One of the potential benefits of hospital medicine is the tangible opportunity to change healthcare in a meaningful way. Although much of the initial ballyhoo for hospital medicine has been around service-related issues, that is about to change.

Hospitalists have been willing to take on the inpatient responsibilities for primarily outpatient-based internists, family practitioners, and pediatricians. We have been available to admit and manage the patients who present to emergency rooms with acute illnesses and who have no physician of record. We have actively worked with surgeons and subspecialists to co-manage their patient’s medical problems.

In addition, because hospitalists are much more readily available to acutely ill inpatients, because we have more expertise with these medical problems, and because practice generally makes for better performance, hospitalists have been expected to provide more effective and more efficient care.

But that is just the front end of what is creating the enormous energy behind the hospital medicine movement. We are moving into an era of measurement of defined patient outcomes and expectations from insurance companies, Medicare, the business community, and—yes—even our patients. That era will require us to step up and deliver higher quality healthcare.

This is the driver to the pay-for-performance movement and a shift from just rewarding physicians and hospitals for doing the procedure or “visiting” the patient and moving to where those who can demonstrate expertise and performance are rewarded financially and by reputation.

Hospitalists and SHM take this very seriously and are creating alliances and programs to help hospitalists become leaders in the quality and performance arenas.

Walking through the approach that SHM is taking in improving glycemic control in hospitalized patients (see below) will serve as a template for other activities SHM has planned in heart failure, VTE, hospitalized infections, and other illnesses hospitalists see and treat every day.

In a practical way, hospitals and health professionals finally came into the performance era with the first publication of the individual hospital performance results to performance measures developed by JCAHO and co-promoted with CMS in their Hospital Compare Web site. This was promulgated widely, especially at www.hospitalcompare.hhs.gov.

Because Hospital Compare was picked up by The New York Times, the Los Angeles Times, and many local papers, hospitals were soon trying to explain why their performance in heart failure, pneumonia, and heart attack looked like a failing grade. Now that the public is involved, hospitals are scrambling to quickly improve their performance rather than attacking the data.

Looking to the future, SHM is working with JCAHO to develop performance standards for glycemic control for inpatients as a way to assess how our hospitals and physicians are doing in managing diabetes. SHM is also allying with many other key stakeholders to form a steering committee for this project. These standards will take almost three years to develop, test, and implement. So the first reporting of how every hospital is doing in diabetes is most likely a 2008 or 2009 event.

Expecting that many hospitals will improve their performance in diabetic care during 2008 and 2009, SHM is now developing the tools and the training to allow hospitalists to be ready with practical solutions.

In October 2005 SHM convened a Working Group on Inpatient Glycemic Control in Chicago. This meeting under the leadership of Greg Maynard, MD, associate clinical professor of medicine, chief of the division of hospital medicine, University of California at San Diego, brought together nationally recognized diabetologists and endocrinologists with hospitalist leaders, as well as experts in the field of nursing, case management, pharmacy, risk management, and nutrition. The end result is an understanding of what constitutes an ideal management of inpatient diabetes and what role hospitalists can play.

This work group now is analyzing what resources currently exist and what gaps need to be filled. Next SHM will develop an implementation plan to get this information out to our nation’s hospitalists.

SHM has some experience in developing quality improvement tools, as you can see in our Resource Rooms on the SHM Web site. For a current working example, take a look at the DVT Quality Improvement Resource Room at www.hospitalmedicine.org/AM/Template.cfm?Section=Quality_Improvement_Resource_Rooms1&Template=/CM/HTMLDisplay.cfm&ContentID=6312.

But SHM plans a more aggressive approach with proposed training sessions at the SHM Annual Meeting quality pre-course and taking these tools and approaches out to our hospitalists at local meetings throughout the country. SHM is also looking into creating a network of quality mentors that will work with individual hospitalists groups as they put SHM quality improvement tools into the workflow at their hospitals. SHM will also develop strategies for baseline measurement, ongoing data collection, involvement of team members, and procurement of local resources. SHM hopes to support research to further develop best practices and approaches.

The game plan goes something like this: SHM will develop the resources hospitalists need to improve management of inpatient diabetes in 2006. In 2007 and 2008 SHM will roll out this strategy to as many hospitalists as we can train. By 2008 JCAHO and CMS will have deployed their Performance Measures in Diabetes. When the first scores show the same deficiencies as we have seen this year in MI and heart failure, our nation’s hospitalists will be well armed to provide practical tangible solutions to improve quality.

And the beauty of this approach is that SHM is working on similar strategies right now for heart failure, DVT, pneumonia, and other key clinical conditions.

Those who pay for and receive care in our hospitals are looking at our current performance and demanding improvements. For the first time hospitals and those with resources are ready to make measurable quality a high priority. The presence of hospitalists in more than 2,000 hospitals (and more in the near future) ideally positions hospitalists to be a key change agent. The tools SHM is developing will give hospitalists the strategies and the expertise to make this happen.

This is a watershed moment in American healthcare. There is a palpable swing in the priorities of our patients. Hospitalists can help the healthcare team find real solutions. SHM has the vision and the plan to provide you with as much help as you need. Together we will do great things. TH

Dr. Wellikson has been CEO of SHM since 2000.

One of the potential benefits of hospital medicine is the tangible opportunity to change healthcare in a meaningful way. Although much of the initial ballyhoo for hospital medicine has been around service-related issues, that is about to change.

Hospitalists have been willing to take on the inpatient responsibilities for primarily outpatient-based internists, family practitioners, and pediatricians. We have been available to admit and manage the patients who present to emergency rooms with acute illnesses and who have no physician of record. We have actively worked with surgeons and subspecialists to co-manage their patient’s medical problems.

In addition, because hospitalists are much more readily available to acutely ill inpatients, because we have more expertise with these medical problems, and because practice generally makes for better performance, hospitalists have been expected to provide more effective and more efficient care.

But that is just the front end of what is creating the enormous energy behind the hospital medicine movement. We are moving into an era of measurement of defined patient outcomes and expectations from insurance companies, Medicare, the business community, and—yes—even our patients. That era will require us to step up and deliver higher quality healthcare.

This is the driver to the pay-for-performance movement and a shift from just rewarding physicians and hospitals for doing the procedure or “visiting” the patient and moving to where those who can demonstrate expertise and performance are rewarded financially and by reputation.

Hospitalists and SHM take this very seriously and are creating alliances and programs to help hospitalists become leaders in the quality and performance arenas.

Walking through the approach that SHM is taking in improving glycemic control in hospitalized patients (see below) will serve as a template for other activities SHM has planned in heart failure, VTE, hospitalized infections, and other illnesses hospitalists see and treat every day.

In a practical way, hospitals and health professionals finally came into the performance era with the first publication of the individual hospital performance results to performance measures developed by JCAHO and co-promoted with CMS in their Hospital Compare Web site. This was promulgated widely, especially at www.hospitalcompare.hhs.gov.

Because Hospital Compare was picked up by The New York Times, the Los Angeles Times, and many local papers, hospitals were soon trying to explain why their performance in heart failure, pneumonia, and heart attack looked like a failing grade. Now that the public is involved, hospitals are scrambling to quickly improve their performance rather than attacking the data.

Looking to the future, SHM is working with JCAHO to develop performance standards for glycemic control for inpatients as a way to assess how our hospitals and physicians are doing in managing diabetes. SHM is also allying with many other key stakeholders to form a steering committee for this project. These standards will take almost three years to develop, test, and implement. So the first reporting of how every hospital is doing in diabetes is most likely a 2008 or 2009 event.

Expecting that many hospitals will improve their performance in diabetic care during 2008 and 2009, SHM is now developing the tools and the training to allow hospitalists to be ready with practical solutions.

In October 2005 SHM convened a Working Group on Inpatient Glycemic Control in Chicago. This meeting under the leadership of Greg Maynard, MD, associate clinical professor of medicine, chief of the division of hospital medicine, University of California at San Diego, brought together nationally recognized diabetologists and endocrinologists with hospitalist leaders, as well as experts in the field of nursing, case management, pharmacy, risk management, and nutrition. The end result is an understanding of what constitutes an ideal management of inpatient diabetes and what role hospitalists can play.

This work group now is analyzing what resources currently exist and what gaps need to be filled. Next SHM will develop an implementation plan to get this information out to our nation’s hospitalists.

SHM has some experience in developing quality improvement tools, as you can see in our Resource Rooms on the SHM Web site. For a current working example, take a look at the DVT Quality Improvement Resource Room at www.hospitalmedicine.org/AM/Template.cfm?Section=Quality_Improvement_Resource_Rooms1&Template=/CM/HTMLDisplay.cfm&ContentID=6312.

But SHM plans a more aggressive approach with proposed training sessions at the SHM Annual Meeting quality pre-course and taking these tools and approaches out to our hospitalists at local meetings throughout the country. SHM is also looking into creating a network of quality mentors that will work with individual hospitalists groups as they put SHM quality improvement tools into the workflow at their hospitals. SHM will also develop strategies for baseline measurement, ongoing data collection, involvement of team members, and procurement of local resources. SHM hopes to support research to further develop best practices and approaches.

The game plan goes something like this: SHM will develop the resources hospitalists need to improve management of inpatient diabetes in 2006. In 2007 and 2008 SHM will roll out this strategy to as many hospitalists as we can train. By 2008 JCAHO and CMS will have deployed their Performance Measures in Diabetes. When the first scores show the same deficiencies as we have seen this year in MI and heart failure, our nation’s hospitalists will be well armed to provide practical tangible solutions to improve quality.

And the beauty of this approach is that SHM is working on similar strategies right now for heart failure, DVT, pneumonia, and other key clinical conditions.

Those who pay for and receive care in our hospitals are looking at our current performance and demanding improvements. For the first time hospitals and those with resources are ready to make measurable quality a high priority. The presence of hospitalists in more than 2,000 hospitals (and more in the near future) ideally positions hospitalists to be a key change agent. The tools SHM is developing will give hospitalists the strategies and the expertise to make this happen.

This is a watershed moment in American healthcare. There is a palpable swing in the priorities of our patients. Hospitalists can help the healthcare team find real solutions. SHM has the vision and the plan to provide you with as much help as you need. Together we will do great things. TH

Dr. Wellikson has been CEO of SHM since 2000.

One of the potential benefits of hospital medicine is the tangible opportunity to change healthcare in a meaningful way. Although much of the initial ballyhoo for hospital medicine has been around service-related issues, that is about to change.

Hospitalists have been willing to take on the inpatient responsibilities for primarily outpatient-based internists, family practitioners, and pediatricians. We have been available to admit and manage the patients who present to emergency rooms with acute illnesses and who have no physician of record. We have actively worked with surgeons and subspecialists to co-manage their patient’s medical problems.

In addition, because hospitalists are much more readily available to acutely ill inpatients, because we have more expertise with these medical problems, and because practice generally makes for better performance, hospitalists have been expected to provide more effective and more efficient care.

But that is just the front end of what is creating the enormous energy behind the hospital medicine movement. We are moving into an era of measurement of defined patient outcomes and expectations from insurance companies, Medicare, the business community, and—yes—even our patients. That era will require us to step up and deliver higher quality healthcare.

This is the driver to the pay-for-performance movement and a shift from just rewarding physicians and hospitals for doing the procedure or “visiting” the patient and moving to where those who can demonstrate expertise and performance are rewarded financially and by reputation.

Hospitalists and SHM take this very seriously and are creating alliances and programs to help hospitalists become leaders in the quality and performance arenas.

Walking through the approach that SHM is taking in improving glycemic control in hospitalized patients (see below) will serve as a template for other activities SHM has planned in heart failure, VTE, hospitalized infections, and other illnesses hospitalists see and treat every day.

In a practical way, hospitals and health professionals finally came into the performance era with the first publication of the individual hospital performance results to performance measures developed by JCAHO and co-promoted with CMS in their Hospital Compare Web site. This was promulgated widely, especially at www.hospitalcompare.hhs.gov.

Because Hospital Compare was picked up by The New York Times, the Los Angeles Times, and many local papers, hospitals were soon trying to explain why their performance in heart failure, pneumonia, and heart attack looked like a failing grade. Now that the public is involved, hospitals are scrambling to quickly improve their performance rather than attacking the data.

Looking to the future, SHM is working with JCAHO to develop performance standards for glycemic control for inpatients as a way to assess how our hospitals and physicians are doing in managing diabetes. SHM is also allying with many other key stakeholders to form a steering committee for this project. These standards will take almost three years to develop, test, and implement. So the first reporting of how every hospital is doing in diabetes is most likely a 2008 or 2009 event.

Expecting that many hospitals will improve their performance in diabetic care during 2008 and 2009, SHM is now developing the tools and the training to allow hospitalists to be ready with practical solutions.

