Editors’ note: We originally conceived this article with the authors just before Hurricanes Katrina and Rita devastated the Gulf Coast last year. Once the hurricanes hit, we decided to “bump” this article in favor of running coverage of the hurricanes and their effects on hospitals in the Gulf Coast area.

The Ochsner Clinic Foundation rests on the eastern bank of an acute flexure in the Mississippi river similar to its twin just downstream, which lurches around a crescent forming the historic and infamous French Vieux Carré, or Old Quarter. From a perch on the hospital’s 11th floor I often start my evening by taking in the full scope of the river’s powerful swirling eddies and copious flotsam churning past in the westerly sun. The view has become a familiar sight to me over the past several years as our hospital’s primary night shift internist.

Though my comrades jokingly refer to me as Ochsner’s “nocturnist,” an assignment surprisingly relished by few, the position has proven mutually beneficial in serving a vital role for the hospital and our group, while accommodating my own crepuscular nature and lifestyle.

Our night position—officially known as IHC (or in-house call)—was conceived from several requisites desired by both administration and physicians. Ochsner Clinic Foundation is steeped in academic history, and the nights have traditionally been dominated by semi-autonomously operating residents. During the past five years, practice changes in the local area afforded Ochsner unprecedented growth, requiring constant accommodation and development of our hospitalist group. Many of these changes were accelerated by the devastation wrought by Hurricane Katrina. With a nod to quality over quantity, we decided against expanding the teaching program in favor of developing several non-resident-based hospital services.

These unique and burgeoning parallel systems of care quickly presented many challenges for those staff clinicians stationed at home when problems arose during the evening. The original expectation was that the residents would have no direct involvement in the care of this subset of patients to avoid overburdening a system already operating near capacity. Subsequent intradepartmental disputation ensued over how to provide our patients with personal on-site care through the wee hours while arresting the surge of hectoring beeps that inevitably start after midnight. The exigency of solving this problem grew as our physicians’ slumber waned and patient admissions soared over the following months.

Our group’s consensus that a full-time night staff physician was needed soon emerged as the best potential remedy for our predicament. As no person wanted to be commandeered for the job, volunteers were sought for a trial run with the very reasonable hours of 4 p.m. to midnight, Monday through Friday. Hardly ever retiring to bed before the witching hour, I accepted the first week of our nascent, early evening shift.

The Rise of the Nocturnist

The expectations were simple. I was to independently admit “bounce-backs:” observation level patients, hip fracture service patients, and overflow admissions from a frequently dropsical emergency department. This specious solution proved very successful but ultimately served to highlight the overall need for a hospitalist to remain in-house for the duration of the evening and early morning hours.

The subsequent creation of a newly expanded, more permanent role for our IHC was proffered for consideration. This vision of moving to 24-hour staff coverage on site met with universal acceptance from the physicians, nursing staff, residents, and administration. The lone problem remained of finding physicians willing to dedicate themselves to working primarily at night.

Rather than rotating doctors weekly, we hoped to maintain some consistency by having certain physicians dedicated to staffing nights. From this graveyard shift arose true nocturnists, as in my case, working evenings nearly 75% of the time. Implementation of a weekend nocturnist to cover Saturday and Sunday is being developed as the need for coverage increases and the success of the current system continues.

Rapid Growth

These expanded changes to the system soon proved fortuitous. Within one year after the inception of IHC, admissions to the medicine services had consistently swollen to between 20 and 30 patients each night—a record for even the busiest periods in the history of the institution. The surge of patients being admitted through our emergency department to medicine proved to be an enduring change, which progressed unabated until Katrina struck. By necessity, the number of “unresidented” services quickly grew to accommodate our patients’ needs and concerns.

In addition, residency-review guidelines governing capitation of resident admissions were also carefully maintained to provide a consistent teaching environment for the house staff. Though stalling momentarily after Katrina struck, medical admissions have continued to climb seemingly without limit. The capacity of our six inpatient medical services with residents is now matched by an equal number of services managed privately by attending physicians alone.

Post-Katrina, the responsibilities of our three primary “nocturnists” have grown in tandem with the increasing number of patients on the wards to now cover the sub-acute nursing facility patients, geriatric nursing home patients, and acute preoperative clearances throughout the night. The lion’s share of time is still spent assisting and facilitating the admissions process for our patients through the emergency department.

In the past several years the role of the night hospitalist has become an integral part of our emergency department. In effect, most of the night is now spent in the emergency department providing consults, triage help, and early assistance with the care of patients ultimately bound for medicine admission. Besides the pragmatic benefits of expedited care, new interpersonal bonds of understanding and empathy have been forged between the two departments. I now count most of the emergency department staff, from physicians to nurses and secretaries, as personal friends and colleagues. The beleaguered admitting process has gradually transformed into a more cooperative, harmonious transfer of patient care between trusting teams.

Tracking Patients

With so many patients now spilling over the next day to various teams, one of the most vital functions of the IHC staff is to provide complete and accurate information about each patient assigned to the accepting teams the following day. This has required cooperation from both emergency staff in writing temporary floor orders, proper information flow between the on-call resident, night float resident and IHC staff, and proper notification of direct admissions arriving on the floor of patients accepted from the on call medicine staff during the day.

Currently each patient is simultaneously tracked by name, clinic number, and diagnosis by both the IHC staff and the overnight resident. The lists are frequently compared for accuracy, and in the morning an individual e-mail notification is sent to every physician on service for the day of every admission, distribution, and diagnosis by the IHC staff. As a second line of defense against error, the resident places an individual phone call to each physician receiving an overnight admission to reiterate any clinical problems.

As a department we have crafted fixed schedules of admission for the following morning so each day a physician knows whether to expect patients on the service or not. These numbers are forwarded to admissions for that day in order to keep each of the services as numerically equitable as possible. These careful tracking mechanisms, expectations of good communication between our physicians, and months of trial and error have proven invaluable during the months of highest volume when essentially every patient admitted overnight must be redistributed to various teams in the morning.

In addition to securing safe transition of the patient between teams and ensuring proper medical care, each patient is greeted in his or her room in the emergency department by the IHC staff, who take a moment to explain the admission process, the future plan of care, and who will assume the patient’s case in the morning. This has continuously provided an early opportunity to establish bonds of trust with each patient and assuage any lingering questions the patient may have after evaluation by the resident physician. Many of our patients are now displaced, frightened, and homeless. The value of providing face-to-face, 24-hour attending level care for our patients cannot be overstated.

Conclusion

Auguring the future of medical practice in New Orleans since hurricanes Katrina and Rita ravaged the city has proved difficult if not impossible. The degree of change during the past six months has shown that flexibility and adaptability are mainstays of the ability to practice good medicine. Without doubt, New Orleans will return more lively, more resilient, and wiser for all of our losses over the past year. TH

Dr. Blalock is based at the Department of Hospital-Based Internal Medicine, Ochsner Clinic Foundation, New Orleans. Special thanks to Steven B. Deitelzweig, MD, Doris Lin, MD, and Srinivas Vuppala, MD, for their assistance with this article.

Editors’ note: We originally conceived this article with the authors just before Hurricanes Katrina and Rita devastated the Gulf Coast last year. Once the hurricanes hit, we decided to “bump” this article in favor of running coverage of the hurricanes and their effects on hospitals in the Gulf Coast area.

The Ochsner Clinic Foundation rests on the eastern bank of an acute flexure in the Mississippi river similar to its twin just downstream, which lurches around a crescent forming the historic and infamous French Vieux Carré, or Old Quarter. From a perch on the hospital’s 11th floor I often start my evening by taking in the full scope of the river’s powerful swirling eddies and copious flotsam churning past in the westerly sun. The view has become a familiar sight to me over the past several years as our hospital’s primary night shift internist.

Though my comrades jokingly refer to me as Ochsner’s “nocturnist,” an assignment surprisingly relished by few, the position has proven mutually beneficial in serving a vital role for the hospital and our group, while accommodating my own crepuscular nature and lifestyle.

Our night position—officially known as IHC (or in-house call)—was conceived from several requisites desired by both administration and physicians. Ochsner Clinic Foundation is steeped in academic history, and the nights have traditionally been dominated by semi-autonomously operating residents. During the past five years, practice changes in the local area afforded Ochsner unprecedented growth, requiring constant accommodation and development of our hospitalist group. Many of these changes were accelerated by the devastation wrought by Hurricane Katrina. With a nod to quality over quantity, we decided against expanding the teaching program in favor of developing several non-resident-based hospital services.

These unique and burgeoning parallel systems of care quickly presented many challenges for those staff clinicians stationed at home when problems arose during the evening. The original expectation was that the residents would have no direct involvement in the care of this subset of patients to avoid overburdening a system already operating near capacity. Subsequent intradepartmental disputation ensued over how to provide our patients with personal on-site care through the wee hours while arresting the surge of hectoring beeps that inevitably start after midnight. The exigency of solving this problem grew as our physicians’ slumber waned and patient admissions soared over the following months.

Our group’s consensus that a full-time night staff physician was needed soon emerged as the best potential remedy for our predicament. As no person wanted to be commandeered for the job, volunteers were sought for a trial run with the very reasonable hours of 4 p.m. to midnight, Monday through Friday. Hardly ever retiring to bed before the witching hour, I accepted the first week of our nascent, early evening shift.

The Rise of the Nocturnist

The expectations were simple. I was to independently admit “bounce-backs:” observation level patients, hip fracture service patients, and overflow admissions from a frequently dropsical emergency department. This specious solution proved very successful but ultimately served to highlight the overall need for a hospitalist to remain in-house for the duration of the evening and early morning hours.

The subsequent creation of a newly expanded, more permanent role for our IHC was proffered for consideration. This vision of moving to 24-hour staff coverage on site met with universal acceptance from the physicians, nursing staff, residents, and administration. The lone problem remained of finding physicians willing to dedicate themselves to working primarily at night.

Rather than rotating doctors weekly, we hoped to maintain some consistency by having certain physicians dedicated to staffing nights. From this graveyard shift arose true nocturnists, as in my case, working evenings nearly 75% of the time. Implementation of a weekend nocturnist to cover Saturday and Sunday is being developed as the need for coverage increases and the success of the current system continues.

Rapid Growth

These expanded changes to the system soon proved fortuitous. Within one year after the inception of IHC, admissions to the medicine services had consistently swollen to between 20 and 30 patients each night—a record for even the busiest periods in the history of the institution. The surge of patients being admitted through our emergency department to medicine proved to be an enduring change, which progressed unabated until Katrina struck. By necessity, the number of “unresidented” services quickly grew to accommodate our patients’ needs and concerns.

In addition, residency-review guidelines governing capitation of resident admissions were also carefully maintained to provide a consistent teaching environment for the house staff. Though stalling momentarily after Katrina struck, medical admissions have continued to climb seemingly without limit. The capacity of our six inpatient medical services with residents is now matched by an equal number of services managed privately by attending physicians alone.

Post-Katrina, the responsibilities of our three primary “nocturnists” have grown in tandem with the increasing number of patients on the wards to now cover the sub-acute nursing facility patients, geriatric nursing home patients, and acute preoperative clearances throughout the night. The lion’s share of time is still spent assisting and facilitating the admissions process for our patients through the emergency department.

In the past several years the role of the night hospitalist has become an integral part of our emergency department. In effect, most of the night is now spent in the emergency department providing consults, triage help, and early assistance with the care of patients ultimately bound for medicine admission. Besides the pragmatic benefits of expedited care, new interpersonal bonds of understanding and empathy have been forged between the two departments. I now count most of the emergency department staff, from physicians to nurses and secretaries, as personal friends and colleagues. The beleaguered admitting process has gradually transformed into a more cooperative, harmonious transfer of patient care between trusting teams.

Tracking Patients

With so many patients now spilling over the next day to various teams, one of the most vital functions of the IHC staff is to provide complete and accurate information about each patient assigned to the accepting teams the following day. This has required cooperation from both emergency staff in writing temporary floor orders, proper information flow between the on-call resident, night float resident and IHC staff, and proper notification of direct admissions arriving on the floor of patients accepted from the on call medicine staff during the day.

Currently each patient is simultaneously tracked by name, clinic number, and diagnosis by both the IHC staff and the overnight resident. The lists are frequently compared for accuracy, and in the morning an individual e-mail notification is sent to every physician on service for the day of every admission, distribution, and diagnosis by the IHC staff. As a second line of defense against error, the resident places an individual phone call to each physician receiving an overnight admission to reiterate any clinical problems.

As a department we have crafted fixed schedules of admission for the following morning so each day a physician knows whether to expect patients on the service or not. These numbers are forwarded to admissions for that day in order to keep each of the services as numerically equitable as possible. These careful tracking mechanisms, expectations of good communication between our physicians, and months of trial and error have proven invaluable during the months of highest volume when essentially every patient admitted overnight must be redistributed to various teams in the morning.

In addition to securing safe transition of the patient between teams and ensuring proper medical care, each patient is greeted in his or her room in the emergency department by the IHC staff, who take a moment to explain the admission process, the future plan of care, and who will assume the patient’s case in the morning. This has continuously provided an early opportunity to establish bonds of trust with each patient and assuage any lingering questions the patient may have after evaluation by the resident physician. Many of our patients are now displaced, frightened, and homeless. The value of providing face-to-face, 24-hour attending level care for our patients cannot be overstated.

Conclusion

Auguring the future of medical practice in New Orleans since hurricanes Katrina and Rita ravaged the city has proved difficult if not impossible. The degree of change during the past six months has shown that flexibility and adaptability are mainstays of the ability to practice good medicine. Without doubt, New Orleans will return more lively, more resilient, and wiser for all of our losses over the past year. TH

Dr. Blalock is based at the Department of Hospital-Based Internal Medicine, Ochsner Clinic Foundation, New Orleans. Special thanks to Steven B. Deitelzweig, MD, Doris Lin, MD, and Srinivas Vuppala, MD, for their assistance with this article.

Editors’ note: We originally conceived this article with the authors just before Hurricanes Katrina and Rita devastated the Gulf Coast last year. Once the hurricanes hit, we decided to “bump” this article in favor of running coverage of the hurricanes and their effects on hospitals in the Gulf Coast area.

The Ochsner Clinic Foundation rests on the eastern bank of an acute flexure in the Mississippi river similar to its twin just downstream, which lurches around a crescent forming the historic and infamous French Vieux Carré, or Old Quarter. From a perch on the hospital’s 11th floor I often start my evening by taking in the full scope of the river’s powerful swirling eddies and copious flotsam churning past in the westerly sun. The view has become a familiar sight to me over the past several years as our hospital’s primary night shift internist.

Though my comrades jokingly refer to me as Ochsner’s “nocturnist,” an assignment surprisingly relished by few, the position has proven mutually beneficial in serving a vital role for the hospital and our group, while accommodating my own crepuscular nature and lifestyle.

Our night position—officially known as IHC (or in-house call)—was conceived from several requisites desired by both administration and physicians. Ochsner Clinic Foundation is steeped in academic history, and the nights have traditionally been dominated by semi-autonomously operating residents. During the past five years, practice changes in the local area afforded Ochsner unprecedented growth, requiring constant accommodation and development of our hospitalist group. Many of these changes were accelerated by the devastation wrought by Hurricane Katrina. With a nod to quality over quantity, we decided against expanding the teaching program in favor of developing several non-resident-based hospital services.

These unique and burgeoning parallel systems of care quickly presented many challenges for those staff clinicians stationed at home when problems arose during the evening. The original expectation was that the residents would have no direct involvement in the care of this subset of patients to avoid overburdening a system already operating near capacity. Subsequent intradepartmental disputation ensued over how to provide our patients with personal on-site care through the wee hours while arresting the surge of hectoring beeps that inevitably start after midnight. The exigency of solving this problem grew as our physicians’ slumber waned and patient admissions soared over the following months.

Our group’s consensus that a full-time night staff physician was needed soon emerged as the best potential remedy for our predicament. As no person wanted to be commandeered for the job, volunteers were sought for a trial run with the very reasonable hours of 4 p.m. to midnight, Monday through Friday. Hardly ever retiring to bed before the witching hour, I accepted the first week of our nascent, early evening shift.

The Rise of the Nocturnist

The expectations were simple. I was to independently admit “bounce-backs:” observation level patients, hip fracture service patients, and overflow admissions from a frequently dropsical emergency department. This specious solution proved very successful but ultimately served to highlight the overall need for a hospitalist to remain in-house for the duration of the evening and early morning hours.

The subsequent creation of a newly expanded, more permanent role for our IHC was proffered for consideration. This vision of moving to 24-hour staff coverage on site met with universal acceptance from the physicians, nursing staff, residents, and administration. The lone problem remained of finding physicians willing to dedicate themselves to working primarily at night.

Rather than rotating doctors weekly, we hoped to maintain some consistency by having certain physicians dedicated to staffing nights. From this graveyard shift arose true nocturnists, as in my case, working evenings nearly 75% of the time. Implementation of a weekend nocturnist to cover Saturday and Sunday is being developed as the need for coverage increases and the success of the current system continues.

Rapid Growth

These expanded changes to the system soon proved fortuitous. Within one year after the inception of IHC, admissions to the medicine services had consistently swollen to between 20 and 30 patients each night—a record for even the busiest periods in the history of the institution. The surge of patients being admitted through our emergency department to medicine proved to be an enduring change, which progressed unabated until Katrina struck. By necessity, the number of “unresidented” services quickly grew to accommodate our patients’ needs and concerns.

In addition, residency-review guidelines governing capitation of resident admissions were also carefully maintained to provide a consistent teaching environment for the house staff. Though stalling momentarily after Katrina struck, medical admissions have continued to climb seemingly without limit. The capacity of our six inpatient medical services with residents is now matched by an equal number of services managed privately by attending physicians alone.

Post-Katrina, the responsibilities of our three primary “nocturnists” have grown in tandem with the increasing number of patients on the wards to now cover the sub-acute nursing facility patients, geriatric nursing home patients, and acute preoperative clearances throughout the night. The lion’s share of time is still spent assisting and facilitating the admissions process for our patients through the emergency department.

In the past several years the role of the night hospitalist has become an integral part of our emergency department. In effect, most of the night is now spent in the emergency department providing consults, triage help, and early assistance with the care of patients ultimately bound for medicine admission. Besides the pragmatic benefits of expedited care, new interpersonal bonds of understanding and empathy have been forged between the two departments. I now count most of the emergency department staff, from physicians to nurses and secretaries, as personal friends and colleagues. The beleaguered admitting process has gradually transformed into a more cooperative, harmonious transfer of patient care between trusting teams.

Tracking Patients

With so many patients now spilling over the next day to various teams, one of the most vital functions of the IHC staff is to provide complete and accurate information about each patient assigned to the accepting teams the following day. This has required cooperation from both emergency staff in writing temporary floor orders, proper information flow between the on-call resident, night float resident and IHC staff, and proper notification of direct admissions arriving on the floor of patients accepted from the on call medicine staff during the day.

Currently each patient is simultaneously tracked by name, clinic number, and diagnosis by both the IHC staff and the overnight resident. The lists are frequently compared for accuracy, and in the morning an individual e-mail notification is sent to every physician on service for the day of every admission, distribution, and diagnosis by the IHC staff. As a second line of defense against error, the resident places an individual phone call to each physician receiving an overnight admission to reiterate any clinical problems.

As a department we have crafted fixed schedules of admission for the following morning so each day a physician knows whether to expect patients on the service or not. These numbers are forwarded to admissions for that day in order to keep each of the services as numerically equitable as possible. These careful tracking mechanisms, expectations of good communication between our physicians, and months of trial and error have proven invaluable during the months of highest volume when essentially every patient admitted overnight must be redistributed to various teams in the morning.

In addition to securing safe transition of the patient between teams and ensuring proper medical care, each patient is greeted in his or her room in the emergency department by the IHC staff, who take a moment to explain the admission process, the future plan of care, and who will assume the patient’s case in the morning. This has continuously provided an early opportunity to establish bonds of trust with each patient and assuage any lingering questions the patient may have after evaluation by the resident physician. Many of our patients are now displaced, frightened, and homeless. The value of providing face-to-face, 24-hour attending level care for our patients cannot be overstated.

Conclusion

Auguring the future of medical practice in New Orleans since hurricanes Katrina and Rita ravaged the city has proved difficult if not impossible. The degree of change during the past six months has shown that flexibility and adaptability are mainstays of the ability to practice good medicine. Without doubt, New Orleans will return more lively, more resilient, and wiser for all of our losses over the past year. TH

Dr. Blalock is based at the Department of Hospital-Based Internal Medicine, Ochsner Clinic Foundation, New Orleans. Special thanks to Steven B. Deitelzweig, MD, Doris Lin, MD, and Srinivas Vuppala, MD, for their assistance with this article.

A75-year-old previously healthy woman presented with one-month history of extensive necrotic coalescing erythematous weeping vesicles and bullae. A skin biopsy was performed. (See right and right bottom for images.)

Based on the skin biopsy and clinical presentation, the most likely diagnosis is:

1. Pemphigoid;
2. Pemphigus vulgaris;
3. Staphylococcus scalded skin syndrome;
4. Porphyria cutanea tarda; or
5. Darier’s disease.

Discussion

The correct answer is B: pemphigus vulgaris. The skin biopsy demonstrates an intra-epidermal split along the basal layer of keratinocytes. The basal cells along the basement membrane zone demonstrate tombstoning consistent with pemphigus vulgaris. Clinically, she has erythematous superficial erosions with slight re-epithelialization.

Pemphigoid is another blistering disorder that often affects the elderly and classically presents with tense bulla that demonstrate an infra-basilar split on histology. Staphylococcus scalded skin syndrome may present similarly, but histology shows acantholysis in the superficial epidermis. Porphyria cutanea tarda often is on the hands, arms, and other sun-exposed areas, and biopsy reveals dermal papillae protruding up toward the bulla (festooning). Darier’s disease is autosomal dominant and presents with greasy hyperkeratotic papules that show acantholysis and dyskeratosis on histology, with occasional suprabasal clefting.

Pemphigus vulgaris is an autoimmune process that often affects those in middle age. It usually first involves the mucous membranes and then progresses to the skin, where intraepidermal bullae form. These bullae are flaccid and easily rupture, often easily extending beyond their original dimensions with only slight perturbation. Because of their fragility patients may not present with any intact bullae and instead only have painful erosions, as in this case.

