The hospitalist movement is going Down Under: In a pilot program starting in January 2007, 20 hospitalists will begin working in 11 Australian hospitals as the country tries to adapt to the new realities of healthcare. The move reflects an ongoing debate in Australia concerning the best way to confront the challenges facing many developed nations in the 21st century: how to provide hospital care to an aging patient population that is growing sicker as medical costs skyrocket.

Current Concerns

Currently, Australia, like the United Kingdom and other Commonwealth countries, has a consultant-led medical system in which a specialist, or consultant, admits a patient and “owns” that individual for the duration of his or her hospital stay. The patient’s day-to-day care generally falls to a senior resident (or registrar) and a junior physician—both of whom consult with the supervising physician on rounds. In the meantime, little attention is paid to standardized indications and protocols for admission and discharge, and many observers complain about the lack of coordination and organization of care and patient flow.1

“In some cases, patient flow through our system can be disjointed, leading to delays in care and frustration from patients and staff,” says Katherine McGrath, MD, deputy director of General Health System Performance in New South Wales (NSW) Health, whose department is overseeing the pilot study. “We believe a new role, like that of the hospitalist, will fill the gap between the current non-clinical time requirements and patient needs.”

Others in Australia agree. “What we’re looking for is a senior presence in the hospital who can provide continuity of care,” says William Lancashire, MD, acting director of intensive care at Port Macquarie Base Hospital in Port Macquarie, NSW.

Rural care is another concern. Currently, 34% of all Australians and 70% of Australian aborigines live outside major urban centers and depend on “bush” hospitals when they become ill. Yet only 23% of medical specialists and 27% of general practitioners work in these remote areas.2 Hospitalists, with their expertise in general medicine and comfort with teamwork and coordination of care, are seen by some as an answer to the shortage of medical personnel in the bush. Some authors have suggested that physicians who work in these settings are already de facto hospitalists.3

The program is also an effort to improve quality of care, in response to studies reporting a troubling rate of medical errors and as many as 10,000 to 14,000 preventable deaths occurring within the Australian hospital system annually.4 When the Australian authorities first considered a hospitalist model and began studying programs in other countries, “we noted the rapid growth in hospitalist numbers and the positive contribution they have made to patient flow and patient safety,” says Dr. McGrath.

The Program

The participating hospitals are all located in the state of New South Wales: Westmead, Nepean, Bulli, Shellharbour, Shoalhaven, St. George, Sutherland, Fairfield, Manly, Mona Vale, and Hornsby. Depending on the institution, hospitalists may work in geriatrics, cardiology, renal, or emergency care.

In an address to the NSW state parliament, Minister for Health John Hatzistergos explains that hospitalists will coordinate care across departments to ensure that patients enjoy a smooth stay. They will also participate in hospital governance and organization, as well as staff education, giving them a say in developing policies and procedures. “The proposal is tantamount to patients having their own general practitioner in the hospital with them to ensure continued quality care,” he says.5

Many of the new hospitalists will probably come from the ranks of career medical officers (CMOs), general physicians recruited directly out of training to work in underserved rural and suburban hospitals. Most CMOs are concentrated in emergency or critical care, but they can be found across a wide range of specialties, including orthopedics, community medicine, and even sexual medicine.4 CMOs may also follow patients after they have been admitted by a specialist.

But even the CMO position is still relatively new, having been created only in the 1980s. “They’ve been an absolutely invaluable resource in non-metropolitan Australia, but we still don’t have a formal system for their ongoing training or certification,” Dr. Lancashire tells The Hospitalist. “We need to provide a clear certification and career structure for these individuals.”

Participation in the hospitalist program is voluntary, says Dr. McGrath. Successful candidates “will be skilled in care coordination, patient flow management, patient safety systems, negotiation, procedural skills relevant to their roles, and clinical specialty modules relevant to the areas of specialty in which they are now working, such as geriatrics and emergency care.” Training will be on the job, “with skills assessment and ‘up-skilling’ as necessary to meet the responsibilities of the role they are filling in the local service.”

Still, the program reflects a tweaking—rather than a full-fledged revamping—of the Australian system. “The hospitalists will work with the consultants, who know them and trust their judgment,” says Abd Malak, executive director of workforce development at Sydney West Area Health Service, which is recruiting hospitalists for Westmead and Nepean hospitals. This means that hospitalists will have the authority to change a patient’s medication or other treatments when they deem it necessary, without waiting for the admitting specialist to come on rounds—but the admitting physician will still bear the ultimate responsibility for the patient’s outcome.

“The hospitalists will answer to the specialist clinicians for their patient care as well as management for patient flow and care coordination,” explains Dr. McGrath.

This approach represents a philosophy that differs sharply from the hospitalist’s position in the United States, in which a hospitalist has full responsibility for the patient’s care as long as that patient is in the hospital. In the Australian model, hospitalists will function almost as middle managers, exercising authority up to a point, but ultimately reporting to a more senior physician. Those who favor this arrangement describe it as organizing a patient’s care, rather than taking it over.4

Not surprisingly, some doctors are taking a dim view of this policy. “I think it’s a mistake. It’s just like giving the specialist another registrar,” says Dr. Lancashire. At Port Macquarie Base Hospital, he is leading the effort to develop a hospitalist program that is closer to the U.S. model because it will give those physicians primary responsibility for their patients.

Challenges

Indeed, good communication among a patient’s various doctors, always an essential element of good care, will be especially critical in the Australian system, says John Nelson, MD, medical director of the hospitalist practice at Overlake Hospital in Bellevue, Wash. “The hospitalists and consultants should try to preserve a collegial culture in which they talk to each other regularly,” he says. “Otherwise, you could wind up with a situation like the one in some European countries where hospital doctors and office doctors seldom communicate and don’t even see themselves as peers.”

Dr. Nelson, who has consulted on the establishment of more than 150 hospitalist practices, also warns the Australians against taking a one-size-fits-all approach. “Each hospital has its own culture, so they should acknowledge that the experience will play out differently at each institution,” he says.

Many Aussies agree with Dr. Nelson. “We find that the outcomes are better when the hospitalists are in charge of patient care,” adds Peter Jamieson, MD, division chief, acute care family medicine at Calgary Health Region in Canada, which has a hospitalist practice of about 80 physicians serving five hospitals. “Hospitalists take a holistic view of the patients and their problems. For example, at discharge they can reconcile a patient’s medications and, in general, make sure the ball isn’t dropped. These are skills that specialists don’t focus on and by putting hospitalists in a secondary, supportive, or bedside role, I don’t think they will capture those benefits.”

Another challenge concerns the effect of a hospitalist program on primary care physicians who practice outside the hospital setting, such as family physicians. “Will they lift those doctors from the community to work in the hospital, or will they employ full-time hospitalists?” asks Dr. Jamieson. “A new program is easiest to administer when you have full-time people on rotation, but it robs the community of some primary care physicians. In Calgary, we have a mix, so as not to deplete the community of those doctors.”

More concrete challenges concern funding streams and convincing hospital and, in a single-payer system, governmental authorities that hospitalists are worth the investment. “Demonstrating value is the first step,” says Dr. Jamieson, who helped develop the hospitalist program in Calgary.

The timely sharing of records is also critical, so electronic medical records or sophisticated faxing systems should be in place as well. “The hospital should send the patient’s records to the office doctor by the end of the day on which that patient is discharged,” explains Dr. Nelson. “If it takes two weeks for the community doctor to get the records, that’s going to be a problem.”

In general, he advises Australian hospitalists to listen well but make their needs and interests clear. “I would tell them to be frank about what they are looking for and how they want their practices to go. I encourage them to develop an ongoing dialogue with North American hospitalists: we can learn from each other.” TH

Norra MacReady is a regular contributor to The Hospitalist.

References

1. Hillman K. The changing role of acute-care hospitals. Med J Aust. 1999 Apr 5;170(7):325-328.
2. Murray RB, Wronski I. When the tide goes out: health workforce in rural, remote and indigenous communities. Med J Aust. 2006 Jul 3;185(1):37-38.
3. Hore CT, Lancashire W, Roberts JB, et al. Integrated critical care: an approach to specialist cover for critical care in the rural setting. Med J Aust. 2003 Nov 3;179(9):95-97.
4. Egan JM, Webber MG, King MR, et al. The hospitalist: a third alternative. Med J Aust. 2000 Apr 3;172(7):335-338.
5. Hatzistergos J. Health care work force innovations. Address before the Parliament of New South Wales, published in NSW Legislative Council Hansard, August 31, 2006, page 1221. Available at: www.parliament.nsw.gov.au/prod/PARLMENT/hansArt.nsf/V3Key/LC20060831012. Last accessed October 10, 2006.

The hospitalist movement is going Down Under: In a pilot program starting in January 2007, 20 hospitalists will begin working in 11 Australian hospitals as the country tries to adapt to the new realities of healthcare. The move reflects an ongoing debate in Australia concerning the best way to confront the challenges facing many developed nations in the 21st century: how to provide hospital care to an aging patient population that is growing sicker as medical costs skyrocket.

Current Concerns

Currently, Australia, like the United Kingdom and other Commonwealth countries, has a consultant-led medical system in which a specialist, or consultant, admits a patient and “owns” that individual for the duration of his or her hospital stay. The patient’s day-to-day care generally falls to a senior resident (or registrar) and a junior physician—both of whom consult with the supervising physician on rounds. In the meantime, little attention is paid to standardized indications and protocols for admission and discharge, and many observers complain about the lack of coordination and organization of care and patient flow.1

“In some cases, patient flow through our system can be disjointed, leading to delays in care and frustration from patients and staff,” says Katherine McGrath, MD, deputy director of General Health System Performance in New South Wales (NSW) Health, whose department is overseeing the pilot study. “We believe a new role, like that of the hospitalist, will fill the gap between the current non-clinical time requirements and patient needs.”

Others in Australia agree. “What we’re looking for is a senior presence in the hospital who can provide continuity of care,” says William Lancashire, MD, acting director of intensive care at Port Macquarie Base Hospital in Port Macquarie, NSW.

Rural care is another concern. Currently, 34% of all Australians and 70% of Australian aborigines live outside major urban centers and depend on “bush” hospitals when they become ill. Yet only 23% of medical specialists and 27% of general practitioners work in these remote areas.2 Hospitalists, with their expertise in general medicine and comfort with teamwork and coordination of care, are seen by some as an answer to the shortage of medical personnel in the bush. Some authors have suggested that physicians who work in these settings are already de facto hospitalists.3

The program is also an effort to improve quality of care, in response to studies reporting a troubling rate of medical errors and as many as 10,000 to 14,000 preventable deaths occurring within the Australian hospital system annually.4 When the Australian authorities first considered a hospitalist model and began studying programs in other countries, “we noted the rapid growth in hospitalist numbers and the positive contribution they have made to patient flow and patient safety,” says Dr. McGrath.

The Program

The participating hospitals are all located in the state of New South Wales: Westmead, Nepean, Bulli, Shellharbour, Shoalhaven, St. George, Sutherland, Fairfield, Manly, Mona Vale, and Hornsby. Depending on the institution, hospitalists may work in geriatrics, cardiology, renal, or emergency care.

In an address to the NSW state parliament, Minister for Health John Hatzistergos explains that hospitalists will coordinate care across departments to ensure that patients enjoy a smooth stay. They will also participate in hospital governance and organization, as well as staff education, giving them a say in developing policies and procedures. “The proposal is tantamount to patients having their own general practitioner in the hospital with them to ensure continued quality care,” he says.5

Many of the new hospitalists will probably come from the ranks of career medical officers (CMOs), general physicians recruited directly out of training to work in underserved rural and suburban hospitals. Most CMOs are concentrated in emergency or critical care, but they can be found across a wide range of specialties, including orthopedics, community medicine, and even sexual medicine.4 CMOs may also follow patients after they have been admitted by a specialist.

But even the CMO position is still relatively new, having been created only in the 1980s. “They’ve been an absolutely invaluable resource in non-metropolitan Australia, but we still don’t have a formal system for their ongoing training or certification,” Dr. Lancashire tells The Hospitalist. “We need to provide a clear certification and career structure for these individuals.”

