Clinical

At A Glance

Series: Hospital Medicine: Current Concepts

Title: Clinical Care Conundrums: Challenging Diagnoses in Hospital Medicine

Edited by: James C. Pile, Thomas E. Baudendistel, Brian Harte

Series Editors: Scott Flanders, Sanjay Saint

Pages: 208

Clinical Care Conundrums is written in 22 chapters, each discussing a clinical case presentation in a format similar to the series by the same name, published frequently in the Journal of Hospital Medicine.

An expert clinician’s approach to the “clinical conundrums” is disclosed using the presentation of an actual patient case in a prototypical “morning report” style. As in a patient care situation, sequential pieces of information are provided to the expert clinician, who is unfamiliar with the case. The focus of each case is the thought processes of both the clinical team caring for the patient and the commentator.

Each case provides great learning potential, not only in the unusual presentation of common diseases or more typical presentations of unusual diseases, but also in discussions of the possibilities in differential diagnoses. The range of information is wide. Readers are taken through discussions of conditions infrequently encountered but potentially fatal in the event of missed or delayed diagnosis, such as strongyloides hyperinfection, a condition that we are reminded is not always accompanied by eosinophilia. Some discussions of the more common conditions include:

• Evaluation of confusion;
• Etiologies of cirrhosis;
• Malignancies associated with hypercalcemia; and
• Work-up for new-onset seizures.

My interest remained high throughout the book, because I never knew what to expect. For example, a patient presenting with acute chest pain caused by esophageal perforation resulting in delayed diagnosis might follow the index case presentation of Whipple’s disease. We are also reminded that, despite the insistence of Gregory House, MD, (Dr. House is the titular character from the television series “House”) that “it’s never lupus,” it sometimes is actually lupus. A couple of interesting lupus cases are presented in a realistically perplexing manner, followed by beneficial discussion.

Analysis

The real value in this book lies in continued reminders of how and why clinicians make diagnostic errors. In fact, an early chapter in the book deals explicitly with improving diagnostic safety.

Robert Wachter, MD, MHM, reminds us in the introductory chapter that diagnostic errors comprise nearly one in five preventable adverse events. Until recently, diagnostic errors have been given relatively little attention, most likely because they are difficult to measure and harder to fix.

As hospital-based providers, the more awareness we have about the “anatomy and physiology” of both good and faulty decision making, the more likely we are to make better decisions. This book can be a crucial resource for any hospital-based care provider.

Dr. Lindsey is medical director of hospital-based physician services at Hospital Corporation of America (HCA).

At A Glance

Series: Hospital Medicine: Current Concepts

Title: Clinical Care Conundrums: Challenging Diagnoses in Hospital Medicine

Edited by: James C. Pile, Thomas E. Baudendistel, Brian Harte

Series Editors: Scott Flanders, Sanjay Saint

Pages: 208

Clinical Care Conundrums is written in 22 chapters, each discussing a clinical case presentation in a format similar to the series by the same name, published frequently in the Journal of Hospital Medicine.

An expert clinician’s approach to the “clinical conundrums” is disclosed using the presentation of an actual patient case in a prototypical “morning report” style. As in a patient care situation, sequential pieces of information are provided to the expert clinician, who is unfamiliar with the case. The focus of each case is the thought processes of both the clinical team caring for the patient and the commentator.

Each case provides great learning potential, not only in the unusual presentation of common diseases or more typical presentations of unusual diseases, but also in discussions of the possibilities in differential diagnoses. The range of information is wide. Readers are taken through discussions of conditions infrequently encountered but potentially fatal in the event of missed or delayed diagnosis, such as strongyloides hyperinfection, a condition that we are reminded is not always accompanied by eosinophilia. Some discussions of the more common conditions include:

• Evaluation of confusion;
• Etiologies of cirrhosis;
• Malignancies associated with hypercalcemia; and
• Work-up for new-onset seizures.

My interest remained high throughout the book, because I never knew what to expect. For example, a patient presenting with acute chest pain caused by esophageal perforation resulting in delayed diagnosis might follow the index case presentation of Whipple’s disease. We are also reminded that, despite the insistence of Gregory House, MD, (Dr. House is the titular character from the television series “House”) that “it’s never lupus,” it sometimes is actually lupus. A couple of interesting lupus cases are presented in a realistically perplexing manner, followed by beneficial discussion.

Analysis

The real value in this book lies in continued reminders of how and why clinicians make diagnostic errors. In fact, an early chapter in the book deals explicitly with improving diagnostic safety.

Robert Wachter, MD, MHM, reminds us in the introductory chapter that diagnostic errors comprise nearly one in five preventable adverse events. Until recently, diagnostic errors have been given relatively little attention, most likely because they are difficult to measure and harder to fix.

As hospital-based providers, the more awareness we have about the “anatomy and physiology” of both good and faulty decision making, the more likely we are to make better decisions. This book can be a crucial resource for any hospital-based care provider.

Dr. Lindsey is medical director of hospital-based physician services at Hospital Corporation of America (HCA).

At A Glance

Series: Hospital Medicine: Current Concepts

Title: Clinical Care Conundrums: Challenging Diagnoses in Hospital Medicine

Edited by: James C. Pile, Thomas E. Baudendistel, Brian Harte

Series Editors: Scott Flanders, Sanjay Saint

Pages: 208

Clinical Care Conundrums is written in 22 chapters, each discussing a clinical case presentation in a format similar to the series by the same name, published frequently in the Journal of Hospital Medicine.

An expert clinician’s approach to the “clinical conundrums” is disclosed using the presentation of an actual patient case in a prototypical “morning report” style. As in a patient care situation, sequential pieces of information are provided to the expert clinician, who is unfamiliar with the case. The focus of each case is the thought processes of both the clinical team caring for the patient and the commentator.

Each case provides great learning potential, not only in the unusual presentation of common diseases or more typical presentations of unusual diseases, but also in discussions of the possibilities in differential diagnoses. The range of information is wide. Readers are taken through discussions of conditions infrequently encountered but potentially fatal in the event of missed or delayed diagnosis, such as strongyloides hyperinfection, a condition that we are reminded is not always accompanied by eosinophilia. Some discussions of the more common conditions include:

• Evaluation of confusion;
• Etiologies of cirrhosis;
• Malignancies associated with hypercalcemia; and
• Work-up for new-onset seizures.

My interest remained high throughout the book, because I never knew what to expect. For example, a patient presenting with acute chest pain caused by esophageal perforation resulting in delayed diagnosis might follow the index case presentation of Whipple’s disease. We are also reminded that, despite the insistence of Gregory House, MD, (Dr. House is the titular character from the television series “House”) that “it’s never lupus,” it sometimes is actually lupus. A couple of interesting lupus cases are presented in a realistically perplexing manner, followed by beneficial discussion.

Analysis

The real value in this book lies in continued reminders of how and why clinicians make diagnostic errors. In fact, an early chapter in the book deals explicitly with improving diagnostic safety.

Robert Wachter, MD, MHM, reminds us in the introductory chapter that diagnostic errors comprise nearly one in five preventable adverse events. Until recently, diagnostic errors have been given relatively little attention, most likely because they are difficult to measure and harder to fix.

As hospital-based providers, the more awareness we have about the “anatomy and physiology” of both good and faulty decision making, the more likely we are to make better decisions. This book can be a crucial resource for any hospital-based care provider.

Dr. Lindsey is medical director of hospital-based physician services at Hospital Corporation of America (HCA).

Clinical question: In patients undergoing noncardiac surgery, are peri-operative beta blockers beneficial in those at high risk and harmful in those at low risk?

Background: Despite multiple RCTs, the exact utility of peri-operative beta-blockade remains unclear, especially in those patients considered low cardiac risk. While initial research prompted guidelines that encouraged the liberal use of peri-operative beta blockers, more recent studies have drawn attention to their potential adverse effects, prompting further investigation.

Study design: Retrospective, observational, cohort study.

Setting: One hundred nineteen Veterans Administration medical centers.

Synopsis: Through the modeling of data from 326,489 patients who underwent noncardiac surgery between 2008 and 2013, this study assessed the effects of beta blocker usage and cardiac risk factors on 30-day surgical mortality.

Analysis demonstrated a significant difference in the effect of beta blocker use on mortality based on the number of cardiac risk factors. For patients with no cardiac risk factors, those receiving beta blockers were at increased risk of death (odds ratio 1.19, 95% confidence interval 1.06-1.35). Among patients with three to four cardiac risk factors, however, those on beta blockers had a decreased risk of death (odds ratio 0.63, 95% confidence interval 0.43-0.93).

Bottom line: In noncardiac surgery, use of beta blockers may be beneficial for those at high cardiac risk and detrimental to those without cardiac risk factors.

Citation: Friedell ML, Van Way CW 3rd, Freyberg RW, Almenoff PL. Beta-blockade and operative mortality in noncardiac surgery: harmful or helpful? JAMA Surgery. 2015;150(7):658-664. doi:10.1001/jamasurg.2015.86.

Clinical question: In patients undergoing noncardiac surgery, are peri-operative beta blockers beneficial in those at high risk and harmful in those at low risk?

Background: Despite multiple RCTs, the exact utility of peri-operative beta-blockade remains unclear, especially in those patients considered low cardiac risk. While initial research prompted guidelines that encouraged the liberal use of peri-operative beta blockers, more recent studies have drawn attention to their potential adverse effects, prompting further investigation.

Study design: Retrospective, observational, cohort study.

Setting: One hundred nineteen Veterans Administration medical centers.

Synopsis: Through the modeling of data from 326,489 patients who underwent noncardiac surgery between 2008 and 2013, this study assessed the effects of beta blocker usage and cardiac risk factors on 30-day surgical mortality.

Analysis demonstrated a significant difference in the effect of beta blocker use on mortality based on the number of cardiac risk factors. For patients with no cardiac risk factors, those receiving beta blockers were at increased risk of death (odds ratio 1.19, 95% confidence interval 1.06-1.35). Among patients with three to four cardiac risk factors, however, those on beta blockers had a decreased risk of death (odds ratio 0.63, 95% confidence interval 0.43-0.93).