The disease is mediated by circulating immunoglobulin G (IgG), which binds to the cell surface of keratinocytes, breaking up intercellular connections and resulting in acantholysis and bulla formation. The process is diagnosed with the shown histology and with direct in vivo immunofluorescence, which demonstrates a “chicken-wire” pattern around keratinocytes. Paraneoplastic pemphigus and pemphigus foliaceous are the other two types of pemphigus, and a work up for underlying malignancy is indicated to rule out the former. Opportunistic infections are common and can lead to exacerbation of the disease, so culture and antimicrobial therapy often play an important role in recovery.

Pemphigus can often be controlled with adequate immunosuppression. High-dose systemic steroids are the first-line treatment. Other immunosuppressive medications, such as dapsone, azathioprine, and mycophenolate mofetil, are used for maintenance therapy during and after the patient has recovered from a flare-up. Intravenous immunoglobulin (IVIG) and plasmapheresis therapy has also showed promising results.1,2

This case was complicated by superinfection with both methicillin-resistant staphylococcus aureus (MRSA) and herpes simplex virus. One course of IVIG produced no benefit. The patient then underwent intensive inpatient wet-dressing therapy with topical steroids and antimicrobial treatment. She was placed on high-dose prednisone and began to recover, without new lesion development and with re-epithelialization. First mycophenolate mofetil followed by azathioprine were started, to which the patient responded well. TH

References

1. Bystryn JC, Rudolph JL. IVIG treatment of pemphigus: how it works and how to use it. J Investig Dermatol. 2005 Dec;125(6):1093-1098.
2. Stanley JR. Therapy of pemphigus vulgaris. Arch Dermatol. 1999 Jan;135(1):76-78.

A75-year-old previously healthy woman presented with one-month history of extensive necrotic coalescing erythematous weeping vesicles and bullae. A skin biopsy was performed. (See right and right bottom for images.)

Based on the skin biopsy and clinical presentation, the most likely diagnosis is:

1. Pemphigoid;
2. Pemphigus vulgaris;
3. Staphylococcus scalded skin syndrome;
4. Porphyria cutanea tarda; or
5. Darier’s disease.

Discussion

The correct answer is B: pemphigus vulgaris. The skin biopsy demonstrates an intra-epidermal split along the basal layer of keratinocytes. The basal cells along the basement membrane zone demonstrate tombstoning consistent with pemphigus vulgaris. Clinically, she has erythematous superficial erosions with slight re-epithelialization.

Pemphigoid is another blistering disorder that often affects the elderly and classically presents with tense bulla that demonstrate an infra-basilar split on histology. Staphylococcus scalded skin syndrome may present similarly, but histology shows acantholysis in the superficial epidermis. Porphyria cutanea tarda often is on the hands, arms, and other sun-exposed areas, and biopsy reveals dermal papillae protruding up toward the bulla (festooning). Darier’s disease is autosomal dominant and presents with greasy hyperkeratotic papules that show acantholysis and dyskeratosis on histology, with occasional suprabasal clefting.

Pemphigus vulgaris is an autoimmune process that often affects those in middle age. It usually first involves the mucous membranes and then progresses to the skin, where intraepidermal bullae form. These bullae are flaccid and easily rupture, often easily extending beyond their original dimensions with only slight perturbation. Because of their fragility patients may not present with any intact bullae and instead only have painful erosions, as in this case.

The disease is mediated by circulating immunoglobulin G (IgG), which binds to the cell surface of keratinocytes, breaking up intercellular connections and resulting in acantholysis and bulla formation. The process is diagnosed with the shown histology and with direct in vivo immunofluorescence, which demonstrates a “chicken-wire” pattern around keratinocytes. Paraneoplastic pemphigus and pemphigus foliaceous are the other two types of pemphigus, and a work up for underlying malignancy is indicated to rule out the former. Opportunistic infections are common and can lead to exacerbation of the disease, so culture and antimicrobial therapy often play an important role in recovery.

Pemphigus can often be controlled with adequate immunosuppression. High-dose systemic steroids are the first-line treatment. Other immunosuppressive medications, such as dapsone, azathioprine, and mycophenolate mofetil, are used for maintenance therapy during and after the patient has recovered from a flare-up. Intravenous immunoglobulin (IVIG) and plasmapheresis therapy has also showed promising results.1,2

This case was complicated by superinfection with both methicillin-resistant staphylococcus aureus (MRSA) and herpes simplex virus. One course of IVIG produced no benefit. The patient then underwent intensive inpatient wet-dressing therapy with topical steroids and antimicrobial treatment. She was placed on high-dose prednisone and began to recover, without new lesion development and with re-epithelialization. First mycophenolate mofetil followed by azathioprine were started, to which the patient responded well. TH

References

1. Bystryn JC, Rudolph JL. IVIG treatment of pemphigus: how it works and how to use it. J Investig Dermatol. 2005 Dec;125(6):1093-1098.
2. Stanley JR. Therapy of pemphigus vulgaris. Arch Dermatol. 1999 Jan;135(1):76-78.

A75-year-old previously healthy woman presented with one-month history of extensive necrotic coalescing erythematous weeping vesicles and bullae. A skin biopsy was performed. (See right and right bottom for images.)

Based on the skin biopsy and clinical presentation, the most likely diagnosis is:

1. Pemphigoid;
2. Pemphigus vulgaris;
3. Staphylococcus scalded skin syndrome;
4. Porphyria cutanea tarda; or
5. Darier’s disease.

Discussion

The correct answer is B: pemphigus vulgaris. The skin biopsy demonstrates an intra-epidermal split along the basal layer of keratinocytes. The basal cells along the basement membrane zone demonstrate tombstoning consistent with pemphigus vulgaris. Clinically, she has erythematous superficial erosions with slight re-epithelialization.

Pemphigoid is another blistering disorder that often affects the elderly and classically presents with tense bulla that demonstrate an infra-basilar split on histology. Staphylococcus scalded skin syndrome may present similarly, but histology shows acantholysis in the superficial epidermis. Porphyria cutanea tarda often is on the hands, arms, and other sun-exposed areas, and biopsy reveals dermal papillae protruding up toward the bulla (festooning). Darier’s disease is autosomal dominant and presents with greasy hyperkeratotic papules that show acantholysis and dyskeratosis on histology, with occasional suprabasal clefting.

Pemphigus vulgaris is an autoimmune process that often affects those in middle age. It usually first involves the mucous membranes and then progresses to the skin, where intraepidermal bullae form. These bullae are flaccid and easily rupture, often easily extending beyond their original dimensions with only slight perturbation. Because of their fragility patients may not present with any intact bullae and instead only have painful erosions, as in this case.

The disease is mediated by circulating immunoglobulin G (IgG), which binds to the cell surface of keratinocytes, breaking up intercellular connections and resulting in acantholysis and bulla formation. The process is diagnosed with the shown histology and with direct in vivo immunofluorescence, which demonstrates a “chicken-wire” pattern around keratinocytes. Paraneoplastic pemphigus and pemphigus foliaceous are the other two types of pemphigus, and a work up for underlying malignancy is indicated to rule out the former. Opportunistic infections are common and can lead to exacerbation of the disease, so culture and antimicrobial therapy often play an important role in recovery.

Pemphigus can often be controlled with adequate immunosuppression. High-dose systemic steroids are the first-line treatment. Other immunosuppressive medications, such as dapsone, azathioprine, and mycophenolate mofetil, are used for maintenance therapy during and after the patient has recovered from a flare-up. Intravenous immunoglobulin (IVIG) and plasmapheresis therapy has also showed promising results.1,2

This case was complicated by superinfection with both methicillin-resistant staphylococcus aureus (MRSA) and herpes simplex virus. One course of IVIG produced no benefit. The patient then underwent intensive inpatient wet-dressing therapy with topical steroids and antimicrobial treatment. She was placed on high-dose prednisone and began to recover, without new lesion development and with re-epithelialization. First mycophenolate mofetil followed by azathioprine were started, to which the patient responded well. TH

References

1. Bystryn JC, Rudolph JL. IVIG treatment of pemphigus: how it works and how to use it. J Investig Dermatol. 2005 Dec;125(6):1093-1098.
2. Stanley JR. Therapy of pemphigus vulgaris. Arch Dermatol. 1999 Jan;135(1):76-78.

Kempainen RR, Migeon MB, Wolf FM. Understanding our mistakes: a primer on errors in clinical reasoning. Med Teach. Mar;2003:25(2);177-181.

Many hospitalists are involved in processes to reduce errors in the hospital. Given the dozens of clinical decisions hospitalists make each day, errors in clinical reasoning are worth exploring. However, few physicians are familiar with the terminology and classes of clinical reasoning errors as described in the literature.

This article outlines two models of clinical reasoning and explains common biases that distort clinical reasoning. Although the examples used to illustrate these errors draw from primary care internal medicine, they are easily recognizable.

Biases are defined as inaccurate beliefs that affect decision-making.

When generating a differential diagnosis, the bias of availability (aka recall bias) involves a clinician being influenced by what is easily recalled, creating a false sense of prevalence. This is especially common with less experienced clinicians, residents, and medical students.

The bias of representativeness (aka judging by similarity) involves the physician choosing a diagnosis based solely on signs and symptoms, while neglecting the prevalence of competing diagnoses.

The bias of confirmation involves the clinician using additional testing to confirm a suspected diagnosis, but failing to test competing hypotheses.

The bias of anchoring and adjustment involves the clinician inadequately adjusting the differential in light of new data.

The bias of bounded rationality (aka search satisfying) involves the clinician stopping the search for additional diagnoses after the anticipated diagnosis has been made.

Outcome bias involves judging a clinical decision retrospectively based on the outcome, rather than on logic and evidence supporting the original decision.

Omission bias involves placing undue emphasis on avoiding the adverse effect of a therapy, leading to under-utilization of a beneficial treatment.

Most of the work in clinical reasoning errors is published in the cognitive psychology and education literature, which most hospitalists do not regularly read. By becoming familiar with the concepts and terminology, hospitalists can more readily engage in discussions of clinical reasoning errors and how to avoid them. TH

Kempainen RR, Migeon MB, Wolf FM. Understanding our mistakes: a primer on errors in clinical reasoning. Med Teach. Mar;2003:25(2);177-181.

Many hospitalists are involved in processes to reduce errors in the hospital. Given the dozens of clinical decisions hospitalists make each day, errors in clinical reasoning are worth exploring. However, few physicians are familiar with the terminology and classes of clinical reasoning errors as described in the literature.

This article outlines two models of clinical reasoning and explains common biases that distort clinical reasoning. Although the examples used to illustrate these errors draw from primary care internal medicine, they are easily recognizable.

Biases are defined as inaccurate beliefs that affect decision-making.

When generating a differential diagnosis, the bias of availability (aka recall bias) involves a clinician being influenced by what is easily recalled, creating a false sense of prevalence. This is especially common with less experienced clinicians, residents, and medical students.

The bias of representativeness (aka judging by similarity) involves the physician choosing a diagnosis based solely on signs and symptoms, while neglecting the prevalence of competing diagnoses.

The bias of confirmation involves the clinician using additional testing to confirm a suspected diagnosis, but failing to test competing hypotheses.

The bias of anchoring and adjustment involves the clinician inadequately adjusting the differential in light of new data.

The bias of bounded rationality (aka search satisfying) involves the clinician stopping the search for additional diagnoses after the anticipated diagnosis has been made.

Outcome bias involves judging a clinical decision retrospectively based on the outcome, rather than on logic and evidence supporting the original decision.

Omission bias involves placing undue emphasis on avoiding the adverse effect of a therapy, leading to under-utilization of a beneficial treatment.

Most of the work in clinical reasoning errors is published in the cognitive psychology and education literature, which most hospitalists do not regularly read. By becoming familiar with the concepts and terminology, hospitalists can more readily engage in discussions of clinical reasoning errors and how to avoid them. TH

Kempainen RR, Migeon MB, Wolf FM. Understanding our mistakes: a primer on errors in clinical reasoning. Med Teach. Mar;2003:25(2);177-181.

Many hospitalists are involved in processes to reduce errors in the hospital. Given the dozens of clinical decisions hospitalists make each day, errors in clinical reasoning are worth exploring. However, few physicians are familiar with the terminology and classes of clinical reasoning errors as described in the literature.

This article outlines two models of clinical reasoning and explains common biases that distort clinical reasoning. Although the examples used to illustrate these errors draw from primary care internal medicine, they are easily recognizable.

Biases are defined as inaccurate beliefs that affect decision-making.

When generating a differential diagnosis, the bias of availability (aka recall bias) involves a clinician being influenced by what is easily recalled, creating a false sense of prevalence. This is especially common with less experienced clinicians, residents, and medical students.

The bias of representativeness (aka judging by similarity) involves the physician choosing a diagnosis based solely on signs and symptoms, while neglecting the prevalence of competing diagnoses.

The bias of confirmation involves the clinician using additional testing to confirm a suspected diagnosis, but failing to test competing hypotheses.

The bias of anchoring and adjustment involves the clinician inadequately adjusting the differential in light of new data.

The bias of bounded rationality (aka search satisfying) involves the clinician stopping the search for additional diagnoses after the anticipated diagnosis has been made.

Outcome bias involves judging a clinical decision retrospectively based on the outcome, rather than on logic and evidence supporting the original decision.

Omission bias involves placing undue emphasis on avoiding the adverse effect of a therapy, leading to under-utilization of a beneficial treatment.

Most of the work in clinical reasoning errors is published in the cognitive psychology and education literature, which most hospitalists do not regularly read. By becoming familiar with the concepts and terminology, hospitalists can more readily engage in discussions of clinical reasoning errors and how to avoid them. TH

In the past decade numerous trends and influences have caused organized trauma surgery to re-examine our role in the care of all acutely ill surgical patients and the training of future general surgeons who will care for these patients.1 In this article we’ll briefly review the influences that brought us to this point, the issues we feel need to be addressed, and the solution that trauma surgery has proposed. In many ways, we believe these trends parallel the influences that led to the development of the hospitalists and, thus, call for a surgical equivalent.

Surgical Trends

The development of laparoscopic surgery has had profound influence on surgical practice. Cholecystectomies and appendectomies are generally 23-hour admissions. Even bariatric surgery is now little more than outpatient surgery, with the average length of stay at two days. Along with laparoscopy, breast surgery is now one of the fastest growing surgical subspecialties.

Many surgeons have tailored their practices to a largely outpatient base. There has been an explosion of free-standing surgery centers with a large shift of this low acuity patient population away from hospitals. This follows an overall shift in medicine to ambulatory practice, which is now projected to increase by 24% over the next five to 10 years. Thus, fewer and fewer surgeons have large inpatient practices. There is growing concern about the reluctance of many surgeons to deal with complex, high acuity patients. The obvious exceptions are transplant and trauma surgeons.

In the past decade profound changes in trauma care have also affected the practices of surgeons and the career choices of surgical residents.2 Following the peak of gun-related violence in the early 1990s, there has been a steady and significant decline in penetrating trauma with a concomitant decrease in operations. Slow but steady improvement in motor vehicle passive safety devices has also decreased the incidence of serious injury to the torso following car crashes.

When a solid organ (liver, spleen, kidney) injury does occur after car crash, fall, or assault, the management has largely shifted away from exploratory laparotomy to non-operative management. This has been made possible by improved imaging techniques, careful monitoring in the ICU and judicious use of interventional radiologic techniques of embolization and percutaneous drainage. Currently, some 60% to 80% of liver and spleen injuries are treated with observation or interventional techniques. Although most surgical residents enjoy the challenges of both trauma surgery and critical care, the decline in operative opportunities has limited the appeal of trauma/critical care as a career choice.2

Many trauma surgeons feel there is a convergence of these two issues—a group of patients that may be underserved and an opportunity to enhance the training and desirability of caring for acutely ill surgical patients.3-5 Either through years of experience or formal training, the vast majority of trauma surgeons are highly experienced in evaluating, operating upon, and providing post-operative care for critically ill and injured patients. In fact, the majority of surgical critical care fellowships are based at level 1 trauma centers and are run primarily by trauma surgeons. Thus, trauma surgeons are ideally situated to address these issues.

[A fellowship] all starts with a core group of people dedicated to hospital medicine. You need a group of people who see the future of hospital medicine and what it can be and who want to dive into different aspects of it. This is the minimum criteria for a successful hospitalist fellowship program.

—Rohit Uppal, MD, MBA

A New Specialty

In 2001 Ron V. Maier, MD, then president of the American Association for the Surgery of Trauma (AAST), commissioned a committee to address these issues and develop an action plan. With broad representation from numerous surgical societies, the committee met several times to consider various training and practice models as potential solutions. After much discussion, the group proposed a model based upon trauma surgery, emergency general surgery, and critical care. This process is outlined in a white paper authored by the committee in 2005.

Basically, the committee recommends the evolution of trauma surgery into a new specialty based on broad training in elective and emergency general surgery, trauma, and critical care surgery. Specific steps to accomplish this goal were outlined by the committee and considerable progress has already been made. After much debate regarding the name, including the consideration of “surgical hospitalists,” the AAST elected to support the name “acute care surgeon.” In fact, this model is how many of us trauma surgeons practice; we take trauma and emergency general surgery call and provide critical care services for these patients.

What was missing from the paradigm was a formal incorporation of emergency general surgery into the training of trauma/surgical critical care fellows and analysis of the benefits of such programs. While this practice paradigm has long been the model at many urban safety net hospitals in cities such as Atlanta, Dallas, Denver, Los Angeles, and Seattle, the practice of many trauma surgeons is often restrained at university hospitals and most level II trauma centers.

Strong Results

The trauma program at University of Pennsylvania, Pittsburgh, under the leadership of C. William Schwab, MD, the current president of the AAST, has taken the lead in documenting the value of incorporating emergency surgery into trauma/surgical critical care training. The addition of emergency general surgery into a trauma/surgical critical care fellowship increases operative experience and fellow satisfaction.3-6 Emergency general surgery now accounts for 57% of operations performed by their faculty. This helps maintain their operative experience despite a decline in operative trauma volume. Finally, with a careful analysis of performance improvement data, there is no compromise in trauma patient outcomes despite the increased patient load.4-5 This experience has been replicated at other trauma centers and strongly suggests that incorporating emergency general surgery into trauma training increases attractiveness to trainees and maintains high standards of patient care. The question is whether it meets an unfilled need.

Recent experience at Vanderbilt Medical Center suggests that the formal incorporation of emergency general surgery into a service has benefits for patients and the hospital.6 The service brings in more referrals from the surrounding community and increases trauma surgeon operative cases. The elective general surgeons also experience an increase in operations and admissions after removing the disruption of emergency admissions. The hospital benefits by the addition of new patients that frequently require operations and intensive care.

In a recent supplement to the The Hospitalist Larry Wellikson, MD, notes that hospitalists add value by (among other things):

• Providing measurable quality improvement;
• Creating seamless continuity from inpatient to outpatient care, from emergency department to floor, and from ICU to floor;
• Doing things other physicians had given up, such as indigent care and hospital committee functions;
• Creating healthcare teams to improve the working environment; and
• Taking care of acutely ill, complex hospitalized patients.7

We believe that trauma surgeons, or acute care surgeons, exemplify these values. We have provided these services to surgical patients for the past 25 years. Trauma surgeons have been leaders in quality improvement, as demonstrated by the American College of Surgeons Committee on Trauma verification program.

We take care of whoever comes through the door, regardless of acuity, time of day (or night), or payer status. We have always provided comprehensive care for our patients—from involvement in prehospital care and planning, through the emergency department, operating room, ICU, and even post-discharge rehabilitation. This requires an effective healthcare team and a truly multidisciplinary approach with other physicians (orthopedics, neurosurgery, anesthesia), nurses, and others, including respiratory, occupational, and physical therapy.

Conclusion

We see a synergy between hospitalist and acute-care surgeons. Both groups have stepped forward to fill a void in patient care. The redefining of trauma surgery as acute care surgery and the development of dedicated training programs will no doubt benefit current and future surgeons, but our patients will benefit the most. TH

Dr. Spain is professor of surgery and chief of Trauma, Emergency and Critical Care Surgery, Stanford University (California). He is also chairman of the Critical Care Committee, American Association for the Surgery of Trauma. Dr. Jurkovich is professor of surgery at the University of Washington, chief of Trauma and Emergency Surgical Services at Harborview Medical Center, and chairman of the Acute Care Surgeon Committee, American Association for the Surgery of Trauma.

References

1. Committee to Develop the Reorganized Specialty of Trauma, Surgical Critical Care, and Emergency Surgery. Acute care surgery: trauma, critical care, and emergency surgery. J Trauma. 2005;58:614-616.
2. Spain DA, Miller FB. Education and training of the future trauma surgeon in acute care surgery: trauma, critical care, and emergency surgery. Am J Surg. 2005;190:212-217.
3. Pryor JP, Reilly PM, Schwab CW, et al. Integrating emergency general surgery with a trauma service: impact on the care of injured patients. J Trauma. 2004 Sep;57(3):467-471.
4. Reilly PM, Schwab CW, Haut ER, et al. Training in trauma surgery: quantitative and qualitative aspects of a new paradigm for fellowship. Ann Surg. 2003 Oct;238(4):596-603.
5. Kim PK, Dabrowski GP, Reilly PM, et al. Redefining the future of trauma surgery as a comprehensive trauma and emergency general surgery service. J Am Coll Surg. 2004 Jul;199(1):96-101.
6. Austin MT, Diaz JJ Jr, Feurer ID, et al. Creating an emergency general surgery service enhances the productivity of trauma surgeons, general surgeons and the hospital. J Trauma. 2005 May;58(5):906-910.
7. Wellikson L. Hospitals recognize and reward value. The Hospitalist. 2005;9:3-5.

In the past decade numerous trends and influences have caused organized trauma surgery to re-examine our role in the care of all acutely ill surgical patients and the training of future general surgeons who will care for these patients.1 In this article we’ll briefly review the influences that brought us to this point, the issues we feel need to be addressed, and the solution that trauma surgery has proposed. In many ways, we believe these trends parallel the influences that led to the development of the hospitalists and, thus, call for a surgical equivalent.