Participation in the hospitalist program is voluntary, says Dr. McGrath. Successful candidates “will be skilled in care coordination, patient flow management, patient safety systems, negotiation, procedural skills relevant to their roles, and clinical specialty modules relevant to the areas of specialty in which they are now working, such as geriatrics and emergency care.” Training will be on the job, “with skills assessment and ‘up-skilling’ as necessary to meet the responsibilities of the role they are filling in the local service.”

Still, the program reflects a tweaking—rather than a full-fledged revamping—of the Australian system. “The hospitalists will work with the consultants, who know them and trust their judgment,” says Abd Malak, executive director of workforce development at Sydney West Area Health Service, which is recruiting hospitalists for Westmead and Nepean hospitals. This means that hospitalists will have the authority to change a patient’s medication or other treatments when they deem it necessary, without waiting for the admitting specialist to come on rounds—but the admitting physician will still bear the ultimate responsibility for the patient’s outcome.

“The hospitalists will answer to the specialist clinicians for their patient care as well as management for patient flow and care coordination,” explains Dr. McGrath.

This approach represents a philosophy that differs sharply from the hospitalist’s position in the United States, in which a hospitalist has full responsibility for the patient’s care as long as that patient is in the hospital. In the Australian model, hospitalists will function almost as middle managers, exercising authority up to a point, but ultimately reporting to a more senior physician. Those who favor this arrangement describe it as organizing a patient’s care, rather than taking it over.4

Not surprisingly, some doctors are taking a dim view of this policy. “I think it’s a mistake. It’s just like giving the specialist another registrar,” says Dr. Lancashire. At Port Macquarie Base Hospital, he is leading the effort to develop a hospitalist program that is closer to the U.S. model because it will give those physicians primary responsibility for their patients.

Challenges

Indeed, good communication among a patient’s various doctors, always an essential element of good care, will be especially critical in the Australian system, says John Nelson, MD, medical director of the hospitalist practice at Overlake Hospital in Bellevue, Wash. “The hospitalists and consultants should try to preserve a collegial culture in which they talk to each other regularly,” he says. “Otherwise, you could wind up with a situation like the one in some European countries where hospital doctors and office doctors seldom communicate and don’t even see themselves as peers.”

Dr. Nelson, who has consulted on the establishment of more than 150 hospitalist practices, also warns the Australians against taking a one-size-fits-all approach. “Each hospital has its own culture, so they should acknowledge that the experience will play out differently at each institution,” he says.

Many Aussies agree with Dr. Nelson. “We find that the outcomes are better when the hospitalists are in charge of patient care,” adds Peter Jamieson, MD, division chief, acute care family medicine at Calgary Health Region in Canada, which has a hospitalist practice of about 80 physicians serving five hospitals. “Hospitalists take a holistic view of the patients and their problems. For example, at discharge they can reconcile a patient’s medications and, in general, make sure the ball isn’t dropped. These are skills that specialists don’t focus on and by putting hospitalists in a secondary, supportive, or bedside role, I don’t think they will capture those benefits.”

Another challenge concerns the effect of a hospitalist program on primary care physicians who practice outside the hospital setting, such as family physicians. “Will they lift those doctors from the community to work in the hospital, or will they employ full-time hospitalists?” asks Dr. Jamieson. “A new program is easiest to administer when you have full-time people on rotation, but it robs the community of some primary care physicians. In Calgary, we have a mix, so as not to deplete the community of those doctors.”

More concrete challenges concern funding streams and convincing hospital and, in a single-payer system, governmental authorities that hospitalists are worth the investment. “Demonstrating value is the first step,” says Dr. Jamieson, who helped develop the hospitalist program in Calgary.

The timely sharing of records is also critical, so electronic medical records or sophisticated faxing systems should be in place as well. “The hospital should send the patient’s records to the office doctor by the end of the day on which that patient is discharged,” explains Dr. Nelson. “If it takes two weeks for the community doctor to get the records, that’s going to be a problem.”

In general, he advises Australian hospitalists to listen well but make their needs and interests clear. “I would tell them to be frank about what they are looking for and how they want their practices to go. I encourage them to develop an ongoing dialogue with North American hospitalists: we can learn from each other.” TH

Norra MacReady is a regular contributor to The Hospitalist.

References

1. Hillman K. The changing role of acute-care hospitals. Med J Aust. 1999 Apr 5;170(7):325-328.
2. Murray RB, Wronski I. When the tide goes out: health workforce in rural, remote and indigenous communities. Med J Aust. 2006 Jul 3;185(1):37-38.
3. Hore CT, Lancashire W, Roberts JB, et al. Integrated critical care: an approach to specialist cover for critical care in the rural setting. Med J Aust. 2003 Nov 3;179(9):95-97.
4. Egan JM, Webber MG, King MR, et al. The hospitalist: a third alternative. Med J Aust. 2000 Apr 3;172(7):335-338.
5. Hatzistergos J. Health care work force innovations. Address before the Parliament of New South Wales, published in NSW Legislative Council Hansard, August 31, 2006, page 1221. Available at: www.parliament.nsw.gov.au/prod/PARLMENT/hansArt.nsf/V3Key/LC20060831012. Last accessed October 10, 2006.

The hospitalist movement is going Down Under: In a pilot program starting in January 2007, 20 hospitalists will begin working in 11 Australian hospitals as the country tries to adapt to the new realities of healthcare. The move reflects an ongoing debate in Australia concerning the best way to confront the challenges facing many developed nations in the 21st century: how to provide hospital care to an aging patient population that is growing sicker as medical costs skyrocket.

Current Concerns

Currently, Australia, like the United Kingdom and other Commonwealth countries, has a consultant-led medical system in which a specialist, or consultant, admits a patient and “owns” that individual for the duration of his or her hospital stay. The patient’s day-to-day care generally falls to a senior resident (or registrar) and a junior physician—both of whom consult with the supervising physician on rounds. In the meantime, little attention is paid to standardized indications and protocols for admission and discharge, and many observers complain about the lack of coordination and organization of care and patient flow.1

“In some cases, patient flow through our system can be disjointed, leading to delays in care and frustration from patients and staff,” says Katherine McGrath, MD, deputy director of General Health System Performance in New South Wales (NSW) Health, whose department is overseeing the pilot study. “We believe a new role, like that of the hospitalist, will fill the gap between the current non-clinical time requirements and patient needs.”

Others in Australia agree. “What we’re looking for is a senior presence in the hospital who can provide continuity of care,” says William Lancashire, MD, acting director of intensive care at Port Macquarie Base Hospital in Port Macquarie, NSW.

Rural care is another concern. Currently, 34% of all Australians and 70% of Australian aborigines live outside major urban centers and depend on “bush” hospitals when they become ill. Yet only 23% of medical specialists and 27% of general practitioners work in these remote areas.2 Hospitalists, with their expertise in general medicine and comfort with teamwork and coordination of care, are seen by some as an answer to the shortage of medical personnel in the bush. Some authors have suggested that physicians who work in these settings are already de facto hospitalists.3

The program is also an effort to improve quality of care, in response to studies reporting a troubling rate of medical errors and as many as 10,000 to 14,000 preventable deaths occurring within the Australian hospital system annually.4 When the Australian authorities first considered a hospitalist model and began studying programs in other countries, “we noted the rapid growth in hospitalist numbers and the positive contribution they have made to patient flow and patient safety,” says Dr. McGrath.

The Program

The participating hospitals are all located in the state of New South Wales: Westmead, Nepean, Bulli, Shellharbour, Shoalhaven, St. George, Sutherland, Fairfield, Manly, Mona Vale, and Hornsby. Depending on the institution, hospitalists may work in geriatrics, cardiology, renal, or emergency care.

In an address to the NSW state parliament, Minister for Health John Hatzistergos explains that hospitalists will coordinate care across departments to ensure that patients enjoy a smooth stay. They will also participate in hospital governance and organization, as well as staff education, giving them a say in developing policies and procedures. “The proposal is tantamount to patients having their own general practitioner in the hospital with them to ensure continued quality care,” he says.5

Many of the new hospitalists will probably come from the ranks of career medical officers (CMOs), general physicians recruited directly out of training to work in underserved rural and suburban hospitals. Most CMOs are concentrated in emergency or critical care, but they can be found across a wide range of specialties, including orthopedics, community medicine, and even sexual medicine.4 CMOs may also follow patients after they have been admitted by a specialist.

But even the CMO position is still relatively new, having been created only in the 1980s. “They’ve been an absolutely invaluable resource in non-metropolitan Australia, but we still don’t have a formal system for their ongoing training or certification,” Dr. Lancashire tells The Hospitalist. “We need to provide a clear certification and career structure for these individuals.”

Participation in the hospitalist program is voluntary, says Dr. McGrath. Successful candidates “will be skilled in care coordination, patient flow management, patient safety systems, negotiation, procedural skills relevant to their roles, and clinical specialty modules relevant to the areas of specialty in which they are now working, such as geriatrics and emergency care.” Training will be on the job, “with skills assessment and ‘up-skilling’ as necessary to meet the responsibilities of the role they are filling in the local service.”

Still, the program reflects a tweaking—rather than a full-fledged revamping—of the Australian system. “The hospitalists will work with the consultants, who know them and trust their judgment,” says Abd Malak, executive director of workforce development at Sydney West Area Health Service, which is recruiting hospitalists for Westmead and Nepean hospitals. This means that hospitalists will have the authority to change a patient’s medication or other treatments when they deem it necessary, without waiting for the admitting specialist to come on rounds—but the admitting physician will still bear the ultimate responsibility for the patient’s outcome.

“The hospitalists will answer to the specialist clinicians for their patient care as well as management for patient flow and care coordination,” explains Dr. McGrath.

This approach represents a philosophy that differs sharply from the hospitalist’s position in the United States, in which a hospitalist has full responsibility for the patient’s care as long as that patient is in the hospital. In the Australian model, hospitalists will function almost as middle managers, exercising authority up to a point, but ultimately reporting to a more senior physician. Those who favor this arrangement describe it as organizing a patient’s care, rather than taking it over.4

Not surprisingly, some doctors are taking a dim view of this policy. “I think it’s a mistake. It’s just like giving the specialist another registrar,” says Dr. Lancashire. At Port Macquarie Base Hospital, he is leading the effort to develop a hospitalist program that is closer to the U.S. model because it will give those physicians primary responsibility for their patients.

Challenges

Indeed, good communication among a patient’s various doctors, always an essential element of good care, will be especially critical in the Australian system, says John Nelson, MD, medical director of the hospitalist practice at Overlake Hospital in Bellevue, Wash. “The hospitalists and consultants should try to preserve a collegial culture in which they talk to each other regularly,” he says. “Otherwise, you could wind up with a situation like the one in some European countries where hospital doctors and office doctors seldom communicate and don’t even see themselves as peers.”

Dr. Nelson, who has consulted on the establishment of more than 150 hospitalist practices, also warns the Australians against taking a one-size-fits-all approach. “Each hospital has its own culture, so they should acknowledge that the experience will play out differently at each institution,” he says.

Many Aussies agree with Dr. Nelson. “We find that the outcomes are better when the hospitalists are in charge of patient care,” adds Peter Jamieson, MD, division chief, acute care family medicine at Calgary Health Region in Canada, which has a hospitalist practice of about 80 physicians serving five hospitals. “Hospitalists take a holistic view of the patients and their problems. For example, at discharge they can reconcile a patient’s medications and, in general, make sure the ball isn’t dropped. These are skills that specialists don’t focus on and by putting hospitalists in a secondary, supportive, or bedside role, I don’t think they will capture those benefits.”

Another challenge concerns the effect of a hospitalist program on primary care physicians who practice outside the hospital setting, such as family physicians. “Will they lift those doctors from the community to work in the hospital, or will they employ full-time hospitalists?” asks Dr. Jamieson. “A new program is easiest to administer when you have full-time people on rotation, but it robs the community of some primary care physicians. In Calgary, we have a mix, so as not to deplete the community of those doctors.”