Bottom line: In noncardiac surgery, use of beta blockers may be beneficial for those at high cardiac risk and detrimental to those without cardiac risk factors.

Citation: Friedell ML, Van Way CW 3rd, Freyberg RW, Almenoff PL. Beta-blockade and operative mortality in noncardiac surgery: harmful or helpful? JAMA Surgery. 2015;150(7):658-664. doi:10.1001/jamasurg.2015.86.

Clinical question: In patients undergoing noncardiac surgery, are peri-operative beta blockers beneficial in those at high risk and harmful in those at low risk?

Background: Despite multiple RCTs, the exact utility of peri-operative beta-blockade remains unclear, especially in those patients considered low cardiac risk. While initial research prompted guidelines that encouraged the liberal use of peri-operative beta blockers, more recent studies have drawn attention to their potential adverse effects, prompting further investigation.

Study design: Retrospective, observational, cohort study.

Setting: One hundred nineteen Veterans Administration medical centers.

Synopsis: Through the modeling of data from 326,489 patients who underwent noncardiac surgery between 2008 and 2013, this study assessed the effects of beta blocker usage and cardiac risk factors on 30-day surgical mortality.

Analysis demonstrated a significant difference in the effect of beta blocker use on mortality based on the number of cardiac risk factors. For patients with no cardiac risk factors, those receiving beta blockers were at increased risk of death (odds ratio 1.19, 95% confidence interval 1.06-1.35). Among patients with three to four cardiac risk factors, however, those on beta blockers had a decreased risk of death (odds ratio 0.63, 95% confidence interval 0.43-0.93).

Bottom line: In noncardiac surgery, use of beta blockers may be beneficial for those at high cardiac risk and detrimental to those without cardiac risk factors.

Citation: Friedell ML, Van Way CW 3rd, Freyberg RW, Almenoff PL. Beta-blockade and operative mortality in noncardiac surgery: harmful or helpful? JAMA Surgery. 2015;150(7):658-664. doi:10.1001/jamasurg.2015.86.

Clinical question: Do stable, low-risk patients hospitalized for chest pain after negative ED evaluation experience adverse cardiac events in the hospital?

Background: Chest pain results in more than seven million ED visits annually, with a cost of over $11 billion to hospitalize these patients for closer monitoring. It is not well known to what extent these low-risk patients experience in-hospital adverse cardiac events after a negative ED evaluation.

Study design: Blinded data review from a prospectively collected, multicenter database.

Setting: Three community teaching hospitals in the U.S.

Synopsis: Researchers identified 11,230 patients, aged 18 and older, hospitalized with chest pain symptoms after negative serial troponin, from July 2008 through June 2013. Demographics included mean age 58 years, 55% female, with several co-morbid medical illnesses. One hundred ninety-seven patients met the primary outcomes of in-hospital life-threatening arrhythmia, ST segment elevation MI, cardiac or respiratory arrest, and death.

Blinded reviewers further stratified these patients and excluded any patients with initial abnormal vital signs, with ECG evidence of ischemia, or with an uninterpretable ECG. This resulted in four patients who experienced the primary outcome in hospital after presenting with chest pain, stable vital signs, and no evidence of ischemia. By verifying inclusion data from 5% of the primary cohort and extrapolating, they calculated a primary outcome incidence of 0.06% [95% CI, 0.02%-0.14%].

Results were in hospital only and were not time specific. Authors were unable to control for confounders, prevent data collection bias, or verify inclusion criteria for more than 5% of the initial sample.

Bottom line: Risk for in-hospital adverse cardiac events is low in patients hospitalized from the ED with chest pain and normal vital signs, negative serial troponin, and non-ischemic ECG.

Citation: Weinstock MB, Weingart S, Orth F, et al. Risk for clinically relevant adverse cardiac events in patients with chest pain at hospital admission. JAMA Intern Med. 2015;175(7):1207-1212. doi: 10.1001/jamainternmed.2015.1674.

Clinical question: Do stable, low-risk patients hospitalized for chest pain after negative ED evaluation experience adverse cardiac events in the hospital?

Background: Chest pain results in more than seven million ED visits annually, with a cost of over $11 billion to hospitalize these patients for closer monitoring. It is not well known to what extent these low-risk patients experience in-hospital adverse cardiac events after a negative ED evaluation.

Study design: Blinded data review from a prospectively collected, multicenter database.

Setting: Three community teaching hospitals in the U.S.

Synopsis: Researchers identified 11,230 patients, aged 18 and older, hospitalized with chest pain symptoms after negative serial troponin, from July 2008 through June 2013. Demographics included mean age 58 years, 55% female, with several co-morbid medical illnesses. One hundred ninety-seven patients met the primary outcomes of in-hospital life-threatening arrhythmia, ST segment elevation MI, cardiac or respiratory arrest, and death.

Blinded reviewers further stratified these patients and excluded any patients with initial abnormal vital signs, with ECG evidence of ischemia, or with an uninterpretable ECG. This resulted in four patients who experienced the primary outcome in hospital after presenting with chest pain, stable vital signs, and no evidence of ischemia. By verifying inclusion data from 5% of the primary cohort and extrapolating, they calculated a primary outcome incidence of 0.06% [95% CI, 0.02%-0.14%].

Results were in hospital only and were not time specific. Authors were unable to control for confounders, prevent data collection bias, or verify inclusion criteria for more than 5% of the initial sample.

Bottom line: Risk for in-hospital adverse cardiac events is low in patients hospitalized from the ED with chest pain and normal vital signs, negative serial troponin, and non-ischemic ECG.

Citation: Weinstock MB, Weingart S, Orth F, et al. Risk for clinically relevant adverse cardiac events in patients with chest pain at hospital admission. JAMA Intern Med. 2015;175(7):1207-1212. doi: 10.1001/jamainternmed.2015.1674.

Clinical question: Do stable, low-risk patients hospitalized for chest pain after negative ED evaluation experience adverse cardiac events in the hospital?

Background: Chest pain results in more than seven million ED visits annually, with a cost of over $11 billion to hospitalize these patients for closer monitoring. It is not well known to what extent these low-risk patients experience in-hospital adverse cardiac events after a negative ED evaluation.

Study design: Blinded data review from a prospectively collected, multicenter database.

Setting: Three community teaching hospitals in the U.S.

Synopsis: Researchers identified 11,230 patients, aged 18 and older, hospitalized with chest pain symptoms after negative serial troponin, from July 2008 through June 2013. Demographics included mean age 58 years, 55% female, with several co-morbid medical illnesses. One hundred ninety-seven patients met the primary outcomes of in-hospital life-threatening arrhythmia, ST segment elevation MI, cardiac or respiratory arrest, and death.

Blinded reviewers further stratified these patients and excluded any patients with initial abnormal vital signs, with ECG evidence of ischemia, or with an uninterpretable ECG. This resulted in four patients who experienced the primary outcome in hospital after presenting with chest pain, stable vital signs, and no evidence of ischemia. By verifying inclusion data from 5% of the primary cohort and extrapolating, they calculated a primary outcome incidence of 0.06% [95% CI, 0.02%-0.14%].

Results were in hospital only and were not time specific. Authors were unable to control for confounders, prevent data collection bias, or verify inclusion criteria for more than 5% of the initial sample.

Bottom line: Risk for in-hospital adverse cardiac events is low in patients hospitalized from the ED with chest pain and normal vital signs, negative serial troponin, and non-ischemic ECG.

Citation: Weinstock MB, Weingart S, Orth F, et al. Risk for clinically relevant adverse cardiac events in patients with chest pain at hospital admission. JAMA Intern Med. 2015;175(7):1207-1212. doi: 10.1001/jamainternmed.2015.1674.

Clinical question: Can a diagnostic strategy that utilizes a clinical prediction rule combined with an immunoassay appropriately guide management for patients with suspected heparin-induced thrombocytopenia (HIT)?

Background: The appropriate and timely diagnosis of HIT can decrease the risks of thromboembolic and major bleeding events. Unfortunately, the reference standard tests for diagnosing HIT (e.g. serotonin release assay) are time-intensive. Immunoassays such as PF4/H-PaGIA provide a faster diagnostic approach but have been limited by poor specificity.

Study design: Single-group prospective cohort trial.

Setting: Four hospitals in Ontario, Canada between 2008 and 2013.

Synopsis: In 526 patients with suspected HIT, the results of a diagnostic strategy that combined the 4Ts score system and a PF4/H-PaGIA assay were compared to a HIT reference standard. For the identification of patients with HIT, the use of (1) an intermediate 4Ts score and negative PF4/H-PaGIA or (2) a low 4Ts score regardless of PF4/H-PaGIA result incorrectly excluded patients with HIT in 1.1% of cases (95% confidence interval 0.2-2.1%). For patients with low and intermediate 4Ts scores, however, a negative PF4/H-PaGIA result did not result in any incorrect exclusion.

Bottom line: In patients with low or intermediate 4Ts scores, a negative PF4/H-PaGIA assay may be used to exclude HIT, but further research into how to approach patients with a low 4Ts score and a positive PF4/H-PaGIA assay is needed.

Citation: Linkins LA, Bates SM, Lee AY, Heddle NM, Wang G, Warkentin TE. Combination of 4Ts score and PF4/H-PaGIA for diagnosis and management of heparin-induced thrombocytopenia: prospective cohort study. Blood. 2015;126(5):597-603.

Clinical question: Can a diagnostic strategy that utilizes a clinical prediction rule combined with an immunoassay appropriately guide management for patients with suspected heparin-induced thrombocytopenia (HIT)?

Background: The appropriate and timely diagnosis of HIT can decrease the risks of thromboembolic and major bleeding events. Unfortunately, the reference standard tests for diagnosing HIT (e.g. serotonin release assay) are time-intensive. Immunoassays such as PF4/H-PaGIA provide a faster diagnostic approach but have been limited by poor specificity.