Surgical Trends

The development of laparoscopic surgery has had profound influence on surgical practice. Cholecystectomies and appendectomies are generally 23-hour admissions. Even bariatric surgery is now little more than outpatient surgery, with the average length of stay at two days. Along with laparoscopy, breast surgery is now one of the fastest growing surgical subspecialties.

Many surgeons have tailored their practices to a largely outpatient base. There has been an explosion of free-standing surgery centers with a large shift of this low acuity patient population away from hospitals. This follows an overall shift in medicine to ambulatory practice, which is now projected to increase by 24% over the next five to 10 years. Thus, fewer and fewer surgeons have large inpatient practices. There is growing concern about the reluctance of many surgeons to deal with complex, high acuity patients. The obvious exceptions are transplant and trauma surgeons.

In the past decade profound changes in trauma care have also affected the practices of surgeons and the career choices of surgical residents.2 Following the peak of gun-related violence in the early 1990s, there has been a steady and significant decline in penetrating trauma with a concomitant decrease in operations. Slow but steady improvement in motor vehicle passive safety devices has also decreased the incidence of serious injury to the torso following car crashes.

When a solid organ (liver, spleen, kidney) injury does occur after car crash, fall, or assault, the management has largely shifted away from exploratory laparotomy to non-operative management. This has been made possible by improved imaging techniques, careful monitoring in the ICU and judicious use of interventional radiologic techniques of embolization and percutaneous drainage. Currently, some 60% to 80% of liver and spleen injuries are treated with observation or interventional techniques. Although most surgical residents enjoy the challenges of both trauma surgery and critical care, the decline in operative opportunities has limited the appeal of trauma/critical care as a career choice.2

Many trauma surgeons feel there is a convergence of these two issues—a group of patients that may be underserved and an opportunity to enhance the training and desirability of caring for acutely ill surgical patients.3-5 Either through years of experience or formal training, the vast majority of trauma surgeons are highly experienced in evaluating, operating upon, and providing post-operative care for critically ill and injured patients. In fact, the majority of surgical critical care fellowships are based at level 1 trauma centers and are run primarily by trauma surgeons. Thus, trauma surgeons are ideally situated to address these issues.

[A fellowship] all starts with a core group of people dedicated to hospital medicine. You need a group of people who see the future of hospital medicine and what it can be and who want to dive into different aspects of it. This is the minimum criteria for a successful hospitalist fellowship program.

—Rohit Uppal, MD, MBA

A New Specialty

In 2001 Ron V. Maier, MD, then president of the American Association for the Surgery of Trauma (AAST), commissioned a committee to address these issues and develop an action plan. With broad representation from numerous surgical societies, the committee met several times to consider various training and practice models as potential solutions. After much discussion, the group proposed a model based upon trauma surgery, emergency general surgery, and critical care. This process is outlined in a white paper authored by the committee in 2005.

Basically, the committee recommends the evolution of trauma surgery into a new specialty based on broad training in elective and emergency general surgery, trauma, and critical care surgery. Specific steps to accomplish this goal were outlined by the committee and considerable progress has already been made. After much debate regarding the name, including the consideration of “surgical hospitalists,” the AAST elected to support the name “acute care surgeon.” In fact, this model is how many of us trauma surgeons practice; we take trauma and emergency general surgery call and provide critical care services for these patients.

What was missing from the paradigm was a formal incorporation of emergency general surgery into the training of trauma/surgical critical care fellows and analysis of the benefits of such programs. While this practice paradigm has long been the model at many urban safety net hospitals in cities such as Atlanta, Dallas, Denver, Los Angeles, and Seattle, the practice of many trauma surgeons is often restrained at university hospitals and most level II trauma centers.

Strong Results

The trauma program at University of Pennsylvania, Pittsburgh, under the leadership of C. William Schwab, MD, the current president of the AAST, has taken the lead in documenting the value of incorporating emergency surgery into trauma/surgical critical care training. The addition of emergency general surgery into a trauma/surgical critical care fellowship increases operative experience and fellow satisfaction.3-6 Emergency general surgery now accounts for 57% of operations performed by their faculty. This helps maintain their operative experience despite a decline in operative trauma volume. Finally, with a careful analysis of performance improvement data, there is no compromise in trauma patient outcomes despite the increased patient load.4-5 This experience has been replicated at other trauma centers and strongly suggests that incorporating emergency general surgery into trauma training increases attractiveness to trainees and maintains high standards of patient care. The question is whether it meets an unfilled need.

Recent experience at Vanderbilt Medical Center suggests that the formal incorporation of emergency general surgery into a service has benefits for patients and the hospital.6 The service brings in more referrals from the surrounding community and increases trauma surgeon operative cases. The elective general surgeons also experience an increase in operations and admissions after removing the disruption of emergency admissions. The hospital benefits by the addition of new patients that frequently require operations and intensive care.

In a recent supplement to the The Hospitalist Larry Wellikson, MD, notes that hospitalists add value by (among other things):

• Providing measurable quality improvement;
• Creating seamless continuity from inpatient to outpatient care, from emergency department to floor, and from ICU to floor;
• Doing things other physicians had given up, such as indigent care and hospital committee functions;
• Creating healthcare teams to improve the working environment; and
• Taking care of acutely ill, complex hospitalized patients.7

We believe that trauma surgeons, or acute care surgeons, exemplify these values. We have provided these services to surgical patients for the past 25 years. Trauma surgeons have been leaders in quality improvement, as demonstrated by the American College of Surgeons Committee on Trauma verification program.

We take care of whoever comes through the door, regardless of acuity, time of day (or night), or payer status. We have always provided comprehensive care for our patients—from involvement in prehospital care and planning, through the emergency department, operating room, ICU, and even post-discharge rehabilitation. This requires an effective healthcare team and a truly multidisciplinary approach with other physicians (orthopedics, neurosurgery, anesthesia), nurses, and others, including respiratory, occupational, and physical therapy.

Conclusion

We see a synergy between hospitalist and acute-care surgeons. Both groups have stepped forward to fill a void in patient care. The redefining of trauma surgery as acute care surgery and the development of dedicated training programs will no doubt benefit current and future surgeons, but our patients will benefit the most. TH

Dr. Spain is professor of surgery and chief of Trauma, Emergency and Critical Care Surgery, Stanford University (California). He is also chairman of the Critical Care Committee, American Association for the Surgery of Trauma. Dr. Jurkovich is professor of surgery at the University of Washington, chief of Trauma and Emergency Surgical Services at Harborview Medical Center, and chairman of the Acute Care Surgeon Committee, American Association for the Surgery of Trauma.

References

1. Committee to Develop the Reorganized Specialty of Trauma, Surgical Critical Care, and Emergency Surgery. Acute care surgery: trauma, critical care, and emergency surgery. J Trauma. 2005;58:614-616.
2. Spain DA, Miller FB. Education and training of the future trauma surgeon in acute care surgery: trauma, critical care, and emergency surgery. Am J Surg. 2005;190:212-217.
3. Pryor JP, Reilly PM, Schwab CW, et al. Integrating emergency general surgery with a trauma service: impact on the care of injured patients. J Trauma. 2004 Sep;57(3):467-471.
4. Reilly PM, Schwab CW, Haut ER, et al. Training in trauma surgery: quantitative and qualitative aspects of a new paradigm for fellowship. Ann Surg. 2003 Oct;238(4):596-603.
5. Kim PK, Dabrowski GP, Reilly PM, et al. Redefining the future of trauma surgery as a comprehensive trauma and emergency general surgery service. J Am Coll Surg. 2004 Jul;199(1):96-101.
6. Austin MT, Diaz JJ Jr, Feurer ID, et al. Creating an emergency general surgery service enhances the productivity of trauma surgeons, general surgeons and the hospital. J Trauma. 2005 May;58(5):906-910.
7. Wellikson L. Hospitals recognize and reward value. The Hospitalist. 2005;9:3-5.

In the past decade numerous trends and influences have caused organized trauma surgery to re-examine our role in the care of all acutely ill surgical patients and the training of future general surgeons who will care for these patients.1 In this article we’ll briefly review the influences that brought us to this point, the issues we feel need to be addressed, and the solution that trauma surgery has proposed. In many ways, we believe these trends parallel the influences that led to the development of the hospitalists and, thus, call for a surgical equivalent.

Surgical Trends

The development of laparoscopic surgery has had profound influence on surgical practice. Cholecystectomies and appendectomies are generally 23-hour admissions. Even bariatric surgery is now little more than outpatient surgery, with the average length of stay at two days. Along with laparoscopy, breast surgery is now one of the fastest growing surgical subspecialties.

Many surgeons have tailored their practices to a largely outpatient base. There has been an explosion of free-standing surgery centers with a large shift of this low acuity patient population away from hospitals. This follows an overall shift in medicine to ambulatory practice, which is now projected to increase by 24% over the next five to 10 years. Thus, fewer and fewer surgeons have large inpatient practices. There is growing concern about the reluctance of many surgeons to deal with complex, high acuity patients. The obvious exceptions are transplant and trauma surgeons.

In the past decade profound changes in trauma care have also affected the practices of surgeons and the career choices of surgical residents.2 Following the peak of gun-related violence in the early 1990s, there has been a steady and significant decline in penetrating trauma with a concomitant decrease in operations. Slow but steady improvement in motor vehicle passive safety devices has also decreased the incidence of serious injury to the torso following car crashes.

When a solid organ (liver, spleen, kidney) injury does occur after car crash, fall, or assault, the management has largely shifted away from exploratory laparotomy to non-operative management. This has been made possible by improved imaging techniques, careful monitoring in the ICU and judicious use of interventional radiologic techniques of embolization and percutaneous drainage. Currently, some 60% to 80% of liver and spleen injuries are treated with observation or interventional techniques. Although most surgical residents enjoy the challenges of both trauma surgery and critical care, the decline in operative opportunities has limited the appeal of trauma/critical care as a career choice.2

Many trauma surgeons feel there is a convergence of these two issues—a group of patients that may be underserved and an opportunity to enhance the training and desirability of caring for acutely ill surgical patients.3-5 Either through years of experience or formal training, the vast majority of trauma surgeons are highly experienced in evaluating, operating upon, and providing post-operative care for critically ill and injured patients. In fact, the majority of surgical critical care fellowships are based at level 1 trauma centers and are run primarily by trauma surgeons. Thus, trauma surgeons are ideally situated to address these issues.

[A fellowship] all starts with a core group of people dedicated to hospital medicine. You need a group of people who see the future of hospital medicine and what it can be and who want to dive into different aspects of it. This is the minimum criteria for a successful hospitalist fellowship program.

—Rohit Uppal, MD, MBA

A New Specialty

In 2001 Ron V. Maier, MD, then president of the American Association for the Surgery of Trauma (AAST), commissioned a committee to address these issues and develop an action plan. With broad representation from numerous surgical societies, the committee met several times to consider various training and practice models as potential solutions. After much discussion, the group proposed a model based upon trauma surgery, emergency general surgery, and critical care. This process is outlined in a white paper authored by the committee in 2005.

Basically, the committee recommends the evolution of trauma surgery into a new specialty based on broad training in elective and emergency general surgery, trauma, and critical care surgery. Specific steps to accomplish this goal were outlined by the committee and considerable progress has already been made. After much debate regarding the name, including the consideration of “surgical hospitalists,” the AAST elected to support the name “acute care surgeon.” In fact, this model is how many of us trauma surgeons practice; we take trauma and emergency general surgery call and provide critical care services for these patients.

What was missing from the paradigm was a formal incorporation of emergency general surgery into the training of trauma/surgical critical care fellows and analysis of the benefits of such programs. While this practice paradigm has long been the model at many urban safety net hospitals in cities such as Atlanta, Dallas, Denver, Los Angeles, and Seattle, the practice of many trauma surgeons is often restrained at university hospitals and most level II trauma centers.

Strong Results

The trauma program at University of Pennsylvania, Pittsburgh, under the leadership of C. William Schwab, MD, the current president of the AAST, has taken the lead in documenting the value of incorporating emergency surgery into trauma/surgical critical care training. The addition of emergency general surgery into a trauma/surgical critical care fellowship increases operative experience and fellow satisfaction.3-6 Emergency general surgery now accounts for 57% of operations performed by their faculty. This helps maintain their operative experience despite a decline in operative trauma volume. Finally, with a careful analysis of performance improvement data, there is no compromise in trauma patient outcomes despite the increased patient load.4-5 This experience has been replicated at other trauma centers and strongly suggests that incorporating emergency general surgery into trauma training increases attractiveness to trainees and maintains high standards of patient care. The question is whether it meets an unfilled need.

Recent experience at Vanderbilt Medical Center suggests that the formal incorporation of emergency general surgery into a service has benefits for patients and the hospital.6 The service brings in more referrals from the surrounding community and increases trauma surgeon operative cases. The elective general surgeons also experience an increase in operations and admissions after removing the disruption of emergency admissions. The hospital benefits by the addition of new patients that frequently require operations and intensive care.

In a recent supplement to the The Hospitalist Larry Wellikson, MD, notes that hospitalists add value by (among other things):

• Providing measurable quality improvement;
• Creating seamless continuity from inpatient to outpatient care, from emergency department to floor, and from ICU to floor;
• Doing things other physicians had given up, such as indigent care and hospital committee functions;
• Creating healthcare teams to improve the working environment; and
• Taking care of acutely ill, complex hospitalized patients.7

We believe that trauma surgeons, or acute care surgeons, exemplify these values. We have provided these services to surgical patients for the past 25 years. Trauma surgeons have been leaders in quality improvement, as demonstrated by the American College of Surgeons Committee on Trauma verification program.

We take care of whoever comes through the door, regardless of acuity, time of day (or night), or payer status. We have always provided comprehensive care for our patients—from involvement in prehospital care and planning, through the emergency department, operating room, ICU, and even post-discharge rehabilitation. This requires an effective healthcare team and a truly multidisciplinary approach with other physicians (orthopedics, neurosurgery, anesthesia), nurses, and others, including respiratory, occupational, and physical therapy.

Conclusion

We see a synergy between hospitalist and acute-care surgeons. Both groups have stepped forward to fill a void in patient care. The redefining of trauma surgery as acute care surgery and the development of dedicated training programs will no doubt benefit current and future surgeons, but our patients will benefit the most. TH

Dr. Spain is professor of surgery and chief of Trauma, Emergency and Critical Care Surgery, Stanford University (California). He is also chairman of the Critical Care Committee, American Association for the Surgery of Trauma. Dr. Jurkovich is professor of surgery at the University of Washington, chief of Trauma and Emergency Surgical Services at Harborview Medical Center, and chairman of the Acute Care Surgeon Committee, American Association for the Surgery of Trauma.

References

1. Committee to Develop the Reorganized Specialty of Trauma, Surgical Critical Care, and Emergency Surgery. Acute care surgery: trauma, critical care, and emergency surgery. J Trauma. 2005;58:614-616.
2. Spain DA, Miller FB. Education and training of the future trauma surgeon in acute care surgery: trauma, critical care, and emergency surgery. Am J Surg. 2005;190:212-217.
3. Pryor JP, Reilly PM, Schwab CW, et al. Integrating emergency general surgery with a trauma service: impact on the care of injured patients. J Trauma. 2004 Sep;57(3):467-471.
4. Reilly PM, Schwab CW, Haut ER, et al. Training in trauma surgery: quantitative and qualitative aspects of a new paradigm for fellowship. Ann Surg. 2003 Oct;238(4):596-603.
5. Kim PK, Dabrowski GP, Reilly PM, et al. Redefining the future of trauma surgery as a comprehensive trauma and emergency general surgery service. J Am Coll Surg. 2004 Jul;199(1):96-101.
6. Austin MT, Diaz JJ Jr, Feurer ID, et al. Creating an emergency general surgery service enhances the productivity of trauma surgeons, general surgeons and the hospital. J Trauma. 2005 May;58(5):906-910.
7. Wellikson L. Hospitals recognize and reward value. The Hospitalist. 2005;9:3-5.

In the past decade numerous trends and influences have caused organized trauma surgery to re-examine our role in the care of all acutely ill surgical patients and the training of future general surgeons who will care for these patients.1 In this article we’ll briefly review the influences that brought us to this point, the issues we feel need to be addressed, and the solution that trauma surgery has proposed. In many ways, we believe these trends parallel the influences that led to the development of the hospitalists and, thus, call for a surgical equivalent.

Surgical Trends

The development of laparoscopic surgery has had profound influence on surgical practice. Cholecystectomies and appendectomies are generally 23-hour admissions. Even bariatric surgery is now little more than outpatient surgery, with the average length of stay at two days. Along with laparoscopy, breast surgery is now one of the fastest growing surgical subspecialties.

Many surgeons have tailored their practices to a largely outpatient base. There has been an explosion of free-standing surgery centers with a large shift of this low acuity patient population away from hospitals. This follows an overall shift in medicine to ambulatory practice, which is now projected to increase by 24% over the next five to 10 years. Thus, fewer and fewer surgeons have large inpatient practices. There is growing concern about the reluctance of many surgeons to deal with complex, high acuity patients. The obvious exceptions are transplant and trauma surgeons.

In the past decade profound changes in trauma care have also affected the practices of surgeons and the career choices of surgical residents.2 Following the peak of gun-related violence in the early 1990s, there has been a steady and significant decline in penetrating trauma with a concomitant decrease in operations. Slow but steady improvement in motor vehicle passive safety devices has also decreased the incidence of serious injury to the torso following car crashes.

When a solid organ (liver, spleen, kidney) injury does occur after car crash, fall, or assault, the management has largely shifted away from exploratory laparotomy to non-operative management. This has been made possible by improved imaging techniques, careful monitoring in the ICU and judicious use of interventional radiologic techniques of embolization and percutaneous drainage. Currently, some 60% to 80% of liver and spleen injuries are treated with observation or interventional techniques. Although most surgical residents enjoy the challenges of both trauma surgery and critical care, the decline in operative opportunities has limited the appeal of trauma/critical care as a career choice.2

Many trauma surgeons feel there is a convergence of these two issues—a group of patients that may be underserved and an opportunity to enhance the training and desirability of caring for acutely ill surgical patients.3-5 Either through years of experience or formal training, the vast majority of trauma surgeons are highly experienced in evaluating, operating upon, and providing post-operative care for critically ill and injured patients. In fact, the majority of surgical critical care fellowships are based at level 1 trauma centers and are run primarily by trauma surgeons. Thus, trauma surgeons are ideally situated to address these issues.

[A fellowship] all starts with a core group of people dedicated to hospital medicine. You need a group of people who see the future of hospital medicine and what it can be and who want to dive into different aspects of it. This is the minimum criteria for a successful hospitalist fellowship program.

—Rohit Uppal, MD, MBA

A New Specialty

In 2001 Ron V. Maier, MD, then president of the American Association for the Surgery of Trauma (AAST), commissioned a committee to address these issues and develop an action plan. With broad representation from numerous surgical societies, the committee met several times to consider various training and practice models as potential solutions. After much discussion, the group proposed a model based upon trauma surgery, emergency general surgery, and critical care. This process is outlined in a white paper authored by the committee in 2005.

Basically, the committee recommends the evolution of trauma surgery into a new specialty based on broad training in elective and emergency general surgery, trauma, and critical care surgery. Specific steps to accomplish this goal were outlined by the committee and considerable progress has already been made. After much debate regarding the name, including the consideration of “surgical hospitalists,” the AAST elected to support the name “acute care surgeon.” In fact, this model is how many of us trauma surgeons practice; we take trauma and emergency general surgery call and provide critical care services for these patients.

What was missing from the paradigm was a formal incorporation of emergency general surgery into the training of trauma/surgical critical care fellows and analysis of the benefits of such programs. While this practice paradigm has long been the model at many urban safety net hospitals in cities such as Atlanta, Dallas, Denver, Los Angeles, and Seattle, the practice of many trauma surgeons is often restrained at university hospitals and most level II trauma centers.

Strong Results

The trauma program at University of Pennsylvania, Pittsburgh, under the leadership of C. William Schwab, MD, the current president of the AAST, has taken the lead in documenting the value of incorporating emergency surgery into trauma/surgical critical care training. The addition of emergency general surgery into a trauma/surgical critical care fellowship increases operative experience and fellow satisfaction.3-6 Emergency general surgery now accounts for 57% of operations performed by their faculty. This helps maintain their operative experience despite a decline in operative trauma volume. Finally, with a careful analysis of performance improvement data, there is no compromise in trauma patient outcomes despite the increased patient load.4-5 This experience has been replicated at other trauma centers and strongly suggests that incorporating emergency general surgery into trauma training increases attractiveness to trainees and maintains high standards of patient care. The question is whether it meets an unfilled need.

Recent experience at Vanderbilt Medical Center suggests that the formal incorporation of emergency general surgery into a service has benefits for patients and the hospital.6 The service brings in more referrals from the surrounding community and increases trauma surgeon operative cases. The elective general surgeons also experience an increase in operations and admissions after removing the disruption of emergency admissions. The hospital benefits by the addition of new patients that frequently require operations and intensive care.

In a recent supplement to the The Hospitalist Larry Wellikson, MD, notes that hospitalists add value by (among other things):

• Providing measurable quality improvement;
• Creating seamless continuity from inpatient to outpatient care, from emergency department to floor, and from ICU to floor;
• Doing things other physicians had given up, such as indigent care and hospital committee functions;
• Creating healthcare teams to improve the working environment; and
• Taking care of acutely ill, complex hospitalized patients.7

We believe that trauma surgeons, or acute care surgeons, exemplify these values. We have provided these services to surgical patients for the past 25 years. Trauma surgeons have been leaders in quality improvement, as demonstrated by the American College of Surgeons Committee on Trauma verification program.

We take care of whoever comes through the door, regardless of acuity, time of day (or night), or payer status. We have always provided comprehensive care for our patients—from involvement in prehospital care and planning, through the emergency department, operating room, ICU, and even post-discharge rehabilitation. This requires an effective healthcare team and a truly multidisciplinary approach with other physicians (orthopedics, neurosurgery, anesthesia), nurses, and others, including respiratory, occupational, and physical therapy.

Dr. Jurkovich

Dr. Spain

Conclusion

We see a synergy between hospitalist and acute-care surgeons. Both groups have stepped forward to fill a void in patient care. The redefining of trauma surgery as acute care surgery and the development of dedicated training programs will no doubt benefit current and future surgeons, but our patients will benefit the most. TH

Dr. Spain is professor of surgery and chief of Trauma, Emergency and Critical Care Surgery, Stanford University (California). He is also chairman of the Critical Care Committee, American Association for the Surgery of Trauma. Dr. Jurkovich is professor of surgery at the University of Washington, chief of Trauma and Emergency Surgical Services at Harborview Medical Center, and chairman of the Acute Care Surgeon Committee, American Association for the Surgery of Trauma.