In October 2005 SHM convened a Working Group on Inpatient Glycemic Control in Chicago. This meeting under the leadership of Greg Maynard, MD, associate clinical professor of medicine, chief of the division of hospital medicine, University of California at San Diego, brought together nationally recognized diabetologists and endocrinologists with hospitalist leaders, as well as experts in the field of nursing, case management, pharmacy, risk management, and nutrition. The end result is an understanding of what constitutes an ideal management of inpatient diabetes and what role hospitalists can play.

This work group now is analyzing what resources currently exist and what gaps need to be filled. Next SHM will develop an implementation plan to get this information out to our nation’s hospitalists.

SHM has some experience in developing quality improvement tools, as you can see in our Resource Rooms on the SHM Web site. For a current working example, take a look at the DVT Quality Improvement Resource Room at www.hospitalmedicine.org/AM/Template.cfm?Section=Quality_Improvement_Resource_Rooms1&Template=/CM/HTMLDisplay.cfm&ContentID=6312.

But SHM plans a more aggressive approach with proposed training sessions at the SHM Annual Meeting quality pre-course and taking these tools and approaches out to our hospitalists at local meetings throughout the country. SHM is also looking into creating a network of quality mentors that will work with individual hospitalists groups as they put SHM quality improvement tools into the workflow at their hospitals. SHM will also develop strategies for baseline measurement, ongoing data collection, involvement of team members, and procurement of local resources. SHM hopes to support research to further develop best practices and approaches.

The game plan goes something like this: SHM will develop the resources hospitalists need to improve management of inpatient diabetes in 2006. In 2007 and 2008 SHM will roll out this strategy to as many hospitalists as we can train. By 2008 JCAHO and CMS will have deployed their Performance Measures in Diabetes. When the first scores show the same deficiencies as we have seen this year in MI and heart failure, our nation’s hospitalists will be well armed to provide practical tangible solutions to improve quality.

And the beauty of this approach is that SHM is working on similar strategies right now for heart failure, DVT, pneumonia, and other key clinical conditions.

Those who pay for and receive care in our hospitals are looking at our current performance and demanding improvements. For the first time hospitals and those with resources are ready to make measurable quality a high priority. The presence of hospitalists in more than 2,000 hospitals (and more in the near future) ideally positions hospitalists to be a key change agent. The tools SHM is developing will give hospitalists the strategies and the expertise to make this happen.

This is a watershed moment in American healthcare. There is a palpable swing in the priorities of our patients. Hospitalists can help the healthcare team find real solutions. SHM has the vision and the plan to provide you with as much help as you need. Together we will do great things. TH

Dr. Wellikson has been CEO of SHM since 2000.

W­hen I was a kid I remember saying that “ain’t ain’t a word because ain’t ain’t in the dictionary.” I just found “ain’t” in my online dictionary, which warned against using “ain’t” because it “does not form a part of standard English and should not be used in formal contexts.”

If the dictionary is the final arbiter of what is and is not a word, then finally “hospitalist” is a word (as we reported last month, see Nov. The Hospitalist, p. 17). Of course we have been using the word since Bob Wachter and Lee Goldman first coined it in their paper in the New England Journal of Medicine in 1996.1 But the 2005 update of the Eleventh Edition of Merriam-Webster’s Collegiate Dictionary defines a “hospitalist” as “a physician who specializes in treating hospitalized patients of other physicians in order to minimize the number of hospital visits by other physicians.”

While I am delighted that our specialty is in the dictionary, I would argue that the role of a hospitalist is about more than saving other physicians’ commute time. In fact SHM published an entire supplement that catalogued the many roles of hospitalists and how we add value.2 But even if the dictionary didn’t get the definition quite right, the presence of the word hospitalist is yet more evidence of the increasing importance and growth of our field. I want to share with you some of the exciting projects that the SHM is working on to further define our field.

Board Certification

We have been in discussion with the American Board of Internal Medicine and other societies that represent important interests in internal medicine regarding board certification for hospitalists. At this point I cannot tell you what certification will look like, how it will be conferred, or when it will come about; however, SHM is committed to developing a process that recognizes the expertise and experience of hospitalists and supports high quality care for patients. As you might imagine, any process of certification for hospitalists has huge implications for all physicians who practice internal medicine, and we are working to consider these issues carefully as we move ahead. Board certification, and the process of making it come about, marks another step along the path in the maturing of our field.

Journal of Hospital Medicine and Research

More evidence of our growth as a field is the coming publication of the Journal of Hospital Medicine. Under the editorship of Mark Williams, MD, the journal will be the first dedicated to hospital medicine and the care of hospitalized patients. I still remember the early discussions at the SHM Board of Directors meetings where we first discussed having a journal. At the time there were only three or four hospitalist researchers and our major concern was whether there would be sufficient content to fill a journal once let alone six or more times a year; however, at the time we also saw where our field was headed. We knew that in order to continue to define the field of hospital medicine a journal was key.

Perhaps our decision several years ago was hubris, perhaps it was blind optimism, but I like to think it was faith in our members and our society and a belief that hospital medicine was here to stay and would only get bigger. Next month SHM will proudly publish the first volume of the Journal of Hospital Medicine. I am happy to report that we have plenty of high quality content to fill the journal. Our field has continued to expand and with it more and more researchers are focusing on hospital medicine. One walk around the poster session at our annual meeting is enough to demonstrate all of the outstanding academic work that hospitalists at academic centers and community hospitals are doing.

Hand in hand with the publication of our journal has been our research initiative. I firmly believe that in order for SHM to lead hospital medicine, we must also lead in the area of research. In order to coordinate and expand our efforts in research, we recently brought Kathleen Kerr on board at SHM as a senior advisor to lead our research initiative. Kathleen brings a new level of rigor and enthusiasm to our research initiative and helps support the outstanding work of our research committee led by Andy Auerbach, MD. At SHM research reflects our members and includes hospitalists from all settings. I invite you to present your work at our annual meeting (we are currently accepting submissions through Jan. 6, 2006, for the Research, Innovations and Clinical Vignettes competition for the 2006 annual meeting) so we can all benefit and learn from the work we are doing. I also invite you to submit your work for publication in the Journal of Hospital Medicine.

Core Competency

Yet another sign of our maturing as a field will be the publication of the Core Competencies in Hospital Medicine as a supplement to the first volume of the Journal of Hospital Medicine. The core competencies reflect hundreds of hours of work by a dedicated group of hospitalists and SHM staff led by Tina Budnitz MPH, to define the core of what hospitalists need to know. Yes, hospitalists are more than just timesavers for other physicians. The core competencies in hospital medicine will outline what hospital medicine is about and serve as the foundation for educational programs, curricula, and initiatives in hospital medicine. The core competencies will also form the basis for certification of hospitalists by defining the key attitudes and skills needed to be a hospitalist. Look for the core competencies in early 2006 along with your first volume of the journal.

Evolution of Other “Ists”

If imitation is the finest form of flattery, then hospitalists should be very flattered by the proliferation of other “-ists.” Within our own field we find “nocurnists,” hospitalists who care for patients in the hospital overnight. Although it is not clear whether being a nocturnist is a permanent state in which you work only nights or a title that you hold temporarily, it is clear that “hospitalist” is leading to a wide use of the “-ist” suffix to describe the practice of physicians.

Even more interesting is the emergence of hospitalists in other fields such as surgery and obstetrics (see our related coverage in The Hospitalist—“What Is a Laborist,” Oct. 2005, p. 6; “Trendwatch: The specialization of hospital medicine,” Oct. 2005, p. 27; and “The Doctor Is In: The role of psychiatric hospitalists,” Oct. 2005, p. 30). Because the “ist” doesn’t work well universally (neither “surgicalist” nor “obstetricist” sounds right and neither does “deliverist”) the terms being used are “surgical hospitalist” or “OB hospitalist.” In either case the idea is that there is a physician, surgeon, or an obstetrician who sees patients in the hospital instead of the patients’ primary physician. Typically these physicians are employed by the hospital to care for unassigned patients admitted through the emergency department. The adoption of “hospitalist” by other fields in medicine to describe clinicians whose professional identity revolves around the hospital is a testament to the acceptance—and even normalization—of hospitalists and to the profound change in the way we care for hospitalized patients brought about by our field.

We certainly have come a long way from the days when our newly formed society decided not to use the word hospitalist or hospital or anything like it in our name for fear of inciting animosity. In just a few short years we find a world where hospitalist is in the dictionary and other physicians begin to use the term to describe themselves. Reflecting this maturing of our field, SHM is involved in several initiatives including certification, research, a journal, and core competencies to further define hospital medicine.

If you have been thinking about getting more involved in the SHM, do so now. Become an active member; volunteer for committees. Help shape our field and the world of hospital medicine in the future. This ride certainly ain’t over. In fact, it’s just beginning. TH

SHM President Dr. Pantilat is an associate professor of clinical medicine at the University of California at San Francisco.

References

1. Wachter RM, Goldman L. The emerging role of “hospitalists” in the American health care system. N Engl J Med. 1996;335(7):514-517.
2. Pile J. How hospitalists add value. The Hospitalist. 2005;9:Supplement 1.

W­hen I was a kid I remember saying that “ain’t ain’t a word because ain’t ain’t in the dictionary.” I just found “ain’t” in my online dictionary, which warned against using “ain’t” because it “does not form a part of standard English and should not be used in formal contexts.”

If the dictionary is the final arbiter of what is and is not a word, then finally “hospitalist” is a word (as we reported last month, see Nov. The Hospitalist, p. 17). Of course we have been using the word since Bob Wachter and Lee Goldman first coined it in their paper in the New England Journal of Medicine in 1996.1 But the 2005 update of the Eleventh Edition of Merriam-Webster’s Collegiate Dictionary defines a “hospitalist” as “a physician who specializes in treating hospitalized patients of other physicians in order to minimize the number of hospital visits by other physicians.”

While I am delighted that our specialty is in the dictionary, I would argue that the role of a hospitalist is about more than saving other physicians’ commute time. In fact SHM published an entire supplement that catalogued the many roles of hospitalists and how we add value.2 But even if the dictionary didn’t get the definition quite right, the presence of the word hospitalist is yet more evidence of the increasing importance and growth of our field. I want to share with you some of the exciting projects that the SHM is working on to further define our field.

Board Certification

We have been in discussion with the American Board of Internal Medicine and other societies that represent important interests in internal medicine regarding board certification for hospitalists. At this point I cannot tell you what certification will look like, how it will be conferred, or when it will come about; however, SHM is committed to developing a process that recognizes the expertise and experience of hospitalists and supports high quality care for patients. As you might imagine, any process of certification for hospitalists has huge implications for all physicians who practice internal medicine, and we are working to consider these issues carefully as we move ahead. Board certification, and the process of making it come about, marks another step along the path in the maturing of our field.

Journal of Hospital Medicine and Research

More evidence of our growth as a field is the coming publication of the Journal of Hospital Medicine. Under the editorship of Mark Williams, MD, the journal will be the first dedicated to hospital medicine and the care of hospitalized patients. I still remember the early discussions at the SHM Board of Directors meetings where we first discussed having a journal. At the time there were only three or four hospitalist researchers and our major concern was whether there would be sufficient content to fill a journal once let alone six or more times a year; however, at the time we also saw where our field was headed. We knew that in order to continue to define the field of hospital medicine a journal was key.

Perhaps our decision several years ago was hubris, perhaps it was blind optimism, but I like to think it was faith in our members and our society and a belief that hospital medicine was here to stay and would only get bigger. Next month SHM will proudly publish the first volume of the Journal of Hospital Medicine. I am happy to report that we have plenty of high quality content to fill the journal. Our field has continued to expand and with it more and more researchers are focusing on hospital medicine. One walk around the poster session at our annual meeting is enough to demonstrate all of the outstanding academic work that hospitalists at academic centers and community hospitals are doing.

Hand in hand with the publication of our journal has been our research initiative. I firmly believe that in order for SHM to lead hospital medicine, we must also lead in the area of research. In order to coordinate and expand our efforts in research, we recently brought Kathleen Kerr on board at SHM as a senior advisor to lead our research initiative. Kathleen brings a new level of rigor and enthusiasm to our research initiative and helps support the outstanding work of our research committee led by Andy Auerbach, MD. At SHM research reflects our members and includes hospitalists from all settings. I invite you to present your work at our annual meeting (we are currently accepting submissions through Jan. 6, 2006, for the Research, Innovations and Clinical Vignettes competition for the 2006 annual meeting) so we can all benefit and learn from the work we are doing. I also invite you to submit your work for publication in the Journal of Hospital Medicine.

Core Competency

Yet another sign of our maturing as a field will be the publication of the Core Competencies in Hospital Medicine as a supplement to the first volume of the Journal of Hospital Medicine. The core competencies reflect hundreds of hours of work by a dedicated group of hospitalists and SHM staff led by Tina Budnitz MPH, to define the core of what hospitalists need to know. Yes, hospitalists are more than just timesavers for other physicians. The core competencies in hospital medicine will outline what hospital medicine is about and serve as the foundation for educational programs, curricula, and initiatives in hospital medicine. The core competencies will also form the basis for certification of hospitalists by defining the key attitudes and skills needed to be a hospitalist. Look for the core competencies in early 2006 along with your first volume of the journal.

