicians … .”

A key feature operating as part of the EHR is the focus on computer-based provider order entry (CPOE). CPOE can help physicians make correct clinical decisions, says Dr. Saint. He cites the example of a pilot test he and co-workers conducted at the Seattle VA: After 72 hours of urinary catheterization in a patient, an alert reminded physicians to remove the catheter. From that simple type of quality improvement experiment, the data revealed that those patients for whom the reminder had been used had a significantly reduced rate of infection compared with those for whom it had not.

One particularly good, but perhaps underutilized, aspect of the computerized system is the use of care protocols or models that can be used across the VA, says Peter Kaboli, MD, MS, hospitalist at the Iowa City VA Hospital, an affiliate of the University of Iowa. “And we could probably … have more available electronically [that] could be modified for the local care environment,” he says, adding that insulin protocols come to mind first.

Another key EHR feature is an extensive adverse event reporting system, including registering near misses. About 96% of prescriptions and physician orders are entered with the system; in private sector hospitals, the rough estimate is 8%. There is also a bar-coding system for verification of medications and identification of patients. The VA “has done a great job of changing the culture to foster systems-based care and to address errors and adverse patient outcomes straightforward[ly] and deal with them up front.”

Another distinguishing feature of the VA, says Dr. Saint, is its heavy investment in quality improvement and health services research (HSR). The VA has large repositories of administrative and clinical data for performing research with hospitalized patients. Dr. Saint also points out that a lot of the academic centers benefit from having a VA as an affiliate. “The house staff, medical students, and physicians often will be at the VA [and can] see the state-of-the-art electronic medical records and CPOE system and inquire, ‘Why can’t we have that at the university hospital?’ ”

Discharge: Seamless Transition

Dr. Kaboli can point to another advantage for hospital medicine in the VA: a concerted interest in developing hospitalists. Two-thirds of VA medical centers (VAMCs) use hospitalists, and two-thirds of inpatients are cared for by hospitalists. In total, approximately 400 hospitalists are employed by the VA, making it the largest single employer of hospitalists in the United States. Within two years, 75% of VAMCs will use hospitalists.2

Dr. Kaboli has also become well versed on the advantages of the VA’s EHR in the area of patient discharge. The greatest benefit to hospitalists of having a fully integrated medical record with CPOE and all inpatient and outpatient notes available in all the VA facilities across the country, he says, “is the almost seamless transition of these records both from the clinic side to the hospital and from the hospital back to the clinic.”

One “great luxury” of having that integrated system, Dr. Kaboli adds, is that a hospitalist can hand patients their discharge summaries and advise them to pass the information on in the next doctor’s visit. “Even though you’re going to send it via e-mail, [in a] fax, or by mail, you have that as another option to translate that information to other docs,” he explains. Hospitalists can also “alert other providers by making them co-signers to notes so that when it comes into their inbox, they know that a patient was discharged, and they get the discharge summary immediately.”

There is no connection electronically with non-VA providers, however, which is the same situation that exists in any other non-VA healthcare system. “We know [that] a fairly large percentage of veterans receive care, both within and outside the VA, who are what we call co-managed,” says Dr. Kaboli. “If a patient doesn’t live near a VA hospital or clinic, he may have to travel an hour or two, so that person might as well have a local doctor. Without that [EHR system], if [the patient is] speaking to a primary care physician in a local community, [that physician is] up against the same challenges as [someone who works] outside the VA.”

Get on the EHR Bandwagon

“The federal government has a crucial leadership role in promoting a national health information infrastructure,” said Dr. Kizer in his June 17, 2004 testimony to Congress. When asked about that statement, Dr. Saint (who is also director of the VA/University of Michigan Patient Safety Enhancement Program) has one piece of advice for his hospitalist colleagues. “You don’t want perfect to become the enemy of the very good,” he says. “Rather than waiting until there is a national technology information infrastructure, which may be years—if not decades—away, you can at least advocate for change in your own hospital.”

Use the VA as a model, he says. “You don’t have to use the exact same system, but at least you can point to some of the quality advantages that electronic medical records and CPOE can provide. You can also point out some of the advantages that investment in quality improvement and health services research can bring to an organization and say, ‘We can adapt—not necessarily adopt—what the VA has done.’ ”

How can hospitalists best do that? Many publications in the peer-reviewed literature address the quality improvement focus of the VA. There is also a VA Web site that discusses the focus on HSR and development (www1. va.gov/health). A VA-sponsored national health services research and development (HSR&D) meeting, at which investigators from all over the country present their latest findings, is held annually in Washington, D.C., usually in February.

For the young hospitalist who wants to pursue additional training, Dr. Saint says, there are VA-funded fellowships, HSR&D, a quality scholars program, and other career development opportunities within the VA that promote leadership roles both in and outside the VA.

Dr. Kaboli suggests identifying networks of hospitalists within and outside of your own healthcare system that you can work with and learn from. Hospitalists can also collaborate in developing protocols that incorporate local modifications. Also, he suggests, “there are a lot of questions that come up in the day-to-day care of patients. If you have colleagues as interested as you are, as hospitalists, in the quality of care for hospitalized medical patients, you can tap into that passion. The SHM listservs are a great way to connect; one for VA hospitalists has just been organized.

Anyone interested in the OpenVista Electronic Health Record, Medsphere’s commercial product (which, Dr. Kizer says, “is VistA at the core” and is being marketed to hospitals and large clinics) can learn more at www.medsphere.com.

Dr. Kizer says hospitalists will need to understand the needs of future healthcare and help prepare for and welcome it. “For example, performance measurement is an absolute part of the future of healthcare,” he says. “I think, by and large, hospitalists understand that better and are more accepting of that than certainly most docs in private practice.”

He believes hospitalists “can help promote that understanding among their peers and their hospitals and keep moving things forward as opposed to resisting it.” This is just one aspect of the “openness and transparency that we want to see in so many areas,” says Dr. Kizer, and hospitalists can be “pushing for the tools to make it happen. The hospitalists, I would think, should be leading the charge for electronic health records.”

Now and Tomorrow

Dr. Kizer, who is one of nine experts on veterans’ issues named to the newly formed Commission on the Future for America’s Veterans and is board certified in six medical specialties, also has a personal view on the work of hospital medicine. Recently, his wife was hospitalized in the ICU at the University of California at Davis Medical Center for a number of months, and Dr. Kizer says that a succession of hospitalists have served as her principal providers. It’s given him a more intimate view of what matters, beyond strictly clinical care, to patients and their families.