References

1. Committee to Develop the Reorganized Specialty of Trauma, Surgical Critical Care, and Emergency Surgery. Acute care surgery: trauma, critical care, and emergency surgery. J Trauma. 2005;58:614-616.
2. Spain DA, Miller FB. Education and training of the future trauma surgeon in acute care surgery: trauma, critical care, and emergency surgery. Am J Surg. 2005;190:212-217.
3. Pryor JP, Reilly PM, Schwab CW, et al. Integrating emergency general surgery with a trauma service: impact on the care of injured patients. J Trauma. 2004 Sep;57(3):467-471.
4. Reilly PM, Schwab CW, Haut ER, et al. Training in trauma surgery: quantitative and qualitative aspects of a new paradigm for fellowship. Ann Surg. 2003 Oct;238(4):596-603.
5. Kim PK, Dabrowski GP, Reilly PM, et al. Redefining the future of trauma surgery as a comprehensive trauma and emergency general surgery service. J Am Coll Surg. 2004 Jul;199(1):96-101.
6. Austin MT, Diaz JJ Jr, Feurer ID, et al. Creating an emergency general surgery service enhances the productivity of trauma surgeons, general surgeons and the hospital. J Trauma. 2005 May;58(5):906-910.
7. Wellikson L. Hospitals recognize and reward value. The Hospitalist. 2005;9:3-5.

In the past decade numerous trends and influences have caused organized trauma surgery to re-examine our role in the care of all acutely ill surgical patients and the training of future general surgeons who will care for these patients.1 In this article we’ll briefly review the influences that brought us to this point, the issues we feel need to be addressed, and the solution that trauma surgery has proposed. In many ways, we believe these trends parallel the influences that led to the development of the hospitalists and, thus, call for a surgical equivalent.

Surgical Trends

The development of laparoscopic surgery has had profound influence on surgical practice. Cholecystectomies and appendectomies are generally 23-hour admissions. Even bariatric surgery is now little more than outpatient surgery, with the average length of stay at two days. Along with laparoscopy, breast surgery is now one of the fastest growing surgical subspecialties.

Many surgeons have tailored their practices to a largely outpatient base. There has been an explosion of free-standing surgery centers with a large shift of this low acuity patient population away from hospitals. This follows an overall shift in medicine to ambulatory practice, which is now projected to increase by 24% over the next five to 10 years. Thus, fewer and fewer surgeons have large inpatient practices. There is growing concern about the reluctance of many surgeons to deal with complex, high acuity patients. The obvious exceptions are transplant and trauma surgeons.

In the past decade profound changes in trauma care have also affected the practices of surgeons and the career choices of surgical residents.2 Following the peak of gun-related violence in the early 1990s, there has been a steady and significant decline in penetrating trauma with a concomitant decrease in operations. Slow but steady improvement in motor vehicle passive safety devices has also decreased the incidence of serious injury to the torso following car crashes.

When a solid organ (liver, spleen, kidney) injury does occur after car crash, fall, or assault, the management has largely shifted away from exploratory laparotomy to non-operative management. This has been made possible by improved imaging techniques, careful monitoring in the ICU and judicious use of interventional radiologic techniques of embolization and percutaneous drainage. Currently, some 60% to 80% of liver and spleen injuries are treated with observation or interventional techniques. Although most surgical residents enjoy the challenges of both trauma surgery and critical care, the decline in operative opportunities has limited the appeal of trauma/critical care as a career choice.2

Many trauma surgeons feel there is a convergence of these two issues—a group of patients that may be underserved and an opportunity to enhance the training and desirability of caring for acutely ill surgical patients.3-5 Either through years of experience or formal training, the vast majority of trauma surgeons are highly experienced in evaluating, operating upon, and providing post-operative care for critically ill and injured patients. In fact, the majority of surgical critical care fellowships are based at level 1 trauma centers and are run primarily by trauma surgeons. Thus, trauma surgeons are ideally situated to address these issues.

[A fellowship] all starts with a core group of people dedicated to hospital medicine. You need a group of people who see the future of hospital medicine and what it can be and who want to dive into different aspects of it. This is the minimum criteria for a successful hospitalist fellowship program.

—Rohit Uppal, MD, MBA

A New Specialty

In 2001 Ron V. Maier, MD, then president of the American Association for the Surgery of Trauma (AAST), commissioned a committee to address these issues and develop an action plan. With broad representation from numerous surgical societies, the committee met several times to consider various training and practice models as potential solutions. After much discussion, the group proposed a model based upon trauma surgery, emergency general surgery, and critical care. This process is outlined in a white paper authored by the committee in 2005.

Basically, the committee recommends the evolution of trauma surgery into a new specialty based on broad training in elective and emergency general surgery, trauma, and critical care surgery. Specific steps to accomplish this goal were outlined by the committee and considerable progress has already been made. After much debate regarding the name, including the consideration of “surgical hospitalists,” the AAST elected to support the name “acute care surgeon.” In fact, this model is how many of us trauma surgeons practice; we take trauma and emergency general surgery call and provide critical care services for these patients.

What was missing from the paradigm was a formal incorporation of emergency general surgery into the training of trauma/surgical critical care fellows and analysis of the benefits of such programs. While this practice paradigm has long been the model at many urban safety net hospitals in cities such as Atlanta, Dallas, Denver, Los Angeles, and Seattle, the practice of many trauma surgeons is often restrained at university hospitals and most level II trauma centers.

Strong Results

The trauma program at University of Pennsylvania, Pittsburgh, under the leadership of C. William Schwab, MD, the current president of the AAST, has taken the lead in documenting the value of incorporating emergency surgery into trauma/surgical critical care training. The addition of emergency general surgery into a trauma/surgical critical care fellowship increases operative experience and fellow satisfaction.3-6 Emergency general surgery now accounts for 57% of operations performed by their faculty. This helps maintain their operative experience despite a decline in operative trauma volume. Finally, with a careful analysis of performance improvement data, there is no compromise in trauma patient outcomes despite the increased patient load.4-5 This experience has been replicated at other trauma centers and strongly suggests that incorporating emergency general surgery into trauma training increases attractiveness to trainees and maintains high standards of patient care. The question is whether it meets an unfilled need.

Recent experience at Vanderbilt Medical Center suggests that the formal incorporation of emergency general surgery into a service has benefits for patients and the hospital.6 The service brings in more referrals from the surrounding community and increases trauma surgeon operative cases. The elective general surgeons also experience an increase in operations and admissions after removing the disruption of emergency admissions. The hospital benefits by the addition of new patients that frequently require operations and intensive care.

In a recent supplement to the The Hospitalist Larry Wellikson, MD, notes that hospitalists add value by (among other things):

• Providing measurable quality improvement;
• Creating seamless continuity from inpatient to outpatient care, from emergency department to floor, and from ICU to floor;
• Doing things other physicians had given up, such as indigent care and hospital committee functions;
• Creating healthcare teams to improve the working environment; and
• Taking care of acutely ill, complex hospitalized patients.7

We believe that trauma surgeons, or acute care surgeons, exemplify these values. We have provided these services to surgical patients for the past 25 years. Trauma surgeons have been leaders in quality improvement, as demonstrated by the American College of Surgeons Committee on Trauma verification program.

We take care of whoever comes through the door, regardless of acuity, time of day (or night), or payer status. We have always provided comprehensive care for our patients—from involvement in prehospital care and planning, through the emergency department, operating room, ICU, and even post-discharge rehabilitation. This requires an effective healthcare team and a truly multidisciplinary approach with other physicians (orthopedics, neurosurgery, anesthesia), nurses, and others, including respiratory, occupational, and physical therapy.

Dr. Jurkovich

Dr. Spain

Conclusion

We see a synergy between hospitalist and acute-care surgeons. Both groups have stepped forward to fill a void in patient care. The redefining of trauma surgery as acute care surgery and the development of dedicated training programs will no doubt benefit current and future surgeons, but our patients will benefit the most. TH

Dr. Spain is professor of surgery and chief of Trauma, Emergency and Critical Care Surgery, Stanford University (California). He is also chairman of the Critical Care Committee, American Association for the Surgery of Trauma. Dr. Jurkovich is professor of surgery at the University of Washington, chief of Trauma and Emergency Surgical Services at Harborview Medical Center, and chairman of the Acute Care Surgeon Committee, American Association for the Surgery of Trauma.

References

1. Committee to Develop the Reorganized Specialty of Trauma, Surgical Critical Care, and Emergency Surgery. Acute care surgery: trauma, critical care, and emergency surgery. J Trauma. 2005;58:614-616.
2. Spain DA, Miller FB. Education and training of the future trauma surgeon in acute care surgery: trauma, critical care, and emergency surgery. Am J Surg. 2005;190:212-217.
3. Pryor JP, Reilly PM, Schwab CW, et al. Integrating emergency general surgery with a trauma service: impact on the care of injured patients. J Trauma. 2004 Sep;57(3):467-471.
4. Reilly PM, Schwab CW, Haut ER, et al. Training in trauma surgery: quantitative and qualitative aspects of a new paradigm for fellowship. Ann Surg. 2003 Oct;238(4):596-603.
5. Kim PK, Dabrowski GP, Reilly PM, et al. Redefining the future of trauma surgery as a comprehensive trauma and emergency general surgery service. J Am Coll Surg. 2004 Jul;199(1):96-101.
6. Austin MT, Diaz JJ Jr, Feurer ID, et al. Creating an emergency general surgery service enhances the productivity of trauma surgeons, general surgeons and the hospital. J Trauma. 2005 May;58(5):906-910.
7. Wellikson L. Hospitals recognize and reward value. The Hospitalist. 2005;9:3-5.

In the past decade numerous trends and influences have caused organized trauma surgery to re-examine our role in the care of all acutely ill surgical patients and the training of future general surgeons who will care for these patients.1 In this article we’ll briefly review the influences that brought us to this point, the issues we feel need to be addressed, and the solution that trauma surgery has proposed. In many ways, we believe these trends parallel the influences that led to the development of the hospitalists and, thus, call for a surgical equivalent.

Surgical Trends

The development of laparoscopic surgery has had profound influence on surgical practice. Cholecystectomies and appendectomies are generally 23-hour admissions. Even bariatric surgery is now little more than outpatient surgery, with the average length of stay at two days. Along with laparoscopy, breast surgery is now one of the fastest growing surgical subspecialties.

Many surgeons have tailored their practices to a largely outpatient base. There has been an explosion of free-standing surgery centers with a large shift of this low acuity patient population away from hospitals. This follows an overall shift in medicine to ambulatory practice, which is now projected to increase by 24% over the next five to 10 years. Thus, fewer and fewer surgeons have large inpatient practices. There is growing concern about the reluctance of many surgeons to deal with complex, high acuity patients. The obvious exceptions are transplant and trauma surgeons.

In the past decade profound changes in trauma care have also affected the practices of surgeons and the career choices of surgical residents.2 Following the peak of gun-related violence in the early 1990s, there has been a steady and significant decline in penetrating trauma with a concomitant decrease in operations. Slow but steady improvement in motor vehicle passive safety devices has also decreased the incidence of serious injury to the torso following car crashes.

When a solid organ (liver, spleen, kidney) injury does occur after car crash, fall, or assault, the management has largely shifted away from exploratory laparotomy to non-operative management. This has been made possible by improved imaging techniques, careful monitoring in the ICU and judicious use of interventional radiologic techniques of embolization and percutaneous drainage. Currently, some 60% to 80% of liver and spleen injuries are treated with observation or interventional techniques. Although most surgical residents enjoy the challenges of both trauma surgery and critical care, the decline in operative opportunities has limited the appeal of trauma/critical care as a career choice.2

Many trauma surgeons feel there is a convergence of these two issues—a group of patients that may be underserved and an opportunity to enhance the training and desirability of caring for acutely ill surgical patients.3-5 Either through years of experience or formal training, the vast majority of trauma surgeons are highly experienced in evaluating, operating upon, and providing post-operative care for critically ill and injured patients. In fact, the majority of surgical critical care fellowships are based at level 1 trauma centers and are run primarily by trauma surgeons. Thus, trauma surgeons are ideally situated to address these issues.

[A fellowship] all starts with a core group of people dedicated to hospital medicine. You need a group of people who see the future of hospital medicine and what it can be and who want to dive into different aspects of it. This is the minimum criteria for a successful hospitalist fellowship program.

—Rohit Uppal, MD, MBA

A New Specialty

In 2001 Ron V. Maier, MD, then president of the American Association for the Surgery of Trauma (AAST), commissioned a committee to address these issues and develop an action plan. With broad representation from numerous surgical societies, the committee met several times to consider various training and practice models as potential solutions. After much discussion, the group proposed a model based upon trauma surgery, emergency general surgery, and critical care. This process is outlined in a white paper authored by the committee in 2005.

Basically, the committee recommends the evolution of trauma surgery into a new specialty based on broad training in elective and emergency general surgery, trauma, and critical care surgery. Specific steps to accomplish this goal were outlined by the committee and considerable progress has already been made. After much debate regarding the name, including the consideration of “surgical hospitalists,” the AAST elected to support the name “acute care surgeon.” In fact, this model is how many of us trauma surgeons practice; we take trauma and emergency general surgery call and provide critical care services for these patients.

What was missing from the paradigm was a formal incorporation of emergency general surgery into the training of trauma/surgical critical care fellows and analysis of the benefits of such programs. While this practice paradigm has long been the model at many urban safety net hospitals in cities such as Atlanta, Dallas, Denver, Los Angeles, and Seattle, the practice of many trauma surgeons is often restrained at university hospitals and most level II trauma centers.

Strong Results

The trauma program at University of Pennsylvania, Pittsburgh, under the leadership of C. William Schwab, MD, the current president of the AAST, has taken the lead in documenting the value of incorporating emergency surgery into trauma/surgical critical care training. The addition of emergency general surgery into a trauma/surgical critical care fellowship increases operative experience and fellow satisfaction.3-6 Emergency general surgery now accounts for 57% of operations performed by their faculty. This helps maintain their operative experience despite a decline in operative trauma volume. Finally, with a careful analysis of performance improvement data, there is no compromise in trauma patient outcomes despite the increased patient load.4-5 This experience has been replicated at other trauma centers and strongly suggests that incorporating emergency general surgery into trauma training increases attractiveness to trainees and maintains high standards of patient care. The question is whether it meets an unfilled need.

Recent experience at Vanderbilt Medical Center suggests that the formal incorporation of emergency general surgery into a service has benefits for patients and the hospital.6 The service brings in more referrals from the surrounding community and increases trauma surgeon operative cases. The elective general surgeons also experience an increase in operations and admissions after removing the disruption of emergency admissions. The hospital benefits by the addition of new patients that frequently require operations and intensive care.

In a recent supplement to the The Hospitalist Larry Wellikson, MD, notes that hospitalists add value by (among other things):

• Providing measurable quality improvement;
• Creating seamless continuity from inpatient to outpatient care, from emergency department to floor, and from ICU to floor;
• Doing things other physicians had given up, such as indigent care and hospital committee functions;
• Creating healthcare teams to improve the working environment; and
• Taking care of acutely ill, complex hospitalized patients.7

We believe that trauma surgeons, or acute care surgeons, exemplify these values. We have provided these services to surgical patients for the past 25 years. Trauma surgeons have been leaders in quality improvement, as demonstrated by the American College of Surgeons Committee on Trauma verification program.

We take care of whoever comes through the door, regardless of acuity, time of day (or night), or payer status. We have always provided comprehensive care for our patients—from involvement in prehospital care and planning, through the emergency department, operating room, ICU, and even post-discharge rehabilitation. This requires an effective healthcare team and a truly multidisciplinary approach with other physicians (orthopedics, neurosurgery, anesthesia), nurses, and others, including respiratory, occupational, and physical therapy.

Dr. Jurkovich

Dr. Spain

Conclusion

We see a synergy between hospitalist and acute-care surgeons. Both groups have stepped forward to fill a void in patient care. The redefining of trauma surgery as acute care surgery and the development of dedicated training programs will no doubt benefit current and future surgeons, but our patients will benefit the most. TH

Dr. Spain is professor of surgery and chief of Trauma, Emergency and Critical Care Surgery, Stanford University (California). He is also chairman of the Critical Care Committee, American Association for the Surgery of Trauma. Dr. Jurkovich is professor of surgery at the University of Washington, chief of Trauma and Emergency Surgical Services at Harborview Medical Center, and chairman of the Acute Care Surgeon Committee, American Association for the Surgery of Trauma.

References

1. Committee to Develop the Reorganized Specialty of Trauma, Surgical Critical Care, and Emergency Surgery. Acute care surgery: trauma, critical care, and emergency surgery. J Trauma. 2005;58:614-616.
2. Spain DA, Miller FB. Education and training of the future trauma surgeon in acute care surgery: trauma, critical care, and emergency surgery. Am J Surg. 2005;190:212-217.
3. Pryor JP, Reilly PM, Schwab CW, et al. Integrating emergency general surgery with a trauma service: impact on the care of injured patients. J Trauma. 2004 Sep;57(3):467-471.
4. Reilly PM, Schwab CW, Haut ER, et al. Training in trauma surgery: quantitative and qualitative aspects of a new paradigm for fellowship. Ann Surg. 2003 Oct;238(4):596-603.
5. Kim PK, Dabrowski GP, Reilly PM, et al. Redefining the future of trauma surgery as a comprehensive trauma and emergency general surgery service. J Am Coll Surg. 2004 Jul;199(1):96-101.
6. Austin MT, Diaz JJ Jr, Feurer ID, et al. Creating an emergency general surgery service enhances the productivity of trauma surgeons, general surgeons and the hospital. J Trauma. 2005 May;58(5):906-910.
7. Wellikson L. Hospitals recognize and reward value. The Hospitalist. 2005;9:3-5.

Hospital-based palliative care programs are gaining traction in the United States as studies show their efficacy in decreasing length of stay and improved quality of patient care.1,2 According to the American Hospital Association, 22% of all U.S. hospitals now have such programs.3 These programs—with their emphasis on coordinated, team-delivered care and communication—seem tailor-made for the expertise of hospitalists who are increasingly taking the lead to establish them at their institutions.

Through the SHM Web site (www.hospitalmedicine.org) and the Center to Advance Palliative Care (www.capc.org) ample resources exist for developing program infrastructure and acquiring on-site training (see www.capc.org/palliative-care-leadershipinitiative/overview).

There are unwritten protocols, however, that can make or break a palliative care service. Hospitalists involved with palliative care often find themselves relating to oncologists because many patients who have palliative care needs are undergoing inpatient curative treatments (such as brachytherapy) or are actively dying. Palliative care experts interviewed for this article agreed that in order to encourage referrals from their oncology colleagues, hospitalists must be attentive to oncologists’ concerns and to consultation etiquette.

“Palliative care has been something that oncologists traditionally think they do pretty well,” says David H. Lawson, MD, section chief, Medical Oncology at Emory Clinic. “I think there will be a lot of variability between oncologists about what they see as their province and what they see as open for someone else.”

Assessing Oncologists’ Needs

During the organizational phase of a hospital-based palliative care service, it is advisable to meet with oncologists one-on-one, believes Charles F. von Gunten, MD, PhD, medical director of the Palliative Care Consultation Service at the University of California, San Diego, and director of the Center for Palliative Studies at San Diego Hospice and Palliative Care. “All consult services are fundamentally about providing advice to the managing physician when requested, about what is requested, and nothing else.”

He recommends that hospitalists involved in development of a hospital-based palliative care service find out how key oncologists at their hospital perceive the needs in the area of palliative care. “This may not match what the hospitalist thinks the oncologist needs, but that’s immaterial,” he cautions.

This advice squares with that of Steve Pantilat, MD, immediate past-president of SHM, and his team at the University of California, San Francisco. The palliative care service at UCSF is one of six Palliative Care Leadership Centers nationwide, so designated during an initiative launched two years ago by the Center to Advance Palliative Care. (The Robert Wood Johnson Foundation underwrites training activities at the six centers.) The issue in establishing palliative care services, says Dr. Pantilat, is “figuring out what would attract oncologists about such a program. What issues are most salient to them? Instead of saying, ‘I have a new service; would you please use it?’ You have to come in and say, ‘We’re thinking of starting this new service; how can we be of help to you?’ ”

Dr. Lawson agrees with Dr. von Gunten and Dr. Pantilat that hospitalists must develop communication with oncologists early during the start-up phase of a palliative care service. Hospitalists who offer palliative care services should also take time to familiarize themselves with patients’ treatment plans.

“I think there is going to be a learning curve for palliative care specialists,” says Dr. Lawson. “Part of that learning is to get some sense of how oncologists make decisions about whether to give chemo[therapy] or not. Oftentimes, there are pressures that might not be obvious.”

For instance, it may appear to a palliative care consultant that a certain patient should not undergo chemotherapy, but in fact the patient or the family may demand it.

Stephanie Grossman, MD, assistant professor of medicine and co-director of the Palliative Care Program for Emory University Hospital and Emory Crawford Long Hospital in Atlanta, says the majority of consults she does are with oncology patients. She has found that attending Monday morning sign-out meetings with Emory oncologists has not only increased referrals to the palliative care service, but has added to her understanding of oncologists’ decision-making processes.

“When I go to weekly meetings, I hear the full spectrum of what they are doing. I see how oncologists work and how they decide about treatments,” she says. “It’s been a really good experience because I never would have seen this from the hospitalist viewpoint.”

Emory’s palliative care program was launched in November 2005 and has grown so quickly that they already need additional staff.

The Primary Client

The “key message” for a hospitalist when asked to do a palliative care consult is to remember that the client of a consultation service is the referring physician, points out geriatrician Diane E. Meier, MD, director of the Center to Advance Palliative Care and the director of the Hertzberg Palliative Care Institute at Mount Sinai School of Medicine in New York City. “As a geriatrician, if I call in an infectious disease consultant, I’m calling that physician to help me make decisions about my patient—not for that person to take over the care of my patient or to undermine my relationship to that patient. This is basic consultation etiquette, but physicians are often not taught in medical school or residency the difference between a primary care responsibility and a consultation responsibility.”