Study design: Single-group prospective cohort trial.

Setting: Four hospitals in Ontario, Canada between 2008 and 2013.

Synopsis: In 526 patients with suspected HIT, the results of a diagnostic strategy that combined the 4Ts score system and a PF4/H-PaGIA assay were compared to a HIT reference standard. For the identification of patients with HIT, the use of (1) an intermediate 4Ts score and negative PF4/H-PaGIA or (2) a low 4Ts score regardless of PF4/H-PaGIA result incorrectly excluded patients with HIT in 1.1% of cases (95% confidence interval 0.2-2.1%). For patients with low and intermediate 4Ts scores, however, a negative PF4/H-PaGIA result did not result in any incorrect exclusion.

Bottom line: In patients with low or intermediate 4Ts scores, a negative PF4/H-PaGIA assay may be used to exclude HIT, but further research into how to approach patients with a low 4Ts score and a positive PF4/H-PaGIA assay is needed.

Citation: Linkins LA, Bates SM, Lee AY, Heddle NM, Wang G, Warkentin TE. Combination of 4Ts score and PF4/H-PaGIA for diagnosis and management of heparin-induced thrombocytopenia: prospective cohort study. Blood. 2015;126(5):597-603.

Clinical question: Can a diagnostic strategy that utilizes a clinical prediction rule combined with an immunoassay appropriately guide management for patients with suspected heparin-induced thrombocytopenia (HIT)?

Background: The appropriate and timely diagnosis of HIT can decrease the risks of thromboembolic and major bleeding events. Unfortunately, the reference standard tests for diagnosing HIT (e.g. serotonin release assay) are time-intensive. Immunoassays such as PF4/H-PaGIA provide a faster diagnostic approach but have been limited by poor specificity.

Study design: Single-group prospective cohort trial.

Setting: Four hospitals in Ontario, Canada between 2008 and 2013.

Synopsis: In 526 patients with suspected HIT, the results of a diagnostic strategy that combined the 4Ts score system and a PF4/H-PaGIA assay were compared to a HIT reference standard. For the identification of patients with HIT, the use of (1) an intermediate 4Ts score and negative PF4/H-PaGIA or (2) a low 4Ts score regardless of PF4/H-PaGIA result incorrectly excluded patients with HIT in 1.1% of cases (95% confidence interval 0.2-2.1%). For patients with low and intermediate 4Ts scores, however, a negative PF4/H-PaGIA result did not result in any incorrect exclusion.

Bottom line: In patients with low or intermediate 4Ts scores, a negative PF4/H-PaGIA assay may be used to exclude HIT, but further research into how to approach patients with a low 4Ts score and a positive PF4/H-PaGIA assay is needed.

Citation: Linkins LA, Bates SM, Lee AY, Heddle NM, Wang G, Warkentin TE. Combination of 4Ts score and PF4/H-PaGIA for diagnosis and management of heparin-induced thrombocytopenia: prospective cohort study. Blood. 2015;126(5):597-603.

Clinical question: Can vasoactive medications be safely given in the ICU via peripheral intravenous (PIV) access instead of central venous access?

Background: Vasoactive medications are given to a variety of patients in shock to maintain hemodynamic function. These medications are given through central venous catheters, partly out of concern for extravasation and tissue injury from PIV access use; however, placement and use of central catheters are also associated with significant morbidity.

Study design: Single-arm, observational, consecutive patient study.

Setting: Single, 18-bed medical ICU.

Synopsis: Investigators identified 734 ICU patients who received vasoactive medications through PIV lines between September 2002 and June 2014. They were 54% male gender, with an average age of 72 years and a SAPS II score average of 75. Norepinephrine, dopamine, and phenylephrine were included in the study. The decision to use these medications was based on clinical judgment. A specific pre-approved protocol, involving PIV and vein size and location, use of ultrasound confirmation, and a maximum duration of 72 hours, was used to administer these medications via PIV. Extravasation was immediately treated with injected phentolamine and topical nitroglycerin.

The average duration of PIV vasoactive medication use was 49 hours. Of the study patients, 13% eventually required central catheters, 2% experienced peripheral extravasation of medication, and none experienced tissue injury as defined by the study group.

Because the study was observational, there was no control group, and outcomes/efficacy compared to central catheters could not be assessed. Patient characteristics and other variables were not controlled for, and its single-center design makes reproducibility uncertain.

Bottom line: Vasoactive medications can be safely and feasibly administered to ICU patients through PIV lines using adequate protocols.

Citation: Cardenas-Garcia J, Schaub KF, Belchikov YG, Narasimhan M, Koenig SJ, Mayo PH. Safety of peripheral intravenous administration of vasoactive medication [published online ahead of print May 26, 2015]. J Hosp Med. doi: 10.1002/jhm.2394.

Clinical question: Can vasoactive medications be safely given in the ICU via peripheral intravenous (PIV) access instead of central venous access?

Background: Vasoactive medications are given to a variety of patients in shock to maintain hemodynamic function. These medications are given through central venous catheters, partly out of concern for extravasation and tissue injury from PIV access use; however, placement and use of central catheters are also associated with significant morbidity.

Study design: Single-arm, observational, consecutive patient study.

Setting: Single, 18-bed medical ICU.

Synopsis: Investigators identified 734 ICU patients who received vasoactive medications through PIV lines between September 2002 and June 2014. They were 54% male gender, with an average age of 72 years and a SAPS II score average of 75. Norepinephrine, dopamine, and phenylephrine were included in the study. The decision to use these medications was based on clinical judgment. A specific pre-approved protocol, involving PIV and vein size and location, use of ultrasound confirmation, and a maximum duration of 72 hours, was used to administer these medications via PIV. Extravasation was immediately treated with injected phentolamine and topical nitroglycerin.

The average duration of PIV vasoactive medication use was 49 hours. Of the study patients, 13% eventually required central catheters, 2% experienced peripheral extravasation of medication, and none experienced tissue injury as defined by the study group.

Because the study was observational, there was no control group, and outcomes/efficacy compared to central catheters could not be assessed. Patient characteristics and other variables were not controlled for, and its single-center design makes reproducibility uncertain.

Bottom line: Vasoactive medications can be safely and feasibly administered to ICU patients through PIV lines using adequate protocols.

Citation: Cardenas-Garcia J, Schaub KF, Belchikov YG, Narasimhan M, Koenig SJ, Mayo PH. Safety of peripheral intravenous administration of vasoactive medication [published online ahead of print May 26, 2015]. J Hosp Med. doi: 10.1002/jhm.2394.

Clinical question: Can vasoactive medications be safely given in the ICU via peripheral intravenous (PIV) access instead of central venous access?

Background: Vasoactive medications are given to a variety of patients in shock to maintain hemodynamic function. These medications are given through central venous catheters, partly out of concern for extravasation and tissue injury from PIV access use; however, placement and use of central catheters are also associated with significant morbidity.

Study design: Single-arm, observational, consecutive patient study.

Setting: Single, 18-bed medical ICU.

Synopsis: Investigators identified 734 ICU patients who received vasoactive medications through PIV lines between September 2002 and June 2014. They were 54% male gender, with an average age of 72 years and a SAPS II score average of 75. Norepinephrine, dopamine, and phenylephrine were included in the study. The decision to use these medications was based on clinical judgment. A specific pre-approved protocol, involving PIV and vein size and location, use of ultrasound confirmation, and a maximum duration of 72 hours, was used to administer these medications via PIV. Extravasation was immediately treated with injected phentolamine and topical nitroglycerin.

The average duration of PIV vasoactive medication use was 49 hours. Of the study patients, 13% eventually required central catheters, 2% experienced peripheral extravasation of medication, and none experienced tissue injury as defined by the study group.

Because the study was observational, there was no control group, and outcomes/efficacy compared to central catheters could not be assessed. Patient characteristics and other variables were not controlled for, and its single-center design makes reproducibility uncertain.

Bottom line: Vasoactive medications can be safely and feasibly administered to ICU patients through PIV lines using adequate protocols.

Citation: Cardenas-Garcia J, Schaub KF, Belchikov YG, Narasimhan M, Koenig SJ, Mayo PH. Safety of peripheral intravenous administration of vasoactive medication [published online ahead of print May 26, 2015]. J Hosp Med. doi: 10.1002/jhm.2394.

Clinical question: What is the cost and frequency of ED revisits within three days and 30 days?

Background: ED revisits lead to a financial and resource utilization burden on the medical system. The costs and rates of these return visits are unknown and limited in characterization.

Study design: Observational study.

Setting: Six states, using Healthcare Cost and Utilization Project databases.

Synopsis: An observational study examined data from 2006-2010 across six states to determine cost and frequency of ED revisits within a 30-day period from initial ED treatment and discharge. The study examined revisit rates within the first three days of discharge, as well as the 30 days following discharge from the initial presentation.

Three-day revisit rates were 8.2%, with 29% resulting in admission; 32% of the revisits took place at a different institution.

The 30-day revisit rate was 19.9%, with 28% resulting in admission. The most common diagnoses were skin and soft tissue infections (23.9%) and abdominal pain (9.7%). The vast majority of revisits (89%) resulted in the same diagnosis as the first encounter.

Cost of the revisits was more difficult to assess, because only one of six states had full data (Florida); the cost data was extrapolated for the other states involved. In Florida, three-day revisit costs accounted for 30.3% of all primary visit costs. Thirty-day revisit costs were 118% of all primary ED visits costs within that time period.

There was not always an indication of whether the revisit was due to a planned revisit, worsening of symptoms, or inadequate initial treatment, however, leaving the evaluation of cost and revisit burden incomplete.

Bottom line: Initial evaluation of ED revisits shows that rates and cost are significant, though the nature of the revisits remains underevaluated. Preliminary data demonstrate that ED revisits are a significant cost to the healthcare system, though the number of preventable revisits remains unknown.