“By and large, I’ve always supported the hospitalist notion,” he says, “because it … supports my view [that] keeping up to date on all the science and technology and running an office practice [at the same time] is just more than you can reasonably expect anyone to do.” What he has especially noticed now, as a family caregiver visiting a hospital, “is that there is tremendous variability in how much [hospitalists] communicate with the patient and his or her family and how they view the episode of care within the context of the family and their community.”

Dr. Kizer, who has studied communications for a long time and in myriad ways, notes that a lot of the hospitalists he has met during this recent experience “think they’re communicating, but they often don’t take the time to determine if they are actually connecting with the family or addressing the issues that are important to the patient and family.”

In the same vein, he agrees that the better the electronic communication systems of a healthcare system—including proficiency in identifying medical errors—the more minutes can be freed up for a physician to pull up a chair and talk with a patient. “It is also a powerful tool to educate and to help inform,” he says. “For example, when [a hospitalist] can just quickly graph out where the patient’s blood pressure … or blood sugars or … creatinine has been, you can use the display of data to quickly educate the patient and/or the family about what has happened and where you need to go. One picture can save you 10 minutes of explaining.”

Conclusion

The VA has taken a lead in addressing the issues that have been brought up over the years by organizations such as the Institute of Medicine and the Institute for Healthcare Improvement. Their integrated electronic health records system can serve as a model for non-VA hospitals. Until there is a national integration of computerized technology, hospitalists can become advocates for improving their own hospital technology systems. “Electronic health records and hospitalists should go hand in glove,” concludes Dr. Kizer. “It’s potentially a great marriage of technology and the human element.” TH

Andrea Sattinger is a regular contributor to The Hospitalist.

References

1. Arnst C. The best medical care in the U.S.: How Veterans Affairs transformed itself—and what it means for the rest of us. BusinessWeek online. July 17, 2006. Available at www.businessweek.com/magazine/content/06_29/b3993061.htm?chan=top+news_top+news. Last accessed October 20, 2006.
2. Kaboli PJ, Barrett T, Vazirani S, et al. Growth of hospitalists in the Veterans Administration (VA) healthcare system: 1997-2005. Hosp Med. Abstract. 2006;1(S2):1-30.
3. Lurie JD, Merrens EJ, Lee J, et al. An approach to hospital quality improvement. Med Clin North Am. 2002 Jul;86(4):825-845.

A Hospitalist Revolutionizes UCSD’s Online Clinical Systems

Josh Lee, MD, is a hospitalist. But Dr. Lee is also a computer geek, and the combination has served him and patient care well.

As medical director of Information Services at the University of California at San Diego (UCSD), Dr. Lee has oversight over all online clinical systems, and that is no small task. With Dr. Lee’s guidance, UCSD is now a leader in the medical informatics movement. With the exception of physician documentation, the system has comprehensive electronic records; that is, some physicians still prefer to “wet-sign” their notes. Lab results at UCSD are 100% electronic, as is order entry for adult inpatients. “We have now completed what we call the entire order life cycle: physician orders, direct integrations through our pharmacy, pharmacy validation, and bar-coded administration at bedside,” he says.

As opposed to the VA’s homegrown EHR, UCSD did what many healthcare systems do: They bought an off-the-shelf product—this one was Invision from Siemens—but UCSD calls their product PCIS, for Patient Care Information Services.

“A lot of people are able to do cool stuff [with medical informatics],” says Dr. Lee, “but they have done it with a proprietary product, so it’s different than VA, where they are using something they have total control over.”

He says many people are now focused on order entry, “but I think the newest area of research and integration [involves the question], how do we communicate key clinical issues and follow-up for discharge?” (See Figure 1, above.) At UCSD Medical Center, these screens can be printed and the pages given directly to the patient upon discharge.) “We have leveraged our electronic system to ensure that, at the moment of discharge, not only is the patient informed about [his or her] care, but it is clear to anybody on our side, or from the side of the receiving physician, what is supposed to happen next.”

As any hospitalist knows, there can be a huge “voltage drop” in this area, as Robert Wachter, MD, professor and associate chairman at UCSF’s Department of Medicine, San Francisco, refers to it. Dr. Wachter is

And the great advantages of the VA’s electronic products are not available to the “99% of American hospitalists who don’t practice in closed systems,” says Dr. Lee.

Because most hospitalists don’t have that advantage, careful and complete discharge communications are imperative. That’s why UCSD built screens that can accommodate the specific information patients need, he says. “It’s different from the classic discharge summary, which is usually a lengthy, unwieldy, dictated document that is mostly [composed] after the patient leaves the hospital. This is done in real time … and these print-outs are immediately available for the patient.”

Before Dr. Lee came to UCSD, he worked with Drs. Jon Lurie, Mark Splaine, and Ed Merrens, all members of the general internal medicine division at Dartmouth-Hitchcock Medical Center in Hanover, N.H.3 As part of the team’s exploration of quality improvement and medical informatics, they particularly looked at how to adapt products to be workflow sensitive.

And one of the most important things Dr. Lee says he would tell his counterparts at other institutions is “to ensure that computerized solutions for safety and documentation are appropriately matched to the work flow.” He thinks that when these initiatives fail it is often due to an underappreciation of the impact that these changes and enhancements have on actual provision of care. “Do those things that are [the] most highly successful, leverage moments that you’re going to do anyway, but then automate it, make it safer, make it more comprehensive,” he says. “That’s my challenge to my colleagues.”—AS

Patient discharged from group therapy kills psychiatrist, patient, and himself

Oakland County (MI) Circuit Court

The plaintiff, age 57, attended regular group therapy with a psychiatrist. Another patient, Mr. B, was dismissed from group therapy by the psychiatrist, but returned to the office with a gun during one of the regular sessions. Mr. B shot and killed the psychiatrist then entered the group meeting room and discharged his gun, fatally injuring another patient and wounding the plaintiff. Mr. B then turned the gun on himself and committed suicide. The plaintiff suffered gunshot wounds to the lower leg, foot, and hand and was away from work for 6 weeks.

The plaintiff alleged that the psychiatrist, his associates, and his daughter—who is also a psychiatrist at the office—knew Mr. B was dangerous and should not have been included in group therapy. The plaintiff claimed that Mr. B had a history of questionable psychotic behavior and other patients should not have been exposed to him. The psychiatrist’s associates contended that they had no way to anticipate this event and had used due care and caution in their practice.