“The biggest mistake that people make in putting together palliative care services,” concurs Dr. von Gunten, “is thinking that the patient is the client. That isn’t true. It is the person requesting the consultation—meaning, the referring physician or the managing service. The patient is the secondary beneficiary.

“The language we use—‘my patient’—is fundamental to the practice of American medicine,” explains Dr. von Gunten. You have to respect that. If you go to someone’s home, you don’t redecorate it because you don’t like their taste. You do not comment on their choice of draperies or their choice of food. The same applies to medical consultations.” (See “Consult Etiquette for Palliative Care Services,” p. 33.)

Oncologists generally feel “very possessive” about their patients, adds Dr. von Gunten. Even though oncologists are technically also consultants (to the patient’s primary care physician), the pattern in American medicine is that oncologists treating patients acquire the status of a primary care physician. “So,” he says, “you treat them with that kind of respect, which means that you ask permission before you do things, and you don’t disparage what they are doing—either to their faces or to their patients or to other bystanders like nurses.”

Dr. Lawson agrees that oncologists often have a strong personal bond with their patients. “These personal feelings are often reciprocated by the patients and families,” he says. “Accepting another person [the hospitalist as palliative care consultant] into the equation can be difficult at times, even more so while the patient is still in the hospital and the oncologist is still around.”

The palliative care program at Emory is consult-driven. “The doctor has to agree to us getting involved, so I don’t get into territorial issues,” says Dr. Grossman. “When I do get involved with patients, the oncologists welcome me taking care of them and realize the benefit of what I’m doing. They see that my approach is collaborative.”

Dr. Grossman has been able to offer services to oncologists whose patients are receiving chemotherapy and experiencing significant symptoms, such as pain. When hospitalists on the hospital medicine service consult her about cancer patients, she calls the primary oncologist to familiarize herself with the patient’s background and to check if other treatments are available.

Strengths of Hospitalists

Palliative care should be distinguished from hospice or end-of-life care, although it can be concurrent. Palliative care needs—ranging from symptom management to alleviating psychological suffering—can exist at any point along the cancer care trajectory, notes Dr. von Gunten, who was a co-developer with Dr. Pantilat and others of the California Hospital Initiative in Palliative Services program to assist hospitals to develop palliative services.4

Hospitalists, says Dr. von Gunten, already possess some of the baseline skills needed to deliver palliative care: They’re based in the hospital and so have the opportunity to interact with patients and their families; they are experienced in hospital-based management of patients; they are experienced in teamwork with other providers also based in the hospital. The ability to be available to patients and physicians 24/7 is a real advantage in symptom management, says Dr. Lawson.

Because hospitalists by definition care for people who are not their primary care patients, the sophistication and sensitivity about working with one’s colleagues “is already inculcated,” observes Dr. Meier. In addition, “hospitalists understand that their responsibility to and relationship with the patient is only one piece of being a good doctor. Ensuring good care for a patient means very high level and high intensity communications with everyone involved in that patient’s care: all the other specialists, the primary care physician, and the floor team—the social workers, nurses, certified nursing assistants, dietary staff, and rehab and physiatry staff. Unless everyone is reading from the same page, the patient’s care will not be good. Very often, it’s the hospitalist or palliative care consultant who is at the center of the wheel, making sure that all the spokes are getting the same message,” she says.

Busy oncologists may call upon Dr. Grossman’s service to conduct family meetings about care plans. “Patients are very loyal to their oncologists, and they want their oncologists to be supportive of their decisions,” she notes. “I always explain to patients that my consultation was requested or supported by their oncologist. I am not there to cause more barriers; I’m there to have everybody on board and to understand where the patient is. We call everybody in—the social worker, the nurse, chaplaincy staff—because our approach is interdisciplinary and these are the essential members of our team.”

Dr. Grossman believes that hospitalists’ training in teamwork and communications are key to providing a good experience for oncology patients and their families. She is board certified in palliative care, which allows her to bring additional expertise to symptom support, including situations where she can help the dying process be as peaceful as possible—for both patient and family.

The issues important in palliative care—availability to patients, families, and referring physicians, ability to work in teams, and quality of care—dovetail with the primary goals of hospital medicine. Hospitalists’ palliative care services can thrive when they forge strong foundational relationships with their referring colleagues. TH

Gretchen Henkel regularly contributes to The Hospitalist.

References

1. Selwyn PA, Rivard M, Kappell D, et al. Palliative care for AIDS at a large urban teaching hospital: program description and preliminary outcomes. J Palliat Med. 2003 Jun;6(3):461-474.
2. Ryan A, Carter J, Lucas J, Berger J. You need not make the journey alone: overcoming impediments to providing palliative care in a public urban teaching hospital. Am J Hosp Palliat Care. 2002 May-June;19(3):171-180.
3. The Case for Hospital-Based Palliative Care, published by the Center to Advance Palliative Care. Available online at: www.capc.org/building-a-hospital-based-palliative-care-program/case/support-from-capc/capc_publications/making-the-case.pdf. Last accessed March 22, 2006.
4. Pantilat SZ, Rabow MW, Citko J, et al. Evaluating the California Hospital Initiative in Palliative Services. Arch Intern Med. 2006 Jan 23;166(2):227-230.

Hospital-based palliative care programs are gaining traction in the United States as studies show their efficacy in decreasing length of stay and improved quality of patient care.1,2 According to the American Hospital Association, 22% of all U.S. hospitals now have such programs.3 These programs—with their emphasis on coordinated, team-delivered care and communication—seem tailor-made for the expertise of hospitalists who are increasingly taking the lead to establish them at their institutions.

Through the SHM Web site (www.hospitalmedicine.org) and the Center to Advance Palliative Care (www.capc.org) ample resources exist for developing program infrastructure and acquiring on-site training (see www.capc.org/palliative-care-leadershipinitiative/overview).

There are unwritten protocols, however, that can make or break a palliative care service. Hospitalists involved with palliative care often find themselves relating to oncologists because many patients who have palliative care needs are undergoing inpatient curative treatments (such as brachytherapy) or are actively dying. Palliative care experts interviewed for this article agreed that in order to encourage referrals from their oncology colleagues, hospitalists must be attentive to oncologists’ concerns and to consultation etiquette.

“Palliative care has been something that oncologists traditionally think they do pretty well,” says David H. Lawson, MD, section chief, Medical Oncology at Emory Clinic. “I think there will be a lot of variability between oncologists about what they see as their province and what they see as open for someone else.”

Assessing Oncologists’ Needs

During the organizational phase of a hospital-based palliative care service, it is advisable to meet with oncologists one-on-one, believes Charles F. von Gunten, MD, PhD, medical director of the Palliative Care Consultation Service at the University of California, San Diego, and director of the Center for Palliative Studies at San Diego Hospice and Palliative Care. “All consult services are fundamentally about providing advice to the managing physician when requested, about what is requested, and nothing else.”

He recommends that hospitalists involved in development of a hospital-based palliative care service find out how key oncologists at their hospital perceive the needs in the area of palliative care. “This may not match what the hospitalist thinks the oncologist needs, but that’s immaterial,” he cautions.

This advice squares with that of Steve Pantilat, MD, immediate past-president of SHM, and his team at the University of California, San Francisco. The palliative care service at UCSF is one of six Palliative Care Leadership Centers nationwide, so designated during an initiative launched two years ago by the Center to Advance Palliative Care. (The Robert Wood Johnson Foundation underwrites training activities at the six centers.) The issue in establishing palliative care services, says Dr. Pantilat, is “figuring out what would attract oncologists about such a program. What issues are most salient to them? Instead of saying, ‘I have a new service; would you please use it?’ You have to come in and say, ‘We’re thinking of starting this new service; how can we be of help to you?’ ”

Dr. Lawson agrees with Dr. von Gunten and Dr. Pantilat that hospitalists must develop communication with oncologists early during the start-up phase of a palliative care service. Hospitalists who offer palliative care services should also take time to familiarize themselves with patients’ treatment plans.

“I think there is going to be a learning curve for palliative care specialists,” says Dr. Lawson. “Part of that learning is to get some sense of how oncologists make decisions about whether to give chemo[therapy] or not. Oftentimes, there are pressures that might not be obvious.”

For instance, it may appear to a palliative care consultant that a certain patient should not undergo chemotherapy, but in fact the patient or the family may demand it.

Stephanie Grossman, MD, assistant professor of medicine and co-director of the Palliative Care Program for Emory University Hospital and Emory Crawford Long Hospital in Atlanta, says the majority of consults she does are with oncology patients. She has found that attending Monday morning sign-out meetings with Emory oncologists has not only increased referrals to the palliative care service, but has added to her understanding of oncologists’ decision-making processes.

“When I go to weekly meetings, I hear the full spectrum of what they are doing. I see how oncologists work and how they decide about treatments,” she says. “It’s been a really good experience because I never would have seen this from the hospitalist viewpoint.”

Emory’s palliative care program was launched in November 2005 and has grown so quickly that they already need additional staff.

The Primary Client

The “key message” for a hospitalist when asked to do a palliative care consult is to remember that the client of a consultation service is the referring physician, points out geriatrician Diane E. Meier, MD, director of the Center to Advance Palliative Care and the director of the Hertzberg Palliative Care Institute at Mount Sinai School of Medicine in New York City. “As a geriatrician, if I call in an infectious disease consultant, I’m calling that physician to help me make decisions about my patient—not for that person to take over the care of my patient or to undermine my relationship to that patient. This is basic consultation etiquette, but physicians are often not taught in medical school or residency the difference between a primary care responsibility and a consultation responsibility.”

“The biggest mistake that people make in putting together palliative care services,” concurs Dr. von Gunten, “is thinking that the patient is the client. That isn’t true. It is the person requesting the consultation—meaning, the referring physician or the managing service. The patient is the secondary beneficiary.

“The language we use—‘my patient’—is fundamental to the practice of American medicine,” explains Dr. von Gunten. You have to respect that. If you go to someone’s home, you don’t redecorate it because you don’t like their taste. You do not comment on their choice of draperies or their choice of food. The same applies to medical consultations.” (See “Consult Etiquette for Palliative Care Services,” p. 33.)

Oncologists generally feel “very possessive” about their patients, adds Dr. von Gunten. Even though oncologists are technically also consultants (to the patient’s primary care physician), the pattern in American medicine is that oncologists treating patients acquire the status of a primary care physician. “So,” he says, “you treat them with that kind of respect, which means that you ask permission before you do things, and you don’t disparage what they are doing—either to their faces or to their patients or to other bystanders like nurses.”

Dr. Lawson agrees that oncologists often have a strong personal bond with their patients. “These personal feelings are often reciprocated by the patients and families,” he says. “Accepting another person [the hospitalist as palliative care consultant] into the equation can be difficult at times, even more so while the patient is still in the hospital and the oncologist is still around.”

The palliative care program at Emory is consult-driven. “The doctor has to agree to us getting involved, so I don’t get into territorial issues,” says Dr. Grossman. “When I do get involved with patients, the oncologists welcome me taking care of them and realize the benefit of what I’m doing. They see that my approach is collaborative.”

Dr. Grossman has been able to offer services to oncologists whose patients are receiving chemotherapy and experiencing significant symptoms, such as pain. When hospitalists on the hospital medicine service consult her about cancer patients, she calls the primary oncologist to familiarize herself with the patient’s background and to check if other treatments are available.

Strengths of Hospitalists

Palliative care should be distinguished from hospice or end-of-life care, although it can be concurrent. Palliative care needs—ranging from symptom management to alleviating psychological suffering—can exist at any point along the cancer care trajectory, notes Dr. von Gunten, who was a co-developer with Dr. Pantilat and others of the California Hospital Initiative in Palliative Services program to assist hospitals to develop palliative services.4

Hospitalists, says Dr. von Gunten, already possess some of the baseline skills needed to deliver palliative care: They’re based in the hospital and so have the opportunity to interact with patients and their families; they are experienced in hospital-based management of patients; they are experienced in teamwork with other providers also based in the hospital. The ability to be available to patients and physicians 24/7 is a real advantage in symptom management, says Dr. Lawson.

Because hospitalists by definition care for people who are not their primary care patients, the sophistication and sensitivity about working with one’s colleagues “is already inculcated,” observes Dr. Meier. In addition, “hospitalists understand that their responsibility to and relationship with the patient is only one piece of being a good doctor. Ensuring good care for a patient means very high level and high intensity communications with everyone involved in that patient’s care: all the other specialists, the primary care physician, and the floor team—the social workers, nurses, certified nursing assistants, dietary staff, and rehab and physiatry staff. Unless everyone is reading from the same page, the patient’s care will not be good. Very often, it’s the hospitalist or palliative care consultant who is at the center of the wheel, making sure that all the spokes are getting the same message,” she says.

Busy oncologists may call upon Dr. Grossman’s service to conduct family meetings about care plans. “Patients are very loyal to their oncologists, and they want their oncologists to be supportive of their decisions,” she notes. “I always explain to patients that my consultation was requested or supported by their oncologist. I am not there to cause more barriers; I’m there to have everybody on board and to understand where the patient is. We call everybody in—the social worker, the nurse, chaplaincy staff—because our approach is interdisciplinary and these are the essential members of our team.”

Dr. Grossman believes that hospitalists’ training in teamwork and communications are key to providing a good experience for oncology patients and their families. She is board certified in palliative care, which allows her to bring additional expertise to symptom support, including situations where she can help the dying process be as peaceful as possible—for both patient and family.

The issues important in palliative care—availability to patients, families, and referring physicians, ability to work in teams, and quality of care—dovetail with the primary goals of hospital medicine. Hospitalists’ palliative care services can thrive when they forge strong foundational relationships with their referring colleagues. TH

Gretchen Henkel regularly contributes to The Hospitalist.

References

1. Selwyn PA, Rivard M, Kappell D, et al. Palliative care for AIDS at a large urban teaching hospital: program description and preliminary outcomes. J Palliat Med. 2003 Jun;6(3):461-474.
2. Ryan A, Carter J, Lucas J, Berger J. You need not make the journey alone: overcoming impediments to providing palliative care in a public urban teaching hospital. Am J Hosp Palliat Care. 2002 May-June;19(3):171-180.
3. The Case for Hospital-Based Palliative Care, published by the Center to Advance Palliative Care. Available online at: www.capc.org/building-a-hospital-based-palliative-care-program/case/support-from-capc/capc_publications/making-the-case.pdf. Last accessed March 22, 2006.
4. Pantilat SZ, Rabow MW, Citko J, et al. Evaluating the California Hospital Initiative in Palliative Services. Arch Intern Med. 2006 Jan 23;166(2):227-230.

Hospital-based palliative care programs are gaining traction in the United States as studies show their efficacy in decreasing length of stay and improved quality of patient care.1,2 According to the American Hospital Association, 22% of all U.S. hospitals now have such programs.3 These programs—with their emphasis on coordinated, team-delivered care and communication—seem tailor-made for the expertise of hospitalists who are increasingly taking the lead to establish them at their institutions.

Through the SHM Web site (www.hospitalmedicine.org) and the Center to Advance Palliative Care (www.capc.org) ample resources exist for developing program infrastructure and acquiring on-site training (see www.capc.org/palliative-care-leadershipinitiative/overview).

There are unwritten protocols, however, that can make or break a palliative care service. Hospitalists involved with palliative care often find themselves relating to oncologists because many patients who have palliative care needs are undergoing inpatient curative treatments (such as brachytherapy) or are actively dying. Palliative care experts interviewed for this article agreed that in order to encourage referrals from their oncology colleagues, hospitalists must be attentive to oncologists’ concerns and to consultation etiquette.

“Palliative care has been something that oncologists traditionally think they do pretty well,” says David H. Lawson, MD, section chief, Medical Oncology at Emory Clinic. “I think there will be a lot of variability between oncologists about what they see as their province and what they see as open for someone else.”

Assessing Oncologists’ Needs

During the organizational phase of a hospital-based palliative care service, it is advisable to meet with oncologists one-on-one, believes Charles F. von Gunten, MD, PhD, medical director of the Palliative Care Consultation Service at the University of California, San Diego, and director of the Center for Palliative Studies at San Diego Hospice and Palliative Care. “All consult services are fundamentally about providing advice to the managing physician when requested, about what is requested, and nothing else.”

He recommends that hospitalists involved in development of a hospital-based palliative care service find out how key oncologists at their hospital perceive the needs in the area of palliative care. “This may not match what the hospitalist thinks the oncologist needs, but that’s immaterial,” he cautions.

This advice squares with that of Steve Pantilat, MD, immediate past-president of SHM, and his team at the University of California, San Francisco. The palliative care service at UCSF is one of six Palliative Care Leadership Centers nationwide, so designated during an initiative launched two years ago by the Center to Advance Palliative Care. (The Robert Wood Johnson Foundation underwrites training activities at the six centers.) The issue in establishing palliative care services, says Dr. Pantilat, is “figuring out what would attract oncologists about such a program. What issues are most salient to them? Instead of saying, ‘I have a new service; would you please use it?’ You have to come in and say, ‘We’re thinking of starting this new service; how can we be of help to you?’ ”

Dr. Lawson agrees with Dr. von Gunten and Dr. Pantilat that hospitalists must develop communication with oncologists early during the start-up phase of a palliative care service. Hospitalists who offer palliative care services should also take time to familiarize themselves with patients’ treatment plans.

“I think there is going to be a learning curve for palliative care specialists,” says Dr. Lawson. “Part of that learning is to get some sense of how oncologists make decisions about whether to give chemo[therapy] or not. Oftentimes, there are pressures that might not be obvious.”

For instance, it may appear to a palliative care consultant that a certain patient should not undergo chemotherapy, but in fact the patient or the family may demand it.

Stephanie Grossman, MD, assistant professor of medicine and co-director of the Palliative Care Program for Emory University Hospital and Emory Crawford Long Hospital in Atlanta, says the majority of consults she does are with oncology patients. She has found that attending Monday morning sign-out meetings with Emory oncologists has not only increased referrals to the palliative care service, but has added to her understanding of oncologists’ decision-making processes.

“When I go to weekly meetings, I hear the full spectrum of what they are doing. I see how oncologists work and how they decide about treatments,” she says. “It’s been a really good experience because I never would have seen this from the hospitalist viewpoint.”

Emory’s palliative care program was launched in November 2005 and has grown so quickly that they already need additional staff.

The Primary Client

The “key message” for a hospitalist when asked to do a palliative care consult is to remember that the client of a consultation service is the referring physician, points out geriatrician Diane E. Meier, MD, director of the Center to Advance Palliative Care and the director of the Hertzberg Palliative Care Institute at Mount Sinai School of Medicine in New York City. “As a geriatrician, if I call in an infectious disease consultant, I’m calling that physician to help me make decisions about my patient—not for that person to take over the care of my patient or to undermine my relationship to that patient. This is basic consultation etiquette, but physicians are often not taught in medical school or residency the difference between a primary care responsibility and a consultation responsibility.”

“The biggest mistake that people make in putting together palliative care services,” concurs Dr. von Gunten, “is thinking that the patient is the client. That isn’t true. It is the person requesting the consultation—meaning, the referring physician or the managing service. The patient is the secondary beneficiary.

“The language we use—‘my patient’—is fundamental to the practice of American medicine,” explains Dr. von Gunten. You have to respect that. If you go to someone’s home, you don’t redecorate it because you don’t like their taste. You do not comment on their choice of draperies or their choice of food. The same applies to medical consultations.” (See “Consult Etiquette for Palliative Care Services,” p. 33.)

Oncologists generally feel “very possessive” about their patients, adds Dr. von Gunten. Even though oncologists are technically also consultants (to the patient’s primary care physician), the pattern in American medicine is that oncologists treating patients acquire the status of a primary care physician. “So,” he says, “you treat them with that kind of respect, which means that you ask permission before you do things, and you don’t disparage what they are doing—either to their faces or to their patients or to other bystanders like nurses.”

Dr. Lawson agrees that oncologists often have a strong personal bond with their patients. “These personal feelings are often reciprocated by the patients and families,” he says. “Accepting another person [the hospitalist as palliative care consultant] into the equation can be difficult at times, even more so while the patient is still in the hospital and the oncologist is still around.”

The palliative care program at Emory is consult-driven. “The doctor has to agree to us getting involved, so I don’t get into territorial issues,” says Dr. Grossman. “When I do get involved with patients, the oncologists welcome me taking care of them and realize the benefit of what I’m doing. They see that my approach is collaborative.”

Dr. Grossman has been able to offer services to oncologists whose patients are receiving chemotherapy and experiencing significant symptoms, such as pain. When hospitalists on the hospital medicine service consult her about cancer patients, she calls the primary oncologist to familiarize herself with the patient’s background and to check if other treatments are available.

Strengths of Hospitalists

Palliative care should be distinguished from hospice or end-of-life care, although it can be concurrent. Palliative care needs—ranging from symptom management to alleviating psychological suffering—can exist at any point along the cancer care trajectory, notes Dr. von Gunten, who was a co-developer with Dr. Pantilat and others of the California Hospital Initiative in Palliative Services program to assist hospitals to develop palliative services.4

Hospitalists, says Dr. von Gunten, already possess some of the baseline skills needed to deliver palliative care: They’re based in the hospital and so have the opportunity to interact with patients and their families; they are experienced in hospital-based management of patients; they are experienced in teamwork with other providers also based in the hospital. The ability to be available to patients and physicians 24/7 is a real advantage in symptom management, says Dr. Lawson.

Because hospitalists by definition care for people who are not their primary care patients, the sophistication and sensitivity about working with one’s colleagues “is already inculcated,” observes Dr. Meier. In addition, “hospitalists understand that their responsibility to and relationship with the patient is only one piece of being a good doctor. Ensuring good care for a patient means very high level and high intensity communications with everyone involved in that patient’s care: all the other specialists, the primary care physician, and the floor team—the social workers, nurses, certified nursing assistants, dietary staff, and rehab and physiatry staff. Unless everyone is reading from the same page, the patient’s care will not be good. Very often, it’s the hospitalist or palliative care consultant who is at the center of the wheel, making sure that all the spokes are getting the same message,” she says.

