If you want something done, the saying goes, ask a busy person to do it. That was precisely the situation when SHM’s Core Competencies Task Force editorial board was formed in May 2003. Charged with producing the society’s first-ever curriculum guidance document, the editorial team faced a daunting task: solicit, organize, and edit chapters for the competencies framework on topics from specific clinical conditions to ethical issues. Over the next two and a half years, each of the physician members contributed hundreds of hours of uncompensated time to the project, juggling work, family, and other professional obligations.

Because they are so involved with their own institutions and the future of hospital medicine, the physicians tapped to guide the core competencies to reality were the right pick.

“Working with the four of them was phenomenal,” says SHM staff member Tina Budnitz, MPH, who serves on both the Education Committee and the Core Competencies Task Force. “They are all incredibly hard working, driven, and intelligent. I think the hardest thing was just the logistics of coordinating schedules, since this was a volunteer activity for them.” Budnitz points out that the original target date for completion of the core competencies was early 2005. Instead, the sheer bulk of editing work pushed the deadline back to early 2006, when release of The Core Competencies in Hospital Medicine: A Framework for Curriculum Development by the Society of Hospital Medicine coincides with the premiere of the Journal of Hospital Medicine.

Recently, The Hospitalist caught up with each of the editorial board members, who divulged some of their personal motivations for participating in the ambitious core competencies project. They also discussed the workings of the editorial board and assessed the success of their efforts.

Genesis and Vision

During a July 2002 Educational Summit the SHM Education Committee and Board of Directors determined that one element necessary to evolve SHM’s educational offerings would be a framework to guide and prioritize their efforts. A parallel conversation within the Education Committee, according to Budnitz, revolved around the need to better define hospital medicine. “We’re frequently asked, ‘what differentiates a hospitalist from other general internists? What exactly should the expectations be for a practicing hospitalist?’ ” she explains.

The Editorial Board

Michael J. Pistoria, DO, FACP, associate program director, Internal Medicine Residency, and medical director of both the Hospitalist Services and the Express Admission Unit at Lehigh Valley Hospital in Allentown, Pa., began his journey as chair of the Core Competencies Task Force shortly after SHM’s September 2002 Education Summit retreat.

Dr. Pistoria also serves on SHM’s Education Committee and admits that his allegiance to the field was a strong motivation for agreeing to participate in generating the Core Competencies.

“In my mind, hospital medicine is one of the neatest things in medicine to come along in a long time,” says Dr. Pistoria. “Hospital medicine has the potential to make a significant, positive difference in the way healthcare is delivered in the United States. And to have the opportunity to be a part of a process that helps define hospital medicine, to me, was just something almost too good to be true.”

A very active SHM member, Alpesh Amin, MD, MBA, FACP, is the associate program director for the Internal Medicine Residency Program and the medicine clerkship director at the University of California Irvine (UCI), where he also founded the UCI hospitalist program in 1998. His role in education at his institution informed his active participation in SHM’s Education Committee, which he chaired for four years, and his key role in the Core Competencies Task Force editorial board.

“It was one of my goals—while chairing the Education Committee—for our society to put together the core competencies for hospital medicine,” says Dr. Amin. “I felt that if we had core competencies, this would be the next step to move us toward defining the field of hospital medicine.”

Accordingly, Dr. Amin was instrumental during the first and second SHM Education Summits in securing both committee and SHM Board of Directors’ buy-in of such a project.

For Daniel D. Dressler, MD, MSc, director of hospital medicine at Emory University Hospital and assistant professor of medicine at Emory University School of Medicine, involvement with SHM’s (and formerly NAIP’s) Education Committee was a natural extension of his own interests in medical education. At Emory University Hospital, Dr. Dressler conducts a hospital medicine elective for house staff, “to give them a better understanding of what hospital medicine is and what we do, both in the community setting and in the academic setting.”

“I thought that [development of core competencies] was something that hospitalists as a group needed to do in order to a) become recognized and b) to clarify our own understanding and expectations of hospitalist physicians around the country,” he says.

We originally thought the document would be ready in early 2005. I think we were under the misimpression that the chapters would come back, that we’d read through them in a month or two, and it would be done. It turns out that just the sheer logistics of editing four or five versions of 70 chapters was quite a process.

—Tina Budnitz, MPH

Like her colleagues on the editorial board, Sylvia C.W. McKean, MD, FACP, medical director, Brigham and Women’s Hospital/Faulkner Hospitalist (BWF) Service (Boston), attended the 2002 SHM Education Summit and subsequently joined the Core Competencies Task Force. She is also co-chair of the society’s Career Satisfaction Task Force and views this role as linked to the missions of core competencies and education because education is a key component of professional advancement and engagement in the field. The Career Satisfaction Task Force, she notes, examines what components contribute to a long and satisfying career in hospital medicine.

Dr. McKean’s personal motivation for participation on the Core Competencies Task Force relates directly to her love of teaching. Having developed two hospitalist programs (one with physicians Andy Halpert, former chief of medicine for Harvard Vanguard Associations and subsequently the BWF program in 1998) she has seen firsthand that “people right out of residency do not have all the skills that they need in order to be effective hospitalists.”

As medical director of the BWF Hospitalist Service, Dr. McKean developed a weekly Harvard Medical School CME conference Update in Hospital Medicine for members of the hospitalist service, as well a medical consultation syllabus for the newest members of the hospitalist service to distribute to residents.

“I identified what the newest members of our service right out of residency didn’t learn during their residency training and tried to make sure that we would have people come in and teach them about hospital medicine,” she explains.

As the hospitalist service matured, hospitalists developed significant expertise in these topics and frequently participate in this didactic series of lectures.

“Initially,” recounts Dr. McKean, “I was the only senior physician with experience in hospital medicine, but now my job is much easier, as I continue to learn from other hospitalists in our program.”

A Framework, Not a Text

“We have a great team,” says Dr. Amin of the Task Force editorial board. “I think our goals were clear. We wanted to develop a set of competencies that would be unique and offer 1) an opportunity to define the space that we, as hospitalists, lead in system-based practice; and 2) a framework that would cross over the span of time, so that others could use that framework to develop future curricula.

“Once you write a book, the context is fixed. We thought this [framework for curriculum development] was a creative way of facilitating future projects and ideas,” he continues. “It becomes more of a bible for competencies in hospital medicine.”

Budnitz says the idea was to develop an enduring, flexible blueprint. “We set out to develop a guide that would serve as a blueprint for curricular development in hospital medicine,” she explains. “We wanted to standardize the expectations for learning outcomes but still allow curriculum developers to add their expertise of content and context. Each chapter of the guide is written as a set of learning objectives. We crafted these objectives to clearly indicate a proficiency level.

“For example,” says Budnitz, “it is a different expectation that someone can list the drugs that they might order for a particular condition, versus analyzing the benefits and limitations of different therapeutic approaches. And in both scenarios we have left it up to the content and curriculum developers to determine the precise list of therapeutic agents that are included in curricula and the educational approach that will most likely yield the intended learning outcome.”

Dr. Dressler elaborates on his colleagues’ characterizations of the document: “We weren’t planning on this being an overarching, comprehensive text on hospital medicine. We were not trying to develop or even provide content.”

Instead, he says, the aim was to provide medical educators with a relatively generic framework that would retain flexibility for change. “For instance,” he explains, “if a new drug comes out that is useful for [treating] heart failure, the expectation is that hospitalists should be able to explain and utilize the new and useful medications, but that we were not going to list every drug in the Core Competencies compendium.”

“The one idea that we kept coming back to is that we wanted to design a set of competencies,” said Dr. Pistoria. “We didn’t want to publish a textbook; we didn’t want to come up with a curriculum per se. We wanted to come up with a framework that someone could use to develop their own hospitalist program in their own institution.”

Soliciting Input

The Core Competencies Task Force developed an initial organizational structure for the guide and a list of chapter topics. The resulting chapter list was turned into a survey and sent to the SHM Board of Directors, Core Competencies Task Force, and Education Committee. The survey was also sent to a sample of members within each SHM region or chapter via its chapter or region director. A review of core competencies generated by other medical specialties and allied health professional societies followed.

Then, the task force put out a call for nominations of chapter contributors. Budnitz judges that there were between 150-200 responses for potential contributors. Reviewing all the nominations was no small task. In some cases the editorial board deemed it necessary to recruit non-hospitalist content experts to generate some chapters, such as those dealing with medical-legal issues. In those instances, the “outside expert” was often paired with a hospitalist to ensure that the hospitalist perspective was included.

Strategies for Content Inclusion

Dr. Amin points out that the task force “went as broad and as wide as we could to get feedback on the content for the Core Competencies.” However, it was simply not possible—nor was it the editorial board’s intent—to compile an exhaustive list of all the hundreds of diagnoses that hospitalists may see on a regular basis. The editorial board identified common diagnoses from the top 15-20 DRGs from the Medicare database. The task was then to communicate the most important aspects of what hospitalists do, in the domains of knowledge, skills, and attitudes.

To manage the sheer bulk of solicited CVs and potential chapter authors, the editorial board used a divide-and-conquer strategy. Even so, says Dr. Pistoria, this process took a fair amount of time. When chapters began arriving and the task force was reduced to the core editorial board, “the homework started kicking up, with a lot of home editing time, telephone and e-mail editing, and some face-to-face meetings to ensure that chapters were standardized and had the same format.”

Once the editorial board began its work, it was relatively easy to decide that majority rule would be the best process for resolving differences of opinion, “but honestly,” says Dr. McKean, “only a handful of issues were generated. If we didn’t develop a consensus or if we were not all in agreement, then we sometimes looked for feedback from experts outside of the task force and the editorial board.”

Keeping with the ethos of inclusion, most board members consulted with other experts at their institution about key elements to include in the document.

Regarding the “majority rules” process, “Everyone had the chance during the editorial process to voice their opinions,” says Dr. Pistoria. “If they had concerns and were able to persuade enough people, the appropriate change would be made. I think, in the end, that everyone in the core editorial group felt that their opinions were heard, and I think that lends itself to the pride that we all feel in the final product.”

We wanted to develop a set of competencies that would be unique and offer 1) an opportunity to define the space that we, as hospitalists, lead in system-based practice; and 2) a framework that would cross over the span of time, so that others could use that framework to develop future curricula.

—Alpesh Amin, MD, MBA, FACP

A Work in Progress

Budnitz contributed critical guidance when the board generated writing guidelines for chapter authors. Each received a template for their chapter: a document instructing them how to write a competency, and a letter indicating the intent for their particular chapter. The template went through several iterations, she says, as early chapters were returned and the board began their editing.

For example, each clinical condition is discussed through the domains of knowledge, skills, and attitudes. It was the board’s job to ensure that concepts consistently appeared in the same domain across chapters with a similar degree of specificity and in the same order. “Partway through the process, we refined our template and made it more specific,” reports Budnitz. “We were able to give the second round of contributors a little more guidance as a result.

“We originally thought the document would be ready in early 2005,” she explains. “I think we were under the misimpression that the chapters would come back, that we’d read through them in a month or two, and it would be done. It turns out that just the sheer logistics of editing four or five versions of 70 chapters was quite a process.”

“I think [the Core Competencies] is something that SHM can be proud of,” said Dr. Pistoria of the group’s efforts. “But this is by no means the end of the project – it’s only the beginning. It is a work in progress.”

Dr. Dressler agreed with Dr. Pistoria’s characterization of the Core Competencies as a work in progress.

“I am pretty satisfied with what we’ve accomplished,” says Dr. Dressler. “By no means do I feel that this is the end-all, be-all for hospital medicine, or even for education in hospital medicine. It’s a start. We expect comment. We expect criticism. Being hospitalists, we are all open and aware and willing to make changes. And so we make a start, our initial best effort to get something out there that hospitalists can look at, utilize, and then offer feedback. Our primary goal is to provide a structure for consistency in practice and consistency in expectations. We would like to make [the Core Competencies] something that hospitalists and hospitalist educators feel is useful and that can change with the needs of our specialty.”

I think, in the end, that everyone in the core editorial group felt that their opinions were heard, and I think that lends itself to the pride that we all feel in the final product.

—Michael Pistoria, DO, FACP

Concluding Thoughts

“[Working on the Core Competencies] was an exciting project,” says Dr. Amin. “It took a lot of time. We had to spend a fair amount of time learning before we could actually define what we wanted from our chapter authors. But it was a good process. It was a four-year process to develop a document that would be worthwhile and hopefully stand the test of time in defining the core aspects of the field of hospital medicine. It was great to be chairing [the] education [committee] and seeing the value of helping to facilitate this project, and now looking more broadly across how to apply this project to future educational efforts.”

The project certainly had its challenges, most of which were related to time constraints.

“All of us were working very hard in our respective programs,” notes Dr. McKean, “and we were doing this on a volunteer basis. I think we had 10 face-to-face meetings, and sat at our computers on Saturday afternoons for conference calls using a Web-based editing program.”

For her part, Dr. McKean found working on the core competencies “very satisfying. I think I learned a lot from other people on this task force, editorial board, and the organization of the Society of Hospital Medicine. This project helped me reflect upon skills that I should try to obtain, and to think about more global issues than the day-to-day hospital politics in which I was involved. I did more strategic planning and thinking about retreats. So, it was a learning experience for me, and I also felt that I was contributing to something worthwhile. It was a chance to make a difference.

“From my own professional experience, the development process has helped me here, at Brigham and Women’s Hospital, so I hope that anyone who wants to apply the core competencies would feel free to e-mail us or contact us if they have any questions at all,” she says.

Dr. Pistoria agrees with Dr. McKean’s observations. “Working on the Core Competencies had a really big impact on me, both personally and professionally,” he says. “The process helped me mature in how I deal with running a project like this because I have been given the opportunity to do some similar things at my institution. Some of the ideas that we hit upon as we were editing and developing these competencies make one think, ‘We need to do this at our institution.’ Let’s take a strong look at, say, discharge processes, get a group together, and generate some recommendations that we can then institute.”

Other editorial board members also acknowledged that their participation gave them new insights into their own practice of hospital medicine.

“It’s easy to have in your head what you think is the right thing to do,” notes Dr. Dressler, “But until you actually have to try to develop consistency in wording and expectations, to put a process together that can result in a protocol, you realize that sometimes some elements get left out—for instance, the importance of family communication in the setting of DVT.”

Regarding the board members’ hard work, Budnitz remarks, “I can’t say enough about the dedication of the editorial board. They volunteered a tremendous amount of time and stuck with the project for three years. Since the board lived in multiple time zones, we often had calls where people would be participating at 6 a.m. or 9 p.m. We convened on weekends in multiple cities across the U.S. I sincerely enjoyed the opportunity to be a part of this project and hopefully impact the future of medical education.

“I think the document makes a bold statement. It defines the hospitalist as the captain of the ship—and calls on hospitalists to lead multidisciplinary teams to improve the quality of care. I hope it sparks interest and debate about how we recruit, train, prepare, and certify physicians in hospital medicine.”

Dr. Pistoria believes that the Core Competencies will advance hospitalist programs. In fact, he says, hospitalists around the country have already affected improvements in care coordination. The hospitalist movement in general furnishes hospitals with physicians who say, “ ‘I’m going to take ownership of what happens within the four walls of this hospital,’ ” says Dr. Pistoria. “Previous to that, people obviously cared about what happened in the hospital, but they also worried about their office practices. This is our office practice. We want it to work as well as it can for our patients, for us, for our nursing colleagues, for our janitors—everybody needs to, and should, benefit from this.” TH

Writer Gretchen Henkel wrote about cultural competency in the September issue of The Hospitalist.

If you want something done, the saying goes, ask a busy person to do it. That was precisely the situation when SHM’s Core Competencies Task Force editorial board was formed in May 2003. Charged with producing the society’s first-ever curriculum guidance document, the editorial team faced a daunting task: solicit, organize, and edit chapters for the competencies framework on topics from specific clinical conditions to ethical issues. Over the next two and a half years, each of the physician members contributed hundreds of hours of uncompensated time to the project, juggling work, family, and other professional obligations.

Because they are so involved with their own institutions and the future of hospital medicine, the physicians tapped to guide the core competencies to reality were the right pick.

“Working with the four of them was phenomenal,” says SHM staff member Tina Budnitz, MPH, who serves on both the Education Committee and the Core Competencies Task Force. “They are all incredibly hard working, driven, and intelligent. I think the hardest thing was just the logistics of coordinating schedules, since this was a volunteer activity for them.” Budnitz points out that the original target date for completion of the core competencies was early 2005. Instead, the sheer bulk of editing work pushed the deadline back to early 2006, when release of The Core Competencies in Hospital Medicine: A Framework for Curriculum Development by the Society of Hospital Medicine coincides with the premiere of the Journal of Hospital Medicine.

Recently, The Hospitalist caught up with each of the editorial board members, who divulged some of their personal motivations for participating in the ambitious core competencies project. They also discussed the workings of the editorial board and assessed the success of their efforts.

Genesis and Vision

During a July 2002 Educational Summit the SHM Education Committee and Board of Directors determined that one element necessary to evolve SHM’s educational offerings would be a framework to guide and prioritize their efforts. A parallel conversation within the Education Committee, according to Budnitz, revolved around the need to better define hospital medicine. “We’re frequently asked, ‘what differentiates a hospitalist from other general internists? What exactly should the expectations be for a practicing hospitalist?’ ” she explains.

The Editorial Board

Michael J. Pistoria, DO, FACP, associate program director, Internal Medicine Residency, and medical director of both the Hospitalist Services and the Express Admission Unit at Lehigh Valley Hospital in Allentown, Pa., began his journey as chair of the Core Competencies Task Force shortly after SHM’s September 2002 Education Summit retreat.

Dr. Pistoria also serves on SHM’s Education Committee and admits that his allegiance to the field was a strong motivation for agreeing to participate in generating the Core Competencies.

“In my mind, hospital medicine is one of the neatest things in medicine to come along in a long time,” says Dr. Pistoria. “Hospital medicine has the potential to make a significant, positive difference in the way healthcare is delivered in the United States. And to have the opportunity to be a part of a process that helps define hospital medicine, to me, was just something almost too good to be true.”

A very active SHM member, Alpesh Amin, MD, MBA, FACP, is the associate program director for the Internal Medicine Residency Program and the medicine clerkship director at the University of California Irvine (UCI), where he also founded the UCI hospitalist program in 1998. His role in education at his institution informed his active participation in SHM’s Education Committee, which he chaired for four years, and his key role in the Core Competencies Task Force editorial board.

“It was one of my goals—while chairing the Education Committee—for our society to put together the core competencies for hospital medicine,” says Dr. Amin. “I felt that if we had core competencies, this would be the next step to move us toward defining the field of hospital medicine.”

Accordingly, Dr. Amin was instrumental during the first and second SHM Education Summits in securing both committee and SHM Board of Directors’ buy-in of such a project.

For Daniel D. Dressler, MD, MSc, director of hospital medicine at Emory University Hospital and assistant professor of medicine at Emory University School of Medicine, involvement with SHM’s (and formerly NAIP’s) Education Committee was a natural extension of his own interests in medical education. At Emory University Hospital, Dr. Dressler conducts a hospital medicine elective for house staff, “to give them a better understanding of what hospital medicine is and what we do, both in the community setting and in the academic setting.”

“I thought that [development of core competencies] was something that hospitalists as a group needed to do in order to a) become recognized and b) to clarify our own understanding and expectations of hospitalist physicians around the country,” he says.