• A $2 million verdict was returned
  

Dr. Grant’s observations

Warn and protect

In this case, several unavailable facts may have supported the successful negligence claim. For example, why was Mr. B dismissed from the group? Did he threaten someone in the group? Did he tell the group or the group leader about thoughts of violence or homicide? If so, perhaps a violent event was foreseeable.

Was Mr. B dismissed because of delusional or paranoid thoughts? What was done to help him, and were appropriate referrals in place? Instituting the right interventions requires clinicians to walk a fine line between preserving doctor-patient confidentiality and protecting other patients and the general public.

Doctor-patient confidentiality is deeply rooted in medical ethics and protected by law—in various forms—in all jurisdictions. Directives requiring a physician to reveal information without a patient’s consent are either legislated—and tend to be clear—or are based on court precedent, which is more open to interpretation. These mandated exceptions are purpose-specific and intended to preserve overall doctor-patient confidentiality.^{“Is this patient dangerous?” by John Battaglia, MD, and “Protect yourself from patient assault”, an interview between Dr. Battaglia and Lois E. Krahn, MD.}

Patient discharged from group therapy kills psychiatrist, patient, and himself

Oakland County (MI) Circuit Court

The plaintiff, age 57, attended regular group therapy with a psychiatrist. Another patient, Mr. B, was dismissed from group therapy by the psychiatrist, but returned to the office with a gun during one of the regular sessions. Mr. B shot and killed the psychiatrist then entered the group meeting room and discharged his gun, fatally injuring another patient and wounding the plaintiff. Mr. B then turned the gun on himself and committed suicide. The plaintiff suffered gunshot wounds to the lower leg, foot, and hand and was away from work for 6 weeks.

The plaintiff alleged that the psychiatrist, his associates, and his daughter—who is also a psychiatrist at the office—knew Mr. B was dangerous and should not have been included in group therapy. The plaintiff claimed that Mr. B had a history of questionable psychotic behavior and other patients should not have been exposed to him. The psychiatrist’s associates contended that they had no way to anticipate this event and had used due care and caution in their practice.

• A $2 million verdict was returned
  

Dr. Grant’s observations

Warn and protect

In this case, several unavailable facts may have supported the successful negligence claim. For example, why was Mr. B dismissed from the group? Did he threaten someone in the group? Did he tell the group or the group leader about thoughts of violence or homicide? If so, perhaps a violent event was foreseeable.

Was Mr. B dismissed because of delusional or paranoid thoughts? What was done to help him, and were appropriate referrals in place? Instituting the right interventions requires clinicians to walk a fine line between preserving doctor-patient confidentiality and protecting other patients and the general public.

Doctor-patient confidentiality is deeply rooted in medical ethics and protected by law—in various forms—in all jurisdictions. Directives requiring a physician to reveal information without a patient’s consent are either legislated—and tend to be clear—or are based on court precedent, which is more open to interpretation. These mandated exceptions are purpose-specific and intended to preserve overall doctor-patient confidentiality.^{“Is this patient dangerous?” by John Battaglia, MD, and “Protect yourself from patient assault”, an interview between Dr. Battaglia and Lois E. Krahn, MD.}

Patient discharged from group therapy kills psychiatrist, patient, and himself

Oakland County (MI) Circuit Court

The plaintiff, age 57, attended regular group therapy with a psychiatrist. Another patient, Mr. B, was dismissed from group therapy by the psychiatrist, but returned to the office with a gun during one of the regular sessions. Mr. B shot and killed the psychiatrist then entered the group meeting room and discharged his gun, fatally injuring another patient and wounding the plaintiff. Mr. B then turned the gun on himself and committed suicide. The plaintiff suffered gunshot wounds to the lower leg, foot, and hand and was away from work for 6 weeks.

The plaintiff alleged that the psychiatrist, his associates, and his daughter—who is also a psychiatrist at the office—knew Mr. B was dangerous and should not have been included in group therapy. The plaintiff claimed that Mr. B had a history of questionable psychotic behavior and other patients should not have been exposed to him. The psychiatrist’s associates contended that they had no way to anticipate this event and had used due care and caution in their practice.

• A $2 million verdict was returned
  

Dr. Grant’s observations

Warn and protect

In this case, several unavailable facts may have supported the successful negligence claim. For example, why was Mr. B dismissed from the group? Did he threaten someone in the group? Did he tell the group or the group leader about thoughts of violence or homicide? If so, perhaps a violent event was foreseeable.

Was Mr. B dismissed because of delusional or paranoid thoughts? What was done to help him, and were appropriate referrals in place? Instituting the right interventions requires clinicians to walk a fine line between preserving doctor-patient confidentiality and protecting other patients and the general public.

Doctor-patient confidentiality is deeply rooted in medical ethics and protected by law—in various forms—in all jurisdictions. Directives requiring a physician to reveal information without a patient’s consent are either legislated—and tend to be clear—or are based on court precedent, which is more open to interpretation. These mandated exceptions are purpose-specific and intended to preserve overall doctor-patient confidentiality.^{“Is this patient dangerous?” by John Battaglia, MD, and “Protect yourself from patient assault”, an interview between Dr. Battaglia and Lois E. Krahn, MD.}

New findings questioning the value of second-generation antipsychotics (SGAs) for treating acute behaviors in patients with Alzheimer’s disease have raised more questions on when and how to use these agents in the elderly.

The National Institute of Mental Health-sponsored Clinical Antipsychotic Trial of Intervention Effectiveness-Alzheimer’s disease (CATIE-AD) concluded that SGAs offer no overall advantage over placebo. Although SGAs helped some trial patients, the medications were discontinued for approximately 8 in 10 patients because of intolerable side effects or ineffectiveness.

CATIE-AD’s principal investigator says the findings—published in the October 12 New England Journal of Medicine¹—will guide clinicians in adjusting SGA dosages and durations for older patients with dementia.

But other psychiatrists argue that the study—led by prominent researchers and published in a prestigious medical journal—will deter clinicians from trying SGAs for older patients with dementia-related psychosis, aggression, or agitation.