Busy oncologists may call upon Dr. Grossman’s service to conduct family meetings about care plans. “Patients are very loyal to their oncologists, and they want their oncologists to be supportive of their decisions,” she notes. “I always explain to patients that my consultation was requested or supported by their oncologist. I am not there to cause more barriers; I’m there to have everybody on board and to understand where the patient is. We call everybody in—the social worker, the nurse, chaplaincy staff—because our approach is interdisciplinary and these are the essential members of our team.”

Dr. Grossman believes that hospitalists’ training in teamwork and communications are key to providing a good experience for oncology patients and their families. She is board certified in palliative care, which allows her to bring additional expertise to symptom support, including situations where she can help the dying process be as peaceful as possible—for both patient and family.

The issues important in palliative care—availability to patients, families, and referring physicians, ability to work in teams, and quality of care—dovetail with the primary goals of hospital medicine. Hospitalists’ palliative care services can thrive when they forge strong foundational relationships with their referring colleagues. TH

Gretchen Henkel regularly contributes to The Hospitalist.

References

1. Selwyn PA, Rivard M, Kappell D, et al. Palliative care for AIDS at a large urban teaching hospital: program description and preliminary outcomes. J Palliat Med. 2003 Jun;6(3):461-474.
2. Ryan A, Carter J, Lucas J, Berger J. You need not make the journey alone: overcoming impediments to providing palliative care in a public urban teaching hospital. Am J Hosp Palliat Care. 2002 May-June;19(3):171-180.
3. The Case for Hospital-Based Palliative Care, published by the Center to Advance Palliative Care. Available online at: www.capc.org/building-a-hospital-based-palliative-care-program/case/support-from-capc/capc_publications/making-the-case.pdf. Last accessed March 22, 2006.
4. Pantilat SZ, Rabow MW, Citko J, et al. Evaluating the California Hospital Initiative in Palliative Services. Arch Intern Med. 2006 Jan 23;166(2):227-230.

Hospitalists are playing an increasingly bigger role in our state—Mississippi’s—hospitals. And that role became even more important during preparation for Hurricane Katrina. Many hospitalists in the coastal area came to their hospitals before the storm hit to be on call for other doctors who were unable to make it to the facility during the severe weather conditions. After the storm, hospitalists were also key to community recovery efforts.

Practicing medicine is difficult enough without any kind of communication with the outside world, with only limited supplies of drinking water and no water pressure, with nowhere to discharge patients, and an increasingly steady stream of patients coming in. But it’s even more difficult to do that when you are worrying about your own family’s safety. And that is what many Mississippi hospitalists were faced with during Hurricane Katrina and its aftermath.

After the storm, hospital employees were faced with trying to pick up the pieces of their personal lives and taking care of patients at the same time. Employees without homes have contributed to hospital staffing problems in some areas. For example, 65% of the staff of Biloxi Regional Medical Center (BRMC) in Biloxi and 50% of physicians completely lost their houses and all of their personal effects. As of Dec. 1, 2005, BRMC had lost 82 staff due to their struggles dealing with these losses. For those who lost homes, housing is a big issue—second only to those who had children in school and who are trying to get them through the school year without a hitch.

The medical infrastructure in the six Mississippi counties hardest hit by Hurricane Katrina is slowly recovering. Information and Quality Healthcare (IQH), the state’s Medicare quality improvement organization, was charged with keeping track of the progress of the healthcare community in Mississippi after the storm. They reported in December 2005 that about 60% of the 775 clinics and medical practices along the Mississippi Gulf Coast were fully operational and about 80% of the area’s physicians were back on the job. Almost 70 other clinics or medical practices were either partially operational or doing business from a temporary location, leaving 10 that will not rebuild. The status of another 160 or so was uncertain because the agency was unable to contact them.

IQH conducted a survey showing that 36% of primary-care clinics in the lower six counties of the state were either destroyed or closed in the wake of the hurricane. But the region has rebounded, and IQH estimates that about eight in 10 doctors are now back on the job. All 14 hospitals in the region, including specialty facilities, have reopened. Three acute-care hospitals, including 104-bed Hancock Medical Center (HMC), were forced to close temporarily.

Located in Bay St. Louis where the eye of Hurricane Katrina came ashore, HMC was the hardest hit of our facilities and was severely affected by the strong storm surge. Its emergency department reopened on Oct. 5, and hospital beds were available by Oct. 28. By December, diagnostic services were being offered once again. As of early December, Hancock Medical Center had 100 on staff, compared with 495 staff members before the storm.

According to IQH, many physicians have remained in Mississippi. The physicians—and the whole state—have been fairly resilient. A lot of physicians are in temporary locations. Some have found temporary offices or are working closely with hospital medical staffs. Hospitals have provided temporary locations. But the hospitals on the coast have rebounded well.

As a hospital association, we were very busy in response to the multitude of needs after the storm hit. We had two staff members at the Mississippi Department of Health’s Emergency Operations Center during the hurricane, and they worked together with other staff to outline and coordinate hospital and community health needs after the hurricane. We helped coordinate national efforts to get needed supplies and donations to our hospitals statewide.

Working in conjunction with the American Hospital Association, the Alabama Hospital Association, and the Louisiana Hospital Association, we created a tri-state care fund to accept donations to assist hospital employees who had lost everything during the hurricane. This fund collected more than $3 million for hospital employees affected by Hurricane Katrina. More information can be found at www.mhacares.com.

Because our hospitals needed to receive Katrina-related information quickly, we also set up a “Hurricane Katrina Information for Hospitals” blog right after the hurricane and still post relevant information to it today. You can view it at http://mhanewsnow.typepad.com/katrina.

With things slowly getting back to normal, we understand that the mental health of our hospital employees and the community will be an ongoing concern. Though Hurricane Katrina dealt a terrible blow to our state’s hospitals, it also brought us all together to work for a common cause: our patients. I was never more proud to be a part of the healthcare community in our state. It reminded me once again that together we can—and do—make a difference. TH

Sam Cameron is CEO of the Mississippi Hospital Association.

Hospitalists are playing an increasingly bigger role in our state—Mississippi’s—hospitals. And that role became even more important during preparation for Hurricane Katrina. Many hospitalists in the coastal area came to their hospitals before the storm hit to be on call for other doctors who were unable to make it to the facility during the severe weather conditions. After the storm, hospitalists were also key to community recovery efforts.

Practicing medicine is difficult enough without any kind of communication with the outside world, with only limited supplies of drinking water and no water pressure, with nowhere to discharge patients, and an increasingly steady stream of patients coming in. But it’s even more difficult to do that when you are worrying about your own family’s safety. And that is what many Mississippi hospitalists were faced with during Hurricane Katrina and its aftermath.

After the storm, hospital employees were faced with trying to pick up the pieces of their personal lives and taking care of patients at the same time. Employees without homes have contributed to hospital staffing problems in some areas. For example, 65% of the staff of Biloxi Regional Medical Center (BRMC) in Biloxi and 50% of physicians completely lost their houses and all of their personal effects. As of Dec. 1, 2005, BRMC had lost 82 staff due to their struggles dealing with these losses. For those who lost homes, housing is a big issue—second only to those who had children in school and who are trying to get them through the school year without a hitch.

The medical infrastructure in the six Mississippi counties hardest hit by Hurricane Katrina is slowly recovering. Information and Quality Healthcare (IQH), the state’s Medicare quality improvement organization, was charged with keeping track of the progress of the healthcare community in Mississippi after the storm. They reported in December 2005 that about 60% of the 775 clinics and medical practices along the Mississippi Gulf Coast were fully operational and about 80% of the area’s physicians were back on the job. Almost 70 other clinics or medical practices were either partially operational or doing business from a temporary location, leaving 10 that will not rebuild. The status of another 160 or so was uncertain because the agency was unable to contact them.

IQH conducted a survey showing that 36% of primary-care clinics in the lower six counties of the state were either destroyed or closed in the wake of the hurricane. But the region has rebounded, and IQH estimates that about eight in 10 doctors are now back on the job. All 14 hospitals in the region, including specialty facilities, have reopened. Three acute-care hospitals, including 104-bed Hancock Medical Center (HMC), were forced to close temporarily.

Located in Bay St. Louis where the eye of Hurricane Katrina came ashore, HMC was the hardest hit of our facilities and was severely affected by the strong storm surge. Its emergency department reopened on Oct. 5, and hospital beds were available by Oct. 28. By December, diagnostic services were being offered once again. As of early December, Hancock Medical Center had 100 on staff, compared with 495 staff members before the storm.

According to IQH, many physicians have remained in Mississippi. The physicians—and the whole state—have been fairly resilient. A lot of physicians are in temporary locations. Some have found temporary offices or are working closely with hospital medical staffs. Hospitals have provided temporary locations. But the hospitals on the coast have rebounded well.

As a hospital association, we were very busy in response to the multitude of needs after the storm hit. We had two staff members at the Mississippi Department of Health’s Emergency Operations Center during the hurricane, and they worked together with other staff to outline and coordinate hospital and community health needs after the hurricane. We helped coordinate national efforts to get needed supplies and donations to our hospitals statewide.

Working in conjunction with the American Hospital Association, the Alabama Hospital Association, and the Louisiana Hospital Association, we created a tri-state care fund to accept donations to assist hospital employees who had lost everything during the hurricane. This fund collected more than $3 million for hospital employees affected by Hurricane Katrina. More information can be found at www.mhacares.com.

Because our hospitals needed to receive Katrina-related information quickly, we also set up a “Hurricane Katrina Information for Hospitals” blog right after the hurricane and still post relevant information to it today. You can view it at http://mhanewsnow.typepad.com/katrina.

With things slowly getting back to normal, we understand that the mental health of our hospital employees and the community will be an ongoing concern. Though Hurricane Katrina dealt a terrible blow to our state’s hospitals, it also brought us all together to work for a common cause: our patients. I was never more proud to be a part of the healthcare community in our state. It reminded me once again that together we can—and do—make a difference. TH

Sam Cameron is CEO of the Mississippi Hospital Association.

Hospitalists are playing an increasingly bigger role in our state—Mississippi’s—hospitals. And that role became even more important during preparation for Hurricane Katrina. Many hospitalists in the coastal area came to their hospitals before the storm hit to be on call for other doctors who were unable to make it to the facility during the severe weather conditions. After the storm, hospitalists were also key to community recovery efforts.

Practicing medicine is difficult enough without any kind of communication with the outside world, with only limited supplies of drinking water and no water pressure, with nowhere to discharge patients, and an increasingly steady stream of patients coming in. But it’s even more difficult to do that when you are worrying about your own family’s safety. And that is what many Mississippi hospitalists were faced with during Hurricane Katrina and its aftermath.

After the storm, hospital employees were faced with trying to pick up the pieces of their personal lives and taking care of patients at the same time. Employees without homes have contributed to hospital staffing problems in some areas. For example, 65% of the staff of Biloxi Regional Medical Center (BRMC) in Biloxi and 50% of physicians completely lost their houses and all of their personal effects. As of Dec. 1, 2005, BRMC had lost 82 staff due to their struggles dealing with these losses. For those who lost homes, housing is a big issue—second only to those who had children in school and who are trying to get them through the school year without a hitch.

The medical infrastructure in the six Mississippi counties hardest hit by Hurricane Katrina is slowly recovering. Information and Quality Healthcare (IQH), the state’s Medicare quality improvement organization, was charged with keeping track of the progress of the healthcare community in Mississippi after the storm. They reported in December 2005 that about 60% of the 775 clinics and medical practices along the Mississippi Gulf Coast were fully operational and about 80% of the area’s physicians were back on the job. Almost 70 other clinics or medical practices were either partially operational or doing business from a temporary location, leaving 10 that will not rebuild. The status of another 160 or so was uncertain because the agency was unable to contact them.

IQH conducted a survey showing that 36% of primary-care clinics in the lower six counties of the state were either destroyed or closed in the wake of the hurricane. But the region has rebounded, and IQH estimates that about eight in 10 doctors are now back on the job. All 14 hospitals in the region, including specialty facilities, have reopened. Three acute-care hospitals, including 104-bed Hancock Medical Center (HMC), were forced to close temporarily.

Located in Bay St. Louis where the eye of Hurricane Katrina came ashore, HMC was the hardest hit of our facilities and was severely affected by the strong storm surge. Its emergency department reopened on Oct. 5, and hospital beds were available by Oct. 28. By December, diagnostic services were being offered once again. As of early December, Hancock Medical Center had 100 on staff, compared with 495 staff members before the storm.

According to IQH, many physicians have remained in Mississippi. The physicians—and the whole state—have been fairly resilient. A lot of physicians are in temporary locations. Some have found temporary offices or are working closely with hospital medical staffs. Hospitals have provided temporary locations. But the hospitals on the coast have rebounded well.

As a hospital association, we were very busy in response to the multitude of needs after the storm hit. We had two staff members at the Mississippi Department of Health’s Emergency Operations Center during the hurricane, and they worked together with other staff to outline and coordinate hospital and community health needs after the hurricane. We helped coordinate national efforts to get needed supplies and donations to our hospitals statewide.

Working in conjunction with the American Hospital Association, the Alabama Hospital Association, and the Louisiana Hospital Association, we created a tri-state care fund to accept donations to assist hospital employees who had lost everything during the hurricane. This fund collected more than $3 million for hospital employees affected by Hurricane Katrina. More information can be found at www.mhacares.com.

Because our hospitals needed to receive Katrina-related information quickly, we also set up a “Hurricane Katrina Information for Hospitals” blog right after the hurricane and still post relevant information to it today. You can view it at http://mhanewsnow.typepad.com/katrina.

With things slowly getting back to normal, we understand that the mental health of our hospital employees and the community will be an ongoing concern. Though Hurricane Katrina dealt a terrible blow to our state’s hospitals, it also brought us all together to work for a common cause: our patients. I was never more proud to be a part of the healthcare community in our state. It reminded me once again that together we can—and do—make a difference. TH

Sam Cameron is CEO of the Mississippi Hospital Association.

In the last installment of this series, we introduced the concept of critical appraisal of the statistical methods used in a paper. The statistical analysis in a study is often the final barrier between the study’s results and application of those results to patient care, so making sure that the findings have been properly evaluated is of obvious importance.

We have previously discussed P values and confidence intervals—two of the most common statistical outcomes upon which clinical decisions are based. In this segment, we will discuss several specific issues that can help a reader decide how much faith to place in a study’s results.

Test Assumptions

Statistical tests generally require that a variety of assumptions be satisfied for the test procedure to be valid. These assumptions vary from test to test, and unfortunately most computer packages do not ask users whether they want to examine these assumptions more closely. This is one of the dangers of “black box” analysis, when researchers with little statistical training run their data through a statistical package without fully understanding how the output is generated.

Many statistical tests are based on the theory of the bell curve, or normal distribution. These tests require a large enough sample size, usually at least 30 subjects per group and sometimes much greater, for this theory to hold. In addition, the data should not be skewed excessively. For example, consider a study comparing two treatments for mild pain for which scores on a continuous 0-10 visual analog scale are expected to be between 0 and 2. Because of the asymmetry of the data, an underlying bell curve isn’t likely to make much sense. Therefore, a two-sample t-test may not be appropriate for this study even with two large samples.

Another commonly violated assumption is that the two groups being compared may need to be independent. The simplest case occurs when the same subjects are measured before and after a procedure. A two-sample statistical test is not appropriate here because the two groups are actually the same, and therefore clearly not independent. In this case, a paired analysis is required. The issue of independence becomes more complicated when we consider tests of multiple variables that may be related to one another, or studies of effects over time. In these instances, additional expertise in selecting the correct analysis approach is usually needed.

The best way to ensure that these assumptions and the many others required for valid statistical testing are met is to plan your analyses with the help of a trained statistician. If this is not an option, it is incumbent upon the researcher to learn about these assumptions and evaluate their study to make sure the appropriate methods are applied.

Negative Study Results

A more straightforward issue concerns interpretation of negative study results. Most clinicians are familiar with statistical power: A small study may yield a negative finding because this is the correct result or because there is not enough power to discern a difference between the groups being tested. Often, the width of the confidence interval provides insight into this problem. If the confidence interval includes a difference that would be clinically meaningful, a negative study should be viewed skeptically. In such cases, a larger study or a meta-analysis may be needed to better address the question. If, on the other hand, the confidence interval suggests that no clinically relevant result is likely, the negative study finding becomes more compelling.

Multiple Statistical Tests

When we perform a statistical test and set the level of significance at 0.05, we are acknowledging a 5% chance that if the null hypothesis were in fact true we would nonetheless falsely reject it with our test. Turned around, this loosely means a 95% chance of “getting it right,” subject to the limitations of P value interpretation described in the previous segment of this series. This seems reasonable for a single test, but what about the typical research study in which dozens of statistical tests are run? For two independent tests, the chance of “getting it right” in both cases would be 0.95 x 0.95 = 90%. For 20 tests, this probability would be only 36%, meaning a more than 50% chance of drawing at least one false conclusion. The trouble is that there is no way to know which of the 20 tests might have yielded a wrong conclusion!

To address this issue, researchers may set their initial level of significance at a stricter level—perhaps 0.01. There are also mathematical ways to adjust the level of significance to help with multiple comparisons. The key point is that the more tests you run, the more chances you have to draw a false conclusion. Neither you nor your patients can know when this occurs, though. The same arguments apply to subgroup analyses and data-driven, or post hoc, analyses. Such analyses should be regarded as hypothesis-generating rather than hypothesis-testing, and any findings from these analyses should be evaluated more directly by additional research.

Sensitivity Analysis

A rarely considered aspect of study interpretation is whether the results would change if only a few data points changed. Studies with rare events and wide confidence intervals are often sensitive to a change in even one data point. For example, a study published in 2000 by Kernan, et al., presented a statistically significant finding of increased risk of hemorrhagic stroke in women using appetite suppressants containing phenylpropanolamine. This result was based on six cases and one control, with an unadjusted odds ratio of 11.9 (95% CI, 1.4-99.4).

Shifting just one patient who had used phenylpropanolamine from the case group to the control group would change the odds ratio to 5.0, with a nonsignificant CI of 0.9-25.8. Such an analysis should make readers question how quickly they wish to apply the study results to their own patients, especially if the benefits of the drug are significant. A result that is sensitive to small changes in the study population is probably not stable enough to warrant application to the entire patient population.

Back to the Common-Sense Test

An excellent way to judge whether a study’s results should be believed is to step back and consider whether they make sense based on current scientific knowledge. If they do not, either the study represents a breakthrough in our understanding of disease or the study’s results are flawed. Remember, if the prevalence of a disease is very low, even a positive diagnostic test with high sensitivity and specificity is likely to be a false positive. Similarly, a small P value may represent a false result if the hypothesis being tested does not meet standard epidemiologic criteria for causality such as biological plausibility. Statistics are primarily a tool to help us make sense of complex study data. They can often suggest when new theories should be evaluated, but they should not determine by themselves which results we apply to patient care.

Series Conclusion

This series has been intended as a brief introduction to many different facets of evidence-based medicine. The primary message of evidence-based medicine is that critical assessment of every aspect of research is necessary to ensure that we make the best possible decisions for our patients. Understanding the important concepts in study design and analysis may seem daunting, but this effort is made worthwhile every time we positively affect patient care.

Hospitalists are uniquely situated at the interface of internal medicine and essentially every other area of medicine and because of this have a tremendous opportunity to broadly impact patient care. My hope is that evidence-based medicine-savvy hospitalists will capitalize on this for the benefit of our patients, will play a prominent role in educating future clinicians on the importance of evidence-based medicine, and will use it to lead the next wave of patient care advances. TH

Dr. West practices in the Division of General Internal Medicine, Mayo Clinic College of Medicine, Rochester, Minn.

References

• Greenhalgh T. How to read a paper. Statistics for the non-statistician. I: Different types of data need different statistical tests. BMJ. 1997;315:364-366.
• Greenhalgh T. How to read a paper. Statistics for the non-statistician. II: “Significant” relations and their pitfalls. BMJ. 1997;315:422-425.
• Guyatt G and Rennie D, eds. Users’ guides to the medical literature. Chicago: AMA Press; 2002.
• Kernan WN, Viscoli CM, Brass LM, et al. Phenylpropanolamine and the risk of hemorrhagic stroke. N Engl J Med. 2000;343:1826-1832.

In the last installment of this series, we introduced the concept of critical appraisal of the statistical methods used in a paper. The statistical analysis in a study is often the final barrier between the study’s results and application of those results to patient care, so making sure that the findings have been properly evaluated is of obvious importance.

We have previously discussed P values and confidence intervals—two of the most common statistical outcomes upon which clinical decisions are based. In this segment, we will discuss several specific issues that can help a reader decide how much faith to place in a study’s results.

Test Assumptions

Statistical tests generally require that a variety of assumptions be satisfied for the test procedure to be valid. These assumptions vary from test to test, and unfortunately most computer packages do not ask users whether they want to examine these assumptions more closely. This is one of the dangers of “black box” analysis, when researchers with little statistical training run their data through a statistical package without fully understanding how the output is generated.

Many statistical tests are based on the theory of the bell curve, or normal distribution. These tests require a large enough sample size, usually at least 30 subjects per group and sometimes much greater, for this theory to hold. In addition, the data should not be skewed excessively. For example, consider a study comparing two treatments for mild pain for which scores on a continuous 0-10 visual analog scale are expected to be between 0 and 2. Because of the asymmetry of the data, an underlying bell curve isn’t likely to make much sense. Therefore, a two-sample t-test may not be appropriate for this study even with two large samples.

Another commonly violated assumption is that the two groups being compared may need to be independent. The simplest case occurs when the same subjects are measured before and after a procedure. A two-sample statistical test is not appropriate here because the two groups are actually the same, and therefore clearly not independent. In this case, a paired analysis is required. The issue of independence becomes more complicated when we consider tests of multiple variables that may be related to one another, or studies of effects over time. In these instances, additional expertise in selecting the correct analysis approach is usually needed.

The best way to ensure that these assumptions and the many others required for valid statistical testing are met is to plan your analyses with the help of a trained statistician. If this is not an option, it is incumbent upon the researcher to learn about these assumptions and evaluate their study to make sure the appropriate methods are applied.