More concrete challenges concern funding streams and convincing hospital and, in a single-payer system, governmental authorities that hospitalists are worth the investment. “Demonstrating value is the first step,” says Dr. Jamieson, who helped develop the hospitalist program in Calgary.

The timely sharing of records is also critical, so electronic medical records or sophisticated faxing systems should be in place as well. “The hospital should send the patient’s records to the office doctor by the end of the day on which that patient is discharged,” explains Dr. Nelson. “If it takes two weeks for the community doctor to get the records, that’s going to be a problem.”

In general, he advises Australian hospitalists to listen well but make their needs and interests clear. “I would tell them to be frank about what they are looking for and how they want their practices to go. I encourage them to develop an ongoing dialogue with North American hospitalists: we can learn from each other.” TH

Norra MacReady is a regular contributor to The Hospitalist.

References

1. Hillman K. The changing role of acute-care hospitals. Med J Aust. 1999 Apr 5;170(7):325-328.
2. Murray RB, Wronski I. When the tide goes out: health workforce in rural, remote and indigenous communities. Med J Aust. 2006 Jul 3;185(1):37-38.
3. Hore CT, Lancashire W, Roberts JB, et al. Integrated critical care: an approach to specialist cover for critical care in the rural setting. Med J Aust. 2003 Nov 3;179(9):95-97.
4. Egan JM, Webber MG, King MR, et al. The hospitalist: a third alternative. Med J Aust. 2000 Apr 3;172(7):335-338.
5. Hatzistergos J. Health care work force innovations. Address before the Parliament of New South Wales, published in NSW Legislative Council Hansard, August 31, 2006, page 1221. Available at: www.parliament.nsw.gov.au/prod/PARLMENT/hansArt.nsf/V3Key/LC20060831012. Last accessed October 10, 2006.

Leon Reinstein, MD, has worked as a hospitalist for more than 20 years—long before the term “hospitalist” was commonly used.

Leon Reinstein, MD, was a hospitalist long before he even realized he was one. When he came to Sinai Hospital in Baltimore in 1985 to establish an inpatient rehabilitation unit, he became a staff physician. He enjoyed the opportunity to pay more attention to patient care and educational activities than to administration and business concerns, but he didn’t have a name for what he did. “I actually stumbled across the concept. I read an article about hospitalists,” he says. “And I realized that I was one.”

Following Dr. Reinstein through a day in his life as a hospitalist offers insight into what makes him so effective in his work and why—after 20 years—he continues to enjoy his role and to inspire other physicians to follow in his footsteps.

Round and Round

Dr. Reinstein, one of four hospitalists on the 46-bed unit, begins his day at 7:30 with rounds at the hospital. Unlike his colleagues in private practice, however, his hospital patients are just steps from his office. His rounds, involving mostly total joint replacement and fracture patients, take approximately 45 minutes, after which he returns to his office to write up notes. He also prepares for the daily 9:45 a.m. “morning report.” This meeting with Dr. Reinstein’s resident, Melita Moore, MD, along with representatives from nursing, social work, and physical therapy, is an opportunity to review any changes or developments from the previous evening.

One of the meeting’s goals is to prepare patients for discharge. With an average 10-day length of stay, the team has to address problems such as constipation or infections that could hinder patients’ progress and delay their release. Pain issues are also a common topic. Getting and keeping pain under control is a top priority for Dr. Reinstein and his team. When patients are comfortable, he notes, they are better able to participate in physical therapy and rehab, and they eat and sleep better.

Plugging into Patient Care

After the morning report, Dr. Reinstein gets on the computer to input some notes and check lab results. He can do this thanks to the hospital’s computerized physician order entry (CPOE) system. He loves having access to information “in a second at my fingertips.” For example, he looks up lab values for one patient and records them on a warfarin flow sheet. He then orders medication using a “quick orders” tab that gives him a choice of dosages. At the same time, he is able to view a chest X-ray for another patient.

“I’m not a computer geek, but I love this system. It’s very interactive and easy to use,” says Dr. Reinstein, adding, “It includes information on everything from allergies and patient alerts to diet, activities, and diagnostic tests.” He spends about 15%-20% of his day at the computer.

Leon Reinstein, MD, has worked as a hospitalist for more than 20 years—long before the term “hospitalist” was commonly used.

Afternoon: The Pace Picks up

After a quick lunch, during which he catches up with his fellow hospitalists and other colleagues, Dr. Reinstein begins his busy afternoon. On Wednesday, this starts with a 12:30 team conference. This is an important meeting in which all of the team members—social workers, physical therapists, occupational therapists, nurses, and Dr. Reinstein’s resident—meet to discuss every patient in detail and prepare each for discharge.

At the meeting, conversations focus on patient functioning, physical therapy progress, medical condition, and pain control. The group discusses arrangements for community support and/or family education needs for some patients and subacute care options for others. The team also addresses patient goals and how they can help meet these. For example, one patient has requested an assistive device. While the equipment is not considered medically necessary by the insurance company, the group discusses how to arrange this in order to satisfy the patient’s wishes.

Afternoon Consults

Following the team conference, Dr. Reinstein spends most of the afternoon on consults. Today, he has been asked to see a number of patients in order to determine if admission to the rehab unit is appropriate for each one. Patients’ attending physicians make these referrals, and Dr. Reinstein works with them to make a final decision. In a typical day, he sees five to six new consults—most of them the day after surgery. At the same time, he follows up with four to five patients a few days after he first saw them to check progress, finalize decisions, and—when appropriate—prepare them to transfer to the rehab unit.

“I try to see the patients first who will be admitted to our unit today. We want to do the admits earlier. There are staff onsite to help them settle in, and it frees a bed for the hospital,” explains Dr. Reinstein.

Each consult starts with the patient’s chart, which he reviews carefully. In addition to medical issues, he looks at relevant social information, such as whether the patient lives in an apartment or a two-story house. This can affect goals and how much rehab the patient will need to function post-discharge. Dr. Reinstein checks medication regimens, vital signs, lab data, and other information on a nearby COW (or computer on wheels). These are located throughout the facility for easy access by clinicians.

After pulling and reviewing the chart, Dr. Reinstein goes to the patient’s room armed with a special form he uses to record his assessments and final recommendation. Following a greeting, he conducts a brief physical exam and asks the patient about pain and other relevant issues. He also considers weight-bearing status, a big issue in rehab.

The consults, which can take several hours, usually result in some new admissions to the rehab unit and the need for some follow-up visits that he will have to conduct in two or three days.

Leon Reinstein, MD, has worked as a hospitalist for more than 20 years—long before the term “hospitalist” was commonly used.

System Challenges

Preparing patients for discharge can be like playing “Beat the Clock” for Dr. Reinstein and his team. “Insurance companies will only approve a certain number of days, and there have to be strong medical reasons for an extended stay before they will pay,” he says. He emphasizes that his decisions are based on several factors that have to do with the patient’s well being and health rather than on an insurance company’s criteria. He also stresses that the patient is part of this decision making.

In particular, he mentions one individual who was waiting for an assistive device and expressed concern about going home before she had it and could get used to it. “I’m not going to push someone like this out the door,” he says. “We have to weigh the pros and cons and—ultimately—do what is best for each individual patient.”

Most of Dr. Reinstein’s patients—the majority of whom are 65 and older—want to get back to their homes and communities, and the team works hard to make that happen. In fact, 80% of patients are discharged to the community, with 20% going to a nursing facility or subacute unit.

Private insurance companies require prior authorization before patients can be admitted to the rehab unit following surgery or a fracture. “The main problem here arises when the insurance company decides that the patient doesn’t need this level of rehab,” says Dr. Reinstein. “At this point, we have to sit down with patients and families [and discuss] the options—including self-pay or transfer to a less expensive subacute facility.”

Hospital rehab can be expensive—up to $1,000 per day—so payment plans are often part of the discussion.

The majority of Dr. Reinstein’s patients have Medicare insurance, and this has some advantages because these individuals don’t need prior authorization to enter the rehab unit after surgery. Of course, he adds, Medicare does have a right to conduct a post review.

With Medicare patients comes the Medicare prescription drug benefit, and this has presented some challenges for Dr. Reinstein. He recalls one patient whose drug plan refused coverage for a prescription medication. Frustrated and in pain, she called Dr. Reinstein in a panic. He contacted the drug plan and tried to wade quickly through the red tape, but was unable to help. In frustration, he finally suggested that the patient contact her Congressional representative. She called Dr. Reinstein back an hour later to say that she had gotten her prescription filled. “Sometimes you have to be persistent and creative to get things done,” he says.

Dr. Reinstein has a great deal of experience fighting claim denials and other insurance-related issues, and he is not afraid to go to bat for his patients. “If I think there is a medical reason to keep the patient here, I will do so,” says Dr. Reinstein. “And I will fight the insurance company later.”

Of course, dealing with insurance companies isn’t his only challenge. In fact, Dr. Reinstein notes that his major frustration is that “I set high standards for myself and others. Sometimes, things don’t work the way I would like them to. I want everything done right, and I can’t control all of the details.” He adds that such frustration “is not unique to this setting. It actually is a larger societal issue that we all face.”

Smooth the Way with Communication

Working—and potentially clashing—with private-practice physicians can be a challenge for many hospitalists. Dr. Reinstein has mastered this skill.

“The key to working with primary-care doctors is communication,” he says. “The first thing we do here is to write on the patient’s chart all of the physicians involved in his or her care—their specialt[ies], phone number[s], and so on. Then we keep these practitioners abreast and involved. The patient’s primary care doctor may have seen this person for 20 years and knows things that we don’t, so reviewing issues with this practitioner is key.”

Dr. Reinstein also stresses communication as part of ensuring a smooth transition from the hospital to community care. For example, “We type a discharge summary on discharge day,” he says. “We give a copy to the patient and fax or mail one to his or her referring physician. We also keep a computerized copy.”

He also has the patient’s family bring in the bottles for all of the medications the patient is taking, and he goes over every one to make sure prescriptions are up to date, filled as necessary, and not likely to interact with other medications. “This only takes a few minutes, and it is an important part of great patient care,” he explains.

What Keeps Him Going?

“I take a lot of personal satisfaction in my work here,” says Dr. Reinstein. “When patients come here, they can’t do much. When they leave, they are prepared to take care of themselves. We make sure that they have the level of functioning, medications, assistance, and personal confidence they need to continue their progress and resume their lives.”

Watching his community-based colleagues rush from the hospital back to their offices or to other hospitals, Dr. Reinstein appreciates the fact that he spends his entire day at one facility.

“I don’t have to spend time running around from place to place, so I get to spend more time on direct patient care,” he says. “That is a real plus for me.” At the same time, being part of an institution means that “everything happens right away. If someone has chest pains, I’m there in a few minutes. I can order tests, have them done, and get results back quickly.”

Dr. Reinstein likes the control he has over his schedule: “I don’t have the same time pressures that you do in private practice. Basically, by the end of the day, I need to have seen all consults and follow-ups. But I can pace myself.”

He also likes the abundance of educational opportunities he has at Sinai. “I can conduct and participate in educational activities without leaving the building,” he says. He also enjoys working with residents and providing hands-on teaching.

Not having to deal with the business aspects of private practice is another advantage for Dr. Reinstein. “I’m salaried by the hospital, and my position removes me from a lot of the economics of medicine,” he explains. “For example, I complete a billing form on each patient every day, but that’s my only dealing with the billing. I don’t have to worry about census, overhead, hiring or firing staff, or the bottom line.

“You’re not your own boss, and some see this as a disadvantage,” cautions Dr. Reinstein. “A lot people become physicians because they want to be their own boss. This is the antithesis of that. You are part of a company.”

Overall, however, the advantages of hospitalist life far outweigh the disadvantages. “I get a lot of personal satisfaction from my work, I get to work with a consistent team, and I get four weeks of vacation,” he says. He adds that when he goes on vacation, he doesn’t have to worry about his patients. He knows that they are cared for and that his department is running smoothly in his absence.