Evolution of Other “Ists”

If imitation is the finest form of flattery, then hospitalists should be very flattered by the proliferation of other “-ists.” Within our own field we find “nocurnists,” hospitalists who care for patients in the hospital overnight. Although it is not clear whether being a nocturnist is a permanent state in which you work only nights or a title that you hold temporarily, it is clear that “hospitalist” is leading to a wide use of the “-ist” suffix to describe the practice of physicians.

Even more interesting is the emergence of hospitalists in other fields such as surgery and obstetrics (see our related coverage in The Hospitalist—“What Is a Laborist,” Oct. 2005, p. 6; “Trendwatch: The specialization of hospital medicine,” Oct. 2005, p. 27; and “The Doctor Is In: The role of psychiatric hospitalists,” Oct. 2005, p. 30). Because the “ist” doesn’t work well universally (neither “surgicalist” nor “obstetricist” sounds right and neither does “deliverist”) the terms being used are “surgical hospitalist” or “OB hospitalist.” In either case the idea is that there is a physician, surgeon, or an obstetrician who sees patients in the hospital instead of the patients’ primary physician. Typically these physicians are employed by the hospital to care for unassigned patients admitted through the emergency department. The adoption of “hospitalist” by other fields in medicine to describe clinicians whose professional identity revolves around the hospital is a testament to the acceptance—and even normalization—of hospitalists and to the profound change in the way we care for hospitalized patients brought about by our field.

We certainly have come a long way from the days when our newly formed society decided not to use the word hospitalist or hospital or anything like it in our name for fear of inciting animosity. In just a few short years we find a world where hospitalist is in the dictionary and other physicians begin to use the term to describe themselves. Reflecting this maturing of our field, SHM is involved in several initiatives including certification, research, a journal, and core competencies to further define hospital medicine.

If you have been thinking about getting more involved in the SHM, do so now. Become an active member; volunteer for committees. Help shape our field and the world of hospital medicine in the future. This ride certainly ain’t over. In fact, it’s just beginning. TH

SHM President Dr. Pantilat is an associate professor of clinical medicine at the University of California at San Francisco.

References

1. Wachter RM, Goldman L. The emerging role of “hospitalists” in the American health care system. N Engl J Med. 1996;335(7):514-517.
2. Pile J. How hospitalists add value. The Hospitalist. 2005;9:Supplement 1.

W­hen I was a kid I remember saying that “ain’t ain’t a word because ain’t ain’t in the dictionary.” I just found “ain’t” in my online dictionary, which warned against using “ain’t” because it “does not form a part of standard English and should not be used in formal contexts.”

If the dictionary is the final arbiter of what is and is not a word, then finally “hospitalist” is a word (as we reported last month, see Nov. The Hospitalist, p. 17). Of course we have been using the word since Bob Wachter and Lee Goldman first coined it in their paper in the New England Journal of Medicine in 1996.1 But the 2005 update of the Eleventh Edition of Merriam-Webster’s Collegiate Dictionary defines a “hospitalist” as “a physician who specializes in treating hospitalized patients of other physicians in order to minimize the number of hospital visits by other physicians.”

While I am delighted that our specialty is in the dictionary, I would argue that the role of a hospitalist is about more than saving other physicians’ commute time. In fact SHM published an entire supplement that catalogued the many roles of hospitalists and how we add value.2 But even if the dictionary didn’t get the definition quite right, the presence of the word hospitalist is yet more evidence of the increasing importance and growth of our field. I want to share with you some of the exciting projects that the SHM is working on to further define our field.

Board Certification

We have been in discussion with the American Board of Internal Medicine and other societies that represent important interests in internal medicine regarding board certification for hospitalists. At this point I cannot tell you what certification will look like, how it will be conferred, or when it will come about; however, SHM is committed to developing a process that recognizes the expertise and experience of hospitalists and supports high quality care for patients. As you might imagine, any process of certification for hospitalists has huge implications for all physicians who practice internal medicine, and we are working to consider these issues carefully as we move ahead. Board certification, and the process of making it come about, marks another step along the path in the maturing of our field.

Journal of Hospital Medicine and Research

More evidence of our growth as a field is the coming publication of the Journal of Hospital Medicine. Under the editorship of Mark Williams, MD, the journal will be the first dedicated to hospital medicine and the care of hospitalized patients. I still remember the early discussions at the SHM Board of Directors meetings where we first discussed having a journal. At the time there were only three or four hospitalist researchers and our major concern was whether there would be sufficient content to fill a journal once let alone six or more times a year; however, at the time we also saw where our field was headed. We knew that in order to continue to define the field of hospital medicine a journal was key.

Perhaps our decision several years ago was hubris, perhaps it was blind optimism, but I like to think it was faith in our members and our society and a belief that hospital medicine was here to stay and would only get bigger. Next month SHM will proudly publish the first volume of the Journal of Hospital Medicine. I am happy to report that we have plenty of high quality content to fill the journal. Our field has continued to expand and with it more and more researchers are focusing on hospital medicine. One walk around the poster session at our annual meeting is enough to demonstrate all of the outstanding academic work that hospitalists at academic centers and community hospitals are doing.

Hand in hand with the publication of our journal has been our research initiative. I firmly believe that in order for SHM to lead hospital medicine, we must also lead in the area of research. In order to coordinate and expand our efforts in research, we recently brought Kathleen Kerr on board at SHM as a senior advisor to lead our research initiative. Kathleen brings a new level of rigor and enthusiasm to our research initiative and helps support the outstanding work of our research committee led by Andy Auerbach, MD. At SHM research reflects our members and includes hospitalists from all settings. I invite you to present your work at our annual meeting (we are currently accepting submissions through Jan. 6, 2006, for the Research, Innovations and Clinical Vignettes competition for the 2006 annual meeting) so we can all benefit and learn from the work we are doing. I also invite you to submit your work for publication in the Journal of Hospital Medicine.

Core Competency

Yet another sign of our maturing as a field will be the publication of the Core Competencies in Hospital Medicine as a supplement to the first volume of the Journal of Hospital Medicine. The core competencies reflect hundreds of hours of work by a dedicated group of hospitalists and SHM staff led by Tina Budnitz MPH, to define the core of what hospitalists need to know. Yes, hospitalists are more than just timesavers for other physicians. The core competencies in hospital medicine will outline what hospital medicine is about and serve as the foundation for educational programs, curricula, and initiatives in hospital medicine. The core competencies will also form the basis for certification of hospitalists by defining the key attitudes and skills needed to be a hospitalist. Look for the core competencies in early 2006 along with your first volume of the journal.

Evolution of Other “Ists”

If imitation is the finest form of flattery, then hospitalists should be very flattered by the proliferation of other “-ists.” Within our own field we find “nocurnists,” hospitalists who care for patients in the hospital overnight. Although it is not clear whether being a nocturnist is a permanent state in which you work only nights or a title that you hold temporarily, it is clear that “hospitalist” is leading to a wide use of the “-ist” suffix to describe the practice of physicians.

Even more interesting is the emergence of hospitalists in other fields such as surgery and obstetrics (see our related coverage in The Hospitalist—“What Is a Laborist,” Oct. 2005, p. 6; “Trendwatch: The specialization of hospital medicine,” Oct. 2005, p. 27; and “The Doctor Is In: The role of psychiatric hospitalists,” Oct. 2005, p. 30). Because the “ist” doesn’t work well universally (neither “surgicalist” nor “obstetricist” sounds right and neither does “deliverist”) the terms being used are “surgical hospitalist” or “OB hospitalist.” In either case the idea is that there is a physician, surgeon, or an obstetrician who sees patients in the hospital instead of the patients’ primary physician. Typically these physicians are employed by the hospital to care for unassigned patients admitted through the emergency department. The adoption of “hospitalist” by other fields in medicine to describe clinicians whose professional identity revolves around the hospital is a testament to the acceptance—and even normalization—of hospitalists and to the profound change in the way we care for hospitalized patients brought about by our field.

We certainly have come a long way from the days when our newly formed society decided not to use the word hospitalist or hospital or anything like it in our name for fear of inciting animosity. In just a few short years we find a world where hospitalist is in the dictionary and other physicians begin to use the term to describe themselves. Reflecting this maturing of our field, SHM is involved in several initiatives including certification, research, a journal, and core competencies to further define hospital medicine.

If you have been thinking about getting more involved in the SHM, do so now. Become an active member; volunteer for committees. Help shape our field and the world of hospital medicine in the future. This ride certainly ain’t over. In fact, it’s just beginning. TH

SHM President Dr. Pantilat is an associate professor of clinical medicine at the University of California at San Francisco.

References

1. Wachter RM, Goldman L. The emerging role of “hospitalists” in the American health care system. N Engl J Med. 1996;335(7):514-517.
2. Pile J. How hospitalists add value. The Hospitalist. 2005;9:Supplement 1.

In a 2001 Hospital Practice article Robert Wachter, MD, named malpractice as one of the top 10 issues that require consideration as it relates to the hospitalist movement.1 There are many areas to consider when looking at malpractice insurance for hospitalists as opposed to other physician specialties. Just one area being reviewed by insurance carriers: Underwriters are grouping hospitalists with internal medicine physicians because hospitalists do not yet have their own classification code.

“When physicians spend 85% to 100% of their time in the office,” wrote Dr. Wachter, “it seems prudent to base assessments of competence on the quality of the office practice rather than that of the hospital practice. As in other situations, the hospitalist movement has exposed the inadequacies of the earlier system.” This assessment seems applicable to the area of insurance as well. There may be a need to create means by which hospitalists can be better protected from malpractice risk and coverage inadequacy. This area, like all others associated with hospital medicine, is evolving.

In this article we highlight malpractice insurance for hospitalists: what you should consider now and in the future regarding policy coverage. policies Available to Hospitalists

The types of malpractice insurance available to hospitalists include:

1. Policies provided under your employer’s policy or purchased for yourself;
2. Policies that cover you when any event actually occurs or when the claim is filed; and
3. Policies purchased by hospitals where the payouts for claims are made either by the insurance company (the carrier) or by the employer (the hospital).

Most hospitalists are covered by institutional or group employers. In most cases, hospitalists are hired directly by hospitals or by an agency that contracts with hospitalists and administrates this relationship with the hospital.

“We recommend that the hospitals employ the hospitalists and that they put them on their hospital malpractice policy,” says Pam Kirks, insurance broker with the Gallagher Health Insurance Company in Raleigh, N.C., “because that’s the cheapest way to go for the hospitalist. There are different types of coverage out there that they can get; they can get their own coverage certainly. But I think the majority of them are becoming hospital employees.”

Occurrence or Claims Made

The types of medical malpractice insurance available to hospitalists are either “occurrence” or “claims-made” policies. An occurrence policy is one in which the policy that responds to a claim is the one that was in effect when the incident actually occurred. A claims-made policy that responds to a claim is the one that is in effect when the claim is made—provided that you also had continuous coverage from the time that the incident occurred.

Joe Zorola, director of underwriting at ProMutual Insurance Company in Boston, further explains the claims-made policy. “For instance, let’s say you have a policy this year and something happens tomorrow and five years down the line [the patient] file[s] a claim because of what happened tomorrow,” he explains. “You should have continued this policy through the next five years so that there’s no lapse of coverage, but the policy that will respond will be the policy five years from now.”

Of the 52 hospitals and 14,000 people that ProMutual insures, half of the policies are individual policies and half are group policies.

“The majority of [policies] are in Massachusetts and so are written under an occurrence basis,” says Zorola. “The ones outside of Massachusetts—and those are the group policies that we do have—are claims made.”

Physicians and insurance carriers each have preferences between the two types. “The occurrence policy is the policy that a lot of physicians like because they understand that if they did something today, [they can think] ‘I never have to worry about having insurance in the future for it,’” says Zorola. “The claims-made policy is the one that we as [insurance] companies like because it allows us to close our books on each policy year much sooner because we know that we aren’t going to have any more claims attached to the policy this year or in another year or two.”

Fully Insured or Self Insured?

Malpractice policies available through employers are either fully insured or self insured. The difference between the two types involves who is responsible for the claims payouts. With fully insured plans, the employer pays a premium to an insurer and the insurer pays claims out of the pool of premiums it collects from everyone it insures. Under a self-insured plan, the employer is responsible for paying all claims out of company assets. The Employee Retirement Income Security Act (ERISA) regulates self-insured plans; the plans are then under the jurisdiction of the U.S. Department of Labor.

“The hospitalists that we do [under]write [fully insured policies] for tend to be in the smaller community hospitals, which may not necessarily have the huge need for hospitalists; whereas the larger institutions may have a larger need for hospitalists [and] they usually tend to be self-insured,” says Zorola.