Negative Study Results

A more straightforward issue concerns interpretation of negative study results. Most clinicians are familiar with statistical power: A small study may yield a negative finding because this is the correct result or because there is not enough power to discern a difference between the groups being tested. Often, the width of the confidence interval provides insight into this problem. If the confidence interval includes a difference that would be clinically meaningful, a negative study should be viewed skeptically. In such cases, a larger study or a meta-analysis may be needed to better address the question. If, on the other hand, the confidence interval suggests that no clinically relevant result is likely, the negative study finding becomes more compelling.

Multiple Statistical Tests

When we perform a statistical test and set the level of significance at 0.05, we are acknowledging a 5% chance that if the null hypothesis were in fact true we would nonetheless falsely reject it with our test. Turned around, this loosely means a 95% chance of “getting it right,” subject to the limitations of P value interpretation described in the previous segment of this series. This seems reasonable for a single test, but what about the typical research study in which dozens of statistical tests are run? For two independent tests, the chance of “getting it right” in both cases would be 0.95 x 0.95 = 90%. For 20 tests, this probability would be only 36%, meaning a more than 50% chance of drawing at least one false conclusion. The trouble is that there is no way to know which of the 20 tests might have yielded a wrong conclusion!

To address this issue, researchers may set their initial level of significance at a stricter level—perhaps 0.01. There are also mathematical ways to adjust the level of significance to help with multiple comparisons. The key point is that the more tests you run, the more chances you have to draw a false conclusion. Neither you nor your patients can know when this occurs, though. The same arguments apply to subgroup analyses and data-driven, or post hoc, analyses. Such analyses should be regarded as hypothesis-generating rather than hypothesis-testing, and any findings from these analyses should be evaluated more directly by additional research.

Sensitivity Analysis

A rarely considered aspect of study interpretation is whether the results would change if only a few data points changed. Studies with rare events and wide confidence intervals are often sensitive to a change in even one data point. For example, a study published in 2000 by Kernan, et al., presented a statistically significant finding of increased risk of hemorrhagic stroke in women using appetite suppressants containing phenylpropanolamine. This result was based on six cases and one control, with an unadjusted odds ratio of 11.9 (95% CI, 1.4-99.4).

Shifting just one patient who had used phenylpropanolamine from the case group to the control group would change the odds ratio to 5.0, with a nonsignificant CI of 0.9-25.8. Such an analysis should make readers question how quickly they wish to apply the study results to their own patients, especially if the benefits of the drug are significant. A result that is sensitive to small changes in the study population is probably not stable enough to warrant application to the entire patient population.

Back to the Common-Sense Test

An excellent way to judge whether a study’s results should be believed is to step back and consider whether they make sense based on current scientific knowledge. If they do not, either the study represents a breakthrough in our understanding of disease or the study’s results are flawed. Remember, if the prevalence of a disease is very low, even a positive diagnostic test with high sensitivity and specificity is likely to be a false positive. Similarly, a small P value may represent a false result if the hypothesis being tested does not meet standard epidemiologic criteria for causality such as biological plausibility. Statistics are primarily a tool to help us make sense of complex study data. They can often suggest when new theories should be evaluated, but they should not determine by themselves which results we apply to patient care.

Series Conclusion

This series has been intended as a brief introduction to many different facets of evidence-based medicine. The primary message of evidence-based medicine is that critical assessment of every aspect of research is necessary to ensure that we make the best possible decisions for our patients. Understanding the important concepts in study design and analysis may seem daunting, but this effort is made worthwhile every time we positively affect patient care.

Hospitalists are uniquely situated at the interface of internal medicine and essentially every other area of medicine and because of this have a tremendous opportunity to broadly impact patient care. My hope is that evidence-based medicine-savvy hospitalists will capitalize on this for the benefit of our patients, will play a prominent role in educating future clinicians on the importance of evidence-based medicine, and will use it to lead the next wave of patient care advances. TH

Dr. West practices in the Division of General Internal Medicine, Mayo Clinic College of Medicine, Rochester, Minn.

References

• Greenhalgh T. How to read a paper. Statistics for the non-statistician. I: Different types of data need different statistical tests. BMJ. 1997;315:364-366.
• Greenhalgh T. How to read a paper. Statistics for the non-statistician. II: “Significant” relations and their pitfalls. BMJ. 1997;315:422-425.
• Guyatt G and Rennie D, eds. Users’ guides to the medical literature. Chicago: AMA Press; 2002.
• Kernan WN, Viscoli CM, Brass LM, et al. Phenylpropanolamine and the risk of hemorrhagic stroke. N Engl J Med. 2000;343:1826-1832.

In the last installment of this series, we introduced the concept of critical appraisal of the statistical methods used in a paper. The statistical analysis in a study is often the final barrier between the study’s results and application of those results to patient care, so making sure that the findings have been properly evaluated is of obvious importance.

We have previously discussed P values and confidence intervals—two of the most common statistical outcomes upon which clinical decisions are based. In this segment, we will discuss several specific issues that can help a reader decide how much faith to place in a study’s results.

Test Assumptions

Statistical tests generally require that a variety of assumptions be satisfied for the test procedure to be valid. These assumptions vary from test to test, and unfortunately most computer packages do not ask users whether they want to examine these assumptions more closely. This is one of the dangers of “black box” analysis, when researchers with little statistical training run their data through a statistical package without fully understanding how the output is generated.

Many statistical tests are based on the theory of the bell curve, or normal distribution. These tests require a large enough sample size, usually at least 30 subjects per group and sometimes much greater, for this theory to hold. In addition, the data should not be skewed excessively. For example, consider a study comparing two treatments for mild pain for which scores on a continuous 0-10 visual analog scale are expected to be between 0 and 2. Because of the asymmetry of the data, an underlying bell curve isn’t likely to make much sense. Therefore, a two-sample t-test may not be appropriate for this study even with two large samples.

Another commonly violated assumption is that the two groups being compared may need to be independent. The simplest case occurs when the same subjects are measured before and after a procedure. A two-sample statistical test is not appropriate here because the two groups are actually the same, and therefore clearly not independent. In this case, a paired analysis is required. The issue of independence becomes more complicated when we consider tests of multiple variables that may be related to one another, or studies of effects over time. In these instances, additional expertise in selecting the correct analysis approach is usually needed.

The best way to ensure that these assumptions and the many others required for valid statistical testing are met is to plan your analyses with the help of a trained statistician. If this is not an option, it is incumbent upon the researcher to learn about these assumptions and evaluate their study to make sure the appropriate methods are applied.

Negative Study Results

A more straightforward issue concerns interpretation of negative study results. Most clinicians are familiar with statistical power: A small study may yield a negative finding because this is the correct result or because there is not enough power to discern a difference between the groups being tested. Often, the width of the confidence interval provides insight into this problem. If the confidence interval includes a difference that would be clinically meaningful, a negative study should be viewed skeptically. In such cases, a larger study or a meta-analysis may be needed to better address the question. If, on the other hand, the confidence interval suggests that no clinically relevant result is likely, the negative study finding becomes more compelling.

Multiple Statistical Tests

When we perform a statistical test and set the level of significance at 0.05, we are acknowledging a 5% chance that if the null hypothesis were in fact true we would nonetheless falsely reject it with our test. Turned around, this loosely means a 95% chance of “getting it right,” subject to the limitations of P value interpretation described in the previous segment of this series. This seems reasonable for a single test, but what about the typical research study in which dozens of statistical tests are run? For two independent tests, the chance of “getting it right” in both cases would be 0.95 x 0.95 = 90%. For 20 tests, this probability would be only 36%, meaning a more than 50% chance of drawing at least one false conclusion. The trouble is that there is no way to know which of the 20 tests might have yielded a wrong conclusion!

To address this issue, researchers may set their initial level of significance at a stricter level—perhaps 0.01. There are also mathematical ways to adjust the level of significance to help with multiple comparisons. The key point is that the more tests you run, the more chances you have to draw a false conclusion. Neither you nor your patients can know when this occurs, though. The same arguments apply to subgroup analyses and data-driven, or post hoc, analyses. Such analyses should be regarded as hypothesis-generating rather than hypothesis-testing, and any findings from these analyses should be evaluated more directly by additional research.

Sensitivity Analysis

A rarely considered aspect of study interpretation is whether the results would change if only a few data points changed. Studies with rare events and wide confidence intervals are often sensitive to a change in even one data point. For example, a study published in 2000 by Kernan, et al., presented a statistically significant finding of increased risk of hemorrhagic stroke in women using appetite suppressants containing phenylpropanolamine. This result was based on six cases and one control, with an unadjusted odds ratio of 11.9 (95% CI, 1.4-99.4).

Shifting just one patient who had used phenylpropanolamine from the case group to the control group would change the odds ratio to 5.0, with a nonsignificant CI of 0.9-25.8. Such an analysis should make readers question how quickly they wish to apply the study results to their own patients, especially if the benefits of the drug are significant. A result that is sensitive to small changes in the study population is probably not stable enough to warrant application to the entire patient population.

Back to the Common-Sense Test

An excellent way to judge whether a study’s results should be believed is to step back and consider whether they make sense based on current scientific knowledge. If they do not, either the study represents a breakthrough in our understanding of disease or the study’s results are flawed. Remember, if the prevalence of a disease is very low, even a positive diagnostic test with high sensitivity and specificity is likely to be a false positive. Similarly, a small P value may represent a false result if the hypothesis being tested does not meet standard epidemiologic criteria for causality such as biological plausibility. Statistics are primarily a tool to help us make sense of complex study data. They can often suggest when new theories should be evaluated, but they should not determine by themselves which results we apply to patient care.

Series Conclusion

This series has been intended as a brief introduction to many different facets of evidence-based medicine. The primary message of evidence-based medicine is that critical assessment of every aspect of research is necessary to ensure that we make the best possible decisions for our patients. Understanding the important concepts in study design and analysis may seem daunting, but this effort is made worthwhile every time we positively affect patient care.

Hospitalists are uniquely situated at the interface of internal medicine and essentially every other area of medicine and because of this have a tremendous opportunity to broadly impact patient care. My hope is that evidence-based medicine-savvy hospitalists will capitalize on this for the benefit of our patients, will play a prominent role in educating future clinicians on the importance of evidence-based medicine, and will use it to lead the next wave of patient care advances. TH

Dr. West practices in the Division of General Internal Medicine, Mayo Clinic College of Medicine, Rochester, Minn.

References

• Greenhalgh T. How to read a paper. Statistics for the non-statistician. I: Different types of data need different statistical tests. BMJ. 1997;315:364-366.
• Greenhalgh T. How to read a paper. Statistics for the non-statistician. II: “Significant” relations and their pitfalls. BMJ. 1997;315:422-425.
• Guyatt G and Rennie D, eds. Users’ guides to the medical literature. Chicago: AMA Press; 2002.
• Kernan WN, Viscoli CM, Brass LM, et al. Phenylpropanolamine and the risk of hemorrhagic stroke. N Engl J Med. 2000;343:1826-1832.

Spend time with hospitalists and their competitive natures readily emerge. Striving for excellence in clinical care, hospital efficiency, and patient satisfaction, they are their hospitals’ beacons for attracting patients from referring physicians. As hospitalists’ capabilities grow, they hone pathways and procedures, improving their hospitals over time. What would happen if those hospitalists systematically shared their collective knowledge?

That’s what’s happening for hospitalists from nine health systems in southeast Michigan. Transcending their individual pursuits of excellence, they have united as Hospitalists as Emerging Leaders in Patient Safety (HELPS), a unique two-year consortium to improve patient safety regionally. Through large and small group meetings, HELPS is defining and tackling paramount patient safety issues, and collecting and sharing data about what works best.

A $117,000 grant from the Blue Cross/Blue Shield Foundation of Michigan awarded in 2005 to the University of Michigan Health Systems (UMHS) spurred the regional collaboration. Co-principal Investigator Scott Flanders, MD, UMHS’ chief of the hospitalist service and an SHM board member, conceived the project several years ago.

“What galvanized me is when I realized that we are a relatively small number of hospitalists overseeing a large number of patients—between 80,000 to 85,000 admissions annually,” he explains. “Those numbers indicated that we need to share our knowledge, treatment guidelines, and processes if we are to significantly improve patient safety.

“I assumed that many hospitalist groups wanted to improve patient safety,” continues Dr. Flanders. “But we were all working in isolation and were too busy caring for our patients to take the time to collaborate with colleagues in other programs.”

Dr. Flanders and HELPS’ other co-principal investigator, Sanjay Saint, MD, MPH, a hospitalist who heads UMHS’ Patient Safety Enhancement Program, were willing to spearhead a regional patient safety initiative with input from fellow hospitalists and patient safety officers. The Blue Cross/Blue Shield Foundation grant allowed the hospitalists to meet face-to-face periodically, target patient safety concerns, share hospitalist medicine group initiatives, collect data, and disseminate findings and best practices among the participants.

Dr. Saint and his colleagues provided one template for change. By using reminders and automatic order sets to prompt doctors to remove urinary catheters in a timely manner and by using anti-bacterial catheters, the team has shown that it can reduce bloodstream and urinary tract infections among its patients.

Drs. Flanders and Saint outlined a broad range of targets for the consortium hospitalists, including eliminating medication errors, creating a culture of safety, increasing the use of prophylactic medications for surgical patients, improving intensive care practices including pneumonia prevention, and examining end-of-life care practices such as pain management and the use of advance directives. Focusing on the elderly, who often fare poorly during hospitalizations, HELPS is looking for ways to prevent falls and delirium for that patient population. Through regular meetings, the hospitalists are developing techniques and benchmarks for performing quality improvement research and compiling lessons learned.

Nora Maloy, who works for Blue Cross/Blue Shield Foundation and who is Michigan’s senior program officer, positions the hospitalist collaboration as part of her foundation’s broader initiative to improve patient safety in response to the Institute of Medicine’s 1999 “Crossing the Quality Chasm” report that 98,000 unnecessary deaths occur annually in U.S. hospitals.

“We are very excited about the HELPS initiative,” says Maloy. “We hope to see outcomes data and best practices emerge from the nine different systems in the project, and to support a hospitalist consortium that can serve as a national model.”

At early meetings the hospitalists developed this process for their work together:

• Identify a common problem to study;
• Present data on the individual hospitalist or hospitalist group’s experience with the problem and a patient safety initiative to correct it;
• Create a steering committee and a team to research and present data on the initiative;
• Capture and organize data;
• Have an on-site visit from a principal investigator who participates in rounds and discusses data collection capabilities;
• Present to the group key steps in performing the patient safety initiative;
• Implement the initiative in as many of the nine hospitals that want to participate;
• Collect data from the larger group and report to the consortium; and
• Disseminate results through other regional and national meetings, and peer-reviewed journals.

HELPS’ funding frees participating hospitalists to attend quarterly meetings. Reflecting on their busy professional lives, Dr. Flanders says that groups are participating on different levels.

“We know that some hospitalist groups are stable, and they will propose initiatives, collect data, etc.,” he explains. “Other groups that may have recruiting and turnover issues and are just surviving won’t be able to do so, but their attendance at the meetings is very important. There are also small ad hoc meetings for those working on specific patient safety projects.

Took the Challenge

Bobby Lee, MD, director of inpatient medical education at the 600-bed Oakwood Hospital and Medical Center in Dearborn, Mich., eagerly joined the consortium when he realized that a large number of patients were being managed by a small number of hospitalist physicians.

“Scott [Flanders] and Sanjay [Saint] were very inclusive of hospitalists from different programs,” says Dr. Lee. “They articulated what’s important to us as hospitalists—that we bring something special to a hospital, to make it a safer place than when we got there.”

Sharing an Idea

Dr. Lee’s initiative, “Preventing Failure to Resuscitate,” addresses the issue that—on average—between 66% and 70% of patients outside the ICU on whom a code blue is called have alterations in their vital signs six to eight hours before the code. Dr. Lee’s solution was a rapid response team (RRT), developed after process analysis and data collection. And he has shared the initiative with HELPS.

“We did a literature review and then collected historical data on code blues at Oakwood,” explains Dr. Lee. “I took the data to our director of accreditation, an RN, and we felt that we could do better.”

After conducting several small pilot projects on different units to determine optimal staffing, equipment, and medications necessary for a quick response to a code, Dr. Lee presented his findings to Oakwood’s senior management, who committed the necessary resources. That includes a CCU nurse, respiratory therapist, either a hospitalist or intensivist, and a medical service resident—four teams in all for 24/7 coverage.

“There were a surprising number of models and variables we had to look at, such as streamlining lab results, getting test results to the bedside faster, and getting emergency boxes with the right pharmaceuticals on each unit,” adds Dr. Lee.

One interesting twist was Oakwood’s inclusion of hospitalists from private hospital medicine groups on the RRT. “Involving both community-based and academic medicine hospitalists has fostered a culture of inclusiveness, and that works,” says Dr. Lee. His final word: “We can’t leave our patients on the edge of the quality chasm. For not a lot of money, an RRT can help us help someone survive a code blue, and beat the odds that only 17% of code blues live to be discharged from the hospital.”

As the HELPS team continues on its two-year journey to better patient safety, the hospitalists will share what works, what doesn’t work, and what obstacles need to be removed. Overall, though, the HELPS’ vision that a small number of hospitalists joining together can have a huge effect on the care of upward of 80,000 patients has already succeeded. TH

Marlene Piturro is a frequent contributor to The Hospitalist.

Spend time with hospitalists and their competitive natures readily emerge. Striving for excellence in clinical care, hospital efficiency, and patient satisfaction, they are their hospitals’ beacons for attracting patients from referring physicians. As hospitalists’ capabilities grow, they hone pathways and procedures, improving their hospitals over time. What would happen if those hospitalists systematically shared their collective knowledge?

That’s what’s happening for hospitalists from nine health systems in southeast Michigan. Transcending their individual pursuits of excellence, they have united as Hospitalists as Emerging Leaders in Patient Safety (HELPS), a unique two-year consortium to improve patient safety regionally. Through large and small group meetings, HELPS is defining and tackling paramount patient safety issues, and collecting and sharing data about what works best.

A $117,000 grant from the Blue Cross/Blue Shield Foundation of Michigan awarded in 2005 to the University of Michigan Health Systems (UMHS) spurred the regional collaboration. Co-principal Investigator Scott Flanders, MD, UMHS’ chief of the hospitalist service and an SHM board member, conceived the project several years ago.

“What galvanized me is when I realized that we are a relatively small number of hospitalists overseeing a large number of patients—between 80,000 to 85,000 admissions annually,” he explains. “Those numbers indicated that we need to share our knowledge, treatment guidelines, and processes if we are to significantly improve patient safety.

“I assumed that many hospitalist groups wanted to improve patient safety,” continues Dr. Flanders. “But we were all working in isolation and were too busy caring for our patients to take the time to collaborate with colleagues in other programs.”

Dr. Flanders and HELPS’ other co-principal investigator, Sanjay Saint, MD, MPH, a hospitalist who heads UMHS’ Patient Safety Enhancement Program, were willing to spearhead a regional patient safety initiative with input from fellow hospitalists and patient safety officers. The Blue Cross/Blue Shield Foundation grant allowed the hospitalists to meet face-to-face periodically, target patient safety concerns, share hospitalist medicine group initiatives, collect data, and disseminate findings and best practices among the participants.

Dr. Saint and his colleagues provided one template for change. By using reminders and automatic order sets to prompt doctors to remove urinary catheters in a timely manner and by using anti-bacterial catheters, the team has shown that it can reduce bloodstream and urinary tract infections among its patients.

Drs. Flanders and Saint outlined a broad range of targets for the consortium hospitalists, including eliminating medication errors, creating a culture of safety, increasing the use of prophylactic medications for surgical patients, improving intensive care practices including pneumonia prevention, and examining end-of-life care practices such as pain management and the use of advance directives. Focusing on the elderly, who often fare poorly during hospitalizations, HELPS is looking for ways to prevent falls and delirium for that patient population. Through regular meetings, the hospitalists are developing techniques and benchmarks for performing quality improvement research and compiling lessons learned.

Nora Maloy, who works for Blue Cross/Blue Shield Foundation and who is Michigan’s senior program officer, positions the hospitalist collaboration as part of her foundation’s broader initiative to improve patient safety in response to the Institute of Medicine’s 1999 “Crossing the Quality Chasm” report that 98,000 unnecessary deaths occur annually in U.S. hospitals.

“We are very excited about the HELPS initiative,” says Maloy. “We hope to see outcomes data and best practices emerge from the nine different systems in the project, and to support a hospitalist consortium that can serve as a national model.”

At early meetings the hospitalists developed this process for their work together:

• Identify a common problem to study;
• Present data on the individual hospitalist or hospitalist group’s experience with the problem and a patient safety initiative to correct it;
• Create a steering committee and a team to research and present data on the initiative;
• Capture and organize data;
• Have an on-site visit from a principal investigator who participates in rounds and discusses data collection capabilities;
• Present to the group key steps in performing the patient safety initiative;
• Implement the initiative in as many of the nine hospitals that want to participate;
• Collect data from the larger group and report to the consortium; and
• Disseminate results through other regional and national meetings, and peer-reviewed journals.

HELPS’ funding frees participating hospitalists to attend quarterly meetings. Reflecting on their busy professional lives, Dr. Flanders says that groups are participating on different levels.

“We know that some hospitalist groups are stable, and they will propose initiatives, collect data, etc.,” he explains. “Other groups that may have recruiting and turnover issues and are just surviving won’t be able to do so, but their attendance at the meetings is very important. There are also small ad hoc meetings for those working on specific patient safety projects.

Took the Challenge

Bobby Lee, MD, director of inpatient medical education at the 600-bed Oakwood Hospital and Medical Center in Dearborn, Mich., eagerly joined the consortium when he realized that a large number of patients were being managed by a small number of hospitalist physicians.

“Scott [Flanders] and Sanjay [Saint] were very inclusive of hospitalists from different programs,” says Dr. Lee. “They articulated what’s important to us as hospitalists—that we bring something special to a hospital, to make it a safer place than when we got there.”

Sharing an Idea

Dr. Lee’s initiative, “Preventing Failure to Resuscitate,” addresses the issue that—on average—between 66% and 70% of patients outside the ICU on whom a code blue is called have alterations in their vital signs six to eight hours before the code. Dr. Lee’s solution was a rapid response team (RRT), developed after process analysis and data collection. And he has shared the initiative with HELPS.

“We did a literature review and then collected historical data on code blues at Oakwood,” explains Dr. Lee. “I took the data to our director of accreditation, an RN, and we felt that we could do better.”