We originally thought the document would be ready in early 2005. I think we were under the misimpression that the chapters would come back, that we’d read through them in a month or two, and it would be done. It turns out that just the sheer logistics of editing four or five versions of 70 chapters was quite a process.

—Tina Budnitz, MPH

Like her colleagues on the editorial board, Sylvia C.W. McKean, MD, FACP, medical director, Brigham and Women’s Hospital/Faulkner Hospitalist (BWF) Service (Boston), attended the 2002 SHM Education Summit and subsequently joined the Core Competencies Task Force. She is also co-chair of the society’s Career Satisfaction Task Force and views this role as linked to the missions of core competencies and education because education is a key component of professional advancement and engagement in the field. The Career Satisfaction Task Force, she notes, examines what components contribute to a long and satisfying career in hospital medicine.

Dr. McKean’s personal motivation for participation on the Core Competencies Task Force relates directly to her love of teaching. Having developed two hospitalist programs (one with physicians Andy Halpert, former chief of medicine for Harvard Vanguard Associations and subsequently the BWF program in 1998) she has seen firsthand that “people right out of residency do not have all the skills that they need in order to be effective hospitalists.”

As medical director of the BWF Hospitalist Service, Dr. McKean developed a weekly Harvard Medical School CME conference Update in Hospital Medicine for members of the hospitalist service, as well a medical consultation syllabus for the newest members of the hospitalist service to distribute to residents.

“I identified what the newest members of our service right out of residency didn’t learn during their residency training and tried to make sure that we would have people come in and teach them about hospital medicine,” she explains.

As the hospitalist service matured, hospitalists developed significant expertise in these topics and frequently participate in this didactic series of lectures.

“Initially,” recounts Dr. McKean, “I was the only senior physician with experience in hospital medicine, but now my job is much easier, as I continue to learn from other hospitalists in our program.”

A Framework, Not a Text

“We have a great team,” says Dr. Amin of the Task Force editorial board. “I think our goals were clear. We wanted to develop a set of competencies that would be unique and offer 1) an opportunity to define the space that we, as hospitalists, lead in system-based practice; and 2) a framework that would cross over the span of time, so that others could use that framework to develop future curricula.

“Once you write a book, the context is fixed. We thought this [framework for curriculum development] was a creative way of facilitating future projects and ideas,” he continues. “It becomes more of a bible for competencies in hospital medicine.”

Budnitz says the idea was to develop an enduring, flexible blueprint. “We set out to develop a guide that would serve as a blueprint for curricular development in hospital medicine,” she explains. “We wanted to standardize the expectations for learning outcomes but still allow curriculum developers to add their expertise of content and context. Each chapter of the guide is written as a set of learning objectives. We crafted these objectives to clearly indicate a proficiency level.

“For example,” says Budnitz, “it is a different expectation that someone can list the drugs that they might order for a particular condition, versus analyzing the benefits and limitations of different therapeutic approaches. And in both scenarios we have left it up to the content and curriculum developers to determine the precise list of therapeutic agents that are included in curricula and the educational approach that will most likely yield the intended learning outcome.”

Dr. Dressler elaborates on his colleagues’ characterizations of the document: “We weren’t planning on this being an overarching, comprehensive text on hospital medicine. We were not trying to develop or even provide content.”

Instead, he says, the aim was to provide medical educators with a relatively generic framework that would retain flexibility for change. “For instance,” he explains, “if a new drug comes out that is useful for [treating] heart failure, the expectation is that hospitalists should be able to explain and utilize the new and useful medications, but that we were not going to list every drug in the Core Competencies compendium.”

“The one idea that we kept coming back to is that we wanted to design a set of competencies,” said Dr. Pistoria. “We didn’t want to publish a textbook; we didn’t want to come up with a curriculum per se. We wanted to come up with a framework that someone could use to develop their own hospitalist program in their own institution.”

Soliciting Input

The Core Competencies Task Force developed an initial organizational structure for the guide and a list of chapter topics. The resulting chapter list was turned into a survey and sent to the SHM Board of Directors, Core Competencies Task Force, and Education Committee. The survey was also sent to a sample of members within each SHM region or chapter via its chapter or region director. A review of core competencies generated by other medical specialties and allied health professional societies followed.

Then, the task force put out a call for nominations of chapter contributors. Budnitz judges that there were between 150-200 responses for potential contributors. Reviewing all the nominations was no small task. In some cases the editorial board deemed it necessary to recruit non-hospitalist content experts to generate some chapters, such as those dealing with medical-legal issues. In those instances, the “outside expert” was often paired with a hospitalist to ensure that the hospitalist perspective was included.

Strategies for Content Inclusion

Dr. Amin points out that the task force “went as broad and as wide as we could to get feedback on the content for the Core Competencies.” However, it was simply not possible—nor was it the editorial board’s intent—to compile an exhaustive list of all the hundreds of diagnoses that hospitalists may see on a regular basis. The editorial board identified common diagnoses from the top 15-20 DRGs from the Medicare database. The task was then to communicate the most important aspects of what hospitalists do, in the domains of knowledge, skills, and attitudes.

To manage the sheer bulk of solicited CVs and potential chapter authors, the editorial board used a divide-and-conquer strategy. Even so, says Dr. Pistoria, this process took a fair amount of time. When chapters began arriving and the task force was reduced to the core editorial board, “the homework started kicking up, with a lot of home editing time, telephone and e-mail editing, and some face-to-face meetings to ensure that chapters were standardized and had the same format.”

Once the editorial board began its work, it was relatively easy to decide that majority rule would be the best process for resolving differences of opinion, “but honestly,” says Dr. McKean, “only a handful of issues were generated. If we didn’t develop a consensus or if we were not all in agreement, then we sometimes looked for feedback from experts outside of the task force and the editorial board.”

Keeping with the ethos of inclusion, most board members consulted with other experts at their institution about key elements to include in the document.

Regarding the “majority rules” process, “Everyone had the chance during the editorial process to voice their opinions,” says Dr. Pistoria. “If they had concerns and were able to persuade enough people, the appropriate change would be made. I think, in the end, that everyone in the core editorial group felt that their opinions were heard, and I think that lends itself to the pride that we all feel in the final product.”

We wanted to develop a set of competencies that would be unique and offer 1) an opportunity to define the space that we, as hospitalists, lead in system-based practice; and 2) a framework that would cross over the span of time, so that others could use that framework to develop future curricula.

—Alpesh Amin, MD, MBA, FACP

A Work in Progress

Budnitz contributed critical guidance when the board generated writing guidelines for chapter authors. Each received a template for their chapter: a document instructing them how to write a competency, and a letter indicating the intent for their particular chapter. The template went through several iterations, she says, as early chapters were returned and the board began their editing.

For example, each clinical condition is discussed through the domains of knowledge, skills, and attitudes. It was the board’s job to ensure that concepts consistently appeared in the same domain across chapters with a similar degree of specificity and in the same order. “Partway through the process, we refined our template and made it more specific,” reports Budnitz. “We were able to give the second round of contributors a little more guidance as a result.

“We originally thought the document would be ready in early 2005,” she explains. “I think we were under the misimpression that the chapters would come back, that we’d read through them in a month or two, and it would be done. It turns out that just the sheer logistics of editing four or five versions of 70 chapters was quite a process.”

“I think [the Core Competencies] is something that SHM can be proud of,” said Dr. Pistoria of the group’s efforts. “But this is by no means the end of the project – it’s only the beginning. It is a work in progress.”

Dr. Dressler agreed with Dr. Pistoria’s characterization of the Core Competencies as a work in progress.

“I am pretty satisfied with what we’ve accomplished,” says Dr. Dressler. “By no means do I feel that this is the end-all, be-all for hospital medicine, or even for education in hospital medicine. It’s a start. We expect comment. We expect criticism. Being hospitalists, we are all open and aware and willing to make changes. And so we make a start, our initial best effort to get something out there that hospitalists can look at, utilize, and then offer feedback. Our primary goal is to provide a structure for consistency in practice and consistency in expectations. We would like to make [the Core Competencies] something that hospitalists and hospitalist educators feel is useful and that can change with the needs of our specialty.”

I think, in the end, that everyone in the core editorial group felt that their opinions were heard, and I think that lends itself to the pride that we all feel in the final product.

—Michael Pistoria, DO, FACP

Concluding Thoughts

“[Working on the Core Competencies] was an exciting project,” says Dr. Amin. “It took a lot of time. We had to spend a fair amount of time learning before we could actually define what we wanted from our chapter authors. But it was a good process. It was a four-year process to develop a document that would be worthwhile and hopefully stand the test of time in defining the core aspects of the field of hospital medicine. It was great to be chairing [the] education [committee] and seeing the value of helping to facilitate this project, and now looking more broadly across how to apply this project to future educational efforts.”

The project certainly had its challenges, most of which were related to time constraints.

“All of us were working very hard in our respective programs,” notes Dr. McKean, “and we were doing this on a volunteer basis. I think we had 10 face-to-face meetings, and sat at our computers on Saturday afternoons for conference calls using a Web-based editing program.”

For her part, Dr. McKean found working on the core competencies “very satisfying. I think I learned a lot from other people on this task force, editorial board, and the organization of the Society of Hospital Medicine. This project helped me reflect upon skills that I should try to obtain, and to think about more global issues than the day-to-day hospital politics in which I was involved. I did more strategic planning and thinking about retreats. So, it was a learning experience for me, and I also felt that I was contributing to something worthwhile. It was a chance to make a difference.

“From my own professional experience, the development process has helped me here, at Brigham and Women’s Hospital, so I hope that anyone who wants to apply the core competencies would feel free to e-mail us or contact us if they have any questions at all,” she says.

Dr. Pistoria agrees with Dr. McKean’s observations. “Working on the Core Competencies had a really big impact on me, both personally and professionally,” he says. “The process helped me mature in how I deal with running a project like this because I have been given the opportunity to do some similar things at my institution. Some of the ideas that we hit upon as we were editing and developing these competencies make one think, ‘We need to do this at our institution.’ Let’s take a strong look at, say, discharge processes, get a group together, and generate some recommendations that we can then institute.”

Other editorial board members also acknowledged that their participation gave them new insights into their own practice of hospital medicine.

“It’s easy to have in your head what you think is the right thing to do,” notes Dr. Dressler, “But until you actually have to try to develop consistency in wording and expectations, to put a process together that can result in a protocol, you realize that sometimes some elements get left out—for instance, the importance of family communication in the setting of DVT.”

Regarding the board members’ hard work, Budnitz remarks, “I can’t say enough about the dedication of the editorial board. They volunteered a tremendous amount of time and stuck with the project for three years. Since the board lived in multiple time zones, we often had calls where people would be participating at 6 a.m. or 9 p.m. We convened on weekends in multiple cities across the U.S. I sincerely enjoyed the opportunity to be a part of this project and hopefully impact the future of medical education.

“I think the document makes a bold statement. It defines the hospitalist as the captain of the ship—and calls on hospitalists to lead multidisciplinary teams to improve the quality of care. I hope it sparks interest and debate about how we recruit, train, prepare, and certify physicians in hospital medicine.”

Dr. Pistoria believes that the Core Competencies will advance hospitalist programs. In fact, he says, hospitalists around the country have already affected improvements in care coordination. The hospitalist movement in general furnishes hospitals with physicians who say, “ ‘I’m going to take ownership of what happens within the four walls of this hospital,’ ” says Dr. Pistoria. “Previous to that, people obviously cared about what happened in the hospital, but they also worried about their office practices. This is our office practice. We want it to work as well as it can for our patients, for us, for our nursing colleagues, for our janitors—everybody needs to, and should, benefit from this.” TH

Writer Gretchen Henkel wrote about cultural competency in the September issue of The Hospitalist.

If you want something done, the saying goes, ask a busy person to do it. That was precisely the situation when SHM’s Core Competencies Task Force editorial board was formed in May 2003. Charged with producing the society’s first-ever curriculum guidance document, the editorial team faced a daunting task: solicit, organize, and edit chapters for the competencies framework on topics from specific clinical conditions to ethical issues. Over the next two and a half years, each of the physician members contributed hundreds of hours of uncompensated time to the project, juggling work, family, and other professional obligations.

Because they are so involved with their own institutions and the future of hospital medicine, the physicians tapped to guide the core competencies to reality were the right pick.

“Working with the four of them was phenomenal,” says SHM staff member Tina Budnitz, MPH, who serves on both the Education Committee and the Core Competencies Task Force. “They are all incredibly hard working, driven, and intelligent. I think the hardest thing was just the logistics of coordinating schedules, since this was a volunteer activity for them.” Budnitz points out that the original target date for completion of the core competencies was early 2005. Instead, the sheer bulk of editing work pushed the deadline back to early 2006, when release of The Core Competencies in Hospital Medicine: A Framework for Curriculum Development by the Society of Hospital Medicine coincides with the premiere of the Journal of Hospital Medicine.

Recently, The Hospitalist caught up with each of the editorial board members, who divulged some of their personal motivations for participating in the ambitious core competencies project. They also discussed the workings of the editorial board and assessed the success of their efforts.

Genesis and Vision

During a July 2002 Educational Summit the SHM Education Committee and Board of Directors determined that one element necessary to evolve SHM’s educational offerings would be a framework to guide and prioritize their efforts. A parallel conversation within the Education Committee, according to Budnitz, revolved around the need to better define hospital medicine. “We’re frequently asked, ‘what differentiates a hospitalist from other general internists? What exactly should the expectations be for a practicing hospitalist?’ ” she explains.

The Editorial Board

Michael J. Pistoria, DO, FACP, associate program director, Internal Medicine Residency, and medical director of both the Hospitalist Services and the Express Admission Unit at Lehigh Valley Hospital in Allentown, Pa., began his journey as chair of the Core Competencies Task Force shortly after SHM’s September 2002 Education Summit retreat.

Dr. Pistoria also serves on SHM’s Education Committee and admits that his allegiance to the field was a strong motivation for agreeing to participate in generating the Core Competencies.

“In my mind, hospital medicine is one of the neatest things in medicine to come along in a long time,” says Dr. Pistoria. “Hospital medicine has the potential to make a significant, positive difference in the way healthcare is delivered in the United States. And to have the opportunity to be a part of a process that helps define hospital medicine, to me, was just something almost too good to be true.”

A very active SHM member, Alpesh Amin, MD, MBA, FACP, is the associate program director for the Internal Medicine Residency Program and the medicine clerkship director at the University of California Irvine (UCI), where he also founded the UCI hospitalist program in 1998. His role in education at his institution informed his active participation in SHM’s Education Committee, which he chaired for four years, and his key role in the Core Competencies Task Force editorial board.

“It was one of my goals—while chairing the Education Committee—for our society to put together the core competencies for hospital medicine,” says Dr. Amin. “I felt that if we had core competencies, this would be the next step to move us toward defining the field of hospital medicine.”

Accordingly, Dr. Amin was instrumental during the first and second SHM Education Summits in securing both committee and SHM Board of Directors’ buy-in of such a project.

For Daniel D. Dressler, MD, MSc, director of hospital medicine at Emory University Hospital and assistant professor of medicine at Emory University School of Medicine, involvement with SHM’s (and formerly NAIP’s) Education Committee was a natural extension of his own interests in medical education. At Emory University Hospital, Dr. Dressler conducts a hospital medicine elective for house staff, “to give them a better understanding of what hospital medicine is and what we do, both in the community setting and in the academic setting.”

“I thought that [development of core competencies] was something that hospitalists as a group needed to do in order to a) become recognized and b) to clarify our own understanding and expectations of hospitalist physicians around the country,” he says.

We originally thought the document would be ready in early 2005. I think we were under the misimpression that the chapters would come back, that we’d read through them in a month or two, and it would be done. It turns out that just the sheer logistics of editing four or five versions of 70 chapters was quite a process.

—Tina Budnitz, MPH

Like her colleagues on the editorial board, Sylvia C.W. McKean, MD, FACP, medical director, Brigham and Women’s Hospital/Faulkner Hospitalist (BWF) Service (Boston), attended the 2002 SHM Education Summit and subsequently joined the Core Competencies Task Force. She is also co-chair of the society’s Career Satisfaction Task Force and views this role as linked to the missions of core competencies and education because education is a key component of professional advancement and engagement in the field. The Career Satisfaction Task Force, she notes, examines what components contribute to a long and satisfying career in hospital medicine.

Dr. McKean’s personal motivation for participation on the Core Competencies Task Force relates directly to her love of teaching. Having developed two hospitalist programs (one with physicians Andy Halpert, former chief of medicine for Harvard Vanguard Associations and subsequently the BWF program in 1998) she has seen firsthand that “people right out of residency do not have all the skills that they need in order to be effective hospitalists.”

As medical director of the BWF Hospitalist Service, Dr. McKean developed a weekly Harvard Medical School CME conference Update in Hospital Medicine for members of the hospitalist service, as well a medical consultation syllabus for the newest members of the hospitalist service to distribute to residents.

“I identified what the newest members of our service right out of residency didn’t learn during their residency training and tried to make sure that we would have people come in and teach them about hospital medicine,” she explains.

As the hospitalist service matured, hospitalists developed significant expertise in these topics and frequently participate in this didactic series of lectures.

“Initially,” recounts Dr. McKean, “I was the only senior physician with experience in hospital medicine, but now my job is much easier, as I continue to learn from other hospitalists in our program.”

A Framework, Not a Text

“We have a great team,” says Dr. Amin of the Task Force editorial board. “I think our goals were clear. We wanted to develop a set of competencies that would be unique and offer 1) an opportunity to define the space that we, as hospitalists, lead in system-based practice; and 2) a framework that would cross over the span of time, so that others could use that framework to develop future curricula.

“Once you write a book, the context is fixed. We thought this [framework for curriculum development] was a creative way of facilitating future projects and ideas,” he continues. “It becomes more of a bible for competencies in hospital medicine.”

Budnitz says the idea was to develop an enduring, flexible blueprint. “We set out to develop a guide that would serve as a blueprint for curricular development in hospital medicine,” she explains. “We wanted to standardize the expectations for learning outcomes but still allow curriculum developers to add their expertise of content and context. Each chapter of the guide is written as a set of learning objectives. We crafted these objectives to clearly indicate a proficiency level.

“For example,” says Budnitz, “it is a different expectation that someone can list the drugs that they might order for a particular condition, versus analyzing the benefits and limitations of different therapeutic approaches. And in both scenarios we have left it up to the content and curriculum developers to determine the precise list of therapeutic agents that are included in curricula and the educational approach that will most likely yield the intended learning outcome.”

Dr. Dressler elaborates on his colleagues’ characterizations of the document: “We weren’t planning on this being an overarching, comprehensive text on hospital medicine. We were not trying to develop or even provide content.”

Instead, he says, the aim was to provide medical educators with a relatively generic framework that would retain flexibility for change. “For instance,” he explains, “if a new drug comes out that is useful for [treating] heart failure, the expectation is that hospitalists should be able to explain and utilize the new and useful medications, but that we were not going to list every drug in the Core Competencies compendium.”

“The one idea that we kept coming back to is that we wanted to design a set of competencies,” said Dr. Pistoria. “We didn’t want to publish a textbook; we didn’t want to come up with a curriculum per se. We wanted to come up with a framework that someone could use to develop their own hospitalist program in their own institution.”