Citation: Duseja R, Bardach NS, Lin GA, et al. Revisit rates and associated costs after and emergency department encounter. Ann Intern Med. 2015;162(11):750-756.

Clinical question: What is the cost and frequency of ED revisits within three days and 30 days?

Background: ED revisits lead to a financial and resource utilization burden on the medical system. The costs and rates of these return visits are unknown and limited in characterization.

Study design: Observational study.

Setting: Six states, using Healthcare Cost and Utilization Project databases.

Synopsis: An observational study examined data from 2006-2010 across six states to determine cost and frequency of ED revisits within a 30-day period from initial ED treatment and discharge. The study examined revisit rates within the first three days of discharge, as well as the 30 days following discharge from the initial presentation.

Three-day revisit rates were 8.2%, with 29% resulting in admission; 32% of the revisits took place at a different institution.

The 30-day revisit rate was 19.9%, with 28% resulting in admission. The most common diagnoses were skin and soft tissue infections (23.9%) and abdominal pain (9.7%). The vast majority of revisits (89%) resulted in the same diagnosis as the first encounter.

Cost of the revisits was more difficult to assess, because only one of six states had full data (Florida); the cost data was extrapolated for the other states involved. In Florida, three-day revisit costs accounted for 30.3% of all primary visit costs. Thirty-day revisit costs were 118% of all primary ED visits costs within that time period.

There was not always an indication of whether the revisit was due to a planned revisit, worsening of symptoms, or inadequate initial treatment, however, leaving the evaluation of cost and revisit burden incomplete.

Bottom line: Initial evaluation of ED revisits shows that rates and cost are significant, though the nature of the revisits remains underevaluated. Preliminary data demonstrate that ED revisits are a significant cost to the healthcare system, though the number of preventable revisits remains unknown.

Citation: Duseja R, Bardach NS, Lin GA, et al. Revisit rates and associated costs after and emergency department encounter. Ann Intern Med. 2015;162(11):750-756.

Clinical question: What is the cost and frequency of ED revisits within three days and 30 days?

Background: ED revisits lead to a financial and resource utilization burden on the medical system. The costs and rates of these return visits are unknown and limited in characterization.

Study design: Observational study.

Setting: Six states, using Healthcare Cost and Utilization Project databases.

Synopsis: An observational study examined data from 2006-2010 across six states to determine cost and frequency of ED revisits within a 30-day period from initial ED treatment and discharge. The study examined revisit rates within the first three days of discharge, as well as the 30 days following discharge from the initial presentation.

Three-day revisit rates were 8.2%, with 29% resulting in admission; 32% of the revisits took place at a different institution.

The 30-day revisit rate was 19.9%, with 28% resulting in admission. The most common diagnoses were skin and soft tissue infections (23.9%) and abdominal pain (9.7%). The vast majority of revisits (89%) resulted in the same diagnosis as the first encounter.

Cost of the revisits was more difficult to assess, because only one of six states had full data (Florida); the cost data was extrapolated for the other states involved. In Florida, three-day revisit costs accounted for 30.3% of all primary visit costs. Thirty-day revisit costs were 118% of all primary ED visits costs within that time period.

There was not always an indication of whether the revisit was due to a planned revisit, worsening of symptoms, or inadequate initial treatment, however, leaving the evaluation of cost and revisit burden incomplete.

Bottom line: Initial evaluation of ED revisits shows that rates and cost are significant, though the nature of the revisits remains underevaluated. Preliminary data demonstrate that ED revisits are a significant cost to the healthcare system, though the number of preventable revisits remains unknown.

Citation: Duseja R, Bardach NS, Lin GA, et al. Revisit rates and associated costs after and emergency department encounter. Ann Intern Med. 2015;162(11):750-756.

Clinical question: What are the differences between factors associated with early (zero to seven days after discharge) and late (eight to 30 days after discharge) readmission?

Background: Thirty-day readmission rates are a quality metric; however, recent evidence challenges the notion that readmissions represent unnecessary and preventable healthcare use. It remains unclear whether the 30-day window post-discharge represents a homogenous period or if there are factors that contribute to readmission during that time.

Study design: Retrospective, single-center, cohort study.

Setting: Large, urban teaching hospital.

Synopsis: Based on 13,355 admissions representing 8,078 patients over a two-year period, the overall readmission rate was 19.7%, with 7.8% early (zero to seven days post-discharge) readmissions, and 11.9% late (eight to 30 days post-discharge) readmissions. Variables were categorized as indicators of acute illness burden, chronic illness burden, patient care process factors, and social determinants of health.

Several markers of acute illness burden were associated with early readmission only. Some markers of chronic illness burden were associated with late readmissions only (e.g. hemodialysis), while others were associated with readmissions throughout the 30-day period. Worse social determinants of health increased odds of readmission in both periods.

The single-center study was able to examine detailed clinical variables; however, this approach limited the generalizability of the the results.

Bottom line: Policies to reduce 30-day readmissions should reflect the different risk factors at play across that time frame.

Citation: Graham KL, Wilker EH, Howell MD, Davis RB, Marcantonio ER. Differences between early and late readmissions among patients: A cohort study. Ann Intern Med. 2015;162(11):741-749.

Clinical question: What are the differences between factors associated with early (zero to seven days after discharge) and late (eight to 30 days after discharge) readmission?

Background: Thirty-day readmission rates are a quality metric; however, recent evidence challenges the notion that readmissions represent unnecessary and preventable healthcare use. It remains unclear whether the 30-day window post-discharge represents a homogenous period or if there are factors that contribute to readmission during that time.

Study design: Retrospective, single-center, cohort study.

Setting: Large, urban teaching hospital.

Synopsis: Based on 13,355 admissions representing 8,078 patients over a two-year period, the overall readmission rate was 19.7%, with 7.8% early (zero to seven days post-discharge) readmissions, and 11.9% late (eight to 30 days post-discharge) readmissions. Variables were categorized as indicators of acute illness burden, chronic illness burden, patient care process factors, and social determinants of health.

Several markers of acute illness burden were associated with early readmission only. Some markers of chronic illness burden were associated with late readmissions only (e.g. hemodialysis), while others were associated with readmissions throughout the 30-day period. Worse social determinants of health increased odds of readmission in both periods.

The single-center study was able to examine detailed clinical variables; however, this approach limited the generalizability of the the results.

Bottom line: Policies to reduce 30-day readmissions should reflect the different risk factors at play across that time frame.

Citation: Graham KL, Wilker EH, Howell MD, Davis RB, Marcantonio ER. Differences between early and late readmissions among patients: A cohort study. Ann Intern Med. 2015;162(11):741-749.

Clinical question: What are the differences between factors associated with early (zero to seven days after discharge) and late (eight to 30 days after discharge) readmission?

Background: Thirty-day readmission rates are a quality metric; however, recent evidence challenges the notion that readmissions represent unnecessary and preventable healthcare use. It remains unclear whether the 30-day window post-discharge represents a homogenous period or if there are factors that contribute to readmission during that time.

Study design: Retrospective, single-center, cohort study.

Setting: Large, urban teaching hospital.

Synopsis: Based on 13,355 admissions representing 8,078 patients over a two-year period, the overall readmission rate was 19.7%, with 7.8% early (zero to seven days post-discharge) readmissions, and 11.9% late (eight to 30 days post-discharge) readmissions. Variables were categorized as indicators of acute illness burden, chronic illness burden, patient care process factors, and social determinants of health.

Several markers of acute illness burden were associated with early readmission only. Some markers of chronic illness burden were associated with late readmissions only (e.g. hemodialysis), while others were associated with readmissions throughout the 30-day period. Worse social determinants of health increased odds of readmission in both periods.

The single-center study was able to examine detailed clinical variables; however, this approach limited the generalizability of the the results.

Bottom line: Policies to reduce 30-day readmissions should reflect the different risk factors at play across that time frame.

Citation: Graham KL, Wilker EH, Howell MD, Davis RB, Marcantonio ER. Differences between early and late readmissions among patients: A cohort study. Ann Intern Med. 2015;162(11):741-749.

Clinical question: How can patient adherence to pharmacological thromboprophylaxis be improved?

Background: Prior studies suggest that the hospital-wide prevalence of nonadministration of VTE thromboprophylaxis orders ranges from 5% to 13%, with patient refusal listed as the most common reason for nonadministration.

Study design: Quasi-experimental, pre-post intervention, with intervention and control units.

Setting: Academic medical center in Philadelphia.

Synopsis: Researchers identified 20,208 admissions for the study; 8,293 (41%) admissions occurred prior to the intervention and 11,915 (59%) after. The three-part intervention, which was composed of (1) standardized nurse response to patient refusal, (2) integration of daily assessment of VTE into rounds, and (3) regular audit with feedback, resulted in a decrease in nonadministration rates during the intervention. Rates continued to decline in the 21-month follow-up period.

After the intervention, the rate of missed doses of pharmacological thromboprophylaxis decreased from 24.7% to 14.7% (P<0.01). This was due to a decrease in patient refusal from 18.3% to 9.4% (P<0.01).

Although there was a decrease in the missed doses of thromboprophylaxis, there was no statistically significant change in the rate of hospital-associated VTE.

Bottom line: A multifaceted intervention resulted in a decrease in the proportion of missed and refused doses of pharmacological VTE thromboprophylaxis, but this was not associated with a statistically significant change in VTE rates.

Citation: Baillie CA, Guevara JP, Boston RC, Hecht TE. A unit-based intervention aimed at improving patient adherence to pharmacological thromboprophylaxis [published online ahead of print June 2, 2015]. BMJ Qual Saf. doi:10.1136/bmjqs-2015-003992.

Clinical question: How can patient adherence to pharmacological thromboprophylaxis be improved?

Background: Prior studies suggest that the hospital-wide prevalence of nonadministration of VTE thromboprophylaxis orders ranges from 5% to 13%, with patient refusal listed as the most common reason for nonadministration.