Controlled Risk Insurance Company of Vermont, known as CRICO and located in Cambridge, Mass, is one example of a self-insured system. “We only have one [malpractice insurance] product for a closed system where our clients are the Harvard teaching hospitals” says Karen O’Rourke, senior vice president of CRICO.

Individual Policies for Certain Circumstances

Hospitalists who take out individual policies are usually practicing part-time or moonlighting and have another policy with a carrier that is covering their primary practice. “And this is true across the country,” says Zorola. “Most carriers will have some sort of part-time credit that they will provide [to] the people who come to them for policies. Now there are some carriers, and these are usually the large hospital carriers, who won’t provide individual policies to physicians. They only provide coverage for the hospital and the hospital’s employees.”

Hospitalists who take out their own individual policies usually get coverage from one of the local Physician Insurers Association of America carriers.

Why Are Hospitalists Sued?

In general, hospitalists are infrequently sued for medical malpractice. They may be named in initial claims, but many are dropped before the case is resolved. However, while experts report that lawsuits against hospitalists are scarce, they also reference the lack of classification code specifically created for the hospitalist and his/her duties. Without it, it’s impossible to distinguish in data to learn when and in how many cases hospitalists were named.

O’Rourke says that internists in ambulatory or outpatient practice settings are usually at risk for claims of failure to diagnose—mostly failure to diagnose cancer or myocardial infarctions. In contrast, “the hospitalists’ failures come in the communication area,” she says, “because that’s primarily what they’re there for is to make sure that the patient receives the medical care that they’re supposed to in a hospital setting.”

O’Rourke, who directs the management of underwriting claims as part of her work at CRICO, believes there is a vast difference between the reasons for claims for internists versus hospitalists.3

“We receive so many failure-to-diagnose cases with internal medicine physicians,” she elaborates. “There have been huge losses associated with them throughout other systems that we’ve seen—some of our own, such as increases in [the rates of] breast cancer or colorectal cancer. You’re not going to see that with a hospitalist unless there’s a post-op complication—bleeding that isn’t caught and failure to diagnose—that kind of issue—soon enough. But they’re still under a surgeon’s care normally.”

O’Rourke recognizes that the care of the hospital patient is a team effort. “So it’s going to be a question of how the hospital defines the hospitalist role for each and every condition or [for] surgical patients,” she says.

If the Hospitalist Sees the Patient

A new claim that ProMutual recently received involves a hospitalist. The allegation is “failure to monitor a patient for suicide.” The claim states that the patient attempted suicide twice by trying to hang herself. The patient was admitted to the psychiatric unit of the hospital. Although a medical consultation must be done any time a patient is admitted, the hospitalist was not consulted to assess for suicide precautions. The hospitalist’s next involvement was after the attempted suicide when she responded to the code and admitted the patient to the ICU.

Given the lines of protocol, it is likely to be decided that the named psychiatrist was responsible for noting the risks with this patient and the hospitalist’s name will be dropped from the claim. The important thing for hospitalists to know is that because the hospitalist was listed as seeing the patient, she was named in the claim and this is customary procedure.

“A lot of times the plaintiff attorney will note every doctor who has seen the patient over the last number of years,” says Zorola, “because they probably don’t know a lot about the claim either, at that point. So until the investigation is done, and you can perform the depositions and find out exactly who was responsible for what,” the hospitalist will be a part of this process.

The Classification of Hospitalists

The growing trend is that insurance underwriters are creating a separate hospitalist classification. ProMutual underwriters established a classification for hospitalist and placed it in the same rate group as internal medicine physicians. But then the underwriters listened to what some of the hospitalists were saying: that because they are more specialized and are seeing patients who are more aware of the care that should be provided in the hospital, being grouped with physicians who spend most of the their time in office practice was not an accurate way to classify them.

Zorola and his colleagues now see that “setting up a separate classification for [hospitalists] allows us in the future to review their experience and determine whether they ought to be grouped with internal medicines or whether they belong in a lower or higher classification.” Hospitalists might belong in a higher, risk-associated classification “because they are seeing sick patients whereas internal medicine and family practice doctors have a mixture of sick and well patients,” he notes.

In fact, the common assumption is that hospitalists are doing riskier work simply because they work in places in which they have more opportunities to encounter risk. O’Rourke can’t say definitively how many hospitalists CRICO insures. But she can say that few claims involve hospitalists.

“We thought they were a riskier group for a while, but we couldn’t find any evidence of that in our data,” she explains. “We had a couple of claims involving people who were hospitalists, but nothing of concern.”

Whether hospitalists prove to be a riskier group in future research will depend on first determining more precisely what hospitalists do.

What Do Hospitalists Really Do?

“I can imagine that some of [the answer to this question] is that you go find out what works best for the systems you already have in place and develop systems that are needed to really quantify what [hospitalists] are supposed to do,” says O’Rourke. “And that will vary from institution to institution depending on whether it’s a teaching hospital or not.”

But there are other factors and issues at play, some of which are entirely out of control of the insured hospitalist. Barry Halpern, an attorney with Snell and Wilmer Law Firm, whose insured clients are spread over the western half of the United States, says “malpractice insurers, for a variety of reasons, … have many, many classifications for underwriting purposes and others [have] not very many at all. There are marketing issues associated with that and they don’t have a lot to do with the aspects of the specialty.”4

Your Policy Type May Matter

“[A]s you look at this from an insurance perspective, there are pros and cons for having separate insurance for hospitalists and the hospital,” says Halpern. “Where there is separate insurance, there is sometimes greater potential for conflict tension among the provider team than when the insurance is provided on an entity basis, particularly when entity claims against hospitals are a [somewhat] growing trend.”

Halpern notes that, in general, the courts are delivering their verdicts without considering the actual relationship between a hospital and a staff physician.3 “Of course,” he adds, “the courts are hunting for ways to make hospitals responsible on an entity basis rather than specifically for negligence in credentialing, or negligence in supervising, or negligence in providing staff and tools.”

Halpern thinks that in lawsuits where any staff physician is considered as part of the entity of the hospital institution, “it may make sense for the hospitalist to be insured under the hospital’s coverage, so that you minimize the potential for finger-pointing within the hospital-based team.” Besides creating potential tension within the group, Halpern says, “there may be indemnity agreements entered into between the hospitalists and the hospital that shift legal responsibility in a way that is sometimes not as carefully considered at the front end of an arrangement than at the back end, when a problem occurs.”

Halpern says that those kinds of situations must be looked at carefully. “[T]hose kinds of indemnity agreements can lead to a whole world of collateral claims litigation and can sometimes compromise insurance coverage,” he says. “For instance, if a hospitalist group signs an indemnity contract with the hospital without clearing it with the hospitalist’s insurer, the insurer might look at that and say, ‘We didn’t underwrite that additional obligation to defend and pay damages for the benefit of the hospital. And therefore, we deny coverage.’”

What Should Hospitalists Do?

If you are an individual hospitalist and your hospital provides your coverage, our experts have some suggestions on how to best protect yourself from surprises later about your liability insurance.

“[Y]ou certainly ought to get a copy of the policy,” says Halpern, and “focus very carefully on several things: 1) what’s covered, 2) what’s excluded, 3) what are the limits, and 4) who’s providing the coverage?”

You need to be able to feel that you can say “yes” to the question, “Is this a company that I can be confident will be there when it’s needed?”

If after a careful review of your policy, you have areas you would like to discuss with the hospital, it’s a matter of negotiation. And when you have the “negotiation muscle” to get what you need for protection, says Halpern, you’re in a better position.

“Frankly, most hospitals are interested in maintaining quality staff, quality relations with physicians—both employed and on the consulting staff,” says Halpern. “[They] are not typically in the business of muscling people and treating them badly. So if the hospitalist finds a legitimate gap in coverage or a concern, by and large hospitals look to be fair in working those things out. If they’re not, there are two basic approaches, and one is to not continue in the relationship.” (In other words, quit). “The second [approach] is to insure over the gap by going to an insurance broker and seeing if you can find coverage.”

Conclusion

Although most hospitalists are covered under their hospital policies, all hospitalists would benefit from understanding the specifics of their malpractice coverage. The dynamics of the hospitalist model will require changes in many areas including malpractice insurance. The trend of insurance carriers to establish a separate classification for hospitalists is likely to provide more precisely written coverage that accounts for the particulars of hospital medicine practice TH

Writer Andrea Sattinger will write about risk management for hospitalists in the Jan. ’06 issue.

References

1. Wachter RM. The hospitalist movement: ten issues to consider. Hosp Pract. 1999;34(2):104-106.
2. Entman SS, Glass CA, Hickson GB, et al. The relationship between malpractice claims history and subsequent obstetric care JAMA. 1994;272:1588-1591.
3. Alpers A. Key legal principles for hospitalists. Am J Med. 2001;111:5-9.
4. Pham HH, Devers KJ, Kuo S, et al. Health care market trends and the evolution of hospitalist use and roles. J Gen Intern Med. 2005;20:101-107.

In a 2001 Hospital Practice article Robert Wachter, MD, named malpractice as one of the top 10 issues that require consideration as it relates to the hospitalist movement.1 There are many areas to consider when looking at malpractice insurance for hospitalists as opposed to other physician specialties. Just one area being reviewed by insurance carriers: Underwriters are grouping hospitalists with internal medicine physicians because hospitalists do not yet have their own classification code.

“When physicians spend 85% to 100% of their time in the office,” wrote Dr. Wachter, “it seems prudent to base assessments of competence on the quality of the office practice rather than that of the hospital practice. As in other situations, the hospitalist movement has exposed the inadequacies of the earlier system.” This assessment seems applicable to the area of insurance as well. There may be a need to create means by which hospitalists can be better protected from malpractice risk and coverage inadequacy. This area, like all others associated with hospital medicine, is evolving.

In this article we highlight malpractice insurance for hospitalists: what you should consider now and in the future regarding policy coverage. policies Available to Hospitalists

The types of malpractice insurance available to hospitalists include:

1. Policies provided under your employer’s policy or purchased for yourself;
2. Policies that cover you when any event actually occurs or when the claim is filed; and
3. Policies purchased by hospitals where the payouts for claims are made either by the insurance company (the carrier) or by the employer (the hospital).

Most hospitalists are covered by institutional or group employers. In most cases, hospitalists are hired directly by hospitals or by an agency that contracts with hospitalists and administrates this relationship with the hospital.

“We recommend that the hospitals employ the hospitalists and that they put them on their hospital malpractice policy,” says Pam Kirks, insurance broker with the Gallagher Health Insurance Company in Raleigh, N.C., “because that’s the cheapest way to go for the hospitalist. There are different types of coverage out there that they can get; they can get their own coverage certainly. But I think the majority of them are becoming hospital employees.”

Occurrence or Claims Made

The types of medical malpractice insurance available to hospitalists are either “occurrence” or “claims-made” policies. An occurrence policy is one in which the policy that responds to a claim is the one that was in effect when the incident actually occurred. A claims-made policy that responds to a claim is the one that is in effect when the claim is made—provided that you also had continuous coverage from the time that the incident occurred.

Joe Zorola, director of underwriting at ProMutual Insurance Company in Boston, further explains the claims-made policy. “For instance, let’s say you have a policy this year and something happens tomorrow and five years down the line [the patient] file[s] a claim because of what happened tomorrow,” he explains. “You should have continued this policy through the next five years so that there’s no lapse of coverage, but the policy that will respond will be the policy five years from now.”

Of the 52 hospitals and 14,000 people that ProMutual insures, half of the policies are individual policies and half are group policies.

“The majority of [policies] are in Massachusetts and so are written under an occurrence basis,” says Zorola. “The ones outside of Massachusetts—and those are the group policies that we do have—are claims made.”

Physicians and insurance carriers each have preferences between the two types. “The occurrence policy is the policy that a lot of physicians like because they understand that if they did something today, [they can think] ‘I never have to worry about having insurance in the future for it,’” says Zorola. “The claims-made policy is the one that we as [insurance] companies like because it allows us to close our books on each policy year much sooner because we know that we aren’t going to have any more claims attached to the policy this year or in another year or two.”

Fully Insured or Self Insured?

Malpractice policies available through employers are either fully insured or self insured. The difference between the two types involves who is responsible for the claims payouts. With fully insured plans, the employer pays a premium to an insurer and the insurer pays claims out of the pool of premiums it collects from everyone it insures. Under a self-insured plan, the employer is responsible for paying all claims out of company assets. The Employee Retirement Income Security Act (ERISA) regulates self-insured plans; the plans are then under the jurisdiction of the U.S. Department of Labor.

“The hospitalists that we do [under]write [fully insured policies] for tend to be in the smaller community hospitals, which may not necessarily have the huge need for hospitalists; whereas the larger institutions may have a larger need for hospitalists [and] they usually tend to be self-insured,” says Zorola.