Soliciting Input

The Core Competencies Task Force developed an initial organizational structure for the guide and a list of chapter topics. The resulting chapter list was turned into a survey and sent to the SHM Board of Directors, Core Competencies Task Force, and Education Committee. The survey was also sent to a sample of members within each SHM region or chapter via its chapter or region director. A review of core competencies generated by other medical specialties and allied health professional societies followed.

Then, the task force put out a call for nominations of chapter contributors. Budnitz judges that there were between 150-200 responses for potential contributors. Reviewing all the nominations was no small task. In some cases the editorial board deemed it necessary to recruit non-hospitalist content experts to generate some chapters, such as those dealing with medical-legal issues. In those instances, the “outside expert” was often paired with a hospitalist to ensure that the hospitalist perspective was included.

Strategies for Content Inclusion

Dr. Amin points out that the task force “went as broad and as wide as we could to get feedback on the content for the Core Competencies.” However, it was simply not possible—nor was it the editorial board’s intent—to compile an exhaustive list of all the hundreds of diagnoses that hospitalists may see on a regular basis. The editorial board identified common diagnoses from the top 15-20 DRGs from the Medicare database. The task was then to communicate the most important aspects of what hospitalists do, in the domains of knowledge, skills, and attitudes.

To manage the sheer bulk of solicited CVs and potential chapter authors, the editorial board used a divide-and-conquer strategy. Even so, says Dr. Pistoria, this process took a fair amount of time. When chapters began arriving and the task force was reduced to the core editorial board, “the homework started kicking up, with a lot of home editing time, telephone and e-mail editing, and some face-to-face meetings to ensure that chapters were standardized and had the same format.”

Once the editorial board began its work, it was relatively easy to decide that majority rule would be the best process for resolving differences of opinion, “but honestly,” says Dr. McKean, “only a handful of issues were generated. If we didn’t develop a consensus or if we were not all in agreement, then we sometimes looked for feedback from experts outside of the task force and the editorial board.”

Keeping with the ethos of inclusion, most board members consulted with other experts at their institution about key elements to include in the document.

Regarding the “majority rules” process, “Everyone had the chance during the editorial process to voice their opinions,” says Dr. Pistoria. “If they had concerns and were able to persuade enough people, the appropriate change would be made. I think, in the end, that everyone in the core editorial group felt that their opinions were heard, and I think that lends itself to the pride that we all feel in the final product.”

We wanted to develop a set of competencies that would be unique and offer 1) an opportunity to define the space that we, as hospitalists, lead in system-based practice; and 2) a framework that would cross over the span of time, so that others could use that framework to develop future curricula.

—Alpesh Amin, MD, MBA, FACP

A Work in Progress

Budnitz contributed critical guidance when the board generated writing guidelines for chapter authors. Each received a template for their chapter: a document instructing them how to write a competency, and a letter indicating the intent for their particular chapter. The template went through several iterations, she says, as early chapters were returned and the board began their editing.

For example, each clinical condition is discussed through the domains of knowledge, skills, and attitudes. It was the board’s job to ensure that concepts consistently appeared in the same domain across chapters with a similar degree of specificity and in the same order. “Partway through the process, we refined our template and made it more specific,” reports Budnitz. “We were able to give the second round of contributors a little more guidance as a result.

“We originally thought the document would be ready in early 2005,” she explains. “I think we were under the misimpression that the chapters would come back, that we’d read through them in a month or two, and it would be done. It turns out that just the sheer logistics of editing four or five versions of 70 chapters was quite a process.”

“I think [the Core Competencies] is something that SHM can be proud of,” said Dr. Pistoria of the group’s efforts. “But this is by no means the end of the project – it’s only the beginning. It is a work in progress.”

Dr. Dressler agreed with Dr. Pistoria’s characterization of the Core Competencies as a work in progress.

“I am pretty satisfied with what we’ve accomplished,” says Dr. Dressler. “By no means do I feel that this is the end-all, be-all for hospital medicine, or even for education in hospital medicine. It’s a start. We expect comment. We expect criticism. Being hospitalists, we are all open and aware and willing to make changes. And so we make a start, our initial best effort to get something out there that hospitalists can look at, utilize, and then offer feedback. Our primary goal is to provide a structure for consistency in practice and consistency in expectations. We would like to make [the Core Competencies] something that hospitalists and hospitalist educators feel is useful and that can change with the needs of our specialty.”

I think, in the end, that everyone in the core editorial group felt that their opinions were heard, and I think that lends itself to the pride that we all feel in the final product.

—Michael Pistoria, DO, FACP

Concluding Thoughts

“[Working on the Core Competencies] was an exciting project,” says Dr. Amin. “It took a lot of time. We had to spend a fair amount of time learning before we could actually define what we wanted from our chapter authors. But it was a good process. It was a four-year process to develop a document that would be worthwhile and hopefully stand the test of time in defining the core aspects of the field of hospital medicine. It was great to be chairing [the] education [committee] and seeing the value of helping to facilitate this project, and now looking more broadly across how to apply this project to future educational efforts.”

The project certainly had its challenges, most of which were related to time constraints.

“All of us were working very hard in our respective programs,” notes Dr. McKean, “and we were doing this on a volunteer basis. I think we had 10 face-to-face meetings, and sat at our computers on Saturday afternoons for conference calls using a Web-based editing program.”

For her part, Dr. McKean found working on the core competencies “very satisfying. I think I learned a lot from other people on this task force, editorial board, and the organization of the Society of Hospital Medicine. This project helped me reflect upon skills that I should try to obtain, and to think about more global issues than the day-to-day hospital politics in which I was involved. I did more strategic planning and thinking about retreats. So, it was a learning experience for me, and I also felt that I was contributing to something worthwhile. It was a chance to make a difference.

“From my own professional experience, the development process has helped me here, at Brigham and Women’s Hospital, so I hope that anyone who wants to apply the core competencies would feel free to e-mail us or contact us if they have any questions at all,” she says.

Dr. Pistoria agrees with Dr. McKean’s observations. “Working on the Core Competencies had a really big impact on me, both personally and professionally,” he says. “The process helped me mature in how I deal with running a project like this because I have been given the opportunity to do some similar things at my institution. Some of the ideas that we hit upon as we were editing and developing these competencies make one think, ‘We need to do this at our institution.’ Let’s take a strong look at, say, discharge processes, get a group together, and generate some recommendations that we can then institute.”

Other editorial board members also acknowledged that their participation gave them new insights into their own practice of hospital medicine.

“It’s easy to have in your head what you think is the right thing to do,” notes Dr. Dressler, “But until you actually have to try to develop consistency in wording and expectations, to put a process together that can result in a protocol, you realize that sometimes some elements get left out—for instance, the importance of family communication in the setting of DVT.”

Regarding the board members’ hard work, Budnitz remarks, “I can’t say enough about the dedication of the editorial board. They volunteered a tremendous amount of time and stuck with the project for three years. Since the board lived in multiple time zones, we often had calls where people would be participating at 6 a.m. or 9 p.m. We convened on weekends in multiple cities across the U.S. I sincerely enjoyed the opportunity to be a part of this project and hopefully impact the future of medical education.

“I think the document makes a bold statement. It defines the hospitalist as the captain of the ship—and calls on hospitalists to lead multidisciplinary teams to improve the quality of care. I hope it sparks interest and debate about how we recruit, train, prepare, and certify physicians in hospital medicine.”

Dr. Pistoria believes that the Core Competencies will advance hospitalist programs. In fact, he says, hospitalists around the country have already affected improvements in care coordination. The hospitalist movement in general furnishes hospitals with physicians who say, “ ‘I’m going to take ownership of what happens within the four walls of this hospital,’ ” says Dr. Pistoria. “Previous to that, people obviously cared about what happened in the hospital, but they also worried about their office practices. This is our office practice. We want it to work as well as it can for our patients, for us, for our nursing colleagues, for our janitors—everybody needs to, and should, benefit from this.” TH

Writer Gretchen Henkel wrote about cultural competency in the September issue of The Hospitalist.

Welcome to 2006 and another coming-out party for SHM and hospitalists. In just a few short months more than a thousand hospitalists will come together in our nation’s capitol for the SHM Annual Meeting May 3-5, 2006. In addition to the largest convention of hospitalists, hundreds of other stakeholders in hospital medicine will gather for what has become the centerpiece of their year.

In addition to the opportunity to hear our nation’s experts talk about the up-to-date, state-of-the art medical knowledge for hospitalists, the SHM Annual Meeting is the place to find your next job, reconnect with colleagues from around the country, express your own opinions and vision for hospital medicine at the Special Interest Forums, and so much more.

SHM will be literally in the center of our nation’s capitol. It will be an opportunity for hospitalists to not only see the power center for our country, but with SHM’s help, a time for hospitalists to engage our legislators about issues important to hospitalists and our patients.

Taking advantage of the location of this year’s Annual Meeting, SHM’s Public Policy Committee has organized the first SHM Legislative Day on May 3, 2006. SHM meeting attendees can voluntarily sign up to meet with their congressmen and senators and their staffs.

SHM will make all the appointments for these Congressional visits. In addition, May 3 will kick off with a Washington overview and practical sessions on how best to approach your legislators to get your message across.

In addition, SHM has been working with HPA, a nationally recognized information resource in D.C. to put together a “Hospital Medicine White Paper” to concisely describe the emerging specialty of hospital medicine and how our perspectives and ideas are important to the healthcare debate.

The white paper will be a useful document to leave with your legislator and to use as a reference for your discussions. It will also contain some suggested policy recommendations supported by the SHM Board that can form the basis of what we would like to see move forward in Congress and on the Hill.

I have participated in many of these Legislative Days in my time on the ASIM and ACP Boards. I have found the legislators and their staffs interested in hearing from a passionate, informed part of their constituencies. Often these conversations were informal and personal and led to an ongoing relationship that continued when we were back home. I looked forward to coming back to Washington to renew our discussions.

And there can be real tangible changes as a result of these Congressional visits. I have seen changes in Medicare scope of benefits and reimbursement and methodologies based on messages I carried with the support of my professional medical societies.

Hospitalists are in a unique position to influence the current and future medical debates in Washington. We are young (average age 37) with a long professional career ahead of us. Hospitalists are at the center of many issues and initiatives that affect hospitals and the acutely ill patients they treat. Hospitalists measure and improve inpatient healthcare in an era of decreasing resources and increasing expectations.

Right now there is significant activity in pay for performance and in developing quality performance measures. There is also debate on gain-sharing and discussions of reducing and reshaping reimbursement for physicians. There are discussions on how to fund medical education and how to make sure all Americans get healthcare—even the 45 million without any insurance coverage. There are issues of access and limitations of crowded emergency departments and hospitals running at capacity.

There is no shortage of ideas and proposals, and most of these will affect hospitalists and the patients we treat and the hospitals we work in. In many ways these issues will shape our professional futures and determine how satisfying a career as a physician and specifically as a hospitalist will be.

Hospitalists and SHM must be part of the dialogue. We must clearly state where we stand and be prepared to back this up with data and to propose realistic solutions we are prepared to implement.

So clear your schedules May 3-5, 2006, and come to Washington, D.C., to join more than a thousand of your hospitalist colleagues as we take our first determined steps at the power center of our country. SHM will provide the support and materials for your success. But you must supply the voice and the presence. We owe no less to our profession and our patients now and in the future. TH

Dr. Wellikson has been CEO of SHM since 2000.

Welcome to 2006 and another coming-out party for SHM and hospitalists. In just a few short months more than a thousand hospitalists will come together in our nation’s capitol for the SHM Annual Meeting May 3-5, 2006. In addition to the largest convention of hospitalists, hundreds of other stakeholders in hospital medicine will gather for what has become the centerpiece of their year.

In addition to the opportunity to hear our nation’s experts talk about the up-to-date, state-of-the art medical knowledge for hospitalists, the SHM Annual Meeting is the place to find your next job, reconnect with colleagues from around the country, express your own opinions and vision for hospital medicine at the Special Interest Forums, and so much more.

SHM will be literally in the center of our nation’s capitol. It will be an opportunity for hospitalists to not only see the power center for our country, but with SHM’s help, a time for hospitalists to engage our legislators about issues important to hospitalists and our patients.

Taking advantage of the location of this year’s Annual Meeting, SHM’s Public Policy Committee has organized the first SHM Legislative Day on May 3, 2006. SHM meeting attendees can voluntarily sign up to meet with their congressmen and senators and their staffs.

SHM will make all the appointments for these Congressional visits. In addition, May 3 will kick off with a Washington overview and practical sessions on how best to approach your legislators to get your message across.

In addition, SHM has been working with HPA, a nationally recognized information resource in D.C. to put together a “Hospital Medicine White Paper” to concisely describe the emerging specialty of hospital medicine and how our perspectives and ideas are important to the healthcare debate.

The white paper will be a useful document to leave with your legislator and to use as a reference for your discussions. It will also contain some suggested policy recommendations supported by the SHM Board that can form the basis of what we would like to see move forward in Congress and on the Hill.

I have participated in many of these Legislative Days in my time on the ASIM and ACP Boards. I have found the legislators and their staffs interested in hearing from a passionate, informed part of their constituencies. Often these conversations were informal and personal and led to an ongoing relationship that continued when we were back home. I looked forward to coming back to Washington to renew our discussions.

And there can be real tangible changes as a result of these Congressional visits. I have seen changes in Medicare scope of benefits and reimbursement and methodologies based on messages I carried with the support of my professional medical societies.

Hospitalists are in a unique position to influence the current and future medical debates in Washington. We are young (average age 37) with a long professional career ahead of us. Hospitalists are at the center of many issues and initiatives that affect hospitals and the acutely ill patients they treat. Hospitalists measure and improve inpatient healthcare in an era of decreasing resources and increasing expectations.

Right now there is significant activity in pay for performance and in developing quality performance measures. There is also debate on gain-sharing and discussions of reducing and reshaping reimbursement for physicians. There are discussions on how to fund medical education and how to make sure all Americans get healthcare—even the 45 million without any insurance coverage. There are issues of access and limitations of crowded emergency departments and hospitals running at capacity.

There is no shortage of ideas and proposals, and most of these will affect hospitalists and the patients we treat and the hospitals we work in. In many ways these issues will shape our professional futures and determine how satisfying a career as a physician and specifically as a hospitalist will be.

Hospitalists and SHM must be part of the dialogue. We must clearly state where we stand and be prepared to back this up with data and to propose realistic solutions we are prepared to implement.

So clear your schedules May 3-5, 2006, and come to Washington, D.C., to join more than a thousand of your hospitalist colleagues as we take our first determined steps at the power center of our country. SHM will provide the support and materials for your success. But you must supply the voice and the presence. We owe no less to our profession and our patients now and in the future. TH

Dr. Wellikson has been CEO of SHM since 2000.

Welcome to 2006 and another coming-out party for SHM and hospitalists. In just a few short months more than a thousand hospitalists will come together in our nation’s capitol for the SHM Annual Meeting May 3-5, 2006. In addition to the largest convention of hospitalists, hundreds of other stakeholders in hospital medicine will gather for what has become the centerpiece of their year.

In addition to the opportunity to hear our nation’s experts talk about the up-to-date, state-of-the art medical knowledge for hospitalists, the SHM Annual Meeting is the place to find your next job, reconnect with colleagues from around the country, express your own opinions and vision for hospital medicine at the Special Interest Forums, and so much more.

SHM will be literally in the center of our nation’s capitol. It will be an opportunity for hospitalists to not only see the power center for our country, but with SHM’s help, a time for hospitalists to engage our legislators about issues important to hospitalists and our patients.

Taking advantage of the location of this year’s Annual Meeting, SHM’s Public Policy Committee has organized the first SHM Legislative Day on May 3, 2006. SHM meeting attendees can voluntarily sign up to meet with their congressmen and senators and their staffs.

SHM will make all the appointments for these Congressional visits. In addition, May 3 will kick off with a Washington overview and practical sessions on how best to approach your legislators to get your message across.

In addition, SHM has been working with HPA, a nationally recognized information resource in D.C. to put together a “Hospital Medicine White Paper” to concisely describe the emerging specialty of hospital medicine and how our perspectives and ideas are important to the healthcare debate.

The white paper will be a useful document to leave with your legislator and to use as a reference for your discussions. It will also contain some suggested policy recommendations supported by the SHM Board that can form the basis of what we would like to see move forward in Congress and on the Hill.

I have participated in many of these Legislative Days in my time on the ASIM and ACP Boards. I have found the legislators and their staffs interested in hearing from a passionate, informed part of their constituencies. Often these conversations were informal and personal and led to an ongoing relationship that continued when we were back home. I looked forward to coming back to Washington to renew our discussions.

And there can be real tangible changes as a result of these Congressional visits. I have seen changes in Medicare scope of benefits and reimbursement and methodologies based on messages I carried with the support of my professional medical societies.

Hospitalists are in a unique position to influence the current and future medical debates in Washington. We are young (average age 37) with a long professional career ahead of us. Hospitalists are at the center of many issues and initiatives that affect hospitals and the acutely ill patients they treat. Hospitalists measure and improve inpatient healthcare in an era of decreasing resources and increasing expectations.

Right now there is significant activity in pay for performance and in developing quality performance measures. There is also debate on gain-sharing and discussions of reducing and reshaping reimbursement for physicians. There are discussions on how to fund medical education and how to make sure all Americans get healthcare—even the 45 million without any insurance coverage. There are issues of access and limitations of crowded emergency departments and hospitals running at capacity.

There is no shortage of ideas and proposals, and most of these will affect hospitalists and the patients we treat and the hospitals we work in. In many ways these issues will shape our professional futures and determine how satisfying a career as a physician and specifically as a hospitalist will be.

Hospitalists and SHM must be part of the dialogue. We must clearly state where we stand and be prepared to back this up with data and to propose realistic solutions we are prepared to implement.

So clear your schedules May 3-5, 2006, and come to Washington, D.C., to join more than a thousand of your hospitalist colleagues as we take our first determined steps at the power center of our country. SHM will provide the support and materials for your success. But you must supply the voice and the presence. We owe no less to our profession and our patients now and in the future. TH

Dr. Wellikson has been CEO of SHM since 2000.

Editors’ note: During 2006 we will publish coverage of hospital practices in other countries. This is the first article in that effort.

Over the past two decades Afghanistan became known to many for its invasion by the Soviets (the war the mujahideen fought against its occupiers), the bloody infighting that followed the Soviet withdrawal, and the horrific rule of the Taliban. The expulsion of the Taliban in 2001 by coalition forces and Afghanistan’s recent steps toward democracy have made it the focus of much world attention.

Afghanistan’s health situation is among the worst in the world.1 The data that emerged in 2002 after the fall of the Taliban reported a maternal mortality ratio of 1,600 per 100,000 women, which translates into a lifetime risk that one in six women will die of complications of pregnancy and delivery.2-3 The same study showed severe inequities in mortality rates between rural and urban areas: Kabul’s maternal mortality ratio is 400 per 100,000, whereas in rural Badakhshan province it is 6,500 per 100,000—the highest recorded rate in the world in modern times.2 Afghanistan is the only country in the world where men outlive women. Twenty-five percent of children die before age five—most of treatable diseases such as diarrhea and pneumonia, and preventable diseases such as measles and pertussis. Children, women, and men face risks from communicable diseases that are among the highest in the world, as well as the risk of death or serious injury from landmines and other unexploded ordnance.