“These drugs are not FDA-approved for dementia. They may cause diabetes. They cause weight gain. They carry boxed warnings that they could increase risk of stroke and—in patients over age 85—can increase risk of dying,” says Sumer Verma, MD, director of the geriatric psychiatry education program at McLean Hospital (Belmont, MA). “Doctors already were reluctant to use SGAs, and now these researchers publish this study in one of the country’s most respected journals and make an unqualified statement to the effect that [SGAs] are no better than placebo. How many clinicians will be comfortable prescribing them?”

Box

‘Discouraging’ discontinuation

CATIE-AD—a double-blind, multicenter, randomized trial (Box)—followed 421 ambulatory outpatients with Alzheimer’s disease and psychosis, aggression, or agitation. Patients received the SGAs olanzapine (mean dosage, 5.5 mg/d), quetiapine (mean 56.5 mg/d), risperidone (mean 1 mg/d), or placebo. Dosages were adjusted as needed.

After 36 weeks, times to discontinuation because of lack of efficacy were longest for olanza-pine and risperidone, but these drugs also had the highest rates of discontinuation because of intolerability (24% and 18%, respectively). Quetiapine’s rate of discontinuation because of intolerability was 16%.

SGAs were stopped because of lack of efficacy or intolerable side effects—such as parkinsonism, extrapyramidal symptoms, sedation, or weight gain—in:

• 63% of treatment and placebo group patients within 12 weeks
• 82% of all patients within 36 weeks.

Lon Schneider, MD, principal investigator for CATIE-AD, acknowledged that the findings could discourage psychiatrists from prescribing SGAs for acute dementia-related behaviors, specifically in patients with Alzheimer’s disease.

But although discontinuation because of intolerability was most prevalent among patients taking risperidone or olanzapine, both SGAs were more effective than placebo for treating problem behaviors in some participants, Dr. Schneider notes. He adds that the patient population and most SGA dosages in CATIE-AD reflected typical geriatric psychiatric practice in the community.

An editorial in the October 12 New England Journal of Medicine² praised CATIE-AD for allowing physicians to titrate and stop SGA regimens as needed while maintaining the double-blind design. Results of fixed-dose trials with prespecified time points are more difficult to apply to clinical practice because the course of Alzheimer’s disease and patients’ ability to tolerate specific drugs change over time.²

“This study can inform clinicians that they should not be prescribing medication and then not following up or maintaining it indefinitely,” says Dr. Schneider, who is professor of psychiatry, neurology and gerontology, University of Southern California, Los Angeles.

‘Black box’ fears?

Dr. Verma, however, reports that many clinicians have been hesitant to prescribe SGAs to older patients since last year—when the FDA ordered that SGAs carry “black box” warnings of a possible increased mortality risk in that population.

“CATIE-AD will intensify clinicians’ fears of litigation by implying that the risks of using SGAs outweigh their benefits, especially when SGAs are reported to be no better than placebo,” Dr. Verma predicts. “A lawyer could say to a clinician, ‘You used an SGA on Mr. Smith despite the risks, and he developed XYZ complication?’ Try to work yourself out of that one.

“A paper like this will be snapped up by pharmacy and therapeutics committees around the country, as well as Medicare, Medicaid, and other insurers,” Dr. Verma adds. “They’ll say, ‘These expensive drugs are no better than placebo. Why bother covering them?’”

Echoing Dr. Verma’s fears, the American Association for Geriatric Psychiatry (AAGP) responded to CATIE-AD by urging regulatory agencies not to overreact to the findings or “prevent physicians from exercising clinical judgment.”³ AAGP also is calling for more research “based on clinical and evidence-based protocols designed to help physicians know when and how to start, continue, and discontinue psychotropics” for older patients.³

Another problem with generalizing the CATIE-AD findings, Dr. Verma says, is that many Alzheimer’s patients are more severely impaired than those who participated in CATIE-AD.

“These are people who cannot be managed,” adds Barbara Kamholz, MD, clinical associate professor, University of Michigan, and staff psychiatrist, VA Medical Center, Ann Arbor. “They can’t get through the day. They can’t eat or use the bathroom properly. You can’t treat their medical problems if you can’t manage grossly abusive or violent behaviors.”

Dr. Schneider, however, notes that the outpatients in CATIE-AD were nearly as symptomatic as patients in nursing homes—as suggested by CATIE-AD patients’ mean Brief Psychiatric Rating Scale and Neuropsychiatric Inventory scores (28 and 37, respectively).

Also, Dr. Schneider says, most trials of SGAs conducted among nursing home patients have not yielded statistically significant results.⁴

‘Informing’ practice

Dr. Schneider warns against drastic interpretation of CATIE-AD, saying the trial should guide clinical practice, not radically alter it. He says he will keep prescribing SGAs for short-term acute treatment of older patients whose behavioral problems do not respond to psychosocial interventions, distraction, redirection, environmental manipulation, or other treatments.

“I’m not sure this study has changed my use of [SGAs],” Dr. Schneider says. “What it has done is better inform my considerations in prescribing. But I use [SGAs] in patients with significant behavioral problems—and especially with delusions, paranoia and aggression—who can’t be otherwise treated.”

Studies show that despite their risks, SGAs:

• are associated with one-tenth the risk of tardive dyskinesia compared with first-generation antipsychotics (FGAs) such as haloperidol⁵
• are less likely to cause extrapyramidal symptoms than FGAs.⁶

Dr. Verma notes that the cardiac, cerebrovascular, and cardiopulmonary side effects described in the “black box” warnings on SGAs are prevalent conditions in the elderly, independent of medication.

“Despite the side effects, 20% to 30% of patients [in CATIE-AD] continued to take [SGAs] for the entire study,”

Dr. Verma adds. “[SGAs] are not perfect drugs, but they’re the best we’ve got right now and better than what we had.”

Dr. Schneider acknowledges that no evidence supports use of other drug classes to treat problem behaviors in the elderly. “Antidepressants have their own adverse effects, and you wouldn’t expect them to work for delusions or aggression. And benzodiazepines are strongly associated with falling and oversedation.”

Dr. Kamholz fears that some psychiatrists might eschew SGAs in older patients and prescribe another type of medication that carries a greater side-effect risk.

“If they’re not using [SGAs], they might be using something more dangerous,” Dr. Kamholz says. “For example, haloperidol is an old standby, but very few studies address its global effects. So we’re groping around in the dark. I’ve also seen some bad deliriums caused by benzodiazepines.”