Study design: Quasi-experimental, pre-post intervention, with intervention and control units.

Setting: Academic medical center in Philadelphia.

Synopsis: Researchers identified 20,208 admissions for the study; 8,293 (41%) admissions occurred prior to the intervention and 11,915 (59%) after. The three-part intervention, which was composed of (1) standardized nurse response to patient refusal, (2) integration of daily assessment of VTE into rounds, and (3) regular audit with feedback, resulted in a decrease in nonadministration rates during the intervention. Rates continued to decline in the 21-month follow-up period.

After the intervention, the rate of missed doses of pharmacological thromboprophylaxis decreased from 24.7% to 14.7% (P<0.01). This was due to a decrease in patient refusal from 18.3% to 9.4% (P<0.01).

Although there was a decrease in the missed doses of thromboprophylaxis, there was no statistically significant change in the rate of hospital-associated VTE.

Bottom line: A multifaceted intervention resulted in a decrease in the proportion of missed and refused doses of pharmacological VTE thromboprophylaxis, but this was not associated with a statistically significant change in VTE rates.

Citation: Baillie CA, Guevara JP, Boston RC, Hecht TE. A unit-based intervention aimed at improving patient adherence to pharmacological thromboprophylaxis [published online ahead of print June 2, 2015]. BMJ Qual Saf. doi:10.1136/bmjqs-2015-003992.

Clinical question: How can patient adherence to pharmacological thromboprophylaxis be improved?

Background: Prior studies suggest that the hospital-wide prevalence of nonadministration of VTE thromboprophylaxis orders ranges from 5% to 13%, with patient refusal listed as the most common reason for nonadministration.

Study design: Quasi-experimental, pre-post intervention, with intervention and control units.

Setting: Academic medical center in Philadelphia.

Synopsis: Researchers identified 20,208 admissions for the study; 8,293 (41%) admissions occurred prior to the intervention and 11,915 (59%) after. The three-part intervention, which was composed of (1) standardized nurse response to patient refusal, (2) integration of daily assessment of VTE into rounds, and (3) regular audit with feedback, resulted in a decrease in nonadministration rates during the intervention. Rates continued to decline in the 21-month follow-up period.

After the intervention, the rate of missed doses of pharmacological thromboprophylaxis decreased from 24.7% to 14.7% (P<0.01). This was due to a decrease in patient refusal from 18.3% to 9.4% (P<0.01).

Although there was a decrease in the missed doses of thromboprophylaxis, there was no statistically significant change in the rate of hospital-associated VTE.

Bottom line: A multifaceted intervention resulted in a decrease in the proportion of missed and refused doses of pharmacological VTE thromboprophylaxis, but this was not associated with a statistically significant change in VTE rates.

Citation: Baillie CA, Guevara JP, Boston RC, Hecht TE. A unit-based intervention aimed at improving patient adherence to pharmacological thromboprophylaxis [published online ahead of print June 2, 2015]. BMJ Qual Saf. doi:10.1136/bmjqs-2015-003992.

Clinical question: Is there a score that will predict the mortality rate in elderly patients presenting with a non-ST-elevation myocardial infarction (NSTEMI)?

Background: Although they represent only 9% of patients in clinical trials, patients over the age of 75 make up one third of patients with NSTEMI, accounting for more than half of NSTEMI-related mortality.

Study design: Retrospective cohort analysis for score calculator design, with prospective cohort validation.

Setting: The retrospective cohort was derived from a meta-analysis of 55 papers. The prospective validation arm used a cohort of patients from a randomized multicenter Italian trial.

Synopsis: The authors developed and validated a mortality predictor for patients 75 and older who present with an NSTEMI. The calculator: hemoglobin less than 10 g/dl (two points), elevated troponin levels, ECG ischemic changes, estimated glomerular filtration rate (eGFR) less than 45, previous vascular event (one point each two). The calculator predicted probabilities of death in one year ranging from 2% (score of zero) to 75% (score of six). The calculator allowed stratification into low (score: zero to one), intermediate (score: two), or high (score: three or greater) risk. High-risk patients appeared to benefit from intervention with significantly reduced risk for mortality (odds ratio 0.44).

Bottom line: A simple risk calculator stratifies elderly patients into low, intermediate, or high risk to predict mortality from NSTEMI. High-risk patients appear to achieve a mortality benefit from intervention.

Citation: Angeli F, Cavallini C, Verdecchia P, et al. A risk score for predicting 1-year mortality in patients ≥75 years of age presenting with non-ST-elevation acute coronary syndrome. Am J Cardiol. 2015;116(2):208-213.

Clinical question: Is there a score that will predict the mortality rate in elderly patients presenting with a non-ST-elevation myocardial infarction (NSTEMI)?

Background: Although they represent only 9% of patients in clinical trials, patients over the age of 75 make up one third of patients with NSTEMI, accounting for more than half of NSTEMI-related mortality.

Study design: Retrospective cohort analysis for score calculator design, with prospective cohort validation.

Setting: The retrospective cohort was derived from a meta-analysis of 55 papers. The prospective validation arm used a cohort of patients from a randomized multicenter Italian trial.

Synopsis: The authors developed and validated a mortality predictor for patients 75 and older who present with an NSTEMI. The calculator: hemoglobin less than 10 g/dl (two points), elevated troponin levels, ECG ischemic changes, estimated glomerular filtration rate (eGFR) less than 45, previous vascular event (one point each two). The calculator predicted probabilities of death in one year ranging from 2% (score of zero) to 75% (score of six). The calculator allowed stratification into low (score: zero to one), intermediate (score: two), or high (score: three or greater) risk. High-risk patients appeared to benefit from intervention with significantly reduced risk for mortality (odds ratio 0.44).

Bottom line: A simple risk calculator stratifies elderly patients into low, intermediate, or high risk to predict mortality from NSTEMI. High-risk patients appear to achieve a mortality benefit from intervention.

Citation: Angeli F, Cavallini C, Verdecchia P, et al. A risk score for predicting 1-year mortality in patients ≥75 years of age presenting with non-ST-elevation acute coronary syndrome. Am J Cardiol. 2015;116(2):208-213.

Clinical question: Is there a score that will predict the mortality rate in elderly patients presenting with a non-ST-elevation myocardial infarction (NSTEMI)?

Background: Although they represent only 9% of patients in clinical trials, patients over the age of 75 make up one third of patients with NSTEMI, accounting for more than half of NSTEMI-related mortality.

Study design: Retrospective cohort analysis for score calculator design, with prospective cohort validation.

Setting: The retrospective cohort was derived from a meta-analysis of 55 papers. The prospective validation arm used a cohort of patients from a randomized multicenter Italian trial.

Synopsis: The authors developed and validated a mortality predictor for patients 75 and older who present with an NSTEMI. The calculator: hemoglobin less than 10 g/dl (two points), elevated troponin levels, ECG ischemic changes, estimated glomerular filtration rate (eGFR) less than 45, previous vascular event (one point each two). The calculator predicted probabilities of death in one year ranging from 2% (score of zero) to 75% (score of six). The calculator allowed stratification into low (score: zero to one), intermediate (score: two), or high (score: three or greater) risk. High-risk patients appeared to benefit from intervention with significantly reduced risk for mortality (odds ratio 0.44).

Bottom line: A simple risk calculator stratifies elderly patients into low, intermediate, or high risk to predict mortality from NSTEMI. High-risk patients appear to achieve a mortality benefit from intervention.

Citation: Angeli F, Cavallini C, Verdecchia P, et al. A risk score for predicting 1-year mortality in patients ≥75 years of age presenting with non-ST-elevation acute coronary syndrome. Am J Cardiol. 2015;116(2):208-213.

There are two types of memory, the cognitive and the emotional, and the latter is more enduring. Maya Angelou characterized the distinction between these two types of memory most eloquently and succinctly when she said, “I’ve learned that people will forget what you said, people will forget what you did, but people will never forget how you made them feel.” She was ahead of her time, because neurocognitive research has objectified with science what Ms. Angelou captured so elegantly in her prose. Emotional events are processed in the sensory systems and then transmitted to the medial-temporal lobe and the amygdale for the formation of an emotional memory. When the memory is cued and retrieved from the amygdale, it triggers an emotional response. Emotional experiences leave strong traces in the brain. Memories about emotional situations are stored in both the conscious and unconscious memory, which is part of the reason emotional memories are so enduring.¹ Studies of patients with severe anterograde amnesia following circumscribed bilateral hippocampal brain damage showed enduring memories of emotion despite the absence of conscious memories.² This has a demonstrably practical application in patients with dementia, who we now know have feelings of happiness and sadness long after they have forgotten what caused the emotion.³

The distinction is important because patients judge the quality of their medical care based on emotions. The patient satisfaction disconnect arises from the fact that physicians live in their cognitive memory, while patients live in their emotional memory. Being cognitive and objective is a critical skill a physician must bring to the bedside every day; the reason we don’t allow physicians to treat family members is that their ability to remain objective will be impaired. I realized that my emotion, my passion, and my empathy for the dying would impair my judgment when I started medical school, and I launched myself on a conscious and systematic discipline to keep those feelings out of my mind during patient care. The effort worked and, for the most part, I have been able to remain objective and unemotional as I care for my patients. Recently, however, I realized that my focus on objectivity negatively impacts patient experience. As a result, I have expanded my view: While I must stay objective and detached with my thinking, I must be emotionally engaged to provide a great patient experience.