In this setting, the Ministry of Public Health made two major decisions in 2002: All health services would be contracted to nongovernmental organizations and the Ministry would be the steward of the health system, setting policies and regulating services; and the Basic Package of Health Services would be the main policy that all service providers would follow.4-5 This package defines specific services focused on women’s and children’s needs by level and by appropriate intervention.6 The Basic Package also stresses equity by giving priority to rural over urban areas and to women’s participation over men’s. A related policy on hospitals limits spending on hospitals to 40% of the national health budget, with the remaining 60% to be spent on basic health services.7

State of Hospitals

Many health facilities—especially hospitals—had been damaged or destroyed. A survey of all health facilities in the country by Management Sciences for Health (MSH) in 2002, with funding from the U.S. Agency for International Development and other donors, found that 35% of the facilities were severely damaged due to war or natural disasters, and the rest failed to meet current World Health Organization standards.8 A second major concern was the lack of health professionals, many of whom had fled the country during the war years. Finally, the staff remaining, especially physicians, lacked good clinical training and continuing education, which compromised quality of care. The Rural Expansion of Afghanistan’s Community-based Healthcare (REACH) was designed to address all these issues. REACH is a program funded by the U.S. Agency for International Development and implemented by MSH and the Afghan Ministry of Public Health. Partners include the Academy for Educational Development; JHPIEGO (an international health organization affiliated with Johns Hopkins University); Technical Assistance, Inc., and the University of Massachusetts/Amherst.

Hospitals are a critical element of the Afghan health system because they are part of the referral system that plays an essential role in reducing high maternal and early childhood mortality rates. In addition, hospitals use many of the most skilled health workers and the financial resources of the health system. Dramatic improvements in hospital management are needed so hospitals can use these scarce resources effectively and efficiently.9

click for large version

Challenges

In brief, the key issues facing hospitals in the Afghan health system are:

• Maldistribution of hospitals and hospital beds throughout the country, which means a lack of equitable access to hospital care. People in urban areas have access but semi-urban and rural populations have limited access. For example, Kabul has 1.28 beds per 1,000 people while the provinces have only .22 per 1,000;
• Lack of standards for clinical patient care, resulting in poor quality of care; and
• Lack of hospital management skills, which results in inefficiently run hospitals, poorly managed staff, lack of supplies, and inoperable equipment due to lack of maintenance.10

Response: The Hospital Management Improvement Initiative

REACH began helping to rebuild the health sector in 2003. Initial efforts focused on expanding basic services, and in two years we have moved from 5% to 77% coverage of the population of Afghanistan. In 2004, the contract was amended to include the hospital sector, with a focus on provincial hospitals. REACH developed the Hospital Management Improvement Initiative to build the clinical and management capacity of hospitals so that:

1. Health services are delivered more efficiently;
2. The quality of services are improved;
3. The population has increased access to hospital services; and
4. There is a positive impact on health status—especially on the morbidity and mortality of women and children.

Introducing clinical and management improvements, combined with appropriate resources, will improve quality of care, increase access to hospital services, and streamline hospital operations. These improvements will ultimately result in achievement of the goals of improved health status, improved patient and community satisfaction with hospitals, and an improved referral system for Afghanistan.

Although the need was great, it was not possible to train the management team at each hospital in Afghanistan. Instead, clinical and management capacities at the provincial and central hospitals were strengthened through training, mentoring, networking and modeling, and provision of resources.

Areas of Standards for Hospitals in Afghanistan Governance

• Hospital community board*

Clinical Services

• Internal medicine
• General surgery *
• Anesthesia*
• Obstetrics and gynecology*
• Pediatrics*
• Emergency care*
• Outpatient department
• Infection prevention*

Diagnostic/Ancillary Services

• Laboratory
• Blood transfusion/blood bank*
• Radiology/x-ray
• Pharmacy*

Nursing Services

• Nursing care in patient wards
• Central service/sterilization
• Operating theater

Administration and Support Services

• Medical records
• Human resource (personnel) management*
• Housekeeping
• Catering/food service
• Laundry
• Facilities and equipment maintenance*
• Purchasing/medical stores
• Business office and administration

*=Standards developed and implemented at five provincial hospitals as of Sept. 2005.

Training

The Standards Based Management/Performance Quality Improvement approach that JHPIEGO has successfully developed and used to improve the quality of reproductive health services in many resource-poor settings has been expanded and adapted by REACH into a comprehensive approach to improve hospital management in Afghanistan. This process includes all clinical services (surgery, anesthesia, emergency care, pediatrics, infection prevention, and blood transfusion and blood banks) and management systems (governance, facilities and equipment management, pharmacy management, human resource systems) for general hospitals.

Standards were developed in each of these areas, and training modules developed. Eight workshops have been held to train key staff from each hospital, who return to their hospitals to introduce the standards to their medical and administrative staff. Each workshop produces a plan for implementing the standards according to the circumstances of each hospital. The training is incremental. For instance, rather than doing a one- to two-week workshop presenting all the training modules, two modules on standards (usually one clinical and one management area) are presented. Two new modules are presented quarterly thereafter, to prevent information overload, allow trainees to integrate what they have learned with real day-to-day management, and avoid the problem of hospitals being left without leadership for an extended period.

Mentoring

A skilled hospital management advisor visits the hospitals regularly so managers have the opportunity to work with a mentor to apply what they have learned to their hospitals. This practical experience involves applying principles to real-life situations with someone experienced enough to help overcome obstacles not anticipated in the workshops. Mentors from REACH and the Ministry of Public Health visit the provincial hospitals to discuss problems, review progress, talk about problems that prevented achievement of goals, and set goals for the next three-month period.

The first four provincial hospitals selected for this intervention are all in areas formerly controlled by the Taliban, and security issues have added other challenges to this program because of repeated terrorist attacks on non-governmental organizations and people employed by international organizations. The mentors involved must speak Pashto, the local language, and integrate into the culture so they do not attract attention or create local opposition. Mentoring is a necessary but dangerous activity for the success of the program.

Networking and Modeling

As more hospital managers and senior clinicians are trained through this program, networking becomes another important tool. The network uses meetings twice a year for two days in a participating hospital to provide an opportunity for hospital managers to discuss common issues and develop system-wide solutions. Between these meetings, hospital managers in the same region exchange visits to learn from each other. REACH facilitates this networking using e-mail (some of the provincial hospitals have Internet access, which has dramatically increased their participation in evidence-based approaches), dissemination of reports, and passing on requests for communication between hospitals. These formal meetings and informal exchanges permit hospital managers to interact about common problems and learn how other hospitals have solved those problems. This networking will slowly expand to cover more provincial hospitals and will assist in expanding the number of trainers and mentors.

click for large version

Modeling means trying new systems and methods generated by the trainees to address their self-identified problems. Improvements in five provincial hospitals (in Khost, Paktika, Paktia, Ghazni, and Badakhshan) will provide a model that demonstrates to the public that hospitals can be well run and serve the community. These hospitals can also be used as training grounds for other hospital managers from around the country as the initiative expands to more of the remaining 28 provincial hospitals. The goal is to develop optimism and creativity because one of the main barriers in training is that some managers have difficulty imagining things being different because they feel the system “has always been broken.” When trainees see that other hospitals have successfully tried new approaches, they will consider a broader range of possibilities for their own hospitals.

Resources

Along with the management improvements achieved through training, mentoring, and networking, additional resources are needed to improve hospital services. REACH has been the conduit for U.S. government funding, providing $2.6 million in critical resources to drive improvements in the five provincial hospitals. These funds are channeled through the contracted nongovernmental organizations, which hire staff and pay decent salaries.

The average hospital physician in the Ministry of Public Health is paid $50 a month. In this setting “under-the-table” charges for clinical services are common, and physicians usually leave the hospital by lunch to attend to their private clinics. This initiative pays physicians up to $500 a month with the expectations that they will work a full day, provide 24-hour emergency coverage, and not charge patients. Eighteen months of experience suggest that these expectations are being met. Resources are also used for remodeling facilities, purchasing equipment and supplies, and providing essential medicines. The management standards developed are designed to make rational use of these scarce resources.

click for large version

Prerequisites for the Initiative

Two key prerequisites for starting the Hospital Management Initiative were:

1. Identifying where standards had to be developed: REACH has assisted the Ministry of Public Health to identify the standards that must be developed: responsibilities of hospitals to the community, patient care (clinical care), human resource management, management systems, environmental health, and leadership and management.10 “Areas of Standards for Hospitals in Afghanistan” shows the standards that have been or are to be developed. (See sidebar at left.)
2. Essential Package of Hospital Services: To ensure that donor support does not stimulate a proliferation of hospitals and high-tech equipment that are not appropriate or sustainable for Afghanistan, REACH has been helping the Ministry of Public Health define the levels of hospitals (district, provincial, regional), the populations they serve, the services they offer, and the equipment, staff, supplies, and pharmaceuticals they need. The result was the publication of the Essential Package of Hospital Services, which defines these for each of the three levels of hospitals in the country, in 2005. This package will provide guidance for Afghanistan’s hospitals for the coming decade, much as the Basic Package of Health Services has done for primary healthcare services. The hospital package will also support long-term planning and help the Ministry make the best use of donor assistance for redeveloping the hospital sector.

Developing and Implementing Standards

Standards-based management begins by identifying existing clinical guidelines and standards developed by American or international specialty societies. Specialist consultants in each clinical area with many years’ experience in Afghanistan (some of them Afghan-American physicians) are contracted to develop these standards and then adapt them to the Afghan context, in consultation with physicians in Afghanistan.

For example, standards for acute abdominal pain had to be adapted to a situation where CAT scans and ultrasounds are not readily available, and the lack of electrolyte laboratory capacity in hospitals stimulated physicians to adapt standards for shock, and fluid and electrolyte balance that do not rely on knowing electrolyte levels. The standards development teams aimed to raise the standards of Afghan hospitals to a realistic extent but not set the bar so high that improvement was unattainable.

After the standards were developed, clinicians from Afghan hospitals reviewed and revised the standards to ensure that they were appropriate. This review also served as a means of training because the participants were able and eager to question the contracted expert about the standards in developed countries and the evidence supporting those standards. Once the standards are revised, a workshop is held to introduce them to hospital staff. The hospital teams then develop an action plan for introducing the standards into their facilities.

Quality improvement teams at each of the five hospitals take responsibility for shepherding the action plans through implementation. An advisor visits each hospital quarterly to review progress, assess barriers, and help hospital staff develop ways to overcome problems and accelerate standards implementation. During the mentor’s first visit after new standards have been introduced, he performs a baseline assessment of the hospital’s current compliance with the standards. This serves as a benchmark for future measurement of progress in meeting the standards.

The Results

The hospitals have been enthusiastic about this process and the gains they have seen in the quality of care at their facilities. “We have made more progress in four months of the Hospital Management Improvement Initiative than we made in the previous five years with many other donors because this methodology is sound and appropriate for Afghanistan,” said Dr. Mohammed Ismael, the director of Ghazni Provincial Hospital.

One example of the process and results was the first area in which standards were developed—essential obstetric care. Physicians examined seven components of the quality of emergency obstetric care: handling of pregnancy complications; labor, delivery, and postpartum and newborn care; support services; infection prevention; health education given to families and mothers; human, physical, and material resources; and management systems in the obstetrics/gynecology department. After the standards were established, the first step was to find out where each hospital stood in meeting them. (For the combined results of that first baseline assessment for four hospitals, see Figure 1, p. 20.)

The changes in standards for emergency obstetric care at the hospitals from July 2004 to July 2005 have been impressive. The overall composite scores for emergency obstetric care for the four hospitals have improved from 31% at the baseline assessment to 47%. Here are the average improvements in the same four hospitals over one year:

Lessons Learned

The principal lesson learned through this hospital management improvement initiative is that combining clinical and management improvements can create innovation in a developing country. Improvements are made throughout a hospital—not just in one clinical area. Second, mentoring has proven essential as a follow-up to training. The training alone will not bring about significant positive changes. Only with on-site visitation is there the opportunity to integrate new knowledge with practical implementation issues that have proven troublesome to overcome. Third, setting standards is key to the sustainability of improvements. Training individuals in skills is helpful but is not sustainable if those trained staff depart. Using hospital teams and common standards throughout different hospitals leads to institutionalization of the process.

Staff motivation has also proven to be essential to sustainability. Staff have been motivated because they see that many positive changes are within their control; they do not have to wait for someone else to make an improvement before they can introduce positive change. An ethic of continuous quality improvement is achieved through staff who are proud of the changes they have introduced. The iterative nature of this process has been essential to quality improvement: The standards are continually revisited and revised as needed. At times, new standards for other areas are developed when the hospitals need them. Finally, providing resources to pay adequate salaries, renovate facilities, buy equipment and supplies, and provide essential medicines are all important elements of this success.

This method has proven successful in such a short time that the Minister of Public Health, Dr. Mohammad Amin Fatimie, has expressed his desire to extend it to many other hospitals in the country in an effort to improve the quality of hospital care throughout Afghani-stan. The U.S. Agency for International Development and MSH have agreed to support this request, and the program will expand in future years. TH

Dr. Hartman

Dr. Newbrander

Dr. Hartman, is a family physician with subspecialty training in infectious diseases, epidemiology, and public health. He serves as the technical director and deputy chief of party of the REACH Project, based in Kabul. Dr. Newbrander is a health economist who has served in Afghanistan since 2002 as a senior advisor to the Ministry of Health. He is currently Health Financing and Hospital Management Advisor for the USAID-funded REACH Project.

Acknowledgment: Funding for this article was provided by the United States Agency for International Development under the REACH Project, contract number EEE-C-00-03-00015-00. The opinions expressed herein are those of the authors and do not necessarily reflect the views of USAID.

References

1. Newbrander W, Ickx P, Leitch GH. Addressing the immediate and long-term health needs in Afghanistan. Harvard Health Pol Rev. 2003;4.
2. Ministry of Health Transitional Islamic Government of Afghanistan (TISA), US Centers for Disease Control and Prevention, United Nations Children’s Fund. Maternal mortality in Afghanistan: magnitude, causes, risk factors and preventability. Kabul: TISA; 2002.
3. Bartlett LA, Mawji S, Whitehead S, et al. Where giving birth is a forecast of death: maternal mortality in four districts of Afghanistan, 1999-2002. Lancet. 2005;365:864-870.
4. Strong L, Wali A, Sondorp E. Health Policy in Afghanistan: Two Years of Rapid Change: A Review of the Process from 2001 to 2003. London: London School of Hygiene and Tropical Medicine; 2005.
5. Afghanistan’s health challenge. Lancet. 2003;362:841.
6. Ministry of Health Transitional Islamic Government of Afghanistan (TISA). The Basic Package of Health Services for Afghanistan. Kabul: TISA; 2003.
7. Ministry of Health Transitional Islamic Government of Afghanistan (TISA). Hospital Policy for Afghanistan’s Health System. Kabul: TISA; 2004.
8. Ministry of Health Transitional Islamic Government of Afghanistan (TISA), Management Sciences for Health. Afghanistan national health resources assessment: Preliminary results. Kabul: TISA; 2002.
9. A crucial time for Afghanistan’s fledgling health system. Lancet. 2005; 365:819-820.
10. Ministry of Public Health (MOPH) Islamic Republic of Afghanistan. The Essential Package of Hospital Services for Afghanistan. Kabul: MOPH; 2005.

Editors’ note: During 2006 we will publish coverage of hospital practices in other countries. This is the first article in that effort.

Over the past two decades Afghanistan became known to many for its invasion by the Soviets (the war the mujahideen fought against its occupiers), the bloody infighting that followed the Soviet withdrawal, and the horrific rule of the Taliban. The expulsion of the Taliban in 2001 by coalition forces and Afghanistan’s recent steps toward democracy have made it the focus of much world attention.

Afghanistan’s health situation is among the worst in the world.1 The data that emerged in 2002 after the fall of the Taliban reported a maternal mortality ratio of 1,600 per 100,000 women, which translates into a lifetime risk that one in six women will die of complications of pregnancy and delivery.2-3 The same study showed severe inequities in mortality rates between rural and urban areas: Kabul’s maternal mortality ratio is 400 per 100,000, whereas in rural Badakhshan province it is 6,500 per 100,000—the highest recorded rate in the world in modern times.2 Afghanistan is the only country in the world where men outlive women. Twenty-five percent of children die before age five—most of treatable diseases such as diarrhea and pneumonia, and preventable diseases such as measles and pertussis. Children, women, and men face risks from communicable diseases that are among the highest in the world, as well as the risk of death or serious injury from landmines and other unexploded ordnance.

In this setting, the Ministry of Public Health made two major decisions in 2002: All health services would be contracted to nongovernmental organizations and the Ministry would be the steward of the health system, setting policies and regulating services; and the Basic Package of Health Services would be the main policy that all service providers would follow.4-5 This package defines specific services focused on women’s and children’s needs by level and by appropriate intervention.6 The Basic Package also stresses equity by giving priority to rural over urban areas and to women’s participation over men’s. A related policy on hospitals limits spending on hospitals to 40% of the national health budget, with the remaining 60% to be spent on basic health services.7

State of Hospitals

Many health facilities—especially hospitals—had been damaged or destroyed. A survey of all health facilities in the country by Management Sciences for Health (MSH) in 2002, with funding from the U.S. Agency for International Development and other donors, found that 35% of the facilities were severely damaged due to war or natural disasters, and the rest failed to meet current World Health Organization standards.8 A second major concern was the lack of health professionals, many of whom had fled the country during the war years. Finally, the staff remaining, especially physicians, lacked good clinical training and continuing education, which compromised quality of care. The Rural Expansion of Afghanistan’s Community-based Healthcare (REACH) was designed to address all these issues. REACH is a program funded by the U.S. Agency for International Development and implemented by MSH and the Afghan Ministry of Public Health. Partners include the Academy for Educational Development; JHPIEGO (an international health organization affiliated with Johns Hopkins University); Technical Assistance, Inc., and the University of Massachusetts/Amherst.

Hospitals are a critical element of the Afghan health system because they are part of the referral system that plays an essential role in reducing high maternal and early childhood mortality rates. In addition, hospitals use many of the most skilled health workers and the financial resources of the health system. Dramatic improvements in hospital management are needed so hospitals can use these scarce resources effectively and efficiently.9

click for large version

Challenges

In brief, the key issues facing hospitals in the Afghan health system are:

• Maldistribution of hospitals and hospital beds throughout the country, which means a lack of equitable access to hospital care. People in urban areas have access but semi-urban and rural populations have limited access. For example, Kabul has 1.28 beds per 1,000 people while the provinces have only .22 per 1,000;
• Lack of standards for clinical patient care, resulting in poor quality of care; and
• Lack of hospital management skills, which results in inefficiently run hospitals, poorly managed staff, lack of supplies, and inoperable equipment due to lack of maintenance.10

Response: The Hospital Management Improvement Initiative

REACH began helping to rebuild the health sector in 2003. Initial efforts focused on expanding basic services, and in two years we have moved from 5% to 77% coverage of the population of Afghanistan. In 2004, the contract was amended to include the hospital sector, with a focus on provincial hospitals. REACH developed the Hospital Management Improvement Initiative to build the clinical and management capacity of hospitals so that:

1. Health services are delivered more efficiently;
2. The quality of services are improved;
3. The population has increased access to hospital services; and
4. There is a positive impact on health status—especially on the morbidity and mortality of women and children.