Controlled Risk Insurance Company of Vermont, known as CRICO and located in Cambridge, Mass, is one example of a self-insured system. “We only have one [malpractice insurance] product for a closed system where our clients are the Harvard teaching hospitals” says Karen O’Rourke, senior vice president of CRICO.

Individual Policies for Certain Circumstances

Hospitalists who take out individual policies are usually practicing part-time or moonlighting and have another policy with a carrier that is covering their primary practice. “And this is true across the country,” says Zorola. “Most carriers will have some sort of part-time credit that they will provide [to] the people who come to them for policies. Now there are some carriers, and these are usually the large hospital carriers, who won’t provide individual policies to physicians. They only provide coverage for the hospital and the hospital’s employees.”

Hospitalists who take out their own individual policies usually get coverage from one of the local Physician Insurers Association of America carriers.

Why Are Hospitalists Sued?

In general, hospitalists are infrequently sued for medical malpractice. They may be named in initial claims, but many are dropped before the case is resolved. However, while experts report that lawsuits against hospitalists are scarce, they also reference the lack of classification code specifically created for the hospitalist and his/her duties. Without it, it’s impossible to distinguish in data to learn when and in how many cases hospitalists were named.

O’Rourke says that internists in ambulatory or outpatient practice settings are usually at risk for claims of failure to diagnose—mostly failure to diagnose cancer or myocardial infarctions. In contrast, “the hospitalists’ failures come in the communication area,” she says, “because that’s primarily what they’re there for is to make sure that the patient receives the medical care that they’re supposed to in a hospital setting.”

O’Rourke, who directs the management of underwriting claims as part of her work at CRICO, believes there is a vast difference between the reasons for claims for internists versus hospitalists.3

“We receive so many failure-to-diagnose cases with internal medicine physicians,” she elaborates. “There have been huge losses associated with them throughout other systems that we’ve seen—some of our own, such as increases in [the rates of] breast cancer or colorectal cancer. You’re not going to see that with a hospitalist unless there’s a post-op complication—bleeding that isn’t caught and failure to diagnose—that kind of issue—soon enough. But they’re still under a surgeon’s care normally.”

O’Rourke recognizes that the care of the hospital patient is a team effort. “So it’s going to be a question of how the hospital defines the hospitalist role for each and every condition or [for] surgical patients,” she says.

If the Hospitalist Sees the Patient

A new claim that ProMutual recently received involves a hospitalist. The allegation is “failure to monitor a patient for suicide.” The claim states that the patient attempted suicide twice by trying to hang herself. The patient was admitted to the psychiatric unit of the hospital. Although a medical consultation must be done any time a patient is admitted, the hospitalist was not consulted to assess for suicide precautions. The hospitalist’s next involvement was after the attempted suicide when she responded to the code and admitted the patient to the ICU.

Given the lines of protocol, it is likely to be decided that the named psychiatrist was responsible for noting the risks with this patient and the hospitalist’s name will be dropped from the claim. The important thing for hospitalists to know is that because the hospitalist was listed as seeing the patient, she was named in the claim and this is customary procedure.

“A lot of times the plaintiff attorney will note every doctor who has seen the patient over the last number of years,” says Zorola, “because they probably don’t know a lot about the claim either, at that point. So until the investigation is done, and you can perform the depositions and find out exactly who was responsible for what,” the hospitalist will be a part of this process.

The Classification of Hospitalists

The growing trend is that insurance underwriters are creating a separate hospitalist classification. ProMutual underwriters established a classification for hospitalist and placed it in the same rate group as internal medicine physicians. But then the underwriters listened to what some of the hospitalists were saying: that because they are more specialized and are seeing patients who are more aware of the care that should be provided in the hospital, being grouped with physicians who spend most of the their time in office practice was not an accurate way to classify them.

Zorola and his colleagues now see that “setting up a separate classification for [hospitalists] allows us in the future to review their experience and determine whether they ought to be grouped with internal medicines or whether they belong in a lower or higher classification.” Hospitalists might belong in a higher, risk-associated classification “because they are seeing sick patients whereas internal medicine and family practice doctors have a mixture of sick and well patients,” he notes.

In fact, the common assumption is that hospitalists are doing riskier work simply because they work in places in which they have more opportunities to encounter risk. O’Rourke can’t say definitively how many hospitalists CRICO insures. But she can say that few claims involve hospitalists.

“We thought they were a riskier group for a while, but we couldn’t find any evidence of that in our data,” she explains. “We had a couple of claims involving people who were hospitalists, but nothing of concern.”

Whether hospitalists prove to be a riskier group in future research will depend on first determining more precisely what hospitalists do.

What Do Hospitalists Really Do?

“I can imagine that some of [the answer to this question] is that you go find out what works best for the systems you already have in place and develop systems that are needed to really quantify what [hospitalists] are supposed to do,” says O’Rourke. “And that will vary from institution to institution depending on whether it’s a teaching hospital or not.”

But there are other factors and issues at play, some of which are entirely out of control of the insured hospitalist. Barry Halpern, an attorney with Snell and Wilmer Law Firm, whose insured clients are spread over the western half of the United States, says “malpractice insurers, for a variety of reasons, … have many, many classifications for underwriting purposes and others [have] not very many at all. There are marketing issues associated with that and they don’t have a lot to do with the aspects of the specialty.”4

Your Policy Type May Matter

“[A]s you look at this from an insurance perspective, there are pros and cons for having separate insurance for hospitalists and the hospital,” says Halpern. “Where there is separate insurance, there is sometimes greater potential for conflict tension among the provider team than when the insurance is provided on an entity basis, particularly when entity claims against hospitals are a [somewhat] growing trend.”

Halpern notes that, in general, the courts are delivering their verdicts without considering the actual relationship between a hospital and a staff physician.3 “Of course,” he adds, “the courts are hunting for ways to make hospitals responsible on an entity basis rather than specifically for negligence in credentialing, or negligence in supervising, or negligence in providing staff and tools.”

Halpern thinks that in lawsuits where any staff physician is considered as part of the entity of the hospital institution, “it may make sense for the hospitalist to be insured under the hospital’s coverage, so that you minimize the potential for finger-pointing within the hospital-based team.” Besides creating potential tension within the group, Halpern says, “there may be indemnity agreements entered into between the hospitalists and the hospital that shift legal responsibility in a way that is sometimes not as carefully considered at the front end of an arrangement than at the back end, when a problem occurs.”

Halpern says that those kinds of situations must be looked at carefully. “[T]hose kinds of indemnity agreements can lead to a whole world of collateral claims litigation and can sometimes compromise insurance coverage,” he says. “For instance, if a hospitalist group signs an indemnity contract with the hospital without clearing it with the hospitalist’s insurer, the insurer might look at that and say, ‘We didn’t underwrite that additional obligation to defend and pay damages for the benefit of the hospital. And therefore, we deny coverage.’”

What Should Hospitalists Do?

If you are an individual hospitalist and your hospital provides your coverage, our experts have some suggestions on how to best protect yourself from surprises later about your liability insurance.

“[Y]ou certainly ought to get a copy of the policy,” says Halpern, and “focus very carefully on several things: 1) what’s covered, 2) what’s excluded, 3) what are the limits, and 4) who’s providing the coverage?”

You need to be able to feel that you can say “yes” to the question, “Is this a company that I can be confident will be there when it’s needed?”

If after a careful review of your policy, you have areas you would like to discuss with the hospital, it’s a matter of negotiation. And when you have the “negotiation muscle” to get what you need for protection, says Halpern, you’re in a better position.

“Frankly, most hospitals are interested in maintaining quality staff, quality relations with physicians—both employed and on the consulting staff,” says Halpern. “[They] are not typically in the business of muscling people and treating them badly. So if the hospitalist finds a legitimate gap in coverage or a concern, by and large hospitals look to be fair in working those things out. If they’re not, there are two basic approaches, and one is to not continue in the relationship.” (In other words, quit). “The second [approach] is to insure over the gap by going to an insurance broker and seeing if you can find coverage.”

Conclusion

Although most hospitalists are covered under their hospital policies, all hospitalists would benefit from understanding the specifics of their malpractice coverage. The dynamics of the hospitalist model will require changes in many areas including malpractice insurance. The trend of insurance carriers to establish a separate classification for hospitalists is likely to provide more precisely written coverage that accounts for the particulars of hospital medicine practice TH

Writer Andrea Sattinger will write about risk management for hospitalists in the Jan. ’06 issue.

References

1. Wachter RM. The hospitalist movement: ten issues to consider. Hosp Pract. 1999;34(2):104-106.
2. Entman SS, Glass CA, Hickson GB, et al. The relationship between malpractice claims history and subsequent obstetric care JAMA. 1994;272:1588-1591.
3. Alpers A. Key legal principles for hospitalists. Am J Med. 2001;111:5-9.
4. Pham HH, Devers KJ, Kuo S, et al. Health care market trends and the evolution of hospitalist use and roles. J Gen Intern Med. 2005;20:101-107.

In a 2001 Hospital Practice article Robert Wachter, MD, named malpractice as one of the top 10 issues that require consideration as it relates to the hospitalist movement.1 There are many areas to consider when looking at malpractice insurance for hospitalists as opposed to other physician specialties. Just one area being reviewed by insurance carriers: Underwriters are grouping hospitalists with internal medicine physicians because hospitalists do not yet have their own classification code.

“When physicians spend 85% to 100% of their time in the office,” wrote Dr. Wachter, “it seems prudent to base assessments of competence on the quality of the office practice rather than that of the hospital practice. As in other situations, the hospitalist movement has exposed the inadequacies of the earlier system.” This assessment seems applicable to the area of insurance as well. There may be a need to create means by which hospitalists can be better protected from malpractice risk and coverage inadequacy. This area, like all others associated with hospital medicine, is evolving.

In this article we highlight malpractice insurance for hospitalists: what you should consider now and in the future regarding policy coverage. policies Available to Hospitalists

The types of malpractice insurance available to hospitalists include:

1. Policies provided under your employer’s policy or purchased for yourself;
2. Policies that cover you when any event actually occurs or when the claim is filed; and
3. Policies purchased by hospitals where the payouts for claims are made either by the insurance company (the carrier) or by the employer (the hospital).

Most hospitalists are covered by institutional or group employers. In most cases, hospitalists are hired directly by hospitals or by an agency that contracts with hospitalists and administrates this relationship with the hospital.

“We recommend that the hospitals employ the hospitalists and that they put them on their hospital malpractice policy,” says Pam Kirks, insurance broker with the Gallagher Health Insurance Company in Raleigh, N.C., “because that’s the cheapest way to go for the hospitalist. There are different types of coverage out there that they can get; they can get their own coverage certainly. But I think the majority of them are becoming hospital employees.”

Occurrence or Claims Made

The types of medical malpractice insurance available to hospitalists are either “occurrence” or “claims-made” policies. An occurrence policy is one in which the policy that responds to a claim is the one that was in effect when the incident actually occurred. A claims-made policy that responds to a claim is the one that is in effect when the claim is made—provided that you also had continuous coverage from the time that the incident occurred.

Joe Zorola, director of underwriting at ProMutual Insurance Company in Boston, further explains the claims-made policy. “For instance, let’s say you have a policy this year and something happens tomorrow and five years down the line [the patient] file[s] a claim because of what happened tomorrow,” he explains. “You should have continued this policy through the next five years so that there’s no lapse of coverage, but the policy that will respond will be the policy five years from now.”

Of the 52 hospitals and 14,000 people that ProMutual insures, half of the policies are individual policies and half are group policies.

“The majority of [policies] are in Massachusetts and so are written under an occurrence basis,” says Zorola. “The ones outside of Massachusetts—and those are the group policies that we do have—are claims made.”

Physicians and insurance carriers each have preferences between the two types. “The occurrence policy is the policy that a lot of physicians like because they understand that if they did something today, [they can think] ‘I never have to worry about having insurance in the future for it,’” says Zorola. “The claims-made policy is the one that we as [insurance] companies like because it allows us to close our books on each policy year much sooner because we know that we aren’t going to have any more claims attached to the policy this year or in another year or two.”

Fully Insured or Self Insured?

Malpractice policies available through employers are either fully insured or self insured. The difference between the two types involves who is responsible for the claims payouts. With fully insured plans, the employer pays a premium to an insurer and the insurer pays claims out of the pool of premiums it collects from everyone it insures. Under a self-insured plan, the employer is responsible for paying all claims out of company assets. The Employee Retirement Income Security Act (ERISA) regulates self-insured plans; the plans are then under the jurisdiction of the U.S. Department of Labor.

“The hospitalists that we do [under]write [fully insured policies] for tend to be in the smaller community hospitals, which may not necessarily have the huge need for hospitalists; whereas the larger institutions may have a larger need for hospitalists [and] they usually tend to be self-insured,” says Zorola.