I can remain objective and detached in my clinical judgment as I engage and connect emotionally during my patient encounters. This delicate balancing act has taken years of trial and error, however. I recently cared for a woman in her 60s who had fallen and broke her hip. Everyone was pleased that a top orthopedic surgeon was on call and able to give her the first-rate care she needed to begin walking again. The surgery went smoothly, and she was transferred to the medical/surgical ward, where things took a turn for the worse. She had a lot of anxiety in addition to her osteoporosis. Objectively, she was doing great, and we had a big success on our hands; however, she remained anxious, and she peppered the surgeon with fears that, while unfounded, were very real in her mind. The surgeon brushed them off, saying that her fears were not real and that he didn’t need to address them; his response made her emotional state spiral out of control. Her nurse notified me of the situation, and I came to her bedside. She was very agitated. I sat down at a low level and just started listening. She got all of her anxieties out in words. I held her hand, looked her in the eye, and assured her that I would be there for her and that things were going to be alright. Subsequently, she wrote letters of gratitude and proclaimed to any medical staff who would listen what a talented and great doctor I was. I did not have the skill to fix her broken hip; if it had been left to me alone, she would still be bed-bound. But I did have the human skills to connect with her and fix her agitated mind. If we remember the enduring power of the emotional memory, we can create great patient experiences.

The importance of these experiences was illustrated to me at the 2014 Dignity Health Patient Experience Summit, a powerful event featuring motivational speakers and leaders from across the country. The most powerful speakers, however, were patients. These patients had received terrible diagnoses that committed them to a prolonged interaction with the healthcare system. They were scared of what their diagnoses would mean for their future, they were subjected to uncomfortable procedures in which they struggled to maintain their dignity, and they repeatedly met the indifference of healthcare providers and clerical people who were only there to do a job. They related how the lack of caring and empathy made fears and anxiety much worse. But each of them had a story about that one person, that one care provider, who took the time to reassure them, to show that they cared, and to ensure that the patient did not feel alone. In most of these stories, the stand-out care providers took the time to hold their hands and reassure the patients. They took the time to connect with the patient’s emotional memory in a positive way, and that simple gesture of empathy had a powerful and lasting impact on the patient.

Invariably, the care provider at the heart of the patients’ stories was a nurse. Nurses have the reputation for being angels of mercy because they do the simple, empathetic gestures that let a patient know they are being cared for. These feelings endure in the patients’ memories long after the treatment is over. Doctors can, and should, be that type of care provider. It requires us to recognize that patients are scared and anxious, even though they may do their best not to show it. We, as physicians, often don’t see their anxiety, and we are so focused on the cognitive memory that we don’t address the anxiety and fear that is just under the surface. But taking just a few minutes to acknowledge their emotions, to explore them, and to reassure the patient that we are there for them has a lasting impact. In my group, we talk about the “human-business-human” encounter with patients. We begin all interactions with a human interaction (“Hello, I am Dr. McIlraith…”), conduct the business we came to provide (“Now I am going to examine you…”), and end with a human interaction (“What else can I do for you today?”). Patients expect physical contact with us during the “business” part of that interaction. I find that respectful, reassuring, and appropriate physical contact during the final “human” portion of that interaction helps solidify my patients’ experience. It helps make them feel that they have been cared for, particularly if the visit includes bad news.

Much of the recent focus on patient satisfaction has been driven by financial incentives. In 2013, CMS began penalizing hospitals 1.25% for poor HCAHPS scores as a part of the Affordable Care Act. In 2014, the maximum penalty increased to 2%, and to 3% in 2015. Hospitals have notoriously high overhead costs and slim profit margins, so these penalties can have a profound impact on the financial viability of an institution. But, while hospitals across the country have taken notice (see related article in this edition of The Hospitalist), I find doctors are more motivated by the well-being of their patients than are their hospital administrators. Satisfied patients are more compliant with treatment plans and have better outcomes.^4,5 Hospitalists spend a lot of effort making sure their heart failure patients are on an ACE inhibitor, and their heart attack patients are discharged on aspirin, beta blockers, and statins so that they will have a good outcome following treatment for their acute illness. The same outcome-driven, evidence-based practice of medicine relates to patient satisfaction, however. Success in HCAHPS is as important as core measures when it comes to patient outcomes. And if I can’t convince you patient satisfaction is important because of the good it does for hospitals and patients, think about yourself for a minute. Satisfied patients are much less likely to sue their physicians.⁶ Practicing quality, evidence-based medicine will keep you out of peer review; however, satisfied patients will keep you out of the courtroom.

I frequently hear the comment that “we can do great on patient satisfaction, but then it gets busy, and patient satisfaction goes out the window.” My own experience contradicts this maxim, however. It is not how much time you spend with your patient but, rather, what you do with the time you have. One of the most powerful things we can do is listen. I used to make the mistake that I only wanted to hear the information I needed to figure out my patients’ problems so I could start treating them; however, I have come to learn that being heard is, in itself, therapy for my patients. It is often quoted that physicians interrupt their patients within 18 seconds of starting the interview.⁷ A lot of physicians dispense with attentive listening when they are under time pressure, when they should instead dispense with lengthy discourses on the patient treatment plan. It is important to educate our patients on their illness and treatment, I admit. I find a lot of hospitalists want to impart their knowledge and their treatment rationale to their patients; however, they frequently give patients and families much more information than they can hold in their cognitive memory. And time pressures are not the only anxieties hospitalists carry with them to the bedside. Our increasingly metric-driven profession means that we not only have to worry about morning discharges, interdisciplinary rounds, length of stay, and so on, but we also have to consider patient experience. It is not easy to hide all the stress we are under when we come to the bedside of a patient, but we have to. The easiest way to do that is to take a deep breath, sit next to the patient, ask an open-ended question, and then say nothing until the patient is done speaking. Active listening with good eye contact and encouragement to continue solidifies the patient’s experience of being heard. There are extreme cases when a patient is in a manic phase and won’t ever stop speaking; bend the rules a bit in those circumstances. However, the above rule works very effectively in the majority of physician-patient interactions. Being heard leaves an enduring emotional memory with our patients.

Hospital medicine often looks to other industries for inspiration on how we can improve. The airline industry is often held up as an example of how we can model patient safety, for instance, but these comparisons oversimplify the challenges we face. The same is true with patient satisfaction. In the business world, adages like “The customer is always right” are central to customer satisfaction, yet completely irrelevant to HM practice. Patients and families frequently have inappropriate and unrealistic expectations of their hospitalist physicians. We cannot, and should not, tell the patient addicted to narcotics that they can have as much IV Dilaudid as they would like. We cannot fix the patient with end-stage cancer, heart failure, or dementia. This is where we have to part ways with comparisons to principles that guide other industries if we are going to find a way forward with patient experience in hospital medicine. Because we have to set limits for patients, we often have to give our patients and families bad news, and because we have to tell them things they don’t like to hear, like “You can’t have any salt in your diet,” or “You must quit drinking alcohol,” we must develop our own principles on patient experience and satisfaction. Otherwise our options are either delivering inappropriate medical care or abandoning the pursuit of patient satisfaction all together. This is when we must remember that emotional memories are more enduring. We can’t always give our patients what they want, and we can’t always tell them what they want to hear, but we can always show them that we care. When we show our patients that we care in a palpable way, we leave them with the feeling that they have been cared for regardless of their condition, and the positive memory will endure despite the negative information we may have to convey. Maybe they won’t cut down on their salt or quit drinking alcohol, but they will never forget that their hospitalist physician cared.

And if they remember that the physician cared, it is much more likely that they will cut down on the salt or quit drinking alcohol when they go home. To paraphrase Maya Angelou, “I can’t always tell my patients what they want to hear, I can’t always tell them that their lifestyle is appropriate, but I can always show them that I care.”

Dr. McIlraith is chairman of the department of hospital medicine of Mercy Medical Group in Sacramento, Calif.

References

1. LeDoux JE. Emotional memory. Scholarpedia. Accessed August 2, 2015.
2. Feinstein JS, Duff MC, D Tranel D. Sustained experience of emotion after loss of memory in patients with amnesia. Proc Natl Acad Sci. 2010:107(17):7674-7679.
3. Guzmán-Vélez E, Feinstein JS, Tranel D. Feelings without memory in Alzheimer disease. Cogn Behav Neurol. 2014;27(3):117-129.
4. Institute of Medicine. Crossing the quality chasm: a new health system for the 21st century. March 2001. Accessed August 2, 2015.
5. Bertakis KD, Azari R. Patient-centered care is associated with decreased health care utilization. J Am Board Fam Med. 2011;24(3):229-239.
6. Stelfox HT, Gandhi TK, Orav EJ, Gustafson ML. The relation of patient statisfaction with complaints against physicians and malpractice lawsuits. Am J Med. 2005;118(10):1126-1133.
7. Beckman HB, Frankel RM. The effect of physician behavior on the collection of data. Ann Intern Med. 1984;101(5):692-696.

There are two types of memory, the cognitive and the emotional, and the latter is more enduring. Maya Angelou characterized the distinction between these two types of memory most eloquently and succinctly when she said, “I’ve learned that people will forget what you said, people will forget what you did, but people will never forget how you made them feel.” She was ahead of her time, because neurocognitive research has objectified with science what Ms. Angelou captured so elegantly in her prose. Emotional events are processed in the sensory systems and then transmitted to the medial-temporal lobe and the amygdale for the formation of an emotional memory. When the memory is cued and retrieved from the amygdale, it triggers an emotional response. Emotional experiences leave strong traces in the brain. Memories about emotional situations are stored in both the conscious and unconscious memory, which is part of the reason emotional memories are so enduring.¹ Studies of patients with severe anterograde amnesia following circumscribed bilateral hippocampal brain damage showed enduring memories of emotion despite the absence of conscious memories.² This has a demonstrably practical application in patients with dementia, who we now know have feelings of happiness and sadness long after they have forgotten what caused the emotion.³

The distinction is important because patients judge the quality of their medical care based on emotions. The patient satisfaction disconnect arises from the fact that physicians live in their cognitive memory, while patients live in their emotional memory. Being cognitive and objective is a critical skill a physician must bring to the bedside every day; the reason we don’t allow physicians to treat family members is that their ability to remain objective will be impaired. I realized that my emotion, my passion, and my empathy for the dying would impair my judgment when I started medical school, and I launched myself on a conscious and systematic discipline to keep those feelings out of my mind during patient care. The effort worked and, for the most part, I have been able to remain objective and unemotional as I care for my patients. Recently, however, I realized that my focus on objectivity negatively impacts patient experience. As a result, I have expanded my view: While I must stay objective and detached with my thinking, I must be emotionally engaged to provide a great patient experience.