Introducing clinical and management improvements, combined with appropriate resources, will improve quality of care, increase access to hospital services, and streamline hospital operations. These improvements will ultimately result in achievement of the goals of improved health status, improved patient and community satisfaction with hospitals, and an improved referral system for Afghanistan.

Although the need was great, it was not possible to train the management team at each hospital in Afghanistan. Instead, clinical and management capacities at the provincial and central hospitals were strengthened through training, mentoring, networking and modeling, and provision of resources.

Areas of Standards for Hospitals in Afghanistan Governance

• Hospital community board*

Clinical Services

• Internal medicine
• General surgery *
• Anesthesia*
• Obstetrics and gynecology*
• Pediatrics*
• Emergency care*
• Outpatient department
• Infection prevention*

Diagnostic/Ancillary Services

• Laboratory
• Blood transfusion/blood bank*
• Radiology/x-ray
• Pharmacy*

Nursing Services

• Nursing care in patient wards
• Central service/sterilization
• Operating theater

Administration and Support Services

• Medical records
• Human resource (personnel) management*
• Housekeeping
• Catering/food service
• Laundry
• Facilities and equipment maintenance*
• Purchasing/medical stores
• Business office and administration

*=Standards developed and implemented at five provincial hospitals as of Sept. 2005.

Training

The Standards Based Management/Performance Quality Improvement approach that JHPIEGO has successfully developed and used to improve the quality of reproductive health services in many resource-poor settings has been expanded and adapted by REACH into a comprehensive approach to improve hospital management in Afghanistan. This process includes all clinical services (surgery, anesthesia, emergency care, pediatrics, infection prevention, and blood transfusion and blood banks) and management systems (governance, facilities and equipment management, pharmacy management, human resource systems) for general hospitals.

Standards were developed in each of these areas, and training modules developed. Eight workshops have been held to train key staff from each hospital, who return to their hospitals to introduce the standards to their medical and administrative staff. Each workshop produces a plan for implementing the standards according to the circumstances of each hospital. The training is incremental. For instance, rather than doing a one- to two-week workshop presenting all the training modules, two modules on standards (usually one clinical and one management area) are presented. Two new modules are presented quarterly thereafter, to prevent information overload, allow trainees to integrate what they have learned with real day-to-day management, and avoid the problem of hospitals being left without leadership for an extended period.

Mentoring

A skilled hospital management advisor visits the hospitals regularly so managers have the opportunity to work with a mentor to apply what they have learned to their hospitals. This practical experience involves applying principles to real-life situations with someone experienced enough to help overcome obstacles not anticipated in the workshops. Mentors from REACH and the Ministry of Public Health visit the provincial hospitals to discuss problems, review progress, talk about problems that prevented achievement of goals, and set goals for the next three-month period.

The first four provincial hospitals selected for this intervention are all in areas formerly controlled by the Taliban, and security issues have added other challenges to this program because of repeated terrorist attacks on non-governmental organizations and people employed by international organizations. The mentors involved must speak Pashto, the local language, and integrate into the culture so they do not attract attention or create local opposition. Mentoring is a necessary but dangerous activity for the success of the program.

Networking and Modeling

As more hospital managers and senior clinicians are trained through this program, networking becomes another important tool. The network uses meetings twice a year for two days in a participating hospital to provide an opportunity for hospital managers to discuss common issues and develop system-wide solutions. Between these meetings, hospital managers in the same region exchange visits to learn from each other. REACH facilitates this networking using e-mail (some of the provincial hospitals have Internet access, which has dramatically increased their participation in evidence-based approaches), dissemination of reports, and passing on requests for communication between hospitals. These formal meetings and informal exchanges permit hospital managers to interact about common problems and learn how other hospitals have solved those problems. This networking will slowly expand to cover more provincial hospitals and will assist in expanding the number of trainers and mentors.

click for large version

Modeling means trying new systems and methods generated by the trainees to address their self-identified problems. Improvements in five provincial hospitals (in Khost, Paktika, Paktia, Ghazni, and Badakhshan) will provide a model that demonstrates to the public that hospitals can be well run and serve the community. These hospitals can also be used as training grounds for other hospital managers from around the country as the initiative expands to more of the remaining 28 provincial hospitals. The goal is to develop optimism and creativity because one of the main barriers in training is that some managers have difficulty imagining things being different because they feel the system “has always been broken.” When trainees see that other hospitals have successfully tried new approaches, they will consider a broader range of possibilities for their own hospitals.

Resources

Along with the management improvements achieved through training, mentoring, and networking, additional resources are needed to improve hospital services. REACH has been the conduit for U.S. government funding, providing $2.6 million in critical resources to drive improvements in the five provincial hospitals. These funds are channeled through the contracted nongovernmental organizations, which hire staff and pay decent salaries.

The average hospital physician in the Ministry of Public Health is paid $50 a month. In this setting “under-the-table” charges for clinical services are common, and physicians usually leave the hospital by lunch to attend to their private clinics. This initiative pays physicians up to $500 a month with the expectations that they will work a full day, provide 24-hour emergency coverage, and not charge patients. Eighteen months of experience suggest that these expectations are being met. Resources are also used for remodeling facilities, purchasing equipment and supplies, and providing essential medicines. The management standards developed are designed to make rational use of these scarce resources.

click for large version

Prerequisites for the Initiative

Two key prerequisites for starting the Hospital Management Initiative were:

1. Identifying where standards had to be developed: REACH has assisted the Ministry of Public Health to identify the standards that must be developed: responsibilities of hospitals to the community, patient care (clinical care), human resource management, management systems, environmental health, and leadership and management.10 “Areas of Standards for Hospitals in Afghanistan” shows the standards that have been or are to be developed. (See sidebar at left.)
2. Essential Package of Hospital Services: To ensure that donor support does not stimulate a proliferation of hospitals and high-tech equipment that are not appropriate or sustainable for Afghanistan, REACH has been helping the Ministry of Public Health define the levels of hospitals (district, provincial, regional), the populations they serve, the services they offer, and the equipment, staff, supplies, and pharmaceuticals they need. The result was the publication of the Essential Package of Hospital Services, which defines these for each of the three levels of hospitals in the country, in 2005. This package will provide guidance for Afghanistan’s hospitals for the coming decade, much as the Basic Package of Health Services has done for primary healthcare services. The hospital package will also support long-term planning and help the Ministry make the best use of donor assistance for redeveloping the hospital sector.

Developing and Implementing Standards

Standards-based management begins by identifying existing clinical guidelines and standards developed by American or international specialty societies. Specialist consultants in each clinical area with many years’ experience in Afghanistan (some of them Afghan-American physicians) are contracted to develop these standards and then adapt them to the Afghan context, in consultation with physicians in Afghanistan.

For example, standards for acute abdominal pain had to be adapted to a situation where CAT scans and ultrasounds are not readily available, and the lack of electrolyte laboratory capacity in hospitals stimulated physicians to adapt standards for shock, and fluid and electrolyte balance that do not rely on knowing electrolyte levels. The standards development teams aimed to raise the standards of Afghan hospitals to a realistic extent but not set the bar so high that improvement was unattainable.

After the standards were developed, clinicians from Afghan hospitals reviewed and revised the standards to ensure that they were appropriate. This review also served as a means of training because the participants were able and eager to question the contracted expert about the standards in developed countries and the evidence supporting those standards. Once the standards are revised, a workshop is held to introduce them to hospital staff. The hospital teams then develop an action plan for introducing the standards into their facilities.

Quality improvement teams at each of the five hospitals take responsibility for shepherding the action plans through implementation. An advisor visits each hospital quarterly to review progress, assess barriers, and help hospital staff develop ways to overcome problems and accelerate standards implementation. During the mentor’s first visit after new standards have been introduced, he performs a baseline assessment of the hospital’s current compliance with the standards. This serves as a benchmark for future measurement of progress in meeting the standards.

The Results

The hospitals have been enthusiastic about this process and the gains they have seen in the quality of care at their facilities. “We have made more progress in four months of the Hospital Management Improvement Initiative than we made in the previous five years with many other donors because this methodology is sound and appropriate for Afghanistan,” said Dr. Mohammed Ismael, the director of Ghazni Provincial Hospital.

One example of the process and results was the first area in which standards were developed—essential obstetric care. Physicians examined seven components of the quality of emergency obstetric care: handling of pregnancy complications; labor, delivery, and postpartum and newborn care; support services; infection prevention; health education given to families and mothers; human, physical, and material resources; and management systems in the obstetrics/gynecology department. After the standards were established, the first step was to find out where each hospital stood in meeting them. (For the combined results of that first baseline assessment for four hospitals, see Figure 1, p. 20.)

The changes in standards for emergency obstetric care at the hospitals from July 2004 to July 2005 have been impressive. The overall composite scores for emergency obstetric care for the four hospitals have improved from 31% at the baseline assessment to 47%. Here are the average improvements in the same four hospitals over one year:

Lessons Learned

The principal lesson learned through this hospital management improvement initiative is that combining clinical and management improvements can create innovation in a developing country. Improvements are made throughout a hospital—not just in one clinical area. Second, mentoring has proven essential as a follow-up to training. The training alone will not bring about significant positive changes. Only with on-site visitation is there the opportunity to integrate new knowledge with practical implementation issues that have proven troublesome to overcome. Third, setting standards is key to the sustainability of improvements. Training individuals in skills is helpful but is not sustainable if those trained staff depart. Using hospital teams and common standards throughout different hospitals leads to institutionalization of the process.

Staff motivation has also proven to be essential to sustainability. Staff have been motivated because they see that many positive changes are within their control; they do not have to wait for someone else to make an improvement before they can introduce positive change. An ethic of continuous quality improvement is achieved through staff who are proud of the changes they have introduced. The iterative nature of this process has been essential to quality improvement: The standards are continually revisited and revised as needed. At times, new standards for other areas are developed when the hospitals need them. Finally, providing resources to pay adequate salaries, renovate facilities, buy equipment and supplies, and provide essential medicines are all important elements of this success.

This method has proven successful in such a short time that the Minister of Public Health, Dr. Mohammad Amin Fatimie, has expressed his desire to extend it to many other hospitals in the country in an effort to improve the quality of hospital care throughout Afghani-stan. The U.S. Agency for International Development and MSH have agreed to support this request, and the program will expand in future years. TH

Dr. Hartman

Dr. Newbrander

Dr. Hartman, is a family physician with subspecialty training in infectious diseases, epidemiology, and public health. He serves as the technical director and deputy chief of party of the REACH Project, based in Kabul. Dr. Newbrander is a health economist who has served in Afghanistan since 2002 as a senior advisor to the Ministry of Health. He is currently Health Financing and Hospital Management Advisor for the USAID-funded REACH Project.

Acknowledgment: Funding for this article was provided by the United States Agency for International Development under the REACH Project, contract number EEE-C-00-03-00015-00. The opinions expressed herein are those of the authors and do not necessarily reflect the views of USAID.

References

1. Newbrander W, Ickx P, Leitch GH. Addressing the immediate and long-term health needs in Afghanistan. Harvard Health Pol Rev. 2003;4.
2. Ministry of Health Transitional Islamic Government of Afghanistan (TISA), US Centers for Disease Control and Prevention, United Nations Children’s Fund. Maternal mortality in Afghanistan: magnitude, causes, risk factors and preventability. Kabul: TISA; 2002.
3. Bartlett LA, Mawji S, Whitehead S, et al. Where giving birth is a forecast of death: maternal mortality in four districts of Afghanistan, 1999-2002. Lancet. 2005;365:864-870.
4. Strong L, Wali A, Sondorp E. Health Policy in Afghanistan: Two Years of Rapid Change: A Review of the Process from 2001 to 2003. London: London School of Hygiene and Tropical Medicine; 2005.
5. Afghanistan’s health challenge. Lancet. 2003;362:841.
6. Ministry of Health Transitional Islamic Government of Afghanistan (TISA). The Basic Package of Health Services for Afghanistan. Kabul: TISA; 2003.
7. Ministry of Health Transitional Islamic Government of Afghanistan (TISA). Hospital Policy for Afghanistan’s Health System. Kabul: TISA; 2004.
8. Ministry of Health Transitional Islamic Government of Afghanistan (TISA), Management Sciences for Health. Afghanistan national health resources assessment: Preliminary results. Kabul: TISA; 2002.
9. A crucial time for Afghanistan’s fledgling health system. Lancet. 2005; 365:819-820.
10. Ministry of Public Health (MOPH) Islamic Republic of Afghanistan. The Essential Package of Hospital Services for Afghanistan. Kabul: MOPH; 2005.

Editors’ note: During 2006 we will publish coverage of hospital practices in other countries. This is the first article in that effort.

Over the past two decades Afghanistan became known to many for its invasion by the Soviets (the war the mujahideen fought against its occupiers), the bloody infighting that followed the Soviet withdrawal, and the horrific rule of the Taliban. The expulsion of the Taliban in 2001 by coalition forces and Afghanistan’s recent steps toward democracy have made it the focus of much world attention.

Afghanistan’s health situation is among the worst in the world.1 The data that emerged in 2002 after the fall of the Taliban reported a maternal mortality ratio of 1,600 per 100,000 women, which translates into a lifetime risk that one in six women will die of complications of pregnancy and delivery.2-3 The same study showed severe inequities in mortality rates between rural and urban areas: Kabul’s maternal mortality ratio is 400 per 100,000, whereas in rural Badakhshan province it is 6,500 per 100,000—the highest recorded rate in the world in modern times.2 Afghanistan is the only country in the world where men outlive women. Twenty-five percent of children die before age five—most of treatable diseases such as diarrhea and pneumonia, and preventable diseases such as measles and pertussis. Children, women, and men face risks from communicable diseases that are among the highest in the world, as well as the risk of death or serious injury from landmines and other unexploded ordnance.

In this setting, the Ministry of Public Health made two major decisions in 2002: All health services would be contracted to nongovernmental organizations and the Ministry would be the steward of the health system, setting policies and regulating services; and the Basic Package of Health Services would be the main policy that all service providers would follow.4-5 This package defines specific services focused on women’s and children’s needs by level and by appropriate intervention.6 The Basic Package also stresses equity by giving priority to rural over urban areas and to women’s participation over men’s. A related policy on hospitals limits spending on hospitals to 40% of the national health budget, with the remaining 60% to be spent on basic health services.7

State of Hospitals

Many health facilities—especially hospitals—had been damaged or destroyed. A survey of all health facilities in the country by Management Sciences for Health (MSH) in 2002, with funding from the U.S. Agency for International Development and other donors, found that 35% of the facilities were severely damaged due to war or natural disasters, and the rest failed to meet current World Health Organization standards.8 A second major concern was the lack of health professionals, many of whom had fled the country during the war years. Finally, the staff remaining, especially physicians, lacked good clinical training and continuing education, which compromised quality of care. The Rural Expansion of Afghanistan’s Community-based Healthcare (REACH) was designed to address all these issues. REACH is a program funded by the U.S. Agency for International Development and implemented by MSH and the Afghan Ministry of Public Health. Partners include the Academy for Educational Development; JHPIEGO (an international health organization affiliated with Johns Hopkins University); Technical Assistance, Inc., and the University of Massachusetts/Amherst.

Hospitals are a critical element of the Afghan health system because they are part of the referral system that plays an essential role in reducing high maternal and early childhood mortality rates. In addition, hospitals use many of the most skilled health workers and the financial resources of the health system. Dramatic improvements in hospital management are needed so hospitals can use these scarce resources effectively and efficiently.9

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Challenges

In brief, the key issues facing hospitals in the Afghan health system are:

• Maldistribution of hospitals and hospital beds throughout the country, which means a lack of equitable access to hospital care. People in urban areas have access but semi-urban and rural populations have limited access. For example, Kabul has 1.28 beds per 1,000 people while the provinces have only .22 per 1,000;
• Lack of standards for clinical patient care, resulting in poor quality of care; and
• Lack of hospital management skills, which results in inefficiently run hospitals, poorly managed staff, lack of supplies, and inoperable equipment due to lack of maintenance.10

Response: The Hospital Management Improvement Initiative

REACH began helping to rebuild the health sector in 2003. Initial efforts focused on expanding basic services, and in two years we have moved from 5% to 77% coverage of the population of Afghanistan. In 2004, the contract was amended to include the hospital sector, with a focus on provincial hospitals. REACH developed the Hospital Management Improvement Initiative to build the clinical and management capacity of hospitals so that:

1. Health services are delivered more efficiently;
2. The quality of services are improved;
3. The population has increased access to hospital services; and
4. There is a positive impact on health status—especially on the morbidity and mortality of women and children.

Introducing clinical and management improvements, combined with appropriate resources, will improve quality of care, increase access to hospital services, and streamline hospital operations. These improvements will ultimately result in achievement of the goals of improved health status, improved patient and community satisfaction with hospitals, and an improved referral system for Afghanistan.

Although the need was great, it was not possible to train the management team at each hospital in Afghanistan. Instead, clinical and management capacities at the provincial and central hospitals were strengthened through training, mentoring, networking and modeling, and provision of resources.

Areas of Standards for Hospitals in Afghanistan Governance

• Hospital community board*

Clinical Services

• Internal medicine
• General surgery *
• Anesthesia*
• Obstetrics and gynecology*
• Pediatrics*
• Emergency care*
• Outpatient department
• Infection prevention*

Diagnostic/Ancillary Services

• Laboratory
• Blood transfusion/blood bank*
• Radiology/x-ray
• Pharmacy*

Nursing Services

• Nursing care in patient wards
• Central service/sterilization
• Operating theater

Administration and Support Services

• Medical records
• Human resource (personnel) management*
• Housekeeping
• Catering/food service
• Laundry
• Facilities and equipment maintenance*
• Purchasing/medical stores
• Business office and administration

*=Standards developed and implemented at five provincial hospitals as of Sept. 2005.

Training

The Standards Based Management/Performance Quality Improvement approach that JHPIEGO has successfully developed and used to improve the quality of reproductive health services in many resource-poor settings has been expanded and adapted by REACH into a comprehensive approach to improve hospital management in Afghanistan. This process includes all clinical services (surgery, anesthesia, emergency care, pediatrics, infection prevention, and blood transfusion and blood banks) and management systems (governance, facilities and equipment management, pharmacy management, human resource systems) for general hospitals.

Standards were developed in each of these areas, and training modules developed. Eight workshops have been held to train key staff from each hospital, who return to their hospitals to introduce the standards to their medical and administrative staff. Each workshop produces a plan for implementing the standards according to the circumstances of each hospital. The training is incremental. For instance, rather than doing a one- to two-week workshop presenting all the training modules, two modules on standards (usually one clinical and one management area) are presented. Two new modules are presented quarterly thereafter, to prevent information overload, allow trainees to integrate what they have learned with real day-to-day management, and avoid the problem of hospitals being left without leadership for an extended period.

Mentoring

A skilled hospital management advisor visits the hospitals regularly so managers have the opportunity to work with a mentor to apply what they have learned to their hospitals. This practical experience involves applying principles to real-life situations with someone experienced enough to help overcome obstacles not anticipated in the workshops. Mentors from REACH and the Ministry of Public Health visit the provincial hospitals to discuss problems, review progress, talk about problems that prevented achievement of goals, and set goals for the next three-month period.

The first four provincial hospitals selected for this intervention are all in areas formerly controlled by the Taliban, and security issues have added other challenges to this program because of repeated terrorist attacks on non-governmental organizations and people employed by international organizations. The mentors involved must speak Pashto, the local language, and integrate into the culture so they do not attract attention or create local opposition. Mentoring is a necessary but dangerous activity for the success of the program.