When to prescribe SGAs

At what point does the need to manage psychosis, aggression, or agitation in Alzheimer’s disease outweigh SGAs’ risks?

“Frankly, I’d rather not use medications unless I have to—and then only enough to preserve function while treating the behavioral disturbance,” Dr. Verma says. “I don’t want to anesthetize these patients. I just want to maintain their function, dignity, and quality of life.”

Seeking other causes of acute behaviors is essential before prescribing an SGA, Drs. Verma and Schneider say. Psychotic disorientation, for example, can occur with underlying psychiatric problems (such as delirium), hearing and sight deficits, disrupted schedules, poor sleep and appetite, incontinence, pain, unrelated medical complications, or environmental stressors.

For many older patients with problem behaviors, SGAs are worth the risk after other interventions have failed, Dr. Kamholz says. Weighing behavioral against pharmacologic risks is key, Dr. Schneider adds.

“What are the consequences of the behavior or paranoid ideation?” Dr. Schneider asks. “What about when the patient is refusing food? Or when caregivers cannot approach the patient, or the behavior creates a rift between family members so that the patient’s basic needs cannot be met? If psychosocial and environmental interventions haven’t worked, [SGAs] are worth a try.”

Because acute behavior hastens caregiver burnout—a major cause of nursing home admission⁶—appropriate SGA use also can help older patients remain at home, Drs. Schneider, Kamholz, and Verma say.

Practical applications

Drs. Schneider, Verma, and Kamholz agree that SGAs are a short-term intervention for problem behaviors in dementia. Because Alzheimer’s symptoms wax and wane as the disease progresses, patients need to be monitored continually, and medication regimens should be modified as needed and discontinued if possible.

Dr. Verma advises starting risperidone, olanza-pine, or quetiapine at low dosages, titrating slowly, and monitoring the patient carefully (Table).

Dr. Schneider suggests discontinuing the SGA after 12 to 20 weeks in patients who have responded. If behavior worsens after an SGA is discontinued, restart the medication, he says.

“If patients have adverse events with SGAs, do not try to tough it out,” Dr. Schneider adds. “Either adjust medications to eliminate adverse events or change the medication. If patients have been tolerating the medication for, say, 12 weeks, that doesn’t mean adverse reactions cannot develop later, so be ready to make adjustments.”

To guard against medicolegal risk when prescribing SGAs to older patients, Dr. Verma suggests that you clearly document:

• the reason you are prescribing the SGA
• your understanding of the risk/benefit ratio in using SGAs and that, in your clinical judgment, using an SGA in this patient is warranted because the benefits outweigh the risks
• that you considered other medications and the reasons those medications are inappropriate (for example, “I opted against a benzodiazepine because it could be too sedating and could increase the risk of falls and consequent injury”).

Also, get updates from the patient’s primary care physician on the patient’s cardiopulmonary and cerebrovascular health. Finally, provide extensive information about SGAs’ risks to family members, and keep signed documentation that you provided these warnings.

Table

Recommended second-generation antipsychotic dosing for older patients

Related resources

• American Association for Geriatric Psychiatry. AAGP position statement: Principles of care for patients with dementia resulting from Alzheimer disease.www.aagponline.org/prof/position_caredmnalz.asp.

Drug brand names

• Haloperidol • Haldol
• Olanzapine • Zyprexa
• Quetiapine • Seroquel
• Risperidone • Risperdal

Acknowledgment

Peter A. Kelly is senior editor, Current Psychiatry.

Lynn Waltz, a medical writer and editor in Norfolk, VA, helped prepare this article from transcripts of interviews with Drs. Kamholz, Schneider, and Verma.

New findings questioning the value of second-generation antipsychotics (SGAs) for treating acute behaviors in patients with Alzheimer’s disease have raised more questions on when and how to use these agents in the elderly.

The National Institute of Mental Health-sponsored Clinical Antipsychotic Trial of Intervention Effectiveness-Alzheimer’s disease (CATIE-AD) concluded that SGAs offer no overall advantage over placebo. Although SGAs helped some trial patients, the medications were discontinued for approximately 8 in 10 patients because of intolerable side effects or ineffectiveness.

CATIE-AD’s principal investigator says the findings—published in the October 12 New England Journal of Medicine¹—will guide clinicians in adjusting SGA dosages and durations for older patients with dementia.

But other psychiatrists argue that the study—led by prominent researchers and published in a prestigious medical journal—will deter clinicians from trying SGAs for older patients with dementia-related psychosis, aggression, or agitation.

“These drugs are not FDA-approved for dementia. They may cause diabetes. They cause weight gain. They carry boxed warnings that they could increase risk of stroke and—in patients over age 85—can increase risk of dying,” says Sumer Verma, MD, director of the geriatric psychiatry education program at McLean Hospital (Belmont, MA). “Doctors already were reluctant to use SGAs, and now these researchers publish this study in one of the country’s most respected journals and make an unqualified statement to the effect that [SGAs] are no better than placebo. How many clinicians will be comfortable prescribing them?”

Box

‘Discouraging’ discontinuation

CATIE-AD—a double-blind, multicenter, randomized trial (Box)—followed 421 ambulatory outpatients with Alzheimer’s disease and psychosis, aggression, or agitation. Patients received the SGAs olanzapine (mean dosage, 5.5 mg/d), quetiapine (mean 56.5 mg/d), risperidone (mean 1 mg/d), or placebo. Dosages were adjusted as needed.

After 36 weeks, times to discontinuation because of lack of efficacy were longest for olanza-pine and risperidone, but these drugs also had the highest rates of discontinuation because of intolerability (24% and 18%, respectively). Quetiapine’s rate of discontinuation because of intolerability was 16%.

SGAs were stopped because of lack of efficacy or intolerable side effects—such as parkinsonism, extrapyramidal symptoms, sedation, or weight gain—in:

• 63% of treatment and placebo group patients within 12 weeks
• 82% of all patients within 36 weeks.

Lon Schneider, MD, principal investigator for CATIE-AD, acknowledged that the findings could discourage psychiatrists from prescribing SGAs for acute dementia-related behaviors, specifically in patients with Alzheimer’s disease.

But although discontinuation because of intolerability was most prevalent among patients taking risperidone or olanzapine, both SGAs were more effective than placebo for treating problem behaviors in some participants, Dr. Schneider notes. He adds that the patient population and most SGA dosages in CATIE-AD reflected typical geriatric psychiatric practice in the community.