Despite his enthusiasm for his work as a hospitalist, not all of Dr. Reinstein’s residents follow in his footsteps. “The ambulatory/orthopedic field is very lucrative and more attractive to many,” he says. “Being a hospitalist is not for everyone, and some want the experience of being in private practice.”

The Day Is Done: Satisfaction

“You have to decide how you want to live your life and what you want to do. I follow my own pace,” says Dr. Reinstein. “I do work I love. I collect a steady paycheck and get to focus on caring for my patients.”

His work day is long; but at the end, he gets to go home to his wife of 39 years knowing he made a difference today and that he will return to the same place and work with the same team to make a difference tomorrow. TH

Joanne Kaldy is frequent contributor to The Hospitalist.

Leon Reinstein, MD, has worked as a hospitalist for more than 20 years—long before the term “hospitalist” was commonly used.

Leon Reinstein, MD, was a hospitalist long before he even realized he was one. When he came to Sinai Hospital in Baltimore in 1985 to establish an inpatient rehabilitation unit, he became a staff physician. He enjoyed the opportunity to pay more attention to patient care and educational activities than to administration and business concerns, but he didn’t have a name for what he did. “I actually stumbled across the concept. I read an article about hospitalists,” he says. “And I realized that I was one.”

Following Dr. Reinstein through a day in his life as a hospitalist offers insight into what makes him so effective in his work and why—after 20 years—he continues to enjoy his role and to inspire other physicians to follow in his footsteps.

Round and Round

Dr. Reinstein, one of four hospitalists on the 46-bed unit, begins his day at 7:30 with rounds at the hospital. Unlike his colleagues in private practice, however, his hospital patients are just steps from his office. His rounds, involving mostly total joint replacement and fracture patients, take approximately 45 minutes, after which he returns to his office to write up notes. He also prepares for the daily 9:45 a.m. “morning report.” This meeting with Dr. Reinstein’s resident, Melita Moore, MD, along with representatives from nursing, social work, and physical therapy, is an opportunity to review any changes or developments from the previous evening.

One of the meeting’s goals is to prepare patients for discharge. With an average 10-day length of stay, the team has to address problems such as constipation or infections that could hinder patients’ progress and delay their release. Pain issues are also a common topic. Getting and keeping pain under control is a top priority for Dr. Reinstein and his team. When patients are comfortable, he notes, they are better able to participate in physical therapy and rehab, and they eat and sleep better.

Plugging into Patient Care

After the morning report, Dr. Reinstein gets on the computer to input some notes and check lab results. He can do this thanks to the hospital’s computerized physician order entry (CPOE) system. He loves having access to information “in a second at my fingertips.” For example, he looks up lab values for one patient and records them on a warfarin flow sheet. He then orders medication using a “quick orders” tab that gives him a choice of dosages. At the same time, he is able to view a chest X-ray for another patient.

“I’m not a computer geek, but I love this system. It’s very interactive and easy to use,” says Dr. Reinstein, adding, “It includes information on everything from allergies and patient alerts to diet, activities, and diagnostic tests.” He spends about 15%-20% of his day at the computer.

Leon Reinstein, MD, has worked as a hospitalist for more than 20 years—long before the term “hospitalist” was commonly used.

Afternoon: The Pace Picks up

After a quick lunch, during which he catches up with his fellow hospitalists and other colleagues, Dr. Reinstein begins his busy afternoon. On Wednesday, this starts with a 12:30 team conference. This is an important meeting in which all of the team members—social workers, physical therapists, occupational therapists, nurses, and Dr. Reinstein’s resident—meet to discuss every patient in detail and prepare each for discharge.

At the meeting, conversations focus on patient functioning, physical therapy progress, medical condition, and pain control. The group discusses arrangements for community support and/or family education needs for some patients and subacute care options for others. The team also addresses patient goals and how they can help meet these. For example, one patient has requested an assistive device. While the equipment is not considered medically necessary by the insurance company, the group discusses how to arrange this in order to satisfy the patient’s wishes.

Afternoon Consults

Following the team conference, Dr. Reinstein spends most of the afternoon on consults. Today, he has been asked to see a number of patients in order to determine if admission to the rehab unit is appropriate for each one. Patients’ attending physicians make these referrals, and Dr. Reinstein works with them to make a final decision. In a typical day, he sees five to six new consults—most of them the day after surgery. At the same time, he follows up with four to five patients a few days after he first saw them to check progress, finalize decisions, and—when appropriate—prepare them to transfer to the rehab unit.

“I try to see the patients first who will be admitted to our unit today. We want to do the admits earlier. There are staff onsite to help them settle in, and it frees a bed for the hospital,” explains Dr. Reinstein.

Each consult starts with the patient’s chart, which he reviews carefully. In addition to medical issues, he looks at relevant social information, such as whether the patient lives in an apartment or a two-story house. This can affect goals and how much rehab the patient will need to function post-discharge. Dr. Reinstein checks medication regimens, vital signs, lab data, and other information on a nearby COW (or computer on wheels). These are located throughout the facility for easy access by clinicians.

After pulling and reviewing the chart, Dr. Reinstein goes to the patient’s room armed with a special form he uses to record his assessments and final recommendation. Following a greeting, he conducts a brief physical exam and asks the patient about pain and other relevant issues. He also considers weight-bearing status, a big issue in rehab.

The consults, which can take several hours, usually result in some new admissions to the rehab unit and the need for some follow-up visits that he will have to conduct in two or three days.

Leon Reinstein, MD, has worked as a hospitalist for more than 20 years—long before the term “hospitalist” was commonly used.

System Challenges

Preparing patients for discharge can be like playing “Beat the Clock” for Dr. Reinstein and his team. “Insurance companies will only approve a certain number of days, and there have to be strong medical reasons for an extended stay before they will pay,” he says. He emphasizes that his decisions are based on several factors that have to do with the patient’s well being and health rather than on an insurance company’s criteria. He also stresses that the patient is part of this decision making.

In particular, he mentions one individual who was waiting for an assistive device and expressed concern about going home before she had it and could get used to it. “I’m not going to push someone like this out the door,” he says. “We have to weigh the pros and cons and—ultimately—do what is best for each individual patient.”

Most of Dr. Reinstein’s patients—the majority of whom are 65 and older—want to get back to their homes and communities, and the team works hard to make that happen. In fact, 80% of patients are discharged to the community, with 20% going to a nursing facility or subacute unit.

Private insurance companies require prior authorization before patients can be admitted to the rehab unit following surgery or a fracture. “The main problem here arises when the insurance company decides that the patient doesn’t need this level of rehab,” says Dr. Reinstein. “At this point, we have to sit down with patients and families [and discuss] the options—including self-pay or transfer to a less expensive subacute facility.”

Hospital rehab can be expensive—up to $1,000 per day—so payment plans are often part of the discussion.

The majority of Dr. Reinstein’s patients have Medicare insurance, and this has some advantages because these individuals don’t need prior authorization to enter the rehab unit after surgery. Of course, he adds, Medicare does have a right to conduct a post review.

With Medicare patients comes the Medicare prescription drug benefit, and this has presented some challenges for Dr. Reinstein. He recalls one patient whose drug plan refused coverage for a prescription medication. Frustrated and in pain, she called Dr. Reinstein in a panic. He contacted the drug plan and tried to wade quickly through the red tape, but was unable to help. In frustration, he finally suggested that the patient contact her Congressional representative. She called Dr. Reinstein back an hour later to say that she had gotten her prescription filled. “Sometimes you have to be persistent and creative to get things done,” he says.

Dr. Reinstein has a great deal of experience fighting claim denials and other insurance-related issues, and he is not afraid to go to bat for his patients. “If I think there is a medical reason to keep the patient here, I will do so,” says Dr. Reinstein. “And I will fight the insurance company later.”

Of course, dealing with insurance companies isn’t his only challenge. In fact, Dr. Reinstein notes that his major frustration is that “I set high standards for myself and others. Sometimes, things don’t work the way I would like them to. I want everything done right, and I can’t control all of the details.” He adds that such frustration “is not unique to this setting. It actually is a larger societal issue that we all face.”

Smooth the Way with Communication

Working—and potentially clashing—with private-practice physicians can be a challenge for many hospitalists. Dr. Reinstein has mastered this skill.

“The key to working with primary-care doctors is communication,” he says. “The first thing we do here is to write on the patient’s chart all of the physicians involved in his or her care—their specialt[ies], phone number[s], and so on. Then we keep these practitioners abreast and involved. The patient’s primary care doctor may have seen this person for 20 years and knows things that we don’t, so reviewing issues with this practitioner is key.”

Dr. Reinstein also stresses communication as part of ensuring a smooth transition from the hospital to community care. For example, “We type a discharge summary on discharge day,” he says. “We give a copy to the patient and fax or mail one to his or her referring physician. We also keep a computerized copy.”

He also has the patient’s family bring in the bottles for all of the medications the patient is taking, and he goes over every one to make sure prescriptions are up to date, filled as necessary, and not likely to interact with other medications. “This only takes a few minutes, and it is an important part of great patient care,” he explains.

What Keeps Him Going?

“I take a lot of personal satisfaction in my work here,” says Dr. Reinstein. “When patients come here, they can’t do much. When they leave, they are prepared to take care of themselves. We make sure that they have the level of functioning, medications, assistance, and personal confidence they need to continue their progress and resume their lives.”

Watching his community-based colleagues rush from the hospital back to their offices or to other hospitals, Dr. Reinstein appreciates the fact that he spends his entire day at one facility.

“I don’t have to spend time running around from place to place, so I get to spend more time on direct patient care,” he says. “That is a real plus for me.” At the same time, being part of an institution means that “everything happens right away. If someone has chest pains, I’m there in a few minutes. I can order tests, have them done, and get results back quickly.”

Dr. Reinstein likes the control he has over his schedule: “I don’t have the same time pressures that you do in private practice. Basically, by the end of the day, I need to have seen all consults and follow-ups. But I can pace myself.”

He also likes the abundance of educational opportunities he has at Sinai. “I can conduct and participate in educational activities without leaving the building,” he says. He also enjoys working with residents and providing hands-on teaching.

Not having to deal with the business aspects of private practice is another advantage for Dr. Reinstein. “I’m salaried by the hospital, and my position removes me from a lot of the economics of medicine,” he explains. “For example, I complete a billing form on each patient every day, but that’s my only dealing with the billing. I don’t have to worry about census, overhead, hiring or firing staff, or the bottom line.

“You’re not your own boss, and some see this as a disadvantage,” cautions Dr. Reinstein. “A lot people become physicians because they want to be their own boss. This is the antithesis of that. You are part of a company.”

Overall, however, the advantages of hospitalist life far outweigh the disadvantages. “I get a lot of personal satisfaction from my work, I get to work with a consistent team, and I get four weeks of vacation,” he says. He adds that when he goes on vacation, he doesn’t have to worry about his patients. He knows that they are cared for and that his department is running smoothly in his absence.

Despite his enthusiasm for his work as a hospitalist, not all of Dr. Reinstein’s residents follow in his footsteps. “The ambulatory/orthopedic field is very lucrative and more attractive to many,” he says. “Being a hospitalist is not for everyone, and some want the experience of being in private practice.”

The Day Is Done: Satisfaction

“You have to decide how you want to live your life and what you want to do. I follow my own pace,” says Dr. Reinstein. “I do work I love. I collect a steady paycheck and get to focus on caring for my patients.”

His work day is long; but at the end, he gets to go home to his wife of 39 years knowing he made a difference today and that he will return to the same place and work with the same team to make a difference tomorrow. TH

Joanne Kaldy is frequent contributor to The Hospitalist.

Leon Reinstein, MD, has worked as a hospitalist for more than 20 years—long before the term “hospitalist” was commonly used.

Leon Reinstein, MD, was a hospitalist long before he even realized he was one. When he came to Sinai Hospital in Baltimore in 1985 to establish an inpatient rehabilitation unit, he became a staff physician. He enjoyed the opportunity to pay more attention to patient care and educational activities than to administration and business concerns, but he didn’t have a name for what he did. “I actually stumbled across the concept. I read an article about hospitalists,” he says. “And I realized that I was one.”