Networking and Modeling

As more hospital managers and senior clinicians are trained through this program, networking becomes another important tool. The network uses meetings twice a year for two days in a participating hospital to provide an opportunity for hospital managers to discuss common issues and develop system-wide solutions. Between these meetings, hospital managers in the same region exchange visits to learn from each other. REACH facilitates this networking using e-mail (some of the provincial hospitals have Internet access, which has dramatically increased their participation in evidence-based approaches), dissemination of reports, and passing on requests for communication between hospitals. These formal meetings and informal exchanges permit hospital managers to interact about common problems and learn how other hospitals have solved those problems. This networking will slowly expand to cover more provincial hospitals and will assist in expanding the number of trainers and mentors.

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Modeling means trying new systems and methods generated by the trainees to address their self-identified problems. Improvements in five provincial hospitals (in Khost, Paktika, Paktia, Ghazni, and Badakhshan) will provide a model that demonstrates to the public that hospitals can be well run and serve the community. These hospitals can also be used as training grounds for other hospital managers from around the country as the initiative expands to more of the remaining 28 provincial hospitals. The goal is to develop optimism and creativity because one of the main barriers in training is that some managers have difficulty imagining things being different because they feel the system “has always been broken.” When trainees see that other hospitals have successfully tried new approaches, they will consider a broader range of possibilities for their own hospitals.

Resources

Along with the management improvements achieved through training, mentoring, and networking, additional resources are needed to improve hospital services. REACH has been the conduit for U.S. government funding, providing $2.6 million in critical resources to drive improvements in the five provincial hospitals. These funds are channeled through the contracted nongovernmental organizations, which hire staff and pay decent salaries.

The average hospital physician in the Ministry of Public Health is paid $50 a month. In this setting “under-the-table” charges for clinical services are common, and physicians usually leave the hospital by lunch to attend to their private clinics. This initiative pays physicians up to $500 a month with the expectations that they will work a full day, provide 24-hour emergency coverage, and not charge patients. Eighteen months of experience suggest that these expectations are being met. Resources are also used for remodeling facilities, purchasing equipment and supplies, and providing essential medicines. The management standards developed are designed to make rational use of these scarce resources.

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Prerequisites for the Initiative

Two key prerequisites for starting the Hospital Management Initiative were:

1. Identifying where standards had to be developed: REACH has assisted the Ministry of Public Health to identify the standards that must be developed: responsibilities of hospitals to the community, patient care (clinical care), human resource management, management systems, environmental health, and leadership and management.10 “Areas of Standards for Hospitals in Afghanistan” shows the standards that have been or are to be developed. (See sidebar at left.)
2. Essential Package of Hospital Services: To ensure that donor support does not stimulate a proliferation of hospitals and high-tech equipment that are not appropriate or sustainable for Afghanistan, REACH has been helping the Ministry of Public Health define the levels of hospitals (district, provincial, regional), the populations they serve, the services they offer, and the equipment, staff, supplies, and pharmaceuticals they need. The result was the publication of the Essential Package of Hospital Services, which defines these for each of the three levels of hospitals in the country, in 2005. This package will provide guidance for Afghanistan’s hospitals for the coming decade, much as the Basic Package of Health Services has done for primary healthcare services. The hospital package will also support long-term planning and help the Ministry make the best use of donor assistance for redeveloping the hospital sector.

Developing and Implementing Standards

Standards-based management begins by identifying existing clinical guidelines and standards developed by American or international specialty societies. Specialist consultants in each clinical area with many years’ experience in Afghanistan (some of them Afghan-American physicians) are contracted to develop these standards and then adapt them to the Afghan context, in consultation with physicians in Afghanistan.

For example, standards for acute abdominal pain had to be adapted to a situation where CAT scans and ultrasounds are not readily available, and the lack of electrolyte laboratory capacity in hospitals stimulated physicians to adapt standards for shock, and fluid and electrolyte balance that do not rely on knowing electrolyte levels. The standards development teams aimed to raise the standards of Afghan hospitals to a realistic extent but not set the bar so high that improvement was unattainable.

After the standards were developed, clinicians from Afghan hospitals reviewed and revised the standards to ensure that they were appropriate. This review also served as a means of training because the participants were able and eager to question the contracted expert about the standards in developed countries and the evidence supporting those standards. Once the standards are revised, a workshop is held to introduce them to hospital staff. The hospital teams then develop an action plan for introducing the standards into their facilities.

Quality improvement teams at each of the five hospitals take responsibility for shepherding the action plans through implementation. An advisor visits each hospital quarterly to review progress, assess barriers, and help hospital staff develop ways to overcome problems and accelerate standards implementation. During the mentor’s first visit after new standards have been introduced, he performs a baseline assessment of the hospital’s current compliance with the standards. This serves as a benchmark for future measurement of progress in meeting the standards.

The Results

The hospitals have been enthusiastic about this process and the gains they have seen in the quality of care at their facilities. “We have made more progress in four months of the Hospital Management Improvement Initiative than we made in the previous five years with many other donors because this methodology is sound and appropriate for Afghanistan,” said Dr. Mohammed Ismael, the director of Ghazni Provincial Hospital.

One example of the process and results was the first area in which standards were developed—essential obstetric care. Physicians examined seven components of the quality of emergency obstetric care: handling of pregnancy complications; labor, delivery, and postpartum and newborn care; support services; infection prevention; health education given to families and mothers; human, physical, and material resources; and management systems in the obstetrics/gynecology department. After the standards were established, the first step was to find out where each hospital stood in meeting them. (For the combined results of that first baseline assessment for four hospitals, see Figure 1, p. 20.)

The changes in standards for emergency obstetric care at the hospitals from July 2004 to July 2005 have been impressive. The overall composite scores for emergency obstetric care for the four hospitals have improved from 31% at the baseline assessment to 47%. Here are the average improvements in the same four hospitals over one year:

Lessons Learned

The principal lesson learned through this hospital management improvement initiative is that combining clinical and management improvements can create innovation in a developing country. Improvements are made throughout a hospital—not just in one clinical area. Second, mentoring has proven essential as a follow-up to training. The training alone will not bring about significant positive changes. Only with on-site visitation is there the opportunity to integrate new knowledge with practical implementation issues that have proven troublesome to overcome. Third, setting standards is key to the sustainability of improvements. Training individuals in skills is helpful but is not sustainable if those trained staff depart. Using hospital teams and common standards throughout different hospitals leads to institutionalization of the process.

Staff motivation has also proven to be essential to sustainability. Staff have been motivated because they see that many positive changes are within their control; they do not have to wait for someone else to make an improvement before they can introduce positive change. An ethic of continuous quality improvement is achieved through staff who are proud of the changes they have introduced. The iterative nature of this process has been essential to quality improvement: The standards are continually revisited and revised as needed. At times, new standards for other areas are developed when the hospitals need them. Finally, providing resources to pay adequate salaries, renovate facilities, buy equipment and supplies, and provide essential medicines are all important elements of this success.

This method has proven successful in such a short time that the Minister of Public Health, Dr. Mohammad Amin Fatimie, has expressed his desire to extend it to many other hospitals in the country in an effort to improve the quality of hospital care throughout Afghani-stan. The U.S. Agency for International Development and MSH have agreed to support this request, and the program will expand in future years. TH

Dr. Hartman

Dr. Newbrander

Dr. Hartman, is a family physician with subspecialty training in infectious diseases, epidemiology, and public health. He serves as the technical director and deputy chief of party of the REACH Project, based in Kabul. Dr. Newbrander is a health economist who has served in Afghanistan since 2002 as a senior advisor to the Ministry of Health. He is currently Health Financing and Hospital Management Advisor for the USAID-funded REACH Project.

Acknowledgment: Funding for this article was provided by the United States Agency for International Development under the REACH Project, contract number EEE-C-00-03-00015-00. The opinions expressed herein are those of the authors and do not necessarily reflect the views of USAID.

References

1. Newbrander W, Ickx P, Leitch GH. Addressing the immediate and long-term health needs in Afghanistan. Harvard Health Pol Rev. 2003;4.
2. Ministry of Health Transitional Islamic Government of Afghanistan (TISA), US Centers for Disease Control and Prevention, United Nations Children’s Fund. Maternal mortality in Afghanistan: magnitude, causes, risk factors and preventability. Kabul: TISA; 2002.
3. Bartlett LA, Mawji S, Whitehead S, et al. Where giving birth is a forecast of death: maternal mortality in four districts of Afghanistan, 1999-2002. Lancet. 2005;365:864-870.
4. Strong L, Wali A, Sondorp E. Health Policy in Afghanistan: Two Years of Rapid Change: A Review of the Process from 2001 to 2003. London: London School of Hygiene and Tropical Medicine; 2005.
5. Afghanistan’s health challenge. Lancet. 2003;362:841.
6. Ministry of Health Transitional Islamic Government of Afghanistan (TISA). The Basic Package of Health Services for Afghanistan. Kabul: TISA; 2003.
7. Ministry of Health Transitional Islamic Government of Afghanistan (TISA). Hospital Policy for Afghanistan’s Health System. Kabul: TISA; 2004.
8. Ministry of Health Transitional Islamic Government of Afghanistan (TISA), Management Sciences for Health. Afghanistan national health resources assessment: Preliminary results. Kabul: TISA; 2002.
9. A crucial time for Afghanistan’s fledgling health system. Lancet. 2005; 365:819-820.
10. Ministry of Public Health (MOPH) Islamic Republic of Afghanistan. The Essential Package of Hospital Services for Afghanistan. Kabul: MOPH; 2005.

Syringomatous carcinoma (SC), considered by some to be a variant of microcystic adnexal carcinoma (MAC),1 is a rare malignant neoplasm of sweat gland origin. SC encompasses a range of neoplasms with different degrees of differentiation, and its nomenclature has varied over the years. SC also has been referred to as syringoid eccrine carcinoma,2 basal cell tumor with eccrine differentiation,3 malignant syringoma,4 and sclerosing sweat duct carcinoma.5 Its diagnosis has been a dilemma in a number of reported cases, probably due to the combination of its rarity and thus limited clinical and histopathologic information, microscopic similarities to other benign and malignant neoplasms, and characteristic histologic features that may only be apparent in surgical excisions containing deeper tissue. We report a case of SC that masqueraded as an epidermoid cyst in an unusually young patient.

Case Report
A 23-year-old Asian man, who was otherwise healthy, presented with an asymptomatic slowly enlarging nodule of one year's duration on the right medial eyebrow. Prior treatment with intralesional steroid injections resulted in minimal improvement. The patient had no personal or family history of skin cancers. Physical examination results demonstrated a well-demarcated, mobile, nontender subcutaneous nodule measuring 7 mm in diameter. The clinical presentation favored a diagnosis of an epidermal inclusion cyst, and the patient underwent surgical excision of the lesion. Results of the histopathologic examination revealed a neoplasm in the dermis consisting of bands and nests of pale staining basaloid cells extending between the collagen fibers (Figure 1). There were focal areas of ductal differentiation, scattered individual necrotic cells, moderate dermal fibrosis, and chronic inflammation with numerous eo-sinophils. Moderate nuclear atypia also was present (Figure 2). Perineural involvement was not seen. Results of immunohistochemical analysis revealed positive staining for high—and low—molecular-weight cytokeratins, as well as carcinoembryonic antigen (CEA)(Figure 3). There was scattered positivity with S-100 protein in occasional cells lining lumina and in dendritic cells (Figure 4). The histopathologic findings supported the diagnosis of SC. Because the neoplasm extended to the surgical margins of the specimen, repeat surgical excision with continuous microscopic control under the Mohs micrographic technique was performed to prevent local recurrence and spare normal tissue. At the 18-month follow-up visit, no local recurrence was seen.

Comment SC is a rare, malignant sweat gland neoplasm that usually occurs in the fourth and fifth decades of life.4-8 SC typically presents as a slow-growing, solitary, painless nodule or indurated plaque on the head or neck region.6-8 It has been frequently found on the upper and lower lips; however, it also has been reported to occur on the finger and breast.9,10 Predisposing factors for the development of SC are unclear11 but may include previous radiation to the face and history of receiving an organ transplant with immunosuppressive drug therapy.12-17 Histopathologically, SC is characterized by asymmetric and deep dermal invasion of tumor cells, perineural involvement, ductal formation, keratin-filled cysts, multiple nests of basaloid or squamous cells, and desmoplasia of the surrounding dermal stroma (Table 1).5,6 Some authors consider SC to be closely related to MAC but generally describe SC as more basaloid with larger tubules and a more sclerotic stroma than MAC.18-26 If histologic examination of SC is limited to the superficial dermis, SC demonstrates similarities to other neoplasms, including syringomas, trichoadenomas, trichoepitheliomas, basal cell carcinomas, or squamous cell carcinomas. In the reported cases in which SC was initially misdiagnosed as another benign or malignant neoplasm, many misdiagnoses were due to either a benign clinical appearance of the lesion or biopsy specimens that were too superficial to contain the deeper characteristic histologic features of SC.8,9,11,27-30

Immunohistochemical studies can facilitate the diagnosis of SC and differentiate it from other neoplasms. SC stains positively for CEA, S-100 protein, epithelial membrane antigen, cyto-keratin, and gross cystic disease fluid protein 15,31 all of which aid in the confirmation of a sweat gland neoplasm (Table 2).8,32,33,39 Positivity for CEA in the ductal lining cells and the luminal contents of tumor ducts confirms sweat gland differentiation.25,33,34 This ductal immunoreactivity to CEA appears to be one of the most reliable findings to differentiate SC and MAC from other adnexal tumors, especially desmoplastic trichoepithelioma, which may be one of the more challenging histo-pathologic differential diagnoses.35 In addition, epithelial membrane antigen positivity can be found in the areas showing glandular features.35 This can assist in distinguishing SC from a desmoplastic trichoepithelioma or sclerosing type basal cell carcinoma, both of which demonstrate negativity to epithelial membrane antigen.35 S-100 protein positivity in dendritic cells, as well as in some cords and ducts in SC, further verifies dendritic differentiation toward sweat gland structures and is useful as an adjunct in the confirmation of glandular differentiation.25,33,34,36

Without proper and timely diagnosis and management, SC can cause severe patient morbidity. Although SC rarely metastasizes and can have an indolent course, it can be locally de-structive and lead to potentially disfiguring outcomes.5-7 SC can invade deeply and infiltrate into the dermis, subcutaneous fat tissue, muscle, perichondrium, periosteum, and galea.8 Goto et al9 reported a case of an SC that was initially misdiagnosed as a basal cell carcinoma of the left middle finger. The deeper, characteristic features of SC were not recognized until after the affected finger required amputation due to erosion of the bone. Hoppenreijs et al11 described an aggressive case of an SC arising at a site of previously irradiated squamous cell carcinoma of the lower eyelid. Extensive involvement of the SC in the orbit led to the recommendation of an orbital exenter-ation; however, it was not performed because of the poor clinical condition of the patient. Treatments for SC have included wide local excision and Mohs micrographic surgery (MMS). SC treatment with wide local excision often resulted in incomplete excision of the neoplasm despite having taken an adequate margin around the clinically assessable tumor.5 Cases of SC treated with wide local excision had a recurrence rate of 47%.5 The positive surgical margins following wide local excision may be due to the deep infiltration of SC, which frequently exceeds the clinically predicted size of the tumor.5 Due to the close relationship of MAC and SC, we feel that MMS treatment of SC will reduce recurrences as it has for MAC. Currently, there is strong support for the treatment of MAC with MMS as a gold standard to ensure complete clearance of the neoplasm and to reduce the local recurrence rate.12,13,17,21,22,37,38 In a study of MAC by Chiller et al,37 the authors demonstrated a median 4-fold increase in defect size when they compared the clinically estimated pretreatment size of the lesion with the MMS-determined posttreatment size of the lesion. The authors therefore suggest that, similar to the MMS-treated lesions, the lesions completely treated with wide local excision also would produce a defect size that is at least 4 times greater than the predicted pretreatment size of the lesion. Because wide local excision relies on predicted margins of the lesion, which the authors have shown can be greatly underestimated, Chiller et al37 argue that the use of MMS, which does not rely on predicted margins, is a reasonable first-line therapeutic modality for effectively treating patients with MAC. Furthermore, MMS allows for the examination of the entire peripheral and deep margins of the lesion, which is critical when considering the deep infiltrative nature of MAC. The reported local recurrence rate of MAC treated with MMS is 0% to 5%,12,13,21,26,38 which is much lower than the reported local recurrence rate following treatment with wide local excision. This reduced recurrence rate found in MAC cases treated with MMS is probably due to the ability to confirm complete removal of the neoplasm with MMS. 

Conclusion To our knowledge, this case report describes the occurrence of SC, a rare sweat gland neoplasm, in the youngest reported patient and is only the second reported case of SC treated with MMS. Adequate sampling of tissue with an excisional biopsy allowed for appropriate evaluation with histologic and immunohistochemical studies to arrive at the diagnosis that could easily have been missed with a superficial biopsy. In our patient, histopathologic evaluation showed typical nests of basaloid cells, ductal differentiation, and ductal fibrosis seen in SC. However, perineural involvement that is particularly characteristic of SC was not present. This may portend a better prognosis for our patient whose tumor was completely excised after one stage of MMS and has not shown evidence of recurrence at the 18-month follow-up visit. MMS allowed for evaluation of the entire surgical margin and decreased risk of local recurrence resulting from an incomplete excision. In addition, it also allowed for sparing of normal tissue in a cosmetically sensitive area where SC commonly occurs. In summary, this case highlights the importance of including SC in the differential diagnosis of an enlarging cystic lesion in a younger patient and its successful treatment with MMS. 

Syringomatous carcinoma (SC), considered by some to be a variant of microcystic adnexal carcinoma (MAC),1 is a rare malignant neoplasm of sweat gland origin. SC encompasses a range of neoplasms with different degrees of differentiation, and its nomenclature has varied over the years. SC also has been referred to as syringoid eccrine carcinoma,2 basal cell tumor with eccrine differentiation,3 malignant syringoma,4 and sclerosing sweat duct carcinoma.5 Its diagnosis has been a dilemma in a number of reported cases, probably due to the combination of its rarity and thus limited clinical and histopathologic information, microscopic similarities to other benign and malignant neoplasms, and characteristic histologic features that may only be apparent in surgical excisions containing deeper tissue. We report a case of SC that masqueraded as an epidermoid cyst in an unusually young patient.

Case Report
A 23-year-old Asian man, who was otherwise healthy, presented with an asymptomatic slowly enlarging nodule of one year's duration on the right medial eyebrow. Prior treatment with intralesional steroid injections resulted in minimal improvement. The patient had no personal or family history of skin cancers. Physical examination results demonstrated a well-demarcated, mobile, nontender subcutaneous nodule measuring 7 mm in diameter. The clinical presentation favored a diagnosis of an epidermal inclusion cyst, and the patient underwent surgical excision of the lesion. Results of the histopathologic examination revealed a neoplasm in the dermis consisting of bands and nests of pale staining basaloid cells extending between the collagen fibers (Figure 1). There were focal areas of ductal differentiation, scattered individual necrotic cells, moderate dermal fibrosis, and chronic inflammation with numerous eo-sinophils. Moderate nuclear atypia also was present (Figure 2). Perineural involvement was not seen. Results of immunohistochemical analysis revealed positive staining for high—and low—molecular-weight cytokeratins, as well as carcinoembryonic antigen (CEA)(Figure 3). There was scattered positivity with S-100 protein in occasional cells lining lumina and in dendritic cells (Figure 4). The histopathologic findings supported the diagnosis of SC. Because the neoplasm extended to the surgical margins of the specimen, repeat surgical excision with continuous microscopic control under the Mohs micrographic technique was performed to prevent local recurrence and spare normal tissue. At the 18-month follow-up visit, no local recurrence was seen.