I can remain objective and detached in my clinical judgment as I engage and connect emotionally during my patient encounters. This delicate balancing act has taken years of trial and error, however. I recently cared for a woman in her 60s who had fallen and broke her hip. Everyone was pleased that a top orthopedic surgeon was on call and able to give her the first-rate care she needed to begin walking again. The surgery went smoothly, and she was transferred to the medical/surgical ward, where things took a turn for the worse. She had a lot of anxiety in addition to her osteoporosis. Objectively, she was doing great, and we had a big success on our hands; however, she remained anxious, and she peppered the surgeon with fears that, while unfounded, were very real in her mind. The surgeon brushed them off, saying that her fears were not real and that he didn’t need to address them; his response made her emotional state spiral out of control. Her nurse notified me of the situation, and I came to her bedside. She was very agitated. I sat down at a low level and just started listening. She got all of her anxieties out in words. I held her hand, looked her in the eye, and assured her that I would be there for her and that things were going to be alright. Subsequently, she wrote letters of gratitude and proclaimed to any medical staff who would listen what a talented and great doctor I was. I did not have the skill to fix her broken hip; if it had been left to me alone, she would still be bed-bound. But I did have the human skills to connect with her and fix her agitated mind. If we remember the enduring power of the emotional memory, we can create great patient experiences.

The importance of these experiences was illustrated to me at the 2014 Dignity Health Patient Experience Summit, a powerful event featuring motivational speakers and leaders from across the country. The most powerful speakers, however, were patients. These patients had received terrible diagnoses that committed them to a prolonged interaction with the healthcare system. They were scared of what their diagnoses would mean for their future, they were subjected to uncomfortable procedures in which they struggled to maintain their dignity, and they repeatedly met the indifference of healthcare providers and clerical people who were only there to do a job. They related how the lack of caring and empathy made fears and anxiety much worse. But each of them had a story about that one person, that one care provider, who took the time to reassure them, to show that they cared, and to ensure that the patient did not feel alone. In most of these stories, the stand-out care providers took the time to hold their hands and reassure the patients. They took the time to connect with the patient’s emotional memory in a positive way, and that simple gesture of empathy had a powerful and lasting impact on the patient.

Invariably, the care provider at the heart of the patients’ stories was a nurse. Nurses have the reputation for being angels of mercy because they do the simple, empathetic gestures that let a patient know they are being cared for. These feelings endure in the patients’ memories long after the treatment is over. Doctors can, and should, be that type of care provider. It requires us to recognize that patients are scared and anxious, even though they may do their best not to show it. We, as physicians, often don’t see their anxiety, and we are so focused on the cognitive memory that we don’t address the anxiety and fear that is just under the surface. But taking just a few minutes to acknowledge their emotions, to explore them, and to reassure the patient that we are there for them has a lasting impact. In my group, we talk about the “human-business-human” encounter with patients. We begin all interactions with a human interaction (“Hello, I am Dr. McIlraith…”), conduct the business we came to provide (“Now I am going to examine you…”), and end with a human interaction (“What else can I do for you today?”). Patients expect physical contact with us during the “business” part of that interaction. I find that respectful, reassuring, and appropriate physical contact during the final “human” portion of that interaction helps solidify my patients’ experience. It helps make them feel that they have been cared for, particularly if the visit includes bad news.

Much of the recent focus on patient satisfaction has been driven by financial incentives. In 2013, CMS began penalizing hospitals 1.25% for poor HCAHPS scores as a part of the Affordable Care Act. In 2014, the maximum penalty increased to 2%, and to 3% in 2015. Hospitals have notoriously high overhead costs and slim profit margins, so these penalties can have a profound impact on the financial viability of an institution. But, while hospitals across the country have taken notice (see related article in this edition of The Hospitalist), I find doctors are more motivated by the well-being of their patients than are their hospital administrators. Satisfied patients are more compliant with treatment plans and have better outcomes.^4,5 Hospitalists spend a lot of effort making sure their heart failure patients are on an ACE inhibitor, and their heart attack patients are discharged on aspirin, beta blockers, and statins so that they will have a good outcome following treatment for their acute illness. The same outcome-driven, evidence-based practice of medicine relates to patient satisfaction, however. Success in HCAHPS is as important as core measures when it comes to patient outcomes. And if I can’t convince you patient satisfaction is important because of the good it does for hospitals and patients, think about yourself for a minute. Satisfied patients are much less likely to sue their physicians.⁶ Practicing quality, evidence-based medicine will keep you out of peer review; however, satisfied patients will keep you out of the courtroom.

I frequently hear the comment that “we can do great on patient satisfaction, but then it gets busy, and patient satisfaction goes out the window.” My own experience contradicts this maxim, however. It is not how much time you spend with your patient but, rather, what you do with the time you have. One of the most powerful things we can do is listen. I used to make the mistake that I only wanted to hear the information I needed to figure out my patients’ problems so I could start treating them; however, I have come to learn that being heard is, in itself, therapy for my patients. It is often quoted that physicians interrupt their patients within 18 seconds of starting the interview.⁷ A lot of physicians dispense with attentive listening when they are under time pressure, when they should instead dispense with lengthy discourses on the patient treatment plan. It is important to educate our patients on their illness and treatment, I admit. I find a lot of hospitalists want to impart their knowledge and their treatment rationale to their patients; however, they frequently give patients and families much more information than they can hold in their cognitive memory. And time pressures are not the only anxieties hospitalists carry with them to the bedside. Our increasingly metric-driven profession means that we not only have to worry about morning discharges, interdisciplinary rounds, length of stay, and so on, but we also have to consider patient experience. It is not easy to hide all the stress we are under when we come to the bedside of a patient, but we have to. The easiest way to do that is to take a deep breath, sit next to the patient, ask an open-ended question, and then say nothing until the patient is done speaking. Active listening with good eye contact and encouragement to continue solidifies the patient’s experience of being heard. There are extreme cases when a patient is in a manic phase and won’t ever stop speaking; bend the rules a bit in those circumstances. However, the above rule works very effectively in the majority of physician-patient interactions. Being heard leaves an enduring emotional memory with our patients.

Hospital medicine often looks to other industries for inspiration on how we can improve. The airline industry is often held up as an example of how we can model patient safety, for instance, but these comparisons oversimplify the challenges we face. The same is true with patient satisfaction. In the business world, adages like “The customer is always right” are central to customer satisfaction, yet completely irrelevant to HM practice. Patients and families frequently have inappropriate and unrealistic expectations of their hospitalist physicians. We cannot, and should not, tell the patient addicted to narcotics that they can have as much IV Dilaudid as they would like. We cannot fix the patient with end-stage cancer, heart failure, or dementia. This is where we have to part ways with comparisons to principles that guide other industries if we are going to find a way forward with patient experience in hospital medicine. Because we have to set limits for patients, we often have to give our patients and families bad news, and because we have to tell them things they don’t like to hear, like “You can’t have any salt in your diet,” or “You must quit drinking alcohol,” we must develop our own principles on patient experience and satisfaction. Otherwise our options are either delivering inappropriate medical care or abandoning the pursuit of patient satisfaction all together. This is when we must remember that emotional memories are more enduring. We can’t always give our patients what they want, and we can’t always tell them what they want to hear, but we can always show them that we care. When we show our patients that we care in a palpable way, we leave them with the feeling that they have been cared for regardless of their condition, and the positive memory will endure despite the negative information we may have to convey. Maybe they won’t cut down on their salt or quit drinking alcohol, but they will never forget that their hospitalist physician cared.

And if they remember that the physician cared, it is much more likely that they will cut down on the salt or quit drinking alcohol when they go home. To paraphrase Maya Angelou, “I can’t always tell my patients what they want to hear, I can’t always tell them that their lifestyle is appropriate, but I can always show them that I care.”

Dr. McIlraith is chairman of the department of hospital medicine of Mercy Medical Group in Sacramento, Calif.

References

1. LeDoux JE. Emotional memory. Scholarpedia. Accessed August 2, 2015.
2. Feinstein JS, Duff MC, D Tranel D. Sustained experience of emotion after loss of memory in patients with amnesia. Proc Natl Acad Sci. 2010:107(17):7674-7679.
3. Guzmán-Vélez E, Feinstein JS, Tranel D. Feelings without memory in Alzheimer disease. Cogn Behav Neurol. 2014;27(3):117-129.
4. Institute of Medicine. Crossing the quality chasm: a new health system for the 21st century. March 2001. Accessed August 2, 2015.
5. Bertakis KD, Azari R. Patient-centered care is associated with decreased health care utilization. J Am Board Fam Med. 2011;24(3):229-239.
6. Stelfox HT, Gandhi TK, Orav EJ, Gustafson ML. The relation of patient statisfaction with complaints against physicians and malpractice lawsuits. Am J Med. 2005;118(10):1126-1133.
7. Beckman HB, Frankel RM. The effect of physician behavior on the collection of data. Ann Intern Med. 1984;101(5):692-696.