Following Dr. Reinstein through a day in his life as a hospitalist offers insight into what makes him so effective in his work and why—after 20 years—he continues to enjoy his role and to inspire other physicians to follow in his footsteps.

Round and Round

Dr. Reinstein, one of four hospitalists on the 46-bed unit, begins his day at 7:30 with rounds at the hospital. Unlike his colleagues in private practice, however, his hospital patients are just steps from his office. His rounds, involving mostly total joint replacement and fracture patients, take approximately 45 minutes, after which he returns to his office to write up notes. He also prepares for the daily 9:45 a.m. “morning report.” This meeting with Dr. Reinstein’s resident, Melita Moore, MD, along with representatives from nursing, social work, and physical therapy, is an opportunity to review any changes or developments from the previous evening.

One of the meeting’s goals is to prepare patients for discharge. With an average 10-day length of stay, the team has to address problems such as constipation or infections that could hinder patients’ progress and delay their release. Pain issues are also a common topic. Getting and keeping pain under control is a top priority for Dr. Reinstein and his team. When patients are comfortable, he notes, they are better able to participate in physical therapy and rehab, and they eat and sleep better.

Plugging into Patient Care

After the morning report, Dr. Reinstein gets on the computer to input some notes and check lab results. He can do this thanks to the hospital’s computerized physician order entry (CPOE) system. He loves having access to information “in a second at my fingertips.” For example, he looks up lab values for one patient and records them on a warfarin flow sheet. He then orders medication using a “quick orders” tab that gives him a choice of dosages. At the same time, he is able to view a chest X-ray for another patient.

“I’m not a computer geek, but I love this system. It’s very interactive and easy to use,” says Dr. Reinstein, adding, “It includes information on everything from allergies and patient alerts to diet, activities, and diagnostic tests.” He spends about 15%-20% of his day at the computer.

Leon Reinstein, MD, has worked as a hospitalist for more than 20 years—long before the term “hospitalist” was commonly used.

Afternoon: The Pace Picks up

After a quick lunch, during which he catches up with his fellow hospitalists and other colleagues, Dr. Reinstein begins his busy afternoon. On Wednesday, this starts with a 12:30 team conference. This is an important meeting in which all of the team members—social workers, physical therapists, occupational therapists, nurses, and Dr. Reinstein’s resident—meet to discuss every patient in detail and prepare each for discharge.

At the meeting, conversations focus on patient functioning, physical therapy progress, medical condition, and pain control. The group discusses arrangements for community support and/or family education needs for some patients and subacute care options for others. The team also addresses patient goals and how they can help meet these. For example, one patient has requested an assistive device. While the equipment is not considered medically necessary by the insurance company, the group discusses how to arrange this in order to satisfy the patient’s wishes.

Afternoon Consults

Following the team conference, Dr. Reinstein spends most of the afternoon on consults. Today, he has been asked to see a number of patients in order to determine if admission to the rehab unit is appropriate for each one. Patients’ attending physicians make these referrals, and Dr. Reinstein works with them to make a final decision. In a typical day, he sees five to six new consults—most of them the day after surgery. At the same time, he follows up with four to five patients a few days after he first saw them to check progress, finalize decisions, and—when appropriate—prepare them to transfer to the rehab unit.

“I try to see the patients first who will be admitted to our unit today. We want to do the admits earlier. There are staff onsite to help them settle in, and it frees a bed for the hospital,” explains Dr. Reinstein.

Each consult starts with the patient’s chart, which he reviews carefully. In addition to medical issues, he looks at relevant social information, such as whether the patient lives in an apartment or a two-story house. This can affect goals and how much rehab the patient will need to function post-discharge. Dr. Reinstein checks medication regimens, vital signs, lab data, and other information on a nearby COW (or computer on wheels). These are located throughout the facility for easy access by clinicians.

After pulling and reviewing the chart, Dr. Reinstein goes to the patient’s room armed with a special form he uses to record his assessments and final recommendation. Following a greeting, he conducts a brief physical exam and asks the patient about pain and other relevant issues. He also considers weight-bearing status, a big issue in rehab.

The consults, which can take several hours, usually result in some new admissions to the rehab unit and the need for some follow-up visits that he will have to conduct in two or three days.

Leon Reinstein, MD, has worked as a hospitalist for more than 20 years—long before the term “hospitalist” was commonly used.

System Challenges

Preparing patients for discharge can be like playing “Beat the Clock” for Dr. Reinstein and his team. “Insurance companies will only approve a certain number of days, and there have to be strong medical reasons for an extended stay before they will pay,” he says. He emphasizes that his decisions are based on several factors that have to do with the patient’s well being and health rather than on an insurance company’s criteria. He also stresses that the patient is part of this decision making.

In particular, he mentions one individual who was waiting for an assistive device and expressed concern about going home before she had it and could get used to it. “I’m not going to push someone like this out the door,” he says. “We have to weigh the pros and cons and—ultimately—do what is best for each individual patient.”

Most of Dr. Reinstein’s patients—the majority of whom are 65 and older—want to get back to their homes and communities, and the team works hard to make that happen. In fact, 80% of patients are discharged to the community, with 20% going to a nursing facility or subacute unit.

Private insurance companies require prior authorization before patients can be admitted to the rehab unit following surgery or a fracture. “The main problem here arises when the insurance company decides that the patient doesn’t need this level of rehab,” says Dr. Reinstein. “At this point, we have to sit down with patients and families [and discuss] the options—including self-pay or transfer to a less expensive subacute facility.”

Hospital rehab can be expensive—up to $1,000 per day—so payment plans are often part of the discussion.

The majority of Dr. Reinstein’s patients have Medicare insurance, and this has some advantages because these individuals don’t need prior authorization to enter the rehab unit after surgery. Of course, he adds, Medicare does have a right to conduct a post review.

With Medicare patients comes the Medicare prescription drug benefit, and this has presented some challenges for Dr. Reinstein. He recalls one patient whose drug plan refused coverage for a prescription medication. Frustrated and in pain, she called Dr. Reinstein in a panic. He contacted the drug plan and tried to wade quickly through the red tape, but was unable to help. In frustration, he finally suggested that the patient contact her Congressional representative. She called Dr. Reinstein back an hour later to say that she had gotten her prescription filled. “Sometimes you have to be persistent and creative to get things done,” he says.

Dr. Reinstein has a great deal of experience fighting claim denials and other insurance-related issues, and he is not afraid to go to bat for his patients. “If I think there is a medical reason to keep the patient here, I will do so,” says Dr. Reinstein. “And I will fight the insurance company later.”

Of course, dealing with insurance companies isn’t his only challenge. In fact, Dr. Reinstein notes that his major frustration is that “I set high standards for myself and others. Sometimes, things don’t work the way I would like them to. I want everything done right, and I can’t control all of the details.” He adds that such frustration “is not unique to this setting. It actually is a larger societal issue that we all face.”

Smooth the Way with Communication

Working—and potentially clashing—with private-practice physicians can be a challenge for many hospitalists. Dr. Reinstein has mastered this skill.

“The key to working with primary-care doctors is communication,” he says. “The first thing we do here is to write on the patient’s chart all of the physicians involved in his or her care—their specialt[ies], phone number[s], and so on. Then we keep these practitioners abreast and involved. The patient’s primary care doctor may have seen this person for 20 years and knows things that we don’t, so reviewing issues with this practitioner is key.”

Dr. Reinstein also stresses communication as part of ensuring a smooth transition from the hospital to community care. For example, “We type a discharge summary on discharge day,” he says. “We give a copy to the patient and fax or mail one to his or her referring physician. We also keep a computerized copy.”

He also has the patient’s family bring in the bottles for all of the medications the patient is taking, and he goes over every one to make sure prescriptions are up to date, filled as necessary, and not likely to interact with other medications. “This only takes a few minutes, and it is an important part of great patient care,” he explains.

What Keeps Him Going?

“I take a lot of personal satisfaction in my work here,” says Dr. Reinstein. “When patients come here, they can’t do much. When they leave, they are prepared to take care of themselves. We make sure that they have the level of functioning, medications, assistance, and personal confidence they need to continue their progress and resume their lives.”

Watching his community-based colleagues rush from the hospital back to their offices or to other hospitals, Dr. Reinstein appreciates the fact that he spends his entire day at one facility.

“I don’t have to spend time running around from place to place, so I get to spend more time on direct patient care,” he says. “That is a real plus for me.” At the same time, being part of an institution means that “everything happens right away. If someone has chest pains, I’m there in a few minutes. I can order tests, have them done, and get results back quickly.”

Dr. Reinstein likes the control he has over his schedule: “I don’t have the same time pressures that you do in private practice. Basically, by the end of the day, I need to have seen all consults and follow-ups. But I can pace myself.”

He also likes the abundance of educational opportunities he has at Sinai. “I can conduct and participate in educational activities without leaving the building,” he says. He also enjoys working with residents and providing hands-on teaching.

Not having to deal with the business aspects of private practice is another advantage for Dr. Reinstein. “I’m salaried by the hospital, and my position removes me from a lot of the economics of medicine,” he explains. “For example, I complete a billing form on each patient every day, but that’s my only dealing with the billing. I don’t have to worry about census, overhead, hiring or firing staff, or the bottom line.

“You’re not your own boss, and some see this as a disadvantage,” cautions Dr. Reinstein. “A lot people become physicians because they want to be their own boss. This is the antithesis of that. You are part of a company.”

Overall, however, the advantages of hospitalist life far outweigh the disadvantages. “I get a lot of personal satisfaction from my work, I get to work with a consistent team, and I get four weeks of vacation,” he says. He adds that when he goes on vacation, he doesn’t have to worry about his patients. He knows that they are cared for and that his department is running smoothly in his absence.

Despite his enthusiasm for his work as a hospitalist, not all of Dr. Reinstein’s residents follow in his footsteps. “The ambulatory/orthopedic field is very lucrative and more attractive to many,” he says. “Being a hospitalist is not for everyone, and some want the experience of being in private practice.”

The Day Is Done: Satisfaction

“You have to decide how you want to live your life and what you want to do. I follow my own pace,” says Dr. Reinstein. “I do work I love. I collect a steady paycheck and get to focus on caring for my patients.”

His work day is long; but at the end, he gets to go home to his wife of 39 years knowing he made a difference today and that he will return to the same place and work with the same team to make a difference tomorrow. TH

Joanne Kaldy is frequent contributor to The Hospitalist.

Wayne Fenton, MD, an associate director of the National Institute of Mental Health (NIMH), was murdered September 3—allegedly by a patient—in his Bethesda, MD, office. The case has led other mental health professionals to wonder how susceptible they are to assault and whether they are doing all they can to protect themselves.

To explore these safety issues, Current Psychiatry Deputy Editor Lois E. Krahn, MD, talked with John Battaglia, MD, medical director of the Program of Assertive Community Treatment (PACT) in Madison, WI.

Dr. Battaglia’s work takes him into the community to treat patients with severe chronic mental illnesses. The Madison PACT program uses an intensive, team-based approach for patients who have been inadequately treated in usual mental health services. Patients with complicated psychiatric, social, and legal problems are seen in their homes, at work, or on the streets in an assertive and comprehensive style of case management.

Dr. Krahn: Dr. Fenton’s death was a tremendous loss to the psychiatric community.

Dr. Battaglia: We were all shaken; my first reaction was horror and sadness.

Dr. Krahn: Dr. Fenton was a very experienced psychiatrist (Box 1). His murder makes us think about our own vulnerability and wonder if such an assault could happen to us.

Dr. Battaglia: Yes, it’s very common for psychiatrists or mental health providers to be assaulted (Box 2).

Box 1

Wayne S. Fenton, MD: Advocate for the mentally ill

Dr. Fenton devoted his life to schizophrenia, through his compassion for those afflicted and his research that aided untold numbers of the mentally ill and their caregivers.

So it was especially sad that Dr. Fenton died while reaching out to a patient in need. On September 3, the NIMH associate director answered an urgent call to help a distressed, psychotic young man. A short time later, Dr. Fenton was found beaten to death at his Bethesda, MD, office.