Controlled Risk Insurance Company of Vermont, known as CRICO and located in Cambridge, Mass, is one example of a self-insured system. “We only have one [malpractice insurance] product for a closed system where our clients are the Harvard teaching hospitals” says Karen O’Rourke, senior vice president of CRICO.

Individual Policies for Certain Circumstances

Hospitalists who take out individual policies are usually practicing part-time or moonlighting and have another policy with a carrier that is covering their primary practice. “And this is true across the country,” says Zorola. “Most carriers will have some sort of part-time credit that they will provide [to] the people who come to them for policies. Now there are some carriers, and these are usually the large hospital carriers, who won’t provide individual policies to physicians. They only provide coverage for the hospital and the hospital’s employees.”

Hospitalists who take out their own individual policies usually get coverage from one of the local Physician Insurers Association of America carriers.

Why Are Hospitalists Sued?

In general, hospitalists are infrequently sued for medical malpractice. They may be named in initial claims, but many are dropped before the case is resolved. However, while experts report that lawsuits against hospitalists are scarce, they also reference the lack of classification code specifically created for the hospitalist and his/her duties. Without it, it’s impossible to distinguish in data to learn when and in how many cases hospitalists were named.

O’Rourke says that internists in ambulatory or outpatient practice settings are usually at risk for claims of failure to diagnose—mostly failure to diagnose cancer or myocardial infarctions. In contrast, “the hospitalists’ failures come in the communication area,” she says, “because that’s primarily what they’re there for is to make sure that the patient receives the medical care that they’re supposed to in a hospital setting.”

O’Rourke, who directs the management of underwriting claims as part of her work at CRICO, believes there is a vast difference between the reasons for claims for internists versus hospitalists.3

“We receive so many failure-to-diagnose cases with internal medicine physicians,” she elaborates. “There have been huge losses associated with them throughout other systems that we’ve seen—some of our own, such as increases in [the rates of] breast cancer or colorectal cancer. You’re not going to see that with a hospitalist unless there’s a post-op complication—bleeding that isn’t caught and failure to diagnose—that kind of issue—soon enough. But they’re still under a surgeon’s care normally.”

O’Rourke recognizes that the care of the hospital patient is a team effort. “So it’s going to be a question of how the hospital defines the hospitalist role for each and every condition or [for] surgical patients,” she says.

If the Hospitalist Sees the Patient

A new claim that ProMutual recently received involves a hospitalist. The allegation is “failure to monitor a patient for suicide.” The claim states that the patient attempted suicide twice by trying to hang herself. The patient was admitted to the psychiatric unit of the hospital. Although a medical consultation must be done any time a patient is admitted, the hospitalist was not consulted to assess for suicide precautions. The hospitalist’s next involvement was after the attempted suicide when she responded to the code and admitted the patient to the ICU.

Given the lines of protocol, it is likely to be decided that the named psychiatrist was responsible for noting the risks with this patient and the hospitalist’s name will be dropped from the claim. The important thing for hospitalists to know is that because the hospitalist was listed as seeing the patient, she was named in the claim and this is customary procedure.

“A lot of times the plaintiff attorney will note every doctor who has seen the patient over the last number of years,” says Zorola, “because they probably don’t know a lot about the claim either, at that point. So until the investigation is done, and you can perform the depositions and find out exactly who was responsible for what,” the hospitalist will be a part of this process.

The Classification of Hospitalists

The growing trend is that insurance underwriters are creating a separate hospitalist classification. ProMutual underwriters established a classification for hospitalist and placed it in the same rate group as internal medicine physicians. But then the underwriters listened to what some of the hospitalists were saying: that because they are more specialized and are seeing patients who are more aware of the care that should be provided in the hospital, being grouped with physicians who spend most of the their time in office practice was not an accurate way to classify them.

Zorola and his colleagues now see that “setting up a separate classification for [hospitalists] allows us in the future to review their experience and determine whether they ought to be grouped with internal medicines or whether they belong in a lower or higher classification.” Hospitalists might belong in a higher, risk-associated classification “because they are seeing sick patients whereas internal medicine and family practice doctors have a mixture of sick and well patients,” he notes.

In fact, the common assumption is that hospitalists are doing riskier work simply because they work in places in which they have more opportunities to encounter risk. O’Rourke can’t say definitively how many hospitalists CRICO insures. But she can say that few claims involve hospitalists.

“We thought they were a riskier group for a while, but we couldn’t find any evidence of that in our data,” she explains. “We had a couple of claims involving people who were hospitalists, but nothing of concern.”

Whether hospitalists prove to be a riskier group in future research will depend on first determining more precisely what hospitalists do.

What Do Hospitalists Really Do?

“I can imagine that some of [the answer to this question] is that you go find out what works best for the systems you already have in place and develop systems that are needed to really quantify what [hospitalists] are supposed to do,” says O’Rourke. “And that will vary from institution to institution depending on whether it’s a teaching hospital or not.”

But there are other factors and issues at play, some of which are entirely out of control of the insured hospitalist. Barry Halpern, an attorney with Snell and Wilmer Law Firm, whose insured clients are spread over the western half of the United States, says “malpractice insurers, for a variety of reasons, … have many, many classifications for underwriting purposes and others [have] not very many at all. There are marketing issues associated with that and they don’t have a lot to do with the aspects of the specialty.”4

Your Policy Type May Matter

“[A]s you look at this from an insurance perspective, there are pros and cons for having separate insurance for hospitalists and the hospital,” says Halpern. “Where there is separate insurance, there is sometimes greater potential for conflict tension among the provider team than when the insurance is provided on an entity basis, particularly when entity claims against hospitals are a [somewhat] growing trend.”

Halpern notes that, in general, the courts are delivering their verdicts without considering the actual relationship between a hospital and a staff physician.3 “Of course,” he adds, “the courts are hunting for ways to make hospitals responsible on an entity basis rather than specifically for negligence in credentialing, or negligence in supervising, or negligence in providing staff and tools.”

Halpern thinks that in lawsuits where any staff physician is considered as part of the entity of the hospital institution, “it may make sense for the hospitalist to be insured under the hospital’s coverage, so that you minimize the potential for finger-pointing within the hospital-based team.” Besides creating potential tension within the group, Halpern says, “there may be indemnity agreements entered into between the hospitalists and the hospital that shift legal responsibility in a way that is sometimes not as carefully considered at the front end of an arrangement than at the back end, when a problem occurs.”

Halpern says that those kinds of situations must be looked at carefully. “[T]hose kinds of indemnity agreements can lead to a whole world of collateral claims litigation and can sometimes compromise insurance coverage,” he says. “For instance, if a hospitalist group signs an indemnity contract with the hospital without clearing it with the hospitalist’s insurer, the insurer might look at that and say, ‘We didn’t underwrite that additional obligation to defend and pay damages for the benefit of the hospital. And therefore, we deny coverage.’”

What Should Hospitalists Do?

If you are an individual hospitalist and your hospital provides your coverage, our experts have some suggestions on how to best protect yourself from surprises later about your liability insurance.

“[Y]ou certainly ought to get a copy of the policy,” says Halpern, and “focus very carefully on several things: 1) what’s covered, 2) what’s excluded, 3) what are the limits, and 4) who’s providing the coverage?”

You need to be able to feel that you can say “yes” to the question, “Is this a company that I can be confident will be there when it’s needed?”

If after a careful review of your policy, you have areas you would like to discuss with the hospital, it’s a matter of negotiation. And when you have the “negotiation muscle” to get what you need for protection, says Halpern, you’re in a better position.

“Frankly, most hospitals are interested in maintaining quality staff, quality relations with physicians—both employed and on the consulting staff,” says Halpern. “[They] are not typically in the business of muscling people and treating them badly. So if the hospitalist finds a legitimate gap in coverage or a concern, by and large hospitals look to be fair in working those things out. If they’re not, there are two basic approaches, and one is to not continue in the relationship.” (In other words, quit). “The second [approach] is to insure over the gap by going to an insurance broker and seeing if you can find coverage.”

Conclusion

Although most hospitalists are covered under their hospital policies, all hospitalists would benefit from understanding the specifics of their malpractice coverage. The dynamics of the hospitalist model will require changes in many areas including malpractice insurance. The trend of insurance carriers to establish a separate classification for hospitalists is likely to provide more precisely written coverage that accounts for the particulars of hospital medicine practice TH

Writer Andrea Sattinger will write about risk management for hospitalists in the Jan. ’06 issue.

References

1. Wachter RM. The hospitalist movement: ten issues to consider. Hosp Pract. 1999;34(2):104-106.
2. Entman SS, Glass CA, Hickson GB, et al. The relationship between malpractice claims history and subsequent obstetric care JAMA. 1994;272:1588-1591.
3. Alpers A. Key legal principles for hospitalists. Am J Med. 2001;111:5-9.
4. Pham HH, Devers KJ, Kuo S, et al. Health care market trends and the evolution of hospitalist use and roles. J Gen Intern Med. 2005;20:101-107.

Supplement Editor:
G. Willy Davila, MD

Contents

Preface: Sizing up the evolution of reconstructive pelvic surgery
G. Willy Davila, MD

Contemporary views on female pelvic anatomy
Matthew D. Barber, MD, MHS

Vaginal vault prolapse: Identification and surgical options
Daniel H. Biller, MD, and G. Willy Davila, MD

Anterior vaginal wall prolapse: Innovative surgical approaches
Mark D. Waters, MD, and Marie Fidela R. Paraiso, MD

Optimizing pelvic surgery outcomes
G. Willy Davila, MD

Supplement Editor:
G. Willy Davila, MD

Contents

Preface: Sizing up the evolution of reconstructive pelvic surgery
G. Willy Davila, MD

Contemporary views on female pelvic anatomy
Matthew D. Barber, MD, MHS

Vaginal vault prolapse: Identification and surgical options
Daniel H. Biller, MD, and G. Willy Davila, MD

Anterior vaginal wall prolapse: Innovative surgical approaches
Mark D. Waters, MD, and Marie Fidela R. Paraiso, MD

Optimizing pelvic surgery outcomes
G. Willy Davila, MD

Supplement Editor:
G. Willy Davila, MD

Contents

Preface: Sizing up the evolution of reconstructive pelvic surgery
G. Willy Davila, MD

Contemporary views on female pelvic anatomy
Matthew D. Barber, MD, MHS

Vaginal vault prolapse: Identification and surgical options
Daniel H. Biller, MD, and G. Willy Davila, MD

Anterior vaginal wall prolapse: Innovative surgical approaches
Mark D. Waters, MD, and Marie Fidela R. Paraiso, MD

Optimizing pelvic surgery outcomes
G. Willy Davila, MD

Hospitalized patient hangs himself; estate blames vacationing psychiatrist

Los Angeles County (CA) Superior Court

Police took a 34-year-old man to an inpatient psychiatric facility after they found him walking naked on a city street. The hospital admitted him on a 72-hour involuntary hold because of his suicidal thoughts, although the psychiatrist did not believe he intended to kill himself. The patient had never attempted suicide before. The psychiatrist ordered treatment with risperidone and monitoring every 30 minutes.

Two days later, at the beginning of the psychiatrist’s vacation, the hospital started a 14-day hold process. After 3 days, the on-call psychiatrist documented the patient’s refusal to communicate and take medication, but the patient denied suicidal thinking.

After 3 more days, staff discovered the patient sitting unconscious on the floor next to the toilet, with his pants wrapped around his neck and tied to a grab bar. Staff attempted cardiopulmonary resuscitation and called paramedics, but the patient was dead.

The patient’s estate claimed that the hospital and first treating psychiatrist did not take appropriate measures to prevent the suicide. It charged the hospital with negligence in failing to have a breakaway grab bar and claimed the original psychiatrist did not adequately communicate the patient’s status with the covering psychiatrist before leaving on vacation.

The defense claimed the patient was not at high risk for suicide and that the standard of care is to communicate information regarding high-risk patients to the covering psychiatrist. The original psychiatrist also claimed the patient was doing well when he left for vacation.

• The jury decided for the defense
  

Dr. Grant’s observations

Patients and their families may feel abandoned in their psychiatrists’ absence. But this absence does not legally constitute abandonment unless:

• a doctor-patient relationship exists
  
• the doctor terminates the relationship
  
• there is a need for continuing care
  
• termination lacks reasonable notice so arrangements for continuing care cannot be made.
  

While travel is at times necessary, psychiatrists must ensure that emergency-prone patients have access to care in their absence (Box). You can delegate this responsibility to a covering psychiatrist, but choose him or her wisely. Selecting a physician you know is incapable of providing sound treatment is considered negligent. The primary psychiatrist cannot be held responsible for a substitute psychiatrist’s negligence if the choice of substitute is viewed as a competent delegation.