An editorial in the October 12 New England Journal of Medicine² praised CATIE-AD for allowing physicians to titrate and stop SGA regimens as needed while maintaining the double-blind design. Results of fixed-dose trials with prespecified time points are more difficult to apply to clinical practice because the course of Alzheimer’s disease and patients’ ability to tolerate specific drugs change over time.²

“This study can inform clinicians that they should not be prescribing medication and then not following up or maintaining it indefinitely,” says Dr. Schneider, who is professor of psychiatry, neurology and gerontology, University of Southern California, Los Angeles.

‘Black box’ fears?

Dr. Verma, however, reports that many clinicians have been hesitant to prescribe SGAs to older patients since last year—when the FDA ordered that SGAs carry “black box” warnings of a possible increased mortality risk in that population.

“CATIE-AD will intensify clinicians’ fears of litigation by implying that the risks of using SGAs outweigh their benefits, especially when SGAs are reported to be no better than placebo,” Dr. Verma predicts. “A lawyer could say to a clinician, ‘You used an SGA on Mr. Smith despite the risks, and he developed XYZ complication?’ Try to work yourself out of that one.

“A paper like this will be snapped up by pharmacy and therapeutics committees around the country, as well as Medicare, Medicaid, and other insurers,” Dr. Verma adds. “They’ll say, ‘These expensive drugs are no better than placebo. Why bother covering them?’”

Echoing Dr. Verma’s fears, the American Association for Geriatric Psychiatry (AAGP) responded to CATIE-AD by urging regulatory agencies not to overreact to the findings or “prevent physicians from exercising clinical judgment.”³ AAGP also is calling for more research “based on clinical and evidence-based protocols designed to help physicians know when and how to start, continue, and discontinue psychotropics” for older patients.³

Another problem with generalizing the CATIE-AD findings, Dr. Verma says, is that many Alzheimer’s patients are more severely impaired than those who participated in CATIE-AD.

“These are people who cannot be managed,” adds Barbara Kamholz, MD, clinical associate professor, University of Michigan, and staff psychiatrist, VA Medical Center, Ann Arbor. “They can’t get through the day. They can’t eat or use the bathroom properly. You can’t treat their medical problems if you can’t manage grossly abusive or violent behaviors.”

Dr. Schneider, however, notes that the outpatients in CATIE-AD were nearly as symptomatic as patients in nursing homes—as suggested by CATIE-AD patients’ mean Brief Psychiatric Rating Scale and Neuropsychiatric Inventory scores (28 and 37, respectively).

Also, Dr. Schneider says, most trials of SGAs conducted among nursing home patients have not yielded statistically significant results.⁴

‘Informing’ practice

Dr. Schneider warns against drastic interpretation of CATIE-AD, saying the trial should guide clinical practice, not radically alter it. He says he will keep prescribing SGAs for short-term acute treatment of older patients whose behavioral problems do not respond to psychosocial interventions, distraction, redirection, environmental manipulation, or other treatments.

“I’m not sure this study has changed my use of [SGAs],” Dr. Schneider says. “What it has done is better inform my considerations in prescribing. But I use [SGAs] in patients with significant behavioral problems—and especially with delusions, paranoia and aggression—who can’t be otherwise treated.”

Studies show that despite their risks, SGAs:

• are associated with one-tenth the risk of tardive dyskinesia compared with first-generation antipsychotics (FGAs) such as haloperidol⁵
• are less likely to cause extrapyramidal symptoms than FGAs.⁶

Dr. Verma notes that the cardiac, cerebrovascular, and cardiopulmonary side effects described in the “black box” warnings on SGAs are prevalent conditions in the elderly, independent of medication.

“Despite the side effects, 20% to 30% of patients [in CATIE-AD] continued to take [SGAs] for the entire study,”

Dr. Verma adds. “[SGAs] are not perfect drugs, but they’re the best we’ve got right now and better than what we had.”

Dr. Schneider acknowledges that no evidence supports use of other drug classes to treat problem behaviors in the elderly. “Antidepressants have their own adverse effects, and you wouldn’t expect them to work for delusions or aggression. And benzodiazepines are strongly associated with falling and oversedation.”

Dr. Kamholz fears that some psychiatrists might eschew SGAs in older patients and prescribe another type of medication that carries a greater side-effect risk.

“If they’re not using [SGAs], they might be using something more dangerous,” Dr. Kamholz says. “For example, haloperidol is an old standby, but very few studies address its global effects. So we’re groping around in the dark. I’ve also seen some bad deliriums caused by benzodiazepines.”

When to prescribe SGAs

At what point does the need to manage psychosis, aggression, or agitation in Alzheimer’s disease outweigh SGAs’ risks?

“Frankly, I’d rather not use medications unless I have to—and then only enough to preserve function while treating the behavioral disturbance,” Dr. Verma says. “I don’t want to anesthetize these patients. I just want to maintain their function, dignity, and quality of life.”

Seeking other causes of acute behaviors is essential before prescribing an SGA, Drs. Verma and Schneider say. Psychotic disorientation, for example, can occur with underlying psychiatric problems (such as delirium), hearing and sight deficits, disrupted schedules, poor sleep and appetite, incontinence, pain, unrelated medical complications, or environmental stressors.

For many older patients with problem behaviors, SGAs are worth the risk after other interventions have failed, Dr. Kamholz says. Weighing behavioral against pharmacologic risks is key, Dr. Schneider adds.

“What are the consequences of the behavior or paranoid ideation?” Dr. Schneider asks. “What about when the patient is refusing food? Or when caregivers cannot approach the patient, or the behavior creates a rift between family members so that the patient’s basic needs cannot be met? If psychosocial and environmental interventions haven’t worked, [SGAs] are worth a try.”

Because acute behavior hastens caregiver burnout—a major cause of nursing home admission⁶—appropriate SGA use also can help older patients remain at home, Drs. Schneider, Kamholz, and Verma say.

Practical applications

Drs. Schneider, Verma, and Kamholz agree that SGAs are a short-term intervention for problem behaviors in dementia. Because Alzheimer’s symptoms wax and wane as the disease progresses, patients need to be monitored continually, and medication regimens should be modified as needed and discontinued if possible.

Dr. Verma advises starting risperidone, olanza-pine, or quetiapine at low dosages, titrating slowly, and monitoring the patient carefully (Table).