Dr. Fenton was just 53 when he died, but his accomplishments were great. He joined NIMH in 1999, helping the organization find new treatments to enable schizophrenia patients to function in society. In this role, he galvanized colleagues nationwide to tackle the complex issue of difficult-to-treat schizophrenia. Before joining NIMH, Dr. Fenton was director and CEO of the Chestnut Lodge Hospital in Rockville, MD, where he did pivotal long-term studies of therapies for schizophrenia. From 2000 to 2005, he was deputy editor-in-chief of the journal Schizophrenia Bulletin. He served on numerous boards and in advocacy roles and won numerous awards.

In addition to these responsibilities, Dr. Fenton made time for his patients. And he gave his life, as he had lived it, trying to help. His obituary in the Washington Post included this quotation from Dr. Fenton, whom the newspaper interviewed in 2002:

All one has to do is walk through a downtown area to appreciate that the availability of adequate treatment for patients with schizophrenia and other mental illnesses is a serious problem for the country. We wouldn’t let our 80-year-old mother with Alzheimer’s live on a grate. Why is it all right for a 30-year-old daughter with schizophrenia?

In one study, more than 50% of psychiatrists and 75% of mental health nurses reported experiencing an act or threat of violence within the past year.¹

Dr. Krahn: Have you been assaulted by a patient?

Dr. Battaglia: Yes I have, and I think we need to define assault. A 15-year analysis of assaults on staff in a Massachusetts mental health system divided the acts into four types: physical, sexual, nonverbal threats/intimidation, and verbal assault.² And you might think physical assault would be worse than verbal assaults. But a threat from a patient—especially one aimed toward your family—can leave you feeling vulnerable, stressed, and hypervigilant. Every sound at night makes you wonder if that person is coming after your family.

Dr. Krahn: What kinds of patients are associated with violence and assault?

Dr. Battaglia: The DSM-IV-TR diagnosis that comes up most often is schizophrenia, but it’s debatable whether diagnosis alone increases the risk of violence.

A study in Sweden published this year found a definite correlation between severe mental illness and violent crime. The authors concluded that about 5% of violent crimes in that country were committed by persons with severe mental illness.³

Also this year, a study of data from the Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) found an increased risk of violence in schizophrenia patients with positive psychotic symptoms but a decreased risk in those with predominantly negative symptoms such as social withdrawal. Those with a combination of above-median positive and below-median negative symptoms were at highest risk for serious violence (Box 3).

Among a sample of 1,410 chronic schizophrenia patients enrolled in the NIMH-sponsored CATIE, 19% were involved in either minor or serious violent behavior in the past 6 months and 3.6% in serious violent behavior.⁴

Nobody argues that someone with schizophrenia is clearly at higher risk of becoming violent when in a high arousal state with positive symptoms or unpleasant delusions or hallucinations. A person with schizophrenia who is in an agitated, aroused psychotic state with active paranoid delusions and hallucinations is clearly at higher risk for committing violence.^5,6 The patient who has been charged in the beating death of Dr. Fenton was a 19-year-old man with severe psychosis.

Dr. Krahn: Are there other disorders, such as bipolar mania, that are high risk for patient violence?

Dr. Battaglia: Acute manic states are higher risk.⁷ But, again, the diagnosis of bipolar disorder in and of itself does not show an increased incidence of violence. Personality disorders can be higher risk, as can nonspecific neurologic abnormalities, such as abnormal EEGs or neurologic “soft signs” by exam or testing.

Dr. Krahn: What about substance abuse?

Dr. Battaglia: The risk of violence is higher in patients who are under the influence of certain stimulants such as cocaine and methamphetamines, as opposed to marijuana or sedatives.⁸

Dr. Krahn: How can we predict whether a patient is at high risk for assault?

Dr. Battaglia: The best predictor is a history of violence, especially when the act was unprovoked or resulted in injury.⁹ A small number of patients is responsible for the majority of aggression. One study showed that recidivists committed 53% of all violent acts in a health care setting.¹⁰

Dr. Krahn: What if the patient’s history is unknown?

Dr. Battaglia: Most assaults in health care occur in high arousal states. Planned, methodical assaults are significantly less frequent. So, in the case of patients making threats against staff—let’s say you terminated your relationship with a patient and obtained a restraining order—very commonly that patient’s passion toward the clinic will wane over time.

Dr. Krahn: But not every arousal state results in assault.

Dr. Battaglia: Right. I have a colleague who says, “Risk factors make you worry more, and nothing makes you worry less.” That’s the attitude to have. Nothing should make you lower your antenna.

Box 2

Mental health care: A high-risk occupation

Source: U.S. Department of Justice, National Crime Victimization Survey, 1993 to 1999

Dr. Krahn: Is the risk higher with a new patient, or does it go down as you establish a relationship?

Dr. Battaglia: Clearly, untreated patients in high arousal states are a much greater risk. Does risk go down with somebody you’ve known for a while? I don’t know. My own experiences with assault have sometimes occurred with people I’ve grown to trust and when I let my guard down.

Dr. Krahn: So we might relax once we know the patient, but then we might be more vulnerable. Any clues that should put us on high alert?

Dr. Battaglia: The first clue—and this is going to sound obvious—is our internal, visceral, emotional sense of impending danger. In my experience, psychiatrists have a very good sense of that, but we override or don’t pay attention to it. Part of that inattention is an occupational hazard; we have to turn off our sense of danger again and again so that we can stay in situations that would repulse most people.

For instance, medical students with no psychiatric experience might sit in an interview with an agitated patient and feel an intense need to flee. Their antennae are telling them the situation looks dangerous. Seasoned psychiatrists, however, will calm themselves and stay through the interview. We are so used to being healers and helpers that we often turn off or dampen our sense of danger.

Dr. Krahn: Can you elaborate?

Dr. Battaglia: A nurse and I were with a patient who was highly agitated. He was labile; he was angry; he was spitting as he was speaking. In any other context, people would be keeping their distance because the signals were so powerful. Instead, the nurse leaned in, held his hand, and started telling him, “Come on now (Bob), you need to settle down. This is scaring us.”

That’s what I call the “leaning-in response.” We do that day in and day out. We turn off our danger signals in order to be therapeutic, and that makes us vulnerable.

Dr. Krahn: So, how do we keep our signals tuned?

Dr. Battaglia: When our senses are telling us we’re scared or we’re noticing a feeling of wanting to flee, we have to shift away from the goal of being therapeutic and focus on the goal of harm reduction. In assault cases, two clinician errors I see are:

• people had a sense that something was dangerous, but they ignored or dampened it
• people were passive when tension was mounting and didn’t abort an assault situation.

Anger is easy to recognize. Raised voice, inappropriate staring, clenched fists, agitation, and verbal threats are common before a violent episode. This seems self-evident, yet it’s surprising—even when these signs are obvious—that clinicians often took no de-escalation measures to ward off violence. A verbal threat is a red flag to prepare for violence.

Dr. Krahn: So, your senses are tingling. What do you do?

Dr. Battaglia: If the patient is threatening you and is in a negative affective arousal state that does not allow verbal redirection, you need to get away. Before you make your move, however, announce your behavior so that the patient will not interpret it as an attack (“Bob, I am standing up now because I need to leave the room”).

Box 3

CATIE trial data:
Schizophrenia symptoms associated with violent behavior

Schizophrenia patients with combined low negative and high positive PANSS scores were at highest risk to cause bodily injury or harm someone with a weapon in the past 6 months.

Source: Reference 4

Dr. Krahn: Can that be a difficult call?

Dr. Battaglia: I think you learn when to shift gears. You undergo a number of incidents where you question yourself, and you go to an experienced colleague and say, “I was in a session with this patient. Here’s what I did. Do you think I was exposing myself unnecessarily?” Go over the incident in detail with someone who is supportive and understanding but also has a critical eye.

Dr. Krahn: Any suggestions as to how the room or other staff can be positioned to keep the risk as low as possible? Do you recommend alarms inside offices?

Dr. Battaglia: I think it’s smart to have an alarm system. And you need to think about the physical layout of the room ahead of time. You and the patient may need to have equal access to the door. If the patient is high-risk, you might want to arrange seating at a 90-degree angle rather than face-to-face to limit sustained confrontational eye contact. You might want to place your chair greater than an arm swing or leg kick away. You need to decide whether it’s safe to be alone, and whether to have the door open or to have security posted.

Dr. Krahn: What kind of training should staff be given?

Dr. Battaglia: Every office should have policies and protocols for handling behavioral emergencies. Who calls 911? What are each person’s responsibilities? Also, staff should be confident but not confrontational. That, in itself, may dissuade a patient from acting out.

Everyone should be taught de-escalation techniques. Body language can send threatening signals or they can signal a person that you’re not a threat and you’re going to work with them.

Dr. Krahn: Can you give an example where training might have helped?

Dr. Battaglia: I recently reviewed an incident where a nurse and a psychologist had a delusional, paranoid patient in their office and he wanted to leave. He was relapsed and clearly agitated; he was psychotic; he needed to be hospitalized. He wanted to escape, and they barred the door because they wanted to get him in the hospital.

The patient punched the nurse. If you bar someone’s escape, you’re very likely to get hurt. Let the patient go and call the police, who are trained to bring people in.

Dr. Krahn: What about building security? I know of a situation where a patient was found waiting for a psychiatrist in the parking garage. If there are threats, should an escort system be in place?

Dr. Battaglia: Security needs to work with the staff to come up with a plan.

Dr. Krahn: If someone in your office is assaulted, how do you handle the aftermath?

Dr. Battaglia: The person who is assaulted needs to get help. Crisis debriefing has been debated in trauma treatment, but there’s no debate about the benefit of “psychological first aid.” It provides an opportunity for the person to talk in confidence with another professional about what’s happened and how it may be affecting him or her.

Dr. Krahn: Can you continue to treat someone who has assaulted you?

Dr. Battaglia: That decision has to be made on a case-by-case basis. The main question is whether you feel safe enough to be therapeutic with the person in the future. Outside of a controlled setting, I don’t think you can effectively treat a patient you fear.

Dr. Krahn: Dr. Fenton’s death brings home that we need to be vigilant each day. We meet new patients every week, and any of them may have the disorders and risk factors that can lead to violence.

Dr. Battaglia: That’s true, yet being in a constant state of fear can impair mental health professionals’ ability to do our work. It’s a dynamic balance—we attempt a measured calmness in our work yet pay attention to external and visceral cues of impending danger.

Dr. Krahn: I think some psychiatrists feel patient violence occurs only in correctional settings or emergency rooms—not in their world. But Dr. Fenton’s death shows that it can happen anywhere. You just don’t know.

Related resources

• Joint Commission on Accreditation of HealthCare Organizations (JCAHO). Rules on application of seclusion and restraint. www.jointcommission.org.

Acknowledgment

This article was edited by Lynn Waltz, a medical writer and editor in Norfolk, VA, from the transcript of the September 29, 2006 interview of Dr. Battaglia by Dr. Krahn.

Wayne Fenton, MD, an associate director of the National Institute of Mental Health (NIMH), was murdered September 3—allegedly by a patient—in his Bethesda, MD, office. The case has led other mental health professionals to wonder how susceptible they are to assault and whether they are doing all they can to protect themselves.

To explore these safety issues, Current Psychiatry Deputy Editor Lois E. Krahn, MD, talked with John Battaglia, MD, medical director of the Program of Assertive Community Treatment (PACT) in Madison, WI.

Dr. Battaglia’s work takes him into the community to treat patients with severe chronic mental illnesses. The Madison PACT program uses an intensive, team-based approach for patients who have been inadequately treated in usual mental health services. Patients with complicated psychiatric, social, and legal problems are seen in their homes, at work, or on the streets in an assertive and comprehensive style of case management.

Dr. Krahn: Dr. Fenton’s death was a tremendous loss to the psychiatric community.

Dr. Battaglia: We were all shaken; my first reaction was horror and sadness.

Dr. Krahn: Dr. Fenton was a very experienced psychiatrist (Box 1). His murder makes us think about our own vulnerability and wonder if such an assault could happen to us.