Hospitalized patient hangs himself; estate blames vacationing psychiatrist

Los Angeles County (CA) Superior Court

Police took a 34-year-old man to an inpatient psychiatric facility after they found him walking naked on a city street. The hospital admitted him on a 72-hour involuntary hold because of his suicidal thoughts, although the psychiatrist did not believe he intended to kill himself. The patient had never attempted suicide before. The psychiatrist ordered treatment with risperidone and monitoring every 30 minutes.

Two days later, at the beginning of the psychiatrist’s vacation, the hospital started a 14-day hold process. After 3 days, the on-call psychiatrist documented the patient’s refusal to communicate and take medication, but the patient denied suicidal thinking.

After 3 more days, staff discovered the patient sitting unconscious on the floor next to the toilet, with his pants wrapped around his neck and tied to a grab bar. Staff attempted cardiopulmonary resuscitation and called paramedics, but the patient was dead.

The patient’s estate claimed that the hospital and first treating psychiatrist did not take appropriate measures to prevent the suicide. It charged the hospital with negligence in failing to have a breakaway grab bar and claimed the original psychiatrist did not adequately communicate the patient’s status with the covering psychiatrist before leaving on vacation.

The defense claimed the patient was not at high risk for suicide and that the standard of care is to communicate information regarding high-risk patients to the covering psychiatrist. The original psychiatrist also claimed the patient was doing well when he left for vacation.

• The jury decided for the defense
  

Dr. Grant’s observations

Patients and their families may feel abandoned in their psychiatrists’ absence. But this absence does not legally constitute abandonment unless:

• a doctor-patient relationship exists
  
• the doctor terminates the relationship
  
• there is a need for continuing care
  
• termination lacks reasonable notice so arrangements for continuing care cannot be made.
  

While travel is at times necessary, psychiatrists must ensure that emergency-prone patients have access to care in their absence (Box). You can delegate this responsibility to a covering psychiatrist, but choose him or her wisely. Selecting a physician you know is incapable of providing sound treatment is considered negligent. The primary psychiatrist cannot be held responsible for a substitute psychiatrist’s negligence if the choice of substitute is viewed as a competent delegation.

Hospitalized patient hangs himself; estate blames vacationing psychiatrist

Los Angeles County (CA) Superior Court

Police took a 34-year-old man to an inpatient psychiatric facility after they found him walking naked on a city street. The hospital admitted him on a 72-hour involuntary hold because of his suicidal thoughts, although the psychiatrist did not believe he intended to kill himself. The patient had never attempted suicide before. The psychiatrist ordered treatment with risperidone and monitoring every 30 minutes.

Two days later, at the beginning of the psychiatrist’s vacation, the hospital started a 14-day hold process. After 3 days, the on-call psychiatrist documented the patient’s refusal to communicate and take medication, but the patient denied suicidal thinking.

After 3 more days, staff discovered the patient sitting unconscious on the floor next to the toilet, with his pants wrapped around his neck and tied to a grab bar. Staff attempted cardiopulmonary resuscitation and called paramedics, but the patient was dead.

The patient’s estate claimed that the hospital and first treating psychiatrist did not take appropriate measures to prevent the suicide. It charged the hospital with negligence in failing to have a breakaway grab bar and claimed the original psychiatrist did not adequately communicate the patient’s status with the covering psychiatrist before leaving on vacation.

The defense claimed the patient was not at high risk for suicide and that the standard of care is to communicate information regarding high-risk patients to the covering psychiatrist. The original psychiatrist also claimed the patient was doing well when he left for vacation.

• The jury decided for the defense
  

Dr. Grant’s observations

Patients and their families may feel abandoned in their psychiatrists’ absence. But this absence does not legally constitute abandonment unless:

• a doctor-patient relationship exists
  
• the doctor terminates the relationship
  
• there is a need for continuing care
  
• termination lacks reasonable notice so arrangements for continuing care cannot be made.
  

While travel is at times necessary, psychiatrists must ensure that emergency-prone patients have access to care in their absence (Box). You can delegate this responsibility to a covering psychiatrist, but choose him or her wisely. Selecting a physician you know is incapable of providing sound treatment is considered negligent. The primary psychiatrist cannot be held responsible for a substitute psychiatrist’s negligence if the choice of substitute is viewed as a competent delegation.

It was a dreary cold, December day and I was on call. It had been slow, but that was about to change. An 82-year-old man was admitted to my service with diarrhea, vomiting, fever, and abdominal cramps. He had never had any gastrointestinal problems and was on no medications. The only pertinent history was that his grandson was sick with a similar illness, and his daughter had been sick three days earlier.

Moments later, I received a second call for a preop clearance on a man who had been electrocuted while decorating his house for the holidays. He had fallen and broken his hip. Before I put the phone down the pager went off again—a patient admitted with a glucose level of 820. The light bulb over my head went off: We had entered the Dangerous Season.

What is this season that bodes well for no one? This poorly understood clinical risk factor begins during Halloween and lasts through Christmas, New Year’s, Valentine’s Day, and—in some areas of the country—until Mardi Gras. And now they’re upon us again: the holidays. Our bodies shudder, increasingly deprived of sunlight and oversupplied with calories, as we begin our festive mode.

All Hallow’s Eve: The Dangerous Season starts with Halloween, a pagan ritual. What child would not want to stay up after dark, run around in a mask scaring people, and eat too much candy to commemorate the leprous dead?

Halloween is the most medical of holidays. Many costumes and traditions are related to medicine: Frankenstein’s monster was assembled from body parts obtained by anatomic grave robbers. Mummies are well-preserved corpses, and mummy powder was a traditional remedy for skin ailments for centuries. Vampires may have nutritional deficiencies, and werewolves porphyria. Spider web is a traditional therapy used cutaneously as a styptic and internally for asthma.

For diabetics—especially diabetic children—Halloween is a painful time. In addition, there’s no shortage of pumpkin seed-induced diverticulitis, not to mention the unfortunate periodic occurrence of poisoned candy. According to the American College of Emergency Physicians there’s also a serious increase in risk of injury from collisions with motor vehicles, eye injuries from sharp objects, and burns from flammable costumes.

Other Halloween problems include minor inconveniences such as lost fillings secondary to nougat, falls from trees while removing toilet paper, and the occasional rotten egg to the posterior occiput. In our household there appears to be a higher than usual incidence of emesis and general abdominal pain.

Turkey Day: Next comes Thanksgiving, a seemingly benign day of turkey consumption and family cheer. The greatest danger of this holiday remains Salmonella, though Campylobacter jejuni lurks somewhere nearby. Undercooked turkey is a potent source of this infection, as are uncooked eggs in cookie dough.

The amount of time to properly thaw and cook a whole turkey, for example, is much longer than the standard-size poultry pieces and cuts of meat served year-round. When thawed correctly in the refrigerator or at a temperature of no more than 40 degrees F, a 20-pound turkey requires two to three days to thaw completely. Thawing the turkey completely before cooking is important. Otherwise, the outside of the turkey will be done before the inside.

To check a turkey for doneness, insert a food thermometer into the inner thigh area near the breast of the turkey (but not touching bone). The turkey is done when the temperature reaches 180 degrees F. If the turkey is stuffed, the temperature of the stuffing should be 165 degrees F. It is not unusual for whole families to fall ill after eating the Thanksgiving feast. Salmonella may be found in turkey, gravy, stuffing, pies, and other foods served at the Thanksgiving dinner.

Another danger of turkey consumption is its high L-tryptophan concentration. Excessive turkey consumption may lead to significant sleepiness, which when combined with substantial alcohol intake may lead to traffic accidents or, at minimum, falling asleep in front of the television. Of course Thanksgiving is not a healthy day for turkeys.

Perhaps the safest thing about Thanksgiving day is the cranberry sauce. If you can get real sauce and not canned, jellied sugar, you might prevent a urinary tract infection caused by E. coli by inhibiting the bacterial podocytes’ adherence to your bladder wall.

Christmas: Christmas can be a time of great stress, especially for the non-Christian members of our society, who are deluged with holiday images. There is an increased incident of suicide over the peri-Christmas timeframe, perhaps worsened by seasonal affective disorder, though there is no study showing higher suicide rates in this time period in the north.

For some unclear reason there’s a higher rate of deadly train collisions and other disasters over Christmas. The year 1910 was an especially bad year, with eight accidents in the United States, England, and France on Christmas Eve and Day with a total mortality of 56 lives.

As per Thanksgiving, the same dietary risks exist at Christmas, along with the addition of deadly bacterially infested homemade eggnog (best to drink the pasteurized variety). Fruitcake, a mysterious substance not currently listed on the periodic table, is used most frequently as a doorstop. In a limited survey of holiday revelers none of the subjects had actually ever eaten any. In all fairness to fruitcakes, Dec. 27 is National Fruitcake Day.

The most dangerous part of Christmas, besides paper cuts from wrapping presents and frustration from assembling bicycles, is the venerable Christmas tree. A tradition that likely started in 16th century Germany, Christmas trees only became accepted in the United States in the mid-1840s. Trees are a fire hazard and can fall, injuring children. The biggest problem, though, is electrocution from holiday lights placed on the tree and home.

In 1999 the New Zealand Ministry of Consumer Affairs’ Energy Safety Service warned consumers to cease using certain types of lights because of a danger of electrocution. Metal objects—especially tinsel—from a Christmas tree could come in contact with the adapter and act as a conductor. Perhaps Charlie Brown’s tree was best after all.

Both Hanukkah and Kwanzaa have candle-lighting ceremonies—the menorah and kinara, respectively—and carry an increased risk of burns and fires.

New Year’s and Valentine’s: New Year’s Eve (aka amateur night) is a chance for those who never stay up late drinking to do so. Other than vehicular manslaughter, a major risk of this evening is stray gunfire. The Los Angeles Police Department has launched a Citywide Gunfire Reduction Campaign for New Year’s because this has become a time to shoot guns. The best-known treatment for over-libation is the ever-popular menudo (a Mexican soup made with hominy and tripe—not the boy band).

Saint Valentine’s Day is another Hallmark bonanza, as well as an amateur day for lovers. There are many myths involving this saint. One legend contends that Valentine was a priest who served during the third century in Rome. When Emperor Claudius II decided that single men made better soldiers than those with wives and families, he outlawed marriage for young men—his crop of potential soldiers. Valentine, realizing the injustice of the decree, defied Claudius and continued to perform marriages for young lovers in secret. When Valentine’s actions were discovered, Claudius ordered that he be put to death.

A less likely version is that while in prison Valentine fell in love with a young girl—his jailer’s daughter—who visited him during his confinement. Before his death he allegedly wrote her a letter, which he signed “From your Valentine,” an expression still in use today.

The dangers of Valentine’s Day are so pervasive and hideous it is difficult to write about them all, so I won’t. Let it be said, though, that from herpes to HIV, lipstick on the collar to lymphogranuloma venereum, lust can kill.

In the South, Mardi Gras ends the dangerous season. Eye trauma from flying beads and sightings of flying monkeys are a constant threat. I have been to Mardi Gras, but this is all I can remember of it.

So ’tis the season to be jolly, to spend time with our loved ones, and to bask in the familial hearth. Bah, hum and bug. TH

Jamie Newman, MD, FACP, is the physician editor of The Hospitalist, senior associate consultant, Hospital Internal Medicine, and assistant professor of internal medicine and medical history, Mayo Clinic College of Medicine at the Mayo Clinic College of Medicine, Rochester, Minn.

It was a dreary cold, December day and I was on call. It had been slow, but that was about to change. An 82-year-old man was admitted to my service with diarrhea, vomiting, fever, and abdominal cramps. He had never had any gastrointestinal problems and was on no medications. The only pertinent history was that his grandson was sick with a similar illness, and his daughter had been sick three days earlier.

Moments later, I received a second call for a preop clearance on a man who had been electrocuted while decorating his house for the holidays. He had fallen and broken his hip. Before I put the phone down the pager went off again—a patient admitted with a glucose level of 820. The light bulb over my head went off: We had entered the Dangerous Season.

What is this season that bodes well for no one? This poorly understood clinical risk factor begins during Halloween and lasts through Christmas, New Year’s, Valentine’s Day, and—in some areas of the country—until Mardi Gras. And now they’re upon us again: the holidays. Our bodies shudder, increasingly deprived of sunlight and oversupplied with calories, as we begin our festive mode.

All Hallow’s Eve: The Dangerous Season starts with Halloween, a pagan ritual. What child would not want to stay up after dark, run around in a mask scaring people, and eat too much candy to commemorate the leprous dead?

Halloween is the most medical of holidays. Many costumes and traditions are related to medicine: Frankenstein’s monster was assembled from body parts obtained by anatomic grave robbers. Mummies are well-preserved corpses, and mummy powder was a traditional remedy for skin ailments for centuries. Vampires may have nutritional deficiencies, and werewolves porphyria. Spider web is a traditional therapy used cutaneously as a styptic and internally for asthma.