After conducting several small pilot projects on different units to determine optimal staffing, equipment, and medications necessary for a quick response to a code, Dr. Lee presented his findings to Oakwood’s senior management, who committed the necessary resources. That includes a CCU nurse, respiratory therapist, either a hospitalist or intensivist, and a medical service resident—four teams in all for 24/7 coverage.

“There were a surprising number of models and variables we had to look at, such as streamlining lab results, getting test results to the bedside faster, and getting emergency boxes with the right pharmaceuticals on each unit,” adds Dr. Lee.

One interesting twist was Oakwood’s inclusion of hospitalists from private hospital medicine groups on the RRT. “Involving both community-based and academic medicine hospitalists has fostered a culture of inclusiveness, and that works,” says Dr. Lee. His final word: “We can’t leave our patients on the edge of the quality chasm. For not a lot of money, an RRT can help us help someone survive a code blue, and beat the odds that only 17% of code blues live to be discharged from the hospital.”

As the HELPS team continues on its two-year journey to better patient safety, the hospitalists will share what works, what doesn’t work, and what obstacles need to be removed. Overall, though, the HELPS’ vision that a small number of hospitalists joining together can have a huge effect on the care of upward of 80,000 patients has already succeeded. TH

Marlene Piturro is a frequent contributor to The Hospitalist.

Spend time with hospitalists and their competitive natures readily emerge. Striving for excellence in clinical care, hospital efficiency, and patient satisfaction, they are their hospitals’ beacons for attracting patients from referring physicians. As hospitalists’ capabilities grow, they hone pathways and procedures, improving their hospitals over time. What would happen if those hospitalists systematically shared their collective knowledge?

That’s what’s happening for hospitalists from nine health systems in southeast Michigan. Transcending their individual pursuits of excellence, they have united as Hospitalists as Emerging Leaders in Patient Safety (HELPS), a unique two-year consortium to improve patient safety regionally. Through large and small group meetings, HELPS is defining and tackling paramount patient safety issues, and collecting and sharing data about what works best.

A $117,000 grant from the Blue Cross/Blue Shield Foundation of Michigan awarded in 2005 to the University of Michigan Health Systems (UMHS) spurred the regional collaboration. Co-principal Investigator Scott Flanders, MD, UMHS’ chief of the hospitalist service and an SHM board member, conceived the project several years ago.

“What galvanized me is when I realized that we are a relatively small number of hospitalists overseeing a large number of patients—between 80,000 to 85,000 admissions annually,” he explains. “Those numbers indicated that we need to share our knowledge, treatment guidelines, and processes if we are to significantly improve patient safety.

“I assumed that many hospitalist groups wanted to improve patient safety,” continues Dr. Flanders. “But we were all working in isolation and were too busy caring for our patients to take the time to collaborate with colleagues in other programs.”

Dr. Flanders and HELPS’ other co-principal investigator, Sanjay Saint, MD, MPH, a hospitalist who heads UMHS’ Patient Safety Enhancement Program, were willing to spearhead a regional patient safety initiative with input from fellow hospitalists and patient safety officers. The Blue Cross/Blue Shield Foundation grant allowed the hospitalists to meet face-to-face periodically, target patient safety concerns, share hospitalist medicine group initiatives, collect data, and disseminate findings and best practices among the participants.

Dr. Saint and his colleagues provided one template for change. By using reminders and automatic order sets to prompt doctors to remove urinary catheters in a timely manner and by using anti-bacterial catheters, the team has shown that it can reduce bloodstream and urinary tract infections among its patients.

Drs. Flanders and Saint outlined a broad range of targets for the consortium hospitalists, including eliminating medication errors, creating a culture of safety, increasing the use of prophylactic medications for surgical patients, improving intensive care practices including pneumonia prevention, and examining end-of-life care practices such as pain management and the use of advance directives. Focusing on the elderly, who often fare poorly during hospitalizations, HELPS is looking for ways to prevent falls and delirium for that patient population. Through regular meetings, the hospitalists are developing techniques and benchmarks for performing quality improvement research and compiling lessons learned.

Nora Maloy, who works for Blue Cross/Blue Shield Foundation and who is Michigan’s senior program officer, positions the hospitalist collaboration as part of her foundation’s broader initiative to improve patient safety in response to the Institute of Medicine’s 1999 “Crossing the Quality Chasm” report that 98,000 unnecessary deaths occur annually in U.S. hospitals.

“We are very excited about the HELPS initiative,” says Maloy. “We hope to see outcomes data and best practices emerge from the nine different systems in the project, and to support a hospitalist consortium that can serve as a national model.”

At early meetings the hospitalists developed this process for their work together:

• Identify a common problem to study;
• Present data on the individual hospitalist or hospitalist group’s experience with the problem and a patient safety initiative to correct it;
• Create a steering committee and a team to research and present data on the initiative;
• Capture and organize data;
• Have an on-site visit from a principal investigator who participates in rounds and discusses data collection capabilities;
• Present to the group key steps in performing the patient safety initiative;
• Implement the initiative in as many of the nine hospitals that want to participate;
• Collect data from the larger group and report to the consortium; and
• Disseminate results through other regional and national meetings, and peer-reviewed journals.

HELPS’ funding frees participating hospitalists to attend quarterly meetings. Reflecting on their busy professional lives, Dr. Flanders says that groups are participating on different levels.

“We know that some hospitalist groups are stable, and they will propose initiatives, collect data, etc.,” he explains. “Other groups that may have recruiting and turnover issues and are just surviving won’t be able to do so, but their attendance at the meetings is very important. There are also small ad hoc meetings for those working on specific patient safety projects.

Took the Challenge

Bobby Lee, MD, director of inpatient medical education at the 600-bed Oakwood Hospital and Medical Center in Dearborn, Mich., eagerly joined the consortium when he realized that a large number of patients were being managed by a small number of hospitalist physicians.

“Scott [Flanders] and Sanjay [Saint] were very inclusive of hospitalists from different programs,” says Dr. Lee. “They articulated what’s important to us as hospitalists—that we bring something special to a hospital, to make it a safer place than when we got there.”

Sharing an Idea

Dr. Lee’s initiative, “Preventing Failure to Resuscitate,” addresses the issue that—on average—between 66% and 70% of patients outside the ICU on whom a code blue is called have alterations in their vital signs six to eight hours before the code. Dr. Lee’s solution was a rapid response team (RRT), developed after process analysis and data collection. And he has shared the initiative with HELPS.

“We did a literature review and then collected historical data on code blues at Oakwood,” explains Dr. Lee. “I took the data to our director of accreditation, an RN, and we felt that we could do better.”

After conducting several small pilot projects on different units to determine optimal staffing, equipment, and medications necessary for a quick response to a code, Dr. Lee presented his findings to Oakwood’s senior management, who committed the necessary resources. That includes a CCU nurse, respiratory therapist, either a hospitalist or intensivist, and a medical service resident—four teams in all for 24/7 coverage.

“There were a surprising number of models and variables we had to look at, such as streamlining lab results, getting test results to the bedside faster, and getting emergency boxes with the right pharmaceuticals on each unit,” adds Dr. Lee.

One interesting twist was Oakwood’s inclusion of hospitalists from private hospital medicine groups on the RRT. “Involving both community-based and academic medicine hospitalists has fostered a culture of inclusiveness, and that works,” says Dr. Lee. His final word: “We can’t leave our patients on the edge of the quality chasm. For not a lot of money, an RRT can help us help someone survive a code blue, and beat the odds that only 17% of code blues live to be discharged from the hospital.”

As the HELPS team continues on its two-year journey to better patient safety, the hospitalists will share what works, what doesn’t work, and what obstacles need to be removed. Overall, though, the HELPS’ vision that a small number of hospitalists joining together can have a huge effect on the care of upward of 80,000 patients has already succeeded. TH

Marlene Piturro is a frequent contributor to The Hospitalist.

Retaining good hospitalists is one of the major factors in building a successful hospital medicine group—but it’s also one of the biggest challenges faced in the industry today. Why is hospitalist retention a problem, and what can be done to ensure your hospitalists stay for the long haul?

“As in any profession, there are some [hospitalists] who constantly look for bigger and better opportunities in the employment world,” admits Kenneth G. Simone, DO, founder and president of Hospitalist and Practice Solutions, Veazie, Maine, and a consultant to hospital medicine groups. “Sometimes this involves individuals looking for a better practice fit or for a better financial compensation package. In addition, hospitalist medicine can lead to burnout if the practice is not created or operated in a prudent manner, thus leading to turnover.”

Retention Is Crucial

Why is it so important to retain your hospitalists? For one thing, keeping physicians in your program for the long term can directly decrease costs, time, and effort related to recruitment and training.

More importantly, by decreasing staff turnover, retention can stabilize your hospitalist program. “A stable staff is influential in maintaining the providers’ focus on the practice mission, goals and objectives, and values,” points out Dr. Simone. “It de-emphasizes personal agendas, which may develop if an individual was looking to move on to another practice or up the ladder at the expense of the practice and fellow providers, and allows the practice team to gel over time. This is in some ways similar to a professional sports team, where chemistry and trust in one’s teammates are created over time.”

You can get your own hospitalist team to gel by retaining physicians for years if you initiate a program with that very goal.

How-Tos of Retention Programs

“There are a lot of [hospitalist] programs that haven’t developed retention programs at the outset,” says Dr. Simone. “They may be behind the eight ball, but they can and should create one. Successful programs identify their practice mission, values, and objectives, and clearly and concisely spell them out. This policy can then be utilized with the existing staff to align the team’s values and can also be used in recruiting future candidates.”

Once you have a solid written mission and vision statement, check to see if your hospitalists share the same values. Have your clinical director or an administrator sit down with providers one-on-one and find out their vision, values, and objectives. If what you hear differs from the core values of the practice, then you must develop a plan on which you can all agree.

“You may also have to consider altering some of the program’s vision and objectives, if appropriate,” says Dr. Simone.

Scheduling: A Core Value

Your group’s values can be reflected in the schedule you set for staff. “The practice structure and schedule plays a very important role in provider retention,” says Dr. Simone. “In general, various schedule types work for different individuals, and—in all probability—the provider will seek out the practices that offer a particular schedule to their liking.”

A hospital group that values time over money may offer larger chunks of time off. “We’ve found that our recruitment and retention improved when we went to a schedule of seven days on, seven off,” says Dr. Simone. “A lot of individuals are attracted to this because it gives them a week at a time to spend with their families or to pursue other interests, such as travel or educational pursuits.”

Whatever schedule you choose, there are some basic tenets Dr. Simone recommends, including:

• Create a schedule that is consistent and stable rather than constantly changing;
• Make sure the schedule is perceived as fair for all providers;
• Ensure that all providers get appropriate time off;
• Give providers enough flexibility to participate in other projects such as teaching, subspecialty clinics, administrative duties, or special projects; and
• Adhere to a schedule that promotes/accommodates a safe patient to provider ratio.

Salary and Bonuses

Money does matter in retention. As long as the pay you offer is perceived as fair, you have a good start. “In the end, you can only afford what your finances dictate,” says Dr. Simone. “Smaller hospitals may fall short on salary, so it’s important for them to recognize their strengths and sell them in order to compete.”

Your hospitalists may be attracted to participate in an incentive program that rewards them for hard work and productivity. “Incentives help change behavior, and people are stimulated when they have direct control over their own pay,” says Dr. Simone. “There are hospitalist programs with incentive plans, but many programs aren’t sure how to incentivize. You don’t want to reward doctors solely on the amount of work they do.”

For instance, a hospital-based program that rewards hospitalists on the basis of how many patients they admit is basically encouraging them to hospitalize every patient they see.

“I recommend finding a way to reward quality work and dedication, while not neglecting productivity,” says Dr. Simone. “In my opinion, the focus needs to be on increasing the program’s ability to standardize care following evidence-based protocols, encouraging participation in the value-added services that hospitalists are so good at, like participating in a rapid response team or a code blue team, acting as hospital leaders, educating hospital staff and residents, etc.”

Feeling Connected

Unlike many other physicians, hospitalists don’t get many opportunities to connect with patients or a community.

“In my opinion, a hospitalist’s professional job satisfaction and retention is influenced by the perception of feeling connected to the practice and providers, patients, colleagues, and the hospital,” says Dr. Simone. “There are various characteristics of an employment arrangement that may help an individual feel connected. When an employee feels connected, he/she will typically dedicate themselves to the mission of the company and perform at or above expectations.”

Create or revisit your group’s retention program today. By ensuring that the values and objectives of your practice are clearly stated, and catering to those values and objectives in scheduling and other management practices, you can begin to build your retention. TH

Jane Jerrard writes the “Career Development” column every month for The Hospitalist.

Retaining good hospitalists is one of the major factors in building a successful hospital medicine group—but it’s also one of the biggest challenges faced in the industry today. Why is hospitalist retention a problem, and what can be done to ensure your hospitalists stay for the long haul?

“As in any profession, there are some [hospitalists] who constantly look for bigger and better opportunities in the employment world,” admits Kenneth G. Simone, DO, founder and president of Hospitalist and Practice Solutions, Veazie, Maine, and a consultant to hospital medicine groups. “Sometimes this involves individuals looking for a better practice fit or for a better financial compensation package. In addition, hospitalist medicine can lead to burnout if the practice is not created or operated in a prudent manner, thus leading to turnover.”

Retention Is Crucial

Why is it so important to retain your hospitalists? For one thing, keeping physicians in your program for the long term can directly decrease costs, time, and effort related to recruitment and training.

More importantly, by decreasing staff turnover, retention can stabilize your hospitalist program. “A stable staff is influential in maintaining the providers’ focus on the practice mission, goals and objectives, and values,” points out Dr. Simone. “It de-emphasizes personal agendas, which may develop if an individual was looking to move on to another practice or up the ladder at the expense of the practice and fellow providers, and allows the practice team to gel over time. This is in some ways similar to a professional sports team, where chemistry and trust in one’s teammates are created over time.”

You can get your own hospitalist team to gel by retaining physicians for years if you initiate a program with that very goal.

How-Tos of Retention Programs

“There are a lot of [hospitalist] programs that haven’t developed retention programs at the outset,” says Dr. Simone. “They may be behind the eight ball, but they can and should create one. Successful programs identify their practice mission, values, and objectives, and clearly and concisely spell them out. This policy can then be utilized with the existing staff to align the team’s values and can also be used in recruiting future candidates.”

Once you have a solid written mission and vision statement, check to see if your hospitalists share the same values. Have your clinical director or an administrator sit down with providers one-on-one and find out their vision, values, and objectives. If what you hear differs from the core values of the practice, then you must develop a plan on which you can all agree.

“You may also have to consider altering some of the program’s vision and objectives, if appropriate,” says Dr. Simone.

Scheduling: A Core Value

Your group’s values can be reflected in the schedule you set for staff. “The practice structure and schedule plays a very important role in provider retention,” says Dr. Simone. “In general, various schedule types work for different individuals, and—in all probability—the provider will seek out the practices that offer a particular schedule to their liking.”

A hospital group that values time over money may offer larger chunks of time off. “We’ve found that our recruitment and retention improved when we went to a schedule of seven days on, seven off,” says Dr. Simone. “A lot of individuals are attracted to this because it gives them a week at a time to spend with their families or to pursue other interests, such as travel or educational pursuits.”

Whatever schedule you choose, there are some basic tenets Dr. Simone recommends, including:

• Create a schedule that is consistent and stable rather than constantly changing;
• Make sure the schedule is perceived as fair for all providers;
• Ensure that all providers get appropriate time off;
• Give providers enough flexibility to participate in other projects such as teaching, subspecialty clinics, administrative duties, or special projects; and
• Adhere to a schedule that promotes/accommodates a safe patient to provider ratio.

Salary and Bonuses

Money does matter in retention. As long as the pay you offer is perceived as fair, you have a good start. “In the end, you can only afford what your finances dictate,” says Dr. Simone. “Smaller hospitals may fall short on salary, so it’s important for them to recognize their strengths and sell them in order to compete.”

Your hospitalists may be attracted to participate in an incentive program that rewards them for hard work and productivity. “Incentives help change behavior, and people are stimulated when they have direct control over their own pay,” says Dr. Simone. “There are hospitalist programs with incentive plans, but many programs aren’t sure how to incentivize. You don’t want to reward doctors solely on the amount of work they do.”

For instance, a hospital-based program that rewards hospitalists on the basis of how many patients they admit is basically encouraging them to hospitalize every patient they see.

“I recommend finding a way to reward quality work and dedication, while not neglecting productivity,” says Dr. Simone. “In my opinion, the focus needs to be on increasing the program’s ability to standardize care following evidence-based protocols, encouraging participation in the value-added services that hospitalists are so good at, like participating in a rapid response team or a code blue team, acting as hospital leaders, educating hospital staff and residents, etc.”

Feeling Connected

Unlike many other physicians, hospitalists don’t get many opportunities to connect with patients or a community.

“In my opinion, a hospitalist’s professional job satisfaction and retention is influenced by the perception of feeling connected to the practice and providers, patients, colleagues, and the hospital,” says Dr. Simone. “There are various characteristics of an employment arrangement that may help an individual feel connected. When an employee feels connected, he/she will typically dedicate themselves to the mission of the company and perform at or above expectations.”

Create or revisit your group’s retention program today. By ensuring that the values and objectives of your practice are clearly stated, and catering to those values and objectives in scheduling and other management practices, you can begin to build your retention. TH

Jane Jerrard writes the “Career Development” column every month for The Hospitalist.

Retaining good hospitalists is one of the major factors in building a successful hospital medicine group—but it’s also one of the biggest challenges faced in the industry today. Why is hospitalist retention a problem, and what can be done to ensure your hospitalists stay for the long haul?

“As in any profession, there are some [hospitalists] who constantly look for bigger and better opportunities in the employment world,” admits Kenneth G. Simone, DO, founder and president of Hospitalist and Practice Solutions, Veazie, Maine, and a consultant to hospital medicine groups. “Sometimes this involves individuals looking for a better practice fit or for a better financial compensation package. In addition, hospitalist medicine can lead to burnout if the practice is not created or operated in a prudent manner, thus leading to turnover.”

Retention Is Crucial

Why is it so important to retain your hospitalists? For one thing, keeping physicians in your program for the long term can directly decrease costs, time, and effort related to recruitment and training.

More importantly, by decreasing staff turnover, retention can stabilize your hospitalist program. “A stable staff is influential in maintaining the providers’ focus on the practice mission, goals and objectives, and values,” points out Dr. Simone. “It de-emphasizes personal agendas, which may develop if an individual was looking to move on to another practice or up the ladder at the expense of the practice and fellow providers, and allows the practice team to gel over time. This is in some ways similar to a professional sports team, where chemistry and trust in one’s teammates are created over time.”

You can get your own hospitalist team to gel by retaining physicians for years if you initiate a program with that very goal.

How-Tos of Retention Programs

“There are a lot of [hospitalist] programs that haven’t developed retention programs at the outset,” says Dr. Simone. “They may be behind the eight ball, but they can and should create one. Successful programs identify their practice mission, values, and objectives, and clearly and concisely spell them out. This policy can then be utilized with the existing staff to align the team’s values and can also be used in recruiting future candidates.”

Once you have a solid written mission and vision statement, check to see if your hospitalists share the same values. Have your clinical director or an administrator sit down with providers one-on-one and find out their vision, values, and objectives. If what you hear differs from the core values of the practice, then you must develop a plan on which you can all agree.

“You may also have to consider altering some of the program’s vision and objectives, if appropriate,” says Dr. Simone.

Scheduling: A Core Value

Your group’s values can be reflected in the schedule you set for staff. “The practice structure and schedule plays a very important role in provider retention,” says Dr. Simone. “In general, various schedule types work for different individuals, and—in all probability—the provider will seek out the practices that offer a particular schedule to their liking.”

A hospital group that values time over money may offer larger chunks of time off. “We’ve found that our recruitment and retention improved when we went to a schedule of seven days on, seven off,” says Dr. Simone. “A lot of individuals are attracted to this because it gives them a week at a time to spend with their families or to pursue other interests, such as travel or educational pursuits.”

Whatever schedule you choose, there are some basic tenets Dr. Simone recommends, including:

• Create a schedule that is consistent and stable rather than constantly changing;
• Make sure the schedule is perceived as fair for all providers;
• Ensure that all providers get appropriate time off;
• Give providers enough flexibility to participate in other projects such as teaching, subspecialty clinics, administrative duties, or special projects; and
• Adhere to a schedule that promotes/accommodates a safe patient to provider ratio.

Salary and Bonuses

Money does matter in retention. As long as the pay you offer is perceived as fair, you have a good start. “In the end, you can only afford what your finances dictate,” says Dr. Simone. “Smaller hospitals may fall short on salary, so it’s important for them to recognize their strengths and sell them in order to compete.”

Your hospitalists may be attracted to participate in an incentive program that rewards them for hard work and productivity. “Incentives help change behavior, and people are stimulated when they have direct control over their own pay,” says Dr. Simone. “There are hospitalist programs with incentive plans, but many programs aren’t sure how to incentivize. You don’t want to reward doctors solely on the amount of work they do.”

For instance, a hospital-based program that rewards hospitalists on the basis of how many patients they admit is basically encouraging them to hospitalize every patient they see.

“I recommend finding a way to reward quality work and dedication, while not neglecting productivity,” says Dr. Simone. “In my opinion, the focus needs to be on increasing the program’s ability to standardize care following evidence-based protocols, encouraging participation in the value-added services that hospitalists are so good at, like participating in a rapid response team or a code blue team, acting as hospital leaders, educating hospital staff and residents, etc.”

Feeling Connected

Unlike many other physicians, hospitalists don’t get many opportunities to connect with patients or a community.

“In my opinion, a hospitalist’s professional job satisfaction and retention is influenced by the perception of feeling connected to the practice and providers, patients, colleagues, and the hospital,” says Dr. Simone. “There are various characteristics of an employment arrangement that may help an individual feel connected. When an employee feels connected, he/she will typically dedicate themselves to the mission of the company and perform at or above expectations.”

Create or revisit your group’s retention program today. By ensuring that the values and objectives of your practice are clearly stated, and catering to those values and objectives in scheduling and other management practices, you can begin to build your retention. TH

Jane Jerrard writes the “Career Development” column every month for The Hospitalist.