Dr. Battaglia: Yes, it’s very common for psychiatrists or mental health providers to be assaulted (Box 2).

Box 1

Wayne S. Fenton, MD: Advocate for the mentally ill

Dr. Fenton devoted his life to schizophrenia, through his compassion for those afflicted and his research that aided untold numbers of the mentally ill and their caregivers.

So it was especially sad that Dr. Fenton died while reaching out to a patient in need. On September 3, the NIMH associate director answered an urgent call to help a distressed, psychotic young man. A short time later, Dr. Fenton was found beaten to death at his Bethesda, MD, office.

Dr. Fenton was just 53 when he died, but his accomplishments were great. He joined NIMH in 1999, helping the organization find new treatments to enable schizophrenia patients to function in society. In this role, he galvanized colleagues nationwide to tackle the complex issue of difficult-to-treat schizophrenia. Before joining NIMH, Dr. Fenton was director and CEO of the Chestnut Lodge Hospital in Rockville, MD, where he did pivotal long-term studies of therapies for schizophrenia. From 2000 to 2005, he was deputy editor-in-chief of the journal Schizophrenia Bulletin. He served on numerous boards and in advocacy roles and won numerous awards.

In addition to these responsibilities, Dr. Fenton made time for his patients. And he gave his life, as he had lived it, trying to help. His obituary in the Washington Post included this quotation from Dr. Fenton, whom the newspaper interviewed in 2002:

All one has to do is walk through a downtown area to appreciate that the availability of adequate treatment for patients with schizophrenia and other mental illnesses is a serious problem for the country. We wouldn’t let our 80-year-old mother with Alzheimer’s live on a grate. Why is it all right for a 30-year-old daughter with schizophrenia?

In one study, more than 50% of psychiatrists and 75% of mental health nurses reported experiencing an act or threat of violence within the past year.¹

Dr. Krahn: Have you been assaulted by a patient?

Dr. Battaglia: Yes I have, and I think we need to define assault. A 15-year analysis of assaults on staff in a Massachusetts mental health system divided the acts into four types: physical, sexual, nonverbal threats/intimidation, and verbal assault.² And you might think physical assault would be worse than verbal assaults. But a threat from a patient—especially one aimed toward your family—can leave you feeling vulnerable, stressed, and hypervigilant. Every sound at night makes you wonder if that person is coming after your family.

Dr. Krahn: What kinds of patients are associated with violence and assault?

Dr. Battaglia: The DSM-IV-TR diagnosis that comes up most often is schizophrenia, but it’s debatable whether diagnosis alone increases the risk of violence.

A study in Sweden published this year found a definite correlation between severe mental illness and violent crime. The authors concluded that about 5% of violent crimes in that country were committed by persons with severe mental illness.³

Also this year, a study of data from the Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) found an increased risk of violence in schizophrenia patients with positive psychotic symptoms but a decreased risk in those with predominantly negative symptoms such as social withdrawal. Those with a combination of above-median positive and below-median negative symptoms were at highest risk for serious violence (Box 3).

Among a sample of 1,410 chronic schizophrenia patients enrolled in the NIMH-sponsored CATIE, 19% were involved in either minor or serious violent behavior in the past 6 months and 3.6% in serious violent behavior.⁴

Nobody argues that someone with schizophrenia is clearly at higher risk of becoming violent when in a high arousal state with positive symptoms or unpleasant delusions or hallucinations. A person with schizophrenia who is in an agitated, aroused psychotic state with active paranoid delusions and hallucinations is clearly at higher risk for committing violence.^5,6 The patient who has been charged in the beating death of Dr. Fenton was a 19-year-old man with severe psychosis.

Dr. Krahn: Are there other disorders, such as bipolar mania, that are high risk for patient violence?

Dr. Battaglia: Acute manic states are higher risk.⁷ But, again, the diagnosis of bipolar disorder in and of itself does not show an increased incidence of violence. Personality disorders can be higher risk, as can nonspecific neurologic abnormalities, such as abnormal EEGs or neurologic “soft signs” by exam or testing.

Dr. Krahn: What about substance abuse?

Dr. Battaglia: The risk of violence is higher in patients who are under the influence of certain stimulants such as cocaine and methamphetamines, as opposed to marijuana or sedatives.⁸

Dr. Krahn: How can we predict whether a patient is at high risk for assault?

Dr. Battaglia: The best predictor is a history of violence, especially when the act was unprovoked or resulted in injury.⁹ A small number of patients is responsible for the majority of aggression. One study showed that recidivists committed 53% of all violent acts in a health care setting.¹⁰

Dr. Krahn: What if the patient’s history is unknown?

Dr. Battaglia: Most assaults in health care occur in high arousal states. Planned, methodical assaults are significantly less frequent. So, in the case of patients making threats against staff—let’s say you terminated your relationship with a patient and obtained a restraining order—very commonly that patient’s passion toward the clinic will wane over time.

Dr. Krahn: But not every arousal state results in assault.

Dr. Battaglia: Right. I have a colleague who says, “Risk factors make you worry more, and nothing makes you worry less.” That’s the attitude to have. Nothing should make you lower your antenna.

Box 2

Mental health care: A high-risk occupation

Source: U.S. Department of Justice, National Crime Victimization Survey, 1993 to 1999

Dr. Krahn: Is the risk higher with a new patient, or does it go down as you establish a relationship?

Dr. Battaglia: Clearly, untreated patients in high arousal states are a much greater risk. Does risk go down with somebody you’ve known for a while? I don’t know. My own experiences with assault have sometimes occurred with people I’ve grown to trust and when I let my guard down.

Dr. Krahn: So we might relax once we know the patient, but then we might be more vulnerable. Any clues that should put us on high alert?

Dr. Battaglia: The first clue—and this is going to sound obvious—is our internal, visceral, emotional sense of impending danger. In my experience, psychiatrists have a very good sense of that, but we override or don’t pay attention to it. Part of that inattention is an occupational hazard; we have to turn off our sense of danger again and again so that we can stay in situations that would repulse most people.

For instance, medical students with no psychiatric experience might sit in an interview with an agitated patient and feel an intense need to flee. Their antennae are telling them the situation looks dangerous. Seasoned psychiatrists, however, will calm themselves and stay through the interview. We are so used to being healers and helpers that we often turn off or dampen our sense of danger.

Dr. Krahn: Can you elaborate?

Dr. Battaglia: A nurse and I were with a patient who was highly agitated. He was labile; he was angry; he was spitting as he was speaking. In any other context, people would be keeping their distance because the signals were so powerful. Instead, the nurse leaned in, held his hand, and started telling him, “Come on now (Bob), you need to settle down. This is scaring us.”

That’s what I call the “leaning-in response.” We do that day in and day out. We turn off our danger signals in order to be therapeutic, and that makes us vulnerable.

Dr. Krahn: So, how do we keep our signals tuned?

Dr. Battaglia: When our senses are telling us we’re scared or we’re noticing a feeling of wanting to flee, we have to shift away from the goal of being therapeutic and focus on the goal of harm reduction. In assault cases, two clinician errors I see are:

• people had a sense that something was dangerous, but they ignored or dampened it
• people were passive when tension was mounting and didn’t abort an assault situation.

Anger is easy to recognize. Raised voice, inappropriate staring, clenched fists, agitation, and verbal threats are common before a violent episode. This seems self-evident, yet it’s surprising—even when these signs are obvious—that clinicians often took no de-escalation measures to ward off violence. A verbal threat is a red flag to prepare for violence.

Dr. Krahn: So, your senses are tingling. What do you do?

Dr. Battaglia: If the patient is threatening you and is in a negative affective arousal state that does not allow verbal redirection, you need to get away. Before you make your move, however, announce your behavior so that the patient will not interpret it as an attack (“Bob, I am standing up now because I need to leave the room”).

Box 3

CATIE trial data:
Schizophrenia symptoms associated with violent behavior

Schizophrenia patients with combined low negative and high positive PANSS scores were at highest risk to cause bodily injury or harm someone with a weapon in the past 6 months.

Source: Reference 4

Dr. Krahn: Can that be a difficult call?

Dr. Battaglia: I think you learn when to shift gears. You undergo a number of incidents where you question yourself, and you go to an experienced colleague and say, “I was in a session with this patient. Here’s what I did. Do you think I was exposing myself unnecessarily?” Go over the incident in detail with someone who is supportive and understanding but also has a critical eye.

Dr. Krahn: Any suggestions as to how the room or other staff can be positioned to keep the risk as low as possible? Do you recommend alarms inside offices?

Dr. Battaglia: I think it’s smart to have an alarm system. And you need to think about the physical layout of the room ahead of time. You and the patient may need to have equal access to the door. If the patient is high-risk, you might want to arrange seating at a 90-degree angle rather than face-to-face to limit sustained confrontational eye contact. You might want to place your chair greater than an arm swing or leg kick away. You need to decide whether it’s safe to be alone, and whether to have the door open or to have security posted.

Dr. Krahn: What kind of training should staff be given?

Dr. Battaglia: Every office should have policies and protocols for handling behavioral emergencies. Who calls 911? What are each person’s responsibilities? Also, staff should be confident but not confrontational. That, in itself, may dissuade a patient from acting out.

Everyone should be taught de-escalation techniques. Body language can send threatening signals or they can signal a person that you’re not a threat and you’re going to work with them.

Dr. Krahn: Can you give an example where training might have helped?

Dr. Battaglia: I recently reviewed an incident where a nurse and a psychologist had a delusional, paranoid patient in their office and he wanted to leave. He was relapsed and clearly agitated; he was psychotic; he needed to be hospitalized. He wanted to escape, and they barred the door because they wanted to get him in the hospital.

The patient punched the nurse. If you bar someone’s escape, you’re very likely to get hurt. Let the patient go and call the police, who are trained to bring people in.

Dr. Krahn: What about building security? I know of a situation where a patient was found waiting for a psychiatrist in the parking garage. If there are threats, should an escort system be in place?

Dr. Battaglia: Security needs to work with the staff to come up with a plan.

Dr. Krahn: If someone in your office is assaulted, how do you handle the aftermath?

Dr. Battaglia: The person who is assaulted needs to get help. Crisis debriefing has been debated in trauma treatment, but there’s no debate about the benefit of “psychological first aid.” It provides an opportunity for the person to talk in confidence with another professional about what’s happened and how it may be affecting him or her.

Dr. Krahn: Can you continue to treat someone who has assaulted you?

Dr. Battaglia: That decision has to be made on a case-by-case basis. The main question is whether you feel safe enough to be therapeutic with the person in the future. Outside of a controlled setting, I don’t think you can effectively treat a patient you fear.

Dr. Krahn: Dr. Fenton’s death brings home that we need to be vigilant each day. We meet new patients every week, and any of them may have the disorders and risk factors that can lead to violence.

Dr. Battaglia: That’s true, yet being in a constant state of fear can impair mental health professionals’ ability to do our work. It’s a dynamic balance—we attempt a measured calmness in our work yet pay attention to external and visceral cues of impending danger.

Dr. Krahn: I think some psychiatrists feel patient violence occurs only in correctional settings or emergency rooms—not in their world. But Dr. Fenton’s death shows that it can happen anywhere. You just don’t know.

Related resources

• Joint Commission on Accreditation of HealthCare Organizations (JCAHO). Rules on application of seclusion and restraint. www.jointcommission.org.

Acknowledgment

This article was edited by Lynn Waltz, a medical writer and editor in Norfolk, VA, from the transcript of the September 29, 2006 interview of Dr. Battaglia by Dr. Krahn.

Wayne Fenton, MD, an associate director of the National Institute of Mental Health (NIMH), was murdered September 3—allegedly by a patient—in his Bethesda, MD, office. The case has led other mental health professionals to wonder how susceptible they are to assault and whether they are doing all they can to protect themselves.

To explore these safety issues, Current Psychiatry Deputy Editor Lois E. Krahn, MD, talked with John Battaglia, MD, medical director of the Program of Assertive Community Treatment (PACT) in Madison, WI.