Dr. Schneider suggests discontinuing the SGA after 12 to 20 weeks in patients who have responded. If behavior worsens after an SGA is discontinued, restart the medication, he says.

“If patients have adverse events with SGAs, do not try to tough it out,” Dr. Schneider adds. “Either adjust medications to eliminate adverse events or change the medication. If patients have been tolerating the medication for, say, 12 weeks, that doesn’t mean adverse reactions cannot develop later, so be ready to make adjustments.”

To guard against medicolegal risk when prescribing SGAs to older patients, Dr. Verma suggests that you clearly document:

• the reason you are prescribing the SGA
• your understanding of the risk/benefit ratio in using SGAs and that, in your clinical judgment, using an SGA in this patient is warranted because the benefits outweigh the risks
• that you considered other medications and the reasons those medications are inappropriate (for example, “I opted against a benzodiazepine because it could be too sedating and could increase the risk of falls and consequent injury”).

Also, get updates from the patient’s primary care physician on the patient’s cardiopulmonary and cerebrovascular health. Finally, provide extensive information about SGAs’ risks to family members, and keep signed documentation that you provided these warnings.

Table

Recommended second-generation antipsychotic dosing for older patients

Related resources

• American Association for Geriatric Psychiatry. AAGP position statement: Principles of care for patients with dementia resulting from Alzheimer disease.www.aagponline.org/prof/position_caredmnalz.asp.

Drug brand names

• Haloperidol • Haldol
• Olanzapine • Zyprexa
• Quetiapine • Seroquel
• Risperidone • Risperdal

Acknowledgment

Peter A. Kelly is senior editor, Current Psychiatry.

Lynn Waltz, a medical writer and editor in Norfolk, VA, helped prepare this article from transcripts of interviews with Drs. Kamholz, Schneider, and Verma.

New findings questioning the value of second-generation antipsychotics (SGAs) for treating acute behaviors in patients with Alzheimer’s disease have raised more questions on when and how to use these agents in the elderly.

The National Institute of Mental Health-sponsored Clinical Antipsychotic Trial of Intervention Effectiveness-Alzheimer’s disease (CATIE-AD) concluded that SGAs offer no overall advantage over placebo. Although SGAs helped some trial patients, the medications were discontinued for approximately 8 in 10 patients because of intolerable side effects or ineffectiveness.

CATIE-AD’s principal investigator says the findings—published in the October 12 New England Journal of Medicine¹—will guide clinicians in adjusting SGA dosages and durations for older patients with dementia.

But other psychiatrists argue that the study—led by prominent researchers and published in a prestigious medical journal—will deter clinicians from trying SGAs for older patients with dementia-related psychosis, aggression, or agitation.

“These drugs are not FDA-approved for dementia. They may cause diabetes. They cause weight gain. They carry boxed warnings that they could increase risk of stroke and—in patients over age 85—can increase risk of dying,” says Sumer Verma, MD, director of the geriatric psychiatry education program at McLean Hospital (Belmont, MA). “Doctors already were reluctant to use SGAs, and now these researchers publish this study in one of the country’s most respected journals and make an unqualified statement to the effect that [SGAs] are no better than placebo. How many clinicians will be comfortable prescribing them?”

Box

‘Discouraging’ discontinuation

CATIE-AD—a double-blind, multicenter, randomized trial (Box)—followed 421 ambulatory outpatients with Alzheimer’s disease and psychosis, aggression, or agitation. Patients received the SGAs olanzapine (mean dosage, 5.5 mg/d), quetiapine (mean 56.5 mg/d), risperidone (mean 1 mg/d), or placebo. Dosages were adjusted as needed.

After 36 weeks, times to discontinuation because of lack of efficacy were longest for olanza-pine and risperidone, but these drugs also had the highest rates of discontinuation because of intolerability (24% and 18%, respectively). Quetiapine’s rate of discontinuation because of intolerability was 16%.

SGAs were stopped because of lack of efficacy or intolerable side effects—such as parkinsonism, extrapyramidal symptoms, sedation, or weight gain—in:

• 63% of treatment and placebo group patients within 12 weeks
• 82% of all patients within 36 weeks.

Lon Schneider, MD, principal investigator for CATIE-AD, acknowledged that the findings could discourage psychiatrists from prescribing SGAs for acute dementia-related behaviors, specifically in patients with Alzheimer’s disease.

But although discontinuation because of intolerability was most prevalent among patients taking risperidone or olanzapine, both SGAs were more effective than placebo for treating problem behaviors in some participants, Dr. Schneider notes. He adds that the patient population and most SGA dosages in CATIE-AD reflected typical geriatric psychiatric practice in the community.

An editorial in the October 12 New England Journal of Medicine² praised CATIE-AD for allowing physicians to titrate and stop SGA regimens as needed while maintaining the double-blind design. Results of fixed-dose trials with prespecified time points are more difficult to apply to clinical practice because the course of Alzheimer’s disease and patients’ ability to tolerate specific drugs change over time.²

“This study can inform clinicians that they should not be prescribing medication and then not following up or maintaining it indefinitely,” says Dr. Schneider, who is professor of psychiatry, neurology and gerontology, University of Southern California, Los Angeles.

‘Black box’ fears?

Dr. Verma, however, reports that many clinicians have been hesitant to prescribe SGAs to older patients since last year—when the FDA ordered that SGAs carry “black box” warnings of a possible increased mortality risk in that population.

“CATIE-AD will intensify clinicians’ fears of litigation by implying that the risks of using SGAs outweigh their benefits, especially when SGAs are reported to be no better than placebo,” Dr. Verma predicts. “A lawyer could say to a clinician, ‘You used an SGA on Mr. Smith despite the risks, and he developed XYZ complication?’ Try to work yourself out of that one.

“A paper like this will be snapped up by pharmacy and therapeutics committees around the country, as well as Medicare, Medicaid, and other insurers,” Dr. Verma adds. “They’ll say, ‘These expensive drugs are no better than placebo. Why bother covering them?’”

Echoing Dr. Verma’s fears, the American Association for Geriatric Psychiatry (AAGP) responded to CATIE-AD by urging regulatory agencies not to overreact to the findings or “prevent physicians from exercising clinical judgment.”³ AAGP also is calling for more research “based on clinical and evidence-based protocols designed to help physicians know when and how to start, continue, and discontinue psychotropics” for older patients.³

Another problem with generalizing the CATIE-AD findings, Dr. Verma says, is that many Alzheimer’s patients are more severely impaired than those who participated in CATIE-AD.