Comment SC is a rare, malignant sweat gland neoplasm that usually occurs in the fourth and fifth decades of life.4-8 SC typically presents as a slow-growing, solitary, painless nodule or indurated plaque on the head or neck region.6-8 It has been frequently found on the upper and lower lips; however, it also has been reported to occur on the finger and breast.9,10 Predisposing factors for the development of SC are unclear11 but may include previous radiation to the face and history of receiving an organ transplant with immunosuppressive drug therapy.12-17 Histopathologically, SC is characterized by asymmetric and deep dermal invasion of tumor cells, perineural involvement, ductal formation, keratin-filled cysts, multiple nests of basaloid or squamous cells, and desmoplasia of the surrounding dermal stroma (Table 1).5,6 Some authors consider SC to be closely related to MAC but generally describe SC as more basaloid with larger tubules and a more sclerotic stroma than MAC.18-26 If histologic examination of SC is limited to the superficial dermis, SC demonstrates similarities to other neoplasms, including syringomas, trichoadenomas, trichoepitheliomas, basal cell carcinomas, or squamous cell carcinomas. In the reported cases in which SC was initially misdiagnosed as another benign or malignant neoplasm, many misdiagnoses were due to either a benign clinical appearance of the lesion or biopsy specimens that were too superficial to contain the deeper characteristic histologic features of SC.8,9,11,27-30

Immunohistochemical studies can facilitate the diagnosis of SC and differentiate it from other neoplasms. SC stains positively for CEA, S-100 protein, epithelial membrane antigen, cyto-keratin, and gross cystic disease fluid protein 15,31 all of which aid in the confirmation of a sweat gland neoplasm (Table 2).8,32,33,39 Positivity for CEA in the ductal lining cells and the luminal contents of tumor ducts confirms sweat gland differentiation.25,33,34 This ductal immunoreactivity to CEA appears to be one of the most reliable findings to differentiate SC and MAC from other adnexal tumors, especially desmoplastic trichoepithelioma, which may be one of the more challenging histo-pathologic differential diagnoses.35 In addition, epithelial membrane antigen positivity can be found in the areas showing glandular features.35 This can assist in distinguishing SC from a desmoplastic trichoepithelioma or sclerosing type basal cell carcinoma, both of which demonstrate negativity to epithelial membrane antigen.35 S-100 protein positivity in dendritic cells, as well as in some cords and ducts in SC, further verifies dendritic differentiation toward sweat gland structures and is useful as an adjunct in the confirmation of glandular differentiation.25,33,34,36

Without proper and timely diagnosis and management, SC can cause severe patient morbidity. Although SC rarely metastasizes and can have an indolent course, it can be locally de-structive and lead to potentially disfiguring outcomes.5-7 SC can invade deeply and infiltrate into the dermis, subcutaneous fat tissue, muscle, perichondrium, periosteum, and galea.8 Goto et al9 reported a case of an SC that was initially misdiagnosed as a basal cell carcinoma of the left middle finger. The deeper, characteristic features of SC were not recognized until after the affected finger required amputation due to erosion of the bone. Hoppenreijs et al11 described an aggressive case of an SC arising at a site of previously irradiated squamous cell carcinoma of the lower eyelid. Extensive involvement of the SC in the orbit led to the recommendation of an orbital exenter-ation; however, it was not performed because of the poor clinical condition of the patient. Treatments for SC have included wide local excision and Mohs micrographic surgery (MMS). SC treatment with wide local excision often resulted in incomplete excision of the neoplasm despite having taken an adequate margin around the clinically assessable tumor.5 Cases of SC treated with wide local excision had a recurrence rate of 47%.5 The positive surgical margins following wide local excision may be due to the deep infiltration of SC, which frequently exceeds the clinically predicted size of the tumor.5 Due to the close relationship of MAC and SC, we feel that MMS treatment of SC will reduce recurrences as it has for MAC. Currently, there is strong support for the treatment of MAC with MMS as a gold standard to ensure complete clearance of the neoplasm and to reduce the local recurrence rate.12,13,17,21,22,37,38 In a study of MAC by Chiller et al,37 the authors demonstrated a median 4-fold increase in defect size when they compared the clinically estimated pretreatment size of the lesion with the MMS-determined posttreatment size of the lesion. The authors therefore suggest that, similar to the MMS-treated lesions, the lesions completely treated with wide local excision also would produce a defect size that is at least 4 times greater than the predicted pretreatment size of the lesion. Because wide local excision relies on predicted margins of the lesion, which the authors have shown can be greatly underestimated, Chiller et al37 argue that the use of MMS, which does not rely on predicted margins, is a reasonable first-line therapeutic modality for effectively treating patients with MAC. Furthermore, MMS allows for the examination of the entire peripheral and deep margins of the lesion, which is critical when considering the deep infiltrative nature of MAC. The reported local recurrence rate of MAC treated with MMS is 0% to 5%,12,13,21,26,38 which is much lower than the reported local recurrence rate following treatment with wide local excision. This reduced recurrence rate found in MAC cases treated with MMS is probably due to the ability to confirm complete removal of the neoplasm with MMS. 

Conclusion To our knowledge, this case report describes the occurrence of SC, a rare sweat gland neoplasm, in the youngest reported patient and is only the second reported case of SC treated with MMS. Adequate sampling of tissue with an excisional biopsy allowed for appropriate evaluation with histologic and immunohistochemical studies to arrive at the diagnosis that could easily have been missed with a superficial biopsy. In our patient, histopathologic evaluation showed typical nests of basaloid cells, ductal differentiation, and ductal fibrosis seen in SC. However, perineural involvement that is particularly characteristic of SC was not present. This may portend a better prognosis for our patient whose tumor was completely excised after one stage of MMS and has not shown evidence of recurrence at the 18-month follow-up visit. MMS allowed for evaluation of the entire surgical margin and decreased risk of local recurrence resulting from an incomplete excision. In addition, it also allowed for sparing of normal tissue in a cosmetically sensitive area where SC commonly occurs. In summary, this case highlights the importance of including SC in the differential diagnosis of an enlarging cystic lesion in a younger patient and its successful treatment with MMS. 

Syringomatous carcinoma (SC), considered by some to be a variant of microcystic adnexal carcinoma (MAC),1 is a rare malignant neoplasm of sweat gland origin. SC encompasses a range of neoplasms with different degrees of differentiation, and its nomenclature has varied over the years. SC also has been referred to as syringoid eccrine carcinoma,2 basal cell tumor with eccrine differentiation,3 malignant syringoma,4 and sclerosing sweat duct carcinoma.5 Its diagnosis has been a dilemma in a number of reported cases, probably due to the combination of its rarity and thus limited clinical and histopathologic information, microscopic similarities to other benign and malignant neoplasms, and characteristic histologic features that may only be apparent in surgical excisions containing deeper tissue. We report a case of SC that masqueraded as an epidermoid cyst in an unusually young patient.

Case Report
A 23-year-old Asian man, who was otherwise healthy, presented with an asymptomatic slowly enlarging nodule of one year's duration on the right medial eyebrow. Prior treatment with intralesional steroid injections resulted in minimal improvement. The patient had no personal or family history of skin cancers. Physical examination results demonstrated a well-demarcated, mobile, nontender subcutaneous nodule measuring 7 mm in diameter. The clinical presentation favored a diagnosis of an epidermal inclusion cyst, and the patient underwent surgical excision of the lesion. Results of the histopathologic examination revealed a neoplasm in the dermis consisting of bands and nests of pale staining basaloid cells extending between the collagen fibers (Figure 1). There were focal areas of ductal differentiation, scattered individual necrotic cells, moderate dermal fibrosis, and chronic inflammation with numerous eo-sinophils. Moderate nuclear atypia also was present (Figure 2). Perineural involvement was not seen. Results of immunohistochemical analysis revealed positive staining for high—and low—molecular-weight cytokeratins, as well as carcinoembryonic antigen (CEA)(Figure 3). There was scattered positivity with S-100 protein in occasional cells lining lumina and in dendritic cells (Figure 4). The histopathologic findings supported the diagnosis of SC. Because the neoplasm extended to the surgical margins of the specimen, repeat surgical excision with continuous microscopic control under the Mohs micrographic technique was performed to prevent local recurrence and spare normal tissue. At the 18-month follow-up visit, no local recurrence was seen.

Comment SC is a rare, malignant sweat gland neoplasm that usually occurs in the fourth and fifth decades of life.4-8 SC typically presents as a slow-growing, solitary, painless nodule or indurated plaque on the head or neck region.6-8 It has been frequently found on the upper and lower lips; however, it also has been reported to occur on the finger and breast.9,10 Predisposing factors for the development of SC are unclear11 but may include previous radiation to the face and history of receiving an organ transplant with immunosuppressive drug therapy.12-17 Histopathologically, SC is characterized by asymmetric and deep dermal invasion of tumor cells, perineural involvement, ductal formation, keratin-filled cysts, multiple nests of basaloid or squamous cells, and desmoplasia of the surrounding dermal stroma (Table 1).5,6 Some authors consider SC to be closely related to MAC but generally describe SC as more basaloid with larger tubules and a more sclerotic stroma than MAC.18-26 If histologic examination of SC is limited to the superficial dermis, SC demonstrates similarities to other neoplasms, including syringomas, trichoadenomas, trichoepitheliomas, basal cell carcinomas, or squamous cell carcinomas. In the reported cases in which SC was initially misdiagnosed as another benign or malignant neoplasm, many misdiagnoses were due to either a benign clinical appearance of the lesion or biopsy specimens that were too superficial to contain the deeper characteristic histologic features of SC.8,9,11,27-30

Immunohistochemical studies can facilitate the diagnosis of SC and differentiate it from other neoplasms. SC stains positively for CEA, S-100 protein, epithelial membrane antigen, cyto-keratin, and gross cystic disease fluid protein 15,31 all of which aid in the confirmation of a sweat gland neoplasm (Table 2).8,32,33,39 Positivity for CEA in the ductal lining cells and the luminal contents of tumor ducts confirms sweat gland differentiation.25,33,34 This ductal immunoreactivity to CEA appears to be one of the most reliable findings to differentiate SC and MAC from other adnexal tumors, especially desmoplastic trichoepithelioma, which may be one of the more challenging histo-pathologic differential diagnoses.35 In addition, epithelial membrane antigen positivity can be found in the areas showing glandular features.35 This can assist in distinguishing SC from a desmoplastic trichoepithelioma or sclerosing type basal cell carcinoma, both of which demonstrate negativity to epithelial membrane antigen.35 S-100 protein positivity in dendritic cells, as well as in some cords and ducts in SC, further verifies dendritic differentiation toward sweat gland structures and is useful as an adjunct in the confirmation of glandular differentiation.25,33,34,36

Without proper and timely diagnosis and management, SC can cause severe patient morbidity. Although SC rarely metastasizes and can have an indolent course, it can be locally de-structive and lead to potentially disfiguring outcomes.5-7 SC can invade deeply and infiltrate into the dermis, subcutaneous fat tissue, muscle, perichondrium, periosteum, and galea.8 Goto et al9 reported a case of an SC that was initially misdiagnosed as a basal cell carcinoma of the left middle finger. The deeper, characteristic features of SC were not recognized until after the affected finger required amputation due to erosion of the bone. Hoppenreijs et al11 described an aggressive case of an SC arising at a site of previously irradiated squamous cell carcinoma of the lower eyelid. Extensive involvement of the SC in the orbit led to the recommendation of an orbital exenter-ation; however, it was not performed because of the poor clinical condition of the patient. Treatments for SC have included wide local excision and Mohs micrographic surgery (MMS). SC treatment with wide local excision often resulted in incomplete excision of the neoplasm despite having taken an adequate margin around the clinically assessable tumor.5 Cases of SC treated with wide local excision had a recurrence rate of 47%.5 The positive surgical margins following wide local excision may be due to the deep infiltration of SC, which frequently exceeds the clinically predicted size of the tumor.5 Due to the close relationship of MAC and SC, we feel that MMS treatment of SC will reduce recurrences as it has for MAC. Currently, there is strong support for the treatment of MAC with MMS as a gold standard to ensure complete clearance of the neoplasm and to reduce the local recurrence rate.12,13,17,21,22,37,38 In a study of MAC by Chiller et al,37 the authors demonstrated a median 4-fold increase in defect size when they compared the clinically estimated pretreatment size of the lesion with the MMS-determined posttreatment size of the lesion. The authors therefore suggest that, similar to the MMS-treated lesions, the lesions completely treated with wide local excision also would produce a defect size that is at least 4 times greater than the predicted pretreatment size of the lesion. Because wide local excision relies on predicted margins of the lesion, which the authors have shown can be greatly underestimated, Chiller et al37 argue that the use of MMS, which does not rely on predicted margins, is a reasonable first-line therapeutic modality for effectively treating patients with MAC. Furthermore, MMS allows for the examination of the entire peripheral and deep margins of the lesion, which is critical when considering the deep infiltrative nature of MAC. The reported local recurrence rate of MAC treated with MMS is 0% to 5%,12,13,21,26,38 which is much lower than the reported local recurrence rate following treatment with wide local excision. This reduced recurrence rate found in MAC cases treated with MMS is probably due to the ability to confirm complete removal of the neoplasm with MMS. 

Conclusion To our knowledge, this case report describes the occurrence of SC, a rare sweat gland neoplasm, in the youngest reported patient and is only the second reported case of SC treated with MMS. Adequate sampling of tissue with an excisional biopsy allowed for appropriate evaluation with histologic and immunohistochemical studies to arrive at the diagnosis that could easily have been missed with a superficial biopsy. In our patient, histopathologic evaluation showed typical nests of basaloid cells, ductal differentiation, and ductal fibrosis seen in SC. However, perineural involvement that is particularly characteristic of SC was not present. This may portend a better prognosis for our patient whose tumor was completely excised after one stage of MMS and has not shown evidence of recurrence at the 18-month follow-up visit. MMS allowed for evaluation of the entire surgical margin and decreased risk of local recurrence resulting from an incomplete excision. In addition, it also allowed for sparing of normal tissue in a cosmetically sensitive area where SC commonly occurs. In summary, this case highlights the importance of including SC in the differential diagnosis of an enlarging cystic lesion in a younger patient and its successful treatment with MMS. 

Distinguishing the cause of a patient’s psychotic symptoms can be clinically challenging in a primary care practice. This case was submitted by Matthew Rosenberg, MD, who practices family medicine at Sacramento (CA) County Primary Care Clinic. This month’s consultant is Bezalel Dantz, MD.

How would you have advised Dr. Rosenberg?

Case: ‘you’re just gonna die’

I was seeing Mr. J, age 31, weekly to monitor abdominal complaints. For 3 weeks he experienced increasing epigastric pain, and he had been evaluated twice in the emergency room for this complaint. Plain films, ultrasound, CT, and an elevated lipase reading suggested an inconclusive diagnosis of pancreatitis.

During his second office visit, Mr. J also complained of “hearing voices.” Further questioning revealed that he had been hearing voices—often male—making degrading comments for several years. The voices have increased in frequency during his illness, and their negative comments include, “What do you have to live for?” and “You’re just gonna die.”

Mr. J blames the voices on distant drug use, claiming his parents “forced” him as a young teen to take hallucinogens. He often thinks he is being followed and does not trust others. He said both parents had mental illnesses but does not know the diagnoses or seriousness of their disorders.

His thoughts are well-organized with clear content. He shows no signs of depression or mania. He plays guitar in a band and appears to be a thoughtful and high-functioning individual.

I need help with the differential diagnosis and suggestions of possible treatment options.

Dr. Dantz’s consultation

The first step in evaluating psychosis is to determine whether it indicates a medical disorder, substanceinduced disorder, or primary psychiatric illness. The chronicity and nature of Mr. J’s psychotic symptoms (auditory hallucinations and paranoid delusions), his age, and a family history of psychiatric illness suggest a primary psychiatric disorder. The elevated lipase might explain his abdominal pain but is likely independent of his psychosis.

Medical workup. Conduct a comprehensive physical exam and medical and psychiatric history. Obtain collateral information from the family about the patient’s psychiatric symptoms, family history, recreational drug use, and stressors. Acute onset, age >40, comorbid medical conditions, lack of acute psychosocial stressors, and a negative personal or family psychiatric history suggest a medical cause (The skinny on one patient’s psychosis,” November 2005.) Also assess for use of alcohol, marijuana, hallucinogens, narcotics, stimulants, and inhalants. Until any drug has been stopped for at least 1 week, its contribution to psychosis may be unclear.

Table 1

Medical conditions that may present as psychosis

Lab testing. When signs or symptoms do not suggest an organic disease, laboratory tests have a low yield and are of questionable value.² In primary care practice, however, many psychotic patients complain of somatic symptoms. Given the devastating impact of psychotic illness, one can argue that even a yield <5% justifies a workup.

A urine toxicology screen is by far the most important lab test. CBC, comprehensive metabolic panel, thyroid function tests, erythrocyte sedimentation rate, and calcium level may reveal a medical cause. Consider HIV antibody and syphilis tests in at-risk individuals.

Findings on physical exam or abnormal lab results would guide further testing. Because of Mr. J’s GI and neurologic symptoms, a 24-hour urine test may be reasonable, particularly if he has had episodes of acute intermittent porphyria.

Neuroimaging. Consider a scan when psychosis is comorbid with:

• age >40
• neurologic complaints (such as headache, numbness, vertigo, seizures)
• focal neurologic findings (such as weakness, gait abnormality, clonus, or spasticity)
• confusion, cognitive deficit, history of malignancy
• head trauma
• immunocompromised state
• atypical psychotic symptoms (such as visual or olfactory hallucinations).

Psychiatric workup. If the history and physical exam reveal no organic basis, the next step is to determine the nature of this patient’s psychosis. The two most common psychiatric conditions associated with psychosis are:

• schizophrenic spectrum disorders (such as schizophreniform, schizophrenia and schizoaffective disorder)
• affective disorders (such as psychotic depression and bipolar disorder).

Distinguishing among these conditions can be challenging (Table 2) because patients rarely present with typical syndromes.

For example, a bipolar patient may present in a mixed state with both depressive and manic features. Psychosis in schizophrenia may be brief (<6 months in schizophreniform disorder) and may be characterized by manic-like grandiose delusions or negative symptoms (flat affect, poverty of speech) that mimic affective symptoms. Finally, some patients have both an affective disorder and schizophrenia, as in schizoaffective disorder.

For Mr. J, years of uninterrupted hallucinations, longstanding paranoid delusions, and absence of prominent affective symptoms suggest schizophrenia. His hallucinations are typical of those reported in schizophrenia. Voices giving a running commentary on a person’s thoughts and actions and derogatory comments are two of the most common auditory hallucinations.

Somatic concerns are also prominent in schizophrenia. Patients may describe symptoms in bizarre terms, such as “electric shocks in my head” or “there’s a fire in my spleen.”