Dr. Battaglia’s work takes him into the community to treat patients with severe chronic mental illnesses. The Madison PACT program uses an intensive, team-based approach for patients who have been inadequately treated in usual mental health services. Patients with complicated psychiatric, social, and legal problems are seen in their homes, at work, or on the streets in an assertive and comprehensive style of case management.

Dr. Krahn: Dr. Fenton’s death was a tremendous loss to the psychiatric community.

Dr. Battaglia: We were all shaken; my first reaction was horror and sadness.

Dr. Krahn: Dr. Fenton was a very experienced psychiatrist (Box 1). His murder makes us think about our own vulnerability and wonder if such an assault could happen to us.

Dr. Battaglia: Yes, it’s very common for psychiatrists or mental health providers to be assaulted (Box 2).

Box 1

Wayne S. Fenton, MD: Advocate for the mentally ill

Dr. Fenton devoted his life to schizophrenia, through his compassion for those afflicted and his research that aided untold numbers of the mentally ill and their caregivers.

So it was especially sad that Dr. Fenton died while reaching out to a patient in need. On September 3, the NIMH associate director answered an urgent call to help a distressed, psychotic young man. A short time later, Dr. Fenton was found beaten to death at his Bethesda, MD, office.

Dr. Fenton was just 53 when he died, but his accomplishments were great. He joined NIMH in 1999, helping the organization find new treatments to enable schizophrenia patients to function in society. In this role, he galvanized colleagues nationwide to tackle the complex issue of difficult-to-treat schizophrenia. Before joining NIMH, Dr. Fenton was director and CEO of the Chestnut Lodge Hospital in Rockville, MD, where he did pivotal long-term studies of therapies for schizophrenia. From 2000 to 2005, he was deputy editor-in-chief of the journal Schizophrenia Bulletin. He served on numerous boards and in advocacy roles and won numerous awards.

In addition to these responsibilities, Dr. Fenton made time for his patients. And he gave his life, as he had lived it, trying to help. His obituary in the Washington Post included this quotation from Dr. Fenton, whom the newspaper interviewed in 2002:

All one has to do is walk through a downtown area to appreciate that the availability of adequate treatment for patients with schizophrenia and other mental illnesses is a serious problem for the country. We wouldn’t let our 80-year-old mother with Alzheimer’s live on a grate. Why is it all right for a 30-year-old daughter with schizophrenia?

In one study, more than 50% of psychiatrists and 75% of mental health nurses reported experiencing an act or threat of violence within the past year.¹

Dr. Krahn: Have you been assaulted by a patient?

Dr. Battaglia: Yes I have, and I think we need to define assault. A 15-year analysis of assaults on staff in a Massachusetts mental health system divided the acts into four types: physical, sexual, nonverbal threats/intimidation, and verbal assault.² And you might think physical assault would be worse than verbal assaults. But a threat from a patient—especially one aimed toward your family—can leave you feeling vulnerable, stressed, and hypervigilant. Every sound at night makes you wonder if that person is coming after your family.

Dr. Krahn: What kinds of patients are associated with violence and assault?

Dr. Battaglia: The DSM-IV-TR diagnosis that comes up most often is schizophrenia, but it’s debatable whether diagnosis alone increases the risk of violence.

A study in Sweden published this year found a definite correlation between severe mental illness and violent crime. The authors concluded that about 5% of violent crimes in that country were committed by persons with severe mental illness.³

Also this year, a study of data from the Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) found an increased risk of violence in schizophrenia patients with positive psychotic symptoms but a decreased risk in those with predominantly negative symptoms such as social withdrawal. Those with a combination of above-median positive and below-median negative symptoms were at highest risk for serious violence (Box 3).

Among a sample of 1,410 chronic schizophrenia patients enrolled in the NIMH-sponsored CATIE, 19% were involved in either minor or serious violent behavior in the past 6 months and 3.6% in serious violent behavior.⁴

Nobody argues that someone with schizophrenia is clearly at higher risk of becoming violent when in a high arousal state with positive symptoms or unpleasant delusions or hallucinations. A person with schizophrenia who is in an agitated, aroused psychotic state with active paranoid delusions and hallucinations is clearly at higher risk for committing violence.^5,6 The patient who has been charged in the beating death of Dr. Fenton was a 19-year-old man with severe psychosis.

Dr. Krahn: Are there other disorders, such as bipolar mania, that are high risk for patient violence?

Dr. Battaglia: Acute manic states are higher risk.⁷ But, again, the diagnosis of bipolar disorder in and of itself does not show an increased incidence of violence. Personality disorders can be higher risk, as can nonspecific neurologic abnormalities, such as abnormal EEGs or neurologic “soft signs” by exam or testing.

Dr. Krahn: What about substance abuse?

Dr. Battaglia: The risk of violence is higher in patients who are under the influence of certain stimulants such as cocaine and methamphetamines, as opposed to marijuana or sedatives.⁸

Dr. Krahn: How can we predict whether a patient is at high risk for assault?

Dr. Battaglia: The best predictor is a history of violence, especially when the act was unprovoked or resulted in injury.⁹ A small number of patients is responsible for the majority of aggression. One study showed that recidivists committed 53% of all violent acts in a health care setting.¹⁰

Dr. Krahn: What if the patient’s history is unknown?

Dr. Battaglia: Most assaults in health care occur in high arousal states. Planned, methodical assaults are significantly less frequent. So, in the case of patients making threats against staff—let’s say you terminated your relationship with a patient and obtained a restraining order—very commonly that patient’s passion toward the clinic will wane over time.

Dr. Krahn: But not every arousal state results in assault.

Dr. Battaglia: Right. I have a colleague who says, “Risk factors make you worry more, and nothing makes you worry less.” That’s the attitude to have. Nothing should make you lower your antenna.

Box 2

Mental health care: A high-risk occupation

Source: U.S. Department of Justice, National Crime Victimization Survey, 1993 to 1999

Dr. Krahn: Is the risk higher with a new patient, or does it go down as you establish a relationship?

Dr. Battaglia: Clearly, untreated patients in high arousal states are a much greater risk. Does risk go down with somebody you’ve known for a while? I don’t know. My own experiences with assault have sometimes occurred with people I’ve grown to trust and when I let my guard down.

Dr. Krahn: So we might relax once we know the patient, but then we might be more vulnerable. Any clues that should put us on high alert?

Dr. Battaglia: The first clue—and this is going to sound obvious—is our internal, visceral, emotional sense of impending danger. In my experience, psychiatrists have a very good sense of that, but we override or don’t pay attention to it. Part of that inattention is an occupational hazard; we have to turn off our sense of danger again and again so that we can stay in situations that would repulse most people.

For instance, medical students with no psychiatric experience might sit in an interview with an agitated patient and feel an intense need to flee. Their antennae are telling them the situation looks dangerous. Seasoned psychiatrists, however, will calm themselves and stay through the interview. We are so used to being healers and helpers that we often turn off or dampen our sense of danger.

Dr. Krahn: Can you elaborate?

Dr. Battaglia: A nurse and I were with a patient who was highly agitated. He was labile; he was angry; he was spitting as he was speaking. In any other context, people would be keeping their distance because the signals were so powerful. Instead, the nurse leaned in, held his hand, and started telling him, “Come on now (Bob), you need to settle down. This is scaring us.”

That’s what I call the “leaning-in response.” We do that day in and day out. We turn off our danger signals in order to be therapeutic, and that makes us vulnerable.

Dr. Krahn: So, how do we keep our signals tuned?

Dr. Battaglia: When our senses are telling us we’re scared or we’re noticing a feeling of wanting to flee, we have to shift away from the goal of being therapeutic and focus on the goal of harm reduction. In assault cases, two clinician errors I see are:

• people had a sense that something was dangerous, but they ignored or dampened it
• people were passive when tension was mounting and didn’t abort an assault situation.

Anger is easy to recognize. Raised voice, inappropriate staring, clenched fists, agitation, and verbal threats are common before a violent episode. This seems self-evident, yet it’s surprising—even when these signs are obvious—that clinicians often took no de-escalation measures to ward off violence. A verbal threat is a red flag to prepare for violence.

Dr. Krahn: So, your senses are tingling. What do you do?

Dr. Battaglia: If the patient is threatening you and is in a negative affective arousal state that does not allow verbal redirection, you need to get away. Before you make your move, however, announce your behavior so that the patient will not interpret it as an attack (“Bob, I am standing up now because I need to leave the room”).

Box 3

CATIE trial data:
Schizophrenia symptoms associated with violent behavior

Schizophrenia patients with combined low negative and high positive PANSS scores were at highest risk to cause bodily injury or harm someone with a weapon in the past 6 months.

Source: Reference 4

Dr. Krahn: Can that be a difficult call?

Dr. Battaglia: I think you learn when to shift gears. You undergo a number of incidents where you question yourself, and you go to an experienced colleague and say, “I was in a session with this patient. Here’s what I did. Do you think I was exposing myself unnecessarily?” Go over the incident in detail with someone who is supportive and understanding but also has a critical eye.

Dr. Krahn: Any suggestions as to how the room or other staff can be positioned to keep the risk as low as possible? Do you recommend alarms inside offices?

Dr. Battaglia: I think it’s smart to have an alarm system. And you need to think about the physical layout of the room ahead of time. You and the patient may need to have equal access to the door. If the patient is high-risk, you might want to arrange seating at a 90-degree angle rather than face-to-face to limit sustained confrontational eye contact. You might want to place your chair greater than an arm swing or leg kick away. You need to decide whether it’s safe to be alone, and whether to have the door open or to have security posted.

Dr. Krahn: What kind of training should staff be given?

Dr. Battaglia: Every office should have policies and protocols for handling behavioral emergencies. Who calls 911? What are each person’s responsibilities? Also, staff should be confident but not confrontational. That, in itself, may dissuade a patient from acting out.

Everyone should be taught de-escalation techniques. Body language can send threatening signals or they can signal a person that you’re not a threat and you’re going to work with them.

Dr. Krahn: Can you give an example where training might have helped?

Dr. Battaglia: I recently reviewed an incident where a nurse and a psychologist had a delusional, paranoid patient in their office and he wanted to leave. He was relapsed and clearly agitated; he was psychotic; he needed to be hospitalized. He wanted to escape, and they barred the door because they wanted to get him in the hospital.

The patient punched the nurse. If you bar someone’s escape, you’re very likely to get hurt. Let the patient go and call the police, who are trained to bring people in.

Dr. Krahn: What about building security? I know of a situation where a patient was found waiting for a psychiatrist in the parking garage. If there are threats, should an escort system be in place?

Dr. Battaglia: Security needs to work with the staff to come up with a plan.

Dr. Krahn: If someone in your office is assaulted, how do you handle the aftermath?

Dr. Battaglia: The person who is assaulted needs to get help. Crisis debriefing has been debated in trauma treatment, but there’s no debate about the benefit of “psychological first aid.” It provides an opportunity for the person to talk in confidence with another professional about what’s happened and how it may be affecting him or her.

Dr. Krahn: Can you continue to treat someone who has assaulted you?

Dr. Battaglia: That decision has to be made on a case-by-case basis. The main question is whether you feel safe enough to be therapeutic with the person in the future. Outside of a controlled setting, I don’t think you can effectively treat a patient you fear.

Dr. Krahn: Dr. Fenton’s death brings home that we need to be vigilant each day. We meet new patients every week, and any of them may have the disorders and risk factors that can lead to violence.

Dr. Battaglia: That’s true, yet being in a constant state of fear can impair mental health professionals’ ability to do our work. It’s a dynamic balance—we attempt a measured calmness in our work yet pay attention to external and visceral cues of impending danger.

Dr. Krahn: I think some psychiatrists feel patient violence occurs only in correctional settings or emergency rooms—not in their world. But Dr. Fenton’s death shows that it can happen anywhere. You just don’t know.

Related resources

• Joint Commission on Accreditation of HealthCare Organizations (JCAHO). Rules on application of seclusion and restraint. www.jointcommission.org.

Acknowledgment

This article was edited by Lynn Waltz, a medical writer and editor in Norfolk, VA, from the transcript of the September 29, 2006 interview of Dr. Battaglia by Dr. Krahn.