“These are people who cannot be managed,” adds Barbara Kamholz, MD, clinical associate professor, University of Michigan, and staff psychiatrist, VA Medical Center, Ann Arbor. “They can’t get through the day. They can’t eat or use the bathroom properly. You can’t treat their medical problems if you can’t manage grossly abusive or violent behaviors.”

Dr. Schneider, however, notes that the outpatients in CATIE-AD were nearly as symptomatic as patients in nursing homes—as suggested by CATIE-AD patients’ mean Brief Psychiatric Rating Scale and Neuropsychiatric Inventory scores (28 and 37, respectively).

Also, Dr. Schneider says, most trials of SGAs conducted among nursing home patients have not yielded statistically significant results.⁴

‘Informing’ practice

Dr. Schneider warns against drastic interpretation of CATIE-AD, saying the trial should guide clinical practice, not radically alter it. He says he will keep prescribing SGAs for short-term acute treatment of older patients whose behavioral problems do not respond to psychosocial interventions, distraction, redirection, environmental manipulation, or other treatments.

“I’m not sure this study has changed my use of [SGAs],” Dr. Schneider says. “What it has done is better inform my considerations in prescribing. But I use [SGAs] in patients with significant behavioral problems—and especially with delusions, paranoia and aggression—who can’t be otherwise treated.”

Studies show that despite their risks, SGAs:

• are associated with one-tenth the risk of tardive dyskinesia compared with first-generation antipsychotics (FGAs) such as haloperidol⁵
• are less likely to cause extrapyramidal symptoms than FGAs.⁶

Dr. Verma notes that the cardiac, cerebrovascular, and cardiopulmonary side effects described in the “black box” warnings on SGAs are prevalent conditions in the elderly, independent of medication.

“Despite the side effects, 20% to 30% of patients [in CATIE-AD] continued to take [SGAs] for the entire study,”

Dr. Verma adds. “[SGAs] are not perfect drugs, but they’re the best we’ve got right now and better than what we had.”

Dr. Schneider acknowledges that no evidence supports use of other drug classes to treat problem behaviors in the elderly. “Antidepressants have their own adverse effects, and you wouldn’t expect them to work for delusions or aggression. And benzodiazepines are strongly associated with falling and oversedation.”

Dr. Kamholz fears that some psychiatrists might eschew SGAs in older patients and prescribe another type of medication that carries a greater side-effect risk.

“If they’re not using [SGAs], they might be using something more dangerous,” Dr. Kamholz says. “For example, haloperidol is an old standby, but very few studies address its global effects. So we’re groping around in the dark. I’ve also seen some bad deliriums caused by benzodiazepines.”

When to prescribe SGAs

At what point does the need to manage psychosis, aggression, or agitation in Alzheimer’s disease outweigh SGAs’ risks?

“Frankly, I’d rather not use medications unless I have to—and then only enough to preserve function while treating the behavioral disturbance,” Dr. Verma says. “I don’t want to anesthetize these patients. I just want to maintain their function, dignity, and quality of life.”

Seeking other causes of acute behaviors is essential before prescribing an SGA, Drs. Verma and Schneider say. Psychotic disorientation, for example, can occur with underlying psychiatric problems (such as delirium), hearing and sight deficits, disrupted schedules, poor sleep and appetite, incontinence, pain, unrelated medical complications, or environmental stressors.

For many older patients with problem behaviors, SGAs are worth the risk after other interventions have failed, Dr. Kamholz says. Weighing behavioral against pharmacologic risks is key, Dr. Schneider adds.

“What are the consequences of the behavior or paranoid ideation?” Dr. Schneider asks. “What about when the patient is refusing food? Or when caregivers cannot approach the patient, or the behavior creates a rift between family members so that the patient’s basic needs cannot be met? If psychosocial and environmental interventions haven’t worked, [SGAs] are worth a try.”

Because acute behavior hastens caregiver burnout—a major cause of nursing home admission⁶—appropriate SGA use also can help older patients remain at home, Drs. Schneider, Kamholz, and Verma say.

Practical applications

Drs. Schneider, Verma, and Kamholz agree that SGAs are a short-term intervention for problem behaviors in dementia. Because Alzheimer’s symptoms wax and wane as the disease progresses, patients need to be monitored continually, and medication regimens should be modified as needed and discontinued if possible.

Dr. Verma advises starting risperidone, olanza-pine, or quetiapine at low dosages, titrating slowly, and monitoring the patient carefully (Table).

Dr. Schneider suggests discontinuing the SGA after 12 to 20 weeks in patients who have responded. If behavior worsens after an SGA is discontinued, restart the medication, he says.

“If patients have adverse events with SGAs, do not try to tough it out,” Dr. Schneider adds. “Either adjust medications to eliminate adverse events or change the medication. If patients have been tolerating the medication for, say, 12 weeks, that doesn’t mean adverse reactions cannot develop later, so be ready to make adjustments.”

To guard against medicolegal risk when prescribing SGAs to older patients, Dr. Verma suggests that you clearly document:

• the reason you are prescribing the SGA
• your understanding of the risk/benefit ratio in using SGAs and that, in your clinical judgment, using an SGA in this patient is warranted because the benefits outweigh the risks
• that you considered other medications and the reasons those medications are inappropriate (for example, “I opted against a benzodiazepine because it could be too sedating and could increase the risk of falls and consequent injury”).

Also, get updates from the patient’s primary care physician on the patient’s cardiopulmonary and cerebrovascular health. Finally, provide extensive information about SGAs’ risks to family members, and keep signed documentation that you provided these warnings.

Table

Recommended second-generation antipsychotic dosing for older patients

Related resources

• American Association for Geriatric Psychiatry. AAGP position statement: Principles of care for patients with dementia resulting from Alzheimer disease.www.aagponline.org/prof/position_caredmnalz.asp.

Drug brand names

• Haloperidol • Haldol
• Olanzapine • Zyprexa
• Quetiapine • Seroquel
• Risperidone • Risperdal

Acknowledgment

Peter A. Kelly is senior editor, Current Psychiatry.

Lynn Waltz, a medical writer and editor in Norfolk, VA, helped prepare this article from transcripts of interviews with Drs. Kamholz, Schneider, and Verma.