There are two types of memory, the cognitive and the emotional, and the latter is more enduring. Maya Angelou characterized the distinction between these two types of memory most eloquently and succinctly when she said, “I’ve learned that people will forget what you said, people will forget what you did, but people will never forget how you made them feel.” She was ahead of her time, because neurocognitive research has objectified with science what Ms. Angelou captured so elegantly in her prose. Emotional events are processed in the sensory systems and then transmitted to the medial-temporal lobe and the amygdale for the formation of an emotional memory. When the memory is cued and retrieved from the amygdale, it triggers an emotional response. Emotional experiences leave strong traces in the brain. Memories about emotional situations are stored in both the conscious and unconscious memory, which is part of the reason emotional memories are so enduring.¹ Studies of patients with severe anterograde amnesia following circumscribed bilateral hippocampal brain damage showed enduring memories of emotion despite the absence of conscious memories.² This has a demonstrably practical application in patients with dementia, who we now know have feelings of happiness and sadness long after they have forgotten what caused the emotion.³

The distinction is important because patients judge the quality of their medical care based on emotions. The patient satisfaction disconnect arises from the fact that physicians live in their cognitive memory, while patients live in their emotional memory. Being cognitive and objective is a critical skill a physician must bring to the bedside every day; the reason we don’t allow physicians to treat family members is that their ability to remain objective will be impaired. I realized that my emotion, my passion, and my empathy for the dying would impair my judgment when I started medical school, and I launched myself on a conscious and systematic discipline to keep those feelings out of my mind during patient care. The effort worked and, for the most part, I have been able to remain objective and unemotional as I care for my patients. Recently, however, I realized that my focus on objectivity negatively impacts patient experience. As a result, I have expanded my view: While I must stay objective and detached with my thinking, I must be emotionally engaged to provide a great patient experience.

I can remain objective and detached in my clinical judgment as I engage and connect emotionally during my patient encounters. This delicate balancing act has taken years of trial and error, however. I recently cared for a woman in her 60s who had fallen and broke her hip. Everyone was pleased that a top orthopedic surgeon was on call and able to give her the first-rate care she needed to begin walking again. The surgery went smoothly, and she was transferred to the medical/surgical ward, where things took a turn for the worse. She had a lot of anxiety in addition to her osteoporosis. Objectively, she was doing great, and we had a big success on our hands; however, she remained anxious, and she peppered the surgeon with fears that, while unfounded, were very real in her mind. The surgeon brushed them off, saying that her fears were not real and that he didn’t need to address them; his response made her emotional state spiral out of control. Her nurse notified me of the situation, and I came to her bedside. She was very agitated. I sat down at a low level and just started listening. She got all of her anxieties out in words. I held her hand, looked her in the eye, and assured her that I would be there for her and that things were going to be alright. Subsequently, she wrote letters of gratitude and proclaimed to any medical staff who would listen what a talented and great doctor I was. I did not have the skill to fix her broken hip; if it had been left to me alone, she would still be bed-bound. But I did have the human skills to connect with her and fix her agitated mind. If we remember the enduring power of the emotional memory, we can create great patient experiences.

The importance of these experiences was illustrated to me at the 2014 Dignity Health Patient Experience Summit, a powerful event featuring motivational speakers and leaders from across the country. The most powerful speakers, however, were patients. These patients had received terrible diagnoses that committed them to a prolonged interaction with the healthcare system. They were scared of what their diagnoses would mean for their future, they were subjected to uncomfortable procedures in which they struggled to maintain their dignity, and they repeatedly met the indifference of healthcare providers and clerical people who were only there to do a job. They related how the lack of caring and empathy made fears and anxiety much worse. But each of them had a story about that one person, that one care provider, who took the time to reassure them, to show that they cared, and to ensure that the patient did not feel alone. In most of these stories, the stand-out care providers took the time to hold their hands and reassure the patients. They took the time to connect with the patient’s emotional memory in a positive way, and that simple gesture of empathy had a powerful and lasting impact on the patient.

Invariably, the care provider at the heart of the patients’ stories was a nurse. Nurses have the reputation for being angels of mercy because they do the simple, empathetic gestures that let a patient know they are being cared for. These feelings endure in the patients’ memories long after the treatment is over. Doctors can, and should, be that type of care provider. It requires us to recognize that patients are scared and anxious, even though they may do their best not to show it. We, as physicians, often don’t see their anxiety, and we are so focused on the cognitive memory that we don’t address the anxiety and fear that is just under the surface. But taking just a few minutes to acknowledge their emotions, to explore them, and to reassure the patient that we are there for them has a lasting impact. In my group, we talk about the “human-business-human” encounter with patients. We begin all interactions with a human interaction (“Hello, I am Dr. McIlraith…”), conduct the business we came to provide (“Now I am going to examine you…”), and end with a human interaction (“What else can I do for you today?”). Patients expect physical contact with us during the “business” part of that interaction. I find that respectful, reassuring, and appropriate physical contact during the final “human” portion of that interaction helps solidify my patients’ experience. It helps make them feel that they have been cared for, particularly if the visit includes bad news.

Much of the recent focus on patient satisfaction has been driven by financial incentives. In 2013, CMS began penalizing hospitals 1.25% for poor HCAHPS scores as a part of the Affordable Care Act. In 2014, the maximum penalty increased to 2%, and to 3% in 2015. Hospitals have notoriously high overhead costs and slim profit margins, so these penalties can have a profound impact on the financial viability of an institution. But, while hospitals across the country have taken notice (see related article in this edition of The Hospitalist), I find doctors are more motivated by the well-being of their patients than are their hospital administrators. Satisfied patients are more compliant with treatment plans and have better outcomes.^4,5 Hospitalists spend a lot of effort making sure their heart failure patients are on an ACE inhibitor, and their heart attack patients are discharged on aspirin, beta blockers, and statins so that they will have a good outcome following treatment for their acute illness. The same outcome-driven, evidence-based practice of medicine relates to patient satisfaction, however. Success in HCAHPS is as important as core measures when it comes to patient outcomes. And if I can’t convince you patient satisfaction is important because of the good it does for hospitals and patients, think about yourself for a minute. Satisfied patients are much less likely to sue their physicians.⁶ Practicing quality, evidence-based medicine will keep you out of peer review; however, satisfied patients will keep you out of the courtroom.

I frequently hear the comment that “we can do great on patient satisfaction, but then it gets busy, and patient satisfaction goes out the window.” My own experience contradicts this maxim, however. It is not how much time you spend with your patient but, rather, what you do with the time you have. One of the most powerful things we can do is listen. I used to make the mistake that I only wanted to hear the information I needed to figure out my patients’ problems so I could start treating them; however, I have come to learn that being heard is, in itself, therapy for my patients. It is often quoted that physicians interrupt their patients within 18 seconds of starting the interview.⁷ A lot of physicians dispense with attentive listening when they are under time pressure, when they should instead dispense with lengthy discourses on the patient treatment plan. It is important to educate our patients on their illness and treatment, I admit. I find a lot of hospitalists want to impart their knowledge and their treatment rationale to their patients; however, they frequently give patients and families much more information than they can hold in their cognitive memory. And time pressures are not the only anxieties hospitalists carry with them to the bedside. Our increasingly metric-driven profession means that we not only have to worry about morning discharges, interdisciplinary rounds, length of stay, and so on, but we also have to consider patient experience. It is not easy to hide all the stress we are under when we come to the bedside of a patient, but we have to. The easiest way to do that is to take a deep breath, sit next to the patient, ask an open-ended question, and then say nothing until the patient is done speaking. Active listening with good eye contact and encouragement to continue solidifies the patient’s experience of being heard. There are extreme cases when a patient is in a manic phase and won’t ever stop speaking; bend the rules a bit in those circumstances. However, the above rule works very effectively in the majority of physician-patient interactions. Being heard leaves an enduring emotional memory with our patients.

Hospital medicine often looks to other industries for inspiration on how we can improve. The airline industry is often held up as an example of how we can model patient safety, for instance, but these comparisons oversimplify the challenges we face. The same is true with patient satisfaction. In the business world, adages like “The customer is always right” are central to customer satisfaction, yet completely irrelevant to HM practice. Patients and families frequently have inappropriate and unrealistic expectations of their hospitalist physicians. We cannot, and should not, tell the patient addicted to narcotics that they can have as much IV Dilaudid as they would like. We cannot fix the patient with end-stage cancer, heart failure, or dementia. This is where we have to part ways with comparisons to principles that guide other industries if we are going to find a way forward with patient experience in hospital medicine. Because we have to set limits for patients, we often have to give our patients and families bad news, and because we have to tell them things they don’t like to hear, like “You can’t have any salt in your diet,” or “You must quit drinking alcohol,” we must develop our own principles on patient experience and satisfaction. Otherwise our options are either delivering inappropriate medical care or abandoning the pursuit of patient satisfaction all together. This is when we must remember that emotional memories are more enduring. We can’t always give our patients what they want, and we can’t always tell them what they want to hear, but we can always show them that we care. When we show our patients that we care in a palpable way, we leave them with the feeling that they have been cared for regardless of their condition, and the positive memory will endure despite the negative information we may have to convey. Maybe they won’t cut down on their salt or quit drinking alcohol, but they will never forget that their hospitalist physician cared.

And if they remember that the physician cared, it is much more likely that they will cut down on the salt or quit drinking alcohol when they go home. To paraphrase Maya Angelou, “I can’t always tell my patients what they want to hear, I can’t always tell them that their lifestyle is appropriate, but I can always show them that I care.”

Dr. McIlraith is chairman of the department of hospital medicine of Mercy Medical Group in Sacramento, Calif.

References

1. LeDoux JE. Emotional memory. Scholarpedia. Accessed August 2, 2015.
2. Feinstein JS, Duff MC, D Tranel D. Sustained experience of emotion after loss of memory in patients with amnesia. Proc Natl Acad Sci. 2010:107(17):7674-7679.
3. Guzmán-Vélez E, Feinstein JS, Tranel D. Feelings without memory in Alzheimer disease. Cogn Behav Neurol. 2014;27(3):117-129.
4. Institute of Medicine. Crossing the quality chasm: a new health system for the 21st century. March 2001. Accessed August 2, 2015.
5. Bertakis KD, Azari R. Patient-centered care is associated with decreased health care utilization. J Am Board Fam Med. 2011;24(3):229-239.
6. Stelfox HT, Gandhi TK, Orav EJ, Gustafson ML. The relation of patient statisfaction with complaints against physicians and malpractice lawsuits. Am J Med. 2005;118(10):1126-1133.
7. Beckman HB, Frankel RM. The effect of physician behavior on the collection of data. Ann Intern Med. 1984;101(5):692-696.