Supporting evidence for a schizophrenia diagnosis would include a history of social isolation, lack of interest in work, and poor social interaction. Mr. J has a supportive partner, and we are told he appears to be high-functioning and active as a guitarist in a band. These factors might support an alternate diagnosis of affective psychosis. Finally, his past drug use and somatic symptoms raise the possibility of active substance abuse.

Table 2

Differential diagnosis of primary psychosis: Typical features

Suicide risk. Ask psychotic patients if they think about harming themselves. Lifetime risk of suicide in schizophrenia is 10% to 15%, and rates in bipolar disorder are higher. If patients deny suicidality, ask them why. Reassuring responses include religious prohibition, hopefulness about the future, concern about suicide’s effect on a loved one, fear of dying, or lack of means.

Candidates for emergent psychiatric consultation or hospitalization include patients with violent or homicidal thoughts and any patient who has attempted suicide, has a family history of suicide, has access to means, and lacks compelling reasons against suicide. Consider immediate psychiatric evaluation and admission of patients whose delusions or behaviors put them at risk for harm.

Abdominal pain workup. Although Mr. J’s abdominal pain may be functional, also seek an organic cause. His first-time disclosure of psychotic symptoms suggests that a serious medical stressor may be exacerbating a chronic psychiatric illness. Because the elevated lipase may indicate pancreatitis, consider an endoscopic or MRI examination of the pancreas and bile ducts. In consultation with a gastroenterologist, evaluate other causes such as peptic ulcer disease, ischemic bowel (perhaps as a result of cocaine use), inflammatory bowel disease, vasculitis, porphyria, and abdominal migraine.

Managing psychosis

Psychiatric consultation is strongly recommended for patients beginning therapy for psychotic disorders who have shown a particularly high risk for suicide. Uncontrolled symptoms, unanticipated psychiatric side effects, and the humiliation that results from the insight gained through treatment may contribute to this risk.

Assuming that Mr. J does not meet criteria for acute psychiatric hospitalization, the primary care clinician can stabilize the psychotic symptoms while awaiting psychiatric referral. Any atypical antipsychotic would be appropriate (Table 3).

Table 3

Starting an atypical antipsychotic* for primary psychosis

Patients who refuse treatment pose a quandary. If the patient is not acutely ill, try to establish an alliance over several visits rather than endangering the therapeutic relationship through confrontation or overzealous persuasion (Table 4).

Table 4

Strategies to build a therapeutic alliance with psychotic patients

Monitoring. The primary care physician’s role after the patient begins antipsychotic therapy is to:

• assess his or her symptoms (particularly suicidality) and adherence to psychiatric visits and treatment
• monitor for adverse effects from medications.

Atypical antipsychotics have been associated with weight gain, hyperglycemia, and hyperlipidemia. Check fasting glucose and lipids quarterly for the first year of antipsychotic therapy and annually thereafter.⁵ Watch for drug-drug interactions whenever a new medication is added. Monitor for abnormal movements, even though the risk of extrapyramidal symptoms and tardive dyskinesia is lower with atypical antipsychotics than with traditional agents.

For Mr. J’s psychiatric symptoms, I would:

• assess his willingness to start medication to reduce or eliminate the voices
• suggest he accept psychiatric referral
• assure him that I will remain involved in his care and continue to evaluate his abdominal symptoms.

I would also request permission to discuss his case with his partner and a family member to gather pertinent history and enlist their support for treatment. I would then start Mr. J on any drug listed in Table 3.

Distinguishing the cause of a patient’s psychotic symptoms can be clinically challenging in a primary care practice. This case was submitted by Matthew Rosenberg, MD, who practices family medicine at Sacramento (CA) County Primary Care Clinic. This month’s consultant is Bezalel Dantz, MD.

How would you have advised Dr. Rosenberg?

Case: ‘you’re just gonna die’

I was seeing Mr. J, age 31, weekly to monitor abdominal complaints. For 3 weeks he experienced increasing epigastric pain, and he had been evaluated twice in the emergency room for this complaint. Plain films, ultrasound, CT, and an elevated lipase reading suggested an inconclusive diagnosis of pancreatitis.

During his second office visit, Mr. J also complained of “hearing voices.” Further questioning revealed that he had been hearing voices—often male—making degrading comments for several years. The voices have increased in frequency during his illness, and their negative comments include, “What do you have to live for?” and “You’re just gonna die.”

Mr. J blames the voices on distant drug use, claiming his parents “forced” him as a young teen to take hallucinogens. He often thinks he is being followed and does not trust others. He said both parents had mental illnesses but does not know the diagnoses or seriousness of their disorders.

His thoughts are well-organized with clear content. He shows no signs of depression or mania. He plays guitar in a band and appears to be a thoughtful and high-functioning individual.

I need help with the differential diagnosis and suggestions of possible treatment options.

Dr. Dantz’s consultation

The first step in evaluating psychosis is to determine whether it indicates a medical disorder, substanceinduced disorder, or primary psychiatric illness. The chronicity and nature of Mr. J’s psychotic symptoms (auditory hallucinations and paranoid delusions), his age, and a family history of psychiatric illness suggest a primary psychiatric disorder. The elevated lipase might explain his abdominal pain but is likely independent of his psychosis.

Medical workup. Conduct a comprehensive physical exam and medical and psychiatric history. Obtain collateral information from the family about the patient’s psychiatric symptoms, family history, recreational drug use, and stressors. Acute onset, age >40, comorbid medical conditions, lack of acute psychosocial stressors, and a negative personal or family psychiatric history suggest a medical cause (The skinny on one patient’s psychosis,” November 2005.) Also assess for use of alcohol, marijuana, hallucinogens, narcotics, stimulants, and inhalants. Until any drug has been stopped for at least 1 week, its contribution to psychosis may be unclear.

Table 1

Medical conditions that may present as psychosis

Lab testing. When signs or symptoms do not suggest an organic disease, laboratory tests have a low yield and are of questionable value.² In primary care practice, however, many psychotic patients complain of somatic symptoms. Given the devastating impact of psychotic illness, one can argue that even a yield <5% justifies a workup.

A urine toxicology screen is by far the most important lab test. CBC, comprehensive metabolic panel, thyroid function tests, erythrocyte sedimentation rate, and calcium level may reveal a medical cause. Consider HIV antibody and syphilis tests in at-risk individuals.

Findings on physical exam or abnormal lab results would guide further testing. Because of Mr. J’s GI and neurologic symptoms, a 24-hour urine test may be reasonable, particularly if he has had episodes of acute intermittent porphyria.

Neuroimaging. Consider a scan when psychosis is comorbid with:

• age >40
• neurologic complaints (such as headache, numbness, vertigo, seizures)
• focal neurologic findings (such as weakness, gait abnormality, clonus, or spasticity)
• confusion, cognitive deficit, history of malignancy
• head trauma
• immunocompromised state
• atypical psychotic symptoms (such as visual or olfactory hallucinations).

Psychiatric workup. If the history and physical exam reveal no organic basis, the next step is to determine the nature of this patient’s psychosis. The two most common psychiatric conditions associated with psychosis are:

• schizophrenic spectrum disorders (such as schizophreniform, schizophrenia and schizoaffective disorder)
• affective disorders (such as psychotic depression and bipolar disorder).

Distinguishing among these conditions can be challenging (Table 2) because patients rarely present with typical syndromes.

For example, a bipolar patient may present in a mixed state with both depressive and manic features. Psychosis in schizophrenia may be brief (<6 months in schizophreniform disorder) and may be characterized by manic-like grandiose delusions or negative symptoms (flat affect, poverty of speech) that mimic affective symptoms. Finally, some patients have both an affective disorder and schizophrenia, as in schizoaffective disorder.

For Mr. J, years of uninterrupted hallucinations, longstanding paranoid delusions, and absence of prominent affective symptoms suggest schizophrenia. His hallucinations are typical of those reported in schizophrenia. Voices giving a running commentary on a person’s thoughts and actions and derogatory comments are two of the most common auditory hallucinations.

Somatic concerns are also prominent in schizophrenia. Patients may describe symptoms in bizarre terms, such as “electric shocks in my head” or “there’s a fire in my spleen.”

Supporting evidence for a schizophrenia diagnosis would include a history of social isolation, lack of interest in work, and poor social interaction. Mr. J has a supportive partner, and we are told he appears to be high-functioning and active as a guitarist in a band. These factors might support an alternate diagnosis of affective psychosis. Finally, his past drug use and somatic symptoms raise the possibility of active substance abuse.

Table 2

Differential diagnosis of primary psychosis: Typical features

Suicide risk. Ask psychotic patients if they think about harming themselves. Lifetime risk of suicide in schizophrenia is 10% to 15%, and rates in bipolar disorder are higher. If patients deny suicidality, ask them why. Reassuring responses include religious prohibition, hopefulness about the future, concern about suicide’s effect on a loved one, fear of dying, or lack of means.

Candidates for emergent psychiatric consultation or hospitalization include patients with violent or homicidal thoughts and any patient who has attempted suicide, has a family history of suicide, has access to means, and lacks compelling reasons against suicide. Consider immediate psychiatric evaluation and admission of patients whose delusions or behaviors put them at risk for harm.

Abdominal pain workup. Although Mr. J’s abdominal pain may be functional, also seek an organic cause. His first-time disclosure of psychotic symptoms suggests that a serious medical stressor may be exacerbating a chronic psychiatric illness. Because the elevated lipase may indicate pancreatitis, consider an endoscopic or MRI examination of the pancreas and bile ducts. In consultation with a gastroenterologist, evaluate other causes such as peptic ulcer disease, ischemic bowel (perhaps as a result of cocaine use), inflammatory bowel disease, vasculitis, porphyria, and abdominal migraine.

Managing psychosis

Psychiatric consultation is strongly recommended for patients beginning therapy for psychotic disorders who have shown a particularly high risk for suicide. Uncontrolled symptoms, unanticipated psychiatric side effects, and the humiliation that results from the insight gained through treatment may contribute to this risk.

Assuming that Mr. J does not meet criteria for acute psychiatric hospitalization, the primary care clinician can stabilize the psychotic symptoms while awaiting psychiatric referral. Any atypical antipsychotic would be appropriate (Table 3).

Table 3

Starting an atypical antipsychotic* for primary psychosis

Patients who refuse treatment pose a quandary. If the patient is not acutely ill, try to establish an alliance over several visits rather than endangering the therapeutic relationship through confrontation or overzealous persuasion (Table 4).

Table 4

Strategies to build a therapeutic alliance with psychotic patients

Monitoring. The primary care physician’s role after the patient begins antipsychotic therapy is to:

• assess his or her symptoms (particularly suicidality) and adherence to psychiatric visits and treatment
• monitor for adverse effects from medications.

Atypical antipsychotics have been associated with weight gain, hyperglycemia, and hyperlipidemia. Check fasting glucose and lipids quarterly for the first year of antipsychotic therapy and annually thereafter.⁵ Watch for drug-drug interactions whenever a new medication is added. Monitor for abnormal movements, even though the risk of extrapyramidal symptoms and tardive dyskinesia is lower with atypical antipsychotics than with traditional agents.

For Mr. J’s psychiatric symptoms, I would:

• assess his willingness to start medication to reduce or eliminate the voices
• suggest he accept psychiatric referral
• assure him that I will remain involved in his care and continue to evaluate his abdominal symptoms.

I would also request permission to discuss his case with his partner and a family member to gather pertinent history and enlist their support for treatment. I would then start Mr. J on any drug listed in Table 3.

Distinguishing the cause of a patient’s psychotic symptoms can be clinically challenging in a primary care practice. This case was submitted by Matthew Rosenberg, MD, who practices family medicine at Sacramento (CA) County Primary Care Clinic. This month’s consultant is Bezalel Dantz, MD.

How would you have advised Dr. Rosenberg?

Case: ‘you’re just gonna die’

I was seeing Mr. J, age 31, weekly to monitor abdominal complaints. For 3 weeks he experienced increasing epigastric pain, and he had been evaluated twice in the emergency room for this complaint. Plain films, ultrasound, CT, and an elevated lipase reading suggested an inconclusive diagnosis of pancreatitis.

During his second office visit, Mr. J also complained of “hearing voices.” Further questioning revealed that he had been hearing voices—often male—making degrading comments for several years. The voices have increased in frequency during his illness, and their negative comments include, “What do you have to live for?” and “You’re just gonna die.”

Mr. J blames the voices on distant drug use, claiming his parents “forced” him as a young teen to take hallucinogens. He often thinks he is being followed and does not trust others. He said both parents had mental illnesses but does not know the diagnoses or seriousness of their disorders.

His thoughts are well-organized with clear content. He shows no signs of depression or mania. He plays guitar in a band and appears to be a thoughtful and high-functioning individual.

I need help with the differential diagnosis and suggestions of possible treatment options.

Dr. Dantz’s consultation

The first step in evaluating psychosis is to determine whether it indicates a medical disorder, substanceinduced disorder, or primary psychiatric illness. The chronicity and nature of Mr. J’s psychotic symptoms (auditory hallucinations and paranoid delusions), his age, and a family history of psychiatric illness suggest a primary psychiatric disorder. The elevated lipase might explain his abdominal pain but is likely independent of his psychosis.

Medical workup. Conduct a comprehensive physical exam and medical and psychiatric history. Obtain collateral information from the family about the patient’s psychiatric symptoms, family history, recreational drug use, and stressors. Acute onset, age >40, comorbid medical conditions, lack of acute psychosocial stressors, and a negative personal or family psychiatric history suggest a medical cause (The skinny on one patient’s psychosis,” November 2005.) Also assess for use of alcohol, marijuana, hallucinogens, narcotics, stimulants, and inhalants. Until any drug has been stopped for at least 1 week, its contribution to psychosis may be unclear.

Table 1

Medical conditions that may present as psychosis

Lab testing. When signs or symptoms do not suggest an organic disease, laboratory tests have a low yield and are of questionable value.² In primary care practice, however, many psychotic patients complain of somatic symptoms. Given the devastating impact of psychotic illness, one can argue that even a yield <5% justifies a workup.

A urine toxicology screen is by far the most important lab test. CBC, comprehensive metabolic panel, thyroid function tests, erythrocyte sedimentation rate, and calcium level may reveal a medical cause. Consider HIV antibody and syphilis tests in at-risk individuals.

Findings on physical exam or abnormal lab results would guide further testing. Because of Mr. J’s GI and neurologic symptoms, a 24-hour urine test may be reasonable, particularly if he has had episodes of acute intermittent porphyria.

Neuroimaging. Consider a scan when psychosis is comorbid with:

• age >40
• neurologic complaints (such as headache, numbness, vertigo, seizures)
• focal neurologic findings (such as weakness, gait abnormality, clonus, or spasticity)
• confusion, cognitive deficit, history of malignancy
• head trauma
• immunocompromised state
• atypical psychotic symptoms (such as visual or olfactory hallucinations).

Psychiatric workup. If the history and physical exam reveal no organic basis, the next step is to determine the nature of this patient’s psychosis. The two most common psychiatric conditions associated with psychosis are:

• schizophrenic spectrum disorders (such as schizophreniform, schizophrenia and schizoaffective disorder)
• affective disorders (such as psychotic depression and bipolar disorder).

Distinguishing among these conditions can be challenging (Table 2) because patients rarely present with typical syndromes.

For example, a bipolar patient may present in a mixed state with both depressive and manic features. Psychosis in schizophrenia may be brief (<6 months in schizophreniform disorder) and may be characterized by manic-like grandiose delusions or negative symptoms (flat affect, poverty of speech) that mimic affective symptoms. Finally, some patients have both an affective disorder and schizophrenia, as in schizoaffective disorder.

For Mr. J, years of uninterrupted hallucinations, longstanding paranoid delusions, and absence of prominent affective symptoms suggest schizophrenia. His hallucinations are typical of those reported in schizophrenia. Voices giving a running commentary on a person’s thoughts and actions and derogatory comments are two of the most common auditory hallucinations.

Somatic concerns are also prominent in schizophrenia. Patients may describe symptoms in bizarre terms, such as “electric shocks in my head” or “there’s a fire in my spleen.”

Supporting evidence for a schizophrenia diagnosis would include a history of social isolation, lack of interest in work, and poor social interaction. Mr. J has a supportive partner, and we are told he appears to be high-functioning and active as a guitarist in a band. These factors might support an alternate diagnosis of affective psychosis. Finally, his past drug use and somatic symptoms raise the possibility of active substance abuse.

Table 2

Differential diagnosis of primary psychosis: Typical features

Suicide risk. Ask psychotic patients if they think about harming themselves. Lifetime risk of suicide in schizophrenia is 10% to 15%, and rates in bipolar disorder are higher. If patients deny suicidality, ask them why. Reassuring responses include religious prohibition, hopefulness about the future, concern about suicide’s effect on a loved one, fear of dying, or lack of means.

Candidates for emergent psychiatric consultation or hospitalization include patients with violent or homicidal thoughts and any patient who has attempted suicide, has a family history of suicide, has access to means, and lacks compelling reasons against suicide. Consider immediate psychiatric evaluation and admission of patients whose delusions or behaviors put them at risk for harm.

Abdominal pain workup. Although Mr. J’s abdominal pain may be functional, also seek an organic cause. His first-time disclosure of psychotic symptoms suggests that a serious medical stressor may be exacerbating a chronic psychiatric illness. Because the elevated lipase may indicate pancreatitis, consider an endoscopic or MRI examination of the pancreas and bile ducts. In consultation with a gastroenterologist, evaluate other causes such as peptic ulcer disease, ischemic bowel (perhaps as a result of cocaine use), inflammatory bowel disease, vasculitis, porphyria, and abdominal migraine.

Managing psychosis

Psychiatric consultation is strongly recommended for patients beginning therapy for psychotic disorders who have shown a particularly high risk for suicide. Uncontrolled symptoms, unanticipated psychiatric side effects, and the humiliation that results from the insight gained through treatment may contribute to this risk.

Assuming that Mr. J does not meet criteria for acute psychiatric hospitalization, the primary care clinician can stabilize the psychotic symptoms while awaiting psychiatric referral. Any atypical antipsychotic would be appropriate (Table 3).

Table 3

Starting an atypical antipsychotic* for primary psychosis

Patients who refuse treatment pose a quandary. If the patient is not acutely ill, try to establish an alliance over several visits rather than endangering the therapeutic relationship through confrontation or overzealous persuasion (Table 4).

Table 4

Strategies to build a therapeutic alliance with psychotic patients

Monitoring. The primary care physician’s role after the patient begins antipsychotic therapy is to:

• assess his or her symptoms (particularly suicidality) and adherence to psychiatric visits and treatment
• monitor for adverse effects from medications.

Atypical antipsychotics have been associated with weight gain, hyperglycemia, and hyperlipidemia. Check fasting glucose and lipids quarterly for the first year of antipsychotic therapy and annually thereafter.⁵ Watch for drug-drug interactions whenever a new medication is added. Monitor for abnormal movements, even though the risk of extrapyramidal symptoms and tardive dyskinesia is lower with atypical antipsychotics than with traditional agents.

For Mr. J’s psychiatric symptoms, I would:

• assess his willingness to start medication to reduce or eliminate the voices
• suggest he accept psychiatric referral
• assure him that I will remain involved in his care and continue to evaluate his abdominal symptoms.

I would also request permission to discuss his case with his partner and a family member to gather pertinent history and enlist their support for treatment. I would then start Mr. J on any drug listed in Table 3.