For diabetics—especially diabetic children—Halloween is a painful time. In addition, there’s no shortage of pumpkin seed-induced diverticulitis, not to mention the unfortunate periodic occurrence of poisoned candy. According to the American College of Emergency Physicians there’s also a serious increase in risk of injury from collisions with motor vehicles, eye injuries from sharp objects, and burns from flammable costumes.

Other Halloween problems include minor inconveniences such as lost fillings secondary to nougat, falls from trees while removing toilet paper, and the occasional rotten egg to the posterior occiput. In our household there appears to be a higher than usual incidence of emesis and general abdominal pain.

Turkey Day: Next comes Thanksgiving, a seemingly benign day of turkey consumption and family cheer. The greatest danger of this holiday remains Salmonella, though Campylobacter jejuni lurks somewhere nearby. Undercooked turkey is a potent source of this infection, as are uncooked eggs in cookie dough.

The amount of time to properly thaw and cook a whole turkey, for example, is much longer than the standard-size poultry pieces and cuts of meat served year-round. When thawed correctly in the refrigerator or at a temperature of no more than 40 degrees F, a 20-pound turkey requires two to three days to thaw completely. Thawing the turkey completely before cooking is important. Otherwise, the outside of the turkey will be done before the inside.

To check a turkey for doneness, insert a food thermometer into the inner thigh area near the breast of the turkey (but not touching bone). The turkey is done when the temperature reaches 180 degrees F. If the turkey is stuffed, the temperature of the stuffing should be 165 degrees F. It is not unusual for whole families to fall ill after eating the Thanksgiving feast. Salmonella may be found in turkey, gravy, stuffing, pies, and other foods served at the Thanksgiving dinner.

Another danger of turkey consumption is its high L-tryptophan concentration. Excessive turkey consumption may lead to significant sleepiness, which when combined with substantial alcohol intake may lead to traffic accidents or, at minimum, falling asleep in front of the television. Of course Thanksgiving is not a healthy day for turkeys.

Perhaps the safest thing about Thanksgiving day is the cranberry sauce. If you can get real sauce and not canned, jellied sugar, you might prevent a urinary tract infection caused by E. coli by inhibiting the bacterial podocytes’ adherence to your bladder wall.

Christmas: Christmas can be a time of great stress, especially for the non-Christian members of our society, who are deluged with holiday images. There is an increased incident of suicide over the peri-Christmas timeframe, perhaps worsened by seasonal affective disorder, though there is no study showing higher suicide rates in this time period in the north.

For some unclear reason there’s a higher rate of deadly train collisions and other disasters over Christmas. The year 1910 was an especially bad year, with eight accidents in the United States, England, and France on Christmas Eve and Day with a total mortality of 56 lives.

As per Thanksgiving, the same dietary risks exist at Christmas, along with the addition of deadly bacterially infested homemade eggnog (best to drink the pasteurized variety). Fruitcake, a mysterious substance not currently listed on the periodic table, is used most frequently as a doorstop. In a limited survey of holiday revelers none of the subjects had actually ever eaten any. In all fairness to fruitcakes, Dec. 27 is National Fruitcake Day.

The most dangerous part of Christmas, besides paper cuts from wrapping presents and frustration from assembling bicycles, is the venerable Christmas tree. A tradition that likely started in 16th century Germany, Christmas trees only became accepted in the United States in the mid-1840s. Trees are a fire hazard and can fall, injuring children. The biggest problem, though, is electrocution from holiday lights placed on the tree and home.

In 1999 the New Zealand Ministry of Consumer Affairs’ Energy Safety Service warned consumers to cease using certain types of lights because of a danger of electrocution. Metal objects—especially tinsel—from a Christmas tree could come in contact with the adapter and act as a conductor. Perhaps Charlie Brown’s tree was best after all.

Both Hanukkah and Kwanzaa have candle-lighting ceremonies—the menorah and kinara, respectively—and carry an increased risk of burns and fires.

New Year’s and Valentine’s: New Year’s Eve (aka amateur night) is a chance for those who never stay up late drinking to do so. Other than vehicular manslaughter, a major risk of this evening is stray gunfire. The Los Angeles Police Department has launched a Citywide Gunfire Reduction Campaign for New Year’s because this has become a time to shoot guns. The best-known treatment for over-libation is the ever-popular menudo (a Mexican soup made with hominy and tripe—not the boy band).

Saint Valentine’s Day is another Hallmark bonanza, as well as an amateur day for lovers. There are many myths involving this saint. One legend contends that Valentine was a priest who served during the third century in Rome. When Emperor Claudius II decided that single men made better soldiers than those with wives and families, he outlawed marriage for young men—his crop of potential soldiers. Valentine, realizing the injustice of the decree, defied Claudius and continued to perform marriages for young lovers in secret. When Valentine’s actions were discovered, Claudius ordered that he be put to death.

A less likely version is that while in prison Valentine fell in love with a young girl—his jailer’s daughter—who visited him during his confinement. Before his death he allegedly wrote her a letter, which he signed “From your Valentine,” an expression still in use today.

The dangers of Valentine’s Day are so pervasive and hideous it is difficult to write about them all, so I won’t. Let it be said, though, that from herpes to HIV, lipstick on the collar to lymphogranuloma venereum, lust can kill.

In the South, Mardi Gras ends the dangerous season. Eye trauma from flying beads and sightings of flying monkeys are a constant threat. I have been to Mardi Gras, but this is all I can remember of it.

So ’tis the season to be jolly, to spend time with our loved ones, and to bask in the familial hearth. Bah, hum and bug. TH

Jamie Newman, MD, FACP, is the physician editor of The Hospitalist, senior associate consultant, Hospital Internal Medicine, and assistant professor of internal medicine and medical history, Mayo Clinic College of Medicine at the Mayo Clinic College of Medicine, Rochester, Minn.

It was a dreary cold, December day and I was on call. It had been slow, but that was about to change. An 82-year-old man was admitted to my service with diarrhea, vomiting, fever, and abdominal cramps. He had never had any gastrointestinal problems and was on no medications. The only pertinent history was that his grandson was sick with a similar illness, and his daughter had been sick three days earlier.

Moments later, I received a second call for a preop clearance on a man who had been electrocuted while decorating his house for the holidays. He had fallen and broken his hip. Before I put the phone down the pager went off again—a patient admitted with a glucose level of 820. The light bulb over my head went off: We had entered the Dangerous Season.

What is this season that bodes well for no one? This poorly understood clinical risk factor begins during Halloween and lasts through Christmas, New Year’s, Valentine’s Day, and—in some areas of the country—until Mardi Gras. And now they’re upon us again: the holidays. Our bodies shudder, increasingly deprived of sunlight and oversupplied with calories, as we begin our festive mode.

All Hallow’s Eve: The Dangerous Season starts with Halloween, a pagan ritual. What child would not want to stay up after dark, run around in a mask scaring people, and eat too much candy to commemorate the leprous dead?

Halloween is the most medical of holidays. Many costumes and traditions are related to medicine: Frankenstein’s monster was assembled from body parts obtained by anatomic grave robbers. Mummies are well-preserved corpses, and mummy powder was a traditional remedy for skin ailments for centuries. Vampires may have nutritional deficiencies, and werewolves porphyria. Spider web is a traditional therapy used cutaneously as a styptic and internally for asthma.

For diabetics—especially diabetic children—Halloween is a painful time. In addition, there’s no shortage of pumpkin seed-induced diverticulitis, not to mention the unfortunate periodic occurrence of poisoned candy. According to the American College of Emergency Physicians there’s also a serious increase in risk of injury from collisions with motor vehicles, eye injuries from sharp objects, and burns from flammable costumes.

Other Halloween problems include minor inconveniences such as lost fillings secondary to nougat, falls from trees while removing toilet paper, and the occasional rotten egg to the posterior occiput. In our household there appears to be a higher than usual incidence of emesis and general abdominal pain.

Turkey Day: Next comes Thanksgiving, a seemingly benign day of turkey consumption and family cheer. The greatest danger of this holiday remains Salmonella, though Campylobacter jejuni lurks somewhere nearby. Undercooked turkey is a potent source of this infection, as are uncooked eggs in cookie dough.

The amount of time to properly thaw and cook a whole turkey, for example, is much longer than the standard-size poultry pieces and cuts of meat served year-round. When thawed correctly in the refrigerator or at a temperature of no more than 40 degrees F, a 20-pound turkey requires two to three days to thaw completely. Thawing the turkey completely before cooking is important. Otherwise, the outside of the turkey will be done before the inside.

To check a turkey for doneness, insert a food thermometer into the inner thigh area near the breast of the turkey (but not touching bone). The turkey is done when the temperature reaches 180 degrees F. If the turkey is stuffed, the temperature of the stuffing should be 165 degrees F. It is not unusual for whole families to fall ill after eating the Thanksgiving feast. Salmonella may be found in turkey, gravy, stuffing, pies, and other foods served at the Thanksgiving dinner.

Another danger of turkey consumption is its high L-tryptophan concentration. Excessive turkey consumption may lead to significant sleepiness, which when combined with substantial alcohol intake may lead to traffic accidents or, at minimum, falling asleep in front of the television. Of course Thanksgiving is not a healthy day for turkeys.

Perhaps the safest thing about Thanksgiving day is the cranberry sauce. If you can get real sauce and not canned, jellied sugar, you might prevent a urinary tract infection caused by E. coli by inhibiting the bacterial podocytes’ adherence to your bladder wall.

Christmas: Christmas can be a time of great stress, especially for the non-Christian members of our society, who are deluged with holiday images. There is an increased incident of suicide over the peri-Christmas timeframe, perhaps worsened by seasonal affective disorder, though there is no study showing higher suicide rates in this time period in the north.

For some unclear reason there’s a higher rate of deadly train collisions and other disasters over Christmas. The year 1910 was an especially bad year, with eight accidents in the United States, England, and France on Christmas Eve and Day with a total mortality of 56 lives.

As per Thanksgiving, the same dietary risks exist at Christmas, along with the addition of deadly bacterially infested homemade eggnog (best to drink the pasteurized variety). Fruitcake, a mysterious substance not currently listed on the periodic table, is used most frequently as a doorstop. In a limited survey of holiday revelers none of the subjects had actually ever eaten any. In all fairness to fruitcakes, Dec. 27 is National Fruitcake Day.

The most dangerous part of Christmas, besides paper cuts from wrapping presents and frustration from assembling bicycles, is the venerable Christmas tree. A tradition that likely started in 16th century Germany, Christmas trees only became accepted in the United States in the mid-1840s. Trees are a fire hazard and can fall, injuring children. The biggest problem, though, is electrocution from holiday lights placed on the tree and home.

In 1999 the New Zealand Ministry of Consumer Affairs’ Energy Safety Service warned consumers to cease using certain types of lights because of a danger of electrocution. Metal objects—especially tinsel—from a Christmas tree could come in contact with the adapter and act as a conductor. Perhaps Charlie Brown’s tree was best after all.

Both Hanukkah and Kwanzaa have candle-lighting ceremonies—the menorah and kinara, respectively—and carry an increased risk of burns and fires.

New Year’s and Valentine’s: New Year’s Eve (aka amateur night) is a chance for those who never stay up late drinking to do so. Other than vehicular manslaughter, a major risk of this evening is stray gunfire. The Los Angeles Police Department has launched a Citywide Gunfire Reduction Campaign for New Year’s because this has become a time to shoot guns. The best-known treatment for over-libation is the ever-popular menudo (a Mexican soup made with hominy and tripe—not the boy band).

Saint Valentine’s Day is another Hallmark bonanza, as well as an amateur day for lovers. There are many myths involving this saint. One legend contends that Valentine was a priest who served during the third century in Rome. When Emperor Claudius II decided that single men made better soldiers than those with wives and families, he outlawed marriage for young men—his crop of potential soldiers. Valentine, realizing the injustice of the decree, defied Claudius and continued to perform marriages for young lovers in secret. When Valentine’s actions were discovered, Claudius ordered that he be put to death.

A less likely version is that while in prison Valentine fell in love with a young girl—his jailer’s daughter—who visited him during his confinement. Before his death he allegedly wrote her a letter, which he signed “From your Valentine,” an expression still in use today.

The dangers of Valentine’s Day are so pervasive and hideous it is difficult to write about them all, so I won’t. Let it be said, though, that from herpes to HIV, lipstick on the collar to lymphogranuloma venereum, lust can kill.

In the South, Mardi Gras ends the dangerous season. Eye trauma from flying beads and sightings of flying monkeys are a constant threat. I have been to Mardi Gras, but this is all I can remember of it.

So ’tis the season to be jolly, to spend time with our loved ones, and to bask in the familial hearth. Bah, hum and bug. TH

Jamie Newman, MD, FACP, is the physician editor of The Hospitalist, senior associate consultant, Hospital Internal Medicine, and assistant professor of internal medicine and medical history, Mayo Clinic College of Medicine at the Mayo Clinic College of Medicine, Rochester, Minn.